Secondary prevention in patients with atrial fibrillation and stroke or transient ischemic attack - an insight from the FACTS programme

Background. Cardioembolic stroke secondary to atrial fibrillation (AF) accounts for 1.5%-23.5% of all ischemic strokes. Patients with prior stroke or transient ischemic attack (TIA) are at high risk for stroke recurrence. Prognosis for patients with AF related stroke is worse than those with other types of stroke. According to the current guidelines secondary prevention in these patients should be based on anticoagulant therapy. Aim of the study. The purpose of this analysis is to evaluate the extent of anticoagulation in clinical practice in patients with previous stroke or TIA. Methods. We have evaluated records obtained from the FACTS registry. We included 374 patients with AF and a history of stroke or TIA, from different areas of Romania, and collected data regarding antithrombotic therapy. Results. According to CHADS2 all patients were at high risk and should receive anticoagulation therapy. In our group 51,37% were treated with OAC alone and 15,77% with OAC in combination with antiplatelet therapy. Of OAC the most used drug was acenocoumarol and optimal anticoagulation (INR between 2 and 3) was found in 68% patients. There were no differences between genders and OAC prescription was not influenced by AF type. OAC was preferred in 68.52% patients with high bleeding score (HASBLED > 3). Conclusion. The main finding of the analysis was that adherence to guidelines recommendation concerning AF patients with previous stroke/TIA is still low. However, patients at high risk for stroke recurrence and high bleeding score were mostly treated according to current recommendations, suggesting that there is an increasing awareness and adherence to current clinical guidelines.

Total gastrectomy performed in emergency conditions for gastric necrosis due to acute gastric dilatation

Acute massive gastric dilatation is a rare event, with a pathogenesis still debated. Acute massive gastric dilatation invariably leads to necrosis and perforation. We present the case of a 50 year-old woman, admitted in emergency conditions with circulatory collapse and abdominal distension with the onset 12 hours prior to presentation. An emergency laparotomy was performed revealing a stomach occupying the entire abdominal cavity with necrosis and anterior pyloric perforation. The operation consisted in total gastrectomy with stapled Roux-en-Y anastomosis. The postoperative evolution was simple, without complications. Acute massive gastric dilatation is a severe, lethal condition with multiple etiologic factors like anorexia nervosa, trauma, diabetes, postoperative period in abdominal surgery, electrolyte disturbances. In most cases emergency surgical treatment is necessary, dictated by gastric necrosis or perforation. Conservative treatment may represent an option if it is early instituted.

Characteristics of patients with atrial fibrillation and history of stroke or transient ischemic attack - some results from the FACTS Database

Background and purpose. Atrial fibrillation (AF) is the most common arrhythmia in adult population and represents an independent risk factor for stroke with an annual risk for thromboembolic events for chronic fibrillation estimated at three to six percentage. The risk of stroke is five time more frequent in AF patients and the outcome of the ischemic stroke in AF patients is worse than other forms of ischemic stroke. There are few data regarding the specific management and outcome of the 200,000 estimated AF patients in Romania. The aim of the present study (part of the FACTS program) was to determine the characteristics of patients with AF/AFl and their management. In this paper we have analyzed the characteristics of the subgroup of patients with history of stroke or transient ischemic attack (TIA). Methods and results. From March 2011 to April 2012 a total of 3700 patients from 27 sites, ambulatories or hospitals, were enrolled including regions all over the country. Of this cohort 374 patients had documented history of stroke or TIA. Hypertension, sedentary lifestyle, associated diseases (cardiovascular and non-cardiovascular) statistically correlate with history of stroke/TIA. CHADS2 and CHA2DS2Vasc scores had higher values for patients with stroke/TIA. Conclusion. This database (part of the Romanian AF Registry) offers an insight into patient’s characteristics with AF/AFl and stoke/TIA history and provides comprehensive data that will allow a range of evaluation at national level and contribute to better understand the management of AF/AFl in Romania. Next evaluation aims to analyze anticoagulant therapy in patients with AF and especially of those with stroke/TIA history.

Left renal cyst - left duplex kidney with compromised superior renal unit and ectopic ureteral orifice in the prostatic urethra

The urinary abnormalities are an important health problem. If they are not recognized in due time, they usually lead to the loss of the renal unit function. In many cases, the diagnosis is late and incidental.

CASE PRESENTATION

We present the case of M.I., a 74-year-old male admitted in our surgical unit with diffuse left lumbar pain, low urinary tract symptoms and slow increase in abdomen volume in the past 4 years. Computer tomography scan and ecography showed a large left lumbar cyst like mass with a dilated supernumerary ureter with ectopic ureteral orifice in the prostatic urethra and apparently normal anatomic inferior renal unit. The goal was the excision of the "cyst like" mass (superior left renal unit) but because of the anatomical particularities (extensive fibrosis and local topographical changes) total nephrectomy was performed.

CONCLUSIONS

Given a normal contralateral kidney, the discovery of a urinary abnormality can be a real challenge, their evolution being a silent one. This type of disease can be suspected only with the development of clinical symptoms. The anatomic particularities (duplex kidney) together with the long evolution of the disease changed the local topography making the preservation of the inferior left renal unit a difficult, almost impossible task for the surgeon.

Laparoscopic treatment of perforated duodenal ulcer -- a multicenter study

AIM

The aim of this study is to evaluate the results of the laparoscopic treatment of perforated duodenal ulcer performed in 6 Romanian surgical centres with experience in the field of laparoscopic surgery.

MATERIAL AND METHOD

Between 1996 and 2005, 186 patients with perforated duodenal ulcer were operated on in the centers participating in this retrospective study, all patients being ASA I-II. Thirty-nine patients (20.0%) presented mild peritonitis, 120 (64.5%) medium peritonitis and 27 (15.5%) severe (20.0%) simple suture was performed, in 110 (59.1%) suture with epiplonoplasty, for 1 (0.5%) only epiplonoplasty and 1 (0.5%) underwent excision of the perforation and suture.

RESULTS

The operative time was between 30-120 minutes, with an average of 75 minutes. No death was noted. Average hospitalization time was 6 days, with periods varying between 3 and 18 days. Postoperative complications included: 5 patients (2,6%) presented infections of the abdominal walls, 1 patient (0.5%) duodenal fistula, 1 patient (0.5%) intra-abdominal abscess, 1 patient (0.5%) a superior digestive hemorrhage by "mirrored ulcer" and 1 patient (0.5%) duodenal stenosis 6 months after operation. The patients were administered 50% less analgesics, used 70% less dressings, 30% less antibiotics and had 60% less complications in comparison with those operated by the classical approach.

CONCLUSION

The laparoscopic approach of perforated duodenal ulcer constitutes the first choice for patients without important co-morbidities, allowing a quick recovery and a significant reduction in the consumption of analgesics, antibiotics and dressing materials.

[Bilateral anterior uveiopapillitis, suspicious of Lyme disease--case report]

We present the case of a patient which associated bilateral anterior uveitis manifestations with those of bilateral anterior inflammatory optic neuropathy. We followed the evolution of the case under treatment and we discussed the differential diagnosis and the association of the two ocular pathologies.

[Intraoperative floppy iris syndrome--a prospective study]

PURPOSE

is to evaluate the incidence and typical signs of floppy iris syndrome intraoperatory revealed in patients diagnosed with cataracts.

METHODS

We studied a total of 15 eyes diagnosed with cataracts, belonging to 14 patients who had been treated chronically with Tamsulosin for benign prostatic hyperplasia.

RESULTS

In 80% of cases we have seen a preoperative semimidriasis which required iris hooks in 5 eyeballs. On 1 eye preoperative semimidriasis was sufficient for capsulorhexis, but later pupil became miotic, requiring iris hooks. On 4 eye flaccid iris was noticed, that prolabated in corneal incision.

CONCLUSIONS

floppy iris syndrome occurs in patients treated with Tamsulosin for benign prostatic hyperplasia, generating a series of difficulties during cataract surgery.

Clinical, evolution and therapeutical considerations upon a case of fibrodysplasia ossificans progressiva (FOP)

Fibrodysplasia ossificans progressiva (FOP) is an autosomal dominant genetic transmitted disease, with a rare incidence (1-2 cases/million persons) and it usually affects female patients. Its manifestations include acute pain episodes that tend to repeat, involving the soft tissue and the axial muscles with later appearance of ectopic bone tissue in ligaments, joints and tendons. In the great majority of times, the skeletal modifications are observed at birth but the first clinical symptoms occur at 2-4 years old. The clinical symptoms include pain and inflammation of the soft tissue, sometimes associated with fever and cutaneous erythema, joint symptoms--pain, stiffness most frequently concerning the scapular and pelvic girdle, bone malformations--short hallux, microdactilia, kyphoscoliosis, thorax malformations. The diagnosis is established based on the clinical symptoms and the imagistic investigations: CT, MRI - which indicate the joint modification and the ectopic bone tissue. Muscular biopsy is not indicated as it leads to new lesions in the already traumatized areas.

The cardiovascular risk factors of the Roma (gypsies) people in Central-Eastern Europe: a review of the published literature

BACKGROUND

Estimated number of the Roma people in central-eastern Europe cannot be precisely appreciated, but official data suggest that in the 2004 they were approximately 4.2 million. At this time, there are few available data about the health status of the Roma people, mostly assessing genetic and infectious diseases, which reflect poverty, overcrowding, and lack of education. There is even less data regarding non-communicable and chronic diseases, especially cardiovascular diseases.

METHODS

We searched the published literature on the cardiovascular risk factors in Roma people using PubMed from January 2000 to July 2011. The searching criteria were: (1) randomized, prospective observational, retrospective and meta-analysis; (2) adult patients with cardiac diseases or cardiovascular risk factors (3) data available for cardiovascular patients. Search terms included dyslipidemia, obesity, tobacco, hypertension, and diabetes mellitus.

RESULTS

Twenty-five studies were identified. Approximately 75% of them were related to just four countries: Slovakia, Croatia, Czech Republic, and Serbia. This paper is a review based on existing literature concerning classical risk factors in Roma people with emphasis on their ethnical features. Despite limited data, the results showed that this ethnicity has the incriminated risk factors more frequently than the majority and consequently a higher cardiovascular morbidity rate.

CONCLUSIONS

Quantification of the cardiovascular risk factor and their implication in the shortening of life expectancy in Roma population was a provocation due to a paucity of reliable data. At this time, we should pay more attention on the Roma health issues and the cultural concerns that might affect them in the context of borderless Europe.

Ring autosomes: some unexpected findings

Ring chromosomes are rare entities, usually associated with phenotypic abnormalities in correlation with the loss of genetic material. There are various breakpoints and sometimes there is a dynamic mosaicism that is reflected in clinical features. Most of the ring chromosomes are de novo occurrences. Our study reflects the experience of three Romanian cytogenetic laboratories in the field of ring chromosomes. We present six cases with ring chromosomes involving chromosomes 5, 13, 18, and 21. All ring chromosomes were identified after birth in children with plurimalformative syndromes. The ring chromosome was present in mosaic form in three cases, and this feature reflects the ring's instability. In case of ring chromosome 5, we report a possible association with oculo-auriculo-vertebral spectrum.

Considerations on dental bridges' stability and balance for mandibulary teeth with coronary-root amputation

Dental occlusion represent the function of dentomaxillary system at which realization participate all the components of that system holding the equilibrium between them. Setting up the treatment with dental bridges in partial edentuluous is rule by some principles that have aims like restore the morphology and functions change by edentuluous condition and also prevention disorders of remaining teeth and other structures and functions of dentomaxillary system. During the prosthetic treatment with fixed bridgeworks in clinical cases presents in this study , we used also terapeutical techniques specifically other dental domains like endodontology and oral surgery. For avoid the appearance of occlusal dysfunction is necessary a good knowledge and respecting the biomorphocinematic behaviour of dentomaxillary system structure under action of occlusal force during mastication and also biomechanical rules that influence the functional equilibrium of teeth and dental bridges.

Genetic disorder or toxoplasma myocarditis: a case report of dilated cardiomyopathy with hypertrabeculation in a young asymptomatic woman

Isolated noncompaction of the left ventricle (LV) is a rare disorder, classified as a primary genetic cardiomyopathy by the American Heart Association. The European Society of Cardiology Working Group on Myocardial and Pericardial Diseases classified LV noncompaction as an unclassified cardiomyopathy. LV noncompaction cardiomyopathy characterized by the following features: 1) an altered myocardial wall with prominent trabeculae and deep intertrabecular recesses resulting in thickened myocardium with two layers, consisting of compacted and noncompacted myocardium and 2) continuity between the left ventricular cavity and the deep intertrabecular recesses, which are filled with blood from the ventricular cavity, without evidence of communication with the epicardial coronary artery system. Features of LV noncompaction can overlap with dilated cardiomyopathy, hypertrophic cardiomyopathy (especially the apical variant), and restrictive cardiomyopathy. The phenotypic expression can vary considerably within the same family. The LV noncompaction can rarely occur as a transient phenomenon during myocarditis. We present the case of a 23-year-old patient, admitted to our Department for cardiac evaluation because of ECG changes and cardiac enlargement revealed at thoracic radiography. She had a history of chronic toxoplasmosis. An echocardiography was performed revealing left ventricular enlargement with severe systolic and diastolic dysfunction, diffuse hypokinesia and signs of isolated left ventricular non-compaction. Under these circumstances, we have considered the presence of isolated left ventricular non-compaction. A cardiac Magnetic Resonance Imaging was performed and it sustained the diagnosis. The alternative cause of isolated left ventricular noncompaction (prominent trabeculation due to myocardial toxoplasmosis) was considered improbable.

Two cases of infection with Bacillus anthracis, Romania, October 2011

A cluster of two confirmed cases of anthrax were reported in October 2011 from a small village with a population of 3,400 people, in south-eastern Romania.One was a fatal case of cutaneous and anthrax meningoencephalitis, while the other had cutaneous anthrax. Both cases had been exposed to one Bacillus anthracis-infected cow via consumption of its meat or being involved in its slaughter.

Two cases of infection with Bacillus anthracis, Romania, October 2011

A cluster of two confirmed cases of anthrax were reported in October 2011 from a small village with a population of 3,400 people, in south-eastern Romania. One was a fatal case of cutaneous and anthrax meningoencephalitis, while the other had cutaneous anthrax. Both cases had been exposed to one Bacillus anthracis-infected cow via consumption of its meat or being involved in its slaughter.

Multifactorial anticancer effects of digalloyl-resveratrol encompass apoptosis, cell-cycle arrest, and inhibition of lymphendothelial gap formation in vitro

Background:

Digalloyl-resveratrol (di-GA) is a synthetic compound aimed to combine the biological effects of the plant polyhydroxy phenols gallic acid and resveratrol, which are both radical scavengers and cyclooxygenase inhibitors exhibiting anticancer activity. Their broad spectrum of activities may probably be due to adjacent free hydroxyl groups.

Methods:

Protein activation and expression were analysed by western blotting, deoxyribonucleoside triphosphate levels by HPLC, ribonucleotide reductase activity by ¹⁴C-cytidine incorporation into nascent DNA and cell-cycle distribution by FACS. Apoptosis was measured by Hoechst 33258/propidium iodide double staining of nuclear chromatin and the formation of gaps into the lymphendothelial barrier in a three-dimensional co-culture model consisting of MCF-7 tumour cell spheroids and human lymphendothelial monolayers.

Results:

In HL-60 leukaemia cells, di-GA activated caspase 3 and dose-dependently induced apoptosis. It further inhibited cell-cycle progression in the G1 phase by four different mechanisms: rapid downregulation of cyclin D1, induction of Chk2 with simultaneous downregulation of Cdc25A, induction of the Cdk-inhibitor p21^Cip/Waf and inhibition of ribonucleotide reductase activity resulting in reduced dCTP and dTTP levels. Furthermore, di-GA inhibited the generation of lymphendothelial gaps by cancer cell spheroid-secreted lipoxygenase metabolites. Lymphendothelial gaps, adjacent to tumour bulks, can be considered as gates facilitating metastatic spread.

Conclusion:

These data show that di-GA exhibits three distinct anticancer activities: induction of apoptosis, cell-cycle arrest and disruption of cancer cell-induced lymphendothelial disintegration.