ARCHIVES OF THE BALKAN MEDICAL UNION

485-487

Authors: Camelia Diaconu

The international guidelines for the management of type 2 diabetes mellitus have seen many changes over the last decade. They have moved from a strict glycemic control in all patients with diabetes to a more individualized approach of the diabetic patient. These changes are the result of some trials which have demonstrated, for example, that in patients with long-standing type 2 diabetes a strict glycemic control may increase the risk of complications, such as hypoglycemia and cardiovascular events1-3. While glucose lowering prevents the appearance of microvascular complications, its impact is less significant on the cardiovascular and renal complications. The most preferred oral antidiabetic drug is undoubtedly metformin. There are six antidiabetic drug classes currently recommended by the American and European international societies, in addition to metformin: sodium-glucose cotransporter 2 (SGLT2) inhibitors, glucagon-like peptide 1 receptor agonists, dipeptidyl peptidase 4 inhibitors, sulfonylureas, thiazolidinediones, and insulin. SGLT2 inhibitors are a promising new class of antidiabetic drugs, that have entered very recently in the diabetes therapeutic armamentarium. These drugs enhance the urinary glucose excretion and decrease hyperglycemia, acting independently from insulin and being effective in all diabetic patients with preserved renal function. They have a favorable efficacy-to adverse event profile in type 2 diabetes patients with moderate-to-high risk. Currently, there are four SGLT2 inhibitors approved by the US Food and Drug Administration (FDA) and the European Medicines Agency: canaglifozin, dapaglifozin, empaglifozin, and ertuglifozin3. These may be used as monotherapy or in combination with other antidiabetic agents.SGLT2 inhibitors have also pleiotropic effects, such as reducing body weight by 2-3 Kg, decreasing the blood pressure (both systolic and diastolic), decreasing plasma triglycerides, increasing HDL cholesterol, attenuating some factors associated with nonalcoholic steatohepatitis and nonalcoholic liver disease, improving the whole-body sodium balance and volume status by stimulating the natriuresis, which leads further to a better endothelial function by reducing the vascular stiffness1. Due to these effects, SGLT2 inhibitors are useful especially in obese patients with arterial hypertension. They may be indicated as single or combination therapy, with other antidiabetic agents, and are contraindicated in patients with kidney failure1 with a GFR < 45 mL/min/1.73 m2. Regarding the glucose control, in a meta-analysis, the HbA1c reduction at 24-weeks was higher in studies that included younger patients, with a shorter duration of diabetes and a higher body mass index, HbA1c and basal glucose4. The cardiovascular benefits of SGLT2 inhibitors have been demonstrated by some major trials, such as EMPA-REG OUTCOME trial (Empaglifozin Cardiovascular Outcome Event Trial in Type 2 Diabetes Mellitus Patients)5 and CANVAS (Canaglifozin Cardiovascular Assessment Study)6. EMPA-REG OUTCOME trial has found a reduced incidence of cardiovascular death in diabetic patients treated with Empaglifozin and also a decreased rate of hospitalization for heart failure5. CANVAS Program has showed also a decreased rate of hospitalization for heart failure in patients treated with Canaglifozin6. This is extremely important, especially for patients with type 2 diabetes and already established cardiovascular diseases, as they may benefit most from the treatment with SGLT2 inhibitors. The main side effects of SGLT2 inhibitors consist in the increased risk of genital infections (up to four-fold in clinical trials). Other side effects, more rarely, may be the risk of hypoglycemia, diabetic ketoacidosis, bone fractures (with Canaglifozin). Recently, the US Food and Drug Administration warned about the risk of necrotizing fasciitis of the perineum (Fournier’s gangrene) in patients treated with SGLT2 inhibitors7. This is an extremely rare, but life-threatening infection of the tissues around the perineal muscles, nerves, fat and blood vessels. In conclusion, SGLT2 inhibitors are the newest antidiabetic drugs class, with cardiovascular benefits in a selected population of type 2 diabetes patients. There are ongoing studies with these antidiabetic agents expected to report their data in the near future.

497-505

Authors: Tatiana V. KHMARA1 , Illia I. OKRIM1, Mariana O. RYZNYCHUK1, Igor I. ZAMORSKII1, Oleksandr M. RAK1

Introduction. It is necessary to clearly understand the norms of morphometric parameters of thorax during the fetal period of human ontogenesis, which is one of the main directions to solve the problem of modern normology. Objective. To trace the dynamics of changes of morphometric parameters of the bony thorax in human fetuses aged 7-10 months. Materials and methods. The anatomical study involved 39 human fetuses specimens of 231.0-375.0 mm of crown-rump length (CRL). The study was conducted by means of macro-microscopic preparation, morphometry and variation statistics method. Results. It was found that the length of the costal cartilage increases from rib I to VII and is the longest in the rib VII. The ribs are the highest along the midclavicular line. At the same time, the height of the ribs decreases along the posterior axillary line and becomes the shortest along the scapular line. It was revealed the greatest width of the II and III intercostal spaces along the parasternal and midclavicular lines. The width of the four superior intercostal spaces along the midclavicular line on the right and on the left is larger than the height of the corresponding ribs. The width of the II-X intercostal spaces on the right and on the left along the scapular lines exceeds the height of the corresponding ribs in 1.33-1.65 times. The greatest width of the II, IV and VII intercostal spaces was along the posterior axillary line both sided. The greatest width of the II, IV and X of the intercostal spaces was noted along the scapular lines. Conclusions. The length of the costal cartilage increases from rib I to VII and is the largest in VII ones. The smallest value of the length of the costal cartilage was found in the rib XII. During the 7th-10th months of the intrauterine development, an intensive increase in the length of costal cartilages of the ribs I-III occurs, on average, by 1.5 times, and there is a slow increase in the length of the costal cartilage of the rib VII. The ribs along the midclavicular line are the highest. At the same time, the height of the ribs decreases along the posterior axillary line and along the scapular line it is the lowest.

512-516

Authors: Natalia D. FILIPETS1, Taras I. KMET1 , Tamara I. HRACHOVA1, Tetiana S. BULYK1, Mariana I. KRYVCHANSKA1

The objective of the study was to investigate the changes of the kidney functions in mature rats with rapid acetylation type, under conditions of subacute cadmium-nitrate intoxication and preventive introduction of Echinacea purpurea. Methods. Male rats, 6 months of age, with rapid acetylation type, were divided into 3 groups: І – control; ІІ – rats with of subacute cadmium-nitrate intoxication model; ІІІ – rats receiving intragastric alcohol tincture of fresh rhizomes with roots of Echinacea purpurea (LC “State Municipal Enterprise “Pharmaceutical Plant Vishpha””, Ukraine; 0,25 mk/rg). Results. Under the effect of preventive introduction of Echinacea purpurea in rats with rapid acetylation type and cadmium-nitrate lesion of the kidneys, diuresis and glomerular filtration rate became normal; distal transport of sodium ions increased; hyponatraemia and decreased natriuresis remained without changes; concentrations of creatinine in the blood plasma, potassium ions in the blood plasma and urine, kaliuresis decreased. Similar to the group of rats without Echinacea purpurea, proximal reabsorption of sodium ions, which is standardized by glomerular filtration, decreased. Conclusion. Under conditions of preventive introduction of Echinacea purpurea, volume regulating kidney function is maintained in mature rats with rapid acetylation type and subacute cadmium-nitrate intoxication, but it does not prevent the development of toxic nephropathy, with prevailing lesion of the nephron proximal portion, disorders of ion regulating kidney function and water-electrolytic balance.

523-528

Authors: Liliia STOIKO1 , Khrystyna KURYLO2

Introduction. Throughout the centuries, plants have been used not only as a source of nutrition, but also in the fight against diseases. The most interesting are medicinal plants being well tolerated by patients regardless of age. One of these plants is Centaurium erythraea Rafn. The aim of the study was to develop an optimal technology for obtaining an alcoholic extract with the highest content of biologically active substances: hydroxycinnamic acids, phenolic compounds. Materials and methods. We have performed a study of the concentration of ethanol and multiplicity of dilution with the help of a symmetric rotary composite plan of the second order. Results and discussion. The regression equations were adequate – Fexp. < Ftab. The nature of the influence of the studied factors was determined by the magnitude and signs of the coefficients from regression. To obtain the alcohol extract with the highest content of hydroxycinnamic acids and phenolic compounds, the concentration of ethanol should be 69%, and the ratio of raw material to extractant should be 1 to 5. Conclusions. Further pharmacological studies showed the extract obtained reliability of its application for an increase in gastric acid secretion.

535-543

Authors: Michael I. SHEREMET1 , Viktor O. SHIDLOVSKYI2, Olexandr V. SHIDLOVSKYI2, Vitaliy V. MAKSYMYUK1, Volodimir V. TARABANCHUK1, Nina P. TKACHUK1, Oleksandr V. BILOOKYI1, Hana Ya. STUPNYTSKA3, Galina V. GRYGORUK4, Igor O. MALISHEVSKY5, Lalita M. HERASYM6, Ala A. HALAHDYNA6, Ivanna I. ABRAMCHUK7 , Natalia V. VATAMANYUK7

Introduction. Autoimmune thyroiditis is one of the most important problems of modern endocrinology, with inadequately studied etiological and pathogenic mechanisms of development. It is characterized by the lack of objective and reliable diagnostic methods, effective treatment methods, uncertain therapy or indications for the choice of treatment methods. The aim of the study. Determination of markers for prediction of clinical course and choice of surgery’ volume in patients with nodular goiter and autoimmune thyroiditis, taking into account the oxidative, autoimmune and apoptotic processes. Material and methods. A total of 95 patients who were operated for a nodular endemic goiter on the background of autoimmune thyroiditis were examined. The status of pro- and antioxidant systems, the activity of proinflammatory cytokines, hormonal function of thyroid gland, the level of antibodies to thyroperoxidase, thyroglobulin antibodies and ultrasound structural changes in the thyroid gland have been evaluated in all patients, before and after surgery. Results. In patients with nodular endemic goiter and autoimmune thyroiditis, in the remote period after surgical treatment, there is a significant increase in the peroxide oxidation index and a decrease in the activity of antioxidant defense systems, against the suppression of apoptotic processes and the activation of pro-inflammatory cytokines. These processes lead to functional failure, hyperplasia and the progression of structural thyroid abnormalities, with progression of the functional incapacity of the thyroid gland and inadequate long-term outcome of treatment. Conclusions. The study allowed to clarify the indications and contraindications of different methods of treatment in patients with NGAIT, taking into account the parameters of severity of peroxide oxidation processes, the activity of apoptosis and functional capacity of the gland.

551-556

Authors: Dan ANGHELESCU1 , Elisa POPESCU1, Diana MIHALCEA2, Laura CARSTOCEA3, Florentina GHERGHICEANU3, Adrian CURSARU1,3, Bogdan SERBAN1, Catalin CIRSTOIU1,3

Introduction. A better predictive tool to use for assessing the risk of cardiovascular complications and postoperative mortality in elderly with femoral neck fracture is still not fully developed, and new data in stratifying the cardiovascular risk are still necessary. The objective of the study was to determine the influence of preoperative variables from the cardiovascular preoperative assessment on mortality, and to try to set some standards in the preoperative management of patients with cardiac risk and hip fractures who need surgery. Material and methods. We analyzed age, metabolic equivalents according (METS) to Duke Activity Status Index (DASI), hemoglobin, N-terminal prohormone of brain natriuretic peptide (NT-proBNP) and high sensitive C-reactive protein values, echographic measurements such as left ventricular ejection fraction (LVEF), left ventricular diastolic volume (LVDV) and diameter (LVDD), left ventricular wall hipertrophy (LVH) calculated as a mean of the posterior wall and the interventricular septum, the left ventricular contraction velocity S, pulmonary artery pressure (PAPs), the tricuspid anular plane systolic excursion (TAPSE), and time to surgery, for 72 patients aged over 60 y.o, hospitalised in the Orthopaedics Department of the University Emergency Hospital of Bucharest, Romania, between 2015-2016. Results. The deaths after 3 months from surgery were 13 (18%). The best correlation with 3 month mortality was the delay in surgery over 4 days (p<0,0001), with an area under the ROC curve of 0.943 and NT-proBNP values over 731 pg/L (p<0.0001) and an area under the ROC curve of 0.898. Good correlations were found for an echocardiographic value of s < 7.7, with an area under the curve of 0.745 and a TAPSE < 19.5, corresponding to a area under the curve of 0.807. Conclusions. The mortality was relatively high, and in our opinion, the gold standard should be speeding up the cardiovascular investigations and compensation of cardiovascular pathology, to allow surgery as early as possible, for a better survival of patients with femoral neck fractures.

563-567

Authors: Oksana V. BAKUN1 , Svitlana Y. KARATIEIEVA1, Svitlana B. SEMENENKO1, Oksana I. YURKIV1, Ksenia V. SLOBODIAN1

Introduction. The study of anti-ovarian autoantibodies in patients with ovarian insufficiency against the background of normal levels of gonadotropins, prolactin and androgens shows that the incidence of autoimmune oophoritis among such women varies from 19.2% to 31.5%. The objective of the study was to study the anti-ovarian antibodies level in infertile women at the preparatory stage for in vitro fertilization. Materials and methods. We examined 30 women, who were divided into the following groups: control group – 10 reproductively healthy women, who had a birth in the history (from 1 to 3); study group – 20 women with infertility of tube origin, who were included in the in vitro fertilization program. The study was performed between 2015-2017 in the Bukovinian State Medical University and Centre of Reproductive Medicine, Ukraine. The women signed the informed consent. Results. The anti-ovarian antibodies level in infertile women was found out to be 1.7 times less than in the control group. Reduction of the level of anti-ovarian antibodies in patients from the study group was marked by the obstetric and gynecological history. Conclusions. Anti-ovarian antibodies are present in both reproductively healthy women and in patients with infertility. The level of anti-ovarian antibodies can be both increased and reduced, depending on the pathological process that caused infertility. In both cases, this fact can testify the infertility. After plasmapheresis, the increased level of anti-ovarian antibodies sharply decreases.

573-579

Authors: Marius S. POP1 , Petru MIHANCEA2, Daiana DEBUCEAN1

Introduction. In recent years, the incidence of chronic cervical pain, as the result of degenerative processes, increased among younger people. Studies show a close relationship between cervical pain and sedentarism, as well as occupational risk factors. Throughout life, intervertebral discs are prone to a physiological wear-out process; in the degenerative discopathy, the wear is accelerated, even when it comes to young people, due to the increasingly frequent postural alterations. Objectives. To demonstrate a direct link between the postural system receptors disruption and the degenerative disc pathology, as well as the importance of postural rehabilitation strategies and specific manual therapy in the clinical-functional and therapeutic approach of degenerative cervical discopathies with a painful component. Methods. 174 patients divided into two groups undergone specific assessment tests. The study group followed a personalized therapeutic program (manual therapy, postural re-education), while the control group benefited exclusively from the standard therapeutic program, according to the medical prescription. Results. The data confirm the increased incidence of cervical algic syndromes of myofascial origin among the young population and its close relationship to postural syndromes and CCM biomechanical changes identified in the patients included in the study. This study also highlights the importance of a multidisciplinary approach of the patient with myofascial cervical pain. Conclusions. A significant and long lasting improvement in postural balance results in an obvious improvement in cervical algic syndromes and in slowing the evolution of the cervical disc degeneration process.

585-589

Authors: Konstantinos LAIOS1 , Grégoire TSOUCALAS2, Efstathia LAGIOU 1,3, Georges ANDROUTSOS4, Marianna KARAMANOU1,4

The mandrake, not just a narcotic: its place in medicine and ancient greek civilization Hippocrates and his followers, as well as Pedanius Dioscorides, Pseudo-Galen and Aretaeus of Cappadocia are just a few of the many ancient Greek physicians who have used the plant mandrake. Its narcotic properties were not limited to palliate pain during surgery, but they have been also used to treat pulmonary, neurological and mental diseases. Moreover, mandrake was celebrated in ancient Greek mythology, religion and comedy.

594-598

Authors: Alin BODOG1, Nicolae BACALBASA2,3,4 , Irina BALESCU5, Ioan SUCIU6, Mihaela VILCU3,4, Iulian BREZEAN3,4

Vulvar cancer is a rare gynecologic malignancy usually amenable to surgery, especially in cases diagnosed in early stages of the disease. Although initially it had been considered that extended radical surgery should be routinely performed in such cases, the high rates of perioperative complications led to the modification of the therapeutic protocol, more limited surgical procedures being proposed. The extent of the surgical procedure was modified in terms of both vulvar resections and extent of lymph node dissection, sentinel lymph node dissection being widely recommended in the last decade. This is a literature review of the most consistent studies conducted on the theme of sentinel lymph node biopsy for early stage vulvar cancer patients.

603-607

Authors: Elena-Codruța DOBRICĂ1, Mihnea-Alexandru GĂMAN1 , Matei-Alexandru COZMA1, Florentina GHERGHICEANU1, Anca PANTEA STOIAN1, Bogdan SOCEA1,2, Ana Maria A. STĂNESCU1, Ovidiu G. BRATU1,3, Tiberiu P. NEAGU1,4, Camelia C. DIACONU1,5

Introduction. Primary cardiac tumours are very rare neoplasms, usually with a late diagnosis in clinical practice, because of nonspecific symptoms and clinical signs. Case presentation. We report the case of a 28-yearold woman, who presented for right flank and right iliac fossa pain, radiating to the right lower limb. The pain was progressive and had had its onset 3-4 days previously. The patient was known with renal calyceal microlithiasis (with renal colic in the history) and mild iron deficiency anaemia, and had a medical history of recurrent miscarriages. Physical examination revealed: sinus bradycardia (50-54 bpm), low-grade fever, and positive Giordano sign on the right side. The pain was considered as right renal colic and analgesics and antispasmodics were administered. Blood tests revealed normocytic, hypochromic anaemia and a mild inflammatory syndrome. Abdominal ultrasound revealed bilateral renal microlithiasis and also a triangular, hypoechoic area in the right kidney parenchyma, with no colour Doppler ultrasound signals. Echocardiography revealed a left atrial mass with a diameter of 1.5 cm, hyperechoic, heterogeneous, mobile, attached to the interatrial septum. Chest-abdomen-pelvis CT confirmed the presence of the cardiac mass, as well as an area of right renal infarction. Anticoagulant therapy with low molecular weight heparin was initiated. The patient was referred to the cardiovascular surgery department, where the cardiac mass was removed and sent for histological examination, which confirmed the diagnosis of left atrial myxoma. The patient had a favourable evolution. Conclusions: The presence of sinus bradycardia in a young patient, without known cardiac diseases, led to the necessity of an echocardiography, which revealed the left atrial mass. Peripheral embolization with right kidney infarction represented the clinical onset of the cardiac tumour. In this patient, who presented with abdominal and right flank pain, the previous known diagnosis of renal microlithiasis was initially misleading. Cardiac tumours have unspecific symptoms and the first manifestations could be due to the embolization of tumour fragments in the periphery, mimicking, thus, other disorders.

612-615

Authors: Bogdan SOCEA1 , Anca A. NICA1, Alexandru C. SMARANDA1, Ovidiu G. BRATU2, Camelia C. DIACONU3, Vlad D. BĂLEANU1, Dragoș V. DAVIȚOIU1, Mihai DIMITRIU4, Alexandru C. CARÂP1, Simona BOBIC1, Vlad D. CONSTANTIN1

Hereditary spherocytosis (HS) is an inherited abnormality of the red blood cell, caused by defects in structural membrane proteins. The condition is dominantly inherited in 75% of people. The severity of the disorder is related to the type and amount of membrane disruption, which is genetically determined. A patient who suffers from this disorder is commonly found in a surgical ward when the disease becomes unmanageable by a hematologist. Surgeons encounter complications such as: jaundice, splenomegaly, gallstone sand severe anemia. We present the case of a 66-year-old woman with a history of hereditary spherocytosis who presented at the emergency room for pain in the right upper quadrant, jaundice and anemia and was diagnosed with gallbladder stones and common bile duct obstruction.

619-622

Authors: Bogdan SOCEA1 , Alexandru C. SMARANDA1, Anca A. NICA1, Ovidiu G. BRATU2, Camelia C. DIACONU3, Vlad D. BĂLEANU1, Cezar E. MOCULESCU1, Mihai DIMITRIU4, Alexandru C. CARÂP1, Simona BOBIC1, Vlad D. CONSTANTIN1

Sigmoid volvulus happens when the sigmoid wraps around itself and its mesentery. Sigmoid volvulus accounts for 2% to 50% of all colonic obstructions. This pathology generally affects adults, and it is more common in males. The etiology is multifactorial and controversial; the main symptoms are diffuse abdominal pain, distention and constipation, while the pregnant signs are abdominal distention and tenderness. Laboratory findings are not pathognomonic: abdominal X-ray radiographs show a dilated sigmoid colon and multiple intestinal air-fluid levels, abdominal CT and MRI demonstrate a whirled sigmoid mesentery. Flexible endoscopy reveals a spiral sphincter-like twist of the mucosa. The diagnosis of sigmoid volvulus is established by clinical, radiological, endoscopic, and sometimes operative findings. Although flexible endoscopic detorsion is advocated as the primary treatment choice, emergency surgery is required for patients who present with peritonitis, bowel gangrene, or perforation, or for patients whose non-operative treatment is unsuccessful. Although emergency surgery includes various non-definitive or definitive procedures, resection with primary anastomosis is the most commonly recommended procedure. After a successful non-operative detorsion, elective sigmoid resection and anastomosis is recommended. The overall mortality is 10% to 50%, while the overall morbidity is 6% to 24%.