Trace Element Deficiency in Systemic Sclerosis-Too Much Effort for Some Traces?

Trace elements are essential for several physiological processes. To date, various data have suggested that inadequate levels of trace elements may be involved in the pathogenesis of different chronic diseases, including immune-mediated ones, or may develop during their course. Systemic sclerosis (SSc) is a complex autoimmune multisystemic disease, primarily characterized by microvascular dysregulation, the widespread activation of the immune system and tissue fibrosis. According to the latest reports regarding the pathogenesis of SSc, the main pathophysiological processes-inflammation, vasculopathy and fibrosis-may include various trace element derangements. The present literature review aims to update the available data regarding iron, zinc, copper and selenium status in SSc as well as to underline the possible implications of these trace elements in the complexity of the pathogenic process of the disease. We observe that the status of trace elements in SSc plays a crucial role in numerous pathogenic processes, emphasizing the necessity for proper monitoring and supplementation. The reported data are heterogenous and scarce, and future studies are needed in order to draw clearer conclusions about their complete spectrum.

Giant Myxofibrosarcoma in the Lower Limb: An Overview of Diagnostic and Clinical Management.

Myxofibrosarcoma (MFS), an aggressive soft tissue sarcoma, is one of the undifferentiated pleomorphic sarcomas; it has a low incidence, affecting people in the sixth to eighth decades of life. It usually involves the extremities and is painless with a slow-growing pattern. Based on the case of a 52-year-old female patient who presented with a painful, massive, rapid-growing, ulcerated tumor of the anterior surface of the left thigh, we performed a literature review regarding the current standard of care for patients with MFS. Computed tomography examination, followed by magnetic resonance imaging and surgical biopsy with histopathological examination, confirmed the diagnosis and the presence of lung and inguinal lymph node metastases. Due to the rapid-growing pattern and the local aggressiveness, our tumor board team recommended emergency excisional surgery, with subsequent reconstructive procedures followed by referral to an oncological center. This review emphasizes the importance of proper and rapid diagnosis, followed by multidisciplinary management, for MFS cases with atypical presentation and distal metastases to improve overall outcomes.

Mechanical Properties and Liquid Absorption of Calcium Phosphate Composite Cements.

Calcium phosphate cements present increased biocompatibility due to their chemical composition being similar to that of the hydroxyapatite in the hard tissues of the living body. It has certain limitations due to its poor mechanical properties, such as low tensile strength and increased brittleness. Thus, the optimal way to improve properties is through the design of novel composite cements. The purpose was fulfilled using a 25% hydroxyethyl methacrylate (HEMA) mixed with 3% urethane dimethacrzlate (UDMA) base matrix with various ratios of polyethylene glycol (PEG 400) and polycaprolactone (PCL). Mineral filler is based on tricalcium phosphate (TCP) with different chitosan ratio used as bio-response enhancer additive. Four mixtures were prepared: S0-unfilled polymer matrix; S1 with 50% TCP filler; S2 with 50% chitosan + TCP filler; and S3 with 17.5% chitosan + TCP mixed with 17.5% nano hydroxyapatite (HA). The mechanical properties testing revealed that the best compressive strength was obtained by S2, followed by S3, and the worst value was obtained for the unfilled matrix. The same tendency was observed for tensile and flexural strength. These results show that the novel filler system increases the mechanical resistance of the TCP composite cements. Liquid exposure investigation reveals a relative constant solubility of the used filler systems during 21 days of exposure: the most soluble fillers being S3 and S2 revealing that the additivated TCP is more soluble than without additives ones. Thus, the filler embedding mode into the polymer matrix plays a key role in the liquid absorption. It was observed that additive filler enhances the hydrophobicity of UDMA monomer, with the matrix resulting in the lowest liquid absorption values, while the non-additivated samples are more absorbent due to the prevalence of hydrolytic aliphatic groups within PEG 400. The higher liquid absorption was obtained on the first day of immersion, and it progressively decreased with exposure time due to the relative swelling of the surface microstructural features. The obtained results are confirmed by the microstructural changes monitored by SEM microscopy. S3 and S2 present a very uniform and compact filler distribution, while S1 presents local clustering of the TCP powder at the contact with the polymer matrix. The liquid exposure revealed significant pore formation in S0 and S1 samples, while S3 and S2 proved to be more resistant against superficial erosion, proving the best resistance against liquid penetration.

Human Enamel Fluorination Enhancement by Photodynamic Laser Treatment.

Poor oral hygiene leads to serious damages of theteeth's surface enamel such as micro-abrasions and acid erosion. These alterations combined with bacterial plaque result in cavity appearance. Prophylactic measures include various techniques for enamel surface restoration. Fluorination is one of the most important treatments for this purpose. Therefore, in the present research, we investigated the classical fluorination treatment compared with laser photodynamic fluorination performed on human enamel samples with poor surface quality. Three sample groups were investigated: veneer (F), inlay (I), and crowns (C). The general morphologic aspect was investigated by scanning electron microscopy (SEM), and the specific details such as the fine microstructure and nanostructure were investigated by atomic force microscopy (AFM) of the surface roughness. The samples were also investigated by Fourier transformed infrared attenuated total reflectance (FTIR-ATR) to evidence the fluorination effect on the enamel surface. Results showed that all initial samples had an altered state with micro-abrasions and erosion with mineral loss, which increase the surface roughness. The F group was the most damaged, having a higher roughness, and the I group was less damaged. Classic fluorination treatment partially restored the enamel by local re-mineralization, but did not obtain the parameters of healthy enamel. However, a significant decrease of the roughness was observed (statistical relevance p = 0.001 with the Breusch-Pagan Test). This fact was supported by the presence of newly formed fluorides in the FTIR-ATR spectra. The photodynamic laser fluorination restores the enamel in an enhanced manner by a strong re-mineralization, which implies a significant roughness value decrease comparable to healthy enamel. The Breusch-Pagan Test confirmed the relevance with p = 0.001. This is due to an extended re-mineralization abundant in fluoride crystals as observed by AFM and FTIR. Statistical p-values regarding laser application were in the range of 0.02-0.06, supporting its relevance in the fluorination effect. The final conclusion is that the photodynamic effect is able to favor the newly formed fluoride deposition onto the affected sites of the enamel surface.

Esophageal ulcer associated with mild hemophilia A: case report.

In this paper, we present the case of a 68-year-old male with personal medical history of coagulopathy issues, who presented to our Emergency Room (Emergency County Hospital, Arad, Romania) with bleeding of the superior tract of the digestive system; the case was difficult to manage, thus warranting the intervention of the Department of Gastroenterology. Endoscopy was performed to localize the site of bleeding and to stop the hemorrhage. This procedure was not successful. The patient was transferred to our Intensive Care Unit where different medications, such as proton pump inhibitor, hemostatic agent and prokinetic drugs were administered. Unfortunately, our attempt to stop bleeding failed; this led us to expand our investigation. We focused on a possible hemophilia as the cause of bleeding, which was confirmed as hemophilia A through the coagulometry test after a period of three days. Patient medical history and coagulation test led us to believe that this is a very rare case of a mild hemophilia A. Finally, the correction of Factor VIII deficiency and repeated endoscopic hemostasis clip was able to stop patients bleeding and ensured a favorable clinical evolution of the patient.

In-Depth Comparative Assessment of Different Metallic Biomaterials in Simulated Body Fluid.

Invitro experiments have been conducted on metallic biomaterials used for orthopedic implants in order to determine their behavior when immersed in simulated body fluid (SBF). Thus, 3Ti-based metallic biomaterial samples already available on the marked were purchased and immersed in simulated blood plasma, and kept at 37 °C for 4 months. In-depth characterization consisted of a wide series of structural characterizations of both the samples and SBF. Sample analysis consisted of the following: optical (OM) and scanning electron microscopy (SEM) in order to establish the surface and deep corrosion, mass gain/loss assessment for determining the metallic ions loss and/or protective layer formation, and X-ray diffraction in order to establish if and what kind of layers are formed. SBF analysis consisted of using inductively coupled plasma mass spectroscopy (ICP-MS) in order to establish if and/or how many metallic ions have dissociated from the metallic samples into the SBF, and measurements of pH and electrical conductivity. The key findings of the research are as follows: during the four months while kept in SBF, the samples show surface corrosion degradation and protective layer generation. Also, the amount of metallic ions dissociated into the SBF is making them suitable for use. Taking into account that it is highly improbable for such a large area of metal as the one considered within this work to be exposed to real body fluids and that all the samples have developed protective oxide films, the overall conclusion is that they are appropriate for implant use.

Review of calcium-sulphate-based ceramics and synthetic bone substitutes used for antibiotic delivery in PJI and osteomyelitis treatment.

Infection in orthopaedic and trauma surgery remains a destructive complication with particularly challenging diagnosis and treatment due to bacterial antibiotic resistance and biofilm formation.Along with surgical debridement and systemic antibiotics, an important type of adjuvant therapy is local antibiotic delivery, with the purpose of eliminating bacterial colonization and biofilm development.Calcium sulphate, as a synthetic absorbable biomaterial used for local antibiotic delivery, has experienced an increasing popularity during the last decade, with multiple promoted advantages such as predictable antibiotic elution kinetics, complete and quick biodegradation, good biocompatibility, and limited associated complications.A series of commercially available antibiotic-delivery systems based on calcium sulphate are under investigation and in clinical use, with different presentations, compositions, and application techniques.The current article presents the main available calcium-sulphate-based products and the existing data about the clinical and preclinical research results, stemming from their implementation as local antibiotic carriers for surgical site and implant-associated infections treatment and prevention. Cite this article: EFORT Open Rev 2021;6:297-304. DOI: 10.1302/2058-5241.6.200083.

The Role of Biomaterials in Upper Digestive Tract Transoral Reconstruction.

This study aims to establish whether the use of biomaterials, particularly polydimethylsiloxane (PDMS), for surgical reconstruction of the esophagus with templates, Montgomery salivary tube, after radical oncology surgery for malignant neoplasia is an optimal choice for patients' safety and for optimal function preservation and organ rehabilitation. Structural analysis by Raman spectrometry and biomechanical properties with dynamic mechanical analysis are performed for fatigue strength and toughness, essential factors in durability of a prosthesis in the reconstruction practice of the esophagus. Nanocomposites with silicone elastomers and nanoparticles used in implantable devices and in reconstruction surgery present risks of infection and fatigue strength when required to perform a mechanical effort for long periods of time. This report takes into account the effect of silver (Ag) nanoparticles on the fatigue strength using polydimethylsiloxane (PDMS) matrix, representative for silicon elastomers used in implantable devices. PDMS with 5% (wt) Ag nanoparticles of 100-150 nm during mechanical fatigue testing at shear strength loses elasticity properties after 400 loading-unloading cycles and up to 15% shear strain. The fatigue strength, toughness, maximum shear strength, as well as clinical properties are key issues in designing Montgomery salivary tube and derivates with appropriate biomechanical behavior for each patient. Prosthesis design needs to indulge both clinical outcomes as well as design methods and research in the field of biomaterials.

An extremely uncommon case of pancreatic extragastrointestinal stromal tumor in a 53-year-old female patient.

Gastrointestinal stromal tumors (GISTs) are the most frequently encountered mesenchymal tumors that develop anywhere along the gastrointestinal (GI) tract, but they account for less than 1% of all GI tumors. However, GISTs can also develop outside the GI tract. They are referred to as extragastrointestinal stromal tumors (EGISTs) and represent around 5-10% of all GISTs. In this latter case, the tumor itself is not connected to the GI tract and can affect the omentum, mesentery, and retroperitoneum. EGISTs can also originate from the pancreas, but they are extremely uncommon. It is estimated that pancreatic EGISTs account for about 5% of all EGISTs, with around 30 cases being reported in the literature so far. The current report presents an extremely rare case of pancreatic EGIST encountered in a 53-year-old woman with no remarkable personal or family medical history. Surgical resection of the pancreatic head tumor through pancreaticoduodenectomy using Whipple procedure combined with negative resection margins and adjuvant Imatinib mesylate treatment led to a favorable postoperative evolution. The follow-up at six months after surgery did not reveal any malignant changes.

MR spectroscopy of the liver - a reliable non-invasive alternative for evaluating non-alcoholic fatty liver disease.

Non-alcoholic fatty liver disease (NAFLD) is one of the most common conditions worldwide that targets the liver parenchyma. NAFLD represents an intrahepatic triglyceride accumulation in the absence of excessive alcohol consumption and other diseases that affect the liver parenchyma. The current "gold standard" for evaluating the amount of intrahepatic fat is represented by liver biopsy, but many patients are reluctant and hardly accept undergoing this procedure due to its invasive nature. The current study addresses this aspect by evaluating the reliability of liver magnetic resonance spectroscopy (MRS) in diagnosing NAFLD, compared to the traditional invasive liver biopsy. The present study included a total of 38 patients based on several well-defined inclusion and exclusion criteria. We used the same NAFLD grading system for both liver MRS and liver biopsy: grade 0: <5% hepatocytes are affected; grade I: 5-33% hepatocytes are affected; grade II: 34-66% hepatocytes are affected; grade III: >66% hepatocytes are affected. Regarding the NAFLD grade, over three-quarters of patients were classified as grade I and grade II, with a strong predilection for men. The current results indicated a significant association between the NAFLD grade indicated by liver MRS and the NAFLD grade indicated by liver biopsy. At the end of our study, we recommend using liver MRS for evaluating and grading NAFLD in association with other parameters like serum triglycerides and body mass index grade as this protocol can enhance early detection and provide an accurate grading that will lead to a proper management of this disease.

Histopathological findings in the advanced natural evolution of the SARS-CoV-2 infection.

We are reporting a case of natural evolution and pathological data from a young person that was diagnosed with coronavirus disease 2019 (COVID-19). All data has been collected from the autopsy of a 30-year-old female, which was performed by the Department of Forensic Medicine from Emergency County Hospital, Drobeta Turnu Severin, Mehedinti County, Romania. The infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) was confirmed by reverse transcription polymerase chain reaction (RT-PCR) on the lung tissue which was obtained during autopsy. This case provides the opportunity to study the natural evolution of COVID-19 pneumonia in a young person with clinical signs of pneumonia but without associated comorbidities. The patient had not received any treatment. The histopathological examination of the lung revealed a process of productive proliferation, proteinaceous and fibrin-macrophagic interalveolar spaces exudate, and lesions consistent with vasculitis. In the heart, we identified a cardiac thrombus. These changes are likely to suggest an advanced natural evolution of SARS-CoV-2 virus infection.

Failure Analysis of Retrieved Osteosynthesis Implants.

Failure of osteosynthesis implants is an intricate matter with challenging management that calls for efficient investigation and prevention. Using implant retrieval analysis combined with standard radiological examination, we evaluated the main causes for osteosynthesis implant breakdown and the relations among them for a series of cases. Twenty-one patients diagnosed with implant failure were assessed for this work. For metallurgical analysis, microscopy techniques such as scanning electron microscopy (SEM), stereomicroscopy, and optical microscopy were employed. The results showed that material structural deficiencies (nine patients) and faulty surgical techniques (eight patients) were the main causes for failure. An important number of patients presented with material structural deficiencies superimposed on an imperfect osteosynthesis technique (six patients). Consequently, the importance of failure retrieval analysis should not be overlooked, and in combination with other investigational techniques, must provide information for both implant manufacturing and design improvement, as well as osteosynthesis technique optimization.

Proximal humerus chondrosarcoma in a young male patient.

Proximal humerus chondrosarcoma is a rare localization of the common primary malignant cartilaginous tumor. Management is based on oncological surgical excision because of the inherent resistance to chemotherapy and radiation therapy. The most important prognostic factors with great impact on treatment strategy are histological grading and localization of the tumor. Proximal humerus chondrosarcoma carries a slightly better prognosis, especially for the low and moderate grade tumors. We present the case of a young patient with proximal humerus chondrosarcoma surgically managed in our Department, with the purpose of underlining the challenges posed by this localization for oncological excision and reconstruction but also the importance of histological grading for the treatment algorithm.

Chondrosarcoma of the pelvis - case report.

Chondrosarcoma (CHS) is the third most common primary bone tumor after myeloma and osteosarcoma. Histologically, it is made of pure hyaline cartilage differentiation. The tumor itself may have myxoid modification and calcification. It occurs especially after 50 years, with an equal gender distribution. Most CHS are solitary, the etiology is still unclear and most of them are discovered accidentally. Early diagnosis is crucial for a good prognosis. In this paper, we would like to present a case of a female patient with an accidentally discovered CHS of the iliopubic and ischiopubic ramus of the pelvis. The purpose of this report is to highlight the importance of multidisciplinary management of tumor pathology, especially when the site of the tumor is surgically hardly accessible and to underline possible common genetic aspects of benign and malignant tumors.

Proximal tibial osteosarcoma in young patients: early diagnosis, modular reconstruction.

Osteosarcoma is the most common bone tumor that occurs in children and young adults with prevalence of teenage. There can be identified many subtypes of osteosarcoma by how they look on X-rays and under the microscope. Osteosarcoma can be classified as high-grade, intermediate grade, or low-grade. This has a significant prognostic value of tumor development suggesting the growth rate and the potential for expansion. Between 2009-2013, in the Department of Orthopedics and Traumatology, University Emergency Hospital of Bucharest, Romania, were treated seven cases of osteosarcoma of the proximal third of the tibia in young, early-diagnosed cases without metastasis. The treatment involved resection of tumor formation and reconstruction with a modular prosthesis. Postoperative patients were mobilized for a week without charging the operated limb under the protection of orthesis. During this period continued active and passive mobilization of the ankle and foot to prevent stiffness and to reduce postoperative swelling. From the second postoperative week, patients are mobilizing with progressive charging but not being allowed to do any flexion in order to protect de insertion of medial gastrocnemius muscle rotation flap used to cover the prosthesis and to protect the patellar tendon reinsertion. This extensive surgery does not improve survival rate of these patients compared to treatment by amputation of this pathology but greatly increases the comfort of life and in all cases ensure socio-professional reintegration of these patients. To ensure optimal postoperative results perform a complete diagnosis and preoperative oncological treatment before surgery, if applicable.

Negative Pressure, a "Solution" in the Treatment of Infected Knee Prosthesis?

INTRODUCTION: Negative-pressure wound therapy is a therapeutic technique that uses a vacuum dressing in order to promote healing in acute or chronic wounds. The continued vacuum draws out fluid from the wound and increases blood flow to the area. The aim of this study was to establish the effectiveness of negative pressure therapy increasing this way the chances of rehabilitation after knee prosthesis infections. MATERIAL AND METHOD: 11 patients with septic complications after total knee joint replacement were involved into this study, from the Department of Orthopaedic and Traumatology of Bucharest Emergency University Hospital. In all of the cases negative pressure wound treatment was applied. The surgical approach was chosen according to the surgeon's preferences or along the pre-existing surgical approach. RESULTS AND DISCUSSIONS: Time from the knee arthroplasty to the clinical and biological manifestation of septic complications was about 35 days with limits between 21 and 42 days. In most cases we managed to keep the implant, the outcome obviously being conditioned by using the negative pressure. Knee infections are still a hazardous problem in orthopedic surgery. Negative-pressure system increased the granulation tissue formation and the local blood flow and enhanced the bacterial clearance function. CONCLUSIONS: The clinical outcome in our cases indicates that the Negative-Pressure Wound Therapy can be a valuable contribution to the treatment of knee joint infections.

Synovial inflammation in patients with different stages of knee osteoarthritis.

The synovium is an intra-articular mesenchymal tissue and essential for the normal joint function. It is involved in many pathological characteristic processes and sometimes specific for this distinctive tissue. In this study, we refer to synovial proliferative disorders according to the stage of osteoarthritis (OA) disease. Forty-three patients with knee OA were treated in the Department of Orthopedics and Traumatology, Emergency University Hospital of Bucharest, Romania, in the last two years. In all cases, we used at least five criteria for the knee OA: knee pain, knee joint tenderness, no palpable warmth over the knee, stiffness, erythrocyte sedimentation rate and C-reactive protein levels. In all the cases the synovial tissue was selected by the orthopedic surgeon. X-ray examination was taken in every case of the affected joint. Patients who were considered to have early OA underwent arthroscopic synovial biopsy of the symptomatic joint. Synovial tissue samples from patients with late OA were obtained at the time of knee joint arthroplasty. Microscopic examination in early osteoarthritis revealed for more than half of patients with synovial biopsy through arthroscopic technique having synovitis lesions with mononuclear infiltrates, diffuse fibrosis, thickening of the lining layer, macrophages appearance and neoformation vessels also. The synovitis seen in advanced OA knees tends to be diffuse and is not mandatory localized to areas of chondral defects, although an association has been reported between chondral defects and associated synovitis in the knee medial tibio-femoral compartment. The overexpression of mediators of inflammation and the increased mononuclear cell infiltration were seen in early OA, compared with late OA.

Treatment of Anterior Instability of the Shoulder.

OBJECTIVES: The aim of this study is to compare the long term results of the treatment of anterior instability of the shoulder. MATERIALS AND METHODS: The study included a total of 37 patients diagnosed with anterior instability of the shoulder, on the basis of clinical data (anamnesis, physical examination) and imaging (X-rays, MRI examination), operated in the Department of Orthopedics and Traumatology - Emergency University Hospital Bucharest, Romania, between 2009-2012. They were divided in 3 groups, according to the surgical technique used (open Bankart, arthroscopic Bankart and Bristow procedure), and the results were evaluated at 2 years postoperatively using Rowe and Constant scores. Statistical analysis was performed using one-way ANOVA test. RESULTS: There were no intra- or postoperative complications. No reluxations were recorded. Statistically significant differences (F> Fcrit; p <0.05) of the Constant score were recorded between the three groups on the range of movement variable, especially external rotation, their mean values being higher in the group treated arthroscopically compared to the other two groups. CONCLUSION: Arthroscopic shoulder stabilization surgery gives the best long time results in terms of functional recovery of the shoulder, objectified by Constant and Rowe scores. Data from the literature show a higher rate of recurrence after arthroscopic interventions, suggesting that the indications of this technique still requires further clarifications. It's required a more precise preoperative evaluation, in order to detect any lesions associated with Bankart lesion (bone defects of the anterior rim of glenoid, Hill-Sachs lesion, capsular laxity, rotator cuff tears, long head of biceps injuries). Mastering a surgical techniques is not always enough in order to obtain the best results. The choice of proper surgical technique for each patient, however, can significantly reduce the recurrence rate of shoulder dislocation.

Titanium preformed implants in orbital floor reconstruction - case presentation, review of literature.

The management of orbital fractures is one of the most interesting and difficult areas in facial trauma. The consequences of an orbital fracture are sometimes dramatic. They include varying types of defects from a loss of vision to diplopia, loss of an eye, epiphora, a disturbing loss of facial sensation, or even an unacceptable appearance of the eye and the hard and soft tissues around it. The controversies surrounding orbital fractures, and orbital floor fractures in particular include the following: the timing of primary surgery (early or late), bone grafting versus alloplastic materials, the management and prevention of diplopia, the prevention of enophtalmos, the management of infraorbital nerve numbness or dysesthesia.

Methods of investigating metastatic lymph nodes in head and neck cancer.

ABSTRACT: When dealing with patients who have head and neck cancer - squamous cell carcinoma and have clinically N0 neck disease it is very difficult to assess the real extension of the malignant proccess. This is why several techniques are curently in use to determine the actual TNM clasiffication for each patient in order to apply best suited therapy management. Up until today the staging of the neck has been done by using a combination of the physical exam and conventional imaging studies. Recent studies and research have tried to determine weather the use of sentinel lymph node biopsy is a more reliable tool in predicting occult metastasis in cancer patients with clinically N0 neck disease. There are no guidelines in this matter and as such the use of the sentinel lymph node detection technique is yet to be used on a routine basis. The authors are trying to assess the benefits of different paraclinical investigation regarding the improvement of overall survival rates in patients with T1/T2 squamous cell carcinoma of the head and neck and N0 neck disease.