Category Archives: AMM 2023

Air guns: An underestimated danger – case presentation, literature review and legal interpretation

DOI: 10.2478/amma-2023-0013

Introduction: The compressed air weapon is a type of arm to which the projectile is propelled due to the compression of air in a sealed chamber. These types of weapons belong to the category of non-lethal weapons and ammunition subject to authorization. However, accidental fatal cases, suicides or even deaths with intention attributed to these types of weapons are described in the literature.
Case presentation: We are discussing the case of a 5-year-old boy who, at a picnic with several families, is shot and killed with a compressed air rifle, left unattended. The medical crew arrived at the scene could not save the boy’s life. Necroptic examination revealed a gunshot wound through the heart, with the projectile stuck in the lateral-internal wall of the right ventricle. The projectile identified was a metal type projectile (lead), with a length of 8.5 mm and a diameter of 4.5 mm.
Conclusions: Compressed air weapons, although considered non-lethal, have proven over time their extremely dangerous potential through the fatal injuries produced. Raising public awareness, limiting use and enforcing strict legislation could prevent tragic events.

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Clinical characteristics and endoscopic findings in autoimmune gastritis – a retrospective study

DOI: 10.2478/amma-2023-0012

Objectives: Autoimmune gastritis (AG) is a rare condition that increases the risk of developing stomach adenocarcinomas or carcinoid tumours. The objectives of the present research were to summarise the clinical traits of AG patients, together with gastroscopic and histopathologic findings, demographic data, and hematologic characteristics.
Patients and methods: A medical centre assessed 58 AG patients from January 2019 to December 2022.
Results: The majority of the patients were female (73.7%), and the mean age of the participants at the time of the diagnosis was 57.7 ± 12.1 years. We identified pernicious anaemia (54.4%), iron deficiency anaemia (21.1%), as well as autoimmune disorders (96.5%). Though 78.9% of patients reported having gastrointestinal symptoms, 69% presented exclusively upper gastrointestinal symptoms, 17% only had lower, and 14% had concurrent upper and lower gastrointestinal symptoms.  All 58 AG patients were examined for associated gastric lesions, although abnormal injuries were detected in only 22 of them. One patient (1.8%) had adenocarcinoma, while five patients (8.8%) had type 1 neuroendocrine tumours (NET). In addition, hyperplastic polyps were found in 16 (28.1%) individuals.
Conclusions: Other autoimmune diseases were present with AG, which showed a female predominance. Clinicians should give AG more significant thought by allowing access to interdisciplinary teams.

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Intermittent fasting for the management of NAFLD: Is there enough evidence?

DOI: 10.2478/amma-2023-0001

The pathogenesis of the non-alcoholic fatty liver disease (NAFLD) has been described as multifactorial, with genetic and environmental factors acting synergistically and causing excessive hepatic lipid accumulation, insulin resistance, and downstream pathogenetic insults. High-calorie diets, particularly those rich in foods with high (saturated) fat and sugar content, and sugar-sweetened beverages, are among the behavioral risk factors with a crucial role in the disease pathogenesis. In addition, meal frequency and meal timing appear to be relevant factors associated with NAFLD. Current guidelines recommend a hypocaloric, preferably Mediterranean diet as the main dietary intervention approach, but various other dietary models have been evaluated in patients with NAFLD. Among these, several intermittent fasting regimens have shown promising results. Diets based on Time-Restricted Feeding and Intermittent Energy Restriction have demonstrated some improvements in body adiposity, liver enzymes, and hepatic steatosis, but most studies included a small number of subjects, were of relatively short-duration, and used surrogate markers of NAFLD. The best intermittent fasting regimen for NAFLD is not yet known, and further well-designed research that evaluates the feasibility (mainly on long-term), safety and efficacy outcomes of these dietary interventions is still needed. Our review has evaluated the up-to-date information regarding the intermittent fasting dietary intervention in NAFLD and generated some key-point messages that are relevant to physicians and dietitians involved in the care of patients with NAFLD.

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Inter-observer variability on the value of endoscopic images for the documentation of upper gastrointestinal endoscopy – our center experience

DOI: 10.2478/amma-2023-0015

Objective: Endoscopy is an essential and invaluable diagnostic tool in the arsenal of every gastroenterologist. ESGE presented additional guidelines for standardized image documentation in upper and lower gastrointestinal endoscopy. Clinical disagreement is a common challenge in most, if not all, fields of medicine. Settling disagreements is important so as to find ways to minimize it. Clinical disagreement in gastroscopy may be demonstrated by studying the observer variability.
Methods: We retrospectively recruited 120 random patients that underwent conventional upper gastrointestinal endoscopy between 2021-2022 in our Department of Gastroenterology, all of them performed by one endoscopist. As part of the study, all video-endoscopic recordings were stored using one internal server. In order to study interobserver variability, four physicians (endoscopists and gastroenterologist specialists) were invited to complete the questionnaire.
Results: The interobserver variability in our study ranged from moderate to very good in the assessment of the esophagus, with the highest degree of agreement in response to questions concerning characteristic findings such as normal mucosa, esophagitis Class A Los Angeles, hiatal hernia for the esophagus endoscopic evaluation, benign ulcer niche in gastric antrum, normal gastric corpus mucosa, intestinal metaplasia and angiodysplasia in gastric corpus. The question on atrophic mucosa in the first and second part of the duodenum was the most difficult to agree upon.
Conclusion: The present study found that the variability between observers in the assessment of images obtained from patients that underwent conventional upper gastrointestinal endoscopy in our center was acceptably good.

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Should we screen for sarcopenia in Romanian patients with osteoporosis? An overview of the current knowledge on osteosarcopenia

DOI: 10.2478/amma-2023-0014

The combination of osteoporosis and sarcopenia is wider known as “osteosarcopenia”, and it is considered to be a “hazardous duet” for the patient. The clinical consequences of this geriatric syndrome include a higher risk of fractures and mortality compared to osteoporosis or sarcopenia alone. Fractures are considered to be a burden for the patient but also for the health care system from an economic point of view, therefore it is important to prevent them. Emerging evidence shows that osteosarcopenia is an increasingly prevalent disease. The Fracture Risk Assessment Tool (FRAX) is of major importance for the management of a patient, however, muscle weakness is not part of this instrument. It has been suggested to go “beyond the FRAX” and to evaluate muscle mass/strength besides bone mineral density when it comes to the management of a patient with a sustained fragility fracture. In this review we try to answer whether this is feasible or not when it comes to Romanian patients.

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Anatomical variations of nutrient foramina on the long bones of the upper extremities – Importance and application in everyday clinical practice

DOI: 10.2478/amma-2023-0011

Objectiv: Anatomic characterization of the nutrient artery of upper extremity long bones differs among the several textbooks on human anatomy. To elucidate the anatomical features of the nutrient foramen (NF) through which the nutrient arteries pass, we examined the morphology and topography of the NF on the diaphysis of the long bones of the upper extremities.
Methods: A total of 150 (50 humeri, 50 radii, 50 ulnae) macerated and degreased adults, long bones of the upper extremities, unknown age, and gender were used as material in this study. The following parameters were determined for each bone: total number of NF, foramina index (FI), total bone length, position of the NF based on the FI value and the surface of the shaft/body of the bones, and obliquity of the nutritional canal (NC).
Results: The largest number of NF was found on the middle third of the anteromedial side of the humerus diaphysis, with NC directed distally, that is, towards the elbow. Radius and ulna had predominantly one NF, on middle third of anterior surface, with NC directed proximally.
Conclusion: This study provides additional and important information on the location and number of NF in the long bones of the upper and lower extremities in the Bosnian and Herzegovinian population.

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Oral cancer chemoprevention: A review

DOI: 10.2478/amma-2023-0010

Oral cancer is increasing in prevalence and its treatment is associated with high degree of morbidity and mortality. Thus, prevention of oral cancer is of utmost importance. Chemoprevention is the use of natural, synthetic, or biologic compounds to halt, reverse, or prevent the initial phases of carcinogenesis or the progression of neoplastic cells to cancer. This modality has been extensively researched in the last two decades for the prevention of oral cancer with the emergence of new information. Retinoids were the first chemopreventive agents to be tested in clinical settings. Since then, a number of new agents such as COX2 inhibitors, EGFR inhibitors, p53 targeted agents, thiazolidinediones and several natural agents have shown promise in oral cancer prevention. Chemopreventive trials in oral cancer tend to be long term studies and are thus challenging. This review article looks into the clinical evidence for the application of chemopreventive agents in clinical settings and also highlights the recent trends in oral cancer chemopreventive trials.

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Blood biomarkers predicting adverse clinical
outcomes in congenital heart disease patients, with consideration for pulmonary valve replacement

DOI: 10.2478/amma-2023-0009

Objective: This review aims to make a brief overview of blood biomarkers’ clinical decision limits, possibly aiding in outcome prediction in all-aged Tetralogy of Fallot patients. Potentially, these biomarkers could also assist in necessity and timing of pulmonary valve replacement. Methods: Studies with all-aged patients with Tetralogy or Pentalogy of Fallot and blood biomarkers, BNP, NT-proBNP and hs-cTn, usage in clinical outcome prediction were included. Additionally, pulmonary valve replacement indications were considered. Other congenital heart diseases, biomarkers irrelevant to clinical outcome and associated pathologies or physiological status were the exclusion criteria. Keywords, Tetralogy and Pentalogy of Fallot, pulmonary valve replacement, blood biomarkers, yielded 69 suitable studies from Google Scholar, PubMed and Web-of-Science. 30 studies were selected. Results: Blood biomarkers were increased in TOF patients in comparison to controls; the higher the values, the worse adverse outcomes. Blood biomarkers combined with other biomarkers, imagistic methods or parameters showed promising results in outcome prediction. Conclusions: Blood biomarkers are validated as follow-up predictors in congenital heart disease paediatric patients. Further research is required to establish age-appropriate clinical decision limits. Pulmonary valve replacement timing remains controversial.

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Testosterone deficiency is associated with clinically relevant depression symptoms

DOI: 10.2478/amma-2023-0008

Objective: To investigate the association between testosterone deficiency and depressive and/or anxiety symptoms.
Methods: A cross-sectional study was conducted at the urology outpatient clinic from Ludus County Hospital. A set of validated questionnaires ((International Prostate Symptoms Score (IPSS), Depression Anxiety and Stress Scale (DASS-21), Zung Self-rating Depression Scale (Zung SDS)) were self-administrated. Inclusion criteria: age > 40 years. Exclusion criteria: any relevant psychiatric, cardiovascular, or cancer comorbidity. Statistical analyzes were performed using the statistical software Statistical Package for Social Sciences (SPSS, version 23, Chicago, IL, USA).
Results: From the total of 55 participants included in the study, 23 (41.8%) had testosterone deficiency. Most were from the 60-69 years decade, 23 participants (41.8%), and the mean age was 59.3 (SD 9.03) years. Eleven (20%) patients had depressive symptoms according to the depression subscale, of these, 7 had mild symptoms and 4 according to Zung SDS. Testosterone deficiency was associated with an increased DASS-21 global score, p=0.021, and depression score, p=0.047.
Conclusions: Patients with testosterone deficiency are presenting symptoms of depression. Therefore, these patients need a multi-disciplinary approach that should include a psychological evaluation before making a further management decision.

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