The Journal of Bucharest College of Physicians and the Romanian Academy of Medical Sciences

Tiberiu Paul Neagu

Tiberiu Paul Neagu

Characteristics of Anemia in Rheumatoid Arthritis

Rheumatoid arthritis (RA) is an inflammatory, chronic and systemic disease that primarily affects the synovial joints. Anemia is a common extra-articular manifestation in the absence of an effective treatment. The main mechanisms involved include shortening the lifespan of erythrocytes, inadequate bone marrow and abnormalities in iron metabolism. Eighty-eight patients over 18 years with definite diagnosis of rheumatoid were included in this study. The prevalence, respectively the characteristics of anemia were analyzed, together with demographic data, the type of symptoms, the type of comorbidities, the hematological indices and treatments. The mean age of the study population was 65.31 ± 12.57 years. Treat to target was achieved in one third of the patients (36.4%). The prevalence of anemia was 55% with higher prevalence in males (57%) than females (50%). Anemia was associated with higher disease activity (p=0.036). Out of the anemic patients, 7.14% had megaloblastic anemia, 40.48% had anemia of chronic disease and 21.43% suffered from iron deficiency anemia. Microcytic normochromic and normocytic hypochromic patterns can have mixed causes, belonging to both iron-pathophysiological processes and chronic inflammation. The prevalence of anemia at the 1-year check-up was 29.44% and the percentage of patients who achieved treat-to-target goals increased from 36.40% to 40.90%. The majority (48.80%) did not prove to have anemia neither at admission nor at follow-up. The results of the study suggest that anemic patients tend to have a higher level of RA activity, therefore screening for anemic syndrome should be part of the management of these patients, in an effort to establish the best therapeutic conduct.

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The Outcome of Rectal Cancer Patients During SARS-CoV-2 Pandemic

Introduction: Rectal cancer is a complex pathology that requires a multidisciplinary approach according to current guidelines, and surgery is one of the main stages of treatment, the type of intervention being established in relation to the location of the tumor at the rectal level. Material and method: The present study aims to analyze the diagnostic features, study the evolution, treatment and complications of patients with rectal cancer in a period marked by the SARS-CoV-2 pandemic. After completing the inclusion criteria, but also the exclusion group, the remaining group consisted of 55 patients with rectal cancer. Results: For the 55 patients, abdominal-pelvic rectal amputation was performed in 17 cases, rectosigmoid resection with colostomy in 13 cases, and rectosigmoid resection with anastomosis in 25 cases. It was also taken into account that the access to medical services was delayed compared to the pre-pandemic period, the increase of the time interval between the treatment stages being an important aspect of the study. Complications associated with surgery have been reported in 13 patients, the most common being the pelvic abscess. Conclusions: The results of the study show a high incidence rate in the age group 60-69 years, with a predominance of males, a delay in making the diagnosis of certainty, an extension of the period from the beginning of neoadjuvant treatment to access to surgery, and the rate of postoperative complications is similar to that described in other studies conducted during the SARS-CoV-2 pandemic, but also outside it.

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Mesenteric Lymphangioma – a Rare Tumor of the Abdomen

Mesenteric lymphangioma (ML) is a cystic tumor developed at the base of the mesentery, which occurs frequently in children, rarely in adults, with nonspecific symptoms, often diagnosed late. The diagnosis is made by computer tomography and the curative treatment is the surgical one with good results and with optimal postoperative outcome. A 44-year-old patient for whom mesh surgery for incisional hernia post appendectomy has been performed was admitted to our clinic for non-specific gastrointestinal symptoms for which he has also been investigated multiple times in other services. On the right flank and iliac fossa, a tumor of firm-elastic consistency is detected, relatively well delimited. Computed tomography (CT) describes the lesion as a mesenteric tumor. Intraoperatively, a cystic tumor is detected, which is punctured, the biochemical result highlighting the lymphatic character. The surgical treatment was represented by segmental intestinal resection with entero-enteroanastomosis. No postoperative events were
reported.

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Personalized Treatment in Rectal Cancer – a Single Center Study

The study aims to evaluate the incidence, characteristics of diagnosis and treatment for patients with rectal cancer, but also the evolution of patients diagnosed with this neoplasia, so that a personalized treatment can be applied and followed, adapted to the patient’s clinical-imaging picture. The study included 127 patients operated on between January 2018 and November 2021. Dixon resection was performed in 63 patients, rectal amputation (Miles) in 42 patients, and Hartmann resection in 22 patients. For the Miles-type intervention, the patients in a more advanced stage were selected, which represented a percentage of 33.07% of the total. This type of intervention involves a permanent colostomy and has a strong impact on the patient’s life. Of the total of 127 patients, the presence of complications was relatively rare, occurring in only 14 patients. Of the 14 patients, the most common complication was abscess, which occurred in 6 patients, while peritonitis and occlusion occurred in only 4 patients. After analyzing the data obtained, it can be seen that the results coincide with world statistics, the highest incidence of rectal cancer occurring in the age range 60-69 years, with an increased incidence among male patients.

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Comparison between Young and Elderly Onset of Rheumatoid Arthritis in a Romanian Cohort

Rheumatoid arthritis (RA) is a chronic inflammatory disease that predominantly affects middle-aged adults in the third to fifth decades of life, but can also occur at any age. Significant differences were observed between patients with the diagnose of the disease under the age of 65 years – young- onset of RA (YORA) and those with the onset over the age of 65 years -elderly-onset of RA (EORA). The literature has shown that patients in the EORA group, in comparison to the young, have more severe onset, shorter duration of morning stiffness, lower frequency of seropositivity and a more important biological inflammatory syndrome.

Objective: Describe and compare the clinical characteristics, laboratory features, functional status, therapeutic approach and disease progression in elderly-onset and young-onset rheumatoid arthritis (RA) patients.

Materials and Methods: This retrospective, transversal study included 102 patients diagnosed with rheumatoid arthritis according to the ACR / EULAR criteria and who had at least 3 visits to our clinic, the last one during 2019-2020. Depending on the age at disease onset, we divided them into 2 groups- EORA and YORA and analyzed them comparing the clinical, laboratory and treatment data obtained at diagnosis. Subsequently we studied the evolution of the disease activity and the therapy efficiency at 6 months of follow-up and at the last hospitalization for each group.

Results: The percentage of women is similar and predominant in both groups, YORA and EORA (68.3% and 71.8%). YORA was associated with a longer disease length and a prolonged symptom duration prior to the diagnosis in comparison to EORA (p<0.001 and P=0.002). Extra-articular manifestations were more frequent in elderly-onset RA patients at diagnosis, especially the presence of rheumatoid nodules (46.2% vs 22.2%. p=0.011) and weight loss (82.1% vs 34.9%, p<0.001). Anemia was statistically associated with the EORA group (p=0.037). Analyzing the radiological findings, there was a greater number of patients who showed erosions (48.7%) and geodes (28.2%) in EORA, than in YORA group (33.3% and 19.0%). The prevalence of specific auto-antibodies positivity as anti-CCP was higher in YORA (76.2% vs 53.8%, p=0.019), as well as the positivity of Rheumatoid factor (RF) (84.1% vs 61.5%, p=0.010). The majority of patients began treatment with synthetic DMARD monotherapy, 54.0% of YORA and 64.1% of EORA. Methotrexate was the main drug administrated in both groups (61.5% in EORA and 54.0% in YORA, p-value= 0.602). Other medications, such as Sulfasalazine and Leflunomide, were less preferred in the two groups. Biologic therapy was preferred in younger patients than in those with RA at 65 years of age or over (69.8% vs 35.9%, p=0.001). Disease activity measured with DAS28(CRP) score was similar between the two groups at baseline, but significantly lower for YORA patients measured at the last hospitalization (p=0.020), treat to target (low disease activity and remission) being achieved in 53% of cases in the YORA group versus 23% of EORA patients (p=0.002).

Conclusions: The definite diagnosis of RA was delayed in YORA patients in comparison to EORA patients and the extra-articular manifestations of the disease were more frequently found in the EORA group. Seropositivity was statistically significantly associated with the YORA group. Anemia was predominant in patients with disease onset over 65 years old. Both groups underwent DMARDs therapy in the early stages of the disease, but biologic therapy was more often administered in younger patients. Disease activity at diagnosis was similar in both groups, but in dynamic, the treat to target endpoint was achieved more frequent in YORA population.

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Evaluation of Treatment Response in Lupus Nephritis

Objectives: To evaluate the effectiveness of the treatment reflected by the rate of response to therapy at 6 months and 12 months of follow-up respectively. Methods: We retrospectively analyzed clinical, laboratory data, treatment regimens, the type of response and relapse rate of 51 patients diagnosed with LN between January 2017 and February 2020. Results:47.06% of the patients underwent renal biopsy, classes III and IV being the most common lupus nephritis types (totaling 35.3% of biopsied patients). All induction therapy choices analyzed in the study- CYC, Glucocorticoids (GCs) and MMF- proved effective at reducing the proteinuria of the patients (p=0.001, p=0.012 and p=0,019 respectively. The 12 months evaluation demonstrated an ascending trend of the complete response, starting from 27.45% at 6 months and almost doubling at 1 year (56.86%). Almost half of patients (49.02%) did not relapse, while most of them (27.45%) had only 1 relapse. Analyzing the risk of relapse for each induction drug used, CYC had the highest rate of recurrence (62.07%). The use of MMF as a maintenance drug associated the lowest degree of recurrence. Conclusions: Both CYC and MMF as induction therapy are significantly effective in reducing proteinuria. The complete response was more frequently identified as an endpoint at 12 months of follow-up.

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Particularities of Surgical Treatment for the Neuropathic Diabetic Foot

Diabetic neuropathy is one of the chronic complications of diabetes and along with other complications causes a pathology called diabetic foot. The present study analyzed a group of 164 patients admitted to the surgery department of the Clinical Hospital “Doctor Ioan Cantacuzino” Bucharest, between September and December 2019. The results of the study highlight the potential for contamination of neuropathic lesions and the need for curative surgery, most conservative. The conclusion of the analysis emphasizes that the imbalance of the underlying disease changes, in a negative sense, the prognosis of any complication of it.

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Infectious Complications in Severely Burned Adult Patients-Diagnostic and Therapeutic Algorithm

Severe burn injuries represent a major challenge to the entire healthcare system in developing countries and even for states with a high standard of care. A clear understanding of the physiopathology of burn injuries is essential for providing an adequate prompt treatment to ensure an optimal patient outcome. Early recognition and treatment of burns complications, especially severe infections represent an important prevention strategy, improving survival after these severe injuries. Specific treatment must be conducted according to the characteristics of the patients in order to reduce morbidity and mortality and avoid the development of antimicrobial resistance. A diagnostic and therapeutic algorithm is presented, centered on infectious source prevention and control with early surgical excision and skin grafting together with culture-guided antimicrobial therapy. It is a known fact that, indifferent of the involved germ, the best intervention for both prophylaxis and treatment of infections in the burn patient is the early excision of the devitalized tissue and subsequent closure of burn wounds with skin grafts, measures that diminish local and systemic mediator releasing effects in burnt tissue, attenuating the progressive inflammatory chain.

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Abdominal Wall Reconstruction–Diagnostic and Therapeutic Algorithm

Due to its complex structure, the abdominal wall is vital as it serves to protect the internal organs, maintain the upright position and regulate the intraabdominal pressure. Complex abdominal defects are a major health problem, with challenging treatment, many complications and risks. It is not a completely elucidated pathology as there is no consensus in literature regarding the definition and classification. Although there are various reconstruction techniques, there is no sistematic protocol in literature that allows the surgeon to choose the best treatment suitable for each patient. Therefore, the first step to manage these patients is a carefull assesment of the patient background and only after that, a complete analysis of the actual wound should be made. Second step is appropriate abdominal wall closure. After the analysis of current data from international literature, we identified a decision-making algorithm to offer guidance in surgical management in order to obtain an optimal functional outcome. The foundation of the algorithm is the idea of gradually improving the local tissue status, in order to deal with a clean wound as much as possible. This way, the success rate of the surgical reconstruction improves.

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Fungal Infections in Major Burns - 2 Years Overview

Infections are the most severe and the most frequent complication in major burns requiring adequate diagnosis and treatment. Extensive burned areas, impaired immune system and antibiotic therapy contribute to the development of opportunistic fungal infections. An important aspect is the increased level of antimicrobial resistance in our country. We present a two years study on the burn patients hospitalized in our institution. A total of 355 burned patients were hospitalized during this period, 210 (59%) of them being addmited in Critical Care Burn Unit. We noted the main infectious complications and established a dinamic microbian mapping during patient hospitalization. Fungal infections were noted. We performed microbiological screening: testing at admission and once a week or in case of clinical signs from all potential sites. For the clinical therapy of mycoses, it is mandatory to know whether a fungal colonization or a fungal infection is involved. Unfortunately, often in severe burned patients, clinical presentation is unspecific and sensitivity of diagnostic results may be unreliable. Invasive fungal infections due to Candida species and Aspergillus species are important emerging causes of morbidity and mortality. The systemic use of antifungal agents is conducted depending on the general condition of the burn patient, the fungal species involved and the confirmation of fungemia. In conclusion, specific treatment of infectious complications has to be conducted according to the characteristics of the patients in order to reduce morbidity and mortality and avoid the development of antimicrobial resistance.

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Viral Myocarditis: Clinical and Paraclinical Diagnosis

Myocarditis is an inflammatory disease of the myocardium, that can be produced by a multitude of infectious or noninfectious agents. The incidence rate of the disease is between 10 to 22 per 100,000 individuals. Among the infectious causes, viruses are considered to be the most frequent pathogens. Regarding the clinical presentation, viral myocarditis may have a wide variety of manifestations, ranging from asymptomatic disease to chest pain, myalgia, fatigue, heart failure, arrhythmias and, in some cases, sudden death. A definitive diagnosis of viral myocarditis involves histological evidence for myocarditis associated with positive viral polymerase chain reaction (PCR). Endomyocardial biopsy represents the gold standard for diagnosis; in the absence of histological, immunologic and immunohistochemical criteria, a definitive diagnosis cannot be established.

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Iron and Erythropoiesis – Optimizing the Link

Purpose of review: The aim of this paper is to provide the clinician an overview about the link between iron homeostasis and erythropoiesis and how we can promote this relationship in order to improve surgical patients’ outcome. Key elements: Iron is essential for various cellular processes, like cell signalling, oxygen transport, erythrocyte and heme synthesis, mitochondrial respiration, host defence, nucleic acid replication. Erythropoietin and iron are the main erythropoiesis regulators. Under iron-restricted conditions, the erythrocytes production is impaired, leading to microcytic hypochromic anemia appearance. Iron-restricted condition enables patient capacity to recover from post-surgery anemia. Long-term consequences of chronic anemia affect patient’s quality of life. Therefore, parenteral iron supplementation, in patients with anemia secondary to blood loss, can lead to a fivefold increase in erythropoietic response, therefore enhancing recovery. Summary: Under normal circumstances, the link between iron and erythropoiesis is maintained especially through regulatory feedback mechanisms, with minimal external support. In face of important blood loss, with secondary acquired iron-restricted anemia, parenteral iron supplementation improves the bone marrow erythroid response and helps correcting haemoglobin levels.

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Hydrofluoric Acid Burn Management – Case Presentation

Background: Hydrofluoric acid (HF) is an extremely dangerous weak inorganic acid, which can produce extensive burn lesions, depending especially on the solution concentration and exposure time, systemic toxicity occurring in patients with large burn areas, high concentration of acid or an extensive time of exposure. The subcutaneous infiltration and intravenous administration of calcium gluconate is essential for preventing dyselectrolytemia and severe pain appearance. Case summary: A 26-year-old man patient presented to our hospital after a hydrofluoric burn, secondary to an occupational accident. At the scene, the wound was irrigated with fresh water and topical calcium gluconate was applied. In the Emergency Department, we started the intravenous calcium gluconate administration, and in the Burn Unit it was injected subcutaneously and the pain was thus diminished. A prolonged QT interval was identified upon admission that has been corrected over the next few days. Particularly, the serum pseudocholinesterase levels were within normal range. The local treatment involved repeated copious lavage with sterile water and Betadine solution, the evolution being rapidly favorable with the burn lesions completely healed in the next week. Conclusion: HF burns are a very special type of chemical burn taking into account that exposure to a small quantity of solution can be life threatening and that the immediate treatment is mandatory in order to maximize the outcome. It is of vital importance that any medical facility had a chemical burn protocol.

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Defensive Surgery - a New Under-Recognized Reality among Surgeons

In recent years, the number of medical litigations is increasing and defensive medicine becomes a widespread approach among physicians all over the world. Defensive behavior of physicians is more common in scheduled, elective, compared to emergency medical services. The immediate direct consequences of this defensive behavior are found in the increase of costs (additional investigations) and the increase of waiting time for certain procedures and interventions (repeated postponements). Difficult and uncomfortable to admit that it exists, but defensive behavior is a reality. It raises numerous and complex ethical issues, and the goal of health policies should be to reduce this phenomenon.

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Is There an Increased Complications Rate in After-Hours Colorectal Surgery?

When a surgical team is dealing with an after-hours colorectal surgery, they are actually confronting with a chain of elements and events, some linked to the patient and severity of the surgical case, others related to the medical team ability to cooperate, from nurses to surgeon and anesthetist. There is a series of differences between elective and emergency performed surgeries, two of them and most important elements are the patient (disease type, age, preoperative condition) and the operating team (experience, technical performance after-hours, especially at night).

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Life-threatening Consequence of a Psychiatric Behavior

Introduction: The prevalence of hypokalemia in psychiatric population is very high with eating disorders and laxative abuse being the main incriminated factors. Case presentation: We report a case of a 34-year-old woman with history of sleeve gastrectomy and breast implant, who presented for fatigue, severe myalgia, generalized hypotonia and palpitations. Laboratory exams revealed severe hypokalemia and rhabdomyolysis. The electrocardiography showed prolonged QT interval and ST segment depression with second-degree atrioventricular block. She received intravenous potassium supplementation with consecutive hydration. When potassium level was within safety limits, the patients received loop diuretics in order to decrease rhabdomyolysis and avoid kidney injury. The underlying cause was a pathological behavior, with frequent self-provoked episodes of nausea and vomiting after eating and chronic consumption of laxatives. She started psychotherapy. Conclusion: Psychiatric behaviour can lead to life-threatening conditions, therefore it should be discovered and managed promptly.

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The importance of high flow nasal cannula (HFNC) oxygen therapy

High flow nasal cannula (HFNC) oxygen therapy devices are used on a daily-basis in many intensive care units and postoperative wards. Such a device deliver a mixture of air and oxygen, warmed, humidifi ed, with gas flow between 20-60 L/min, and inspired oxygen fraction between 0.21-1. Therefore, it improves oxygenation, decreases dead space, washes out the carbon dioxide (CO2) from patients’ airways, improves thoraco-abdominal synchrony and decreases the work of breathing. Studies have shown effi cacy of HFNC oxygen therapy use for acute hypoxemic respiratory failure, for patients with exacerbations of chronic pulmonary diseases, after extubation in order reduce the need for mechanical ventilation, in perioperative period to prevent atelectasis and in palliative care, in order to reduce breathlessness. It isn`t feasible for patients with severe altered neurological status, facial trauma, basal skull fracture, complete airway obstruction or epistaxis. There are no standardized recommendation for the use or contraindication of HFCN oxygen therapy. The weaning is realised according with patients’ tolerance, oxygen saturation, respiratory and heart rates.

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Abdominal Compartment Syndrome - a Surgical Emergency

Over the past six decades, abdominal compartment syndrome (ACS) remained a very controversial subject, both in surgical and non-surgical specialties. Doctors failed to understand why critically ill patients died in the ICU with distended abdomens without fi nding any cause or why postoperative patients with wound defects such as dehiscence died after suturing the wound again „very tightly”. After the concept of intra-abdominal pressure (IAP) was established and methods for measuring it and diagnosing intra-abdominal hypertension (IAH) were available for clinicians to use it, it became clearer that ACS was a very serious and life threating pathology and the need for a correct treatment is essential. In this article we will try to make a literature review of the past decade and see when and how to diagnose correctly a patient with ACS and also how the diagnostic and treatments methods changed over the years.

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The Labyrinth Behind an Acute Respiratory Failure

Acute hypoxemic respiratory failure may have different causes. Case presentation: We present the case of a 42-year-old woman, with history of recent thyroidectomy and a late history of sleeve gastrectomy, who presented for acute dyspnoea. The chest X-ray revealed hydropneumothorax, and, therefore, an intercostals chest tube drainage was inserted. The evolution was unfavourable, with further respiratory status deterioration. A computed tomography of the thorax and abdomen was performed, that revealed a dilated thoracic oesophagus and stenosis of the esophagogastric junction, with lack of substance in the oesophageal wall and extravasation of oesophageal content in the posterior mediastinum, due to an oesophageal pleural fi stula. An oesophageal stent was inserted under endoscopic guidance and the patient underwent minim-invasive surgical interventions for evacuation of the mediastinal and pleural collections, with a favourable evolution. Conclusions: Acute respiratory failure can be the face of multiple conditions, some of these can be life threatening and in need for rapid detection and treatment.

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Unusual Combination of Posterior Femoral Head Dislocation and Ipsilateral Intertrochanteric Open Fracture: Case Report

The combination of posterior femoral head dislocation with ipsilateral intertrochanteric fracture is an extremely rare occurrence, therefore, few reports exist. The posterior femoral head dislocation is an injury most common encountered in road traffic accident (dash-board) and may associate various types of acetabular, femoral head or femoral neck fractures[1-3] but almost never an intertrochanteric fracture. [...]

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Results in Breast Reconstruction - Retrospective Study

In the last century, the breast reconstruction after mastectomy has become an important element of the multicentric treatment of the patients suffering from breast cancer. Breast reconstruction was initially developed to reduce the complications of mastectomy and the deformations of the thoracic wall. Currently, it is known the fact that reconstruction can improve the psychosocial state and the quality of life of the patients with breast cancer[1]. [...]

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Negative Prognostic Factors in Severe Burns - Implication for Clinical Outcome

Burn injuries are a major public health problem all over the world and despite significant improvements in critical care and surgical treatment, major burns are associated with high morbidity and mortality and poor recovery outcome. Patients with severe burns need immediate intervention and rapid initiation of speci-alized treatment in a dedicated critical care burn unit in order to minimize morbidity and mortality. The complex nature of burn injuries requires an integrative approach, by a multidisciplinary team in order to obta-in an optimal care. [...]

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Posttraumatic Renal Artery Thrombosis

Posttraumatic renal artery thrombosis is a very rare complication of abdominal trauma which occurs especially in young people, after car accidents, with an increasing incidence in the last few years. There are about 400 reported cases in the literature[1], meaning less than 0.08% of all reported abdominal traumas and being found in 1-4% of patients with renal damage[2]. [...]

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The Versatility, Plasticity and Esthetic Aspect of Latissimus Dorsi Muscle-Cutaneous Flap in Breast Reconstruction - Case Report

In the last decades, the approach manner of the defects of the soft parts post-mastectomy developed significantly together with the innovative surgical techniques of oncoplastic surgery.
Among these techniques, the reconstruction of the breast with LD flap and implant continues to be a reliable and easy to perform method, both by the experi-enced surgeons and also for the beginners[1]. [...]

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Versatility of the Cross-Finger Flap for Reconstruction of the Thumb

It is well known that the thumb is responsible for 40% of the hand function. Th erefore, preserving its length and mobility represents the main objective of the plastic surgeon while choosing the most appropriate reconstruction technique[1]. When resurfacing of the fingers is needed after hand injuries, cross-finger flaps have proved themselves very useful[2]. Since its premier many years ago[3], this type of flap remains an elegant method in order to cover exposed bones or tendons of the fi n-ger, in order to ensure length preservation and function recovery. [...]

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How Complicated a Complicated Case Can Become?

The incidence of work related injuries is high worldwide. More than 300 million accidents happen during work and are responsible for almost 2 millions of deaths. The incidence of crush syndrome is 2-15% in all trauma patients and frequently can determine trauma-related amputations, especially if the lower limb is involved and the main mechanism is crushing. Crush syndrome is the systemic manifestation of rhabdomyolysis due to muscles reperfusion injury that happened when the compressive forces on the tissues are released, being of-ten related with occupational accidents[1]. [...]

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A Curious Case of Rhinophyma in a 73-Year-Old Patient

Rhinophyma is a benign tumor characterized by a pro-gressive hypertrophy of the nose soft tissues, with a re-ddish and bulky appearance, affecting most frequently elderly Caucasian males[1], which may also cause functional airway obstruction. It is believed to be the end stage of severe acne rosacea, but the real cause and the exact etiology remain unknown[1]. The male to female ratio of rhinophyma patient varies between 5 to 1 and 30 to 1 [2,3]. The diagnosis is based on the clinical features of this rare and disfiguring disease using Rhinophyma Severity Index Score (RHISI)[4]. The main differential diagnosis is the basal cell carcinoma (BCC), with an occult incidence of 3% to 10% in patients with rhinophyma[1]. [...]

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Charcot Foot Diagnosis - Still an Issue?

The Lisfranc fracture-dislocation of the foot is uncommon and many cases are misdiagnosed. The Lisfranc lesion involves the medial cuneiform and base of the second metatarsal which are considered to be the keystone of the structural integrity of the midfoot. This joint has a stabilization effect on longitudinal and transverse arches of the foot. A neglected or untreated injury to the Lisfranc joint can lead to secondary arthritis and significant morbidity with disability. Furthermore, it is well known the correlation between pacients with periferic neuropathy and this type of lesion, also known as Charcot Foot[1]. It has been documented to occur as a consequence of various peripheral neuropathies, but diabetic neuropathy has become the most common etiology[2]. [...]

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Single-Stage Reconstruction of Distal Third of the Dorsum Nasi Using a Nasolabial Flap after Removal of Basal Cell Carcinoma

The nose represents a common site for skin cancer, especially for Basal Cell Carcinoma (BCC) which is the most common malignant tumor in humans[1-3]. The removal of the tumor will lead to a defect that can involve skin, cartilage and even nasal mucosa. Therefore, reconstruction of this tridimensional structure can be a challenge even for the most experienced surgeons[4]. There are many techniques described in the literature for restoring the lining and skeletal framework[1-8], but all of these techniques should be adapted to the patient’s needs. In this paper we described our preferred surgical method to cover a medium defect of the distal third of the dorsum nasi after tumor excision using a nasolabial flap. In order to perform a single-stage reconstruction, we pushed the limits of the flap measurements and did some tricks so as the pedicle to be well fitted, leading to good aesthetic results. [...]

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Breast Reconstruction Particularities after Radiotherapy - Case Report

Postmastectomy radiation therapy decreases the incidence of locoregional disease recurrence in patients with invasive breast cancer and has been proven to reflect a survival advantage for patients with node positive disease[1,2]. The optimal timing and technique of breast reconstruction procedures in patients requiring post-mastectomy radiation therapy are controversial[1] . Patients undergoing postmastectomy breast reconstruction, with a history of prior radiation therapy, present a particular clinical scenario. This is because of their well-documented higher complication rates, secondary to deleterious effects of irradiation on the soft tissue envelope of the remaining breast. [...]

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Multivisceral Resection for Pancreatic Adenocarcinoma. Case Report and Literature Review

Pancreatic cancer (PC) remains a deadly disease with a dismal prognosis in which the mortality rate nearly equals its incidence [1,4]. Despite advances in modern chemoradiotherapy, the best and only chance of cure for patients with PC is an oncological surgical resection aimed at complete removal of all gross and microscopic disease[5]. Early disease and curative-intent surgery are the best predictors of outcome. Locally advanced cancer of the pancreatic tail involving adjacent organs is often considered unresectable. Radical distal pancreatectomy with en bloc resection of the invaded viscera with or without vascular reconstruction was introduced to treat these tumors[2,3]. Tumors of the body and tail have evidence of involvement of surrounding structures either by tumor infiltration or inflammatory adhesions. In such circumstances, it is advisable to perform en bloc resections to obtain negative surgical margins[6]. According to Shoup, multivisceral resections are technically feasible and, based on the limited data available, these resections are associated with improved survival (5-year survival rates of 16-22%) [7,8]. Given the high morbidity and mortality associated with these procedures, they should be performed only when the possibility of achieving R0 seems distinctly feasible[3,6,8]. [...]

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Comparison of Osteosynthesis Using Plates and Screws Versus Kirschner Wire Fixation for Unstable Metacarpal Fractures: a...

Hand surgery is considered to be the biggest challenge for every plastic surgeon. The social value of the hand is appreciated by any individual, butmostly by plastic surgeons which are, par excellence, hand-working persons. When a hand injury is treated you must consider the Hippocratic concept which states that "healing is a matter of time but it is sometimes also a matter of opportunity". The hand forms a functional unit with the forearm which is a high-precision machine, with multiples levers, who has tactile intelligence that ensure its auto-mechanism, being able to grab and maintain, in any spatial position, large and small tools invented by human genius. The hand is both a motor and sensory organ, and in terms of society,it is an organ of defense, an organ of creation and expression. This is why hand surgery is very important, both in medical and social terms, and any research in this domain has one purpose: improving the treatment of hand injuriesin order to obtain functional results closer to the genetic scale of the divine creation. The purpose of this study was to assess different osteosynthesis techniques in order to establish which one is better in matters of functional results. [...]

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Advances in Peripheral Nerve Regeneration: Materials, Methods, Techniques

Peripheral nerve injuries have a high incidence in limb trauma and have a devastating impact on the quality of life of the patient. Results after surgical treatment are unsatisfactory especially in cases with complete tran-section of the nerve (neurotmesis) associated with late repair. Thus, the necessity to implement into current practice new techniques, materials and methods for nerve repair. [...]

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