AB0205 TENDERNESS AND RADIOGRAPHIC PROGRESSION IN RHEUMATOID ARTHRITIS AND PSORIATIC ARTHRITIS

Background

In inflammatory arthritis swelling is regarded as a sign of synovitis and is associated with radiographic progression. However, the association of tenderness with radiographic progression is not clear.

Objectives

To assess the predictive value of tenderness alone and with consideration of sonographic signs for synovitis, disease duration and baseline radiographic damage for subsequent radiographic progression in rheumatoid arthritis (RA) and psoriatic arthritis (PsA).

Methods

Clinical and sonographic (grey scale (GS) and power Doppler (PD)) examination of 22 joints of the hand were performed cross-sectionally in consecutive patients with RA and PsA with at least one tender joint. Radiographs were scored for erosions and joint space narrowing (JSN) at inclusion and radiographic progression of each joint was assessed after 2 years. The impact of tenderness on progression was analyzed in non-swollen joints for RA and PsA separately with logistic regression analyses. As a second step, the association of PD, GS, disease duration, C-reactive protein, baseline erosions and JSN and global joint counts with subsequent structural damage was assessed using univariate logistic regression in tender non-swollen joints again on the joint level.

Results

We included 1207 joints in 54 RA patients and 396 joints in 18 PsA patients. Tenderness was associated with subsequent radiographic progression in non-swollen joints in PsA (OR 3.44, 95%CI 1.78-6.62, p<0.01) but not in RA (OR 1.60, 95% CI 0.99-2.48, p=0.55) (Figure 1). In tender non-swollen joints in RA patients, PD (OR 3.74, 95% CI 1.10-13.30, p=0.04) and baseline erosions (OR 4.42, 95% CI 1.22-15.95, p=0.02) had a significant impact on radiographic progression. In PsA patients, PD (OR 8.46, 95% CI 1.72-41.72, p<0.01), baseline erosions (OR 6.71, 95% CI 1.43-31.39, p=0.02), baseline JSN (OR 7.27, 95% CI 1.47-35.89, p=0.02) and SJC (OR 1.26, 95%CI 1.07-1.48, p<0.01) were associated with radiographic progression.

Figure 1.

The proportion of joints with progression in tender non-swollen and non-tender non-swollen joints in patients with rheumatoid and psoriatic arthritis; NTNS: non-tender non-swollen; TNS: tender non-swollen

Conclusion

Our findings indicate that tenderness in non-swollen joints is associated with subsequent radiographic progression in PsA, while in RA it is a risk factor for radiographic progression only in the presence of additional factors, such as sonographic signs for synovitis.

Disclosure of Interests

Irina Gessl: None declared, Mihaela Popescu: None declared, Gabriela Supp: None declared, Thomas Deimel: None declared, Paul Studenic: None declared, Martina Durechova: None declared, Michael Zauner: None declared, Josef S. Smolen Speakers bureau: AbbVie, Amgen, AstraZeneca, Astro, Bristol-Myers Squibb, Celgene, Celltrion, Chugai, Gilead, ILTOO, Janssen, Lilly, Merck Sharp & Dohme, Novartis- Sandoz, Pfizer, Roche, Samsung, Sanofi, and UCB, Grant/research support from: Abbvie, AstraZeneca, Lilly and Roche, Daniel Aletaha Speakers bureau: Abbvie, Amgen, Lilly, Janssen, Merck, Novartis, Pfizer, Roche, Sandoz, Grant/research support from: Abbvie, Amgen, Lilly, Novartis, Roche, SoBi, Sanofi

, Peter Mandl Speakers bureau: from AbbVie, Janssen and Novartis, Grant/research support from: from AbbVie, BMS, Novartis, Janssen, MSD and UCB;

Clinicopathological features, imaging characteristics and surgical management in a novel tumour entity - aggressive meningiomas

Meningiomas are common neoplasms of the central nervous system, comprising between 24 and 30% of primary intracranial tumours, most commonly affecting females in their middle age or later adult life [1] [2]. Meningiomas are classified as benign, atypical or anaplastic meningiomas depending mostly on histopathological criteria known to be associated with worse prognosis in terms of tumour progression, recurrence risk after surgery and overall survival. The 2016 edition of the World Health Organization (WHO) classification of Central Nervous System (CNS) tumours recognizes brain invasion as an independent criterion for diagnosing an atypical grade II meningioma [3]. Meningioma grading based on the WHO classification of CNS tumours thoroughly impacts therapeutic management and tumour prognosis. Aggressive meningiomas, a different phenotype of tumours, characterized by rapid growth and involvement of adjacent brain tissue, blood vessels and bone, was not previously listed as an independent entity in the WHO classification of meningothelial-cell tumours.  Regarding the increasing importance of tumour grading in meningioma treatment strategies, the authors here provide an overview of clinicopathological and radiographic features, surgical management and long-term prognosis of this novel meningothelial tumour entity, the aggressive meningioma. In particular, we aimed to describe pre-, intra- and postoperative methods for recognizing aggressive meningiomas and explore the implications of this diagnosis on both surgical strategies and adjuvant therapy.

Imaging characteristics, histopathological features and surgical considerations regarding aggressive meningiomas

Meningiomas are tumours of the meninges that arise primarily from arachnoidal cap cells, but they can also occur rarely as primary tumours in other localizations, such as within the ventricles. They stand for 24-30% of primary intracranial tumours and affect mostly women in their middle age or later adult life [1, 2]. Meningiomas can be classified, according to the World Health Organization (WHO) classification of Central Nervous System (CNS) tumours, as benign (grade I, most frequently encountered type), atypical (grade II) or anaplastic (grade III), based mostly on histopathological criteria known to be associated with tumour progression, recurrence risk and survival. Since meningioma grading based on the WHO classification is the most important factor determining therapeutic management and tumour prognosis, there has been an increasing interest in adding new criteria for better characterization of these tumours. Thus, the 2016 edition of the WHO classification recognized brain invasion as an independent criterion for atypical (grade II) meningioma diagnosis [3]. However, meningiomas that display aggressive features such as rapid growth and higher recurrence rate, can also involve blood vessels and bone. Hence, the authors aim to describe a different entity, aggressive meningiomas, not previously listed as a tumour phenotype in the WHO classification of meningothelial-cell tumours, with regard to pre-, intra- and postoperative methods for diagnosis and explore the implications on surgical strategies and adjuvant therapy.

Variations in color and reflectance on the surface of asteroid (101955) Bennu

Visible-wavelength color and reflectance provide information about the geologic history of planetary surfaces. Here we present multispectral images (0.44 to 0.89 micrometers) of near-Earth asteroid (101955) Bennu. The surface has variable colors overlain on a moderately blue global terrain. Two primary boulder types are distinguishable by their reflectance and texture. Space weathering of Bennu surface materials does not simply progress from red to blue (or vice versa). Instead, freshly exposed, redder surfaces initially brighten in the near-ultraviolet region (i.e., become bluer at shorter wavelengths), then brighten in the visible to near-infrared region, leading to Bennu's moderately blue average color. Craters indicate that the time scale of these color changes is ~10⁵ years. We attribute the reflectance and color variation to a combination of primordial heterogeneity and varying exposure ages.

P690 Pulmonary valve endocarditis complicated with fistula between right ventricle outflow tract and aorta in a patient with patent ductus arteriosus

Background

The majority of cases of right sided infective endocarditis involve the tricuspid valve. Isolated pulmonary valve (PV) endocarditis is rare. Congenital heart disease are risk factors. Material and methods: We present the case of 36 years old male, without any known cardiovascular disease, who was admitted with signs and symptoms of heart failure, pulmonary embolism and fever. He was evaluated clinically, 12 lead ECG, pulmonary radiography, thoracic computer tomography (CT) scan, transthoracic and transesophageal echocardiography, laboratory investigations. Results: Transthoracic and transesophageal echocardiogram revealed large vegetations located on pulmonary valve, pulmonary regurgitation and dilation of the pulmonary valve, patent ductus arteriosus (PDA) with bidirectional shunt and local complications: fistula between right ventricle outflow tract (RVOT) and aorta, pleural and pericardial effusion. Blood cultures were negative. ECG aspect was right bundle branch block. Radiography and thoracic CT scan revealed pulmonary embolism aspect. The patient was treated with antibiotics and surgical option included debridement of the infected area, vegetation excision with valve replacement, relief of RVOT, fistula closure with pericardial patch and ligature of PDA. Evolution after surgical intervention was good.Conclusions: This presentation reveals a favorable evolution of a patient with infective endocarditis located to pulmonary valve. In most of cases, right heart endocarditis presents with signs and symptoms of respiratory disease and fever; these are due to septic pulmonary embolization. Isolated PV endocarditis still remains a challenging and needs carefully echocardiographic evaluation for a correct diagnosis and risk factors identification.

P3759Comparison of equations for renal function assessment and major adverse outcomes in atrial fibrillation: an analysis from the EORP-AF long-term general registry

Background

Several equations exist to estimate creatinine clearance according to serum creatinine values and baseline characteristics. The CKD-EPI equation is usually recommended in general population, while the Cockroft-Gault (CG) equation has been used in atrial fibrillation (AF) clinical trials.

Purpose

To perform a comparison between 6 different equations for evaluation of renal function in AF patients.

Methods

We calculated CKD-EPI, CG, body surface area adjusted CG (CG BSA), MDRD, BIS1 and FAS equations in AF patients enrolled in the EORP-AF Long-Term General Registry. Outcomes at 1-year follow-up were considered.

Results

Renal equations were calculated in 7725 patients. According to CKD-EPI mean (SD) creatinine clearance was 69.14 (21.06) mL/min/1.73 m2. Taking CKD-EPI as reference, the MDRD equation showed the highest agreement (weighted kappa [95% CI]: 0.843 [0.833–0.852]), while CK showed the lowest agreement (weighted kappa [95% CI]: 0.593 [0.580–0.606]. The remaining equations showed moderate agreement. Cox regression analysis showed that all equations were inversely associated with all major adverse outcomes [Figure]. The CKD-EPI equation showed modest predictive ability for the three outcomes (c-statistics: any TE/ACS/CV Death: 0.63379; CV Death: 0.68512; All-Cause Death: 0.67183), with all other equations reporting higher c-statistics (delta-c statistic ranging from +0.01497 for FAS equation for any TE/ACS/CV Death to +0.04547 for CG BSA for all-cause death) for all outcomes (all p<0.0001, for any equation for any outcome). Compared to CKD-EPI, all the other equations showed an improvement in prediction of outcomes, according to IDI and NRI, with the exception of FAS equation for any TE/ACS/CV Death. CG BSA equation showed the greatest improvement in prediction of outcomes compared to CKD-EPI (relative IDI: 21.9% for any TE/ACS/CV Death, 28.8% for CV Death, 34.4% for All-Cause Death).

Cox Regression Analysis

Conclusions

Compared to CKD-EPI equation, all the other equations for creatine clearance has stronger associations with adverse outcomes, with the CG BSA reporting the higher yield for all the outcomes considered.

Cosmic Ray Energy Spectrum derived from the Data of EAS Cherenkov Light Arrays in the Tunka Valley

The extensive air shower Cherenkov light array Tunka-133 collected data during 7 winter seasons from 2009 to 2017. From 2175 hours of data taking, we derived the differential energy spectrum of cosmic rays in the energy range 6 · 1015 2 · 1018 eV. The TAIGA-HiSCORE array is in the process of continuous expansion and modernization. Here we present the results obtained with 28 stations of the first HiSCORE stage from 35 clear moonless nights in the winter of 2017-2018. The combined spectrum of two arrays covers a range of 2 · 1014 – 2 · 1018 eV.

Comparative efficacy of oral contraceptive versus local treatment versus intense pulsed light combined with vacuum in endocrine acne in women

Acne is the most common affection of adolescents, although it can be also found in adult women. Our study was aimed at the comparative assessment of three different therapies over a three-month period, applied to women with moderate comedogenic and papulo-pustular endocrine acne. In the study 116 female patients with endocrine localized face acne were included and divided into three groups: group I with 42 patients was treated with a combination of contraceptive pill + local treatment + pulsed-vacuum light; group II with 38 patients was treated with contraceptives and pulsed-vacuum light and group III with 36 patients was treated only with local treatment. The acne evaluation was made using the Global Acne Grading System (GAGS). Statistical data processing was carried out using the STATA software. For the comedogenic form of acne, the good and very good results were superior in group I vs group II and III (83.33% vs 31.58% vs 5.56%) at the end of the three months of treatment. For the papulo-pustulous form of acne, good and very good results were similar in groups I and II (92.86% vs 73.68%) both after the first month of treatment and at the end of the study, well above the local treatment group (13.99%). Our study highlighted the superiority of laser treatment combined with hormonal treatment, compared to hormonal and local treatment in the comedogenic form of acne, and the superiority of hormonal treatment combined (or not) with laser treatment in the papulo-pustular form compared to local treatment.

Early Illness Recognition Using In-home Monitoring Sensors and Multiple Instance Learning

Background: Many older adults in the US prefer to live independently for as long as they are able, despite the onset of conditions such as frailty and dementia. Solutions are needed to enable independent living, while enhancing safety and peace of mind for their families. Elderly patients are particularly at-risk for late assessment of cognitive changes.

Objectives: We predict early signs of illness in older adults by using the data generated by a continuous, unobtrusive nursing home monitoring system.

Methods: We describe the possibility of employing a multiple instance learning (MIL) framework for early illness detection. The MIL framework is suitable for training classifiers when the available data presents temporal or location uncertainties.

Results: We provide experiments on three datasets that prove the utility of the MIL framework. We first tuned our algorithms on a set of 200 normal/abnormal behavior patterns produced by a dedicated simulator. We then conducted two retrospective studies on residents from the Tiger Place aging in place facility, aged over 70, which have been monitored with motion and bed sensors for over two years. The presence or absence of the illness was manually assessed based on the nursing visit reports.

Conclusions: The use of simulated sensor data proved to be very useful for algorithm development and testing. The results obtained using MIL for six Tiger Place residents, an average area under the receiver operator characteristic curve (AROC) of 0.7, are promising. However, more sophisticated MIL classifiers are needed to improve the performance.

TAIGA - a hybrid array for high energy gamma astronomy and cosmic ray physics

The physics motivations and advantages of the new TAIGA (Tunka Advanced Instrument for cosmic ray physics and Gamma Astronomy) detector are presented. TAIGA aims at gamma-ray astronomy at energies from a few TeV to several PeV, as well as cosmic ray physics from 100 TeV to several EeV. For the energy range 30 – 200 TeV the sensitivity of 10 km2 area TAIGA array for the detection of local sources is expected to be 5 × 10-14 erg cm-2 sec-1 for 300 h of observations. Reconstruction of the given EAS energy, incoming direction and its core position, based on the timing TAIGA-HiSCORE data, allows one to increase a distance between the IACTs up to 600-1000 m. The low investments together with the high sensitivity for energies ≥ 30-50 TeV make this pioneering technique very attractive for exploring the galactic PeVatrons and cosmic rays. At present the TAIGA first stage has been constructed in Tunka valley, 50 km West from the Lake Baikal. The first experimental results of the TAIGA first stage are presented.

Erratum to: 36th International Symposium on Intensive Care and Emergency Medicine: Brussels, Belgium. 15-18 March 2016

[This corrects the article DOI: 10.1186/s13054-016-1208-6.].

Therapeutical Attitude and Analysis of Results in Brain Metastases

Objectives - The aim of this study is to assess therapeutic outcomes in patients presenting with brain metastases as the first manifestation of malignancies either as a final stage in the evolution of malignancies. Materials and methods - We've performed a complex retrospective study on a total of 81 patients with brain metastases treated in Medical Oncology Clinic of the Emergency County Hospital Craiova between 1 January 2005-31 December 2010. Results - The average age of women (55 years) was statistically significantly low compared to men (64 years) (p = 0.000). The most affected age group was 51-60 years in women with maximum frequency of breast cancer and 61-70 years for men, with predominance of lung cancer. Most cases were presented with multiple metastases (90.12%) and the average latency-free interval from primary tumor detection to onset of symptoms was 29.8 months. Clinical manifestations, in most cases, occurred in less than 6 months after diagnosis of the primary tumor being a consequence of the evolution of disease at distance (36 patients / 62 patients in oncological evidence 58.06%) and 12 months after diagnosis survival rate was low being detected in patients with a controlled primary tumor and distant resumption of the disease (14 patients / 62 patients in oncological evidence-22.58%).Median survival in patients with irradiated brain metastases was 7 months. Multivariate statistical analysis of the survival rate has detected statistically significant differences depending on the type of the primary tumor (p = 0.000) and the manner of the onset of brain metastases as the first manifestation or evolution of neoplastic disease (p = 0.000).Survival was affected, without statistical significance threshold, by the number of metastases, patient gender and the loco-regional status of the primary tumor.

Incidence of Pulmonary and/or Systemic Thromboembolism in Pregnancy

Pregnancy associate with thromboembolism is one of leading causes of maternal morbidity and mortality. Worldwide the incidence of pregnancy related venous thromboembolism is approximately 1 in 1500 deliveries. The arterial thromboembolism risk is increased from 3 to 4 fold and the risk of venous thromboembolism is five times higher in a pregnant that in a non-pregnant woman. With an appropriate prophylaxis and therapy, prevention of death from systemic thromboembolism in pregnancy necessitates a high index of clinical suspicion succeeded by a timely and accurate diagnostic approach. In pregnancy the clinical diagnosis of systemic thromboembolism is notoriously difficult due to the overlap of signs and symptoms between the pulmonary embolus with or without deep venous thrombosis. We performed a retrospective study of 86 pregnant women with Pulmonary thromboembolism (PTE) and Deep venous thrombosis (DVT) diagnosed between 2009-2015 in Obstetrics-Gynecology Clinic 1 at Emergency County Hospital of Craiova. Our study evaluated these cases considering frequency, maternal and fetus risk associated with thromboembolism. In 6 years we had 35 women diagnosed as PTE, 8 women diagnosed as DVT and PTE, and 43 patients diagnosed as DVT. The underlying disease in our study was hypertension and the most frequent symptoms reported were dyspnea and limb swelling.(100%).During the third trimester of pregnancy the incidence of PTE was 45% and DVT 57%. 12 cases of DVT were related to thrombophilia. Also we found 25 % of PTE that occurred after cesarean and 8 % of PTE after vaginal delivery. We notice that vaginal delivery is safer than cesarean surgery. Also the importance of third trimester of pregnancy and postpartum it is evident.

Lipoprotein-associated phospholipase A2, myeloperoxidase and vascular endothelial growth factor - predictors of high vascular risk in respiratory bacterial infections

Objective. Respiratory bacterial infections are associated with important coagulation disturbances that amplify the pulmonary lesions and determine a more severe course of the disease. The aim of our study was to investigate the correlation between the evolution of the general clinical parameters and the occurrence of thrombotic events on one side, and plasma levels of selected proteins involved in inflammation and coagulation on the other side, with the intent to establish and to validate a laboratory test panel for the assessment of the vascular risk in patients with bacterial respiratory infections. Methods. The study included 111 patients (divided into two groups, 61 without thrombosis and 50 with thrombosis) with bacterial respiratory infections and 30 healthy controls, age and gender-matched. The baseline evaluation of the patients included clinical, biological, and respiratory examination. LpPLA2 and MPO activities were measured by the spectrophotometric method. VEGF was quantified with an ELISA kit. Results. The collected data showed a correlation between the occurrence of superimposed thrombosis in respiratory infection patients, and the intensity of the inflammatory process, reflected by the increased MPO activity, and the dynamics of LpPLA2 and VEGF. Conclusion. Bacterial respiratory infections associate thrombotic vascular events of various degrees of severity, which correlate with the intensity of the inflammatory process, and the severity of endothelium dysfunction at the level of microcirculation. Starting from the recorded data, and based on the established severity scales in use, it is possible to compute a vascular risk score that takes into consideration the values of the three biomarkers under investigation. Abbreviations: COPD = chronic obstructive pulmonary disease,hsCRP = high sensitivity C reactive protein,EC = endothelial cells, ICAM-1 = intercellular adhesion molecule1, LpPLA2 = lipoprotein-associated phospholipase A2, MPO = myeloperoxidase,NK cells = natural killer cells,VEGF = vascular endothelial growth factor, VCAM-1 = vascular cell adhesion molecule 1.

Computer Tomograph (CT) imaging of mandibular anatomical substrate in animal model restored with nanostructured hydroxyapatite compounds

INTRODUCTION

This study was meant to test a new type of bone graft on an animal model. This material was a nanostructured hydroxyapatite.

MATERIALS AND METHODS

the study was conducted according to Ethic Committee Regulation on animal model (Oryctolagus cuniculus - rabbit) between August and November 2014, at "Carol Davila" University of Medicine and Pharmacy, Bucharest. The animals were tested by using a CT at the level of the mandible before and after using the nanostructured hydroxyapatite.

RESULTS

The animals were CT scanned at 1, 2 and respectively 3 months, noticing a growth of the mandibular bone density. After 3 months, a bone density equal with the density of the healthy bone was noticed.

CONCLUSIONS

The use of the bone graft could be a viable alternative to available materials. The advantage was that bone recovery had a density similar to the density of the healthy bone and the cost of production was low because it was made out of Calcium azotate and monobasic ammonium phosphate.

Efficacy of cetuximab in metastatic colon cancer - case report

In recent years, targeted therapies have proved effective in the treatment of colon cancer, but even in these conditions,metastatic disease is generally considered incurable.Cetuximab is approved for the treatment of advanced colorectal cancer patients with KRAS wild-type, in order to increase survival and hinder progression of the disease. We report a case of a 55 year-old woman, diagnosed with stenosing sigmoid cancer and liver metastases, which underwent multimodal treatment: palliative surgery -Hartmann segmental colectomy, and adjuvant chemotherapy -second line monotherapy with cetuximab, according to standard protocols. After 6 months of XELOX chemotherapy,during which she showed progression of metastatic disease, she was switched to monotherapy with cetuximab, with favorable outcome. Comparing relevant literature, in which complete response to treatment with cetuximab is obtained in low percentages ( 3%) after 3 months of treatment with cetuximab the patient shows clinical and paraclinical complete response and increased quality of life. Proper selection of patients with metastatic colon cancer for treatment with anti-EGFR therapy may lead to prolonged survival and time to progression.

Cardiac vectors in the healthy human fetus: developmental changes assessed by magnetocardiography and realistic approximations of the volume conductor

This study sought to characterize the developmental changes of three measures used to describe the morphology of the fetal cardiac vector: QRS peak-amplitude, QRS duration and QRS time-amplitude integral. To achieve this objective, we rely on a recently developed methodology for fetal cardiac vector estimation, using multichannel fetal magnetocardiographic (fMCG) recordings and realistic approximations of the volume conductors obtained from free-hand ultrasound imaging. fMCG recordings and 3D ultrasound images were obtained from 23 healthy, uncomplicated pregnancies for a total of 77 recordings performed at gestational ages between 22 and 37 weeks. We report the developmental changes of the cardiac vector parameters with respect to gestational age and estimated fetal weight, as well as their dependence on the estimated ventricular mass derived from cardiac dimensions measured with M-mode ultrasound. The normative values can be used along with the cardiac time intervals reported by previous fMCG studies to assist future clinical studies investigating conditions that affect fetal cardiac function.

Effect of intraperitoneal administration of sterile human cerebrospinal fluid in rats

INTRODUCTION

Distal ventriculoperitoneal shunt failure can be attributed to unabsorbed cerebrospinal fluid (CSF) from peritoneum. The objective of the experiment was to determine peritoneal reaction in rats after intraperitoneal administration of human CSF and evolution of local inflammatory response.

MATERIALS AND METHODS

Wistar rats were used divided into four groups: three groups in which intraperitoneal injection of 3 mL, 2 mL and 0.5 mL of sterile human CSF was done and a control group. After sacrificing the animals, at 24, 48 or 72 hours, macro- and microscopic examination of the peritoneal cavity and peritoneal fluid analysis were performed. The experiment was done in compliance with legislation regarding animal research.

RESULTS

Administration of high dose CSF (3 mL) led to death of all specimens. The dose of 0.5 mL of sterile CSF intraperitoneally administered was compatible with survival. Peritoneal response varied from necrotic-purulent reaction, with maximum intensity in group 1, and milder in group 2, to minimum inflammation in small foci and polymorphic cells in group 3. Inflammation only partially resolved in some specimens from group 3 after 72 hours, which incriminates the role of unabsorbed peritoneal CSF in pathogenesis of abdominal complications of ventriculoperitoneal shunts.

CONCLUSIONS

Intraperitoneal administration of sterile human CSF caused inflammatory response of varying degrees and with multiple locations. High doses of CSF led to death of specimens. At 24 hours, the peritoneal response ranging from congestion to purulent reaction was acute, intense and diffuse but after 72 hours, the inflammatory response was mild, focal and limited.

Laparoscopic surgery complications: postoperative peritonitis

INTRODUCTION

Complications within laparoscopic surgery, similar to classic surgery are inevitable and require immediate actions both to diminish intraoperative risks and to choose the appropriate therapeutic attitude. Peritonitis and hemorrhagic incidents are both part of the complications aspect of laparoscopic surgery. Fortunately, the incidence is limited, thus excluding the rejection of celioscopic methods. Patient's risks and benefits are to be analyzed carefully prior recommending laparoscopic surgery.

MATERIALS AND METHODS

This study presents a statistical analysis of peritonitis consecutive to laparoscopic surgery, experience of "Sf. Ioan" Emergency Hospital, Bucharest, and Department of Surgery (2000-2010).

RESULTS

There were 180 (0,96%) complicated situations requiring reinterventions, from a total of 18676 laparoscopic procedures. 106 cases (0,56%) represented different grades of postoperative peritonitis. Most frequently, there were consecutive laparoscopic appendicectomia and colecistectomia. During the last decade, few severe cases of peritonitis followed laparoscopic bariatric surgical procedures.

CONCLUSIONS

This study reflects the possibility of unfavorable evolution of postoperative peritonitis comparing with hemorrhagic incidents within laparoscopic surgery.

Spinal involvement with spinal cord compression syndrome in hematological diseases

Primary spinal involvement in hematological diseases is rare.

PURPOSE

The purpose of this article is studying diagnostic and treatment strategies in patients with spinal cord primary hematologic tumors causing spinal cord compression syndrome.

PATIENTS AND METHODS

We report two cases with spinal cord primary hematologic tumors causing spinal cord compression syndrome. One patient had a diffuse large B-cell non-Hodgkin's lymphoma located in the thoracic spine and the second patient had a plasmocytic plasmacytoma located in the thoraco-lumbar spine.

RESULTS

Both patients underwent surgery, with resection of the intracanalar tumor and spinal cord decompression and adjuvant systemic and intrathecal chemotherapy. Neurological outcome was favorable with partial remission of spinal cord compression syndrome. Finally, patients developed secondary dissemination and succumbed due to progression of the hematological disease.

CONCLUSIONS

Clinical onset and radiographic evaluation is uncharacteristic in early stages. Spinal MRI is mandatory in cases with rebel pain, unresponsive to conservative treatment. Surgery is indicated in all patients with spinal cord compression syndrome. Early diagnosis is associated with better prognosis. Recommended treatment is surgical resection and systemic and intrathecal chemotherapy adapted to histological form of each tumor. In selected cases, if indicated radiotherapy can also be associated.

Randomised clinical trial: efficacy of peginterferon alfa-2a in HBeAg positive chronic hepatitis B patients with lamivudine resistance

BACKGROUND

Previous studies suggested that a finite course of peginterferon alfa-2a may offer an alternative rescue therapy for patients with lamivudine resistance. However, because of the limitation of study design and small sample size, it is difficult to make definitive conclusion.

AIM

To explore the role of peginterferon alfa-2a, in the rescue treatment of HBeAg-positive chronic hepatitis B patients with lamivudine resistance.

METHODS

In this randomised study, chronic hepatitis B patients with lamivudine resistance were treated with peginterferon alfa-2a for 48 weeks (n=155) or adefovir for 72 weeks (n=80). All enrolled patients were treated with lamivudine for the first 12weeks.

RESULTS

At 6 months posttreatment, 14.6% (18/123) of peginterferon alfa-2a-treated patients achieved HBeAg seroconversion, in contrast to 3.8% (3/80) of adefovir-treated patients after 72 weeks continuous therapy (P=0.01). For peginterferon alfa-2a-treated patients, the rate of HBeAg seroconversion at week 72 was significantly higher in patients who had HBsAg decline >0.5 Log(10) IU/mL from baseline at week 24, compared with patients with HBsAg decline ≤0.5 Log(10) IU/mL from baseline at week 24 (25.5% vs. 7.7%, P=0.01). After 72 weeks continuous adefovir treatment, 22.5% of patients achieved HBV DNA <80 IU/mL, compared with 10.6% in peginterferon alfa-2a-treated patients at 6months off-treatment (P=0.02).

CONCLUSIONS

Overall, the response to peginterferon alfa-2a among patients with lamivudine resistance was suboptimal. HBeAg seroconversion rate at week 72 by 48 weeks peginterferon alfa-2a treatment was higher than continuous adefovir therapy. Monitoring HBsAg levels can help to predict response to peginterferon alfa-2a.

Molecular basis of vascular events following spinal cord injury

The aim of this article is to analyze the effects of the molecular basis of vascular events following spinal cord injury and their contribution in pathogenesis. First of all, we reviewed the anatomy of spinal cord vessels. The pathophysiology of spinal cord injuries revealed two types of pathogenic mechanisms. The primary event, the mechanic trauma, results in a disruption of neural and vascular structures into the spinal cord. It is followed by secondary pathogenesis that leads to the progression of the initial lesion. We reviewed vascular responses following spinal cord injury, focusing on both primary and secondary events. The intraparenchymal hemorrhage is a direct consequence of trauma; it has a typical pattem of distribution into the contused spinal cord, inside the gray matter and, it is radially extended into the white matter. The intraparenchymal hemorrhage is restricted to the dorsal columns, into adjacent rostral and caudal spinal segments. Distribution of chronic lesions overlaps the pattern of the early intraparenchymal hemorrhage. We described the mechanisms of action, role, induction and distribution of the heme oxygenase isoenzymes 1 and 2. Posttraumatic inflammatory response contributes to secondary pathogenesis. We analyzed the types of cells participating in the inflammatory response, the moment of appearance after the injury, the decrease in number, and the nature of their actions. The disruption of the blood-spinal cord barrier is biphasic. It exposes the spinal cord to inflammatory cells and to toxic effects of other molecules. Endothelin 1 mediates oxidative stress into the spinal cord through the modulation of spinal cord blood flow. The role of matrix metalloproteinases in blood-spinal cord barrier disruption, inflammation, and angiogenesis are reviewed.

Vascular dysfunctions following spinal cord injury

The aim of this article is to analyze the vascular dysfunctions occurring after spinal cord injury (SCI). Vascular dysfunctions are common complications of SCI. Cardiovascular disturbances are the leading causes of morbidity and mortality in both acute and chronic stages of SCI. Neuroanatomy and physiology of autonomic nervous system, sympathetic and parasympathetic, is reviewed. SCI implies disruption of descendent pathways from central centers to spinal sympathetic neurons, originating in intermediolateral nuclei of T1-L2 cord segments. Loss of supraspinal control over sympathetic nervous system results in reduced overall sympathetic activity below the level of injury and unopposed parasympathetic outflow through intact vagal nerve. SCI associates significant vascular dysfunction. Spinal shock occurs during the acute phase following SCI and it is a transitory suspension of function and reflexes below the level of the injury. Neurogenic shock, part of spinal shock, consists of severe arterial hypotension and bradycardia. Autonomic dysreflexia appears during the chronic phase, after spinal shock resolution, and it is a life-threatening syndrome of massive imbalanced reflex sympathetic discharge occurring in patients with SCI above the splanchnic sympathetic outflow (T5-T6). Arterial hypotension with orthostatic hypotension occurs in both acute and chronic phases. The etiology is multifactorial. We described a few factors influencing the orthostatic hypotension occurrence in SCI: sympathetic nervous system dysfunction, low plasma catecholamine levels, rennin-angiotensin-aldosterone activity, peripheral alpha-adrenoceptor hyperresponsiveness, impaired function of baroreceptors, hyponatremia and low plasmatic volume, cardiovascular deconditioning, morphologic changes in sympathetic neurons, plasticity within spinal circuits, and motor deficit leading to loss of skeletal muscle pumping activity. Additional associated cardiovascular concerns in SCI, such as deep vein thrombosis and long-term risk for coronary heart disease and systemic atherosclerosis are also described. Proper prophylaxis, including non-pharmacologic and pharmacological strategies, diminishes the occurrence of the vascular dysfunction following SCI. Each vascular disturbance requires a specific treatment.

Invasive thymoma

Thymomas are rare tumors of the thymic epithelium with a broad spectrum of morphological and clinical features. Despite a benign histological appearance, it can invade nearby structures or metastasize. The majority of patients are asymptomatic, but some may present with paraneoplastic syndromes such as myasthenia gravis, red cell aplasia, or hypogammaglobulinemia. Various staging systems of thymomas have been defined based on the degree of invasiveness. According to the WHO Classification, there are six histologic types of thymic epithelial tumors. The most important prognostic factor is the stage according to Masaoka's system. We report a case of invasive thymoma diagnosed incidentally in a patient with cardiovascular risk factors referred to the cardiologist with suspected thoracic aorta aneurism.

Supratentorial pilocytic astrocytoma in children

Brain tumors hold second place in tumoral pediatric pathology and have a complex etiopathogeny. The authors describe the case of a child aged 2 years and 4 months with increased intracranial pressure, symptomatology accompanied by rapid deterioration of general condition. Head CT imaging examination showed intra-nevraxial replacement space process, supratentorial. Histopathological examination revealed the typical grade I pilocytic astrocytoma. Time of diagnosis and surgical intervention is essential for further evolution and prognosis.

Thyroid regional metastasis from a giant cell malignant fibrous histiocytoma of the larynx in a patient with history of trichinellosis and tuberculosis

Sarcomas represent less than 1% of malignant laryngeal tumors and giant cell malignant fibrous histiocytoma is exceptionally rare. Diagnosis is histologically based and immunohistochemistry allows differentiation from other fibro-histiocytic neoplasms. We present the case of a 53-year-old male patient with positive medical history for trichinellosis and tuberculosis, and a laryngeal tumor invading the thyroid and causing respiratory distress by airway obstruction. Total laryngectomy and thyroidectomy were performed followed by thyroxine replacement therapy and radiotherapy. Histologically, the tumor consisted of spindle shaped cells with prominent mitoses, and abundant, osteoclast-like, multinucleated giant cells. Similar lesions were identified in the thyroid, adipose and muscular tissues. Parasitic elements were present in muscles. Tumoral cells showed positive immunostaining for Ki67 (40-50%) and vimentin and negative for AE1/AE3, CD31, S100 and myoglobin; the giant multinucleated cells were CD68-positive. Chronic infection might have had a pathogenic significance.

[Correlations between the occlusal plane angle and the risk of relapse after surgical orthodontic treatment of Angle Class III anomalies]

An important criterion in the diagnostic and therapeutic assessment of severe true mandibular prognathia (characterized by excessive growth of the mandible and hiperdivergent facial growth pattern) is the orientation of the occlusal plane compared with the facial benchmark represented by the Frankfurt horizontal line. This is because orthognatic surgery in this pathology (sagittal bilateral osteotomy) envisages not only the shortening of the mandible, but also the counterclockwise rotation of the mandible to restore facial and dento-alveolar harmony in the three planes (sagittal, transverse, vertical). The aim of the study is the analysis of the evolution of the maxillo-mandibular complex in relation to the occlusal plane after orthognatic surgery (sagittal osteotomy of the mandible and bilateral Le Fort I of the maxilla), in a group of 15 patients with a mean age 22+3 years diagnosed with skeletal class III malocclusion, hiperdivergent facial pattern, initial average value of the occlusal plane angle 130+0.60. t test applied for comparative statistical analysis for the linear and angular parameters considered in four therapeutic stages (initial presurgical, post surgical, one year post surgical) show statistically significant changes in parameters related to the mandibular length and rotation, without significant variations one year after the surgical phase.

Laparoscopic treatment of abdominal complications following ventriculoperitoneal shunt

The aim of this study is the evaluation of laparoscopic treatment in abdominal complications following ventriculoperitoneal (VP) shunt.

METHODS

We report a retrospective study including 17 patients with abdominal complications secondary to VP shunt for hydrocephalus, laparoscopically treated in our department, between 2000 and 2007.

RESULTS

Patients' age ranged from 1 to 72 years old (mean age 25.8 years old). Male: female ratio was 1.4. Abdominal complications encountered were: shunt disconnection with intraperitoneal distal catheter migration 47.05% (8/17), infections 23.52% (4/17) such as abscesses and peritonitis, pseudocysts 11.76% (2/17), CSF ascites 5.88% (1/17), inguinal hernia 5.88% (1/17), and shunt malfunction due to excessive length of intraperitoneal tube 5.88% (1/17). Free-disease interval varies from 1 day to 21 years, depending on the type of complication, short in peritoneal irritation syndrome and abscesses (days) and long in ascites, pseudocysts (months-years). Laparoscopic treatment was: extraction of the foreign body in shunt disconnection with intraperitoneal distal catheter migration, evacuation, debridement, lavage and drainage for pseudocysts, abscess and peritonitis, shortening of the tube in shunt malfunction due to excessive length of intraperitoneal tube and hemioraphy. One diagnostic laparoscopy was performed in a peritoneal irritation syndrome, which found only CSF ascites. There were no conversions to open surgery. The overall mortality was of 5.88% and postoperative morbidity was of 11.76%. In 7 patients operated for abscesses, peritonitis, pseudocysts, and CSF ascites the shunting system was converted in to a ventriculocardiac shunt.

CONCLUSIONS

Abdominal complication following VP shunt can be successfully performed laparoscopically. Abdominal surgery required, in selected cases, the repositioning of the distal catheter, frequently as a ventriculocardiac shunt. There are abdominal complications with no indication of surgery, like peritoneal irritation syndrome and CSF ascites. Free-disease interval varies from days (peritoneal irritation syndrome, abscesses) to month-years (pseudocyst, ascites), according to type of complication.

Neuroprotective and consequent neurorehabilitative clinical outcomes, in patients treated with the pleiotropic drug cerebrolysin

BACKGROUND

Discovery of neurotrophic factors--emblematic: the nerve growth factor (NGF)--resulted in better approaching central nervous system (CNS) lesions. Recently, another crucial property has been unveiled: their rather unique pleiotropic effect. Cerebrolysin is a peptide mixture that penetrates the blood-brain barrier in significant amounts and mimics the effects of NGF.

METHODS

Comparative analysis: Cerebrolysin treated (10 ml x 2/day, i.v. x 3 weeks) vs. non-treated, in patients (all received aside, a rather equivalent complementary, pharmacological and physical, therapy). Two lots of patients, admitted in our Physical & Rehabilitation (neural-muscular) Medical-PR(n-m)M-Clinic Division, during 2007-2009: 69 treated with Cerebrolysin (22 F, 47 M; Average: 59.333; Mean of age: 61.0 Years old; Standard deviation 16.583) and 70 controls (41 F, 29 M; A: 70.014; M.o.a.: 70.5 Y.o.; S.d.: 6.270) were studied. The total number of assessed items was 13: most contributive in relation with the score of Functional Independence Measure at discharge (d FIM), were: admission (a FIM), number of physical therapy days (PT), number of hospitalization days (H), age (A) and--relatively--days until the first knee functional extension (KE). Concomitantly, the main/key, focused on neuro-motor rehabilitative outcomes, functional/analytical parameters, have been assessed regarding the speed in achieving their functional recovery.

RESULTS

Concerning d FIM, there have not been objectified significant differences between the two lots (p=0.2453) but regarding key, focused on neuro-motor rehabilitative outcomes, functional/analytical parameters: KE (p=0.0007) and days until the first time recovery of the ability to walk between parallel bars (WPB--p=0.0000)--highly significant differences in favor of Cerebrolysin lot resulted.

CONCLUSION

Cerebrolysin administration, as neurorehabilitative outcomes, proved to hasten, statistically significant, especially the recovery of some critical, for standing and walking, parameters. Thus encouraged, we have now initiated a comprehensive national, 5 year retrospective, multi-centre--based on unitary data acquisition frame and mathematical apparatus--study, to evaluate the results of the treatment with Cerebrolysin in traumatic brain injuries (TBI).

Peginterferon alpha-2a (40 kDa) and ribavirin: comparable rates of sustained virological response in sub-sets of older and younger HCV genotype 1 patients

The average age of patients initiating therapy for HCV is increasing, with older patients exhibiting lower responses to therapy than younger patients. Identification of those older patients likely to respond needs to be addressed. Using data from 569 genotype-1 patients enrolled in two phase III studies (NV15801/NV15942) randomized to peginterferon alpha-2a (40 KDa) 180 microg/week plus ribavirin 1000/1200 mg/day for 48-weeks, we investigated factors associated with sustained virological response (SVR; undetectable HCV-RNA 24-weeks post-treatment) in patients >50 years. SVR rates among patients <or=50 was greater than those >50 years (52%vs 39%; P = 0.0073). Older patients with a rapid virological response (RVR; undetectable HCV-RNA at treatment week 4) or complete early virological response (cEVR; detectable HCV-RNA at week 4 but HCV-RNA <50 IU/mL at week-12) demonstrated high SVR rates (83% and 61% respectively). Older patients had lower cumulative peginterferon alpha-2a exposure and significantly lower cumulative ribavirin exposure (252 g vs 304 g in younger patients; P < 0.0001). Higher relapse rates were observed in older patients (41%vs 25%; P = 0.0042). Cumulative drug exposure and achievement of RVR or cEVR were significantly predictive of SVR by multiple logistic regression analysis in patients >50 years. Other baseline characteristics predictive of SVR in those >50 years of age were lower baseline HCV-RNA level (P = 0.0067), higher ALT-ratio (P = 0.0113) and absence of cirrhosis (P = 0.0482). Response rates were high among patients >50 years without cirrhosis who maintained adequate drug exposure and those achieving an RVR or cEVR. More frequent dose modifications of ribavirin in those >50 years likely contributed to the observed higher relapse rates.