Category Archives: AMM 2014, Volume 60, Number 2

Current Surgical Attitude Towards Hydatid Liver Disease – Experience of Ist Surgical Department of the Emergency Hospital of Craiova

DOI: 10.2478/amma-2014-0016

Introduction: The aim of this study is the evaluation of the diagnostic and therapeutic strategy in liver hydatid disease.
Methods: We analyzed 97 cases of liver hydatid cyst (63 females/34 males, aged between 5 and 85 years) hospitalized in the Ist Surgical Department of the Emergency County Hospital of Craiova between 2000 and 2012. The diagnosis was established clinically, by laboratory and imaging tests.
Results: The hydatid cysts were unilocular in 60 cases, the majority (68.31%) being located on the right liver, multilocular in 39 cases, located on both lobes of the liver (9.9%); 17 patients had other locations of the cysts as well (spleen 5 cases, peritoneum 12 cases). Fourty-five (46.39%) cases were uncomplicated and the other 52 cases presented one ore more evolutionary complications: biliary – 44 (43.36%), infection – 15 (14.85%), rupture into peritoneum – 12 cases and bilio-bronchial fistula in 1 case. All patients were operated: 90 patients by open surgery and 7 by laparoscopic approach. Albendazole was administered as prophylaxis of postoperative recurrence. In 73 cases (72.27%) the evolution was favorable. We recorded 26 cases (25.74%) of postoperative complications: infectious – 9 cases, external biliary fistula – 12 cases and general complications in 6 cases. The overall postoperative mortality was 2.06%. We did not register any postoperative complication in the laparoscopic group.
Conclusions: Laparoscopic approach is both safe and feasible, with well codified indications. The most important factor to achieve a successful laparoscopic procedure is the adequate selection of patients. Both intraoperative and postoperative data clearly indicated that the minimal invasive approach provided superior results to open access surgery in terms of complications rate, early recovery and hospital stay.

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Botanical Investigation Of Fallopia Dumetorum (L.) Holub (Polygonaceae) And Qualitative And Quantitative Assessment Of Its Polyphenolic Compounds

DOI: 10.2478/amma-2014-0015

Background: Considering the continuous need to find new sources of polyphenolic compounds, we performed a pharmacognostical examination of the species Fallopia dumetorum (L.) Holub sin. Polygonum dumetorum L. (Polygonaceae). The plant is common in the plain regions of Romania and has not been exploited therapeutically.
Materials and method: Microscopic examination was performed on cross-sections, surface preparations and on powder obtained from the aerial parts of the flowering plant. Qualitative chemical analysis was realized by phytochemical screening and thin layer chromatography (TLC). Phenolic compounds were assayed by spectrophotometric methods: flavonoids expressed as rutin (with aluminium chloride), phenol-carboxylic acids expressed as chlorogenic acid (Arnow’s method) and proanthocyanidins expressed as cyanidin chloride (in acidic medium, by conversion to anthocyanins).
Results: The species has the following microscopic characters: anomocytic stomata, druses of calcium oxalate, sessile, pluricellular glandular hairs and pollen grains with smooth exine. Polysaccharides, reducing compounds, coumarins, sterols/triterpenes, phenol-carboxylic acids, flavones, proanthocyanidins, tannins and carotenoids were identified by phytochemical screening; chlorogenic acid, caffeic acid, quercetin and stigmasterol/beta-sitosterol were detected by TLC. F. dumetori herba has a content of 1.49 ± 0.105 g% polyphenol-carboxylic acids, 0.40 ± 0.087g% flavonoids and 0.18 ± 0.002 g% proanthocyanidins.
Conclusions: We have characterized pharmacognostically the native species F. dumentorum. Due to its content in phenolic compounds it might serve as a source of polyphenols.

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Augmentation Strategies for Patients with Major Depressive Disorder with an Inadequate Response to Antidepressant Monotherapy

DOI: 10.2478/amma-2014-0014

Introduction: Major depressive disorder is a chronic and debilitating disease characterized by a wide range of emotional and physical symptoms that coexist during a depressive episode and may reoccur at some point during the progression of the disease for the majority of patients. The purpose of the study was to investigate psychiatrists’ experience regarding the response to antidepressive treatment and their options regarding augmentation strategies in depression with incomplete response to antidepressant monotherapy.
Method: We applied an 18-item questionnaire containing multiple choice questions to adult psychiatrists working in ambulatories, hospitals or mental health centers.
Results: Fourty-two psychiatrists have agreed to answer the questionnaire. The majority of them were psychiatry specialists, between 35 and 49 years of age, working in an outpatient unit. For the majority of doctors, SSRIs (Serotonin Reuptake Inhibitors) proved to be the first line treatment both for the first depressive episode and for recurrent depression, followed by SNRI (Serotonin and Noradrenalin Reuptake Inhibitors). Regarding the duration of maintenance treatment for the patients who achieved complete remission after the first episode of depression, the results showed a wide spectrum from 4 to 9 months.
Conclusions: Incomplete response to antidepressive monotherapy is very frequent both for the first depressive episode and for recurrent depression. Given the pharmacological profile that some atypical antipsychotic have, augmentation with atypical antipsychotics in patients with inadequate response to antidepressant monotherapy is a useful therapeutic strategy that should be considered.

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Implantation of Biventricular Cardiac Devices Using a Double Venous Approach — An Alternative Implantation Technique

DOI: 10.2478/amma-2014-0013

Background: A standard technique regarding venous approach for implantation of biventricular cardiac electrical devices used for cardiac resynchronization therapy implementation has not yet been established. We analyzed the safety and efficiency of implanting these devices using a double venous approach (cephalic and subclavian) by comparing it with the simple approaches, in order to overcome some of their inconvenients.
Materials and methods: We retrospectively analyzed all 228 resynchronization patients implanted at the Timișoara Institute of Cardiovascular Medicine between January 1st, 2000 and January 1st, 2013. The 204 patients successfully implanted with biventricular pacemakers or defibrillators were divided according to the implantation techniques, and compared by complication rates and values of acute stimulation-detection thresholds. Group A featured a subclavian approach (48 patients), group B a cephalic approach (81 patients) and group C a double venous approach (76 patients).
Results: Adjusting for age, sex and device type there is no evidence in the data that complication rates are significantly different when using the different techniques: 6 complications (12.5%) in group A, 8 (9.87%) in group B and 5 (6.75%) in group C (p = 0.51). A slight downward trend was observed by using double venous approach. Values of acute stimulation-detection thresholds had no statistically significant differences neither (p = 0.36). Cephalic vein was of high quality in 59.8% of cases.
Conclusions: Subclavian and cephalic double venous approach implantation technique for biventricular devices proved to be feasible and at least as safe as single venous approach using subclavian or cephalic vein alone, and it can be used as a first resort technique.

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Facial Profile Characteristics Evaluation in a Population of Central Romania Region

DOI: 10.2478/amma-2014-0012

Objectives: The aim of the study was to evaluate the variables that define the facial profile of a sample of the population in the centre of Romania, and to compare male’s and female’s soft tissue profile. These values could be useful in elaborating the aesthetic objectives for treating the population in this area.
Material and methods: Fifty subjects were included in the study — patients and students of the University of Medicine and Pharmacy of Tîrgu Mureș (29 females and 21 males) between 18 to 28 years of age, having dental class I and a balanced profile. The photographs were taken in the natural head position (NHP). The anthropometric points were recorded and four of the angles that characterize a harmonious profile were traced and measured: the nasofrontal angle (G-N-Nd), the nasolabial angle (Cm-Sn-Ls), the mentolabial angle (Li-Sm-Pg), and the facial angle (G-Sn-Pg).
Results: The values obtained for the two sexes were compared using the t-student test. All angles had values that were larger for females (nasofrontal: females 137.1 degrees, males 135.79 degrees, p = 0.0019; nasolabial: females 105.3 degrees, males 102.19 degrees, p = 0.00002; mentolabial angle: females 126.07 degrees, males 118.27 degrees, p = 0.000009; facial angle: females 170.32 degrees, males 168.85 degrees, p = 0.0033).
Conclusions: Differences between the two sexes were obtained, all angles were statistically significant larger in females. These results show that for the population in the centre of Romania the treatment objectives are different for females and for males. The angular values range between those that characterize the Caucasian population.


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Short Segment Fixation Versus Short Segment Fixation With Pedicle Screws at the Fracture Level for Thoracolumbar Burst Fracture

DOI: 10.2478/amma-2014-0011

Objective: The most prevailing surgical procedure in the treatment of thoracolumbar burst fractures, Short Segment Fixation (SSF), is often followed by loss of correction or hardware failure which may be significant enough to require another surgical intervention. In order to take advantage of its benefits but to avoid or diminish the risk and impact of associated drawbacks, some other alternatives have been lately developed among which we refer to short segment fixation with intermediate screws (SSF+IS). This article provides a comparative picture over the effectiveness of the two above-mentioned surgical treatments, focusing on their potential to prevent the loss of correction.

Methods: After a systematic literature review over research papers published between 2000 and 2012, 14 articles which met the criteria were included in the meta-analysis. The relevant data extracted and compared for each subgroup of patients treated either with SSF or SSF+IS, were the weighted averages for the pre-operative, post-operative and last follow up kyphosis angles. We also considered common associated complications, operation time, and blood loss values for each surgical subgroups.
Results: The values for the loss of correction at the last follow-up were: 5.5° for SS and 7.4° for SSF+IS, which didn’t prove to be statistically different. With reference to other parameters, such as operation time, blood loss and correction attainment, the values did not present statistically significant differences, either. Regarding complications, we noticed that both SSF and SSF+IS display a similar incidence for hardware failure, screw breakages, superficial infections, deep venous thrombosis.
Conclusions: This paper concludes that, adding one or two screws at the fractured vertebra level (SSF+IS) does not bring forth a significant improvement compared to the traditional approach (SSF). Apparently, the blood loss depends mostly on the approach type (open or percutaneous) and less on the surgery type.

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The Importance of Identification of M-BCR-ABL Oncogene and JAK2V617F Mutation in Myeloproliferative Neoplasms

DOI: 10.2478/amma-2014-0010

Background: The elucidation of the genetic background of the myeloproliferative neoplasms completely changed the management of these disorders: the presence of the Philadelphia chromosome and/or the BCR-ABL oncogene is pathognomonic for chronic myeloid leukemia and identification of JAK2 gene mutations are useful in polycytemia vera (PV), essential thrombocytemia (ET) and myelofibrosis (PMF). The aim of this study was to investigate the role of molecular biology tests in the management of myeloproliferative neoplasms.
Materials and methods: We tested the blood samples of 117 patients between April 2008 and February 2013 at the Molecular Biology of UMF Târgu Mureş using RQ-PCR (for M-BCR-ABL oncogene) and/or allele-specific PCR (for JAK2V617F mutation).
Results: Thirty-two patients presented the M-BCR-ABL oncogene, 16 of them were regularly tested as a follow-up of the administered therapy: the majority of chronic phase patients presented decreasing or stable values, while in case of accelerated phase and blast phase the M-BCR-ABL values increased or remained at the same level. Twenty patients were identified with the JAK2V617F mutation: 8 patients with PV, 4 with ET, 3 with PMF, 4 with unclassifiable chronic myeloproliferative disease and 1 patient with chronic myelomonocytic leukemia. There was no case of concomitant occurance of both molecular markers.
Conclusions: Molecular biology testing plays an important role in the management of myeloproliferative neoplasms: identification of the molecular markers confirms the final diagnosis, excluding secondary causes of abnormal blood count parameters. Regular monitoring of M-BCR-ABL expression level is useful in the follow-up of therapeutic efficiency.

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Combination of Ropivacaine and Lidocaine for Long Lasting Locoregional Anesthesia

DOI: 10.2478/amma-2014-0009

Objective: The aim of this study was to evaluate the clinical utility of Ropivacaine 0.5% and Lidocaine 0.5% anestethic combination in performing locoregional anesthesia, using either peripheral nerve stimulator or ultrasounds for brachial plexus block.
Study design: A prospective randomized clinical study was performed at the County Emergency Clinical Hospital of Tîrgu Mureș, between January and May 2013 on patients undergoing elective or emergency surgical interventions on upper limbs with locoregional anesthesia. Brachial plexus block with axillary approach was performed in 65 patients using randomly the nerve stimulator or the ultrasound guided technique. The parameters recorded were the duration of the anesthetic technique, the installation time and the length of anesthesia. All anesthetic incidents during and after anesthesia were observed as well. The recorded data were analyzed and statistically processed.
Results: We enrolled 40 (61.5%) patients for the nerve stimulation technique and 25 (38.5%) patients for ultrasound guidance. The quality of the block was acceptable, an inadequate anesthesia was reported in 9 patients (13.8%). The mean time of installation of anesthesia was 34.36 (± 11.56) minutes, time recorded from the initiation of the anesthetic technique until complete motor block. The mean duration of the motor block was 481.3 (± 128.6) minutes which represents over 8 hours. None of the patients required conversion of the anesthesia due to the extended period of the surgical intervention. One patient presented a mild allergic reaction to the anesthetic drugs.
Conclusion: Combination of the ropivacaine and lidocaine can be safely used for locoregional anesthesia, especially in those cases where long surgical intervention time is anticipated or in order to achieve a better postoperative analgesia.


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Assessment of Ventricular Dissynchrony in Right Ventricular Single Chamber Pacing using Echocardiografic Parameters

DOI: 10.2478/amma-2014-0008

Background: Right ventricular apical pacing has been used since the early years of pace-makers, despite the fact that it determined nonphysiological ventricular depolarization. As medical technologies developed, septal lead implantation became feasible, in order to outrun the above mentioned inconveniences. The question whether the apical or septal lead position is better still gives rise to a lot of controversies. Different echocardiographic parameters are currently used to assess the impact of specific sites of stimulation on ventricular function. The aim of the study was to determine which of the followed synchronicity parameters varied significantly during apical stimulation, compared to septal stimulation in patients requiring single chamber pacing.
Material and method: Fifty-nine patients admitted between January 1st – December 31st 2012 either for battery replacement or for first implant of a single chamber pace-maker were included in this prospective study. Thirty-eight of them had the lead placed in the apex of the right ventricle and 21 on the interventricular septum. All were subjected to echocardiografic examination after device implantation. Measurements included complete chamber and valvular assessment, apart from the synchronicity evaluation, that comprised interventricular mechanical delay (IVMD), septal to posterior wall delay (SPWMD) and electro systolic delays (ESD), in order to assess the presence and compare the relevance of interventricular and intraventricular dissyncrony. All the investigations were in accordance with the Declaration of Helsinki.
Results: Although preejection times were significantly different, there were no statistically significant differences (p = 0.06) between the values of IVMD in the two groups, as well as regarding the longitudinal intraventricular dyssynchrony expressed by ESD. Significant differences appeared though, between the values of SPWMD, reflecting the fact that radial intraventricular dissyncrony is present in apical stimulation.
Conclusions: During apical right ventricular pacing, radial intraventricular dissyncrony appears, while in the case of septal pacing this parameter is close to normal. Surprisingly, although right ventricular pacing determines interventricular and longitudinal intraventricular dissincrony, we found no significant differences in this respect, between apical and septal pacing.

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Unsaturated Heteropolyoxotungstates with Platinum Cation Complexation

DOI: 10.2478/amma-2014-0007


Background: Polyanions are a special category of coordination compounds with a large development in last years. By coordination of metal oxoions at the lacunary polyoxometalates are obtained new compounds which are studied for theirs possible antitumoral and antiviral activities. The polyoxometalates can bind cations by oxygen atoms from their saturated surface structure or by embedding in vacant sites.
Material and method: The methods used for determining cation coordination with the unsaturated polyoxotungstate are spectrophotometry and conductometry. The solutions used in this study were: for ligand a solution of K27[KAsW40O140] and for cation a solution of K2[PtCl6].
The variation of electrical conductivity of ionic species found in solution, caused by their concentrations, decreases during the complex formation, which was determined by conductometry. The spectrophotometric assay was performed to verify ratios between cation:ligand combination, determined by conductometry.
Results: The graphical representations of conductivity function of number of moles of added titrant solutions emphasize that there are two types of coordination compounds with two different combination ratios ligand:cation at 1:2 or 1:4. The spectrophotometric determination performed, confirmed these ratios.
Conclusions: There are two types of coordination complexes, and the ligand:cation ratios are well known for encrypting polyoxotungstates type used in the study. Besides the main active position SC where K+ alkaline cation is coordinated, it has four active stand side S1–4, which can coordinate metal cations, depending on the size of their cationic radius and the electronic charge they hold.

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