Hepatitis C Infection in Hemodialysis Patients.

Three centuries after the identification of hepatitis C virus (HCV), specialized literature has outlined the epidemiology, viral kinetics and clinical manifestations of this infection. A major cause of morbidity-mortality in patients with renal transplantation and in hemodialysis patients is HCV infection. In high seroprevalence countries, internal accounts are not uniform. The European trend is to decrease the incidence and prevalence of HCV in hemodialysis patients. In Europe, the prevalence of HCV infection among hemodialysis patients tends to be higher than that of the general population, but it is variable by region. Some studies indicate a decrease in incidence in parallel with prevalence in dialysis centers over the last 10 years, while others maintain a high incidence. In some countries, as is the case with Romania, both prevalence and incidence remain high, with the major route of transmission being nosocomial, probably due to limited resources for a rapidly growing dialyzed population. Some authors recommend more isolation measures to be taken in centers with high prevalence of infection.

Therapy Side Effects in Systemic Lupus Erythematosus.

Glucosteroids (GS) are widely used drugs for various inflammatory pathologies (Nephrotic syndrome, Proliferative glomerulonephritis, Extramembrane glomerulonephritis, Nephropathy of the Nodous Poliarterita (PAN), Nephropathy from purple Henoch-Schonlein, lupus nephropathy (LN), Acute adrenal insufficiency Waterhouse-Friederichsen, Chronic adrenal insufficiency Addison, Systemic Lupus Erythematosus (SLE), Polymyositis and dermatomyositis, Chronic granulomatosis, Crohn's disease, Hemorrhagic rectocolitis, Hemolytic anemias, Acute leukemias and chronic lymphocytic leukemia, Hodgkin's lymphoma). Although they are prescribed for their anti-inflammatory and immunosuppressive properties, they also have many side effects, hyperglycemia being one of the most common and representative, which is why these drugs need careful monitoring when administered over the long term. This paper presents the case of a 39 year old patient diagnosed with systemic lupus erythematosus (SLE) with class IV lupus nephropathy (LN) who developed numerous complications due to the pathogenic side effects: diabetes, amenorrhea, recurrent infections, and depression.

VENOUS ULCER--A NEW THERAPEUTIC APPROACH.

Trophic leg ulcer is a major health problem affecting approximately 1-2% of the population, the incidence being higher in the elderly (70-80 years). It is a multifactorial condition, but the most common cause is chronic venous insufficiency. This can be attributed to reflux in the saphenous system and calf perforator vein incompetence. These were first described by Linton, the first intervention designed to correct perforator vein incompetence bearing his name. Today Linton's operation has been abandoned due to the large unaesthetic incision and great postoperative pain. Also, ulcer healing time is long (2 months) and recurrence rate is high. Currently a series of minimally invasive procedures are used to close these perforator veins, such as ultrasound-guided sclerotherapy. The advantages of these techniques are less discomfort to the patients, low rate of complications, short hospital stay.

SURGICAL TREATMENT OF POSTPARTUM ILIOFEMORAL DEEP VEIN THROMBOSIS--CASE REPORTS.

The writing committee for Antithrombotic Therapy for Venous Thromboembolic Disease of the 2008 ACCP guidelines made the following recommendations for thrombus removal strategies in patients with deep vein thrombosis (DVT): open surgical thrombectomy is recommended in patients with acute iliofemoral DVT to reduce symptoms and post-thrombotic morbidity; whenever available, catheter-directed thrombolysis is preferred to surgical venous thrombectomy, the risk of hemorrhage being diminished; surgical venous thrombectomy is recognized to be efficient in cases where catheter-directed thrombolysis is unavailable or the patients are not suitable candidates for such a procedure. Randomized studies comparing surgical thrombectomy and anticoagulant therapy in patients with iliofemoral DVT (IFDVT) showed that at 6 months, 5 years, and 10 years the patients in the thrombectomy group presented increased permeability, lower venous pressure, less edema, and fewer postthrombotic symptoms compared to the patients receiving anticoagulant therapy. In this article we present 3 cases of IFDVT in postpartum patients diagnosed by Doppler ultrasound of the deep venous system. The 3 patients received anticoagulant therapy prior to surgery. Surgery consisted in thrombectomy of the common, superficial and deep femoral veins, external and internal iliac veins, and femoral-saphenous arteriovenous fistula. The patients received postoperative antithrombotic therapy and were followed-up at 3, 6 and 9 months by Doppler ultrasound of the deep venous system.

Clinical and epidemiological assessment concerning hybrid revascularization techniques in the treatment of multilevel arterial occlusive disease.

UNLABELLED: Aim of the study was to report a novel hybrid technique for multilevel arterial lesions of the lower extremities and to evaluate the clinical outcomes. In patients with multilevel arterial disease, the combined (hybrid) treatment, consisting of endovascular intervention and classical surgical intervention on the same vascular axis seems to be the most indicated treatment in order to obtain an adequate inflow and outflow. MATERIAL AND METHODS: We have performed a non-randomized study during a 44-month period (January 2010 - September 2013) in a number of 94 patients treated by hybrid revascularization techniques. All the patients included in the study have been post-surgically surveyed at well established intervals (1, 3, 6, 9, 12, 24 and 36 months) by: clinical examination, laboratory tests, Duplex ultrasound, and, as needed, CT or MR Angiography. RESULTS: The 6 months primary patency in each studied group (corresponding to the years of 2010, 2011 and 2012) was 58.69%, 68.42%, and 62.06%, respectively; the 12 months primary patency was 45.65%, 57.89%, and 34.48%, respectively. Clinical improvement has been noticed in 83 patients (88.29%). There have been registered 19 amputations (20.21% of the cases): 11 majors (thigh and below the knee), representing 11.7% of the total number of cases and 8 minors (toe or transmetatarsal), representing 8.51% of the total number of cases. The amputation-free survival period ranged between 7 days and 24 months, with an average of 7.66 months. CONCLUSIONS: The hybrid techniques are a feasible option for the multilevel arterial disease, with favorable patency and limb salvage rates.

Paraganglioma of the carotid body: case report.

With an incidence of 0.03% of all tumors, carotid body tumors (CBTs) are extremely rare. We present the case of a 63 year old female patient with an asymptomatic right sided neck mass of 3 cm diameter. Doppler ultrasound and contrast-enhanced CT confirmed the clinical suspicion of carotid body tumor. The patient underwent complete surgical excision of the Shamblin group II tumor and an adjacent lymph node, without preoperative embolization. The histopathological examination diagnosed a benign CBT. There were no postoperative complications at 1 and 6 months follow-ups.

Surgical techniques in the treatment of multilevel arterial occlusive disease.

AIM OF THE STUDY: To report the surgical techniques for multilevel arterial lesions of the lower extremities and to evaluate the clinical outcomes. In patients with multilevel arterial disease, the treatment consisting of sequentially surgical intervention on the same vascular axis is one of the methods indicated in order to obtain an adequate inflow and outflow. MATERIAL AND METHODS: we have performed a nonrandomized study during a 44-month period (January 2010-September 2013) in a number of 58 patients treated by classical revascularization techniques. All the patients included in the study have been post-surgically surveyed at well-established intervals (1, 3, 6, 9, 12, 24 and 36 months) by: clinical examination, laboratory tests, Duplex ultrasound, and, as needed, CT Angiography. RESULTS: the 6 months primary patency in each studied group (corresponding to the years of 2010, 2011 and 2012) was 95%, 93.33%, and 91.3%, respectively; the 12 months primarypatency was 85%, 80%, and 82.6%, respectively. Clinical improvement has been noticed in44 patients (75.86%). There have been registered 14 amputations (24.13% of the cases): 7 majors (thigh and below the knee), representing 12.06% of the total number of cases and 7 minors (toe or transmetatarsal), representing 12.06% of the total number of cases. Limb salvage rate for the patients in stage III and IV Leriche-Fontaine was 85.10%. CONCLUSIONS: the surgical techniques are a feasible option for the multilevel arterial disease, with

Complex utrasound study of the atherosclerotic plaque.

UNLABELLED: Carotid surgery concept is wining ground both among neurologists who recommend and vascular surgeons who perform an increased number of interventions. Regardless of the technique, we are interested in the tendency of the plaque to grow and determine stenosis. Ultrasound (US) is 91-94% sensitive and 85-99% specific in detecting a significant stenosis of the internal carotid artery. AIM: To establish a correlation between the preoperative US and intraoperative plaque characteristics in order to determine the restenosis rate. MATERIAL AND METHODS: From January 1, 2012 to December 31, 2012, 70 consecutive patients were included in this study. Two groups were formed: 35 patients with stenotic ICA and 35 patients presenting stenosis at the femoral artery bifurcation (control group). The comparison between these two groups started from the premise of a similar pattern for internal carotid artery--deep femoral artery and external carotid artery- superficial femoral artery. US scans were performed on admission in all patients. All images were normalized and Gray Scale Median (GSM) was calculated. RESULTS: Femoral plaque GSM values were higher in relation with hyperechogenicity highlighting the intensely calcified structure. Unstable plaques were more heterogenic, with higher transparency and lower GSM than stable plaques. This was the case of carotid plaques. During follow-up US revealed no restenosis. CONCLUSIONS: Femoral bifurcation plaques are calcified and determine chronic ischemic symptoms, while carotid bifurcation plaques are unstable and determine cerebral symptoms. US remain the gold standard non-invasive technique both for screening and diagnosis and set the therapeutic coordinates.

Epidemiological characteristics of peripheral artery disease: retrospective study.

UNLABELLED: Peripheral artery disease (PAD) is a common condition. Over the past 20 years the risk factors for PAD have changed. AIMS: To identify the regional characteristics of the patients with PAD and the sex- and urban/rural-related differences. MATERIAL AND METHODS: Retrospective study on patients admitted to the Iasi "St. Spiridon' University Hospital in the interval 2007-2012. The dataset was prepared for t student analysis in in view of determining statistical significance. RESULTS: Of the 361,248 patients admitted to the 20 units of the hospital, 2,623 patients were diagnosed with advanced stages of PAD (Leriche--Fontain III and IV). Significant statistical differences were found between men and women, and between rural and urban men (p = 0.001). 20.5% of the patients underwent amputations. CONCLUSIONS: This is one of the first studies that has identified urban/rural differences. The characteristics specific to PAD patients from North-Eastern Romania are presented.

Surgical revascularization in chronic mesenteric ischemia.

Chronic mesenteric ischemia (CMI) is a disease causing death either by starvation or enteromesenteric infarction. Diagnosis is often delayed before the patient is referred to a vascular surgery unit. Atherosclerosis is the main cause of CMI. Arteriography is essential in diagnosing CMI and delineating the atherosclerotic lesions. The revascularization procedure consists in an aortomesenteric bypass reconstructing 1-3 visceral arteries. This paper presents two consecutive CMI cases treated at the Vascular Surgery Unit of the Iasi "Sf Spiridon" Hospital during 2010. Both patients had symptoms suggestive of mesenteric and aortoiliac diseases. CT angiography revealed specific lesions both for aortoiliac disease and stenotic or occlusive lesions in the celiac trunk and mesenteric arteries. Both cases benefited from aortobifemural bypass surgery using a synthetic graft associated with aortic-superior mesenteric artery bypass with reversed vein graft (in the first case both mesenteric arteries were revascularized). Immediate and remote results were favorable, with remission of intestinal symptoms and weight gain. Bypass patency was followed-up by CT angiography and Doppler ultrasound. CMI is a diagnostic and therapeutic challenge. Open surgery provides symptom remission in 90% of cases. Permeability at 5 years is 80-90% for open surgery, higher than by endovascular therapy. Average permeability of the two types of intervention is 70% at 5 years, similar to the infraaortic bypasses.

Parastomal hernia mesh repair, variant of surgical technique without stoma relocation.

RATIONALE: Due to the improvement of prognosis through adjuvant therapy, the life expectancy of neoplasia patients is continuously increasing, which, in conjunction with the progressive occurrence of parastomal hernias during the disease evolution, explains the growing number of reported parastomal hernias affecting patients with permanent colostomy. Conventional techniques of local repair are inappropriate considering the high recurrence rate, and the decision of stoma relocation depends on the associated pathology, which may counter-indicate general anesthesia, and on previous surgical interventions that are usually followed by a dense peritoneal adhesion syndrome. OBJECTIVE: The purpose of this article is to make known a variant of alloplastic technique, without translocation, with a low degree of invasiveness, which can be performed successfully under spinal anesthesia, followed by a reduced period of hospitalization. METHODS AND RESULTS: The study group consisted of 6 patients with permanent left iliac anus who underwent these interventions one to three years prior to the occurrence of parastomal hernia. Patients were followed at 1 year and 2 years postoperatively and the results were favorable, with no recurrence and improved quality of life through proper prosthesis of the stoma. DISCUSSION: We suggest that this technique variation is applied to small and medium parastomal hernias, in case of patients with permanent left iliac anus, with the declared intent of minimal invasiveness.

Urinary tract infections in the potential vertebroplasty patient: incidence, significance, and management.

SUMMARY: Percutaneous vertebroplasty has been deferred due to potential complications from urinary tract infections (UTIs). Our aim was to help sort out the types of treatment needed for percutaneous vertebroplasty patients and the length delay for performing the procedure. We searched for information regarding the ramifications of infection from the literature and devised a plan of treatment for the various infectious problems that may occur in patients undergoing percutaneous vertebroplasty. We devised a plan of action for the screening, testing, diagnosis and treatment of patients with a potential UTI who are presenting for a percutaneous vertebroplasty.

Partial infection of the aorto-uni(bi)femoral graft partial conservation and replacement with autologous material. Is it a reality?

UNLABELLED: The infection of the aorto-uni(bi)femoral graft is a serious complication, associated with high morbidity and mortality rates - severe implications on the vital prognosis (haemorrhage, sepsis) or of the peripheral vascularisation. Frequently, the infections of aorto-uni (bi) femoral grafts first appear at the level of the distal anastomosis, in Scarpa's triangle. MATERIAL AND METHODS: We are going to discuss a number of 6 cases of localised unilateral infection, situated in Scarpa's triangle. The infections appeared either during the first 3 months after the initial implantation of the graft, or later on (2 cases), after 2 and 5 years, respectively. The cases span over a period of 10 years covering a total number of 226 patients with aorto-uni(bi)lateral grafts. Our treatment of choice was to use autologous material, namely the superficial femoral vein, as replacement for the partially infected graft, which was harvested and placed in the iliac position during the same procedure. The surgical intervention was divided into an aseptic time, which involved harvesting the autologous conduit (superficial femoral vein), the proximal anastomosis between the non-contaminated portion of the graft and the venous graft, followed by closure; next, there was a septic time, that included entering the infected wound, extracting the contaminated segment of the graft and distal anastomosis between the femoral vein graft and the receptive artery. In five of the cases the venous conduit was passed through the same anatomical space from where the graft was extracted; in one case it was passed through the obturator channel and anastomosed to the superficial femoral artery at a lower level. The patients received pre- and postoperative intravenous antibiotics in accordance to the cultures taken from the infected wound, up to a period of 2-3 weeks, followed by another 3 weeks of oral antibiotics after discharge. RESULTS: All the patients survived the intervention. Postoperatively oedema of the lower leg and thigh was observed in all of the patients, similar to that appearing in deep venous thrombosis, and required treatment with low molecular weight heparin and long term oral anticoagulation with antivitamin K products.Patients were monitored postoperatively at intervals of one, three and six months followed by two annual check-ups. Biological tests and colour Duplex scans showed no signs of recurrent infection. CONCLUSIONS: Localized partial graft infections are a reality, confirmed by clinical, biological, ultrasound examinations, intra-operative explorations and postoperative results achieved by selective surgical resection. Infectious reoccurrence was not observed during the period of study.

[Oral and perioral endogenous pigmented lesions]. / Leziuni pigmentare endogene orale i periorale.

Pigmented lesions are commonly found in the mouth. Such lesions represent a variety of clinical entities, ranging from physiologic changes to manifestations of systemic illnesses and malignant neoplasms. Two groups of pigmented lesions of the oral mucosa are recognized: 1) endogenous lesions, including racial pigmentations, melanotic macules, melanocytic nevi, malignant melanoma and 2) exogenous lesions (e.g., blood-related pigmentations, metallic pigmentations). The etiology, differential diagnosis, clinical and histopathological features and management of endogenous pigmented lesions is discussed and the current literature is reviewed. In this article, pigmented lesions are described to allow practitioner to elaborate a positive diagnosis of endogenous pigmented lesions and to facilitate an early detection of these lesions particularly the malignant ones.

Effects of 6-hydroxydopamine-induced severe or partial lesion of the nigrostriatal pathway on the neuronal activity of pallido-subthalamic network in the rat.

The origin of changes in the neuronal activity of the globus pallidus (GP) and the subthalamic nucleus (STN) in animal models of Parkinson's disease (PD) is still controversial. The aim of the study was to investigate the neuronal activity of STN and GP neurons under urethane anesthesia in an early and in an advanced stage PD rat model. 6-Hydroxydopamine (6-OHDA) injection into the striatum induced a partial lesion of dopamine cells in the substantia nigra pars compacta (SNc) and fibers in the striatum. The GP firing rate decreased significantly with no significant change of the pattern. 6-OHDA injection into the SNc induced a total or subtotal lesion without any change in the firing rate and patterns of GP neurons. Concerning the STN, after partial lesion, the firing rate remained unchanged but the firing pattern significantly changed towards a more irregular and bursty pattern. In rats with total or subtotal lesion of the SNc the firing rate increased significantly and the relative amount of tonic neurons significantly decreased. Our results demonstrate that neuronal reactivity in the basal ganglia network considerably differs in the early versus late stage model of PD. We showed that the pathological activity of STN neurons after severe lesion is not mediated by the GP. Moreover, the unchanged activity of GP neurons is likely to be a consequence of the STN hyperactivity. These data suggest that in the GP-STN-GP network, the excitatory influence of the STN-GP pathway overrides that of the GABAergic GP-STN pathway, questioning the classical model of basal ganglia organization.

Usage of venous grafts in aorto-iliac reconstructive surgery.

UNLABELLED: The authors present their clinical experience utilizing venous grafts (greater saphenous vein and superficial femoral vein) in the aorto-femoral position. MATERIALS AND METHODS: Span of study is five years. The situations when these techniques were implemented are as follows:-(A). Infected synthetic prosthesis and (B). aorto-iliac occlusive disease in younger patients. A. In synthetic prosthetic infections there are 2 situations: (1) IMMEDIATE INFECTION. Observed in 10 cases, from which 2 cases where of severe infection and 8 cases of superficial infection--localized in the postoperative wound--Scarpa triangle region (7 cases) and left para-rectal (1 case). Superficial infections were treated successfully by daily dressings, excision of necrotic debris, antibiotic-therapy according to local antibiogram (only cases involving local invasion), and of course secondary wound closure at a later on date. The 2 cases of severe graft infection required harvesting of the superficial femoral vein and its usage in the aorto-femoral position. (2) LATE INFECTIONS. 3 patients were diagnosed with late infection of the synthetic prosthesis. In 2 cases, the infection was localized in the Scarpa triangle region, and the third in the abdomen (at the level of the aortic anastomosis). B. Aorto-iliac occlusive disease in younger patients--2 cases benefited from an aorto-bifemoral bypass reconstruction using the superficial femoral vein, and 5 cases where the greater saphenous vein was used in the iliac position. RESULTS: Only 1 patient with severe prosthetic infection died due to multiple organ dysfunctions after the operation; the rest survived without any major amputation. CONCLUSIONS: the harvesting and usage of these venous grafts is sometimes the final solution for patients with synthetic prosthesis infection.

Lesion of the pedunculopontine nucleus reverses hyperactivity of the subthalamic nucleus and substantia nigra pars reticulata in a 6-hydroxydopamine rat model.

The pedunculopontine nucleus (PPN) and the subthalamic nucleus (STN) are reciprocally connected by excitatory projections. In the 6-hydroxydopamine (6-OHDA) rat model the PPN was found to be hyperactive. Similarly, the STN and the substantia nigra pars reticulata (SNr) showed increased activity in Parkinson's disease (PD) animal models. A lesion of the STN was shown to restore increased activity levels in the SNr of 6-OHDA-treated rats. As the STN and the PPN were reciprocally connected by excitatory projections and both structures were shown to be hyperactive in PD animal models, the present study was performed in order to investigate the changes in neuronal activity of the STN and SNr under urethane anesthesia after unilateral ibotenic acid lesioning of the PPN in animals with previous unilateral 6-OHDA lesions of the substantia nigra pars compacta (SNc). The firing rate of STN neurons significantly increased from 10.3 +/- 0.6 spikes/s (mean +/- SEM) to 17.8 +/- 1.8 spikes/s after SNc lesion and returned to normal levels of 10.8 +/- 0.7 spikes/s after additional lesion of the PPN. Similarly, the firing rate of SNr neurons significantly increased from 19.0 +/- 1.1 to 25.9 +/- 1.4 spikes/s after SNc lesion, the hyperactivity being reversed after additional PPN lesion to 16.8 +/- 1.2 spikes/s. The reversal of STN and SNr hyperactivity of 6-OHDA-treated rats by additional PPN lesion suggests an important modulatory influence of the PPN on STN activity. Moreover, these findings could indicate a new therapeutic strategy in PD by interventional modulation of the PPN.

Iron-magnesium silicate bioweathering on Earth (and Mars?).

We examined the common, iron-magnesium silicate minerals olivine and pyroxene in basalt and in mantle rocks to determine if they exhibit textures similar to bioweathering textures found in glass. Our results show that weathering in olivine may occur as long, narrow tunnels (1-3 microm in diameter and up to 100 microm long) and as larger irregular galleries, both of which have distinctive characteristics consistent with biological activity. These weathering textures are associated with clay mineral by-products and nucleic acids. We also examined olivine and pyroxene in martian meteorites, some of which experienced preterrestrial aqueous alteration. Some olivines and pyroxenes in the martian meteorite Nakhla were found to contain tunnels that are similar in size and shape to tunnels in terrestrial iron-magnesium silicates that contain nucleic acids. Though the tunnels found in Nakhla are similar to the biosignatures found in terrestrial minerals, their presence cannot be used to prove that the martian alteration features had a biogenic origin. The abundance and wide distribution of olivine and pyroxene on Earth and in the Solar System make bioweathering features in these minerals potentially important new biosignatures that may play a significant role in evaluating whether life ever existed on Mars.

Total body irradiation prior to bone marrow transplantation--the experience of the Institute of Oncology Prof. Dr. Al. Trestioreanu Bucharest.

PURPOSE: To present the technique of total body irradiation (TBI), applied for the first time in Romania, at the Institute of Oncology Bucharest, as part of stem cell transplantation for hematological malignancies. PATIENTS AND METHODS: The total dose administered was 12 Gy at the reference point, 2 Gy/fraction, one fraction per day, 6 consecutive days, with a total dose of 8 - 11.4 Gy delivered to the lung, using Mevatron Primus linear accelerator (6 MV & 15 MV, 200-300 cGy/min in isocenter), in vivo dosimetry detectors and equipment for the reference dosimetry, personalized blocks for lung shielding sustained by polymethylmethaacrylate (PPMA) plate, Simulix HP simulator, and computer tomographic (CT) scans. Techniques used were: a) two parallel opposed anteroposterior / posteroanterior (AP/PA) fields with the patient in prone and supine position; b) two parallel opposed lateral fields with the patient placed on a lateral table, at 320 cm from the source. The percentage depth dose, tissue maximum ratio (TMR), off axis ratio (OAR) and the reference dose rate were measured for every patient's geometrical characteristics, with an uncertainty of +/- 2.2% and were used to calculate monitor units and to evaluate the dose in organs at risk (lungs, gonads, eyes etc). RESULTS: 5 patients (3 with the AP/PA technique and 2 with the lateral technique) were irradiated. All patients completed their irradiation in good clinical condition. The acute side effects were minimal (WHO grade 1: nausea/ vomiting--all patients; diarrhea--1 patient; headache--2 patients; photophobia and diplopia--1 patient; head and neck skin erythema--all patients). Because of the short follow-up period no safe evaluation of late side effects can be done. However, during this period one patient developed a non-aggressive form of chronic liver graft vs. host disease (GVHD) and one patient died due to acute GVHD. CONCLUSION: TBI as part of stem cell transplantation for hematological malignancies was successfully realized at our Institute, with favorable clinical results. This technique is easy to carry out and reproducible.