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An increasing number of robotic hysterectomies are being performed and the most common indication is fibroids. Fibroid uterus is common indication for hysterectomy for enlarged uteri. The role of robotic approach for complex pathologies as enlarged uterus is still debatable. The study aimed to analyze the feasibility of robotic hysterectomy in patients with enlarged uteri and the impact of uterine weight on surgical outcomes and on operative time length.One hundred and thirty-eight patients who underwent robotic hysterectomy for benign indications at the 2nd Division of Obstetrics and Gynecology, Azienda Ospedaliero-Universitaria Pisana, University of Pisa were consecutively enrolled.Data of patients undergoing robotic surgery for benign indications were collected. Patients were stratified in two groups based on their uterine weight, to analyze the effective impact of uterine weight and dimension on surgical performance, operative time and postoperative outcomes. Conversion rate was 0%. Median uterine weight was 615 g (range 400-1900 g). Median total operating time was 131 minutes (range 70-255 minutes). Increase in uterine weight significantly increased operative times (p=0.003) and morcellation time (p=0.001). On the other hand, operative time was just partially influenced by route for removal of the uterus (p=0.085) but significantly affected by uterine weight (p=0.008), previous surgeries (p=0.003) and BMI of the patient (p=0.005).Robotic hysterectomy is feasible and safe for challenging cases as large uteri. This technique could enable patients with outsized uteri, not suitable for vaginal hysterectomy, to undergo minimally invasive surgery with excellent results. Larger studies to investigate and compare robotic with other surgical approaches for difficult hysterectomies are needed to confirm these data.

The increase of the intensity and frequency of rainfall-dominated flood is considered a main effect of climate change. The present study evaluated the effect of a rainfall flood event on coralligenous reefs. The flooded site was compared to three control sites using a Before/After-Control/Impact (BACI) design. Sites were sampled using the STAR (STAndaRdized coralligenous evaluation procedure) approach and three ecological indices (ESCA, COARSE and ISLA) were calculated. At the disturbed site the number of species per sample, beta diversity, sensitivity levels of assemblages and the values of the three indices were lower after the flooding event, while the same variables did not decrease at the control sites. Algal turf and Dictyotales increased at the disturbed sites after the flood event, while Udoteaceae, erect sponges, bryozoans and Corallium rubrum decreased. This study provides evidence for identifying floods as a further cause of degradation for the coralligenous reef assemblages.

The establishment and spread of Non-Indigenous Species (NIS) can be facilitated through perturbations that lower the resilience of native communities to invasion. After a disturbance to a rocky subtidal macroalgal assemblage in the Mediterranean Sea (Italy) by a shipwreck (Costa Concordia), we compared native and non-native seaweed community structure at the disturbed site and two reference sites using traditional abundance measures, in addition to employment of the ALien Biotic IndEX (ALEX). ALEX has been recently proposed as a potential multi-metric indicator to evaluate biological invasions in Mediterranean macroalgal assemblages, taking into account both the relative abundance of macroalgal NIS to native seaweed abundances and the invasive traits of those NIS. We found that macroalgal NIS were initially more abundant at the disturbed site, but four months later were decreased and there were no difference with the reference sites. Native macroalgal cover at the disturbed site was lower than at reference sites in the initial survey, but unexpectedly decreased significantly four months later. Despite the decline in the cover of macroalgal NIS, ALEX was consistently lower through time at the disturbed site, due to concurrent declines in native seaweed abundances. This suggests that evaluation of macroalgal NIS should not be based on cover of macroalgal NIS alone and that the relative cover of native species should also be considered. ALEX may represent a versatile tool to be employed in both monitoring programs and impact evaluation studies.

Volcanoes subjected to hydrothermal activity develop weak cores as a result of alteration and due to elevated pore pressures. Edifices constructed at the angle of repose of volcanoclastics, or at even more gentle slopes, respond to internal weakening by initially deforming slowly, but may then collapse catastrophically. Such a process has so far been described for only a few volcanoes, such as Casita, Nicaragua; however, the conditions for flank spreading are widespread and many, if not most volcanoes should suffer some alteration-related flank spreading. We provide analogue models that characterise the structure — surface deformation fields and internal structures — of a spreading flank. Deformation creates a characteristic concave-convex-concave flank profile producing structures such as basal thrusts, summit normal faults, grabens and strike-slip relay faults. Three deformation regimes are found: a ‘pit collapse’ regime is associated with very small volumes of ductile material located far from the edifice surface. This would not appear in nature, as time for deformation is greater than the lifetime of a volcano, unless very low rock viscosities are present. The other two regimes are flank spreading regimes, one symmetric and one asymmetric. The latter is the most common, as most volcanic structures are asymmetrical in form and in distribution of physical properties. The deformation is controlled by altered region dimensions, volume and position relative to the edifice, and to a lesser extent by its shape. As the flanks spread, landslides are created, initially on the steepened portion, but also from fault scarps. Major flank collapse may occur leading to explosive hydrothermal decompression and to a debris avalanche rich in hydrothermally altered material. We provide several new examples of volcanoes that have structures and morphologies compatible with flank spreading. We suggest that it is a common feature, important in the tectonics and hazards of many volcanoes.

We present a method of reconstructing volcanic morphology using multiple digital views ( N -view), captured at different angles around an object. This approach uses recent advances in the field of Computer Vision to provide accurate 3-D measurements of volcanic surfaces. Videogrammetry (digital image reconstruction) is used, as it is best adapted to numerical processing. The method is tested and now used in the laboratory on analogue volcanic cones. The method begins with calibrating the camera and finding image positions, using an accurate N -view calibration method. This is done by estimating internal and external parameters of the camera using several views of a specially constructed calibration target. The N -view reconstruction of the real object is then done by iteratively deforming an initial theoretical model of the surface. Laboratory tests show that reconstruction accuracy is about 10 −4 m for a distance between the object and the camera of 0.5 m, and is potentially several orders of magnitude higher for surfaces of finer texture and using higher precision sensors. This is easily high enough to be useful for the accuracy required for morphological studies. It is also sufficient for monitoring most types of volcano deformation. The technique has the potential to detect morphology changes of the order of mm. Use of the method in the field requires a slightly different approach from that in the laboratory: textures and lighting are more variable, and the sensor and ground control point location and model calibration must be done differently. We provide case studies from laboratory tests and qualitative image analysis for two field cases: Piton de la Fournaise (Indian Ocean) and Santaguito (Guatemala). These illustrate the technique’s potential and explore problems of field application. Using current sensors, the method has the potential to provide sufficient precision for fine (mm–cm) scale reconstruction, and will represent a valuable, simple and flexible tool when compared with classical stereophotogrammetry techniques.

Blood viscosity plays a key role in regulating microvascular flow and alterations of hemorheological variables can lead to hyperviscosity, thus favoring the occurrence of occlusive thrombotic events. In the last few years an association between alterations in the hemorheologic profile and the severity of blood flow disturbances has been emphasized in several clinical and experimental conditions, possibly contributing to a better understanding of the pathophysiology of vascular disorders. The presence of alterations in hemorheological variables proved to be associated in several studies with an increased risk of cardiovascular disease and a higher mortality. The role of blood viscosity has also been analyzed in retrospective studies, which demonstrated that alterations in some hemorheological variables may increase the incidence of embolic events in patients with atrial fibrillation and may influence the responsiveness to antiplatelet drugs in patients with acute coronary syndromes. Recently, alterations of some hemorheological parameters were shown to be associated with complete occlusion of coronary arteries, favoring the occurrence of myocardial infarction with ST-segment elevation. In patients with this clinical condition, an increase in blood viscosity and some of its determinants was associated with increased infarct size and worse acute left ventricular dysfunction. Finally, the results of some observational clinical studies have shown that alterations of hemorheological variables may help to explain the pathophysiological mechanisms of some clinical disorders in which microvascular damage has been demonstrated, such as idiopathic sudden sensorineural hearing loss, retinal vein occlusion, and systemic sclerosis.

We describe a 63-year-old man in sinus rhythm (SR) with an ischaemic stroke involving basal ganglia region on the right side. The patient was known to be heterozygous for factor V Leiden (FVL) mutation. On diagnostic work-up, no arterial sources of embolism were found. Transoesophageal echocardiography evidenced a left atrial (LA) thrombosis without relevant cardiopathies. LA thrombosis is generally associated to atrial fibrillation, atrial enlargement, mitral valve stenosis and left ventricular dysfunction, whereas mitral regurgitation is considered protective. To our knowledge, this is the first report of cardioembolic stroke related to a LA thrombosis in a patient in SR without risk factors for thrombus formation except for FVL heterozygosity.

Argues that the ability to address swiftly the requirements of a changing market or to integrate a new technology or satisfy unique customer features enhances the success and the life span of a communication software product like a packet switching network. The authors describe how this requirement was addressed during the development of the Integrated Packet Switching Network (IPN) and provide examples of its successful application. It is concluded that the use of structured design, modular software applications, strict configuration management procedures, and standard development environments, results in a system with the required capabilities. >

Swell enhances wind-induced wave growth in the third-generation wave models of the WAM family (e.g., WAM, SWAN, TOMAWAC). This is contrary to observations in laboratory conditions where swell reduces wind-induced wave growth. To improve the performance of these models, it is hypothesized here that high-frequency whitecapping is increased by surface-straining near the crests of low-frequency waves. The pulse-based parameterization of whitecapping in these models is accordingly scaled at every frequency with the ratio of high-frequency steepness over total wave steepness (in an experimental version of SWAN). A generic laboratory experiment which illustrates the phenomenon can now be reproduced. The growth of young wind sea in idealized conditions is not affected. Moreover, the spectral shape (both in frequency and direction) improves. However, in the one field case that is considered here, the effects are marginal.

Although the results of surgical repair for congenital pulmonary stenosis are generally good, some patients develop progressive symptoms related to pulmonary regurgitation and right ventricular dilation. Pulmonary homograft implantation may have a beneficial effect on these symptoms, due to a reduction in the volume overload of the right ventricle and hemodynamic improvement. We describe our experience of one patient with severe pulmonary regurgitation following pulmonary valvotomy performed with the Brock technique during childhood because of pulmonary valve stenosis. The patient was admitted to our Institution because of dyspnea on exertion (NYHA functional class II-III) and paroxysmal episodes of supraventricular arrhythmias. Echocardiography showed severe pulmonary regurgitation, an important right ventricular dilation associated with severe tricuspid insufficiency and a patent foramen ovale without any significant shunts. Surgical repair was performed through a median sternotomy with cardiopulmonary bypass and moderate hypothermia. The right ventricular infundibulum was opened and a cryopreserved pulmonary homograft was implanted with continuous sutures. De Vega annuloplasty was performed on the tricuspid valve and the patent foramen ovale was closed with a running suture. Postoperative course was uneventful and the patient was discharged on the seventh postoperative day. Three months after surgery the patient is asymptomatic and echocardiographic evaluation shows no evidence of pulmonary or tricuspid regurgitation, a decrease in right ventricular dilation and a significant improvement in biventricular systolic and diastolic function. In conclusion, pulmonary regurgitation after surgical valvotomy can be treated with the implantation of a cryopreserved pulmonary homograft with satisfactory results. It would appear advisable to perform surgical repair of concomitant right heart anomalies, such as secondary tricuspid insufficiency, to obtain both a decrease in right ventricular overload and a regression of its preoperative dilation.

Calcium channel blockers and ACE-inhibitors are among the most common drugs prescribed for the initial treatment of hypertension. While their ability to control surrogate outcomes, such as blood pressure and left ventricular hypertrophy, is proven, there is limited evidence of their prevention of major cardiovascular events, including mortality. The aim of our work was to assess the use of these drugs in Italy in comparison with beta-blockers and diuretics. We examined the consumption of the four main antihypertensive classes of drugs (beta-blockers, diuretics, calcium channel blockers and ACE- inhibitors). In-hospitalization data from the GIFA (Gruppo Italiano di Farmacoepidemiologia nell'Anziano) database were used. During the period from 1988 to 1995, the most frequently prescribed antihypertensive drugs were calcium channel blockers (47%) followed by diuretics (37%), ACE-inhibitors (33%) and beta-blockers (5.5%). Changes over time in the use of these drugs were analysed: ACE-inhibitors had the greatest increase in use over time. Calcium channel blockers, ACE-inhibitors and beta-blockers were usually prescribed to the youngest patients (aged65 years), while diuretics to the oldest. Calcium channel blockers were prescribed to 60% of patients with myocardial infarction and to 55% of those with congestive heart failure. In conclusion, our study demonstrates that the Italian physicians very often prescribe drugs like calcium channel blockers and ACE-inhibitors. Among these pharmacological agents, enalapril (twice per day) and slow release calcium channel blockers are the most frequently prescribed drugs.

1. The effect of the NSAIDs indomethacin, indoprofen, diclofenac and acetylsalicylic acid on the increase in guanosine 3':5'-cyclic monophosphate (cyclic GMP) induced by nitric oxide-donor agents was tested in human whole platelets and in platelet crude homogenate. 2. In whole platelets, indomethacin reduced the increase in cyclic GMP induced by the nitric oxide-donors (NO-donors) sodium nitroprusside (NaNP) and S-nitroso-N-acetylpenicillamine (SNAP) in a dose-dependent way, its IC50 being 13.7 microM and 15.8 microM, respectively. 3. Of the other cyclooxygenase inhibitors tested, only indoprofen reduced the increase in cyclic GMP induced by both NO-donors in a dose-dependent way (IC50=32.7 microM, NaNP and 25.0 microM, SNAP), while acetylsalicylic acid (up to 1000 microM) and diclofenac (up to 100 microM) were ineffective. 4. However, in platelet crude homogenate neither indomethacin nor indoprofen reduced the cyclic GMP production. 5. Indomethacin (10 microM), indoprofen (30 microM), diclofenac (100 microM) and acetylsalicylic acid (1000 microM) showed a comparable efficacy in inhibiting platelet thromboxane B2 (TXB2) production, suggesting that the inhibitory effect of indomethacin and indoprofen on the increase in cyclic GMP induced by both NO-donors was not mediated by inhibition of cyclooxygenase. 6. In vitro, the NSAIDs analysed did not interfere with nitrite production of SNAP. 7. The unhomogeneous behaviour of NSAIDs on the increase in cyclic GMP induced by NO-donors in whole platelets may contribute to the different pharmacological and toxicological characteristics of the drugs, providing new knowledge on the effect of indomethacin and indoprofen.

The high sensitivity and specificity of echocardiography in the diagnosis of infective endocarditis have been well established for a number of years. However, little is known yet about the incremental value of this technique over the clinical and serological findings already available in subsets of patients presenting different initial probabilities in infective endocarditis. In this report, sensitivity and specificity of echocardiography were calculated in 173 consecutive patients with suspected infective endocarditis who underwent echocardiography within 5 days following admission. The echocardiogram was considered positive when Duke major criteria were fulfilled. Infective endocarditis was diagnosed in 88 patients, while other illnesses in the remaining 85. The diagnoses were confirmed retrospectively with a follow-up done after at least 3 months, at surgery or during autopsy. Sensitivity and specificity of the echocardiography in this population were 85 and 97% respectively. The initial probabilities of infective endocarditis in patients with different clinical presentations were taken from a thorough review of the literature available in English and from personal research. The positive predictive value of echocardiography is already high or very high even at low or very low levels of initial probability, and this has a strong impact on clinical decisions. In these situations and with intermediate probabilities, a negative echocardiogram would theoretically rule out the disease. However, this result, if considered alone, calls for a careful reassessment of the entire clinical context. As with any other test, when the initial probabilities of infective endocarditis are highest, the incremental value of echocardiography is poor.

Cardiological involvement in HIV infection is relatively rare but it presents important clinical aspects that are still open questions. We report our experience with HIV patients who underwent cardiological evaluation, Doppler echocardiography and follow-up.We selected 127 patients (9%) on the basis of clinical suspicion of heart disease, taking them from the 1398 admitted for HIV infection between 1992 and 1995. Ninety-six patients had AIDS (group A) and 31 were in pre-AIDS phase (group B). The age was 21-52 years: 83 were males, 44 were females and 91% of the patients had been drug addicts. Echocardiography was executed with Hp Sonos 1000 and Sonos 2500 devices. Follow-up was 6-36 months.Ninety-two patients (6.5% on total admitted patients) had heart disease. Thirty-five patients were normal on echocardiography. Other diseases were: pericardial effusion in 38 cases (30%), with CD4+ number significantly lower (p0.005); dilated cardiomyopathy in 20 patients (16%), with a low CD4+ number (p0.005); reversible segmental or diffuse hypokinesia compatible with clinical myocarditis was seen in 11 patients (9%), especially in group A (p0.005); infective endocarditis in 17 patients (13%), especially group B (p0.005); right ventricular dilatation in 7; discrete right ventricular mass in 3 patients. Sixty-five patients (51%) died during follow-up (group A only). There were 19 cardiac deaths (15%), which represents 1.3% of the total number of patients. Nine of these (47%) were in patients with cardiomyopathy. Total mortality was 85% in patients with dilated cardiomyopathy, 73% in myocarditis cases, 71% in pericarditis cases (especially extracardiac), 66% in right ventricular dilatation cases, 18% in endocarditis cases, 34% in normal cases.Cardiac complications assume clinical importance, especially in the AIDS phase of HIV infection, but early diagnosis in the pre-AIDS phase is important for treatment. Clinical evaluation and echocardiography are corner-stones of the diagnosis. Prognosis depends especially on the clinical stage of HIV infection and myocardial involvement.

Isolated alterations of the left ventricular diastolic function have been described in diabetic insulin-dependent patients (IDDM), even in the absence of old age, hypertension, ischemic heart disease, left ventricular hypertrophy. Such alterations have been associated with microangiopathy but it is not known whether it is reversible or if there is a relation with the way the therapy is given.Fifty-five subjects have been studied, of which 15 were healthy, 30 recently diagnosed IDDM without microangiopathy and 10 IDDM with microangiopathy. All the patients were under 35 years old and did not present risk factors for coronary artery disease, hypertension or autonomic neuropathy. The maximal exercise stress test proved negative. The diastolic function was studied using the results of Doppler echocardiography of the mitral flow and of isovolumetric relaxation time, with continuous and discrete parameters.The velocity of wave A and E, the relationship between them and their integrals are significantly greater in diabetics with microangiopathy than in those without it and in healthy subjects. There are no significant differences between healthy and diabetic subjects without microangiopathy using continuous parameters. Using discrete parameters diastolic damage is absent in the healthy subjects and is present in 48% of diabetics without microangiopathy and in 90% of those with it.Slight preclinical diastolic dysfunction is present in young recently diagnosed IDDM without microangiopathy. More severe dysfunction is present when there is also microangiopathy.

Two women suffered from aortic dissection during the third term of pregnancy. The first one, 37 years old, died from a sudden and intractable cardiovascular shock at the end of pregnancy, but the fetus was saved by cesarean. The diagnosis was made post mortem. In the second case a faster diagnosis and a slower development of the aortic dissection allowed, during the 29th week of pregnancy, a surgical treatment after cesarean saving both the mother's and newborn's life. The histological examination in both cases showed only non specific alterations of the collagenous and the elastic fibres.

This article deals with videogrammetric reconstruction of volcanic structures. As a first step, the method is tested in laboratory. The objective is to reconstruct small sand and plaster cones, analogous to volcanoes, that deform with time. The initial stage consists in modelling the sensor (internal parameters) and calculating its orientation and position in space, using a multi-view calibration method. In practice two sets of views are taken: a first one around a calibration target and a second one around the studied object. Both sets are combined in the calibration software to simultaneously compute the internal parameters modelling the sensor, and the external parameters giving the spatial location of each view around the cone. Following this first stage, a N-view reconstruction process is carried out. The principle is as follows: an initial 3D model of the cone is created and then iteratively deformed to fit the real object. The deformation of the meshed model is based on a texture coherence criterion. At present, this reconstruction method and its precision are being validated at laboratory scale. The objective will be then to follow analogue model deformation with time using successive reconstructions. In the future, the method will be applied to real volcanic structures. Modifications of the initial code will certainly be required, however excellent reconstruction accuracy, valuable simplicity and flexibility of the technique are expected, compared to classic stereophotogrammetric techniques used in volcanology.

Thirty-two patients with non acute myocardial infarction (inferior in twenty, anterior in ten, anterior and inferior in two) were studied with contrast left ventriculography, two-dimensional echocardiography and radionuclide angiography to assess left ventricular wall motion. We adopted the CASS criteria for the standard left ventriculography, and the Mayo Clinic classification for the echocardiographic study. Radionuclide angiography studies were obtained in left anterior oblique view; the images were evaluated with the use of Walsh-Hadamard transform; the left ventricle was divided in basal and apical septal, apical, posterolateral, posterobasal and two central segments. We tried to correlate the findings of the three techniques both for single segments and larger regions made of contiguous segments. Left ventricular angiography and two-dimensional echocardiography showed a fair concordance for both anterobasal and posterolateral left ventricular wall, whereas for the septal, apical and posterolateral regions contrast and radionuclide angiography had the best correlation. Compared to left ventricular angiography two-dimensional echocardiography shows better sensitivity than radionuclide angiography; the latter is more specific in defining left ventricular wall motion. The two non invasive techniques are therefore helpful in the evaluation of wall motion and their role is complementary.

One hundred and twenty asymptomatic patients underwent a submaximal treadmill exercise 2-3 weeks after an acute myocardial infarction. These patients were subsequently followed from 15 to 54 months (average 2 years). Coronary events (cardiac death or angina) occurred in 14% of the patients with normal response, in 55% of those with ischemic response and in 12% of those with abnormal but non-ischemic response. The incidence of coronary events in patients with ischemic response is significantly higher than in the other two groups. However, among the patients who had a normal response, one out of seven suffered from a coronary event during the follow-up period. More than 25% of our patients with an ischemic response to the early exercise testing showed a non-ischemic response during a second one. On the other hand, more than 25% of our patients with normal early exercise test had an ischemic response when the test was performed at the end the follow-up period. Submaximal exercise testing of asymptomatic patients early after an acute myocardial infarction does not seem to be predictive of future coronary events and its long-term reproducibility is poor.