ARCHIVES OF THE BALKAN MEDICAL UNION

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Authors: Camelia C. DIACONU

Atrial fibrillation is one of the most common arrhythmias encountered in clinical practice, associated with a higher risk of cardioembolic stroke and systemic embolism. Oral anticoagulant therapy is needed to prevent stroke, based on a structured risk assessment of each patient, to decide whether this therapy should be prescribed. The selection of the optimal therapy for patients with atrial fibrillation is sometimes difficult, because of the lack of a proper prediction of benefits and risks. To facilitate this decision, the 2020 European Society of Cardiology Guidelines for the diagnosis and management of atrial fibrillation recommend the use of CHA2DS2-VASc (Congestive heart failure, Hypertension, Age  75 years, Diabetes mellitus, Stroke, Vascular disease, Age 65-74 years, Sex category – female) and HAS-BLED (Hypertension, Abnormal renal/liver function, Stroke, Bleeding history or predisposition, Labile INR, Elderly > 65 years, Drugs/Alcohol concomitantly) scores1. These scores take into consideration only clinical variables, that can limit their power of prediction and calibration. Due to the heterogeneity of the population of patients with atrial fibrillation, recent research has focused on identifying new biomarkers for a better prediction of an individualized risk of stroke.

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Authors: Adrian COTIRLET, Laura GAVRIL, Eduard POPA, Marius NEDELCU

L’Académie Nationale de Chirurgie de France est la plus ancienne institution chirurgicale française. Elle développe des relations avec un grand nombre de sociétés spécialisées et a pour ancêtre l’Académie Royale de Chirurgie créée en 1731 par Georges Mareschal, premier chirurgien de Louis XV et par François La Peyronie, successeur de Mareschal. Le rôle de l’Académie Nationale de Chirurgie est représenté par la grande responsabilité morale en tout ce qui concerne la chirurgie, étant un gardien de son histoire, le témoin de son évolution et le garant de son éthique. L’évaluation prudente et rigoureuse du développement des aspects techniques de l’art chirurgical et de leurs changements, la définition des bonnes pratiques chirurgicales : références, recommandations, stratégies, le contrôle des conditions de l’exercice spécifique de la chirurgie et l’appréciation de la formation et du recrutement des

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Authors: Cuong TRAN CHI, Phung NGUYEN KIM, Tuan NGO MINH, Duy Toan PHAM

Introduction. Pseudoaneurysms of superior mesenteric artery and its branches are extremely rare but life threatening when complications occur. However, the diagnosis is often missed or delayed because of its non-specific signs and symptoms. Treatments depend on patient’s characteristics. In contrast to conventional open surgery, endovascular therapy has been reported as an effective option with minimally invasion, low complication, short recovery time and good outcome, especially in high-risk patients. Case presentation. We describe a case of ruptured pseudoaneurysm of ileal artery, a branch of superior mesenteric artery, presenting with gastrointestinal bleeding signs while on anticoagulant therapy. Both upper and lower gastrointestinal endoscopy were inconclusive. The diagnosis was confirmed by angiography and the patient was successfully treated by coil embolization. Conclusions. Ruptured pseudoaneurysm of superior mesenteric artery and its branches should be suspected in patients with unexplained gastrointestinal hemorrhage. Endovascular intervention is a feasible approach, especially in patients with multiple comorbidities and high bleeding risk.

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Authors: Vasile MUSTEATA

Introduction. A growing number of studies indicates the increased susceptibility of patients with hematologic malignancies to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection as compared to the apparently healthy population. The objective of our study was to identify and evaluate the contemporary epidemiological and diagnosis patterns of chronic myeloid leukemia (CML) in the context of coronavirus disease 2019 (COVID-19) pandemic, to optimize the management of this hematologic malignancy. Material and methods. This analytical, descriptive and prospective study included 15 patients with CML and COVID-19, who were treated and followed up in the Institute of Oncology Chisinau, Republic of Moldova, between 2005–2021. SARS-CoV-2 infection was diagnosed in these patients between April 2020– September 2021. Results. These 15 cases represented 10.6% out of 142 patients diagnosed with CML and followed up under the treatment with tyrosine kinase inhibitors. There were 9 (60.0%) males and 6 (40.0%) females, with the male/female ratio 1.5/1. The patients’ age at diagnosis of COVID-19 ranged between 38-74 years (average age 54.2 years). According to the World Health Organization classification of COVID-19 severity, mild forms were registered in 4 (26.7%) cases, moderate in 6 (40.0%) and severe in 5 (33.3%) cases. Eight (53.3%) patients were hospitalized for treatment of COVID-19: 5 patients with severe forms and 3 patients with moderate forms. Viral pneumonia was diagnosed in 6 patients: 5 with severe and one with moderate form of COVID-19. Non-infectious comorbidities were registered in 4 of 5 patients with severe COVID-19 forms. Conclusions. COVID-19 commonly affects CML patients of male gender and older than the average age of patients with CML. Patients without hematologic response presented an unfavorable evolution of both diseases, CML and COVID-19.

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Authors: Ilir GJERMENI, Ergita NELAJ, Irida KECAJ, Eliona GJERMENI, Mihal TASE

Introduction. Acetaminophen (paracetamol) is a widely used drug and known as a safe analgesic and antipyretic. Hepatotoxicity is usually the first complication of acetaminophen overdose. Nephrotoxicity usually appears after liver toxicity. Most studies on this topic focused on cases of acute over dosage of acetaminophen, with fewer studies on the effects of chronic overdose. Case presentation. We present the case of 74-year-old woman with acute kidney failure because of chronic overdose of acetaminophen and a minireview of the literature. The patient presented to the emergency unit for confusion, with altered vital parameters. She had regularly used 5-6 g/ day of paracetamol over the previous 4 weeks because of articular pain. Acute kidney and hepatic failure were diagnosed. After specific treatment, the patient was discharged in a good condition. Conclusions. An appropriate history of administered drugs (including those without prescription by the physician) allows the accurate diagnosis and enables a faster therapeutic management. In the case presented, hyperkalemia accompanied by syncope from bradycardia raised the suspicion of the diagnosis of acute kidney injury.

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Authors: Victor TIMERCAN, Tatiana TIMERCAN

Introduction. Metabolism is the key factor underlying the cardiomyocyte function. The inadequate coronary perfusion results in tissue acidosis due to elevated lactate production, which is considered a sensitive marker of myocardial ischemia. Isoproterenol is a synthetic catecholamine that produces diffuse myocardial necrosis at high doses. The aim of the study was to assess the changes of serum and tissue lactate content in isoproterenol-induced acute myocardial infarction to evaluate the lactate potential as an early diagnosis marker of cardiac ischemia. Materials and methods. Forty adult male rats were divided into 5 groups: sham (L1=11), control 0.9% NaCl (L2=11), and with experimental myocardial infarction (L3=6, L4=6; L5=6), induced by the subcutaneous injection of Isoproterenol Hydrochloride solution 100 mg/kg, and sacrificed over 6 hours, 24 hours and 7 days post infarction. The results were presented by median and interquartile range. The groups were compared using Kruskal-Wallis and Mann-Whitney nonparametric tests, and the Spearman correlation coefficient was calculated (SPSS 23.0). A p≤0.05 was considered statistically significant.Results. Both glucose and lactate serum levels presented a slight decrease in L3, followed by a significant increase in L4, with a repeated fall in L5 group. In homogenate glucose content initially expressed an elevation in L3, with relevant decrease in L4, and inconsistent increase in L5, while lactate values significantly decreased in L3, returned to baseline levels in L4 and slightly declined in L5 compared to sham and control groups. Conclusion. The collected data suggest the utility of lactate assessment in early diagnosis and risk stratification in acute myocardial infarction.

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Authors: Veska T. GERGOVA, Asena H. SERBEZOVA, Dobriana A. SIDJIMOVA

Introduction. Sponsors of clinical trials propose variations of home visits and virtual contact points with the patients instead of visits at the clinical sites, as well as other digital and remote solutions. The objective of the study was to search and analyse the experience and practice of European countries on applying decentralized elements and a hybrid approach of conducting clinical trials’ activities and procedures, as well as to establish the applicable rules and regulation. Material and methods. A questionnaire survey was conducted among European countries in the period December 2020 – February 2021, by email communication. Results. In most of the countries, it was not forbidden, and respondents indicated the opportunity of medical specialists to help patients at their home. 37.50% of the countries indicated that the applicable legislation cannot be related to the medical or clinical trials legislation or national commercial law but “Other”. Based on the practice, all or some of the activities can be done as a home care. 68.75% responded negatively to the application of the “site-less” model, but 81.25% considered that the combination of on-site and home visits can be better than only visits at sites. Conclusion. Based on this research, the implementation of decentralized elements in the clinical trials in Europe is often based on a case-by-case evaluation only. Notwithstanding the application of various national requirements and acts, they are either fragmentary, or not specifically applicable for such cases.

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Authors: Raluca A. CORB ARON, Delia M. TIT, Radu MOLERIU, Cosmin M. VESA, Sergiu BUNGAU, Alexandra G. TARCE, Tapan BEHL, Simona G. BUNGAU

Introduction. The composition of gut microbiota can be affected by type 2 diabetes mellitus (T2DM) and metabolic syndrome (MS), its improvement is frequently ignored in metabolic disorders. The objective of the study was a comparative evaluation of the faecal microbiota of healthy controls and of T2DM and MS patients (n = 150). Materials and methods. A retrospective crosssectional study was performed, between July 2019- December 2020 in the Bio-standard laboratory Oradea, Romania. A group of 75 patients with non-insulin dependent T2DM and MS (study group = SG) and 75 healthy subjects (control group = CG) has been included in the study. The composition of the microbiome and the influence of oral antidiabetic treatment on the microbiome in SG patients were compared. Results. 8 out of 19 species of the analysed bacteria had a different relative abundance in the SG, compared to CG; Enterococcus spp. were significantly higher (3.18x106 vs 1.94x106, p=0.004), while Akkermansia muciniphila (2.55x109 vs. 4.66x109, p<0.001) and Eubacterium spp. (3.51x108 vs 4.16x108, p=0.047) had significantly lower values in the SG vs. CG. Conclusions. The results indicated differences in the relative abundance of microbial species between the two groups, with significant changes in gut microbiome in the SG.

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Authors: Galyna Ya. STELMAKH, Tatiana V. KHMARA, Inna V. LUKASHEVYCH, Volodymyr V. VIZNIUK, Iryna D. KIIUN, Ruslan P. KNUT

Introduction. The development of angiosurgery requires the morphologists to clarify in more details the topographic anatomical peculiarities of arterial vessels, considering their morphogenesis, peculiarities of innervation, age and individual anatomical variability in different periods of human ontogenesis. The objective of the study was to clarify the sources and peculiarities of innervation of the aortic arch and thoracic aorta in human fetuses. Materials and methods. The study was performed on 36 preparations of human fetuses of 81.0-375.0 mm of parietal-coccygeal length using a combination of methods, such as macro-microscopic preparation, vascular injection, application staining, making of 3D reconstruction models, morphometry. Results. The sources of innervation of the aortic arch in human fetuses are the cervical cardiac branches of the vagus nerve, the cervical cardiac nerve and the single branches of the upper three or four thoracic ganglia of the sympathetic trunks. The innervation of the thoracic aorta is performed by the branches of the thoracic aortic plexus, collateral trunk and also the branches of the paraaortic plexus, which is located between the sympathetic trunk and the thoracic aorta on both sides. From each thoracic ganglion and internodal branch of the sympathetic trunks depart 2-6 branches, some of which go to the thoracic aorta along the posterior intercostal arteries, and the other branches are connected by connecting branches forming the collateral trunk. The vagus nerve throughout the thoracic region gives branches to the thoracic aorta with the formation of the thoracic aortic plexus. Conclusions. In human fetuses, the paraaortic plexus is found between the right and left sympathetic trunks and the thoracic aorta, in addition to the intermediate plexus or collateral trunk. In the dynamics of the fetal period of ontogenesis, a bilateral asymmetry in the structure and formation of plexuses of the thoracic aorta is observed. At the end of the human fetal period, the number of connecting branches between the nerve branches of the paraaortic plexus increases.