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Michael Stark,1 Ospan Mynbaev,1 Antonio Malvasi,1,2 Andrea Tinelli1,3 1The New European Surgical Academy, Berlin, Germany; 2Department of Obstetrics and Gynecology, Santa Maria Hospital G.V.M. Care & Research, Bari, Italy; 3Department of Obstetrics and Gynecology and CERICSAL (CEntro di RIcerca Clinico SALentino), Veris delli Ponti Hospital, Scorrano, Lecce, ItalyCorrespondence: Michael Stark, Email mstark@nesacademy.orgAbstract: Throughout history, the upright position was the norm for most deliveries. However, due to cultural reasons, this practice was changed in the 17th century, and since then, the majority of deliveries have been conducted with the parturient lying on her back. The aim of this review article is to challenge the nowadays recumbent birth position and to emphasize the added value of gravity to the childbirth. Physiologically there is a strong argument for delivering in an upright position due to the significant role of gravity. The baby’s presenting part does not move back between contractions as happens in today’s recumbent position when due to the anatomy of the pelvis, the presenting part moves uphill. In this position, the second stage is shorter, and the signal for active pushing occurs spontaneously. It is recommended that any parturient should be informed about the risks and benefits of each birthing option to decide the birthing position that suits her.Keywords: labor position, birth, upright birth, delivery

Uterine fibroids affect almost one in two patients, causing many pelvic problems and requiring pharmacologic and surgical treatment. For many years, the importance of the fibroid was emphasized as uterine pathology, without focusing on the complex myometrial biology peripheral to fibroid. Moreover, the traditional surgical technique in fibroid removal has not been investigated for years. In recent years, on the contrary, morphological, neuroendocrine and anatomical studies have demonstrated the importance of a biological and surgical structure surrounding myoma, rich in neurotransmitters and neurofibres, the myoma pseudocapsule. This structure is formed in the womb peripheral to fibroid onset, it separates the fibroid from the myometrium and acts as a tissue regenerator after the removal of the fibroid from the uterus. The translation of scientific research on pseudocapsules into surgical practice has allowed us to identify new techniques of myomectomy, removing the myoma inside the pseudocapsule and promoting the pseudocapsules sparing surgery. All this to favor the subsequent biological process of uterine scarring and healing, by activating the neurotransmitters and neurofibres present in the myometrial fovea. The correct healing after fibroid removal restores the uterine anatomy, with a positive impact on subsequent reproductive function, reducing problems related to the muscle scar.

We examine the cost-effectiveness of treating epilepsy with anti-epileptic medicines in autistic children, looking at impacts on healthcare providers (in England, Ireland, Italy and Spain) and children's families (in Ireland). We find carbamazepine to be the most cost-effective drug to try first in children with newly diagnosed focal seizures. For England and Spain, oxcarbazepine is the most cost-effective treatment when taken as additional treatment for those children whose response to monotherapy is suboptimal. In Ireland and Italy, gabapentin is the most cost-effective option. Our additional scenario analysis presents the aggregate cost to families with autistic children who are being treated for epilepsy: this cost is considerably higher than healthcare provider expenditure.

Introduction. Although uterine myomas are becoming more common in pregnancies due to advanced maternal age, the literature lacks reports on complications, such as hysterectomy following cesarean myomectomy (CM). The aim of this work was to describe when CM is inevitable, complicated by severe intrapartum hemorrhage and requiring a hysterectomy. Case outline. A pregnant, with a term pregnancy and large multiple myomas, was referred for elective cesarean section (CS). During the CS, forced enucleation of a 100 mm anterior and left myoma previa (pre-fetal extraction) was necessary, and a 2,800 g neonate was delivered through the lower uterine segment incision. After the delivery and another CM, it was necessary to stop a massive hemorrhage from the myometrial myoma bed. Following provisory suturings of the hysterotomies, an urgent hysterectomy was performed with left salpingo-oophorectomy, due to a large hematoma in the left retroperitoneal space. The patient’s further recovery was uneventful and she was discharged with her baby on the sixth postoperative day. The histopathology report revealed a 135 × 190 × 150 mm uterus, weighing together with the enucleated myomas and left adnexa 5,000 g in total. The weight of the enucleated myomas was 1,670 g. The histopathological examination also showed 12 intramural and subserous myomas in the myometrium, ranging 30–190 mm. Conclusion. Large myomas, especially previa, may present a serious problem for fetal extraction during a CS. Therefore, the authors suggest an informed consent for CM, in patients who should undergo a CS. Additionally, such patients should be counseled about the possibility of an intrapartum hysterectomy.

It has been known that inositols function as insulin second messengers and mediate different insulin-dependent processes and are a valid natural, non-pharmaceutical alternative to contrast insulin-resistance as well as associated metabolic syndrome in women with Polycystic ovarian disease (PCOS). Several studies also have shown positive effects of resveratrol in reducing glucose and lipid concentrations in patients. Recently, clinical evidence has proven that an D-chiro-inositol/resveratrol combination has a potential role to play in maintaining metabolic and endocrine health, however no large clinical trials have demonstrated the medical effectiveness of the combination, and the combined mode of action remains poorly discussed. Herein, we address the hypothesis of a synergistic mechanism adopted by D-chiro-inositol and resveratrol in reducing insulin resistance and hyperlipidemia and thus showing a greater therapeutic potential compared to treatment with inositol’s alone.

The growing understanding of the molecular mechanisms underlying epithelial-to-mesenchymal transition (EMT) may represent a potential source of clinical markers. Despite EMT drivers have not yet emerged as candidate markers in the clinical setting, their association with established clinical markers may improve their specificity and sensitivity. Mass spectrometry-based platforms allow analyzing multiple samples for the expression of EMT candidate markers, and may help to diagnose diseases or monitor treatment efficiently. This review highlights proteomic approaches applied to elucidate the differences between epithelial and mesenchymal tumors and describes how these can be used for target discovery and validation.

Based on high quality surgery and scientific data, scientists and surgeons are committed to protecting patients as well as healthcare staff and hereby provide this Guidance to address the special issues circumstances related to the exponential spread of the Coronavirus disease 2019 (COVID-19) during this pandemic. As a basis, the authors used the British Intercollegiate General Surgery Guidance as well as recommendations from the USA, Asia, and Italy. The aim is to take responsibility and to provide guidance for surgery during the COVID-19 crisis in a simplified way addressing the practice of surgery, healthcare staff and patient safety and care. It is the responsibility of scientists and the surgical team to specify what is needed for the protection of patients and the affiliated healthcare team. During crises, such as the COVID-19 pandemic, the responsibility and duty to provide the necessary resources such as filters, Personal Protective Equipment (PPE) consisting of gloves, fluid resistant (Type IIR) surgical face masks (FRSM), filtering face pieces, class 3 (FFP3 masks), face shields and gowns (plastic ponchos), is typically left up to the hospital administration and government. Various scientists and clinicians from disparate specialties provided a Pandemic Surgery Guidance for surgical procedures by distinct surgical disciplines such as numerous cancer surgery disciplines, cardiothoracic surgery, ENT, eye, dermatology, emergency, endocrine surgery, general surgery, gynecology, neurosurgery, orthopedics, pediatric surgery, reconstructive and plastic surgery, surgical critical care, transplantation surgery, trauma surgery and urology, performing different surgeries, as well as laparoscopy, thoracoscopy and endoscopy. Any suggestions and corrections from colleagues will be very welcome as we are all involved and locked in a rapidly evolving process on increasing COVID-19 knowledge.

Abstract Background Risk stratification and treatment benefit prediction models are urgent to improve negative sentinel lymph node (SLN-) melanoma patient selection, thus avoiding costly and toxic treatments in patients at low risk of recurrence. To this end, the application of artificial intelligence (AI) could help clinicians to better calculate the recurrence risk and choose whether to perform adjuvant therapy. Methods We made use of AI to predict recurrence-free status (RFS) within 2-years from diagnosis in 94 SLN- melanoma patients. In detail, we detected quantitative imaging information from H&E slides of a cohort of 71 SLN- melanoma patients, who registered at Istituto Tumori “Giovanni Paolo II” in Bari, Italy (investigational cohort, IC). For each slide, two expert pathologists firstly annotated two Regions of Interest (ROIs) containing tumor cells alone (TUMOR ROI) or with infiltrating cells (TUMOR + INF ROI). In correspondence of the two kinds of ROIs, two AI-based models were developed to extract information directly from the tiles in which each ROI was automatically divided. This information was then used to predict RFS. Performances of the models were computed according to a 5-fold cross validation scheme. We further validated the prediction power of the two models on an independent external validation cohort of 23 SLN- melanoma patients (validation cohort, VC). Results The TUMOR ROIs have revealed more informative than the TUMOR + INF ROIs. An Area Under the Curve (AUC) value of 79.1% and 62.3%, a sensitivity value of 81.2% and 76.9%, a specificity value of 70.0% and 43.3%, an accuracy value of 73.2% and 53.4%, were achieved on the TUMOR and TUMOR + INF ROIs extracted for the IC cohort, respectively. An AUC value of 76.5% and 65.2%, a sensitivity value of 66.7% and 41.6%, a specificity value of 70.0% and 55.9%, an accuracy value of 70.0% and 56.5%, were achieved on the TUMOR and TUMOR + INF ROIs extracted for the VC cohort, respectively. Conclusions Our approach represents a first effort to develop a non-invasive prognostic method to better define the recurrence risk and improve the management of SLN- melanoma patients.

On-pump techniques are the methods of choice for organ protection and heart support during thoracoabdominal aortic aneurysm surgical repair. We present a case of a patient with a symptomatic saccular aneurysm of the visceral segment of a severe atheromatous aorta requiring a surgical type IV aortic repair during which we adopted a temporary passive arterial shunt from the left axillary artery to ensure visceral and distal aortic perfusion. The old-fashioned technique of passive shunting to ensure visceral and distal aortic perfusion seems to offer an appealing alternative to on-pump techniques in selected patients.

We report the case of a 65-year-old male patient who was deemed unfit for open surgery and underwent zone 0 endovascular repair with a physician-modified fenestrated endograft for a symptomatic penetrating ulcer. A thoracic stent graft was modified creating a large fenestration for the innominate artery and the left common carotid artery, and a second small fenestration for the left subclavian artery and the left vertebral artery, which had a common origin. No bridging stent was used for the left subclavian artery to avoid coverage of the left vertebral artery. The postoperative course was uneventful, and no leaks nor other complications were detected on postoperative computed tomography angiography. Although long-term durability needs to be better assessed, our experience suggests that physician-modified fenestrated endografts are a feasible option for the emergent treatment of aortic arch lesions in unfit patients and provide satisfactory results in the short term.

Ospan A Mynbaev,1–4 Marina Yu Eliseeva,2 Antonio Malvasi,5 Andrea Tinelli6 1International Translational Medicine and Biomodeling Research Team, MIPT Center for Human Physiology, Department of Applied Mathematics, Moscow Institute of Physics and Technology (State University), Dolgoprudny, Moscow Region, Russia; 2Department of Obstetrics, Gynecology and Reproductive Medicine, Peoples’ Friendship University of Russia, Moscow, Russia; 3Laboratory of Pilot Projects, Moscow State University of Medicine and Dentistry, Moscow, Russia; 4The New European Surgical Academy, Berlin, Germany; 5Department of Obstetrics and Gynecology, Santa Maria Hospital, Bari, Italy; 6Department of Obstetrics and Gynaecology, Division of Experimental Endoscopic Surgery, Imaging, Minimally Invasive Therapy and Technology, Vito Fazzi Hospital, Lecce, ItalyWith great interest we have read an article by Wu et al1 recently published in the International Journal of Nanomedicine aimed to estimate cytotoxicity, toxicity, and histopathological changes, as well as the postsurgical antiadhesion potential of biodegradable and thermosensitive micelles by combining in vitro and in vivo models.Our congratulations to Wu et al1 for their new, precisely designed, and promising study of nanoparticles used in the prevention of postsurgical adhesions. Even more so when we know that in most clinical studies the adhesion prevention adjuvants have failed. Taking into account medical and financial problems associated with postsurgical adhesions worldwide in the health care system, new developments in this area are welcomed and call for further investigation.View orginal paper by Wu et al