TLR7-dependent eosinophil degranulation links psoriatic skin inflammation to small intestinal inflammatory changes in mice.

Recent evidence of gut microbiota dysbiosis in the context of psoriasis and the increased cooccurrence of inflammatory bowel disease and psoriasis suggest a close relationship between skin and gut immune responses. Using a mouse model of psoriasis induced by the Toll-like receptor (TLR) 7 ligand imiquimod, we found that psoriatic dermatitis was accompanied by inflammatory changes in the small intestine associated with eosinophil degranulation, which impaired intestinal barrier integrity. Inflammatory responses in the skin and small intestine were increased in mice prone to eosinophil degranulation. Caco-2 human intestinal epithelial cells were treated with media containing eosinophil granule proteins and exhibited signs of inflammation and damage. Imiquimod-induced skin and intestinal changes were attenuated in eosinophil-deficient mice, and this attenuation was counteracted by the transfer of eosinophils. Imiquimod levels and the distribution of eosinophils were positively correlated in the intestine. TLR7-deficient mice did not exhibit intestinal eosinophil degranulation but did exhibit attenuated inflammation in the skin and small intestine following imiquimod administration. These results suggest that TLR7-dependent bidirectional skin-to-gut communication occurs in psoriatic inflammation and that inflammatory changes in the intestine can accelerate psoriasis.

An Ectopic Parathyroid Adenoma of the Retropharynx in a Patient with Primary Hyperparathyroidism and Papillary Thyroid Cancer-A Rare Case.

The frequency of concurrent thyroid cancer in patients with primary hyperparathyroidism (pHPT) varies. While the pathological association between thyroid and parathyroid disorders is frequently noted, the co-occurrence of parathyroid adenoma and papillary thyroid cancer is exceptionally rare. Furthermore, an ectopic parathyroid adenoma in the retropharyngeal space is exceedingly rare. Therefore, anatomical variations through the utilization of relevant diagnostic tools play a crucial role in guiding decisions pertaining to clinical manifestations, diagnostic methods, surgical interventions, and operative strategies for parathyroid tumors. We present a case of a 51-year-old female patient with papillary thyroid carcinoma in the right thyroid lobe and an ectopic parathyroid adenoma in the retropharyngeal space confirmed through surgical intervention. The elevated preoperative levels of serum calcium and parathyroid hormone, along with low serum phosphate, returned to normal ranges after surgery. This case sheds light on the unusual occurrence of an ectopic parathyroid adenoma in the retropharyngeal region within a thyroid cancer patient, providing valuable insights into the realm of thyroid malignancies.

Applying the heteroskedastic ordered probit model on injury severity for improved age and gender estimation.

OBJECTIVE: Driver characteristics have been linked to the frequency and severity of car crashes. Among these, age and gender have been shown to impact both the possibility and severity of a crash. Previous studies have used standard ordered probit (OP) models to analyze crash data, and some research has suggested heteroskedastic ordered probit (HETOP) could provide improved model fit. The objective of this paper is to evaluate potential improvements of the heteroskedastic ordered probit (HETOP) model compared to the standard ordered probit (OP) model in crash analysis, by examining the effect of gender across age on injury severity among drivers. This paper hypothesizes that the HETOP model can provide a better fit to crash data, by allowing heteroskedasticity in the distribution of injury severity across driver age and gender. METHODS: Data for 20,222 crashes were analyzed for North Carolina from 2016 to 2018, which represents the state with the highest number of fatalities per 100 million vehicle miles traveled amongst available crash data from the Highway Safety Information System. RESULTS: Darker lighting conditions, severe road surface conditions, and less severe weather were associated with increased injury severity. For driver demographics, the probability of severe injuries increased with age and for male drivers. Moreover, the variance of severity increased with age disproportionately within and across genders, and the HETOP was able to account for this. CONCLUSIONS: The results of the two applied approaches revealed that HETOP model outperformed the standard OP model when measuring the effects of age and gender together in injury severity analysis, due to the heteroskedasticity in injury severity within gender and age. The HETOP statistical method presented in this paper can be more broadly applied across other contexts and combinations of independent variables for improved model prediction and accuracy of causal variables in traffic safety.

Quenching of a no-insulation high-temperature superconducting magnet.

We report details on the quenching incident of an 18 T high-temperature superconducting (HTS) magnet, which occurred in December 2020. It has been received that the no-insulation (NI) design of an HTS magnet is relatively safe in quenching. However, the NI design could not completely prevent the magnet from quenching and damaging the associated system. Due to significant vibrations and fast energy dissipation during quenching, the magnet and the detector components are seriously damaged. The manufacturer inspected the magnet after the incident and repaired it in the spring of 2021. The magnet showed stable and consistent performance after the repair. It is evident that the NI-HTS magnet still requires quench protection circuits to secure the magnet and associated system.

Extended Axion Dark Matter Search Using the CAPP18T Haloscope.

We report an extended search for the axion dark matter using the CAPP18T haloscope. The CAPP18T experiment adopts innovative technologies of a high-temperature superconducting magnet and a Josephson parametric converter. The CAPP18T detector was reconstructed after an unexpected incident of the high-temperature superconducting magnet quenching. The system reconstruction includes rebuilding the magnet, improving the impedance matching in the microwave chain, and mechanically readjusting the tuning rod to the cavity for improved thermal contact. The total system noise temperature is ∼0.6 K. The coupling between the cavity and the strong antenna is maintained at ß≃2 to enhance the axion search scanning speed. The scan frequency range is from 4.8077 to 4.8181 GHz. No significant indication of the axion dark matter signature is observed. The results set the best upper bound of the axion-photon-photon coupling (g_{aγγ}) in the mass ranges of 19.883 to 19.926 µeV at ∼0.7×|g_{aγγ}^{KSVZ}| or ∼1.9×|g_{aγγ}^{DFSZ}| with 90% confidence level. The results demonstrate that a reliable search of the high-mass dark matter axions can be achieved beyond the benchmark models using the technology adopted in CAPP18T.

A preliminary study about the potential risks of the UV-weathered microplastic: The proteome-level changes in the brain in response to polystyrene derived weathered microplastics.

The growing use of plastic materials has resulted in a constant increase in the risk associated with microplastics (MPs). Ultra-violet (UV) light and wind break down modify MPs in the environment into smaller particles known as weathered MPs (WMPs) and these processes increase the risk of MP toxicity. The neurotoxicity of weathered polystyrene-MPs remains unclear. Therefore, it is important to understand the risks posed by WMPs. We evaluated the chemical changes of WMPs generated under laboratory-synchronized environmentally mimetic conditions and compared them with virgin MPs (VMPs). We found that WMP had a rough surface, slight yellow color, reduced molecular weight, and structural alteration compared with those of VMP. Next, 2 µg of ∼100 µm in size of WMP and VMP were orally administered once a day for one week to C57BL/6 male mice. Proteomic analysis revealed that the WMP group had significantly increased activation of immune and neurodegeneration-related pathways compared with that of the VMP group. Consistently, in in vitro experiments, the human brain-derived microglial cell line (HMC-3) also exhibited a more severe inflammatory response to WMP than to VMP. These results show that WMP is a more profound inflammatory factor than VMP. In summary, our findings demonstrate the toxicity of WMPs and provide theoretical insights into their potential risks to biological systems and even humans in the ecosystem.

Safety and Tolerability of Weekly Genexol-PM, a Cremophor-Free Polymeric Micelle Formulation of Paclitaxel, with Carboplatin in Gynecologic Cancer: A Phase I Study.

PURPOSE: This phase I study was conducted to determine the maximum tolerated dose and the recommended phase II dose of weekly administered Genexol-PM combined with carboplatin in patients with gynecologic cancer. MATERIALS AND METHODS: This open-label, phase I, dose-escalation study of weekly Genexol-PM included 18 patients with gynecologic cancer, who were equally divided into three cohorts of dose levels. Cohort 1 received 100 mg/m2 Genexol-PM and 5 area under the curve (AUC) carboplatin, cohort 2 received 120 mg/m2 Genexol-PM and 5 AUC carboplatin, and cohort 3 received 120 mg/m2 Genexol-PM and 6 AUC carboplatin. The safety and efficacy of each dose were analyzed for each cohort. RESULTS: Of the 18 patients, 11 patients were newly diagnosed and seven patients were recurrent cases. No dose-limiting toxicity was observed. The maximum tolerated dose was not defined, but a dose up to 120 mg/m2 of Genexol-PM in combination with AUC 5-6 of carboplatin could be recommended for a phase II study. In this intention-to-treat population, five patients dropped out of the study (carboplatin-related hypersensitivity, n=1; refusal of consent, n=4). Most patients (88.9%) with adverse events recovered without sequelae, and no treatment-related death occurred. The overall response rate of weekly Genexol-PM in combination with carboplatin was 72.2%. CONCLUSION: Weekly administered Genexol-PM with carboplatin demonstrated an acceptable safety profile in gynecologic cancer pati-ents. The recommended phase II dose of weekly Genexol-PM is up to 120 mg/m2 when combined with carboplatin.

CD8α+ dendritic cells potentiate antitumor and immune activities against murine ovarian cancers.

Dendritic cell (DC)-based immunotherapies have been shown to be a potential treatment option for various cancers; however, the exact strategies in ovarian cancer remain unknown. Here, we report the effectiveness of mouse CD8α+ DCs derived from bone marrow hematopoietic stem cells (BM-HSCs), equivalent to human CD141+ DCs, which have proven to be a highly superior subset. Mono-DCs from monocytes and stem-DCs from HSCs were characterized by CD11c+ CD80+ CD86+ and CD8α+ Clec9a+ expression, respectively. Despite a lower dose compared with Mono-DCs, mice treated with pulsed Stem-DCs showed a reduced amount of ascitic fluid and lower body weights compared with those of vehicle-treated mice. These mice treated with pulsed stem-DCs appeared to have fewer tumor implants, which were usually confined in the epithelium of tumor-invaded organs. All mice treated with DCs showed longer survival than the vehicle group, especially in the medium/high dose pulsed Stem-DC treatment groups. Moreover, the stem-DC-treated group demonstrated a low proportion of myeloid-derived suppressor cells and regulatory T cells, high interleukin-12 and interferon-γ levels, and accumulation of several tumor-infiltrating lymphocytes. Together, these results indicate that mouse CD8α+ DCs derived from BM-HSCs decrease tumor progression and enhance antitumor immune responses against murine ovarian cancer, suggesting that better DC vaccines can be used as an effective immunotherapy in EOC treatment. Further studies are necessary to develop potent DC vaccines using human CD141+ DCs.

A proposed methodology for trip recovery training without a specialized treadmill.

Falls are the leading cause of accidental injuries among adults aged 65 years and older. Perturbation-based balance training is a novel exercise-based fall prevention intervention that has shown promise in reducing falls. Trip recovery training is a form of perturbation-based balance training that targets trip-induced falls. Trip recovery training typically requires the use of a specialized treadmill, the cost of which may present a barrier for use in some settings. The goal of this paper is to present a methodology for trip recovery training that does not require a specialized treadmill. A trial is planned in the near future to evaluate its effectiveness. If effective, non-treadmill trip recovery training could provide a lower cost method of perturbation-based balance training, and facilitate greater implementation outside of the research environment.

Wearing a back-support exoskeleton impairs single-step balance recovery performance following a forward loss of balance - An exploratory study.

Back-support exoskeletons (BSEs) are a promising ergonomic intervention for reducing physical demands on the low-back, but little is known regarding whether BSE use alters balance recovery following external perturbations. Hence, we investigated the effects of wearing a BSE on single-step balance recovery following a forward loss of balance. Sixteen (8 M, 8F) young, healthy participants were released from static forward-leaning postures and attempted to recover their balance with a single step while wearing a BSE (backXTM) with three different levels of support torque (i.e., no torque, low, and high) and in a control condition (no exoskeleton). Lean angle was increased until they failed in two consecutive trials to recover their balance with a single step. The maximum lean angle from which individuals could successfully recover was not significantly altered when wearing the BSE. However, wearing the BSE under all torque conditions increased reaction times. The BSE also impeded hip flexion (i.e., decrease in both peak hip flexion angle and angular velocity), resulting in decreased peak knee flexion velocity, knee range of motion, and step length. Measures of the margin of stability decreased significantly in the high-torque BSE condition. Overall, our results suggest that use of a BSE that provides external hip extension torque impairs balance recovery responses. Future work extending kinetic analyses to recovery responses, as well as a study of recovery when responding to slips and trips while walking, would offer a more complete picture of how a BSE may impact balance recovery following a loss of balance.

Correlation between endoscopic resection outcomes and endosonographic findings in gastric tumors with muscularis propria origin.

Endoscopic resection is an effective treatment for subepithelial tumors arising from the muscularis propria layer of the stomach. However, the invasion pattern revealed by the pathological examination of tumor specimens is often not consistent with the findings of preprocedural endoscopic ultrasounds (EUS). We compared the real growing patterns of tumors, as evaluated on histopathological examination, with their EUS images, and analyzed the outcomes of endoscopic resections in relation to the EUS findings. From January 2006 to June 2015, 32 patients underwent endoscopic resection for gastric tumors originating from the muscularis propria at our hospital. We divided the patients into 3 groups according to the location of the tumor as diagnosed using pre procedural EUS: submucosa (group I, n = 5), muscularis propria (group II, n = 14), and tumors extending into the outer cavity (group III, n = 13). Histopathological examination revealed 15 patients with gastrointestinal stromal tumors (GISTs), 14 with leiomyomas, and 3 with schwannomas. Accuracy of EUS in evaluating tumor invasion was 56%. Some tumors in groups I and II was removed by endoscopic submucosal dissection only. Muscular dissection was needed in 10 patients (71%) in group II and 9 patients (69%) in group III. Four patients (31%) in group III were found to have subserosal tumors. The complete resection rate was 88% (23 patients) among patients who underwent endoscopic submucosal dissection and endoscopic muscular dissection, and 67% (4 patients) among patients who underwent endoscopic subserosal dissection (ESSD). The tumor was completely removed in 12 patients (86%) in group II and 10 patients (77%) in group III. EUS accurately predicts the layer of the subepithelial tumor in the stomach; however, the pattern of invasion of surrounding structures is difficult to evaluate using EUS.

Fall impacts from standing show equivalence between experts in stage combat landing strategy and naïve participants after training.

BACKGROUND: Slips, trips, and falls are the second leading cause of non-fatal injuries in workplace in the United States. A stage combat landing strategy is used in the theatre arts to reduce the risk of fall-induced injury, and may be a viable approach among some working populations. OBJECTIVE: The goal of this study was to compare fall impact characteristics between experts in stage combat landing strategy and naïve participants after four training sessions of stage combat landing strategy training. METHODS: Forward and backward falls from standing were induced by releasing participants from static leans. Participants fell onto a foam mat, and impact force was measured using force platforms under the mat. A statistical equivalence test was used to determine if impact characteristics between groups were similar. RESULTS: Results indicated equivalence between groups in peak impact force during backward but not forward falls. Equivalence between groups in impact time suggested a mechanism by which equivalence in peak impact force as achieve. CONCLUSIONS: Four training sessions was sufficient for naïve participants to exhibit fall impact characteristics similar to experts in an anecdotally-effective landing strategy, and support further study. To our knowledge, this was the first study to investigate training for a landing strategy involving stepping after losses of balance from standing.

Searching for Invisible Axion Dark Matter with an 18 T Magnet Haloscope.

We report the first search results for axion dark matter using an 18 T high-temperature superconducting magnet haloscope. The scan frequency ranges from 4.7789 to 4.8094 GHz. No significant signal consistent with the Galactic halo dark matter axion is observed. The results set the best upper bound of axion-photon-photon coupling (g_{aγγ}) in the mass ranges of 19.764 to 19.771 µeV (19.863 to 19.890 µeV) at 1.5×|g_{aγγ}^{KSVZ}| (1.7×|g_{aγγ}^{KSVZ}|), and 19.772 to 19.863 µeV at 2.7×|g_{aγγ}^{KSVZ}| with 90% confidence level, respectively. This remarkable sensitivity in the high mass region of dark matter axion is achieved by using the strongest magnetic field among the existing haloscope experiments and realizing a low-noise amplification of microwave signals using a Josephson parametric converter.

Endoscopic subserosal dissection for gastric tumors: 18 cases in a single center.

BACKGROUND: Endoscopic submucosal dissection has technical limitations for the resection of gastric epithelial tumors with severe fibrosis and mixed or exophytic gastric subepithelial tumors (SETs). AIMS: To analyze the safety and effectiveness of endoscopic subserosal dissection (ESSD) for tumors growing in the subserosal space. METHODS: This observation study enrolled 18 patients who were diagnosed with gastric tumors and underwent ESSD at the Presbyterian Medical Center from 2010 to March 2019. RESULTS: A total of 18 patients were treated by ESSD. The mean age of the patients was 61.7 years. The mean length of the long axis of the tumor was 18.0 ± 5.0 mm. The mean operation time was 44 (range 11-167) min. The pathologic diagnosis was leiomyoma in nine cases (50.0%), gastrointestinal stromal tumor in six (33.3%), low-grade adenoma with severe fibrosis in two (11.1%), and schwannoma in one (5.6%). There were three cases of perforation, which were treated conservatively. The complete resection rate was 94%, and local or systemic tumor recurrence was not seen in a mean 70 months of follow-up. CONCLUSION: ESSD can be used for epithelial tumors with severe fibrosis and mixed or exophytic gastric SETs in the lesser curvature, cardia, or fundus that cannot be treated using standard methods.

Effects of Back-Support Exoskeleton Use on Lower Limb Joint Kinematics and Kinetics During Level Walking.

We assessed the effects of using a passive back-support exoskeleton (BSE) on lower limb joint kinematics and kinetics during level walking. Twenty young, healthy participants completed level walking trials while wearing a BSE (backXTM) with three different levels of hip-extension support torque (i.e., no torque, low, and high) and in a control condition (no-BSE). When hip extension torques were required for gait-initial 0-10% and final 75-100% of the gait cycle-the BSE with high supportive torque provided ~ 10 Nm of external hip extension torque at each hip, resulting in beneficial changes in participants' gait patterns. Specifically, there was a ~ 10% reduction in muscle-generated hip extension torque and ~ 15-20% reduction in extensor power. During the stance-swing transition, however, BSE use produced undesirable changes in lower limb kinematics (e.g., 5-20% increase in ankle joint velocity) and kinetics (e.g., ~ 10% increase in hip flexor, knee extensor, and ankle plantarflexor powers). These latter changes likely stemmed from the need to increase mechanical energy for propelling the leg into the swing phase. BSE use may thus increase the metabolic cost of walking. Whether such use also leads to muscle fatigue and/or postural instability in long-distance walking needs to be confirmed in future work.

Microglial phagocytosis of polystyrene microplastics results in immune alteration and apoptosis in vitro and in vivo.

The remarkable increase in plastic usage and widespread microplastic (MP) pollution has emerged as a substantial concern today. Many recent studies have revealed MPs as potentially hazardous substances in mammals. Despite several reports on the impact of small MPs in the brain and behaviors in aquatic animals, it is still unclear how small MPs affect the brain and its underlying cellular physiology in terrestrial animals. In this study, we investigated the accumulation of polystyrene MPs (PS-MPs) in mouse brain after oral treatment using three types of fluorescent PS-MPs of different sizes (0.2,2 and 10 µm). We found that PS-MPs were deposited in microglial cells of the brain. Following differential treatment of PS-MPs in human microglial HMC-3 cells, we identified changes in cellular morphology, immune responses, and microglial apoptosis induced by phagocytosis of 0.2 and 2 µm PS-MPs. By analyzing the PS-MP-treated HMC-3 cell transcriptome, we showed that PS-MPs treatment altered the expression of clusters of immune response genes, immunoglobulins, and several related microRNAs. In addition, we confirmed alterations in microglial differentiation marker expression with the activation of NF-κB, pro-inflammatory cytokines and apoptotic markers in PS-MP-treated human microglial cells and in mouse brain. Our findings suggest a potential risk of small PS-MPs in microglial immune activation, which leads to microglial apoptosis in murine and human brains.

Single-Incision versus Multiport Robotic Myomectomy: A Propensity Score Matched Analysis of Surgical Outcomes and Surgical Tips.

We aimed to compare the perioperative outcomes of single-incision robotic myomectomy (SIRM) and multiport robotic myomectomy (MPRM) and provide surgical tips. We retrospectively analyzed the medical records of 462 patients with symptomatic leiomyoma who underwent MPRM or SIRM between March 2019 and April 2021. Demographic characteristics and surgical outcomes, including the total operative time (OT), estimated blood loss (EBL), and surgical complication rate, were compared between the two groups. Patients in the SIRM group had lower a body mass index and rate of previous pelvic surgery and were younger than those in the MPRM group. The myoma type was not different between groups; however, the MPRM group had larger, and more myomas than the SIRM group. After propensity score matching, these variables were not significantly different between the groups. The total OT, EBL, difference in hemoglobin levels, transfusion rate, and postoperative fever were not different between the groups. No postoperative complications occurred in the SIRM group. In the MPRM group, one patient needed conversion to laparotomy, and two patients had postoperative complications (umbilical incisional hernia and acute kidney injury). In conclusion, both MPRM and SIRM are feasible and effective surgical options for symptomatic myomas with cosmetic benefits and minimal risk of laparotomy conversion.

Application of Immunoprofiling Using Multiplexed Immunofluorescence Staining Identifies the Prognosis of Patients with High-Grade Serous Ovarian Cancer.

Immunoprofiling has an established impact on the prognosis of several cancers; however, its role and definition in high-grade serous ovarian cancer (HGSOC) are mostly unknown. This study is to investigate immunoprofiling which could be a prognostic factor in HGSOC. We produced tumor microarrays of 187 patients diagnosed with HGSOC. We performed a multiplexed immunofluorescence staining using Opal Multiplex IHC kit and quantitative analysis with Vectra-Inform system. The expression intensities of programmed death-ligand 1 (PD-L1), CD4, CD8, CD20, FoxP3, and CK in whole tumor tissues were evaluated. The enrolled patients showed general characteristics, mostly FIGO stage III/IV and responsive to chemotherapy. Each immune marker showed diverse positive densities, and each tumor sample represented its immune characteristics as an inflamed tumor or noninflamed tumor. No marker was associated with survival as a single one. Interestingly, high ratios of CD8 to FoxP3 and CD8 to PD-L1 were related to the favorable overall survival (77 vs. 39 months, 84 vs. 47 months, respectively), and CD8 to PD-L1 ratio was also a significant prognostic factor (HR 0.621, 95% CI 0.420-0.917, p = 0.017) along with well-known clinical prognostic factors. Additionally, CD8 to PD-L1 ratio was found to be higher in the chemosensitive group (p = 0.034). In conclusion, the relative expression levels of CD8, FoxP3, and PD-L1 were significantly related to the clinical outcome of patients with HGSOC, which could be a kind of significant immunoprofiling of ovarian cancer patients to apply for treatment.

Improved Electrical Characteristics of Gallium Oxide/P-Epi Silicon Carbide Static Induction Transistors with UV/Ozone Treatment Fabricated by RF Sputter.

In this study, static induction transistors (SITs) with beta gallium oxide (ß-Ga2O3) channels are grown on a p-epi silicon carbide (SiC) layer via radio frequency sputtering. The Ga2O3 films are subjected to UV/ozone treatment, which results in reduced oxygen vacancies in the X-ray photoelectron spectroscopy data, lower surface roughness (3.51 nm) and resistivity (319 Ω·cm), and higher mobility (4.01 cm2V-1s-1). The gate leakage current is as low as 1.0 × 10-11 A at VGS = 10 V by the depletion layer formed between n-Ga2O3 and p-epi SiC at the gate region with a PN heterojunction. The UV/O3-treated SITs exhibit higher (approximately 1.64 × 102 times) drain current (VDS = 12 V) and on/off ratio (4.32 × 105) than non-treated control devices.

New Surgical Technique for Robotic Myomectomy: Continuous Locking Suture on Myoma (LSOM) Technique.

Robot-assisted laparoscopic myomectomy (RALM) has broadened the indications even in complex myomas. However, the high cost of RALM remains the main disadvantage. Therefore, a surgical technique that can reduce the cost of RALM and still has the advantages of robotic surgery is required. We propose a "locking suture on myoma (LSOM)" technique and compared the operative and perioperative outcomes of patients who underwent RALM with or without the LSOM technique. We included 337 patients who underwent RALM with (n = 160) or without (n = 177) the LSOM technique between March 2019 and August 2020. The LSOM group had low parity and gravidity, with a low rate of Cesarean sections. Myoma type was not different between the groups; however, patients in the LSOM group had larger, heavier, and higher number of myomas, although fewer patients had multiple myomas and were discharged earlier. Total operating time, estimated blood loss, pre- and postoperative hemoglobin levels, transfusion rate, and postoperative fever were not different between the two groups. In conclusion, the LSOM technique may be a viable surgical option for myomas, as it can reduce the cost of RALM by obviating the need for robotic Tenaculum forceps.