Category Archives: AMM 2016, Volume 62, Number 2

Cancer in Children – The Role of Supportive Treatment

Cancer represents a major public health problem with an increasing incidence in the last years. Worldwide, 1 of 500 children is diagnosed with cancer, which equals with 130-140/1000000 children, having a higher incidence in the age group under 5 years (1). The incidence and survival in children with cancer depends on the time trends and the geographical variance. According to the international records of cancer such as Automated Childhood Cancer Information System (ACCIS) and Eurocare, the highest incidence among children under 15 years of age, is owned by leukemia – 34%, followed by cerebral tumors 23%, lymphomas – 12%, the rest being nephroblastomas, neuroblastomas and others (2). Due to the introduction of the standard protocols adapted for every malignancy, the total survival among children with cancer increased very much, starting under 20% before 1975 (1) to over 80% in 2014 (2, 3). Therefore, it is very important to establish an early and accurate diagnosis in order to initiate an adequate treatment, the delay of diagnosis determining an increase of the morbidity and mortality (3). The progresses and survival in cancer are mostly a result of the improvements in supportive care. [More]

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Correlations of Endogenous Testosterone and DHEA-S in Peripheral Arterial Disease

DOI: 10.1515/amma-2016-0021

Background: there is an overt bias between cardiovascular morbidity and mortality in male and female patients. Research of the past decades postulated that this difference could be due to the lipid-lowering effect of male sexual-steroids, that show decreased values in cardiovascular disease.
Methods: the aim of our study was to determine total serum testosterone and dehydroepiandrosterone sulfate (DHEA-S) on a peripheral arterial disease patient’s cohort (n=35), in comparison with a healthy control group, (n=23) and to establish correlations with other biological risk factors like serum lipids, C-reactive protein, plasma fibrinogen, and the ankle-brachial pressure index.
Results: our results showed that total serum testosterone and DHEA-S were significantly decreased in PAD patients in comparison to the control group. We could not observe any significant correlation with the presence of critical ischemia, the levels of total cholesterol, HDL-cholesterol, triglycerides, lipoprotein (a), C-reactive protein or plasma fibrinogen.
Conclusion: these results express that low androgen levels could be implicated in the pathogenesis of peripheral arterial disease, but testosterone and DHEA-S are not markers of disease severity. The elucidation of their exact role needs larger, population-based studies.

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The Role of Supportive Therapy in Pediatric Malignancies

DOI: 10.1515/amma-2016-0027

Childhood cancer is a major psycho-social and health problem. International study groups establish complex, efficient, and concrete Cytostatic Protocols for every cancer type. During chemotherapy patients become extremely vulnerable to infections, so it is necessary to complete the treatment with blood substitution, anti-infection medication, growth factors and other complementary products.
Materials and Methods: We studied the importance of the wide palette of adjuvant therapy near the intensive cytostatic treatment in the period of March 2014-November 2015 at the hemato-oncology department in Pediatric Clinic of Mures County Hospital.
Results: In this period we treated 20 children (9 female, 11 male) aged between 9 months-18 years. We had 15 cases of haemopathies (13 acute leukemia and two lymphomas), and five solid tumors. Packed red blood cells, platelets, and fresh frozen plasma were given in the aplastic period. A patient benefited, on average, a total of 70ml/kg packed red blood cells and 50 U platelets. For infection prophylaxis and treatment every child benefited associated infective medication.
Discussions: Packed red blood cells, platelets, and fresh frozen plasma were given to patients with a deficiency in the ability to produce normal blood cells which are temporarily worsened by chemotherapy. Antibiotic and antifungal medications are given to all febrile and neutropenic patients. We use wide spectrum antibiotics in association for preventing sepsis. Growth factors are stimulating the bone marrow to increase leukocyte number. Since introducing additional immunostimulant medication, we observed a significant decrease of infection in the aplastic period.
Conclusions: Oncology protocols use only 3-5 cytostatic drugs. Maintaining the patient’s life during the treatment, it is necessary to use a large spectrum of supportive medications.

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Pulmonary and Cerebral Infarcts Due to Secondary Thrombosis Risk of a Genetic Mutation: Life-threating Methylentetrahydrofolate Reductase (MTHFR) Deficiency with Early Onset

DOI: 10.1515/amma-2016-0026

Methylentetrahydrofolate reductase (MTHFR) is a key enzymatic component of the folate cycle, converting 5,10-methylentetrahydrofolate into 5-methylentetrahydrofolate. Severe MTHFR deficiency is a rare recessive disease leading to major hyperhomocysteinemia, homocystinuria, and progressive neurological distress within the two first decades of life.
We present the case of a young, 21 years old female patient who was admitted and treated in Clinic of Pneumology Tirgu Mures for a postero-basal left pneumonia without favourable radiologic evolution under antibiotic and symptomatic treatment. Thoracotomy was recommended in order to elucidate the diagnosis. The histopatological examination revealed the zone of pulmonary infarction. After 12 weeks from surgical intervention, the patient was admitted in Department of Neurology for stroke attack. The complex laboratory investigations reveal deficiency of methylentrahydrofolate reductase (MTHFR) caused by a genetic mutation.

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Cytomegalovirus Infection and Pre-Eclampsia

DOI: 10.1515/amma-2016-0023

Introduction: Pre-eclampsia is a pregnancy-specific disease characterized by hypertension after 20 weeks of gestation and proteinuria. It is a major cause of maternal and perinatal morbidity and mortality. The pathogenesis of pre-eclampsia is not completely understood. In our study we investigated if there is a potential link between cytomegalovirus infection and pre-eclampsia and if cytomegalovirus infection is the triggering factor of pre-eclampsia.
Material and methods: This study was carried out in a secondary care hospital between January 2014 and July 2015. We included two groups of pregnant women: 66 with pre-eclampsia and 62 without pre-eclampsia. Enzyme linked immunosorbent assay (ELISA) technique was performed to detect cytomegalovirus Immunoglobulin G levels in maternal serum.
Results: The p-value between median values of positive cytomegalovirus IgG in pre-eclamptic women and in controls was not significant (p:0.867). Odds ratio for cytomegalovirus IgG in pre-eclamptic group (OR:0.967; 95%CI:0.535-1.748) do not differ greatly from the value recorded in the control group (OR:1.036; 95%CI:0.571-1.880). The risk for preterm birth in pre-eclamptic women with cytomegalovirus IgG positive values (OR:1.009; 95%CI:0.329-3.090) was greater than those which had term delivery (OR:0.994; 95%CI:0.472-2.095) but the two values are not very high. We found a positive correlation coefficient (0.217) at a “p” value of 0.08 between white blood cells, but a negative correlation coefficient between the percentage of neutrophils and cytomegalovirus infection.
Conclusion: Cytomegalovirus infection may be associated with pre-eclampsia but it is unlikely to be the triggering factor of pre-eclampsia.

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A Multiparameter Model for the Correlation Between CT Hounsfield Unit and Blood Components

DOI: 10.1515/amma-2016-0022

Objective: To search for a dependency between blood Hounsfield Units values as measured by Computed Tomography and blood components with regards to hemoglobin oxygenated status, demographic data and acquisition parameters.
Methods: A retrospective study included a convenience sample of 144 SCJU patients who underwent routine thoracic CT examinations (Siemens Somatom AS 64 or 128 MDCT) in 2014 and had laboratory examinations done in nearby time. Variables included age, sex, mA, mV, aortic HU values, PA HU values, RBC, HTC, HGB, PLT, WBC blood sugar, PT and INR. Statistical analysis was performed using R version 3.1.1 and MedCalc 12.5 with a statistical significance factor of 0.05.
Results: The examined patients had an average age of 56.25, with a predominance of males (M:F=1.62). While there was a minor difference between HU values in Males vs Females (1.01 HU) it was proven as statistically significant (p=0.0051). No statistical significant difference between oxygenated/non-oxygenated blood (p=0.9636). Regression analysis found positive correlation between HU values and RGB, HGB and HCT with a significance level below 0.0001, the strongest being for the HGB level.
Conclusions: While HU values seem to carry multifactorial sources and the red blood cells being the most important an importance should be given to the fibrinoid plasma components which appear to bear negative impact.

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The Importance of Home Versus 24-Hour Ambulatory Blood Pressure Monitoring and Assessment of Blood Pressure Variability in Hypertension

DOI: 10.1515/amma-2016-0020

Background: A number of studies reveal that home blood pressure variability is associated with cardiovascular risk factors. However, we do not have a consensus regarding the variability index and the frequency of measurements.
Objective: The aim of the study was to assess home blood pressure variability for a period of 7 consecutive days and 24-hour ambulatory blood pressure variability using the average real variability index and to test whether home blood pressure variability represents a suitable parameter for long-term monitoring of the hypertensive patients.
Material and methods: A number of 31 hypertensive patients were included in the study, 8 male, 23 female, mean age 60.19±7.35 years. At the inclusion ambulatory blood pressure monitoring was performed, home blood pressure monitoring was carried out for 7 consecutive days with 2 measurements daily. We compared ambulatory blood pressure values, variability using paired t-test. We were looking for correlations between HBP values and cardiovascular risk factors.
Results: Ambulatory versus home blood pressure derived mean blood pressure was 131.38±15.2 versus 131.93±8.25, p=0.81. Ambulatory derived variability was 10.65±2.05 versus home variability 10.56±4.83, p=0.91. Home versus ambulatory pulse pressure was 51.8± 9.06 mmHg vs. 54.9±11.9 mmHg, p=0.046. We found positive correlation between HBPV and home BP values, p=0.027, r2=0.1577, (CI: 0.04967 to 0.6588). Home, as well as ambulatory derived variability were positively correlated to age p=0.043, r2=0.1377 (CI: 0.01234 to 0.6451) versus p<0.0001, CI: 0.3870 to 0.8220, r2=0.4302.
Conclusion: Assessment of home blood pressure monitoring and variability could represent a well-tolerated alternative for long-term follow-up of hypertension management.

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Kaposi Sarcoma in HIV Infected Patients

DOI: 10.1515/amma-2016-0019

Objective: The aim of the study was to describe clinical and laboratory characteristics in HIV-infected patients with Kaposi sarcoma (KS).
Methods: We retrospectively studied data on HIV-infected patients hospitalized in one tertiary care hospital in Bucharest, Romania, in whom Kaposi Sarcoma was diagnosed, between January 2008 and November 2013.
Results: We identified 27 HIV-infected patients diagnosed with KS within 6 years. They had a median age of 42 years old and a median CD4 cell count of 101 cells per mm3 at the time of KS diagnosis. All patients received antiretroviral therapy (ART), with 18 patients (66%) already on ART at the time of KS diagnosis. Most patients (59%) were classified as ACTG poor-risk and 56% as Mitsuyasu stage I. The overall prognosis was poor, with 41% mortality, in a median time span of 6 months, significantly correlated with gastrointestinal involvement (p=0.019), poor-risk KS in ACTG classification (p<0.001) and stage IV Mitsuyasu (p=0.006).
Conclusion: KS remains an important cause of morbidity and mortality in patients with HIV infection, especially in late presenters.

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Comparative Study on the Effectiveness of Early or Delayed Weight-Bearing After Anterior Cruciate Ligament Reconstruction

DOI: 10.1515/amma-2016-0018

Objectives. The aim of this study is to evaluate the efficacy of immediate weight-bearing versus two weeks delayed weight-bearing following anterior cruciate reconstruction.
Methods. We conducted a prospective observational study on the efficiency of immediate or delayed weight-bearing following anterior cruciate reconstruction. 30 patients undergoing anterior cruciate ligament reconstruction were included in the study. The patients in the first group were allowed the maximum endurance level of weight-bearing on the operated leg from the first postoperative day, resuming normal walking as soon as possible. Patients in group II were barely allowed the loading of the affected limb after 2 weeks postoperatively. Patient assessment was performed preoperatively, immediately after the procedure and postoperatively at 6 weeks, 3 and 6 months.
Results. The average pre- and postoperative values of the arthometric assessment show a statistically significant improvement of joint stability in both groups of patients. There were no significant differences in the development of joint mobility averages between the two groups. Following the evolution of functional test average values, there is a gradual function improvement in both groups of patients. The assessment results at 6 weeks and three months postoperatively shows that patients in the first group are significantly better in comparison with the results of patients in group II. The final evaluation showed no significant differences between the two groups of patients.
Conclusions. The final assessment revealed no statistically significant difference in reported or objectively measured function. We believe that the weight-bearing exercises and the non–weight-bearing exercises are equally effective and safe in the post-ligamentoplasty recovery.

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Surgical Strategy in Bouveret’s Syndrome. A Case Report

DOI: 10.1515/amma-2016-0017

Bouveret’s syndrome is a high mechanical obstruction due to impaction of a gallstone into the duodenum, through a cholecystoduodenal fistula. It belongs to a larger group of gallstone ileus, a disease which occurs after developing a fistula between the gallbladder and the gastrointestinal tract. This is a rare complication of gallstones but because it appears in elderly people, it has a high morbidity and mortality. Patients have various symptoms and the treatment is individualized. We present here a case of a 67 years old patient, admitted in emergency, presenting symptoms of high bowel obstruction, with onset 5 days before admission. Abdominal ultrasound reveals a 5 cm stone that seems to be in the gallbladder, gastric stasis and at gastroscopy appears a foreign body impacted in the duodenum. After a short preparation the patient underwent surgery. We found a dilated stomach and a large cholecystoduodenal fistula with an impacted gallstone in the duodenum. We performed one stage surgery: cholecystectomy, extraction of the stone and suturing of the fistula. We reestablished the continuity of the intestinal tract. We performed also an ileostomy for feeding the patient and protecting the anastomoses. The postoperative evolution was favorable.
We consider that one stage surgical treatment in gallstone ileus is an option, if the patient is in good condition and we have an adequate postoperative intensive care management.

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