A Single-Session Process-Based Cognitive-Behavioral Intervention Combined with Multimodal Rehabilitation Treatment for Chronic Pain Associated with Emotional Disorders

BACKGROUND AND OBJECTIVES

Defined by chronic pain, rheumatic diseases are often co-occurring with anxiety and depression. Among the available psychological interventions, cognitive-behavioral therapies have an already-proven efficiency in these cases. However, the need to adjust their structure became ubiquitous during the post-pandemic period. Hence, the objective of this study was to investigate the impact of a single-session, process-based cognitive-behavioral intervention for patients with rheumatic conditions within an in-patient setting.

MATERIALS AND METHODS

A total of 31 participants (mean age 58.9 years) completed the single-session intervention. Assessments were conducted prior to the intervention, post-intervention and after one month.

RESULTS

Pearson's correlations, paired samples T tests and a covariance analysis based on the Linear Mixed Model were performed for exploring the relations between baseline variables and evaluating the impact of the SSI intervention. Immediately after the intervention, a significant reduction in cognitive fusion (p = 0.001, d = 1.78), experiential avoidance (p = 0.001, d = 1.4) and dysfunctional behavioral processes was observed. At the one-month evaluation, participants reported decreased pain (p = 0.001, d = 1.11), anxiety (p = 0.004, d = 0.55) and depression (p = 0.001, d = 0.72).

CONCLUSIONS

The single-session, process-based approach represents a promising intervention in healthcare contexts, as an integrative part of a multimodal rehabilitation treatment in patients with rheumatic conditions.

Radiomics in the CT diagnosis of ovarian cystic malignancies - a pilot study

Background and aims

The conventional computed tomography (CT) appearance of ovarian cystic masses is often insufficient to adequately differentiate between benign and malignant entities. This study aims to investigate whether texture analysis of the fluid component can augment the CT diagnosis of ovarian cystic tumors.

Methods

Eighty-four patients with adnexal cystic lesions who underwent CT examinations were retrospectively included. All patients had a final diagnosis that was established by histological analysis in forty four cases. The texture features of the lesions content were extracted using dedicated software and further used for comparing benign and malignant lesions, primary tumors and metastases, malignant and borderline lesions, and benign and borderline lesions. Texture features' discriminatory ability was evaluated through univariate and receiver operating characteristics analysis and also by the use of the k-nearest-neighbor classifier.

Results

The univariate analysis showed statistically significant results when comparing benign and malignant lesions (the Difference Variance parameter, p=0.0074) and malignant and borderline tumors (the Correlation parameter, p=0.488). The highest accuracy (83.33%) was achieved by the classifier when discriminating primary tumors from ovarian metastases.

Conclusion

Texture parameters were able to successfully discriminate between different types of ovarian cystic lesions based on their content, but it is not entirely clear whether these differences are a result of the physical properties of the fluids or their appartenance to a particular histopathological group. If further validated, radiomics can offer a rapid and non-invasive alternative in the diagnosis of ovarian cystic tumors.

Early Versus Delayed Laparoscopic Cholecystectomy for Acute Cholecystitis: A Single Center Experience

Introduction: Acute cholecystitis (AC) represents a public health problem, increasing hospitalization costs, especially determined by the surgical treatment of these patients. Laparoscopic cholecystectomy (LC) has become the therapeutic gold standard, the timing of the intervention: early (ELC) versus late (DLC), is still debated, impacting the results. The primary objective of the study was to compare postoperative outcomes between ELC and DLC. Secondary objectives assessed surgical outcomes from the pre-pandemic period with those from the Covid-19 pandemic. Material and methods: A retrospective observational study is presented of 266 patients diagnosed with AC who were admitted to Clinic I of General Surgery, County Emergency Clinical Hospital of T #226;rgu Mure #351;, from 2018 to 2022. They were classified into the ELC group ( 72 hours from the onset of symptoms) and DLC ( 72 hours from symptom onset) and were further stratified into prepandemic and pandemic cohorts. Data on clinical symptoms, paraclinical data, surgical details, and postoperative course were collected and analyzed. Discussion: The results confirm fewer conversions to open surgery and reduced hospitalization in the ELC group. The pandemic did not significantly alter the timing of surgeries or patient demographics. Conclusion: In conclusion, ELC for AC patients offers significant advantages, justifying its preference over DLC Despite the decrease in the incidence of AC hospitalizations during the pandemic, postoperative outcomes are comparable to those in the pre-pandemic period. Future multicenter studies are recommended for a broader analysis of the efficacy of laparoscopic surgery in emergency settings.

Textural Analysis of the Hyperdense Artery Sign in Patients with Acute Ischemic Stroke Predicts the Outcome of Thrombectomy

Textural analysis is pivotal in augmenting the diagnosis and outcomes of endovascular procedures for stroke patients. Due to the detection of changes imperceptible to the human eye, this type of analysis can potentially aid in deciding the optimal type of endovascular treatment. We included 40 patients who suffered from acute ischemic stroke caused by large vessel occlusion, and calculated 130 different textural features based on the non-enhanced CT scan using an open-source software (3D Slicer). Using chi-squared and Mann-Whitney tests and receiver operating characteristics analysis, we identified a total of 21 different textural parameters capable of predicting the outcome of thrombectomy (quantified as the mTICI score), with variable sensitivity (50-97.9%) and specificity (64.6-99.4%) rates. In conclusion, CT-based radiomics features are potential factors that can predict the outcome of thrombectomy in patients suffering from acute ischemic stroke, aiding in the decision between aspiration, mechanical, or combined thrombectomy procedure.

Pregnancy-Associated Spontaneous Coronary Acute Dissection as a Cause of Sudden Cardiac Death-Autopsy Findings and Literature Review: Is COVID-19 Related?

Sudden cardiac death (SCD) is the leading cause of mortality globally (violent or non-violent), with few to no feasible remedies. The etiopathogenesis of SCD involves a complex and multilayered substrate in which dynamic factors interact with a preexistent cardiovascular pathology, which is often undiagnosed and untreated, leading to the rapid development of cardiac rhythm disorders and cardiac arrest. Cardiovascular disease is a rare but emerging factor in maternal mortality that can be justified by an upward trend in the mean age of pregnant individuals. Spontaneous coronary artery dissection (SCAD) is defined as a non-traumatic and non-iatrogenic separation of the coronary arterial wall by intramural hemorrhage with or without an intimal tear. The resulting intramural hematoma compresses the coronary arteries, reducing blood flow and causing myocardial ischemia. SCAD continues to be misdiagnosed, underdiagnosed, and managed as an atherosclerotic acute coronary syndrome, which may harm patients with SCAD. The latest research shows that individuals who have or have had coronavirus disease 2019 (COVID-19) may also present coagulation abnormalities, so infection with COVID-19 during pregnancy can increase this hypercoagulable condition, thus increasing the risk of SCAD and SCD. This present study reports two cases over 35 years, one being infected with SARS-COV2 one month before the event and the other being tested positive during admission, both asymptomatic, who were declared healthy on periodic clinical evaluations, with pregnancies over 35 weeks, with normal fetal development, which suddenly caused chest pain, dyspnea, and loss of consciousness, required emergency c-sections, and died suddenly after they were performed. In both cases, the cause of death was SCAD on the anterior-descending artery. In both cases, emergency percutaneous coronary intervention was performed. The second part of the study represents a literature overview of SCAD during COVID-19. In addition to pregnancy hormonal changes, other potential hormone-mediated SCAD triggers are still under discussion.

Intimal CD31-Positive Relative Surfaces Are Associated with Systemic Inflammatory Markers and Maturation of Arteriovenous Fistula in Dialysis Patients

BACKGROUND

Arteriovenous fistula dysfunction is a widely disputed subject in the scientific literature on end-stage kidney disease (ESKD). The main cause of mortality and morbidity in these patients is the non-maturation or dysfunction of the arteriovenous fistula. Despite the many complications, the native arteriovenous fistula remains the gold standard in the treatment of these patients requiring renal replacement. This study aims to discuss the predictive role of some systemic inflammatory biomarkers (NLR, PLR, SII, IL-6), intimal hyperplasia, and neoangiogenesis (characterized by intimal-media CD31-positive relative surface) in arteriovenous fistula maturation failure.

METHODS

The present study was designed as an observational, analytical, and prospective study which included patients diagnosed with ESKD with indications of radio-cephalic arteriovenous fistula (RCAVF). Demographic data, comorbidities, preoperative laboratory data and histological/digital morphometry analysis results were processed. The patients included were divided into two groups based on their AVF maturation status at 8 weeks: "Maturation" (Group 1) and "Failed Maturation" (Group 2).

RESULTS

There was no difference in the demographic data. In terms of comorbidities, the second group had a greater incidence of heart failure (p = 0.03), diabetes (p = 0.04), peripheral artery disease (p = 0.002), and obesity (p = 0.01). Additionally, regarding the laboratory findings, these patients had higher levels of serum uric acid (p = 0.0005), phosphates (p < 0.0001), and creatinine (p = 0.02), as well as lower levels of total calcium (p = 0.0002), monocytes (p = 0.008), and lymphocytes (p < 0.0001). Moreover, all inflammatory markers (p = 0.001; p < 0.0001; p = 0.006, and p = 0.03) and Ca-P product (p < 0.0001) had higher baseline values in Group 2. Upon immunohistochemical analysis, regarding the density of neoformed vessels, there was a higher incidence of CD31-positive surfaces (p = 0.006) and CD31-positive relative surfaces (p = 0.001); the NLR (r = 0.323; p = 0.03), PLR (r = 0.381; p = 0.04), SII (r = 0.376; p = 0.03), and IL-6 (r = 0.611; p < 0.001) are all significantly correlated with vascular density, as evidenced by CD31.

CONCLUSIONS

Heart failure, peripheral artery disease, obesity, and diabetes, as well as the systemic inflammatory markers (NLR, PLR, SII, IL-6), intimal hyperplasia, and CD31-positive relative surfaces are predictors of arteriovenous fistula maturation failures.

Increased Epicardial Adipose Tissue and Heart Characteristics Are Correlated with BMI and Predict Silent Myocardial Infarction in Sudden Cardiac Death Subjects: An Autopsy Study

BACKGROUND

Sudden cardiac death (SCD) is a significant global public health issue and the leading cause of death worldwide. Its etiopathogenesis is complex and multilayered, involving dynamic factors interacting with a preexistent cardiovascular pathology, frequently unknown, and resulting in cardiac rhythm disorders and cardiac arrest; Methods: This study conducted a retrospective descriptive analysis over a one-year period, identifying 321 autopsy cases of sudden deaths from the Institute of Legal Medicine in Mures County, Romania, in 2019. From the 321 sudden death cases, 189 autopsy reports were selected for analysis based on inclusion and exclusion; Results: The autopsies had a mean age of 61.16 years and included 140 males and 49 females. No significant differences were found between the silent myocardial infarction (SMI) and no-SMI groups regarding demographic data. The SMI group exhibited higher thickness of LV (left ventricle), IV (interventricular septum), EAT LCx (epicardial adipose tissue at left circumflex artery), EAT LAD (epicardial adipose tissue at left anterior descending artery), heart weight, and BMI (body mass index). The left coronary artery showed a higher incidence of type V plaques, while the right coronary artery showed higher incidences of type V and type VI plaque. The SMI group also exhibited a higher incidence of moderate and severe valvular atherosclerosis, severe left ventricle dilatation, and a lower incidence of mild left ventricle dilatation. In addition, the SMI group showed a higher presence of contraction band necrosis on histological examination. Multivariate analysis revealed that type V and type VI plaques for the right and left coronary arteries, moderate and severe valvular atherosclerosis, severe left ventricle dilatation, heart weight, EAT LCx, EAT LAD, LV thickness, IV thickness, BMI, and the presence of contraction band necrosis are all independent predictors of SMI; Conclusions: The findings suggest that SCD is a complex condition, and its etiopathogenesis involves dynamic factors interacting with pre-existing cardiovascular pathology. The risk factors of SCD are similar to those of ischemic heart disease. The findings of this study could guide clinicians in identifying patients at risk of SCD and implementing preventive measures.

Blood Count-Derived Inflammatory Markers Correlate with Lengthier Hospital Stay and Are Predictors of Pneumothorax Risk in Thoracic Trauma Patients

(1) Background: Trauma is one of the leading causes of death worldwide, with the chest being the third most frequent body part injured after abdominal and head trauma. Identifying and predicting injuries related to the trauma mechanism is the initial step in managing significant thoracic trauma. The purpose of this study is to assess the predictive capabilities of blood count-derived inflammatory markers at admission. (2) Materials and Methods: The current study was designed as an observational, analytical, retrospective cohort study. It included all patients over the age of 18 diagnosed with thoracic trauma, confirmed with a CT scan, and admitted to the Clinical Emergency Hospital of Targu Mureş, Romania. (3) Results: The occurrence of posttraumatic pneumothorax is highly linked to age (p = 0.002), tobacco use (p = 0.01), and obesity (p = 0.01). Furthermore, high values of all hematological ratios, such as the NLR, MLR, PLR, SII, SIRI, and AISI, are directly associated with the occurrence of pneumothorax (p < 0.001). Furthermore, increased values of the NLR, SII, SIRI, and AISI at admission predict a lengthier hospitalization (p = 0.003). (4) Conclusions: Increased neutrophil-to-lymphocyte ratio (NLR), monocyte-to-lymphocyte ratio (MLR), platelet-to-lymphocyte ratio (PLR), systemic inflammatory index (SII), aggregate inflammatory systemic index (AISI), and systemic inflammatory response index (SIRI) levels at admission highly predict the occurrence of pneumothorax, according to our data.

Increased Epicardial Adipose Tissue (EAT), Left Coronary Artery Plaque Morphology, and Valvular Atherosclerosis as Risks Factors for Sudden Cardiac Death from a Forensic Perspective

Background: In sudden cardiac deaths (SCD), visceral adipose tissue has begun to manifest interest as a standalone cardiovascular risk factor. Studies have shown that epicardial adipose tissue can be seen as a viable marker of coronary atherosclerosis. This study aimed to evaluate, from a forensic perspective, the correlation between body mass index (BMI), heart weight, coronary and valvular atherosclerosis, left ventricular morphology, and the thickness of the epicardial adipose tissue (EAT) in sudden cardiac deaths, establishing an increased thickness of EAT as a novel risk factor. Methods: This is a retrospective case−control descriptive study that included 80 deaths that were autopsied, 40 sudden cardiac deaths, and 40 control cases who hanged themselves and had unknown pathologies prior to their death. In all the autopsies performed, the thickness of the epicardial adipose tissue was measured in two regions of the left coronary artery, and the left ventricular morphology, macro/microscopically quantified coronary and valvular atherosclerosis, and weight of the heart were evaluated. Results: This study revealed a higher age in the SCD group (58.82 ± 9.67 vs. 53.4 ± 13.00; p = 0.03), as well as a higher incidence in females (p = 0.03). In terms of heart and coronary artery characteristics, there were higher values of BMI (p = 0.0009), heart weight (p < 0.0001), EAT of the left circumflex artery (LCx) (p < 0.0001), and EAT of the left anterior descending artery (LAD) (p < 0.0001). In the multivariate analysis, a high baseline value of BMI (OR: 4.05; p = 0.004), heart weight (OR: 5.47; p < 0.001), EAT LCx (OR: 23.72; p < 0.001), and EAT LAD (OR: 21.07; p < 0.001) were strong independent predictors of SCD. Moreover, age over 55 years (OR: 2.53; p = 0.045), type Vb plaque (OR: 17.19; p < 0.001), mild valvular atherosclerosis (OR: 4.88; p = 0.002), and moderate left ventricle dilatation (OR: 16.71; p = 0.008) all act as predictors of SCD. Conclusions: The data of this research revealed that higher baseline values of BMI, heart weight, EAT LCx, and EAT LAD highly predict SCD. Furthermore, age above 55 years, type Vb plaque, mild valvular atherosclerosis, and left ventricle dilatation were all risk factors for SCD.

Systemic Inflammatory Biomarkers and Chest CT Findings as Predictors of Acute Limb Ischemia Risk, Intensive Care Unit Admission, and Mortality in COVID-19 Patients

Background: Numerous tools, including inflammatory biomarkers and lung injury severity scores, have been evaluated as predictors of thromboembolic events and the requirement for intensive therapy in COVID-19 patients. This study aims to verify the predictive role of inflammatory biomarkers [monocyte to lymphocyte ratio (MLR), neutrophil to lymphocyte ratio (NLR), platelet to lymphocyte ratio (PLR), systemic inflammatory index (SII), Systemic Inflammation Response Index (SIRI), and Aggregate Index of Systemic Inflammation (AISI)] and the CT Severity Score in acute limb ischemia (ALI) risk, intensive unit care (ICU) admission, and mortality in COVID-19 patients.; Methods: The present study was designed as an observational, analytical, retrospective cohort study and included all patients older than 18 years of age with a diagnosis of COVID-19 infection, confirmed through real time-polymerase chain reaction (RT-PCR), and admitted to the County Emergency Clinical Hospital of Targu-Mureș, Romania, and Modular Intensive Care Unit of UMFST “George Emil Palade” of Targu Mures, Romania between January 2020 and December 2021. Results: Non-Survivors and “ALI” patients were associated with higher incidence of cardiovascular disease [atrial fibrillation (AF) p = 0.0006 and p = 0.0001; peripheral arterial disease (PAD) p = 0.006 and p < 0.0001], and higher pulmonary parenchyma involvement (p < 0.0001). Multivariate analysis showed a high baseline value for MLR, NLR, PLR, SII, SIRI, AISI, and the CT Severity Score independent predictor of adverse outcomes for all recruited patients (all p < 0.0001). Moreover, the presence of AF and PAD was an independent predictor of ALI risk and mortality. Conclusions: According to our findings, higher MLR, NLR, PLR, SII, SIRI, AISI, and CT Severity Score values at admission strongly predict ALI risk, ICU admission, and mortality. Moreover, patients with AF and PAD had highly predicted ALI risk and mortality but no ICU admission.

Uncommon Surgical Management by AVF between the Great Saphenous Vein and Anterior Tibial Artery for Old Radiocephalic AVF Failure

Introduction: Autologous native arteriovenous fistula (AVF) created in the non-dominant arm is the gold standard vascular access for dialysis in end-stage renal disease, but the post-surgical vascular access dysfunction causes a reduction in the patient’s quality of life. Creating a functional upper extremity permanent arteriovenous access is limited by the upper limb’s vascular resources, so good management of a complicated arteriovenous fistula may improve patient outcomes. This article highlights the importance of new surgical options in treating complicated AVFs. Case report: We present the case of a patient with a 17-year-old complex radio-cephalic arterio-venous fistula and a series of surgical interventions performed for life salvage in the first place and functional vascular access in the second place. Furthermore, we describe a successfully created uncommon type of fistula in the lower extremity between the great saphenous vein and the anterior tibial artery as the last possible access for hemodialysis in this patient. Results: The patient underwent the first successful dialysis using the newly created lower limb fistula 1 month after the surgery. Conclusion: Applying new surgical techniques to manage AVFs gives a unique chance to improve the quality of life and reduce morbidity and mortality in these patients.

CT in the Differentiation of Gliomas from Brain Metastases: The Radiomics Analysis of the Peritumoral Zone

Due to their similar imaging features, high-grade gliomas (HGGs) and solitary brain metastases (BMs) can be easily misclassified. The peritumoral zone (PZ) of HGGs develops neoplastic cell infiltration, while in BMs the PZ contains pure vasogenic edema. As the two PZs cannot be differentiated macroscopically, this study investigated whether computed tomography (CT)-based texture analysis (TA) of the PZ can reflect the histological difference between the two entities. Thirty-six patients with solitary brain tumors (HGGs, n = 17; BMs, n = 19) that underwent CT examinations were retrospectively included in this pilot study. TA of the PZ was analyzed using dedicated software (MaZda version 5). Univariate, multivariate, and receiver operating characteristics analyses were used to identify the best-suited parameters for distinguishing between the two groups. Seven texture parameters were able to differentiate between HGGs and BMs with variable sensitivity (56.67–96.67%) and specificity (69.23–100%) rates. Their combined ability successfully identified HGGs with 77.9–99.2% sensitivity and 75.3–100% specificity. In conclusion, the CT-based TA can be a useful tool for differentiating between primary and secondary malignancies. The TA features indicate a more heterogenous content of the HGGs’ PZ, possibly due to the local infiltration of neoplastic cells.

Multiple Hepatic Hydatid Cysts - Review of the Literature and Case Report

Introduction: Hydatid disease is a parasitic disease caused by and is commonly met in clinical practice. The most common location for hydatic cysts is the liver, while the lung is the second organ in terms of localization frequency. Case report: We present the case of a 40-year-old patient with pulmonary hydatid cysts (two hydatid cysts located in the upper and lower pulmonary left lobes), and multiple hepatic hydatid cysts (ten cysts located in both hepatic lobes). Initially, the patient underwent thoracic surgery and was subjected to atypical lung resection of the upper and lower left pulmonary lobes. The patient underwent surgical treatment of the hepatic hydatid cysts 6 months after the thoracic surgery. The patient underwent multiple partial cystectomies, cholecystectomy, Kehr drainage with two hepatic hydatid cysts showing biliary fistulas. The postoperative evolution was favorable with patient discharge 10 days following surgery. Conclusions: Although the hepatic hydatid cyst is a seemingly benign disease, there are complex cases of disseminated echinococcosis in clinical practice that may require complex treatment. Surgical treatment remains the best therapeutic option in these cases. Thus, for these patients, a careful postoperative follow-up is required to detect recurrence of hydatid disease.

The Importance of Neutrophil to Lymphocyte Ratio and Platelet to Lymphocyte Ratio in Predicting the Appearance of the Rectal Stenosis or Rectal Obstruction in Patients with Rectal Adenocarcinomas

The purpose of this study was to establish a correlation between markers of inflammation and the risk of rectal stenosis or obstruction, in patients with rectal adenocarcinomas. We performed a retrospective observational study on 188 patients diagnosed with rectal adenocarcinomas. We attempted to establish a correlation between the neutrophils to lymphocyte ratio(NLR), platelet to lymphocyte ratio(PLR) levels and the presence of rectal stenosis or rectal obstruction. From 188 patients included in the study, 65 patients had stenotic tumors (34.57% of cases) and 10 patients had occlusive tumors (5.31% of cases). We obtained a statistically significant correlation between the blood levels of neutrophils, lymphocytes, platelets, and the existence of rectal stenosis. (p[0.05). The cutoff value of NLR that correlates with the presence of rectal stenosis was 2.5 (95% CI: 0.426-0.574, AUC: 0.500). As for PLR, the cutoff value correlated with the presence of rectal stenosis was 106,522 (95%CI: 0.428-0.575, AUC: 0.502). We established a statistically significant correlation between NLR, PLR and rectal obstruction (p[0.05). The cutoff value of the NLR that correlates with the presence of rectal obstruction was 4.633 (95%CI: 0.614-0.751, AUC: 0.685). As for PLR, the cutoff value correlated with the presence of rectal stenosis was 345.05 (95% CI: 0.673-0.803, AUC: 0.742). Our study shows that there is a statistically significant correlation between NLR and PLR and the risk of rectal obstruction in patients with adenocarcinomas. It is still necessary to conduct prospective studies on much larger lots of patients to determine the NLR and PLR values that can predict rectal stenosis as well as rectal obstruction.

Regeneration of Bone Defects Using Bioactive Glass Combined with Adipose-derived Mesenchymal Stem Cells. An experimental in vivo study

Large bone defects are a medical concern as these are often unable to heal spontaneously, based on the host bone repair mechanisms. In their treatment, bone tissue engineering techniques represent a promising approach by providing a guide for osseous regeneration. As bioactive glasses proved to have osteoconductive and osteoinductive properties, the aim of our study was to evaluate by histologic examination, the differences in the healing of critical-sized calvarial bone defects filled with bioactive glass combined with adipose-derived mesenchymal stem cells, compared to negative controls. We used 16 male Wistar rats subjected to a specific protocol based on which 2 calvarial bone defects were created in each animal, one was filled with Bon Alive S53P4 bioactive glass and adipose-derived stem cells and the other one was considered control. At intervals of one week during the following month, the animals were euthanized and the specimens from bone defects were histologically examined and compared. The results showed that this biomaterial was biocompatible and the first signs of osseous healing appeared in the third week. Bone Alive S53P4 bioactive glass could be an excellent bone substitute, reducing the need of bone grafts.

Transarterial Chemoembolization (TACE) with Lipiodol� in HCC PatientsTechnical, clinical and imagistic aspects

Hepatocellurar carcinoma (HCC) is the most frequent primary hepatic tumor, the vast majority of patients have less than a 12 month survival rate. The aim of this study was to evaluate the efficacy of TACE in patients with HCC, based on a case series and literature review. The study included 12 consecutive patients with HCC who underwent surgical treatment (resection, liver transplantation � resection) at the Department of Transplantation and Surgery, Semmelweis University, Budapest, during 2009-2015. All the patients received at least one TACE session. Patients with BCLC B-stage who benefit from TACE and another alternative therapy (eg, RFA) may be associated with or exhibit tumor stagnation, or tumor necrosis in most cases. In C BCLC stages, desperate cases - the two patients to whom TACE was the last therapeutic attitude, despite the predicted prognosis, TACE assured the prolongation of life and increased life quality. In the majority of patients in this study, stage A BCLC, chemoembolization was a therapeutic attitude that allowed subsequent liver transplantation (when it was not feasible initially due to tumor size) or liver resection in apparently inoperable cases. The arterial chemotherapy is the unanimously accepted indication in patients with stage B, BCLC. The data presented encourages us to opt for TACE with the intention of destaging BCLC and giving an operability character to the hepatic tumors (resection � hepatic transplantation). In stage C BCLC, TACE can be a last attempt to improve the quality of life and to control tumor progression.

The use of heterologous bovine pericardium in the surgical treatment of large tracheo-oesophageal fistulas and dilaceration of the membranous wall of the trachea. Case report

The tracheo-oesophageal fistula is a severe condition endangering the patients' live. The main cause of this condition is the prolonged ventilation. The purpose of this paper is to present an innovative technique in treating this affection. CASE REPORT: We present the case of a 32 years old female patient with multiple trauma due to traffic accident. The patient was hospitalized with the diagnosis of brain injury, subarachnoid hemorrhage, and fractured femur. After 11 days of mechanical ventilation and intubation via endotracheal route, the patient was diagnosed with a large (7x3 cm) tracheo-oesophageal fistula with dilaceration of the membranous wall of the trachea. A cervical and right thoracic approach was performed to repair the tracheo-oesophageal fistula. The reconstruction of the membranous wall of the trachea was performed by using heterologous bovine pericardium patch, and the of the esophageal defect using single-layer suture protected by a heterologous bovine pericardium patch. The postoperative evolution was favorable, the patient being discharged 22 days postoperatively and in good health after 6 months. To our knowledge this is the first reported case regarding the use of two heterologous bovine pericardium in the surgical treatment of large tracheo-oesophageal fistula with dilaceration of the membranous wall of the trachea to reconstruct the membranous wall of the trachea and to protect the esophageal suture. KEY WORDS: Heterologous bovine pericardium, Trachea-oesophageal fistula.

Chronic impalement- Case report of a knitting needle 33 years' ascension

Background

We report the case of a 72-year-old female complaining of hemoptysis due to a thoracic-abdominal knitting needle inserted 33 years ago for self-induced abortion.

Case Presentation

The PA/LL chest x-ray showed a metallic foreign body on thorax extending into the abdomen. An CT examination confirmed the transdiaphragmatic knitting needle extending from liver into right upper lobe.

Conclusions

Surgical removal of the foreign body and wedge resection were performed with good follow-up results.

Allele-specific PCR method for identification of EGFR mutations in non-small cell lung cancer: formalin-fixed paraffin-embedded tissue versus fresh tissue

The study of epidermal growth factor receptor (EGFR) gene mutations in lung adenocarcinoma patients has a special clinical significance in the selection of patients for tyrosine-kinase inhibitor therapy. The aim of this study was to identify patients with EGFR mutations using allele-specific polymerase chain reaction (PCR), from formalin-fixed paraffin-embedded (FFPE) tissue and fresh tissue (FT).

MATERIALS AND METHODS

We performed a retrospective study using 13 cases of FFPE lung adenocarcinoma, and a prospective study using seven fresh samples of lung carcinomas (FT), collected by intraoperative dissection of the tumors. Using the DNA extracted from the FFPE tissue and FT, we attempted to identify deletions of exon 19 and point mutations of exon 21, according to the allele-specific PCR method described by Dahse et al. (2008).

RESULTS

In all seven cases of FT (three adenocarcinomas, three squamous carcinomas, one large-cell carcinoma), we identified the wild type allele and the internal control in case of exon 19, and the wild type allele for exon 21, but not the mutated alleles. Considering that no standard method for formalin fixation and paraffin embedding has been implemented at the Laboratory of Pathology, the DNA extracted from these samples became fragmented and damaged, which compromised the results of PCR testing aimed at the detection of EGFR mutations.

CONCLUSIONS

The presented method can be implemented at our laboratory to identify these mutations from fresh tissue collected during surgical resection. Additionally, standardization of formalin fixation and paraffin embedding of surgical samples is required, in order the enable subsequent processing using molecular biology methods.

A fatal complication of an incarcerated diaphragmatic hernia: pyo-pneumopericardium due to a gastro-pericardial fistula Case report and literature review

INTRODUCTION

The pyo-pneumopericardium is a very rare complication of an incarcerated diaphragmatic hernia. Usually, it depends on the existence of a gastropericardial fistula and, in most cases, it is a deadly complication.

CASE REPORT

We present the case of a 65 year old man who was admitted to our emergency service with clinical signs of septic shock. With the help of the CT scan a pyo-pneumopericardium and incarcerated diaphragmatic hernia was diagnosed. He was subjected to emergency surgical intervention with double approach (thoracic and abdominal), discerning during surgery the existence of a pericardial abscess due to a gastro-pericardial fistula due to an incarcerated diaphragmatic hernia. The gastric fundus was resected with abolition of the gastro-pericardial fistula, evacuation of the pericardial abscess, performing the splenectomy (in order to have a better surgical access) and adequate treatment of the diaphragmatic hernia. Despite the medical efforts, the patient died on the 10th postoperative day due to septic complications. To our knowledge this is the first case reported in the literature of gastro-pericardial fistula complicated with pyo-pneumo-pericardium due to an incarcerated diaphragmatic hernia. In such cases we consider that only by performing a double surgical approach (thoracic and abdominal) we can provide a proper resolution of the case, also based on the objective situation found during surgery, where the splenectomy can provide an easier approach to the diaphragmatic hernia.

KEY WORDS

Diaphragmatic hernia, Gastropericardial fistula, Pyo-pneumopericardium.

A fatal complication of an incarcerated diaphragmatic hernia Pyo-pneumopericardium due to a gastro-pericardial fistula, case report and literature review

A fatal complication of an incarcerated diaphragmatic hernia: pyo-pneumopericardium due to a gastro-pericardial fistula, case report and literature review

INTRODUCTION

The pyo-pneumopericardium is a very rare complication of an incarcerated diaphragmatic hernia. Usually, it depends on the existence of a gastropericardial fistula and, in most cases, it is a deadly complication.

CASE REPORT

We present the case of a 65 year old man who was admitted to our emergency service with clinical signs of septic shock. With the help of the CT scan a pyo-pneumopericardium and incarcerated diaphragmatic hernia was diagnosed. He was subjected to emergency surgical intervention with double approach (thoracic and abdominal), discerning during surgery the existence of a pericardial abscess due to a gastro-pericardial fistula due to an incarcerated diaphragmatic hernia. The gastric fundus was resected with abolition of the gastro-pericardial fistula, evacuation of the pericardial abscess, performing the splenectomy (in order to have a better surgical access) and adequate treatment of the diaphragmatic hernia. Despite the medical efforts, the patient died on the 10th postoperative day due to septic complications. To our knowledge this is the first case reported in the literature of gastro-pericardial fistula complicated with pyo-pneumo-pericardium due to an incarcerated diaphragmatic hernia. In such cases we consider that only by performing a double surgical approach (thoracic and abdominal) we can provide a proper resolution of the case, also based on the objective situation found during surgery, where the splenectomy can provide an easier approach to the diaphragmatic hernia.

Significant Shrinkage of Multifocal Liver Metastases and Long-Term Survival in a Patient With Rectal Cancer, After Trans-Arterial Chemoembolization (TACE): A Case Report

In this paper, we present the successful therapeutic approach of unresectable liver metastases in a patient with rectal cancer.A 63-year-old male underwent endoscopic polypectomy followed by rectosigmoid resection for an adenocarcinoma of the rectum diagnosed in pT2N0 stage. The angio-computed tomography (CT) revealed four metastatic hepatic nodules ranging from 12 to 130 mm in diameter. After one cure of trans-arterial chemoembolization (TACE) with lipiodol and 5-fluorouracil, combined with FOLFOX4 + capecitabine systemic chemotherapy, the diameter of all hepatic nodules decreased to half size, at 6 months after TACE. Further curative surgical hepatic metastasectomy was done and complete pathologic response was obtained. The patient is free of recurrences and metastases after 26 months of follow-up.This representative case shows that an efficient trans-disciplinary approach could lead to successful therapeutic management even in patients with advanced-staged colorectal carcinomas.

Large piece of wood board removal and long term survival in a patient with stabbed thoracic wound - case report

Stabbed thoracic trauma is quite common in military practice,but they very rarely occur in civilian life, where they are predominantly accidental injuries. Thoracic stabbed wounds are more commonly observed in men than in women and in younger rather than older people. The management and prognosis depend on the composition, size and location of the foreign body. A 28-year-old Caucasian woman presented to the emergency room with hemorrhagic shock, a large stabbed wound and retention of a large piece of wood board.Less than 10 minutes after arriving to the emergency room she underwent open surgical thoracotomies and resection of the spleen rupture without any significant postoperative complications. At the end of the procedure the left breast was reconstructed. The original aspects of this case are the singularity of the foreign body and its relative harmlessness in spite of its large size.

New ways of bronchial stump closure after lung resection: experimental study

INTRODUCTION

Lung surgery has long been associated with a high rate of mortality and morbidity. Bronchial stump fistula is one of the leading causes of high morbidity and high mortality rate. The objectives of our study are to asses the effect of new ways of closure the bronchial stump after lung resections.

MATERIALS AND METHODS

For our study, we used eighteen adult rabbits. We performed left trans-thoracic inferior lobectomy to each animal because left lung functional capacities are smaller than right lung functional capacities. The bronchial stump was closed in three different ways: simple running suture of 5.0 monofilament polypropylene (Sweet procedure), running suture of 5.0 monofilament polypropylene (horizontal "U" shape model) and Vycril patch, running suture of 5.0 monofilament polypropylene (horizontal "U" shape model) and bovine pericardium patch. All surviving rabbits were sacrificed in 30 day postoperatively.

RESULTS

In our study, we did not notice any deaths among our experimental animals and we did not observe any bronchial stump fistula. In the group of rabbits in which the bronchial stump was closed using a patch of heterologous bovine pericardium, the histological exams revealed a cvasinormal bronchial wall with a normal bronchial epithelium and basal membrane integrity and no inflammatory lympho-plasmocytary infiltrate cell, absence of macrophages at this level.

CONCLUSIONS

Using the heterologous bovine pericardium patch to reinforce the bronchial stump could be beneficial because of the faster healing and scarring process. To our knowledge, no studies have previously evaluated this procedure of bronchial stump closure. Our findings could therefore, serve as an impetus for further research in this area.

[Preliminary results regarding vascular endothelial growth factor (VEGF-A) levels in the serum of gastric cancer patients]

The most studied VEGF molecule is VEGF-A (Vascular Endothelial Growth Factor). Its involvement in various neoplastic processes represents an intensely controversial hypothesis.

MATERIAL AND METHODS

This is a prospective study extending over a period of 7 months, and including 38 hospitalized patients who underwent surgery for gastric cancer between 01/01/2011-07/01/2011, at the Surgery Departments of the Emergency Clinical County Hospital Mureş. Survival rate was determined based on age and gender of the patients, the macroscopic and microscopic appearance of the tumor, and pT, N, M parameters of the resected specimens. All these tumor parameters were correlated with preoperative VEGF-A levels, measured at the Central Laboratory of the Emergency Clinical County Hospital Mureş, using plasma samples and a human VEGF ELISA kit with cross-reactivity with VEGF 165 (BioLife Group), according to the instructions provided by the manufacturer. No enrolled patient had any preoperative treatment. In order to establish the reference value for VEGF-A in serum, we tested a group of 14 apparently healthy persons, and we calculated a mean value.

RESULTS

The reference value for VEGF-A in serum was 157.3 pg/ml. In gastric cancer patients the preoperative VEGF-A levels were 376, 188 +/- 247.11, showing significant elevation vs. the control group (p < 0.001), but it did not correlate with any of the tested tumor parameters. Survival rate displayed statistical correlation with histological type of the tumor, and VEGF-A serum levels, so that patients with intestinal type gastric cancer showed a superior survival vs. those with diffuse type (p = 0.0043). A better survival was noted in patients with VEGF-A serum levels over the threshold value of 173 pg/ml.

DISCUSSION AND CONCLUSIONS

The VEGF-A levels in serum are significantly increased preoperatively in gastric cancer patients, compared to apparently healthy persons, but they do not show correlation with tumor parameters. As a result it cannot be used as prognostic factor, but it may be an evolution marker. Survival rate is significantly higher in intestinal type gastric cancers, ads compared to the diffuse type, as well as in patients with serum VEGF-A values over the threshold value.