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Objective Based on the SUCCOR study database, our primary objective was to identify the independent clinical pathological variables associated with the risk of relapse in patients with stage IB1 cervical cancer who underwent a radical hysterectomy. Our secondary goal was to design and validate a risk predictive index (RPI) for classifying patients depending on the risk of recurrence. Methods Overall, 1116 women were included from January 2013 to December 2014. We randomly divided our sample into two cohorts: discovery and validation cohorts. The test group was used to identify the independent variables associated with relapse, and with these variables, we designed our RPI. The index was applied to calculate a relapse risk score for each participant in the validation group. Results A previous cone biopsy was the most significant independent variable that lowered the rate of relapse (odds ratio [OR] 0.31, 95% confidence interval [CI] 0.17–0.60). Additionally, patients with a tumor diameter >2 cm on preoperative imaging assessment (OR 2.15, 95% CI 1.33–3.5) and operated by the minimally invasive approach (OR 1.61, 95% CI 1.00–2.57) were more likely to have a recurrence. Based on these findings, patients in the validation cohort were classified according to the RPI of low, medium, or high risk of relapse, with rates of 3.4%, 9.8%, and 21.3% observed in each group, respectively. With a median follow-up of 58 months, the 5-year disease-free survival rates were 97.2% for the low-risk group, 88.0% for the medium-risk group, and 80.5% for the high-risk group (p < 0.001). Conclusion Previous conization to radical hysterectomy was the most powerful protective variable of relapse. Our risk predictor index was validated to identify patients at risk of recurrence.

Background. Beta hemolytic streptococcus (BHS) represents a worldwide health problem because of the complications that can occur. Thus, it is important to identify the presence and type of BHS in time to start treatment if needed, avoiding the complications. Aim. Our aim was to identify the prevalence of Beta Hemolytic Streptococcus in a Children’s Tertiary Care Hospital in Timisoara. Methods. A cross-sectional study was conducted from April-June 2018 in Emergency Hospital for Children Timisoara. The study lot consists from 1100 children, ages between 0-18 years, which were not given, in the preceding two weeks, any antibiotics. We compared the study with two studies from different cities in Nepal, with the same subject as ours. Group A and Group C Streptococci were identified by beta hemolytic colonies, bacitracin sensitivity, catalase negativity test and latex agglutination test (Oxoid Streptococcal Grouping kit). ASO (Antistreptolysin O) test was also performed from serum samples, for patients with positive cultures. We also tested the antibiotic sensitivity to: Cefepime, Clindamycin, Erythromycin, Tetracycline. Results. The prevalence of BHS (Beta Hemolytic Streptococcus), especially GABHS (Group A Beta Hemolytic Streptococcus) was 4%, in children from a tertiary care hospital in Timisoara, Romania; which is comparable to the findings of similar studies. In the first study, the prevalence of GABHS was 7.2%, and in the second study was 9%. The patients with positive cultures were also tested for ASO, 28 patients (52%) had high levels, while 26 (48%) had normal levels. On all positive patients an antibiogram was made and we observed that most of the isolates were sensitive to the antibiotics used. A few isolates in Group A were resistant. Conclusions. Considering the limited data found on our subject, further epidemiological studies on streptococcal disease complex are needed.

We report the case of a 29-year-old patient with low-grade squamous intraepithelial lesion (L-SIL), negative human papilloma virus (HPV), positive p16/Ki-67 dual-staining and colposcopy suggestive for severe dysplastic lesion. The patient underwent a loop electrosurgical excision procedure (LEEP), the pathology report revealing mesonephric hyperplasia and adenocarcinoma. The patient also opted for non-standard fertility-sparing treatment. The trachelectomy pathology report described a zone of hyperplasia at the limit of resection towards the uterine isthmus. Two supplementary interpretations of the slides and immunohistochemistry (IHC) were performed. The results supported the diagnosis of mesonephric adenocarcinoma, although with difficulty in differentiating it from mesonephric hyperplasia. Given the discordant pathology results that were inconclusive in establishing a precise diagnosis of the lesion and the state of the limits of resection, the patient was referred to a specialist abroad. Furthermore, the additional interpretation of the slides and IHC were performed, the results suggesting a clear cell carcinoma. The positive p16/Ki-67 dual-staining prior to LEEP, the non-specific IHC and the difficulties in establishing a diagnosis made the case interesting. Given the limitations of cytology and the fact that these variants are independent of HPV infection, dual staining p16/Ki-67 could potentially become useful in the diagnosis of rare adenocarcinoma variants of the cervix, however further documentation is required.

The objective of our paper is to underline the importance of assessing microarray genetic analysis for the detection of chromosomal abnormalities in rare cases such as left atrial isomerism, mostly in the context of antenatally detected syndromes. We present the case of a 26-year-old primipara, at 26 weeks of gestation, with prior first trimester normal anomaly scan, who presented in our department accusing lower abdominal pain. An anomaly ultrasound examination of the fetus revealed cardiomegaly with increased size of the right atrium, non-visualization of the atrial septum or the foramen ovale, malalignment of the three-vessel view, location of the superior vena cava above the two-vessel view, slight pericardial effusion, and no interruption of the inferior vena cava nor presence of azygos vein being noted. Associated extracardiac abnormalities, such as small kidneys at the level of the iliac fossa, micrognathia, dolichocephaly with hypoplasia of the cerebellum, increased nuchal fold, and reduced fetal movements were also reported. A diagnostic amniocentesis was performed, and, while the conventional rapid prenatal diagnostic test of the multiplex quantitative fluorescent polymerase chain reaction (PCR) came as normal, the microarray analysis (ChAS, NCBI Built 37 hg 19, detection of microdeletions or microduplications larger than 100 kb) revealed two chromosomal abnormalities: a 22.84 Mb loss of genetic material in the 18q21.31–18q23 chromosomal region and a gain of 22.31 Mb of genetic material in the 20p13–20p11.21 chromosomal region. After the termination of pregnancy, a necropsy of the fetus was performed, confirming heterotaxy syndrome with a common atrium, no atrial septum, superior vena cava draining medianly, and pulmonary veins that drained into the lower segment of the left atrium due to an anatomically enlarged single common atrium. The extracardiac findings consisted of two bilobar lungs, dysmorphic facies, low-set ears, nuchal fold edema, and small kidneys located in the iliac fossa. These findings are conclusive evidence that left atrial isomerism is a more complex syndrome. The genetic tests of the parents did not reveal any translocations of chromosomes 18 and 20 when the Fluorescent in situ Hybridization (FISH) analysis was assessed. The antenatal detection of corroboration between different structural abnormalities using serial ultrasound examinations and cardiac abnormalities, together with the detection of the affected chromosomes, improves the genetic counseling regarding the prognosis of the fetus and the recurrence rate of the condition for siblings.

Study Objective To present a case of pelvic organ prolapse associated with stress urinary incontinence treated by laparoscopic pectopexy followed by Burch colposuspension. Design Case report. Setting University Gynecology Clinic of the Emergency Clinical City Hospital Timișoara, Romania. Patients We present the case of a 41-year-old woman, gravida 1 para 1, with no notable medical or surgical history, with a body mass index of 40 kg/m2, who presented in our service with heavy menstrual bleeding, dysmenorrhea, pelvic pressure, dyspareunia, stress urinary incontinence, and voiding difficulties. Local examination revealed a cervix descended 2 cm below the hymenal ring, cystocele, urethrocele, and a positive cough stress test. The pelvic prolapse was classified as pelvic organ prolapse quantification stage 3. Ultrasound exam revealed a uterus with diffuse adenomyosis of the posterior uterine wall and normal adnexa. Because of the patient's obesity, the treatment plan was laparoscopic supracervical hysterectomy for the treatment of adenomyosis, laparoscopic pectopexy for the correction of the apical defect, and Burch colposuspension for the cure of stress incontinence. Interventions The patient was placed in the standard dorsal lithotomy position with the hips in extension and the knees flexed and the table in 45° Trendelenburg position. One 10-mm umbilical optical trocar and three 5-mm trocars were used—2 inserted 2 cm above and medial to the anterior superior iliac crests, and the third, 5 cm below the umbilical trocar. The dissection started on the left side of the pelvis. The peritoneum was incised in the center of a V-shaped area bordered by the left round ligament and the obliterated umbilical artery (the medial umbilical ligament). The soft tissue was dissected, and the left iliopectineal ligament (also known as the inguinal ligament of Cooper) was identified right under the external iliac vein and prepared. The same steps were repeated on the right side of the pelvis. The procedure continued with the dissection of the vesicovaginal space. The anterior vaginal wall was exposed with the help of a retractor placed inside the vagina and held by an assistant. A supracervical hysterectomy was performed. An 8 × 15-cm polypropylene mesh, cut in a T shape, was introduced in the abdomen. First, the short arm of the T was fixed on the anterior vaginal wall using multiple absorbable tacks (AbsorbaTack fixation device; Medtronic, Dublin, Ireland). To use a type of nonabsorbable fixation, we decided to also fix the mesh to the cervix stump with 3 isolated stitches (Silk Suture 2-0; Ethicon, Somerville, NJ). Second, with the purpose of ensuring a permanent fixation, the lateral arms of the mesh were attached to the iliopectineal ligaments with multiple nonabsorbable tacks on both sides (ProTack fixation device; Medtronic, Dublin, Ireland). The procedure continued with the complete closure of the peritoneum with VICRYL 2-0 sutures (Ethicon). Because the patient also had stress urinary incontinence, a Burch colposuspension was performed. To expose its limits, the urinary bladder was filled with 200 mL of saline. After the incision of the peritoneum, the avascular space of Retzius was opened. The dissection continued until the Cooper's ligaments were exposed bilaterally. The proper suture placement points on the vaginal wall were facilitated by an assistant's intravaginal finger. Two isolated nonabsorbable silk stitches (Silk Suture 2-0) were placed through the Cooper's ligament and through the anterior vaginal wall on each side. The knots were tied just enough to properly lift the vaginal wall in the normal position, assessed by the assistant by vaginal route, but not too tight to avoid urethral obstruction. Measurements and Main Results The duration of the surgery was 95 minutes, with minimal blood loss of about 60 mL. The patient recovered well, with the Foley catheter being removed after 12 hours. The patient was discharged after 48 hours. The 6-month follow-up examination revealed a correct anatomical position of the anterior vaginal wall and of the cervix at 6 cm above the hymenal ring and no urinary incontinence. Conclusion Laparoscopic pectopexy represents a new option for the treatment of pelvic organ prolapse. In the case we reported, no intraoperative or postoperative complications were present, and the follow-up assessment revealed an effective correction of the prolapse. Further studies are needed to conclude the efficiency and safety of this new procedure.

SUCCOR study: an international European cohort observational study comparing minimally invasive surgery versus open abdominal radical hysterectomy in patients with stage IB1 cervical cancer FREE http://orcid.org/0000-0002-1908-3251Luis Chiva1, Vanna Zanagnolo2, Denis Querleu3, Nerea Martin- Calvo4, Juan Arévalo-Serrano5, Mihai Emil Căpîlna6, Anna Fagotti7, Ali Kucukmetin8, Constantijne Mom9, Galina Chakalova10, Shamistan Aliyev11, Mario Malzoni12, http://orcid.org/0000- 0001-5809-3535Fabrice Narducci13, Octavio Arencibia14, Francesco Raspagliesi15, Tayfun Toptas16, David Cibula17, Dilyara Kaidarova18, http://orcid.org/0000-0001-6763-9720Mehmet Mutlu Meydanli19, Mariana Tavares20, Dmytro Golub21, http://orcid.org/0000-0003-3140-4772Anna Myriam Perrone22, Robert Poka23, Dimitrios Tsolakidis24, Goran Vujić25, http://orcid.org/0000-0001-8935- 0311Marcin A Jedryka26, Petra L M Zusterzeel27, Jogchum Jan Beltman28, Frederic Goffin29, Dimitrios Haidopoulos30, Herman Haller31, Robert Jach32, Iryna Yezhova33, Igor Berlev34, Margarida Bernardino35, Rasiah Bharathan36, Maximilian Lanner37, Minna M Maenpaa38, http://orcid.org/0000-0002-4403-3707Vladyslav Sukhin39, Jean-Guillaume Feron40, Robert Fruscio41, 42, Kersti Kukk43, Jordi Ponce44, Jose Angel Minguez45, http://orcid.org/0000-0002-9618- 5606Daniel Vázquez-Vicente45, Teresa Castellanos45, Enrique Chacon46 and http://orcid.org/0000-0002-9700-0853Juan Luis Alcazar47 On behalf of the SUCCOR study Group Author affiliations Abstract Background Minimally invasive surgery in cervical cancer has demonstrated in recent publications worse outcomes than open surgery. The primary objective of the SUCCOR study, a European, multicenter, retrospective, observational cohort study was to evaluate disease-free survival in patients with stage IB1 (FIGO 2009) cervical cancer undergoing open vs minimally invasive radical hysterectomy. As a secondary objective, we aimed to investigate the association between protective surgical maneuvers and the risk of relapse. Methods We obtained data from 1272 patients that underwent a radical hysterectomy by open or minimally invasive surgery for stage IB1 cervical cancer (FIGO 2009) from January 2013 to December 2014. After applying all the inclusion-exclusion criteria, we used an inverse probability weighting to construct a weighted cohort of 693 patients to compare outcomes (minimally invasive surgery vs open). The first endpoint compared disease-free survival at 4.5 years in both groups. Secondary endpoints compared overall survival among groups and the impact of the use of a uterine manipulator and protective closure of the colpotomy over the tumor in the minimally invasive surgery group. Results Mean age was 48.3 years (range ; 23–83) while the mean BMI was 25.7 kg/m2 (range ; 15–49). The risk of recurrence for patients who underwent minimally invasive surgery was twice as high as that in the open surgery group (HR, 2.07 ; 95% CI, 1.35 to 3.15 ; P=0.001). Similarly, the risk of death was 2.42-times higher than in the open surgery group (HR, 2.45 ; 95% CI, 1.30 to 4.60, P=0.005). Patients that underwent minimally invasive surgery using a uterine manipulator had a 2.76-times higher hazard of relapse (HR, 2.76 ; 95% CI, 1.75 to 4.33 ; P

Several diagnostic methods for the evaluation and monitoring were used to find out the pro-inflammatory status, as well as incidence of sepsis in critically ill patients. One such recent method is based on investigating the genetic polymorphisms and determining the molecular and genetic links between them, as well as other sepsis-associated pathophysiologies. Identification of genetic polymorphisms in critical patients with sepsis can become a revolutionary method for evaluating and monitoring these patients. Similarly, the complications, as well as the high costs associated with the management of patients with sepsis, can be significantly reduced by early initiation of intensive care.

Study Objective To present a case of a cesarean scar ectopic pregnancy treated by laparoscopic resection followed by isthmocele repair. Design A case report. Settings The University Gynecology Clinic of the Emergency Clinical City Hospital Timișoara, Timișoara, România. Background Cesarean scar pregnancy is a rare form of ectopic pregnancy. In recent years, its prevalence has risen because of the increasing number of cesarean sections. An early diagnosis can lead to early management, decreasing the risk of life-threatening complications such as uterine rupture and massive hemorrhage. Many therapeutic options are available, medical and surgical, but the current literature suggests that the laparoscopic approach with ectopic pregnancy resection is the best option. Case Report We present the case of a 30-year-old woman with a previous cesarean section in 2012 who was diagnosed by transvaginal ultrasound with a 6-week live pregnancy implanted at the level of the cesarean scar. The initial management was the administration of a 2-dose methotrexate protocol, but after 72 hours the transvaginal ultrasound showed an embryo with cardiac activity still present associated with an increased beta human chorionic gonadotropin level. We decided on laparoscopic surgical treatment, aiming to extract the pregnancy and repair the scar defect. A similar case was presented by Mahgoub et al [1] , but their case had a different evolution, with decreasing levels of hCG. Interventions In order to reduce the blood loss, the anterior trunks of the hypogastric arteries were clipped. The side wall peritoneum was cut bilaterally, and the ureters and the hypogastric arteries were dissected. Next, we performed the dissection of the vesicouterine space. Because of the previous cesarean section, the identification of the correct dissection plane was difficult. A uterine manipulator was used to facilitate the dissection. The exact location of the gestational sac was demonstrated using intraoperative transvaginal ultrasound. To reduce the bleeding, Glypressin (Ferring GmbH, Saint Prex, Switzerland) was injected at the level of the uterine scar. The cesarean scar was cut using a monopolar knife. The gestation sac was reached easily and then extracted from the abdominal cavity with the use of an endobag. In order to obtain proper healing, the margins of the scar were resected using cold scissors. The hysterotomy was closed using a double-layered suture with 2.0 Vicryl (Ethicon Inc., Cincinnati, OH). We used methylene blue to verify the tightness of the suture. The final step was the removal of the clips. Measurements and Main Results The operative time was 85 minutes with minimal blood loss of about 20 mL. The patient recovered well and was discharged 2 days after the procedure. A transvaginal ultrasound was performed 1 month after the surgery showing good healing of the anterior uterine wall. Conclusion The laparoscopic approach with excision and repair of the uterine wall represents a safe and efficient therapeutic option for the treatment of the cesarean scar ectopic pregnancy.

One of the leading causes of death among patients with malignancies is represented by bone cancer. According to current studies, the leading cause of death among these patients is represented by late diagnosis, poor response to therapy, and the lack of accuracy in terms of clinical evaluation. In this regard, there have been developed a series of methods of diagnosis and evaluation, the most investigated being represented by miRNA expression. In this updated work, we want to present a series of changes in the expression of miRNAs in bone cancer. Moreover, we want to present the implications of miRNAs in targeted therapy in such patients. Studies available in scientific databases such as PubMed and Scopus were examined. The studies were searched using the keywords “miRNAs expression”, “bone cancer”, “genetic therapy” and “genetic biomarkers.” For the evaluation and monitoring of bone cancer, the expression of miRNAs can be successfully used due to increased specificity. Using miRNAs as gene therapy can be also considered a therapeutic method of the future, mainly due to selective and targeted response of the body.

A high percentage of critical patients are found to develop acute respiratory distress syndrome (ARDS). Several studies have reported high mortality rates in these cases which are most frequently associated with multiple organ dysfunctions syndrome. Lately, many efforts have been made to evaluate and monitor ARDS in critical patients. In this regard, the assessment of genetic polymorphisms responsible for developing ARDS present as a challenge and are considered future biomarkers. Early detection of the specific polymorphic gene responsible for ARDS in critically ill patients can prove to be a useful tool in the future, able to help decrease the mortality rates in these cases. Moreover, identifying the genetic polymorphism in these patients can help in the implementation of a personalized intensive therapy scheme for every type of patient, based on its genotype.

Study Objective To present a case of uterine prolapse in a pregnant patient at 10 weeks of gestation who was successfully treated by laparoscopic promontohysteropexy. To our knowledge, this is the first case of laparoscopic promontopexy during pregnancy to be reported in the literature. Design Step-by-step description of the surgery using videos (Canadian Task Force classification 3). Setting Uterine prolapse is a rare condition in young patients and is extremely rare in pregnant women. The reported incidence of uterine prolapse during pregnancy is 1/10,000 to 15,000 deliveries [1] . To date, only a few cases of prolapse during pregnancy have reported in the literature, most of which were treated with pessary insertion. A case involving laparoscopic surgery for uterine prolapse during pregnancy was reported by Matsumoto et al 1999 [2] , but the authors did not perform the promontohysteropexy technique. Intervention A 27-year-old patient with uterine prolapse at 10 weeks of gestation was referred to our clinic for severe pelvic pain. Conservative treatment with pessary insertion was attempted but failed. Consequently, the patient was scheduled for laparoscopic promontohysteropexy. The surgery was made difficult by the increased size and softness of the uterus. To create an adequate surgical field, the sigmoid colon and right adnexa were suspended at the abdominal wall. The peritoneum above the promontorium was incised, and the longitudinal ligament was dissected. The paravesical spaces were opened, and the vesicovaginal space was dissected. A polypropylene mesh in the shape of an inverted “T” was introduced. The small arm was sutured to the anterior vaginal wall, and the posterior arms were passed through the posterior leaves of the broad ligament and fixed to the cervix at the level of the uterosacral ligaments. Both posterior arms were fixed at the level of the promontory using the Protack device (Medtronic, Minneapolis, MN). The mesh was completely covered with peritoneum. The patient was discharged 3 days after surgery, with no pain and with normal pelvic floor status. The pregnancy proceeded uneventfully, and she delivered a 3500-g healthy baby by scheduled cesarean section at 39 weeks of gestation. During surgery, the position of the mesh around the uterus was assessed. The mesh was completely covered with peritoneum, and there were no adhesions due to mesh insertion. At 6 months after delivery, pelvic floor status was reassessed and found to be normal. Written informed consent for reporting this case was obtained from the patient before the procedure. The procedure was performed in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki and its later amendments. The Institutional Review Board and Ethical Committee of Victor Babes University of Medicine and Pharmacy ruled that approval was not required for this study. Conclusion Laparoscopic promontohysteropxy can be performed during pregnancy if conservative treatment, such as pessary insertion, fails to restore the normal pelvic floor status.

Ovarian cancer malignancies have the worst prognosis among all gynecological malignancies. As angiogenesis represents a key step for tumor progression, vascular endothelial growth factor (VEGF) is one of the most discussed pro-angiogenic factors. VEGF expression was investigated in 62 cases of ovarian carcinomas. Microvessel density (MVD) was evaluated by correlating the results with clinical and histopathological parameters. Because of the controversial results reported in other studies, VEGF was assessed together with MVD. Our results suggest a more complex angiogenic mechanism in ovarian cancer based on the discrepancies between VEGF expression, microvessel density and their correlation with clinical parameters. The conflicting data arising from this study supports the implications of different growth factors, others than VEGF in ovarian cancer. This hypothesis is sustained by the lack of correlation between VEGF and clinical parameters, and by the significant correlation between microvessel density and clinicopathological parameters. Thus, further studies are needed for a complete evaluation of angiogenesis in ovarian cancer.