Search

Vascular calcification (VC) is a frequent condition in chronic kidney disease (CKD) and a well-established risk factor for the development of cardiovascular disease (CVD). Gut dysbiosis may contribute to CVD and inflammation in CKD patients. Nonetheless, the role of gut and blood microbiomes in CKD-associated VC remains unknown. Therefore, this pilot study aimed to explore the link between gut and blood microbiomes and VC in CKD patients on peritoneal dialysis (CKD-PD). Our results showed relative changes in specific taxa between CKD-PD patients with and without VC, namely Coprobacter, Coprococcus 3, Lactobacillus, and Eubacterium eligens group in the gut, and Cutibacterium, Pajaroellobacter, Devosia, Hyphomicrobium, and Pelomonas in the blood. An association between VC and all-cause mortality risk in CKD-PD patients was also observed, and patients with higher mortality risk corroborate the changes of Eubacterium eligens in the gut and Devosia genus in the blood. Although we did not find differences in uremic toxins, intestinal translocation markers, and inflammatory parameters among CKD-PD patients with and without VC, soluble CD14 (sCD14), a nonspecific marker of monocyte activation, positively correlated with VC severity. Therefore, gut Eubacterium eligens group, blood Devosia, and circulating sCD14 should be further explored as biomarkers for VC, CVD, and mortality risk in CKD.

Purpose It has been proved that the gut microbiome is altered in patients with chronic kidney disease. This contributes to chronic inflammation and increases cardiovascular risk and mortality, especially in those undergoing hemodialysis. Phosphate binders may potentially induce changes in their microbiome. This trial aimed to compare the changes in the gut microbiome of hemodialysis patients treated with calcium acetate to those treated with sucroferric oxyhydroxide. Methods Twelve hemodialysis patients were distributed to receive calcium acetate or sucroferric oxyhydroxide for 5 months. Blood samples (for biochemical analysis) and stool samples (for microbiome analysis) were collected at baseline, 4, 12, and 20 weeks after treatment initiation. Fecal DNA was extracted and a 16S rRNA sequencing library was constructed targeting the V3 and V4 hypervariable regions. Results Regarding clinical variables and laboratory parameters, no statistically significant differences were observed between calcium acetate or sucroferric oxyhydroxide groups. When analyzing stool samples, we found that all patients were different (p = 0.001) among themselves and these differences were kept along the 20 weeks of treatment. The clustering analysis in microbial profiles grouped the samples of the same patient independently of the treatment followed and the stage of the treatment. Conclusion These results suggest that a 5-month treatment with either calcium acetate or sucroferric oxyhydroxide did not modify baseline diversity or baseline bacterial composition in hemodialysis patients, also about the high-variability profiles of the gut microbiome found among these patients.

Systolic pulmonary artery pressure (SPAP) and right heart adaptation in relation to pre-existing preload are often disregarded. To determine volume-related changes in the pulmonary-right ventricle (RV) unit and the preload dependence of its components, we analysed pulmonary haemodynamics and right ventricular performance, taking advantage of the plasma volume removal associated to haemodialysis (HD).Fifty-three stable patients on chronic HD with LVEF 50% and without heart failure were recruited (mean age 63.0 ± 12.4 years; 31.2% women; hypertension in 89% and diabetes in 53%) and evaluated just before and after HD (mean ultrafiltration volume 2.4 ± 0.7 l). SPAP from both times were available in 39 patients. After HD, SPAP decreased (42.2 ± 12.6 to 33.7 ± 11.6 mmHg, p 0.001) without modification of non-invasive pulmonary vascular resistance (1.75 ± 0.44 to 1.75 ± 0.40 eWU, p = 0.94). Age and drop in the E/e' ratio were the variables associated with greater reduction in PASP (p = 0.022 and p = 0.049, respectively). A significant reduction of right chamber sizes was observed, along with a diminution in measures of RV contractility, excluding RV longitudinal strain. Functional tricuspid regurgitation (FTR) diminution was observed in 26% of patients, occurring in every case with more than mild FTR. On multivariate analyses, left atrial size was the only predictor of pulmonary hypertension (defined as SPAP 40 mmHg) (OR 1.29 (1.07-1.56), p = 0.006).Rapid volemic changes may affect FTR grading, RV size and contractility, with RV longitudinal strain being less variable than conventional parameters. SPAP decreases after HD, and this reduction is related to age and greater diminution of the E/e' ratio.

Background Ambrisentan is a selective endothelin receptor antagonist used for the treatment of pulmonary arterial hypertension (PAH). Little is known about ambrisentan removal by hemodialysis in patients with end-stage renal disease (ESRD). Case presentation A 53-year-old woman with HIV/hepatitis C virus (HCV) co-infection, PAH and ESRD on regular hemodialyis was admitted in our hospital due to refractory heart failure while on treatment with bosentan (125 mg twice daily) and tadalafil (20 mg once daily) for PAH and antiretroviral treatment (cART) including darunavir/cobicistat (800/150 mg once daily). Excessive exposure to bosentan due to drug interactions between bosentan and darunavir/cobicistat was suspected. Bosentan was replaced by ambrisentan, with progressive improvement in her clinical condition. Pre- and postdialyzer cocentrations of ambrisentan in plasma were determined and hemodialysis extraction ratio for ambrisentan was 2%. Conclusions Our results suggest that hemodialysis results in minimal ambrisentan removal, and therefore no specific ambrisentan dosage adjustment seems to be required in ESRD patients undergoing hemodialysis.

Chronic hepatitis C (CHC) is a leading cause of liver disease. Despite the improved efficacy of new antivirals, their high costs preclude their adoption in resource-limited settings, where CHC prevalence is highest. We developed a triplex high-resolution melting assay for the simultaneous assessment of three genetic polymorphisms related to the response to treatment and development of advanced fibrosis in CHC: IFNL3 rs12979860, ABCB11 rs2287622, and RNF7 rs16851720. We validated the assay in clinical samples from 130 CHC patients treated with classic therapy. The assay showed excellent reproducibility and 100% accuracy, sensitivity, and specificity against the gold standard Sanger sequencing. When added to routine examination data, genotype information significantly improved their performance for prediction of advanced liver fibrosis and sustained virological response (P = 0.041 and P = 0.011, respectively). Correspondingly, the full models had area under the receiver operating characteristic curve values of 0.842 (95% CI, 0.773-0.911) and 0.921 (95% CI, 0.870-0.972) and integrated discrimination improvements of 7.5% (95% CI, 2.5%-12.5%; P = 0.003) and 11.5% (95% CI, 5.8%-17.2%; P 0.001), respectively. This is the first report on a diagnostic test for simultaneous genotyping of IFNL3, ABCB11, and RNF7 in CHC patients. Reliable and inexpensive, the assay should provide useful information for the clinical management of CHC, like identification of patients at risk of rapid disease progression or with high chances of response to classic therapy.

Hepatocellular carcinoma (HCC) is one of the leading causes of cancer related deaths worldwide, while at the same time having a constant growth in incidence. A commonly used biomarker in managing liver cancer cases, alpha-fetoprotein (AFP) is losing clinical ground in favor of imaging studies and emerging biomarkers. The study aims to reassess potential prognosis indicators and risk factors for an elevated level of this glycoprotein by analyzing its relationship with macroscopic morphology tumor-related features.One hundred and thirty-one newly diagnosed HCC patients had their clinical, tumor and liver disease features investigated in contrast to elevated AFP levels with 200 IU∕mL being used as preferred cut-off.Tumor size =5 cm [odds ratio (OR) 3.36, 95% confidence interval (CI): 1.29-8.74, p=0.013] is an independent tumor-related predictor of markedly elevated AFP values. Noteworthy connections with the type of tumor, multinodular appearance and portal vein thrombosis were also found through univariate analysis.AFP could still be a reliable tool in diagnosis and prognosis of HCC patients especially in developing countries due to its relevant association with aspects of advanced tumor and liver disease, gender and a poor functional status.

Altres ajuts: This work was supported by the project, integrated in the National R + D + I and funded by the ISCIII and the European Regional Development Fund (http://www.isciii.es). Also by the "Suport Grups de Recerca" programme of Secretaria d'Universitats i Recerca, Dept. Empresa i Coneixement, Generalitat de Catalunya , Group REMAR, http://agaur.gencat.cat), the Instituto de Salud Carlos III-Red de Investigación Renal (REDinREN) (Feder Funds, http://www.isciii.es, http://redinren.org), and Fundació Cellex. FEB is sponsored by the "Researchers Stabilization Program" from the Spanish "Sistema Nacional de Salud" (SNS- ISCIII, http://www.isciii.es) and "Direcció d'Estratègia i Coordinació" Catalan Health Department (CES07/015). Kidney transplantation (KTx) is the best therapeutic approach for chronic kidney diseases leading to irreversible kidney failure. Considering the origin of the graft, several studies have reported differences between living (LD) and deceased donors (DD) in graft and patient survival. These differences seem to be related to multiple factors including, donor age and time of cold ischemia among others. Many of transplanted organs come from old-aged DDs, in which pre-transplant biopsy is recommended. However, kidney biopsy has several limitations, and there is a need to develop alternatives to assess the status of a kidney before transplantation. As the analysis of urinary extracellular vesicles (uEVs) rendered promising results as non-invasive biomarkers of kidney-related pathologies, this pilot study aimed to investigate whether profiling uEVs of LDs and DDs may be of help to assess the quality of the kidney before nephrectomy. uEVs from 5 living donors and 7 deceased donors were isolated by size-exclusion chromatography, and their protein and miRNA content were analysed by liquid chromatography followed by mass spectrometry and next generation sequencing, respectively. Then, hierarchical clustering and venn diagrams were done with Perseus software and InteractiVenn tool. Specific EVs data bases were also used for Gene Ontology analysis. Next generation sequencing revealed that uEVs from DDs contained less miRNAs than LDs, but most of the DD-expressed miRNAs were shared with LDs (96%). Only miR-326 (targeting the apoptotic-related Bcl2) was found significantly over-represented in LD. Focusing on the protein content, we detected a low intra-group correlation in both types of donors. Despite these differences, hierarchical clustering of either miRNA or protein data could not identify a differential profile between LDs and DDs. Of note, 90% of transplanted patients had a functional graft after a year from KTx. In this pilot study we found that, in normo-functional grafts, minor differences in uEVs profile could not discriminate between LDs and DDs.

International audience; Chronic hepatitis C (CHC) is a major burden for public health worldwide. Although newer direct-acting antivirals show good efficacy, their cost precludes their wide adoption in resource-limited regions. Thus, strategies are being developed to help identify patients with high susceptibility to response to classic PEG-interferon + ribavirin therapy. IL28B polymorphism rs12979860 C/T is an important predictor for an efficient response to interferon-based therapy. A genetic variant in adiponutrin (PNPLA3) gene, rs738409 C/G, is associated with steatosis, severity, and progression of liver fibrosis in CHC patients, and predicts treatment outcome in difficult-to-cure HCV-infected patients with advanced fibrosis. We developed a rapid and inexpensive assay based on duplex high-resolution melting (HRM) for the simultaneous genotyping of these two polymorphisms. The assay validation was performed on synthetic DNA templates and 132 clinical samples from CHC patients. When compared with allele-specific PCR and sequencing, our assay showed 100% (95% CI: 0.9724-1) accuracy, with 100% sensitivity and specificity. Our assay was robust against concentration and quality of DNA samples, melting curve normalization intervals, HRM analysis algorithm, and sequence variations near the targeted SNPs (single nucleotide polymorphism). This duplex assay should provide useful information for patient-oriented management and clinical decision-making in CHC.

Background Some lesions not included in the Banff classification, such as inflammation in the scarred areas and total inflammation, have been described to have prognostic value in the evaluation of graft biopsies. Our aim was to reassess kidney graft biopsies and study the impact of histopathologic lesions, both those graded in the Banff classification and those related to inflammation, on the graft function and evolution. Methods We selected 20 biopsies exhibiting chronic pathology without a specific phenotype, and we reevaluated them with the use of a modified Banff score. Results We found statistically significant association between the presence of total inflammation (P = .048; P = .038), the presence of inflammation in scared area (P = .037; P = .018), and creatinine at the time of renal biopsy and 1 year after the renal biopsy, respectively. Conclusions Our results suggest that the presence of both inflammation in the scarred areas and total inflammation are related to renal function at the time of the biopsy and to renal function 1 year after the biopsy.

In vascular surgery the crossover iliofemoral bypass grafting is a well-known surgical technique. In general surgery the repair of an abdominal defect using a Polypropylene mesh is also a standard procedure. A particular technique is defined by the performance of these 2 separate procedures inside a single operation in which the crossover arterial graft is directed from the retroperitoneal space toward the contra-lateral femoral bifurcation through a Polypropylene mesh which closes the musculoaponeurotic layers of the abdominal wall. We present our experience with the use of this particular surgical technique in patients with critical limb ischemia and with indication for extra-anatomic crossover bypass (high-risk patients with contra-indication for the transperitoneal approach, extensive calcified aortic or iliac wall which contraindicated the direct arterial reconstruction or secondary arterial reconstruction after the occlusion of an aorto- femoral graft).In principle, the hernioplasty was performed by using the Lichtenstein tension-free hernia repair technique, followed by the crossover iliofemoral bypass. The main feature of this technique is to pass the vascular graft from the retroperitoneal space above the mesh through a calibrated hole in the mesh RESULTS: The 7 patients with inguinal hernia and l limb-threatening ischemia had favorable evolution, without hernia recurrence, limb-threatening ischemia or any graft complication at 3 years.Using this particular surgical technique we treated 2 surgical diseases using a single intervention for highrisk patients who had both inguinal hernia and contra-lateral critical limb ischemia. Being encouraged by the initial satisfactory results, we extended this technique even for the patients with indication of crossover iliofemoral bypass but without inguinal hernia.The particular surgical technique of the crossover bypass in which the vascular graft crosses a tension-free Polypropylene mesh from the retroperitoneal space toward the Retzius space represents an efficient and short procedure which treats simultaneously 2 different surgical diseases (inguinal hernia and contra-lateral critical limb ischemia) in high-risk patients. The results were satisfactory: we had no hernia recurrence and the limb-threatening ischemia was successfully treated. The preferred vascular graft for this particular technique is the reversed autogenous vein because its resistance to infections and the vein long-term patency is better than of a vascular prosthesis. When a prosthetic graft is required, we prefer to use the classic technique in which the crossover graft is placed in an under-aponeurosis site, in order to diminish the prosthesis infection risk.Abdominal wall, Iliofemoral bypass, Vascular surgery.Spesso, la malattia vascolare può essere associata ad ernia inguinale richiedendo un trattamento chirurgico in entrambi i casi. Tuttavia, l’innesto incrociato può comportare l’ernia inguinale o femorale. Per risolvere questo problema, vi presentiamo una tecnica chirurgica in cui l’innesto vascolare ileofemorale incrociato attraversa una protesi addominale di riparazione.Abbiamo eseguito questa tecnica in 18 pazienti ad alto rischio. Sette pazienti avevano comorbilità - ernia inguinale e occlusione dell’arteria iliaca controlaterale) curati contemporaneamente: innesto vascolare incrociato è diretto dallo spazio retroperitoneale mediante la protesi di ernioplastica verso l’arteria femorale contro-laterale. Abbiamo esteso questa tecnica per 11 pazienti senza ernia associata. Innesti vascolari: 10 vene autogene, 8 innesti protesici. Ulteriori indagini sono state completati per tutti i 18 pazienti da un esame clinico. Il periodo mediano di follow-up è stato di 2,5 ani. Abbiamo paragonato questa tecnica con gli interventi incrociati „classici”. che sono state eseguite mediante le tecniche tradizionali. Risultati: non ci sono stati ulteriori recidive di ernia o di ischemia al livello degli arti (nei primi 3 anni), 1 caso di infezione tardiva della protesi e 3 casi di trombosi tardiva della protesi.Questa tecnica è stata applicata al trattamento di pazienti ad alto rischio, con 2 malattie, utilizzando un’unico intervento e sembra essere fattibile come procedura incrociata di routine incrociata.

Liver disease is a major cause of morbidity and mortality worldwide. As in other fields of medicine, there is a stringent need for non-invasive markers to improve patient diagnostics, monitoring and prognostic ability in liver pathology. Cell-free circulating RNA molecules have been recently acknowledged as an important source of potential medical biomarkers. However, many aspects related to the biology of these molecules remain to be elucidated. In this review, we summarize current concepts related to the origin, transportation and possible functions of cell-free RNA. We outline current development of extracellular RNA-based biomarkers in the main forms of non-inherited liver disease: chronic viral hepatitis, hepatocellular carcinoma, non-alcoholic fatty liver, hepato-toxicity, and liver transplantation. Despite recent technological advances, the lack of standardization in the assessment of these markers makes their adoption into clinical practice difficult. We thus finally review the main factors influencing quantification of circulating RNA. These factors should be considered in the reporting and interpretation of current findings, as well as in the proper planning of future studies, to improve reliability and reproducibility of results.

Sweet's syndrome is rare acute febrile neutrophilic dermatosis whose onset is either idiopathic or associated with other underlying conditions, such as infections, autoimmune diseases, pregnancy, use of certain medications, or malignancy. We report the case of a young male with known history of ulcerative colitis and abrupt onset of high fever, malaise, blurred vision and eruption of painful erythematous nodules and papules, localized on the head, neck, trunk and upper limbs. Ophthalmological examination established the diagnosis of anterior uveitis. Inflammatory markers were positive. Histological examination of skin lesions revealed a dense neutrophilic infiltrate of the dermis. Clinical, laboratory and histological findings were suggestive for the diagnosis of Sweet's syndrome and uveitis on a background of ulcerative colitis. Systemic and ophthalmic administration of corticotherapy leads to a prompt resolution of symptoms and inflammatory syndrome. The particularity of this case is the occurrence of two simultaneous extraintestinal manifestations in a young male with inflammatory bowel disease and colonic involvement. Although a relatively rare condition, Sweet's syndrome should be considered as a differential diagnosis in patients with acute onset of high fever and skin rash, as it may have notable internal involvement and can be easily treated.

Laparoscopic sleeve gastrectomy (LSG) has gained ground in Eastern Europe in the decade but fewer reports of large series with medium-term follow-up exist. We describe a single-surgeon experience in LSG (the first 101 consecutive cases) in a Balkan emerging bariatric center. A prospectively maintained database of the initial 101 consecutive patients submitted to LSG in our clinic between October 2010 and February 2016 was reviewed. The percentages of mean excess weight loss (%EWL) in the 101 patients (mean age of 42 ± 10.6 years, 77 % female, median preoperative body mass index (BMI) of 44.5 kg/m2) were 51.3 (n = 82 followed-up patients) at 6 months postoperatively, 78.2 (n = 69) at 1 year, and 75.8 (n = 39), 77.1 (n = 20), 67.5 (n = 17), and 52.9 (n = 7) at 2, 3, 4, and 5 years, respectively. One year after LSG, all comorbidities showed remission or significant improvement in all 69 followed-up patients; the highest resolution was seen with hypertension (73.3 %). We noted a negative correlation between a decrease in %EWL and both the age of the patient and the initial state weight and BMI. The mortality in our group was nil; we had three cases (2.9 %) of bleeding and no leaks. LSG is a safe procedure, with low postoperative morbidity rates and excellent short-term %EWL results up to 3 years after surgery, including resolution or improvement of the main obesity-related comorbidities. The results were superior in the category of younger and lower initial BMI obese patients.

INTRODUCTION: IGF-1 (insulin-like growth factor-1) is a hormone involved in cell growth and other important processes. In the kidney, IGF-1 has a stimulating effect, increasing the blood flow and glomerular filtration rate. Although many experimental animal studies regarding the role of IGF-1 in the kidney have been conducted, few human studies are available in the literature. Obesity is a cause of renal failure, and several glomerular lesions associated with obesity have been described. However, no studies regarding the levels of IGF-1 in morbidly obese patients with renal injury associated with obesity have been conducted. AIM: To determine the serum IGF-1 concentrations in morbidly obese patients with normal renal function but with different types of early obesity-related glomerular lesions and to evaluate the possible relationship between IGF-1 and the presence of renal lesions. METHODS: Eighty morbidly obese patients with renal biopsy, including 11 patients with no evidence of renal lesion, 17 patients with single glomerulomegaly, 21 patients with single podocyte hypertrophy, 10 patients with glomerulomegaly and podocyte hypertrophy, 5 patients with focal segmental hyalinosis, and 16 patients with increased mesangial matrix and/or mesangial proliferation, participated in this study. Biological parameters, including serum IGF-1 concentrations with the standard deviation score for age (SDS-IGF-1), were determined for all patients. RESULTS: Eighty patients (50 women and 30 men) with a mean BMI of 52.63 ± 8.71 and a mean age of 42.40 ± 9.45 years were included in this study. IGF-1, IGF-1 SDS and IGF-1BP3 levels according to the renal injury were compared (normal glomeruli: IGF-1 = 190.17 ± 72.46; glomerulomegaly: IGF-1 = 122.3 ± 50.05; podocyte hypertrophy: IGF-1 = 119.81 ± 60.34; focal segmental hyalinosis: IGF-1 170.98 ± 100.83, increased mesangial matrix and/or mesangial proliferation: IGF-1 117.73 ± 63.87). Statistically significant differences were observed between serum levels of IGF-1 and between the levels of SDS-IGF-1 by comparing the group without glomerular lesion with the group formed by patients with any type of glomerular injury. Logistic regression analysis was performed, with the dependent variable defined as the glomerular injury. In the multivariate analysis, only SDS-IGF-1 was associated with glomerular injury, and low levels of IGF-1 SDS were a risk factor for kidney injury. CONCLUSIONS: Our study demonstrates that low IGF-1 serum levels are associated with renal lesions in morbidly obese patients without overt clinical renal manifestations

Patients with chronic kidney disease (CKD) are characterized by a state of inflammation and oxidative stress that seems to improve after kidney transplantation (KT). Nevertheless, there is controversy regarding what is the best marker that better define inflammation and specially oxidative stress. To evaluate the biomarkers which are associated with improvements in inflammation and lipid peroxidation in patients who have undergone KT. To evaluate the relationship between inflammation, lipid peroxidation and mortality in KT. 196 KT (between 2003 and 2008). 67.9% men; median age: 51.9 years. Inflammation markers analyzed previous KT and 3 months after KT: c-reactive protein(CRP), interleukin 6(IL-6), tumor necrosis factor alpha(TNF alpha), soluble tumor necrosis factor receptor alpha(sTNFR alpha), soluble interleukin-2 receptor (sIL-2R). Lipid peroxidation markers analyzed: oxidized low-density lipoprotein (oxLDL) and anti-oxLDL antibodies. Calculation of glomerular filtration rate after KT: MDRD equation. Following KT, there is a significant decrease in CRP (p = 0.006), IL-6 (p = 0.0037), TNF alpha (p < 0.0001), sTNFR alpha (p < 0.0001) and sIL-2R (p < 0.0001), while levels of oxLDL increase after KT (p < 0.0001) and there is not a significantly difference in anti-oxLDL. 12.8% of the patients had died in 2012. These patients had higher levels of IL-6 (p = 0.011) and sTNFR alpha (p < 0.006) after KT and a lower MDRD (p < 0.0001), hemoglobin (p = 0.012) and albumin (p = 0.007). We observed no statistically differences in the levels of markers previous KT. Of the patients who died, the 43.5% of them had anti-oxLDL antibody levels greater than 75th percentile (P-75: 3781 UI/ml, p = 0.028). In the multivariate analysis, age (OR:1.12; p = 0.0129), MDRD (OR:0.92; p = 0.013) and P-75 of anti-oxLDL(OR: 5.19; p = 0.026) were independent risk factors for mortality. Independent risk factors for survival were: P-75 of IL-6 (HR: 2.45; p = 0.027), oxLDL (HR:19.85; p = 0.002) and anti-oxLDL (HR: 9.55; p = 0.003). KT improved inflammation but not lipid oxidative state. KT patients who died had a higher inflammatory state (with higher levels of IL-6 and sTNFR alpha), a worse lipid oxidative state and a worse renal function 3 months after KT. Age, anti-oxLDL and renal function at 3 months after KT were independent risk factors for mortality.

Data on dolutegravir removal by hemodialysis are lacking. To study this, we measured dolutegravir plasma concentrations in samples of blood entering and leaving the dialyzer and of the resulting dialysate from 5 HIV-infected patients with end-stage renal disease. The median dolutegravir hemodialysis extraction ratio was 7%. The dolutegravir concentrations after the dialysis session remained far above the protein-binding-adjusted inhibitory concentration. Our results show minimal dolutegravir removal by hemodialysis, with no specific dolutegravir dosage adjustments required in this setting. (This study is registered at ClinicalTrials.gov under registration number NCT02487706.)

Background Post-transplant recurrent glomerulonephritis (RGN) is the third cause of graft failure in the first year after renal transplantation (RT). The purpose of this study was to analyze the incidence of RGN, clinical presentation, and clinical evolution of transplanted renal graft in patients who underwent RT at our center. Methods We studied patients with glomerulonephritis (GN) who underwent RT (2007 to 2013).We analyzed sex, age, time in dialysis, type of GN, type of RT, time to post-transplant RGN, kidney function at the time of diagnosis of RGN, and renal graft evolution. Renal biopsy samples were processed in the anatomic pathology laboratory. Results Three hundred sixteen patients received kidney transplantation during this time period. In 83 cases, the reason for transplantation was primary GN. Of these 83 patients, 15 (18%) had RGN confirmed by renal biopsy. Data for these 15 patients include sex: 73.3% men, 26.7% women; mean age: 42.2 (29–73) years; type of RT: 80% cadaveric donor (CD) versus 20% living donor (LD); type of GN: 18.4% immunoglobulin (Ig)A nephropathy, 35.7% membranous GN, 10.53% type I membrano-proliferative GN (MPGN I), and 16.6% focal segmental glomerular sclerosis (FSGS). The mean time to post-transplant RGN was 2 years (1 month to 16 years). Patients who received an LD transplant had a shorter time to post-transplant RGN than those who had a CD transplant. One patient with FSGS and one with MPGN I had a time to post-transplant RGN of less than 1 year. In the evolution of renal function, 33.3% of patients had graft failure. Conclusions The incidence of RGN was lower (18%) than that published in the literature. Membranous nephropathy was the most frequent cause of post-transplant RGN. Patients who underwent LD transplantation and those with IgA nephropathy had a shorter interval of time to post-transplant RGN than patients with FSGS and MPGN I.

Background Historically, alongside regulatory and jurisdictional differences in scope of practices, practice patterns of naturopathic doctors (NDs) have varied widely to promote holistic or whole-person treatment using a variety of therapies including: controlled substances, minor surgery, a variety of complementary therapies, as well as both novel and conventional assessments. However, little is known about the observed practice patterns of NDs, the services provided to their patients, or the type of conditions for which patients of NDs are seeking treatment. In order to address this gap, a cross-sectional descriptive analysis of the largest Canadian teaching clinic for NDs was undertaken to better understand the services provided to the community and increase the knowledge regarding the use of naturopathic medicine. Methods Data stemmed from two sources at the Toronto, Ontario clinic: a passive patient satisfaction survey, and the clinic’s point-of-sale (POS) system. Data included patient demographics, postal codes, health services utilization, ICD-10 codes, therapies employed, along with other data relating to the financial transactions associated with the visit. Simple descriptive statistics and the Kruskal-Wallis test were used to compare different age-based groups and examine health services use between years. This study was approved by the Research Ethics Board of the Canadian College of Naturopathic Medicine. Results 13,412 patients were treated in 76,386 patient visits spanning three clinic years. Median age of patients was 37; females outnumbered males (2.6:1) in all age-based groups except the pediatric population. In the patient satisfaction survey, there were 1552 potential survey respondents; with 118 responses received (response rate: 7.6%). Obtaining health education, health prevention and help with chronic health conditions were the primary motivators for patient visits identified in the patient survey. Conclusion The clinic attracts people from a wide area in the metropolitan Toronto and surrounding region with health concerns and diagnoses that are consistent with primary care, providing health education and addressing acute and chronic health conditions. Further explorations into health services delivery from the broader naturopathic or other complementary/alternative medical professions would provide greater context to these findings and expand understanding of the patients and type of care being provided by these health professionals. Electronic supplementary material The online version of this article (doi:10.1186/s12906-015-0550-6) contains supplementary material, which is available to authorized users.

Aims: No long-term studies of renal function evolution in morbidly obese (MO) patients after weight loss are available. The aim of our work was to ascertain the long-term influence of drastic weight reduction on renal function in MO patients with obesity-related glomerular lesions. Methods: 92 MO patients with normal renal function and biopsy evidence of mild obesity-related glomerulopathy underwent bariatric surgery (BS) and subsequent drastic weight loss. A long-term prospective follow-up (mean duration: 76 ± 42 months) was carried out. Basal renal biopsies and basal and long-term metabolic and renal function studies were performed in all cases. Linear mixed models were applied. Results: Blood pressure dropped early after BS and remained stable thereafter. Creatinine clearance and BMI fell in the first 2 years, rose slightly after 5 years and then remained stable. Serum creatinine and albuminuria decreased throughout the follow-up period. Renal function and albuminuria evolution showed non-significant differences in relation to the number of glomerular lesions. Conclusions: Drastic weight loss in BS-treated MO patients with pre-surgical normal renal function and mild obesity-related glomerular lesions is associated with short- and long-term maintenance of normal renal function and improvement in both arterial hypertension and albuminuria.

Isolated polycystic liver disease is a rare congenital cystic liver disease with autosomal dominant transmission. Its main feature is the presence of a large number of cysts of different sizes in the hepatic parenchyma, which have a benign evolution.We present the case of an 80 years old male patient with massive polycystic liver disease, diagnosed three years ago by ultrasound examination and abdominal computed tomography scan. The evolution of the disease had been complicated by compressive symptoms, caused by the large dimensions of the cysts. The patient presented with abdominal pain, nausea, vomiting and lost weight. Cyst fenestration through laparoscopic approach resolved the symptoms.The patient was mobilized on the day of the surgery, and was discharged on the 9th postoperative day, after drainage tube removal.Isolated polycystic liver disease is rare. Surgical treatment is indicated only if complications occur. The laparoscopic approach is an alternate treatment method, if needed. The patients benefit from the advantages of minimally invasive surgery.

Colorectal cancer is the most common malignant tumor of digestive tract with high mortality due to local reccurences and metastases. These are due to micrometastases undetected by classical microscopic examination of regional lymph nodes. Sentinel lymph node SLN technique in colorectal cancer may lead to identification of micrometastases using immunohistochemistry.We present our experience in SLN mapping in colorectal cancer using a limphofil dye, on 52 patients. We present the patients selection criteria in the study, the technique of SLN detection.Identification of SLN was performed in 48 cases, it failed in 4 cases. In 27 cases, 1 SLN was identified, in 21 cases 2 SLN were found. In 4 cases the SLN were false negative. In 30 cases SLN were negative on histopathology and immunohistochemistry. In 14 cases, SLN were positive, 4 cases presented micrometastases confirmed only by immunohistochemical methods.SLN technique in colorectal cancer: - doesn't change the surgical approach regarding the regional lymphadenectomy; - can modify the tumor stadialization by detecting lymph nodes micrometastases; - increase the number of patients who can benefit from the adjuvant chemotherapy and therefore, it may improve the prognosis.

The aim of the study is to evaluate the outcome of a selected group of 24 patients who underwent surgery for refractory ascites, in a 10 years period, 1995-2005.Alcoholic cirrhosis (n=18), inferior cava thrombosis (n=2), splenic vein thrombosis (n=1), cryptogenic cirrhosis (n=3), with association of variceal bleeding and refractory ascites. The surgical procedures consisted of porto-sistemic shunts (n=12), peritoneo-saphene shunts (n=10), mesenterico-caval shunt (n=1), mesenterico-right atrium shunt (n=1). Early results were very good: no postoperative mortality, no general haemo-dinamic failure, no renal fonctional failure, no encephalopathy. 7 of 10 peritoneo-saphene shunts had an excelent evolution, but in three cases the results were unsatisfactory, the patients continuing the medical treatment. Except one patient who died after 2 years, for B virus and alcoholic abuse, all the patients survived 5 or more years. There was not evidence of digestive hemorrhage or uncontrolable encephalopathy and thrombocytopenia. The grade of esophageal varices was mantained lower than II, ascites remained minimum or absent, and biological parameters were normal or slightly elevated.In the absence of the technical and economical possibilities of TIPS and liver transplantation, surgery for intractable ascites is a good option in selected patients, especially in the absence of viruses and alcohol consumption, and can improve complications in the natural evolution of the disease.

The gastrointestinal stromal tumours expand from the undefine mezenchimal cells of the intestinal wall and the origin is in the Cajal interstitial cells. The agresivity of GIST is difficult to be evaluate. Very importants factors for grading are the tumour localisation, the invasion of serosa or mucosa, the dimensions of tumour and the number of mytosis. We present a case with haemoragic gastric stromal tumour, with small dimensions, which was initially diagnosed as a "benign" tumour. Seven years after the operation, the patient presented voluminous liver metastases. After right hepathectomy and medical treatment with Glivec we followed up the case. Eleven years after the first operation she presented a subcutaneus metastasis in parietal region, which was confirmed with imunohistochemical exam. The patient is still under observation with higher doses of Glivec.The gastrointestinals stromal tumours represent a very rare group of digestive tract tumors, with malignant potentially evolution; the first choice of treatment is surgery, with complete ablation of the tumour. The medical treatment with Glivec is necessary in case of reccurence or metastases; the stromal tumours present a strange evolution, for this reason all the patients must be under medical observation, for the rest of their life.

By local recurrence we define the appearance of the same anatomopathological type of cancer like the one initially described in the primary tumor, limited at the rectum or pelvis.The study is based on the analysis of all the cases with rectal cancer who undergone surgical procedures in Surgical Clinic No.2 Tg. Mures in the last 5 years. Using the most important parameters for each patient we identified some risk factors for the recurrence of the rectal cancer: surgical procedures--there were no major variations in the local recurrence between the sphincter-saving operations and abdominal perineal resections. The most frequent recurrence tumors appeared after Hartmann I operation; the moderate aggressive adenocarcinomas at the old patients and high aggressive adenocarcinomas in young patients, T3, T4 stages. The recurrent rectal cancer is more frequent in aged patients with high aggressive adenocarcinomas. There were no major differences in recurrence rate between the sphincter-saving operations and abdominal perineal procedures.

Trauma is the principal cause of mortality among the population under 40 years. The aim of our study was to compare predictive trauma scores and demonstrate their utility in the evaluation of the quality of care in polytrauma.A retrospective study was performed between 2000-2011 including polytrauma patients with abdominal lesions and pelvic fracture who under went emergency laparotomy. We calculated ISS, GCS, RTS,TRISS, ASCOT trauma scores and W score for evaluation of treatment quality.We obtained the necessary data to calculate the predictive scores in 38 cases. Comparing the scores of the survivals and non-survivals we noted the following regarding mortality predictive scores: GCS 13.74 vs. 6.13 (p 0.0001),ISS 28.52 vs. 35 (p=0.0169), RTS 6.96 vs. 3.07 (p 0.0001),TRISS 84.67% vs. 28.7% (p 0.0001), ASCOT 10.34% vs.64.32% (p 0.0001). The W score in TRISS and ASCOT methodology was -2.05 (p=0.7997) and -7.81 (p=0.336),respectively. There was no statistically significant difference between actual and predicted mortality, the former being 39.47%.We did not observe differences between the two methodologies TRISS and ASCOT in mortality prediction (p=0.5401). Both of them can be used to predict polytrauma patient evolution. The W score is useful in treatment quality assessment.

Controversy still exists regarding the optimal surgical management of esophageal cancer. This study was performed to determine and compare early and late morbidity,mortality and overall survival after transthoracic (TTE) and transhiatal esophagectomies (THE).Between 1997-2011, 100 patients underwent TTE or THE for squamous esophageal carcinoma (90 patients)and adenocarcinoma (10 patients). Assessed parameters included patient demographics, operative data, pathology results, postoperative morbidity and mortality and 1-3 year survival.Thoracic approach was preferred in cases of more advanced tumors, located in the upper and mid-third of the esophagus, in patients with a better cardiopulmonary status. Perioperative blood loss was significantly higher after transthoracic resections (p=0.0004) and these surgeries took significantly longer than transhiatal esophagectomies(p=0.02). We identified complications in 70.7% patients who under went TTE and in 59.3% patients with transhiatal approach. Respiratory complications were statistically significant in the TTE- group (p-0.0003). The 30-day mortality rates were 12.2% for patients in TTE group and 10.1% in THE patients group, respectively. The mortality ratefor the entire period of the study has been calculated at 84.4%.We have identified a survival rate after 1 year of 62.2%, after 2 years of 39.3% and after 3 years - 15.1%.According to the results of this study, both procedures appear to be acceptable depending on surgeon preference and appropriate patient selection.

Cervical anastomotic fistula are reported in the surgical literature in 10-30% of the patients, providing a much longer hospitalisation, a higher morbidity and in some cases even mortality. Between 1997-2003, 91 patients underwent surgical treatment for esophageal cancers and 14 patients for chemical burns. In the cancer group the rate of resection was 67,03% (61 patients). In 8 patients with non-resection tumours a retrosternal esophageal by-pass with stomach was carried out. Cervical anastomosis were performed in 68 patients, by hand sutures. Anastomotic fistula were noted in 9 patients (13,24%). In 6 cases temporarily fistula occurred, with spontaneous healing by local treatment, in 8-28 days. 2 patients required reoperation and one patient a definitive feeding jejunostomy. Most common causes of fistula are technical problems, ischemic gastric or colonic tube, postoperative respiratory failure, with prolonged hypoxia. An anastomosis in the neck results in less postoperative complications than one of the lower level.

Background There are few reports about the clinical course and prognosis of monoclonal gammopathy of undetermined significance (MGUS) in long-term immunosuppressed patients. Our aim was to study the association and evolution of MGUS and renal transplantation. Methods Subjects submitted to renal transplantation between 1996 and 2011 who presented MGUS before or after immunosuppressive treatment was established were selected. Results Patients (N = 587) underwent kidney transplantation in our center during the selected period. MGUS was detected in 17 (2.9%) patients (10 men and 7 women with a mean age of 69.9 ± 10.07 years), with a median follow-up of 6 years. All patients had a functioning graft. Nine had MGUS before transplantation. One patient had multiple myeloma, and 8 remained stable. Eight patients had development of MGUS after transplantation. Six patients remained stable, 1 showed no MGUS, and 1 displayed an increased monoclonal component in further controls. Conclusions In our study, renal transplantation is not a risk factor for the development of malignant processes in patients with MGUS before transplantation. There is a group of patients who tend to have MGUS after transplantation; nevertheless, they had a benign evolution during a 6-year follow-up.

In this study are noted technical problems regarding "en bloc" multiple organ resections and the anatomic and functional reconstruction for carcinoma of the upper stomach and cardia. From 1997 to 2002, a total of 264 patients with cancers of the stomach were operated in the service. 75 patients presented cancers localized at the proximal stomach and cardia (97.33% adenocc.). The rate of resectability was 27.77% (27 pt.). Types of operations in this series were: standard esophagogastrectomy in 7 patients; total gastrectomy with regional lymphadenectomy in 9 patients; 11 patients underwent "en bloc" multiple organ resection, with the removal of the stomach, partial or total esophagectomy and, occasionally, ablation of the spleen, pancreas, left hepatectomy, resection of the diaphragm and an extensive lymphadenectomy. Surgical mortality for the complex multivisceral resections was noted in 3 patients (8.88%). The global 5 years survival in the service is poor: 15.9%.

Dynamic Contrast-Enhanced Magnetic Resonance Mammography (DCE-MRM) represents the most sensitive examination for breast cancer (BC) diagnosis. However literature data reports very inhomogeneous specificity. The aim of our study was to evaluate the clinical efficiency of a new MRM technique - diffusion weighted imaging with background body signal suppression T2 image fusion in BC diagnosis, compared to DCE-MRM.We retrospectively analyzed 50 consecutive DCE-MRM examinations with DWIBS sequence from the archives of the Department of Radiology, Lyon Sud Hospital, (02.2010- 02.2011), summing up to 64 breast lesions. Fusions were created using the Osirix software from the DWIBS images (b=1000 s mm2) and their T2 correspondents. Interpretation was performed using an adapted BI-RADS system. The final histopathological examination or a minimum 6-months follow-up served as gold standard.Out of the 64 examined breast lesions, 35(54.7%) were classified as malignant by DCE-MRM and 24(37.5%) cases by DWIBS T2, respectively. Thus the DWIBS T2 fusion had a Sensitivity of 62.5%(95%CI:35.4-84.8) and a Specificity of 70.8%(95%CI:55.9-83.3) while DCE-MRM had a higher Sensitivity: 87.5%(95%CI:61.6-98.4) but a lower Specificity: 56.2%(95%CI:41.1-70.5).DWIBS T2 fusion is an innovative MRM technique, with a specificity superior to DCE-MRM, showing a large potential for improving the clinical efficiency of classical MRM.

Studying the correlation between elements of metabolic syndrome and histological changes of the liver in nonalcoholic fatty liver disease.Thirty-nine patients with nonalcoholic fatty liver disease were included in our study. Inclusion criteria were: presence of liver steatosis on ultrasound in patients with waist circumference over 94 cm in men and over 80 cm in women and with serologic elements of metabolic syndrome. Exclusion criteria were: chronic viral hepatitis, autoimmune hepatitis, Wilson disease, hemochromatosis, regular alcohol consumption. Body mass index, waist circumference, fasting plasma glucose, serum triglyceride and cholesterol levels and serum ALT were determined. On liver biopsy specimens, performed in each patient, the NASH score, representing the sum of fibrosis, steatosis, lobular inflammation and ballooning, was calculated.Necroinflammation was mild in 15 patients, medium in 19 patients and severe in five patients. Mild fibrosis was present in four cases, medium in 14 cases, severe in six, and two patients were diagnosed with cirrhosis. We found statistically significant correlation between waist circumference and the grade of histological activity, the presence of diabetes and both fibrosis grade and histological activity, and the serum ALT and histological activity.Noninvasive assessment of the severity of hepatic histological changes in nonalcoholic fatty liver disease could be made by anthropometric parameters or by serologic components of metabolic syndrome, but it is not an accurate method to identify patients with high-risk for disease progression. These noninvasive parameters cannot replace liver biopsy.

Lymphangiomas are uncommun congenital malformations of the lymphatic system, that involve the skin and subcutaneous tissues. Of the several types of treatment, surgical excision has been the preferred. There is a high recurrence rate because lymphangiomas tend to infiltrate the surrounding tissues. The bleomycin is a cytotoxic antitumoral antibiotic, that causes modifications of DNA. It has been also successfully used in intralesional injection treatment of cystic hygromas and haemangiomas, based specifically on a high sclerosing effect on vascular endothelium. We report the cases of five patients, with congenital lymphangioma, localized on the leg, in cervical and latero-thoracal region, treated with repeated intralesional bleomycin injections. The treatment indication was given by the location of this lesions and the infiltration of the surrounding vital tissues, that made the complete surgical excision impossible. Intralesional injection of bleomycin into the lymphangiomas was given at a dose, not exceeding 0,5 mg/kg of body weight, at intervals of 4 weeks. Complete resolution (n = 4) or significant improvement (n = 1) occurred in all patients treated. No other treatment was needed. We didn't notice local or general adverse effects. With this method we set the purpose to treat effectively this congenital malformations, obviating the need for invasive primary surgery or systemic treatment regimens. Toward other methods, intralesional bleomycin injections have a minimal risk of side effects (ulceration, pulmonary fibrosis).

Sacrococygeal teratomas are congenital tumors of newborns, originate from one or more of the three germinal layers. Most sacrococygeal teratomas are found in newborns, infants and children youger than 4 years. The prenatal ultrasound exams have increased the number of sacrococygeal teratomas presenting in fetuses. Radical resection, including the coccyx must be performed even if the primary lesion is benign in up to 70% of cases. We report a 16 days old baby girl presented with a large, type 111 sacrococygeal teratoma. The tumor was diagnosed only at 36 weeks of pregnancy. The teratoma was disected from the surrounding structures and excised en bloc with the coccyx. The postoperative recovery was uneventful. There are good functional and cosmetic results at six months follow-up.

Gastro-intestinal stromal tumours develop in the digestive tract wall, in the undifferentiated mesenchymal cells with a starting point at the level of the interstitial cells of Cajal. Gastro-intestinal stromal tumours often lead to peritoneal and hepatic metastasis. Assessment of aggressive behavior of GIST is difficult. A special attention should be paid to localization, serosal invasion, mucous ulceration, size of the tumor and mitotic index, in order to set the prognosis of the patient. We here by present two cases of gastro-intestinal stromal tumours one with gastric location and one jejunal tumor with ulceration and hemorrhage, of small sizes, initially diagnosed as benign but developing in the late evolution liver metastases. Right lobectomy was performed in both cases, in one case being associated with segment II resection. The patients have been followed-up at oncology and they received Imatinib, and when the metastasis reappeared was reintroduced, increasing the dose.

Hepatic resection is the only treatment with possible curative effect both for primary and secondary tumors. An increase of the rate of resectability for tumors considered inoperable at first, and a decrease of the postoperative morbidity and mortality can be realized by right portal branch ligature and two-step hepatectomy. We would like to present the case of a patient with left bowel cancer with a hepatic metastasis. Right portal branch ligature was performed which was followed by systemic postoperative chemotherapy. The right portal branch occlusion was followed by right lobe atrophy and left lobe hypertrophy, confirmed by CT scanning. Three months after the portal occlusion the patient underwent a right lobe hepatectomy. The postoperative evolution was favorable, eight days of hospitalization were necessary. The portal branch ligature can be made in several cases of hepatic tumors to increase the resectability rate.

Nephroureterectomy with perimeatal cystectomy is the gold standard for the treatment of urothelial upper urinary-tract carcinoma (UUTC). Ureteral endoscopic surgery has been proposed as a complementary step in nephroureterectomy, either open or laparoscopic, in order to obviate the low abdominal incision. Our goal was to establish the value of two techniques for endoscopic distal-ureteral management in one-step nephroureterectomy for UUTC.Between June 1995 and January 2006, 100 nephroureterectomies with an endoscopic distal ureteral approach were performed for UUTC (stage pT(a) in 31 cases, pT1 in 27 cases, pT2 in 21 cases, pT3 in 18 cases, and pT(4) in 3 cases). The tumor was pyelocaliceal in 65 cases, ureteral in 18 cases, and both ureteral and pyelocaliceal in 17 cases. Among the patients, 72 underwent "pluck" transurethral detachment of the intramural ureter, and 28 were managed by ureteral stripping. The follow-up was performed by cystoscopy with urinary cytology, ultrasonography, and intravenous urography. The mean follow-up was 44 months (range 4-129 months).All but two of the procedures were completed successfully. In these two patients, ureteral stripping failed, and open surgery was performed. The complication rate was 2.8% for the pluck technique and 7.1% for ureteral stripping. During follow-up, 23 patients had bladder recurrences, 2 had renal fossa tumors, 3 had secondary lymph-node invasion, 2 had contralateral UUTC, and 1 had asynchronous liver metastases. The disease-specific mortality rate was 12%.The endoscopic approach to the terminal ureter is safe and effective as part of one-step nephroureterectomy. Differences between the techniques with regard to operative time, complications, and oncologic outcome were not significant.

one of the most frequent complications of a laparotomy is the development of an incisional hernia. Proper surgical technique can somewhat reduce the incidence, but it still remains a common sequel. Application of prolene mesh for the reconstruction of the abdominal wall with tension-free methods has excellent results.between 2001-2005, 50 abdominal wall reconstructions were performed using prolene mesh in sublay position including the peritoneal sac of the incisional hernia.postoperative complication was found in one case only, namely a haematoma was formed in the rectus sheat possibly due to an injury of a branch of the inferior epigastric artery. The haematoma was managed non-operatively by suction drainage. No postoperative respiratory problems were detected; all we noticed was minimal abdominal pain. Patients were mobilized shortly after the surgery.application of prolene mesh in sublay position including the hernia sac is an effective alternative procedure for preventing postoperative complications, when large incisional hernias are repaired in median laparotomy scars.

The most frequent postoperative morbidity and mortality in the colorectal surgery is caused by the failure of the anastomosis. On the base of the statistics the postoperative mortality caused by the failure of the anastomosis can rise up to 20%. In the last decade a lot of types of anastomoses was initiated, for example: telescopic anastomosis, mechanical anastomosis with stapler, anastomosis with a bio-fragmentary ring. In the technique of the telescopic anastomosis, introduced from the beginning of 20th century, many changes had made. The experimental and the operative results shown that the telescopic anastomosis is a secure, fast and cheap procedure in the surgery of the colon.the telescopic anastomosis is applicable also in emergency, with a short septic time , easy procedure and doesn't need special instruments.

The study compares the quality of post-operatory life after total gastrectomy with that after subtotal gastrectomy for gastric carcinoma. The routine use of "de principe" total gastrectomy remains controversial. Most surgeons believe that the routine use of it increases both postoperative morbidity and mortality and also the nutritional deficiencies, without improving the 5-year survival rate. It is also associated with a poorer outcome in terms of postoperative quality of life, the evidence of which is still under study. At the Surgical Clinics I and II in Targu Mures 414 patients have undergone, during January 1997 January 2004 subtotal gastrectomies (241) respectively total gastrectomies (173) for gastric carcinoma, of which 133 were resections performed with a curative intent, using radical D2-lymphadenectomy. Quality of post-operatory life at the moment of study was evaluated using our own questionnaire, developed upon studying and in accordance to those internationally in use by the de EORTC (European Organization for Research and Treatment of Cancer) and ECOG (Eastern Cooperative Oncology Group). The results of the study show that the quality of life of patients who underwent subtotal gastrectomies is significantly better than of those with total gastrectomies (without pouch). The imposing conclusion is that subtotal gastrectomy is recommended as the treatment of choice (when oncologically feasible) for tumors of the stomach, dismissing the "de principe" total gastrectomy.

The life quality of the patient suffering from hepatic cirrhosis is affected by ascites refractory to drugs treatment. In the last 30 years, in the ascites treatment there were performed peritoneo-jugular shunts through synthetic prosthesis with unidirectional valve-LeVeen, Denver. The siliconated prostheses are expensive and in the process of time complications are registered consisting of clogged valve or obstruction, requiring thus their replacement. The unidirectional drainage of the ascites can also be performed through peritoneo-saphenous shunt. In our clinic, the peritoneo-saphenous shunt was applied for the first time in 2004, in three patients with hepatic cirrhosis with ascites refractory to drugs treatment. The postsurgical evolution was favourable, a gradual increase of diuresis and reduction of abdominal diameter being registered in all the three cases.the peritoneo-saphenous shunt is a simple procedure, it does not require special devices and it can be applied with success in the treatment of refractory ascites.

For patients with ulcerative colitis and familial adenomatous polyposis the restorative proctocolectomy with ileo-anal-pouch anastomosis is the surgical treatment of choice. Leakage from the ileo-pouch anastomosis is the surgical treatment of choice. Leakage from the ileo-pouch-anastomosis can be a difficult to manage complication, which in some cases resists all attempts at local repair. A surprising complication of a 28 years old woman patient with an ileo-anal-pouch anastomotic fistula is presented. The fistula developed the 4th day postoperatively. Local irrigation and transanal drainage seemed to have a good result, the patient being examined after two weeks. During an apparently better evolution, after one month, the patient developed a transsacral fistula with local abscess and osteolysis. The ileo-anal-pouch anastomosis was converted to a less comfortable conventional ileostomy, but with good local and general final result.

A 34-year-old woman with no history of any liver diseases was admitted to the service for a Budd-Chiari syndrome and an extensive thrombosis of the inferior vena cava. The symptoms of the portal hypertension were present, with an enormous ascites, mild esophagogastric varices, associated with increased edema of the lower limbs, perineum and abdominal wall. The diagnosis was established by color Doppler ultrasonography, CT and cavography. An ilio-mesenterico-atrial shunt, between the right iliac vein, the superior mesenteric vein and the right atrium was successfully performed, transdiaphragmatically, by abdominally and right thoracic approach, using a 35 cm Dacron prosthesis. Postoperative evolution was very good. The color Doppler ultrasonography showed a good flow in the shunts. After 14 days ascites decreased over 70% and the inferior edema almost disappeared. 2 month later ascites decreased over 80%, the esophageal varices and edema disappeared completely. To our knowledge, this is the first case in the country, in which a patient underwent ilio-mesenterico-atrial shunt for Budd-Chiari syndrome and inferior vena cava extensive thrombosis.

The regulation of human natural killer (NK) activity by IgG described previously by us depends on the ability of cytophilic molecules of monomeric IgG (mIgG) to inhibit the subsequent killing of NK-sensitive targets. Highly purified NK cells obtained from human peripheral blood are able to directly bind mIgG as well as antigen-complexed IgG through its Fc region. The demonstration that NK cells bear labile cytophilic IgG, a property which usually has been attributed to L cells, indicates that mIgG-induced inhibition of NK activity is mediated by direct interactions between the inhibitory ligand and cytotoxic effector cells. The Fc receptor (FcR) mediating downregulation of NK cytotoxicity appeared to be FcR gamma III, previously found to be selectively expressed on NK cells and granulocytes. In studies of unidirectional cross-inhibition of mIgG binding to NK cells by various anti-CD16 monoclonal antibodies, binding characteristics of mIgG or complexed IgG were similar. Thus, the FcR gamma III for mIgG appear to be indistinguishable from receptors responsible for binding of polymeric IgG on human NK cells. The negative regulation of NK activity by mIgG was not attributable to inhibition of conjugate formation between effector cells and K532 targets, but rather to inhibition of a post-binding event involved in killing of conjugated targets. The data presented suggest that the Fc gamma RIII on human NK cells can either mediate killing against IgG antibody-coated target cells or, upon interaction with cytophilic monomeric ligand in soluble form, induce inhibition of NK activity.

348 spleens surgically removed have been examined microscopically and classified into 3 groups: (I) 154 emergency splenectomies (86 traumatic ruptures, 44 enlarged supramesocolic exeresis, 44 cirrhosis), (II) 143 therapeutic splenectomies (135 cases of hypersplenism among which 10 apparently primitive, 7 myeloproliferative syndromes, 1 hairy cell leukemia), and (III) 51 diagnostic splenectomies (7 non specific inflammations, 2 tuberculosis, 1 mycosis, 6 echinococcosis, 12 leukemias, 9 non-Hodgkin's lymphomas, 13 Hodgkin's lymphomas, 1 primary splenic hemangioma). The study of the first group material, obtained especially of traumatic rupture, has been very valuable to follow the spleen microscopic structure in normal humans of different age. The latter two group cases have raised interesting problems of microscopic diagnosis, permitting at the same time a better understanding of the pathology of this organ.

Inhibition of human natural killer (NK) cell activity upon exposure of peripheral blood lymphocytes (PBL) to IgG in monomeric form (mIgG) was found to be dose-, time- and temp-dependent. PBL incubated for 2 hr at 37 degrees C in the presence of myeloma protein of a certain class or subclass had a significant reduction of their NK activity when exposed to IgG, but not to IgM or IgD, and the IgG-induced inhibition of NK cells was observed only when IgG1 or IgG3 paraproteins were used. IgG3 isolated from normal serum had a higher inhibitory property than that of total mIgG. The cytophilic activity of the IgG molecules was confined entirely to the Fc region and seemed to be localized in the CH3 domain, since human and rabbit Facb fragments had a reduced ability to inhibit NK activity. When synthetic peptides representing various sequences of the human gamma-chain were tested for inhibition of NK activity, only treatment of effector cells with a peptide comprising the sequence Tyr407-Arg416 of the CH3 domain showed a reduction of NK cell function comparable to the inhibition obtained following incubation of cells in the presence of mIgG. However, on a molar basis, this peptide was 20 times less active than mIgG. In contrast, peptides derived from sequences in the CH2 domain lacked this inhibitory capacity. Our data indicate that the structural site responsible for inhibiting NK cell activity is located in the C-terminal domain of the IgG molecule.