Microsurgery in the treatment of local advanced laryngeal cancer

IMSP Institutul Oncologic, Al XI-lea Congres al Asociației Chirurgilor „Nicolae Anestiadi” din Republica Moldova și cea de-a XXXIII-a Reuniune a Chirurgilor din Moldova „Iacomi-Răzeșu” 27-30 septembrie 2011Anual în Republica Moldova sunt depistați circa 150 pacienți cu cancer localizat în zon larinofaringiană. În majoritatea cazurilor clinice procesului este local avansat, ce necesită un tratament combinat, complex şi o reabilitare chirurgicală amplă. Pe lîngă metodele tradiționale de reabilitare chirurgicală, în secția tumorilor capului şi gâtului din luna mai 1989 a fost implimentată metoda microchirurgicală de reabilitare a pacienților. În perioada 1989 până în prezent după această metodă au fost tratați circa 150 pacienți, 66 din ei au fost tratați pentru cancer local avansat al zonei laringofaringiene. Toți pacienții au fost supuşi tratamentului radioterapic pre- sau/şi postoperator, în volum 40 – 66 Gr. În toate cazurile au fost efectuate laringectomii cu formare de faringoesofagostomie planică. Toți pacienții au fost supuşi intervenției chirurgicale la căile limfatice cervicale.Primul grup – lambourile utilizate pentru formarea tunicii interne a traiectului faringoesofagian. Lambouri libere: 1. cutanofasciale: radial 10 cazuri; scapular 10 cazuri; 2. viscerale: jejunal 7 cazuri; stomac- epiplon 4 cazuri. Al doilea grup: lambourile utilizate pentru formarea tunicii externe a traiectului faringoesofagian. Lambouri libere: 1. cutanomusculare: TDL 22 cazuri; TFL 1 caz; TDL + SL 2 cazuri. Complicațiile postoperatorii au fost cauzate de dereglări în microcirculația lamboului şi anastomozei vasculare. În 40% cazuri dereglările de microcirculație s-au manifestat prin declanşarea necrozei parțiale a lamboului şi apariția fistulei faringo-esofagiene. Într-un caz a fost constatată necroza totală a lamboului. Durata perioadei de reabilitare a pacienților cu restabilirea totală a traiectului faringo-esofagian a constituit în mediu 25 zile.Each year, in Moldova, about 150 pacients are being traced, having laryngopharyngeal cancer. In most cases, the process is in advanced stage, needing a combined and complex treatment, with a large surgical rehabilitation. Besides the traditional methods, the Departement of Head and Neck Tumors, since May 1989, has implemented the microsurgical method of rehabilitation. Beginning with 1989 until present, with the help of this method, about 150 patients have been treated, 66 of them having local advanced laryngopharyngeal cancer.All patients have passed radiotherapy, either before the surgical intervention, after it or both, in terms of 40-66 Gr. Laryngectomy with planned pharyngoesophagostomy has been performed in every case. All patients have passed surgical intervention on lymphatic cervical canals. First group – the flaps used for forming the internal tunic of pharyngoesophageal path.Free flaps:1)cutanofascial: radial – 10 cases, scapular – 10 cases;2)visceral: jejunal – 7 cases; stomach-omentum – 4 cases;Second group – the flaps used for forming the external tunic of pharyngoesophageal path.Free flaps:1)cutanomuscular: TDL – 22 cases, TFL – 1 case, TDL+SL – 2 cases.The after-surgical complications have been caused by disorders, appeared in the microcirculation of the flap and the vascular anastomosis. In 40% of all cases, the microcirculation disorders have been displayed by triggering the partial necrosis of the flap and by the appearance of pharyngoesophageal fistula. In one case, there has been observed a total necrosis of the flap.The period of rehabilitation, with total recovery of the pharyngoesophageal path, has lasted an average of 25 days

Rolul factorului uman în generarea discordanţei deciziei de tratament pe exemplul unui model de apreciere a frecvenţei respiratorii

Studiul de tip prospectiv a fost efectuat asupra a 63 pacienţi internaţi într-o unitate de terapie intensivă. Scopul a fost evaluarea rolului factorului uman în generarea discordanţei deciziei terapeutice, comparând înregistrarea manuală cu cea automată a frecvenţei respiratorii (parametru luat drept model experimental). Valorile frecvenţei respiratorii, înregistrate manual, au fost semnifi cativ diferite faţă de cele redate de monitor. Disordanţa deciziilor de corecţie a funcţiei respiratorii, luate în baza datelor scrise, au fost semnifi cativ diferite faţă de cele luate în baza monitorizării. Monitorizarea pacienţilor este indispensabilă pentru luarea unei decizii de tratament corecte şi reduce semnifi cativ impactul factorului uman în generarea discordanţei

Interhospital transportation of major trauma patients in the Republic of Moldova

NCEM (Centre of Emergency Medicine), SMPhU (State Medical and Pharmaceutical University) „N. Testemitanu”, Congresul II Internaţional al Societăţii Anesteziologie Reanimatologie din Republica Moldova 27-30 august 2009Actuality Transportation of major trauma patients to, between, and within hospitals can be associated with potentially adverse events. Researchers have shown that increased vigilance, appropriate equipment, and well-trained personnel can lead to improved safety while major trauma patients are being transported. The aim of the study is to evaluate interhospital transportation of major trauma patients from district hospitals to trauma center on territory the Republic of Moldova. Materials and Methods Was performed retrospective analysis of 39 patients from archive, transferred from regional hospitals to National Centre of Emergency Medicine (NCEM) during the year 2008. Age between 20-74 years, 30 males, 9 females. Severity of trauma was evaluated according to NISS (New Injury Severity Score) with average value 45,1 ± 10,3 points, and MPMoIII (Mortality Probability Admission Model), with average value 67,3±18,9%. Patients were analyzed in dependencies on period of trauma, on distance and on severity of trauma. Results In table №1 is represented two comparable groups according to number of patients, gender, age, NISS. Patients who were transported before 48 hours were influenced by transportation more vastly (MPMoIII is higher) and had mortality in two times above. Rate of mortality was less for patients who were transported from distance < 70 km (table №2). Rate of mortality was directly dependant on severity of trauma (NISS) and conditions at admission (MPMoIII) in trauma center (table №3) and increased vastly in cause NISS>40 or MPMoIII>70%. Conclusions 1. It was observed some tendencies for major trauma patients during transportation. They depend on phase of trauma, distance between hospitals and severity of trauma according to NISS and MPMoIII. 2. The transportation of major trauma patients needs optimization through increasing caution, good equipping and special trained personal. 3. Activity of Department of Emergency Medicine should be directed on achievement of “Golden Hour” strategy in all territory the Republic of Moldova

Conclusions of nonoperative management in blunt splenic injuries

USMF “N. Testemiţanu”, Clinica Chirurgie Nr.1 “N. Anestiadi”, Clinica ATI „V. Ghereg”, Chişinău, Republica Moldova, Al XI-lea Congres al Asociației Chirurgilor „Nicolae Anestiadi” din Republica Moldova și cea de-a XXXIII-a Reuniune a Chirurgilor din Moldova „Iacomi-Răzeșu” 27-30 septembrie 2011Material şi metode: Studiul prospectiv(2008-2011) – 60 traumatizați cu Leziuni Lienale(LL ) închise; B:F/2:1, vârsta medie 39.97±20,35ani; RTS=7,66±0,5; ISS=19,06±8,95. S-a efectuat: USG(100%) de primă intenție în diagnosticarea hemoperitoneului, TC(80%), laparoscopia(20,27%). În 21(35%) cazuri LL a fost izolată, în 39(65%) – asociată. Rezultate: 13(21,66%) pacienți cu PAs≤80mmHg – 11 politraumatizați cu LL: gr.II(7) și III(5) şi fracturi pelviene, 2 pacienți cu LL izolată s-au stabilizat prin repleție volemică fără suport vasotensiv. Trei politraumatizați cu Glasgow ≤12p. şi LL gr.II(2), gr.III(1), (în 2 cazuri instabili hemodinamic) au fost soluționați nonoperator. Severitatea LL(AAST): gr.I-9(15%), gr.II-24(40%), gr.III-25(41,67%), gr.IV-2(3,33%), cele severe constituind 45%. Hemoperitoneul în LL gr.III a constituit 581,25±158,88ml (400-1000ml), în gr.II – 67,65±113,11ml (p<0,001). Volumul hemotransfuziei în LL gr.III asociate cu locomotor şi/sau torace a fost semnificativ mai mare vs pacienții cu gr.III izolat (648,67±49ml vs 283,33±51ml; p<0,001), iar în gr.II asociat valoarea hemotransfuziei a fost 452,5±379ml în raport cu 0 transfuzii în cele izolate (p<0,05). Eşec s-a înregistrat în 6(10%) cazuri: în 5(8,3%) din cauza LL cu hemoperitoneu 1400±200ml (gr.III(2) cu ruptură în doi timpi, gr.IV(2) izolată cu hemoragie prelungită, gr.II(1) cu pseudoanevrism lienal) şi una(1,66%) din cauza perforației jejunului, splina fiind păstrată. Concluzii: LL de gr.I-III izolate, cât şi asociate pot fi rezolvate cu succes, cele de gr.IV necesită o monitorizare complexă riguroasă. Scăderea hematocritului şi hemotransfuziile prelungite la politraumatizați nu pot prezice nereuşita MNO. Volumul şi extinderea hemoperitoneului poate fi un criteriu orientativ de prognostic al eşecului MNO, însă la volume mai mari de 500ml. Lipsa conştiinței nu este un criteriu de evitare a MNO, laparoscopia în aceste condiții ar putea concretiza reuşita opțiunii.Material and methods: Prospective study(2008-2011) on 60 patients with blunt Splenic Injuries(SI): M:F/2:1, mean age 39,27±20,35 years, 21(35%)-isolated SI, 39(65%)- associated, RTS=7,66±0,5; ISS=19,06±8,95. Diagnostic tools: USG in 100%, CT in 48(80%), laparoscopy in 16(20,27%); Results: 13(21,66%) patients with SBP≤80mmHg: 11 polytrauma patients–IInd degree 7, IIIrd dgr.–5 (SI with pelvic trauma), 2 patients with isolated SI, all were stabilized by fluid perfusions, without vasoactive support. 3 polytrauma patients: II nd dgr.-2, III rd dgr.-1, with GCS≤12p. were successfully treated nonoperatively. The severity of SI(AAST) revealed: Istdgr.-9(15%), IInddgr.- 24(40%), IIIrddgr.-25(41,67%), IVthdgr.-2(3.33%), IIIrd degree prevailed, severe injuries being determined in 45%. Hemoperitoneum volume in IIIrd dgr. SI was 581,25±158,88(400-1000ml), in IInddgr.- 67,65±113,11ml (p<0,001). The blood transfusion volume in IIIrddgr. associated SI with thorax or musculo-skeletal trauma was significantly higher vs isolated SI (648,67±49ml vs 283,33±51ml, p<0,001), while in IInddgr. associated SI the average volume of blood transfusion was 452,5±379ml in contrast to 0 transfusions in isolated SI(p<0,05). NOM failure reported in 6(10%) cases: in 5(8,3%) because of SI with hemoperitoneum 1400±200ml (IIIrddgr. (2)-delayed splenic rupture, IVthdgr.(2)-isolated SI with prolonged bleeding, IInddgr.(1)-lienal pseudoaneurism) and 1(1,66%) failure case caused by jejunal rupture, the spleen being preserved.Conclusions: Both isolated and associated Ist-IIIrddgr. SI can be treated nonoperatively, IVthdgr. SI requiring close and complex monitoring. Reduction of haematocrit and expanded blood transfusions in polytrauma patients could not predict NOM failure. The volume and extent of hemoperitoneum could serve as a failure index of NOM when it exceeds 500ml. Lack of awareness is not a criterion to avoid NOM, laparoscopy reflecting the success of the option

An information-theoretic Phase I/II design for molecularly targeted agents that does not require an assumption of monotonicity

For many years phase I and phase II clinical trials have been conducted separately, but there has been a recent shift to combine these phases. Although a variety of phase I–II model‐based designs for cytotoxic agents have been proposed in the literature, methods for molecularly targeted agents (TAs) are just starting to develop. The main challenge of the TA setting is the unknown dose–efficacy relationship that can have either an increasing, plateau or umbrella shape. To capture these, approaches with more parameters are needed or, alternatively, more orderings are required to account for the uncertainty in the dose–efficacy relationship. As a result, designs for more complex clinical trials, e.g. trials looking at schedules of a combination treatment involving TAs, have not been extensively studied yet. We propose a novel regimen finding design which is based on a derived efficacy–toxicity trade‐off function. Because of its special properties, an accurate regimen selection can be achieved without any parametric or monotonicity assumptions. We illustrate how this design can be applied in the context of a complex combination–schedule clinical trial. We discuss practical and ethical issues such as coherence, delayed and missing efficacy responses, safety and futility constraints

The cancer of the oral floor

Rezumat. Tumorile maligne ale planșeului bucal ocupă locul al doilea între cancerele cavității orale, fiind situat procentual foarte aproape de cancerul limbii. Reprezintă cca. 25-30% din localizările cancerului oral și 2% din totalul cancerelor umane. Apare în special la bărbați, dupa vîrsta de 45 de ani. În dezvoltarea cancerului mucoasei cavităţii bucale cel mai important rol îl are tabagismul, fumătorii avînd un risc de 30 de ori mai mare de a face un cancer al mucoasei cavităţii bucale. Are importanţă consumul cronic de alcool, în cantităţi mari, infecţia cu HPV, patologia cronică dentară. Exista în prezent dovezi certe ale unei incidente crescute a cancerului oral la pacienții imunosupresați. Formele clinice de creştere ale cancerului mucoasei orale sînt: • ulcerativă, • nodulară • fisurală Cel mai frecvent întîlnite sînt formele de creştere ulcerativă şi fisurală. Clinic, tumora poate evolua în 2 direcții, și anume: ulcero-distructiv sau ulcero-vegetant. Forma ulcero-vegetantă sau proliferativă se prezintă ca o ulcerație acoperită de muguri cărnoși, brăzdați de fisuri și acoperiți de un strat superficial cu aspect granulativ. Forma ulcero-distructivă are o tendință marcată de invazie loco-regională și se prezintă ca o ulcerație cu margini anfractuoase, cu baza îndurată, cu fundul ulcerației murdar, acoperit de țesut granulativ și zone necrotice. Tratament. Scopul tratamentului multimodal complex în tumorile maligne oro-maxilo-faciale urmărește 2 deziderate majore, și anume: 1) perioada de supraviețuire să fie cît mai lungă; 2) asigurarea calității vieții, fapt realizat prin plastia reconstructivă imediată sau tardivă, care va favoriza reintegrarea bolnavului cît mai rapid în societate, precum și restabilirea și reabilitarea precoce a disfuncțiilor postchirurgicale. Tratamentul multimodal complex include, în funcție de stadializare, starea generală și opțiunea bolnavului, prioritățile fie de etapa chirurgicală asociată cu radio–, chimio–, imunoterapia, fie posibilitatea reconversiei tumorale și/sau a tratamentului paliativ radio–, chimio– și imunoterapic urmat sau nu de intervenția chirurgicală. În general, conform statisticilor U.I.C.C., rata de supraviețuire în tumorile maligne ale planșeului bucal, după tratamentul multimodal complex, este relativ mică. În T1 este de cca. 68%, în T2 de 42%, iar în T3 este sub 11%. Avînd în vedere aceste statistici sumbre, credem că depistarea precoce, alături de radicalitatea intervenției, în contextul unui tratament multimodal complex, ar mări șansele de supraviețuire ale acestor bolnavi.Summary. Malignant tumors of the floor of the mouth are on the second place among the oral cavity cancers. Localizations are about 25-30% of oral cancer and 2% of human cancers. It occurs mostly in men over the age of 45 years. Smoking has a important role in the development of buccal mucosa cancer. Smokers have a risk 30 times more likely to develop cancer of the oral mucosa. Chronic alcohol consumption is important în large quantities, HPV infection, and chronic dental pathology. There is now clear evidence of an increased incidence of oral cancer in immunosuppressed patients. Clinical forms of oral mucosa cancer growth are: • ulcerative • nodular • fissural The most commonly encountered forms of growth are ulcerative and fisssural. Clinically, the tumor can develop in two directions, namely: ulcerative or ulcerative destructive. Proliferative ulcerative form presents as an ulcer covered with fleshy buds, crossed by cracks and cover a surface layer with grain appearance. Ulcerative destructive form has a marked tendency to invade locally and represents an ulcer, with ulceration covered with granulation tissue and necrotic areas. Treatment. Purpose of complex multimodal treatment of malignant tumors of oro-maxillofacial follows two major goals, namely: 1) increase survival time 2) improve quality of life, which is achieved by immediate or delayed reconstructive plastic surgery, which will help the patient reintegrate into society as quickly and early recovery and rehabilitation of post surgical dysfunction. Complex multimodal treatment includes, according to staging and overall patient choice, or priorities associated with radio-surgical stage, chemotherapy, immunotherapy or retraining opportunity tumor and / or palliative treatment of radio-, chemo-and immunotherapy followed or no by surgery. Generally, as shown by UICC, the survival rate în malignant tumors of the floor of the mouth after multimodal treatment complex is relatively small. The T1 is about 68%, 42% in T2 and T3 is below 11%. Given these grim statistics, we believe that early detection, with radical surgery, in the context of a complex multimodal treatment would increase the chances of survival of these patients

2009: North Pacific cyclonic and anticyclonic transients in a global warming context: Possible consequences for Western North American daily precipitation and temperature extremes

Abstract Trajectories of surface cyclones and anticyclones were constructed using an automated scheme by tracking local minima and maxima of mean daily sea level pressure data in the NCEP-NCAR reanalysis and the Centre National de Recherches Météorologiques coupled global climate Model (CNRM-CM3) SRES A2 integration. Mid-latitude lows and highs traveling in the North Pacific were tracked and daily frequencies were gridded. Transient activity in the CNRM-CM3 historical simulation was validated against reanalysis. The GCM correctly reproduces winter trajectories as well as mean geographical distributions of cyclones and anticyclones over the North Pacific in spite of a general under-estimation of cyclones&apos; frequency. On inter-annual time scales, frequencies of cyclones and anticyclones vary in accordance with the Aleutian Low (AL) strength. When the AL is stronger (weaker), cyclones are more (less) numerous over the central and eastern North Pacific, while anticyclones are significantly less (more) numerous over this region. The action of transient cyclones and anticyclones over the central and eastern North Pacific determines seasonal climate over the West Coast of North America, and specifically, winter weather over California. Relationships between winter cyclone/anticyclone behavior and daily precipitation/cold temperature extremes over Western North America (the West) were examined and yielded two simple indices summarizing North Pacific transient activity relevant to regional climates. These indices are strongly related to the observed inter-annual variability of daily precipitation and cold temperature extremes over the West as well as to large scale seasonally averaged near surface climate conditions (e.g., air temperature at 2 m and wind at 10 m). In fact, they represent the synoptic links that accomplish the teleconnections. Comparison of patterns derived from NCEP-NCAR and CNRM-CM3 revealed that the model reproduces links between cyclone/anticyclone frequencies over the Northeastern Pacific and extra-tropical climate conditions but is deficient in relation to tropical climate variability. The connections between these synoptic indices and Western weather are well reproduced by the model. Under advanced global warming conditions, that is, the last half of the century, the model predicts a significant reduction of cyclonic transients throughout the mid-latitude North Pacific with the exception of the far northern and northeastern domains. Anticyclonic transients respond somewhat more regionally but consistently to strong greenhouse forcing, with notably fewer anticyclones over the Okhotsk/Kamchatka sector and generally more anticyclones in the Northeastern Pacific. These modifications of synoptic weather result in regional feedbacks, that is, regional synoptic alterations of the anthropogenic warming signal around the North Pacific. In the eastern Pacific, for example, synoptic feedbacks, having to do especially with the northward shift of the eastern Pacific storm-track (responding, in turn, to a weaker equator-to-pole temperature gradient), are favorable to more anticyclonic conditions off the American mid-latitude west coast and more cyclonic conditions at higher latitudes. These circulation feedbacks further reduce the equator-to-pole A. Favr

DOI 10.1007/s00382-007-0353-7 The relative importance of tropical variability forced from the North Pacific through ocean pathways

Abstract To what extent is tropical variability forced from the North Pacific through ocean pathways relative to locally generated variability and variability forced through the atmosphere? To address this question, in this study we use an anomaly-coupled model, consisting of a global, atmospheric general circulation model and a 4layer, reduced-gravity, Pacific-Ocean model. Three solutions are obtained; with coupling over the entire basin (CNT), with coupling confined to the tropics and wind stress and heat fluxes in the North and South Pacific specified by climatology (TP), and with coupling confined to the Tropics and wind stress and heat fluxes in the North Pacific specified by output from CNT (NPF). It is found that there are two distinct signals forced in the North Pacific that can impact the tropics through ocean pathways. These two signals are forced by wind stress and surface heat flux anomalies in the subtropical North Pacific. The first signal is relatively fast, impacts tropical variability less than a year after forcing, is triggered from November to March, and propagates a