Pancreaticogastrostomy versus Pancreaticojejunostomy and the Proposal of a New Postoperative Pancreatic Fistula Risk Score

Despite the substantial decrease in mortality rates following a pancreaticoduodenectomy to less than 5%, morbidity rates remain significant, reaching even 73%. Postoperative pancreatic fistula is one of the most frequent major complications and is significantly associated with other complications, including patient death. Currently, there is no consensus regarding the ideal type of pancreatic anastomosis, as the question of the choice between a pancreaticogastrostomy and pancreaticojejunostomy is still open. Furthermore, worldwide implementation of an ideal pancreatic fistula risk prediction score is missing. Our study found several significant predictive factors for the postoperative occurrence of fistulas, such as the soft consistency of the pancreas, non-dilated Wirsung duct, important intraoperative blood loss, other perioperative complications, preoperative patient hypoalbuminemia, and patient weight loss. Our study also revealed that for patients who exhibit fistula risk factors, pancreaticogastrostomy demonstrates a significantly lower pancreatic fistula rate than pancreaticojejunostomy. The occurrence of pancreatic fistulas has been significantly associated with the development of other postoperative major complications, and patient death. As the current pancreatic fistula risk scores proposed by various authors have not been consensually validated, we propose a simple, easy-to-use, and sensitive score for the risk prediction of postoperative pancreatic fistula occurrence based on important predictors from statistical analyses that have also been found to be significant by most of the reported studies. The new pancreatic fistula risk score proposed by us could be extremely useful for improved therapeutic management of cephalic pancreaticoduodenectomy patients.

Chronic Wound Management: From Gauze to Homologous Cellular Matrix

BACKGROUND

Chronic wounds are a significant health problem with devastating consequences for patients' physical, social, and mental health, increasing healthcare systems' costs. Their prolonged healing times, economic burden, diminished quality of life, increased infection risk, and impact on patients' mobility and functionality make them a major concern for healthcare professionals.

PURPOSE

This review offers a multi-perspective analysis of the medical literature focusing on chronic wound management.

METHODS USED

We evaluated 48 articles from the last 21 years registered in the MEDLINE and Global Health databases. The articles included in our study had a minimum of 20 citations, patients > 18 years old, and focused on chronic, complex, and hard-to-heal wounds. Extracted data were summarized into a narrative synthesis using the same health-related quality of life instrument.

RESULTS

We evaluated the efficacy of existing wound care therapies from classical methods to modern concepts, and wound care products to regenerative medicine that uses a patient's pluripotent stem cells and growth factors. Regenerative medicine and stem cell therapies, biologic dressings and scaffolds, negative pressure wound therapy (NPWT), electrical stimulation, topical growth factors and cytokines, hyperbaric oxygen therapy (HBOT), advanced wound dressings, artificial intelligence (AI), and digital wound management are all part of the new arsenal of wound healing.

CONCLUSION

Periodic medical evaluation and proper use of modern wound care therapies, including the use of plasma-derived products [such as platelet-rich plasma (PRP) and platelet-rich fibrin (PRF)] combined with proper systemic support (adequate protein levels, blood sugar, vitamins involved in tissue regeneration, etc.) are the key to a faster wound healing, and, with the help of AI, can reach the fastest healing rate possible.

Hyperferritinemia: the link between COVID-19, inflammation, and patient comorbidities

Ferritin is a key molecule in iron metabolism, as it stores the iron in a non-toxic form for the cells. Serum ferritin is a parameter that reflects the iron content of the body. However, serum ferritin is also an acute-phase reactant protein, as increased levels of serum ferritin are reported in many diseases associated with inflammation. Hyperferritinemia was also reported in COVID-19 (the coronavirus disease 19) patients, where it is considered an independent prognostic factor for the patients, indicating increased severity of the disease, risk for complications, and death. Certain categories of patients (older, those with comorbidities) have an increased risk of SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2) infectivity and developing more severe forms of COVID-19. Chronic/acute systemic inflammatory states often characterize such preexisting comorbidities. In the current paper, a new pathogenic link is proposed and analyzed: between preexisting hyperferritinemia in the context of patient comorbidities (metabolic, cardiovascular, kidney, inflammatory, autoimmune, cancer) and the risk of SARS-CoV-2 infectivity and of developing more severe forms of infection. Ferritin per se can be a causal agent in COVID-19, as it can generate and aggravate inflammation and contributes to the development of a severe cytokine storm. A severe, uncontrolled inflammatory state occurs, triggered by the high levels of serum ferritin, preexisting comorbidities, and SARS-CoV-2 infection, cause of lethality in many patients. The inflammatory stimuli can further aggravate the infection by activating ADAM-17 (disintegrin and metalloprotease 17), a key enzyme involved in ACE2 (angiotensin-converting enzyme 2) activation and viral infectivity. In this context, iron chelators and antioxidants could become potential lines of treatment in COVID-19.

ACE2 enzymatic role in the SARS-CoV-2 activation: a perspective through the evolutionary promiscuity and substrate diversity of enzymes

The SARS-CoV-2 is an RNA B type β-coronavirus that distinguishes itself from previous coronaviruses by its high infectivity and mortality rates. The mechanism of viral entry into the host cell via ACE2 is currently under research. Several proteases have been nominated to activate the virus but identifying the exact enzyme/enzymes is missing.   Moreover, recent work suggests that TMPRSS2 cannot be the enzyme to cleave the SARS-CoV-2 spike or that multiple proteases contribute to SARS-CoV-2 activation. The multitude of proteases that have been nominated to activate the virus suggests that the consensual identification of the precise, key enzyme is still missing. In this context, we synthesize the current controversies regarding the putative enzymes involved in SARS-CoV-2 infectivity and analyze whether ACE2 could have unexpected enzymatic roles in this process, besides its acknowledged receptor role. We hypothesize that ACE2 plays an enzymatic role as well in SARS-CoV-2 activation. Understanding the exact roles of ACE2 in COVID-19 is capital for the future design of specific, efficient therapies and deserves dedicated research. Our conviction is therefore not "if", “but” "when" will the researchers start to wonder about what is hidden behind the apparent only role of ACE2 as a receptor for SARS-CoV-2.

Renin-angiotensin-aldosterone system inhibitors – a realm of confusion in COVID-19

Currently, there is a persisting dispute regarding the renin-angiotensin-aldosterone-system (RAAS) inhibitors' safety of use in COVID-19 pandemics. On one side, RAAS inhibitors appear to determine an overexpression of ACE2, the receptor of SARS-CoV-2. Therefore, they could increase the risk of SARS-CoV-2 infection and its degree of severity. On the other side, the discontinuation of RAAS leads to cardiovascular decompensation and has been discouraged by the major medical societies. Also, large-cohort studies report beneficial or at least neutral effects for the RAAS inhibitors in COVID-19 patients. Worldwide, millions of patients receive RAAS inhibitors for the treatment of hypertension and other important comorbidities. In this context, knowledge of the exact effect of these medications becomes of crucial significance. This paper aims to fill in a gap in the current knowledge and presents a putative mechanism by which RAAS inhibitor administration's beneficial results can be explained better. RAAS inhibitors can be beneficial, as they counteract the excessive detrimental activation of the classical angiotensin-converting enzyme (ACE) axis, decreasing the angiotensin II levels. The angiotensin receptor blockers (ARBs) increase the angiotensin II levels, while the angiotensin-converting enzyme inhibitors (ACEI) increase the angiotensin I levels; these substrates will compete with the SARS-CoV-2 for the ACE2 binding, decreasing the viral infectivity. In addition, following the RAAS inhibitors treatment, the up-regulated ACE2 will cleave these substrates (angiotensin I and II), particularly to angiotensin 1-7 that possesses vasodilator, protective effects.

Understanding SARS-CoV-2 features of infectivity, aggressiveness, and transmissibility: an insect-vector theory for SARS-CoV-2 dissemination

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a ribonucleic acid–based (RNA-based) lineage B β-coronavirus characterized by 10-20 times higher infectivity and transmissibility even across species than previous coronaviruses. The significant infectivity rate of SARS-CoV-2 is due to its different host cell entry mechanisms that are mainly via angiotensin-converting enzyme 2 (ACE2) receptors contrasting earlier coronaviruses that used mainly the endosomal route. Due to the widespread distribution of ACE2 receptors throughout our body, various routes of infectivity are possible, highlighting the necessity of employing multiple forms of protection besides face masks to limit inter-human transmissibility. SARS-CoV-2 exhibits other remarkable features such as the ability to escape the immune system repeated genomic mutations that make it difficult to design a vaccine to address all viral strains and form huge host cell syncytia leading to massive tissue destruction. If we accept SARS-CoV-2 primary reservoir from bats, we should investigate the routes of viral inter-species propagation. In this article, a new theory is proposed- that the dissemination of the virus from the bats to other species and humans could have been possible via an insect vector, as insects possess significant amounts of both ACE2 receptors and a disintegrin and metalloprotease 17 (ADAM-17) enzymes that are essential for virus infectivity. .

Prognostic factors for the primary and secondary retroperitoneal sarcomas. Impact on the therapeutic approach

BACKGROUND

There is little knowledge on retroperitoneal sarcoma, but there are many controversies. The objective of the current study was to define the common and distinctive features of primary and secondary retroperitoneal sarcomas in terms of presentation, prognostic and therapeutic approach to improve the current management of these tumors. Vascular involvement impact was assesed in the two sets of patients.

PATIENTS AND METHODS

We have performed a retrospective and prospective study on a group of 34 patients diagnosed with primary and secondary retroperitoneal sarcomas.

RESULTS

We have found that primary and secondary retroperitoneal sarcomas have many common features, but hold distinctive aspects in terms of manifestation, predictors of survival and treatment.

CONCLUSIONS

Vascular involvement is one of the most important predictors of poor survival in primary retroperitoneal sarcoma patients, because it often limits radicality. In this group, radicality is a major prognostic factor for a higher survival. Instead, secondary retroperitoneal sarcomas appear to be less dependent on the radicality of the treatment and their survival can be increased by complementary treatments.

Primitive retroperitoneal tumors. Vascular involvement--a major prognostic factor

Primitive retroperitoneal tumors, although very rare, arouse an increased interest, because of the poor prognosis, unsatisfactory surgical and complementary therapy results. Up to now, the very low number of cases has impeded the acquisition of a unitary view of these tumors, a unanimously accepted algorithm of diagnostic and treatment being absent. Randomized trials regarding the effects of different therapies have not been possible. The main factor that can fundamentally increase the survival of these patients is radical resection, some authors even recommending compartmental surgery. We found no significant statistical difference between the survival rates of the patients with different types of non-radical interventions, that shoud be therefore, as much as possible, avoided. Our study evidences that vascular involvement is the main limiting factor in achieving radicality. The involvement of large retroperitoneal vessels makes often impossible a radical intervention, usually because of the lack of an adequate material and human endowment for ample vascular resections followed by laborious reconstructions. That is why, in our study, vascular involvement was associated with a decreased survival rate for operated patients. Therefore, we underline the necessity both of a solid material base and of establishing multidisciplinary surgical teams for adequate vascular interventions in oncologic general surgery.

An unusual sarcomatous retroperitoneal metastasis. A rare case report with a brief literature review

Retroperitoneal sarcomas are rare tumors associated with a high rate of recurrence and very bad prognosis. Their only efficient treatment is a negative- margin surgical resection that is extremely difficult to achieve. Retroperitoneal metastases from extremity sarcomas are considered unusual. In literature, such a metastatic pattern is described extremely rarely. In this paper we report a case of a very aggressive extremity chondrosarcoma, associated with local recurrence, multiple distant metastases, that finally led to a retroperitoneal metastasis. The recurrence and progression of the sarcoma in this localization were impressive, with a fast overcome of therapeutic options. Chemo- and radiotherapy have not proved to be efficacious in this context and they could have had a role in the deterioration of patient state of health. New tumor markers for the detection and follow-up of these tumors should be considered.

Cytomegalovirus antibody detection in blood donors and mothers of very low birth weight neonates by using three serologic methods

We compared three serologic methods for cytomegalovirus (CMV) antibody detection and determined the CMV antibody seroprevalence of blood donors and mothers of very low birth weight (less than 1250 g) neonates in the Greater Hartford region. CMV serology was determined for 577 healthy blood donors as well as for 147 mothers of premature infants. Plasma from blood donors and sera from mothers were tested by either latex agglutination (LA) or by an immunofluorescent antibody assay (IFA), and results were compared with those from an enzyme-linked immunosorbent assay (ELISA). Sensitivity and specificity for LA to ELISA were significantly better than for IFA to ELISA [sensitivity 79/81 (97%) vs 171/202 (85%), and specificity 90/94 (96%) vs 257/347 (74%), p less than 0.01]. These differences remained whether plasma or sera were tested. Borderline values explained only two (33%) of six LA-ELISA as well as only 70 (58%) of 121 IFA-ELISA discordance. CMV seroprevalence rate for the donor blood population was 38%, and for the mothers was 53%. The LA assay is superior to the IFA assay for CMV screening of blood donors and maternal populations.

Effect of calcium/phosphorus ratio on mineral retention in parenterally fed premature infants

We hypothesized that retention of parenterally delivered calcium (Ca) and phosphorus (P) is affected by the ratio of the delivered minerals and that a 1.7:1 ratio would be optimal since this is the ratio of retention of these minerals by the fetus. Forty-one very low birth weight (VLBW) infants were randomly assigned to one of three total parenteral nutrition (TPN) solutions that were different only in their Ca:P ratios: 2:1 (76 mg/kg/day Ca and 38 mg/kg/day of P), and 1.3:1 (58 mg/kg/day Ca and 45 mg/kg/day P), and 1.3:1 (58 mg/kg/day of Ca and 45 mg/kg/day of P). Serum levels of calcium, phosphorus, and alkaline phosphatase, retentions of calcium and phosphorus and urinary cyclic AMP levels were measured after 48 h on the assigned Ca to P ratio. Calcium retentions were higher with the 2:1 and 1.7:1 ratios and phosphorus retentions were higher with the 1.3:1 and 1.7:1 ratios. The 1.7:1 ratio allowed for the highest absolute retention of both minerals and was the closest to published in utero accretion of calcium and phosphorus. The serum and urine studies demonstrated no abnormalities on any of the three ratios. Cyclic AMPs were not different among groups and were not elevated compared to previous reports suggesting that none resulted in parathyroid hormone (PTH) stimulation. We conclude that the 1.7:1 ratio is better than higher or lower ratios for delivery of calcium and phosphorus in TPN solutions at the quantities studied.