Category Archives: AMM 2011, Volume 57, Number 6

Management Algorithm for Surgical Patients Infected with Human Immunodeficiency Virus

Zaharia Kézdi Erzsébet Iringó1, Boţianu A2, Ioniţă Alexandrina1, Georgescu Anca1, Incze Andrea1, Şincu Nina1

1 Clinic of Infectious Diseases I, Tîrgu Mureș, Romania
2 Surgery Clinic II, University of Medicine and Pharmacy, Tîrgu Mureș, Romania

Objective: The purpose of this study was to establish the risk factors which influence the postoperative evolution of surgical patients infected with human immunodeficiency virus (HIV), and to conceive a management algorithm based upon these factors.
Methods: We have performed a bidirectional transversal study on a group of 73 HIV-positive patients who had undergone 104 surgical procedures during 2006–2010 in the university medical center of Tîrgu Mureş. We studied risk factors such as the number of CD4 T-cells (LTCD4) < 100/µl, anemia, thrombocytopenia, hypoproteinemia, leukopenia, wasting syndrome, ASA (American Society of Anesthesiologists) score, Altemeier class and NNISS (National Nosocomial Infections Survey Systems) score. We defined any registered postoperative complication, as well as all deaths within the first 30 days from surgery as poor outcome. We used GraphPad statistical program, Fisher test for the statistical analysis of data, we interpreted p <0.05 as statistically significant, for a CI of 95%.
Results: We have registered a total of 15 complications, 5 deaths. Risk factors associated with poor postoperative outcome were LTCD4 <100/µl (p=0.03) wasting syndrome (p=0.0001), ASA score > 1 (p=0.01), Altemeier class > II (p=0.0001), NNISS score 1 (p=0.0001).
Conclusions: HIV-infected patients with emergency surgical pathology will benefit of surgical treatment when the anesthetic risk does not overpass the surgical risk, while patients who require elective interventions will be operated after the correction of risk factors.

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Lyme Neuroborreliosis – A Retrospective Study

Țilea Brîndușa1, Țilea I2, Brînzaniuc Klara3, Georgescu Anca1, Gîrbovan Cristina1

1 1st Clinic of Infectious Diseases, Faculty of Medicine, University of Medicine and Pharmacy, Tîrgu Mureș, Romania
2 Internal Medicine III, Faculty of Medicine, University of Medicine and Pharmacy, Tîrgu Mureș, Romania
3 Anatomy and Human Embriology Department, Faculty of Medicine, University of Medicine and Pharmacy, Tîrgu Mureș, Romania

Background: Lyme Neuroborreliosis represents the acute or chronic infection of the central nervous system (CNS) and peripheric nervous system (PNS), as a consequence of a systemic infection.
Objectives: to evaluate the epidemiological, clinical, serological and post-therapeutic implications of CNS and PNS damage during Borrelia burgdorferi (Bb) infection.
Material and method: We performed a retrospective study on 23 patients admitted between January 1st, 2009 – December 31, 2010. The patient’s inclusion was made respecting the criteria of the European Center for Diseases Control (ECDC) and the European Union Concerted Action on Lyme Borreliosis (EUCALB). The levels of antiBb antibodies (IgM, IgG) were measured in the cerebro-spinal fluid (CSF) and in the serum using ELISA and Western blot methods. Imaging techniques were used in the case of patients with meningeal and cerebral lesions. The patients were treated with 3rd generation cephalosporins and cyclins. Statistical analysis was performed using the Chi square and Student tests.
Results: Twenty patients (86.96%) were included in the acute phase and 3 patients (13.04%) in the chronic phase of the disease. Meningeal damage was observed in 16 patients (69.56%), cerebral damage in 4 patients (17.39%), cranial nerve lesions in 2 patients (8.69%), radiculoneuritis in 1 patient (4.34%). Serological investigations using the ELISA method revealed the presence of antiBb antibodies in 100% of cases, in the CSF antiBb IgM antibodies were found in 18 patients (78.26%), IgG in 3 patients (13.04%); using the Western-blot method IgM antibodies were found in 20 patients (86.96%) and IgG in 3 patients (13.04%).
Conclusions: Early diagnosis and therapy led to a favorable evolution compared with patients who were treated late, the latter presenting neurological sequelae and relapses.

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Therapeutical Features of Permanent Atrial Fibrillation in Hypertensive Elderly Patients

Toma L1, Baricz Emőke1, Dorgo Monica1, Caraşca E1,2

1 Medical Clinic IV, Tîrgu Mureș, Romania
2 Internal Medicine Departament, University of Medicine and Pharmacy, Tîrgu Mureș, Romania

Introduction: The atrial fibrillation is a form of arrhythmia, which occurs most frequently among the aged and which often influences the therapy prescribed to them.
Material and methods: The present study addresses to a focus group of 79 hypertensive elderly patients, hospitalized at the Internal Medicine Clinic of Targu Mures during the year 2007. The parameters taken into consideration were distribution by age groups, gender, the existence of atrial fibrillation or other comorbidities and the administrated therapy.
Results: The distribution by age groups and gender reveals a higher number of hypertensive patients between 70 and 75 years and a more frequent affection of male patients. The associated comorbidities to our group of 28 patients with atrial fibrillation were cardiac ischemic disease (13 patients), heart failure (2 patients), both of these (6 patients) and chronic obstructive lung disease (7 patients). The medication administrated for the rate control consists of: beta-blocker in almost 50% of cases (13 out of 28 patients), digitalis (2 patients), and beta-blocker+digitalis for 6 patients. In 7 cases the rate control medication was not required.
Conclusions: The atrial fibrillation is a common condition among the hypertensive elders, and not infrequently associated with other cardiac comorbidities which contribute to the choice of appropriate medication.

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Identification of the Photodegradation Products of the Tricyclic Antidepressant Drugs Clomipramine and Doxepine

Székely P1, Gyéresi Á2, Hancu G2, Laczkó Zöld Eszter3, Vancea Szende4

1 Department of Pharmaceutical Marketing, University of Medicine and Pharmacy, Tîrgu Mureş, Romania
2 Department of Pharmaceutical Chemistry, University of Medicine and Pharmacy, Tîrgu Mureş, Romania
3 Department of Pharmacognosy, University of Medicine and Pharmacy, Tîrgu Mureş, Romania
4 Department of Physical Chemistry, University of Medicine and Pharmacy, Tîrgu Mureş, Romania

Objective: Isolation and identification of the photodegradation products of the tricyclic antidepressant drugs clomipramine and doxepine after irradiation with ultraviolet light.
Methods: The photodegradation products were separated by a thin layer cromatographic method, followed by scraping the spots from the chromatoplate and extracting in methanol, which was followed by their identification by mass spectrometry.
Results: In the case of clomipramine seven degradation products were separated and the corresponding m/z values were determined, while analyzing doxepine there have been separated eight degradation products, of which six were identified by their m/z values. The results obtained for clomipramine are in accordance with literature data, except for desmethyl-clomipramine, for which we could not find any reference. Conclusions: The m/z values indicate that the possible degradation products for clomipramine are imipramine, HO-imipramine, desmethyl-clomipramine and HO-imipramine-N-oxide. In the case of doxepine we could identify two possible photodegradation products, HO-doxepine and doxepine-N-oxide.

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Modification of Renal Permeability for Proteins after General Anesthesia with Sevoflurane and Desfluran

Stoian M1, Stoian Adina2, Cozma D3, Brusnic Olga4, Pascarenco Ofelia4, Iacob Oana2, Șchiopu A2

1 Department of Anesthesiology and Intensive Care, County Emergency Hospital, Tîrgu Mureș, Romania
2 Department of Pathophysiology, University of Medicine and Pharmacy, Tîrgu Mureș, Romania
3 Surgery Clinic no. 1, County Emergency Hospital, Tîrgu Mureș, Romania
4 Gastroenterology Clinic, County Emergency Hospital, Tîrgu Mureș, Romania

Introduction: Sevoflurane degradation by carbon dioxide absorbents during low-flow anesthesia lead to the formation of a haloalkene called compound A, which causes nephrotoxicity.
Material and methods: We determined proteinuria by spectophotometry at 600 nm, preoperatively and postoperatively at 24 and 72 hours in 52 patients undergoing general anesthesia with sevoflurane and 25 patients undergoing general anesthesia with Desfluran. We selected patients without previous renal disease, with anesthetic risk ASA I–III who underwent major abdominal and thoracic surgery lasting more than 150 minutes and we used a 2 l/minute FGF-fresh gas flow, with a MAC-minimal alveolar concentration of 1.5 to 1.8 for Sevoflurane, and of 6–8 MAC for Desfluran.
Results: Renal permeability is impaired by general anesthesia with Sevoflurane (p ˂ 0.0001) and Desfluran (p > 0,001). The amount of filtered protein has a maximum at 24 hours after surgery with gradual decrease within 72 hours, but without reaching the normal preoperative values.
Conclusions: There is proteinuria after exposure to volatile agents like Sevoflurane and Desfluran recording a maximum in the first 24 hours and there is also a tendency to normalization within 72 hours. We noticed a marked impairment of renal permeability in association with specific groups of pathology as septic patients, diabetics, hypertensives, especially after Sevoflurane anesthesia. There was no-one case of acute renal failure in which to criminalize Sevoflurane or Desfluran.

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The Preventive Surgery of Proximal Aortic Manifestations in Marfan Syndrome

Seres-Sturm L jr1, Suciu H2, Szabolcs Z3

1 Department of Cardiac Surgery, University of Pécs, Hungary
2 Institute of Cardiovascular Diseases and Transplantation, University of Medicine and Pharmacy, Tîrgu Mureș, Romania
3 Department of Cardiac Surgery, Semmelweis University, Budapest, Hungary

Background: Marfan syndrome (MFS) is a genetic connective tissue disease with an incidence of 2–3/10000 individuals resulting in multiple organ system affection, aortic dilatation, dissection and rupture the most severe cardiovascular complications according to natural history. These consequences can be prevented by prophylactic aortic surgery.
Methods: Results are presented of patients (N=22; mean age: 26.95±9.01, min: 9; max: 42; male/female ratio=16/6) underwent elective preventive surgery over a 11 years period.
Results: Preventive operations have zero 30 days mortality and still the best results in approaching normal population life extent compared to the survival of other indication groups. Secondary vascular complications should be monitored life-long after the succesful treatment of the diseased thoracic aorta of Marfan patients due to the systemic property of the extant syndrome.
Conclusions: After identifying the condition and registering people with MFS in a national database, the regular check-ups, preventive operations bear great importance. Timing is crucial for the preventive operation, because the underlying disease (MFS) exposes the aorta to be a “ticking” bomb that can lead to serious consequences like aortic dissection or rupture with possible fatal outcome. Preventive aortic operations at MFS patients enjoy the benefitial outcomes and nature of the management compared to other acute type, emergency or urgent operations. The effective prevention lays on carrying out the prophylactic surgery together with the continuous check-up of the predisposed and operated patients by the help of a professional nationwide register for people with MFS that, if not created yet, should be established as well.

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Does the Result of Completion Axillary Lymph Node Dissection Influence the Recommendation for Adjuvant Treatment in Sentinel Lymph Node Positive Patients?

Sávolt Á1, Mátrai Z1, Tóth L1, Polgár C2, Musonda P3, Szabó É4, Horváth Z5, Kásler M6, Péley G7

1 Department of General and Thoracic Surgical Oncology, National Institute of Oncology, Budapest, Hungary
2 Department of Radiotherapy, National Institute of Oncology, Budapest, Hungary
3 School of Medicine, Health Policy and Practice, University of East Anglia, Norwich, UK
4 Department of Diagnostic Radiology , National Institute of Oncology, Budapest, Hungary
5 Department of Medical Oncology, National Institute of Oncology, Budapest, Hungary
6 National Institute of Oncology, Budapest, Hungary
7 Department of General Surgery, Norfolk and Norwich University Hospital, Norwich, UK

Aims: The Hungarian National Institute of Oncology has just closed a single-centre randomized clinical study. The OTOASOR (Optimal Treatment of the Axilla – Surgery or Radiotherapy) trial compares completion axillary lymph node dissection (ALND) to regional nodal irradiation (RNI) in patients with sentinel lymph node-positive (SLN+) primary invasive breast cancer. In the investigational treatment arm patients received 50 Gy RNI instead of completion ALND. In these patients we had information only about the SLN status, but the further axillary nodal involvement remained unknown. The aim of this study was to investigate whether the result of completion ALND influenced the recommendation for adjuvant treatment in SLN+ breast cancer patients.
Patients and methods: Patients with SLN+ primary breast cancer were randomized for completion ALND (arm A-standard treatment) or RNI (arm B-investigational treatment). Adjuvant systemic treatments was given according to the standard institutional protocol and patients were followed according to the actual institutional guidelines.
Results: Between August 2002 and June 2009, 474 SLN+ patients were randomized to completion ALND (arm A-standard treatment, 244 patients) or RNI (arm B-investigational treatment, 230 patients). There were no significant differences in terms of major prognostic factors between the two arms. Two-hundred and fourty-two patients (99.6%) on arm A and 229 patients (99.6%) on arm B received adjuvant systemic treatments including chemotherapy and/or endocrine treatment (p=NS). One-hundred and ninety-four patients (79.5%) received adjuvant chemotherapy on arm A and 159 patients (69.1%) on arm B (p=0.031). Two-hundred and four patients (83.6%) received adjuvant endocrine treatment on arm A and 196 patients (85.2%) on arm B (p=NS). Six patients (2.5%) received adjuvant trastuzumab treatment on arm A and 13 patients (5.7%) on arm B (p=NS).
Conclusions: The result of completion ALND after positive SLNB appears to have no major impact on the administration of adjuvant systemic therapy.

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TNF-α and MMP-8 as Biomarkers for Diagnosing Knee Cartilage Lesions — Preliminary Results

Russu OM1, Gergely I1, Zazgyva Ancuţa1, Zuh SGy1, Nagy E2, Nagy Ö1, Pop TS1

1 Department of Orthopaedics and Traumatology, University of Medicine and Pharmacy, Tîrgu Mureş, Romania
2 Department of Pharmaceutical Biochemistry, University of Medicine and Pharmacy, Tîrgu Mureş, Romania

Objective: To analyse the correlations between the levels of Tumor Necrosis Factor α, Matrix Metalloproteinase 8, Interleukin 6 and the presence of cartilage lesions in the knee.
Methods: We studied 79 individuals divided in three groups – a group with cartilage lesions, a group with meniscal lesions and a control group. All patients underwent arthroscopic surgical interventions – either diagnostic or therapeutic. Venous blood samples and synovial fluid samples were obtained and we determined the levels of TNF-α, MMP-8 and IL-6 respectively. All study participants filled out the International Knee Documentation Committee (IKDC) Subjective Knee Evaluation Score questionnaire, based on which the IKDC score was calculated.
Results: we found higher levels of MMP-8 in both serum and synovial fluid for groups 1 and 2 compared to the control group, but no correlation between the serum and synovial fluid levels of MMP-8. The serum MMP-8 levels showed a significant negative correlation with the highest level of activity without pain and significant giving way. The synovial MMP-8 could be correlated to the IKDC score. Serum levels and synovial levels of TNF-α were in strong correlation. We found no association between serum and/or synovial TNF-α and MMP-8 levels.
Conclusions: We found that synovial MMP-8 concentrations showed a reverse correlation with the IKDC scores (an activity-based score) – thus MMP-8 might be a diagnostic and prognostic marker in knee osteoarthritis.

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Revascularization Therapy in Stable Coronary Artery Disease

Pretorian A1, Borda Angela2, Dobreanu D3, Pretorian Ana-Maria1

1 Department of Cardiology, Municipal Hospital, Gheorgheni, Romania
2 Department of Pathology, Faculty of Medicine, University of Medicine and Pharmacy, Târgu Mureş, Romania
3 Department of Cardiology, Institute of Cardiovascular Diseases and Transplantation, Târgu Mureş, Romania

Introduction: In patients with stable coronary artery disease, there are controversial studies that compare the optimal medical therapy with revascularization therapy in reducing the risk of cardiovascular events.
Material and method: The study included 221 patients with stable coronary artery disease who underwent coronarography and had objective evidence of significant coronary disease. Of these, 73 underwent percutaneous coronary intervention, 71 underwent coronary artery bypass grafting, both subgroups with optimal medical therapy, and 77 received optimal medical therapy alone. Primary outcomes were cardiac death and non fatal myocardial infarction, during a follow-up period of 4.5 years. Secondary outcomes were persistent disabling angina (quality of life) and the need for repeat revascularization.
Results: There were 15 primary events in the medical-therapy group, 5 events in the surgical group and 5 events in the percutaneous coronary intervention group. In subgroups analysis, among patients with non-high risk criteria (one or two-vessel disease, without significant ventricular dysfunction), the primary outcome was 2.5% in the medical group and 1.78% in the PCI group, while the persistent disabling angina occurred in 22.5% in the medical group versus 12.50% in the interventional group versus 18.75% in the coronary artery bypass grafting group (p = 0.42). Among high-risk criteria patients there was a tendency for increased repeat target vessel revascularization in the interventional group vs surgical group (17.64% vs 5.45%). The primary outcome was similar in both groups (11.76% vs 9.09%).
Conclusion: For patients with stable angina that is not significantly interfering with the quality of life and without high-risk characteristics, medical therapy rather than immediate revascularization seems to be the right option. Patients with high-risk criteria benefit from a more complete revascularization by coronary artery bypass grafting, but most often the patient will prefer the interventional aproach.

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Accelerated Partial Breast Irradiation with Multicatheter Brachytherapy: 15-year Results of a Phase II Clinical Trial

Polgár C1, Major T1, Fodor J1, Sulyok Z2, Somogyi A1, Németh Gy1, Kásler M3

1 Department of Radiotherapy, National Institute of Oncology, Budapest, Hungary
2 Department of General and Thoracic Surgery, National Institute of Oncology, Budapest, Hungary
3 National Institute of Oncology, Budapest, Hungary

Background and purpose: To report the 15-year updated results of accelerated partial breast irradiation (APBI) using multicatheter interstitial high-dose-rate (HDR) brachytherapy (BT).
Patients and methods: Forty-five prospectively selected patients with T1N0-N1mi, nonlobular breast cancer without the presence of an extensive intraductal component and with negative surgical margins were treated with APBI after breast-conserving surgery (BCS) using interstitial HDR BT. A total dose of 30.3 Gy (n=8) and 36.4 Gy (n=37) in seven fractions within 4 days was delivered to the tumour bed plus a 1–2 cm margin. The median follow-up time was 166 months for surviving patients. Local control, disease-free (DFS), cancer-specific (CSS), and overall survival (OS), as well as late side effects, and cosmetic results were assessed.
Results: Five (11.1%) ipsilateral breast tumour recurrences were observed, for a 5-year, 10-year, and 15-year actuarial rate of 4.4%, 9.4%, and 11.9%, respectively. The 15-year DFS, CSS, and OS was 75.4%, 86.2%, and 82.0%, respectively. Grade 3 fibrosis was observed in 1 patient (2.2%). No patient developed grade 3 teleangiectasia. Fat necrosis requiring surgical intervention occurred in 1 woman (2.2%). Cosmetic results were rated excellent or good in 36 patients (80%).
Conclusions: Fifteen-year results with APBI using HDR multicatheter interstitial implants continue to demonstrate excellent long-term local tumour control, survival, and cosmetic results with a low-rate of late side effects.

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