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Quality of life assessment for patients with elbow arterio-venous fistula – a multicenter study

Abstract

End stage renal disease (ESRD) is a chronic medical condition that has become a public health problem. A vascular access is mandatory for patients with ESRD in order to receive hemodialysis. The elbow fistula is the most used procedure for creating the vascular access. Maintaining the fistula’s patency represents a constant struggle for these patients representing their lifeline. Our goal was to evaluate the impact that the elbow fistula has on the patient’s life quality (QoL). We performed a multicenter study in the 2nd surgical clinic, Timisoara Emergency County Hospital and the General Surgery department, “Carol Davila” Nephrology Clinical Hospital, Bucharest. We included only the patients that had their first vascular access procedure (elbow fistula) created in one of our centers. All patients completed the SF-36 questionnaire before surgery and at 6 months and 1 year after surgery. The SF-36 score has two major categories: the physical component summary (PCS) and the mental component summary (MCS). The results showed a decrease in the patients QoL after surgery (13.63% for the PCS and 6.87% for the MCS). Also elderly patients (>60 years age) had a decrease in the QoL of 19.11%PCS and 8.17%MCS compared to 10.20%PCS and 4.12%MCS for younger patients. Socio-economic status also has an impact on the patients QoL. Once the vascular access is created, patients must maintain their new lifeline through thorough self care actions and also by restricting their activities affecting the patient’s QoL. Further studies are required to help clarify the association between vascular access and the patient’s QoL.

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What is Europe Aiming at?

Abstract

The problems faced in the first decade of the 21st century by the integrating Europe are quite serious and require an effective action. The above is true for both economic, political and social issues. Economic dilemmas are best seen in the Economic and Monetary Union, competitiveness and economic growth. Their importance has been raised even higher by the now overwhelming global economic downturn. Political issues are invariably connected with the future vision of the European Union, and relate, among others, to the identity, security, stability and prominence of individual states. The formal empowerments of the EU remain debatable, especially when seen through the context of (non)ratification of the EU Constitution and the Lisbon Treaty. Social problems focus mainly on the demographic decline, illegal immigration, dissimilation, inequalities in life quality, etc. The EU has to be constantly guided by the demand that these difficulties are effectively surmounted.

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Late-onset hypogonadism: Review of the problem

Late-onset hypogonadism: Review of the problem

The study investigates late-onset hypogonadism (LOH), its influence on male joint system, build, cardiovascular system, haematopoesis, cognitive functions, and sexual function. LOH is a clinical and biochemical syndrome, which is related to aging and characterised by typical symptoms and a decreased serum testosterone level. It causes a worsened life quality, and the functions of various organs are badly affected. LOH is diagnosed when the testosterone level is below 8 nmol/l (230 ng/dl) or it is at the border-line (from 8 and 12 nmol/l) and there are LOH clinical symptoms such as a decreased libido, erectile dysfunction, reduced muscular mass and strength, increased obesity, reduced bone mineral density, osteoporosis, and depression. All patients with LOH are indicated testosterone replacement therapy (TRT). TRT is contra-indicated to patients suffering from prostate or thoracic gland carcinoma. In case of erythrocytosis (haematocrit > 52%), severe heart failure, marked prostate benign hyperplasia with the obstruction of urine pathways, and obstructive sleep apnoe syndrome, TRT is relatively contra-indicated and should not be started unless these dysfunctions are cured. The treatment of LOH requires thorough patient monitoring, which includes digital rectal examination and Prostate Specific Antigen conducted after 3-6 months and 12 months in the first treatment year. It is necessary to determine the total blood count after 3-4 and 12 months in the first treatment year and afterwards once a year.

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Limited Cutaneous Scleroderma-Related Pulmonary Arterial Hypertension — a Case Report

Abstract

Background: Pulmonary hypertension (PH), defined by mean pulmonary arterial pressure (PAPm) ≥25 mm Hg, can lead to increasing pulmonary vascular resistance, which eventually results in right ventricle failure. Scleroderma, as an autoimmune connective tissue disease, is associated with PH as a sub-group according to the 2015 ESC/ERS PH classification. Pulmonary arterial hypertension (PAH) associated with scleroderma (SSc-PAH) can often result in poor prognosis with increased mortality. Early diagnosis and specific treatment of PH can significantly improve the prognosis of these patients.

Case report: We present the case of a 50 year-old male, with no relevant family history, with a 2-year history of echocardiography-based diagnosis of PH (PAPm 78 mmHg). Physical examination revealed limited hand and forearm areas of non-folding thick skin, vital signs in the normal range and peripheral oxygen saturation of 96%. Severity and risk assessment were performed based on clinical and imaging tests, and hemodynamics. 12-lead rest ECG revealed sinus tachycardia and right bundle branch block, the six-minute walk test confirmed limited exertion capacity, Borg scale 9. Transthoracic echocardiography pointed to dilated right heart cavities and moderate pericardial effusion. Right heart catheterization confirmed the PAH (PAPm: 36 mmHg), and pulmonary CT angiography excluded massive pulmonary embolism. Rheumatologic examination and immune serology identified a scleroderma subset, limited cutaneous sclerosis form (lcSSc) with early onset PH. Combined specific PH drug therapy was initiated, followed by clinical and functional improvement in clinical status, prognosis and life quality.

Conclusions: In clinical group 1 of PH, the subgroup etiology of PAH associated with connective tissue disease (1.4.1) often goes undiagnosed, mainly due to the diminish of lung involvement symptoms in early CTD stages. Multidisciplinary approach is essential in order to refine the diagnosis and set out the treatment algorithm.

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Obstructive Hypertrophic Cardiomyopathy with Concomitant Mitral Regurgitation Treated with a Septal Myectomy and MV Repair: A Case Report

Abstract

Case presentation

Hypertrophic cardiomyopathy (HCM) is the most common and very heterogeneous genetic cardiac disease with a different clinical presentation and prognosis. The overall prevalence of the disease is estimated between 0.05-0.2% of the population. Left ventricular outflow obstruction at rest is present in about 20% of patients. Most of the patients have a normal life expectancy, however high risk patients might develop heart failure, atrial fibrillation, ventricular arrhythmias and sudden cardiac death.

We present the case of 47-year-old Caucasian man who was hospitalized at our clinic with a history of chest pain and shortness of breath on physical activity in the last six months, which caused significant limitations of his life quality. Hypertrophic obstructive cardiomyopathy was diagnosed in 2011, when the patient was put on therapy with beta blocker. Transthoracic echocardiography revealed normal systolic function, presence of systolic anterior mitral valve motion (SAM) with moderate mitral regurgitation (MR). There was a significant concentric left ventricular hypertrophy predominantly located in the ventricular septum. The intraventricular gradient at rest was 77.8 mmHg. MRI of the heart confirmed significant LV hypertrophy with regions of fibrosis at the septum. The patient shortness of breath worsened progressively in the last month (NYHA III) despite optimized medical treatment with maximal beta blocker dose. Surgical approach with septal myectomy was performed with mitral valve repair. There were no operative complications, with excellent postoperative recovery and complete symptoms resolution. Control Doppler echocardiograms revealed LVOT rest gradient reduction to 34 mmHg. The good operative results were still present 9 months after the intervention.

Our case confirmed that septal myectomy with MV repair is an excellent treatment approach in young patient with obstructive hypertrophic cardiomyopathy and mitral valve involvement refractory to medical treatment.

Open access
Modern Trends in Prosthetic Implant Rehabilitation of Patients: Case Report with 5-Year Follow-Up

Summary

Background/Aim: Implant treatment expands extensively the possibilities of prosthetic treatment, which provide benefits, bigger comfort as well as general improvement of the patient’s life quality. In cases with no possibility of implantation, it is possible to improve conditions by using modern methods for bone tissue repair. One of factors important for the long-term success is proper oral hygiene, as well as raising awareness of its importance to patients. The aim of the paper is to present a patient rehabilitated with multiple implants and followed-up for a five-year period, and to point out the importance of raising patient’s awareness and motivation in order to preserve the results of the treatment.

Case Report: A 31-year-old patient was admitted to the oral surgery clinic for rehabilitation of a poor oral health status. After taking history, clinical examination and additional analysis, the following treatment plan was suggested: to remove impacted upper canines and to put an implant supported by fixed prosthesis in the upper jaw, to make two implants supported by bridges laterally and one dental supported by bridge in the inter-canine sector in the lower jaw. The treatment was carried out in several stages that involved extraction of residual roots and impacted teeth, augmentation of bone defects with bone substitutes and bio-absorbable membranes, placing implant, and prosthetic rehabilitation. By verbal communication with the patient, we pointed out the importance of proper oral hygiene and regular check-ups. The five year follow-up showed the absence of factors that could adversely affect the success of the treatment, and the patient was still highly motivated to maintain proper oral hygiene.

Conclusions: It is possible to achieve predictable results in complex cases by using a multiphase prosthetic treatment supported by implants. Concerning a long-term success, motivation, proper information and patient’s willingness to cooperate play an important role.

Open access
Safety of concomitant treatment with Non-Vitamin K Oral Anticoagulants and SSRI/SNRI antidepressants

Abstract

Introduction: Warfarin has been considered as a “gold standard” in the prevention and treatment of thromboembolic events since 1954. Since the introduction of direct oral anticoagulants in the last few years (NOAC-Non-Vitamin K antagonist Oral Anticoagulants) prescriptions volume for apixaban, edoxaban, dabigatran and rivaroxaban have been gradually surpassing warfarin. The benefits include: anticoagulation from day one, fixed daily dosing, elimination for the need of international normalised ratio (INR) monitoring, fewer interactions with food and co-administered medicines with reduced risk of bleeding and better overall life quality.

Objectives: Assessing evidence for the safe use of Non-vitamin K Oral Anticoagulants (NOAC) with Selective Serotonin Reuptake Inhibitors (SSRI) and Serotonin and Noradrenaline Reuptake Inhibitors (SNRI).

Method: Review of literature published between 2014 and 2016 was made using the key words: Selective Serotonin Reuptake Inhibitor, Serotonin and Noradrenaline Reuptake Inhibitors, apixaban, dabigatran, edoxaban, rivaroxaban, bleeding, interaction, depression with time description from 2014 to 2018. Evidence within the literature was then compared with guidelines from the National Institute for Health and Care Excellence (UK), British National Formulary (UK), Clinical Excellence Commission (Australia), Thrombophilia and Anticoagulation Clinic (USA) and Summaries of Product Characteristics (SPC).

Results: 1. Serotonin plays a critical role in maintaining homeostasis. Use of SSRI/SNRI compromises its platelet reuptake increasing risk of bleeding. 2. Increased tolerability and safety of NOAC over Warfarin, although caution is advised when NOAC is used with SSRI/SNRI with less evidence suggesting pharmacodynamic interactions. 3. It is not recommended to use NOAC with strong CYP and P-gp inhibitors.

Conclusions: With limited literature evidence, caution is advised when co-prescribed NOACs with SSRI/SNRI, especially with other cofactors and interacting medicines further increasing risk of bleeding.

Open access
Considerations Regarding The Quality Of Rehabilitation And Physical Medicine Services From Patients Perspective

Abstract

The research study aims to assess the quality of physical medicine and rehabilitation (MFR) services offered to the population by specialized sanatoriums and hospitals in Dobrogea, in order to identify some appropriate measures to improve the quality of such services.

The target group (593 respondents) consisted of 6 independent batches, different in number, selected from 6 medical units. The patients responded to a specific questionnaire regarding the quality of MFR services and the collected data were analyzed statistically.

According to the patients′ answers, the medical staff meets their expectations in terms of the information provided at the time of admission, promptitude, kindness, availability, which reflects just one segment of the quality of medical rehabilitation services.

As regards the entity recommending the medical rehabilitation physician, of the total answers, the lowest ratio in the study is held by the answer “family doctor / another doctor”. It thus highlights the poor knowledge of family doctors or other doctors on the therapy benefits specific to medical rehabilitation and therefore the access to such services is not facilitated, a disservice to the patients′ life quality. There is a dependence relation between the level of education and the reason of admission. We see that is not prevention taking the first position, but the pain, which reflects a deficient education for health in all social levels.

Assessing the patient’s satisfaction regarding the mobility facilities in the sanatorium / hospital a percentage of 6.6% patient responded that they are not satisfied. It results that all the 6 partner institutions in the study must evolve to provide decent conditions ensuring the mobility independence to the patients.

Open access
Effects of Cyp2c19 and P2y12 Gene Polymorphisms on Clinical Results of Patients Using Clopidogrel After Acute Ischemic Cerebrovascular Disease

Abstract

The CY2C19 and P2Y12 gene polymorphisms are responsible for resistance to clopidogrel, known as drug unresponsiveness. In this study we researched the effect of gene polymorphism on clinical results of patients who began clopidogrel therapy after acute ischemic cerebrovascular disease.

The study included 51 patients. The patient group included patients who had begun prophylactic clopidogrel due to acute ischemic cerebrovascular disease in the last 2 years. All patients were monitored by the Neurology Outpatient Clinic at Çanakkale Onsekiz Mart Üniversity Research Hospital, Çanakkale, Turkey, and only those monitored for at least 1 year were included in the study.

When the *1, *2 and *3 alleles of the CYP2C19 gene polymorphism were evaluated, two patients were homozygotes for *2/*2, 13 patients were heterozygous for *1/*2 and 36 patients were homozygotes for the wild type *1/*1. No patient had the *3 allele. Three heterozygous patients, one for *2/*2 and two for *1/*2, stopped clopidogrel therapy due to repeated strokes and began taking warfarin. When evaluating P2Y12 52 (G>T) and 34 (C>T) polymorphisms, all alleles were of the wild type.

The CYP2C19 and P2Y12 gene polymorphisms may cause recurring strokes linked to insufficient response to treatment of ischemic cerebrovascular disease. In our patient group, three patients suffered repeated strokes and these patients had the CYP2C19*2 gene polymorphism. As a result, before medication use, genetic testing is important for human life, quality of life and economic burden.

Open access
Exploring amenity migration towards coastal areas of Latvia: A case study of the Engure coastal area

Abstract

Migration has key importance in explaining the spatial distribution of the population in Latvia. The study contributes to an understanding of population shift towards coastal areas affected by amenity-driven migration, beach-oriented tourism and land development. This research explores characteristics of the inhabitants of the Engure coastal area, with special attention to individual attitudes on specific life quality attributes. Using a survey of local residents conducted in 2010, we found statistically significant correlations between groups of the research population. The results show that in-migrants differ from long-term residents with regard to most socio-demographic and attitude variables studied. Similarly, differences were found by out-migration intentions of residents. The area selected for the case study serves as a prominent and instructive laboratory for our analysis due to its suburban location, comparatively stable population growth rates and richness in natural amenities. Moreover, the territory is set as a long-term socio-ecological research platform in Latvia.

Open access