Marina Ruxandra Otelea
Stamatis Karakonstantis, Mina Koulouridi, Kyriakos Pitsillos, Eirini Kalokyri, Anna Kozyri, Galateia Gourniezaki and Charalampos Lydakis
Introduction: Several diagnoses have been associated with leukemoid reaction (LR). In patients with LR the diagnostic and prognostic value of detailed manual blood smear counts (such as the percentage of band cells or grading of neutrophil toxic changes) has not been studied previously.
Methods: We prospectively recorded all hospitalized adult (>18 years old) patients with LR (≥30000/ul) of neutrophilic predominance, excluding patients with pre-existing leukocytosis due to hematological malignancies. We examined the diagnoses and prognosis (in-hospital mortality and post-discharge mortality up to a year after the end of the study) of these patients as well as the value of manual peripheral smear review.
Results: We recorded a total of 93 patients with LR from January 2017 to December 2017. Infection was the most common diagnosis (70%), followed by malignancy (7.5%) and bleeding (6.5%). In-hospital mortality (45%) and post-discharge mortality (35% of those discharged) were very high. Among blood smear findings, only neutrophil vacuolation was significantly more common in patients with infections (34%), although it was also observed in many patients without any infection (13%). Blood smear findings were not associated with prognosis
Conclusion: Detailed manual smear review is a labor-intensive procedure and has limited diagnostic and prognostic value in unselected hospitalized patients with neutrophilic LR.
Mile Bosilkovski, Marija Dimzova, Marija Cvetkova, Kostadin Poposki, Katerina Spasovska and Ivan Vidinic
Introduction: The study aimed to compare the etiologic spectrum of diseases causing fever of unknown origin (FUO) and methods for definitive diagnosis in a tertiary care hospital in Republic of North Macedonia during two different time periods.
Patients and methods: retrospectively were analysed the causes for FUO and final diagnostic approaches in 185 patients with classic FUO that were treated at the University Hospital for Infectious diseases in Skopje during two time periods. Seventy nine patients were treated during 1991 to 1995 and 106 patients during 2011 to 2015.
Results: When comparing these two periods, infections were present in 46.8% and 29.2% (p=0.014), non-infective inflammatory disorders in 22.8% and 25.5% (p=0.674), neoplasms in 10.1% and 13.2% (p=0.522), miscellaneous in 8.9% and 12.3% (p=0.461) and undiagnosed cases in 11.4% and 19.8% (p=0.124), respectively. The most common causes for FUO during the first period were abscesses (8.9%), tuberculosis and systemic lupus erythematosus (7.6% each), whereas in the second period the commonest causes were adult onset Still disease and solid organ neoplasm (7.6% each), polymyalgia rheumatica, abscesses and visceral leishmaniasis (5.7% each). The newer imaging techniques and clinical course evaluation had superior diagnostic significance during the second period.
Conclusion: A changing pattern of diseases causing FUO during the examined periods was evident. Infections continue to be the most common cause but with decreasing incidence when compared to 20 year ago. Even nowadays clinical evaluation and follow-up still remain the vital diagnostic tools in determining the etiology of FUO.
Cristian Baicus, Paul Balanescu, Adriana Gurghean, Camelia Georgeta Badea, Vlad Padureanu, Ciprian Rezus, Florin Mitu, Ruxandra Jurcut, Andra Rodica Balanescu, Ioana Daha, Eugenia Balanescu, Mihai Bojinca, Larisa Pinte, Alexandru Marian Constantin, Nicoleta Dima, Mariana Floria, Maria Magdalena Leon-Constantin, Mihai Roca, Magda Mitu, Silvia Chiriac, Mariana Floria, Codruta Minerva Badescu, Simona Daniela Ionescu, Elena Mitrea, Gabriel Rosu, Georgeta Daniela Ionescu, Ana Maria Visinescu, Gabriela Mihailescu, Emilia Oprisan, Stefan Zeh, Isabelle Scholl and Martin Härter
Background: Shared decision making (SDM) is becoming more and more important for the patient-physician interaction. There has not been a study in Romania evaluating patients’ point of view in the SDM process yet. Therefore, the present study aims to evaluate the psychometric parameters of the translated Romanian version of SDM-Q-9.
Material and methods: A multicentric cross-sectional study was performed comprising eight recruitment centers. The sample consisted of in- and outpatients who referred to Hospital Units for treatment for atrial fibrillation or collagen diseases. Furthermore, patients who were members of Autoimmune Disease Patient Society were able to participate via an online survey. All participants completed the Romanian translated SDM-Q-9.
Results: Altogether, 665 questionnaires were filled in within the hospital setting (n = 324; 48.7%) and online (n= 341; 51.3%). The Romanian version had good internal consistency (Cronbach α coefficient of 0.96.) Corrected item correlations were good ranging from 0.64 to 0.89 with low corrected item correlations for item 1 and item 7. PCA found a one-factorial solution (similar with previous reports) but the first item had the lowest loading.
Conclusion: SDM-Q-9 is a useful tool for evaluation and improvement in health care that was validated in Romania and can be used in clinical setting in this country.
Caterina Delcea, Camelia Badea, Ciprian Jurcut, Adrian Purcarea, Silvia Sovaila, Emma Weiss, Elena Alistar, Horia Balan and Cristian Baicus
Quality of care in medicine is not necessarily proportional to quantity of care and excess is often useless or even more, potentially detrimental to our patients. Adhering to the European Federation of Internal Medicine’s initiative, the Romanian Society of Internal Medicine (SRMI) launched the Choosing Wisely in Internal Medicine Campaign, aiming to cut down diagnostic procedures or therapeutics overused in our country. A Working Group was formed and from 200 published recommendations from previous international campaigns, 36 were voted as most important. These were submitted for voting to the members of the SRMI and posted on a social media platform. After the two voting rounds, the top six recommendations were established.
Larisa Pinte, Daniel Vasile Balaban, Cristian Băicuș and Mariana Jinga
Obesity is a growing health burden worldwide, increasing the risk for several diseases featuring the metabolic syndrome - type 2 diabetes mellitus, dyslipidemia, non-alcoholic fatty liver disease and cardiovascular diseases. With the increasing epidemic of obesity, a new pathologic condition has emerged as a component of the metabolic syndrome - that of non-alcoholic fatty pancreas disease (NAFPD). Similar to non-alcoholic fatty liver disease (NAFLD), NAFPD comprises a wide spectrum of disease - from deposition of fat in the pancreas -fatty pancreas, to pancreatic inflammation and possibly pancreatic fibrosis. In contrast with NAFLD, diagnostic evaluation of NAFPD is less standardized, consisting mostly in imaging methods. Also the natural evolution of NAFPD and its association with pancreatic cancer is much less studied. Not least, the clinical consequences of NAFPD remain largely presumptions and knowledge about its metabolic impact is limited. This review will cover epidemiology, pathogenesis, diagnostic evaluation tools and treatment options for NAFPD, with focus on practices for clinicians.
Igor Kaidashev, Liudmyla G. Savchenko, Nataliia I. Digtiar, Liudmyla G. Selikhova, Elvira I. Kaidasheva, Oksana A. Shlykova and Liudmyla E. Vesnina
Introduction: Liraglutide (L) is the analogue of human glucagon-like peptide 1 which stimulates glucose-dependent insulin secretion and can modify a level of inflammatory biomarkers. L can influence NF-kB inflammatory cascade, but the mechanisms of anti-inflammatory activities of L remain to be determined. In animal models L influenced an activity of Sirtuin 1(SIRT1). Moreover, recent evidences strongly suggest that SIRT1 up-regulation may serve as a potent therapeutic approach against development and progression of diabetic complications . The aim of this study was to investigate L effects directed on pro-inflammatory NF-kB pathway and expression of SIRT1 in obese patients with type 2 diabetes mellitus (DM). Materials and Methods: 15 obese patients with type 2 diabetes were studied, all using metformin (1-2 g/day) and sulfonylurea (glimiperide). All patients received L 1.2 mg daily add-on to stable therapy for 6 weeks. Blood samples were collected before, 6 weeks after start of treatment and after an overnight fast 6 weeks after stopping L, mononuclear cells (MNC) were isolated. The mRNA expression of TNF-α, TLR2, TLR4, NOD1, IL-2 and SIRT1 were measured in MNC by RT-PCR. Ceruloplasmin concentration was measured in plasma by photometric method. Results: In this add-on pilot clinical investigation we received new data that L can inhibit proinflammatory NF-kB pathway by increased SIRT1 expression in obese patients with type 2 DM improving metabolic profile. The mRNA expression in MNC of TNF-α, IkB, TLR2, TLR4, and plasma ceruloplasmin fell after 6 weeks of L. Expressions of IL-2 and NOD-1 were stable. There was a significant increase of SIRT1 mRNA expression. The mRNA expression in MNC of TNF-α, IkB, TLR2, TLR4, NOD1, SIRT1 and ceruloplasmin concentrations didn’t reverse to baseline levels after 6 weeks stopping of L treatment. IL-2 expression decreased in comparison with basic level. Conclusions: L has a potent anti-inflammatory effect as do GLP-1 agonists due to inhibition of NF-kB pathways and up-regulate SIRT1 expression, down-regulating pro-inflammatory factors including cytokines (TNF-α), extra- and intracellular receptors (TLR2, TLR4), and inflammation markers such as ceruloplasmin. Long lasting effects of L can be mediated by epigenetic regulation of NF-kB pathway by SIRT-1.
Kristyn L. Lewis, Timothy D. Malouff, Alex M. Kesler and Dana M. Harris
Hypokalemic periodic paralysis (HOKPP) is a rare neuromuscular disorder caused by altered transport of cellular potassium that leads to significant muscle weakness of the extremities. Paralytic attacks are induced by a drop in the serum potassium level and have been associated with specific triggers. This case describes a 21-year-old male who has had recurrent presentations of acute paralytic attacks following vigorous physical activity. At presentation, this patient exhibited flaccid paralysis of all skeletal muscles below the neck, but was alert and oriented with stable vital signs. The patient was found to have a potassium level of 2.1mmol/l and an EKG demonstrating U waves (characteristic of hypokalemia). The patient was treated with potassium supplementation with resolution of symptoms. The mainstay of prevention of long term permanent muscle weakness is avoidance of triggers that can lead to hypokalemia. Through education on disease process and lifestyle modifications, we were able to end the cycle of recurrent hospital readmissions and the subsequent financial burden this generated for the patient and his family.
Gabriel Ungureanu, Ioana-Dana Alexa and Maria-Christina Ungureanu
The authors discuss an important chapter of iatrogenic pathology – unneccessary medicine, by reviewing epidemiological aspects and financial impact and identifying such elements in no less than 10 areas: surgery, interventional medicine, diagnostic investigation, substitute procedures, preventive medicine, drug therapy, aesthetic shared medical appointments, surgery, unconventional medicine, medicine on political demand. We shall review the causes, motives and mechanisms of unnecessary medicine such as one’s hyperprudence to cover oneself with diagnosis arguments or to prevent potential complications through preventive therapies (defensive medicine), weak functionality of the institutionalized inspection bodies, onerous motivation. The respect for the fundamental principles of medical ethics (the primum non-nocere principle doubled by the principle of doing good), the use of practice guidelines, the proper functioning self-control mechanisms in exercising the medical profession, a different management of error and the existence of a consistent protective legislation for both the patient and doctor would be key-elements to avoiding unnecessary medicine.
Raul Mateescu, Raluca Costache, Petru Nuţă, Mariana Jinga, Florentina Ioniţă-Radu, Mihai Pătrășescu, Bogdan Macadon, Roxana Călin and Săndica Bucurică
Background. Colonoscopy is a common performed procedure in Gastroenterology, and it’s widely used for diagnosis, treatment and surveillance of a wide range of conditions and symptoms. Properly performed, it’s generally safe, more accurate than a virtual colonoscopy and well-tolerated by patients. The completion of a colonoscopy is defined by cecal intubation with the visualization of colonic mucosa and distal terminal ileum when it’s possible.
Patients and methods. We reviewed retrospectively all consecutive endoscopies database of the lower digestive tract, done over a period from 2014-2017 in our clinic. The recommended completion based on the latest guidelines ranges from 90-95% completion rate according to the indication.
Results. 11214 consecutive colonoscopies were done. Overall cecal intubation was successful in 9456 procedures (87.3%). If we exclude the interventional procedures (414 procedures), where cecal intubation was not necessary, the main reasons of non-intubation were due to intolerance of the patients (388 patients), followed on the second place by patients with obstructive cancer (299 patients). The presence of diverticulosis, poor preparation for colonoscopy and post-surgical adhesions were significant findings in non-successful procedures.
Conclusions. In normal daily practice, colonoscopy is completed in 88.01% of the procedures but we think that this result will stimulate the efforts to incorporate more quality measures and time in our endoscopy laboratory.