BONE QUALITY IN A YOUNG COHORT OF HIV-POSITIVE PATIENTS.

CONTEXT: In HIV+ patients, several factors related to patient and antiretroviral therapy (ART) could determine early onset of bone mineral density (BMD) disturbances. OBJECTIVE: Evaluation of bone quality according to gender in patients from the HIV Romanian cohort. DESIGN: A cross-sectional study in "Prof. Dr. Matei Bals" National Institute for Infectious Diseases, Bucharest between 2016-2018. SUBJECT AND METHODS: We collected data regarding HIV infection, ART history, viral hepatitis co-infections and we calculated patients body mass index (BMI). CD4 cell count, HIV viral load (VL), vitamin-D levels were determined. Dual-energy X-ray absorptiometry (DXA) scans were used to evaluate BMD. RESULTS: We enrolled 97 patients with the median age of 26 years. According to the DXA T-scores, 10 males and 8 females had osteopenia and 4 males and 4 females had osteoporosis. According to Z-scores 2 males and 1 female had osteoporosis. Hip DXA T-scores revealed osteopenia in 6 males and 9 females, whereas T and Z-scores showed osteoporosis in 2 males and 3 females. Lumbar spine (LS) T-score diagnosed osteopenia in 9 males and 6 females, while T and Z-scores revealed osteoporosis in 3 males and females. In males, low T-scores were associated with decreased BMI; low LS DXA Z-scores with low vitamin-D levels; low T and Z-scores and LS-BMD with high VL. CONCLUSIONS: Evaluating bone quality in patients with a long history of HIV infection, multiple factors should be taken into account.

Stainless steel surface biofunctionalization with PMMA-bioglass coatings: compositional, electrochemical corrosion studies and microbiological assay.

A solution is proposed to surpass the inconvenience caused by the corrosion of stainless steel implants in human body fluids by protection with thin films of bioactive glasses or with composite polymer-bioactive glass nanostructures. Our option was to apply thin film deposition by matrix-assisted pulsed laser evaporation (MAPLE) which, to the difference to other laser or plasma techniques insures the protection of a more delicate material (a polymer in our case) against degradation or irreversible damage. The coatings composition, modification and corrosion resistance were investigated by FTIR and electrochemical techniques, under conditions which simulate their biological interaction with the human body. Mechanical testing demonstrates the adhesion, durability and resistance to fracture of the coatings. The coatings biocompatibility was assessed by in vitro studies and by flow cytometry. Our results support the unrestricted usage of coated stainless steel as a cheap alternative for human implants manufacture. They will be more accessible for lower prices in comparison with the majority present day fabrication of implants using Ti or Ti alloys.

Lipodystrophy syndrome in HIV treatment-multiexperienced patients: implication of resistin.

BACKGROUND: Impaired production of adipocytokines is a major factor incriminated in the occurrence of lipodystrophy (LD). OBJECTIVE: To evaluate LD prevalence and subtypes in HIV treatment-multiexperienced patients, and to determine the correlations between adipocytokines and LD subtypes. METHODS: Cross-sectional study in a Romanian tertiary care hospital, between 2008 and 2010, in HIV-positive patients, undergoing cART for ≥6 months. LD diagnosis, based on clinical and anthropometric data, was classified into lipoatrophy (LA), lipohypertrophy (LH) and mixed fat redistribution (MFR). Blood samples were collected for leptin, adiponectin and resistin assessments. RESULTS: We included 100 patients, 44 % with LD, among which LA had 63 %. LA patients had sex ratio, median age, treatment duration and median number of ARV regimens of 1, 20, 93 and 3.5 compared to non-LD patients: 1.65, 31, 44 and 1. LH and MFR patients were older and had higher total and LDL cholesterol versus non-LD patients. For both overall group and female group, LA was associated in univariate and multivariate analysis with increased resistin (p = 0.02 and 0.04) and number of ARV regimens (p < 0.001). Determination coefficient (Nagelkerke R (2)) of increased resistin and the number of ARV combinations in the presence of LA was 33 % in overall group and 47 % in female patients. CONCLUSIONS: In our young HIV-positive population, LD had high prevalence with predominance of LA subtype. LA was associated with high resistin levels and greater number of ARV regimens in overall group and female subgroup. Resistin could be used as a marker of peripheral adipose tissue loss and might be used as a target for new anti-LD therapeutic strategies.

Risk factors for complications after duodenopancreatectomy. Initial results after implementing a standardized perioperative protocol.

INTRODUCTION: During 1993-2008 period, in the Surgical Clinic III were conducted several retrospective studies, in order to identify risk factors for complications after cephalic duodenopancreatectomy(DP). As a result of these studies, a preoperative protocol was developed for preparation of patients proposed for DPC, as well as a number of intraoperative technical changes in order to improve postoperative morbidity and mortality. Implementation of the protocol was gradually and inomogenic done in our service. METHODS: The study is prospective, conducted in 2009-2012, ina group of 180 patients and aims to evaluate immediate results after DPC for periampular malignancy, looking to analyze the effects of implementation of the protocol mentioned above.We analyzed the rates of complications (pancreatic fistula,blunt pancreatitis, bleeding from the pancreatic blunt, delayed gastric emptiness), and the factors that might influence their occurrence. RESULTS AND CONCLUSIONS: of the 180 patients, 10 (5.5%) developed pancreatic fistula and 24 (13.3%) had delayed gastric emptiness. Among the factors that have been significant associated with these complications we mention: the pancreatico-jejunalanastomosis and gastro-jejunal transmesocolic assembly. With the implementation of the protocol, the risk factors previously identified in retrospective studies performed in our service(elevated transaminases, experienced surgical team, etc.) have lost significance, but they have not disappeared entirely, due to fact that the conduit proposed was not entirely followed. We believe that the homogeneous application of a perioperative guide, together with a standardized surgical technique, will lead to improve immediate results after DP.

Gastrojejunocolic fistula: report of six cases and review of the literature.

UNLABELLED: Six gastrojejunocolic fistulae were recorded at our service between 1995-2005. All the fistulae occurred in men who had gastric resection performed for duodenal ulcer. METHOD: Diarrhea, weight loss, postprandial pain and fecal breath were the clinical findings present in descending frequency. Preoperative diagnosis was possible in 5 patients by endoscopy and barium contrast studies. In five patients the option was a one-stage procedure with revision gastrectomy and segmental resection of the transverse colon. In one case simple dismantling of the fistula was performed. RESULTS: Although in two patients anastomotic leakage developed no mortality was recorded.

Surgical technique in the laparoscopic repair of Morgagni hernia in adults. How do we do it?

INTRODUCTION: Adult Morgagni hernias are rare congenital diaphragmatic hernias, which can present with an array of symptoms based on the size and the contents of it. This article focuses primarily on the laparoscopic repair with transfascial suturing. METHODS: A number of five patients over the course of 10 years were admitted in our clinic, one of them being admitted with emergency symptoms. Four of the patients were treated laparoscopically, one of them requiring conversion to open approach. RESULTS: The median age was 53 (range 44-71), 80% of the patients being females. Four of the patients received laparoscopic treatment with transfascial suturing, the fifth being converted, but respecting the same technique. The median surgery duration was 110 min, with a median blood loss of 30 ml. Removal of the sac was attempted in two cases. Median hospitalization stay was 3 days, with a median follow-up of 21 months, with no postoperative complications reported. CONCLUSIONS: Laparoscopic repair with transfascial suturing provides an feasible and efficient repair, compared to the other laparoscopic techniques. Although no postoperative complications were reported, the removal of the sac still remains an controversial issue.

[Therapeutic approach for patients with positive resection line (R1) after gastrectomy for gastric cancer]. / Atitudinea terapeutica la pacientii cu transa de rezectie pozitiva (R1) dupa gastrectomii pentru cancer gastric.

INTRODUCTION: The radical treatment of the gastric cancer consist in large gastric resections and lymphadenectomy. Resection line involvement at microscopic histopathological examination (R1) could change prognostic unfavorable. MATERIAL AND METHODS: They were 135 patients with gastric cancer operated between 2006-2007, with radical gastric resections and lymphadenectomy. In 3 patients with early gastric cancer and 23 patients with different stages of cancers, histopathological examination showed resection line involvement. From this study were eliminated the patients with stage IV cancers in whom resections were palliative. RESULTS: Incidence of positive resection line involvement was 19,25%. 88,46% of the tumors were staged pT2 and pT3 and the majority was poorly differentiated or undifferentiated (G3 and G4). Lymphatic involvement (pN1 or pN2) was demonstrated in 18 (69,23%0 patients with R1. Perioperative complications were encountered in 15,38% of this patients, with 7,69% mortality. CONCLUSIONS: Presence of tumoral tissue at resection line level could decrease survival in this patients. Therapeutic protocol in patients with resection line involvement (re-laparotomy with re-resection or surveillance) must be establish in accordance with several factors: T and N category, risks of another surgical interventions, patients acceptance.

[Surgical management of malignant large bowel obstructions]. / Managementul chirurgical in urgenta al ocluziilor prin cancere colonice si rectale.

INTRODUCTION: Despite significant progress, the management of acute colonic obstruction still remains a challenging problem. The purpose of this study was represented by the evaluation of the clinical results of different techniques of resection for malignant colorectal (primary or staged) obstruction. METHODS: We performed a non-randomized clinical study. 590 patients with malignant colorectal occlusion who underwent surgery treatment an 3rd Surgical Clinic Cluj-Napoca between 1996-2005 were included. RESULTS: Patients with large bowel obstruction underwent one-stage primary resection with anastomosis in 267 cases or staged interventions in 323 cases. The groups were matched in: age, sex, comorbidities, tumor staging, serum preoperative levels of hemoglobin and proteins. The analysis of mortality and morbidity following surgical treatment for large bowel obstruction returned no significant difference among the two groups (p > 0.05). Moreover, the presented results showed a higher incidence of mortality (11.45% vs 9.33 %), morbidity (25.38% vs 14.6%) and increased hospitalization period (p = 0.029) among the patients that undergone seriate resections. CONCLUSIONS: One stage primary resections with anastomosis of the large bowel can be performed safely in case of emergency whenever patient comorbidities and local conditions do not stand as major restrictions.

Ti-Si-C thin films produced by magnetron sputtering: correlation between physical properties, mechanical properties and tribological behavior.

Ti-Si-C thin films were deposited onto silicon, stainless steel and high-speed steel substrates by magnetron sputtering, using different chamber configurations. The composition of the produced films was obtained by Electron Probe Micro-Analysis (EPMA) and the structure by X-ray diffraction (XRD). The hardness and residual stresses were obtained by depth-sensing indentation and substrate deflection measurements (using Stoney's equation), respectively. The tribological behavior of the produced films was studied by pin-on-disc. The increase of the concentration of non-metallic elements (carbon and silicon) caused significant changes in their properties. Structural analysis revealed the possibility of the coexistence of different phases in the prepared films, namely Ti metallic phase (alpha-Ti or beta-Ti) in the films with higher Ti content. The coatings with highest carbon contents, exhibited mainly a sub-stoichiometric fcc NaCI TiC-type structure. These structural changes were also confirmed by resistivity measurements, whose values ranged from 10(3) omega/sq for low non-metal concentration, up to 10(6) omega/sq for the highest metalloid concentration. A strong increase of hardness and residual stresses was observed with the increase of the non-metal concentration in the films. The hardness (H) values ranged between 11 and 27 GPa, with a clear dependence on both crystalline structure and composition features. Following the mechanical behavior, the tribological results showed similar trends, with both friction coefficients and wear revealing also a straight correlation with the composition and crystalline structure of the coatings.

[The role of diagnostic laparoscopy in periampullary and pancreatic cancers. A study based on 27 cases]. / Rolul laparoscopiei diagnostice în cancerele periampulare si pancreatice. studiu bazat pe un numar de 27 cazuri.

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.

[Intrabiliary rupture of hepatic hydatid cysts: results of 17 years' experience]. / Chisturile hidatice hepatice rupte în arborele biliar: experienta a 17 ani.

UNLABELLED: Between 1990 and 2006 in the III-rd Surgical Clinic Cluj-Napoca, 366 pacients with hepatic hydatid cyst were admitted and underwent surgery; 81 (22.13%) of them, who had a cyst-biliary comunication, were retrospectively reviewed: 52 (64.2%) had an occult communications and 29 (35.8%) had a frank intrabiliary rupture. The sex ratio was M/F=46/35 with a mean age of 44.5 years and with ages between 17 and 73 years. Choledochotomy, evacuation of parasitic material and lavage of the CBP were performed in all patients with frank intrabiliary rupture. In 25 patients, partial pericystectomy and choledochoduodenostomy/T-tube drainage of CBP was performed. Internal drainage by a Roux-en-Y pericystectojejunostomy and biliodigestive anastomosis was carried out in 2 patients, while other two patients underwent external drainage of cystic cavity and T-tube drainage of CBP. 15 patients (51.7%) had postoperative external bile leaks (fistulas). Occult communications were managed by partial pericystectomy +/- narrowing of the residual cavity (capitonage with an omentum flap or invagination of the fibrosis capsule margins into the cavity) in 35 patients (67.3%) while in 10 patients (19.2%) internal drainage by a Roux-en-Y pericystectojejunostomy was carried out. Regional resection of the liver was performed in 4 cases (7.7%) and external drainage of residual cavity in 3 patients (5.7%). 13 patients (25%) had postoperative external bile leaks (fistulas). The mean postoperative hospitalisation was 20 days with the range 5-85 days. The mortality rate was 2.4% (2 patients): one died due to septicemia and MOFS and the other due to pulmonary thromboembolism. CONCLUSION: Postoperative bile leaks (fistulas) fallowing conservative surgery of ruptured hydatid hepatic cyst into the biliary tract are not rare regardless of the type of rupture (frank or occult). Although the opening of the biliary duct is sutured, the risk of biliary fistulas is not clearly corelated with this approach; in such cases internal drainage provides a good alternative with low morbidity.

[Laparoscopic antireflux surgery--long-term results]. / Montaje antireflux efectuate pe cale laparoscopica--rezultate pe termen lung.

METHOD AND MATERIAL: Between 1995 and 2005 a number of 98 antireflux laparoscopic procedures have been performed. The patients have answered to a 7 point questionnaire regarding the disappearance of specific gastro-esophageal symptoms, the necessity of medical adjuvant treatment as well as regarding the measure in which surgery brought a real subjective improvement. The average follow-up was 57 months (4.7 years). RESULTS: 43 laparoscopic patients have answered the questions. 10 patients had dysphagia, most of which had a spontaneous remission. Only 3 of those patients needed an endoscopic dilatation. Bloating was still possible for 33 of the patients. Retrosternal pain remained present for 14 patients. Intestinal transit disorders have showed up in 11 cases. Reflux persisted at a variable degree in 12 patients. Only 7 patients continue to follow a systematic drug treatment. 35 patients consider that the surgery has brought an improvement of their disease.

[Morbidity and mortality in gastric cancer surgery--analysis of 468 cases with gastric adenocarcinoma]. / Morbiditate si mortalitate în chirurgia cancerului gastric--analiza a 468 cazuri de adenocarcinom gastric.

The aim of this study is to evaluate the morbidity and mortality in the surgical treatment of gastric cancer and the factors that could influencing them. We made a retrospective analysis of a group of 468 patients with gastric adenocarcinoma which have been operated in the 3RD Surgical Clinic-Cluj Napoca--01.01.1998-31.12.2003. We analyzed parameters related to patient, pTNM stage and type of treatment. Morbidity was significantly higher in these circumstances: elder patients, cases with lower serum levels of hemoglobin and total proteins, after Billroth II procedures; we found no significant differences of morbidity depending on gender, pTNM stage, type of intervention: simple or multiorgan resection, subtotal or total gastrectomy, radical or palliative procedure or only exploratory laparotomy, presence or absence of splenectomy or caudal pancreatectomy, D1 or D2 lymphadenectomy (in radical procedures), palliative resection or gastrojejunal bypass. Elder patients and male patients have had a mortality significantly higher; we found no significant differences of mortality depending on serum levels of hemoglobin and total proteins, pTNM stage, type of intervention: simple or multiorgan resection, subtotal or total gastrectomy, radical or palliative procedure or only exploratory laparotomy, presence or absence of splenectomy or caudal pancreatectomy, D1 or D2 lymphadenectomy (in radical procedures), type of restoring of the digestive continuity after subtotal gastrectomy, palliative resection or gastrojejunal bypass.

[Clinical aspects with prognostic value in gastric cancer--analysis of 468 cases with gastric adenocarcinoma]. / Aspecte clinice cu implicatie prognostica în cancerul gastric--analiza a 468 cazuri de adenocarcinom gastric.

The aim of this study is to assess clinico-pathological parameters and find out the correlation between them and their possible prognostic value. We made a retrospective analysis of a group of 468 patients with gastric adenocarcinoma which were operated in the 3rd Surgical Clinic--Cluj Napoca--01.01.1998-31.12.2003. The median age was 62 years. Patients in pTNM 0 stage were significantly younger than the rest of patients, with an average of 7.5 years. The male/female ratio was 1.7:1, this ratio being significantly higher in cases with proximal gastric cancers. There was not found any significant correlation between the interval : onset of symptoms and surgery, and pTNM stage. The most frequent signs and symptoms were epigastric pain, weight loss, indigestion, fatigue, pallor and loss of appetite, each of them were found in more than 40% patients. Multivariate analysis of symptoms showed that weight loss (p=0.00638) was independently correlated to advanced pTNM stages. The number of signs and symptoms was significantly correlated to advanced pTNM stages (p=0.000026). This significant group of patients studied has maintained characteristics encountered in populations with higher incidence of gastric adenocarcinoma, men being more frequently affected, distal localization and intestinal histologic type being encountered more frequently.

[Management of colorectal resections for treatment of neoplastic intestinal occlusions. Experience of surgery clinic No III, Cluj-Napoca]. / Managementul rezectiilor colorectale în tratamentul ocluziilor intestinale neoplazice. Experienta Clinicii Chirurgie III Cluj-Napoca.

PURPOSE: We analyzed the clinical results of different techniques of resection for malignant colorectal (primary or staged) obstruction. METHODS: The subjects of this retrospective nonrandomized clinical study were 165 patients with malignant colorectal occlusion who underwent surgery treatment in our Department between 2002-2006. Patients with peritonitis or treated by means of permanent colostomy, palliative anastomosis, primary Hartman resection and rectal excision were excluded. RESULTS: Patients with large bowel obstruction caused by obstructive malignant colorectal lesions underwent either one-stage primary resection with anastomosis (77 patients) or staged interventions (88 patients). There were no differences in age, sex, comorbidities, tumor staging, serum preoperative levels of hemoglobin and proteins between the two groups of patients defined by the different surgical techniques. Regarding mortality and morbidity following surgical treatment for large bowel obstruction no significant difference among the two groups (p > 0.05) or the fistula rate (p = 0.435) was obtained. Moreover, results showed a higher incidence of mortality (11.8% vs 7.8%), morbidity (13.6 vs 10.4) and increased hospitalization period (p = 0.03) among the patients that undergone series resections. CONCLUSIONS: One stage primary resections with anastomosis of the large bowel can be performed safely in case of emergency whenever patient comorbidities and local conditions do not stand as major restrictions.

Coping strategies, satisfaction with life, and quality of life in Crohn's disease: A gender perspective using structural equation modeling analysis.

OBJECTIVE: To identify coping strategies and socio-demographics impacting satisfaction with life and quality of life in Crohn's disease (CD). METHODS: 402 patients completed the Patient Harvey-Bradshaw Index, Brief COPE Inventory, Satisfaction with Life Scale (SWLS), Short Inflammatory Bowel Disease Questionnaire (SIBDQ). We performed structural equation modeling (SEM) of mediators of quality of life and satisfaction with life. RESULTS: The cohort comprised: men 39.3%, women 60.1%; P-HBI 4.75 and 5.74 (p = 0.01). In inactive CD (P-HBI≤4), both genders had SWLS score 23.8; men had SIBDQ score 57.4, women 52.6 (p = 0.001); women reported more use of emotion-focused, problem-focused and dysfunctional coping than men. In active CD, SWLS and SIBDQ scores were reduced, without gender differences; men and women used coping strategies equally. A SEM model (all patients) had a very good fit (X2(6) = 6.68, p = 0.351, X2/df = 1.114, SRMR = 0.045, RMSEA = 0.023, CFI = 0.965). In direct paths, economic status impacted SWLS (ß = 0.39) and SIBDQ (ß = 0.12), number of children impacted SWLS (ß = 0.10), emotion-focused coping impacted SWLS (ß = 0.11), dysfunctional coping impacted SWLS (ß = -0.25). In an indirect path, economic status impacted dysfunctional coping (ß = -0.26), dysfunctional coping impacted SIBDQ (ß = -0.36). A model split by gender and disease activity showed that in active CD economic status impacted SIBDQ in men (ß = 0.43) more than women (ß = 0.26); emotional coping impacted SWLS in women (ß = 0.36) more than men (ß = 0.14). CONCLUSIONS: Gender differences in coping and the impacts of economic status and emotion-focused coping vary with activity of CD. Psychological treatment in the clinic setting might improve satisfaction with life and quality of life in CD patients.

[Laparoscopic cholecystectomy for porcelain gallbladder]. / Colecistectomie laparoscopica pentru vezicula de portelan.

The porcelain gallbladder is uncommon type of chronically inflamed gallbladder wall considered to be associated with a high frequency of adenocarcinoma and subsequently not suitable for a laparoscopic approach. In 12,000 patients chosen for a laparoscopic cholecystectomy 4 porcelain gallbladders were diagnosed. In 2 cases the laparoscopic approach was successful. One conversion was due to an unconfirmed suspicion of gallbladder cancer and the other one to a fistula between the gallbladder and the common bile duct. Patients with a preoperative diagnosis of porcelain gallbladder must not be excluded from the laparoscopic approach yet a low threshold for conversion must be maintained in those with a cancer suspicion.

[A possible protocol for postoperative management in laparoscopic cholecystectomy]. / Posibil protocol de abordare perioperatorie a colecistectomiei laparoscopice.

The goal of the "Prospect" programme (sponsored by Pfizer) is to create possible evidence-based protocols related to the management of postoperative pain after certain type of surgical intervention (e.g. hernia repairs, hysterectomies, etc.). This article is introducing the protocol for laparoscopic cholecystectomy for both day-case and longer hospital admission cases. The protocol is designed for preoperative, intra and postoperative period, choosing only those measures which were effective for postoperative pain, published in the literature. We are also presenting an analyze of our 13,000 laparoscopic cholecystectomies, from "Prospect" protocol point of view, and what we should do to improve the management of postoperative pain.

Mini-invasive treatment of complications following laparoscopic cholecystectomy.

BACKGROUND: Even though laparoscopic cholecystectomy (LC) has become the customary method for treating gallstones, some incidents and complications appear rather more frequently than with the open technique. Several aspects of these complications and their treatment possibilities are analysed. MATERIALS AND METHODS: Over the last 9 years 9542 laparoscopic cholecystectomies have been performed, of which 13.9% were carried out for acute cholecystitis, 38.4% in obese patients and 7.6% in patients aged > 65 years. RESULTS: The main postoperative complications were bile leakage and choleperitoneum (54 cases), haemorrhage (15 cases), subhepatic abscess (10 cases) and retained bile duct stones (11 cases). Classic re-interventions were practiced in 28.8% of cases with complications. Mini-invasive techniques were used in 42.2% of cases with complications: laparoscopic re-interventions (15 cases) for choleperitoneum, haemoperitoneum and subhepatic abscess and endoscopic sphincterotomy (22 cases) for prolonged bile leak on subhepatic drain and for early diagnosed remnant lithiasis of the common bile duct. All cases healed. Another 26 patients were treated conservatively. DISCUSSION: With a precise diagnosis and a good indication, the mini-invasive treatment of complications was completed with good results. 16 laparoscopic re-operations and 22 endoscopic sphyncterotomies were performed (for the treatment of bile leakage and remnant gallbladder stones).