THE MULTIFARIOUS CUSHING'S - LESSONS FROM A CASE SERIES.

Endogenous Cushing's syndrome is rare, with an incidence of 0.7-2.4 per a million people a year. Clinical presentation of Cushing syndrome can be pleomorphic, and establishing diagnosis can be difficult. Early recognition and rapid control of hypercortisolaemia are necessary to decrease morbidity and mortality in these patients. We report a series of 6 endogenous Cushing's syndromes of different etiologies (4 Cushing's disease and 2 adrenal Cushing's syndrome) assessed in our endocrine department over a decade (2009-2019). In order to highlight the diversity of clinical forms, diagnostic tools and specific management of this condition we labelled each case suggestively: the typical Cushing's disease, the Pseudo Cushing's, the elusive Cushing's disease, the mild autonomous cortisol hypersecretion, Cushing's syndrome in pregnancy and Cushing's disease with thromboembolism. We discussed their particularities which were revelatory for the diagnosis, such as dermatologic, cardiovascular, musculoskeletal, neuropsychiatric, or reproductive signs, reviewing literature for each manifestation. We also discuss the commonalities and differences in laboratory and imagistic findings. Therapeutic approach can also differ with respect to the particular condition of each patient and the multiple choices of therapy will be reviewed.

Gastrointestinal Stromal Tumors - Diagnosis and Surgical Treatment.

Gastrointestinal stromal tumors (GIST) are the most common mesenchymal tumors of the gastrointestinal tract, previously classified as leiomyomas, leiomyosarcomas, leiomyoblastomas or schwannomas. They are now recognized as a distinct entity with origin in the mesodermal interstitial cell of Cajal, cells that express the c-KIT protein (tirozine kinase receptor). The definitive diagnosis is established by immunohistochemistry, more than 95% of GISTs being positive for CD117. Despite the major progress of chemotherapy, the treatment of choice is surgery, and it implies the complete resection of the tumor. The evolution of these tumors is unpredictable and the prognosis depends on localization, tumor size and mitotic index. Benign tumors have an excellent prognosis after surgery, with a 5 year survival of 90%, while malignant tumors resistant to radiotherapy and chemotherapy have a dismal prognosis even after surgical resection, with a median survival of 1 year. We studied a group of 15 patients diagnosed with TSGI in the Surgery Clinic of the œProf. Dr. Agrippa Ionescu Clinical Emergency Hospital, between 2003 and 2013, following the particularities of presentation, diagnosis and treatment, with focus on the prognostic factors according to available literature data.

Piperlongumine promotes autophagy via inhibition of Akt/mTOR signalling and mediates cancer cell death.

BACKGROUND: The Akt/mammalian target of rapamycin (mTOR) signalling pathway serves as a critical regulator of cellular growth, proliferation and survival. Akt aberrant activation has been implicated in carcinogenesis and anticancer therapy resistance. Piperlongumine (PL), a natural alkaloid present in the fruit of the Long pepper, is known to exhibit notable anticancer effects. Here we investigate the impact of PL on Akt/mTOR signalling. METHODS: We examined Akt/mTOR signalling in cancer cells of various origins including prostate, kidney and breast after PL treatment. Furthermore, cell viability after concomitant treatment with PL and the autophagy inhibitor, Chloroquine (CQ) was assessed. We then examined the efficacy of in vivo combination treatment using a mouse xenograft tumour model. RESULTS: We demonstrate for the first time that PL effectively inhibits phosphorylation of Akt target proteins in all tested cells. Furthermore, the downregulation of Akt downstream signalling resulted in decrease of mTORC1 activity and autophagy stimulation. Using the autophagy inhibitor, CQ, the level of PL-induced cellular death was significantly increased. Moreover, concomitant treatment with PL and CQ demonstrated notable antitumour effect in a xenograft mouse model. CONCLUSIONS: Our data provide novel therapeutic opportunities to mediate cancer cellular death using PL. As such, PL may afford a novel paradigm for both prevention and treatment of malignancy.

Laparoscopic treatment in achalasia of the cardia.

BACKGROUND: Achalasia, although a rare disease (an incidence of 1 100 000 individuals each year) is one of the common causes of motor dysphagia and is characterized by loss of peristalsis in the esophageal body and lack of relaxation of the lower esophageal sphincter. AIM: The aim of our study was to perform a clinical,therapeutic and evolution evaluation in patients diagnosed with achalasia and operated in our department between 1997 and 2013. MATERIAL AND METHODS: We performed a retrospective study using the clinical charts, operatory protocols, imagistic and video database of the 17 patients with achalasia operated in our department. RESULTS: We encountered an equal repartition in women and men and a predominance of urban provenience. Ages were between 24 and 86 years (with an average age of 51). There were two cases of recurrent achalasia at 2, respectively 5 years after the first operation. In all cases, Heller myotomy was used, with the addition of a Dor fundoplication in 12 cases and Toupet fundoplication in five cases, as an antireflux procedure. Mean operation time was 117.6 minutes.There were three iatrogenic perforations of the esophageal mucosa, all of them recognized and treated in the same operative time. No postoperative complications related to the Heller-Dor Heller-Toupet procedure were encountered.The follow-up was between 3 and 72 months. CONCLUSIONS: Laparoscopic approach in the treatment of achalasia provides the advantages of minimally invasive surgery, but also and very important, a good visualization of the abdominal esophagus and gastroesophageal junction.Heller esocardiomyotomy is usually associated with anantireflux procedure. A Dor fundoplication is generally used,although the Toupet fundoplication may also be used with the same advantages. It is important to monitor these patients on a yearly basis, knowing the risk of dysplasia carcinoma in achalasia.

The surgical treatment for Crohn's disease.

INTRODUCTION: Crohn's disease is a chronic idiopathic medical and surgical disease, in which the transmural intestinal inflammatory process frequently leads to complications such as strictures or fistulae. The disease is considered to be the result of an imbalance between the proinflammatory mediators and the anti-inflammatory ones; it can be localized on any segment of the gastrointestinal tract, but it especially affects the terminal ileum. The purpose of the study is to assess Crohn's disease from the point of view of the complications requiring surgical treatment, the manner in which they are solved, as well as the postoperative evolution. MATERIAL AND METHOD: we followed retrospectively the patients hospitalized and operated in our department during the period January 2001 - December 2011. We examined the clinical observation charts, the paraclinical investigations, the surgical protocols and the histopathological results. RESULTS: the 11 patients included in the study underwent 13 surgical interventions. Their ages were comprised between 16 and 67, the average age being 42.9. The men women ratio was 7 4 (1.75); the interventions performed were segmental enterectomies, right ileo- hemicolectomy, ileotransverse anastomosis, an exploratory laparotomy and an exploratory laparoscopy. CONCLUSIONS: the purpose of the treatment of Crohn's disease is to obtain the best possible clinical, laboratory and paraclinical control of the inflammatory process with the least adverse reactions to the medication. The surgical indications for the treatment of the disease are imposed by severe complications such as perforation, stenosis, fistulisation and even malignancy. Consequently, although Crohn's disease is a chronic disease with many relapses, the correct medical and surgical treatment helps patients to maintain a reasonable quality of life, with a good prognosis and a very low mortality rate.

[Unique duodenal hamartomatous polyp--case report]. / Polip hamartomatos duodenal unic--prezentare de caz clinic.

Duodenal tumors are very rare tumors, with the lower incidence among the tumors of the small bowel, whose frequence is less than 5 % of all digestive tumors. In most of the cases these tumors remain asymptomatic, sometimes the entire life. When they become symptomatic, their first manifestation is the loss of digested blood (melena), secondary anemia and obstructive symptomatology. Early diagnosis of these tumors is difficult because of the unsystematic symptomatology and becomes easy when the complications appear. In most of the cases the diagnosis is establish by the superior digestive endoscopy, followed by barium contrast studies, CT and ultrasound. We present a case of duodenal hamartomatous polip, unique, at the level of D3, in a female patient 66 years old, addressing to our service for superior digestive hemorrhage exteriorizated by melena, secondary anemia and physical asthenia; we operated the patient procedeeing a polypectomy by a duodenotomy.

[Diagnostics and surgical treatment of liver echinococcosis in Latvia].

The results of treatment of 44 patients (during the period 1996 - 2010) with liver echinococcosis (LE) were analysed. Echinococcosis hydatid (EH) cyst was found in 15 patients, alveolar echinococcosis (AE)--in 29 patients, 11.3% of cases were asymptomatical, different clinical symptoms were found in 36.4% of patients and 52.3% of patients were admited due to severe complications. Surgical treatment was performed in 41 patients. Among 15 patients with hydatid liver cyst 3--underwent liver resection, 8--pericystechinococcectomy, 4--guided percutaneous treatment--PAIR. No complications or recurrences were noted. Radical operations were performed in 12 patients with AE (41.3%), 11 of them had asymptomatical or noncomplicated disease. Recurrence appeared in one patient (8.3%). Nonradical or palliative operations due to AE complications were performed in 15 patients (51.7%). Complication at the postoperative periods occurred in 17% of patients with AE and lethality rate came to 3.4%. The diagnosis made at the early asymptomatic state and the following selection of combination of surgical approach and medicamental treatment (albendazol) can improve the results of treatment of patients with liver echinococcosis.

[Gastrointestinal stromal tumor with primary hepatic unique location--clinical case]. / Tumora gastrointestinala stromala cu localizare hepatica primara unica--caz clinic.

The gastrointestinal stromal tumors are mesenchymal tumors whose primary extradigestive location is very rare (less than 10% primary liver localization). We present a clinical case of primary hepatic location of GIST in a 28 year-old patient. The discovery of this tumor is a chance, the patient presenting for non-specific dyspeptic syndrome and epigastralgia. During the presentation an abdominal ultrasound is performed which identifies an whell-delineated hepatic mass - 5/4 cm. Clinical and paraclinical investigations (CT, EDS, EDI, examination of the intestinal lumen with the videocapsula), confirm the diagnosis of unique hepatic mass of segments III-IV. The diagnosis is confirmed intraoperatory and we perform an atypical liver resection of segments III-IV (with 1 cm safety-margin). The histopatologic exam: GIST.

Double-stranded RNA-mediated silencing of genomic tandem repeats and transposable elements in the D. melanogaster germline.

BACKGROUND: The injection of double-stranded RNA (dsRNA) has been shown to induce a potent sequence-specific inhibition of gene function in diverse invertebrate and vertebrate species. The homology-dependent posttranscriptional gene silencing (PTGS) caused by the introduction of transgenes in plants may be mediated by dsRNA. The analysis of Caenorhabditis elegans mutants impaired with dsRNA-mediated silencing and studies in plants implicate a biological role of dsRNA-mediated silencing as a transposon-repression and antiviral mechanism. RESULTS: We investigated the silencing of testis-expressed Stellate genes by paralogous Su(Ste) tandem repeats, which are known to be involved in the maintenance of male fertility in Drosophila melanogaster. We found that both strands of repressor Su(Ste) repeats are transcribed, producing sense and antisense RNA. The Stellate silencing is associated with the presence of short Su(Ste) RNAs. Cotransfection experiments revealed that Su(Ste) dsRNA can target and eliminate Stellate transcripts in Drosophila cell culture. The short fragment of Stellate gene that is homologous to Su(Ste) was shown to be sufficient to confer Su(Ste)-dependent silencing of a reporter construct in testes. We demonstrated that Su(Ste) dsRNA-mediated silencing affects not only Stellate expression but also the level of sense Su(Ste) RNA providing a negative autogenous regulation of Su(Ste) expression. Mutation in the spindle-E gene relieving Stellate silencing also leads to a derepression of the other genomic tandem repeats and retrotransposons in the germline. CONCLUSIONS: Homology-dependent gene silencing was shown to be used to inhibit Stellate gene expression in the D. melanogaster germline, ensuring male fertility. dsRNA-mediated silencing may provide a basis for negative autogenous control of gene expression. The related surveillance system is implicated to control expression of retrotransposons in the germline.

Heterochromatic Stellate gene cluster in Drosophila melanogaster: structure and molecular evolution.

The 30-kb cluster comprising close to 20 copies of tandemly repeated Stellate genes was localized in the distal heterochromatin of the X chromosome. Of 10 sequenced genes, nine contain undamaged open reading frames with extensive similarity to protein kinase CK2 beta-subunit; one gene is interrupted by an insertion. The heterochromatic array of Stellate repeats is divided into three regions by a 4.5-kb DNA segment of unknown origin and a retrotransposon insertion: the A region (approximately 14 Stellate genes), the adjacent B region (approximately three Stellate genes), and the C region (about four Stellate genes). The sequencing of Stellate copies located along the discontinuous cluster revealed a complex pattern of diversification. The lowest level of divergence was detected in nearby Stellate repeats. The marginal copies of the A region, truncated or interrupted by an insertion, escaped homogenization and demonstrated high levels of divergence. Comparison of copies in the B and C regions, which are separated by a retrotransposon insertion, revealed a high level of diversification. These observations suggest that homogenization takes place in the Stellate cluster, but that inserted sequences may impede this process.

Recurrence after hepatic resection in colorectal cancer liver metastasis -Review article-.

The outcomes and management of colorectal liver metastasis have undergone many changes. The incidence of recurrence after liver resection for hepatic metastasis remains very high. Liver resection, which provides the only curative treatment, is believed to have improved the long-term outcome of these patients. However, the management and outcomes of patients with colorectal liver metastasis have greatly improved in the last decade, suggesting that the current use of aggressive multimodality treatments, including surgical resection combined with modern chemotherapeutic regimens, effectively prolong the life expectancy of these patients.

Repeated, protein-encoding heterochromatic genes cause inactivation of a juxtaposed euchromatic gene.

Euchromatic genes are often silenced by rearrangements that place them within or near heterochromatin, a phenomenon known as position effect variegation (PEV). However, little is known about molecular structure of cis-acting heterochromatic fragments responsible for PEV. Here we report that heterochromatic cluster containing Stellate repeats, that encode putative regulatory subunit of protein kinase CK2 cause PEV of a reporter white 'mini-gene'. It is the first example of an euchromatic gene being silenced because of the proximity to the natural, well-defined heterochromatic repeat cluster.

[The study of interaction between paralogous tandem repeats stellate and suppressor of stellate in the genome of Drosophila melanogaster]. / Issledovaniie vzaimodeistviia paralogichnykh tandemnykh povtorov Stellate i Suppressor of stellate v genome Drosophila melanogaster.

Testis-specific expression of tandemly repeated Stellate genes, located in eu- and heterochromatin regions of the X chromosome of Drosophila melanogaster, is suppressed by homologous Suppressor of Stellate repeats located on the Y chromosome. Using transgenic lines, we have demonstrated that three Su(Ste) copies failed to change the expression of the reporter construction carrying the bacterial beta-galactosidase gene under control of the Stellate gene regulatory sequence. Possible mechanisms of the Su(Ste) repeat suppressor activity are discussed.

Nuclear mobility and mitotic chromosome binding: similarities between pioneer transcription factor FoxA and linker histone H1.

There exists a hierarchy by which transcription factors can engage their target sites in chromatin, in that a subset of factors can bind transcriptionally silent, nucleosomal DNA, whereas most factors cannot, and this hierarchy is reflected, at least in part, in the developmental function of the factors. For example, transcription factors possessing the Forkhead box (Fox) DNA-binding domain contain an overall fold resembling that of linker histone and thus are structured to bind DNA, site specifically, in a nucleosomal context. Where tested, Fox factors bind early in the developmental or physiological activation of target genes, thereby enabling the binding of other factors that cannot engage chromatin on their own. To investigate the basis for early chromatin binding, we have used fluorescence recovery after photobleaching (FRAP) to analyze the mobility, in the live cell nucleus, of FoxA factors in comparison to linker histone and other transcription factors. We have further analyzed the factors for their ability to bind to chromatin in mitosis and thereby serve as epigenetic marks. The results indicate that the "pioneer" features of FoxA factors involve various chromatin-binding parameters seen in linker histones and that distinguish the factors with respect to their regulatory and mechanistic functions.

Segmented gene conversion as a mechanism of correction of 18S rRNA pseudogene located outside of rDNA cluster in D. melanogaster.

The peculiarities of the sequences of 18S rDNA included in a 90-kb DNA segment cloned in YAC vector are described. This heterochromatic segment is situated on the X chromosome distal to the main rDNA cluster. The pseudo 18S rDNA sequence comprised undamaged stretches of rDNA interspersed with segments characterized by high density of nucleotide substitutions and insertions/deletions. The observed patchwork arrangement of unaltered rDNA sequences was considered as evidence of segmented gene conversion events between the normal and damaged genes which are thought to constitute one of the mechanisms of rDNA array homogenization. The 18S rDNA fragment (510 bp) located nearby, homologous to the internal, undamaged part of pseudo 18S rDNA, carries comparable density of randomly distributed nucleotide substitutions with no evidence of correction.

Contact lenses in the correction of childhood aphakia.

PURPOSE: To evaluate the results of extended-wear silicone contact lenses (Silsoft, Bausch & Lomb, Rochester, NY, U.S.A) after congenital cataract extraction. METHOD: Case records of congenital cataract extraction performed between 1992-1999, in the Department of Ophthalmology, Dokuz Eylül University School of Medicine, were retrospectively reviewed. Convenient-power extended-wear silicone contact lenses (Silsoft) were prescribed for patients 5 to 12 days after surgery. Patients were scheduled for follow-up control visits once per month in the first year, bimonthly in the second year, and quarerly visits thereafter. Visual acuity, fixation, binocularity, and deviation were checked at each follow-up visit. Examination of the cornea and the contact lens surface was also performed at each visit. RESULTS: A total of 51 children (83 eyes) were included in the study. Mean age was 19.4 +/- 18 months. Mean duration of contact lens wear per lens was 26 +/- 11 weeks. Contact lens wear was discontinued for 11 eyes: 6 because of unstable lens, frequent loss, and financial problems, and 5 were discontinued because of recurrent irritation and corneal infiltration. Mean contact lens usage time per patient was 5.8 years, and mean contact lens loss was 0.98 per year. Visual acuity improved in 58 (69.8%) eyes and remained unaltered in the remaining 25 eyes. CONCLUSION: Extended-wear silicone contact lenses offer a safe, easy treatment option for childhood aphakia, providing prolonged wearing time and low rates of complications and drop out.