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Liver transplantation is the last life-saving solution for patients with end stage liver disease. The discrepancy between waiting list and available organs has led to the appearance of extended donation criteria and the development of several scores (Child-Pugh score, MELD score, DRI score, SOFT score), in order to find the most suitable donor-recipient match. But none of these scores can predict survival after transplantation. Artificial Intelligence (AI) has recently been shown as an excellent tool for the study of the liver and comes in this aid with its various methods (random forest, artificial neural networks, decision tree, Bayesian networks, and support vector machine). Materials and Methods. By reviewing the literature (mostly retrospective multicenter studies), we aimed to establish if the AI is a proper or even a more accurate method of predicting posttransplant survival, in comparison with the existing linear statistical models. Results. Machine learning showed better results than several current scoring systems that use either isolated donor/recipient scores or combined donor/recipient factors. The advantages of this model are its capacity for analyzing both linear and nonlinear relationships between features and outcomes, its robustness of overfitting by design, and built-in insights into feature importance aiding model explainability. Nevertheless, machine learning has its limitations because it requires large amounts of data, which can be difficult to obtain, it also requires high levels of technical skill, can be difficult to engineer and it’s expensive. Conclusion. AI may have significant potential in aiding clinical decision-making during liver transplantation, including donor-recipient matching.

Colorectal cancer is currently a public health concern due to its high incidence, morbidity, and mortality rates. Researchers have identified the intestinal microbiome as a crucial factor in the development of this disease. Currently, specialized literature data support the role of the microbiota in both the development of colorectal cancer and resistance to oncological therapies. Therefore, studying the composition of the gut microbiome can aid in creating risk assessment tools to identify specific populations that would benefit from tailored screening approaches. Also, manipulation of the intestinal microbiome can be useful in improving the response to chemotherapy or immunotherapy. Identifying the pathogenic mechanisms responsible for this causal link can aid in the discovery of novel treatment targets. This article will provide the latest information regarding the influence of the intestinal microbiota on the development and progression of colorectal cancer.

The awareness concerning RNA-based therapies was boosted significantly after the successful development of COVID-19 vaccines. However, they can potentially lead to significant advances in other areas of medicine, such as oncology or chronic diseases. In recent years, there has been an exponential increase in the number of RNA-based therapies that were evaluated as potential treatments for cardiovascular disorders. One of the areas that was not explicitly assessed about these therapies is represented by their overall ethical framework. Some studies evaluate ethical issues of RNA-based treatments in general or targeting specific disorders (especially neurodegenerative) or interventions for developing RNA-based vaccines. Much less information is available regarding the ethical issues associated with developing these therapeutic strategies for cardiovascular disorders, which is the main aim of this study. We will focus our analysis on three main topics: risk-benefit analysis (including the management of public awareness about these technologies), and justice (in both research and clinical medicine).

Colorectal cancer is the second leading cause of cancer-related mortality worldwide. Numerous pathophysiological mechanisms, such as abnormal cell proliferation, cell differentiation, resistance to apoptosis, invasion of structures adjacent to colorectal tumor cells, and distant metastasis, are involved in colorectal carcinogenesis. These processes are initiated by the complex interaction of a number of genetic and environmental factors, including sedentary lifestyle, obesity, alcohol consumption, smoking, or gut microbiota. Despite the significant progress achieved in the diagnostic and therapeutic management of patients with colorectal cancer, there has been recently a noteworthy increase in the incidence of colorectal cancer in individuals below the age of 50 years. Early-onset colorectal cancer has a different frequency of oncogenic mutations, a higher prevalence of mucinous histology, a distinct deoxyribonucleic acid (DNA) methylation profile, a more distal location, and lower survival rates. A significant improvement in the prognosis of these patients can be achieved through the detection and removal of modifiable risk factors, along with the implementation of personalized screening strategies for individuals at high risk for this malignancy. Furthermore, gaining comprehension of the pathophysiological mechanisms by which these risk factors contribute to the process of oncogenesis may facilitate the discovery of novel therapeutic targets.

The digital transformation of healthcare services is a hot topic during the coronavirus disease 2019 (COVID-19) pandemic. To limit the spreading of the severe acute respiratory coronavirus 2 (SARS-CoV-2), in a short period of time an accelerated digitalization took place in many societies. The direct, physical interaction between doctors and patients was replaced by digital types of communication and examination, to avoid the patients’ exposure to the risk of infection in healthcare facilities or during their travel to hospitals or medical offices. Telemedicine was introduced as an alternative option, being reimbursed for consultations and remote monitoring of patients with different pathologies. The role of the digital healthcare services when the pandemic will end and will eventually transform in endemic in certain areas and populations is unclear now. A large part of the modern communication, either professional or personal implies the use of digital technologies (e-mail, SMS, message sharing apps, video etc.) and different social media platforms or applications (apps). In healthcare facilities, patients’ medical data are almost entirely recorded in a digital system and can be easily accessed and shared with different physicians. The remote approach is a valuable tool for patients’ convenience when the social interaction is impossible or prohibited. However, issues related to protection of personal data and data security have been raised in this context, especially in highly regulated healthcare systems. Moreover, there are legitimate concerns that physicians will limit their physical interaction with patients and the medical examination will be entirely digital, without the touch of empathy, compassion, and direct human-to-human communication and support, that have been part of the art of medical practice for centuries. The digitalization may also increase the risk of social inequalities, where patients without access to modern digital technologies or internet may be left behind. Another issue is related to medical responsibility when using artificial intelligence: will the doctor be held responsible for negative results when applying the digital algorithms and digital decision-making tools? The responsibilities must be clearly defined. There are opinions that digitalization of healthcare services will not necessarily lead to better patients’ outcomes, despite their increased accessibility. One big concern is related to the teaching methods of medical universities. The traditional academic model of teaching medical students to the bedsides of the afflicted and practical training in the hospitals has largely shifted during COVID-19 pandemic to online teaching methods. In this context, there is the possibility that a few generations of medical students will graduate without bedside clinical instruction or contact between students and patients. What will be the impact on the medical practice in the future? Nobody knows yet. There is a high probability that the future of medicine will be hybrid, divided between face-to-face visits and virtual care and monitoring. Healthcare digital technologies can be used in certain clinical settings, where their added value is undeniable, and they offer better outcomes at a reasonable cost. Where they lead to poorer healthcare outcomes or inequalities, the traditional medical approach should be preferred. Digitalization of healthcare services must be driven by the needs of patients and health care professionals, to shape a better future of patient’s care.

Myocarditis is an inflammatory disease of the myocardium, that can be produced by a multitude of infectious or noninfectious agents. The incidence rate of the disease is between 10 to 22 per 100,000 individuals. Among the infectious causes, viruses are considered to be the most frequent pathogens. Regarding the clinical presentation, viral myocarditis may have a wide variety of manifestations, ranging from asymptomatic disease to chest pain, myalgia, fatigue, heart failure, arrhythmias and, in some cases, sudden death. A definitive diagnosis of viral myocarditis involves histological evidence for myocarditis associated with positive viral polymerase chain reaction (PCR). Endomyocardial biopsy represents the gold standard for diagnosis; in the absence of histological, immunologic and immunohistochemical criteria, a definitive diagnosis cannot be established.

Hematogenous path remains an important pathway of spread for ovarian cancer; the most commonly reported sites of involvement are represented by liver and lungs. The aim of this paper is to report a rare situation in which adrenal metastasis from ovarian carcinoma was encountered. Case report. The 55-year-old patient with previous history of surgically treated ovarian cancer was diagnosed at 18 months follow-up with an isolated lesion at the level of the right adrenal gland. After completing the biochemical analysis, in order to exclude an endocrine disorder, the final suspicion of diagnostic was of an adrenal metastasis and was submitted to adrenalectomy. The histopathological studies confirmed the presence of an adrenal metastasis of ovarian cancer. Conclusions. Although rare situations, adrenal metastases from ovarian cancer can be encountered and might be successfully treated by surgery with curative intent.

The aim of this study is to analyze the feasibility and safety of left upper abdominal resections as part of debulking surgery. Case series presentation. Between January 2015 and August 2019, 32 patients were submitted to left upper abdominal resections. Left upper abdominal resections were performed as part of primary cytoreduction in 22 cases, as part of secondary cytoreduction in eight cases, and respectively as part of tertiary cytoreduction in two cases. The complexity of the resection increased from primary to secondary and tertiary cytoreduction; in the meantime, the rates of postoperative complications also increased with the attempt of cytoreduction. Therefore the postoperative morbidity rate was of 27% at the time of primary cytoreduction, 37.5% at the time of secondary cytoreduction and 50% at the time of tertiary cytoreduction. However, association of left upper abdominal resections leaded to a complete resection rate of 77% at the time of primary cytoreduction, 62.5% at the time of secondary cytoreduction and 50% at the time of tertiary cytoreduction. Conclusions. Left upper abdominal resections might increase the rates of complete debulking in the setting of advanced stage or relapsed ovarian cancer. However the complexity of procedures and the risk of postoperative complications increase with the number of attempts of debulking.

Nowadays, more and more evidence points out to the interrelationship between intestinal microbiota and cardiovascular diseases. Gut microbiota is composed of a large number of microorganisms that live in the human gut and are involved in many physiological processes. Changes in the composition and activity of intestinal microbiota may lead or may accelerate the evolution of some cardiovascular diseases. Alterations in the composition of gut microbiota will induce dysbiosis, causing inflammation and initiating the development of cardiovascular diseases. These alterations may be secondary to intestinal infections, exposure to some environmental factors, changes in dietary habits, high stress, use of antibiotics. Studies have shown that gut microbiota is composed of six families, the Firmicutes, Bacteroidetes, Proteobacteria, Actino-bacteria, Fusobacteria, and Verrucomicrobia phyla1. These microorganisms are involved in the immune processes of the host, the fight against the pathogenic microorganisms and also in maintaining the integrity of intestinal barriers. Coronary heart disease and arterial hypertension are chronic diseases with a high prevalence. Some studies have demonstrated a link between the composition of gut microbiota and the increased risk of atherosclerosis, which is the main cause of coronary heart disease2,3. These studies have identified different species of bacteria, both in the gut and in the atheromatous plaques, suggesting that gut is a source of atherogenic bacteria2,3. The mechanisms by which these bacteria can initiate the atherosclerotic process (or in some cases protect against it) are still unknown. Trimethylamine N-oxide (TMAO) is a microbial metabolite that was studied for its effects on cardiovascular diseases after the discovery of a positive correlation between the serum level of TMAO and the atherosclerotic plaque area. This correlation was partially explained by the role that TMAO plays in the inhibition of reverse cholesterol transport and the accumulation of macrophage cholesterol4,5. One study has found that the TMAO level in patients with an acute coronary syndrome is an independent predictor of short-term and long-term major adverse cardiac events6. The implication of gut microbiota in arterial hypertension has been demonstrated by animal studies7,8. Adnan et al have shown that the blood pressure can be influenced by the exchange of gut microbiota between spontaneously hypertensive rats and Wistar-Kyoto rats7. The ratio of Firmicutes and Bacteroidetes is considered specific for intestinal dysbiosis9. In animal studies, the alteration of this ratio correlated with arterial hypertension, suggesting that gut microbiota could be a potential target of future antihypertensive therapies9. Heart failure is the final stage of evolution of the majority of cardiovascular diseases, with high mortality rates. One study has comparatively analyzed the bacteria and fungi in the feces of patients with heart failure with those of healthy controls and demonstrated that patients with chronic heart failure have more pathogenic bacteria10. Moreover, some species, like Candida, Shigella, and Campylobacter, were positively correlated with the severity of the heart failure10. Patients with heart failure, with decreased cardiac output, have gastrointestinal mucosa congestion and ischemia, with subsequent alterations in the composition of gut microflora and also intestinal functions. These alterations will lead to bacterial translocation, the release of endotoxins in the circulation, promoting a systemic inflammatory response. Some authors suggested that TMAO can be used as a biomarker for prognosis stratification in patients with heart failure11, although the exact mechanisms of increased levels of TMAO in patients with heart failure are still unknown. Other gut microbiota metabolites, p-cresyl sulfate and phenylacetylglutamine, have been suggested by some studies to be involved in the appearance of cardiovascular diseases12,13. Based on the above findings, the future cardiovascular therapies may include gut microbiota and their metabolites as potential targets. These therapies could be represented not only by drugs but also by diet changes and supplementation with prebiotics and/or probiotics.

Clostridium difficile infection (CDI) has become a global health challenge, due to the dramatic worldwide increase in incidence and severity in the past three decades. Furthermore, the incidence of CDI has increased in surgical patients. The surgery itself is a known risk factor, that, together with the postoperative care (hospitalization, antibiotic treatment, intensive care unit admission), facilitate the development of CDI. Therefore, a matter of paramount importance is the optimization of the management of surgical patients and prevention of Clostridium difficile infection.

Pre-procedure mitral regurgitation (MR) is a frequent coexistent finding in patients undergoing transcatheter aortic valve replacement (TAVR), and most of them (up to 55%) experience a significant improvement in MR after the procedure. Although seldom described, mitral valve perforation after TAVR is a potentially serious complication that physicians should be aware of, as moderate or severe MR in TAVR recipients is associated with a high early mortality rate. We herein describe the case of a 65-year-old man presenting with worsening heart failure symptoms 5 months after TAVR due to an intraprocedural anterior mitral leaflet perforation and discuss the diagnostic process and therapeutic course of the case. Furthermore, we draw attention to the essential role of echocardiography in the management of TAVR procedures, taking into account its ability in detecting early complications, and emphasize the value of CT as a main determinant to predict long-term MR improvement after TAVR and to assess the potential candidates for double valve repair with percutaneous techniques.

Background. The relationship between chronic pancreatitis and diabetes is well established. This form of diabetes is secondary to exocrine pancreatic disorder and is known as diabetes mellitus type 3c (T3cDM). Materials and Methods. In this retrospective study we included 261 patients, 59 patients being diagnosed with chronic pancreatitis and secondary diabetes mellitus, and admitted in the Fundeni Clinical Institute, 2nd Department of Gastroenterology or N.C. Paulescu Institute/ Carol Davila University of Medicine and Pharmacy. Results and Discussions. Patients were 22.2% women and 77.8% men, with an average age of 56.8 years and 53.4 years respectively. 63% came from urban areas. The mean duration of chronic pancreatitis was six years. Non-diabetic patients were compared with patients who were previously diagnosed with T3cDM and who had been analyzed for body mass index (BMI). Imaging investigations were also performed to confirm pseudotumors or pancreatic tumours. Patients already considered non-diabetic had basal blood glucose values and were mostly overweight and obese. In this context, insulin resistance cannot be excluded for this group of patients. Conclusions. T3cDM is a new pathological entity that needs to be explored more deeply, and that should benefit from both a diagnostic stratification and treatment.

Pyrrolizidine alkaloids (PAs) are a class of toxic compounds found in the composition of more than 6000 plants. People can be exposed to PAs by consuming phytotherapeutic products, food from crops contaminated with seeds of some species with high content of PAs, and/ or contaminated animal products like bee products. For this reason we developed and validated a method for quantitative determination of PAs, from the most frequently contaminated food sources, honey and flour. Colorimetric Ehrlich reagent method was used with standard addition (1mg/kg senecionine). The extraction solvent was methanol 50% acidified with citric acid to pH 2-3, as this solvent can be used for alkaloids and N-oxides. We found that, in extracting the alkaloid only once from the dietary sources, the percent of recovery is low (52.5% for honey, and 45.75% for flour). Using successive extractions, three times with the same solvent, the senecionine retrieval percentage increased to 86.0% for honey and 76.0% for flour. The method was validated using the following parameters: selectivity, linearity (0,25- 20 mg/ mL senecionine), accuracy (average recovery 93.5 - 107.93%) and precision (RSD 3,26-4.55%.). The calculated limit of quantification (0.174 mg/ mL) makes this method applicable for determining Pas occurring at toxic levels for consumers.

Introduction. In the last five years (from 1st of January 2013 to 31st of December 2017), we noticed 6 cases of rectal cancer, developed in patients who underwent stoma reversal more than two years before, for different pathologies. The objective of the study. That was a starting point to analyze whether the restoration of a total digestive diversion, well known to improve life quality, also increases the risk of malignancy. Material and methods. We studied all the patients with colostomy reversal hospitalized in the General Surgery Clinic of the Emergency Clinical Hospital “Sfântul Pantelimon“, Bucharest, Romania, in a ten years interval (1st of January 2008 – 31st of December 2017), no matter the primary cause of colostomy was. Results. Our study showed that stoma reversal increase the risk of developing a rectal malignancy two years from restoration. Conclusions. We recommend annual control by recto‑sigmoidoscopy both in patients with terminal permanent colostomy and in those with stoma reversal, in order to early discover a subsequent rectal cancer.

Introduction. Focal liver lesions represent one of the main indications of ultrasound-guided liver biopsy. The purpose of the study was to evaluate the advantages and risks of liver biopsy, and to highlight the importance of a close follow-up in the prevention of postprocedural complications. Methods. We have retrospectively analyzed a number of 52 patients, who underwent liver biopsies in the Clinical Emergency Hospital of Bucharest, Romania, after being diagnosed with various types of focal liver lesions through ultrasound scanning. Results. Regarding the quality of the bioptic samples obtained: 98% of them were diagnostic, only 2% being nondiagnostic, mainly due to the tissue necrosis found within the tumor. The majority of the cases selected for the study had multiple liver lesions (70%), the rest of 30% had single lesions identified by ultrasound scanning. After histopathological analysis, in 89 % of the cases the lesion proved to be malignant (of which 70% were hepatic metastases and 30% were liver carcinomas), the rest of 11% were benign. This last category included hepatic adenomas and focal nodular hyperplasia, identified in young female population. Our study did not reveal any relation between the location of the lesion within the liver and the number of needle passes needed in order to obtain viable biopsy specimens (P = 0.16). Of all the cases that underwent liver biopsy, only 4% had complications, mainly minor bleeding and only 1% major bleeding and transitory hypotension. There was no case of death registered. Conclusions. Ultrasound guided percutaneous liver biopsy is a fast, economical and user-friendly procedure, frequently used in the diagnosis of focal liver lesions. The success rate of the biopsy in obtaining viable samples is high and it depends more on the structure of the lesion and the materials used, rather than on the anatomical localization of the lesion within the liver. Severe complications can be avoided if a close follow-up of the patients is performed.

The aim of this paper was to analyze the prognostic features, clinical presentation, diagnosis and treatment of primary renal sarcomas. A thorough review of the literature was made using the PubMed database. Sarcomas of the kidney are very rare malignant tumors, with a very poor prognosis compared with the other urogenital sarcomas. Several histological types have been reported, with the most common type being leiomyosarcoma. Besides complete surgical resection with wide margins, anatomical, histological, molecular and genetic factors should be taken into consideration regarding the prognosis.

Vasculitele sistemice sunt un grup heterogen de afecţiuni rare, cu tablou clinic complex şi variabil, caracterizate în principal de infl amaţia peretelui vascular, ce are ca şi rezultat alterarea circulaţiei în teritoriul respectiv şi apariţia ischemiei tisulare. Etiopatogenia este de obicei necunoscută, fi ind caracterizate de un sindrom infl amator intens. Fără intervenţie terapeutică rapidă, prognosticul vasculitelor este rezervat. Din punct de vedere al manifestărilor clinice, acestea sunt heterogene şi polimorfe, putând debuta cu semne generale de tip febră, artralgii sau stare generală alterată şi continua cu manifestări sistemice cum sunt ulcerele cutanate, erupţiile purpurice, iridociclită, glomerulonefrită etc. O categorie specială de manifestări clinice în vasculite, mai puțin bine cunoscute, sunt cele determinate de afectarea pulmonară. Manifestările pulmonare sunt mai frecvente în cadrul vasculitelor de vas mic, în special cele ANCA pozitive, şi debutează iniţial nespecifi c, cu fenomene de tip dispnee, sinusită, epistaxis, tuse sau astm bronșic. Din cauza frecvenţei şi semnifi caţiei prognostice, evaluarea clinică, funcţională şi radiologică a aparatului respirator trebuie inclusă în algoritmul de diagnostic al pacienţilor cu vasculite, în special al celor cu ANCA

Introduction. Takayasu’s arteritis or pulseless disease is a systemic inflammatory disease of an unknown etiology, affecting medium and large arteries and their branches, leading to stenosis, occlusions, or aneurysmal degeneration. It is more frequent in young Asian women. Case presentation. We present a rare case of Takayasu’s disease in a young woman, who initially developed an acute ischemic cholecystitis. Ischemia is one of the mechanisms involved in the pathogenesis of acute acalculous cholecystitis. As this mechanism is most often involved in elderly people, such an uncommon finding at young age should be a reason to suspect a vasculitis with small vessel occlusion. Conclusions. Acute cholecystitis in this patient was the first onset sign of Takayasu’s arteritis. An acute acalculous cholecystitis at young age could be of ischemic origin and should also be considered as a possible epiphenomenon of a generalized vasculitis disease.

Introduction. Ingestion of corrosive substances often causes serious damage to the upper gastrointestinal mucosa, occasionally perforation and, in rare cases, death. Most of these events are accidental, especially in children and the elderly, and voluntary (for suicidal purposes) in adults. If the patient survives the acute episode, the long-term complications are mainly esophageal and/or gastric stenosis and esophageal cancer after 1-2 decades of evolution. Endoscopic treatment of benign esophageal stenosis consists of dilation with Savary bougies and dilation balloon, esophageal stent assembly, with the purpose of restoring esophageal luminal patency. Superior digestive endoscopy plays an important role in the evaluation of benign esophageal stenosis in terms of the severity and the extent of stenosis. Case presentation. We present the case of a 47-yearold patient admitted to our clinic for dysphagia for solid and semi-solid foods. Endoscopy revealed an esophageal stricture due to the voluntary ingestion of caustic substance with suicidal purpose, 9 months before presentation. After multiple sessions of endoscopic dilatation with Savary bougies, an esophageal stent was placed, that solved patient’s dysphagia. Conclusions. Post-caustic esophageal stenosis is a common cause of dysphagia in patients with ingestion of corrosive substances. Patients can benefit from endoscopic esophageal stent placement treatment.

Introduction. Iatrogenic injury of the urinary tract in women undergoing pelvic surgeries is one of the most feared complications and an important source of significant morbidity. Moreover, they cause a lot of anxiety to both patient and surgeon and they also create many legal concerns. The most commonly affected organs are the ureter, bladder and urethra. Urologic injury during obstetrics and gynecologic surgery should always be a matter of prevention, but there are situations in which prevention fails. With this article we intend to raise the awareness on potential situations leading to iatrogenic urinary tract lesions during obstetrics and gynecology surgery. CASE Cases presentation. Three different cases of iatrogenic injuries at various sites of the urinary tract during pelvic surgeries are presented and preventive and treatment measures are discussed. Conclusions. Most iatrogenic urinary tract lesions are prone to occur during difficult surgeries, but a significant number of iatrogenic injuries are made during routine interventions, even by the most trained surgeons. Therefore, preventing and recognizing iatrogenic urinary tract injuries is of highest importance for all surgeons performing interventions in the pelvic area.

Illicit drugs use is a real public health issue, especially among young people. The totality of the drugs harmful effects on the body is difficult to quantify, especially because of poor epidemiological data and ethical concerns about the inclusion of consumers in clinical trials. However, health professionals need to be alert to identify, report and fight drug-related pathology. This article aims to draw attention to the lung pathology induced by the consumption of some of the most commonly used illicit drugs: cocaine, heroin and cannabis.

Rheumatoid arthritis (RA) is a systemic autoimmune disorder that causes progressive, symmetric, erosive destruction of cartilage and bone, which is usually associated with autoantibodies production. It is common that articular signs and symptoms develop long before extraarticular signs, but sometimes lung involvement is the first manifestation of RA and the most aggressive feature of the disease. Respiratory symptoms can precede the articular symptoms in 10–20% of cases. However, they may be masked by the poor functional status from joint disease or chronic inflammation. The pulmonary involvement can be due to the chronic inflammation caused by the disease or it can be secondary to immune-modulating medication. The pulmonary disease due to the disease itself includes: interstitial lung diseases, airways involvement (large and small airways), pleural involvement, rheumatoid pulmonary nodules and vascular pathology. The most used medication in patients with RA, such as metotrexate, leflunomide, TNF alpha blockers, but also other used drugs, may cause pulmonary diseases.

Starting from the idea that psoriasis can be triggered at any age and considering that it affects both sexes equally, we come to the current subject, the woman of reproductive age who suffers from psoriasis. During pregnancy in patients with psoriasis various changes take place which require a special approach of the dermatologist, obstetrics and gynecology, family doctor, psychologist and in some cases the neonatologist. Among the changes that may occur during pregnancy in patients with psoriasis include: psoriasis aggravation or remission, cardiac complications, premature birth, low birth weight, depression etc.

Patients with psoriasis are prone to develop cardiovascular disease, being one of the main causes of mortality. Risk factors for patients with psoriasis for cardiovascular disease are very common either on their own or in combination. Among these risk factors we can mention: diabetes, obesity, hypertension, dyslipidemia, metabolic syndrome, smoking. The presence of arthritis along with psoriasis is a negative prognosis in terms of cardiovascular disease. Sleep disturbances, depression and anxiety disorders also contribute to the increase in the frequency of cardiovascular disease in patients with psoriasis.

Colonic intussusception in adults is extremely rare, accounting for about 5% of all cases of intussusception. The telescoping of a proximal segment in the lumen of the adjacent segment has a classic classical triad in the symptomatology of children: abdominal pain, bloody diarrhea and palpable abdominal mass. In the adult patient, the symptoms are almost absent, and rarely they consist of constipation, bloody stool, or a malignant pathology that accompanies intussusception, weight loss, and anemia. We present the case of a 86-year-old patient who underwent a surgical procedure for repairing a rectal prolapse; intraoperatively, we discovered a sigmoid intussusception for which we performed a segmentary sigmoidectomy, repairing the rectal prolapse by rectosacropexy with alloplastic mesh.

Cardiac hepatopathy is the term that describes liver damage due to cardiac diseases. The cardiac hepatopathy is divided into congestive hepatopathy, due to passive venohepatic congestion, and acute cardiogenic liver injury, due primarily to acute cardio-circulatory failure. Congestive hepatopathy can be determined by chronic heart failure, constrictive pericarditis, tricuspid regurgitation and right-sided heart failure. On the other hand, acute myocardial infarction, acute decompensated heart failure or myocarditis may cause acute cardiogenic liver injury. Monitoring of liver function tests, such as -glutamyltransferase, alkaline phosphatase and liver-derived metabolites, such as bilirubin, is an effective way to assess liver function. Also, the measurement of serum aminotransferases concentration is increasingly being studied, in order to identify the correlation between their values and the extent of the cardiac damage. Clinical examination, laboratory tests, and imaging tests are necessary for the diagnosis of cardiac cirrhosis in patients with heart failure. Patients with cardiac cirrhosis may be asymptomatic, but present abnormal liver biochemistry. Patients with congestive hepatopathy have elevated cholestasis markers, such as bilirubin, alkaline phosphatase, and -glutamyltransferase, while elevated levels of aminotransferases and lactate dehydrogenase are found in acute cardiogenic liver injury. There is no specific treatment for congestive hepatopathy, the treatment is that of the underlying cardiac disease. Restoration of the cardiac output and hemodynamics is the most important in the management of the acute cardiogenic liver injury.

Entre 6-8 octobre 2017, la Section Nationale Bulgare de l’Union Médicale Balkanique (UMB) a organisé à Sofia, en Bulgarie, „La 21-ème Session des Journées Médicales Balkaniques”, sous le patronage du Président de l’Académie des Sciences de la Bulgarie, Acad. Prof. Julian Revalski et du Recteur de l’Université de Médecine de Sofia, Prof. Dr. Victor Zlatkov. Le président du comité d’organisation a été le Prof. Dr. Latchezar Traykov, Président de la Section Nationale bulgare de l’UMB, secondé par le Prof. Dr. Valentina Petkova, secrétaire général de la section nationale bulgare de l’UMB et Prorecteur de l’Université de Médecine de Sofia. Le thème du congrès a été „Santé et Longévité des Peuples Balkaniques”. La séance officielle d’ouverture a eu lieu le 6 octobre, au siège de l’Académie des Sciences de la Bulgarie, en la présence du Président de l’Académie, du Recteur de l’Université de Médecine et Pharmacie de Sofia, des Prorecteurs de celle-ci, du Doyen de la Faculté de Pharmacie, de la direction de la Section Nationale Bulgare de l’UMB et de la direction des autres sections nationales membres, du Prof. Pierre- François Plouin (Académie Nationale de Médecine de France).

Introduction. Obstructive sleep apnea syndrome (OSAS) is a disease with increasing prevalence nowadays, being associated with multiple cardiovascular diseases, such as arterial hypertension. The objective of the study was to evaluate the effect of continuous positive airway pressure (CPAP) on blood pressure values. Materials and methods. We performed a prospective interventional study on 52 patients with obstructive sleep apnea syndrome. The patients were divided into 2 groups: Group A (who received both pharmacological and CPAP treatment) and Group B (who received only pharmacological treatment), and were followed up at 3 and 6 months. The statistical analysis was made with SPSS and Microsoft Excel. At the same time, using the surrogate marker –RDW, we tried to evaluate the persistence of systemic inflammation, knowing that OSAS is associated with inflammation. Results. The systolic blood pressure values decreased at 6 months in all OSAS patients who have used CPAP, including patients with normal values of blood pressure. At the same time, the lack of OSAS treatment led to increased values of blood pressure by approximately 10 mmHg. We noticed a link between RDW, age and blood pressure values, respectively the increase of RDW and age may result in an increase in blood pressure. Conclusions. The OSAS treatment can decrease the blood pressure values. A higher RDW may be considered a negative prognostic factor for these patients, reflecting the role of systemic inflammation in the appearance of cardiovascular disorders.

We present the case of a 64 years old man, who was admitted in our surgical clinic with a giant median incisional hernia after a previously colonic resection and anastomosis for a colonic tumor. We had to deal with a loss of domain giant ventral hernia. The patient was known with chronic obstructive pulmonary disease (COPD) and chronic coughing, that was an aggravating condition. We did an alloplasty in Rives-Stoppa manner, accompanied by an anterior component separation. The clinical postoperative outcome was very good and we present the results. ˝

We present the case of a 82 years old women, who was admitted in our surgical clinic with two giant breast tumors, located on the left breast, with skin ulceration and suprainfection, accompanied by a big axillary mass in the left axilla. The patient was known with a previous rectal tumor, recently operated in another surgical service, for which it was an anterior rectal resection and definitive left colostomy done. The case is an atypical form of presentation of a Lynch II syndrome. The indication for total mastectomy and axillary lymphadenectomy was sustained by tumors' dimensions and suprainfection, although the case was oncologically overcome.

The international guidelines for the management of type 2 diabetes mellitus have seen many changes over the last decade. They have moved from a strict glycemic control in all patients with diabetes to a more individualized approach of the diabetic patient. These changes are the result of some trials which have demonstrated, for example, that in patients with long-standing type 2 diabetes a strict glycemic control may increase the risk of complications, such as hypoglycemia and cardiovascular events1-3. While glucose lowering prevents the appearance of microvascular complications, its impact is less significant on the cardiovascular and renal complications. The most preferred oral antidiabetic drug is undoubtedly metformin. There are six antidiabetic drug classes currently recommended by the American and European international societies, in addition to metformin: sodium-glucose cotransporter 2 (SGLT2) inhibitors, glucagon-like peptide 1 receptor agonists, dipeptidyl peptidase 4 inhibitors, sulfonylureas, thiazolidinediones, and insulin. SGLT2 inhibitors are a promising new class of antidiabetic drugs, that have entered very recently in the diabetes therapeutic armamentarium. These drugs enhance the urinary glucose excretion and decrease hyperglycemia, acting independently from insulin and being effective in all diabetic patients with preserved renal function. They have a favorable efficacy-to adverse event profile in type 2 diabetes patients with moderate-to-high risk. Currently, there are four SGLT2 inhibitors approved by the US Food and Drug Administration (FDA) and the European Medicines Agency: canaglifozin, dapaglifozin, empaglifozin, and ertuglifozin3. These may be used as monotherapy or in combination with other antidiabetic agents.SGLT2 inhibitors have also pleiotropic effects, such as reducing body weight by 2-3 Kg, decreasing the blood pressure (both systolic and diastolic), decreasing plasma triglycerides, increasing HDL cholesterol, attenuating some factors associated with nonalcoholic steatohepatitis and nonalcoholic liver disease, improving the whole-body sodium balance and volume status by stimulating the natriuresis, which leads further to a better endothelial function by reducing the vascular stiffness1. Due to these effects, SGLT2 inhibitors are useful especially in obese patients with arterial hypertension. They may be indicated as single or combination therapy, with other antidiabetic agents, and are contraindicated in patients with kidney failure1 with a GFR < 45 mL/min/1.73 m2. Regarding the glucose control, in a meta-analysis, the HbA1c reduction at 24-weeks was higher in studies that included younger patients, with a shorter duration of diabetes and a higher body mass index, HbA1c and basal glucose4. The cardiovascular benefits of SGLT2 inhibitors have been demonstrated by some major trials, such as EMPA-REG OUTCOME trial (Empaglifozin Cardiovascular Outcome Event Trial in Type 2 Diabetes Mellitus Patients)5 and CANVAS (Canaglifozin Cardiovascular Assessment Study)6. EMPA-REG OUTCOME trial has found a reduced incidence of cardiovascular death in diabetic patients treated with Empaglifozin and also a decreased rate of hospitalization for heart failure5. CANVAS Program has showed also a decreased rate of hospitalization for heart failure in patients treated with Canaglifozin6. This is extremely important, especially for patients with type 2 diabetes and already established cardiovascular diseases, as they may benefit most from the treatment with SGLT2 inhibitors. The main side effects of SGLT2 inhibitors consist in the increased risk of genital infections (up to four-fold in clinical trials). Other side effects, more rarely, may be the risk of hypoglycemia, diabetic ketoacidosis, bone fractures (with Canaglifozin). Recently, the US Food and Drug Administration warned about the risk of necrotizing fasciitis of the perineum (Fournier’s gangrene) in patients treated with SGLT2 inhibitors7. This is an extremely rare, but life-threatening infection of the tissues around the perineal muscles, nerves, fat and blood vessels. In conclusion, SGLT2 inhibitors are the newest antidiabetic drugs class, with cardiovascular benefits in a selected population of type 2 diabetes patients. There are ongoing studies with these antidiabetic agents expected to report their data in the near future

Background/Aim: Locally advanced liver tumours with vascular invasion have been considered for a long period of time as unresectable lesions, so the patient was further deferred to oncology services for palliation. However, improvement of the surgical techniques and the results reported so far came to demonstrate that extended hepatic and vascular resections might be safely performed in such cases and might significantly improve the long-term outcomes. Materials and Methods: A 61-year-old patient was diagnosed with a caudate lobe tumour invading the inferior cava vein and the right hepatic pedicle. Results: The patient was successfully submitted to surgery, and an extended right hepatectomy en bloc with cava vein resection was performed; the continuity of the cava vein was re-established by the placement of a synthetic graft. The postoperative outcome was uneventful. Conclusions: Although initially considered as a formal contraindication for resection, vascular invasion of the greater vessels should not preclude surgery if complete resection is achievable.

Background: pancreatic cancer is one of the most lethal malignancies and a leading cause of cancer-related death worldwide. The only chance to improve the long-term outcomes of patients with pancreatic cancer is surgery with radical intent. Methods: in the present paper, we aim to describe a case series of 9 patients submitted to radical surgery for borderline resectable pancreatic cancer. Results: in all cases, negative resection margins were achieved. The types of venous resection consisted of tangential portal vein resection in four cases, circumferential portal vein resection with direct reanastomosis in one case and circumferential resection with graft placement in another four cases; postoperatively, one patient developed a vascular surgery-related complication consisting of graft thrombosis and thus necessitated prolonged anticoagulant therapy. Conclusions: extended venous resections can be a safe and efficient way to maximize the benefits of radical surgery in locally advanced, borderline resectable pancreatic cancer.

he Spieghelian hernia or ventro-lateral hernia is produced through the effect of rupture of the abdominal wall fibers, near the semi lunar line. The hernia sac is usually accompanied by extra peritoneal fatty tissue and is intra parietal, it passes through the aponeurosis of the transverse muscle and internal oblique muscle, and it grows under the aponeurosis of the external oblique muscle. The Spiegel hernia is rare and is difficult to diagnose clinically. In this article we present the case of a 43-year-old patient who presented at the emergency department for a pseudo-tumor mass in the left flank and was diagnosed with Spiegel hernia.

Introduction: The larvae of Echinococcus, a parasitic tapeworm, cause hydatid disease. The most commonly involved organ after the liver is the lung but there are cases of hydatid cysts in all systems and organs, such as brain, muscle tissue, adrenal glands, mediastinum and pleural cavity. Extra-pulmonary intrathoracic hydatidosis can be a diagnostic challenge and a plain chest x-ray can be misleading. It can also lead to severe complications such as anaphylactic shock or tension pneumothorax. The purpose of this paper is to present a severe case of primary pleural hydatidosis, as well as discussing the difficulties that come with it during diagnosis and treatment. Case Report: We present the case of a 43-year-old male, working as a shepherd, presenting with moderate dyspnea, chest pain and weight loss. Chest x-ray revealed an uncharacteristic massive right pleural effusion and thoracic computed tomography (CT) confirmed it, as well as revealing multiple cystic formations of various sizes and liquid density within the pleural fluid. Blood work confirmed our suspicion of pleural hydatidosis with an elevated eosinophil count, typical in parasite diseases. Surgery was performed by right lateral thoracotomy and consisted of removal of the hydatid fluid and cysts found in the pleura. Patient was discharged 13 days postoperative with Albendazole treatment. Conclusion: Cases of primary pleural hydatidosis are very rare but must be taken into consideration in patients from endemic regions with jobs that may have exposure to this parasite. Proper treatment, both surgical and antiparasitic medication, can lead to a full recovery and a low chance of recurrent disease.

Introduction: The purpose of this paper is to study the type, the clinical presentation, and the best diagnostic methods for pleural solitary fibrous tumors (PSFTs), as well as to evaluate which is the most appropriate treatment, especially as PSFTs represent a rare occurrence in the thoracic pathology. Material and Method: A retrospective study was conducted on a group of 45 patients submitted to surgery between January 2015 and December 2019. In most cases, the diagnosis was established through imaging studies—thoracic computed tomography (CT) scan with or without contrast—but also using magnetic resonance imaging (MRI) or positron emission tomography (PET) scans when data from CT scans were scarce. All patients were submitted to surgery with curative intent. Results: Most patients included in this study were asymptomatic, with this pathology being more common in patients over 60 years of age, and more common in women. The occurrence of malignant PSFT in our study was 17.77% (8 cases). All cases were submitted to surgery with curative intent, with a single case developing further recurrence. In order to achieve complete resection en bloc resection of the tumor with the chest wall, resection was performed in two cases, while lower lobectomy, pneumectomy, and hemidiaphragm resection, respectively, were needed in each case. Postoperative mortality was null. Conclusion: Thoracic CT scan remains the most important imagistic investigation in diagnosing. MRI is superior to thoracic CT, especially in cases that involved the larger blood vessels within the thorax, spinal column, or diaphragm. Complete surgical resection is the gold standard in treatment of PSFT, and the prognosis in benign cases is very good.

Background/Aim: Synchronous gynecological malignancies are rarely encountered, and most often these cases are represented by synchronous ovarian and endometrial cancer. The aim of this paper is to present the case of a 53-year-old patient who was diagnosed with synchronous cervical and ovarian cancer. Case presentation: The patient had been initially investigated for vaginal bleeding and was submitted to a biopsy confirming the presence of a cervical adenocarcinoma. Once the diagnostic of malignancy was confirmed, the patient was submitted to a computed tomography which revealed the presence of large abdominal tumoral nodules of peritoneal carcinomatosis and was submitted to palliative chemotherapy with poor response. Eighteen months later she developed intestinal obstruction and was submitted to surgery. At that moment, synchronous ovarian and cervical tumors were diagnosed. Total radical hysterectomy with bilateral adnexectomy, pelvic and para-aortic lymph node dissection, omentectomy, and pelvic peritonectomy was performed; in the meantime, the histopathological studies confirmed the presence of two synchronous malignancies. Conclusion: Although synchronous lesions are rarely encountered, this eventuality should not be omitted. In such cases, surgery should be taken in consideration and the intent of radicality should regard both lesions.

Background and objectives: To identify the risk factors for para-aortic lymph node metastases in cases with presumed early stage ovarian cancer. Materials and methods: Between 2014 and 2019, 48 patients with apparent early stage ovarian cancer were submitted to surgery. In all cases, pelvic and para-aortic lymph node dissection was performed for staging purposes. Results: Among the 48 cases we identified nine cases with positive pelvic lymph nodes and 11 cases with positive para-aortic lymph nodes. The positivity of the retrieved lymph nodes was significantly correlated with the histopathological subtype represented by serous histology (p = 0.02), as well as with the degree of differentiation (p = 0.004). Conclusion: Patients with serous ovarian carcinomas in association with a poorer degree of differentiation are at risk of associated lymph node metastases even in presumed early stages of the disease. Therefore, lymph node dissection should be performed in such cases in order to provide adequate staging and tailoring of further treatment.

Background and Objectives: Cirrhotic cardiomyopathy is a chronic cardiac dysfunction associated with liver cirrhosis, in patients without previous heart disease, irrespective of the etiology of cirrhosis. Electrocardiography (ECG) is an important way to evaluate patients with cirrhosis and may reveal significant changes associated with liver disease. Our study aimed to evaluate ECG changes in patients with diagnosed liver cirrhosis and compare them to patients with chronic hepatitis. Materials and Methods: We evaluated laboratory findings and ECG tracings in 63 patients with cirrhosis and 54 patients with chronic hepatitis of viral etiology. The end points of the study were prolonged QT interval, QRS hypovoltage and T-peak-to-T-end decrease. We confirmed the diagnosis of cirrhotic cardiomyopathy using echocardiography data. Results: Advanced liver disease was associated with prolonged QT intervals. Also, QRS amplitude was lower in patients with decompensated cirrhosis than in patients with compensated liver disease. We found an accentuated deceleration of the T wave in patients with cirrhosis. These findings correlated to serum levels of albumin, cholesterol and ammonia. Conclusions: ECG changes in liver cirrhosis are frequently encountered and are important noninvasive markers for the presence of cirrhotic cardiomyopathy.

Introduction: Extended pelvic resection might be the option of choice in patients presenting locally advanced cervical cancer. However, the possibility of a co-existence of an ectopic, pelvic kidney that is invaded by such a tumor is extremely rare. Case Presentation: A 54-year-old female patient, diagnosed with locally advanced cervical cancer in the presence of a pelvic kidney, was submitted to surgery with curative intent. A large, abscessed cervical tumor invading the urinary bladder and the rectum was found, so a total exenteration was planned. Intraoperatively, tumor invasion of the left kidney, which was found in an ectopic, pelvic position was also encountered; therefore, total pelvic exenteration in association with a left nephrectomy was successfully performed. Conclusions: The presence of an ectopic, pelvic disposition of the kidney makes it susceptible to be invaded by locally advanced pelvic tumors; in such cases, a nephrectomy might also be needed.

Chronic heart failure continues to represent a major problem for the healthcare systems worldwide, because of high prevalence and impact on patients’ quality of life. Between May 25-28, 2018, in Vienna, Austria, took place the European Congress of Heart Failure and the World Congress on Acute Heart Failure, organized by the European Society of Cardiology. The congress was a forum of exchanging expertise in diagnosis and treatment of heart failure, and also an opportunity to present the latest progresses regarding the management of this pathology. It seems that an integrated, multidisciplinary team approach is the future for heart failure management. This team should include internists, cardiologists, general practitioners, and nurses. The new President of the Heart Failure Association of the European Society of Cardiology is from a Balkan country, Prof. Petar M. Seferovic, from the Belgrade University Medical Center, Serbia. In one of his presentations, Prof. Seferovic highlighted that the treatment of chronic heart failure should explore new frontiers. Recently, there is much interest in established antidiabetic drugs to treat cardiovascular complications of diabetes. Introduction of sodium-glucose transport protein 2 (SGLT2) inhibitors in the late 1990s was a major breakthrough in the treatment of diabetes complications. These drugs are the only antidiabetic drugs with good results in the treatment of cardiovascular diseases, demonstrated by several large randomized controlled trials, such as EMPA-REG (the first study to demonstrate a significant reduction in both cardiovascular mortality and heart failure-related hospitalization in patients treated with empaglifozin, a SGLT2 inhibitor). SGLT2 inhibitors are now recommended by some guidelines for the prevention of heart failure and associated mortality in patients with type 2 diabetes. The international registry REPORT HF, presented in Vienna, enrolled more than 18,000 patients from 44 countries across North America (NA), Central and South America (CSA), Western (WE) and Eastern Europe (EE), the Eastern Mediterranean and Africa (EMA), South East Asia (SEA) and the Western Pacific (WP), under the study co-chairs, Prof. Gerasimos Filippatos (Greece) and Prof. Mihai Gheorghiade (USA). Inter-regional differences in the hospital entry point, comorbidities and precipitants have been observed. Ischemia was a common precipitant in SEA, WP and EMA, whereas non-adherence to diet and medication was more common in NA. There have been also observed differences regarding the treatment, especially in time to initial intravenous therapy. Patients in NA have significantly longer time to first therapy, compared with other regions; this may impact the symptoms, because the sooner the IV therapies are delivered, the sooner symptoms will improve. There are differences regarding the implementation of international heart failure guidelines, which may influence the patients’ outcomes. Researchers from the Institute of Molecular Biotechnology at the Vienna BioCenter have studied the first systems for heart regeneration following complex heart attacks in mammals. In vivo neonatal models showed that, after a heart attack, mice underwent total repair of cardiac injury. This type of repair had been encountered previously in fish, but not in mammals. The researchers set up now genetic systems to identify the molecular signals that mediate this regeneration of the heart. Biotechnologies may become the future of the heart failure treatment.

Liver transplantation (LT) is considered the curative treatment option for selected patients who suffer from end-stage or acute liver disease or hepatic malignancy (primary). After LT, patients should be carefully monitored for complications that may appear, partially due to immunosuppressive therapy, but not entirely. Cardiovascular diseases are frequently encountered in patients with LT, being responsible for high morbidity and mortality. Patients with underlying cardiovascular and metabolic pathologies are prone to complications after the transplant, but these complications can also appear de novo, mostly associated with immunosuppressants. Metabolic syndrome, defined by obesity, hypertension, dyslipidemia, and hyperglycemia, is diagnosed among LT recipients and is aggravated after LT, influencing the long-term survival. In this review, our purpose was to summarize the current knowledge regarding cardiovascular (CV) diseases and the metabolic syndrome associated with LT and to assess their impact on short and long-term morbidity and mortality.

Bolile infl amatorii intestinale cronice reprezintă o cauză importantă de morbiditate şi mortalitate, afectând în special persoanele tinere. Cuprind două entităţi: boala Crohn şi rectocolita ulcero-hemoragică. Studiul de faţă a încercat să stabilească particularităţile endoscopice ale bolii Crohn şi rectocolitei ulcero-hemoragice la un lot de 37 de pacienţi, cu vârste cuprinse între 0-18 ani, internaţi în Spitalul Fundeni în perioada 1995- 2004.

Even if, ileal carcinoid tumours have a low incidence (0.2-0.8/100000), the diagnosis must be considered in the presence of hepatic metastasis of unknown origin. We report a case of 55 years old female that presents persistent nausea, for one year prior to admission. She was suspected of gallbladder stones and an abdominal ultrasound was performed. The result was normal and the patient presented to our clinic for a routine check-up. At the repeated ultrasound we found multiple focal hyperechoic liver lesions of maximum 10 mm. She was referred immediately for a CT-scan with intravenous contrast but the result was surprisingly normal. We insisted in our investigation and the patient was sent for a total abdominal MRI. The result revealed ileal tumour of 2 cm with liver metastases. Palliative surgery with resection of ileal tumour and liver metastasis biopsy is performed. The pathology result was compatible with neuroendocrine tumor G1(Ki 67 index 1-2%) with liver metastasis. [ABSTRACT FROM AUTHOR]

Crohn's disease (CD) may affect any segment of the gastrointestinal tract. Although rare, its oesophageal manifestation may be seen as the first sign of this disease. We present the case of a 27 years old female who is admitted with heartburn and dysphagia for 4 years, being misdiagnosed as reflux esophagitis. Endoscopy performed in our unit pointed out erythema, segmental ulcers separated by normal mucosa, “cobble stone’’ aspect. The histological findings were ulcers and a chronic inflammatory mucosal infiltrate. The patient was unresponsive to PPI(Proton Pump Inhibitor), but a rapid improvement was seen after corticosteroid administration. Differential diagnosis and treatment opportunities are presented below. [ABSTRACT FROM AUTHOR]

The link between vitiligo and depression is complex in many ways. Vitiligo predisposes to depression because it is a chronic, unpredictable, without curative treatment that affects the quality of life, especially because of skin damage. This meta-analysis emphasizes the importance of addressing depression in patients with vitiligo in medical practice as well as the predisposing factors of vitiligo that contribute to the further development of depression. There is a need for more studies on this issue.