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Founded 1897 • New Series
Vol. CXXII • Suppl/2019 • October
REVISTA DE MEDICINĂ MILITARĂ
Military Medicine
Romanian Journal of
Journal included in Web of Science, Emerging Sources Citation Index, Index Copernicus International, National Library of Medicine Catalog, Ulrich’s Periodicals Directory database, Directory of Open Access Journals, Directory of Research Journals Index, Eurasian Scientific Journal Index, Science Library Index and Open Academic Journals Index.
Editorial Board of Romanian Journal of Military Medicine
Under the patronage Romanian Association of Military Physicians and Pharmacists Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
Honorary Editor Acad. Victor Voicu MD, PhD
Editors-in-Chief Florentina Ioniță Radu MD, PhD, MBA Dan Mischianu MD, PhD
Executive Editors Daniel O. Costache MD, PhD, MBA Victor L. Purcărea PhD, MBA
Associate Editor Mariana Jinga MD, PhD, MBA
Redactors Raluca S. Costache MD, PhD, MBA – Bucharest Mihail S. Tudosie MD, PhD – Bucharest
Editorial Assistants Ioana Bratu MD Cristina Solea
Technical Secretary Oana Ciobanu Ionuț M. Olteanu
Publisher Carol Davila University of Medicine and Pharmacy Publishing House
International Editorial Board
Natan Børnstein (Israel) Silviu Brill (Israel)
Cris S. Constantinescu (UK) Daniel Dănilă (USA)
Stergios Ganatsios (Greece)
Mihai Moldovan (Denmark) Ioan Opriș (USA)
Gerard Roul (France) Erwin Santo (Israel)
Adrian Săftoiu (Denmark)
Ioanel Sinescu (Romania) C. Ionescu Târgovişte (Romania)
Radu Ţuţuian (Switzerland) Shyam Varadarajulu (USA) Peter Vilmann (Denmark)
Scientific Publishing Committee
Adrian Barbilian (Bucharest) Anda Băicuş (Bucharest)
Cristian Băicuş (Bucharest) Andra R. Bălănescu (Bucharest)
Mircea Beuran (Bucharest) Ovidiu Bratu (Bucharest)
Daciana Brănișteanu (Iași) Dragoș Bumbăcea (Bucharest)
Marian Burcea (Bucharest) Mihai Ciocârlan (Bucharest)
Sofia Colesca (Bucharest) Gabriel Constantinescu (Bucharest)
Silviu Constantinoiu (Bucharest) Dan Corneci (Bucharest)
Raluca S. Costache (Bucharest) Dragoș Cuzino (Bucharest)
Camelia Diaconu (Bucharest) Mircea Diculescu (Bucharest)
Lidia Dobrescu (Bucharest) Cosmin Dobrin (Bucharest)
Dumitru Constantin Dulcan (Bucharest) Silviu Dumitrescu (Bucharest)
Carmen G. Fierbințeanu (Bucharest) Cristian Gheorghe (Bucharest) Liana S. Gheorghe (Bucharest)
Viorel Jinga (Bucharest) Carmen Moldovan (Bucharest)
Ovidiu Nicodin (Bucharest)
Tudor Nicolaie (Bucharest) Ana Maria Oproiu (Bucharest)
Carmen Orban (Bucharest) Bogdan A. Popescu (Bucharest) Aurelian E. Ranetti (Bucharest)
Corneliu Romanițan (Bucharest)
Mugurel Rusu (Bucharest) Andrada Seicean (Cluj Napoca)
Carmen A. Sîrbu (Bucharest) Silviu Stanciu (Bucharest)
Ion Țintoiu (Bucharest) Sorin G. Țiplica (Bucharest) Daniel Vasile (Bucharest)
Dragoş Vinereanu (Bucharest)
REDACTION
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Romanian Journal of Military Medicine (RJMM) is included in Romanian College of Physicians Medical Publications Index.
www.revistamedicinamilitara.ro
Romanian Journal of Military Medicine, New Series, vol. CXXII, Suppl/2019, October
ISSN-L 1222-5126; eISSN 2501-2312; pISSN 1222-5126
Vol. CXXII • Suppl/2019 • October • Romanian Journal of Military Medicine
1
Founded 1897 • New Series
Vol. CXXII • No. 3/2019 • December
Edited by the Romanian Association of Military Physicians and Pharmacists.
Contents
INTERNAL MEDICINE PAPERS
3
SURGICAL PAPERS
27
NURSING PAPERS
39
Guidelines for authors 52
RJMM Romanian Journal of Military Medicine
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Vol. CXXII • Suppl/2019 • October • Romanian Journal of Military Medicine
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INTERNAL MEDICINE PAPERS
A case report of esophageal dismotility following laparoscopic sleeve gastrectomy
Andrada L. Popescu, Raluca S. Costache, Florin Savulescu, Mariana Jinga, Florentina Ionita-Radu
Laparoscopic sleeve gastrectomy (LSG) is becoming popular
between bariatric procedures. There are few data available
of LSG impact on esophagogastric physiology, some patients
may have gastrointestinal symptoms such as reflux,
dysphagia or odynophagia. This case report describes a 42-
year-old female with esophageal dysmotility following LSG.
She experienced globus sensation and minor GERD
symptoms prior to the surgical intervention, the upper GI
tract endoscopy revealed erosive esophagitis grade A ( Los
Angeles Classification), and high-resolution esophageal
manometry (HRM) showed normal lower esophageal
sphincter relaxation and distal esophageal spasm ( > 20%
premature contraction). HRM was analyzed according to the
Chicago classification v3.0. One year after the procedure, the
patient lost 40 kg, but she has mild dysphagia, early satiety,
fullness and reflux. Her dysphagia could be associated with a
structural cause or attributed to a “sleeve dysmotility
syndrome.” The result of upper gastrointestinal endoscopy
was no esophagitis, normal gastric scar on the posterior wall,
but on HRM more than 50% of contractions were ineffective
swallows (ineffective motility), with normal relaxation of LES
( IRP less than 15 mmHg). Also increased intragastric
pressure (IIGP) after water swallows was observed in 30-40%
of the ten swallows examined. A proposed alternative to
pharmacological treatment to relieve reflux symptoms
might be the gastric bypass, but it will not resolve the poor
esophageal contractility.
Conclusions: Motility studies should be required for all
patients planning to undergo a LSG to rule out preexisting
esophageal dysmotility. Conversion to gastric bypass is not a
universal method for managing esophageal dysmotility after
LSG.
Optimizing diagnosis in pancreatic cystic neoplasms
Vasile Balaban, Andreea Zoican, Victor Mina, Raluca S. Costache, Petrut Nuță, Florentina Ioniță Radu, Mariana Jinga
With the widespread use of cross-sectional abdominal
imaging for various indications, pancreatic cystic lesions
(PCL) are being increasingly encountered in clinical practice.
The stake is to differentiate neoplastic from non-neoplastic
PCLs. Several guidelines have been proposed over the last
years, balancing careful follow-up with need for surgery -
misdiagnosis can lead to unnecessary, high-morbidity and
mortality surgery or missing a potentially neoplastic lesion.
In this setting, establishing a strong diagnosis becomes of
utmost importance. Along with high-resolution imaging,
endoscopic ultrasound plays an important role in the
management of PCLs. Novel techniques such as cyst fluid
analysis of molecular markers and cyst wall sampling can
prove valuable in providing a definite diagnosis for a PCL.
Also, innovative algorithms have been developed to aid
clinicians in the management of PCLs.
Capsule endoscopy in Blue rubber bleb syndrome
Alexandra Lulache, Mariana Jinga, Florentina Ioniță Radu, Diana O. Preda, Săndica Bucurică, Andrada Popescu, Mihăiță Pătrășescu, Vasile Balaban, Andrei I. Gavrilă, Raluca S. Costache
Background: The small bowel evaluation remained unclear
until 1996, when the first live pictures from pig
gastrointestinal tract with wireless device was obtained.
Hundreds of thousands patients have been examined since.
4
Nowadays it becomes the “key” method for evaluation of
small bowel pathology.
Material and method: We present the case of young girl
referred to our clinic for gastrointestinal bleeding with
normal upper and lower endoscopy and severe anemia. At
14 years old she was diagnosed abroad with Blue Rubber
Bleb Syndrom with duodenal and jejunal angiomas. We used
the Olympus Endocapsule® System.
Results: The patient performed a standard small intestine
complete examination, meaning the capsule reach the
caecum. The result show the source of bleeding: multiple big
angiomas of the small intestine.
Conclusion: The capsule endoscopy represents in our days
the gold standard for small bowel tumor evaluations but has
his own limitation – impossibility of therapeutic approach.
The role of transarterial chemoembolization (TACE) in the modern management of hepatocellular carcinoma
Florentina Ioniță Radu, Cezar Bețianu, Cezar Călin, Andrada L. Popescu, Alexandra I. Păun, Raluca M. Ștefan, Iulia Fulga, Maria M. Chereja, Anca Jianu, Alexandra I. Lulache, Andrei I. Gavrilă
Introduction: Our objective is to review current international
guidelines for the management of hepatocellular carcinoma
and to present our hospital`s experience with transarterial
chemoembolization (TACE) for hepatocellular carcinoma.
Materials and methods: Hepatocellular carcinoma (HCC) is
the most common type of primary liver cancer. This type of
malignant tumour has a very rich blood supply, mostly from
the hepatic artery, while the rest of the liver tissue gets
blood from the portal vein. This means that blocking the
hepatic artery to cut off the blood supply to the tumour will
not affect the rest of the liver.
Chemoembolization is a palliative type of treatment that
delivers chemotherapy directly to the liver tumor through
the hepatic artery and then the artery is blocked
("embolized") to cut of blood flow to the tumor.
TACE can be performed in patients who have a good liver
function, without ascites or portal vein thrombosis and the
tumour can’t be removed with surgery but it hasn’t spread
to the major blood vessels in the liver, lymph nodes or other
parts of the body. Another indication for this procedure
(called “bridging” therapy) is to control the dimensions of
HCC in patients waiting for liver transplant.
Results and conclusion: Despite ongoing efforts, there is no
definitive consensus in the management of hepatocellular
carcinoma. The Barcelona Clinic Liver Cancer (BCLC) system
that is widely used nowdays has it`s limitations, meaning
that the role of transarterial chemoembolization (TACE) in
hepatocellular carcinoma management can be refined.
Topographic endomicroscopic morphology of normal stomach
Săndica Bucurică, Raluca S. Costache, Petruț Nuță, Mariana Jinga, Florentina Ioniță Radu
Normal stomach has a particular morpho- functional
strategy to balance the secretion of acid and bicarbonate,
and this is made by various mucosal cell types and
component, with specific topography in different parts of
the stomach. From histopathologic point of view there are
two mucosal compartments: foveolar – that is superficial
and glandular – in depth of mucosa, with different structure
varying with the stomach site. The correspondence between
this morphology and endomicroscopic appearance is very
important in order to establish the subtle pathology changes
that may not have endoscopic definite features and may
benefit from endomicroscopic examination such as
metaplasia or atrophy. The cardial aspect is characterized by
branched glands (sometimes cystic, produce mucus), while
the mucosa of the fundus has oxyntic glands that are
straight, with higher proportion of glands/foveola
comparative with antrum. In the antrum the mucus
producing glands are also branched, but vacuolated, while
the parietal cells are in the glands from fundus and body of
the stomach, with function to produce acid, to bind the
gastrin produced by antral cells and stimulate vagus nerve.
Scattered in the fundus/body there are endocrine cells and
chief cells that produce pepsinogen I/II are most in the
fundus and body. So, having this various aspects, for the
endomicroscopic examination of the stomach the key point
is knowledge of normal mucosa. The Classification of gastric
pit patterns by confocal endomicroscopy was proposed by
Zhang who states that the pits patterns of stomach
examined by confocal endomicroscopy are well correlated
with histopathologic findings.
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High-resolution esophageal manometry: interpretation in clinical practice
Andrada L. Popescu, Ionel P. Nuță, Raluca S. Costache, Săndica Bucurică, Bogdan Macadon, Mihaiță Pătrășescu, Mirela Chereja, Andrei I. Gavrilă, Mariana Jinga, Florentina Ioniță-Radu
Esophageal high-resolution manometry (HRM) defines the
function of the lower esophageal sphincter and the
esophageal body peristalsis, and is indicated to establish the
diagnosis of suspected cases of achalasia, diffuse esophageal
spasm, also for detecting esophageal motor abnormalities
associated with systemic disease (connective tissue disease)
or for placement of intraluminal devices (correct positioning
of the probe for the 24-hour pH monitoring).
Esophageal high-resolution manometry (HRM) is the current
state-of-the art diagnostic tool to evaluate esophageal
motility patterns. HRM uses a high-resolution catheter to
transmit intraluminal pressure data that are subsequently
converted into dynamic esophageal pressure topography
(EPT) plot. The pressure analysis is done according to the
Chicago Classification, a formal analytic scheme for
esophageal motility disorders, which is currently in version
3.0.
The standard HRM examination consists of a baseline phase
and a series of 10 wet swallows in the supine position. In
addition, in some cases, data from swallows in the seated
position or provocative solid meal HRM is performed.
In our hospital this GI functional procedure is available since
2017 with the HR solid-state catheter and ManoScan ESO HR
system (form Given Imaging), and recently with Unisensor
HRIM catheters (from Isolab), with more than 170
procedures performed.
Conclusion: Esophageal HRM is a valuable and sophisticated
clinical tool to evaluate esophageal motility patterns, useful
in a case-by-case basis or to compare the physiological
response among groups of individuals. Manometric
screening for severe peristalsis dysfunction remains
reasonable in specialized gastroenterology departments.
From Zenker diverticulum to a complex esophageal ailment
Mihăiță Pătrășescu, Săndica Bucurică, Raluca S. Costache, Vasile Balaban, Mariana Jinga, Florentina Ioniță Radu
Background: Zenker diverticulum is an out-pouching of
mucosa and submucosa in Killian triangle which is a
hypopharyngeal weak part between the fibers of inferior
constrictor pharyngeal muscle and cricopharyngeal muscle.
Pathophysiology may imply a disfunction of cricopharyngeal
muscle which increases intraluminal pressure just above
upper esophageal sphincter. The prevalence is very low
(0.01-0.1%) but many cases go undiagnosed because of lack
of symptoms.
Case report: I present a case of a 35-year-old patient who is
admitted for dysphagia, halitosis, heartburn and
regurgitation. The onset of symptoms was 10 years ago. The
esophagogram shows a typical image of Zenker
diverticulum. Upper digestive endoscopy was performed,
and the surprise was the unmasking of two other esophageal
pathologies: two areas of cervical esophageal “kissing”
gastric patches and a short Barrett esophagus.
Conclusion: Zenker diverticulum is a rare ailment that may
share symptoms with other diseases of esophagus (Barrett
and gastric patches). These associations render a very
important implication as diagnosis confounding factor and
they may change the therapy management of patient.
The role of high-resolution esophageal manometry in achalasia
Andrada L. Popescu, Andrei I. Gavrilă, Mirela Chereja, Ionel P. Nuță, Raluca S. Costache, Săndica Bucurică, Bogdan Macadon, Mihăiță Pătrășescu, Vasile Balaban, Mariana Jinga, Florentina Ioniță-Radu
The role of this paper is to point out the importance of
esophageal manometry in the diagnosis of achalasia.
Esophageal achalasia is a primary motility disorder
characterized by impaired lower esophageal sphincter
relaxation and absence of esophageal peristalsis leading to
impaired bolus transit. The Eckardt score is used to assess
the severity of achalasia symptoms and it is based on four
major symptoms: dysphagia, regurgitations, chest pain and
weight loss. The Eckardt score is also used to evaluate the
efficiency of a treatment durring the follow-up, a score of
6
less than 3 points is considered as remission of the disease.
The suspicion of the disease is clinical, completed by upper
gastrointestinal tract endoscopy or barium swallow. The
gold standard diagnostic tool for achalasia remains
esophageal manometry. High-resolution manometry (HRM)
of the esophagus is a new technique that provides a more
precise assessment of esophageal motility than conventional
techniques, using catheters with 36 solid-state sensors
spaced 1cm apart. The main innovation of this method is the
conversion of pressure data into a topographical plot. Thus
we can evaluate the esophageal motor pattern, the
contraction amplitude and LES pressure and function. HRM
defines three manometric types of achalasia that seem to
have different responsiveness to treatment. In our hospital
this GI functional procedure is available since 2017 and we
performed until now approximately 150 procedures.
Conclusions: HRM provide a detailed assessment of
esophageal function and helps to identify distinct
phenotypes of esophageal motility disorders, but more
important HRM increased the recognition and diagnosis of
achalasia.
Non-invasive diagnosis in hepatic fibrosis
Florentina Ioniță Radu, Raluca S. Costache, Mirela M. Chereja, Andrada l. Popescu, Anca Jianu, Alexandra I. Drugău-Păun, Raluca M. Ștefan, Iulia Fulga, Alexandra I. Lulache, Andrei I. Gavrilă
Introduction: Our objective is to review current non-invasive
methods of assessing liver fibrosis, their availability and their
utility in modern medical practice.
Materials and methods: The evaluation of the degree of liver
fibrosis has been traditionally assessed by liver biopsy, an
invasive “gold-standard” that, during the past 25 years, has
been deemed imperfect; even according to its advocates, it
is only “the best” among available methods.
Attempts at uncovering non-invasive diagnostic tools have
yielded multiple scores and formulae based on biological
parameters, and also multiple imaging techniques. All of
them are better tolerated and more acceptable for the
patient, safer and they can be repeated essentially as often
as required. Another advantage is that they are much less
expensive than liver biopsy. Consequently, their use is
growing, and in most countries the number of liver biopsies
performed, at least for routine evaluation of viral hepatitis
(B or C), has declined sharply.
The major setback is that the accuracy and diagnostic value
of most, if not all, of these methods remains debatable. The
good news is that we may be witnessing the beginning of the
end of the first phase of non-invasive markers development.
Actual evidence suggests that they might be at least as good
as liver biopsy. Novel experimental biomarkers and imaging
techniques could produce a dramatic change in liver fibrosis
diagnosis in the near future.
Results and conclusion: Liver biopsy has now been named
the old standard for diagnosing liver fibrosis in most clinical
settings and non-invasive diagnostic scores, formulae, and
imaging modalities, all of which have several advantages
compared to biopsy have been shown to be at least as good
as liver biopsy in assessing the degree of liver fibrosis.
The importance of imaging: functional investigations in the diagnosis of gastrointestinal stromal tumors
Anca Minea, Iulia Enache, Alexandra Gheorghe, Raluca S. Costache, Petruț Nuță, Săndica Bucurică, Mihăiță Pătrășescu, Andrada Popescu, Vasile Balaban, Florentina Ioniță Radu, Mariana jinga, Bogdan Macadon
GISTs (gastrointestinal stromal tumors) are the most
common mesenchymal neoplasms affecting the
gastrointestinal tract - most often located in the anterior and
posterior wall of the gastric fundus and proximal small
intestine.
GISTs occur predominantly in middle-aged and older
individuals (are rare in children or persons under the age of
40).
In adults are characterized by the expression CD117 antigen
- synonymous with the KIT transmembrane receptor
tyrosine kinase. In 95% of cases they occur sporadically,
while in 5% of cases they are associated with syndromes
such as Carney-Stratakis syndrome, neurofibromatosis type
1.
In 70% of cases the tumors are benign. The malignant ones
do not metastasize in the lymph nodes, but they can
Vol. CXXII • Suppl/2019 • October • Romanian Journal of Military Medicine
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disseminate in the liver and into the peritoneal cavity.
The clinical behavior of GISTs is highly variable; many are
asymptomatic, being discovered incidentally - endoscopic or
radiologic examination. When they become symptomatic,
they are associated with nonspecific symptoms, unless they
grow large enough to cause pain or obstruction, ulcerate,
and bleed.
The endoscopic appearance is suggestive in the presence of
an extramucosal structure, hemispherical in shape, with a
normal overlying mucosa, which may present ulceration or
bleeding.
Oral or intravenous contrast-enhanced computed
tomography (CT) can characterize an abdominal mass,
evaluate its extent, the presence or absence of metastatic
disease.
Magnetic resonance imaging (MRI) may be preferred for
GISTs affecting the rectum or the liver, especially when
evaluating for surgery.
The endoscopic ultrasonography (EUS) is able to identify the
layer of origin and enabling guided-tissue acquisition for
diagnostic studies, including immunohistochemistry.
Positron emission tomography (PET) is sensitive for
detecting tumors with a high glucose metabolism, including
GIST. PET can be useful for resolving ambiguities from CT or
detecting an unknown primary site.
Metaplasia: still a challenge-versatile endoscopic appearance of non-atrophic gastritis metaplasia
Săndica Bucurică, Mihaela Ailenei, Raluca S. Costache, Petruț Nuță, Mihăiță Pătrășescu, Bogdan Macadon, Andrei Gavrilă, Roxana Călin, Vasile Balaban, Andrada Popescu, Mirela Chereja, Mariana Jinga, Florentina Ioniță Radu
Introduction: Gastric atrophy and intestinal metaplasia are
common findings from routine endoscopies and the earliest
steps in gastric carcinogenesis. There is a real controversy
regarding the correlation of macroscopic endoscopic
appearance and histopathologic diagnostic.
Aim: The aim of this study is to determine the correlation
between endoscopic diagnostic and the histopathologic
result, also the implication of targeted or non-targeted
biopsies in 2 selected groups of patients with macroscopic
suspicion of gastric atrophy or intestinal metaplasia. One
group had respected the Sydney non-targeted biopsy
protocols and the second group had targeted biopsies from
suspected lesions.
Methods: In this cross-sectional comparative study on the 54
patients from Gastroenterology Departament of University
Central Military Hospital "Dr Carol Davila", Bucharest, we
used for one group (n=25) the Sydney system for biopsy
sampling protocol with 5 tissue specimens from the gastric
mucosa (two from antral mucosa, two from corpus, and one
sample from incisura angularis) and for the other
comparative group (n=29) we took targeted biopsies from
macroscopic suspicious lesions. We have classified
endoscopic appearance into 6 phenotypes: whitish mucosa,
hyperemic, erosions/ulceration, modified vascular pattern,
elevation of mucosa and normal aspect. The atrophy status
of each slide was determined as atrophic or non-atrophic
and intestinal metaplasia as absent or present.
Results: As a particular finding, in most of the cases
metaplasia was found in non-atrophic gastritis that could be
a characteristic of the study group and needs to be verified
in general population. In our study we found that metaplasia
could take various forms of endoscopic expressions and
those was not correlated with a specific phenotype, but for
sure will not appear as normal(p<0.05, adjusted R-squared
=-2.3).
Among the 154 biopsies, 75 (48.7%) were classified by
endoscopic phenotype as whitish mucosa, 16 (10.4%) as
hyperemic, 12 (7.8%) as erosions/ulceration, 13 (8.4%) as
modified vascular pattern, 16 (10.4%) as elevation of mucosa
and 22 (14.3%) as normal. The incidence of the intestinal
metaplasia was 16.9% (26 biopsies), higher in the targeted
biopsies group (41.4%) than random biopsies group (12%).
Metaplasia has moderate correlated with targeted
biopsies(r=0.271, p<0.01).
In the group with targeted biopsies (p<0.01) we found more
cases with histological changes from the erodated and
elevated lesions (adjusted R-squared=2.1 and 6.1) than
other phenothypes described by endoscopists as whitish,
hyperemic, but with no predominance of metaplasia. In all
cases described being normal, the histology showed no
changes (adjusted R-squared=2.4).
Metaplasia was not correlated with the grade of
gastritis(r=0.042, p>0.01), but it was associated (p<0.01)
with the moderate grade of gastritis (adjusted R-
squared=3.3), and negative associated with severe gastritis
(adjusted R-squared=-2).
8
Conclusions: Metaplasia found in non-atrophic gastritis can
take multiple endoscopic faces and could appear as: whitish
mucosa, hyperemia, erosions/ulceration, elevation of
mucosa, but none as normal. There is a bigger chance with
statistical significance to find metaplasia by taking targeted
biopsies. So, metaplasia does not have a specific endoscopic
phenotype and its versatile appearance needs the support of
additional or red flag techniques for endoscopic diagnosis
and mapping of metaplasia.
The role of hepatitis C virus core antigen in the diagnosis and treatment algorithm of HCV infection
Corina Taubner, Clara Neguț
Chronic hepatitis C virus (HCV) infection is prevalent in
approximately 1.1% of the world population and can lead to
liver fibrosis, cyrrhosis, and hepatocellular carcinoma.
Currently, HCV diagnosis is a process that starts with
screening assays for anti-HCV antibodies (HCV Ab). Such an
assay can only inform about the exposure to the virus and
can not diferentiate between acute and chronic infection,
active replication and ongoing infection. On the one hand,
even when a person cleared HCV or have been cured by
treatment, HCV antibodies remain in a person’s blood for
years. On the other hand, the serological window for
conversion to a positive antibody response is variabile with
an average of 60 days and may remain negative for patients
on haemodialysis or immunocompromised. Summarizing
diagnosis of active HCV infection requires antibody testing
and additional HCV RNA testing in order to confirm active
HCV infection and to monitor antiviral therapy. An HCV RNA
assay involving nucleic acid testing (NAT) is a confirmatory
test, a highly sensitive and specific method, but requires
expensive reagents and skilled personnel.
The hepatitis C core antigen (HCVc Ag) is a viral protein that
forms the internal capsid which is highly conserved and
antigenic and it can usually be found in the bloodstream two
weeks after infection. Testing for HCV core antigen is a
potential replacement for NAT as an indirect marker for HCV
replication, as an atractive alternative due to the lower cost
and short turnaround time. HCVc antigen can also be used
to monitor the response to antiviral therapy.
Currently, seven tests for HCVc Ag detection are available: 1.
The Abbott Architect HCV Ag assay; 2. The Fujirebio Otto
HCV Ag test; 3. The Eiken Lumispot HCV Ag ; 4. The Hunan
Jynda Bioengineering Group HCVc Ag ELISA; 5. The Ortho
ELISA-Ag; 6. Bio-RAD Monolisa HCV Ag-an ULTRA; 7. HUNAN
JYNDA HCV Core Ag ELISA.
At this moment, the immunology departament of our
medical laboratory, analysis the opportunity of
implementing both the two confirmatory tests for HCV
infection, NAT and HCVc Ag testing.
Human dirofilariasis, an emerging zoonosis: case series in Romania
Valeriu Gheorghiță, Raluca M. Hrișcă, Adelina M. Radu, Ion Ștefan, Ruxandra Moroti
Background: The genus Dirofilaria (D.) includes vector-borne
filarial nematodes, which are usually transmitted by
mosquito bites. Human dirofilariasis is an unusual zoonotic
infection, increasingly reported in recent years in many parts
of the world. The European Mediterranean region is
considered highly D. repens-endemic in animals. The
objective of our report is to increase the level of awareness
among physicians regarding the emergence of human
dirofilariasis cases in Romania.
Methods: A retrospective analysis of the human dirofilariasis
cases that we diagnosed in our centers in a sixteen years
period (2003-August 2019)
Results: In our settings we recorded 10 patients diagnosed
with dirofilariasis, one case in 2010, eight cases during 2012-
2013 and the last case in the summer of 2019. Age
distribution varied between 16-74 years (average 50.9) and
the sex-ratio was 1:4 (male to female). Nine out of 10
patients are living in south-east and one in north-west of
Romania, with an equal distribution for rural and urban
areas (5:5). Eight out of 10 are living near puddles or swampy
regions. All reported mosquitos’ bites. Five patients had
ocular dirofilariasis and another five had subcutaneous
dirofilariasis. The diagnosis was misinterpreted as other
diseases in 7 out of 10 patients such as bacterial orbital/soft
tissues cellulitis and thoracic herpes zoster.
Conclusions: The diagnosis of human dirofilariasis does not
require a high level of expertise in parasitic diseases, which
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is why we consider important to know the clinical features
of this parasite, to avoid a misinterpretation of the patient
anamnesis and a misdiagnosis.
The practical utility of ultrasonography of small parts and soft tissue
Mirela Oancea, Cătălin Mazilu, Raluca Mititelu, Carmen Tipar
Introduction: Currently, medical imaging presents a rapid
development, at an exponential rate, on all the component
branches (including ultrasonography).
The immediate value of the ultrasound results from the fact
that it is a fast, cheap, non-invasive, non-irradiating imaging
method, without contraindications or special previous
training, which has developed a great deal and has been
diversified in the different areas in which it is used.
An example is the ultrasound of superficial soft tissue, with
great applicability including in the surgical specialties
(general surgery, ENT surgery, and orthopedics).
Material and methods: Patient G.M., aged 54, admitted to
the Surgery II section for a presternal localized mass that had
been growing in size lately. For the purpose of excision the
mass, the surgeon asked the problem of clarifying the
relationships that the respective formation could have with
the surrounding structures (thyroid, vascular and muscular
planes).
In addition, the patient also had diffuse enlargement of the
anterolateral cervical region.
Results: The ultrasound of the enlarged presternal region
revealed a thickening of the subcutaneous cellular tissue
with a diffuse lipomatous appearance, with the inclusion of
the sternal and clavicular ends of the bilateral
sternocleidomastoid muscle.
Also, at the level of the anterolateral and submentonal
cervical region, has been viewed the same diffuse
lipomatous aspect of the subcutaneous tissue and
connective tissue between the musculotendinous planes.
In addition, it was also noted that all the surrounding
structures (thyroid gland, vascular pedicles, tendons and
muscles) were respected by this pathological
transformation.
Conclusions/observations: Superficial soft tissue/small parts
ultrasonography is a simple imaging method, with easy
applicability and within the reach of any dedicated
sonographer.
Also, because of its speed and low cost, it is an excellent
method of solving some equivocal pathological situations in
order to make the best surgical protocol decisions.
Role of radiotherapy in primary mediastinal B-cell lymphoma: case report
Răzvan G. Curcă, Alexandra T. Pasăre, Remus C. Stoica, Diana A. Mitrea, Ștefănel C. Vlad
Introduction. Primary mediastinal B-cell lymphoma is
regarded as a subtype of diffuse large B-cell lymphoma. Due
to the rarity of primary mediastinal B-cell lymphoma, there
are few studies analyzing treatment efficacy, including
radiotherapy. Considering the generous life expectancy of
patients successfully treated, a good therapeutic intent is to
minimize long and short term toxicity. Standard of care
consists of chemotherapy combined with immunotherapy,
the most common combination being R-CHOP. Radiotherapy
of the mediastinum can be used to consolidate the
treatment.
Materials and methods. We are presenting the case of a 45
year old man, diagnosed with primay mediastinal B-cell
lymphoma, onset symptoms consisting in pain of the
anterior thorax. After the initial diagnosis, the patient
started with a course of R-CHOP, followed by 6 courses of R-
dose adjusted EPOCH. The indication for radiotherapy was
established after a PET-CT scan revealed residual metabolic
disease.
Results and discussions. Standard treatment for primary
mediastinal B-cell lymphoma consist of chemotherapy
combined with immunotherapy. Modern treatment
techniques show a good control of local disease and low
recurrence rates. PET is the most recommended technique
in the diagnosis, follow-up and post-treatment evaluation.
Although recent data suggest that DA-EPOCH-R can obviate
the need for routine mediastinal radiation, some patients
require to undergo radiotherapy.
10
Anti-inflammatory interventions in major depressive disorder: status of research and therapeutic perspectives
Octavian Vasiliu, Daniel Vasile, A.G. Mangalagiu, B.M. Petrescu. C.A. Cândea, Corina Tudor, D. Ungureanu, M. Miclos, A. Drăghici, C. Florescu
Background: New data about the pathophysiology of major
depression are arising based on preclinical models, and
investigational drugs are being tested starting from these
translational models. Inflammation has been considered a
potential trigger for the lack of responsivity in a sub-group of
patients diagnosed with major depression and anti-
cytokines treatment has been suggested as a possible
solution for these cases.
Objectives: To assess the current evidence that may support
the recommendation of anti-inflammatory drugs as add-on
in the treatment of major depressive disorder.
Method: A literature review was conducted in the main
electronic databases (PubMed, EMBASE, CINAHL, Thomson
Reuters/Web of Science) using the search paradigm “anti-
inflammatory drugs” OR “anti-cytokines” OR “monoclonal
antibodies” OR “TNF-alfa inhibitor” OR “IL-6 modulators”
AND “major depressive disorder” OR “treatment-resistant
depression”. All peer-reviewed papers published between
2000 and 2019 containing clinical trials, systematic reviews
and meta-analyses were included in the first level of this
study.
Results: A number of 23 papers remained after filtering the
results according to the inclusion and exclusion criteria, in
the second level of our study. Adalimumab decreased the
severity of depressive symptoms after 12 weeks in patients
with psoriazis, while etanercept confirmed its efficacy over
the affective symptoms during an 84 week-extension trial in
patients with the same dermatological pathology and
comorbid depression. Infliximab decreased depression
severity in patients with an increased initial level of
inflammatory markers. Tocilizumab and sirukumab are
studied as add-ons to antidepressat drugs, in severe cases of
major depressive disorder, but the research has so far
proved inconclusive.
Conclusions: Although antiinflammatory therapy is a
relatively new intervention for affective disorders, it may be
a promising intervention for major depression with partial
response to classic therapeutic approaches, in a subgroup of
patients with high levels of inflammatory markers.
Radiotherapy in thymoma: case report
Diana A. Mitrea, Remus C. Stoica, Maria Vlăsceanu, Gheorghe Bălașa, Ștefănel Vlad
Introduction. Invasive thymomas are rare tumors in the
anterior mediastinum, representing 50% of the anterior
mediastinal masses and about 20-30% of all mediastinal
tumors. They are of unknown etiology. About 50% of
patients with thymomas are diagnosed incidentally. Disease
stage and completeness of resection have been found
consistently to correlate with the duration of progresion-
free and overall survival.
Materials and method. This case study presents a 68 year-
old man with complaints of breathlessness, nosea, vomiting,
chest pain and fever. CT images revealed a defined
heterogenous anterior mediastinal mass with evidence of
infiltrations into the anterior mediastinal fat and an enlarged
necrotic paratracheal lymph node. An incomplete resection
was made and the findings of histopathological and
imunohistochemistry analysis were consistent with
thymoma type A. The patient underwent adjuvant
radiotherapy.
Results and discussion. The standard primary treatment for
this tumors is thymectomy. Modern external beam
radiotherapy improves local control in adjuvant setting of
incomplete resections. Studies and contouring guidelines
regarding thymoma do not recommend elective nodal
irradiation due to the fact that these tumors do not
commonly metastasize to regional lymph nodes. An
exception was made, in this case, for the paratracheal lymph
node, considering its malignant appearances on the CT.
IMRT technique improved dose distribution, decreasing
toxicity to normal tissues.
Follow up appointments, after external beam radiotherapy,
confirmed no evidence of local recurrence.
Vol. CXXII • Suppl/2019 • October • Romanian Journal of Military Medicine
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A rare cause of bone pain in a young patient
Oana Stancu, Mihai Șotcan, Adrian Anghel, Gabriel D. Stoicescu, Mihaela Iordache, Oana Ionescu, Lucian Ciobîcă
We present the case of a patient aged 40 years, without
exposure to professional toxics and without significant
pathological personal background that is presented in our
service in order to establish the etiology of intense rashes
with important functional impotence started about 4
months with progressive accentuation in the last weeks
associated with unilateral eyelid ptosis suddenly installed a
few days before hospitalization. He performed in an
outpatient ophthalmological evaluation, neurological brain
CT that did not establish the cause of the palpebral ptosis
and also MRI that revealed bone infiltrative lesions in the
lumbar segment. Biologically on admission: major
inflammatory biologic syndrome, moderate normochromic
anemia, high titration of alkaline phosphatase, high titration
of lactate dehydrogenase. Taking into account the presence
of bone lesions with possible tumor substrate, an extensive
nonplastic balance was performed (tumor markers,
endoscopic balance, serum protein electrophoresis –
polyclonal hypergamaglobulinemia, immunogram and
negative immunofixation). Also, a complete autoimmune-
negative and infectious disease balance was performed,
which revealed the presence of positive anti-HIV 1 and 2
type antibodies. The presence of antiretroviral antibodies
has been confirmed by using a different method so this was
the reason why the patient was guided in the Department of
Infectious Diseases in order to complete the investigations.
After thorough investigations, the diagnosis of retroviral
infection was established with certainty and it was decided
further, considering the increasing titration of alkaline
phosphatase and of lactate dehydrogenase, the
performance of a bone scintigraphy. This investigation
revealed bone lesions with uncertain substrate - the most
likely tumoral. An osteomedular biopsy was performed
signaling the presence of Burkitt cells establishing the
diagnosis of diffuse Burkitt lymphoma with large cells.
Providencia stuartii outbreaks and antibiotic susceptibility in a Romanian tertiary hospital
Raluca M. Hrișcă, Ion Ștefan, Constantin F. Ghiațău, Valeriu Gheorghiță
Background: Providencia stuartii (P. stuartii), the most
common species of Providencia, is an opportunistic human
pathogen with intrinsic resistance to polymyxin and
tigecycline. The prevalence of carbapenem-resistant
P.stuartii is increasing, and the selection of appropriate
antibiotic therapy has become limited to a few antibiotics.
Methods: We retrospectively investigated the clinical
features and the antibiotic susceptibility of P. stuarti strains
isolated in our center between July 2017 and June 2019. In
addition, we established the epidemiological links of the
cases.
Results: We included 35 patients who had positive
specimens with P. stuartii. Only one positive specimen from
different sites was isolated in 28 patients: urine (n=11),
blood (n=7), respiratory (n=5) and wound (n=5). In the other
patients at least two positive samples were diagnosed during
hospitalization in each case. We identified 18 cases with
epidemiological linkage and two different outbreaks in the
intensive care unit (ICU). The first between May-August 2018
and affected 6 patients, and the second between February-
May 2019 and affected 11 patients from two departments (6
in the ICU, 5 in the coronary-ICU).The susceptibility profile
showed high level of resistance to imipenem (77.8%),
amikacin (43.9%) and aztreonam (29.8%). 4 isolates were
pan-resistant to antibiotics.
Conclusions: P. stuartii represents a highly resistant and
opportunistic pathogen causing severe infections especially
in ICU debilitated patients with an increased ability to spread
in a hospital environment probably as a result of an excessive
use of colistin and tigecycline, the presence of multiple site-
catheters and vascular lines and the cross-contamination
between patients.
12
The usefulness of QuantiFERON®-TB Gold in diagnosis of active extrapulmonary tuberculosis: A comparative retrospective study between HIV positive and negative patients in a tertiary hospital
Valeriu Gheorghiță, Adelina M. Radu, Ion Ștefan, Adrian Streinu-Cercel
Introduction: Tuberculosis (TB) is the leading cause of death
among people leaving with human immunodeficiency virus
(HIV). The main objective of our study was to assess the
clinical usefulness of the QuantiFERON®-TB Gold test in
diagnosis of active extrapulmonary-TB in HIV-positive and
HIV-negative patients.
Methods: We performed a comparative retrospective study
on ganglionary-TB in HIV-positive patients versus non-HIV
patients in a tertiary hospital from Bucharest, Romania,
between October 2012 and June 2018. The main inclusion
criteria were the definitive diagnosis of active ganglionary-
TB in patients over 18 years old.
Results: A total of 50 patients were eligible for analysis, out
of which 33 with HIV co-infection and 17 without HIV. The
median age at the time of TB diagnosis was 32 years (IQR,
26.5-37.5) in the HIV-positive group and 58 years (IQR, 29-
76) in the non-HIV group (p=0.003). The QuantiFERON®-TB
Gold test was positive in 53% (n=9) of non-HIV patients and
27% (n=9) of the HIV-positive patients (p=0.07). In HIV-
positive patients with positive QuantiFERON® test the
median CD4 count was 230/mm3 (IQR, 178-259) versus
62/mm3 (IQR, 26-152) in those with negative test (p=0.01).
The HIV-positive patients had more extensive TB (61%
[n=22] had multicentric diseases) compared with HIV-
negative patients (18% [n=3]) (p=0.006).
Conclusions: Although the rate of positive QuantiFERON®-TB
Gold test in HIV co-infected individuals is lower compared
with HIV-negative patients and active TB, it remain an useful
tools especially for the diagnosis of latent TB than for active
diseases in a population with an increased prevalence of TB.
The "immunological window" of anti-HCV antibodies and the relevance for the serological diagnosis of acute hepatitis C: a retrospective study in a tertiary hospital
Valeriu Gheorghiță, Adelina M. Radu, Ion Ștefan, Adrian Streinu-Cercel
Background: Acute HCV infection is often asymptomatic and
is associated with higher rate of chronicity. The main
objective of our study was to investigate the "immunological
window" of anti-HCV antibodies (HCV-Ab) and the relevance
for the serological diagnosis of acute hepatitis C. The
secondary objectives were limited to define the
epidemiological and clinical features of acute hepatitis C.
Methods: We performed a descriptive, retrospective
analysis on all adult patients diagnosed with acute HCV
infection during January 2010-December 2016 in the
National Institute for Infectious Diseases "Prof. Dr. Matei
Balș", Bucharest, Romania.
Results: We included 80 eligible patients with a median age
of 47 years (IQR, 34-60) of which 58.8% (n=47) were male.
The risk factors associated with infection were identified in
62.5% (n=50) of cases, of which 78% (n=39) were health-care
associated infections, including surgical interventions in
74.3% (n=29). The median values of alanine
aminotransferases, total bilirubin and prothrombin
concentration were 1177 IU/L (IQR, 682-1865), 4.0 mg/dl
(IQR, 1.35-9.25) and 96% (IQR, 83.9-109.5), respectively. The
rate of positive HCV-Ab was 86.25% (n=69) with a median
value of 11.3 (IQR, 6.02-21.5). 44 patients have available
HCV-RNA at the baseline diagnosis. The median value was
1.054.334 IU/ml (IQR, 60.442-4.568.326), including 43.2%
(n=19) with lower than 600.000 IU/ml.
Conclusions: The majority of patients have already
developed seroconversion when hospitalized, which
highlights the idea that, at least in symptomatic cases, the
"immunological window" is transient and disappears rapidly,
making HCV-Ab seroconversion one of the most reliable test
for diagnosis of acute hepatitis C.
Vol. CXXII • Suppl/2019 • October • Romanian Journal of Military Medicine
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18F-FDG PET-CT in the evaluation of carcinoma of unknown primary
Raluca Mititelu, Cătălin Mazilu, Dragoș Cuzino, Magdalena Iriciuc, Carmen Tipar, M. Tudoran, T. Mititelu
Carcinoma of unknown primary (CUP) represents a
heterogeneous group of cases with demonstrated
metastatic disease but in which primary tumor was
impossible to detect despite complete and extensive
evaluation. This pathology is not rare and associates many
difficulties in therapeutic management.
CUP is one of the 10 most frequent groups of cancer
worldwide and represents the 4th most frequent cause of
neoplasia related deaths in both men and woman. The
management of these patients is complex, and usually
includes high performance histopathology and imaging
techniques. Most CUP are aggressive histopathologic forms
and median survival rates reported in literature is 2-10
months from diagnosis.
Identifying of primary tumor is of great importance because
it can determine optimization of therapy with significant
improvement of outcome and survival.
At present 18F-FDG PET-CT is consider to have an important
role in management of CUP and in identifying primary
tumor. This is a non-invasive functional and metabolic
method which complement anatomic information obtained
from radiologic techniques (CT and MRI). Its utility comes
from the fact that carcinomatous cells usually are glucose-
avid, leading to a better efficiency in detecting the primary
tumor.
This papers aims to review literature data concerning the use
of 18F-FDG PET-CT in this pathology and to present our
experience in the evaluation of these patients.
PET-CT in lung cancer: assessment of recurrence or residual disease
Cătălin Mazilu, Dragoș Cuzino, Carmen Tipar, Magdalena Iriciuc, Raluca Mititelu, M. Tudoran
Purpose: To present role of PET-CT fusion imaging in
assessment of patients with lung cancer following surgery
(pneumectomy, lobectomy, atypical resection) for primary
tumor/lung metastases.
Matherial and method: Studied cases were represented by
patients with pneumectomy, lobectomy, atypical resection
for oncological disorders which were assessed between
March 2018 – June 2019 in Nuclear Medicine Department of
SUUMC “Dr. Carol Davila” for suspected local or distance
recurrence, based on clinical, biological and radiological
findings, at least 3 months following surgery. Acquisition of
images was performed at 1 hr following iv injection of 2.5-3
MBq kg bw of F18-FDG, from tentorium to proximal 1/3 of
thighs, also completed with planar details or vertex-plantar
level scans when needed.
Results: Assessment of changes has includes and SUV lbm
(standard uptake value lean body mass) using a cut-off of
2.5. Compared with standard post-surgery CT imaging, PET-
CT scan has changed staging of disease by showing new
lesions (mainly local disease recurrences and bone and
lymph nodes metastases), changing the therapeutical
approach, also excluding previously suspected CT
recurrences.
Conclusion: Fused PET-CT imaging has excellent results in
post-surgery assessment in patients with lung tumoral
pathology.
Hepatitis E virus infection in Romania: a neglected cause of hepatitis
Valeriu Gheorghiță, Adelina M. Radu, Ion Ștefan, Ioana D. Olaru, Adrian Streinu-Cercel
Background: The seroprevalence of hepatitis E virus (HEV)
infection throughout Europe varies between and within
countries and over time. The primary goal of our study was
to estimate the prevalence of autochthonous HEV infection
in Romania. The secondary objectives were the identification
of the risk factors associated with the HEV seropositive
status.
Methods: Between January 2015 and December 2016, a
total of 201 adult patients, were tested for anti-HEV-IgG.
Multivariate logistic regression was used to examine for
factors associated with a positive HEV-IgG test. The level of
significance was set at α = 0.05. The study was approved by
the Hospitals’ Ethics Committees.
14
Results: The final analysis included 175 patients who
followed the study protocol, of which 46 (26.3%) had
positive, 121 (69.1%) had negative, and 8 (4.6%) had
indeterminate HEV-IgG results. Patients with positive HEV-
IgG were older [median age of 54.5 years (IQR 43-65)]
compared to patients with negative HEV-IgG [median age of
37.5 years (IQR 28-57.5)], p <0.001. A positive HEV serology
was more common in patients with history of blood
transfusions [n=10 (22.7%) versus (vs) n=11 (9.4%), p=0.025],
in those with immunosuppressive conditions [n=18 (40.9%)
vs n=27 (23.1%), p=0.025] and in patients with positive HBs
antigen (HBsAg) [n=14 (31.1%) vs n=10 (10.3%), p=0.002].
Conclusions: We identified that autochthonous HEV
infection is common in the Romanian adult population. Thus,
we strongly encourage the inclusion of HEV infection testing
from the beginning in all cases of acute hepatitis, acute-on-
chronic liver diseases and chronic hepatitis in
immunosuppressed conditions.
IL 17 inhibitors a new therapeutic class for treatment of patients with psoriasis
Marcela Poenaru, Anton M. Ţilea, Monica S. Dărmănescu, Anca Ilean, Viorel Trifu
Psoriasis is a chronic, inflammatory disease, characterized by
multiple recurrences that profoundly impact the patient’s
quality of life.
Due to the numerous pathogenic pathways and risk factors
involved, psoriasis vulgaris represents a complex therapeutic
challenge, usually requiring the combination of multiple
treatment schemes, including: topical corticosteroids,
sistemic retinoids, Methotrexate, biologic therapies. The
characteristic inflammatory response in psoriasis is involving
high levels of TNFα, IL-17, IL-23.
We present the cases of 2 patients with psoriasis vulgaris
who were treated with Sekukinumab, an IL-17A inhibitor,
which led to a significant improvement in both patients.
Hepatocellular carcinoma: Key points
Clara Ion, Romelia Sfetcu, Maria M. Iosif, Cezar Călin
Hepatocellular carcinoma (HCC) is one of the most common
cancers worldwide and is associated with high level of
morbidity and mortality being the second most common
cause of cancer-related death. Risk factors for HCC are
chronic hepatitis B or C virus, alcohol abuse, aflatoxins,
metabolic disorders and autoimmune-related disease. In up
to 90% of cases, HCC develops in a cirrhotic liver. The
pathogenesis of HCC is complex and involves chronic liver
injury and genetic alteration. HCC has a poor prognosis if
diagnosed at an advanced stage, with a 5 –year survival rate
of 0-10%, that is why surveillance of patients at risk for HCC
should be carried out by abdominal US every six months with
or without workout of AFP.
Diagnosis of HCC is based on history, examination,
laboratory tests, assessment of portal hypertension, imaging
studies and tumour biopsy.
Staging system for HCC must take into account the next main
factors: the assessment of tumour extent, AFP level, liver
function, portal pressure, patient’s physical status and
effects of treatment.
Current management options in HCC depends on the stage
of disease and liver function. Management of early and
intermediate HCC are: liver resection, orthotopic liver
transplantation and local ablation therapy and those are
potentially curative treatment for patients with HCC.
Management of advanced disease – conventional
chemotherapy regimens have not been found to be
particularly effective in patients with HCC, and is not
recommended.
Sorafenib is the standard of care for patients with advanced
HCC and those with intermediate stage disease not eligible
for, or progressing despite locoregional therapies. It is
recommended in patients with well- preserved liver function
and with an ECOG PS 0-2.
EMA recommends Lenvatinib as a front-line systemic
treatment for patients with advanced HCC without main
portal vein invasion and with ECOG PS 0-1. Guides
recommends Regorafenib for patients with advanced HCC
who have tolerated Sorafenib but progressed. Cabozantinib
can be considered for patients who has progressive disease
on one/two systemic therapies.
Pending approval from EMA for Ramucirumab in second-line
Vol. CXXII • Suppl/2019 • October • Romanian Journal of Military Medicine
15
patients with HCC and immunotherapy for patients who are
intolerant or have progressed under TKI therapy. Further
studies are needed.
Follow-up for patients with HCC includes: clinical evaluation
for signs of liver decompensation, dynamic CT/MRI, mRECIST
criteria.
The importance of multidisciplinary management of a
patients with HCC is crucial and key specialities involved:
primary care physician, diagnostic radiologist, hepatologist/
gastroenterologist, surgical oncologist/transplant surgeon,
interventional radiologist, medical oncologist, palliative care
physician.
The level of awareness of the general population regarding sun tanning beds
Irina G. Tănase, Mihaela Georgescu
Introduction: In order to assess the risk of skin cancer,
patients should be counseled on the factors that play a major
role in the development of this condition by their primary
care physicians. UV radiations are used by artificial tanning
devices, such as sun lamps and tanning beds. Despite the fact
that these devices are thought to be carcinogenic, they are
still sold as a safe alternative to UV exposure for both tanning
and vitamin D biosynthesis.
Materials and methods: We created a Google form
composed of 7 questions to assess the general knowledge of
the population regarding sun tanning beds.
Results: A number of 128 persons responded to the Google
form, 81.9% females and 18.9% males. The majority (63.3%)
population is between 25-35 age interval. 25% admitted that
they have used a sun tanning bed only for cosmetic
purposes, but 6.3% confirmed using it also as a medical
device. The majority of the population is aware that sun
tanning beds cause melanoma. As alternatives to sun
tanning beds people have used the sun (58.6%), special
creams (13.3%), other devices, and a big portion (25.8%) did
not use another alternative. A small percent of 3.9% consider
a sun tan bed identical to the sun.
Conclusion: The general population should be made aware
of the negative effects of sun tanning beds. This include
National Health Care program, implication of the National
Society of Dermatology and Government.
Comparative study on the use of 19G vs 22G needles used for EBUS-TBNA performed in the Department of Pulmonology, SUUMC
Ioana Ștefănescu, Elvis Firoiu, Florina Vasilescu
Between 2015-2019 in our Department of Pulmonology
were performed approximately 100 EBUS-TBNA, 20 of these
were performed using 19G biopsy needles. We made a
comparative study regarding the use of 22G vs 19G biopsy
needles. Given that the number of EBUS-TBNA with 19G
needles was smaller than those used with 22G needles, the
results cannot be interpreted as very relevant, we will return
with details to future events, but we can draw the following
conclusions: the lung cancer confirmation rate is comparable
(about 85%), but since we use 19G biopsy needles, we had a
100% confirmation rate of Sarcoidosis with mediastinal
lymph node involvement, while no suspicion of Sarcoidosis
was confirmed when we used the 22G needles The risk of
bleeding has increased about 3 times since we use 19G
needles, but no bleeding required special therapeutic
measures (transfusions, surgery, admission to ATI, etc.), all
of which were controlled by bronchoscopic methods, cold
serum administration, locally administered adrenaline
dilution.
New pharmacological approaches for binge-eating disorder
Octavian Vasiliu, Daniel Vasile, E.A. Morariu, R.D.A. Stănescu, A.F. Fainarea, M.C. Pătrașcu, R.E. Manolache, I.A. Alexandru, I.E. Ghenoiu, R.A. Lecu, M.I. Gionea, F. Găinaru, I. Amanolesei, R.G. Vlaicu
Background: Binge eating disorder (BED) is the most
frequently diagnosed eating disorder among the US adults,
and its worldwide incidence is almost double than the next
most prevalent disorder, bulimia nervosa. Therefore,
16
important research efforts at both basic and clinical levels
have been reported in the last decades, with several drugs
reaching the market, while still other investigational
products are in the late phase of development.
Objective: To describe the current status of the
pharmacological treatment in BED, based on the available
data in the literature, and to hierarchize these therapeutic
interventions according to their relevance for the clinical
practice.
Methods: An electronic databases search was realized
(PubMed, UpToDate, Thomson Reuters/Web of Science and
clinicaltrials.gov) using as keywords “binge eating disorder”
and “pharmacological treatment”. All published papers,
including finalized or ongoing trials found between 2000 and
2019 were selected for the primary analysis.
Results: Lisdexamfetamine dimesylate is the only drug with
enough evidence to support its recommendation for the
treatment of patients diagnosed with BED. However, it may
be associated with significant risk of addiction, which
requires continuous monitoring during the entire duration of
the therapy. Fluoxetine, sertraline, duloxetine, bupropion,
atomoxetine, armodafinil, disulfiram, naltrexone+
bupropion, baclofen, zonisamide, topiramate, lamotrigine,
samidorphan, chromium picolinate, liraglutide, orlistat and
rimonabant have been associated with mixed results in
clinical trials. GSK1521498 is an opioid antagonist that may
be a solution for BED managment in the near future, and
dasotraline, a serotonin-norepinephrine-dopamine
reuptake inhibitor is in phase III of clinical trials, and it seems
to be associated with significant efficacy.
Conclusions: A single molecule is nowadays available for
clinical use in the treatment of BED, lisdexamphetamine
dimesylate, based on solid evidence derived from pivotal
trials. Many other drugs are evaluated for this indication, but
unfortunately most of them seem to be associated with
mixed results.
Correlations between hematoxylin & eosin stain photomicrographs and multiphoton microscopy images in encapsulated thyroid nodules
Lucian Eftimie, Radu Hristu, Marius Dumitrescu, Rodica Bulata, Alexandra Calu, Marius Curea, Liana Toma, Florina Vasilescu, Remus Glogojeanu, Mariana Costache, Ștefan Stanciu, Maria Sajin, Gheorghe Stanciu
Introduction: The diagnosis of malignancy must be
confirmed by histopathology which has been the main tool
used in the diagnosis of cancer. This technique has evolved
from an era of diagnosis based on Hematoxylin and Eosin
(H&E) and evaluation of tumors by immunohistochemistry
(IHC) to confirm tumor histogenesis and histological subtype
to the emerging multiphoton microscopy imaging which is a
promising technique as an aid to traditional techniques.
Second harmonic generation (SHG) microscopy is a
promising technique for non-invasive in vivo high-resolution
optical imaging. SHG signals are generated from specific
endogenous molecules with a non-centrosymmetric
structure, hence this contrast mechanism is intrinsic to
collagen in living tissue. Investigating collagen distribution
with SHG in tissues enables a precise and non-invasive
assessment of extracellular matrix modifications, which
represent a hallmark of many pathologies, including cancers.
Objective: The purpose of this study was to compare the
accuracy of multiphoton microscopy images with H&E stain
photomicrographs in the diagnosis of thyroid cancer to
demonstrate some changes in the collagen structure and
organization in papillary thyroid carcinoma (PTC) and
follicular adenoma (FA) nodule capsules.
For this purpose, multiphoton microscopy images might help
the pathologist to diagnose thyroid cancer easier and faster.
Method: The SHG imaging was performed using a Leica TCS-
SP confocal laser scanning microscope modified for
nonlinear optical imaging. The microscope was equipped
with a Ti:Sapphire laser (Chameleon Ultra II, Coherent) which
was tuned at 860 nm, with ~140 fs pulses and a repetition
rate of 80 MHz. A 10X magnification and 0.3 numerical
aperture objective was used for focusing the laser beam on
the sample and for collecting the backward-generated SHG
signals. The forward generated SHG was collected using a 0.9
NA condenser. We acquired images with SHG microscopy on
4 μm thick tissue sections mounted on glass slides without
H&E staining and assessed collagen organization of tumoral
capsular tyroid nodules and we compared them with the
H&E stain photomicrographs of the same capsular level of
tyroid nodules (PTC, FA) respectively of the thyroid capsule
with Leica microscop to gold standard H&E sample stained.
Results: Images were acquired on the same field of view with
the optical microscope and the multiphoton microscope and
the images were compared. Important features of PTC were
the regions of interest (capsular invasion or capsular
microangioinvasion). Images were also taken from the
Vol. CXXII • Suppl/2019 • October • Romanian Journal of Military Medicine
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nodule capsule and its surroundings. It was noticed that SHG
signals are very useful for the interpretation of the tissues
state.
Conclusions: This study confirmed multiphoton microscopy
images examination as a reliable and useful diagnostic
procedure to demonstrate some changes in the collagen
structure and organization in PTC. The results of our study
demonstrate that multiphoton microscopy images is an
accurate method which can aid in the diagnosis of thyroid
cancer.
PET-CT in the management of infective endocarditis
Raluca Mititelu, Cătălin Mazilu, Silviu Stanciu, Dragoș Cuzino, Carmen Tipar, Magdalena Iriciuc, T. Mititelu, M. Tudoran
Infectious endocarditis is a serious condition, which has been
increasing in recent years as a result of the growth in the
number of surgical procedures involving implantation of
prosthetic material in the heart. Infectious endocarditis is
associated with a high mortality rate - 20% in-hospital and
40% at one year with maximum treatment.
The diagnosis of infectious endocarditis is mainly based on
clinical and ultrasound criteria. However, there are many
situations in which the severity of the phenomena and the
multiple pathological associations prevent or delay the
precise diagnosis. For this reason, it is necessary in many
cases to perform imaging procedures withe higher
specificity.
Increased glucose uptake at the site of infection represents
the pathophysiological basis for using PET-CT with
radiolabelled glucose in assessing infectious processes,
including fever of unknown origin. Many researchers and
clinicians have suggested the potential diagnostic role of
18F-FDG PET-CT in accurately diagnosis of infectious
endocarditis, especially in prosthetic valves.
In normal conditions there is variable physiologic glucose
uptake in the heart and for this reason it is very important
an adequate preparation of the patient, in order to minimize
FDG uptake in the normal heart tissue - low carbohydrate
diet 24 hours before the investigation, fasting at least 6
hours before the investigation, the eventual administration
of heparin iv which, according to many authors would
further reduce the physiological uptake of glucose in the
heart. All these measures have the role of increasing the
specificity and accuracy of the diagnosis.
In this paper we will review the literature regarding the use
of 18F-FDG PET-CT in the evaluation of patients with
infectious endocarditis.
Coexistence of TIA and minor stroke in the same vascular territory with possible mixed hemodynamic and embolic mechanism
Cristina D. Ghizdavet, Florentina C. Pleșa, Sebastian Botezatu, Ionuț Caloianu, Alexandru Nistor, Carmen A. Sîrbu
Introduction: Transient ischemic attack (TIA) is a
neurological emergency. 10% of patients with TIA or minor
stroke will develop a stroke within the next 90 days,
maximum risk being within the first 24 hours. Up to 80% of
this risk could be prevented. The mechanisms of TIA are
multiple, sometimes being intricate, therefore difficult to
specify.
Case report: 65 years old male, presented right hemiparesis
and aphasia, with total recover in less than one hour. He
refused the hospitalization proposed by the ambulance
crew. 24 hours after the first TIA, the symptomatology
repeats. He arrives at ER and he is hospitalized. After the
complete anamnesis, the neurological examination and the
paraclinical investigations, ischemic lesions in left MCA
territory and 70% left ICA stenosis were discovered. Left ICA
stenosis has been evaluated at angiography as subocclusive
stenosis and it has being stented.
Particularities: The hemodynamic mechanism has been
confirmed during the angiography evaluation, when systolic
blood pressure dropped from 180mmHg to 100 mmHg,
resulting in a TIA recurrence (right hemiparesis and speech
disorder for a few minutes). On the other hand, ultrasound
images of atheroma and the presence of ischemic lesions in
MCA territory (not in the border territories) suggest an
arterio-arterial embolic mechanism.
Conclusion: The identification of the pathogenic mechanism
is important for prophylactic therapy. There was no
significant difference between minor stroke and TIA in
prognosis. The treatment for preventing an ischemic stroke
after TIA and recurrent stroke following a minor stroke are
18
similar.
The anticoagulation in venous and arterial thromboembolic events associated with acquired thrombophilia
Maria A. Jercan, Lavinia Bârsan, Mihai Șotcan
There are three acquired thrombophilia that carry a high risk
of arterial and venous thromboembolism. These acquired
thrombophilia are antiphospholipid syndrome (APS) and its
variant – catastrophic APS, heparin induced thrombo-
cytopenia (HIT), and paroxysmal nocturnal hemoglobinuria
(PNH).
The pathogenesis of thromboembolic disease in APS, HIT,
and PNH is complex and includes cellular and/or
complement - mediated mechanism.
The treatment of thrombotic events associated with these
pathologies, the primary and secondary prophylaxis consist
in anticoagulation and had some particularities. The gold
standard of treatment in APS remains vitamin K antagonists
(VKA), after initial overlap with unfractionated heparin
(UNH) or low molecular weight heparin (LMWH). There are
additional options in pregnancy associated with APS and in
catastrophic APS, that includes the association of aspirin,
plasmapheresis, corticosteroids, hydroxychloroquine to the
anticoagulation.
The thromboembolism in HIT must be treated with
nonheparin anticoagulant initially and after clinically
resolution of thrombosis, we can switch the nonheparin
anticoagulant to VKA.
PNH is a rare disease and the most important treatment is
the eculizumab which stops the pathogenic mechanism. The
anticoagulation treatment such as LMWH, of venous or
arterial thrombosis associated with PNH must be started
immediately and can be switch to VKA after clinically
improvement.
Direct oral anticoagulants (DOACs) did not show a good
effectiveness in this kind of pathologies, and their use is
reserved for low risk acquired thrombophilia in prevention
of thrombosis. Further studies are needed.
A rare tumor entity: Leiomyosarcoma of the mesenteric veins
Alexandra D. Radu, Raida T. Stănescu, Cezar Beţianu, Cristina Sandu, Teodor Voiosu, Elena Busuioc
Introduction: Vascular leiomyosarcoma is a rare clinical
entity of malignant soft tissue tumours. The majority of
reported cases arise from the inferior vena cava, followed by
leiomyosarcoma of the main vessels of extremities, renal,
hepatic and mesenteric veins.
Case report: A 76-year-old male patient with a history of
class II congestive heart failure, ischaemic heart disease,
stage II hypertension, paroxysmal atrial fibrillation, type 2
diabetes, stage III chronic kidney disease and
hypothyroidism, was reffered to our clinic with diffuse
abdominal pain. Blood tests revealed a slight elevation of
serum transaminases and mild cholestasis (TGO, TGP and
GGT twice the upper limit of normal). An abdominal
ultrasound revealed a 10cm hypoechoic non-homogenous
mass close to the pancreatic head, with invasion of the
splenic vein and mesenteric artery at the origin from the
abdominal aorta, with no exact determination of its origin.
A contrast computed tomography of the thorax, abdomen
and pelvis was performed, revealing a large hypodense non-
homogenous tumour, probably with mesenteric vein origin.
The patient underwent endoscopic ultrasound examination
with fine needle biopsy that showed a heterogenous
hypoechoic solid tumour with Doppler signal. The pathology
and immunohistochemistry reports revealed the diagnosis
of leiomyosarcoma.
Conclusion: We report a case of an unresectable
leiomyosarcoma of the mesenteric vessels, which has no
certain indication for neoadjuvant chemotherapy or
radiotherapy because of its low incidence.
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Mass casualty incident by bomb attack: multinational exercise Bucharest 2019
Bogdan C. Teușdea, Daniel Negoiță, R. David
Vigorous Warrior 2019 (VW19), was the biggest NATO
medical exercise until now and was conducted in April 2019
in Romania. Representatives from Romania and 38 other
nations took part in this exercise.
At the end of this international exercise a bomb attack at a
subway station in the center of the capital was simulated and
managed under military command.
The goal of the exercise was that the military and civilian
entities, both national and multinational act in a coherent
and effective way.
The forces involved in rescuing the simulant victims
included: Romanian firefighters, Hungarian rescue teams,
Romanian and foreign medical personnel, SMURD and
civilian ambulances, and a large number of personnel,
vehicles and medical systems from the Central Military
Emergency Hospital Bucharest (SUUMC “Dr Carol Davila”).
Rescue actions included the extraction of over 200 victims
from the subway tunnels and the provision of on-site triage
and emergency care. A ROL1 hospital was deployed by the
Central Military Emergency Hospital at the Academy of
Economic Studies.
During the exercise 18 victims were evacuated to SUUMC
“Dr Carol Davila”. Of these, 17 were simulated victims (12
red, 3 yellow and 2 green code of emergency) and one was a
real case – one of the volunteers present in the subway
station who presented medical problems requiring urgent
medical attention.
Case managers from different countries supervised the
interventions.
The staff involved in this exercise managed to work in a
coherent way, even when crews were assembled of
members from different countries and different institutions.
Radiotherapy in adrenocortical carcinoma: case report
Remus C. Stoica, Diana A. Mitrea, Răzvan G. Curcă, Alexandra T. Pasăre, Mihai Dumitrache, Ștefănel Vlad
Introduction. Neuroendocrine tumors are comprised from a
broad tumor family, the most common of them are in the
lungs, thymus, pancreas and gastrointestinal tract. Pituitary,
adrenal, thyroid, parathyroid gland tumors are less common.
Adrenocortical carcinoma is a rare malignancy with an
estimated incidence of ~ 0.5 – 2 cases per million people per
year.
Materials and Method. We are reporting a rare case of
adrenocortical carcinoma in a 47 years old female patient,
with uncontrolled systemic blood pressure and a left
abdominal mass, which is displacing the surrounding
structures. After imaging investigations, it was confirmed the
malignant features of the left adrenal mass. In this clinical
case report, the patient was treated with a complete surgical
excision of the tumor, followed by adjuvant radiotherapy.
Results and Discussion. Given its rarity, adrenal carcinoma
has been difficult to study and therefore treat. Surgery is
considered to be the main approach for locoregional control
in early stages, but systemic therapy and radiotherapy, in
advanced tumors or with high-risk recurrence features, are
useful as adjuvant treatments. Modern external beam
radiotherapy, with its recent advances, improves local
control in adjuvant setting.
Follow up appointments, after external beam radiotherapy,
confirmed the normal blood pressure and no evidence of
local recurrence.
Is there still a role for biomarkers in sepsis
Sebastian Dogaru, Bogdan C. Teușdea
The last definition of sepsis (Sepsis 3- 2016) as life-
threatening organ dysfunction caused by a dysregulated
host response to infection is based on qSOFA criteria in order
to help the prehospital and ED teams. It was conceived as a
tool for rapid diagnostic. Although a good working definition,
after the initial enthusiasm, there are more and more
experts saying that the threshold is too high. Waiting until
the quick SOFA criteria should be met in order to diagnose
sepsis it is sometime too late for an increasing number of
patients that are growing older and with a complex adjacent
20
pathology. Although very specific, the last definition is not
very sensitive. The doctor’s goal should be the cure of the
patient, not a specific diagnostic. The 2018 sepsis update
states that the older 3 hour and 6 hour bundles (Sepsis 2)
should be done in 1 hour, meaning that time is critical.
Combining a not so specific score/ criteria with a specific
biomarker in certain circumstances should buy the very
necessary time in order that the patients’ status not to
become critical, life-threatening. Faster the answer, better
the prognosis.
This is why we think that the role of biomarkers in the field
is not an obsolete one and the proactive intervention, early
in the evolution of an infection, would save lives. A
biomarker with good prognostic value should alert the
doctor in charge that more proactive, more aggressive
therapy should be applied earlier in order to prevent the
degradation of patient status. Further research should be
done.
An unusual case of chronic kidney disease with lymphadenopathy
Oana Stancu, Mihai Șotcan, Adrian Anghel, Gabriel D. Stoicescu, Oana Ionescu, Lucian Ciobîcă
We present the case of a patient aged 52 year, extensively
investigated in the nephrology service for a moderate
nitrogen retention syndrome with proteinuria and
polyclonal hypergamaglobulinemia – with the exclusion of
multiple myeloma. Patient is referred to our service for
further investigations in the conditions of persistent
nitrogen retention syndrome which is associated with the
presence of adenopathies in the peripheral ganglion areas.
Serum protein immunofixation is performed, K/lambda
chain ratio – normal, immunogram – negative; increased
rheumatoid factor. Biologically upon admission: moderate
normochromic anemia – osteomedular biopsy was
performed showing a nodular lymphoid infiltrate with small
cells with nodular appearance. Autoimmune disease
investigations was performed with negative results. At the
CT scan, hepatosplenomegaly, peripheral and lumboaortic
adenopathy, minimal bilateral pleurisy, osteocondensating
vertebral lesions and lithic lesion of the left iliac wing are
highlighted. Cardiac ultrasound shows minimal pericarditis
and dilated right cavities with moderate pulmonary
hypertension. The excision of an inguinal adenopathy with a
histopathological examination that detects the
lymphoganglionic Castelman's disease is decided.
Immunohistochemical examination of the lymph node
reveals Castelman Disease with the hyaline-vascular
subtype; chronic sclerogenic reactive lymphadenitis with
Castelman Disease changes. In order to complete the
paraclinic investigations, an osteo-medullary biopsy is
performed, revealing the presence of a plasmocitoid
population, a positive variable at CD 56 invoking the
differential diagnosis of multiple myeloma/POEMS and
dysmegakariopoiesis at differential diagnosis with a
myeloproliferative syndrome - diagnoses that could not be
clinically supported. The final diagnosis was the one of
Castelman's disease type lymphoproliferative syndrome for
which there was a CHOP chemotherapy treatment in 3
sessions: initially with favorable evolution, later with relapse
and deterioration of the general condition with massive
pleurisy and aggravation of renal insufficiency.
Controversy in thrombolysis
Lorena F. Davidescu, Florentina C. Pleșa
Introduction: Stroke is the second leading cause of mortality
worldwide after cardiovascular disease. In Romania, stroke
is responsible for approximately 54,000 deaths annually.
Approved by FDA in 1996, intravenous thrombolysis with
rtPA is addressed to patients with acute ischemic stroke
within the first 4.5 hours after the onset of symptomatology,
in the absence of contraindications.
Objective: Intravenous thrombolysis with rtPT has raised
numerous controversies from the beginning to present and
the aim of our study is to explore them.
Methods: We analised the AHA/ASA asociation and ESO
Guidelines for the Early Management of Acute Ischemic
Stroke and also the most recent PubMed articoles about
controversies in trombolysis.
Results: We took into account the issues regarding the use
of thrombolytic treatment such as: the correct identification
of the acute stroke, considering clinical signs, severity and
atypical presentations, the posibility of extending
Vol. CXXII • Suppl/2019 • October • Romanian Journal of Military Medicine
21
therapeutic window and the presence of relative
contraindications. There is also the debate regarding brain
imaging, because in difficult cases advanced neuroimaging
techniques might be required.
Conclusions: Proper anamnesis, rigorous neurological
clinical examination and complete paraclinical and imaging
investigation ensure strict and adequate selection of
patients with acute ischemic stroke eligible for Alteplase
thrombolytic treatment with a favorable risk-benefit ratio.
Diabetic foot ulcers: new questions, the same problem
Ciprian Constantin, Laura Gagiu, Georgiana Constantin, Oriana Moraru, Cosmin Buzilă
Background: There are quite a number of treatments
available for the management of diabetic foot ulcers (DFUs):
local therapies, vasodilators, antibiotics, neuropathic and
neurotrophic drugs, wound dressings, skin substitutes,
growth factors and inflammatory modulators.
Material and methods: Study of regular Clinical Statements
reveals that American Diabetes Association is the main
professional association that aims to standardize the
intervention to prevent this complication of diabetes
mellitus, but the spread of this disease is the main reason for
increasing incidence and prevalence of minor and major
amputation caused by DFUs.
Results and conclusion: Lower-extremity peripheral artery
disease (PAD) is a complication of diabetes and occurs in 4.3-
29% of all patients, not only diabetics, worldwide.
A new solution is on his way to be aproved: Alpha2C
adrenoceptor (A2Ca). A2Ca is a silent Gi-protein-coupled
receptor stored in the endoplasmatic reticulum (ER) that
implies: a translocation to the cell surface enhances
catecholamine-signaling à vasoconstriction, a execution of
translocation by external stressors (e.g. cold, endothelial
dysfunction), alpha2C adrenoceptor signaling found
preferentially in distal vascular smooth muscle cells, and
could inhibits presynaptic release of norepinephrine and
other neurotransmitters such as dopamine and serotonin.
Will be this A2Ca the solution for this multifactorial problem
or will be a part of this problem?
How easily can the diagnosis of ruptured brain arteriovenous malformation be missed
Ionuț R. Dumitru, Carmen A. Sîrbu
Introduction: Arteriovenous malformations (AVMs) have a
small rate of occurrence, 10% of them being localised to the
posterior fossa (cerebellum). Even though the diagnosis is
relatively easy to establish, an incomplete anamnesis along
with a superficial neurological examination might lead us
towards false conclusions.
Methods and Materials: We’ll present the case of a 23-year-
old man, who arrived at the ER with vomiting, imbalance,
laterodeviation, mild cephalagia and diplopia. We will point
out the errors in diagnosis, from both the prehospital stage
(biliary dyskinesia) and the hospital one (labyrinthitis), and
the way by which the patient, a medical student and
volunteer with the ambulance service, had a decisive role in
solving his own medical case.
Results: The cerebral CT performed showed a spontaneous
hyperdense cerebellar lesion (identified as a tumour, with no
hope in a therapeutic path for the patient!). The MRA, and
especially the “4-vessel” angiogram found a cerebellar AVM
with medium flow, arising from the superior left cerebellar
artery, with drainage through a unique vein in the left
transverse sinus. Considering the characteristics of this
specific case, embolization of the newly formed structure
has been chosen as the preferred course of action, with
optimal results.
Discussion and conclusions: The essential aspect which
raised the patient’s doubts was diplopia. It was this symptom
that caused the complex investigations that preceded the
correct diagnosis. The clinical abilities based on vast medical
knowledge lead to the rational use of paraclinical
investigations and the establishment of correct diagnosis.
22
Fast-track: a new way for rapid evaluation in the ED
Bogdan C. Teușdea, Mihai Toma
Medical triage of the patients admitted into the ED is made
on the basis of specific criteria established by the national
laws taking into account their clinical condition, stability of
vital functions, aggravating potential of their status, the
necessity of starting a treatment or to carry out some
investigations etc. setting up the priorities of the medical
care. There are 5 triage categories/levels that establish
patient’s waiting time, from zero minutes – code red, to
maximum 240 minutes the white code.
Fast-track – a new way for rapid evaluation in ED – Is a new
concept that permits receiving the patients outside the ED,
evaluation (eg. ECG, topical administrations of medications)
and treatment of some types of emergencies (e.g fever,
allergic reaction, dental problems).
Intricate presentation of a novel disease
Raida Stănescu, Alexandra Radu, Andreea Petridean, Florin Rusu, Elena Busuioc
Introduction: IgG4-related disease (IgG4RD) is a fibro-
inflammatory condition that can affect nearly any organ.
Common presentations include major salivary and lacrimal
gland enlargement, orbital disease, autoimmune
pancreatitis, and retroperitoneal fibrosis.
Case report: A 59-year-old female with a history of
schizoaffective disorder was referred to our clinic for
evaluation of elevated levels of serum creatinine. Her
previous lab work also showed a long-standing normocytic,
normochromic anemia, hypergammaglobulinemia and
inflammatory syndrome with a high ESR. At the time of the
referral the patient was unwell, with pale skin and mucous
membranes. Blood work revealed a severe anemia (Hb-
6.8g/dL), hyperkalemia (K-5.72mmol/L), high serum
creatinine (Cr-6.8g/dL), inflammatory syndrome (ESR-
70mm/h, CRP-43.32mg/L), hypergammaglobulinemia
(gamma-24.8%), and high IgG levels (IgG-2374 mg/dL).
Abdominal ultrasound displayed bilateral grade 3
hydronephrosis and a hypoechoic mass surrounding the
aorta and inferior vena cava (IVC). Computed tomography of
the chest, abdomen and pelvis, performed without
administration of contrast material, demonstrated
numerous enlarged retroperitoneal lymph nodes forming an
extensive mass entrapping the aorta, IVC and both ureters.
Bilateral double-J right ureteral catheters were placed with
a good clinical outcome. Bone marrow aspiration and biopsy
revealed 10% plasma cells, while radiographs of the skull,
chest and pelvis showed no lytic lesions. Laparoscopic biopsy
of the retroperitoneal mass was performed in a clinic in Italy
demonstrating storiform fibrosis, lymphoplasmacytic
infiltrate enriched with IgG4-positive plasma cells. A clinico-
pathological diagnosis of IgG4RD was made.
Methylprednisolone 48mg/day was started with favourable
clinical and paraclinical evolution after one month (Hb-
10.3g/dL, Cr-2.27mg/dL, IgG-1816mg/dL, gamma-22.3%).
Conclusion: The present study reports a case of IgG4RD
presenting with hypergammaglobulinemia,
lymphadenopathies and inflammatory syndrome. The
diagnostic challenge of IgG4-RD is generated by the clinical
and laboratory similarities with other hematologic diseases
(lymphoma, plasma cell neoplasms).
The Ketogenic diet: is it suitable for everyone?
Laura Gagiu, Ciprian Constantin
Background: The Ketogenic diet has become very popular in
the last period of time, among both people that are trying to
lose weight but do not have any other comorbidities and
among patients with different types of disease. The
ketogenic diet is based on limiting very much the amount of
carbohydrates (2-5%), increasing lipids (80-90%) and filling
the rest with protein (8-15%).
Material and methods: There are various studies performed
on the ketogenic diet published on NCBI and Medscape that
have proved its benefits but also it’s limits. It is well known
that a diet with low carbohydrate intake can improve
symptoms in epilepsy and that the ketogenic diet has been
included by NICE (the National Institute for health and Care
Excellence) as a treatment option in the Clinical Guidelines
Vol. CXXII • Suppl/2019 • October • Romanian Journal of Military Medicine
23
for Epilepsies. Also, recently it has been discovered that it is
also safe and well tolerated in patients with relapsing
multiple sclerosis by reducing proinflammatory
adipokines.On the other hand low carbohydrate diets have
been proven to increase both cardiovascular and cancer
mortality data that has been presented on the ESC Congress
in 2018.
Results and conclusion: Obesity is a worldwide problem that
affects various aspects of a patient’s life and should be
considered as a disease that can also be prevented. When
prevention fails, losing weight should be the first measure
taken in order to improve the patient’s quality of life. The
ketogenic diet is one of the options that could be considered
but when the decision is taken, all the comorbidities should
be taken into consideration, and the balance between risks
and benefits should lean towards benefits. For example in a
diabetic patient,lowering the carbohydrate intake has been
proven to reduce the glycemic levels but the excess fat has
increased LDL levels which also increases its cardiovascular
risk.
Even though there are both recommendations and
restrictions regarding the ketogenic diet it depends very
much on the patient and its associated diseases and also on
how the doctor can make variations of the diet according to
the patients needs.
suPAR: a biomarker in evaluation of patients with fever
Mihai Toma, Bogdan C. Teușdea
Background: Severe infection can cause sepsis that is a
potentially fatal whole-body inflammation. Biomarkers are
widely used in clinical practice and they are useful for
monitoring the infectious process. Procalcitonin (PCT),
lactate and C-reactive protein (CRP) have been most widely
used, but even these have limited abilities to distinguish
sepsis from other inflammatory conditions or to predict
outcome.
The aim of our study was to investigate the role of new
biomarkers – soluble urokinase-type plasminogen receptor
(suPAR) in patients with fever.
Methods: Between January – July 2019, blood samples were
taken after obtaining informed consent from 45 patients
with fever. We determine five biomarkers: leucocyte,
procalcitonin (PCT), lactate and suPAR. We obtained clinical
data and calculate SIRS and qSOFA score. Statistical analysis
was performed with StatDirect program.
Results: The mean values for the biomarkers were: leucocyte
16038.46/ml, procalcitonin 1.48 µg/ml, lactate 1.34 mmol/l
and suPAR 5.68 ng/ml.
Discussion & conclusions: PCT and CRP are main markers
used in clinical practice and are more useful to rule out
infection. PCT is the most studied biomarker that guides
early stopping of antibiotic therapy in adults. In our study
elevated suPAR was associated with more hospitalization
days, and was much better correlation with elevation of
leucocyte than procalcitonin.
Relationship between HLA-B27 positivity and radiological damages in patients with Ankylosing Spondylitis
Daniela Anghel, Livia Otlocan, Raluca Bursuc, Elena Busuioc, Anca Manolache, Valeriu Smedescu, Maria M. Negru, Cristina F. Pleșa, Ciprian Jurcuț
Background: Axial spondyloarthritis (AxSpA) is a disease
where back pain is the main symptom. The disease can cause
axial-joint inflammation, erosion and new bone formation,
leading to functional impairment. Traditional assessment
tools include Bath Ankylosing Spondylitis Disease Activity
Index (BASDAI) which is designed to assess spondyloarthritis
(SpA) disease activity and daily function. Although this tool is
well validated, the relationships between disease activity,
functional status, axial-joint inflammation and degree of
syndesmophytes formation are more complicated. Studies
showed that disease activity might not correlate with axial-
joint inflammation and functional impairment could be
caused by both axial-joint inflammation and structural
damage of the spine.
Objectives: We are trying to find the prognostic factors for
syndesmophytes formation. So far, the identified potential
risk factors include male sex, human leukocyte antigen (HLA)
B27 positivity, smoking, and an initially raised C-reactive
protein (CRP). As some of the risk factors are potentially
24
modifiable, it would be of interest to know if they will also
apply in our local population. By categorizing a group of
patients with AxSpA, we aimed to describe the clinical
characteristics and their relationships with disease activity,
functional status, and syndesmophytes formation.
Methods: This is an observational and descriptive study of 35
patients with AxSpA recruited from the Department of
Internal Medicine II, “Dr. Carol Davila” Central Military
Emergency University Hospital, from October 2018 to July
2019. Our study aims to determine the changes in magnetic
resonance imaging (MRI) in patients with AxSpA.
Inclusion criteria included diagnosed AxSpA patients with
current back pain. Exclusion criteria included pregnancy and
inability to undergo MRI examination.
Clinical and blood parameters were collected. These
included age, sex, smoking and drinking history, duration of
back pain, location and characteristic of back pain,
extraspinal features, associated medical history, HLA-B27
status, CRP, and erythrocyte sedimentation rate (ESR).
Patients completed a self-assessment questionnaire: BASDAI
– to calculate the Ankylosing Spondylitis Disease Activity
Score (ASDAS).
Radiological sacroiliitis based on the Modified New York
criteria: grade 0, normal; 1, doubtful; 2, obvious; 3, fusion.
Bilateral sacroiliitis grade 2 or above or unilateral sacroiliitis
grade 3 or above was defined as radiological SpA. All patients
had spine and sacroiliac joints MRI.
Results: 35 patients were recruited. Our cohort was
characterized by long disease duration, high disease activity,
moderate functional impairment and significant radiological
damage.
Result 1: High disease activity (main BASDAI=4.28) and high
radiological damages were found on 21 (60%) patients. HLA-
B27 positivity was found in 70.0% of the population. Most of
them were male (75.0%). There were 68% smokers. Average
age was 44.5 year and mean CRP was 9.5 mg/dl.
Result 2: Low disease activity (BASDAI=3.34) and some
radiological damages were found on 5 (14.29%) patients. All
patients were found to have HLA-B27 positivity. All of them
were male. All of population were smokers. Average age was
37.8 years and mean CRP was 0.75 mg/dl.
Result 3: High disease activity (BASDAI=4.87) and minimal
radiological damages were found on 4 (11.43%) patients. All
patients were found to have HLA-B27 positivity. All of them
were female. None of the population were smoker. Average
age was 43.5 years and mean CRP was 5.11 mg/dl.
Result 4: Highest BASDAI (BASDAI=5.41) and some
radiological damages were found on 5 (14.29%) patients. All
patients were HLA-B27 negative. Female patients were
61.9% of the study group. There was no smoker. Average age
was 47.5 years and mean CRP was 5.46 mg/dl.
Conclusions: In a group of patients with long-standing SpA,
we described the clinical characteristics in relation to disease
activity, functional status and radiological damages.
We found that the group of patients with high axial-joint
inflammation and structural damage of the spine were male
smokers with HLA-B27 positivity. The findings correlate with
poor prognostic factors.
In patients with HLA-B27 positive who do not have
radiological changes, it is important to perform MRI for the
diagnosis of ankylosing spondylitis.
By describing different characteristics of patients with SpA in
relations to disease activity, functional status, and
radiological damages, we hope to provide a clearer picture
for rheumatologists to understand and interpret different
clinical parameters and to provide the best management to
patients.
The experience of the Central Military Hospital in the thrombolytic treatment of acute ischemic stroke
Oana C. Tache, Florentina C. Pleșa, Carmen A. Sîrbu, Gabriel Boeru, Cătălin Andrei, Gabriel Ștefănescu, Cristina L. Otavă, Simona Gheorghevici
Introduction: Thrombolytic medication is the Gold Standard
treatment of acute ischemic stroke for eligible patients.
Objective: The purpose of this work is to evaluate the
efficiency of thrombolysis in terms of operation time,
teamwork, evolution, complications and to identify the
dysfunctions, in order to optimize the therapy.
Methods: We analyzed a group of patients thrombolysed in
our hospital, noticing their evolution during the
hospitalization, at one and 3 months after hospitalization,
appreciated by functionality scales. We have also followed
the evolution of thrombolysis over time from its introduction
as a treatment method for stroke.
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The first thrombolysis was performed in 1958 when out of
three patients treated only one presented improvement of
symptoms. Intravenous thrombolysis was initiated in the
clinical neurological activity more than 15 years ago.
Thrombolysis was introduced in the Central Military Hospital
in March 2019 and now we have 10 patients who have
benefited from this therapy.
Thrombolysis is possible with the fast and synchronous
intervention of a team made out of: neurologist, emergency
doctor and radiologist. Considering the hospital’s
compartmental structure, the team spirit is the binder that
leads to obtaining the optimal times.
Thrombolysis had a beneficial effect on the majority of
patients, the disability scores being significantly improved.
The complications were reduced and in the case of death, it
was mainly due to their comorbidities and complications,
not to the thrombolytic treatment.
Conclusion: In conclusion, analyzing the thrombolysis cases
from our hospital, we found a mortality rate of 30%, which
was mainly due to the associated comorbidities. Being still at
the beginning of the road, we cannot compare these results
with those existing in the literature.
Thrombolysis role in the treatment of stroke
Mihaela M. Micu, Pleșa Andreea, Florentina C. Pleșa
Introduction: Stroke is one of the leading causes of morbidity
and mortality worldwide. Stroke is the second leading cause
of dementia and a common cause of depression and epilepsy
in the elderly.
Objective: The purpose of this paper is to present a modern
method for the treatment of stroke: thrombolysis. We will
follow the whole procedure, starting with the onset of the
symptoms and taking into account its indications,
contraindications, risks and benefits.
Methods: We considered the National Protocol for
Thrombolysis and emphasized the importance of correct
diagnosis, proper indication and accurate procedure,
everything happening in the therapeutic window.
The FAST method (Face, Arms, Speech, Time) plays an
important role is early identification of a stroke. Clinical sings
such as: facial asymmetry, inability to raise both arms and
speech problems are warning signals and require a fast
presentation at the emergency room.
Time lost means brain tissue lost. Hypoxia causes irreversible
lesions in the center of the ischemic area. In contrast, the
edges contain neurons that can be saved if the blood flow is
restored timely. Consequently, thrombolysis has the highest
success rate in the first hour, known as the "golden hour".
However, therapeutic efficacy can be achieved up to 4.5
hours after the onset of symptomatology.
Conclusion: Finally, we would like to highlight that
thrombolysis is a modern procedure for stroke treatment,
proved to significantly improve patient evolution. Inter-
clinical cooperation and promptness of intervention
contribute to therapeutic success.
Efficient neuromotor recovery of a young patient with tetraparesis after traumatic vertebral meduller by road accident
Gigi Teodoru, Ovidiu C. Chiriac, Ovidiu S. Indrei
We present the case of a patient aged 35 year, patient
immobilized in bed, with spastic tetraparesis after vertebro-
medullary trauma by road accident, following the local
clinical examination neuro-myo-arthro-kinetic functional,
can make the transfers with help, cannot maintain the short
sitting position at the edge of the bed and verticalization no
was initiated.
For three weeks our medical collentive has progressively
initiated verticalization and displacement with the help of a
new generation device Robogait. Robogait are stationary
gait rehabilitation systems. The Robogait is designed to be
used with patients recovering from traumatic brain and
spine injuries, stroke, neurological or orthopedic causes.
This system provides a safe, controlled environment for gait
rehabilitation over a treadmill. The speed of the treadmill is
synchronized with the exoskeleton and the rehabilitation
program.
The RoboGait reduces the number of physiotherapists
required to work with a patient. The wearable robot
increases the quantity of steps that can be achieved during
26
each training session and ensures that they are all
consistent. In these systems, the patient is suspended on the
walking band and positioned perpendicular to the foot and
connected to the robotic. The physiotherapist will decide
after the examinations that the weight of the body will be
reduced by the device and where the device will contribute
to the walk. In the robotic walking system, the patient is
executed according to the natural walking pattern on the
walking band, while the receiver mounted on the patient's
hips and knees evaluates the response of the body to the
computer and reports to the computer which step is the
problem. When the patient goes out of the normal walking
pattern, the robot automatically corrects walking. Repetitive
gait in robotic assisted walking therapy helps regain the
impaired signal flow due to disease or injury between the
cerebrospinal and muscles. Other benefits of this treatment
include strengthening the muscles in bed-dependent and
non-walking patients, providing circulation in the legs,
reducing bone loss and fracture risk due to movement, and
preventing bed sores and vascular occlusions.
After 9 sessions, the patient moves with help, metal frame,
has considerably improved mobility.
Vol. CXXII • Suppl/2019 • October • Romanian Journal of Military Medicine
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SURGICAL PAPERS
Management of recurrent craniopharyngioma. Case presentation and literature review
O.M. Sîrbu, Alin V. Chirteș, A.M. Sîrbu, Adina Mazilu, Marian Mitrică
Craniopharyngioma, described by Cushing as ‘‘one of the
most baffling problems which confront the neurosurgeon’’,
account for less than 5% of all intracranial tumours. They are
derived from remnants of Rathke's pouch along a line from
the nasopharynx to the diencephalon. Although
histologically benign they may be locally aggressive and their
close proximity to vital structures such as the hypothalamic–
pituitary axis, thalamus and optic apparatus makes them one
of the most challenging pathologies in neurosurgery.
We present an ilustrative case and an updated literature
review of the management options following unsuccessful
initial surgery or recurrence.
Treatment options for recurrent craniopharyngioma include
repeat surgery, radiotherapy or intracystic procedures.
Several small retrospective studies suggest that rates of
obesity and diabetes insipidus related to hypotalamic
injuries may be lower in patients treated with more
conservative surgical approaches. Prospective studies with
long-term follow-up are still needed.
Contemporary radiotherapie techniques (stereotactic
radiotherapy, intensity-modulated radiation therapy, proton
beam therapy) permit greater treatment precision and
conformity but do not eliminate long-term toxicity.
With intracavitary chemotherapy experience is more
limited. Bleomicin and interferon alfa have been reported in
some centers with promising results.
An experienced multidisciplinary team (neurosurgery,
radiotherapie, neuro-oncology, endocrinology,
ophthalmology) is essential for the optimal management of
craniopharingiomas. Future treatment with neoadjuvants
chemotherapy and minimal surgical resection in order to
preserve neurological status may improve the outcomes of
these patients.
Approaches in anterolateral abdominal wall defects
Costin Duțu, Mădălina Vlad, A. Luchian, Ovidiu Albița, Cristian Mușat, Remus Nica, Teodor Rogin, Cristian Cîrlan, Florin Săvulescu
The treatment of anterolateral abdominal parietal defects is,
in most cases, surgical. Surgery can be performed open or
minimally invasively.
The open procedure consists in repairing parietal defect,
followed by the reinforcement of the wall by placing a
consolidation mesh (preaponeurotic / preperitoneal
placement). In the last years, the laparoscopic minimally
invasive procedure e-TEP has been developed, through
which small incisions of maximum 10 mm are practiced and
an intraperitoneal or retromuscular mesh is installed to
prevent recurrence. The study analyzed data from 180
patients with abdominal wall defects whose surgical
treatment was performed, through the different approaches
already mentioned, during one year in the Second
department of general surgery.
The age, weight, BMI, ASA score, defect size and placement,
the size and nature of the mesh used, intraoperative blood
loss, duration of the intervention, duration of
hospitalization, association of diastasis or visceral lesions,
the frequency and type of perioperative complications, the
quality of the postoperative life, the time required for
recovery and social reintegration were analyzed and
compared.
The conclusions of the study revealed the advantages of
minimally invasive procedures (rapid postoperative
recovery, decreased postoperative complications, aesthetic
role, and rapid recovery of social and professional activities.
On the other hand, in case of bulky abdominal eventrations
28
associated with a reduced medical education, the role of
open procedure is important, especially in the emergency
situations and associated lesions.
“Upside-down stomach”: a rare complication of hiatal hernia
Rareș Munteanu, Roni Gherghinoiu, Aurelian Sfetcu, Dumitru Lăcătușu
Hiatal hernia represents the stomach’s protrusion in the
chest through the esophagus diaphragm Hiatal hernia can
be: slip (cardia is in the chest), rolling (esogastric junction
remains in the abdomen) or mixed form. A special form is
hiatal hernia complicated with axial organ gastric (upside-
down stomach). After a review of the specialized literature,
we present the case of a 55-year-old patient who has
emerged urgently in the emergency room for dysphagia,
vomiting, nausea, palpitations. Standard radiological
examinations with contrast substance and computer
tomography revealed giant hiatal hernia mixed form and
gastric volvulus (upside down stomach). After usual
preparing the patient for surgery, the laparoscopic
intervention occurred, the hernia was reduced, the
diaphragm opening was recalibrated (pile suture), after
which an antireflux procedure (Nissen fundoplication) was
performed. The postoperator was subjected to radiological
control with the contrast substance, the patient being exited
7 days postoperatively.
Enucleation of huge symptomatic liver hemangioma
Liviu Mosoia, Florin Macău, Traian Calu, Tanita Stancu
Objective: The cavernous hemangioma is the most common
benign tumor of the liver and become symptomatic as it
reaches a certain size. Giant hepatic hemangiomas greater
than 20 cm in maximum diameter are often reported. Tumor
resection or enucleation is tratment of choice for
symptomatic hemangioma.
Materials & methods: A 41-year-old female presented with
symptomatic huge hemangioma of the liver was treated by
enucleation.
Results: The surgical indication was abdominal pain,
complaints of a 4.5-kg weight loss, fullness in the right upper
quadrant and increased abdominal girth. The tumor size was
24 x 18x 14cm.
Technical aspects were analysed.
The postoperative period was uneventful and the hospital
stay was 5 days. Follow up imaging controls showed no
recurrences.
Conclusion: Abdominal pain and enlargement are major
surgical indications of symptomatic giant hemangiomas.
Most of the symptoms disappear after the surgical
treatment. Enucleation is the best surgical tehnique for
management of symptomatic giant hemangioma.
eTEP in linea alba defects repair surgery
Costin Duțu, Mădălina Vlad, A. Luchian, C. Blăjuț, M. Iordache
eTEP (Extended-View Totally Extraperitoneal) technique was
initially used for minimally invasive approach for inguinal
hernia, but it was also applied for minimally invasive
surgeries for linea alba defects, diastasis and ventral
abdominal wall eventrations. We aim to present the initial
results of patients with linea alba defects, diastasis and
ventral abdominal wall eventrations for whom minimally
invasive treatment was performed using eTEP technique.
A prospective analysis of cases with linea alba defects,
diastasis and ventral abdominal wall eventrations with eTEP
repair, made between October 2018 and May 2019 by two
operating teams, in a single center was made. All patients
were followed postoperatively for 2 months.
Patient history, defects characteristics, technical details of
interventions, perioperative complications and quality of life
outcomes were included in data analysis. The results of the
Vol. CXXII • Suppl/2019 • October • Romanian Journal of Military Medicine
29
case series were analyzed in detail.
The synthetic graft had dimensions between 10x10 cm and
20x30 cm. The mean duration of the intervention was 148
minutes, the intraoperative blood loss was 74.16 ml and the
mean duration of hospitalization was 3.2 days. The
peritoneum was opened in 80% of cases.
Only one case required conversion to laparoscopic surgery -
the IPOM + technique. Postoperative complications were
not significant and the quality of life was clearly improved
after surgery (California Comfort Scale). Mean costs of
intervention were lower in case of eTEP surgery than open
or laparoscopic techniques. There were none readmissions
in the first 30 days after the surgery.
The feasibility and advantages of this technique were
highlighted on initial evaluation: decreased postoperative
pain, low rates of postoperative complications, rapid
recovery of social and professional activities and reduced
mean costs than IPOM+ laparoscopic technique (due to the
abandonment of using Dual Mesh graft) and open technique
(due to decrease hospitalization duration). We intend to
further analyze these data on a larger number of cases.
Glioblastoma multiforme (grade IV)
Cristian Năstase, Cristian Popescu
Introduction: The most malignant astrocytoma and the most
common primary brain tumor. Histopathologycal pattern:
areas of necrosis, neovscularisation with endothelial
proliferation, gemistocytic astrocytes etc
Material and methods: We would like to present you our
experience in treatment of this kindes of tumors. We
operate more 1oo patients with GBM in our service and
some of them survive more 3 years with adjuvant treatment
(radiotherapy, chimiotherapy, etc).
Prognostic: Survival is highly dependent on condition at the
time of surgery
Results: Anaplazic astrocitoma & GBM has severe prognosis;
Neuroimaging: MRI – main tool; Mass effect: emergency
intervention; Radiotherapy & chemotherapy: limited effect.
Breast cancer: where are we and what can we do
Remus I. Nica, Cristian J. Mușat, Doriana Vintilescu, Florina Vasilescu
Introduction. In Romania breast cancer accounts for 25% of
all cancer cases and it is responsible for 1.56% of the total
number of deaths. The genetic factors known to be involved
in breast cancer risk comprise several high or moderate -
penetrance genes and a high number of low-penetrance
genes.
Aim. In this study we would like to present some
representative cases of breast cancer that were
encountered in our clinic and results regarding the
interactions between low penetrance risk factors in the
sporadic forms of invasive ductal carcinoma.
Materials and methods. Approximately 70% of investigated
subjects had invasive ductal carcinoma. Women with
invasive ductal carcinoma (n=125) and clinically healthy
subjects without history of malignant disease (n=150) were
selected for a case-control study. Mutations in six low-
penetrance genes were determined for each sample.
Multifactor Dimensionality Reduction analysis was used to
investigate the epistatic relationships between the tested
variables.
Results. The birth of the first child after age 30 (p <0.01) was
the main non-genetic risk factor associated with breast
cancer. The simultaneous presence of TGFb -509T and IL6 -
174C (p <0.01) was a risk factor for invasive ductal carcinoma
in the studied group.
Conclusions. The interaction between different categories of
risk factors can increase the risk for sporadic forms of breast
cancer. The birth of the first child after the age of 30 is a
significant risk factor for the disease.
30
Combined dermato-surgical techniques in treating rhinophyma
Viorel Trifu, Monica Dărmănescu, Marcela Poenaru, Mihai Țilea, Răzvan Șerban
Rhinophyma is a slow evolving pathology that affects the
nose (rhis' - nose; phyma - grows) and it represents the final
stage of rosacea. It is characterized by a cauliflower-shaped,
bulbous, thickened skin, erythematous, edematous,
enlarged sebaceous glands accompenied by sebum plugs.
It mainly affects men starting at the age of 45 and can also
affect other regions such as chin (gnatophyma), ears
(otophyma), eyelids (blepharophyma) and forehead
(metophyma)
Non-surgical treatment of rhinophyma consists of a
prophylactic approach aimed at patients with rosacea but
there are various systemic and topical treatments which can
be used to lower the volume in the early stages of
rhynophyma.
Surgical approach represents the gold-standard in treating
Rhinophyma by using combined techniques in order to
obtain a favorable result. Among the methods used we
mention dermaplaning, dermabrasion, electrotherapy, CO2
Laser, Nd: YAG, Er: YAG, cryosurgery.
The cases selected in this presentation are of patients with
rhinophyma of different severity grades who have been
treated in the Dermatology Clinic.
Rhinophyma is a condition that affects the quality of life,
especially regarding its social impact, as patients often
report social isolation, especially because of their physical
appearance, which can be corrected by proper
dermatological and surgical treatment.
Remnant cystic duct: cause of post cholecystectomy syndrome
Ovidiu Albița, Teodor Rogin, R. Marin
Remnant duct pathology represents a rare evolution of the
disease after cholecystectomy, caused by anatomo-clinical
details at primary surgery, open or laparoscopically. Usually
symptoms are discordant to imagistic exploration. However
only a new operation, although technically demanding,
provides very good results.
Foreign body in the hypopharynx: surgical approach
Claudiu Nistor, Daniel Pantile, Adrian Ciuche
Introduction: While pharyngeal foreign bodies are a
common complaint in children, for adults this is a relatively
rare condition, which can be resolved endoscopically in a
majority of cases.
Material and method: We present the case of a young
patient with complete dysphagia, sialorrhea, odynophagia,
and a sensation of foreign body. The symptomatology
appears after ingesting a foreign body on an otherwise
normal esophagus.
Paraclinical investigations (cervico-thoracic X-Ray, cervical
and thoracic CT scan) highlight some foreign body in the
hypopharynx. Superior endoscopy and laryngoscopy do not
visualize the foreign body, only some erythema on the
hipopharinx.
Endoscopic extraction of the foreign body has been tried,
with no results. Considering this situation, the surgical
approach has been decided, through a slightly atypical
approach – right side approach, the foreign body being on
the right side of the esophagus.
Results: Intraoperative, the foreign body is identified in the
right esophageal wall, puncturing the esophageal mucosa.
With favorable postoperative outcome, the patient showed
no signs of mediastinitis or esophageal fistula.
Discussion: For most cases of foreign bodies stuck in the
hypopharynx, superior endoscopy is 80-100% efficient in
extracting the foreign body. In the presented case, nor the
endoscopy or laryngoscopy succeeded extracting it. The
surgical intervention was the final, salvatory, solution.
Conclusions: Endoscopic treatment remains the mainstay
treatment for most ingested foreign bodies. This patient
required surgical intervention because of the impossibility to
visualize the foreign body through an endoscopic procedure.
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A rare case: vulvar extra-mammary Paget’s disease
Alexandra T. Pasăre, Răzvan G. Curcă, Remus C. Stoica, Ștefănel C. Vlad
Introduction. Paget's disease of the vulva is a rare vulvar
neoplasm most commonly seen in Caucasian
postmenopausal women. Probably because of its
multicentric nature, Paget's disease has a chronic and
relapsing course. Surgery is the treatment of choice, but the
disease can extend from the visible lesion and the surgical
margins are frequently positive.
Materials and methods. This is the rare case of a 50 year old
patient, known with vulvar Paget’s disease since 2010. She
underwent large wide excision of the left labia, with clear
surgical margins and a good postoperative evolution. After
nine years, the disease relapsed and the proposed treatment
was left hemivulvectomy, followed by adjuvant external
beam radiotherapy.
Results and discussions. The standard of treatment for vulvar
Paget’s disease has been surgery with the control of the
surgical margins, but given the fact that the positive margins
and recurrence rates are greater than 50%, combined
treatments have been proposed. Radiotherapy can be used
as a curative treatment or in an adjuvant setting to prevent
local recurrence. After the combined treatment, the follow
up showed minimal adverse effects after radiotherapy, with
good local control of the disease.
Giant left ovarian fibroma: Demons-Meigs Syndrome in a 69-year-old female patient
Ioana A. Negoiță, Nicolae Niculescu, Bogdan Panaite, Florin Năftănăilă-Mali, Ioana Niculescu, Ovidiu V. Nicodin
Goals: Among the different types of ovarian tumours,
ovarian fibromas are mostly silent tumours, without clinical
impact (especially when they are small in size), being non-
functional tumours. There are cases that can show sterility,
compression disorders, dysmenorrhea, secondary
amenorrhea, and in cases of solid ovarian tumours, they may
associate Demon-Meigs Syndrome. The diagnostic
orientation is based on clinico-biological, imaging and
anatomo-pathological elements. Demons-Meigs Syndrome,
first described in 1937 by Professor Joe V. Meigs, is defined
as an association of a benign ovarian tumor (ovarian fibroma
or thecoma) complicated by hydrothorax (most commonly
on the right side) and ascites in large quantities. Surgical
removal of ovarian formation leads to disappearance of
ascites and hydrothorax.
Summary: The authors present the case of a 69-year-old
female patient, with multiple pathology (cardiac, pulmonary,
diabetes mellitus, gastroduodenal), who came to the ED of
the SUUMC for general condition worsened in the last days,
showing severe dyspnea, increased volume of the abdomen,
epigastralgia. It will be presented the manner of approaching
this case, from hospitalization and its evolution.
To be retained: 1. Meigs Syndrome is a challenge in
establishing differential and certainty diagnosis. 2. The
therapy of choice remains surgical resection, either
ovariectomy/adnexectomy/tumorectomy or, at
postmenopausal ages, total hysterectomy with bilateral
adnexectomy. 3. The ascites and the hydrothorax remit after
surgical treatment. 4. The prognosis in Demons-Meigs
Syndrome is a very good one.
Liver resection for huge hepatocellular carcinoma in non-cirrhotic liver
Liviu Mosoia, Florin Macău, Traian Calu, Tanita Stancu, Marian Vasile
Objective: HCC in non-cirrhotic liver has low prevalence and
tumor size may be large at an advanced stage as surveillance
is not performed in a non cirrhotic liver. Tumor resection is
the only curative treatment if resecability criteria are
achieved.
Materials & Methods: Three patients with huge HCC (18, 20
and 23 cm) underwent liver resection in our department. In
one patient, due to the insufficient future liver remnant, we
performed right portal vein ligation (PVL) in the first
instance, to convert the unresectable tumor to resectable
for potential cure. Technical aspects were analysed.
Results: One patient underwent right hepatectomy after 7
weeks after PVL; the others underwent right hepatectomy
resection. In the patient with the biggest tumor (23/20 cm)
32
we used anterior approach and the hanging manoeuvre due
to the huge volume of the tumor. The postoperative period
was uneventful and the hospital stay were 7 to 9 days.
Histopathology revealed in one patient a mixed off HCC with
cholangiocarcinoma and all the patients are alive, disease
free currently.
Conclusion: Surgical resection for huge HCC in non cirrhotic
liver is possible even in elderly patients or even if initially, the
future liver remnant does not allowed surgical therapy.
Minimally invasive approach for anterior flail chest
Claudiu Nistor, Dragoș Marin, Aurora Fera, Daniel Pantile, Adrian Ciuche
Introduction: Anterior flail chest is a life-threatening medical
condition that occurs when a segment of the rib cage breaks
due to trauma and becomes detached from the rest of the
chest wall. Over time several stabilizing methods have been
imagined.
Material and method: We present a method of stabilization
for anterior flail chest using the minimally invasive repair
procedure for pectus excavatum – Nuss procedure.
This procedure consists of a concave stainless-steel bar
slipped under the sternum fixed by a stabilizer fitted around
the bar and into the ribcage.
Preoperative CT scan with 3D bone reconstruction helps the
surgeon decide the best position for the stainless-steel bar.
The surgical intervention is performed under thoracoscopic
control.
Results: The results were very good in both patients. The
patients were extubated immediate postoperative, followed
by respiratory recovery.
Discussion: Although our experience is limited to just two
cases, postoperative results were encouraging in both cases.
Each time patients were extubated immediately
postoperative, and the paradoxical movement of the rib
cage disappeared. The stainless-steel bar was removed 2-4
months after surgery, with a good quality chest wall
stabilization.
Conclusions: The results obtained using this method of chest
wall stabilization were encouraging. Patients’ recovery is
quick and of good quality. By being a minimally invasive
procedure, esthetic results are far superior, and patients’
mobilization can begin early.
Functional and reconstructive otologic surgery in private medical centers
Vasile Ciuchi, Oana I. Popa
Purpose: Otologic surgery without hospitalization or
involving one day hospitalization applied in external and
middle ear pathology, except oncologic disease, represent a
new approach in the practice of E.N.T. speciality.This new
approach in functional and reconstructive otologic surgery
became widespread due to the occurrence of private
medical centers which offers possibilities of investigation
and modern treatment.
Methods: The authors present the experience of 12 years
and 8 months of activity in two private medical centers,
where they performed numerous surgical interventions of
external and middle ear. They present the most commonly
addressed diseases as well as surgical techniques and some
useful conclusions for otologic surgeons in training.
Imagery in diagnosis of anterior segment pathology
Mihail Zemba, Ovidiu Mușat, Cornel Ștefan
Purpose: to show the usefulness of imagery
Methods: some clinical cases are presented, insisting on how
imagery was essential in establishing the diagnosis or the
therapeutic attitude
Results: lack of imagery would have done establishing of a
proper diagnosis much more difficult
Conclusions: though clinical examination is simple, some
particular cases with anterior segment pathology need
additional investigations, every methods with its indications
and limits
Vol. CXXII • Suppl/2019 • October • Romanian Journal of Military Medicine
33
Therapeutical approach for right pulmonary artery aneurysm: case presentation
Claudiu Nistor, Olivia Batog, Daniel Pantile, Adrian Ciuche
Introduction: Aneurysms of the pulmonary artery are rare
and often underdiagnosed. Pulmonary artery aneurysms
generally occur in a younger age group than aortic
aneurysms with an equal sex incidence, affecting main
branches of the pulmonary artery.
Material and method: The authors present a case of a
patient admitted with small efforts dyspnea for a round, well
defined lung tumor, located in the right lower lobe.
Paraclinical investigations are described and the surgical
intervention has been recommended in order to remove the
tumor.
Intraoperative, the surgical team has identified the tumor as
a pulmonary artery aneurysm and an arterio-arterial shunt
between the systemic and pulmonary circulation. Right
lower lobectomy has been performed with the removal of
the aneurysm.
Massive hemorrhage was imminent until the aneurysm has
been removed.
Results: The postoperative outcome was favorable, with the
remission of dyspnea.
Discussion: Despite modern diagnostic methods, there is no
clear guideline for the best therapeutic approach, and there
is limited experience because of the infrequency of the
disease. Overall, idiopathic pulmonary artery aneurysm
seems to be a relatively benign condition, and clinical
manifestations are dominated by refractory dyspnea.
Conclusions: Pulmonary artery aneurysms seldom occur, are
rarely diagnosed, and do not present with distinct
symptoms. Although there are no clear guidelines on the
optimal treatment for patients with pulmonary artery
aneurysms because of the small number of cases, surgical
treatment remains an important approach, especially in
symptomatic patients.
Thoracic oulet syndrome: case presentation
Daniel Pantile, Adrian Iordache, Claudiu Nistor
Introduction: The cervical rib represents the elongated
costal element of the seventh cervical vertebra. It’s an
important cause of thoracic outlet syndrome. Bilateral
cervical ribs are very rare, with an incidence of less than 1%.
We chose to present this case to highlight the possibility of
bilateral cervical ribs as a cause for thoracic outlet syndrome.
Material and method: We present the case of a 32-year-old
patient, referred to our department with pain in right
shoulder and arm, debuted a year prior to her presentation.
The cervical X-Ray revealed bilateral cervical ribs; on the
right side the rib being fixed to the first rib. Doppler
ultrasound shows bilateral subclavian shunt, more
important on the right side. MRI imaging showed right
brachial plexus compression.
The surgical intervention was performed under general
anesthesia, through an anterior cervical approach.
Intraoperative findings: cervical rib, fixed to the first thoracic
rib; the cervical rib has been completely removed.
Results: Postoperative outcome was satisfactory, the patient
began recovery the third postoperative day. Patient’s
symptomatology has decreased gradually, and 5 months
postoperative the patient’s sole complain was a mild right
arm paresthesia. Doppler ultrasound performed
postoperative shows great improvement in subclavian artery
blood flow.
Discussion: Although a congenital condition, the cervical rib
becomes symptomatic at the age of 20-25 years old. The
cervical rib is more frequent in women, on the left side; the
right cervical rib is more often symptomatic – especially in
right-handed people. After the resection of the cervical rib,
the symptomatology gradually decreases.
Conclusions: While a rare condition, bilateral cervical ribs
must be considered in differential diagnosis of upper
member neurological pain. Sometimes a cervical rib can
mimic cervical radiculopathy and myelopathy.
High index of suspicion and detailed clinical evaluation is
needed to prevent inappropriate cervical spine surgery!
34
Proliferative diabetic retinopathy: surgical treatment
Ovidiu Mușat, Cornel Ștefan, Mihail Zemba, Monica Armegioiu, Liliana Pulbere, Horațiu Manole, Laura Macovei, Cătălin Cornăcel
This paper presents the case of a patient with neglected type
I Diabetus Mellitus and Proliferative Diabetic Retinopathy.
Posterior vitrectomy was practiced with peeling of
membranes and silicone oil endotamponade. Postoperative
evolution was favorable.
We will also discuss several treatment options for this type
of cases.
Corneo-conjunctival tumor: diagnostic and therapeutic challenges
Mihail Zemba, Ovidiu Mușat, Cornel Ștefan, Alexandra Calu
Purpose: to show the diagnosis, preoperator assessment and
surgical treatment for a corneoconjunctival tumor
Methods: there is a review of clinical and paraclinical
arguments for the diagnosis; surgical solution is shown in a
video film
Results: two months postoperatively there is good functional
recovery; 4 months postoperatively there is no sign of
relapse of the tumor
Conclusions: the main treatment for corneoconjunctival
tumor is surgical; in very large tumors the surgeon must be
able to cover the area of conjunctival excision and use
solutions to prevent relapse.
Malignant insulinoma: Therapeutical approach
Tanita Stancu, Augustin Dima, Cezar Bețianu, Florina Vasilescu, Aurelian Ranetti
Introduction: Malignant insulinoma is very rare (1-
4/100,000) and the most common pancreatic
neuroendocrine tumor. Originated from B-pancreatic cells
which synthesize and secrete insulin. Diagnostic is based on
clinical symptoms and signs (Whipple triad) and it is
confirmed by CT Scan/RMI.
DESCRIPTION: We will report the case of a young man 44 y.o.
BMI: 27 kg/m2, diagnosed by classical signs and symptoms,
confirmed by CT Scan, with a large tumor in the body of the
pancreas, with metastatic lymph nodes, without any distant
metastasis. The patient underwent minimally invasive
surgical treatment (laparoscopic distal spleno-
pancreatectomy with extensive lymph node dissection)
The postoperative course was uneventful and the patients
was discharged in the the tenth postoperative day. The
anatomopathological report confirmed the malignant
insulinoma with multiple lymph nodes metastasis and R0
resection.
Conclusion: The surgical treatment is the only curative
treatment with a good survival rate at 5-10 years. Minimal
invasive approach is recommended and feasible in
specialized centers in pancreatic surgery.
Laparoscopic hepatic left lateral sectionectomy: How I do it
Augustin Dima, Tanita Stancu, Șerban Spiratos, Cezar Bețianu
We present a video case of a 72 y.o. man admitted to our
surgical unit for left hepatic lobe hepatoceular carcinoma.
Patient has HCV cirrhosis Child-Pugh A diagnosed in 2010 for
which he was treated with Viekirax, Exviera and Rivabirin
between Oct. 2016 - Jan. 2017. AFP is not elevated. Hepatic
ultrasound with enhanced contrast and CT scan strongly
suggests an HCC located on the lateral section of the left
liver. No previous abdominal surgery. According to our
multidisciplinary team is proposed laparoscopic left
lobectomy. Pringle maneuver was not performed, blood
transfusion was not required. Postoperative course was
uneventful. In our experience, minimally invasive resection
Vol. CXXII • Suppl/2019 • October • Romanian Journal of Military Medicine
35
in cirrhotic liver should be performed in selective patients
and by an experienced team in hepatic surgery.
Radical antegrade modular pancreatosplenectomy for borderline resectable pancreatic cancer
Augustin Dima, Tanita Stancu, Cezar Bețianu, Delia Mateescu
Introduction: Radical antegrade modular pancreato-
splenectomy (RAMPS) was first reported by Strasberg in
2003 and since then has attracted increasing attention in the
treatment on left sided pancreatic cancer. There is not
enough data in literature to sustain the efficacy of RAMPS vs.
standard approach.
Discussion: We report a 72 y.o man BMI: 24kg/m2,
diagnosed with border-line resectable left side pancreatic
adenocarcinoma who underwent before surgery 6 courses
of neoadjuvant chemotherapy based on FOLFIRINOX
regimen, with decreased tolerance. We performed RAMPS
with en block mezenteric-portal vein confluence resection
and venous reconstruction by interposition of left renal vein
graft. The postoperative course was uneventful. The
anatomopathological report concluded the R0 resection
without any lymph node metastasis.
Conclusion: The patient was able to resume postoperative
chemotherapy with the same regimen at two months after
surgery. The RAMPS procedure for the treatment of border-
line resectable left sided pancreatic cancer can achieve high
rates of R0 resection and is the best option to choose when
vascular resection is required.
Locally advanced/border-line resectable pancreatic cancer: A challenge for the surgeon
Augustin Dima, Tanita Stancu, Șerban Spiratos, Cezar Bețianu, Theodor Voiosu
Introduction: Pancreatic cancer is the fourth leading cause of
cancer death in the world. Median survival for patients
treated by surgical resection is 15-23 months, with a five
year survival <20%. Even though over the past decade
improvements in diagnostic, imaging and treatment, the
overall survival rate remains poor.
Discussion: In both border-line and locally advanced
pancreatic cancer, the tumor is localized to the pancreas but
adheres to or invades adjacent vascular structures, including
the celiac axis vessels, superior mesenteric artery, superior
mesenteric vein, and portal vein. Patients with border-line
and locally advanced pancreatic cancer represent a special
subset of patients who are not candidates for primary
surgical resection and there is now emerging consensus that
a subgroup of patients’ poor candidates for surgery may
become eligible for resection after neoadjuvant
chemotherapy.
Conclusion: Current studies suggest that 25-30% of initially
border-line respectable pancreatic cancer may become
candidates for resection following neoadjuvant
chemotherapy. Lack of consensus definition and the paucity
of randomized trials in therapeutic algorithms have delayed
the progress of proposing good practice guidelines for
diagnosis and treatment.
Reconstruction of the forehead and temporal area
Viorel Trifu, Monica Dărmănescu, Țilea Mihai, Marcela Poenaru, Răzvan Șerban
Surgical approach of the forehead and temporal area poses
several unique challenges for the dermatologic surgeon. A
thorough understanding of the anatomic structures of the
forehead and temporal area is paramount to optimal surgical
result.
A case series of regional reconstruction of forehead and
temporal area is presented, with a variety of reconstructive
techniques. The anatomy of the region is reviewed; it is
important to preserve the function of motor and sensory
nerves, although aesthetic concerns are of great importance
in forehead and temple reconstruction. For optimal
operative results, flaps must be properly sized in all
dimensions, including thickness. In forehead and temporal
reconstruction with skin flaps, the surgeon should anticipate
36
secondary motion accurately, as not distorting anatomic free
margin. Respecting the normal position of facial landmarks
such as the eyebrows and hairline can be challenging during
reconstruction.
The goals of reconstruction include hiding incisions in natural
rhytids, maintaining natural hairlines and eyebrows and
preserving motor and sensory function.
The reliability of the radial forearm free flap for intraoral reconstruction
Dragoș Muraru, Iulia Muraru, Ioana Tuhar, Ionuț Guzganu, Paul Ionescu, Liliana Moraru, Adrian Gabără, Ana Căruntu, Bogdan M. Marinescu
Introduction: Head and neck defects after tumor resection
can be difficult to reconstruct using autogenous tissue
without utilizing a free flap. The radial forearm free flap is
one of the workhorse flaps used for reconstruction of
intraoral defects after resections due to malignancy.
Objective: The aim of this paper is to emphasize the
reliability of the radial forearm free flap, by presenting our
clinical experience and results.
Methods: Three patients with intraoral carcinoma have been
reviewed, one with floor of the mouth and buccal mucosa
defect and two with hemiglossectomies. They underwent
immediate reconstruction using fascio-cutaneous free flaps
from the radial forearm. In all cases we used one of the radial
comitant veins for the venous T-T anastomosis with the
facial vein.
Results: There weren’t any microvascular failures, the
intraoral healing time was reduced to 10 days on average
and hospitalization was less than two weeks. Two donor
sites with width less than 4cm underwent direct closure and
one was grafted with an autograft harvested from the
ipsilateral thigh. The donor site healed uneventfully in all
patients.
Conclusion: The radial forearm free flap is a very effective
method for reconstruction after resection of intraoral
malignancies.
Postmastectomy breast reconstruction with autologous tissue in previously irradiated patients
Bogdan M. Marinescu, Ioana Tuhar, Ionuț Guzganu, Paul Ionescu, Dragoș Muraru
Introduction: Breast cancer represents the most common
cause of cancer death among women worldwide.
Mastectomy is an important tool in breast cancer therapy, in
order to prevent any possibility of disease recurrence. After
mastectomy, we can rebuild the shape and the volume of the
breast, by using various techniques of breast reconstruction,
including implants, skin expanders, reconstruction with
autologous tissue (flaps), combination of implants and flaps.
The reconstructive procedure can be made at the same time
as the mastectomy or later on.
Material and method: In these paper, we will present our
experience by using latissimus dorsi and transverse rectus
abdominis myocutaneous flaps in breast reconstruction. In
the last 2 years, 15 patients underwent breast
reconstruction with 10 LD flaps – 8 unilateral and 1 bilateral,
7 TRAM flaps – 5 unilateral and 1 bilateral. In mastectomy
patients reconstructed with LD flap, we use implants
underneath the muscle flaps, in order to obtain adequate
volume for the reconstructed breast. All the patients
received adjuvant radio-therapy before reconstruction. We
perform in all patients delayed breast reconstruction. Donor
sites were closed primarily.
Results: In our case series all flaps survived. There was just
one case of partial flap loss (TRAM flap group). The
reconstructed breasts have a natural shape, volume and
contour. Donor sites morbidity were acceptable with no
significant functional loss. There are no major complications
and the patient satisfaction was high.
Conclusions: A large variety of techniques are now available
for breast reconstruction. Among the possibilities for breast
reconstruction, the transfer of autologous tissue from
adjacent regions to the breast, keeping up the original blood
supply is a good option for previously irradiated patients.
Vol. CXXII • Suppl/2019 • October • Romanian Journal of Military Medicine
37
Cataract following penetrating keratoplasty
Mihail Zemba, Ovidiu Mușat, Cornel Ștefan
Purpose: to discuss about ethiology and specific issues of
surgical technique in a case of cataract after keratoplasty
Methods: evolution and surgical solutions for management
of the case, starting with deep corneal ulcer
Results: after four surgeries, visual acuity is 0.5
Conclusions: multiple surgeries may be necessary for a good
visual result
Corneal transplantation: permanent challenge for ophthalmologist surgeon
Mihail Zemba, Ovidiu Mușat, Cornel Ștefan
Corneal transplantation is a complex and multi-step surgical
procedure, it is a permanent challenge for ophthalmologist
surgeon. Most often the procedure is done for optical
purposes. Corneal transplantation is constantly undergoing
changes in surgical technique. In Romania corneal
transplantation has a long history and in 1983 the first
corneal transplant was performed in a child of one and a half
years old. We will present this clinical case after 35 years.
The monitoring and treatment center of the glaucoma: the computerized program
Ovidiu Mușat, Cornel Ștefan, Mihail Zemba, Horațiu Manole, Liliana Pulbere, Laura Macovei, Monica Armegioiu, Cătălin Cornăcel, Elena Gosav, Nicolae Alexe, Cristina Timaru
The monitoring and treatment center of the glaucoma in
Central Universitary Emergency Military Hospital is a
necessity because Glaucoma is increasing in number of
cases, early onset glaucoma (when the disorder appears
before the age of 40) and the methods of diagnosis and
treatment are constantly upgraded.
The computerized program is useful for building the
database, interconnecting diagnostic terminals including
imaging with end-scopes - determining the algorithm of
treatment.
In the modern era of AAA treatment is still open surgery the gold standard
Ionel Droc, Mihai Dumitrașcu, Cosmin Buzilă, Tudor Păduraru
Endovascular repair has emerged as an alternative to open
repair for patients with abdominal aortic aneurysm.
Although the method’s safety and efficacy have been
established, challenging anatomy and especially inadequate
landing zones create limitations to its application. Stent
grafts, fenestrated and branched, were developed to
overpass these anatomic restrictions. Contrast-enhanced
Ultrasound (CEUS) is investigated as a novel, noninvasive
technique that can be employed to characterize endoleak
type and consequently prescribe appropriate treatment in
the follow up of this procedures.
Open repair is a safe and durable procedure. But it has some
long term complications as graft thrombosis, infection or
paraanastomotic aneurysms. Aorto enteric fistula is a rare
but difficult to treat complication. Also open surgery is used
for graft explantation for graft failure or infection. The
overall mortality for open procedures is about 4.5%.
In conclusion, open surgery for AAA remains the gold
standard in young and low risk surgical patiets. Endovascular
procedures are of first choice in all high risk patients, even in
emergency situations.
38
The endovascular treatment of thoracic aortic aneurysm – case presentation
Ionel Droc, Daniel Nita, Elena Dumitru, Ioana Vlad, Liviu Stan
Thoracic Aortic Aneurysms are serious conditions with risks
for potentially lethal complications. The decision regarding
the treatment options for a TAA is made according to the age
of the patient, the risk assessment, and the vessel anatomy.
Nowadays, in Romania, TAAs are mostly treated with open
surgery – clamping, removing the affected aortic segment,
and replacing it with a graft. Endovascular treatment of TAAs
is an infrequent treatment solution in our country, but with
increasing average. We have had few patients treated with
TEVAR in our clinic.
We present the case of a TAA treated in our clinic with
thoracic endovascular aortic repair (TEVAR). 45-year-old
male patient admitted to our hospital with post-traumatic
thoracic aortic aneurysm underwent endovascular stent
grafting with prior carotid-subclavian by-pass and proximal
ligation of the subclavian. Following the procedures the
patient’s outcome was uncomplicated. CT scan 6 months
after discharge shows a reduction in both the internal and
external diameters of the thoracic aortic aneurysm.
Thoracic endovascular aortic repair (even when covering the
origin of the left subclavian artery) is an effective and safe
treatment option for patients in Romania.As the current
international recommendations, in patients for whom
TEVAR is accompanied by the debranching of the LSA, we
suggest mandatory surgical revascularizarization of LSA.This
operation should be performed prior to the endovascular
procedure in order to prevent the ischemic or neurologic
complications associated with LSA occlusion. The long-term
prognosis of such cases is not known and remains to be
determined in the future.
Surgery for intramiocardial wall foreign body (bullet) – case presentation
Ionel Droc, Dragos Trandafir, Alin Toader, Vasile Murgu
We present a very rare case of a 37 year old male patient
diagnosed with an intramiocardial wall fordeign body
(bullet) – resting in the diaphragmatic wall of the right
ventricle. It was operated with success three months after
the accident. The patient was shot parasternally, in the left
third intercostal space, with a high-velocity military AK 47
projectile. The shot was indirect – the bullet hit the patient
after two rebounds on the metallic struts of the car he was
driving. Shortly thereafter, the patient was examined in a
hospital. A diagnosis of antero-inferior mediastinal foreign
body (bullet) was established then.We examined the patient
3 months after the acccident. The plain X-Ray confirmed the
diagnosis. We performed a thoracic CT scan which showed
that the bullet was „most probably located above the
diaphragm, in the lower anterior mediastinum, 1.5 cm
behind the sternum”. We also performed a fluoroscopy,
which showed that the bullet was moving synchronously
with the heart and, therefore, we asked for a cardiac
echography in order to rule out a cardiac/pericardial location
of the bullet. The trans-thoracic cardiac echography did not
establish the presence of the bullet in the myocardiun or
pericardium, nor has it shown indirect signs of cardiac or
pericardial wounds. We therefore performed a subxyfoidian
approach. We examined the anterior mediastinum but we
failed to find the bullet, although we palpated a structure
feeling very much like the bullet. We then opened the
pericardium as in a pericardial window and we found the
bullet embedded in the lower aspect of the right ventricular
wall.The patient was operated under extracorporeal
circulation and the bullet was extracted from the right
venticle.The resting orifice was closed with separete sutures
on daflon patches using also reinforcement of the tissue with
bioglue.The postoperateve evolution was simple.No
infection or bleeding were noted. In conclusion the
intramural ventricular foreign bodies (extremely rare non
fatal) can be safely treated surgically under extracorporeal
circulation.
Vol. CXXII • Suppl/2019 • October • Romanian Journal of Military Medicine
39
NURSES PAPERS
The hydro-electrolyte balance and the acid base balance: interpretation of the ASTRUP
Mariana Ene, Nicoleta Tudora
The water balance: the role in bio-chemical processes,
electrolyte and acid base balances, transmission of nerve
impulse, transmission of genetic information, etc.
Electrolytic balance: it strictly refers to the balance of salts
of the blood plasma. Acid base balance: human organism, for
a proper function, must maintain the balance between
acidity and alkalinity of its fluids. The utility of the blood test:
the evaluation and assesing the severity of patient’s
condition. The technique of collection of blood. The
interpretation and recognition of the main imbalances
Scintigraphy: preparation of the patient and the fear of radiation
Maria A. Gherman, Eugenia Rusu, Constanța Bandulea, Mariana Ciaușescu
In order to achieve the best scintigraphic images it is very
important to know how to prepare the patient for
investigation. With the large variety of organs that can be
seen with this investigation, the preparation differs in
function of the organ that is desired to be seen, in function
of the kinetics inside the cell of the specific organ, the
medication that the patient is taking and the quality of the
image that is being taken (eliminating artifacts). Since
Chernobyl and Fukushima, the word radiation brings up the
idea that something bad is happening or that we shouldn’t
get in touch with it. But, in the case of nuclear medicine, the
word radiation means the improvement in detecting cancers
and other malfunctions of the organs. Taken into
consideration that there are some dose limits, that the
patients are advised what to do after a nuclear medicine
procedure in order to minimize the population exposure and
that the scintigraphic investigation is being taken under the
ALARA principle there should not be any fear of radiation.
Medullar transplant
Adriana A. Andrei, Florența M. Nicolescu; Mihai A. Șotcan
The transplant of hematopoietic stem cells implies
reconstructing the haematopoiesis by transferring stem cells
(from a donor or from the patient). Unlike the transfusion of
blood components (where the effects are temporary due to
limited viability of the transfused cells), transplanting
progenitor strain cells causes a long-term effect through its
capacity to proliferate in the medulla. The source of hsc may
be the hematopoietic bone marrow, the peripheral blood or
the umbilical cord. The donor may be a healthy person
(allotransplant) or the patient himself/herself (auto-
transplant). Currently the HSC transplantation is widely used
in a variety of hematologic and non-hematologic
impairments. Yet the procedure is not harmless, entailing
high morbidity and mortality due to its complications.
Therefore the indication of transplant shall be discussed for
each particular case and a decision shall be made only after
considering the risk and benefit for each particular case.
Malign diseases: acute lymphoblastic leukaemia, acute
myeloblastic leukaemia, chronic granulocytic leukaemia,
Hodgkin’s disease, multiple myeloma, solid tumours –
breast, ovary, lung (auto-transplant only). Non-malign
diseases: congenital and acquired aplastic anaemia,
autoimmune diseases and hemoglobinopathies.
Purpose: Suppressing the patient’s immune system,
suppressing the bone marrow and destroying the tumour
cells. The treatment consists in post-transplant radiotherapy
and chemotherapy.
40
Impact of nurses involvement in fundraising and social activities: RxRun, we are running for our patients
Ani Ivan, Andrei Toma, Norocel Bocănială, Ștefănel C. Vlad
The impact that a trained nurse or RTT can have on their
community in Romania is huge. It is so much more than just
a job in the hospital. The work they do, caring for their
patients will have an immeasurably large reach and change
the lives of countless vulnerable people, such as patients
with cancer in advanced stages. People decide to run long
distances for all sorts of reasons. Some do it for exercise and
health benefits, because they love running. We do it for our
patients, we put our passion for a cause: to help patients
with incurable disease to have good quality palliative care in
Hospice Casa Sperantei. We started the fundraising activities
in patient's benefit in 2016, as RxRun, a team of runners, one
doctor and three nurses working in the Radiotherapy
Department of the Central University Emergency Military
Hospital “Dr. Carol Davila”, Bucharest. Another two young
radiotherapy doctors joined the team in 2018 and 2019. We
have participated in numerous races, crossing distances
from few kilometers to marathon and half-marathon. With
the help of friends who have sustained our cause we succeed
in fundraising important amounts, representing palliative
care services for many hospice-treated cancer patients from
Hospice Casa Sperantei. It is important for any nurse
involved in oncological field to be part of social activities, to
highlight the difficulties faced by many patients with cancer
to receive good quality care and to deal with their disease.
Renal lithyasis patient care
Manuela Flămânzeanu
Kidney stones are small, hard deposits that form in one or
both kidneys. The stones are made up of minerals or other
compounds found in urine. Kidney stones vary in size, shape
and color. To be cleared from the body or ’’passed ‘’, the
stones need to travel through ducts that carry urine from the
kidneys to the bladder (ureters) and be excreted. Depending
of their size, kidney stones generally take days to weeks to
pass out of the body and can cause severe pain. Kidney
stones can cause abdominal or back pain (renal colic). This
pain usually begins sporadically but then becomes constant
and can lead to nausea and vomiting. The nurse administers
painkillers, anti-inflammatory and anti-vomiting drugs at the
doctor’s advice and she write everything in the care plan.
They can be extremely painful and can lead to kidney
infections or the kidney not working properly if left
untreated.
Nurse’s role in taking care for the patient with pleural effusion
Marcela Brighiu, Ionela Paraschiv
A pleural effusion is defined by the accumulation of a fluid
inside the pleural cavity, with or without the inflammation
of the pleura. A pleural effusion usually accompanies other
local or systemic affections. The presence of pleural fluid
inside the pleural cavity has a major impact on the
respiratory and circulatory function.
The authors present several measures needed to be taken
by the nursing personnel for patients with pneumothorax.
Some nursing care plans are described and explained in
order to fully understand what is needed when taking care
for a patient with a pleural effusion.
Carefully nursing a patient with a pleural effusion (usually a
patient with associated health problems) has very good
results if the nursing plans are respected. Reducing the
postoperative pain and improving the respiratory function
are essential for patients’ evolution.
The goals of the nursing plans include relief of pain,
adherence to prescribed pharmacological regimen,
establishment of a normal, effective respiratory pattern as
evidenced by absence of cyanosis, and demonstration of
increase in perfusion. If these goals are achieved, the patient
can be safely discharged.
The nurse’s role in taking care for the patient with a pleural
effusion is very important. The nurse helps the patient reach
Vol. CXXII • Suppl/2019 • October • Romanian Journal of Military Medicine
41
several goals during the hospital stay. Good nursing means
better quality of life for the patient!
Challenges in the determination of the blood group and compatibility
Anca L. Mogoi, Cristiana Chiriță, Carmen B.Ș. Jianu, Gabriela Vasile, Carmen Măcău
The human body contains approximately 4- 6 L of blood,
depending on the body mass of the individual. The red blood
cells (RBC), haematids, which represent 45% of the blood
volume, have a crucial role in the oxygen transportation to
the tissues, and implicitly in maintaining the organism alive.
On the red blood cells membranes, there are proteins that
carry the blood group antigens. These were discovered by
Landsteiner, who classified them in the ABO system.
Nowadays, more than 300 RBC antigens are identified and
categorized into 36 major systems. The determination of the
ABO/Rh blood group is based on a relatively simple test that
can be performed in 5-10 minutes depending on the
technique used. However, there are situations in which the
determination of the blood group may involve additional
techniques that require more time and foremost knowledge
on the medical history of the patient. The aim of the
compatibility tests is to highlight the interactions between
the donor’s antigen and the patient’s antibodies. Selecting a
compatible blood unit is often challenging due to the
presence of a multitude of antigens and antibodies with high
immunogenicity or unexpected antibodies (auto- or irregular
erythrocyte antibodies), cases in which time-consuming
supplementary testing is required.
This paper describes the most common particular cases
encountered in our practice when performing blood group
and compatibility determination.
Headache in neurology disorders
Cătălin Dinoiu, Alexandru Gila, Claudia Lia
A headache is pain or discomfort in the head or face area.
Headaches vary greatly in terms of pain location, pain
intensity, and how frequently they occur. Headache
syndromes can be associated with focal neurological
symptoms or signs. Good knowledge of primary headaches,
a detailed history and a thorough clinical examination are
prerequisites for their differential diagnosis. The
neurological symptoms produced by the migraine aura are
the most characteristic and recognisable. However,
structural lesions, such as vascular malformations, can
produce similar symptoms to migraine with aura, which
highlights that paraclinical investigations are necessary in
most patients with headache and focal neurological
symptoms.
The different types of primary headaches are: migraines,
tension headaches and cluster headaches. The full extent of
the problem may not be understood immediately, but may
be revealed with a comprehensive medical evaluation and
diagnostic testing. The diagnosis of a headache is made with
a careful history, physical examination and diagnostic tests.
The ultimate goal of treatment is to stop headaches from
occurring. Adequate headache management depends on the
accurate identification of the type of headache.
Some headaches may require immediate medical attention
including hospitalization for observation, diagnostic testing,
or even surgery. Treatment is individualized depending on
the underlying condition causing the headache. Full recovery
depends on the type of headache and other medical
problems that may be present.
The conflict
Giorgeta Grosu
A conflict is a disagreement between two or more people
whose attitudes, beliefs, values, feelings or needs differ and
it is, at the same time, a part of every working environment,
medical care organizations included. Needs, perceptions,
power, values, feelings and emotions are all involved within
a conflict. In the past, conflicts from the working
42
environment were seen as dysfunctional issues and they
were supposed to solve by themselves or to be solved having
a winner and a loser. Nowadays, conflicts are expected to
occur in a dynamic organizational environment and are not
considered harmful anymore. Medical staff may face four
levels of organizational conflicts: intrapersonal,
interpersonal, intragroup and intergroup, however most
organizational conflicts occur at interpersonal and
intergroup levels, substantial and personalized conflicts
being the most common two types of conflicts. Supervisors
and managers who mediate conflicts need to stay calm, to
take measures in order to promptly put an end to negative
conflicts and to stay positive until a final resolution is
reached. It is essential to separate the problem from the
person, to be impartial, to look for creative solutions, to
discuss with all parties involved in the conflict so that people
feel they are involved in the process and will contribute to
the final result. Confrontation, compromise, collaboration,
admittance and avoidance are the five common approaches
to solve conflicts, each of them having its own specific
characteristics.
Challenges in IMRT: RTTs point of view
Andrei Toma, Norocel Bocănială, Mihai Dumitrache, Ștefănel C. Vlad
Within the radiation oncology department of the Military
Emergency and University Central Hospital “Dr. Carol
Davila”, Bucharest we are using 2 techniques of treatment
delivery: 3D conformal and intensity-modulated radiation
therapy (IMRT).
IMRT is an advanced type of high-precision radiotherapy,
that allows for the radiation dose to conform more precisely
to the 3D shape of the tumor by modulating the intensity of
the radiation beam in multiple small volumes. Due to its high
complexity and the need of confirmation of the dose
distribution to the target volume, the positioning of the
patient has to be highly accurate and it has to be checked
daily.
It should be noted that the duration of treatment using IMRT
technique is higher than 3DCRT, therefore the number of
patients that are being treated is limited. Taking into
consideration the high number of patients coming to the
department, we had to extend the working schedule in order
to maintain a lower waiting time compared to other public
clinics in the country. It should be also mentioned that the
radiotherapy installation is being overused, which may lead
to the wear of some components.
These issues are important, but also motivating, due to the
importance of IMRT technique in modern approach of
oncological cases, because it allows higher radiation doses
to be focused on the tumor while minimizing the dose to
surrounding normal critical structures.
Implantable ports used in chemotherapy
Maria L. Berbece, Casandra Marin
Many times during cancer treatment, the medical team in
charge of the patient must have access to the patient’s veins
be that to administer the cytostatic treatment or for other
intravenous perfusions or injectable antibiotics. For these
procedures to be as comfortable as possible for the patient,
the oncologist recommends implanting a special device
called implantable port (port-a-cath) which allows repeated
administrations of cytostatic treatment during a long period
of time. The port is attached in the operating theatre by a
medical team consisting of the surgeon and the
anaesthesiologist, experienced in performing this kind of
procedures. The intervention takes place in the operating
room under local anaesthesia and/or mild sedation.
Conclusions: the implanting is performed only once during
the entire period of treatment, the procedure is mildly
invasive and performed under local anaesthesia, the access
to blood veins is easy, the toxic effect of cytostatic on the
veins is significantly reduced, the cytostatic treatment may
be administered continuously or intermittently, the period
of usage is long, the device has a good aesthetic appearance
and allows exposure to water, nevertheless, the
recommendation to implant such a port must come after
discussing the matter with the oncologist.
Vol. CXXII • Suppl/2019 • October • Romanian Journal of Military Medicine
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Patient care with acute subdural hematoma
Florina C. Tănăsescu, Andreea Ciurea
The care process involves five stages, each stage having a
number of key components, as follows: Data collection/Their
analysis and interpretation/Care planning. Pre and
postoperative care: the preoperative care includes:/The
physical and mental preparation of the pacient; /General
preparation;/Preparation for surgery. Postoperative care:
Post-operative surveillance of the patient starts from the
time of completion of the surgery. It can be said that the
pacients are divided into two categories: the first – those
who return to the ward and the second- the patients who
are admitted to the intensive care unit; During transport the
following will be observed: skin coloration, breathing, pulse,
the functioning of the various devices used for monitoring,
perfusion. Sudden movements will be avoided. Positioning
of the patient in bed varies depending on the type of surgery
and anesthesia.The most common position is the dorsal
decubitus.Positive diagnosis for acute subdural hematomas
is mainly based on advanced radiogical investigations which
highlight the acute subdural collections which, correlated
with the clinical findings, confirm the clinical diagnosis.
Menopause: between physiology and pathology
Nicoleta Mavriș, Mihaela Moscaliuc, Ancuța Istrate, Carmen Miron, Aglaia Nedelcu, Tatiana Onofrei, Florentina Rogojină, Andreea Serafim, Nicoleta Vale, Corina Enache, Luminița Crăciun
Menopause and menopausal transition are physiologic, but
symptoms are frequent and often require medical attention.
Approximately 60% to 80% of menopausal women
experience hot flashes at some point during menopausal
transition. They are more likely to develop anxiety
symptoms at perimenopause and postmenopause and
depressive symptoms or clinical depressive disorders in late
perimenopause. Sleep disturbances are frequent. Vaginal
dryness and genital atrophy can cause sexual dysfunction.
Lately, postmenopausal osteoporosis leads to increased
morbidity and mortality as well as an important reduction of
the quality of life as a consequence of fractures. We present
our experience with menopausal patients seeking medical
attention in our department.
Patient care after cardiac pacemaker implantation
Elena M. Dumitrescu, Cecilia Pătru
The pacemaker is a special device that is implanted in the
prepectoral and subclavicular level. The device generates
electrical impulses at the heart, determining to work in
optimal parameters. Recently, the cardiac pacemaker has
gained a crucial importance in the life of patients with
pathologies such as: symptomatic sinus bradycardia,
complete atrio-ventricular block (grade III), sinus node
disease, etc. In present, it is estimated that annually.
Approximately 200,000 people benefit from a cardiac
pacemaker. In this context, efficient management of
postimplant pacemaker care lead to an increase in the
quality of life of the patient as well as to a substantial
reduction of the complications that may occur
postoperatively. We note that overinfection of the wound is
one of the most important complications. The present paper
aims to highlight the most important aspects of care for the
patient post device implantation so that he / she will benefit
from the best medical care and his recovery will be fust and
properly.
In fact, a very important aspect of care of the post-implant
patient is his education, according to the lifestyle that he
must adopt. Upon discharge from the hospital, the patient is
taught how to care and protect the wound. Also, the patient
is educated on the activity that can be performed during the
recovery: the patient will limit the use of the arm for a period
of 1.5-3 months and will strictly respect the indications
received from the medical team.
44
Utilization of ATP bioluminescence assay in monitoring medical hand hygiene compliance in healthcare workers
Raluca M. Hrișcă, Tudorița Marinescu, Adriana Ruță, Daniel Păun
Healthcare associated infections (HCAI) are an important
problem in terms of the associated morbidity, mortality and
cost. Hand hygiene is an important part of quality care, and
it is the simplest, low cost and evidence supported method
to reduce the HCAI. We want to evaluate the healthcare
workers hand hygiene from our settings. Retrospective study
conductes in our setting between 1st May 2019- 31 July
2017, based on the swab sample collected from healthcare
workers hands using Adenosine Triphosphate Hygiene
Monitoring System. We set 60 RLU as the upper limit for a
proper hand hygiene (≤ 60 RLU -PASS, > 60 RLU –FAIL). While
collecting the samples we conduct an interview about the
reasons that prevent them from practicing hand hygiene
regularly. We collect 416 sample, 46.63% PASS and 53.34%
failed the test. The main 4 reasons given for failing was:
cleaning hands causes skin irritation and dryness, the
accessibility (the disinfectant vial no longer matches with the
dispenser), sink location and the lack of time. Conclusions:
We must insist on the hand hygiene policies; the hospital
units must be properly equipped; we have to use less skin
aggressive disinfectants and to use hand cream for
prevention of skin dryness and irritations.
Fournier gangrene diagnosed patient’s care
Georgiana Niculae
Etiology: Fournier gangrene is a form of fulminant fasciitis
necrotizing of perianal region, perineal and genital.
Determining factors are: aerobic germs (E-Coli), anaerobic
germs (Bacterioides).
Other factors are: Proteus, Staphylococcus, Enterococcus,
Klebsiella, and Clostridium.
Favoring factors are: diabetes, alcoolism, obesity, old age,
AIDS
Clinical diagnosis: The onset is sudden or preceded by a
prodromal syndrome with: fever, digestive disorders, and
genital pruritus.
Subsequent will appear painful erythematous edema with
cyanosis and tissue necrosis.
Treatment: Patient resuscitation, broad-spectrum
antibiotics, debridement, removing of the necrotizing tissue
are required.
Preoperative it is necessary hemodynamic equilibration,
glycemia, anemia, coagulation disorders.
Conclusions: Fournier gangrene is a major urological
emergency, with rapid escalation, with high risk mortality up
to 30%.
Presenting time to the hospital, age, and associative
disorders are key factors in this disorder.
Characteristics of care for patients with autonomic regulation therapy
Carmen M. Bosincianu, Silviu Dumitrescu, Mihai Dumitrașcu
Introduction: Any form of structural heart disease that
impairs ventricle functional ability to fill or to eject blood
according to the needs of the tissue may cause heart failure
syndrome. Many people are diagnosed with heart failure
syndrome and in spite of prescribed medical treatments they
continue to suffer from fatigue and shortness of breath.
Trying to handle heart failure syndrome in terms of surgical
approach is based on the vagus nerve stimulation through
device implantation which sends an electrical impulse from
the brain to the heart.
Objectives: implanting the device is an innovative treatment
BAT(baroreflex activation therapy) which restores the
equilibrium of the autonomic nervous system, leading to
enhanced cardiac performance, improving the pumping
capacity of the heart, reducing the risk of malignant
ventricular arrhythmias associated with heart failure and
ultimately improving the quality of life and increasing the
Vol. CXXII • Suppl/2019 • October • Romanian Journal of Military Medicine
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rate of survival.
Material and method: we studied 5 patients who were
operated between January- July 2019
Results: we analysed the postoperative evolution, showing
the special nursing cares.
Conclusions: the study marks out distinguished
particularities of nursing patients with the vagus nerve
stimulation. The nurses’ role, besides medical treatment
given by physicians, involves continuous monitoring during
hospitalization and educating the patients on how to lead a
healthy life.
Dudenopancreatectomy in the eyes of medical assistance
Imola Grigore
Introduction: Cephalic duodenopancreatectomy is one of
the most complex operations in abdominal surgery, reserved
mainly for surgeons with experience in hepato-
biliopancreatic pathology. If in the past it was used
sporadically, today it has become a routine intervention.
Objectives: The main indication of CPD is the pancreatic
cephalic neoplasm, along with the periampullary neoplasms
(distal choledochial cancer, pulmonary ampuloma, duodenal
cancer). DPC remains a difficult, complex intervention, due
to vascular relations (portal vein, mesenteric vessels) and
restoration of bile, pancreatic and digestive continuity. Two
types of operations are used: Whipple and
TraversoLongmire. Improvement of surgical techniques and
progress in anesthesia, intensive care and nutritional
support have led to decreased postoperative mortality in
CPD but also radical intervention with increased survival.
Material and method: we will study 2 patients with CPD
performed in our clinic this year.
Results: we will analyze the post-operative evolution of the
cases, especially from the point of view of the care offered
by the nurse.
Conclusions: To date, surgical resection is the only effective
therapy that offers the prospect of a significant prolongation
of the survival and healing potential of patients with cancer
in the pancreatic-biliary sphere.
The role of the nurse is very important in the postoperative
care by administering the medication indicated by the
doctors and continuous monitoring during the
hospitalization as well as by educating the patient to adopt
a healthy lifestyle, which will extend his life.
Thrombolysis therapy in acute ischemic stroke
Olguța Preda-Carsote, Oana Rada, Violeta Gâlcă, Nicoleta Balint
Stroke is a major cause of mortality and thrombolysis has
served as a catalyst for major changes in the management of
acute ischaemic stroke. Modern management of stroke
includes rapid assessment and admission protocols,
thrombolysis for acute ischaemic stroke, early specialist
management in a stroke unit and appropriate physiological
monitoring. Thrombolysis restores cerebral blood flow in
some patients with acute ischemic stroke and may lead to
improvement or resolution of neurologic deficits. The most
important factor in successful reperfusion therapy of acute
ischemic stroke is early treatment with Alteplase (Actylise).
Intravenous alteplase (actylise) is the only approved
thrombolitic agent at present indicated for acute ischaemic
stroke. While the licensed time window extends to three
hours from symptoms onset, recent data suggest that the
trial window can be extended to four and a half hours with
overall benefits. Identification of viable penumbra based on
computed tomography/magnetic resonance imaging may
allow future extension of the time window. Intracranial
haemorrhage is the major complication associated with
thrombolysis, and the key factors increasing risk of
haemorrhage include increasing age, high blood pressure,
and diabetes and stroke severity. Some people with
ischaemic stoke are eligible for a clot-busting drug. Actylise
aims to disperse the clot and return the blood supply to the
brain. For most people thrombolysis needs to be given
within four and a half hours since the stroke symptom
started.
46
Emergency nurse and acute trauma evaluation
Ion M. Lefter
The Advanced Trauma Life Support (ATLS) was developed in
response to a perceived need to identify a safe, consistent,
standardized, and effective way to initially evaluate and
resuscitate patients with multiple injuries.
The principles of ATLS and triage need to be known by all
personal, included nurses.
Nurse’s role in esophageal manometry
Elena Zanfir, Mariana Moldoveanu, Corina Marcovici-Petu, Aurica Avram, Cristiana Tablan, Nicoleta Helmis, Andrei Crișu, Liliana Radu, Raluca S. Costache, Andrada L. Popescu
Introduction: In this paper we want to point out the nurse
role in performing esophageal manometry - a procedure
used to measure the strength and function of the esophagus
as food and liquids pass from the mouth to the stomach.
Esophageal manometry is done to evaluate the cause of
stomach reflux back up into the esophagus, to determine the
cause of dysphagia, and the cause of non-cardiac chest pain.
Esophageal manometry is indicated to establish the
diagnosis of suspected cases of achalasia or diffuse
esophageal spasm, also for detecting esophageal motor
abnormalities associated with systemic disease or for correct
positioning of the probe for the 24-hour pH monitoring.
The nurse is preparing the patient, informing him about the
procedure, about the time needed and the steps of it. The
nurse will verify that the patient had nothing by mouth in the
last 6 hours prior to the test. After the sterilization of the
probe and calibration, the nostril and throat is numbed with
a topical anesthetic, then the probe is inserted in a sitting
upright position while the patient swallows water. The
patient will lie down and the nurse will give him small sips of
water to record the progression of the swallow. The
contractions of the esophageal muscle will be measured at
rest and during swallows.
Conclusion: In our hospital this GI functional procedure is
available since 2017, and we performed until now
approximately 150 procedures. Manometric screening for
severe peristalsis dysfunction remains reasonable in
specialized gastroenterology departments.
Management of operative wound infections
Maria Stoian, Carmen Florea
Introduction: All the surgical wounds are microbially
contaminated, but only a small part of them can become
infected. In most cases surgical wounds are considered to be
clean or contaminated clean. The main factors recognized as
influencing the evolution of the wound (healing as well as
the aesthetic aspect) are quantitative and qualitative
contamination.
Objectives: The paper presents: the risk factors in surgical
wound contamination, diagnostic criteria for the infection of
the wound, the treatment and the prophylactic measures
preoperative, intraoperative and postoperative.
Materials and methods: We present our experience on 2000
patients operated in 2018 of which approximately:
- 40% of the surgery wounds were clean (hernias, classic or
laparoscopic; other interventions, classic or laparoscopic);
- 30% of the surgery wounds were contaminated clean
(classic and laparoscopic interventions on the cholecyst,
stomach, small intestine, colon, rectum);
- 30 % surgery wounds 100% septic (abscesses, phlegm,
gangrene, peritonitis).
The evolution of clean surgery wounds was favorable in all
cases for the contaminated clean and the contaminated
ones. The evolution was favorable in proportion of 80%, the
rest of 20% was unfavorable due to other diseases (diabetes,
malnourished patients, and neoplasic patients)
Conclusions: The correct application of the aseptic and
antiseptic techniques, the observance of the guides and
protocols regarding the surgical techniques and the
antibiotic prophylaxis, the observance of the hygiene rules
for both the patient and the medical personnel are essential
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conditions, absolutely necessary for the favorable evolution
of the surgical wounds.
Heart attack
Delia Spătaru, Ramona Oancea
A heart attack occurs when the flow of blood to the heart is
blocked. The blockage is most often a buildup of fat,
cholesterol and other substances, which form a plaque in the
arteries that feed the heart (coronary arteries). The plaque
eventually breaks away and forms a clot. The interrupted
blood flow can damage or destroy part of the heart muscle.
A heart attack, also called a myocardial infarction, can be
fatal, but treatment has improved dramatically over the
years. It's crucial to call 211 or emergency medical help if you
think you might be having a heart attack. In the CTIC
department of January 2018 so far, over 700 patients with
heart attack have been admitted, and over 200 patients have
come into the RO-STEMI program. In the absence of
adequate treatment: heart attack mortality 50%. Between
50% years produce in the first 2 hours of debut and 40% long
in the first months of heart attack debut.
When to see a doctor
Act immediately. Some people wait too long because they
don't recognize the important signs and symptoms. Take
these steps:
• Call for emergency medical help. If you suspect you're
having a heart attack, don't hesitate. Immediately call 112 or
your local emergency number. If you don't have access to
emergency medical services, have someone drive you to the
nearest hospital.
Drive yourself only if there are no other options. Because
your condition can worsen, driving yourself puts you and
others at risk.
• Take nitroglycerin, if prescribed to you by a doctor. Take it
as instructed while awaiting emergency help.
• Take aspirin, if recommended. Taking aspirin during a
heart attack could reduce heart damage by helping to keep
your blood from clotting.
Aspirin can interact with other medications, however, so
don't take an aspirin unless your doctor or emergency
medical personnel recommend it. Don't delay calling 112 to
take an aspirin. Call for emergency help first.
What to do if you see someone who might be having a heart
attack
If you see someone who's unconscious and you believe is
having a heart attack, first call for emergency medical help.
Then check if the person is breathing and has a pulse. If the
person isn't breathing or you don't find a pulse, only then
should you begin CPR to keep blood flowing. Push hard and
fast on the person's chest in a fairly rapid rhythm — about
100 to 120 compressions a minute. If you haven't been
trained in CPR, doctors recommend performing only chest
compressions. If you have been trained in CPR, you can go
on to opening the airway and rescue breathing.
Cryoultrasound therapy
Laura Iosif, Daniela E. Iuga
Cryoultrasound therapy exploits the action of two different
therapeutic physical modalities: cryotherapy and
therapeutic ultrasound. Cryotherapy is generally regarded as
a basic component of most injury management strategies
and has proved its effectiveness in reducing edema and
short-term pain. Ultrasound consists of high-frequency
sinusoidal sound waves with a peak pressure of 0.5 bar,
approximately 1000 times lower than shock wave
Therapeutic ultrasound may induce thermal and nonthermal
effects in the tissues. Thermal effects include a rise in blood
flow, reduction of muscle spasm, increase in the extensibility
of collagen fibers and a pro-inflammatory response. Non-
thermal effects are cavitation and acoustic microstreaming
that induce stimulation of fibroblast activity, increase in
protein synthesis and in blood flow, tissue regeneration, and
bone healing. It has been suggested that the non-thermal
effects of ultrasound are more important in the treatment of
soft tissue lesions than are thermal effects. Cryoultrasound
therapy is a new technology that could combine the benefits
of therapeutic ultrasound with those of cryotherapy, which
could reinforce both, avoiding the possible complications of
the thermal heating effect of the ultrasound therapy and
improving its mechanical and biological therapeutical
effects. In fact, a temperature decrease in deep tissues
48
permits an enhancement in waves density in the tissue itself,
increases the mechanical effect and, notably, reduces the
thermic effect of the ultrasound. Recently, cryoultrasound
therapy has been tested for musculoskeletal and
musculotendinous disorders.
Lung diffusing capacity
Gabriela Drilea
This year our department was endowed with a pulmonary
diagnosis line. The device comprises the module for
spirometry, for measuring lung volumes of Nitrogen
washout and for Lung Diffusion Capacity.
Measuring diffusion in pulmonary function laboratories can
provide information about the transfer of gas between the
alveoli and the pulmonary capillary blood. Measurement of
the diffusing capacity is usually performed by using an
inspired gas containing Carbon Monoxide because of its high
affinity for Hemoglobin.
This is a simple non-invasive procedure and consists of
instructing the patient to carry out a maximal inspiration and
an 8-10 second breath (during which the expiratory valve is
closed), followed by a slow exhalation to the level of Residual
Volume.
This investigation is indespensable in the diagnosis of diffuse
interstitial pneumopathy , diffuse pulmonary emphysemia,
vasculitis, neuro-vascular disease, thoracic deformities, is
recommended for the surveillance of people at high risk of
disease (exposure to asbestos, beryllium, aluminum
powders, patients with extrapulmonary collagenosis or
extrinsic alveolitis, patients treated with certain drugs),
useful in the evaluation of emphysematous component or
the global evaluation of the gas exchanges at COPD, can
evaluate the therapy administered , can appreciate the
prognosis of lung diseases, can determine the degree of
functional disability.
The Lung Diffusing Capacity CO (DLCO) test is very useful in
diagnosing lung disease coming to the aid of many patients.
A few considerations about fever and nursing in fever
Dana Sorica, Carmen Hornea
Fever is defined as the elevation of core body temperature
above normal; in normal adults, the average oral
temperature is 37°C (98.6°F). In medical practice, a single
temperature of more than 38.3°C (101°F) or three readings
(at least 1 hour apart) of more than 38°C (100.4° F) are
considered significant. Fever of an unknown origin (FUO) is
defined as a febrile illness lasting more than 3 weeks, with
temperatures exceeding 38.3°C on several occasions, and
lacking a definitive diagnosis after 1 week of evaluation in
the hospital.
The febrile response, of which fever is but one component,
is a complex physiologic reaction to disease involving a
cytokine-mediated rise in body temperature, generation of
acute-phase reactants, and activation of numerous
physiologic, endocrinologic, and immunologic systems.1 The
temperature of the body is dependent on maintaining a
balance between the production and dissipation of heat.
Goals of care: The presence of fever is associated with
potential metabolic consequences, including dehydration
and increased oxygen consumption and metabolic rate. If
prolonged, fever may be associated with an increase in
nutritional demands, which may be problematic if the
patient already is compromised nutritionally. Prolonged
fever may also lead to debilitating fatigue Suppression of
fever may help to alleviate uncomfortable, constitutional
symptoms of fatigue, myalgias, diaphoresis, and chills. In
addition to constitutional symptoms, focal findings related
to the etiology of fever may contribute to the burden of
symptoms. For example, the formation of an abscess is often
associated with pain, whereas uncomfortable dyspnea and
cough may be related to pneumonia. For instance,
individuals seeking comfort-oriented care exclusively may
decline parenteral antibiotic treatment of pneumonia to
avoid hospitalization and remain at home. For others,
treating the underlying etiology of fever with more
aggressive interventions, such as surgical drainage of a
painful abscess, will offer symptom palliation and potentially
contribute to the prolongation of life.
Vol. CXXII • Suppl/2019 • October • Romanian Journal of Military Medicine
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Multiple sclerosis
Georgiana Drăghici
Multiple sclerosis (MS) involves an immune-mediated
process in which an abnormal response of the body’s
immune system is directed against the central nervous
system (CNS). The CNS is made up of the brain, spinal cord
and optic nerves. Within the CNS, the immune system causes
inflammation that damages myelin — the fatty substance
that surrounds and insulates the nerve fibers — as well as
the nerve fibers themselves, and the specialized cells that
make myelin.There are several types of MS: Clinically
isolated syndrome (CIS), Relapsing-remitting MS (RRMS),
Primary progressive MS (PPMS) and Secondary progressive
MS (SPMS).
Treatments for MS attacks
Disease-modifying therapies (DMTs) are designed to slow
disease progression and lower the relapse rate. In 2017, the
Food and Drug Administration (FDA) approved the first DMT
for people with PPMS. This injectable drug is called
ocrelizumab (Ocrevus), and it can also be used to treat
RRMS.
The bottom line
MS is a lifelong condition. The patient face unique challenges
that can change over time.They should focus on
communicating concerns with the doctor, learning all they
can about MS, and discovering what makes them feel their
best. Many people with MS even choose to share their
challenges and coping strategies through in-person or online
support groups.
Pages from the history of blood transfusion: old Romanian press reflection
Elena I. Milea, Nicoleta M. Băltărețu, Florența N. Borhan, Camelia Tudor, Laura M. Constantin
More and more researchers appeal to old press to
investigate their chosen subject. Newspapers and
magazines, historical image of the time when they were
printed, are work instruments for researchers. While trying
to find out as much novelties as possible about blood
transfusion history, I have researched the Romanian
Academy’s Library newspapers and magazines published
between 1881 and just after the Second World War. Among
the researched magazines, I would like to mention:”Bulletin
de l’Academie de Medicine” (1881 – 1944).
Pages from old newspapers and magazines describe the first
transfusion performed from animal to human, from human
to human, but also the first blood transfusion performed in
Romania, quite late when compared to Western Europe.
After an unsuccessful blood transfusion performed in 1853
by Carol Davila, the next blood transfusion was performed in
Romania in 1912 – 1914.
The press of the time highlighted the great discoveries
regarding blood transfusion. Lots of pages have been
dedicated to indirect blood transfusion, veno-venous
transfusion performed with the aid of a device (during the
World War I – Oehlecker), or to the discovery of blood types.
On the agenda were also International Transfusion
Congresses, the appearance of blood banks, flourishing
businesses or great scandals when patients died due to
blood transfusion.
Old newspapers and magazines are archives of the daily life
of those times. Only by reading them one can acknowledge
the progress of medicine and of blood transfusion, progress
preparing the events of today, as today’s progress prepares
us for the events of tomorrow.
Chronic pancreatitis
Adina Bălan, Viorica Gogor, Mihaela Vasile, Cătălina Oana
Chronic pancreatitis is a chronic inflammatory disease of the
pancreas, with progressive evolution towards exocrine and
endocrine pancreatic destruction, leading to pancreatic
insufficiency. Symptom for pancreatitis are dbdominal pain -
the dominant symptom epigastric, periumbilical, triggered
by heavy meals or alcohol consumption. Steatoreea - a late
sign, when malabsorption occurs bulky, pasty chairs, with a
rancid smell; always accompanied by weight deficit. History
50
and clinical picture of chronic alcoholism - recognized or not
(collateral history, in the relatives). The most important
cause of PC (over 90% of cases) necroptic > 45% of alcoholics
showed morphological changes of PC, in the absence of
clinical signs of disease toxic dose of pure alcohol. Some
patients may have ethanolic hepatopathy (steatosis,
alcoholic hepatitis or even ethyl hepatic cirrhosis)
Treatment: Dietary: complete and definitive abolition of
alcohol consumption; avoiding abundant meals rich in lipids
and proteins; in episodes of PA on PC background dietary
rest, parenteral nutrition, naso-gastric well. Drug: pain
relievers (Algocalmin, Piafen, Tramal); high lipase
preparations (Creon, Panyztrat, Festal, Cotazym, Nutryzym,
Digestal) even in the absence of malabsorption; when there
is malabsorption, minimum 20,000 U lipase/mass; if the
preparation is not gastroprotected, before the meal, an
antisecretory is given before 30 minutes.
Nursing applied to a thrombophlebitis patient
Cristina Filimon, Cecilia Pătru
Thrombophlebitis is an inflammatory process that causes a
blood clot to form and block one or more veins, usually in
the legs. The affected vein may be near the surface of the
skin or deep within a muscle. Causes include trauma, surgery
or prolonged inactivity. The three main factors that are
causing this pathology are the endothelial lesions, the
inflammation localised on the vein’s wall and the
hypercoagulation process. Thrombophlebitis frequently
occurs in cardiac insufficiency cases and diseases followed
by venous stasis as a result in prolonged inactivity. The
primary physiopathological alteration is the formation of a
blood clot that is the mechanical obstructive element.
Symptoms include warmth, tenderness and pain in the
affected area, as well as redness and swelling.
Complications- from thrombophlebitis are rare. However,
complications might include: pulmonary embolism- if part of
a deep vein clot becomes dislodged, it can travel to the
lungs, where it can block an artery and become potentially
life-threatening, postphlebitic syndrome- this condition also
known as post-thrombotic syndrome, can develop months
after a person had DVT. This can cause lasting and possibly
disabling pain, swelling and a feeling of heaviness in the
affected leg. For superficial thrombophlebitis, the doctor
might recommend applying heat to the painful area,
elevating the affected leg and possibly wearing compression
stockings. Another recommendation is the treatment with
blood-thinning medications, such as heparin or clot-
dissolving medication. Prescription strenght compression
stockings help prevent swelling and reduce the chances of
complications of DVT.
Clostridium difficile infection: a nurse’s point of view
Mariana Bogriceanu, Grațiela Olteanu, Liliana Bulat
Introduction: Our objective is to review current guidelines in
managing Clostridium difficile colitis and our department`s
experience in this field.
Materials and methods: Clostridium difficile is a Gram-
positive spore-forming anaerobe that was identified,
beginning with 1978 as the causative pathogen in the
majority of antibiotic-associated diarrhea and colitis cases. It
is believed that a small percent of healthy individuals have
this bacterium in their colon, but it is more often found in
the ground, water, animal or human feces, C. difficile being
a growing cause for nosocomial disease.
The most common risk factor for C. difficile infection is the
use of antibiotics, as they can disrupt the normal microbial
balance in the colon.
This bacterium is dangerous because it can secret two toxins
(A and B) that cause inflammation of the colonic mucosae,
which can lead to moderate diarrhea, pseudomembranous
colitis (most frequent form) or fulminant colitis. If the
physician suspects a C. difficile infection, it is the nurse`s task
to explain to the patient how to collect a stool sample and
take it as fast as possible to the laboratory.
After infection is confirmed, it is up to the nurse to assure
contact precautions: isolate the patient with single use
gowns and gloves being available at room entrance;
environmental disinfection; explaining the importance of
hand hygiene and of course making sure that the patient
takes his medication correctly, according to the physician`s
recommendations.
Results and conclusion: C. difficile colitis has become the
most frequent infectious cause of healthcare-associated
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51
diarrhea, causing high morbidity and mortality, mainly
because of the use of broad-spectrum antibiotics.
Immunoglobulin therapy: the election treatment for primary immunodeficiency diseases
Nicoleta Voinea
The term “immunoglobulin” refers to the fraction of blood
plasma that contains immunoglobulins. Immunoglobulin
therapy is a purified product prepared from human plasma
donors. Its main therapeutic indications are primary and
secondary immunodeficiences. Immunodeficiences are
diseases with variable genetic transmission.
Immunoglobulin therapy is generally administered
subcutaneously, intramuscularly or intravenously. In our
hospital the most used is the intravenous administration and
the product used is Intratect. The systemic adverse reactions
of immunoglobulin therapy are usually determined by the
patient’s intolerability to a rapid infusion (headache, nausea,
general altered state, fatigue, dispnea). The adverse
reactions which occur during subcutaneous administration
are localized skin reactions at the site of the injection:
swelling, inflammation, rash, and induration.
Immunoglobulin therapy is a complex therapy which can
lengthen many patients’ life span.
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ADMINISTRATIVE ISSUES
Guidelines for authors
Thank you for your interest in Romanian Journal of Military Medicine. Please read the complete Author Guidelines carefully prior to submission, including the section on copyright. To ensure fast peer review and publication, manuscripts that do not adhere to the following instructions will be returned to the corresponding author for technical revision before undergoing peer review. Note that submission implies that the content has not been published or submitted for publication elsewhere except as a brief abstract in the proceedings of a scientific meeting or symposium. Once you have prepared your submission in accordance with the Guidelines, manuscripts should be submitted online at rjmilmed@yahoo.com. We look forward to your submission.
EDITORIAL AND CONTENT CONSIDERATIONS Aims and Scope Romanian Journal of Military Medicine (RJMM) is the official journal of the Romanian Association of Military Physicians and Pharmacists. The Journal publishes peer-reviewed original papers, reviews, meta-analyses and systematic reviews, and editorials concerned with clinical practice and research in the fields of medicine. Papers cover the medical, surgical, radiological, pathological, biochemical, physiological, ethical and historical aspects of the subject areas. Clinical trials are afforded expedited publication if deemed suitable. RJMM also deals with the basic sciences and experimental work, particularly that with a clear relevance to disease mechanisms and new therapies. Case reports and letters to the Editor will not be considered for publication. Editorial Review and Acceptance The acceptance criteria for all papers and reviews are based on the quality and originality of the research and its clinical and scientific significance to our readership. All manuscripts are peer reviewed under the direction of an Editor. The Editor reserves the right to refuse any material for review that does not conform to the submission guidelines detailed throughout this document, including ethical issues, completion of an Exclusive License Form and stipulations as to length.
ETHICAL CONSIDERATIONS Principles for Publication of Research Involving Human Subjects Manuscripts must contain a statement to the effect that all human studies have been reviewed by the appropriate ethics committee and have therefore been performed in accordance with the ethical standards laid down in an appropriate version of the Declaration of Helsinki (as revised in Brazil 2013), available at http://www.wma.net/en/30publications/10policies/b3/index.html. It should also state clearly in the text that all persons gave their informed consent prior to their inclusion in the study. Details that might disclose the identity of the subjects under the study should be
omitted. Photographs need to be cropped sufficiently to prevent human subjects being recognized (or an eye bar should be used). Registration of Clinical Trials We strongly recommend, as a condition of consideration for publication, registration in a public trials registry. Trials register at or before the onset of patient enrolment. This policy applies to any clinical trial. We define a clinical trial as any research project that prospectively assigns human subjects to intervention or comparison groups to study the cause-and-effect relationship between a medical intervention and a health outcome. Studies designed for other purposes, such as to study pharmacokinetics or major toxicity (e.g., phase 1 trials) are exempt. We do not advocate one particular registry, but registration with a registry that meets the following minimum criteria: (1) Accessible to the public at no charge; (2) Searchable by standard, electronic (Internet-based) methods; (3) Open to all prospective registrants free of charge or at minimal cost; (4) Validates registered information; (5) Identifies trials with a unique number; and (6) includes information on the investigator(s), research question or hypothesis, methodology, intervention and comparisons, eligibility criteria, primary and secondary outcomes measured, date of registration, anticipated or actual start date, anticipated or actual date of last follow-up, target number of subjects, status (anticipated, ongoing or closed) and funding source(s). Plagiarism Detection The journal employs a plagiarism detection system. By submitting your manuscript to this journal you accept that your manuscript may be screened for plagiarism against previously published works. Committee on Publication Ethics The journal subscribes to the principles of the Committee on Publication Ethics (COPE).
MANUSCRIPT CATEGORIES AND SPECIFICATIONS All articles, with the exception of Editorials, must contain an abstract of no more than 250 words. Abstracts for original articles should be formatted into subheadings, as detailed below. Titles must not be longer than 120 characters (including spaces). Editorials These are invited by the Editor-in-Chief or their delegated editor, and should be a brief review of the subject concerned, with reference to and commentary about one or more articles published in the same issue of RJMM. Editorials are generally 1200–1500 words, may contain one table or figure and cite up to 15 references, including the source article [this should be cited as Military Med. Today (year); (vol): [this issue]. Review Articles RJMM welcomes reviews of important topics across the scientific basis of medicine, and advances in clinical practice. Most published
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reviews are in response to editorial invitation, including thematically related “mini-series” of reviews. Authors considering submitting a review for RJMM are advised to canvas their possible review with the Editor-in-Chief or a colleague editor; this avoids early rejection if the subject matter is not deemed a high priority for the Journal at the time of submission. Reviews are limited to 3500–5000 words, with an abstract of up to 250 words and up to 75 references and 3–7 figures or tables. Meta-Analyses or Systematic Reviews RJMM particularly welcomes submission of Meta-Analyses and Systematic Reviews, which underpin evidence-based medicine. Guidelines for preparation of Meta-Analysis and Systematic Reviews are similar to other reviews, and articles are subject to the usual peer review process. Meta-Analyses and Systematic Reviews have a word limit of 3500–5000 words, with an abstract of up to 250 words and up to 75 references and 3–7 figures or tables. Original Articles (including clinical trials) RJMM welcomes original articles concerned with clinical practice and research in the fields of medicine. Papers can cover the medical, surgical, radiological, pathological, biochemical, physiological, ethical and/or historical aspects of the subject areas. Clinical trials are afforded expedited publication if deemed suitable. RJMM also deals with the basic sciences and experimental work, particularly that with a clear relevance to disease mechanisms and new therapies. Original articles are limited to 3000 words, with an abstract of up to 250 words and up to 50 references and 3–7 figures and tables. Education and Imaging The Editors welcome contributions to the Education and Imaging section. The purpose is to present imaging for the evaluation of unusual features of common conditions or diagnosis of unusual cases. Contributions will be reviewed by the Education and Imaging Coordinating Editors. The format of the Images pages involves two parts, each of which will occupy up to one journal page. In part 1, a case will be described briefly, including a summary of the presentation, clinical features and key laboratory results. One to two key images will then be presented. It is helpful to the reader if the author responds to questions that follow from the images of the case, such as ‘What is your diagnosis? What are the features indicated on the CT scan? What is the differential diagnosis?’ Part 2 will briefly describe the imaging features, particularly those that lead to diagnosis or which are critical for management. Differential diagnosis should be mentioned. It will be useful to include either further images or pathological details that validate the imaging diagnosis. Occasionally, presentation of analogous cases or related images from a similar case might be appropriate. Please include between one and three references to definitive studies and appropriate reviews of the subject. The format of the Images page involves a brief background to and description of the disorder of interest together with two figures of high quality. Colored photographs are encouraged. The submission may take the form of a case report or may illustrate particular features from more than one patient.
MANUSCRIPT PREPARATION Style Manuscripts should follow the style of the Vancouver agreement detailed in the International Committee of Medical Journal Editors’ revised ‘Uniform Requirements for Manuscripts Submitted to Biomedical Journals: Writing and Editing for Biomedical Publication’, as presented at http://www.ICMJE.org/. Spelling. The journal uses US spelling and authors should therefore follow the latest edition of the Merriam-Webster’s Collegiate Dictionary. Units. All measurements must be given in SI units as outlined in the latest edition of Units, Symbols and Abbreviations: A Guide for
Biological and Medical Editors and Authors (Royal Society of Medicine Press, London). Abbreviations should be used sparingly and only where they ease the reader’s task by reducing repetition of long technical terms. Initially use the word in full, followed by the abbreviation in parentheses. Thereafter use the abbreviation. Trade names should not be used. Drugs should be referred to by their generic names, rather than brand names. Parts of the Manuscript The manuscript should be submitted in separate files: title page; main text file; figures. Title page The title page should contain (i) a short informative title that contains the major key words. The title should not contain abbreviations; (ii) the full names of the authors (if possible, not more than 5 authors per title); (iii) the author's institutional affiliations at which the work was carried out; (iv) the full postal and email address, plus telephone number, of the author to whom correspondence about the manuscript should be sent; (v) disclosure statement; and (vi) acknowledgements. The present address of any author, if different from that where the work was carried out, should be supplied in a footnote. Disclosure statement The source of financial grants and other funding should be acknowledged, including a frank declaration of the authors’ industrial links and affiliations. In the case of clinical trials or any article describing use of a commercial device, therapeutic substance or food must state whether there are any potential conflicts of interest for each of the authors: failure to make such a statement may jeopardize the article being sent out for peer-review. Acknowledgments The contribution of colleagues or institutions should also be acknowledged. Thanks to anonymous reviewers are not allowed. Main text As papers are double-blind peer reviewed the main text file should not include any information that might identify the authors. The main text of the manuscript should be presented in the following order: (i) abstract and key words, (ii) text, (iii) references, (iv) tables (each table complete with title and footnotes), (vii) figure legends. Figures and supporting information should be submitted as separate files. Footnotes to the text are not allowed and any such material should be incorporated into the text as parenthetical matter. Abstract and keywords Original articles must have a structured abstract that states in 250 words or less the purpose, basic procedures, main findings and principal conclusions of the study. Divide the abstract with the headings: Background and Aim, Methods, Results, Conclusions. The abstracts of reviews need not be structured. The abstract should not contain abbreviations or references. Three to five keywords should be supplied below the abstract and should be taken from those recommended by the US National Library of Medicine’s Medical Subject Headings (MeSH) browser—(http://www.nlm.nih.gov/ mesh/meshhome.html). Text Authors should use subheadings to divide the sections of their ma-nuscript: Introduction, Methods, Results, Discussion Acknowledg-ments and References. References The Vancouver system of referencing should be used. In the text, references should be cited using superscript Arabic numerals in the order in which they appear. If cited only in tables or figure legends, number them according to the first identification of the table or figure in the text. In the reference list, the references should be numbered and listed in order of appearance in the text. Cite the names of all authors when there are six or less; when seven or more list the first three followed by et al. Names of journals should be
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abbreviated in the style used in MEDLINE. Reference to unpublished data and personal communications should appear in the text only. References should be listed in the following form: Number references in the order cited as Arabic numerals in parentheses on the line. Only literature that is published or in press (with the name of the publication known) may be numbered and listed; abstracts and letters to the editor may be cited, but they must be less than 3 years old and identified as such. Refer to only in the text, in parentheses, other material (manuscripts submitted, unpublished data, personal communications, and the like) as in the following example: (Chercheur X, unpublished data). If the owner of the unpublished data or personal communication is not an author of the manuscript under review, a signed statement is required verifying the accuracy of the attributed information and agreement to its publication. Use Index Medicus as the style guide for references and other journal abbreviations. List all authors up to six, using six and "et al." when the number is greater than six. Tables Tables should be self-contained and complement, but not duplicate, information contained in the text. Number tables consecutively in the text in Arabic numerals. Type tables on a separate page with the legend above. Legends should be concise but comprehensive – the table, legend and footnotes must be understandable without reference to the text. Vertical lines should not be used to separate columns. Column headings should be brief, with units of measurement in parentheses; all abbreviations must be defined in footnotes. Footnote symbols: †, ‡, §, ¶ should be used (in that order) and *, **, *** should be reserved for P-values. Statistical measures such as SD or SEM should be identified in the headings. Figure legends Type figure legends on a separate page. Legends should be concise but comprehensive – the figure and its legend must be understandable without reference to the text. Include definitions of any symbols used and define/explain all abbreviations and units of measurement Indicate the stains used in histopathology. Identify statistical measures of variation, such as standard deviation and standard error of the mean. Figures All illustrations (line drawings and photographs) are classified as figures. Figures should be numbered using Arabic numerals, and cited in consecutive order in the text. Each figure should be supplied as a separate file, with the figure number incorporated in the file name. Preparation of Electronic Figures for Publication: Although low quality images are adequate for review purposes, publication requires high quality images to prevent the final product being blurred or fuzzy.
SUBMISSION REQUIREMENTS Manuscripts should be submitted online at rjmilmed@yahoo.com A cover letter containing an authorship statement should be included. The cover letter should include a statement covering each of the following areas: 1. Confirmation that all authors have contributed to and agreed on the content of the manuscript, and the respective roles of each author. 2. Confirmation that the manuscript has not been published previously, in any language, in whole or in part, and is not currently under consideration elsewhere. 3. A statement outlining how ethical clearance has been obtained for the research, particularly in relation to studies involving human subjects, and animal experimentation. The institutional ethics
committees approving this research must comply with acceptable international standards (such as the Declaration of Helsinki) and this must be stated. 4. For research involving pharmacological agents, devices or medical technology, a clear Conflict of Interest statement in relation to any funding from or pecuniary interests in companies that could be perceived as a potential conflict of interest in the outcome of the research. 5. For clinical trials, that these have been registered in a publically accessible database. If the above items are not included in the cover letter, manuscripts cannot be sent for review. Please also note that the cover letter does not require a detailed or lengthy description of the content or structure of the manuscript itself. Two Word-files need to be included upon submission: A title page file and a main text file that includes all parts of the text in the sequence indicated in the section 'Parts of the manuscript', including tables and figure legends but excluding figures which should be supplied separately. The main text file should be prepared using Microsoft Word, doubled-spaced. The top, bottom and side margins should be 30 mm. All pages should be numbered consecutively in the top right-hand corner, beginning with the first page of the main text file. Each figure should be supplied as a separate file, with the figure number incorporated in the file name. For submission, low-resolution figures saved as .jpg or .bmp files should be uploaded, for ease of transmission during the review process. Upon acceptance of the article, high-resolution figures (at least 300 d.p.i.) saved as .eps or .tif files will be required.
PUBLICATION PROCESS AFTER ACCEPTANCE Accepted papers will be passed to production team for publication. The author identified as the formal corresponding author for the paper will receive an email, being asked to complete an electronic license agreement on behalf of all authors on the paper. Accepted Articles The accepted ‘in press’ manuscripts are published online very soon after acceptance, prior to copy-editing or typesetting. Accepted Articles are published online a few days after final acceptance, appear in PDF format only, are given a Digital Object Identifier (DOI), which allows them to be cited and tracked. After print publication, the DOI remains valid and can continue to be used to cite and access the article. Given that copyright licensing is a condition of publication, a completed copyright form is required before a manuscript can be processed as an Accepted Article. Proofs Once the paper has been typeset, the corresponding author will receive an e-mail alert containing instructions on how to provide proof corrections to the article. It is therefore essential that a working e-mail address is provided for the corresponding author. Proofs should be corrected carefully; the responsibility for detecting errors lies with the author. The proof should be checked, and approval to publish the article should be emailed to the Publisher by the date indicated; otherwise, it may be signed off on by the Editor or held over to the next issue. Offprint A PDF reprint of the article will be supplied free of charge to the corresponding author. Additional printed offprint may be ordered for a fee.
COPYRIGHT, LICENSING AND ONLINE OPEN Details are on the Copyright Agreement Form that must be completed and signed when the Article is accepted.
Romanian Journal of Military Medicine
New Series, Vol. CXXII, Suppl/2019, October
ISSN-L 1222-5126; eISSN 2501-2312; pISSN 1222-5126