Surgical technique for laparoscopic removal of bulky para-aortic nodes without repositioning surgical field during laparoscopic debulking for advanced ovarian cancer.

Background: In the last years, laparoscopy has been progressively introduced in the management of advanced- stage ovarian cancer (AOC) not only to evaluate tumour resectability, but also to perform primary or interval minimally invasive debulking surgery in selected patients. During laparoscopic debulking for AOC, the need to change the surgical field to treat disease in the upper abdomen can be a time-consuming procedure. Objective: To demonstrate feasibility, safety and effectiveness of laparoscopic approach to remove bulky para- aortic nodes in AOC with a 30-degree 3D-endoscope without repositioning the laparoscopic surgical field. Materials and Methods: A 51-year-old woman was referred to our centre due to AOC with bulky para-aortic nodes (7 cm polylobate mass at CT-scan). The narrated surgical video article demonstrates the surgical steps for laparoscopic removal of bulky para-aortic nodes with a 30-degree 3D-endoscope, maintaining the vision from the upper abdomen perpendicular to the main axis of the vascular structures for the whole duration of the surgery ("top-bottom" view), without repositioning surgical field. Main Outcomes measures: Complete laparoscopic excision of disease was achieved. Results: Post-operative course was uneventful. Patient recovered from surgery and was able to start adjuvant chemotherapy within 30 days from surgery. Conclusions: Repositioning the surgical field to perform para-aortic dissection can be a time-consuming procedure during laparoscopic debulking for ovarian cancer. Laparoscopic removal of bulky para-aortic nodes with a 30-degree 3D-endoscope and "top-bottom view" is feasible, safe and effective.

Diagnostic accuracy and economic impact of three work-up strategies identifying risk groups in endometrial cancer, fully incorporating sentinel lymph node algorithm.

BACKGROUND: According to the European Society for Medical Oncology/ European Society of Gynaecological Oncology/European Society for Radiotherapy and Oncology (ESMO/ESGO/ESTRO) Consensus Conference, the role of preoperative risk groups (RGs) in endometrial cancer (EC) is to direct surgical nodal staging. We compared diagnostic accuracy and economic impact of three work-up strategies to identify RGs. METHODS: A retrospective multicentre study including patients with early-stage EC. The three different work-up strategies were as follows:-Mondovì Hospital: transvaginal ultrasonography, pelvic magnetic resonance imaging (MRI); frozen section examination of the uterus in case of imaging discordance. High-risk patients underwent abdominal computed tomography.-Gemelli Hospital: transvaginal ultrasonography, MRI, One-Step Nucleic Acid Amplification (OSNA) of sentinel lymph node (SLN); frozen section examination of the uterus in case of imaging discordance.-Negrar Hospital: positron emission tomography (PET), frozen section examination of the uterus and of SLN. For statistical purposes patients were assigned, preoperatively and postoperatively, to two groups: group A (high-risk) and group B (not high-risk). RESULTS: Three hundred eighty-five patients were included (93 Mondovì, 215 Gemelli, 77 Negrar). Endometrial biopsy errors led to 47.3% misclassifications. Test accuracy of Mondovì, Gemelli and Negrar strategies was 0.83 (95%CI 0.734-0.901), 0.95 (95%CI 0.909-0.975) and 0.94 (95%CI 0.866-0.985), respectively. Preoperative work-up mean cost per patient in group A was €514.5 at Mondovì, €868.5 at Gemelli, and €1212.8 at Negrar hospital (p-value < 0.001), while in group B was €378.8 at Mondovì, €941.2 at Gemelli, and €1848.4 at Negrar hospital (p-value < 0.001). CONCLUSIONS: In our study, work-up strategies with more relevant economic impact showed a better diagnostic accuracy. Upcoming guidelines should specify recommendations about the gold standard work-up strategy, including the role of SLN.

Retinal transduction profiles by high-capacity viral vectors.

Retinal gene therapy with adeno-associated viral (AAV) vectors is safe and effective in humans. However, the limited cargo capacity of AAV prevents their use for therapy of those inherited retinopathies (IRs) due to mutations in large (>5 kb) genes. Viral vectors derived from adenovirus (Ad), lentivirus (LV) and herpes virus (HV) can package large DNA sequences, but do not target efficiently retinal photoreceptors (PRs) where the majority of genes responsible for IRs are expressed. Here, we have evaluated the mouse retinal transduction profiles of vectors derived from 16 different Ad serotypes, 7 LV pseudotypes and from a bovine HV. Most of the vectors tested transduced efficiently the retinal pigment epithelium. We found that LV-GP64 tends to transduce more PRs than the canonical LV-VSVG, albeit this was restricted to a narrow region. We observed more extensive PR transduction with HdAd1, 2 and 5/F35++ than with LV, although none of them outperformed the canonical HdAd5 or matched the extension of PR transduction achieved with AAV2/8.

Efficient gene delivery to the cone-enriched pig retina by dual AAV vectors.

Gene therapy with adeno-associated viral (AAV) vectors is limited by AAV cargo capacity that prevents their application to the inherited retinal diseases (IRDs), such as Stargardt disease (STGD) or Usher syndrome type IB (USH1B), which are due to mutations in genes larger than 5 kb. Trans-splicing or hybrid dual AAV vectors have been successfully exploited to reconstitute large gene expression in the mouse retina. Here, we tested them in the large cone-enriched pig retina that closely mimics the human retina. We found that dual AAV trans-splicing and hybrid vectors transduce pig photoreceptors, the major cell targets for treatment of IRDs, to levels that were about two- to threefold lower than those obtained with a single AAV vector of normal size. This efficiency is significantly higher than that in mice, and is potentially due to the high levels of dual AAV co-transduction we observe in pigs. We also show that subretinal delivery in pigs of dual AAV trans-splicing and hybrid vectors successfully reconstitute, albeit at variable levels, the expression of the large genes ABCA4 and MYO7A mutated in STGD and USH1B, respectively. Our data support the potential of dual AAV vectors for large gene reconstitution in the cone-enriched pig retina that is a relevant preclinical model.

Risk of non-Hodgkin's lymphoma and residential exposure to air pollution in an industrial area in northern Italy: a case-control study.

The aim of this study was to evaluate the risk of non-Hodgkin's lymphoma (NHL) in an adult population residing in an area in northern Italy exposed to industrial air pollution from a big power plant, a coke oven, 2 chemical factories, and some minor plants. The design was a population-based case-control study and information about residential history and the main risk factors for NHL was obtained interviewing 133 cases and 279 controls using a structured questionnaire. Three exposure categories (heavy, moderate, and slight) were defined on the basis of the location of the major facilities with respect to the subject residence. NHL risk was not associated either with location or duration of residence in the heavily polluted area. However, the unavoidable limitations of this study prevent us from drawing definitive conclusions.

[The 2013 Seville Consensus Document on alternatives to allogenic blood transfusion. An update on the Seville Document]. / 2013. Documento Sevilla de Consenso sobre Alternativas a la Transfusión de Sangre Alogénica. Actualización del Documento Sevilla.

Since allogeneic blood transfusion (ABT) is not harmless, multiple alternatives to ABT (AABT) have emerged, though there is great variability in their indications and appropriate use. This variability results from the interaction of a number of factors, including the specialty of the physician, knowledge and preferences, the degree of anemia, transfusion policy, and AABT availability. Since AABTs are not harmless and may not meet cost-effectiveness criteria, such variability is unacceptable. The Spanish Societies of Anesthesiology (SEDAR), Hematology and Hemotherapy (SEHH), Hospital Pharmacy (SEFH), Critical Care Medicine (SEMICYUC), Thrombosis and Hemostasis (SETH) and Blood Transfusion (SETS) have developed a Consensus Document for the proper use of AABTs. A panel of experts convened by these 6 Societies have conducted a systematic review of the medical literature and have developed the 2013 Seville Consensus Document on Alternatives to Allogeneic Blood Transfusion, which only considers those AABT aimed at decreasing the transfusion of packed red cells. AABTs are defined as any pharmacological or non-pharmacological measure aimed at decreasing the transfusion of red blood cell concentrates, while preserving patient safety. For each AABT, the main question formulated, positively or negatively, is: « Does this particular AABT reduce the transfusion rate or not?¼ All the recommendations on the use of AABTs were formulated according to the Grades of Recommendation Assessment, Development and Evaluation (GRADE) methodology.

[The 2013 Seville Consensus Document on alternatives to allogenic blood transfusion. An update on the Seville Document]. / 2013. Documento Sevilla de Consenso sobre Alternativas a la Transfusión de Sangre Alogénica. Actualización del Documento Sevilla.

Since allogeneic blood transfusion (ABT) is not harmless, multiple alternatives to ABT (AABT) have emerged, though there is great variability in their indications and appropriate use. This variability results from the interaction of a number of factors, including the specialty of the physician, knowledge and preferences, the degree of anemia, transfusion policy, and AABT availability. Since AABTs are not harmless and may not meet cost-effectiveness criteria, such variability is unacceptable. The Spanish Societies of Anesthesiology (SEDAR), Hematology and Hemotherapy (SEHH), Hospital Pharmacy (SEFH), Critical Care Medicine (SEMICYUC), Thrombosis and Hemostasis (SETH) and Blood Transfusion (SETS) have developed a Consensus Document for the proper use of AABTs. A panel of experts convened by these 6 Societies have conducted a systematic review of the medical literature and have developed the 2013 Seville Consensus Document on Alternatives to Allogeneic Blood Transfusion, which only considers those AABT aimed at decreasing the transfusion of packed red cells. AABTs are defined as any pharmacological or non-pharmacological measure aimed at decreasing the transfusion of red blood cell concentrates, while preserving patient safety. For each AABT, the main question formulated, positively or negatively, is: "Does this particular AABT reduce the transfusion rate or not?" All the recommendations on the use of AABTs were formulated according to the Grades of Recommendation Assessment, Development and Evaluation (GRADE) methodology.

The gluteal fold fascio-cutaneous flap for reconstruction after radical excision of primary vulvar cancers.

OBJECTIVES: Reconstructive surgery plays an important role in cosmetic and functional results of major excisional surgery performed as a treatment for invasive vulvar cancer. Traditional techniques -- gracilis myocutaneous o rectus abdominis flaps -- have several limits. We describe here a different surgical approach that we have used since 1998 in an effort to obtain better results in vulvar reconstruction. METHODS: From January 1998 to June 2007, thirty three patients who underwent excisional radical surgery for invasive vulvar tumors, were treated with vulvar reconstruction using the gluteal fold fascio-cutaneous local flap. Flaps were designed along the gluteal fold in adequate length and size. They were oval or triangular in shape depending on the defect they were supposed to cover. The flaps -- which always included the fascial layer -- were raised up to identify a perforator branch of the internal pudendal artery and then harvested as an island flap to achieve better mobility. RESULTS: We had no major complications, only two patients presented marginal necrosis and eight patients experienced significant seromas. Advantages over the alternative techniques included reduced dimensions of scars, absence of flap liponecrosis, no need of modifying patient's position on the surgical table, and very limited blood loss. CONCLUSIONS: We conclude that gluteal fold flap offers excellent cosmetic and functional results with a low complication rate. Therefore we support the gluteal fold flap as a valid surgical option whenever reconstruction is needed after radical excision of vulvar neoplasms.

Prostate cancer in Italy before and during the 'PSA era': survival trend and prognostic determinants.

The aim of the study was to investigate the variations in prostate cancer prognosis during a period of major diagnostic change, such as the introduction of the prostate-specific antigen (PSA) test. Data were provided by 14 Italian cancer registries (CRs). Incidence and follow-up information was collected for patients diagnosed from 1978 to 1994. Relative survival was computed taking into account incidence period, age, tumour stage and grade at diagnosis. A multivariate analysis was carried out to evaluate the independent simultaneous effect on survival of some prognostic determinants. A large geographical variability was observed: in 1993-1994 Italian survival rates ranged from 76% to 52%, with a north-south gradient. A striking prognostic improvement (up to +27 percentage points) between the late 1980s and the early 1990s occurred in almost all CRs, particularly with regard to younger patients. Multivariate analysis showed a strong influence of incidence period on survival, also after correction by tumour stage. The slowdown of metastatic cancers suggests that the survival improvement could be due both to the introduction of an effective opportunistic screening and to a quantitative change in the application of clinical treatment, even if the effect of the lead-time bias phenomenon has to be taken into account.

Relative survival in elderly European cancer patients: evidence for health care inequalities. The EUROCARE Working Group.

This paper examines the survival of elderly European cancer patients, on the basis of the EUROCARE II results. Using Hakulinen and Abeywickrama's method, the relative survival rates at 1 and 5 years from diagnosis were computed by sex and quinquennial age group for the elderly (65-99 years old). Age-standardised rates for the whole elderly group were also calculated. The analysis covered: all malignancies combined, stomach, colon, rectum, pancreas, lung, melanoma, bladder, kidney and non-Hodgkin's lymphomas for both sexes; prostate and larynx for men; and breast, ovary, uterine cervix and corpus for women. Data relating to 701521 cancer patients came from 44 population-based cancer registries in 16 European countries. The relative risks of death (RRs) of older patients (65-99) with respect to middle-aged adults (55-64) were computed by sex and country, for all malignancies only. The most prominent finding was the decrease in survival rates with increasing age for almost all cancer sites. The age-curves of survival rates at 1 year from diagnosis usually had a steeper slope than those at 5 years, particularly in women. This suggests that disease stage at presentation plays an important role in determining survival, particularly in the elderly. Thus, all factors which influence timing diagnosis in the elderly and cause a delay in tumour detection, such as psycho-social factors, access to care, co-morbidities and other clinical features affecting performance status, are very important predictors of prognosis. Very large geographic variations in relative survival rates were found among European countries. The ordering of countries was similar for almost all cancer sites. Western and Central Europe generally had the best survival, followed by Northern countries and by Southern ones (the latter with survival around the European average: 39% in men, 47% in women). The UK had survival rates unexpectedly lower than rates of nearest nations, often below the European average. Eastern countries usually had the lowest rates. In the very elderly patients (over 85 years), an apparent rise in the survival rates was noted, particularly at 5 years from diagnosis and in men. This 'too good' survival is unlikely to be due to real better prognosis, but rather to a selection bias. Countries with this unusual rise are also those registering a high proportion of DCO cases (those cases retrieved by death certificate only) (around 10%) or DCO unavailable. Another 'natural' bias has also to be taken into account: in elderly patients with a very bad prognosis, who are often suffering from other serious co-morbid conditions, cancer diagnoses could be under-notified and not reach at all the data sources commonly monitored by cancer registries.

Characterisation of a cDNA encoding gamma-glutamylcysteine synthetase in Medicago truncatula.

A gamma-ECS cDNA from Medicago truncatula was isolated using an Arabidopsis thaliana cDNA as probe. The analysis of the amino acid sequence deduced from this cDNA revealed 80% identity with the gamma-ECS from A. thaliana and Brassica juncea and suggested a plastidial localisation for the enzyme. Gamma-ECS activity and high level of GSH were detected in the gamma-ECS-deficient E. coli strain expressing a fusion protein containing the M. truncatula gamma-ECS protein. Southern blot analysis suggests that gamma-ECS is encoded by a small multigenic family in M. truncatula and shows that homologous genes are present in two other leguminous plants, Medicago sativa and Pisum sativum. Gamma-ECS gene expression was analysed by Northern blot in seedlings, plantlets and mature plants.

Absence of synproportionation between oxy and ferryl leghemoglobin. off.

The synproportionation reaction between ferryl leghemoglobin and oxyleghemoglobin does not occur, at least under conditions where this process could be clearly demonstrated with myoglobin and hemoglobin. In contrast, a cross synproportionation can occur between oxyleghemoglobin and ferryl myoglobin or between ferryl leghemoglobin and oxymyoglobin. The non-exposure, at the surface of the leghemoglobin molecule, of the nearest tyrosine residue to the heme group could explain this behaviour. Thus leghemoglobin per se does not appear to be able to act as an antioxidant in removing H2O2 by synproportionation. However, in the presence of ascorbate and/or glutathione which can reduce ferryl leghemoglobin, this hemoprotein could act as an H2O2-removing antioxidant, in a process similar to that described for myoglobin. This could also explain why, despite the absence of synproportionation, ferryl leghemoglobin is not detected in nodule extracts.

Uptake of iron by symbiosomes and bacteroids from soybean nodules.

Symbiosomes and bacteroids isolated from soybean nodules are able to take up the iron-citrate complex. The kinetics are characterized by initial high rates of iron internalization, and ATPase inhibitors significantly lower the uptake. This is consistent with an energy-dependent process on both membranes, although the involvement of a simultaneous facilitated diffusion can not be completely ruled out. Citrate alone is poorly absorbed by symbiosomes; this uptake is greatly enhanced by addition of iron. Iron-citrate was found both in the nodule cytosol and in the bacteroids. These results provide the first experimental evidence for the existence, at least in young nodules, of an important iron trafficking system from the plant host cell to the microsymbiont, through the peribacteroid membrane.

The reactivity of thiol compounds with different redox states of leghaemoglobin: evidence for competing reduction and addition pathways.

Reaction of the ferric form of leghaemoglobin with hydrogen peroxide has been previously shown to give rise to an iron(IV)-oxo (ferryl) species, and a protein radical. Inclusion of a variety of thiol compounds in this system is shown to lead to rapid loss of the iron(IV)-oxo species and the regeneration of the ferric form and/or the formation of novel sulf species formed by nucleophilic attack of the thiol group on the tetrapyrrole ring. The reduction process also results in the generation of thiyl radicals which have been detected by EPR spin trapping. The relative yields of the products produced by these two competing pathways is shown to be highly dependent on the steric and electronic characteristics of the thiol compound. Evidence has also been obtained, in the absence of hydrogen peroxide, for both the reduction of the ferric form of the protein to the oxy-ferrous form, via a process believed to involve the deoxy-ferrous species, and the formation of sulf-leghaemoglobin species. Both of these pathways are again highly dependent on the structure of the thiol, and the former also results in the generation of thiyl radicals. Inclusion of the sulfide anion in place of the organic thiols results in somewhat different behaviour, in that this species appears to both reduce the iron centre and form a complex with the iron atom. This ligation process is reversible, and the sulfide complex is shown to react readily with both strong oxidizing and reducing agents. The behaviour of this protein, which is structurally related to myoglobin, is dramatically different to that demonstrated by myoglobin; this is rationalized in terms of the much more open heme site of leghaemoglobins, and the presence of an electronic gate which hinders access by negatively charged molecules. The contribution of these processes to the maintenance of the leghaemoglobin proteins in the oxy-ferrous form in vivo and the binding of oxygen is discussed.

Glutathione-dependent conversion of ferryl leghaemoglobin into the ferric form: a potential protective process in soybean (Glycine max) root nodules.

GSH is able to reduce soybean (Glycine max) ferryl-leghaemoglobin [Lb(IV)] formed by the reaction of ferric or ferrous Lb with H2O2; in both cases, ferric Lb is obtained and GSH is incapable of reducing ferric Lb to ferrous Lb. Furthermore, the addition of GSH before H2O2 to ferric Lb prevents side reactions which lead to a species whose spectrum differs markedly from that of Lb(IV). These reactions are likely to occur in vivo, as high GSH concentrations have been detected in soybean nodules. The GSH-dependent reduction of Lb(IV) is associated with the oxidation of GSH to GSSG. E.s.r. experiments show that the glutathione thiyl radical (GS.) is formed during this reaction. In the case of ferric Lb, both ferryl Lb and a globin-derived radical previously described appear to be involved in the formation of GS.. Both of these processes may be protective and can help account for the exclusive presence of ferrous (oxygenated or not) Lb in functioning nodules.

Oxidation of dimethylsulphoxide to formaldehyde by oxyhaemoglobin and oxyleghaemoglobin in the presence of hydrogen peroxide is not mediated by "free" hydroxyl radicals.

In the presence of excess hydrogen peroxide, human oxyhaemoglobin and oxyleghaemoglobin from soybean root nodules cause oxidation of dimethylsulphoxide to formaldehyde. This reaction is inhibited by thiourea but not by phenylalanine, HEPES, mannitol or arginine. It is concluded that dimethylsulphoxide oxidation is not mediated by "free" hydroxyl radicals, consistent with previous conclusions that intact haemoglobin, leghaemoglobin or myoglobin molecules do not react with H2O2 to form hydroxyl radicals detectable outside the protein.

Formation of hydroxyl radicals from hydrogen peroxide in the presence of iron. Is haemoglobin a biological Fenton reagent?

The ability of oxyhaemoglobin and methaemoglobin to generate hydroxyl radicals (OH.) from H2O2 has been investigated using deoxyribose and phenylalanine as 'detector molecules' for OH.. An excess of H2O2 degrades methaemoglobin, releasing iron ions that react with H2O2 to form a species that appears to be OH.. Oxyhaemoglobin reacts with low concentrations of H2O2 to form a 'reactive species' that degrades deoxyribose but does not hydroxylate phenylalanine. This 'reactive species' is less amenable to scavenging by certain scavengers (salicylate, phenylalanine, arginine) than is OH., but it appears more reactive than OH. is to others (Hepes, urea). The ability of haemoglobin to generate not only this 'reactive species', but also OH. in the presence of H2O2 may account for the damaging effects of free haemoglobin in the brain, the eye, and at sites of inflammation.