Photochemical /Photocytotoxicity Studies of New Tetrapyrrolic Structures as Potential Candidates for Cancer Theranostics.

BACKGROUND: Detailed photochemical and photocytotoxicity studies of two new porphyrins: 5,10,15,20-meso-tetrakis-(4-acetoxy-3-methoxyphenyl) porphyrin (P2.1) and 5-(4-hydroxy-3- methoxyphenyl)-10,15,20-tris-(4-acetoxy-3-methoxyphenyl)porphyrin (P2.2) are reported, as potential candidates for theranostics. For powdered samples of P2.1 and P2.2 adsorbed onto a powdered biocompatible substrate, polyethylene glycol (PEG), a concentration study was performed, correlating the fluorescence emission intensity with sample absorption to determine the useful concentration range for photodynamic therapy of cancer (PDT) in which aggregation does not occur. Cytotoxicity studies were performed in dark and illuminated conditions. METHODS: The laser induced luminescence set-up is home-made, a N2 laser is used as the excitation source and a time gated charged-coupled device (ICCD) as the detector. Fluorescence lifetime determinations were made using pulsed light sources from the excitation LEDs and measures of the fluorescence intensities at different time delays after the excitation pulse. The singlet oxygen formation quantum yields ΦΔ measurements were obtained by comparing the total area of the emission spectra for the reference compound and also for the samples under study in the same solvent and with the same optical density at the excitation wavelength (405 nm). An integrating sphere for relative and absolute measurements was used in this work as an alternative methodology to obtain the values for the fluorescence emission quantum yields (ΦF) of the adsorbed porphyrin under study. The cytotoxicity evaluation was made in the dark and under irradiation, using four different human tumor cell lines and one non-tumor primary cell culture. RESULTS: In order to establish the useful range of concentrations of the sensitizer for PDT, and due to the use of powdered samples, a special methodology was needed: the variations of the fluorescence lifetimes and fluorescence quantum yields were evaluated as a function of the concentration of the dye, measured by (1-R)*fdye. Both ΦF and τF are constant in the range from 0.002 to about 0.050 µmol g-1, and only after that a concentration quenching effect becomes visible, decreasing both ΦF and τF. This methodology is based in the correlations established between the Remission Function values and ΦF and τF obtained for increasing values of the sensitizer concentrations. CONCLUSIONS: The study of the aggregation effects of P2.1 and P2.2 porphyrins into a PEG matrix allowed us to determine the usable concentration range for photodynamic therapy use, where the aggregation of porphyrins decreases, therefore reducing the PDT action. The use of an integrating sphere for relative and absolute measurements of fluorescence quantum yields and also the lifetime studies as a function of the dye loading confirms the useful range for the use of P2.1 and P2.2 in PEG as powdered samples. The determination of the GI50, the porphyrin concentration which inhibits 50% of the cell growth, evidences that P2.2, the A3B porphyrin overtakes P2.1 (the A4 porphyrin) in terms of PDT efficiency and both porphyrins are much better PDT agents than the unsubstituted porphyrin, TPP. These data clearly show that porphyrins P2.2 and P2.1 exhibit an excellent behaviour in terms of its photocytotoxicity. These results encourage us to pursuit in the study of this family of porphyrins in which a balance of hydrophobic versus hydrophilic substituents in the phenyl group was achieved.

Measurement of Quality of Life after Total Parathyroidectomy in Patients with Secondary Hyperparathyroidism and End Stage Renal Disease.

BACKGROUND: Surgery is the definitive treatment of secondary hyperparathyroidism (2HPT) and end stage renal disease patients. The aim of this study to assess the impact of surgery on the evolution of quality of life (QoL) in patients with 2HPT, and to identify the variables that influence this evolution. METHODS: A series of 85 consecutive unselected patients underwent total parathyroidectomy for 2HPT in our clinic. QoL was measured using the Short-Form Health Survey(SF-36) and alleviation of symptoms was documented using an outcome tool (PAS score), based on visual analog scales, preoperatively, postoperatively and at 6 months. RESULTS: Preoperatively, patients had lower SF-36 scores than the general population in all 8 individual and 2 component summary scales, with significant decrease in the physical health scales(p 0.0001). Patients improved in all ten scales at 6 months follow-up, most significant being: Body Pain (45.02‚+-5.52 vs 33.12‚+-8.82, p 0.0001), Role-physical (41.00‚+-7.43 vs 33.46‚+-8.54, p 0.0001), Physical functioning (40.06 ‚+-7.77 vs 33.36 ‚+-10.84, p 0.0001). PAS Scores decreased from preoperatory levels of 569.99 ‚+- 136.45 to 372.20 ‚+- 104.62 at 7 days after surgery and furthermore at 292.64 ‚+- 85.16 at 6 months follow-up (p 0.0001). CONCLUSIONS: We found no correlation between preoparatory PTH or Calcium levels and clinical symptoms. Parathyroidectomy clearly alleviates symptomatology and improves QoL in 2HPT patients, with durable effect at 6 months.

Surgical Attitude in Patients with Secondary Hyperparathyroidism Undergoing Dialysis.

BACKGROUND: Secondary hyperparathyroidism (SHPT), develops, more or less in all the patients with chronic kidney disease. The pathology is even more severe as it intervenes in a suffering patient in whom the chronic kidney disease frequently associates severe comorbidities. General mortality is higher than in general population. The failure of the medical therapy is an indication for parathyroidectomy. METHODS: The study analyzed 200 patients with SHPT and chronic kidney disease, admitted in the clinic from October 2011 until January 2015.In this period, 179 (89.5 %) total-parathyroidectomies have been performed a long with 14 (7%) subtotal parathyroidectomies. Also 7 (3.5%) surgical interventions were incomplete. RESULTS: Overall mortality was 1% (2 patients) and postoperative specific morbidity 3.5% -4 local hemorrhagic complications and 3 cases of dysphonia have been encountered (12% if we include the reinterventions for recurrent hyperparathyroidism - 17 patients). CONCLUSIONS: Total parathyroidectomy is encumbered by a reduced number of postoperative complications and the risk of recurrent disease in almost nonexistent. The disadvantages of this surgical approach are the tendency of immediate postoperative hypocalcemia and long therm substitution with calcium and vitamine D.

Technical Factors Involved in Parathyroid Surgery.

We aimed to investigate the frequency of ectopic and supernumerary parathyroid glands in our series of renal hyperparathyroidism. From October 2011 to November 2014, 202 patients with chronic renal failure and advanced SHPT nonresponsive to medical therapy were hospitalized in the General Surgery Department of the Carol Davila Nephrology Hospital. These patients underwent a number of 188 (93%) total parathyroidectomies and a number of 14 patients (7%) subtotal parathyroidectomies. Of these 202 patients, reoperation was carried out for 14 patients (7%) in which we identified ectopic and supernumerary parathyroid glands. Operative details and pathology results were prospectively collected and reviewed after we obtained informed consent for data and pictures use. In 188 patients (93% cases), four or more parathyroid glands were removed at the first operation. In 14 cases (7%) high PTH level persisted after the initial operation. In 22 of them (11%), supernumerary glands were found at the first operation and in 6 of them (3%) at the second operation. We conclude that extensive cervical exploration in addition with preoperative imaging tests, parathyroid ultrasound; scintigraphy with Tc will reduce secondary hyperparathyroidism surgery.

The Role of Collagen Metabolism in the Formation and Relapse of Incisional Hernia.

Despite the continuous development of synthetic prosthetic meshes and their wide use, recurrent incisional hernias still appear in 5 to 20% of cases, with a linear incidence curve over the years, suggesting a multifactorial process rather than a simple failing technical repair as the underlying cause. Recent molecular biological research provide increasing evidence of connective tissue alterations such as a defective wound healing with impaired scarring process in patients with incisional hernia. Although there are some promising results, at present, in-depth understanding of the pathophysiological mechanisms and of the role that collagens play in the development and recurrence of incisional hernia is rather scarce. The aim of this systematic review is to summarize and evaluate the biochemical mechanisms involved in incisional hernia formation and recurrence, with a primary focus on collagen I to III ratio. Also, the consequences for surgical practice are discussed.

[Complex reconstruction with internal locking plate fixation for Charcot arthropathy]. / Komplexe Rekonstruktionen mit winkelstabiler interner Plattenfixation bei Charcot-Arthropathie.

BACKGROUND: Osteosynthesis and reposition of the Charcot foot is challenging with respect to choice of a proper implant. There is currently no international consensus regarding the optimal implant. OBJECTIVES: Locking plates seem to be an innovative and stable method for reconstruction. The aim of this work is to analyze bone fusion, complications, pseudoarthrosis, and patient satisfaction. METHODS: This paper presents a retrospective analysis of 63 consecutive Charcot feet treated between 2004 and 2014. The mean follow-up time was 2.4 years. RESULTS: All Charcot feet treated between 2004 and 2014 were Sanders type II or III. A bony fusion was achieved in 50 % of the cases, 26 % had a functional pseudoarthrosis with intact implants and pain-free mobility, and 22 % showed no healing with broken implants. Conclusion Internal fixation with locking plates is superior to screw fixation only with regard to biomechanics. We prefer internal fixation plates to external fixation because of stability even in the case of pseudoathrosis and because of the learning curve.

Translating clinical research of Molecular Biology into a personalized, multidisciplinary approach of colorectal cancer patients.

Although multimodal treatment has brought important benefit, there is still great heterogeneity regarding the indication and response to chemotherapy in Stage II and III, and individual variations related to both overall survival and toxicity of new therapies in metastatic disease or tumor relapse. Recent research in molecular biology led to the development of a large scale of genetic biomarkers, but their clinical use is not concordant with the high expectations. The Aim of this review is to identify and discuss the molecular markers with proven clinical applicability as prognostic and/or predictive factors in CRC and also to establish a feasible algorithm of molecular testing, as routine practice, in the personalized, multidisciplinary approach of colorectal cancer patients in our country. Despite the revolution that occurred in the field of molecular marker research, only Serum CEA, Immunohistochemical analysis of mismatch repair proteins and PCR testing for KRAS and BRAF mutations have confirmed their clinical utility in the management of colorectal cancer. Their implementation in the current practice should partially resolve some of the controversies related to this heterogenic pathology, in matters of prognosis in different TNM stages, stage II patient risk stratification, diagnosis of hereditary CRC and likelihood of benefit from anti EGFR therapy in metastatic disease. The proposed algorithms of molecular testing are very useful but still imperfect and require further validation and constant optimization.

Microsatellite instability in the management of stage II colorectal patients.

BACKGROUND: Up-to-date it is unclear whether stage II colorectal cancer patients should receive adjuvant chemotherapy.The presence of high risk features (T4, CEA 5 ng dl, less than 12 lymph nodes examined) is an indication for Oxaliplatin based treatment. In their absence, there is no consensus, 5 Fluorouracil regimens, or observation only being equally recommended by oncologists. Microsatellite instability is associated with good prognosis in stage II colorectal cancer and also with poor response to 5 Fluorouracil and should be used as a predictive marker. METHODS: We performed a prospective descriptive study on 115 consecutive patients who received surgical resection for colorectal cancer in our clinic during 2011 and 2012 using a risk stratification algorithm based on TNM staging, clinico pathologic and molecular markers. RESULTS: From the 44 stage II colorectal cancer patients, 10 cases were classified as high risk, in 26 cases we performed Immunohistochemical analysis that identified 8 patients with low risk microsatellite instability phenotype, with no indication for adjuvant chemotherapy; 26 intermediate risk patients received 5-FluoroUracil regimens. CONCLUSION: We believe that microsatellite instability testing provides a useful tool in the goal of better characterizing patients with stage II colorectal cancer in matters of risk of recurrence and likelihood of benefit from chemotherapy.

Molecular factors of failure in incisional hernia surgery.

Incisional hernias occur as frequent as they did 20 years ago even if we use modern technologies in terms of suture. Sutures techniques, either primary repair or applied after failure of primary repair are characterized by high rates of recurrence. Using the hernia mesh has become mandatory in repairing of all types of hernias - inguinal, ventral or incisional. Implantation of the mesh is a relatively well-coded surgical procedure. But surgery is only the first step in the process of healing. Implantation starts a strong response with haematological mechanisms: protein absorption, complement activation, coagulation, platelet activation, neutrophil activation and tissue mechanisms: proliferation, adhesion, fibrosis. Recurrence rates are consistently lower when replacement meshes are used and a variety of meshes have been developed for this purpose. How the mesh is embedded by the human body and how the biomechanical limits of the abdominal wall are restored is still a subject of debate for surgeons. Histopathological studies and progress in design and materials are the only keys to solve this problem. Also pathological studies should determine the right material for personalized repair according to each patient's biology. This paper attempts to analyze the molecular failure factors in incisional hernia surgery, different from errors in surgery procedures. Complications can be avoided or reduced by an appropriate selection of the type of place in a particular case, and by performing a meticulous technique. Incisional hernias are considered at this moment a biological progressive phenomenon, and not only a strictly technical one, a "simple hole in the abdominal wall" that has to be firmly sutured.

Septic remnants, a crucial factor in the outcome of suppurated pancreatitis.

Scheduled reinterventions, or dictated by necessity in order to drain the septic foci occupy an important place in the surgery of the pancreatic suppurations. Approximately 50% of the operated patients require one or more reinterventions, in order to accomplish the debridement and evacuation of the necrotic-suppurative remnants. The authors reanalyze the retroperitoneal space as a center of the necrotic-suppurative processes, emphasizing over the insufficiency of the approach of the retroperitoneum only through the omental bursa. The anatomical considerations infirm the belief according to which the approach of the omental bursa would be the primary gesture of retroperitoneal access. The pancreas and the surrounding atmosphere are hosted within the anterior an posterior pararenal space. In order to avoid septic remnants it is insisted on six access pathways to the pararenal space. These ways of approach are dictated according to topography of the suppurated necrosis. Post surgical evolutional future of the patient is directly dependent on the presence or absence of the remnants after the first surgical intervention. Evidently, the remnants will be present where the debridement and evacuation of the sepsis didn't take place- meaning all the dependencies of the pararenal space. The large, multiple drainage, closed or opened, with or without continuous lavage, can not correct the septic omissions. Partial and incomplete debridements must not be based on the corrections through the scheduled reinterventions.

Rives technique, a gold standard for incisional hernias -- our experience.

Incisional hernias are a real problem in abdominal surgery and occur in up to 18% of patients undergoing surgery. Simple sutures or so-called anatomical processes lead to recurrence in up to 50% of cases. Performance of an alloplastic procedure decreases relapse rate to 10%, down from 12%. Popularized in Europe by Rives and Stoppa, the sublay mesh repair technique has proven very effective, with low recurrence rates (0% -23%) and minimal complications. In our clinic we have been using this technique for about 10 years, adding some changes that we consider beneficial to the further evolution of the patient and especially to obtaining a strong abdominal wall, equally functional in terms of bio-mechanics. During the study period, we recorded a total of 45 patients with abdominal incisional hernias operated by this technique. All patients were operated on by the same surgical team. No patients required surgical reintervention. Our results show that the Rives-Stoppa technique is an effective method for repairing incisional hernias. Complications and recurrence rates are comparable with the results of other techniques.

The role of imaging evidence in pancreatic suppurations.

The authors wish to propose an interpretation protocol of the imaging dedicated to the pancreatic suppurations that appear in acute necrotising pancreatitis. Analyzing the data from the literature regarding the extension mode of the pancreatic suppurations, it promotes the idea according to which the surgeon must himself utilize and interpret the offered imaging. Using well known anatomical references, highlighted on the CT and MRI images and reconstructions, the surgeon is able to appreciate more accurately, on the basis of evidence, the references and limits of the suppurative collections. Thus, it is obtained a more precise topographic map of the suppurative areas and so it proposes the necessity of reporting to precisely named retroperitoneal spaces, that are part of the pararenal bilateral area. Hence it is identified the lumenal, parenchymal and vascular anatomical marks, which permit the exact anatomical reference of the retroperitoneal spaces interested by the pathological process. In this way, it creates the possibility of aimed surgical approach, with the selection of the ways of access towards the suppurative zones in order to avoid septic omissions. Finally, the authors propose the imaging reference to 13 retroperitoneal areas, areas that are contained under the name of pararenal space.

Present and future tense in operable rectal cancer.

In the last three decades it has been repeatedly insisted on the total mesorectal excision (TME), as being the key for pelvic recurrence. The authors have focused upon issues still "questionable", that invite reflection, having as a starting point now become the classic precepts of RJ Heald. The authors stop mainly on defining points that justify the complex therapeutical approach of rectal cancer. There are discussed some issues still subject to controversy: the extent of regional extirpation, critical points of surgical risk, the attitude towards the protection of genito-urinary innervation. In this purpose surgical considerations are presented on: the anatomy of the rectum and mesorectum, TME and its limits, on dissemination issues and pathology tumor grading, pelvic relapse and the place of adjuvant therapy. Complication rate is also analyzed and the quality of life of patients undergoing TME. Finally conclusions are advanced, some of them having the capacity to provide topics for future study and debate.

Congenital splenic cyst - case study.

BACKGROUND: Splenic cysts represent a pathology seldom encountered in practice, the most often etiology being, parasitic, congenital and pseudo-cysts, which usually appear post-traumatically or after a splenic infarction.Splenic cysts indicate a surgical treatment when they are large (and thus present a high risk for complications such as rupture, hemorrhaging, compression of the neighboring organs), when they are symptomatic or present complications. CASE REPORT: We present the case of a patient diagnosed with splenic cyst in our Clinic, its discovery being incidental, while conducting investigations for an abdominal pain syndrome. DISCUSSIONS: The clinical case presented completely abides to the literary description-the diagnostic has been incidental, the large size of the cyst has determined the need for surgery (splenectomy), its etiology has been established by means of anatomo-pathological report (the presence of the epithelial inner wall that indicates congenital cysts).

Prognostic factors in colorectal cancer evolution.

BACKGROUND: This paper tries to evaluate prognostic value of various pre and post-operative colorectal cancer markers. MATERIALS AND METHODS: In the study conducted in our clinic over a period of five years we tried to emphasize the biological factors of prognostic value in colorectal cancer, and to demonstrate the important role of these factors in predicting survival, but also of early relapse or, in some cases, resistance to chemotherapy. Most important component of these factors remains molecular tumor markers. RESULTS: Of the markers of tumor load increased preoperative serum levels of carcinoembryonic antigen (CEA) means increased risk of neoplastic recurrence and reducing survival expectancy. Aneuploidy tumor cells would have the same importance. CONCLUSIONS: Although for their study modern and expensive techniques are necessary, molecular tumor markers have an increasingly role appreciated by researchers both in estimating the risk of relapse and neoplastic dissemination and the response rate to adjuvant treatment. It is estimated that the study of molecular/genetic profile of colorectal tumors in the future will dictate therapeutic decisions ahead.

The microscopic structure of an exactly solvable model binary solution that exhibits two closed loops in the phase diagram.

An exactly solvable lattice model describing a binary solution is considered where rodlike molecules of types AA and BB cover the links of a honeycomb lattice, the neighboring molecular ends having three-body and orientation-dependent bonding interactions. At phase coexistence of AA-rich and BB-rich phases, the average fraction of each type of triangle of neighboring molecular ends is calculated exactly. The fractions of the different types of triangles are then used to deduce the local microscopic structure of the coexisting phases for a case of the model that contains two closed loops in the phase diagram.

Phase separation in an exactly solvable model binary solution with three-body interactions and intermolecular bonding.

A model is presented in which the bonds of a honeycomb lattice are covered by rodlike molecules of types AA and BB, molecular ends near a common site having both three-body interactions and orientation-dependent bonding between two A molecular ends and between an A and a B molecular end. Phase diagrams corresponding to the separation into AA-rich and BB-rich phases are calculated exactly. Depending on the relative strengths of the interactions, one of several qualitatively different types of phase diagrams can result, including diagrams containing phenomena such as a double critical point or two separate asymmetric closed loops. The model is essentially a limiting case of a previously considered ternary solution model, and it is equivalent to a two-component system of interacting A and B molecules on the sites of a kagomé lattice.

An exactly solvable model for a ternary solution with three-body interactions and orientationally dependent bonding.

A model is considered in which the bonds of a honeycomb lattice are covered by rodlike molecules of types AA, BB, and AB. Neighboring molecular ends have three-body and orientation-dependent interactions. The model is shown to be equivalent to a spin-1/2 Ising model on the same lattice with a field, but with only pairwise interactions. Symmetric and asymmetric coexistence surfaces for the separation into an AA-rich and a BB-rich phase are calculated exactly.