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Ursu Lake is located in the Middle Miocene salt deposit of Central Romania. It is stratified, and the water column has three distinct water masses: an upper freshwater-to-moderately saline stratum (0-3 m), an intermediate stratum exhibiting a steep halocline (3-3.5 m), and a lower hypersaline stratum (4 m and below) that is euxinic (i.e. anoxic and sulphidic). Recent studies have characterized the lake's microbial taxonomy and given rise to intriguing ecological questions. Here, we explore whether the communities are dynamic or stable in relation to taxonomic composition, geochemistry, biophysics, and ecophysiological functions during the annual cycle. We found: (i) seasonally fluctuating, light-dependent communities in the upper layer (≥0.987-0.990 water-activity), a stable but phylogenetically diverse population of heterotrophs in the hypersaline stratum (water activities down to 0.762) and a persistent plate of green sulphur bacteria that connects these two (0.958-0.956 water activity) at 3-3.5 to 4 m; (ii) communities that might be involved in carbon- and sulphur-cycling between and within the lake's three main water masses; (iii) uncultured lineages including Acetothermia (OP1), Cloacimonetes (WWE1), Marinimicrobia (SAR406), Omnitrophicaeota (OP3), Parcubacteria (OD1) and other Candidate Phyla Radiation bacteria, and SR1 in the hypersaline stratum (likely involved in the anaerobic steps of carbon- and sulphur-cycling); and (iv) that species richness and habitat stability are associated with high redox-potentials. Ursu Lake has a unique and complex ecology, at the same time exhibiting dynamic fluctuations and stability, and can be used as a modern analogue for ancient euxinic water bodies and comparator system for other stratified hypersaline systems., (© 2019 The Authors. Environmental Microbiology published by Society for Applied Microbiology and John Wiley & Sons Ltd.)

Selection and dissemination of resistant bacteria and antibiotic resistance genes (ARGs) require a deeper understanding since antibiotics are permanently released to the environment. The objective of this paper was to evaluate the phenotypic resistance of 499 isolates of Pseudomonas spp. from urban water sources, and the prevalence of 20 ARGs within those isolates. Resistance to penicillins, cephalosporins, carbapenems, quinolones, macrolides, and tetracyclines was mainly observed in the hospital effluent, municipal wastewater and river water downstream the city. Resistant strains were frequently identified as P. aeruginosa and P. putida. P. aeruginosa isolates were mostly resistant to cefepime, ceftazidime, imipenem, and gentamycin, while P. putida strains were especially resistant to piperacillin-tazobactam. ARGs such as bla TEM-1 , bla SHV-1 , bla PER-1 , bla AmpC , bla VIM-1 , PstS, qnrA, qnrB, ermB, tetA, tetB and tetC have been detected. The bla AmpC gene was found in P. aeruginosa, while bla TEM-1 and bla PER-1 genes were found in P. putida. Class 1 integron integrase gene was found in 6.81% of the Pseudomonas isolates.

Background and Purpose: To determine the diagnostic value of bright spotty lesions (BSLs) for aquaporin-4 antibody-positive neuromyelitis optica spectrum disorder (NMOSD AQP4+ ), the predictive value of axial-BSLs for AQP4-IgG seropositivity, and the radio-clinical differences in NMOSD AQP4+ patients with and without axial-BSLs., Materials and Methods: Retrospective study that included patients aged≥16 years, with a first acute spinal cord syndrome between 2005 and 2018 and abnormal spinal cord MRI with axial and sagittal T2 sequences. Patients with MRI findings consistent with compressive myelopathy were excluded. All spinal cord MRI were retrospectively evaluated for the presence of BSLs by 2 radiologists blinded to the diagnosis of acute myelopathy., Results: A total of 82 patients were included; 15 aquaporin-4 antibody-positive neuromyelitis optica spectrum disorder patients (NMOSD AQP4+ ), and 67 other patients, considered as the other causes of myelopathy (OM) group. The specificity of axial-BSLs for NMOSD AQP4+ patients was 94.0% (95% CI [85.6 to 97.7]). The sensitivity was 40.0% (95% CI [19.8 to 64.3]). In the multivariable analysis, the only MRI characteristic associated with AQP4-IgG positivity was the presence of axial-BSLs (OR: 9.2, 95% CI [1.2 to 72.9]; P=0.022). In NMOSD AQP4+ patients, the median of cord expansion ratio was higher with axial-BSL (1.2, IQR [1.1-1.3]) than without axial-BSL (1.1, IQR [1.0-1.2]; P=0.046)., Conclusion: After a first acute spinal cord syndrome, the presence of axial-BSLs on spinal cord MRI seems very specific for NMOSD AQP4+ and seems to be a predictor radiological marker of AQP4-IgG positivity., (Copyright © 2020 Elsevier Masson SAS. All rights reserved.)

Purpose: The purpose of this study was to evaluate the accuracy of virtual planning using customized surgical devices (VP3D) in fibula free flap mandibular reconstruction., Methods: Fourteen patients received VP3D and 16 patients underwent conventional surgery (CS). Virtual planning was compared to postoperative scans using cephalometric and three-dimensional (3D) measurements. Operative times of both VP3D and CS groups were compared., Results: Comparisons of cephalometric measurements revealed no significant difference between virtual planning and postoperative scans. 3D analysis demonstrated a high level of virtual planning accuracy. In the VP3D group, total operative time gain was 88 min (p < 0.001) and total ischemia time gain was 36 min (p = 0.04)., Conclusion: Virtual surgical planning using customized devices enables 'tailored' surgery that is accurate and reliable and results in operative and ischemia time gain., Clinical Trial: NCT03869723.

Background: All patients undergoing thyroid operations should be subjected to preoperative neck ultrasound (US) followed by fine needle aspiration cytology (FNAC) of suspicious lesions. In Western countries, thyroid surgeons routinely perform neck ultrasound. The role of prophylactic central neck dissection (PCND) remains a topic of debate. For treatment of papillary thyroid carcinoma (PTC), in 2014 we introduced two new adjuncts: PCND based on criteria of the European Society of Endocrine Surgeons (ESES) consensus group and surgeon-performed US (S-US). Methods: In order to better understand the role of these two adjuncts in our shift of strategy we aimed to evaluate the outcomes of our patients in two successive 5-year time periods based on a retrospective analysis of our prospectively maintained database (total of 286 patients were included in this study). Results: The two groups were similar regarding epidemiological and clinical data. FNAC was done in only 21.66% of all PTC cases. PTC diagnosis was done in the majority of suspicious cases by FS. S-US guided the selective lateral node dissections (LND), leading to more lymph node metastases detections and it also surpassed endocrinologist performed US (E-US) in terms of PPV. PCND rate of complications was significantly higher due only to transient hypoparathyroidism. Conclusions: Preoperative surgeon-performed ultrasonography is a useful tool in the arsenal of PTC treatment. The systematic preoperative FNAC diagnosis and intraoperative frozen sections in uncertain cases are mandatory. PCND is a safe method of treatment and staging in PTC., (Celsius.)

Introduction: We report the case of a 77-year-old female patient with the diagnosis of pancreatic head insulinoma, in whom we used near infrared light (NIR) to detect synchronous pancreatic tumors and potential secondary lymph node or liver involvement. The patient presented with hypoglycemia manifesting by lipothymia. With the diagnosis of secretory neuroendocrine tumor (insulinoma) of the pancreatic head, cephalic pancreatoduodenectomy with the preservation of the pylorus was performed after NIR visualization of the pancreatic tumor mass. At 6, 12, 18 months postoperatively, the patient no longer had hypoglycemia and her general state was good., Conclusion: NIR with indocyanine green (ICG) evidences pancreatic neuroendocrine tumors, as well as possible synchronous tumors and secondary lymph node or liver involvement., (Copyright © 2019 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Context: The current therapeutical management of secondary hyperparathyroidism (S-HPTH) is difficult to obtain due to the lack of kidney donors. Surgical intervention on the pathologic parathyroid tissue has been suggested as a method to alleviate symptoms in patients with chronic kidney disease (CKD)., Objective: The aim of our study was to evaluate the outcomes of parathyroid surgery in patients with S-HPTH and the advantages of intraoperative quick PTH (iqPTH) to improve surgical results., Material and Methods: In a real-life study, we compared one group of S-HPTH with iqPTH performed after removing all suspected glands and before wound suture (Group 1) and one group in that iqPTH was not assessed (Group 2). When iqPTH dropped less than 50%, additional exploration followed., Results: Eight out of the 34 patients from Group 1, who underwent subtotal parathyroidectomy, showed elevated levels of serum PTH and calcium, which remained elevated during follow-up, thus, suggesting disease persistence. From the 21 patients in Group 2, none showed early postoperative disease persistence. Serum calcium, but not PTH was increased in one patient from the iqPTH group but normalized after one month. Overall, iqPTH allowed detection of a supplementary parathyroid gland in one case, thereby increasing early post-surgery remission to 100% in Group 2 compared to 76.47% in Group 1. Late postoperative remission of hyperparathyroidism with no further increase in the rate of hypoparathyroidism was obtained in Group 2., Conclusions: Assessment of intra-operative PTH levels proved to be a useful tool in augmenting the outcome of S-HPTH surgery. In patients which are eligible for renal transplantation who undergo a subtotal resection, iqPTH can enhance the post-operative quality of life by lowering disease recurrence rates until the kidney transplant procedure., Competing Interests: The authors declare that they have no conflict of interest.

For a long time, treatment of peritoneal metastases (PM) was mostly palliative and thus, this status was link with "terminal status/despair". The current multimodal treatment strategy, consisting of cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC), has been strenuously achieved over time, but seems to be the best treatment option for PM patients. As we reviewed the literature data, we could emphasize some milestones and also, controversies in the history of proposed multimodal treatment and thus, outline the philosophy of this approach, which seems to be an unusual one indeed. Initially marked by nihilism and fear, but benefiting from a remarkable joint effort of human and material resources (multi-center and -institutional research), over a period of 30 years, CRS and HIPEC found their place in the treatment of PM. The next 4 years were dedicated to the refinement of the multimodal treatment, by launching research pathways. In selected patients, with requires training, it demonstrated a significant survival results (similar to the Hepatic Metastases treatment), with acceptable risks and costs. The main debates regarding CRS and HIPEC treatment were based on the oncologists' perspective and the small number of randomized clinical trials. It is important to statement the PM patient has the right to be informed of the existence of CRS and HIPEC, as a real treatment resource, the decision being made by multidisciplinary teams.

Hypersaline meromictic lakes are extreme environments in which water stratification is associated with powerful physicochemical gradients and high salt concentrations. Furthermore, their physical stability coupled with vertical water column partitioning makes them important research model systems in microbial niche differentiation and biogeochemical cycling. Here, we compare the prokaryotic assemblages from Ursu and Fara Fund hypersaline meromictic lakes (Transylvanian Basin, Romania) in relation to their limnological factors and infer their role in elemental cycling by matching taxa to known taxon-specific biogeochemical functions. To assess the composition and structure of prokaryotic communities and the environmental factors that structure them, deep-coverage small subunit (SSU) ribosomal RNA (rDNA) amplicon sequencing, community domain-specific quantitative PCR and physicochemical analyses were performed on samples collected along depth profiles. The analyses showed that the lakes harbored multiple and diverse prokaryotic communities whose distribution mirrored the water stratification patterns. Ursu Lake was found to be dominated by Bacteria and to have a greater prokaryotic diversity than Fara Fund Lake that harbored an increased cell density and was populated mostly by Archaea within oxic strata. In spite of their contrasting diversity, the microbial populations indigenous to each lake pointed to similar physiological functions within carbon degradation and sulfate reduction. Furthermore, the taxonomy results coupled with methane detection and its stable C isotope composition indicated the presence of a yet-undescribed methanogenic group in the lakes' hypersaline monimolimnion. In addition, ultrasmall uncultivated archaeal lineages were detected in the chemocline of Fara Fund Lake, where the recently proposed Nanohaloarchaeota phylum was found to thrive.

Background: Psammocarcinomas (PCas) are rare epithelial tumors, usually originating in the ovaries or the peritoneum. These tumors are morphologically characterized by extensive psammomatous calcifications, invasiveness and low-grade cytological features., Case Report: We present the case of a 54-year-old woman who was referred to our department with an umbilical tumor and increasing abdominal girth. The patient had had an umbilical hernia for more than 20 years. The CA 125 level was normal. The CT scan showed small peritoneal nodules at the level of the Douglas pouch, including the posterior wall of the uterus, and the entire colon, as well as large nodules located on the caecum and the sigmoid colon. We performed partial enterectomy, total colectomy with ileo-rectal anastomosis, omentectomy, total histerectomy and bilateral adnexectomy, pelvic peritonectomy of the Douglas pouch. Pathology findings were consistent with F.I.G.O. stage IIIC peritoneal PCa. The patient received adjuvant chemotherapy with Taxol and Carboplatin. To date, twelve months after surgery, the follow-up shows no evidence of disease., Conclusion: Standardized treatment protocols are hindered by the rarity of the PCas. However, literature concludes that optimal debulking is mandatory, whereas the efficacy of adjuvant chemotherapy remains to be elucidated.

Perennially stratified salt lakes situated in the Transylvanian Basin (Central Romania) were surveyed for the diversity of culturable halophilic archaea (Fam. Halobacteriaceae). The physical and chemical characteristics of the waters indicated that all the investigated lakes were meromictic and neutral hypersaline. Samples collected from upper, intermediate, and deeper water layers and sediments were used for the isolation of halophilic strains followed by 16S rRNA gene-based identification and phenotypic characterization. The phylogenetic analysis of the 16S rRNA gene sequences revealed that all 191 isolates reported in this study and 43 strains previously isolated were affiliated with the family Halobacteriaceae and classified to 18 genera. Haloferax was the most frequently isolated genus (~47 %), followed by Halobacterium spp. (~12 %), and Halorubrum spp. (~11 %). Highest culturable diversity was detected in Brâncoveanu Lake, the oldest and saltiest of all studied lakes, while the opposite was observed in the most stable and least human-impacted Fără Fund Lake. One strain from Ursu Lake might possibly constitute a novel Halorubrum species as shown by phylogenetic analysis. Several haloarchaeal taxa recently described in Asian (i.e., Iran, China) saline systems were also identified as inhabiting the Transylvanian salt lakes thus expanding our knowledege on the geographic distribution of Halobacteriaceae.

Flap monitoring technology has progressed alongside flap design. The highly variable vascular anatomy and the complexity associated with modern perforator flaps demands dynamic, real-time, intraoperative information about the vessel location, perfusion patterns and flap physiology. Although most surgeons still assess flap perfusion and viability based solely on clinical experience, studies have shown that results may be highly variable and often misleading. Poor judgment of intraoperative perfusion leads to major complications. Employing dynamic perfusion imaging during flap reconstruction has led to a reduced complication rate, lower morbidity, shorter hospital stay, and an overall better result. With the emergence of multiple systems capable of intraoperative flap evaluation, the purpose of this article is to review the two systems that have been widely accepted and are currently used by plastic surgeons: Indocyanine green angiography (ICGA) and dynamic infrared thermography (DIRT).

Halophilic organisms are having adaptations to extreme salinity, the majority of them being Archaean, which have the ability to grow at extremely high salt concentrations, (from 3 % to 35 %). Level of salinity causes natural fluctuations in the halophilic populations that inhabit this particular habitat, raising problems in maintaining homeostasis of the osmotic pressure. Samples such as salt and water taken from Turda Salt Mine were analyzed in order to identify the eco-physiological bacterial groups. Considering the number of bacteria of each eco-physiological group, the bacterial indicators of salt quality (BISQ) were calculated and studied for each sample. The phosphatase, catalase and dehydrogenases enzymatic activities were quantitatively determined and the enzymatic indicators of salt quality (EISQ) were calculated. Bacterial isolates were analyzed using 16S rRNA gene sequence analysis. Universal bacterial primers, targeting the consensus region of the bacterial 16S rRNA gene were used. Analysis of a large fragment, of 1499 bp was performed to improve discrimination at the species level.

Saline, meromictic lakes with significant depth are usually formed as a result of salt mining activity. Ocnei Lake is one of the largest Transylvanian (Central Romania) neutral, hypersaline lake of man-made origin. We aimed to survey the seasonal dynamics of archaeal diversity in the water column of Ocnei Lake by employing microbiological methods as well as molecular techniques based on the sequence analysis of the 16S rRNA gene. We found that archaeal diversity in the water column increased with depth and salinity, with 8 OTUs being detected in the epilimnion compared to 21 found in the chemocline, and 32 OTUs in the monimolimnion. Down to 3.5 m depth, the archaeal community was markedly dominated by the presence of an unclassified archaeon sharing 93% sequence identity to Halogeometricum spp. At the chemocline, the shift in archaeal community composition was associated with an increase in salinity, the main factor affecting the vertical distribution of archaeal assemblages. It appears that the microoxic and hypersaline monimolimnion is populated by several major haloarchaeal taxa, with minor fluctuations in their relative abundances throughout all seasons. The culturable diversity was reasonably correlated to the dominant OTUs obtained by molecular methods. Our results indicate that Ocnei Lake represents a relatively stable extreme habitat, accommodating a diverse and putatively novel archaeal community, as 30% of OTUs could not be classified at the genus level.

Background: Noble metal nanoparticles such as gold nanoparticles can strongly absorb light in the visible region by inducing coherent collective oscillation of conduction band electrons in strong resonance with visible frequencies of light. This phenomenon is frequently termed as surface plasmon resonance (SPR)., Objectives: The main objective was to study the effects of laser photoactivated gold nanoparticles (by means of SPR) on human pancreatic cancer cells., Results: Gold nanoparticles obtained using standard wet chemical methods (with sodium borohydride as a reducing agent) underwent photoexcitation using 2w 808 nm laser and further administered to 1.4E7 pancreatic cancer cell lines. Flow cytometry, transmission electron microscopy, phase contrast microscopy, quantitative proteomics and confocal microscopy combined with immunochemical staining were used to examine the interaction between photo excited gold nanoparticles and pancreatic cancer cells., Conclusion: The study shows that phonon-phonon interactions following laser photoexcitation of gold nanoparticles exhibit increased intracellular uptake, as well as mitochondrial swelling, closely followed by mitochondrial inner membrane permeabilization and depolarization. This unique data may represent a major step in mitochondria-targeted anticancer therapies using laser-activated gold nanoparticles.

More than 60% of neuroendocrine tumours, also called carcinoids, are localised within the gastrointestinal tract. Small bowel neuroendocrine tumours have been diagnosed with increasing frequency over the past 35 years, being the second most frequent tumours of the small intestine. Ileal neuroendocrine tumours diagnosis is late because patients have non-specific symptoms. We have proposed to illustrate as an example the case of a patient, and on its basis, to make a brief review of the literature on small bowel neuroendocrine tumours, resuming several recent changes in the field, concerning classification criteria of these tumours and new recommendations and current advances in diagnosis and treatment. This patient came to our emergency department with a complete bowel obstruction, along with a 2-year history of peristaltic abdominal pain, vomits and diarrhoea episodes. During emergency laparotomy, an ileal stricture was observed, that showed to be a neuroendocrine tumour of the small bowel.

Papillary thyroid carcinoma frequently metastasises to the regional neck lymph nodes. However, cervical lymph node metastases as sole manifestation of occult papillary thyroid carcinoma are observed rarely. The authors report the case of a 52-year-old man presenting for slowly enlarging neck region and shortness of breath, with an insidious history for 15 years. Thyroid imaging showed a goitre predominantly of the right lobe, but histopathological finding revealed a multi-centric thyroid papillary carcinoma with lymph node metastasis.

The aim of the present study was to examine soil samples from various vegetation zones in terms of physicochemical properties, microbial communities, and isolation and identification (by polymerase chain reaction and transmission electron microscopy) of bacteria producing poly-β-hydroxybutyrates (PHBs). Soil samples were analysed originating from zones with heterogeneous environmental conditions from the Romanian Carpathian Mountains (mountain zone with alpine meadow, karstic zone with limestone meadow, hill zone with xerophilous meadow, and flood plain zone with hygrophilic meadow). Different bacterial groups involved in the nitrogen cycle (aerobic mesophilic heterotrophs, ammonifiers, denitrifiers, nitrifiers, and free nitrogen-fixing bacteria from Azotobacter genus) were analysed. Soil biological quality was assessed by the bacterial indicator of soil quality, which varied between 4.3 and 4.7. A colony polymerase chain reaction technique was used for screening PHB producers. With different primers, specific bands were obtained in all the soil samples. Some wild types of Azotobacter species were isolated from the 4 studied sites. Biodegradable polymers of PHB were assessed by negative staining in transmission electron microscopy. The maximum PHB granules density was obtained in the strains isolated from the xerophilous meadow (10-18 granules/cell), which was the most stressful environment from all the studied sites, as the physicochemical and microbiological tests proved.

Background and Aim: Wilson disease is a genetic disorder associated with copper overload due to mutations within the ATP7B gene. Although copper and iron metabolism are closely linked, the influence of mutations of the ATP7B gene on iron homeostasis is unknown. Therefore, the present study was carried out to elucidate iron metabolism in Atp7b(-/-) mice, an animal model of Wilson disease., Methods: Hepatic iron content, serum iron parameters and blood hemoglobin levels of Atp7b(-/-) mice and wild type mice were studied. Hepatic and duodenal expression of iron metabolism-related genes was measured quantitatively by real-time reverse transcription-polymerase chain reaction and post-translational expression of Dmt1 was analyzed by immunoblot., Results: Atp7b(-/-) mice displayed copper accumulation (P < 0.001), slightly elevated hepatic iron content (P = NS), and a low serum ceruloplasmin oxidase activity (1.5 +/- 1.9 U/L vs 18.9 +/- 4.0 U/L, P < 0.001) when compared with wild type mice. Serum iron, serum transferrin saturation, and blood hemoglobin levels were significantly lower in Atp7b(-/-) mice compared with controls (121.2 +/- 35.3 microg/dL vs 201.8 +/- 34.9 microg/dL (P < 0.001); 44.0 +/- 12.7% vs 68.0 +/- 8.2% (P < 0.001); and 12.7 +/- 0.2 g/dl vs 15.3 +/- 0.1 g/dl (P < 0.001), respectively). Hepatic mRNA expression of hepcidin, TfR-1, TfR-2, hemojuvelin, and Dmt1 + IRE did not differ significantly between Atp7b(-/-) and wild type mice. In the duodenum of Atp7b(-/-) mice Dmt1 + IRE and hephaestin did not show any differences in their mRNA levels compared with wild type mice, while Dcytb mRNA expression was 1.7-fold increased compared with wild type mice (P = 0.01)., Conclusion: Atp7b(-/-) mice demonstrated decreased serum iron parameters and hemoglobin levels most likely related to a low serum ceruloplasmin oxidase activity and not due to total body iron deficiency.

Background: Starting from the premise that abdominal tumours require very accurate assessment and staging, the study "DIASTAL" (laparoscopic diagnosis and staging of abdominal tumours) proposed to establish the effectiveness of laparoscopy in the diagnosis and resectability of these neoplasms. The aim of this study was to evaluate diagnostic laparoscopy for periampullary and pancreatic neoplasms., Methods: The clinical study was based on the analysis two different groups including 27 patients in total, in whom we used also diagnostic laparoscopy as a staging method., Results: The percentage of understaged patients after preoperative examinations was high in both groups range 59.09%-63.63%. Diagnostic laparoscopy reduced the number of unnecessary laparotomies., Conclusions: Diagnostic laparoscopy could lead to more accurate assessment of periampullary and pancreatic cancers, not only as a staging method but also as a minimally invasive surgical technique for palliation.

Gastric cancer is one of the most frequent gastro-intestinal neoplasia. The prognosis of this disease is correlated with tumor stage, surgery being the only method which offers an important improvement in survival rate. Even after curative intent surgery, some patients develop peritoneal carcinomatosis, being the most frequent modality of relapse in these cases. Performing peritoneal cytology during diagnostic laparoscopy, especially in T3 cases, might modify therapeutic strategy of those cases.

BACKGROUND. Laparoscopy and laparoscopic ultrasonography may assist in the more accurate staging of digestive cancers. We assessed the diagnostic value of staging laparoscopy in patients with cancers of lower esophagus, stomach, liver, biliary tract, pancreas and colon. MATERIAL AND METHOD. Extended staging laparoscopy, laparoscopic ultrasonography and peritoneal cytology were performed in 165 patients with primary digestive cancers, admitted between January 2006 and December 2008 at three tertiary referral hospitals participating in the study. Staging laparoscopy was immediately followed by open surgery in 63 patients without distant metastases or with uncertain primary tumor resectability, and in 20 colorectal cancer patients with resectable hepatic metastases. The sensibility, sensitivity and diagnostic accuracy of staging laparoscopy for distant metastases and tumor resectability were assessed against the findings on open surgery and the final pathological report. RESULTS. An unnecessary laparotomy was avoided in 36 of the 99 patients (36.4%) without distant metastases on imaging pre-therapeutic staging. The staging laparoscopy sensitivity for distant metastases varied between 66% and 100% and the diagnostic accuracy between 87% for the lower esophageal cancer and 100% for the biliary tract tumors. The overall morbidity of staging laparoscopy was 2.5% and the mortality 0. CONCLUSION. Staging laparoscopy avoids unnecessary laparotomies and changes the therapeutic plan in a significant number of patients. It can be performed just before the planned surgery or as a separate diagnostic procedure. The laparoscopy indications in digestive cancers are changing fast, with ongoing new developments in cancer treatment and laparoscopic technology.

We report the first case of an association of pancreatic hamartoma with SAPHO syndrome mimicking disseminated bone metastases. A 46 year old male with intermittent back pain for 10 years, relieved by NSAIDs and desquamation erythemathous palmo-plantar eruption one year before, presented with symptoms of duodenal stenosis, a cystic tumor at the head of the pancreas and osteoformative (hyperostosis) and osteodestructive (osteitis) lesions of the clavicle, mandible, lumbar spine. The bone lesions resembled bone metastases, but an inflammatory infiltrate and fibrosis were found on the excisional biopsy of left clavicle, compatible with the SAPHO syndrome. The pancreatic tumor grew rapidly and showed a histological aspect of malignancy at laparoscopy. A cephalic duodenopancreatectomy was performed, but the histological findings established the diagnosis of pancreatic hamartoma. Several months later, the bone Tc99m scintigraphy was normal.

Three major issues drive the cross-cultural use of virtual patients (VPs): an increased mobility of healthcare professionals, students and patients; limited resources for developing VPs; and emerging standards for the exchange of VPs across institutions. Many students are trained in countries other than where they were born. In addition, healthcare professionals often move between countries and are today meeting more and more patients from cultures different from their own. VPs can be used both for learning a new "medical" language as well as for illustrating different perspectives on illness in the new culture. Therefore, it may be important to develop cases reflecting patients from a wide variety of regions and cultures to prepare these professionals to understand both the background of these patients as well as the different medical conditions they may present. However, the benefits of using VPs may be limited at many universities by insufficient resources to develop all the VPs needed for their curricula. The option to acquire VPs from other universities may therefore be appealing, but as these may only be available in English, it is important to consider whether VPs reflecting the local illness panoramas and medical procedures are needed.

Background: Surgical therapy remains the most effective treatment modality in gastric cancer. The importance of multimodal treatment for advanced gastric cancer has contributed to the development of more accurate preoperative staging strategies. We examined the diagnostic accuracy of staging laparoscopy (SL) for abdominal metastases and the predictive value of SL for tumor resectability., Material and Method: This is a prospective, cohort, observational study of 98 patients with primary gastric adenocarcinoma admitted at a tertiary referral hospital over a three year period. Extended SL, laparoscopic ultrasonography and peritoneal cytology were performed in 45 patients with gastric cancer without distant metastases on pre-therapeutic imaging staging. Of the 45 patients, 17 (37.8%) had distant metastases on SL and were offered palliative therapy and/or supportive care. Open laparotomy and gastrectomy was performed in the patients without distant metastases or with uncertain resectability on SL., Results: An unnecessary laparotomy was avoided in 17 (37.8%) patients. The overall SL sensitivity for distant metastases was 89%, specificity 100% and diagnostic accuracy 95.5%. The sensitivity for lymph node metastases was 54.5%, the specificity 100% and the diagnostic accuracy 64.3%. The SL positive predictive value for resectability was 96% and the negative predictive value was 50%. The morbidity of SL was 2.2% and the mortality 0., Conclusion: Staging laparoscopy is a safe and effective staging modality in patients with gastric carcinoma. It avoids unnecessary laparotomies in a significant number of patients and should be mandatory if neoadjuvant treatment is planned.

Aim: To identify the risk, the host-related prognostic factors and their predictive value for anastomotic leakage after colorectal resections following cancer., Method: 993 patients who underwent large bowel resection and primary anastomosis above 12 centimeters from the anal verge, without a temporary or permanent stoma at the Surgical Hospital No.3 (Cluj-Napoca, Romania) were retrospectively reviewed., Results: 32 (3.22 percent) anastomotic leaks were confirmed. Univariate analysis showed that the preoperative variables significantly associated with anastomotic leakage included: weight loss, smoking, cardiovascular disease, lung disease, hypoproteinemia, diabetes, anemia, leukocytosis, presence of two or more underlying diseases. Alcohol use, cerebrovascular disease, bowel preparation, type of anastomosis, tumor location, stage and histology were not significant variables. Hypoproteinemia (total serum protein level < or = 6 g/dl) and anemia (serum hemoglobin level < or = 11 g/dl) remained significant in the logistic regression model. The prognostic role of serum hemoglobin and proteins for the anastomotic leak was assessed using ROC curve analysis. For the cut-off value of serum protein level = 5.5 g/dl, a sensitivity of 61.6 percent and a specificity of 84.2 percent were calculated. The area under the curve was 0.703 (p= 0.0024). The area under the curve for serum hemoglobin was 0.616 (p=0.028). A sensitivity of 64.0 percent and a specificity of 64.7 per cent were obtained for a cut-off value of 9.4 g/dl. CONCLUSION. A serum protein level lower than 5.5 g/dl and serum hemoglobin lower than 9.4 g/dl could be considered as host-related predictive markers for anastomotic leak in large bowel resections for cancer.

Multivisceral trauma and exanguinating hemorrhage lead to hypothermia, coagulopathy and acidosis. Formal resections and reconstructions in these unstable patient is often result in irreversible physiologic insult. For the patients with life-threatening injuries the staged control and repair of injuries may be a saving surgical strategy. The initial phase of "damage control" involves an abbreviated laparotomy, which entails temporary hemorrhage control, perfusion of vital organs and avoidance of enteric or urinary spillage. The surgical procedure is rapidly terminated, with emphasis on a temporary physiologic equilibrium rather than anatomic integrity. That is, the damage control surgery represents an extension of resuscitation phase of trauma in the operating room. The second therapeutic phase involves standard resuscitation and control of hypothermia, coagulopathy and acidosis, combined with surveillance and management of the abdominal compartment syndrome. The last phase involves the definitive repair of all temporized injuries, homeostasis, vascular reconstruction and abdominal wall repair.

The acute intra-abdominal hypertension causes profound physiologic abnormalities, both within and outside the abdomen. Just as in compartment syndrome in the extremities, gut mucosal ischemia begins long before clinical signs are evident, explaining the name of "abdominal compartment syndrome" given to the acute, markedly increased intra-abdominal pressure. The abdominal compartment syndrome was initially described in patients with severe abdominal injuries and massive transfusions and crystalloid infusions, caused by the closure of fascia or skin under tension, the use of bulky abdominal packs to control diffuse bleeding, the massive bowel distension and edema, and the continued bleeding into the abdominal cavity. Intra-abdominal pressure can be monitored by measuring the urinary bladder pressure with a manometer, connected to the transurethral Foley catheter, with the symphysis pubis as the zero point. A persistent elevation of the intra-abdominal pressure beyond 20-25 cmH2O, with significant respiratory, hemodynamic and renal dysfunction is an indication for abdominal decompression, before the manifestations of abdominal compartment syndrome became clinically evident. The mortality in patients with abdominal compartment syndrome is over 40%, even when adequately treated.