www.revistamedicinamilitara.ro

Founded 1897 • New Series

Vol. CXXII • Suppl/2019 • October

REVISTA DE MEDICINĂ MILITARĂ

Military Medicine

Romanian Journal of

Journal included in Web of Science, Emerging Sources Citation Index, Index Copernicus International, National Library of Medicine Catalog, Ulrich’s Periodicals Directory database, Directory of Open Access Journals, Directory of Research Journals Index, Eurasian Scientific Journal Index, Science Library Index and Open Academic Journals Index.

Editorial Board of Romanian Journal of Military Medicine

Under the patronage Romanian Association of Military Physicians and Pharmacists Carol Davila University of Medicine and Pharmacy, Bucharest, Romania

Honorary Editor Acad. Victor Voicu MD, PhD

Editors-in-Chief Florentina Ioniță Radu MD, PhD, MBA Dan Mischianu MD, PhD

Executive Editors Daniel O. Costache MD, PhD, MBA Victor L. Purcărea PhD, MBA

Associate Editor Mariana Jinga MD, PhD, MBA

Redactors Raluca S. Costache MD, PhD, MBA – Bucharest Mihail S. Tudosie MD, PhD – Bucharest

Editorial Assistants Ioana Bratu MD Cristina Solea

Technical Secretary Oana Ciobanu Ionuț M. Olteanu

Publisher Carol Davila University of Medicine and Pharmacy Publishing House

International Editorial Board

Natan Børnstein (Israel) Silviu Brill (Israel)

Cris S. Constantinescu (UK) Daniel Dănilă (USA)

Stergios Ganatsios (Greece)

Mihai Moldovan (Denmark) Ioan Opriș (USA)

Gerard Roul (France) Erwin Santo (Israel)

Adrian Săftoiu (Denmark)

Ioanel Sinescu (Romania) C. Ionescu Târgovişte (Romania)

Radu Ţuţuian (Switzerland) Shyam Varadarajulu (USA) Peter Vilmann (Denmark)

Scientific Publishing Committee

Adrian Barbilian (Bucharest) Anda Băicuş (Bucharest)

Cristian Băicuş (Bucharest) Andra R. Bălănescu (Bucharest)

Mircea Beuran (Bucharest) Ovidiu Bratu (Bucharest)

Daciana Brănișteanu (Iași) Dragoș Bumbăcea (Bucharest)

Marian Burcea (Bucharest) Mihai Ciocârlan (Bucharest)

Sofia Colesca (Bucharest) Gabriel Constantinescu (Bucharest)

Silviu Constantinoiu (Bucharest) Dan Corneci (Bucharest)

Raluca S. Costache (Bucharest) Dragoș Cuzino (Bucharest)

Camelia Diaconu (Bucharest) Mircea Diculescu (Bucharest)

Lidia Dobrescu (Bucharest) Cosmin Dobrin (Bucharest)

Dumitru Constantin Dulcan (Bucharest) Silviu Dumitrescu (Bucharest)

Carmen G. Fierbințeanu (Bucharest) Cristian Gheorghe (Bucharest) Liana S. Gheorghe (Bucharest)

Viorel Jinga (Bucharest) Carmen Moldovan (Bucharest)

Ovidiu Nicodin (Bucharest)

Tudor Nicolaie (Bucharest) Ana Maria Oproiu (Bucharest)

Carmen Orban (Bucharest) Bogdan A. Popescu (Bucharest) Aurelian E. Ranetti (Bucharest)

Corneliu Romanițan (Bucharest)

Mugurel Rusu (Bucharest) Andrada Seicean (Cluj Napoca)

Carmen A. Sîrbu (Bucharest) Silviu Stanciu (Bucharest)

Ion Țintoiu (Bucharest) Sorin G. Țiplica (Bucharest) Daniel Vasile (Bucharest)

Dragoş Vinereanu (Bucharest)

REDACTION

B-dul Eroii sanitari, Nr.8, Sector 5, București, Tel/fax 021/318.07.59, tel. 021/318.08.62/Int. 199; Email rjmilmed@yahoo.com

Romanian Journal of Military Medicine (RJMM) is included in Romanian College of Physicians Medical Publications Index.

www.revistamedicinamilitara.ro

Romanian Journal of Military Medicine, New Series, vol. CXXII, Suppl/2019, October

ISSN-L 1222-5126; eISSN 2501-2312; pISSN 1222-5126

Vol. CXXII • Suppl/2019 • October • Romanian Journal of Military Medicine

1

Founded 1897 • New Series

Vol. CXXII • No. 3/2019 • December

Edited by the Romanian Association of Military Physicians and Pharmacists.

Contents

INTERNAL MEDICINE PAPERS

3

SURGICAL PAPERS

27

NURSING PAPERS

39

Guidelines for authors 52

RJMM Romanian Journal of Military Medicine

2

Vol. CXXII • Suppl/2019 • October • Romanian Journal of Military Medicine

3

INTERNAL MEDICINE PAPERS

A case report of esophageal dismotility following laparoscopic sleeve gastrectomy

Andrada L. Popescu, Raluca S. Costache, Florin Savulescu, Mariana Jinga, Florentina Ionita-Radu

Laparoscopic sleeve gastrectomy (LSG) is becoming popular

between bariatric procedures. There are few data available

of LSG impact on esophagogastric physiology, some patients

may have gastrointestinal symptoms such as reflux,

dysphagia or odynophagia. This case report describes a 42-

year-old female with esophageal dysmotility following LSG.

She experienced globus sensation and minor GERD

symptoms prior to the surgical intervention, the upper GI

tract endoscopy revealed erosive esophagitis grade A ( Los

Angeles Classification), and high-resolution esophageal

manometry (HRM) showed normal lower esophageal

sphincter relaxation and distal esophageal spasm ( > 20%

premature contraction). HRM was analyzed according to the

Chicago classification v3.0. One year after the procedure, the

patient lost 40 kg, but she has mild dysphagia, early satiety,

fullness and reflux. Her dysphagia could be associated with a

structural cause or attributed to a “sleeve dysmotility

syndrome.” The result of upper gastrointestinal endoscopy

was no esophagitis, normal gastric scar on the posterior wall,

but on HRM more than 50% of contractions were ineffective

swallows (ineffective motility), with normal relaxation of LES

( IRP less than 15 mmHg). Also increased intragastric

pressure (IIGP) after water swallows was observed in 30-40%

of the ten swallows examined. A proposed alternative to

pharmacological treatment to relieve reflux symptoms

might be the gastric bypass, but it will not resolve the poor

esophageal contractility.

Conclusions: Motility studies should be required for all

patients planning to undergo a LSG to rule out preexisting

esophageal dysmotility. Conversion to gastric bypass is not a

universal method for managing esophageal dysmotility after

LSG.

Optimizing diagnosis in pancreatic cystic neoplasms

Vasile Balaban, Andreea Zoican, Victor Mina, Raluca S. Costache, Petrut Nuță, Florentina Ioniță Radu, Mariana Jinga

With the widespread use of cross-sectional abdominal

imaging for various indications, pancreatic cystic lesions

(PCL) are being increasingly encountered in clinical practice.

The stake is to differentiate neoplastic from non-neoplastic

PCLs. Several guidelines have been proposed over the last

years, balancing careful follow-up with need for surgery -

misdiagnosis can lead to unnecessary, high-morbidity and

mortality surgery or missing a potentially neoplastic lesion.

In this setting, establishing a strong diagnosis becomes of

utmost importance. Along with high-resolution imaging,

endoscopic ultrasound plays an important role in the

management of PCLs. Novel techniques such as cyst fluid

analysis of molecular markers and cyst wall sampling can

prove valuable in providing a definite diagnosis for a PCL.

Also, innovative algorithms have been developed to aid

clinicians in the management of PCLs.

Capsule endoscopy in Blue rubber bleb syndrome

Alexandra Lulache, Mariana Jinga, Florentina Ioniță Radu, Diana O. Preda, Săndica Bucurică, Andrada Popescu, Mihăiță Pătrășescu, Vasile Balaban, Andrei I. Gavrilă, Raluca S. Costache

Background: The small bowel evaluation remained unclear

until 1996, when the first live pictures from pig

gastrointestinal tract with wireless device was obtained.

Hundreds of thousands patients have been examined since.

4

Nowadays it becomes the “key” method for evaluation of

small bowel pathology.

Material and method: We present the case of young girl

referred to our clinic for gastrointestinal bleeding with

normal upper and lower endoscopy and severe anemia. At

14 years old she was diagnosed abroad with Blue Rubber

Bleb Syndrom with duodenal and jejunal angiomas. We used

the Olympus Endocapsule® System.

Results: The patient performed a standard small intestine

complete examination, meaning the capsule reach the

caecum. The result show the source of bleeding: multiple big

angiomas of the small intestine.

Conclusion: The capsule endoscopy represents in our days

the gold standard for small bowel tumor evaluations but has

his own limitation – impossibility of therapeutic approach.

The role of transarterial chemoembolization (TACE) in the modern management of hepatocellular carcinoma

Florentina Ioniță Radu, Cezar Bețianu, Cezar Călin, Andrada L. Popescu, Alexandra I. Păun, Raluca M. Ștefan, Iulia Fulga, Maria M. Chereja, Anca Jianu, Alexandra I. Lulache, Andrei I. Gavrilă

Introduction: Our objective is to review current international

guidelines for the management of hepatocellular carcinoma

and to present our hospital`s experience with transarterial

chemoembolization (TACE) for hepatocellular carcinoma.

Materials and methods: Hepatocellular carcinoma (HCC) is

the most common type of primary liver cancer. This type of

malignant tumour has a very rich blood supply, mostly from

the hepatic artery, while the rest of the liver tissue gets

blood from the portal vein. This means that blocking the

hepatic artery to cut off the blood supply to the tumour will

not affect the rest of the liver.

Chemoembolization is a palliative type of treatment that

delivers chemotherapy directly to the liver tumor through

the hepatic artery and then the artery is blocked

("embolized") to cut of blood flow to the tumor.

TACE can be performed in patients who have a good liver

function, without ascites or portal vein thrombosis and the

tumour can’t be removed with surgery but it hasn’t spread

to the major blood vessels in the liver, lymph nodes or other

parts of the body. Another indication for this procedure

(called “bridging” therapy) is to control the dimensions of

HCC in patients waiting for liver transplant.

Results and conclusion: Despite ongoing efforts, there is no

definitive consensus in the management of hepatocellular

carcinoma. The Barcelona Clinic Liver Cancer (BCLC) system

that is widely used nowdays has it`s limitations, meaning

that the role of transarterial chemoembolization (TACE) in

hepatocellular carcinoma management can be refined.

Topographic endomicroscopic morphology of normal stomach

Săndica Bucurică, Raluca S. Costache, Petruț Nuță, Mariana Jinga, Florentina Ioniță Radu

Normal stomach has a particular morpho- functional

strategy to balance the secretion of acid and bicarbonate,

and this is made by various mucosal cell types and

component, with specific topography in different parts of

the stomach. From histopathologic point of view there are

two mucosal compartments: foveolar – that is superficial

and glandular – in depth of mucosa, with different structure

varying with the stomach site. The correspondence between

this morphology and endomicroscopic appearance is very

important in order to establish the subtle pathology changes

that may not have endoscopic definite features and may

benefit from endomicroscopic examination such as

metaplasia or atrophy. The cardial aspect is characterized by

branched glands (sometimes cystic, produce mucus), while

the mucosa of the fundus has oxyntic glands that are

straight, with higher proportion of glands/foveola

comparative with antrum. In the antrum the mucus

producing glands are also branched, but vacuolated, while

the parietal cells are in the glands from fundus and body of

the stomach, with function to produce acid, to bind the

gastrin produced by antral cells and stimulate vagus nerve.

Scattered in the fundus/body there are endocrine cells and

chief cells that produce pepsinogen I/II are most in the

fundus and body. So, having this various aspects, for the

endomicroscopic examination of the stomach the key point

is knowledge of normal mucosa. The Classification of gastric

pit patterns by confocal endomicroscopy was proposed by

Zhang who states that the pits patterns of stomach

examined by confocal endomicroscopy are well correlated

with histopathologic findings.

Vol. CXXII • Suppl/2019 • October • Romanian Journal of Military Medicine

5

High-resolution esophageal manometry: interpretation in clinical practice

Andrada L. Popescu, Ionel P. Nuță, Raluca S. Costache, Săndica Bucurică, Bogdan Macadon, Mihaiță Pătrășescu, Mirela Chereja, Andrei I. Gavrilă, Mariana Jinga, Florentina Ioniță-Radu

Esophageal high-resolution manometry (HRM) defines the

function of the lower esophageal sphincter and the

esophageal body peristalsis, and is indicated to establish the

diagnosis of suspected cases of achalasia, diffuse esophageal

spasm, also for detecting esophageal motor abnormalities

associated with systemic disease (connective tissue disease)

or for placement of intraluminal devices (correct positioning

of the probe for the 24-hour pH monitoring).

Esophageal high-resolution manometry (HRM) is the current

state-of-the art diagnostic tool to evaluate esophageal

motility patterns. HRM uses a high-resolution catheter to

transmit intraluminal pressure data that are subsequently

converted into dynamic esophageal pressure topography

(EPT) plot. The pressure analysis is done according to the

Chicago Classification, a formal analytic scheme for

esophageal motility disorders, which is currently in version

3.0.

The standard HRM examination consists of a baseline phase

and a series of 10 wet swallows in the supine position. In

addition, in some cases, data from swallows in the seated

position or provocative solid meal HRM is performed.

In our hospital this GI functional procedure is available since

2017 with the HR solid-state catheter and ManoScan ESO HR

system (form Given Imaging), and recently with Unisensor

HRIM catheters (from Isolab), with more than 170

procedures performed.

Conclusion: Esophageal HRM is a valuable and sophisticated

clinical tool to evaluate esophageal motility patterns, useful

in a case-by-case basis or to compare the physiological

response among groups of individuals. Manometric

screening for severe peristalsis dysfunction remains

reasonable in specialized gastroenterology departments.

From Zenker diverticulum to a complex esophageal ailment

Mihăiță Pătrășescu, Săndica Bucurică, Raluca S. Costache, Vasile Balaban, Mariana Jinga, Florentina Ioniță Radu

Background: Zenker diverticulum is an out-pouching of

mucosa and submucosa in Killian triangle which is a

hypopharyngeal weak part between the fibers of inferior

constrictor pharyngeal muscle and cricopharyngeal muscle.

Pathophysiology may imply a disfunction of cricopharyngeal

muscle which increases intraluminal pressure just above

upper esophageal sphincter. The prevalence is very low

(0.01-0.1%) but many cases go undiagnosed because of lack

of symptoms.

Case report: I present a case of a 35-year-old patient who is

admitted for dysphagia, halitosis, heartburn and

regurgitation. The onset of symptoms was 10 years ago. The

esophagogram shows a typical image of Zenker

diverticulum. Upper digestive endoscopy was performed,

and the surprise was the unmasking of two other esophageal

pathologies: two areas of cervical esophageal “kissing”

gastric patches and a short Barrett esophagus.

Conclusion: Zenker diverticulum is a rare ailment that may

share symptoms with other diseases of esophagus (Barrett

and gastric patches). These associations render a very

important implication as diagnosis confounding factor and

they may change the therapy management of patient.

The role of high-resolution esophageal manometry in achalasia

Andrada L. Popescu, Andrei I. Gavrilă, Mirela Chereja, Ionel P. Nuță, Raluca S. Costache, Săndica Bucurică, Bogdan Macadon, Mihăiță Pătrășescu, Vasile Balaban, Mariana Jinga, Florentina Ioniță-Radu

The role of this paper is to point out the importance of

esophageal manometry in the diagnosis of achalasia.

Esophageal achalasia is a primary motility disorder

characterized by impaired lower esophageal sphincter

relaxation and absence of esophageal peristalsis leading to

impaired bolus transit. The Eckardt score is used to assess

the severity of achalasia symptoms and it is based on four

major symptoms: dysphagia, regurgitations, chest pain and

weight loss. The Eckardt score is also used to evaluate the

efficiency of a treatment durring the follow-up, a score of

6

less than 3 points is considered as remission of the disease.

The suspicion of the disease is clinical, completed by upper

gastrointestinal tract endoscopy or barium swallow. The

gold standard diagnostic tool for achalasia remains

esophageal manometry. High-resolution manometry (HRM)

of the esophagus is a new technique that provides a more

precise assessment of esophageal motility than conventional

techniques, using catheters with 36 solid-state sensors

spaced 1cm apart. The main innovation of this method is the

conversion of pressure data into a topographical plot. Thus

we can evaluate the esophageal motor pattern, the

contraction amplitude and LES pressure and function. HRM

defines three manometric types of achalasia that seem to

have different responsiveness to treatment. In our hospital

this GI functional procedure is available since 2017 and we

performed until now approximately 150 procedures.

Conclusions: HRM provide a detailed assessment of

esophageal function and helps to identify distinct

phenotypes of esophageal motility disorders, but more

important HRM increased the recognition and diagnosis of

achalasia.

Non-invasive diagnosis in hepatic fibrosis

Florentina Ioniță Radu, Raluca S. Costache, Mirela M. Chereja, Andrada l. Popescu, Anca Jianu, Alexandra I. Drugău-Păun, Raluca M. Ștefan, Iulia Fulga, Alexandra I. Lulache, Andrei I. Gavrilă

Introduction: Our objective is to review current non-invasive

methods of assessing liver fibrosis, their availability and their

utility in modern medical practice.

Materials and methods: The evaluation of the degree of liver

fibrosis has been traditionally assessed by liver biopsy, an

invasive “gold-standard” that, during the past 25 years, has

been deemed imperfect; even according to its advocates, it

is only “the best” among available methods.

Attempts at uncovering non-invasive diagnostic tools have

yielded multiple scores and formulae based on biological

parameters, and also multiple imaging techniques. All of

them are better tolerated and more acceptable for the

patient, safer and they can be repeated essentially as often

as required. Another advantage is that they are much less

expensive than liver biopsy. Consequently, their use is

growing, and in most countries the number of liver biopsies

performed, at least for routine evaluation of viral hepatitis

(B or C), has declined sharply.

The major setback is that the accuracy and diagnostic value

of most, if not all, of these methods remains debatable. The

good news is that we may be witnessing the beginning of the

end of the first phase of non-invasive markers development.

Actual evidence suggests that they might be at least as good

as liver biopsy. Novel experimental biomarkers and imaging

techniques could produce a dramatic change in liver fibrosis

diagnosis in the near future.

Results and conclusion: Liver biopsy has now been named

the old standard for diagnosing liver fibrosis in most clinical

settings and non-invasive diagnostic scores, formulae, and

imaging modalities, all of which have several advantages

compared to biopsy have been shown to be at least as good

as liver biopsy in assessing the degree of liver fibrosis.

The importance of imaging: functional investigations in the diagnosis of gastrointestinal stromal tumors

Anca Minea, Iulia Enache, Alexandra Gheorghe, Raluca S. Costache, Petruț Nuță, Săndica Bucurică, Mihăiță Pătrășescu, Andrada Popescu, Vasile Balaban, Florentina Ioniță Radu, Mariana jinga, Bogdan Macadon

GISTs (gastrointestinal stromal tumors) are the most

common mesenchymal neoplasms affecting the

gastrointestinal tract - most often located in the anterior and

posterior wall of the gastric fundus and proximal small

intestine.

GISTs occur predominantly in middle-aged and older

individuals (are rare in children or persons under the age of

40).

In adults are characterized by the expression CD117 antigen

- synonymous with the KIT transmembrane receptor

tyrosine kinase. In 95% of cases they occur sporadically,

while in 5% of cases they are associated with syndromes

such as Carney-Stratakis syndrome, neurofibromatosis type

1.

In 70% of cases the tumors are benign. The malignant ones

do not metastasize in the lymph nodes, but they can

Vol. CXXII • Suppl/2019 • October • Romanian Journal of Military Medicine

7

disseminate in the liver and into the peritoneal cavity.

The clinical behavior of GISTs is highly variable; many are

asymptomatic, being discovered incidentally - endoscopic or

radiologic examination. When they become symptomatic,

they are associated with nonspecific symptoms, unless they

grow large enough to cause pain or obstruction, ulcerate,

and bleed.

The endoscopic appearance is suggestive in the presence of

an extramucosal structure, hemispherical in shape, with a

normal overlying mucosa, which may present ulceration or

bleeding.

Oral or intravenous contrast-enhanced computed

tomography (CT) can characterize an abdominal mass,

evaluate its extent, the presence or absence of metastatic

disease.

Magnetic resonance imaging (MRI) may be preferred for

GISTs affecting the rectum or the liver, especially when

evaluating for surgery.

The endoscopic ultrasonography (EUS) is able to identify the

layer of origin and enabling guided-tissue acquisition for

diagnostic studies, including immunohistochemistry.

Positron emission tomography (PET) is sensitive for

detecting tumors with a high glucose metabolism, including

GIST. PET can be useful for resolving ambiguities from CT or

detecting an unknown primary site.

Metaplasia: still a challenge-versatile endoscopic appearance of non-atrophic gastritis metaplasia

Săndica Bucurică, Mihaela Ailenei, Raluca S. Costache, Petruț Nuță, Mihăiță Pătrășescu, Bogdan Macadon, Andrei Gavrilă, Roxana Călin, Vasile Balaban, Andrada Popescu, Mirela Chereja, Mariana Jinga, Florentina Ioniță Radu

Introduction: Gastric atrophy and intestinal metaplasia are

common findings from routine endoscopies and the earliest

steps in gastric carcinogenesis. There is a real controversy

regarding the correlation of macroscopic endoscopic

appearance and histopathologic diagnostic.

Aim: The aim of this study is to determine the correlation

between endoscopic diagnostic and the histopathologic

result, also the implication of targeted or non-targeted

biopsies in 2 selected groups of patients with macroscopic

suspicion of gastric atrophy or intestinal metaplasia. One

group had respected the Sydney non-targeted biopsy

protocols and the second group had targeted biopsies from

suspected lesions.

Methods: In this cross-sectional comparative study on the 54

patients from Gastroenterology Departament of University

Central Military Hospital "Dr Carol Davila", Bucharest, we

used for one group (n=25) the Sydney system for biopsy

sampling protocol with 5 tissue specimens from the gastric

mucosa (two from antral mucosa, two from corpus, and one

sample from incisura angularis) and for the other

comparative group (n=29) we took targeted biopsies from

macroscopic suspicious lesions. We have classified

endoscopic appearance into 6 phenotypes: whitish mucosa,

hyperemic, erosions/ulceration, modified vascular pattern,

elevation of mucosa and normal aspect. The atrophy status

of each slide was determined as atrophic or non-atrophic

and intestinal metaplasia as absent or present.

Results: As a particular finding, in most of the cases

metaplasia was found in non-atrophic gastritis that could be

a characteristic of the study group and needs to be verified

in general population. In our study we found that metaplasia

could take various forms of endoscopic expressions and

those was not correlated with a specific phenotype, but for

sure will not appear as normal(p<0.05, adjusted R-squared

=-2.3).

Among the 154 biopsies, 75 (48.7%) were classified by

endoscopic phenotype as whitish mucosa, 16 (10.4%) as

hyperemic, 12 (7.8%) as erosions/ulceration, 13 (8.4%) as

modified vascular pattern, 16 (10.4%) as elevation of mucosa

and 22 (14.3%) as normal. The incidence of the intestinal

metaplasia was 16.9% (26 biopsies), higher in the targeted

biopsies group (41.4%) than random biopsies group (12%).

Metaplasia has moderate correlated with targeted

biopsies(r=0.271, p<0.01).

In the group with targeted biopsies (p<0.01) we found more

cases with histological changes from the erodated and

elevated lesions (adjusted R-squared=2.1 and 6.1) than

other phenothypes described by endoscopists as whitish,

hyperemic, but with no predominance of metaplasia. In all

cases described being normal, the histology showed no

changes (adjusted R-squared=2.4).

Metaplasia was not correlated with the grade of

gastritis(r=0.042, p>0.01), but it was associated (p<0.01)

with the moderate grade of gastritis (adjusted R-

squared=3.3), and negative associated with severe gastritis

(adjusted R-squared=-2).

8

Conclusions: Metaplasia found in non-atrophic gastritis can

take multiple endoscopic faces and could appear as: whitish

mucosa, hyperemia, erosions/ulceration, elevation of

mucosa, but none as normal. There is a bigger chance with

statistical significance to find metaplasia by taking targeted

biopsies. So, metaplasia does not have a specific endoscopic

phenotype and its versatile appearance needs the support of

additional or red flag techniques for endoscopic diagnosis

and mapping of metaplasia.

The role of hepatitis C virus core antigen in the diagnosis and treatment algorithm of HCV infection

Corina Taubner, Clara Neguț

Chronic hepatitis C virus (HCV) infection is prevalent in

approximately 1.1% of the world population and can lead to

liver fibrosis, cyrrhosis, and hepatocellular carcinoma.

Currently, HCV diagnosis is a process that starts with

screening assays for anti-HCV antibodies (HCV Ab). Such an

assay can only inform about the exposure to the virus and

can not diferentiate between acute and chronic infection,

active replication and ongoing infection. On the one hand,

even when a person cleared HCV or have been cured by

treatment, HCV antibodies remain in a person’s blood for

years. On the other hand, the serological window for

conversion to a positive antibody response is variabile with

an average of 60 days and may remain negative for patients

on haemodialysis or immunocompromised. Summarizing

diagnosis of active HCV infection requires antibody testing

and additional HCV RNA testing in order to confirm active

HCV infection and to monitor antiviral therapy. An HCV RNA

assay involving nucleic acid testing (NAT) is a confirmatory

test, a highly sensitive and specific method, but requires

expensive reagents and skilled personnel.

The hepatitis C core antigen (HCVc Ag) is a viral protein that

forms the internal capsid which is highly conserved and

antigenic and it can usually be found in the bloodstream two

weeks after infection. Testing for HCV core antigen is a

potential replacement for NAT as an indirect marker for HCV

replication, as an atractive alternative due to the lower cost

and short turnaround time. HCVc antigen can also be used

to monitor the response to antiviral therapy.

Currently, seven tests for HCVc Ag detection are available: 1.

The Abbott Architect HCV Ag assay; 2. The Fujirebio Otto

HCV Ag test; 3. The Eiken Lumispot HCV Ag ; 4. The Hunan

Jynda Bioengineering Group HCVc Ag ELISA; 5. The Ortho

ELISA-Ag; 6. Bio-RAD Monolisa HCV Ag-an ULTRA; 7. HUNAN

JYNDA HCV Core Ag ELISA.

At this moment, the immunology departament of our

medical laboratory, analysis the opportunity of

implementing both the two confirmatory tests for HCV

infection, NAT and HCVc Ag testing.

Human dirofilariasis, an emerging zoonosis: case series in Romania

Valeriu Gheorghiță, Raluca M. Hrișcă, Adelina M. Radu, Ion Ștefan, Ruxandra Moroti

Background: The genus Dirofilaria (D.) includes vector-borne

filarial nematodes, which are usually transmitted by

mosquito bites. Human dirofilariasis is an unusual zoonotic

infection, increasingly reported in recent years in many parts

of the world. The European Mediterranean region is

considered highly D. repens-endemic in animals. The

objective of our report is to increase the level of awareness

among physicians regarding the emergence of human

dirofilariasis cases in Romania.

Methods: A retrospective analysis of the human dirofilariasis

cases that we diagnosed in our centers in a sixteen years

period (2003-August 2019)

Results: In our settings we recorded 10 patients diagnosed

with dirofilariasis, one case in 2010, eight cases during 2012-

2013 and the last case in the summer of 2019. Age

distribution varied between 16-74 years (average 50.9) and

the sex-ratio was 1:4 (male to female). Nine out of 10

patients are living in south-east and one in north-west of

Romania, with an equal distribution for rural and urban

areas (5:5). Eight out of 10 are living near puddles or swampy

regions. All reported mosquitos’ bites. Five patients had

ocular dirofilariasis and another five had subcutaneous

dirofilariasis. The diagnosis was misinterpreted as other

diseases in 7 out of 10 patients such as bacterial orbital/soft

tissues cellulitis and thoracic herpes zoster.

Conclusions: The diagnosis of human dirofilariasis does not

require a high level of expertise in parasitic diseases, which

Vol. CXXII • Suppl/2019 • October • Romanian Journal of Military Medicine

9

is why we consider important to know the clinical features

of this parasite, to avoid a misinterpretation of the patient

anamnesis and a misdiagnosis.

The practical utility of ultrasonography of small parts and soft tissue

Mirela Oancea, Cătălin Mazilu, Raluca Mititelu, Carmen Tipar

Introduction: Currently, medical imaging presents a rapid

development, at an exponential rate, on all the component

branches (including ultrasonography).

The immediate value of the ultrasound results from the fact

that it is a fast, cheap, non-invasive, non-irradiating imaging

method, without contraindications or special previous

training, which has developed a great deal and has been

diversified in the different areas in which it is used.

An example is the ultrasound of superficial soft tissue, with

great applicability including in the surgical specialties

(general surgery, ENT surgery, and orthopedics).

Material and methods: Patient G.M., aged 54, admitted to

the Surgery II section for a presternal localized mass that had

been growing in size lately. For the purpose of excision the

mass, the surgeon asked the problem of clarifying the

relationships that the respective formation could have with

the surrounding structures (thyroid, vascular and muscular

planes).

In addition, the patient also had diffuse enlargement of the

anterolateral cervical region.

Results: The ultrasound of the enlarged presternal region

revealed a thickening of the subcutaneous cellular tissue

with a diffuse lipomatous appearance, with the inclusion of

the sternal and clavicular ends of the bilateral

sternocleidomastoid muscle.

Also, at the level of the anterolateral and submentonal

cervical region, has been viewed the same diffuse

lipomatous aspect of the subcutaneous tissue and

connective tissue between the musculotendinous planes.

In addition, it was also noted that all the surrounding

structures (thyroid gland, vascular pedicles, tendons and

muscles) were respected by this pathological

transformation.

Conclusions/observations: Superficial soft tissue/small parts

ultrasonography is a simple imaging method, with easy

applicability and within the reach of any dedicated

sonographer.

Also, because of its speed and low cost, it is an excellent

method of solving some equivocal pathological situations in

order to make the best surgical protocol decisions.

Role of radiotherapy in primary mediastinal B-cell lymphoma: case report

Răzvan G. Curcă, Alexandra T. Pasăre, Remus C. Stoica, Diana A. Mitrea, Ștefănel C. Vlad

Introduction. Primary mediastinal B-cell lymphoma is

regarded as a subtype of diffuse large B-cell lymphoma. Due

to the rarity of primary mediastinal B-cell lymphoma, there

are few studies analyzing treatment efficacy, including

radiotherapy. Considering the generous life expectancy of

patients successfully treated, a good therapeutic intent is to

minimize long and short term toxicity. Standard of care

consists of chemotherapy combined with immunotherapy,

the most common combination being R-CHOP. Radiotherapy

of the mediastinum can be used to consolidate the

treatment.

Materials and methods. We are presenting the case of a 45

year old man, diagnosed with primay mediastinal B-cell

lymphoma, onset symptoms consisting in pain of the

anterior thorax. After the initial diagnosis, the patient

started with a course of R-CHOP, followed by 6 courses of R-

dose adjusted EPOCH. The indication for radiotherapy was

established after a PET-CT scan revealed residual metabolic

disease.

Results and discussions. Standard treatment for primary

mediastinal B-cell lymphoma consist of chemotherapy

combined with immunotherapy. Modern treatment

techniques show a good control of local disease and low

recurrence rates. PET is the most recommended technique

in the diagnosis, follow-up and post-treatment evaluation.

Although recent data suggest that DA-EPOCH-R can obviate

the need for routine mediastinal radiation, some patients

require to undergo radiotherapy.

10

Anti-inflammatory interventions in major depressive disorder: status of research and therapeutic perspectives

Octavian Vasiliu, Daniel Vasile, A.G. Mangalagiu, B.M. Petrescu. C.A. Cândea, Corina Tudor, D. Ungureanu, M. Miclos, A. Drăghici, C. Florescu

Background: New data about the pathophysiology of major

depression are arising based on preclinical models, and

investigational drugs are being tested starting from these

translational models. Inflammation has been considered a

potential trigger for the lack of responsivity in a sub-group of

patients diagnosed with major depression and anti-

cytokines treatment has been suggested as a possible

solution for these cases.

Objectives: To assess the current evidence that may support

the recommendation of anti-inflammatory drugs as add-on

in the treatment of major depressive disorder.

Method: A literature review was conducted in the main

electronic databases (PubMed, EMBASE, CINAHL, Thomson

Reuters/Web of Science) using the search paradigm “anti-

inflammatory drugs” OR “anti-cytokines” OR “monoclonal

antibodies” OR “TNF-alfa inhibitor” OR “IL-6 modulators”

AND “major depressive disorder” OR “treatment-resistant

depression”. All peer-reviewed papers published between

2000 and 2019 containing clinical trials, systematic reviews

and meta-analyses were included in the first level of this

study.

Results: A number of 23 papers remained after filtering the

results according to the inclusion and exclusion criteria, in

the second level of our study. Adalimumab decreased the

severity of depressive symptoms after 12 weeks in patients

with psoriazis, while etanercept confirmed its efficacy over

the affective symptoms during an 84 week-extension trial in

patients with the same dermatological pathology and

comorbid depression. Infliximab decreased depression

severity in patients with an increased initial level of

inflammatory markers. Tocilizumab and sirukumab are

studied as add-ons to antidepressat drugs, in severe cases of

major depressive disorder, but the research has so far

proved inconclusive.

Conclusions: Although antiinflammatory therapy is a

relatively new intervention for affective disorders, it may be

a promising intervention for major depression with partial

response to classic therapeutic approaches, in a subgroup of

patients with high levels of inflammatory markers.

Radiotherapy in thymoma: case report

Diana A. Mitrea, Remus C. Stoica, Maria Vlăsceanu, Gheorghe Bălașa, Ștefănel Vlad

Introduction. Invasive thymomas are rare tumors in the

anterior mediastinum, representing 50% of the anterior

mediastinal masses and about 20-30% of all mediastinal

tumors. They are of unknown etiology. About 50% of

patients with thymomas are diagnosed incidentally. Disease

stage and completeness of resection have been found

consistently to correlate with the duration of progresion-

free and overall survival.

Materials and method. This case study presents a 68 year-

old man with complaints of breathlessness, nosea, vomiting,

chest pain and fever. CT images revealed a defined

heterogenous anterior mediastinal mass with evidence of

infiltrations into the anterior mediastinal fat and an enlarged

necrotic paratracheal lymph node. An incomplete resection

was made and the findings of histopathological and

imunohistochemistry analysis were consistent with

thymoma type A. The patient underwent adjuvant

radiotherapy.

Results and discussion. The standard primary treatment for

this tumors is thymectomy. Modern external beam

radiotherapy improves local control in adjuvant setting of

incomplete resections. Studies and contouring guidelines

regarding thymoma do not recommend elective nodal

irradiation due to the fact that these tumors do not

commonly metastasize to regional lymph nodes. An

exception was made, in this case, for the paratracheal lymph

node, considering its malignant appearances on the CT.

IMRT technique improved dose distribution, decreasing

toxicity to normal tissues.

Follow up appointments, after external beam radiotherapy,

confirmed no evidence of local recurrence.

Vol. CXXII • Suppl/2019 • October • Romanian Journal of Military Medicine

11

A rare cause of bone pain in a young patient

Oana Stancu, Mihai Șotcan, Adrian Anghel, Gabriel D. Stoicescu, Mihaela Iordache, Oana Ionescu, Lucian Ciobîcă

We present the case of a patient aged 40 years, without

exposure to professional toxics and without significant

pathological personal background that is presented in our

service in order to establish the etiology of intense rashes

with important functional impotence started about 4

months with progressive accentuation in the last weeks

associated with unilateral eyelid ptosis suddenly installed a

few days before hospitalization. He performed in an

outpatient ophthalmological evaluation, neurological brain

CT that did not establish the cause of the palpebral ptosis

and also MRI that revealed bone infiltrative lesions in the

lumbar segment. Biologically on admission: major

inflammatory biologic syndrome, moderate normochromic

anemia, high titration of alkaline phosphatase, high titration

of lactate dehydrogenase. Taking into account the presence

of bone lesions with possible tumor substrate, an extensive

nonplastic balance was performed (tumor markers,

endoscopic balance, serum protein electrophoresis –

polyclonal hypergamaglobulinemia, immunogram and

negative immunofixation). Also, a complete autoimmune-

negative and infectious disease balance was performed,

which revealed the presence of positive anti-HIV 1 and 2

type antibodies. The presence of antiretroviral antibodies

has been confirmed by using a different method so this was

the reason why the patient was guided in the Department of

Infectious Diseases in order to complete the investigations.

After thorough investigations, the diagnosis of retroviral

infection was established with certainty and it was decided

further, considering the increasing titration of alkaline

phosphatase and of lactate dehydrogenase, the

performance of a bone scintigraphy. This investigation

revealed bone lesions with uncertain substrate - the most

likely tumoral. An osteomedular biopsy was performed

signaling the presence of Burkitt cells establishing the

diagnosis of diffuse Burkitt lymphoma with large cells.

Providencia stuartii outbreaks and antibiotic susceptibility in a Romanian tertiary hospital

Raluca M. Hrișcă, Ion Ștefan, Constantin F. Ghiațău, Valeriu Gheorghiță

Background: Providencia stuartii (P. stuartii), the most

common species of Providencia, is an opportunistic human

pathogen with intrinsic resistance to polymyxin and

tigecycline. The prevalence of carbapenem-resistant

P.stuartii is increasing, and the selection of appropriate

antibiotic therapy has become limited to a few antibiotics.

Methods: We retrospectively investigated the clinical

features and the antibiotic susceptibility of P. stuarti strains

isolated in our center between July 2017 and June 2019. In

addition, we established the epidemiological links of the

cases.

Results: We included 35 patients who had positive

specimens with P. stuartii. Only one positive specimen from

different sites was isolated in 28 patients: urine (n=11),

blood (n=7), respiratory (n=5) and wound (n=5). In the other

patients at least two positive samples were diagnosed during

hospitalization in each case. We identified 18 cases with

epidemiological linkage and two different outbreaks in the

intensive care unit (ICU). The first between May-August 2018

and affected 6 patients, and the second between February-

May 2019 and affected 11 patients from two departments (6

in the ICU, 5 in the coronary-ICU).The susceptibility profile

showed high level of resistance to imipenem (77.8%),

amikacin (43.9%) and aztreonam (29.8%). 4 isolates were

pan-resistant to antibiotics.

Conclusions: P. stuartii represents a highly resistant and

opportunistic pathogen causing severe infections especially

in ICU debilitated patients with an increased ability to spread

in a hospital environment probably as a result of an excessive

use of colistin and tigecycline, the presence of multiple site-

catheters and vascular lines and the cross-contamination

between patients.

12

The usefulness of QuantiFERON®-TB Gold in diagnosis of active extrapulmonary tuberculosis: A comparative retrospective study between HIV positive and negative patients in a tertiary hospital

Valeriu Gheorghiță, Adelina M. Radu, Ion Ștefan, Adrian Streinu-Cercel

Introduction: Tuberculosis (TB) is the leading cause of death

among people leaving with human immunodeficiency virus

(HIV). The main objective of our study was to assess the

clinical usefulness of the QuantiFERON®-TB Gold test in

diagnosis of active extrapulmonary-TB in HIV-positive and

HIV-negative patients.

Methods: We performed a comparative retrospective study

on ganglionary-TB in HIV-positive patients versus non-HIV

patients in a tertiary hospital from Bucharest, Romania,

between October 2012 and June 2018. The main inclusion

criteria were the definitive diagnosis of active ganglionary-

TB in patients over 18 years old.

Results: A total of 50 patients were eligible for analysis, out

of which 33 with HIV co-infection and 17 without HIV. The

median age at the time of TB diagnosis was 32 years (IQR,

26.5-37.5) in the HIV-positive group and 58 years (IQR, 29-

76) in the non-HIV group (p=0.003). The QuantiFERON®-TB

Gold test was positive in 53% (n=9) of non-HIV patients and

27% (n=9) of the HIV-positive patients (p=0.07). In HIV-

positive patients with positive QuantiFERON® test the

median CD4 count was 230/mm3 (IQR, 178-259) versus

62/mm3 (IQR, 26-152) in those with negative test (p=0.01).

The HIV-positive patients had more extensive TB (61%

[n=22] had multicentric diseases) compared with HIV-

negative patients (18% [n=3]) (p=0.006).

Conclusions: Although the rate of positive QuantiFERON®-TB

Gold test in HIV co-infected individuals is lower compared

with HIV-negative patients and active TB, it remain an useful

tools especially for the diagnosis of latent TB than for active

diseases in a population with an increased prevalence of TB.

The "immunological window" of anti-HCV antibodies and the relevance for the serological diagnosis of acute hepatitis C: a retrospective study in a tertiary hospital

Valeriu Gheorghiță, Adelina M. Radu, Ion Ștefan, Adrian Streinu-Cercel

Background: Acute HCV infection is often asymptomatic and

is associated with higher rate of chronicity. The main

objective of our study was to investigate the "immunological

window" of anti-HCV antibodies (HCV-Ab) and the relevance

for the serological diagnosis of acute hepatitis C. The

secondary objectives were limited to define the

epidemiological and clinical features of acute hepatitis C.

Methods: We performed a descriptive, retrospective

analysis on all adult patients diagnosed with acute HCV

infection during January 2010-December 2016 in the

National Institute for Infectious Diseases "Prof. Dr. Matei

Balș", Bucharest, Romania.

Results: We included 80 eligible patients with a median age

of 47 years (IQR, 34-60) of which 58.8% (n=47) were male.

The risk factors associated with infection were identified in

62.5% (n=50) of cases, of which 78% (n=39) were health-care

associated infections, including surgical interventions in

74.3% (n=29). The median values of alanine

aminotransferases, total bilirubin and prothrombin

concentration were 1177 IU/L (IQR, 682-1865), 4.0 mg/dl

(IQR, 1.35-9.25) and 96% (IQR, 83.9-109.5), respectively. The

rate of positive HCV-Ab was 86.25% (n=69) with a median

value of 11.3 (IQR, 6.02-21.5). 44 patients have available

HCV-RNA at the baseline diagnosis. The median value was

1.054.334 IU/ml (IQR, 60.442-4.568.326), including 43.2%

(n=19) with lower than 600.000 IU/ml.

Conclusions: The majority of patients have already

developed seroconversion when hospitalized, which

highlights the idea that, at least in symptomatic cases, the

"immunological window" is transient and disappears rapidly,

making HCV-Ab seroconversion one of the most reliable test

for diagnosis of acute hepatitis C.

Vol. CXXII • Suppl/2019 • October • Romanian Journal of Military Medicine

13

18F-FDG PET-CT in the evaluation of carcinoma of unknown primary

Raluca Mititelu, Cătălin Mazilu, Dragoș Cuzino, Magdalena Iriciuc, Carmen Tipar, M. Tudoran, T. Mititelu

Carcinoma of unknown primary (CUP) represents a

heterogeneous group of cases with demonstrated

metastatic disease but in which primary tumor was

impossible to detect despite complete and extensive

evaluation. This pathology is not rare and associates many

difficulties in therapeutic management.

CUP is one of the 10 most frequent groups of cancer

worldwide and represents the 4th most frequent cause of

neoplasia related deaths in both men and woman. The

management of these patients is complex, and usually

includes high performance histopathology and imaging

techniques. Most CUP are aggressive histopathologic forms

and median survival rates reported in literature is 2-10

months from diagnosis.

Identifying of primary tumor is of great importance because

it can determine optimization of therapy with significant

improvement of outcome and survival.

At present 18F-FDG PET-CT is consider to have an important

role in management of CUP and in identifying primary

tumor. This is a non-invasive functional and metabolic

method which complement anatomic information obtained

from radiologic techniques (CT and MRI). Its utility comes

from the fact that carcinomatous cells usually are glucose-

avid, leading to a better efficiency in detecting the primary

tumor.

This papers aims to review literature data concerning the use

of 18F-FDG PET-CT in this pathology and to present our

experience in the evaluation of these patients.

PET-CT in lung cancer: assessment of recurrence or residual disease

Cătălin Mazilu, Dragoș Cuzino, Carmen Tipar, Magdalena Iriciuc, Raluca Mititelu, M. Tudoran

Purpose: To present role of PET-CT fusion imaging in

assessment of patients with lung cancer following surgery

(pneumectomy, lobectomy, atypical resection) for primary

tumor/lung metastases.

Matherial and method: Studied cases were represented by

patients with pneumectomy, lobectomy, atypical resection

for oncological disorders which were assessed between

March 2018 – June 2019 in Nuclear Medicine Department of

SUUMC “Dr. Carol Davila” for suspected local or distance

recurrence, based on clinical, biological and radiological

findings, at least 3 months following surgery. Acquisition of

images was performed at 1 hr following iv injection of 2.5-3

MBq kg bw of F18-FDG, from tentorium to proximal 1/3 of

thighs, also completed with planar details or vertex-plantar

level scans when needed.

Results: Assessment of changes has includes and SUV lbm

(standard uptake value lean body mass) using a cut-off of

2.5. Compared with standard post-surgery CT imaging, PET-

CT scan has changed staging of disease by showing new

lesions (mainly local disease recurrences and bone and

lymph nodes metastases), changing the therapeutical

approach, also excluding previously suspected CT

recurrences.

Conclusion: Fused PET-CT imaging has excellent results in

post-surgery assessment in patients with lung tumoral

pathology.

Hepatitis E virus infection in Romania: a neglected cause of hepatitis

Valeriu Gheorghiță, Adelina M. Radu, Ion Ștefan, Ioana D. Olaru, Adrian Streinu-Cercel

Background: The seroprevalence of hepatitis E virus (HEV)

infection throughout Europe varies between and within

countries and over time. The primary goal of our study was

to estimate the prevalence of autochthonous HEV infection

in Romania. The secondary objectives were the identification

of the risk factors associated with the HEV seropositive

status.

Methods: Between January 2015 and December 2016, a

total of 201 adult patients, were tested for anti-HEV-IgG.

Multivariate logistic regression was used to examine for

factors associated with a positive HEV-IgG test. The level of

significance was set at α = 0.05. The study was approved by

the Hospitals’ Ethics Committees.

14

Results: The final analysis included 175 patients who

followed the study protocol, of which 46 (26.3%) had

positive, 121 (69.1%) had negative, and 8 (4.6%) had

indeterminate HEV-IgG results. Patients with positive HEV-

IgG were older [median age of 54.5 years (IQR 43-65)]

compared to patients with negative HEV-IgG [median age of

37.5 years (IQR 28-57.5)], p <0.001. A positive HEV serology

was more common in patients with history of blood

transfusions [n=10 (22.7%) versus (vs) n=11 (9.4%), p=0.025],

in those with immunosuppressive conditions [n=18 (40.9%)

vs n=27 (23.1%), p=0.025] and in patients with positive HBs

antigen (HBsAg) [n=14 (31.1%) vs n=10 (10.3%), p=0.002].

Conclusions: We identified that autochthonous HEV

infection is common in the Romanian adult population. Thus,

we strongly encourage the inclusion of HEV infection testing

from the beginning in all cases of acute hepatitis, acute-on-

chronic liver diseases and chronic hepatitis in

immunosuppressed conditions.

IL 17 inhibitors a new therapeutic class for treatment of patients with psoriasis

Marcela Poenaru, Anton M. Ţilea, Monica S. Dărmănescu, Anca Ilean, Viorel Trifu

Psoriasis is a chronic, inflammatory disease, characterized by

multiple recurrences that profoundly impact the patient’s

quality of life.

Due to the numerous pathogenic pathways and risk factors

involved, psoriasis vulgaris represents a complex therapeutic

challenge, usually requiring the combination of multiple

treatment schemes, including: topical corticosteroids,

sistemic retinoids, Methotrexate, biologic therapies. The

characteristic inflammatory response in psoriasis is involving

high levels of TNFα, IL-17, IL-23.

We present the cases of 2 patients with psoriasis vulgaris

who were treated with Sekukinumab, an IL-17A inhibitor,

which led to a significant improvement in both patients.

Hepatocellular carcinoma: Key points

Clara Ion, Romelia Sfetcu, Maria M. Iosif, Cezar Călin

Hepatocellular carcinoma (HCC) is one of the most common

cancers worldwide and is associated with high level of

morbidity and mortality being the second most common

cause of cancer-related death. Risk factors for HCC are

chronic hepatitis B or C virus, alcohol abuse, aflatoxins,

metabolic disorders and autoimmune-related disease. In up

to 90% of cases, HCC develops in a cirrhotic liver. The

pathogenesis of HCC is complex and involves chronic liver

injury and genetic alteration. HCC has a poor prognosis if

diagnosed at an advanced stage, with a 5 –year survival rate

of 0-10%, that is why surveillance of patients at risk for HCC

should be carried out by abdominal US every six months with

or without workout of AFP.

Diagnosis of HCC is based on history, examination,

laboratory tests, assessment of portal hypertension, imaging

studies and tumour biopsy.

Staging system for HCC must take into account the next main

factors: the assessment of tumour extent, AFP level, liver

function, portal pressure, patient’s physical status and

effects of treatment.

Current management options in HCC depends on the stage

of disease and liver function. Management of early and

intermediate HCC are: liver resection, orthotopic liver

transplantation and local ablation therapy and those are

potentially curative treatment for patients with HCC.

Management of advanced disease – conventional

chemotherapy regimens have not been found to be

particularly effective in patients with HCC, and is not

recommended.

Sorafenib is the standard of care for patients with advanced

HCC and those with intermediate stage disease not eligible

for, or progressing despite locoregional therapies. It is

recommended in patients with well- preserved liver function

and with an ECOG PS 0-2.

EMA recommends Lenvatinib as a front-line systemic

treatment for patients with advanced HCC without main

portal vein invasion and with ECOG PS 0-1. Guides

recommends Regorafenib for patients with advanced HCC

who have tolerated Sorafenib but progressed. Cabozantinib

can be considered for patients who has progressive disease

on one/two systemic therapies.

Pending approval from EMA for Ramucirumab in second-line

Vol. CXXII • Suppl/2019 • October • Romanian Journal of Military Medicine

15

patients with HCC and immunotherapy for patients who are

intolerant or have progressed under TKI therapy. Further

studies are needed.

Follow-up for patients with HCC includes: clinical evaluation

for signs of liver decompensation, dynamic CT/MRI, mRECIST

criteria.

The importance of multidisciplinary management of a

patients with HCC is crucial and key specialities involved:

primary care physician, diagnostic radiologist, hepatologist/

gastroenterologist, surgical oncologist/transplant surgeon,

interventional radiologist, medical oncologist, palliative care

physician.

The level of awareness of the general population regarding sun tanning beds

Irina G. Tănase, Mihaela Georgescu

Introduction: In order to assess the risk of skin cancer,

patients should be counseled on the factors that play a major

role in the development of this condition by their primary

care physicians. UV radiations are used by artificial tanning

devices, such as sun lamps and tanning beds. Despite the fact

that these devices are thought to be carcinogenic, they are

still sold as a safe alternative to UV exposure for both tanning

and vitamin D biosynthesis.

Materials and methods: We created a Google form

composed of 7 questions to assess the general knowledge of

the population regarding sun tanning beds.

Results: A number of 128 persons responded to the Google

form, 81.9% females and 18.9% males. The majority (63.3%)

population is between 25-35 age interval. 25% admitted that

they have used a sun tanning bed only for cosmetic

purposes, but 6.3% confirmed using it also as a medical

device. The majority of the population is aware that sun

tanning beds cause melanoma. As alternatives to sun

tanning beds people have used the sun (58.6%), special

creams (13.3%), other devices, and a big portion (25.8%) did

not use another alternative. A small percent of 3.9% consider

a sun tan bed identical to the sun.

Conclusion: The general population should be made aware

of the negative effects of sun tanning beds. This include

National Health Care program, implication of the National

Society of Dermatology and Government.

Comparative study on the use of 19G vs 22G needles used for EBUS-TBNA performed in the Department of Pulmonology, SUUMC

Ioana Ștefănescu, Elvis Firoiu, Florina Vasilescu

Between 2015-2019 in our Department of Pulmonology

were performed approximately 100 EBUS-TBNA, 20 of these

were performed using 19G biopsy needles. We made a

comparative study regarding the use of 22G vs 19G biopsy

needles. Given that the number of EBUS-TBNA with 19G

needles was smaller than those used with 22G needles, the

results cannot be interpreted as very relevant, we will return

with details to future events, but we can draw the following

conclusions: the lung cancer confirmation rate is comparable

(about 85%), but since we use 19G biopsy needles, we had a

100% confirmation rate of Sarcoidosis with mediastinal

lymph node involvement, while no suspicion of Sarcoidosis

was confirmed when we used the 22G needles The risk of

bleeding has increased about 3 times since we use 19G

needles, but no bleeding required special therapeutic

measures (transfusions, surgery, admission to ATI, etc.), all

of which were controlled by bronchoscopic methods, cold

serum administration, locally administered adrenaline

dilution.

New pharmacological approaches for binge-eating disorder

Octavian Vasiliu, Daniel Vasile, E.A. Morariu, R.D.A. Stănescu, A.F. Fainarea, M.C. Pătrașcu, R.E. Manolache, I.A. Alexandru, I.E. Ghenoiu, R.A. Lecu, M.I. Gionea, F. Găinaru, I. Amanolesei, R.G. Vlaicu

Background: Binge eating disorder (BED) is the most

frequently diagnosed eating disorder among the US adults,

and its worldwide incidence is almost double than the next

most prevalent disorder, bulimia nervosa. Therefore,

16

important research efforts at both basic and clinical levels

have been reported in the last decades, with several drugs

reaching the market, while still other investigational

products are in the late phase of development.

Objective: To describe the current status of the

pharmacological treatment in BED, based on the available

data in the literature, and to hierarchize these therapeutic

interventions according to their relevance for the clinical

practice.

Methods: An electronic databases search was realized

(PubMed, UpToDate, Thomson Reuters/Web of Science and

clinicaltrials.gov) using as keywords “binge eating disorder”

and “pharmacological treatment”. All published papers,

including finalized or ongoing trials found between 2000 and

2019 were selected for the primary analysis.

Results: Lisdexamfetamine dimesylate is the only drug with

enough evidence to support its recommendation for the

treatment of patients diagnosed with BED. However, it may

be associated with significant risk of addiction, which

requires continuous monitoring during the entire duration of

the therapy. Fluoxetine, sertraline, duloxetine, bupropion,

atomoxetine, armodafinil, disulfiram, naltrexone+

bupropion, baclofen, zonisamide, topiramate, lamotrigine,

samidorphan, chromium picolinate, liraglutide, orlistat and

rimonabant have been associated with mixed results in

clinical trials. GSK1521498 is an opioid antagonist that may

be a solution for BED managment in the near future, and

dasotraline, a serotonin-norepinephrine-dopamine

reuptake inhibitor is in phase III of clinical trials, and it seems

to be associated with significant efficacy.

Conclusions: A single molecule is nowadays available for

clinical use in the treatment of BED, lisdexamphetamine

dimesylate, based on solid evidence derived from pivotal

trials. Many other drugs are evaluated for this indication, but

unfortunately most of them seem to be associated with

mixed results.

Correlations between hematoxylin & eosin stain photomicrographs and multiphoton microscopy images in encapsulated thyroid nodules

Lucian Eftimie, Radu Hristu, Marius Dumitrescu, Rodica Bulata, Alexandra Calu, Marius Curea, Liana Toma, Florina Vasilescu, Remus Glogojeanu, Mariana Costache, Ștefan Stanciu, Maria Sajin, Gheorghe Stanciu

Introduction: The diagnosis of malignancy must be

confirmed by histopathology which has been the main tool

used in the diagnosis of cancer. This technique has evolved

from an era of diagnosis based on Hematoxylin and Eosin

(H&E) and evaluation of tumors by immunohistochemistry

(IHC) to confirm tumor histogenesis and histological subtype

to the emerging multiphoton microscopy imaging which is a

promising technique as an aid to traditional techniques.

Second harmonic generation (SHG) microscopy is a

promising technique for non-invasive in vivo high-resolution

optical imaging. SHG signals are generated from specific

endogenous molecules with a non-centrosymmetric

structure, hence this contrast mechanism is intrinsic to

collagen in living tissue. Investigating collagen distribution

with SHG in tissues enables a precise and non-invasive

assessment of extracellular matrix modifications, which

represent a hallmark of many pathologies, including cancers.

Objective: The purpose of this study was to compare the

accuracy of multiphoton microscopy images with H&E stain

photomicrographs in the diagnosis of thyroid cancer to

demonstrate some changes in the collagen structure and

organization in papillary thyroid carcinoma (PTC) and

follicular adenoma (FA) nodule capsules.

For this purpose, multiphoton microscopy images might help

the pathologist to diagnose thyroid cancer easier and faster.

Method: The SHG imaging was performed using a Leica TCS-

SP confocal laser scanning microscope modified for

nonlinear optical imaging. The microscope was equipped

with a Ti:Sapphire laser (Chameleon Ultra II, Coherent) which

was tuned at 860 nm, with ~140 fs pulses and a repetition

rate of 80 MHz. A 10X magnification and 0.3 numerical

aperture objective was used for focusing the laser beam on

the sample and for collecting the backward-generated SHG

signals. The forward generated SHG was collected using a 0.9

NA condenser. We acquired images with SHG microscopy on

4 μm thick tissue sections mounted on glass slides without

H&E staining and assessed collagen organization of tumoral

capsular tyroid nodules and we compared them with the

H&E stain photomicrographs of the same capsular level of

tyroid nodules (PTC, FA) respectively of the thyroid capsule

with Leica microscop to gold standard H&E sample stained.

Results: Images were acquired on the same field of view with

the optical microscope and the multiphoton microscope and

the images were compared. Important features of PTC were

the regions of interest (capsular invasion or capsular

microangioinvasion). Images were also taken from the

Vol. CXXII • Suppl/2019 • October • Romanian Journal of Military Medicine

17

nodule capsule and its surroundings. It was noticed that SHG

signals are very useful for the interpretation of the tissues

state.

Conclusions: This study confirmed multiphoton microscopy

images examination as a reliable and useful diagnostic

procedure to demonstrate some changes in the collagen

structure and organization in PTC. The results of our study

demonstrate that multiphoton microscopy images is an

accurate method which can aid in the diagnosis of thyroid

cancer.

PET-CT in the management of infective endocarditis

Raluca Mititelu, Cătălin Mazilu, Silviu Stanciu, Dragoș Cuzino, Carmen Tipar, Magdalena Iriciuc, T. Mititelu, M. Tudoran

Infectious endocarditis is a serious condition, which has been

increasing in recent years as a result of the growth in the

number of surgical procedures involving implantation of

prosthetic material in the heart. Infectious endocarditis is

associated with a high mortality rate - 20% in-hospital and

40% at one year with maximum treatment.

The diagnosis of infectious endocarditis is mainly based on

clinical and ultrasound criteria. However, there are many

situations in which the severity of the phenomena and the

multiple pathological associations prevent or delay the

precise diagnosis. For this reason, it is necessary in many

cases to perform imaging procedures withe higher

specificity.

Increased glucose uptake at the site of infection represents

the pathophysiological basis for using PET-CT with

radiolabelled glucose in assessing infectious processes,

including fever of unknown origin. Many researchers and

clinicians have suggested the potential diagnostic role of

18F-FDG PET-CT in accurately diagnosis of infectious

endocarditis, especially in prosthetic valves.

In normal conditions there is variable physiologic glucose

uptake in the heart and for this reason it is very important

an adequate preparation of the patient, in order to minimize

FDG uptake in the normal heart tissue - low carbohydrate

diet 24 hours before the investigation, fasting at least 6

hours before the investigation, the eventual administration

of heparin iv which, according to many authors would

further reduce the physiological uptake of glucose in the

heart. All these measures have the role of increasing the

specificity and accuracy of the diagnosis.

In this paper we will review the literature regarding the use

of 18F-FDG PET-CT in the evaluation of patients with

infectious endocarditis.

Coexistence of TIA and minor stroke in the same vascular territory with possible mixed hemodynamic and embolic mechanism

Cristina D. Ghizdavet, Florentina C. Pleșa, Sebastian Botezatu, Ionuț Caloianu, Alexandru Nistor, Carmen A. Sîrbu

Introduction: Transient ischemic attack (TIA) is a

neurological emergency. 10% of patients with TIA or minor

stroke will develop a stroke within the next 90 days,

maximum risk being within the first 24 hours. Up to 80% of

this risk could be prevented. The mechanisms of TIA are

multiple, sometimes being intricate, therefore difficult to

specify.

Case report: 65 years old male, presented right hemiparesis

and aphasia, with total recover in less than one hour. He

refused the hospitalization proposed by the ambulance

crew. 24 hours after the first TIA, the symptomatology

repeats. He arrives at ER and he is hospitalized. After the

complete anamnesis, the neurological examination and the

paraclinical investigations, ischemic lesions in left MCA

territory and 70% left ICA stenosis were discovered. Left ICA

stenosis has been evaluated at angiography as subocclusive

stenosis and it has being stented.

Particularities: The hemodynamic mechanism has been

confirmed during the angiography evaluation, when systolic

blood pressure dropped from 180mmHg to 100 mmHg,

resulting in a TIA recurrence (right hemiparesis and speech

disorder for a few minutes). On the other hand, ultrasound

images of atheroma and the presence of ischemic lesions in

MCA territory (not in the border territories) suggest an

arterio-arterial embolic mechanism.

Conclusion: The identification of the pathogenic mechanism

is important for prophylactic therapy. There was no

significant difference between minor stroke and TIA in

prognosis. The treatment for preventing an ischemic stroke

after TIA and recurrent stroke following a minor stroke are

18

similar.

The anticoagulation in venous and arterial thromboembolic events associated with acquired thrombophilia

Maria A. Jercan, Lavinia Bârsan, Mihai Șotcan

There are three acquired thrombophilia that carry a high risk

of arterial and venous thromboembolism. These acquired

thrombophilia are antiphospholipid syndrome (APS) and its

variant – catastrophic APS, heparin induced thrombo-

cytopenia (HIT), and paroxysmal nocturnal hemoglobinuria

(PNH).

The pathogenesis of thromboembolic disease in APS, HIT,

and PNH is complex and includes cellular and/or

complement - mediated mechanism.

The treatment of thrombotic events associated with these

pathologies, the primary and secondary prophylaxis consist

in anticoagulation and had some particularities. The gold

standard of treatment in APS remains vitamin K antagonists

(VKA), after initial overlap with unfractionated heparin

(UNH) or low molecular weight heparin (LMWH). There are

additional options in pregnancy associated with APS and in

catastrophic APS, that includes the association of aspirin,

plasmapheresis, corticosteroids, hydroxychloroquine to the

anticoagulation.

The thromboembolism in HIT must be treated with

nonheparin anticoagulant initially and after clinically

resolution of thrombosis, we can switch the nonheparin

anticoagulant to VKA.

PNH is a rare disease and the most important treatment is

the eculizumab which stops the pathogenic mechanism. The

anticoagulation treatment such as LMWH, of venous or

arterial thrombosis associated with PNH must be started

immediately and can be switch to VKA after clinically

improvement.

Direct oral anticoagulants (DOACs) did not show a good

effectiveness in this kind of pathologies, and their use is

reserved for low risk acquired thrombophilia in prevention

of thrombosis. Further studies are needed.

A rare tumor entity: Leiomyosarcoma of the mesenteric veins

Alexandra D. Radu, Raida T. Stănescu, Cezar Beţianu, Cristina Sandu, Teodor Voiosu, Elena Busuioc

Introduction: Vascular leiomyosarcoma is a rare clinical

entity of malignant soft tissue tumours. The majority of

reported cases arise from the inferior vena cava, followed by

leiomyosarcoma of the main vessels of extremities, renal,

hepatic and mesenteric veins.

Case report: A 76-year-old male patient with a history of

class II congestive heart failure, ischaemic heart disease,

stage II hypertension, paroxysmal atrial fibrillation, type 2

diabetes, stage III chronic kidney disease and

hypothyroidism, was reffered to our clinic with diffuse

abdominal pain. Blood tests revealed a slight elevation of

serum transaminases and mild cholestasis (TGO, TGP and

GGT twice the upper limit of normal). An abdominal

ultrasound revealed a 10cm hypoechoic non-homogenous

mass close to the pancreatic head, with invasion of the

splenic vein and mesenteric artery at the origin from the

abdominal aorta, with no exact determination of its origin.

A contrast computed tomography of the thorax, abdomen

and pelvis was performed, revealing a large hypodense non-

homogenous tumour, probably with mesenteric vein origin.

The patient underwent endoscopic ultrasound examination

with fine needle biopsy that showed a heterogenous

hypoechoic solid tumour with Doppler signal. The pathology

and immunohistochemistry reports revealed the diagnosis

of leiomyosarcoma.

Conclusion: We report a case of an unresectable

leiomyosarcoma of the mesenteric vessels, which has no

certain indication for neoadjuvant chemotherapy or

radiotherapy because of its low incidence.

Vol. CXXII • Suppl/2019 • October • Romanian Journal of Military Medicine

19

Mass casualty incident by bomb attack: multinational exercise Bucharest 2019

Bogdan C. Teușdea, Daniel Negoiță, R. David

Vigorous Warrior 2019 (VW19), was the biggest NATO

medical exercise until now and was conducted in April 2019

in Romania. Representatives from Romania and 38 other

nations took part in this exercise.

At the end of this international exercise a bomb attack at a

subway station in the center of the capital was simulated and

managed under military command.

The goal of the exercise was that the military and civilian

entities, both national and multinational act in a coherent

and effective way.

The forces involved in rescuing the simulant victims

included: Romanian firefighters, Hungarian rescue teams,

Romanian and foreign medical personnel, SMURD and

civilian ambulances, and a large number of personnel,

vehicles and medical systems from the Central Military

Emergency Hospital Bucharest (SUUMC “Dr Carol Davila”).

Rescue actions included the extraction of over 200 victims

from the subway tunnels and the provision of on-site triage

and emergency care. A ROL1 hospital was deployed by the

Central Military Emergency Hospital at the Academy of

Economic Studies.

During the exercise 18 victims were evacuated to SUUMC

“Dr Carol Davila”. Of these, 17 were simulated victims (12

red, 3 yellow and 2 green code of emergency) and one was a

real case – one of the volunteers present in the subway

station who presented medical problems requiring urgent

medical attention.

Case managers from different countries supervised the

interventions.

The staff involved in this exercise managed to work in a

coherent way, even when crews were assembled of

members from different countries and different institutions.

Radiotherapy in adrenocortical carcinoma: case report

Remus C. Stoica, Diana A. Mitrea, Răzvan G. Curcă, Alexandra T. Pasăre, Mihai Dumitrache, Ștefănel Vlad

Introduction. Neuroendocrine tumors are comprised from a

broad tumor family, the most common of them are in the

lungs, thymus, pancreas and gastrointestinal tract. Pituitary,

adrenal, thyroid, parathyroid gland tumors are less common.

Adrenocortical carcinoma is a rare malignancy with an

estimated incidence of ~ 0.5 – 2 cases per million people per

year.

Materials and Method. We are reporting a rare case of

adrenocortical carcinoma in a 47 years old female patient,

with uncontrolled systemic blood pressure and a left

abdominal mass, which is displacing the surrounding

structures. After imaging investigations, it was confirmed the

malignant features of the left adrenal mass. In this clinical

case report, the patient was treated with a complete surgical

excision of the tumor, followed by adjuvant radiotherapy.

Results and Discussion. Given its rarity, adrenal carcinoma

has been difficult to study and therefore treat. Surgery is

considered to be the main approach for locoregional control

in early stages, but systemic therapy and radiotherapy, in

advanced tumors or with high-risk recurrence features, are

useful as adjuvant treatments. Modern external beam

radiotherapy, with its recent advances, improves local

control in adjuvant setting.

Follow up appointments, after external beam radiotherapy,

confirmed the normal blood pressure and no evidence of

local recurrence.

Is there still a role for biomarkers in sepsis

Sebastian Dogaru, Bogdan C. Teușdea

The last definition of sepsis (Sepsis 3- 2016) as life-

threatening organ dysfunction caused by a dysregulated

host response to infection is based on qSOFA criteria in order

to help the prehospital and ED teams. It was conceived as a

tool for rapid diagnostic. Although a good working definition,

after the initial enthusiasm, there are more and more

experts saying that the threshold is too high. Waiting until

the quick SOFA criteria should be met in order to diagnose

sepsis it is sometime too late for an increasing number of

patients that are growing older and with a complex adjacent

20

pathology. Although very specific, the last definition is not

very sensitive. The doctor’s goal should be the cure of the

patient, not a specific diagnostic. The 2018 sepsis update

states that the older 3 hour and 6 hour bundles (Sepsis 2)

should be done in 1 hour, meaning that time is critical.

Combining a not so specific score/ criteria with a specific

biomarker in certain circumstances should buy the very

necessary time in order that the patients’ status not to

become critical, life-threatening. Faster the answer, better

the prognosis.

This is why we think that the role of biomarkers in the field

is not an obsolete one and the proactive intervention, early

in the evolution of an infection, would save lives. A

biomarker with good prognostic value should alert the

doctor in charge that more proactive, more aggressive

therapy should be applied earlier in order to prevent the

degradation of patient status. Further research should be

done.

An unusual case of chronic kidney disease with lymphadenopathy

Oana Stancu, Mihai Șotcan, Adrian Anghel, Gabriel D. Stoicescu, Oana Ionescu, Lucian Ciobîcă

We present the case of a patient aged 52 year, extensively

investigated in the nephrology service for a moderate

nitrogen retention syndrome with proteinuria and

polyclonal hypergamaglobulinemia – with the exclusion of

multiple myeloma. Patient is referred to our service for

further investigations in the conditions of persistent

nitrogen retention syndrome which is associated with the

presence of adenopathies in the peripheral ganglion areas.

Serum protein immunofixation is performed, K/lambda

chain ratio – normal, immunogram – negative; increased

rheumatoid factor. Biologically upon admission: moderate

normochromic anemia – osteomedular biopsy was

performed showing a nodular lymphoid infiltrate with small

cells with nodular appearance. Autoimmune disease

investigations was performed with negative results. At the

CT scan, hepatosplenomegaly, peripheral and lumboaortic

adenopathy, minimal bilateral pleurisy, osteocondensating

vertebral lesions and lithic lesion of the left iliac wing are

highlighted. Cardiac ultrasound shows minimal pericarditis

and dilated right cavities with moderate pulmonary

hypertension. The excision of an inguinal adenopathy with a

histopathological examination that detects the

lymphoganglionic Castelman's disease is decided.

Immunohistochemical examination of the lymph node

reveals Castelman Disease with the hyaline-vascular

subtype; chronic sclerogenic reactive lymphadenitis with

Castelman Disease changes. In order to complete the

paraclinic investigations, an osteo-medullary biopsy is

performed, revealing the presence of a plasmocitoid

population, a positive variable at CD 56 invoking the

differential diagnosis of multiple myeloma/POEMS and

dysmegakariopoiesis at differential diagnosis with a

myeloproliferative syndrome - diagnoses that could not be

clinically supported. The final diagnosis was the one of

Castelman's disease type lymphoproliferative syndrome for

which there was a CHOP chemotherapy treatment in 3

sessions: initially with favorable evolution, later with relapse

and deterioration of the general condition with massive

pleurisy and aggravation of renal insufficiency.

Controversy in thrombolysis

Lorena F. Davidescu, Florentina C. Pleșa

Introduction: Stroke is the second leading cause of mortality

worldwide after cardiovascular disease. In Romania, stroke

is responsible for approximately 54,000 deaths annually.

Approved by FDA in 1996, intravenous thrombolysis with

rtPA is addressed to patients with acute ischemic stroke

within the first 4.5 hours after the onset of symptomatology,

in the absence of contraindications.

Objective: Intravenous thrombolysis with rtPT has raised

numerous controversies from the beginning to present and

the aim of our study is to explore them.

Methods: We analised the AHA/ASA asociation and ESO

Guidelines for the Early Management of Acute Ischemic

Stroke and also the most recent PubMed articoles about

controversies in trombolysis.

Results: We took into account the issues regarding the use

of thrombolytic treatment such as: the correct identification

of the acute stroke, considering clinical signs, severity and

atypical presentations, the posibility of extending

Vol. CXXII • Suppl/2019 • October • Romanian Journal of Military Medicine

21

therapeutic window and the presence of relative

contraindications. There is also the debate regarding brain

imaging, because in difficult cases advanced neuroimaging

techniques might be required.

Conclusions: Proper anamnesis, rigorous neurological

clinical examination and complete paraclinical and imaging

investigation ensure strict and adequate selection of

patients with acute ischemic stroke eligible for Alteplase

thrombolytic treatment with a favorable risk-benefit ratio.

Diabetic foot ulcers: new questions, the same problem

Ciprian Constantin, Laura Gagiu, Georgiana Constantin, Oriana Moraru, Cosmin Buzilă

Background: There are quite a number of treatments

available for the management of diabetic foot ulcers (DFUs):

local therapies, vasodilators, antibiotics, neuropathic and

neurotrophic drugs, wound dressings, skin substitutes,

growth factors and inflammatory modulators.

Material and methods: Study of regular Clinical Statements

reveals that American Diabetes Association is the main

professional association that aims to standardize the

intervention to prevent this complication of diabetes

mellitus, but the spread of this disease is the main reason for

increasing incidence and prevalence of minor and major

amputation caused by DFUs.

Results and conclusion: Lower-extremity peripheral artery

disease (PAD) is a complication of diabetes and occurs in 4.3-

29% of all patients, not only diabetics, worldwide.

A new solution is on his way to be aproved: Alpha2C

adrenoceptor (A2Ca). A2Ca is a silent Gi-protein-coupled

receptor stored in the endoplasmatic reticulum (ER) that

implies: a translocation to the cell surface enhances

catecholamine-signaling à vasoconstriction, a execution of

translocation by external stressors (e.g. cold, endothelial

dysfunction), alpha2C adrenoceptor signaling found

preferentially in distal vascular smooth muscle cells, and

could inhibits presynaptic release of norepinephrine and

other neurotransmitters such as dopamine and serotonin.

Will be this A2Ca the solution for this multifactorial problem

or will be a part of this problem?

How easily can the diagnosis of ruptured brain arteriovenous malformation be missed

Ionuț R. Dumitru, Carmen A. Sîrbu

Introduction: Arteriovenous malformations (AVMs) have a

small rate of occurrence, 10% of them being localised to the

posterior fossa (cerebellum). Even though the diagnosis is

relatively easy to establish, an incomplete anamnesis along

with a superficial neurological examination might lead us

towards false conclusions.

Methods and Materials: We’ll present the case of a 23-year-

old man, who arrived at the ER with vomiting, imbalance,

laterodeviation, mild cephalagia and diplopia. We will point

out the errors in diagnosis, from both the prehospital stage

(biliary dyskinesia) and the hospital one (labyrinthitis), and

the way by which the patient, a medical student and

volunteer with the ambulance service, had a decisive role in

solving his own medical case.

Results: The cerebral CT performed showed a spontaneous

hyperdense cerebellar lesion (identified as a tumour, with no

hope in a therapeutic path for the patient!). The MRA, and

especially the “4-vessel” angiogram found a cerebellar AVM

with medium flow, arising from the superior left cerebellar

artery, with drainage through a unique vein in the left

transverse sinus. Considering the characteristics of this

specific case, embolization of the newly formed structure

has been chosen as the preferred course of action, with

optimal results.

Discussion and conclusions: The essential aspect which

raised the patient’s doubts was diplopia. It was this symptom

that caused the complex investigations that preceded the

correct diagnosis. The clinical abilities based on vast medical

knowledge lead to the rational use of paraclinical

investigations and the establishment of correct diagnosis.

22

Fast-track: a new way for rapid evaluation in the ED

Bogdan C. Teușdea, Mihai Toma

Medical triage of the patients admitted into the ED is made

on the basis of specific criteria established by the national

laws taking into account their clinical condition, stability of

vital functions, aggravating potential of their status, the

necessity of starting a treatment or to carry out some

investigations etc. setting up the priorities of the medical

care. There are 5 triage categories/levels that establish

patient’s waiting time, from zero minutes – code red, to

maximum 240 minutes the white code.

Fast-track – a new way for rapid evaluation in ED – Is a new

concept that permits receiving the patients outside the ED,

evaluation (eg. ECG, topical administrations of medications)

and treatment of some types of emergencies (e.g fever,

allergic reaction, dental problems).

Intricate presentation of a novel disease

Raida Stănescu, Alexandra Radu, Andreea Petridean, Florin Rusu, Elena Busuioc

Introduction: IgG4-related disease (IgG4RD) is a fibro-

inflammatory condition that can affect nearly any organ.

Common presentations include major salivary and lacrimal

gland enlargement, orbital disease, autoimmune

pancreatitis, and retroperitoneal fibrosis.

Case report: A 59-year-old female with a history of

schizoaffective disorder was referred to our clinic for

evaluation of elevated levels of serum creatinine. Her

previous lab work also showed a long-standing normocytic,

normochromic anemia, hypergammaglobulinemia and

inflammatory syndrome with a high ESR. At the time of the

referral the patient was unwell, with pale skin and mucous

membranes. Blood work revealed a severe anemia (Hb-

6.8g/dL), hyperkalemia (K-5.72mmol/L), high serum

creatinine (Cr-6.8g/dL), inflammatory syndrome (ESR-

70mm/h, CRP-43.32mg/L), hypergammaglobulinemia

(gamma-24.8%), and high IgG levels (IgG-2374 mg/dL).

Abdominal ultrasound displayed bilateral grade 3

hydronephrosis and a hypoechoic mass surrounding the

aorta and inferior vena cava (IVC). Computed tomography of

the chest, abdomen and pelvis, performed without

administration of contrast material, demonstrated

numerous enlarged retroperitoneal lymph nodes forming an

extensive mass entrapping the aorta, IVC and both ureters.

Bilateral double-J right ureteral catheters were placed with

a good clinical outcome. Bone marrow aspiration and biopsy

revealed 10% plasma cells, while radiographs of the skull,

chest and pelvis showed no lytic lesions. Laparoscopic biopsy

of the retroperitoneal mass was performed in a clinic in Italy

demonstrating storiform fibrosis, lymphoplasmacytic

infiltrate enriched with IgG4-positive plasma cells. A clinico-

pathological diagnosis of IgG4RD was made.

Methylprednisolone 48mg/day was started with favourable

clinical and paraclinical evolution after one month (Hb-

10.3g/dL, Cr-2.27mg/dL, IgG-1816mg/dL, gamma-22.3%).

Conclusion: The present study reports a case of IgG4RD

presenting with hypergammaglobulinemia,

lymphadenopathies and inflammatory syndrome. The

diagnostic challenge of IgG4-RD is generated by the clinical

and laboratory similarities with other hematologic diseases

(lymphoma, plasma cell neoplasms).

The Ketogenic diet: is it suitable for everyone?

Laura Gagiu, Ciprian Constantin

Background: The Ketogenic diet has become very popular in

the last period of time, among both people that are trying to

lose weight but do not have any other comorbidities and

among patients with different types of disease. The

ketogenic diet is based on limiting very much the amount of

carbohydrates (2-5%), increasing lipids (80-90%) and filling

the rest with protein (8-15%).

Material and methods: There are various studies performed

on the ketogenic diet published on NCBI and Medscape that

have proved its benefits but also it’s limits. It is well known

that a diet with low carbohydrate intake can improve

symptoms in epilepsy and that the ketogenic diet has been

included by NICE (the National Institute for health and Care

Excellence) as a treatment option in the Clinical Guidelines

Vol. CXXII • Suppl/2019 • October • Romanian Journal of Military Medicine

23

for Epilepsies. Also, recently it has been discovered that it is

also safe and well tolerated in patients with relapsing

multiple sclerosis by reducing proinflammatory

adipokines.On the other hand low carbohydrate diets have

been proven to increase both cardiovascular and cancer

mortality data that has been presented on the ESC Congress

in 2018.

Results and conclusion: Obesity is a worldwide problem that

affects various aspects of a patient’s life and should be

considered as a disease that can also be prevented. When

prevention fails, losing weight should be the first measure

taken in order to improve the patient’s quality of life. The

ketogenic diet is one of the options that could be considered

but when the decision is taken, all the comorbidities should

be taken into consideration, and the balance between risks

and benefits should lean towards benefits. For example in a

diabetic patient,lowering the carbohydrate intake has been

proven to reduce the glycemic levels but the excess fat has

increased LDL levels which also increases its cardiovascular

risk.

Even though there are both recommendations and

restrictions regarding the ketogenic diet it depends very

much on the patient and its associated diseases and also on

how the doctor can make variations of the diet according to

the patients needs.

suPAR: a biomarker in evaluation of patients with fever

Mihai Toma, Bogdan C. Teușdea

Background: Severe infection can cause sepsis that is a

potentially fatal whole-body inflammation. Biomarkers are

widely used in clinical practice and they are useful for

monitoring the infectious process. Procalcitonin (PCT),

lactate and C-reactive protein (CRP) have been most widely

used, but even these have limited abilities to distinguish

sepsis from other inflammatory conditions or to predict

outcome.

The aim of our study was to investigate the role of new

biomarkers – soluble urokinase-type plasminogen receptor

(suPAR) in patients with fever.

Methods: Between January – July 2019, blood samples were

taken after obtaining informed consent from 45 patients

with fever. We determine five biomarkers: leucocyte,

procalcitonin (PCT), lactate and suPAR. We obtained clinical

data and calculate SIRS and qSOFA score. Statistical analysis

was performed with StatDirect program.

Results: The mean values for the biomarkers were: leucocyte

16038.46/ml, procalcitonin 1.48 µg/ml, lactate 1.34 mmol/l

and suPAR 5.68 ng/ml.

Discussion & conclusions: PCT and CRP are main markers

used in clinical practice and are more useful to rule out

infection. PCT is the most studied biomarker that guides

early stopping of antibiotic therapy in adults. In our study

elevated suPAR was associated with more hospitalization

days, and was much better correlation with elevation of

leucocyte than procalcitonin.

Relationship between HLA-B27 positivity and radiological damages in patients with Ankylosing Spondylitis

Daniela Anghel, Livia Otlocan, Raluca Bursuc, Elena Busuioc, Anca Manolache, Valeriu Smedescu, Maria M. Negru, Cristina F. Pleșa, Ciprian Jurcuț

Background: Axial spondyloarthritis (AxSpA) is a disease

where back pain is the main symptom. The disease can cause

axial-joint inflammation, erosion and new bone formation,

leading to functional impairment. Traditional assessment

tools include Bath Ankylosing Spondylitis Disease Activity

Index (BASDAI) which is designed to assess spondyloarthritis

(SpA) disease activity and daily function. Although this tool is

well validated, the relationships between disease activity,

functional status, axial-joint inflammation and degree of

syndesmophytes formation are more complicated. Studies

showed that disease activity might not correlate with axial-

joint inflammation and functional impairment could be

caused by both axial-joint inflammation and structural

damage of the spine.

Objectives: We are trying to find the prognostic factors for

syndesmophytes formation. So far, the identified potential

risk factors include male sex, human leukocyte antigen (HLA)

B27 positivity, smoking, and an initially raised C-reactive

protein (CRP). As some of the risk factors are potentially

24

modifiable, it would be of interest to know if they will also

apply in our local population. By categorizing a group of

patients with AxSpA, we aimed to describe the clinical

characteristics and their relationships with disease activity,

functional status, and syndesmophytes formation.

Methods: This is an observational and descriptive study of 35

patients with AxSpA recruited from the Department of

Internal Medicine II, “Dr. Carol Davila” Central Military

Emergency University Hospital, from October 2018 to July

2019. Our study aims to determine the changes in magnetic

resonance imaging (MRI) in patients with AxSpA.

Inclusion criteria included diagnosed AxSpA patients with

current back pain. Exclusion criteria included pregnancy and

inability to undergo MRI examination.

Clinical and blood parameters were collected. These

included age, sex, smoking and drinking history, duration of

back pain, location and characteristic of back pain,

extraspinal features, associated medical history, HLA-B27

status, CRP, and erythrocyte sedimentation rate (ESR).

Patients completed a self-assessment questionnaire: BASDAI

– to calculate the Ankylosing Spondylitis Disease Activity

Score (ASDAS).

Radiological sacroiliitis based on the Modified New York

criteria: grade 0, normal; 1, doubtful; 2, obvious; 3, fusion.

Bilateral sacroiliitis grade 2 or above or unilateral sacroiliitis

grade 3 or above was defined as radiological SpA. All patients

had spine and sacroiliac joints MRI.

Results: 35 patients were recruited. Our cohort was

characterized by long disease duration, high disease activity,

moderate functional impairment and significant radiological

damage.

Result 1: High disease activity (main BASDAI=4.28) and high

radiological damages were found on 21 (60%) patients. HLA-

B27 positivity was found in 70.0% of the population. Most of

them were male (75.0%). There were 68% smokers. Average

age was 44.5 year and mean CRP was 9.5 mg/dl.

Result 2: Low disease activity (BASDAI=3.34) and some

radiological damages were found on 5 (14.29%) patients. All

patients were found to have HLA-B27 positivity. All of them

were male. All of population were smokers. Average age was

37.8 years and mean CRP was 0.75 mg/dl.

Result 3: High disease activity (BASDAI=4.87) and minimal

radiological damages were found on 4 (11.43%) patients. All

patients were found to have HLA-B27 positivity. All of them

were female. None of the population were smoker. Average

age was 43.5 years and mean CRP was 5.11 mg/dl.

Result 4: Highest BASDAI (BASDAI=5.41) and some

radiological damages were found on 5 (14.29%) patients. All

patients were HLA-B27 negative. Female patients were

61.9% of the study group. There was no smoker. Average age

was 47.5 years and mean CRP was 5.46 mg/dl.

Conclusions: In a group of patients with long-standing SpA,

we described the clinical characteristics in relation to disease

activity, functional status and radiological damages.

We found that the group of patients with high axial-joint

inflammation and structural damage of the spine were male

smokers with HLA-B27 positivity. The findings correlate with

poor prognostic factors.

In patients with HLA-B27 positive who do not have

radiological changes, it is important to perform MRI for the

diagnosis of ankylosing spondylitis.

By describing different characteristics of patients with SpA in

relations to disease activity, functional status, and

radiological damages, we hope to provide a clearer picture

for rheumatologists to understand and interpret different

clinical parameters and to provide the best management to

patients.

The experience of the Central Military Hospital in the thrombolytic treatment of acute ischemic stroke

Oana C. Tache, Florentina C. Pleșa, Carmen A. Sîrbu, Gabriel Boeru, Cătălin Andrei, Gabriel Ștefănescu, Cristina L. Otavă, Simona Gheorghevici

Introduction: Thrombolytic medication is the Gold Standard

treatment of acute ischemic stroke for eligible patients.

Objective: The purpose of this work is to evaluate the

efficiency of thrombolysis in terms of operation time,

teamwork, evolution, complications and to identify the

dysfunctions, in order to optimize the therapy.

Methods: We analyzed a group of patients thrombolysed in

our hospital, noticing their evolution during the

hospitalization, at one and 3 months after hospitalization,

appreciated by functionality scales. We have also followed

the evolution of thrombolysis over time from its introduction

as a treatment method for stroke.

Vol. CXXII • Suppl/2019 • October • Romanian Journal of Military Medicine

25

The first thrombolysis was performed in 1958 when out of

three patients treated only one presented improvement of

symptoms. Intravenous thrombolysis was initiated in the

clinical neurological activity more than 15 years ago.

Thrombolysis was introduced in the Central Military Hospital

in March 2019 and now we have 10 patients who have

benefited from this therapy.

Thrombolysis is possible with the fast and synchronous

intervention of a team made out of: neurologist, emergency

doctor and radiologist. Considering the hospital’s

compartmental structure, the team spirit is the binder that

leads to obtaining the optimal times.

Thrombolysis had a beneficial effect on the majority of

patients, the disability scores being significantly improved.

The complications were reduced and in the case of death, it

was mainly due to their comorbidities and complications,

not to the thrombolytic treatment.

Conclusion: In conclusion, analyzing the thrombolysis cases

from our hospital, we found a mortality rate of 30%, which

was mainly due to the associated comorbidities. Being still at

the beginning of the road, we cannot compare these results

with those existing in the literature.

Thrombolysis role in the treatment of stroke

Mihaela M. Micu, Pleșa Andreea, Florentina C. Pleșa

Introduction: Stroke is one of the leading causes of morbidity

and mortality worldwide. Stroke is the second leading cause

of dementia and a common cause of depression and epilepsy

in the elderly.

Objective: The purpose of this paper is to present a modern

method for the treatment of stroke: thrombolysis. We will

follow the whole procedure, starting with the onset of the

symptoms and taking into account its indications,

contraindications, risks and benefits.

Methods: We considered the National Protocol for

Thrombolysis and emphasized the importance of correct

diagnosis, proper indication and accurate procedure,

everything happening in the therapeutic window.

The FAST method (Face, Arms, Speech, Time) plays an

important role is early identification of a stroke. Clinical sings

such as: facial asymmetry, inability to raise both arms and

speech problems are warning signals and require a fast

presentation at the emergency room.

Time lost means brain tissue lost. Hypoxia causes irreversible

lesions in the center of the ischemic area. In contrast, the

edges contain neurons that can be saved if the blood flow is

restored timely. Consequently, thrombolysis has the highest

success rate in the first hour, known as the "golden hour".

However, therapeutic efficacy can be achieved up to 4.5

hours after the onset of symptomatology.

Conclusion: Finally, we would like to highlight that

thrombolysis is a modern procedure for stroke treatment,

proved to significantly improve patient evolution. Inter-

clinical cooperation and promptness of intervention

contribute to therapeutic success.

Efficient neuromotor recovery of a young patient with tetraparesis after traumatic vertebral meduller by road accident

Gigi Teodoru, Ovidiu C. Chiriac, Ovidiu S. Indrei

We present the case of a patient aged 35 year, patient

immobilized in bed, with spastic tetraparesis after vertebro-

medullary trauma by road accident, following the local

clinical examination neuro-myo-arthro-kinetic functional,

can make the transfers with help, cannot maintain the short

sitting position at the edge of the bed and verticalization no

was initiated.

For three weeks our medical collentive has progressively

initiated verticalization and displacement with the help of a

new generation device Robogait. Robogait are stationary

gait rehabilitation systems. The Robogait is designed to be

used with patients recovering from traumatic brain and

spine injuries, stroke, neurological or orthopedic causes.

This system provides a safe, controlled environment for gait

rehabilitation over a treadmill. The speed of the treadmill is

synchronized with the exoskeleton and the rehabilitation

program.

The RoboGait reduces the number of physiotherapists

required to work with a patient. The wearable robot

increases the quantity of steps that can be achieved during

26

each training session and ensures that they are all

consistent. In these systems, the patient is suspended on the

walking band and positioned perpendicular to the foot and

connected to the robotic. The physiotherapist will decide

after the examinations that the weight of the body will be

reduced by the device and where the device will contribute

to the walk. In the robotic walking system, the patient is

executed according to the natural walking pattern on the

walking band, while the receiver mounted on the patient's

hips and knees evaluates the response of the body to the

computer and reports to the computer which step is the

problem. When the patient goes out of the normal walking

pattern, the robot automatically corrects walking. Repetitive

gait in robotic assisted walking therapy helps regain the

impaired signal flow due to disease or injury between the

cerebrospinal and muscles. Other benefits of this treatment

include strengthening the muscles in bed-dependent and

non-walking patients, providing circulation in the legs,

reducing bone loss and fracture risk due to movement, and

preventing bed sores and vascular occlusions.

After 9 sessions, the patient moves with help, metal frame,

has considerably improved mobility.

Vol. CXXII • Suppl/2019 • October • Romanian Journal of Military Medicine

27

SURGICAL PAPERS

Management of recurrent craniopharyngioma. Case presentation and literature review

O.M. Sîrbu, Alin V. Chirteș, A.M. Sîrbu, Adina Mazilu, Marian Mitrică

Craniopharyngioma, described by Cushing as ‘‘one of the

most baffling problems which confront the neurosurgeon’’,

account for less than 5% of all intracranial tumours. They are

derived from remnants of Rathke's pouch along a line from

the nasopharynx to the diencephalon. Although

histologically benign they may be locally aggressive and their

close proximity to vital structures such as the hypothalamic–

pituitary axis, thalamus and optic apparatus makes them one

of the most challenging pathologies in neurosurgery.

We present an ilustrative case and an updated literature

review of the management options following unsuccessful

initial surgery or recurrence.

Treatment options for recurrent craniopharyngioma include

repeat surgery, radiotherapy or intracystic procedures.

Several small retrospective studies suggest that rates of

obesity and diabetes insipidus related to hypotalamic

injuries may be lower in patients treated with more

conservative surgical approaches. Prospective studies with

long-term follow-up are still needed.

Contemporary radiotherapie techniques (stereotactic

radiotherapy, intensity-modulated radiation therapy, proton

beam therapy) permit greater treatment precision and

conformity but do not eliminate long-term toxicity.

With intracavitary chemotherapy experience is more

limited. Bleomicin and interferon alfa have been reported in

some centers with promising results.

An experienced multidisciplinary team (neurosurgery,

radiotherapie, neuro-oncology, endocrinology,

ophthalmology) is essential for the optimal management of

craniopharingiomas. Future treatment with neoadjuvants

chemotherapy and minimal surgical resection in order to

preserve neurological status may improve the outcomes of

these patients.

Approaches in anterolateral abdominal wall defects

Costin Duțu, Mădălina Vlad, A. Luchian, Ovidiu Albița, Cristian Mușat, Remus Nica, Teodor Rogin, Cristian Cîrlan, Florin Săvulescu

The treatment of anterolateral abdominal parietal defects is,

in most cases, surgical. Surgery can be performed open or

minimally invasively.

The open procedure consists in repairing parietal defect,

followed by the reinforcement of the wall by placing a

consolidation mesh (preaponeurotic / preperitoneal

placement). In the last years, the laparoscopic minimally

invasive procedure e-TEP has been developed, through

which small incisions of maximum 10 mm are practiced and

an intraperitoneal or retromuscular mesh is installed to

prevent recurrence. The study analyzed data from 180

patients with abdominal wall defects whose surgical

treatment was performed, through the different approaches

already mentioned, during one year in the Second

department of general surgery.

The age, weight, BMI, ASA score, defect size and placement,

the size and nature of the mesh used, intraoperative blood

loss, duration of the intervention, duration of

hospitalization, association of diastasis or visceral lesions,

the frequency and type of perioperative complications, the

quality of the postoperative life, the time required for

recovery and social reintegration were analyzed and

compared.

The conclusions of the study revealed the advantages of

minimally invasive procedures (rapid postoperative

recovery, decreased postoperative complications, aesthetic

role, and rapid recovery of social and professional activities.

On the other hand, in case of bulky abdominal eventrations

28

associated with a reduced medical education, the role of

open procedure is important, especially in the emergency

situations and associated lesions.

“Upside-down stomach”: a rare complication of hiatal hernia

Rareș Munteanu, Roni Gherghinoiu, Aurelian Sfetcu, Dumitru Lăcătușu

Hiatal hernia represents the stomach’s protrusion in the

chest through the esophagus diaphragm Hiatal hernia can

be: slip (cardia is in the chest), rolling (esogastric junction

remains in the abdomen) or mixed form. A special form is

hiatal hernia complicated with axial organ gastric (upside-

down stomach). After a review of the specialized literature,

we present the case of a 55-year-old patient who has

emerged urgently in the emergency room for dysphagia,

vomiting, nausea, palpitations. Standard radiological

examinations with contrast substance and computer

tomography revealed giant hiatal hernia mixed form and

gastric volvulus (upside down stomach). After usual

preparing the patient for surgery, the laparoscopic

intervention occurred, the hernia was reduced, the

diaphragm opening was recalibrated (pile suture), after

which an antireflux procedure (Nissen fundoplication) was

performed. The postoperator was subjected to radiological

control with the contrast substance, the patient being exited

7 days postoperatively.

Enucleation of huge symptomatic liver hemangioma

Liviu Mosoia, Florin Macău, Traian Calu, Tanita Stancu

Objective: The cavernous hemangioma is the most common

benign tumor of the liver and become symptomatic as it

reaches a certain size. Giant hepatic hemangiomas greater

than 20 cm in maximum diameter are often reported. Tumor

resection or enucleation is tratment of choice for

symptomatic hemangioma.

Materials & methods: A 41-year-old female presented with

symptomatic huge hemangioma of the liver was treated by

enucleation.

Results: The surgical indication was abdominal pain,

complaints of a 4.5-kg weight loss, fullness in the right upper

quadrant and increased abdominal girth. The tumor size was

24 x 18x 14cm.

Technical aspects were analysed.

The postoperative period was uneventful and the hospital

stay was 5 days. Follow up imaging controls showed no

recurrences.

Conclusion: Abdominal pain and enlargement are major

surgical indications of symptomatic giant hemangiomas.

Most of the symptoms disappear after the surgical

treatment. Enucleation is the best surgical tehnique for

management of symptomatic giant hemangioma.

eTEP in linea alba defects repair surgery

Costin Duțu, Mădălina Vlad, A. Luchian, C. Blăjuț, M. Iordache

eTEP (Extended-View Totally Extraperitoneal) technique was

initially used for minimally invasive approach for inguinal

hernia, but it was also applied for minimally invasive

surgeries for linea alba defects, diastasis and ventral

abdominal wall eventrations. We aim to present the initial

results of patients with linea alba defects, diastasis and

ventral abdominal wall eventrations for whom minimally

invasive treatment was performed using eTEP technique.

A prospective analysis of cases with linea alba defects,

diastasis and ventral abdominal wall eventrations with eTEP

repair, made between October 2018 and May 2019 by two

operating teams, in a single center was made. All patients

were followed postoperatively for 2 months.

Patient history, defects characteristics, technical details of

interventions, perioperative complications and quality of life

outcomes were included in data analysis. The results of the

Vol. CXXII • Suppl/2019 • October • Romanian Journal of Military Medicine

29

case series were analyzed in detail.

The synthetic graft had dimensions between 10x10 cm and

20x30 cm. The mean duration of the intervention was 148

minutes, the intraoperative blood loss was 74.16 ml and the

mean duration of hospitalization was 3.2 days. The

peritoneum was opened in 80% of cases.

Only one case required conversion to laparoscopic surgery -

the IPOM + technique. Postoperative complications were

not significant and the quality of life was clearly improved

after surgery (California Comfort Scale). Mean costs of

intervention were lower in case of eTEP surgery than open

or laparoscopic techniques. There were none readmissions

in the first 30 days after the surgery.

The feasibility and advantages of this technique were

highlighted on initial evaluation: decreased postoperative

pain, low rates of postoperative complications, rapid

recovery of social and professional activities and reduced

mean costs than IPOM+ laparoscopic technique (due to the

abandonment of using Dual Mesh graft) and open technique

(due to decrease hospitalization duration). We intend to

further analyze these data on a larger number of cases.

Glioblastoma multiforme (grade IV)

Cristian Năstase, Cristian Popescu

Introduction: The most malignant astrocytoma and the most

common primary brain tumor. Histopathologycal pattern:

areas of necrosis, neovscularisation with endothelial

proliferation, gemistocytic astrocytes etc

Material and methods: We would like to present you our

experience in treatment of this kindes of tumors. We

operate more 1oo patients with GBM in our service and

some of them survive more 3 years with adjuvant treatment

(radiotherapy, chimiotherapy, etc).

Prognostic: Survival is highly dependent on condition at the

time of surgery

Results: Anaplazic astrocitoma & GBM has severe prognosis;

Neuroimaging: MRI – main tool; Mass effect: emergency

intervention; Radiotherapy & chemotherapy: limited effect.

Breast cancer: where are we and what can we do

Remus I. Nica, Cristian J. Mușat, Doriana Vintilescu, Florina Vasilescu

Introduction. In Romania breast cancer accounts for 25% of

all cancer cases and it is responsible for 1.56% of the total

number of deaths. The genetic factors known to be involved

in breast cancer risk comprise several high or moderate -

penetrance genes and a high number of low-penetrance

genes.

Aim. In this study we would like to present some

representative cases of breast cancer that were

encountered in our clinic and results regarding the

interactions between low penetrance risk factors in the

sporadic forms of invasive ductal carcinoma.

Materials and methods. Approximately 70% of investigated

subjects had invasive ductal carcinoma. Women with

invasive ductal carcinoma (n=125) and clinically healthy

subjects without history of malignant disease (n=150) were

selected for a case-control study. Mutations in six low-

penetrance genes were determined for each sample.

Multifactor Dimensionality Reduction analysis was used to

investigate the epistatic relationships between the tested

variables.

Results. The birth of the first child after age 30 (p <0.01) was

the main non-genetic risk factor associated with breast

cancer. The simultaneous presence of TGFb -509T and IL6 -

174C (p <0.01) was a risk factor for invasive ductal carcinoma

in the studied group.

Conclusions. The interaction between different categories of

risk factors can increase the risk for sporadic forms of breast

cancer. The birth of the first child after the age of 30 is a

significant risk factor for the disease.

30

Combined dermato-surgical techniques in treating rhinophyma

Viorel Trifu, Monica Dărmănescu, Marcela Poenaru, Mihai Țilea, Răzvan Șerban

Rhinophyma is a slow evolving pathology that affects the

nose (rhis' - nose; phyma - grows) and it represents the final

stage of rosacea. It is characterized by a cauliflower-shaped,

bulbous, thickened skin, erythematous, edematous,

enlarged sebaceous glands accompenied by sebum plugs.

It mainly affects men starting at the age of 45 and can also

affect other regions such as chin (gnatophyma), ears

(otophyma), eyelids (blepharophyma) and forehead

(metophyma)

Non-surgical treatment of rhinophyma consists of a

prophylactic approach aimed at patients with rosacea but

there are various systemic and topical treatments which can

be used to lower the volume in the early stages of

rhynophyma.

Surgical approach represents the gold-standard in treating

Rhinophyma by using combined techniques in order to

obtain a favorable result. Among the methods used we

mention dermaplaning, dermabrasion, electrotherapy, CO2

Laser, Nd: YAG, Er: YAG, cryosurgery.

The cases selected in this presentation are of patients with

rhinophyma of different severity grades who have been

treated in the Dermatology Clinic.

Rhinophyma is a condition that affects the quality of life,

especially regarding its social impact, as patients often

report social isolation, especially because of their physical

appearance, which can be corrected by proper

dermatological and surgical treatment.

Remnant cystic duct: cause of post cholecystectomy syndrome

Ovidiu Albița, Teodor Rogin, R. Marin

Remnant duct pathology represents a rare evolution of the

disease after cholecystectomy, caused by anatomo-clinical

details at primary surgery, open or laparoscopically. Usually

symptoms are discordant to imagistic exploration. However

only a new operation, although technically demanding,

provides very good results.

Foreign body in the hypopharynx: surgical approach

Claudiu Nistor, Daniel Pantile, Adrian Ciuche

Introduction: While pharyngeal foreign bodies are a

common complaint in children, for adults this is a relatively

rare condition, which can be resolved endoscopically in a

majority of cases.

Material and method: We present the case of a young

patient with complete dysphagia, sialorrhea, odynophagia,

and a sensation of foreign body. The symptomatology

appears after ingesting a foreign body on an otherwise

normal esophagus.

Paraclinical investigations (cervico-thoracic X-Ray, cervical

and thoracic CT scan) highlight some foreign body in the

hypopharynx. Superior endoscopy and laryngoscopy do not

visualize the foreign body, only some erythema on the

hipopharinx.

Endoscopic extraction of the foreign body has been tried,

with no results. Considering this situation, the surgical

approach has been decided, through a slightly atypical

approach – right side approach, the foreign body being on

the right side of the esophagus.

Results: Intraoperative, the foreign body is identified in the

right esophageal wall, puncturing the esophageal mucosa.

With favorable postoperative outcome, the patient showed

no signs of mediastinitis or esophageal fistula.

Discussion: For most cases of foreign bodies stuck in the

hypopharynx, superior endoscopy is 80-100% efficient in

extracting the foreign body. In the presented case, nor the

endoscopy or laryngoscopy succeeded extracting it. The

surgical intervention was the final, salvatory, solution.

Conclusions: Endoscopic treatment remains the mainstay

treatment for most ingested foreign bodies. This patient

required surgical intervention because of the impossibility to

visualize the foreign body through an endoscopic procedure.

Vol. CXXII • Suppl/2019 • October • Romanian Journal of Military Medicine

31

A rare case: vulvar extra-mammary Paget’s disease

Alexandra T. Pasăre, Răzvan G. Curcă, Remus C. Stoica, Ștefănel C. Vlad

Introduction. Paget's disease of the vulva is a rare vulvar

neoplasm most commonly seen in Caucasian

postmenopausal women. Probably because of its

multicentric nature, Paget's disease has a chronic and

relapsing course. Surgery is the treatment of choice, but the

disease can extend from the visible lesion and the surgical

margins are frequently positive.

Materials and methods. This is the rare case of a 50 year old

patient, known with vulvar Paget’s disease since 2010. She

underwent large wide excision of the left labia, with clear

surgical margins and a good postoperative evolution. After

nine years, the disease relapsed and the proposed treatment

was left hemivulvectomy, followed by adjuvant external

beam radiotherapy.

Results and discussions. The standard of treatment for vulvar

Paget’s disease has been surgery with the control of the

surgical margins, but given the fact that the positive margins

and recurrence rates are greater than 50%, combined

treatments have been proposed. Radiotherapy can be used

as a curative treatment or in an adjuvant setting to prevent

local recurrence. After the combined treatment, the follow

up showed minimal adverse effects after radiotherapy, with

good local control of the disease.

Giant left ovarian fibroma: Demons-Meigs Syndrome in a 69-year-old female patient

Ioana A. Negoiță, Nicolae Niculescu, Bogdan Panaite, Florin Năftănăilă-Mali, Ioana Niculescu, Ovidiu V. Nicodin

Goals: Among the different types of ovarian tumours,

ovarian fibromas are mostly silent tumours, without clinical

impact (especially when they are small in size), being non-

functional tumours. There are cases that can show sterility,

compression disorders, dysmenorrhea, secondary

amenorrhea, and in cases of solid ovarian tumours, they may

associate Demon-Meigs Syndrome. The diagnostic

orientation is based on clinico-biological, imaging and

anatomo-pathological elements. Demons-Meigs Syndrome,

first described in 1937 by Professor Joe V. Meigs, is defined

as an association of a benign ovarian tumor (ovarian fibroma

or thecoma) complicated by hydrothorax (most commonly

on the right side) and ascites in large quantities. Surgical

removal of ovarian formation leads to disappearance of

ascites and hydrothorax.

Summary: The authors present the case of a 69-year-old

female patient, with multiple pathology (cardiac, pulmonary,

diabetes mellitus, gastroduodenal), who came to the ED of

the SUUMC for general condition worsened in the last days,

showing severe dyspnea, increased volume of the abdomen,

epigastralgia. It will be presented the manner of approaching

this case, from hospitalization and its evolution.

To be retained: 1. Meigs Syndrome is a challenge in

establishing differential and certainty diagnosis. 2. The

therapy of choice remains surgical resection, either

ovariectomy/adnexectomy/tumorectomy or, at

postmenopausal ages, total hysterectomy with bilateral

adnexectomy. 3. The ascites and the hydrothorax remit after

surgical treatment. 4. The prognosis in Demons-Meigs

Syndrome is a very good one.

Liver resection for huge hepatocellular carcinoma in non-cirrhotic liver

Liviu Mosoia, Florin Macău, Traian Calu, Tanita Stancu, Marian Vasile

Objective: HCC in non-cirrhotic liver has low prevalence and

tumor size may be large at an advanced stage as surveillance

is not performed in a non cirrhotic liver. Tumor resection is

the only curative treatment if resecability criteria are

achieved.

Materials & Methods: Three patients with huge HCC (18, 20

and 23 cm) underwent liver resection in our department. In

one patient, due to the insufficient future liver remnant, we

performed right portal vein ligation (PVL) in the first

instance, to convert the unresectable tumor to resectable

for potential cure. Technical aspects were analysed.

Results: One patient underwent right hepatectomy after 7

weeks after PVL; the others underwent right hepatectomy

resection. In the patient with the biggest tumor (23/20 cm)

32

we used anterior approach and the hanging manoeuvre due

to the huge volume of the tumor. The postoperative period

was uneventful and the hospital stay were 7 to 9 days.

Histopathology revealed in one patient a mixed off HCC with

cholangiocarcinoma and all the patients are alive, disease

free currently.

Conclusion: Surgical resection for huge HCC in non cirrhotic

liver is possible even in elderly patients or even if initially, the

future liver remnant does not allowed surgical therapy.

Minimally invasive approach for anterior flail chest

Claudiu Nistor, Dragoș Marin, Aurora Fera, Daniel Pantile, Adrian Ciuche

Introduction: Anterior flail chest is a life-threatening medical

condition that occurs when a segment of the rib cage breaks

due to trauma and becomes detached from the rest of the

chest wall. Over time several stabilizing methods have been

imagined.

Material and method: We present a method of stabilization

for anterior flail chest using the minimally invasive repair

procedure for pectus excavatum – Nuss procedure.

This procedure consists of a concave stainless-steel bar

slipped under the sternum fixed by a stabilizer fitted around

the bar and into the ribcage.

Preoperative CT scan with 3D bone reconstruction helps the

surgeon decide the best position for the stainless-steel bar.

The surgical intervention is performed under thoracoscopic

control.

Results: The results were very good in both patients. The

patients were extubated immediate postoperative, followed

by respiratory recovery.

Discussion: Although our experience is limited to just two

cases, postoperative results were encouraging in both cases.

Each time patients were extubated immediately

postoperative, and the paradoxical movement of the rib

cage disappeared. The stainless-steel bar was removed 2-4

months after surgery, with a good quality chest wall

stabilization.

Conclusions: The results obtained using this method of chest

wall stabilization were encouraging. Patients’ recovery is

quick and of good quality. By being a minimally invasive

procedure, esthetic results are far superior, and patients’

mobilization can begin early.

Functional and reconstructive otologic surgery in private medical centers

Vasile Ciuchi, Oana I. Popa

Purpose: Otologic surgery without hospitalization or

involving one day hospitalization applied in external and

middle ear pathology, except oncologic disease, represent a

new approach in the practice of E.N.T. speciality.This new

approach in functional and reconstructive otologic surgery

became widespread due to the occurrence of private

medical centers which offers possibilities of investigation

and modern treatment.

Methods: The authors present the experience of 12 years

and 8 months of activity in two private medical centers,

where they performed numerous surgical interventions of

external and middle ear. They present the most commonly

addressed diseases as well as surgical techniques and some

useful conclusions for otologic surgeons in training.

Imagery in diagnosis of anterior segment pathology

Mihail Zemba, Ovidiu Mușat, Cornel Ștefan

Purpose: to show the usefulness of imagery

Methods: some clinical cases are presented, insisting on how

imagery was essential in establishing the diagnosis or the

therapeutic attitude

Results: lack of imagery would have done establishing of a

proper diagnosis much more difficult

Conclusions: though clinical examination is simple, some

particular cases with anterior segment pathology need

additional investigations, every methods with its indications

and limits

Vol. CXXII • Suppl/2019 • October • Romanian Journal of Military Medicine

33

Therapeutical approach for right pulmonary artery aneurysm: case presentation

Claudiu Nistor, Olivia Batog, Daniel Pantile, Adrian Ciuche

Introduction: Aneurysms of the pulmonary artery are rare

and often underdiagnosed. Pulmonary artery aneurysms

generally occur in a younger age group than aortic

aneurysms with an equal sex incidence, affecting main

branches of the pulmonary artery.

Material and method: The authors present a case of a

patient admitted with small efforts dyspnea for a round, well

defined lung tumor, located in the right lower lobe.

Paraclinical investigations are described and the surgical

intervention has been recommended in order to remove the

tumor.

Intraoperative, the surgical team has identified the tumor as

a pulmonary artery aneurysm and an arterio-arterial shunt

between the systemic and pulmonary circulation. Right

lower lobectomy has been performed with the removal of

the aneurysm.

Massive hemorrhage was imminent until the aneurysm has

been removed.

Results: The postoperative outcome was favorable, with the

remission of dyspnea.

Discussion: Despite modern diagnostic methods, there is no

clear guideline for the best therapeutic approach, and there

is limited experience because of the infrequency of the

disease. Overall, idiopathic pulmonary artery aneurysm

seems to be a relatively benign condition, and clinical

manifestations are dominated by refractory dyspnea.

Conclusions: Pulmonary artery aneurysms seldom occur, are

rarely diagnosed, and do not present with distinct

symptoms. Although there are no clear guidelines on the

optimal treatment for patients with pulmonary artery

aneurysms because of the small number of cases, surgical

treatment remains an important approach, especially in

symptomatic patients.

Thoracic oulet syndrome: case presentation

Daniel Pantile, Adrian Iordache, Claudiu Nistor

Introduction: The cervical rib represents the elongated

costal element of the seventh cervical vertebra. It’s an

important cause of thoracic outlet syndrome. Bilateral

cervical ribs are very rare, with an incidence of less than 1%.

We chose to present this case to highlight the possibility of

bilateral cervical ribs as a cause for thoracic outlet syndrome.

Material and method: We present the case of a 32-year-old

patient, referred to our department with pain in right

shoulder and arm, debuted a year prior to her presentation.

The cervical X-Ray revealed bilateral cervical ribs; on the

right side the rib being fixed to the first rib. Doppler

ultrasound shows bilateral subclavian shunt, more

important on the right side. MRI imaging showed right

brachial plexus compression.

The surgical intervention was performed under general

anesthesia, through an anterior cervical approach.

Intraoperative findings: cervical rib, fixed to the first thoracic

rib; the cervical rib has been completely removed.

Results: Postoperative outcome was satisfactory, the patient

began recovery the third postoperative day. Patient’s

symptomatology has decreased gradually, and 5 months

postoperative the patient’s sole complain was a mild right

arm paresthesia. Doppler ultrasound performed

postoperative shows great improvement in subclavian artery

blood flow.

Discussion: Although a congenital condition, the cervical rib

becomes symptomatic at the age of 20-25 years old. The

cervical rib is more frequent in women, on the left side; the

right cervical rib is more often symptomatic – especially in

right-handed people. After the resection of the cervical rib,

the symptomatology gradually decreases.

Conclusions: While a rare condition, bilateral cervical ribs

must be considered in differential diagnosis of upper

member neurological pain. Sometimes a cervical rib can

mimic cervical radiculopathy and myelopathy.

High index of suspicion and detailed clinical evaluation is

needed to prevent inappropriate cervical spine surgery!

34

Proliferative diabetic retinopathy: surgical treatment

Ovidiu Mușat, Cornel Ștefan, Mihail Zemba, Monica Armegioiu, Liliana Pulbere, Horațiu Manole, Laura Macovei, Cătălin Cornăcel

This paper presents the case of a patient with neglected type

I Diabetus Mellitus and Proliferative Diabetic Retinopathy.

Posterior vitrectomy was practiced with peeling of

membranes and silicone oil endotamponade. Postoperative

evolution was favorable.

We will also discuss several treatment options for this type

of cases.

Corneo-conjunctival tumor: diagnostic and therapeutic challenges

Mihail Zemba, Ovidiu Mușat, Cornel Ștefan, Alexandra Calu

Purpose: to show the diagnosis, preoperator assessment and

surgical treatment for a corneoconjunctival tumor

Methods: there is a review of clinical and paraclinical

arguments for the diagnosis; surgical solution is shown in a

video film

Results: two months postoperatively there is good functional

recovery; 4 months postoperatively there is no sign of

relapse of the tumor

Conclusions: the main treatment for corneoconjunctival

tumor is surgical; in very large tumors the surgeon must be

able to cover the area of conjunctival excision and use

solutions to prevent relapse.

Malignant insulinoma: Therapeutical approach

Tanita Stancu, Augustin Dima, Cezar Bețianu, Florina Vasilescu, Aurelian Ranetti

Introduction: Malignant insulinoma is very rare (1-

4/100,000) and the most common pancreatic

neuroendocrine tumor. Originated from B-pancreatic cells

which synthesize and secrete insulin. Diagnostic is based on

clinical symptoms and signs (Whipple triad) and it is

confirmed by CT Scan/RMI.

DESCRIPTION: We will report the case of a young man 44 y.o.

BMI: 27 kg/m2, diagnosed by classical signs and symptoms,

confirmed by CT Scan, with a large tumor in the body of the

pancreas, with metastatic lymph nodes, without any distant

metastasis. The patient underwent minimally invasive

surgical treatment (laparoscopic distal spleno-

pancreatectomy with extensive lymph node dissection)

The postoperative course was uneventful and the patients

was discharged in the the tenth postoperative day. The

anatomopathological report confirmed the malignant

insulinoma with multiple lymph nodes metastasis and R0

resection.

Conclusion: The surgical treatment is the only curative

treatment with a good survival rate at 5-10 years. Minimal

invasive approach is recommended and feasible in

specialized centers in pancreatic surgery.

Laparoscopic hepatic left lateral sectionectomy: How I do it

Augustin Dima, Tanita Stancu, Șerban Spiratos, Cezar Bețianu

We present a video case of a 72 y.o. man admitted to our

surgical unit for left hepatic lobe hepatoceular carcinoma.

Patient has HCV cirrhosis Child-Pugh A diagnosed in 2010 for

which he was treated with Viekirax, Exviera and Rivabirin

between Oct. 2016 - Jan. 2017. AFP is not elevated. Hepatic

ultrasound with enhanced contrast and CT scan strongly

suggests an HCC located on the lateral section of the left

liver. No previous abdominal surgery. According to our

multidisciplinary team is proposed laparoscopic left

lobectomy. Pringle maneuver was not performed, blood

transfusion was not required. Postoperative course was

uneventful. In our experience, minimally invasive resection

Vol. CXXII • Suppl/2019 • October • Romanian Journal of Military Medicine

35

in cirrhotic liver should be performed in selective patients

and by an experienced team in hepatic surgery.

Radical antegrade modular pancreatosplenectomy for borderline resectable pancreatic cancer

Augustin Dima, Tanita Stancu, Cezar Bețianu, Delia Mateescu

Introduction: Radical antegrade modular pancreato-

splenectomy (RAMPS) was first reported by Strasberg in

2003 and since then has attracted increasing attention in the

treatment on left sided pancreatic cancer. There is not

enough data in literature to sustain the efficacy of RAMPS vs.

standard approach.

Discussion: We report a 72 y.o man BMI: 24kg/m2,

diagnosed with border-line resectable left side pancreatic

adenocarcinoma who underwent before surgery 6 courses

of neoadjuvant chemotherapy based on FOLFIRINOX

regimen, with decreased tolerance. We performed RAMPS

with en block mezenteric-portal vein confluence resection

and venous reconstruction by interposition of left renal vein

graft. The postoperative course was uneventful. The

anatomopathological report concluded the R0 resection

without any lymph node metastasis.

Conclusion: The patient was able to resume postoperative

chemotherapy with the same regimen at two months after

surgery. The RAMPS procedure for the treatment of border-

line resectable left sided pancreatic cancer can achieve high

rates of R0 resection and is the best option to choose when

vascular resection is required.

Locally advanced/border-line resectable pancreatic cancer: A challenge for the surgeon

Augustin Dima, Tanita Stancu, Șerban Spiratos, Cezar Bețianu, Theodor Voiosu

Introduction: Pancreatic cancer is the fourth leading cause of

cancer death in the world. Median survival for patients

treated by surgical resection is 15-23 months, with a five

year survival <20%. Even though over the past decade

improvements in diagnostic, imaging and treatment, the

overall survival rate remains poor.

Discussion: In both border-line and locally advanced

pancreatic cancer, the tumor is localized to the pancreas but

adheres to or invades adjacent vascular structures, including

the celiac axis vessels, superior mesenteric artery, superior

mesenteric vein, and portal vein. Patients with border-line

and locally advanced pancreatic cancer represent a special

subset of patients who are not candidates for primary

surgical resection and there is now emerging consensus that

a subgroup of patients’ poor candidates for surgery may

become eligible for resection after neoadjuvant

chemotherapy.

Conclusion: Current studies suggest that 25-30% of initially

border-line respectable pancreatic cancer may become

candidates for resection following neoadjuvant

chemotherapy. Lack of consensus definition and the paucity

of randomized trials in therapeutic algorithms have delayed

the progress of proposing good practice guidelines for

diagnosis and treatment.

Reconstruction of the forehead and temporal area

Viorel Trifu, Monica Dărmănescu, Țilea Mihai, Marcela Poenaru, Răzvan Șerban

Surgical approach of the forehead and temporal area poses

several unique challenges for the dermatologic surgeon. A

thorough understanding of the anatomic structures of the

forehead and temporal area is paramount to optimal surgical

result.

A case series of regional reconstruction of forehead and

temporal area is presented, with a variety of reconstructive

techniques. The anatomy of the region is reviewed; it is

important to preserve the function of motor and sensory

nerves, although aesthetic concerns are of great importance

in forehead and temple reconstruction. For optimal

operative results, flaps must be properly sized in all

dimensions, including thickness. In forehead and temporal

reconstruction with skin flaps, the surgeon should anticipate

36

secondary motion accurately, as not distorting anatomic free

margin. Respecting the normal position of facial landmarks

such as the eyebrows and hairline can be challenging during

reconstruction.

The goals of reconstruction include hiding incisions in natural

rhytids, maintaining natural hairlines and eyebrows and

preserving motor and sensory function.

The reliability of the radial forearm free flap for intraoral reconstruction

Dragoș Muraru, Iulia Muraru, Ioana Tuhar, Ionuț Guzganu, Paul Ionescu, Liliana Moraru, Adrian Gabără, Ana Căruntu, Bogdan M. Marinescu

Introduction: Head and neck defects after tumor resection

can be difficult to reconstruct using autogenous tissue

without utilizing a free flap. The radial forearm free flap is

one of the workhorse flaps used for reconstruction of

intraoral defects after resections due to malignancy.

Objective: The aim of this paper is to emphasize the

reliability of the radial forearm free flap, by presenting our

clinical experience and results.

Methods: Three patients with intraoral carcinoma have been

reviewed, one with floor of the mouth and buccal mucosa

defect and two with hemiglossectomies. They underwent

immediate reconstruction using fascio-cutaneous free flaps

from the radial forearm. In all cases we used one of the radial

comitant veins for the venous T-T anastomosis with the

facial vein.

Results: There weren’t any microvascular failures, the

intraoral healing time was reduced to 10 days on average

and hospitalization was less than two weeks. Two donor

sites with width less than 4cm underwent direct closure and

one was grafted with an autograft harvested from the

ipsilateral thigh. The donor site healed uneventfully in all

patients.

Conclusion: The radial forearm free flap is a very effective

method for reconstruction after resection of intraoral

malignancies.

Postmastectomy breast reconstruction with autologous tissue in previously irradiated patients

Bogdan M. Marinescu, Ioana Tuhar, Ionuț Guzganu, Paul Ionescu, Dragoș Muraru

Introduction: Breast cancer represents the most common

cause of cancer death among women worldwide.

Mastectomy is an important tool in breast cancer therapy, in

order to prevent any possibility of disease recurrence. After

mastectomy, we can rebuild the shape and the volume of the

breast, by using various techniques of breast reconstruction,

including implants, skin expanders, reconstruction with

autologous tissue (flaps), combination of implants and flaps.

The reconstructive procedure can be made at the same time

as the mastectomy or later on.

Material and method: In these paper, we will present our

experience by using latissimus dorsi and transverse rectus

abdominis myocutaneous flaps in breast reconstruction. In

the last 2 years, 15 patients underwent breast

reconstruction with 10 LD flaps – 8 unilateral and 1 bilateral,

7 TRAM flaps – 5 unilateral and 1 bilateral. In mastectomy

patients reconstructed with LD flap, we use implants

underneath the muscle flaps, in order to obtain adequate

volume for the reconstructed breast. All the patients

received adjuvant radio-therapy before reconstruction. We

perform in all patients delayed breast reconstruction. Donor

sites were closed primarily.

Results: In our case series all flaps survived. There was just

one case of partial flap loss (TRAM flap group). The

reconstructed breasts have a natural shape, volume and

contour. Donor sites morbidity were acceptable with no

significant functional loss. There are no major complications

and the patient satisfaction was high.

Conclusions: A large variety of techniques are now available

for breast reconstruction. Among the possibilities for breast

reconstruction, the transfer of autologous tissue from

adjacent regions to the breast, keeping up the original blood

supply is a good option for previously irradiated patients.

Vol. CXXII • Suppl/2019 • October • Romanian Journal of Military Medicine

37

Cataract following penetrating keratoplasty

Mihail Zemba, Ovidiu Mușat, Cornel Ștefan

Purpose: to discuss about ethiology and specific issues of

surgical technique in a case of cataract after keratoplasty

Methods: evolution and surgical solutions for management

of the case, starting with deep corneal ulcer

Results: after four surgeries, visual acuity is 0.5

Conclusions: multiple surgeries may be necessary for a good

visual result

Corneal transplantation: permanent challenge for ophthalmologist surgeon

Mihail Zemba, Ovidiu Mușat, Cornel Ștefan

Corneal transplantation is a complex and multi-step surgical

procedure, it is a permanent challenge for ophthalmologist

surgeon. Most often the procedure is done for optical

purposes. Corneal transplantation is constantly undergoing

changes in surgical technique. In Romania corneal

transplantation has a long history and in 1983 the first

corneal transplant was performed in a child of one and a half

years old. We will present this clinical case after 35 years.

The monitoring and treatment center of the glaucoma: the computerized program

Ovidiu Mușat, Cornel Ștefan, Mihail Zemba, Horațiu Manole, Liliana Pulbere, Laura Macovei, Monica Armegioiu, Cătălin Cornăcel, Elena Gosav, Nicolae Alexe, Cristina Timaru

The monitoring and treatment center of the glaucoma in

Central Universitary Emergency Military Hospital is a

necessity because Glaucoma is increasing in number of

cases, early onset glaucoma (when the disorder appears

before the age of 40) and the methods of diagnosis and

treatment are constantly upgraded.

The computerized program is useful for building the

database, interconnecting diagnostic terminals including

imaging with end-scopes - determining the algorithm of

treatment.

In the modern era of AAA treatment is still open surgery the gold standard

Ionel Droc, Mihai Dumitrașcu, Cosmin Buzilă, Tudor Păduraru

Endovascular repair has emerged as an alternative to open

repair for patients with abdominal aortic aneurysm.

Although the method’s safety and efficacy have been

established, challenging anatomy and especially inadequate

landing zones create limitations to its application. Stent

grafts, fenestrated and branched, were developed to

overpass these anatomic restrictions. Contrast-enhanced

Ultrasound (CEUS) is investigated as a novel, noninvasive

technique that can be employed to characterize endoleak

type and consequently prescribe appropriate treatment in

the follow up of this procedures.

Open repair is a safe and durable procedure. But it has some

long term complications as graft thrombosis, infection or

paraanastomotic aneurysms. Aorto enteric fistula is a rare

but difficult to treat complication. Also open surgery is used

for graft explantation for graft failure or infection. The

overall mortality for open procedures is about 4.5%.

In conclusion, open surgery for AAA remains the gold

standard in young and low risk surgical patiets. Endovascular

procedures are of first choice in all high risk patients, even in

emergency situations.

38

The endovascular treatment of thoracic aortic aneurysm – case presentation

Ionel Droc, Daniel Nita, Elena Dumitru, Ioana Vlad, Liviu Stan

Thoracic Aortic Aneurysms are serious conditions with risks

for potentially lethal complications. The decision regarding

the treatment options for a TAA is made according to the age

of the patient, the risk assessment, and the vessel anatomy.

Nowadays, in Romania, TAAs are mostly treated with open

surgery – clamping, removing the affected aortic segment,

and replacing it with a graft. Endovascular treatment of TAAs

is an infrequent treatment solution in our country, but with

increasing average. We have had few patients treated with

TEVAR in our clinic.

We present the case of a TAA treated in our clinic with

thoracic endovascular aortic repair (TEVAR). 45-year-old

male patient admitted to our hospital with post-traumatic

thoracic aortic aneurysm underwent endovascular stent

grafting with prior carotid-subclavian by-pass and proximal

ligation of the subclavian. Following the procedures the

patient’s outcome was uncomplicated. CT scan 6 months

after discharge shows a reduction in both the internal and

external diameters of the thoracic aortic aneurysm.

Thoracic endovascular aortic repair (even when covering the

origin of the left subclavian artery) is an effective and safe

treatment option for patients in Romania.As the current

international recommendations, in patients for whom

TEVAR is accompanied by the debranching of the LSA, we

suggest mandatory surgical revascularizarization of LSA.This

operation should be performed prior to the endovascular

procedure in order to prevent the ischemic or neurologic

complications associated with LSA occlusion. The long-term

prognosis of such cases is not known and remains to be

determined in the future.

Surgery for intramiocardial wall foreign body (bullet) – case presentation

Ionel Droc, Dragos Trandafir, Alin Toader, Vasile Murgu

We present a very rare case of a 37 year old male patient

diagnosed with an intramiocardial wall fordeign body

(bullet) – resting in the diaphragmatic wall of the right

ventricle. It was operated with success three months after

the accident. The patient was shot parasternally, in the left

third intercostal space, with a high-velocity military AK 47

projectile. The shot was indirect – the bullet hit the patient

after two rebounds on the metallic struts of the car he was

driving. Shortly thereafter, the patient was examined in a

hospital. A diagnosis of antero-inferior mediastinal foreign

body (bullet) was established then.We examined the patient

3 months after the acccident. The plain X-Ray confirmed the

diagnosis. We performed a thoracic CT scan which showed

that the bullet was „most probably located above the

diaphragm, in the lower anterior mediastinum, 1.5 cm

behind the sternum”. We also performed a fluoroscopy,

which showed that the bullet was moving synchronously

with the heart and, therefore, we asked for a cardiac

echography in order to rule out a cardiac/pericardial location

of the bullet. The trans-thoracic cardiac echography did not

establish the presence of the bullet in the myocardiun or

pericardium, nor has it shown indirect signs of cardiac or

pericardial wounds. We therefore performed a subxyfoidian

approach. We examined the anterior mediastinum but we

failed to find the bullet, although we palpated a structure

feeling very much like the bullet. We then opened the

pericardium as in a pericardial window and we found the

bullet embedded in the lower aspect of the right ventricular

wall.The patient was operated under extracorporeal

circulation and the bullet was extracted from the right

venticle.The resting orifice was closed with separete sutures

on daflon patches using also reinforcement of the tissue with

bioglue.The postoperateve evolution was simple.No

infection or bleeding were noted. In conclusion the

intramural ventricular foreign bodies (extremely rare non

fatal) can be safely treated surgically under extracorporeal

circulation.

Vol. CXXII • Suppl/2019 • October • Romanian Journal of Military Medicine

39

NURSES PAPERS

The hydro-electrolyte balance and the acid base balance: interpretation of the ASTRUP

Mariana Ene, Nicoleta Tudora

The water balance: the role in bio-chemical processes,

electrolyte and acid base balances, transmission of nerve

impulse, transmission of genetic information, etc.

Electrolytic balance: it strictly refers to the balance of salts

of the blood plasma. Acid base balance: human organism, for

a proper function, must maintain the balance between

acidity and alkalinity of its fluids. The utility of the blood test:

the evaluation and assesing the severity of patient’s

condition. The technique of collection of blood. The

interpretation and recognition of the main imbalances

Scintigraphy: preparation of the patient and the fear of radiation

Maria A. Gherman, Eugenia Rusu, Constanța Bandulea, Mariana Ciaușescu

In order to achieve the best scintigraphic images it is very

important to know how to prepare the patient for

investigation. With the large variety of organs that can be

seen with this investigation, the preparation differs in

function of the organ that is desired to be seen, in function

of the kinetics inside the cell of the specific organ, the

medication that the patient is taking and the quality of the

image that is being taken (eliminating artifacts). Since

Chernobyl and Fukushima, the word radiation brings up the

idea that something bad is happening or that we shouldn’t

get in touch with it. But, in the case of nuclear medicine, the

word radiation means the improvement in detecting cancers

and other malfunctions of the organs. Taken into

consideration that there are some dose limits, that the

patients are advised what to do after a nuclear medicine

procedure in order to minimize the population exposure and

that the scintigraphic investigation is being taken under the

ALARA principle there should not be any fear of radiation.

Medullar transplant

Adriana A. Andrei, Florența M. Nicolescu; Mihai A. Șotcan

The transplant of hematopoietic stem cells implies

reconstructing the haematopoiesis by transferring stem cells

(from a donor or from the patient). Unlike the transfusion of

blood components (where the effects are temporary due to

limited viability of the transfused cells), transplanting

progenitor strain cells causes a long-term effect through its

capacity to proliferate in the medulla. The source of hsc may

be the hematopoietic bone marrow, the peripheral blood or

the umbilical cord. The donor may be a healthy person

(allotransplant) or the patient himself/herself (auto-

transplant). Currently the HSC transplantation is widely used

in a variety of hematologic and non-hematologic

impairments. Yet the procedure is not harmless, entailing

high morbidity and mortality due to its complications.

Therefore the indication of transplant shall be discussed for

each particular case and a decision shall be made only after

considering the risk and benefit for each particular case.

Malign diseases: acute lymphoblastic leukaemia, acute

myeloblastic leukaemia, chronic granulocytic leukaemia,

Hodgkin’s disease, multiple myeloma, solid tumours –

breast, ovary, lung (auto-transplant only). Non-malign

diseases: congenital and acquired aplastic anaemia,

autoimmune diseases and hemoglobinopathies.

Purpose: Suppressing the patient’s immune system,

suppressing the bone marrow and destroying the tumour

cells. The treatment consists in post-transplant radiotherapy

and chemotherapy.

40

Impact of nurses involvement in fundraising and social activities: RxRun, we are running for our patients

Ani Ivan, Andrei Toma, Norocel Bocănială, Ștefănel C. Vlad

The impact that a trained nurse or RTT can have on their

community in Romania is huge. It is so much more than just

a job in the hospital. The work they do, caring for their

patients will have an immeasurably large reach and change

the lives of countless vulnerable people, such as patients

with cancer in advanced stages. People decide to run long

distances for all sorts of reasons. Some do it for exercise and

health benefits, because they love running. We do it for our

patients, we put our passion for a cause: to help patients

with incurable disease to have good quality palliative care in

Hospice Casa Sperantei. We started the fundraising activities

in patient's benefit in 2016, as RxRun, a team of runners, one

doctor and three nurses working in the Radiotherapy

Department of the Central University Emergency Military

Hospital “Dr. Carol Davila”, Bucharest. Another two young

radiotherapy doctors joined the team in 2018 and 2019. We

have participated in numerous races, crossing distances

from few kilometers to marathon and half-marathon. With

the help of friends who have sustained our cause we succeed

in fundraising important amounts, representing palliative

care services for many hospice-treated cancer patients from

Hospice Casa Sperantei. It is important for any nurse

involved in oncological field to be part of social activities, to

highlight the difficulties faced by many patients with cancer

to receive good quality care and to deal with their disease.

Renal lithyasis patient care

Manuela Flămânzeanu

Kidney stones are small, hard deposits that form in one or

both kidneys. The stones are made up of minerals or other

compounds found in urine. Kidney stones vary in size, shape

and color. To be cleared from the body or ’’passed ‘’, the

stones need to travel through ducts that carry urine from the

kidneys to the bladder (ureters) and be excreted. Depending

of their size, kidney stones generally take days to weeks to

pass out of the body and can cause severe pain. Kidney

stones can cause abdominal or back pain (renal colic). This

pain usually begins sporadically but then becomes constant

and can lead to nausea and vomiting. The nurse administers

painkillers, anti-inflammatory and anti-vomiting drugs at the

doctor’s advice and she write everything in the care plan.

They can be extremely painful and can lead to kidney

infections or the kidney not working properly if left

untreated.

Nurse’s role in taking care for the patient with pleural effusion

Marcela Brighiu, Ionela Paraschiv

A pleural effusion is defined by the accumulation of a fluid

inside the pleural cavity, with or without the inflammation

of the pleura. A pleural effusion usually accompanies other

local or systemic affections. The presence of pleural fluid

inside the pleural cavity has a major impact on the

respiratory and circulatory function.

The authors present several measures needed to be taken

by the nursing personnel for patients with pneumothorax.

Some nursing care plans are described and explained in

order to fully understand what is needed when taking care

for a patient with a pleural effusion.

Carefully nursing a patient with a pleural effusion (usually a

patient with associated health problems) has very good

results if the nursing plans are respected. Reducing the

postoperative pain and improving the respiratory function

are essential for patients’ evolution.

The goals of the nursing plans include relief of pain,

adherence to prescribed pharmacological regimen,

establishment of a normal, effective respiratory pattern as

evidenced by absence of cyanosis, and demonstration of

increase in perfusion. If these goals are achieved, the patient

can be safely discharged.

The nurse’s role in taking care for the patient with a pleural

effusion is very important. The nurse helps the patient reach

Vol. CXXII • Suppl/2019 • October • Romanian Journal of Military Medicine

41

several goals during the hospital stay. Good nursing means

better quality of life for the patient!

Challenges in the determination of the blood group and compatibility

Anca L. Mogoi, Cristiana Chiriță, Carmen B.Ș. Jianu, Gabriela Vasile, Carmen Măcău

The human body contains approximately 4- 6 L of blood,

depending on the body mass of the individual. The red blood

cells (RBC), haematids, which represent 45% of the blood

volume, have a crucial role in the oxygen transportation to

the tissues, and implicitly in maintaining the organism alive.

On the red blood cells membranes, there are proteins that

carry the blood group antigens. These were discovered by

Landsteiner, who classified them in the ABO system.

Nowadays, more than 300 RBC antigens are identified and

categorized into 36 major systems. The determination of the

ABO/Rh blood group is based on a relatively simple test that

can be performed in 5-10 minutes depending on the

technique used. However, there are situations in which the

determination of the blood group may involve additional

techniques that require more time and foremost knowledge

on the medical history of the patient. The aim of the

compatibility tests is to highlight the interactions between

the donor’s antigen and the patient’s antibodies. Selecting a

compatible blood unit is often challenging due to the

presence of a multitude of antigens and antibodies with high

immunogenicity or unexpected antibodies (auto- or irregular

erythrocyte antibodies), cases in which time-consuming

supplementary testing is required.

This paper describes the most common particular cases

encountered in our practice when performing blood group

and compatibility determination.

Headache in neurology disorders

Cătălin Dinoiu, Alexandru Gila, Claudia Lia

A headache is pain or discomfort in the head or face area.

Headaches vary greatly in terms of pain location, pain

intensity, and how frequently they occur. Headache

syndromes can be associated with focal neurological

symptoms or signs. Good knowledge of primary headaches,

a detailed history and a thorough clinical examination are

prerequisites for their differential diagnosis. The

neurological symptoms produced by the migraine aura are

the most characteristic and recognisable. However,

structural lesions, such as vascular malformations, can

produce similar symptoms to migraine with aura, which

highlights that paraclinical investigations are necessary in

most patients with headache and focal neurological

symptoms.

The different types of primary headaches are: migraines,

tension headaches and cluster headaches. The full extent of

the problem may not be understood immediately, but may

be revealed with a comprehensive medical evaluation and

diagnostic testing. The diagnosis of a headache is made with

a careful history, physical examination and diagnostic tests.

The ultimate goal of treatment is to stop headaches from

occurring. Adequate headache management depends on the

accurate identification of the type of headache.

Some headaches may require immediate medical attention

including hospitalization for observation, diagnostic testing,

or even surgery. Treatment is individualized depending on

the underlying condition causing the headache. Full recovery

depends on the type of headache and other medical

problems that may be present.

The conflict

Giorgeta Grosu

A conflict is a disagreement between two or more people

whose attitudes, beliefs, values, feelings or needs differ and

it is, at the same time, a part of every working environment,

medical care organizations included. Needs, perceptions,

power, values, feelings and emotions are all involved within

a conflict. In the past, conflicts from the working

42

environment were seen as dysfunctional issues and they

were supposed to solve by themselves or to be solved having

a winner and a loser. Nowadays, conflicts are expected to

occur in a dynamic organizational environment and are not

considered harmful anymore. Medical staff may face four

levels of organizational conflicts: intrapersonal,

interpersonal, intragroup and intergroup, however most

organizational conflicts occur at interpersonal and

intergroup levels, substantial and personalized conflicts

being the most common two types of conflicts. Supervisors

and managers who mediate conflicts need to stay calm, to

take measures in order to promptly put an end to negative

conflicts and to stay positive until a final resolution is

reached. It is essential to separate the problem from the

person, to be impartial, to look for creative solutions, to

discuss with all parties involved in the conflict so that people

feel they are involved in the process and will contribute to

the final result. Confrontation, compromise, collaboration,

admittance and avoidance are the five common approaches

to solve conflicts, each of them having its own specific

characteristics.

Challenges in IMRT: RTTs point of view

Andrei Toma, Norocel Bocănială, Mihai Dumitrache, Ștefănel C. Vlad

Within the radiation oncology department of the Military

Emergency and University Central Hospital “Dr. Carol

Davila”, Bucharest we are using 2 techniques of treatment

delivery: 3D conformal and intensity-modulated radiation

therapy (IMRT).

IMRT is an advanced type of high-precision radiotherapy,

that allows for the radiation dose to conform more precisely

to the 3D shape of the tumor by modulating the intensity of

the radiation beam in multiple small volumes. Due to its high

complexity and the need of confirmation of the dose

distribution to the target volume, the positioning of the

patient has to be highly accurate and it has to be checked

daily.

It should be noted that the duration of treatment using IMRT

technique is higher than 3DCRT, therefore the number of

patients that are being treated is limited. Taking into

consideration the high number of patients coming to the

department, we had to extend the working schedule in order

to maintain a lower waiting time compared to other public

clinics in the country. It should be also mentioned that the

radiotherapy installation is being overused, which may lead

to the wear of some components.

These issues are important, but also motivating, due to the

importance of IMRT technique in modern approach of

oncological cases, because it allows higher radiation doses

to be focused on the tumor while minimizing the dose to

surrounding normal critical structures.

Implantable ports used in chemotherapy

Maria L. Berbece, Casandra Marin

Many times during cancer treatment, the medical team in

charge of the patient must have access to the patient’s veins

be that to administer the cytostatic treatment or for other

intravenous perfusions or injectable antibiotics. For these

procedures to be as comfortable as possible for the patient,

the oncologist recommends implanting a special device

called implantable port (port-a-cath) which allows repeated

administrations of cytostatic treatment during a long period

of time. The port is attached in the operating theatre by a

medical team consisting of the surgeon and the

anaesthesiologist, experienced in performing this kind of

procedures. The intervention takes place in the operating

room under local anaesthesia and/or mild sedation.

Conclusions: the implanting is performed only once during

the entire period of treatment, the procedure is mildly

invasive and performed under local anaesthesia, the access

to blood veins is easy, the toxic effect of cytostatic on the

veins is significantly reduced, the cytostatic treatment may

be administered continuously or intermittently, the period

of usage is long, the device has a good aesthetic appearance

and allows exposure to water, nevertheless, the

recommendation to implant such a port must come after

discussing the matter with the oncologist.

Vol. CXXII • Suppl/2019 • October • Romanian Journal of Military Medicine

43

Patient care with acute subdural hematoma

Florina C. Tănăsescu, Andreea Ciurea

The care process involves five stages, each stage having a

number of key components, as follows: Data collection/Their

analysis and interpretation/Care planning. Pre and

postoperative care: the preoperative care includes:/The

physical and mental preparation of the pacient; /General

preparation;/Preparation for surgery. Postoperative care:

Post-operative surveillance of the patient starts from the

time of completion of the surgery. It can be said that the

pacients are divided into two categories: the first – those

who return to the ward and the second- the patients who

are admitted to the intensive care unit; During transport the

following will be observed: skin coloration, breathing, pulse,

the functioning of the various devices used for monitoring,

perfusion. Sudden movements will be avoided. Positioning

of the patient in bed varies depending on the type of surgery

and anesthesia.The most common position is the dorsal

decubitus.Positive diagnosis for acute subdural hematomas

is mainly based on advanced radiogical investigations which

highlight the acute subdural collections which, correlated

with the clinical findings, confirm the clinical diagnosis.

Menopause: between physiology and pathology

Nicoleta Mavriș, Mihaela Moscaliuc, Ancuța Istrate, Carmen Miron, Aglaia Nedelcu, Tatiana Onofrei, Florentina Rogojină, Andreea Serafim, Nicoleta Vale, Corina Enache, Luminița Crăciun

Menopause and menopausal transition are physiologic, but

symptoms are frequent and often require medical attention.

Approximately 60% to 80% of menopausal women

experience hot flashes at some point during menopausal

transition. They are more likely to develop anxiety

symptoms at perimenopause and postmenopause and

depressive symptoms or clinical depressive disorders in late

perimenopause. Sleep disturbances are frequent. Vaginal

dryness and genital atrophy can cause sexual dysfunction.

Lately, postmenopausal osteoporosis leads to increased

morbidity and mortality as well as an important reduction of

the quality of life as a consequence of fractures. We present

our experience with menopausal patients seeking medical

attention in our department.

Patient care after cardiac pacemaker implantation

Elena M. Dumitrescu, Cecilia Pătru

The pacemaker is a special device that is implanted in the

prepectoral and subclavicular level. The device generates

electrical impulses at the heart, determining to work in

optimal parameters. Recently, the cardiac pacemaker has

gained a crucial importance in the life of patients with

pathologies such as: symptomatic sinus bradycardia,

complete atrio-ventricular block (grade III), sinus node

disease, etc. In present, it is estimated that annually.

Approximately 200,000 people benefit from a cardiac

pacemaker. In this context, efficient management of

postimplant pacemaker care lead to an increase in the

quality of life of the patient as well as to a substantial

reduction of the complications that may occur

postoperatively. We note that overinfection of the wound is

one of the most important complications. The present paper

aims to highlight the most important aspects of care for the

patient post device implantation so that he / she will benefit

from the best medical care and his recovery will be fust and

properly.

In fact, a very important aspect of care of the post-implant

patient is his education, according to the lifestyle that he

must adopt. Upon discharge from the hospital, the patient is

taught how to care and protect the wound. Also, the patient

is educated on the activity that can be performed during the

recovery: the patient will limit the use of the arm for a period

of 1.5-3 months and will strictly respect the indications

received from the medical team.

44

Utilization of ATP bioluminescence assay in monitoring medical hand hygiene compliance in healthcare workers

Raluca M. Hrișcă, Tudorița Marinescu, Adriana Ruță, Daniel Păun

Healthcare associated infections (HCAI) are an important

problem in terms of the associated morbidity, mortality and

cost. Hand hygiene is an important part of quality care, and

it is the simplest, low cost and evidence supported method

to reduce the HCAI. We want to evaluate the healthcare

workers hand hygiene from our settings. Retrospective study

conductes in our setting between 1st May 2019- 31 July

2017, based on the swab sample collected from healthcare

workers hands using Adenosine Triphosphate Hygiene

Monitoring System. We set 60 RLU as the upper limit for a

proper hand hygiene (≤ 60 RLU -PASS, > 60 RLU –FAIL). While

collecting the samples we conduct an interview about the

reasons that prevent them from practicing hand hygiene

regularly. We collect 416 sample, 46.63% PASS and 53.34%

failed the test. The main 4 reasons given for failing was:

cleaning hands causes skin irritation and dryness, the

accessibility (the disinfectant vial no longer matches with the

dispenser), sink location and the lack of time. Conclusions:

We must insist on the hand hygiene policies; the hospital

units must be properly equipped; we have to use less skin

aggressive disinfectants and to use hand cream for

prevention of skin dryness and irritations.

Fournier gangrene diagnosed patient’s care

Georgiana Niculae

Etiology: Fournier gangrene is a form of fulminant fasciitis

necrotizing of perianal region, perineal and genital.

Determining factors are: aerobic germs (E-Coli), anaerobic

germs (Bacterioides).

Other factors are: Proteus, Staphylococcus, Enterococcus,

Klebsiella, and Clostridium.

Favoring factors are: diabetes, alcoolism, obesity, old age,

AIDS

Clinical diagnosis: The onset is sudden or preceded by a

prodromal syndrome with: fever, digestive disorders, and

genital pruritus.

Subsequent will appear painful erythematous edema with

cyanosis and tissue necrosis.

Treatment: Patient resuscitation, broad-spectrum

antibiotics, debridement, removing of the necrotizing tissue

are required.

Preoperative it is necessary hemodynamic equilibration,

glycemia, anemia, coagulation disorders.

Conclusions: Fournier gangrene is a major urological

emergency, with rapid escalation, with high risk mortality up

to 30%.

Presenting time to the hospital, age, and associative

disorders are key factors in this disorder.

Characteristics of care for patients with autonomic regulation therapy

Carmen M. Bosincianu, Silviu Dumitrescu, Mihai Dumitrașcu

Introduction: Any form of structural heart disease that

impairs ventricle functional ability to fill or to eject blood

according to the needs of the tissue may cause heart failure

syndrome. Many people are diagnosed with heart failure

syndrome and in spite of prescribed medical treatments they

continue to suffer from fatigue and shortness of breath.

Trying to handle heart failure syndrome in terms of surgical

approach is based on the vagus nerve stimulation through

device implantation which sends an electrical impulse from

the brain to the heart.

Objectives: implanting the device is an innovative treatment

BAT(baroreflex activation therapy) which restores the

equilibrium of the autonomic nervous system, leading to

enhanced cardiac performance, improving the pumping

capacity of the heart, reducing the risk of malignant

ventricular arrhythmias associated with heart failure and

ultimately improving the quality of life and increasing the

Vol. CXXII • Suppl/2019 • October • Romanian Journal of Military Medicine

45

rate of survival.

Material and method: we studied 5 patients who were

operated between January- July 2019

Results: we analysed the postoperative evolution, showing

the special nursing cares.

Conclusions: the study marks out distinguished

particularities of nursing patients with the vagus nerve

stimulation. The nurses’ role, besides medical treatment

given by physicians, involves continuous monitoring during

hospitalization and educating the patients on how to lead a

healthy life.

Dudenopancreatectomy in the eyes of medical assistance

Imola Grigore

Introduction: Cephalic duodenopancreatectomy is one of

the most complex operations in abdominal surgery, reserved

mainly for surgeons with experience in hepato-

biliopancreatic pathology. If in the past it was used

sporadically, today it has become a routine intervention.

Objectives: The main indication of CPD is the pancreatic

cephalic neoplasm, along with the periampullary neoplasms

(distal choledochial cancer, pulmonary ampuloma, duodenal

cancer). DPC remains a difficult, complex intervention, due

to vascular relations (portal vein, mesenteric vessels) and

restoration of bile, pancreatic and digestive continuity. Two

types of operations are used: Whipple and

TraversoLongmire. Improvement of surgical techniques and

progress in anesthesia, intensive care and nutritional

support have led to decreased postoperative mortality in

CPD but also radical intervention with increased survival.

Material and method: we will study 2 patients with CPD

performed in our clinic this year.

Results: we will analyze the post-operative evolution of the

cases, especially from the point of view of the care offered

by the nurse.

Conclusions: To date, surgical resection is the only effective

therapy that offers the prospect of a significant prolongation

of the survival and healing potential of patients with cancer

in the pancreatic-biliary sphere.

The role of the nurse is very important in the postoperative

care by administering the medication indicated by the

doctors and continuous monitoring during the

hospitalization as well as by educating the patient to adopt

a healthy lifestyle, which will extend his life.

Thrombolysis therapy in acute ischemic stroke

Olguța Preda-Carsote, Oana Rada, Violeta Gâlcă, Nicoleta Balint

Stroke is a major cause of mortality and thrombolysis has

served as a catalyst for major changes in the management of

acute ischaemic stroke. Modern management of stroke

includes rapid assessment and admission protocols,

thrombolysis for acute ischaemic stroke, early specialist

management in a stroke unit and appropriate physiological

monitoring. Thrombolysis restores cerebral blood flow in

some patients with acute ischemic stroke and may lead to

improvement or resolution of neurologic deficits. The most

important factor in successful reperfusion therapy of acute

ischemic stroke is early treatment with Alteplase (Actylise).

Intravenous alteplase (actylise) is the only approved

thrombolitic agent at present indicated for acute ischaemic

stroke. While the licensed time window extends to three

hours from symptoms onset, recent data suggest that the

trial window can be extended to four and a half hours with

overall benefits. Identification of viable penumbra based on

computed tomography/magnetic resonance imaging may

allow future extension of the time window. Intracranial

haemorrhage is the major complication associated with

thrombolysis, and the key factors increasing risk of

haemorrhage include increasing age, high blood pressure,

and diabetes and stroke severity. Some people with

ischaemic stoke are eligible for a clot-busting drug. Actylise

aims to disperse the clot and return the blood supply to the

brain. For most people thrombolysis needs to be given

within four and a half hours since the stroke symptom

started.

46

Emergency nurse and acute trauma evaluation

Ion M. Lefter

The Advanced Trauma Life Support (ATLS) was developed in

response to a perceived need to identify a safe, consistent,

standardized, and effective way to initially evaluate and

resuscitate patients with multiple injuries.

The principles of ATLS and triage need to be known by all

personal, included nurses.

Nurse’s role in esophageal manometry

Elena Zanfir, Mariana Moldoveanu, Corina Marcovici-Petu, Aurica Avram, Cristiana Tablan, Nicoleta Helmis, Andrei Crișu, Liliana Radu, Raluca S. Costache, Andrada L. Popescu

Introduction: In this paper we want to point out the nurse

role in performing esophageal manometry - a procedure

used to measure the strength and function of the esophagus

as food and liquids pass from the mouth to the stomach.

Esophageal manometry is done to evaluate the cause of

stomach reflux back up into the esophagus, to determine the

cause of dysphagia, and the cause of non-cardiac chest pain.

Esophageal manometry is indicated to establish the

diagnosis of suspected cases of achalasia or diffuse

esophageal spasm, also for detecting esophageal motor

abnormalities associated with systemic disease or for correct

positioning of the probe for the 24-hour pH monitoring.

The nurse is preparing the patient, informing him about the

procedure, about the time needed and the steps of it. The

nurse will verify that the patient had nothing by mouth in the

last 6 hours prior to the test. After the sterilization of the

probe and calibration, the nostril and throat is numbed with

a topical anesthetic, then the probe is inserted in a sitting

upright position while the patient swallows water. The

patient will lie down and the nurse will give him small sips of

water to record the progression of the swallow. The

contractions of the esophageal muscle will be measured at

rest and during swallows.

Conclusion: In our hospital this GI functional procedure is

available since 2017, and we performed until now

approximately 150 procedures. Manometric screening for

severe peristalsis dysfunction remains reasonable in

specialized gastroenterology departments.

Management of operative wound infections

Maria Stoian, Carmen Florea

Introduction: All the surgical wounds are microbially

contaminated, but only a small part of them can become

infected. In most cases surgical wounds are considered to be

clean or contaminated clean. The main factors recognized as

influencing the evolution of the wound (healing as well as

the aesthetic aspect) are quantitative and qualitative

contamination.

Objectives: The paper presents: the risk factors in surgical

wound contamination, diagnostic criteria for the infection of

the wound, the treatment and the prophylactic measures

preoperative, intraoperative and postoperative.

Materials and methods: We present our experience on 2000

patients operated in 2018 of which approximately:

- 40% of the surgery wounds were clean (hernias, classic or

laparoscopic; other interventions, classic or laparoscopic);

- 30% of the surgery wounds were contaminated clean

(classic and laparoscopic interventions on the cholecyst,

stomach, small intestine, colon, rectum);

- 30 % surgery wounds 100% septic (abscesses, phlegm,

gangrene, peritonitis).

The evolution of clean surgery wounds was favorable in all

cases for the contaminated clean and the contaminated

ones. The evolution was favorable in proportion of 80%, the

rest of 20% was unfavorable due to other diseases (diabetes,

malnourished patients, and neoplasic patients)

Conclusions: The correct application of the aseptic and

antiseptic techniques, the observance of the guides and

protocols regarding the surgical techniques and the

antibiotic prophylaxis, the observance of the hygiene rules

for both the patient and the medical personnel are essential

Vol. CXXII • Suppl/2019 • October • Romanian Journal of Military Medicine

47

conditions, absolutely necessary for the favorable evolution

of the surgical wounds.

Heart attack

Delia Spătaru, Ramona Oancea

A heart attack occurs when the flow of blood to the heart is

blocked. The blockage is most often a buildup of fat,

cholesterol and other substances, which form a plaque in the

arteries that feed the heart (coronary arteries). The plaque

eventually breaks away and forms a clot. The interrupted

blood flow can damage or destroy part of the heart muscle.

A heart attack, also called a myocardial infarction, can be

fatal, but treatment has improved dramatically over the

years. It's crucial to call 211 or emergency medical help if you

think you might be having a heart attack. In the CTIC

department of January 2018 so far, over 700 patients with

heart attack have been admitted, and over 200 patients have

come into the RO-STEMI program. In the absence of

adequate treatment: heart attack mortality 50%. Between

50% years produce in the first 2 hours of debut and 40% long

in the first months of heart attack debut.

When to see a doctor

Act immediately. Some people wait too long because they

don't recognize the important signs and symptoms. Take

these steps:

• Call for emergency medical help. If you suspect you're

having a heart attack, don't hesitate. Immediately call 112 or

your local emergency number. If you don't have access to

emergency medical services, have someone drive you to the

nearest hospital.

Drive yourself only if there are no other options. Because

your condition can worsen, driving yourself puts you and

others at risk.

• Take nitroglycerin, if prescribed to you by a doctor. Take it

as instructed while awaiting emergency help.

• Take aspirin, if recommended. Taking aspirin during a

heart attack could reduce heart damage by helping to keep

your blood from clotting.

Aspirin can interact with other medications, however, so

don't take an aspirin unless your doctor or emergency

medical personnel recommend it. Don't delay calling 112 to

take an aspirin. Call for emergency help first.

What to do if you see someone who might be having a heart

attack

If you see someone who's unconscious and you believe is

having a heart attack, first call for emergency medical help.

Then check if the person is breathing and has a pulse. If the

person isn't breathing or you don't find a pulse, only then

should you begin CPR to keep blood flowing. Push hard and

fast on the person's chest in a fairly rapid rhythm — about

100 to 120 compressions a minute. If you haven't been

trained in CPR, doctors recommend performing only chest

compressions. If you have been trained in CPR, you can go

on to opening the airway and rescue breathing.

Cryoultrasound therapy

Laura Iosif, Daniela E. Iuga

Cryoultrasound therapy exploits the action of two different

therapeutic physical modalities: cryotherapy and

therapeutic ultrasound. Cryotherapy is generally regarded as

a basic component of most injury management strategies

and has proved its effectiveness in reducing edema and

short-term pain. Ultrasound consists of high-frequency

sinusoidal sound waves with a peak pressure of 0.5 bar,

approximately 1000 times lower than shock wave

Therapeutic ultrasound may induce thermal and nonthermal

effects in the tissues. Thermal effects include a rise in blood

flow, reduction of muscle spasm, increase in the extensibility

of collagen fibers and a pro-inflammatory response. Non-

thermal effects are cavitation and acoustic microstreaming

that induce stimulation of fibroblast activity, increase in

protein synthesis and in blood flow, tissue regeneration, and

bone healing. It has been suggested that the non-thermal

effects of ultrasound are more important in the treatment of

soft tissue lesions than are thermal effects. Cryoultrasound

therapy is a new technology that could combine the benefits

of therapeutic ultrasound with those of cryotherapy, which

could reinforce both, avoiding the possible complications of

the thermal heating effect of the ultrasound therapy and

improving its mechanical and biological therapeutical

effects. In fact, a temperature decrease in deep tissues

48

permits an enhancement in waves density in the tissue itself,

increases the mechanical effect and, notably, reduces the

thermic effect of the ultrasound. Recently, cryoultrasound

therapy has been tested for musculoskeletal and

musculotendinous disorders.

Lung diffusing capacity

Gabriela Drilea

This year our department was endowed with a pulmonary

diagnosis line. The device comprises the module for

spirometry, for measuring lung volumes of Nitrogen

washout and for Lung Diffusion Capacity.

Measuring diffusion in pulmonary function laboratories can

provide information about the transfer of gas between the

alveoli and the pulmonary capillary blood. Measurement of

the diffusing capacity is usually performed by using an

inspired gas containing Carbon Monoxide because of its high

affinity for Hemoglobin.

This is a simple non-invasive procedure and consists of

instructing the patient to carry out a maximal inspiration and

an 8-10 second breath (during which the expiratory valve is

closed), followed by a slow exhalation to the level of Residual

Volume.

This investigation is indespensable in the diagnosis of diffuse

interstitial pneumopathy , diffuse pulmonary emphysemia,

vasculitis, neuro-vascular disease, thoracic deformities, is

recommended for the surveillance of people at high risk of

disease (exposure to asbestos, beryllium, aluminum

powders, patients with extrapulmonary collagenosis or

extrinsic alveolitis, patients treated with certain drugs),

useful in the evaluation of emphysematous component or

the global evaluation of the gas exchanges at COPD, can

evaluate the therapy administered , can appreciate the

prognosis of lung diseases, can determine the degree of

functional disability.

The Lung Diffusing Capacity CO (DLCO) test is very useful in

diagnosing lung disease coming to the aid of many patients.

A few considerations about fever and nursing in fever

Dana Sorica, Carmen Hornea

Fever is defined as the elevation of core body temperature

above normal; in normal adults, the average oral

temperature is 37°C (98.6°F). In medical practice, a single

temperature of more than 38.3°C (101°F) or three readings

(at least 1 hour apart) of more than 38°C (100.4° F) are

considered significant. Fever of an unknown origin (FUO) is

defined as a febrile illness lasting more than 3 weeks, with

temperatures exceeding 38.3°C on several occasions, and

lacking a definitive diagnosis after 1 week of evaluation in

the hospital.

The febrile response, of which fever is but one component,

is a complex physiologic reaction to disease involving a

cytokine-mediated rise in body temperature, generation of

acute-phase reactants, and activation of numerous

physiologic, endocrinologic, and immunologic systems.1 The

temperature of the body is dependent on maintaining a

balance between the production and dissipation of heat.

Goals of care: The presence of fever is associated with

potential metabolic consequences, including dehydration

and increased oxygen consumption and metabolic rate. If

prolonged, fever may be associated with an increase in

nutritional demands, which may be problematic if the

patient already is compromised nutritionally. Prolonged

fever may also lead to debilitating fatigue Suppression of

fever may help to alleviate uncomfortable, constitutional

symptoms of fatigue, myalgias, diaphoresis, and chills. In

addition to constitutional symptoms, focal findings related

to the etiology of fever may contribute to the burden of

symptoms. For example, the formation of an abscess is often

associated with pain, whereas uncomfortable dyspnea and

cough may be related to pneumonia. For instance,

individuals seeking comfort-oriented care exclusively may

decline parenteral antibiotic treatment of pneumonia to

avoid hospitalization and remain at home. For others,

treating the underlying etiology of fever with more

aggressive interventions, such as surgical drainage of a

painful abscess, will offer symptom palliation and potentially

contribute to the prolongation of life.

Vol. CXXII • Suppl/2019 • October • Romanian Journal of Military Medicine

49

Multiple sclerosis

Georgiana Drăghici

Multiple sclerosis (MS) involves an immune-mediated

process in which an abnormal response of the body’s

immune system is directed against the central nervous

system (CNS). The CNS is made up of the brain, spinal cord

and optic nerves. Within the CNS, the immune system causes

inflammation that damages myelin — the fatty substance

that surrounds and insulates the nerve fibers — as well as

the nerve fibers themselves, and the specialized cells that

make myelin.There are several types of MS: Clinically

isolated syndrome (CIS), Relapsing-remitting MS (RRMS),

Primary progressive MS (PPMS) and Secondary progressive

MS (SPMS).

Treatments for MS attacks

Disease-modifying therapies (DMTs) are designed to slow

disease progression and lower the relapse rate. In 2017, the

Food and Drug Administration (FDA) approved the first DMT

for people with PPMS. This injectable drug is called

ocrelizumab (Ocrevus), and it can also be used to treat

RRMS.

The bottom line

MS is a lifelong condition. The patient face unique challenges

that can change over time.They should focus on

communicating concerns with the doctor, learning all they

can about MS, and discovering what makes them feel their

best. Many people with MS even choose to share their

challenges and coping strategies through in-person or online

support groups.

Pages from the history of blood transfusion: old Romanian press reflection

Elena I. Milea, Nicoleta M. Băltărețu, Florența N. Borhan, Camelia Tudor, Laura M. Constantin

More and more researchers appeal to old press to

investigate their chosen subject. Newspapers and

magazines, historical image of the time when they were

printed, are work instruments for researchers. While trying

to find out as much novelties as possible about blood

transfusion history, I have researched the Romanian

Academy’s Library newspapers and magazines published

between 1881 and just after the Second World War. Among

the researched magazines, I would like to mention:”Bulletin

de l’Academie de Medicine” (1881 – 1944).

Pages from old newspapers and magazines describe the first

transfusion performed from animal to human, from human

to human, but also the first blood transfusion performed in

Romania, quite late when compared to Western Europe.

After an unsuccessful blood transfusion performed in 1853

by Carol Davila, the next blood transfusion was performed in

Romania in 1912 – 1914.

The press of the time highlighted the great discoveries

regarding blood transfusion. Lots of pages have been

dedicated to indirect blood transfusion, veno-venous

transfusion performed with the aid of a device (during the

World War I – Oehlecker), or to the discovery of blood types.

On the agenda were also International Transfusion

Congresses, the appearance of blood banks, flourishing

businesses or great scandals when patients died due to

blood transfusion.

Old newspapers and magazines are archives of the daily life

of those times. Only by reading them one can acknowledge

the progress of medicine and of blood transfusion, progress

preparing the events of today, as today’s progress prepares

us for the events of tomorrow.

Chronic pancreatitis

Adina Bălan, Viorica Gogor, Mihaela Vasile, Cătălina Oana

Chronic pancreatitis is a chronic inflammatory disease of the

pancreas, with progressive evolution towards exocrine and

endocrine pancreatic destruction, leading to pancreatic

insufficiency. Symptom for pancreatitis are dbdominal pain -

the dominant symptom epigastric, periumbilical, triggered

by heavy meals or alcohol consumption. Steatoreea - a late

sign, when malabsorption occurs bulky, pasty chairs, with a

rancid smell; always accompanied by weight deficit. History

50

and clinical picture of chronic alcoholism - recognized or not

(collateral history, in the relatives). The most important

cause of PC (over 90% of cases) necroptic > 45% of alcoholics

showed morphological changes of PC, in the absence of

clinical signs of disease toxic dose of pure alcohol. Some

patients may have ethanolic hepatopathy (steatosis,

alcoholic hepatitis or even ethyl hepatic cirrhosis)

Treatment: Dietary: complete and definitive abolition of

alcohol consumption; avoiding abundant meals rich in lipids

and proteins; in episodes of PA on PC background dietary

rest, parenteral nutrition, naso-gastric well. Drug: pain

relievers (Algocalmin, Piafen, Tramal); high lipase

preparations (Creon, Panyztrat, Festal, Cotazym, Nutryzym,

Digestal) even in the absence of malabsorption; when there

is malabsorption, minimum 20,000 U lipase/mass; if the

preparation is not gastroprotected, before the meal, an

antisecretory is given before 30 minutes.

Nursing applied to a thrombophlebitis patient

Cristina Filimon, Cecilia Pătru

Thrombophlebitis is an inflammatory process that causes a

blood clot to form and block one or more veins, usually in

the legs. The affected vein may be near the surface of the

skin or deep within a muscle. Causes include trauma, surgery

or prolonged inactivity. The three main factors that are

causing this pathology are the endothelial lesions, the

inflammation localised on the vein’s wall and the

hypercoagulation process. Thrombophlebitis frequently

occurs in cardiac insufficiency cases and diseases followed

by venous stasis as a result in prolonged inactivity. The

primary physiopathological alteration is the formation of a

blood clot that is the mechanical obstructive element.

Symptoms include warmth, tenderness and pain in the

affected area, as well as redness and swelling.

Complications- from thrombophlebitis are rare. However,

complications might include: pulmonary embolism- if part of

a deep vein clot becomes dislodged, it can travel to the

lungs, where it can block an artery and become potentially

life-threatening, postphlebitic syndrome- this condition also

known as post-thrombotic syndrome, can develop months

after a person had DVT. This can cause lasting and possibly

disabling pain, swelling and a feeling of heaviness in the

affected leg. For superficial thrombophlebitis, the doctor

might recommend applying heat to the painful area,

elevating the affected leg and possibly wearing compression

stockings. Another recommendation is the treatment with

blood-thinning medications, such as heparin or clot-

dissolving medication. Prescription strenght compression

stockings help prevent swelling and reduce the chances of

complications of DVT.

Clostridium difficile infection: a nurse’s point of view

Mariana Bogriceanu, Grațiela Olteanu, Liliana Bulat

Introduction: Our objective is to review current guidelines in

managing Clostridium difficile colitis and our department`s

experience in this field.

Materials and methods: Clostridium difficile is a Gram-

positive spore-forming anaerobe that was identified,

beginning with 1978 as the causative pathogen in the

majority of antibiotic-associated diarrhea and colitis cases. It

is believed that a small percent of healthy individuals have

this bacterium in their colon, but it is more often found in

the ground, water, animal or human feces, C. difficile being

a growing cause for nosocomial disease.

The most common risk factor for C. difficile infection is the

use of antibiotics, as they can disrupt the normal microbial

balance in the colon.

This bacterium is dangerous because it can secret two toxins

(A and B) that cause inflammation of the colonic mucosae,

which can lead to moderate diarrhea, pseudomembranous

colitis (most frequent form) or fulminant colitis. If the

physician suspects a C. difficile infection, it is the nurse`s task

to explain to the patient how to collect a stool sample and

take it as fast as possible to the laboratory.

After infection is confirmed, it is up to the nurse to assure

contact precautions: isolate the patient with single use

gowns and gloves being available at room entrance;

environmental disinfection; explaining the importance of

hand hygiene and of course making sure that the patient

takes his medication correctly, according to the physician`s

recommendations.

Results and conclusion: C. difficile colitis has become the

most frequent infectious cause of healthcare-associated

Vol. CXXII • Suppl/2019 • October • Romanian Journal of Military Medicine

51

diarrhea, causing high morbidity and mortality, mainly

because of the use of broad-spectrum antibiotics.

Immunoglobulin therapy: the election treatment for primary immunodeficiency diseases

Nicoleta Voinea

The term “immunoglobulin” refers to the fraction of blood

plasma that contains immunoglobulins. Immunoglobulin

therapy is a purified product prepared from human plasma

donors. Its main therapeutic indications are primary and

secondary immunodeficiences. Immunodeficiences are

diseases with variable genetic transmission.

Immunoglobulin therapy is generally administered

subcutaneously, intramuscularly or intravenously. In our

hospital the most used is the intravenous administration and

the product used is Intratect. The systemic adverse reactions

of immunoglobulin therapy are usually determined by the

patient’s intolerability to a rapid infusion (headache, nausea,

general altered state, fatigue, dispnea). The adverse

reactions which occur during subcutaneous administration

are localized skin reactions at the site of the injection:

swelling, inflammation, rash, and induration.

Immunoglobulin therapy is a complex therapy which can

lengthen many patients’ life span.

52

ADMINISTRATIVE ISSUES

Guidelines for authors

Thank you for your interest in Romanian Journal of Military Medicine. Please read the complete Author Guidelines carefully prior to submission, including the section on copyright. To ensure fast peer review and publication, manuscripts that do not adhere to the following instructions will be returned to the corresponding author for technical revision before undergoing peer review. Note that submission implies that the content has not been published or submitted for publication elsewhere except as a brief abstract in the proceedings of a scientific meeting or symposium. Once you have prepared your submission in accordance with the Guidelines, manuscripts should be submitted online at rjmilmed@yahoo.com. We look forward to your submission.

EDITORIAL AND CONTENT CONSIDERATIONS Aims and Scope Romanian Journal of Military Medicine (RJMM) is the official journal of the Romanian Association of Military Physicians and Pharmacists. The Journal publishes peer-reviewed original papers, reviews, meta-analyses and systematic reviews, and editorials concerned with clinical practice and research in the fields of medicine. Papers cover the medical, surgical, radiological, pathological, biochemical, physiological, ethical and historical aspects of the subject areas. Clinical trials are afforded expedited publication if deemed suitable. RJMM also deals with the basic sciences and experimental work, particularly that with a clear relevance to disease mechanisms and new therapies. Case reports and letters to the Editor will not be considered for publication. Editorial Review and Acceptance The acceptance criteria for all papers and reviews are based on the quality and originality of the research and its clinical and scientific significance to our readership. All manuscripts are peer reviewed under the direction of an Editor. The Editor reserves the right to refuse any material for review that does not conform to the submission guidelines detailed throughout this document, including ethical issues, completion of an Exclusive License Form and stipulations as to length.

ETHICAL CONSIDERATIONS Principles for Publication of Research Involving Human Subjects Manuscripts must contain a statement to the effect that all human studies have been reviewed by the appropriate ethics committee and have therefore been performed in accordance with the ethical standards laid down in an appropriate version of the Declaration of Helsinki (as revised in Brazil 2013), available at http://www.wma.net/en/30publications/10policies/b3/index.html. It should also state clearly in the text that all persons gave their informed consent prior to their inclusion in the study. Details that might disclose the identity of the subjects under the study should be

omitted. Photographs need to be cropped sufficiently to prevent human subjects being recognized (or an eye bar should be used). Registration of Clinical Trials We strongly recommend, as a condition of consideration for publication, registration in a public trials registry. Trials register at or before the onset of patient enrolment. This policy applies to any clinical trial. We define a clinical trial as any research project that prospectively assigns human subjects to intervention or comparison groups to study the cause-and-effect relationship between a medical intervention and a health outcome. Studies designed for other purposes, such as to study pharmacokinetics or major toxicity (e.g., phase 1 trials) are exempt. We do not advocate one particular registry, but registration with a registry that meets the following minimum criteria: (1) Accessible to the public at no charge; (2) Searchable by standard, electronic (Internet-based) methods; (3) Open to all prospective registrants free of charge or at minimal cost; (4) Validates registered information; (5) Identifies trials with a unique number; and (6) includes information on the investigator(s), research question or hypothesis, methodology, intervention and comparisons, eligibility criteria, primary and secondary outcomes measured, date of registration, anticipated or actual start date, anticipated or actual date of last follow-up, target number of subjects, status (anticipated, ongoing or closed) and funding source(s). Plagiarism Detection The journal employs a plagiarism detection system. By submitting your manuscript to this journal you accept that your manuscript may be screened for plagiarism against previously published works. Committee on Publication Ethics The journal subscribes to the principles of the Committee on Publication Ethics (COPE).

MANUSCRIPT CATEGORIES AND SPECIFICATIONS All articles, with the exception of Editorials, must contain an abstract of no more than 250 words. Abstracts for original articles should be formatted into subheadings, as detailed below. Titles must not be longer than 120 characters (including spaces). Editorials These are invited by the Editor-in-Chief or their delegated editor, and should be a brief review of the subject concerned, with reference to and commentary about one or more articles published in the same issue of RJMM. Editorials are generally 1200–1500 words, may contain one table or figure and cite up to 15 references, including the source article [this should be cited as Military Med. Today (year); (vol): [this issue]. Review Articles RJMM welcomes reviews of important topics across the scientific basis of medicine, and advances in clinical practice. Most published

Vol. CXXII • Suppl/2019 • October • Romanian Journal of Military Medicine

53

reviews are in response to editorial invitation, including thematically related “mini-series” of reviews. Authors considering submitting a review for RJMM are advised to canvas their possible review with the Editor-in-Chief or a colleague editor; this avoids early rejection if the subject matter is not deemed a high priority for the Journal at the time of submission. Reviews are limited to 3500–5000 words, with an abstract of up to 250 words and up to 75 references and 3–7 figures or tables. Meta-Analyses or Systematic Reviews RJMM particularly welcomes submission of Meta-Analyses and Systematic Reviews, which underpin evidence-based medicine. Guidelines for preparation of Meta-Analysis and Systematic Reviews are similar to other reviews, and articles are subject to the usual peer review process. Meta-Analyses and Systematic Reviews have a word limit of 3500–5000 words, with an abstract of up to 250 words and up to 75 references and 3–7 figures or tables. Original Articles (including clinical trials) RJMM welcomes original articles concerned with clinical practice and research in the fields of medicine. Papers can cover the medical, surgical, radiological, pathological, biochemical, physiological, ethical and/or historical aspects of the subject areas. Clinical trials are afforded expedited publication if deemed suitable. RJMM also deals with the basic sciences and experimental work, particularly that with a clear relevance to disease mechanisms and new therapies. Original articles are limited to 3000 words, with an abstract of up to 250 words and up to 50 references and 3–7 figures and tables. Education and Imaging The Editors welcome contributions to the Education and Imaging section. The purpose is to present imaging for the evaluation of unusual features of common conditions or diagnosis of unusual cases. Contributions will be reviewed by the Education and Imaging Coordinating Editors. The format of the Images pages involves two parts, each of which will occupy up to one journal page. In part 1, a case will be described briefly, including a summary of the presentation, clinical features and key laboratory results. One to two key images will then be presented. It is helpful to the reader if the author responds to questions that follow from the images of the case, such as ‘What is your diagnosis? What are the features indicated on the CT scan? What is the differential diagnosis?’ Part 2 will briefly describe the imaging features, particularly those that lead to diagnosis or which are critical for management. Differential diagnosis should be mentioned. It will be useful to include either further images or pathological details that validate the imaging diagnosis. Occasionally, presentation of analogous cases or related images from a similar case might be appropriate. Please include between one and three references to definitive studies and appropriate reviews of the subject. The format of the Images page involves a brief background to and description of the disorder of interest together with two figures of high quality. Colored photographs are encouraged. The submission may take the form of a case report or may illustrate particular features from more than one patient.

MANUSCRIPT PREPARATION Style Manuscripts should follow the style of the Vancouver agreement detailed in the International Committee of Medical Journal Editors’ revised ‘Uniform Requirements for Manuscripts Submitted to Biomedical Journals: Writing and Editing for Biomedical Publication’, as presented at http://www.ICMJE.org/. Spelling. The journal uses US spelling and authors should therefore follow the latest edition of the Merriam-Webster’s Collegiate Dictionary. Units. All measurements must be given in SI units as outlined in the latest edition of Units, Symbols and Abbreviations: A Guide for

Biological and Medical Editors and Authors (Royal Society of Medicine Press, London). Abbreviations should be used sparingly and only where they ease the reader’s task by reducing repetition of long technical terms. Initially use the word in full, followed by the abbreviation in parentheses. Thereafter use the abbreviation. Trade names should not be used. Drugs should be referred to by their generic names, rather than brand names. Parts of the Manuscript The manuscript should be submitted in separate files: title page; main text file; figures. Title page The title page should contain (i) a short informative title that contains the major key words. The title should not contain abbreviations; (ii) the full names of the authors (if possible, not more than 5 authors per title); (iii) the author's institutional affiliations at which the work was carried out; (iv) the full postal and email address, plus telephone number, of the author to whom correspondence about the manuscript should be sent; (v) disclosure statement; and (vi) acknowledgements. The present address of any author, if different from that where the work was carried out, should be supplied in a footnote. Disclosure statement The source of financial grants and other funding should be acknowledged, including a frank declaration of the authors’ industrial links and affiliations. In the case of clinical trials or any article describing use of a commercial device, therapeutic substance or food must state whether there are any potential conflicts of interest for each of the authors: failure to make such a statement may jeopardize the article being sent out for peer-review. Acknowledgments The contribution of colleagues or institutions should also be acknowledged. Thanks to anonymous reviewers are not allowed. Main text As papers are double-blind peer reviewed the main text file should not include any information that might identify the authors. The main text of the manuscript should be presented in the following order: (i) abstract and key words, (ii) text, (iii) references, (iv) tables (each table complete with title and footnotes), (vii) figure legends. Figures and supporting information should be submitted as separate files. Footnotes to the text are not allowed and any such material should be incorporated into the text as parenthetical matter. Abstract and keywords Original articles must have a structured abstract that states in 250 words or less the purpose, basic procedures, main findings and principal conclusions of the study. Divide the abstract with the headings: Background and Aim, Methods, Results, Conclusions. The abstracts of reviews need not be structured. The abstract should not contain abbreviations or references. Three to five keywords should be supplied below the abstract and should be taken from those recommended by the US National Library of Medicine’s Medical Subject Headings (MeSH) browser—(http://www.nlm.nih.gov/ mesh/meshhome.html). Text Authors should use subheadings to divide the sections of their ma-nuscript: Introduction, Methods, Results, Discussion Acknowledg-ments and References. References The Vancouver system of referencing should be used. In the text, references should be cited using superscript Arabic numerals in the order in which they appear. If cited only in tables or figure legends, number them according to the first identification of the table or figure in the text. In the reference list, the references should be numbered and listed in order of appearance in the text. Cite the names of all authors when there are six or less; when seven or more list the first three followed by et al. Names of journals should be

54

abbreviated in the style used in MEDLINE. Reference to unpublished data and personal communications should appear in the text only. References should be listed in the following form: Number references in the order cited as Arabic numerals in parentheses on the line. Only literature that is published or in press (with the name of the publication known) may be numbered and listed; abstracts and letters to the editor may be cited, but they must be less than 3 years old and identified as such. Refer to only in the text, in parentheses, other material (manuscripts submitted, unpublished data, personal communications, and the like) as in the following example: (Chercheur X, unpublished data). If the owner of the unpublished data or personal communication is not an author of the manuscript under review, a signed statement is required verifying the accuracy of the attributed information and agreement to its publication. Use Index Medicus as the style guide for references and other journal abbreviations. List all authors up to six, using six and "et al." when the number is greater than six. Tables Tables should be self-contained and complement, but not duplicate, information contained in the text. Number tables consecutively in the text in Arabic numerals. Type tables on a separate page with the legend above. Legends should be concise but comprehensive – the table, legend and footnotes must be understandable without reference to the text. Vertical lines should not be used to separate columns. Column headings should be brief, with units of measurement in parentheses; all abbreviations must be defined in footnotes. Footnote symbols: †, ‡, §, ¶ should be used (in that order) and *, **, *** should be reserved for P-values. Statistical measures such as SD or SEM should be identified in the headings. Figure legends Type figure legends on a separate page. Legends should be concise but comprehensive – the figure and its legend must be understandable without reference to the text. Include definitions of any symbols used and define/explain all abbreviations and units of measurement Indicate the stains used in histopathology. Identify statistical measures of variation, such as standard deviation and standard error of the mean. Figures All illustrations (line drawings and photographs) are classified as figures. Figures should be numbered using Arabic numerals, and cited in consecutive order in the text. Each figure should be supplied as a separate file, with the figure number incorporated in the file name. Preparation of Electronic Figures for Publication: Although low quality images are adequate for review purposes, publication requires high quality images to prevent the final product being blurred or fuzzy.

SUBMISSION REQUIREMENTS Manuscripts should be submitted online at rjmilmed@yahoo.com A cover letter containing an authorship statement should be included. The cover letter should include a statement covering each of the following areas: 1. Confirmation that all authors have contributed to and agreed on the content of the manuscript, and the respective roles of each author. 2. Confirmation that the manuscript has not been published previously, in any language, in whole or in part, and is not currently under consideration elsewhere. 3. A statement outlining how ethical clearance has been obtained for the research, particularly in relation to studies involving human subjects, and animal experimentation. The institutional ethics

committees approving this research must comply with acceptable international standards (such as the Declaration of Helsinki) and this must be stated. 4. For research involving pharmacological agents, devices or medical technology, a clear Conflict of Interest statement in relation to any funding from or pecuniary interests in companies that could be perceived as a potential conflict of interest in the outcome of the research. 5. For clinical trials, that these have been registered in a publically accessible database. If the above items are not included in the cover letter, manuscripts cannot be sent for review. Please also note that the cover letter does not require a detailed or lengthy description of the content or structure of the manuscript itself. Two Word-files need to be included upon submission: A title page file and a main text file that includes all parts of the text in the sequence indicated in the section 'Parts of the manuscript', including tables and figure legends but excluding figures which should be supplied separately. The main text file should be prepared using Microsoft Word, doubled-spaced. The top, bottom and side margins should be 30 mm. All pages should be numbered consecutively in the top right-hand corner, beginning with the first page of the main text file. Each figure should be supplied as a separate file, with the figure number incorporated in the file name. For submission, low-resolution figures saved as .jpg or .bmp files should be uploaded, for ease of transmission during the review process. Upon acceptance of the article, high-resolution figures (at least 300 d.p.i.) saved as .eps or .tif files will be required.

PUBLICATION PROCESS AFTER ACCEPTANCE Accepted papers will be passed to production team for publication. The author identified as the formal corresponding author for the paper will receive an email, being asked to complete an electronic license agreement on behalf of all authors on the paper. Accepted Articles The accepted ‘in press’ manuscripts are published online very soon after acceptance, prior to copy-editing or typesetting. Accepted Articles are published online a few days after final acceptance, appear in PDF format only, are given a Digital Object Identifier (DOI), which allows them to be cited and tracked. After print publication, the DOI remains valid and can continue to be used to cite and access the article. Given that copyright licensing is a condition of publication, a completed copyright form is required before a manuscript can be processed as an Accepted Article. Proofs Once the paper has been typeset, the corresponding author will receive an e-mail alert containing instructions on how to provide proof corrections to the article. It is therefore essential that a working e-mail address is provided for the corresponding author. Proofs should be corrected carefully; the responsibility for detecting errors lies with the author. The proof should be checked, and approval to publish the article should be emailed to the Publisher by the date indicated; otherwise, it may be signed off on by the Editor or held over to the next issue. Offprint A PDF reprint of the article will be supplied free of charge to the corresponding author. Additional printed offprint may be ordered for a fee.

COPYRIGHT, LICENSING AND ONLINE OPEN Details are on the Copyright Agreement Form that must be completed and signed when the Article is accepted.

Romanian Journal of Military Medicine

New Series, Vol. CXXII, Suppl/2019, October

ISSN-L 1222-5126; eISSN 2501-2312; pISSN 1222-5126