The association between sporadic Legionnaires' disease and weather and environmental factors, Minnesota, 2011-2018.

From 2011 through 2018, there was a notable increase in sporadic Legionnaires' disease in the state of Minnesota. Sporadic cases are those not associated with a documented outbreak. Outbreak-related cases are typically associated with a common identified contaminated water system; sporadic cases typically do not have a common source that has been identified. Because of this, it is hypothesised that weather and environmental factors can be used as predictors of sporadic Legionnaires' disease. An ecological design was used with case report surveillance data from the state of Minnesota during 2011 through 2018. Over this 8-year period, there were 374 confirmed Legionnaires' disease cases included in the analysis. Precipitation, temperature and relative humidity (RH) data were collected from weather stations across the state. A Poisson regression analysis examined the risk of Legionnaires' disease associated with precipitation, temperature, RH, land-use and age. A lagged average 14-day precipitation had the strongest association with Legionnaires' disease (RR 2.5, CI 2.1-2.9), when accounting for temperature, RH, land-use and age. Temperature, RH and land-use also had statistically significant associations to Legionnaires' disease, but with smaller risk ratios. This study adds to the body of evidence that weather and environmental factors play an important role in the risk of sporadic Legionnaires' disease. This is an area that can be used to target additional research and prevention strategies.

CALCITONIN REVISITED IN 2020.

Calcitonin (CT) is a polypeptidic hormone specifically secreted by the thyroid parafollicular cells (C cells) and tangentially involved in human phosphocalcic and bone metabolism. CT from other species (e.g. salmon) is more potent than human CT and has limited therapeutic applications. The neoplastic proliferation of C cells leads to medullary thyroid carcinoma (MTC) generally characterized by an increase of CT secretion. Serum CT is therefore the ideal marker for MTC and can confirm its presence at an early stage, as well as the follow up of its remission or progression/relapse/survival after surgery. There are, however, controversies such as the necessity of CT screening in patients with thyroid nodules, or particular situations causing false positive or false negative results. Our minireview also deals with an up-to-date of surgical procedures for MTC, as well as with non-surgical therapy.

VITAMIN D DEFICIENCY, A NONINVASIVE MARKER OF STEATOHEPATITIS IN PATIENTS WITH OBESITY AND BIOPSY PROVEN NONALCOHOLIC FATTY LIVER DISEASE.

CONTEXT: Nonalcoholic fatty liver disease (NAFLD) includes simple steatosis, steatohepatitis (NASH) which can evolve with progressive fibrosis, cirrhosis and hepatocellular carcinoma. As liver biopsy cannot be used as a screening method, noninvasive markers are needed. OBJECTIVE: The aim of this study was to test if there is a significant association between vitamin D deficit and the severity of NAFLD. DESIGN: The patients were divided into two groups (vitamin D insufficiency/deficiency) and statistical analyses were performed on the correlation of clinical and biochemical characteristics with histopathological hepatic changes. SUBJECTS AND METHODS: We prospectively studied 64 obese patients referred for bariatric surgery between 2014 and 2016 to our Surgical Unit. Anthropometric, clinical measurements, general and specific biological balance were noted. NAFLD diagnosis and activity score (NAS) were evaluated on liver biopsies. RESULTS: Increased serum fibrinogen was correlated with NASH (p=0.005) and higher NAS grade. T2DM was positively correlated with liver fibrosis (p=0.002). 84.37% of the patients had vitamin D deficit and 15.62% were vitamin D insufficient. Lobular inflammation correlated with vitamin D deficit (p=0.040). Fibrosis (p=0.050) and steatohepatitis (p=0.032) were independent predictors of low vitamin D concentration. CONCLUSIONS: Vitamin D status in conjunction with other parameters - such as T2DM - or serum biomarkers - namely fibrinogen level and PCR level - may point out the aggressive forms of NAFLD and the need for liver biopsy for appropriate management.

THE VOLUME OF SOLITARY PARATHYROID ADENOMA IS RELATED TO PREOPERATIVE PTH AND 25OH-D3, BUT NOT TO CALCIUM LEVELS.

PURPOSE: To correlate the volume of parathyroid adenomas with the hormonal and metabolic profile at patients diagnosed with primary hyperparathyroidism (pHPTH). PATIENTS AND METHODS: Cross-sectional multicentric study, enrolling 52 patients with pHPTH from two medical institutions. Serum calcium and PTH were evaluated in all patients before surgery, whereas 25OHD3 was measured only in the 33 patients recruited form one medical unit. The volume of parathyroid adenoma was measured by using the formula of a rotating ellipsoid. RESULTS: We observed a significant correlation of the volume of parathyroid adenomas with PTH at patients from the two units and in the whole group (p < 0.0001), but not with serum calcium (p = 0.494). Twenty-five out of the 33 patients at whom 25OHD3 was measured had levels in the range of deficiency. 25OHD3 was not correlated with PTH or calcium levels, but was negatively correlated to the adenoma volume and positively to the PTH/volume ratio (p = 0.041 and p = 0.048, respectively). CONCLUSIONS: The volume of parathyroid adenoma seems to be related to preoperative PTH and 25OHD3, but not to calcium level. Vitamin D deficiency is frequently found at patients with pHPTH and may contribute to particular disease profiles, including larger parathyroid adenomas.

ADENOCARCINOMA AND TUBERCULOSIS OF THE SIGMOID COLON AND FALLOPIAN TUBE--A RARE ASSOCIATION. A CASE REPORT AND REVIEW OF THE LITERATURE.

Association of adenocarcinoma and tuberculosis (TB) of the sigmoid colon is a rare clinical condition even in an endemic country as Romania, with challenging diagnosis and treatment. Case report. We present the case of a 57-year-old female patient who was admitted on emergency basis for a diagnosis of obstructive sigmoid adenocarcinoma. The patient was operated on and it an obstructive sigmoid tumor with serosal invasion, adherent (invading) to the body of uterus and left adnexa and urinary bladder serosa, no liver or peritoneal metastases. A sigmoidectomy was performed "en bloc" with subtotal hysterectomy, left adnexectomy and extramucosal cistectomy. The histopathological exam showed a moderately differentiated, ulcerated adenocarcinoma, widely infiltrating the colon wall invading the myometrium. Ziehl Neelsen (ZN) stain identified the presence of metachromatic bacillary structures in the colonic wall, lymph nodes and adnexal areas. Postoperative course was uneventful and the patient was discharged 10 days postoperatively in good clinical condition. After one year when the patient completed the full course of anti-tubercular drugs, a thorough work-up was performed. Colonoscopy, CT of the thorax, abdomen, pelvis showed no signs of recurrence while tumoral marker CEA (1.62 ng/ml - n<3.4) and QFT (Quantiferon-TB Gold) test were within normal range. Discussion and conclusion. Although digestive tuberculosis is included in differential diagnosis for those patients presenting abdominal pain or obstructive digestive symptoms in endemic regions, in this case the absence of TB infection criteria and positive endoscopic biopsy for colonic adenocarcinoma did not allow a complete pre- or perioperative diagnosis.

99mTc MIBI THYMIC SCINTIGRAPHY IN DIAGNOSIS AND THERAPEUTIC DECISION MAKING: WHAT IS BEHIND THE IMAGE?

CONTEXT: Despite CT being generally used in thymic pathology, in the case of regions with the same tissue density, only functional radioisotopic imaging can hint towards malignity. OBJECTIVES: To assess the usefulness of 99mTc MIBI scintigraphy for diagnosis and treatment planning in thymoma, in relation with the radiotracer uptake mechanism. PATIENTS AND METHODS: 99mTc MIBI thymic scans for 19 patients diagnosed with thymic disorders were assessed using tumor uptake ratio (UR). Specimens of thymectomies were examined and cytological assessments were correlated with the UR. RESULTS: The UR of all surgical patients was higher than 1.2, with a 1.5 cutoff between lymphoid hyperplasia and thymoma. The UR values were correlated with the histopathologic diagnosis (Pearson correlation 0.91, significant at p<0.01). The highest UR was 3.24, found in the case of an AB thymoma where the rate lymphocytes/epithelial cells (L/E) was 1.6. In B1 thymoma UR was 1.14 and L/E was 2.46. CONCLUSION: Phenotype differences between thymoma types correlate with 99mTc MIBI cellular uptake: lower rate L/E corresponds to higher UR, higher malignity potential and invasiveness. A thymic 99mTc MIBI UR higher than 1.5, corresponding to a CT tumoral image, is suggestive for a thymoma, requiring surgical treatment first.

NONALCOHOLIC FATTY LIVER DISEASE AND ITS COMPLICATIONS--ASSESSING THE POPULATION AT RISK. A SMALL SERIES REPORT AND LITERATURE REVIEW.

UNLABELLED: The aim of the study was to highlight correlations between serum biochemical markers and different degrees of liver inflammation or fibrosis revealed by liver biopsy in morbidly obese patients. We also wanted to emphasize that the occurrence of hepatocellular carcinoma (HCC) is increasingly associated with obesity, metabolic syndrome and nonalcoholic fatty liver disease. MATERIAL AND METHODS: A clinical retrospective study was carried out on a series of 13 patients operated for morbid obesity in our surgical unit. Included in this study were only the obese patients referred for bariatric surgery without other risk factors for liver disease and in whom a liver biopsy was taken during metabolic surgery. RESULTS: The pathology report revealed different stages of nonalcoholic fatty liver disease in all 13 patients: pathological features of steatohepatitis (7 patients), hepatic steatosis (5 patients) and lesions specific for evolving cirrhosis (1 patient). Regardless of the pathological changes of the liver, except the patient with evolving cirrhosis, none of these patients showed changes in classical liver function blood tests. DISCUSSIONS: Hepatic alteration in obese patients, ranging from simple steatosis to steatohepatitis or even cirrhosis, is not always correlated with the values of classical biological liver function tests. Literature data suggest the involvement of adipokines in the development and progression of steatosis as the hepatic expression of metabolic and chronic inflammation syndrome occurring in obese patients. Furthermore, these proteins secreted by adipose tissue seem to be related to the HCC occurrence. However, none of these studies show the exact pathway followed by the hepatic cell from simple fatty liver to hepatocellular carcinoma. CONCLUSIONS: finding and selecting the population at risk for fatty liver disease progression and for HCC development among obese patients is mandatory.

Life-threatening complications of impacted common bile duct lithiasis. A case report.

Impacted common bile duct (CBD) lithiasis poses therapeutical challenges and repeated attempts of removal may result in life-threatening complications. CASE REPORT. A 45 year-old female patient was admitted in emergency for right upper quadrant abdominal pain and jaundice. Clinical, lab data, abdominal ultrasound (US) and cholangio-MRI established the diagnosis of acute cholecystitis and obstructive jaundice due to distal CBD lithiasis. Endoscopic retrograde colangiopancreatography (ERCP) confirmed the presence of a distal CBD stone but extraction failed. The patient was operated on and surgical procedure consisted of cholecistectomy, intraoperative cholangiography and a side-to-side choledocho-duodenal anastomosis was performed because all attempts to extract the stone through choledocotomy or duodenotomy and enlargement of endoscopic shincterotomy failed. The postoperative course was endangered by a severe pancreatitis, a massive upper digestive bleeding and portal vein thrombosis that responded to conservative management in the intensive care unit. The patient was discharged after 34 days in good clinical condition and approximately 9 months later was readmitted electively for an incisional hernia. Apart from this, physical examination, lab tests and imagistic studies were normal; the patient was operated and rapidly discharged in good condition. In conclusion, the management of CBD lithiasis may be a serious challenge both for interventional endoscopists and surgeons and require a concerted team effort.

Multidisciplinary treated thymomas with fatal outcome. A retrospective study.

UNLABELLED: The aim of the study was to assess factors concurring to fatal outcome of patients operated for thymoma with or without myasthenia gravis. MATERIAL AND METHODS: A retrospective observational study was carried out on a series of 10 patients treated for thymoma in the IIIrd Surgical Unit of "St. Spiridon" University Hospital. RESULTS: Mean survival time was 4.45 years and mortality rate was 38.4%. In 8 patients III and IV Osserman stage myasthenia gravis was associated. 2 patients without myasthenia gravis were diagnosed with a locally advanced stage of thymic carcinoma. According to WHO pathological classification of thymoma, 2 cases were included in type C, those without myasthenia gravis associated and the rest in type B1 (2 cases) and B2 (6 cases). According to Masaoka classification all cases presented invasive thymoma: 6 cases type II, 3 cases type III and one case with type IV. Apart of one case in stage IV, all cases benefitted of complete surgical resection. No perioperative and early postoperative mortality was recorded. On long-term follow-up the cause of death was related to aggravation of myasthenia gravis in 6 cases, to cardiac failure in 2 cases (acute myocardial infarction and constrictive pericarditis) and in 2 cases to metastatic disease (thymoma related death - 20%). CONCLUSIONS: Aggravation of myasthenia gravis was the first cause of death in this series in spite of complete resection and intensive immunosupressive treatment. Completeness of surgical resection is the most important prognostic factor. The histopathological type of thymoma with fatal outcome was type B and C after WHO classification.

Split-thickness skin grafting in oncologic surgery of the limb--a case report.

Large excision of tumor soft tissues is often complicated by infections, seriously undermined blood supply and venous drainage, tendon exposure, functional impairment. We report the case of a 67 years old woman admitted for a sarcoma of the right forearm occurring 14 years after a modified radical mastectomy and adjuvant chemotherapy for carcinoma of the right breast. A wide excision of the lesion and split-thickness skin graft was performed with uneventful recovery and satisfactory healing of the graft tissue and functional aspect of the arm. In the last few decades, there has been a search for solutions in tissue repair without need for auto grafts, such as biological substitutes that could repair or improve the function of tissue. In case none of these products are available, auto graft is a good choice and it may be commonly used in the surgical treatment of postoperative soft tissues defects after oncologic surgery.

Metabolic disorders in patients operated for pancreatic cancer.

Adenocarcinoma of the pancreas presents a major threat with a 5-years survival rate of 5%. Whipple pancreaticoduodenectomy (PD) is the standard procedure for cephalo-pancreatic neoplasm. After an extended resection and reconstruction of superior gastrointestinal tract the digestive physiology might be heavily disrupted. A literature review of metabolic alterations of patients who suffered a major pancreatic resection is performed, regarding micronutrients, lipid absorption and pancreatogenic diabetes. Long-term survivors following PD generally have a satisfactory nutritional status although with subclinical iron, vitamin D and selenium deficiency. These patients should be followed-up also regarding these micronutrients and properly dietary supplemented when necessary, also considering the increased life expectancy. Approximately 17-25% of patients will develop insulin-dependent diabetes but pancreatogenic diabetics have elevated levels of serum insulin and minimal or absent response to food intake, as opposed to a type I diabetics, where insulin serum is normal or elevated and there is an exaggerated response to ingestion of sugar.

Jod-Basedow effect due to prolonged use of lugol solution-case report.

Graves' disease is the most common form of hyperthyroidism, accounting for 60-80% of all cases of thyrotoxicosis. If left untreated, it may lead to severe thyrotoxicosis with cardiovascular, ocular, psychiatric complication, and in extreme cases thyrotoxic crisis with a high mortality rate. We present the case of a 50-years-old woman diagnosed in another service with Graves' disease and treated for many years with antithyroid drugs (ATDs), admitted to our service for a relapse due to treatment discontinuation. The surgical treatment was planned and the preoperative preparation with Lugol solution was initiated. Due to a misunderstanding, the administration of iodine solution was extended for a period of about 30 days, thus generating the so-called Jod-Basedow effect, with the exacerbation of the manifestations of thyrotoxicosis and risk of thyroid storm. The patient received treatment with high ATDs doses, glucocorticoids, and beta-blockers, resulting in the progressive improvement of symptoms. She was discharged from hospital and given the risk of thyrotoxic crisis the surgery was postponed. After a month, the patient underwent thyroidectomy without preoperative preparation with iodine solution. The operative and postoperative courses were uneventful.

Immune regulatory plasmacytoid dendritic cells selectively accumulate in perithyroidal lymph nodes of patients with Graves disease: implications for the understanding of autoimmunity.

UNLABELLED: Endocrine orbitopathy (EO) is the most common extrathyroidal manifestation of Graves disease (GD) but the involvement of the underlying immunological dysregulations remains largely unknown. The major source for IFNa-production, plasmacytoid dendritic cells (PDC) are fundamentally involved in the integration of TH1 and TH2 immune responses but also implicated in the pathogenesis of autoimmune diseases such as lupus. AIM: To establish whether PDC may play a role in GD autoimmune reaction and in the pathogenesis of EO. MATERIAL AND METHODS: In a series of six sequential patients with GD as well as six further patients with multinodular goiter, cervical lymph nodes (LN) were sampled and preserved in the setting of thyroid resection. In parallel, peripheral blood samples were collected. The frequency of PDC from the peripheral blood and lymph nodes were determined. Mononuclear cells (MC) were enriched from lymph nodes and peripheral blood using Fiquoll-hypaque density gradient centrifugation. Mononuclear cells were stained using BDCA-2-PE and CD123-FITC monoclonal antibodies and their frequency subsequently analyzed using fluorescence activated cell sorting (FACS). Dead cells were excluded from analysis by appropriate gating strategies and propidium iodide (PI) staining. RESULTS: In all patients with GD (with or without EO), PDC frequency was significantly increased in perithyroidal LN as compared to LN of patient not suffering form autoimmune diseases, e. g. patients with multinodular goiter (p < 0.01). The number of PDC infiltrating lymph nodes (LN-PDC) was also higher when compared to peripheral blood PDC (pB-PDC) of patients with multinodular goiter (p < 0.05). Finally, LN-PDC counts in perithyroidal lymph nodes of patients with GD were substantially increased when compared to pB-PDC of the same patients (p < 0.01) indicating a migration and accumulation of PDC in the draining LN. CONCLUSIONS: We found evidence that PDC selectively accumulate in perithyoidal LN of patients with GD, but not other thyroid diseases such as multinodular goiter. Based on their central importance in the pathogenesis of autoimmune processes such as in lupus erythematoides, we suggest that the migration and accumulation of PDC in an anatomical joining point between the thyroid gland and orbita may be of critical importance for the initiation and maintenance of a chronic autoimmune stimulation. This implies a so far unknown role for PDC in GD and as putative cellular targets for new therapeutic approaches.

Myasthenia gravis associated with thymoma and toxic multinodular goiter. A case report.

Adequate antithyroid drug treatment or surgery usually generates remission of myasthenia gravis (MG) in patients with thymus hyperplasia associated with Graves' hyperthyroidism. The case of a 46-year-old woman diagnosed with MG based on the clinical picture, anticholinesterase drug test and positive electromyography (EMG) is presented. The cervico-thoracic computer tomography revealed a compressive nodular goiter and normal antero-superior mediastinum and led to the diagnosis of MG secondary to the hyperthyroidism. An uneventful total thyroidectomy was performed, but postoperatively the MG symptoms worsened. TC99m tetrofosmin scintigraphy revealed an area of hyperfixation in the antero-inferior mediastinum, suggestive for thymoma, as confirmed by a repeated thoracic CT scan. Following a longitudinal sternotomy, a well incapsulated tumor of approximately 6/5 cm located in the antero-inferior mediastinum was found and an extensive thymomectomy was performed. The postoperative course was uneventful and the patient was discharged 9 days later with complete remission of myasthenia. The pathology report of the specimen revealed a mixt thymoma or AB thymoma after Muller-Hermelink and WHO classification, with invasive capsular foci corresponding to Masaoka II stadium. In conclusion, scintigraphy proved to be useful in the diagnosis and decision making of a thymoma.

Haemophilus influenzae type b infection, vaccination, and H. influenzae carriage in children in Minnesota, 2008-2009.

An increase in invasive Haemophilus influenzae type b (Hib) cases occurred in Minnesota in 2008 after the recommended deferral of the 12-15 months Hib vaccine boosters during a US vaccine shortage. Five invasive Hib cases (one death) occurred in children; four had incomplete Hib vaccination (three refused/delayed); one was immunodeficient. Subsequently, we evaluated Hib carriage and vaccination. From 18 clinics near Hib cases, children (aged 4 weeks-60 months) were surveyed for pharyngeal Hib carriage. Records were compared for Hib, diphtheria-tetanus-acellular pertussis (DTaP), and pneumococcal (PCV-7) vaccination. Parents completed questionnaires on carriage risk factors and vaccination beliefs. In 1631 children (February-March 2009), no Hib carriage was detected; Hib vaccination was less likely to be completed than DTaP and PCV-7. Non-type b H. influenzae, detected in 245 (15%) children, was associated with: male sex, age 24-60 months, daycare attendance >15 h/week, a household smoker, and Asian/Pacific Islander race/ethnicity. In 2009, invasive Hib disease occurred in two children caused by the same strain that circulated in 2008. Hib remains a risk for vulnerable/unvaccinated children, although Hib carriage is not widespread in young children.

Ectopic adrenocorticotropic hormone syndrome caused by a carcinoid tumor of the thymus. A case report.

Ectopic ACTH secretion accounts for less that 10% of all causes of endogenous Cushing's syndrome. Carcinoids are rare thymic tumors, and when associated with ACTH hypersecretion display local or distant aggressive behavior. A 32-year-old woman was admitted to the Endocrinology Unit for obesity, moon face, facial hirsutism, hyperpigmentation, and secondary amenorrhea. Laboratory test confirmed the hypercortisolism and excess ACTH, while dexamethasone suppressive test was negative. Thorax computed tomography (CT) showed an antero-superior mediastinal tumor invading the pericardium and left mediastinal pleura. A complete resection through median sternotomy of the tumor, pericardium and left mediastinal pleura was performed. After a one-year symptom-free period, hypercortisolism recurred, confirmed by laboratory findings. Although no signs of local recurrence were seen on thorax CT, left internal mammary lymph nodes involvement and vertebral body metastases at C7 and LI were found. Refractory electrolyte disturbances could not be corrected resulting in severe cardiac arrhythmia and death from cardiac arrest. The reported case draws attention on the aggressiveness of ACTH-secralso due to the refractory electrolyte disturbances with fatal outcome.

[The evaluation of mortality in abdominal surgery of patients aged over 75. A retrospective study on a series of 111 cases]. / Evaluarea mortalitatii în patologia chirurgicala abdominala la pacientii peste 75 de ani. Studiu retrospectiv.

UNLABELLED: Abdominal surgery of patients aged over 75 is a real challenge, regarding the risk-benefit ratio, especially in emergency cases. The aim of the study was to assess the mortality in elderly patients admitted for abdominal surgical conditions. MATERIAL AND METHODS: A retrospective study was carried out on a series of 111 patients aged over 75 that died during hospitalization for abdominal diseases in the 3rd Surgical Unit during the period 2007-2010. Data from the medical files, operating books and pathology reports were collected and analyzed. RESULTS: Of the 61 cases admitted for benign conditions, 11 deceased prior to surgery due to high ASA risk. 50 patients underwent surgery, mainly on emergency basis (42 cases). Most of the patients in this group suffered from intestinal infarction (22), followed by abdominal sepsis (16), intestinal obstruction (12) and digestive bleeding (10). Resection followed by anastomosis was performed in 17 cases; of these, anastomotic fistula with sepsis developed in 7 cases (41%). Malignant abdominal diseases were diagnosed in 50 patients, most frequently colorectal cancer (25) followed by gastric cancer (14), pancreatic cancer (5), billiary duct carcinoma (3), malignant ampuloma (2) and hepatoma (1). In this group, 46 patients were operated on, mainly in emergency (35). Of the 32 cases where resection was performed, anastomostic fistula with sepsis developed in 21 (65,6 %). CONCLUSIONS: the main cause of death was abdominal sepsis due to anastomotic fistula following resections, for both benign and malignant condition.

Objective evaluation of minimally invasive surgical skills for transplantation. Surgeons using a virtual reality simulator.

BACKGROUND: The learning curve in laparoscopic surgery may be associated with higher patient risk, which is unacceptable in the setting of kidney donation. Virtual reality simulators may increase the safety and efficiency of training in laparoscopic surgery. The aim of this study was to investigate if the results of a training session reflect the actual skill level of transplantation surgeons and whether the simulator could differentiate laparoscopic experienced transplantation surgeon from advanced trainees. SUBJECTS AND METHODS: 16 subjects were assigned to one of two groups: 5 experienced transplantation surgeon and 11 advanced residents, with only assistant role during transplantation. The level of performance was measured by a relative scoring system that combines single parameters assessed by the computer. RESULTS: The higher the level of transplantation experience of a participant, the higher the laparoscopic performance. Experienced transplantation surgeons showed statistically significant better scores than the advanced group for time and precision parameters. CONCLUSIONS: Our results show that performance of the various tasks on the simulator corresponds to the respective level of experience in transplantation surgery in our research groups. This study confirms construct validity for the LapSim. It thus measures relevant skills and can be integrated in an endoscopic training and assessment curriculum for transplantations surgeons.