Addressing recurrent hypoglycaemia through thoracic surgical intervention: understanding Doege-Potter syndrome, a rarity in syndromes.

Doege-Potter syndrome (DPS), a rare paraneoplastic phenomenon characterised by non-islet cell tumour hypoglycaemia (NICTH), presents clinicians with intricate diagnostic and therapeutic challenges. This comprehensive review consolidates current understanding, clinical presentations, diagnostic modalities, therapeutic interventions, and emerging trends in managing DPS. The pathophysiology of DPS revolves around dysregulated insulin-like growth factors (IGF), particularly IGF-2, produced by mesenchymal tumours, notably solitary fibrous tumours (SFT). Clinical manifestations encompass recurrent hypoglycaemic episodes, often distinct from typical hypoglycaemia, with implications for insulin and counterregulatory hormone levels. Diagnosis necessitates a multidisciplinary approach integrating biochemical assays, imaging studies, and histopathological confirmation of the underlying neoplasm. Surgical resection remains the cornerstone of treatment, complemented by adjunctive therapies to manage persistent hypoglycaemia. Prognosis is influenced by successful tumour resection and long-term surveillance for recurrence. A patient-centred approach, incorporating supportive services and multidisciplinary care, is essential for optimal outcomes in individuals affected by DPS.

Secondary aortoenteric fistula: a narrative review of the view of the surgeon.

Aortoenteric fistula (AEF) is defined as the abnormal communication between the aorta and the gastrointestinal tract. AEFs are divided into primary and secondary usually after abdominal aortic aneurysm (AAA) recovery and are a rare but quite dangerous cause of gastrointestinal bleeding that the general surgeon may face during his/her career. Secondary AEF was first described in 1953 to a 44-year-old woman 3 months after an AAA operation. This review presents the role of the surgeon in the management of secondary aortoenteric fistulas. AEFs are a rare but fatal gastrointestinal bleeding cause that the general surgeon may be asked to manage. Diagnosis requires the combination of strong clinical suspicion and the presence of a history of AAA surgery. Although a vascular surgery case, general surgeons play a role in choosing the technique of restoring the intestinal tract, which seems to be significantly related to subsequent morbidity and mortality.

Demographic and clinical characteristics of patients with varicose veins in Albania: a retrospective, single-centre analysis.

Introduction: Chronic venous disease (CVD) constitutes a frequently underdiagnosed pathological condition that progressively diminishes patients' quality of life and imposes an escalating strain on healthcare resources. This study aims to comprehensively investigate the epidemiological landscape of varicose vein disease, examining age group distributions, gender patterns, residence influences, marital status correlations, weight considerations, educational impacts, and various aspects related to varicose veins. Material and methods: This was a single-centre retrospective analysis, in Albania from May 2018 to September 2023. Data were collected retrospectively through hospital records. Data collection involved administering a structured questionnaire to study participants, categorically organised into three sections. The first section focused on collecting demographic information, the second section involved self-perception of identifying risk factors associated with varicose veins, and the final section included inquiries about the history of variceal surgery. Results: The CEAP classification distribution in our cohort revealed a predominant presence of C2 (varicose veins) in 53.3% of patients, followed by C3 (oedema) at 29.2%, and C4 (changes in skin and subcutaneous tissue secondary to CVD) at 10.5%, whereas C5 (healed venous ulcer) and C6 (active venous ulcer) were less frequent. Based on the body mass index (BMI) scale, data from patients indicated that 9.7% were in the category of underweight, 54.8% had a normal BMI, and 35.5% were categorised as overweight. Conclusions: The study's thorough exploration of patient perspectives, risk factors, and treatment choices contributes to a holistic understanding of varicose vein management, emphasising the importance of personalised approaches that account for demographic variations and individual beliefs.

Challenges and pitfalls in the perioperative management of mediastinal mass syndrome: an up-to-date review.

The perioperative management of patients undergoing mediastinal mass operations presents a persistent challenge across multiple clinical specialties. General anesthesia administration further increases the risk of perioperative cardiorespiratory decompensation. The interdisciplinary team plays a crucial role in ensuring a safe perioperative period. However, due to the rarity and variability of mediastinal mass syndromes, specific management protocols are lacking. This review aims to outline the multitude of challenges and pitfalls encountered during perioperative management in patients with the mediastinal mass syndrome. We describe diagnostic evaluation, preoperative optimization, intraoperative considerations, and postoperative care strategies, emphasizing the paramount significance of a multidisciplinary approach and personalized treatment plans. Preoperative multidisciplinary discussions, meticulous anesthetic management, and well-established protocols for emergency situations are pivotal to ensuring patient safety. Healthcare providers involved in the care of patients with mediastinal mass syndrome must grasp these challenges and pitfalls, enabling them to deliver safe and effective perioperative management.

Automatic quantitative analysis of in-stent restenosis using FD-OCT in vivo intra-arterial imaging.

PURPOSE: A new segmentation technique is implemented for automatic lumen area extraction and stent strut detection in intravascular optical coherence tomography (OCT) images for the purpose of quantitative analysis of in-stent restenosis (ISR). In addition, a user-friendly graphical user interface (GUI) is developed based on the employed algorithm toward clinical use. METHODS: Four clinical datasets of frequency-domain OCT scans of the human femoral artery were analyzed. First, a segmentation method based on fuzzy C means (FCM) clustering and wavelet transform (WT) was applied toward inner luminal contour extraction. Subsequently, stent strut positions were detected by utilizing metrics derived from the local maxima of the wavelet transform into the FCM membership function. RESULTS: The inner lumen contour and the position of stent strut were extracted with high precision. Compared to manual segmentation by an expert physician, the automatic lumen contour delineation had an average overlap value of 0.917 ± 0.065 for all OCT images included in the study. The strut detection procedure achieved an overall accuracy of 93.80% and successfully identified 9.57 ± 0.5 struts for every OCT image. Processing time was confined to approximately 2.5 s per OCT frame. CONCLUSIONS: A new fast and robust automatic segmentation technique combining FCM and WT for lumen border extraction and strut detection in intravascular OCT images was designed and implemented. The proposed algorithm integrated in a GUI represents a step forward toward the employment of automated quantitative analysis of ISR in clinical practice.

Tacrolimus and 3-hydroxy-3-methylglutaryl-coenzyme A reductase inhibitors: An interaction study in CYP3A5 non-expressors, renal transplant recipients.

OBJECTIVES: Atherosclerosis is a significant factor affecting long-term outcome in renal transplant recipients. Studies have been conducted to determine the pharmacogenomic pathways involved in statin efficacy, efficiency, and adverse effect likelihood. However, little is known about the influence of statins on tacrolimus kinetics. The aim of this study was to investigate possible pharmacological interactions between tacrolimus and statins in CYP3A5 non-expressors, renal transplant recipients. MATERIALS AND METHODS: Twenty-four patients, treated with tacrolimus (n=24), methylprednisolone (n=24), and mycophenolate mofetil (n=19)/azathioprine (n=1)/everolimus (n=4), participated in the study. After an observation time of 112±36 days, statins, namely, atorvastatin (n=12), simvastatin (n=8), pravastatin (n=2), or fluvastatin (n=2), were administered for additional 101±34 days. DNA was extracted from whole blood sample and polymerase chain reaction followed by restriction fragment length polymorphism analysis was used for CYP3A5 genotyping. Student's t-test and Mann-Whitney test were used to test the significance of difference in variables that passed or did not pass Kolmogorov's normality test, respectively. RESULTS: No statistically significant difference was observed in tacrolimus daily dose, concentration, concentration/dose ratio, and volume of distribution before and during the administration of statins. Statistically significant decrease in serum cholesterol was observed after initiation of statins. Renal and hepatic function remained unchanged and no skeletal muscle abnormalities were reported. CONCLUSIONS: The results of this study show that tacrolimus and statins do not interact in terms of efficacy, efficiency, and adverse effect likelihood. No significant clinical interaction or effect was observed, even with the use of atorvastatin or simvastatin, which are metabolized by CYP3A4 such as tacrolimus.

Investigation of clinical interaction between omeprazole and tacrolimus in CYP3A5 non-expressors, renal transplant recipients.

BACKGROUND: As proton pump inhibitors share CYP3A4 enzyme with tacrolimus for their hepatic elimination, they potentially affect its pharmacokinetics, most prominently in patients with CYP2C19 or CYP3A5 gene mutations. Our aim was to investigate the impact of omeprazole on tacrolimus pharmacokinetics in CYP3A5 non-expressors, kidney transplant recipients. METHODS: Twelve patients (five males/seven females) were observed for 175 +/- 92.05 days. Omeprazole (20 mg pos) was administrated for 75.83 +/- 45.17 days. Immunosuppressant regimen consisted of tacrolimus (n = 12), methylprednisolone (n = 10), mycophenolate mofetil (n = 11), azathioprine (n = 1), and everolimus (n = 2). Patient's body weight, coadministered drugs, and tacrolimus trough levels were monitored. Aspartate and alanine aminotransferase, gamma-glutamyltransferase, and bilirubin were used for evaluating hepatic function. Tacrolimus kinetics were estimated with daily dose, concentration, dose adjusted concentration, and volume of distribution with and without coadministration of omeprazole. CYP3A5 genotyping was performed with PCR followed by restriction fragment length polymorphism analysis. Statistical analysis was performed with Prism 4 software (GraphPad Software, Inc). RESULTS: No statistically significant difference was observed in tacrolimus kinetics and hepatic function during coadministration of omeprazole. CONCLUSION: Our results let us propose that there is no need for more frequent therapeutic drug monitoring of tacrolimus when coadministrated with omeprazole in CYP3A5 nonexpressors, though prospective studies with more patients and longer observation period are needed to confirm these findings.

Factors affecting the long-term response to tacrolimus in renal transplant patients: pharmacokinetic and pharmacogenetic approach.

BACKGROUND: The aim of our study was to determine the impact of CYP3A5*1 and CYP3A5*3 on the kinetics of tacrolimus in renal transplant recipients. MATERIAL AND METHODS: Forty kidney recipients were selected to participate. Maintenance scheme consisted of tacrolimus, a purine inhibitor and a steroid. CYP3A5 genotyping was performed with PCR and RFLP. Pharmacokinetic model was developed with Linear Regression and General Linear Model repeated measures approach. The impact of sex, CYP3A5*1 allele, age at transplantation, hepatic and renal function on tacrolimus kinetics was examined. RESULTS: The frequency of CYP3A5*3/*3 and CYP3A5*1/*3 genotype was 35/40 and 5/40, respectively. No CYP3A5*1/*1 was detected. CYP3A5*1 variant was associated with significant lower TAC dose adjusted concentration at 3, 6, 12 and 36 months after transplantation. Hepatic and renal function showed a significant effect on tacrolimus dose adjusted concentration 3 months after transplantation (p=0.000 and 0.028, respectively). Sex did not show a significant impact on tacrolimus kinetics. Carriers of CYP3A5*1 allele had lower predicted measures for tacrolimus dose adjusted concentration and higher predicted measures for volume of distribution. CONCLUSION: We proved that CYP3A5*1 carriers need higher tacrolimus dose than CYP3A5*3 homozygotes to achieve the target blood concentration.

Salvage laparoscopic extraperitoneal radical prostatectomy after failed high-intensity focused ultrasound and radiotherapy for localized prostate cancer.

OBJECTIVES: To investigate the feasibility and efficacy of salvage endoscopic extraperitoneal radical prostatectomy (EERPE) in cases of recurrent prostate cancer after high-intensity focused ultrasound therapy (HIFU) or radiotherapy. METHODS: Nine patients underwent salvage EERPE with curative intent for biopsy-proven, locally recurrent prostate cancer. Of these 9 patients, 3 had previously undergone HIFU and 6 radiotherapy. Perioperative parameters (operation time, estimated blood loss, conversion to open surgery rate, transfusion rate, transurethral catheter time), functional outcome, and short-term oncologic outcome were reviewed. RESULTS: Mean patient age was 63.3 years (range 48 to 74 years). Mean preoperative PSA value was 12.64 ng/mL and mean prostate weight was 49.2 g. Mean blood loss was 238 mL. There was no need for conversion to open surgery or transfusion. Mean operation time was 148 minutes, and mean total transurethral catheter time was 6 days. No intraoperative complications were reported. There was no clear difference in operation difficulty between the post-HIFU and postradiotherapy EERPE. After a mean follow-up of 17 months, 7 patients were completely continent, and 2 needed 1 to 2 pads per day. Three patients were potent before the surgical treatment, but no patient reported potency postoperatively. In 1 patient a PSA relapse (1.20 ng/mL) was recognized 12 months postoperatively. CONCLUSIONS: Salvage EERPE after failed HIFU and radiation therapy is a safe and efficient method to treat locally recurrent prostate cancer. Short-term oncologic and functional outcomes are promising, but further study should be made on the long-term oncologic outcomes of this technique.

Transcranial cerebral oximetry and transcranial doppler sonography in patients with ruptured cerebral aneurysms and delayed cerebral vasospasm.

BACKGROUND: Vasospasm is a major cause of ischemic neurological deficits developing after subarachnoid hemorrhage. The goal was to identify hemodynamic changes and the presence of clinical vasospasm in patients suffering from subarachnoid hemorrhage secondary to ruptured intracranial aneurysms. MATERIAL/METHODS: Pre- and postoperative serial transcranial cerebral oximetry and transcranial doppler sonography (TCD) examinations were performed in 75 patients operated for aneurysmal subarachnoid hemorrhage. RESULTS: No significant difference (p=0.14) was found in the levels of regional oxygen saturation (rSO2) between patients with vasospasm and those without. In patients who developed clinical vasospasm, the blood flow velocity values were significantly higher compared with those who did not (127.5+/-2.7 versus 92.5+/-1.2 cm/sec, p<0.001). In six patients with clinical vasospasm and low TCCO measurements, the use of triple-H therapy led to oxygen saturation increment and clinical improvement. CONCLUSIONS: Transcranial cerebral oximetry seems to be of limited value for the detection of vasospasm in patients with subarachnoid hemorrhage. However, it may be useful in estimating the clinical impact of triple-H therapy in such patients.

Role of laparoscopy for reconstructive urology.

PURPOSE OF REVIEW: Laparoscopic reconstructive urology is a challenging and technically demanding field of urology. As urologists' experience strengthened and technical modifications developed, urologic laparoscopy was applied in the treatment of malignancies and evolved from simple to technically demanding reconstructive techniques. This article reviews the latest published literature in the field of laparoscopic reconstructive urology and introduces our own persuasion for the role of this approach in urology. RECENT FINDINGS: Some laparoscopic procedures like orchidopexy, ureterolithotomy, pyelolithotomy and pyeloplasty require "a middle class level of laparoscopic skills" whereas other reconstructive techniques such as radical prostatectomy and cystectomy and partial nephrectomy are technically demanding and are still being developed with promising results. The reconstructive part of partial nephrectomy is small and refers to good hemostasis whereas in radical prostatectomy and cystectomy, the reconstructive part--urethrovesical anastomosis and urinary diversion, respectively--is an important factor, affecting the patient's postoperative quality of life. SUMMARY: The development of new instrumentation as well as the amelioration of urologists' laparoscopic skills will pave the way for the establishment of laparoscopic reconstructive urology in everyday practice. So far, laparoscopic reconstructive urology seems to be a well tolerated and effective treatment modality but still with not a completely clear role.