ARCHIVES OF THE BALKAN MEDICAL UNION

3

Authors: Camelia C. DIACONU

Heart failure (HF) is a heterogeneous syndrome, with progressive evolution and negative impact on quality of life and mortality of patients. The incidence of HF in Europe and the United States of America varies between 1 to 9 cases per 1000 inhabitants, depending on the population studied and the diagnostic criteria used1. Currently, it is estimated that approximately 64.3 million people suffer from HF world-wide2. One of the most important therapeutic goals for patients with HF is represented by maintaining and improving the quality of life. Many patients value functional status and quality of life more than longevity. The most important predictors of the quality of life in HF are the presence of symptoms and their severity, functional status and depression3. Current guidelines recommend the combined use of medical and behavioural interventions to improve the functional status of these patients3.

4

Authors: Nikoleta G. TABAKOVA

Introduction. Platelet-rich plasma (PRP) is a novel treatment of lichen sclerosus vulvae. Case presentation. We describe a case of lichen sclerosus vulvae in a 25-year-old woman treated with PRP. The diagnosis was confirmed by the histological examination. The patient’s symptoms were evaluated using Female Sexual Function Index (FSFI) questionnaire. PRP was prepared using Regen lab Cellular Matrix Kit and administered every two weeks, three times. The lesions disappeared at the visual examination. Conclusions. Our case confirms the effectiveness of PRP treatment for lichen sclerosus vulvae reported by other case reports. Nevertheless, future randomized controlled studies are needed to evaluate the safety of PRP treatment and to establish effective clinical protocols for its use in lichen sclerosus vulvae.

5

Authors: Theodoros MICHAILIDIS, Aris LIAKOS, Nikolaos KAKALETSIS, Ioannis AVGERINOS, Stylianos MAMALIS, Sophia ASPRAGATHOU

Introduction. Multisystem inflammatory syndrome in adults (MIS-A) is a rare but potentially life-threatening sequel of SARS-CoV-2 infection, requiring early recognition and treatment. Nevertheless, it is often hard to distinguish MIS-A from other COVID-19-related hyperinflammatory complications. Case presentation. A 74-year-old male presented to the emergency department with persistent fever, diarrhea, altered consciousness, polymorphous rash with oral lesions and erythema of the palms and soles, with progressive exfoliation. The patient had been hospitalized for COVID-19 four weeks before and was suffering from chronic lymphocytic leukemia, diabetes and hypertension. During his recent hospital stay he received multiple courses of antibiotics and was discharged home with instructions to add sitagliptin and re-initiate therapy with ibrutinib. Upon re-admission, polymerase chain reaction test for SARS-CoV-2 was still positive and inflammatory markers were markedly elevated. Although MIS-A could not be excluded, a presumptive diagnosis of Stevens-Johnson Syndrome (SJS) was made, and the patient was treated empirically with intravenous immunoglobulin and high-dose methylprednisolone. SJS is usually considered an adverse drug reaction that affects the skin and mucous membranes. In this patient, MIS-A was also initially included in the differential diagnosis due to previous COVID-19, despite the patient’s advanced age and lack of cardiac involvement or conjunctivitis. The patient only partially fulfilled current diagnostic criteria for MIS-A. Conclusions. SJS results from a dysregulated immune response and can have a similar presentation to MIS-A. A better characterization of both conditions is required particularly in older adults with comorbidities, to facilitate timely diagnosis and management and to reduce mortality.

5

Authors: Rosen B. TSOLOV

Introduction. Melanomas are the most aggressive skin carcinomas and a major cause of premature death from cancer. The risk factors for melanomas are UV rays, personal or family history of melanoma, large numbers of naevi, fair complexion, immunodeficiency, solar-damaged skin, etc. The scars from malignant melanoma on the face are serious challenge for the surgeons, so the successful plastic reconstruction of skin defects is very important for the normal life of the patient after surgery. Case presentation. A 82-year-old patient with a large malignant melanoma of the left cheek was admitted to the Clinic of Maxillo-facial Surgery, University Hospital „St. George”, Medical University of Plovdiv, Bulgaria, for treatment. The preoperative examination revealed the presence of a sloping heterogonic tumour, with axial dimensions of 55/28 mm, penetrating and engaging the dermis, subcutaneous tissue, levator oris and muscular orbicularis oris. Surgery was performed, under general anaesthesia. The tumour was removed, and the defect was repaired using several skin flaps, to use the adjacent tissues. The final outcome was favourable and the surgery was functionally successful. This case highlights the importance of an accurate diagnosis of malignant melanoma, that is essential for an adequate management and follow-up, considering its potentially aggressive behaviour.

6

Authors: Miglena TARNOVSKA, Rositsa DIMOVA, Gergana PETROVA

Introduction. The introduction of COVID-19 screening through rapid antigen tests has become a key mechanism to ensure the continuity of the learning process and safety of school environment during pandemic. The objective of the study was to investigate and analyse the attitudes and beliefs of students, teachers, and parents regarding the rapid antigen test as a method to limit COVID-19 spreading in school environment. Material and methods. An online anonymous survey was conducted among 228 participants, 11th and 12th grade high school students (n=114), teachers (n=44) and parents (n=70) in November 2021. Results. 43.9% of students and 52.9% of parents agree with rapid antigen testing for COVID-19, while over 63.3% of teachers disagree with it. Students (45.6%) and parents (48.6%) shared optimistic expectations that testing for COVID-19 would reduce the spread of the virus in schools, while 59.1% of the teachers surveyed remained sceptical about this prevention measure. The interruption of school classes does not find support among students and parents, as well as among members of the teaching staff. Conclusions. According to students and parents, rapid antigen testing for COVID-19 seems a more acceptable solution than closing school completely. Given the concern of teachers to conduct antigen tests in the school environment, it is necessary to adequately plan the participation of medical professionals in this process, instead of delegating these activities to teachers.

7

Authors: Pavlo PETAKH, Vitaliia ISEVYCH, Vasilij GRIGA, Aleksandr KAMYSHNYI

Introduction. Leptospirosis is a re-emerging illness with a wide spectrum of clinical manifestations, from asymptomatic or moderate to severe and lethal results. Leptospirosis can be adequately treated if detected early; however, comparable clinical presentations with various other febrile illnesses or co-infections, as well as laboratory diagnosis problems can result in misdiagnosis, leading to severe illness. Identifying clinical predictors for the severe form of the disease is critical to reduce the disease complications and mortality. The objective of the study was to establish the risk factors for mortality in patients with leptospirosis. Materials and methods. A retrospective study of 102 medical records of patients diagnosed with leptospirosis in the period from 2009 to 2019 was conducted. Quantitative variables in the presence of normal distribution were compared using a paired Student’s t-test, and in the case of an abnormal distribution, the Mann–Whitney U test was used. The criterion χ2 was used for qualitative variables. A two-step cluster analysis was also performed. Results. The following factors associated with death from leptospirosis have been identified: oliguria (OR, 13.5; 95% confidence interval [CI], 2.56-71.12), serum creatinine and urea levels, direct and total bilirubin, platelets, and white blood cells count. Conclusions. These „red flag” laboratory and clinical characteristics will aid medical personnel in rapidly identifying a patient at risk of death, which is critical in determining the severity of the condition and the need for early intensive care and therapy adjustment.

9

Authors: Olga PENINA

Introduction. Evidence on disparities of mortality by place of residence based on reliable data is needed for appropriate public health programmes aimed at reducing high mortality in Moldova. The objective of the study was to determine changes in mortality disparities for all causes and major groups of causes of death between rural and urban populations of the Republic of Moldova after independence. Material and methods. The data were analysed by sex and place of residence for all causes and seven main groups of causes of death for two periods: 1991-93 and 2017-19. Abridged life tables and standardised death rates with 95% confidence intervals were computed. Mortality inequities between rural and urban areas were analysed in absolute and relative terms. Results. Cardiovascular diseases and digestive system diseases in both sexes and external causes and respiratory system diseases among men accounted for the rural mortality disadvantage. Cancer mortality had a negative rural-urban gradient. During independence, the rural-urban gradient of all-cause mortality declined among women, but not among men. A more rapid reduction in mortality from circulatory system diseases and a more rapid growth of neoplasm mortality in rural areas than in urban areas narrowed the rural-urban disparities. For external causes and diseases of the respiratory system, inequalities in mortality between rural and urban areas increased over the study period. Conclusions. Public health programmes aimed at reducing elevated cardiovascular mortality in rural areas are a key strategy for addressing mortality disparities between rural and urban populations.

9

Authors: Horatiu MOLDOVAN, Oana FRONEA, Claudia NICA, Mihai CACOVEANU, Cristian VOICA, Silvia PREDA, Marian BROASCA, Andra SIBISAN, Robert TIGANASU, Sabina SAFTA, Lucian CALMAC, Ondin ZAHARIA, Liliana MIREA, Camelia C. DIACONU, Horatiu SUCIU

Introduction. Heart failure (HF) is a clinical syndrome caused by structural and/or functional cardiac abnormalities, resulting in a reduced cardiac output and/or elevated intracardiac pressures at rest or during stress. It is a progressive disease with a high risk of death in the first 6-12 months after the diagnosis of end stage HF. Cases presentation. We present the successful implantation of a left-ventricular assist device (LVAD) HEART MATE III in a 54-year-old male with ischemic cardiomyopathy and end stage HF, and a heart transplant in a 31-year-old male with non-ischemic dilated cardiomyopathy and end stage HF. Both procedures were guided by experienced surgeons and the overall management was according to the current standardised protocol. Conclusions. HF is one of the leading causes of death world-wide. The effort to stabilize and effectively treat patients with ventricular assist devices and/or orthotopic heart transplant is increasing. One of the few drawbacks is the complex Heart Team training, a difficult process that involves each member acquiring the necessary skills and knowledge. The end stage HF Team is composed of a large variety of members, such as cardiologists, cardiac surgeons, anaesthetists and intensive care doctors, interventional cardiology doctors, and nurses.

5-7

Authors: Camelia DIACONU

The digital transformation of healthcare services is a hot topic during the coronavirus disease 2019 (COVID-19) pandemic. To limit the spreading of the severe acute respiratory coronavirus 2 (SARS-CoV-2), in a short period of time an accelerated digitalization took place in many societies. The direct, physical interaction between doctors and patients was replaced by digital types of communication and examination, to avoid the patients’ exposure to the risk of infection in healthcare facilities or during their travel to hospitals or medical offices. Telemedicine was introduced as an alternative option, being reimbursed for consultations and remote monitoring of patients with different pathologies. The role of the digital healthcare services when the pandemic will end and will eventually transform in endemic in certain areas and populations is unclear now. A large part of the modern communication, either professional or personal implies the use of digital technologies (e-mail, SMS, message sharing apps, video etc.) and different social media platforms or applications (apps). In healthcare facilities, patients’ medical data are almost entirely recorded in a digital system and can be easily accessed and shared with different physicians. The remote approach is a valuable tool for patients’ convenience when the social interaction is impossible or prohibited. However, issues related to protection of personal data and data security have been raised in this context, especially in highly regulated healthcare systems. Moreover, there are legitimate concerns that physicians will limit their physical interaction with patients and the medical examination will be entirely digital, without the touch of empathy, compassion, and direct human-to-human communication and support, that have been part of the art of medical practice for centuries. The digitalization may also increase the risk of social inequalities, where patients without access to modern digital technologies or internet may be left behind. Another issue is related to medical responsibility when using artificial intelligence: will the doctor be held responsible for negative results when applying the digital algorithms and digital decision-making tools? The responsibilities must be clearly defined. There are opinions that digitalization of healthcare services will not necessarily lead to better patients’ outcomes, despite their increased accessibility. One big concern is related to the teaching methods of medical universities. The traditional academic model of teaching medical students to the bedsides of the afflicted and practical training in the hospitals has largely shifted during COVID-19 pandemic to online teaching methods. In this context, there is the possibility that a few generations of medical students will graduate without bedside clinical instruction or contact between students and patients. What will be the impact on the medical practice in the future? Nobody knows yet. There is a high probability that the future of medicine will be hybrid, divided between face-to-face visits and virtual care and monitoring. Healthcare digital technologies can be used in certain clinical settings, where their added value is undeniable, and they offer better outcomes at a reasonable cost. Where they lead to poorer healthcare outcomes or inequalities, the traditional medical approach should be preferred. Digitalization of healthcare services must be driven by the needs of patients and health care professionals, to shape a better future of patient’s care.

17-22

Authors: Igor LAKHNO, Iryna KNIAZKOVA, Olga LAKHNO and Kemin UZEL

Introduction. The role of autonomic imbalance in maternal cardiac arrhythmia (CA) is still debatable. The objective of the study was to assess the relationship between maternal autonomic tone and CA in pregnant women. Materials and methods. The cross-sectional study was carried out among pregnant women admitted to Kharkiv Municipal Perinatal Center between 1 December 2015 and 31 July 2020. 117 patients at 28-36 weeks of gestation were enrolled. 20 of them had sinus rhythm and were included in Group I (control). In Group II, 55 pregnant women with CA and cardiovascular comorbidity were observed. 42 patients with idiopathic CA were monitored in Group III. The daily electrocardiogram and heart rate variability (HRV) were obtained. The density of ectopic beats (DEB) was defined as the percentage of ectopic to total beats. Results. The investigation of the HRV revealed heterogeneity in the groups of study. The enhanced sympathetic activity was determined in women with CA and structural heart disease. Pregnant women with idiopathic CA demonstrated a parasympathetic pattern of autonomic nervous regulation. The revealed relations between DEB and sympathetic or parasympathetic regulation demonstrate an increased sympathetic tone in patients with structural heart disease. In women with idiopathic CA, parasympathetic regulation played a significant role in the scenario of cardiac ectopy. Conclusions. The idiopathic CA could be the result of abnormally elevated parasympathetic regulation in the second half of pregnancy.

30-35

Authors: Petar A. UCHIKOV, Petar A. ANTONOV and Atanas S. IVANOV

Introduction. According to the European Association of Urology guidelines, flexible ureterorenoscopy is one of the treatment modalities for kidney stones less than 2 cm. Disposable flexible ureterorenoscopes are superior to reusable ones in terms of scope performance deterioration, damage repair costs and special gas-sterilization equipment. Despite the undeniable progress of disposable flexible ureterorenoscopes in everyday urological practice, the literature lacks a rich database on their technological design and clinical effectiveness. The objective of this paper is to present our experience in the management of kidney stones by a flexible disposable ureteroscope – WiScopeTM. Material and methods. Between the 1st of January 2020 –the 1st of January 2021, 76 patients with kidney stones were treated in our centre by flexible ureteroscopy and laser lithotripsy. The evaluation of demographics, efficacy and safety of the procedure was performed. Results. A successful procedure was recorded in 94.7% (72/76) of the patients. We evaluated the total stone-free rate 8 weeks after the intervention, which was 94.4% (70/72). The complications rate was 13.1% (10/76). No serious adverse events were observed. Conclusions. The use of flexible disposable ureteroscopes has proven a good efficacy and safety. WiScopeТМ is a comparable option among all available flexible disposable ureteroscopes, in terms of all basic characteristics.

45-53

Authors: Diana BODOARCA, Oana M. PATRASCU, Camelia C. DIACONU, Samuel BODOARCA and Mariana COSTACHE

Introduction. Cutaneous metastases are usually observed in end-stage cancers. In some cases, the diagnosis of skin metastases is not clinically evident. New studies have found that serological markers, such as fibrinogen and lactate dehydrogenase (LDH), represent predictive factors of cutaneous metastases and could be used in the follow-up. The objective of our study was to evaluate these two markers (fibrinogen and LDH) and to find if there are any correlation between different parameters such as patients’ age, dimensions, and type of the tumour, as well as local complications. Materials and methods. We conducted a retrospective study on 56 patients with cutaneous metastases. We analysed different parameters of patients who underwent skin biopsies or surgical excision, such as age, number, diameter, localization or complications, type of primary neoplasia, other internal organ malignancies, as well as serological levels of LDH and fibrinogen. Results. The study included patients with various types of malignant tumours, most of them with melanoma, followed by different types of adenocarcinomas and leiomyosarcoma. Our cohort also included some rare cases of uterine cervix adenocarcinoma metastases, renal cell metastases and pancreatic metastases. Regarding the serological markers, we identified that fibrinogen correlates with the diameter of the skin nodules, LDH correlates with the age of the patients diagnosed with melanoma, and the two serological parameters correlate with one another. Conclusions. Fibrinogen and LDH can be considered poor prognostic factors for patients with melanoma metastases. As the two markers correlate with one another and with some of the analysed parameters, they could, in the future, be useful to better estimate the malignant disease outcome.

63-70

Authors: Oleksandr V. SHIDLOVSKY, Michael I. SHEREMET, Viktor O. SHIDLOVSKYI, Dragos CRETOIU, Yan V. GYRLA, Oleksandr V. BILOOKYI, Oleksandr V. LAZARUK, Vitaliy V. MAKSYMYUK, Volodymyr V. TARABANCHUK, Andryi I. POPOVYCH, Oksana Y. OLINIK, Tetyana Y. LAZARUK and Galyna Y. STELMAKH

Introduction. Nodular goiters are clinically recognizable enlargements of the thyroid gland characterized by structural and/or functional transformation of one or several areas within the normal thyroid tissue. In the absence of thyroid dysfunction, autoimmune thyroid disease, thyroiditis, and thyroid malignancy, they constitute an entity described as simple nodular goiter. The objective of the study was to determine the scope of surgery in patients with unilateral nodular goiter with autoimmune thyroiditis (NGAIT) with compression syndrome and predict the long-term results of surgical treatment, based on the study of proliferation of apoptosis and autoimmune disorders. Materials and methods. Long-term results of hemithyroidectomy were analysed in 101 women aged between 23-72 years, with unilateral NGAIT. We analysed the volume of the gland lobe and the echo structure variant before surgery, blood levels of thyroid-stimulating hormone (TSH), free thyroxine and triiodothyronine, thyroid peroxidase antibodies (TPOab), apoptosis and proliferation indicators showing satisfactory or unsatisfactory treatment results. Results. In 75 patients, three years after hemithyroidectomy, no thyroid dysfunction was detected. At ultrasound, in the remaining thyroid the signs of autoimmune thyroiditis (AIT) did not progress. Twenty-six patients showed an increase in the remaining thyroid gland and progression of the autoimmune disease, with hypothyroidism. Conclusions. Hemithyroidectomy can be performed in patients with NGAIT and compression syndrome in conditions of preserved gland function, activation of proliferation and apoptosis, and pseudo micronodular parenchymal echo structure.

84-90

Authors: Radka KOMITOVA, Petar VASILEV, Ani KEVORKYAN and Vanya RANGELOVA

Dengue is estimated to be the most common mosquito-borne disease globally, affecting mainly tropical and subtropical countries. It has been identified as a disease of the future, due to persistent trends in urbanization of societies, scarce water resources and changes in the environment. The four dengue virus serotypes cause from the usual mild illness to a potentially fatal syndrome associated with increased vascular permeability. The unique antigenic and biological properties of the virus have made it difficult to develop vaccines. The authors have analysed “Dengvaxia”, the only licensed vaccine with partial efficacy (it protects most of the people, but makes others more susceptible to serious diseases) and complex performance. The impact of these results on the future of the dengue vaccines is discussed.

99-105

Authors: Alexandru MARTINIUC, Ana STANILA, Daniela TABACELIA, Radu POENARU, Stefana DUMITRAS, Florina A. NITU, Radu DUMITRU, Madalina M. FLORESCU, Raluca R. GRIGORESCU, Cristian ROSIANU, Laura POPA, Adelina BIRCEANU, Dragos CHIRITA and Cezar STROESCU

Introduction. The coronavirus disease 2019 (COVID-19) pandemic has constrained healthcare units to reorganize hospital departments, substantially reducing their capacity to perform oncology-related surgeries. Despite the efforts to reduce the risk of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) during hospitalization, COVID-19 has complicated the recovery of many surgical patients. Our objective was to assess the impact of SARS-CoV-2 infection on the postoperative evolution of patients with pancreatic surgery. Cases presentation. We present four patients with pancreaticoduodenectomy for malignant disease, operated in our hepato-biliary-pancreatic surgery department, who presented COVID-19 in the postoperative period, despite initial negative screening. 10% of patients who had pancreaticoduodenectomies were subsequently detected with minimal, moderate to severe forms of COVID-19 in the postoperative period, which led to an extension of the hospitalization period, in some cases, by up to five weeks. Conclusions. The side effects of COVID-19 pandemic are yet to have reached their limits. Pancreaticoduodenectomy is a complex surgery with high morbidity rates, but during the COVID-19 pandemics it has become more challenging.