The Role of Cytokines and Molecular Pathways in Lung Fibrosis Following SARS-CoV-2 Infection: A Physiopathologic (Re)view.

SARS-CoV-2 infection is a significant health concern that needs to be addressed not only during the initial phase of infection but also after hospitalization. This is the consequence of the various pathologies associated with long COVID-19, which are still being studied and researched. Lung fibrosis is an important complication after COVID-19, found in up to 71% of patients after discharge. Our research is based on scientific articles indexed in PubMed; in the selection process, we used the following keywords: "lung fibrosis", "fibrosis mediators", "fibrosis predictors", "COVID-19", "SARS-CoV-2 infection", and "long COVID-19". In this narrative review, we aimed to discuss the current understanding of the mechanisms of initiation and progression of post-COVID-19 lung fibrosis (PC-19-LF) and the risk factors for its occurrence. The pathogenesis of pulmonary fibrosis involves various mediators such as TGF-ß, legumain, osteopontin, IL-4, IL-6, IL-13, IL-17, TNF-α, Gal-1, Gal-3, PDGF, and FGFR-1. The key cellular effectors involved in COVID-19 lung fibrosis are macrophages, epithelial alveolar cells, neutrophils, and fibroblasts. The main fibrosis pathways in SARS-CoV-2 infection include hypoxemia-induced fibrosis, macrophage-induced fibrosis, and viral-fibroblast interaction-induced fibrosis.

Minimally invasive surgery for gastro-oesophageal junction adenocarcinoma: Current evidence and future perspectives.

Minimally invasive surgery is increasingly indicated in the management of malignant disease. Although oesophagectomy is a difficult operation, with a long learning curve, there is actually a shift towards the laparoscopic/thoracoscopic/ robotic approach, due to the advantages of visualization, surgeon comfort (robotic surgery) and the possibility of the whole team to see the operation as well as and the operating surgeon. Although currently there are still many controversial topics, about the surgical treatment of patients with gastro-oesophageal junction (GOJ) adenocarcinoma, such as the type of open or minimally invasive surgical approach, the type of oesophago-gastric resection, the type of lymph node dissection and others, the minimally invasive approach has proven to be a way to reduce postoperative complications of resection, especially by decreasing pulmonary complications. The implementation of new technologies allowed the widening of the range of indications for this type of surgical approach. The short-term and long-term results, as well as the benefits for the patient - reduced surgical trauma, quick and easy recovery - offer this type of surgical treatment the premises for future development. This article reviews the updates and perspectives on the minimally invasive approach for GOJ adenocarcinoma.

Pregnancy and Gastric Cancer: A Narrative Review.

Cases of digestive cancers diagnosed during pregnancy are rare. The increasing prevalence of pregnancy in women aged 30-39 years (and not exceptionally 40-49 years) could explain the frequent co-occurrence of cancers and pregnancy. The diagnosis of digestive cancers in pregnancy is difficult due to the overlap between neoplasm symptomatology and the clinical picture of pregnancy. A paraclinical evaluation may also be difficult depending on the trimester of the pregnancy. Diagnosis is also delayed by practitioners' hesitation to use invasive investigations (imaging, endoscopy, etc.) due to fetal safety concerns. Therefore, digestive cancers are often diagnosed during pregnancy in advanced stages, where complications such as occlusions, perforations, and cachexia have already arisen. In this review, we highlight the epidemiology, clinical aspects, paraclinical evaluation, and particularities of the diagnosis and treatment of gastric cancer during pregnancy.

Esophageal diverticula: from diagnosis to therapeutic management-narrative review.

Background and Objective: Esophageal diverticulum (ED) is a relatively rare condition, characterized by high etio- and pathophysiological versatility, with an uncommon clinical impact, consequently requiring a complete and complex diagnostic evaluation, so that the therapeutic decision is "appropriate" to a specific case. The aim of the paper is, therefore, a reassessment of the diagnostic possibilities underlying the establishment of the therapeutic protocol and the available therapeutic resources, making a review of the literature, and a non-statistical retrospective analysis of cases hospitalized and operated in a tertiary center. Methods: Thus, classical investigations (upper digestive endoscopy, barium swallow) need to be correlated with complex, manometric, and imaging evaluations with direct implications in therapeutic management. Moreover, in the absence of a precise etiology, the operative indication needs to be established sparingly, with the imposition of the identification and interception of the pathophysiological mechanisms through the therapeutic gesture. Key Content and Findings: The identification of the pathophysiological mechanisms is mandatory for the management of diverticular disease, the result obtained-restoring swallowing and comfort/good quality of life in the postoperative period-is directly related to the chosen therapeutic procedure. In addition, management appears to be a difficult goal in the context of the low incidence of ED but also of the results that emphasize important differences in the reports in the medical literature. Although ED is a benign condition, surgical techniques are demanding, impacted by significant morbidity and mortality. The causes of these results are multiple: possible localizations anywhere in the esophagus, diverticulum size/volume from a few millimeters to an impressive one, over 10-12 cm, metabolic impact in direct relation to the alteration swallowing, numerous diverticular complications but, perhaps most importantly, alteration of the quality of the diverticular wall by inflammatory phenomena, with an impact on the quality of the suture. Conclusions: The accumulation of cases in a tertiary profile center, with volume/hospital, respectively volume/surgeon + gastroenterologist could be a solution in improving the results. One consequence would be the identification of alternative solutions to open surgical techniques, a series of minimally invasive or endoscopic variants can refine these results.

Giant Gallbladder Tumor, Unusual Cancer-Case Report and Short Review of Literature.

BACKGROUND: Giant gallbladder is an uncommon condition that can result from a benign pathology and rarely presents with malignancy. Intracholecystic papillary-tubular neoplasm (ICPN) is a relatively new entity first described by V. Adsay in 2012 and included in the World Health Classification of Digestive System Tumours in 2019. Intracholecystic papillary-tubular neoplasm is a preinvasive lesion with an incidence of around 1% that may present as four histologic subtypes-biliary, gastric, intestinal, or oncocytic-of which the biliary subtype has the highest risk of associated invasive cancer. Although invasive carcinoma is present in about 50% of cases of ICPN, these patients have a significantly better prognosis than those with usual gallbladder cancer, suggesting that the entities may have distinct biological signatures. CASE REPORT: A 77-year-old female presented to the hospital with progressive swelling in the right hemiabdomen, a loss of appetite, and weight loss. MRI highlighted a giant abdominal tumor located in the right hypochondrium and right abdominal flank with liver invasion (segment V). Preoperatively, a gallbladder 25 × 17 cm in size was noted, and the patient underwent radical cholecystectomy. It was surprising to find such a giant malignant gallbladder tumor, diagnosed as invasive poorly cohesive carcinoma associated with ICPN. DISCUSSION: A megacholecyst is a rare discovery. Although most often found in benign pathologies, giant gallbladder cancer can be considered. The neoplastic features and the loco-regional extension of the tumor must be evaluated by imaging scans. Few cases of giant benign gallbladder have been reported in the literature; however, this appeared to be the largest resectable gallbladder carcinoma reported to date according to the literature. CONCLUSION: The stage of gallbladder neoplasia is not correlated with the size of the gallbladder. Regardless of tumor size, the prognosis seems to be directly related to the stage, morphology, and resectability.

Rare Diaphragmatic Hernias in Adults-Experience of a Tertiary Center in Esophageal Surgery and Narrative Review of the Literature.

A rare entity of non-hiatal type transdiaphragmatic hernias, which must be clearly differentiated from paraoesophageal hernias, are the phrenic defects that bear the generic name of congenital hernias-Bochdalek hernia and Larey-Morgagni hernia, respectively. The etiological substrate is relatively simple: the presence of preformed anatomical openings, which either do or do not enable transit from the thoracic region to the abdominal region or, most often, vice versa, from the abdomen to the thorax, of various visceral elements (spleen, liver, stomach, colon, pancreas, etc.). Apart from the congenital origin, a somewhat rarer group is described, representing about 1-7% of the total: an acquired variant of the traumatic type, frequently through a contusive type mechanism, which produces diaphragmatic strains/ruptures. Apparently, the symptomatology is heterogeneous, being dependent on the location of the hernia, the dimensions of the defect, which abdominal viscera is involved through the hernial opening, its degree of migration, and whether there are volvulation/ischemia/obstruction phenomena. Often, its clinical appearance is modest, mainly incidental discoveries, the majority being digestive manifestations. Severe digestive complications such as strangulation, volvus, and perforation are rare and are accompanied by severe shock, suddenly appearing after several non-specific digestive prodromes. Diagnosis combines imaging evaluations (plain radiology, contrast, CT) with endoscopic ones. Surgical treatment is recommended regardless of the side on which the diaphragmatic defect is located or the secondary symptoms due to potential complications. The approach options are thoracic, abdominal or combined thoracoabdominal approach, and classic or minimally invasive. Most often, selection of the type of approach should be made taking into account two elements: the size of the defect, assessed by CT, and the presence of major complications. Any hiatal defect that is larger than 5 cm2 (the hiatal hernia surface (HSA)) has a formal recommendation of mesh reinforcement. The recurrence rate is not negligible, and statistical data show that the period of the first postoperative year is prime for recurrence, being directly proportional to the size of the defect. As a result, in patients who were required to use mesh, the recurrence rate is somewhere between 27 and 41% (!), while for cases with primary suture, i.e., with a modest diaphragmatic defect, this is approx. 4%.

The Features of Stomach Vascularisation Pattern and Their Impact on Oesophageal Reconstruction with a Gastric Pull-up.

Regardless of the reconstruction surgery used, the fundamental concepts of visceral reconstruction are based on the vascular support needed for the substituting graft. The vascular factor is the main element of any reconstruction technique, as an underlying condition for the visceral material stretch and, along with other factor, for the suture safety. In the case of the stomach, a consistent vascular flow and the minimal vascular anatomy variations are the first theoretical argument. A second argument is based on the intraparietal vascular network features allowing for supplementing visceral perfusion as the blood flow is stopped in one or more pediculi. Graft hypoperfusion is, however, a potential cause of failure, and the most frequently invoked complication is, therefore, a high risk of anastomosis fistulae. A series of modern techniques - arteriography data for the pre-operative vascular reconstruction or Doppler laser fluorometry intraoperative assessments, graft oximetry, laser speckle (spot) scan or the use of indocyanine green staining (ICG) - represent methods of early determination of the gastric graft perfusion/microperfusion quality used in reducing such risks. The doubts regarding the gastric perfusion mandate the use of vascular augmentation techniques. If such techniques are not used, the final outcome is uncertain and difficult to correct.

Management of Chylothorax in Esophageal Surgery by Minimally Invasive Thoracoscopic Approach: Case Series.

Chylothorax is a rare complication, especially after esophageal cancer surgery. It may occur mainly in the thoracic stage of esophagectomy. The management of chylothorax is usually conservative, surgical reoperation with thoracic duct ligation being reserved for those cases refractory to that treatment. We discuss issues of diagnosis and therapeutic attitude, as evidenced by the literature, although a general consensus has not been established, most likely due to the low frequency of this complication. We emphasize the minimally invasive thoracoscopic approach, as it has been applied for two cases with this type of complication. A high rate of suspicion for thoracic duct injury should be maintained in all patients after esophageal surgery, with any pleural effusion entering the differential diagnosis of chylothorax.

Pollution and Weather Reports: Using Machine Learning for Combating Pollution in Big Cities.

Air pollution has become the most important issue concerning human evolution in the last century, as the levels of toxic gases and particles present in the air create health problems and affect the ecosystems of the planet. Scientists and environmental organizations have been looking for new ways to combat and control the air pollution, developing new solutions as technologies evolves. In the last decade, devices able to observe and maintain pollution levels have become more accessible and less expensive, and with the appearance of the Internet of Things (IoT), new approaches for combating pollution were born. The focus of the research presented in this paper was predicting behaviours regarding the air quality index using machine learning. Data were collected from one of the six atmospheric stations set in relevant areas of Bucharest, Romania, to validate our model. Several algorithms were proposed to study the evolution of temperature depending on the level of pollution and on several pollution factors. In the end, the results generated by the algorithms are presented considering the types of pollutants for two distinct periods. Prediction errors were highlighted by the RMSE (Root Mean Square Error) for each of the three machine learning algorithms used.

Idiopathic Megacolon-Short Review.

INTRODUCTION: Idiopathic megacolon (IM) is a rare condition with a more or less known etiology, which involves management challenges, especially therapeutic, and both gastroenterology and surgery services. With insufficiently drawn out protocols, but with occasionally formidable complications, the condition management can be difficult for any general surgery team, either as a failure of drug therapy (in the context of a known case, initially managed by a gastroenterologist) or as a surgical emergency (in which the diagnostic surprise leads additional difficulties to the tactical decision), when the speed imposed by the severity of the case can lead to inadequate strategies, with possibly critical consequences. METHOD: With such a motivation, and having available experience limited by the small number of cases (described by all medical teams concerned with this pathology), the revision of the literature with the update of management landmarks from the surgical perspective of the pathology appears as justified by this article. RESULTS: If the diagnosis of megacolon is made relatively easily by imaging the colorectal dilation (which is associated with initial and/or consecutive clinical aspects), the establishing of the diagnosis of idiopathic megacolon is based in practice almost exclusively on a principle of exclusion, and after evaluating the absence of some known causes that can lead to the occurrence of these anatomic and clinical changes, mimetically, clinically, and paraclinically, with IM (intramural aganglionosis, distal obstructions, intoxications, etc.). If the etiopathogenic theories, based on an increase in the performance of the arsenal of investigations of the disease, have registered a continuous improvement and an increase of objectivity, unfortunately, the curative surgical treatment options still revolve around the same resection techniques. Moreover, the possibility of developing a form of etiopathogenic treatment seems as remote as ever.

The Țigani Community Adaptability to Changes in Rural Romania and the COVID-19 Impact.

Romanian rural villages are struggling to survive present times when youngsters leave for a better life in the city while elders work the land like a hundred years ago. Our paper integrates human environments research with public health preparedness, presenting the Țigani (Gypsy/Roma) ethnic group from rural Romania as an example to the world. The future security of mankind will require a new understanding of the human place in its environment. That will lead to a new society, not the most powerful or intelligent, but the one that is more adaptable to changes, with sensitive and interconnected community members. Therefore, the Țigani ethnic group that fought for its rights and flourished despite unfavorable odds, including the recent COVID-19 pandemic, represents the best example for a new world that prioritizes humans, promotes health and wellbeing, facilitating innovation and transformative networks environmental integration. This research attempts to quantify the Țigani's unique attributes that helped their communities survive and made them more adaptive to change. Always marginalized, they identified the other ethnic groups' weaknesses to penetrate the villages and learned to use the smartphone apps to communicate, for their trades, coppersmith, metal roof tiles and drainage systems. Our research was based on Geographical Information System, Microsoft Power Bi analytics data visualization tools and statistical analysis with SPSS V20 to demonstrate what enables their flourishing and what resistance they face locally. We argue that the Țigani's intense social cooperation, strong sense of family, community and mutual assistance helped them to fight COVID-19, generating their significant adaptability to the societal changes and their power to keep intact their cultural identity. The results show how the constant growing Țigani population changed and may change Romania's rural environments in the future.

Palliative ("Toilet") Mammectomy, A Decision-Making Dilemma - Short Review.

Breast cancer is one of the most severe health issues globally, but the therapy advancements and the constant adaptation of treatment protocols radically changed its prognoses. This article review of the literature from a surgical perspective, thus allowing for the optimum detection and placement of its role and benefits in the surgical and oncology therapeutics. The role of surgery becomes controversial, with sometimes "pretentious" techniques, hard to quantify benefits and challenges that require a thorough assessment prior to opting for surgery. Another interesting aspect is the relative lack of guidelines for such cases with an extreme lesion plurimorphism. This is the very reason for the term "advanced breast cancer" NOT covering all possible situations, leaving room for niches difficult to frame within a therapy plan.

On the propagation of waves in the atmosphere.

The leading-order equations governing the unsteady dynamics of large-scale atmospheric motions are derived, via a systematic asymptotic approach based on the thin-shell approximation applied to the ellipsoidal model of the Earth's geoid. We present some solutions of this single set of equations that capture properties of specific atmospheric flows, using field data to choose models for the heat sources that drive the motion. In particular, we describe standing-waves solutions, waves propagating towards the Equator, equatorially trapped waves and we discuss the African Easterly Jet/Waves. This work aims to show the benefits of a systematic analysis based on the governing equations of fluid dynamics.

Pregnancy and Colorectal Cancer, from Diagnosis to Therapeutical Management - Short Review.

Colorectal cancer (CRC) is one of the most common human malignancies, affecting one of 20 persons in areas with high socio-economic standard but cases of digestive cancers during pregnancy are rare. From an etiological point of view, CRC represents an entity induced on the one hand by environmental factors and on the other hand by genetic factors or, not rarely, by their combination. The difficulty of diagnosing digestive cancers in pregnancy is the consequence of a symptomatology often masked by signs and symptoms that can be attributed to pregnancy. Essential in terms of assessing the staging of TNM in CRC, CT remains the subject of numerous debates. Over the last 40 years CT has been contraindicated in pregnant women due to teratogenic and carcinogenic effects on the fetus. Pregnancy MRI method is preferable to any other method of investigation that uses ionizing radiation. The CRC's treatment plan must take into account the interests of two people, the mother and the fetus, so that the "interest" of one does not affect the other, respecting an axiom: for the mother, treatment as soon as possible after birth, respectively, for the foetus, delaying the therapy until it is viable. Colorectal neoplasia is, in generally, a predominantly surgical pathology at the time of disease discovery, especially in conditions of a major complication that leaves no time for a therapeutic alternative (obstruction, perforation, significant bleeding). A chemotherapy-type oncology protocol option is preferred for cases with advanced, metastatic neoplasms.

A transformation between stationary point vortex equilibria.

A new transformation between stationary point vortex equilibria in the unbounded plane is presented. Given a point vortex equilibrium involving only vortices with negative circulation normalized to -1 and vortices with positive circulations that are either integers or half-integers, the transformation produces a new equilibrium with a free complex parameter that appears as an integration constant. When iterated the transformation can produce infinite hierarchies of equilibria, or finite sequences that terminate after a finite number of iterations, each iteration generating equilibria with increasing numbers of point vortices and free parameters. In particular, starting from an isolated point vortex as a seed equilibrium, we recover two known infinite hierarchies of equilibria corresponding to the Adler-Moser polynomials and a class of polynomials found, using very different methods, by Loutsenko (Loutsenko 2004 J. Phys. A: Math. Gen. 37, 1309-1321 (doi:10.1088/0305-4470/37/4/017)). For the latter polynomials, the existence of such a transformation appears to be new. The new transformation, therefore, unifies a wide range of disparate results in the literature on point vortex equilibria.

Geosystems' Pathways to the Future of Sustainability.

The world's future development depends on effective human-computer linkages. From local to global, the virtual illustrations of a geographical place have to emphasize in an integrative approach peoples' key position in the Geosystem. Human values and social networks are now empowered by the unlimited creativity of smartphone applications. Our Geosystem grounded theory envisions that the sustainable management of natural resources is a lifelong learning environment where the poor communities have access to the new technological advances. This paper will attempt to show the effectiveness of Geomedia techniques in the Geosystems identification, evaluation, and valorization processes for the benefit of local inhabitants. This present research methodology uses smartphone apps, Google Earth environmental datasets, Global Positioning Systems, and WebGIS for a geographical investigation and objective assessment of regions throughout the world. The results demonstrate that self-sustainable Geosystems will always be capable to regulate, control and assess progress towards their dynamic equilibrium state, continuously adapting to environmental and societal changes.

The Value of Intraoperative Endoscopy and Manometry in the Surgical Treatment of Achalasia.

Introduction: Achalasia is the most common esophageal motility disorder. So far, the treatment, which can be medical, endoscopic or surgical, provides only symptomatic relief. However, this can grant a normal life to the patients. We focused our study on the value of pre- and intraoperative endoscopy and manometry for improving outcome of surgical treatment. MATERIAL AND METHOD: This is a retrospective chart review of a cohort of patients diagnosed with achalasia at St Mary Clinical Hospital, Bucharest between 2013 and 2017. The objective of this study was the assessment of the immediate and long term efficacy of laparoscopic Heller myotomy associated with Dor anterior fundoplication, intraoperative endoscopy and intraoperative manometry, as well as the assessment of late post-operative complications. The diagnosis of achalasia was based on symptoms, barium esophagogram, upper endoscopy and esophageal manometry. The immediate efficacy was assessed by comparing Eckhart score, LES pressure and LES vector volume before and after surgery. Results: In total, 47 patients, had surgical treatment for achalasia between 2013 and 2017. For 7 patients who failed prior endoscopic or surgical, this was the second therapeutic intervention. 39 patients underwent laparoscopic surgery, 30 patients had associated intraoperative endoscopy and, 22 patients had associated intraoperative manometry. There was a significant improvement in mean Eckardt score (from 6,5 to 1,26, p 0,001), mean LES pressure (from 18,5 mmHg to 7 mmHg, p 0,001). Morbidity was 2,12 % and we have had 1 recurrence and 2 postoperative esophagitis. Conclusions: At present, laparoscopic Heller myotomy with an anterior Dor fundoplication, is a standard indication in achalasia, proving its efficiency and safety. Intraoperative use of endoscopy is recommended and intraoperative manometry may provide additional information on the effectiveness of myotomy. Surgical treatment of achalasia should be performed in specialized, experienced centers.

Early Postoperative Complications of Thoracic Esophageal Diverticula: A Review of 10 Cases from "Saint Mary" Hospital, Bucharest, Romania.

Introduction: Thoracic esophageal diverticulum is a rare pathology frequently associated with esophageal motility disorders. Surgery is the only option in patients with severe symptoms. METHOD: This is a retrospective case series study of 10 patients who underwent diverticulectomy for thoracic (epiphrenic or mid-esophageal) diverticula. It was recorded: main preoperative symptoms, usual blood tests, barium swallow, upper endoscopy and esophageal manometry. We analyzed the postoperative complications, length of stay in hospital and intensive care unit. Results: Most patients presented with regurgitation and/or dysphagia. The surgical approach was through left thoracotomy or abdominal for epiphrenic diverticula and through right thoracotomy or thoracoscopy for mid-esophageal diverticula. 4 patients had severe complications: 3 had major leaks (one death) and one had chylothorax. DISCUSSIONS: Surgery for thoracic diverticula is associated with high mortality and morbidity rates. Leak from the suture line is the most common complication, unlike chylothorax which is a rare complication. Conclusions: Thoracic diverticula represent a benign pathology which can have "žmalignant" postoperative complications. A thorough preoperative work-up is mandatory for choosing the appropriate surgical technique. Use of multiple cartridges for stapling suture increase the risk of leakage, but oversewing the suture may diminish it.

Use of the Stomach in Esophageal Reconstructive Surgery in Era of Minimally Invasive Approach.

Esophagectomy is standard indication for surgical treatment of resectable esophageal cancer, but it can also be performed for the management of benign conditions. Esophagectomy is followed by esophageal reconstruction using other parts of the digestive tract and is associated with increased postoperative morbidity and mortality. Gastric interposition with intrathoracic or cervical esophago- gastric anastomosis is currently the preferred technique for reconstruction after esophagectomy. The incidence of esophagectomy performed by the minimal invasive approach has increased in recent years due to the advanced technology of endoscopic surgery and image enhancement that provides a better estimate of anatomical plans, facilitates access to narrow spaces and more precise dissection with less tissue trauma. Randomized clinical trials have found a significant reduction in postoperative respiratory complications, decreased hospital stay and equivalent oncological results to open esophagectomy. We present the operative technique of minimally invasive esophagectomy performed in our clinic by three-stage modified McKeown approach thoracoscopic, laparoscopic and cervical with esophageal reconstruction with stomach.

Dedifferentiated Liposarcoma of Sigmoid Mesocolon - A Case Report.

Dedifferentiated liposarcoma is a liposarcoma that contains a well-differentiated liposarcoma component juxtaposed to areas of high-grade non-lipogenic sarcoma and was believed to occur from well-differentiated liposarcoma after several years. Dedifferentiated liposarcoma most commonly occurs in the retroperitoneum, while an intraperitoneal location is extremely rare, only seven cases have been reported in literature. Many pathologists recognize that a large number of intra-abdominal poorly differentiated sarcomas are dedifferentiated liposarcomas. We present the case of a 73 years old patient known with multiple cardiovascular comorbidities, stroke sequelae and a large abdominal mass evolving for 3 years. He was referred to our clinic for abdominal pain and bowel disorders. Instead of all clinical and imagistic aspects suggested a gastrointestinal stromal tumour, the histological exam revealed the diagnosis of a dedifferentiated liposarcoma.