Search

Vitamin D receptor is present in almost every cell of the body. Although some studies have suggested that values >30ng/ml would be sufficient, there is no consensus on the optimal values of serum vitamin D. Vitamin D deficiency can lead to “benign” manifestations, such as back pain, joint pain, fatigue, and heavy sweating. Premature ventricular contractions (PVCs) originating from the right ventricular outflow tract (RVOT) are considered “benign,” as they occur in patients without structural heart disease and their exact cause remains unknown. We describe the case of a 10-year-old boy with frequent PVCs and vitamin D deficiency that was corrected after vitamin D supplementation. On the contrary, his twin brother had normal serum vitamin D and no PVCs. The disappearance of PVCs occurred after treatment with vitamin D 2000 IU/day.

Ongoing research in the field of pediatric oncology has led to an increased number of childhood cancer survivors reaching adulthood. Therefore, ensuring a good quality of life for these patients has become a rising priority. Considering this, the following review focuses on summarizing the most recent research in anthracycline-induced cardiac toxicity in children treated for leukemia. For pediatric cancers, anthracyclines are one of the most used anticancer drugs, with over half of the childhood cancer survivors believed to have been exposed to them. Anthracyclines cause irreversible cardiomyocyte loss, leading to chronic, progressive heart failure. The risk of developing cardiotoxicity has been known to increase with the treatment-free interval and total cumulative dose. However, because of individual variations in anthracycline metabolism, it has recently been shown that there is no risk-free dose. Moreover, studies have shown that diagnosing anthracycline-induced cardiomyopathy in the symptomatic phase is associated with poor treatment response and prognosis. Thus, early and systematic evaluation of these patients is crucial to allow optimal therapeutic intervention. Although currently echocardiographic assessment of left ventricle ejection fraction and cardiac biomarker evaluation are being used for cardiac function monitoring in oncologic patients, there is no established follow-up and treatment protocol for these patients, and these methods are neither specific nor sensitive for identifying early cardiac dysfunction. All things considered, the need for ongoing research in the field of pediatric cardiooncology is crucial to offer these patients a chance at a good quality of life as adults.

Background/Aim: Convalescent plasma collected from COVID-19 survivors contains antibodies against receptor binding domains with potent antiviral activity. The use of this therapy for COVID-19 is still under investigation, as the pathophysiological and immunological mechanisms responsible for the evolution of the disease have not been fully identified. Patients and Methods: In this retrospective observational study, we included all patients with a confirmed SARS-Cov-2 infection based on positive RT-PCR testing, who received convalescent plasma treatment in addition to standard therapy, between 17.05.2020 and 27.11.2020, following hospitalization in the Anaesthesia and Intensive Care Unit of the Sibiu County Emergency Clinical Hospital, Romania. Results: Convalescent plasma therapy of patients with SARS-Cov-2 infection and severe forms of the disease (requiring only high-flow oxygen therapy or non-invasive ventilation) significantly improved inflammatory markers (CRP, fibrinogen) and ventilatory parameters (SaO2, paO2, paO2/FiO2) reducing the need of supplemental oxygen delivery (p

The use of high-sensitivity cardiac troponin (hs-cTn) assays has become part of the daily practice in most of the laboratories worldwide in the initial evaluation of the typical chest pain. Due to their early surge, the use of hs-cTn may reduce the time needed to recognise myocardial infarctions (MI), which is vital for the patients presenting in the emergency departments for chest pain. The latest European Society of Cardiology Guidelines did not only recognise their central role in the diagnosis algorithm but also recommended their use for rapid rule-in/rule-out of MI. High-sensitivity cardiac troponins are also powerful prognostic markers for long-term events and mortality, not only in a wide spectrum of other cardiovascular diseases (CVD) but also in several non-CVD pathologies. Moreover, these biomarkers became a powerful tool in special populations, such as paediatric patients and, most recently, COVID-19 patients. Although highly investigated, the assessment and interpretation of the hs-cTn changes are still challenging in the patients with basal elevation such as CKD or critically ill patients. Moreover, there are still various analytical characteristics not completely understood, such as circadian or sex variability, with major clinical implications. In this context, the present review focuses on summarizing the most recent research in the current use of hs-cTn, with a main consideration for its role in the diagnosis of MI but also its prognostic value. We have also carefully selected the most important studies regarding the challenges faced by clinicians from different specialties in the correct interpretation of this biomarker. Moreover, future perspectives have been proposed and analysed, as more research and cross-disciplinary collaboration are necessary to improve their performance.

The outbreak of COVID-19 pandemic has changed the provision of medical services worldwide. We assessed the impact of the pandemic on the oncological patients' visits to a tertiary cancer centre.We analysed registrations from the administrative data system of in- and outpatients in all of the departments of the Cluj-Napoca Oncology Institute, during March-October 2020, and compared to the same 7-month period of the previous year.The decrease during March-October 2020 was 40.2% for new referrals overall (with the most significant drop in April, of 80%), 52.5% for medical oncology inpatients, 39% for paediatric oncology department inpatients, 69% for radiotherapy inpatients, 34.9% for surgical interventions and 31% decrease of issued pathology reports. The decrease was less important for outpatients: only 10% for medical oncology outpatient department, 33% for radiotherapy and 27% for breast cancer unit outpatients. Imaging investigations were only slightly influenced by the pandemic (reduction of 5% for MRI scans, 19% for mammograms,whereas performed CT scans were even more after the outbreak of COVID-19).Our results show a decrease in the number of patients during the period after the outbreak of the COVID-19 pandemic, more for inpatients and less significant for outpatient departments, probably because of the internal circuits reorganization but also because of health care measures taken nationally and locally to limit the spread of the pandemic.

Catheter ablation is established as a treatment option for patients with high number Premature Ventricular Contractions (PVCs). However, complications can occur: cardiac tamponade, coronary artery injury or infectious endocarditis. Reversible causes such as hypocalcaemia, hypomagnesaemia and hypokalemia can be responsible for PVCs. Here, a case of nine years old boy, with vitamin D deficiency that presented high number PVCs which corrected using vitamin D dietary supplementation was described. A nine-year-old boy was hospitalised in the Cardiology Department for catheter ablation of PVCs. He presented short of breath during football matches and asthenia. Electrocardiography(ECG) and Holter ECG demonstrated high number PVCs with a morphology consistent of Right Ventricular Outflow Tract (RVOT) origin. Catheter ablation was postponed until Vitamin D came to normal values. Dietary supplementation was performed, together with Holter ECG monitoring. After vitamin D normalisation, PVC burden reduced significantly without the need of catheter ablation or anti-arrhythmic drugs. Catheter ablation and anti-arrhythmic drugs can be avoided in patients with frequent PVCs and vitamin D deficiency.

(1) Background: Febrile neutropenia (FN) remains one of the most challenging problems in medical oncology and is a very severe side effect of chemotherapy. Its late consequences, when it is recurrent or of a severe grade, are dose reduction and therapy delays. Current guidelines allow the administration of granulocyte-colony-stimulating factors (G-CSF) for profound FN (except for the case when a pegylated form of G-CSF is administrated with prophylactic intention) in addition to antibiotics and supportive care. (2) Methods: This is a prospective study that included 96 patients with confirmed malignancy, treated with chemotherapy, who developed FN during their oncological therapy, and were hospitalized. They received standard treatment plus a dose of G-CSF of 16 µg/Kg/day IV continuous infusion. (3) Results: The gender distribution was almost symmetrical: Male patients made up 48.96% and 51.04% were female patients, with no significance on recovery from FN (p = 1.00). The patients who received prophylactic G-CSF made up 20.21%, but this was not a predictive or prognostic factor for the recovery time from aplasia (p = 0.34). The median chemotherapy line where patients with FN were included was two and the number of previous chemotherapy cycles before FN was three. The median serological number of neutrophils (PMN) was 450/mm3 and leucocytes (WBC) 1875/mm3 at the time of FN. Ten patients possess PMN less than 100/mm3. The median time to recovery was 25.5 h for 96 included patients, with one failure in which the patient possessed grade 5 FN. Predictive factors for shorter recovery time were lower levels of C reactive protein (p &lt, 0.001) and procalcitonin (p = 0.002) upon hospital admission and higher WBC (p = 0.006) and PMN (p &lt, 0.001) at the time of the provoking cycle of chemotherapy for FN. The best chance for a shorter duration of FN was a short history of chemotherapy regarding the number of cycles) (p &lt, 0.0001). (4) Conclusions: Continuous IV administration of G-CSF could be an alternative salvage treatment for patients with profound febrile neutropenia, with a very fast recovery time for neutrophiles.

Simple Summary Around 90% of children diagnosed with acute lymphoblastic leukemia are long-term survivors due to the efforts made in the last decades to tailor the chemotherapy protocols, which is not the case for the adult population. This literature review proposes to bring together all the relevant data to answer the ardent question: why the results in adults, adolescents and young adults are not nearly as good as those obtained in children? Abstract It is a new and exciting time for acute lymphoblastic leukemia (ALL). While nearly 50 years ago, only one in nine children with ALL survived with chemotherapy, nowadays nearly 90% of children have a chance of long-term survival. Adults with ALL, as well as the special category of adolescents and young adult (AYA) patients, are catching up with the new developments seen in children, but still their prognosis is much worse. A plethora of factors are regarded as responsible for the differences in treatment response, such as age, ethnicity, disease biology, treatment regimens and toxicities, drug tolerance and resistance, minimal residual disease evaluation, hematopoietic stem cell transplantation timing and socio-economic factors. Taking these factors into account, bringing pediatric-like protocols to adult patient management and incorporating new agents into frontline treatment could be the key to improve the survival rates in adults and AYA.

The aim of this study is to compare the efficiency of conventional imaging and 18F-FDG PET-CT in detecting progressive disease and recurrences over a period of one year (2018), in the case of ovarian cancer, and also to assess the importance of 18F-FDG PET/CT in changing the course of the treatment for these patients. This study included 29 patients diagnosed in various stages with ovarian carcinoma, most of them of epithelial origin. All patients were evaluated throughout their treatment using 18F-FDG PET/CT and various conventional techniques (computed tomography (CT), magnetic resonance imaging (MRI), abdominal and intravaginal ultrasound, chest X-ray). PET/CT was more useful and effective in our group of patients in detecting progressive disease compared with conventional imaging (37.93% vs. 17.24%) and also in establishing the recurrences (24.14% vs. 6.90%). Moreover, F18-FDG PET-CT led to a therapeutic change in 55.17% of the patients of our group, compared with only 17.24% after conventional imaging. This underlines the crucial aspect of the metabolic changes of tumors that should be assessed alongside the morphological ones, with PET-CT imaging remaining the only viable tool for achieving that at present. PET/CT with 18F-FDG represents one of the most important imaging techniques used in the diagnosis and management of ovarian carcinoma. Our results seem to fall in line with what other authors reported, indicating that 18F-FDG PET-CT is potentially gaining more ground in the management of ovarian carcinoma, by influencing therapeutic strategies and by being able to detect relapse and progression accurately.

Aims. Reference values of the P-wave on 12 lead electrocardiograms are lacking for children and adolescents in Eastern Europe. Hence, the present study is aimed at determining the standard values of the P-wave in children and adolescents based on ECG data from the CARDIOPED project, a large-scale general population of children who participated in a screening program in Transylvania, Romania. Methods and Results. A total of 22,411 ECGs of participants aged 6 to 18 years old from a school-based ECG screening were obtained between February 2015 and December 2015 in Transylvania, Romania. Three pediatric cardiologists manually reviewed each ECG. P-wave duration, voltage, axis, and correlation with gender and age were analyzed. The mean P-wave duration was88±10.7 ms, with a maximum duration of 128 ms. P-wave showed a positive correlation with age but did not differ between sexes. There was a positive correlation between the P-wave duration and the heart rate, but not with the body max index. The mean P-wave axis was40.4±31.1, and the mean P-wave amplitude was0.12±0.03 mV. Conclusion. In this study on many pediatric subjects, we have provided normal limits for the P-wave in Romanian children aged 6-18 years. Our findings are useful for creating interpretation guidelines for pediatric ECG.

Highlights • Paraneoplastic cerebellar degeneration may precede the diagnosis of cancer. • Early diagnosis of paraneoplastic cerebellar degeneration improve the prognosis. • Treatment includes immunotherapy, oncological therapy and supportive therapy. • Paraneoplastic cerebellar degeneration suspected in neurological symptoms in women., Paraneoplastic neurologic syndromes (PNS) are a rare heterogeneous group of disorders associated with malignancy that can result in significant functional impairment. One syndrome in particular, paraneoplastic cerebellar degeneration (PCD), may be severely disabling. PCD is a rare neurological syndrome, associated with active or subclinical cancer, characterized by acute or subacute onset cerebellar ataxia due to tumor-induced autoimmunity against cerebellar antigens. Treatment of paraneoplastic syndromes is generally unsatisfactory, but early diagnosis and treatment of PCD, which includes neurological treatment, immunotherapy and oncological treatment of associated malignancy, may improve the neurological prognosis. We reported the case of a 59-year-old woman who presented PCD as the first sign of ovarian cancer. Laboratory investigations showed the presence of anti-Yo antibodies in the serum. The brain MRI revealed specific modifications for PCD. After oncological treatment, intravenous immunoglobulin therapy and corticosteroid therapy, the oncological response was satisfactory, but no improvement of the neurologic symptoms was achieved.

When a cardiologist is asked to evaluate the cardiac toxic effects of chemotherapy, he/she can use several tools: ECG, echocardiography, coronary angiography, ventriculography, and cardiac MRI. Of all these, the fastest and easiest to use is the ECG, which can provide information on the occurrence of cardiac toxic effects and can show early signs of subclinical cardiac damage. These warning signs are the most desired to be recognized by the cardiologist, because the dose of chemotherapeutics can be adjusted so that the clinical side effects do not occur, or the therapy can be stopped in time, before irreversible side effects. This review addresses the problem of early detection of cardiotoxicity in adult and pediatric cancer treatment, by using simple ECG recordings.

Introduction: F18-FDG PET/CT is the most important hybrid imaging used in the diagnostic, staging, follow-up, and treatment evaluation response in cancer patients. However, it is well-known that in breast cancer the use of F18-FDG is not included in the first line protocol of initial diagnostic, both in female and male breast cancer patients. F18-FDG PET/CT is a valuable tool to provide information on extra-axillary lymph node involvement, distant metastases, and other occult primary cancers. This study assesses F18-FDG PET/CT systemic staging in male patients with diagnosed breast cancer and determines detection rates for unsuspected distant metastases and synchronous malignancies. Methods: We analyzed a number of 170 male patients with breast cancer, seen between 2000–2020, in a tertiary center. From this group, between 2013–2020 a number of 23 patients underwent F18-FDG PET/CT. Rates of upstaging were determined for each case and the detection of other primary malignancies was analyzed. Results: Median age of male breast cancer group was 61.3 y (range, 34–85 y), most had intraductal carcinoma (82.4%) and unsuspected distant metastases, which increased patient stage to IV, observed in 27%. In 4 out 23 patients (17.4%), F18-FDG PET/CT identified synchronous cancers (2 prostate cancers, 1 thyroid and 1 colon cancer). Conclusion: F18-FDG PET/CT is a valuable tool to provide information on extra-axillary lymph node involvement, distant metastases, and other occult primary cancers. Baseline F18-FDG PET/CT has a substantial impact on the initial staging and on clinical management in male breast patients and should be considered for use in newly diagnosed patients.

Until 1989, Romania was one of the countries of the communist bloc in Europe and its healthcare system was characterized by centralized planning and severe underfunding, with low performance and low quality healthcare. Since 1998, Romania replaced the Semashko model with a social health insurance system, highly centralized under the management of the Ministry of Health as the central administrative authority. After joining the European Union, quality of life increased in our country and there were efforts to improve the quality of healthcare, including pediatric and neonatal care. Still, Romania has the lowest share of health expenditure of gross domestic product among the European Union Member States and the lowest level of expenditure per inhabitant. The Romanian health system is organized on three levels of assistance: primary, secondary and tertiary assistance. This overview presents the organization and the characteristics of pediatric and neonatal healthcare in Romania at all levels, the infrastructure and the human resources, the educational system from medical school to pediatric residency, professional organizations, national health programs, and the child health status in Romania. Infant mortality, the most descriptive single indicator of the quality of a health system, decreased constantly for the last 30 years in Romania, but is still the highest in the European Union. Even though there were great improvements in the healthcare for children, more efforts should be made to assure a better quality of care for the future of our nation, both on the human resources (in great danger due to the brain-drain of medical professionals during the last 12 years), and on the infrastructure plan.

Gastric cancer represents one of the most severe cancers with poor overall survival. Despite the availability of published data on the efficacy of adjuvant treatment, the actual percentage of treated patients remains low. The toxicity of radiotherapy or chemotherapy regimens differ and clinicians need accessible tools in order to better select candidates for adjuvant treatment. In this review, we present published data from clinical trials and cancer registries that might be useful for properly balancing the efficacy and toxicity of adjuvant treatment in gastric cancer patients who underwent surgery with curative intent.

Simple Summary Lung cancer is still one of the most commonly diagnosed and deadliest cancers in the world. Its diagnosis at an early stage is highly necessary and will improve the standard of care of this disease. The aim of this article is to review the importance and applications of next generation sequencing in lung cancer diagnosis. As observed in many studies, next generation sequencing has been proven as a very helpful tool in the early detection of different types of cancers, including lung cancer, and has been used in the clinic, mainly due to its many advantages, such as low cost, speed, efficacy, low quantity usage of biological samples, and diversity. Abstract Lung cancer is still one of the most commonly diagnosed cancers, and one of the deadliest. The high death rate is mainly due to the late stage of diagnosis and low response rate to therapy. Previous and ongoing research studies have tried to discover new reliable and useful cbiomarkers for the diagnosis and prognosis of lung cancer. Next generation sequencing has become an essential tool in cancer diagnosis, prognosis, and evaluation of the treatment response. This article aims to review the leading research and clinical applications in lung cancer diagnosis using next generation sequencing. In this scope, we identified the most relevant articles that present the successful use of next generation sequencing in identifying biomarkers for early diagnosis correlated to lung cancer diagnosis and treatment. This technique can be used to evaluate a high number of biomarkers in a short period of time and from small biological samples, which makes NGS the preferred technique to develop clinical tests for personalized medicine using liquid biopsy, the new trend in oncology.

e13607 Background: The outbreak of COVID-19 pandemic has changed the provision of medical services worldwide. Oncological patients continued receiving specialty treatments. We assess the impact of the pandemic on the oncological patients' visits to a tertiary cancer center. Methods: We analyzed registrations from the administrative data system of in and outpatients in all departments of the Cluj-Napoca Oncology Institute, during March-October 2020, compared to the same 7-month period of the previous year. Results: The decrease during March-October 2020 was of 40.2% for new referrals overall (with the most significant drop in April, of 80%), of 52.5% for medical oncology inpatients, 39% for pediatric oncology department inpatients, 69% for radiotherapy inpatients, 34.9% for surgical interventions and 31% decrease of issued pathology reports. The decrease was less important for outpatients: only 10% for medical oncology outpatient department, 33% for radiotherapy, and 27% for breast cancer unit outpatients. Imaging investigations were only slightly influenced by the pandemic (reduction of 5% for MRI scans, 19% for mammograms, whereas performed CT scans were even more after the outbreak of COVID-19). Conclusions: Our results show a decrease in the number of patients during the period after the outbreak of the COVID-19 pandemic, more for inpatients and less significant for outpatient departments, probably because of the internal circuits reorganization but also because of healthcare measures taken nationally and locally to limit the spread of the pandemic. Keywords: COVID-19, pandemic, oncology referrals, disruption.

Introduction: During the last three decades, there has been an excess weight epidemic due to changes in nutrition and lifestyle. Few data on the prevalence of overweight and obesity in children in Romania were published, without a single study representative at the national level. There are reports on the higher level of overweight and obesity in urban areas compared to rural ones. This study aimed to estimate the prevalence of underweight, overweight, obesity and severe obesity in children enrolled in schools from the urban area. Material and methods: For this cross-sectional study, children from 177 schools from the urban area of five counties from the northwestern part of Romania were included after the parents signed written informed consent. Anthropometric data were recorded (weight, height) based on World Health Organization (WHO) recommendations and Body-Mass-Index (BMI), and the z-score for BMI were calculated. The nutritional status was estimated using three reference criteria: WHO, International Obesity Task Force (IOTC) and the Center for Disease Control and Prevention (CDC). Results: We analyzed data of 21,650 children (48.19% boys) age between 7 and 18 years. The prevalence of overweight was 13.8%, 16.2% and 20.3%, of obesity was 10.7%, 10.0% and 5.7% and of severe obesity was 5.1%, 1.2% and 1.6% (using WHO, CDC and IOTF cut-offs). Underweight was present in 5.2% (WHO), 6% (CDC) and 2.6% (IOTF). The highest prevalence of overweight (including obesity) was found in children aged 10 years, and the lowest in adolescents at 18 years. Boys have a higher prevalence of excess weight than girls. Using IOTF cut-offs, the prevalence of obesity and severe obesity was lower than using WHO criteria. Conclusions: The prevalence of overweight (including obesity) in children from the urban area of Western Romania was recorded at alarming levels, higher in boys and at the pre-puberty ages. There are significant differences based on the reference system used. It is important to correctly choose the reference for the definition of overweight and obesity to have the correct estimation of the target for public health measures.

Introduction Non-communicable diseases (NCDs) account for 70% of global mortality and represent the leading cause of death and disability worldwide. In Romania, the cardiovascular diseases represent the first cause of mortality. Unhealthy behavior, malnutrition, both overweight or obesity, and physical inactivity are known risk factors for metabolic syndrome, which is involved as a cause for cardiovascular diseases in adults. The education for health in children is one of the most effective ways to reduce exposure to risk factors for NCDs and decrease the morbidity in the future adults. “Healthy Life-style for a Healthy Childhood – A Healthy Child is A Happy Child!’ is a program for education for health for children developed under the NCD Child Advocacy in Action Grant Program of the American Academy of Pediatrics. The goal of this program was to promote the healthy life-style for children of three schools from Cluj-Napoca, Romania. The objectives were education for healthy lifestyle in school-aged children (by publication of brochures, live courses about the importance of healthy lifestyle: nutrition, physical activity, healthy behaviors), promotion of healthy nutrition (including workshops with healthy cooking where children and their parents prepare different healthy meals) and promoting of physical activity (running events for children involved in the program). The website of the program contains online courses accessible for children involved in the program, but also to other children of school-age, being produced in three languages (Romanian, Hungarian and English). There are modules about healthy life-style and nutrition, including quizzes, one collection of recipes for healthy meals where the children could promote theirs healthy recipes. The children involved in the project could participate in one running event and then one team represented the project in the main running event in our city. Based on the experience gained in this project all the activities will continue during the following years with an extension in other schools from our city, for a larger number of school-aged children. Conclusions The education for health, promoting the change of the life-style of our children with a healthier one is considered the most beneficial preventive action in order to have a healthy population in the future and to decrease the risk for metabolic syndrome and cardiovascular disorders.

Introduction Celiac disease is an immune-mediated systemic disorder elicited by gluten which causes malabsorption and small-bowel mucosal inflammation in genetically susceptible individuals. Although the gastrointestinal tract is the target of autoimmune insult, celiac disease is also associated with extra-intestinal problems: autoimmune disorders, malignancies, dermatologic conditions, rheumatologist conditions, neurologic and psychiatric disorders. The psychological symptoms are one of the most interesting and unexpected presentations, which may be the result of nutrient malabsorption or increased levels of proinflammatory cytokines. Case report We present the case of a 15 year old adolescent girl with a history of autoimmune thyroiditis on replacement therapy with levothyroxine, who was hospitalised because of behaviour disorders and oligobradimenorrhea. On clinical examination the patient presented drowsiness, sudden behavioural changes, learning problems, bradylalia and a tendency to isolate herself. Blood tests showed positive anti-TG2 antibodies (>10x normal) and EMA antibodies. HLA typing was also performed and was positive for HLA-DQ2 cis: DQA1*05 - DQB1*02 - DRB1*03. On the psychiatric consult she was diagnosed with a minor depressive syndrome. She was immediately started on a gluten free diet. Although she showed low compliance to the diet on the follow-up examinations, removing gluten resulted in positive effects on the psychiatric symptomatology. We would also like to add that the patient refused the oesophagogastroduodenoscopy and psychological counselling. Conclusion Recent studies have shown an association between celiac disease and psychiatric conditions, especially depression. Medical personnel should be aware of this atypical presentation of the disease in order to correctly diagnose and treat celiac disease. Also, psychiatric patients who are resistant to traditional therapy should be investigated for celiac disease in case they also present symptoms of CD or if a positive family history exists.

Introduction The presence of CYP24A1 mutations explains the increased sensitivity to vitamin D in patients with idiopathic infantile hypercalcemia and is a genetic risk factor for the development of symptomatic hypercalcemia that may be triggered by vitamin D prophylaxis in otherwise apparently healthy infants. Case report We present a case of a 4-month old girl who was initially hospitalized for severe hypotonia, lethargy and failure to thrive. The patient’s history revealed recurrent vomiting. On the clinical examination we also noted a high forehead, a high arched palate and short metacarpal bones. Blood tests showed hypercalcemia, low PTH and phosphate and high vitamin D levels. Renal ultrasound showed medullary nephrocalcinosis. Correlating the clinical examination with the blood work vitamin D intoxication, hyperparathyroidism and Jansen’s metaphyseal dysplasia were considered and ruled out. Genetic testing was performed and a compound heterozygote state was identified (mutations p.E143del and p.R396W) confirming the diagnosis of idiopathic infantile hypercalcemia. Both mutations have been formerly identified as loss-of-function mutations in the vitamin D-24-hydroxylase gene. Rehydration and furosemide therapy was applied and resulted in the normalization of calcium values and clinical improvement. On the long term the patient followed a low calcium diet and vitamin D supplementation was discontinued. Conclusion Clinical symptoms, such as failure to thrive, vomiting, increased thirst, anorexia, hypotonia should always bring in discussion the possibility of hypercalcemia in order to diagnose and treat idiopathic infantile hypercalcemia early and also to prevent long-term complications.

Introduction Celiac disease is an immune-mediated small intestinal enteropathy with an increasing global prevalence. Despite worldwide awareness, the diagnosis is frequently delayed because of a broad range of clinical manifestations of this disorder. Case-report We report a 12-year-old boy who was referred from another hospital with the suspicion of a chronic hepatopathy, with peripheral oedema, abdominal distension (possibly ascites), hypoalbuminemia, coagulopathy (INR 2.5) and low ceruloplasmin level. The disease progressed gradually with these symptoms for 2 weeks. Furthermore, the patient complained of intermittent diarrhoea, weight loss (8 kg), growth failure, chronic abdominal pain and fatigue for 18 months. The patient presented severe wasting and stunting (BMI 13.7), pallor, dry skin, clubbing, lack of energy and bradycardia. Ultrasonography detected diffusely hyperechoic liver, polyserositis and dilated bowel loops. ALT was slightly elevated, bilirubin level and ammonemia were normal, INR 1.2 after vitamin K parenterally administered (Koller test) and urinary copper excretion rate was low. We excluded the hypothesis of liver failure. Antibody TG >200 U/ml, positive EMA and HLA-DQ2 typing, led us to the final diagnosis of celiac disease. Treatment included a gluten-free diet, albumin, calcium and magnesium supplements, with an improved clinical appearance. Conclusions The coagulopathy caused by vitamin K malabsorption and hypoproteinemia could be misdiagnosed as liver disease, leading to delayed diagnosis and inappropriate treatment of celiac disease. Further attention should be given towards the uncommon presentations of celiac disease.

Introduction Arterial hypertension is a major risk factor for cardiovascular, cerebrovascular and renal morbidity and mortality. Renovascular disease is the third most common cause of hypertension in children after coarctation of the aorta and parenchymal renal disease. The spectrum of renovascular diseases in children is very broad compared to adults. Besides fibromuscular dysplasia and renal artery stenosis as the main causes, narrow/hypoplastic accessory renal artery or multiple accessory renal artery or multiple renal arteries could also be involved in ischemic nephropathy. Case report We describe the case of a 15-year-old girl who presented with palpitations, chest pain and headache. The physical examination revealed a high blood pressure (over the 99th percentile for age, gender and height). She had insignificant personal and family medical history regarding the cardiovascular risk factors. Laboratory analysis and relevant radiological evaluation were obtained in order to determine the etiology for suspected secondary hypertension. Direct plasmatic renin, plasmatic aldosterone, urinary cathecolamines, plasmatic metanephrines, vanilmandelic acid, thyroid function tests were all within normal limits. In order to rule out possible renal artery stenosis, CT angiography of the renal artery was performed, surprisingly demonstrating a small caliber (hypoplastic) accessory right superior renal artery. Accessory renal artery stenosis/hypoplastic is a possible etiology for secondary hypertension, presumptively leading to renin secretion by the underperfused kidney. Conclusion Physicians should be alert to the possibility of the causal role of accessory renal arteries in patients with severe and difficult to manage hypertension. For several reasons this possibility may be greater in children.

Introduction The excessive mortality seen in patients with end-stage renal disease (ESRD) is closely related to cardiac disease. We aimed to assess if there were distinctive parameters that can early predict cardiac disfunction in children on maintainance dialysis (MD). Methods From the ESRD database of our tertiary referral centre (2017–2018), we enrolled all patients on MD. For statistical analysis we used STATA software version 13. Results Twenty-four patients were on MD: mean age (± SD) 14.6 ± 4.7 years, mean duration of MD 3.5 years, 55% male. The study population was divided into two groups: group-1 consisted of patients with cardiomyopathy and group-2 included patients without cardiac disfunction. The two groups were similar regarding demographic characteristics, cardiovascular risk factors and uremia-related metabolic cardiac risk factors. On univariate analysis, a statistically significant difference was seen in the value of serum albumin (p=0.049) and s wave velocity on tissue doppler imaging (TDI) (p=0.02). No significant difference between the two groups was found for type of dialysis (hemodialysis or peritoneal dialysis), growth delay, laboratory parameters like homocisteine and NT-pro BNP (and a lot other), ECG parameters. Conclusions Some echocardiographic parameters such as systolic dysfunction assesed by s wave on TDI are the best tools for early diagnosis of cardiac disfunction. No ECG parameters were found to predict early disfunction. There are also bioumoral factors that can alert the clinician regarding cardiac malfunction such low level of seric albumin. Protocols for regular echocardiographic screening, diagnosis and monitoring of heart disease are recommended in the follow-up of these patients in order to provide a proper management of the disease and prevent complications like cardiac disease which is the main cause of morbidity and mortality in children with end-stage renal disease.

Introduction Acute liver failure (ALF) is a syndrome defined by rapid decline of hepatic function, jaundice, coagulopathy (INR >1.5) and hepatic encephalopathy in patients with no evidence of previous liver disease. The aetiology of ALF in children varies on the age. Material and methods We have analysed retrospectively the aetiology of the ALF in children followed-up in our clinic during 7-year period (January 2012 - December 2018). We studied the main causes of ALF based on the age of children and their evolution after treatment. Results During this period, 97 patients (46 males, 47.42%) were admitted with ALF: 33 infants (0–12 months), 30 children (1–14 years) and 34 adolescents (14–18 years). In infants the most important causes of ALF were viral and bacterial infections: 24 patients (72.72%). Cytomegalovirus, Epstein-Barr virus, Herpesvirus, Parvovirus or Gram-negative bacteria were involved, with a high mortality: 10 patients (30.30%). Metabolic disorders were the cause of ALF in 9 patients (43.47%): 3 infants with mitochondrial disorder, 2 infants with galactosemia and tyrosinemia respectively, and one with neonatal haemochromatosis and hereditary fructose intolerance. Of those, 3 survived after supportive therapy and diet, one is alive after liver transplantation and 5 died. In children, toxic hepatitis was the most important cause of ALF (18 patients, 60%): albendazole in 11 children, mushrooms in 3 children, and one child with each acetaminophen, valproate or fluconazole. Viral and bacterial infections were the causes of ALF in 5 children (16.66%), 2 of them developed fatal aplastic anaemia. There were also 4 children with autoimmune hepatitis (AIH, 13.33%) and 3 children with Wilson disease (WD, 10%) presenting ALF at the time of diagnosis. The mortality in children with ALF was 20% (6 patients). Drugs and mushrooms intoxication was the most common cause of ALF among adolescents: 27 patients (79.41%), acetaminophen being the most often involved (17 patients). Fortunately, the mortality was low and only one patient died after colchicine overdose. There were 4 patients with AIH and 4 with WD. One patient died with Fulminant WD, other 2 were transplanted and the others are alive with supportive therapy. Conclusions In children, the aetiology of ALF is different depending on age and is associated with a high mortality despite optimal medical therapy, but without emergency liver transplantation. The management of this cases requires a multidisciplinary team involving paediatric hepatologist, critical care specialist, nephrologist or liver transplant surgeon.

Adenosine is a nucleoside that is normally found inside the human body. It has a negative chronotropic and dromotropic effect. It slows the sinus node rate and also the conduction through the AV node. Adenosine’s mechanism of action is mainly on the sinus node and atrioventricular node. It stimulates the potassium current Ikr, Ado and Ach , inducing cellular hyperpolarization and blocking the conduction through the AV node with subsequent interruption of PSVT that is node-dependent. Adenosine can induce reentry using an accessory pathway. By slowing the anterograde conduction through the AV node, it allows retrograde activation of the atrium through the accessory pathway. Human studies have also demonstrated that adenosine administration reveals dormant PV conduction. The ADVICE trial demonstrated that 53% of the patients that received adenosine had dormant conduction.

Colorectal cancer remains one of the most frequent malignancies (third place at both genders) worldwide in the last decade, owing to significant changes in modern dietary habits. Approximately half of the patients develop metastases during the course of their disease. The available therapeutic armamentarium is constantly evolving, raising questions regarding the best approach for improving survival. Bevacizumab remains one of the most widely used therapies for treating metastatic colorectal cancer and can be used after progression. This study aimed to identify the best chemotherapy partner for bevacizumab after progression. We performed a retrospective analysis of patients with metastatic colorectal cancer who were treated with bevacizumab as first- and second-line chemotherapy. Data were collected for 151 patients, 40 of whom were treated with double-dose bevacizumab after the first progression. The two standard chemotherapy regimens combined with bevacizumab were FOLFIRI/CAPIRI and FOLFOX4/CAPEOX. The initiation of first-line treatment with irinotecan-based chemotherapy improved progression-free survival and time to treatment failure but not overall survival. After the first progression, retreatment with the same regimen as that used in the induction phase was the best approach for improving overall survival (median overall survival: 46.5 vs. 27.0 months for the same vs. switched strategy, respectively). No correlations were observed between the dose intensity of irinotecan, oxaliplatin, 5-fluorouracil, or bevacizumab and the overall survival, progression-free survival in the first-/second-line treatment, and time to treatment failure. Interaction between an irinotecan-based regimen as a second-line treatment and double-dose bevacizumab after progression was associated with an improved overall survival (p = 0.06). Initiating systemic treatment with an irinotecan-based regimen in combination with bevacizumab improved the progression-free survival in the first-line treatment and time to treatment failure. In terms of overall survival, bevacizumab treatment after the first progression is better partnered with the same regimen as that used in the induction phase.

Pediatric thyroid carcinoma is a current area of interest, because there are few studies in this field, the current classification and treatment guidelines are extrapolated from adults, sometimes leading to overly aggressive treatments or incomplete treatment of the disease. The purpose of this retrospective study is to analyze the presentation, diagnosis, treatment, complications, and outcome of children diagnosed with thyroid cancer in the last two decades (2000&ndash, 2018) at the Oncological Institute &ldquo, Prof. Dr. Ion Chiricuță&rdquo, Cluj-Napoca (IOCN) Romania, a tertiary center in a region with environmental influences from both the nuclear fallout of the Chernobyl accident and from iodine deficiency. The results were compared with those obtained in a previous study carried out in the same institution between 1991&ndash, 2010, and with those obtained in a similar study carried out in Netherlands between 1970&ndash, 2013, a cohort of children not exposed to the post-Chernobyl fallout. We statistically analyzed 62 patients. Papillary form was present in the majority of cases, and we highlighted the occurrence of thyroid microcarcinoma in children. A total of 85.4% of patients received radioiodine, the total activity being significantly lower compared with the data from literature. In our study, the prognosis of the disease was excellent, with 100% overall survival.

Background & Aim: Endoscopic ultrasonography (EUS) and EUS-guided fine-needle aspiration (EUS-FNA) are considered good tools for the diagnosis of pancreatic cancer and for obtaining material for cytology or histology. The accuracy of EUS-FNA can rise to 85-95%, but it is lower in cases with a chronic pancreatitis background or with previous biliary stenting. We aimed to establish the diagnostic yield of the visible length of the core biopsy samples in pancreatic cancer by using one single type of standard 22G needle and to evaluate the factors which can influence the results. Method: EUS-FNA was performed by using a 22G standard needle on patients prospectively recruited with the suspicion of pancreatic masses on transabdominal ultrasound or CT scan over a period of eight months. The number of passes was limited by the length of the core obtained. The final diagnosis was based on EUS-FNA or hepatic biopsy for their metastasis or by follow up every three month by imaging methods. Results: The study included 118 patients. Previous stents were present in 10 patients and chronic pancreatitis features were found in 3 patients. The procedure sensitivity was 89% and the global accuracy was 89%. The presence of biliary stents did not impede the accuracy of results. The number of passes did not influence the results. Conclusions: The diagnostic rate of core biopsy by using 22G needles had a high accuracy and it is safe when the length of core dictates the number of passes. The presence of biliary stents did not influence the results. Abbreviations: AUC: area under the curve; EUS: endoscopic ultrasonography; EUS-FNA: fine needle aspiration under endosonographic guidance; FNA: fine needle aspiration; INR: international normalised ratio; OR: odds ratio.

e15523 Background: Despite the progress for cancer treatment, some drugs remain a cornerstone for an optimal approach. Hypersensitivity reactions to chemotherapy may render these essential chemotherapeutic agents useless and for some types of cancer continuing the therapeutic scheme could be crucial. Various regimens for desensitization to allow chemotherapy administration through the time were conceived, with different dilutions, time and settings of administration. Methods: A prospective study of patients with systemic treatment for histopathologically confirmed cancer in our Oncological Institute „Prof. Ion Chiricuta” Cluj-Napoca, with an allergic reaction during treatment being the keys inclusion criteria in the analysis. Patients were administered a three days desensitization regimen from the following cycle of treatment with blood samples that were taken to observe the predictive value of biological markers. Results: Eighty-two patients were the initial pool, with a median age of 56 years. Platin derivates containing regiments were responsible for an allergic reaction for 75 out of 82 patients. Four of them were known with a previous allergic reaction for chemotherapy in their personal medical history, and 56 of them had more than one chemotherapy line in their treatment. More than 688 desensitization cycles were administrated during our study with a rate of failure of 1.3 %. The main reason for discontinuation was disease progression or adjuvant character (limited duration) of the chemotherapy administration. Conclusions: Allergic reaction does not impede the administration of the responsible drug. A 3-day inpatient regimen could be a valuable option with a successful rate of administration without the need for ICU monitoring.

Granulocyte-colony stimulating factor (G-CSF) is a glycoprotein, the second CSF, sharing some common effects with granulocyte macrophage-colony stimulating factor (GM-CSF), interleukin-3 (IL-3) and interleukin-5 (IL-5). G-CSF is mainly produced by fibroblasts and endothelial cells from bone marrow stroma and by immunocompetent cells (monocytes, macrophages). The receptor for G-CSF (G-CSFR) is part of the cytokine and hematopoietin receptor superfamily and G-CSFR mutations cause severe congenital neutropenia.The main action of G-CSF - G-CSFR linkage is stimulation of the production, mobilization, survival and chemotaxis of neutrophils, but there are many other G-CSF effects: growth and migration of endothelial cells, decrease of norepinephrine reuptake, increase in osteoclastic activity and decrease in osteoblast activity.In oncology, G-CSF is utilized especially for the primary prophylaxis of chemotherapy-induced neutropenia, but it can be used for hematopoietic stem cell transplantation, it can produce monocytic differentiation of some myeloid leukemias and it can increase some drug resistance.The therapeutic indications of G-CSF are becoming more and more numerous: non neutropenic patients infections, reproductive medicine, neurological disturbances, regeneration therapy after acute myocardial infarction and of skeletal muscle, and hepatitis C therapy.

The progress made in the last few years made available a large amount of information that needs to be integrated and ordered by oncologists. Tumor markers are one of the pieces that physicians need to fit into the bigger puzzle. This article will detail the most frequent etiologies for the surges in the carcinoembryonic antigen (CEA), cancer-related antigen 72-4 (CA 72-4), cancer-related antigen 19-9 (CA 19-9) serum levels and their indications. Although tumor markers are an invaluable asset to medical practice, their role in screening, diagnosis and oncologic treatment remains poorly standardized. Ongoing or future clinical trials will shed light on pending problems.

Cancer is one of the most difficult diseases to be treated. The particularities regarding the tumors' occurrence mechanism, their evolution under chemotherapy, disease-free interval, but also the increasing number of patients make cancer an intensively studied health domain. Although introduced in therapy since the early 80s, platinum derivatives play an essential role in anticancer therapy. Their use in therapy resulted in improving the patient quality of life and prolonging disease-free interval, which makes them still a benchmark for other anticancer compounds. However, adverse reactions and allergic reactions are a major impediment in therapy with platinum derivatives. This paper summarizes data about platinum derivatives through a multidisciplinary approach, starting from a chemical point of view and on to their mechanism of action, mechanism of cellular resistance, predictive factors for the outcome of chemotherapy such as micro RNAs (miRNAs), tumor suppressor protein p53, and the excision repair cross-complementing 1 protein (ERCC1).

Introduction Anorexia nervosa (AN) is a psychiatric eating disorder with a prevalence of 0,5%–1% among adolescents, characterised by a decrease in caloric intake, weight loss and behavioural changes. Patients with AN may also suffer from bone marrow suppression and multiple metabolic complications caused by severe malnutrition. There are 3 main causes of hyperhomocysteinemia: genetic defects, nutritional deficiencies (vitamins B12, B6 or folate) and insufficient elimination. The homocysteine plasma level in patients with AN is linked to cognitive impairment and depression, the latter being the most common psychiatric comorbidity. Case-presentation We describe the case of AN in a 15 year old female, complicated by extended deep and superficial vein thrombosis of the upper limb. She also had a mild form of depression. At the admission, she presented flat affect, a BMI of 13 kg/m2, dry skin with trophic changes, loss of muscle mass, resting bradycardia and hypotension. Blood tests indicated hypoglicemia, mild neutropenia and thrombocytopenia, normal liver and renal function, normal serum ionogram. On the 10th day of hospitalisation she presented signs of acute inflammation at the left upper limb, at the venous catheter placement. Doppler ultrasonography confirmed findings of the axillary, brachial and cephalic veins consistent with extended new and old thrombi at the left upper limb. Within thrombophilia evaluation, we found a heterozygous MTHFR A1298C mutation, which causes mild hyperhomocysteinemia. Anticoagulation therapy with subcutaneous Enoxaparin, antidepressant treatment, controlled caloric and vitamin intake, parenteral electrolyte supplementation and bed rest led to the reduction of the thrombi and the improvement of the biological and clinical condition of the patient. Conclusions Hospitalised patients with AN can have a complex coagulation profile, with elements of hypocoagulopathy (thrombocytopenia and elevated INR) and of hypercoagulability, like immobilisation and hyperhomocysteinemia. The latter, which is a hallmark for AN, is linked to a high risk of cardiovascular disease, stroke and peripheral vascular disease. There is a study in which thromboelastography was used to evaluate the coagulation status of patients with severe AN and assist in guiding venous thrombosis prophylaxis therapy. Among the psychiatric disorders, AN is associated with the highest mortality rate, with numerous complications, requiring a multidisciplinary approach.

Novel emerging therapies have changed paradigms in metastatic colorectal cancer. The advantages of molecular targeted treatments, either the anti-angiogenic or the anti-epidermal growth factor receptor drugs, reside in the fact that while their specificity for the cancer cell is higher, their toxicity on normal tissues is significantly lower when compared to chemotherapy. But when it comes to their safety, especially from a cardiovascular point of view, they still need to pass the test of time and further prospective studies are needed. Clinical trial patients are very well selected with regards to comorbidities and therefore, they often differ from real-life patients. In order to maximize the benefits from these drugs, we need to better identify the population at risk, understand and early diagnose their on- and off-target adverse effects and to adequately choose the diagnostic tools; with a better prevention and early treatment, the quality and quantity of our patients’ lives can be significantly improved.