Horseshoe appendix: a extremely rare anomaly.

Appendiceal anomalies are extremely rare malformations. We presented the case of a patient 43-year-old who had undergone emergency surgery for bowel occlusion. Incidentally we have found an "horseshoe-shaped" appendix which removed. After review of the literature we have introduced this appendiceal variant in a complete classification of appendiceal anomalies.

Primary varices pathogenesis. The appealing unitary model.

Primary varices pathogenesis is still unclear about the trigger event and the disease progression. Throughout time, a lot of hypotheses were created, each with a certain degree of veracity, to explain the aforementioned dilemmas. Present day investigation technologies allowed the undeniable progress in deciphering venous mechanics and biochemistry. Objectifying venous hemodynamic and valvular-parietal changes, their dynamic progression as well, lead to important clarifications in primary varicose disease physiopathogenesis. The importance of establishing a complete, unitary pathogenic model implies the practical possibility of immediately applying the right therapy addressing the pathogenic mechanism of this disease (i.e. correcting the "pressure escape" gateway) correlated with the progression stage (reflux degree) and the type of primary varices (gravitational, non-gravitational, or "suspended" varices). Initially, our study produces a critical evaluation of the classic pathogenic hypotheses and, later on, based on our long time experience in this field, it presents a complete and unitary, evolutive and pathogenic model in primary varices. The proposed model details a pathogenesis and a progression far more nuanced in primary varices, based on solid evidence, having obvious therapeutic implications and predictable results.

[Postoperative enteral feeding in digestive anastomosis with proximal oesophageal partner]. / Nutritia enterala postoperatorie în anastomozele digestive ce au ca partener proximal esofagul.

This paper aim is to discuss the advantages of enteral postoperative feeding on patients submitted to surgery finalized through an eso-digestive anastomosis; in these cases enteral feeding is often delayed 5-8 days after the surgery, and in case of an anastomotic dehiscence may be even impossible. Also, the paper promotes duodenostomy as an important enteral feeding way, and discusses the indications and contraindications of different enteral nutrition pathways in such cases. There were studied 230 cases, 149 cases submitted to cancer surgery and 81 cases with benign condition surgery followed by an eso-digestive anastomosis, in which the following enteral nutrition pathways was practiced: nasogastric or naso-esojejunal feeding tube (55 cases); Witzel jejunostomy (28 cases); gastrostomy (79 cases); duodenostomy (68 cases). Postoperative morbidity induced exclusively by the enteral nutrition pathway was encountered in 36% of patients. On patients with an eso-gastric cervical anastomosis or esogastric thoracic anastomosis we used jejunostomy as enteral feeding path and a gastric tube passed by pyloric canal for gastric decompression. In cases of esophageal reconstruction for benign esophageal strictures gastrostomy remains the best feeding method. Duodenostomy was practiced as a feeding pathway in cases of total gastrectomy with esojejunal anastomosis, with closure of the duodenal stump.

[Soft tissue sarcoma--problems of diagnosis and treatment]. / Sarcoamele de parti moi--probleme de diagnostic si tratament.

Soft tissue sarcomas are a rare group of cancers compromising 1% of all malignancies and there has been a slight increase in incidence. We present 3 cases of soft tissue sarcomas (the tumors were located to the right axilary region, perianal and dorsale face of the left leg) hospitalized in 2nd Surgical Clinic of Emergency Hospital of Craiova and we discuss the difficulties of diagnosis and treatment. The classification and characterization of soft-tissue sarcomas have evolved as the information supplied by histologic analysis has been supplemented with that provided by immunohistochemical analysis. Surgical resection involving wide margins, with or without radiotherapy, offers the best chance of cure in the absence of metastatic disease. There is little evidence that local recurrence increases the likelihood of metastatic spread, although debate on this point continues. Except for rhabdomyosarcomas and Ewing's sarcomas, the use of adjuvant chemotherapy generally does little to influence the natural history of the disease. In conclusion surgical treatment is mainstay of treatment for soft-tissue sarcomas and is usefull the prompt diagnosis for decrease the risk of local recurrence and metastatic disease.

[Esophago-digestive anastomosis dehiscence]. / Dehiscenta anastomozelor esofagodigestive.

This paper aim is to discuss the main etiopathogenic aspects responsible for eso-digestive anastomotic leakage, as well as prophylactic and therapeutic measures of this postoperative complication. There were studied 173 consecutive eso-digestive anastomosis: 103 anastomosis performed for malignancy and 70 anastomosis for benign conditions. Surgical operations followed by an eso-digestive anastomosis were: esophageal reconstruction for benign esophageal caustic strictures (n=67); total gastrectomy (n=55); total esophagectomy (n=13); total esophagectomy plus total gastrectomy (one case); eso-gastrectomies (n=34); upper gastric pole resection (n=2); distal esophageal resection (n=1). Eso-digestive anastomosis topography were cervical (n=81), intrathoracic (n=37) and abdominal (n=57). There were 30 eso-gastrostomies, 81 eso-jejunostomies, and 62 eso-colostomies. There were recorded 24 eso-digestive anastomotic dehiscences (13.8%): 14 in the cervical region (17.2% out of 81 cervical anastomosis); 5 intrathoracic leakages (14.2% out of 35 anastomosis); 5 intraabdominal anastomotic dehiscences (8.7% out of 57 intraabdominal anastomosis). Four patients died as an anastomotic leakage consequence: two patients died after cervical eso-gastrostomy dehiscences, one patient died after an intrathoracic eso-jejunostomy leakage, and one patient died after intraabdominal eso-gastrostomy leakage. In conclusion, we analyze postoperative results, emphasizing the role of discovering and removal of predisposing factors which may lead to an eso-digestive anastomotic leakage.

T4 Colon Cancer - Current Management.

Colorectal cancer is the third most often encountered type of cancer and represents the third leading cause of cancer related deaths, on both sexes. One of the most important prognostic parameters is the tumor's stage at the time of the diagnosis. T4 cancers represent advanced tumors associated with penetration of the visceral peritoneum (T4a) and/or direct invasion in adjacent structures (T4b). Preoperative diagnosis is influenced by the inability of the existent imaging modalities to accurately differentiate the true invasion from the simple, inflammatory adherence to the neighboring structures. As a consequence surgical treatment must follow the principle of en bloc resection; however the ability of achieving an R0 resection depends on the tumor location, invaded organ, and the type of the surgical procedure required. Neoadjuvant treatment for advanced colon cancer it may be very difficult to be applied. This review is focused on preoperative workup, therapeutic strategies and subsequent results in advanced T4 colon cancers.

Squamous Esophageal Carcinoma Synchronous to Pericolic Malignant Conjunctive Tumor.

Esophageal carcinoma represents a great diagnostic and therapeutic challenge due to the anatomical situation and physiopathology of the disease. The medical challenge can be even greater since esophageal carcinoma can evolve concomitant to another malignant tumor with different localization. This paper's aim is to present a case of squamous esophageal cancer associated to another primitive malignant tumor-malignant pericolic conjunctive tumor, this kind of association being singular in medical literature from our knowledge. Upon emergency presentation the patient was sketching a sub-occlusive syndrome with mild anemia and inflammatory syndrome, somehow suggesting a possible right colon cancer. However, discreet upper digestive pole symptomatology that, on first sight, seemed secondary, made the consultant to perform a superior digestive endoscopy that raised a strong suspicion of early stage esophageal carcinoma. Further exploration was not completed because occlusive complication occurred and the patient needed emergency surgery. On laparotomy a stenotic right colic angle tumor was discovered that later proved to be extra-mucosal, with conjunctive origin. Our paper focuses on highlighting the crucial importance of the imagistic explorations in the primary diagnosis of esophageal carcinoma, in the correct staging (lymphatic extension, loco-regional or distant metastases) and also for malignant tumors with another localization that can radically modify the therapeutic strategy.

Update on Endoscopy-Based Imaging Techniques in the Diagnosis of Esophageal Cancer.

The early diagnosis of esophageal cancer is necessary for improving the surviving of patients with this disease. To ensure an accurate staging, there are necessary imaging tests to establish the local and regional extension, as well as excluding the metastases. Computed tomography (CT), endoscopic ultrasonography (EUS), and positron emission computed tomography (PET-CT) constitute standard methods for esophageal cancer staging. These techniques are complementary; using only one of these tests is not suitable for correct staging. The role of EUS has improved the doctors' ability to evaluate and select the patients to undergo surgery, radiotherapy, or chemotherapy.

Immunohistochemical Study of Sentinel Lymph Node in Colon Cancer.

Identification of sentinel lymph node (SLN) in colon cancer is very important in order to increase the accuracy of lymph node staging. The number of examined lymph nodes represents a significant predictor of survival. This study aims to show the importance of SLN histological and immunohistochemical examination in adjuvant oncological treatment. The study includes 23 patients with colon cancer (44% women and 56% men) who came in our clinic for surgical intervention. In all cases, the SLN was identified and prepared for histological examination. In 13 of the cases, micrometastases were found onhaematoxylin-eosin (HE) staining, there were 5 cases with positive immunohistochemistry using antibodies anti-p53, anti-VEGF-C, anti-CD34, and 5 cases with SLN negative both for HE and immunohistochemistry. Altogether we had a detection rate of 92%, an accuracy of 78,2%, a sensitivity of 90%, a false negative rate of 10% and a negative predictive value of 71,4%, good values according to the literature. Four (17,3%) patients had micrometastases exclusively in the sentinel lymph node, after performing additional histological examination, using multilevel section and immunohistochemistry. After assessing the SNL on our patients, we concluded that it is a reproducible practice for lymph node analysis.

On the mechanism of diazoxide-induced hyperglycemia.

Infusion of diazoxide (16.5 mg./kg. in 10 minutes) into normal unanesthetized dogs resulted in a prompt hyperglycemia due to increased hepatic glucose production as measured with a 3-3H-glucose primer-infusion technique. Plasma insulin and glucagon were decreased. Glucose uptake failed to increase. Diazoxide administration during period of alpha adrenergic receptor blockade with phentolamine still caused hyperglycemia and increased glucose production. Glucose uptake was inhibited despite adequate plasma insulin. Infusion of somatostatin along with insulin prevented the effects of diazoxide on plasma glucose and glucose production. It is concluded that diazoxide hyperglycemia is not due solely to decreased insulin secretion or increased epinephrine secretion and that glucagon is not a contributory factor. Diazoxide may act directly to increase glucose production and inhibit glucose uptake. Somatostatin appears capable of blocking the effect of diazoxide on glucose production by an unknown mechanism.

Correlations Between Intratumoral Microvessel Density and Histopathological Type or Neoadjuvant Radiotherapy for Rectal Carcinoma.

PURPOSE: This study aims to evaluate intratumoral microvessel density in rectal carcinoma cases with different histopathological type (adenocarcinoma and mucinous carcinoma) and different preoperatory neoadjuvant radiotherapy status (irradiated / non-irradiated) ,thus analyzing any possible statistical correlation between these parameters. MATERIAL AND METHODS: Our prospective study consists in standard immunohistochemistry procedures using CD34, CD31 and CD105 antibodies, which were performed on 25 samples of rectal carcinoma, in order to determine intratumoral microvessel density. RESULTS: The 25 case study group was divided either by histopathological type or by prior radiotherapeutical treatment as follows: 9 cases of mucinous carcinoma versus 16 cases of adenocarcinoma and 13 cases of rectal cancer that have not received neoadjuvant radiotherapy versus 12 cases of rectal cancer with preoperatory radiotherapy. CONCLUSIONS: The number of intratumoral microvessels is higher in non-irradiated rectal tumors and in adenocarcinomas, this remark being statistical significant (with only one exception - CD34 staining in non-irradiated versus irradiated tumors) for all types of vessels (new-grown and mature). This result is due to the benefic effect of neoadjuvant radiotherapy on decreasing angiogenic activity, thus having an important prognostic value for rectal cancer.

Psychiatric comorbidity in patients with spasmodic torticollis.

Several studies have reported raised levels of psychopathology based on self-rating scales in patients with spasmodic torticollis. Recent publications have also proposed that psychopathology, especially symptoms of depression, might be a reaction to dystonia or constitute a nonspecific reaction pattern. To determine the actual frequency of psychiatric disorders, we evaluated 44 patients with spasmodic torticollis (20 female, 24 male; mean age 43.6 years, SD 10.4) using the standard instrument for psychiatric diagnosis in the DSM-III-R (Structured Clinical Interview Schedule, SCID). The SCID permits retrospective diagnosis for most of the major psychiatric disorders, including the time before onset of dystonia. SCID criteria for at least one psychiatric disorder were fulfilled in 65.9% of patients, including both lifetime and current diagnosis. The most frequent diagnostic categories were panic disorder with or without agoraphobia (29.5%), major depressive disorder (25%), substance abuse (13.6%), and obsessive compulsive disorders (6.8%) were diagnosed less frequently. The patient-recalled onset of psychiatric symptoms preceded onset of torticollis symptoms in 43.2% of those investigated.

[Long-term treatment with botulinum toxin: dosage, treatment schedules and costs]. / Langzeitbehandlung mit Botulinum Toxin: Dosierung, Behandlungsabstände und Kosten.

Local injection of botulinum toxin A (BTX) is considered as the treatment of choice for spasmodic torticollis (ST), blepharospasm (BS) and, with certain limitations, for hemifacial spasm (HFS). Long-term data from 89 patients with ST, 39 patients with BS and 15 patients with HFS were evaluated and subgroups of patients who received at least three (60 ST, 17 BS, 9 HFS), six (35 ST, 10 BS, 8 HFS) and nine (26 ST) re-injections were formed. These groups were investigated in regard of increases in the dosage of BTX and in regard of shorter treatment intervals in cases of repeated treatment. Annual drug costs were calculated from these data. Patients treated at least three times were asked to fill out a questionnaire concerning satisfaction and the quality of life after BTX treatment. Furthermore, the patients' "willingness to pay" for BTX treatment was investigated. Our calculations showed neither a significant increase in the dosage of BTX nor a significant reduction in the length of treatment intervals after 3 or 6 treatment sessions. Annual drug costs for BTX for the treatment of ST were 10,542 ATS, of BS 2847 ATS and of HFS 1029 ATS. 86.1% of patients with ST, 88.9% with BS and 100% with HFS were very satisfied or satisfied with the BTX treatment. In all 3 diagnostic groups, a significant mean improvement of quality of life was measured on a visual analogue scale (p < 0.001). We conclude that the injection of botulinum toxin A is a highly effective and cost effective treatment for ST, BS and HFS, and significantly increases the quality of life of all these patients.

[Botulinum toxin in the treatment of focal hyperhidrosis]. / Intradermale Botulinumtoxininjektionen in der Behandlung fokaler Hyperhidrosen.

INTRODUCTION: Botulinum A toxin (BTX-A) acts primarily at peripheral cholinergic synapses, inhibiting the release of acetylcholine. Initially it has been used to block the neuromuscular junction in focal dystonic and spastic syndromes. Recently there has been suggestions for potential clinical indications in non-muscular diseases where cholinergic terminals play a role. GUSTATORY SWEATING: In 1995 physicians reported a long-lasting anhidrotic effect of intracutaneous BTX-A injections in patients suffering from gustatory sweating (Frey's syndrome). Consequently, a number of clinical studies demonstrated good efficacy of intradermal injections of botulinumtoxin in patients with focal hyperhidrosis. FOCAL HYPERHIDROSIS OF THE PALMS AND AXILLAE: Focal hyperhidrosis is usually confined to the palms and axillae. Excessive sweating may be a social handicap and an occupational hazard. The management of focal hyperhidrosis remains controversial. Topical antiperspirants are only effective in very mild cases. Iontophoresis with tap water or anticholinergic drugs is messy and time consuming with only short-lived effect. Sympathectomy, the cornerstone of surgical management, is usually effective in palmar hyperhidrosis. Complications of this technique include surgical risks, postoperative and cosmetic problems and compensatory hyperhidrosis. AXILLARY HYPERHIDROSIS: Several studies confirmed that intracutaneous injections of botulinum toxin are useful in the majority of patients with axillary hyperhidrosis resistant to conventional treatment. In axillary hyperhidrosis total doses are ranging from 200-400 mU Dysport or from 80 to 130 mU Botox to reach a good clinical response. Injections are usually well tolerated and no serious side-effects have been observed. The mean duration of anhidrotic effect ranges between 3 and 9 weeks. PALMAR HYPERHIDROSIS: The use of botulinumtoxin in patients with palmar hyperhidrosis is rather difficult. The therapeutic window is smaller because injections are complicated by transient weakness of the small hand-muscles. Furthermore the injections at the palms are painful which can be overcomed by application of local anaesthetics or the blockade of the ulnar and median nerves. The duration of anhidrotic effect ranges from 20 to 50 weeks. CONCLUSION: Intracutaneous injections of botulinum-toxin should be offered to patients with focal hyperhidrosis of the palms and axillae causing serious social, psychologic and occupational problems, resistant to other conventional treatment options.

[The specific serological profile in hepatitis B virus infection in children]. / Profil serologic particular în infectia cu virusul hepatitei B la copii.

UNLABELLED: Hepatitis B virus infection (HBV) has a very well known specific serologic profile. In the last years the molecular biology methods reveal some "particular serological profiles" by genomic mutation. One particular profile consists in the absence of anti-HBc total antibodies simultaneously with the presence of HBsAg. Our tested group consists of 372 children aged 0.1 to 15 years. The presence of HBsAg was determined by ELISA "sandwich" and confirmed by neutralisation test. For HIV infection we used two ELISA tests (competitive and indirect) and the Western Blot test for confirmation. Of the total, there were 13 children HBsAg positive and without anti-HBc antibody (3.49% respectively), 7 of the 13 children (53.8%) were dystrophic and 4 were HIV positive (30.76%). From 372 cases, 104 were HBsAg positive (27.9%) and 53 (14.2%) of them had chronic hepatitis. CONCLUSIONS: 1. The particular serologic profile requires the testing of all serological markers specific for HBV. 2. This particular serologic profile is correlated with HIV positive status and dystrophy.

[The prevalence of HBsAg in hospitalized children as a marker of hepatitis B virus infection]. / Prevalenta AgHBs la copii spitalizati, ca marker al infectiei cu virusul hepatitei B.

UNLABELLED: The aim of this study was to determine the prevalence of hepatitis B surface antigen (HBsAg) in hospitalised children, as specific marker for hepatitis B virus (HBV) infection. Our study group consists of 517 children, 68 of them diagnosed with chronic hepatitis. For HBsAg determination we used an ELISA test (Labsystems); for some children we also tested by ELISA the following markers: the antibodies and anti-hepatitis C virus (HCV) antibodies. From 517 children 24.28% were HBSAg positive and 75% of children with chronic hepatitis were positive for the same marker. Almost 100% of chronic active hepatitis (CAH) patients was positive for HBSAg. CONCLUSIONS: 1. The prevalence of HBsAg was much higher as compared with the healthy population prevalence; it is a clear prove that HBV infection has an important role in chronic hepatitis appearance. 2. For all HBsAg positive patients, it is necessary to determine other markers like HBeAg-anti-HBe antibodies system as well as markers for other viral hepatitis (HDV, HCV). 3. The anti-HBV infection vaccine will reduce significantly the prevalence of HBV and HDV infections; 4. Biological molecular technique, like PCR will be necessary in our country, in the future, even the price is so high, to monitoring the IFN treatment for chronic infection as unique solution for these patients.

Data condensed synthesis regarding kinesiotherapeutic procedures used in spasticity therapy.

Spasticity represents an important feature of the upper motoneuron syndrome (UMNS). The clinical signs, such as the abnormal movement models, the unwanted muscular co-contractions, the muscular and joint rigidity with a consecutive deformity can be signs of spasticity and, also of upper motoneuron lesion. The different therapeutic options applied in the management of spasticity are a basic component of UMNS treatment scheme. This article presents the main kinesiotherapeutic procedures used in spasticity therapy.

Current issues and considerations about the central role of rehabilitation therapies in the functional recovery of neurological impairments after stroke in adults.

Well-organized acute and intermediate rehabilitation after stroke can provide patients with the best functional results. Several studies led to major changes in recommendations concerning remobilization therapies following stroke. Controlled studies including early mobilization in stands and training with partial body weight support on treadmills and "gait training" systems showed superior results compared to traditional treatment strategies. In case of spasticity and equinovarus and stiff knee pattern following stroke, botulinum neurotoxin A injections and/or casting enable the achievement of adequate alignment of the ankle for stance phase and allow the improvement of joint mobility during swing phase when restricted.