Publications by authors named "Antonella Pino"

24 Publications

  • Page 1 of 1

Drawbacks of neural monitoring troubleshooting algorithms in transoral endoscopic thyroidectomy.

Langenbecks Arch Surg 2021 Jul 15. Epub 2021 Jul 15.

Division of Thyroid Surgery, China-Japan Union Hospital of Jilin University, 126 Xiantai Blvd, Changchun City, Jilin Province, China.

Introduction: The application of intraoperative neural monitoring (IONM) trouble-shooting algorithms procedures in transoral endoscopic thyroidectomy vestibular approach (TOETVA) was investigated.

Methods: Loss of signal (LOS) is defined as a loss of the primary electromyographic (EMG) normal biphasic waveform with reduced amplitude response to less than 100μV with a stimulation level intensity of 1-2mA. A systematic review of the IONM system at LOS was covered methodically: (i) correct endotracheal tube verification, (ii) stimulation of the recurrent laryngeal nerve (RLN) at entry point, (iii) ipsilateral or contralateral vagal nerve (VN) stimulation, and (iv) laryngeal twitch (LT).

Results: The function of 223 nerves at risk (NAR) was recorded with IONM. Twenty-seven (12%) NAR experienced a suspected LOS. LT could not be appreciated. In 15/27 (55%) cases, the application of the IONM trouble-shooting algorithm revealed upward displacement of the EMG tube (all orotracheal intubations). In 9 (4%) NAR, VN stimulation was not accomplished. In detail, there were n.5 left and n. 4 right VNs. Two VNs were ipsilateral, and 7 VNs contralateral. For EMG tube displacement, because the oral/nasal area is included in the aseptic field, it is less possible to re-check by the laryngoscope or fiberscope.

Conclusions: A limit for applying the IONM trouble-shooting algorithm to TOETVA is determined by (a) inability to appreciate the LT, (b) difficulty in stimulating the ipsilateral and contralateral VN, and (c) remodeling EMG endotracheal tube position. A modified IONM trouble-shooting algorithm for TOETVA is proposed.
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http://dx.doi.org/10.1007/s00423-021-02217-6DOI Listing
July 2021

An Improved Recurrent Laryngeal Nerve-Monitoring Device: Technical Note for NIM Vital™.

Surg Technol Int 2021 Jun 3;38. Epub 2021 Jun 3.

Division for Endocrine and Minimally Invasive Surgery, Department of Human Pathology in Adulthood and Childhood "G. Barresi", University Hospital G. Martino, University of Messina, Messina, Italy.

A new device for monitoring the laryngeal nerves during thyroid surgery has been developed. NIM Vital™ (Medtronic Xomed, Inc., Jacksonville, FL, USA) incorporates (a) a new wireless design, (b) NIM NerveTrendTM (Medtronic Xomed) EMG reporting, (c) intelligent noise-reduction technology that suppresses artifacts, (d) smart troubleshooting pop-up alerts, and (e) NIM Nervassure ™ (Medtronic Xomed) for continuous monitoring. This device offers enhanced stability and flexibility for both intermittent and continuous laryngeal nerve monitoring. The new NIM NerveTrend ™ EMG reporting makes it possible to track the recurrent laryngeal nerve condition throughout a procedure, even when using intermittent nerve monitoring. During both continuous and intermittent monitoring, green, yellow and red status bars provide visual information and associated tones provide audible cues, making it easy to monitor nerve function and interpret EMG trends. This new tool for laryngeal nerve monitoring has the potential to augment nerve dissection during surgery. Measurements of long-term outcome are needed to establish their efficacy.
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June 2021

C2 Xplore® for Intermittent and Continuous Laryngeal Nerve Monitoring: Technical Note.

Surg Technol Int 2021 05 27;38. Epub 2021 May 27.

Division for Endocrine and Minimally Invasive Surgery, Department of Human Pathology in Adulthood and Childhood "G. Barresi", University Hospital G. Martino, University of Messina, Messina, Italy.

Due to the direct anatomical relationship between the recurrent laryngeal nerve (RLN) and the thyroid gland, the function and anatomical integrity of the RLN is fundamentally at risk in every thyroid operation. While a RLN morbidity rate of less than 5% is achieved in specialized clinics, the morbidity rates are significantly higher in non-specialized centers. Thus, the aim is to reduce the complication rate by establishing standardized interventions. Exact knowledge of the anatomical course of the RLN, the nerve-sparing dissection technique and the supportive use of intraoperative neuro-monitoring (IONM) to identify anatomical variations are the basis for nerve-sparing surgery. We tested the new C2 Xplore® system (inomed Medizintechnik GmbH, Emmendingen, Germany) as a tool for performing intermittent and continuous laryngeal nerve monitoring during thyroid surgery. The C2 Xplore® helps to enhance surgeon-IONM interaction, and provides comprehensive digital EMG documentation with EMG quantification. EMG artifacts are removed. Image quality and EMG feedback are highly acceptable for intraoperative monitoring. The C2 Xplore® system does not have a deleterious impact on the proper function of other surgical instruments. C2 Xplore® is effective for intraoperative monitoring, optimizing RLN dissection, and supporting surgical deliberations, and for forensic use and research. A step-by-step C2 Xplore® procedure is described.
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May 2021

Use of Vivostat® Autologous Fibrin Sealant in Thyroid Surgery.

Surg Technol Int 2021 05 27;38. Epub 2021 May 27.

Division for Endocrine and Minimally Invasive Surgery, Department of Human Pathology in Adulthood and Childhood "G. Barresi", University Hospital G. Martino, University of Messina, Messina, Italy.

Introduction: Post-thyroidectomy hemorrhage is a rare but potentially life-threatening and unpredictable complication of thyroid surgery. Therefore, intraoperative bleeding control and hemostasis are crucial. However, the most efficient, cost-effective, and standardized way to achieve this is not clear. This study aimed to evaluate the outcome of total thyroidectomy (TT) and partial thyroidectomy (PT) performed using the Vivostat® hemostatic system (Vivostat A/S, Lillerød, Denmark).

Methods: Patients underwent TT and PT for benign and malignant diseases (multinodular goiter, Graves' disease, differentiated thyroid carcinoma). The primary endpoint was 1st-day postoperative drain output and bleeding that required reintervention. Secondary endpoints included surgery duration and postsurgical complications (vocal fold palsy, hypocalcemia, seroma, wound infection).

Results: Between October 2020 and December 2020, 56 patients were enrolled; 69.6% female; mean age 49.5 years. The mean 24-h drain output was 40 ml. No redo surgery was needed. Seroma was present in 5.3% of cases; no permanent vocal palsy or hypocalcemia was observed.

Conclusion: This study shows that the Vivostat® system is both safe and effective for hemostasis during thyroid surgery.
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May 2021

Correction to: Posture and dysphonia associations in patients undergoing total thyroidectomy: stabilometric analysis.

Updates Surg 2021 May 11. Epub 2021 May 11.

Division for Otorhinolaryngology, Department of Adult and Development Age Human Pathology "Gaetano Barresi", University of Messina, Via Consolare Valeria 1, 98125, Messina, ME, Italy.

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http://dx.doi.org/10.1007/s13304-021-01077-5DOI Listing
May 2021

Tensile strength analysis of automatic periodic stimulation for continuous intraoperative neural monitoring in a piglet model.

Sci Rep 2021 Mar 15;11(1):5898. Epub 2021 Mar 15.

Division of Thyroid Surgery, China-Japan Union Hospital of Jilin University, Jilin Provincial Key Laboratory of Surgical Translational Medicine, Changchun City, Jilin Province, China.

Continuous intraoperative neural monitoring (C-IONM) during thyroid surgery is a useful tool for preventing recurrent laryngeal nerve (RLN) injury. The present study aims to analyze the tensile strength tolerance of C-IONM electrodes on the vagal nerve (VN). A C-IONM wire was enclosed in a hand-held tensile testing system. The probe displacement on the VN was continuously monitored by positioning a second probe far-up/proximally in a piglet model, and an automatic periodic stimulation (APS) accessory was used. The 3-mm and 2-mm APS accessory has a mean tensile strength of 20.6 ± 10 N (range, 14.6-24.4 N) and 11.25 ± 8 N (range, 8.4-15.6 N), respectively (P = 0.002). There was no difference between bilateral VNs. The mean amplitude before and during electrode displacement was 1.835 ± 102 μV and 1.795 ± 169 μV, respectively (P = 0.45). The mean percentage of amplitude decrease on the electromyography (EMG) was 6.9 ± 2.5%, and the mean percentage of latency increase was 1.9 ± 1.5%. No significant amplitude reduction or loss of signal (LOS) was observed after > 50 probe dislocations. C-IONM probe dislocation does not cause any LOS or significant EMG alterations on the VN.
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http://dx.doi.org/10.1038/s41598-021-84988-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7960733PMC
March 2021

Past and Future of the Molecular Characterization of the T Cell Repertoire: Some Highlights of Eli Sercarz's Contributions.

Crit Rev Immunol 2020 ;40(3):249-253

Department of Translational Medicine and Surgery, Section of General Pathology, Università Cattolica del Sacro Cuore, 00168 Rome, Italy; Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy.

The contribution of Eli E. Sercarz to immunology and immunopathology has been remarkable and achieved many milestones in the understanding of the processes of the mechanisms fine-tuning immune responses. A part of his work was dedicated to the study of the deep complexity of the lymphocyte T cell repertoire and its importance during the physiologic development and disease, such as clonal heterogeneity of T cell responses. Starting from these studies, under his mentoring, we had the opportunity to implement the spectratyping method and apply it to human and experimental autoimmune diseases, obtaining intriguing results. The open question of this brief review is the possible role of this fine and complex technique, the immunoscope analysis, in the era of the big data and omics.
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http://dx.doi.org/10.1615/CritRevImmunol.2020034613DOI Listing
June 2021

Usefulness of PET-CT scan in recurrent thyroid cancer.

World J Otorhinolaryngol Head Neck Surg 2020 Sep 7;6(3):182-187. Epub 2020 Jul 7.

Nuclear Medicine Unit, Department of Biomedical and Dental Sciences and Morpho-Functional Imaging, University Hospital G. Martino, University of Messina, Messina, Italy.

The aim of this paper is to discuss the risk of recurrence in patients with differentiated thyroid cancer and emphasize the importance of risk-group stratification, early recurrence identification and application of new imaging modalities, what is the PET-CT. Moreover, follow-up of patients with thyroid carcinoma should be carried out by specialized teams throughout life. Therefore, interdisciplinary case discussions in tumor conferences may improve the use of multimodal therapy especially in patients with poorly differentiated thyroid carcinomas. After baseline follow-up, if there is a suspicion of thyroid carcinoma, early PET-CT should be used for early detection and appropriate planning. Fortunately, due to the good localization possibility, the PET-CT enables a focused surgical procedure with avoidance of an unnecessary tumor search and thereby a reduction of the risk of injury of neighboring structures which is a concern with reoperative neck surgery.
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http://dx.doi.org/10.1016/j.wjorl.2020.02.008DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7548382PMC
September 2020

Publisher Correction: The dual role of curcumin and ferulic acid in counteracting chemoresistance and cisplatin-induced ototoxicity.

Sci Rep 2020 Sep 30;10(1):16468. Epub 2020 Sep 30.

Department of Neuroscience, Università Cattolica del Sacro Cuore, Roma, Italia.

An amendment to this paper has been published and can be accessed via a link at the top of the paper.
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http://dx.doi.org/10.1038/s41598-020-70073-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7527566PMC
September 2020

Posture and dysphonia associations in patients undergoing total thyroidectomy: stabilometric analysis.

Updates Surg 2020 Dec 11;72(4):1143-1149. Epub 2020 Jul 11.

Division for Otorhinolaryngology, Department of Adult and Development Age Human Pathology "Gaetano Barresi", University of Messina, Via Consolare Valeria 1, 98125, Messina, ME, Italy.

The aim of this study is the analysis of postural changes of patients affected by vocal disorders post-thyroidectomy, in the absence of post-operative organ damage, through a stabilometry analysis, evaluating the effectiveness of a speech-language intensive treatment in phoniatric and postural quality recovery. 260 patients with vocal dysfunction after surgery without iatrogenic damage were enrolled. 130 patients were subject to post-surgical logopedic rehabilitative training (Group A); other 130 patients were not subject to any post-surgical treatment (Group B). For all patients, vocal and stabilometric parameters were evaluated before and after 2 days and 1 month from surgery. Vocal parameters evaluated were Voice Handicap Index-10, Maximum Phonation Time and objective evaluation of voice with Multidimensional Voice Program (MDVP). Stabilometric parameters evaluated were Sway area (mm) and Sway velocity (mm/s) in firm surface and foam pad with eyes opened and closed. Regarding the stabilometric parameters, Group A obtained a statistically significant recovery of the correct posture statistically significant compared to Group B, after a month of speech therapy. Vocal parameters (VHI, MPT, MDVP) were statistically different between the two groups (p < 0.05), with a better improvement in Group A. Thanks to our study, we have shown that a logopedic rehabilitation therapy in patients with dysfunctional post-thyroidectomy dysphonia improves both the vocal and postural outcomes.
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http://dx.doi.org/10.1007/s13304-020-00844-0DOI Listing
December 2020

Anti-oxidant and anti-inflammatory effects of caffeic acid: in vivo evidences in a model of noise-induced hearing loss.

Food Chem Toxicol 2020 Sep 5;143:111555. Epub 2020 Jul 5.

Fondazione Policlinico Universitario A, Gemelli IRCCS, Roma, Italy; Department of Head and Neck Surgery, Università Cattolica del Sacro Cuore, Roma, Italy. Electronic address:

Scope: The imbalance of cellular redox status, in conjunction with the activation of inflammatory processes, have been considered common predominant mechanisms of noise-induced hearing loss. The identification of novel natural products as potential therapeuticstargeting oxidative stress and inflammatory pathways is an emerging field. Here, we focused on the polyphenol caffeic acid (CA), the major representative of hydroxycinnamic acids and phenolic acid, in order to investigate its protective capacity in a model of sensorineural hearing loss induced by noise.

Methods And Results: Hearing loss was induced by exposing animals (Wistar rats) to a pure tone, 120 dB, 10 kHz for 60 min. By using auditory brainstem responses (ABRs) and immunofluorescence analysis, we found that CA protects auditory function and limits cell death in the cochlear middle/basal turn, damaged by noise exposure. Immunofluorescence analysis provided evidence that CA mediates multiple cell protection mechanisms involving both anti-inflammatory and anti-oxidant effects by decreasing NF-κB and IL-1β expression in the cochlea and opposing the oxidative/nitrosative damage induced by noise insult.

Conclusions: These results demonstrate that the supplementation of polyphenol CA can be considered a valid therapeutic strategy for attenuating noise-induced hearing loss and cochlear damage targeting both inflammatory signalling and cochlear redox balance.
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http://dx.doi.org/10.1016/j.fct.2020.111555DOI Listing
September 2020

Strategies for superior thyroid pole dissection in transoral thyroidectomy: a video operative guide.

Surg Endosc 2020 08 7;34(8):3711-3721. Epub 2020 May 7.

Division of Thyroid Surgery, Jilin Provincial Key Laboratory Of Surgical Translational Medicine, Jilin Provincial Precision Medicine Laboratory of Molecular Biology and Translational Medicine On Differentiated Thyroid Carcinoma, China-Japan Union Hospital Of Jilin University, 126 Xiantai Blvd, Changchun city, Jilin province, People's Republic of China.

Background: The dissection of the superior thyroid gland pole is challenging when using the in TransOral Endoscopic Thyroidectomy Vestibular Approach (TOETVA) due to (a) the cranio-caudal approach, (b) cranial-caudal view, and (c) the restriction of maneuverability inside the narrow neck air pocket.

Methods: In this paper and operative video guide, a series of TOETVA's tips and tricks are presented with an emphasis on the strategies for a safe approach to the superior thyroid gland pole structures.

Results: Management of the upper thyroid pole structures includes: (a) use of a 5 mm/30°-45° endoscope; (b) retraction ports up to the limit of the lower jaw edge; (c) lateral retraction of 1/3 of the cranial strap muscles; (d) isthmectomy; (e) cutting the sternothyroid muscle cranially for 1 cm; (f) retraction of the thyroid upwards and laterally; (g) monitoring the external branch of the superior laryngeal nerve, and (h) sealing individual vessel branches.

Conclusion: Access to the superior thyroid pole space through the TOETVA approach presents some challenges, particularly when accessing thyroid vessels or nodules located or displaced more cranially. Strategies that enhance a critical view of the superior thyroid gland structures can protect them from damage and have the potential to improve the safety of the TOETVA and decrease potential conversion rates.
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http://dx.doi.org/10.1007/s00464-020-07577-6DOI Listing
August 2020

Postoperative Bleeding after Thyroid Surgery: Care Instructions.

Sisli Etfal Hastan Tip Bul 2019 21;53(4):329-336. Epub 2019 Nov 21.

Department of Human Pathology in Adulthood and Childhood ''G. Barresi'', Division for Endocrine and Minimally Invasive Surgery, University Hospital G. Martino, University of Messina, Messina, Italy.

Prospective studies on the incidence, etiology, and prognosis of well-characterized patients with bleeding after thyroid surgery are lacking. Bleeding after thyroid surgery cannot be predicted or prevented even if risk factors are known in every single procedure, which enhances the im-portance of the following issues: (a) meticulous hemostasis and surgical technique; (b) coopera-tion with the anesthesiologist, i.e., controlling the Valsalva maneuver, adequate blood pressure at the end of the operation as well as at extubation phase and (c) in case of bleeding, a prompt management to guarantee a better outcome. This requires an intensive postoperative clinical monitoring of patients, ideally, in a recovery room with trained staff for at least 4-6 h. Early recognition of postoperative bleeding with immediate intervention is the key to the management of this complication.
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http://dx.doi.org/10.14744/SEMB.2019.95914DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7192296PMC
November 2019

Limitations of Continuous Neural Monitoring in Thyroid Surgery.

Sisli Etfal Hastan Tip Bul 2019 26;53(2):81-83. Epub 2019 Jun 26.

Division for Endocrine Surgery, Department of Human Pathology in Adulthood and Childhood "G. Barresi", University Hospital G. Martino, University of Messina, Messina, Italy.

Continuous intraoperative neuromonitoring is currently the gold standard technique available to prevent recurrent laryngeal nerve injuries. It significantly reduces the complication rate compared with intermittent intraoperative neuromonitoring, and represents significant progress in thyroid surgery, particularly in cases of more difficult dissections. There are, however, some technological and interpretative limits related to the lack of standardization of continuous intraoperative neuromonitoring and the prolonged length of time employed in the surgical positioning of the probe, despite various proposed approaches to the vagal nerve. Nonetheless, this method can be considered a safe and modern approach to thyroid surgery that reduces post-surgical complications and provides useful information.
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http://dx.doi.org/10.14744/SEMB.2019.85698DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7199830PMC
June 2019

Pre-Prototype Stimulating and Recording Endotracheal Tube for Continuous Monitoring of the Recurrent Laryngeal Nerve During Thyroid Surgery.

J Invest Surg 2020 Mar 9:1-11. Epub 2020 Mar 9.

Division for Endocrine and Minimally Invasive Surgery, Department of Human Pathology in Adulthood and Childhood ''G. Barresi'', University Hospital G. Martino, University of Messina, Messina, Italy.

Continuous intraoperative neural monitoring (C-IONM) is a promising technology used to decrease recurrent laryngeal nerve (RLN) damage during thyroid surgery. However, C-IONM use is limited due to its challenging application. C-IONM requires dissection of the carotid sheath and placement of an electrode around the vagus nerve (VN). In our study, we simultaneously stimulated and monitored the proximal RLN trans-tracheally using surface electrodes that were positioned solely on the endotracheal tube. We described the design, implementation, and testing of a pre-prototype, combined stimulating and recording endotracheal tube (SRET) that continually delivered current from tube edge, and tested the function of the RLN at the vocal cords (VC). The SRET was tested in vivo on 10 RLNs using 5 pigs as animal models. The SRET was capable of the following, delivery of continuous trans-tracheal stimulation to the proximal RLN, continuous trans-tracheal stimulation-induced VC movement, and standard ipsilateral RLN biphasic waveforms with latency and amplitude; and recording evoked responses were recorded in the ipsilateral RLN. The pre-prototype SRET represents a possible advancement in technology because it simplified the C-IONM. Thus, the SRET provides a minimally invasive, alternative application to the C-IONM vagal nerve cuff electrodes.
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http://dx.doi.org/10.1080/08941939.2020.1734693DOI Listing
March 2020

Neural monitoring in thyroid surgery is here to stay.

Gland Surg 2020 Jan;9(Suppl 1):S43-S46

Division of Thyroid Surgery, Jilin Provincial Key Laboratory of Surgical Translational Medicine, Jilin Provincial Precision Medicine Laboratory of Molecular Biology and Translational Medicine on Differentiated Thyroid Carcinoma, China-Japan Union Hospital Of Jilin University, Changchun 130000, China.

The iatrogenic injury of the recurrent laryngeal nerve (RLN), more clinically significant than those affecting the external branch of the superior laryngeal nerve (EBSLN), constitute one of the most feared perioperative complications of thyroid surgery and parathyroid glands, in terms of impact in clinical and economic-social costs. Moreover, these events rank among the leading reasons for medicolegal litigation of surgeons because of its attendant reduction in quality of life. The average incidence of RLN paralysis, permanent and temporary, after thyroidectomy is high and stands between 2.3% and 9.8% respectively. Given the elements described above, it is essential for the surgeon to adhere to a carefully standardized intraoperative technique that minimizes the possibility of RLN injuries. Intraoperative neuromonitoring (IONM) was introduced to reduce RLN injuries and for this reason, it achieved considerable success among endocrine surgeons. However, even today it is considered an adjunct device to the direct identification of the RLN. In this perspective, IONM of RLN constitutes an important aid, since it represents a reliable tool for the evaluation of functional neural integrity. Despite the ever-increasing diffusion of the IONM, prospective randomized studies are needed for further validation. The purpose of this work is to analyze scientific evidence to show that IONM in thyroid surgery is here to stay.
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http://dx.doi.org/10.21037/gs.2019.10.24DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6995897PMC
January 2020

The dual role of curcumin and ferulic acid in counteracting chemoresistance and cisplatin-induced ototoxicity.

Sci Rep 2020 01 23;10(1):1063. Epub 2020 Jan 23.

Department of Neuroscience, Università Cattolica del Sacro Cuore, Roma, Italia.

Platinum-based agents, such as cisplatin, form the mainstay of currently used chemotherapeutic regimens for several malignancies; however, the main limitations are chemoresistance and ototoxic side effects. In this study we used two different polyphenols, curcumin and ferulic acid as adjuvant chemotherapeutics evaluating (1) in vivo their antioxidant effects in protecting against cisplatin ototoxicity and (2) in vitro the transcription factors involved in tumor progression and cisplatin resistance. We reported that both polyphenols show antioxidant and oto-protective activity in the cochlea by up-regulating Nrf-2/HO-1 pathway and downregulating p53 phosphorylation. However, only curcumin is able to influence inflammatory pathways counteracting NF-κB activation. In human cancer cells, curcumin converts the anti-oxidant effect into a pro-oxidant and anti-inflammatory one. Curcumin exerts permissive and chemosensitive properties by targeting the cisplatin chemoresistant factors Nrf-2, NF-κB and STAT-3 phosphorylation. Ferulic acid shows a biphasic response: it is pro-oxidant at lower concentrations and anti-oxidant at higher concentrations promoting chemoresistance. Thus, polyphenols, mainly curcumin, targeting ROS-modulated pathways may be a promising tool for cancer therapy. Thanks to their biphasic activity of antioxidant in normal cells undergoing stressful conditions and pro-oxidant in cancer cells, these polyphenols probably engage an interplay among the key factors Nrf-2, NF-κB, STAT-3 and p53.
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http://dx.doi.org/10.1038/s41598-020-57965-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6978317PMC
January 2020

How to Avoid and Manage Mental Nerve Injury in Transoral Thyroidectomy.

Surg Technol Int 2019 11;35:101-106

Division for Endocrine and Minimally Invasive Surgery, Department of Human Pathology in Adulthood, and Childhood, University Hospital G. Martino, University of Messina, Messina, Italy.

Transoral endoscopic thyroidectomy by vestibular approach (TOETVA) represents an innovative and scarless technique for thyroid surgery. The procedure is conducted via a three-port technique at the oral vestibule using a 10mm port for the 30° endoscope and two additional 5mm ports for the dissecting and coagulating instruments. Patients meeting the following criteria can be considered as candidates for TOETVA: (a) an ultrasonographically (US) estimated thyroid diameter =10cm; (b) US-estimated gland volume =45mL; (c) nodule size =50mm; (d) presence of a benign tumor, such as a thyroid cyst or a single- or multinodular goiter; (e) Bethesda 3 and/or 4 categories, and (f) papillary microcar-cinoma without the evidence of metastasis. Beyond the classic complications of thyroid surgery, namely cervical hematoma, recurrent laryngeal nerve injury and hypoparathyroidism, novel consequences can occur as mental nerve (MN) injury. In this paper, leading experts in the field report on their current clinical experience with the TOETVA approach for thyroid gland surgery, with emphasis given to tips and tricks to avoid and manage MN injury.
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November 2019

Human cadaveric model for studying the preservation of mental nerve during transoral endoscopic thyroidectomy.

Surg Radiol Anat 2020 Jan 23;42(1):55-62. Epub 2019 Aug 23.

Division of thyroid Surgery, China-Japan Union Hospital of Jilin University, Jilin Provincial Key Laboratory of Surgical Translational Medicine, Jilin Provincial Precision Medicine Laboratory of Molecular Biology and Translational Medicine on Differentiated Thyroid Carcinoma, 126 Xiantai Blvd, Changchun, Jilin, People's Republic of China.

Purpose: Mental nerve (MN) injury can be caused by transoral endoscopic thyroidectomy vestibular approach (TOETVA). The purpose of this experimental study was to determine the location and distribution pattern of MN structures in relation to oral vestibular incisions.

Methods: Ten cadaver specimens were included, yielding a total of 20 MNs. The difference between standard 10-mm TOETVA median incision and modified incision (i.e. lower and perpendicular) was compared.

Results: All 20 MNs were successfully dissected and presented as bifid (100%), lateral toward medial direction. The branches of MNs were equally distributed into both right and left sides. Standard lateral 5-mm vestibular incisions did not determine any division of MN branches. Two left MNs (25%) and one right MN (12.5%) were injured by standard median vestibular incision. Using a more inferiorly positioned and a vertical median incision, the integrity of MN branches was preserved.

Conclusions: Standard lateral 5-mm vestibular incisions are safe for determining MN integrity. The 10-mm median vestibular incision divided the medial ramifications of MN at a rate of 12-25%. These may result in MN ipsilateral or bilateral paralysis. Hence, it is recommended to locate the median incision more inferiorly or vertically.
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http://dx.doi.org/10.1007/s00276-019-02306-8DOI Listing
January 2020

The Laboratory Role in anti-TNF Biological Therapy Era.

Immunol Invest 2020 Apr 12;49(3):317-332. Epub 2019 Jul 12.

Istituto di Patologia Generale - Fondazione Policlinico Universitario Agostino Gemelli- IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy.

Along years, the advent of biological therapy widely modified treatment of rheumatic diseases and other disorders. However, many agents may elicit in anti-drug antibodies (ADAbs) upon consecutive infusions, with a loss of response. For the right strategy of a personalized medicine, the therapeutic monitoring of TNF-α inhibitors and ADAbs represents an important effort in diagnostic-therapeutic pathway, to improve overall patient management and favoring an appropriate clinical approach. A raising number of diagnostic tests have been designed to elucidate the efficacy and/or safety of a specific drug or class of drugs for a targeted patient's group. Our paper reviewed the current understanding of the immunogenicity of biological drugs employed in the treatment of inflammatory diseases underlying the laboratory role.
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http://dx.doi.org/10.1080/08820139.2019.1637434DOI Listing
April 2020

Hyperhomocysteinemia as a Risk Factor and Potential Nutraceutical Target for Certain Pathologies.

Front Nutr 2019 24;6:49. Epub 2019 Apr 24.

Laboratory of Neuronal Cell Signaling, EBRI Rita Levi-Montalcini Foundation, Rome, Italy.

Hyperhomocysteinemia is recognized as a risk factor for several diseases, including cardiovascular and neurological conditions. Homocysteine (HCys) is a key metabolite involved in the biosynthesis and metabolism of methionine (Met), which plays a pivotal role in the physiological cell's life cycle. The biochemistry of Met is finely regulated by several enzymes that control HCys concentration. Indeed, balanced activity among the enzymes is essential for the cell's well-being, while its malfunction could raise HCys concentration which can lead to the onset of several pathological conditions. The HCys concentration increase seems to be caused mainly by the widely diffused polymorphisms of several enzymes. Nowadays, a blood test can easily detect elevated concentrations of HCys, referred to as Hyperhomocysteinemia (HHCys). Prolonged exposure to this condition can lead to the onset of cardiovascular disease and can lead to the development of atherosclerosis, stroke, inflammatory syndromes like osteoporosis and rheumatism, as well as neuronal pathologies including Alzheimer's and Parkinson's diseases. In this review, we analyzed the literature of several pathological conditions in which the molecular pathways of HHCys are involved. Interestingly, several observations indicate that the calibrated assumption of correct doses of vitamins such as folic acid, vitamin B6, vitamin B12, and betaine may control HHCys-related conditions.
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http://dx.doi.org/10.3389/fnut.2019.00049DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6491750PMC
April 2019

New Paradigms for Neural Monitoring in Thyroid Surgery.

Surg Technol Int 2019 May;34:79-86

Ospedale di Circolo di Varese, Varese, Italy.

Intraoperative neuromonitoring (IONM) in thyroid gland surgery provides real-time feedback to the endocrine surgeon regarding the electrophysiological consequences of surgical manipulation of the laryngeal nerves. The goal of monitoring modalities is to detect surgical or physiological insults to the recurrent laryngeal nerve (RLN) while they are still reversible or, in cases where prevention is not an option, to minimize the damage done to these structures during thyroidectomy. In recent decades, monitoring of the RLN has become a fundamental part of endocrine surgery. IONM is a feasible procedure in both open and endoscopic, robotic thyroidectomy. Experts in IONM have organized a working group of general, endocrine, head and neck ENT surgeons and endocrinologists (International Neural Monitoring Study Group; INMSG) to develop standards for practicing this technique in endoscopic and robotic thyroidectomy. This paper presents recent clinical and research experience with intraoperative neural monitoring for thyroid gland surgery.
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May 2019

How does neural monitoring help during thyroid sugery for Graves' disease?

J Clin Transl Endocrinol 2019 Mar 20;15:6-11. Epub 2018 Nov 20.

Division of Head and Neck Endocrine Surgery, Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA.

We evaluate the role of intraoperative neuromonitoring (IONM) in thyroidectomy performed for Graves' disease (GD) with an emphasis on recurrent laryngeal nerve (RLN) management and completeness of resection. The study is a retrospective series comprising 55 thyroidectomy (control group) versus 82 procedures with intermittent IONM (I-IONM) and 72 by means of continuous IONM (C-IONM). In the control group the laryngeal nerves have been identified by visualization solely. In the I-IONM group both vagal nerve (VN) and RLN have been localized and monitored during thyroid resection. C-IONM was achieved with a vagal stimulation probe. I-IONM group had shorter operating times (P = 0.032). RLN morbidity, meaning palsy rate, was 2.7% in the C-IONM group, 3.6% in I-IONM and 5.4% in the control group (P = 0.058). The proportion of complete procedures (total or near total resections) were significantly higher using monitoring technology (P = 0.049). Persistent positive serum TBII values were found in 25 (45%), 25 (30%) and 20 (27%) patients at 12 months in the control, I-IONM and C-IONM groups respectively (P = 0,04). IONM is an effective technology in GD patients.
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http://dx.doi.org/10.1016/j.jcte.2018.11.002DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6258110PMC
March 2019

The Antioxidant Effect of Rosmarinic Acid by Different Delivery Routes in the Animal Model of Noise-Induced Hearing Loss.

Otol Neurotol 2018 03;39(3):378-386

Institute of Otolaryngology, Università Cattolica School of Medicine, Rome.

Hypothesis: Trans-tympanic Rosmarinic Acid (RA), as compared with the systemic administration, protects against noise-induced auditory hair cell and hearing losses in rats in vivo.

Background: ROS production, lipoperoxidative damage, and an imbalance of antioxidant defences play a significant role in noise-induced hearing loss. Several molecules with antioxidant properties have been tested to restore redox homeostasis; however, drug delivery system represents a challenge for their effectiveness. In our model, acute and intense noise exposure induces hearing loss, hair cell death, and oxidative stress, with an increase in superoxide production and over-expression of lipid peroxidation in cochlear structures.

Methods: RA was administrated in male Wistar rats by trans-tympanic (20 μl) and systemic (10 mg/kg) modality. In systemic administration, RA was injected 1 hour before noise exposure and once daily for the following 3 days. ABRs were measured before and at days 1, 3, 7, and 30 after noise exposure. Rhodamine-phalloidin staining, dihydroethidium and 8-isoprostane immunostainings were performed to assess and quantify outer hair cells loss, superoxide production, and lipid peroxidation in the different experimental groups.

Results: Systemic RA administration significantly decreased noise-induced hearing loss and the improvement of auditory function was paralleled by a significant reduction in cochlear oxidative stress. The trans-tympanic modality of drug administration showed a similar degree of protection both at the functional and morphological levels.

Conclusion: The effectiveness of RA given via trans-tympanic injection could be interesting for the future application of this minimally-invasive procedure in the treatment of ROS-induced hearing loss.
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http://dx.doi.org/10.1097/MAO.0000000000001700DOI Listing
March 2018
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