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.

Screening of Congenital Hypothyroidism in North-East Romania. Benefits and Messages for Further Improvement.

BACKGROUND: If not diagnosed at birth, congenital hypothyroidism (CH) can cause deleterious, irreversible neurodevelopmental sequels. The importance of thyroid newborn screening (NBS) is therefore well established. OBJECTIVE: To evaluate the efficacy of NBS for CH in North-East Romania. METHODS: Retrospective, descriptive study involving 271662 newborns screened between 2010 and 2019 for CH and phenylketonuria in maternities from six Romanian North-Eastern counties by measuring neonatal TSH (neoTSH) in the whole blood extracted from the heel between days 3 and 5 after birth. Values found higher than a cut-off level of 10 mIU/L were followed by serum evaluation of TSH and fT4 for the confirmation of CH. Thyroid ultrasound was further performed at children found with CH. RESULTS: NeoTSH was found elevated in 417 newborns, but CH was subsequently confirmed in only 57 cases (1/4766 newborns). Mean age at the time when diagnosis was communicated was of 37.2 ± 15 days (between 9 and 157 days). Mean age when therapy was started was of 44.2 ± 17.9 days (between 13 and 160 days) with a mean delay of one week from diagnosis (between 0 and 62 days). Thyroid ultrasound revealed athyreosis in only 3 cases, atrophic thyroid gland in other 10 cases, whereas the thyroid was described as present in the remnant 44 cases. The number of first year follow-up visits greatly varied from 0 to 5, with an average of 2. CONCLUSIONS: NBS allowed rapid diagnosis of CH in North East Romania. The communication of diagnosis to families and therapy onset were however often delayed. Diagnosis and therapy onset before the age of two weeks, as well as a tighter follow-up should be assured by the healthcare system. Etiological diagnosis should be more accurate, for a better prognosis of disease severity, as well as the possibility of genetic advice in selected cases.

Adrenalectomy for Cushing's syndrome: do's and don'ts.

Aim. To present specific aspects of adrenalectomy for Cushing's syndrome (CS) by introducing well established aspects ("do's") and less known aspects ("don'ts"). Material and Method. This is a narrative review. Results. The "do's" for laparoscopic adrenalectomy (LA) are the following: it represents the "gold standard" for secretor and non-secretor adrenal tumors and the first line therapy for CS with an improvement of cardio-metabolic co-morbidities; the success rate depending on the adequate patients' selection and the surgeon's skills. The "don'ts" are large (>6-8 centimeters), locally invasive, malignant tumors requiring open adrenalectomy (OA). Robotic adrenalectomy is a new alternative for LA, with similar safety and conversion rate and lower pain drugs use. The "don'ts" are the following: lack of randomized controlled studies including oncologic outcome, different availability at surgical centers. Related to the sub-types of CS, the "do's" are the following: adrenal adenomas which are cured by LA, while adrenocortical carcinoma (ACC) requires adrenalectomy as first line therapy and adjuvant mitotane therapy; synchronous bilateral adrenalectomy (SBA) is useful for Cushing's disease (only cases refractory to pituitary targeted therapy), for ectopic Cushing's syndrome (cases with unknown or inoperable primary site), and for bilateral cortisol producing adenomas. The less established aspects are the following: criteria of skilled surgeon to approach ACC; the timing of surgery in subclinical CS; the need for adrenal vein catheterization (which is not available in many centers) to avoid unnecessary SBA. Conclusion. Adrenalectomy for CS is a dynamic domain; LA overstepped the former OA area. The future will improve the knowledge related to RA while the cutting edge is represented by a specific frame of intervention in SCS, children and pregnant women. Abbreviations: ACC = adrenocortical carcinoma, ACTH = Adrenocorticotropic Hormone, CD = Cushing's disease, CS = Cushing's syndrome, ECS = Ectopic Cushing's syndrome, LA = laparoscopic adrenalectomy, OA = open adrenalectomy, PA = partial adrenalectomy, RA = robotic adrenalectomy, SCS = subclinical Cushing' syndrome.

Parathyroidectomy: is vitamin D a player for a good outcome?

Background: The field of parathyroidectomy (PTx) is complex and brings together many specialists. Even if the surgical approaches changed from classical to minimally invasive PTx, a good outcome is correlated with an adequate localization before and during PTx, while blood assays, such as parathormone (PTH) or 25-hydroxyvitamin D, become useful additional markers. Aim. Specific aspects related to parathyroidectomy and vitamins D (VD) were introduced. Material and Method. The article represents a PubMed-based narrative review. Results. The growing evidence regarding the high prevalence of hypovitaminosis D and early detection of primary hyperparathyroidism (HPT) requires a particular attention to the association of these two disorders, which may be incidental, but some common pathogenic links are displayed. Low VD stimulates PTH production as a secondary or even tertiary type of HPT diagnosis. VD deficiency is associated with larger parathyroid adenomas and higher levels of PTH before and after surgery for primary HPT. Asymptomatically and normocalcemic forms of primary HPT, which are not immediately referred to PTx, require a normalization of the VD levels. VD supplements are safe under some serum calcium cutoffs and offer a better outcome after PTx. However, primary HPT is cured by surgery and, if the indication is well established, this should not be delayed too long to replace VD. Up to half of PTx cases may experience increased PTH levels after surgery, but most of these are transitory if rapid VD correction is done and only a few remaining cases will eventually develop persistent / recurrent primary HPT. Conclusion. A close following of 25-hydroxivitamin D represents one of the keys for a good outcome in the field of parathyroid surgery. Abbreviations: HPT = hyperparathyroidism, MEN = Multiple Endocrine Neoplasia Syndrome, PTx = parathyroidectomy, PTH = parathormone, VD = Vitamin D.

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.

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.

The laparoscopic management of simple hepatic cysts.

The hepatic polycystic disease represents a hereditary condition with a reduced prevalence in the general population, sometimes associated with polycystic kidney disease. We present a retrospective observational study applied to 49 patients. The study aimed to observe the laparoscopic surgery of simple hepatic cysts. Laparoscopic approach is a simple and successful surgery management of these types of cysts.

Retrospective study minimally invasive management of postoperative lithiasis of the common bile duct.

INTRODUCTION: Postoperative common bile duct (CBD) lithiasis holds a significant place in the bilio-pancreatic pathology, both due to its high frequency as well as to the diagnostic and treatment issues it triggers. MATERIAL AND METHODS: Based on a 5-year experience (2008-2012), assessed retrospectively, totalling 51 patients with postoperative lithiasis of CBD, we tried to elaborate on several recommendations for the treatment of this pathology. The recommendations were guided by the existing alternative therapeutic options and by the ideas in the literature regarding the results achieved by every manner of treatment. RESULTS: The rate of clearance of the CBD was of 93.6%,the morbidity rate was of 10.65% and the mortality rate was of 0%, which entitles us to deem the effectiveness of the minimally invasive treatment as maximum in the treatment of this pathology. CONCLUSIONS: The endoscopic treatment of postoperative lithiasis of the CBD proved to be possible, efficient and we believe it good to be used as a principle; open surgery should be the solution in case of failures or of contraindications to minimally invasive treatment.

Minimally invasive treatment of cholecysto-choledochal lithiasis - "Rendez-vous" technique.

INTRODUCTION: In our paper we present the results of a study that was meant to provide a complex answer to the question:"Which is the most appropriate, most correct and least expensive treatment for mixt cholecysto-choledochal lithiasis(MCCL)?" MATERIAL AND METHODS: Based on a five year experience (2008-2012), analysed retrospectively, during which 143 patients with MCCL were treated, we are trying to find answers to some of the questions that we have asked ourselves from the very beginning of this period. The answers were guided by alternative therapeutic options, for a pathology that does not have a "gold standard", with respect to the solutions available. RESULTS: Given the fact that the period during which the study was conducted was chosen randomly and that the patients were included consecutively, the representativeness of the results is ensured for any other patient diagnosed with this pathology and admitted to a clinic with the same specialty, dimensions and equipment as the one presented. CONCLUSIONS: This paper compares the results of our study to those of others, in terms of different or similar approach therapeutic options, developed in other minimally invasive surgery centres in the world, the final conclusions being encouraging for the therapeutic sequence that we practice.

Is prosthetic repair of the abdominal wall in clean-contaminated surgical interventions possible?

The present study tries to provide an expressive, customized answer to the question in the title. The study relies on a ten-year experience (2000-2009), evaluated retrospectively on a group of 488 prosthetic repairs of incisional herniae, out of which 432 were performed in a clean environment and 56 cases in a clean-contaminated one. The two groups are superimposable based on the Apache score. The visceral surgical procedures associated to the surgery of the parietal defect were varied (cholecystectomy, appendectomy, enterectomy enterorrhaphy,colectomy colotomy-colorrhaphy, hysterectomy with adnexectomy). The assessment of postoperative suppurative complications showed no significant differences between the two groups (p 0.001). These results lead us to the idea of defining the indication for parietal prosthetic repair in a contaminated environment. The major factors of this decision are: the nature, the source and the amount of the septicinoculum, the duration of exposure, the intensity of the host inflammatory response (more difficult to quantify), and finally the surgical judgment. The last mentioned factor will evaluate the above-mentioned data and will take into account that not all bacterial contaminations are necessarily followed by an established infection. Thus, additional exaggerations - which would mean taking useless, ineffective precautions- as well as negative exaggerations - which would mean hazardous boldness- will be avoided.

Prognostic and predictive factors in colorectal cancer.

Colorectal cancer (CRC) is an important public health problem; it is a leading cause of cancer mortality in the industrialized world, second to lung cancer: each year there are nearly one million new cases of CRC diagnosed worldwide and half a million deaths (1). This review aims to summarise the most important currently available markers for CRC that provide prognostic or predictive information. Amongst others, it covers serum markers such as CEA and CA19-9, markers expressed by tumour tissues, such as thymidylate synthase, and also the expression/loss of expression of certain oncogenes and tumour suppressor genes such as K-ras and p53. The prognostic value of genomic instability, angiogenesis and proliferative indices, such as the apoptotic index, are discussed. The advent of new therapies created the pathway for a personalized approach of the patient. This will take into consideration the complex genetic mechanisms involved in tumorigenesis, besides the classical clinical and pathological stagings. The growing number of therapeutic agents and known molecular targets in oncology lead to a compulsory study of the clinical use of biomarkers with role in improving response and survival, as well as in reducing toxicity and establishing economic stability. The potential predictive and prognostic biomarkers which have arisen from the study of the genetic basis of colorectal cancer and their therapeutical significance are discussed.

[Certitudes and controversy regarding neural elements preservation in total mesorectal excision technique (ETM)]. / Certitudini si controverse privind conservarea elementelor nervoase în tehnica de excizie totala a mezorectului (ETM).

The total excision of the mezorect, as a technique of reference in the surgical solution of rectal cancer, is evaluated today through the view of the oncological and functional outcome. Within the functional outcome, the genito-urinary disorders which follow the damage of the pelvic vegetative nervous structures, still cause discussions and controversy among dedicated specialists in this area. The work plans to share an experience of over ten years of ETM practice, in which the technico-tactical accumulation have been realized progressively, outlining a relatively codificated attitude, centered on the "critical moments" of this intervention.

Peculiarities of diagnosis and treatment in the polyp-cancer sequence.

Colorectal cancer, a public health problem with major social implications, has attracted major economic resources and specialized centers focused in the direction of obtaining an early diagnosis from effective screening means in the last decades. It is obvious that the therapeutic results and the social costs are primarily dependent on the precocity of diagnosis. The present paper aims to bring to attention a number of orientations, which may open a new perspective in approaching the genetic and molecular level of these lesions. Out of these, the value of the molecular screening based on the detection of the APC gene located on the short arm of chromosome 5, a method that allows the selection of the subjects to be subjected to further endoscopic screening is underlined. The optimization of the costs as well as the increased compliance of the subjects to such a method is thus accomplished.

Telocytes form networks in normal cardiac tissues.

Telocytes (TC) are a class of interstitial cells present in heart. Their characteristic feature is the presence of extremely long and thin prolongations (called telopodes). Therefore, we were interested to see whether or not TCs form networks in normal cardiac tissues, as previously suggested. Autopsy samples of cardiac tissues were obtained from 13 young human cadavers, without identifiable cardiac pathology and with a negative personal history of cardiovascular disease. Immunohistochemistry on formalin-fixed paraffin-embedded tissues was performed using monoclonal antibodies for CD117/c-kit. Additionally, ventricular samples from 5 Sprague-Dawley rats were ultrastructurally evaluated under transmission electron microscopy. We found c-kit positive cells with TC features in subepicardium, as well in subepicardial arteries and in subepicardial fat. TCs were also present in the subendocardium. Light and electron microscopy revealed the existence of intramyocardial networks built up by bipolar TCs. Larger c-kit positive multipolar TCs were found between cardiac muscle bundles. Our results support the existence of a cardiac network of telocytes.

Skin telocytes.

A distinctive stromal cell-type, the telocyte (TC), has recently been described to send specific long prolongations (telopodes) alternating thin segments (podomers) with dilations (podoms). Even though one would expect TCs to be identified in various stromal tissues, there were not yet reported evidence of skin TCs. We aimed to check for the presence of TCs in human skin dermis. Transmission electron microscopy revealed the presence in dermis of TCs projecting specific telopodes. Skin TCs were closely related to or contacting fibroblasts, mast cells, adipocytes, and connective fiber bundles (collagenous and elastic). As it appears, skin TCs exist and are related to other stromal cells. The structural association of TCs to elastic fibers deserves further investigation.

Tracheal telocytes.

Recently, a novel type of stromal cell - the telocytes (TC) - was identified in mouse trachea. These cells are known to possess the ultrastructural characteristics, which support their role in intercellular signaling. We found TC in all stromal compartments of the tracheal wall. TC with long prolongations (telopodes, Tp) were lining longitudinally the collagen bundles, and were serially arranged (end-to-end connections of Tp were found). Noteworthy, Tp frequently establish stromal synapses with mast cells (MC). Primary cilia were also identified in TC. In conclusion, tracheal TC could be involved in the tracheal regulation (e.g. secretion, contractility). The tandem TC-MC deserves further investigations.

[Quantitative microscopic modifications of the diaphragm and the paraesophageal structures in hiatal hernia. Clinical aspects]. / Modificarile microscopice cantitative ale diafragmei si structurilor anatomice periesofagiene în herniile hiatale. Corelatii clinice.

In the last decade has seen an increase in hiatal hernia diagnosis. These issues led us to study and deepen the anatomic substrate of the changes that occur in the diaphragm muscle and periesophageal structures for optimum management of the disorder. The studied material was represented by fragments of the thoraco-abdominal diaphragm and tissues around the esophagus, biopsy sampling by classic open approach or celioscopic in patients with hiatal hernia, compared with a control group. Histological processing was carried out by current or special methods. After qualitative examining of the selected structures, quantification was performed using an interactive digital program. In the adult diaphragm with hiatal hernia was found in percentage volume reduction pillar of the diaphragm muscle fibers, increased the percentage of vascular lumina in the muscle portion of the crura, while the percentage volume of interstitial spaces increase. The changes of the percentage volume of connective tissue are significant, both crura suffering a fibrous transformation of muscle portions. Microanatomic changes are their quantitative objectivity suggest loss of elasticity and reduced functional capacity of diaphragm muscle in hiatal hernias.

The modifications suffered by the peri-esophageal anatomical structures in the hiatal hernia disease: a qualitative and quantitative microanatomic study.

This paper presents the results of a surgical and histopathological study regarding the microanatomical modifications of the thoraco-abdominal diaphragm and of the peri-esophageal structures in the hiatal hernias, establishing a cause-effect relationship between these structural modifications and the hiatal hernia. The study was represented by two groups of patients: a control group and a group with hiatal hernia. The study method consisted in intraoperatory biopsy of fragments from the diaphragm as well as from the tissue around the esophagus, which were studied from the histopathological viewpoint, using histological methods and quantitative microanatomy. In the end, the results obtained from the two groups were compared. The microscopic examination revealed the presence of an inflammatory infiltrate located between muscle fibers, especially near blood vessels, at the level of the diaphragm crura and the phreno-esophageal membrane. Also, they found red blood cell at this level, most likely due to pressure from the hernia at this level. From the quantitative micro-anatomical viewpoint, there has been noticed an increase in the percent of the vascular lumen (accentuated vasodilatation) as well as the interstices occupied with the edema and hemorrhage, to the detriment of the muscle fibers, the most significant modifications being met at the level of the crura.

Laryngotracheal non-Hodgkin's lymphoma.

OBJECTIVES: Malignant lymphomas of larynx and trachea are rare tumors and require special diagnostic and therapeutic attention. The authors present an unexpected case of nonHodgkin Lymphoma localized in the subglottic larynx and upper cervical trachea. The clinical presentation, diagnostic and therapeutic approach, evolution and prognosis are discussed. METHOD: We report a case of 25-year-old male patient, with progressive dyspnea, presented in our ENT Department with severe airway obstruction caused by a large subglottic tumoral mass migrated in the glottic space during an accidental fall. An emergency tracheotomy was performed. The flexible endoscopy and CT-scan revealed a large mass arising from the subglottic larynx and anterior wall of upper cervical trachea with the obstruction of 2/3 of the laryngotracheal lumen. RESULTS: After a complex assessment, the tumor was excised by external approach (median thyrotomy). The histopathologic exam of the surgical specimen showed malignant nonHodgkin lymphoma and the immunohistochemical profiles were evaluated in order to establish the therapeutic strategy including chemotherapy in the Department of Oncology. CONCLUSIONS: Invasion of the subglottic larynx and trachea by lymphoma is an uncommon problem which can cause severe airway obstruction and requires multidisciplinary approach (ENT, pneumology, oncology/hematology). The clinicopathological features of this case have been described and compared with previously reported cases.

Typical and atypical neurovascular relations of the trigeminal nerve in the cerebellopontine angle: an anatomical study.

The aim of the present study was to anatomically evaluate in adults the neurovascular trigeminal relations in the cerebellopontine angle (CPA), from a morphological and topographical perspective and thus to improve, detail and debate the pre-existing information, with educational and surgical implications. For the present anatomical study we performed bilateral dissections on 20 human adult skull bases, in formalin-fixed cadavers, at the level of the cerebellopontine angle, using the anatomical superior approach; we also studied 20 additional drawn specimens-cerebellum and brainstems, from autopsied cadavers, in order to better document the vasculature at the trigeminal root entry zone (REZ). The most constant but not exclusive neurovascular relations of the trigeminal nerves were those with the superior cerebellar artery (SCA) and the superior petrosal vein (the petrosal vein of Dandy). The regular possibility for the SCA to appear divided into a medial and a lateral branch and these to represent individual trigeminal relations at the level of the pontine cistern or REZ must not be neglected. The petrosal vein tributaries can also represent superior, inferior, or interradicular trigeminal relations. Arterioles emerging from the SCA or the anterior inferior cerebellar artery (AICA) represented trigeminal relations either at the REZ or were coursing between the trigeminal roots. A dissected specimen presented a radicular trigeminal artery emerging from the basilar artery and entering the trigeminal cavum inferior to the nerve. Another specimen presented two bony lamellae superior to the trigeminal nerve at the entrance in the trigeminal cavum-these lamellae were embedded within the lateral border of tentorium cerebelli and the posterior petroclinoid ligament. So we bring here an evidence-based support extremely useful not only for specialists dealing with this area but also for educational purposes. It appears important not only to consider the typical anatomy at this level but also to take into account the atypical and hardly predictable morphologies that may alter the diagnoses and the specific surgical procedures.