Spatio-Temporal Pattern of Tuberculosis Distribution in Romania and Particulate Matter Pollution Associated With Risk of Infection

The study proposes a dynamic spatio-temporal profile of the distribution of tuberculosis incidence and air pollution in Romania, where this infectious disease induces more than 8,000 new cases annually. The descriptive analysis for the years 2012-2021 assumes an identification of the structuring patterns of mycobacterium tuberculosis risk in the Romanian population, according to gender and age, exploiting spatial modeling techniques of time series data. Through spatial autocorrelation, the degree of similarity between the analyzed territorial systems was highlighted and the relationships that are built between the analysis units in spatial proximity were investigated. By modeling the geographical distribution of tuberculosis, the spatial correlation with particulate matter (PM2.5) pollution was revealed. The identification of clusters of infected persons is an indispensable step in the construction of efficient tuberculosis management systems. The results highlight the link between the distribution of tuberculosis, air pollution and socio-economic development, which requires a detailed analysis of the epidemiological data obtained in the national tuberculosis surveillance and control program from the perspective of geographical distribution.

Increased femoral antetorsion correlates with higher degrees of lateral retropatellar cartilage degeneration, further accentuated in genu valgum

PURPOSE

The role of increased femoral antetorsion (femAT) as a contributor to patellofemoral (PF) osteoarthritis (OA) is unknown. The purpose of this study was to investigate whether increased femAT was associated with advanced cartilage degeneration in the lateral PF joint.

METHODS

Patients who underwent complete radiographic workup for surgical intervention due to OA in any knee joint compartment were included. Cartilage morphology according to the International Cartilage Repair Society (ICRS) cartilage lesion classification system in the PF joint, femoral and tibial torsion, frontal leg axis, and tibial tuberosity-trochlear groove (TT-TG) distance were assessed. Increased femAT was defined as  > 20° according to previous reports.

RESULTS

A total of 144 patients were included. Ninety-seven patients had a femAT of  < 20° and 45 of  > 20°. A significant odds ratio (OR) was found for lateral retropatellar (OR 3.5; p = 0.02) ICRS grade 3 and 4 cartilage degeneration and increased femAT  ≥ 20°. In the medial PF compartment, increased femAT had an inverse effect (OR 0.16; p = 0.01). No significant ORs were found for TT-TG distance, tibial torsion, or leg axis. The lateral retropatellar ICRS grade showed a linear correlation to increased femAT values. In valgus knees, isolated lateral PF OA had an even more pronounced correlation to increased femAT (p = 0.004).

CONCLUSION

Increased femAT showed higher grades of lateral retropatellar cartilage degeneration, which was even more pronounced in valgus knees.

LEVEL OF EVIDENCE

Cohort study: Level III.

THE VARIATION OF INTRAOCULAR PRESSURE IN THE CONTEXT OF ABDOMINAL SURGERY

The human body can be envisioned as a high-performance machine that operates on the principle of "gears". As a consequence, any disorder at a certain level might lead to imbalances in other areas, which are sometimes difficult to detect and measure. One such relationship between two seemingly unrelated systems is that of abdominal surgery and intraocular pressure. The literature on this subject is poor, but available research suggests the occurrence of a change in intraocular pressure in the context of abdominal surgery. The present study analyzed the variation of intraocular pressure for two groups of patients who underwent classical or laparoscopic cholecystectomy. The present research is based on a prospective, non-interventional, observational, descriptive study, carried out in the IIIrd General Surgery Clinic of the University Emergency Hospital, Bucharest. The study included patients who underwent abdominal surgery during January 2018 - December 2019. The study gathered a total of 67 patients, separated into two groups: 52 patients who underwent laparoscopic cholecystectomy and 15 who underwent open cholecystectomy. No definite relationship between intra-abdominal pressure and intraocular pressure was found in the analyzed group, probably due to the small sample size, but further research is encouraged.

Recent advances in the surgical treatment of malunions in hand and forearm using three-dimensional planning and patient-specific instruments

Malunions of the forearm and hand cause significant disability. Moreover, intraarticular deformities may contribute to early onset osteoarthritis. Such conditions require precise surgical correction in order to improve functional outcomes and prevent early or late complications. The purpose of this study was to describe the technical advantages of accurate anatomical reconstruction using 3D guided osteotomies and patient specific instruments (PSI) in multiple joints of the hand and forearm. Acquisition of three-dimensional (3D) datasets and surgical implementation of PSI was performed in a series of patients between December 2014 and July 2017. Patients had intra- or extra-articular malunions of the forearm, radiocarpal joint, trapeziometacarpal joint, or proximal interphalangeal joint. A previously described 3D surface model that incorporates CT data was used for segmentation (Mimics®, Materialise™, Belgium). For all the cases, CT scans of both forearms were acquired to use the contralateral uninjured side as the anatomic reconstruction template. Computer-assisted assessment of the deformity, the preoperative plan, and the design of PSI are described. Outcomes were determined by evaluating step-off correction, fusion, changes in range of motion (ROM) and grip strength. Six patients were included in the study; all achieved fusion. Improved clinical outcomes including pain reduction, better ROM and grip strength were obtained. Complete correction of intraarticular step-off was achieved in all cases with intraarticular malunions. 3D guided osteotomies are an established surgical treatment option for malunions of the hand and forearm. 3D analysis is a helpful diagnostic tool that provides detailed information about the underlying deformity. PSI can be developed and used for surgical correction with maximal accuracy for both intraarticular step-off and angular deformity.

IS THERE A LINK BETWEEN ABDOMINAL SURGERY AND OCULAR PRESSURE?

The mechanisms of variation of intraocular pressure (IOP) during abdominal surgical interventions it is not completely clear and its result on the recovering patient may vary from benign alterations to disabilities. This review aims to identify the most important triggers and its impact of IOP along with individual risk factors during the perioperative period of abdominal surgeries. International literature is providing limited data on this topic. We reviewed 9 studies using PubMed, Scopus, and Web of Science as database. From the multitude of effects and implications that abdominal surgery has onto the physiology of eyeball, the highest impact was linked to the positioning of the patient, induction of anesthesia, perianesthetic events such as intubation and extubation, type of anesthesia and anesthetic used, pneumoperitoneum induced in laparoscopic surgeries and its contribution to the alterations of ocular parameters which are increasing the risk of ocular events. In addition to this, the association of individual risk factors as well as the pre-existing of ophthalmologic diseases may have severe consequences onto the visual function.

INGUINAL HERNIA – LAPAROSCOPIC VERSUS OPEN – A SINGLE CENTER EXPERIENCE

Inguinal hernia is one of the most common surgical pathologies, which appears mainly due to the weakening of the abdominal muscles. Currently, the gold standard in the repair of inguinal hernias by open approach is the Lichtenstein procedure, while the gold standard of laparo-endoscopic procedures are the pre-peritoneal transabdominal technique (TAPP) and the total extraperitoneal technique (TEP). The purpose of this study is to evaluate, for a period of 4 years, the cases of inguinal hernias operated both by laparoscopic and open procedures to analyze their characteristics, under the conditions in which none was imposed as absolute gold standard for groin hernias. The present study was retrospective and descriptive, including a number of 214 cases hospitalized with the diagnosis of inguinal hernia. In the surgery of the groin hernia, both laparoscopic and open procedures have demonstrated their feasibility. Our study shows the preference for open surgery in elderly patients and those with comorbidities, as well as a faster evolution, with earlier discharge in the case of laparoscopic interventions.

HEMATOLOGICAL PARAMETERS AND TUMOR SIZE IN RECTAL CANCER

Rectal cancer is a pathology that still has a high incidence, mortality and morbidity all around the world. As with other types of neoplasm, researchers all around the world are attempting to find statistically significant linkages between easy and inexpensive hematological parameters and the progression of this disease which is affecting approximately 1.8 million individuals. The present study aims to investigate whether biological parameters measured in rectal cancer patients change significantly with tumor growth. The results show a significant change in WBC (white blood cell counts) (p = 0.002).

SURGICAL APPROACH IN A CASE OF GENERALIZED MYASTHENIA GRAVIS

Myasthenia gravis(MG)is an antibody mediated, T cell dependent autoimmune disease characterized by a disorderof neuromuscular junction with progressive inability to sustain a maintained or repeated contraction of striated muscle. It is represented by antibodies directed against the nicotinic acetylcholine receptors (nAchR) of the post junctional membranes. We present the case of an 82-year-old patient, who was admitted to the hospital for plasmapheresis due to an aggravation of her auto-immune generalized myasthenia. The clinical examination at admission revealed ptosis, dysphagia, a medium effort dyspnea, difficulties in closing the mouth, dysphonia with a nasal voice and limited walking with a bent head and camptocormia, with Osserman score 46/100 (diplopia and bilateral ptosis). The thoracic scanner describes a tissue lesion in the thymus region with a diameter of 35 mm corresponding to a thymoma. The Magnetic Resonance Imaging confirmed the possible thymoma. A thymectomy using video-assisted thoracoscopic surgery (VATS) technique was performed according to the age and general status of the patient. Post-operative histological examination revealed a B2 type thymoma and the TNM staging system classifies the thymoma as being T1bNx.    

DIFFICULT INCISIONAL HERNIA NOSOLOGICAL SETTINGS AND APPROACH STRATEGIES

Even in the age of minimally invasive surgery, incisional hernias remain frequent complications where standard resolution is alloplasty in various technical variants. The revolution brought by the introduction of synthetic materials is overshadowed by the unsatisfactory results obtained in some lesional types that seem to go beyond the nosological framework of standard incisional hernias and which can be reunited under the name of difficult incisional hernias. Our work attempts to make a conceptual clarification in a lesional amalgam through the two compulsory targets required for surgical correction: to solidly cover the parieto-abdominal defect and to maintain intra-abdominal postoperative pressure to values that did not trigger the pathophysiological cascade of intraabdominal hypertension.

STRANGE CARDIAC COMPLICATION AFTER MEDIAN EVENTRATION SURGERY

A 51-year old patient comes to the hospital complaining of 20-30 bowel movements every day andabdominal pain following the introduction of a new medication for his cardiological problems(notable aspirin). His relevant medical history shows antecedents of hemorrhagic recto-colitis,non-stented coronaropathy, and a colectomy performed more than 10 years before. The diagnosiswas simple to make following laboratory, imagistic and clinical investigations – pouchitis andmedian eventrations following the prior surgery. The real problem appeared the next day followinghis eventration cure – cardiac tamponade in the context of antiplatelet medication. The patient wassuccessfully managed by the cardiothoracic surgeons. An intracardiac foreign body was found andeliminated during the intervention. Taking into consideration the fact that the patient had beentaking antiplatelet medication for almost a month, it is very likely that the foreign body hadmigrated there during or after the corrective surgical procedure for the eventration and created thehemopericardium in this particular context.

PARTICULARITIES OF DIAGNOSIS AND TREATMENT IN A CASE OF SYNCHRONOUS COLORECTAL CANCER

In literature, synchronous colorectal cancer refers to the simultaneous presence of two or moremalignant lesions located along different segments of the large intestine or separated by at least 4cm, detected either pre-, intraoperatively or after maximum 6 months since a surgery addressed to acolon tumor. The incidence of synchronous tumors is approximately 3,5% of all cases of colorectalcarcinoma, while in others it reaches up to 8,4%. It is believed that this difference is mainly due tofalse negative results. The present paper presents the case of a 75-year-old patient, with a history ofessential hypertension and type 2 insulin-requiring diabetes who came to the emergency roomaccusing diffuse abdominal pain and bloating accompanied by the absence of intestinal transit forfecal matter over the past 6 days and an episode of vomiting. The results of the investigationscorrelated with the patient’s symptomatology indicate the diagnosis of bowel obstruction. Theexploratory laparotomy reveals an ulcero- vegetative, partially stenotic mass lesion in the sigmoidcolon with a diameter of about 5/6 cm. A second ulcero-vegetative, stenotic mass was identified atthe hepatic flexure of the colon with a diameter of approximately 8/7 cm. No metastatic lesions onthe liver or in the abdominal cavity were noted. Right hemicolectomy with end-to-endileotransverse-anastomosis and end-to-end colorectal anastomosis were performed. The presentpaper aims to expose the particular aspects of the diagnosis and treatment of bowel obstruction bysynchronous tumors on a patient with abdominal symptomatology attenuated on the background ofneurological complications of diabetes.

OUR EXPERIENCE IN THE SURGICAL MANAGEMENT OF PATIENTS WITH RECTAL NEOPLASTIC DISEASE

Colorectal cancer is one of the most commonly incriminated neoplastic pathologies and it has afairly high mortality rate. Although the therapeutic arsenal of rectal cancer has steadily improvedthrough the acquisition of biology, technology and pharmacology, the central role of surgicaltechnique is widely recognized in obtaining local control, on the one hand and a good quality of lifeof operated patient on the other hand. This article is a retrospective analysis of surgical proceduresfor rectal neoplasia conducted in order to determine to what extent technological development andcontinuous improvement of surgical techniques have influenced the evolution of patientmanagement with this pathology. This study was retrospective, observational, descriptive, single-center and it was held in the Department of General Surgery and Emergency III of the UniversityEmergency Hospital Bucharest during 1 January 2007 - March 31, 2016 and included a total of127 patients.

OUTCOME OF INTERNAL HEMIPELVECTOMY IN A PATIENT WITH MULTIPLE MYELOMA--CASE REPORT

A patient treated for thyroid cancer was diagnosed with multiple myeloma in the context of trauma. After the pelvic tumor devascularization she underwent internal hemipelvectomy Type I + IIA Enneking Classification using polymerizing bioneutral gel embolization, "Glubran 2". The purpose of this case report is to demonstrate the importance of careful selection of treatment methods, together with adequate physical therapy in order to obtain favorable long-term results.

Esophageal disorders in mixed connective tissue diseases

Extra Musculoskeletal manifestations are a distinct clinical entity that refers to a combination of clinical features, which are found in multiple rheumatic diseases. Besides the standard manifestations, other organs can be damaged such as the vascular system, skin, gastrointestinal tract, musculoskeletal system, cardiopulmonary system, hematologic system, kidneys, and the central nervous system. Among the gastrointestinal MCTD symptoms, the most frequent are the esophageal ones. Treatment of patients with MCTD must be performed by both medical and surgical multidisciplinary teams in order to provide a management suitable for the patients' needs. All authors have contributed significantly and have been involved in the writing of the manuscript in draft and any revision stages, and have read and approved its final version.

Considerations on risk factors correlated to the occurrence of gastric stump cancer

Gastric stump cancer (GSC) is the malignant tumor that develops in the gastric remnant after partial gastrectomy was performed both for benign and malignant lesions. This paper presents the results of the case studies from the scientific literature, which focused on GSC, and has been published in the last 10 years. The search was performed with the help of the specific tools offered by the international databases. The subject was approached because of the constant rising incidence of GSC in the past few years, now reaching values between 1% and 7%. The outcome report is consistent and similar to the period that ended approximately 25 years ago, when general surgeons dedicated a significant part of their activity to treating gastric ulcer. Statistics revealed that the main risk factors are the following: the type of reconstruction after distal gastrectomy (Billroth I or Billroth II), the presence of duodenogastric reflux, the time between gastric resections, and the moment of diagnosis of gastric stump cancer, the initial pathology for which partial gastrectomy was performed, gender, age, helicobacter pylori infection, Epstein Barr virus infection and the presence of vagotomy. All the authors have significantly contributed to the article and have been involved in the writing of the manuscript in draft and any revision stages, and have read and approved the final version.

A RARE CASE OF A GIANT RETROPERITONEAL RECURRENT LIPOSARCOMA

We report the case of a giant retroperitoneal liposarcoma, with two rare histological subtypes: pleomorphic subtype at initial surgical resection, and dedifferentiated subtype at the recurrence. A 61-year-old male patient, presented at the University Emergency Hospital Bucharest, for progressive enlargement of the abdomen. The exploratory laparotomy found a deforming mass in the retroperitoneal area, with medial displacement of the left colon, from the splenic flexure to the recto-sigmoid junction. After assessing the resectability of the tumor, it was decided and performed an en-bloc excision of the tumor, without multiorgan resection and with macroscopic free safety margins. Due to the intersection with the genital vessels, their resection was imposed. The tumor was trefoil-shaped, with a diameter of 35 cm. After 7 months of chemotherapy, tumor recurrence occured, within the same location, confirmed as a dedifferentiated subtype. The same surgical procedure was performed, and the oncologist decided to continue with a more aggressive chemotherapy. Pleomorphic liposarcoma has a high rate of recurrence and has a high resistantce at chemotherapy. Due to its deep retroperitoneal location, the relations with the inferior vena cava, the aorta and the genital vessels are essential, in some cases multiorgan resections being necessary.The case presents a rare malignant tumor, a 35 cm diameter retroperitoneal liposarcoma, highly resistant to chemotherapy and with a high recurrence rate.

ILIZAROV APPARATUS – A BREAKTHROUGH IN ORTHOPEDIC SURGERY

Dr. Gavriil Ilizarov is one of the most significant names in the orthopedic field, his innovations in bone deformities treatment, fracture management and limb lengthening being successfully used up until now. Although at first his principles were hardly accepted by his colleagues, his work was confirmed with many studies worldwide and his technique became the basis of modern practices. Ilizarov external fixator evolved from being a last resort solution to a method used to treat a great number of bone disorders. One of the most famous principle is “distraction osteogenesis” also called “callotasis” or “callus distraction”, a technique involving slow distraction of the callus in response to a corticotomy. It has the benefit of increasing both bone length and surrounding tissues. The purpose of this article is to present an overview of the history of Ilizarov apparatus, the mechanical laws that underlie it, the current clinical use, the most important complications and future research.

PECULIARITIES OF DIAGNOSIS IN THE PHYLLODES TUMOR

Phyllodes tumor (PT) is an uncommon and distinct category of breast cancer, being a particular form of intracanalicular fibroadenoma. A definitive diagnosis is difficult to make just based on imaging investigations and fine needle biopsy; also PTs are frequently misinterpreted as breast fibroadenomas. In the case of of a 26-year old woman with a suspected PT (based on clinical investigation) which was first diagnosed as a fibroadenoma using ultrasonography and preoperative biopsy, further investigation was needed. A limited resection was performed and the postoperative histopathology confirmed the diagnosis as PT.