ARCHIVES OF THE BALKAN MEDICAL UNION

281-283

Authors: Camelia C. DIACONU

The clinical data obtained during the pandemic of coronavirus disease 2019 (COVID-19) indicated that this is a disease associated with an increased risk of thrombosis. Thromboembolic events in patients with COVID-19 lead to a worse clinical evolution and a poor prognosis. Some studies analyzed the prevalence and risk factors for thrombotic complications in patients with COVID-19. An observational study on 3,334 patients admitted for COVID-19 has found that 16% of patients had a thrombotic complication during hospitalization(1). 11.1% of these cases had an arterial thrombosis, 8.9% had myocardial infarction, 1.6% ischemic stroke and 1% systemic arterial thrombosis(1). Venous thromboembolism was encountered in 6.2% of patients(1). Older age, man sex, personal history of ischemic heart disease, and increased D-dimers were all risk factors for thrombosis in this study1. Almost one third of patients admitted in the intensive care unit presented thrombotic events and these were associated with a higher risk for in-hospital mortality(1). Interestingly, another study on non-hospitalized patients with COVID-19 did not find a significant difference regarding the incidence of venous thromboembolism between these patients and those without COVID-19(2). The authors analyzed data of 220,588 patients tested for COVID-19 and reported the incidence of thrombosis in out-patients and in-patients, at 30 days. From these patients, 11.8% tested positive for infection with SARS-CoV-2; within 30 days after the positive test, 0.8% of patients developped venous thromboembolism, compared to 0.5% of patients with negative tests(2). However, this study had some limitations regarding the diagnosis of venous thromboembolism and the empirical use of anticoagulants and/or anti-inflammatory drugs. The authors of this study suggested that anticoagulants need to be studied in prospective clinical trials, to evaluate the impact of anticoagulant treatment on outpatients’ outcomes. Regarding the pathophysiology of thrombosis in COVID-19, new data highlight that patients with severe forms of disease have sustained platelet activation, that contribute to the increased risk of thrombosis. Endhotelial injury is another pathophysiological factor that may intervene, by altering hemostasis. Cytokine storm, that appears in patients with severe forms of the disease, will also increase the risk of coagulopathy and thrombosis. The overproduction of inflammatory cytokines, such as tumor necrosis factor (TNF), interleukin-6, interleukin-8 and interleukin-1 is considered the cause of cytokine storm, that may cause multiorgan failure and possibly death(3). Laboratory tests usually reveal increased D-dimers, thrombocytopenia, elevated fibrin degradation products, and fibrinogen(4). D-dimer levels are especially increased in patients with critical forms of disease, admitted in intensive care units(4) and may be a surrogate marker for the disease severity(5). Because of the clinical consequences of hypercoagulability in patients with COVID-19, hemogram with platelet count, peripheral blood smear, prothrombin time, aPTT, fibrinogen and D-dimers should be monitored in all hospitalized patients with COVID-19. Furthermore, these patients must be investigated and screened for deep venous thrombosis, preferably by duplex scan. Pulmonary thromboembolism, in some studies, has been more frequent than deep venous thrombosis in patients with COVID-19. A study of 1,765 patients diagnosed with COVID-19 reported an incidence of pulmonary embolism of 22%, and even higher in patients admitted in intensive care units(6). Patients with COVID-19 may also present coagulation abnormalities similar to thrombotic thrombocytopenic purpura, disseminated intravascular coagulation, or hemolytic uremic syndrome. Thrombotic complications in COVID-19 have some unique characteristics that must be deeper investigated, for a better management of this disease.

291-297

Authors: Ecaterina PAVLOVSCHI, Valeriana PANTEA, Djina BOROVIC, Olga TAGADIUC

Introduction. Arterial hypertension (HTN) is one of the leading public health problems, causing a challenging and complex visual impairment known as hypertensive retinopathy (HR). Its pathogenesis is caused not only by changes in retinal homeostasis because of high blood pressure (BP) but, undoubtedly, other pathological mechanisms are involved, including oxidative stress (OS). The aim of the study was to evaluate the serum and tears total antioxidant capacity (TAC), as a single parameter of oxidative stress associated with the development of HR and to establish whether there is a correlation between its level and the grade of HR. Materials and methods. 90 hypertensive patients divided according to the Keith-Wagner-Barker grading system of HR into three groups: GI – 36 patients; GII – 35 patients; GIII – 19 patients. TAC in tears and serum was measured and the obtained results were analysed by Kruskal-Wallis and Mann-Whitney tests in SPSS Statistics. The Spearman correlation coefficient was determined. A p≤0.05 was considered statistically significant. Results. TAC values in the tears samples of hypertensive patients increased statistically significant as HR advanced in grade (p=0.003). Serum level of TAC showed only a tendency of decrease (p=0.182). Only tears TAC levels correlate significantly with low power with HR degree (r=0.357**, p=0.001). Serum and tears levels of TAC have a statistically significant negative low power correlated with each other (r= – 0.226*, p=0.032). Conclusions. The continuous rise in TAC levels in tears along with HR progression is a possible mechanism by which the eye copes with the damaging reactive oxygen species produced by OS. The increase in TAC may partially explain the gradual and delayed development of retinopathy stages in HTN.

309-316

Authors: Tatiana ROTARU, Natalia LOGHIN-OPREA, Lucia MAZUR-NICORICI, Virginia SALARU, Maria GARABAJIU, Victoria SADOVICI-BOBEICA, Minodora MAZUR

Introduction. Psoriatic arthritis (PsA) is chronic disease associated with considerable psychological burden and impaired quality of life (QoL). The objective of the study was to determine the medical and social status of patients with PsA, to optimize the management of these patients and increase their QoL. Material and Methods. We performed a cross-sectional study in which were included patients with PsA. Demographic and clinical data were collected using a special questionnaire, including employment and profesional status, information related to disease onset and duration, clinical overview related to the disease. In order to apreciate the burden of PsA, we applied the Rankin’s scale, Health Assessment Questionnaire (HAQ), Short Form 8 (SF-8), Work Productivity and Activity Impairment (WPAI) and Disease Activity score in Psoriatic Arthritis (DAPSA), Patient Global Assessment (PGA) to assess the disease activity. Results. 92 PsA patients were enrolled in the study. Male to female ratio was 1.09:1, the patient’s mean age was 48.53±11.42 years. According to DAPSA, patients had moderate to high disease activity. 34.78% of patients from the group of study were full-time employees. The assessment of work productivity by WPAI determined a level of absenteeism of 9.39±11.79% and presenteeism of 37.57±27.31%. The QoL in PsA patients was diminished in both mental and physical domains; the average HAQ score value was 0.61, which indicates a moderate functional status. According to Rankin’s scale, the most frequent degree was the 2nd, found in 32 (34.78 %) patients. Conclusions. Patients with PsA have medium/low medical and social status, caused by low physical functionality and psychological problems. To optimize the management of patients with PsA, it is necessary to integrate rheumatological, dermatological, psychological and social services.

329-335

Authors: Vanya RANGELOVA, Ani KEVORKYAN, Ralitsa RAYCHEVA, Diruchi AMUDZHIYAN, Mariana ALEKSANDROVA, Sara SARIYAN

Introduction. Vaccination is the most effective and safest means of preventing influenza infection. The coverage with influenza vaccine is not satisfactory across Europe and one of the main obstacles is vaccine hesitancy. The objective of the study was to assess the knowledge, attitudes, and practices of the population towards the seasonal influenza vaccine. Materials and methods. Between November 2016 – February 2017 a cross-sectional study using a semi-structured questionnaire was conducted in Plovdiv (Bulgaria), covering 545 people over 18 years old. Standard descriptive statistics was used to summarize demographic characteristics. Differences between observed and theoretical distributions were tested using chi-square test for independence. A 2-sided p-value of <0.05 was considered statistically significant. Results. The vaccine uptake was 11%. An association was found between the age of the respondents and administration of the vaccine (χ2=16.687 p=0.005), vaccination status and educational level (χ2=27.002, p=0.00002). 27.6% of the unvaccinated respondents were uncertain about the effectiveness of the vaccine and 26.8% had the perception this is not a serious disease. More than half of the respondents (51.1%) were willing to change their attitude towards the influenza vaccination, the recommendation from a doctor being the most important (40.8%). Conclusions. Seasonal influenza vaccine uptake was low in our study and the main drivers for vaccine hesitancy were concerns regarding its safety and effectivenes. Recommendation of the vaccine from a general physician was the most important source for influencing the attitudes towards the vaccine. This highlights the importance of general physicians’ involvement and the need to spread public awareness regarding the efficacy and benefits of seasonal influenza vaccination.

342-348

Authors: Calin POPOVICI, Petru ARMEAN, Andrei KOZMA

Introduction. In Romania, the number of cases of maternal death has decreased significantly in recent years. Material and methods. The objective of this review is to assess maternal mortality in Romania in the last decade (2010-2019) in terms of the evolution of the number of cases and socio-demographic characteristics, by death groups and the identification of predictors of severe obstetric morbidity. Results. The number of maternal deaths decreased during the analyzed period by almost 60% (from 51 deaths in 2010 to 20 in 2019). We observed the decrease of maternal death index from 24.0/100,000 live births in 2010 to 10.6/100,000 live births in 2019. Considering maternal death groups, the result is mainly due to the decrease of abortion and indirect obstetrical risk, maintaining the trend of a higher mortality through direct obstetrical risk. Maternal deaths and mortality as a whole also decreased in terms of distribution by area for this period, generally maintaining the gap in favor of the rural environment. A number of factors have been identified as playing a predictive role for severe obstetric morbidity. Conclusions. The decrease in maternal mortality has been influenced by several factors, including the increase in the number and quality of prenatal care, reducing the risk of maternal death from indirect causes. Another factors are the quality and promptness of hospital care, more relevant in the case of deaths from direct obstetric causes; nevertheless, the risk of death in this group is still almost double. The analysis of severe obstetric morbidity can be performed considering the following groups of predictors: demographics (over 34 years old, etc.), general medical (hypertension, etc.) and obstetric factors (multiple pregnancies, antenatal hospitalizations, emergency cesarean section, etc). Their identification can determine a focus on women who require higher attention during pregnancy.

358-362

Authors: Vanya BOZHIDAROVA GEORGIEVA

The coronavirus disease 2019 (COVID-19) is the latest life-threatening disease affecting health and economic sectors worldwide. The ethical principles during the COVID-19 pandemic can be shaken because of distributive and social injustice, healthcare collapse, distress among healthcare workers, lack of confidentiality of personal data, development of strategies for exiting pandemics, isolation, mass vaccination and last, but not least, ethical principles of scientific studies during COVID-19. This overview article discusses the ethical issues raised during the COVID-19 global pandemic.

376-382

Authors: Iulia SIMA, Eliza M. POPA, Lavinia RAICU, Rosana MANEA

Introduction. Sinusitis is caused by allergens, viruses, fungi or bacteria. The main signs of the disease are those of a common cold. Untreated sinusitis can lead to severe orbital or intracranial complications, such as brain abscess. Case presentation. We present the case of a 52-year-old man who presented to the emergency department with aphasic speech disorders and headache persisting for two days. After computed tomography (CT) evaluation, the suspicion was raised of a brain abscess and subdural empyema, with the starting point in the paranasal sinus infection. The treatment included neurosurgery and broad-spectrum antibiotics continuously for 4 weeks. The aim of this case study is to underline the importance of properly administered treatment in chronic sinusitis and the severity of the complications that may occur. Conclusions. Untreated sinusitis can lead to life-threatening complications, such as brain abscess and subdural empyema, even though the symptoms are often ignored. For the complete diagnosis and further treatment, the use of CT and magnetic resonance imaging (MRI) is necessary.