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

Subclinical hypothyroidism and cognitive dysfunction in the elderly.

While overt hypothyroidism is associated with reversible dementia in the elderly, the relationship of subclinical hypothyroidism with cognition remains a controversial issue. Our aim was to investigate the correlation between subclinical hypothyroidism and cognition in the elderly, with particular reference to long term memory and selective attention. We selected 337 outpatients (177 men and 160 women), mean age 74.3 years, excluding the subjects with thyroid dysfunction and those treated with drugs influencing thyroid function. The score of Mini Mental State Examination (MMSE) was significantly lower in the group of patients with subclinical hypothyroidism than in euthyroid subjects (p<0.03). It was observed that patients with subclinical hypothyroidism had a probability about 2 times greater (RR = 2.028, p<0.05) of developing cognitive impairment. Prose Memory Test (PMT) score resulted significantly lower in subjects with subclinical hypothyroidism (p<0.04). Considering the Matrix Test (MT) score, the performance was slightly reduced in subclinical hypothyroidism (NS). Furthermore, TSH was negatively correlated with MMSE (p<0.04), PMT (p<0.05) and MT score (NS). No correlation was found between FT4 and FT3 and MMSE, PMT and MT score. In the elderly, subclinical hypothyroidism is associated with cognitive impairment, and its impact on specific aspects of cognition (long term memory and selective attention) is less evident.

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.

Effects of amitriptyline and intra-oral device appliance on clinical and laser-evoked potentials features in chronic tension-type headache.

In the present study, we examined clinical and laser-evoked potentials (LEP) features in two groups of chronic tension-type headache (CTTH) patients treated with two different approaches: intra-oral appliance of prosthesis, aiming to reduce muscular tenderness, and 10 mg daily amitriptyline. Eighteen patients suffering from CTTH (IHS, 2004) participated in the study. We performed a basal evaluation of clinical features and LEPs in all patients (T0) vs. 12 age- and sex-matched controls; successively, patients were randomly assigned to a two-month treatment by amitriptyline or intra-oral device appliance. The later LEPs, especially the P2 component, were significantly increased in amplitude in the CTTH group. Both the intra-oral prosthesis and amitriptyline significantly reduced headache frequency. Total Tenderness Score was significantly reduced in the group treated by the prosthesis. The amplitude of P2 response elicited by stimulation of pericranial zones showed a reduction after amitriptyline treatment. The results of this study may confirm that pericranial tenderness is primarily a phenomenon initiating a self-perpetuating circuit, favoured by central sensitisation at the level of the cortical nociceptive areas devoted to the attentive and emotive compounds of pain. Both the interventions at the peripheral and central levels may interrupt this reverberating circuit, improving the outcome of headache.

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.

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.

Small aorta syndrome: hypothesis or reality?

A syndrome of peripheral obliterating arterial disease characterised by aortoiliac steno-occlusion is reported in the literature under the name small aorta syndrome, occurring in young women of small stature with relatively typical risk factors. Starting from an analysis of the studies reported in the literature and on the basis of our own results, we have attempted to ascertain whether small aorta syndrome represents an independent nosological entity. By analysing studies on the small aorta syndrome and in the light of a recent study made by our group on arterial diameters measured in cadavers, which highlights a significant correlation between aortic diameter and age, it can be affirmed that a pathology of this nature does not respond to absolute criteria for existence. Therefore, the aortoiliac diameter in women suspected of being affected by small aorta syndrome appears to be broadly in proportion to that expected in healthy women of the same age. Small aorta syndrome does not therefore appear to represent a separate nosological entity. It takes the form of a hypoplastic vascular disorder, which is probably congenital, correlated to other arterial districts in the same subject. However, it may encourage the onset of early symptoms in women of small stature.

Acute lower limb thrombosis caused by a congenital fibrous ring of the superficial femoral artery.

Segmentary isolated stenosis or obstructions of the superficial femoral artery in young people are rarely reported. In patients, most of them women, affected by chronic symptomatology of the lower limbs, the aetiology has been referred to fibromuscular dysplasia with unusual localization. We report a case of acute lower limb thrombosis in a young woman caused by a congenital fibrous ring of the superficial femoral artery and the treatment we performed in this situation including the complication that happened after the percutaneous transluminal angioplasty that we carried out in order to reduce the stenosis of the femoral superficial artery. Histological examination of the lesion demonstrated the nature of the fibrous ring caused by an embryological anomaly, followed by a secondary thrombosis in a woman not using oral contraceptives and without any alteration of the coagulation chain. Fibromuscular dysplasia of the femoral artery is commonly caused by previous thigh injuries, thromboembolic events with recanalization of the artery or arteritis, but in some cases appears to be the consequence of primitive intimal dysplasia. When a fibromuscular dysplasia is suspected, all authors agree on the necessity for a screening of the two preferential localizations of the disease: common carotid artery and renal artery, in the case reported the result was negative.

Pars plana vitrectomy for persistent, visually significant vitreous opacities.

PURPOSE: To evaluate the role of vitrectomy in patients with persistent, visually disabling vitreous opacities. METHODS: Six consecutive eyes of five men (age 58-66 years) with pseudophakia or aphakia and vitreous opacities resulting in visual symptoms for more than 1 year that underwent vitrectomy were retrospectively reviewed. Postoperative questionnaires regarding functional performance and quality-of-life issues were completed by the participants to assess subjective patient satisfaction. RESULTS: Postoperative Snellen visual acuity was improved or equal to preoperative acuity in all cases (8-44 month follow-up) and there were no surgical complications. All patients expressed high satisfaction with overall visual function. Analysis of the National Eye Institute Visual Function Questionnaire-39 indicated that general vision, near activities, distance activities, mental health, role difficulties, and peripheral vision were significantly improved (P < 0.05) following surgical intervention. CONCLUSIONS: Vitrectomy may be indicated in a select group of patients with visually disabling vitreous floaters, although objective assessment of visual dysfunction from vitreous floaters requires further evaluation.

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.

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.

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.

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.

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.

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.

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.

Syphilis exposure in patients with uveitis.

PURPOSE: The purpose of the study is to determine the frequency of syphilis exposure in patients with uveitis, identify patient characteristics associated with serologic fluorescent treponemal antibody assays (FTA-ABS) reactivity, and examine the clinical implications of syphilis exposure in patients with uveitis. METHODS: A retrospective review of the records of 552 consecutive patients examined in the referral uveitis clinic of an urban eye hospital between January 1989 and January 1994 was performed. RESULTS: Forty-four (8%) of 552 consecutive patients with uveitis had serologic evidence of syphilis exposure on the basis of a strongly reactive serum FTA-ABS. Syphilis was presumed to be the sole cause of uveitis in 24 patients (4.3%) over the 5-year period. The racial demographic profile of those patients with serologic evidence of syphilis was consistent with the reported distribution of syphilis cases, but there were relatively few identifiable risk factors for sexually transmitted disease (including only three patients who were positive with human immunodeficiency virus). The choice of antibiotic treatment of these patients was variable and sometimes suboptimal. CONCLUSIONS: This study implicates syphilis exposure as a more common etiology of uveitis than did previous reports, advocates routine serum FTA-ABS testing of patients with uveitis, and indicates a need for a more aggressive role of the ophthalmologist in antibiotic treatment of patients with uveitis and syphilis exposure.