One step minilaparotomy-assisted transmesenteric portal vein recanalization combined with transjugular intrahepatic portosystemic shunt placement: A novel surgical proposal in pediatrics

Transjugular intrahepatic portosystemic shunt (TIPS) placement is a standard procedure for the treatment of portal hypertension complications. When this conventional approach is not feasible, alternative procedures for systemic diversion of portal blood have been proposed. A one-step interventional approach, combining minilaparotomy-assisted transmesenteric (MAT) antegrade portal recanalization and TIPS, is described in an adolescent with recurrent esophageal varice bleeding and portal cavernoma (PC). A 16-year-old girl was admitted to our Unit because of repeated bleeding episodes over a short period of time due to esophageal varices in the context of a PC. A portal vein recanalization through an ileocolic vein isolation with the MAT approach followed by TIPS during the same session was performed. In the case of failed portal recanalization, this approach, would also be useful for varice endovascular embolization. Postoperative recovery was uneventful. Treatment consisting of propanolol, enoxaparin and a proton pump inhibitor was prescribed after the procedure. One month post-op, contrast enhanced computed tomography confirmed the patency of the portal and intrahepatic stent grafts. No residual peritoneal fluid was detected nor opacification of the large varices. Endoscopy showed good improvement of the varices. Doppler ultrasound confirmed the accelerated flow in the portal stent and hepatopetal flow inside the intrahepatic portal branches. Three months post-op, TIPS maintained its hourglass shape despite a slight expansion. Portal hypertension and life threatening conditions related to PC would benefit from one-step portal recanalization. MAT-TIPS is feasible and safe for the treatment of PC even in children. This minimally invasive procedure avoids or delays surgical treatment or re-transplantation when necessary in pediatric patients

Minimally invasive procedure for removal of infected ventriculoatrial shunts

Background: Ventriculoatrial shunts were one of the most common treatments of hydrocephalus in pediatric and adult patients up to about 40 years ago. Thereafter, due to the widespread recognition of the severe cardiac and renal complications associated with ventriculoatrial shunts, they are almost exclusively implanted when other techniques fail. However, late infection or atrial thrombi of previously implanted shunts require removal of the atrial catheter several decades after implantation. Techniques derived from management of central venous access catheters can avoid cardiothoracic surgery in such instances. Methods: We retrospectively investigated all the patients requiring removal of a VA shunt for complications treated in the last 5 years in our institution. Results: We identified two patients that were implanted 28 and 40 years earlier. Both developed endocarditis with a large atrial thrombus and were successfully treated endovascularly. The successful percutaneous removal was achieved by applying, for the first time in this setting, the endoluminal dilation technique as proposed by Hong. After ventriculoatrial shunt removal and its substitution with an external drainage, both patients where successfully weaned from the need for a shunt and their infection resolved. Conclusion: Patients carrying a ventriculoatrial shunt are now rarely seen and awareness of long-term ventriculoatrial shunt complications is decreasing. However, these complications must be recognized and treated by shunt removal. Endovascular techniques are appropriate even in the presence of overt endocarditis, atrial thrombi, and tight adherence to the endocardial wall. Moreover, weaning from shunt dependence is possible even decades after shunting

Green Tattoo Pre-Operative Renal Embolization for Robotic-Assisted and Laparoscopic Partial Nephrectomy: A Practical Proof of a New Technique

Background: Our aim is to describe a new mixed indocyanine-non-adhesive liquid embolic agent (Onyx-18) pre-operative renal embolization technique for assisted-robotic and laparoscopic partial nephrectomy with near-infra-red fluorescence imaging. (2) Methods: Thirteen patients with biopsy-proven renal tumors underwent pre-operative mixed indocyanine–ethylene vinyl alcohol (EVOH) embolization (Green-embo) between June 2021 and August 2022. All pre-operative embolizations were performed with a super selective stop-flow technique using a balloon microcatheter to deliver an indocyanine-EVOH mixture into tertiary order arterial branch feeders and the intra-lesional vascular supply. Efficacy (evaluated as complete embolization, correct tumor mapping on infra-red fluorescence imaging and clamp-off surgery) and safety (evaluated as complication rate and functional outcomes) were primary goals. Clinical and pathological data were also collected. (3) Results: Two male and eleven female patients (mean age 72 years) received pre-operative Green-embo. The median tumor size was 29 mm (range 15–50 mm). Histopathology identified renal cell carcinoma (RCC) in 9 of the 13 (69%) patients, oncocytoma in 3 of the 13 (23%) patients and sarcomatoid RCC in 1 of the 13 (8%) patients. Lesions were equally distributed between polar, meso-renal, endo- and exophytic locations. Complete embolization was achieved in all the procedures. A correct green mapping was identified during all infra-red fluorescence imaging. All patients were discharged on the second day after the surgery. The median blood loss was 145 cc (10–300 cc). No significant differences were observed in serum creatinine levels before and after the embolization procedures. (4) Conclusions: The Green-tattoo technique based on a mixed indocyanine-non-adhesive liquid embolic agent (Onyx-18) is a safe and effective pre-operative embolization technique. The main advantages are the excellent lesion mapping for fluorescence imaging, reduction in surgical time, and definitive, complete and immediate tumor devascularization based on the deep Onyx-18 penetration, leading to a very low intra-operative blood loss

The Italian arm of the PREPARE study: an international project to evaluate and license a maternal vaccine against group B streptococcus.

BACKGROUND: Group B streptococcus (GBS) is a leading cause of sepsis, pneumonia and meningitis in infants, with long term neurodevelopmental sequelae. GBS may be associated with poor pregnancy outcomes, including spontaneous abortion, stillbirth and preterm birth. Intrapartum antibiotic prophylaxis (IAP) is currently the only way to prevent early-onset disease (presenting at 0 to 6 days of life), although it has no impact on the disease presenting over 6 days of life and its implementation is challenging in resource poor countries. A maternal vaccine against GBS could reduce all GBS manifestations as well as improve pregnancy outcomes, even in low-income countries. MAIN BODY: The term "PREPARE" designates an international project aimed at developing a maternal vaccination platform to test vaccines against neonatal GBS infections by maternal immunization. It is a non-profit, multi-center, interventional and experimental study (promoted by the St George University of London. [UK]) with the aim of developing a maternal vaccination platform, determining pregnancy outcomes, and defining the extent of GBS infections in children and mothers in Africa. PREPARE also aims to estimate the protective serocorrelates against the main GBS serotypes that cause diseases in Europe and Africa and to conduct two trials on candidate GBS vaccines. PREPARE consists of 6 work packages. In four European countries (Italy, UK, Netherlands, France) the recruitment of cases and controls will start in 2020 and will end in 2022. The Italian PREPARE network includes 41 centers. The Italian network aims to collect: GBS isolates from infants with invasive disease, maternal and neonatal sera (cases); cord sera and GBS strains from colonized mothers whose infants do not develop GBS infection (controls). SHORT CONCLUSION: PREPARE will contribute information on protective serocorrelates against the main GBS serotypes that cause diseases in Europe and Africa. The vaccine that will be tested by the PREPARE study could be an effective strategy to prevent GBS disease

Carbon footprint of FFP2 protective facial masks against SARS-CoV-2 used in the food sector: effect of materials and dry sanitisation

PurposeInternational outbreak of the SARS-CoV-2 infection has fostered the Italian government to impose the FFP2 protective facial masks in closed environments, including bar, restaurants and, more in general, in the food sector. Protective facial masks are rocketing, both in mass and in costs, in the food sector imposing efforts in fostering reuse strategies and in the achievement of sustainable development goals. The scope of the present paper is to depict possible strategies in manufacturing and reuse strategies that can reduce the carbon footprint (CF) of such devices.Design/methodology/approachTo implement circular economy strategies in the protective facial masks supply chain, it was considered significant to move towards a study of the environmental impact of such devices, and therefore a CF study has been performed on an FFP2 facial mask used in the food sector. Different materials besides the mostly used polypropylene (PP) (polyethylene (PE), polycarbonate (PC), poly (lactic acid) (PLA), cotton, polyurethane (PUR), polystyrene (PS) and nylon 6,6) and different sanitisation alternatives as reuse strategies (both laboratory and homemade static oven, ultraviolet germicidal irradiation) readily implemented have been modelled to calculate the CF of a single use of an FFP2 mask.FindingsThe production of textiles in PP, followed by disposal was the main contributor to CF of the single-use FFP2 mask, followed by packaging and transportations. PP and PE were the least impacting, PC, cotton and Nylon 6-6 of the same weight results the worst. PLA has an impact greater than PP and PE obtained from crude oil, followed by PUR and PS. Static laboratory oven obtained an 80.4% reduction of CF with respect to single use PP-made FFP2 mask, whereas homemade oven obtained a similar 82.2% reduction; UV cabinet is the best option, showing an 89.9% reduction.Research limitations/implicationsThe key strategies to reduce the environmental impacts of the masks (research for new materials and reuse with sanitisation) should ensure both the retention of filtering capacities and the sanitary sterility of the reused ones. Future developments should include evaluations of textile recycling impacts, using new materials and the evaluation of the life cycle costs of the reused masks.Practical implicationsThis paper intends to provide to stakeholders (producers, consumers and policy makers) the tools to choose the best option for producing and reuse environmentally friendly protective facial masks to be used in the food sector, by using both different materials and easily implemented reuse strategies.Social implicationsThe reduction of the CF of protective facial masks in the food sector surely will have relevant positive effects on climate change contributing to reach the goals of reducing CO2 emissions. The food sector may promote sustainable practices and attract a niche piece of clients particularly sensible to such themes.Originality/valueThe paper has two major novelties. The first one is the assessment of the CF of a single use of an FFP2 mask made with different materials of the non-woven filtering layers; as the major contribution to the CF of FFP2 masks is related to the non-woven textiles manufacturing, the authors test some other different materials, including PLA. The second is the assessment of the CF of one single use of a sanitised FFP2 mask, using different sanitation technologies as those allowed in bars or restaurants

Practical method for flow velocity measurements in ungauged sections

The river flow forecasting represents a crucial point to employ for improving a management policy addressed to the right use of water resources as well as for conjugating prevention and defence actions against environmental degradation. Indeed, for that the European directive 2000/60/CEE states the relevance of the monitoring and control activities as support to define the whole of protection measures to adopt for achieving the “good state” of the water body. Thus, the quantitative monitoring of rivers is an essential step for environmental purposes both for addressing middle and long term surveillance and control activities, and for civil protection purposes in terms of flood forecasting and risk mitigation. In such cases, a focal point is mainly represented by a continuous updating of flow depth/discharge ratio in each gauged section. This update relies on intense field activities not to easily carry out because of several factors mainly related to weather conditions and high costs. Thus, the aim of the present work is the development and implementation of quick and efficient sampling methods for discharge assessment in order to reduce the data acquisition time and processing maintaining a good level of accuracy and precision. This is of great interest in the chain of environmental monitoring for both gauged and ungauged river sections. In according with ISO rules, the choice of measurement verticals and velocity points has been derived by an optimization tolerance analysis proposing sampling procedures based on a set of discrete velocity measures collected following a fixed geometric pattern and grid (verticals and points). The backbone of the proposed methodology deals with the rationale that in a river flow the large amount of the moving fluid volume (discharge) is generally concentrated in about 30% up to 50% of the whole cross section and in this area the maximum velocity usually occurs. Three main verticals (i.e., placed at 1/3, ½ and 2/3 of the total observed width) are fixed for the field measurement considering the points velocities in 30% of the area below the free surface. Thus, the assessment of maximum and average velocities is available and the entropy velocity profile can be derived. The reliability of such method has been tested to gauged river sites located along the Alzette natural channel, in Grand-Duchy of Luxembourg. The results show a good “technical” agreement among observed and estimated water discharges with errors not exceeding 25%, overall

Yogurt Technique for Descemet Membrane Endothelial Keratoplasty Graft Preparation: Early Clinical Outcomes

Purpose:The aim of this study was to evaluate the efficacy and safety of the Yogurt technique for Descemet membrane endothelial keratoplasty (DMEK) graft preparation.Methods:This study included patients who underwent DMEK combined or not with phacoemulsification surgery using donor tissues prepared by a surgeon with the DMEK Tzamalis disposable punch at 2 referral hospitals between October 2019 and June 2021. Primary outcomes were duration of graft preparation, surgeon grading of graft quality, and endothelial cell density measured at 1 and 6 months after surgery. Secondary outcomes were best-corrected visual acuity (BCVA) measured at 1 and 6 months postoperatively and DMEK intraoperative and postoperative complications.Results:Forty-nine patients were included in this study. The mean DMEK graft preparation time was 7.2 ± 1.4 minutes. Donor grafts were rated good in 67.3% of cases (33 of 49), sufficient in 24.5% (12 of 49), and poor in 8.2% (4 of 49). Donor mean endothelial cell density was 2580 ± 155 preoperatively, which were reduced to 2269 ± 191 (P < 0.000) and 1697 ± 142 (P < 0.0001) at 1 and 6 months, respectively. No significant difference was found in graft preparation outcome (P = 0.543). The preoperative BCVA was 0.65 ± 0.44 logMAR, which improved to 0.31 ± 0.43 logMAR (P < 0.0001) and 0.12 ± 0.14 logMAR (P < 0.0001) at 1 and 6 months after surgery, respectively.Conclusions:This study shows that the DMEK Tzamalis punch can be used as an effective and safe method for DMEK graft preparation with a shallow learning curve that allows it to be successfully performed by relatively inexperienced surgeons

How to address velocity measurements during high floods by using the entropy theory: the Case Study of the gauged section along the Alzette River, Mersch, in Luxembourg

It is well known that the information entropy represents a measure of the uncertainty linked to a probability distribution and it is fundamental for solving several problems based on statistical models, where the absence of data requires general assumptions for parameters estimating. This is the case of the flow velocity distribution at river cross-sections and, in this context, Chiu (1987) was the pioneer in applying the entropy theory for the formulation of the velocity distribution in the probability domain. Based on this probabilistic formulation, the mean velocity, um, can be expressed as a linear function of the maximum velocity, , through a dimensionless entropy parameter M. The correlation among these two quantities was investigated for some gauged river sections across the world and a perfect agreement between the mean and maximum velocity was found. Therefore, the possibility to assess the velocity distribution only considering the maximum velocity and the entropic parameter M is of great interest in the context of discharge monitoring by standard techniques and, in particular, during high floods. Although there are a large number of studies on the velocity profiles analysis in natural channels, only a few have been addressed for estimating the spatial velocity distribution during high floods when it is not possible to measure the whole velocity field and in particular in the lower portion of the flow area. Indeed, the sampling procedure of velocity measurements in a river cross section, in this case, might be difficult and dangerous for cableway operators. On the other hand, the value of maximum flow velocity could be more easily sampled since its position is located in the upper portion of the flow area where velocity measurements can be carried out also during high flow conditions. Considering that the rating curve accuracy is strictly connected to experimental data availability which have to be referred both to low and high flow depths, we well know as a quick and accurate determination of high flow passing through a river section may be fundamental for the rating curve assessment. Therefore, a model based on the entropy theory and able to assess the velocity profiles, also when velocity data are not available in any portion of the flow area is welcome. The objective of the work is, then, to propose a procedure for addressing the velocity measurements during high floods by sampling the only. The procedure is based on the entropy velocity profile coupled with an elliptical/parabolic distribution of the maximum velocities, in the flow area. The elliptical/parabolic distribution of is derived by Chezy’s formula and by assuming a distribution of the verticals depth in the flow area depending on the depth of the vertical where is sampled and on the distance of each vertical from the side walls. The gauged section, named Mersch, along the Alzette River in Luxembourg is used as case study. A sample of fifteen velocity measurements for a total number of 200 sampled verticals is considered for the analysis. The entropic parameter value, M, is found equal to 2.32 with a determination coefficient R2=0.95. The velocity profiles uncertainty is also addressed by considering the error in estimating the observed velocity points. Results show that the procedure is able to estimate accurate velocity profiles using all velocity points sampled in the upper portion of the flow area and fairly accurate profiles if only is surmised sampled, regardless the distribution of maximum velocities adopted in the flow area. The main assets of the proposed approach are both to guarantee the safety conditions for the operators during the measurement and to drastically drop the time of sampling. It is worth noting that this aspect is fundamental for the practice hydrology because the monitoring of the maximum velocity, nowadays, can be done by using a portable radar unit, which makes possible a very quick measurement and, hence, for the same flood more gauged river sites can be monitored; condition that never can be accomplished by using traditional techniques as the one based on the use of current meter