Category Archives: AMM 2018

Case Presentation: Unusual Association Between Possible Bilateral Intraventricular Xanthogranulomas, Postero-inferior Cerebellar Artery Aneurysm and Thrombophilia

DOI: 10.2478/amma-2018-0027

Introduction: Xanthogranulomas are rare, benign, usually asymptomatic, cutaneous tumors most frequently seen in children (juvenile xanthogranulomas). Some lesions can be found accidentally at randomly performed cerebral computer tomography (CT) or magnetic resonance imaging (MRI) or even on autopsy.
Case report: We present the case of a 44 year-old woman, known with a thrombophilic disorder (PAI-1 gene mutation, MTHFR C677T and A1298C) on chronic anticoagulant treatment. The onset of symptoms was in 2010, when she presented paresthesia and lower limbs weakness. Two years later the patient presents with severe intermittent headache and left hemicrania and a cerebral angio-MRI is performed showing a left postero-inferior cerebellar artery aneurysm and two choroid plexus intraventricular masses in the lateral ventricles. The patient developed a new symptom, dysarthria in 2014 and in 2015 has multiple episodes of loss of consciousness, interpreted as epileptic seizures. Routine blood tests were within normal range, except for a high cholesterol level. The patient was tested for autoimmune, infectious, endocrine and metabolic diseases that were negative. Surgical treatment and biopsy from the lesion was proposed, however the patient refused both procedures.
Conclusions: There is an association between xanthogranulomas localization and the choroid plexus, the most frequent CNS origin being in the trigon of the lateral ventricle. Our case does not resemble with any other case published, mostly because the unusual presentation, symptomatology and the association between xanthogranulomas, thrombophilia and postero-inferior cerebellar artery aneurysm which were never reported before in other cases of xanthogranulomas from the literature.

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Uncommon Finding of a Gastrointestinal Stromal Tumor in a Patient with Hyperechoic Liver Lesions – Case Report

DOI: 10.2478/amma-2018-0026

Introduction: Hyperechoic liver lesions identified by conventional ultrasonography are diverse in underlying pathology and most of the time require further investigations. Gastrointestinal stromal tumors (GIST) are rare neoplasms of the gastrointestinal tract which are uncommonly found in metastatic stages at first presentation.
Case report: We present the case of a 51 years old woman with nonspecific symptoms in which conventional ultrasonography showed hyperechoic lesions in the right lobe of the liver with a diameter up to 40 mm. Esophagogastroduodenoscopy revealed a submucosal tumor on the small curvature of the stomach, on the anterior wall, with central ulceration, with normal narrow band imaging (NBI) mucosal pattern and negative gastric biopsy. Contrast enhanced ultrasonography was performed, describing multiple lesions with inhomogeneous enhancement in the arterial phase and rapid washout at the end of arterial phase. Endoscopic ultrasound with fine needle aspiration (EUS-FNA) biopsy examination was definitive for the final diagnosis of epithelioid gastric gastrointestinal stromal tumor. The patient was diagnosed with T2N0M1 epithelioid gastric GIST, stage IV, and is currently under treatment with tyrosine kinase inhibitors.
Conclusions: GIST represent a diagnostic challenge in medical practice because of its size, unusual location in the submucosal layer and lack of symptoms. The role of EUS-FNA is of paramount importance in increasing the accuracy of diagnosis in the case of GIST. The particularity in our case consists of the unusual presentation with the lack of specific symptoms and signs associated with the presence of metastatic lesions at the moment of the diagnosis of GIST.

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Going the Full Circle: Upgrading the Patient Field Chart and Tag for Electronic Mass Casualty Incidents Solutions in Romania

DOI: 10.2478/amma-2018-0025

Objective: Mass casualty incidents and disasters require functional and efficient patient data management systems, as well as smart interconnections with patient tracking applications. Various initiatives developed and tested patient field charts for large-scale events but there is no one definite general format accepted. The current research proposes an upgraded model of the official patient field chart issued by the Romanian Department for Emergency Situations in 2015 to be used for large-scale events.
Measures: An upgraded model is created after a thorough content analysis, physical analysis, design upgrade and optimization process. Differences between the official and the upgraded model are measured and compared, and statistical computations are carried out.
Results: The main distinctive features of the patient field chart are dynamic triage, unique code identification, QR visual codes, wireless tags and irreversible clear contamination status highlighting. The upgrade process results in almost doubling the available active area without the need to change the document size format of the product. Visual elements and features are included to optimize operation workflow.
Conclusions: The upgraded model offers a variety of improvements for both the overall rescue effort as well as the end user of the product. It allows for previously unavailable features like unlimited dynamic triage and enables the use of electronic management solutions.

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Eating Behaviour and Food Preferences of Tîrgu Mures High School Students

DOI: 10.2478/amma-2018-0014

Introduction. Due to a busy and exhausting urban lifestyle parents do not always have the necessary time to pay sufficient attention to the quality of the dietary habits of their children.
Objective. Starting from the premise that teenagers have insufficient information about healthy eating, the present study aimed to highlight eating behaviours and nutrition knowledge deficits in a group of 427 high school students from Tîrgu Mures.
Methods. An observational study based on lifestyle and food frequency consumption was conducted. In 2017, students in fifteen classes from several High School Institutions from Targu Mures, Romania, were asked to complete a questionnaire with questions relating to the current state of health, lifestyle characteristics, anthropometric indicators, frequency of daily meal consumption, significance and intake of food additives, leisure activities performed and also teenagers’ preferences for food products.
Results. The average age of the respondents was 16.1 years old, 72.6% were boys, and 82% lived in the city. 43.6% of respondents stated that food is a necessity, while 22% asserted that food characterizes a pleasure for them. Concerning the calorific value of foods, 32.8% stated that they have no interest in the calorie content of different food products while only 26%, mainly girls, took notice of these. 31.10% of respondents indicated that they include the recommended amount of vegetables in their daily diet, 22% prefer to eat preserved foods while increased consumption of sweets was observed in 39.80%. 55.50% of respondents ate breakfast on a regular basis, and 37% read food labels.
Conclusions. The results emphasize the necessity to develop more effective educational programs designed to create necessary background information for a young generation, change adolescent dietary behaviours for the better, and thus prevent dietary related diseases.

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Effect of Food on the Pharmacokinetics of Gliclazide 60 mg Modified Release Tablet in Healthy Caucasian Volunteers

DOI: 10.2478/amma-2018-0022

Objective: To evaluate the food effect on glicazide disposition in clinical trials conducted on healthy Caucasian volunteers who were given a new modified release oral formulation of Gliclazide 60 mg developed by Sun Pharmaceutical Industries, India.
Methods: The studies were designed as open-label, randomized, single-dose, crossover studies that consisted of two periods. During each study, venous blood samples were taken before and after drug administration up to 96 hours. Subsequently, individual plasma profiles were determined and non-compartmental method was employed for the assessment of food effect on the pharmacokinetic profile of gliclazide. The statistical significance of differences for the main pharmacokinetic parameters was evaluated by ANOVA test, for p < 0.05 statistical significance was decided. The relative profiles of absorption of gliclazide were obtained by mathematical deconvolution. All calculations were performed by Phoenix WinNonlin®.
Results: High-fat, high-calorie meal decreased gliclazide exposure. The mean maximum plasma concentration decreased with 14%, while the mean total area under the plasma concentration-time profile registered a 17% decrease. The elimination half-lives under fasted and fed conditions were comparable and the time to maximum plasma concentration was shortened under fed condition. Safety evaluation showed that overall gliclazide was well tolerated under both fasted and fed condition.
Conclusions: The statistical analysis revealed the lack of food effect on the new modified release tablets of Gliclazide 60 mg. However, before stating a definite conclusion regarding the food effect on gliclazide pharmacokinetic profile, additional studies on patients with type 2 diabetes mellitus should be conducted.

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New Insights in Growth Hormone Stimulation Tests Protocols

DOI: 10.2478/amma-2018-0021

Objective: The objective of this study was to analyze the performance of 2 stimulation tests used in the diagnosis of growth hormone deficiency.
Method: A retrospective study was conducted on a non-random sample of 310 patients, between 2 and 20 years old, who were hospitalized in the Mureș County Hospital’s Endocrinology Department and in the National Institute of Endocrinology C.I. Parhon with short stature between 2009-2015. Inclusion criteria: all subjects who underwent growth hormone stimulation tests in accordance with the national protocol. Microsoft Office Excel was used for data collection and MedCalc v 12.5 was used for statistical analysis.
Results: From the total of 310 patients, 102 were diagnosed in Târgu Mureș and 208 in Bucharest. Sex ratio favored boys (boys:girls 1.64:1). In 173 subjects growth hormone deficiency was confirmed. For both tests the percentage of maximum response was the highest for the 60 minutes blood sample regardless if the test were positive or not. Both tests have 100% sensitivity and negative predictive value, with the highest specificity for the 60 minutes clonidine and 30 minutes insulin. The false positive rate was 60% for the insulin test and 27.2% for clonidine for Târgu Mureș sample and 86.9% for the insulin test and 62.5% for clonidine for Bucharest sample. The concordance of the 2 tests was 49.36%.
Conclusions: Stimulating growth hormone testing has a number of limitations but is still needed in some auxological circumstances. We recommend performing the clonidine test first to exclude idiopathic short stature and then the insulin tolerance test for the diagnosis of growth hormone deficiency.

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General Characteristics and Quality of Stroke-Related Online Information – A Cross-Sectional Assessment of the Romanian and Hungarian Websites

DOI: 10.2478/amma-2018-0023

Background: The quality of online health-related information may affect users’ understanding and medical decision-making with dramatic impact, particularly in case of stroke.
Objective: The objective of this study was to assess the quality of information about stroke on the Romanian and Hungarian websites in terms of completeness and accuracy.
Methods: The research was designed as an observational cross-sectional study. The sample included 25 Romanian and 25 Hungarian websites presenting information about stroke for the general public. General characteristics such as website ownership, main goal, website genre and medical approach were identified by the evaluators using a predetermined set of common instructions. The completeness and accuracy of the information were assessed by two independent assessors against a quality benchmark.
Results: Overall, most of the websites were owned by private commercial companies (42%), had educational goal (66%), were designed as medical web-portals (46%) and had a conventional medicine approach (72%). Mean completeness score was 5.6 points (SD± 1.9) for Romanian sites and 4.1 points (SD ± 2.4) for Hungarian sites (p = 0.017). Mean accuracy score was 6.2 points (SD ± 1.1) for Romanian sites and 7.0 points (SD ± 0.7) for Hungarian sites (p = 0.02).
Conclusions: The information about stroke on the Romanian and Hungarian websites had poor quality. Although we found statistically significant differences between the quality scores of the two language sub-samples and two site characteristics associated with significantly higher quality, the practical relevance of these findings for online health information seekers should be interpreted with caution.

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Histopathological Diagnostic Criteria for Non-invasive Follicular Thyroid Neoplasm with Papillary-like Nuclear Features Highlighted by Six Illustrative Cases

DOI: 10.2478/amma-2018-0015

Introduction. The encapsulated, non-invasive subtype of follicular variant of papillary thyroid carcinoma (FVPTC) represents approximately 10% to 20% of all thyroid cancers. Many studies over the past decade have shown that these tumors carry an indolent clinical course, with no recurrence, even in patients treated by lobectomy. Their reclassification as neoplasms with “very low malignant potential” has recently been suggested by an international group of experts and a new terminology was proposed: “non-invasive follicular thyroid neoplasm with papillary-like nuclear features” (NIFTP). However, a diagnosis of NIFTP is still challenging for many pathologists in daily practice.
Presentation of case series. By presenting six illustrative cases of NIFTP, this article aims to highlight the diagnostic criteria and the burden difficulties when dealing with NIFTP cases. Characteristic histological features, inclusion and exclusion criteria for NIFTP, as well as sampling guidelines and differential diagnosis challenges are all discussed.
Conclusions. The diagnosis of NIFTP is not straightforward and requires meeting strict inclusion and exclusion criteria. Total sampling of the tumor capsule in these cases is mandatory in order to exclude invasion (capsular and/or vascular). A diagnosis of NIFTP promotes a less-aggressive patient management that is, no need for completion thyroidectomy or radioactive iodine therapy.

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