Archive issue

Current Health Sciences Journal

vol. 46 no. 4, 2020

1. Biliary Stenting for Malignant Biliary Obstruction Secondary to Pancreatic Cancer


Despite progresses made in oncology, pancreatic adenocarcinoma has a grim prognosis and commonly presents with rapidly advancing jaundice which requires endoscopic treatment. Aim: Our objective was to show the perspective of a high ERCP volume dedicated Center on endoscopic stenting for malignant biliary obstruction consecutive to pancreatic cancer. Methods: We conducted a retrospective study, between October 2017 and October 2020, and enrolled hospitalized patients within the Gastroenterology Department of the Clinical Emergency Hospital Bucharest, diagnosed with pancreatic cancer with secondary malignant biliary obstruction which underwent ERCP stenting. Results: We identified 269 patients which were admitted in our Clinic with a pancreatic lesion on computed tomography or magnetic resonance imaging and underwent EUS-FNA. 115 patients with proven pancreatic malignancy were selected and underwent ERCP stenting. 69 received plastic stents and 46 metal biliary stents, with the stent chosen based on patient’s characteristics and availability at the time of the procedure. Per total 234 stents were used for relief of the cholestasis syndrome. The number of ERCP procedures was higher in the plastic stents group with a median of 1,8 whereas the SEMS had 1,5 range of procedures. Procedures were successful in 54 patients following plastic stents and 33 that underwent SEMS. At 30 days, overall mortality rate was of 5%. Conclusions: Malignant obstruction secondary to pancreatic cancer is amenable by ERCP. However, choosing the right stents still varies. SEMS seem to be more efficient on a long term with fewer complications rates and further studies should be performed

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2. Developmental Abnormalities of the Skull Base in Patients with Turner Syndrome


The skull base is one of the most complex anatomic structures of the skeleton that is responsible for protecting and supporting the brain and is also involved in the development of the facial structures. The main objective of our study was to evaluate skull base abnormalities in a group of patients diagnosed with Turner syndrome by assessing lateral cephalometric radiographs. A total of 7 patients diagnosed with Turner syndrome in the Endocrinology Department of the Emergency Clinical County Hospital of Craiova were included in the study. The following cephalometric variables were measured in our study: total skull base (N-Ba): Nasion (N)-Basion (Ba); anterior skull base (N-S): Nasion (N)-Sella (S); posterior skull base (S-Ba): Sella (S)-Basion (Ba). Regarding the investigated cephalometric variables, the mean±standard deviation (SD) recorded values in our study were 86.34±4.26mm for the total skull base (N-Ba), 63.87±2.54mm for the anterior skull base (N-S) and 38.33±4.87mm for the posterior skull base (S-Ba). The results of our study were compared to the ones provided by one of the most representative studies described in the literature. A reduced size of the posterior base of the skull is considered pathognomonic in subjects diagnosed with Turner syndrome. Also, the posterior base of the skull directly influences the maxillomandibular skeletal relationships and it is therefore necessary to calculate this cephalometric variable, which is easily highlighted on a lateral cephalometric radiograph.

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3. Clinicopathological Study of 117 Body Fluids: Comparison of Conventional Smear and Cell Block Technique


Background. Cell block method (CB) has emerged as an invaluable tool for diagnosis of effusions. It can help overcome the problems faced by conventional smear (CS) by differentiating between reactive, inflammatory and malignant cells. The aim of the study is to compare and correlate the CB diagnosis with the CS findings of various pathological conditions including malignancy. Materials and Methods. Two years prospective cross-sectional study of 117 fluids received for routine examination and/or for cytology was conducted. CS as well as CB was simultaneously prepared from the fluid and the results were correlated and tabulated for statistical analysis. Results. Mean age of presentation was 43±21.1 years and male: female ratio was 1.3:1. Ascitic fluid (46.2%) was the most common followed by pleural (40.2%). Among malignancies, primary ovarian and lung carcinoma were the most common to present with malignant ascites (33.3%) and pleural effusion (66.7%) respectively. Six suspicious for malignancy on CS were provided a definitive diagnosis of malignancy on CB. Overall, CB increased the yield of malignancy by 8.3%. The agreement between CB and CS for malignant effusions and suspicious for malignancy were 41.7% and 14.3% respectively. Sensitivity of CS method when compared to CB, for malignant peritoneal and pleural effusions was 90% and 75% respectively while the specificity was 68% and 79% respectively. Conclusion. CB has a better diagnostic yield of malignancy and helps in providing a definitive diagnosis for cases that are suspicious for malignancy on CS. Hence, CB should be routinely employed along with CS for all effusions.

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4. Oral Mucosa Changes Associated with Wearing Removable Acrylic Dentures


The main purpose of the study was to highlight the incidence of various changes in the oral mucosa associated with wearing removable acrylic dentures. Materials and method. The study was performed on a total of 45 subjects who presented at the Prosthodontics Clinic and the Oral Rehabilitation Clinic of Craiova Faculty of Dental Medicine during January 2018-May 2020. Results. Of the 45 subjects that were wearing at least one acrylic denture 31,11% presented oral mucosa changes or lesions. The most common mucosal lesion was type 1 according to Newton's classification.

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5. Systemic Immune-Inflammation Index (SII) Predicts Increased Severity in Psoriasis and Psoriatic Arthritis


Background: Psoriasis is a common chronic inflammatory dermatosis. Systemic immune inflammation index (SII) is an inflammation-based biomarker, which has been shown to be an effective prognostic factor in diseases with an inflammation-related etiology. Objectives: The aim of the present study was to investigate the potential efficacy of SII as a prognostic factor in patients with psoriasis and psoriatic arthritis. Materials and methods: This is a study developed based on the analysis of the medical records of patients with psoriasis. The study retrospectively evaluated the records of the participants for complete blood count results. The SII was calculated by the formula: neutrophil x platelet/lymphocyte. Neutrophil-lymphocyte ratio (NLR), monocyte-lymphocyte ratio (MLR) and platelet-lymphocyte ratio (PLR) were determined. Results: SII was significantly higher in patients with psoriasis than in controls (578.1 vs. 396, p<0.001). The differences between the median NLR (2.2 vs. 1.5, p<0.001), MLR (0.25 vs. 0.21, p<0.001) and the mean red cell distribution width coefficient of variation (13.8 vs. 12.8, p<0.001) values of patient and control group were significant. SII was higher in patients with moderate/severe psoriasis than patients with mild psoriasis (687.3 vs. 506.6, p=0.034). A positive correlation was observed between SII and PASI (p<0.001; r=0.37). SII was higher in patients with arthritis than patients without (672.1 vs. 548.2, p=0.018). Conclusion: This is the first study to prove that SII might serve as an independent prognostic indicator for patients with psoriasis and psoriatic arthritis.

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6. Palate Squamous Cell Carcinomas: A Ten-Year Single Institute Experience


The literature date estimated that about 5% of all oral cavity cancers are hard palate cancers while soft palate cancers account for about 5-12% of oropharyngeal cancers. Although rare, usually these tumors had a more aggressively behavior than other oral cancer sites. That is why our study aimed to investigate comparatively the epidemiological, clinical and histopathological peculiarities of the two palatal sites of oral squamous cell carcinomas. We conducted a retrospective study limited to a period of 10 years in a single medical institution to investigate the morphoclinical profile of such tumors. We found that patients with hard palate SCCs had an average age slightly larger compared to those who developed soft palate tumors. Also, those with hard palate tumors are mostly diagnosed in less advanced stages compared to those at the level of the soft palate, and implicitly the former had a longer survival time. Histopathologically the most encountered hard palate SCC were the conventional well-differentiated tumor, and from the peculiar SCC variant the papillary and verrucous forms while for the soft palate SCC prevailed the moderate and poor differentiated conventional SCC and from the peculiar SCC variant the basaloid and acantholytic forms. In conclusion hard palate tumors differ in many aspects from those of the soft palate, and thus specification of the origin tumor site become important for the assessment of prognosis, treatment and survival outcome of such patients.

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7. Oxidative Stress and Vitamin D as Predictors in Multiple Sclerosis


Multiple Sclerosis (MS) is a multifactorial demyelinating diseases that affect mostly the young and active people. Here, is crucial to identify new strategies in order to slow down the diseases progression and maintain a good functional outcome. Our hypothesis was that the interconnection between anti-oxidant molecules and anti-inflammatory or neuroprotective molecules can act as predictors of diseases progression. In the study were included 36 patients with MS. Inclusion criteria were the following: patients over 18 years old were divided in three groups, 16 relapsing-remitting MS (RRMS) group, 10 secondary progressive MS (SPMS) group and 10 healthy control group. We showed that the vitamin D sufficiency did not improve de EDSS score in the later stage of diseases. Also, we showed that in the early stage (RRMS) the vitamin D status can significantly improve the EDSS and IADL score and may slow down the diseases progression. started with the early stage of diseases (RRMS) we found that catalase activity, an enzyme that act as anti-oxidant, is significantly decreased compare with healthy people, and can be associated with a low level of vitamin D. we concluded that a pro-oxidative and anti-oxidative balance is an important player in the multifactorial mechanism of MS diseases progression and additional prospective studies are needed to determine optimal vitamin D levels that lead to clinical and immunological benefits for patients with MS. Long-term follow-up studies using high-dose vitamin D supplementation are needed to confirm the preliminary results of the studies.

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8. Claudin-4 Immunoexpression in Urothelial Carcinomas


The involvement of claudins in urothelial carcinogenesis is controversial. In this study, we analyzed Claudin-4 immunoexpression in 50 cases of bladder urothelial carcinomas depending on the main prognostic parameters of the lesions represented by the tumor grade and tumor extension. Claudin-4 immunoexpression scores were significantly higher in high-grade urothelial carcinomas and in tumors with invasion in muscularis propria. The results obtained indicate the involvement of Claudin-4 in the progression of urothelial bladder carcinomas.

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9. Inflammation and Arterial Hypertension-Pathophysiological Links and Clinical Aspects


Arterial hypertension represents one of the most common pathologies in the adult population. Hypertensive patients have structurally altered arteries, with a higher rigidity that leads to a significant decrease in vascular compliance. At the base of the pathophysiological process stands the inflammation, as a reaction of the organism to injury. Objectives: This study aims to highlight clinical-paraclinical correlations in people diagnosed with arterial hypertension and inflammatory status. Thus, we would like to evaluate possible correlations between the usual inflammatory markers and blood pressure values. Materials and methods: The sample comprises 64 adults who were subsequently divided based on the diagnosis of arterial hypertension, by using Automatic Blood Pressure Monitoring, as following: Study group=26 patients (with arterial hypertension) and Control group: 38 patients (without arterial hypertension). Results: The study has revealed negative correlations between the neutrophil/lymphocyte ratio (NLR) and the general diastolic average (r=-0.248 and p=0.047), the diurnal diastolic average (r=-0.258 and p=0.038) and the diurnal mean arterial pressure (r=-0.249 and p=0.046) and a negative correlation between the red cell distribution width (RDW) and the dipping index (r=-0.402 and p=0.013), each of them accomplishing the level of statistical significance. Conclusions: NLR can be used as a predictor of diastolic blood pressure values and as a factor of prognosis for the evolution of arterial hypertension. RDW is higher in non-dipping patients.

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10. Imaging of the Posttraumatic Knee in Pediatric Patients


Owing to its continuous transformation, the musculoskeletal system of pediatric patients presents some unique features with respect to both anatomy and physiology. The lesional pattern of the knee in pediatric patients is both similar to and in many aspects different from the lesional pattern in adults with knee injuries. In the case of pediatric patients, meniscal, tendinous and ligamentous lesions occur most frequently as a consequence of traumatic episodes. The purpose of the present study is to emphasize the importance of MRI examinations in pediatric patients exhibiting symptoms of knee joint injury. The imaging assessment of the extent of the lesions, which can be either simple or complex alterations, can directly influence the clinical management of these cases by appreciating the growth potential of the specific segment of immature skeleton involved.

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11. Managing Low Back Pain in Primary Care


Low back pain (LBP) is one of the most common pathologies for which patients present for consultation in primary medical practice. The objective of the study was to determine the number of patients with LBP who presented to the general practitioner 's (GP) office between October 2019 and March 2020, to determine risk factors, favoring factors and their correlation with clinical data obtained after performing the clinical examination, with paraclinical data obtained by imaging investigation. 347 patients, aged between 17 and 82 years, were included in the study, presenting a sex ratio of men: women of approximately 2: 1. The main pain symptoms of the patients were: localized pain in the lumbar spine, radicular pain, referred to the lower limbs, subjective sensitivity disorders felt in the lower limbs, distal motor deficit in the lower limbs, paravertebral muscle contractions and the feeling of instability in the low back. The main risk factors were smoking, the existence of a trauma to the lumbar spine, sedentary lifestyle, maintaining a prolonged fixed position and intense physical exercise, either occasionally or daily. Among the patients included in the study, a number of 93 patients required the granting of medical leave both by the attending GP and by other specialists. Regardless of the etiology and pathophysiological mechanisms involved in the occurrence of LBP, therapeutic management should aim to stop pain symptoms and prevent recurrences.

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12. Analysis of Prostate Adenocarcinoma Histopathological Types in Relation to Tumor Grade


Prostate adenocarcinomas are some of the most common malignancies diagnosed in men, and the evaluation of tumor growth patterns is the basis for establishing the aggressiveness of the lesions. The study included 283 cases of prostate adenocarcinomas for which histopathological type and tumor grade were analyzed. The results indicated the association of ductal, sarcomatoid and signet ring-like cell types with aggressive growth patterns and high scores, atrophic and pseudohyperplastic types with mild growth patterns and low scores, foamy gland type presented intermediate growth patterns/scores, while conventional and colloid types had variable aspects. The grading systems used may be considered consistent with the histological types of prostate adenocarcinomas.

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13. Correlations Between the Glasgow Score and the Survival Period in Patients with Severe Traumatic Brain Injury


Traumatic brain injury (TBI) contributes by 30% to the mortality induced by traumatic injuries, also being one of the major causes of invalidity worldwide. The clinical classification of the severity of mild, moderate or severe TBI is made according to the Glasgow scale, according to the patient’s conscious state, motric changes, speech changes and eye opening. In our study, we evaluated the correlation between the Glasgow score at admission and the survival period of patients suffering from TBI, using the data recorded in the Forensic Medicine Institute of Craiova between 2011-2017 on 1005 cases with the diagnosis of death by TBI. We observed that TBI affects persons of all ages, starting from babies up to the elderly aged over 90 years old. Regarding the generation mechanism, most deaths were caused by fallings (438 cases, 43.58%), followed by car accidents (333 cases, representing 33.13%). The number of patients who presented a post-traumatic survival period was 802 (79.80%), of which 779 adults (77.51%) and 23 children (2.29%). Among these, 785 (78.11%-764 adults and 21 children) were hospitalized, while in 64.58% of the TBI patients there was recorded the Glasgow score at admission. 75% of the TBI patients in whom there was recorded the Glasgow score presented a 1st-4th coma degree, with a Glasgow score from 3 to 8 and only 25% had a slightly altered or preserved conscious state, with a Glasgow score=9-15. The survival period varied from less than 24 hours to over 15 days. In the hospitalized patients, there were performed emergency surgeries in 269 (26.76%) cases, the surgical intervention being temporized in 108 (10.74%) patients.

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14. Involvement of Oxidative Stress in Resistance to Tyrosine-Kinase Inhibitors Therapy in Chronic Myeloid Leukemia


Oxidative stress involves disruption of the cellular redox status through excessive production of reactive oxygen species or through deficiency in the cellular antioxidant capacity. It is involved in the pathogeny of multiple entities (hematological diseases, metabolic disorders, cardiovascular and renal pathology etc.), as well as in the pharmacokinetics of specific treatments for these pathologies. Chronic myeloid leukemia is a chronic myeloproliferative disease for which current standard treatment is BCR-ABL tyrosine kinase inhibitors. The innovation of this therapy has significantly improved life expectancy for patients with chronic myeloid leukemia, but in some cases, this treatment becomes ineffective, installing the resistance to tyrosine kinase inhibitors therapy. There were described two types of tyrosin kinase inhibitors resistance: primary and secondary resistance. In the present paper we proposed to evaluate the involvement of oxidative in the resistance to tyrosine kinase inhibitors therapy, in the clonal instability in chronic myeloid leukemia and in the progression of the disease to an advanced stage. We concluded that oxidative stress can play a dual role in the evolution of chronic myeloid leukemia: on the one hand it can promote genomic instability and accelerate the progression of the disease to advanced stages associated with tyrosin kinase inhibitors resistance and, on the other hand, it can contribute to leukemic cell apoptosis. It seems to be outlined a fragile balance between the pro- and anti-apoptotic effects of the reactive oxygen species, closely related to their level in the leukemic cells.

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15. Thyroid Angiosarcoma-Rare Case or Hard to Find


Introduction: Thyroid Angiosarcoma is a rare malignant condition of the thyroid gland with higher incidence reported in mountainous Alpine regions (Switzerland, Austria and northern Italy), featured with poor prognosis. Case presentation: A 76 years old male patient presented in our hospital complaining about difficulty in breathing, altered voice (hoarseness), fatigue and dysphagia. Careful observation of the frontal neck region revealed hemorrhaging petechiae and purpura, while palpation indicated a large nodule movable with deglutition, presumably derived by the thyroid gland. Serum biochemical thyroid function tests were normal. Ultrasound of the thyroid gland showed enlargement of the right lobe with a nodular lesion. FNAC indicated a “suspicious for malignancy” lesion. After patient’s consensus, total thyroidectomy took place accompanied by excision of infiltrated infrahyoid muscles. The cytopathologic results were positive for primary thyroid angiosarcoma. Patient’s postoperative condition was regular, but he died of disease progression 6 months later. Discussion: Angiosarcomas are malignant neoplasms arising from endothelial cells of blood vessels. They are most commonly found in skin, soft tissue, breast, bone, liver and spleen. Angiosarcomas tend to be highly hemorrhaging and invasive. Thyroid gland is a rare location of development. Cytopathologically they are grossly characterized by freely anastomosing vascular channels lined by atypical endothelial cells unusually enlarged, often multinucleated with many nucleoli and vacuoles into the cytoplasm containing fragments of erythrocytes. The immunohistological identity of angiosarcomas are endothelial line markers (CD31, CD34 and vimentin). Surgical excision when feasible is the first line treatment while adjuvant radio-and/or chemo-therapy are ambiguous. Infiltration of surrounding tissues and distant metastasis (lymph nodes and lungs) are negative prognostic factors.

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16. Paroxysmal Atrial Fibrillation of Vagal Mechanism with Episodes of Wide QRS Complex Tachycardia Due to Gouaux-Ashman’s Phenomenon


A 38-year-old male patient consulted for nocturnal palpitations described as fast chest pounding that woke him up from sleep. A physical examination yielded no remarkable findings. A 24-hour Holter ECG monitoring demonstrated nocturnal episodes of paroxysmal atrial fibrillation (PAF) with the coexistence of wide QRS complex tachycardia. To the best of our knowledge, this is the first reported case of nocturnal episodes of wide QRS complex tachycardia during vagally mediated PAF resulting from Gouaux-Ashman’s phenomenon. It is paramount for general physicians to recognize this phenomenon because it should be differentiated from ventricular tachycardia, since prognosis and treatment of both entities are entirely different. General and emergency physicians should be aware in order to improve adequate diagnostic and therapeutic management of the arrhythmic episodes.

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17. Chronic Spontaneous Pneumoperitoneum with Pneumatosis Cystoides Intestinalis of the Small and Large Intestine


Pneumoperitoneum can be an alarming radiological finding and a manifestation of a surgical emergency that warrant urgent intervention, or it can be a manifestation of chronic benign condition that can be managed conservatively. The sequela of misdiagnosing pneumoperitoneum due to surgical abdomen as a chronic benign pneumoperitoneum can be life-threatening and misdiagnosing chronic spontaneous pneumoperitoneum due to chronic condition as surgical emergency will lead to unnecessary surgical interventions. Diagnosis of chronic spontaneous pneumoperitoneum can be challenging to the unwary healthcare-providers. We present a case of chronic pneumoperitoneum secondary to pneumatosis cystoides intestinalis that has been managed conservatively.

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18. Policeman to the Rescue; A Case of Ruptured Hepatocellular Carcinoma


Spontaneous rupture of hepatocellular carcinoma (HCC) are rare. Most cases present with acute abdominal pain and hemorrhagic shock. Various modalities of treatment are available which range from conservative treatment to surgical excision of the tumour. Various factors have to be considered when deciding on the treatment, but patient prognostic factors is the key in decision making. In this case we decided on an early laparotomy and surgical excision of the tumor since the patient was hemodynamically stable and as the omentum adhered to the site of rupture. Treatment in these cases requires a multidisciplinary approach to decide on the best possible procedure for each case.

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