Virtual User in the IoT: Definition, Technologies and Experiments.

Virtualization technologies are characterizing major advancements in the Internet of Things (IoT) arena, as they allow for achieving a cyber-physical world where everything can be found, activated, probed, interconnected, and updated at both the virtual and the physical levels. We believe these technologies should apply to human users other than things, bringing us the concept of the Virtual User (VU). This should represent the virtual counterpart of the IoT users with the ultimate goal of: (i) avoiding the user from having the burden of following the tedious processes of setting, configuring and updating IoT services the user is involved in; (ii) acting on behalf of the user when basic operations are required; (iii) exploiting to the best of its ability the IoT potentialities, always taking always account the user profile and interests. Accordingly, the VU is a complex representation of the user and acts as a proxy in between the virtual objects and IoT services and application; to this, it includes the following major functionalities: user profiling, authorization management, quality of experience modeling and management, social networking and context management. In this respect, the major contributions of this paper are to: provide the definition of VU, present the major functionalities, discuss the legal issues related to its introduction, provide some implementation details, and analyze key performance aspects in terms of the capability of the VU to correctly identify the user profile and context.

Uptake from water, internal distribution and bioaccumulation of selenium in Scenedesmus obliquus, Unio mancus and Rattus norvegicus: part B.

(75)Se-selenite transfer was investigated in a phytoplankton-mussel-rat food chain model consisting of Scenedesmus obliquus (Turpin) Kützing, Unio mancus Lamark and Rattus norvegicus Berkenhout. (75)Se-metabolized forms were investigated in order to identify potential critical steps in the food chain, as well as its relative bioavailability looking also at intracellular, cellular and organ partitioning. Tissue and intracellular distribution of (75)Se in mussels fed with (75)Se-S. obliquus was different compared to those exposed only to inorganic (75)Se-selenite. The intracellular distribution of (75)Se in the hepatopancreas and mantle of mussels fed (75)Se-microalgae was similar to hepatic and renal distributions in rats, suggesting that their stomach dissociated larger (75)Se-containing molecules. The (75)Se partitioned from water (culture medium) to microalgae showing a bioconcentration factor of 435. The bottleneck in the trophic transfer of (75)Se occurred between S. obliquus-U. mancus. From microalgae to mussels and subsequently to rats no bioaccumulation was verified.

Uptake from water, internal distribution and bioaccumulation of selenium in Scenedesmus obliquus, Unio mancus and Rattus norvegicus: part A.

The (75)Se internal bioavailability was investigated in microalgae, mussels and rats as biological experimental models. The (75)Se accumulation from freshwater to microalgae [Scenedesmus obliquus (Turpin) Kützing], from freshwater to mussels (Unio mancus Lamark) and, finally, per os to rats (Rattus norvegicus Berkenhout) was followed using (75)Se-labelled selenite looking at (75)Se uptake, retention, intracellular distribution and binding with cellular biocomplexes. After exposure to 10, 50 and 500 µg Se L(-1), the microalgae showed an inhibitory effect on population growth only at the highest concentration. Mussels exposed to 105 µg Se L(-1) showed an accumulation of the element with time in all tissues. Intracellularly, Se was present in all subcellular fractions, especially in the cytosol. Rats were treated via oral administration with 5 µg Se rat(-1). After 24 h, liver and kidney showed the highest Se concentration.

Papillary Thyroid Microcarcinoma: Differences between Lesions in Incidental and Nonincidental Settings-Considerations on These Clinical Entities and Personal Experience.

Papillary thyroid microcarcinoma (PTMC) represents 35-40% of all papillary cancers; it is defined as a nodule ≤ 10 mm at the time of histological diagnosis. The clinical significance of PTMC is still controversial, and it may be discovered in two settings: incidental PTMC (iPTMC), in which it is identified postoperatively upon histological examination of thyroid specimens following thyroid surgery for benign disease, and nonincidental PTMC (niPTMC), in which it is diagnosed before surgery. While iPTMC appears to be related to mild behavior and favorable clinical outcomes, niPTMC may exhibit markers of aggressiveness. We retrospectively review our experience, selecting 54 PTMCs: 28 classified as niPTMC (52%) and 26 classified as iPTMC (48%). Patients with niPTMC showed significant differences, such as younger age at diagnosis (p < 0.001); a lower male/female ratio (p < 0.01); a larger mean nodule diameter (p < 0.001); and a higher rate of aggressive pathological findings, such as multifocality, capsular invasion and/or lymphovascular invasion (p = 0.035). Other differences found in the niPTMC subgroup included a higher preoperative serum TSH level, higher hospital morbidity and a greater need for postoperative iodine ablation therapy (p < 0.05), while disease-free long-term survival did not differ between subgroups (p = 0.331) after a mean follow-up (FU) of 87 months, with one nodal recurrence among niPTMCs. The differences between iPTMC and niPTMC were consistent: patients operated on for total thyroidectomy and showing iPTMC can be considered healed after surgery, and follow-up should be designed to properly calibrate hormonal supplementation; conversely, niPTMC may sometimes exhibit aggressive behavior, and so the FU regimen should be closer and aimed at early detection of cancer recurrence.

When mastectomy is needed: is the nipple-sparing procedure a new standard with very few contraindications?

BACKGROUND AND OBJECTIVES: Nipple-sparing mastectomy (NSM) improves cosmetic results after mastectomy. As most consider advanced tumors, or tumors near the nipple-areola complex (NAC), as a contraindication for this type of surgery, we challenged this hypothesis. METHODS: One hundred thirty-eight NSM were performed in 121 consecutive patients. In 122 procedures for cancer, patients were included if there was no evidence of NAC proximity (<1 cm), and if the retro-areolar margin was negative, even for locally advanced tumors or after neoadjuvant chemotherapy. RESULTS: Total NAC necrosis occurred in six cases (4.3%). Additionally, NAC was removed after histological exam of the retro-areolar tissue in 19 cases (16% of cancer patients). Among 93 cases whose tumor-to-NAC distance was recorded, NAC was removed in 11/31 cases (35%) if the distance was 1 cm, and in 8/62 cases (12.9%) if it was more than 1 cm (P = 0.01). NAC was removed more frequently in the first half of the study (17/69 vs. 8/69: P = 0.05). At a median follow-up of 26 months for the cancer patient group, there was only one local recurrence (outside the NAC). CONCLUSIONS: Our experience adds evidence that NSM is safe, if the retro-areolar resection margin is clear and maximal surgical clearance is performed.

Management of low colorectal anastomotic leakage using negative pressure therapy with Transanal Minimally Invasive Surgery (TAMIS): description of a case and review of the literature.

Anastomotic leakage (AL) represents a major post-operative complication after low anterior resection (LAR) for rectal cancer. It is associated with increased morbidity, mortality, length of hospital stay and risk of permanent stoma. Herein we report the case of a 75-year-old male patient submitted to a minimally invasive LAR who developed an AL on the fifth post-operative day. This complication has been successfully managed by placing a Vacuum-Assisted Therapy device (Endo-SPONGE®) with an unusual Transanal Minimally Invasive Surgery (TAMIS) approach; the size of the abscess cavity was measured and the Endo-SPONGE® was cut according to the size of the fistulous defect. This procedure has been performed at regular intervals, achieving quick reduction of anastomotic defect. After the discharge from our department, the patient was addressed to adjuvant treatment. TAMIS may represent an alternative to the endoscopic approach to position an Endo-SPONGE® whenever a conservative management of an AL is required.

Lobular breast cancer: same survival and local control compared with ductal cancer, but should both be treated the same way? analysis of an institutional database over a 10-year period.

BACKGROUND: Invasive lobular carcinoma (ILC) is believed to be more often multicentric and bilateral compared with invasive ductal cancer (IDC), leading clinicians to pursue a more aggressive local and contralateral approach. METHODS: Retrospective review of a consecutive cohort of breast cancer patients operated at one institution from January 2000 to January 2010 was performed. Median follow-up was 4 years. RESULTS: There were 171 ILC (14.5%) and 1,011 IDC patients in the study period. Median age (63 vs. 65 years) and tumor diameter (1.7 cm) were similar in the two groups. Diagnoses of ILC were more frequent in the second half of the study period (55/465 vs. 116/662, p<0.01). Multicentricity was reported in 108/1,011 (10.6%) IDC and in 31/171 (18.1%) ILC patients (p<0.01). A positive margin of resection at initial surgery was documented in 71/1,011 (7%) IDC and in 21/171 (12.3%) ILC patients (p<0.001). Although the rate of mastectomy decreased over time in both groups, this was more pronounced for ILC patients (p<0.001). Locoregional control, contralateral cancer, overall survival, disease-free survival, and survival according to diameter, nodal status, and type of surgical intervention did not differ between IDC and ILC. On multivariate analysis, stage of disease and hormone receptor status were associated with disease-free survival, but histology was not. CONCLUSIONS: Although ILC is more often multicentric, bilateral, and associated with a positive margin of resection, local control and survival are similar to IDC. ILC can be treated similarly to IDC with good results.

Extended surgical resection for nonfunctioning duodenal neuroendocrine tumor.

Duodenal neuroendocrine tumors (NETs) account for <3% of all gastrointestinal NET. Most lesions are small-sized and are located in the first or second duodenal part. Tumoral grading, evaluated by Ki67 index, strongly influences patient's outcome. Endoscopic resection is recommended for lesions measuring <2 cm, while pancreaticoduodenectomy should be the treatment of choice for large duodenal NET; Whipple procedure should be preferred in case of duodenal origin and contiguity with gastric antrum. Involvement of surrounding structures, as well as the presence of resectable liver metastases, does not contraindicate surgical resection. Herein we report a case of a 68-year-old male, presenting with an extensive mass of the descending pre-ampullary duodenal part, with involvement of the right colon and the presence of a pericholecystic single liver metastasis. In spite of such advanced disease, surgery on the patient was successful, with an uneventful postoperative outcome.

Hybrid sequential treatment of a giant serous mesenteric cyst: description of a case and review of the literature.

Mesenteric cysts are uncommon benign abdominal tumors that may extend from the root of the mesenteric layers of the gastrointestinal tract into the retroperitoneum or the peritoneal cavity; they are usually asymptomatic and often represent an occasional finding. Definitive diagnosis is confirmed by the surgical intraoperative view and by histopathological examination. Surgical excision of the cyst is the treatment of choice. We present a case of a female patient who presented with back pain and a palpable abdominal mass. Due to large size of the mass and its contiguity with midline, patient underwent an hybrid combined surgical technique, with a first open phase followed by a laparoscopic excision. Complete surgical removal of the cyst was successfully performed without bowel resection, intraoperative spillage of cystic content and without morbidity. Histopathology confirmed diagnosis of simple mesenteric cyst. We strongly recommend a combined approach whenever a large intraperitoneal benign cystic lesion has been diagnosed.

Small bowel adenocarcinoma: natural history of recurrence after surgical resection.

Small bowel adenocarcinomas (SBA) are a rare entity associated with a poor prognosis and an advanced stage of disease at diagnosis. Surgical resection is considered the gold standard of treatment for stage I-III, while stage IV disease approach is still debated. We present a case of a young woman affected by a duodenojejunal junction SBA treated with surgical resection and FOLFOX adjuvant chemotherapy. The patient later underwent a palliative duodenojejunal bypass for peritoneal carcinomatosis.

Functional results after mesorectal excision for rectal cancer: comparative study among surgical approaches.

BACKGROUND: We analyzed the evolution of genitourinary dysfunctions in patients undergoing surgical treatment for rectal cancer, and compared open surgery, laparoscopy, robotic and TaTME. METHODS: Functional outcomes were evaluate using standardized questionnaires, compiled at the start of treatment, after the end of Radiotherapy, at 1 and 6 months after surgery. RESULTS: In 72 patients 37.5% had low, 27.8% middle, and 34.7% high rectal cancers. Open technique was performed in 25% of cases, while 29.2% underwent laparoscopy, 20.8% TaTME and 25% robotic. We noted a deterioration in urogenital function: surgical technique can influence the result both in urinary and male sexual function but not ejaculation. Robotics and laparoscopy bring better outcomes than open surgery and TaTME. Female sexuality worsening seems not influenced by the technique. In general age, stage, complications, and anastomotic leakage appear to be predictive factors for functional dysfunctions. As reported in literature rectal cancer treatment leads to urogenital worsening: this seems to be progressive in male sexuality only, while female one and urinary function show a slight improvement in the first months, although a full recovery possibility is discussed. Is also reported how robotic and laparoscopy have a lower functional impact. TaTME has gained consensus thank to the excellent oncological and function outcomes, but in our study leads to worse results. CONCLUSIONS: Mini-invasive techniques guarantee the same oncological result than more invasive ones, but with better functional outcomes and tolerability; robotic surgery seems to be slight superior to laparoscopy, but with longer operative time.

Regret and Quality of Life After Mastectomy With or Without Reconstruction.

BACKGROUND: Mastectomy represents a deep burden for women with breast cancer. Very little is known about the psychological consequences over time and the quality of life (QoL) of women so treated, with or without breast reconstruction (BR). PATIENTS AND METHODS: A total of 709 patients underwent mastectomy with or without BR between 2002 and 2012 at one institution. Among 468 surviving patients, a 60-query QoL questionnaire on personal issues including some European Organization for the Research and Treatment of Cancer Quality of Life Questionnaire items was presented either by email, letter, or telephone interview. RESULTS: Of those questioned, 328 patients participated, whereas 140 (30%) declined the invitation or were unavailable. The median age was 63 years (range, 30-93 years). Stage I or II of disease was recorded in 73% of patients. Immediate BR was performed in 168 (51%) of 328 patients. Of the remaining patients, only 7 (4%) of 160 proceeded to delayed BR. Younger women had significantly worse Emotional Functioning and Social Functioning (SF) scores (P < .001), independently of tumor stage, and immediate BR improved that (P = .02). SF score was also worsened by chemotherapy (P = .03). Cognitive Functioning score was independent of age, BR, stage, or adjuvant therapies. Body Image and Sexual Functioning scores improved with BR (P < .03), and age was a strong co-variable (P < .001). On multivariate analysis, immediate BR was correlated with age and preoperative plastic surgery consultation. Some 68 (21%) of 328 patients regretted their decision or were disappointed with their choice regarding BR. CONCLUSIONS: Younger patients with breast cancer report a worse impact on their Emotional Functioning and SF scores after mastectomy, both of which are improved by BR. Reconstructing the breast at the time of mastectomy has a significant impact on Body Image and Sexual Functioning scores. A preoperative plastic surgeon consultation improves the rate of immediate BR, whereas delayed reconstruction is rarely adopted. Some 20% of patients are disappointed in or regret their decision regarding BR. We need to improve our management in consideration of these findings.

Clinical risk analysis with failure mode and effect analysis (FMEA) model in a dialysis unit.

BACKGROUND: The aim of clinical risk management is to improve the quality of care provided by health care organizations and to assure patients' safety. Failure mode and effect analysis (FMEA) is a tool employed for clinical risk reduction. We applied FMEA to chronic hemodialysis outpatients. METHODS: FMEA steps: (i) process study: we recorded phases and activities. (ii) Hazard analysis: we listed activity-related failure modes and their effects; described control measures; assigned severity, occurrence and detection scores for each failure mode and calculated the risk priority numbers (RPNs) by multiplying the 3 scores. Total RPN is calculated by adding single failure mode RPN. (iii) Planning: we performed a RPNs prioritization on a priority matrix taking into account the 3 scores, and we analyzed failure modes causes, made recommendations and planned new control measures. (iv) Monitoring: after failure mode elimination or reduction, we compared the resulting RPN with the previous one. RESULTS: Our failure modes with the highest RPN came from communication and organization problems. Two tools have been created to ameliorate information flow: "dialysis agenda" software and nursing datasheets. We scheduled nephrological examinations, and we changed both medical and nursing organization. Total RPN value decreased from 892 to 815 (8.6%) after reorganization. CONCLUSIONS: Employing FMEA, we worked on a few critical activities, and we reduced patients' clinical risk. A priority matrix also takes into account the weight of the control measures: we believe this evaluation is quick, because of simple priority selection, and that it decreases action times.

Recent advances in the surgical care of breast cancer patients.

A tremendous improvement in every aspect of breast cancer management has occurred in the last two decades. Surgeons, once solely interested in the extipartion of the primary tumor, are now faced with the need to incorporate a great deal of information, and to manage increasingly complex tasks. As a comprehensive assessment of all aspects of breast cancer care is beyond the scope of the present paper, the current review will point out some of these innovations, evidence some controversies, and stress the need for the surgeon to specialize in the various aspects of treatment and to be integrated into the multidisciplinary breast unit team.

Positive bone marrow biopsy is associated with a decreased disease-free survival in patients with operable breast cancer.

BACKGROUND: Bone marrow (BM) biopsy has been suggested as an independent prognostic factor in patients with breast cancer. METHODS: Patients operated for breast cancer from June 2000 to April 2008 were enrolled in this protocol after signing an informed consent. After primary surgery, BM aspirate from the iliac crest was obtained and 5-10 cc of blood collected. Since 2002 a peripheral blood (PB) sample was also obtained. Both carcinoembryonic antigen (CEA) and Mammaglobin-specific nested reverse-transcription polymerase chain reaction (RT-PCR) were used to examine BM and PB samples. Physicians and patients were blinded to results. RESULTS: Two hundred seventy-three patients underwent BM and/or PB test. The median age of the patients was 63 years (31-80 years), and the median tumor diameter was 1.5 cm (0.1-6 cm). BM aspirates were unsuccessful in nine patients, and RT-PCR was not technically feasible in 18 women, leaving 246 patients available for analysis of results and follow-up. Among them, 110 patients (45%) had either a BM or a PB test positive for CEA or Mammaglobin (Test+). At median follow-up of 60 months, 31 events (deaths or relapse) occurred (13%). Disease-free survival (DFS) was significantly lower in the Test+ group (BP and/or PB) (P<0.001). This effect was independent of nodal status. At 5 years, event-free survival for Node-/Test- patients was 46/49 (94%) and for Node+/Test+ patients was 21/33 (64%), while patients with only one status positive (Node-/Test+ or Node+/Test-) had an intermediate disease-free survival (35/43, 81%) (P=0.005). In a subgroup analysis, RT-PCR results for BM and Mammaglobin retained statistical significance on DFS (P<0.001), while those for PB and CEA did not. CONCLUSIONS: This study confirms that RT-PCR of the BM is an independent prognostic factor for disease-free survival of breast cancer patients, and may improve their staging, allowing better strategies for therapy and follow-up.

Application of failure mode and effect analysis in total laparoscopic hysterectomy in benign conditions.

BACKGROUND: Hysterectomy is the most common major gynecological operation in developed countries. The rate of intraoperative complications related to the laparoscopic approach during hysterectomy is a relevant issue. The failure mode and effect analysis (FMEA) method is a prospective approach, which tries to identify possible errors before they occur. METHODS: In this study we applied the FMEA method to laparoscopic approach to hysterectomy in order to reduce the theorized risk of intraoperative complications. We selected a team who analyzed and deconstructed the total laparoscopic hysterectomy (TLH) process recording on the FMEA worksheet phases and activities of the entire procedure. Each activity-related failure mode and their potential effects were developed. The team also described actions to eliminate or decrease the likelihood of mistakes. RESULTS: A numerical value reflecting the risk was assigned to each activity. Five activities were identified as high priority risk, and for each activity actions were then taken to mitigate the identified risk. After introduction of these actions, the risk scores for each activity were recalculated, and we obtained a total risk reduction of 55%. CONCLUSIONS: It is our opinion that the systematic implementation of the FMEA model can reduce the risk of human error during laparoscopic surgery, improving patient safety.

Sentinel lymph node biopsy in women with pT1a or "microinvasive" breast cancer.

The role of sentinel lymph node biopsy (SLNB) in pT1a and "microinvasive" breast cancer has not been extensively studied. We report our experience with SLNB in patients with "minimal" breast cancer to determine the incidence and type of SLN metastases, and to study the potential impact on their surgical or oncological management. Among some 3387 women operated upon for primary breast cancer who underwent sentinel lymph node biopsy at nine institutions participating in the Rome Breast Cancer Study Group, 251 were staged pT1a or pT1mic (7.4%). There were 13 cases of sentinel lymph node metastases identified in this group of patients (5.2%), seven macrometastases and six micrometastases. Additionally, ITC were diagnosed by immunohistochemistry in four cases (1.6%). The incidence of SLN metastases was 7/174 (4%) and 6/77 (7.8%) in patients with pT1a and pT1mic tumors, respectively (p=0.2). Age and histological grade were predictive factors for SLN metastases. Chemotherapy was seldom directed by axillary node status (8/38 patients). As the incidence of SLN metastases in these patients is very small, particularly in the pT1a group, the indications for even a minimally invasive procedure, such as sentinel lymph node biopsy, should be probably individualized.

DNA-damage induction by eight metal compounds in TK6 human lymphoblastoid cells: results obtained with the alkaline Comet assay.

Metal compounds are long-lived and can react with different macromolecules, producing a wide range of biological effects, including DNA damage. Since their reactivity is associated with their chemical structure, it is important to obtain information on more than one compound from the same metal. In this study, the DNA-damaging potential of two mercury compounds (mercury chloride and methyl mercury chloride), two nickel compounds (nickel chloride and potassium hexafluoronickelate), two palladium compounds (ammonium tetrachloropalladate and ammonium hexachloropalladate), and two tellurium compounds (sodium tellurite and sodium tellurate) was evaluated in human lymphoblastoid TK6 cells by use of the alkaline version of the Comet assay. As the use of computerized image-analysis systems to collect comet data has increased, the metric used for quantifying DNA damage was the Olive tail moment. Treatments lasted for 3h and the range of concentrations tested was different for each metal compound, depending on its toxicity. Both mercury agents produced DNA damage in TK6 cells, with mercury chloride producing considerably more DNA damage than methyl mercury chloride. Of the two nickel compounds, only nickel chloride (a Ni(II) compound) induced DNA breaks. Similarly, of the two palladium compounds, only the Pd(II) compound (ammonium tetrachloropalladate) was positive in the assay. Sodium tellurite was clearly positive, producing concentration-related increases in DNA damage, while sodium tellurate gave a negative response. In conclusion, the ability of inducing DNA damage by the selected metal compounds in human TK6 cells, when measured with the Comet assay, was dependent on the chemical form and, in general, compounds containing the metal in the lower valence state displayed the greater DNA-damaging ability.

Sentinel lymph node biopsy in breast cancer.

The clinical management of breast cancer has improved tremendously in the last 2 decades. Sentinel lymph node biopsy (SNB) allows conservation of the axillary lymph nodes in most patients who have breast cancer. Furthermore, it allows identification of occult nodal disease after step sectioning and more detailed staging. Although large breast tumors, multicentric disease, recurrent cancers, and use of neoadjuvant therapy were previously considered contraindications to SNB, a large body of evidence is accumulating to support its use in these cases. The prognostic significance of micrometastases and isolated tumor cells needs clarification in prospective, randomized trials.

Autophagy as an ultrastructural marker of heavy metal toxicity in human cord blood hematopoietic stem cells.

Stem cells are a key target of environmental toxicants, but little is known about their toxicological responses. We aimed at developing an in-vitro model based on adult human stem cells to identify biomarkers of heavy metal exposure. To this end we investigated the responses of human CD34+ hematopoietic progenitor cells to hexavalent chromium (Cr[VI]) and cadmium (Cd). Parallel cultures of CD34+ cells isolated from umbilical cord blood were exposed for 48 h to 0.1 microM and 10 microM Cr(VI) or Cd. Cultures treated with 10 microM Cr(VI) or Cd showed marked cell loss. Ultrastructural analysis of surviving cells revealed prominent autophagosomes/autophagolysosomes, which is diagnostic of autophagy, associated with mitochondrial damage and replication, dilatation of the rough endoplasmic reticulum and Golgi complex, cytoplasmic lipid droplets and chromatin condensation. Treated cells did not show the morphologic hallmarks of apoptosis. Treatment with 0.1 microM Cr(VI) or Cd did not result in cell loss, but at the ultrastructural level cells showed dilated endoplasmic reticulum and evidence of mitochondrial damage. We conclude that autophagy is implicated in the response of human hematopoietic stem cells to toxic concentrations of Cr(VI) and Cd. Autophagy, which mediates cell survival and death under stress, deserves further evaluation to be established as biomarker of metal exposure.