Systematic Review and Cumulative Analysis of Oncologic and Functional Outcomes After Robot-assisted Radical Cystectomy

CONTEXT Although open radical cystectomy (ORC) is still the standard approach, laparoscopic radical cystectomy (LRC) and robot-assisted radical cystectomy (RARC) are increasingly performed. OBJECTIVE To report on a systematic literature review and cumulative analysis of pathologic, oncologic, and functional outcomes of RARC in comparison with ORC and LRC. EVIDENCE ACQUISITION Medline, Scopus, and Web of Science databases were searched using a free-text protocol including the terms robot-assisted radical cystectomy or da Vinci radical cystectomy or robot* radical cystectomy. RARC case series and studies comparing RARC with either ORC or LRC were collected. A cumulative analysis was conducted. EVIDENCE SYNTHESIS The searches retrieved 105 papers, 87 of which reported on pathologic, oncologic, or functional outcomes. Most series were retrospective and had small case numbers, short follow-up, and potential patient selection bias. The lymph node yield during lymph node dissection was 19 (range: 3-55), with half of the series following an extended template (yield range: 11-55). The lymph node-positive rate was 22%. The performance of lymphadenectomy was correlated with surgeon and institutional volume. Cumulative analyses showed no significant difference in lymph node yield between RARC and ORC. Positive surgical margin (PSM) rates were 5.6% (1-1.5% in pT2 disease and 0-25% in pT3 and higher disease). PSM rates did not appear to decrease with sequential case numbers. Cumulative analyses showed no significant difference in rates of surgical margins between RARC and ORC or RARC and LRC. Neoadjuvant chemotherapy use ranged from 0% to 31%, with adjuvant chemotherapy used in 4-29% of patients. Only six series reported a mean follow-up of >36 mo. Three-year disease-free survival (DFS), cancer-specific survival (CSS), and overall survival (OS) rates were 67-76%, 68-83%, and 61-80%, respectively. The 5-yr DFS, CSS, and OS rates were 53-74%, 66-80%, and 39-66%, respectively. Similar to ORC, disease of higher pathologic stage or evidence of lymph node involvement was associated with worse survival. Very limited data were available with respect to functional outcomes. The 12-mo continence rates with continent diversion were 83-100% in men for daytime continence and 66-76% for nighttime continence. In one series, potency was recovered in 63% of patients who were evaluable at 12 mo. CONCLUSIONS Oncologic and functional data from RARC remain immature, and longer-term prospective studies are needed. Cumulative analyses demonstrated that lymph node yields and PSM rates were similar between RARC and ORC. Conclusive long-term survival outcomes for RARC were limited, although oncologic outcomes up to 5 yr were similar to those reported for ORC. PATIENT SUMMARY Although open radical cystectomy (RC) is still regarded as the standard treatment for muscle-invasive bladder cancer, laparoscopic and robot-assisted RCs are becoming more popular. Templates of lymph node dissection, lymph node yields, and positive surgical margin rates are acceptable with robot-assisted RC. Although definitive comparisons with open RC with respect to oncologic or functional outcomes are lacking, early results appear comparable.

Transdiaphragmatic Resuscitative Open Cardiac Massage: Description of the Technique and a First Case-Series of an Alternative Approach to the Heart

Abstract BACKGROUND: The purpose of this paper is to describe the transdiaphragmatic approach to the heart for open CPR in patients that arrest at laparotomy and to present a first case series of patients that have undergone this procedure. METHODS: All patients who had undergone intraperitoneal transdiaphragmatic open CPR between January 1, 2002 and December 31, 2012 were retrieved from the operation registry at Bern University Hospital, Switzerland. Transdiaphragmatic access to the heart is initiated with a 10-cm-long anterocaudal incision in the central tendon of the diaphragm--approximately at 2 o'clock. Internal cardiac compression through the diaphragmatic incision can be performed from both sides of the patient. From the right side of the patient, cardiac massage is performed with the right hand and vice versa. RESULTS: A total of six patients were identified that suffered cardiac arrest during laparotomy with open CPR performed through the transdiaphragmatic approach. Four patients suffered cardiac arrest during orthotopic liver transplantation and two trauma patients suffered cardiac arrest during damage control laparotomy. In three patients, cardiac activity was never reestablished. However, three patients regained a perfusion heart rhythm and two of these survived to the ICU. One patient ultimately survived to discharge. CONCLUSIONS: In patients suffering cardiac arrest during laparotomy, the transdiaphragmatic approach allows for a rapid, technically easy, and almost atraumatic access to the heart, with excellent CPR performance. After this potentially life-saving procedure, pulmonary or surgical site complications are expected to occur much less compared with the conventionally performed emergency department left-sided thoracotomy.

A 2-year multicentre, open-label, randomized, controlled study of growth hormone (Genotropin(®) ) treatment in very young children born small for gestational age: Early Growth and Neurodevelopment (EGN) Study

OBJECTIVE In Europe, growth hormone (GH) treatment for children born small for gestational age (SGA) can only be initiated after 4 years of age. However, younger age at treatment initiation is a predictor of favourable response. To assess the effect of GH treatment on early growth and cognitive functioning in very young (<30 months), short-stature children born SGA. DESIGN A 2-year, randomized controlled, multicentre study (NCT00627523; EGN study), in which patients received either GH treatment or no treatment for 24 months. PATIENTS Children aged 19-29 months diagnosed as SGA at birth, and for whom sufficient early growth data were available, were eligible. Patients were randomized (1:1) to GH treatment (Genotropin(®) , Pfizer Inc.) at a dose of 0·035 mg/kg/day by subcutaneous injection, or no treatment. MEASUREMENTS The primary objective was to assess the change from baseline in height standard deviation score (SDS) after 24 months of GH treatment. RESULTS Change from baseline in height SDS was significantly greater in the GH treatment vs control group at both month 12 (1·03 vs 0·14) and month 24 (1·63 vs 0·43; both P < 0·001). Growth velocity SDS was significantly higher in the GH treatment vs control group at 12 months (P < 0·001), but not at 24 months. There was no significant difference in mental or psychomotor development indices between the two groups. CONCLUSIONS GH treatment for 24 months in very young short-stature children born SGA resulted in a significant increase in height SDS compared with no treatment.

An Appropriate Role for the Leadership: A Quantitative Analysis of the Effects of House Leadership on Open-Seat Races

This paper investigates the effects on open-seat races in the United States House of Representatives. This project focuses on the influence that the House leadership exerts on races. Generally, the leadership influences race through spending by party organizations and leadership visits. During each election cycle, national party organizations spend millions of dollars to get their candidates into office. I have developed a multiple regression model that measures different types of spending from the Democratic Congressional Campaign Committee, the National Republican Congressional Committee, and the Republican National Committee and the effects of these spending types on the election results. Also, the study examines the number of visits by each party’s leadership to each race. I introduced control variables that account for the year, the competitiveness of each race, and the individual candidate fundraising. In terms of statistical significance, the results were mixed showing one type of party spending to be highly influential in the outcome of the race. Competitiveness and individual candidate fundraising also achieved statistical significance. The study also includes a qualitative investigation of leadership visits and individual case studies in order to understand better the way in which the data interact in real campaigns.

Future pandemic influenza control (FPIC) related strategic management plan based on the 2009 H1N1 pandemic influenza review of health policy decisions, their practice and implications

This cross-sectional study is based on the qualitative and quantitative research design to review health policy decisions, their practice and implications during 2009 H1N1 influenza pandemic in the United States and globally. The “Future Pandemic Influenza Control (FPIC) related Strategic Management Plan” was developed based on the incorporation of the “National Strategy for Pandemic Influenza (2005)” for the United States from the U.S. Homeland Security Council and “The Canadian Pandemic Influenza Plan for the Health Sector (2006)” from the Canadian Pandemic Influenza Committee for use by the public health agencies in the United States as well as globally. The “global influenza experts’ survey” was primarily designed and administered via email through the “Survey Monkey” system to the 2009 H1N1 influenza pandemic experts as the study respondents. The effectiveness of this plan was confirmed and the approach of the study questionnaire was validated to be convenient and the excellent quality of the questions provided an efficient opportunity to the study respondents to evaluate the effectiveness of predefined strategies/interventions for future pandemic influenza control.^ The quantitative analysis of the responses to the Likert-scale based questions in the survey about predefined strategies/interventions, addressing five strategic issues to control future pandemic influenza. The effectiveness of strategies defined as pertinent interventions in this plan was evaluated by targeting five strategic issues regarding pandemic influenza control. For the first strategic issue pertaining influenza prevention and pre pandemic planning; the confirmed effectiveness (agreement) for strategy (1a) 87.5%, strategy (1b) 91.7% and strategy (1c) 83.3%. The assessment of the priority level for strategies to address the strategic issue no. (1); (1b (High Priority) > 1a (Medium Priority) > 1c (Low Priority) based on the available resources of the developing and developed countries. For the second Strategic Issue encompassing the preparedness and communication regarding pandemic influenza control; the confirmed effectiveness (agreement) for the strategy (2a) 95.6%, strategy (2b) 82.6%, strategy (2c) 91.3% and Strategy (2d) 87.0%. The assessment of the priority level for these strategies to address the strategic issue no. (2); (2a (highest priority) > 2c (high priority) >2d (medium priority) > 2b (low priority). For the third strategic issue encompassing the surveillance and detection of pandemic influenza; the confirmed effectiveness (agreement) for the strategy (3a) 90.9% and strategy (3b) 77.3%. The assessment of the priority level for theses strategies to address the strategic Issue No. (3) (3a (high priority) > 3b (medium/low priority). For the fourth strategic issue pertaining the response and containment of pandemic influenza; the confirmed effectiveness (agreement) for the strategy (4a) 63.6%, strategy (4b) 81.8%, strategy (4c) 86.3%, and strategy (4d) 86.4%. The assessment of the priority level for these strategies to address the strategic issue no. (4); (4d (highest priority) > 4c (high priority) > 4b (medium priority) > 4a (low priority). The fifth strategic issue about recovery from influenza and post pandemic planning; the confirmed effectiveness (agreement) for the strategy (5a) 68.2%, strategy (5b) 36.3% and strategy (5c) 40.9%. The assessment of the priority level for strategies to address the strategic issue no. (5); (5a (high priority) > 5c (medium priority) > 5b (low priority).^ The qualitative analysis of responses to the open-ended questions in the study questionnaire was performed by means of thematic content analysis. The following recurrent or common “themes” were determined for the future implementation of various predefined strategies to address five strategic issues from the “FPIC related Strategic Management Plan” to control future influenza pandemics. (1) Pre Pandemic Influenza Prevention, (2) Seasonal Influenza Control, (3) Cost Effectiveness of Non Pharmaceutical Interventions (NPI), (4) Raising Global Public Awareness, (5) Global Influenza Vaccination Campaigns, (6)Priority for High Risk Population, (7) Prompt Accessibility and Distribution of Influenza Vaccines and Antiviral Drugs, (8) The Vital Role of Private Sector, (9) School Based Influenza Containment, (10) Efficient Global Risk Communication, (11) Global Research Collaboration, (12) The Critical Role of Global Public Health Organizations, (13) Global Syndromic Surveillance and Surge Capacity and (14) Post Pandemic Recovery and Lessons Learned. The future implementation of these strategies with confirmed effectiveness to primarily “reduce the overall response time’ in the process of ‘early detection’, ‘strategies (interventions) formulation’ and their ‘implementation’ to eventually ensure the following health outcomes: (a) reduced influenza transmission, (b) prompt and effective influenza treatment and control, (c) reduced influenza related morbidity and mortality.^

Control of the master virulence regulatory gene atxA in Bacillus anthracis

Transcription of the Bacillus anthracis structural genes for the anthrax toxin proteins and biosynthetic operon for capsule are positively regulated by AtxA, a transcription regulator with unique properties. Consistent with the role of atxA in virulence factor expression, a B. anthracis atxA-null mutant is avirulent in a murine model for anthrax. In batch culture, multiple signals impact atxA transcript levels, and the timing and steady state level of atxA expression is critical for optimal toxin and capsule synthesis. Despite the apparent complex control of atxA transcription, only one trans-acting protein, the transition state regulator AbrB, has been demonstrated to directly interact with the atxA promoter. The AbrB-binding site has been described, but additional cis-acting control sequences have not been defined. Using transcriptional lacZ fusions, electrophoretic mobility shift assays, and Western blot analysis, the cis-acting elements and trans-acting factors involved in regulation of atxA in B. anthracis strains containing either both virulence plasmids, pXO1 and pXO2, or only one plasmid, pXO1, were studied. This work demonstrates that atxA transcription from the major start site P1 is dependent upon a consensus sequence for the housekeeping sigma factor SigA, and an A+T-rich upstream element (UP-element) for RNA polymerase (RNAP). In addition, the data show that a trans-acting protein(s) other than AbrB negatively impacts atxA transcription when it binds specifically to a 9-bp palindrome within atxA promoter sequences located downstream of P1. Mutation of the palindrome prevents binding of the trans-acting protein(s) and results in a corresponding increase in AtxA and anthrax toxin production in a strain- and culture-dependent manner. The identity of the trans-acting repressor protein(s) remains elusive; however, phenotypes associated with mutation of the repressor binding site have revealed that the trans-acting repressor protein(s) indirectly controls B. anthracis development. Mutation of the repressor binding site results in misregulation and overexpression of AtxA in conditions conducive for development, leading to a marked sporulation defect that is both atxA- and pXO2-61-dependent. pXO2-61 is homologous to the sensor domain of sporulation sensor histidine kinases and is proposed to titrate an activating signal away from the sporulation phosphorelay when overexpressed by AtxA. These results indicate that AtxA is not only a master virulence regulator, but also a modulator of proper B. anthracis development. Also demonstrated in this work is the impact of the developmental regulators AbrB, Spo0A, and SigH on atxA expression and anthrax toxin production in a genetically incomplete (pXO1+, pXO2-) and genetically complete (pXO1+, pXO2+) strain background. AtxA and anthrax toxin production resulting from deletion of the developmental regulators are strain-dependent suggesting that factors on pXO2 are involved in control of atxA. The only developmental deletion mutant that resulted in a prominent and consistent strain-independent increase in AtxA protein levels was an abrB-null mutant. As a result of increased AtxA levels, there is early and increased production of anthrax toxins in an abrB-null mutant. In addition, the abrB-null mutant exhibited an increase in virulence in a murine model for anthrax. In contrast, virulence of the atxA promoter mutant was unaffected in a murine model for anthrax despite the production of 5-fold more AtxA than the abrB-null mutant. These results imply that AtxA is not the only factor impacting pathogenesis in an abrB-null mutant. Overall, this work highlights the complex regulatory network that governs expression of atxA and provides an additional role for AtxA in B. anthracis development.

(Table 3) Collembola species density and diversity in control and OTC plots near Abisco Research Station

Ecosystems at high northern latitudes are subject to strong climate change. Soil processes, such as carbon and nutrient cycles, which determine the functioning of these ecosystems, are controlled by soil fauna. Thus assessing the responses of soil fauna communities to environmental change will improve the predictability of the climate change impacts on ecosystem functioning. For this purpose, trait assessment is a promising method compared to the traditional taxonomic approach, but it has not been applied earlier. In this study the response of a sub-arctic soil Collembola community to long-term (16 years) climate manipulation by open top chambers was assessed. The drought-susceptible Collembola community responded strongly to the climate manipulation, which substantially reduced soil moisture and slightly increased soil temperature. The total density of Collembola decreased by 51% and the average number of species was reduced from 14 to 12. Although community assessment showed species-specific responses, taxonomically based community indices, species diversity and evenness, were not affected. However, morphological and ecological trait assessments were more sensitive in revealing community responses. Drought-tolerant, larger-sized, epiedaphic species survived better under the climate manipulation than their counterparts, the meso-hydrophilic, smaller-sized and euedaphic species. Moreover it also explained the significant responses shown by four taxa. This study shows that trait analysis can both reveal responses in a soil fauna community to climate change and improve the understanding of the mechanisms behind them.

GPS raw data (control points and ground control points) from the Liguria Region, Borghetto Santo Spirito, Italy

Monitoring the impact of sea storms on coastal areas is fundamental to study beach evolution and the vulnerability of low-lying coasts to erosion and flooding. Modelling wave runup on a beach is possible, but it requires accurate topographic data and model tuning, that can be done comparing observed and modeled runup. In this study we collected aerial photos using an Unmanned Aerial Vehicle after two different swells on the same study area. We merged the point cloud obtained with photogrammetry with multibeam data, in order to obtain a complete beach topography. Then, on each set of rectified and georeferenced UAV orthophotos, we identified the maximum wave runup for both events recognizing the wet area left by the waves. We then used our topography and numerical models to simulate the wave runup and compare the model results to observed values during the two events. Our results highlight the potential of the methodology presented, which integrates UAV platforms, photogrammetry and Geographic Information Systems to provide faster and cheaper information on beach topography and geomorphology compared with traditional techniques without losing in accuracy. We use the results obtained from this technique as a topographic base for a model that calculates runup for the two swells. The observed and modeled runups are consistent, and open new directions for future research.

Estrategias para el control microclimático del espacio entre edificaciones en clima cálido – húmedo

La presente investigación parte del problema en las zonas de clima cálido - húmedo en las cuales se producen impactos asociados a la incomodidad térmica producto de la intensa radiación solar, altas temperaturas y elevada humedad. Estos factores reducen la calidad de los espacios abiertos y desarrollan en la población una actitud de rechazo hacia el uso del microespacio urbano entre edificaciones en los desarrollos urbanos - conjuntos urbanos - , los mismos frecuentemente admiten soluciones que al parecer no contribuyen a la realización de las actividades comunes de esparcimiento de la población residente. Por lo tanto, el objetivo de la investigación es profundizar en la temática urbano - ambiental - social y el diseño urbano vinculada a la particularidad morfológica local, las condiciones microclimáticas, el uso del microespacio y los requerimientos de los usuarios. La finalidad de desarrollar estrategias de control microclimático del microespacio entre edificios en clima cálido - húmedo en búsqueda de soluciones óptimas que satisfagan las necesidades de los usuarios de los espacios exteriores en estas áreas residenciales. La investigación se centra en el estudio de las particularidades contextuales relacionadas con el microclima y las características urbanas - morfotipológicas, básicamente los factores microclimáticos (soleamiento y ventilación), los morfológicos y edificatorios y las características de las superficies (pavimentos). En coherencia con el objetivo propuesto el trabajo se desarrolla en cuatro fases: la primera aborda la revisión documental, literatura relevante e investigaciones relativas a la calidad ambiental, medio social, medio físico, el microespacio urbano, control y diseño sostenible, modelización proyectual y estrategias sostenibles; la segunda fase se refiere al marco contextual, características urbanas, datos climáticos locales, planes y procesos urbanos, tipologías y conformación urbana. En esta fase se describe el proceso de selección, análisis y evaluación urbano - ambiental de los casos de estudio (conjuntos residenciales). En la tercera fase se aborda el marco evaluativo y estudio de casos, consideraciones físicas, climáticas y valoración térmico - ambiental de los conjuntos residenciales seleccionados. En esta fase se aplican Técnicas Estadísticas y de Simulación Computacional y se analizan los resultados obtenidos. Finalmente, la cuarta fase propositiva incluye el establecimiento de Estrategias, Principios y Lineamientos de optimación térmica y se exponen las Conclusiones parciales de la tesis, alcances y perspectivas futuras. Finalmente, los resultados obtenidos en la investigación demuestran que el análisis en las experiencias de la realidad permiten comprobar que las situaciones y alteraciones ambientales sustanciales, los niveles de afectación térmica y las condiciones de confortabilidad e impacto derivan de las características urbanas, los componentes del microespacio y de las condiciones climáticas las cuales afectan el desarrollo de las actividades y el uso efectivo del microespacio entre edificios. El análisis de los factores morfo - climáticos incidentes y el estudio de los efectos de interacción contribuyen al establecimiento de Principios y Lineamientos para la evaluación y diseño sostenible del microespacio entre edificios y el uso correcto de los elementos del clima en estas áreas urbanas destinadas a la actividad social y al esparcimiento de la población residente. ABSTRACT This research starts from the problem of hot - humid climate zones where impacts related to thermal discomfort are produced as a result from the intense solar radiation and high temperatures and humidity. These factors reduce the quality of open spaces and people develop an attitude of rejection towards the use of urban microspace among buildings within urban developments - urban complexes - . Usually, these complexes admit solutions that apparently do not contribute to the achievement of common leisure activities in the resident dwellers. Therefore, the main purpose of this research is to deepen in the urban - environmental - social issue and urban design linked to the local morphological particularity, microclimate conditions, use of microspace and users’ requirements. In order to develop microclimate control strategies of microspace among buildings in hot - humid climate to look for optimal solutions that satisfy users’ needs of outdoors spaces in these residential areas. The research focuses in the study of contextual particularities related to microclimate and urban - morphotypological characteristics. Basically, microclimate (sunlight and ventilation), morphological and building factors as well as road surface characteristics. According to the proposed objective, this research is developed in four phases: the first one considers documentary review, relevant literature and researches related to environmental quality, social environment, physical environment, urban microspace, control and sustainable design, project modelling and sustainable strategies; while the second phase refers to contextual framework, urban characteristics, local climate data, plans and urban processes, typologies and urban structure. In this phase, the process of selection, analysis and urban - environmental evaluation of case studies (residential complexes) is described. The third phase approaches the assessment framework and case studies, physical and climate considerations as well as environmental - thermal evaluation of selected residential complexes. In this phase, statistical techniques and computational simulations are applied. Likewise, results obtained are analysed. Similarly, fourth and proposing phase includes the establishment of strategies, principles and guidelines of thermal optimization and partial conclusions of the thesis, scopes and future perspectives are exposed. Finally, from the results obtained, it is demonstrated that the analysis on reality experiences allow proving that situations and substantial environmental changes, levels of thermal affectations, comfort conditions and impact derive from urban characteristics, microspace components and from climate conditions which affect the development of activities and the effective use of microspace among buildings. The analysis of incidental morpho - climate factors and the study of interaction effects contribute to the establishment of principles and guidelines for the assessment and sustainable design of microspace among buildings as well as the correct use of climate elements in these urban areas oriented to social and leisure activities of resident population.