Microscopic Positive Margins in Gastric Adenocarcinoma Following Oncological Resection: Prognostic Factors and Long-Term Survival.

BACKGROUND: In the context of gastric cancer, surgical resection stands as the sole curative treatment. Central to influencing overall survival are the resection margins. This research aims to identify the factors influential in determining microscopically positive resection margins (R1) and to evaluate overall survival. METHODS: Our study encompassed 549 patients diagnosed with adenocarcinoma of the stomach who underwent curative-intent surgery between January 2011 and December 2021 in our Surgery Department. We investigated the incidence of positive margins (R1) and their impact on survival rates, as well as the determinants of R1. The standardization of R1 involved ensuring a margin distance of less than 1 mm from the tumor line to the margin. RESULTS: The incidence of R1 margins was 13.29% (73 patients). Among these, proximal R1 margins were observed in 29 patients (39.72%), while 49 cases (67.12%) presented circumferentially positive margins, with 20 cases (27.39%) exhibiting distally positive margins. Nineteen patients (26.02%) had two R1 margins, and 3 patients had all resection margins microscopically positive (4.10%). Factors such as tumor dimension, invasion of other organs, pT stage, pN stage, pL1 stage, pV1 stage, pPn stage, Lauren type, and tumoral grading demonstrated significance (p < 0.01) in the occurrence of positive R1 margins. CONCLUSION: Tumor dimension, invasion of other organs, pT stage, pN stage, pL1 stage, pV1 stage, pPn stage, Lauren type, and tumoral grading could be regarded as factors for predicting microscopically positive margins. Moreover, positive resection margins have a detrimental impact on overall survival.

Vaccine Hesitancy among European Parents-Psychological and Social Factors Influencing the Decision to Vaccinate against HPV: A Systematic Review and Meta-Analysis.

BACKGROUND: Due to low adherence to HPV vaccination programs, the European region struggles with vaccination rates lower than 30% among the targeted population. The present report investigated various socio-demographic and psychological factors influencing European parents' hesitancy towards vaccinating their children. METHODS: As of September 2023, four databases were searched. After applying inclusion criteria, all articles comparing psychological and socio-demographic factors in parents who vaccinate or do not vaccinate their children were included. RESULTS: Twenty-five primary publications met the criteria, totaling 385,460 responders, of which 311,803 want to or have already vaccinated their child, and 73,555 do not wish to do so. Immigrant and employment status, religion, age of parents and the child's gender seemed to influence their decision to vaccinate their child. Previous experience with vaccines, perceived safety and efficacy and the mother's previous abnormal CCS results also impacted their decision. The caregivers' education, gender, civil status, number of children, family history of neoplasia or mother's CCS attendance did not influence their hesitancy to vaccine. CONCLUSION: Multiple demographic, social, economic and psychological barriers involved in the parents' hesitancy to vaccinate their children against the HPV virus were highlighted. Specific at-risk categories that need to be targeted with information, education and vaccination campaigns were identified.

Assessment of Physicians' Willingness to Work with Patients Not Yet Diagnosed with COVID-19 in a Romanian Sample.

BACKGROUND: The risk to physicians who worked with patients without confirmed COVID-19 testing during the pandemic has been little studied. However, they were at high risk. METHODS: In the summer of 2020, 1285 Romanian physicians participated in a single-center study. Participants (mean age = 48.21 years; 302 males and 982 females, all specialties) completed a series of single-item measures adapted from previous studies on work ethics and responsibility. This study used Mann-Whitney comparisons between physicians who reported that they knowingly had direct contact with COVID patients and those who did not regarding their willingness to work. RESULTS: Compared with their colleagues, physicians who reported not knowingly having direct contact with COVID patients reported less access to protective equipment, less overall willingness to respond when asked to work with infected patients, more likely to work out of fear of losing their jobs, and fear of legal repercussions. They received less training in the use of protective equipment. CONCLUSIONS: Physicians who worked with patients not yet diagnosed with COVID-19 were significantly less willing to work. The perception of invisible risk may explain the observed differences.

Comparison of the Burden Evolution of the Family Caregivers for Patients With Cancer and Nononcological Diseases Who Need Palliative Care: A Prospective Longitudinal Study.

Background: The family caregiver (FCG) is with the patient from diagnosis till the end of life. The accumulated burden has a negative impact on the caregiver's quality of life and on his physical and emotional well-being. Objective: To quantify the burden of care for a patient with palliative needs, and to compare the burden experienced by caregivers for nononcological patients with those for cancer patients. Design: Prospective longitudinal study. Setting/Participants: One hundred forty patient-primary caregiver pairs participated in the study, which were separated into two groups: those who cared for patients with nononcological diseases (n = 63) and those who cared for patients with cancer (n = 77). Measurements: The burden measurement was assessed with Burden Scale for FCGs. Results: The average score of the FCG's burden was significantly higher in the nononcological group (45 ± 14.45 vs. 36.52 ± 15.05; p = 0.001). In the case of caregivers for cancer patients it is noticed that the caregivers' burden decreases after the intervention of the specialized team (45.58 ± 14.11 at T1 vs. 36.65 ± 16.10 at T2; p = 0.001). The burden values for caring for patients with nononcological diseases remained in the plateau, indicating incremental caregiver adaptation, although the rising trend is still present toward the end of the term (47.43 ± 13.32 vs. 56.69 ± 15.44; p < 0.001). Conclusions: The burden dynamics are different depending on the patient's disease, duration of care, degree of dependence, number of comorbidities, and on the intervention of the palliative care team that ensures the support of the caregiver for the palliative patient.

Exploring why European primary care physicians sometimes do not think of, or act on, a possible cancer diagnosis. A qualitative study.

BACKGROUND: While primary care physicians (PCPs) play a key role in cancer detection, they can find cancer diagnosis challenging, and some patients have considerable delays between presentation and onward referral. AIM: To explore European PCPs' experiences and views on cases where they considered that they had been slow to think of, or act on, a possible cancer diagnosis. DESIGN & SETTING: A multicentre European qualitative study, based on an online survey with open-ended questions, asking PCPs for their narratives about cases when they had missed a diagnosis of cancer. METHOD: Using maximum variation sampling, PCPs in 23 European countries were asked to describe what happened in a case where they were slow to think of a cancer diagnosis, and for their views on why it happened. Thematic analysis was used to analyse the data. RESULTS: A total of 158 PCPs completed the questionnaire. The main themes were as follows: patients' descriptions did not suggest cancer; distracting factors reduced PCPs' cancer suspicions; patients' hesitancy delayed the diagnosis; system factors not facilitating timely diagnosis; PCPs felt that they had acted wrongly; and problems with communicating adequately. CONCLUSION: The study identified six overarching themes that need to be addressed. Doing so should reduce morbidity and mortality in the small proportion of patients who have a significant, avoidable delay in their cancer diagnosis. The 'Swiss cheese' model of accident causation showed how the themes related to each other.

Physicians' Trust in Relevant Institutions during the COVID-19 Pandemic: A Binary Logistic Model.

Little research has been done on professionals' perceptions of institutions and governments during epidemics. We aim to create a profile of physicians who feel they can raise public health issues with relevant institutions during a pandemic. A total of 1285 Romanian physicians completed an online survey as part of a larger study. We used binary logistic regression to profile physicians who felt they were able to raise public health issues with relevant institutions. Five predictors could differentiate between respondents who tended to agree with the trust statement and those who tended to disagree: feeling safe at work during the pandemic, considering the financial incentive worth the risk, receiving training on the use of protective equipment, having the same values as colleagues, and enjoying work as much as before the pandemic. Physicians who trusted the system to raise public health issues with the appropriate institutions were more likely to feel that they shared the same values as their colleagues, to say they were trained to use protective equipment during the pandemic, to feel that they were safe at work during the pandemic, to enjoy their work as much as before the pandemic, and to feel that the financial bonus justified the risk.

The Multifaceted Role and Regulation of Nlrp3 Inflammasome in Colitis-Associated Colo-Rectal Cancer: A Systematic Review.

Colitis-associated colo-rectal cancer remains the leading cause of mortality in inflammatory bowel diseases, with inflammation remaining one of the bridging points between the two pathologies. The NLRP3 inflammasome complex plays an important role in innate immunity; however, its misregulation can be responsible for the apparition of various pathologies such as ulcerative colitis. Our review focuses on the potential pathways of upregulation or downregulation of the NLRP3 complex, in addition to evaluating its role in the current clinical setting. Eighteen studies highlighted the potential pathways of NLRP3 complex regulation as well as its role in the metastatic process in colo-rectal cancer, with promising results. Further research is, however, needed in order to validate the results in a clinical setting.

Do Patient Delay and Diagnostic Delay Influence Long Term Survival in Patients with Gastric Cancer?

BACKGROUND AND AIMS: Gastric cancer is one of the most common malignancies, with an aggressive evolution and a poor long-term prognosis. No screening program is available in Europe for this pathology; therefore, the delay from the appearance of the first symptom until the initiation of treatment might influence the prognosis of gastric cancer patients. We aimed to investigate the impact on the prognosis of the delay in the presentation and diagnosis in patients with gastric adenocarcinoma. METHODS: Our study is a retrospective, single-center, observational cohort study, based on patients diagnosed with gastric adenocarcinoma and operated in our institution between 2013 and 2021. We have defined patient delay as the time from the onset of symptoms to the first encounter with a health care provider and diagnosis delay as the time from the first consultation with a health care provider to the establishment of the final diagnosis. RESULTS: A total of 671 patients were included in our study. The survival rate at 5 years was 55% for the patients operated with curative intent and 7.4% for the patients operated with palliative intent. Patient delay and diagnosis delay were not correlated with the overall survival. A lower survival was observed for patients admitted through transfer (p<0.001) or the emergency department (p<0.001). No statistically significant relationship was identified between patient delay or diagnosis delay and the age, gender or area of origin of patients. Patients that experienced melena or hematemesis had a shorter patient delay, with a highly significant statistical relationship (p<0.01). Patients that experienced nausea, epigastric pain, palpable epigastric tumor mass or anorexia also had a highly significant statistical relationship between the symptoms and the patient delay interval. CONCLUSIONS: The overall survival is not influenced by the patient delay or diagnosis delay. An earlier presentation was correlated with some specific exhibited symptoms: upper gastro-intestinal bleeding, abdominal pain, palpable epigastric tumor, nausea.

Nanotechnology in the Diagnostic and Therapy of Hepatocellular Carcinoma.

Hepatocellular carcinoma is the most common liver malignancy and is among the top five most common cancers. Despite the progress of surgery and chemotherapy, the results are often disappointing, in part due to chemoresistance. This type of tumor has special characteristics that allow the improvement of diagnostic and treatment techniques used in clinical practice, by combining nanotechnology. This article presents a brief review of the literature focused on nano-conditioned diagnostic methods, targeted therapy, and therapeutic implications for the pathology of hepatocellular carcinoma. Within each subdomain, several modern technologies with significant impact were highlighted: serological, imaging, or histopathological diagnosis; intraoperative detection; carrier-type nano-conditioned therapy, thermal ablation, and gene therapy. The prospects offered by nanomedicine will strengthen the hope of more efficient diagnoses and therapies in the future.

Computed Tomography for the Diagnosis of Intraperitoneal Infected Fluid Collections after Surgery for Gastric Cancer. Role of Texture Analysis.

BACKGROUND AND AIMS: Several computed tomographic (CT) imaging features have been proposed to describe the infection of postoperative abdominal fluid collections; however, these features are vague, and there is a significant overlap between infected and non-infected collections. We assessed the role of textural parameters as additional diagnostic tools for distinguishing between infected and non-infected peritoneal collections in patients operated for gastric cancer. METHODS: From 527 patients operated for gastric cancer, we retrospectively selected 82 cases with intraperitoneal collections who underwent CT exams. The fluid component was analyzed through a novel method (texture analysis); different patterns of pixel intensity and distribution were extracted and processed through a dedicated software (MaZda). A univariate analysis comparing the parameters of texture analysis between the two groups was performed. Afterwards, a multivariate analysis was performed for the univariate statistically significant parameters. RESULTS: The study included 82 patients with bacteriologically verified infected (n=40) and noninfected (n=42) intraperitoneal effusions. The univariate analysis evidenced statistically significant differences between all the parameters involved. The multivariate analysis highlighted 10 parameters as being statistically significant, adjusted to Bonferroni correction. CONCLUSIONS: Our evidence supports the fact that textural analysis can be used as a complementary diagnostic tool for the detection of infected fluid collections after gastric cancer surgery. Further studies are required to validate the accuracy of this method.

Primary Care System Factors and Clinical Decision-making in Patients that Could Have Lung Cancer: a Vignette Study in Five Balkan Region Countries.

INTRODUCTION: Lung cancer is the leading cause of cancer death, with wide variations in national survival rates. This study compares primary care system factors and primary care practitioners' (PCPs') clinical decision-making for a vignette of a patient that could have lung cancer in five Balkan region countries (Slovenia, Croatia, Bulgaria, Greece, Romania). METHODS: PCPs participated in an online questionnaire that asked for demographic data, practice characteristics, and information on health system factors. Participants were also asked to make clinical decisions in a vignette of a patient with possible lung cancer. RESULTS: The survey was completed by 475 PCPs. There were significant national differences in PCPs' direct access to investigations, particularly to advanced imaging. PCPs from Bulgaria, Greece, and Romania were more likely to organise relevant investigations. The highest specialist referral rates were in Bulgaria and Romania. PCPs in Bulgaria were less likely to have access to clinical guidelines, and PCPs from Slovenia and Croatia were more likely to have access to a cancer fast-track specialist appointment system. The PCPs' country had a significant effect on their likelihood of investigating or referring the patient. CONCLUSIONS: There are large differences between Balkan region countries in PCPs' levels of direct access to investigations. When faced with a vignette of a patient with the possibility of having lung cancer, their investigation and referral rates vary considerably. To reduce diagnostic delay in lung cancer, direct PCP access to advanced imaging, availability of relevant clinical guidelines, and fast-track referral systems are needed.

Factors Influencing the Quality of Life of the Primary Caregiver of a Palliative Patient: Narrative Review.

Introduction: Quality of life is a difficult concept to understand and therefore difficult to evaluate. From the general definition to the individuality of the person, there are factors that positively or negatively influence quality of life. Aim: The aim is to identify the factors that influence the quality of life of primary caregivers of patients with progressive life-threatening illnesses. Methodology: PUBMED was searched to retrieve the relevant literature for our research questions used the following keywords: "Quality of life and caregiver or caretaker and palliative care or life threatening disease." Only quantitative studies containing randomized trials were included using at least one caregiver's quality-of-life tool, not older than 10 years, written in English, and with subjects older than 18 years, who considered they were involved in the active care of a palliative patient. Results: A number of 687 articles were identified from which only 38 were analyzed in detail regarding the impact of different interventions over the quality-of-life of the caregiver. The factors that influence the quality-of-life can be distributed into four areas: social, psycho-emotional, financial, and physical. The disruption of daily routine, non-existential financial resources, multiple responsibilities and psychological tension are reduce the caregiver's quality-of-life. Family involvment, knowledge about disease and treatment, abilities to communicate patient and the team and optimistic atitude improve caregiver's quality-of-life. Conclusions: The quality of life of the caregiver be improved by social, and relaxation techniques, reduction of insecurity or anxiety. Furthermore, the caregiver's quality of increases through and adequate communication diagnosis, a proper conducted treatment and education over the care maneuvers.

Analysis of the MLH1, MLH2, MLH6, PMS2 genes and their correlations with clinical data in rectal mucinous adenocarcinoma.

BACKGROUND: Microsatellites are short repeated DNA sequences normally found in the human genome. Following specific mutations, microsatellites can vary in the number of repeats thus making the DNA unstable. Microsatellite instability (MSI) is responsible for approximately 20% of rectal cancers, while the remaining 80% are caused by chromosomal instability. One of the following genes, MLH1, MLH2, MLH 6, and PMS2, is inactivated, leading to MSI colorectal cancers. AIM: This study aimed to analyze the expression of some MMR system genes presenting mutations in mucinous rectal cancer and their correlations with clinical data. METHODS: A retrospective study was performed on patients with rectal mucinous adenocarcinoma who underwent surgery between January 2000 and January 2017. We collected a total of 42 patients and analyzed the demographic data, histopathological results and MMR system genes mentioned above. RESULTS: Almost 93% of the cases analyzed had MSI-H and only 7% were MSI-L. For MLH1, 50% of stage T2 and 50% of stage T4 had weak expression, while in stage T3, 42.50% had moderate expression. Regarding the N stage, we found that 66.67% of the patients with moderate gene expression (2+) were N2, while 42% of the patients with weak expression were N0. For MSH2, the majority of patients with strong gene expression were in stage T3 (27%). Weak expression was found in 50% of the patients in stage T2, 35% of the patients in stage T3, and 33.3% in T4. In 44.44% of the weak expression was N2, while for strong expression, there was an equivalent percentage of 33.33% in stages N1 and N2. Describing the MSH6 gene, we found that the most heterogeneous results were in stage T3. Weak expression was observed in 38.46% of the patients, while moderate and strong expression was observed in 30.77% and 11.54% respectively. Analysis of PMS2 revealed that 66.67% of the patients in stage T4 had a weak expression of the gene, while the same expression was found in 38.46% of the patients in stage T3. A total of 23.08% of patients in stage T3 had strong gene expression. We also analyzed the overall gene expression. Thus, we found that three patients (7.14%) had only 1, three genes were expressed, nine (21.42%) had two genes and the remaining 27 patients had all 4. The 1-year survival rate in the analyzed lot was 75%, decreasing to 60% in the second year and 35% in the 3rd. There were no statistically significant differences in survival data between the stages or gene expression. CONCLUSIONS: Our study showed no statistical difference regarding the survival on different gene expression or staging, consistent with studies that found that mucin expression does not have a significant impact on local recurrence, nor does it affect nodal down staging. KEY WORDS: Mucinous adenocarcinoma, Microsatelites instability.

Lights and Shadows of the Perception of the Use of Telemedicine by Romanian Family Doctors During the COVID-19 Pandemic.

INTRODUCTION: Telemedicine has emerged as a critical technology to mitigate SARS-CoV-2 infection. We aim in this work to explore how general practitioners (GPs) perceived the use of telemedicine, recently recognized and reimbursed by the Public Health Insurance House (PHIH) for primary care (PC) provision. METHODS: A cross-sectional study was performed in 2020 in one county of Romania using an anonymous questionnaire that assessed physicians' perceptions regarding teleconsultation, reliability in tele-decision, remote pathology management, pregnant women's surveillance, patients' satisfaction with telemedicine, the need for its further reimbursement. Bivariate correlation was used to measure associations between the investigated issues. RESULTS: More than a quarter of GPs (28.6%) found it easier to address patients' healthcare needs remotely, while 60.7% considered time-consuming teleconsultations compared to face-to-face visits. Tele-diagnostic uncertainty was expressed by 64.3% of physicians, and a quarter were confident in tele-decisions. Almost half of GPs (43%) observed patients' satisfaction with tele-visits, while half said patients encountered difficulties using technology. A large percentage of doctors (62.5%) perceived that patients felt as well treated by virtual as in-person visit and 91.1% suggested post-pandemic reimbursement. The results of the bivariate correlation showed that physicians who perceived positive patient feedback on telemedicine were more supportive of subsequent reimbursement. CONCLUSION: This study showed the GPs' positive perception of the use of telemedicine. Its adoption in PC has shed light on the shadows of the pandemic. The time-consuming nature of teleconsultations, uncertainty in tele-decisions, patients' difficulties in using technology were seen as shadows of telecare. However, most of the GPs surveyed agreed with the need for further reimbursement. Future work should focus on innovative solutions for integrating telemedicine as complementary form of PC, the need for telemedicine-based training for GPs to improve capacity building, and patients' perceptions of virtual care, helping to build trust and satisfaction.

Stapled Hemorrhoidopexy: Technique and Long Term Results.

Background: Stapled hemorrhoidopexy (Longo operation) is a infrequent technique in our area. A different concept from hemorrhoidectomy, a proportionally important raise in cost and a special training may have contributed to it. We report our long-term results with the standard technique. Methods: The data of 35 patients with symptomatic second- and third-degree hemorrhoids who had stapled hemorrhoidopexy using a PPH03 stapler, from 01 January 2012 to 04 December 2020, were retrospectively collected. The sex ratio male: female was 3:4 and the mean age 45 (range 28-60) years. The follow-up consisted in a rectal exam and evaluated anatomical recurrence or prolapse. Results: The mean operative time was 42 (30-70) min. The mean parenteral analgesic doses during the first 24 h were 1,52. The mean postoperative hospital stay was 1.55 (1-2) days. A single patient needed reoperation for a staple line bleeding, two patients had a thrombosis of internal hemorrhoids and in one patient a small prolapse was diagnosed at 3 months follow-up. No hematoma, anastomotic stenosis, persistent anal pain, tenesmus, or impaired anal continence was recorded. One patient mentioned discomfort related to the presence of staples. Patients were followed-up for 6 (1-9) years. Global satisfaction rate was 94%. Conclusion: Stapled hemorrhoidopexy procedure is a safe and feasible procedure, which necessitates few analgesics and allows an early discharge. A rigorous selection of cases and a correct surgical technique allow to obtain good long-term results and offer a high level of patients satisfaction.

Primary care practitioners' diagnostic action when the patient may have cancer: an exploratory vignette study in 20 European countries.

OBJECTIVES: Cancer survival rates vary widely between European countries, with differences in timeliness of diagnosis thought to be one key reason. There is little evidence on the way in which different healthcare systems influence primary care practitioners' (PCPs) referral decisions in patients who could have cancer.This study aimed to explore PCPs' diagnostic actions (whether or not they perform a key diagnostic test and/or refer to a specialist) in patients with symptoms that could be due to cancer and how they vary across European countries. DESIGN: A primary care survey. PCPs were given vignettes describing patients with symptoms that could indicate cancer and asked how they would manage these patients. The likelihood of taking immediate diagnostic action (a diagnostic test and/or referral) in the different participating countries was analysed. Comparisons between the likelihood of taking immediate diagnostic action and physician characteristics were calculated. SETTING: Centres in 20 European countries with widely varying cancer survival rates. PARTICIPANTS: A total of 2086 PCPs answered the survey question, with a median of 72 PCPs per country. RESULTS: PCPs' likelihood of immediate diagnostic action at the first consultation varied from 50% to 82% between countries. PCPs who were more experienced were more likely to take immediate diagnostic action than their peers. CONCLUSION: When given vignettes of patients with a low but significant possibility of cancer, more than half of PCPs across Europe would take diagnostic action, most often by ordering diagnostic tests. However, there are substantial between-country variations.

A combined laparoscopic and endoscopic approach for the removal of a gastric foreign body. A case report and review of the literature.

BACKGROUND AND AIM: Foreign bodies that are ingested and will not pass spontaneously through the gastrointestinal tract, need to be removed either endoscopically or surgically. Surgery will be required when endoscopy alone fails to retrieve the foreign body. In this study, we aimed to present our experience with an combined minimal invasive approach for the removal of a gastric foreign body and to review the medical literature on the complexities related to its management. METHODS: We report a successful technique represented by a combined laparoscopic and endoscopic approach for the retrieval of a gastric foreign body. A 51 year old male patient, with a longstanding psychiatric history, who ingested a folded bank card with suicidal purpose, had the foreign body removed using this combined minimal invasive approach. RESULTS: The operating time was 150 minutes, there was no blood loss and no perioperative complications. The patient fulfilled the discharge criteria on the 3rd postoperative day DISCUSSION : The approach for ingested foreign bodies should be considered for each patient independently, depending on the characteristics, location and existence of complications of the retained object. CONCLUSION: This combined minimal invasive technique is safe and feasible, with excellent results for the retrieval of large, non-malleable gastric foreign bodies. KEY WORDS: Endoscopy, Foreign body, Laparoscopy, Removal.

Inferior Pancreatico-Duodenal Artery Aneurysm with Superior Mesenteric Artery Stenosis.

Pancreatico-duodenal artery aneurysm (PDAA) associated with stenosis or occlusion of the celiac trunk is a rare condition. Furthermore, PDAAs associated with stenosis of the superior mesenteric artery (SMA) are even more uncommon, with only six cases reported in the literature. We report a case of a 61-year old male patient who presented with hematemesis, haematochezia and haemorrhagic shock. The upper gastrointestinal endoscopy revealed an ulcerous lesion at the third portion of the duodenum, without achieving the haemostasis. The emergency laparotomy (suture of the lesion and gastro-entero-anastomosis) permitted temporary haemostasis. Computed tomography angiography identified the PDAA ruptured into the third portion of the duodenum and the SMA stenosis at its origin; a dense network of collateral vessels was present. The patient was successfully managed with coil embolization. Short and mid-term follow-up were without incidents.

Laparoscopic cholecystectomy for overlooked duplicated gallbladder. A case report and review of the literature.

INTRODUCTION: Duplicated gallbladder is a seldom surgical finding that frequently eludes detection on routine preoperative imaging and in some circumstances it might be even overlooked during surgery. Identification of this anomaly and its various types is important in order prevent post operative complications and recurrent symptoms after cholecystectomy. PRESENTATION OF CASE: We present a female patient with biliary simptomatology who had previous cholecystectomy. Preoperatory imaging (MRCP) suspects a duplicated gallbladder which was confirmed intraoperatory and cholecystectomy was performed. The postoperative recovery was uneventful. DISCUSSION: There are a very small number of reported cases with laparoscopic cholecystectomy for overlooked gallbladder duplication. Preoperative diagnosis holds a major contribution in planning surgery and preventing potential biliary injuries or re-operation if accessory gallbladder has been overlooked during initial surgery. CONCLUSION: Accessory gallbladder is a uncommon congenital anomaly that demands particular consideration. Duplicated gallbladder is associated with increased operative difficulty and risks, including conversion to open cholecystectomy common bile duct injury or second cholecystectomy due to overlooked accessory gallbladder. KEY WORDS: Duplicated gallbladder, Laparoscopic cholecystectomy, Overlooked accessory gallbladder, Reoperation.

Children`s lifestyle behaviors in relation to anthropometric indices: a family practice study.

INTRODUCTION: Obesity prevention in children represents one of the main concerns in primary care. In order to develop into a healthy adult, the child has to follow a healthy lifestyle in all aspects: nutritional, behavioral, physical and recreational. Our main goal was to identify which habits may influence the children's somatic development. METHOD: Our study, performed in a family practice, consisted in a questionnaire regarding physical activity, diet and use of electronic devices.After obtaining the parent's and child's informed consent to participate in our cross-sectional study, 98 consecutive children aged 5-15 years, examined in the family practice, were enlisted. After collecting the answers, weight, height, waist circumference, wrist circumference, subscapular skinfold thickness were measured and body mass index was calculated. RESULTS: The analysis of the relationship between the anthropometric data showed a significant difference between girls and boys only in respect of the wrist circumference. The groups performing daily household activities had a significantly increased weight, BMI, abdominal and wrist circumference. Participation in physical education classes in school was associated significantly only with the wrist circumference. Frequent change of the option for extracurricular sport showed a significant difference in weight, waist circumference, and wrist in favor of the group that practiced many sports. Fast food diet and the type of alimentary habits of the family (home cooked, pre-cooked, or ordered food) showed differences between medians of the anthropometric indices with higher values for those eating more frequently fast food or ordered food, yet without reaching statistical significance. CONCLUSION: Both girls and boys, in the presence of an unhealthy lifestyle (lack of recreational and educational physical activity, food habits, inappropriate time spent in front of a screen) had unfavorable adiposity indices.