Meat consumers are nowadays more conscious about the effects of fatty acids on health, preferring meat with low saturated fat content and high levels of omega-3. Grass-fed ruminants have been shown to produce a more desirable fatty acid composition than those that are grain fed. Our study evaluates different lamb finishing systems. Overall, better sensory attribute scores were detected for lambs slaughtered at weaning. Meat from the three lamb production systems studied achieved health claimable levels of omega-3 fatty acids, especially in lambs slaughtered at weaning. There were no differences between the three systems of production for juiciness, however lamb finished on pasture presented a lower flavor score than animals finished on alfalfa or those slaughtered at weaning. The low level of cholesterol found in the three systems studied, along with low levels of total fat and saturated fat, classified these meats as extra lean. Opportunities exist for both, sheep producers and the industry, to take advantage of a more balanced fatty acid composition and health attributes of lamb meat produced in extensive farming systems. Developing finishing strategies on pastoral based systems is crucial to improve production characteristics, such as growth and carcass yield, without compromising the nutritive value of meat.Western Patagonia lamb production systems are based on extensive rangeland. The harsh climate limits the adoption of more intensive systems. Therefore, producers must focus on developing differentiated products. The aim of this study was to evaluate growth patterns, carcasses and nutritive value of meat from 45 lambs. Lambs were divided into three groups: 15 lambs were slaughtered at weaning (W), with the remaining 30 weaned lambs being allocated to grazing either alfalfa (AG) or permanent pasture (PPG). AG lambs were significantly heavier and had higher condition scores than PPG lambs. Further, AG lambs showed higher carcass weight and larger tissue depth and commercial cuts. Moreover, W lambs had lower shear force and more tender meat than either AG or PPG lambs. The three systems showed a low shear force and acceptable sensory traits. Low levels of cholesterol, with low levels of saturated fat, classified these cuts of meat as extra lean. W lambs had higher omega-3 fatty acid content than AG or PPG lambs. Overall, results showed that meat from the three lamb production systems showed health claimable levels of omega-3 fatty acids and were low in fat and thereby, can be classified as lean meat. Lamb production in Western Patagonia (Chile) is based on grass, matching the growth curve of pastures. The main crop of lambs is harvested from extensive rangeland farms at weaning time, i.e., early summer, and delivers carcass weights in the order of 11–13 kg. Fatty acid composition of grass-fed meat has been seen as an opportunity for market advantages . Lambs fPlant composition of species-diverse mountain grasslands can affect the sensorial and chemical attributes of milk and meat products, with implications for human health. Analyzing natural grasslands in the Italian alpine region, Enri et al.  found thAs forage availability of improved permanent grasslands occurs during summer in the lowlands of Western Patagonia, lambs weaned from tussock areas could graze these pastures in order to improve their performance. However, it is of importance to verify if this extended rearing period influences meat characteristics and quality, as well as fatty acid composition. The objective of this work was to compare lamb growth patterns, carcasses and nutritive value of meat from tussock weaned lambs grazing either improved permanent pasture or alfalfa pastures. Meat variables were also compared with traditional lambs slaughtered at weaningFestuca pallescens, Poa dussenni, Puccinellia sp. and Trifolium repens. Weaning occurred on a single day when lambs averaged 27 kg live weight (LW) and 90 d of age. The lambs were then randomly allocated into three groups on the basis of their live weight (LW) and condition score [The work was conducted in accordance with requirements of the Chilean Law 20,380 on Animal Protection and with the approval of the INIA Bioethics Committee. A total of 45 male Corriedale lambs were raised to weaning with their dams on a typical sheep farm, representative of the main range farming area, located in the Aysén region of Western Patagonia. Ewes and lambs were grazed together on extensive rangeland, where the vegetation was dominated by The remaining 30 lambs were transported to the Instituto de Investigaciones Agropecuarias, INIA Tamel Aike research station , located in Simpson Valley, Western Patagonia, Chile.Medicago sativa), (AG), n = 15, and grazing on improved permanent pasture, (PPG), n = 15. Improved permanent pasture was based on cocksfoot (Dactylis glomerata) and white clover (Trifolium repens). Animals were allocated to treatment groups based on LW. A rotational grazing was imposed which was controlled by an electric net fence. Lambs were shifted and weighed weekly during the experiment. Pasture was abundant (4700 and 3200 kg dry matter (DM) ha−1 on average for alfalfa and permanent pasture, respectively); net fence was moved when the residual was approximately 2500 and 1600 kg DM ha−1 for alfalfa and permanent pasture, respectively. There was a 7 d pre-experimental period to accustom animals to the two grazing systems and management conditions. No attempt was made to measure DM intake. At the beginning of the experiment, the lambs were treated with Fenbendazol 100mg (Panacur® 10%), at 6 mg per kg, against liver, lung and intestinal parasites. Free access to watering was provided at all time. The experiment ranged from 21 January 2016 to 28 March 2016 (68 d) and lambs were slaughtered thereafter.Lambs were assigned to two feeding groups: grazing on a legume-based pasture of alfalfa  as well as plant species within these groups were determined. Statistical evaluation of botanical analysis of pasture samples results was not performed as only an average (n = 3) pasture sample was available. For chemical characteristics, simulated grazed pasture samples were collected in polythene plastic bags from the allowance pasture strips. All the feed samples were transported under refrigeration to the laboratory and were dried for 48 h at 60 °C for chemical analyses. The chemical content of the feed samples was analyzed at the INIA Remehue Animal Nutrition and Environment Laboratory in Osorno, Chile.The botanical composition and chemical characteristics of improved permanent pasture and alfalfa consumed after weaning during the grazing period are shown in The dry matter (DM), crude protein (CP), and ash were measured with the methods described by the AOAC . The metIn all cases, slaughter took place at the same local commercial abattoir, with pre slaughter live weights being recorded after 18 h of fasting. Lambs were stunned, and the carcasses were eviscerated and skinned according to normal commercial practices, weighed hot and held at 5 °C for 8 h. The hot carcass weight (HCW) included kidney-pelvic fat. The day after slaughter, cold carcasses were weighed (CCW) and graded for conformation using a four-point scale to represent very good, good, average or poor muscling, according to the Chilean standard for lamb carcasses . FurtherLongissimus dorsi) was measured (mm) on both sides of the carcass with a sharpened steel ruler. Tissue depth (grade rule—GR) was also measured, as described by Kirton and Johnson [Longissimus muscles were vacuum packaged and transported to the meat laboratory of INIA-Remehue, Chile and kept frozen at −18 °C until analyses.Carcasses were split with a band saw between the 12th and 13th ribs and the fat depth over the eye muscle .The Longissimus muscle samples were thawed for analysis for 48 h at 4 ± 2 °C, after which instrumental color was measured. The samples were then kept at room temperature for 30 min before measuring pH levels with a pH meter  with a penetration electrode . To analyze shear force, samples were cut into 3 cm samples and the external fat was removed. The samples were cooked in an oven at 170 °C until reaching a central temperature of 73 ± 1 °C (approximately 15 min). After being cooked, the samples were chilled at 4 ± 2 °C for 24 h. Some 6 to 10 1.3 cm circular specimens were extracted with a hollow punch to measure shear force with a texture analyzer  using the Warner–Bratzler method (WBSF) at a crosshead speed of 1 mm s−1 with an inlet pressure of 15 psi, using the split injection method (100:1). The injector temperature was fixed at 250 °C and the detector temperature at 260 °C. The injected sample volume was 1.0 µL and the oven temperature was programmed to increase from 140 (held for 5 min) to 240 °C (held for 15 min) at 4 °C min−1. Fatty acids were identified by comparing the retention times of the chromatograph peaks to those of the methyl esters from a mixture prepared with a 37-component FAME mix standard , C18:1 t-11 methyl ester standard  and c-9, t-11 octadecadienoic conjugated methyl acid .Samples of 10 g were used for the fatty acid analyses of meat, at the Animal Nutrition and Environment Laboratory of INIA Remehue in Osorno, Chile. Fat extraction method was performed according to Lumley and Colwell . In the An 11-member trained panel participated in the sensory analysis. The panelists were selected from a group of 30 persons without previous experience in sensory evaluation. The training and testing sessions were conducted at the Sensory laboratory of INIA Remehue. The panelists completed 48 h of training sessions on the evaluation of a set of selected lamb meat attributes . The sensory laboratory was designed according to ISO standards with separate booths, and samples were evaluated in a sequence established to avoid the effect of sample order presentation, first-order or carry-over effects . The panThe data were subjected to ANOVA to examine the effect of grazing group (two treatments after weaning) on lamb performance, carcass characteristics and meat cut characteristics. For the chemical and physical characteristics and FA composition of meat, comparisons were made between the three production systems (including the “at weaning” treatment). Comparisons of discrete variables  were performed using Kruskal–Wallis non parametric test. These data were analyzed using the General ANOVA procedure in InfoStat Software , considering a completely randomized design, treatment differences were tested for significance at the 0.05 probability level based on the Fisher’s least significant difference (LSD) method. The ANOVA for sensory data  were performed with the General Linear Model (GLM) procedure of the SAS system . Treatments were used as fixed effects and differences among effects were tested using Tukey’s test.The effects of post-weaning lamb fattening system on LW gain and condition score for the two feeding groups: grazing on a legume-based pasture of alfalfa (Medicago sativa), (AG) and grazing on improved permanent pasture, (PPG), are presented in p < 0.001) in AG lambs, compared to PPG lambs, therefore AG lambs averaged a 4.3 kg heavier body weight (p < 0.001) than PPG lambs. Condition score classification followed a similar pattern, with AG lambs presenting a significantly higher condition score (p < 0.001) than PPG lambs.Lamb LW gain was higher  and CCW (p < 0.001) compared to PPG lambs. Furthermore, AG lambs had significantly (p < 0.05) larger tissue depth (GR) than PPG grazed lambs. The fattening system did not alter significantly dressing percentage, carcass length, KKCF, fat grade and conformation classification measurements (p > 0.05).Alfalfa grazed lambs reached a significantly higher HCW (p < 0.05) by the type of pasture to a lesser or greater extent, except for rump bone and residues, as a result of the PPG lambs being smaller and having a lighter carcass than AG lambs.The different cuts of meat  were allp < 0.05) dry matter content of the meat from PPG lambs was detected, compared with animals slaughtered at weaning (W) or AG lambs.The chemical and physical characteristics of lambs fattened on different pasture systems are presented in p > 0.05) of production systems on protein content, ether extract, pH and muscle color parameters. Lambs slaughtered at weaning had greater (p < 0.05) ash content than AG lambs. Further, lambs slaughtered at weaning presented lower (p < 0.05) shear force than either AG or PPG lambs.There were no significant effects (p < 0.05) tender meat than lambs finished on permanent pasture, with alfalfa grazed lambs being intermediate for tenderness. There were no differences (p > 0.05) between the three systems of production for juiciness, however lambs finished on permanent pasture presented a lower (p < 0.05) flavor score than lambs finished on alfalfa or slaughtered at weaning.The effects of system of production on three sensory traits are presented in −1) is presented in p > 0.05) between the three lamb production systems in terms of their saturated and monounsaturated fat content, ranging between 1295 and 1362 mg 100 g−1 for saturated fat content and between 946 and 1033 mg 100 g−1 for monounsaturated fat content. However, there was a significant effect in (p < 0.05) polyunsaturated fatty acid (PUFA) content in lambs slaughtered at weaning, in relation to animals finished on alfalfa or permanent pasture. It is important to note a higher (p < 0.05) linoleic content on animals slaughtered at weaning in comparison to animals finished on permanent pasture, with animals finished on alfalfa being intermediate for this trait.Fatty acid content of Longissimus muscle (mg 100 gp < 0.05) content of alpha-linolenic acid, eicosapentaenoic acid (EPA), docosahexaenoic acid (DHA) and overall omega 3 content, than lambs finished on alfalfa or permanent pasture.Furthermore, lambs slaughtered at weaning had a significantly higher (p < 0.05) cholesterol level was detected when animals where finished on permanent pasture, in comparison with the other two groups of lambs.A lower , EPA, DHA and overall long chain n-3 PUFA content was measured on lambs fed on natural rangeland and slaughtered at weaning, in relation to animals finished on alfalfa or permanent pasture. It has been pointed out, that the type of diet has a significant effect on PUFA content of the resulting meat . Previou−1 meat will meet this standard.Functionally, the two most important omega-3 fatty acids are EPA (20:5n-3) and DHA 22:6n-3), however, docosapetaenoic acid  has also been shown to have an important role . Accordi:6n-3, hoWhen considering the standard portion of 135 g fresh meat, EPA plus DHA content recorded in this study for the three systems were 42.1; 32.1, and 31.6 mg per serving for lambs slaughtered at weaning, finished on alfalfa and finished on permanent pasture, respectively. This indicates that meat from the three lamb production systems studied in our region, achieved levels of omega-3 fatty acids that can be claimed as healthy, especially in lambs slaughtered at weaning.The low levels of cholesterol found in the three systems studied, along with low levels of total fat and saturated fat, classified these cuts of meat as “extra lean”, according to the Chilean legislation .Given that the demand for healthy foods in the world is increasing, and that pastoral based feeding systems are viewed by consumers as more natural and friendly, the outcomes of this study are important for the marketing of grass-fed lamb meat. The three pastoral systems studied showed a low shear force and acceptable sensory traits. Lamb meats produced under the three pastoral systems studied were low in fat, and they can be also classified as lean meat according to Chilean standards. Overall, the meat produced on the three pastoral based feeding systems is considered appropriate for human health, with an especially higher content of EPA and DHA. It is however important to note that these results are for lamb loins, and it would be beneficial to assess whether these characteristics apply to the rest of the commercial cuts. On the other hand, much care should be taken when taking the decision to finish the lambs on grass after weaning, on pasture, if food available is in short supply thereafter.


I); and soil water stress coefficient (Ks). Shading hail net reduced air temperature (−1°C), wind speed (−57%), solar radiation (−32%), while increased relative air humidity (+9.5%). Compared to the control treatment , the innovative management (DI + shading hail net + mulching) reduced seasonal volumes of irrigation water (−25%) and increased both final yield (+36%) and WPI (+53%). Saving water resources without losing yield is an achievable goal by peach orchards growing under the Mediterranean climate if the DI agro-technique is adopted conjointly with shading hail net and soil mulching.Microclimatic and soil management studies emphasize that roofing above the canopy or soil mulching contributes to reduce water losses from horticultural cropping systems and, at the same time, to increase water use efficiency. The aim of this 2-year on-farm study, carried out on a late ripening peach  orchard, was to investigate the combined effect of water supply , incoming light (hail or shading net), and soil management (tilling or mulching) on: microclimate; fruit growth; yield; irrigation water use productivity (WP Deficit irrigation (DI) is a sustainable way to use the water resources in the Mediterranean cropping systems. Results from the scientific literature on DI allow concluding that it is possible to reduce irrigation volumes without penalizing yields . In addiClimate scenarios in the Mediterranean region, both in the short and medium terms, stress the importance of DI, as well as of tuning the set of water-saving agronomic techniques accordingly .Screen covers placed over the orchard canopies modify microclimate  since thMulching materials placed over the soil surface reduce soil evaporation by cutting off the vapor transport path between the soil surface and the atmosphere and contrasting weeds growth and the related transpiration as well as. Compared to soil tillage, mulching has significant advantages in soil moisture preservation , reducinAlthough some researches have analyzed the effects of shading hail net  or of muSince DI does cause soil water stress, a research prerequisite consists in handling at the field scale a friendly indicator to define the stress experienced by the crop along the whole season, in place of the soil stress coefficient (Ks) which fluctuates during the vegetative cycle at the daily scale, following the soil water balance variations. Successively the combined effects of light screening and soil management on the Ks seasonal indicator can be analyzed, as well as the relationships between such synthetic Ks and plant behavior.The aim of the study was to verify the hypothesis that canopy and soil coverages acting together can alleviate soil water stress when irrigation is supplied with limited volumes. A seasonal indicator for the Ks variations is proposed as a deputy criterion for evaluating the effects of the adopted agro-techniques on the peach orchard performances (fruit growth and yield).Conclusions from this study will provide friendly tools for designing the suitable DI agronomic strategies which reduce the impact on yield and on water resources of horticultural species growing in areas characterized by the Mediterranean climate.2 flat surface, within a 5 ha commercial orchard. The physico-chemical characteristics were similar within the experimental plot  and wilting point  were 0.32 and 0.18 m3 m−3, respectively (measured in the Richards chambers). The soil water reserve was moderate (192 mm) because the root system did not develop below 0.6 m in this site.The study was conducted during the 2017 and 2018 seasons in southern Italy , in a private farm. Observations were carried out on a 15-year old peach orchard of a late ripening cv , trained as open vase and grafted on GF677 rootstock, spaced 5.0 m (between the rows) × 3.0 m (within the row), and managed according to the usual farm practices. The peach experimental set-up was realized on a 3,600 mtal plot Table 1.tal plot  having 3The experimental site is under the Mediterranean climate, characterized by warm and dry summers, with minimum and maximum annual air temperatures ranging from 0 to 5°C and 32 to 43°C, respectively. The annual rainfall is 560 mm. Rains are distributed mainly in autumn and late winter, and they are negligible in the spring–summer period . Therefoini = 0.15; Kcmed = 0.80; Kcend = 0.60) and depletion fraction (p = 0.5) were those tabulated in the 56 FAO handbook. Corrections of Kcini (for precipitation events), Kcmed, and Kcend (for climatic conditions and crop height) were performed according the The input agrometeorological data  for calculating reference evapotranspiration according to per tree and a flow rate of 8 l h−1per dripper. Seasonal irrigation volumes, irrigation depth (mm), and number of irrigations per season (n.) scheduled in full (FI) and deficit irrigation (DI) treatments are reported in Water was supplied by a drip irrigation system having two drippers Three agromanagement factors Figure 1two light regimes (Lr): reduction of incident solar radiation by 10% for hail nets (H) and by 30% for shading hail nets (S), both having high diffusivity. The nets were placed horizontally over the trees (4 m above soil surface) to shade all the rows within the test area. The nets were installed using a supporting tensile structure with longitudinal and transversal steel cables tensioned to a supporting structure of concrete and wood as described by two soil managements (Sm): tilled soil (T) and mulching with a biodegradable film (M) on the row. The M treatment was realized by laying the film tape (2 m wide) at the beginning of each vegetative season along each side of the rows; while in autumn (after harvest) it was ploughed into the soil. The biodegradable film had a black surface facing the soil and a white surface facing the sky to reflect the incident radiation.two irrigation regimes (Ir): full irrigation (FI), supplying the amount of water lost by evapotranspiration (ETc) and deficit irrigation (DI), restoring 50% of ETc (from August until the end of irrigation season) in 2017 or 75% of ETc during the whole irrigation season (1/6–10/9) in 2018. In average, the seasonal deficit imposed for both the years was 25% Table 2.Each Lr treatment (H and S) was sized (25 m × 60 m) in a way that the central part of the surveyed plots was not influenced by the diffuse light coming from the nearby plots having different Lr. Moreover, the size of each plot allowed detecting the differences between the micro-climatic conditions monitored in H and S treatments.Within each light regime plot, soil managements  and irrigation regimes treatments , were set-up orthogonally each other. The distances between the irrigation regime treatments were enough to avoid the horizontal flow of water between adjacent plot treatments. The great surfaces needed to manage these kind of factors  under field conditions do not allow the complete randomization of the treatments; however, soil properties showed a low variability which get realistic to retain uniform the experimental site Figure 22 where 30 trees were growing.The combination of the three experimental factors  resulted in eight different crop management treatments: HTFI (control), HTDI, HMFI, HMDI, STFI, STDI, SMFI, and SMDI. To Each treatment corresponded a surveyed area of 450 mDuring the irrigation season (June–September) and for H and S managements, the climatic parameters: air temperature (Tair), relative humidity (RH), wind speed (u) and solar radiation (Rs), were monitored by agrometeorological sensors placed at 0.5 m above the canopy and below the H and S shelters.via GPRS mode. Soil specific calibration functions were used to calculate the volumetric SWC.Soil water content (SWC) in volume was measured by capacitive probes . For each treatment, three points were monitored . At eachi) was determined for the soil profile (0.6 m) by integrating the values measured at each depth, since each probe was supposed to detect the water content in a 0.2 m soil layer  and the related Absolute Growth Rate  of fruit volume (−1) was evaluated measuring the fruit weight per tree (kg tree−1), the related number of fruits (n. tree−1), and the average fruit weight (g). Harvest was performed when fruit achieved their commercial ripening checking flesh firmness and soluble solid content.In order to evaluate the effect of the different orchard management on soil as well as on tree performance, three trees similar for dimension vigor and health state, in correspondence with the soil moisture probes, were chosen within each treatment. As reported in other studies, three trees per treatment, considering each tree as a replicate, could be considered representative in uniform experimental sites . Fruit gt volume . PotentiI) and soil water stress coefficient (Ks) were calculated.For each orchard management, irrigation water productivity (WPI (3) supplied to the orchard.Where Y is yield of marketable product and I is seasonal irrigation volume. WPI  stands fi) were calculated setting 0.5 the “p” value, i.e. the readily available water threshold (Ks (dimensionless) represents a transpiration reduction factor depending on available soil water ranging from 0—maximum stress, to 1—no stress. When SWC is below the RAW threshold, Ks values are less than 1 and crops activate physiological mechanisms  to reduce transpiration. Daily Ks values (Kshreshold :st) with minimum values (Ksmin) calculated during the irrigation season:Seasonal Ks values were standardized  by season (2017 and 2018) using the statistical package Statgraphics Plus 5.1 . Duncan’s multiple range post-hoc test was used for mean separation when the interaction between three factors indicated significant differences.KsI, the covariance analysis (ANCOVA) was performed, considering the number of fruits as the covariate variable.In order to manage the possible influence of undesired differences of crop load on fruit growth, yield and WPst and yield was performed by the regression analysis (through Statgraphics Plus 5.1).The relationship between Ksst April–30th September) were similar for air temperature . Temperatures ranged between 38°C in summer and rare events below 0°C. The total rainfall was higher in 2018 than in 2017; during the irrigation period (1st June–10th September) the extent of the difference between the two seasons was 133 mm . The reduction in solar radiation was in line with the net manufacturer specifications: 9% for the hail net and 32% for the shading hail net , avoiding any water stress. In both seasons, the SWC (from −0.10 m to −0.50 m soil depth) reached the field capacity, after irrigation or consistent precipitations. Only at the end of the 2017 irrigation season, SWC values exceed field capacity. At the beginning of July 2018, irrigation was skipped due to technical problems: in this period, a reduction in SWC under RAW was observed also in FI treatments Figure 5In 2017, the SWC (mm) pattern along the whole soil profile for the eight treatments was quite similar Figure 5In 2018, SWC observed in the FI treatment varied between the field capacity and RAW threshold. Just before the irrigation supply SWC dropped below RAW in orchard plots under the hail nets; while SWC kept above the RAW threshold in the shading hail net treatments. As for the DI treatments, SWC values above the RAW threshold occurred only in the SMDI treatment (st).In this section the daily dynamics of soil water stress coefficient (Ks) is analyzed and a seasonal value is conceptualized, defined as standardized soil water stress coefficient  resulted in a greater occurrence of Ks values lower than 1. The minimum Ks values attained 0.6 for fully irrigated treatment (HTFI) and 0.3 for HTDI , while it became low (around 0.6) in the DI treatment  and mulching (M). Under FI management, no water stress in the soil was observed, and Ks values were close to 1 all the season long. Under DI treatment (SMDI), Ks never dropped below 0.82 , calculated from the average values of agrometeorological data .The statistical analysis revealed that Lr, Sm, and Ir factors affected in the same way Kseatments Table 4.st = 0.98–0.97); 2) SMDI–STFI–HMFI (Ksst = 0.76–0.84); 3) STDI–HMDI–HTFI (Ksst = 0.59–0.69); 4) HTDI (Ksst = 0.31–0.42).By analyzing the significant interactions among all factors, the same ranking was derived in both seasons Figure 8st values , consistent with those observed in the full irrigated  treatments  and the final fruit weight.The influence of fruit number was significant for Yield and WPth and March 26th, respectively. In both years, the interaction among the three factors was not significant for fruit growth; fruit volume and AGR were affected by Lr. In 2017, at the beginning of the fruit monitoring survey , S and H treatments showed similar fruit volume and AGR. Excluding on 140 and 154 DAFB, S showed the fruit volume higher than H for all the season long . This difference disappeared till 127 DAFB. On 148 DAFB, H showed fruit volume higher than S, while on 169 DAFB an opposite behavior was observed. This difference was maintained until harvest when the fruit volumes were 286.1 cm3 and 256.3 cm3 in S and H, respectively  was significantly affected by the irrigation regime (DI vs FI) for both years  than FI (11.06 kg m−3) while in 2018 WPI was 9.62 and 6.66 kg m−3 in DI and FI, respectively. In 2017 WPI was higher for S (13.77 kg m−3) than under the H (10.86 kg m−3) roofing.Water productivity  did affect significantly the Ksst values detected in both years  were reduced when these techniques were combined together. The Ksst could be retained as the link between the changes in the SWC and the crop behavior.There are no data showing the effects of covering the peach orchard with mulching, so the results of this study represent a novelty in this area. The agronomic strategies aiming at modulating the light (Lr) or at managing the soil (Sm) or at reducing irrigation volume (Ir) acted on SWC. In the peach orchard, when the DI technique was applied, actually SWC reduced 6 and sost in both seasons, suggests that the DI should be coupled with those agronomic strategies which preserve the water stored in the soil profile to increase its effectiveness.Annual and perennial crops , if affest values . The reduction of 9% of the incident radiation showed the lowest values of Ksst, especially when it was combined with the deficit irrigation technique .Shading hail net used in this study reduced direct incident solar radiation by 32% and the microclimatic conditions in the peach orchard changed Table 3.st value = 0.37). On the contrary, techniques aiming at reducing soil evaporation ameliorated SWC. When mulching is adopted, in comparison with the tilled treatments, Ksst generally increased: 0.62 and 0.8 in T and M treatments, respectively. With respect to tillage management, in mulching treatment Ksst increased by 31% and production by 12%  was reached when evapotranspiration was mitigated by reducing irradiance and soil evaporation. Under shading hail net, saving water by means of DI demonstrated to be a suitable tool: the Ksst in the SMDI treatment was 0.80, of the same order than that observed, in average, in all the FI treatments  of incident solar radiation improved peach yield and fruit weight . Fruit gI) stands for the ability of a crop system to convert the irrigation water in marketable fruits. WPI was affected by the irrigation strategy as well as by the Lr when the crop load was not reduced , and its WPI was one of the highest  values reported in the present study  conditions well-suited for peach cultivation. The peculiar meteorological trend in 2018  did not allow for holding the same inference  reduction in yield (I by 20–40% (considering hail net covered and full irrigated treatments as control). The results here reported suggest the positive effect of the integration of different agro-techniques as a promising  strategy for saving irrigation water.These results emphasize that the detrimental effect of water shortage could be balanced by suitable modulation of the microclimate and contrasting the extra water losses . Recent in yield . The comI but can trigger yield decrease. The use of sound agro-techniques as shading hail net and soil mulching, better if used conjointly, demonstrated to be effective. Through adequate crop managements, also under the Mediterranean climate, it is possible to reduce irrigation water volumes and to improve water productivity .Since the sustainability of full irrigation techniques is questionable in the Mediterranean climate environments, alternative approaches should be proposed. In the case of peach trees, mainly the late ripening varieties, irrigation management aiming at provoking temporary soil water deficit periods can improve WPOutcomes here shown on microclimate modulation and on orchard floor management open new ways to further research aiming at evaluating the response of plant  to combined water friendly techniques.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.PC: conceptualization, methodology, writing original draft. LG: data curation, validation, discussion of productive results. MM: writing, review and editing. PL: definition of experimental setup, formal analysis.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Since aortic aneurysms (AAs) are mostly asymptomatic, but they have a high mortality rate upon rupture, their detection and progression evaluation are clinically important issues. To discover diagnostic biomarkers for AA, we performed proteome analysis of aortic media from patients with thoracic atherosclerotic AA (TAAA), comparing protein levels between the aneurysm and normal tissue areas. After hierarchical clustering analysis of the proteome analysis data, tissue samples were classified into three groups, regardless of morphological features. This classification was shown to reflect disease progression stage identified by pathological examination. This proteomics-based staging system enabled us to identify more significantly altered proteins than the morphological classification system. In subsequent data analysis, Niemann-Pick disease type C2 protein (NPC2) and insulin-like growth factor-binding protein 7 (IGFBP7) were selected as novel biomarker candidates for AA and were compared with the previously reported biomarker, thrombospondin 1 (THBS1). Blood concentrations of NPC2 and IGFBP7 were significantly increased, while THBS1 levels were decreased in TAAA and abdominal atherosclerotic AA patients. Receiver operating characteristic analysis of AA patients and healthy controls showed that NPC2 and IGFBP7 have higher specificity and sensitivity than THBS1. Thus, NPC2 and IGFBP7 are promising biomarkers for the detection and progression evaluation of AA. The early detection and progression evaluation of AA are clinically urgent issues, because surgical treatments, such as the implantation of stent grafts or aortic prosthesis, are available5. AA is often detected by chance in diagnostic imaging, for example, by computed tomography, magnetic resonance imaging, or ultrasonic echo for other diseases, or during voluntary health examination6. However, highly sensitive and specific diagnostic tests for the detection of AA have not yet been developed. D-dimer and C-reactive protein (CRP) levels in the blood have been reported to be suitable for the diagnosis of AA9. However, these markers have poor disease specificity and effectiveness due to their primary design and aims, and do not reflect aortic tissue degeneration during the formation and progression of the aneurysm11. Therefore, novel biomarkers based on the molecular mechanism of the development and progression of AA are highly desired for the diagnosis of AA.Aortic aneurysm (AA) is a disease of aortic dilation that results in a bulge or swelling in the aorta. AAs are mostly asymptomatic, but they have a high mortality rate upon dissociation or rupture12. Although the pathogenic mechanism of atherosclerosis is not fully understood, it is well recognized that endothelial cell dysfunction occurs as a first step, followed by the accumulation of low-density lipoprotein (LDL) in endothelial spaces. LDL is then oxidised and induces inflammation, which stimulates the adhesion of monocytes to endothelial cells and their invasion into the vascular wall. The monocytes then differentiate into macrophages, ingest oxidized LDL, and finally transform into foam cells, which are the hallmark of the initiation of atherosclerosis13. During the progression of atherosclerosis, aortic smooth muscle cells (SMCs) differentiate into a synthetic phenotype and actively migrate from the aortic media to the lumenal side15. SMCs are the main components of atherosclerotic plaques derived from the aortic wall and some of them differentiate into foam cells16. Since the degeneration of the aortic media in the atherosclerotic lesion is a crucial step for disease progression, detailed omics analysis of the aortic media would allow the identification of essential factors associated with or participating in the development and progression of AA.A major cause of aortic aneurysm is atherosclerosis. In the advanced atherosclerosis lesion, aortic wall structure is usually disrupted and embrittled. Fragile aortas are then enlarged, resulting in an aneurysm19. Therefore, we designed this study to search for biomarker candidates from proteins differentially expressed between diseased and normal areas of the aneurysm. This study aimed to rationally select and narrow down candidate biomarkers and determine their blood concentrations in AA patients and controls. Thus, we performed proteomic analysis of diseased and normal areas of the aortic media in the aneurysm tissues excised from patients with thoracic atherosclerotic AA (TAAA). Based on hierarchical clustering analysis of these proteome analysis data, we established a new staging method, designated as a proteomics-based progression staging method, and identified proteins with significantly altered expression levels in AAs. Niemann-Pick disease type C2 protein (NPC2) and insulin-like growth factor-binding protein 7 (IGFBP7) were selected as novel biomarker candidates, and their significant elevation was confirmed in blood samples of patients with TAAA and abdominal atherosclerotic AA (AAAA).Since blood samples are most frequently used for diagnosis in the clinical setting, due to the minimal invasiveness of their collection, it is preferable to identify biomarkers that are measurable in the plasma or serum. However, the direct identification of biomarkers by comparing blood samples is still challenging, since the high concentrations of abundant proteins prevent the detection of minute alterations in low-concentration proteins. Although previous studies have attempted to identify novel biomarkers for AA in the blood, few biomarkers have been applicable to clinical practiceAs the first step in developing a new diagnostic method for AA, we performed proteome analysis of aortic media from patients with TAAA, to search for novel biomarkers of AA in the aortic wall. Table 21. 2DICAL data analysis resulted in the identification and quantification of 15,240 peptide peaks from all the aortic media samples analysed in this study. Protein levels in the aortic media were then calculated using in-house software, which averaged the multiple tryptic peptide peak data for each protein. Details of the protein identification and quantification procedures are described in the Supplementary Methods. Finally, the expression levels of 1311 proteins in the aortic media of TAAA patients were determined with a high degree of confidence and these were statistically compared.Firstly, to identify differentially expressed proteins between Group D and Group N, we performed non-target proteome analysis using nano-liquid chromatography, coupled with tandem mass spectrometry (LC-MS/MS), followed by quantitative data analysis using the 2DICAL software22. Unexpectedly, aortic media tissues of Group D and Group N were clearly classified into three clusters, regardless of their morphological features. Since these clusters were assumed to be associated with the disease progression of TAAA, based on the proteins used for clustering (see below), we tentatively designated the three clusters as Stage P , Stage I (intermediate), and Stage A (advanced)  Fig. .Figure 124, according to the stage of disease progression , Masson’s trichrome (MT), and elastica-van Gieson (EVG) staining were performed using the TAAA tissue sets representing the three tentative progression stages Fig. . Staininp < 0.05), while for the proteomics-based progression stages, a total of 919 proteins showed significantly different expression levels between Stage I and Stage P (688 proteins) (p < 0.05) or between Stage I and Stage A (597 proteins) (p < 0.05). We identified 2.5 times more differentially expressed proteins in the aortic media of TAAA patients using the new staging method. Therefore, using this staging method results in an increased chance of identifying new biomarker candidates.Next, we compared the numbers of differentially expressed proteins according to conventional morphological classification groups (Groups N and D) with those differentially expressed according to the novel proteomics-based progression stages  Fig. . For theTo discover useful and reliable biomarkers, we searched extensively for biomarker candidates for detecting the onset and progression of TAAA from the differentially expressed proteins in the aortic media of TAAA, according to the proteomics-based progression staging. The outline for the selection and investigation of biomarker candidates is shown in Fig. First, all proteins differentially expressed between Stage P and Stage I were listed. We then narrowed down from 688 proteins to 406 proteins by selecting those showing more than 1.4-fold change. These proteins were presumed to be associated with the progression of atherosclerotic AA. Next, we focused on the onset of atherosclerotic AA and compared protein levels in Stage P with those of NVDC tissues. Since the tissues in Stage P were in the initial stage of lesion formation, the differentially expressed proteins between Stage P and NVDC were assumed to be associated with the onset of atherosclerotic AA. For the NVDC samples, aortic roots excised from transplant recipients and ascending or descending aorta samples from autopsy cases were collected. Protein expression levels in the aortic media of these samples were analysed by the same proteome analysis method 30.To further narrow down the candidate proteins, we performed gene ontology (GO) analysis of the 275 proteins described above. A total of 125 GO terms  were enriched and of these, 26 GO terms were associated with atherosclerosis or blood vessel function  compared with HC subjects  than in HC subjects  and AAAA (n = 51) and HC subjects (n = 44), whose characteristics are summarised in Table ts Figs. . In contcts Fig. . We perfcts Fig. . We alsocts Fig. . These rTo discover novel biomarkers for the detection and progression evaluation of atherosclerotic AA, we performed proteome analysis of aortic media from TAAA patients and NVDCs. The aortic media is mainly composed of SMCs and matrices within the aortic wall and are recognized as the target tissue for the initiation and progression of atherosclerosis, which often results in AA. Therefore, the proteome analysis of aortic media of TAAA patients with different stages of disease progression was expected to identify biomarker candidates applicable to clinical practice. Using a morphological classification system, aortic aneurysm tissues were divided into aneurysm (Group D), border, and normal areas (Group N) based on their diameter and pathological features. Unexpectedly however, after hierarchical clustering analysis of proteome analysis data from the aortic media of TAAA patients (Groups D and N), aortic media samples were classified into three clusters according to their disease progression stage. This classification was confirmed by pathological examination, as well as by measuring the expression levels of proteins known to be altered in atherosclerotic AA Fig. . Of the To select useful and reliable biomarker candidates for atherosclerotic AA, we identified differentially expressed proteins using the proteomics-based progression staging system and then narrowed down the selection using several criteria, as shown in Fig. 34. Cholesterol accumulation is a crucial event in the development of atherosclerosis, and physiological roles of NPC1 in cholesterol transport and its association with atherosclerosis have been reported35. Although NPC2 is known to bind cholesterol and promote cholesterol transport, in conjunction with NPC1, its contribution to atherosclerosis has not yet been established. In atherosclerotic plaques, lysosomal enzymes are released from macrophages and hydrolyze LDL36. NPC2 is presumed to participate with NPC1 in cholesterol transport in lysosomes. From these data, it is reasonable to hypothesize that NPC2 is actively expressed in and secreted from macrophages, accumulates in atherosclerotic plaques, and shows elevated blood concentrations. In parallel with this hypothesis, immunohistochemical staining of NPC2 in atherosclerotic AA showed strong positive signals in the atheroma, in foam cells around cholesterol clefts, and in SMCs , though the difference was rather small; the median of THBS1 levels was 6% lower in the AA group than in the non-AA control group. In our present study, the median plasma THBS1 level in the AAAA group was 41% lower than that of the HC group (p < 0.001). Although the concentration range was approximately 30-fold lower in our study, probably because of the difference in samples (serum and plasma), a significant decrease in the THBS1 levels was commonly observed in both the studies.Moxon The blood levels of NPC2 and IGFBP7 in the TAAA groups were two fold-three fold higher than those in the HC group Fig. , which w45. We also analysed the correlation between the blood levels of NPC2, IGFBP7, and THBS1 with those of LDL cholesterol (LDL-C), high-density lipoprotein cholesterol (HDL-C), total cholesterol (TC), triglyceride (TG), and CRP. There was no significant correlation between these indices in patients with TAAA and AAAA. Even when HC subjects were added to the group of AA patients, a weak negative correlation (r = −0.36) was observed only between the NPC2 and the LDL-C levels and not between other combinations. Collectively, NPC2 and IGFBP7 have been considered as diagnostic biomarker candidates that are superior to the known AA biomarkers like THBS1 and have practically no correlation with the blood indices of lipid metabolism and inflammation.ROC analysis showed that NPC2 and IGFBP7 had higher diagnostic ability for TAAA and AAAA than the known AA biomarkers, based on the data shown in Fig. Based on the data described above, we concluded that these two proteins are promising biomarkers that should be clinically validated by measuring their levels in different stages and types of AA. THBS1 also showed diagnostic utility, but at a lower extent than NPC2 and IGFBP7. Since there are no atherosclerotic AA biomarkers in clinical use that directly reflect the pathological conditions of AA tissue, the newly identified biomarkers, NPC2 and IGFBP7, are expected to be effective in clinical applications. By evaluating correlation of their blood concentrations with clinical data of patients with AA and other related diseases in the large-scale study, the clinical significance of these biomarkers will be elucidated. This will pave the way for the diagnostic use of these biomarkers in clinical settings.There were several limitations of this study. Firstly, this study was a single-centre investigation with a limited number of patients and subjects; i.e., the numbers of TAAA, AAA, NVDC, and HC subjects were 29, 51, 14, and 44, respectively. In particular, the number of NVDCs was limited, due to the reasons described below. Thus, the blood levels of these novel biomarkers have not been compared in patients with different progression stages. Secondly, there was a large age difference between patients with TAAA or AAAA and NVDCs. Among the 14 NVDC samples collected, nine samples were from the root portions of aortas accompanying hearts excised from transplant recipients. Thus, the main reason for the age difference was the restriction on who can receive heart transplantations in Japan. We also collected additional aorta samples from autopsy cases who had not been diagnosed with vascular disease. These were in an age range comparable to TAAA and AAAA patients. However, pathological examination of these samples showed that most of the aortic tissues had atherosclerotic denaturation and only five samples were judged to be usable as NVDCs. There were also age differences between patients with TAAA or AAAA and HCs, since HC blood samples were collected during medical examinations of the general population. Thirdly, there was an unexpected personal and regional heterogeneity of the collected aortic tissues and the two sample areas  were not uniformly dissected and collected from AA tissues. Fourthly, our proteome analysis only targeted the aortic media of AAs and other aortic wall components, such as the intima, adventitia, and endothelium, have not yet been analysed. Finally, we did not confirm the genetic background of the TAAA and AAAA patients. Therefore, these data need to be interpreted and discussed under these limitations.In conclusion, we established a novel progression staging system for TAAA on the basis of the protein expression profiles in the aortic media, which consisted of the preclinical, intermediate, and advanced stages, and were confirmed by pathological evaluation. NPC2 and IGFBP7, the two novel biomarkers for TAAA and AAAA, would have not been discovered without this progression staging. This demonstrates that the proteomics-based progression staging system is effective and innovative as compared with the conventional morphological classification used in most studies. The present study will contribute towards establishing proteomics-based disease progression staging systems in other diseases, and may facilitate the discovery of new biomarkers.This study followed the principles of the Declaration of Helsinki and all patients provided written informed consent for tissue sampling and proteome analyses. The protocol was approved by the Institutional Review Board of the National Cerebral and Cardiovascular Center, Japan (M22–029). Aortic wall tissues were collected from TAAA (n = 29) and NVDC n = 14) patients. Blood samples were collected from TAAA (n = 29) and AAAA (n = 51) patients, and HC volunteers (n = 44), whose biochemical test results were within the normal limits. Details of the characteristics of the enrolled subjects have been listed in Table 4 patientNVDC patients were younger than the AA group patients (TAAA and AAAA). Among 14 NVDC patients, nine patients were heart transplant recipients, where the recipients were restricted by age in Japan, while the others were autopsy cases. HC subjects were also younger than the AA patients, since HC blood samples were collected during medical examinations of the general population. Mainly due to these reasons, there were age differences between the TAAA or the AAAA patients and the NVDC or the HC subjects. Levels of TC, LDL-C, and TG, and the systolic blood pressure were higher in the AA group than those in the NVDC patients. Levels of UA and TG were higher, and HDL-C were lower in the AA group than those in the HC subjects. Only in the case of CRP, the NVDC patients showed higher values than the AA group and the HC subjects, probably due to the implantation of a ventricular-assisted device (transplantation) and the courses of treatment (autopsy).Aortic wall tissues from the patients with TAAA were collected during elective surgery. NVDC thoracic aortic tissues were collected from the ascending or descending aortas of autopsy cases or from the root portions of aortas accompanying hearts excised from transplant recipients. The NVDC tissues had no prominent symptoms of atherosclerosis or vascular disease.Aortic wall tissues with dissociation or calcification were excluded to maintain the homogeneity of the tissues analysed. Aortic tissues were then divided into two sections according to the degree of morphological disease progression, as determined by the surgeons: 1) diseased area - maximum diameter region of the AA and 2) normal area - normal diameter and shape of the aorta. The border area between the normal area and the diseased area in the aneurysm was removed. Each tissue was further dissected into the intima, media, and adventitia. In this study, aortic media of the diseased area and the normal area from the TAAA patients were used for proteome analysis. These aortic media were weighed, divided into pieces, and frozen in liquid nitrogen. Aortic media of the NVDC tissues were also prepared using the same procedures. All samples were stored at −80 °C until proteome analysis.Blood samples were collected from the TAAA patients and the AAAA patients immediately before surgery, and not from the NVDC patients. Blood samples were also collected from the HC volunteers. Serum and plasma were separated by one or two centrifugation steps, respectively, at 3,000 rpm for 15 min at 4 °C. All samples were stored at −80 °C until biomarker measurements.21. Aortic media tissues were pulverized under frozen conditions at −80 °C using a Shake Master Neo instrument , suspended in methanol, and aliquoted to obtain a target amount of tissue (2 mg) in each tube. After centrifugation and evaporation to dryness, the pulverized tissue was suspended in 2% sodium deoxycholate and heated at 95 °C for 10 min to denature proteins and inactivate intrinsic proteases. After cooling, urea  and ammonium bicarbonate  were added and denatured tissues were digested with lysyl endopeptidase  at 37 °C for 3 h, followed by trypsin  at 37 °C for 20 h. Sodium deoxycholate was removed using the phase-transfer method46, and the resulting digests were desalted using C18 StageTips47. Tryptic peptides were dissolved in 50 μL of 0.1% formic acid and their concentrations were determined using a Qubit fluorometer . A portion of the tryptic peptide fraction (300 ng) was separated using a NanoFrontier nano-LC instrument , with a Halo ES-C18 column , using a gradient elution of acetonitrile in 0.1% formic acid from 2.0 to 11.6% acetonitrile for 5 min, followed by 11.6 to 45.2% acetonitrile for 60 min. The column effluent was introduced to a TripleTOF 5600 tandem mass spectrometer  and subjected to high-resolution MS and MS/MS analyses. Peptides were identified using MASCOT software , using UniProt as the reference database. Quantitative estimation of peptides was performed using 2DICAL2 software 21. Then, the protein levels were calculated using multiple peptide data from each protein. The detailed procedure for identification and quantification of proteins is summarised in Supplementary Methods.Tissue digestion and MS analysis were performed according to our previous reporthttp://david.abcc.ncifcrf.gov/) to calculate the enrichment of GO terms in biological processes49.Hierarchical cluster analysis of proteome data was performed with GeneSpring software , using Ward’s method. Differentially expressed proteins were analysed using the Database for Annotation, Visualization, and Integrated Discovery tool . Protein concentrations were determined using a Qubit fluorometer. The protein extract  was subjected to SDS-polyacrylamide gel electrophoresis in a 10–20% gradient gel  and then transferred onto a polyvinylidene difluoride (PVDF) membrane. After blocking with PVDF Blocking Reagent for Can Get Signal , the membrane was incubated with one of the following primary antibodies: rabbit polyclonal anti-human NPC2 antibody , rabbit polyclonal anti-human IGFBP7 antibody , rabbit polyclonal anti-human ACTB antibody , rabbit polyclonal anti-human GAPDH antibody , or mouse monoclonal anti-human THBS1 antibody . After washing, the membrane was incubated with the following secondary antibody: horseradish peroxidase-labeled anti-rabbit immunoglobulin G . Protein bands were visualized using an ECL Prime kit  and were detected on a LAS-2000 image analyser .50. The following antibodies were used for IHC analyses: anti-NPC2  and anti-THBS1 . Both of these antibodies were also used in western blotting analyses. For IGFBP7 analysis, a mouse monoclonal antibody against human IGFBP7  was used.Portions of the surgical specimens from the TAAA patients and the NVDC patients were immediately fixed with 4% formalin overnight  and then embedded in paraffin, without dissection into three layers. For conventional histochemistry, paraffin-embedded tissues were cut into 3 μm-thick sections using a sledge microtome, mounted on slides, and processed with HE, MT and EVG stains to determine aortic wall morphology. Immunohistochemical (IHC) procedures were performed as previously described, using formalin-fixed, paraffin-embedded sectionsThe concentrations of serum NPC2 and IGFBP7 and plasma THBS1 were measured using an NPC2 ELISA kit , an ELISA Kit for Insulin Like Growth Factor Binding Protein 7 , and a Human Thrombospondin-1 Quantikine ELISA Kit , respectively, according to the respective manufacturer’s instructions.StatFlex Ver.6  and BellCurve for Excel  were used for statistical analyses. Welch’s t-test was used for comparisons of two groups and the Steel-Dwass test was used for comparisons of three or more groups. In these analyses, a p-value less than 0.05 was considered significant. ROC analysis was performed to evaluate the capacity of biomarker candidates to discriminate between HCs and atherosclerotic AA patients (TAAA and AAAA). For the combined analysis of biomarker candidates, discriminant analysis was first performed using their concentration data and the resulting discriminant score was subjected to ROC analysis.Supplementary Information.


Background: Modified Makuuchi (MM) incision is less popular among the urological fraternity as Chevron, subcostal, flank, and midline incisions are commonly used for most of the complex renal and adrenal conditions. We present our experience and report the outcomes of patients operated using this incision.Materials and methods: The records of patients who underwent open surgery for upper abdominal urological conditions using MM incision over the last five years in our department were retrospectively reviewed. Patient demographics, laterality of the lesion, size of the lesion, level of inferior vena caval (IVC) thrombus, intraoperative blood loss, local tumor invasion, need for concomitant hepatectomy, need of diaphragmatic resection, use of self-retaining retractors, operative time, hospital stay, wound-related complications, and readmissions were analyzed.Results: Some 18 patients underwent open surgery by this incision for various complex renal and adrenal conditions during the study period. Patients included those with large upper pole renal and adrenal masses, renovascular conditions like renal artery aneurysm, renal/adrenal masses with liver and diaphragmatic infiltration requiring hepatectomy, diaphragmatic resections, or IVC thrombectomy. The mean size of renal and adrenal masses was 13.8 (±6.3) cm, mean operative time was 370 (±210.6) minutes, mean blood loss was 1124 (±990.3) mL, and mean hospital stay was 11.65 (±13.2) days. Four patients had surgical site infection (SSI) and one had readmission.Conclusion: The MM incision can be widely adapted for complex renal and adrenal surgeries and should become a part of the various commonly used incisions by urologists. Complex renal surgeries are usually operated by flank, Chevron, subcostal, midline, and thoracoabdominal incisions whenever an open surgery is deemed mandatory . SimilarThe medical records of all 18 patients who underwent complex open renal and adrenal surgeries via MM incision  was used for statistical analysis. Wound-related complications were expressed using Clavien Dindo Classification.Operations performed in these 18 patients included three RNs (mean size - 18.3 cm in maximum dimension) Figure , two RNs A special mention of RCC with IVC thrombus is needed here. One case of level I thrombus, three cases of level II, two cases of level III, and one case of level IV thrombus were operated. Surgeries of RCC with level I and level II thrombi were successfully performed by MM incision without any additional maneuvers. A case of level III IVC thrombus had a long bland thrombus in the infrarenal portion of IVC extending up to common iliac veins and this patient underwent IVC thrombectomy of tumour thrombus after complete liver mobilization by Piggyback technique, Pringle’s maneuver, control of extensive peritumoral collaterals and IVC interruption via double Makuuchi incision. Double Makuuchi incision consisted of a vertical limb extended from the angle of MM incision below the umbilicus up to the pubic symphysis Figure .Another patient had level IIId IVC thrombus with intrapericardial extension. Complete mobilization of the liver with opening of the central diaphragm tendon and the pericardium exposed the supradiaphragmatic and intrapericardial IVC thereby permitting IVC thrombus removal without a median sternotomy. The case of RCC with level IV IVC thrombus underwent nephrectomy and liver mobilization via MM incision and thrombectomy from the right atrium via median sternotomy by cranial extension of the vertical limb of MM incision.Similarly, a case of 30 cm x 30 cm right adrenal lesion with right renal, hepatic, diaphragmatic, and IVC infiltration was successfully operated via MM incision where adrenalectomy, en bloc right nephrectomy, resection of right hemidiaphragm, right hepatectomy, resection of an infiltrated segment of IVC followed by its graft reconstruction were done. Here, as supra-diaphragmatic IVC control was needed in view of hepatic venous involvement, a median sternotomy was done by cranial extension of the vertical limb of MM incision, and the procedure was completed successfully after veno-venous bypass Figure .We routinely use self-retaining retractors like Thompson or Bookwalter to maximize the exposure whenever a MM incision is employed.Patient demographics, diagnosis, surgery performed, various maneuvers employed, and outcomes are listed in Table The original description of Makuuchi incision by Masatoshi Makuuchi in 1993 seems to be similar to Giuliani’s incision which is described as an anterolateral transabdominal approach for renal tumors providing good visualization and good access to the renal pedicle, as well as good exposure caudally as far as the aortic bifurcation and cranially as far as the diaphragm . A modifThe traditionally used incisions like flank, subcostal, chevron and midline by the urologist for renal and adrenal pathologies are sufficient in most of the situations, but, for very large tumors or surgeries requiring the manipulation of great vessels and other structures like spleen, liver and pancreas, they have their own shortcomings . The flaThe utility of Makuuchi incision in major upper abdominal surgeries is described in great depth by Pandit et al. In their experience of 144 cases of upper gastrointestinal and hepato-pancreatico-biliary surgeries, the authors have described that the incision provided superior operative ergonomics, ease of entry and closure, ease of extension whenever required, maintained muscle integrity and resulted in less postoperative pain .The available literature of Makuuchi incision in renal and adrenal tumors, though sparse, has come up recently. In a study of 29 cases of renal tumors described by Ali Atan and colleagues, the authors performed 26 RNs and three partial nephrectomies. The mean tumor size was 11.3 cm roughly similar to our study parameter 12.8 cm). The authors have also described 11 cases of RCC with venous tumor thrombus operated through this incision  and higher blood loss [median: 900 (range: 300-3800) mL] in our study are supported by the fact that there are seven cases of RCC with IVC thrombus and two cases of RCC with liver infiltration and blood loss in such cases with longer operative times is usually anticipated. The MM incision provides excellent exposure to structures in the right upper abdomen for a wide variety of complex and advanced renal and adrenal pathologies mainly tumors. Also, urologists, cardiothoracic and liver surgeons can work through the same incision where renal/adrenal, major vascular and hepatobiliary/splenic pathologies are being dealt with simultaneously.


Motorcyclists are often victims of road traffic incidents. Though elderly patients seem to have worse survival outcomes and sustain more severe injuries than younger patients, concordance in the literature for this does not exist. The aim of the study is to evaluate the impact of age and injury severity on the mortality of patients undergoing motorcycle trauma.Data of 1725 patients consecutively admitted to our Trauma Center were selected from 2002 to 2016 and retrospectively analyzed. The sample was divided into three age groups: ≤ 17 years, 18–54 years, and ≥ 55 years. Mortality rates were analyzed for the overall population and patients with Injury Severity Score (ISS) ≥ 25. Differences in survival among age groups were evaluated with log-rank test, and multivariate logistic regression models were created to identify independent predictors of mortality.p = 0.049) and in those sustaining critical injuries . Age , ISS , and Revised Trauma Score (RTS)  resulted as independent predictors of death. Multivariate analysis identified head , chest , abdominal , and pelvic  injuries as independent risk factors related to mortality as well. Compared to the theoretical probability of survival, patients of all age groups showed a survival advantage when managed at a level I trauma center.A lower survival rate was detected in patients older than 55 years (83.6% vs 94.7%, We detected anatomical injury distributions and mortality rates among three age groups. Patients aging more than 55 years had an increased risk of death, with a prevalence of severe chest injuries, while younger patients sustained more severe head trauma. Age represented an independent predictor of death. Management of these patients at a level I trauma center may lead to improved outcomes. Motorcyclists represent a significant percentage of road traffic victims worldwide and have a greater risk of injury-related death than car occupants , 2. DespGenerally, young motorcyclists are more likely to be involved in incidents under the influence of alcohol, riding without insurance, or not wearing a helmet or other protective clothing . FurtherResults reported in the literature regarding mortality rates between younger and older motorcyclists and the patterns of injuries in different age groups are often discordant. Some authors suggest that advanced age may be associated with worse outcomes after motorcycle trauma whereas other studies suggest the opposite –13. The All details about trauma patients managed at Niguarda Hospital, a level 1 Trauma Center in Milan, Italy , are colData were recorded in a computerized spreadsheet  and analyzed with statistical software .The sample distribution was evaluated with Kolmogorov-Smirnov and Shapiro-Wilk tests resulting in a non-Gaussian distribution for any of the examined variable. Continuous variables were compared by independent sample Kruskal-Wallis test, while categorical variables were analyzed using Pearson’s chi-squared test. Mortality rates were obtained for the overall population and patients with ISS ≥ 25 considering the age group stratification mentioned above. In-hospital mortality was estimated calculating the elapsed time since admission to the Emergency Room to hospital discharge or death.p < 0.1) variables at bivariate analysis were included in the multivariate models p values below .05 were considered statistically significant.Survival curves were obtained with Kaplan-Meier analysis, and log-rank test was assessed to evaluate differences in cumulative survival among age groups. Bivariate logistic regression was used to provide odds ratio for individual variables, identifying possible predictors of mortality. Two different multivariate regression models were then built: one for general variables  and another one for injured anatomical regions in order to detect independent risk factors for death and to estimate the adjusted odds ratio (OR) and 95% confidence interval (CI). Only significant  system.The institution of trauma registry for all major trauma admitted to our trauma center has been approved by the Niguarda Ethical Committee Milano Area 3 (record number 534-102018). Given the retrospective nature of the study, a specific ethical review board approval was not required.n = 462) sustained critical injuries, as defined by an ISS ≥ 25.During a 14-year period, from 2002 to 2016, 6691 major trauma patients were managed at Niguarda Hospital, a level 1 Trauma Center in Milan, Italy. A total of 1725 motorcycle incident victims were selected from the trauma registry. One hundred thirty-four patients (7.8%) were less than 18 years old (group 1), 1447 (83.9%) between 18 and 54 years old (group 2), and 144 (8.3%) more than 55 years old (group 3). Of the overall population, 26.8%  in the older age group as compared to the other groups.p < 0.001). Probability of survival estimated with Trauma and Injury Severity Score (TRISS) was 91.44% ± 19.09 for group 1, 90.97% ± 21.1 for group 2, and 81.46% ± 29.39 for group 3 (p < 0.001).Since we started collecting comorbidities information from 2011 onward, ASA score was available only for 979 patients. More than 85% of this subset of patients had an ASA score of 1, and patients belonging to the third group had the greatest proportion of ASA 2 and 3. The comparison among groups showed a significant difference  (Table 725 (Tablp < 0.001). Moreover, survival was different in the three age groups. Patients aging more than 55 years showed a significantly worse prognosis compared with younger patients  were 30.4% in overall population and 57.2% when only AIS ≥ 3 were considered. Severe head injuries were prevailing in younger (37.3%) and chest injuries less represented (17%). In older patients, the opposite result was observed: critical chest injuries were more frequent (37.6%) than head injuries (24.2%).p = 0.358, OR 0.52, 95% CI, 0.129–2.095)Significant variables which correlated with mortality using bivariate logistic regression analysis were ISS, RTS, and PS. Because of substantial multicollinearity with age (variance inflation factor (VIF) 6.31), PS was excluded from the multivariate model. All variables entered in the multiple regression model were confirmed independent predictors of death , multivariate analysis demonstrated that head, chest, and abdominal injuries were independent risk factors related to mortality, with elevated odds ratios particularly for head and chest injuries Table .Table 4By comparing observed and TRISS-estimated survival rates, patients of all age groups treated at a trauma center had a survival advantage. The result was even more relevant when considering the subgroup of patients with ISS ≥ 25 and patients older of 55 years  and multivariate analysis confirmed that age is an independent predictor of death.ASA score was available just for a bit more than a half of our sample. Due to this limitation, we could not adjust our survival analysis for comorbidities. Anyway, the subgroup analysis failed to highlight a contribution of comorbidities on the survival outcome and the negative OR of bivariate logistic regression would indicate a worse outcome for lower ASA scores. This could be explained by the fact that all ASA 3 patients survived; by contrast, 22 out of 24 deaths in the subgroup were ASA 1.Despite the results of the subgroup analysis, because of the similar values of ISS and RTS between age groups, we tend to believe that older patients have a lower tolerance for injuries of the same severity and increased ASA score may be a determinant of worsen outcome.Talving et al. focused on the anatomical region injured, underlining that older patients, defined as greater than 55 years old, are significantly more likely to suffer severe head injuries, chest injuries, and spinal fractures . DischinIn our investigation, head injuries were the anatomic region most frequently injured overall. In the subset of severe injuries, chest injuries (33.1%) and head injuries (23.6%) were the most represented. By considering the group of critical injuries defined by an AIS 98′ ≥ 3, patients sustaining head trauma had a near 9-fold increased risk of death, whereas those sustaining chest and abdominal injuries had a 3.6-fold and a 2.4-fold increased mortality risk, respectively. Older ages were associated with higher mortality and with a higher frequency of chest injuries with less severe head injuries. The thoracic cage of the elderly is more prone to costal and sternal fractures resulting in severe injuries to internal organs, which may be fatal. Given the atrophy of the brain in elderly patients, severe head injuries may evolve more slowly, as more blood is required to cause increased intracranial pressure. Younger patients have less atrophy, and thus, an even small bleed may progress to clinically significant increased intracranial pressure.It is worth noting that on multivariate analysis, extremity injuries showed a correlation with a hypothetical improved prognosis . This effect could be explained by the high number of extremity injuries, present in approximately 20% of the overall population, the majority of whom have survived.In our sample mortality distributed in a bimodal fashion with a greater proportion of acute (within the first 48 h) rather than early or late deaths confirms the findings of other authors in the current literature –26. The Many data available in the literature demonstrate improved survival of major trauma patients when treated in a dedicated trauma center showing a reduction in mortality rate, length of hospital stay, and an improved physical function –30. MacKTo our knowledge, our study represents the largest single-center representation of major motorcycle injuries at a level 1 trauma center in Europe with the review of 1725 patient’s data collected in a standardized registry during a 14-year period.Nevertheless, some limitations exist in our study. A major concern could be raised considering that our data are not adequately weighted: especially in the older group, the influence of comorbidities on prognosis cannot be neglected. However, this type of data has started being gathered in the registry only since 2011, so our decision to not control for comorbidities is due to a lack of information in the database that eventually could alter the accuracy of the results. Finally, due to the non-homogeneous distribution of the sample among age groups (with most of the study population belonging to the young adults’ group), the opportunity to investigate the effect of every anatomical region injured in each age group was precluded. Moreover, it is possible that a potential survivorship bias comparing young, adults, and senior patients exists because in our database, information about pre-hospital are unavailable due to an increase of the pre-hospital mortality.Moreover, the Trauma and Injury Severity Score (TRISS) was originally conceived in 1983 and in 2010, and its coefficients were further revised , 33. ThiOur findings show anatomical injury distributions and mortality rates among three age groups of patients involved in motorcycle trauma. The age of the patient is a predictor of death, and patients older than 55 years showed an increased mortality rate, more commonly secondary to chest injuries as compared with younger patients. This finding could suggest the necessity of a more aggressive treatment for this subset of patients. Our study further strengthens the importance of utilizing a level I trauma center in the management of these patients as demonstrated by their improved survival rates.