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Introduction. Endocrino-metabolic rehabilitation represent one of the most complex sector in clinical medicine, regarding functional rehabilitation. Sex hormones deficiency plays an important role in the etiology of osteoporosis in men. At the same time, with age, the trophic role of androgens on muscle decreases and determines an increased frequency of falls. The objective of our study is to determine the association between sexsteroids deficiency, reduction of bone mineral density (BMD) and falling risk in men. Methods. Our retrospective cross-sectional study included 146 men aged between 65–85 years with low BMD (study group) and 121 men with normal BMD (control group). The measurement of Total testosterone (Tt), free testosterone (Tf) and estradiol (E2) serum levels was performed using the immunoassay or the immunoenzymatic methods. Femoral neck and lumbar spine BMD was determined using Dual-energy X-ray absorptiometry (DEXA). The risk of falls was assessed by Tandem Standing, Up & Go, Chair – Rising and walking speed tests. Results. We found a significantly association between Tf and E2 deficiency and low BMD (p=0.007). Also, in men with reduced BMD (study group) we observed significant lower levels of Tf (p

Introduction. Osteoporosis has a major influence on the quality of life because of its impact on bone strength. Osteoporosis and fractures are frequent in patients with multiple sclerosis, decreased mobility being an important risk factor in these patients. Objectives. This paper presents a case of severe osteoporosis in a patient with multiple sclerosis, to emphasize a correlation between this two pathologies. Material and Methods. We present the case of a female Caucasian patient, aged 65 years, known with progressive multiple sclerosis, on long-term use of glucocorticoids, and severe osteoporosis, who is investigated for mechanical pain and functional deficiency in the lumbar spine and the right hip, motor deficit, predominantly on right limbs and walking disorders. The patient was diagnosed with severe osteoporosis treated with raloxifene and bisphosphonates, with multiple vertebral fractures and vitamin D deficiency. During hospitalization the patient followed myorelaxant therapy and an individualized rehabilitation program. Results and discussion. During follow-up, there was a significant increase followed by a recent decrease in bone mass density in the lumbar spine and hip. The patient was recommended a loading dose of cholecalciferol for three months and initiation of teriparatide therapy after restoring 25-hydroxy vitamin D levels. Conclusion. In patients with multiple sclerosis,screening and early management of osteoporosis and osteopenia are essential. Keywords: multiple sclerosis, glucocorticoid therapy, osteoporosis

Our purpose is to provide new insights concerning the challenges of pituitary apoplexy in pregnancy (PAP) and the postpartum period (PAPP). This is a narrative review of the English literature using a PubMed search. The inclusion criteria were clinically relevant original studies (January 2012–December 2022). Overall, we included 35 original studies: 7 observational studies (selected cases on PA) and 28 case reports, including 4 case series (N = 49; PAP/PAPP = 43/6). The characteristics of PAP patients (N = 43) are as follows: maternal age between 21 and 41 (mean of 27.76) years; 21/43 subjects with a presentation during the third trimester (only one case during first trimester); average weak of gestation of 26.38; most females were prim gravidae; 19 (out of 30 patients with available data on delivery) underwent a cesarean section. Headache remains the main clinical feature and is potentially associated with a heterogeneous panel (including visual anomalies, nausea, vomiting, cranial nerve palsies, diabetes insipidus, photophobia, and neck stiffness). Pre-pregnancy medication included dopamine agonists (15/43) and terguride (1/43) in addition to subsequent insulin therapy for gestational diabetes (N = 2) and type 1 diabetes mellitus (N = 1). Overall, 29/43 females received the conservative approach, and 22/43 women had trans-sphenoidal surgery (TSS) (and 10/22 had the initial approach). Furthermore, 18/43 patients had a pituitary adenoma undiagnosed before pregnancy. Most PA-associated tumors were prolactinomas (N = 26/43), with the majority of them (N = 16/26) being larger than 1 cm. A maternal–fetal deadly outcome is reported in a single case. The characteristics of PAPP patients (N = 6) are as follows: mean age at diagnosis of 33 years; 3/6 subjects had PA during their second pregnancy; the timing of PA varied between 5 min and 12 days after delivery; headache was the main clinical element; 5/6 had no underlying pituitary adenoma; 5/6 patients were managed conservatively and 1/6 underwent TSS; pituitary function recovered (N = 3) or led to persistent hypopituitarism (N = 3). In conclusion, PAP represents a rare, life-threatening condition. Headache is the most frequent presentation, and its prompt distinction from other conditions associated with headache, such as preeclampsia and meningitis, is essential. The index of suspicion should be high, especially in patients with additional risk factors such as pre-gestation treatment with dopamine agonists, diabetes mellitus, anticoagulation therapy, or large pituitary tumors. The management is conservative in most cases, and it mainly includes corticosteroid substitution and dopamine agonists. The most frequent surgical indication is neuro-ophthalmological deterioration, although the actual risk of pituitary surgery during pregnancy remains unknown. PAPP is exceptionally reported. To our knowledge, this sample–case series study is the largest of its kind that is meant to increase the awareness to the benefit of the maternal–fetal outcomes from multidisciplinary insights.

Different theories link chronic musculoskeletal pain with lifestyle components, including diet. However, nutritional assesment and optimization is not routinely included into the medical management of patients with muskuloskeletal diseases (MSKD). In this study we aimed to evaluate the diet and nutritional status of a group of women with MSKD and to assess the extent to which they comply with the general recommendations for a healthy diet. The results showed that 97% of the subjects included were overweight or obese, and the compliance to different general nutritional recommandations ranged between 3% to 57%. Furthermore, the quality of life of this patients measured through SF-36 question-naire was severly affected and the reported pain intensity on numeric pain scale had a mean of 8 (±1.3) in our study group. Although there are currently no specific guidelines for the nutrition of patients with chronic pain, an important first step would be to guide these patients towards an increase in diet quality and a healthy lifestyle by adhering to general nutritional recommendations regarding healthy eating.

It is well known that vitamin D deficiency increases the risk of osteoporosis and that vertebral compressions fractures are a manifestation of osteoporosis. This paper presents the case of a patient with severe osteoporosis associated with vitamin D deficiency who developed over the course of two years multiple vertebral compression fractures. Method: We present the case of a 76-year-old caucasian female diagnosed with osteoporosis and significant vitamin D deficiency who was investigated for mechanical pain and functional deficit at the level of the spine and walking disorders. The patient was hospitalized in our Rehabilitation department twice. At the first hospitalization two years ago, the deficiency of vitamin D was found and the treatment was initiated. During the sec-ond hospitalization, biochemical and radiological investigations were per-formed to establish the diagnosis. Numerous vertebral compression fractures were dis-covered which were not re-vealed in the imaging investigations performed two years earli-er. She underwent symptomatic and appropriate medical rehabilitation treatment. Results and discussion: The evolution was fa-vorable after the hospitalization period, with a decrease in pain and functional deficit, as well as walking improvement. After endocrinological consultation it was decided to initiate therapy with Teriparatide which can decrease the risk of future fractures and reduce the back pain. Con-clusions: Adequate and prompt treatment of vitamin D deficiency and osteoporosis is very im-portant to avoid vertebral compression fractures or other complications of this disease. Physical and rehabilitation medicine also plays an important role in management of these patients.

Various complications of pituitary neuroendocrine tumors (PitNET) are reported, and an intratumor hemorrhage or infarct underlying pituitary apoplexy (PA) represents an uncommon, yet potentially life-threatening, feature, and thus early recognition and prompt intervention are important. Our purpose is to overview PA from clinical presentation to management and outcome. This is a narrative review of the English-language, PubMed-based original articles from 2012 to 2022 concerning PA, with the exception of pregnancy- and COVID-19-associated PA, and non-spontaneous PA (prior specific therapy for PitNET). We identified 194 original papers including 1452 patients with PA (926 males, 525 females, and one transgender male; a male-to-female ratio of 1.76; mean age at PA diagnostic of 50.52 years, the youngest being 9, the oldest being 85). Clinical presentation included severe headache in the majority of cases (but some exceptions are registered, as well); neuro-ophthalmic panel with nausea and vomiting, meningism, and cerebral ischemia; respectively, decreased visual acuity to complete blindness in two cases; visual field defects: hemianopia, cranial nerve palsies manifesting as diplopia in the majority, followed by ptosis and ophthalmoplegia (most frequent cranial nerve affected was the oculomotor nerve, and, rarely, abducens and trochlear); proptosis (N = 2 cases). Risk factors are high blood pressure followed by diabetes mellitus as the main elements. Qualitative analysis also pointed out infections, trauma, hematologic conditions (thrombocytopenia, polycythemia), Takotsubo cardiomyopathy, and T3 thyrotoxicosis. Iatrogenic elements may be classified into three main categories: medication, diagnostic tests and techniques, and surgical procedures. The first group is dominated by anticoagulant and antiplatelet drugs; additionally, at a low level of statistical evidence, we mention androgen deprivation therapy for prostate cancer, chemotherapy, thyroxine therapy, oral contraceptives, and phosphodiesterase 5 inhibitors. The second category includes a dexamethasone suppression test, clomiphene use, combined endocrine stimulation tests, and a regadenoson myocardial perfusion scan. The third category involves major surgery, laparoscopic surgery, coronary artery bypass surgery, mitral valvuloplasty, endonasal surgery, and lumbar fusion surgery in a prone position. PA in PitNETs still represents a challenging condition requiring a multidisciplinary team from first presentation to short- and long-term management. Controversies involve the specific panel of risk factors and adequate protocols with concern to neurosurgical decisions and their timing versus conservative approach. The present decade-based analysis, to our knowledge the largest so far on published cases, confirms a lack of unanimous approach and criteria of intervention, a large panel of circumstantial events, and potential triggers with different levels of statistical significance, in addition to a heterogeneous clinical picture (if any, as seen in subacute PA) and a spectrum of evolution that varies from spontaneous remission and control of PitNET-associated hormonal excess to exitus. Awareness is mandatory. A total of 25 cohorts have been published so far with more than 10 PA cases/studies, whereas the largest cohorts enrolled around 100 patients. Further studies are necessary.

Intermittent oxygen therapy (IHT), initially used in the hypoxic administration variant, has been shown to be effective in various pathologies studied, from cardiopulmonary to vascular and metabolic pathologies and more. IHT used to prevent and treat various diseases has thus gained more and more attention as the years have passed. The mechanisms underlying the beneficial effects have been investigated at multiple biological levels, from systemic physiological reactions to genomic regulation. In the last decade, a new method of intermittent oxygen therapy has been developed that combines hypoxic and hyperoxic periods. They can be applied both at rest and during physical exercise, hence the specific indications in sports medicine. It has been hypothesized that replacing normoxia with moderate hyperoxia may increase the adaptive response to the intermittent hypoxic stimulus by upregulating reactive oxygen species and hypoxia-inducible genes. This systematic literature review is based on the “Preferred Reporting Items for Systematic Reviews and Meta-Analysis”—“PRISMA”—methodology, the widely internationally accepted method.

Horner’s syndrome (HS), caused by lesions of the 3-neuron oculosympathetic nerve pathway (ONP), includes the triad: blepharoptosis, miosis and anhidrosis (ipsilateral with ONP damage). Thyroid–related HS represents an unusual entity underling thyroid nodules/goiter/cancer–HS (T-HS), and post-thyroidectomy HS (Tx-HS). We aim to overview Tx-HS. This is a narrative review. We revised PubMed published, full-length, English papers from inception to November 2022. Additionally, we introduced data on post-thyroidectomy lymphocele/chylous leakage (Tx-L), and introduced a new pediatric case with both Tx-HS and Tx-L. Tx-HS: the level of statistical evidence varies from isolated case reports, studies analyzing the large panel of post-thyroidectomy complications reporting HS among the rarest side effects (as opposite to hypocalcemia), or different series of patients with HS due to various disorders, including T-HS/Tx-HS. Tx-HS is related to benign or malignant thyroid conditions, regardless the type of surgery. A pre-operatory rate of T-HS of 0.14%; a post-operatory rate of Tx-HS between 0.03% and 5% (mostly, 0.2%) are identified; a possible higher risk on endoscopic rather than open procedure is described. Incomplete HS forms, and pediatric onset are identified, too; the earliest identification is after 2 h since intervention. A progressive remission is expected in most cases within the first 2–6 months to one year. The management is mostly conservative; some used glucocorticoids and neurotrophic agents. One major pitfall is an additional contributor factor like a local compression due to post-operatory collections (hematoma, cysts, fistula, Tx-L) and their correction improves the outcome. The prognostic probably depends on the severity of cervical sympathetic chain (CSC) lesions: indirect, mild injury due to local compressive masses, intra-operatory damage of CSC like ischemia and stretching of CSC by the retractor associate HS recovery, while CSC section is irreversible. Other iatrogenic contributors to HS are: intra-operatory manipulation of parathyroid glands, thyroid microwave/radiofrequency ablation, and high-intensity focused ultrasound, and percutaneous ethanol injection into thyroid nodules. Tx-L, rarely reported (mostly

Osteoarthritis (OA) is the most prevalent chronic joint disease, increases in prevalence with age, and affects most individuals over 65. The present study aimed to assess the oxidative status in relation to diet and physical activity in patients with OA. We used a cross-sectional study applied to 98 females with OA. Blood samples were collected to determine oxidative stress markers: malonyl dialdehyde (MDA), reduced glutathione (GSH), oxidized glutathione (GSSG), and GSH/GSSG. Diet was estimated with a standardized food frequency questionnaire. We used the International Physical Activity Questionnaire (IPAQ) to assess the females’ physical activity. Multiple regression analyses were executed to determine the association between the oxidative markers and the intake of vegetables and fruit. The study showed that most patients were overweight or obese (88.8%). The level of physical activity was above the recommended level for adults, mainly based on household activities. The intake of vegetables and fruit was low. The MDA marker was inversely, statistically significantly associated with the consumption of vegetables (p < 0.05). Public health policies must address modifiable risk factors to reduce energy intake and obesity and increase the intake of vegetables and fruit. Higher consumption of vegetables and fruit may provide natural antioxidants that can balance oxidative compounds.

Background and Objectives: Carcinoma showing thymus-like differentiation (CASTLE) is a low-grade thyroid carcinoma, with an indolent clinical course and usually a favorable prognosis. The clinical and imagistic features are not specific for CASTLE but similar to other malignant lesions of the thyroid. Definite diagnosis is based on an immunohistochemical examination, as this carcinoma shows positive CD5 immunoreactivity when compared to other aggressive thyroid carcinomas. Case presentation: The main focus of this study is to outline a rare case of CASTLE compressing the trachea in a 50-year-old female patient who was initially diagnosed with undifferentiated thyroid carcinoma, for which she underwent unsuccessful surgery, as well as postoperative radiotherapy and chemotherapy. After receiving a second medical opinion, the patient underwent a challenging radical resection consisting in total thyroidectomy and central neck dissection, with no local recurrence after 6 months and 2 years of follow-up and negative metastatic follow-up. The correct diagnosis has been established based on pathological and immunohistochemical examinations. Conclusions: In summary, the diagnosis of CASTLE is difficult and requires an experienced histological analysis and CD5 immunoreactivity. Lack of metastasis, complete removal of the tumor, and a low degree of tumor infiltration into nearby structures are all associated with better long-term survival.

Introduction. The common peroneal nerve and the tibial nerve are the two major components into which the sciatic nerve divides. The severity of common peroneal nerve damage depends on the aetiopathogenic mechanism and the place of injury. The peroneal ram of the sciatic nerve injury is the most common cause of mononeuropathy of the lower limb which can cause a signi-ficant disability if is not properly diagnosed and treated. Material and method. We present the case of a 40-year-old patient who suffered a polytrauma by road accident resulting in left tro-chanteric-diaphyseal femoral comminuted open fracture, lacerated wound on the posterolateral middle third of the left thigh, left sacral wing fracture without displacement, left L1, L2, L3 tran-sverse apophyseal fractures and splenic laceration, treated surgically and orthopedically. The pa-tient was admitted to the Medical Reabilitation Department of Sibiu for left leg motor deficit, mechanical pain and functional deficit of the left hip and ankle, gait disorders. Complex rehabi-litation treatment was initiated 3 months after the accident. Results and discussion. Common pe-roneal nerve palsy was confirmed following neurological consultation the day after admission to Orthopaedics-Traumatology Department of Sibiu where continuous extension-traction was performed in order to relax the fracture and subsequent osteosynthesis surgery of the femur fracture. The presence of a deep and lacerating wound on the posterolateral left thigh caused the nerve injury. The coagulase-negative Staphylococcus aureus overinfection of the wound required secondary suturing and subsequently led to fibrous scar formation, adversely affecting the post-injury repair of the common fibular nerve. Conclusions. In patients with posttraumatic common peroneal nerve palsy, early diagnosis and appropriate treatment, including medical rehabilitation, are essential. Medical rehabilitation should be continued on a sustained basis be-cause nerve regeneration occurs slowly. The prognosis mainly depends on the severity of the initial nerve injury. Keywords: common fibular nerve injury, polytrauma, medical rehabilitation

Chronic thyroiditis may present a focal lesion, often-palpable abnormality, simulating nodular disease. The number and morphology of the Hürthle cells (HC) vary in the thyroid aspirate. Distinguishing between neoplastic and non-neoplastic HC lesions is difficult when using the fine-needle aspiration cytology (FNAC). We present the case of a 46-year-old female with a large right nodular goiter and hypothyroidism and high titer of anti-thyroid peroxidase antibody (TPO). The thyroid ultrasound showed a large well-defined nodule (more than 6.8 cm) with hypoechogenicity and microcalcification. FNAC (Mayo Clinic technique) smears revealed HC arranged in flat sheets in 75% in the sample with moderate nuclear pleomorphism, abundant granular cytoplasm showing eosinophilia and well-defined cytoplasmic borders, a lightly eccentric enlarged nuclei; the colloid was reduced and lymphocytes were also described. The final histological examination revealed that oncocyte cell proliferation is limited to the thyroid parenchyma and does not exceed the capsule and has no vascular invasion. The presence of lymphocytic infiltration and a performing FNAC (like Mayo Clinic technique) is absolutely necessary in a focal autoimmune thyroiditis in order to exclude HC carcinoma.

Tuberculous chancre is an extremely rare form of cutaneous tuberculosis. The genital area is a possible site of presentation. We present a case of a young male with a persistent balanopreputial ulceration resembling a luetic chancre with negative serology for syphilis. The diagnosis was based on the specific pathologic features and the positive intradermal reaction to tuberculin. A successful treatment was achieved by combining antituberculosis treatment and surgical approach with circumcision. After six months of antituberculosis treatment, the patient developed paradoxical inguinal lymph node enlargement, which, after surgical excision and biopsy, was not followed by a relapse of the disease and needed no further therapy. Tuberculosis should be considered a potential diagnosis in the case of a persistent genital ulcer.