Metachronous Ampulla of Vater Carcinoma after Curative-Intent Surgery for Klatskin Tumor.

Resection represents the single hope for long-term survival in a patient diagnosed with a hilar cholangiocarcinoma (Klatskin tumor). However, the largest part of these patients develops a recurrent disease. Second metachronous periampullary cancers after a curative-intent surgery for a Klatskin tumor represent an exceptional pathology, and the management of these patients was poorly documented. Hereby, it is presented a 32-year-old patient with bile duct resection, left hemi-hepatectomy and loco-regional lymph nodes dissection, for a type IIIB Bismuth-Corlette Klatskin tumor, which, furthermore, 6 years later, underwent a pancreaticoduodenectomy for a metachronous carcinoma of the ampulla of Vater. The management and outcomes were discussed in the reported case, along with a literature review of the previously published patients. In conclusion, a metachronous periampullary carcinoma after resection of a Klatskin tumor should be distinguished from a loco-regional recurrent disease. While most of the patients with recurrences are suitable to only chemotherapy and or radiotherapy, a second curative-intent surgery (i.e., pancreaticoduodenectomy) is feasible in the largest part of the patients with a metachronous cancer, with good long-term outcomes.

Guidance synthesis. Medical research for and with older people in Europe: proposed ethical guidance for good clinical practice: ethical considerations.

INTRODUCTION: In Europe the population is ageing rapidly. Older people are taking many medicinal products daily and these may not necessarily be suitable for them. Publications show that older patients are underrepresented in clinical trials, especially those over 75 years, with multiple co-morbidities, concomitant treatments and/or frailty. This document provides a summary of recommendations on ethical aspects of clinical trials with older people, who may in some cases be considered a vulnerable patient population. The EFGCP's Geriatric Medicine Working Party (GMWP) has developed this guidance to promote such research and to support health care professionals in their efforts. ETHICAL, SCOPE AND CONTEXT: The definition of a geriatric patient is reviewed. Frail and vulnerable patients, who are a minority of geriatric patients, should be included whenever it is relevant. The legal context is described. THE PROCESS OF INFORMED CONSENT: All adults should be presumed capable of consent, unless proven otherwise; informed consent must be sought for all older people who are able to consent. A simple, short and easy-to-understand information sheet and consent form will contribute to improving the readability and understanding of the older participant. A participant guide and the use of a simple tool to ensure decision making capacity, are recommended. Whenever older people are unable to consent, their assent should be sought systematically using adequate information, in addition to seeking the consent of their legal or authorised representative as appropriate. ETHICS COMMITTEES: Research ethics committees need internal and/or external geriatric expertise to balance the benefits and risks of research in older people and to appreciate and recognise their autonomy. DESIGN AND ANALYSES: Design and Analyses should be adapted to the objectives with appropriate outcomes and are not different from other clinical trials. CONCLUSIONS: The absence of proper recruitment or insufficient presence of older patients in clinical development plans for new medicinal products is detrimental; there is a need to improve evidence-based knowledge, understanding and management of their conditions and treatment. The aim of this guidance is to facilitate clinical research for and with the older patient population. The long version of the guidance will be available on the EFGCP's website: www.efgcp.be/.

The synergy between lasers and adipose tissues surgery in cervicofacial rejuvenation: histopathological aspects.

BACKGROUND AND AIMS: Nowadays patients want a long-lasting youthful appearance but through a less invasive approach. Our unique approach, "AdipoLASER reJuvenation (ALJ)", involves a variety of less invasive techniques based on simultaneous laser resurfacing, and lipolysis together with adipose tissue graft and redistribution. Recently, we added to this platelet-rich plasma therapy. We conducted a study aiming to emphasize the histopathological changes occurred following these procedures. PATIENTS AND METHODS: Between 2011-2012, we included 50 patients that were preparing for abdominoplasty (tummy tuck) in which we applied ALJ procedures, in two comparative zones of inferior abdomen. Histological examination varied from 10 days to four months, according to the time of the abdominoplasty. RESULTS: There was a notable histological difference between stimulated and non-stimulated fat graft regarding adipose cells structure and number, neocollagenesis, and dermal matrix remodeling. CONCLUSIONS: The low level laser therapy effect (LLLT) of the fractional CO2 laser combined with the effect of the growth factors derived from activated platelets (PRP) prolonged the life and improved the take of the facial fat graft, increase collagen formation and lead to a better remodeling of the dermal matrix. This unique surgical combination of all four approaches in our ALJ with additional PRP offers a real less invasive but strongly visible - yet natural result - as an alternative to the classic facelift.

The sinergy between lasers and adipose surgery in face and neck rejuvenation: a new approach from personal experience.

BACKGROUND AND AIMS: Patients now want a long-lasting youthful appearance but with a minimally-invasive approach. Our unique approach, "AdipoLASER reJuvenation (ALJ)", involves a variety of minimally-invasive laser- and lipolysis-based techniques, and the present study assessed the impact of this ALJ approach. SUBJECTS AND METHODS: From 2008 - 2011, we prospectively enrolled 221 patients into the study. 71 of them, underwent the ALJ approach: 2 reductive techniques via microliposuction and laser-assisted lipolysis (LAL); and 2 regenerative techniques via autologous fat graft and fractional CO2 laser resurfacing. The remaining 150 patients underwent only 1 or 2 of these techniques. Patients were monitored through 1 to 18 months, clinical photography was taken and histological assessments were performed. RESULTS: ignificantly better and long-lasting results were obtained for the complete ALJ approach regarding all aspects of the face, mandible and neck compared with controls. The combination of the regenerative and the reductive approaches delivered on excellent balance, restoring a youthful, natural appearance to the face. CONCLUSIONS: The fractional CO2 laser has both a photodestructive, or HLLT, effect and an LLLT component in the beam periphery. This LLLT effect possibly prolonged the life and improved the take of the fat grafts, with the well-documented HLLT effect inducing swift collagenesis and better remodeling of the dermal matrix. A natural look in depressed areas was thus restored with the combination of fat redistribution and the HLLT/LLLT effect. Microlipolysis and laser-assisted lipolysis (LAL) could at the same time remove those areas of redundant and prolapsed fat while countering skin laxity, and address both jowl formation and submental flaccidity. The unique combination of all four approaches in our "AdipoLASER reJuvenation" proved to be superior to any other lesser approach in both the long- and short term with very little patient downtime, but did not present much more in terms of treatment time and cost to the patient. We believe that the ALJ approach offers a real minimally-invasive alternative to the classic surgical facelift.

Serum markers in skin melanoma--preliminary study.

Skin melanoma presents the strongest metastatic capacity and the highest mortality rate of all types of skin cancer, being one of the most aggressive forms of human cancer. Although melanoma represents only 4% of skin cancers, it accounts for 80% of skin cancer deaths. The aim of this study was the investigation of two specific serum markers for melanoma: S100B and melanoma inhibitory activity in relation to disease development. The longitudinal study was performed on 51 patients diagnosed with skin melanoma and 72 healthy volunteers. For serum S100B and MIA measurement standard ELISA was used. The serum concentration of S100B was found significantly different from normal values only in patients in stage IV, in contrast to MIA, where significant differences occurred as early as stage II. The dynamics of the studied serum markers was in accordance with the skin melanoma evolution, especially for serum MIA. Only both increased S100B and MIA serum levels can indicate the disease evolution towards advanced stages and appearance of the metastatic processes.

[Osteomyelitis, a cause of prolonged fever in adults]. / Osteomielita, cauza de sindrom febril prelungit la adult.

A 35 years old male patient with an unexplained prolonged fever, after serial unsuccessful investigations in 3 different services, suffers a fracture of the lower third of the right femur produced by a minor trauma. This raises the suspicion of a pathological fracture. The surgical intervention and the microbiological exam confirms the existence of an osseous infection with Gram-negative germs, and the clinical course is uneventful after stabilization with an external fixator and appropriate antibiotic therapy. Osteomyelitis, although rare in adults, should be included in the differential diagnosis of any prolonged fever of unknown origin in adults.