Host and immunosuppression-related factors influencing fibrosis occurrence post liver transplantation

Post liver transplantation (LT) fibrosis has a negative impact on graft function. Cytokine production in the host immune response after LT may contribute to the variable CYP3A-dependent immunosuppressive drug disposition, with subsequent impact on liver fibrogenesis, together with host-related factors. We aimed to investigate whether the cytochrome P4503A5*3 (CYP3A5*3) or TBX21 genotypes impact post-LT liver fibrogenesis. Furthermore, the impact of immunosuppressants on cellular apoptosis has been evaluated using human hepatocytes harvested from cirrhotic explanted livers. We have enrolled 98 LT recipients that were followed for occurrence of liver fibrosis for at least 12 months. There was a statistically significant higher trough level of TAC in patients with homozygous CC-TBX21 genotype (7.83 ± 2.84 ng/ml) vs. 5.66 ± 2.16 ng/ml in patients without this genotype (p = 0.009). The following variables were identified as risk factors for fibrosis ≥2: donor age (p = 0.02), neutrophil to lymphocyte ratio (p = 0.04) and TBX21 genotype CC (p = 0.009). In the cell culture model cytometry analysis has indicated the lowest apoptotic cells percentage in human cirrhotic hepatocytes cultures treated with mycophenolate mofetil (MMF) (5%) and TAC + MMF (2%) whereas the highest apoptosis percentage was registered for the TAC alone (11%). The gene expression results are concordant to cytometry study results, indicating the lowest apoptotic effect for MMF and MMF + TAC immunosuppressive regimens. The allele 1993C of the SNP rs4794067 may predispose to the development of late significant fibrosis of the liver graft. MMF-based regimens have a favourable anti-apoptotic profile in vitro, supporting its use in case of LT recipients at high risk for liver graft fibrosis.

Wellness Beyond Cancer Program: building an effective survivorship program

BACKGROUND

The Wellness Beyond Cancer Program (wbcp) was launched in 2012, first accepting patients with colorectal cancer (crc) and, subsequently, those with breast cancer (bca), with the aim of standardizing and streamlining the discharge process from our cancer centre. Patients are discharged either to the wbcp nurse practitioner or to their primary care provider (pcp). The program incorporates survivorship care plans (scps) and education classes; it also has a rapid re-entry system in case of recurrence. The objective of this paper is to describe the process by which a cancer survivorship program was developed at our institution and to present preliminary evaluation results.

METHODS

Qualitative surveys were mailed to patients and pcps 1 year after patients had been referred to the wbcp. The surveys addressed knowledge of the program content, satisfaction on the part of patients and providers, and whether scp recommendations were followed. Questions were scored on the level of agreement with each of a list of statements (1 = strongly disagree to 5 = strongly agree).

RESULTS

From March 2012 to November 2014, 2630 patients were referred to the wbcp (809 with crc, 1821 with bca). Surveys were received from 289 patients and 412 pcps. Patients and pcps gave similar scores (average: 4) to statements about satisfaction; pcps gave scores below 4 to statements about communication with the wbcp.

CONCLUSIONS

At 1 year after discharge, patients and pcps were satisfied with program content, but there is an opportunity to improve on communication and provision of cancer-specific information to the pcps. Using the wbcp to ensure a safe transition to the most appropriate health care provider, we have standardized the discharge process for crc and bca patients.

New mediators of vascular damage in dialysed patients

Cardiovascular events are the main causes of mortality in dialysed patients. Traditional risk factors such as hypertension, aging, smoking, diabetes, and abnormal lipid metabolism does not fully explain the high frequency of cardiovascular disease in renal patients, indicating that some other distinct pathogenesis may be involved. Vascular calcification have been associated with high cardiovascular morbidity and mortality in chronic kidney disease (CKD) patients. It is an active process that resembles osteogenesis, regulated by bone proteins and osteoblast-like cells. Elements involved in the pathogenesis are: the risk factors that initiates the process, the promoters released and overexpressed and the dysregulation of the inhibitor factors of extraskeletal calcifications. Although researches in the past decade have greatly improved our knowledge of the multiple factors and mechanisms involved in vascular calcification, many questions remain unanswered.

Photodynamic diagnosis of non-muscle invasive bladder cancer using hexaminolevulinic acid

Bladder cancer (BC) is the most common tumor of the urinary tract. White light cystoscopy (WLC) is currently considered the standard investigation for diagnosis of bladder tumors. Recent studies suggest that using exogenous fluorescence (photodynamic diagnosis, PDD) can improve its diagnostic sensitivity and specificity.

OBJECTIVE

Our study aims to analyze the value of using fluorescent cystoscopy (PDD) in the diagnosis and treatment of non-muscle invasive bladder cancer (NMIBC).

PATIENTS AND METHODS

The study designed as a prospective randomized clinical trial was conducted over a 12 months period and included 44 patients with primitive NMIBC diagnosed and treated in our department in 2009. Twenty-two patients were included in the study group (PDD), while 22 patients were diagnosed and treated by conventional methods (WLC).

RESULTS

There were no statistically significant differences between the two groups regarding age, sex, place of origin, smoking history, clinical symptoms or presence of urological history as well as tumor size, location or number. Fluorescence cystoscopy examination identified 25.8% more tumors than the conventional examination (p=0.004). We demonstrated a significant reduction of tumor recurrence rates at 3, 6, 9 and 12 months by using PDD (HR=0.3271, 95% CI 0.1091-0.9809; p=0.0461).

CONCLUSIONS

The use of PDD in patients with NMIBC results in significant improvement of the efficiency of their initial diagnosis cystoscopy (by over 25%). We demonstrated improved patient prognosis and quality of life following conservative TUR treatment of these tumors by significantly reducing the tumor recurrence rate (by 9-27%) in the first year of follow-up.

The Social Intervention for People with Alzheimer Disease in Transylvania Region

The Alzheimer disease affects mostly old people but sometimes even adults; it manifests itself as a series of brain modifications which determine several perturbations: thinking, memory, language, mood disturbances. All these disturbances take place gradually and strengthens as the illness advances. The exact causes that determine the Alzheimer disease are still unknown, that is why it can not be prevented or cured. Although, a diagnostic in the first stages and treatment as soon as possible is absolutely necessary for slowing it's evolution.

Unfortunately, the number of persons affected by Alzheimer is rising in Transylvania region. I estimated that only 12-15% of the cases are discovered in the early stages. The effect of the illness doesn't just affect the ill one, but all his family. Taking care of someone who suffers from Alzheimer means a lot of effort, because he needs permanently supervision and help in any kind of activity. Moreover, most of the times, the family is notable to take care of the sick person at home, and it has to take him to a residential center. Although, this is not always the best solution, especially that after being institutionalized, they are often having a nervous breakdown and the disease has a bad evolution. The social worker plays a very important role in helping the person who suffers from Alzheimer. The social intervention has to consider not only the specific needs of the ill, but also the family needs and it has to take place in both directions.

Assessment of Extracorporeal Shock Wave Lithotripsy (ESWL) Therapeutic Efficiency in Urolithiasis

Extracorporeal shock wave lithotripsy (ESWL) revolutionized the treatment of urolithiasis and gradually became the favorite treatment option so that today it is considered to be the first line of treatment for more than 75% of the patients with urolithiasis. The purpose of this study was the assessment of the therapeutic efficiency, complications and limitations of ESWL in urolithiasis in the initial experience using a third generation electromagnetic lithotripter.  Between 2007 and 2008 we performed ESWL for 167 patients with urolithiasis. We recorded 92 patients with single stone (55.1%) and 72 with multiple lithiasis (44.9%). Stone size varied between 7 and 24 mm with an average of 12.3±7.1 mm. Radioopac stones were found in 104 patients (62.3%) while radiolucent stones in 63 only (37.6%).    Complete stone disintegration and clearance was achieved in most cases (86.2%). Complications were mostly minor and rare (transitory haematuria, renal colic). Severe complications (renal hematoma, steinstrasse) were diagnosed for a limited number of patients (3.6%) and their management was mostly nonsurgical or minimally invasive (retrograde ureteroscopy). ESWL is therefore the first line of treatment for urolithiasis with stone size smaller than 2.5 cm. It has an efficiency rate above 85%, low procedure time, high safety and good tolerability (new generation lithotripters do not require anesthesia) and minimal complications.

Septal myomectomy and coronary artery bypass in one case of hypertrophic obstructive cardiomyopathy

Surgery of the hypertrophic cardiomyopathy remains controversial. The safest procedure and the simples procedure is the mitral valve replacement. Septal myomectomy is difficult because of the poor surgical exposure and complications: incomplete resection, complete heart block, ventricular septal defect.

CASE PRESENTATION

A 56 years old man with hypertrophic cardiomyopathy, double coronary stenosis and grade II mitral regurgitation by systolic anterior motion was long time stable under treatment with b-blockers. He developed angina and the circumflex and the left anterior descending arteries were stented. Re-stenosis developed in the left anterior descending stent and the patient was referred to surgery. The intraventricular gradient was 80 mmHg and the maximal septal thickness 28 mm. He was successfully treated by septal myomectomy and bypass on the left anterior descending artery with the left internal thoracic artery. Perioperative transesophageal echography was used to establish the limits of the surgical resection and to control the remnant gradient. The patient is asymptomatic 6 months after the procedure, he has a 30 mmHg remnant gradient and a grade I mitral regurgitation.

CONCLUSION

Septal myomectomy is a safe alternative to mitral valve replacement for hypertrophic cardiomyopathy. This procedure must be guided by perioperative transesophageal echography to avoid incomplete resection.

[Anatomo-clinical considerations regarding the celiac-mesenteric junction]

AIM

This work points out the access ways - both the classical ones and the ones less known and used - to the origin and the first centimeters of the superior mesenteric artery (SMA), underlining the advantages and disadvantages of each of them.

MATERIAL AND METHOD

Our work is based on dissection of 30 human bodies and 200 selective arteriographies.

RESULTS

There are two classical ways to access the first part of SMA: inter-duodeno-pancreatic and the left thoraco-abdominal ways.

CONCLUSIONS

An access way to the origin of the SMA is necessary for the revascularisation through different techniques of the visceral territory depending on the SMA, taking into account the fact that at this level we have the most frequent localization of the atheroma plaques, which leads to acute or chronic intestinal ischemia (manifest in the form of postprandial abdominal 'angor').

[A primary undifferentiated pleomorph cardiac sarcoma. Case report]

The aim of the study was to characterize the clinical and histological picture of a malignant cardiac tumor, to assess the prognosis and to develop a management strategy. We described a primary cardiac sarcoma, located in the right ventricle. Minimal invasive right thoracotomy was used and a partial surgical excision of the malignant cardiac tumor was made as a palliative procedure. The malignant cardiac tumour continues to have a poor prognosis despite of the individualization of the approach.

Septal myomectomy and coronary artery bypass in one case of hypertrophic obstructive cardiomyopathy

trophic cardiomyopathy remains controversial. The safest procedure and the simplest procedure is the mitral valve replacement. Septal myomectomy is difficult because of the poor surgical exposure and complications: incomplete resection, complete heart block, ventricular septal defect.

CASE PRESENTATION

A 56-years old man with hypertrophic cardiomyopathy, double coronary stenosis and grade II mitral regurgitation by systolic anterior motion was long time stable under treatment with b-blockers. He developed angina and the circumflex and the left anterior descending arteries were stented. Re-stenosis developed in the left anterior descending stent and the patient was referred to surgery. The intraventricular gradient was 80 mmHg and the maximal septal thickness 28 mm. He was successfully treated by septal myomectomy and bypass on the left anterior descending artery with the left internal thoracic artery. Perioperative transesophageal echography was used to establish the limits of the surgical resection and to control the remnant gradient. The patient is asymptomatic 6 months after the procedure, he has a 30 mmHg remnant gradient and a grade I mitral regurgitation.

CONCLUSION

Septal myomectomy is a safe alternative to mitral valve replacement for hypertrophic cardiomyopathy. This procedure must be guided by perioperative transesophageal echography to avoid incomplete resection.

[The first case of coronary artery by-pass grafting surgery (CABG) in a patient on maintenance dialysis in Iaşi]

Coronary artery disease has a significantly higher prevalence in chronic dialysis patients compared to the general population, explained by a cluster of non-specific and specific (uremia-associated) cardiovascular risk factors, typical for these patients. Nephrologists and cardiovascular surgeons worldwide are rather reluctant to offer CABG to dialysis patients, because of concerns about higher risks associated with this procedure in this frail population. However, there is an increasing opinion supporting a more aggressive management of coronary artery disease in uremic individuals. To illustrate this "positive attitude", we report here the first dialysis patient ever treated by CABG in Iaşi; his good outcome was both rewarding and encouraging for us all.

[Morphologic study of cardiac myxomas]

The aim of the paper was the morphological study of the cardiac myxomas, admitted and operated at CCI, between 2000 and 2004. We evaluated the histology of the tumor, the incidence of the specific lesions, and we analysed the tumoral types on the basis of cardiac myxoma macroscopic appearance in correlation with clinical picture of tumor.

Blood warm reperfusion: a necessary adjunct to heart-valve surgery in low-risk patients?

AIM

The aim of this prospective, randomized study was to determine whether blood warm reperfusion improves myocardial protection provided by cold crystalloid cardioplegia in patients undergoing first-time elective heart-valve surgery, using cardiac troponin I release as the criterion for evaluating the adequacy of myocardial protection.

METHODS

Seventy patients with a left ventricular ejection fraction greater than 40% were randomly assigned to 1 of 2 myocardial protection strategies: 1) cold crystalloid cardioplegia with no reperfusion or 2) cold crystalloid cardioplegia followed by 2-minute blood warm reperfusion before aortic unclamping. Cardiac troponin I concentrations were measured in serial venous blood samples drawn immediately prior to cardiopulmonary bypass and after aortic unclamping at 6, 9, 12, and 24 h.

RESULTS

Randomization produced 2 equivalent groups. The total amount of cardiac troponin I released (7.17+/- 14.8 mg in the crystalloid cardioplegia with no reperfusion group and 5.82+/-4.66 mg in the crystalloid cardioplegia followed by blood warm reperfusion group) was not different (P > 0.2). Cardiac troponin I concentration did not differ for any sample in either of the 2 groups. The total amount of cardiac troponin I released was higher in patients who required inotropic support (9.14 +/-16.2 mg) than those who did not (4.73+/-4.52 mg; P = 0.009).

CONCLUSIONS

Our study shows that adding blood warm reperfusion to cold crystalloid cardioplegia provides no additional myocardial protection in low-risk patients undergoing heart-valve surgery.

["Mammary loop" technique--new method of multiple coronary revascularization using internal mammary arteries]

The internal mammary arteries are "the gold standard" conduits for coronary by-pass because their' s patency is superior to the saphenous graft. There are some surgical techniques which allow to use the entire length of the mammary arteries: the Y graft, the T graft and the pi graft. We describe recently the "mammary loop" technique that allows to make a Y graft using only one internal mammary artery. This technique also simplifies the construction of a pi graft. In this article we present the variants of this technique and discuss the indications and our early experience results.

[Surgical treatment of pulmonary atresia with ventricular septal defect]

Pulmonary atresia with ventricular septal defect (PAVSD) is a complex cardiopathy represented by a complete obstruction between the right ventricle outflow and the pulmonary trunk associated with a ventricular septal defect (VSD) and major aortopulmonary collaterals (MAPCA). The goal of the unifocalization in the PAVSD is to prepare the pulmonary tree for the complete repair by connecting the MAPCAs to the central pulmonary arteries that should be enlarged. After that we can made the VSD or other intracardiac repair. This is a retrospective study on 31 patients. We report our results discussing the PAVSD classification and the strategy of the complete repair in comparison with other reported results.

Endovascular treatment of the traumatic rupture of the aortic isthmus

The traumatic rupture of the aortic isthmus is a dehiscence of all or part of the aortic wall, occurring as a result of a closed thoracic trauma. Standard surgical technique requires left thoracotomy, aortic cross-clamping and use of the cardiopulmonary by-pass to prevent ischemic complications, in special the neurologic and visceral ones. The endovascular treatment of these lesions is a more simple solution and there are recent reports on the stent-grafting of the isthmic rupture of the thoracic aorta. We report three cases of successful endovascular repair of the aortic isthmic rupture and we discuss the emergency indications, the advantages and the limits of this technique.

Ultrastructural aspects in skin allergic vasculitis

Twelve cases of skin allergic vasculitis were electronmicroscopically studied. The most striking changes were noticed at the level of capillaries, whose wall components were all affected, especially the endothelial cells. These presented at first adaptive changes, with swelling, microvillosities of plasmalemma protruding into the lumen, and many pinocytotic vesicles showing an intensely active transport. Followed different degrees of degenerative changes of cytoplasms and nuclei, the junctional complexes being interrupted, even discontinuous. The pericytes showed similar changes. The basement membrane was thickened, nonhomogeneous, with a spongy aspect, small discontinuities and some electron-dense depots. The endothelial cell damage and the discontinuity of basement membranes, as well as the alteration of pericytes allowed the migration of blood cells into interstitial spaces, followed by leucocytoclasia. As a consequence, in the perivascular tissue a polymorphous cellular infiltrate developed. The mechanisms and significance of these changes are discussed.

Histoenzymological and ultrastructural changes of axillary lymph nodes with breast cancer metastases

Histoenzymatic and ultrastructural changes were studied in axillary lymph nodes from patients with breast cancer by comparison between lymph nodes without metastases, with incipient metastases and completely metastatically transformed. Metastases is preceded by intense macrophagic reactions of lymph nodes, and prepared by the development of vascular stroma. Neoplastic cells in course of invasion presented an intense respiratory activity, while those replacing the lymphoid elements an accentuated synthesis of glycoproteins.

Liver ultrastructural changes following portal circulation disturbances

Liver cell changes produced in rats by the ligature of the portal vein and of the spleen pedicle were studied by electron microscopy. There were differences in the liver response to the various types of circulatory disturbances. The earliest and most marked lesions of hepatic cells were noticed in the case of portal vein ligature, and occurred at the level of rough endoplasmic reticulum, mitochondria and lysosomes. No significant changes in Kupffer cells. When the spleen pedicle was ligated, the hepatic cell changes were less obvious, but the Kupffer cells changes were more prominent, testifying and increased hetero- and autophagy.