Relationship between Middle Cerebral Artery Pulsatility Index and Delayed Neurocognitive Recovery in Patients undergoing Robot-Assisted Laparoscopic Prostatectomy.

A steep Trendelenburg (ST) position combined with pneumoperitoneum may cause alterations in cerebral blood flow with the possible occurrence of postoperative cognitive disorders. No studies have yet investigated if these alterations may be associated with the occurrence of postoperative cognitive disorders. The aim of the study was to evaluate the association between an increased middle cerebral artery pulsatility index (Pi), measured by transcranial doppler (TCD) 1 h after ST combined with pneumoperitoneum, and delayed neurocognitive recovery (dNCR) in 60 elderly patients undergoing robotic-assisted laparoscopic prostatectomy (RALP). Inclusion criteria were: ≥65 years; ASA class II-III; Mini-Mental Examination score > 23. Exclusion criteria were: neurological or psychiatric pathologies; any conditions that could interfere with test performance; severe hypertension or vascular diseases; alcohol or substance abuse; chronic pain; and an inability to understand Italian. dNCR was evaluated via neuropsychological test battery before and after surgery. Anesthesia protocol and monitoring were standardized. The middle cerebral artery Pi was measured by TCD, through the trans-temporal window and using a 2.5 MHz ultrasound probe at specific time points before and during surgery. In total, 20 patients experiencing dNCR showed a significantly higher Pi after 1 h from ST compared with patients without dNCR (1.10 (1.0-1.19 95% CI) vs. 0.87 (0.80-0.93 95% CI); p = 0.003). These results support a great vulnerability of the cerebral circulation to combined ST and pneumoperitoneum in patients who developed dNCR. TCD could be used as an intraoperative tool to prevent the occurrence of dNCR in patients undergoing RALP.

Lung-protective ventilation during Trendelenburg pneumoperitoneum surgery: A randomized clinical trial.

Study objective To assess the effects of a protective ventilation strategy during Trendelenburg pneumoperitoneum surgery on postoperative oxygenation. DESIGNS: Parallel-group, randomized trial. SETTING: Operating room of a university hospital, Italy. PATIENTS: Morbidly obese patients undergoing Trendelenburg pneumoperitoneum gynaecological surgery. INTERVENTIONS: Participants were randomized to standard (SV: tidal volume = 10 ml/kg of predicted body weight, PEEP = 5 cmH2O) or protective (PV: tidal volume = 6 ml/kg of predicted body weight, PEEP = 10 cmH2O, recruitment maneuvers) ventilation during anesthesia. MEASUREMENTS: Primary outcome was PaO2/FiO2 one hour after extubation. Secondary outcomes included day-1 PaO2/FiO2, day-2 respiratory function and intraoperative respiratory/lung mechanics, assessed through esophageal manometry, end-expiratory lung volume (EELV) measurement and pressure-volume curves. MAIN RESULTS: Sixty patients were analyzed (31 in SV group, 29 in PV group). Median [IqR] tidal volume was 350 ml [300-360] in PV group and 525 [500-575] in SV group. Median PaO2/FiO2 one hour after extubation was 280 mmHg [246-364] in PV group vs. 298 [250-343] in SV group (p = 0.64). Day-1 PaO2/FiO2, day-2 forced vital capacity, FEV-1 and Tiffenau Index were not different between groups (all p > 0.10). Intraoperatively, 59% of patients showed complete airway closure during pneumoperitoneum, without difference between groups: median airway opening pressure was 17 cmH2O. In PV group, airway and transpulmonary driving pressure were lower (12 ± 5 cmH2O vs. 17 ± 7, p < 0.001; 9 ± 4 vs. 13 ± 7, p < 0.001), PaCO2 and respiratory rate were higher (48 ± 8 mmHg vs. 42 ± 12, p < 0.001; 23 ± 5 breaths/min vs. 16 ± 4, p < 0.001). Intraoperative EELV was similar between PV and SV group (1193 ± 258 ml vs. 1207 ± 368, p = 0.80); ratio of tidal volume to EELV was lower in PV group (0.45 ± 0.12 vs. 0.32 ± 0.09, p < 0.001). CONCLUSIONS: In obese patients undergoing Trendelenburg pneumoperitoneum surgery, PV did not improve postoperative oxygenation nor day-2 respiratory function. PV was associated with intraoperative respiratory mechanics indicating less injurious ventilation. The high prevalence of complete airway closure may have affected study results. TRIAL REGISTRATION: Prospectively registered on http://clinicaltrials.govNCT03157479 on May 17th, 2017.

InTrathecal mORphine, traNsversus Abdominis Plane Block, and tramaDOl Infusion for Catheter-Related Bladder Discomfort in Patients Undergoing Robot-Assisted Laparoscopic Prostatectomy (TORNADO): A Pilot Prospective Controlled Study.

Catheter-related bladder discomfort (CRBD), affecting surgical patients requiring large catheters, is often intolerable. In this prospective controlled study, we compared the efficacy of three analgesic approaches in the management of CRBD. Here, 33 patients undergoing robot-assisted laparoscopic prostatectomy (RALP) were allocated to the following three groups: intrathecal morphine (IM), transversus abdominis plane block (TAP), and tramadol intravenous infusion (TI). The primary outcome was CRBD assessed at admission in the recovery room (RR) (T0), and 1 h (T1), 12 h (T2), and 24 h (T3) after surgery. The secondary outcomes included the following: Aldrete score; postoperative pain, measured with a numerical rate scale (NRS) at T0, T1, T2, and T3; postoperative opioid consumption; and flatus. The patients of the IM group showed significantly lower CRBD values over time compared to the patients of the TI group (p = 0.006). Similarly, NRS values decreased significantly over time in patients receiving IM compared to patients treated with TI (p < 0.0001). Postoperative nausea and vomiting did not differ among the three groups. Postoperative opioid consumption was significantly lower in the IM group compared to the other two groups. Most patients of the IM group (9 of 11) had flatus on the first postoperative day. In conclusion, IM may prevent CRBD and reduce pain perception and postoperative opioid consumption and expedite bowel function recovery.

Systemic chemotherapy and pressurized intraperitoneal aerosol chemotherapy (PIPAC): A bidirectional approach for gastric cancer peritoneal metastasis.

BACKGROUND: Few patients affected by gastric cancer peritoneal metastasis (GCPM) are offered locoregional treatment, despite several proof-of-efficacy trials. Pressurized intraperitoneal aerosol chemotherapy (PIPAC) has emerged in recent years as a promising tool to control peritoneal carcinomatosis. The combination of PIPAC with systemic chemotherapy may offer a greater clinical benefit than standard treatment alone. METHODS: A single-center cohort of 28 consecutive patients affected by GCPM was scheduled for bidirectional treatment, comprising PIPAC and systemic chemotherapy, from September 2017 to September 2019. Data recorded included safety, efficacy and survival outcomes. Ascite volumes, the Peritoneal Cancer Index (PCI) and pathological response through the Peritoneal Regression Grading Score (PRGS) were compared in those patients who underwent more than one PIPAC procedure. RESULTS: Forty-six PIPAC procedures were administered, with a mean of 1.7 PIPAC procedures per patient. The median time to resume systemic chemotherapy after PIPAC was 6 days (range 4-7). Concerning safety, two grade 3-4 CTCAE (Common Terminology Criteria for Adverse Events v4.0) toxicity events and one intraoperative complication were recorded. Thirteen patients repeated PIPAC. A pathological response was recorded in 61.5% of patients (one with complete and seven with partial regression). The median overall survival was 12.3 months in the overall population and 15.0 months in patients undergoing more than one PIPAC procedure. CONCLUSIONS: A bidirectional approach for GCPM was feasible and safe, as the PIPAC procedure integrates well with several systemic chemotherapy regimens. The pathological response demonstrated the antitumoral efficacy of PIPAC. The proposed bidirectional approach may be further investigated in the first-line treatment of metastatic gastric cancer.

Airway Closure during Surgical Pneumoperitoneum in Obese Patients.

BACKGROUND: Airway closure causes lack of communication between proximal airways and alveoli, making tidal inflation start only after a critical airway opening pressure is overcome. The authors conducted a matched cohort study to report the existence of this phenomenon among obese patients undergoing general anesthesia. METHODS: Within the procedures of a clinical trial during gynecological surgery, obese patients underwent respiratory/lung mechanics and lung volume assessment both before and after pneumoperitoneum, in the supine and Trendelenburg positions, respectively. Among patients included in this study, those exhibiting airway closure were compared to a control group of subjects enrolled in the same trial and matched in 1:1 ratio according to body mass index. RESULTS: Eleven of 50 patients (22%) showed airway closure after intubation, with a median (interquartile range) airway opening pressure of 9 cm H2O (6 to 12). With pneumoperitoneum, airway opening pressure increased up to 21 cm H2O (19 to 28) and end-expiratory lung volume remained unchanged (1,294 ml [1,154 to 1,363] vs. 1,160 ml [1,118 to 1,256], P = 0.155), because end-expiratory alveolar pressure increased consistently with airway opening pressure and counterbalanced pneumoperitoneum-induced increases in end-expiratory esophageal pressure (16 cm H2O [15 to 19] vs. 27 cm H2O [23 to 30], P = 0.005). Conversely, matched control subjects experienced a statistically significant greater reduction in end-expiratory lung volume due to pneumoperitoneum (1,113 ml [1,040 to 1,577] vs. 1,000 ml [821 to 1,061], P = 0.006). With airway closure, static/dynamic mechanics failed to measure actual lung/respiratory mechanics. When patients with airway closure underwent pressure-controlled ventilation, no tidal volume was inflated until inspiratory pressure overcame airway opening pressure. CONCLUSIONS: In obese patients, complete airway closure is frequent during anesthesia and is worsened by Trendelenburg pneumoperitoneum, which increases airway opening pressure and alveolar pressure: besides preventing alveolar derecruitment, this yields misinterpretation of respiratory mechanics and generates a pressure threshold to inflate the lung that can reach high values, spreading concerns on the safety of pressure-controlled modes in this setting.

The role of robotic aortic lymphadenectomy in gynecological cancer: surgical and oncological outcome in a single institution experience.

BACKGROUND AND OBJECTIVE: This study aims to investigate the surgical outcomes observed in robotic transperitoneal aortic lymphadenectomy (AL) in gynecological cancer patients. METHODS: Retrospective data were collected and analyzed on 71 patients undergoing robotic surgical procedures for gynecological cancers, including transperitoneal AL, between December 2014 and February 2018 at the Catholic University of the Sacred Heart, Rome, Italy. RESULTS: Median age of the sample population was 50 years (range, 26-76 years). The median operative time was 210 minutes (range, 75-480 minutes), the median estimated blood loss was 50 ml (range, 20-300 ml). The number of para-aortic nodes removed was 12 (range, 7-43). In the whole series, 13 patients (18.3%) had at least one metastatic node. Overall, 10 patients (14.1%) experienced any grade early postoperative complications. Three patients experienced more than one complication. Three intraoperative complications occurred with two cases of vascular injury. Conversion to laparotomy was necessary for one patient (1.4%). CONCLUSIONS: The present study shows the safety and adequacy of robotic transperitoneal AL as surgical staging step for gynecological cancers in terms of perioperative and postoperative outcomes.

Goal-directed hemodynamic management in patients undergoing primary debulking gynaecological surgery: A matched-controlled precision medicine study.

BACKGROUND: Usefulness of intraoperative goal-directed hemodynamic management (GDHM) for patients without comorbidities is debated. After clinical implementation of a pulse contour analysis-guided GDHM protocol, which foresees early vasopressor use for recruiting unstressed volume, we conducted a matched-controlled analysis to explore its impact on the amount of fluids intraoperatively administered to patients without comorbidities who underwent extended abdominal surgery for ovarian cancer. METHODS: After 1:1 matching accounting for body mass index, oncologic disease severity and intraoperative blood losses, 22 patients treated according to this GDHM protocol were compared to a control group of 22 patients who had been managed according to the clinical decision of attending physicians, taken without advanced monitoring. Results are displayed as median[interquartile range]. RESULTS: All analyzed patients underwent radical hysterectomy, bilateral adnexectomy, bowel resection, peritonectomy and extended pelvic/periaortic lymphadenectomy; median length of surgery was 517[480-605] min in patients receiving GDHM and 507[480-600] min in control group. Intraoperatively, patients undergoing GDHM received less fluids (crystalloids 2950[2700-3300] vs. 5150[4700-6000] mL, p < 0.001; colloids 100[50-200] vs. 750[500-1000] mL, p < 0.001) and showed a trend to more frequent vasopressor administration (32 vs 9%, p = 0.13). Greater intraoperative diuresis (540[480-620] mL vs. 450[400-500] mL, p = 0.007), lower blood lactates at surgery end (1.5[1.1-2] vs. 4.1[3.3-5] mmol/L, p < 0.001), shorter time to bowel function recovery (1 [1, 2] vs. 4 [3-5] days, p < 0.001) and hospital discharge (7 [6-8] vs 12 [9-16] days, p < 0.0001) were detected in patients receiving GDHM. CONCLUSIONS: In high-tumor load gynaecological patients without comorbidities who receive radical and prolonged surgery, intraoperative use of this novel GDHM protocol helped limit fluids administration with safety.

Heat accumulation period in the Mediterranean region: phenological response of the olive in different climate areas (Spain, Italy and Tunisia).

The main characteristics of the heat accumulation period and the possible existence of different types of biological response to the environment in different populations of olive through the Mediterranean region have been evaluated. Chilling curves to determine the start date of the heat accumulation period were constructed and evaluated. The results allow us to conclude that the northern olive populations have the greatest heat requirements for the development of their floral buds, and they need a period of time longer than olives in others areas to completely satisfy their biothermic requirements. The olive trees located in the warmest winter areas have a faster transition from endogenous to exogenous inhibition once the peak of chilling is met, and they show more rapid floral development. The lower heat requirements are due to better adaptation to warmer regions. Both the threshold temperature and the peak of flowering date are closely related to latitude. Different types of biological responses of olives to the environment were found. The adaptive capacity shown by the olive tree should be considered as a useful tool with which to study the effects of global climatic change on agro-ecosystems.

Climate change impact on the olive pollen season in Mediterranean areas of Italy: air quality in late spring from an allergenic point of view.

Recent studies have shown that there are many effects of climate change on aeroallergens, and thus on allergic diseases in humans. In the Mediterranean region, despite the importance of the olive tree for production, there is high allergenicity of olive pollen and related risks to human health. Aerobiological sampling techniques can be used to analyse the pollinosis phenomenon through determination of mean daily pollen concentrations per cubic metre of air. The present study was carried out from 1999 to 2008 in 16 olive-growing areas in Italy, to update the information on the pollinosis characteristics of Olea europaea in the study areas. The analysis of the average flowering season over the study period highlights a temporal scaling of pollen in the atmosphere that depends on the different climatic characteristics. This is mainly dependent on temperature, and in part, determined by latitude. Generally, the levels of O. europaea pollen in the atmosphere are higher from mid-April to the end of June, with the period of greatest risk to human health due to this olive pollen in this area currently limited primarily to the last 10 days of May. However, the pollen season can move, depending on the climate scenario considered, and data here can be used to determine potential time shifts in pollinosis that might cause more precocious asthma and allergy problems. The allergy season for this type of pollen might be significantly precocious in future decades (20-30 days earlier in the year), which will impact on the severity and duration of allergies attributable to olive tree pollen.

The role of environmental and socio-demographic indicators in the analysis of land use changes in a protected area of the Natura 2000 Network: the case study of Lake Trasimeno, Umbria, Central Italy.

This article sets out to analyse how and to what degree land use is linked to the physical characteristics of the territory itself, and the way in which changes in land use are determined by agricultural and socio-demographic dynamics. The study was conducted within the territorial boundaries of five municipalities surrounding Lake Trasimeno and refers to the periods 1977-2000 for land use and 1971-2001 for socio-demography data. The use of environmental, social, economic and agricultural indicators demonstrates how a mix of various indicators are useful for monitoring the changes which took place. It also shows the powerful influence that socio-demographic factors exert upon land use and landscape change.

Olive flowering trends in a large Mediterranean area (Italy and Spain).

The aim of this study was to investigate the main climatic and biological trends related to olive flowering in central-southern Italy compared to those in Andalusia, Spain. Results since 1982 were compared for the two long-series monitoring areas of Cordoba and Perugia, and since 1992-1999 for the short-series areas. The relationship between climatic trends and the biological response of the olive, a widespread culture in the Mediterranean basin, were investigated. An aerobiological method involving capturing pollen released into the atmosphere was utilised as a bioindicator of flowering phenology. The study results confirm the strong relationship between flowering periods and spring temperature trends for the olive. Temperature during March, April and May was the parameter most related to flowering date in the study areas, particularly in Italy. In some cases we found a significant correlation between flowering and past autumn temperatures, probably due to their effect on floral bud dormancy induction, but this phenomenon appeared to be of minor importance in the studied areas. The phenological trend results show the continuous advance of flowering dates to the late 1990s, followed by a relatively stationary time series related to a short-term temperature fluctuation in the Mediterranean area. This latter period probably represents a mesoscale event forced by a macroscale event-the North Atlantic Oscillation. The results reveal that the trend towards increased temperatures, and the consequent flowering advance of some species, indicated some years ago is nowadays not as clear as was expected and should be confirmed over the next few years in the Mediterranean areas under investigation.

Morphological and cytological development and starch accumulation in hermaphrodite and staminate flowers of olive (Olea europaea L.).

In olive (Olea europaea L.), the formation of functionally staminate flowers rather than fully functional hermaphrodites is one of the major factors limiting fruit set, as flowers with aborted pistils are incapable of producing fruit. Studies conducted on various angiosperm species have shown a correlation between flower abortion and starch content. Thus, it is important to know if starch content plays a role in regulating pistil development in olive and if so, what mechanism regulates starch distribution. Cyto-histological observations of staminate and hermaphrodite olive flowers show that pistil development in staminate flowers is interrupted after the differentiation of the megaspore mother cell. At that stage, starch grains were only detected in the ovary, style and stigma of the hermaphrodite flowers. No starch was observed in the pistils of the staminate flowers. This finding suggests a tight correlation between starch content and pistil development. The secondary origin of starch within the flower is indicated by low chlorophyll content in the gynoecium, undetectable Rubisco activity in the pistils of these two kinds of flowers and by the ultrastructure of the plastids observed by transmission electron microscope analysis. The plastids have few thylakoid membranes and grana and in the staminate flowers appeared very similar to proplastids. Considering differences in starch content between staminate and hermaphrodite flowers and the secondary origin of the starch, differences in pistil development in the staminate and hermaphrodite flowers could be related to differences in the sink strength of these two types of flowers.

Ozone and nitric oxide induce cGMP-dependent and -independent transcription of defence genes in tobacco.

Here, we analyse the temporal signatures of ozone (O3)-induced hydrogen peroxide(H2O2) and nitric oxide (NO) and the role of the second messenger guanosine3',5'-cyclic monophosphate (cGMP) in transcriptional changes of genes diagnostic for biotic and abiotic stress responses. Within 90 min O3 induced H2O2 and NO peaks and we demonstrate that NO donors cause rapid H2O2 accumulation in tobacco (Nicotiana tabacum) leaf. Ozone also causes highly significant, late (> 2 h) and sustained cGMP increases, suggesting that the second messenger may not be required in all early (< 2 h) responses to O3,but is essential and sufficient for the induction of some O3-dependent pathways.This hypothesis was tested resolving the time course of O3-induced transcript accumulation of alternative oxidase (AOX1a), glutathione peroxidase (GPX),aminocyclopropancarboxylic acid synthase (ACS2) that is critical for the synthesis of ethylene, phenylalanine ammonia lyase (PALa) and the pathogenesis-related protein PR1a.The data show that early O3 and NO caused transcriptional activation of the scavenger encoding proteins AOX1a, GPX and the induction of ethylene production through ACS2 are cGMP independent. By contrast, the early response of PALa and the late response of PR1a show critical dependence on cGMP.

NO release by nitric oxide donors in vitro and in planta.

Artificial nitric oxide (NO) donors are widely used as tools to study the role of NO in plants. However, reliable and reproducible characterisation of metabolic responses induced by different NO donors is complicated by the variability of their NO release characteristics. The latter are affected by different physical and biological factors including temperature and light. Here we critically evaluate NO release characteristics of the donors sodium nitroprusside (SNP), S-nitrosoglutathione (GSNO) and nitric oxide synthase (NOS), both in vitro and in planta (Nicotiana tabacum L. cv. BelW3) and assess their effects on NO dependent processes such as the transcriptional regulation of the mitochondrial alternative oxidase gene (AOX1a), accumulation of H(2)O(2) and induction of cell death. We demonstrate that, contrary to NOS and SNP, GSNO is not an efficient NO generator in leaf tissue. Furthermore, spectrophotometric measurement of NO with a haemoglobin assay, rather than diaminofluorescein (DAF-FM) based detection, is best suited for the quantification of tissue NO. In spite of the different NO release signatures by SNP and NOS in tissue, the NO dependent responses examined were similar, suggesting that there is a critical threshold for the NO response.

Bioclimatic requirements for olive flowering in two Mediterranean regions located at the same latitude (Andalucia, Spain and Sicily, Italy).

The Mediterranean Region is the major area devoted to olive tree crop, and therefore a study of olive flowering is of great interest for the European Community. On the other hand, olive pollen is one of the main causes of pollen allergy in the Mediterranean area. Olive flowering is affected by climatic factors such as temperature and photoperiod, which vary geographically in latitude and altitude. Temperature has been used to study those processes that lead to flowering in the olive tree. The aim of the present paper is firstly the comparison of the flowering full bloom dates in two Mediterranean areas, Sicily (Italy) and Cordoba (Spain), located in the same latitudinal band (37-38 degrees N) and to calculate the heat requirement until flowering by determination of different threshold temperatures and methods of heat accumulation. A delay of the full flowering dates in the Spanish compared with the Italian olive groves was observed. The most suitable threshold temperatures were carried out in a 7 degrees -15 degrees C range by considering the heat accumulation start on 1 January in each olive grove. In particular, some causes were indicated as responsible for the different threshold temperatures recorded in the 2 study areas: First, the different climatic conditions (continental and insular climate) secondly the different cultivars present in the olive groves.