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Controlling pain after major orthopedic surgery may be challenging, and it is related to delayed recovery, the development of chronic pain, and analgesic dependence. It is well known that effective postoperative pain control can reduce hospital stays by ensuring a more rapid rehabilitation, thereby decreasing the overall costs. Despite the development of analgesics, the use of opioids and their derivates remains the cornerstone of treatment for patients with acute moderate-to-severe pain in association with general or regional anesthesia. To reduce the risk of side effects and opioid addiction, considering the alarming epidemiological reports in relation to opioid abuse, combined analgesic methods are used, in addition to lower dosages or different forms of administration, such as transdermal administration. Fentanyl transdermal patches appear to be effective in controlling postoperative pain as part of multimodal analgesic regimens in knee and hip surgery, shoulder arthroplasty, traumatic fractures, and one-day surgery; this treatment has fewer associated side effects and can be safely used even in patients with renal impairment. It is also recommended for postoperative pain management in combination with a femoral–sciatic nerve block during foot and ankle surgery. [ABSTRACT FROM AUTHOR]

Postoperative anaemia can affect more than 90% of patients undergoing major surgeries. Patients develop an absolute iron deficiency in the face of significant blood loss or preoperative anaemia and major surgery. Studies have shown the negative impact of these factors on transfusion requirements, infections, increased hospitalisation and long-term morbidities.

Nowadays, schizophrenia is treated with atypical antipsychotics that can determine neuroleptic malignant syndrome or rhabdomyolysis appearance. In addition to trauma and muscular hypoxia, there are some drugs and toxins associated with rhabdomyolysis development, among which olanzapine. A case of severe rhabdomyolysis syndrome, with extremely high levels of serum creatine kinase (CK), followed by acute kidney failure, secondary to olanzapine overdose and prolonged immobilization is outlined. Continuous renal replacement therapy was performed, with a slow clearance of serum CK levels. Under supportive therapy, systemic alkalinisation with volume resuscitation and corticotherapy, patient’s general condition was improved, as well as his lower limb paresis. He followed frequent psychiatric evaluations and psychotherapies, before and after being transferred to a medical service. Rhabdomyolysis diagnosis is difficult in mild cases due to non-specific signs and symptoms, but it also has some typical manifestation, generically called “the rhabdomyolysis syndrome triad”. The treatment is usually supportive; renal replacement therapy is required in the presence of acute kidney injury unresponsive to aggressive volume resuscitation. The systemic myoglobin release is responsible for renal injury. Olanzapine muscle toxicity can lead to severe rhabdomyolysis syndrome complicated with acute kidney injury and multiple organ dysfunction syndrome. Rapid identification and aggressive therapeutic management are essential for improving patients’ outcome and prevent the occurrence of irreversible injuries.

Chronic kidney disease (CKD) represents an increasingly common pathology that affects patients' quality of life, and it is frequently associated with a high mortality rate, especially in the final stages of the disease. At the same time, diabetes mellitus is a chronic disease that contributes to the increased number of patients with CKD through diabetic kidney disease (DKD). The alternation of hypoglycemia with hyperglycemia is a condition in the occurrence of microvascular complications of diabetes, including DKD, which involves structural and functional changes in the kidneys. The therapeutic management of diabetic nephropathy is a much-discussed topic, both from nutritional medical recommendations and a pharmacotherapy perspective. The diet starting point for patients with DKD is represented by a personalized and correct adjustment of macro- and micronutrients. The importance of nutritional status in DKD patients is given by the fact that it represents a modifiable factor, which contributes to the evolution and prognosis of the disease. Since, in most cases, it is necessary to restrict many types of food, malnutrition must be considered and avoided as much as possible. [ABSTRACT FROM AUTHOR]

High flow nasal cannula (HFNC) oxygen therapy devices are used on a daily-basis in many intensive care units and postoperative wards. Such a device deliver a mixture of air and oxygen, warmed, humidifi ed, with gas flow between 20-60 L/min, and inspired oxygen fraction between 0.21-1. Therefore, it improves oxygenation, decreases dead space, washes out the carbon dioxide (CO2) from patients’ airways, improves thoraco-abdominal synchrony and decreases the work of breathing. Studies have shown effi cacy of HFNC oxygen therapy use for acute hypoxemic respiratory failure, for patients with exacerbations of chronic pulmonary diseases, after extubation in order reduce the need for mechanical ventilation, in perioperative period to prevent atelectasis and in palliative care, in order to reduce breathlessness. It isn`t feasible for patients with severe altered neurological status, facial trauma, basal skull fracture, complete airway obstruction or epistaxis. There are no standardized recommendation for the use or contraindication of HFCN oxygen therapy. The weaning is realised according with patients’ tolerance, oxygen saturation, respiratory and heart rates.

Burns represent one of the worldwide leading causes of injury. Burn wounds are associated with increased mortality and morbidity, especially the impaired quality of life due to hypertrophic scarring, scar pain and itching, paresthesia, and contractures. To properly influence the burn wound healing, it is important to establish a correct classification of the acute injury and to understand the main phase of burn wound healing process. There are various local and systemic factors that can be influenced to obtain proper healing. The most important factors include local necrosis and infection, increased local pressure and edema, anemia, hypoxia, hypotension, the presence of important chronic disease and medication, immunosuppression, nutritional status, age, and body constitution. After adequate fluid resuscitation and patient stabilization, the main step is represented by the detachment of the devitalized tissues and rapid coverage of the lesion. There are various methods to be used, like autologous or allogenic skin grafting, the use of skin substitutes, or tissue bioengineering. Knowing all these aspects, allows clinicians to properly define a therapeutic management for patients presenting severe burns. [ABSTRACT FROM AUTHOR]

Venous thromboembolism (VTE), essentially deep venous thrombosis and pulmonary embolism, urinary tract infection, and renal failure are the main unplanned hospital events with negative long-term impact on burn patients’ rehabilitation. Due to the hypercoagulable state induced by severe critical burns, either in the acute or recovery phase and the intimal vascular damage, the risk of VTE is increased, with an incidence varying from 0.4% to almost 60%. Other risk factors for VTE in burn patients are prolonged immobilization, long and multiple surgical interventions, central venous catheterization, wound infection and sepsis, extensive burns, and red blood cell transfusion. To avoid underdiagnosing VTE, in face of increased incidence of asymptomatic venous thromboembolism, high risk-patients should be routinely screened using Doppler ultrasound. Patients’ weight and burn size, as well as the high incidence of heparin resistance in the first weeks after injury, should be considered when establishing the optimal dose for venous thromboembolism prophylaxis, targeting an anti-Xa level of 0.2-0.5 IU/mL. [ABSTRACT FROM AUTHOR]

Thumb carpometacarpal (CMC) joint dislocation is rare, and the treatment options may vary from conservatives’ strategies to open reduction and fixation. In face of pain and joint instability persistence, surgical intervention is required. We present the case of a 67-year-old male that was referred to our hospital with pain and edema of the left hand, after the failure of a conservative treatment. After initial refusal of open surgery, due to the persistent joint instability, open reduction of the CMC joint dislocation was performed, and stabilized using two percutaneous Kirschner wires after repairing the joint capsule and dorsoradial ligament. Immobilization was required for 4 weeks. After that, the Kirschner wires were removed. Along with physiotherapy, the follow-up showed no pain persistence nor CMC joint luxation reoccurrence while the joint recovered its mobility. Further studies are required in order to determine the optimal therapy for such cases and to provide standardized recommendations, taking into account that the restoration of thumb CMC joint mobility is one of the most important goals in hand surgery. [ABSTRACT FROM AUTHOR]

Pain control is crucial in surgical patients, being an essential part of enhanced recovery after surgery protocols. Lidocaine, an amide local anesthetic, was primarily used as an antiarrhythmic. It has analgesic, antihyperalgesic and anti-inflammatory effects, with various actions on cardiovascular, respiratory, and digestive systems. Lidocaine has been shown to also have antithrombotic, antimicrobial, and antitumoral effects. Numerous studies have reported its safe profile and role in managing perioperative pain after breast cancer, abdominal, genitourinary, gynecologic, obstetric, orthopedic, cardiothoracic, spine, thyroid, and upper airway surgery. Lidocaine, as part of multimodal analgesia, also shows promising results in ambulatory surgery. Therefore, the use of intravenous lidocaine in the perioperative period is mainly associated with better pain control, reduced opioid use, diminished incidence of postoperative nausea, vomiting, and ileus, and exhibits antithrombotic effects. [ABSTRACT FROM AUTHOR]

Hospitalized COVID-19 patients often develop acute kidney injury (AKI), leading to increased mortality. In order to improve patients’ survival rate, it is important to understand the pathophysiology mechanism of AKI. In this brief review, we highlight the most important elements of the etiology and pathophysiology of COVID-19 associated AKI. Acute tubular injury seems to be more frequent than prerenal azotemia in COVID-19 patients and collapsing glomerulopathy is the most encountered form of glomerular disease. Another important role in acute kidney injury seems to play immune cell infiltration, inflammation, endothelial injury and microvascular thrombi. Renin-angiotensin-aldosterone system is also important in the pathophysiology of COVID-19 associated AKI. [ABSTRACT FROM AUTHOR]

Alcohol abuse is one of the leading health problems, with subsequent alcohol withdrawal syndrome (AWS) affecting around 50% of hospitalized patients, varying from mild to severe forms. Rapid recognition of AWS symptoms, along with prompt therapeutic management in the first 24 hours, can lead to better outcome. Improper treatment is correlated with seizure or delirium tremens, requiring specific intensive care management, and being the cause of with various complications, high mortality, and increased costs. Some studies reported possible predictive factors that may help clinicians identify patients at risk of developing severe or resistant forms. [ABSTRACT FROM AUTHOR]

As COVID-19 pandemic continues to test the medical world, due to rapid viral transmission and subsequent mutations, the old burning health crisis continues to surface, one of them being the blood shortage. The current situation has disrupted the fragile balance between blood donors and the real need of blood in hospitals, especially due to repetitive lock-downs, isolation, social-restrictions, and ongoing anxiety promoted by social media, threatening the quality of medical cares. [ABSTRACT FROM AUTHOR]

Purpose of review: The aim of this paper is to provide the clinician an overview about the link between iron homeostasis and erythropoiesis and how we can promote this relationship in order to improve surgical patients’ outcome. Key elements: Iron is essential for various cellular processes, like cell signalling, oxygen transport, erythrocyte and heme synthesis, mitochondrial respiration, host defence, nucleic acid replication. Erythropoietin and iron are the main erythropoiesis regulators. Under iron-restricted conditions, the erythrocytes production is impaired, leading to microcytic hypochromic anemia appearance. Iron-restricted condition enables patient capacity to recover from post-surgery anemia. Long-term consequences of chronic anemia affect patient’s quality of life. Therefore, parenteral iron supplementation, in patients with anemia secondary to blood loss, can lead to a fivefold increase in erythropoietic response, therefore enhancing recovery. Summary: Under normal circumstances, the link between iron and erythropoiesis is maintained especially through regulatory feedback mechanisms, with minimal external support. In face of important blood loss, with secondary acquired iron-restricted anemia, parenteral iron supplementation improves the bone marrow erythroid response and helps correcting haemoglobin levels. [ABSTRACT FROM AUTHOR]

Hydrotherapy represents the use of water for medical purpose, being involved in burn wound care since the 17th century. Burn wound cleansing, performed daily, twice a day, or as needed, as part of standard care, should be scheduled by a burn surgeon and supervised by proper specialists. It can be performed by various methods, like shower, immersion, bedside irrigation or wiping. Due to the high risk of cross-contamination, immersion is no longer recommended. Tap water seems to be superior to saline solution in burn wound care, and adjuvants can be added, especially chlorhexidine, povidone-iodine, or special detergents. Disposable plastic sheets use during showering and the following of cleaning protocols for washing areas have decreased the risk of infection. Apart from the wound-cleansing role, hydrotherapy reduces itching and pain, improves wound healing, favours early mobilization and increases patients’ comfort. Controversy persists around the optimal method and appropriate solutions for cleaning burn injuries and clinical studies are further required to solve this matter. In the absence of standardized recommendations, most burn centers are guided by experience. [ABSTRACT FROM AUTHOR]

The presence of inhalation injury has a negative impact on the evolution of burned patients, being associated with increased mortality. It occurs as a direct consequence of thermal action, or secondary to the presence of respiratory irritants or absorption of toxins, and actual therapeutic management is mainly supportive. Several clinical findings are relevant to raising suspicion and guiding further examinations, fiberoptic bronchoscopy being the gold standard of diagnosis and staging. In burned patients with inhalation injuries, various reports showed that nebulized heparin (5,000 or 10,000 units) with a 4-hour administration regimen leads to improved outcome, reduces the days of mechanical ventilation and consequently the length of hospital stay, reduces pulmonary complications and improves lung function, having a safe profile, with fewer side effects. [ABSTRACT FROM AUTHOR]

Introduction: The prevalence of hypokalemia in psychiatric population is very high with eating disorders and laxative abuse being the main incriminated factors. Case presentation: We report a case of a 34-year-old woman with history of sleeve gastrectomy and breast implant, who presented for fatigue, severe myalgia, generalized hypotonia and palpitations. Laboratory exams revealed severe hypokalemia and rhabdomyolysis. The electrocardiography showed prolonged QT interval and ST segment depression with second-degree atrioventricular block. She received intravenous potassium supplementation with consecutive hydration. When potassium level was within safety limits, the patients received loop diuretics in order to decrease rhabdomyolysis and avoid kidney injury. The underlying cause was a pathological behavior, with frequent self-provoked episodes of nausea and vomiting after eating and chronic consumption of laxatives. She started psychotherapy. Conclusion: Psychiatric behaviour can lead to life-threatening conditions, therefore it should be discovered and managed promptly. [ABSTRACT FROM AUTHOR]

Introduction: Acute hypoxemic respiratory failure may have different causes. Case presentation: We present the case of a 42-year-old woman, with history of recent thyroidectomy and a late history of sleeve gastrectomy, who presented for acute dyspnoea. The chest X-ray revealed hydropneumothorax, and, therefore, an intercostals chest tube drainage was inserted. The evolution was unfavourable, with further respiratory status deterioration. A computed tomography of the thorax and abdomen was performed, that revealed a dilated thoracic oesophagus and stenosis of the esophagogastric junction, with lack of substance in the oesophageal wall and extravasation of oesophageal content in the posterior mediastinum, due to an oesophageal pleural fi stula. An oesophageal stent was inserted under endoscopic guidance and the patient underwent minim-invasive surgical interventions for evacuation of the mediastinal and pleural collections, with a favourable evolution. Conclusions: Acute respiratory failure can be the face of multiple conditions, some of these can be life threatening and in need for rapid detection and treatment. [ABSTRACT FROM AUTHOR]

Work-related accidents have a great spread worldwide. The incidence of crush syndrome is 2-15% in all trauma patients and in many cases may lead to trauma related amputation. This type of patients are at risk of developing cardio-vascular instability, renal failure, other organ failure and metabolic abnormalities. The treatment is complex and should prevent and treat all the complications. In the present paper we reported a case of work related injury which lead to the above-knee amputation, followed by severe complication and difficult social rehabilitation. In this particularly cases, when you think that the fight is almost over, a new organ failure may occur and threaten the life of the patient. [ABSTRACT FROM AUTHOR]

The nose represents one of the most common sites for skin cancer, therefore, treatment usually leads to defects of this aesthetic unit that needs reconstruction procedures. Even if there are many surgical methods described in the literature, repairing this complex structure is a challenge for every surgeon. In this paper we described our method in order to cover a medium defect of the distal third of the dorsum nasi after tumor removal. A long and narrow nasolabial flap was used in a single-stage reconstruction procedure. Some minor complications were encountered due to the pushing of the flap measurement limits and the defatted choice of flap, therefore with a thin blood supply. This method lead to good outcomes with tumor recurrence-free after a 2 years follow-up and to a very good cosmetic result according to the patient's appreciation. [ABSTRACT FROM AUTHOR]

Work-related accidents have a great spread worldwide. The incidence of crush syndrome is 2-15% in all trauma patients and in many cases may lead to trauma related amputation. This type of patients are at risk of developing cardio-vascular instability, renal failure, other organ failure and metabolic abnormalities. The treatment is complex and should prevent and treat all the complications. In the present paper we reported a case of work related injury which lead to the above-knee amputation, followed by severe complication and diffi cult social rehabilitation. In this particularly cases, when you think that the fi ght is almost over, a new organ failure may occur and threaten the life of the patient. [ABSTRACT FROM AUTHOR]

The nose represents one of the most common sites for skin cancer, therefore, treatment usually leads to defects of this aesthetic unit that needs reconstruction procedures. Even if there are many surgical methods described in the literature, repairing this complex structure is a challenge for every surgeon. In this paper we described our method in order to cover a medium defect of the distal third of the dorsum nasi after tumor removal. A long and narrow nasolabial flap was used in a single-stage reconstruction procedure. Some minor complications were encountered due to the pushing of the flap measurement limits and the defatted choice of flap, therefore with a thin blood supply. This method lead to good outcomes with tumor recurrence-free after a 2 years follow-up and to a very good cosmetic result according to the patient's appreciation. [ABSTRACT FROM AUTHOR]

Upper extremities are frequently involved in fire burns due to the natural protective reflexes. The presence of bilateral Dupuytrenʼs disease and COVID-19 disease in patients with circumferential upper extremity burns can negatively impact the outcome, through severe contracture and a tendency to hypoxia or infections, which affects normal wound healing. Enzymatic debridement with a concentrate of proteolytic enzymes enriched in bromelain prevents compartment syndrome development in such patients, reduces blood loss, surgery duration, and appears to favor a more rapid recovery. [ABSTRACT FROM AUTHOR]

The latest treatment guidelines for patients with arterial hypertension continues to indicate as the first line therapy a minimal association between renin-angiotensin system (RAS) blockers and a thiazide-type or a thiazide-like diuretic. In addition, according to 2018 ESC/ESH (European Society of Cardiology/European Society of Hypertension) guidelines for the management of arterial hypertension, a mineralocorticoid receptor antagonist may be added in resistant hypertension cases (uncontrolled hypertension under at least 3 classes of antihypertensive drugs including a RAS blocker, thiazide diuretic and a calcium channel blocker) for general population. For chronic kidney disease (CKD) patients, achieving the optimal blood pressure (BP) level can be difficult because high complication rates can be encountered in any antihypertensive class mentioned, especially for RAS blockers and mineralocorticoid receptor inhibitors. This brief review aims to highlight the importance of diuretics use in CKD patients and the boundaries of their usage. [ABSTRACT FROM AUTHOR]

The negative impact of an elevated serum uric acid on the onset and/or progression of different diseases is well known. During the last decade, new forms of therapies were developed, with beneficial results on correcting hyperuricemia, but also with potential side effects that should not be overlooked as most of the hyperuricemic patients are presenting concomitant comorbidities that could influence the decision in prescribing a specific lowering serum uric acid drug. The review will describe recent treatment options, part of them available also in our country. [ABSTRACT FROM AUTHOR]

Rhinophyma is a benign tumor characterized by a progressive hypertrophy of the nasal soft tissue and it is believed to be the end stage of severe acne rosacea. It is more common in Caucasian men. The main differential diagnosis is the basal cell carcinoma. Non-surgical treatment proved insufficient in reversing this disease, while surgery remains the golden standard, even if a spontaneous regression may be observed in extremely rare cases. We presented a case of a severe rhinophyma associated with a giant nodule successfully treated with surgical removal of the suspicious tissues with safety margin and grafting of the excised area. The postoperative outcome was satisfactory for the patient. [ABSTRACT FROM AUTHOR]

The hand is both a motor and sensory organ, and in terms of society, it is an organ of defense, of creation and an organ of expression. This is why hand surgery is very important and studies regarding the functional results of different treatments in order to treat injuries are necessary. In this paper, we presented the results of a retrospective clinical study in order to compare osteosynthesis using plates and screws (n=36) versus fixation using Kirschner wires (n=32) in order to treat metacarpal fractures of 68 patients. The functional outcomes where assessed using the DASH and the TAM score measured at two and twelve months from surgery.The DASH scores were lower (showing better results) in the PS group compared to the KW group, with a mean difference of 20.53 after two months and 6.41 after twelve months, while the TAM scores were higher (235° at two and 261° at twelve months in the PS group compared with 218° at two and 257° at twelve months in the KW group). Therefore, we concluded that osteosynthesis using plates and screws leads to better functional recovery than osteoynthesis using Kirschner wire. [ABSTRACT FROM AUTHOR]

The hand is both a motor and sensory organ, and in terms of society, it is an organ of defense, of creation and an organ of expression. This is why hand surgery is very important and studies regarding the functional results of different treatments in order to treat injuries are necessary. In this paper, we presented the results of a retrospective clinical study in order to compare osteosynthesis using plates and screws (n=36) versus fi xation using Kirschner wires (n=32) in order to treat metacarpal fractures of 68 patients. The functional outcomes where assessed using the DASH and the TAM score measured at two and twelve months from surgery.The DASH scores were lower (showing better results) in the PS group compared to the KW group, with a mean difference of 20.53 after two months and 6.41 after twelve months, while the TAM scores were higher (235° at two and 261° at twelve months in the PS group compared with 218° at two and 257° at twelve months in the KW group). Therefore, we concluded that osteosynthesis using plates and screws leads to better functional recovery than osteoynthesis using Kirschner wire. [ABSTRACT FROM AUTHOR]