Search

Portal vein thrombosis, in the clinical setting of liver cirrhosis, is a complication which increases mortality rate by leading to specific complications. Its presence also serves as a negative prognostic factor for these patients. Specialized literature, although rich in papers on this subject, presents loose and sometimes contradictory information regarding its prognosis and specific treatment. This paper brings into discussion the issue of recent portal vein thrombosis in cirrhotic patients, with emphasis on indications for initiation of anticoagulant therapy and the optimal drug of choice. It also highlights the utility of using correct terminology for facilitating clinical approach of guideline recommendations as well as increasing the quality of published scientific papers. The coagulation homeostasis of the cirrhotic patient presents many particularities that can make the optimal therapeutic choice extremely difficult when portal vein thrombosis is established. Absence of randomized clinical trials and lack of consensus regarding anticoagulant treatment in these patients leaves it up to the clinician to decide when and what anticoagulant to use. Analysis of the newest guidelines and recent meta-analysis made it possible to identify the right context for initiating therapy with the most used anticoagulants currently: low molecular weight heparin, vitamin K antagonists and direct oral anticoagulants.

Objective Our goal was to characterize a cohort of heart failure patients with and without COVID-19 in terms of demographics, comorbid conditions, treatment regimens, lab test results and outcome. Methods We performed a retrospective, unicentric, cohort study on consecutive patients admitted to our department between September and December 2021. Results We enrolled a total of 76 HF patients – 65.3% COVID-19 (+). The median age was 72 years with a female predominance (59.2%). The median length of hospitalization was 13 days, longer for COVID-19 (+). Only 20.7% of all patients were fully vaccinated. COVID-19 (+) patients had higher ICU admission rates and mortality (in-hospital and at follow-up). The most common associated conditions were HTN (78.9%), T2DM (38.2%), cancer (18.4%), CAD (17.1%), late-stage CKD (16.7%), AF (14.5%) and stroke (11.8%). Patients with a history of stroke were more likely to require ICU management. At-home treatment with ACEi/ARB/ARNi made no difference for COVID-19 severity (p = 0.393), mechanical ventilation (p = 0.101) or mortality (in-hospital: p = 0.316; follow-up: p = 0.563); however, ICU admission rates were lower in these patients (p = 0.023). Conclusion Heart failure with preserved ejection fraction and low symptom severity were common findings among COVID-19 positive patients. However, COVID-19 positive patients were hospitalized for longer, required more ICU care and had higher mortality both in-hospital and at follow-up.

Background. Peripheral artery disease (PAD) is a distinct atherosclerotic syndrome marked by stenosis or occlusion of the arteries, particularly of the lower extremities. The major risk factors for PAD are similar to those for coronary and cerebrovascular disease, comprising smoking, hypertension, hypercholesterolemia and diabetes. The factors involved in the progression of PAD are less well defined. Vascular age (VA) is represented by the apparent age of the vascular system derived from the associated cardiovascular risk factors. This concept has been used so far mainly in primary prevention, being usefull for communication with the patient. Aim. The purpose of the study was to investigate the factors involved in the progression of arterial stenosis in patients already having PAD. Moreover, we tried to determine the utility of VA in increasing patient compliance with therapeutic decisions. Methods. Between 1st February 2015 - 31st December 2015, 270 consecutive patients (pts) referred for vascular echo-Doppler assessment were enrolled in the study. 106 pts with non-significant arterial stenosis were prospectively evaluated. All pts underwent complete clinical examination, carotid, femoral ultrasound, echocardiography and laboratory evaluation. Presence of atherosclerotic plaques in the carotid arteries were recorded. Medical history, drug use, smoking behavior, blood pressure, duration of diabetes, presence of premature atherosclerotic PAD in relatives, characterized by disease diagnosis before the age of 50 years, were evaluated. Serum total cholesterol (TC), HDL cholesterol (HDL-C), serum glucose, A1c hemoglobine (HbA1c), serum creatinine, estimated glomerular filtration rate (eGFR) were determined. VA was estimated using Framingham score and intima-media thickness (IMT). The primary end-point was the occurrence of significant peripheral artery stenosis (PAS), defined as a two-fold increase Doppler velocity across the stenosis. Results. At baseline, median age of enrolled pts was 57 years, with male predominance (69,8%). Less than 40% had high blood pressure (39.3%), 36.4% had treated hypertension. The median left ventricular mass index (LVMI) was 108.5 g/m2 and concentric hypertrophy was present in 29.9% of patients. Patients with hypertension had LVMI of 113.12 g/m2 and those without hypertensiun, had 105.6 g/m2. Diabetes mellitus (DM) was present in 20.6% of patients, majority treated (88%). Among them, 10.3% had more than 10 years duration of DM. Median HbA1c was 5.8%. The majority of the patients are smokers (75.5%). Mean pack-years of smoking was 29.8. During the 4.5 years follow-up, 31.25% quit smoking. The median ejection fraction (EF) was 51.6%. The median TC concentration was 191.6 mg/dl and median HDL-c level was 62.9 mg/dl. 45.8% of the patients received treatment with statins. Premature atherosclerotic PAD in relatives was present in 25.2 % of the patients, and carotid atheromas (CA) in 35.5%. Aortic calcifications (AC) were found in 37.4% of the patients. Median arterial elastance (Ea) was 2.07 mmHg/ml. Median serum creatinine was 1.03 mg/dl and eGFR was 75.6 ml/ml/1.73 m2. Median value of the VA calculated by IMT (VA-IMT) was 65.5 years and the median VA calculated by cardiovascular risk factors (VA-RF) was 62.9 years. After 4.5 years of follow-up, 35 (32.7%) patients developed significant PAS. 22 patients had popliteal artey stenosis (62.85%) and 13 patients had superficial femoral artery stenosis (37.15%). During the 4.5 years follow-up, 25 patients (31.25%) quit smoking. Median age of population who developed significant PAS at follow-up was 62.6 years and 39.2% were males. Individuals who developed stenosis tended to be smokers, older, receiving hypertensive and statin therapy, having diabetes, especially more than 10 years duration, having dyslipidemias and CA. They all had higher VA-IMT and VA-RF values compared to patients that did not develop PAS. Median value of VA-IMT was 72.6 years and VA-RF was 74.2 years (p Conclusion. We demonstrated that some of the classical cardiovascular risk factors were involved in PAD progression: smoking, dyslipidemia, diabetes, carotid atherosclerosis. At multivariate analysis the independent variables associated with PAD progression were pack-years of smoking, glycosilated hemoglobin and HDL-cholesterol values and presence of CA. VA assessed by cardiovascular risk scales and by directly measured IMT both predict the progression of PAD, as did Ea, but without independent predictive value for the outcome. Nevertheless, VA was usefull in comunicating with the patients, influencing their perception of disease progression and adherence to therapy, improving shared decision making, mainly quitting smoking. We have shown that even after 4.5 years of smoking cessation there was a measurable effect on PAD progression.

People living with HIV live longer now due to highly active antiretroviral therapy. Due to their increased life expectancy, they have an increased cardiovascular risk cause by the traditional risk factors (smoking, use of ilicit drugs, obesity/lipodystrophy, dyslipidemia, diabetes, hypertension) and particular risk factors (endothelial dysfunction, inflammation, coagulation abnormalities, viral coinfections and antiretroviral therapy. The pathophysiology of accelerated atherosclerosis is complex. Coronary artery disease become an important cause of mortality in these patients. The incidence of coronary artery disease and especially of acute myocardial infarction is generally low among HIV patients, but it may by twice as high as in patients with the similar characteristics. Medical treatment for coronary disease in these patients has no special particularities comparing to general population, but possible drug interactions must be considered. Indication for coronary revascularization, either angioplasty, or aorto-coronary by-pass follows general indications for general population.

Cystic hydatid disease commonly affects the liver and lungs. Cardiac hydatid cysts are a rare occurrence and can cause fatal complications, including anaphylactic shock, systemic or pulmonary embolism, dissemination, arrhythmias, valvular dysfunction or sudden death. The case of a 19-year-old male from a rural area who was admitted to the emergency room with anaphylactic shock is presented in the current study. The patient was subsequently referred to the Department of Pneumology due to a mild fever, a dry cough and thoracic pain. Pneumonia was suspected and antibiotics were administered. As the patient didn't respond to the antibiotics, a pulmonary CT-scan was performed, which demonstrated a bilateral pulmonary embolism of the segmental arteries and the patient was referred to the Department of Cardiology. Transthoracic echocardiography (TTE) demonstrated the presence of a right ventricular mass of ~25x18 mm, attached to its free wall, adjacent to the tricuspid valve causing no tricuspid inflow obstruction. Blood tests were positive for echinococcal infection. Considering that previous reviews had included cases published up until 2018, the present study also included a short literature review of the studies published between 2018 and 2021. The review showed that cardiac hydatid cysts are diagnosed more often in underdeveloped countries, especially in men. Transthoracic echocardiography is the most useful non-invasive imaging technique for diagnosis. Surgery is the treatment of choice, but consideration must be given to the risk-benefit ratio and the shared decision-making approach. The complete surgical removal of the cyst(s) is the major prognosis factor of the cardiac manifestation. This study emphasizes the importance of considering cardiac echinococcosis as a potential diagnosis in patients from endemic or farming areas.

The thromboembolism of an asymptomatic carotid artery stenosis (CAS) causes stroke in 10-15% cases and in Europe, stroke causes more than 1 million deaths a year. This important cause of mortality may be evaluated by duplex ultrasound (DUS). In five decades of experience, carotid DUS has proven to be a risk -free procedure, being widely available, easy to use, inexpensive, painless and quite reproducible. The purpose of this article was to try to extend the usual indications of DUS assessment of carotid atherosclerosis (CA) in order to offer a tool for less experienced ultrasonographers to gather useful information for optimizing patient’s management. We tried to review the literature and to provide a simple, easy to apply algorithm for estimating the presence and severity of CA.

The digestive system has an innate monitoring and defense capacity, which allows the recognition and elimination of different dangerous substances. The complex analysis of the intestinal content comprises the cross-interactions between the epithelial cells, the enteroendocrine cells, the neural tissue and the cellular defense mechanisms. The enteric nervous system, also called "the enteric brain" or "the second brain" is the only neuronal network outside the central nervous system capable of autonomous reflex activity. The enteric nervous system activity is mostly independent of the central nervous system, but not in all aspects. In fact, even the enteral reflexes are a consequence of the bidirectional intestine-brain relation. The central nervous and enteric nervous systems are coupled through the sympathetic and parasympathetic branches of the autonomic nervous system. The gastrointestinal functions are regulated due to the interaction between the intrinsic neurons within the gastrointestinal wall and the extrinsic neurons outside the gastrointestinal tract. Here we provide an overview of the important role of the enteric brain in defensive behavior, as well as its structural and functional particularities that make it a special organ.

Objectives. Our study aimed to compare to what extent the characteristics of patients with ankylosing spondylitis (AS) differ, depending on the presence / absence of peripheral manifestations of the disease. Materials and method. We analyzed a batch of 124 patients admitted to the rheumatology clinics of two hospitals, with ankylosing spondylitis according to the modified New York criteria. All individual patient characteristics were documented from patient observation sheets. We divided the population into two groups: the P + group representing the patients with peripheral manifestations of arthritis or enthesitis (N = 56) and the P- group representing the patients without the peripheral manifestations (N = 68). Statistical processing was performed using IBM SPSS and Microsoft Excel. Results. In the subtype of patients P+ the mean age was 45.14 14.16 years, and in the subtype P- mean age was 43.84 years 12.58 years. Gender distribution of patients in the two subgroups shows higher frequencies for patients without peripheral manifestations P- in both genders, respectively 55.4% in males and 52.2% in females. The highest frequencies were registered at the normal BMI of 18.5-24.9 in both sublots, respectively 51.8% for the P+ patients and 45.6% for the P- patients. The degree of activity of the disease, based on the ASDAS - CRP score, within both P + and P- subgroups, revealed a majority of patients with inactive disease (≤ 1.3). Within the P+ and P- sublots, most patients had the BASDAI index in the range 0-0.9, that is 67.9% of the patients in the P+ sublot and 64.7% of those in the P- sublot, respectively. This shows that the majority of patients in both subgroups had a good therapeutic response to biological treatment, with symptoms such as pain and / or fatigue absent or very low in intensity. There were no statistically significant differences between the two subgroups. Conclusion. Even though there were no major paraclinical differences between the patients with pure axial ankylosing spondylitis and patients with AS with peripheral manifestations, the patients with peripheral manifestations of the disease should be approached by a multidisciplinary team.

BACKGROUND Shared decision making (SDM) is very important from patients' perspective. This process has not yet been evaluated in Romania. The study aims to evaluate SDM from the patients' perspective and to evaluate patients' characteristics that associate with SDM. MATERIAL AND METHODS A cross-sectional multicentric study comprising eight recruitment centres was performed. Inpatients and outpatients who referred to Hospital Units treating autoimmune diseases or atrial fibrillation were included. Another sample consisted of members of the Autoimmune Disease Patient Society, who completed an online anonymous questionnaire. All participants completed the Romanian translated version of the 9-item Shared Decision Making Questionnaire (SDM-Q-9), as these samples were used for the validation of this questionnaire, too. Patients had to refer to the visit in which the decision concerning the antithrombotic treatment was taken (atrial fibrillation patients), or the immunosuppressive treatment was last time changed (autoimmune disease patients). Ordinal regression having the total SDM score as dependent variable was used. RESULTS A total of 665 questionnaires were filled in within the hospital setting (n = 324; 48.7%) and online (n = 341; 51.3%). The median score for SDM was 34 of 45, but it differed between hospital completion -39/45 and online completion (anonymous) -20/45 (P < .001). Patients with higher education were influenced most by the setting, giving the best marks in hospital and low marks online, while those with lower education gave lower marks in both settings. In ordinal regression with SDM score as dependent variable, hospital completion of the questionnaire (OR = 9.5, 95% confidence interval, 5.69-16), collagen disease diagnosis (OR = 2.4, 95% confidence interval, 1.39-4.14), and immunosuppressive treatment (OR = 2.16, 95% confidence interval, 1.43-3.26) were independent predictors. CONCLUSION In our study, full anonymity was associated with significantly lower scores for the SDM process. The patients with higher education were most influenced by this condition, while those with the lowest education were the most critical.

Infective endocarditis is an infection of the endocardial surface of the heart. Usually, it affects one or more heart valves or an intracardiac device. Neurologic events (silent or symptomatic) account for 20 to 40% of all patients with infective endocarditis. We are presenting the case of a 57 -year-old man with cardiovascular risk factors admitted to our clinic for aphasia. His medical history included a recent stroke and small fiber neuropathy with a gradual onset for the past six months. Despite extensive investigations, no cause for strokes and neuropathy could be found. To identify a potential source of embolism, a transoesophageal echocardiography was performed. It revealed vegetation attached to both aortic and mitral valves. Blood cultures were positive for Streptococcus gallolyticus. The patient underwent emergency aortic and mitral valve replacement and a 6-week course of antibiotic treatment with ceftriaxone and gentamicin with the improvement of both aphasia and peripheral neuropathy. Central nervous system complications such as encephalopathy, seizures, stroke or severe cerebral hemorrhage are commonly described in infective endocarditis, but peripheral nervous system involvement is rarely reported in the literature. Although no cause for neuropathy has been found, it is difficult to asses whether it was a complication of the infective endocarditis.

The current HAART has modified natural history of HIV infection and it has practically turned the disease into a manageable chronic condition. Even though the benefits of HAART use are overwhelmingly greater than possible metabolic syndrome and cardiovascular disease risks, close management of those patients is called for, especially due to the fact that general population risk factors now overlap with specific ones in this population. Cardiovascular screening for HIV-infected patients who are receiving HAART must be done constantly with a collaboration between the infectious disease specialist and the internist.

Objectives. The aim of this paper is to compare the degree of accuracy between the BASDAI and mini-BASDAI indices in assessing the activity of ankylosing spondylitis (AS), especially in patients without peripheral manifestations. Materials and method. Our cross-sectional study consisted of a group of 124 patients with AS, according to the modified New York criteria. All patients offered their informed consent. All the individual characteristics of the patients were documented, both demographic and disease-related. The activity of the disease was measured using the BASDAI questionnaire, from which we calculated the mini-BASDAI by eliminating the questions about peripheral arthritis and entesitis. The functional impairment of mobility in the spine and sacro-iliac joints was measured by the Schober index, lateral spinal flexion, occiput-wall, menton-sternum and finger-ground index. Results. The mean age of the patients was 43.43 +/− 13.27 years, mean height 174.3 +/− 8.46 cm, weight 78.23 +/− 14.19 kg, duration of disease in years 15.06 +/− 9.19 and number of years from initiation of biological therapy 6.42 +/− 3.08. The BASDAI score was 1.26 +/− 1.93, while the mini-BASDAI score was 1.51 +/− 2.08. In the group of patients without peripheral manifestations, both BASDAI and mini-BASDAI correlated significantly with the occiput-wall index, besides ESR, CRP, ASDAS-CRP and the Schober index. Conclusion. Mini-BASDAI is not superior to BASDAI in evaluating patients with ankylosing spondylitis without peripheral manifestations, but it has shown a better correlation in addition to BASDAI with the indices of flexion of the cervico-dorsal spine.

Introduction. The treatment of neoplasia has advanced due to targeted molecular therapies. Erlotinib, a tyrosine kinase inhibitor that acts by blocking epidermal growth factor receptor (EGFR), is used to treat advanced or metastatic chemotherapy-resistant non-small cell lung cancers (NSCLC). Erlotinib is a safe and well tolerated medication. Although the most common adverse effects are cutaneous or gastrointestinal, its cardiotoxicity is an important topic in the treatment and follow-up of neoplastic patients. Clinical case. A 76-year-old male patient with 40 Pack Year history of smoking that has quitted 20 years ago, was admitted in 2009 for night sweats, dry cough and weight loss. He is diagnosed with lung cancer in the right upper lobe (T4N2M1), with the histopathological diagnosis of clear cell adenocarcinoma. The patient performs radiotherapy and chemotherapy with 6 series of Gemcitabine and Cisplatin with partial response, followed by Erlotinib treatment with favorable progression with regression of tumor size. In December 2017, he presents recurrent episodes of atypical angina lasting about 2 weeks. The electrocardiographic examination reveals ST segment elevation, with tall T waves and Q waves are present in the lower branches, associated with the increase of myocardial necrosis enzymes. Echocardiography highlights inferior hypokinesia with left ventricle ejection rate estimated at 45%. The patient has a favorable evolution during admission without recurrence of pain. Coronary angiography is performed at distance with evidence of vascular atherosclerotic lesions and the installation of active pharmacodynamic stents. Discussions. Tyrosine kinase inhibitors may be the cause of acute coronary events both by affecting myocardiocytes following EGFR inhibition, but also by increasing atheromatic plaque instability and by prolonging theQT segment. In conclusion a systemic cardiologic assessment of Erlotinib-treated patients may be recommended throughout the course of therapy.

Background . Shared decision making (SDM) is becoming more and more important for the patient-physician interaction. There has not been a study in Romania evaluating patients’ point of view in the SDM process yet. Therefore, the present study aims to evaluate the psychometric parameters of the translated Romanian version of SDM-Q-9. Material and methods . A multicentric cross-sectional study was performed comprising eight recruitment centers. The sample consisted of in- and outpatients who referred to Hospital Units for treatment for atrial fibrillation or collagen diseases. Furthermore, patients who were members of Autoimmune Disease Patient Society were able to participate via an online survey. All participants completed the Romanian translated SDM-Q-9. Results . Altogether, 665 questionnaires were filled in within the hospital setting (n = 324; 48.7%) and online (n = 341; 51.3%). The Romanian version had good internal consistency (Cronbach α coefficient of 0.96.) Corrected item correlations were good ranging from 0.64 to 0.89 with low corrected item correlations for item 1 and item 7. PCA found a one-factorial solution (similar with previous reports) but the first item had the lowest loading. Conclusion . SDM-Q-9 is a useful tool for evaluation and improvement in health care that was validated in Romania and can be used in clinical setting in this country.

Anaphylactic shock became, unfortunately, a common presence in Romanian mass-media, due to some fatal cases in the last months. The coincidence that in December 2014 the American Academy of Allergy, Asthma and Immunology, the American College of Allergy, Asthma and Immunology, and the Joint Council of Allergy Asthma and Immunology released Practice parameters offers a good opportunity to renew for all practitioners what is now considered the “golden standard” of good practice. Epinephrine must be considered the cornerstone and the most urgent measure to be applied in these cases, immediately after the diagnosis. A very important notice is to forget the administration of antihistamines or corticosteroids as first line therapy instead of epinephrine. Proper positioning of the subjects and quick fluid replacement (1-2 l of normal saline in a few minutes) are also mandatory.