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Anti-epidermal growth factor receptor (EGFR)-targeted therapy has been intensely researched in the last years, motivated by the favorable results obtained with monoclonal antibodies in HER2-enriched breast cancer (BC) patients. Most researched alternatives of anti-EGFR agents were tyrosine kinase inhibitors (TKIs) and monoclonal antibodies. However, excluding monoclonal antibodies trastuzumab and pertuzumab, the remaining anti-EGFR molecules have exhibited disappointing results, due to the lack of specificity and frequent adverse side effects. TKIs have several advantages, including reduced cardiotoxicity, oral administration and favorable penetration of blood-brain barrier for brain metastatic BC. Lapatinib and neratinib and recently pyrotinib (approved only in China) are the only TKIs from dozens of molecules researched over the years that were approved to be used in clinical practice with limited indications, in a subset of BC patients, single or in combination with other chemotherapy or hormonal therapeutic agents. Improved identification of BC subtypes and improved characterization of aggressive forms (triple negative BC or inflammatory BC) should lead to advancements in shaping of targeted agents to improve the outcome of patients., Competing Interests: The authors declare that they have no competing interests., (Copyright © 2020, Spandidos Publications.)

Suspicion of lead poisoning is confirmed by its concentration in blood and protoporphyrin red blood cells. At low concentrations, lead influences the synthesis of the heme in the sense of lowering it. Acute and chronic lead intoxication is extremely polymorphic in regards to its clinical manifestations, with digestive, hematological, cardiovascular, renal hepatic and neurological features. The aim of the study was to evaluate the presence of lead in human whole blood and urine harvested before and during chelation treatment in the case of lead poisoning. An atomic absorption spectroscopic method for the analysis of lead was developed using graphite furnace atomic absorption spectrophotometer (GF-AAS), Varian Spectra AA-880 with a hollow cathode lead lamp and a deuterium lamp for background correction, coupled to a GTA-100 atomizer and a programmable sample dispenser. Standard calibration solutions were used for the range 10-100 µ g / l. The linearity range was 10.0 to 100.0 µ g / l with the correlation coefficient of 0.999. We established that the method can be applied for the determination of lead in whole blood and urine, and the results obtained are useful for monitoring chelation therapy in cases of acute lead poisoning, a neglected cause of abdominal colic pain in an emergency situation., Competing Interests: The authors declare that they have no competing interests., (Copyright © 2020, Spandidos Publications.)

The present study aimed to compare the clinical, paraclinical, intraoperative findings, and postoperative complications in acute cholecystitis in diabetic patients vs. non-diabetic patients. A 2-year retrospective study was performed on the patients who underwent emergency cholecystectomy for acute cholecystitis between 2017 and 2019 at the 4th Department of Surgery, Emergency University Hospital Bucharest. The diabetic subgroup numbered 46 eligible patients and the non-diabetic one 287 patients. Demographics, the severity of the clinical forms, biological variables (including white cell count, urea, creatinine, coagulation and liver function tests) comorbidity status, surgical approach, postoperative complications, and hospital stay were analyzed. Statistical analyses were performed to assess comparative results between the aforementioned data (SPSS V 13.0). The CCI and ASA risk classes were increased in the diabetic group, with 34.78% of patients having 3 or more associated comorbidities. No statistically significant associations were demonstrated between diabetes and the severity of the cholecystitis and risk for conversion. Postoperatively both minor complications such as surgical site infections and major cardiovascular events were more common in the diabetic subgroup (P=0.0254), well associated with the preoperative status and baseline cardiovascular comorbidities. Laparoscopic cholecystectomy is a safe procedure for diabetic patients, which can provide the best outcomes, by decreasing the risks of surgical wounds. Attentive perioperative care and good glycemic control must be provided to minimize the risk of complications., Competing Interests: The authors declare that they have no competing interests., (Copyright © 2020, Spandidos Publications.)

This review discusses the evidence on diabetic retinopathy (DR) in patients with diabetic foot ulceration (DFU). A systematic literature review was performed on PubMed, Medline, Springer Nature, and Scopus, following the PRISMA guidelines, using the following terms, individually or in combination: "diabetic foot ulcer" OR "diabetic foot syndrome" OR "DFU" and "diabetic retinopathy." The initial search yielded 648 articles published between 1975 and 2020. After applying exclusion and inclusion criteria, a total of 9 articles were analyzed, assessing the correlations between DR and DFU. In all cases, DR and especially proliferative diabetic retinopathy were significantly higher in the presence of DFU, though the frequency of DR showed large variability (22.5% to 95.6%). There was a significant correlation between advanced stages of DFU and increased frequency of DR and proliferative diabetic retinopathy. On the other hand, there is a risk of accelerated progression of DR in nonhealing DFUs, possibly related to chronic inflammation and associated infection. Hence, patients with DFUs should be monitored by an ophthalmologist, and those with DR should be promptly referred to a specialized diabetic foot clinic.

The present study investigated the effects of the COVID-19 pandemic on the clinical presentation and therapeutic management of acute surgical abdomen. A retrospective study of emergency hospitalizations with a diagnosis of acute surgical abdomen between April and July 2020 vs. a similar period in 2019 was performed. The observation sheets and the operating protocols were analyzed. Between April and July 2020, 50 cases of acute surgical abdomen were hospitalized and treated, compared to 43 cases in the same period last year. The main types of pathology in both groups included: Occlusions (60%, respectively 44.2% in 2019) and peritonitis (32%, respectively 41.8% in 2019). There was an increased rate of patients with colorectal cancers neglected therapeutically or uninvestigated, who presented during the pandemic period with emergencies for complications such as occlusion or tumor perforation (32 vs. 6.97%, P=0.0039). One case, with gastric perforation, was COVID-positive, with no pulmonary symptoms at admission. The number of postoperative infectious complications was lower during the pandemic (2 vs. 13.95%, P=0.0461). As the COVID-19 pandemic appears to be still far from ending, we should learn to adapt our surgical protocols to the new evidence. Oncological patients are a vulnerable group, who were neglected in the first months of the pandemic. SARS-Cov-2 infection may be a cause of abdominal pain and should be taken into account in different diagnoses of acute abdomen in surgical wards. Correct wearing of adequate personal protective equipment (PPE) and respecting strict rules of asepsis and antisepsis are required for preventing in-hospital transmission of infection., Competing Interests: The authors declare that they have no competing interests., (Copyright © 2021, Spandidos Publications.)

Background and Objectives: This study investigates the impact of age upon the safety and outcomes of laparoscopic cholecystectomy performed for acute cholecystitis, by a multivariate approach. Materials and Methods: A 2-year retrospective study was performed on 333 patients admitted for acute cholecystitis who underwent emergency cholecystectomy. The patients included in the study group were divided into four age subgroups: A ≤49 years; B: 50-64 years; C: 65-79 years; D ≥80 years. Results: Surgery after 72 h from onset ( p = 0.007), severe forms, and higher American Society of Anesthesiologists Physical Status Classification and Charlson comorbidity index scores ( p < 0.001) are well correlated with older age. Both cardiovascular and surgical related complications were significantly higher in patients over 50 years ( p = 0.045), which also proved to be a turning point for increasing the rate of conversion and open surgery. However, the comparative incidence did not differ significantly between patients aged from 50-64 years, 65-79 years and over 80 years (6.03%, 9.09% and 5.8%, respectively). Laparoscopic cholecystectomy (LC) was the most frequently used surgical approach in the treatment of acute cholecystitis in all age groups, with better outcomes than open cholecystectomy in terms of decreased overall and postoperative hospital stay, reduced surgery related complications, and the incidence of acute cardiovascular events in the early postoperative period ( p < 0.001). Conclusions: The degree of systemic inflammation was the main factor that influenced the adverse outcome of LC in the elderly. Among comorbidities, diabetes was associated with increased surgical and systemic postoperative morbidity, while stroke and chronic renal insufficiency were correlated with a high risk of cardiovascular complications. With adequate perioperative care, the elderly has much to gain from the benefits of a minimally invasive approach, which allows a decreased rate of postoperative complications and a reduced hospital stay.

Burnout is a state of physical or mental collapse caused by overwork or stress. Burnout during residency training has gained significant attention secondary to concerns regarding job performance and patient care. The new COVID-19 pandemic has raised public health problems around the world and required a reorganization of health services. In this context, burnout syndrome and physical exhaustion have become even more pronounced. Resident doctors, and especially those in certain specialties, seem even more exposed due to the higher workload, prolonged exposure and first contact with patients. This article is a short review of the literature and a presentation of some considerations regarding the activity of the medical residents in a non-Covid emergency hospital in Romania, based on the responses obtained via a questionnaire. Burnout prevalence is not equal in different specialties. We studied its impact and imagine the potential steps that can be taken in order to reduce the increasing rate of burnout syndrome in the pandemics., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Nowadays, surgical innovations incorporate new technological conquests and must be validated by evidence-based medicine. The use of augmented reality-assisted indocyanine green (ICG) fluorescence has generated a myriad of intraoperative applications such as demonstration of key anatomical landmarks, sentinel lymph nodes, and real-time assessment of local blood flow. This paper presents a systematic review of the clinical evidence regarding the applications of ICG near-infrared (NIR) fluorescence in colorectal surgery. After we removed duplicate publications and screened for eligibility, a total of 36 articles were evaluated: 23 on perfusion assessment, 10 on lymph node mapping, and 3 on intraoperative identification of ureters. Lack of homogenous studies, low statistical power, and confounding evidence were found to be common amongst publications supporting the use of ICG in colorectal surgery, raising concerns over this seductive technique's cost efficiency and redundancy. The compiled data showed that ICG NIR fluorescence may be a game-changer in particular situations, as proven for low colorectal anastomosis or lateral pelvic lymph node dissection, but it remains controversial for routine use and sentinel lymph node assessment. Further randomized studies are needed to confirm these conclusions. Future research directions include tumor-targeted fluorescence imaging and digital software for quantitative evaluation of fluorescence.

Introduction: Ogilvie syndrome, or acute colonic pseudo-obstruction (ACPO), represents a pathological entity, potentially with a severe outcome, due to the acute important dilation of the large bowel, in the absence of a mechanical luminal obstruction. Usually, it occurs in patients admitted in intensive care unit, that associate severe surgical or medical pathologies. The mechanism of the ACPO has not been completely explained, but it is assumed that the motor function of the colon may be affected, as a result of autonomic regulation disturbance. Early diagnosis and treatment help reduce the risk of severe outcome, such as ischemia or perforation. Material and Method: In addition to our experience, a literature search was elaborated in order to evaluate the incidence, the etiology, the clinical presentation and the diagnosis of the ACPO. Results and Conclusions: The present study may be of help in the process of guiding the optimal management of a critically ill patient is at high risk of developing colonic pseudo-obstruction., (Celsius.)

Patients with spinal cord injury (SCI) with neurogenic bladder (NB) represent a major medical problem, which initiated the search for a non-invasive and effective treatment that is easy to apply and without side effects. A study was performed using interferential medium frequency current electrical stimulation (IMFC ES) on 332 patients shortly after SCI diagnosed with NB dysfunction. All subjects received standard care and patients of the experimental group additionally received IMFC ES. Urinary management results included volitional control of voiding, intermittent catheterization, post-voidance residuum (PVR) quantity and quantity of urine lost (LOSS). Results were assessed based on the American spinal cord injury association impairment scale (AIS). The IMFC ES included two channels of medium frequency stimulation that were marginally different. Within the body, a low frequency field was generated through the interaction of the medium frequencies, which stimulated the urinary structures. In the IMFC ES group, interference stimulation was applied for 10 min with frequencies cycling from 0-100 Hz and back in 10 sec intervals. The strength of the low frequency stimulation, achieved by the interference of the two medium-frequency fields, was adjusted to the patients' vibration sensation. The intensities triggering vibration sensation were between 20-80 mA for patients with AIS levels B, C and D. For patients with AIS level A intensities <20 mA were used for therapeutic effects without causing skin injuries. Safety of IMFC ES was based on occurrence of adverse events of which none were recorded in the experimental group. IMFC ES was effective in patients with AIS levels B and C, significantly decreasing PVR and LOSS compared with patients receiving standard care No significant improvements in urinary management were observed following IMFC ES treatment of patients with AIS level A. Patients with SCI and NB classed as AIS levels B and C that exhibit preserved sensitivity were the best beneficiaries of IMFC ES therapy.

Introduction: Metastatic diseases are seen in approximately 25% of all cases with renal cell carcinoma and sometimes they can appear in unusual sites., Case Presentation: We present a 35-year old patient with a painful left axillary mass which causes the functional impairment of the left arm. The axillary mass appeared 2 years after the nephrectomy performed for a left renal cell carcinoma. Numerous metastases have been identified through CT scans during the postoperative evolution of the disease for which the patient underwent adjuvant therapy with tyrosine-kinase inhibitors., Discussions: Particular to our case is not just the rare metastatic site but also the fact that the tumor appeared despite the adjuvant therapy with tyrosine-kinase inhibitors. Unfortunately, the prognosis of metastatic RCC with skin metastasis is in most cases unfavorable., Conclusions: We believe that our case could add more information to subsequent measures, complete the frame of rare oncologic cases and consolidate the data published on the topic so far., (Copyright © 2017.)

Periampullary duodenal diverticula are associated with the presence of common bile duct stones, being encountered more frequently with the increase of age. We present the case of a 76 years old female patient, who underwents emergency surgery for a perforated lithiasic gangrenous acute cholecystitis and for whom we perform a cholecystectomy and an external biliary drainage using a transcystic tube. Both preoperative and postoperative imaging and endoscopic examinations certify the presence of a periampullary duodenal diverticulum. Postoperative cholangiography performed on the transcystic tube raises the suspicion of retained common bile duct lithiasis. An endoscopic retrograde cholangiopancreatography is performed, initially failing to cannulate the common bile duct. A precut sphincterotomy fistula technnique is performed, using as reference a guide inserted on the transcystic tube, with the extraction of biliay sludge from the common bile duct, and with subsequently favorable development. Association between common bile duct lithiasis and a periampullary duodenal diverticulum may represent a therapeutic challenge because of the increased risk of failure of the endoscopic treatment., (Celsius.)