The Impact of Cancer Stem Cells in Colorectal Cancer.

Despite incessant research, colorectal cancer (CRC) is still one of the most common causes of fatality in both men and women worldwide. Over time, advancements in medical treatments have notably enhanced the survival rates of patients with colorectal cancer. Managing metastatic CRC involves a complex tradeoff between the potential benefits and adverse effects of treatment, considering factors like disease progression, treatment toxicity, drug resistance, and the overall impact on the patient's quality of life. An increasing body of evidence highlights the significance of the cancer stem cell (CSC) concept, proposing that CSCs occupy a central role in triggering cancer. CSCs have been a focal point of extensive research in a variety of cancer types, including CRC. Colorectal cancer stem cells (CCSCs) play a crucial role in tumor initiation, metastasis, and therapy resistance, making them potential treatment targets. Various methods exist for isolating CCSCs, and understanding the mechanisms of drug resistance associated with them is crucial. This paper offers an overview of the current body of research pertaining to the comprehension of CSCs in colorectal cancer.

Parathyroid Cancer-A Rare Finding during Parathyroidectomy in High Volume Surgery Centre.

Background and Objectives: Parathyroid cancer is a very rare endocrine tumor, especially in patients with secondary hyperparathyroidism due to end stage renal disease failure. This pathology is difficult to diagnose preoperatively because it has nonspecific clinical manifestations and paraclinical aspects. Our study of the literature identified 34 reported cases of parathyroid carcinoma over the last 40 years in patients undergoing dialysis. We present our experience as illustrative of the features of clinical presentation and histopathological findings of parathyroid carcinoma and assess its management considering the recent relevant literature. Materials and Methods: From January 2012 to November 2022, 650 patients with secondary hyperparathyroidism undergoing dialysis were treated at our academic Department of General Surgery and only two cases of parathyroid carcinoma were diagnosed on histopathological examination. Results: All patients presented with symptomatic hypercalcemia, with no clinical or imaging suspicion of malignant disease and were surgically treated by total parathyroidectomy. Histopathological examination revealed morphologic aspects of parathyroid carcinoma in two cases and immunostaining of Ki-67 was performed for diagnostic confirmation. Postoperative follow-up showed no signs of recurrence and no oncological adjuvant treatment or surgical reinterventions were needed. Conclusions: Parathyroid neoplasia is a particularly rare disease, that remains a challenge when it comes to diagnosis and proper management. Surgical approach is the only valid treatment to remove the malignant tissue and thus improve the patient's prognosis. Medical and oncologic treatment may be beneficial to control hypercalcemia in case of tumor recurrence.

CD34-Structure, Functions and Relationship with Cancer Stem Cells.

The CD34 protein was identified almost four decades ago as a biomarker for hematopoietic stem cell progenitors. CD34 expression of these stem cells has been exploited for therapeutic purposes in various hematological disorders. In the last few decades, studies have revealed the presence of CD34 expression on other types of cells with non-hematopoietic origins, such as interstitial cells, endothelial cells, fibrocytes, and muscle satellite cells. Furthermore, CD34 expression may also be found on a variety of cancer stem cells. Nowadays, the molecular functions of this protein have been involved in a variety of cellular functions, such as enhancing proliferation and blocking cell differentiation, enhanced lymphocyte adhesion, and cell morphogenesis. Although a complete understanding of this transmembrane protein, including its developmental origins, its stem cell connections, and other functions, is yet to be achieved. In this paper, we aimed to carry out a systematic analysis of the structure, functions, and relationship with cancer stem cells of CD34 based on the literature overview.

Open and Laparoscopic Surgical Approache in Incisional Hernias: A Descriptive Analysis.

Background: Incisional hernias, occurring in 10-20% of patients post-abdominal surgery, significantly affect patient quality of life and healthcare systems. This study analyses two hernia repair methods: laparoscopic intraperitoneal onlay mesh (IPOM) and open on-lay hernioplasty. Key analysis factors include operative time, postoperative pain, complications, length of hospital stay, recovery speed, and recurrence rates, with the goal of identifying the most effective and beneficial approach for patients. Methods: We conducted a retrospective study on 70 patients with postoperative parietal defects at the Dr Carol Davila Clinical Nephrology Hospital, Bucharest, from January 2018 to December 2021. Patients underwent either laparoscopic IPOM (42 patients) or open hernioplasty (28 patients) for uncomplicated incisional hernia repair. We analyzed demographic data, comorbidities, defect size and location, previous surgeries, and surgical outcomes. Results: The laparoscopic group had a slightly shorter operative time and significantly lower postoperative pain levels, as assessed by the Visual Analog Scale. The laparoscopic approach also resulted in shorter hospital stays and quicker return to routine activities. Complications, such as seroma and hematoma, were more common in the open surgery group, but no wound infections or prosthesis rejections were observed in either group. Notably, the open surgery group showed a higher recurrence rate (11 %) compared to none in the laparoscopic group within a one-year follow-up. Conclusion: Laparoscopic IPOM for incisional hernia repair shows benefits over open hernioplasty, with less pain, shorter hospitalization, faster recovery, and lower recurrence. Its growing preference and potential for further research are highlighted.

Interstitial Cells of Cajal-Origin, Distribution and Relationship with Gastrointestinal Tumors.

The interstitial cells of Cajal (ICC) represent a particular network formed by some peculiar cells that were first described by the great neuroanatomist, S. Ramon y Cajal. Nowadays, the ICC have become a fascinating topic for scientists, arousing their curiosity; as a result, there is a vast number of published articles related to the ICC. Today, everybody widely accepts that the ICC represent the pacemaker of the gastrointestinal tract and are highly probable to be the origin cells for gastrointestinal tumors (GISTs). Recently, Cajal-like cells (ICLC) were described, which are found in different organs but with an as yet unknown physiological role that needs further study. New information regarding intestinal development indicates that the ICC (fibroblast-like and muscle-like) and intestinal muscle cells have the same common embryonic cells, thereby presenting the same cellular ultrastructure. Nowadays, there is a vast quantity of information that proves the connection of the ICC and GISTs. Both of them are known to present c-kit expression and the same ultrastructural cell features, which includes minimal myoid differentiation that is noticed in GISTs, therefore, supporting the hypothesis that GISTs are ICC-related tumors. In this review, we have tried to highlight the origin and distribution of Cajal interstitial cells based on their ultrastructural features as well as their relationship with gastrointestinal stromal tumors.

Intraoperative Monitoring of Parathormone in the Surgical Treatment of Renal Hyperparathyroidism.

Intraoperative monitoring of parathyroid hormone can confirm the complete excision of hyperfunctional parathyroid tissue, as the plasma half-life of PTH is approximately 5 minutes. The purpose of this study was to analyse the values of parathormon (PTH) and the intraoperative impact in patients with secondary hyperparathyroidism of renal cause (sHPT). A series of 86 patients who were hospitalised in our clinic between February 2015 to December 2018, were included in the study rom. All patients underwent surgery with PTH monitoring. PTH was determined preoperatively, intraoperatively 15 minutes after parathyroidectomy and postoperatively. Out of a total of 86 patients, 6 patients had non-functional renal transplant. 81 patients were operated on per primam and 5 patients were operated for disease recurrence. There were 77 total parathyroidectomies and 4 subtotal parathyroidectomies. One patient had 5 parathyroid glands. There were 4 patients with recurrent hyper-plastic tissue excision. Blood samples were collected intraoperatively through the puncture of the jugular vein. The PTH value was determined by the Elecsys PTH STATÃÂî test. The mean value of preoperative PTH was 1658 pg / mL and decreased to 46.5 pg / mL at the end of the operation. Subsequently, the level of PTH harvested at 3-6 months increased slightly to 59.8 pg / mL. 80 (93%) of patients had elevated preoperative calcium values. Recurrent hyperparathyroidism was found in 1 of the 4 patients who underwent subtotal parathyroidectomy. IPTH value is influenced by the intraoperative manipulation of the parathyroid glands, the individual variability of PTH half-life and the physiological state of the patient. The decrease of PTH measured intraoperatively at 15 minutes after harvest with at least 90% of the preoperative value indicates the success of a total parathyroidectomy, with normalisation of calcium and PTH.

Parameters for Predicting Tumour Response Following Neoadjuvant Chemoradiotherapy for Patients with Rectal Cancer.

Introduction: Pathologic response following neoadjuvant chemoradiotherapy (nCRT) can vary from pathologic complete response (pCR), to tumour downstaging or minimum to no response. Our goal was to evaluate the parameters that could predict response to neoadjuvant therapy for patients with rectal cancer. Method: We performed a retrospective study and reviewed the medical documentation for patients that received treatment for rectal cancer in our surgical department between 2014-2018 and received nCRT. Results: A total of 98 patients were included in the study. 66 patients were males (67,3%) and 32 were females (32,7%). The mean age was 64,6 (39-87). The 48 months overall survival rate was 81,63% and the 48 months disease-free survival rate was 69,38%. Tumour grading was considered as a statisti cally significant parameter for evaluating the pathologic response. The tumours most likely to respond to radio-chemotherapy were G1 or G2 grade. T4 tumours compared with lesser T stages were less likely to achieve pathologic complete response. Elevated CEA levels predicted a poor pathologic response to nCRT. Conclusion: Our study concluded that tumour related factors, biologic and imagistic findings such as tumour stage, lymph node, tumour differentiation grade and CEA levels can be used as parameters for predicting the tumour response following neoadjuvant therapy.

The Value of Endoscopy as a Predictive Factor when Evaluating the Clinical Response to Neoadjuvant Chemoradiotherapy for Patients with Rectal Cancer.

Introduction: Standard treatment rectal cancer according to numerous international guidelines recommends neoadjuvant chemoradiotherapy (nCRT). Literature data suggests that a better response to nCRT (greater tumour regression) leads to improved overall survival rates (OS) and disease-free survival rates (DFS). Tumour response to nCRT can be assessed either through clinical or pathological examination. The clinical tumour response is evaluated via a digital rectal examination, endoscopy (with or without ultrasound) and DWI-MRI. Our goal was to see if, when evaluating the clinical response to neoadjuvant chemoradiotherapy we can rely on the endoscopic findings and if it could have a predictive value for the overall outcomes. Method: A retrospective study was performed on 43 patients that were treated for rectal cancer in our clinic following neoadjuvant chemoradiotherapy. We divided the patients into two groups regarding the endoscopy grading. Results: Patients with a better response (endoscopy good grade) had a better disease free survival rate and lower recurrence rate compared to patients with a endoscopy low grade (86,5% vs 56,6%) and (10.34% vs 42,85%). Conclusion: Endoscopy could be a useful tool in appreciating the tumour response to nCRT, and further research is needed in determining the best method for evaluating clinical response to neo adjuvant therapy in patients with rectal cancer.

The Value of Imaging of the Parathyroid Glands in Secondary Hyperparathyroidism.

It is estimated that up to 90% of patients with chronic kidney disease develop secondary hyperparathyroidism (sHPT). Although the disease has multiple manifestations, the most important pathological feature, from the point of view of increased mortality, is represented by the ectopic arterial, myocardial and cardiac valvular calcifications. The calcifications are progressive and lead to high blood pressure, left ventricular hypertrophy, atrio-ventricular blocks, angina and myocardial infarction. Therefore the risk of cardio-vascular events is increased. Failure of drug therapy to control disease progression is an indication for parathyroidectomy. In sHPT all parathyroid glands are affected, hence the need to detect 4 glands intraoperatively, by bilateral cervical exploration. However, considering the possibility of ectopic localization of these glands as well as the possibility of some supernumerary glands, it is desirable to have an imagistic map as accurate as possible, thus avoiding the risk of postoperative recurrence. The available imaging investigations are represented by the ultrasound of the cervical region, the parathyroid scintigraphy and those of the second line - CT or MRI examination. If in primary hyperparathyroidism, where there is only one parathyroid adenoma (or two), the preoperative imaging results are satisfactory, in sHPT there are many cases in which the imaging does not reveal all four parathyroid glands.

Clinical Aspects of Parathyroid Hyperplasia in Secondary Renal Hyperparathyroidism.

The secondary hyperparathyroidism (sHPT) affects all patients with chronic renal failure in different degrees. The chronic kidney disease is often associated with multiple severe comorbidities, therefore the figures for mortality are higher than in the general population. The failure of medical treatment is an indication for surgical treatment. The recurrence of the disease in secondary hyperpara-thyroidism after surgical treatment using total parathyroid with autotransplantation or subtotal parathyroidectomy may be a challenge due to hyperplasia of the remaining tissue. The purpose of this retrospective study was to highlight the risk factors for the occurrence of glandular hyperplasia in patients with secondary hyperparathyroidism and to determine optimal surgery approach for secondary hyperparathyroidism in order to minimize relapse rates. Parathyroid size evaluation may suggest the presence of nodular hyperplasia contributing to an early parathyroidectomy and at the same time selecting the best surgical treatment for sHPT patients. As resistance to medical therapy is due to the presence of nodular hyperplasia, some authors recomends subtotal parathyroidectomy with the excision of these glands, with the remaining parathyroids tissue and function controlled by medical therapy (20).

A Pilot Study on Tamoxifen Sexual Side Effects and Hand Preference in Male Breast Cancer.

Recent clinical and imaging studies suggest that sex hormones modulate sexuality according to a psychophysiologic process of lateralization of the brain, with androgens playing a greater role in sexual functioning of left hemibrain/right handedness and estrogens possibly for right hemibrain/left handedness. Based on this perspective, the current study attempted to specify the relationship between hand preference, estrogens, and sexual function in subjects with male breast cancer, taking into account the sexual side effects of tamoxifen as the agent for inhibiting estrogen action. Twenty-eight Romanian men-17 right-handed and 11 left-handed-undergoing treatment with tamoxifen for male breast cancer participated in this study. These men were assessed both prior to and during tamoxifen treatment using the International Index of Erectile Function, a standardized instrument used for the evaluation of various aspects of sexual functioning, including erectile function (EF), orgasmic function (OF), sexual desire (SD), and overall functioning (OF). A main effect for handedness was found on EF, OF, SD, and OS scales, with right-handed men showing higher functioning than left-handed men. Regarding interaction effects, the left-handed group of men showed greater decreased sexual functioning during tamoxifen (on three subscales: OF, SD, OS) compared to right-handed men. Further research should be conducted in order to support and refine this potential lateralized process of sexual neuromodulation within the brain.

How could perioperative anxiety be addressed via surgical team communication approaches? Findings from a scoping review.

OBJECTIVES: Surgical patients and their families experience high rates of perioperative anxiety, which determine a negative impact on their surgery-related outcomes. Understanding what communicational aspects positively impact perioperative anxiety may help promote more efficient, patient-centered communication approaches which could address this issue. The aim of this scoping review was to synthesize published research on communication between surgical employees and adult patients and their relatives, and its role in managing perioperative anxiety. METHODS: A scoping review approach was used across four international databases to search for publications detailing communicational interventions and approaches employed in surgical contexts and their impact on surgical patients' and their caregivers' perioperative anxiety levels. Results were narratively synthesized. RESULTS: Twenty-two studies were included in this scoping review, which were grouped according to their communication intervention into one of five categories: technology-assisted interventions, interpersonal communication, educational programs, tools for facilitating exchange of information and theory-derived communication strategies. Records reported mixed results in terms of reducing perioperative anxiety. Facilitating and hindering factors in interpersonal communication in this context were further synthesized. CONCLUSION: A multitude of communicational approaches and their effect on anxiety have been investigated within surgical settings, with varying results. Existing evidence suggests that it is vital to address surgical patients' anxiety through personalized empathetic communication, tailored to an individual's case, preferences, and needs. Key aspects of patient-healthcare professional communication which may impact perioperative anxiety were identified and may be utilized in future trainings for communication skills among surgical teams.

Preliminary study with bicalutamide in heterosexual and homosexual patients with prostate cancer: a possible implication of androgens in male homosexual arousal.

OBJECTIVE: • Not only has a precise characterization of libido and sexual arousal in men as a central neural process been lacking, but the interactive role of gonadal hormones and sexual orientation in such processes has never been investigated. We investigate the relationships among sexual hormones, sexual arousal, and sexual orientation in men by comparing the self-reported sexual response of heterosexual and homosexual men with locally advanced prostate neoplasm, receiving the non-steroidal anti-androgen bicalutamide as monotherapy. PATIENTS AND METHODS: • 29 Romanian men participated in this study: 17 heterosexual and 12 homosexual. Patients were undergoing treatment for prostate cancer consisting of a standard daily dose of 50 mg bicalutamide, a fast acting non-steroidal anti-androgen with action comparable to other anti-androgen drugs but with reportedly fewer sexual side effects. • Patients retrospectively provided information regarding their sexual functioning measured by the IIEF prior to commencing bicalutamide treatment. • Then, about five weeks later, patients were asked to prospectively provide information regarding their current sexual functioning while undergoing bicalutamide treatment. RESULTS: • Overall IIEF scores as well as the Erectile Function, Orgasmic Function, Sexual Desire, and Overall Satisfaction subscales showed group, treatment, and group by treatment effects. • The Intercourse Satisfaction subscale showed group and group by treatment effects. • On most subscales, homosexual men showed lower functioning than heterosexual men, primarily in response to treatment with bicalutamide. CONCLUSIONS: • Treatment with an anti-androgen in a clinical population of men undergoing therapy for prostate cancer affected homosexual men more than heterosexual men, although not all heterosexual men were unaffected. • These results are discussed in the context of dual sexual natures, a concept recently developed in the sexual literature. • Furthermore, these findings reiterate the importance of incorporating such variables as sexual orientation into studies investigating medical treatments on sexual response.

A histopathological and immunohistochemical approach of surgical emergencies of GIST. An interdisciplinary study.

The tailored approach to gastrointestinal stromal tumors (GISTs) has led to better prognosis for these types of tumors. Also, finding out GIST's pathology has led to a better understanding of oncogenesis and cancer therapy in general. The rapid expansion of molecular and pathological knowledge of GISTs has given this disease a promising future. We analyze 30 cases of GISTs operated on in our clinic with confirmed diagnosis by immunohistochemistry. Most of the cases were acute cases that required urgent surgical therapy. An extended analysis of these cases is performed in order to underline their special features. We recorded 17 GISTs of the stomach, 12 GISTs of the small bowel and one esophageal GIST. Of the 30 cases, 15 cases required urgent surgery presenting with GI bleeding or shock following intraperitoneal rupture and bleeding or intestinal obstruction. Of the 15 cases that required urgent surgery 12 cases presented with serosal involvement. Twenty-four cases presented spindle cell histology, four cases were epithelioid and two cases presented mixed cellularity. Although acute presentation of GISTs is not the rule, 15 of 30 of our cases required immediate surgery and a high proportion of them (12/15) presented with serosal involvement. Serosal involvement may warrant the need for a macroscopic classification of GISTs and correlation to therapy. While overall mortality was not high in our series, morbidity is affected by acute presentation, though not specifically pertaining to the diagnosis of GIST. Acute presentations were more frequent, in our series, for small bowel GISTs, compared to gastric GISTs. Serosal involvement was more frequent in the group with acute presentation compared with non-acute GISTs and was present at the most cases of small bowel GISTs with acute onset. The Ki-67 index showed no difference between acute and non-acute onset of GISTs.

[Pulmonary hydatic cyst--a case report]. / Chist hidatic pulmonar--prezentare de caz.

We present the case of a patient diagnosed in our clinic with pulmonary hydatid cyst, the discovery being incidental, during the investigations for a febrile syndrome accompanied by cough and thoracic pain. Pulmonary Hydatidosis is a disease caused by the location and growing inside the lungs of larval form of Taenia echinococcus granulosus, the way of infection is digestive. Hydatid cyst is a rare pathology, the incidence is higher in some populations related to professions such as sheep or goat raising. Pulmonary cyst diagnosis is made by imagistic methods (chest x-ray, CT, MRI) and bio-umoral methods (white cell count, specific serology), anamnesis and clinical exam can be inconclusive. The treatment of the hydatid cyst is surgical, medical treatment (antibiotic, parasiticid) has some specific indication. We administer antibiotics when we have bacterial suprainfection and parasiticid postoperatively for preventing recurrences or when we suspect rupture of the cyst. From the surgical methods cystectomy followed by capitonnage of the residual cavity (Dor procedure) is to be chosen, so that this fulfills the objectives of removing the cyst and treating the residual cavity with preserving as much as possible from the lung tissue.

Occupational burnout levels in emergency medicine--a nationwide study and analysis.

INTRODUCTION: The specificity of the emergency medical act strongly manifests itself on account of a wide series of psycho-traumatizing factors augmented both by the vulnerable situation of the patient and the paroxysmal state of the act. Also, it has been recognized that the physical solicitation and distress levels are the highest among all medical specialties, this being a valuable marker for establishing the quality of the medical act. MATERIAL AND METHODS: We have surveyed a total of 4725 emergency medical workers with the MBI-HSS instrument, receiving 4693 valid surveys (99.32% response rate). Professional categories included Emergency Department doctors (M-EMD), ambulance doctors (M-AMB), ED doctors with field work in emergency and resuscitation (including mobile intensive care units and airborne intensive care units) (D-SMU), medical nurses in Emergency Departments (N-EMD), medical nurses in the ambulance service (N-AMB), ED medical nurses with field activity in emergency and resuscitation (N-SMU), ambulance drivers (DRV) and paramedic (EMT). The n values for every category of subjects and percentage of system coverage (table 3) shows that we have covered an estimated total of 29.94% of the Romanian emergency medical field workers. RESULTS: MBI-HSS results show a moderate to high level of occupational stress for the surveyed subjects. The average values for the three parameters, corresponding to the entire Romanian emergency medical field were 1.41 for EE, 0.99 for DP and 4.47 for PA (95% CI). Average results stratified by professional category show higher EE average values (v) for the M-SMU (v=2.01, 95%CI) and M-EMD (v=2.21, 95% CI) groups corresponding to higher DP values for the same groups (vM-EMD=1.41 and vM-SMU=1.22, 95% CI). PA values for these groups are below average, corresponding to an increased risk factor for high degrees of burnout. Calculated PA values are 4.30 for the M-EMD group and 4.20 for the M-SMU group. CONCLUSIONS: Of all surveyed groups, our study shows a high risk of burnout consisting of high emotional exhaustion (EE) and high depersonalization (DP) values for Emergency Department doctors, Emergency, and Resuscitation Service doctors (M-SMU). Possible explanations for this might be linked to high patient flow, Emergency Department crowding, long work hours and individual parameters such as coping mechanisms, social development and work environment.

Occupational burnout levels in emergency medicine--a stage 2 nationwide study and analysis.

INTRODUCTION: The first stage of this nationwide study and analysis of the occupational burnout and psychological risk parameters showed a high consistency of emotional exhaustion, depersonalization and low personal accomplishment for doctors working in Emergency Departments and Emergency and Resuscitation Services. These workers were then set in the highest risk group for burnout syndrome and depression. This stage II of our research will focus on those two groups analyzing causal factors, coping mechanisms and possible repercussions of these findings. DEMOGRAPHICS: We have issued a total of 272 surveys from which we have received a total of 263 complete and valid ones (n = 263, response rate = 96, 69%). INSTRUMENTS: The Maslach Burnout Inventory--Human Services Survey MBI-HSS is an instrument designed to assess the three components of the burnout syndrome: emotional exhaustion (EE), depersonalization (DP), and reduced personal accomplishment (PA). The COPE questionnaire is a 52 item addressing different ways of coping with stress. The Center for Epidemiologic Studies Depression Scale (CES-D) has been shown to be a reliable measure in assessing the number, types, and duration of depressive symptoms across racial, gender, and age categories. RESULTS AND DISCUSSION: Results were not correlated with gender, age or marital status, but an important correlation was found with professional experience in the Emergency Departments. We have shown that during the first 4 years of experience, the EE factor has been at a satisfying average of 2.4, this variable rising to an average of 2.85 after another 3 years of work. The same type of correlation was found with the CES-D results. CONCLUSIONS: Of the two surveyed groups, the EMD group showed higher values for all risk parameters and low personal accomplishment on the MBI-HSS survey. Also, emotional exhaustion and depression were found to have a powerful correlation with work experience. Coping mechanisms were found to be invariable to the general population, with a slight incline towards active coping and behavioral disengagement.

Molecular basis of vascular events following spinal cord injury.

The aim of this article is to analyze the effects of the molecular basis of vascular events following spinal cord injury and their contribution in pathogenesis. First of all, we reviewed the anatomy of spinal cord vessels. The pathophysiology of spinal cord injuries revealed two types of pathogenic mechanisms. The primary event, the mechanic trauma, results in a disruption of neural and vascular structures into the spinal cord. It is followed by secondary pathogenesis that leads to the progression of the initial lesion. We reviewed vascular responses following spinal cord injury, focusing on both primary and secondary events. The intraparenchymal hemorrhage is a direct consequence of trauma; it has a typical pattem of distribution into the contused spinal cord, inside the gray matter and, it is radially extended into the white matter. The intraparenchymal hemorrhage is restricted to the dorsal columns, into adjacent rostral and caudal spinal segments. Distribution of chronic lesions overlaps the pattern of the early intraparenchymal hemorrhage. We described the mechanisms of action, role, induction and distribution of the heme oxygenase isoenzymes 1 and 2. Posttraumatic inflammatory response contributes to secondary pathogenesis. We analyzed the types of cells participating in the inflammatory response, the moment of appearance after the injury, the decrease in number, and the nature of their actions. The disruption of the blood-spinal cord barrier is biphasic. It exposes the spinal cord to inflammatory cells and to toxic effects of other molecules. Endothelin 1 mediates oxidative stress into the spinal cord through the modulation of spinal cord blood flow. The role of matrix metalloproteinases in blood-spinal cord barrier disruption, inflammation, and angiogenesis are reviewed.

Vascular dysfunctions following spinal cord injury.

The aim of this article is to analyze the vascular dysfunctions occurring after spinal cord injury (SCI). Vascular dysfunctions are common complications of SCI. Cardiovascular disturbances are the leading causes of morbidity and mortality in both acute and chronic stages of SCI. Neuroanatomy and physiology of autonomic nervous system, sympathetic and parasympathetic, is reviewed. SCI implies disruption of descendent pathways from central centers to spinal sympathetic neurons, originating in intermediolateral nuclei of T1-L2 cord segments. Loss of supraspinal control over sympathetic nervous system results in reduced overall sympathetic activity below the level of injury and unopposed parasympathetic outflow through intact vagal nerve. SCI associates significant vascular dysfunction. Spinal shock occurs during the acute phase following SCI and it is a transitory suspension of function and reflexes below the level of the injury. Neurogenic shock, part of spinal shock, consists of severe arterial hypotension and bradycardia. Autonomic dysreflexia appears during the chronic phase, after spinal shock resolution, and it is a life-threatening syndrome of massive imbalanced reflex sympathetic discharge occurring in patients with SCI above the splanchnic sympathetic outflow (T5-T6). Arterial hypotension with orthostatic hypotension occurs in both acute and chronic phases. The etiology is multifactorial. We described a few factors influencing the orthostatic hypotension occurrence in SCI: sympathetic nervous system dysfunction, low plasma catecholamine levels, rennin-angiotensin-aldosterone activity, peripheral alpha-adrenoceptor hyperresponsiveness, impaired function of baroreceptors, hyponatremia and low plasmatic volume, cardiovascular deconditioning, morphologic changes in sympathetic neurons, plasticity within spinal circuits, and motor deficit leading to loss of skeletal muscle pumping activity. Additional associated cardiovascular concerns in SCI, such as deep vein thrombosis and long-term risk for coronary heart disease and systemic atherosclerosis are also described. Proper prophylaxis, including non-pharmacologic and pharmacological strategies, diminishes the occurrence of the vascular dysfunction following SCI. Each vascular disturbance requires a specific treatment.