Category Archives: AMM 2023

Renal Ewing sarcoma with extensive neuroectodermal differentiation: Case report and literature review

Alexandra Daniela Sava1, Tiberiu Bogdan Szekely1,2, Cornelia Togănel1,2, Adela Vacar1, Catalina Bungardean3, Simona Gurzu4,5,6

1. Department of Oncology, Clinical County Hospital, Targu Mures, Romania
2. Department of Oncology, George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Targu Mures, Romania
3. Department of Pathology, Clinical City Hospital, Cluj Napoca, Romania
4. Department of Pathology, George Emil Palade University of Medicine, Pharmacy, Science and Technology, Targu Mures, Romania
5. Romanian Academy of Medical Sciences
6. Research Center for Oncopathology and Translational Medicine (CCOMT), George Emil Palade University of Medicine, Pharmacy, Science and Technology, Targu Mures, Romania

DOI: 10.2478/amma-2023-0034

Ewing sarcoma with renal localization is one of the rarest members of the Ewing sarcoma family with less than 200 cases reported in the Medline database. Considering the fact that the majority of data published on the Ewing sarcoma with neuroectodermal differentiation is obtained through a few case reports and case series, it becomes understandable why we currently have no universally accepted treatment regimens.
Case summary: A 33-year-old patient presented to the Emergency Department with right lumbar pain following a mild trauma and an episode of macroscopic hematuria. Physical examination confirmed hematuria and flank pain and a palpable flank mass was identified. MRI showed a cystic lesion of the upper pole of the right kidney of 127/110/123 mm. After prior agreement of the multidisciplinary team, a 3D laparoscopic right radical nephrectomy was done. The histopathological diagnosis revealed an Ewing sarcoma with extensive neuroectodermal differentiation staged as pT3N1M0L1V2R0. Despite swift implementation of the chemotherapy protocol, the progression of the disease was quickly noted. Currently, one year after diagnosis, the disease is still progressing despite the chemotherapy treatment, the patient being a third line chemotherapy candidate. As renal localization of Ewing sarcoma with extensive neuroectodermal differentiation is extremely rare, multimodal treatment strategies must be established by a multidisciplinary team. Despite its aggressive biological behavior, a proper therapeutic management might increase patient life expectancy.

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Evaluating demand of High Dependency Unit beds in a hospital with insights on return on capital investment

Sonia Daga1, Janipalli Lakshmi Prasad2, Naveen P. Kumar1

1. Department of Hospital Administration, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, India
2. Department of Hospital Administration, All India Institute of Medical Sciences, Bhopal, Madhya Pradesh, India

DOI: 10.2478/amma-2023-0033

Introduction: Hospital administration will have to constantly work around predicting demand of the critical care beds and evaluating the options of expanding the existing capacity. These expansions will be constantly requested by clinicians in private hospitals in India. It becomes imperative to infuse capital into such expansions predicting the utilisation pattern of the new beds. This study concentrates on factors considered for estimating the infrastructure enhancement in step down beds in progression of patient care.
Methodology: Retrospective measurement of past bed occupancy rates of existing critical care beds, number of patients denied admissions through emergency department due to lack of intensive care beds was counted during previous 1 year. Cost estimates of building, equipment, manpower was collected. The prices that can be charged per rack basis was estimated, for revenue calculation. Return on investment tool using annual revenues divided by annual investment was used to measure the outputs.
Results: For setting up a 34 bed HDU (High Dependency Unit), 4760 square feet of space was utilised, with USD 594,555 as investment, at a revenue of USD 527,425, which is 75% return in first year, provided occupancy is at 100%. At occupancy of 60%, which was seen within 6 months of commissioning new HDU, the breakeven can be achieved at 450 days. At 100% occupancy breakeven can be achieved in 290 days.
Conclusion: Demand estimation and Utilisation analysis is valuable tools for administration to make decisions on major capital investments.

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Iron metabolism and metabolic dysfunction-associated fatty liver disease

Zoltán-Zsombor Élthes1, Monica Iudita Maria Szabó2

1. Endocrinology Resident Doctor, Mures County Clinical Hospital, Targu Mures, Romania
2. George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Targu Mures, Romania

DOI: 10.2478/amma-2023-0031

Objective: The primary objective of this study was to investigate the association between biomarkers of iron metabolism and metabolic dysfunction-associated fatty liver disease in individuals with type 2 diabetes and non-diabetic individuals compared to a control group. We also examined the possible association between estimated liver fibrosis and serum ferritin levels in all three groups.
Methods: We conducted a descriptive, cross-sectional, comparative study involving subjects diagnosed with diabetes and/or metabolic dysfunction-associated fatty liver disease from an outpatient diabetology clinic and two general practices in Târgu Mureș. The patient population was divided into 3 groups: first group including diabetic patients suffering from fatty liver disease, second group including patients without fatty liver disease and third group with non-diabetic patients suffering from fatty liver disease. We compared the three groups based on specific laboratory tests.
Results: Patients with fatty liver disease had significantly higher ferritin and transferrin saturation levels than non-fatty liver disease sufferers (p<0.05). Transferrin saturation of the first group was significantly (p<0.05) higher compared to the non-diabetic fatty liver disease group. Ferritin correlated well with Fibrosis-4 index level (τ= 0.193, p<0.01) considering the whole sample and especially in the first group.
Conclusions: In our study, there was a clear association between higher ferritin levels and the presence of metabolic dysfunction-associated fatty liver disease. The higher transferrin saturation observed in diabetic patients suffering from metabolic dysfunction-associated fatty liver disease may indicate the possible etiological significance of iron overload. Higher ferritin levels in diabetes increase the risk of liver fibrosis.

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Current screening and diagnostic approaches of
retinoblastoma in limited setting

Nunki Puspita Utomo1, Devie Kristiani2, Sri Mulatsih3, Pande Komang Wahyu Pradana1

1.Faculty of Medicine, Duta Wacana Christian University, Yogyakarta, Indonesia
2. Department of Pediatric Hematology and Oncology, Bethesda Hospital, Yogyakarta, Indonesia
3. Department of Pediatric Hematology and Oncology, Sardjito Hospital, Yogyakarta, Indonesia

DOI: 10.2478/amma-2023-0032

As the most common intraocular malignancy in children, retinoblastoma poses a vision, globe, and life-threatening risk and hence requires thorough evaluation and surveillance. While the disease is one of the most curable malignancies in established countries, children of lower-middle-income countries are not so fortunate, especially those with familial history of retinoblastoma. The delay of diagnosis proposes a grave prognosis, thus screening is a must. This study aimed to review the literature on various screening programs and applications described for the early detection of retinoblastoma, especially in a setting where genetic examination performance is limited. A literature search across PubMed®, ProQuest, and EbscoHost (MEDLINE Full text) with the topic of current methods and programs of retinoblastoma screening in neonates, infants, and children were carried out denoting various guideline and recommendations but the implementation is not uniform. Examination under anesthesia and red-reflex tests are among the most frequently conducted but the practices vastly vary especially in a place with low resources. Recent updates in mobile phone freeware should be rigorously upgraded due to its current inadequate sensitivity and specificity in detecting retinoblastoma but pose a promising future for retinoblastoma screening and diagnosis, especially in lower-middle-income countries.

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Knowledge, attitudes, and willingness of community pharmacy staff in Mures County, Romania, to provide the brief advice to stop smoking: A cross-sectional study

Ingrid Nădășan, Loránd Ferencz, Geanina Moldovan, Zoltán Ábrám, Valentin Nădășan

George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Targu Mures, Romania

DOI: 10.2478/amma-2023-0030

Background and objective: Providing brief advice to stop smoking (BASS) can significantly increase motivation to quit, long-term smoking cessation rates, and substantially impact public health. The study aimed to evaluate knowledge, attitudes, and willingness of community pharmacy staff in Mures County, Romania, to provide BASS to smokers.
Methods: The observational, cross-sectional study included a sample of 96 professionals working in community pharmacies in Mures County, Romania. Data were collected using an online questionnaire. Descriptive statistics were calculated. Results: Generally, more than 90% of the respondents acknowledged that smoking is addictive, represents a health hazard, and increases the risk of lung and laryngeal cancer, chronic obstructive pulmonary disease, heart attack, and stroke. Up to 70% of the respondents recognized the most common scientifically proven quit medications, such as nicotine replacement therapy, bupropion, and varenicline. Most pharmacists agreed that they should regularly ask the patients about their smoking status and encourage smokers to quit. They also declared they should receive continual education regarding quit services, medications, and techniques. BASS was credited with very high efficacy by 17.1%, high efficacy by 26.8%, and moderate efficacy by 46.3% of the respondents. The most common perceived barriers to providing BASS in community pharmacies were lack of demand from smokers (78.0%), lack of time (73.2%), and lack of educational materials (39.0%). About 70% of the pharmacists received no formal training regarding quit services, but more than 75% were interested in earning such a qualification. About 65% of the respondents estimated they could dedicate 10-15 minutes of their daily working time to provide BASS to interested customers. Conclusions: Overall, the study found an acceptable level of knowledge and willingness of the participants in offering BASS, suggesting that a program to provide BASS in Mures County community pharmacies may be feasible and useful.

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The digital presence of the leading brands in the
category of Food for Special Medical Purposes

Marius Călin Cherecheș, Alin Dospinescu, Hajnal Finta

Faculty of Pharmacy, George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Targu Mures, Romania

DOI: 10.2478/amma-2023-0029

Objective: Food for Special Medical Purposes (FSMP) is a niche area in the food and healthcare industries that produces foods to meet the dietary requirements of people with specific medical conditions. These products provide specific nutrient amounts and ratios, which can be used as a supplement to a conventional diet, part of an entire medical treatment plan, or as a sole source of Nutrition. The market is expected to generate revenues of $19.67 billion in 2028. Most FSMPs products are purchased individually by patients or caregivers. Although these products are not advertised directly to the public might be bought online from pharmacies and other online shops. This research aims to evaluate the online presence of the most important brands within the FSMPs category and how the patients get to the online shops without direct-to-consumer advertisement.
Methods: This exploratory qualitative research study examines the online presence of FSMP products and key brands using SEO as the main digital technique. Data sources included Romanian websites, Google SERPs, Brandmentions.com, Semrush, and Ubersuggest.
Results: The findings showed that these websites received only a small amount of direct traffic, with only a few hundred monthly visits. To increase organic visibility, businesses must follow regulatory requirements, collaborate with medical experts, engage with potential clients, and exhibit their products at medical events and fairs. Content marketing is crucial for FSMP brands to engage with their target audience and deliver valuable information.
Conclusions: FSMP brands cannot advertise directly to consumers. Instead, they should focus on SEO, reputable online pharmacies, e-commerce shops, and content marketing. This research applies to FSMP brands, digital marketers, and online pharmacies to effectively connect with target demographics, promote products, navigate regulatory constraints, and enhance online presence, improving accessibility and awareness.

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Differences in literacy, education level, and healthcare attendance in two different Roma subgroups from Transylvania, Romania

Boglárka Varga1, László Marton1, Anita Balázs2, Anita Lőrincz3, Tímea Kovács4, Orsolya Sorbán5, Monica IM Szabó6,7

1. Compartment of Diabetology, Emergency Clinical County Hospital of Targu Mures, Romania
2. Internal Medicine Clinic, Municipal Hospital of Odorheiu Secuiesc, Romania
3. Obstetrics and Ginecology, Szent Imre Egyetemi Oktatókórház, Hungary
4. Internal Medicine, Emergency Clinical County Hospital of Targu Mures, Romania
5. Diabest Medical Center, Sfântu Gheorghe, Romania
6. Compartment of Diabetology, Emergency Clinical County Hospital of Targu Mures, Romania
7. George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Targu Mures, Romania

DOI: 10.2478/amma-2023-0028

Background: Literacy and education levels were demonstrated to be low in the Roma population. The outcomes after the implementation of different educational policies, in different countries, were not properly assessed for Roma subgroups until now.
Aims: We aimed to study literacy, education level, and healthcare attendance in two well-defined Roma subgroups, compared to the majority population, in a specific Transylvanian rural region.
Material and methods: A non-interventional, cross-sectional comparative survey was conducted in 2016-2017 between two Roma subgroups and the general population, from a rural region in Transylvania regarding their literacy, education level and healthcare attendance.
Results: Illiteracy was 33.3%, 66.6%, and 4.2% in the Gabor, Lovari Roma, and general population (p < 0.001). 29.5% of the Gabors and 45.6% of the Lovari Roma did not attend any school, compared to 2.7% of the general population. Almost none of the Roma population attended school after finishing 8 classes. Healthcare service attendance was significantly lower for the Roma subgroups, and directly related to their education level. 32.7% of the Gabors, 28.3% of the Lovari Roma, comparing to 7.3% of the general population never attended the general practitioner (p < 0.001).
Conclusions: Gabor Roma population had a significantly lower proportion of illiteracy and a higher school attendance than Lovari Roma group, but still illiterate by a high percentage. The Roma’s healthcare attendance was far lower than the general population’s, having been even worse in the Gabor group. Healthcare counseling was directly correlated with education level.

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Vagus Nerve Stimulation (VNS) Therapy System in pharmacoresistant epilepsy: A literature review

Valentin Moroșanu1, Iulian Roman-Filip1, Sanda Petruțiu1, Rodica Bălașa1,2

1. Neurology 1 Clinic, Emergency Clinical Hospital Mures, Targu Mures, Romania
2. Deparment of Neurology, George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Targu Mures, Romania

DOI: 10.2478/amma-2023-0027

Epilepsy affects approximately 50 million of people worldwide and 30% of them are resistant to drugs. Neuromodulation is becoming a key option in patients with drug-resistant epilepsy who are not feasible for resective surgery. Vagus nerve stimulation (VNS) is the most commonly used adjunctive neuromodulatory method in every patient aged 4 years and older who is unsuitable for resective surgery. It is a minimally invasive, non-teratogenic, extracranial pacemaker-like device which delivers electrical stimuli to the vagus nerve and desynchronize aberrant cerebral rhythms involved in epileptogenesis. In this review we approached the information and clinical data of VNS development history, clinical applications and possible mechanism of action. We will also review optimal stimulation parameters and information about closed and open loop devices. Vagus nerve stimulation is safe, efficient with no significant side effects and substantial cost-saving benefit, that also shows an important improvement in mood, behavior, cognition and quality of life. The overall responder rate was observed in more than 50% of patients. On the other hand, it is not clear which patients will respond to this method of treatment and why the response is not immediate, there are no available biomarkers or other features like age, sex, seizure type/epileptic syndrome to predict response to vagus nerve stimulation therapy. The VNS Therapy System continues to be an important prospect in the treatment of pharmacoresistant epilepsy, that requires further studies in order to ensure the most advantageous therapeutic response.

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Complicated idiopathic portal and mesenteric venous thrombosis: A case report

Dan Nicolae Bele

2nd Department of General Surgery, “Iuliu Hatieganu” University of Medicine and Pharmacy, Cluj-Napoca, Romania

DOI: 10.2478/amma-2023-0020

Introduction: Acute mesenteric ischemia is a life-threatening condition that can lead to intestinal ischemia, bowel obstruction and peritonitis. It is predominantly caused by arterial occlusion (acute arterial thromboembolism or thrombosis); however, it can rarely be secondary to mesenteric or portal vein thrombosis.
Case presentation: We present the case of a 61-year-old man admitted to the emergency service for intense abdominal pain and lack of bowel movement. A computed tomography angiography (CTA) was performed, revealing portal and mesenteric vein thrombosis. Anticoagulant treatment was established. To appraise the extension of the necrotic tissue, the surgical team performed exploratory laparotomy, followed by segmental enterectomy. The following day, the patient complained of acute pain in the left lower limb and a CTA was performed indicating acute ischemic phenomenon. The surgical team performed thrombectomy using a Fogarty catheter. The ischemic enteral region extended, and the patient developed an enterocutaneous fistula that required surgical reintervention (enterectomy and right hemicolectomy).
Conclusion: Conservative treatment with anticoagulants is the first line treatment, followed by surgical treatment only in case of complications. Even though venous thrombosis is an exceptional cause of intestinal infarction, it can be the cause of life-threatening complications such as necrosis, peritonitis and septic shock.

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Hyperkalemia, self-medication, and over-the-counter drug usage in patients with cardiovascular disease in the perspective of polypragmasy

Erika-Gyöngyi Bán, Zsuzsánna Simon-Szabó, Eszter-Anna Dho-Nagy, Patrick Lechsner

George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Targu Mures, Romania

DOI: 10.2478/amma-2023-0003

Cardiovascular disease is a leading cause of death globally. 40 percent of the adult Romanian population is hypertensive, and only three out of seven patients are getting the appropriate treatment. Hyperkalemia is in a close relationship with certain cardiovascular diseases, although the influence of a certain medical treatment on hyperkalemia is not yet established. The aim of our study was to evaluate the pharmacotherapy of a group of patients with cardiovascular disease, representative for the adult population of our are and to analyze the administered drug therapy regarding polypragmasy (the concomitant usage of more than five different classes of substances), over-the-counter drugs and usage of drugs used without medical – physician prescribed – indication, and to evaluate serum potassium levels. The cross-sectional, observational, prospective, pharmaco-epidemiological study targets the observation, recording and analysis of 301 adult patients’ pharmacotherapy and laboratory findings. Based on the demographic data we found that the study group is representative for the adult population of our region. Hypertension was observed in 173 cases, and more than 60 percent of the patients were older than 65 years of age. Other comorbidities, such as ischemic cardiac disease, heart failure, arrhythmias, other cardiovascular diseases as well as chronic kidney failure and diabetes mellitus were positively associated with hypertension. In 50.8 percent of the cases usage of drugs without prescription was present. Likewise, multiple drug combinations were frequent with high rates of polypragmasy. Multiple drug combinations were observed, and self-medication rates were very high, which should be reduced substantially to obtain a more successful pharmacotherapy and a reduced drug interaction-induced side effect.

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