Clinico-radiological diagnosis and grading of rapidly progressive osteoarthritis of the hip.

Due to the current lack of standard definitions for rapidly progressive osteoarthritis of the hip (RPOH) in the literature, this observational study aimed to describe new diagnostic criteria and a grading system for the disease.From a consecutive series of patients undergoing total hip replacement, 2 groups were selected: 1 with RPOH and 1 with primary hip osteoarthritis (POH), and their clinical, paraclinical, and demographic data were compared. The newly proposed clinico-radiological diagnostic criteria are based on characteristics of pain, joint mobility, and radiological assessment. The radiological grading system's inter- and intraobserver reliability was assessed through serial evaluations by 2 blinded reviewers.From the total 863 cases, 82 cases (9.5%) of RPOH were identified and compared with 107 cases of POH. Mean age and disease bilaterality were similar, with a predominance of female patients in the RPOH group (P = 0.03). There were significant differences between the 2 groups in disease onset and aggravation, and intraoperative blood loss. The grading system showed significant inter- and intraobserver agreement (weighted kappa 0.93, and 0.89).Our study presents distinctive, easily recognizable clinico-radiological characteristics of RPOH and confirmed the inter- and intraobserver reliability of the newly proposed grading system.

Using the ionospheric response to the solar eclipse on 20 March 2015 to detect spatial structure in the solar corona.

The total solar eclipse that occurred over the Arctic region on 20 March 2015 was seen as a partial eclipse over much of Europe. Observations of this eclipse were used to investigate the high time resolution (1 min) decay and recovery of the Earth's ionospheric E-region above the ionospheric monitoring station in Chilton, UK. At the altitude of this region (100 km), the maximum phase of the eclipse was 88.88% obscuration of the photosphere occurring at 9:29:41.5 UT. In comparison, the ionospheric response revealed a maximum obscuration of 66% (leaving a fraction, Φ, of uneclipsed radiation of 34±4%) occurring at 9:29 UT. The eclipse was re-created using data from the Solar Dynamics Observatory to estimate the fraction of radiation incident on the Earth's atmosphere throughout the eclipse from nine different emission wavelengths in the extreme ultraviolet (EUV) and X-ray spectrum. These emissions, having varying spatial distributions, were each obscured differently during the eclipse. Those wavelengths associated with coronal emissions (94, 211 and 335 Å) most closely reproduced the time varying fraction of unobscured radiation observed in the ionosphere. These results could enable historic ionospheric eclipse measurements to be interpreted in terms of the distribution of EUV and X-ray emissions on the solar disc.This article is part of the themed issue 'Atmospheric effects of solar eclipses stimulated by the 2015 UK eclipse'.

Open vs robotic radical gastrectomy for locally advanced gastric cancer.

BACKGROUND: This study aims to evaluate the immediate outcomes of robotic and open gastrectomy for patients with locally advanced gastric adenocarcinomas. METHODS: A retrospective analysis was performed on patients undergoing curative intent gastrectomies between 2004 and 2013 in our department. Operative and postoperative outcomes as well as long-term survival data were analysed. RESULTS: Two groups of patients were analysed: the robotic group (n = 18) and the open surgery group (n = 29). Operating time in the robotic group (320.833 ± 85.186 min) was significantly longer (p = 0.0004) as compared with the open group (243.366 ± 57.973 min). The number of retrieved lymph nodes was not statistically different between the two groups (p = 0.108) and neither was the rate of postoperative complications (p = 0.294). CONCLUSIONS: Robotic gastrectomy is a safe procedure, with satisfactory short- and long-term outcomes in locally advanced gastric cancer. Studies on a larger number of patients are necessary in order to confirm whether an immediate benefit in survival exists due to robotic surgery. Copyright © 2015 John Wiley & Sons, Ltd.

Cellular and Kaposi's sarcoma-associated herpes virus microRNAs in sepsis and surgical trauma.

Once a patient is in septic shock, survival rates drop by 7.6% for every hour of delay in antibiotic therapy. Biomarkers based on the molecular mechanism of sepsis are important for timely diagnosis and triage. Here, we study the potential roles of a panel of cellular and viral miRNAs as sepsis biomarkers. We performed genome-wide microRNA (miRNA) expression profiling in leukocytes from septic patients and nonseptic controls, combined with quantitative RT-PCR in plasmas from two cohorts of septic patients, two cohorts of nonseptic surgical patients and healthy volunteers. Enzyme-linked immunosorbent assay, miRNA transfection and chromatin immunoprecipitation were used to study the effects of Kaposi sarcoma herpes virus (KSHV) miRNAs on interleukin's secretion. Differences related to sepsis etiology were noted for plasma levels of 10 cellular and 2 KSHV miRNAs (miR-K-10b and miR-K-12-12*) between septic and nonseptic patients. All the sepsis groups had high KSHV miRNAs levels compared with controls; Afro-American patients had higher levels of KSHV-miR-K12-12* than non-Afro-American patients. Both KSHV miRNAs were increased on postoperative day 1, but returned to baseline on day 7; they acted as direct agonists of Toll-like receptor 8 (TLR8), which might explain the increased secretion of the IL-6 and IL-10. Cellular and KSHV miRNAs are differentially expressed in sepsis and early postsurgical patients and may be exploited for diagnostic and therapeutic purposes. Increased miR-K-10b and miR-K12-12* are functionally involved in sepsis as agonists of TLR8, forming a positive feedback that may lead to cytokine dysregulation.

Bisphosphonate-related osteonecrosis of jaw (BRONJ): diagnostic criteria and possible pathogenic mechanisms of an unexpected anti-angiogenic side effect.

Recently, bisphosphonates (BPs) have been widely used in medical practice as anti-resorptive agents owing to their anti-osteoclatic action. In addition, these compounds are also used for their analgesic action and their potential anti-tumour effect. Patients treated with BPs may subsequently develop osteonecrosis of the jaw or maxillary bone after minor local trauma including dental work, recently labelled as bisphosphonate osteonecrosis of jaw (BRONJ). However, the etiopathogenic mechanisms of this pathological condition are poorly understood. Although, several pathways have been proposed for BRONJ occurrence, no single model can explain all morphological changes observed at the macro- and microscopic level. Recent research suggests that BPs may promote an anti-angiogenic effect which contributes directly to the clinical features associated with BRONJ. Remarkably, the anti-angiogenic effect promoting BRONJ might be in keeping with the anti-neoplastic action of BPs. The current review, presents clinical diagnostic criteria. In addition, based on our own experience we describe the histopathological criteria for diagnosis of BRONJ and the possible pathways which may lead to this frustrating pathological condition.

The value of image-guided intensity-modulated radiotherapy in challenging clinical settings.

OBJECTIVE: To illustrate the wider potential scope of image-guided intensity-modulated radiotherapy (IG-IMRT), outside of the "standard" indications for IMRT. METHODS: Nine challenging clinical cases were selected. All were treated with radical intent, although it was accepted that in several of the cases the probability of cure was low. IMRT alone was not adequate owing to the close proximity of the target to organs at risk, the risk of geographical miss, or the need to tighten planning margins, making image-guided radiotherapy an essential integral part of the treatment. Discrepancies between the initial planning scan and the daily on-treatment megavoltage CT were recorded for each case. The three-dimensional displacement was compared with the margin used to create the planning target volume (PTV). RESULTS: All but one patient achieved local control. Three patients developed metastatic disease but benefited from good local palliation; two have since died. A further patient died of an unrelated condition. Four patients are alive and well. Toxicity was low in all cases. Without daily image guidance, the PTV margin would have been insufficient to ensure complete coverage in 49% of fractions. It was inadequate by >3 mm in 19% of fractions, and by >5 mm in 9%. CONCLUSION: IG-IMRT ensures accurate dose delivery to treat the target and avoid critical structures, acting as daily quality assurance for the delivery of complex IMRT plans. These patients could not have been adequately treated without image guidance. ADVANCES IN KNOWLEDGE: IG-IMRT can offer improved outcomes in less common clinical situations, where conventional techniques would provide suboptimal treatment.

Robotic surgery of locally advanced gastric cancer -- an initial experience.

BACKGROUND: The treatment of gastric cancer is currently based on open gastric resection and regional lymph node dissection. Although the minimally invasive approach is currently being adopted for ever more complex procedures in order to improve post-operative outcomes, the laparoscopic radical D2 gastrectomy has not yet gained a wide acceptance, it being considered one of the most difficult operations in general surgery. Robotic surgery is better than the conventional laparoscopic approach, in that it avoids some of its limitations. Wristed instruments with seven degrees of freedom, the tremor filtering system, the ability to scale motion, and tridimensional vision improve the surgeons' dexterity when a fine manipulation of tissues in a narrow, fixed operating field or handsewn sutures are required. This study will attempt to evaluate the feasibility of robotic total and subtotal gastrectomy for locally advanced gastric cancer. METHODS: Two patients with locally advanced gastric adenocarcinoma underwent robot-assisted gastrectomy with D2 lymph node dissection, with no open or laparoscopic conversion. RESULTS: The post-operative evolution was uneventful and they were both discharged without complications. The number of lymph nodes retrieved was comparable to open surgery. Currently, after a follow-up period of 23 and 26 months respectively, both patients are disease-free. CONCLUSIONS: Robotic surgery can be a simpler way of expanding the indications of minimally invasive surgery so as to include the advanced gastric cancer. However, controlled prospective studies are needed in order to evaluate the role of robotics in the management of gastric cancer.

Stapled esophagojejunal anastomoses: particular aspects of minimally invasive surgery and comparison with manual anastomoses--a single team experience.

BACKGROUND/AIMS: Surgery remains a mainstay of current approaches for the treatment of gastric cancer. Since the introduction of the first mechanical stapling devices, a debate started about whether mechanical staplers or manual suture produce better results. METHODS: 88 patients operated by a single team between January 2004 and November 2011 were included in this study: 14 patients underwent minimally invasive total gastrectomy and 74 patients had an open total gastrectomy. Manual suture anastomoses were performed on 59 patients and stapled anastomoses were done on 29 patients. RESULTS: There were no cases of anastomotic leakage or stenosis for the stapled group. There were 4 cases of anastomotic leakage in the manually suture group. There were no cases of anastomosis related mortality. CONCLUSION: the data support the use of stapled esophagojejunal anastomosis as a safe way to create a esophagojejunal anastomosis, with superior results in term of anastomotic leakage or stenosis to those with hand suturing.

Robotic spleen-preserving distal pancreatectomy. A case report.

Distal pancreatectomy (DP) is the removal of the pancreatic tissue at the left side of the superior mesenteric vein and it is traditionally approached by an open or laparoscopic exposure. Preservation of the spleen is optional but appears to have a better immunological outcome. We present the case of a 53-year old patient with a 2.4/2.2 tumor located in the tail of the pancreas, with high tumour marker values for whom we decided to perform a robotic spleen-preserving distal pancreatectomy (RSPDP). The postoperative outcome was satisfactory. In conclusion, we recommend this type of approach for small pancreatic tail lesions.

[Nonparasitic splenic cysts--therapeutic solutions]. / Chistele splenice neparazitare--solutii terapeutice.

Between 2002-2009, 25 cases of non-parasytic splenic cysts were treated in the Center of General Surgery and Liver Transplantation of Fundeni Clinical Institute. Among these cases, 11 patients were approached classically (8 total splenectomie and 3 partial cystectomies) and 14 patients were operated in a minimally invasive fashion (there were 3 total splenectomies, 2 subtotal splenectomies and 7 partial cystectomies, all accomplished laparoscopically, and one robotic total splenectomy and one robotic subtotal splenectomy). Recurrence rates vary according to the procedure. Laparoscopic partial cystectomy is a safe and feasible method, with minimal morbidity but with higher recurrence rates. The treatment of choice is the minimally invasive ideal cystectomy, achieved by laparoscopic partial splenectomy, that has the benefits of preserving the immune function of the spleen.

Vascular endothelial growth factor, lipoporotein-associated phospholipase A2, sP-selectin and antiphospholipid antibodies, biological markers with prognostic value in pulmonary hypertension associated with chronic obstructive pulmonary disease and systemic lupus erithematosus.

OBJECTIVE: Pulmonary arterial hypertension (PH) is a progressive disease with a poor prognosis that ultimately leads to right ventricular failure and death. The pathogenesis of severe PH seems to be related to inflammatory responses and coagulation disturbances. Many diseases can develop PH in their course, thus aggravating their outcome. The objective was to investigate the values of vascular endothelial growth factor (VEGF), sP-selectin, lipoprotein-associated phospholipase A2 (PLA2-LDL), antiphospholipid antibodies (APLA) and their relation with PH, in systemic lupus erythematosus (SLE) and chronic obstructive pulmonary disease (COPD), two conditions in which the occurrence of PH is frequent. DESIGN: Prospective clinical study. SETTING: A University Department of Internal Medicine, a National Institute of Research. PATIENTS: 30 SLE patients (15 patients without PH (group I) and 15 patients with PH group II)), 30 patients with COPD (15 patients without PH (group III) and 15 patients with PH (group IV)) and 10 healthy controls, selected by clinical, immunological, echocardiographical criteria and pulmonary functional tests. MAIN OUTCOME MEASURES: VEGF, sP-selectin and PLA2-LDL level in plasma and presence of antiphospholipids antibodies (lupus anticoagulant, anticardiolipin and anti beta2 GPI) in plasma. - RESULTS: In patients with PH, the values of VEGF were significantly increased [group II (1023.1) and IV (904.3)] compared with group I (744.2), III (356.4), and controls (330.3). The values of sP-selectin in group II (9.7), and IV (10.4) were also increased compared with controls (6). APLA were present in all patients in group II (100%), and in 8 patients in group IV (53%), while in the other groups the frequency was low (33% group I and 13% group III). PLA2-LDL activity was higher in group II (429.1) and group IV (394.5) than in group I (317.8), group III (343.2) and controls (256.3). CONCLUSION: PH is a severe complication in COPD and SLE. The increased values of VEGF, PLA2-LDL and P-selectin in patients with long standing PH are related to severe endothelial dysfunction and may have prognostic values. APLA may have pathogenic value in SLE patients with PH. APLA are possibly implicated in the pathogenesis of PH in these diseases. VEGF, APLA and sP-selectin may constitute new therapeutic targets for PH.

Laparoscopic subtotal splenectomy in hereditary spherocytosis : to preserve the upper or the lower pole of the spleen?

BACKGROUND: Clinical manifestations of hereditary spherocytosis can be controlled by splenectomy. The use of this procedure has been restricted due to concerns regarding exposure of patients to a lifelong risk of overwhelming infections. Subtotal splenectomy, which removes 85-90% of the enlarged spleen, is a logical alternative. In the first cases performed by laparoscopy we have chosen to preserve the upper pole. However, this technique showed some disadvantages, especially concerning the correct intraoperative evaluation of the splenic remnant volume. Therefore, we developed a new variant of the procedure by preserving the lower pole of the spleen. METHODS: Based on the authors' experience in laparoscopy (176 laparoscopic splenectomies), 10 laparoscopic subtotal splenectomies were performed in patients with hereditary microspherocytosis, preserving either the upper or the lower splenic pole. RESULTS: Patient age ranged between 5 and 35 years. The mean volume of the remnant spleen was 41.4 cm3. There were no complications, and no transfusions were needed. Follow-up for 1-30 months was available. CONCLUSIONS: Subtotal splenectomy appears to control hemolysis while maintaining splenic function. The laparoscopic approach is safe and effective and should be considered the procedure of choice in hereditary microspherocytosis. Laparoscopic subtotal splenectomy presents an advantage over open subtotal splenectomy, resulting in decreased blood loss, shorter hospital stay, no conversions, fewer operative and postoperative complications, and excellent remission rates. On the basis of our experience, the preservation of the lower pole of the spleen seems to be a first-line option for the optimal evaluation of the residual splenic mass.

[Colonic angiodysplasia in a chronic renal failure patient]. / Angiodisplazie colonica asociata cu insuficientai renala cronica.

An important cause of intestinal bleeding in patients with chronic renal failure is angiodysplasia. In retrospective reports up to 19-32% of patients had bleeding from angiodysplastic lesions. These are usually multiple, have a high tendency of rebleeding (25-47%) and are often located in the stomach and duodenum, but can affect the colon and the jejunum as well. Bleeding from angiodysplastic lesions is usually low grade and stops spontaneously in more than 90% of patients, but some times may be life threatening necessitate therapeutic interventions to achieve hemostasis. We report a case of an 18-year old female with renal failure on CAPD who presented a massive lower gastrointestinal bleeding and imposed emergency surgery.

[Frey operation--valuable alternative in the surgical treatment of chronic pancreatitis]. / Operatia Frey--o solutie de rezerva în chirurgia pancreatitei cronice.

The "golden standard" of the surgical treatment of chronic pancreatitis with an inflammatory mass in the head of the pancreas seems to be the duodenum preserving resection of the head of the pancreas as described by Beger. However, in some cases, the inflammatory process may induce an encasement of the retropancreatic intestinal vessels making the dissection of the portal vein very difficult. The local resection of the head of the pancreas combined with longitudinal pancreaticojejunostomy (Frey operation) was developed in order to provide a simple and less time consuming procedure, that avoids the dissection of the portal vein and is especially indicated in cases with severe inflammatory and edematous alterations of the head of the pancreas at this level and with dilated pancreatic duct. Two patients with chronic pancreatitis with severe pain, addiction to analgesics and weight loss underwent a Frey procedure. In both patients an inflammatory mass in the head of the pancreas and dilated pancreatic duct were demonstrated. The freeing of the head of the pancreas from the portal vein was not possible because of the intense inflammatory process. The local resection of the pancreatic head and the longitudinal pancreatico-jejunostomy was successfully performed. There were no postoperative mortality or morbidity and the short and long term results (pain relief and nutritional status) are excellent.

Incidence and progression of diabetic retinopathy in Hispanics and non-Hispanic whites with type 2 diabetes. San Luis Valley Diabetes Study, Colorado.

OBJECTIVE: To learn if Hispanic people with type 2 diabetes have excess incidence and/or progression of diabetic retinopathy and to explore the association of risk factors with diabetic retinopathy. RESEARCH DESIGN AND METHODS: There were 244 subjects with type 2 diabetes (65.3% Hispanic) with at least one follow-up visit between 1984 and 1992 examined for the development of retinopathy over a median of 4.8 years (range 2.0-6.6 years). Stereo fundus photos were graded by the University of Wisconsin Reading Center. RESULTS: Of the 169 subjects without retinopathy at baseline, 47 developed some retinopathy, an incidence rate of 63.7 per 1,000 person-years (PY), or a 4-year cumulative incidence of 22.5%. The Hispanic incidence rate was 58.3/1,000 PY (95% CI: 39.4-83.3), which was lower than among non-Hispanic whites, 76.1/1,000 PY (44.3-121.9). Progression occurred in 24 of the 75 subjects with retinopathy at baseline, a 4-year cumulative rate of 24.1%. Logistic regression showed that insulin treatment was associated with higher risk of any retinopathy (odds ratio [OR] = 8.45, 2.65-26.97), and both systolic blood pressure (odds ratio [OR] = 1.58, 0.99-2.52) and total GHb (OR = 1.46, 0.99-2.17) nearly attained statistical significance. After adjustment for multiple potential risk factors, the Hispanic/non-Hispanic white OR was 0.66 (0.28-1.57). CONCLUSIONS: No excess risk for incident retinopathy was found among Hispanic compared with non-Hispanic white subjects in this population. These results are consistent with our previously reported prevalence data from the same population but differ from reports of excess prevalence among Texas Hispanics. No other Hispanic incidence data are available to assist in reconciling this difference.

Construction of single amino acid substitution mutants of cloned Bacillus stearothermophilus DNA polymerase I which lack 5'-->3' exonuclease activity.

Two individual amino acid substitutions were engineered at a selected site in the 5' --> 3' exonuclease domain of the cloned Bacillus stearothermophilus DNA polymerase I gene. These mutations resulted in the expression of enzymes lacking the 5' --> 3' exonuclease activity while maintaining normal polymerizing activity. The mutated and non-mutated enzymes were each constitutively expressed in an Escherichia coli host without the use of an exogenous or inducible promoter, and the mutated enzymes were demonstrated to be equivalent to the subtilisin large fragment of the native holoenzyme in sequencing reactions.

Comparative study of the treatment with tetracyclic and tricyclic antidepressants in patients with minor depressive disorders.

One hundred and twenty-nine cases with depression were submitted to a comparative therapeutic study, using a flexible treatment administration: mianserin 30-60 mg and imipramine 50-150 mg. The mean dosages were 43.6 mg of mianserin and 62 mg/day of imipramine. Twenty-nine patients were excluded from the study, the rest constituting 2 equal groups of 50 cases each. The study covered a period of 4 weeks. After this period, almost 40% of the cases were discharged due to their obvious improvement. The significant benefits of mianserin were evident in the 7th and in the 21st day of the study on HDRS for the total score and in the 7th day on HDRS for the anxiety-somatization score. The superiority of mianserin was also obvious due to the total score on Lipmann-Rickels' scale as well as for the general neurotic symptoms. No statistically significant differences between mianserin and imipramine for the antidepressive efficacy were observed by the end of the study. A greater number of secondary effects was noticed in the group treated with imipramine. It seems that mianserin was a better therapy for this category of psychic patients, especially for older cases, probably due to the anxiolytic influence and to a lower incidence of side-effects.

Preclinical trials using an immunoconjugate of T101 and methotrexate in an athymic mouse/human T-cell tumor model.

We made an immunoconjugate (IC) using the anti-CD5 monoclonal antibody T101 and the chemotherapeutic drug methotrexate. Methotrexate was conjugated to T101 using an active ester intermediate, yielding a drug: antibody molar ratio of 12.4. Although T101 immunoreactivity was not significantly altered by conjugation, the IC did not demonstrate antigen-specific cytotoxicity in vitro. Methotrexate activity, assayed in vitro, decreased approximately 100-fold following conjugation. The IC was tested for in vivo efficacy in athymic mice bearing human T-cell (MOLT 4) xenografts. Experimental arms used in the study included i.p. injections of saline, T101, methotrexate, the IC, and a mixture of T101 and methotrexate. Doses ranged from 500 micrograms T101 (17.5 micrograms methotrexate) to 2 mg T101 (70 micrograms methotrexate). Injections were administered only after palpable tumors were established. In experiments at all doses, totaling 66 animals per arm, injection of the IC significantly inhibited tumor growth, and resulted in more tumor regressions and fewer animal deaths than the other four experimental arms. These data demonstrate that the IC promotes a potential advantage over the use of methotrexate through an increase in the therapeutic index.