Laparoscopic cholecystectomy in patients aged 60 years and over - our experience.

Aim. To analyze the efficiency of laparoscopic cholecystectomy for the population aged 60 years and over admitted with acute cholecystitis, the clinical features and associated pathology presented by these patients and the impact of these factors on the choice of surgical technique. Materials and method. A retrospective study was carried out between February 2010 and February 2015, on patients aged 60 years and over, operated in emergency for acute cholecystitis in our clinic. All data were extracted from the registered medical documents and operatory protocols. Results. A total of 497 surgeries were performed for acute cholecystitis, of which 149 were patients aged 60 years and over (30%). Open surgery is much better represented in the population aged over 60 years (61.75% vs. 29.98%). One major cause is the associated pathology that increases the anesthetic risk and hampers a laparoscopic procedure. The conversion rate in the study group presented a higher percentage, but not more exaggerated than in the general population (6.71% vs. 4.63 %).Patients who underwent laparoscopic surgery had a faster recovery and required lower doses and shorter term pain medication, in contrast to conventional surgery (1,8 days vs. 5.7 days). Bile leak has been of reduced quantity, short-term and stopped spontaneously. Only one case needed reintervention, in which aberrant bile ducts that were clipped were found in the gallbladder bed, was operated by laparoscopy. Wound infections and swelling were also encountered more frequently in patients that underwent classic surgery (3.24%). Conclusions. Performing laparoscopic cholecystectomy, when possible, has produced very good results, reducing the average length of stay of patients and even decreasing the number of postoperative complications, thus allowing a faster reintegration of patients into society. The main concern was related to the associated pathology that increased the anesthetic risk.

Brief report: Serial capillary lactate measurement predict the evolution of early sepsis.

OBJECTIVE: In intensive care settings, blood lactate level measurement proved to be an excellent predictor of outcomes. In patients requiring less urgent treatment, the arterial blood lactate is less sensitive and its usefulness remains to be proven. Capillary blood lactate dosing, an emergent point-of-care technique readily available should be more sensitive to changes in these settings. METHOD: prospective, observational, monocentric study conducted in a polyvalent internal medicine ward in a French University Hospital. The inclusion criteria were the existence of new symptoms of abrupt onset in an otherwise stable patient. All the patients had a point of care measurement of baseline capillary and venous lactate levels (EDGE, ApexBio) and standardized control before any therapeutic means were initiated. A follow-up test was performed once again within 12 to 36 hours. All the patients received standard medical care adapted to their condition. The primary outcomes were considered dying within 30 days or requiring intensive care or invasive therapeutic procedures. RESULTS: 13 patients were analyzed. Seven patients reached the composite outcome with 3 deaths. The superimposed complication proved to be infectious in every case. The median lactate levels were at baseline (mmol/ l): capillary Mc0=5.2(2.16), venous Mv0=2.3(2.0) and arterial Ma0=1.8(1.7) and at follow-up (mmol/ l) capillary: Mc1=3.3(1.1), venous Mv1=1.8(1.8) and arterial Ma1=1.3(0.7). In nonparametric analysis, the absence of normalization of capillary lactate at follow-up was correlated well with poor outcomes (p=.05). This was not the case of arterial or venous lactate measurements. The positive lactate clearance was present in the majority of patients (83.3%) but it did not predict the outcomes (p=.435) and there was no correlation between the baseline lactate and the clinical outcome (p>.05). CONCLUSION: In non intensive care settings, capillary lactate level could be a more sensitive method than the classical lactate measurement for predicting the outcomes of acute conditions, especially infectious. A persistently high lactate level rather than its initial value or clearance seems to correlate better with poorer outcomes. ABBREVIATIONS: SSC = Surviving sepsis campaign, ED = Emergency department, ICU = intensive care unit, , POC = Point of care, ICC = inter class coefficient.

Molecular events in gastric carcinogenesis.

Gastric cancer represents an important problem for the public health, being one of the main causes of mortality. At present, it represents the second cause of mortality due to cancer, after the bronchopulmonary cancer in men and the fourth cause of mortality in women. Important progresses have been made in the last couple of years in determining the neoplastic etiopathogenesis, but it cannot be affirmed that the genetic mutations chain, which leads to the appearance of the malignant cell, has been fully understood.

Cardiovascular disease risk scores in the current practice: which to use in rheumatoid arthritis?

Cardiovascular disease (CVD) is the highest prevalence disease in the general population (GP) and it accounts for 20 million deaths worldwide each year. Its prevalence is even higher in rheumatoid arthritis. Early detection of subclinical disease is critical and the use of cardiovascular risk prediction models and calculators is widely spread. The impact of such techniques in the GP was previously studied. Despite their common background and similarities, some disagreement exists between most scores and their importance in special high-risk populations like rheumatoid arthritis (RA), having a low level of evidence. The current article aims to single out those predictive models (models) that could be most useful in the care of rheumatoid arthritis patients.

Utility of different cardiovascular disease prediction models in rheumatoid arthritis.

BACKGROUND: Rheumatoid arthritis comes with a 30% higher probability for cardiovascular disease than the general population. Current guidelines advocate for early and aggressive primary prevention and treatment of risk factors in high-risk populations but this excess risk is under-addressed in RA in real life. This is mainly due to difficulties met in the correct risk evaluation. This study aims to underline the differences in results of the main cardiovascular risk screening models in the real life rheumatoid arthritis population. METHODS: In a cross-sectional study, patients addressed to a tertiary care center in Romania for an biannual follow-up of rheumatoid arthritis and the ones who were considered free of any cardiovascular disease were assessed for subclinical atherosclerosis. Clinical, biological and carotidal ultrasound evaluations were performed. A number of cardiovascular disease prediction scores were performed and differences between tests were noted in regard to subclinical atherosclerosis as defined by the existence of carotid intima media thickness over 0,9 mm or carotid plaque. RESULTS: In a population of 29 Romanian rheumatoid arthritis patients free of cardiovascular disease, the performance of Framingham Risk Score, HeartSCORE, ARIC cardiovascular disease prediction score, Reynolds Risk Score, PROCAM risk score and Qrisk2 score were compared. All the scores under-diagnosed subclinical atherosclerosis. With an AUROC of 0,792, the SCORE model was the only one that could partially stratify patients in low, intermediate and high-risk categories. The use of the EULAR recommended modifier did not help to reclassify patients. CONCLUSION: The only score that showed a statistically significant prediction capacity for subclinical atherosclerosis in a Romanian rheumatoid arthritis population was SCORE. The additional calibration or the use of imaging techniques in CVD risk prediction for the intermediate risk category might be warranted.