Experimental Setup Employed in the Operating Room Based on Virtual and Mixed Reality: Analysis of Pros and Cons in Open Abdomen Surgery.

Currently, surgeons in operating rooms are forced to focus their attention both on the patient's body and on flat low-quality surgical monitors, in order to get all the information needed to successfully complete surgeries. The way the data are displayed leads to disturbances of the surgeon's visuals, which may affect his performances, besides the fact that other members of the surgical team do not have proper visual tools able to aid him. The idea underlying this paper is to exploit mixed reality to support surgeons during surgical procedures. In particular, the proposed experimental setup, employed in the operating room, is based on an architecture that put together the Microsoft HoloLens, a Digital Imaging and Communications in Medicine (DICOM) player and a mixed reality visualization tool (i.e., Spectator View) developed by using the Mixed Reality Toolkit in Unity with Windows 10 SDK. The suggested approach enables visual information on the patient's body as well as information on the results of medical screenings to be visualized on the surgeon's headsets. Additionally, the architecture enables any data and details to be shared by the team members or by external users during surgical operations. The paper analyses in detail advantages and drawbacks that the surgeons have found when they wore the Microsoft HoloLens headset during all the ten open abdomen surgeries conducted at the IRCCS Hospital "Giovanni Paolo II" in the city of Bari (Italy). A survey based on Likert scale demonstrates how the use of the suggested tools can increase the execution speed by allowing multitasking procedures, i.e., by checking medical images at high resolution without leaving the operating table and the patient. On the other hand, the survey also reveals an increase in the physical stress and reduced comfort due to the weight of the Microsoft HoloLens device, along with drawbacks due to the battery autonomy. Additionally, the survey seems to encourage the use of DICOM Viewer and Spectator View both for surgical education and for improving surgery outcomes. Note that the real use of the conceived platform in the operating room represents a remarkable feature of this paper, since most if not all the studies conducted so far in literature exploit mixed reality only in simulated environments and not in real operating rooms. In conclusion, the study clearly highlights that, despite the challenges required in the forthcoming years to improve the current technology, mixed reality represents a promising technique that will soon enter the operating rooms to support surgeons during surgical procedures in many hospitals across the world.

Meta-analysis on the utility of radiotherapy for the treatment of Ocular Melanoma

Introduction: Uveal melanoma is the most common intraocular tumor in the adult population. It can affect any part of the uveal tract: the iris, ciliary body, and choroid. Historically, enucleation has been the mainstay of treatment for primary melanoma. In the last decade, however, radiotherapy has acquired an increasingly important role and has now become our first-line modality. However, it is still widely debated what is the most effective radiotherapy technique for this tumor. Purpose to perform a literature review on the utility of radiotherapy for primary ocular melanoma and determine the most effective radiotherapy technique Materials and Methods: We included all systematic and narrative reviews on the topic, published between September 2007 and November 2017 on PubMed and SCOPUS. Two independent reviewers assessed the eligibility criteria for each article using the PRISMA checklist. The methodological quality of narrative and systematic reviews was evaluated with the INSA and AMSTAR checklists, respectively Results: Our study analyzed a total of 23 studies, including 18 narrative reviews and 5 systematic reviews. Radiotherapy with Brachytherapy, Proton Therapy, SRS/SRT with gamma knife and cyber knife, are the most common choices for the treatment of primary ocular melanoma. These techniques allow for excellent lesion spread control, eye, and vision conservation, and improve overall patients' quality of life. Among the narrative reviews, the highest INSA score was 5/7, the lowest 2/7, the mean was 3.83/7 and median was 4/7. Among the systematic reviews, the highest AMSTAR score was 9/12, the lowest 4/12, the mean 5.6/7 and median 4/7 Conclusion: The number of studies available on this topic is scarce. Among those published, the methodological quality is modest, as assessed with the INSA and AMSTAR checklists. As a result, we are not able to determine what the most effective radiotherapy technique is

Calcium modulation activates Epstein-Barr virus genome in latently infected cells.

In many viral infections the host cell carries the viral genome without producing viral particles, a phenomenon known as viral latency. The cellular mechanisms by which viral latency is maintained or viral replication is induced are not known. The modulation of intracellular calcium concentrations by calcium ionophores induced Epstein-Barr viral antigens in lymphoblastoid cell lines that carry the virus. When calcium ionophores were used in conjunction with direct activators of protein kinase C (12-O-tetradecanoyl phorbol-13-acetate and a synthetic diacylglycerol), a greater induction of viral antigens was observed than with either agent alone. Activation of protein kinase C may be required for the expression of the viral genome.

Remote image based retinopathy of prematurity diagnosis: a receiver operating characteristic analysis of accuracy.

BACKGROUND/AIMS: Telemedicine offers potential to improve the accessibility and quality of diagnosis of retinopathy of prematurity (ROP). The aim of this study was to measure accuracy of remote image based ROP diagnosis by three readers using receiver operating characteristic (ROC) analysis. METHODS: 64 hospitalised infants who met ROP examination criteria underwent two consecutive bedside procedures: dilated examination by an experienced paediatric ophthalmologist and digital retinal imaging with a commercially available wide angle camera. 410 images from 163 eyes were reviewed independently by three trained ophthalmologist readers, who classified each eye into one of four categories: no ROP, mild ROP, type 2 prethreshold ROP, or ROP requiring treatment. Sensitivity and specificity for detection of mild or worse ROP, type 2 prethreshold or worse ROP, and ROP requiring treatment were determined, compared to a reference standard of dilated ophthalmoscopy. ROC curves were generated by calculating values for each reader at three diagnostic cut-off levels: mild or worse ROP (that is, reader was asked whether image sets represented mild or worse ROP), type 2 prethreshold or worse ROP (that is, reader was asked whether image sets represented type 2 prethreshold or worse ROP), and ROP requiring treatment. RESULTS: Areas under ROC curves ranged from 0.747-0.896 for detection of mild or worse ROP, 0.905-0.946 for detection of type 2 prethreshold or worse ROP, and 0.941-0.968 for detection of ROP requiring treatment. CONCLUSIONS: Remote interpretation is highly accurate among multiple readers for the detection of ROP requiring treatment, but less so for detection of mild or worse ROP.

Evidence for three binding sites for C3 (hemolytically inactive), C3b and C3d on a CR2-positive Burkitt lymphoma-derived cell line (Raji).

The present investigation shows that C3 (hemolytic inactive) as well as C3b and C3d bind Raji, a CR2-positive Burkitt lymphoma-derived cell line. Pretreatment of the cells with OKB-7 inhibited the binding of C3, whereas pretreatment with HB-5 inhibited the binding of C3b. Furthermore, the cells coated either with OKB-7 or HB-5 bound high amounts of C3d. TPA-treated cells showed binding for C3b and weak binding for C3 and C3d. Taken together, the data suggest that Raji cells may express three binding sites for C3, C3b and C3d which can be differently modulated by anti-CR2 MoAbs and TPA.

Cross-linking of at least three binding sites mediates signal transduction in a CR2-positive Burkitt lymphoma derived cell line (Raji).

In this study we demonstrate that Raji cells, a CR2-positive Burkitt lymphoma-derived cell line, during cell growth, need the cross-linking of multiple OKB7 binding sites or C3d determinants to mediate signal transduction. The loss of one of these affects the cellular response. Moreover, OKB7, the anti-CR2 MoAb, recognizes C3d determinants on the cell surface and inhibits signal transduction induced by anti-C3d polyclonal antibody. Since Raji cells are always CR2 positive during cell growth, we suppose that at least another protein, along with CR2, may be involved in setting up a cell surface complex able to receive and transduce the signal triggered by OKB7. In our experimental system the protein that offers a third binding site to OKB7, may be represented by a 33 kDa protein bearing C3d determinants.

Activity of azelaic acid on cultures of lymphoma- and leukemia-derived cell lines, normal resting and stimulated lymphocytes and 3T3 fibroblasts.

Azelaic acid (C9- -dicarboxylic acid) is a competitive inhibitor of tyrosinase and some oxidoreductase in vitro, and in vivo has a beneficial effect on lentigo maligna and malignant melanoma. A definite cytotoxic effect in cultures of malignant melanocytes was also reported. In order to establish if the cytotoxic effect of the diacid is exerted equally in the absence of tyrosinase, lymphoma- and leukemia-derived cell lines were cultured for 72 hr with 10(-3) M, 10(-2) M and 5 X 10(-2) M C9 disodium salt. Normal resting lymphocytes, lymphocytes activated by phytohemoagglutinin, and mouse Balb/c 3T3 fibroblasts were also tested to study a possible effect of azelaic acid on DNA synthesis and cell duplication. At 10(-3) M C9 had no effect on the viability of all the cells tested; at 10(-2) M and 5 X 10(-2) M, C9 2Na had a 50-80% cytotoxic effect on lymphoma- and leukemia-derived cell lines, while at the same concentrations it was not toxic to normal lymphocytes, either resting or stimulated, or to 3T3 fibroblasts. The experiments on cellular incorporation of (1-9 14C) azelaic acid showed that the radiocarbon uptake was two to three times higher for lymphoma- and leukemia-derived cell lines than for lymphocytes, either resting or stimulated, or 3T3 fibroblasts. Biochemical analysis revealed that the diacid underwent beta-oxidation in all the cell cultures. Fractionated centrifugations of 3T3 fibroblasts cultured in the presence of radiolabelled azelaic acid (2 X 10(-4) M) plus cold C9 2Na (10(-2) M), showed that the radioactivity was mainly concentrated in the cytoplasm. The results, being similar to those obtained by adding azelaic acid to cultures of melanoma cells, suggest that the cytotoxic effect of azelaic acid may be due to interference with mitochondrial oxido-reductase enzymes, rather than with tyrosinase. The difference in reaction between lymphoma- and leukemia-derived cell lines and normal or stimulated lymphocytes, and 3T3 fibroblasts, could be explained on the basis of a different degree of permeability of the cell membrane, and/or to a possible different sensitivity of reaction of mitochondrial functions. A similar argument could be used to explain the absence of an effect of dicarboxylic acids upon normal as compared with hyperactive or malignant melanocytes in vivo.

Epstein-Barr virus serology in nasopharyngeal carcinomas and other head and neck neoplasms in Italy.

This paper reports the results of the EBV-specific antibody response in 17 Italian nasopharyngeal carcinoma (NPC) patients, 15 other head and neck tumor patients and 15 normal controls. Nucleic acid hybridization has been performed on the biopsy tissue from 4 of the NPC patients, and EBV-DNA was present in two undifferentiated (WHO 3) tumors, and absent in two samples of the keratinizing (WHO 1) type. EBV serology appears to be specifically related to NPC, more evidently for VCA-IgA and EA-IgG antibodies, and useful as an aid in diagnosis of NPC. However, in order to assess a prognostic value of the above markers, a greater number of patients followed for a longer period of time (at least 5 years) is needed, and is currently being pursued.

The expanding clinical spectrum of unilateral acute idiopathic maculopathy.

OBJECTIVE: To report on new features of unilateral acute idiopathic maculopathy (UAIM). PATIENTS: We have evaluated an additional 17 patients with UAIM since 1991. This is a report of new features of the maculopathy noted in seven patients from this new series. RESULTS: New clinical findings in UAIM included eccentric macular lesions, subretinal exudation, papillitis, and bilaterality. The occurrence of UAIM in association with pregnancy and human immunodeficiency virus was also observed. CONCLUSIONS: The description of these newly reported features broadens our understanding of the nature of UAIM. With recognition of the expanded clinical spectrum of this disorder, a more confident approach to diagnosis and management may be achieved.

Rifabutin-associated uveitis in an immunosuppressed pediatric patient without acquired immunodeficiency syndrome.

PURPOSE: To describe a case of bilateral, symptomatic rifabutin-associated uveitis with hypopyon and vitreal opacities in an immunosuppressed pediatric patient without acquired immunodeficiency syndrome (AIDS). METHOD: Case report. An 8-year-old boy presented with bilateral uveitis 24 months after a bilateral lung transplant. RESULTS: Our patient, whose medications included rifabutin, clarithromycin, and immunosuppressive agents, responded to discontinuation of the rifabutin and initiation of intensive topical corticosteroid therapy with complete resolution of the uveitis. CONCLUSION: Rifabutin-associated uveitis may occur in a non-AIDS pediatric patient.

Neovascular complications associated with rubeosis iridis and peripheral retinal detachment after retinal detachment surgery.

PURPOSE: To report clinical features and surgical management of neovascular complications associated with rubeosis iridis and peripheral retinal detachment after retinal detachment surgery in nondiabetic patients. METHODS: Seven consecutive eyes of seven nondiabetic patients who developed neovascular complications associated with rubeosis iridis and peripheral retinal detachment after scleral buckling and vitrectomy procedures were retrospectively reviewed. None of the eyes had clinical evidence of anterior segment ischemia or retinal vascular disease, but each eye developed rubeosis iridis and neovascular complications. RESULTS: Of the seven eyes with rubeosis iridis and peripheral retinal detachment, six developed recurrent or progressive vitreous hemorrhage, and three developed progressive neovascular glaucoma. Four eyes underwent a revision procedure to repair the peripheral retinal detachment, and anterior proliferative vitreoretinopathy was found in each of these cases. Rubeosis iridis regressed in all three eyes in which surgery resulted in complete reattachment of the retina. In one eye with persistent peripheral retinal detachment and in the three remaining eyes that did not undergo revision surgery, rubeosis iridis persisted and was associated with long-term neovascular complications. Final corrected visual acuity was 20/70 to 20/400 in three eyes with total retinal reattachment and no light perception to hand motions in four eyes with persistent peripheral retinal detachment and rubeosis iridis. CONCLUSION: Visually significant neovascular complications may occur in eyes that develop rubeosis iridis associated with peripheral retinal detachment after retinal detachment surgery in nondiabetic patients. Successful repair of the peripheral retinal detachment may induce regression of rubeosis iridis, reduce associated complications, and improve the long-term prognosis of these eyes.

Intravitreal triamcinolone for the treatment of refractory diabetic macular oedema with hard exudates: an optical coherence tomography study.

AIM: To investigate the use of intravitreal triamcinolone acetonide (IVTA) for the treatment of diabetic macular oedema (DMO) unresponsive to previous laser photocoagulation. METHOD: A retrospective, interventional, non-comparative case series. There were 30 eyes of 22 consecutive patients with refractory DMO. An intravitreal injection of triamcinolone acetonide at the dose of 4 mg in 0.1 ml was administered. Best corrected visual acuity was measured at each examination. In addition the central macular thickness was quantitatively measured by optical coherence tomography (OCT) examination at each visit. The amount of hard exudates deposition in the macula was subjectively evaluated using colour fundus photographs. RESULTS: 30 eyes of 22 patients completed 6 months or more of follow up and were included in the study. Mean (SD) visual acuity improved from 0.17 (0.12) at baseline to 0.34 (0.18), 0.36 (0.16), and 0.31 (0.17) at the 1, 3, and 6 month follow up respectively. Mean (SD) OCT macular thickness decreased from 476 (98.32) microm at baseline to 277.46 (96.77) microm, 255.33 (95.73) microm, and 331.25 (146.76) microm at the 1, 3, and 6 month follow up period respectively. 18 and seven eyes completed 12 months and 18 months of follow up, respectively. Mean (SD) visual acuity was 0.36 (0.15) and 0.35 (0.16) at the 12 and 18 month follow up period respectively. 12 eyes received two, seven eyes received three, and two eyes received four IVTA injections. The mean (SD) interval between the first and second IVTA injection was 5.7 (2.67) months and between the second and third was 5.7 (3.25) months. Hard exudates were present in the macula at baseline in all eyes. Progressive reduction in the number and size of the hard exudates was noted after IVTA in all cases. Intraocular pressure was raised above 21 mm Hg in 12 (40%) of 30 eyes. Two eyes developed posterior subcapsular cataract and two developed vitreous haemorrhage. CONCLUSIONS: IVTA is a promising treatment for patients with DMO refractory to laser treatment. IVTA is effective in improving vision, reducing macular thickness, and inducing reabsorption of hard exudates. Further investigation is warranted to assess the safety of IVTA for the treatment of DMO.

Soluble cellular adhesion molecules in proliferative vitreoretinopathy and proliferative diabetic retinopathy.

PURPOSE: To measure vitreous levels of soluble intercellular adhesion molecule-1 (sICAM-1) and soluble vascular cellular adhesion molecule-1 (sVCAM-1) in the eyes of patients with retinal detachment (RD) due to proliferative diabetic retinopathy (PDR) or proliferative vitreoretinopathy (PVR) and to determine whether the levels of these mediators correlated with clinical parameters of disease. METHODS: Undiluted vitreous specimens were collected from 50 eyes of 48 patients undergoing vitrectomy for traction RD due to PDR (21 specimens) and recurrent RD due to PVR (19 specimens). Control vitreous specimens were obtained from patients undergoing macular hole repair (10 specimens). The levels of sICAM-1 and sVCAM-1 were measured in each sample by specific enzyme-linked immunoadsorbent assays. RESULTS: Vitreous levels of sICAM-1 were significantly increased in vitreous specimens from both PVR (median +/- SD; 12.0 +/- 76.3 ng/ml; P < 0.01) and PDR (8.4 +/- 24.0 ng/ml; P < 0.01) when compared to vitreous from eyes with macular holes (0. 3 +/- 4.2 ng/ml). Vitreous levels of sVCAM-1 were significantly increased in both PVR (36.5 +/- 255.2 ng/ml; P < 0.001) and PDR (26. 2 +/- 93.5 ng/ml; P < 0.01) when compared to control vitreous (17.7 +/- 7.8 ng/ml). The vitreous levels of sICAM-1 were higher in cases of PDR which developed recurrent proliferative disease (P < 0.01) and recurrent RD (P = 0.01), whereas the levels of sICAM-1 in PVR and sVCAM-1 in PDR and PVR did not significantly correlate with these clinical parameters. CONCLUSIONS: Soluble forms of ICAM-1 and VCAM-1 are increased in the vitreous cavity of patients with RD due to PDR or PVR, reflecting the inflammatory nature of these conditions and suggesting a possible role for these mediators in the pathogenesis of proliferative retinal disease. The vitreous levels of these sCAMs at the time of surgery may serve as a marker of inflammation, but their specific levels do not predict the likelihood of recurrent proliferation or surgical anatomic success in most cases of PVR and PDR.

Binding of (3H)R5020 to progesterone receptor and serum contaminants in human endometrium.

The binding of [3H]R5020 to cytosol from human endometrium was utilized to evaluate the concentration of progesterone receptor by means of agar gel electrophoresis, using D-norgestrel as cold competitor. It was observed that radioligand binds predominantly to the receptor, and that serum contaminants such as albumin and corticosteroid-binding globulin do not interfere in the assay procedure.

Levels of estrogen and progesterone receptor in human endometrium during the menstrual cycle.

Receptors for estrogens and progesterone have been assayed in 24 samples of normal human endometria at different phases of the menstrual cycle. In the proliferative endometrium the concentration of estrogen binding sites was significantly higher than that of progesterone receptor while, in the secretive endometrium, the concentration of estrogen receptor was low, compared to that of progesterone receptor. The highest concentration of both receptors was observed during the periovulatory period. From the correlation observed between estrogen and progesterone receptors and the levels of the respective steroids in the plasma, it is suggested that the levels of plasma estradiol or its own tissue receptor determine the synthesis of progesterone receptors in the periovulatory period.

PIP: Estrogen and progesterone receptors were assayed in 24 samples of normal human endometrium at different phases of the menstrual cycle to determine any changes in receptor concentration associated with menstruation or cyclic body alterations. Estrogen binding sites were found to be significantly higher than progesterone receptor sites in proliferative-phase endometrium. In secretive phase, the concentration of estrogen receptor was low compared with that of the progesterone receptor. The periovulatory period provided the highest values of receptors of both steroids. The correlation between estrogen and progesterone receptors reported, and the levels of the respective steroids in plasma, leads to the suggestion that the levels of plasma estradiol or estradiol tissue receptor determine the synthesis of progesterne receptors during the periovulatory period.

Superior mesenteric and renal artery embolism during PTA and re-stenting of infrarenal abdominal aorta. Report of a case and review of the literature.

The authors report a case of acute superior mesenteric and right renal artery embolism that occurred during an interventional radiological procedure on the abdominal aorta of a young diabetic woman. The onset of a severe abdominal pain during the procedure evoked the clinical suspicion of intestinal ischemia related to the dislodgement of atheroembolic material into the mesenteric artery; the event was correctly diagnosed, but the surgical therapy was delayed by many hours because of the fact that the patient was in a peripheral hospital of the region and had to be transferred to our institution. Fortunately in spite of the considerable delay, the operation was fully successful, probably because of the favourable location of the embolus, which allowed collateral splanchnic circulation to maintain a good metabolic balance.

Aneurysms of the hypogastric artery following surgery of the abdominal aorta. A report of two cases and review of the literature.

Isolated aneurysms of the hypogastric artery are very rare and account for between 0.04% and 0.4% of all intra-abdominal aneurysms. In 85% of cases they are monolateral and are present in association with an aneurysm of the infrarenal abdominal aorta and of the common and external iliac arteries, they make up part of a poly-aneurysmal disease. Unless the patient is an extremely poor condition, surgical treatment is generally indicated for aneurysms greater than 3 cm; close monitoring of those with smaller aneurysms is recommended. Two patients presented with isolated aneurysm of an internal iliac artery which had developed several years after aortoiliac surgery. The one received surgical treatment; the other, who was in poor general conditions and at high risk for surgery, underwent endovascular embolization. Both procedures were successful, with a current follow-up between 15 and 18 months. Endovascular embolization, as performed in the 2(nd) patient, provided an alternative to the surgical procedure. After injection in the aneurysmal sac of the Gianturco spirals, a covered stent was placed in the iliac axis to exclude the inflow of the hypogastric artery. According to our experience of 2 patients, the one treated surgically and the other submitted to a less invasive endovascular procedure, we can state that both methods are practicable. The final choice lies with the vascular surgeon, after weighing the multiple factors that each case involves.

Vagal paraganglioma. Report of a case surgically treated and review of the literature.

The authors report the observation of one case of vagal paraganglioma occurred in a young woman. The tumor manifested itself as a left sub-mandibular tumescence; the very first diagnostic approach was achieved through echography, which showed a mass behind the internal carotid artery and compressing the internal jugular vein. The following examinations, represented by neck CT, NMR, angiography and fine needle aspiration initially directed towards the suspicion of chemodectoma. Only at operation, the anatomical situation of the tumor, which encapsulated the vagus nerve and the subsequent results of the hystological examination revealed the correct diagnosis of vagal paraganglioma.

Surgical repair of abdominal aortic or iliac aneurysms associated with treatment of urological neoplasias.

Safe surgical repair of an abdominal aortic aneurysm in conjunction both with nephrectomy (for monolateral or bilateral kidney carcinoma) or with radical cystectomy and orthotopic urinary diversion (for bladder carcinoma) can be performed. These combined surgical procedures can be performed without morbidity due to excessive blood loss, increased operative time or vascular graft infection. A nephrectomy associated with abdominal aortic aneurysm repair can be performed both by a median single surgical approach or by a double one during the same intervention. The authors describe and discuss 4 case reports and the techniques required for these combined procedures.

Prospects of prostanoid therapy. Preliminary results.

BACKGROUND: To evaluate the efficacy of treatment with prostaglandins (Iloprost and Alprostadil) in patients with peripheral arterial disease in whom a surgical act or a redo operation is not proposable and to set the role of these drugs in the therapy of arterial diseases. METHODS: We analyzed the results of 96 treatments in patients with peripheral arterial diseases of different etiology, treated in the Day Hospital in the Division of Vascular Surgery from the 1/1/1993 to the 30/6/1998. The efficacy of the treatment has been evaluated on the basis of the clinical picture (healing or reduction of ulcers, reduction of rest-pain, improvement of the ability to walk). RESULTS: We had positive results in 60% of the patients who completed the treatment, a good outcome for patients with particularly severe arterial disease. Interruptions induced by the occurrence of uncontrolled side-effects are a few (6.25%). Better results have been found in a special category of disease (arterial diseases not associated with diabetes, not very advanced clinical picture, female gender). Iloprost proved to be superior to Alprostadil. CONCLUSIONS: Prostaglandins today represent an effective therapeutic solution to be considered. Further studies need to be done to find a category of patients who can have the best benefit from this kind of drug.