Comorbidities and Laryngeal Cancer in Patients with Obstructive Sleep Apnea: A Review.

Introductions: The global prevalence of obstructive sleep apnea shows that this disease appears in 1 billion people, with the prevalence exceeding 50% in some countries. Treatment is necessary to minimize negative health impacts. Obstructive sleep apnea (OSA) is defined as a cause of daytime sleepiness, as well as a clinical manifestation of sleep-disordered breathing. In the literature, there are numerous controversial studies regarding the etiology of this condition, but it is universally accepted that reduced activity in the upper airway muscles plays a significant role in its onset. Additionally, OSA has been associated with a series of comorbidities, such as type II diabetes, metabolic syndrome, and cardiovascular and pulmonary conditions, as well as head and neck tumors, especially oropharyngeal and laryngeal tumors. This is a review of the subject of OSA that considers several aspects: an analysis of the comorbidities associated with OSA, the involvement of tumor pathology in the onset of OSA, and the association of OSA with various types of laryngeal cancers. Additionally, it includes an evaluation of postoperative and medical outcomes for patients with OSA and laryngeal tumors treated surgically and medically, including chemotherapy. Relevant Sections: By taking into consideration the stated objective, a systematic analysis of the available literature was conducted, encompassing the PubMed, Medline, and Scopus databases. The evaluation was based on several keywords, including head and neck cancer, diabetes, diabetic, overlap syndrome, cardiovascular conditions, laryngeal neoplasm, radiotherapy, and chemotherapy, as well as the concept of quality of life in laryngectomized patients and patients with OSA. Discussions: The review evaluates the involvement of OSA in the presence of comorbidities, as well as the increased incidence of OSA in patients with laryngeal cancer. It is important to note that surgical and post-surgical treatment can play a significant role in triggering OSA in these patients. Conclusions: The studies regarding the correlations between OSA, comorbidities, and head and neck tumors indicate a significantly increased risk of OSA in association with conditions such as diabetes, metabolic syndrome, cardiovascular diseases, and head and neck tumors, particularly laryngeal tumors. This association has a physio-pathological basis. The various surgical methods followed by radiation and chemotherapy for tumor treatment do not exclude an increased risk of developing OSA after treatment. This significantly influences the quality of life of patients who survive these types of tumors. Future directions: Due to the multiple comorbidities associated with OSA, the extension of polysomnography associated with investigations during sleep, such as drug-induced sleep endoscopy, represents a tendency for the early diagnosis of this pathology, which affects the quality of life of these patients. Patients with head and neck cancer are at high risk of developing obstructive sleep apnea; this is why it is necessary to expand the polysomnographic investigation of these patients after surgical procedures or after radiotherapy and chemotherapy.

[Exacerbation of obstructive pulmonary diseases by SARS-CoV-2 infection in patients treated in the Pulmonology Clinic of Târgu Mures]. / Obstruktív tüdobetegségek súlyosbodása SARS-CoV-2-fertozés hatására a marosvásárhelyi Pulmonológiai Klinika beteganyagában.

INTRODUCTION: Literature data show an increased severity of SARS-CoV-2 infection in patients with cardiovascular, renal comorbidities, chronic obstructive pulmonary disease (COPD), asthma, obesity, diabetes, tumors and immunosuppression. METHOD: This retrospective study includes 90 patients with SARS-CoV-2 infection associated with COPD or asthma exacerbations from 303 patients hospitalized during a 7-month period (29.7%). The clinical aspect of COPD/asthma exacerbations overlapped to the one by SARS-CoV-2 infection, therefore, we compared our group with 90 patients with SARS-CoV-2 without obstructive disease. We excluded from both groups the patients with known severe cardiac impairment, diabetes, or tumors in order to not having interference with other unfavorable prognostic factors. We assessed the cases severity on clinical basis, pulzoximetry, CT/chest x-ray, and inflammatory markers. RESULTS: 72.2% of our group (48/52 with COPD and 17/38 with asthma) had moderate/severe pneumonia (bilateral interstitial-alveolar infiltrates, increased inflammatory markers, respiratory dysfunction) compared with 56.6% from the nonobstructive group. 14 patients required intensive therapy (including mechanical ventilation). We recorded 4 deaths in COPD group, 1 in asthma group, compared to 2 in non-obstructive patients (fatality 7.6% in COPD compared to 2.2% in nonobstructive group). Treatment included maximized inhaled bronchodilators ± corticosteroids, oxygen, antivirals, anticoagulants, corticosteroids, symptomatic. All patients were referred for clinical-functional and CT scan reassessment 2 months after discharge. CONCLUSION: The association of SARS-CoV-2 infection in patients with COPD or asthma was common, leading to exacerbation with significant severity. Fatality increased in COPD. Outpatient follow-up aims to restage adjust the treatment and monitor post-COVID-19 possible sequels. Orv Hetil. 2023; 164(2): 43-50.

[Characteristics of the association between tuberculosis and HIV infection in Mures county, Romania]. / A tuberkulózis és a HIV-fertozés kapcsolatának jellemzoi Maros megyében, Romániában.

INTRODUCTION: Despite the decrease in morbidity due to human immunodeficiency virus (HIV) infection in Romania, it remains a significant risk factor for tuberculosis. OBJECTIVE: Analyzing the characteristics of tuberculosis-HIV co-infection in Maros county, Romania, during 2014-2020. METHOD: Retrospective data processing of the study group and comparing with internationally reported data (similar group, same geographic region, during 2004-2013). RESULTS: The study includes 40 patients with tuberculosis-HIV co-infection: 24 men, 16 women, 22 from rural areas, 22 smokers, 20 alcohol and 4 drug users. Most of them had poor living conditions. 30 patients were in the 26-40-year-old age group, significantly influencing their personal development. 25 patients were diagnosed with acquired immunodeficiency syndrome (AIDS). We identified 28 pulmonary tuberculosis cases, 1 extrapulmonary tuberculosis, and 11 mixed forms. In 13 cases, the pathogen was not identified; the diagnosis was based on probability criteria (epidemiology, clinical, and imaging methods). The number of hepatitis, parasitological, and other opportunistic infections decreased significantly, but the frequency of anemia, neurological and respiratory diseases increased. The incidence of drug-resistant forms and the death rate also decreased significantly. DISCUSSION: Due to the poor living conditions, these patients are not adherent to examinations and treatment. Tuberculosis-HIV co-infection is more likely to cause complications, drug resistance, and high mortality rate. For early diagnosis, screening all patients with tuberculosis for HIV infection and all HIV-infected patients for tuberculosis is crucial. CONCLUSION: Prevention, early diagnosis, and treatment of both diseases must be increased by intensifying the fight against poverty and promoting better education. Orv Hetil. 2023; 164(1): 19-28.

Lung function and comorbidities in patients with exacerbated chronic obstructive pulmonary disease hospitalized in Tirgu-Mureș Pulmonology Clinic / Súlyos krónikus obstruktív tüdobetegségben szenvedo betegek tüdofunkciója és társbetegségei a marosvásárhelyi Tüdogyógyászati Klinikán

two-thirds and partial remission in one-third of the lesions. At doses above 100 J/cm², severe erythema was observed 24 hours after the treatment. To avoid this, we calculated the time to be spent outdoor by dosimetry. Partial remission was achieved in 15%, complete remission in 85% of the actinic keratoses with good tolerability. Discussion: The stepwise modification of the treatment protocol resulted in an effective and well-tolerated treatment in actinic keratoses under the local climatic conditions. Conclusion: The method has been successfully adapted in our clinic and is used in daily practice to treat actinic keratoses.

Applicability of lung ultrasound in the assessment of COVID-19 pneumonia: Diagnostic accuracy and clinical correlations.

BACKGROUND: The purpose of this study was to assess the diagnostic accuracy of lung ultrasound (LUS) in determining the severity of coronavirus disease 2019 (COVID-19) pneumonia compared with thoracic computed tomography (CT) and establish the correlations between LUS score, inflammatory markers, and percutaneous oxygen saturation (SpO2). METHODS: This prospective observational study, conducted at Târgu-Mureș Pulmonology Clinic included 78 patients with confirmed severe acute respiratory syndrome coronavirus-2 infection via nasopharyngeal real-time-polymerase chain reaction (RT-PCR) (30 were excluded). Enrolled patients underwent CT, LUS, and blood tests on admission. Lung involvement was evaluated in 16 thoracic areas, using AB1 B2 C (letters represent LUS pattern) scores ranging 0-48. RESULTS: LUS revealed bilateral B-lines (97.8%), pleural irregularities with thickening/discontinuity (75%), and subpleural consolidations (70.8%). Uncommon sonographic patterns were alveolar consolidations with bronchogram (33%) and pleural effusion (2%). LUS score cutoff values of ≤14 and > 22 predicted mild COVID-19 (sensitivity [Se] = 84.6%; area under the curve [AUC] = 0.72; P = 0.002) and severe COVID-19 (Se = 50%, specificity (Sp) = 91.2%, AUC = 0.69; P = 0.02), respectively, and values > 29 predicted the patients' transfer to the intensive care unit (Se = 80%, Sp = 97.7%). LUS score positively correlated with CT score (r = 0.41; P = 0.003) and increased with the decrease of SpO2 (r = -0.49; P = 0.003), with lymphocytes decline (r = -0.52; P = 0.0001). Patients with consolidation patterns had higher ferritin and C-reactive protein than those with B-line patterns (P = 0.01; P = 0.03). CONCLUSIONS: LUS is a useful, non-invasive and effective tool for diagnosis, monitoring evolution, and prognostic stratification of COVID-19 patients.

Extrapulmonary tuberculosis - a diagnostic and therapeutic challenge / Extrapulmonalis tuberculosis - diagnosztikai és terápiás kihívás

Allograft degeneration can be effectively treated with the use of covered stents. Transaxillary approach is an alternative to a compromised transfemoral access. Ipsilateral transradial access may increase the safety of a percutaneous transaxillary puncture.

A rare association of cutaneous leukocytoclastic angiitis (hypersensitivity vasculitis) and hypersensitivity pneumonia (extrinsic allergic alveolitis) in a pigeon breeder - case report and literature review.

Extrinsic allergic alveolitis is an occupational condition intensively studied and published about, unlike cutaneous leukocytoclastic angiitis. The coexistence of these two diseases is even more rare in the same patient with exposure to occupational pollutants of animal origin. We present the case of a 44-year-old man, a pigeon breeder admitted to hospital with a pruritic purpuric eruption and lower limb paresthesia, dyspnea on exertion, polymyalgia rheumatica, mixed polyarthralgias. Based on the clinical, paraclinical and laboratory investigations (electroneuromyography, plethysmography, computed tomography scan, musculocutaneous biopsy, current laboratory tests and immunoassays), the main diagnoses of extrinsic allergic alveolitis and leukocytoclastic vasculitis were determined. The patient underwent treatment with corticosteroids with a favorable outcome, but which becomes aggravated by the occurrence of necrotic skin lesions at the cessation of corticosteroid therapy on the patient's own initiative. After the resumption of the corticosteroid therapy, the lesions and symptoms improve. To our knowledge, this case report is the first one that describes an association of two major conditions, extrinsic allergic alveolitis and cutaneous leukocytoclastic angiitis, in the same clinical context of an occupational exposure to specific pollutants. Long-term corticosteroid therapy has proved to be useful in preventing relapses and improving the patient's clinical status with the association of cutaneous leukocytoclastic angiitis and extrinsic allergic alveolitis. Considering our findings in this case report, we may suggest the inclusion of systemic vasculitis on the list of recognized professional diseases.

Modified enteromesenteric bridging operation for primary lymphedema.

BACKGROUND: Primary lymphedema represents a condition which affects the lymph vessels and their cells without any pathologic patient history leading to soft tissue swelling. They are described in the literature three types: congenital primary lymphedema, or Milroy disease, lymphedema praecox, which occurs in puberty, and lymphedema tarda, when, the same symptoms, develop over 35 years old patients. The aim of this paper is to present a modified Kimmoth's original procedure for a praecox lymphedema by introducing an omental flap in the resorptive area. CASE REPORT: We present a case of 18 year-old patient with a significant lymphedema of the lower limbs and genitalia associated with high-symptomatic under-knee and scrotal ulcerative, necrotic and inflammatory lesions. The ultrasound and computed-tomography scans showed bilateral hypertrophic lymph-nodes in the inguinal and external iliac areas. Considering this diagnosis we decided to perform a physiologic lymph drainage by combining the enteromesenteric bridge with the omental transposition. The postoperative course was favorable without wound complications. Three months after, it was resected the remnant scrotal sclero-lymphatic tissue. 3 years after surgery, the clinical follow-up showed a significant reduced lymphedema with 10 cm shank / 15 cm thigh circumference lost. CONCLUSIONS: The enteromesenteric bridge combined with the omental flap proved to be efficient in ensuring the lymphatic drainage in a case with proximal lymphatic occlusion. KEY WORDS: Enteromesenteric bridging operation, Omental flap transposition, Primary lymphedema.

Pulmonary Langerhans cell histiocytosis in a 26-year-old female: still a diagnostic challenge.

Langerhans cell histiocytosis (LCH) is a rare disorder caused by monoclonal Langerhans cells proliferation in bone, skin, lung, lymph nodes, liver, spleen, nervous or hematopoietic system. Pulmonary LCH is a diagnostic trap that is displayed on computed tomography (CT) as an interstitial disorder with honeycomb aspect. In this paper, we present an unusual case of a 26-year-old female that was hospitalized with progressive worsening dyspnea and history of recurrent pneumonia. Lung biopsy showed fibrosis of the interalveolar septa, architectural distortion and large cells with foamy cytoplasm and convoluted nuclei that were marked by CD68, S-100 and the specific antibody CD1a that allowed establishing the diagnosis of pulmonary LCH. The only extrapulmonary manifestations were femoral bone cysts that were radiologically seen 10 years before and were not modified along the years. The therapy consisted on smoking cessation and oral corticosteroids without significant improvement of the clinical symptoms and enlargement of the cystic spaces during six months of follow-up. This case highlights for a rare disorder of the lung that should be taken into account in young patients with progressive pulmonary fibrosis.

Laparoscopic gastric plication for the treatment of morbid obesity by using real-time imaging of the stomach pouch.

BACKGROUND: Bariatric surgery is a continuously evolving field. Laparoscopic greater curvature plication is a new investigational procedure used to treat patients with morbid obesity. The demand for this operation from the obese patients is also rising. The problem is that during gastric plication the exact dimensions and volume of the pouch are not known so frequently it is too large or too tight thus compromising the results. The aim of the study was to identify the parameters that can improve the outcomes after this procedure. METHODS: We performed laparoscopic greater curvature plication in 75 obese patients during 2013-2015. The last 25 patients underwent surgery with a modified surgical technique using real-time imaging of the stomach pouch. The inclusion criteria for the 25 patients enrolled in this case series were the usual, body mass index higher than 40 or higher than 35 but with comorbidities along with the option of the patients for laparoscopic gastric plication. The operative technique was enhanced by using a computerized device and special intragastric catheters during the procedure that permitted real-time imaging of the gastric geometry. With this new operative approach we obtained the desired volume of the gastric remnant and we avoided strictures, obstruction or irregular shape of the pouch, problems that otherwise could have compromised the outcomes. RESULTS: We found an increased excess weight loss of 55% at six month and 65% over a 12-month follow-up period with alleviation of comorbidities. There were no major complications (gastric outlet obstructions or leaks) and less minor complications (nausea and vomiting) than in the patients operated with classic gastric plication procedure. CONCLUSIONS: This study shows that in case of laparoscopic gastric plication the use of our modified operative technique has better outcomes than in the classical setting. This is a new operative approach in the bariatric literature which can lead to greater acceptance of gastric plication among bariatric surgeons. The target population is represented by the obese patients who want to obtain similar results to those after gastric bypass and sleeve gastrectomy but are concerned about removing a part of their stomach and the postoperative complications that may occur, especially leaks and nutritional complications. KEY WORDS: Gastric geometry, Laparoscopic gastric plication, Morbid obesity, Real-time imaging.

Tuberculosis and its particularities in Romania and worldwide.

Tuberculosis (TB) is a global health issue, with a rising incidence since the beginning of this century. It poses a severe mortality risk and also poses a serious economic risk as it reduces the working capacity of an individual in the most productive part of life. Developing countries face widespread tuberculosis infection - up to 95% of all cases and 98% of deaths, respectively. It is a highly contagious infectious disease caused by Mycobacterium tuberculosis (the Koch bacillus) that can be contracted from either humans or animal hosts. Infection is also associated with immunodepressive conditions and can be contacted through airborne, digestive, cutaneous or other routes of transmission. Pulmonary TB can be either primary - when events follow a first contact between the organism and the bacillus, and secondary - in case of a reactivation of a latent primary infection. One of the aims of this review is to present the current epidemiological data of TB infections in Romania, compared to the rest of the world, with an analysis of associated conditions and extra-respiratory TB infections. One of the main conclusions of our review is that optimal management of this complex disease can only be achieved through a coherent national prevention and treatment program, with centralized financing and sufficient epidemiological, imaging and laboratory support, in conjunction with good patient compliance.

Crossover iliofemoral bypass graft through tension-free abdominal wall-repair mesh.

INTRODUCTION: In vascular surgery the crossover iliofemoral bypass grafting is a well-known surgical technique. In general surgery the repair of an abdominal defect using a Polypropylene mesh is also a standard procedure. A particular technique is defined by the performance of these 2 separate procedures inside a single operation in which the crossover arterial graft is directed from the retroperitoneal space toward the contra-lateral femoral bifurcation through a Polypropylene mesh which closes the musculoaponeurotic layers of the abdominal wall. We present our experience with the use of this particular surgical technique in patients with critical limb ischemia and with indication for extra-anatomic crossover bypass (high-risk patients with contra-indication for the transperitoneal approach, extensive calcified aortic or iliac wall which contraindicated the direct arterial reconstruction or secondary arterial reconstruction after the occlusion of an aorto- femoral graft). METHODS: In principle, the hernioplasty was performed by using the Lichtenstein tension-free hernia repair technique, followed by the crossover iliofemoral bypass. The main feature of this technique is to pass the vascular graft from the retroperitoneal space above the mesh through a calibrated hole in the mesh RESULTS: The 7 patients with inguinal hernia and l limb-threatening ischemia had favorable evolution, without hernia recurrence, limb-threatening ischemia or any graft complication at 3 years. DISCUSSION: Using this particular surgical technique we treated 2 surgical diseases using a single intervention for highrisk patients who had both inguinal hernia and contra-lateral critical limb ischemia. Being encouraged by the initial satisfactory results, we extended this technique even for the patients with indication of crossover iliofemoral bypass but without inguinal hernia. CONCLUSIONS: The particular surgical technique of the crossover bypass in which the vascular graft crosses a tension-free Polypropylene mesh from the retroperitoneal space toward the Retzius space represents an efficient and short procedure which treats simultaneously 2 different surgical diseases (inguinal hernia and contra-lateral critical limb ischemia) in high-risk patients. The results were satisfactory: we had no hernia recurrence and the limb-threatening ischemia was successfully treated. The preferred vascular graft for this particular technique is the reversed autogenous vein because its resistance to infections and the vein long-term patency is better than of a vascular prosthesis. When a prosthetic graft is required, we prefer to use the classic technique in which the crossover graft is placed in an under-aponeurosis site, in order to diminish the prosthesis infection risk. KEY WORDS: Abdominal wall, Iliofemoral bypass, Vascular surgery.

Multimacronodular pulmonary tuberculosis (bacteriologically negative) confirmed histologically.

Background: Pulmonary tuberculosis can be confirmed by positive bacteriology of sputum, bronchial aspirate or by biopsies (microscopy and/ or culture) or by histopathological examination highlighting specific tuberculous granulomas. When microscopy is repeatedly negative during noninvasive methods, lung biopsy by thoracoscopy is needed for confirmation and differential diagnosis. Case presentation: A 40-year-old female patient (nonsmoker, diabetic, with previous exposure to chemicals) was admitted to the hospital for weight loss, dry cough, loss of appetite, pallor, and fatigue. Chest-X-ray and thoracic CT revealed multiple irregular macronodules with various shapes, randomly spread across the lungs. Bacteriology for acid fast bacilli (AFB) from six spontaneous sputum was negative. Bronchoscopy showed an acute bronchitis. Bronchial aspirate was negative for tumor cells and AFB. Several biopsies from bronchial wall showed unspecific changes. The molecular biology tests for specific nucleic acids detection (Polymerase Chain Reaction) or positron-emission-tomography (to differentiate benign nodules from malign ones) were not accessible. Multiple biopsies from lung parenchyma and pleura were obtained using thoracoscopy. Histopathology revealed multiple specific tuberculous granulomas. The complex antituberculous treatment (9 months) has led to the total cure of the disease and resorption of the nodules. The patient's last visit (after 2 years) showed no clinical/imagistic or bacteriologic relapse of the disease. Conclusion: Tuberculosis may present in the form of multiple macronodules spread randomly across the lung parenchyma. Thoracoscopy coupled with multiple large lung biopsies are recommended for diagnosis of multinodular lung lesions, especially when common bacteriology/cytology from bronchoscopic aspiration failed to achieve diagnosis. Histological exam from thoracoscopic biopsies allows differential diagnosis between entities that have macronodular features: tuberculosis, primitive lung cancer, lymphomas, metastatic disease or invasive fungal disease.

The role of quantitative computed tomography in the diagnosis of chronic obstructive pulmonary disease.

In the last 25 years, there have been important improvements in computed tomography (CT) that may give more details about the lung structure in chronic obstructive pulmonary disease (COPD). The clinical exam and "classic" radiology (chest X-ray, conventional CT) have important roles: they raise the suspicion of hyperinflation, they highlight aspects of pulmonary hypertension, they may detect the triggers of exacerbations, they rule out some COPD complications and other lung diseases that can cause dyspnea (pneumothorax, tumors, bronchiectasis, and fibrosis). The spirometry may confirm the obstructive ventilatory disorder pattern of the disease. The modern CT scan technique - High Resolution CT (HRCT) with Multi-Detector CT procedure (MDCT) gives additional information about morphological details of parenchyma, bronchi, pulmonary vessels or lung function (ventilation/perfusion disorders) without significant lung irradiation. The new techniques provide quantifiable parameters that characterize the emphysema, the main COPD phenotypes and the risk of disease progression. Quantitative volumetric analysis of emphysema provides an early diagnosis of the disease in patients exposed to smoking and pollution. An early personalized diagnostic in COPD offers stronger reasons to prophylaxis by smoking and exposure cessation and an early targeted treatment (inhaled bronchodilators, anti-inflammatory medication, pulmonary rehabilitation, education for lifestyle changes).

Advanced Sarcoidosis with Apparent Onset by Respiratory Failure.

We present the case of a 14 years-old male (with poor living condition, non-smoker) hospitalized for a sudden onset of a rest dyspnea, mucopurulent cough. We found bronchial sibilant rales, wheezing, cyanosis, peripheral adenopathies, hepatosplenomegaly, purulent tonsillitis. the chest-x-ray revealed bilateral mediastinal lymphadenopathy and bilateral lung infiltrations. Spirometry: severe mixed ventilator dysfunction without reversibility. Sputum: negative microscopy and culture for Koch bacillus. Stool examination: cysts of Lamblia giardia. The patient refused bronchoscopy and mediastinoscopy, so it was performed axillary lymph node biopsy which confirmed sarcoidosis (non-caseating epithelioid granulomas). The treatment included antibiotics, antiparasites, oral and inhaled corticosteroids (CS), bronchodilators, oxygen, with clinical/functional improvement after 3 months. CS was followed 1.5 years with poor compliance. A relapse occurred after 3 years and the CS were reinserted. The computerized tomography (CT) scan revealed a diffuse interstitial fibrosis with bronchiectasis. The case particularity relies on the atypical early onset of the sarcoidosis, with respiratory failure and progression to lung fibrosis despite CS treatment. The association of proinflammatory risk factors such as multiple infections needs to be noted.

Neuroendocrine pancreatic tumor - diagnosis circumstances, staging and treatment: a case report.

Neuroendocrine neoplasms (NENs) of the pancreas are rare and frequently malignant. Our presentation of a pancreatic NEN analyzes the diagnosis circumstances, staging, treatment, one-year evolution and disease particularities. A 39-year-old nonsmoker patient was admitted in the Clinic of Pulmonology, Tirgu Mures, Romania with a pneumonia suspicion (fever, thoracic pain irradiated below the diaphragm, mild dyspnea). The chest X-ray showed a rise of the left diaphragm. Abdominal ultrasound revealed a large pancreas-related tumor. Computerized tomography (CT) scan with contrast confirmed a well-vascularized pancreatic tumor, which invades spleen, collateral circulation of the splenic vein, enlarged liver without secondary lesions and no retroperitoneal adenopathies. The patient was referred to the surgery where there was performed total tumor resection, spleen resection, and large lymphadenectomy. Histopathology and immunohistochemistry revealed the pancreatic NEN G2 grade, T3N1M0 and allowed accurate treatment. 2010 World Health Organization (WHO) NENs classification recommends further treatment-related biomarkers determination only in selected cases. Our case evolution after one year was favorable without local tumor relapse or metastases. The close survey of the patient (by clinical exam, imaging and biological markers) is ongoing. The onset of asymptomatic pancreatic tumor may have atypical respiratory symptoms. Imaging methods (ultrasound, contrast CT) are recommended in borderline symptomatology. Radical surgical resection of the tumor with lymphadenectomy, histopathology with immuno-histochemistry play an essential role in the correct diagnostic, grading, staging and treatment of pancreatic NENs. Close survey of the clinical, imagistic and biological markers is recommended.

Basic thoracic ultrasound for the respiratory physician.

Thoracic ultrasound (TUS) evolved in the last ten years as the method of choice for evaluating pleural abnormalities and for guiding lung procedures. TUS can "see" almost all structures in the chest, including thoracic wall, pleura, pleural space, the heart, the great vessels and the peripheral layers of the lungs. However, there is still a great need to develop TUS services in respiratory departments in Romania. To facilitate this development we reviewed the literature and selected what we considered to be essential practical information for the beginner in TUS, including technique, normal findings, and common abnormalities. Moreover, we describe here a step-by-step scanning technique for chest physicians. Our aim is to raise awareness of TUS. Because TUS is rapid, accurate, noninvasive and can be applied in any ward, we recommend facilitating the training of all junior respiratory doctors in this technique, as it is likely to improve patient experience, clinical effectiveness and to reduce costs with chest radiographs or CT scans in the future.

[Solitary pulmonary nodule: diagnosis criteria and management]. / Nodulul pulmonar solitar: criterii de diagnostic, management.

The solitary pulmonary nodule (SPN) is a frequent aspect on the chest X-ray and computed tomography (CT). The diagnosis and management of the SPN is not yet standardized. A high percentage of the SPNs is represented by the malignant lesions (primary lung cancer or metastasis of other extra pulmonary tumors). The first aim of the diagnosis is to evaluate the malignant or benign feature of the SPN using noninvasive techniques: this technique will guide the further diagnosis and treatment management. The noninvasive diagnosis tools are: clinical aspects (age, risk-factors - smoking history, exposure to toxic environment, history of previous tumors or tuberculosis), CT aspects (SPN size, growth rate, nodule's borders, calcifications, "bronchial sign", satellite nodules, invasion), positron emission tomography (PET) and PET-CT fusion, contrast PET-CT (high uptake in malignant processes). An initial high probability benign diagnosis will avoid invasive treatment (pulmonary resection); the initial diagnosis of a malignant process will recommend further invasive investigations (percutaneous or bronchoscopic transbronchial biopsies, thoracoscopy, thoracotomy) and an early appropriate treatment for radical cure with high-survival rate (SPN = stage IA for lung cancer).