Evil Eye Medical Tourism: Self Reports of Laser Eye Surgery in Turkey

First author: Mădălina Moldovan

Coauthors: Ștefania Andra Haiduc

Coordinator(s): Lecturer Daniela-Rodica Mitrea

Keywords: Medical tourism Eye laser surgery Turkey

Background: Medical tourism, or seeking medical treatment abroad, is prevalent in Turkey, particularly for laser eye surgery. Understanding the viewpoints held by patients who travel for medical purposes could allow local providers to align their services with those offered by international counterparts.
Objective: This qualitative research analyzed web-based narratives from health travelers in Turkey, comparing them with locals who received similar treatments at the same clinics. The main question was: What can we learn about health travelers' experiences in Turkey through their online narratives? Secondary questions included: (1) What is the medical tourists' satisfaction with their treatments in Turkey? (2) Is dissatisfaction related to travel or medical aspects?
Material and Method: A total of 40 narratives from medical tourists who visited Turkey (n=22), and locals who served as controls (n=18), were collected. Data were selected using purposeful sampling. Reviews meeting criteria were included: (1) written by the patient, according either maximum of five stars (12 from medical travelers, 10 from locals) or minimum of one star (10 from medical travelers, 8 from locals) (2) in English, and (3) describing the procedure. The analysis involved open coding to identify themes aligned with the research questions. NVivo Pro Version 11 (QSR International) was utilized to explore relationships.
Results: Negative reviews from travelers were based on: both medical and travel-related factors (50%), travel and accommodation issues alone (30%, all associated with unexpected costs), and solely procedural concerns (20%). Eye laser procedures elicited similar levels of satisfaction (60%) and dissatisfaction (40%) among medical travelers. Medical dissatisfaction stemmed primarily from unsatisfactory results and incomplete vision restoration (60%), followed by complications, dry eye, photophobia, and corneal pain (30%), as well as lengthy procedures (10%). Locals expressed predominantly satisfaction with the medical procedures, with only 12% reporting dissatisfaction. As with travelers, unexpected costs were the main reason for dissatisfaction for locals (70%). 
Conclusions: Whilst locals express high satisfaction with eye laser procedures, medical travelers are split between satisfaction and dissatisfaction. Dissatisfaction among travelers arises from unsatisfactory results, complications, lengthy procedures, and, most notably, unexpected costs.

Evaluation of the impact of nutritional status on the evolution of patients with acute myocardial infarction - follow-up study

First author: Dana-Simina Pop

Coauthors: Eduard-Ianis Popa Theofana Mihaila Ana Popoaia Dalia Elena Oniga

Coordinator(s): Professor Theodora Benedek Theodora

Keywords: CONUT nutritional status malnutrition MACE

Background: The influence of overall nutritional status on cardiovascular risk factors is widely recognized and malnutrition affects the prognosis of cardiovascular disease. Acute myocardial infarction (AMI) has been a major cause of death around the world.  Objective: Thus, we investigated the impact of malnutrition as defined by Controlling Nutritional Status (CONUT) on non-fatal myocardial infarction, non-fatal stroke, cardiovascular death, 3-point major adverse cardiovascular events (3P-MACE) in AMI patients.
Material and Method: 86 consecutive patients with AMI receiving primary revascularisation were included in the study, but, unfortunately, 3 patients were lost to follow-up (3.4%). For the rest 83 patients, we assessed baseline characteristics and composite endpoints (non-fatal stroke, non-fatal myocardial infarction, cardiovascular death and 3P-MACE) during the follow-up period of 36 months.
Results: Patients were divided into a well-nourished group (CONUT score 0–2, n = 67) and moderate-to-severe nutritional deficit group (CONUT score ≥ 3, n = 16). Patients with altered nutritional status presented more frequent major cardiovascular events: 21.25% vs. 8.95% (p=0.03) for non-fatal myocardial infarction, 18.75% vs. 5.97% (p=0.12) for non-fatal stroke, 31.25% vs. 7.46% (p=0.02) for cardiovascular death and 62.50% vs. 19.40% (p=0.001) for 3P-MACE.
Conclusions: The assessment of CONUT during the convalescence period is a useful risk predictor for patients with AMI and may have a potential for predicting major cardiovascular events. Nutritional guidance may improve the prognosis of patients with poor nutritional status.

SARCOIDOSIS IN PEDIATRIC PATIENTS- A CHALLENGE OF DIAGNOSIS

First author: Ioana-Alexandra Chindriș

Coauthors: Carcea Svetlana

Coordinator(s): Assistant Professor Maria Oana Sasaran , Professor Cristina Oana Marginean

Keywords: Sarcoidosis Adenopathies ACE Thyroiditis

Introduction: Sarcoidosis is a chronic disease characterized by non-caseating granulomatous inflammation with multisystemic manifestations. It most commonly affects young adults and is very rare in children. Due to the various forms of clinical presentation, its diagnosis may represent a challenge.
Case Report: We present the case of a 14-year-old male patient, known with medication-controlled asthma, recurrent episodes of fever associated with arthralgia, left pleural effusion, and recurrent hydrocele, admitted to the Pediatrics Department of County Emergency Clinical Hospital of Târgu Mureș. At the time of admission, the patient presented with high fever, dry cough, serous rhinorrhoea, headache, exanthema, and pain in the lower limbs. The blood culture was positive for Group G β-hemolytic Streptococcus, which was treated with antibiotics according to the antibiogram. The imaging findings revealed a left pleural effusion, multiple axillary and mediastinal, bilateral adenopathies, splenomegaly, an enlarged thyroid gland, and bilateral hydrocele. Because of the systemic inflammatory syndrome associated with multiple thoracic adenopathies, sarcoidosis was suspected. The ACE level was measured and was increased (76,9 U/L). The thyroid function revealed normal values of FT3 and FT4, but increased values of TSH and increased anti-TPO and anti-TG antibodies titer. To rule out other causes of the inflammatory syndrome, specific antibodies for several autoimmune diseases were investigated, but the results came back negative. A thoracic punction was performed to rule out tuberculosis and the pleural effusion turned out to be a transudate. To confirm the diagnosis of sarcoidosis and to rule out a neoplasm, a biopsy from a peripheral axillary lymph node was performed but revealed only a reactive histiocytosis, common in every inflammatory condition.
Discussions: The diagnostic criteria for sarcoidosis involve a characteristic clinical and radiological picture, pathologic evidence of non-caseating granulomas, and the exclusion of other diseases with similar findings. Even though the lymph node biopsy was negative in this case, probably due to the peripheral site of sampling, the clinical picture which included multiple thoracic lymphadenopathies, recurrent hydrocele and pleural effusion, cutaneous eruptions of the lower limbs, the association of autoimmune thyroiditis and the persistently increased values of ACE were highly suggestive of sarcoidosis, so corticosteroid therapy was initiated with favorable outcome.
Conclusions: Sarcoidosis is present in a wide variety of clinical forms, which makes the diagnosis a real challenge, especially at pediatric ages.

Molecular testing clarifies HLA-B27 flow-cytometry ambigous result

First author: Alexandra Onea

Coordinator(s): Other Ionela-Maria Cotoi , Professor Minodora Dobreanu

Keywords: ankylosing spondylitis HLA-B27 flow cytometry

Introduction: Ankylosing spondylitis is a chronic, inflammatory, auto-immune disease that affects spinal joints leading to fusion and limiting movement. It causes chronic pain, as well as articular and extra-articular symptoms. Most affected individuals are positive for HLA-B27, which is a predisposing factor for the disease. Case Report: We present the case of a patient known with pulmonary fibrosis and asthma diagnosed with professional lumbar discopathy since December 2023. The disease evolved with chronic pain in the small joints of the hands, feet, ankles, and bilateral omalgia with limited abduction of the upper limbs. Notably they complained of treatment-resistant chronic pain of the spine with persistent cervical pain. The MRI revealed diffuse sclerotic degeneration and inflammatory changes in the cervical and sacroiliac joints. In January 2024, the patient was discovered with leukocytosis and neutrophilia, while having an extended negative panel of other inflammatory markers. It is worth noting that the patient's HLA-B27 flow cytometry testing has yielded an uncertain result, but molecular testing confirmed the presence of the marker. Discussions: Ankylosing spondylitis is a seronegative arthropathy strongly associated with HLA-B27 as a genetic risk factor involved in the pathogenesis of the disease. In terms of diagnostics, immunological test is the first-line laboratory analysis performed, as it is a cost effective and time-efficient test compared to molecular testing. In the case of our patient, we observed an ambiguous flow cytometry result, T-cells were expressing dim (diminished expression) HLA-B27 marker. Therefore, the result needed a genetic test to confirm the presence of HLA-B27. Literature debates the reasons behind the unclear labeling patterns in flow cytometry, possibly explained through cross-reactive binding of anti-HLA-B27 antibodies to different HLA-B molecules such as HLA-B18, HLA-B35, HLA-B14, and especially HLA-B07, which could have such strong cross-reactivity that it can mask the presence of HLA-B27. Sequence-specific oligonucleotide (SSO) and sequence-specific primer (SSP) technologies could be employed for HLA typing to establish if this was true in the aforementioned case. Nevertheless, the quality of the technique and positive control is paramount in the immunological test Conclusions: AS is commonly diagnosed using flow-cytometry HLA-B27 testing, but the commercially available antibodies have been proven to have cross-reactivity to other HLA-B molecules, leading to unclear test results. In such cases genetic testing needs to be performed for confirmation.

The cardiovascular effects of N-acetylcysteine in a healthy rat model of fast-paced exercise: a study on oxidative stress, inflammation, and transmission electron microscopy

First author: Mădălina Moldovan

Coauthors: Sandra Andrea Schauer Mara Muntean

Coordinator(s): Lecturer Daniela-Rodica Mitrea

Keywords: Treadmill running N-acetylcysteine Cardiovascular Antioxidant

Background: A common protocol among athletes is progressive increase in exercise strenuousness. The additional metabolic requirement leads to higher electron transport chain activity, resulting in supplementary amounts of reactive oxygen species (ROS). In the cardiovascular system, ROS regulate blood pressure, but may also cause damage. Thus, antioxidants are increasingly utilized because of their ability to aid the body's defense mechanisms.
Objective: The study investigated the in vivo cardiovascular effects of N-acetylcysteine (NAC), a glutathione precursor and popular antioxidant among athletes, on a healthy male rat model that underwent progressive fast-paced exercise. 
Material and Method: Treatments were administered orally for four weeks, before exertion, as follows: Control group (given normal saline, n=10) and NAC group (given N-acetylcysteine, n=10). The exercise duration consisted of five-minute rounds at progressive speeds. Samples of heart and aorta tissues were collected on the final day of the experiment for oxidative stress, inflammation, and transmission electron microscopy (TEM) examination.
Results: Oxidative stress analysis in heart samples revealed that NAC significantly decreased lipid peroxidation, and increased antioxidant protection. Upon TEM, the Control group displayed an altered endocardium. The NAC group exhibited a typical heart intima, with only some instances of media alteration. In the aorta, NAC decreased the lipid peroxidation, whilst significantly increasing both iNOS and TNF-α. Upon TEM examination of the aorta, the Control group displayed an altered intima, similar to the NAC group. 
Conclusions: N-acetylcysteine exhibited notable antioxidant effects in the heart. Nevertheless, it failed to protect against the observed ultrastructural damage. In the aorta, NAC effectively reduced lipid peroxidation, however, its concurrent increase in pro-inflammatory cytokines resulted in only moderate protection of the intima against exercise-induced ultrastructural damage.

Aggressive Ulcerated Nodular Melanoma with In-Transit Metastases and High Breslow Index: A Case Report and Discussion of Prognostic Factors

First author: Dennis George

Coauthors: Mimansa Sah

Coordinator(s): Assistant Professor Andreaa Catalina

Keywords: Melanoma Ulceration Microsatellites

Background: Melanoma is the most aggressive form of skin cancer, accounting for a small percentage of skin cancers but responsible for the majority of skin cancer-related deaths. Early diagnosis and proper surgical management are crucial for improving prognosis. This case report presents a patient with a high-risk melanoma exhibiting several concerning features, including ulceration, high Breslow index, in-transit metastases, and microsatellites.
Objective: To analyze the clinical and pathological characteristics of this aggressive melanoma case, discuss its prognostic factors, and highlight the importance of prompt diagnosis and multidisciplinary management in high-risk melanoma patients.
Material and Method: A detailed review of the medical records and pathology reports of a 72-year-old male patient diagnosed with ulcerated nodular melanoma following left mastectomy.
Results: The patient presented with an exophytic, pigmented lesion on the left breast diagnosed as a 14 mm Breslow thickness, Clark level V ulcerated nodular melanoma with in-transit metastases and multiple microsatellites. Immunohistochemical profile confirmed the diagnosis. Prognostic factors included advanced tumor stage (pT4bN1cMx), high mitotic rate (80%), presence of microsatellites and tumor satellites, and nipple involvement. BRAF and NRAS testing were recommended for targeted therapy options.
Conclusions: This case highlights the aggressive nature of melanomas with specific high-risk features. The presence of ulceration, high Breslow index, in-transit metastases, and microsatellites significantly worsen the prognosis. Early diagnosis through regular skin examinations and prompt surgical intervention are crucial for improved outcomes. Multidisciplinary management, including consideration of adjuvant therapy based on BRAF and NRAS mutation status, plays a vital role in optimizing care for high-risk melanoma patients.

ANATOMICAL VARIATIONS THAT CAN INTERRACT WITH COCHLEAR IMPLANTATION IN A PACIENT WITH CONGENITAL BILATERAL HEARING LOSS

First author: Carcea Svetlana

Coauthors: Ioana-Alexandra Chindriș

Coordinator(s): Professor Adriana Neagos , Medical Doctor Cristian Neagos

Keywords: Anatomical variations Sigmoid sinus Cochlear implant CT scan

Introduction: Congenital hearing loss can become a chronic condition if untreated. Children born with this illness struggle with language and speech acquisition, cognitive functions, and social interactions. Early detection and treatment, which include cochlear implantation, play a huge role in further development and quality of life.
Case Report:  We present a case of a 10-month-old female patient, who was brought to the Otorhinolaryngology Clinic from Targu Mures complaining of hearing impairment. Several tests were performed. Clinical examination reveals a narrow ear canal.Tympanometry dysplays an As tympanogram curve type. Otoacoustic emissions and Auditory Brainstem Response are bilaterally negative. Early auditory evoked potentials shows the fifth wave present bilaterally at 70-80 dB. Auditory Steady-State Response (ASSR) reveals the hearing threshold at 70-85 dB in the left ear and 75-85 dB in the right ear. Based on these findings the patient was diagnosed with Congenital Bilateral Mixed Severe Hearing Loss, so a Cochlear Implantation was recommended. A preoperative CT scan discovered an anatomical variation of the Sigmoid Sinus. During the surgery, turned out that the Sigmoid Sinus protruded and partially covered the surgical field, so the access to the Round Window was complicated. This situation forced the surgeon to adopt a new surgical technique to perform the cochlear implant.
Discussions: The surgical procedure involves working close to important structures including the Sigmoid sinus, Chorda tympani nerve, Facial Nerve, and Semicircular canals. Anatomical abnormalities of any of these components may harden the surgical technique. In the given case, the Sigmoid Sinus protrusion partially occluded the access to the Round Window. The CT images couldn't predict the real struggle that was later discovered on the operating table. 
Conclusions: Some anatomical variations can harden the surgical procedure of Cochlear implantation. Sometimes preoperative imaging can't reveal the real anatomical features and the surgery becomes a real challenge as the surgeon has to rethink the technique during the operation.

Optimizing Amiodarone Hydrochloride Semisolid Formulations for Cardiac Therapy

First author: Cezara Pintea

Coauthors: Iulia Alexandra Puscas

Coordinator(s): Lecturer Robert-Alexandru Vlad , Professor Adriana Ciurba

Keywords: Amiodarone hydrochloride bigels texture analysis pharmacotechnical evaluation

Background: Since their initial discovery in 1960, gels have known a flourishing rise in the field of semisolid formulations. Their unique structure and characteristics have prompted scientists to further expand their knowledge and find novel ways to provide treatment for patients.
Objective: This study aimed to develop different formulations of amiodarone bigels that combine properties of both hydrophilic and lipidic components and can be designed for topical application to avoid the side effects produced by oral administration. Provided that amiodarone can be found in the second bio-pharmaceutical class, its lack of solubility determined the usage of this biphasic form as a vector for drug delivery.
Material and Method: During the preformulation study, multiple concentrations were tested, resulting in the preparation of oleogels using sunflower (SFO) and almond oil (AO) containing either beeswax (BW) or carnauba wax (CW) as gelling agents. Carboxymethyl cellulose (CMC) and Carbopol 940 (CBP) were the polymers used to develop a hydrogel. Combining the two phases was possible by adding emulsifiers such as cholesterol, Tween 80, and Span 80, using an automated mixing device (unguator). The six formulations obtained were then subjected to texture analysis, consistency test, rheology, and microbiological evaluation, while the amiodarone concentration was determined using a UV-spectrophotometric method.
Results: Due to their high oil concentration and predisposition for separation, the gels with CW and SFO (ABG3, ABG4, ABG5) did not pass the stability tests and were thereby excluded from the study. ABG6 (BW, AO, CMC 3.5%) was significantly more fluid than the other formulations, which presented a more solid, cream-like consistency. However, the spreadability was optimal, a fact also shown through extensometry: 2163.8(+/-)58.3 mm² for ABG6, 1734.06(+/-)0.0 mm² for ABG1 (BW, AO, CMC 5%), and 2122.54(+/-)0.0 mm² for ABG2 (BW, AO, CBP). ABG2 and ABG6 presented a thixotropic pseudoplastic flow, while ABG1 had a thixotropic flow. The texture profile analysis generated the highest values for ABG6 regarding hardness (0.94N) and resilience (0.079). The cohesiveness values for the three gels were in the range of 0.55 (ABG2) and 0.72 (ABG6). The concentration of amiodarone was 1.43(+/-)0.26 g% for ABG1, 1.35(+/-)0.16 g% for ABG2 and 1.49(+/-)0.06 g% for ABG6. Furthermore, there was no contamination found during the microbiological examination using Chapman, Sabouraud, and Agar mediums. 
Conclusions: Based on the determinations carried out, the aforementioned types of preparations are suitable for amiodarone incorporation. While the concentration between the two phases should further be investigated, the underscored characteristics recommend them for amiodarone bigels manufacturing.

Diffuse Alveolar Hemorrhage as a Recurrent Manifestation of pANCA-positive Microscopic Polyangiitis: Long-term Prognosis and Effects on Disease Management

First author: Mara Spatar

Coauthors: Delia-Ioana Răduțiu Paula-Cristina Matei

Coordinator(s): Lecturer Laura Muntean

Keywords: Microscopic polyangiitis pANCA diffuse alveolar hemorrhage Rituximab

Introduction: Microscopic polyangiitis (MPA) is a form of ANCA-associated small vessel necrotizing vasculitis. MPA can often present with rapidly progressive glomerulonephritis (RPGN) and pulmonary involvement as mode of onset. Diffuse alveolar hemorrhage (DAH) is a life-threatening pulmonary complication of MPA following the disruption of the alveolar-capillary interface.
Case Report: We present the case of a 63-year-old female with a history of MPA, insulin-dependent type 2 diabetes mellitus, and dialysis-dependent chronic kidney disease KDIGO G5. The MPA was diagnosed in 2016, following the rapid decline of kidney function by RPGN. Management of the patient included prednisone, cyclophosphamide, plasmapheresis, and Pneumocystis jiroveci prophylaxis. Azathioprine usage was discouraged due to adverse effects. A pulmonary AngioCT (2023) revealed changes suggestive of alveolar hemorrhage (areas of pulmonary consolidation and ground-glass opacities bilaterally, with centro-lobular distribution, confluent, more pronounced in the postero-basal regions, with air bronchograms, without pleural collections). The patient suffered two episodes of sepsis (2016, 2023) as a side-effect of cyclophosphamide. In January 2024 the patient presented with fatigue and hemoptysis which began 5 days prior. Anemia (Hbg=9,4 g/dl), increased CRP (10,49 mg/dl), sed rate (97 mm/h), creatinine (4,88 mg/dl), transaminases (TGP=74 U/L, TGO=47 U/L), and elevated pANCA levels (163 UR/ml) indicated active MPA. Prednisone was increased to 35 mg/day. Based on her previous side-effects to therapy and her suboptimal clinical presentation the medical team decided switching to Rituximab induction therapy with a dose of 375mg/m2, administered weekly, for four cycles, with a reevaluation scheduled at 8, 16, and 24 weeks. 
Discussions: In patients with MPA complicated by DAH, the 1- and 5-year survival rates are notably lower compared to the general MPA population, highlighting DAH as a significant factor contributing to mortality. Factors associated with increased mortality risk in MPA patients with DAH include age over 65, low PaO2/FiO2 ratio, extent of lung involvement, and elevated serum creatinine levels. Early diagnosis, comprehensive management, and regular follow-up are crucial for improving survival rates. Rituximab has emerged as a validated induction treatment for severe MPA, showing comparable efficacy to cyclophosphamide, especially in refractory cases and those with contraindications to cyclophosphamide. Additionally, rituximab demonstrates superiority over conventional immunosuppressive treatments for remission maintenance therapy. Further studies are needed to confirm the efficacy of rituximab in MPA patients, particularly those with DAH.
Conclusions: DAH is a life-threatening condition and a predictor of long-term morbidity and mortality in patients with MPA.

Why we depend on teamwork: highlighting the importance of interdisciplinary cooperation with a complex pediatric case with digestive and cardiac malformation

First author: Isabelle Noémi Eros

Coauthors: Ștefana-Anastasia Talău Adisa Brezger Axelle Brun Michalina Gabrusiewicz

Coordinator(s): Lecturer Zoltán Derzsi

Keywords: pediatric surgery interdisciplinary cooperation organ malformation sepsis

Introduction: Medicine relies on teamwork due to its vast scope, necessitating collaboration across disciplines. While some fields naturally intersect, others require interdisciplinary cooperation for complex cases. However, challenges arise, such as establishing intervention priorities and managing medication interactions. 

Case Report: The presented case involves a male neonate born from a pathological pregnancy, exhibiting postnatal cyanosis and hypoxia necessitating transfer to the neonatal ICU. Already intra-utero cardiac examination suspected congenital ductal dependent malformation, severe aortic contraction, hypoplasia of the distal aortic arch, malformation of the mitral and aortic valve, ostium secundum atrial septal defect with sinister-dexter shunt, ventricular septal defect of the muscular part, persistent arterial canal along with pulmonary hypertension. Prostaglandin administration and angio-CT imaging ensued. Collaboration with pediatric cardiologists facilitated daily cardiac function assessments.  Discussions: The management of the presented case was challenged by complications, further complicating the severity of the malformation. It became evident that establishing the appropriate sequence of interventions is crucial. All this requires well-coordinated teamwork, meticulous consideration of potential drug interactions and procedural cross-reactions, and judicious decision-making regarding surgical interventions. 
Conclusions: Thus, this case underscores the importance of strategic planning and interdisciplinary collaboration in navigating challenging clinical scenarios.    

DEEP INFERIOR EPIGASTRIC ARTERY PERFORATOR FLAP (DIEP) - A SIGNIFICANT RECONSTRUCTIVE SURGICAL METHOD FOR POSTMASTECTOMY PATIENTS

First author: Andreea-Ioana Feraru

Coauthors: Delia Popovici Bianca Maria Grecu Bianca Vaduva Radu Balasescu

Coordinator(s): Lecturer Dorin Constantin Dorobanțu , Medical Doctor Anamaria Cozlov

Keywords: DIEP flap Breast reconstructive technique Breast cancer Internal mammary artery

Introduction: Breast cancer is a prevalent health concern affecting millions of women worldwide, with significant physical and psychological impacts. Mastectomy often leaves individuals with altered body image and self-esteem. Reconstructive surgery, particularly the Deep Inferior Epigastric Perforator (DIEP) flap procedure, has emerged as a transformative option.  Case Report: We present the case of a 52-year-old female patient, admitted in Plastic and Reconstructive Surgery Compartment of Târgu-Mureș with right hemithorax scar post radical mastectomy for breast carcinoma pT2aN2M0. The reconstructive procedure began with the excision of the old scar and creation of a subcutaneous pocket followed by dissection of the right parasternal pectoral muscle, excision of the costal cartilage of the third rib and isolation of the right internal mammary pedicle. An elliptic incision at the inferior abdominal level was made with isolation of the umbilical stump and the elevation of the free DIEP flap on the left paraumbilical perforator. The establishment of end-to-end anastomosis between the deep inferior epigastric artery and the internal mammary artery, as well as connection of the two comitant veins to the internal mammary vein, followed. The flap was incorporated into the hemithorax region by securing it with parasternal, anterior axillary line and inframammary groove anchoring sutures to ensure optimal placement and stability. Furthermore, a paramedian suprafascial dissection of the abdominal wall was performed, extending up to the level of the xiphoid process. The abdominal wall was reinforced using progressive tension sutures, which were placed to evenly distribute tension and minimize the risk of complications such as wound dehiscence. Additionally, a midline umbilicoplasty was performed for reshaping and repositioning the umbilicus to achieve a natural and pleasing contour.   Discussions:  The DIEP flap surgery has become a preferred method for breast reconstruction in post-mastectomy breast cancer patients. This technique offers several advantages, including natural-looking results and reduced risk of complications compared to implants. The postoperative outcomes revealed complete viability of the flap with no local complications. Both recovery and aesthetic results were highly remarkable. Additionally, as part of the procedure, a cartilaginous fragment was banked at the left side of the T incision within the inframammary groove with the intention of subsequent nipple reconstruction.  Conclusions: In conclusion, DIEP flap surgery stands as a valuable option for breast cancer patients seeking reconstruction post-mastectomy, providing both aesthetic and functional benefits. Continued research and refinement of techniques will further enhance its role in improving patient outcomes and satisfaction.

LC-MS/MS analysis of ten food supplements with CBD

First author: Andreea Raluca Simion

Coordinator(s): Assistant Professor Ruxandra Ștefănescu , Other Lenard Farczadi

Keywords: Cannabis sativa LC-MS/MS Cannabigerol Commercial Products

Background: Cannabis Sativa, is a plant species that has been utilized for centuries, for its antiemetic, anxiolytic and psychoactive properties. Cannabidiol (CBD), is a non-psychoactive compound found in cannabis that has been shown to have different effects like anti-inflammatory, analgesic and antioxidant actions. Objective: This study aimed to quantify CBD and five other cannabinoids by an LC-MS/MS method in ten commercial products. Material and Method: The content of the products was assessed using high-performance liquid chromatography coupled with mass spectrometry. We analyzed six cannabinoids : cannabidiolic acid (CBDA), cannabigerolic acid (CBGA), cannabidivarinic acid (CBGVA), cannabidiol (CBD), cannabigerol (CBG) and cannabidinol (CBN). Ten CBD commercial products bought from local pharmacies were analyzed. The analysis was performed by monitoring different transitions of the analytes using a negative electrospray ionization source. A system composed of a Flexar FX10 UHPLC and QTOF MS was used. The calibration curve was composed of ten levels with nominal concentrations between 5-1000 ng/mL for each of the analytes and was plotted using 1/y². We calculated the accuracy of every calibration standard. Results: The LC-MS/MS method revealed the concentration of different cannabinoids in the commercial products we used for assessment. The results were then compared to the concentration of CBD labeled on the products. The lowest concentration was found to be in a CBD tea product (0.02% CBD). The highest measured concentration of CBD was 14.19%. After the comparison of our results with the declared concentration the greatest discrepancy was found in a food supplement that stated a 10% CBD concentration, while our results indicated a concentration of only 6.44% CBD. Regarding the concentration of other cannabinoids, CBG and CBN were found in high concentration in several products. Conclusions: The LC-MS/MS method we conducted revealed varying CBD concentrations (0.02%-14.19%) and also some discrepancies between our measurements and the labeled values. Notably, some products failed to mention the CBD concentration. Acknowledgement: This work was supported by the George Emil Palade University of Medicine, Pharmacy, Science and Technology of Târgu Mureș, Research Grant number 163 /7/ 10.01.2023.

CASE REPORT: PRADER-WILLI SYNDROME, A RARE GENETIC DISEASE THAT NEVER SATIATES THE HUNGER

First author: Carla Prodea

Coauthors: Danusia-Elena Stuparu Alexia Simina Ioana-Alexandra Pop

Coordinator(s): Assistant Professor Delia Ștefan

Keywords: Prader-Willi syndrom hedonic feeding hypotalamic dysfunction morbid obesity

Introduction: Prader-Willi syndrome (PWS) is a complex neurodevelopmental disorder caused by the lack of expression of genes in the 15q11.2-q13 region of the paternally inherited chromosome. The first clinical manifestation observed during infancy is severe hypotonia which is also the cause of poor suck, resulting in extremely thin children. However, this apparent slenderness is temporary, because due to hypothalamic dysfunction, these children do not feel satiety and develop hyperphagia followed by alarming obesity which is the cause of many comorbidities. Moreover, other phenotypical characteristics include short stature, incomplete pubertal development, obsessive-compulsive disorder concerning food, and central hypogonadism with growth hormone deficiency.  
Case Report: A six-month-old was admitted to the hospital, the reason for the initial presentation being generalized hypotonia, craniofacial dysmorphism (reduced biparietal distance, narrow palpebral fissures, bilateral epicanthus, thin upper lip, low-set ears, micrognathism), bilateral cryptorchidism. Therefore, MS-MLPA testing was performed, detecting a heterozygous deletion of the 15q11-q13 region and hypermethylation of the SNRPN, which confirms the initial suspicion of Prader-Willi syndrome. In subsequent years, the male patient is hospitalized for re-evaluation, presenting: epilepsy under treatment with Lamictal and Clobazam, age-appropriate stature development (SDS= +1.33), overweight (+46% for waist, BMI>p97% compared to waist), maintained craniofacial dysmorphism, dental dystrophies, hypoplasia of the external genital organs, moderate generalized hypotonia, expressive language delay, low IGF1. Consequently, he starts treatment with growth hormone (Genotropin) at age 5, a treatment which improves body fat distribution and cognitive development. He is also recommended a hypocaloric well-supervised diet, kinesiotherapy, frequent dental consults, and continued stimulation of mental functions under specialized care. 
Discussions: The evolution over the years shows an interesting situation of early adrenarche followed up by late pubarche. Research shows that hypothalamus dysfunction is the nucleus of the insatiable appetite, the arcuate nucleus being responsible for homeostatic satiety, cognitive process and motivational drive. Furthermore, the patient is frequently readmitted to the hospital for morbid obesity with insulin resistance, developed at the age of 10-year-old. His parents accuse obsessive-compulsive eating that cannot be kept under control, the child acting on the urge to feed and does not stick to the diet.   
Conclusions: The intellect is not significantly affected, the preeminent comorbidities of this rare genetic disease come from hedonic feeding. Therefore, this case report aims to discuss neurological agents of hyperphagia and obesity in patients with PWS, along with treatment management. 

Anaplastic Ependymoma III WHO

First author: Denisa Diac

Coauthors: Pop Mara

Coordinator(s): Medical Doctor Alina Dragoman

Keywords: Ependymoma radiotherapy chemotherapy tumor

Introduction: The simple characterization of the ependymoma would be a rare developing tumor with a neuroectodermal origin. This disease occurs frequently in the brain of pediatric patients and it can be classified by the mechanisms involved in carcinogenesis and proliferation. 
Case Report: CE, a 2 years old boy is diagnosed with a giant tumor in the left frontal lobe that is extended contralaterally, walk disorder and diplopia. The diagnostic is sustained by the following: EEG asymmetric background path in the frontal derivations (hypervoltage theta/delta rhythm) left FCT. Conclusions: Left FCT lesional focus, IRM-dimension 96/86/73, the voluminous tumor occupies the entire left frontal lobe, extended subfalciformly, the structure is inhomogeneous, both cystic and parenchymatous, diffusion restriction, spots of subacute and chronic bleeding, mass effect on the adjacent structures. The patient had multiple surgeries for the gross resection of the tumor with intraoperative monitoring and neuronavigation. The proton therapy was realised in France after the radical resection of the ependymoma.
Discussions: Based on risk stratification of this rare disease, the clinical management is truthfully demanding and requires an international collaboration. The treatment consists in gross total resection followed by proton radiation therapy. Chemotherapy does not provide any use as primary treatment and it is still under studies.
Conclusions: The multidisciplinary cooperation and international collaboration made the treatment a real success due to the complexity of the disease.

Assessment of immediate post-extraction implantation procedures from clinical and radiological perspective: a narrative review

First author: Madalina Mihali

Coordinator(s): Lecturer Alina Ormenisan

Keywords: implant surgery post-extraction radiology

Background: Nowadays, there are various treatment options available for all kinds of edentates, one of which is the implant-prosthetic one. There are requirements that must be met in order to select the best option. One surgical technique, quick post-extraction implant implantation, has gained popularity recently despite being controversial.
Objective: This narrative review aims to make a comparison regarding different techniques of surgical approach to implanto-prosthetic restorations. The most used and up-to-date implant surgical procedures will be discussed: postextraction implant insertion without bone addition, implant insertion with guided bone regeneration (GBR-Guided bone regeneration), socket-shield technique and immediate dento-alveolar restoration (IDR-Immediate Dentoalveolar Restoration).
Material and Method: With the terms implant, surgery, and post-extractional, electronic searches were performed in PubMed and Embase to gather information for this study. Included were only original prospective longitudinal studies conducted up until 2020.
Results: Several studies have demonstrated that single-surgery therapy regimens allow for highly predictable effective outcomes and are less traumatic. Prior to implant implantation, bone deficiencies can be corrected predictably with guided bone regeneration (GBR) for both vertical and horizontal bone development; however, different methods have varying clinical outcomes. In the maxillary and mandibular regions, GBR in conjunction with a combination of autogenous and xenogeneic grafts in the form of particles and i-PRF has been shown in certain trials to be effective for both vertical and horizontal bone growth, providing enough bone gain for the implantation of future implants.
Conclusions: An important component of success from a cosmetic and functional standpoint is the appropriate treatment of the soft tissues and bone in the post-extraction sockets. Selecting the right method will enable the implantation of a temporary crown, which is a common request from patients.

The assessment of non-infectious gastritis in children

First author: Alessandra Buricea

Coordinator(s): Lecturer Lorena Elena Meliț

Keywords: non-infectious gastritis, gastric inflammation, children

Background: The gastric mucosa may be affected by numerous factors, the most well-known being the Helicobacter pylori infection. However, the incidence of causes unrelated to infectious diseases has been increasing recently, which may be concerning given the paucity of research and knowledge regarding the factors that could affect the gastric mucosa.
Objective: Emphasizing the risk factors for gastric mucosal inflammation that are not related to bacterial, viral, or parasitic infections in children assessing the specific characteristics of the population under investigation (gender, age distribution, type of histopathological changes, provenience and laboratory results).
Material and Method: We performed a retrospective observational study examining the medical records of pediatric patients (aged 1-17 years) diagnosed with acute gastritis, at the Pediatrics I Clinic of the Emergency County Clinical Hospital in Târgu Mureș from 2018 to 2022.
Results: A total of 141 cases presenting epigastric pain were examined in order to determine the underlying cause. They were divided into two groups based on the findings of the histopathological examination: the study group (79 cases) showing mucosal lesions and the control group (62 cases) not presenting any gastric modifications. The inflammatory infiltrate determines whether a mucosal inflammation is acute or chronic. While polymorphonuclears are prevalent in the acute phase, mononuclears are present in long-term inflammation. Clinical manifestations are more severe in the acute phase including abdominal pain and even gastrointestinal bleeding, while in the chronic cases the pain is associated to indigestion and loss of appetite. Regarding the etiology of gastritis, reactive lesions (48%) were identified in the majority of cases, the most common causes being biliary reflux (24 cases) and proton pomp inhibitor consumption (8 cases). In contrast, the cases of the control group were mainly related to abdominal colonic spasms (13 cases) and duodenitis (6 cases). No significant difference was found between the study group and control group in terms of sex, origin and biliary reflux (p >0.05). However, the study group's children were significantly younger than those in the control group (p < 0.01). We found significant differences between the two groups in terms of laboratory findings, the study group presenting significantly lower values of hemoglobin, lymphocytes and neutrophils (p < 0.01). 
Conclusions: Non-infectious gastritis was found in 56% cases, mainly in children of 14-17 years, the acute inflammation often being associated with gastrointestinal hemorrhage. In contrast, in the control group, chronic inflammation of the mucosa was more commonly related to abdominal colonic spasms and constipation in children of 12-15 years.

TORSION OF A SUBESROSAL UTERINE LEIOMYOMA A CHALLENGING DIAGNOSTIC OF ACUTE ABDOMEN PAIN: A CASE REPORT

First author: Lazar Tudor

Coauthors: Stan Theodor

Coordinator(s): Assistant Professor Francisc Florin Rozsnyai

Keywords: Torsion Acute abdominal uterine fibroid computerized tomography

Introduction: Uterine leiomyoma its the most common benign tumor in women of reproductive age. Fibroids could have different uterine localization like subserosal, intramural and submucosal, and different dimension and symptoms are specifically those characteristics. Various complication can develop, from chronic complication like chronic pelvic pain, abnormal bleeding, dysmenorrhea, infertility to acute complication like torsion or acute degenerative fibroid. Torsion is specifically to subserosal pediculate fibroids and is a rare acute complication which cause acute abdominal pain that require immediately surgical treatment. This acute complication of fibroids is often difficult to diagnose preoperatory and misdiagnosed or prolonged time till intervention could lead to severe comorbidities.   
Case Report: A 38-year-old women without medical history of uterine fibroid is presenting to emergency department with acute lower abdominal pain. Laboratory data showed WBC: 10.62 103 /µL, Neutrophils 8.68 103/µL, Hb 12.1 g/dL, negative pregnancy test. Due to persistent abdominal pain a CT scan was performed. A nodular image projected on left ovarian fossa with 23/28mm dimension was described and another image nearby without differentiation from the other with 68/70 mm dimension with fluidal characteristics. Right ovary and the uterus were normal described, without others particularities. An exploratory diagnostic laparoscopy was performed and a huge subserosal pediculate uterine fibroma 360 degree torsion was discover. Due to dimension of fibroid (cca.10 x 6 cm) and the torsion a conversion to laparotomy was conducted. A successful myomectomy was performed and patient was discharged 3 days later without complications. 
Discussions: Acute abdominal pain caused by leiomyomas is rarely occurred and others pelvic pathologies should be considerate and because of that its a challenging diagnose. In our patient the CT performed was unable to identify the leiomyoma, but helped to lead to the affected organ, also useful to exclude other possible causes of abdominal pain. Magnetic resonance imaging (MRI) is the most effective modality for visualizing the size and location of the uterine fibroma. 
Conclusions: Despite of paraclinical investigation computerized tomography (CT) the acute abdominal pain still remain one of the most challenging diagnoses among patients who present to the emergency department (ED). Delayed treatment of uterine leiomyoma torsion could led to severe morbidity. Once the diagnose is suspected, the gynecologist must be consulted and surgical intervention should be immediately required .

The journey of an Incredible Low Birth Weight newborn

First author: Teodora Bencic

Coauthors: Mihaela-Anisoara Ilisiu

Coordinator(s): Professor Emanuela Cucerea

Keywords: ILBW ELBW respiratory distress 450g

Introduction: In the realm of neonatology, tiny warriors born with incredibly low birth weights (ELBW & ILBW) stand apart, needing specialized care and attention. ELBW represents a birth weight below 1000 grams, while ILBW refers to newborns weighing under 500 grams. These infants are often exposed to a variety of challenges associated with extreme prematurity, from respiratory dysfunction to developmental hurdles. Expert management of ELBW and ILBW requires a united front of neonatologists, pediatricians, specialized nursing staff, and other medical professionals.
Case Report: Patient C.T. was born naturally with a cranial presentation at a level 2 maternity hospital, weighing 450 grams, with a cranial circumference of 20 cm and a length of 32 cm. The APGAR score was 4/1 min and 6/5 min. Immediately after birth, the patient was transferred to a level 3 unit with hypothermia and moderate respiratory distress. In the first 5-6 days the patient weighed 380g. This newborn was diagnosed with all prematurity pathologies: Newborn Respiratory Distress Syndrome, chronic lung disease, specific perinatal period infection with unspecified germ, extreme immaturity at 22/23 weeks, ELBW newborn, neonatal infection with Serratia Marcescens, metabolic acidosis of the newborn, non-traumatic intraventricular hemorrhage grade 3, prematurity anemia, neonatal jaundice, and carbohydrate metabolism disorders. The therapeutic approach included placement in a heated incubator, monitoring, oxygen therapy under non-invasive ventilator support type nCPAP, hydroelectrolytic rebalancing, initiation of antibiotic therapy according to results, surfactant administration, administration of Phytonadione for hemorrhagic disease prophylaxis, caffeine citrate for respiratory system stimulation, treatment with Dexamethasone for bronchopulmonary dysplasia, phototherapy, administration of erythrocyte mass, and administration of vitamins.
Discussions: This case stands out as one of the uncommon occurrences of ILBW , where it required 110 days for a premature weighing 450 grams at birth to stabilize and eradicate the factors that would have been impossible without the NICU intervention. The patient's progress has been incredibly positive, reaching a weight of 2400g by day 110, with ventilation levels exceeding 94%. Thanks to targeted treatment for Staphylococcus Aureus MSSA, prematurity infections have been effectively eradicated. Hematological analyses have shown all parameters to be within healthy ranges, with no adverse reactions observed during the treatment of anemia.
Conclusions: The patient is now free from any prematurity related conditions, suggesting remarkable improvement. This positive outcome rises the possibility of normalization of ILBW infant. Despite presenting the full spectrum of prematurity complications, the favorable evolutions of this newborn gives hope for more successful outcomes. 

Down Syndrome and Cardiac Malformations in premature newborns:Clinical approach and management

First author: Pop Mara

Coauthors: Mara Tanase Denisa Diac

Coordinator(s): Associate Professor Cucerea Manuela

Keywords: prostaglandin Down phenotype common atrioventricular duct heart malformations

Introduction: Down syndrome also known as Trisomy 21 is one of the most common genetic abnormalities in newborns. Patients with this syndrome have a characteristic phenotypic appearance and may associate with a series of visceral malformations, among which are heart malformations. 
Case Report: In this case presentation we will talk about the management of a newborn with down syndrome who also has several heart malformations, highlighting the method of diagnosis and treatment. The newborn is suspected since the prenatal period of Trisomy 21 associated with heart malformations and is born at 33-34 weeks by C-section. At birth the APGAR score was 6/1 minute and 8/5 minutes, weight 2300g, LG: 47cm and PC:29.5. Further, a physical examination was performed where the characteristic face of down phenotype, muscle hypotonia, syndactyle and clitoris hypertrophy were highlighted. During the examination of the cardiovascular and respiratory system, well-beaten bilateral cardiac noises , vesicular murmur, HR: 160-170 b/min, RR: 58-64 breath/minute and O2 sturatia less than 75% at 10 minutes postpartum were identified.During the echocardiographic examination, the diagnosis of multiplerol heart malformations was confirmed, among which the coarctation of the aorta and common atrioventricular duct was found. Treatment with prostaglandin E1 to maintain the permeability of the arterial duct and avoid circulatory collapse associated with aortic coarctation began with the initial dose of 0.01 mg/kg/min. Heart rate, oxygen sturation, vital parameters were followed to guide subsequent changes in treatment. Due to the improvement in general condition, increased oxygen saturation to 93-95% and absence of side effects of treatment, the dose of prostaglandin E1 gradually decreased to 0.002 mg/kg/min. After 3 week of treatment, the newborn was transferred to the cardiovascular surgery department for surgical correction.  
Discussions: The manager of such a case includes, besides a neonatologist, a multidisciplinary team consisting of pediatric cardiologist, geneticist, cardiovascular surgeon.Long-term patient management relies heavily on the support and education of parents. 
Conclusions: Early diagnosis in combination with proper treatment and care for patients with down syndrome and associated heart malformations leads to the favorable development . A very important aspect for optimizing the care of these children and improving their long-term prognosis is the continuation of research and improvement of clinical practices

SURGICAL APPROACH IN MATURE CATARACT ON ENOPHTALMOS

First author: Georgiana-Alina Olteanu

Coauthors: Maria-Emilia Cerghedean-Florea Corina Tudor

Coordinator(s): Lecturer Adrian Teodoru

Keywords: enophthalmos cataract classic surgery

Introduction: Enophthalmos is the posterior displacement of the entire eyeball into the orbital cavity. It has a variety of causes and can be classified as primary (congenital) or secondary (post-traumatic). The aim of this paper is to highlight the difficulties of cataract surgery in enophthalmic eyes.
Case Report: We present the case of an 82-year-old male patient who came to our clinic for a routine checkup. At the ophthalmological examination BCVA RE-0.3, LE- c.f. IOP (intraocular pressure) RE=11 mmHg, LE= 9 mmHg. The anterior segment for left eye (LE) shows a dense cataract and for the right eye multiple opacities of the lens. Ocular movements were normal in both eyes. The final diagnosis was mature cataract for the left eye and cataract for the right eye; surgical treatment for both eyes was decided in order to improve visual acuity. Unfortunately, due to left eye enophthalmos and dense cataract, optical coherence tomography and specular microscopy could not be performed. Biometry was tried on two different machines. The classic surgical approach was decided due to enophthalmos and mature cataract, with extracapsular lens extraction and artificial intraocular lens implantation, being performed without complications. For the right eye phacoemulsification and artificial intraocular lens implantation was performed without complications, two weeks apart. On the post-operator check-up, BCVA of the left eye was 0.3 and for right eye 0.6, without edema, ocular or periocular pain or hyperemia.
Discussions: Although cataract is one of the most common surgeries performed worldwide, being a fast surgery there are many pathologies associated with a patient that increase the difficulty of the surgical approach. 
Conclusions: The modern procedure of cataract surgery - phacoemulsification and lens implantation- could not be performed on the left eye because of the location of the eyeball in the orbital cavity and mature cataract, resulting in the surgery being longer, the surgical technique more difficult and the healing process taking more time.

Using Low-Level Laser Therapy (LLLT) in the treatment of Androgenic Alopecia

First author: Paul Budau

Coauthors: Bogdan Goia

Coordinator(s): Professor Albert Zsolt Barabas

Keywords: Low-Level Laser Therapy (LLLT) Androgenic Alopecia (AGA) Photobiomodulation Hair density

Background: Androgenic alopecia (AGA) is a genetically determined hair loss condition characterized by the progressive miniaturization of hair follicles. Low-level laser therapy (LLLT) has emerged as a potential non-invasive treatment option for AGA, hypothesized to act through various mechanisms including follicular stimulation, enhanced blood circulation, inflammation modulation, and hormonal influence. 
Objective: To explore the utilization of Low-Level Laser Therapy (LLLT) protocols in the treatment of Alopecia, particularly focusing on Androgenetic Alopecia (AGA), as an alternative therapeutic approach for patients who do not respond favorably or exhibit intolerance to standard treatments, such as minoxidil and finasteride, or they are unable, nor do they want a hair transplant done.
Material and Method: LLLT devices for hair loss treatment include handheld laser combs, helmets, headbands, and professional-grade equipment emitting wavelengths of 650–1200 nm. Treatment involves 15–20 minute sessions, three times weekly for 6 months, with fluences of 1–10 J/cm² and power density of 3–90 mW/cm². LLLT utilizes low-intensity light, predominantly red or near-infrared, to modulate cellular activity via photobiomodulation. Mechanisms include mitochondrial stimulation, increased reactive oxygen species levels, ATP production, and transcription factor activation. Efficacy relies on irradiance and illumination time rather than fluence.
Results: In a broad-scale analysis across multiple studies, LLLT exhibited positive responses in approximately 60% of cases, demonstrating improvements in hair density and thickness. Nevertheless, around 40% of individuals did not show significant benefits, indicating the variable nature of treatment efficacy. The outcomes of LLLT for hair loss might depend on interindividual differences in hair density, hair length, hair color, and skin color, which are factors affecting absorption and transmission of the light.
Conclusions: LLLT emerges as a promising non-invasive and safe treatment option for patients with Androgenetic Alopecia who are unresponsive or intolerant to conventional therapies. With a demonstrated low incidence of adverse effects across diverse medical conditions over more than 50 years, LLLT holds potential as an effective alternative for managing hair loss, available to everyone.

The particularities of myocardial infarction in young individuals

First author: Sar Iulia

Coauthors: Ioana-Patricia Rodean Vasile-Bogdan Halațiu Roman Bianca Teodora

Coordinator(s): Professor Theodora Benedek

Keywords: myocardial infarction lipoprotein (a) young individuals

Background: The etiopathogenesis of myocardial infarction (MI) in young individuals involves a multifactorial interplay of both genetic and behavioural causes, exerting a profound impact on cardiovascular health. The macromolecular complex of lipoprotein (a) [Lp(a)] plays a significant role in the pathogenesis and progression of atherosclerosis, and consequently, MI.
Objective: The present study aims to investigate the particularities of MI in young individuals.  
Material and Method: According to the median value of the age, established at 45 years old, the study population was divided into two groups: group 1 – 41 patients ≤ 45 years and group 2 – 72 patients >45 years old. For all participants, smoker status, body mass index, comorbidities were assessed. Also, the C reactive protein level (CRP), uric acid, N- terminal natriuretic peptide (NT-proBNP) and Lp(a) seric level were determined. 
Results: In younger patients the Lp(a) seric level was significantly higher (0.38 ± 0.35 g/ L vs 0.13 ± 0.15 g/ L, p<0.0001), in contrast to patients over 45 years old who presented more frequent DM (diabetes mellitus) (p=0.008) and a higher BMI (body mass index) (25.75 ± 4.76 kg/ m2 vs 31.29 ± 6.64 kg/ m2, p=0.003). The CRP serum level (14.94 ± 2.32 mg/ L vs 43.75 ± 4.19 mg/ L), uric acid (4.68 ± 1.79 mg/ dl vs 6.27 ± 1.69 mg/ dl, p<0.0001)and NTproBNP level (897.90 ± 141.40 pg/ dl vs 2338.00 ± 349.10 pg/ dl, p=0.02) were higher in group 2 compared with group 1.
Conclusions:  In our study an association between Lp(a) and myocardial infarction at a young age was found, suggesting that cardiovascular risk could be seriously impacted by levels of Lp(a) in younger patients.

Lateral femoro-tibial bypass - a last resort in the lower limb salvage

First author: Erik-Karoly Kiss

Coauthors: Laura Laslo Valentin-Gabriel Ivan Emil Marian Arbanasi Constantin Claudiu Ciucanu

Coordinator(s): Associate Professor Adrian Vasile Muresan , Lecturer Eliza Russu

Keywords: Peripheral arterial disease lower limb revascularization vascular surgery Extra-Anatomic Femoro-Tibial Bypass

Introduction: Peripheral arterial disease (PAD) is an atherosclerotic-driven condition that reduces the flow of blood in peripheral arteries. It remains underdiagnosed and undertreated. Early revascularization is crucial in this situation, and rapid intervention is necessary, utilizing the best option for each patient individually.
Case Report: We present the case of a 73-year-old male patient, known to have peripheral arterial disease, grade II hypertension, type II diabetes mellitus, and chronic smoking history, who presents for a scheduled appointment at the Vascular Surgery Clinic with claudication pain occurring at distances shorter than 10 meters in the left lower limb. Angio-CT reveals occlusion of the superficial femoral artery, popliteal artery, and left tibial-peroneal trunk. Surgical intervention was performed on August 21, 2022, involving extended femoro-popliteal distal axis thromboendarterectomy with arterial flow restoration and angioplasty using a bovine pericardial patch at the level of the popliteal artery. Post-operatively, symptoms improve, and the patient shows favorable progress in the first six months, with a subsequent progressive reduction in walking distance and the onset of rest pain, leading to readmission on February 21, 2023. Due to the occlusion of the tibia-peroneal trunk and post-operative fibrosis, it is decided to perform an anterior femoro-tibial bypass with extra-anatomic tunneling of the graft through the outside of the leg. Subsequently, the patient is discharged five days post-operation, and at the 6 and 12-month follow-up appointments, the bypass remains patent with no signs of restenosis and absence of symptoms.
Discussions: Endovascular treatment is the preferred option for severe stenoses and short occlusions, while surgical treatment is recommended for long occlusions. The patency of below-the-knee arteries is crucial for both treatments. The Extra-Anatomic Femoro-Tibial Bypass is an alternative intervention for lower limb salvage in peripheral arterial disease. It has a favorable prognosis compared to thromboendarterectomy. Hopefully, prediction models will further improve the long-term results of this procedure in the future. 
Conclusions: In conclusion, peripheral arterial disease associated with type 2 diabetes mellitus remains hazardous, representing a common cause of amputation. The extra-anatomic bypass is a feasible solution that can be applied in well-selected cases to save the limb instead of amputating it, with excellent outcomes reflected even after 12 months post-intervention.

EEG Signal Generator Prototype for Healthcare Devices

First author: Adrian-Răzvan Cîrnu

Coordinator(s): Associate Professor Zoltan German-Sallo

Keywords: EEG Signal Replication Biomedical Engineering Signal Generator Design Signal Processing

Background: The ability to reproduce electrophysiological signals is an extremely delicate and important part of checking and, in some cases, adjusting various components of medical electronic equipment to ensure proper functionality and correct readings offered by these machines. This necessity comes from the fact that most of these are used for diagnostics and treatment of patients, which means that errors could have serious consequences on patients health, or the efficacy of the treatment offered. This demands the ability to recreate these signals with an important focus on the Electroencephalogram (EEG) signals as they are by their nature low in frequency and amplitude.
Objective: This project explores the development of a new device capable of generating precise EEG signals that closely mimic the frequency and amplitude characteristics observed in authentic patient recordings. Its primary objective is to replicate the waveforms and other signal parameters expected in genuine EEG recordings, not only as a digital simulation but also as a physical signal output, suitable for integration into medical monitoring equipment used for EEG analysis.
Material and Method: The production of this device involved utilizing a combination of various components, both active and passive, to recreate, filter, and fine-tune the specific characteristics of delta, theta, alpha, beta, and gamma waveforms. The experimental procedure included the design and production of multiple circuit configurations aimed at achieving the desired signal synthesis. Multiple circuit configurations were designed and tested to achieve the desired signal synthesis, with validation conducted using oscilloscopes and combiscopes to ensure accuracy and reliability.
Results: The selected design ultimately demonstrated suitability for the intended task, yielding anticipated outcomes by generating a signal output similar to that of an authentic patient recording, while also withstanding the challenges associated with reproducing low-frequency and low-amplitude signals. The successful replication of these signal characteristics underscores the efficacy of the chosen approach, affirming its compatibility with applications requiring accurate replication of EEG signals. Additionally, this achievement highlights the robustness of our methodology in addressing the complexities inherent in EEG signal synthesis.
Conclusions: In conclusion, the characteristics of the output signal confirm the device's capability to replicate realistic EEG signals. Additionally, the ability to introduce artificial noise to the signal may potentially enhance its realism, although further investigation is required to determine its effectiveness in increasing fidelity without corrupting the original signal.

A case of chronic hypertension with superimposed preeclampsia

First author: Cojan Sara-Regina

Coauthors: Vlad Ciobanu Octavian Alexandru Elisei Rareș Bogdan Feidi

Coordinator(s): Medical Doctor Anca Măcicășan

Keywords: Chronic hypertension Preeclampsia HELLP syndrome Pregnancy

Introduction: Preeclampsia is a hypertensive disorder that occurs during pregnancy. It is defined as a systolic blood pressure ≥ 140 mmHg or diastolic blood pressure ≥ 90 mmHg on two separate occasions at least 4 hours apart, all of which must be identified after 20 weeks of gestation. This complication occurs in up to 8% of pregnant women.
Case Report: We present the case of a 33-year-old female known with grade II hypertension who presented to the ER of the SCJU Targu Mures with a BP of 170/100 mmHg, epigastric pain, and nausea, 36 weeks pregnant. She refused admission and presented on the second day to the Maternity Hospital with a BP of 174/118 mmHg. She had been on antihypertensive medication (Dopegyt and Nifedipine) but was insufficiently controlled. After clinical evaluation accompanied by a urinalysis which revealed proteinuria (31 mg/dl) and a blood sample that showed mild anemia (HGB: 10,8 g/dl, HTC:36,5%), elevated liver enzymes (AST:67 U/L, ALT:54 U/L), and thrombocytopenia (125.000/uL)) was diagnosed with XVIG IIP at 36 weeks of pregnancy, pre-existing grade II hypertension under treatment exacerbated by preeclampsia.
Discussions: Chronic hypertension complicated by superimposed preeclampsia presents significant challenges for clinical management. Differential diagnosis with conditions like HELLP syndrome is essential. Despite the absence of hemolysis, the clinical picture warranted consideration for potential overlap with HELLP syndrome. The patient was kept under observation and treatment for four days, but there was no improvement in her condition. Therefore the decision was made to induce labor with prostaglandins and manage it with oxytocin infusion due to pre-existing hypertension exacerbated by pregnancy. On the other hand, if the patient would have developed an eclamptic crisis, It would have been considered an emergency, requiring a cesarean section intervention.
Conclusions: This case highlights the importance of early recognition and appropriate management of chronic hypertension complicated by superimposed preeclampsia to optimize maternal and fetal outcomes. A wide range of complications can occur, including eclampsia (seizure disorder), HELLP syndrome, coagulation disorder, pulmonary edema, visual disturbances, renal failure, heart failure, and fetal and/or maternal death.

Management of Tibial and Fibular Open Fractures

First author: Raysa-Ariana Mesani

Coauthors: Rareș Bogdan Feidi Melisa Micu Orlando Sorin Ardelean

Coordinator(s): Associate Professor Adrian Ivănescu , Medical Doctor Denis Pasc

Keywords: Tibia Fibula Management Fracture

Introduction: A tibial and fibular type 2 fracture is characterized by a moderate level of soft tissue injury. Immediate surgery is a necessity in these cases. The management of this situation is highly important in orthopedic trauma management. It can prevent several serious complications, such as long-term disability and compartment syndrome.
Case Report: Pacient, male, 24 years old, presents to the Emergency Room accusing severe pain, swelling and restricted mobility in the right calf. Upon further assessment, an open, swollen wound on the right calf can be visualised. Radiography reveals a type two open tibial and fibular fracture in the medial third of the right calf. After stabilizing the patient, immediate surgical intervention was necessary, which consisted in fracture reduction, along with implantation of intramedullary nails to fixate the bones.
Discussions: The management of open fractures on both bones of the right calf is done in an extremely delicate manner. In order to achieve a complete recovery after such a trauma, the medical team is required to pay attention to the debridement process, the inflammation, the possible infections and the post-surgical care and treatment.
Conclusions: Open tibial and fibular fractures can have numerous complications, which can alter the quality of life. Therefore, it is of utter importance that the management is organised, effective and done in time. Close monitoring is essential in these types of trauma. The case highlights how an efficient and structured treatment can help with a rapid recovery.

From diagnosis to intervention: A case study on hysterectomy due to pelvic inflammatory disease

First author: Daria-Stefania Catană

Coauthors: Vlad Ciobanu Maria- Dorina Soporan Mihnea Cristian-Caus

Coordinator(s): Medical Doctor Anca Măcicășan

Keywords: hysterectomy intrauterine device pelvic inflammatory syndrome

Introduction: Hysterectomy is a radical surgical procedure involving the removal of a woman’s uterus and in addition the ovaries and fallopian tubes. Despite its primarily indication for severe pathological conditions, statistics reveal that approximately one in three women will undergo hysterctomy by the age of 60. This case aims to draw attention to the seriousness of recurrent or treatment-resistant infections and their potential to escalate to the development of pelvic inflammatory syndrome, unfortunately culminating in a hysterectomy as a last resort.
Case Report: We present the case of a 42 year old woman with a gynecological history of three births and three abortions, subsequently opting for an intrauterine device (IUD) for contraception. The patient presented with severe abdominal and pelvic pain, symptoms that manifested approximately six months prior but intensified over the preceding two days. During a follow-up pelvic ultrasound, cystic masses on the left ovary and on the right side of the uterus were found, leading to the diagnosis of right adnexal tumor and pelvic pain syndrome. Clinical examination showed vaginal discharge and pelvic tenderness, indicating a possible pelvic infection due to the IUD, which was subsequently removed.
Discussions: To address the severity of the condition, a laparoscopic procedure was performed. Upon opening, adhesion syndrome was observed in the small pelvis, involving the uterus, both appendages, the appendix, the omentum and the bowel loops. These organs displayed visible inflammation. Due to the extent of organ damage and the malignant appearance of the cysts on the uterus and ovary, a subtotal hysterectomy with bilateral salpingo-oophorectomy was decided as the appropriate course of action. Additionally, an adhesiolysis procedure was conducted, during which 500 ml of purulent fluid was drained. The final diagnosis, following the histopathological findings, was endometritis, myometritis, bilateral acute salpingitis, bilateral acute oophoritis, and uterine leiomyoma.
Conclusions: The results confirm that despite the necessity of a hysterectomy, given the extensive lesions discovered, the surgery was deemed a great success. Our case recalls once again the potentially devastating effects of untreated infection on the reproductive organs.

Exploring the Seroprevalence Landscape of TORCH Infections within the Pediatric Population of Cluj county, a Cohort Study

First author: Delia-Ioana Răduțiu

Coordinator(s): Assistant Professor Mădălina Adriana Bordea

Keywords: TORCH epidemiology pediatrics prevalence

Background: TORCH syndrome is a medical abbreviation describing a group of five or more congenital diseases, most of which are viral. It consists of the Taxoplasma gondii parasite, and other agents: Treponema pallidum, Varicella-zoster, Parvovirus B19, Rubella, Cytomegalovirus, and Herpes simplex virus. TORCH syndrome refers to fetal or neonatal infection caused by one of the above-mentioned etiological agents. Congenital forms entail a heightened risk of fetal malformations (especially in the first trimester of pregnancy) and severe infections are often associated with spontaneous abortion. Because many infected patients are asymptomatic, serological diagnosis is critical for prevention. The current research is a cohort-based, randomized, retrospective, and longitudinal type of study. 
Objective: Understanding the TORCH seroprevalence in pediatric populations is crucial for assessing the prevalence of congenital infections, guiding prenatal care, and implementing preventive measures. This study aids in identifying at-risk individuals, and ultimately safeguarding the health and well-being of children and pregnant women in the community. 
Material and Method: The Immunological Chemiluminescence method was the test used for the research. The test detects the presence and measures the quantity of specific antibodies. Essentially, the test detects the body's immune response to infection. The study period consisted of 9 months (January-September 2019), of a statistically significant group. The age range for inclusion was from 3 months to 18 years old. Exclusion standards: individuals with compromised immune systems. The data was provided by the Pediatric Clinic II Cluj-Napoca's Immunology Laboratory and was approved by the Ethics Committee of the "Iuliu Hațieganu" University of Medicine and Pharmacy Cluj-Napoca, Romania.
Results: It was shown that 103 tests (12.8%) were positive for Toxoplasma gondii, 1551 positive tests (75.7%) for CMV, 174 positive tests (51.6%) for HSV-1/2, 12 patients (14-18) - HSV type 2. The prevalence study concluded that the rate of presence of specific antibodies was higher among patients infected with CMV compared to the positive batches of other infections. Toxoplasma - CMV coinfection was detected in 44 of 103 patients diagnosed with Toxoplasmosis. (42.7%). The seroprevalence of TORCH infections was statistically significant (Fisher test, p<0.001) among the pediatric population aged 12-18 years (average age=9.87).
Conclusions: The current study indicates that the prevalence of specific antibodies increases in direct correlation with age. High seroprevalence predicts TORCH risk, affecting pregnant women and newborns. By knowing the epidemiology of TORCH infections, we can develop viable strategies to prevent congenital infections and their long-term consequences. 

Genetic and biochemical studies in Alzheimer's disease (AD), a neurodegenerative disorder

First author: Paula Denisa Saragea

Coordinator(s): Lecturer Cristian Tudose

Keywords: Alzheimer Neurodegeneration Multifactorial Hereditary

Background: Situated within the broad spectrum of neurodegenerative disorders, AD is known for its complexity, heterogeneity, multiple genetic mutations, epigenetic and biochemical modifications, and irreversible evolution from early stages characterized by deficits in the ability to encode and store new information to subsequent progressive cognitive, functional, behavioral decline.
Objective: The central focus of the conducted investigation was to consolidate comprehensive statistics, identify genetic determinants and delineate their intricate correlations with environmental factors, thus highlighting the significance of implementing assessment programs and early introduction of medication, in order to decelerate the progression of neurodegenerative processes.
Material and Method: The first part consisted of analyzing specialized literature, articles published in the last 35 years regarding the mechanisms involved in the onset of this pathology, exploring a wide range of hypotheses, progression stages and treatment possibilities while writing an extensive review. The retrospective study encompassed individuals admitted to the Neurology Department of "Iacob Czihac" Military Emergency Hospital Iași between 01.01.2023 and 31.12.2023. Out of 1012 patients hospitalized with chronic neurological diseases, 98 were diagnosed with AD in various stages. Twenty-one cases (21.429%) exhibiting genetic predisposition were selected and thoroughly analyzed based on medical records. Additionally, the study included a small group of patients from Vrancea, in order to conduct a comparative analysis, both by comparing to the extended cohort and to global statistics, while focusing on a few cases of late-onset familial AD. 
Results: The study emphasizes the significant position of AD among chronic neurological diseases. Although the majority do not present hereditary antecedents (78.57%), predisposing diseases (TBI, T2D, hypercholesterolemia, hypertension, obesity), stress, environmental factors (smoking, alcohol, pesticides, aluminium, organic solvents), as well as the region of residence, play fundamental roles in the determinism. It is observed that individuals in the 60-70 age category (68.36%) from urban areas (70.41%), especially females (62.24%), have a higher probability of developing AD. Maternally transmitted Alzheimer's prevalence was 57.143%, while paternally inherited AD accounted for 33.333%, with only 2 cases having antecedents on both lines (9.524%).
Conclusions: Unequivocally characterized by a vast etiology, neurotrophin depletion, cerebral atrophy, mitochondrial dysfunction, accumulation of neurofibrillary tangles and senile plaques following the appearance of allelic variants (APOE4, MAPT, APOJ, SORT1) or dominant autosomal mutations (PSEN1/2, APP), AD is a multifactorial disorder resulting from the bilateral interaction between genetic and environmental factors or solely one of them. However, the transition from vulnerability to the actual disease is achieved through the continuous corroboration of these two major classes of factors.

Insights into ASD and ADHD: A case study in pediatric psychiatry

First author: Daria-Stefania Catană

Coauthors: Andreea Stefaroi Octavian Alexandru Elisei Paul Sarmasan

Coordinator(s): Medical Doctor Laura Ilașcu

Keywords: autism spectrum disorder ADHD ABA therapy mild intellectual disability

Introduction: Autism Spectrum Disorders (ASD) are increasingly prevalent in child and adolescent psychiatry, characterized by early-onset developmental deficits in social communication and repetitive behaviors. According to CDC data from 2014, ASD affects 1 in 68 children. Given the absence of curative medication, this study aims to highlight the importance of diagnosis by presenting a case study involving a 6-year-old child with autism and subsequently diagnosed with ADHD.
Case Report: The patient, accompanied by both parents, presented at the Pediatric Psychiatry Clinic within the Saint Mary Emergency Children Hospital. The child exhibited difficulties in school integration, social interaction, sleep disturbances, psychomotor agitation, attention deficit, and both self- and hetero-aggression with minimal frustration. Additionally, stereotypical movements, increased adherence to non-functional rituals, and hyperreactivity to various sounds were observed. The child had been diagnosed with ASD at the age of 3 years and 6 months and had received Applied Behavior Analysis (ABA) therapy. A confirmatory diagnosis of ASD in association with ADHD and Mild Intellectual Disability was made according to DSM-5 criteria.
Discussions: The patient was closely monitored by a psychiatrist for the following 6 months. Methylphenidate for ADHD (18mg/day) was initiated, along with a short period of treatment with risperidone (0.50 mg/day) and melatonin (2mg, 30 minutes before bedtime). Additionally, ABA therapy was continued in conjunction with play therapy, music therapy, and sensory integration therapy (especially auditory). Results were gradually positive, with the child successfully continuing school with the assistance of a tutor.
Conclusions: Early diagnosis and intervention are essential in managing ASD and ADHD effectively. A multidisciplinary approach involving medication, therapy, and parental support can significantly improve outcomes for children with these neurodevelopmental disorders. Further research and continuous evaluation of treatment strategies are necessary to optimize interventions and enhance the quality of life for affected individuals and their families.

Recurrent Ovarian Hyperstimulation Syndrome Following GnRH Agonist Trigger : A Case Report

First author: Vasileios- Aiakos Lykouris

Coauthors: Teodora- Karin Gligor Tudor Dima

Coordinator(s): Professor Murat Özekinci , Medical Doctor Arif Can Özsipahi

Keywords: Ovarian Hyperstimulation Syndrome (OHSS) In Vitro Fertilization (IVF) Infertility

Introduction: Ovarian hyperstimulation syndrome (OHSS) is an iatrogenic complication associated with fertility treatments, particularly those involving ovarian stimulation. Excessive ovarian stimulation can lead to ovarian enlargement and increased capillary permeability, potentially resulting in complications such as ascites, hydrothorax, and pericardial effusion.
Case Report: A 33-year-old nulliparous female patient, presenting with a 7-year history of infertility, was referred to our in vitro fertilization (IVF) unit for IVF treatment due to a history of OHSS following two controlled ovarian stimulations. The patient had a history of using antagonist protocol and agonist trigger for final oocyte maturation in her previous two treatments. She had oligomenorrhea in her history and no other symptoms. No additional findings were detected by transvaginal ultrasound, except polycystic ovarian morphology in bilateral ovaries. Since she had a previous history of OHSS with the antagonist protocol, stimulation was started with the medroxyprogesterone acetate (MPA). Stimulation with recombinant FSH (Gonal-f) 150 IU started on day-3 of the menstrual cycle, and the MPA was administered from the first day of stimulation (Tarlusal). After the 9 days stimulation, agonist trigger was initiated and because of the known OHSS, Dostinex (Cabergoline) was administered for one week. Ovum pick-up was performed and out of 34 oocysts, 4 corresponding to maturity day 5 were cryopreserved using “freeze all strategy”. Three days later, she presented with signs and symptoms of OHSS at the Emergency Department: abdominal pain, distention, and ascites. After resolution, she returned two months later for frozen embryo transfer. 3BB-1CB embryos were implanted, resulting in a confirmed pregnancy with high hCG levels, currently expecting dichorionic diamniotic twins under close monitoring. 
Discussions: Although the treatment of choice for infertility is hCG, this could not be used in the presented case due to OHSS. HCG would negatively impact the patient by exacerbating OHSS symptomatology, making it life-threatening. Therefore, the gynaecology team chose MPA and GnRH analogs trigger, combined with prophylactic medication (Dostinex and Tarlusal), to maximize the chances of pregnancy and mitigate threatening symptoms. Even though GnRH alone was proven to almost eliminate the chance of triggering OHSS in women undergoing IVF cycles, in this case, the OHSS was triggered, and the zygote implantation had to be postponed until the symptoms resolved, making it an exceptional occurrence. 
Conclusions: The GnRH agonist method demonstrates the optimal approach to substantially reduce the incidence of OHSS, resulting in a higher yield of mature oocytes and better-quality embryos comparing an hCG trigger.  

AN EPISODE OF SEVERE DEPRESSION: NON-FATAL SUICIDE ATTEMPT BY SELF INFLICTED STAB WOUND IN THE RIGHT VENTRICLE

First author: Sabrina Mancino

Coauthors: Naomi Mancino

Coordinator(s): Assistant Professor Andrei Modiga , Medical Doctor Macedon Bogdan

Keywords: heartstabwound majordepressivedisorder nonfatalsuicide pericardiocentesis

Introduction: Penetrating heart wounds refer to all traumatic cardiac injuries secondary to penetrating action, the leading cause are stab wounds and gunshot wounds, succeeded by accidental or non- accidental implements. The main symptoms in this kind of trauma ranging from complete hemodynamic stability to cardiac arrest. 
Case Report: A 58-year-old male patient transported urgently with the helicopter to the SMURD of the Targu Mures Hospital, with a penetrating chest wound involving the right ventricle through self- stab and cardiac tamponade. Victim of two consecutive cardiac arrests, who responded positively only after the pericardiocentesis. In the emergency department a CT scan was performed, which showed: an epigastric penetrating metallic foreign body with the distal end at ventral pericardial level, with associated hemopericardium and high suspicious of contusion - pericardial and myocardial. The patient underwent to an emergency surgical intervention in the Cardiology Department, where the right ventricular wound is sutured with insulated wires reinforced with a Teflon patch. The pericardial collection was evacuated, with a favorable subsequent postoperative evolution. A post operative X-Ray, echocardiography and an ECG were performed which highlighted an atrial fibrillation and an antiarrhythmic treatment with Cordarone was instituted. The patient was discharged from the Cardiology department after 6 days, he was completely afebrile, hemodynamically and respiratory stable, the surgical wounds were healing correctly. Based on the result of the psychiatric consult which reveal: a severe depressive mood, prevalent maniac ideas of self-devaluation and, negative projections about the future, lack of energy in the performance of activities and denied the attempt to suicide; he was transferred at the Psychiatric Clinic.  
Discussions: A clinical scenario of penetrating cardiac wound needs a promptness management for increase the survival chance of the patient. The possible complications could be hypovolemic shock due to the hemorrhage, cardiac tamponade, arrhythmias, myocardial infarction, endocarditis or mediastinitis, pulmonary embolism and even neurological complications. Cardiac tamponade, even if contributing to rapid mortality, is an early opportunity for survival. According to our clinical case is essential to menage the main cause that conduct the patient to commit a suicide: the major depressive disorder. 
Conclusions: Penetrating cardiac injuries (PCI) are mostly fatal with mortality rate of around 16%–43%. Emergent management is crucial for patients presenting with PCI. The definitive treatment being surgical drainage of pericardial blood and repair of underlying cardiac injury. 

Complications of transarterial chemoembolization in the treatment of liver tumors

First author: Irina-Gabriela Puiu

Coauthors: Denisa Borla Razvan Gligor Paul Sarmasan

Coordinator(s): Medical Doctor Alexandra-Elena Borla

Keywords: TACE hepatocellular carcinoma acute cholecystitis

Introduction: Hepatocellular carcinoma is one of the most common and fatal cancers in the world.
Case Report: We present the case of a 69-year-old patient with a diagnosis of inoperable multicentric hepatocarcinoma, BCLC B for which, considering the performance status, systemic treatment with Sorafenib and local TransArterial ChemoEmbolization treatment is recommended. Objective examination and pre-procedural laboratory tests show: bloating, mild tenderness on abdominal palpation, slightly elevated direct bilirubin and GGT. Post-procedurally the patient presents with intense right upper quadrant pain, pain with lesser intensity throughout the abdomen in association with hypertensive episode (BP=220/133mmHg) and oxygen requirement. The biochemical work-up reveals the presence of inflammatory syndrome with leukocytosis, reacted CRP and PCT, a pancreatic reaction with highly reacted lipase, hepatocytolysis and cholestasis syndrome. Abdominal ultrasound is recommended, but due to significant aerocolia it is difficult to perform. However, it helps in confirming the suspicion of acute pancreatitis, acute cholecystitis by edema of the walls, distention of the cholecyst and presence of pericholecystic fluid, respectively of possible inflammatory pancolitis by the presence of edema of the digestive tract (duodenum, small intestine, large intestine). Subsequently, a CT scan with contrast substance is performed confirming the elements detected on ultrasound, completing the panel by the presence of a bilateral basal pleural collection. It is recommended to stop the patient's enteral feeding and to institute hydro-electrolytic rebalancing treatment, empirical antibiotic therapy (based on possible bacterial translocation and possible infection of the evolving necrotic areas), hepatoprotective treatment, adjustment of antihypertensive treatment, multimodal analgesia, and nasal cannula oxygen therapy with 3L/min to maintain SpO2=98%. In evolution the patient remains clinically stationary, hemodynamically stable, with TAM >65mmHg, decreasing biological samples, reason for which it is decided to discharge him with recommendation of oncological re-evaluation in order to continue the treatment with Sorafenib.  
Discussions: Because of the increased risk of recurrence, TACE is not recommended as a first-line treatment for localised tumours, in which case liver resection techniques are used, but it is the standard of care for patients with multinodular hepatocellular carcinoma and preserved liver function or for patients with inactivated liver cancer who cannot undergo surgery.
Conclusions: Although considered a safe procedure, TACE is associated with several complications, of which acute cholecystitis is the most common. Pulmonary embolism, liver abscess and gastric mucosal injury also outline the picture of post-TACE complications. Acute pancreatitis is less common but is associated with a very high risk.

The Efficacy of Laparoscopic Fowler-Stephens Orchiopexy in the Management of Intra-abdominal Testes: A Case Series from the Pediatric Surgery and Orthopedics Clinic of Târgu Mureș, 2018-2023

First author: Sven-Hubertus Grasshoff

Coordinator(s): Lecturer Zoltan Derzsi , Assistant Professor Zsolt Bara

Keywords: orchiopexy cryptorchidism laparoscopy

Background: Cryptorchidism, or undescended testes, is the most common congenital abnormality in male infants. This condition affects around 3% of full-term births and around 30% of premature boys. Most undescended testicles are palpable but do not fully descend into the scrotum. In 20% of the cases, the tests are non-palpable. One half of these are absent or atrophic while the other half are located intra-abdominal. Non-palpable intra-abdominal testes can lead to long-term complications like fertility problems, increased risk of cancer, torsion, hormonal imbalances, and psychological effects. In most cases of intra-abdominal testes traditional orchiopexy is unfeasible. The 2-Step Fowler Stephens laparoscopic orchiopexy (FSLO) is a surgical method consisting of two stages used in the treatment of intra-abdominal testes. In the first stage, the main testicular vessels are cut using laparoscopy. The collateral circulation of the ductus deferens starts to develop. The second stage takes place after several months involving the mobilization and fixation of the testes into the scrotum. 
Objective: This study focuses on the efficacy of the 2-Step laparoscopic Fowler-Stephens orchiopexy in the management of intra-abdominal testes and highlights the importance of its treatment.  
Material and Method: We examined the clinical and paraclinical results of male patients diagnosed with cryptorchidism who were treated at the Emergency Clinical County Hospital of Târgu Mureș in the Pediatric Surgery and Orthopedics Department from 2018 to 2023.
Results: The retrospective analysis of data from 2018 to 2023 presented a case series of 7 patients with high intra-abdominal testes treated with FSLO. The average age of the patients is 3 years, the oldest being 6 years old. The mean duration between the first and the second intervention was 10 ± 3 months. The main associated anomalies were urological, while also Down syndrome and atrial septal defect were encountered. Most cases involved unilateral left intra-abdominal testes, but two cases of right and one bilateral case were also managed. The average duration of hospitalization per intervention was about 3 days. All the orchiopexies were successfully done. No testicular atrophy or recurrences were noted. 
Conclusions: 2-Step FSLO seems to be an effective approach in managing high intra-abdominal testes. The procedures showed no case of recurrence and have been performed successfully in both unilateral and bilateral cases. Further research is needed due to the lack of long-term data and the small sample size. Additionally, long-term follow-up is necessary to monitor possible complications like fertility problems or malignancies. 

Navigating the Complex Landscape of Stage 4 Pulmonary Adenocarcinoma: A Captivating Five-Year Saga of Targeted Care and Vigilant Follow-Up

First author: Delia-Ioana Răduțiu

Coauthors: Paula-Cristina Matei Mara Oaida Renata Agoston Daniela-Maria Grozea

Coordinator(s): Medical Doctor Alexandru Țîpcu

Keywords: NSCLC oncology radiotherapy

Introduction: Over the past ten years, there has been a groundbreaking transformation in the approach to non-small cell lung cancer (NSCLC), marked by significant advancements in screening, diagnosis, and treatment. The progress in systemic therapy has been largely propelled by the emergence of molecularly targeted drugs, immune checkpoint inhibitors, and anti-angiogenic agents, resulting in markedly enhanced patient prognosis.
Case Report: This case report presents the comprehensive management of a 55-year-old man diagnosed with Stage 4 non-small-cell pulmonary adenocarcinoma with no driver mutations (EGFR-; ALK-). The patient's clinical presentation revealed a challenging scenario with cT4, N0, and pM1 (costal arch X-12mm) staging. The initial therapeutic approach, somewhat contrary to current treatment guidelines, involved upfront surgery, aimed at addressing the primary tumor and the costal metastasis. Following surgery, the patient received antalgic thoracic palliative radiotherapy. After the initial interventions, the treatment strategy incorporated a complex approach. Six total cycles of Gemcitabine 1250mg/m2 and Carboplatin 5AUC chemotherapy were administered to target potential metastatic lesions, followed by a switch to immunotherapy. The patient underwent a sustained five-year course of Nivolumab 240mg q2w (133C), reflecting a surprising sustained disease control. This prolonged immunotherapy regimen aimed to help the patient's immune system to combat cancer cells with enhanced precision. 
Discussions: Current treatment paradigm for NSCLC suggests a stratified approach, based on the disease stage and molecular profile. Early-stage cases are typically managed by surgical intervention or stereotactic radiotherapy, followed by chemotherapy and/or immunotherapy, as indicated by the high-risk features or PD-L1 positivity, respectively. Locoregionally advanced cases benefit from a combination of radio-chemotherapy, chemotherapy and immunotherapy. Metastatic disease is usually treated with upfront chemo-immunotherapy, reserving radiotherapy for palliation of symptoms. If the disease exhibits driver mutations (EGFR/ALK/K-ras etc.), adjuvant targeted therapy takes first place after the local treatment. 
Conclusions: This case stands to challenge, in a way, the current treatment paradigm, underlining the importance of proper local tumor control on one side, and the sequencing of systemic treatment, on the other side.

Time, an important part in bacteriology diagnostic chain-a case report for meningitis

First author: Irina-Gabriela Puiu

Coauthors: Rîpea Alexandra Andreea Stefaroi

Coordinator(s): Assistant Professor Anastasia Simion , Assistant Professor Anastasia Simion

Keywords: bacterial meningitis time antibiotics diagnosis

Introduction: Acute bacterial meningitis is an infectious disease characterized by the presence of meningeal syndrome, inflammation of the leptomeninges and changes in the aspect of CSF. Bacterial meningitis is less common compared to its viral counterpart and presents a more dire prognosis if it is left untreated.
Case Report: We present the case of a 10-year-old patient who presented to the Municipal Hospital in Târnăveni with affected general condition, fever, occipital cephalgia, emesis, rigors. She followed symptomatic treatment without improvement and laboratory tests detected an elevated leukocyte count (93.2% represented by neutrophils), along with increased levels of C-reactive protein (178 mg/l) and high blood glucose levels (150 mg/dl). In the emergency department, the patient underwent a CT scan which revealed a fluid collection occupying the entire left maxillary sinus, but the diagnosis of meningoencephalitis couldn’t be established based on the CT. Infectious Diseases consultation and an MRI were recommended. The patient was transferred to the Infectious Diseases Clinic I. Upon admission, objective examination of the nervous system indicated limited osteotendinous reflexes, positive Brudzinski, meningeal irritation syndrome (limitation of joint movements in the cervical joints). Laboratory investigations showcased the following: cerebrospinal fluid with turbid appearance, a positive CSF Pandy test, no bacterial growth from the CSF sample, a high number of lymphocytes and granulocytes (12288/3), increased protein levels in the CSF. During hospitalization, the patient was treated with Ceftriaxon, Vancomycin, Dexamethasone (as adjuvant in therapy) and Mannitol. Prior to discharge, laboratory tests showed a decrease in the total number of elements (128/3), with 68/3 neutrophils. Also, CSF protein levels and C-reactive protein were much lower than before the initiation of treatment. The outcome was clinically favourable, with remission of febrile syndrome and intracranial hypertension syndrome.
Discussions: Based on the anamnestic data, clinical and paraclinical investigations, a diagnosis of bacterial meningitis was made despite the impossibility of identifying the pathogen. The blood culture collected in the emergency department was free of bacterial growth, as was the CSF sample collected after initiation of antibiotic therapy. This was a favourable case in which the pathogen responded to therapy without showing signs of resistance, but treatment cannot always be given without identifying the bacteria.
Conclusions: Time is an important constant in the treatment of meningitis, which is a medical emergency that must be treated quickly. However, the prioritization of pathogen identification is equally imperative, particularly in instances of uncommon etiologies, to ensure favourable treatment outcomes.

Predictive factors for invasive ventilation in patients with acute exacerbation of chronic obstructive pulmonary disease in the Emergency Department

First author: Suciaghi Bogdan-Marcel

Coauthors: Alexandra-Delia Păcurar

Coordinator(s): Associate Professor Cristian Boeriu , Assistant Professor Andrei Modiga

Keywords: AECOPD APACHE2 HACOR, NIVO invasive ventilation

Background: With 3.23 million fatalities/year, chronic obstructive pulmonary disease (COPD) ranks as the third most common cause of mortality globally. Severe acute COPD exacerbation (AECOPD) patients frequently need ventilatory support in the E.D., making the decision between invasive and non-invasive ventilation (NIV) often difficult to take.
Objective: The purpose of this study was to determine whether scores generally used in intensive care (APACHE2) or scores recently developed specifically for NIV failure (HACOR, NIVO), can be used to identify patients requiring invasive mechanical ventilation.
Material and Method: 74 consecutive patients admitted to the E.D. with AECOPD and who required mechanical ventilation were included in the current analysis. The patients were divided into two groups according to the type of mechanical ventilation used, as follows: Patients in Group 1 received NIV (n=21), while patients in Group 2 required invasive ventilation (n=53). In all patients, APACHE2, NIVO and HACOR scores were calculated upon admission. The data were analyzed using Mann-Whitney test. All continuous variables are presented as median ± SEM. To further evaluate the capacity of these scores to predict the requirement for invasive ventilation, ROC curve analysis was performed. The α value was set at 0.05
Results: Patients requiring invasive ventilation had significantly higher APACHE2 (20.00 ± 0.92 versus 15.00 ± 0.97; p= 0.0005), NIVO (3.00 ± 0.17 versus 2.00 ± 0.32; p= 0.02), and HACOR (7.00 ± 0.79 versus 4.00 ± 0.81; p= 0.001) scores than those requiring NIV. The best cut-off value of APACHE2 score for predicting the need for invasive ventilation was ≥ 17 (sensitivity 71.70%; specificity 66.67%; AUC 0.76; p= 0.0006). For NIVO score, the best cut-off value was ≥ 3 (sensitivity 54.72%; specificity 71.43%; AUC 0.67; p= 0.03), while for HACOR score the best cut-off value was ≥ 5 (sensitivity 64.15%; specificity 66.67%; AUC 0.73; p= 0.002).
Conclusions: The requirement for invasive ventilation can be predicted using the APACHE2, NIVO and HACOR scores that were determined at admission to the E.D.. Early detection of patients exhibiting a predictive value for the need for invasive ventilation can direct the first course of therapeutic action. This can involve the implementation of a more aggressive drug treatment during the early stages of the exacerbation or the simultaneous initiation of early invasive ventilation and drug treatment, to reduce mortality rates. 

Multiple apparent diseases, one common denominator Complex health challenges in a diabetic patient

First author: Giuseppe Avitto

Coauthors: João vitor Lacerda souza

Coordinator(s): Professor Mariana Cornelia Tilinca , Medical Doctor PhD Student Boglárka Varga

Keywords: Type 2 Diabetes Chronic Kidney Disease Severe Depression Dyslipidemia

Introduction: Type 2 diabetes mellitus is considered the most frequent endocrine-metabolic disease, although it remains undiagnosed in almost half of the cases. It is characterized by a deficiency in insulin secretion and insulin sensitivity which leads to altered metabolism of carbohydrates, fats, and proteins. The resulting hyperglycemia can be observed in the fasting state (for increase in hepatic gluconeogenesis), and post-prandial (due to reduced glucose uptake by adipose and muscle cells), which is responsible for the development of micro- and macrovascular complications. 
Case Report: A 74-year-old female presented at the Emergency Department for a myriad of symptoms, including polyuria, polydipsia, visual disturbances, fatigue, weight loss, and paresthesia of lower extremities with a glycemic value of 520 mg/dL. The patient had a history of hypertension and obesity. After admission to the Diabetology Department laboratory findings confirmed severe hyperglycemic dysregulation (HbA1c: 14.5%), stage IIIB chronic kidney disease, severe dyslipidemia. At lower limb examination we found signs and symptoms of peripheral arterial disease of the right lower extremity, and varicose veins. We performed the Beck’s Depression Inventory test which confirmed severe depression. The case requested a multidisciplinary assessment which revealed multiple underlying diseases, among which a giant supraumbilical hernia and stenosis of the right popliteal artery. 
Discussions: Specific symptomatology and a random glycemic value over 200 mg/dL, associated with clinical signs of glycemic decompensation, leads to the diagnosis of diabetes mellitus. Assessing patient characteristics, screening for micro- and macrovascular complications along with the diagnosis of comorbidities are essential at diagnosis. 
Conclusions: Holistic investigation of complex cases is crucial for informed decision-making and to define a suitable treatment plan for the patient. Our patient’s management plan integrates lifestyle recommendations, regular blood glucose monitoring and basal-bolus insulin therapy along with multidisciplinary approaches. It is crucial to emphasize the role of glycemic control, cardiovascular health, acute and chronic complications and psychological well-being in diabetic patients. 

Revealing the malignant nature of an atypical renal cyst using contrast-enhanced ultrasonography. A case report.

First author: Darius Ioan Șerban

Coordinator(s): Lecturer Mirela Liana Gliga

Keywords: CEUS microV wash-out malignant cyst

Introduction: Contrast-enhanced ultrasonography (CEUS) is a non-invasive clinical tool which helps us determine the benign or malignant nature of a complex cystic renal mass. We will present a clinical case with a focal renal lesion that, at first glance, appears to be a simple cyst, but, after CEUS examination, a malignant nature was revealed.
Case Report: A 55-year-old woman with a history of type 2 diabetes, autoimmune thyroiditis, hypercalcemia, hyperparathyroidism and recurrent urinary tract infections came to the Nephrology Department of the Mures County Hospital. She complained of peripheric neuropathy predominant during the night. Laboratory tests revealed positive nitrites in urine, bacteriuria, hematuria, leukocyturia; uACR 121 mg/g, Hg 15.1 g/dL, total calcium 11.4 mg/dL, glucose 108 mg/dL, PTH 145.8 pg/mL. Ultrasound described in the left kidney a transonic lesion suggestive for a cyst and in the right kidney two calyceal stones, 5- and 6-mm length and two focal lesions resembling cortical cysts. One of them, though, had an inhomogeneous content, suspecting an atypical or malignant cyst. Microvascular imaging ultrasound (microV) of the suspected cyst revealed a positive vascular signal located in the periphery and, partially, inside the lesion. Therefore, we decided to do a CEUS examination. We administrated 1,6ml iv contrast solution and after 11 seconds the renal cortex enhanced normally, but the lesion enhanced only at its periphery. The center of the lesion also began to enhance and 20 seconds after contrast's administration the enhancement was uniform with the rest of the parenchyma. The wash-out started 30 seconds after contrast's administration and this strongly suggested a malignant character of the lesion.
Discussions: The 2017 updated guideline for extrahepatic CEUS recommends its use in renal focal lesions with the appearance of atypical cysts Bosniak classes 2F, 3 or 4. Although, renal cysts are very frequent and the presence of two cysts doesn’t usually raise diagnostic problems the characteristics that made us suspicious in this case were the cyst atypical behavior in microV examination and the presence of micro-vascularization in CEUS examination. Those findings together with the wash-out pattern strongly suggest the malignant character of the cyst.
Conclusions: CEUS is an accessible, non-invasive and non-toxic examination, which can differentiate between two focal renal lesions with a similar appearance on ultrasonography, detecting the mass with a highly malignant character.

Correlation assessment of screening tests and comorbidities with Cushing syndrome diagnosis

First author: Francesca Veronica Grieco

Coordinator(s): Assistant Professor Zsuzsánna Réti , Medical Doctor László Szabó

Keywords: Hypercortisolism incidentaloma dexamethasone suppression test comorbidities

Background: Cushing syndrome is a clinical condition caused by prolonged exposure to elevated cortisol levels. This can be due to ACTH-dependent or ACTH-independent causes, such as a pituitary or ectopic adenoma secreting ACTH or adrenal cortisol overproduction, respectively. Screening tests are the first line in the diagnosis of Cushing syndrome. Endogenous hypercortisolism is confirmed by at least two positive first-line tests. Cushing syndrome is often associated with multiple coexisting conditions, including cardiovascular and metabolic disorders. 
Objective: This study focuses on the assessment of screening tests and comorbidities in the diagnosis of Cushing syndrome. 
Material and Method: We examined data from patients suspected of Cushing syndrome and diagnosed with incidentalomas at the Endocrinology Clinic of Târgu Mureş between January and December 2022. This study involved patients who underwent screening tests for hypercortisolism, including an analysis of their comorbidities. Exclusion criteria were represented by the lack of data. Statistical analysis was performed with IBM SPSS Statistics 27, using the Kruskal-Wallis Test, cross-tabulation and Chi-Square Test. Significant if p<0.05.
Results: This study included a total number of 72 patients, 11 males, and 61 females. The mean age at testing was 55 years, and the majority of patients were between 60-70 years (n=30) followed by an age group of 50-60 years (n=17). A total number of 239 tests were performed, with a median of 3 performed tests per patient (min 1, max of 5). 57.74% of the screening tests were positive. We investigated how screening tests such as late-night serum cortisol, late-night salivary cortisol, urinary free cortisol, overnight 1 mg dexamethasone suppression test and two-day low dose dexamethasone suppression test levels correlate with inconclusive diagnoses of Cushing syndrome, ACTH independent and ACTH dependent Cushing syndrome and incidentalomas. We found a strong, significant association between the overnight 1 mg dexamethasone suppression test and Cushing´s diagnosis (p<0.05). No statistically significant correlation (p>0.05) was found in the association of hypertension, diabetes mellitus, obesity, dyslipidemia, osteoporosis, menstrual irregularities, PCOS, hyperandrogenism, pituitary failure, psychiatric abnormalities, and the diagnosis of Cushing syndrome.
Conclusions: Among the analyzed screening tests, the overnight 1 mg dexamethasone suppression test was the only one that evidenced a statistically significant relation with Cushing syndrome diagnosis. Therefore, compared to other first-line tests, it was shown to be the most reliable diagnostic method for the condition. No statistically significant association resulted between the studied comorbidities and diagnosis categories. 

EVALUATION OF THE RELIABILITY AND REPRODUCIBILITY OF DIGITAL MODELS OBTAINED BY INTRAORAL AND DENTAL LABORATORY SCANNING METHODS

First author: Eszter Borbély

Coauthors: Arnelle Gibbs Damiano Musilli Enrica Muggianu Raluca Alexandra Hiebsch

Coordinator(s): Assistant Professor Zsuzsanna Bardocz- Veres

Keywords: Intraoral Scanner, Laboratory Scanner, Accuracy, Precision.

Background: The interest in digital dentistry has increased, however, there has been a lack of thorough study to fully assess various types of scanners using the same set of criteria. Intraoral scanners generate a three-dimensional virtual representation of the oral cavity, whereas laboratory scanning is subject to multiple factors that can impact the precision of the collected data. These digital technologies significantly simplify work processes, improve the accuracy of prosthetic work, and elevate the quality of dental care.
Objective: The study aims to compare five different intraoral, and four different dental laboratory scanners using a standardized set of criteria. The focus was specifically on their performance in accurately measuring alveolar bone resorption.
Material and Method: Four plaster mandibular models were acquired from a simulated jaw with teeth 4.4 and 4.7 prepared with a full-rounded shoulder, with missing teeth (4.5, 4.6) and varying degrees of bone resorption (0, 3, 6, and 9 mm). The correspondent researcher performed a timed digital impression utilizing nine distinct scanners (Intraoral; Trios 3, Medit i700, Helios 600, iTero Element Flex, and Virtuo Vivo. Laboratory; 3Shape E3, Rexcan DS3 Silver, NeWay, and Medit T510). Models were scanned 5 times with each intraoral scanner. Using the obtained STL files, the discrepancies, trueness, and precision in measuring the distances between predetermined points were compared among the scanners using two analysis software. The data was aligned initially using a precise alignment order, refined after using the best-fit alignment approach. The discrepancies between measurements were documented and evaluated. Inferential statistics was performed using GraphPad Prism 8 software, using t-tests for detecting differences between groups. The level of significance was set at 0.05.
Results: The 3D and 2D analyses showed a trend of greater distortion of the impressions in the molar region. Additional discrepancies were detected throughout the scans. The amount of error for each comparison was represented as a spectrum. Green indicating data within the tolerance threshold of 0.05. Scanning discrepancies were noticed in the resorption zone of the comparison models. Statistically insignificant differences in the measured distances were observed. The Rexcan DS3 Silver laboratory scanner showed the quickest scanning times, while Medit i700 the slowest. Conclusions: We observed significant differences in terms of scanning times. Our results reflected differences among scanning devices based on the assessed objective parameters and can aid clinicians in selecting the right scanning devices. Further research is required to analyze the accuracy of available scanners on the market.  

MEDICO-LEGAL ASPECTS IN SEXUAL ASSAULT

First author: Roxana Maria Chitic

Coauthors: Mihai Acon

Coordinator(s): Lecturer Carmen-Corina Radu , Lecturer Roberto Timur Hogea

Keywords: sexual assault rape forensics

Background: Sexual assault encompasses a large variety of undesired, attempted or not, forms of violence, ranging from verbal and sexual harassment, drug and alcohol facilitated sexual relations, to the act of rape itself. It implies the use of coercion, either being explicit, by physical force or through psychological constraint, or implicit, when the victim is unable to freely consent and to defend oneself. This infringement of the sexual autonomy represents a worldwide and long-lasting serious public health issue, which can affect everyone, irrespective of gender and age. Nonetheless, a large number of cases yet remain under-reported.
Objective: This study is aimed at highlighting different patterns of the sexual assault, for instance: age and sex of the victim, traumatic lesion types, number of medico-legal days required, the known or unknown identity of the aggressor, as well as the kind of coercion involved.
Material and Method: By means of descriptive statistics, 27 medico-legal cases of rapes are exposed, which occurred over a span of 2 years (2021-2022), in Mures county, which were collected from the archives of the Institute of Forensic Medicine Targu Mures.
Results: As a result, girls and women are prone to sexual assault, with a percentage of 92,6% (25 cases out of 27), with a median age of 26,4 years. Many of the victims are born in rural areas (74%). 81,48% sought the aid of the authorities the same or the next day after the incident, while the rest were reluctant to act immediately. 55,55% of the victims required medical assistance, and 7,4% presented life endangerment. 40,7% showed lesions eliciting immobilization (wrists, neck, head, and calf areas), and 26% suffered typical areas lesions (inner parts of the thighs, perineum, and breast).77,77% of the victims had a known aggressor, explicit coercion being frequently inflicted (70,37%). In 11,11% cases there were multiple aggressors, and 14,81% of the survivors faced repeated sexual abuse.
Conclusions: As expected, the female gender is subject to most of the sexual assault cases, with clear evidence of bias towards young ones. Often, the aggressor is an acquaintance or an intimate partner, who inflicted injuries on their victims by physical force or by moral constraint.

Methods of monitoring insulin-dependent diabetes mellitus in the age of technology

First author: Maria Albu

Coordinator(s): Assistant Professor Alina Corina Grama

Keywords: T1DM CGM CSII insulin

Background: Type 1 diabetes mellitus (T1DM) is an endocrine disorder in which pancreatic β-cells stop producing insulin, usually due to autoimmune destruction. This leads to hyperglycemia and ketosis. CGM (continous glucose monitoring system) and CSII (Continous subcutaneous insulin infusion system) are modern methods to manage T1D.
Objective: Our main objectives were to group the patients diagnosed with T1D according to age at diagnosis, sex, environment, method of onset, personal pathological and hereditary history, to compare the HbA1c level in patients using CGM/CSII vs classically monitored patients and to identify the impact of modern blood glucose monitoring methods on the quality of life (QoL).
Material and Method: 143 T1D patients in the Pediatric Clinic I of the Târgu Mureș County Emergency Clinical Hospital. A retrospective, observational analytical study, that includes patients admitted between January 1, 2019 and December 31, 2023. The mandatory inclusion criterion is the diagnosis of T1D. 20 (13,98%) of the patients included in the study group use an insulin pump, 18 of them having an augmented pump-sensor system.

Results: Diabetic ketoacidosis (79%) was the main way of onset, compared to the remaining 21% diagnosed following routine medical tests or intercurrents.  Conclusions: CGM and CSII are modern medical tools that determine both the improvement of metabolic control (HbA1c) and increase the QoL in T1D patients.

Pancreatic pseudocysts – revolutionary treatments facing ongoing hardships: a case report

First author: Mihai Alexandru Florescu

Coauthors: Alexia Maria Fodor Dragoș Alexandru Gălățanu

Coordinator(s): Lecturer Ofelia Moșteanu , Lecturer Teodora Atena Pop

Keywords: Pancreatic pseudocyst EUS drainage ERCP

Introduction: Pancreatic pseudocysts (PPCs) have been a topic of debate among surgeons, gastroenterologists, and radiologists regarding their etiology, evolution, and treatment. Often associated with acute or chronic pancreatitis, these accumulations of fluid located in the tissues surrounding the pancreas are sometimes partially or completely encapsulated within the pancreatic tissue itself, thus presenting challenging management.
Case Report: A 55-year-old female patient presented in October 2023 with epigastric pain and nausea. The patient, known to have type 2 diabetes mellitus and class 2 obesity, underwent a cholecystectomy one year prior and was monitored for a PPC, a complication of a severe acute biliary necrotizing pancreatitis episode. On CT examination, the cyst measured 19/13cm and the images showed significant atrophy of the pancreatic parenchyma and splenic vein thrombosis with collateral blood flow. Multiple ultrasound (US) and endoscopic ultrasound (EUS) examinations were conducted, indicating the enlargement of the PPC and raising the suspicion of a Wirsung duct rupture. Magnetic resonance cholangiopancreatography (MRCP) ruled out any communication with the PPC, but the Wirsung duct was still stented during an endoscopic retrograde cholangiopancreatography (ERCP) procedure in December 2023. In January 2024, EUS-guided transmural drainage was performed using two plastic cysto-gastric pigtail stents, improving the patient’s condition. In March 2024, the patient returned for clinical assessment, reporting a weight loss of 10kg without any accompanying symptoms. The pancreatic duct plastic stent was removed. A follow-up CT revealed a significant decrease in the PPC’s dimensions (4 cm). The patient was discharged with pigtail stents still in place.
Discussions: This complex case exemplifies the challenges of treating PPCs due to their volatile and sometimes unpredictable nature. Therefore, many questions arise: When is the optimal time to use EUS and to remove the pigtail stents? Should one opt for a more conventional, surgical approach? Surgical drainage used to be the preferred method for draining PPCs. Thanks to advancements in endoscopic techniques, surgical drainage is now reserved for specific scenarios, such as recurrent PPCs, malignant cyst resection, or symptomatic PPCs that are challenging to access endoscopically.
Conclusions: PPCs are intricate and difficult conditions, yet this case exemplifies the importance of thorough surveillance of PPCs due to their unforeseeable implications. An integrated multi-disciplinary team approach, involving multiple specialists, is crucial to identify the best treatment for each individual patient.

Bile duct strictures – a fine line between benign and malignant. Complications in their rarest form: a case report

First author: Dragoș Alexandru Gălățanu

Coauthors: Mihai Alexandru Florescu Alexia Maria Fodor

Coordinator(s): Lecturer Ofelia Moșteanu , Lecturer Teodora Atena Pop

Keywords: Cholangioscopy Biliary strictures Hematoma Differential diagnosis

Introduction: Biliary epithelial cells possess the capacity to respond to aggressions in multiple ways, resulting in atypical changes such as hyperplasia or the development of biliary neoplasms. A personalized combination of clinical, biochemical, and histological techniques is often needed because benign biliary strictures, despite their non-malignant nature, can mimic malignancies. 
Case Report: This case presents a 76-year-old female patient, transferred from another center in April 2023, complaining of epigastric pain, jaundice, nausea, and vomiting. A previous magnetic resonance cholangiopancreatography (MRCP) detected a 9mm common bile duct (CBD) stricture, which required biopsy and three endoscopic retrograde cholangiopancreatography (ERCP) procedures using plastic stents in April, August (when the patient experienced jaundice and grade I acute cholangitis) and October 2023. The histopathological examinations (HPE) showed no malignancy, and a follow-up endoscopic ultrasound (EUS) revealed an enlarged stricture (17/12mm) and two lymphadenopathies with no signs of malignancy following an EUS-guided fine-needle aspiration. In February 2024, an ERCP and a cholangioscopy were performed to diagnose the nature of the biliary stricture. Biopsies were taken and the biliary stent was removed due to diagnosis of inflammatory CBD stricture. Following the removal of the stent, the patient accused abdominal pain and jaundice, with laboratory findings of sepsis, cholestasis, and hepatic cytolysis. Therefore, another ERCP stent placement was imperative, while the bile culture returned positive for Enterococcus faecium. An abdominal CT revealed an exceptionally rare complication of cholangioscopy: two hepatic hematomas (130/100mm & 52/23 mm). The patient did well with supportive treatment and was discharged after 10 days.
Discussions: This case exemplifies the well documented benefits of ERCP, while also underlining the hardships that may occur even to the most experienced endoscopists. Cholangioscopy and EUS are the preferred modality to establish a diagnosis of biliary stricture malignancy. Should you opt for ERCP and cholangioscopy? Do their benefits outweigh the risks? Our patient suffered an impressive case of hepatic hematomas, with only 61 cases being documented in literature as of 2020. Therefore, debate is still very much present, but its contribution to the evolution of medical practice cannot be denied.
Conclusions: Despite the advancement in radiological techniques when it comes to a differential diagnosis between benign and malignant biliary strictures, bile duct biopsy and fine needle aspiration still uphold their effectiveness. However, considering their low sensitivity, there is a need for a comprehensive medical strategy that includes clinical, laboratory and histopathological data since no single modality is sufficient for a certain differentiation.

Symptoms you should not ignore - underlying appendix cancer: a case report

First author: Alexia Maria Fodor

Coauthors: Dragoș Alexandru Gălățanu Mihai Alexandru Florescu

Coordinator(s): Lecturer Ofelia Moșteanu , Lecturer Teodora Atena Pop

Keywords: Appendix cancer Secondary lesions Treatment

Introduction: Appendiceal neoplasia is rare, making up about 0.5% of gastrointestinal tumors, with an incidence of 6 cases per million annually. It often goes unnoticed and is accidentally identified during appendectomies due to heterogeneous origin and nonspecific symptomatology.
Case Report: A 62-year-old male patient presented with pain in the right hypochondrium and right lumbar regions, increased postprandially, and rectal bleeding with an insidious onset 2 months prior. The patient has a history of Los Angeles Grade A reflux esophagitis, gastroesophageal reflux disease, hiatal hernia, erosive acute duodenitis, hepatic steatosis, and is overweight. An abdominal ultrasound and transient elastography were performed with difficulty because of the adipose tissue, only revealing the preexistent hepatic steatosis, and a colonoscopy was recommended to further investigate. On colonoscopy, multiple colon polyps were found, and an endoscopic polypectomy was performed. Moreover, an appendix tumor was discovered, biopsies were taken, and a CT scan was ordered for staging. Circumferential thickening of the cecum and ascending colon walls and two hepatic secondary lesions were confirmed, measuring 40mm and 58mm respectively, and, while multiple nonspecific lung nodules, calcified lung nodules and a 25mm-wide femoral neck lesion were also found, it is still uncertain whether they are related to the primary tumor. Laboratory findings showed elevated inflammatory markers, slightly elevated carcinoembryonic antigen levels (9.04 ng/ml), while the CA19-9 levels were not detectable.
Discussions: Due to its particular nature, this case raises several imposing questions. How can we prevent further cases of appendix cancer from reaching such lengths? What type of treatment should you opt for, given its heterogenous and multiple origins? Appendectomy and chemotherapy may be performed in cases of localized tumors without metastases. In our patient’s case, depending on histopathological examination, treatment may vary including cytoreductive surgery and hyperthermic intraperitoneal chemoperfusion in the case of mucinous neoplasms. Adenocarcinomas and goblet-cell adenocarcinomas often require right hemicolectomy. Small neuroendocrine tumors are managed with appendectomy, but right hemicolectomy is advised, if there’s a high risk of lymphatic spread.
Conclusions: This case exemplifies the importance of comprehensive evaluation in patients with atypical gastrointestinal symptoms, since they may be the main manifestations of an underlying malignant condition. A thorough personalized treatment strategy is imperative to optimize the outcome due to the rarity of this neoplasia. Also, the advanced staging of this cancer is an example of screening programs failure and underlines the importance of educating patients to seek medical advice as early as possible.

Aspects regarding the activity of students in Medicine in Romania and Italy

First author: Sabina Irina Grecu

Coordinator(s): Lecturer DANIELA-EDITH CEANĂ

Keywords: medical student clinical stage medical education

Background: Practical activities and clinical skills are part of the development of a good future doctor. It is imperative that they be found in the curriculum of any medical university.
Objective: The focal point of this study is the presentation of various practical aspects of clinical activity throughout the years of university and the impact they have on medical students, both from Romania and Italy. 
Material and Method: For this research, we used a questionnaire composed of a number of 29 questions conducted on the platform Google Forms  which was shared online among students at medical schools in Romania and Italy. This is a descriptive, comparative and transversal study. A database was created in the Microsoft Excel program, where responses to the questionnaire were entered, after which the data was homogenized and encoded. We coded the two lots in 1 and 2, the group studying in Italy was coded as lot 1, and the lot doing its studies in Romania was coded as lot 2.
Results: Over 90% of students in group 1 and 72% in group 2 felt they were not satisfied with the way the practical activities are carried out. A statistical difference was obtained with a value of p = 0.008, resulting in students in group 1 being about 20% more dissatisfied with practical activities compared to their colleagues in Romania. 
Conclusions: Even if there are dignified differences between the two lots, there are similarities, both being formed mostly by students who want to actively participate in practical activities, wishing to assimilate as many skills as possible. Simulations of clinical situations or new methods by which they can develop their practical skills, are ideas that could make the clinical stage more captivating for medical students.

Traction Testing of 3D Manufactured Parts

First author: Melisa-Andreea Rîtea

Coordinator(s): Lecturer Paul Răzvan Cazacu

Keywords: PLA Traction testing Infill density 3D Printing

Background: 3D manufacturing is progressing fast, but the knowledge regarding the structural behavior of printed parts is underdeveloped.
Objective: The objective is to determine the strength of 3D manufactured parts to traction forces, involving the application of a progressive load on the specimens and the measurement of the load to which they yield. 10 parts were manufactured and tested this way, each having a different infill density (10% - 100%).
Material and Method: We modeled the parts in Autodesk Inventor Professional 2024, then with the software UltiMaker Cura 5.6.0 we made 10 g-code files, all having set building plate Brim and infill pattern Grid. The printer used is UltiMaker 3, and the material used is PLA (polylactic acid). For the manufacture, 30.19 m of PLA was used, with a mass of 238 g, and the printing time was 13 hours and 9 minutes. When all the tests were printed, we tested them on the DTEC DDW 100H Universal Testing Machine, and the results were displayed in the software: Smart Test. The speed used was 2 mm/min. The results obtained have been translated in the form of graphics in MATLAB.
Results: Based on the chart obtained (which had a quasi-parabolic form) we found that Smax (maximum stress) decreases proportionally in relation to infill density from 10% to 50%, followed by Smax to increase proportionally until it reaches infill density equal to 100%. For infill density equal to 10% Smax is 37.034 MPa, for infill density equals 50% Smax is 22.616 MPa and for infill density equivalent to 100% Smax is 34,767 MPa. These results are obtained by dividing the maximum load by the equivalent sectional area of the ruptured zone. This differs for each individual sample and is calculated considering the percent of the infill area, as well as the shell thickness equal to 0.4 mm made in two layers and which has an infill density of 100%. All the tests had a fragile rupture, so we understood that PLA is a brittle material. There was no area of material yield.
Conclusions: The infill density, as well as the equivalent area of the rupture influence the strength of the manufactured 3D test. It was determined that the optimal infill percents that yield the best strength-to-mass ratio are at the lower-end (10%-20%) and upper-end (90%-100%) of the spectrum. I am going to explore in future studies how these and others influence the strength of the traction tested part.

Exploring the Use of Electrical Signals for Nerve and Muscle Stimulation

First author: Andrea-Erika Szekely

Coauthors: Andreea-Gabriela Zibileanu Șomai Raul-Antonio

Coordinator(s): Professor Zoltán Germán-Salló

Keywords: nerve and muscle stimulation electrical signals mobility problems electronic circuits

Background: The stimu-tens device has a wide range of applicability in various fields, such as physiotherapy and kinetotherapy. The stimu-tens device plays a crucial role in managing pain, improving function, and enhancing quality of life for individuals with various medical conditions.

Objective: To realize a simple but versatile electronic circuit able to generate four types of signals. These signals have different shapes, parameters and different applicability in nerve stimulation process . Also these signals must respect the requirements of nerve and muscle stimulator signals.
Material and Method: To obtain the proposed generator, fundamental electronic circuits as astable oscillators, sine oscillator, monostable, electronic switch are used based both on discrete and integrated electronic devices. Every circuit was designed, simulated and finally implemented in the prototype generator. The wanted signal can be chosen using an analogue multiplexor, after the signal is amplified and applied through electrodes on patient's skin.
Results: The electrical signals mentioned above have been successfully simulated. For the burst signal we used a frequency between 50-100 Hz, the signal has between 2-5 impulses that last 100-500 milliseconds. The break between the bursts is 1-5 seconds. For the second one, which is the monophasic signal with a frequency of 20-50 Hz, the electrical impulses last 100-300 milliseconds. The third one is the pink noise, for this we used a frequency between 50-100 Hz and the impulses last 75 microseconds. Conclusions: The developed setup successfully generates electrical impulses that could be used on patients in order to help alleviate certain mobility problems. The next step for the device is to be used in a clinical trial. As further work the generator can be implemented on a microcontroller based system.

Surgical management of a complex abdominal wall hernia

First author: Alexandra-Maria Tomescu

Coauthors: Cristina Florentina Vladuti Vasilan Ofelia Covasa Alma Maria Petcu

Coordinator(s): Medical Doctor Vlad Făgărășan

Keywords: Complex hernia Occlusion Vacuum assisted closure

Introduction: An abdominal wall hernia is defined as a muscular and fascial defect through which its contents protrude. It may lead to severe complications including intestinal wall ischemia, bowel perforations resulting in sepsis and, ultimately, multiple-organ failure.  Case Report: A 54-year-old female patient known with a twelve-year-old umbilical hernia, primary hypertension, as well as chronic gastritis, presents at the Emergency Room complaining of loss of appetite and a large periumbilical mass with extension into the right flank, irreducible through taxis and associating Celsian signs. The mass is sensitive both spontaneously and upon palpation, without abdominal tenderness. The patient is febrile and hypotensive. 

Discussions:  The particularities of this case consist in the late presentation with a complex hernia complicated by occlusion, perforation, fecaloid abscesses.  Conclusions: A substantial abdominal wall defect escalate the risk of strangulation. Hence, timely intervention is imperative in cases of large hernias complicated by occlusion.

Predictors of re-hospitalization in patients with chronic heart failure

First author: Eduard-Ianis Popa

Coauthors: Dana-Simina Pop Theofana Mihaila

Coordinator(s): Professor Theodora Benedek

Keywords: predictors of heart failure heart failure heart failure readmission heart failure hospitalization

Background: Heart failure (HF) is a prevalent and morbid chronic illness. Despite advances in optimal pharmacologic therapy, patients with HF continue to have significant re-hospitalization rates. 
Objective: The objective of this study was to determine whether demographic, clinical, or physiological variables conferred increased risk of re-hospitalization in a HF population.
Material and Method: Demographic and clinical data were collected from 98 patients admitted with HF to the Cardiology Clinic of Clinical County Emergency Hospital of Targu Mures. The data include the following items: medical history of patients, initial clinical symptoms, precipitating factors of heart failure, preadmission medications, laboratory findings, baseline ECG and echocardiographic findings, in-hospital course.
Results: Mean age of patients was 64.28+/- 14.3 years. The majority of patients were male (60.3%). The most common comorbidity was coronary artery disease (55.3%) followed by diabetes (46.1%) and hypertension (42%). The most prevalent symptom was dyspnea (88.2%) followed by Increasing Fatigue (60%), Angina (60%) and orthopnea (20.1%) At 6 months we had 35 patients with readmission caused by HF(35%). Mean age of patients was 70+/-12.1 years, they were more frequently females and they had a 2 times greater risk for rehospitalization than men. Atrial fibrillation (AF) rhythm was detected in 33.7% of patients and was correlated to readmission(p=0.001). Left ventricular ejection fraction(LVEF) ≤ 35 %, higher NT-proBNP and lower hemoglobin were independent predictors of readmission (p<0.05), also increased length of initial hospital stay has been shown to be a predictor of future readmission (p=0.0021).  
Conclusions: Our data suggest that the female sex has been found to be a predictor of re-hospitalization, as well as the presence of AF, lower LVEF, higher NT-proBNP, lower hemoglobin, and the length of hospital stay.

EVALUATING THE RISK OF ANEMIA AMONG MEDICAL STUDENTS AT UMFST UNIVERSITY

First author: Lorincz Bernadette Cecilia

Coordinator(s): Professor Monica Tarcea

Keywords: Anemia diet nutrition health

Background: Anemia represents the decrease in the amount of hemoglobin within red blood cells, which transport the oxygen necessary for various metabolic processes and ensure the optimal functioning of all organs. Some types of anemia can be prevented through a varied and healthy diet. Demanding study programs and stressful situations often lead medical students to adopt an unhealthy lifestyle and make inadequate dietary choices, thereby inducing anemia. Objective: The objective of this study was to obtain data regarding the habits, dietary choices, and diets of Medical students at UMFST University in Târgu Mureș, in order to determine the correlation between diet and anemia, as well as to promote healthy lifestyle. Material and Method: Material and Method: 81 medical students were recruited, of which 27% were General Nursing students, 37% were General Medicine students, and 36% were Nutrition and Dietetics students. A questionnaire consisting of 36 questions regarding lifestyle, diet, food choices, and food combination methods was used, distributed online through the Google Forms platform. Prior to completing the questionnaires, participants were asked to provide consent for completing the surveys while ensuring their anonymity. Students with forms of anemia other than iron-deficiency anemia were excluded from the study. Results: The results indicate a correlation between the students' diet (food sources, frequency, or quantity of consumption) and the parameter of serum iron levels, with statistically significant values obtained, distributed according to the students' specialization and corresponding study program. Conclusions: Conclusions: These results suggest that diet is the influencing factor in the occurrence of anemia (in the absence of a genetic or metabolic cause), and that an adequate diet can support an optimal state of health.

Listeria monocytogenes meningitis with cloudy CSF

First author: Rîpea Alexandra

Coauthors: Octavian Alexandru Elisei Andreea Stefaroi

Coordinator(s): Assistant Professor Tudor Fleseriu , Professor Anca-Meda Văsieșiu

Keywords: Meningitis Meropenem Listeria monocytogenes Cloudy CSF

Introduction: Listeria monocytogenes meningitis is a severe, life-threatening infection transmitted through contaminated food, primarily affecting individuals with weakened immune systems. L. monocytogenes is a gram-positive bacillus that mainly thrives in improperly processed animal products, posing a significant health risk through its morbidity and mortality. 
Case Report: A 58-year-old patient with history of tuberculosis (TB) is admitted for persistent headache, vertigo, confusion, and high fever which appeared over the course of one day. On clinical examination, the patient showed ataxia and positive bilateral Babinski sign. Laboratory findings suggested a bacterial infection and the brain CT scan was normal. Subsequently, an emergency lumbar puncture was performed, revealing cloudy cerebrospinal fluid (CSF) with an opalescent appearance. The CSF analysis showed 646 predominantly fresh red blood cells/μL, 682 leukocytes cells/μL, CSF glucose was 26 mg/dL and 3558 mg/L CSF proteins.

Discussions: Although Ampicillin is known to be the first-line treatment in L. monocytogenes infections, in this particular case the bacteria seemed to be more susceptible to Meropenem. Another particularity resided in the fact that the macroscopic appearance of the CSF was cloudy, which is rarely seen in this etiology. 
Conclusions: The presented clinical case highlights the effectiveness of antibacterial treatment and the importance of rapid diagnosis of Listeria monocytogenes meningoencephalitis even in the presence of factors that would typically rule out this diagnosis.

DIAGNOSTIC CHALLENGES IN IDENTIFYING POLYCYSTIC OVARY SYNDROME (PCOS)

First author: Giulia Corongiu

Coordinator(s): Assistant Professor Robert Tiucă , Lecturer Ionela Pașcanu

Keywords: PCOS Hyperandrogenism Anovulation Differential diagnosis

Introduction: Polycystic ovary syndrome (PCOS) is a common endocrine and metabolic disease affecting reproductive-aged women. PCOS is generally characterized by cystic morphology of the ovary associated with hyperandrogenism and ovulatory dysfunction. However, there are several PCOS phenotypes that can mimic other diseases. The clinical impact is primarily on the reproductive function, but it can frequently associate concomitant metabolic and psychological comorbidities.
Case Report: An 18 years-old patient was evaluated for signs and symptoms of hyperandrogenism and menstrual irregularities. Paraclinical investigations were performed and they revealed an increased level of androstenedione (4.170 ng/mL), prolactin (518.2 uUI/mL), DHEA (436.8 ug/dl), 17-OH-progesteron (6.78 nmol/L) with normal thyroid function, levels of testosterone, estradiol, progesterone, IGF-1, and Cushing’s screening tests. An ACTH stimulation test was needed to rule out late-onset congenital adrenal hyperplasia, which was subsequently negated based on the measured level of stimulated 17-OH-progesterone (6.51 ng/mL). Utero-ovarian ultrasound was performed and showed the presence of more than 10 follicles between 4-6 mm in diameter in both ovaries. Therefore, by excluding other causes of hyperandrogenism and menstrual irregularities, a diagnosis of PCOS phenotype A was established and treatment with combined contraceptive pills was initiated, the patient having afterwards a favorable clinical response.
Discussions: When considering PCOS as diagnosis for a patient it is essential to exclude other possible causes for hyperandrogenism and ovulatory dysfunction. Non-classical congenital adrenal hyperplasia (NCAH) should always be considered a differential diagnosis in reproductive-aged women, as its symptomatology presents with menstrual irregularities and hyperandrogenism signs, mimicking PCOS. The exclusion of NCAH is performed with measurement of 17-OH progesterone and in some cases ACTH stimulation test is needed. Other pathologies that should be exclude before PCOS diagnosis are Cushing’s syndrome, acromegaly, androgen-secreting tumors, hyperprolactinemia, and thyroid dysfunctions, due to the possible similar clinical presentation, but different therapeutic approach. All these conditions were excluded in our patient based on blood tests and imagistic findings, therefore a diagnosis of PCOS phenotype A was established. Considering the patient’s age and desire to not get pregnant, treatment with combined contraceptive pills was started which eventually improved her quality of life by diminishing the signs and symptoms of hyperandrogenism.
Conclusions: PCOS is consider one of the most common causes of hyperandrogenism and anovulation in reproductive-aged women. However, its diagnosis is not straightforward and excluding other conditions that can mimic PCOS is an essential part in the optimal management of this disorder.

STUDY OF THE TIGHTENING PROCESSES OF SURGICAL SCREWS WHEN FIXING ORTHOPAEDIC PLATES

First author: Maria-Alexandra Moldovan

Coordinator(s): Professor Liviu Moldovan

Keywords: bone fracture fixation plate surgical screw

Background: The scientific literature highlights a number of studies on the behaviour of bone structures during operations. However, orthopaedic biomechanics requires new experiments to understand how metal plates are attached to bone structures.
Objective: Study of the influence of kinematic parameters during fixation of metal plates using surgical screws.
Material and Method: Beef bones were selected from different specimens and of different densities, from young and older specimens respectively. The same type and number of screws were inserted into the bones and the same driving holes were drilled. Tightening forces were measured using a torque wrench.
Results: Following the torque measurements, the critical points of the screw connections, the threshold at which the screw tightening is effective and the maximum tightening torque, after which bone degradation occurs, were detected. Characteristic curves for bones of different densities were plotted.
Conclusions: Bone density is an important characteristic influencing the effective clamping parameters for plate attachments using surgical screws.

Concordance Between Clinical and Histopathological Diagnosis: Case Reports of Misdiagnosed Bronchopneumonia

First author: Elena Alina Porcaru

Coauthors: Bogdan Adrian Mușat Cristina-Laura Radoni

Coordinator(s): Lecturer Laura Chinezu

Keywords: bronchopneumonia misdiagnosis forensic autopsy microscopic evaluation

Introduction: Bronchopneumonia involves acute inflammation of the bronchi with inflamed patches in nearby lung lobules. It is usually bacterial, but can also be due to a viral or fungal infection. Common pathogens include Staphylococcus aureus, Klebsiella pneumoniae, Haemophilus influenzae, Streptococcus pneumoniae, Pseudomonas aeruginosa, and Escherichia coli, with rare cases involving viruses like SARS-Cov-2 or bacteria like Actinomyces.
Case Report: This report describes two male patients, both 67 years old, who died shortly after the admission to the Emergency Room in Târnăveni, Mureș. Notably, both patients received different clinical diagnoses than those determined during the forensic autopsy. One patient, admitted for hypothermia, was initially diagnosed with a fatal heart attack leading to the drop in body temperature. In contrast, the other patient's cause of death was presumed to be a heart attack and further investigations raised suspicions of a neoplastic lung tumor. During the autopsy for the first patient, the macroscopic diagnosis provided no relevant information except for a pancreatic tumor. The microscopic examination revealed the presence of a massive confluent bronchopneumonia associated with an acute pulmonary edema and acute pancreatitis instead of a neoplasm. In the second case, at the macroscopical examination, a massive pulmonary tumor associated with pneumonia were seen. The microscopic analysis revealed an abscessed bronchopneumonia with bacterial colonies suggestive for Actinomyces infection.
Discussions: Overlooking complex medical conditions like bronchopneumonia may lead to misdiagnosis during clinical evaluation. It is important to allow enough time per patient to complete the anamnesis and the physical examination. Further investigations such as blood tests and radiological imaging may offer clues for a better presumptive diagnosis and provide enough data to discuss the differential one. Moreover, the histopathology examination completes clinical assessments by offering insights into the underlying pathology. Forensic autopsy is equally important because it uncovers the true cause of death and corrects diagnostic errors.
Conclusions: These contrasting clinical presentations underscore the challenges in accurately diagnosing and managing complex medical conditions, emphasizing the critical importance of comprehensive evaluations and thorough post-mortem analyses in elucidating the underlying pathology.

Case presentation: Chlamydia in the respiratory tract

First author: Mara Constantinescu

Coauthors: Chinezu Iulia-Andreea Sorana Gorea Sara Murărescu Demenciuc Nicolae

Coordinator(s): Lecturer Corina Budin

Keywords: Chlamydia thracomatis pleural tap pleural consolidation pneumonia

Introduction: Chlamydia is a bacterium that predominantly causes genital infections, but there are also bacterial strains that can reach the respiratory tract causing pneumonia, such as Chlamydia pneumoniae, that presents with symptoms similar to other types of pneumonia, such as: persistent coughing, fever, dyspnea, discomfort in the chest or fatigue. Some individuals may experience only mild symptoms or may be asymptomatic.  Case Report: We present a case of a 52-year-old patient presenting the following symptoms: dry cough, marked fatigue and low-grade fever. He performs a rapid influenza test at home, which comes back positive, and he begins treatment with antivirals, experiencing a slight improvement in symptoms. However, after a few days, his general condition worsens, and he presents to the Infectious Diseases Clinic. Subsequently, he is transferred to the Pneumology Clinic for specialized investigations and treatment. The patient undergoes a chest X-ray revealing pulmonary consolidation in the left lung field and a small amount of left pleural effusion. A pleural tap is performed, evacuating 30+60ml of fluid which is sent to the laboratory for examination. Laboratory tests reveal the following pathological values: the presence of antibodies in the blood: anti Chlamydia trachomatis IgA, anti Chlamydia pneumoniae IgM and IgG, and antibodies to Mycoplasma pneumoniae IgM ang IgG and an increased number in leukocytes, which is a sign of infection. The pleural fluid was exudative, with elevated protein levels and low glucose levels, indicating the transformation of the fluid into empyema, showing that the infection has spread from the lung tissue into the pleural space. 
Discussions: Chlamydia pneumoniae and Mycoplasma pneumoniae can reach the lungs through inhalation: when an infected person coughs or sneezes, the bacteria can enter anoter person’s respiratory tract and reach the lungs, leading to infection. However, it is uncommon for Chlamydia trachomatis to be found in the lungs and the transmission route is uncertain in this case, as it can generally be picked up from contaminated surfaces or from unprotected sexual activities. 
Conclusions: The patient is diagnosed with pneumonia caused by the three bacteria present in the lungs, and antibiotic treatment begins with Gentamicin and Cefuroxime. However, due to a slow favorable evolution, the antibiotic treatment is changed to Meropenem, along with mucolytics, antipyretics and systemic corticosteroid therapy. Consequently, the patient's clinical evolution is favorable, with stable hemodynamics, and he is planned for discharge with outpatient antibiotic and reevaluation by a pneumologist if needed. 

Exploring the Complexity: Unraveling the Mysteries of PBC-AIH Overlap Syndrome

First author: Mihai Pătruț

Coauthors: Victor Tărîță Miculi Diana Maria Sorana Gorea

Coordinator(s): Assistant Professor Krisztina Szalman Borbala

Keywords: Primary biliary cirrhosis Autoimmune hepatitis Overlap syndrome Disease progression

Introduction: Primary biliary cirrhosis (PBC) is a complex autoimmune liver disorder marked by the gradual deterioration of bile ducts within the liver, whereas autoimmune hepatitis (AIH) entails immune-mediated damage to hepatocytes. The medical scenario becomes intricate when both diseases coexist, resulting in a cluster of symptoms that intersect and correlate, suggesting the onset of PBC-AIH overlap syndrome. Emphasizing the vital necessity of continuous, long-term surveillance to assess disease development and consequences is imperative, particularly in patients with co-occurring autoimmune liver disorders.
Case Report: A 43-year-old female initially presented six years ago with nonspecific symptoms of fatigue and pruritus, accompanied by elevated alkaline phosphatase levels. 

Discussions: The presented case epitomizes the intricate interplay between autoimmune liver diseases and the nuanced challenges encountered in their management. PBC-AIH overlap syndrome represents a complex challenge in diagnosis and treatment, necessitating a holistic approach encompassing both medical and surgical modalities. This disease spectrum is dynamic as thrombocytopenia and hernias evolve.
Conclusions: Managing PBC-AIH overlap syndrome necessitates personalized, multidisciplinary care to optimize patient outcomes. Patients in this category need close monitoring, fast medical assistance when needed, and a deep understanding of how the disease progresses in order to be treated adequately.

ASSESSMENT, MONITORING, AND MAINTENANCE OF THE SLAP 2 LESION

First author: Maria-Nicoleta Pop

Coordinator(s): Lecturer Dan-Alexandru Szabo

Keywords: shoulder SLAP rehabilitation glenoid labrum

Background: The rehabilitation expert has a substantial problem when dealing with pathology of the glenoid labrum (SLAP lesion) owing to the intricate nature and diverse range of etiologic variables associated with these injuries. The glenoid labrum is a fibrocartilaginous structure surrounding the edge of the glenoid fossa. It stabilises the glenohumeral joint by contributing approximately 50% of the glenoid depth. It is an attachment site for the glenohumeral ligaments and the long head of the biceps tendon. The symptoms of "SLAP" pathology can be confused with different diagnoses, such as impingement, pain in the acromioclavicular joint, bicipital tendonitis, or glenohumeral instability. Clinical examination frequently shows underlying glenohumeral instability. A positive O-Brien test is also suggested for the diagnosis. The method of choice for diagnosis of SLAP lesion is arthroscopy. Currently, there are no studies for conservative treatment of this type of lesion. The standard treatment is surgery.
Objective: To carry out the conservative maintenance plan of the lesion so that at the time of medical re-evaluation, the athlete does not have complications or an advanced type of lesion, and the symptoms are reduced.
Material and Method: The present work is a case study of a competitive volleyball player during the competitive period. In correlation with her training, the rehabilitation plan will be adapted so that the patient's pain and instability are mainly relieved. Still, at the same time, her sporting activity is affected as little as possible, working in particular on the range of motion and muscular strength of the shoulder girdle muscles - to reduce the effects of the SLAP injury.
Results: Results will be presented during the Marisiensis International Scientific Congress because the study is still ongoing.
Conclusions: The study's findings will be presented at the Marisiensis International Scientific Congress with the results.

Centric Relation Recording: A comprehensive approach to restore severe dental wear

First author: Iulia Taflan

Coauthors: Raluca Alexandra Hiebsch

Coordinator(s): Associate Professor Carmen Ioana Biris , Assistant Professor Manuela Taut

Keywords: centric relation occlusion JIG Lucia rehabilitation

Introduction: In the fields of Prosthodontics and dental occlusion, in particular, the idea of centric relation is important. It describes the position of the mandible in the temporomandibular joint with the disc appropriately positioned between the condyles when they are at their most superior and anterior positions against the articular eminence. This case study emphasises the value of centric relation recording in a case of significant tooth wear that required complex restorative care, which entailed complete rehabilitation at an increased vertical dimension of occlusion. Centric relation recording techniques remain relevant in contemporary dentistry, offering dentists the opportunity to improve treatment outcomes and diagnostic precision.
Case Report: This case study provides a comprehensive workflow for improving function and aesthetics in a 45-year-old patient with severe and uneven dentition wear. The workflow focused on restoring the patient's occlusal function and stability in the correct centric position. An assisted centric relation recording using JIG Lucia was used to create a full occlusal splint for muscle relaxation. After 2 months of wearing it at night and after 2 weeks of check-ups, the certified centric position was used to mount the models into the semi-adjustable articulator to design an analogue bimaxillary wax-up. The wax-up was tested as a mock-up. After validation, twenty-two tooth-supported monolithic zirconia restorations and four implant-supported monolithic zirconia restorations were placed.
Discussions: A good integration in terms of function and aesthetics was obtained with both restorations. Marginal fit, insertion and centric occlusal contacts were achieved together with an aesthetic integration of restorations. Both types of restorations were able to achieve static and dynamic occlusion.
Conclusions: Severe dental wear can be treated using a comprehensive approach consisting of correct positioning of the maxilla and mandible using mounted models in the proper hinge axis position guided by centric relation correct recording. This approach enhances treatment results and diagnostic accuracy in contemporary dentistry.

AGGRESIVE MEDULLARY THYROID CARCINOMA: A CASE REPORT WITH EMPHASIS ON THE MULTIDISCIPLINARY APPROACH

First author: Andreea-Oana Pop-Bandrabula

Coordinator(s): Lecturer Maria-Ionela Pascanu , Assistant Professor Robert-Aurelian Tiuca

Keywords: medullary thyroid cancer multidisciplinary team endocrine malignancy

Introduction: Medullary thyroid carcinoma (MTC) accounts for 4% of thyroid carcinoma and originates from parafollicular cells, secreting mainly calcitonin. If caught in an early stage, MTC generally has a good prognosis; however, aggressive MTC can metastasize to regional lymph nodes, liver, bones, and lungs.
Case Report: A 67-year-old woman presented to the emergency department complaining of generalized physical weakness and weight loss of about 20 kg in a three-month period. Chest x-ray revealed multiple disseminated reticulonodular opacities. She was admitted to the Pulmonary Clinic where a thoracoabdominal computed tomography was performed, revealing a tumor or adenopathy in the right thyroid lobe area. A biopsy was done which indicated malignancy, possibly MTC or small cell lung cancer metastasis. She was referred to the Endocrinology Department where the thyroid ultrasound revealed a right macronodule EU-TIRADS V and multiple lymph nodes with suspicious features. Highly elevated calcitonin and carcinoembryonic antigen supported MTC diagnosis. After ruling out an associated pheochromocytoma/paraganglioma (PPGL), an extensive surgical intervention was recommended but hindered by tumor invasion into the esophagus and tracheal conduct. Therefore, a second lymph node and tumor biopsy were performed which confirmed the diagnosis of MTC, suggesting a spindle cell variant.
Discussions: The expertise of the endocrinologist plays a very important role in diagnosing and managing MTC. The multidisciplinary team for MTC will usually also include a surgeon, oncologist, and pathologist. In this case, a pneumologist was also involved as part of the differential diagnosis, given the initial presentation of the patient. Each one of the specialists played a key role in managing the case and getting to the final diagnosis. This is particularly important, since only several treatment options are available for patients with aggressive MTC. The spindle cell variant is an extremely rare presentation of MTC with few cases reported in the literature with a poor prognosis if surgical treatment fails to control it. Its diagnosis relies on histological morphology and immunohistochemical staining which differentiate it from other similar lesions.
Conclusions: The correct and early diagnosis of MTC, the staging of disease, and the exclusion of associated syndromic diseases are pivotal to plan an efficient therapeutic strategy. Building a multidisciplinary team is the best approach, where every specialist’s expertise contributes to obtaining the most favorable possible outcome, especially in aggressive cases.

The importance of Cardiac Computed Tomography Angiography in guiding interventional procedures – A Case Report

First author: Cezar Pântea

Coauthors: Olga Furtună Corina Pal

Coordinator(s): Professor Theodora Benedek , Medical Doctor Emanuel Blîndu

Keywords: Cardiac computed tomography angiography Percutaneous coronary intervention Multimodal imaging coronary artery disease

Introduction: The use of cardiac computed tomography angiography (CCTA) in guiding interventional procedures provides a comprehensive assessment of atherosclerotic plaque extension, volume, and composition. Prior to percutaneous coronary intervention (PCI), CCTA offers the opportunity to address certain drawbacks associated with the traditional invasive coronary angiography (ICA), such as vessel foreshortening and difficulties in selecting the ideal projections. This is particularly significant in cases involving ostial lesions and chronic total occlusion.
Case Report: We present the case of a 67 years-old female, with a history of hypertension, inferior myocardial infarction with revascularization on right coronary artery (RCA) with multiple stents and subsequent intrastent restenosis, type-2 diabetes-mellitus, presenting to our hospital for her periodic follow-up. The patient reported frequent episodes of angina pectoris and fatigue. Assessing the patient’s history, it was decided to undergo CCTA which revealed the following: RCA stents were non-opacified with contrast, but distally contrast was present, presumably from collateral vessels, left anterior descending artery (LDA) with a significant low attenuation plaque and left circumflex artery (LCX) presenting total occlusion at the proximal level. The patient was admitted to the Cardiology Clinic and underwent an ICA. The ICA confirmed the CCTA findings: occluded stents on RCA, LCX presenting chronic total occlusion and LDA having a 80% stenosis distally to first septal artery, ramus intermedius, a low caliber vessel, presenting total occlusion. It is worth noting that the LDA is giving collaterals for distal part of RCA and LCX. Considering that the LDA was the last patent vessel, the PCI started with approaching the proximal plaque on LDA, with a stent implantation and restoration of vascular lumen. Next, on RCA, the stents were difficultly passed with hardened guidewire followed by intrastent balloon dilatation, resulting in restoration of the vascular lumen. After PCI the patient’s symptoms visibly improved and after five days, she was discharged with double antiplatelet therapy, high dose statin, antihypertensives and SGLT2-inhibitor and diabetic medication.
Discussions: The case of our patient underlines the complexity and challenges encountered in PCI, particularly in instances of difficult anatomical features and intrastent occlusion. Through a multimodal imaging techniques approach involving interventional cardiology, CCTA imaging, and clinical expertise, the team effectively managed the complex coronary artery disease. 
Conclusions: Our case highlights the pivotal role of CCTA in guiding interventional procedures for complex coronary artery disease. By providing detailed anatomical information, CCTA enabled precise planning and navigation during PCI, overcoming challenges associated with traditional invasive coronary angiography (ICA).

Shortness of breath and Chilaiditi sign in a radiotreated laryngeal cancer. What’s the diagnosis?

First author: Sara Murărescu

Coauthors: Mara Constantinescu Mesaros Radu

Coordinator(s): Lecturer Corina Budin , Medical Doctor Nicolae Demenciuc

Keywords: Laryngeal cancer Diaphragm paralysis Chilaiditi sign

Introduction: Left diaphragm elevation and Chilaiditi sign are radiological findings, associated with the upward displacement of the left hemidiaphragm and the malposition of the bowel that can affect the respiratory function, if the interposed colon exerts pressure on the diaphragm. Both serve as diagnosis indicators pointing towards the possibility of left diaphragmatic paralysis, leading to respiratory compromise and complications. 
Case Report: The 70-year-old patient had a laryngeal cancer in 2021, that was locally radiotreated and the doctors performed a tracheostomy as well. This year the patient was subjected to some routine medical tests, such as thoracic radiography and blood tests. After these investigations, the radiology report showed left hemidiaphgram elevation due to moderate/severe aerocoly with left basal pulmonary consolidation, likely atelectasis. Also, it didn’t described any pleural fluid being present and his heart was enlarged. After the blood tests his mean erythrocyte hemoglobin levels were low, monocytes and eosinophils were slightly higher. The total creatine phosphokinase was over the normal limit as well. Considering the results of these investigations, the final diagnosis appeared to be either pneumonia or diaphragmatic rupture.
Discussions: The particularity of this case revolves around the surgical interventions and local radiotherapy he underwent in his battle with laryngeal cancer. Although chances are low, performing a tracheotomy can lead to the excision of left phrenic nerve and radiotherapy can cause inflammation and fibrosis in the tissues surrounding the tumor, which may lead to compression or injury of it, causing the paralysis of the left side of diaphragm. After the X-Ray examination, the presence of Chilaiditi sign was identified, potentially caused by the left diaphragmatic paralysis. Pain distinguishes Chilaiditi syndrome from asymptomatic colonic interposition, which is termed as Chilaiditi sign. Although this sign is primarily used for the differential diagnosis between pneumoperitoneum and pseudopneumoperitoneum associated with chronic constipation, colonic aerocoly and intestinal malposition, it can also be beneficial in the pulmonary evaluation of patients presenting with respiratory symptoms. The decrease in mean erythrocyte hemoglobin levels can be attributed to compromised lung function and impaired gas exchange. Diaphragmatic paralysis can cause atrophy of the affected side, as a result, there may be ongoing damage of muscle fibers, leading to the release of creatine phosphokinase into the bloodstream.  
Conclusions: The conjunction between radiographic signs of diaphragm elevation and potential iatrogenic injuries of the phrenic nerve can support the diagnosis of diaphragmatic paralysis, underscoring the importance of considering these and the past medical history. 

A Journey Through Complexities: Managing Genetic Syndromes, Congenital Heart Disease, Suprarenal Insufficiency and Laryngomalacia in Pediatric Medicine

First author: Olga Furtună

Coauthors: Cezar Pântea

Coordinator(s): Medical Doctor Daniela Toma

Keywords: Smith-Magenis Syndrom Congenital Heart Disease Laryngomalacia Suprarenal Insufficiency

Introduction: Smith-Magenis syndrome (SMS) is a complicated developmental condition that affects several organs. The condition includes behavioral and cognitive issues, congenital abnormalities like tracheobronchial anomalies, cardiovascular malformations, distinctive facial features, bone deformities, intellectual impairment and sleep problems.
Case Report: We present a 1-year-and-3-month-old child under observation since prenatal due to a complex heart defect, initially thought to be Tetralogy of Fallot. Molecular analysis of amniotic fluid revealed evidence of Smith-Magenis-syndrome. Postnatally, the child was diagnosed with double outlet right ventricle Fallot-type (DORV), ductal dependent pulmonary circulation with severe pulmonary valve stenosis, persistent arterial duct with a left-right shunt and a right aortic arch. She underwent initial surgery for a systemic-pulmonary shunt from the right carotid artery to the right pulmonary artery and arterial duct ligation. Hemodynamic instability led to a reoperation involving shunt repositioning to the ascending aorta and thrombectomy. The patient associates sternal dehiscence due to defective ossification from respiratory effort and grade II congenital laryngomalacia diagnosed by ENT, leading to chronic respiratory insufficiency requiring oxygen support. At 3 months, she was hospitalized with hypoglycemia, severe hyponatremia, respiratory acidosis, acute bilateral pneumonia and hepatocytolysis. An endocrinology consultation was sought due to frequent hypoglycemic episodes, prompting suspicion of primary partial adrenal insufficiency and initiating oral hydrocortisone treatment. In November 2023, a cardiac MRI to assess pulmonary anatomy revealed normal dimensions of the pulmonary ring, trunk, and arteries, as well as coronary arteries following a normal trajectory. Currently, the patient is admitted to the Pediatrics ward due to congestive heart failure ROSS III, DORV, systemic-pulmonary shunt, Smith-Magenis-syndrome with mild psychomotor development issues and adrenal insufficiency under treatment. Grade II laryngotracheomalacia necessitated oxygen therapy until November, showing clinical improvement thereafter. The case underwent further review in the cardio-surgical meeting with a plan for secondary correction with preservation of the pulmonary ring, and the decision for surgical intervention was endorsed. Post-interventionally, the patient was left with residual injuries: moderate pulmonary stenosis, large infundibular stenosis, pneumonia and pneumothorax under treatment.
Discussions: Smith-Magenis-syndrome is a multifaceted clinical condition that complicates child development. In our case, there were common clinical manifestations but compared to others, the facial features were not as pronounced, intellectual deficit was mildly affected, and there was multiorgan involvement.
Conclusions: Accurate evaluation of cognitive, developmental and behavioral impairments, along with the severity of systemic abnormalities is crucial for effective management of Smith-Magenis-syndrome. As there is no curative treatment for this syndrome, periodic multidisciplinary consultations are recommended.

Spontaneous retroperitoneal hematoma (SRH) associated with iliac vein rupture leading to cardiac arrest

First author: Hassan Abdullatif

Coauthors: Rudainah Ameen Ahmer Syab Ali Obada Albunni Muhamad Abdullatif Hassan

Coordinator(s): Professor Boeriu Cristian

Keywords: Spontaneous retroperitoneal hematoma Rupture of the iliac vein Iliac vein thrombosis

Introduction: Spontaneous retroperitoneal hematoma (SRH) is a rare but potentially life-threatening condition marked by blood accumulation in the retroperitoneal space. Causes include, renal tumor rupture, aortic aneurysm rupture, trauma, and spontaneous iliac vein rupture. In our case, SRH was linked to iliac vein rupture concurrent with deep vein thrombosis (DVT), further complicated by cardiac arrest. 
Case Report:  A 62-year-old female patient, without significant medical history, brought in Emergency Department by ambulance, in cardiac arrest. Upon arrival she presented pulseless electrical activity, prompting resuscitation. Patient was transferred from the Reghin Hospital with suspicion of femoral neck fracture and DVT in the left lower limb, evident by edema. Pulmonary embolism (PE) was considered as the likely cause of cardiac arrest, but the nurse who accompanied her, reported abdominal pain during the transfer, prompting an abdominal ultrasound (US) during resuscitation to check for internal bleeding, which was negative. A cardiac US to assess for PE couldn't confirm or rule out PE. She had a severe metabolic acidosis despite fluid resuscitation and NaCO3 administration and a decrease in haemoglobin by 3g/dl was observed on repeat analysis 20 minutes after initiation of resuscitation manoeuvres. The patient's husband denied any trauma. Return of spontaneous circulation was noted after 30 minutes and a thoracic CT was conducted, ruling out PE. However, a contrast-enhanced abdominal CT revealed massive SRH associated with thrombosis of the inferior vena cava, iliac vein, femoral vein on the left side. Vascular surgeon was consulted. Upon exploration in the operating room, massive retroperitoneal hematoma that was ruptured into the peritoneal cavity, initially suspected to originate from the psoas muscle, was found. The hematoma was surgically evacuated and the patient was transferred to the intensive care unit. Unfortunately, she died couple of hours later. However, subsequent examination in the morphopathology department revealed it was secondary to iliac thrombosis, which had ruptured, leading to the retroperitoneal hematoma.  
Discussions: Diagnosing and management of SRH is challenging due to its rarity and complexity. In our case, the patient's arrival in cardiac arrest, with limited medical history made the diagnosis more difficult.
Conclusions: A patient with concurrent life-threatening thrombosis and haemorrhage presents a challenge in both diagnosis and management. In our case despite successful resuscitation and recognition of the two life threatening pathologies, due to the late presentation, the outcome was unfavourable.

The silent struggle : a case of asymptomatic severe hepatomegaly

First author: Daria-Maria Damian

Coauthors: Radu Farcas

Coordinator(s): Medical Doctor Simona Mihaela Grad

Keywords: hepatomegaly liver metastasis colonic cancer

Introduction: Cardiovascular symptoms often lead patients to seek medical attention, yet occasionally, such presentations reveal unexpected underlying pathologies. Case Report: We present a case of a 64-year-old patient who initially presented to the general practitioner with dyspnoea and asthenia. The physical examination showed hepatomegaly, with a liver span of 20 cm, and a following cardiology consult disclosed sinusal tachycardia. In this context, the patient was recommended a gastroenterology consult. Further assessment revealed severe hepatomegaly, with a palpable liver up to the level of the left hypochondrium, respectively the right iliac spine, with a liver of hard consistency, and irregular contour with sharp edge, that prompted further exploration. The serological tests showed a moderate microcytic anemia, cholestasys, a very high level of Carcinoembrionar Antigen (CEA) and a negative Fecal Occult Blood Test (FOBT). Liver ultrasonography indicated numerous hypoechoic and hyperechogenic lesions of 1-4 cm in size and undilated intrahepatic bile ducts, suggesting a differential diagnosis of hepatocellular carcinoma or metastasis. A subsequent computed tomography (CT) scan revealed an infiltrative tumor formation in the right hemicolon, near the ileo-cecal valve, with distant adenopathy, peritoneal carcinomatosis and extensive hepatic metastases. Additionally, acute segmental and subsegmental pulmonary thromboembolism was identified. The successive colonoscopy identified the tumor on the ascending colon and the biopsy of the lesions showed moderately differentiated colonic adenocarcinoma. Discussions: The advanced stage of colon cancer was not expected given the patient's mild and non-specific symptoms, including lacking a change in bowel habits or abdominal pain. This case underscores the significance of meticulous evaluation in the face of seemingly unrelated clinical manifestations, presenting the relevance of thorough investigative strategies, as well as broad differential considerations and the importance of the colon cancer screening in the general population. Conclusions: Early recognition and interdisciplinary collaboration are pivotal in optimizing patient outcomes, particularly in cases involving metastatic malignancies, where timely intervention and screening programs can significantly influence disease trajectory and treatment efficacy.

Exploring Behaviour Guidance Methods and Techniques in Paediatric Dentistry

First author: Alyssa Boothe

Coauthors: Enrica Muggianu Antonella D’Andrea Arnelle Gibbs Raluca Alexandra Hiebsch

Coordinator(s): Associate Professor Oana Elena Stoica

Keywords: Behaviour guidance Dental anxiety Children

Background: Managing behavior in pediatric dentistry is crucial for successful dental treatment and patient comfort. With a growing emphasis on minimizing stress and anxiety for young patients, pediatric dentists increasingly rely on a blend of pharmacological and non-pharmacological behavior guidance techniques to facilitate dental procedures and ensure positive experiences. 
Objective: This study aimed to explore the prevalence and efficacy of behaviour guidance techniques among paediatric dentists, focusing on both pharmacological and non-pharmacological methods. The objective was to identify trends in usage based on dentist experience, patient characteristics, and the perceived effectiveness and challenges of these techniques. 
Material and Method: A comprehensive questionnaire was distributed to 150 paediatric dentists with varying levels of experience. The survey included questions on familiarity with, and frequency of use of, behaviour guidance techniques, as well as perceived effectiveness, challenges, and training received. Statistical analysis was performed using IBM SPSS Statistics, with significance set at p<0.05.
Results: Of the respondents, 75% reported a high familiarity with non-pharmacological techniques, with Tell-Show-Do (82%), positive reinforcement (76%), and distraction (69%) being the most commonly used. Pharmacological methods were employed less frequently, with 40% of dentists not using them at all. Among those who did, nitrous oxide was the most popular choice (60%). The use of restraint or protective stabilization was rare, with 90% of respondents using it "Rarely" or "Never". Dentists with over 10 years of experience were more likely to use a broader range of techniques and reported higher effectiveness in managing paediatric patients' behaviour. Challenges identified included parent resistance, especially towards pharmacological methods, and difficulty in managing highly anxious children. Training in behaviour guidance techniques during dental education was positively correlated with confidence and diversity in technique usage.
Conclusions: Non-pharmacological behaviour guidance techniques remain the cornerstone of paediatric dental practice, with a strong emphasis on Tell-Show-Do, positive reinforcement, and distraction. Pharmacological methods are less frequently used, reflecting a cautious approach to their application. The study highlights the need for enhanced training in behaviour guidance techniques within dental education and continuing professional development, to equip dentists with a wide array of effective strategies for managing paediatric patients. Further research into parent perceptions and acceptance of these techniques could inform better communication strategies and increase treatment cooperation.

Anatomical-Clinical Correlations of Helicobacter pylori Infection

First author: Diana-Alexandra Amărinei

Coordinator(s): Professor Simona-Maria Bățagă

Keywords: Helicobacter pylori Endoscopy Histopathology

Background: Helicobacter pylori is a gram-negative bacillus that colonizes half of the world’s population. Through means of host immunity evasion and tissue injury mechanisms, the pathogen is responsible for the development of chronic gastritis, peptic ulcer disease, gastric cancer, and non-gastrointestinal diseases. Objective: The first objective is to determine the prevalence of Helicobacter pylori infection in patients undergoing upper gastrointestinal endoscopy. The second objective is to compare symptoms, endoscopic appearance, and histopathology results between Helicobacter pylori negative and positive patients and to establish if the macroscopic appearance influences the microscopic aspect of the gastric mucosa in the Helicobacter pylori positive population. Material and Method: From 2019 to 2023, 7219 patients had been subjected to gastroscopic evaluation in the gastrointestinal endoscopy unit of the Emergency County Hospital of Târgu Mureș from which 2640 patients underwent upper gastrointestinal biopsy sampling. The presence of Helicobacter pylori infection was confirmed by histopathologic examination of 453 patients. Data analysis was carried out using the Microsoft Excel 365 and Epi Info GraphPad InStat 3 softwares, applying the Chi-square test with a level of significance of 0.05. Results: The prevalence of Helicobacter pylori infection over the course of 2019-2023 was 17.41% with a decrease in trend over the years and an increase with the age of the patients. 47.02% of H. pylori positive patients belong to rural areas (p=0.0145). In terms of endoscopic findings, in the Helicobacter pylori positive population: 23.87% were diagnosed with chronic gastritis (p<0.0001), 25.17% presented evidence of erythematous gastritis (p<0.0001), 14.79% presented gastric erosions (p<0.0001). Gastric ulcers were present in 17% of patients (p=0.0004), and duodenal ulcers were present in 16.56% of patients (p<0.0001). GERDS was found in 14.57% of patients (p=0.0463) and 5.96% of patients were diagnosed with duodenitis (p=0.0267). The histopathologic exam of the gastric tissue reveals that 14.79% of H. pylori positive patients developed glandular atrophy (p<0.0001). 24.5% of the H. pylori positive patients developed intestinal metaplasia and 2.64% were found with dysplasia of the gastric mucosa but with no significant association (p>0.05). Conclusions: Helicobacter pylori infection is associated with older patients from rural areas and is a powerful risk factor for the presence of gastritis lesions, gastric and duodenal ulcers, and glandular atrophy. The positivity rate of Helicobacter pylori shows a decrease in trend over the last five years.

A rare case of volvulus caused by intestinal obstruction with a foreign body

First author: Ioana Tripon

Coauthors: Mihnea-Adrian Tudor Larisa Simon

Coordinator(s): Lecturer Adrian Tudor

Keywords: volvulus foreign body small bowel diverticulum

Introduction: Small bowel volvulus(SBV) is the torsion of the small bowel and its mesentery, and it is a medical emergency. It is categorized as primary or secondary type. Primary SBV is defined as torsion of a segment of the small bowel at the mesentery basis without any evident underlying cause; secondary SBV occurs in the presence of an acquired condition, such as congenital malrotation, postoperative adhesions, and diverticular disease.
Case Report: In this paper, we present the case of an 80-year-old male patient who came to the emergency department with diffuse abdominal pain, nausea, and vomiting. From the personal pathological history, we note the cholecystectomy in 2009, hypertension, and peripheral polyneuropathy. The objective examination revealed a distended abdomen, above the xipho-pubic plane, very sensitive at palpatory examination. Abdominal CT examination revealed intestinal jejunal loops depleted of semifluid content with a luminal diameter of 3 cm and only minimal aerial content, sketching 2 small hydroaeric levels; diverticulums on a small segment of the jejunum, and multiple colonic diverticulosis throughout. It was decided that the patient needed medical-surgical care. The surgical intervention began with exploratory laparotomy followed by the sectioning of the bridle that was caused by post-operatory adhesions. The adhesions contributed to the formation of SBV. Since the intestine was viable detorsion was needed. During the intervention, a compact foreign body of spherical shape was discovered in the small intestine and removed. The foreign body revealed itself after extraction as chicken bones.
Discussions: The fibrous adhesions may have originated from previous surgery and/or inflammation induced by the multiple diverticulum found along the patient’s bowel. The adhesion bands caused obstruction in the small bowel and promoted the unusual formation of the mass of bones that fortunately did not perforate the intestine. Clinical presentation of volvulus is usually nonspecific unless an acute small bowel obstruction occurs, which in this case was most likely caused by the foreign body.
Conclusions: In summary, we presented a case of small bowel volvulus that may be categorized as the secondary type. Early surgical treatment is essential for small bowel volvulus and we should raise suspicion for small bowel volvulus when a patient displays symptoms such as upper abdominal pain, vomiting, and tenderness.

Heart broken twice: a case of recurrent Takatsubo cardiomyopathy

First author: elad cendorf

Coordinator(s): Medical Doctor Elad Cendorf

Keywords: Cardiology cardiomyopathy Broken heart syndrome

Introduction: Takotsubo syndrome is a rare acute cardiac crisis event that frequently is headed by a stressful trigger. In our case, patient had both emotional (first event) and physical trauma (second event). Classically, emotional or physical stress triggers an excessive sympathetic nervous system stimulation responsible for TTC.
Case Report: A 53-year-old woman with a past medical history of diabetes, hypertension, persistent atrial fibrillation on anticoagulation and resolved takotsubo cardiomyopathy (TTC) 2 years ago presented with 2 days of dyspnoea, fever and dysuria. 
Discussions: Takatsubo cardiomyopathy (TTC) is a rare entity and has classical echo findings. 

Conclusions: Clinical significance of recurrence of TTC is not clear due to sparse literature and probable under reporting. But there is increasing evidence that TTC is not a benign disease as various complications like ventricular arrythmias, cardiogenic shock has been reported. Knowledge about rare cardiac entities and their complications is of utmost importance for timely diagnosis and management.

Ulcer Suprainfection with Alcaligenes faecalis: Diagnosis and Management

First author: Hera Valentina-Alexandra

Coauthors: Bălănescu Elena-Georgiana Eduard-Ionuț Iordache Emilia Grosu Orlando Sorin Ardelean

Coordinator(s): Assistant Professor Anca Cighir

Keywords: #alcaligenesfaecalis #ulcer #microbiology #infection

Introduction: Alcaligenes faecalis, a Gram-negative bacteria commonly sourced from soil, water, sewage and occasionally from clinical samples. It is a nonfermentative, nonencapsulated, oxidase-positive, catalase-positive and facultatively anaerobic bacteria, meaning it can grow in both the presence and absence of oxygen. Although typically of low pathogenicity, it may induce opportunistic infections, particularly in individuals with compromised immunity or underlying health issues, leading to diverse manifestations such as urinary tract infections, respiratory tract infections, wound infections, or bloodstream infections. Transmission commonly occurs through droplets and direct contact, such as via nebulizers and ventilation apparatus. 
Case Report: We present the case of a 70-year-old female, known to have a history of multiple cardiovascular comorbidities (peripheral arterial disease, severe ischemic heart disease, severe stenosis of the internal carotid artery, hypertension) and a right hallux amputation. She was admitted to the general surgery department for an ulcerative lesion of the lower limb, from which purulent discharge was collected and sent for microbiological testing. Subsequently, the specimen was cultured on standard media including blood agar, lactose agar, Sabouraud dextrose agar, and Mannitol salt agar. Two pathogens were isolated - Methicillin-Resistant Staphylococcus aureus (MRSA) with Macrolide-Lincosamide-Streptogramin B inducible resistance (MLSBi) strains of Staphylococcus aureus, along with non-fermenting Alcaligenes faecalis. Biochemical characteristics were studied for the identification of Alcaligenes faecalis, and automatic identification using Vitek 2C system (Biomerieux) was performed.
Discussions: Chronic limb ulcers are difficult to heal and create a suitable environment for colonization by opportunistic pathogens like Alcaligenes faecalis. Despite Alcaligenes faecalis not typically being present in such infections, an initial MRSA infection may have facilitated the favorable environment for its colonization, thereby complicating the patient's condition. Improper ulcer management or compromised immune systems elevate the risk of secondary infections, including suprainfections with Alcaligenes faecalis. Susceptibility testing relies on standard methods such as disk diffusion or minimum inhibitory concentration (MIC) determination. Nonetheless, the susceptibility profiles can exhibit significant variability across various strains. Proper wound management entails thorough debridement and localized antibiotic therapy.
Conclusions: Despite severe underlying health conditions predisposing the patient to infection with Alcaligenes faecalis, favorable evolution was observed with appropriate wound care, infection control measures, and comorbidity management.

CO-LOCALIZATION OF TPPP/p25 PROTEIN AND α-SYNUCLEIN IN THE RETINA AND OPTIC NERVE

First author: Tomoni Ștefan

Coordinator(s): Lecturer Robert Gabriel Tripon , Lecturer Florina Vultur

Keywords: TPPP/p25 α-synuclein retina optic nerve

Background: Tubulin polymerization promoting protein (TPPP/p25) is present in the retina, optic nerve and brain, in oligodendrocytes and in neural networks rich in dendrites and axons. TPPP/p25 protein localization was evident inside cellular bodies, nucleus and in the cytoplasm of cell extensions. α - Synuclein is expressed mainly in the dopaminergic neurons in the midbrain and in nerve cells of the central nervous system, at the level of presynaptic nerve endings. A study showed the absence of α-synuclein from the optic nerve under physiological conditions. But the same study found the presence of α-synuclein in the optic nerve in patients with synucleinopathies. α-Synuclein is endogenously present in all cell layers of the retina. 
Objective: This study aims to examine possible co-localization in the retina and optic nerve of this two proteins, based on images from previous studies. 
Material and Method: We analysed available published images of α - synuclein from scientiffic literature and unpublished - own images of TPPP/p25, in order to compare the localisation of this two proteins. The images were obtained using confocal microscopy and immunofluorescent labelling, or transmission electron microscopy (TEM) and immunogold labelling.
Results: TPPP/p25 protein is localized in amacrine cells of the inner nuclear layer (INL) and in ganglion cells from the ganglion cell layer (GCL). Also, TPPP/p25 shows a characteristic 3 stratified display in the inner plexiform layer (IPL). This protein was also present in oligodendrocites of the optic nerve. α-synuclein showed immunofluorescent labelling in cells in the INL and GCL, close to the IPL, and cells of the optic nerve. 
Conclusions: Based on a rigorous evaluation of the retina and optic nerve on available confocal and TEM images, we can conclude with a high degree of confidence that the two proteins are co-localized in amacrine cells, ganglion cells and in the 3 layered stratification of the IPL. Co-localization of these proteins may form a hallmark protein cluster in synucleinopathies.

From Cushing Syndrome to Central Corticosuprarenal Insufficiency: Case Report

First author: Daria-Marisa Gordan

Coauthors: Milu Claudia Emanuela Ioana Grecu Ancuta Giurgi

Coordinator(s): Professor Maria Ionela Pașcanu

Keywords: Cushing adrenalectomy glucocorticoids

Introduction: Cushing Syndrome is a disorder characterized by chronic exposure to elevated levels of cortisol, a hormone produced by the adrenal glands arising from various causes. On the other hand, central corticosuprarenal insufficiency refers to a medical condition characterized by the lack of cortisol production due to dysfunction or damage to the pituitary gland, alternatively termed secondary adrenal insufficiency, alongside impairment to the hypothalamus known as tertiary adrenal insufficiency. 
Case Report: Our patient, a 45-year-old woman, presented with stage 2 hypertension, a 10-kilogram weight gain over the past 6 months, facial flushing, generalized edema, fatigue, and bradymenorrhea. Subsequent to an overnight dexamethasone (DXM) 1mg suppression test and urinary free cortisol analysis, hypercortisolism was documented. Following this, suppressed levels of adrenocorticotropic hormone (ACTH) suggested autonomous cortisol production independent of ACTH stimulation. Furthermore, an abdominopelvic CT scan unveiled a solid nodular mass measuring approximately 30-25 mm on the left adrenal gland. Following the investigations, the conclusive diagnosis was ACTH-independent Cushing's Syndrome, with the recommended treatment being unilateral adrenalectomy. Subsequently, the patient developed adrenal insufficiency due to suppression of the hypothalamic-pituitary-adrenal axis, necessitating replacement therapy with Prednisone 5mg/day postoperatively.
Discussions: Given that the CT scan revealed a mass with a density exceeding 10 Hounsfield Units, the anticipated diagnosis leaned towards adrenal carcinoma. However, subsequent histopathological examination revealed a corticoadrenal adenoma concomitant with a myelolipoma, likely accounting for the observed hyperdensity. Additionally, the functionality of the hypothalamic-pituitary-adrenal (HPA) axis has not been restored even six months post-surgery, as evidenced by the latest laboratory findings.
Conclusions: Adrenal insufficiency frequently occurs following adrenalectomy; however, it is anticipated that the hypothalamic-pituitary-adrenal (HPA) axis will regain function within a year. During this period, glucocorticoids are typically the preferred treatment option.

THE LINK BETWEEN LIPOPROTEIN(A) AND ACUTE CORONARY SYNDROMES IN PATIENTS WITH DIABETES

First author: Ana Popoaia

Coauthors: Ioana-Patricia Rodean Vasile-Bogdan Halațiu Andreea-Oana Pop-Bandrabula Cristina Maria Rad

Coordinator(s): Professor Theodora Benedek

Keywords: Diabetes mellitus acute coronary syndromes (ACS) lipoproteina(a) hsCRP

Background: Acute coronary syndromes (ACS) represent one of the main causes of mortality and morbidity worldwide, with their incidence continuously increasing due to associated risk factors. A risk factor that has recently come to the attention of the public is lipoprotein a [Lp(a)], which has been shown to be an important predictor of ischemic coronary disease. However, the role of Lp(a) in the etiopathogenesis of ACS in patients with diabetes mellitus (DM) is not yet fully known.
Objective: The study aims to underline the link between Lp(a) and ACS in individuals with DM.
Material and Method: The study included 196 consecutives patients admitted into the Cardiology Department of Emergency Clinical County Hospital Târgu Mureș with ACS, who underwent percutaneous coronary interventions. The patients were divided into two groups according to the presence of DM - Group 1, 109 patients without DM, and Group 2, 87 patients with DM. For all patients serum level of high sensitive C reactive protein (hsCRP), Lp(a), triglycerides (TG) were also assessed. 
Results: Patients with DM were significantly younger compared to those without DM (60.17 ± 7.03 vs 55.54 ± 14.36, p = 0.004), with no difference in terms of gender distribution (p=0.25), but the smoker status was more frequent found in patients without DM (p=0.008). Also, it was observed that patients with DM present a significantly higher inflammatory level (2.21 ± 0.35 mg/dL vs 5.64 mg/dL ± 0.75, p = 0.002) and triglyceride values (153.40 ± 20.68 mg/dL vs 239.90 ± 19.10 mg/dL, p<0.0001). Moreover, the Lp(a) seric levels in group 2 were significantly higher compared to group 1 (0.15 ± 0.09 g/L vs 0.33 ± 0.05 g/L, p<0.0001). 
Conclusions: Patients with concomitant ACS and DM are younger and showed a more pronounced serum Lp(a) level with a more exacerbated inflammatory status, while patients without DM were more prone to present the traditional risk factors for ACS.

Diagnostic and Management Challenges of Medullary Thyroid Carcinoma in Pediatric Patients with Inherited MEN2A Syndromes

First author: Anna Szentgyörgyi

Coauthors: Delia-Ioana Suciu

Coordinator(s): Medical Doctor Lia-Oxana Usatiuc

Keywords: multiple endocrine neoplasia type 2A medullary thyroid carcinoma prophylactic total thyroidectomy RET proto-oncogene

Introduction: Multiple endocrine neoplasia 2A (MEN 2A) is an inherited dominant syndrome due to specific RET proto-oncogene mutations characterised by medullary thyroid carcinoma (MTC), adrenal pheochromocytoma and hyperparathyroidism. Molecular genetic diagnostics are currently allowing familial types of MTC to be detected at an asymptomatic stage and surgery thus to be performed at a time when the prognosis is good. The current report aims to highlight the importance of appropriate monitoring of patients with hereditary MEN 2A syndrome as well as the importance of reasonable timing for prophylactic thyroidectomy in a paediatric patient with MTC.
Case Report: We present the case of a 5-year-old male patient with a family history of MEN2A syndrome and metabolic syndrome who was admitted to our department for excessive weight gain and hypertension. Physical examination revealed an overweight patient (96.4th BMI percentile), cervical and axillary acanthosis nigricans and arterial hypertension (BP>95th percentile). Biochemical investigations revealed elevated basal and post-calcium stimulation test calcitonin levels, normal serum, and 24h-urine metanephrines levels and normal PTH levels. Thyroid ultrasound described a marked hypoechogenic area with an ill-defined margin and slightly visible intranodular vascularisation but no calcifications. 18F-FDOPA PET/CT did not describe local or distant metastases. Findings were overall consistent with MTC and the patient underwent total thyroidectomy. Histopathological examination confirmed the diagnosis of in situ MTC. Postoperatively the patient received long-term thyroid replacement therapy and the follow-up included thyroid ultrasound evaluation of residual disease, calcitonin and thyroglobulin levels, fractionated metanephrines and PTH every 6 months. DNA analysis of our patient and his brother, who had no endocrinopathies, confirmed the diagnosis of MEN2A by a mutation at codon 634 of the RET proto-oncogene. 
Discussions: Nearly all patients with MEN2A have either C-cell hyperplasia (CCH) or MTC, but the incidence of these manifestations depends on the underlying RET mutation. Even though our patient was not tested for RET gene mutations preoperatively, the MEN2A family history, high calcitonin levels and imaging findings were considered sufficient for the surgical indication. Even though thyroidectomy is associated with a higher morbidity rate in pediatric patients, in this case, it was necessary to prevent macro-invasive MTC, lymph node involvement and distance metastases.
Conclusions: MTC is the most common cause of death in MEN2A patients, its early diagnosis through regular screenings and the optimal timing for prophylactic thyroidectomy are crucial. Genotype-phenotype correlation in MEN2A familial syndromes has a strong variability even in patients with the same mutation. 

Paraphrenia: The middle ground

First author: Maria-Silvia Oprisiu

Coauthors: Georgiana-Elena Niculica Valentin-Adrian Oarga

Coordinator(s): Assistant Professor Andreea Sima-Comaniciu

Keywords: paraphrenia schizophrenia delusional ideas

Introduction:  Paraphrenia represents a complex presentation characterized by episodes of hallucinatory psychoses intertwined with persistent delusions, notably featuring persecutory themes and megalomaniacal ideation. Systematized paraphrenia is a frequent clinical form of the illness, with late onset, occurring after the age of 35, featuring insidious onset, delusional interpretations, and hallucinations through the phenomenon of triple automatism (ideo-verbal, sensory, and psychomotor).
Case Report: The aim of our report is to present a rare case of paraphrenia. Our 46-year-old patient, previously diagnosed with depressive antecedents at the age of 21, sought evaluation at the psychiatric clinic due to a clinical presentation marked by delusional-hallucinatory symptoms. The onset of the illness was insidious, in 2020, against a situational background, when the patient presented in the emergency service with the following symptoms—allo and autopsychic disorientation; persecutory delusional ideas, suspiciousness, interpretability, bizarre behavior consistent with delusional ideation, and the diagnosis of paranoid delusional disorder was established, with a prescription for antipsychotic treatment. The following year, due to non-compliance with treatment, the patient presented in emergency room of psychiatric clinic, with an exacerbation of previous symptoms, along with physical and verbal heteroaggressiveness towards family members, consistent with delusional ideation, and a tendency towards social isolation. These symptoms are characteristic of schizofrenia, but following these episodes, the patient adhered with antipsychotic and antidepressant treatment and the symptomatology has mostly remitted.
Discussions: Upon the multiple reevaluations of mental state, it was observed that the initial delusional-hallucinatory symptomatology, accompanied by visual hallucinations, is effectively managed and the negative symptoms that characterize schizophrenia were absent. Paraphrenia is a rarely met diagnosis, not because it is such a rare disease, but because very often it passes as a diagnosis of schizophrenia, due to an insufficiently thorough analysis of the symptoms. 
Conclusions: Unlike schizophrenia, paraphrenia is characterized by a slow progression, with preserved lucidity, intellectual capacity, and appropriate contact with reality, alongside the interference of delusional nucleus and hallucinations.  

Depression and organic diseases

First author: Valentin-Adrian Oarga

Coauthors: Maria-Silvia Oprisiu Georgiana-Elena Niculica Mihai-Alexandru Ghircoiaş

Coordinator(s): Assistant Professor Andreea Sima-Comaniciu

Keywords: Depression Stroke brain tumor

Introduction: Depression is a biochemical disorder with genetic components and characterized by various subtypes, with its primary symptoms being sadness, pessimism, anhedonia, micromanic ideas, fatigue, asthenia accompanied memory impairment, psychomotor slowing, including thinking, speaking and motor activity.
Case Report: The psychiatric ward received in the emergency room a 68 years old patient, known with cerebral vascular accident with hemiparesis almost completely recovered, type 2 diabetes mellitus requiring insulin and a history of depression for several years and with an outpatient treatment adhered to positively. The psychopathological symptoms of the current episode were dominated by: depressive mood (motivated by the suicide of the daughter-in-law three weeks before) , generalized anxiety, micromanic ideas of self-devaluation, worthlessness, generalized hypoprosexia with hyperprosexia focused on the theme of the daughter-in-law’s death, hypomnesia, apathy, asthenia, decrease in motivation and voluntary activity, insomnia, inappetence. In the first day of hospitalization, the patient also displayed the following symptoms: bradyphrenia, short periods of verbal incoherence, mild dyshartria, tangential answering to questions, motor aphasia. Following the neurological consult and the investigations conducted (cranial CT), a spontaneous left cerebral hypodense lesion accompanied by circumferential edema (with a compression effect on the left ventricular temporal horn) was detected in the left temporal and left cerebral regions.
Discussions: It’s interesting to compare the similarities between a major depressive episode, a poststroke condition and the symptomatologiy given by a brain tumor, such as the psychomotor sluggishness, which is part of anhedonia, part of the vegetative symptoms, impairment of attention control, cognitive flexibility or working memory. Patients with a history of mental disorders are often examined superficially from the point of view of physical health because some symptoms due to organic diseases can be covered or can be confused with the symptoms of mental illness.
Conclusions: The symptoms of depression can vary considerably in intensity and manifestation, and can include a wide range of physical and cognitive symptoms which can be caused or mimic a variety of other diseases making the diagnosis more difficult because of an availability bias.

Age-related changes in lip anatomy: lip projection to E-line

First author: Andra Elen Popa

Coauthors: Alessandra Galeone Roberto Fiori

Coordinator(s): Lecturer Adrian Ivanescu

Keywords: lip anatomy aging E-line

Background: Age-related alterations in lip anatomy, morphology, and physiological characteristics are crucial factors in estimating age based on facial features, as documented in numerous studies. However, while the majority of research has concentrated on the elongation of lips, lip thinning and changes in oral commissure position with aging, there is a notable scarcity of evidence regarding the anterior projection of the lips to the E-line and their relation to the naso-mental angle.
Objective: The purpose of this study was to investigate age-related differences in lip position relative to Ricketts' aesthetic plane, also known as the ”E-line” Also, to investigate age-related naso-mental angle and collumela-labial angle changes and how this correlates with anterior lip projection. Material and Method: 208 female subjects were included in this study. The inclusion criteria were: age over 20, no previous aesthetic treatments in the lower face, and presence of complete natural arches or prosthetically restored arches with dental bridges. The study population was stratified into 3 age categories as follow: Group 1 comprised individuals aged 20-39, Group 2 included individuals aged 40-59, Group 3 consisted of individuals aged 60 and above. Each subject was photographed using a Canon camera, and the obtained photographs were uploaded into the 3D imaging system VECTRA H2 (Canfield Scientific, USA). Lip projection was evaluated by measuring the distance (mm) from a reference plane E-line (Ricketts’ plane) to the most prominent point of both the upper and lower lip. Also the software automatically measured columella-labial angle and naso-mental angle. The results were statistically analyzed using descriptive statistics and correlation tests.
Results: The distance from the most prominent point of the upper lip to E-line was smaller in younger patients than in elderly and increased with aging. The same results were observed regarding lower lip position to E-line in the 3 study groups. Also there was a correlation between anterior lip projection and naso-mental angle. The value of naso-mental angle did not change significantly with aging. There were no significant correlations between columella-labial angle and anterior lip projection.
Conclusions: The results confirm the hypothesis that aging in oral region comes together with some anatomical changes, including retrusion of both upper and lower lip, partially due to soft tissue changes and partially due to bone remodeling. 

Lipoxins as Potential Therapeutic Mediators in Diabetes-Associated Atherosclerosis

First author: Ivan Bergo

Coordinator(s): Assistant Professor Ylenia Pastorello

Keywords: diabetes mellitus atherosclerosis specialized pro resolving lipid mediators lipoxins

Background: Diabetes mellitus type 2 (DMT2) represents a disorder of glucose homeostasis, characterized by inadequate insulin secretion and resistance (IR) to insulin action in target tissues. The subsequential chronic hyperglycemic state leads to stimulation of a pro-inflammatory milieu, a crucial factor in mediating atherogenesis in all its stages and progression to macrovascular complications of DM, namely diabetes-associated atherosclerosis (DAA). Lipoxins (LXs) are eicosanoid-derived specialized pro-resolving mediators (SPMs), endogenous molecules which, through activation of several pathways, have been proven to restore homeostasis and promote inflammation resolution. Provided the inflammatory implications in “athero-progression”, utilization of LXs in modulation of DAA development is contemplated here.
Objective: This work aims to assess the potential therapeutic role of LXs in blocking and reversing atherosclerosis associated with DMT2.
Material and Method: An extensive English literature search was conducted on PubMed and Google scholar on 23.03.2024. The selected articles were published between 2010 and 2024 and presented the keywords “diabetes mellitus”, “atherosclerosis” “specialized pro resolving lipid mediators”, and “lipoxins”. A total of 15 articles were examined within this work, including a novel study for each therapeutic approach.
Results: Aspirin creates an endogenous mimetic of LXA4, aspirin-triggered lipoxin A4 (ATL), by cyclooxygenase 2 acetylation. A prospective clinical trial investigating the association between systemic inflammation, insulin resistance (IR) and incidence of peripheral artery disease (PAD) and vein graft stenosis showed that ATL levels were significantly decreased in PAD patients (1,06+/-0,81 ng/ml), as opposed to the control group (1,72+/-1,08 ng/ml). Moreover, ATL inhibited vascular smooth muscle cell (VSMC) chemotaxis, important in atherogenesis, via modulation of the platelet-derived growth factor (PDGF) receptor activation, in human saphenous vein SMC cultures. Treatment with LXA4 or Benzo-LXA4 of diabetic Apo−/− murine models significantly attenuated aortic plaque development. 6-week administration of LXA4 or Benzo-LXA4 was effective in decreasing progression of established atherosclerotic lesions- diabetic+vehicle (19,22+/-2.01%) versus diabetic+LXA4 (12.67+/-1,68%) and diabetic+Benzo-LXA4 (13,19+/-1,97%)- with a 30% reduction in aortic arch plaque burden.
Conclusions: LX treatment demonstrated its efficacy in modulation of atherogenesis and regression of established DAA. Further human studies investigating LX therapeutic potential must be carried out in order to introduce these agents in future treatment paradigms. 

Risk factors and management of periprosthetic femoral fractures after total hip arthroplasty

First author: Vasiliu Maria Magdalena

Coauthors: Melissa Zapartan Vlad Florin Tantos

Coordinator(s): Professor Tudor Sorin Pop , Medical Doctor Lorand Vitalis

Keywords: Periprosthetic fractures Total Hip Arthroplasty Vancouver Classification Osteoporosis

Background: Periprosthetic fractures (PFs) present a significant challenge in post-arthroplasty management, primarily in cases of total hip arthroplasty (THA). Constituting approximately 20% of PF occurrences these fractures pose considerable concerns requiring extensive study. Identified etiologies encompass osteoporosis and osteopenia, non-cemented fixation techniques, females, and the activity levels of older adults. The heterogeneity of fracture types and subsequent surgical outcomes necessitates a personalised approach to treatment.
Objective: We aimed to assess radiological changes and identify prevalent risk factors for PFs following THA, using the Vancouver classification as a guiding framework for therapeutic interventions.
Material and Method: A retrospective cohort study was conducted on 29 patients who sustained periprosthetic femoral fractures post-THA between 2019 and 2023. Utilizing the Vancouver classification, we stratified fractures by intervention strategy, including non-operative care, open reduction with internal fixation, and revision arthroplasty. The demographic comprised 18 females and 11 males, with a mean age of 62 years (range: 53-71), monitored over an average of 21 months (range: 12-30).
Results: PFs were often observed in females with osteoporotic profiles and those with non-cemented THAs. Over 50% of fractures were attributed to low-energy traumas. The study revealed a predominant incidence of PFs among females (62.1%), individuals with osteoporosis (69.0%), and those who underwent uncemented THA (58.6%). Low-energy trauma was identified as the precipitating event in over half (55.2%) of the cases. Stratification by the Vancouver classification showed a majority within 'B' category (65.5%), with 'A' category constituting 17.2%, and no instances in group 'C'. The average Harris Hip Score (HHS) indicated a moderate postoperative recovery with group 'A' scoring an average of 75.3 (SD±5.4) and group 'B' scoring an average of 68.4 (SD±7.5), reflecting the increased complexity of their fractures. Noteworthy is the finding that adjunct pharmacotherapy, primarily bisphosphonates, administered to 48% of the patients, correlated with a non-statistically significant trend (p=0.21) towards higher HHS scores.
Conclusions: Our findings confirm osteoporosis, female sex, non-cemented THA, and low-energy trauma as significant contributory factors for PFs. This suggests a potential role for pharmacotherapy in enhancing postoperative outcomes, though further investigation is warranted. Enhanced prophylactic measures and adjunct pharmacotherapy should be might be considered for superior prophylaxis against PFs.

Interplay Between Pseudomonas aeruginosa and Staphylococcus aureus: Insights from In Vitro Studies

First author: Friedrich Dreier

Coordinator(s): Lecturer Cristina Ciurea

Keywords: Pseudomonas aeruginosa Staphylococcus aureus co-culture in vitro

Background: Pseudomonas aeruginosa and Staphylococcus aureus are clinically significant bacteria known for causing various infections, including chronic wounds, burn wounds, cystic fibrosis airways, and medical device-associated infections. Co-infections involving these pathogens are common and pose significant challenges in treatment, possibly also due to the potential interactions between the two bacteria.
Objective: The study aims to investigate the reciprocal influence of P. aeruginosa and S. aureus on each other's growth dynamics during co-culture in vitro.
Material and Method: Standard 0.5 McFarland suspensions of P. aeruginosa and S. aureus were prepared. Ten microliters of each suspension were inoculated separately into 10 mL of Mueller-Hinton broth. Additionally, a mixture of both strains was prepared by inoculating 5 µl of P. aeruginosa and 5 µl of S. aureus into 10 mL of broth. The probes were transferred in separate tubes and incubated for 24 hours at 37°C. The optical density was measured using a spectrophotometer at 600 nm. Subsequently, one microliter of each broth culture was aseptically inoculated onto separate plates of Mannitol Salt Agar (MSA), Mueller-Hinton Agar (MH), and MacConkey Agar (MC), in triplicate. The colonies were counted by the IUL Flash & Grow” counter. The data were analyzed by comparing the OD/colony numbers of co-culture samples with the data from culturing the bacteria alone and the results were expressed as percentages
Results: In the probes containing S. aureus and P. aeruginosa combined there was an increase in the OD by 115% compared with S. aureus alone, and an increase of 52% compared with P. aeruginosa alone. By counting the colonies on MSA, there was a 127% increase in the number of S. aureus colonies in the coculture sample, compared with the monoculture of S. aureus. While culturing P. aeruginosa on MC and MH, confluent growth was observed. r.

Conclusions: The results suggest a dynamic interplay between P. aeruginosa and S. aureus in co-culture, indicating potential implications for the pathogenesis and treatment of polymicrobial infections. Further studies are warranted to elucidate the underlying mechanisms of interaction and their clinical relevance.

Twin-to-twin transfusion syndrome-association in a triplet pregnancy resulting in fetal demise: a case report

First author: Diana Marin

Coordinator(s): Associate Professor Tibor-László Mezei , Assistant Professor Diana Burlacu

Keywords: twin to twin transfusion syndrome fetoscopic vascular ablation pregnancy

Introduction: Twin-to-twin transfusion syndrome (TTTS) occurs in about 10-15% of monochorionic-diamniotic multiple pregnancies, where the fetuses share a single placenta. The syndrome is a result of an unbalanced blood flow between the fetuses due to placental anastomoses. Thus one of the twins becomes the donor and the other one becomes the recipient. TTTS is often associated with twin anemia-polycythemia sequence (TAPS). The treatment of choice is fetoscopic vascular ablation. We report the case of TTTS occuring in a dichorionic-triamniotic triplet pregnancy resulted in one fetal demise due to refusal of treatment at the right time. Case Report: A 33-year-old primigravida with a dichorionic-triamniotic pregnancy was presented in the Obstetrics and Gynecology Department of the County Emergency Clinical Hospital of Targu-Mures, Romania. TTTS with TAPS were ultrasonographically detected during the rutine prenatal visits in her 27 gestational week (GA). The patient was counseled regarding the risks and benefits of various available management options. Fetoscopic vascular ablation was refused by the mother. Given the extreme prematurity, a conservative approach was proposed. By the 31st GA the absence of cardiac activity was ultrasonographically detected in one of the three fetuses. Emergency cesarean section was succesfully performed. The stillborn and the shared placenta were sent to Pathology Department. The autopsy revealed a female stillborn presenting with generalized erithematous skin. Multiple autolyzed organs (stomach, pancreas and adrenal glands) were described. The morphometrical report revealed a 230x185x33 mm and 777 g placenta with 3 velamentously inserted umbilical cords measuring 19x14 mm, 140x11 mm and 76x15 mm. Microscopically, distal villous hipoplasia of the placental parenchyma corresponding to the stillborn was observed. No signs of corioamnionitis were histopathologically detected. The post-operative evolution of the mother and the 2 newborns was favorable, without any complications.  
Discussions: A multiple pregnancy is usually prone to severe feto-maternal risks. In case of TTTS and TAPS as associations, fetoscopic vascular ablation is the method of choice to a successful term pregnancy.
Conclusions:  In the reported case, where this intervention was refused, the pregnancy ended with the death of one of the fetuses, fortunately without endangering the mother or the other 2 prematurely newborns.  

THE PERCEPTION OF STIGMA REGARDING DEMENTIA AMONG YOUNG ADULTS

First author: Bianca Vaduva

Coauthors: Bianca Maria Grecu Andreea-Ioana Feraru

Coordinator(s): Associate Professor Adriana Mihai , Medical Doctor Molnar Rebeca Isabela

Keywords: Dementia Stigma Discrimination Social

Background: Dementia is a complex and debilitating condition that not only affects cognitive functions but also profoundly impacts social interactions and relationships. Despite growing awareness and advocacy efforts, individuals diagnosed with dementia continue to face significant stigma, leading to discrimination, social isolation, and barriers to accessing care and support services.  Objective: This study seeks to evaluate how the general population perceives individuals with dementia by: gathering demographic information (gender, age, education, background), assessing understanding of terms such as “stigma”, “dementia” and “discrimination”, gauging empathy levels through specific questions, analysing data to uncover factors influencing patient stigmatisation.  Material and Method: It is a cross-sectional study based on data collection. The data was collected via a 25-question Google Forms survey and it was analysed using IBM’s SPSS software. The accuracy of the responses on “stigma”, “dementia” and “discrimination” was compared with DEX definitions. The sampling method was used in this study.  Results: In terms of age distribution the majority fall within the 20 to 30 age range. Gender distribution is roughly equal, with 56% female and 44% male participants. Regarding educational background, most have completed high school, and 71% come from urban areas compared to 21% from rural regions. The marital status shows that 74% are unmarried, 23% are married, 2% are divorced, and 1% are widowed. Prior to the study, only 59% of participants were acquainted with the concept of "stigma," with just 21% having a solid grasp of it. Conversely, 96% claimed familiarity with "dementia," but only 41% demonstrated a good understanding. Similarly, 96% were familiar with "discrimination," yet only 44% had a comprehensive understanding. While 39% reported no difficulty communicating with dementia patients, only 66% felt they truly understood and aided them. A notable 46% believed these individuals should be institutionalised, and 59% admitted feeling nervous around them. Only 34% felt comfortable sharing a home with dementia patients, while 40% were open to spending time with them. Concerning relationships, 48% doubted any negative impact from such a diagnosis, and 49% were willing to employ people with dementia for household assistance. Conclusions: Age extremes, urban, unmarried individuals with high school education tend to stigmatise psychiatric or dementia patients the most. Views on "dementia," "stigma," and "discrimination" vary very widely. Knowing someone with dementia reduces judgment of the condition. Trusting reliable medical sources leads to more openness toward entrusting tasks to dementia patients. Dementia patients' premorbid personality affects behaviour and likelihood of stigmatisation.

AN ASSESSMENT OF ONLINE INFORMATION QUALITY ABOUT CERVICAL CANCER ON ROMANIAN AND ENGLISH LANGUAGE WEBSITES- A CROSS SECTIONAL STUDY

First author: Maria Micu

Coauthors: Ioana Ontanu Toboltoc Paul-Cătălin

Coordinator(s): Professor Valentin Nădășan

Keywords: cervical cancer infodemiology consumer health informatics internet

Background: Cervical cancer is a form of cancer commonly found worldwide, but in Romania the incidence is higher than in the rest of the European countries. Our country ranks first in the European Union in cervical cancer mortality, with a rate four times higher than the EU average. Ensuring that the primary information source for the population, the Internet, contains accurate and comprehensive information, is of utmost importance. 
Objective:  The primary objective of the study was to evaluate the accuracy and comprehensiveness of cervical cancer information available on websites intended for non-medical audiences. Additionally, it sought to compare the quality of websites presenting this information in both Romanian and English. Furthermore, the study aimed to determine whether Google's ranking of websites correlates with their quality and reliability. 
Material and Method: Fifty websites, half Romanian and half English were selected according to inclusion and exclusion criteria. For each site, the following were evaluated: site characteristics, credibility level (based on eEurope 2002 credibility criteria), completeness and accuracy of information, according to a predetermined scale. Finally, the results obtained for the two languages were compared and the correlations between completeness/accuracy – and credibility/Google rank were tested. Student-t and Mann-Whitney tests were applied for numerical variables and the Chi-square test was used for categorical variables. The threshold for statistical significance was set at 0.05.
Results: The completeness and accuracy scores for Romanian websites were 5.3 and 8.1, respectively, while for English websites, they were 7.0 and 7.9. Notably, the scores were higher in the English subset compared to the Romanian subset, with significant differences observed in completeness (7.0 vs. 5.3, p=0.0014) but not in accuracy (7.9 vs. 8.1, p=0.7619).
Conclusions: Both Romanian and English websites provide incomplete and unreliable information regarding cervical cancer, underscoring the importance of seeking medical consultation for comprehensive guidance. The credibility of these websites and their Google ranking appear inconsistently related to content quality, suggesting they may not be reliable indicators of information validity.

THE QUALITY OF INFORMATION ABOUT BREAST CANCER ON THE ROMANIAN AND ENGLISH WEB

First author: Ioana Ontanu

Coauthors: Maria Micu Toboltoc Paul-Cătălin

Coordinator(s): Professor Valentin Nădășan

Keywords: breast cancer completeness accuracy internet

Background: Breast cancer is the most common form of cancer in women. The disease is triggered when some cells in the structure of the mammary gland begin to multiply uncontrollably, eventually forming a tumor. It is very important that the main source of information of the population – the Internet – contains complete and correct information.
Objective: First, the study aimed to assess the quality of breast cancer information on websites for people without medical training and to compare the quality of websites in Romanian and English, respectively. Another objective was to assess the relevance of Google's rank to the quality of a particular site. 
Material and Method: Fifty websites, half Romanian and half English were selected according to inclusion and exclusion criteria. For each site, the following were evaluated: site characteristics, credibility level (based on eEurope 2002 credibility criteria), completeness and accuracy of information, according to a predetermined scale. Finally, the results obtained for the two languages were compared and the correlations between completeness/accuracy – and credibility/Google rank were tested. Student-t and Mann-Whitney tests were applied for numerical variables and the Chi-square test was used for categorical variables. The threshold for statistical significance was set at 0.05.
Results: The completeness and accuracy scores were 5.8 and 8.1 for the Romanian websites and 7.0 and 8.4 for the English websites. While English websites had higher scores, the differences were not statistically significant (completeness: 7.0 vs 5.8, p=0.0661; accuracy: 8.4 vs 8.1 p=0.1515).The results of correlation tests were inconsistent. For the Romanian language, there was a positive correlation between credibility and accuracy, but not between credibility and completeness, respectively no correlation at Google rank. For English, lack of correlations to credibility-completeness, credibility-accuracy, negative correlation to rank Google-completeness, positive correlation to rank-Google-accuracy.
Conclusions: Both Romanian and English websites contain incomplete and unreliable information regarding breast cancer, which is why it is absolutely necessary to complete the information through a medical consultation. The websites' credibility and Google ranking seem inconsistently related to content quality and probably are not reliable as indicators of information validity. 

A comparison of antimicrobial toothpaste with low abrasive effect used for veneers

First author: Roberto Fiori

Coauthors: Alessandra Galeone Andra Elen Popa

Coordinator(s): Lecturer Adriana Monea

Keywords: toothpaste antimicrobial effect salivary pH

Background: Saliva is crucial for defending the oral cavity naturally, primarily due to its composition of antimicrobial elements and diverse ions that serve as a buffer, regulating salivary pH within a neutral range. Maintaining a neutral salivary pH is essential because after eating, acidity levels plummet significantly due to the acid produced by food. This drop triggers the demineralization of teeth, a process that can be effectively managed through the buffering capacity of saliva and regular tooth brushing.
Objective: The objective of this study was to assess the oral fluid's alkalinity following the use of specific toothpaste brands to compare their efficacy. Additionally, we examined whether PRANOYA toothpaste exhibits a greater antimicrobial effect compared to similar toothpaste varieties.
Material and Method: The study comprised eighty participants, evenly divided into two groups: forty smokers and forty non-smokers. Five distinct toothpaste brands were evaluated, with each brand tested on eight smokers and eight non-smokers. Saliva samples were collected before and after tooth brushing using 1.5 ml containers. Upon collection, the pH of the saliva samples was promptly measured using pH test paper.
Results:  The pH test results indicate that each toothpaste increases salivary pH by 4-18%, with measurements falling within the range of 7.2-8.1. There was no statistically significant difference between different brands in increasing salivary pH levels. Additionally, it was observed that smokers exhibit slightly more acidic saliva compared to non-smokers.
Conclusions:   This study confirms that every toothpaste assists in alkalizing saliva, consequently mitigating the potential imbalance between demineralization and remineralization of dental hard tissues after exposure to acidic conditions. This mechanism significantly enhances cavity protection for the teeth. Furthermore, Pranoya exhibits effectiveness as an antibacterial toothpaste, comparable to other brands tested in the study.

Innovative Dental Gadget employed by military personnel to remotely operate electronic equipment

First author: Georgiana Băcanu

Coordinator(s): Other Marius-Emilian Andreiana

Keywords: Dental Device Mouth Pad Tactical Maneuvers

Background: The evolution of equipment technology in the military field has been marked by continuous advancements driven by the need for enhanced capabilities, increased efficiency, and improved safety. Militaries around the world often employ a wide range of specialized equipment, including various forms of input devices for controlling electronic systems and machinery.
Objective: A device like this is MouthPad. Its potential application in the military field is significant. While this is a brand-new technology and apparatus, an examination of its design and practical uses in civilian life allows us to believe that it may find its way into military personnel's standard equipment.
Material and Method: Even though more research is required, by examining recent papers and publications, we may make some assumptions about this device's potential future.
Results: Using Bluetooth, MouthPad is a tongue-driven interface that can be used to operate electronic systems and machinery using the movements of your tongue on the device. The touchpad is placed on the hard palate and it is held in place by a clear dental retainer and has attached a battery on the vestibular side of the molars that will be situated in the maxillary vestibule. It could be used in situations where soldiers need to control drones for surveillance or reconnaissance purposes while on the move or in a confined space, a mouth pad with a trackpad could allow for hands-free control of the UAV's flight path, camera orientation, and other functions. Another possibility of using MouthPad is while military personnel may use Robotics and Unmanned Ground Vehicles for tasks such as bomb disposal, reconnaissance, or search and rescue in hazardous environments. A mouth-operated trackpad could enable operators to navigate and manipulate these vehicles remotely while keeping their hands free for other tasks, such as handling equipment or weapons. Furthermore, MouthPad could be used for mapping and navigation, as well as for tactical communication.
Conclusions: : In specific scenarios where conventional input methods are risky or unfeasible, military forces may adopt hands-free input devices, such as MouthPads.

Psychotic dissociative disorder

First author: Georgiana-Elena Niculica

Coauthors: Maria-Silvia Oprisiu Valentin-Adrian Oarga Antonia Todea

Coordinator(s): Assistant Professor Andreea Sima-Comaniciu

Keywords: dissociative psychotic catatonic trauma

Introduction: Psychotic dissociative disorder is a mental process where a person disconnects from their own thoughts, feelings, memories or sense of identity. It usually occurs after the person experienced a traumatic event and it can serve as a defense mechanism against overwhelming emotions.
Case Report: The purpose of this report is to present a rare case of psychotic dissociative disorder with serious damage of physical health. The 18 year old patient was brought to emergency service of psychiatric clinic due bizarre and chaotic behaviour, incomprehensible speech. This acute psychotic episode debuted four days prior and was characterized by auto- and allopsychic disorientation, disjointed and tangential speech, echolalia, marked suggestibility and restlessness, purposeless movements. The patient’s drug test came back negative and she doesn’t have any history of psychiatric disorders. According to the patient's mother, symptoms debuted following a traumatic event at school and they worsened during those 4 days. Over the initial three weeks of hospitalization, the patient was non-cooperative and did not respond to the prescribed treatment regimen. Her condition got gradually worse and she started manifesting muscle spasms, dysphonia, dysphagia and ultimately entering a catatonic state. Consequently, she was transferred to the ICU, where she remained for the next 2 weeks. Upon returning to the psychiatric clinic, her mental state had not improved, she continued to exhibit extreme agitation, aimless laughter, and peculiar behaviour. A revised treatment plan yielded success, leading to the patient's discharge after a month of care. Currently, there have been no recurrences of psychotic episodes, and the patient maintains a stable clinical course.
Discussions: Considering the patient's established hysterical personality tendencies, the traumatic event had an even bigger impact on her. Due to the inclination to seek attention and the reduced capacity to tolerate stress and psychological trauma, the patient dissociated as a way of coping. Several examinations were conducted to ascertain the etiology of her physical deterioration, yet all results returned within normal parameters. This underscores the proposition that her catatonic state was solely precipitated by psychological factors.
Conclusions: Psychotic dissociative disorder stands as a complex and multifaceted condition that requires a comprehensive and meticulous approach, because clearly this disorder poses significant challenges for both those affected and their caregivers, potentially even endangering the patient’s life.

Argon plasma coagulation treatment in radiation proctitis patients

First author: Thea - Alexandra Schiller

Coordinator(s): Assistant Professor Marius Ilie Ciorba , Assistant Professor Paul Grama

Keywords: Argon plasma coagulation Radiation proctitis Radiotherapy Pelvic tumour

Background: Radiation proctitis is a pathology of the rectum, usually developed as a result of radiotherapy of a pelvic tumour. Patients who develop radiation proctitis may present symptoms such as diarrhoea, faecal incontinence and mild bleeding in the acute stages. In chronic stages, complications that may occur include rectal strictures as well as ulceration and fistulisation of the rectum. The most common and efficient treatment method at the moment is endoscopic Argon plasma coagulation, which reduces the bleeding and consequently, the blood transfusion requirement. Objective: The objective of this presentation is to depict the evolution of a patient diagnosed with radiation proctitis after the second therapy session with Argon plasma coagulation. Material and Method: This presentation includes the case of a 86 year old female patient, diagnosed with radiation proctitis secondary to chemo- radiotherapy for a uterine cervix neoplasia. The pathology led to lower digestive tract hemorrhage and moderate secondary anemia. Such a complication of radiation proctitis is usually treated with Argon plasma coagulation. This treatment induces haemostasis and tissue reduction by devitalization. Argon plasma coagulation is a form of electrosurgery. The gas discharges of the argon have a thermal effect on the superficial tissue without coming in direct contact with it. At a 60-80˚C temperature, the denaturation of intracellular proteins occurs. This process is called coagulation and it leads to cell necrosis. Results: The patient was stabilised after a blood transfusion and prepared through an enema for her second endoscopic Argon plasma coagulation session. The enema was not completely effective, and the patient was not very cooperant during the endoscopic procedure, which lead to limited treatment efficiency. Even so, numerous angiodysplasias of various dimensions were identified and treated with Argon plasma. Conclusions: The patient was stabilised, discharged, prescribed medication and recommended to follow a diet which would help in avoiding constipation or dehydration. The recommended re-evaluation time is a month later, at which point in time the patient may have a third argon plasma coagulation treatment session.

Biological therapy for atopic asthma? Unusual treatment for a common illness

First author: Iozefina-Darina Gaidoș

Coauthors: Andrei Man Radu Ilieș

Coordinator(s): Professor Sorin Claudiu Man

Keywords: atopic asthma short-acting beta-agonists inhalator corticosteroids biological therapy

Introduction: Asthma, a prevalent disease, entails persistent inflammation of the respiratory passages, resulting in symptoms such as wheezing, dyspnea, chest tightness, and coughing. In cases of atopic asthma, exposure to various allergens such as pollen, pet dander, and dust can exacerbate these symptoms, potentially leading to a medical emergency known as status asthmaticus. Diagnosis relies on symptomatology, physical assessment, and pulmonary function testing, confirming expiratory airflow obstruction via reduced FEV1/FVC ratio. Treatment typically involves the administration of short-acting beta-agonists and inhaled corticosteroids.
Case Report: We present the case of a 7-year-old boy who presented to the hospital with a persistent dry cough. At 8 months of age, he was initially diagnosed with atopic asthma characterized by fever, dry cough, and wheezing. Allergen testing revealed milk protein, dust mites, cats, dogs, and mold sensitivities .Upon diagnosis, he was discharged with controller therapy consisting of Montelukast, Fluticasone, and Salbutamol. Despite treatment, he experienced multiple exacerbations over the years, necessitating dose adjustments. His most severe exacerbation occurred in 2020 during a measles infection due to a lack of MMR vaccination, resulting in respiratory insufficiency with an oxygen saturation of 60%. He required intensive care unit admission and systemic corticosteroid therapy. Subsequent spirometry indicated obstructive ventilatory dysfunction with an FEV1/FVC ratio of 58%. In addition, he presented with atopic dermatitis and allergic rhinitis, managed with Desloratadine. Although initially screened for cystic fibrosis, the sweat chloride test results were negative. Given the refractory nature of his asthma, biological therapy with Dupilumab was initiated for 2 weeks. At the latest follow-up, the patient reported a significant reduction in exacerbations, down from approximately three episodes per week before initiating Dupilumab therapy. Discussions: Nowadays, the therapeutic approach for asthma includes corticosteroids and beta-agonists. However, their prolonged usage can entail numerous adverse effects, and as evidenced in this case report, they may prove ineffective for moderate to severe asthma. Dupilumab, a human monoclonal antibody targeting the interleukin-4 (IL-4) receptor alpha, approved on 19^th of October 2018, operates by antagonizing the activity of IL-4 and IL-13, therefore attenuating T helper 2 cell (Th2)-mediated inflammation, a pivotal mechanism in moderate-to-severe asthma pathogenesis.
Conclusions: In summary, this case underscores the management of a juvenile patient with a chronic disease, in which the enduring doctor-patient relationship played a significant role in identifying the appropriate medication to improve his quality of life.

Challenges in Managing Early-Onset Crohn’s disease

First author: Teodora Ioana Mustea

Coauthors: Maria Melisa Morar Ada Mihaela Muntean Șerban Nistor

Coordinator(s): Assistant Professor Andrei Vasile Pop

Keywords: Crohn’s disease Hemicolectomy Biological therapy

Introduction: Crohn’s disease is a chronic inflammatory bowel disease which might result from a complex interaction between the following: genetic susceptibility, impaired immune response and environmental triggers. It is delineated by a transmural, granulomatous inflammation that can affect the entire gastrointestinal tract, illustrating a discontinuous pattern. It involves periods of activity and remission, with the presenting symptoms: colicky pain, low-grade fever and weight loss due to diarrhea, anorexia and fear of eating.
Case Report: We report a case of a 41-year-old male with a history of ileocaecal Crohn’s disease who is non-responsive at both immunosuppressive drugs (Azathioprine) and anti-inflammatory drugs (Mesalazine). The patient had undergone ileocolonic anastomosis after right hemicolectomy due to an acute episode in 2010 and has been under immunosuppressive and anti-inflammatory therapy since. He is also known with erosive antral gastritis as well as with an old myocardial infarction for which he follows a therapy with Clopidogrelum and Bisoprololum. Total colonoscopy performed in 2010 illustrated the hemicolectomy as well as grade 1 internal hemorrhoids with small lesions. However, the one performed in 2022 showed an upper rectal sessile polyp, which has been endoscopically excised. An upper GI endoscopy performed in 2022 confirmed the erosive antral gastritis.
Discussions: Since the classical treatment was non-effective for this patient, the biological therapy was implemented. It has to be taken into consideration the fact that the most common indications for surgery are represented by fistula, abscess, obstruction and in this particular case, surgical management was necessary due to the unfavorable evolution. Moreover, patients with elderly onset are associated with a less progressive course of the disease and a better outcome.
Conclusions: To conclude, the presented case displays the situation of a patient that suffered a major complication during the standard therapy, so that the surgical intervention was necessary. The alternative treatment established in this case was the biological one. Currently, the patient has been recommended the new implemented treatment and he is expected for a follow up in order to initiate the proper therapy with Adalimumab.

Comprehensive analysis of Gastroesophageal reflux disease and Barrett's esophagus

First author: Marco Cafisi

Coordinator(s): Medical Doctor Danusia Onisor

Keywords: GERD Barrett's esophagus Heartburn Acid regurgitation

Background: Gastroesophageal reflux disease and Barrett’s esophagus are two strictly connected medical conditions. GERD is a chronic disorder characterized by the reflux of the gastric content back into the esophagus, causing heartburn and acid regurgitation. Sustained exposure of the esophagus to the gastric acid can lead to erosion of the mucosa, promoting the substitution of the esophageal epithelium with the metaplastic epithelium of BE.
Objective: The goal of this study is to provide a comprehensive understanding about the complex interaction between GERD and BE, by assessing the different prevalence trends.
Material and Method: We performed a retrospective observational study, including 51 patients diagnosed with GERD and BE from the database of the Gastroenterology department of the Spitatul Clinic Judeţean of Târgu Mureş, from 2018 to 2024. For each patient we evaluated demographic parameters (age, sex, background), risk factors, symptoms, complications, comorbidities, classifications and treatment strategies.
Results: The mean age of the patients was 62,80 years old, with the majority of the patients in between 60 and 79 years old (n=28). There was a majority of male patients (n=30, 58,8%) and patients who live in rural areas (n=29, 56,8%). Regarding the risk factors: 45% of the patients were smoker, 37,2% were obese, 33,3% of the patients recalled occasional alcohol consumption while 11,7% daily consumption and 35,3% were diagnosed with hiatal hernia. Esophageal symptoms were reported by 98% of the patients, the most common being: heartburn (92,16%), acid regurgitation (88,24%), gastric discomfort (39,22%), hypersalivation (36%), chest pain (21,57%), nausea (15,7%), vomiting (13,73%) and eructation (13,73%). Considering the macroscopical classification of BE, our study reported 78,43% with short-segment BE and 21,57% with long-segment BE, while microscopically 94,12% showed no dysplasia, 3,92% low-grade dysplasia and 1,96% high-grade dysplasia. Complications were detected in 30 patients (58,8%): all of them developed Esophagitis, 3 had also esophageal strictures and 2 esophageal ulcers. Among the patients evaluated 94,12% (n=58) had associated gastrointestinal comorbidities, 50,98% (n=26) cardiac comorbidities, 47,06% (n=24) hepatic comorbidities, 33,3% (n=17) renal comorbidities, 33,3% (n=17) hyperlipidemia, 19,61% (n=10) respiratory comorbidities and 17,65% (n=9) diabetes. Therapeutic strategies included: lifestyle modifications, dietary adjustment, as well as medical therapy: PPI (92,16%), H2 receptor antagonist (7,84%) and antacids.
Conclusions: Our study demonstrated how the increasing age has a major role in the development of GERD and BE. Heartburn and acid regurgitation were found in the vast majority of the patients, while PPIs are clearly the gold standard for treatment.

Early presentation of Ebstein`s anomaly: hemodynamic particularities and management

First author: Nicola Suteu

Coauthors: Jenica Daiana Suciu

Coordinator(s): Assistant Professor Carmen Corina Suteu

Keywords: Ebstein`s anomaly neonate hemodynamic particularities

Background: Ebstein`s anomaly (EA) is a rare congenital cardiac malformation characterized by apical displacement of the tricuspid valve (TRv) and reduced volume of the true functional right ventricle (RV). Despite its low rate of occurrence, neonatal presentation of EA represents the most severe clinical form of this condition, associated with high mortality. The pathophysiology and clinical presentation vary depending on the anatomical severity of the disorder. Symptomatic neonates with EA presented with cyanosis and severe congestive cardiac failure. 
Objective: The identification of risk factors for hemodynamic instability is extremely important in therapeutic management. These factors include lack of effective antegrade pulmonary flow in anatomic or functional pulmonary atresia, severe TRv regurgitation creating a large right-to-left shunt through an atrial septal defect, RV dysfunction, inadequate left ventricle filling owing to ventricular septal bowing, arrhythmias, and the extrinsic compression of lungs by the space-occupying mass of the dilated right heart. In the neonate, these factors are amplified by the elevated pulmonary resistances (PVR).
Material and Method: The classic radiographic appearance of EA is massive “wall-to-wall” cardiomegaly. The echocardiography is the most useful in the diagnosis of EA providing sufficient anatomic and hemodynamic information: the degree of apical displacement of the septal leaflet, the degree of atrialization of the RV, size of TRv annulus, severity of TRv regurgitation. It may be difficult to differentiate physiological from anatomical pulmonary atresia. Following a confirmation of diagnosis by echocardiography, the clinical evolution should be monitored closely. 
Results: Most neonates born with EA do not require surgical intervention. Neonates who are reasonably stable are treated with supplemental oxygen, Prostaglandin E1 as require, and closely observed for adequate cardiac output. The immediate therapy of unstable patients may involve intubation, deep sedation, inotropic support, inhaled nitric oxide to reduce PVR, and Prostaglandin E1 if deemed ductal-dependent. Many neonates tend to stabilize and improve over a few days as PVR decreased. Neonates who continue to decline despite standard resuscitative measures need surgical intervention. Surgical options depend on the hemodynamical anatomical features and ranging from a complete biventricular repair to single-ventricle palliation.
Conclusions: Symptomatic neonates with EA represent the most severe form of the disease and can be effectively managed with good outcomes. Echocardiography is generally the key test for diagnosis. The choice of management pathway based on anatomy and physiology can help reduce morbidity and mortality.

EARLY-ONSET COLORECTAL CANCER: CASE PRESENTATION

First author: Maria Ababei

Coauthors: Mara Gabriela Cătălin

Coordinator(s): Associate Professor Claudia Cristina Burz

Keywords: Lynch syndrome adenocarcinoma adjuvant chemotherapy screening

Introduction: Colorectal cancer (CRC) ranks as the third leading cause of cancer-related mortality worldwide. Recent years have witnessed an increase in the incidence of CRC among adults <50 years old on a global scale. The increased incidence is associated with several variable risk factors, but certain cases of early-onset colorectal cancer (eoCRC) are associated with a genetic predisposition, the majority result from sporadic mutations in the following genes APC, KRAS, BRAF and TP53, which trigger uncontrolled cell proliferation and tumor formation. 
Case Report: We present the case of a 48-years-old male patient who arrived at the Oncological Institut Prof. Dr. Ion Chiricuta in Cluj-Napoca complaining of persistent lower abdominal pain, hematochezia, loss of appetite and significant weight loss. Endoscopically, a rectosigmoid tumor formation confirmed by biopsy was identified for which surgical intervention was performed with resection of poorly differentiated adenocarcinoma (G3), stage III. Due to the risk of recurrence, the patient underwent six cycles of adjuvant chemotherapy which evolved with hematological toxicity. Therefore the treatment was delayed and the administration of granulocyte growth factors was necessary. Three months after the end of the treatment, the imaging evaluation revealed a liver metastasis and increased ACE marker. Local treatment of liver metastasis was performed, but because the marker continued to show high values, a PET scan was done, which revealed liver recurrence. Currently, the patient has restarted systemic chemotherapy associated with targeted therapy, as he has the KRAS wild-type mutation, an essential condition for anti-EGFR therapy.
Discussions: The young age of the patient, the rapid evolution of the disease and the lack of response to oncological treatment point towards a pathology with genetic determinism such as Lynch syndrome, also known as hereditary non-polyposis colorectal cancer (HNPCC). Lynch syndrome, characterized by DNA mismatch repair deficiency, represents a significant paradigm among cancer predisposition syndromes and is notably associated with heightened susceptibility to various cancers, particularly colorectal and endometrial malignancies. Genetic alterations in MMR genes, including MLH1, MSH2, MSH6, PMS2, and EPCAM, compromise DNA repair mechanisms, predisposing affected individuals to a spectrum of malignancies. 
Conclusions: Family members of patients affected by CRC have an increased risk of CRC development. In these individuals, screening is strongly recommended and should be started earlier than in the population with average risk, in order to detect neoplastic precursors, such as adenoma, advanced adenoma, and nonpolypoid adenomatous lesions of the colon.

Beyond hematemesis: A case report on Mallory-Weiss syndrome and alcoholic cirrhosis

First author: Andreea Georgiana Ristea

Coauthors: Ioana-Elena Ristea Stefania Danciu Alexandra-Iuliana Postolache

Coordinator(s): Medical Doctor Paul Grama

Keywords: cirrhosis esophageal varices upper gastrointestinal bleeding

Introduction: Upper gastrointestinal bleeding represents the loss of blood from a gastrointestinal source above the ligament of Treitz. One of the most common causes is the rupture of esophageal varices in people with serious liver diseases. In conditions where portal pressures rise, such as in cirrhosis, veins in the anastomosis dilate, resulting in esophageal varices. The most important predisposing factor is alcohol ingestion.
Case Report: We present a case of a 62-year-old male, chronic alcohol consumer, admitted to our clinic for upper gastrointestinal bleeding manifested as hematemesis. From the personal pathological history, we note the presence of alcoholic liver cirrhosis, hypertension, and Mallory Weiss syndrome firstly identified in 2011. Upon examination, the patient was pale and had large ascites. Laboratory analysis revealed the following: hemoglobin=7.70 g/dl, hematocrit 24,7%, platelet count 127000/mm3, INR 1,44, ALT 60, urea 139 mg/dL, creatinine 2.1 mg/dL. CT scan showed the presence of micronodular cirrhosis, ascites, splenomegaly, and bronchopneumonia. The upper endoscopy revealed third-grade esophageal varices and portal gastropathy. Throughout the hospitalization, the patient experienced epistaxis likely due to hypertension. We initiated the treatment with Carbazochrom, Fitomenadion, Etamsylate, Furosemide, Spironolactone, Carvedilol, Captopril, Indapamid, Ceftriaxone and Rifaximin. The instituted treatment has led to a favorable evolution and the patient was discharged with oral treatment and a firm recommendation to avoid alcohol consumption. He returned two months later for follow up, with positive evolution.  
Discussions: To avoid a new episode of esophageal variceal hemorrhage the treatment with non-selective beta-blockers was instituted and variceal ligation was executed. For both secondary prevention of digestive hemorrhage and the existing hepatic pathology and its complications, the most important measure is abstaining from alcohol consumption. Alcohol use disorder is a medical condition involving brain function and behavioral therapy, support groups and medication should be considered as part of the treatment.
Conclusions: In upper gastrointestinal bleeding, the emphasis is placed on early endoscopic examination targeted at proper diagnosis and therapy. The treatment must be correct and promptly instituted to prevent life-threatening complications.

Unveiling the Mysteries of Chronic Pulmonary Aspergillosis: Unusual Localization Explored

First author: Iulia-Manuela Băbuțan

Coauthors: Ioana Maria Babutan

Coordinator(s): Assistant Professor Andrei Lesan

Keywords: Aspergillus fumigatus Extensive fibrosis Airy crescent Antifungal therapy

Introduction: Chronic pulmonary aspergillosis, commonly caused by Aspergillus fumigatus, is a progressive condition characterized by extensive fibrosis and deterioration of lung function, mainly affecting patients with pre-existing lung disease. Aspergillus species can cause various conditions, including allergic reactions, local superinfection and invasive disease.
Case Report: This report aims to present the case of a 54-year-old man with a history of exposure to industrial dust, smoker, known with type II diabetes mellitus, insulin-dependent and secondary pulmonary fibro-nodular tuberculosis of the upper lobes and right-sided caverns diagnosed and treated three years ago. The patient presented with massive hemoptysis, dyspnea on exertion, weight loss of 8-10 kg in recent months. CT examination revealed the presence of two cavitary lesions in the right upper lobe and the apical level of the lower lobe, containing intracavitary masses of fungus balls, surrounded by an airy crescent (Monod sign), right upper lobe atelectasis and multiple pulmonary micronodules in the ground glass opacity. Biological samples were taken for IgG assay specific to Aspergillus fumigatus subsequently with positive results. Antifungal treatment was initiated with periodic clinico-biological and imaging re-evaluation. At the last check-up, the imaging aspect was in evolution and indicated the appearance of new cavitary lesions near the pre-existing ones with specific aspect of aspergilloma.
Discussions: Even after six months of antifungal therapy using Itraconazole, our patient continued to experience symptoms, and there was a continued worsening of imaging results. Surgery was considered but the patient refused and antifungal therapy was continued for another month. The following images showed an advanced stage of chronic cavitary aspergillosis characterized by extensive pulmonary destruction, irregular cavities bordered by massive fibrosis with the appearance of condensation, affecting 2 surrounding lobes, with significant functional loss. Surgical removal of the upper right lobe and the upper segment of the lower right lobe stands as the ultimate treatment option.
Conclusions: Chronic fibrosing pulmonary aspergillosis represents an uncommon complication of chronic pulmonary aspergillosis, typically detected upon presentation but occasionally emerging after several years in patients untreated with antifungals. The fibrosis typically persists unilaterally, extending extensively without spreading to the opposite lung. Regarding prognosis, while some patients may maintain stable radiological features for several years, others may experience a more rapid decline.

Graphene: From Lab to Battlefield

First author: Maxinan Ovidiu-Alexandru

Coauthors: Alexandru Botoser

Coordinator(s): Medical Doctor Ramona-Rodica Carașca

Keywords: graphene, body armor, unique properties, protection.

Background: Graphene, an atomic-scale hexagonal lattice made of carbon atoms, has emerged as a groundbreaking material with unique properties. This material sheer mechanical strength, high electron mobility, enhanced thermal conductivity, and extreme optical transparency make it a promising candidate for various applications.
Objective: The objective of this study is to explore the potential of graphene in enhancing soldier protection on the battlefield. Specifically, we investigate how graphene-based materials can improve body armor, power generation, and water purification for military personnel. Material and Method: After reviewing the scientific literature and various research from Romania and other international military congresses, we have concluded that graphene is remarkable material of the future, which can make a big difference between life and death.
Results: Graphene offers several advantages for soldier protection. Graphene’s robustness and flexibility surpass that of steel. It can significantly improve existing body armor made from materials like Kevlar. Its higher tensile strength makes it an ideal candidate for protecting soldiers. Graphene can enhance batteries in radios and other devices, allowing quick charging or replacement. Its excellent electrical conductivity contributes to efficient power generation. Also in, the thermal properties of graphene are used to regulate soldiers body temperature under extreme conditions, be it heat or cold. Graphene can also be used in the development of sensors that monitor soldiers health in real time, providing vital data to commanders. Graphene filters exhibit high reactivity with water, making them suitable for water purification systems, a critical resource for soldiers.
Conclusions: Graphene’s exceptional properties position it as a game-changer in soldier protection. As research continues, we anticipate further innovations and commercial availability of graphene-based devices for military applications.

PEDIATRIC ALLERGIC ASTHMA – THE PREVALENCE AND CHALLENGES OF ASSOCIATED COMORBID DISORDERS

First author: Monica Grama

Coordinator(s): Lecturer Corina Ureche

Keywords: ASTHMA RECURRENT WHEEZING PEDIATRIC ALLERGENS

Background: Allergic asthma in children can often be associated with various comorbidities. Some recurrent comorbidities seen in children with allergic asthma may include :allergic rhinitis,atopic dermatitis,and food allergies as the most common situations.Recognition and management of these conditions could give a better control of asthma in children.One of the most frequent non-transmissible disease worldwide , asthma is often associated with comorbidities either pulmonary or extrapulmonary, that may pose a variable degree of burden on the patient regarding higher risks of exacerbation and hospitalisation,overtreatment caused by poor asthma control ,that could lead to other complications and lower treatment adherence, higher healthcare costs, and decreased quality of life.
Objective: The study aims to assess the presence of comorbidities in children with reccurent wheezing and allergic asthma. 
Material and Method: We conducted a retrospective observational study that included children with asthma examined in the Ambulatory Department of Allergology at the Emergency County Hospital Tg.Mures. Patients taken into consideration attended at least one visit between 01.01.2022-01.12.2023, all of them have detailed transcripts about history, clinical examination specific allergology procedures, treatment. The focus was on comorbidities presence.
Results: In this study were included 109 patients between the ages of 0-18 years old, 31 with the diagnosis of recurrent wheezing (RW) (0-5 y/o) and 78 with allergic asthma (AB) ( 6 -18 y/o). In the first group we found 26 patients with comorbidities , the most important being recurrent respiratory infections ( 37,78% ) , followed by allergic rhinitis ( 22,22%) , atopic dermatitis ( 13,33%) ; in the second group 70 patients had associated comorbidities , the most prevalent being allergic rhinitis (35,66%) , recurrent respiratory infections ( 24,03%) , allergic rhinoconjunctivitis ( 13,18% ). The most common allergen found in both study groups were the common house-dust mites (Dermatophagoides farinae and pteronyssinus) : 64,52% in children with recurrent wheezing and 78,21% in children with asthma ; other common allergens were Gramineae Pollen 25,80% , Ambrosia flowers 16,13% for RW and Gramineae Pollen 33,33%, mold 15,38% , animal epithelia and hair 14,10% for asthma.
Conclusions: The key takeaway is the need of better understanding comorbidities associated with asthma and recurrent wheezing , and their mixture of symptoms , because this may lead to propper treatment and better disease control.

Histopathological Aspects of Pancreatic Lesions: Preliminary Results

First author: Diana Diaconu

Coordinator(s): Professor Simona Gurzu

Keywords: ductal adenocarcinoma neuroendocrine tumors pancreas

Background:  The pancreas undergoes several morphological and pathological changes with aging, such as pancreatic atrophy, fatty degeneration, fibrosis, inflammatory cell infiltration and exocrine pancreatic metaplasia. The rate of pancreas diseases is increasing over time and predicting the type of pancreatic lesions based on the histopathological aspects is still a diagnostic challenge.   
Objective: To present our data regarding the histological features of pancreatic lesions.  

Material and Method: We evaluated the clinicopathological parameters related on the pancreatic lesions, consecutive cases, diagnosed at the Department of Pathology of the Clinical Country Emergency Hospital of Targu-Mures, Romania, during 2017-2021.  
Results: Through the examined five years, there were 94 cases diagnosed as pancreatic lesions. The male:female ratio was of 1.35:1 (57.45% males and 42.55% females). We have identified 57 tumors (60.64%) and 37 (39.36%) non-tumor lesions. Of the 57 tumors, 53 have exocrine- and 4 showed endocrine- origins. The most widespread histological type among exocrine tumors was ductal adenocarcinoma (n=42), while the rest of them being represented by cystic mucinous- (n=5) or serous- neoplasms (n=3), adenosquamous carcinoma (n=1), anaplastic carcinoma (n=1) and acinar cell carcinoma (n=1). Based on age categories, most of the patients were diagnosed between 61-70 years-old (35.10%) and 71-90 years (21.26%). In younger patients, however, the number of cases was also high: 5.31% of patients were diagnosed between 31-40 years old, 20.21% between 41-50, and 18.08% between 51-60 years. The mean age of the patients was not significantly different between men and women (60.40 vs. 61.22 years; p=0.74). No significant statistical association was found between the distribution of tumor lesions through males and females (p=0.54).
Conclusions: Among the pancreatic lesions, neoplasia is predominant, with a peak incidence after the sixth decade, in both males and females.   

The Use of Plasma Rich in Growth Factor in Dental Implantology: A Comprehensive review of Applications and Clinical outcomes

First author: Arnelle Gibbs

Coauthors: Carmen Silvano Bianca Oprea

Coordinator(s): Medical Doctor Alina Bianca Iacob

Keywords: PRGF Implantology Osseointegration

Background: Plasma rich in growth factor (PRGF) was created by the BTI Biotechnology Institute PRGF®-Endoret Technology to concentrate autologous whole blood into a plasma that is high in growth factor and cytokines. These factors stimulate several biologic functions such as angiogenesis, proliferation, and differentiation. The use of autologous platelets has shown to increase tissue differentiation and accelerate the osseointegration of dental implants through bone apposition. Plasma rich in growth factor also aids in reducing post-inflammation with its anti-inflammatory properties. With a significant decrease in overall inflammation there is lead to successful healing conditions which promote the complete success of implant osseointegration. The PRGF technique has also been coined as a patient specific treatment and has eliminated the chances of patient reactions and complications associated with foreign substances. Faster recovery and improved patient experience are also solid benefits when using plasma rich in growth factor. 
Objective: This study aims to adequately investigate the process, outcomes, benefits, and drawbacks used in the application of plasma rich growth factor in dental Implantology. Patients were examined after using PRGF in preparation for and during dental implant interventions. 
Material and Method: For this study the step-by-step process of PRGF harvest was documented using guidelines, materials and patients obtained from the Dr. Leahu -Corident, Sibiu dental clinic. Results: Implant therapy is a predictable treatment which usually has excellent long-term results. When teeth are lost the alveolar process undergoes dimensional changes. The extent of these changes influences the overall comprehensive treatment planning. Plasma rich in growth factor has been used to assist with bone and tissue healing along with bone regeneration around implants. The biologic properties of PRGF use autologous platelet- derived growth factors to stimulate many biologic functions such as angiogenesis and proliferation. Each of the cases observed showed that there were considerable amounts of bone maintenance and formation, no post surgical infections, minimal inflammation, osseointegration and overall healing time was shortened. In the case where plasma rich in growth factor (PRGF) was used in post extraction for alveolar ridge preservation there were major improvements in the ridge and socket area. All cases were obtained from Dr. Leahu-Corident clinic, Sibiu through Dr. Angelica Oprea.
Conclusions: In conclusion, plasma rich in growth factor (PRGF) showed promising outcomes in promoting tissue regeneration, wound healing and osteointegration capabilities. This study confirmed that there is usually a higher rate of success in implants when used in conjunction with plasma rich in growth factors, than without.   

Practical contributions to texture analysis of cosmetic products

First author: ANDREEA BUSUIOC

Coordinator(s): Associate Professor Paula Antonoaea , Professor Adriana Ciurba

Keywords: texture analyzer cosmetic products compression TPA

Background: In the current era of the cosmetic industry, there is an increasing emphasis on quality products, and consumers are starting to pay more attention to the skincare products. An important aspect in this regard is the texture of the product and the way it feels on the skin, which contributes to the general perception of product quality and user satisfaction.
Objective: The aim of this research is to investigate and compare the texture characteristics of two cosmetic products (P1 - moisturizing mask, and P2 - repair mask) from the facial masks category. 
Material and Method: The practical aspect of this study focused primarily on the texture profile analysis (TPA) and compression properties of the cosmetic samples using a Texture analyzer TX-700 instrument (samples evaluated at 23.5°C±0.2°C). Texture profile analysis allows the evaluation of the following parameters: hardness (the strength needed to cause a deformity), cohesiveness (the inherent bond of the load that must be defeated to distribute the product on the skin’s surface), adhesion (correlated to the stickiness and responsible for the formation of a bound with the facial surface area), and elasticity (the ability of the material to go back to its original height between the two compression cycles). 
Results: The results of this analysis highlighted a deep understanding of the differences between mask textures, providing objective data for their comparison and evaluation. The highest hardness was observed in the case of product P1. Products with greater hardness have poorer spreadability. The cohesiveness ranged between 0.476 for P1 and 0.517 for P2. Even if the face mask P2 had a value of adhesiveness (646.9 mJ) almost double compared with the value of P1 (383.1 mJ), the two products had similar values of elasticity (0.5000).
Conclusions: These findings hold valuable practical implications for the cosmetics industry, providing pertinent information for the development and continuous improvement of products to effectively meet users’ needs and expectations.

Assessment of pain perception in the initial phases of orthodontic treatment with fixed appliances

First author: Daniela-Maria Vizitiu

Coauthors: Teofana Amarie Ana Guștiuc Diana-Maria Matei Nicoleta Mărginean

Coordinator(s): Professor Mariana Păcurar

Keywords: pain orthodontic treatment cementing rings fixed braces

Background: The International Association for the Study of Pain (I.A.S.P.) defines pain itself as an unpleasant sensory and emotional experience caused by or related to actual or potential tissue damage. Psychogenic pain, on the other hand, is considered to be pain arising from the concurrence of pure psychological factors strictly related to the person concerned or the environment in which he or she lives. Because pain is a predominantly subjective experience, it cannot be adequately assessed by indirect methods.
Objective: To associate orthodontic manoeuvres with the intensity of pain perception in patients who have undergone fixed orthodontic treatment. The severity of pain was analysed in relation to common procedures: application of separating elastics, ring cementing, arch ligation, application of elastic traction.
Material and Method: A sample of patients,  good general health, were assessed during the first months of orthodontic treatment with fixed appliances. They completed a questionnaire to assess pain perception. The results were analysed with Microsoft Excel 2010  and SPSS software, and the statistical value was determined using Student's t-test and ANOVA test. The graphs used to illustrate the results included Pie, Line, Column, Bar, Doughnut in both 2-D and 3-D versions.
Results:  Pain intensity, measured on a large scale, with most patients reporting pain. The most painful period experienced was in the first days after treatment. Self-medication was associated with greater pain, and men generally reported more intense pain than women. Statistical tests confirmed significant differences between genders and between age groups. Pain intensity during orthodontic procedures varied, being greater for ring cementation and arch activation, with olds having more intense pain.
Conclusions: Pain in orthodontic treatment is an important risk factor and its management may involve the use of various methods, including verbal and non-verbal communication, anaesthesia and pain medication. In this study, the majority of patients reported moderate levels of pain. The most intense period of pain was during the first days after the application of fixed orthodontic appliances. The most painful procedure was ring cementing, especially among patients young.

Toxicological Assessment of Bisphenol A Released from Dental Materials: A Literature Review

First author: Teofana Amarie

Coauthors: Daniela-Maria Vizitiu Diana-Maria Matei Ana Guștiuc Oana-Paula Butean

Coordinator(s): Associate Professor Bernadette Kerekes-Máthé

Keywords: bisphenol A dental materials literature review dental composite

Background: Bisphenol A (BPA) is a synthetic organic compound used as a monomer in the production of polycarbonates, epoxy resin and methacrylate. In dentistry, it can be released during the photopolymerization of dental materials. It is toxic at a certain level and it can influence or produce changes in hormonal activity, asthma, diabetes, obesity, behavior changes, cancer, infertility and genital malformations.
Objective: The objective of this review is to assess data regarding the release of BPA from dental materials and its level in the human body as reported in the scientific literature.
Material and Method: A review of the scientific literature was performed by searching PubMed database articles, based on the PRISMA guideline for systematic reviews. The key words used to search were ”Bisphenol A resin composite toxicity”, ”Bisphenol A urine dental”, ”Bisphenol A toxicity dental”, ”Bisphenol A dental materials HPLC”. The newest articles have been selected, between 2019 and 2023. 
Results: The database issued 98 articles. After the first selection we had 25 articles, after the second selection 16 relevant articles were included in the present review. The extracted datas were the materials and methods, the analysed period and the obtained results. Studies that analysed BPA through high-performance liquid chromatography (HPLC) were included. BPA levels were measured from saliva and associated with the use of dental composites and dental sealants. The amount of BPA increased after polymerisation from an average of 2 ng/ml to 35,5 ng/ml in 1 hour and it kept increasing with time. We found no relevant data in the literature regarding levels of BPA in the urine and blood. The studies conducted on specimens of dual cured resin cements did not detect BPA. On the contrary, the ones made on dental composites and compomers concluded that the amount of BPA increases in the first hour after application. The released BPA level depends on the photopolymerization method and it can be decreased by finishing and polishing. The amount of BPA released from dental composites has an average of 2-35,5 ng/ml. The problem that occurs is that the tolerable daily dose is 0,2 ng/kg of body.
Conclusions: Based on the included studies, the amount of BPA released from dental composites depends on different factors and it has an average value bigger than the tolerable daily dose. The release is very high and it can cause changes in the body. BPA can be absorbed in the oral or gastrointestinal mucosa, which can produce systemic toxic effects.

Dental dyschromia. Etiology and therapeutic options.

First author: Ana Guștiuc

Coauthors: Daniela-Maria Vizitiu Teofana Amarie Diana-Maria Matei

Coordinator(s): Professor Mariana Păcurar

Keywords: dental dyschromia white spot lesions fixed orthodontic treatment enamel demineralization

Background: Dental dyschromias represent a significant challenge in terms of dental aesthetics. Any deviation from the shade of bright white can be perceived as an anomaly, causing aesthetic discomfort and damage to self-esteem. It is remarkable how such a subtle characteristic as tooth color can have profound repercussions on the social and emotional dimension of an individual's life.
Objective: The purpose of the study was to evaluate the etiology of dental dyschromia, the frequency and the establishment of some prevention measures.
Material and Method: The study was carried out on a group of 85 patients, aged between 15 and 30 years, who underwent fixed orthodontic treatment at UMFST. The diagnosis was established by consultation, by visual and tactile examination with appropriate magnification and lighting.
Results: Of the total group of 85 patients, 27 (36%) patients presented with WSL. Male patients represent more than half of the studied group (51%); The distribution of WSL by age and teeth categories shows that the 15-20 year old category has the highest incidence of white spot lesions. There is a correlation with increased consumption of acidic foods/beverages at this stage in life and with a more concise, rapid oral hygiene. From the point of view of WSL distribution on the dental arches, it was found that their number is higher in the maxilla (57%) compared to the mandible (43%). The distribution of dyschromias by tooth category shows that in the studied group the most affected are the incisors followed by the canines and premolars. Half of the WSL are located on the vestibular surface of the teeth.
Conclusions: The application of brackets induces an increase in the volume of bacterial plaque, and the plaque has a lower pH than that found in patients without brackets, thus increasing the number of acidogenic bacteria. The prevention consists in: before applying brackets, the periodontal indicators are evaluated, a hygiene instruction is given and its compliance is verified at the controls, vicious habits are deconditioned and acidic drinks are avoided.

Histopathological changes associated with road traffic accident injuries - study based on autopsies.

First author: Andrea Bereczki

Coauthors: Adriana Bodnaruc

Coordinator(s): Lecturer Laura Chinezu

Keywords: road traffic accidents histopathology macroscopic and microscopic examination

Background:  Fatalities related to road traffic accidents (RTAs) are classified as "unusual death" and are subject to an autopsy. Forensic histopathology establishes the cause of death based on microscopic analysis of tissue samples collected from internal organs, also taking into account the macroscopical findings for interpretation.  
Objective: This study aims to investigate the histopathological findings in RTA victims and to identify patterns of injuries and correlations between microscopic and macroscopic changes in the major organs. 
Material and Method: We collected 94 consecutive autopsy reports of RTA victims from the Institute of Forensic Medicine of Târgu Mureș, performed between 2020 and 2021. A cross-sectional observational study was carried out. We investigated the distribution of age and gender. Microscopic and macroscopic findings in the brain, heart, lungs, and liver were analyzed. 
Results: Of all 94 autopsies, 76 were male and 18 were female, with an average age of 49 years (6 months-87 years). Almost every report included a brain sample (90/94) and it was microscopically examined in 70% of cases. The most frequent macroscopic findings were cerebral edema (59,5%), followed by cerebral contusion and laceration (43,6%) and subarachnoid hemorrhage (31,9%). Cardiac muscle samples were included in 89,3% of reports and were microscopically examined only in 43,6% of cases. Macroscopic cardiac lesions related to RTA (ventricular laceration and contusion) were identified in 12 cases (14,2%) and many of them (75%) were also microscopically confirmed. Chronic cardiac lesions were noted in 60% of cases and were confirmed microscopically in 70% of examined cases. Lung samples were taken in almost all cases (93/94) and were microscopically examined in 91,4% of cases. Both lung contusion and bronchopneumonia were macroscopically seen in 29% and bronchopneumonia was microscopically found in 36,1% of cases. Liver samples were taken in 73% of cases and microscopically examined only in 31,9%. Macroscopic changes related to RTA, especially liver laceration, were seen in 30% of reports and were confirmed microscopically in 61,9% of cases. 
Conclusions: Information obtained in this study helps to establish injury patterns related to RTA. Most of the gross findings had significant microscopic resonance. Correlation between the lesions found in the major organs gives an enhanced comprehension of the contributing factors in the cause of death. 

Metabolic syndrome in apparently healthy cardiovascular individuals

First author: Vasile Luchianic

Coauthors: Savca Dumitru

Coordinator(s): Associate Professor Vetrilă Snejana

Keywords: Metabolic syndrome Cardiovascular risk LIVE-CVD SKORE2-OP

Background: Metabolic syndrome represents a cluster of factors significantly elevating the risk of cardiovascular diseases, a growing concern in both Western civilizations and developing nations like the Republic of Moldova. Data indicates a rising prevalence of key risk factors: overweightness -51.0%, obesity -19.1%, high blood pressure -49.1%, and hypercholesterolemia in 47.1% cases. 
Objective: To assess metabolic syndrome among apparently healthy cardiovascular individuals.
Material and Method: A prospective observational study was conducted on 70 apparently healthy cardiovascular individuals using a pre-designed questionnaire. Metabolic syndrome (MS) was diagnosed based on meeting 3 out of 5 criteria. Assessment tools included the SCORE-2 OP, LIVE-CVD chart, and PHQ-9 form for depression. Statistical analysis utilized the EXCEL program.
Results: The study cohort had an average age of 47.27 ± 1.38 years, with 33 (47.1%) men and 37 (52.9%) women, predominantly from rural areas (66.7%), most were married (79.2%), with medium-level education (50.0%), employed (62.5%). Metabolic syndrome was present in 24 (34.3%) subjects, with 10 (41.7%) men and 14 (58.3%) women affected. Diagnostic criteria included abdominal circumference in 100% of men vs 93.0% women, low HDL - 30.0% men vs 43.0% of women, hypertriglyceridemia -80.0% men vs 71.4% women, hyperglycemia - 50.0% men 42.8% of women), and hypertension -100% of cases. Regarding risk factors, obesity was in 91.7% smoking - 45.8%, premature family history - 45.8%, and psychological factors in 95.8% of cases. Comorbidities: chronic kidney disease -26.1%, COPD - 16.7%, inflammatory diseases - 41.7%, and migraines (12.5%). The LIVE-CVD calculator estimated an average life expectancy of 83.6 (73-90) years and 10-year cardiovascular event risk of 6.0 (0.10-17.0) % while current risk was of 39.6 (4.7-50) %. For subjects with MS controlling risk factors could increase life expectancy without cardiovascular diseases by 1.5 years and decrease the estimated 10-year risk by 2.41%, with a reduction of 19.48% in the current risk.
Conclusions: Metabolic syndrome affected 1/3 of apparently healthy cardiovascular individuals, primarily due to hypertension, obesity, and hypertriglyceridemia. Two-thirds of those with MS have moderate to high cardiovascular risk, emphasizing the importance of controlling risk factors to potentially reduce cardiovascular events by 19.5%.

Ochronotic arthropathy- A Case Report

First author: Vlad-Nicolae Rusu

Coauthors: Edna Iordache Andrei Feier Teodora Leonte

Coordinator(s): Professor Tudor Sorin Pop , Associate Professor Octav Marius Russu

Keywords: Alkaptonuria Ochronosis Arthroplasty Hip

Introduction: Alcaptonuria is a highly rare autosomal recessive metabolic illness with an aproximately 1:1.000.000 birth frequency, causing articular buildup of grey-blue pigment known as ochronotic arthropathy (OA). The etiology is represented by a mutation of the homogentisate gene 1,2-dioxygenase (HGD), deficiency that leads to accumulation of homogenetic acid in the connective tissue and blood. 
Case Report: We present the case of a 76-year-old patient, previously diagnosed with type IV Lobstein Osteogenesis Imperfecta, gonarthrosis, spondiloarthritis, who is admitted in 2021 in the Orthopaedic Clinic with complaints of right hip pain sensitivity, functional impairment with limited movements. Following preoperative care for total hip replacement surgery, right hip arthrotomy is initiated, during which a black friable intraarticular matter is distinguished. Hence, arthroplasty is delayed until a morphopatological examination is conducted. The examined compact bone tissue revealed microscopic area of residual cartilage with brown pigment. Upon examination, the synovial tissue presented pigmented hyaline cartilage lesions, inflammatory tissue, as well as foreign-body giant cells, thus establishing the diagnosis of ochronosis. Ultimately, the patient underwent total hip arthroplasty, with no intraoperatory complications. 
Discussions: While there is currently no cure or prophylactic treatment for alcaptonuria, first line of treatment involves administration of HPPD inhibitors, such as Nitisinone, which is known to be effective in decreasing homogensic acid by up to 95%, along with vitamin C supplements for their antioxidant properties. In cases of OA, patients typically seek medical attention after joint involvement, as symptoms often manifest after a latency period. Surgical intervention such as knee, hip or shoulder arthroplasty may thus be necessary. According to current studies, progression of OA cannot be effectively stopped, but rather managed through the modulation of Tyrosine and Phenylalanine metabolism. Consistently, progression of OA leads to degenerative arthritis, precipitating heightened discomfort and diminishing life quality. Ultimately, all instances of OA necessitate treatment via total hip arthroplasty or total knee arthroplasty, with outcomes akin to those observed in classical osteoarthritis interventions. 
Conclusions: Due to symptomatic resemblance between ochronotic and classical degenerative arthropathy, OA should be considered prior to surgical treatment, despite its rarity, based on the family history and clinical findings, which will ensure a better surgical and therapeutical management of the patient. Despite its unusual character, with merely a few reports in medical literature, total arthroplasty is still considered to be the best course of action for patients associating ochronotic degradation of the joint.

Tobacco - a major determinant of dento-parodontal disease in association with other factors

First author: Moldovan Teodor - Andrei

Coauthors: Andrei Nenec

Coordinator(s): Lecturer Adrian Roland Tohati

Keywords: TOBACCO DENTO-PERIODONTAL DENTAL HYGENE

Background: The tabacco is know in history as a recreative or a curative plant, although it has well-known adverse effects as, cardiac or pulmonary disease, even a carcinogenetic impact. Also, in dental field, tobacco is associated with low salivary flow, bacterial plaque and tartar, carious processes, parodontitis and oral cancer.
Objective: This study aims to appreciate the connection between biological and psycho-social factors in using of tabacco, to evaluate if socio-economical and demographic factors in association with tabacco can lead to oral disease, to observe the degree of dento-periodontal damage and also to highlight the possible complications related to single exposure of tabacco or in combination with other factors.
Material and Method: This paper is a questionnair-type study, that includes a number of 130 subjects. The inclusion criteria is represented by tobacco consumers and the following characteristics are evaluated: age and gender, level of education, standard of living, age of starting regular smoking, the presence of general or dental conditions, the process of quitting smoking, the degree of losing teeth and dental sensibility, the presence of other smokers in familiy, the degree of oral hygene.
Results: We have demostrated that tobacco is a major determinant of dento- periodontal disease, alone but also in association with poteating factors. We find that urban subjects are more prone to this harmful habit, resulting a much higher rate of loss of dental structures. Smoking is considered as important as procuring basic food, but more important than dental interventions. Women have a lower rate of quitting smoking compared to men. The act of quitting smoking also increase proportionally with age. People with a higher level of education were more likely to try to quit smoking. The subjects who have one/both parents who smoke, have a significant potential to start smoking before the age of 18. The link between gastro-esophageal reflux and smoking has been confirmed. The subjects with this pathology have an exponentially higher degree of dental sensitivity compared with ,,healty smokers”. Tartar deposits are directly proportional with the number of cigarettes and the absence of teeth. We manage to prove the corelation between the degree of dental hygene and the occurrence of dento-periodontal pathology, which was inversely proportional. 
Conclusions: The goals of this study have been achived, but some aspects require a much more detailed analysis because of the large widespred of this practice and the considerable number of factors that can be associated with.

The utility of scores in differentiating steatosis, steatohepatitis, and fibrosis.

First author: Cristina Trocin

Coordinator(s): Associate Professor Olga Tagadiuc

Keywords: Noninvasive diagnosis, Hepatic scores, Steatosis, Steatohepatitis,

Background: Steatotic liver disease is one of the most common hepatic disorder, which poses a significant economic and health burden worldwide. It can manifest through a wide spectrum of disorders, from steatosis to steatohepatitis, fibrosis, cirrhosis, and ultimately hepatocellular carcinoma. Accurately quantifying the presence and severity of liver disease holds paramount importance in devising therapeutic approaches, prognosis, and stratifying the potential complication risks. 
Objective: The aim of this study was to investigate the effectiveness of widely available biomarker-based scores in identifying liver-related pathological conditions and their stages.
Material and Method: A narrative review was carried out following an extensive search of scientific articles in English with reference to clinical trials published between 2009 and 2024 in major scientific databases, in particular: PubMed, Mayo Clinic Laboratories and Cochrane. Among the 356 articles studied, only 142 were chosen for inclusion in the study.
Results: The phenomenon of hepatic steatosis has shown a vertiginous increase in recent years, where the evolutionary cascade from steatosis to steatohepatitis, fibrosis, and cirrhosis takes more complex diagnostic forms, while the use of invasive tests involves additional risks. Although liver biopsy remains the gold standard for definitive diagnosis and staging of chronic liver disease, it is not the most accessible and suitable, due to its significant resource requirement, inherent invasiveness, and susceptibility to sampling error. In this context, the use of hepatic scores based on serological biomarkers constitutes an alternative, promoted as instruments to address the challenge of early risk stratification in hepatic disease, predict liver-related outcomes, and guide therapeutic interventions. The FibroTest, ActiTest, and SteatoTest have been patented as 'in vitro diagnostic multivariate index assays' designed for the assessment of fibrosis and steatosis grades. These assays are accessible online and incorporate clinical security algorithms adjusted for age and gender. It is noteworthy that these scores exhibit varying performance characteristics across different liver disease contexts, decreasing the necessity for invasive investigations, being rapid to perform and analyze, cost-effective, and reproducible. They also distinctly differentiate between various entities in liver pathology, such as inflammation and fibrosis, while remaining unaffected by impairment in liver function. Furthermore, they possess the capability to predict both progression and regression of liver conditions.  Conclusions: Noninvasive scores are easy and nonexpensive tools to screen for steatosis, steatohepatitis and advanced fibrosis. Furthermore, these scores can be applied across a broad spectrum of patients, facilitating early diagnosis and reducing the incidence of patients identified in advanced stages of the disease.

Idiopathic central pontine myelinolysis

First author: Dariana Pop

Coordinator(s): Assistant Professor Laura Iulia Bărcuțean

Keywords: Idiopathic pontine myelinolysis Hyponatremia Demyelination

Introduction: Central pontine myelinolysis (CPM) is a rare neurological disease characterized by non-inflammatory demyelination in the pons. The most frequent cause of CPM is a significant shift in serum osmolality during metabolic corrections, mainly hyponatremia. 
Case Report: We present the case of a 30-year-old female with no prior medical history, no alcohol consumption, who presented with diplopia, followed after one week by a decrease in muscular strength, gait ataxia, progressive dysarthria, and swallowing difficulties. Neurological examination revealed no meningeal signs, bilateral ataxic gait possible for less than 20m, bilateral divergent strabismus, horizontal diplopia, left peripheral facial palsy, diminished gag reflexes, dysphagia, spastic quadriparesis, brisk deep tendon reflexes, bilateral Babinski sign, bilateral dysmetria, dysarthria, GCS 15 points. Brain MRI with contrast revealed bilateral ponto-mesencephalic and bilateral cerebellar demyelinating lesions with restricted diffusion on DWI, showing a "bat-wing" appearance at the level of the pons, with no contrast enhancement, suggestive of central pontine and extrapontine myelinolysis. There were no recent metabolic abnormalities in the patient's history. Paraclinical investigations, including autoimmune, metabolic, and hormonal panels, were unremarkable except for positive anti-CMV IgM antibodies. The lumbar puncture was within normal parameters, and anti-CMV IgM and IgG antibodies from the cerebrospinal fluid were negative. Treatment with corticosteroids, B vitamins, and kinesiotherapy resulted in favorable evolution. She was discharged with immunosuppressive therapy, azathioprine, which resulted in consistent improvement. At the 6-month reevaluation, the patient was able to walk unassisted, with persistent mild bilateral strabismus, mild left peripheral palsy, quadriparesis grade 4+, and mild bilateral dysmetria. The brain MRI findings remained unchanged.
Discussions: The radiological characteristics were suggestive of the diagnosis of CPM, but the patient's clinical history revealed no significant causes for electrolyte and osmotic disturbances. 
Conclusions: We interpret the case as idiopathic CPM in the absence of any precipitating risk factors. Immunosuppressive therapy with azathioprine and corticosteroids proved to be effective.

BRAF V600E Advanced Melanoma Management: A Case Report

First author: Mara Gabriela Cătălin

Coauthors: Maria Ababei

Coordinator(s): Associate Professor Claudia Cristina Burz

Keywords: melanoma BRAF V600E targeted therapy immunotherapy

Introduction: Melanoma is a melanocytic malignant tumor responsible for less than 10% of skin cancers but is simultaneously the main cause of skin cancer mortality. The aim of this case report is to present the management of a patient with superficial spreading melanoma and BRAF V600E mutation. 
Case Report: A 67-year-old male patient with a 1.5 cm cutaneous black lesion with ulceration and a satellite lesion on the proximal third lateral part of the left leg came to the Cancer Institute. The ultrasound detected chronically reactive features in the left inguinal region, suggestive of regional lymph node involvement. Wide local excision and left inguinal lymph node dissection were done. Histopathological specimen examination confirmed the diagnosis of superficial spreading melanoma, a Breslow thickness of 7 mm, and Clark Level IV, pT4bN2aL0V0R0, stage IIIC. The patient started treatment with Interferon. After ten months, a CT scan identified nonspecific pulmonary nodules, located mostly subpleural and with the largest one being of 6 mm in the lateral basal segment. At one year distance, another CT scan was done, and it showed a few nodules up to 12 mm diameter in both lungs, indicatory of pulmonary metastases. The BRAF V600E mutation was diagnosed, and treatment with Dabrafenib and Trametinib was initiated. After eight months of treatment, pulmonary metastases regressed, and fibrotic changes appeared. Some adverse effects appeared, without the need for discontinuation of treatment: gastrointestinal toxicity grade I, headache, hyperglycemia, grade 1 thrombocytopenia. Following three years of targeted therapy, a cutaneous metastasis on the left arm appeared and it was excised with surgical margins. In multidisciplinary team, it was decided to continue the same treatment due to oligometastatic disease. BRAF+MEK inhibitors were administered for six years until the onset of cerebral metastases, treated by surgery. In the present, the patient with good performance status has started immunotherapy with checkpoint inhibitor, PD L1. 
Discussions: Approximately 50% of melanomas have BRAF mutations, 90% represented by V600E mutation. These mutations activate the MAPK pathway. The BRAF V600E mutation is a positive predictive marker because targeted therapies improve survival of patients with late-stage melanoma. That is why BRAF mutation testing is important for an informed treatment decision. However, recurrences can appear even after surgery and adjuvant therapy, like in our case report. 
Conclusions: This case report shows the importance of targeted therapies after molecular testing and vigilant surveillance for the prevention of melanoma recurrence.

Unravelling the impact of Graves’ disease on bone mineral density

First author: Emilia Aioanei

Coauthors: Stefania Catalina Anghel

Coordinator(s): Professor Maria Ionela Pașcanu , Medical Doctor Paula Maria Chirilă

Keywords: Osteoporosis Hyperthyroidism Graves’ disease Fracture

Introduction: Osteoporosis is a disease characterized by decreased bone mineral density caused by changes to the microstructure of the bones and can be complicated by fragility fractures. There are three types of osteoporosis, depending on the triggering factors. Primary osteoporosis includes postmenopausal osteoporosis and that of old age. Secondary osteoporosis appears in the presence of certain treatments, including glucocorticoids or is caused by various diseases such as hyperthyroidism and hyperparathyroidism. Mixed type occurs when primary and secondary causes coexist. Case Report: We present the case of a 57-year-old female that was diagnosed with severe osteoporosis two years after entering menopause, complaining at that time about lower back pain and the inability to move. MRI showed recent compression fractures at T11, T12, L2, L3 vertebrae and an old one at the L5 level, for which Ibandronate treatment was started. One year later, despite this medication, the patient was still complaining of continuous articular pain. Secondary causes of osteoporosis were investigated. The patient presented an adrenal incidentaloma, with negative screening tests for Cushing syndrome. Also, the thyroid function was evaluated, with a suppressed TSH (0,0001 uUI/ml), elevated levels of free T4 (2,63 ng/dl) and free T3 (4,93 pg/ml). High TSH-receptor antibodies (3,9 UI/l) confirmed the diagnosis of Graves’ disease, for which Methimazole was prescribed, the patient attaining an euthyroid state under treatment. Teriparatide was prescribed for the osteoporosis. After two years, the treatment was pursued with Denosumab. In time the patient had a favorable symptomatic response and an improvement in Dual X-Ray Absorptiometry scores. Discussions: This case report highlights the effects of Graves’ disease on the mineral bone mass, adding a risk towards developing osteoporosis. Elevated thyroid hormones from hyperthyroidism will activate osteoclasts and accelerate the turnover of bone. Furthermore, thyroid hormones may lead to a reduction in the level of active vitamin D, decrease the absorption of calcium and phosphorus in the intestine and increase the excretion of calcium and phosphorus in the kidney. Conclusions: Graves’ disease can be complicated with osteoporosis and fragility fractures, associated with increased morbidity and mortality. It is crucial to seek and manage hyperthyroidism, so that we can reduce its impact on bone metabolism and the fracture risk.

Synchronous breast and lung cancer in Li-Fraumeni syndrome

First author: Cristiana Guzu

Coauthors: Maria-Teodora Gruian

Coordinator(s): Lecturer Andreea Cătană

Keywords: Li-Fraumeni cancer hereditary prophylaxis

Introduction: Li-Fraumeni syndrome is a rare, autosomal dominant disorder characterized by mutations in the TP53 tumor suppressor gene. Affected individuals have an increased risk of developing a wide range of cancers at a young age, including sarcomas, breast cancer, leukemia and adrenal gland tumors.
Case Report: We report the case of a 35 year old woman with an oncological history of a recurrent malignant Phyllodes tumor on the right side. The patient had surgical interventions in 2015, 2016 and 2021, the last one being a mastectomy and a lobectomy of the inferior left pulmonary lobe (for the resection of a pulmonary adenocarcinoma). The somatic molecular testing revealed an allelic load of 70% for the TP53 Arg306Ter variant and 35% for the EGFR Leu858Arg variant. The patient followed adjuvant treatment with carboplatin, pemetrexed and 3rd generation EGFR inhibitors (Osimertinib). Family history revealed that her father died at 32 years old with bronchopulmonary neoplasm and her maternal grandfather at 67 years old with bladder neoplasm. This pointed towards hereditary oncology syndrome so a molecular genetic test was recommended to accurately identify the mutation. The result was positive for a pathogenic mutation at the level of the TP53 gene: c.916C>T (p.Arg306*), that led to the final diagnosis of Li-Fraumeni syndrome. 
Discussions: Prophylaxis is very important in Li-Fraumeni syndrome, as well as avoiding any carcinogenic factors: smoking, radiation exposure, alcohol consumption, high fat diet. Given the fact that the pathogenic mutation in the TP53 gene is linked to a 100% risk of developing a breast neoplasm until the age of 60, considering the patient’s age and the already existing lesion, a bilateral mastectomy with reconstruction is advised. For the prophylaxis of the other specific cancers in Li-Fraumeni syndrome, a multidisciplinary clinical exam, full body MRI and dermatological consult are performed annually, and a colonoscopy once every 2 years. CTs and radiotherapy are contraindicated, as they increase the risk of malignancy. Moreover, the patient has a 2 years old son who tested positive for the mutation; he will need screening.
Conclusions: This case underscores the importance of recognizing Li-Fraumeni syndrome in individuals with a history of early-onset cancers or family history suggestive of hereditary cancer syndromes. Despite its rarity, it poses significant challenges in cancer prevention and management, necessitating a multidisciplinary approach involving oncology, genetics and supportive care services.

Particularities of Idiopathic Intracranial Hypertension Syndrome - a case report

First author: Federica Frau

Coauthors: Federica Menna Samuel Michelini Lucrezia Sanna Massimiliano Cori

Coordinator(s): Assistant Professor Laura Iulia Bărcuțean

Keywords: #Intracranial Pressure #Idiopathic Intracranial Hypertension #Pseudotumor Cerebri #Bilateral Papilledema

Introduction: Idiopathic intracranial hypertension (IIH), also known as Pseudotumor Cerebri, is a disorder characterized by the increase of intracranial pressure (ICP) without a detectable cause. Common symptoms include visual changes, headaches, tinnitus, nausea, and vomiting. It primarily affects overweight women.
Case Report: We present the case of a 61-year-old obese woman (BMI 32.3) with controlled diabetes mellitus and subclinical hypothyroidism. She presented with migraine-like headaches, vertigo, nausea, tinnitus, and blurred vision a year before seeking a neurological consult. The ophthalmological consult revealed bilateral papilledema. The brain MRI revealed distended subarachnoid space surrounding the optic nerves with marked tortuosity of the optic nerves, empty sella, normal brain parenchyma and normal arterial and venous structures. The neurological examination was unremarkable apart from bilateral decreased visual acuity. The patient was admitted and treatment with osmotic diuretics and topiramate were promptly initiated, leading to headache and vertigo relief. The lumbar puncture was performed in lateral decubitus on day 5 after diuretic initiation with apparent normal opening pressure. The CSF analysis revealed no abnormalities. The bloodwork revealed a slightly elevated TSH but with normal thyroid function tests. The patient was discharged with chronic acetazolamide and topiramate treatment, along with weight loss recommendations. Over subsequent 1- and 3-months follow-ups, the symptoms resolved. The patient's papilledema has resolved, as evidenced by a normal fundus examination. The 3-month follow-up MRI was stationary. 
Discussions: The combination of clinical symptoms, bilateral papilledema, and characteristic MRI findings supported the diagnosis of IIH. Timely treatment initiation resulted in a positive outcome. The goals are to preserve optic nerve function, decrease the ICP and for overweight patients, weight loss. Complications arise from untreated or treatment - resistant papillaedema, visual loss and persistent elevated ICP.
Conclusions: Early recognition and therapy initiation are essential in managing IIH. It is ideal to follow a multidisciplinary approach based on the patient’s history, physical examination, and neurological and ophthalmological imaging. Prognosis depends on the severity of symptoms, in this case the evolution was favourable. 

GIANT HIATAL HERNIA- A CASE REPORT

First author: Dana Chiriloiu

Coauthors: Adelina Elena Buciuman Nicola Andras

Coordinator(s): Lecturer Daniel Popa

Keywords: Giant Hiatal Hernia Laparoscopy Nissen Cruroplasty

Introduction: The hiatal hernia is considered one of the most common lesions of the diaphragm. The symptomatology consists of: epigastric pain, angina-like pain, dysphagia, heartburn, gaseous eructation or any combination of these symptoms. Giant hernias, constituting 5%-10% of all hiatal hernias, are characterized by the protrusion of over one-third of the stomach into the thoracic cavity. 
Case Report: We present a case of a 74-year-old woman who presented with the following symptoms : epigastric pain, dysphagia and respiratory disorders . She was subsequently admitted to the Clinical Emergency Hospital Targu Mures' Surgical Department 1. The patient’s diagnosis was concluded to be a giant axial and rolling hiatal hernia, adherential syndrome, chronic cholecystitis, biliary sludge with cardiovascular and pulmonary comorbidities, for which exploratory laparoscopy with adhesiolysis, laparoscopic repair of the hiatal hernia, posterior cruroplasty, Nissen fundoplication, retrograde laparoscopic cholecystectomy, and a subhepatic drainage were performed. The postoperative evolution was favorable and the patient was discharged after three days. 
Discussions: This case presentation aims to present one of the three different types of hiatal hernias: type 4 and to accentuate the importance of a well-chosen treatment with great care to avoid any possible complications associated with this pathology.
Conclusions: The treatment of choice for these cases should be the laparoscopic surgery considering the reduced recovery period and the minimized risk of intra- and post- operative complications even in the case of giant hiatal hernia.

Diagnostic approach in refractory anemia: A pediatric case report

First author: Larisa Simon

Coauthors: Ioana Tripon Alexandra Racz Darius-Gabriel Rigman

Coordinator(s): Assistant Professor Andreea Dincă , Associate Professor Mihaela Chincesan

Keywords: Refractory anemia Diagnostic approach Clostridium difficile Inflammatory disease

Introduction: Iron-deficiency anemia is a prevalent hematological condition in children, characterized by low hemoglobin levels often caused by inadequate iron intake or blood loss. However, there are cases where anemia persists despite adequate iron therapy, being classified as iron-refractory feriprival anemia.The objective of this case report is to highlight the crucial role of a rigorous diagnostic approach in the management of refractory iron-deficiency anemia in children, focusing on identifying the underlying cause.
Case Report: We present the case of a 10-year-old boy diagnosed with autism spectrum disorder and iron deficiency anemia for approximately 2 years, who underwent oral iron therapy without any improvement. The patient presents with severe normochromic, normocytic anemia, elevated ferritin levels, as well as increased inflammatory markers (ESR, C-reactive protein). Suspicion of malabsorption arises, as the patient was tested negative for Helicobacter pylori infection and celiac disease, but elevated calprotectin levels were discovered. Subsequent findings raise suspicion of an inflammatory bowel disease. Also, antinuclear antibodies (ANA) were tested and found to be at the upper limit of normal. Following this, the patient was scheduled for a colonoscopy; however, prior to the procedure, a test for Clostridium difficile was conducted, yielding a positive result. 
Discussions: These findings led to the suspicion of an inflammatory bowel disease, potentially underlying the refractory iron-deficiency anemia in this patient. The importance of a meticulous diagnostic approach is highlighted, focusing on identifying the underlying cause to ensure appropriate management and prevent potential complications.
Conclusions: This case exemplifies the critical role of meticulous diagnostic investigations in elucidating the complex etiology of refractory iron-deficiency anemia in pediatric patients. Despite initial therapeutic efforts targeting iron deficiency, the persistent anemia prompted a comprehensive diagnostic workup, revealing potential underlying factors such as malabsorption and inflammatory bowel disease. 

A RARE CASE OF RUPTURED VOLUMINOUS MALIGNANT OVARIAN CYST – CASE REPORT

First author: Dana Chiriloiu

Coauthors: Nicola Andras Adelina Elena Buciuman Andreea Teodora Buciuman

Coordinator(s): Lecturer Mihai Stanca

Keywords: Ruptured ovarian cysts salpingo-oophorectomy malign laparotomy

Introduction: One of the most prevalent gynecological diseases is the ovarian cyst. Abdominal pain is often experienced by patients with ruptured ovarian cysts. The three basic problems that present to the emergency gynecology department—hemorrhage, torsion, and rupture—are referred to as "ovarian cyst accidents."
Case Report: This is the case of a 55-year-old woman who, after lifting a large weight, suddenly developed pelvic-abdominal pain and went to the emergency room. She was subsequently admitted on January 7th to the Clinical Emergency Hospital Targu Mures' Gynecology Department 1. After appropriate preoperative preparation, surgical intervention is performed and the following diagnosis is made : large hemorrhagic ruptured left ovarian cyst, massive hemoperitoneum. The histological analysis revealed no pathological alterations in the right adnexa, omentum, or appendix, but a left ovarian tumor with adult-type granulosa cells (code: 8620/3, tumor stage: IC2). The ovarian tumor's remarkable diameter and the occurrence of capsular rupture were linked to a significant risk of metastasis and recurrence. 
Discussions: This case presentation aims to emphasize the significance of appropriately managed treatment and the need to be extremely careful when making a differential diagnosis because the symptoms of an appendix torsion, an ectopic pregnancy, and hemorrhage from a ruptured cyst are all similar.
Conclusions: The treatment of choice for these cases should be Type B (Querler-Morrow) hysterectomy, with bilateral salpingo-oophorectomy via laparotomy after the evacuation of the hemoperitoneum, accompanied by careful multidisciplinary monitoring of the patient.

Ombredanne's Disease: postoperative common peroneal nerve palsy in a patient with numerous reinterventions

First author: Teodora Ioana Ursu

Coauthors: Anamaria Cozlov Vlad Iustinian Oniga Vlad-Nicolae Rusu Iulia Diana Sabău

Coordinator(s): Lecturer Zoltan Derzsi , Lecturer Dorin Constantin Dorobanțu

Keywords: Ombredanne's Disease Hereditary Multiple Osteochondromas common peroneal nerve palsy exostosis

Introduction: Hereditary multiple exostosis, also known as Ombredanne's Disease is a rare autosomal dominant condition which typically affects prepubescent children. It presents several benign bone excrescences known as osteochondromas, mainly concerning the flat bones and the epiphysis of long bones. One of the most frequent complications is nerve compression caused by the exostoses, potentially leading to permanent nerve damage and paralysis
Case Report: We bring forward the case of a 14-year-old patient who was admitted to the Paediatric Surgery and Orthopaedics Department in Targu Mures with Hereditary Multiple Osteochondromatosis diagnosed 2 years prior to their current admission, with a medical record of multiple interventions, including excisions of exostoses from the left scapula, distal bilateral femoral epicondyles and fibular heads with complete removal of the proximal end of both fibulas. Histopathological examination revealed multiple osteochondromas without malignant degeneration. The last consultation revealed that reintervention was necessary due to reduced mobility in the lower left limb, with incapacity of executing dorsal flexion of the foot and paraesthesia along its dorsal aspect and lateral side of the leg. EMG investigation revealed bilateral common peroneal nerve axonal neuropathy with a more severe impairment and stagnation on the left side and a slow, but favourable evolution on the right. An external neurolysis procedure was performed by a multidisciplinary team formed with the Plastic Surgery Compartment in order to release the common peroneal nerve. An “S-shaped” incision was made on the lateral proximal half of the leg with excision of the old scar and after proper dissection, extended thick fibrous tissue was revealed, that enveloped the underlying structures causing local compression. Further dissection was needed to ensure complete release on the full length of the common peroneal nerve from the scar tissue formed after multiple surgical interventions. Afterwards, it was transpositioned posteriorly in the popliteal fossa with the wound being closed in anatomical planes and an intradermic suture.
Discussions: The patient had a favourable postoperative outcome. The wound was clean with no apparent signs of local complications and in just 3 weeks post-procedure, the patient started showing signs of improvement with mobility in the lower left limb.
Conclusions: Due to the progressive nature of the disease until puberty, patients are prone to undergo multiple surgeries. Regular screening, in anticipation of newly grown exostoses and possible complications, such as nerve compression syndromes, is mandatory in order to prevent impending progression to irreparable paralysis

A familial case of MEN2A: everything started from hypertensive episodes

First author: Ștefania Chiper

Coauthors: Georgiana-Loredana Bulgariu

Coordinator(s): Assistant Professor Codruța Gherman Lencu

Keywords: MEN2A medullary thyroid carcinoma pheochromocytoma

Introduction: Multiple endocrine neoplasia (MEN2) is a rare autosomal-dominant hereditary cancer syndrome. It is clinically characterized by the presence of medullary thyroid carcinoma (MTC), pheochromocytoma and primary hyperparathyroidism and at least two of the classical clinical features are required for the diagnosis of MEN 2A.  
Case Report: A 34-year-old female patient presented at the cardiologist accusing hypertensive episodes associated with flush, headache, palpitations. Lab results showed an increased level of calcitonin and a high level of metanephrines. Also, at an adrenal ultrasonography were found some masses so a CT was performed. At a thyroid ultrasonography, calcified nodules were found. With these results, the diagnosis of MEN2 syndrome was suspected. Genetic testing for mutations for RET gene was performed on patient and all first-degree relatives. Genetic testing identified the presence of the pathogenic heterozygous mutation of codon 634 at the level of exon 11. The patient’s children were also tested and are negative for the mutation, instead the patient’s mother has the RET mutation. After diagnosis, the patient underwent total thyroidectomy with right lateral-cervical lymphadenectomy for medullary thyroid carcinoma, partial parathyroidectomy and bilateral adrenalectomy. The histopathological examination of the operative parts revealed the presence of a pheochromocytoma on the right adrenal gland (PASS score = 3) and three pheochromocytomas on the left adrenal gland (PASS score = 0). Following the surgical intervention, the patient received substitutive treatment with levothyroxine 100 micrograms, hydrocortisone 25 mg and fludrocortisonum 0,1 mg. The patient’s mother was diagnosed with medullary thyroid carcinoma and primary hyperparathyroidism. For these conditions, the patient underwent total thyroidectomy with lymphadenectomy and subtotal parathyroidectomy. After the intervention, patient received substitution with levothyroxine.   
Discussions: The particularity of this case lies in the fact it was diagnosed beginning from hypertensive episodes and ending with a diagnosis of MEN2A at a mother and daughter. It is well known that rarely pheochromocytoma may be the first manifestation of MEN2.  
Conclusions: Multiple endocrine neoplasia type 2A (MEN2A) is a rare syndrome that presents as medullary thyroid carcinoma, pheochromocytoma, and hyperparathyroidism. Different mutations lead to different levels of activation and MEN2 is therefore characterized by a strong genotype-phenotype correlation.  

Epigastric Pain Resulting in Acute Myocardial Infarction in a Young Patient and the Implications of Cocaine Use - A CASE REPORT.

First author: Cristiana Petrus

Coauthors: Maria Pîrcălabu

Coordinator(s): Assistant Professor Iuliana Nenu

Keywords: epigastric pain myocardal infarction cocaine use

Introduction: ST-segment elevation myocardial infarction (STEMI) frequently manifests as an acute presentation in the Emergency Department. While chest pain is a hallmark symptom along with dyspnea, arm and jaw pain described as dull, heavy, tight or crushing, a considerable number of patients may not exhibit this symptom upon presentation. Epigastric pain is an unusual but potentially critical presenting symptom of STEMI and it poses diagnostic challenges and underscores the importance of considering a broader range of symptoms in the evaluation of acute myocardial infarction(AMI).
Case Report: 33-year-old male patient, presented to the Gastroenterology Emergency Department due to epigastric pain. He has a pertinent family history, with his father succumbing to acute myocardial infarction at a young age. Paraclinical investigations revealed elevated levels of lactate dehydrogenase(434.00 U/L) and C-reactive protein(8.38 mg/L), markers for myocardial damage. However, there were no modifications in creatine kinase-MB levels. An electrocardiogram was promptly performed, revealing ST-segment elevation in derivations V1-V5 which primarily reflect myocardial ischemia involving the septal and anterior walls of the left ventricle. During the anamnesis, it was discovered that the patient had a history of regular cocaine use. This information adds a crucial dimension to the case, as cocaine consumption is associated with an increased risk of acute myocardial infarction owing its vasoconstrictive and pro-thrombotic effects. The patient was transferred to another hospital where they underwent angiography, angioplasty, and echocardiography. During the angiography, a lesion in the left dominant coronary artery was discovered together with significant subocclusive stenosis. PCI IVA was successfully performed during the procedure and the patient’s condition improved, aided also by the young age. 
Discussions: Patients presenting with epigastric pain benefit from an electrocardiogram(EKG), as a significant percentage of both men and women with acute myocardial infarction report in clinics similar symptoms. Given the prevalence of epigastric pain in myocardial infarction cases, conducting an EKG evaluation is crucial to assess for possible cardiac etiologies and ensure a comprehensive differential diagnosis. 
Conclusions:  This case underscores the importance of prompt diagnosis of acute myocardial infarction, particularly when presented with atypical symptoms such as epigastric pain. The recognition of cardiac involvement in patients with non-specific complaints like epigastric pain is crucial for timely intervention and improved outcomes. Additionally, the importance of cocaine use as a contributing factor to the risk of myocardial infarction cannot be overstated. Healthcare providers should remain vigilant for cardiac events in individuals with a history of cocaine use.  

Histrionic personality disorder and the defense mechanisms used

First author: Ștefan Filip

Coauthors: Alexandru-Nicusor Tomut Feher Aida-Medeea Gadam Yarashov FLORIN SBIERA

Coordinator(s): Assistant Professor Lorena Mihaela Grebenișan

Keywords: Histrionic personality disorder Defense mechanisms Dissociation Somatization

Introduction: Introduction: Dissociative psychotic disorder typically has a sudden onset against a backdrop of structural vulnerability. Often, the personality disorder involved in dissociative pathology is histrionic, characterized by features such as emotional immaturity, egocentrism, self-love, demonstrativeness, and hyperexpressiveness.
Case Report:

Discussions: Discussions: It is noteworthy that the patient lacks a social support network, being divorced, with her children living abroad, relying on a granddaughter who cannot provide the necessary care. Without an adequate social support network, the patient feels abandoned, which may explain the psychotic decompensations she experiences as she tries to overcome obstacles in life, becoming a defense mechanism in this way.
Conclusions: Conclusion: This case highlights the use of primitive defense mechanisms such as dissociation and somatization to cope with difficult situations, considering the patient's intellectual, educational level, and socio-cultural context. It is also worth mentioning that the heterogeneous manifestations of histrionic personality disorder made the patient's diagnosis difficult to establish on a prolonged period.

HDAC6 Inhibitors

First author: Leah Freundlich

Coordinator(s): Lecturer Șerban Andrei Gâz , Assistant Professor Octavia Laura Moldovan

Keywords: HDAC6 inhibitors chromatin anticancer drugs histone deacetylase

Background: Histone deacetylases (HDACs) are a class of proteins which catalyze the removal of acetyl groups from lysine residues from both histone and nonhistone proteins, playing a key role in gene transcriptions as well as in all biological processes involving chromatin. Apart from their catalytic activity, HDACs also control other cellular processes such as apoptosis, angiogenesis, or chaperone function. Several classes of HDACs inhibitors have been synthesized and assessed using in silico or in vitro methods. The interest in HDACs inhibitors synthesis is increasing due to their potential anticancer activity.
Objective: The study aims to cover relevant published literature from the last years, focusing on the important discoveries of HDAC6 inhibitors.
Material and Method: Using PubMed, Wiley, Springer, ScienceDirect, and Reaxys database, we have reviewed the most relevant papers covering HDAC6 inhibitors, as well as some in silico docking studies for different ligands to get the best fit for HDAC6 inhibitors.
Results: Before 1996, fewer than 100 papers were published in the field of HDACs. Since then, the number of articles has increased dramatically, with over 10,000 papers published on the topic, including more then 700 papers addressing HDAC6 and their inhibitors by 2023 and 2024.
Conclusions: However, despite significant interest for the topic, challenges remain in optimizing their efficacy and minimizing off-target effects. New inhibitors are being designed using rational algorithms and even AI platforms. Nonetheless, the cumulative data from the last 15 years underscore the potential of HDACs as valuable tools in both basic research and clinical applications, emphasizing the need for ongoing exploration and refinement of these compounds for improved therapeutic outcomes.

Lethal gene mutation in children - how to manage the inevitable?

First author: Cîrjan Teodora-Gabriela

Coauthors: Alexia Maria Chichișan Luca-Mathew Epuras

Coordinator(s): Medical Doctor Andreea Cătană

Keywords: Duchenne muscular dystrophy Frameshift mutation Molecular therapy

Introduction: The most common hereditary neuromuscular disease conventionally known to this day is Duchenne muscular dystrophy (DMD), affecting 7.1 in 100.000 males. This X-linked recessive muscle disease is characterized by the body’s inability to synthesize dystrophin – a muscle protein responsible for the integrity and alignment of the sarcoplasm to the myofibrils during contraction and relaxation. 
Case Report: We present the case of a 9-year-old patient who despite having an APGAR score of 10 at birth, showed early signs of motor deterioration. Throughout the years, his mother reported severe difficulties in walking (flatfoot, toe walking) and in standing up (positive Gowers sign). The patient also presents with chest pain, sleep apnea, lumbar lordosis and delayed intestinal motility. EKG results reveal left ventricular hypertrophy, while the echocardiogram shows minor tricuspid and pulmonary insufficiency. Blood tests indicate – LDH levels reaching 1162 U/l and phosphocreatine kinase levels 4579 U/l. Liver function tests show elevated AST and ALT levels of 188 and 332 respectively. Molecular testing of DMD gene using NGS methods depicted frameshift mutation caused by the deletion of 2 nucleotides: adenine and guanine, 144_145del. The treatment consisted of Prednisone (3x5mg/day), Aspacardin (¼¼ 0/day), Liv52 (2x5ml/day), Uteplex (1 vial/day), logopedic therapy and kinetotherapy. It was later discovered that the patient presented an underlying cognitive deficiency (IQ=65) struggling with learning and talking, as well as hyperkinesia and anxiety. 
Discussions: Duchenne muscular dystrophy is a lethal childhood myodegenerative condition and at the moment there is no effective treatment available for it. Although the median life expectancy for people with DMD has increased impressively in the past decades, it still doesn’t surpass 27 years old without ventilatory support. Muscle damage appears not only in the limbs, but also in cardiac muscle and diaphragm, hence the cardiac and respiratory failure connected to DMD. Promising medical discoveries include molecular therapy as a form of treatment, such as antisense oligonucleotide-mediated exon skipping which enables the synthesis of semi-functional dystrophin. Research shows that AONs can restore dystrophin in cardiac muscle potentially delaying the evolution of heart failure.
Conclusions: This patient represents a rare case of DMD associated with a late diagnosed cognitive deficiency. Although there is no curative treatment available yet, collateral effects can be managed with conservative care and the disease progression can be delayed. Clinicians should therefore be particularly suspicious in cases where young patients present with characteristic clinical indications of muscle weakness, difficulties walking, calf hypertrophy and lumbar lordosis.

Development and characterization of new hydrogel formulations for the treatment of pain and inflammation

First author: Ioana-Andreea Rughinis

Coordinator(s): Associate Professor Paula Antonoaea , Lecturer Robert-Alexandru Vlad

Keywords: diclofenac sodium hydrogel rheology synthetic polymers.

Background: Cutaneous administration is one of the preferred routes for local administration of therapeutic agents especially in pain and inflammation associated with musculoskeletal disorders. The development of hydrogels as semisolid drug delivery systems has increased the attention of researchers considering their easy administration and optimal pharmacological effect.  Objective: This study aimed to prepare and evaluate the pharmaco-technical properties of new hydrogel formulations based on synthetic polymers (Carbopol₉₄₀ and Carbopol₉₈₀) that deliver diclofenac sodium (the active pharmaceutical ingredient - API) through the skin. 
Material and Method: Two series of hydrogels were prepared: a series of four hydrogel bases in which the type and concentration of gelling polymer were varied (B1-3% Carbopol₉₄₀, B2-2% Carbopol₉₄₀, B3-3% Carbopol₉₈₀, B4-2% Carbopol₉₈₀), and a series of four formulation F1-F4 in which 5% w/w API was incorporated. The physicochemical evaluation of the prepared hydrogels included visual evaluation (macro- and microscopically), pH (potentiometric method), rheological properties (Rheotest RV viscometer), spreadability, and texture analysis (Texture analyzer TX-700). For permeability analysis, a UV-Vis Spectrophotometric method (276 nm) was applied using a Mullerman cell, a synthetic membrane (cellophane), and a phosphate buffer solution pH=6.8 (32°±0.2°C) as a receiving medium.
Results: All the obtained formulations were homogeneous, without air bubbles and particle agglomerations. The pH ranged between 5.1 for B3 and 7.2 for F2, which is within the limits allowed by the official rules (Ph. Eur.10). For all hydrogels, a pseudoplastic-thixotropic flow was observed. Hydrogels based on 2% Carbopol₉₈₀ (B4 and F4) had the highest spreadability (S_B4=3017.54mm²; S_F4=3419.46mm²). Texture profile analysis underlined two important parameters: cohesiveness (which influences the distribution of the product on the skin’s surface) and adhesiveness (which influences the stickiness of the product). In the case of the hydrogel series B1-B4, the values of cohesiveness decreased in order: B3 (0.542)>B2 (0.504)>B4 (0.492)>B1 (0.393), and the adhesiveness decreased in order: B4 (3310 mJ)>B3 (2646 mJ)>B2 (2560 mJ)>B1 (1575 mJ). In the case of the hydrogels with API in composition, F4 had the highest value of cohesiveness (0.566) and F1 had the highest value of adhesiveness (3135 mJ). The amount of API after 8 hours decreased in order: F4 (36.59%±4.70)>F2 (19.91%±2.75)>F3 (17.90%±1.57)>F1 (16.35%±2.22). 
Conclusions: The characteristics of the developed formulations were directly influenced by the formulation variables and they generated differences between the hydrogels. However, it can be stated that all hydrogels presented satisfactory results, and F4 being the most optimal formulation will be integrated in future studies. 

LARGE TORSIONED PEDUNCULATED UTERINE LEIOMYOMA

First author: Adelina Elena Buciuman

Coauthors: Dana Chiriloiu Nicola Andras Andreea Teodora Buciuman

Coordinator(s): Lecturer Mihai Stanca

Keywords:  leiomyoma pedunculated  acute abdomen myomectomy

Introduction: Uterine fibroids are monoclonal tumors of the uterine myometrium, also referred to as uterine leiomyoma. Though deemed benign, they cause significant problems with quality of life for about 25% of women. Despite being common, uterine leiomyomas can only be treated surgically by removal; nonetheless, some research has shown that sex steroid hormones play a significant role in the pathophysiology of these tumors.
Case Report: This is the case of a 39-years old female patient, previously known with major surgical history due to a right lower limb transverse hemimelia, who presented and altered general status, anemia, and acute abdomen. Following the completion of the patient's objective examination, the presence of a polyfibromatous uterus was noted. A massive torsioned left cornual uterine pedunculated leiomyoma with compressive phenomenon, two 4 cm-diameter posterior leiomyomas, and a large intraperitoneal fluid effusion were found. The patient was admitted in the First Obstetrics and Gynecology Clinic of Targu Mures, for the immediate surgical treatment. The histopathological examination revealed the peritoneal fluid with non-atypical mesothelial cells, two 4 cm leiomyomas and a large 10 cm nodular leiomyoma with hypercellular and hypocellular areas with lympho-plasmocytic inflammatory infiltrate, and ischemic necrosis.
Discussions: Our objective is to showcase a specific instance of a big anterior pedunculated uterine leiomyoma that underwent surgical removal due to compression and necrobiosis.
Conclusions: In this specific instance, surgery is the preferred course of treatment. Particular importance must be given to preserving the fertility of patients who have not completed their family planning, as in this case. 

Surviving the Wild: Forensic insights into Human-Bear encounters

First author: Maria Mădălina Mariș

Coauthors: Roxana Maria Chitic Raluca Andreea Galdău Dohotari Diana Maria

Coordinator(s): Lecturer Carmen Corina Radu , Assistant Professor Roberto Timur Hogea

Keywords: Bear attack Injuries Forensic Mauling

Background: Romania harbors over 60% of the European population of the brown bear species (Ursus arctos), leading to an escalation in bear-human encounters resulting in attacks. The injuries inflicted by bear attacks are distinguishable due to their unique pattern characterized by rending and cutting with claws and teeth, setting them apart from other injury types.
Objective: This study aims to conduct a forensic medical analysis of injuries resulting from bear attacks in Mures and Harghita counties during the period spanning from 2018 to 2023. 
Material and Method: Retrieving data from the archives of the Institute of Forensic Medicine in Targu Mures and the Service of Forensic Medicine in Miercurea Ciuc, a total of 29 medico-legal examinations performed on bear attack victims were analyzed. Descriptive statistics and graphical representations were employed to examine the primary aspects of the acquired injuries. 
Results: Analysis of the 29 cases revealed that the majority of victims were male (90%), with a smaller proportion being female (10%). The most frequently affected age group was individuals aged 60-69 years (38%), predominantly residing in rural areas (86%) as opposed to urban locales (4%). Bear attacks were most prevalent during the summer season (38%), followed closely by autumn (35%), with fewer incidents occurring in winter (10%). Among the 29 attacks, 17% resulted in fatalities, while the remaining 83% of victims survived. Among the survivors, the majority of injuries were localized to the upper limb (36%), followed by the skull (30%), thorax (22%), and lower limb (12%). Bite wounds accounted for the majority of these injuries (66%), with fractures (14%), bruising and hematoma (11%), and excoriations (9%) constituting a smaller proportion. 
Conclusions: In forensic practice, distinguishing bear attack patterns from those caused by other biological traumatic agents is relatively straightforward due to the distinct paw and bite marks. Furthermore, the prevalence of injuries to the upper limb suggests a defensive reflex in victims. While bear attacks are infrequent, they represent a significant and tragic manifestation of human-wildlife conflict. Hence, dissemination of information regarding appropriate measures to mitigate such conflicts is imperative. 

Cleaner environment by using different methods for biodegradation of polymeric materials

First author: Doru-Bogdan Covriga

Coordinator(s): Professor Ildiko Peter

Keywords: Biodegradation polyethylene bacteria enzyme

Background: Considering the fact that polimeric materials take a really long time to degrade, up to 1000 years, the rising accumulation of such a waste is a major environmental challenge for modern societies, determining serious global consequences. Therefore, there's an urgent need to find, demonstrate and employ effective eco-friendly techniques to counter traditional disposal methods' hazardous impacts.
Objective: The present paper describes a brief analysis on multiple research papers offering methods for biodegradation of plastic materials using multiple valuable and applicable ways for the global pollution problems.
Material and Method: The primary methods identified thus far involve the biodegradation of plastics through processes such as photo-degradation, thermooxidative degradation, and biodegradation using bacterial and enzymatic agents. However, research indicates that the first two methods mentioned are considered unsuitable due to their harmful environmental impact and/or high cost. The bacterial and enzyme mediated biodegradation approach has demonstrated higher efficiency as it operates without the need for specific environmental conditions, relying on bacteria naturally present in the environment and exhibiting no harmful effects. Biodegradation of plastics involves several steps that bacteria and enzymes take to degrade the material and finally break it down completely. Amongst these steps one can have: biodeterioration, depolymerization, and assimilation. There are various types of bacteria and enzymes targeting specific kinds of plastics, with each bacterium possessing its own lifespan and rate of multiplication. Polyethylene (PE) and Low Density Polyethylene (LDPE) are the most common types of plastic, found in all packaging, and the bacteria that destroy them are Bacillus amylolyticus and Bacillus sporothermodurans found in soil. As an example in these two cases bacteria and enzymes help to drastically decrease the degradation time from 500-700 years to 1-2 months, important outcomes for this important environmental problem.
Results: This enzymatic process disintegrates stubborn plastic polymers into microbial biomass and environmentally benign compounds via biodeterioration, depolymerization, assimilation, and mineralization stages. The key to boosting bacteria's plastic degradation capability lies in optimizing environmental conditions.
Conclusions: Utilizing plastics-degrading bacteria for biodegrading plastic waste is a crucial method to preserve environmental quality and mitigate the issues stemming from plastic waste. This process typically has minimal to no adverse effects on the environment. Enhancing bacteria's ability to degrade plastic waste primarily hinges on optimizing environmental conditions.

Screw conveyors with possible use in the pharmaceutical industry

First author: Iulia Romanți

Coordinator(s): Lecturer Sorin Albu

Keywords: screw conveyor pharmaceutical industry circular crown

Background: The screw conveyors are mechanical equipment that can transport the homogeneous mixture used in the production of medicines from the vessel with the contents to the funnel feeding the homogeneous mixture to the pharmaceutical equipment; The funnel is positioned at the top of the tablet equipment.
Objective: The aim of this work is to design a piece of equipment that has as its main component the screw conveyor. This equipment can ensure productivity through easy use by production operators, as well as maintain product quality by safely conveying the homogeneous mixture.
Material and Method: The circular crown which, due to a deformation surrounding the barrel, was made after precise calculations to get the screw. Thus, it winds around the cylindrical helix whose parameters are: the radius of the cylinder on which the crown is wound, the pitch of the helix and the winding direction. As for the radius of curvature of the circular crown, this was calculated using the semi-axes of the ellipse. The realization of the route on which the circular crown is welded to the cylinder, consists of using a right-angled triangle shaped template, according to the calculations made; the plane of the propeller being exactly the template made. Among the possible materials to be used in the pharmaceutical industry is stainless steel, which has good resistance to chemicals and does not react with drugs, making it perfect in the use and design of equipment. The components of the equipment are in accordance with existing standards; the size of the screw conveyor is a factor that may influence its easy use in industry. Equipment modelling was carried out in 3D format using the design tools provided by Inventor, and 3D printing was carried out using an Ultimaker FDM technology printer.
Results: The screw conveyor can be used without any reservations in the pharmaceutical industry as part of a drug compression equipment. It proves to be easy to use and clean, an important factor in this industry.
Conclusions: The development of equipment is carried out taking into account the ease of use by operators and the benefits it brings to production. The equipment made with the main component of the screw conveyor, being thought and designed for this purpose.

Activation of a quiescent choroidal neovascularization in a patient with degenerative myopia

First author: Nicoleta-Paraschiva Barb

Coordinator(s): Assistant Professor Ioana Damian

Keywords: myopia choroidal neovascularization metamorphopsia OCTA

Introduction: Pathologic myopia (PM) is one of the leading causes of visual impairment worldwide. The pathophysiology of PM is not fully understood, but the axial elongation of the eye followed by chorioretinal thinning is suggested as a key mechanism. PM may lead to many complications such as chorioretinal atrophy, foveoschisis, choroidal neovascularization, rhegmatogenous retinal detachment, cataract, and glaucoma. 
Case Report: A 66-year-old female came to the Ophthalmology Clinic for a routine ophthalmologic check-up. She mentioned experiencing an ocular trauma in her right eye (RE) during her youth. Measured refraction was RE: -19.50 Sf, -4.75 cyl 5° while LE: -19.00 Sf, -2.75 cyl 180°. Best corrected visual acuity (BCVA) RE was counting fingers at 30 cm and LE 0.4 with correction. Anterior segment examination revealed RE: stage 5 hypermature cataract while LE: stage 2+ cortico-nuclear cataract. Ocular fundus examination RE: exibited extensive macular atrophy extending close to the temporal vascular arcades, and LE: temporal papillary staphyloma, with a parafoveolar atrophic area. Optical coherence tomography (OCT) showed LE: hyperreflective material in the parafoveolar area, above the pigment epithelium. OCT angiography (OCTA) LE highlighted a hyperreflective material in the central outer retina, consistent with a choroidal neovascular membrane. Given the absence of symptoms and lack of activity in the neovascular membrane, it has been decided to closely monitor the patient. One month later, she reports the onset of metamorphopsia LE (BCVA=0.2). On OCT section, an increase in retinal thickness is observed, with persistent membrane on OCTA. Therefore, it has been decided to initiate treatment with intraocular injection of aflibercept anti-VEGF 0.05 ml. At the one month follow-up, BCVA improved to 0.4, accompanied by a decrease in retinal thickness observed on OCT.
Discussions: The particularity of the case comes from the single functional eye and the absence of symtoms. We chose to reduce the risks for our patient and monitor her closely. Once the first symtoms appeared, prompt treatment with a single intravitreal injection of anti-VEGF therapy was performed.
Conclusions: The choice to closely monitor the pacient and start Aflibercept treatment once the onset of metamorphopsia appeard led to the most favourable response: a significant improvement of visual acuity with a visible decrease in retinal thickness OCT.

A COMPLICATED CASE OF OSTEODISCITIS TREATED WITH A SIMULTANEOUS ANTERIOR AND POSTERIOR FIXATION

First author: Sabrina Mancino

Coauthors: Naomi Mancino Roberta Civita Samuel Michelini

Coordinator(s): Lecturer Rares Chinezu

Keywords: osteodiscitis epidural abscess discectomy anterior and posterior fixation

Introduction: Osteodiscitis, a spinal infection occurring between the discs, predominantly manifests in the lumbar and thoracic regions, with occurrences in the cervical spine being comparatively rare. However, cervical spondylodiscitis can precipitate a more rapid progression, potentially resulting in significant neurological impairments.
Case Report: A 52-year-old male with a history of chronic cervicalgia and minimal left C5 root foraminal stenosis presented with aggravated cervical vertebral pain, radiating to both upper limbs, accompanied by decreased muscle strength (3/5), and bilateral hypoesthesia, and paresthesia in the C6, C7, and C8 dermatomes. Symptoms emerged three weeks before admission, intensifying over the last three days. Upon presentation to the UPU SMURD service, MRI of the cervical spine revealed osteodiscitis at the C3-C4 level, with a compressive epidural collection impinging on the dural sac. MRI STIR sequences depicted heightened edema in the C3-C4 vertebrae. The patient underwent surgical intervention at the Targu Mures Neurosurgery Department, involving posterior cervical approach with posterior C2-C5 lateral mass fixation and anterior subsequently a cervical approach with total discectomy of C3, decompression of the dural sac, insertion of a C3-C4 intervertebral cage, and fixation with an anterior plate and screws. Infection with Staphylococcus Hominis was noted, necessitating initiation of Vancomycin therapy. The patient was discharged 14 days following surgery, with resolved motor and sensory deficits, and no signs of wound complications. 
Discussions: Surgical management of cervical osteodiscitis remains controversial, with options ranging from anterior, posterior, to combined circumferential decompression with or without instrumentation. Anterior cervical approach with debridement, decompression and fusion provides good outcomes, although circumferential fixation may be preferable in cases requiring anterior cervical corpectomies or involving multisegmental disease. In the presented case, the heightened edema indicated poor bone quality and potential anterior failure, warranting cantilever posterior fixation to mitigate anterior stress. 
Conclusions: Circumferential fixation in cervical osteodiscitis offers robust support, facilitating effective anterior decompression and yielding favorable neurological outcomes, albeit posing greater surgical complexity.

The correlation between clinical and paraclinical in tibial plateau fracture, functional outcomes in medium and long term.

First author: Laurentiu-Raul Stan

Coauthors: Mihai Acon Răzvan Cătălin Son Alina-Valentina Damaschin Nicoleta Mărginean

Coordinator(s): Lecturer Adrian Ivănescu

Keywords: Tibial Evaluation Correlation Patients

Background: A tibial plateau fracture represents a significant injury to the knee joint, with implications on functional status and mobility of the patient. Clinical and paraclinical evaluation are two essential aspects in approaching these fractures, providing critical information for treatment planning and assessing outcomes in the medium and long term. 
Objective: The objective is to demonstrate that the clinical and paraclinical evaluation and their correlation are fundamental in managing tibial plateau fractures and ensuring optimal functional outcomes in both medium and long term for patients. 
Material and Method: During the 4-year period (2007-2010), a total of 123 patients were documented to have been diagnosed with tibial plateau fractures. Evaluation was conducted on 82 patients who underwent both orthopedic and surgical treatments.
Results: The uniform distribution may seem unusual, but considering the age at which patients suffer these fractures, differences in physical conditions, anatomical peculiarities, and decreased bone quality (with hormonal determination) present in females should also be considered. The age extremes range from 24 to 82 years, with an average age of 54.8 years. Regarding the distribution based on the affected side, there is a prevalence of 53.66% (44 patients) in the left knee, to the detriment of the right knee. The patients' provenance is mostly urban (64.63%), due to the larger population in this environment and the more difficult access to specialized medical services for rural patients. Using the Schatzker classification, it is observed that predominantly are type II fractures (the lateral tibial plateau is more exposed and less protected from traumatic agents) (21.95%), but also those produced by other mechanisms, namely types V and VI (24.39% each), the different figures being explained by etiology and the age of the patients within them. Depending on several factors (age, associated pathologies, type of fracture, patient compliance), patients received orthopedic treatment (39.03%), either surgical, followed by plaster immobilization (53.65%), which also determines a shorter or longer hospital stay. Much more commonly encountered are also the etiologies and lesions from the same level by slipping (48%), and these are exclusively found in elderly patients. Considering associated injuries, the most commonly encountered are meniscus injuries, but also associated fractures of the fibula, head, or body, the latter being affected to a very large extent in the case of tibial fractures. 
Conclusions: The correlation between clinical and paraclinical, imaging playing a crucial role, aspects in tibial plateau fracture is essential for establishing a precise diagnosis and an effective treatment plan. 

The coexistence of meningioma and intracranial aneurysm - a rare phenomenon

First author: Laura Băjan

Coauthors: Ada Miruna Baciu Diana-Maria Băban

Coordinator(s): Assistant Professor Vlad Adrian Pădurean , Professor Ioan Ștefan Florian

Keywords: meningioma internal carotid aneurysm surgery

Introduction: Meningiomas are the most common benign intracranial tumors, deriving from the arachnoid layer of the meninges. They are slow-growing tumors; therefore, they may remain asymptomatic for a long period of time and reach a substantial size. Although meningiomas and intracranial aneurysms are both common pathologies in the neurosurgery field, their association is rare, and surgical treatment may be challenging.
Case Report: A 45-year-old female patient, known to have sinus tachycardia, is admitted to the Neurosurgery Department of County Emergency Hospital Cluj-Napoca. She complains of vertigo associated with nausea and an episode of syncope, symptoms that have progressively worsened over the last year. Prior to hospitalization, non-contrast CT, angioCT, and MRI scans revealed a left frontal parasagittal extra-axial mass consistent with a meningioma and an aneurysmal dilatation of the left internal carotid artery without any evidence of rupture or dissection. A combined surgery is performed: a left frontolateral craniotomy to access the aneurysm in case of rupture during the intervention, followed by a left parasagittal frontoparietal craniotomy for the removal of the meningioma; ultimately, the aneurysm is clipped. The postoperative angioCT reveals no hemorrhagic collection and complete mass excision. On the first postoperative day, the patient presents a generalized seizure with spontaneous remission. The patient is discharged on the seventh postoperative day without any other complications during hospitalization.
Discussions: The particularity of this case arises from the order in which these pathologies were approached. Usually, when both masses are present, the aneurysm is clipped first due to the risk of intraoperative rupture and bleeding. Because of the meningioma’s mass effect on the adjacent structures and the significant space it occupies in the frontal lobe, which is needed to access the aneurysm, the meningioma was excised first.
Conclusions: While the resection of a meningioma is generally considered a relatively low-risk procedure, the presence of an intracranial aneurysm can pose therapeutic challenges. This case emphasizes the need for tailored surgical approaches, with the meningioma excision prioritized due to its impact on accessing the aneurysm.

Acute Exacerbation of Caries Lesion during Endodontic Treatment: Iodoform Overload Leading to Abscess Formation- A case Study

First author: Iepure Daiana Andreea

Coordinator(s): Assistant Professor Molnar-Varlam Cristina , Assistant Professor Stoica Alexandra

Keywords: Endodontic Treatment Iod Abscess Complications

Introduction: As every dental practitioner wants the best for those they treat, we occasionally use methods that we know would result in the best outcomes, but we sometimes forget that we also have additional side effects or sensitivities to various materials. In this case we will talk about the effects of the iodoform based filling materials in root canal treatments.
Case Report: For the previous five days, a 24-year-old patient has complained of discomfort regarding her 1.5 tooth. As the practitioner began treating the causative tooth, he decided to seal the canal roots first with calcium hydroxide. As the patient returns after two weeks experiencing pain, the practitioner decides to attempt an alternative strategy by applying iodoform as a temporary root canal filling. Experiencing an acute exacerbation twelve hours later the patient began to experience pain, facial swelling, and bruising, facing now a reaction known as flare up, lately leading to an abscess formation. The symptoms reduce only after a surgical intervention. 
Discussions: The patient desired to know more about the outcome of the endodontic procedure, since the first approach with calcium hydroxide caused agony and pain, the practitioner opted to obturate the root canals with iodoform. This results in the creation of an abscess due to excess iodoform in the alveolar bone. The abscess formed after the iodoform entered the periapical tissues via the apical foramen, causing acute inflammation and pus production. The swelling and bruising improved only after an incision was performed draining the surplus iodoform and reducing the abscess. Given the reason for the abscess formation, the patient was given antibiotic treatment for seven days, along with an incision that stimulated iodoform drainage.    Conclusions:  The abscess developed as a result of secondary endodontic treatment, which caused iodoform surplus in the periapical area, resulting in swelling and bruising. Symptoms subsided only after surgical intervention and the use of antibiotics. Resulting in an effective endodontic treatment.

Pneumomediastinum, Pneumothorax, and Subcutaneous Emphysema: A rare complication of laparoscopic surgery

First author: Vlad-Alexandru Pleșa

Coauthors: Rad Adrian Radu Mădălina - Iuliana Bud Victor Tărîță Razvan Soric

Coordinator(s): Lecturer Mircea Stoian , Medical Doctor Sergiu-Ștefan Laszlo

Keywords: bladder diverticulum pneumothorax generalized subcutaneous emphysema

Introduction:

Case Report: Discussions: Conclusions:

Bullying in the academic environment.

First author: Rares Vrajitoru

Coauthors: Răzvan Cătălin Son Alina-Valentina Damaschin Apostol Eduard Bogdan Ioan Bucelea

Coordinator(s): Medical Doctor Maria Dorina Pasca

Keywords: Bullying Aggressor Victim

Background: The population is divided into two camps: the aggressors and the aggressed. In the long run, both sides suffer. The aggressed tend to become individuals with low self-esteem, insecure about themselves, and with various deficiencies in social integration. Meanwhile, the aggressors tend to flirt with the darker side of life, some even ending up on the criminal side. Both camps can come from unstable or problematic families. This trend has gained momentum also due to adults such as teachers, parents, guardians, as they do not take bullying seriously. They consider it simply teasing among peers that most likely cannot have negative repercussions in the medium or long term, right?
Objective: To bring the term 'bullying' into people's perspective. To find ways to diminish this phenomenon.
Material and Method: As a method of psychological investigation, an anonymous questionnaire consisting of 19 questions was used, encompassing both demographic questions (gender, age, year of study, and faculty) and those related to the subject matter. The sample targeted 57 young adults from the university environment, comprising 45.6% females and 54.4% males, with data collection taking place between September 2023 and December 2023.
Results: Following data analysis, it was observed that the majority of individuals had experienced a bullying situation (77.2%), while 15.8% had not experienced such a situation, and the remaining 7% were unsure if they had experienced it. Among those who completed the questionnaire, 61.4% believe they can receive help from outside sources to overcome such situations, while 22.8% believe they have to cope on their own, and the remaining 15.8% are unsure. The study conducted demonstrates the complex nature of individuals and the changes they may undergo throughout their lives. Thus, 24.6% of individuals have experienced the role of the aggressor, 21.1% are not sure, and the majority have never been in this position (54.4%). A person's character is directly influenced by their past, experiences, and choices made. An important pillar in this development is childhood sports; unfortunately, only 47.4% have practiced a sport, with the majority (50.9%) not doing so.
Conclusions: In conclusion, overcoming a bullying situation requires both the involvement of close ones and strong personal character. Character can be well built and strengthened through practicing high-performance sports from childhood.

Medico-legal, demographic and social considerations in the suicidal act

First author: Mihai Acon

Coauthors: Roxana Maria Chitic Laurentiu-Raul Stan Maria Mădălina Mariș

Coordinator(s): Medical Doctor Cosmin Carașca

Keywords: Suicide Demographic factors Autopsy findings Forensic medicine

Background: With a multifactorial determinism, an abundance of etiopathogenetic factors, often embedded against a backdrop of psychological instability, as well as chronic alcohol consumption or even illicit substance use, suicide remains at a constant level, ranking 10th among the causes of death globally, according to the World Health Organisation (WHO).
Objective: The motivation of this study lies in the collective awareness of a complex and delicate phenomenon that affects both the individual and the community as a whole and it is supported by the need to understand suicidal behavior, focussing on the underlaying factors found in every community.
Material and Method: Data regarding individuals who committed suicide in Mures County were collected from the archive of Targu Mures Forensic Department, over one year timeframe. Medicolegal aspects like suicide method, post-mortem findings and toxicological reports as well as demographic and social aspects were analyzed regarding 83 cases that were identified and included in the study.
Results: Of all cases, 84% were males, 63% belonged to a minority (Hungarian) and 68% being from rural areas. The majority of suicides was commited during spring season (32%), closely followed by summer(24%),autumn(23%)and winter (21%).The most common method encountered was hanging (93.9%) with the presence of atypical ligature marks in 72%, followed by other methods in a much lower percentage (self stabing 3.7%, electrocution - 1.2%, gunshot - 1.2%). Ethanol intoxication was found in 46%, and the majority being represented by men.
Conclusions: Forensic expertise regarding suicide cases remains an essential desideratum regarding their subsequent analysis. The data obtained from forensic physicians, corroborated with the experience of psychiatrists, psychologists and social workers, play a crucial role in identifying preventive methods, treating individuals at risk of suicide, and reintegrating those in distress.

Revealing the Diagnostic Mystery: Single-Plaque Psoriasis - A Case Report

First author: Sofia Leonardi

Coauthors: Francesca Rosaria Cannito Lucrezia Sanna Eva-Maria Haftstein

Coordinator(s): Assistant Professor Decean Luminița

Keywords: psoriasis atypical presentation diagnostic biopsy

Introduction: Psoriasis, a chronic immune-inflammatory skin condition, is prevalent worldwide, affecting approximately 2-3% of the population. Typically, psoriasis manifests in various forms such as plaque, guttate, inverse, pustular, or erythrodermic psoriasis, with symmetric psoriatic plaques on common body areas aiding diagnosis. However, atypical presentations challenge clinicians in accurate identification and management of the condition. Case Report: This case report series highlights two patients presenting with a rare manifestation of psoriasis - a single large, erythematous plaque localized on the lower leg. Despite a lack of typical symmetric plaques and poor response to previous treatments, a diagnostic biopsy confirmed psoriasis. Both patients exhibited significant improvement following local therapy. Discussions: The atypical presentation of single-plaque psoriasis in these cases underscores the importance of considering diverse phenotypes in diagnosing psoriasis. While classical presentations facilitate diagnosis, clinicians should remain vigilant for unusual manifestations to avoid misdiagnosis and ensure appropriate treatment. Further research into the pathogenesis and clinical spectrum of psoriasis is warranted to better understand and manage such variants. Conclusions: These case reports shed light on the diagnostic challenge posed by single-plaque psoriasis, urging clinicians to broaden their diagnostic considerations beyond classical presentations. Early recognition and accurate diagnosis are essential for effective management and improved patient outcomes. Continued research efforts are crucial for elucidating the diverse manifestations of psoriasis and optimizing diagnostic and therapeutic strategies.

The importance of Magnetic Resonance Imaging in describing tumor thrombus extension in a patient with right renal tumor cT3bN1M0 and chronic kidney disease

First author: Roman Bianca Teodora

Coauthors: Sar Iulia

Coordinator(s): Lecturer Călin Chibelean , Other Teodor Toporas

Keywords: Right renal tumor IVC thrombus Doppler MRI

Introduction: MRI is an advanced technique used together with CT in the diagnosis and evaluation of renal tumors, including those with IVC (inferior vena cava) thrombus. MRI can establish the extent of venous thrombus in the IVC and categorize it into one of the grades of Mayo classification. CT provides comparative information only with intravenous contrast administration. 
Case Report: A 70-year-old patient with multiple comorbidities (including chronic kidney disease) was admitted to the Urology Clinic complaining of intermittent right lumbar pain. Following native CT abdomen-pelvis (creatinine 2.22 mg/dl), an isodense, heterogeneous mass with a polycyclic contour was identified in the right kidney measuring 88x104x64 mm, showing infiltrative aspects of perirenal fat, invasion of the posterior renal fascia, and laterocaval lymphadenopathy. No anomalies were described in the right renal vein or the inferior vena cava ,,sic”. Due to the unavailability of MRI, Doppler ultrasound, the only available option in hospital, revealed a thrombus in the right renal vein with a 1 cm extension into the IVC. Laparoscopic right radical nephrectomy was attempted but converted to open surgery due to the size of the tumor thrombus in the IVC, requiring an extended subcostal bilateral xiphoid-pararectal incision. Intraoperatively, an enlarged caliber of the IVC, non-compressible up to the suprahepatic veins, was detected. The release of the liver is practiced, then Pringle maneuver, cavotomy with thrombectomy of a tumor thrombus of approximately 10 cm is performed. Postoperatively, the evolution was favorable with improved renal function (creatinine 1.78 mg/dl) and ,,per primam” healing.
Discussions: For the benefit of a faster postoperative recovery, a laparoscopic approach was chosen, but it was converted to open surgery when the size of the thrombus in the IVC proved to be much larger than was described in Doppler ultrasound.
Conclusions: MRI plays a crucial role in establishing the preoperative diagnosis of renal tumors, especially when contrast-enhanced CT or cavography are not viable options, or in the context of limited experience in using Doppler ultrasound.

"Precision in Uncertainty: Minimally Invasive Management of Ovarian Tumors with Indeterminate Behavior – A Case Report".

First author: Stan Theodor

Coauthors: Lazar Tudor

Coordinator(s): Assistant Professor Francisc Florin Rozsnyai

Keywords: minimally invasive surgery laparoscopy ovarian tumor indeterminate behavior

Introduction: Ovarian tumors with uncertain or indeterminate behavior pose significant challenges in gynecological practice. Minimally invasive surgery (MIS) offers a path to balance effective treatment and preservation of ovarian function. This case report illustrates the precise surgical management of an indeterminate ovarian tumor, showcasing the integration of careful diagnostic evaluation and the strategic use of laparoscopic techniques.
Case Report:  A 35-year-old female presented with a unilocular right ovarian cyst and concurrent subserosal and intramural fibroid nodules, contributing to secondary infertility. A laparoscopic approach was employed to excise the pathologic mass while aiming to maintain the patient's ovarian function. The procedure involved the removal of a unilocular ovarian cyst, measured to be 7-8 cm, and the resection of uterine fibroids, with the largest measuring approximately 2 cm. The technical finesse of the surgery ensured minimal tissue disruption and optimized post-operative recovery.
Discussions: This discussion focuses on the decision-making process in cases with indeterminate ovarian tumors, particularly when fertility preservation is a priority - where there might be the case. It examines the role of MIS in providing high-quality patient care, including the assessment of risks and benefits, technical considerations, and potential outcomes. Moreover, the laparoscopic approach also allowed for real-time visual assessment and decision-making, which is crucial when dealing with indeterminate masses that could range from benign to malignant potential.
Conclusions: The laparoscopic management of ovarian tumors with indeterminate behavior can be highly successful when executed with precision. The case underlines the importance of individualized patient care plans and highlights MIS as a cornerstone for managing complex gynecological conditions. The favorable outcome in this case reaffirms the role of laparoscopy as a safe, effective, and patient-centered approach in gynecological oncology.

THE ASSOCIATION OF RECURRENT NASAL POLYPOSIS WITH UNCONTROLLED BRONCHIAL ASTHMA -MANAGEMENT BY A MULTIDISCIPLINARY TEAM

First author: Naomi Mancino

Coauthors: Sabrina Mancino Roberta Civita

Coordinator(s): Professor Gabriela Jimborean , Medical Doctor Dragos Hutanu

Keywords: severebronchialasthma nasalpolyposis monoclonalantibodies multidisciplinarymanagement

Introduction: The association of bronchial asthma (BA) with polypous rhinosinusitis (PRS) is common. The presence of PRS hinders proper air conditioning and favors focal infections that are often the starting point for asthma exacerbations. The diagnosis and treatment of both conditions are important and involve a multidisciplinary approach.
Case Report: A 20-year-old non-smoking female patient was admitted to the Pulmonology Clinic in Targu Mureș for exertional dyspnea, wheezing, mucopurulent cough, daytime sleepiness, snoring, and headache. The patient has had nasal polyposis for 5 years with 3 tonsillectomy surgeries followed by polyp recurrence and respiratory infections requiring antibiotics or oral corticosteroid therapy. The clinical exam noted nasal congestion, dark circles under the eyes, nasal voice, hypertrophic tonsils in the oropharynx, wheezing and snoring rales, BMI 32 kg/m2, retrognathia, Mallampati III, ACT questionnaire score of 12 points corresponding to uncontrolled asthma (normal 20-25 points). Chest X-ray shows pronounced interstitial markings, pharyngeal exudate showed no current microbial growth, negative ASLO, blood eosinophilia with 460 cells/mm3, IgE levels of 240 U/L, spirometry - moderate obstructive ventilatory dysfunction. ENT examination recommended craniofacial CT and repetition of tonsillectomy in the near future. We established treatment with combined inhaled corticosteroids and bronchodilators, antibiotics (macrolides), mucolytics, topical antiallergics (corticosteroids and antihistamines), oral antiallergics, and considered biologic therapy with benralizumab (anti-alpha chain of the interleukin-5 receptor monoclonal antibody), 30mg subcutaneously, every 4 weeks (2 months), then every 8 weeks. The clinical condition improved significantly, blood eosinophils decreased, and the ACT questionnaire score increased to 22 points (indicating improved asthma control). Preoperative sleep study was recommended to assess the presence of obstructive sleep apnea, as well as pneumococcal and influenza vaccination.
Discussions: The association of BA with recurrent PRS confers severity to both diseases, decreasing the quality of life and leading to multiple asthma exacerbations, focal infections, and the onset of obstructive sleep apnea with intellectual decline, cardiovascular and metabolic complications. The treatment of these associations required both local treatment for PRS and BA, as well as a modern approach with anti-inflammatory biologic treatment with monoclonal antibodies (benralizumab being known for reducing symptoms and exacerbations in severe BA with associated PRS).
Conclusions: The presented case with the association of recurrent PRS and uncontrolled BA in a young patient required complex investigations and a combined multidisciplinary approach. Biologic treatment has contributed to significantly reducing the symptomatology and to improving the quality of life.

BEYOND THE NAKED EYE: UNVEILING MICROMETASTASIS IN GASTRIC CARCINOMA - A CASE REPORT

First author: Ana-Maria Grigorii

Coauthors: Melania- Larisa Grosu Teodorescu Anemona Ioana

Coordinator(s): Assistant Professor Emőke Andrea Szász , Medical Doctor Georgian-Nicolae Radu

Keywords: Micrometastases gastric adenocarcinoma lymph nodes signet-ring cells

Introduction: Gastric cancer (GC) is the fifth most common type of cancer worldwide with adenocarcinoma representing the most prevalent subtype, comprising over 90% of all gastric tumors. Due to its abundant lymphatic flow, stomach cancer poses challenges in assessing lymph nodes (LNs) metastasis, most of them being microscopic metastasis (MM). Therefore, the accuracy of pathological diagnosis and staging is crucial in the management of oncologic patients.
Case Report: We present the case of a 54-year-old male who underwent partial gastrectomy with gastrojejunostomy, for a gastric tumour, previously confirmed on a biopsy. During the pathological handling, an ulcerative-infiltrative tumor mass with elevated borders was observed on the lesser curvature. Microscopic evaluation revealed an infiltrative neoplastic process involving the gastric wall up to the subserosal layer. The tumour presented with a heterogenous appearance, comprising of sheets of neoplastic columnar cells, together with nests and single signet-ring cells surrounded by extracellular mucin. Among the 10 regional LNs sampled and examined, only one exhibited positivity for neoplastic cells. Specifically, we detected a small group of neoplastic cells presenting intracytoplasmic mucin with an eccentrically displaced nucleus located within the marginal sinus of that node.
Discussions: Mucinous adenocarcinoma with signet-ring cell component is among the most aggressive subtypes of GC. MM refers to tumour cell clusters measuring less than 2 mm in the greatest dimension. There are conflicting data regarding MM and their significance, yet it is undeniable that they worsen the prognosis. The pathophysiology of MM involves two critical mechanisms: diminished cell-cell adhesion and degradation of the extracellular matrix by proteolytic enzymes. The unique morphology of signet-ring cells component, characterized by reduced cell-cell adhesion due to mucin-rich vacuoles, exacerbates their poor cohesion, thereby influencing tumor behavior and metastatic propensity. Furthermore, lymphangiogenesis, facilitates tumor cell infiltration into lymphatic channels, enhancing MM in the regional LNs. In our case the presence of the metastatic neoplastic cells was only seen under the highest magnification, which could have been easily missed in other settings. Particularly, the presence of MM had worsened the overall staging. According to some available data, MM have the same prognostic value as lymph node macrometastasis.
Conclusions: With GC being a rising health concern in our country, rigorous pathological assessment of MM is crucial for establishing a precise diagnosis and staging, thereby influencing the quality of life for the patients throughout tailored treatment strategies.

VACCINATION NEXUS: SAFEGUARDING AGAINST INFECTIONS IN MULTIPLE SCLEROSIS MANAGEMENT

First author: Ana Dobrin

Coordinator(s): Associate Professor Valeriu Gheorghiță , Lecturer Violeta Melinte

Keywords: measles vaccination protocols disease-modifying therapies proactive screening

Introduction: Multiple sclerosis (MS), characterized by inflammatory and autoimmune processes affecting the central nervous system, often necessitates immunomodulator therapy. However, these treatments can compromise immune function, increasing susceptibility to severe infections. Vaccination against preventable diseases is crucial in managing MS. Despite vaccination efforts, MS patients, including those receiving disease-modifying therapies (DMTs), remain vulnerable to infections such as measles, highlighting the ongoing challenge of ensuring adequate vaccination coverage.
Case Report: A 44-year-old MS patient, immunized against SARS-CoV-2 but lacking influenza vaccination, has a history of MS since 2016 and is undergoing treatment with Gratiramer acetate (Copaxone) 40 mg/2 days. He presents with respiratory complications suggestive of influenza type A, leading to an unfavorable outcome. Firstly, post-influenza pneumonia is diagnosed, necessitating antibiotic therapy (Fluoroquinolones) based on pronounced inflammatory markers and recent flu history. Subsequently, with persistent fever, asthenia, and cough, the patient seeks care at hospital. Despite the absence of inflammatory markers, a viral recurrence is diagnosed, with symptomatic management recommended. Two days prior to admission, a macular erythematous rash with facial onset and craniocaudal extension and jugular mucosa enanthema appears. Laboratory findings reveal leukopenia, significant inflammatory response, and anti-measles IgM antibodies, confirming measles diagnosis.
Discussions: This case underscores the crucial need for thorough patient screening and vaccination before starting DMT in MS patients. It highlights the delicate balance between managing autoimmune disease and preserving immune function. Interdisciplinary collaboration between neurology and infectious diseases specialists is pivotal for timely interventions and optimal patient outcomes. Additionally, baseline assessment of immunological status, infectious disease history, and vaccination status is essential for treatment decisions. While the patient in this case was vaccinated against measles, the absence of influenza vaccination may have heightened susceptibility to influenza type A infection, emphasizing the importance of vaccination adherence. Furthermore, the emergence of measles highlights the global significance of vaccination, with ongoing efforts needed to prevent disease outbreaks and protect vulnerable populations. Adherence to hygiene protocols, including wearing facial masks and handwashing, is paramount in preventing infectious spread and safeguarding vulnerable individuals. 
Conclusions: In summary, this clinical case underscores the complexities inherent in managing MS patients undergoing DMT treatment, particularly regarding infectious diseases and vaccination status. A holistic approach, emphasizing proactive screening, interdisciplinary collaboration, and adherence to vaccination protocols, is crucial for ensuring patient safety. 

HYPOTRICHOSIS AND JUVENILE MACULAR DYSTROPHY: 4 YEAR FOLLOW-UP

First author: Marina Linari Pérez

Coordinator(s): Lecturer Robert Gabriel Tripon

Keywords: Hypotrichosis and juvenile macular dystrophy Epiretinal membrane Macular hole

Introduction: Hypotrichosis and juvenile macular dystrophy (HJMD) is a rare congenital autosomal recessive disorder caused by a CDH3 gene mutation localized in Chromosome 16, responsible for P-Cadherin codification. P-Cadherin is a calcium-binding protein expressed in the retinal pigment epithelium (RPE) and in the hair follicle. The abnormal or absent presentation of this protein causes an increase in the regressing and catagen phases of the hair growth cycle and a progressive macular degeneration, due to the loss of the RPE integrity. Therefore, the disease is characterized by primary hypotrichosis and early visual impairment. The aim of this case report is to analyse the evolution of the disorder and expose how the affected retinal structures have progressed throughout the 4 years passed since the patient was diagnosed of HJMD.
Case Report: A 20-year-old female patient referred to the Ophthalmology Clinic - Targu Mures in 2020 presenting visual impairment, colour vision alteration and visual field reduction. She reported rutinary ophthalmological appointments since she was 8 years old due to the progressive evolution of visual loss. Additional signs were short, sparse, and limited hair growth of the scalp region since birth, whereas the hair condition of the rest of body was normal. The assessment of visual acuity in the last 4 years revealed further decrease of visual acuity. In addition, OCT scans showed continuous decrease in thickness of photoreceptor layer, atrophy of the RPE, elevation of the foveolar region and epiretinal membranes in both eyes, together with a macular hole in the left eye. Nevertheless, the internal retinal layer integrity was preserved. Finally, genetic testing was conducted to the patient and her family in order to confirm the diagnosis. The parents were found to be consanguineous and heterozygous for the CDH3 mutation. On the other hand, both the patient and her sister appeared to have a homozygous mutation. 
Discussions: Vitrectomy and epiretinal membrane peeling is considered for visual acuity preservation, however, improvement is not expected due to the already existent impairment of the photoreceptors layer. A pharmacological curative treatment is currently undefined.
Conclusions: In this report, we highlighted the presence of epiretinal membrane, macular hole and the asymmetric impairment of vision, which are extremely rare or previously undescribed in the scientific literature of HJMD.

Height, Weight, and Whereabouts: Factors Shaping Pediatric Endocrinology Referrals

First author: Olga Ioana Bădan

Coordinator(s): Assistant Professor Robert-Aurelian Tiucă , Associate Professor Raluca-Monica Pop

Keywords: short stature obesity referral parental factors

Background: Referral for a pediatric endocrinology consult in a child is influenced by socio-demographic factors, parental ones, primary care level of knowledge and the community, among others. The main reasons for pediatric endocrinology evaluation are concerns about height, weight or puberty. 
Objective: The aim of the current study was to analyze the relationship between reasons for referral of a child to pediatric endocrinology and parental and sociodemographic factors. 
Material and Method: This was a secondary data analysis on a non-randomized sample of children presenting for consultation in a tertiary endocrine center in Romania in 2022. The first 100 children were included and families were contacted for consent and further information. 2 subjects were excluded from the final sample due to missing information. Data was collected regarding parental factors – level of education, income, housing, environment, height and body mass index (BMI), auxological parameters – height SDS, BMI SDS, pubertal status, and reason for referral. For data collection MO Excel was used and for statistical analysis SPSS v 25 with a level of significance α=0.05. 
Results:  Fifty-one boys (52%) and 47 girls (48%) were included, 65.3% from urban areas. The main reason for referral was short stature (44.9%, n=44), followed by overweight/obesity (28.6%, n=28) and 26.5%, n=26 presented for other reasons. Housing conditions, urban environment and parental height SDS were associated with the reason for referral, with children from rural areas presenting mainly for height concerns, while the urban environment is associated with obesity referrals (p=0.022) and living in an apartment is associated with concerns over weight (p<0.001) as reason for referral. Children with short stature had shorter parents, with a low positive correlation between parents’ height SDS (r=0.255, p=0.011). Parental level of education and child’s gender had no influence the referral diagnosis. 
Conclusions: Socio-demographic factors have more influence compared with parental factors on pediatric endocrinology referrals.

Acute Severe Ulcerative Colitis Associated with Multilocular Pyoderma Gangrenosum and Episcleritis, Successfully Treated with Infliximab

First author: Cristiana-Maria Roatiș

Coauthors: Maria-Teodora Stan Alexia-Gabriela Roatiș

Coordinator(s): Associate Professor Daniela Șerban

Keywords: Ulcerative Colitis, Multilocular Pyoderma Gangrenosum, Episcleritis, Infliximab therapy

Introduction: Paediatric Inflammatory Bowel Disease (PIBD) represents a major psychosocial issue, given its detrimental effects on patients’ quality of life, growth and puberty, nutritional and bone status, as well as increased healthcare costs.
Case Report: A 15-year-old female was admitted to our clinic in June 2023, presenting 10-15 bloody watery stools/day, postprandial vomiting, involuntary weight loss (8 kg.), altered general condition, episcleritis, and multiple vesicular lesions resembling a herpetic infection. First symptoms were noted in January 2023, 1-2 semi-solid stools/day, intermittently bloody. The paediatrician recommended treatment with oral Sulfasalazine for one month, without any endoscopic/imaging investigation. In our clinic, colonoscopy revealed a „cobblestone appearance” of the transverse colon and continuous inflammatory changes distally; upper endoscopy was normal. The case was initially interpreted as severe Crohn’s disease (CD), prompting initiation of Methylprednisolone therapy and exclusive enteral nutrition. Histological examination revealed active severe Ulcerative Colitis (ASUC). The disease course was unfavourable under the above-mentioned therapy, with persistent bloody stools, requiring blood transfusions and albumin administrations, severe activity, and development of multilocular pyoderma gangrenosum. Consequently, Infliximab was initiated as rescue therapy (recommended in both PIBD types) with prompt excellent response, both intestinal and extraintestinal. The patient was discharged with a PUCAI score of 5. Eight months later, our patient maintains a complete clinical, endoscopic, and histologic remission. 
Discussions: We presented a case of ASUC associated with rare complications, multilocular pyoderma gangrenosum and episcleritis, with a remarkable improvement shortly after Infliximab therapy. Notable is the initial appearance of pyoderma gangrenosum resembling a herpetic infection. The severe endoscopic aspect in the transverse colon with transmural inflammation associated with milder mucosal oedema distally is also worth mentioning. Conclusions: Patients presenting with bloody diarrhea should have accurate testing, recommended by current guidelines, before administration of any therapy. The 5-months delay in diagnosis caused an extremely stressful period for our patient, resulting in a moderate depressive episode, exacerbation of the digestive symptoms, weight loss of 8 kg., requiring albumin and blood transfusions, a prolonged corticosteroid treatment and the need of biological therapy to induce remission. Thus, we want to emphasize the importance of a comprehensive diagnosis work-up in PIBD, established through clinical, biological, coprological, imaging, endoscopic, and histological evidence, as well as the need for prompt treatment; otherwise, invalidating complications may occur.

NELSON SYNDROME: The Irony of Having an Exquisite Feedback

First author: Georgiana-Loredana Bulgariu

Coauthors: Mihai Valeriu Brînzan

Coordinator(s): Assistant Professor George-Dorin Pop

Keywords: Nelson syndrome adrenalectomy generalized hyperpigmentation ACTH

Introduction: Nelson syndrome is a rare condition characterized by a range of symptoms including visual deficits, hyperpigmentation, headache, psychological manifestations and signs of pituitary dysfunction. It arises in 26% of patients who have undergone bilateral adrenalectomy for Cushing's disease treatment. Case Report: In 2019, a 51-year-old male patient underwent bilateral adrenalectomy for refractory Cushing's disease diagnosed earlier that year. Before the initial diagnosis, the patient experienced signs and symptoms for a year including a moon-like face, red abdominal striae, centripet obesity with  buffalo hump, osteoalgia and myalgia.

Discussions: The pathophysiological hypothesis proposes that decreased negative feedback on the hypothalamus, following surgery, may lead to the overdevelopment of the ACTH-secreting tumor. Elevated MSH levels could cause generalized darkening of the skin. The upward extension of the tumor can lead to visual disturbances by compressing the optic chiasm. Thyrotropic insufficiency is caused by the compression of the pituitary stalk and of the pituitary non-tumoral tissue.  Conclusions: Though a rare complication, Nelson syndrome is a complex disorder characterized by the enlargement of the pituitary gland and the overproduction of ACTH. Every patient who undergoes bilateral adrenalectomy should be checked every 3-6 months as early detection and prompt management are crucial for enhancing patient outcome.

Deciphering the Enigma of Massive Localized Lymphedema

First author: Cezar Dan

Coauthors: Georgian-Nicolae Radu Maria Iftime Eduard-Ionuț Iordache Paul Ioan Dan

Coordinator(s): Assistant Professor Emoke Andrea Szasz

Keywords: Diagnostic Complexity Lymphedema Obesity Pathophysiological Insights

Introduction: Massive localized lymphedema (MLL) is an uncommon benign soft tissue lesion characterized by the abnormal accumulation of lymphatic fluid and swelling, typically occurring in the thighs or abdominal region. MLL, often referred to as a tumefactive pseudosarcoma, primarily affects morbidly obese adults and was initially described in 1998 by Farshid and Weiss.

Case Report: We present the case of a 58-year-old male who presented to the Surgery Department with two perineal masses, which appeared approximately 8 years ago but exhibited a notable increase in size in recent months. Upon measurement, the dimensions of these two tumors were 200x170mm and 115x100mm, respectively. Microscopic examination revealed numerous dilated lymphatic capillaries surrounded by a perivascular lymphoplasmacytic inflammatory infiltrate. Extensive fibrotic areas were observed in the deep dermis. Numerous spindle-shaped cells with hyperchromatic nuclei, resembling reactive fibroblasts, were noted. Occasional pleomorphic cells, including multinucleated giant cells of "floret-like" appearance, were identified, with no evidence of mitotic activity. Although atypical mitoses were absent and no features suggestive of malignancy were identified, a definitive exclusion of well-differentiated liposarcoma cannot be made without further immunohistochemical analysis, such as MDM2, CDK4 or RB1. Taking into consideration both the histological features and patient’s comorbidities (Hypertension, dyslipidemia and obesity) we decided for this particular benign condition.
Discussions: MLL predominantly affects obese and hypothyroid individuals, with mechanisms that are not fully understood. The present patient, with a BMI of 32.87, falls into the obese class 1 category. A plausible theory in this context involves tissue infiltration by numerous adipocytes, leading to compression of lymphatic capillaries. A much more accurate theory, insufficiently known, would be the association of the condition with the mixed dyslipidemia suffered by the present patient. In patients with mixed dyslipidemia, characterized by elevated levels of cholesterol and triglycerides, lipoproteins circulate in higher concentrations in the bloodstream. These lipoproteins can infiltrate and accumulate within lymphatic vessel walls, causing structural damage and impairing their ability to transport lymphatic fluid efficiently. Moreover, inflammatory mediators associated with dyslipidemia can exacerbate lymphatic vessel dysfunction by promoting inflammation and fibrosis within the vessels.
Conclusions: Despite significant advancements in understanding MLL since its discovery, diagnostic challenges persist due to its resemblance to malignant conditions. With the increasing global prevalence of obesity, investigating this particular pathology becomes highly relevant. Understanding the pathophysiology and microscopic appearance of MLL is crucial for improving diagnostic accuracy and developing targeted therapeutic interventions.

Unraveling the Complexity: Difficulties in the management of a possible tumoral co-secretion

First author: Valentina Paula Oșan

Coauthors: Anda Ileana Simionescu Alexandra Onea

Coordinator(s): Associate Professor Maria Ionela Pașcanu , Assistant Professor Paula Gliga

Keywords: ACTH-dependent Cushing syndrome vasopressin hyponatremia ectopic

Introduction: Paraneoplastic syndromes are disorders characterized by abnormal production and release of certain proteins secondary to malignancies, causing clinical and paraclinical alterations. Ectopic production of adrenocorticotropic hormone (ACTH) leads to the development of Cushing's syndrome (CS), while ectopic secretion of vasopressin (ADH) causes a syndrome of inappropriate antidiuretic hormone secretion. Case Report: We present the case of an 85-year-old woman with a history of heart failure and hypertension who presented to the emergency department for severe abdominal pain. A CT scan was performed, describing a voluminous tumoral mass located in the region of the left adrenal gland measuring 96/52/56 mm, with heterogenous appearance, a smaller hypodense nodule in the right adrenal gland and a heterogeneous pancreatic nodular lesion at the level of the tail measuring 27/23 mm. No suspect lesions of the head or thorax were found. Dynamic imaging revealed increasing size of the adrenal masses, with infitration of the surrounding organs and vascular structures. During her endocrinological evaluation, laboratory tests showed hypercalcemia with low PTH, most likely in the neoplastic context. She also presented with low sodium and low potassium levels. Screening tests for CS were conducted, showing altered biorhythm of cortisol secretion, raised salivary cortisol at midnight, unsuppressed cortisol secretion after 1 mg of dexamethasone overnight and a high ACTH level of 153 pg/mL, establishing the ACTH-dependent CS diagnosis. Additional laboratory tests and investigations would have been necessary, but due to the worsening health condition of the patient, she was discharged at the request of her family members, with a preliminary final diagnosis. The decision regarding the therapeutic management of this case will be made in collaboration with the oncology department. Discussions: Based on the available data, we interpreted the electrolyte imbalance as hypokalemia in the context of the ACTH-dependent CS most likely of ectopic origin, with the concurrent hyponatremia explained by a possible paraneoplastic co-secretion of ADH, for which further investigations would have been required. The association of tumoral co-secretion of ACTH and ADH is rarely described in the literature and raises issues in establishing the diagnosis and in the management of the patient. Conclusions: Concurrent hypokalemia and hyponatremia in a patient with malignant background poses difficulties in establishing their etiology. Paraneoplastic tumoral co-secretion of ACTH and ADH is very rarely reported.

Preoperative Predictors of Aortic Pathologies: A Comprehensive Examination of Inflammatory and Coagulation Markers Across Surgical Phases

First author: Lucy Zimmermann

Coordinator(s): Assistant Professor Cosmin Banceu , Professor Suciu Horatiu

Keywords: Acute Aortic Dissection Aortic Aneurysm Risk Factors Fibrinogen

Background: Aortic aneurysms (AA) and aortic dissections (AD) present significant challenges in cardiothoracic surgery, with AD requiring urgent and accurate diagnosis due to its potentially fatal nature. The Aortic Dissection Detection Risk Score (ADD-RS) assists in this process by incorporating risk factors, clinical findings and D-dimers to help clinicians categorise patients and select appropriate imaging. Ongoing research is extending this approach by investigating the role of other inflammatory and coagulation markers. 
Objective: The aim of this research is to investigate the correlations and predictive value of inflammatory and coagulation markers for the identification of AA and AD and to analyse their behaviour patterns during the preoperative, perioperative and postoperative phases in order to improve the diagnostic process and patient management.
Material and Method: This single-centered retrospective analysis examined the data from 162 patients diagnosed with AA, AD, or both pathologies, undergoing surgery at the Cardiovascular and Transplant Emergency Institute of Târgu Mureș, Romania, from January 2022-February 2024. The levels of selected biomarkers, namely Leukocytes, Thrombocytes, INR, Fibrinogen, Hemoglobin across different surgical stages and their predictive ability for the presence of AA or AD were evaluated.
Results: 43.8% of the patients included have AA, 43.2% have AD and 13% have both pathologies. The AD group showed positive and statistically significant correlations with leukocytes (r=0.464; p<0.001) and prothrombin time (r=0.274; p=0.009), AA group showed moderate positive and statistically significant correlations with haemoglobin (r=0.267; p=0.001) and Fibrinogen (r=0.297; p=0.015). Both univariate and multivariate logistic regression of AD identified preoperative Leukocytes (OR, 1.342; 95% CI, 1.188 - 1.516; p < 0.001, respective OR, 1.508; 95% CI, 1.236-1.839; p < 0.001) and preoperative prothrombin time (OR, 1.492; 95% CI, 1.023 to 2.476; p = 0.021, respective OR, 1.122; 95% CI, 1.000-1.259; p=0.05), as statistically significant predictors for AD. Multivariate logistic regression of AA identified preoperative Fibrinogen (OR, 1.01; 95% CI, 1 - 1.012; p = 0.021) and Haemoglobin (OR, 1.63; 95% CI, 1.63- 1.06; p=0.025) as predictors for AA. 
Conclusions: Despite the small sample size, significant differences in inflammatory and coagulation markers across aortic pathology groups were observed. Elevated leukocyte counts and longer prothrombin time were linked with AD, whereas increased fibrinogen and hemoglobin levels indicated AA. These findings highlight the importance of considering a wider range of laboratory markers than in guidelines for the diagnosis of aortic disease. It should encourage clinicians, to integrate this knowledge into their assessment in emergencies, but further research is needed to fully address this issue.

LAPAROSCOPIC PYELOPLASTY-A MODERN CURE FOR URETEROPELVIC JUNCTION OBSTRUCTION

First author: Darius-Andrei Iclănzan

Coauthors: Alexandra-Diana Iclănzan

Coordinator(s): Assistant Professor Ciprian-Doru Todea-Moga

Keywords: laparoscopic Hynes-Anderson aberrant vessels ureteropelvic junction kidney stones

Introduction: The obstruction of the ureteropelvic junction is known to be one of the many causes of recurrent hydronephrosis, being also associated with kidney stones. The modern technique of transperitoneal laparoscopic Hynes Anderson pyeloplasty represents an outstanding alternative to the conventional open pyeloplasty, due to the ability to perform a complex reconstruction even if the aberrant crossing vessels are the main cause, which is the case for the most adults who suffer from the obstruction of the ureteropelvic junction. 
Case Report: A 28-year-old male patient was admitted in the Urology clinic of Targu Mures for recurrent left pain in the lumbar region in the last 6 months. His medical history revealed that he underwent a left pyeloplasty in 2014 and several left flexible ureteroscopy. From his ultrasound and computer tomography, the identified cause of pain was an ureteropelvic junction obstruction which led to a pelvic stone of 3x2cm, causing 3rd degree hydronephrosis. Given his normal vital signs and physical examination, the surgery of choice was a transperitoneal laparoscopic dismembered Hynes Anderson pyeloplasty combined with a stone extraction and the insertion of a double “J” ureteral catheter. Through a three 1 cm incision made in the abdomen, the ureteropelvic junction obstruction was removed, while carefully preserving the crossing vessels. The next step was reattaching the ureter to the renal pelvis, creating a proper way to drain the urine. A double “J” ureteral stent was left inside at the end of the procedure to strengthen the pyeloplasty and decompress the kidney, and a lumbar drain was placed.
Discussions: After a 210 minutes operation, the postoperative evolution was favorable, the patient presenting no symptoms of infection or inflammation. He was discharged four days later after the lumbar drain was removed. At the four weeks mark, the ureteral stent was pulled out and the patient showed no signs of lumbar pain. 
Conclusions: Based on the progress seen in this case, the laparoscopic pyeloplasty for ureteropelvic junction obstruction should be taken into account, due to the short recovery period, lower risk of complications, and its effectiveness even in cases where it is associated with kidney stones or aberrant crossing vessels. 

Linking Preoperative Biomarkers to Postoperative Outcomes in Aortic Surgery: A Focus on Acute Kidney Injury and In-Hospital Mortality

First author: Lucy Zimmermann

Coordinator(s): Medical Doctor Daiana Cristutiu , Professor Suciu Horatiu

Keywords: Aortic Dissection Acute Kidney Injury In-Hospital Mortality Glomerular Filtration Rate

Background: Individuals affected by aortic dissection (AD) are at a high risk of developing acute kidney injury (AKI) or even dying in hospital postoperatively. Both outcomes are major concerns by affecting patient prognosis and survival. Current research is investigating how certain specific preoperative patient’s characteristics and conditions during surgery, can help predict serious complications. 
Objective: The aim of this study is to elucidate the predisposing factors for AKI and in-hospital death. 
Material and Method: A total of 91 patients undergoing surgery for AD between January 2022 and February 2024 were identified from Cardiovascular and Transplant Emergency Institute Târgu Mureș database. The primary outcome was postoperative AKI as defined by the Kidney Disease Improving Global Outcome criteria and the secondary outcome was in-hospital death. Pearson correlation and Logistic regression models were used to identify univariate and multivariate predictors of AKI and mortality.
Results: 30.77% of patients developed AKI and 60.7% of these patients died during hospitalization. The AKI group showed mild positive and two statistically significant correlations with history of kidney disease (r=0.255; p=0.015), hemopericardium (r=0.225; p=0.032) and preoperative INR (r=0.263; p=0.05). Univariate logistic regression of AKI identified history of kidney disease (OR=3.789; 95% CI=1.241–11.573; p=0.019) and hemopericardium (OR=2.688; 95% CI=1.076-6.714; p=0.034) as statistically significant predictors for AKI. Multivariate logistic regression of AKI identified both variables as statistically significant predictors (Kidney disease: OR=3.796; 95% CI=1.201– 11.998; p=0.023; and hemopericardium: OR=2.692; 95% CI=1.04–6.940; p=0.04). The ROC curve generated an area under the curve (AUC) of 0.673 for both variables. The percentage of patients who died postoperatively inside the hospital was of 53.85% compared to 46.15% who survived. The deceased group showed a positive correlation with cardiopulmonary bypass (CPB) duration (r=0.249; p=0.031) and a negative with glomerular filtration rate (r=-0.228; p=0.035). During univariate logistic regression the positively associated variable revealed an OR of 1.006 (95% CI=1.000-1.01; p=0.037). The produced ROC curve revealed an AUC of 0.661.
Conclusions: Kidney disease history and hemopericardium were associated with the risk of postoperative AKI and longer CPB time was correlated with in-hospital mortality in patients with AD. These findings emphasize the importance of taking into account a comprehensive range of patients and surgery characteristics in prediciting postoperative outcomes. Further studies are needed to support these findings for optimising postoperative patient outcomes.

The role of osteosynthesis with centro-medullary nail in fractures of the proximal femur

First author: Aldea Dorinela-Ioana

Coauthors: Alexandra Antoce

Coordinator(s): Lecturer Adrian Dumitru Ivănescu

Keywords: pertrochanteric fractures centro-medullary nail orthopedics recovery

Background: We are well aware that pertrochanteric fractures are common among people over the age of 60. They can be associated with various pathologies or occur following minor accidents. Young patients may present this type of fracture as a result of major trauma.  
Objective: To analyse the frequency of pertrochanteric fractures among the population in 2021, as well as to study the incidence of this type of fracture by age group and to evaluate the type of implant chosen by the orthopaedic surgeon according to the particularities of each patient.  
Material and Method: This is a retrospective study including 132 patients who suffered a pertrochanteric fracture and who required hospitalization at the Orthopedics Traumatology Department I of the Emergency Clinical County Hospital Târgu Mureș between 01.01.2021 and 31.12.2021. In order to perform this study, we used the necessary data from the following sources: clinical observation reports of the Orthopaedics and Traumatology Department, the mandatory protocols and the online database of the department to obtain the imagistic investigations. We used the following inclusion criteria patients over 18 years old and a diagnosis of pertrochanteric fracture. Patients were divided into 2 groups: under 60 years old and over 60 years old. Persons under 18 years old were excluded. 
Results: The study included 132 patients, of which 45.5% (60 patients) were from urban areas and 54.5% (72 patients) from rural areas. In terms of age, 53 patients (40.2%) were male and 79 patients (59.8%) were female. Following imagistic investigations, especially radiography, we were able to identify the type of fracture according to the AO classification. As a result, 6.8% (9 patients) were classified as grade I, 3.8% (5 patients) as grade II, 3.8% (5 patients) as grade III, 85.6% (113 patients) as grade IV. Following imagistic investigations, AO classification for 61,4%(81 patients) the decision was made to perform static distal bracing, for 24,2%(32 patients) the decision was made to perform dynamic distal bracing, for 13,6%(18 patients) it was necessary to over-stabilize the fracture with a screw and 0,8 preferred conservative treatment. There is a significant correlation (p=0.0044) between the centro-medullary rod and the gender of the patients, therefore in most cases female patients required this particular type of intervention in a higher percentage than male patients. 
Conclusions: Pertrochanteric fractures are severe that have a significant impact on hip motility and mobility and surgical intervention is essential to achieve optimal recovery.

Evaluation of the Biological Activity of Polyphenolic Extracts Obtained from Maclura pomifera (Raf.) CK Schneid bark and periderm

First author: Năstaca - Alina Coman

Coordinator(s): Professor Corneliu Tănase

Keywords: Polyphenols Antioxidant activity Antibacterial activity Enzyme activity

Background: The bark of Maclura pomifera tree, commonly used for natural dye extraction, is believed to harbor bioactive chemical compounds, although literature on this subject is limited. Objective: This research aimed to assess how various extraction methods influence the chemical and biological properties of extracts obtained from the rhytidome and periderme of Maclura pomifera Material and Method: Three different extraction methods were employed: microwave-assisted extraction, ultrasound-assisted extraction, and sonicator-assisted extraction. The extracts were characterized by determining total polyphenol content, and their antioxidant capacity was evaluated using DPPH and ABTS assays. Antimicrobial effects were tested against bacterial strains, while inhibition of enzymatic activity was assessed for α-glucosidase and α-amylase. Results: Results highlighted lower polyphenol content in periderm extracts compared to rhytidome extracts. The highest antioxidant activity was observed in rhytidome extracts using the DPPH method with microwave-assisted extraction, while ultrasound-assisted extraction yielded the most significant activity in ABTS assays. Ethanol extract of rhytidome obtained through sonicator-assisted extraction exhibited the strongest inhibition of enzymatic activity. Additionally, rhytidome extracts displayed pronounced antibacterial potential, emphasizing the utility of this plant as a source of bioactive compounds for various applications. Conclusions:

RENAL MANIFESTATIONS OF TUBEROUS SCLEROSIS COMPLEX - A CASE REPORT

First author: Anna Petra

Coordinator(s): Associate Professor Diana Tania Luminița Moldovan , Medical Doctor Yuriy Maslyennikov

Keywords: Tuberous Sclerosis Complex Angiomyolipoma End Stage Renal Disease Hemodialysis

Introduction: Tuberous sclerosis complex (TSC) is a rare genetic disease, affecting TSC1 or TSC2 gene, that manifests as a multisystem disorder defined by the development of numerous benign tumors, called angiomyolipomas (AMLs). Due to TSC, mutations in the genes cause permanent activation of the mTOR pathway, leading to tumorogenicity, cellular proliferation distributed around blood vessels and lastly is mostly manifested in hemorrage. Renal complications due to TSC can lead to chronic kidney disease (CKD) and, in severe cases, end-stage renal disease (ESRD), requiring renal replacement therapy.  Case Report: A 35-year-old female patient known with CKD and a 10-year history of TSC, presented to Nephrology department for monthly check-up with lack of appetite, asthenia, nausea, vomiting, fatigue suggesting uremic syndrome. In 2013 an abdominal CT showed a right renal AML, giant left AML with retroperitoneal hemorrhage, indicating a mandatory left total nephrectomy. Renal AMLs can lead to complications such as local growth, mechanical pressure that is imposed on the renal parenchyma, and bleeding. In 2018, the patient was treated with Everolimus (immunosuppressant) with right kidney AML not growing further. The presence of AML on a solitary kidney, hypertension and the reduced number of nephrons precipitated the onset and progression of CKD. She developed proteinuria, possible glomerulosclerosis due to hyperfiltration on the remaining nephrons. Given all the facts, ESRD was established and a vascular access via an AV fistula was created. She was initiated in chronic hemodialysis because of severe azotemia associated with clinical symptoms. Discussions: Population-based studies found that 48-to-80 percent of patients, between ages 15-30, with TSC have kidney complications with the presence of AMLs and progression towards renal insufficiency. In patients undergoing maintenance hemodialysis, the mortality rate and morbidity burden are markedky elevated, accompanied by a diminished quality of life.   Conclusions: Due to its infrequency, this case highlights the need to spread further awareness. Vigilant surveillance and therapeutic intervention targeting these renal manifestations are imperative to mitigate the risk of CKD in TSC patients.

The outcome of COVID-19 in patients with type 2 diabetes mellitus

First author: Andreea Denisa Ilieș

Coauthors: Tania Negovan Vicențiu Damian Băcilă Olga Ioana Bădan Alexandra Ioana Asztalos

Coordinator(s): Assistant Professor Ionela Anca Pintea Simon

Keywords: type 2 diabetes mellitus COVID-19 outcome

Background: COVID-19 is a viral infectious disease caused by severe acute respiratory syndrome coronavirus 2. Type 2 diabetes mellitus (T2DM) is a well-known risk factor for a severe clinical course of COVID-19, which may be associated with adverse outcomes.
Objective: The aim of the study is to investigate the clinical characteristics and outcomes of T2DM patients hospitalized with COVID-19, quantified by complication and mortality rate.
Material and Method: We conducted a retrospective case-control study including patients with a primary diagnosis of type 2 diabetes admitted to the Târgu Mureș Emergency Clinical County Hospital, hospitalized at the 2nd Medical Clinic between January 2021 until December 2021. The study included 320 patients with type 2 diabetes mellitus, which were divided into two groups: COVID positive and COVID negative, all of whom were tested using RT PCR. Data were collected from observation sheets, regarding age, comorbidities, home medication, social habits, laboratory parameters, hospital treatment and complications. Statistical analyzes were performed. 
Results: Out of 320 patients, 110 tested positive for COVID-19. The gender distribution of infected patients was 48.1% female and 51.9% male. The incidence of COVID in men was found to be significantly higher than in women (p=0.02). Among infected women, 52.8% died, while among men, the mortality rate was 52.6%. In patients aged ≤70 years, SARS-CoV-2 infection affected 39.8%, contrary to expectations, with a lower percentage of infections in those aged >70 years, at 30.2%. In the analyzed patients, the diagnosis of COVID-19 was a significant risk factor for mortality (OR=1.84), transfer to the intensive care unit (OR=2.36) and respiratory failure (OR=5.56). However, regarding complications such as thrombosis and sepsis, no significant association was identified (p>0.05). Investigating imaging changes, the ground-glass appearance of lung parenchyma was significantly associated with transfer to the intensive care unit (OR=1.7). The administration of Remdesivir to infected patients did not significantly influence the mortality rate or transfer to the intensive care unit (p>0.05).  
Conclusions: The results of the study confirm the hypothesis that SARS-CoV-2 infection has a negative impact on the progression of type 2 diabetes, with severe evolution. COVID-19 patients with preexisting diabetes have seen elevated rates of hospital admission, severe pneumonia, and mortality. Larger future studies are needed to draw firm conclusions. 

Emergency Management of the Refractory Status Epilepticus Evolving to Super-Refractory Status Epilepticus in a Young Patient

First author: Giorgia Arena

Coauthors: Gaia Desiderio Veronica Galizia Chiara Testoni Francesca Rosaria Cannito

Coordinator(s): Medical Doctor Alexandra-Laura Nendrean , Associate Professor Cristian Marius Boeriu

Keywords: #RefractoryStatusEpilepticus #Super-RefractoryStatusEpilepticus #EmergencyManagement #Immunocompromised

Introduction: Status Epilepticus (SE) is an emergency that leads to significant morbidity and mortality; therefore, it must be diagnosed and treated promptly. Refractory SE is defined as ongoing seizures despite two appropriate antiepileptic drugs including a benzodiazepine. The term “Super-Refractory SE” was coined in 2011 and it indicates continuous or recurrent seizures lasting 24 hours or more following administration of anesthetics or seizures that recur on weaning the patient off the anesthetic agent.
Case Report: This case regards a 37-year-old male patient known with HIV and tonic-clonic seizures since childhood, pulmonary tuberculosis (2020), and cerebral toxoplasmosis (2021). At arrival, after 4 generalized seizures and administration of benzodiazepines on the ambulance, his vitals were: GCS 9pt (M4, V3, O2), RR 20/min, BP 187/105mmHg, HR 140/min sinus rhythm, SpO2 82%, temperature 37.6, glycemia 89mg/dl. An unsuccessful second-line therapy with phenytoin was initiated: generalized seizures continued with no return to neurological baseline. The following step was rapid sequence intubation and general anesthesia to control seizures and protect airways. Blood results revealed severe pancytopenia: leukopenia (1.19/µL), lymphopenia (0.27/µL), anemia (Hb 10.2 g/dl), thrombocytopenia (61.4×103/µL). The head CT showed global cerebral atrophy, the pulmonary CT revealed minimal left pneumonia, bilateral fibrosis and emphysema bubbles bilaterally. Hemocultures were obtained and antibiotics were started. After 24 hours and an attempt to wean him off the ventilator, seizures continued. He was then transferred to the ICU, where treatment was continued and 2 days later the patient was conscious, oriented and left the hospital refusing further treatment. Despite being hospitalized and undergoing general anesthesia multiple times during the past 4-6 weeks (because of lack of adherence to treatment and comorbidities), the patient was always discharged in good conditions. 
Discussions: Current guidelines suppose that first-line therapy for GCSE will take 30 minutes. If no satisfactory response is achieved in this time span, the patient is considered in a RSE, for which it is essential to re-assess airways, consider intubation, check glucose, and initiate neurological consultation and bedside EEG. At this point, one of the following three medications can be initiated: Midazolam (0.2 mg/kg bolus, 0.05-0.2 mg/kg/h infusion), Pentobarbital (5-15 mg/kg bolus, 0.5-10 mg/kg/h infusion), or Propofol (3-5 mg/kg bolus, 1-15 mg/kg/h infusion).
Conclusions: Immunocompromised patients and those who do not adhere to treatment are more subjected to develop RSE and SRSE, thus there should be no delay in starting therapy for RSE and efforts should be made to prevent it through a multidisciplinary approach. 

Implementing SNMP-Based monitoring solutions in computer networking: strategies for optimal network management

First author: Diana Banea

Coordinator(s): Other Adrian Mihăileanu

Keywords: Network Monitoring Simple Network Management Protocol Check Mk Zabbix

Background: In the fast-moving world of digital technology, strong network monitoring is essential for companies to stay ahead and run smoothly. Tools that manage networks help businesses quickly adjust to changes in the market and boost their overall performance. This study looks into how SNMP-based monitoring tools, especially Check MK and Zabbix, work in a network that's built on virtual machines using the latest ESXi 8.0.2 software. 
Objective: The study aims to conduct a comparative analysis of Check MK and Zabbix within a virtualized network environment, evaluating their user interfaces, functionality, and the precision of the network data provided. Central to this research is understanding how each tool aligns with the requirements of modern network management, with a particular focus on the essential importance of ongoing network monitoring and the role of SNMP, a protocol extensively utilized for its reliability and scalability in network management across various platforms.
Material and Method: In this research, a virtual network environment was created using ESXi 8.0.2 on a physical server, employing virtual machines to simulate a real-world network.In this environment, several types of network equipment have been created , establishing a comprehensive framework for the comparative analysis of Check MK and Zabbix. The study evaluated each tool from installation to routine operation, with a focus on user interface accessibility, integration ease, and the effectiveness of managing and adding network hosts, aiming to elucidate their relative merits in a contemporary, virtualized network setting.
Results: The evaluation highlight Check MK's emphasis on user-friendly interfaces and plug-and-play functionality, alongside Zabbix's strong points in scalability and predictive analytics for extensive networks. Check MK is adept at quick setup and flexible monitoring, whereas Zabbix is performing in its capacity to manage large-scale network behaviors, showcasing the diverse strengths of each tool tailored to varied network management requirements.
Conclusions: This research emphasizes the importance of choosing a network monitoring tool that not only have robust capabilities but also matches the unique needs of the network it monitors. With the increasing complexity of digital infrastructure, selecting the right monitoring tool is decisive. The study highlights the vital role these tools play in maintaining network reliability and contributing to the success of IT operations, underlining the significance of network monitoring and the essential function of SNMP in achieving these objectives.

Laser trabeculoplasty: a potential alternative to medication in glaucoma treatment-a literature review

First author: Andrei Man

Coauthors: Iozefina-Darina Gaidoș Radu Ilieș

Coordinator(s): Professor Simona Delia Nicoară

Keywords: laser trabeculoplasty glaucoma medication intraocular pressure

Background: Glaucoma causes global blindness and impaired vision, with treatment aiming to reduce intraocular pressure (IOP) to preserve the visual field. Selective laser trabeculoplasty (SLT) is a non-invasive laser procedure improving eye fluid drainage.
Objective: The aim of this review is to evaluate the potential benefits of SLT in comparison with current medication. This therapy can provide longer-lasting reduction in IOP and may be more cost-effective in the long term.
Material and Method: This review selected articles included in the PubMed database that compared laser trabeculoplasty and medication from different perspectives: therapeutical and financial. The phrases used in the search were ,,laser trabeculoplasty” ,,medication” and ,,comparison”. Included articles were mainly randomized clinical trials (RCT) but there was one cross-sectional and one retrospective study. The clinical trials included evaluated therapeutical success, which was defined by lowering the IOP (and therefore the risk of needing medication or even trabeculectomy) or by health-related quality of life. Studies comparing different types of laser trabeculoplasty were not included. Bias risk was not assessed and data were extracted using a standardized abstraction form.
Results: A total of 1435 patients were identified in 13 studies, of which 2 are still ongoing. Gazzard et al (2023) observed a significant reduction in disease progression for SLT: 26.8% of patients treated with medication exhibited disease progression, compared to 19.6% of patients treated with SLT (p=0.006). Trabeculectomy was required in 32 eyes in the eye drops group, compared to 13 eyes in the SLT group (p<0.001). Also, SLT proved to be more cost-effective: patients ended up saving about 500£ in a three-year span. Lee et al (2014) also concluded that patients treated with SLT had a lower IOP (p=0.03) and required fewer medications. Ang et al (2020) reported a significant improvement in the patient's quality of life regarding social well-being. On the other side, Narayanaswamy et al (2015) reported complete success in fewer eyes treated with SLT (60%) compared to prostaglandin analog (PGA-84%), with statistical significance (p=0.008). Also, additional medications were required in 22% of the patients treated with SLT, compared to 8% treated with PGA (p=0.05).
Conclusions: Although some studies prove otherwise, in most of the studies laser trabeculoplasty appears to provide better outcomes for patients with glaucoma, both from a therapeutical and a financial standpoint. However, each study had a different definition of therapeutical success, which made it difficult to compare the results and further investigation is still needed.

Comparative Analysis of Cementation Techniques of Fixed Dental Prostheses between Romania and Turkey

First author: Nino Ilea

Coauthors: Oana Robu Xhina Kristo

Coordinator(s): Lecturer Diana Cerghizan

Keywords: cementation protocol fixed prosthetic restoration cementation materials

Background: The success of fixed dental prostheses, such as crowns and bridges, depends on the use of the right dental cement. Dental cementation is not only responsible for adhesion but also plays a vital role in preventing microleakage, increasing mechanical retention, and ensuring long-term success of the prosthesis. With advancements in dental materials science, there are various types of cement available, each with unique properties and applications. Since dental practices differ globally, it is essential to explore how different regions use these materials to optimize patient outcomes.
Objective: This study aims to compare cementation techniques of fixed dental prostheses between the Faculty of Dental Medicine in Romania and Turkey. The focus is on material selection, application protocols, and clinical outcomes. This comparison highlights procedural nuances, potential areas for standardization, and opportunities for improving clinical practices in dental prosthetics. Material and Method: This study presents a comparative analysis of clinical cases from the Faculty of Dental Medicine in Turkey and Romania. It details the specific cementation protocols used for various types of fixed dental restorations, including single crowns, bridges, and implant-supported prostheses. This comparison offers insights into each technique's effectiveness, aesthetics, and patient outcomes. Results: The Faculty of Dental Medicine from Romania preferred glass ionomer cements due to their ease of use, fluoride release, and chemical adhesion to the tooth structure. This preference aligns with the findings of previous studies highlighting the popularity of glass ionomer cements in Europe for their biocompatibility and preventive qualities. Conversely, Turkey preferred zinc phosphate cement.
Conclusions: The study findings suggest that despite geographical and cultural differences, the principles of selecting and applying dental cement remain universal. However, specific preferences and techniques can significantly vary, influenced by local clinical practice standards, material availability, and clinician experience.

Unraveling the Enigma of Cutaneous Malignancies: The correlation between squamous cell carcinoma and basal cell carcinoma

First author: Alexandra-Iuliana Postolache

Coauthors: Andreea Roșculeț Andreea Georgiana Ristea Luiza Marina Răcilă Ana Porumb

Coordinator(s): Assistant Professor Andreea Cătălina Tinca

Keywords: cutaneous malignancies squamous cell carcinoma basal cell carcinoma basosquamous carcinoma

Introduction: Squamous cell carcinoma (SCC) is a malignant tumor affecting epidermal keratinocytes. It mimics the cytology of squamous cells in the spinous layer of the epidermis. Basal cell carcinoma (BCC) is a malignancy originating from basal cells of the interfollicular epidermis and/or hair follicle. Basosquamous carcinoma is an aggressive variant of basal cell carcinoma, exhibiting characteristics of both BCC and squamous cell carcinoma.
Case Report: A 51-year-old patient presented with multiple ulcerations and cutaneous formations. Two of them were excised, from the right ear and the mid third of the left arm's external side. Histopathological examination revealed moderately differentiated squamous carcinoma in the right ear lesion, whereas the lesion from the left arm exhibited a very rare form of carcinoma known as metatypical (basosquamous) carcinoma, predominantly displaying squamous features. Gross examination for specimen 1 comprised skin fragments, ranging from 32x22 mm to 10x5 mm, with increased consistency. Specimen 2 was an elliptical skin flap, 70x25 mm, with a brown nodular tumor on its surface, measuring 23x20x5 mm. Microscopical examination in specimen 1, Hematoxylin-Eosin (H&E) stain, revealed a keratinized stratified squamous epithelium that appeared ulcerated. Subadjacent there was evidence of an infiltrative tumor proliferation characterized by solid plaques and patches composed of polygonal cells. These cells presented eosinophilic cytoplasm, vesicular nuclei with proeminent nucleoli, cytonuclear atypia, and multiple mitotic figures. Specimen 2 showed an ulcerated epidermis which presented beneath a tumor proliferation comprising squamous cell carcinoma and basal cell carcinoma. The tumor displayed an infiltrative growth pattern and was composed of plaques of large cells with eosinophilic cytoplasm, vesicular nuclei, prominent nucleoli. Palisading phenomenom and small cell with hyperchromatic nuclei were identified. 
Discussions: Squamous carcinoma encompasses a wide etiology, in addition to UV radiation. Localization on the ear and a thickness greater than 2 mm represent a high prognostic risk factor. Basosquamous/metatypical basal cell carcinoma predisposes to sun-exposed skin of older, fair-skinned men. It recurs in 4.5% of cases. Although perineural and lymphovascular invasion were not noted, there is a 5% risk of lymph node and lung metastasis, with a survival rate of 6.5 years (according to specialized literature). 
Conclusions: Basal cell carcinoma is the most common form of skin cancer, while squamous cell carcinoma is a more aggressive type. Basosquamous carcinoma, a rare combination of the two, highlights the complexity of skin malignancies.

Patient with amebic liver abscess imported from Italy

First author: Marta Szczygieł

Coauthors: Mateusz Hałas Maria Piotrowiak marek spichalski

Coordinator(s): Associate Professor Małgorzata Paul

Keywords: amoebiasis amebic liver abscess echinococcosis

Introduction: Amoebiasis is a disease caused by parasitic protozoan Entamoeba histolytica. The disease affects approximately 50 million people each year. The majority of cases come from subtropical and tropical regions with poor sanitation. The infection occurs when food or water contaminated by feces water is ingested. There are intestinal and extraintestinal forms, the most common of which is amebic liver abscess (ALA). The main symptoms of ALA are fever and pain in the right upper quadrant of the abdomen. The intestinal form of amoebiasis is treated pharmacologically with protozoal-killing drugs, while in ALA, additional drainage or percutaneous needle aspiration may be warranted. Case Report: A 74-year-old patient from Italy was admitted to the hospital in November 2023 due to anemia in the course of myelodysplastic syndrome with multilineage dysplasia. Abdominal ultrasound showed dilated bile ducts, an anechogenic lesion, and a low-echogenic structure (approximately 130 mm) with echogenic formations protruding inside. A contrast CT revealed a smooth-wall lesion measuring 125 mm in diameter filled with fluid of increased density. IgG antibodies for Echinococcus granulosus were positive. At the beginning of 2024, the patient, presenting with jaundice, pale stools, and dark urine, was admitted to the University Hospital. On physical examination, Chełmoński's sign was positive. Laboratory tests revealed ALT 133 U/l (<41 U/l), AST 114 (< 37 U/l), total bilirubin 20, 75 mg/dl (<1,2 mg/dl), ALP 298 mg/dl (<120mg/dl), GGTP 557 U/l (<61 U/l). IgG antibodies for Entamoeba histolytica were positive. Contrast CT scan revealed bile ducts compressed by a cyst measuring 130x115x150 mm with dense content and a gas bubble. During drainage procedure, over 1,5 liters of chocolate-colored fluid were drained. Based on laboratory findings and clinical presentation, the diagnosis of ALA was stated. Treatment with metronidazole, chloroquine, doxycycline, blood transfusion, and hydration was implemented, resulting in visible improvement in the patient's condition. Discussions: The patient resided in countries such as Italy and Poland. In Europe, most amoebiasis cases are imported from endemic regions. Symptoms can manifest even decades after returning from endemic areas. However, our patient denied traveling outside of Europe. On the other hand, transmission through sexual contact or by ingestion of imported food contaminated with amoeba cannot be ruled out in this case. Conclusions: Extraintestinal amoebiasis should be suspected in travelers with abdominal pain and focal liver lesions returning from the Mediterranean area, including Italy.

NEURONAVIGATION AND AUGMENTED REALITY IN TRANSSPHENOIDAL PITUITARY MICRO ADENOMA SURGERY

First author: Roberta Civita

Coauthors: Samuel Michelini Sabrina Mancino Federica Frau Naomi Mancino

Coordinator(s): Professor Rares Chinezu

Keywords: PituitaryMicroadenoma Neuronavigation Augmentedreality Advantages

Background: A pituitary microadenoma is a small, usually benign tumor that develops in the pituitary gland. These adenomas are typically less than 10 millimeters in diameter but despite their small size, pituitary microadenomas can cause hormonal imbalances by overproducing certain pituitary hormones. Surgery is challenging due to the small size of the tumours and difficulty in properly finding and resecting the tumor
Objective: The objective of this presentation is to highlight the novelty and effectiveness of intraoperative augmented reality in pituitary micro adenoma surgery
Material and Method: A 54-year-old patient know with cardiac arrythmia, with acromegalic phenotype is diagnosed with an increased IGF-1 of 479 ng/ml. A pituitary MRI showed a left pituitary lesion of 3,5x2,2 mm suggestive of a microadenoma. Microscopic transsphenoidal surgery was performed at the Targu Mures Neurosurgery Department. The surgical technique involved the use of preoperative imaging (CT and MRI) coupled with a state of the art neuronavigation system capable of directly injecting 3D volumes in the surgical microscope  
Results: The use of intraoperative augmented reality allowed for a better understanding of the local anatomy and better approach to otherwise difficult to find microadenoma. Complete surgical resection of the tumour was macroscopically achieved, with an uneventful postoperative trajectory. The patient was discharged to home 4 days following surgery. Histopathology has confirmed the GH secreting nature of the microadenoma. Postoperatively the patient presented the remission of the cardiac arrythmia, with a significant reduction of IGF-1 to 235 ng/ml 
Conclusions: The addition of intraoperative augmented reality offers greater precision, and faster discovery of the microadenoma, providing significant assistance in order to perform a complete surgical resection of these challenging tumours

Cor triatriatum sinister: a sinister prognosis? - a case report in a newborn infant

First author: Paraschiv-Antonio Rusu

Coauthors: Simona Roman Teodorescu Anemona Ioana

Coordinator(s): Assistant Professor Marius Beleaua

Keywords: cor triatriatum, cardiac malformation, heart failure

Introduction: Cor Triatriatum represents an extremely rare congenital cardiac malformation, accounting for 0.1%-0.4% of all congenital heart defects, characterized by an intraatrial membrane dividing one of them into two distinct compartments. Left atrium is more frequently affected, and the upper cavity conduct to malformations of the pulmonary veins.
Case Report: We present the case of a 1-year-old patient admitted to the 2nd Pediatric Department of the Emergency Clinical County Hospital of Craiova, in a severe general condition, hemodynamically unstable, with dyspnea, tachypnea, central and peripheral cyanosis, hepatomegaly, and peripheral edema that started in the last weeks. Maternal history reveals an uncomplicated pregnancy, delivered at 37 weeks by cesarean section. Following the echocardiographic examination, a cor triatriatum malformation, severe pulmonary hypertension, and NYHA class IV heart failure were diagnosed. Due to the potential risk of deterioration, the patient was transfered to the pediatric intensive care unit of the Cardiovascular Emergency Institute of Tg. Mures, where the patient goes into cardiorespiratory arrest and does not respond to resuscitation maneuvers, resulting in death. The autopsy revealed a complex cardiovascular malformation: a septated left atrium through a musculo-conjunctival septum, subnumerary pulmonary veins due to agenesis/atresia of one of the right pulmonary veins, an ostium primum type atrial septal defect, eccentric right ventricular hypertrophy, and microscopic findings of myocardial interstitial edema, acute pulmonary edema, and chronic pulmonary congestion.
Discussions: Cor triatriatum presents a wide spectrum of manifestations, from asymptomatic cases incidentally discovered during routine cardiac consultations or autopsies, to complications such as right heart failure, acute pulmonary edema, atrial fibrillation, and premature death. Diagnosis and treatment require a multidisciplinary team, as early correct diagnosis, in the absence of other malformations, has an excellent prognosis. Surgical intervention is curative, involving membrane resection followed by closure of the defect with a pericardial patch.
Conclusions: The particularity of the case lies in the association of congenital heart malformations that decrease life expectancy and render surgical intervention impossible, with the evolution inevitably leading to death. 

Possibilities of identification and analysis of the compromising emissions from radio frequency sources

First author: IONICĂ CRISTIAN-AURELIAN

Coordinator(s): Professor Simona Miclăuș

Keywords: Compromising emissions Radiofrequency Electromagnetic compatibility Information security

Background: This paper investigate the capture and analysis of compromising radio frequency emissions a relevant topic of information security and confidentiality in the era of advanced technology. In the omnipresent context of devices operating at radio frequencies, from wireless communications and internet to medical equipment and navigation systems, the paper addresses the security challenges posed by compromising emissions. The detailed analysis includes the electromagnetic spectrum and radio frequency sources, the role of electromagnetic compatibility in data protection, case studies on specific equipment, and advanced methods for measuring and protecting against these risks. The paper contributes to the understanding and development of strategies to mitigate threats to information security in the modern digital world.
Objective: The objectives of the paper focus on identifying and analyzing compromising emissions from radio frequency sources, assessing the risks they pose to information security, and developing effective methodologies for capturing and analyzing these emissions. The paper also aims to explore advanced technological solutions for protecting sensitive data against unauthorized interceptions, with the goal of improving electromagnetic compatibility and cybersecurity across various fields of application.
Material and Method: To conduct the analysis of compromising radio frequency emissions, the paper utilizes advanced measurement methods, including monitoring the radio spectrum and using specialized equipment for capturing and demodulating signals. The materials include directional antennas, sensitive receivers, spectrum analyzers, and anechoic shielded chambers for testing in controlled environments. Additionally, specialized software is used for analyzing the data obtained, contributing to the identification of emission patterns and the development of protection solutions against unauthorized interceptions.
Results: The results of the paper reveal the ability of advanced methods to effectively detect and analyze compromising emissions from radio frequency sources. The detailed analysis of the emissions identifies specific patterns and vulnerabilities in current information security systems. The implementation of the developed protection solutions significantly reduces the risk of unauthorized interceptions, thereby improving information security. The paper also highlights the importance of electromagnetic compatibility in effectively protecting data in the contemporary digital environment.
Conclusions: The paper emphasizes the crucial importance of recognizing and combating compromising emissions to ensure information security. By demonstrating the effectiveness of capture and analysis methods, it highlights the need for continuous evolution of protection technologies in response to dynamically evolving threats. The focus on electromagnetic compatibility and the adoption of proactive strategies are essential for protecting sensitive data, thereby strengthening cybersecurity in an ever-changing technological landscape.

Virtualization in Mission-Critical Operations

First author: Catalin Dragomirescu

Coordinator(s): Other Adrian Mihăileanu

Keywords: Network Virtualization Encrypted Communication Mission-Critical Networks Network Scalability

Background: The virtualization of mission-critical networks stands at the forefront of network engineering, driven by the need to simulate complex infrastructures in a secure and efficient manner. Utilizing VMware ESXi hypervisor technology provides a scalable and robust platform for such endeavors. This study progresses this field by crafting a virtual network architecture, comprising LAN, DMZ, and WAN segments, designed to address real-world operational contingencies and security concerns.
Objective: The aim is to leverage virtualization solutions to optimize the mission network core, enhancing functionality and security. The research highlights the utilization of roaming profiles and services such as Domain Controllers with Active Directory, FTP and Mail servers, within the virtual environment orchestrated by ESXi. Furthermore, it assesses the implementation of an encrypted IPSEC connection between the virtual and physical LANs to ensure secure data transit.
Material and Method: A comprehensive virtual network is engineered on the ESXi platform, integrating roaming profiles for user data consistency, a Domain Controller for centralized authentication, FTP and Mail servers for essential communication services. For encrypted communications, an IPSEC tunnel was established between the virtual LAN on ESXi and the physical LAN on a Cisco server. Additionally, a Cisco Unified Communications Manager (CUCM) server was configured along with two VOIP phones, enabling encrypted voice communication testing within the network.
Results: The virtual network operated efficiently, maintaining user setting continuity through roaming profiles. The Active Directory and communication servers provided reliable service delivery, while the pfSense firewall ensured robust network security. The IPSEC tunnel effectively encrypted data between the virtual and physical LANs, thereby securing the critical link. The successful configuration of the CUCM server and VOIP phones allowed for secure and clear voice communications, which are vital for mission-critical operations.
Conclusions: This study verifies the strategic importance of virtualization in creating advanced and secure mission-critical network environments. By integrating services such as CUCM and VOIP, alongside the existing network and security services, the research underscores the versatility of virtual networks to accommodate diverse communication needs. The secure IPSEC tunnel establishment between virtual and physical realms exemplifies a significant step towards operational excellence in network design, paving the way for future innovations in the field of network engineering.

Securing Digital Frontiers: A Systematic and Comparative Review of Virtual Private Network Protocols in Cybersecurity

First author: Dan Costina Daniela

Coordinator(s): Professor Vlad Vasile

Keywords: VPN Encryption Cybersecurity Protocols

Background:

Objective: The core objective of this paper is to provide a systematic and comparative analysis of established VPN protocols – specifically, IPSec, OpenVPN and SSL. The intent is to dissect their conceptual frameworks, scrutinize their strategic implementations, and evaluate their operational performance in authentic cybersecurity contexts. A spotlight is cast on their distinctive strengths, potential weaknesses, and their suitability for various cybersecurity requirements. 
Material and Method: A literature review was conducted, pulling from academic databases, technical whitepapers, and cybersecurity reports. A comparative framework was established, focusing on protocol architecture, encryption standards, and reported vulnerabilities. Practical case studies regarding the deployment of these protocols in heterogeneous environments enriched our research with empirical insights.
Results: The results reveal distinct trade-offs among the protocols. IPSec stands out for its strong encryption and authentication features but present challenges in configuration complexity. OpenVPN is revered for its versatility and robust security offerings, balanced with reasonable resource demands. In contrast, SSL, renowned for securing web transactions, is acknowledged for its user-friendly approach but is not without potential susceptibilities to cipher vulnerabilities. The detection of vulnerabilities is largely dependent on relentless monitoring, periodic audits, and the implementation of patches in a timely fashion.
Conclusions: The paper concludes that the selection of a VPN protocol is not a trivial pursuit but one that demands a detailed comprehension of each protocol’s operational mechanisms, strengths, and frailties. While IPSec is well-suited for extensive corporate networks demanding high-security protocols, OpenVPN shines with its adaptability and scalability. SSL, conversely, is ideal for scenarios prioritizing ease and speed. In the face of ever-evolving cyber threats, it is imperative that encryption technologies and vulnerability management practices advance in tandem. This study provides a strategic blueprint for entities aiming to tailor their VPN deployments to fulfill specific cybersecurity imperatives, thereby enhancing their resilience against cyber adversities.

From Subtle Symptoms to Survival: Precision Medicine's Triumph in Gastric Carcinoma

First author: Melisa-Monica Blaj

Coauthors: Eniko Reka Imre Bogdan Moldovan Georgescu Dan Mihaly Imre

Coordinator(s): Assistant Professor Mihaly Imre

Keywords: Early Gastric Carcinoma (EGC) Precision Medicine Signet Ring Cells Gastrectomy

Introduction: Gastric cancer ranks as the fourth most common cancer globally, impacting approximately one million individuals annually. Early gastric carcinoma (EGC) is characterized as an invasive adenocarcinoma confined to the mucosal or submucosal layers, regardless of the presence or absence of lymph node involvement.
Case Report: We report the case of a 39-year-old male with a background of heavy smoking, now abstinent for 8 years, and employed in a high-stress job, but with no other significant medical history. He presented at our clinic with a body mass index (BMI) of 40 kg/m^2. The patient sought medical attention due to recently developed gastric discomfort, which he noticed specifically after consuming certain foods, such as cheese. 

Discussions: This case report underscores the criticality of precision medicine in interpreting nonspecific clinical manifestations, such as subtle and gradual onset of mild abdominal discomfort. A meticulous clinical history-taking and the implementation of a strategic, targeted approach facilitated the successful elimination of malignant neoplastic lesions within a span of less than 45 days from the initial medical consultation in a relatively young patient.
Conclusions: We concisely delineate the strategic approach employed in the successful management of a rare case of early gastric carcinoma (EGC), illustrating the efficacy of precision medicine. Timely and precise diagnosis facilitated the restoration of the patient’s prospects for a normal life, free from dietary limitations and the necessity for continuous pharmacological therapy.

Evolution of inflammatory bowel disease under biological treatment

First author: Melissa Zapartan

Coauthors: Vladimir Zadea Vasiliu Maria Magdalena Vlad Florin Tantos

Coordinator(s): Professor Simona Bataga , Medical Doctor Naomi Ciurea (Macaru)

Keywords: inflammatory bowel disease biologic therapy calprotectin

Background: Inflammatory bowel disease involves repeated episodes of inflammation in the gastrointestinal tract.Biological drugs are reserved for moderate to severe cases of the disease that are not responding to other options of treatment.
Objective: The main of this study is to track the laboratory results including the routine blood cell count and biochemical parameters, faecal calprotectin and endoscopic findings after 6 months of biological treatment for patients with inflammatory bowel disease and to determine the prevalence of the disease by sex, age and clinical manifestations.
Material and Method: We conducted a longitudinal retrospective study including 27 patients with inflammatory bowel disease who received biologic therapy, admitted to the Gastroenterology department within the Emergency Clinical Hospital Targu Mures, between the years 2022 and 2024.
Results: Patients included in the study were divided in two groups: 13 patients with Crohn’s disease (56%) and 14 patients with ulcerative colitis (48%). In terms of demographic distribution, of the total number of cases, 59% of patients are male and 41%, are female aged 19 to 74 with an average of 43.96 ± 15.89 years (standard deviation). As symptomatology at onset, 52% of the patients included in the study had diarrhoea and rectorrhagia, and 48% had weight loss associated with nausea and vomiting.By tracking associated complications, 41% of patients experienced intestinal complications (lower gastrointestinal bleeding, sthenosis, abscesses, fistulas) and 59% had extraintestinal manifestations (arthritis, erythema nodosum, hepatic steatosis). Regarding the therapeutic conduct, all patients included in the study were subjected to biologic therapy and 33% of them were treated with corticosteroids and immunosuppressants.According to statistical analysis of biological parameters (hemoleucogram, liver function, kidney function, inflammatory markers) at onset and at 6 months post-therapy, no significant difference in values was observed between the two groups (95% CI 0.01-1.05, p=0.05). By dosing the faecal calprotectin at onset and at 6 months post-treatment, a significant difference was observed (95% CI p=0.001), with a dramatic decrease in its value in both groups.By comparing the endoscopic appearance at onset vs. after 6 months of treatment, a significant difference was noticed in terms of remission of the disease in both groups (95% CI, p=0.03).
Conclusions: There are no significant differences in biological parameters after 6 months of treatment with biologics in neither one of the two groups of patients with inflammatory bowel disease, whereas a decrease in the value of faecal calprotectin and endoscopic remission after 6 months are observed in both groups.

Correlating vulnerability markers through Intracoronary Optical Coherence Tomography (OCT) imaging and functional coronary analysis (FFR)

First author: SEBASTIAN MANOILA

Coordinator(s): Professor Theodora Benedek

Keywords: Optical Coherence Tomography fractional flow reserve coronary disease vulnerable plaque

Background: OCT technology  allows real-time visualization of significant details in defining a vulnerable plaque, such as fibrous cap thickness or plaque rupture and stenosis. The Fractional Flow Reserve (FFR) represents a pivotal diagnostic method for assessing the functional significance of coronary stenosis. We posit that the combination of OCT technology and FFR hold significant potential to exert a substantial influence on the prognosis of patients with coronary artery disease, as  POST-IT (Portuguese Study on the Evaluation of FFR-Guided Treatment of Coronary Disease), R3F (French FFR Registry), and ILUMIEN I studies demonstrated a modification in therapeutic decision-making based on these technologies. 
Objective: The aim is to prove the alteration of therapeutic decisions based on comprehensive analysis and intracoronary imaging.
Material and Method: In the present study, a case-control investigation was conducted, involving the enrollment of 60 patients who underwent PCI. These patients were divided into two groups: a control group comprising 30 cases where therapeutic decisions were made based on coronary angiography, and an experimental group where decisions were based on FFR or FFR and OCT findings. Data were collected from patients admitted to the Cardiology department of Emergency Clinical County Hospital in Targu Mures, Romania, between 2021 and 2024.
Results: In Group 1, the therapeutic decision changed in 19 out of 30 cases (representing 63.6%), while in 11 cases (representing 36.3%), the decision remained unchanged. In Group 2, the decision did not change in any case. The p-value between these two groups is 0.0003 (Relative Risk = 0.6333, 95% Confidence Interval: 0.4823 to 0.8316), indicating the statistical significance of the therapeutic decision change.
Conclusions: Intracoronary imaging and functional assessment of coronary plaques have become indispensable elements in the arsenal of any cardiologist; moreover, these methods bring benefits in terms of therapeutic decision-making, guiding the physician towards a much more beneficial long-term outcome for the patient.

UVA Radiation effects on the eye-tissues

First author: Alexandra Salajan

Coauthors: Renata Timar Iuliana-Ingrid Rusu

Coordinator(s): Lecturer Robert Tripon , Lecturer Florina Vultur

Keywords: UVA irradiation Eye tissue penetration

Background: Crosslinking is a process that uses UVA irradiations together with riboflavin to reduce the collagen’s laxity. Controlled amounts of UVA light are already used in medicine to cure different skin diseases or keratoconus, but certain amount of irradiation could be harmful for tissues. Latest research targets crosslinking on tarsus, with the purpose of curing certain types eyelid laxity. However, when these irradiating procedures are performed, UVA also reaches surrounding tissues.
Objective: The purpose of this study is to evaluate whether the histology of eye-tissues are affected by UVA irradiations, and what is the amount of UVA that penetrates specific tissues.
Material and Method: For this experiment, 7 pig eyes were dissected. Small parts from sclera, eyelid, cornea, lens and vitreous body were harvested for irradiation with UVA light, at CCAMF Targu Mures. The intensity of irradiation was 75 mW/cm², for 3 minutes. Measurements regarding tissue penetration were recorded. Afterwards, the samples were preserved formalin and histology analysis was performed after hematoxylin-eosin standard staining. Optical microscope was used for morphology evaluation.
Results: The irradiation process revealed that UVA light cannot pass through the sclera and that just a limited amount of the radiations penetrated through the cornea, lens and vitreous body. Histological examination showed that there were no micropathological modifications in the eyelid, sclera and cornea after 3 minutes UVA exposure.
Conclusions: The UVA irradiation with 75 mW/cm² for 3 minutes seems to be harmless for tissues of the eye. However, further extension of the study is necessary to evaluate neurons of the retina. 

CARDIAC AND RENAL DYSFUNCTION AMONG HYPERTENSIVE PATIENTS ADMITTED TO AN INTERNAL MEDICINE CLINIC

First author: Dragoș-Lucian Iacob

Coordinator(s): Lecturer Maria Cristina Tătar

Keywords: Heart failure Renal dysfunction Hypertension

Background: Heart failure is a clinical syndrome caused by a structural or functional anomaly of the heart, leading to increased intracardiac pressures and/or Inadequate delivery of blood by the heart, at rest and/or during exercise. Renal dysfunction is a frequently observed condition among individuals with heart failure, linked to an increased risk of mortality, particularly in those undergoing prolonged dialysis treatment. Hypertension significantly influences the deterioration of both renal and cardiovascular health outcomes, while declining renal function exacerbates hypertension. Objective: To study the presence of heart failure with reduced, mildly reduced, and preserved ejection fraction, and the presence of renal dysfunction in hypertensive patients admitted to our internal medicine clinic.
Material and Method: We studied all hypertensive patients admitted to our internal medicine clinic between 2022-2023 with the diagnosis of heart failure. 425 patiens were selected, 55.1% female, average age: female 75.1+9.1 years, male 70.8+11.6 years. We analyzed the presence of different forms of heart failure according to the ejection fraction determined by echocardiography. Renal function was evaluated according to estimated glomerular filtration rate (eGFR) – in patients with several values during hospitalization, the last value was considered. We compared the eGFR of patients with different forms of heart failure. Statistical analysis was performed using the IBM SPSS statistics program. As our data was not normally distributed according to the Shapiro-Wilks test we used nonparametric Mann Whitney U test for testing differences. The level of significance was set at p value under 0.05.
Results: Heart failure with reduced ejection fraction (HFrEF) was present in 37.2%, heart failure with mildly reduced ejection fraction (HfmrEF) was present in 23.1% of patients, and heart failure with preserved ejection fraction (HfpEF) was present in 39.7% of patients. According to New York Heart Association clinical stages patients were in stage I 0.2%, stage II 26.1%, stage III 61.9%, stage IV 11.8%. According to stages of renal disease patients were classified to the following stages: stage 1- 32.5%, stage 2- 29.2%, stage 3-31.5%, stage 4-6.1%, stage 5-0.7%. Patients with HFpEF had significantly higher eGFR values than patients with HFmrEF (77.8 versus 68.1p=0.03). Patients with NYHA class III had significantly lower eGFR values than patients with NYHA class II (71.2 versus 82.9, p=0.003)  
Conclusions: Different grades of renal dysfunction is common among hypertensive patients with heart failure admitted to an internal medicine clinic. More severe reduction of eGFR is present in patients with NYHA class III and in patients with HFmrEF. 

Is CRP/Albumin ratio a novel marker in patients with atherosclerotic disease?

First author: Dragos Octavian Tristu

Coauthors: Izabella Lukács

Coordinator(s): Lecturer Zsuzsanna Jeremias

Keywords: Peripheral Arterial Disease CRP/Albumin ratio Cardiovascular Risk Factors

Background: Peripheral arterial disease is most commonly caused by atherosclerosis. Because it is often associated with coronary atherosclerosis and high morbidity and mortality, it is important to better identify risk factors and potential new markers for diagnosis and disease modulation.
Objective: To analyze the relationship between a novel atherosclerosis marker, the CRP/Albumin Ratio, cardiovascular risk factors, incidence and severity of severity of coronary and peripheral arterial disease.
Material and Method: In this cross-sectional study, 30 patients were included between January and March 2024. We collected data on patient history, conventional cardiovascular risk factors, systolic cardiac function, C-reactive protein (CRP) and serum albumin levels and obtained the ankle-brachial index (ABI) using CW Doppler. The patients were divided in groups based on (a) ABI: Severe PAD: ABI< 0.5, Moderate PAD: ABI <0.9, Normal: ABI >=0.9 and <1.4, and (b) based on history or coronary angiography findings: if they had ischemic heart disease or not.
Results: The average age of the patients (18 men and 12 women) was 63.7 years. 46% had coronary artery disease, 48.3% had normal ABI measurements, 41.4% have moderate ABI values and 10.3% have severe ABI values. Most patients with atherosclerosis were on optimal medical therapy including antithrombotics, RAAS modulators and statins. We found no statistically significant correlation between the ABI measurements and the PCR/Albumin ratio (p=0.941). Those who had coronary artery disease also had lower ABI measurements (p=0.03). Also, the patients with coronary stents had worse ABI values (p=0.019). LDL levels were significantly lower in patients with coronary lesions (p=0.042).
Conclusions: Unfortunately, we did not prove our main hypothesis, most probably due to the fact that patients were on optimal medical therapy, including statins. However, our results show that atherosclerosis is a generalized process and coronary and peripheral arterial disease often coexists. Since inflammation plays an important role in the atherosclerothic process, our data suggests that optimal medical therapy reduces inflammation and may reduce global cardiovascular risk, but more research is needed to establish clear correlations.

COVID INFECTION AMONG PATIENTS WITH HEPATIC CARCINOMA

First author: Alexandra-Diana Iclănzan

Coordinator(s): Lecturer Toader-Septimiu Voidăzan

Keywords: Covid hepatic carcinoma oncology

Background: Covid-19 is an infectious disease caused by the SARS-CoV-2 virus and its symptoms can vary from a simple cold to pneumonia and even respiratory distress. Among millions of people who were infected, a more vulnerable category were the oncological patients, who shown more severe complications and higher mortality rates due to their compromised immune system which was the result of both oncological treatment and the effect of cancer itself.
Objective: The aim of this study is to observe if patients with carcinomas, especially with hepatic carcinoma had a worse outcome and to see which of the altered biochemical markers could have predicted the risk of more severe Covid infection.
Material and Method: This research is a retrospective study which was performed on 84 oncological patients who were hospitalized between February 2020 and November 2021 in the palliatives care unit in Mureș Clinical Hospital. The ones previously diagnosed with hepatic carcinoma and had a more complicated disease. Their lab results and evolution were analysed during this study aiming to see if their primary health condition could have led to a more severe Covid infection.
Results: Out of the 84 patients, 58 (69.04%) of them had improved symptoms when discharged, while 26(30,96%) did not present any improvements. 36(42.85%) patients in this study had their liver affected by a carcinoma or multiple hepatic metastasis due to different types of aggressive cancers. Out of the 36 subjects with liver damage, 20 of them (55.55%) had improved symptoms when discharged, 15(41.66%) did not show any improvements in their health condition and 1(2.77%) was deceased. Worse outcomes were seen in cases with higher levels of INR (p=0.008), total(p=0.03) and direct(p=0.0001) bilirubin and decreased levels of albumin (p=0.05).  
Conclusions: This study shows the association between oncological diseases such as hepatic carcinomas or metastasis and a higher risk of complications such as a more severe inflammatory systemic reaction, dramatic weight decrease, thrombophlebitis, early liver failure and a higher mortality rate during the Covid infection. The hepatic biochemical markers such as INR, bilirubin, and albumin were indicators of an impaired liver function, being the consequence of both the high number of angiotensin II receptors located in the liver and the direct damaging effect of cytokines on the hepatic cells.  

The advantages of a 3D printed orthosis

First author: Maria-Magdalena Daviduță

Coordinator(s): Medical Doctor Arpad Solyom

Keywords: 3D printing orthosis patient forearm

Background: Forearm fractures are classically treated with plaster or synthetic plaster. Patients usually experience discomfort from the cast, skin problems and numbness. One problem the patient faces is hygiene, not being able to access certain areas. Objective: The purpose of the study is to bring to the fore the evolution of 3D printing, especially in the field of medicine. Currently, the design of such orthoses is described only in theoretical idea and demonstratively presented. 3D printing can significantly help the orthopedic technician, improving the manufacturing time as well as their quality.
Material and Method: Melt deposition modeling and stereolithography are the most two popular types of 3D printers on the market. Both 3D printing technologies have been adapted for desktop, making them more accessible, easier to use and more capable. The 3D printer is prepared by loading a spool of thermoplastic filament into the printer's filament extruder. The filament is made from pre-selected materials such as PETG and PLA.
Results: Two types of orthoses can be manufactured, depending on the patient's condition. If the patient suffers from fractures and simple injuries, he can use standard orthotics, of different sizes (S, M and L), chosen according to the circumference of the wrist. If the patient has a more complicated trauma, he can opt for a customized orthosis. In order to create it, the orthosis is completed in the design program and then is saved in .stl format and fed into the Ultimaker printer software, loaded with filament. The filament is fed into the printer's heated nozzle or extruder. The nozzle is heated to a temperature that melts the filament, making it malleable for deposition. The 3D printer extruder moves along the X, Y, and Z axes, following the instructions in the sliced model. The molten filament is extruded through a nozzle onto the build platform or previous layer, creating a thin, continuous bead of material. The extruded filament cools and solidifies rapidly, forming a solid layer.
Conclusions: The 3D printing system can reproduce the forearm orthosis with the same dexterity and accuracy as an experienced orthopedic technician, but in a much shorter time. The advantage is the remaining time in which the technician can deal with another patient, while the orthosis is printed. The disadvantage is choosing the material so that it is biocompatible with the patient.

Connecting the dots: Exploring the Link between Type 1 Autoimmune Pancreatitis and Cholangitis

First author: Paula-Cristina Matei

Coauthors: Delia-Ioana Răduțiu Mara Spatar Daria Mateiuc

Coordinator(s): Assistant Professor Irina Dragomir , Professor Andrada Seicean

Keywords: AIP cholangitis autoimmune disease

Introduction: Autoimmune pancreatitis (AIP) is an uncommon form of pancreatic inflammation characterized by an immune-mediated process. It has two types, with type 1 often associated with elevated levels of IgG4. Notably, AIP exhibits a significant response to glucocorticoid therapy, but the relapse is very frequent leading to other complications.
Case Report: A 60-year-old patient presented himself in the gastroenterology department accusing diffuse severe abdominal pain resembling pancreatic pathology and discoloured urine, which started one month before coming to the hospital. Abdomino-pelvic CT revealed a heterogeneous pancreatic structure associated with cephalic hypertrophy and upstream obstruction of the Wirsung duct and common bile duct. Laboratory investigations showed noticeably elevated IgG4 levels (958.6 mg/dl). Endoscopic ultrasound depicted a heterogenous pancreas with parenchymal calcifications, hypertrophied pancreatic head, and a 30/25 mm heterogeneous area with a retrograde dilated Wirsung duct at 5 mm distance. Vascular invasion was not observed. Biopsies from endoscopic ultrasound showed fibrosis and rare inflammatory cells. Immunohistochemical staining including AE3, chromogranin and Ki67, did not reveal any sign of malignancy. Fecal elastase was significantly low (98,4 μg/g), indicating exocrine pancreatic insufficiency. High-dose corticosteroid therapy was initiated for three months, followed by a gradual taper. Post-corticosteroid therapy, cholangio-MRI showed pancreatic and ductal changes with the disappearance of strictures. Additionally, post-treatment biological analysis showed decreasing (but still high) levels of IgG (165 mg/dl). Imuran therapy was initiated. At the six-month follow-up, a new cholangio-MRI pointed out a significant enlargement of the main bile duct (8 mm vs 5 mm after corticosteroids) and a suspicious supraduodenal stricture (26 mm) possibly being a cholangiocarcinoma. Subsequent endoscopic ultrasound confirmed the diagnosis of autoimmune cholangitis. The patient is scheduled for additional corticosteroid therapy combined with Imuran and a follow-up in three months. 
Discussions: A patient diagnosed on CT/MRI with distal common bile duct stenosis usually is referred to the surgical department for DPC (duodenopancreatectomy) with a high suspicion of cholangiocarcinoma/vaterian ampuloma. In the case of this patient, because the common bile duct stenosis occurred after the episode of autoimmune pancreatitis, the logical step was performing a biopsy from the stenosis to rule out malignancy.
Conclusions: This case emphasizes the importance of considering autoimmune ethologies in patients presenting with pancreatic and biliary manifestations. Early diagnosis offers the opportunity to prevent other complications due to the intermittent increase of autoantibodies.

Swollen knee in a runner - a diagnostic puzzle

First author: Maria Toma

Coauthors: Oana-Bianca Tomșa Sabina-Ioana Viziteu

Coordinator(s): Lecturer Ileana Filipescu

Keywords: Ankylosing Spondylitis monoarthritis back pain knee tumefaction

Introduction: Ankylosing Spondylitis (AS) is a chronic and progressive inflammatory disease that affects the axial skeleton. Peripheral joints and extra-articular structures may also be affected. It usually presents in men in their second or third decade and leads to reduced spinal mobility and back pain. Ankylosing Spondylitis presents a strong association with histocompatibility antigen HLA-B27.
Case Report: We present the case of a 43-year-old male, a runner, who presented to the orthopedics yard with complaints of disabling pain and swelling of the right knee. MRI showed inflammatory adhesions and inflamed synovial folds. Four days later he presented to the rheumatology department for further investigations. The knee ultrasound revealed significant fluid accumulation with synovial proliferation and Doppler signal grade two. Examination of the fluid drawn from the knee articulation showed no crystals and no positive culture, ruling out gout and septic arthritis. Differential diagnosis also excluded Reactive Arthritis, as laboratory results revealed negative anti-Chlamydii and negative anti-Mycoplasma antibodies. Anamnesis revealed an episode of lumbar pain four years prior, interpreted as an L5-S1 discopathy, and treated with Nonsteroidal anti-inflammatory drugs (NSAIDs). The clinical exam indicated flattening of the lumbar lordosis, positive patellar reflex, and global tumefaction of the right knee. The pelvic X-ray revealed bilateral sacroiliitis stage II/III. Blood work demonstrated raised ESR (70) and raised C-reactive protein (6.8), pointing towards a case of marked inflammatory syndrome. The patient did not complain of limited mobility or pain in the spine but soon began to develop dactylitis and tendinitis, suggestive of AS. HLAB27 positive, and findings of active and chronic lesions demonstrated by the MRI confirmed the diagnosis.
Discussions: Underdiagnosed inflammatory lumbago is a reason for late diagnosis of ankylosing spondylitis (8 years on average). This delay is often responsible for the occurrence of ankylosing lesions. The atypical onset of AS can represent a diagnostic challenge, therefore it is important to have this thought especially in young men with musculoskeletal disorders. Monoarthritis can have multiple causes that require a differential diagnosis, among them being AS. In this case, the patient's hobby, running, and the atypical onset of the symptoms represented diagnostic pitfalls, and the subsequent appearance of other extraskeletal manifestations outlined a diagnostic puzzle.
Conclusions: This case underscores the importance of conducting a detailed anamnesis when it comes to a young patient with a history of back pain, as it may be the key to early diagnosis and treatment.

Postoperative complications of endoscopic versus open saphenectomy for aorto-coronary bypass surgery: a comparative study

First author: Delia Popovici

Coauthors: DAVID-EMANUEL ANITEI Miruna Bianca Buzamăt Andreea-Ioana Feraru Ioana-Emilia Ghiurea

Coordinator(s): Lecturer Hussam Al Hussein , Assistant Professor Loránd Kocsis

Keywords: Endoscopic Saphenectomy Open Saphenectomy Myocardial revascularization venous graft

Background: Endoscopic saphenectomy, a minimally invasive procedure used to harvest vein grafts in coronary artery bypass surgery, is an alternative to the traditional open saphenectomy technique. Research indicates that endoscopic vein harvesting is associated with a lower incidence of wound complications, offering potential benefits for postoperative recovery.
Objective: Our aim was to compare the postoperative complications of endoscopic saphenectomy with those of open saphenectomy. We also compared the major cardiovascular risk factors and diseases from the patient's personal medical histories.
Material and Method: The study cohort included 42 patients (age 64.5 ± 7 years, 28 men, 14 women) who underwent the endoscopic procedure and 50 patients (age 66.5 ± 7 years, 39 men, 11 women) who underwent open saphenectomy, all indicated for coronary artery bypass grafting. Statistical analysis was performed using IBM SPSS 25, with a p-value of < 0.05 considered statistically significant.
Results: In our analysis of postoperative complications following endoscopic vs. classic saphenectomy, we assessed 11 complications and identified significant differences in 7. Suffusions and ecchymoses were more common in the endoscopic group, whereas necrosis, lymphedema, tegumentary diastasis, paresthesia, and soft tissue inflammation were more frequent in the classic saphenectomy group. From the patients' personal medical history, it is notable, that arterial hypertension, atrial fibrillation, and varicose veins were more common in the classic saphenectomy group. No significant differences were observed in other diseases or major cardiovascular risk factors between the groups.
Conclusions: The study shows that endoscopic saphenectomy causes fewer postoperative complications such as necrosis, lymphoedema, tegumentary diastases, paraesthesia and soft tissue inflammation compared to classic saphenectomy. The more frequent occurrence of certain pathologies in the medical history of patients who underwent classic saphenectomy could influence the occurrence of complications; however, this assertion requires further investigation. These results underline the advantages of endoscopic saphenectomy in terms of reducing postoperative complications and emphasize its superiority in improving patient recovery.

Angiomyolipoma vs Liposarcoma: Diagnostic Complexities in Retroperitoneal Tumors

First author: Maria Iftime

Coauthors: Raluca-Diana Hagău Cezar Dan Eduard-Ionuț Iordache

Coordinator(s): Other Jenő Róbert Bartha , Assistant Professor Emőke- Andrea Szász

Keywords: Retroperitoneal Tumors Angiomyolipoma Differential diagnoses Obesity

Introduction: Angiomyolipomas (AMLs) are neoplastic lesions characterized by the presence of three primary tissue components: thick-walled blood vessels, smooth muscle cells and mature adipose tissue. Previously classified as hamartomas, AMLs are now categorized as perivascular epithelioid cell tumors (PEComas). Despite their marked pleomorphism, AMLs may mimic the histological features of sarcomas and carcinomas; however, they typically demonstrate a benign clinical course, with exceptions being exceedingly rare. 
Case Report: We present a case involving a 55-year-old patient with a medical history of arterial hypertension and class II obesity. The patient requested evaluation at the surgery department, citing exertion-induced pain and the presence of a pseudo-tumoral mass near the umbilicus, which first appeared approximately five years ago. Subsequent surgical exploration revealed a retroperitoneal mass measuring 140x100x65 mm, which underwent excision and was sent to the pathology department alongside fragments of perirenal fat. Upon microscopic examination, the perirenal fat sections displayed no significant alterations. However, multiple sections obtained from the perirenal tumor exhibited consistent characteristics: adipocytes with multi-vacuolar cytoplasm, sporadically enlarged nuclei with uniform contours, small vacuolated nuclei, or multinucleated cells. Vascular structures of varying sizes, surrounded by spindle cells with oval nuclei, tested positive for smooth muscle actin (SMA) and HMB45 immunohistochemical markers. Additionally, scarce CD68-positive macrophages and Ki-67-positive cells were identified. 
Discussions: Differentiating AMLs from well-differentiated liposarcomas (WDLs) can be challenging because both tumors may appear as similar large fat-containing perinephric masses. However, their prognoses differ, highlighting the need for a definitive diagnosis. The specialized literature suggests that obesity may increase the risk of developing renal neoplasms and AMLs as well. 
Conclusions: Our case highlights the diagnostic challenges related to retroperitoneal tumors, implying that obesity might contribute to the development of AMLs, furthermore underscoring the vital role of precise differential diagnoses. 

The intricate maze of trauma, addiction, borderline personality disorder, and its accompanying complexities – a case report

First author: Ioana-Alexandra Burghelea

Coauthors: Bianca-Alexandra Savin Andrei Calancea Karin Groza-Mathe Raul-Ioan Gârbacea

Coordinator(s): Assistant Professor Maria Bonea

Keywords: Borderline personality disorder Childhood abuse Comorbidities Addiction

Introduction: Borderline personality disorder (BPD) is a cluster B personality disorder beginning by early adulthood. Epidemiological data suggests that the prevalence of this condition is 1.6% in the general community and 20% among psychiatric inpatients. BPD is linked with genetic factors and traumatic childhood experiences and is frequently accompanied by other psychiatric comorbidities.
Case Report: A 22-year-old male patient voluntarily presented to the emergency department of an in-patient psychiatry clinic for a distinct period of persistently elevated mood, episodes of impulsivity, self-injurious behaviour to his left forearm and decreased need for sleep while maintaining high energy levels throughout the day. A psychiatric exam was conducted and it revealed: distractibility, pressure of speech, elevated affective mood with moments of despair and hopelessness, paroxysmal anxiety, irritability, low frustration tolerance, increased emotional reactivity, fear of abandonment, marked impulsivity, self-harm by cutting. Moreover, the patient reported suicidal ideation and multiple past suicide attempts. His social history included growing up in foster care and past history of severe childhood abuse. According to DSM-5 criteria, the patient was diagnosed with BPD, post-traumatic stress disorder (PTSD), attention-deficit/hyperactivity disorder (ADHD), substance use disorder, and bipolar disorder (BD). A multidisciplinary treatment approach was initiated. The patient is subject to numerous antidepressants and antipsychotics, including Aripiprazole, whose side-effects, dyskinesia and tremors, are managed with Trihexyphenidyl, an anticholinergic drug. The patient also attends psychotherapy sessions and Narcotics Anonymous meetings. 
Discussions: This case was particularly complex because of cause and symptom overlap, making the precise diagnosis of the patient’s psychiatric conditions challenging. For instance, scientific literature has indicated that childhood abuse is correlated with BPD, PTSD, ADHD and BD. Moreover, suicidal behaviour is a diagnostic criterion for both BPD and a major depressive episode associated with BD. To accurately determine the patient’s conditions, The Structured Clinical Interview for DSM (SCID) and DSM-5 criteria were used. Additionally, the severity of manic and depressive symptoms was assessed using the Young Mania Rating Scale and Beck Depression Inventory. This elaborate diagnostic process was relevant for treatment, as pharmacological options are especially indicated in cases of comorbidity between BPD and other psychiatric disorders, as well as severe BD. 
Conclusions: Childhood abuse can trigger the debut of BPD, which in turn can be associated with multiple interconnected psychiatric disorders. The past history of abuse, addiction issues along with the range of pathologies make this a complex case in need of multivalent treatment options.

Gigantic Splenic Hemangioma: a contrast-enhanced Ultrasonography conundrum

First author: Alexandra Racz

Coauthors: Larisa Simon Silvia Maria Lobonț Andreea Cotoi Cristian Chirila

Coordinator(s): Lecturer Mirela Gliga

Keywords: Benign vascular lesions splenic hemangioma ischemic nephropathy multiparametric ultrasound

Introduction: Splenic hemangiomas are benign vascular lesions with potential for severe complications such as rupture and bleeding. The optimal management of these lesions remains controversial, and appropriate management requires careful evaluation of each individual case. Usually, they are less than 2 cm in diameter and have a specific vascular pattern in Contrast-enhanced ultrasonography (CEUS).The aim of this case study is to illustrate the management of a 70 years old patient with a splenic gigantic focal lesion and to underscore the importance CEUS in describing the vascular pattern.
Case Report:  We present the case of a 70-year-old man with a history of ischemic nephropathy, right renal artery stenting, coronary heart disease, and systemic arteriosclerosis, who has been monitored for 3 months. Patient also had a traumatic event more than 10 years ago. At ultrasound (US) examination, there was a normal vascular pattern in the renal arteries but a huge lesion was found in the spleen. CEUS and CT scan confirmed the benign character of the lesion. 
Discussions: Patient US examination of the abdomen revealed no signs of restenosis at the renal arteries, with a reno-aortic index below 2, and normal acceleration time within both kidneys. Though, in the spleen, a 9.7 cm inhomogeneous lesion was found, more hyperechogenic than the normal spleen tissue, with transonic areas inside, rising the suspicion of a malignant tumor. We used a performant Esaote Mylab9 equipment that allows the microvascularization (microV) and the CEUS examination. There was a late enhancement within the lesion, and a persistence of the contrast agent more than 3 minutes after 1.6 ml of SonoVue bolus injection, that corresponds with a benign pattern. Because of a normal renal function, contrast-enhanced CT scan was performed and the diagnosis was confirmed. Splenic hemangiomas are benign tumors usually les than 2 cm in diameter, but in our case a more complex focal lesion was found. The vascular patters confirmed the hemangioma, although an organized hematoma was initially suspected.
Conclusions: We emphasize that a complex splenic lesion can have a benign character, highlighting the need for a multiparametric imaging approach in patient`s management. The quantification of the vascularization provided vital insights for identifying the benign pattern of the microvascularization. This integrated approach and ongoing patient assessment are essential for effective and comprehensive case management. 

An uncommon Hematological Disease: A Clinical Investigation for the Primary Testicular Lymphoma

First author: Giuseppe Avitto

Coauthors: João vitor Lacerda souza

Coordinator(s): Professor Ioan Macarie

Keywords: Testicular Lymphoma Thrombocytopenia Atrial Fibrillation Heart Failure

Introduction: Primary testicular lymphoma (PTL) is a rare and clinically aggressive form of extranodal non-Hodgkin lymphoma (NHL). It accounts for less than 5% of testicular malignancies and 1% to 2% of nHL cases. PTL predominantly affects older men, with a median age at diagnosis of 66 to 68 years. It is the most common testicular malignancy in men over 60 years old and the most frequent bilateral testicular neoplasm. 
Case Report: A 68 yo patient with a weight of 63 kg, presented with marked asthenia, fatigue, intense pain, and paresthesia in both lower limbs, anorexia, and weight loss. Analyses showed moderate anemia (Hb: 7.9), slightly increased transaminases and LDH. Abdominal ultrasound: normal liver, no ascites, Right Sided Hydronephrosis, showing a Kidney of 10.9 cm of dimension, with dilated pelvis and calyx similar to the previous hospitalization. The patient’s condition is complicated by several associated conditions including moderate secondary anemia associated with neoplasia, febrile neutropenia, post-chemotherapy thrombocytopenia, secondary immunodeficiency, deep vein thrombosis, paroxysmal self-limiting atrial fibrillation, corrected hypokalemia and hyponatremia, congestive heart failure, chronic ischemic heart disease. 
Discussions: The patient was known to have a PTL IIB, directed to the Oncology department for staging and further treatment. He was administered for R-CHOP3 associated with Methotrexate. Since this moment the patient began the treatment showing improved general condition after, showing normal abdomen at palpation. The patient was advised to avoid physical exertion as well as prolonged bed rest. He was recommended to take short daily walks and to follow a salt-free diet for another 3-4 days. 
Conclusions: The case highlights the complexity of managing high-grade mature B-cell testicular lymphoma, stage IIB, with multiple associated conditions. It underscores the importance of a comprehensive approach to patient management, taking into account the various complications that can arise during treatment. 

Utilizing Artificial Intelligence for drug discovery: A Literature Review

First author: Andreea Dobra

Coordinator(s): Professor Diana Camelia Nuță , Professor Carmen Limban

Keywords: drug discovery artificial intelligence personalized therapy scientific advancements

Background: The process by which new drugs are obtained is an expensive and time-consuming one. In a society where medicine and technology intersect in surprising ways, a recent innovation could completely revolutionize the drug development process. Using advanced algorithms, artificial intelligence offers advantages that can be exploited in the field of new drug development, clearly demonstrating its undeniable use in the pharmaceutical industry.
Objective: The purpose of the study is to examine how the application of artificial intelligence techniques helps to identify new therapeutic targets, predict drug properties, design de novo compounds or help generate new synthesis routes. For example, artificial intelligence systems are able to work with large data sets to investigate disease mechanisms and discover proteins or genes that can be targeted to treat these diseases.
Material and Method: We analyzed articles from different databases (Embase, PubMed, Scopus, Reaxys, Google Scholar) to determine the stages at which artificial intelligence can be successfully used in the process of new drug discovery. As keywords, we used: "AI target discovery", "AI drug discovery", "AI clinical relevance", "revolutionizing drug discovery". The research method used is the analysis of specialized literature, therefore there are limitations such as: the lack of information about the progress made after April 2023, the rapid evolution of the field, the inaccessibility of some works, the subjectivity of the researcher in the interpretation of the data.
Results: Starting with captopril and reaching NS018_055, the application of artificial intelligence techniques has shown to deliver many of the promised benefits: reducing discovery time and costs, increasing drug accessibility, addressing conditions previously considered incurable.

Conclusions: It is clear that artificial intelligence is progressing, paving the way to immediate personalized therapy, contributing to the development of a high-performance, non-toxic medicine tailored to the patient's needs, all in a very short time. As artificial intelligence systems continue to advance, the prospect of fully automated drug discovery looks set to become a reality, moving from uncertainty to future opportunity. 

DEGLUTITION DISORDERS – ENT, GASTROENTEROLOGY, NEUROLOGY OR PSYCHIATRY? : A CASE REPORT

First author: Ștefana-Anastasia Talău

Coauthors: Mihaela Chialda Cristian Ichim Isabelle Noémi Eros

Coordinator(s): Lecturer Mihaela Chialda

Keywords: Tracheoesophageal Fistula Chemotherapy Dysphagia Gastroesophageal Reflux

Introduction: Dysphagia, the difficulty swallowing, is a symptom caused by a neuromuscular disorder or a mechanical obstruction. It is classified into two types: oropharyngeal dysphagia and esophageal dysphagia. Tracheoesophageal fistula (TEF) is usually seen in newborns because it is mostly congenital, but in adults, it can be caused by malignancy, infections, trauma, or it can be iatrogenic. Despite being a rare complication of malignancy, more than 50% of TEFs are caused by esophageal or lung cancer. 
Case Report: We present a 92-year-old male patient known with hiatal hernia, GERD, diverticulosis, operated descending colon neoplasm, and an anxiety disorder, presenting with dysphagia, choking, and mild dysphonia. The ENT local examination revealed pyriform sinus stasis and phonasthenia. Computerized tomography revealed a dense accumulation (approximately 60 H.U.) occupying nearly the entire left frontal sinus, as well as the left anterior ethmoidal cell, with a ballooned appearance and prominence within the sinus - similar aspect, a defect in the left lamina papyracea, thickening of the mucosa of the right anterior ethmoidal cells and right maxillary sinus, hypoplasia of the right sphenoidal hemisinus, no pathological changes at the pharyngo-laryngeal level, esophagus with a thicker wall in the upper third, and prevascular mediastinal adenopathies, pretracheal, in the aortopulmonary window, some with esophageal contact. The Barium Swallow revealed the tracheoesophageal fistula through barium sulfate solution leaking onto the tracheal wall.
Discussions: After excluding any type of cervical or thoracic malignancy and any neurological etiology, considering the patient’s age and personal pathological history, it was concluded that the chemotherapy that the patient received, together with GERD, could have caused the tracheoesophageal fistula.
Conclusions: This report aims to raise the clinician’s awareness to the tracheoesophageal fistula in adulthood not caused by cervical malignancy, yet considering TEF as a rare consequence of peptic esophagitis, secondary to GERD, and even more rarely following by chemotherapy.

The Influence of Social Media on Adult Population Vaccination Decision

First author: Bortoș Renata-Maria

Coauthors: GEORGIANA MARIA BOCAN Bora Marian DIMITRIOS BELLO

Coordinator(s): Professor Vladimir Bacârea

Keywords: Research Medical Studies Level of education Vaccine

Background: Social media platforms are digital platforms that can be accessed from any central unit, phone, or tablet connected to the internet. Users utilize these networks for virtual connection and increasingly for information gathering. In the medical field, documenting information obtained from online sources is essential. By verifying the sources of information, one can avoid forming preconceived ideas about a medical subject, in this case, vaccination.
Objective: The main objective of this study is to verify whether the level of education, medical studies, time spent online, and the number of active accounts on the two presented social networks, Facebook and Instagram, can modify users' perception of the information read about the vaccination process and subsequently influence their vaccination decision.

Material and Method: To verify these aspects, we conducted a cross-sectional study using a questionnaire distributed online, targeting both individuals with medical studies and those without. The questionnaire consists of 30 questions, allowing for multiple responses, which aim to gather demographic data in the first part and assess the level of education. Subsequently, we examine the time spent online, reading information about vaccines, source verification, the psychological impact of this information, and the user's opinion on these matters.
Results: The study involved a total of 258 participants, excluding individuals under the age of 18, of which 25.97% had medical studies, while 74.03% did not. Regarding educational level, 58.53% had higher education, demonstrating a statistically significant mild positive correlation between being a student and being informed from medical journals(r = 0.36, p< 0.001). About 54% of respondents had active accounts on both social media platforms, with over half stating that they had read information about vaccines. Among those with medical studies, the majority reported obtaining information from medical journals, specialized publications, or their family doctor.
Conclusions: More than half of the participants in the study spend a significant amount of time online, both on Facebook and Instagram, with a significant percentage stating that they have read information about vaccines, thus being prone to misinformation if the source is not verified. The level of education, especially holding higher education or medical studies, is a factor that influences the source of information, perception, and the user's feelings regarding vaccination.

A rare psoas muscle metastasis after an undiagnosed cervical cancer

First author: Emanuela Andrea Timsac

Coauthors: Alexandra-Mara Tivadar George Ciulei

Coordinator(s): Lecturer Vasile Negrean , Medical Doctor Ioana Roșca

Keywords: cervical cancer psoas muscle metastases hysterectomy

Introduction: Cervical cancer is the 4th most common cancer worldwide among all female cancers. The most frequent cause is the chronic infection with a high-risk type of HPV virus (HPV 16-18). In Romania, cervical cancer ranks as the 3rd most frequent among women and the death rate is exceeding four times the death rate in Europe, this is explained by of the lack of health education programs and the still developing screening programs. 
Case Report: Seven years ago, a 50-year-old woman was diagnosed with uterine fibroids and underwent total bilateral hysterectomy with adnexectomy. The patient underwent an MRI one month after the operation, but no other information was presented to her after. In January 2024, the patient presented to the hospital with back pain of sudden onset for 2 months, radiating to the right lower limb, and a weight loss of 5 kg in the last month. Examination with MRI suggested an abcess of the psoas, but ultrasound showed a solid mass with necrosis. After contacting the previous pathologist that examined the uterine fibroids, we found out that the diagnosis was squamous cell carcinoma. Correlating the symptoms, with the initial diagnosis and with the imaging and cytological results, the diagnosis of cervical cancer metastasis at the level of the psoas muscle was reached. 
Discussions: Cervical cancer is difficult to detect in early stages, but it is a real challenge to start the diagnosis from an unusual single site of metastasis, such as the psoas muscle, and reach the diagnosis that should have been made 7 years ago. Studies have shown that single-site metastasis occurred in almost 70% of cases, the most common being metastasis in the lung (37,9%), bone (16,7%), liver (12,5%), and less than 1% in skeletal muscle. The survival rate of patients who developed metastatic cervical cancer is between 8 and 13 months, just 16,5% of patients survive for more than 5 years. 
Conclusions: This case report evidence the importance of an appropriate screening and also the differential diagnosis for a retroperitoneal mass, taking into account both imaging and cytological results, and also the patient’s history.

The Role of Infections in Paving the Way for Liver Failure in Cirrhosis: Case Report

First author: Elena-Andreea Voina

Coauthors: Anca Maria Stoiu

Coordinator(s): Medical Doctor Ofelia Moșteanu , Medical Doctor Teodora Atena Pop

Keywords: cirrhosis ascites liver failure infections

Introduction: Cirrhosis is the fourteenth most common cause of deaths worldwide. It is characterized by the irreversible hepatic tissue fibrosis with loss of function of the liver, which leads to several systemic complications such as portal hypertension, esophageal varices, ascites, hepatocellular carcinoma etc.
Case Report: We present the case of a 70 years-old man, former smoker and heavy drinker, recently diagnosed with alcoholic liver cirrhosis, low urinary tract infection in treatment with Levofloxacin and sinus tachycardia. He presented to the medical service for loss of appetite and increased volume of the abdomen due to ascites. The ultrasound revealed hepatomegaly, large volume ascites and an inhomogeneous, micronodular, with irregular outline liver. In addition, the thoraco-abdominal-pelvic CT scan showed liver with cirrhotic-type morphology, mild perigastric, perisplenic, omental varices, large ascites, splenomegaly and a tumor at the level of the body and tail of pancreas. For the diagnosis of pancreatic tumor an endoscopic ultrasound (EUS) was performed and a polycystic pancreatic caudal lesion was found. The ascites analysis showed spontaneous bacterial peritonitis (SBP) with 591 polymorphonuclears, for which antibiotics, antifungals and probiotics were initiated. During the follow up the serum creatinine level increase  treatment with Terlipressin and Albumin was started, which lead to a favorable evolution of the hepatorenal syndrome. The patient was discharged after 4 weeks with significant improvement of the liver function, good response of ascites to diuretics and encephalopathy score improvement. The patient returned after one month with jaundice and 10 daily watery stools. Lab test showed severe acute on chronic liver dysfunction and Clostridium difficile infection. Vancomycin treatment was started. The number of stools decreased but the patient evolution was unfavorable, with progressive liver failure and he died after 2 weeks of hospitalization. 
Discussions: Ascites, hepatorenal syndrome and SBP indicate an advanced and decompensated stage of cirrhosis. In this case, the prognosis suggested by studies estimates a low rate of ten years survival. Any type of infections might decompensate the liver function and promote the onset of acute on chronic liver failure. This association might dramatically increase the mortality risk in these kind of patients.
Conclusions: The aim of this case report is to emphasize the wide range of complications that can be generated by alcoholic cirrhosis and the importance of dysbiosis due to strong antibiotherapy to generate further complications in an already frail patient.

Sudden death during COVID-19 pandemic period: consecutive SarsCov-2 positive case series

First author: Adriana Bodnaruc

Coauthors: Andrea Bereczki

Coordinator(s): Lecturer Laura Chinezu

Keywords: sudden death SarsCov-2 infection histopathology

Introduction: Sudden death is a controversial diagnosis, as its unpredictable occurrence makes it difficult to identify the underlying causes. In Romania, sudden death is included among deaths suspected of being violent and is required an autopsy to establish the cause. Some studies show that there was a rise in home deaths during the pandemic in many countries. Our aim was to find and to describe Sars-Cov-2 positive patients that died at home without known clinical data and to identify the cause of death. 
Case Report: All consecutive cases that fulfilled the following inclusion criteria were chosen: non-violent deaths at home during the COVID-19 pandemic, absence of clinical data about the patients from whom histological samples were taken, the confirmation of SarsCov-2 infection during autopsy. The autopsies were performed between October 2020 and May 2021 at the Institute of Legal Medicine of Târgu Mureș. For all seven cases identified, the macroscopic and microscopic changes were noted. Five men and two women were included in our study, with a medium age of 48 years old (between 26 and 63 years). Macroscopically, myocardosclerosis was identified in five cases, all men, and was also confirmed microscopically. Bronchopneumonia was macroscopically seen in four cases, two women and two men and was microscopically confirmed only in two cases. The characteristic acute respiratory distress syndrome was revealed in the rest of the cases. Massive pulmonary edema and cerebral edema were macroscopically and microscopically seen in all cases. An old lacunar infarct of basal ganglia was identified in one case, and old myocardial infarction was revealed in two cases. 
Discussions: The fact that it was generally rare for someone with COVID-19 to die at home (overall 8.3%) suggests that much of the rise of home death is related to patients suffering from other life-threatening conditions. Almost all our SarsCov-2 positive cases were with chronic diseases, except the two women that were younger (medium age 36 years) and with no significant chronic pathological conditions. All our cases died suddenly at home due to COVID-19 disease.
Conclusions: Sudden death involves multiple mechanisms, not all of which have a macroscopic, visible impact on the body. Microscopic changes may suggest certain pathologies. The combination of different types of injuries may explain the cause of death better than a single injury.

Optimization of PtNPs biosinthesis method using Picea abies sp. and Beech sp. aqueous bark extracts

First author: Năstaca - Alina Coman

Coordinator(s): Lecturer Lavinia Berta

Keywords: nanoparticles platinum biosynthesis bark extracts

Background: The study of nanoparticles (NP) is a continuously expanding field. The biosynthesis of NPs with the help of natural extracts presents numerous advantages (simple, economical, safe for the environment, high reproducibility), being preferred by researchers, to the detriment of chemical synthesis. 
Objective: The purpose of this study was to identify the optimal conditions for the synthesis of PtNPs with natural bark extracts.
Material and Method: Methods: First, the aqueous bark extracts were obtained from Picea abies sp. and Beech sp. by ultrasound-assisted extraction. The salt used was K2PtCl6. To identify the optimal conditions of PtNPs biosynthesis, numerous determinations were made in which the concentration of salt solution (0,5 mM, 1mM, 2mM), temperature (50°C, 70°C, 80°C), pH (the initial pH of the mixture±2 pH units), cation:extract ratio (1:10, 1:50, 1:100) varied. The synthesis was monitored for 24 hours, with absorbance reading at 2 hours, wavelength range: 250-450 nm. 
Results: The bioreduction of Pt4+ was confirmed by the color change from pale yellow into black and by UV-VIS spectroscopy. The recorded spectrum shows a surface plasmon band at 263 nm for Pt4+, 280 nm for Picea sp., and 282 nm for Beech sp. In the case of PtNPs all these bands disappear (a characteristic thing for this metal). 
Conclusions: As a result of the optimization processes for PtNPs biosynthesis, the following results were obtained: for Picea abies sp (molid) Pt 1mM, ratio 1:10, pH 10, 80oC; for Beech sp. Pt 1mM, ratio 1:10, pH 10, 70oC. This research topic is still ongoing, following the characterization of nanoparticles (IR, TEM, SEM, TGA) and the analysis of biological activity (antioxidants, antimicrobials, antifungals).

The impact of surgical intervention in cervical spine injuries

First author: Gheorghe Marian Prode

Coauthors: Andreea Iamandi Maria Nistor Ioana Vuță Delia Popovici

Coordinator(s): Professor Adrian Bălașa , Medical Doctor Flaviu Tămaș

Keywords: Cervical spine Surgical intervention fractures dislocations

Background: Cranio-cerebral and spinal traumas can have serious consequences on motor and sensory function, but especially on the quality of life of patients. Therefore, it is important that medical-surgical care be provided under optimal conditions.
Objective: This study investigates how surgical intervention affects the clinical status in traumatic fractures and dislocations of the cervical spine area.
Material and Method: We conducted a study between 2023 and 2024, including 209 patients with cervical traumas at the Emergency County Clinical Hospital Târgu-Mureș. Inclusion criteria were adult age (≥ 18 years), hospitalization during the period 2012-2023, and survival to surgical intervention. The analysis was performed on 61 patients, with data collected from discharge summaries and CT images. Analysis was conducted using Microsoft Excel and IBM SPSS v26, at a significance level of 5%, and graphs were generated using GraphPad Prism 10.2.1."
Results: The results of the statistical analysis show a predominant involvement of male patients (83.6%), originating from rural areas (70.5%), with the highest incidence occurring in the age group between 45 and 50 years. Male patients were significantly more likely to be involved in accidents such as falls from height, blunt force injuries, or forestry accidents, while females were more exposed to road accidents (p<0.05). Most commonly, the mechanism of accidents involved high-energy force and predominantly caused multiple fractures (78.7%), subaxial type (87.5%), as well as subaxial dislocations (92.1%). Additionally, the majority of patients fully regained cerebral activity, an observation based on preoperative Glasgow score measurement (14.02±3.319), which was lower than the postoperative score (14.98 ± 0.128). Furthermore, the Glasgow score varied depending on the presence of multiple fractures (12.33 ± 5.124 compared to 14.72 ± 1.83 in cases of single fractures), hemodynamic stability (14.19 ± 3.043 in stable patients versus 9.00 ± 8.485 in hemodynamically unstable patients). The patient cohort showed a significantly lower postoperative rate of cervical pain, pyramidal signs, sensory deficit, as well as a significant improvement in motor deficits in the limbs (p<0.05).
Conclusions: The preoperative clinical condition significantly improved postoperatively, indicating that surgical intervention had a positive impact on cervical traumatic fractures and dislocations.

Fat Grafting for Implant-Based Breast Reconstruction. Is it a Game Changer?

First author: Radu Ilieș

Coauthors: Maria Căinap Iozefina-Darina Gaidoș Andrei Man

Coordinator(s): Lecturer Maximilian Muntean , Medical Doctor Ionuț Pop

Keywords: Fat grafting Implant Breast Reconstruction

Background: Nowadays, Breast Surgery has become a field full of high expectations where implant-based reconstruction after mastectomy is continuously gaining popularity. Fat grafting can be used to improve aesthetic outcomes after reconstruction with an implant, but this is a debatable subject since extensive research has not been made on this topic. Moreover, the main concerns about it were initially the oncogenic potential and neoplastic calcification, which have been disproven by current research.
Objective: The aim of this review is to determine and quantify the benefits and risks of fat grafting combined with breast reconstruction using implants.
Material and Method: Articles between 2011 and 2023 from PubMed Database were selected based on their topic and title, using the keywords: fat grafting and implant breast reconstruction. In order to be included, articles had to be written in English and free full text must have been available. Animal model studies and single cases were excluded from the selection process. Out of the total number of 108 results, only 16 met the aforementioned criteria and were included in the analysis. From each one of them, data related to complications and aesthetic outcomes (using an aesthetic grading value from 1 to 5) was extracted.
Results: Fat grafting was performed in variable sessions (1–5), depending on the necessity of each patient included in the selected articles. The average volume in one session varied between 59.8 ml and 313 ml. The complications that were met are, in their descending order, fat necrosis (2.7%), seroma, implant infection, hematoma, skin necrosis, implant malposition and even implant rupture (0.1%). The aesthetic score was reported by only 5 out of 16 articles and varied between 4 and 4.8 and it was stated that the group where hybrid breast reconstruction was performed had a higher overall aesthetic score (in terms of volume, appearance and contour) than the control group which underwent reconstruction using either implant or fat grafting.
Conclusions: Breast Reconstruction using implants has proven to be more effective when combined with fat grafting, not only due to its encouraging results (shown by high values of the aesthetic score), but also because it is a safe procedure, with a low rate of complications. Therefore, the obvious benefits justify why fat grafting should be done in current clinical practice, contributing to the development of Breast Surgery.

Sun exposure behaviors and skin imaging: exploring the link

First author: Ioana-Emilia Ghiurea

Coauthors: Dragos Hutanu

Coordinator(s): Assistant Professor Oana Mirela Tiucă , Professor Silviu Horia Morariu

Keywords: sunlight cutaneous parameters sunburn skin elasticity

Background: Prolonged and unprotected sun exposure induces various changes in the skin. These range from hyperpigmentation due to increased melanin production, collagen, and elastin fibers degradation leading to decreased elasticity and wrinkling, and increased erythema due to keratinocytic DNA damage and secondary inflammation.
Objective: This study aims to analyze the cutaneous changes resulting from the action of sunlight on both sun-exposed and non-exposed skin using cutaneous ultrasound and to correlate them with patients’ sun exposure behavior.
Material and Method: This study is a cross-sectional, descriptive analysis conducted strictly between September and December 2023 as such to minimize the influence of direct sunlight exposure on cutaneous parameters. The study consisted of three parts: a specially designed sun exposure behavior questionnaire completed by the patients, clinical, dermatoscopic, and ultrasound examinations conducted by a dermatologist using a Heine DeltaOne dermoscope and DermLab Skin Combo ultrasound machine. Statistical analysis utilized Mann-Whitney U, Kruskal-Wallis, and Wilcoxon tests for quantitative data, and the Chi-square test for qualitative data, with a significance level set at α=0.05.
Results: In this study, 35 patients were included, with a median age of 47 years, and an equal gender distribution: 51.4% male and 48.6% female, predominantly from urban areas (62.9%). Four patients were previously diagnosed with basal cell carcinoma, while another four patients had a history of squamous cell carcinoma. Sun exposure and patients’ reactions to it were also evaluated. Thirty-three patients had a history of sunburn, with a predominant healing time of 2 weeks (n=24). Most patients (n=19) had prolonged sun exposure (more than 10 times a year, n=15) for recreational purposes. Among the entire cohort, only 48.6% confirmed sunscreen use. Significantly higher values of hydration and skin elasticity were observed in unexposed skin compared to sun-exposed skin (p<0.001). Conversely, significantly higher values of erythema and melanin levels were observed in sun-exposed skin (p<0.001).
Conclusions: In summary, our study underscores the detrimental effects of sunlight on skin health, showing decreased hydration and elasticity alongside increased erythema and melanin levels in sun-exposed skin. These findings emphasize the crucial role of sun protection measures in preventing cutaneous damage. 

SEVERE AORTIC STENOSIS IN A PATIENT WITH A MITRAL PROSTHESIS - WHAT DO WE DO?

First author: Sebastian Cucu

Coauthors: Drincal Reka VIorel Constantin Nicolae Elkahlout Ayman

Coordinator(s): Assistant Professor Tunde Pal

Keywords: TAVI Mitral Prosthesis Aortic Stenosis Complications

Introduction: Transcatheter aortic valve implantation (TAVI) has become the safer alternative to surgery when it comes to intermediate-to-high-risk patients. A particular challenge is represented by previous mechanical mitral prostheses, on account of their proximity to the aortic situs of implantation. Considering the currently limited literature regarding TAVI in patients with mitral prostheses, the objective of this case presentation is to emphasize that the benefits of these procedures outweigh the associated risks.
Case Report: A 78-year-old woman was admitted describing dyspnea, fatigue, and typical chest pain, whose medical history revealed permanent atrial fibrillation, a mechanical bileaflet mitral prosthesis (Cardiamed no. 29) and tricuspid annuloplasty, both implanted 9 years prior. The clinical exam revealed an overweight patient with an aortic systolic murmur and a metallic click, with no further abnormalities. The electrocardiogram revealed atrial fibrillation, along with Q waves in DIII. Echocardiography demonstrated severe degenerative aortic stenosis with a gradient of 85/50mmHg, mild aortic regurgitation, mild tricuspid regurgitation, and a hypertrophic, normal diameter left ventricle with an ejection fraction of 60%. Considering the patient’s age, surgical risk (EuroSCORE II of 5.47%), and medical history, TAVI was chosen to treat the aortic stenosis. The doctor performed a femoral transcatheter aortic valve implantation with a balloon-expandable Edwards Sapien 3 no. 26 valve, with good results. Post-TAVI echocardiography revealed a transaortic gradient of 22/11 mmHg with a mild paravalvular leak, a normofunctional mechanical mitral valve and an ejection fraction of 55-60%. Post-TAVI electrocardiogram showed atrial fibrillation, along with intermittent major left bundle branch block. 
Discussions: Besides the risk of paravalvular leak and potential conduction disorders which were anticipated in a severely degenerated aortic valve, the presence of a mechanical mitral valve implied other complications, such as the interference of the mitral prosthesis with the new valve, its embolization or the increased hemorrhagic risk. Despite those, TAVI achieved its goal of reducing the gradient and, most importantly, relieving the patient’s symptoms and hopefully improving her quality of life. 
Conclusions: Undoubtedly, continuous refinement of TAVI techniques and materials is warranted to further mitigate associated risks. Nevertheless, we believe this case achieves its goal of highlighting the outweighing benefits of TAVI in this patient. Considering the relatively scarce literature regarding TAVI in patients with mitral prostheses, we believe this paper contributes to the growing body of evidence that TAVI is a feasible therapeutical option in patients with mitral prostheses. 

Unique Flap for Lower Eyelid Reconstruction After Basal Cell Carcinoma Excision

First author: Silvia Maria Lobonț

Coauthors: Alexandra Racz

Coordinator(s): Lecturer Dorin Constantin Dorobanțu , Medical Doctor Anamaria Cozlov

Keywords: basal cell carcinoma eyelid reconstruction ectropion pediculated flap

Introduction: Basal cell carcinoma (BCC) is the most common type of eyelid cancer and it is a challenging pathology due to its proximity to functionally essential organs. Excision requires meticulous reconstructive techniques that ensures good functionality and aesthetic results. Early diagnosis and complete excision of the primary lesion are crucial to prevent further complications such as local infiltration and recurrences. 
Case Report: We bring forward the case of a 55-year-old male that was admitted in Plastic and Reconstructive Surgery Compartment of Târgu-Mureș with a left lower eyelid cutaneous tumour. After surgical removal, the histopathological exam revealed a mixed BCC (nodular and infiltrative) with free resection margins (tumoral cells at 0,6mm from the lateral excision site). The tarsal plate was reconstructed using a cartilage graft harvested from the left auricular pavilion with good postoperative healing and minimal ectropion formation. Four months later a recurrence occurred at the exact same site of surgical excision of the primary lesion. The treatment consisted of a more radical excision with extemporaneous examination (all tissue samples were tumour-free), with the main part being sent for final histopathological exam. Reconstruction of the left lower eyelid consisted of a pediculated full thickness cutaneous-musculo-tarso-conjunctival flap harvested from the left upper eyelid. Sutures in anatomical planes were used.
Discussions: An understanding of the anterior and posterior lamella of the eyelid is critical in eyelid reconstruction. The anterior lamella includes the skin and orbicularis oculi muscle, while posterior lamella includes the conjunctiva and tarsus. For full-thickness defects, thus in our case, it is important to address reconstruction of both the anterior and posterior lamella. Free anterior and posterior lamellar repairs are not commonly performed together, as it might compromise the vasculature. Our noteworthy unipedicular flap provides a replacement for both the anterior and the posterior lamellae including skin, muscle, tarsus and conjunctiva. Even though cicatricial changes with healing can sometimes predispose the lower lid to cicatricial ectropion, our patient’s postoperative evolution was favourable, with no infection, flap failure, significant scar tissue formation or ectropion.
Conclusions: There are various methods for the reconstruction of the lower eyelid; customizing the reconstruction is necessary to provide proper results for each patient. The primary goal is to completely remove the tumoral mass, while the most important secondary objectives are to restore a functional eyelid and to obtain a normal appearance because of the critical importance of periocular region in social relationships.

Xanthogranuloma of the pituitary region, in the shadow of asthenia and bradycardia, within a pediatric patient

First author: Alexandru Topor

Coauthors: Diana-Maria Cetină Miruna Zaha

Coordinator(s): Associate Professor Simona Sorana Căinap

Keywords: Xanthogranuloma Pituitary Gland Asthenia Occipital Headache

Introduction: Xanthogranulomas are benign lesions frequently found on the skin. The sellar location is remarkably uncommon, usually occurring in adolescents, making it difficult to differentiate from other pituitary lesions. The diagnosis is made postoperatively, during pathological analysis. Given the subtle clinical changes and the tumor's aggressiveness affecting the optic chiasm, prompt patient management is imperative.  Case Report: A 16-year-old male patient presents with an intense occipital headache starting 3 months ago and weight loss after academic overload. During the neurological examination, only bradycardia was discovered, and the patient was referred to the pediatric cardiology department. The cardiological examination showed non-pathological findings, except for significant asthenia and sinus bradycardia on electrocardiogram. The causes of asthenia were investigated, and a hormonal profile of the hypothalamic-pituitary axis was performed, revealing pleiotropic pituitary insufficiency and hyperprolactinemia. MRI revealed a suprasellar lesion occupying the entire pituitary fossa with compression on the pituitary stalk. The tumor was excised through a trans-sphenoidal approach, the histopathological examination suggested a xanthogranuloma. Postoperatively, the evolution was favorable. Temporary substitution with levothyroxine and hydrocortisone was performed until the hormonal parameters normalized. 
Discussions: The patient was diagnosed early, as there were no visual or neurological alterations. The decreased appetite and bradycardia represented subtle signs and symptoms of intracranial hypertension. Investigating hypothyroidism or Addison's disease, a deficiency of hormones on the central axis was revealed.  
Conclusions: Pituitary xanthogranuloma has a subtle clinical evolution. The headache, asthenia and incidental bradycardia were the pillars of this diagnosis. Due to prompt presentation and rapid diagnosis, the outcome was excellent. 

Clinical and morphological correlations in facial erythrosis from rosacea: preliminary results from a two-step observational study

First author: Alina-Valentina Damaschin

Coauthors: Ioana-Emilia Ghiurea Răzvan Cătălin Son Laurentiu-Raul Stan Rares Vrajitoru

Coordinator(s): Assistant Professor Oana Mirela Tiucă , Professor Silviu Horia Morariu

Keywords: rosacea erythema ultrasound

Background: Rosacea is a chronic centrofacial dermatosis, mainly affecting light-skinned patients, and characterized by persistent erythema alongside, depending on the clinical stage, telangiectasias, papules, and pustules. The evaluation of cutaneous parameters and the use of newer techniques such as skin ultrasound examination, though still not so widely employed, prove to be reliable for the management and follow-up of patients suffering from this condition.
Objective: Our research aimed to analyze the clinical, biological, and morphofunctional aspects of facial erythrosis in patients suffering from rosacea and to highlight a possible link between them.
Material and Method: We conducted a two-step observational study that included patients diagnosed with rosacea and admitted to the Dermatology Clinic of Mures Clinical County Hospital. Data referring to sociodemographic status, disease course, subtype, trigger factors, Helicobacter Pylori association, and treatment were extracted from patients' charts and statistically analyzed using Excel software. Ultrasound examination was performed for included patients to assess the following cutaneous parameters: erythema, melanin, hydration level, and skin elasticity. Continuous variables were analyzed with Student’s t-test or Mann–Whitney U test, depending on their normality check. Categorical variables were assessed for intergroup significant differences with the Exact Chi-square test using the Monte Carlo method. The present data refer to patients examined in the winter season and set to return for a second analysis during spring.
Results: 20 patients were enrolled in this study. 11 were females and 9 were males. 8 were from urban areas, and 12 were from rural ones. Patients' ages ranged from 28 to 65 years old. All 3 patients with erythematotelangiectatic subtype had bilateral facial lesions, emotional stress being the trigger at 2 of them and none had Helicobacter Pylori. The majority of patients (n=12) suffering from papulopustular subtype had bilateral facial and nose lesions and a median erythema value of 12. The 4 patients with the phymatous subtype had lesions affecting the whole facial area and most of them were males (n=3). The male patient with ocular subtype (n=1) has facial and ocular involvement, more than 10 years from the beginning of the disease and an 18,9 level of erythema. A correlation between the level of hydration and rosacea (p=0,049) was found.
Conclusions: As rosacea progresses, skin ultrasound parameters modify underlying the subsequent pathophysiological mechanism. Further larger prospective studies are necessary.

ASSESSING DISABILITY IN MULTIPLE SCLEROSIS PATIENTS

First author: Mihai Andrei Popescu

Coordinator(s): Professor Rodica Ioana Bălașa , Medical Doctor Laura Iulia Bărcuțean

Keywords: Multiple Sclerosis, Disability Evolution, Expanded Disability Status Scale, Relapses

Background: Multiple Sclerosis (MS) is a chronic neuro-inflammatory disease of the central nervous system and represents one of the main causes of neurological disability in young individuals. The disease onset and clinical course has a great inter-individual variability, therefore predicting MS’s progression turns out to be quite challenging. 
Objective: To evaluate the demographic and clinical predictors for disability progression, as measured by the Expanded Disability Status Scale (EDSS), in a cohort of MS patients treated with interferon beta.
Material and Method: We retrospectively analysed a cohort of 252 MS patients treated in the Neurology 1 Clinic of Emergency Clinical Country Hospital of Târgu Mureș based on demographic and clinical data. We used Kaplan Meier survival analysis to assess the moment of reaching an EDSS of 3.0 and 6.0.  Results: The lot was composed of 86 (34.12%) male patients and 166 (65.87%) female patients. The mean age of the cohort was 45.5 years ± 12.02, with the mean age at diagnosis of 30.78 years ± 9, and the mean age of treatment initiation of 32.29 ± 9.34 years. At the beginning of the treatment, all 252 had a relapsing-remitting form (RR), while in 2023, 9.1% of the total patients progressed to the secondary-progressive (SP) form. The analysis of the moment of reaching an EDSS of 3.0 from the onset was 25 years [21.12; 28.82 95% CI] and 37 years [34.08; 39.91 95% CI] until they reached EDSS of 6.0. There were no differences based on gender and living environment (p-log-rank >0.05). 
Conclusions: Before the disease-modifying therapy era, MS patients would reach an EDSS of 6.0 in 10-15 years from the onset. The importance of early treatment initiation is reflected in a slower disability accumulation, emphasizing the concept of “optimal therapeutic window”.

Visual transposition of thrombogenic theory on atherosclerotic coronary artery: a case report

First author: Dinu Elena-Georgiana

Coauthors: Denisa Borla Orlando Sorin Ardelean

Coordinator(s): Medical Doctor Dan Dicu-Serban

Keywords: new technique atherosclerotic plaques vascular trunck orange substance

Introduction: Coronary artery disease is a condition arising from the occlusion of the coronary arteries and resulting in a mismatch between oxygen supply and demand. The atherosclerotic process in the coronary arteries begins with endothelial dysfunction and can cause thrombotic total occlusion and myocardial infarction. 

Case Report: Discussions: The necropsy revealed the presence of an atheroma plaque in the lumen of a coronary artery. Using a specific paste technique on the atheroma plaque, a clear imprint of the thrombus was found attached to the atheroma plaque. With these results the final cause of death was established. Conclusions: The method of complete visualisation of the coronary system allowed the precise identification of the cause of death and of the preexistent pathologic background - advanced coronary disease with associated thrombosis, in a young male.

MINIMALLY INVASIVE MANAGEMENT OF INSULIN NEEDLE FRAGMENTATION IN AN OBESE DIABETIC PATIENT: A CASE REPORT

First author: Alessia Condorelli

Coauthors: Yildiz Aktas

Coordinator(s): Medical Doctor Cosma Cătălin Dumitru , Medical Doctor Molnar Călin

Keywords: Insulin Needle Fragmentation Minimally Invasive Surgery Obese Diabetic Management Imaging-Guided Removal

Introduction:  Needle breakage during insulin administration is an unusual but grave complication, particularly in obese patients with chronic diabetes. This case report delineates the clinical approach and management strategy employed for retrieving a fragmented insulin needle in an elderly obese patient with long-standing diabetes. 
Case Report:  A 75-year-old female with Grade 2 obesity and a decade-long history of type 2 diabetes presented with a periumbilical lesion after an insulin needle broke during self-administration. The initial assessment involved an abdominal X-ray to localize the needle fragment, followed by its minimally invasive removal through a precise incision (2 cm) guided by the imaging findings. A post-control x-ray was performed, and five days of profilatic antibiotherapy was administered.  
Discussions:  The incident highlights the technical challenges and increased risk of needle breakage in obese diabetic patients due to the greater fat layer. This case emphasizes the necessity of employing imaging modalities for accurate localization and delineation of the foreign body, facilitating a targeted and minimally invasive surgical approach. It also discusses the significance of postoperative care, including antibiotic and anti-inflammatory therapy, to prevent infection and promote healing.
Conclusions: Minimally invasive techniques, augmented by precise imaging, offer a safe and productive solution for the removal of broken insulin needles in obese patients. This report underlines the importance of comprehensive management protocols and preventive measures in the diabetic population to mitigate such risks.

Exploring the Role of Emergency Department Protocols in Critical Patient Management

First author: Eduard-Ionuț Iordache

Coauthors: Cezar Dan Maria Iftime Hera Valentina-Alexandra Bălănescu Elena-Georgiana

Coordinator(s): Assistant Professor Adrienn Németh , Lecturer Sorana Teodora Truță

Keywords: emergency sepsis hematoma shock

Introduction: Prompt recognition and immediate management of sepsis and septic shock are pivotal for patients' outcomes. Given that the Emergency Department serves as the primary point of medical intervention for septic patients, emergency physicians are critical in the initial stages of patient care. Emergency care involves fast initial diagnosis, prompt resuscitation, and timely initiation of antibiotic therapy.
Case Report:        We report the case of a 71-year-old man with a history of aorto-bifemoral bypass (6 months prior); he presents in the emergency room with an altered general condition, complaining of hypogastric pain with one-week onset, hematuria (24 hours ago), pain in the lumbar region and fever. The initial clinical and preclinical evaluation of the patient revealed important information about his altered state, changes in the blood count, leukocytosis with neutrophilia, metabolic acidosis, and hemodynamic and electrolyte instability. The signs and symptoms of the patient outline the clinical picture of shock. Immediate patient management involved hemodynamic stabilization, antipyretics, analgesics, broad-spectrum antibiotics administration, and further investigations. The imaging results reveal a large, superinfected left retroperitoneal hematoma as a result of a rupture of an aneurysm of the infrarenal abdominal aorta and superinfection. It has been decided that the patient should be admitted to the vascular surgery department for specialized surgical treatment. The case shows that a quick, well-coordinated, and practical approach can significantly affect treatment outcomes and the patient's quality of life.
Discussions: The literature suggests that the susceptible phase for bacterial colonization of shunts may not be limited to the operative procedure, as conventionally assumed, but may persist throughout the postoperative wound healing phase. The particularity of the case is given by the relatively long, asymptomatic period following the surgical intervention and the symptoms at presentation: abdominal pain and hematuria.
Conclusions: This case report illustrates the importance of early diagnosis and prompt treatment and the efficiency of a well-coordinated emergency medical team and multidisciplinary collaboration. Thus, in light of this case, we are reminded that every moment counts and that medical professionals' commitment and expertise can work wonders for those in need.

Is Ibuprofen efficient for the treatment of patent ductus arteriosus in preterm and low birth weight infant?

First author: Mara Tanase

Coauthors: Pop Mara Nicola Suteu Peiu Teodor Jenica Daiana Suciu

Coordinator(s): Associate Professor Manuela Cucerea

Keywords: patent ductus arteriosus Ibuprofen respiratory distress premature infant

Introduction: Patent ductus arteriosus (PDA) is extremely common in premature neonates and is related to gestational age and respiratory status. One of the most frequent pathologies preterm babies can encounter is respiratory distress syndrome (RDS). 
Case Report: We present the case of a premature infant, around 31/32 weeks of gestational age, a physiologic birth, cephalic presentation, weighing less than 1600g, APGAR score of 8/1 min, 9/5 min. The preterm infant presented with moderate respiratory distress syndrome: expiratory moaning, and subcostal retraction. Blood gas analysis revealed acidosis (pH 7.26), hypoxemia (PaO2= 48 mmHg), PaCO2= 40 mmHg, and HCO3= 17,7 mEq/L. An umbilical venous catheter was inserted for parenteral nutrition. The first management was to place the infant under nasal continuous positive airway pressure (CPAP) with end-expiratory pressure of 6 cmH2O and FiO2 of 30%. At the echocardiography exam at 72 hours of life, it was discovered a cardiac dysrhythmia, heart rate 148 b/m, a patent foramen ovale, pulmonary artery flow (PA) = 0,85m/s, ascending aorta flow (Ao)= 0,8m/s, and a patent ductus arteriosus (PDA= 2,8mm) with transductal shunt orientation left-right. Preductal oxigen saturation SpO2 was 97% and postductal SpO2 98%. The persistence of the ductus arteriosus led to a decreased perfusion to the brain and abdomen observed at head ultrasound (resistive index (RI) measured in the anterior cerebral artery=0.89 and diastolic velocity = 1,3 mm/s) and abdominal echography ( RI measured in the celiac trunk =0.86 and diastolic velocity = 1,13mm/s). The treatment approach was intravenous Ibuprofen 10 mg/kg/body weight for the first dose, followed at 24-hour intervals by another two doses of 5 mg/kg each. 
Discussions: The PDA closed within the first 72 hours after treatment initiation. Echocardiography was performed before treatment and 24 hours after each dose and showed decreased diameters of the patent ductus arterious each time ( 2,8 mm – 2,5 mm – 1mm – 0mm). The results of the head ultrasound decreased from RI 0.89 to 0,75 and for the celiac trunk improved as well from 0.86 to 0,76.
Conclusions: In conclusion the pharmacological treatment with Ibuprofen was efficient in closing PDA in a preterm infant with respiratory distress syndrome. The closer of PDA was esential to prevent brain damage and other complications caused by low perfusion.

The effect of recovery treatment in diabetic peripheral neuropathy

First author: Imre Delia-Rozalia

Coordinator(s): Professor Făgăraș Pia-Simona , Assistant Professor Crișan-Mălăncrăvean Patricia-Maria

Keywords: diabetic peripheral neuropathy complication recovery disease

Background: Diabetic neuropathy is a condition where nerves are affected by high and unstable blood sugar levels, being one of the most common complications of diabetes mellitus affecting millions of people worldwide. This condition can have a significant impact on people's quality of life, causing discomfort and interfering with daily functioning. Treatment focuses on managing symptoms and blood sugar levels, but research continues to discover new and more effective methods of prevention and treatment for diabetic neuropathy.
Objective: The aim of this study is to investigate and demonstrate the importance of recovery treatment through physiotherapy and physical therapy in improving the quality of life for individuals affected by diabetic peripheral neuropathy. By evaluating the effectiveness of these complementary interventions, the study aims to provide concrete information regarding the benefits of recovery therapies in reducing symptoms and improving physical function and overall health status of patients. Thus, the research brings to light a solid foundation for integrating recovery treatment into clinical practice and promoting a holistic approach in managing diabetic peripheral neuropathy, with a significant impact on patients' quality of life.
Material and Method: The study will be conducted at the Emergency County Clinical Hospital of Târgu Mureș, from January 2024 to June 2024, and will involve approximately 20 subjects from the diabetology department. It involves evaluating and comparing patients with type 1 and type 2 diabetes who present peripheral neuropathy before and after recovery, monitoring their progression through neurological tests and a questionnaire encompassing multiple parameters: Visual Analog Scale for Pain, Neuropathy Symptoms Score customized for diabetic neuropathy, Neuropathy Disability Score, Muscle Strength Examination, Pinprick Test, Tactile Test, Temperature Perception Test, Vibration Perception Test, Osteotendinous Reflexes.
Results: So far, the results demonstrate a significant improvement in the quality of life of affected individuals who have adhered to the recommended recovery program in the last 3 months compared to those who have not followed it fully or at all. Subjects have reported an easier performance of daily activities and an alleviation of disease-associated symptoms.
Conclusions: Recovering from diabetic peripheral neuropathy is an essential part of improving the overall health status of patients and preventing disease progression. Integrating this therapy into disease management is vital for optimizing it. There are a variety of recovery interventions that can be used, including physical exercises, occupational therapy, massage therapy, electrical stimulation therapy, and other non-invasive techniques.

Clinical Significance of Anatomical Variations in the Popliteal Artery: Insights from a Case Series

First author: Stefan Vunvulea

Coauthors: Jasmina Cioloboc Septimiu Cioloboc

Coordinator(s): Lecturer Vlad Vunvulea , Assistant Professor Emil Arbănași

Keywords: Popliteal artery variations premature bifurcation type II trifurcation

Introduction: The Popliteal artery is the continuation of the Femoral artery,situated below the adductor tendinous hiatus of Hunter.It is located deep in the popliteal fossa,together with the popliteal vein and tibial nerve.It’s main branches are the posterior tibial and fibular artery.At knee level it branches into a patellar plexus.Radiologically it is divided into 3 parts.P1:from the adductor tendinous hiatus of Hunter until the proximal edge of patella,P2 until the intraarticular line and P3 until the origin of the origin of the anterior tibial artery. The popliteal artery presents multiple variations such as:course variations,number and distribution of vessels, diameter and caliber and variations associated with the muscular anatomy.The existence of each and every anatomical variation must be carefully taken into consideration during surgery. 
Case Report: We report a series of 5 cases with significant variations of the popliteal artery, including type II trifurcation, premature bifurcation of the popliteal artery, and lack of fibular artery or tibio-fibular artery. The aforementioned findings were discovered incidentally on contrast enhanced computer-tomography and digitally subtracted angiography.
Discussions: Variations are significant because they can alter the approach of the surgical procedure. Surgical considerations such as low or high bifurcation,tortuosity,or abnormal branching patterns might derail the surgical planning, device selection or procedural complications. Diagnostic imaging could be used to reveal these variations to accurately assess vascular anatomy,and subsequently plan appropriate treatment strategies. In interventional procedures, knowledge about these variants are crucial if procedures are performed such as angioplasty or stenting. 
Conclusions: In conclusion, understanding the anatomical variation of the popliteal artery may provide further insights in clinical practice, from a preclinical point of view. 

Flares in rheumatic diseases after vaccination – Systematic review and proportional meta-analysis

First author: Daniel Panich

Coordinator(s): Professor Monica Chiș

Keywords: Rheumatic diseases Flares Vaccination Proportional meta-analysis

Background: Vaccination is essential for preventive care in rheumatic patients, aiming to decrease the risk of severe infections. But the relationship between vaccination and rheumatic diseases is complex due to both having autoimmune and inflammatory mechanisms. A significant concern is the exacerbation of rheumatic disease or “Flare” following immunization. 
Objective: We aimed to analyze studies reporting on flares occurring postvaccination, pooling the patients and quantifying the rate of flares in a larger group of patients with different rheumatic diseases and various vaccinations.  
Material and Method: We conducted a systematic literature search of PubMed, Scopus, PLOS ONE and Clinicaltrials.gov on the 16th of December of 2023. Every rheumatic disease and vaccination were included. Studies were screened using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta Analyses) method. Data were extracted into a spreadsheet for calculation. A proportional meta-analysis was performed using both a random and fixed-effects model, and the pooled flare rate was calculated. Heterogeneity was measured using the I2 statistic. 
Results: After screening 77 studies were included, of which 48 studies analyzed flares after COVID-19 vaccination, while the other 29 reported on various vaccines such as influenza and childhood vaccines. Combining all study populations 33322 patients were analyzed. The total flare rate with a fixed-effects model was 9.2% [95% CI 8.9-9.5] and with a random-effects model 7.9% [95% CI 6.0-10.0]. Heterogeneity, measured by I2, was 97.47% [95% CI 97.17-97.73].  
Conclusions: This proportional meta-analysis concluded that almost 8% of patients with rheumatic diseases experienced a disease flare after vaccination. This value was calculated through a random-effects model. Significant heterogeneity was found, indicating a high variation between the studies, necessitating a careful interpretation. Further research is essential for finding underlying risk factors for disease flares and to optimize vaccination strategies in rheumatic diseases. 

Multidisciplinary approach in the diagnosis of Birt-Hogg-Dubé Syndrome

First author: Oana-Bianca Tomșa

Coauthors: Sabina-Ioana Viziteu Maria Toma

Coordinator(s): Medical Doctor Andreea Cătană

Keywords: Birt-Hogg-Dubé Syndrome spontaneous pneumothorax kidney tumors genetic testing

Introduction: Birt-Hogg-Dubé syndrome (BHD) is a rare autosomal dominant disorder caused by mutations in the Folliculin gene, which is a tumor suppressing gene. As such, this disorder predisposes to fibrofolliculomas, lung cysts and spontaneous pneumothorax and an increased risk of developing kidney tumors. 
Case Report: A 33 year old woman presented to the Emergency Room with dyspnoea, acute chest pain, tachycardia and cyanosis. Emergency Xray revealed pneumothorax and further Computer Thomography confirms the diagnosis of bilateral paraseptal and centrolobular emphysema and a basal, large, infected lung cyst. There is no family history of similar disease. She was transferred to the pneumology ward, where genetic testing was recommended. After the analysis of 8 genes associated with hereditary predisposition for lung disease using NGS, a pathological mutation of FLCN gene was found: c.30del, p.(Cys11Alafs*44) . This result led us to the final diagnosis of BHD Syndrome.
Discussions: BHD is characterized by high phenotypic heterogeneity, so disease severity can vary significantly among family members and between families. From the 240 pathogenic variants discovered until now, 150 are associated with only a propensity for spontaneous pneumothorax and no other pathogeny. In the case of lung cysts, they are usually bilateral, multifocal and asymptomatic, patients usually discovering them, as in this case, only in the eventuality of a spontaneous pneumothorax. Our patient received treatment for the pulmonary issues and made a full recovery. Further imagistic testing of the lungs and kidneys was recommended, as the patient is 7 times more likely to develop a renal cancer, usually bilateral and multifocal, that can onset as early as 46 years old. The patient was also referred to a dermatologist for more in depth explorations, as she is in the decade of life where skin lesions associated with BHD syndrome may develop, such as: fibrofolliculomas, trichodiscomas and acrochordons. Lastly, as this is a dominantly transmitted autosomal disorder, which means it may manifest in half of the future descendants, the patient was referred to a genetic counsellor.
Conclusions: BHD syndrome is a rare disease usually present in more than one member of a family, as it is transmitted dominantly autosomal. However, it also has a high phenotypic heterogeneity and can manifest itself in any number of symptoms involving the lungs, kidneys and skin. While this may be the result of a de novo mutations, we cannot certify this until the family undergoes a similar genetic testing.

Impact of recurrent respiratory tract infections on the development of secondary AA amyloidosis

First author: Constantina-Maria Mircea

Coauthors: Mihaela-Ionela Mihai Denisa Măianu

Coordinator(s): Medical Doctor Raluca Moldovan

Keywords: amyloidosis sepsis kidney injury

Introduction: Renal amyloidosis is a condition caused by the deposition of abnormal, insoluble amyloid fibrils in the kidneys, associated with chronic inflammation due to recurrent infections or autoimmune.We present a case of renal amyloidosis secondary to a respiratory tract disease, highlighting relevant clinical aspects.
Case Report: A 62-year-old man with a medical history that includes a cystic lung disease since childhood, probably genetic in nature, who has had recurrent episodes of infections over time, is brought to the nephrology ward with a diagnosis of sepsis, with pulmonary origin and severe anuric acute kidney injury.After admission, a nephrotic syndrome and a hepatitis B virus infection, probably chronic were identified. The patient was treated with supportive measures, antibiotics, renal replacement therapy,parenteral rehydration, electrolytes and acid-base rebalancing, which led to correction of respiratory symptoms, remission of the inflammatory syndrome and polyuria with improvement f renal function. Subsequently, the attention was focused on the diagnosis of nephrotic syndrome. Immunological tests, including antinuclear antibodies, anti-neutrophil cytoplasmic antibodies, anti-PLA2R antibodies, anti-GBM antibodies and serum protein immunelectrophoresis, were negative. Ultrasonography revealed enlarged kidneys with thickened and hyperechogenic cortex, hepatomegaly. Renal biopsy was performed to identify the etiology of glomerular lesions, and histopathological examination led to the diagnosis of renal amyloidosis, acute tubular necrosis and chronic interstitial nephritis.Bone marrow aspiration was performed by the haematologist and did not show any abnormality. Thus, the diagnosis of renal AA amyloidosis was established. In order to determine the etiology and prognosis, several paraclinical investigations were performed.
Discussions: The patient has not yet received a clear diagnosis for the childhood-onset lung disease. Clinical tests performed showed superinfected bronchiectasis and right basal pneumonia with suspected pulmonary cysts. Hepatitis B virus infection is being investigated to decide the need for antiviral treatment. After renal biopsy confirmation of the diagnosis of renal amyloidosis the patient returned to investigate the cause of the amyloidosis. The serum immunelectrophoresis, free light chains and the bone marrow aspiration were normal. A cardiac echo doppler was also performed, which did not show any changes suggestive of cardiac amyloidosis, which is important for the patient's prognosis. 
Conclusions: This case emphasizes the need for timely diagnosis, monitoring, and treatment of chronic respiratory infections to prevent secondary amyloidosis. Detection of amyloidosis in a patient with infection-related acute kidney injury underscores the disease's complexity, necessitating a multidisciplinary approach to management.

One of the factors which can lead to altered levels of consciousness – emergency case report

First author: Mara Tanase

Coauthors: Denisa Alexa Andreea Belean Teodorescu Anemona Ioana

Coordinator(s): Medical Doctor Ioan Alexandru Branea

Keywords: cognitive dysfunction acute kidney injury metabolic acidosis uremic encephalopathy

Introduction: To find the real etiology of the twiling state could represent a challenge. Acute kidney injury is characterized by an abrupt increase of serum creatinine and urea levels along with a glomerular filtration below 15ml/min which can lead within hours or days to cognitive dysfunction.  
Case Report: We present a case of a 53 years old women, arrived at the emergency room with the following vital signs: obnubilation state , with tachypnea ( respiratory rate 25-30/min), respiratory effort, intercostal retraction, oxigen saturation pO2 90%, heart rate 99b/min, high blood pressure 188/90 mmHg and Glasgow Coma Scale (GCS) 9 points. Blood gas analysis revealed sever metabolic acidosis with hiperkalemia: Ph= 6,9, pCO2=18.9 mmHg, K+= 7.21 mmol/L, HCO3=4.08 mmol/L. Blood tests showed microcytic hypochromic anemia, elevated levels of trombocytes ( 724.00 x 103/µL), leucocites (31.12 x 103/µL), acute phase reactants: C-reactive protein (CRP)= 90mg/dl and procalcitonin (PCT)= 232 mg/dl and extremely elevated serum creatinine level (19mg/dl) and urea 232mg/dl with a rate of kidney filtration < 3ml/min. At the nephrology examination was performed abdominal ultrasound which demonstrated : an abnormal mass developed in the bladder 81/54 mm with marked bilateral hydronephrosis stage 4 caused by post-renal obstruction, renal parenchymal index for the right kidney was 1.36 cm and for the left kidney was 0.8cm. Considering the worsening status of the patient the best therapeutic approach was to perform an emergent percutaneous nephrostomy for the left kidney. In the following 36h the patient presented a diuresis of 3.6 L/24h, with a favorable evolution of metabolic acidosis ( pH = 6.9 – 7.25 – 7.36 – 7.4) and renal function, observed from progressively decreased values of creatinine and urea. The neurological status improved, the patient became hemodynamically stabel and was transferred to the urology department for further examinations.
Discussions: The etiology of AKI is extremly wide, but we can classify it in 3 categories: pre-renal, renal and post-renal. One of the most serious complication is high serum urea levels which can cause uremic encephalopathy (UE). It is essential to make the differential diagnosis with the pathological conditions which can mimic UE such as cerebrovascular accidents, osmotic demyelination and  infections.
Conclusions: Considering the significant impact of AKI, a prompt recognition with early intervention is essential to prevent the sever complications of the brain, the kidneys and body physiology.

Acute Respiratory Distress Syndrome: a Challenging Life-Threatening Condition

First author: Gaia Desiderio

Coauthors: Mohamed Rashid Mohamud Aadan AMATARAHMAN NOUH ISMAEL Parrok Khan Hadji Rudainah Ameen

Coordinator(s): Associate Professor Sorana Truta , Associate Professor Cristian Boeriu

Keywords: ARDS ICU Ventilation

Introduction: Acute respiratory distress syndrome (ARDS) is a frequent cause of ICU admission associated with high mortality; it is a respiratory condition characterized by severe hypoxemia and bilateral pulmonary opacities that are not fully explained by heart failure or fluid overload. The cause may be pulmonary (pneumonia, aspiration syndrome, inhalation injury, chest contusion) or extrapulmonary (sepsis of extrapulmonary origin, major trauma, massive transfusion, pancreatitis).
Case Report: A 41-year-old woman, without any chronic medical conditions, was brought to the Emergency Department (ED) due to sudden onset dyspnea four hours prior. She presented fever, dry cough, and inappetence for six days and was treated at home with Cefuroxime and Levofloxacin. Upon arrival in the ED, she was conscious, tachypneic, tachycardic, sub febrile, with blood pressure between the normal range, but a SpO2 of 70% on high flow oxygen. Noninvasive ventilation was initiated but proved ineffective, therefore, the patient was intubated and mechanically ventilated three hours after her arrival. A chest CT scan revealed bilateral diffuse ground-glass opacities associated with extensive consolidation with air bronchogram and minimal bilateral pleural effusion.The laboratory tests showed leukocytosis (neutrophilia), a CRP of 160 mg/dL, and a PaO2/FiO2 ratio of 62.Tests for SARS-CoV-2, influenza A, and B infections were negative, and an extended respiratory panel (multiplex PCR test) was also negative for viruses and atypical germs. Blood cultures, urine culture, and respiratory tract culture were negative as well. Empirical broad-spectrum antibiotics were started in the ED, and lung protective ventilation and alveolar recruitment maneuvers specific for severe ARDS were initiated. Thirty-six hours later, a pulmonary CT was repeated, showing improvement with partial regression of alveolar infiltrates, re-aeration of the upper half of the right lung and lung bases bilaterally; the PaO2/FiO2 ratio was 110. The patient was then transferred to the ICU and was ventilated for a total of 192 hours. A prone position was adopted for four hours a day for five days. The patient was extubated after eight days and discharged after an additional seven days. 
Discussions: This case presents an intriguing insight into the complexity of managing a severe respiratory condition such as ARDS, especially in the absence of a clear infectious cause. ARDS is a critical condition marked by the rapid onset of widespread inflammation in the lungs, often leading to severe hypoxemia. 
Conclusions: ARDS diagnosis and management can be challenging, but timely appropriate treatment as advanced ventilation strategies, is crucial.

THE IMPACT OF BIOLOGICS ON THE QUALITY OF LIFE FOR PATIENTS WITH ANKYLOSING SPONDYLITIS

First author: Khaled Khraiba

Coordinator(s): Professor monica chis

Keywords: Ankylosing spondylitis disease-modifying antirheumatic drugs (DMARDs) quality of life (QoL) biologics

Background: Ankylosing spondylitis (AS) is a chronic inflammatory disease that primarily affects the axial skeleton, leading to pain, stiffness, and reduced mobility. Therefore, AS can have a significant impact on the QoL of affected individuals. Biological therapy is a type of treatment that uses genetically engineered proteins or antibodies to target specific molecules or cells involved in the immune response. In the case of Ankylosing Spondylitis (AS), biological therapy is used to target cytokines, which are proteins that play a key role in the inflammatory process that causes the disease. 
Objective: This study objective is to create a concise collective presentation of multiple past studies performed by different researchers about the effectivity of biologics in the treatment of adult patients with ankylosing spondylitis (AS). 
Material and Method: Using 3 past studies that analyzed the data of 1000+ cases of AS patients treated with different kinds of DMARDs across the world. Hence, the relevant data according to the aim of the study were collected. The study is a network meta-analysis of the efficacy of biologics in the treatment of adult patients with AS.
Results: Study 1 demonstrated sustained efficacy and an acceptable safety profile of upadacitinib in bDMARD-IR patients with AS over a 1-year period, supporting its potential as a treatment option for this patient population. 

Conclusions: DMARDs/biologics play a crucial role in improving the quality of life of patients with ankylosing spondylitis. The use of biologics has been associated with reduced pain, improved physical function, and enhanced overall well-being. However, it is important to note that biological therapy is not suitable for all patients with AS, and the decision to use this treatment should be made on a case-by-case basis. This meta-analysis supports existing research and literature, providing further evidence of the positive impact of biologics on quality of life within the AS patient population.

Rare case of ampullary carcinoma associated with an anatomical variant

First author: Ada Mihaela Muntean

Coauthors: Maria Melisa Morar Teodora Ioana Mustea Șerban Nistor

Coordinator(s): Lecturer Răzvan Alexandru Ciocan

Keywords: Ampullary carcinoma pancreas divisum Whipple procedure

Introduction: An ampullary carcinoma is a cancer that arises in the ampulla of Vater. It is a tiny opening in the beginning segment of the small intestine called the duodenum. Pancreatic and bile duct fluids are pumped into the intestines via the ampulla of Vater. Jaundice is the most common symptom of ampullary cancer. This is because the tumor in the ampulla of Vater blocks the bile duct. Instead of flowing into the intestines, the bile enters the bloodstream and causes yellowing of the skin. Other symptoms of ampullary cancer include: loss of appetite and weight loss, abdominal pain and vomiting. This case of ampullary carcinoma is associated with pancreas divisum which is a congenital anomaly where dorsal and ventral buds fail to fuse during fetal development in the seventh week of intra-uterine life. This leads to a dominant dorsal pancreatic duct draining though the minor papilla and a small ventral pancreatic duct draining through the major papilla. 
Case Report: We report the case of a 67 years old female who presented with abdominal pain in the upper and lower abdomen, vomiting for two days and a history of weight loss (20 kilos in 5 months). The patient previously underwent appendectomy, laparoscopic cholecystectomy and varicose vein surgery on both limbs. The patient underwent investigations such as blood tests, histopathology, ultrasonography, computer tomography and ampullary mass biopsy, based on which a final diagnosis was made. Following the diagnosis, a pancreaticoduodenectomy was performed alongside hysterectomy with bilateral adnexectomy. 
Discussions: Considering that the patient has a congenital anomaly of the pancreas, we can raise the question whether this anatomical variant represents a risk factor for the development of ampullary cancer, or if in this situation the pancreas is more prone to other pathologies or not. The surgical approach chosen was the Whipple procedure, a complicated operation that can lead to complications such as fistula or leak in the pancreas, leakage of bile or haemorrhage occurring postoperatively, which requires blood transfusion or reopening. 
Conclusions: Ampullary carcinoma is a very unusual form of carcinoma but can be treated with Whipple procedure. Ampullary carcinoma has a better outcome than pancreatic cancer. It can be managed surgically and the survival rate has also improved.

One CT, multiple tumours: benign or malignant?

First author: Danusia-Elena Stuparu

Coauthors: David Alexandru Poajga Carla Prodea

Coordinator(s): Assistant Professor Ofelia Mosteanu , Lecturer Teodora Atena Pop

Keywords: renal cell carcinoma nephrectomy IPMN EUS FNA

Introduction: One of the most frequent urogenital cancers is represented by renal cell carcinoma (RCC), with a mortality rate of 30-40% due to its fast metastasis, with only 20% of the patients being cured by nephrectomy. We present a RCC’ patient predisposition to develop other types of cancer.   Case Report: A 65-year-old man was referred to our unit for further diagnosis work-up. A computer tomography (CT) showed a subcapsular left kidney mass of 46/62/56 mm, hypervascular, with no invasion of the caliceal system or the hilar vascular structures; the carcinoma has expanded in the posterior pararenal space penetrating the capsule. Furthermore, a calcified cystic cluster turned up in the cephalo-uncinate area of the pancreas along with the dilatated Wirsung and the secondary ducts which raised the suspicion of a cystadenoma or an IPMN (Intraductal Papillary Mucinous Neoplasm). The CT also emphasized a lesion of the L4 vertebral body, and the scintigraphy evidenced only signs of osteosclerosis. An EUS FNA (endoscopic ultrasound with fine needle aspiration) of the renal tumour was further performed and the pancreatic IPMN had no elements of malignancy. Histopathology confirmed a cT4N0M0 renal clear cell carcinoma. Due to the tumoral stage, a radical laparoscopic nephrectomy was performed.  Discussions: The widespread application of CT and EUS for other indications has led to increased detection of renal and pancreatic tumors as an incidental finding. These tumors are typically smaller than those that produce symptoms and are more likely to be resectable. The frequency of multiple primary tumors among all cases of malignancy has been reported as 1 to 3%. The frequency of pancreatic cancer in association with cancer of other organs is estimated to range from 1% to as high as 20%, with malignancies predominately of the stomach, colon, thyroid, and genitourinary tract. Second malignancies reported to be associated with RCC include Non-Hodgkin’s lymphoma, multiple myeloma, chronic lymphatic leukaemia, melanoma and cancers of the bladder, prostate, breast, rectum, and lung with an incidence that varies from 5 to 27%. 
Conclusions: There has only been infrequent reporting of synchronous or metachronous tumors of the pancreas and the kidney. The patient remained under supervision every 6 months. The latest report currently highlights no other signs of malignant tumours in the body, the results of the tests performed both at the level of the pancreas and at the level of the bone system concluding this aspect. 

DOES GENDER PLAY A ROLE, IN THE OUTCOMES OF BOTULINUM TOXIN (BOTOX) TREATMENTS , FOR BRUXISM ?

First author: Xhina Kristo

Coauthors: Nino Ilea

Coordinator(s): Assistant Professor Ismet Toptanci

Keywords: masseter muscle bruxism botulinum toxin teeth grinding

Background: Bruxism, characterized by the involuntary clenching or grinding of teeth, occurs both during wakefulness and sleep. Its prevalence ranges from approximately 10% to 20% within the population, exhibiting varying degrees of severity.Botulinum toxin (Botox) is recognized as a remedy for bruxism when administered into the masseter muscle. Numerous studies have explored the use of Botox for this purpose. 
Objective:  The objective of this study was to evaluate the efficacy of administering Botox in the masseter muscle and determine if it produces comparable outcomes in both female and male patients.
Material and Method: In this study, we had a total of 20 patients aged between 21-25, consisting of 10 women and 10 men. These patients were experiencing bruxism-related symptoms such as masseter muscle pain and tooth sensitivity. We used RDC_TMJ criteria to exclude certain patients from the study. Panoramic radiographies were taken for all patients. The participants were divided into two groups based on gender, and both groups underwent Botulinum toxin injection treatment to see if it could alleviate their symptoms. We also took the patients' history into account and followed up with them after the treatment to check if they still had any pain or discomfort.
Results:  The onset of the botulinum toxin effect was observed to be 3.7±0.82 for the women group and 3.1±0.73 for the men group. We found a significant difference in pain scales before and after treatment (p=0.048 and p<0.05). There was also a significant improvement in discomfort levels before and after the treatment .
Conclusions:

Managing Thrombus Migration In Carotid Artery Stenosis: A Case Study Of Endovascular Intervention

First author: Jasmina Cioloboc

Coauthors: Septimiu Cioloboc Stefan Vunvulea

Coordinator(s): Medical Doctor Lucian Mărginean , Medical Doctor Vlad Vunvulea

Keywords: carotid angioplasty stent thrombus

Introduction: Carotid angioplasty is a minimally invasive treatment procedure for atherosclerosis of the carotid arteries. Carotid angioplasty is necessary in the treatment of high-grade stenosis, as an alternative to surgical procedures (carotid endarterectomy). The intervention restores optimal blood circulation to the brain, thus preventing a transient ischemic attack or ischemic stroke. Carotid angioplasty is performed percutaneously, through a puncture in the skin, without the need for incisions. As a result, recovery is rapid and risks are minimal. 
Case Report: We present a case of carotid artery stenosis in a 73-year-old male patient. He underwent radiological and imaging investigations at the radiology department, where several CT scans were performed. The results indicated the presence of a carotid artery with an abnormally narrow diameter, significantly restricting blood flow to the brain. For treatment, it was decided to perform an endovascular percutaneus angioplasty, during which doctors dilated the narrowed area using a catheter and a small-sized expandable balloon, under the protection of a filter. Additionally, a stent was placed to maintain vessel patency. Despite the initial success of the intervention, migration of a thrombus formed on the stent was observed, obstructing the upper and lower branches of the middle cerebral artery, with consequences on blood circulation to the brain. After several aspiration thrombectomies, blood flow was restored and the normal diameter of the carotid artery was regained.
Discussions: One of the most feared complications when approaching the supra-aortic vessels are formation of blood clots, and their intracerebral migration. Whether the angioplasty is performed under open surgery or through an endovascular approach, protection of the intracerebral vessels in mandatory. Even though the operating team used a filter placed in the petrous segment of the internal carotid artery, migration of a thrombus occurred after the filter was removed. Having a qualified operating team, with access to specialized equipment for thrombectomy is a second layer of prevention. In the presented case, the patient had an excellent outcome, with no neurological deficit, and improvement of the symptoms. 
Conclusions: In conclusion, despite the initial success of the endovascular percutaneous angioplasty procedure for carotid artery stenosis, the migration of a thrombus posed a significant challenge to blood circulation to the brain. However, timely intervention through aspiration thrombectomies ultimately led to the restoration of blood flow and improved patient outcomes.

LEFT GIANT LOCALLY ADVANCED COLON NEOPLASM WITH MASSIVE METACHRONOUS METASTASIS OF LIVER SEGMENTS VII-VIII AND POST CHEMOTHERAPY SINUSOIDAL OBSTRUCTION SYNDROME IN A LYNCH SYNDROME PATIENT

First author: Simona-Maria Sabău-Gălățan

Coordinator(s): Medical Doctor Sever Călin Moldovan

Keywords: Lynch syndrome sinusoidal obstruction syndrome hepatic volumetry anatomical hepatic resection

Introduction: Colorectal cancer is the third most common cancer, with inherited mutations causing 5-10% of cases. Lynch syndrome represents the most common form of hereditary colorectal cancer.
Surgery’s aim was to avoid complications, prolong survival and improve the quality of life of a patient with colon cancer, the first in their family to be diagnosed with Lynch syndrome. An initial intervention removed a huge locally advanced colon tumor and later the patient underwent hepatic surgery for a metachronous secondary tumor.
Case Report: We present a 55-year-old patient initially diagnosed with a giant tumor of the left colon, requiring complex surgery. Comorbidities included: anemia, hypertension, diabetes, obesity. Subsequently the patient developed a massive liver metastasis in segments VII-VIII. Initially, surgery consisted of en bloc resection of the colonic neoplasm with the invaded structures, the resection being performed in healthy tissue: the greater omentum, left perirenal fat, left transverse abdominal, internal oblique, and iliopsoas muscles, along with lifting with the specimen the ganglia and fatty tissue and the vegetative nerve plexuses located anteriorly to the major vessels. Ureterolysis was facilitated by the presence of a preoperatively inserted left ureteral stent, enabling for ureter preservation. Digestive reconstruction was performed simultaneously by a transverse-rectal latero-lateral anastomosis. Follow up imaging revealed a massive secondary liver tumor occupying segments VII-VIII. The patient developed meanwhile hepatic steatosis along with sinusoidal obstruction syndrome secondary to chemotherapy. Liver volumetry showed the need for a 60% liver parenchymal sacrifice with right hepatectomy, not compatible with patient’s survival in this context. Therefore, an anatomical hepatectomy of segments VII-VIII was performed. Resection margins were tumor free, and the liver parenchymal sacrifice was minimal. 
Discussions: Postoperatively, there was a right pneumothorax, which was successfully drained. Liver function remained adequate. 
Conclusions: The patient is in good general condition, eating normally, with motor autonomy and an ECOG status of 1 and carries on with chemotherapy as well as clinical and imaging follow-up, with treatment facilitated by the presence of an implanted port-a-cath installed in 2019. Genetic tests confirmed the presence of Lynch syndrome.

Involvement of risk factors in the development of tuberculosis among the adult population

First author: Claudiu-Daniel Blidea

Coordinator(s): Professor Gabriela Jimborean , Medical Doctor Mara Andreea Vultur

Keywords: Risk factors Tuberculosis Statistical correlations

Background: Tuberculosis (TB) poses a significant threat to global public health as an epidemic. It is a potentially fatal infection caused by the pathogen Mycobacterium Tuberculosis. At the global level, significant risk factors are formed by substandard living and working conditions linked to increased transmission of TB, as well as factors that weaken the body’s ability to defend itself, such as HIV/SIDA infection, malnutrition, tobacco use, diabetes mellitus, chronic alcoholism and massive air pollution.
Objective: The main objective of this study is to identify and correlate several risk factors with the form of TB detected in the selected patients.
Material and Method: In this study, we analysed a number of 155 patients diagnosed with tuberculosis between January 2022 – June 2023 at the Pneumology Clinic of Târgu Mureș. Patients with both pulmonary and extrapulmonary forms of secondary tuberculosis were admitted to this study. Based on clinical and radiological aspects, the patients were grouped according to the clinical form of tuberculosis.
Results: Using the data collected from patients admission records, we were able to associate the presence of various risk factors with the moderate-severe clinical form of tuberculosis. Among the main identified risk factors are : chronic smoking ( OR=6.07, 95% IC= 2.51 - 14.73 ), chronic alcohol consumption ( OR=2.88, 95% IC=1.28-5.44 ) and poor living conditions ( OR=5.62, 95% IC=2.26-13.91 ). In addition to the previously mentioned factors, we also identified the presence of the following risk factors : rural origin ( OR=5.55, 95% IC=2.30-13.40 ), presence of obstructive pulmonary disease ( OR=1.65, 95% IC=0.58-4.71 ) and occupational exposure to pollutants ( OR=1.41, 95% IC=0.29-6.64 ). Among the important risk factors to mention despite the small number of identified subjects are HIV status ( OR=0.20 ) and the presence of diabetes ( OR=0.53 ).
Conclusions: Our statistical analysis revealed the presence of a correlation between a more severe form of tuberculosis and several risk factors. These results highlight the complex range of factors contributing to tuberculosis risk and underscore the imperative for interventions aimed to reduce these factors in order to minimize the harmful impact produced by the infection.

Post chemotherapy lymph node dissection via 3D laparoscopy - a safer and more reliable option in urology

First author: Patrik Buzgau

Coauthors: Mădălina - Iuliana Bud Andrei-Dănuț Ciocaș Dan Mihai Capilna

Coordinator(s): Medical Doctor Mihnea Bogdan Borz , Medical Doctor Vlad Horia Schitcu

Keywords: urology testicular cancer laparoscopy

Introduction: Testicular cancer represents a specific oncological pathology in male patients between 15-35 years old. A large percentage of such cancers diagnosed post puberty are derived from germinal cells. While seminomas are often diagnosed early, non-seminomatous germinal cell tumours are discovered in advanced stages after spreading to retroperitoneal lymph nodes. Traditional laparoscopy has been widely used for difficult lymph node dissection, but lately 3d laparoscopy is emerging as a more precise choice. 3D laparoscopy is associated with improved depth of perception and navigation witch ultimately results in a more precise dissection in difficult areas translated in better clinical outcomes for patients. 
Case Report: A 34-year old patient that underwent right inguinal orchiectomy for mixt non-seminomatous germ cell carcinoma, after 3 rounds of chemotherapy, presented with high alphaphetoprotein levels and a CT scan revealing 4 retroperitoneal enlarged lymph nodes ranging from 37 to 51mm. The patient underwent laparoscopic retroperitoneal lymph node dissection via a transperitoneal 3D laparoscopy using two 5mm and two 10mm ports. All four masses were successfully removed within a reduced operating time of 170 minutes.
Discussions: Case complexity was highlighted by the strong adhesion to the large retroperitoneal vessels and the presence of a 51mm formation encasing the right gonadal vessels along with a 31m formation in close proximity to the superior mesenteric artery. Intraoperative blood loss was negligible and no incidents were reported during the surgery with both drainage tubes being suppressed the following two days. Histopathological analysis on the dissected lymph nodes confirmed the same histological subtype as the initial diagnosis post orchiectomy. The fast recovery period enabled the patient to be discharged in the 7th post-operative day, favouring a fast social reintegration. 
Conclusions: While less researched and used, 3D laparoscopy represents a very effective tool in achieving better clinical outcomes for patients, from reduced surgical complications and hospital stay to aiding in fast social reintegration and recovery. The depth perception and a better offering of details weights a lot in performing such difficult surgeries. Having a steep learning curve, minimally invasive retroperitoneal lymph node dissection is recommended for experienced personnel working in high volume centers.

Aggressive breast cancer with multiple determinations at first admission – Case report

First author: Melania- Larisa Grosu

Coauthors: Bogdan-Mircea-Călin Dumitru Ana-Maria Grigorii

Coordinator(s): Assistant Professor Andrada-Claudia Tatar , Assistant Professor Adrian-Horatiu Sabau

Keywords: Lobular breast cancer pleural effusion ascites fluid immunohistochemistry

Introduction: Breast cancer is a complex and heterogenous disease that affects millions of individuals worldwide, irrespective of age or ethnicity. With numerous subtypes and varying degrees of aggressiveness, breast cancer presents a significant challenge in terms of diagnosis, treatment and management.
Case Report: We report the case of a 57-year-old woman who presented to the Surgery Department, accusing breast discomfort, shortness of breath and abdominal pain. A CT was performed and revealed a diffuse infiltrative lesion spread through the right breast and axillary lymph nodes, bilateral pleural effusion, peritoneal carcinomatosis, ascites and bone metastases. A biopsy of the right breast, thoracocentesis and paracentesis was performed and sent to the Pathology Department. Microscopically, an infiltrative tumoral proliferation was identified, corresponding to an invasive lobular breast carcinoma with signet ring cell component, without in situ component. The tumoral cells were immunohistochemically positive for Citokeratin 7, GATA3 and ER. In the pleural and ascites fluid tumoral cells were identified, with marked cyto-nuclear pleomorphism, that were forming pseudo-glandular structures. Immunohistochemically, the tumoral cells were positive for GATA3 and ER markers.
Discussions: The immunohistochemical profile of the tumoral cells from pleural effusion and ascites fluids suggest their mammary primary origin. The particularity of the case is emphasized by the fact that the patient is at her first admission and all the specimens collected: breast biopsy, pleural and ascites fluid, all confirmed the presence of malignant cells. In addition to this, the CT scan showed signs of bone metastases and peritoneal carcinomatosis.
Conclusions: This case illustrates the importance of interdisciplinary management of the cases with multiple determinations and the weight of immunohistochemistry on correlating all patient’s specimens and giving only one diagnosis. 

Study of bone fractures and bisphosphonate treatment in patients diagnosed with spinal muscular atrophy

First author: Ágnes Ábrahám

Coordinator(s): Lecturer Léna Szabó , Assistant Professor Janka Liptovszky

Keywords: spinal muscular atrophy bisphosphonate treatment pathological fracture osteodensitometry

Introduction: Spinal muscular atrophy (SMA) is a progressive neuromuscular disease with autosomal recessive inheritance. Bone mineral content in SMA is typically lower than in other neuromuscular diseases, increasing the risk of pathological fracture. Bisphosphonate treatment has been shown to be effective in the treatment of osteoporosis, and it is also used in patients with SMA according to guidelines. However, there are few data in the literature on the effect of bisphosphonate on osteodensitometry (ODM). In this study we would like to present the cases of patients where a pathological fracture was detected and/or bisphosphonate treatment was applied.
Case Report: In a previous study, we analysed data from 57 children diagnosed with SMA treated at the Pediatric Center Tűzoltó street Department of Semmelweis University, in whom we also assessed the ODM Z score and bone mineral content. From these, we have now selected 9 children based on the fact that they had received bisphosphonate treatment and/or had a bone fracture. A total of 4 children in the group had a bone fracture and 6 children had received bisphosphonate treatment. All these children received disease-modifying therapy, and changes in ODM Z-score values, beta-crosslaps and osteocalcin hormones were followed in relation to years of treatment.
Discussions: 1 of the 4 patients who suffered a fracture subsequently received bisphosphonate treatment after the fracture, in which case the ODM Z score was also severely reduced. The other children also showed reduced scores compared to the mean before treatment and in the years of treatment, with an average of -2.88 before treatment, -2.07 in the first year of treatment and -2.70, -2.60, -2.27, -4.30 thereafter. After bisphosphonate treatment, no fractures occurred in any of the cases during the follow-up.
Conclusions: Pathological bone fractures can have a major impact on the quality of life of patients, so it is important to monitor these, as well as bone density and other secondary consequences. This could be important because currently the protocol in Hungary recommends using bisphosphonate treatment only after a pathological bone fracture has occurred. Thus, these results may be useful in the future, even in modifying the therapeutic protocol.

The Use of Digital Technologies in the Restoration of Endodontically Treated Teeth

First author: Bianca Oprea

Coordinator(s): Professor Mircea Suciu , Dentist Bogdan Oprea

Keywords: endocrown cad-cam endodontic treatment crown restoration

Background: Recent years have seen significant advancements in dentistry, particularly with the integration of digital technologies. This has notably impacted the restoration of endodontically treated teeth (ETT). Digital technologies have revolutionized the approach to ETT restoration, offering enhanced precision, efficiency, and patient outcomes. This study dives into the diverse ways in which digital technologies contribute to restoring ETT.
Objective: This study aims to assess the effectiveness of "one session dentistry" using chair-side CAD CAM systems in restoring endodontically treated teeth with significant substance loss. This approach offers medical and economic benefits such as preserving dental structures, eliminating intermediate appointments, enhancing precision, ensuring longevity, and saving time for both dentists and patients. The guided preparation technique ensures conservative treatment, removing only the affected tissues, determining preparation limits based on the lesion’s extent, and adhering to bio-prophylactic cavity preparation principles. The study emphasizes the principles and advantages of contemporary tooth preparation methods.
Material and Method: In our study 217 patients and 362 restorations were involved, from Dental Clinic Dr. Leahu - CORIDENT Sibiu. We used conservative methods in preparing the teeth and digital ways in restoring them. Following a vigorous protocol to achieve the best results.
Results: Key findings include a higher prevalence of female patients, with treatments more common in those over 30 and less frequent in those over 60. Most patients received two restorations, with accidents causing partial or total crown fractures occurring less frequently. The distribution of restoration types was relatively even, with endo-crown and endoVcrown approaches being twice as common as classic crowns. Ceramic materials were predominantly used for coronal restorations compared to zirconia.
Conclusions: In conclusion, the adoption of digital technologies, particularly CAD CAM technology, offers significant advancements in dental practice, enabling streamlined workflows and enhanced quality, predictability, and ergonomics in endodontic treatments. The ease of preparation for endocrown and endoVcrown restorations, coupled with the accuracy of design software and milling systems, further enhances dentist confidence and patient satisfaction. Overall, the study underscores the transformative potential of digital technologies in revolutionizing endodontic treatments and restoration practices while prioritizing functional and aesthetic outcomes and maintaining periodontal health.

Evaluation of the mechanical properties of whitening trays before and after usage

First author: Mădălina Mihaela Andreescu

Coordinator(s): Associate Professor Silvia Pop

Keywords: mechanical properties trays whitening solution artificial saliva with macrogols

Background: The mechanical properties of whitening trays are important to ensure comfort and treatment effectiveness. These properties include flexibility, resistance to breakage and durability. The whitening trays need to be flexible enough to adapt optimally to the teeth, yet strong enough resistence to repeated use without deteriorating. Additionally, a good understanding of these properties can help avoid gums irritations or other dental issues associated with the use of whitening trays. 
Objective: This study aims to evaluate the mechanical properties (compression characteristics) of whitening trays under different usage conditions. The secondary objective was to examine alterations in tray parameters based on usage conditions, specifically immersion in whitening solution versus exposure to artificial saliva.
Material and Method: Twenty-one vacuum-formed trays were be divided into three groups: one group immersed in artificial saliva with macrogols, another group treated with whitening solution, and a control group. After 35 hours of storage in sealed containers, the trays were subjected to mechanical testing to evaluate any changes. An Instron testing machine was used to do a compresion test. The data was registered and analyse from the statistical standpoint.
Results: Our results showed modified mechanical properties of all the 3 groups of tested trays. Difference of the compresive load was registered.
Conclusions: Within the limitation of the present study, it can be stated that whitening solutions might modify the mechanical properties of the trays.

Recurrence of hepatic echinococcosis - cardiac hydatid cyst

First author: Mesaros Radu

Coauthors: Ioana-Patricia Rodean Caba Cătălin Andrei

Coordinator(s): Professor Theodora Benedek , Assistant Professor Vasile-Bogdan Halatiu

Keywords: albendazolum cardiac echinococcosis imaging surgery.

Introduction: It is important to note that the diagnosis of cardiac echinococcosis requires a comprehensive evaluation that includes clinical symptoms, imaging studies, and laboratory tests. Given the disease's complexity, a multidisciplinary approach is frequently required for accurate diagnosis and treatment.
Case Report: We present the case of a 43-year-old woman who was admitted to the Cardiology clinic multiple times for atypical chest pain, dyspnea, and fatigue, with a negative coronary angiography and no echocardiographic structural changes. From the personal medical history, we recall multiple hepatic hydatid cysts operated (approximately 12 years previously). At the present admission, the patient complains of atypical chest pain, accompanied by exertional dyspnea. The ECG trace showed ventricular bigeminy and no other significant changes. An echocardiogram is performed, revealing a 1.89x1.40 cm cystic process at the level of the basal interventricular septum, extending towards the right ventricle and the anterior wall of the aorta (PLAX). Given the patient's medical history, echocardiography, and laboratory results (marked eosinophilia 8.2%), the suspicion of cardiac echinococcosis is raised. Furthermore, cardiac MRI was performed and peripheral contrast enhancement was observed in the late contrast enhanced series, indicating a hydatid cyst. A total IgE and anti-Echinococcus granulosus antibodies IgM were tested, and both were positive. A head-thorax and abdomen computed tomography examination ruled out other cystic locations that could explain the laboratory results. In the postoperative preparation, the multidisciplinary team of cardiologist, cardiovascular surgeon, and infectious disease specialist decides on Albendazolum treatment (2x400 mg/day) for 2 weeks. However, after this period, the patient refuses surgical intervention. And it is periodically monitored by a cardiologist and an infectious disease specialist to ensure that the pathology remains stable and that no new outbreaks occur.
Discussions: Cardiac echinococcosis is uncommon, with a prevalence of less than 2%. The diagnosis in this patient was typical, with a cystic appearance on echocardiography, emphasizing the importance of imaging in the diagnosis; however, its location was unusual, with the majority of hydatid cysts described to be located at the level of the free wall of the left ventricle. Surgery is the main method of curative treatment.
Conclusions: Despite the fact that Albendazolum has temporarily halted the evolution of the disease, the only curative treatment remains surgical intervention, which is completed by the anti-parasitic treatment.

INTERSTITIAL LUNG DISEASE IN CONNECTIVE TISSUE DISORDERS: UNRAVELING PATHOGENIC MECHANISMS AND ASSESSING PULMONARY FUNCTIONS AND IMAGING

First author: George-Daniel Buciuta

Coauthors: Maria Louise Fufezan Andrei Buciuta

Coordinator(s): Lecturer Eugenia-Corina Budin , Medical Doctor Delia Rachis

Keywords: Connective Tissue Disorders Interstitial Lung Disease Antifibrotic Therapy Autoimmunity

Introduction: Connective tissue disorders (CTD) represent a group of systemic autoimmune diseases characterized by chronic inflammation. Besides the collagen structures affected frequently in the joints and skin, internal organs can be involved. Among these, interstitial lung disease (ILD) emerges as a critical determinant of morbidity and mortality necessitating a deeper understanding of its pathophysiological mechanisms, clinical presentation and possible progressive course to improve patient management.
Case Report: This retrospective study examines 8 patients diagnosed with various connective tissue disorders over a period of 4 years between 2018 and 2022, including systemic sclerosis (SSC), rheumatoid arthritis (RA), systemic lupus erythematosus (SLE), dermatomyositis (DM) and Sjögren syndrome (SS) who developed secondary ILD. Through detailed clinical evaluation, serological testing, pulmonary function tests (PFTs) and radiological imaging, we evaluate the disease course, response to therapy and outcomes over time, highlighting the heterogeneity of ILD presentations within collagenoses.
Discussions: ILD pathogenesis involves complex immune mechanisms triggering pulmonary fibrosis and inflammation. Diagnostic challenges arise from the ILD's variable presentation, necessitating an extensive approach incorporating high-resolution computed tomography (HRCT) and PFTs. 4 patients did not start anti-fibrotic therapy and were put under observation. Their natural course of disease showed improvement on PFTS and imaging. Patients that showed pathognomonic honeycombing and extensive fibrosis on HRCT with a decrease of PFTs over time have started anti-fibrotic and immunosuppressive therapy. Management strategies, primarily antifibrotic therapy can have positive outcome on disease severity and progression. Our case series underscores the importance of early diagnosis and individualized treatment based on investigations and clinical presentation to mitigate disease progression and improve quality of life.
Conclusions: CTD pose a significant risk for developing ILD. Clinical presentation heterogeneity, severity and rate of progression of ILD can be correlated with the underlying autoimmune disorder. Even if some cases of ILD can be mild with minimal changes on PFTs it is crucial to make an extensive evaluation in all patients presenting with CTD. Honeycombing pattern on HRCT may or may not be present in early disease. Absence of radiological abnormalities and normal PFTs do not exclude the diagnosis of ILD as a complication of CTD. The prognosis and outcome of ILD varies with associated comorbidities.

From Complication to treatment : The Role of Z-Plasty in the penile region after self-Injection

First author: Rudainah Ameen

Coauthors: Hassan Abdullatif Ahmer Syab Ali Muhamad Abdullatif Hassan Hassan Abdullatif Ahmad

Coordinator(s): Professor Cristian Trambitas , Medical Doctor Pap Timea

Keywords: Z-Plasty Self-injection Foreign materials

Introduction: Self injection of vaseline or other foreign materials, like mineral oil or paraffin, into the penis is done for the purpose of larger sexual organ. It can lead to a severe complications such as, infection, inflammation, scarring, erectile dysfunction, deformities, and permanent damage to erectile tissue. Such complications can significantly impair sexual function and quality of life. 
Case Report: 40-year-old male with a history of penile self-injection of Vaseline over a period of five months. Initial presentation to the urology department where they found foreign mass within penile region. They removed the vaseline along with the penile concomitant with penile degloving. As a consequence of the surgical intervention, the anatomical configuration of the patient's penis underwent alterations, resulting in its burying within the scrotal sac. Subsequently, seeking improvements in functionality, aesthetics, and skin elevation around the penis, the patient underwent reconstructive surgery at the plastic surgery department. During the procedure, foreign injected objects were discovered within the subcutaneous layers, which required partial removal due to adherence or proximity to the scrotum. Utilizing the Z-plasty technique, parallel incisions were done for the purpose of elongation and decreasing the tension. The skin was mobilized and multiple cutaneous triangular flaps were repositioned. Furthermore, the excess redundant skin was excised. Scrotal skin flap was used to cover the penile shaft. It is necessary the complete and meticulous lateral dissection of the flaps at a good depth maintaining the skin vascularity. Simple closure of the skin flaps was done after point-to-point haemostasis. This procedure resulted in an augmentation of approximately 6cm in length and improved the contour of the region.  
Discussions: Indications for penis augmentation are the improvement of self confidance as it is seen in our case, as well. The early stage intervention and the extraction of foreign objects is recommended to avoid the possibility of skin necrosis. 
Conclusions: Our case report shows the importance of reconstructive surgery and the use of Z-plasty technique. The presented intervention results in a longer and repositioned scar, avoiding a deforming skin contraction. We successfully corrected functional and aesthetic concerns.

EXTENSIVE CUTANEOUS TUMOR LOCATED ON THE DORSAL REGION

First author: Roberta Civita

Coauthors: Cosmin-Valentin Dragomir

Coordinator(s): Associate Professor Cristian Trambitas

Keywords: cutaneoustumor localadvancementflapsurgery advanyages

Introduction: Skin tumours represent a wide range of neoplasms that arise from the skin. These tumors can manifest in various form, ranging from benign to malignant, and may originate from different cell types within the skin layers. Benign tumours, such as melanocytic nevus and cutaneous fibroma, do not metastasise and often are treated for symptoms or aesthetics purpose. Malignant tumours such as basal cell carcinoma, spinocellular carcinoma and melanoma can manifest with a variety of signs and symptoms, including non-healing skin lesions, changes in the size or colour of pre-existing moles, and persistent itching. Early diagnosis and timely treatment of this tumor are crucial to improve survival prospects and reduce the risk of metastasis
Case Report: I report the case of a young 16-year-old patient who had a large skin tumour on his dorsal region
Discussions: Surgical removal of the tumour was performed under general anaesthesia with oro-tracheal intubation. First the skin was washed with antiseptic solution, then a circumscribed incision of the tumour was performed with excision and transfer for histopathological examination. Copious washings were then performed followed by haemostasis. The integumentary defect was reduced with suture threads and the large skin defect was covered with proximal advancement of the skin flap; after insertion of the drain, the flap was fixed with separate suture threads. The wound was then fixed externally with steri-strips and the operation was completed with dressing. Local advancement flap surgery is a widely utilized technique in plastic surgery for the repair of defects resulting from skin excision, trauma, or tumor removal. This surgical approach involves the movement of adjacent healthy tissue into the defect area to restore both form and function while minimizing scar formation. The key advantage of this procedure lies in its ability to provide excellent color and texture match with surrounding skin, leading to aesthetically pleasing outcomes  
Conclusions: The surgery was successfully performed, and the patient recovered without significant postoperative complications. After an appropriate follow-up period, the patient showed significant improvement in symptoms and aesthetic satisfaction. The patient showed wound healing with no obvious signs of tumour recurrence. Functionality of the dorsal region was preserved, and the patient reported a high degree of aesthetic satisfaction with the final result of the reconstruction 

Inflammatory bowel disease and associated extraintestinal manifestation: A case review of UC in a patient with PSC

First author: Federica Menna

Coordinator(s): Assistant Professor Crina Fofiu

Keywords: Inflammatory Bowel Disease Ulcerative colitis Primary Sclerosing Cholangitis Vedolizumab

Introduction: Inflammatory bowel diseases(IBD) are chronic immune-mediated diseases of the gastrointestinal tract, which include Crohn's disease(CD) and Ulcerative colitis(UC); they are characterized by chronic inflammation caused by a dysregulated immune response that leads to tissue inflammation and destruction. Although IBD is primarily considered an intestinal disorder, it is, moreover, a systemic disease that can affect other parts of the body. Between 25-40% of IBD patients develop extraintestinal manifestations(EIMs). Up to 50% of IBD patients may experience hepatobiliary complications during their disease; this may include diseases such as Primary sclerosing cholangitis(PSC) which is a chronic liver disease characterized by fibrosis of the intrahepatic and extrahepatic bile ducts.
Case Report: A 43-year-old patient known with Ulcerative Colitis(pancolitis)since 2019 and associated Primary Sclerosing Cholangitis, under biological treatment with Vedolizumab (since 09.2021), 5-ASA, and Ursodeoxycholic acid, presented to the clinic due to low consistency stools mixed with mucus and fresh blood and with associated weight loss.
Discussions: At admission, the patient had elevated inflammatory markers (ESR-64mm/h), therefore due to current symptomatology a lower digestive endoscopy was performed, which highlighted the congested and granular appearance of the mucosa and the absence of vascular pattern on multiple portions; the result showed medium activity hemorrhagic UC and a Mayo score of 7 points was calculated. Due to the increase in activity, the therapeutic regime with Vedolizumab was intensified (300mg infusion every 4 weeks). IBD and PSC are often linked together and mentioned with the term PSC-IBD. Research indicates that about 70% of patients diagnosed with PSC also have an underlying IBD condition, with UC being the most common. On the other hand, only 5% of UC patients will develop PSC. It's important to note that cholangitis can be asymptomatic, which is why it's recommended that IBD patients undergo screening with liver function tests to detect PSC. The presence of both PSC and IBD individually increases the risk of malignancy. However, when presented together, the risk is significantly higher. Therefore, regular screening for both colorectal cancer(CRC) and Cholangiocarcinoma(CCA) is necessary at shorter intervals. 
Conclusions: The patient is re-evaluated after 6 months and presents with negative symptomatology, laboratory analysis within normal limits and the endoscopic examination confirmed UC in a phase of remission and a Mayo score of 1 point was calculated. To sum up, it's very important for patients with both UC and PSC to obtain remission and be screened yearly for malignancy due to the increased risk when combined. 

PEDIATRIC ACUTE RESPIRATORY FAILURE: CLINICAL CHARACTERISTICS AND MANAGEMENT STRATEGIES

First author: Alexandra Antoce

Coauthors: ANA-MARIA ARDELEAN

Coordinator(s): Lecturer Ana-Maria Pitea

Keywords: pediatric patients dyspnea acute respiratory failure

Background: Acute respiratory failure refers to a condition in which the respiratory system is unable to adequately supply oxygen to the body to effectively remove carbon dioxide, leading to impaired gas exchange and potentially life-threatening complications. This condition can result from various factors such as respiratory infections, lung diseases, neuromuscular disorders, or trauma, and it can present with symptoms such as increased respiratory effort, tachypnea, cyanosis and altered mental status.
Objective: The purpose of this study is to assess the correspondence in between the clinical presentations and the paraclinical findings in pediatric patients experiencing acute respiratory failure.
Material and Method: For this study, a retrospective study was conducted including 160 patients admitted to Pediatric Clinic I Targu-Mures diagnosed with acute respiratory failure during the period 01.01.2023 to 01.01.2024. The patients were between 28 days and 18 years old. The following data was extracted from each patient’s medical record: sex, age, clinical manifestations, laboratory results, diagnosis, and treatment.
Results: 70% of the cases presented SpO2 under 92% at admission. The most frequently encountered clinical symptom was dyspnea (39%), followed by coughing (31%) and fever (30%). The most frequent pathological element observed during the physical examination was paleness (56%), followed by tachypnea (53%), intercostal retraction and tachycardia (50%), decreased vesicular murmur (45%), perioral and perinasal cyanosis (42%), suprasternal retraction (37%), crepitant rales (33%) and harsh vesicular murmur (30%). Statistical analysis revealed indicators of correspondence between certain variables, demonstrating a statistically significant correlation in between children with asthma and pericarditis (r= , p<0,001), chest X-ray with diffuse opacities and Acinetobacter etiological agent (r= , p<0,01) as well as VSR etiological agent and sibilant rales (r= , p<0,001).
Conclusions: Most pediatric patients with respiratory failure tend to present SpO2 values below 92%. Common clinical symptoms include dyspnea and cough, associated with paleness and tachypnea. The statistical correlations suggest potential relationships between specific etiological agents and clinical manifestations, which can aid in diagnosis and treatment planning.

Confronting Challenges: Surgical Resolution of Giant Frontal Skin Tumor and Ischemic Stroke

First author: Francesca Rosaria Cannito

Coauthors: Sofia Leonardi Lucrezia Sanna Niccolò Maria Simeone

Coordinator(s): Medical Doctor Bogdan-Dan Sbarcea

Keywords: #giantskintumor #ischemicstroke #surgicalmanagement

Introduction: We present the case of a 70-year-old male, with a giant, ulcerated, infected skin tumor in the frontal region extending to the right brow. The tumor infiltrated the front wall of the frontal sinuses. Additionally, the patient had a history of ischemic stroke with right infarct, hypertension, previous splenectomy, and cachexia. Tumor-associated risk factors for stroke include tumor size, location, and the biology of the neoplasm. The association of tumor volume relates to the risk of edema-related compression of blood vessels, resulting in diminished blood flow or complete occlusion of arteries, potentially leading to hypoperfusion or ischemic stroke.
Case Report: The patient underwent surgical intervention. The surgical procedure involved a circumscribed incision of the tumor formation followed by excision with macroscopic margins of oncological safety. Five pieces were excised, including the skin tumor in the frontal region, contents of the right frontal sinus, periosteum, nasal pyramid tissue, and the anterior wall of the frontal sinus. Curettage and eschylectomy were performed. Invasion with lysis of the anterior wall of the frontal sinuses was detected. Hemostasis was achieved, and two passive drains were installed at the level of the frontal sinuses. A local flap rotated on the left temporal pedicle from the parietal level was used to cover the remaining skin defect and soft parts. The flap donor area was covered with a split-thickness skin graft harvested from the front right thigh. Postoperatively, the patient's wound exhibited favorable evolution, with clean wound healing and viable flap and graft integration. The wound showed no signs of inflammation or infection. The patient was recommended to maintain sterile, dry dressing, with dressing changes every 2-3 days and to adhere to prescribed medications. 
Discussions: The surgical management of the giant ulcerated frontal skin tumor with frontal sinus infiltration and ischemic stroke was successful. Complete excision with oncological safety margins was achieved. The patient's postoperative course was uneventful, and he was discharged with recommendations for follow-up care. It is essential to consider tumor-associated risk factors, such as tumor size and location, in patients with concomitant ischemic stroke, as they may influence treatment decisions and outcomes.
Conclusions: This case highlights the successful surgical resolution of a complex condition involving a giant frontal skin tumor with frontal sinus infiltration and concomitant ischemic stroke. Through meticulous surgical techniques and multidisciplinary care, complete excision and favorable postoperative outcomes were achieved. Continued vigilance and follow-up care are crucial in managing such cases effectively.

Neutrophil to lymphocyte ratio predicts the one-month response to statin therapy in patients following an acute coronary syndrome

First author: Maria Nistor

Coauthors: Gheorghe Marian Prode Mihnea Cristian-Caus Delia Pleșca Darius Andrei Olar

Coordinator(s): Assistant Professor Vasile-Bogdan Halațiu , Professor Theodora Benedek

Keywords: acute coronary syndrome low-density lipoprotein neutrophil to lymphocyte ratio statin

Background: The low-density lipoprotein (LDL) cholesterol target for patients undergoing percutaneous coronary intervention (PCI) for acute coronary syndrome (ACS) is less than 55 mg/dL. According to the available data, only about half of the patients reach their target LDL-cholesterol level within a month after the acute event. Under these conditions, identifying potential predictors of response to standard hypolipidemic treatment may lead to improved secondary prevention.
Objective: The purpose of the present study was to investigate if complete blood count derived inflammatory markers can predict the response to lipid-lowering treatment in high-risk patients.
Material and Method: 66 consecutive patients (statin-naïve) admitted to the Cardiology Department of the Emergency Clinical County Hospital Târgu Mureș with ACS who underwent PCI were included in the present study. All patients were discharged on high-dose statin therapy (rosuvastatin 40 mg or atorvastatin 80 mg). Patients were divided into two groups based on their LDL-cholesterol levels at one month after the acute event: Group 1 – patients with LDL-cholesterol <55 mg/dL (n= 39) and Group 2 - patients with LDL-cholesterol ≥55 mg/dL (n= 27). Upon admission, all patients' demographic and laboratory data (complete blood count) were collected. The hemogram data were then used to calculate inflammatory markers such as the neutrophil to lymphocyte ratio (NLR), monocyte to lymphocyte ratio (MLR), and platelets to lymphocyte ratio.
Results: The mean age of patients in Group 1 was 61.41 ± 11.98 years, and in Group 2 was 64.22 ± 10.52 years (p= 0.32), with no difference regarding the gender distribution (66.67% versus 55.56% males; p= 0.44; R.R.= 1.22). The NLR was significantly lower in patients who reached their LDL cholesterol target compared to those who did not (3.88 ± 2.08 versus 6.33 ± 4.35; p= 0.003). The ROC curve analysis revealed that the optimal NLR cut-off value for predicting LDL-cholesterol target attainment was < 3.01, with associated sensitivity (55.72%) and specificity (88.89%). No difference was observed between the two groups in terms of inflammatory markers MLR and PLR (both p>0.05).
Conclusions: The current study's findings indicate that NLR predicts the reach of LDL cholesterol in high-risk patients. Furthermore, the data point to the need for a more aggressive lipid-lowering treatment in patients with NLR > 3.01, in order to achieve the target LDL-cholesterol as soon as possible after an ACS.

Reconstruction of post-sternotomy anterior thoracic wall defect using a rectus abdominis muscle flap

First author: Mike Dederichs

Coordinator(s): Lecturer Prof. Dr. Dorin Dorobantu , Medical Doctor Anamaria Cozlov

Keywords: rectus abdominis flap thoracic wall reconstruction negative pressure wound therapy negative pressure wound therapy

Introduction: Reconstruction of anterior thoracic wall are considered a challenge regarding restoration of form and function. Sternum dehiscence represents a possible complication after cardiac surgery especially in non-compliant, multiple-operated patients. Muscular flaps provide an excellent option for stable soft tissue defects coverage as well as a well vascularised surface.
Case Report:  This paper presents the case of a 75-year-old male patient with a complex medical record of multiple cardiovascular and lung diseases who was transferred from IUBCvT to Plastic and Reconstructive Surgery Compartment of Târgu-Mureș for a post sternotomy wound dehiscence. Previous interventions that required this maneuver consisted in aortic valve replacement and coronary artery bypass followed by sternal osteosynthesis using stainless steel wires. The first intervention was minimal due to patient post-surgical complications (osteitis, mediastinitis, bilateral pachypleuritis) and consisted in soft tissue debridement, eschilectomy, thoracentesis for bilateral pneumothorax performed by thoracic surgeon and sutures in anatomical planes. Reintervention was required due to poor post-operative care after hospital discharge and recurrence of the initial dehiscence. Reconstruction of the thoracic wall was tempted using two local advancement cutaneous flaps with unfavourable results and flaps necrosis. Substantial debridement of the necrotising tissue with sternal osteotomy were necessary to create a favourable ground for reconstructive methods. For proper coverage of the exposed mediastinum a rectus abdominis muscle flap rotated on its proximal pedicle was placed over the sternum. After a midline incision was performed, the muscle was dissected from its fascial layer with the visualisation of superior epigastric artery and deep inferior artery, the latest being ligatured after suprapubic muscle sectioning. After rising the flap over the defect, coverage was ensured by a skin graft harvested from the anterior aspect of the left tight and the abdominal fascia was reinforced using a polypropylene surgical mesh. Post-operative the patient is admitted to the ICU for supportive treatment. 
Discussions:  After a 5-day follow-up the muscular flap was viable, with minimal 4/2cm marginal skin graft necrosis for which negative pressure wound therapy (Vivano) was applied. Sutures were removed progressively at 2-3 weeks after the surgery without any further complications and spontaneous epithelization of skin graft necrosis site.
Conclusions: A notable improvement in clinical results and patient improving health condition was made possible by the effective use of a multimodal therapy strategy. The significance of proper reconstructive techniques and preparation in the management of intricate postoperative complications is demonstrated by the notable final result of the presented case.

Management and complications of UPJ syndrome

First author: Chiara Testoni

Coauthors: Veronica Galizia Giorgia Arena Sofia Leonardi Federica Menna

Coordinator(s): Associate Professor Hodade-Daniel Porav , Medical Doctor Raul-Dumitru Gherasim

Keywords: Ureteropelvic junction syndrome Malrotated kidney Renal stones

Introduction: Ureteropelvic junction (UPJ) obstruction is defined as an obstruction of the flow of urine from the renal pelvis to the proximal ureter. Congenital abnormalities may be observed in both adults and children, but adults may also present with UPJ obstruction secondary to surgery or other disorders that can cause inflammation of the upper urinary tract. In adults, other etiologies must be considered, including stones, ureteral compression due to extrinsic processes, retroperitoneal fibrosis, and other inflammatory processes. The obstruction leads to hydronephrosis. Presenting signs and symptoms include palpable mass, intermitted pain, hematuria, urinary infection, fever, hypertension and renal stones. 
Case Report: The aim of this report is to describe the case of a 50 years old male patient who came to Urology Clinic known with multiple left renal lithiasis, ureteropelvic junction syndrome on the left, left malrotated kidney with left autostatic stent. The patient has history of surgical interventions, diagnosed with dyslipidemia, diabetes mellitus type 2 and acquired renal cyst. 
Discussions: A PCNL and flexible ureteroscopy were attempted on the left side but they were unsuccessful. The next step for this patient will be laparoscopic surgery with pyelolithotomy and pyeloplasty.
Conclusions: Patient discharged with good general condition, afebrile.

Understanding the Histopathological Insights of Neuroendocrine Tumors: A case report

First author: Dana Butilcă

Coordinator(s): Assistant Professor Beleaua Marius-Alexandru , Medical Doctor Patrichi Andrei-Ionut

Keywords: neuroendocrine tumor salt and pepper neuroendocrine markers tumor classification

Introduction: Neuroendocrine tumors are a rare and diverse group of tumors establishing a link between the nervous and endocrine system, with varying degrees of hormone production and organ involvement. Understanding their pathology is crucial for effective diagnosis and treatment. Case Report: We report a case of a 68-year-old patient who presented with acute surgical abdomen to the emergency department. Imagistics revealed descending and sigmoid diverticulosis without inflammatory signs. Subsequently, exploratory laparotomy identified a mesenteric tumor formation with multiple adhesions and fluid collections. Segmental resection of the small intestine and appendix was performed, with the two surgical specimens delivered for histopathological examination. Gross evaluation revealed a paraintestinal nodular mass of 460x30mm adherent to both mesentery and intestinal wall as well an adjacent flattened mass of 6x3mm dimensions similar to the previous one was found. Microscopic evaluation revealed a uniform proliferation of medium size cells, showing round to oval nuclei with salt and pepper chromatin, with 6 mitoses/mm², infiltrating the entire ileal wall with direct invasion of the serosa as well an appendicular metastasis was identified. Immunohistochemical evaluation revealed positivity for Synaptophysin and Chromogranin A, and negativity for CD56, with a Ki-67 index of 1-2%. Four lymph node metastases along with lympho-vascular and perineural invasion were also identified. The lesion was classified as a well-differentiated neuroendocrine tumor with an intermediary histological grade (G2). Discussions: Histopathological evaluation plays a crucial role in diagnosing neuroendocrine tumors regarding the three major criteria for tumor classification: grading (Ki-67 index and mitotic rate), differentiation, and TNM staging. Immunohistochemical staining including Synaptophysin, Chromogranin A, and CD56, plays a pivotal role in confirming neuroendocrine differentiation. Positive staining for these markers aids in guiding clinical decisions regarding patient management, including therapeutic strategies and prognostic assessment. Conclusions: Neuroendocrine tumors pose a clinical challenge due to their rarity, varied presentations, and reliance on hormonal symptoms. The definitive diagnosis, often clinically elusive, is reliably provided only through histopathological examination, emphasizing it’s crucial role in management of these complex cases.

From a decrease in vision to stroke - A severe case of hypertensive retinopathy

First author: Andrei Calancea

Coauthors: Karin Groza-Mathe Ioana-Alexandra Burghelea Stefan Galbau Denis-Florin Ciceu

Coordinator(s): Medical Doctor Calancea Alina-Coralia

Keywords: Retinopathy Arterial Hypertension Transient Ischemic Attack

Introduction: Hypertensive retinopathy represents retinal vascular damage due to chronic high blood pressure (BP) and it is linked to an increased risk of stroke. Left unchecked, uncontrolled hypertension can lead to a spectrum of retinal manifestations, ranging from subtle changes to more severe symptomatology, such as papilledema.
Case Report: A 49-year-old man presented to the ophthalmology clinic complaining of a decrease in vision, mild headaches and light dizziness. His smoking exposure was 10 pack-years. Moreover, his mother had arterial hypertension and died of a stroke. After a fundoscopic examination, he was further referred to a cardiologist, due to the gravity of the findings. This consisted of arteriolar narrowing, accentuation of light reflex, arteriovenous crossing changes, retinal hemorrhages and exudates and the most severe one, papilledema in both eyes. Five days later the patient presented to the emergency department accusing dyspnea, severe headache, dizziness, and paresthesia in his right hand fingers. His blood pressure was 240/100 and a CT scan was performed, which indicated a transient ischemic attack in the left carotid territory. His LDL cholesterol level was 151 mg/dl. He was discharged 4 days later with medication for his newly diagnosed stage III arterial hypertension. The patient presented 4 months later to the ophthalmologist for a check-up and received intravitreal injection treatment with anti-VEGF medication, aflibercept. His vision improved and the retinal changes seen on fundoscopy were ameliorated.   
Discussions: A simple ophthalmological appointment for decreased vision can diagnose a severe underlying condition: stage III hypertension. The gradual loss of vision was the only true symptom the patient experienced and reaching stage 4 of retinopathy is rather uncommon. The retina is the only place in the human body where the microcirculation can be directly visualized, the fundoscopic exam being mandatory in any hypertensive patient. The fact that the patient suffered a stroke a few days after the ophthalmologic consult indicates the advanced stage of his condition. A BP measurement at the ophthalmologist could have made the patient present to the cardiologist earlier and avoid the stroke. This highlights the importance of a BP measurement at every doctor visit, regardless of his speciality.
Conclusions: Hypertensive retinopathy serves as a vital clinical marker for the systemic vascular effects of high blood pressure, offering insight into the microcirculation of the brain. This case also wants to underline the importance of treatment of the underlying condition, hypertension, which can significantly improve the damage to the retina.   

The role of RETURBT in the evolution of bladder cancer

First author: GEORGIANA MARIA BOCAN

Coauthors: Bortoș Renata-Maria

Coordinator(s): Professor ORSOLYA KATALIN ILONA MÁRTHA , Assistant Professor RAUL GHERASIM

Keywords: Bladder cancer RETURBT Histopathological results

Background: Bladder cancer is a commonly encountered malignancy, predominantly affecting men. Alongside genetic predisposition, major risk factors include smoking, occupational exposure to carcinogens, obesity. Transurethral resection of bladder tumors stands as the preferred approach for managing superficial tumors, serving as both a diagnostic and staging tool, as well as a therapeutic intervention. 
Objective: Our primary aim was to describe tumor evolution in patients who underwent repeated transurethral resection of the urinary bladder tumor (RETURBT) and to identify the existence of a difference regarding the histopathological results obtained before and after the procedure.
Material and Method: The current study is descriptive and retrospective, which includes 139 patients admitted to the urology department in Targu Mures, during 2021-2022, with bladder tumors for which RETURBT was performed. Furthermore, we investigated the smoking status and the association of obesity. 
Results: From the total of 139 patients (100%), 112 (80,6%) were male and 27 (19,4%) were female. Obesity was detected in 83 of patients (59,70%). 81 of the patients are active smokers (58,3%), 51 have stopped smoking (36,7%) and 7 have never smoked (5%). Regarding the histopathological result obtained at the first transurethral resection, we detected 63 patients with pTa (45,3%), 61 patients with pT1 (43,9%), 13 patients with pT2 (9,3%). Also, the grade of cell differentiation was G3 in 67 cases (48,2%) and G2 in 54 cases (38,8%). The histopathological results obtained through RETURBT were 53 patients with pTa (38,1%), 35 patients with pT1 (25,2%) and 20 patients with pT2 (14,3%). The grade of cell differentiation was G3 detected in 31 cases (22,3%) and G2 in 42 cases (30,2%). The histopathological results before and after RETURBT were compared statistically, obtaining a p<0.0001, which demonstrates the existence of a significant difference between them. Regarding tumor staging, 52 patients had a downstage (37.41%), 20 patients had an upstage (14.39%) and 67 patients had the same histopathological result before and after RETURBT (48.20%).
Conclusions: The study outlines that males are more affected. Most patients exhibited an association with smoking and obesity. In terms of the evolution of bladder tumors, RETURBT plays a significant role for patients who have remained at the same stage and those with tumor regression, as well as for those who have progressed towards invasiveness. Thus, through RETURBT, an effective tumor staging and a prompt therapeutic method are achieved.

ATOPIC DERMATITIS IN MEDICAL PROFESSIONALS

First author: Isabela Maria Iacob

Coordinator(s): Lecturer Toader Septimiu Voidazan

Keywords: atopic dermatitis medical field aggravation stress

Background: One in ten people will at some point in their lives have atopic dermatitis, also known as atopic eczema, which is a chronic inflammatory skin illness that comes and goes. Immune dysregulation, epidermal gene abnormalities, and environmental factors combine intricately to generate atopic dermatitis. It is well known that people who work in the medical field are more likely to be affected by this disease due to the increased amount of sanitizers used daily and medical gloves which contain latex. Objective: The main objective of this study is to observe if people who are in the medical field with atopic dermatitis are affected in performing their daily tasks and how it influents their well being.
Material and Method: This research is a prospective study which was performed on 316 people through an online form addressed mainly to medical professionals who encountered one or more specific symptoms suggesting an outgoing skin condition.
Results: Out of the 316 responders to my study who are in the medical field, 51,6% are affected by atopic dermatitis, revealing an existing correlation(p=0,01) between the prevalence of this disease,the aggravation of it and their profession . An important role in this pathology is played by the awareness of the aggravating factors, which in this study, were represented by increased stress and anxiety(p=0,003), a high number of the subjects reporting an aggravation in their inflammations and rashes during stressful situations work related. Another relevant finding in this study is represented by the number of people(p=0,008) who declared that their work abilities are highly affected by this skin condition, making it harder for them to perform daily tasks at the work place due to the pain the rash causes them by using detergents, hand sanitizers, soaps, and also the uncomfortable gloves wearing.  
Conclusions: This prospective study shows the existing correlation between people in health care and the prevalence and aggravation of atopic dermatitis, which affects the ability to perform various tasks. As previously shown, numerous health workers suffer of this skin condition and it is a way more common disease than is generally thought.

Silent ureteral stone as a leading cause of nephrectomy.

First author: Veronica Galizia

Coauthors: Raul Dumitru Gherasim Chiara Testoni Giorgia Arena Antoniacopo Pepparelli

Coordinator(s): Associate Professor Daniel Porav-Hodade , Assistant Professor Ciprian Doru Todea-Moga

Keywords: Asymptomaticity Ureteral stone Laparoscopic nephrectomy

Introduction: Urinary stones are an important cause of morbidity in the US. More than 500,000 people are affected yearly, with a female gender prevalence and an age group ranging from 30 to 50 years old. Urinary tract stones are usually diagnosed in the emergency department where the symptomatic patient is admitted due to renal colic, a common symptom of ureterolithiasis. It is also true that ureteral stones can be silent for many months, leading to nephrectomy.
Case Report: 69-years-old female patient, known with primary hypertension and chronic ischemic heart disease, under treatment with metoprolol, perindopril-indapamin and lercadipin; presented to the urology clinic ER complaining of colicky pain on the right side. She also had fever, shivering, nausea, vomiting and dysuria. At presentation the analyses were in normal range and uroculture was negative. The patient medical history reveals an increased cholesterol level, increased ESR, increased urea and a eGFR of 71.39 ml/min. From her surgical history emerged that she had a laparoscopic cholecystectomy. The Computed Tomography (CT scan) revealed a normal left kidney and an atrophic right one, with a decreased parenchymatous index (6mm) and pelvic hypotonia at the level of the caliceal groups, without kidney stones. In the right ureter, the CT showed a voluminous radiopaque mass measuring 48x12mm. Abdominal aortic calcifications were also noted. After repeated analyses, the eGFR was 81.34 ml/min, the ESR was 55ml/h, the cholesterol level was high and the urine culture tested positive for E. Coli, treated with antibiotics. Due to lack of symptoms, the patient developed a large calculus in the right ureter, which caused a hydroureter and a subsequent atrophization of the right kidney. The patient was referred to the surgeon for a nephrectomy.
Discussions: The peculiarity of this case is that a large stone went unnoticed for years because the patient did not develop any symptoms. This led the patient to the operating room for a laparoscopic nephrectomy. The reason behind this surgical decision was to avoid recurrent UTIs, which could have exposed the patient to sepsis.
Conclusions: Asymptomaticity was deleterious for this patient as it laid the foundations for the development of a silent change in the kidney structure, narrowing treatment options to surgery alone. It is possible to say that the nephrectomy could have been avoided if the stone had been caught earlier by being symptomatic. After surgery the patient was discharged in good conditions.

THE IMPORTANCE OF PHISICAL THERAPY OF FLAT FOOT IN SECONDARY SCHOOL

First author: Alexandro Hojda

Coordinator(s): Associate Professor Pia Simona Făgăraș

Keywords: Flat foot Balance Hypermobility Children

Background: The posture of the foot is very important in the proper functioning of the lower body and at the same time in acquiring a correct posture. 
Objective: The study aims to investigate flat feet among secondary school students (11-15 years old) and the relationship between flat foot, hypermobility, static and dynamic balance.  
Material and Method: In order to determine the flat foot, we took the footprints of each participant in the study, after which we calculated some indexes (Chippaux-Smirak index, Clarke angle and Stahelli index). We also used Beighton score to check the general mobility of the subjects. Anthropometric measurements were taken from each participating subject regarding height, weight, abdominal circumference and pelvic circumference. Thus we were able to calculate BMI and WHR for each study participant. To determine the static balance, we used the Sensamove balance platform, on which we performed 2 tests (Neuro muscular Control Test with visual control and without visual control, each lasting 20 seconds). For the assessment of dynamic balance we used a walking assessment, both with eyes open and eyes closed by using the BalanceGait Test app which uses a mobile phone fixed on the subject’s waist.
Results: Results will be presented during the Marisiensis International Scientific Congress because the study is still ongoing.
Conclusions: The study's conclusions will be presented at the Marisiensis International Scientific Congress with the results.

THE IMPACT OF PSYCHONUTRITIONAL INTERVENTION IN IMPROVING THE NUTRITIONAL STATUS OF THE YOUNG OBESE

First author: Adriana Pana

Coauthors: Irina-Elena Muntean

Coordinator(s): Associate Professor Maria Dorina Pașca

Keywords: nutritional status obese patient psychonutrition young people

Background: Obesity is a largely preventable chronic and complex disease that has become alarmingly widespread worldwide, especially among young people. Psychonutritional intervention provides methods and coping strategies to enhance nutritional status.
Objective: We aimed to assess the impact of psychonutritional intervention on nutritional status among young obese patients. 
Material and Method: The study was carried out in the medical office by 1 nutritionist-dietitian and 1 psychologist, between the 1st of June and the 30th of September 2023, on 24 obese patients aged 19 to 25. To track the changes, the sample was divided into two equal groups: the group G1, those who underwent psychonutritional intervention, and the group G2, those who did not benefit from it. Evaluation and monitoring were conducted at the initial consultation (T0) and at the final consultation (Tf).
Results: The gender distribution, female-to-male ratio was 2/1 (n=16 females). At the initial consultation, the average weight was 94.26 kg for G1, and 95.16 kg for G2, while at the final consultation, it was 78.58 kg for G1, and 88.35 kg for G2 (p <0.05). Moreover, we noticed that the average Body Mass Index, at the initial consultation, it was 36.82 kg/m2 for G1, and 37.18 kg/m2 for G2, while at the final consultation, it was 29.63 kg/m2 for G1, and 34.52 kg/m2 for G2 (p <0.05). 
Conclusions: In our study, the findings highlight the beneficial effects of psychonutritional intervention on improving the nutritional status of young obese patients, and underscore the potential of psychonutritional approaches as an effective tool in promoting healthier lifestyles and combating obesity among young individuals.

The efficiency and safety of a biosimilar after multiple treatments with original biologics in a rheumatoid arthritis case

First author: Alexandra-Maria Cimpean

Coauthors: Rares-Stefan Catalina

Coordinator(s): Lecturer Horatiu-Valeriu Popoviciu

Keywords: RA DAS28 Hyrimoz biosimilar

Introduction: Rheumatoid arthritis (RA) is an immune-inflammatory disease, with a complex pathogenesis, characterized by symmetrical, destructive, and deforming polyarthritis of the limbs and multiple systemic manifestations, unfortunately its etiology is still unknown. 

Case Report:  We present the case of a 74-year-old patient diagnosed with rheumatoid arthritis (1982), with a history of hypertension, hypothyroidism, and viral hepatitis B. She receives as part of her chronic treatment medication based on antihypertensive drugs, methylprednisolone, levothyroxine, NSAIDs and conventional and biologic antirheumatic medication. It has been observed that over time, the antirheumatic treatment proved ineffective both for csDMARDs and for the administration of biologic treatment initiated in 2003, with Infliximab, then gradually replaced with Etanercept, respectively Rituximab. Finally, the last therapeutic option (Rituximab) has been replaced by Hyrimoz (Adalimumab biosimilar), which initially led to a change in the DAS28 score from a value of 7.08 (September 2019) to a value of 4.78 (May 2020), ultimately reaching a value of 3.01 at the last medical visit conducted in December 2023.
Discussions: Following the analysis of both DAS scores and the patient's symptomatology, we observe a significant improvement in the activity of her underlying disease. The EULAR criteria for therapeutic response correspond to a good response because the improvement in DAS28 was over 1.2 points, and the final score is below 3.2.
Conclusions: Biologics are effective drugs for treating RA. Regarding biosimilars, these are drugs that do not have clinically significant differences compared to the corresponding reference biologics. They are tested to ensure that they work identically and are as safe as the original drugs. For rheumatic diseases, only a few biosimilar drugs are currently available. However, biosimilars are becoming an increasingly important part of treatment as more options become available.

SPONTANEOUS RUPTURE OF THE URINARY BLADDER AND ITS COMPLICATIONS – A CASE REPORT

First author: Andreea Roșculeț

Coauthors: Alexandra-Iuliana Postolache Ana Porumb Luiza Marina Răcilă

Coordinator(s): Medical Doctor Laurențiu Ursache

Keywords: bladder rupture urohemoperitoneum hematuria

Introduction: Urinary bladder rupture is a pathology more common in males and may occur in the context of various conditions: abdominal traumas, inflammatory diseases, iatrogenic injuries. One of its most severe complications is urohemoperitoneum, representing a surgical emergency characterized by severe abdominal pain, distension, and abdominal tenderness. Left untreated, it presents a high mortality and morbidity rate.
Case Report: We present a 46-year-old man, diabetic, chronic alcohol consumer, who presented to the Emergency Department complaining of progressively worsening dyspnea at rest, progressive abdominal distension, associated with diffuse abdominal pain, dysuria, and oliguria for about a week. The patient reported an episode of acute urinary retention 8 days ago, for which urethral-vesical catheterization was performed. CT examination revealed significant intraperitoneal fluid accumulation, as well as images suggestive of clots on both flanks, more pronounced in the supravesical pelvic region, and cystography under CT control showed bladder rupture at the dome level. Subsequently, emergency surgical intervention was performed, and exploratory laparotomy revealed the presence of hematuric urine in the intraperitoneal cavity in large amounts – 10 liters, with features suggestive of an older bleeding. Viscerolysis was performed, a 4 cm defect was identified in the posterior bladder wall, excisional debridement of bladder defect margins and double-layer cystorrhaphy were performed, with placement of a Foley urethral-vesical catheter. Abundant abdominal lavage was performed. The patient was diagnosed with urohemoperitoneum due to spontaneous bladder rupture.
Discussions: The therapeutic approach to bladder rupture complicated by urohemoperitoneum must be prompt and correct, clinically evaluated, biologically and through imaging examinations, which contribute to establishing and implementing therapeutic methods. CT examination and cystography played an essential role in diagnosis, abdominal CT providing detailed images of the abdominal region, allowing presumptive identification of urinary bladder rupture, as well as evaluation of urohemoperitoneum extension, and cystography confirming the diagnosis and providing information about the rupture location. 
Conclusions: Urohemoperitoneum is a potentially fatal complication, but when promptly treated with care and specific interventions, the patient can make a complete recovery.

Open-source IDS solutions for securing computer networks

First author: Ilie Romanu

Coordinator(s): Other Adrian Mihăileanu

Keywords: Networking Security IPFire Raspberry

Background: In the digital age, protecting computer networks against cyber threats is crucial. Open-source Intrusion Detection Systems (IDS) offer an efficient, flexible, and affordable solution for monitoring and detecting suspicious activities. This paper explores the potential of open-source IDS solutions in securing networks, emphasizing the contribution of developer communities to the continuous improvement of cybersecurity. The aim is to highlight how these systems can be adapted to strengthen the defense of computer networks against a dynamic spectrum of threats. Objective: The main aim of our project was to create a comprehensive security solution tailored for LAN and wireless networks using solely open-source tools. Our objectives included enhancing network security through the deployment of a web proxy, captive portal, and web filtering to manage and monitor network traffic effectively. Moreover, we sought to enable secure remote connections through VPN and safeguard against brute-force attacks targeting SSH services, thereby reinforcing the security framework of our network systems. Material and Method: Our project utilized open-source tools on a Raspberry Pi to secure LAN and wireless networks. IPFire served as the operating system, chosen for its robust firewall and IDS capabilities. We used an IPFire web proxy for LAN security, monitoring HTTP/HTTPS traffic to enforce access policies and protect against unsafe content. A captive portal was implemented for wireless security, requiring user authentication to ensure verified access. Web filtering was achieved through URL Filter on IPFire, blocking categories of websites to enhance safety. For secure remote access, OpenVPN was configured, and the Guardian tool was deployed to counteract brute-force SSH attacks. Results: Implementing our security strategies led to significant achievements. The web proxy effectively managed network traffic, reducing the risk of accessing malicious sites and enhancing network efficiency through caching. The captive portal proved invaluable for secure network access and user management, bolstering both security and user experience. URL filtering further secured online activities by blocking harmful content, aligning with our acceptable use policies. VPN connections offered secure and reliable remote access, safeguarding data integrity. Additionally, the Guardian tool was instrumental in deterring brute-force attacks on SSH services, significantly decreasing the vulnerability of our network to such threats. Conclusions: In conclusion, our study highlights the capability of open-source IDS solutions to provide an advanced level of security for computer networks through an integrated and multi-layered approach. These results confirm the effectiveness and viability of open-source solutions in constructing a robust security infrastructure capable of efficiently responding to cyber threats.

Laparoscopic radical nephrectomy for massive renal tumor – Case report

First author: Andrei-Dănuț Ciocaș

Coauthors: Horea Valentin Rac Patrik Buzgau Octavia Camelia Chirilă Bogdan Crișan

Coordinator(s): Assistant Professor Veronica Ghirca , Lecturer Ciprian Todea

Keywords: laparoscopic radical nephrectomy renal cell carcinoma suprarenalectomy minimal blood loss

Introduction: Laparoscopic nephrectomy has been established as the standard of care for the management of kidney tumors due to its safety, feasibility and lower risk of post-operative morbidity. In the past decade laparoscopic approach has gained worldwide popularity.
Case Report: We present the case of a 48-year-old female diagnosed with voluminous left kidney tumor who was admitted in the Urology Clinic from Targu Mures. The patient’s history reveals that she had radical hysterectomy for endometrial cancer. The BMI is equal to 50,78 ( weight of 130 kg and the height of 160 cm ) resulting in morbid obesity. Preoperative blood results are within parameters. Abdominal ultrasound and computed tomography revealed a tumor mass located in the left kidney superior pole measuring 78/80 mm, without lymph node or distant metastases.
Discussions: Transperitoneal laparoscopic approach was considered the optimal access of choice. Surgical technique was left laparoscopic radical nephrectomy with left suprarenalectomy. Intraoperative incidents were not significant and the loss of blood was minimal ( 100 ml ). Drainage was removed 5th day after the surgery and the hospital stay was 6 days. Postoperative histopathological results revealed clear cell renal carcinoma of the left kidney, grade WHO/ISUP grade 2, left adrenal gland without pathological findings.
Conclusions: Laparoscopic nephrectomy was proven to be a better option in the removal of renal tumor because of the better visualization of anatomical structures, less need for postoperative analgesics, minimal blood loss, lower risk of postoperative complication and morbidity rate, potentially lower costs due to shorter hospital stays. Moreover, in case of obese patients, the laparoscopic approach is preferred over open surgery because of the smaller incisions who lead to less postoperative complications and a faster recovery. A classic nephrectomy can cause serious complications in patients with elevated body mass index due to high incidents of wound infections and dehiscence that can lead to catastrophic results.

CLINICAL AND PATHOLOGICAL PERSPECTIVES ON GASTRITIS IN PEDIATRIC PATIENTS: ASSESSMENT AND THERAPEUTIC APPROACHES

First author: ANA-MARIA ARDELEAN

Coauthors: Alexandra Antoce

Coordinator(s): Professor Cristina Oana Mărginean

Keywords: Pediatric Helicobacter Pylori Gastritis Inflammation

Background: Gastritis is a condition marked by inflammation of the gastric mucosa, can arise from various sources, including infection with due H.Pylori bacteria (a prevalent cause) or the usage of other factors as: medications such as NSAIDs or corticosteroides, excessive alcohol intake, stress or autoimmune factors.  Objective: The aim of the study is to assess the differences concerning the symptoms, paraclinical parameteres of hemograms (hemoglobin, neutrophils, lymphocytes, platelets) and histopatological changes between H.Pylori gastritis and Non-H.Pylori gastritis. Material and Method: We performed a retrospective study on 163 patients aged between 3 to 18 years, hospitalized in the Pediatric Clinic I Târgu-Mureș diagnosed with Gastritis between 01.01.2019 and 01.01.2024. The children were divided into 2 groups: H.Pylori group and Non-H.Pylori group. An upper digestive endoscopy with gastric biopsies and a complete blood count was performed in each case. Results: The most frequently affected age group was the category between 14-18 years (58%) and the least frequently involved were children between 3-5 years (3%), additionally the majority of pacients were women (63%). Children from rural areas were the most frequent patients in the total group (52%). The epigastric pain (p=0,0457) was significantly associed with H.Pylori group. Pacients in the Non-H.Pylori group had diffuse abdominal pain at the level of the right hypochondrium, the entire upper abdominal floor or periumbilical (48%).  Futhermore, we underscored a statistically significant difference in the duration of hospitalization (p=0,0054) and incidence of emesis (p=0,0253) in the Non-H.Pylori group. In the group with H.Pylori, the most frequent endoscopic appearance was a congested, edematous gastric mucosa type, with a predominantly antral nodular/folicular appearance (n=54) and a histopathological appearance of an inflammatory infiltrate with polymorphonuclear neutrophils in the gastric submucosa (n=54). In the group with Non-H.Pylori, the most frequent endoscopic appearance was represented by hyperemic, edematous gastric mucosa (n=39) and a histopathological appearance of an inflammatory infiltrate with neutrophils and superficial erosions (n=40). We found no statistically significant differences regarding laboratory results between the two groups. Conclusions: According to the result, children`s gastritis manifest itself with various clinical and pathological characteristics, influenced by factors such as: age, gender, geographic factors and etiological agents, such as H.Pylori that playing significant roles. Moreover, differences in clinical outcomes and histopathological characteristics between H.Pylori and Non-H.Pylori cases highlight the importance of accurate diagnosis and tailored management approaches.

Pulmonary thromboembolism case report - from prevention to complex therapeutic management

First author: Obada Albunni

Coauthors: Ahmer Syab Ali Hassan Abdullatif Parrok Khan Hadji Muhamad Abdullatif Hassan

Coordinator(s): Assistant Professor Andrei Modiga , Lecturer Sorana-Teodora Truta

Keywords: fibrinolysis pulmonary embolectomy pulmonary thromboembolism

Introduction: The annual incidence of pulmonary thromboembolism (PTE) is estimated to be around 0.5 to 1.0 cases per 1,000 individuals. However, this incidence may be higher in certain high-risk populations. It is critical to note that the management of unstable patients with PTE should be tailored to the patient's clinical presentation, hemodynamic status, and risk factors, with decisions made in collaboration with a multidisciplinary team.
Case Report: We present a case of a 67-year-old female who presented to the E.R. for dyspnoea with sudden onset during the day. At the time of presentation, the BP was 142/82 mmHg, HR 92/min and O2 saturation 92% in ambient air. From the medical history, we note a surgical intervention of amputation of the right thigh 14 days prior, in a territorial hospital, without the administration of prophylactic peri- and postoperative anticoagulant. The ECG revealed S1Q3T3, with no other pathological changes. Echocardiography revealed no evidence of right-sided heart failure, and the left ventricle ejection fraction was estimated at 45%. Based on the positive d-dimer test results and the Wells score of 4.5 points (moderate risk - 16.2% chance of PTE), a CT pulmonary angiogram was performed, which confirmed the diagnosis of bilateral massive PTE. The patient presented a sudden deterioration, with BP dropping to 85/40 mmHg and O2 saturation reaching 80%, necessitating vasoactive support with noradrenaline and high-flow O2 via face mask with reservoir bag. Given the patient's hemodynamic instability and the fact that fibrinolytic treatment was absolutely contraindicated (major surgery within three weeks), the multidisciplinary team (emergency medicine doctor, cardiologist, and cardiovascular surgeon) decided to perform open pulmonary embolectomy, with favourable postoperative evolution. 
Discussions: In patients with risk factors for PTE, such as major surgery, prevention is the "treatment of choice". When we have a suspicion of PTE, especially in patients who present risk factors, early confirmation of the diagnosis is desirable, in order to prevent deterioration of the patient's general condition and achieve favourable outcomes. In the hemodynamically unstable patient with absolute contraindications to fibrinolysis, non-invasive treatment is exhausted, and embolectomy is required to save the patient's life.
Conclusions: This case report highlights the complexities of managing PTE, which is often thought to be a simple disease. Even though prevention is the key, prompt diagnosis and a multidisciplinary approach to therapeutic management are critical in achieving good outcomes.

How The Genes Are Writing Our Future – a Left Ventricular Non-Compaction Cardiomyopathy case

First author: Maria Căinap

Coauthors: Radu Ilieș

Coordinator(s): Associate Professor Cecilia Lazea

Keywords: non-compaction cardiomyopathy genetics familial

Introduction: Left Ventricular Non-Compaction Cardiomyopathy (LVNC) is a complex entity surrounded by controversy regarding its diagnosis, clinical presentation, and prognosis. LVNC is frequently familial, with an autosomal dominant inheritance but variable penetrance and high intrafamilial variability.
Case Report: We report the case of a ten-year-old male patient diagnosed with LVNC cardiomyopathy after family screening. At the time of the diagnosis, the patient was asymptomatic, with very good tolerance to effort. However, the screening was recommended since his father had been diagnosed with LVNC cardiomyopathy at the age of 40. The physical exam revealed no abnormalities of the cardiovascular system. No ECG changes were identified. The echocardiography showed left ventricular dilatation with prominent trabeculations at the apex and lateral wall of the LV, suggestive of myocardial non-compaction. The ejection fraction (EF) was 50%, fractional shortening (FS) was 28%, and diastolic function was preserved. The cardiac MRI confirmed the diagnosis of LVNC cardiomyopathy (non-compaction of the anterior, anterolateral, and inferolateral wall of the mid-cardiac and apical LV). Holter ECG monitoring did not reveal any arrhythmias or conduction disorders. Treatment with ACE inhibitors (Lisinopril) and beta-blocker medication (Concor) was prescribed. The genetic investigation revealed 2 variants of uncertain significance (VUS): a heterozygous mutation in TPM1 gene possibly associated with dilated cardiomyopathy (DCM), and a heterozygous mutation in DTNA gene possibly associated with LVNC. The evolution of the case was progressively unfavourable; periodic echocardiographic evaluations indicated the critical deterioration of LV contractility, with a reduction in EF to 26% at the last evaluation. 
Discussions: Non-compaction cardiomyopathy remains a chameleonic condition: from aetiopathogenesis to clinical presentation and prognosis. Recently, emphasis has been placed on genetics and genotype-phenotype relation. Family aggregation has been described in approximately 40% to 50% of LVNC cases, and therefore, family screening is recommended in all patients to confirm the diagnosis and to identify asymptomatic relatives. In our case, the patient's father (the index case) had mutations (VUSs) in TPM1, DTNA, and MYL4 genes. TPM1 and DTNA genes are known to be involved in LVNC and DCM. Additionally, mutations in MYL4 gene are linked to arrhythmias. The patient had only two identical mutations to his father, but his symptoms were more severe, and his condition was progressing much faster towards heart failure. 
Conclusions: An adequate diagnostic strategy requires integrating different parameters such as family history, genetics, and imaging studies. Genetic testing in patients with LVNC has proved useful in identifying disease-causing variants. 

Laparoscopic Management of Pancreatic Head Insulinoma: Advantages and Challenges

First author: Emilia Grosu

Coauthors: Anca Hategan Hera Valentina-Alexandra Bălănescu Elena-Georgiana

Coordinator(s): Assistant Professor Gabriel Serac , Other Mihai Balan

Keywords: insulinoma laparoscopy hypoglicemia enucleation

Introduction: Insulinoma is a rare tumor of the pancreas that develops from the beta cells of the Langerhans islets, responsible for the production and secretion of insulin. This hypersecretion of insulin can lead to hypoglycemia, which can cause symptoms such as dizziness, confusion, weakness, and, in severe cases, loss of consciousness. The case presentation addresses the management of a pancreatic insulinoma in a patient previously treated for diabetes.
Case Report: We present the case of a 66-year-old patient who is admitted with repeated episodes of loss of consciousness, dizziness, confusion, and hot flashes, along with fluctuating blood glucose levels. Additionally, she has been treated for diabetes mellitus for 3 years during which she has experienced 2 hypoglycemic crises (blood glucose levels of 30 and 50 mg/dL). Following the symptoms, an MRI with contrast reveals a slightly gadolinophilic tumor formation measuring 21/20 mm. Subsequently, a biopsy puncture is recommended, which demonstrates a microscopic appearance and immunohistochemical markers (positive for insulin) compatible with a well-differentiated neuroendocrine tumor. Correlating the imaging diagnosis, histopathological findings, laboratory analyses, and symptoms, we establish the preoperative diagnosis of insulinoma. The patient is admitted to the Department of General Surgery of the Emergency County Clinical Hospital Târgu Mureș with an indication for surgical treatment.
Discussions: After preoperative preparation, an exploratory laparoscopy is performed with an approach to the right hypochondrium. Laparoscopic adhesiolysis is performed, followed by dissection of the duodeno-pancreatic region and enucleation of the tumor. The objectives of laparoscopic intervention for pancreatic insulinoma include rapid postoperative recovery with low morbidity. Precise identification of the tumor and adjacent structures; excision of the tumor, ensuring the integrity of healthy tissues; minimizing injuries and bleeding during the procedure to reduce the risk of complications. 
Conclusions: In conclusion, the clinical and paraclinical differential diagnosis along with laparoscopic surgical treatment represents an efficient and safe option in the management of insulinoma.

Hormone replacement therapy (HRT) in 30-year-old patient experiencing menopause symptoms following Wertheim surgery

First author: Octavia Camelia Chirilă

Coauthors: Andrei-Dănuț Ciocaș Stefania Ghiveci Chinezu Iulia-Andreea Iulia Diana Sabău

Coordinator(s): Medical Doctor Călin Todoran

Keywords: HPV Hormones Menopause Cervix

Introduction: Lately, an increasing number of women have been resorting to hormone replacement therapy to alleviate menopausal symptoms in order to improve their quality of life. 
Case Report: We present the case of a 30-year-old woman who was found to be HPV-16 positive during routine testing. A pap-smear revealed high grade squamous intraepithelial lesion (HSIL), this was followed by a biopsy which established the diagnosis as being squamous cell carcinoma of the cervix. The patient had undergone a caesarean-section 2 years prior and was not HPV vaccinated.

Discussions: Bioidentical hormones are considered the best treatment option for menopause, especially in non-physiological situations such as this case. These hormones are supposed to replace the lack of endogenous hormones and sustain normal bodily function. 
Conclusions: Adjusting and maintaining quality of life can be achieved through functional medicine and individualised treatment.  

Right inguinal sarcoma present in a patient with right inguinal hernia

First author: Mihnea-Adrian Tudor

Coauthors: Livio Vlad-Remo Mazzolini Ioana Tripon

Coordinator(s): Lecturer Adrian Tudor

Keywords: Sarcomas Inguinal hernia Treatment

Introduction: Sarcoma is a malignant tumor of connective tissue. Frequently involved structures include connective, bone, cartilaginous, muscular, and adipose tissues. Sarcoma can occur both in the trunk and in the limbs, head, or neck
Case Report: In this paper, we present the case of a 70-year-old man who was admitted through scheduling with the diagnosis of a right inguinal tumor. The patient reports the onset of a tumoral formation in the right inguinal region 4 months ago. It has grown to 25x20 cm, becoming painful. From the patient's pathological personal history, we note the presence of essential arterial hypertension, bilateral hydrostatic varices, and prostate adenoma. The physical examination reveals a tumoral formation in the right inguinal region, slightly hyperemic, oval, hard, well-defined, fixed to superficial and deep planes, slightly sensitive. Computed tomography examination revealed a tumoral formation in the right inguinal region with a double component - parenchymal, inhomogeneous iodophilic, centrally necrotic, with dimensions of 87/105/130 mm (AP/LL/CC), respectively poliseptate adipose structure, with discreet own wall, microcalcifications and included vascular structures, with dimensions of 102/62/125 mm (AP/LL/CC), several superficial inguinal lymph nodes with maximum dimensions of 13/9 mm. The surgical intervention consisted of elliptical excision of the tumoral formation from cranial to caudal and from medial to lateral. As the tumoral formation penetrated the external oblique muscle aponeurosis and the inguinal ligament, partial excision of these was also necessary. After the removal of the tumoral formation, an external oblique inguinal hernia sac was also identified, which is why inguinal hernia repair and abdominal wall plasty were performed, retrofunicular procedure. The intervention concluded with mobilization of the cutaneous-subcutaneous flaps, their suture, and subcutaneous drainage. The postoperative evolution was favorable, and the patient was discharged on the 5th postoperative day. Histopathological examination revealed a monophasic synovial sarcoma, grade 3 FNCLCC. On section, the tumor presents a multinodular aspect, with areas of necrosis, approximately 40% of the tumor volume.
Discussions: Sarcomas are mesenchymal tumors that can be divided into soft tissue sarcomas and primary bone sarcomas, depending on the tumor type, the therapeutic approach being different. Important prognostic factors are grade, size, and location of the primary tumor.     
Conclusions: Treatment should always address associated lesions, such as the inguinal hernia in the presented case. Surgical treatment with or without radiotherapy remains the first-line treatment for localized soft tissue sarcomas, while chemotherapy may be indicated in cases with high risk.

Maternal knowledge related to breastfeeding

First author: Kristina Kyselytsia

Coordinator(s): Assistant Professor Lidia Man

Keywords: breastfeeding mother benefit obesity

Background: Breast milk is a complex and unique substance, distinct from the lactation secretions of other species. Besides providing essential nutrients, it offers crucial protection during the newborn's adaptation process to the extraterrestrial environment. The components of breast milk not only directly combat pathogens but also stimulate the development of the newborn's immune sys-tem, strengthening its defense capabilities and reducing the risk of allergic conditions.
Objective: The aim of the study was to assess the knowledge of mothers who have breastfed or are currently breastfeeding regarding breastfeeding and its benefits. Specifically, we aimed to explore the impact of the mothers' educational level at the time of breastfeeding on their understanding of the benefits for the infant, especially in terms of reducing obesity, fostering the emotional bond between mother and infant, promoting strong immune system development, ensuring good digestion, and soothing the in-fant. We also analyzed the relationship between the mother's background and the timing of introduc-ing solid foods. 
Material and Method: This study represents a cross-sectional survey conducted between January and February 2024, using a Google Forms questionnaire to assess mothers' knowledge. The questionnaire was distributed on social media platforms, with informed consent and under anonymity protection. It was completed by 1000 individuals. The collected data were analyzed using SPSS (Statistical Package for the Social Scienc-es). Data distribution was tested using the Chi-square test, with p < 0.05 considered statistically signifi-cant.
Results: The study identified a statistically significant association between the level of education and the reduc-tion of obesity risk as a benefit of breastfeeding (p < 0.0001). Another statistically significant association was found between the mother's background and the timing of introducing solid foods (p < 0.001). However, no statistical significance was found between the level of education completed and the emotional bond created between mother and infant during breastfeeding (p > 0.058). Another non-significant association was detected between the completed level of education and breastfeeding as a factor in developing strong infant immunity (p > 0.507), ensuring good digestion (p > 0.283), and soothing the infant (p > 0.52).
Conclusions: This study revealed that the mothers with university and postgraduate studies, are more informed about the benefits of breastfeeding, especially related to reducing infant obesity, compared to the mothers that have high school and post-high school studies. Similarly, the mothers from rural background have introduced solid foods earlier than the ones from urban background.

Anticoagulant of choice in cancer-related venous thrombosis - a challenge

First author: Bianca Maria Grecu

Coauthors: Bianca Vaduva Teodora Ioana Ursu Andreea-Ioana Feraru Iulia Diana Sabău

Coordinator(s): Professor Theodora Benedek , Assistant Professor Vasile-Bogdan Halațiu

Keywords: anticoagulant cancer thromboembolic event

Introduction: The prevalence of cancer-related venous thrombosis varies by study, with reported rates ranging from 1.6% to 6%. The risk of thrombosis in cancer patients is influenced by several factors, including the type, histology, and stage of the malignancy, treatment, and specific biomarkers. Furthermore, it is estimated that between 20% and 30% of all first venous thromboembolic events. Anticoagulant therapy, on the other hand, poses a challenge for these patients.
Case Report: A 56-year-old female, hypertensive, presents to the E.R. for suddenly installed dyspnea, followed by a unique episode of loss of consciousness. At admission, the patient presented tachycardia and O2 saturation of 89%, with no other changes noted during the physical examination. The ECG trace highlighted sinus tachycardia and S1Q3T3. While laboratory analyses indicated a positive D-dimer test (8640 µg/L). A computed tomography pulmonary angiogram was performed and revealed an acute bilateral pulmonary embolism (PE) with thrombus at the bifurcation of the pulmonary trunk. Anticoagulant treatment with unfractionated heparin with optimal apTT control was initiated in the cardiology department, with switch on Rivaroxaban. During hospitalization, further investigations were performed, but no source of PE was identified. The patient presents a favorable evolution, which is why she is discharged hemodynamically and respiratoryly stable. After one month, the patient begins to experience severe dyspepsia, loss of appetite, and a febrile syndrome of unknown cause. She conducted a gastroenterology consultation, including an upper digestive endoscopy, which raised the suspicion of gastric adenocarcinoma, later confirmed by the histopathological result, for which chemotherapy was initiated. After another 4 weeks, the patient presented to the E.R. for an increase in the volume of the left thigh and cardinal signs. The diagnosis of high-deep venous thrombosis of the left lower limb was confirmed. Rivaroxaban anticoagulant treatment was discontinued, and low-molecular-weight heparin (LMWH) was administered in accordance with the patient's weight, with a favorable subsequent evolution.
Discussions: Although both new anticoagulants and LMWH are indicated (class IA) in patients with neoplasia and venous thromboembolism, there are no clear criteria to guide the therapy towards a certain class of anticoagulant.
Conclusions: It is recommended to evaluate each oncological case individually, taking into account the risk of thrombosis/bleeding and, consequently, personalized drug therapy initiation for a better outcome.

Giant right ovarian fibroid with compressive phenomena, associated with uterine leiomyoma, in a patient with recurrent basal cell carcinoma of the face, operated on

First author: Mihnea-Adrian Tudor

Coauthors: Livio Vlad-Remo Mazzolini Ioana Tripon Mohammed Ali Tuncer

Coordinator(s): Lecturer Adrian Tudor

Keywords: Giant ovarian fibroma Ascites Treatment

Introduction: The ovarian fibroma is the most common benign stromal ovarian tumor. It is associated with ascites in 40% of cases and, in a small percentage, with hydrothorax. The symptoms mimic a neoplastic condition, with imaging examinations being very useful in diagnosis.
Case Report: In this paper, we present the case of a 66-year-old patient who was admitted by appointment on October 25, 2023, with a diagnosis of an abdominal tumor, likely of right adnexal origin. The patient reports the onset of lower abdominal pain approximately 4 months ago, associated with abdominal bloating. The symptoms worsened, with the patient noticing a progressive increase in the size of her abdomen. From the patient's medical history, we note: hydrostatic varices of the lower limbs, essential hypertension, NYHA II congestive heart failure, obesity, hepatic steatosis, gallbladder lithiasis, basal cell carcinoma of the face excised in 2020, recurrent and reoperated on October 11, 2023. The physical examination reveals a distended abdomen, with palpation revealing an indistinctly delimited tumor formation, approximately 40x30 cm in size, firm, slightly sensitive, occupying almost the entire abdominal area. Computed tomography reveals a space-occupying process, relatively well-defined, originating from the right adnexa, with a mixed component (tissue and fluid), measuring 18.2/29/22.6 cm (AP/LL/CC). The described formation is located in the mesogastrium, hypogastrium, flanks, and pelvic area, causing a mass effect on the intestinal loops, ascending colon, and sigmoid colon. Significant abdominal-pelvic fluid accumulation is noted, along with a 3.6 cm umbilical hernia, marked infiltration of subcutaneous tissue. On October 26, 2023, surgical intervention was performed, including total hysterectomy with bilateral salpingo-oophorectomy, greater omentum resection, cholecystectomy, omphalectomy, Douglas and subhepatic drainage, abdominal wall repair, and skin closure, for the intraoperative diagnosis of right adnexal tumor adherent to the small intestine loops and greater omentum, ascites, chronic calculous cholecystitis, adhesive syndrome. The postoperative course was favorable, and the patient was discharged on the 7th postoperative day. Histopathological examination revealed right ovarian fibroma, uterine leiomyoma without atypia, and chronic cholecystitis.
Discussions: The association of ovarian fibroma, ascites, and hydrothorax is termed Demons-Meigs syndrome. The association of ovarian fibroma solely with hydrothorax or solely with ascites is called pseudo-Meigs syndrome. Ovarian fibroma accounts for 2-5% of surgically removed ovarian tumors. The preferred treatment is surgical intervention.
Conclusions: The surgical treatment of the patient, who underwent surgery for basal cell carcinoma of the face 15 days ago, resulted in the resolution of symptoms.

CORRECTION OF DOUBLE BOUBBLE DEFORMITY USING FAT GRAFTING AND CAPSULAR SCORING-A CASE REPORT.

First author: Stefania Todea

Coauthors: Andreea Șușca Dora Denisa Avram

Coordinator(s): Lecturer Dinu Dumitrașcu

Keywords: Double bubble deformity capsular scoring fat grafting surgical intervention

Introduction: The double bubble deformity is a rare but unpleasant aesthetic complication in breast augmentation surgery. Due to the persistence of the very well accentuated inframammary groove, the appearance of the breast gives the impression of the existence of two bumps separated by a fold.
Case Report: The use of techniques to correct this deformity, is to improve the appearance and avoid further complications. As a case study, we will have a thirty-four-year-old female patient, who, after breast augmentation with round implants, presented at the clinic with a double bubble deformity in the lower and lateral quadrant of the breast. The appearance of the breast was with two growths delimited by a deep fold which disturbed the patient from an aesthetic point of view.
Discussions: The clinical examination , highlighted the existence of an asymmetric contour of the breasts and the exacerbation of a visible fold that separates the two inflamed tissues. For the correction of this case, which took place nine months after the primary surgical intervention, it was decided to perform a scoring at the capsular level, which consists in releasing the constrictive fibrous tissue and facilitating the optimal positioning of the breast implant and then grafting own fat to fill the visible fold on the inferolateral face of the breast. The post-operative result was satisfactory, obtaining a significant improvement in the contour and the symmetry of the breasts. The double bubble deformity completely disappeared at the six-month post-operative check-up.
Conclusions: The presented case report, exemplifies the importance of the combined techniques of capsular scoring, to relax the ligaments of the inframammary fold , fat grafting,  to fill the formed fold, and also the ability of the surgeon to use it appropriate.The surgical intervention is simple, with very low risks and quick recovery for the patient, which offers a very good aesthetic result.

A life of cystic fibrosis: a case report

First author: Ioana-Alexandra Pop

Coauthors: Florin-Alexandru Popa Ioana-Roxana Pop Carla Prodea

Coordinator(s): Assistant Professor Csilla-Eniko Szabo

Keywords: cystic fibrosis Pseudomonas aeruginosa respiratory infection antibiotic resistance

Introduction: Cystic fibrosis (CF) is a multisystemic autosomal recessive disease caused by a genetic defect in the expression of CFTR protein which acts as a chloride (Cl−) channel expressed in the exocrine glands of several body system. The respiratory system and gastrointestinal tract are the principal systems afflicted, but eventually other organs are also impacted, posing a serious risk to life. Drug therapy, intensive physiotherapy, and dietary support are necessary for management. CF represents a complex chronic disease and therefore requires a multidisciplinary therapeutic approach. Due to its genetic cause the disease cannot be treated, but managed, life expectancy having increased over the later years.
Case Report: We present the case of a 16-year-old boy that was first admitted to our hospital at the age of 2 months for an episode of intestinal occlusion. CF diagnosis was confirmed after a positive sweat chloride test (Cl- concentration of 119 mmol/l) and after the genetic analysis that confirmed the homozygous delta F508 genotype. Since the age of 6, he had frequent pulmonary exacerbations, the colonization with Pseudomonas aeruginosa being confirmed. Because of the recurrent acute respiratory tract infections 3 years later adenoidectomy was performed. The most recent evaluations revealed that in addition to the presence of pancreatic insufficiency he also developed chronic liver disease. Currently, he is receiving chronic mucolytic treatment with Dornase alfa, pancreatic enzyme replacement therapy, chronic antibiotic therapy, treatment for the chronic liver disease, supplementary vitamins and modulator therapy for his genetic defect. 
Discussions: Pseudomonas aeruginosa is one of the main microbial species colonizing the lungs of CF patients and is responsible for the decline in the respiratory function. Around 50% of patients with CF develop an infection with Pseudomonas aeruginosa leading to serious complications in some cases. The bacterial antibiotic resistance and the formation of biofilms represent significant challenges for the treatment and can diminish the life quality of the patients. With appropriate aggressive antibiotic treatment, Pseudomonas aeruginosa infection can be eradicated or effectively controlled in CF patients.
Conclusions: Even though CF can result in multisystemic disease, morbidity and mortality are related to severity of pulmonary manifestations. The survival rate beyond childhood stages in CF patients has increased. This rise can be attributed to improved diagnostic techniques, early recognition of the disease due to the newly introduced screening methods, and the introduction of modulator therapies. 

Management of GIST duodenal tumor with a single hepatic metastasis

First author: Maria Melisa Morar

Coauthors: Teodora Ioana Mustea Șerban Nistor Ada Mihaela Muntean

Coordinator(s): Lecturer Răzvan Alexandru Ciocan

Keywords: GIST hepatectomy molecular therapy

Introduction: Gastrointestinal stromal tumor (GIST) is the most common sarcoma located in the gastrointestinal tract and derives from the interstitial cell of Cajal lineage accounting for 80% of all such GI tumors, and 1 to 3% of all gastrointestinal malignancies. GIST cells highly rely on KIT signal pathway.
Case Report: We report a case of a 54 year old female complaining of pain in the right hypochondrium with posterior irradiation, of increased intensity. The patient was operated in 2014, of a gastrointestinal stromal tumor (GIST with reduced mitotic activity), without neoadjuvant treatment. CT of the abdomen reported a large tumor (20/18 cm) in the right liver lobe. Right hepatectomy and cholecystectomy was performed. Intraoperatively a breach in the middle suprahepatic vein and aspiration occurs. The incident was not followed by complications, the patient did not develop gas embolism. Postoperative evolution was favourable until postoperative day 4 when the patient developed hepatic encephalopathy. Histopathology revealed a 23.5/18.5/9.5 cm liver resection specimen, with deformed capsule and numerous nodular formations of whitish color with brown areas. Adjacent to the tumors formation, satellite nodules were present, with the same appearance as the tumor formation. Microscopic examination of macroscopically described nodules revealed a mixed epithelioid and spindle-shaped pattern. The nodules also compressed adjacent liver tissue, did not extend beyond the liver capsule and did not invade the resection margin. The immunohistochemical profile of tumor cells was as follows: C-kit focal positive. Treatment involved radical surgical resection and adjuvant targeted molecular therapy - TKIs (tyrosin kinase inhibitors): Imatinib and Sunitinib. 
Discussions: Malignant GISTs are rare tumors that account for a small percentage of the gastrointestinal neoplasms. The most common primary site is the stomach (60%–70% of the cases), while 20%–30% of the cases are located in the small intestine. Liver metastases occur in 2 out of 3 cases. The curative intent is the complete excision of the tumor, with a clear margin. The risk of malignancy and prognosis depends on the tumor size, mitotic rate and the site of origin. It has been shown that molecular targeted therapy using tyrosine kinase inhibitors like Imatinib and Sunitinib (for CD117 mutations) increase the overall survival.
Conclusions:  To conclude, GISTs are rare tumors that account for a small percentage of gastrointestinal neoplasms. These tumors require a multidisciplinary approach and postoperative targeted molecular therapy. Further research is needed in order to improve prognosis.

Familial hypercholesterolemia, a silent condition complicated with a myocardial infarction at a young age

First author: Nicoleta Hanganut

Coordinator(s): Medical Doctor Diana Roxana Opriș

Keywords: familial hypercholesterolemia coronary heart disease myocardial infarction young

Introduction: The coronary artery disease (CAD) is one of the most frequent causes of death worldwide, with an increasing prevalence. Familial hypercholesterolemia (FH) is among the most common causes of myocardial infarction at a young age (<35 years) ,defined as a group of inherited genetic defects that predispone to accelerated atherosclerosis, associating an increased risk of premature cardiovascular complications.
Case Report: We present the case of a 29-year-old male patient hospitalized in emergency conditions with continuous retrosternal and increased intensity pain of constrictive character, unresponsive to NTG or morphine. The 12-lead electrocardiogram revealed RS, minor BRD, Q waves in V1-V3, ST-segment elevation in V1-V2, aVR and depression in V5-V6. The medical test report shows high cardiac enzymes (CKMB 57-71, TnI 481-1724.8). Transthoracic echocardiography revealed LV with defective systolic function (EF 30%), hypokinesia antero-posterior SIV, akinesia apex and anterior wall. The patient is diagnosed with anterior Killip class IV AMI . The trivascular coronary disease with acute thrombolytic occlusions and subocclusive stenoses of variable degrees - ADA curvature II, ACD segment II, OM II-III ostial and proximal is detected on coronary angiography.The lesions are addressed serially, practicing thromboaspiration and implantation of 3 pharmacologically active stents at the segments II-III of ADA and curvature II of ACD, without periprocedural complications.In addition, the patient's mother was also diagnosed with coronary disease at a young age. The lipid profile report a total cholesterol of 373 mg/dl; LDL 307mg/dl and HDL 49mg/dl. Taking into account the diagnosis of AMI at a young age, the heredo-collateral antecedents and changes in the lipid profile, the suspicion of familial hypercholesterolemia is draw and testing begins to confirm the diagnosis.
Discussions: The prevalence of FH cases is increasing, however, it continues to remain underdiagnosed and undertreated. FH patients have high levels of atherogenic particles :LDLc and lipoprotein a, since birth, so early diagnosis is vital for patient management. According to the Dutch Lipid Clinic diagnostic criteria for FH, the index case amounts to a total of 8 points. Is suggested a more thorough evaluation of the lipid profile and genetic testing for the most frequent mutations: LDLR, APOB, PCSK9.
Conclusions: FH predispone to premature coronary heart disease, often myocardial infarction being the first manifestation of the disease. An early detection, aggressive treatment, with a strict reduction of LDL are part of the cornerstone of FH.

Ocular complications of obstructive sleep apnea: a literature review

First author: Mihaela Coșpormac

Coauthors: Vasile Vlad

Coordinator(s): Professor Alexandru Corlăteanu

Keywords: Obstructive Sleep Apnea Syndrome Eye complications Eye disease

Introduction: Obstructive sleep apnea syndrome (OSA) is characterized by intermittent upper airway collapse during sleep in obese patients, being a severely underdiagnosed multiorgan disorder. Although the impact of OSA on cardiovascular morbidity is well documented, ocular complications remain an uncertain topic. Eye diseases, taking into account the important cause of the reduction of the quality of life and disability, are a current modern problem of the society.
Case Report: OSA has been identified as a significant risk factor for various eye disorders, including glaucoma, non-arteritic anterior ischemic optic neuropathy (NAION), central serous chorioretinopathy (CSC), retinal vein occlusion, keratoconus, and diabetic retinopathy. The prevalence of these conditions among OSA patients is documented to be considerably higher than in the general population. While some studies indicate a link between OSA and these eye conditions, other research contradicts this association. Ocular diseases can develop in the presence of conditions that reduce ocular blood flow independently of OSA, such as obesity, diabetes, and hypertension. Nevertheless, positive outcomes have been observed with CPAP treatment in patients with glaucoma, NAION, CSC, and diabetic retinopathy.
Discussions: The pathogenic mechanisms involved in the deterioration of the eye are uncertain, however, studies suggest that ophthalmological lesions may occur indirectly, secondary to systemic cardiovascular and metabolic damage, but also through direct pathways. The eyeball is heavily vascularized by the basin of the internal carotid artery. Imbalance of vasoactive substances, oxidative stress, inflammatory cytokine activity and disruption of the blood-retinal barrier will corrupt the integrity of the optic nerve and retinal layers. Intermittent hypoxia will induce hyperactivity of the sympathetic nervous system with the onset of vascular autonomic dysfunction. These phenomena can alter cerebral and ocular circulation, especially during the night, with deregulation of ocular perfusion and increased intraocular pressure.
Conclusions: While the connection between OSAS and eye disease remains subject to debate, recognizing the potential for this association can assist clinicians in delivering holistic care to their patients. Encouraging increased vigilance for ocular symptoms in individuals with sleep apnea is crucial to prevent vision-related complications. Further research should delve into the underlying pathological mechanisms that predispose sleep apnea patients to ocular conditions. Advanced noninvasive technologies like optical coherence tomography and optical coherence tomography angiography hold promise in enhancing our understanding of retinal structures and elucidating the ophthalmic implications of OSA.

Clinical and paraclinical features in the evolution of Epstein Barr virus infectious mononucleosis in children

First author: Vasile Vlad

Coauthors: Mihaela Coșpormac

Coordinator(s): Associate Professor Ludmila Bîrcă

Keywords: Epstein Barr Virus Infectious mononucleosis Children

Background: Infectious mononucleosis is a contagious illness primarily triggered by the Epstein-Barr virus (EBV), accounting for 80-90% of cases. Particularly among children under the age of 5, symptoms are mild or even absent, while adolescents and young adults (in about 50% of cases), typically experience fever, sore throat, lymphadenopathy, headache, skin rash, and hepatosplenomegaly, with liver inflammation occurring in about 80% of cases.
Objective: Evaluation of the clinical-evolutionary and laboratory characteristics of infectious mononucleosis.
Material and Method: This descriptive observational study analyzed 41 patient observation sheets from the Municipal Clinical Hospital for Contagious Children in Chisinau, during the year 2022.
Results: The age distribution within the studied group showed that preschool children accounted for 19 cases (46.3%), schoolchildren (aged 7-14 years) for 15 cases (36.7%), and teenagers (15-18 years) for 7 cases (17%). Boys constituted 56%, while girls - 44% of the total. The annual distribution of cases was relatively balanced. Clinical manifestations included fever in 40 children (97.2%), odynophagia in 37 (90.2%), nasal obstruction and nasal voice in 25 (61%), polyadenopathy in 33 (80.2%), hepatomegaly in 38 (92.7%), and splenomegaly in 22 (53.2%). Purulent tonsillitis was present in 3 cases (7.3%), while skin rash occurred in 4 cases (9.8%). Outpatient treatment with amoxicillin was initiated in 8 cases (19.5%). Hepatitis was diagnosed in 31 cases (75.6%). Ultrasonography examination revealed hepatosplenomegaly in 27 cases (65.8%) and mesadenitis in 3 cases (7.3%). Laboratory findings showed leukocytosis in 31 cases (75.6%), lymphomonocytosis in 33 cases (80.5%), and presence of atypical lymphocytes in 27 cases (65.8%), with elevated erythrocyte sedimentation rate (ESR) in all cases. Primary EBV infection was serologically confirmed in 19 cases (46.3%) and mixed infection with EBV and CMV in 7 cases (17%). The disease presented as average form in 8 patients (19.5%) and severe in 33 patients (80.5%). Patients showed improvement upon discharge, although hepatosplenomegaly persisted in 28% and hypertransaminasemia in 54% of cases. Treatment involved detoxification therapy, antibiotics, hepatoprotective agents, interferon, desensitizers, and vitamins. Corticosteroids were given to 27 patients (65.8%). The average hospital stay was 10 days.
Conclusions: Infectious mononucleosis continues to pose a health challenge due to the absence of etiological treatment. Asymptomatic excretion of the virus contributes to the spread of the infection among children, despite its low contagiousness. Upon discharge, most cases still have cytolysis syndrome and hepatosplenomegaly, needing close outpatient care.

The frequency of Bolton discrepancy in different types of dental malocclusions in a Central Romanian demographic sample

First author: Diana-Maria Matei

Coauthors: Teofana Amarie Ana Guștiuc Daniela-Maria Vizitiu

Coordinator(s): Lecturer Manuela Chibelean

Keywords: Anterior Bolton index Total Bolton index Malocclusion Central Romanian population

Background: Bolton recognised the need of maintaining a balanced connection between teeth in the same arch and between arches. His investigation focused on the ratio of the mandibular and maxillary teeth's total mesiodistal widths and came to the conclusion that a precise number for these ratios must exist in order to establish an optimal occlusion. The 'Bolton Index' is a standard research instrument used to illustrate tooth size disparities and indicate the types of dental corrections required to achieve the optimal occlusion.

Objective: The aim of this research is to investigate any potential correlation between the evaluated Bolton discrepancies and the presence of dento-maxillary abnormalities. Material and Method: In total, 100 models from patients were included (50 males and 50 females) containing samples from all categories of malocclusion (Class I–38 models, Class II/1–19 models, Class II/2–33 models, Class III–10 models) before receiving any orthodontic treatment. By using the calculation formulas, the anterior Bolton index and the total Bolton index were determined for each model by measuring the mesio-distal diameter of the six maxillary and mandibular anterior teeth and the mesio-distal diameter of the twelve maxillary and mandibular teeth (from first molar to first molar). They were then separated into classes, and one-sample t-Student’s test was employed for the statistical analysis.  Results: The findings showed that among the subjects with class II/1 (anterior p=0.046, total p=0.039), class II/2 (anterior p=0.000000123, total p=0.004), and class III (anterior p=0.000313, total p=0.00000217) of malocclusion, there is statistical significance (p<0.05) for both the anterior and total Bolton indexes. In contrast, we found that the anterior and total Bolton indexes of the participants included in class I of malocclusion do not have a statistically significant relationship (p>0.05) (anterior p=0.071, total p=0.932). 
Conclusions: Based on the results, the participants who have dental malocclusions also exhibit a Bolton discrepancy. This suggests that the Bolton indicators have an impact on the incidence of malocclusions in addition to other etiological factors. As a result, the Bolton analysis has diagnostic significance and needs to be taken into account when creating a treatment strategy.

The relationship between color, aesthetic perception, and the modification of incisor inclination

First author: Andrei Nenec

Coauthors: Moldovan Teodor - Andrei

Coordinator(s): Associate Professor Eugen Bud

Keywords: color perception torque smile

Background: The smile, one of the most remarkable characteristics of the facial physiognomy, has a great influence on the social perception. The color is a basic component of the dental composition.
Objective: This study evaluates the coloristic parameters and esthetic perception regarding the changes brought about by dental inclination.
Material and Method: The studied sample consisted of 50 students with complete dentition and no lesions in the upper frontal group. Standardized lighting and positioning conditions were created for each subject. At skin level, the Frankfurt plane was marked. The neutral position of the patient's head was determined, chosen as the reference position (p0): the Frankfurt plane (0 degrees) and the bipupillary line parallel to the ground. To simulate orthodontic torque, the subject was asked to tilt their head posteriorly (+15 degrees) and then anteriorly (-15 degrees) relative to the reference position p0. The Frankfurt plane was adjusted to correspond to the markings for to these degrees, resulting in two new positions, p+15 and p-15. Macro intraoral photographs corresponding to the three head angles (p0, p+15, p-15) were taken using a digital camera stabilized with a tripod with a three-dimensional rotating head and height adjustment. The photographs were imported into Adobe Photoshop for color analysis. Digital measurements were made in the CIELAB color space, which distinguishes color differences using three parameters (L*,a*,b*) and correlates them with the human eye's visual perception. The reference point was the middle of the vestibular face of the upper central incisor. The numerical values of color changes were compared using statistical tests in the OriginLab program. For the evaluation of aesthetic perception, an online questionnaire was conducted via Google Forms in which observers selected the most attractive photographs based on color perception.
Results: The statistically significant regressions are as follows: those for the L* values in all three inclinations: anterior(-15 degrees), posterior(+15 degrees), total(-15, +15 degrees), as well as for the a* value (+15 degrees) and the b* value (-15, +15 degrees). With the head tilted anteriorly, the central incisors are retruded and appear darker and more yellowish, whereas with the head tilted posteriorly, the central incisors are protruded and appear brighter and more greenish. The values remain unchanged for the rest of the parameters. Following the questionnaire, 95% of the observers preferred the pictures in which the central incisors appeared brighter.
Conclusions: Orthodontic treatments involving the application of torque forces to the upper incisor group produces changes in color perception.

PERIPARTUM HYSTERECTOMY FOR SEVERE MATERNAL OUTCOMES – THE LAST FRONTIER

First author: Ioana Marta Melinte

Coauthors: Octavia Misaras Marian Andrei Melinte

Coordinator(s): Professor Lucian Puscasiu

Keywords: Postpartum hysterectomy Obstetric haemorrhage Severe maternal outcome

Background: Obstetric hysterectomy is performed as a life-saving intervention in cases of potentially lethal obstetric complications when other medical or surgical conservative treatments fail. Post-partum hysterectomy is also a valuable indicator used to assess and analyze severe maternal complications.
Objective: The main outcomes were the prevalence and indications of peripartum hysterectomy. Additionally, we compared the prevalence of peripartum hysterectomy between women giving birth vaginally and by cesarean section, and between women giving birth with and without previous cesarean section. 
Material and Method: We performed a descriptive, multicentric study among women who underwent peripartum hysterectomy for severe maternal complications. Data were retrospectively collected from six academic maternity units from different Romanian geographic regions. We included hysterectomies performed from 24 gestational weeks up to 42 days postpartum for severe obstetric complications. 
Results: During the five-year collection interval (1 Jan 2019-31 Dec 2023) a total of 231 post-partum hysterectomies were performed, from a total of 88932 deliveries recorded in six academic maternity units in Romania. The prevalence of post-partum hysterectomy was 26/10000 deliveries (95% CI: 14,41-38,39). We noted important variations across centers, ranging from 14/10000 to 46/10000 deliveries. No maternal death associated with post-partum hysterectomy was identified in our cohort. The lowest post-partum hysterectomy rate was registered in the center with the lowest cesarean section rate. The primary reasons for hysterectomy were post-partum uterine atony refractory to medical and obstetrical management and placental adhesion pathology, respectively. National databases from several European countries reported a much lower prevalence of post-partum hysterectomy (5,2 per 10000 deliveries, ranging from 2,6 in Denmark to 10,7 in Italy). However, it is difficult to translate our findings from six tertiary centers to the entire landscape of Romanian maternity centers, nationwide. 
Conclusions: Despite the availability of national guidelines on postpartum hemorrhage, we detected important differences across academic settings in performing peripartum hysterectomy. The frequency of peripartum hysterectomy is likely to increase as a result of the growing number of cesarean deliveries and subsequent associated placental pathology. To better understand the complex relationship between post-partum hysterectomy rate and maternal outcome we became part of a Multicountry prospective case-control population-based study on hysterectomy -a prospective population-based case-control study in 12 countries in Europe and Africa.  

Abdominal septic shock associated with pneumorrhachis

First author: Maria-Cristina Ureche

Coauthors: Adelina Alexandru

Coordinator(s): Assistant Professor Butiulcă Mihaela

Keywords: Pneumorrhachis Entero-mesenteric infarction Septic shock E. coli

Introduction: Pneumorrhachis is a very rare phenomenon characterized by the presence of spinal air in the extradural or intradural space, the pattern of appearance following traumatic/non-traumatic events.
Case Report: A 67-year-old male was brought into the emergency department in a hypotensive, hyperglycemic state with a GCS of 3 points. He had no history of trauma and no clinical records of comorbidities. Blood work revealed metabolic acidosis, thrombocytopenia, hepatic disfunction and hydroelectrolyte imbalances. Paraclinical investigations, such as cranial CT highlighted diffuse bihemispherical cerebral edema, cervical-thoracic-lumbar pneumorrhachis, and imagistic aspect of frontoparietal intergyral pseudosubarachnoid aneurysm. The main diagnosis was cervical-thoracic-lumbar pneumorrhachis, entero-mesenteric infarction, retroperitoneal necrosis with septic collections extended to the right iliopsoas muscle, abdominal septic shock. Advanced support of vitals function was initiated with mechanical ventilatory support, hydroelectric and acid-base rebalancing, positive inotrope support, vasoactive agents, broad spectrum antibiotics. The patient was taken to the surgery room for an emergency laparotomy. Intraperitoneal liquid was collected by peritoneal puncture, reporting the presence of Escherichia coli cultures. Despite various attempts to maintain the patients’ status, he presented several episodes of extreme bradycardia followed by asystole. Unfortunately, the patient was unresponsive to the resuscitation maneuvers and death was declared. 
Discussions: The literature suggests that the most conventionally assumed criteria for pneumorrhachis is represented by traumatic events following pneumocephalus or pneumomediastinum. This case is particular since none of the mentioned symptoms were associated.
Conclusions: Although the current pathology has a rare incidence - 48 cases confirmed according to a study conducted in 2021 – and it is usually related to trauma, this case is distinct from the others since it does not correspond to any of the preestablished criteria that describes pneumorrhachis.

THE IMPORTANCE OF ACTIVE SURVEILLANCE IN DIFFERENTIATED THYROID CANCER – A CASE REPORT

First author: Raluca Andreea Galdău

Coauthors: Iris Furjes Maria Louise Fufezan Emilia-Maria Găitan Maria Mădălina Mariș

Coordinator(s): Professor Ionela Pașcanu , Associate Professor Robert Tiucă

Keywords: thyroid cancer active surveillance therapeutic response endocrine cancer

Introduction: Thyroid carcinoma is the most common type of endocrine cancer, with an increasing prevalence worldwide. Papillary thyroid carcinoma is the most common histological type. It usually has an indolent, slow progressing course, but there are some histological subtypes that can have a more aggressive evolution. Thus, it is important to have a well-established management algorithm for these cases. This case report aims to present the role of active surveillance in papillary thyroid carcinoma with indeterminate post therapeutic response.
Case Report: We present the case of a 35-year-old male, who underwent a total thyroidectomy for a malignancy suspicious nodule of the right thyroid lobe, the histopathological result being papillary thyroid carcinoma with a 20% tall cell variant. After the surgery, the inadequately high serum thyroglobulin (TG) and the whole-body scan that were performed showed signs of remaining thyroid tissue, which lead to the recommendation of radioiodine ablation therapy. After two courses of radioiodine therapy his TG was still higher than optimal, needing further investigations. Thus, a PET-CT was done, showing no signs of recurrence or distant metastases. Having an indeterminate structural and biochemical response, it was decided to undergo active surveillance under suppressive treatment with levothyroxine. During the last two years in which he has been closely monitored, his TG has been decreasing, and he shows no signs of recurrent or metastatic disease. 
Discussions: In the previous years it was considered that an untreated recurrent disease is a progressive condition that invariably harms the patient. Thus, any sign of remnant or recurrent disease needed further treatment, either surgical or not. However, during the last years a new perspective was proposed, termed active surveillance. Most of the studies performed during this period of time suggest that only a minority of patients with indeterminate biochemical or structural response actually develop clinically significant disease and that an aggressive intervention can do more harm than good in these cases. Active surveillance can be used as a key tool in observing these cases and in ensuring a personalized approach for every patient. 
Conclusions: Active surveillance can be an important tool in early identifying a real recurrence and avoiding aggressive treatment in cases that have an indeterminate response after the initial treatment. Every patient should be treated individually, based on their periodically dosing of TG and ultrasound evaluation. 

Comprehensive Management of a Newborn with Heterotaxy Syndrome: A Case Report

First author: Francesca Veronica Grieco

Coauthors: Sven-Hubertus Grasshoff

Coordinator(s): Assistant Professor Mădălina Anciuc-Crauciuc

Keywords: Heterotaxy syndrome annular pancreas dextrogastria duodenal stenosis

Introduction: Heterotaxy syndrome is a rare congenital disorder characterized by the abnormal arrangement of the thoracoabdominal organs along the left-right axis of the body, compared with situs inversus. It has an incidence of 1 in 10.000 live births and it is frequently associated with congenital heart diseases. It is divided into right atrial isomerism with asplenia or left atrial isomerism with polysplenia. Associated intestinal rotation abnormalities need to be investigated. 
Case Report: We report the case of a male newborn, delivered by cesarean section from a full-term pregnancy in a gravida 4 para 2 Rh-negative mother, without anti-D antibodies. The newborn was hospitalized in 2024 at Târgu Mureş Emergency Clinical County Hospital. Prenatally, intrauterine suspicion of heterotaxic syndrome, single umbilical artery, and pyloric stenosis was raised, with pyloric stenosis being denied after birth. The patient weighed 3200 grams at birth and had a positive postpartum adaptation with an Apgar score of 9 at both 1 and 5 minutes. Surgical consultation recommended the initiation of enteral feeding and nasogastric tube maintenance, however high gastric residual volume and emetic episodes persisted. To evaluate the extent of the anatomical abnormalities, imaging investigations such as contrast radiography, echocardiography, transfontanellar and abdominal ultrasound, and CT angiography were conducted. Contrast radiography revealed the presence of the stomach on the right side with persistent contrast substance six hours post-administration, and no radiological signs of hypertrophic pyloric stenosis. The CT angiography highlighted foci of pulmonary consolidation in an infectious context, levocardia, abdominal situs inversus, esophagus, and gastric air distension with fluid at the fundic level, and right paravertebral splenic nodules. Cardiac and abdominal ultrasound revealed the presence of a hemiazygos vein. Surgical treatment was performed evidencing isomerism, D1 duodenal stenosis through vascular compression, and an annular pancreas, with additional intestinal malposition and malfixation.
Discussions: Heterotaxy syndrome is associated with a variety of cardiac and extracardiac malformations. The complex condition of the patient required a multidisciplinary approach, imaging and surgery were performed to correct duodenal stenosis and gastrointestinal abnormalities which have significant consequences and require intervention. 
Conclusions: Given the complexity of diagnosing digestive malformations in newborns, a multidisciplinary approach and imaging studies are required. Prompt surgical treatment and long-term follow-up are of crucial importance in the management of these patients.

Beyond Numbers: Interpreting lab values in ICU-managed COPD exacerbations

First author: Andra-Maria Chelemen

Coauthors: Dragos Hutanu Ionuț-Alexandru Rența

Coordinator(s): Lecturer Eugenia-Corina Budin

Keywords: COPD exacerbations bacteriological suprainfection

Background: Since COPD is a chronic disease, most of the patients learn over time, with regular appointments at their pulmonologist, how to manage their condition and properly administer their medication. Yet, various elements, like infections or environmental factors can trigger this condition and cause exacerbations, some being life-threatening enough to require ICU(intensive care unit) admissions. Certain lab values, presence of a bacteriological suprainfection or the ventilation mode should be thoroughly analyzed to determine the proper management and the survival rate of these patients.
Objective: The objective of this study was to determine if there was a certain correlation between the number of the white blood cells count, the bacteriological agent involved in the suprainfection, the ventilation mode and the survival rate in ICU-managed COPD exacerbations.
Material and Method: We conducted a retrospective study for the period 01/01/2022-30/10/2023. The data was collected from the informatic system used in the Pulmonology Department at the Mures Clinical County Hospital, Targu Mures, Romania. We included all the patients with COPD exacerbations (84 patients) that required transfer from the Pulmonology Department to the ICU in the mentioned time frame. We excluded the patients presenting a secondary diagnosis of the Sars-COV2 virus.
Results: While white blood cell count is a non-specific lab value for COPD patients, a high value can tell that there might be a bacteriological suprainfection in our patient. The mean value of this parameter was 12950mm3, ranging from 5300 to 27800mm3. The highest values were statistically proven to occur in patients that presented Escherichia coli in their bacteriological exam. Regarding the ventilation mode, there was a significantly higher prevalence of oro-tracheal intubation for the patients that had Acinetobacter baumanii(100%), Staphylococcus aureus(100%) and Streptococcus pneumoniae(80%). On the other side, negative cultures were found in patients that only needed a facial mask(38,2%). Regarding the survival rate, patients presenting Acinetobacter baumanii (39,2%) had the highest death rate, while patients with Staphylococcus aureus had the lowest one(2%).
Conclusions: While most of the exacerbations could be managed in the Pulmonology Department by adjusting the medication doses and symptomatic treatment, some of them require ICU-admissions. For those, it is important to quickly intervene and analyse some key lab values in order to determine the management and course of the treatment, since ventilation plays a key role and death occurs more often in patients presenting certain bacteriological agents.

Classification and Prevalence of Dental Surface Defects in Areas of Gingival Recessions

First author: Enrica Muggianu

Coauthors: Antonella D’Andrea Damiano Musilli Alyssa Boothe Eszter Borbély

Coordinator(s): Lecturer Csilla Benedek

Keywords: Gingival Recessions Class Miller Periodontitis

Background: In literature there is a positive correlation between the appearance of gingival recessions and the prevalence of root caries, abrasions and abfractions. This increasing whenever a periodontal disease is present and following some patterns on the patient’s lifestyle. Gingival recession represents a major concern for the patient, especially from the esthetic point of view but also for the symptoms that can be associated. Patients presents every day to the dental office, complaining about recessions therefore it is imperative to study and better understanding this topic
Objective: Study the prevalence of dental surface defects in gingival recessions and categorize them using Miller’s Classification system. As dental surface defects the presence of abrasion, root caries and tartar was taken into consideration.
Material and Method: Determine with a clinical examination the Miller’s Classification for each gingival recession, presence (A) or absence (B) of CEJ (Cemento-enamel junction) and presence (+) or absence (-) of dental surface discrepancy caused by abrasion (step). Four classes (A+, A-, B+, and B-) will be identified on the basis of these variables. The classification will be used on minimum 200 gingival recessions to examine the distribution of the four classes and presence or absence of root carious lesion. Evaluation of patient’s lifestyle and habits will be evaluated through a questionnaire
Results: The majority of the examined cases showed the presence of the CEJ associated with the absence of a step (p=0.0228). The absence of the CEJ without the step it was the most uncommon amongst groups. On first place were situated the gingival recessions of Miller’s Class I (p<0.034) and on the last place were the gingival recessions of Miller’s Class II (p=0.0008).   
Conclusions: There was a higher incidence of the presence of CEJ associated with the absence of a step, while the least common association is the absence of the CEJ without the step. Gingival recessions of Miller’s Class I are the most prevalent in all age groups. The presence of periodontitis has been found positively correlated to the presence of dental surface defects.  

CBCT evaluation of alveolar bone after orthodontic treatment

First author: Antonella D’Andrea

Coauthors: Enrica Muggianu Nicola D’Andrea Damiano Musilli Alyssa Boothe

Coordinator(s): Associate Professor Silvia Pop

Keywords: alveolar bone height orthodontic treatment root resorption CBCT

Background: For years there has been a long debate about the impact of orthodontic treatment on patients' periodontium. The questions to be answered are: is orthodontic treatment indicated for patients with periodontal conditions, does orthodontic treatment exacerbate or alleviate the conditions, what effect does orthodontic treatment have on the alveolar bone? Therefore, it is important to understand the effect of orthodontic forces on the alveolar bone.
Objective: The main aim of this study is to evaluate the height of the alveolar bone at the buccal, lingual, mesial and distal levels of the central incisors, first premolars and first molar and the root length of the central incisors before and after orthodontic treatment. The secondary objective was to compare and correlate these parameters.
Material and Method: Cone Beam Computed Tomographies (CBCTs) before and after orthodontic treatment of 50 patients were evaluated. Pre-treatment (T0) and post-treatment (T1) measurements at Alveolar bone level (ABL)were made by evaluating the distance from the edge of the buccal alveolar bone (B-ABL) to the enamel-cementum junction (CEJ), the edge of the lingual alveolar bone (L-ABL) to the enamel-cementum junction (CEJ), the edge of the mesial alveolar bone (M-ABL) at the enamel-cementum junction (CEJ), distal alveolar bone margin (D-ABL) at the enamel-cementum junction (CEJ) of the central incisor (CI), first premolar (1st PM) and first molar (1st M). For the anterior teeth, B-ABL and L-ABL measurements was taken in the sagittal plane, for the posterior teeth in the coronal plane; for the anterior teeth the M-ABL and D-ABL measurements was made in the coronal plane, for the posterior teeth in the sagittal plane. Measurements for root resorption was taken by measuring the length of the tooth from the cemento-enamel junction (CEJ) to the tip of the central incisor (CI) apex in the four quadrants. These measurements were made in the sagittal plane/cross section. Data was recorded in tables and statistical analysis was performed.
Results: Changes in the alveolar bone level were recorded in the buccal and lingual segment of the incisors. At the level of premolars and molars the changes were less significant. Regarding the length of the incisors from the cemento-enamel junction to the apex, modifications were present in terms of reduction of the total length.
Conclusions: CBCT evaluation is a valuable tool for precise measurements of alveolar bone levels and root length. However precise indication for use of this indication is required.

Specific peculiarities of pregnancy and childbirth evolution associated with diabetes

First author: Savca Dumitru

Coauthors: Zagorneanu Cezar Roșca Daniela

Coordinator(s): Associate Professor Victor Petrov , Associate Professor Corina Iliadi-Tulbure

Keywords: International Diabetes Federation (IDF) Diabetes Mellitus (Type I and II) Gestational Diabetes Diabetic Fetopathy

Background:

Objective: Material and Method: Results: Patient ages ranged from 17 to 44 years, with a mean age of 30.01±6.05 years. Obesity was prevalent in patients with type II DM (84.2%) and GD (70.5%), while it affected 15.1% of those with type I DM. Complications during pregnancy included: decompensation of type I DM in the third trimester (74.0%), often with diabetic angiopathy and neurological changes (75.3%). Pregnancy-induced hypertension occurred more in GD (18.2%). Severe preeclampsia was predominant in decompensated type I DM (15.1%) and type II DM (15.8%), often requiring emergency C-section. Diabetic fetopathy (44.9%) was associated with fetal distress and placental complex changes (23.0%), with two perinatal deaths. Preterm births were frequent (51.9%), often due to fetal or maternal reasons. Vaginal delivery occurred in 29.2% with 7 cases of vacuum extraction. C-section was performed in 70.8% due to diabetes decompensation, severe preeclampsia, fetopathy, or scarred uterus. Labor complications included premature rupture of membranes (16.9%), dystocic labor (15.8%), and fetal hypoxia (6.8%). 
Conclusions:

STUDY ON THE IMPACT OF STROKE ON ACTIVITIES OF DAILY LIVING

First author: Antonia-Elisa-Theodora Dobrescu

Coordinator(s): Lecturer Alexandra-Camelia Bahar , Assistant Professor Patricia-Maria Crișan-Mălăncrăvean

Keywords: stroke, disability, activities of daily living, occupational therapy

Background: Currently, stroke represents a major concern both in terms of public health and medical research, characterized by a sudden disruption of blood flow, which can result from either a blockage or a bleeding within the brain, to certain regions of the brain, resulting in deprivation of oxygen. Like myocardial infarction for the heart, stroke causes local neural dysfunction, causing devastating effects on brain function. This condition ranks significantly in global mortality and morbidity statistics, representing a major cause of disability and death worldwide. Objective: This study's aim was to examine and evaluate the consequences of stroke on the performance of daily living activities. By analyzing these repercussions and identifying the factors involved, the goal was to obtain a comprehensive understanding of the intervention and therapeutic support required for post-stroke patients. Thus, this study aims to make significant contributions to improving management strategies and optimizing the quality of life for individuals affected by this neurological condition. Material and Method: The study was conducted at the Nova Vita Medical Center in Târgu Mureș, between February 2024 and May 2024, with a sample of approximately 25 subjects. The assessment was focused on the activities of daily living of patients, using questionnaires such as the Barthel Scale, modified Rankin Scale, and ADL Index. To assess patients' independence, tests such as the Wolf Motor Function Test and Berg Balance Scale were applied. For this research, we also used the following methods: bibliographic and observational analysis, complemented by data processing using statistical and graphical techniques. Results: Our findings indicate that most subjects experienced a significant decrease in their ability to perform daily tasks, as well as in their level of independence in carrying out these essential activities. Conclusions: Stroke profoundly affects patients' daily living activities and generates a series of damages and repercussions. The aim of our study was to highlight the impact on the daily lives of post-stroke individuals and to underline the effectiveness of therapeutic interventions in addressing these consequences. Occupational therapy and physiotherapy are just a few of the available modalities for alleviating symptoms and facilitating adaptation to post-stroke life. These therapeutic interventions not only provide solutions but also teach patients to manage and live with their new conditions, contributing to improving their quality of life despite the challenges encountered.

First case of paraganglioma associated with de novo SDHD gene mutation in Romania

First author: Carla-Cristina Hora

Coauthors: Gabriel-Ionut Lefter Iustin-Ciprian Hîrțan

Coordinator(s): Associate Professor Andreea Cătană

Keywords: SDHD gene de novo mutation Paraganglioma Pheochromocytoma

Introduction: SDHD is a gene located on the long arm of chromosome 11 that encodes a component of complex II of the respiratory chain. Its germline heterozygous mutations are associated with pheochromocytomas (PHE), hereditary paragangliomas (PGL), gastrointestinal stromal tumors (GIST) and Cowden-like syndrome. Both PHE and PGL are neuroendocrine tumors that originate from the chromaffin cells of the adrenal gland or extra-adrenal (paraganglia). PGL are rare tumors with an incidence of 2-8 cases per million people.  
Case Report: We report the case of a 29 male patient with no significant family history who presented with a palpable ipsilateral neck mass and was firstly presumed to have lymphoma. After he underwent paraclinical procedures (cervical ultrasonography, MRI scan and cervical biopsy), histopathological results invalidated the presumptive diagnosis and confirmed ipsilateral paraganglioma. The germline testing for the hereditary PHE and PGL susceptible genes was performed using NGS and MLPA: MAX, NF1, SDHA, SDHAF2, SDHB, SDHC, SDHD, TMEM127. The result was positive for the heterozygous potentially pathogenic gene c.209G>T on SDHD. The mutation appeared de novo and the recommended treatment was surgical excision. Screening and prophylaxis of SDHD-associated lesions were noted: biochemical measurements of urine and plasma every 6 months (3 years after diagnosis) and then annually; MRI or CT for screening, PET/CT for systemic dissemination suspicion. Genetic counselling was highly recommended.  
Discussions: PHE and PGL are associated with catecholamine secretion. In the presented case, the tumor is non-secretory and as a result, the patient is asymptomatic; but has a risk of 50 % transmitting this mutation to his descendants considering the autosomal dominant inheritance pattern. Malignant PGL are often linked to SDHB mutation, while the ones associated with SDHD mutation are usually benign. Anasuya Guha et al. (2023) documented that predisposition to malignancy is about 1-3 % in SDHD mutation patients with a hereditary background. Malignant PGL could benefit from tyrosine kinase inhibitor therapy, as Yue Zhou et al. (2022) reported that more than 80% of patients with metastatic PGL achieved disease control after this treatment (p<0.05). In our particular case, molecular therapy is not taken into consideration.
Conclusions: Paraganglioma associated with a heterozygous SDHD gene mutation is usually an asymptomatic benign condition, so patients find it hard to accept the risk of transmitting this disease to descendants. Screening methods and genetic counselling are very important and should be considered a must in matters of prediction, prior management and prophylaxis.  

The Deceptive Nature of Antral Gastric Ulcers in Alcoholics: A Case of Benign Pathology Among Malignancy Suspicion

First author: Evelyn Janette Bran

Coauthors: Ioana-Maria Bloj Aura-Maria Voica

Coordinator(s): Assistant Professor Paul Grama

Keywords: ulcers alcohol malignancy

Introduction: Ulcers are localized lesions found in the gastrointestinal tract or on the skin, characterized by the loss of tissue integrity alongside inflammation. They result from various factors including compromised blood supply, elevated emotional stress, H. pylori infection, excessive acid production, or prolonged use of NSAIDs. Appearing as open sores or wounds, ulcers cause symptoms such as pain, bleeding, and discomfort. Research indicates a significant association between active H. pylori infection and duodenal/gastric ulcers, while alcohol consumption is less frequently identified as a primary cause. However, excessive alcohol intake can damage the stomach lining, leading to erosion and the formation of ulcerous lesions. This case involves a retired male who worked in an oil refinery and was admitted to the gastroenterology department with a suspected diagnosis of chronic hepatopathy. Subsequent findings revealed alcohol-induced gastric and duodenal ulcerations requiring further evaluation and management.
Case Report: We present the case of a 59-year-old male who presented at the emergency room with compromised general condition caused by upper abdominal pain (epigastric area). He was admitted to the gastroenterology clinic for further investigations and treatment. Laboratory tests showed negativity for HBV and HCV, along with consistently elevated liver function tests (AST, ALT), high cholesterol levels, hyperlipidemia, thrombocytopenia, and portal hypertension, indicating liver damage. The detailed medical history highlighted a toxic work environment and chronic alcohol consumption, averaging 4-5 alcohol units/day over the past 30 years. Upper digestive endoscopy revealed ulcerative lesions in the duodenum and stomach, from which biopsies were subsequently taken to investigate the possibility of neoplasia.
Discussions: The presence of ulcers in patients with chronic alcohol consumption requires careful attention due to the increased risk of neoplasia associated with prolonged ethanol exposure. Additionally, exposure to a toxic work environment may further increase the risk of malignancy. Antral cancers can be challenging to evaluate macroscopically during endoscopy due to their often extraluminal expansion. Fortunately, biopsy results for our patient indicated chronic inflammation without suspicious histology.
Conclusions: This case highlights the unique interpretation of gastrointestinal ulcers in the patient, not caused by predisposing factors but rather by the consumption of pure alcohol, resulting in chronic liver damage. While the NHS suggests that alcohol consumption may exacerbate symptoms of preexisting stomach ulcers, the sequence of events leading to ulcer development remains unclear. It is uncertain whether the ulceration was caused by known determining factors or by excessive alcohol consumption compromising the integrity of the stomach and duodenal mucosal barriers.

PNEUMOCOCCAL VACCINE- A NEW OVERVIEW OF S. PNEUMONIAE PROPHYLAXIS

First author: Ioana-Maria Bloj

Coauthors: Evelyn Janette Bran

Coordinator(s): Lecturer Edith-Simona Ianoși , Lecturer Remus Sebastian Șipoș

Keywords: S. pneumoniae vaccine questionnaire

Background: The leading cause of death regarding lower respiratory tract disease is known to be pneumococcal pneumonia, grossing a 1,2 million deaths annually. S. pneumoniae is a Gram-positive coccus, usually found as diplococcus, and naturally inhabits the oropharynx. After colonization, it can expand to the lungs, sinuses, or middle ear. In the view of the continuous curiosity and misconstruing surrounding vaccines nowadays, the burden of informing and educating the non-medical community falls on primary healthcare workers. Objective: The aim of the study is to highlight the perception of the primary healthcare workers over how the national immunization program against pneumococcal infection is being perceived by the population, also including the hurdles that the program may face. Material and Method: The study was based on a survey of 32 family physicians attending a symposium on a separate matter than the one being surveyed, so that there isn’t non-external information that may influence. Out of the 32 physicians 19 practice in the urban area, whereas 13 in the rural one. The survey touched on issues regarding the aspects that may dissuade the patients in the risk group in accessing vaccination, and also the personal view of the professionals on the vaccination, especially after being compensated. Results: 62,5% of the practitioners questioned were able to identify all the risk categories that fit the program criteria. Out of the high-risk categories that beneficiates from the program, the one that accessed the vaccine the most are the ones suffering of chronic respiratory disease, with a stagnantly 78,1%. Regarding the reasons that determine the patients not to get vaccinated 68,8% have evoked the fear of side effects. The age group that accesses the vaccination the most have been reported to be the elderly population with an 81,3%. 53,1% of them consider that the immunization rates have improved after the program implementation, and 81,3% point out the insufficient mediatization of the program. Conclusions:  By improving the population level of information, we could increase the vaccination rates. The target area that needs to be addressed are the misinformation regarding side effects.

Hemi-clamshell approach for bilateral mediastinal goiter with severe tracheal compression

First author: Luca-Mathew Epuras

Coauthors: Alexandra Caziuc Ioana-Medeea Titu Florin Teterea Cîrjan Teodora-Gabriela

Coordinator(s): Medical Doctor Emanuel Palade

Keywords: Mediastinal Goiter Mediastinal tumor Hemi-clamshell incision

Introduction: Mediastinal goiters are a rare type of thyroid enlargement which in the majority of cases represents the extensions of a cervical goiter through the thoracic inlet into the mediastinum. True mediastinal goiters originating from ectopic thyroid tissue are extremely rare. The evolution of mediastinal goiters typically spans across decades with some patients remaining asymptomatic for years. The main symptoms of large mediastinal goiters are related to compression of mediastinal structures, especially the trachea. The treatment of choice consists in total surgical excision of the cervical and mediastinal components, which in some cases impose a combined approach (cervicotomy and sternotomy). The necessity for more extended approaches like hemi-clamshell is an extreme rarity. Our case report presents the particularities and surgical technique of this approach.
Case Report: A 60-year-old female patient presents with progressive dyspnea and stridor almost 15 years after surgical removal of the right thyroid lobe. On CT scan a large left thyroid lobe and two mediastinal paratracheal masses with severe tracheal compression and narrowing were exposed. A benign goiter was confirmed by ultrasound guided needle biopsy. The patient was evaluated and planned for left thyroid and mediastinal mass resection in our thoracic surgery clinic. In order to remove all lesions using one approach and a single stage procedure, a cervicotomy extended by a right sided hemi-clamshell incision in the 4th intercostal space was necessary. For better exposure, the right thymic lobe including its superior horn was removed and the right pleural cavity was opened. The intra and postoperative courses were uneventful.  
Discussions: Mediastinal goiters account for approximately 10% of all intrathoracic masses and represent roughly 8%-19% of all thyroidectomy cases. Affected are mainly patients older than 50 years with a higher proportion of 3:1 found in women. Surgical resection of the thyroid gland including the mediastinal component is mandatory, in cases with severe tracheal obstruction even an emergency procedure. The majority of mediastinal goiters (about 95%) can be removed through cervicotomy, but large masses impose extended approaches including partial or total median sternotomy. With accurate surgical technique, the postoperative complications are rare, consisting mainly in injuries of the recurrent nerve, bleeding and tracheomalacia and the prognosis after resection is excellent. 
Conclusions: Extended surgical approaches such as cervicotomy associated with hemi-clamshell represent the best option for large mediastinal bilateral goiters localized both in the anterior and visceral compartment of mediastinum and are optimally addressed in cooperation with thoracic surgeons experienced in mediastinal surgery.

Biologic therapy for ulcerative colitis: certified success or further hassle?

First author: Aura-Maria Voica

Coauthors: Evelyn Janette Bran

Coordinator(s): Professor Daniela Dobru , Assistant Professor Lavinia Andrada Matei

Keywords: IBD Ulcerative colitis Infliximab Clostridium difficile

Introduction: Inflammatory bowel disease (IBD) is a chronic idiopathic inflammation involving the gastrointestinal tract. Its two main components are ulcerative colitis (UC) and Crohn disease (CD). The immunological pathogenic substrate interacts with the microbiota and environmental factors in genetically susceptible individuals, with a peak incidence in patients aged 25-35. Lesions in UC only involve the colon, usually the left side, with continuous inflammation limited to the mucosa. Associated extraintestinal manifestations such as arthropathies, erythema nodosum or cholangitis are not uncommon.
Case Report: We present the case of a 27-year-old woman who was diagnosed in 2020 with left sided ulcerative colitis and is on biologic therapy with an anti TNF alpha agent (Infliximab) since 2023. This patient comes into our clinic having lost 5–6 kg of weight in the previous month, 2-3 bloody stools a day and spontaneous rectal bleeding. Additionally we found pretibial lesions, oral cavity erosions and knee discomfort. Her medical history reveals multiple Clostridium difficile infections in 2022 treated with different combinations of Vancomycin and Metronidazole.
Discussions: When managing an IBD patient, the current guidelines agree that “step up therapy” is preferred to “step down therapy”. First line agents used for inducing remission include 5 -ASA drugs and corticosteroid medication. Due to clinical progression treatment with the immunomodulator Azathioprine is started following the eradication of Clostridium difficile. In March 2023, erythema nodosum, joint damage, clinical decline, and fecal calprotectin levels of 731 mcg/g led to the introduction of anti TNF alpha biologic therapy. Our patient returns a year later with a deteriorated clinical presentation, higher inflammatory markers (CRP 3.15 mg/Dl, ESR 164mm/h) and fecal calprotectin values of 1680 mcg/g. We conducted stool tests to rule out the potential causes of infectious colitis, and every test produced a negative result. To assess the extent of the colitis we performed a colonoscopy that described continuous colonic lesions, from the caecum to the rectum, congested, friable mucosa exhibiting bleeding upon air insufflation, multiple erosions and a few inflammatory polyps. After increasing corticosteroid doses and managing to improve the general state, the decision to intensify the biologic treatment is considered, to induce remission.
Conclusions: The significance of this case lies in the detrimental evolution despite vigorous therapies, without development of antibodies against Infliximab. The burden this disease imposes especially among young people who have to shape their lives around their illness is something to remember when encountering such cases.

ENDOGENOUS HYPERINSULINISM DUE TO A PANCREATIC TUMOR MANIFESTED AS SEVERE RECURRENT HYPOGLYCEMIA - A CASE REPORT

First author: Zinca-Ioana Chioveanu

Coauthors: Maria Louise Fufezan Smaranda Radu Andra-Maria Chelemen

Coordinator(s): Lecturer Cristina Corina Pop Radu , Assistant Professor Maximilian Gliga

Keywords: endogenous hyperinsulinism insulinoma hypoglycemia

Introduction: An important cause of recurrent hypoglycemia related to endogenous hyperinsulinism is represented by insulinoma, a rare tumor with a low incidence, impacting 1-4 individuals per million of the general population. The hallmark of this condition is an autonomous hypersecretion of insulin, which occurs independently of the normal glycemic control mechanisms. Typically, it results in non-specific neuroglycopenic symptoms and increased sympathoadrenal activity during the hypoglycemic episodes, posing a challenge in diagnosis.
Case Report: This report describes the case of a 66-year-old female patient with recurrent episodes of hypoglycemia, accompanied by various comorbidities including chronic autoimmune thyroiditis, hypertension, dyslipidemia and grade 1 obesity. The patient had been experiencing recurrent episodes of malaise associated with low blood glucose levels (<40 mg/dL) since 2021, with occasional loss of consciousness due to severe hypoglycemia. Initially misdiagnosed as diabetes mellitus type 2, based on a flat oral glucose tolerance test curve, she was treated with Metformin, but discontinued treatment due to persistent symptomatic hypoglycemic episodes. Through meticulous dietary adaptations, the patient achieved control of her early-onset symptoms by unrestricted intake of glucose-rich liquids and foods. Subsequently, the patient was diagnosed with endogenous hyperinsulinism (glucose level of 21 mg/dl during the fasting test, unsuppressed insulin and C-peptide). Abdominal MRI revealed the presence of a cephalic pancreatic nodule, later confirmed to be an insulinoma upon biopsy. The patient underwent surgical intervention for the removal of the tumor and symptomatic episodes improved thereafter.
Discussions: The patient's condition illustrates a typical case of severe hyperinsulinism, that was diagnosed after several years of symptomatic evolution. The patient tolerated the hypoglycemic episodes unexpectedly well, explained by the chronic adaptation of the autonomic nervous system to low glucose levels. Ultimately, the patient was diagnosed with endogenous hyperinsulinism associated with a pancreatic tumor, which was successfully surgically removed. The case also highlights how the possibility of a deceptive appearance, such as a flat OGTT curve in this condition, is misleadingly implying the presence of diabetes mellitus.
Conclusions: Increased awareness to symptoms of hypoglycemia should lead to a prompt evaluation for endogenous hyperinsulinism, which is attributed to a pancreatic tumor in the majority of cases. This condition, if unifocal and surgically accessible, as revealed in our case, can be effectively managed through surgical intervention.

Monomeric C-Reactive Protein and Anti-mCRP Antibodies: Potential Biomarkers of Disease Activity in Systemic Lupus Erythematosus

First author: Karin Groza-Mathe

Coauthors: Sorana Gorea Andrei Calancea Ioana-Alexandra Burghelea

Coordinator(s): Assistant Professor Ylenia Pastorello , Professor Mark Slevin

Keywords: Monomeric C-Reactive Protein Lupus Erythematosus Systemicus Anti-mCRP Antibodies Autoimmune Diseases

Background: Pentameric C-reactive protein (pCRP) is an acute phase protein synthesized by hepatocytes, primarily following expression of the proinflammatory cytokine Interleukin-6 (IL-6), during infection and inflammation. Chronic inflammatory states, such as autoimmune diseases, are characterized by augmented serum levels of pCRP, which is directly reflected in the magnitude of inflammation severity. An exception to this rule is represented by Systemic Lupus Erythematosus (SLE), in which pCRP levels oscillate broadly amongst SLE patients subsets, depending on quiescent or active disease phase and associated manifestations. Dissociation of pCRP to its monomeric subunits, mCRP, occurs upon contact with activated cells and tissues, and has been associated with exposure of new epitopes, neo-CRP. Interestingly, amidst the plethora of auto-antibodies present in SLE, anti-mCRP but not anti-pCRP antibodies have been described in individuals affected by this pathology, therefore, a possible relationship between mCRP, mCRP-antibodies levels, and disease activity is discussed here. Objective: The aim of this study was to assess the association between mCRP, anti-mCRP antibodies levels and SLE activity status.

Material and Method: A search of English literature has been performed on PubMed and Google Scholar. Inclusion criteria for the selected articles consisted of publication between the year 2004 and 2024, and presence of the keywords “monomeric C-reactive protein”, “Systemic Lupus Erythematosus”, anti-mCRP antibodies”, “Autoimmune Diseases”.
Results: A study including 160 patients diagnosed with SLE showed that serum pCRP did not discriminate between active and quiescent disease, however the ratios of mCRP/pCRP reached statistical significance in paired samples, with lower values displayed in active disease as opposed to the dorment state. Furthermore, the mCRP/pCRP ratio was higher during remission. Serially collected sera of 10 patients involved in a prospective control program demonstrated anti-mCRP positivity for 60% of the SLE individuals at flare, whereas all the participants with active lupus nephritis had anti-mCRP positivity at flares. In addition, SLE disease activity index (SLEDAI) scores positively correlated with anti-mCRP levels. A recently conducted study aimed to investigate the prevalence of both pCRP and mCRP on extracellular vesicles (EVs), as the latter are implicated in SLE pathogenesis by exposing nuclear antigens on their external surface, therefore promoting autoantibodies generation. Plasma mCRP+ but not pCRP+ EVs were significantly increased in patients with active SLE state and in anti-mCRP positive participants.
Conclusions: The interrelationship between pCRP and mCRP appears to discriminate SLE activity states. Anti-mCRP antibodies correlated with SLE disease activity, nevertheless, further research exploring their generation by mCRP opsonized EVs and effects are needed.

A CROSS-SECTIONAL STUDY OF THE HORMONAL PROFILE AND COMPLICATIONS OF SUBCLINICAL AND CYCLIC CUSHING SYNDROME.

First author: Maria Louise Fufezan

Coauthors: Andrei Buciuta George-Daniel Buciuta Zinca-Ioana Chioveanu Raluca Andreea Galdău

Coordinator(s): Professor Ionela Pașcanu , Associate Professor Robert Tiucă

Keywords: Cushing syndrome Subclinical Cyclic Intermittent

Background: The prevalence of endogenous Cushing syndrome (CS) is estimated to be between 39-79 cases/million and may be attributed to either autonomous cortisol production by the adrenal gland or excess pituitary or ectopic ACTH secretion. Despite classic endogenous CS being a rare disease, the subclinical and cyclic subtypes are thought to be more widespread due to being clinically less recognizable. Although it is widely known that classic CS is associated with cardiovascular, musculoskeletal, metabolic, and neuropsychiatric complications, less studies detail the prevalence of these comorbidities in subclinical/cyclic CS.
Objective: We aimed to establish the presence of hormonal and metabolic complications in patients diagnosed with subclinical or cyclic CS and furthermore study correlations between these and the associated hypercortisolemia.
Material and Method: The records of patients diagnosed with either subclinical or cyclic CS hospitalized in the Endocrinology Department of the County Clinical Hospital Târgu Mureș between 01/2014-12/2023 were analyzed. Patients with exogenous glucocorticoid use (local/systemic) or diagnosed with PCOS were excluded, reducing confounding errors. Their laboratory findings and accompanying comorbidities/diagnoses were recorded, and statistical tests were performed.
Results: Of 86 eligible patients, 71 had subclinical and 15 had cyclic CS. The majority (76% and 73% respectively) of patients were female. The median age was 64 for females and 54 for males. There was a statistically significant association between males with hypercholesterolemia and subclinical CS (p=0,049). The Pearson coefficient (r) indicated a weak positive correlation (WPC) between serum triglycerides and late-night serum cortisol (LNSC) (r=0,287), moderate positive correlation (MPC) between LDL-cholesterol and urinary free cortisol (UFC) (r=0,348), MPC between erythrocyte count and UFC (r=0,315), WPC between fasting glucose and LNSC (r=0,264), and WPC between leukocyte count and LNSC (r=0,220). Hypertension was frequent in cyclic (80%) and subclinical (81,7%) CS. Diabetes was present in 33,33% of cyclic and 43,67% of subclinical CS patients. 25-OH-vitamin D deficiency was detected in 50% of cyclic and 63,89% of subclinical CS patients. Osteoporosis was present in 13,33% and 28,17% of patients with cyclic and subclinical CS, respectively.
Conclusions: Due to the altered serum parameters and frequent complications of hypercortisolemia seen in subclinical and cyclic CS, it may be worthwhile for clinicians to suspect hypercortisolemia more often before treating comorbidities directly. Screening for CS may lead to identification and treatment of the underlying cause, ultimately facilitating an improved quality of life.

Late-onset congenital adrenal hyperplasia – a low-key differential diagnosis

First author: Iris Furjes

Coauthors: Paula Maria Chirilă

Coordinator(s): Professor Maria Ionela Pașcanu

Keywords: polycystic hyperplasia infertility

Introduction: Polycystic ovary syndrome (PCOS) is a complex endocrine disorder that comprises multiple potential etiologies and clinical manifestations. The diagnosis involves the presence of at least two of the following criteria: clinical and/or biochemical hyperandrogenism, chronic oligo- or anovulation and the ultrasound appearance of polycystic ovaries. Congenital adrenal hyperplasia is a genetic disorder (mostly due to the 21-hydroxylase deficiency) characterized by increased secretion of adrenal androgens. The clinical manifestations depend on the residual enzymatic activity. The non-classical form of congenital adrenal hyperplasia (NCAH) can lead to similar clinical features as PCOS: alopecia, acne, menstrual cycle imbalances and infertility. For its diagnosis, 17-OH-progesterone is measured in early follicular phase, being elevated in NCAH patients.
Case Report: A 31-year-old female patient was diagnosed in 2014 with polycystic ovary syndrome based on the ultrasound appearance and biochemical hyperandrogenism, with the specific hormonal tests performed on the 5th day of the menstrual cycle: testosterone: 79 ng/dl, FSH/LH ratio=1/3. The patient presented with couple infertility, for which multiple ovarian stimulations were performed in 2017 but without obtaining a pregnancy. In 2020, due to weight gain and increased pilosity, she underwent an endocrinological evaluation, with the suspicion of NCAH in the presence of elevated 17-OH-progesterone, with the repeated measurement confirming the diagnosis (17-OH-progesterone: 52.78 nmol/L). Furthermore, 21-hydroxylase deficit was confirmed genetically - compound heterozygote V281L/P453S. In april 2021, the patient obtained a pregnancy through ovarian stimulation treatment with letrozole, menotropin, alpha chorionic gonadotropin and intrauterine insemination. Also, Hydrocortisone was introduced in her treatment but she unfortunately experienced a miscarriage at 4 weeks gestational age. In july 2021, under treatment with metformin, hydrocortisone, letrozol and dydrogesterone another pregnancy occured, but it also resulted in a miscarriage at 9 weeks of gestational age. 
Discussions: Patients with NCAH due to 21-hydroxylase deficiency can achieve pregnancies spontaneously. However, in some cases, treatment with Hydrocortisone may be beneficial. The diagnosis of NCAH is often delayed or missed due to the resemblance to the polycystic ovary syndrome, but must always be taken into consideration. Infertility management is difficult especially since multiple factors have impact on it, since our patient is also a smoker and has obesity.
Conclusions: Infertility, anovulatory cycles and hirsutism are common features of both PCOS and NCAH. Endocrinological evaluation of such women should always include the measurement of 17-OH-progesterone levels in order to exclude NCAH in patients with these clinical manifestations.

Particularities of inflammation in secondary tuberculosis

First author: Prădatu Ana Maria Ionela

Coauthors: Ionuț-Alexandru Rența Dariana Elena Pătrîntașu

Coordinator(s): Lecturer Corina Budin

Keywords: pulmonary tuberculosis neutrophil/lymphocyte ratio inflammation

Background: Tuberculosis (TB) is the leading killer among all infectious diseases worldwide, despite extensive use of the Mycobacterium bovis bacillus Calmette-Guerin (BCG) vaccine. When the host's immune system weakens, the previously asymptomatic dormant bacteria transforms into a transmissible, active state. Neutrophil/lymphocyte ratio seem to be a reliable biomarker to distinguish an active TB from a latent one. 
Objective:   This study's goals included examining the variation in the neutrophil/lymphocyte ratio with smoking status, different types of associated comorbidities, or COVID infection, as well as the variability of this ratio's value in the group of patients analyzed between the time of hospitalization and the time of discharge (after treatment).
Material and Method:   In order to conduct this retrospective study, we gathered the required information from the observation sheets of patients who were treated for pulmonary tuberculosis in the Mures County Clinical Hospital's Pneumology Department between October 2, 2022, and October 2, 2023.  Inclusion criteria: Patients with a diagnosis of pulmonary tuberculosis who have been continuously admitted to the Pneumology/TB Department. Exclusion criteria: Patients who were regularly admitted to the TB Department and Pneumology ward, but whose biohumoral results were not accessible for analysis. After analyzing a database containing 140 hospitalized patients, 105 patients were included in the analyzed group after the criteria for inclusion and exclusion were applied.  Results: The analyzed group consisted of 105 patients, in which the neutrophil/lymphocyte ratio was calculated. The recorded average value of the ratio was 6.92. Elevated values were recorded in the group with associated comorbidities such as cachexia, anemia, and smokinng. The neutrophil/lymphocyte ratio value in patients who associated SarsCov2 infection was 4.34. Among the 105 pacients analyzed, 67 were smokers  . The association of smoking determined an increased value of neutrophil/lymfocyte ratio up to 7.95. The age group over 65 years registered higher values of neutrophil/lymphocyte ratio (7.82). 
Conclusions: The association of comorbidities such as cachexia or anemia in patients with pulmonary tuberculosis has led to much higher values of neutrophil/lymphocyte since admission, which could represent a useful topic in terms of prevention of these risk factors. Smoking is a risk factor that contributes to the increase of inflammation. 

Connecting the Dots: Diabetes as a Risk Factor for Severe Strongyloidiasis

First author: Daniela-Andreea Bondor

Coordinator(s): Assistant Professor Vlad Sever Neculicioiu , Associate Professor Carmen Anca Costache

Keywords: Strongyloides diabetes immunocompetent

Background: Severe strongyloidiasis caused by the parasite Strongyloides stercoralis can manifest in two distinct forms: Strongyloides hyperinfection syndrome (SHS) and disseminated strongyloidiasis. Both can be the result of multiple risk factors with immunosuppression as the underlying theme: usage of immunosuppressive treatments (drugs, irradiation), organ or bone marrow transplantation, coinfection with HTLV-1 or HIV, presence of IRIS, hematologic malignancies, hypogammaglobulinemia, malnutrition or alcoholism. While severe strongyloidiasis has been described in immunocompetent patients with diabetes mellitus, it is still unclear if diabetes can be considered a relevant risk factor for the infection.
Objective: The aim of this comprehensive review is to assess whether diabetes alone can be regarded as a risk factor for the occurrence of severe strongyloidiasis.
Material and Method: A search of the existing literature was conducted in three different databases (PubMed, Web of Science, Scopus) by using two separate search algorithms adapted for each one of them: (strongyloides OR strongyloidiasis) AND diabetes AND (hyperinfection OR disseminated strongyloidiasis); (strongyloides OR strongyloidiasis) AND immunocompetent. The searches were performed on the 27th of February 2024 and yielded a total number of 265 results. Case reports and case report series were selected to further apply the inclusion criteria: coexistence of diabetes mellitus and severe strongyloidiasis without any other risk factor associated with the latter being present. A total of 13 cases written in English were included in the final analysis.
Results: From the total of 13 patients that met the inclusion criteria, 11 (84.62%) were male and 2 (15.38%) were female. The median age for these patients was 61 years (range 31–82 years). The cases mainly originated in Asia (n = 6, 46.15%) with only one case reported in Europe (n = 1, 7.69%) and one in Australia (n = 1, 7.69%). The rest (n = 5, 38.46%) had northern American origin. Most included cases described SHS (n = 9, 69.23%) and only 4 patients (30.77%) presented with eosinophilia. An increased mortality rate (n = 6, 46.15%) was observed, the cause being failure in diagnosing S. stercoralis infection, a delayed diagnosis, or major complications despite starting appropriate treatment. A total of 9 patients (69.23%) were treated with ivermectin, the first-line therapy for strongyloidiasis.  
Conclusions: Based on our findings, we cannot exclude diabetes as a risk factor in the occurrence of severe strongyloidiasis. However, due to limited data, future research is required to further reach a clearer conclusion.

Fulminant descending colon cancer with liver and lung metastases in an asymptomatic patient

First author: Sorana Gorea

Coauthors: Karin Groza-Mathe Mara Constantinescu Sara Murărescu

Coordinator(s): Associate Professor Ligia Bancu , Medical Doctor Venczel Szakac Kinga

Keywords: Colon cancer Lung metastases Liver metastases Cholangiocarcinoma

Introduction:

Case Report:
Discussions:
Conclusions:

Difficulties in diagnosis Chron’s Disease evaluated together with its differential diagnosis: a case-based presentation

First author: Marica Pagano

Coauthors: Eulalia Di Nella Marta Mura Arianna Portulano Niccolò Maria Simeone

Coordinator(s): Lecturer Adina Andone

Keywords: #ChronsDisease #DifferentialDiagnosis #AtypicalHistologicalExam #CeliacDisease

Introduction: One major forms of inflammatory bowel disease (IBD) is recognized as Crohn’s disease (CD), a chronic inflammatory condition with granulomatous inflammation which can affect any part of the gastrointestinal tract; carrying a complex and mixed etiology. 
Case Report: We present a case of a 54 years old male patient admitted with asthenia, fatigue, arthralgia, marked weight loss (20 kg over 2 years), watery diarrheal stools for about 6 months (5-6 soft stools/day), abdominal discomfort and bilateral malleolar edema. Specific investigations were carried out such as colonoscopy, finding out that the mucosa of the terminal ileum was characterized by edema and multiple ulcerations, concludent with a chronic colitis; also the ileo-cecal valve was found presenting edema and non-specific erythema with 2 small ulcers; esophagus was found with class B esophagitis, at the level D2 it showed flattened folds and creped mucosa. Thus the patient had to be subjected to an histological exam: morphological aspect compatible with a chronic duodenitis with reduced/moderate villous atrophy and focal intraepithelial lymphocytosis. Considering the patient’s persistent symptomatology, the imagistic evaluation, the marked weight loss, as well as the serological results which indicate anti-transglutaminase Ig A reactive, adding the endoscopic description, we consider the case as pleading for a gluten enteropathy superimposed on an intestinal inflammatory disease. MRI examination was performed which showed multiple areas of stenosis (>5) on the terminal ileum, small bowel and jejunum, with loss of laminar structure. This together with fecal calprotectin > 845 ug/g, and the initial histopathological result were concludent with Ileal Chron’s Disease.
Discussions: Transmural inflammation of the GI tract is the hallmark of CD with granulomatous features on histological exam. By reporting so, we want to emphasize these atypical features such as the lack of granulomatosis found upon biopsy, added to the presence of a comorbidity such as celiac disease can mislead the diagnosis of Chron’s Disease. The previously described clinical picture could also be indicative of an infection, ruled out by the specific screenings. Considering CD as a final diagnosis, the patient benefited from antibiotic, antimycotic treatment, corticotherapy, amino acids. He was discharged hemodynamically and respiratory stable, with diet and treatment recommendations.
Conclusions: Having seen the difficult path that lead to the conclusion of a Chron’s Disease despite the uncommon findings of the histological exam, we want to emphasize that the positive diagnosis can be established by ruling out possible differential diagnosis and persisting with further examinations combined with the clinical picture.

Thrombocytosis in MDR mixed TB: hematological disease or infectious complication?

First author: Dohotari Diana Maria

Coauthors: Georgian-Vlăduţ Doncean Demenciuc Nicolae Maria Mădălina Mariș Raluca Maria Floca Oprea

Coordinator(s): Lecturer Eugenia Corina Budin

Keywords: tuberculosis hyperuricemia leukocytosis individualized treatment

Introduction: Tuberculosis is one of the most common infectious diseases, generally caused by Mycobacterium tuberculosis. Most commonly, tuberculosis affects the lungs. It is transmitted through the air, through the Flügge droplets. The treatment of tuberculosis is standardized, according to the National Tuberculosis Control Program and according to the antibiogram.
Case Report: Patient aged 43 years, smoker 20 PA withdrawn 5 years ago, without exposure to occupational pollutants, known with secondary nodulo-infiltrative pulmonary tuberculosis, presents himself by appointment, accusing cough with muco-purulent expectorations, predominantly nocturnal and fatiguability. Sputum is collected in order to perform microscopic and bacteriological examination with antimicrobial susceptibility test, which shows the presence of Koch bacillus resistant to Rifampicin. It is decided to hospitalize him for supervision and further treatment. Chest X-ray reveals infiltration of the left hilar lymph nodes and caseous pneumonia of the left upper lobe. The patient presents fibrinogen, PCR, ESR and platelets (606 * 103 / μL) with high values secondary to peritoneal and intestinal tuberculous dissemination, but also a mild secondary anemia (Hb 10 g / dL). Also, uric acid is increased (8.6mg/dL), without any other changes that advocate a rheumatoid condition. The patient was initially treated with Hydrea to correct thrombocytosis, but without an adequate response. Subsequently, this was interpreted as a secondary response due to tuberculosis infection. Culture and antimicrobial sensitivity test are performed from the patient's stool, which reveals a positive result to the tubercle bacillus, resistant to Rifampicin. Individualised treatment with Pyrazinamide 500 mg and Cycloserine 250 mg was initiated. During hospitalization, the patient becomes apathetic and treatment with Serlift is started at the recommendation of a specialist consultation. The evolution of the patient is favorable during hospitalization, hemodynamically stable discharge with appropriate recommendations.
Discussions: The particularity of the case is given by the resistance of bacillus Koch to Rifampicin and the need to implement individualized treatment. Thrombocytosis is a rare complication of tuberculosis, its levels increasing concomitantly with PCR, but improving during hospitalization. Hyperuricaemia with significantly elevated levels (above 110 mg/dL) is a relative contraindication for pyrazinemide administration.
Conclusions: Tuberculosis can present a panel of very complex and variant signs and symptoms, not all triggering mechanisms being fully known. The fact is that they must be discovered early and treated properly to avoid further complications and long hospitalizations.

CORREA CASCADE: the evolution of atrophic gastritis to gastric adenocarcinoma

First author: Lucrezia Sanna

Coauthors: Francesca Rosaria Cannito Federica Frau Federica Menna Sofia Leonardi

Coordinator(s): Lecturer Adina Andone

Keywords: #CorreaCascade #AtrophicGastritis #PrecancerousCondition #GastricCancer

Background: Atrophic gastritis is a chronic inflammatory process that involves the gastric mucosa, resulting in loss of the glandular component. It is categorised into type A atrophic gastritis and type B atrophic gastritis. Type A, autoimmune based, caused by autoantibodies against parietal cells. Type B, results as a consequence of not properly treated acute gastritis induced by Helicobacter Pylori. The stomach is an organ prone to intestinal metaplasia, a reversible process that consists in the conversion of a gastric epithelial area into a wholesome intestinal epithelial area. Nevertheless, it has an increased risk of progression to gastric neoplasia. Indeed, atrophic gastritis is classified as pre-cancerous illness.
Objective: The aim of this study is to analyse the incidence of progression of atrophic gastritis into gastric adenocarcinoma.
Material and Method: The research was conducted through 10 academic articles from scientific databases including American Gastroenterology Association (AGA), Pub Med and Google Scholar, to compare different studies carried out on the correlation between the disease and the possibility of progression to neoplasia. 
Results: The evolution of the disease varies based on its extension and severity. Patients at greatest risk of cancer are those whose inflammation extends to the entire stomach, from the body to the pylorus, and are classified according to two staging systems: OLGA (Operative Link Gastritis Assessment) and OLGIM (Operative Link Gastritis Assessment based on intestinal metaplasia). The evolution of the disease is described through the "CORREA CASCADE". The first step is the development of a chronic mucosal gastric inflammation which, through mechanisms that are not entirely clear, progresses to atrophic gastritis, followed by intestinal metaplasia, which will then differentiate into dysplasia. Dysplasia is classified into grade 1 (mild dysplasia, differentiation of 1/3 of the epithelium), grade 2 (moderate dysplasia, differentiation of 2/3 of the epithelium) and grade 3 (severe dysplasia or carcinoma in situ, differentiation of 3/3 of the epithelium). The terminal stage is the differentiation into gastric adenocarcinoma. The studies highlight that only a small group of patients with chronic atrophic gastritis have a higher risk of developing stomach cancer. The overall annual incidence is 0.1-0.25 %. 
Conclusions: Appropriate identification and surveillance of patients with advanced stages of atrophic gastritis and intestinal metaplasia ensures early diagnosis and reduces gastric cancer mortality.

Mastering Scalp Reconstruction: Unveiling the Potential of Rotational Local Flaps

First author: Eulalia Di Nella

Coauthors: Marta Mura Arianna Portulano Niccolò Maria Simeone Marica Pagano

Coordinator(s): Associate Professor Cristian Trâmbițaș , Medical Doctor Tímea Pap

Keywords: rotational flap scalp reconstruction plastic surgery posttraumatic reconstruction

Introduction: In scalp reconstruction, the utilization of local rotational flap represents a cornerstone in the surgeon’s experience. These techniques offer a versatile approach to scalp defects, ranging from traumatic injuries to oncologic resections. Rotational flaps provide the advantage of utilizing nearby tissue with similar characteristics, ensuring optimal aesthetic outcome and functional restoration. By utilizing the topographic characteristics of the scalp this method guarantees effective wound closure and reduces complications.
Case Report: The aim of this case report is to present the case of a 54-year-old patient, known with a closed head injury. He was firstly operated in the neurosurgical department in 2023 with bifrontal abscess and subdural empyema evacuation, left frontal osteolytic lesion resection and treatment for osteomyelitis with micro abscess formation. He now refers to plastic surgery department with scalp avulsion and bone tissue exposure on the frontal region.
Discussions: The patient is admitted in the Plastic Surgery department for preoperative checkups (cranial CT scan, blood tests, cardiologic and neurosurgical consultation). The scalp's limited elasticity prohibits the direct closure of moderate-sized defects. After adequate preoperative preparation, the following procedures were performed: after the surgical debridement, the size of the defect was assessed, and a flap of matching diameter was outlined next to it. When designing the rotational flaps, it is important to plan for a slightly larger size to accommodate their rotational movement. Careful elevation of the flap within the subgaleal plane is performed, ensuring preservation of the underlying vascularized pericranium. The flap is fixed to the adjacent tissue around the defect and the remaining tissue defect was covered with a split-thickness skin graft (STSG) obtained from the left thigh using a dermatome. The skin graft was attached to the periosteum of the donor site, and a compressive ,,tie-over’’ was applied. Avoiding the complications (hematoma, seroma) an active drainage was used under the local flap. The postoperative local evolution was satisfactory, with no vascular complications regarding the rotational flap and a viable skin graft. At discharge the patient was stable, with no local complications. He left the compartment with the following recommendations: compressive ,,tie-over” dressing for 48 hours, antibiotic therapy, avoiding physical activity and local traumas.
Conclusions: The reconstruction process can be done in a single step surgery, reduces the risk of complications and minimizes scarring. Several publications with 13 month follow up support that this can be particularly important in patients with significant medical comorbidities who cannot tolerate a lengthy operative procedure.

Primary hypothyroidism complicated with massive pericarditis and atherosclerotic carotid artery disease

First author: Alexandra Farkas

Coordinator(s): Professor Alina Scridon , Assistant Professor Dan-Alexandru Cozac

Keywords: Myxedema Pericarditis Pericardiocentesis Atherosclerotic carotid artery disease

Introduction: Primary hypothyroidism occurs after destruction of the thyroid tissue because of autoimmunity,- or medical interventions such as radiation, radioiodine therapy or surgery. Small pericardial effusion is commonly observed in primary hypothyroidism, but massive pericardial effusion with or without cardiac tamponade is rare. This case emphasizes the importance of a rapid and multidisciplinary management of patients with severe, complicated hypothyroidism. 
Case Report: We report the case of a 57-year-old hypertensive, dyslipidemic, female patient, who presented to hospital for stinging chest pain, dyspnea, and lower leg edema. The ECG on admission showed microvoltage in the limb leads and flattened T waves in leads III, aVF, and V2-V3. Echocardiographic evaluation revealed a large pericardial fluid collection, with collapse of right cardiac chambers. Laboratory data showed severe hypothyroidism together with severe hypercholesterolemia and increased liver and myocardial enzymes and D-dimer levels. Pericardial puncture was performed, followed by improvement of symptoms and lack of pericardial effusion recurrence. The patient was started on thyroid hormone replacement therapy. Doppler carotid ultrasound showed bilateral carotid artery stenoses, confirmed at carotid angiography, and right internal carotid artery angioplasty with stent implantation was performed. 
Discussions: This case illustrates the rare association of two severe conditions, massive pericardial effusion and carotid atherosclerosis in the presence of severe dyslipidemia, that guided the physicians towards the diagnosis of severe hypothyroidism.The diagnosis was further supported by the favorable clinical evolution and the absence of effusion recurrence under hormone replacement therapy.
Conclusions: The case underlines the major role that comprehensive patient evaluation and medical reasoning play for establishing a rapid, accurate diagnosis and establishing an adequate, etiologic therapy.

Takayasu arteritis: a rare disease with atypical presentation

First author: Mara-Ioana Someșfalean

Coordinator(s): Medical Doctor Ioana Raluca Dobrota

Keywords: Takayasu tuberculosis stenosis

Introduction: Takayasu arteritis is an uncommon autoimmune disease primarily affecting the aorta and it's major branches, usually seen in young women. While it's classical symptoms include fever, weight loss, and hypertension, Takayasu arteritis can present in atypical ways, leading to a complicated diagnosis.
Case Report: This case involves a 38-year-old female who visited the doctor in 2022 with neck pain, occipital headache, vertigo, and blurred vision, and was diagnosed with C3-C6 cervical discopathy by MRI of the spine. Additionally, the patient had a history of tuberculosis at the age of 16 and is known to have hyperthyroidism, minor valvular insufficiency, and mixed dyslipidemia. The symptoms persisted, making her seek evaluation from a cardiologist in 2023, who identified differences in blood pressure between the two arms during examination (BP left arm: 80/20mmHg, BP right arm: 130/70 mmHg). A Doppler echography revealed tight stenosis in the left subclavian artery and a thoracic computed tomography with contrast was recommended. The CT scan revealed stenosis of the left subclavian artery and involvement of the ascending, arch and descending aorta as well as the left carotid artery. A percutaneous angioplasty with stent placement was performed in July 2023, but restenosis occurred within the stent. A reintervention was performed in February 2024, where drug-eluting balloons were placed and a rheumatological consultation was recommended. A CT angiography was performed, revealing thickening of the aortic wall at the level of the descending aorta and the left common carotid artery. Moreover, the left subclavian artery presents, from its origin, a peripherally thrombosed endoprosthesis with a permeable filiform lumen. This aspect suggests a diagnosis of Takayasu arteritis stage IIb. It was initiated treatment with glucocorticoids 1mg/kg/day (methylprednisolone 48mg/day) for one month, then tapered gradually and immunosuppressive therapy with Methotrexate 15 mg once a week.
Discussions: Notably, the patient's symptoms were atypical for Takayasu arteritis, lacking classical features such as fever, hypertension, and weight loss, and exhibiting stenosis limited to the left main branches of the aortic arch, resulting in unilateral symptomatology. While the precise mechanisms of the disease remain unclear, potential links between tuberculosis and Takayasu arteritis could involve shared immunological pathways or mycobacterial antigens triggering autoimmunity.
Conclusions: This case highlights the challenges in diagnosing and managing Takayasu arteritis, particularly in atypical presentations necessitating multidisciplinary collaboration. Timely recognition and initiation of treatment are crucial to prevent irreversible vascular damage and complications.

Cocaine intoxication in children

First author: Marco Gambera

Coauthors: Brindusa Capilna

Coordinator(s): Medical Doctor Adriana Mihai

Keywords: Cocaine Chronic intoxication Neurological complications

Introduction: Cocaine is a powerful addictive stimulant drug. It is mainly used illegally and recreationally. Its abuse can lead to a chronic intoxication, being a major worldwide health problem.  Case Report: A 6-year-old male presents at the Miercurea Ciuc emergency room with ataxia, hypogastric pain, fever and dysuria. CT scan showed chronic bilateral maxillary sinusitis. The drug test performed, had positive result for cocaine. He immediately was transferred to the Emergency room at the Spitalul Judetan of Târgu Mures. The anamnesis was difficult to perform because of contradictory information given by the mother. Physical examination revealed mydriasis, anisocoria, positive Babinsky sign and agitation. The second CT scan showed a hyper dense lesion at the left part of the brain with a dimension of 8/9.6mm AP/LL. Taking in consideration the hypogastric pain and the dysuria that the patient presented, an ultrasound was performed at the bladder level showing a bladder globe with severe urinary retention.
Discussions: Cocaine intoxication is known for the critical consequences on the entire body, especially the neurological system. Our patient started a multi-drug treatment. The neurology department prescribed him a vitamin therapy with vitamin B1- B6 and C, for boosting the immune system. Pediatric department advised him a treatment with pain killers for the acute hypogastric and bladder pain, hydration and the insertion of a catheter (10FR) for the acute retention. Both Neurology and Infective disease departments recommend an antibiotic for treating the chronic bilateral maxillary sinusitis. At the end, NPI confirmed him the ongoing treatment plus glucocorticoids for the anti-inflammatory effects. Social surveillance, police involvement and child safeguard are recommended.
Conclusions: After the twelve days multi-drug treatment, the patient started to walk individually and presented no pain. He also showed a notable evolution in the neurological aspect with no ataxia as I mentioned before, anisocoria, mydriasis and Babinsky sign. The bladder regained its original activity with no urinary retention and dysuria. For concluding, unfortunately nowadays also the safety of the children is affected by the choices of the adults. Cocaine intoxication keeps showing a high mortality rate by being, in the 2022, the most used drug in Romania from the adolescents and not.

Toddler with febrile seizures or heart block? An interesting case report in pediatrics

First author: Alexandra-Mihaela Preda

Coauthors: Andreea-Iulia Popa Irina-Maria Albean Larisa-Elena Pogor (Costea) Giorgia-Maria Achim

Coordinator(s): Lecturer Luminița Dobrotă

Keywords: Stokes-Adams syncope Third-degree atrioventricular block long QT syndrome

Introduction: Stokes-Adams syndrome characterizes a primary mechanism of syncope stemming from cardiac origins, resulting from disruptions in cardiac rhythm. These rhythm disturbances can manifest as either a fast or slow heart rate, presenting as either regular or irregular patterns.
Case Report: A three-year-old patient was admitted to the hospital due to experiencing myoclonus, gaze fixation and fever. These symptoms were preceded by episodes of vomiting. Upon admission, the family reported that the child had experienced self-limited generalized tonic-clonic seizures lasting 3-4 minutes. The child's grandfather, who has medical experience, likened the convulsions to a myocardial infarction. Following the convulsive episode, the patient's status reveals pupils of equal size and preserved photomotor reflex. Initially, the diagnosis of generalized febrile convulsions might be considered, but upon examination, additional changes were identified. The clinical examination shows rhythmic heart sounds, a low ventricular rate of 48 beats per minute, a systolic murmur at the mitral valve, warm extremities and a congested pharynx. The electrocardiogram indicates a third-degree atrioventricular block along with severe bradycardia and a prolonged QT interval (QTc=0.50second). The cardiac ultrasound shows the ejection fraction of the left ventricle measuring 55% and no abnormalities in the cardiac structure are found. The treatment administered included a 1000 ml intravenous infusion of glucose and electrolytes per 24 hours, 40 ml of 15% mannitol, cortisone hemisuccinate and 0.5 ml per day of intramuscular phenobarbital 10%. The patient's condition showed improvement with no recurrence of syncopal episodes. Bradycardia persisted at 46 beats per minute with a slight tendency to increase upon mobilization. The electrocardiogram continues to exhibit the same changes during hospitalization.  
Discussions: In this case, initially, bradycardia was linked with acute cerebral edema following a seizure, a connection that might have postponed the pacemaker implantation procedure. Given the potential severity of the case, the patient is promptly referred for pacemaker implantation. In children, third-degree atrioventricular block can stem from congenital or acquired type. In the absence of congenital heart defects, the congenital type is often associated with neonatal lupus erythematosus. Other causes include cardiomyopathies, Lyme carditis, acute rheumatic fever or myocarditis. 
Conclusions: Severe bradycardia, third-degree atrioventricular block type and long QT intervals led to the interpretation of the convulsive crisis as cardiac syncope. A potential congenital origin is suspected. Additionally, the parents noted reduced and irregular heart sounds since infancy. Neither parent has a known history of heart disease.

Double Heterozygous BRCA Mutations in Pregnant Woman – A Case Report

First author: Erica Vasile

Coauthors: Daniela-Andreea Bondor

Coordinator(s): Associate Professor Andreea Cătană

Keywords: BRCA double mutation breast cancer

Introduction: BRCA1 (breast cancer susceptibility gene 1) and BRCA2 are tumor suppressor genes, contributing to DNA repair and regulation in case of DNA damage. Mutant phenotypes predispose individuals to certain types of cancer throughout their lifetime, as about 5 to 10% of breast cancers are attributed to genetic susceptibility. Multidisciplinary screening and prevention strategies can reduce the mortality of such patients. However, cases of double heterozygosity of these germline mutations are rarely reported, despite of the uncertain prognosis. Case Report: A 37-year-old pregnant woman presented to the clinician requesting oncogenetic counseling in the context of mother and sister having breast cancer. No relevant medical history was declared. A next generation sequencing test for 125 genes (NGS 125 gene) revealed the following mutations: pathogenic variants for BRCA1 and BRCA2 genes and variant of uncertain significance (VUS) for ATM gene, all three having heterozygous status. In silico prediction algorithms showed that the latter pleads for a well-tolerated variant in phenotype. To the best of our knowledge, double heterozygous BRCA1 and BRCA2 pathogenic defect discovered during pregnancy has not yet been reported. The presence of both germline mutations combined with significant oncological history of first-degree relatives puts the patient at increased risk of breast and ovarian cancer. The chance of occurrence for the first one is 45-60% with 80% chance of bilateralization for each gene mutation. All clinician’s recommendations were prophylactic. Screening for mammary neoplasm for this patient included regular self-, clinical, and imagistic examinations as well as future bilateral mastectomy with optional mammary reconstruction. Screening for ovarian neoplasm consisted of endovaginal ultrasound, annual dosage of CA-125, and eventual salpingo-oophorectomy or total hysterectomy. Family genetic counseling along with counseling therapy and optional nutrigenetic evaluation were also suggested. Discussions: What makes this case report particular is that, besides the double heterozygosity status of the mutations, the patient was diagnosed during pregnancy which brings further distress on a psychological level. However, being aware of the condition enables her to take the best course of action regarding the possibility of a future malignancy, as the physician recommended. Conclusions: Pathogenic variants of both BRCA1 and BRCA2 are rarely reported in the existing literature. In such cases, early genetic diagnosis plays a highly significant role because prophylactic measures can be taken in advance, improving the prognosis.

What do some ethnobotanical products contain?

First author: PRIHOI ANDRADA-OANA

Coauthors: Cimpoeşu Carmen Diana Corlade-Andrei Mihaela

Coordinator(s): Professor Gligor Felicia Gabriela

Keywords: drugs ethnobotanical products gas chromatography psychoactive substances

Background: According to the reports from emergency units in the whole country, the consumption of psychoactive products shows an upward trend. The patients’ treatment diagnosed with acute poisoning caused by the consumption of ethnobotanical products represents a challenge for the doctors working in the Emergency Department, their attention being focused on the problems which may endanger the vital functions. The lack of information on the chemical composition, origin of ingredients and potentially dangerous substances used to manufacture ethnobotanical drugs makes it difficult to assess health risks and toxicity levels.
Objective: The study aims to identify substances contained in ethnobotanical products. This was possible using gas chromatography coupled with mass spectrometry.
Material and Method: Some ethnobotanical products, identified as the most known and, implicitly most consumed, were analysed by gas chromatography-mass spectrometry. The methanolic extracts of the samples were analysed using the FOCUS GC System (Thermo Electron Corporation), equipped with a TR-5MS capillary column with a length of 30 m and an internal diameter of 0.25 mm. Helium was used as carrier gas and the flow rate was 1mL/min.
Results: The tests identified substances with psychoactive properties. Two pyrovalerones (MDPV and MDPBP), psychoactive drugs with stimulant properties, acting as serotonin-dopamine reuptake inhibitors, were identified in one of the products. Acute effects include: extreme anxiety/agitation, sometimes progressing to violent behaviour, insomnia, psychotic delusions, confusion, tachycardia, hypertension, precordial pain, shortness of breath, tachypnea, coughing, hyperthermia, chills, sweating, bruxism, nausea, abdominal pain and transit disorders. 1-penethyl-3-(2-chlorophenyl) indole (JWH-203), one of the most complex types of synthetic cannabis, agonist for both CB1 and CB2, has been identified in another ethnobotanicalwith approximately equal affinity and its effects on the body and brain are more intense than THC, which is only a partial agonist of cannabis. JWH018 alters the mindset of on addicted person and can cause extreme anxiety, panic attacks and seizures. This is due to the fact that affects the GABAneurotransmitters.
Conclusions: The consumption of ethnobotanical products represents a complex issue that does not lend itself to simple conclusions. However, we may draw a clear conclusion: ethnobotanical products thought to be 'safe' or 'low-risk', contain dangerous substances, with harmful effects, some of which may be life-threatening.

CBCT in Combat: Pioneering Anatomical Strategies for Maxillofacial Rehabilitation

First author: Răzvan Costin Tudose

Coordinator(s): Professor Mugurel Constantin Rusu , Medical Doctor Cătălin Constantin Dumitru

Keywords: Military Maxillofacial Trauma Anatomical Variability CBCT Imaging Personalized Anatomical Assessment

Background: The integration of advanced imaging technologies, such as Cone Beam Computed Tomography (CBCT), has transformed the rehabilitation treatment for military maxillofacial trauma, enhancing care delivery. Despite these advancements, the field lacks a comprehensive anatomical analysis of endosteal, zygomatic, and pterygoid implants, a gap that limits clinical decision-making efficacy. Addressing this research void could significantly improve the selection of implants, tailored to the unique challenges of military-induced injuries. This study underscores the necessity of embracing imaging-driven, personalized anatomical insights, particularly for those afflicted by maxillofacial trauma. 
Objective: This research aims to leverage the capabilities of CBCT imaging to optimize rehabilitation for military personnel by focusing on anatomically informed clinical decision-making for maxillofacial injuries. Through a detailed comparative analysis of different implant types, facilitated by CBCT, the study seeks to guide toward refined clinical practices that accommodate the anatomical uniqueness of each patient, thereby enhancing care in military trauma scenarios.
Material and Method: Our analysis involved 50 anonymized CBCT scans, equivalent to 100 hemimaxillae, to study the impact of maxillary morphological variations on implant placement. Advanced software applications such as Planmeca Romexis Viewer (3.5.0.R), Horos for macOS (Horos Project), and Blue Sky Plan 4 were utilized for precise measurements, comprehensive 3D model assessments, and simulations of implant placements. Measurements focused on the height and width of the alveolar process across three main areas: the anterior (premaxilla), middle (at the zygomaticoalveolar crest), and posterior (tuberosity of the maxilla and pterygoid process).
Results: Analysis of the CBCT scans revealed significant variability in the dimensions of the maxillary alveolar process, particularly in the anterior region with widths ranging from 2.7 to 11.65 mm and heights from 6.4 to 27.6 mm. The posterior region also showed significant variability, posing challenges for implant placement. Of note, 21 out of 100 hemimaxillae were unsuitable for zygomatic implants—19 due to extensive maxillary resorption and 2 due to highly pneumatized zygomatic bones. Additionally, 9 hemimaxillae were unsuitable for pterygoid implants due to significant resorption. Remarkably, one patient was ineligible for both zygomatic and pterygoid implants, highlighting the complexity of selecting appropriate implants in patients with severe conditions.
Conclusions: CBCT utilization for pre-surgical planning is indispensable in the anatomically tailored evaluation of patients, especially following maxillofacial combat trauma which can dramatically alter anatomical landscapes. This precise anatomical assessment is crucial for improving clinical decision-making and outcomes, highlighting the paramount importance of individualized imaging in the strategic planning of implant-based reconstructions for personalized patient care.

Quantifying Condyle Displacement in an Isolated Mandibular Fracture: A CBCT-Based Case Report

First author: Răzvan Costin Tudose

Coordinator(s): Professor Mugurel Constantin Rusu , Medical Doctor Cătălin Constantin Dumitru

Keywords: CBCT Imaging Mandibular Condylar Fractures Anatomical Alterations Personalized Anatomy

Introduction: Fractures of the mandibular condylar process represent significant challenges within maxillofacial trauma, characterized by their diverse clinical outcomes. The utilization of Cone Beam Computed Tomography (CBCT) has transformed the diagnostic landscape, providing an in-depth view of fracture patterns and bone architecture, crucial for comprehending the complexity of such injuries. This study employs CBCT to compare the structural integrity of a fractured condylar process with its intact counterpart, aiming to highlight the consequential alterations.
Case Report: Our retrospective analysis utilized an archived high-resolution CBCT scan (0.250 resolution, 130 field of view, 640 × 640 image matrix) of a male patient with a displaced unilateral fracture of the mandibular condylar process. The uncompressed DICOM file was analyzed using Planmeca Romexis Viewer 3.5.0.R software. Detailed measurements revealed significant morphological alterations when compared to the intact side. In axial and sagittal planes, the distance from the mandibular neck to the lateral pterygoid plate was markedly reduced to 7.93 mm from 22.8 mm on the unaffected side. Similarly, the neck-to-coronoid process distance decreased to 15.66 mm from 21.31 mm, and the condyle-to-tuberosity distance diminished to 19.04 mm from 34.18 mm. The most striking finding was the severe displacement of the condyle beneath the articular eminence, with a minimal distance of just 2.7 mm, indicating significant displacement. 
Discussions: The findings from the CBCT analysis indicate the significant impact of mandibular condylar process fractures on the structural integrity and anatomical configuration of the jaw. The diminished distances and altered condyle positioning highlight the necessity of incorporating personalized anatomical assessments into clinical evaluations. This approach is essential for understanding the individualized impacts of such fractures, facilitating tailored treatment strategies that acknowledge the unique anatomical variations of each patient. The study reinforces the role of CBCT in achieving these personalized anatomical assessments, providing a foundation for more informed clinical decision-making and potentially improving patient outcomes in maxillofacial trauma management.
Conclusions: CBCT is a significant diagnostic tool in the diagnosis of mandibular condylar process fractures since it provides important insights regarding the wide range of anatomical modifications. This technology ensures more individualized treatment of these complex injuries and predicts a more focused and, consequently, successful intervention in trauma care in the maxillofacial region. Personalized anatomy is highly recommendable. 

Preserving Facial Harmony: Surgical Approach to Infiltrative Ulcerated Basal Cell Carcinoma of the Nasal Tip

First author: Sofia Leonardi

Coauthors: Francesca Rosaria Cannito Lucrezia Sanna Niccolò Maria Simeone Chiara Testoni

Coordinator(s): Medical Doctor Bogdan-Dan Sbârcea

Keywords: basal cell carcinoma nasal reconstruction surgical management

Introduction: Basal cell carcinoma (BCC) is the most common type of skin cancer, typically arising on sun-exposed areas such as the face. Infiltrative ulcerated BCCs, characterized by their invasive nature and propensity for tissue destruction. The nose, being a prominent facial feature, holds particular importance in terms of cosmetic appearance and function. A successful outcome in the treatment of nasal skin tumors is crucial for preserving facial aesthetics and restoring patient confidence. Case Report: The case involves a 54-year-old female with an infiltrative ulcerative skin tumor at the tip of her nose. Her medical history included previous epileptic crises, hypertension, and obesity grade III, complicating the clinical scenario. Given the potential for tumor progression and the impact on facial aesthetics, prompt surgical intervention was deemed necessary. Surgical excision under general anesthesia was performed, employing precise incisions to delineate tumor margins and ensure oncological safety. Five pieces were excised: the skin tumor, columella, right and left alar cartilage margins, and re-excision of the right columella to ensure complete removal of the tumor. Reconstruction of the nasal structures was achieved using cartilage harvested from the right auricle. Local flaps rotated from bilateral infranasal levels and a local pedicled nasolabial flap rotated to the right were utilized to reconstruct skin and soft tissue defects. Postoperative recovery showed favorable wound healing. Histopathological examination revealed an infiltrative basal cell carcinoma incompletely excised laterally and in depth, with involvement of the columella, right alar cartilage margin, and re-excised right columella. Discussions: The surgical management of the infiltrative ulcerative skin tumor at the tip of the nose was successful in achieving tumor removal and reconstruction of nasal structures. However, the incomplete excision of the carcinoma in certain areas underscores the need for vigilant postoperative monitoring and consideration of further management strategies. The use of auricular cartilage for reconstruction proved effective in restoring nasal anatomy and preserving facial aesthetics. Close follow-up and additional interventions may be necessary to ensure optimal oncological control and patient satisfaction in the long term. Conclusions:

The importance of imaging in head injuries

First author: Adina Mastan

Coauthors: Alina-Sabina Luchi Antonia-Elena Iosif Vlăduț Liviu Ilie

Coordinator(s): Medical Doctor Mihaela Mastan

Keywords: emergency epidural hematoma head trauma pediatric

Introduction: Epidural hematoma is oftentimes a result of traumatic head injuries, being a potentially life-threatening situation for the patient. It is characterised by an accumulation of blood between the dura mater and the skull, therefore timely recognition and intervention are crucial in order to avoid further neurological complications. Case Report: An 11 year old male patient presents to the Pediatric Emergency Unit after having suffered a fall in the School's Sports Hall, 8 hours prior. He manifested a good general state, afebrile, with no signs of organomegaly or signs of meningeal inflammation and a Glasgow Coma Score of 15. The patient claims a vomiting episode after the fall; left periorbital bruising was also noted. Following the laboratory testing, a mild leukocytosis with neutrophilia was revealed, with other results being within normal ranges. A native CT scan uncovered a 19mm thick left fronto-basal epidural hematoma, extending 50mm with an associated mass effect. No other intracranial abnormalities were noticed. He was promptly admitted to the Neurosurgery department for conservatory management. The patient was treated with antispasmodic, analgesic and antiemetic medication, alongside rehydration and electrolytic rebalancing. Discussions: Due to his symptoms having been relieved, the patient was discharged after 4 days without undergoing a surgical intervention. He was instructed to avoid physical effort, harsh weather conditions and neurotoxic substances, with a follow-up consult after 30 days. The follow-up consult revealed the epidural hematoma has resolved. Conclusions: This case highlights how, even head injuries caused by falling from one's height level on a wooden floor can have serious outcomes that must be treated accordingly to avoid catastrophic complications. Through the aid of imaging, the hematoma was swiftly uncovered and treatment ensued rapidly.

Metformin and high blood pressure - What to be aware of when administering it

First author: Maria Morari

Coordinator(s): Associate Professor Gabriela Cioca

Keywords: Metformin high blood pressure vitamin B12 deficiency homocysteine

Background: Metformin (dimethylbiguanide) is part of the biguanide class of antidiabetic drugs. It is a first-line drug in the case of type 2 diabetes. After oral administration is quickly absorbed. Its most common side effects are diarrhea, anorexia, nausea, vomiting. The main mechanism of action of Metformin is through the activation of AMP (adenosine monophosphate)-activated protein kinase, a central pathway in metabolic regulation, cell protection and cell survival. As we age, high blood pressure can occur along with diabetes and rise the risk of renal failure and cardiovascular complications. 
Objective: This paper aims to evaluate the interactions of Metformin with antihypertensive medication and other types of interactions such as with vitamin B12 and how does vitamin B12 affects the cardiovascular system.
Material and Method: This systematic review of literature was shaped trough the usage of databases such as: MedScape, PubMed, UpToDate and Google Scholar. All the literature included in the study was published in English.
Results: Metformin interacts with antihypertensive medication as it follows: Verapamil decreases the effect of Metformin by possibly inhibiting hepatic uptake of Metformin via OCT1 or other transporters; Thiazides and loop diuretics may reduce the blood glucose-lowering effect of Metformin by inhibiting the function of the beta-islet pancreas; Angiotensin-converting enzyme inhibitors increase the toxicity of Metformin by an unknown mechanism; Amlodipine decreases the effect of Metformin by pharmacodynamic antagonism; Beta-blockers and modulators of sympathetic activity cause a decrease in blood glucose by masking the adrenergic symptoms that signal hypoglycemia. Vitamin B12 has two effects on the cardiovascular system: by preventing the conversion of homocysteine to methionine and through the endocrine system. Homocysteine affects the endothelial function and intrinsic thrombolysis. The endocrine system is sensitive to B12 deficiency. The vitamin is needed for the structure of cell membranes, so that the pituitary gland can measure how much of each hormone is in the blood and adjust as needed. A lack of B12 can cause high levels of neurotransmitters, and excitatory hormones, leading to high blood pressure. Metformin may induce hypovitaminosis B12 through different possible mechanisms, such as altered intestinal motility and interaction with the endocytic receptor cubilin.
Conclusions: Type 2 diabetes is frequently associated with high blood pressure, especially in the elderly patient. Interactions of Metformin with antihypertensive therapy must be analyzed to maximize the therapeutic effects and minimize the risks. The aim is of increasing the quality of life and life expectancy of patients with complex pathologies.

FACTORS ASSOCIATED WITH MALNUTRITION AND ITS IMPACT ON POST PERCUTANEUS REVASCULARISATION OUTCOMES IN AMI PATIENTS

First author: Sara Suciu

Coauthors: Rus Andreea Tiberiu Nyulas

Coordinator(s): Other Sara Suciu

Keywords: altered nutritional status geriatric nutritional risk index myocardial infarction complications

Background:  Hospitalized individuals with acute myocardial infarction (AMI) who show altered nutritional status are likely to have a worse clinical prognosis. However, the prognostic significance of malnutrition in patients with critical stage of AMI has not received adequate attention.
Objective: Discovering factors associated with damaged nutritional status in hospitalized patients with resvascularized AMI.
Material and Method: Retrospective observational study by collecting information from the observation sheets of AMI patients admitted to the Cardiology Department, SCJU Tg Mures between September and December 2020. Depending on the nutritional status calculated with the GNRI score, the patients were divided into 2 study groups, those with impaired nutritional status (GNRI<98) and those with normal nutritional status (GNRI≥ 98)
Results: A group of 99 patients was investigated, and according to the GNRI score, almost thirty-three percent of them (30.3%) presented an impaired nutritional status. Out of the total of 99 patients, 7 patients died in the hospital, all of them having impaired nutritional status, p=0.0001. Of the total number of patients with poor nutritional status, during hospitalization, 23.3% experienced cardio-respiratory failure (p=0.0001), 30% displayed supraventricular arrhythmias (p=0.001), and 46.7% necessitated inotropic support (p=0.0001). Malnourished patients had considerably extended hospitalizations in CCU, p=0.02, and hsCRP values were significantly higher both at the initial moment and 5 days after AMI. In the logistic regression analysis, variables significantly associated with malnutrition risk (GNRI<98) were inotropic support (OR: 4.68), cardio-respirator failure in the hospital (OR: 11.85), and supraventricular arrhythmias (OR=11.81).
Conclusions: This study established a connection between a nutritional deficiency and a higher risk of complications, an increased inflamatory status, death inside the hospital, and longer hospitalization days in cardiac care units in patients with acute myocardial infarction who experienced revascularization. 

Clinical associations between atrial fibrillation and ascending aortic aneurysm

First author: Miruna Zaha

Coauthors: Diana-Maria Cetină Alexandru Topor

Coordinator(s): Medical Doctor Dragoș Mihăilă

Keywords: Ascending aortic aneurysm Atrial fibrillation Antithrombotic therapy Surgical treatment

Introduction: Atrial fibrillation is considered to be the most frequently managed arrhythmia in clinical practice, and it is linked to an increased risk of death, stroke, and peripheral embolism. Ascending aortic aneurysm is a life-threatening disease that is often difficult to detect prior to the occurrence of a clinical catastrophe but is a relatively less studied subject compared to abdominal aortic aneurysms.
Case Report: We present the case of a 67-year-old patient admitted to the Clinical Rehabilitation Hospital in Cluj-Napoca for marked decrease in exercise tolerance and atypical chest pain. The pacient is known to suffer from essential arterial hypertension, peripheral artery disease and permanent atrial fibrillation. In addition, the patient has a history of mitral and aortic valve replacements for rheumatic valvular disease, an ascending aortic aneurysm and advanced atherosclerosis involving the abdominal aorta, celiac trunk and left renal artery. An echocardiography performed on admission revealed an ascending aorta with an increased diameter of 52 mm, dilated left atrium, reduced ejection fraction, hypokinetic interventricular septum and ecocardiographic signs of pulmonary hypertension. Laboratory tests revealed elevated BNP values and normocytic normochromic anemia, most likely induced by mechanical hemolysis, due to the presence of the mechanical valves. During hospitalisation, a surgical consultation was performed, which recommended the delay of the surgery for the aortic aneurysm and CT reevaluation over 6 months. Upon discharge, antithrombotic (VKA), antihypertensive, anti-ischemic and hypolipemiant treatment was prescribed. 
Discussions: The ESC 2023 Guide recommends imaging every 6 months for the follow-up of patients with ascending aortic aneurysm. Surgical treatment is indicated for aneurysms greater than 55 mm in diameter. It is debatable whether or not our patient will be able to undergo a new surgical intervention considering the high mortality risk calculated using Euroscore II (16.33%). Another issue worth mentioning is the imposibility of using NOAC as antithrombotic therapy for permanent atrial fibrillation, given the presence of the mechanical mitral and aortic valves, thus having to cope with the difficulties of keeping the INR value within therapeutic range using VKA.
Conclusions: The presented case illustrates the increased risk of patients with multiple cardiovascular comorbidities to develop aortic aneurysm, as well as the need to control cardiovascular risk factors, given the fact that the co-existence of atrial fibrillation and aortic aneurysm is associated with a higher risk of negative clinical outcomes.  

BENEFICIAL FOODS IN IRRITABLE BOWEL SYNDROME AND INTERACTION WITH SOME DRUGS

First author: Șerban Ioana-Stefania

Coordinator(s): Associate Professor Irina Mihaela Matran

Keywords: Drugs Food Microbiome Interactions

Background: Irritable bowel syndrome is a chronic functional gastrointestinal disorder, having among symptoms increased motility, abdominal pain, constipation or diarrhea, distension and bloating. The effects of ingested food is the result of the interaction between intestinal bacteria and intestinal endocrine cells. The patients with irritable bowel syndrome have a lower density of endocrine cells, confirming the diagnosis. This disease is twice as common at women.
Objective: Identifying foods allowed in irritable bowel syndrome and their interactions with different drugs.
Material and Method: This study is a review of the literature based on the clinical studies published on PubMed in the period 2017-2024. 16 scientific sources were researched. They were followed the dietary recommendations for this disease and their interaction with various substances from drugs administered for the treatment of other diseases (Warfarin, Levothyroxine, Levodopa).
Results: The researchers have demonstrated that cranberry juice, orange, lemon, dietary fiber and the vegetables rich in vitamin K, have an influence on the absorbtion of various drugs.
Conclusions: Before starting a drug treatment, it is desirable for each person to consult a dietetician for to give him information about a correct diet from the point of view of nutritional needs, but also associated pathology.

The „off” side of Parkinson’s disease: a case report

First author: Oana Maria Popescu

Coauthors: Florin-Alexandru Popa Maria Pîrcălabu Ioana-Roxana Pop

Coordinator(s): Assistant Professor Nadina-Liana Pop

Keywords: Parkinson's the off phenomenon osteoporosis rehabilitation

Introduction: Parkinson’s disease is a relatively common progressive movement disorder caused by the degeneration of dopamine-releasing neurons in the substantia nigria, patients experiencing tremor at rest, bradykinesia or hypokinesia, limb stiffness and postural instability. Osteoporosis is a skeletal disorder in which low bone density and deterioration of the bone architecture lead to bone fragility and high susceptibility to fractures. In this case, we seek to highlight the challenges that arise while managing the treatment for both of these illnesses, but also the recovery.
Case Report: A 60-year-old male presents at a physical medicine and rehabilitation specialist, complaining of lumbar pain with irradiation to the right hip and knee. In addition, he accuses bradykinesia, lower limbs paresthesia, walking difficulties (the patient uses a cane), negative hyperthymia. He is known to have Parkinson’s disease stage IV (Hoehn & Yahr) for 14 years, right artificial knee joint, left knee arthritis secondary to trauma, osteoporosis and an old fracture of the hip bone. The on-and-off phenomenon is also present, the off phenomenon taking up 50% of the day, for which he was given a Duopa pump. The lumbar spine MRI showed the presence of a degenerative disk disease at L2-L4 level, a T12 compaction fracture (50%). As treatment, he was prescribed Tramadol, Acetaminofen, Diclofenac, vitamin D, besides his chronic medication for Parkinson, with a positive outcome regarding pain level and on-off phenomenon. In addition, physiotherapy (ultrasound therapy, short wave diathermy, laser therapy) and specific exercises were recommended, with good results for the patient’s independence level.
Discussions: The characteristic gait of the patients with Parkinson’s disease, as well as the significant postural instability were most likely the cause of the degenerative disk disease, the knee arthritis and the fractures of the hip bone and T12 vertebrae. Studies also showed that Parkinson’s can lead to low bone density which, besides the old age, could have been the cause for the osteoporosis. Seeing how the physical rehabilitation of these patients can be quite a challenge, we propose deep brain stimulation, especially because of the severe impairment in mobility and quality of life.
Conclusions: Parkinson’s disease can affect many of the body’s systems and patients’ quality of life, which is why maintaining patients’ independence is essential on medium and long term.

Granulocytic Sarcoma and Acute Myeloid Leukemia

First author: Ionut Bosancean

Coauthors: Alexandra-Maria Radu Ștefania Chiper

Coordinator(s): Assistant Professor Oana Mesaroș , Assistant Professor Laura Jimbu

Keywords: Granulocytic sarcoma Acute myeloid leukemia Chemotherapy

Introduction: Granulocytic sarcoma (GS) is a rare extramedullary tumor characterized by the proliferation of immature myeloid cells, called blasts. It is frequently associated with acute myeloid leukemia (AML) or with chronic myeloproliferative or dysplastic syndromes and has a dismal prognosis. 
Case Report: A 60-year-old female presents to a local hospital, from Cluj-Napoca, accusing abdominal symptoms suggestive for a dyspeptic syndrome. An echography was performed and showed a two centimeters mass, in the ileocecal region. This was further confirmed by a colonoscopy and subsequently a CT scan revealed a retroperitoneal mass which surrounded the celiac trunk, the superior mesenteric artery and both renal arteries, its overall size being 81/75 millimeters. Shortly after, the patient was addressed to the hematology department, from Ion Chiricuta Oncology Institute, Cluj-Napoca, where the final diagnosis of GS was established. The peripheral blood smear showed more than 20% blasts and the immunophenotyping, from the bone marrow, confirmed the diagnosis of AML. Molecular biology showed no mutations in FMS-like tyrosine kinase 3 (FLT3) or Nucleophosmin 1 (NPM1) genes. Taking into consideration the age and the fitness of the patient, a combination with azacitidine, a hypomethylating agent and venetoclax, a B-cell lymphoma 2 (BCL-2) inhibitor was started. The patient also received intrathecal prophylaxis with methotrexate, cytarabine and dexamethasone. After only one cycle of treatment, the patient achieved less than 5% blasts in the bone marrow, and the retroperitoneal tumor had shrunk by almost 30 millimeters. Unfortunately, after two cycles, the patient had 10% percent blasts in the peripheral blood, and more than 20% in the bone marrow. Second line treatment was started, and the patient is now undergoing the ‘3+7’ regimen, an intensive chemotherapy which consists of three days of idarubicin and seven days of cytarabine.
Discussions: There is no standardized approach in treating GS but in this case, a less aggressive treatment was preferred, as first line. Even if the patient achieved a remarkable response initially, its duration was very short, suggesting the threatening nature of the diseases. Furthermore, in GS, the risk of central nervous system involvement is high. In the relapsed setting, allogeneic stem cell transplantation is mandatory.
Conclusions:  GS is a rare tumor that can develop in atypical sites and can be discovered either by organ compression in a non-leukemic form or, in other cases, it can manifest clinically associated with AML. 

BORN WITH TRANSPOSITION OF GREAT ARTERIES, WHAT NOW?

First author: Filip Raul

Coordinator(s): Medical Doctor Anca Ioana Sglimbea , Medical Doctor Marius Cosma

Keywords: transposition of great arteries balloon atrial septostomy arterial switch operation

Introduction: Transposition of the great arteries (TGA) is a congenital heart defect that affects 4.7 out of 10,000 newborns. The inversion of the great arteries breaks up the normal circulation, separating the pulmonary circuit from the systemic one. Consequently, oxygen rich blood cannot reach most of the organism and deoxygenated blood is unable to undergo gas exchange without the existence of an anatomic shunt between the two circuits. 
Case Report: We are presenting a female newborn with a prenatal diagnosis of D- transposition of the great arteries (D-TGA). Delivered by caesarean section, she presented difficult adaptation, with initial oxygen saturation of 55% in ambient air and generalised cyanosis, specific for cyanotic heart malformation. Prostaglandin (PGE1) treatment was started, along with transfer to NICU plus a paediatric cardiology consult that confirmed the in utero diagnosis, also showing: a small subpulmonary ventricular septal defect (VSD), a restrictive atrial septal defect (ASD) with bidirectional shunt and a patent ductus arteriosus (PDA) under PGE1 therapy. To aid the stagnant low SO2 saturation, at 4 hours postpartum a balloon atrial septostomy (Rashkind procedure) under echocardiographic guidance was performed to enlarge the ASD. This resulted in increased mixing of blood, thus improving the oxygen delivery in the systemic circulation and maintaining hemodynamic and metabolic stability until 7 days of life, when the surgical correction of the heart lesion could be performed (inversion of the 2 arteries connecting them to their physiologic ventricle, suture of the ASD alongside the VSD and ligature of the PDA).
Discussions: The Rashkind procedure is the fastest and most efficient way to drastically improve the oxygenation of the D-TGA patient, along with the PDA or without it. This palliation provided enough leeway for the NICU to keep the newborn as stable and prepare her for the surgical and curative treatment: arterial switch operation.
Conclusions: D-TGA, if treated promptly, as in the case presented, has an optimistic prognostic, with 90% 15 year survivability. Of upmost importance is the preoperative care, focused on providing adequate mixing and supporting the patient until the procedure, for the most suitable results.

Duodenal diverticulum: a possible answer for a case of reoccurring cholestasis

First author: Mihai Valeriu Brînzan

Coauthors: Daniel-Nicușor Ghiț

Coordinator(s): Lecturer Daniela Maria Matei

Keywords: diverticulum duodenum cholestasis hepatic abscess

Introduction: Duodenal diverticula are sacciform herniations of the intestinal wall, most commonly acquired and associated with old age. They are mostly located periampulary and although usually asymptomatic, can lead to complications in rare cases, such as obstructive jaundice, but also small bowel obstruction, bleeding or acute diverticulitis.
Case Report: An 80-year-old female patient with a history of cardiovascular disease and biliary lithiasis presents with a reoccurrence of cholestatic syndrome. Her history begins in October 2023 when she first presented with abdominal discomfort and unexplained weight loss. At that point, there were signs of cholestasis (hyperbilirubinemia with increased direct bilirubin (BR) of 0,79 mg/dL, increased Alkaline Phosfatase(ALP) of 404 U/L and GammaGT (GGT) of 722 U/L). Cholangio-MRI was performed, revealing dilation of the common bile duct (CBD) of 15 mm and of the intrahepatic bile ducts (IHBD) along with a duodenal periampulary diverticulum of 27 mm in diameter. Unable to reveal any lithiasis or tumoral cause for the obstruction, ERCP was performed which was able to remove a gallstone of approximatively 10 mm in diameter. On second admission in February 2024, the patient had another episode of cholestasis this time with a total BR of 2,95mg/dL and direct BR of 2,2mg/dL and on CT: CBD=12mm in diameter, aerobilia, multiple hypodense hypocaptating nodular lesions (6mm) suggestive of abscesses (some of them with hydroaeric levels) in both hepatic lobes. The case was interpreted as acute cholagitis. Considering the history, an endoscopic ultrasound was performed which revealed the same initial diverticulum extending towards the hepatic hillum and compressing the CBD, which was the most plausible explanation. Further management included antibiotic therapy (Ceftriaxone and Metronidazole), hemocultures (negative) and surgical consultation (which evaluated the patient as unfit for surgical diverticulum resection).  
Discussions: Periampulary diverticula can predispose to obstructive jaundice either by direct obstruction of the CBD in the absence of lithiasis (a rare clinical entity known as Lemmel’s syndrome) or by hindering normal biliary drainage and raising the likelihood for cholelithiasis. Due to the patient’s age and limited information about the diverticulum, it is unclear which is the case. Additionally, considering the negative hemocultures (which can also rule out sepsis) and CBD compression, the hepatic abscesses are probably a result of repeated episodes of acute cholangitis.
Conclusions: Although rarely symptomatic, duodenal periampulary diverticula can be a cause of gastrointestinal complications to be considered among the list of differential diagnoses.

Unusual Hodgkin lymphoma in a patient with celiac disease: a case report

First author: Daniel-Nicușor Ghiț

Coauthors: Ionut Bosancean

Coordinator(s): Lecturer Lidia Munteanu

Keywords: Celiac disease Complication Hodgkin lymphoma Malignancy

Introduction: Celiac disease is an immune-mediated enteropathy triggered by gluten in genetically susceptible patients. The clinical presentation is extremely variable; patients may have severe gastrointestinal symptoms and malabsorption, extraintestinal symptoms or have no symptoms at all. Celiac disease can be complicated by malnutrition, other autoimmune diseases, refractoriness to treatment, and gastrointestinal tumors. 
Case Report: An 80-year-old woman known with celiac disease for 4 years and hepatitis B on treatment with Entecavir presented in 2022 for reevaluation. A CT scan identified hepatic hilar and celiac adenopathies with short axis of maximum 15 mm, respectively a portocaval one of 19 mm. An echo-endoscopy was performed and a fine-needle aspiration (FNA) from hepatic hilar lymph nodes was collected. After the examination of the tissue, a suspicion of an indolent B-cell lymphoma was raised. For the confirmation, the examination was repeated, and the results showed no signs of malignancy, describing the adenopathy as a reactive one. After a year (2023) the patient presented again for reevaluation. A new CT scan was recommended, showing slightly smaller adenopathies than the previous examination (hepatic hilar and celiac adenopathies with short axis of maximum 13 mm and the portocaval one of 15 mm). A new echo-endoscopy was performed, completed with FNA from hepatic hilar lymph nodes and multiple duodenal biopsies. The histopathological results showed chronic duodenitis Marsh 1 and lymphatic tissue compatible with nodular sclerosing Hodgkin lymphoma (giant cells with extensive eosinophilic cytoplasm, mononucleated or binucleated, with huge, round, inclusion-like nucleoli on a lymphocytic and fibrotic background; the abnormal cells were positive for CD30, CD15 and Pax-5). The patient was next referred to hematology for more investigations and management. 
Discussions: Celiac disease is a relatively frequent pathology (1,4% of the population), 3-11% of the patients developing malignant complications because of immune dysregulation. The most common malignancies are enteropathy-associated T-cell lymphoma and small bowel adenocarcinoma, but others are also possible, such as carcinoma of the tongue, colorectal carcinoma, B-cell lymphoma and even Hodgkin lymphoma. Particularly in this case, the celiac disease was diagnosed at an advanced age, and it was complicated by a less common malignancy for these patients, Hodgkin lymphoma, and not a T-cell lymphoma as usual. 
Conclusions: Malignant complications can occur in patients with celiac disease because of immune disturbances, and even if Hodgkin lymphoma is not one of the most common complications, it should be considered in a patient with persistent abdominal adenopathies. 

REBOA use in the context of combat casualty care, a review of the literature

First author: Vlad Contesi

Coordinator(s): Associate Professor Mihai Toma

Keywords: REBOA TCCC EVAC Hypothermia

Background: With the advent of improvised explosive devices and the injury pattern that such contraptions are capable of causing, non-compressible uncontrolled haemorrhage began to represents one of the leading causes of mortality and morbidity on the battlefield. Although stoppage of limb haemorrhage is relatively straightforward given the widespread implementation of tourniquets and haemostatic gauzes supplied to manoeuvre forces, internal and junctional bleeding usually require surgical procedures not amenable to the austere environments of frontline combat to control. Resuscitative endovascular balloon occlusion of the aorta (REBOA) represents a procedure implementable in the Combat Field Care and Combat Evacuation Care phases of Tactical Combat Casualty Care (TCCC).
Objective: Our study and presentation are aimed at raising awareness and interest among military medicine students regarding the current state of development of REBOA technologies and techniques so that implementation of such procedures may be accomplished in emergency care and combat medicine protocols in the near future.
Material and Method: Search of relevant articles in emergency and military medicine journal no older than 10 years was conducted in march 2024 and yielded 11 sources regarding the history of REBOA application in military operations, procedural and adjunct means of limiting ischemic damage to distal organs as well as alternative devices usable in the context of internal haemorrhage on the battlefield. 
Results: Although undoubtably useful in controlling junctional haemorrhage REBOA presents several problems such as reperfusion and ischemia injury to proximal and distal organs respectively and the possibility of ballon misplacement, migration or aortic rupture. To this end recent studies have shown the utility of using distal hypothermia, endovascular variable aortic control (EVAC) techniques and an alternative rescue stent in aortic occlusion procedures to limit organ damage and of implementing a model of arterial occlusion device based on CO₂ ballon inflation starting at the injury site to prevent ballon migration, misplacement and arterial injury. Placement confirmation strategies using radiofrequency and dual-channel broadband diffuse optical spectroscopy have been sown to be useful in confirming ballon placement and algorithms for deciding upon REBOA vs thoracotomy deployment have been developed recently and are presented here.
Conclusions: REBOA represents a therapeutic option with an uncomfortably low cost/benefit ratio at the moment which precludes its largescale implementation. Although innovations have been made since its first deployment by Lieutenant Colonel (LTC) Carl Hughes in 1954 there is still work to be done in order to ensure the long-term benefice of the procedure.

Postoperative Physical Recovery and Rehabilitation in Patients with Peripheral Arterial Disease

First author: Tiberiu-Andrei Constantin

Coordinator(s): Lecturer Mircea-Cătălin Coșarcă , Assistant Professor Patricia-Maria Crișan-Mălăncrăvean

Keywords: Peripheral Arterial Disease (PAD) Postoperative Recovery Massage Kinesiotherapy

Background: Peripheral Arterial Disease (PAD) is a serious cardiovascular condition that affects millions of people worldwide. It is characterized by the narrowing of arteries that carry blood to the lower limbs, leading to significant pain and discomfort. Following surgical interventions for PAD, patients often experience substantial pain and reduced quality of life. Objective: The purpose of this study is to explore the effectiveness of massage and kinesiotherapy techniques in improving well-being and reducing pain in postoperative PAD patients. We aim to demonstrate that these methods can contribute to faster and more efficient recovery. Material and Method: A clinical study involving a sample of 30 subjects with PAD who have recently undergone surgery is currently underway at the Emergency County Clinical Hospital in Târgu Mureș, from March to June 2024. The subjects are undergoing a six-week program of massage and kinesiotherapy. We regularly monitor their well-being and pain levels through standardized questionnaires and clinical assessments. Results: Our findings indicate a significant improvement in well-being and a reduction in pain among subjects who participated in the massage and kinesiotherapy program. Most subjects reported better quality of life and improved ability to perform daily activities. Conclusions: Massage and kinesiotherapy can play a crucial role in the recovery and rehabilitation of postoperative PAD patients. These non-invasive and cost-effective methods should be considered an integral part of postoperative treatment plans for PAD patients. Our study suggests that these techniques can significantly enhance patients' quality of life and alleviate pain associated with PAD.

Choroidal neovascular membrane: more than meets the eye

First author: Antonia Maria Roberta Bărbănțan

Coordinator(s): Assistant Professor Ioana Damian

Keywords: angioid streaks choroidal neovascularization nAMD pseudoxanthoma elasticum

Introduction: Angioid streaks represent ruptures of the mineralized Bruch membrane. Typically, they are linear and radiate from the optic disc. They may be asymptomatic or may develop secondary choroidal neovascularization (CNV) and lead to vision impairment. These can be idiopathic or associated with systemic diseases, such as pseudoxanthoma elasticum, acromegaly or Sickle cell disease.

Case Report: A 64-year-old male came to the Ophthalmology Clinic complaining about decreased near visual acuity in both eyes. He was known with essential high blood pressure grade 3, first-degree atrioventricular block, possible bicuspid aortic valve, aortic sinus dilatation, aortic insufficiency, mild mitral insufficiency, mild tricuspid insufficiency, hypertriglyceridemia, prostate hypertrophy, ascending aortic aneurysm and hepatic hemangioma. He also had a history of nephrectomy for a renal carcinoma (March 2023). He has been undergoing treatment with Metoprololum, Rilmenidinum, Atorvastatinum and a combination of Perindoprilum, Indapamidum and Amlodipinum. Fundus examination of his right eye (RE) revealed an area of fibrosis approximately 1/3 papillary diameter, surrounded by a few hyperpigmented lesions and a larger yellow lesion, while his left (LE) exhibited paracentrally an area of retinal atrophy and a few drusen. Fundus autofluorescence of both eyes: hypofluorescent lines together with stippled hyperfluorescence emerging from the optic nerve head. Optical coherence tomography (OCT) scans revealed RE: hyperreflective material under retinal pigment epithelium, atrophy in the external retinal layers, large intraretinal cystic spaces; LE: several intraretinal cysts in the inner retinal layer, disruption of outer retinal layers, an area of mixed RPE atrophy and hyperplasia. OCT angiography RE: neovascular structure “medusa head” pattern in the outer retinal slab, while for the LE: no pathological changes are visible.    
Discussions: Considering the patient's age and bilateral presentation, the diagnosis of RE: nAMD (neovascular age-related Macular Degeneration) and LE: dry AMD was taken into consideration. However, the presence of angioid streaks raises suspicion of secondary CNV. Furthermore, considering the associated cardiovascular pathology (aortic aneurysm, HBP) possible pseudoxanthoma elasticum is also considered.   
Conclusions: Each of the pathologies associated represents a risk factor for our patient’s prognosis, such as they make it harder to determine the exact etiology of the choroidal condition. This case must be followed for further signs which could resolve our suspicions.

Electronic circuit for magnetic levitation

First author: Popa Vlad-Dorin

Coauthors: Popoviciu Bianca-Ramona

Coordinator(s): Associate Professor Zoltan German-Sallo

Keywords: Electromagnet Metal objects Regulator circuit Infrared

Background: Magnetic levitation is a method by which an object is suspended with no support other than magnetic fields. Magnetic force is used to counteract the effects of the gravitational force and any other forces. The term magnetic levitation has come to be used in a wide variety of different contexts ranging from suspending a small laboratory-scale stationary object to large-scale mobile applications. The general principle is straight forward: An electromagnet pulls a small metallic object upward while a light beam measures the exact position of the object's top edge. The magnet's lifting force is adjusted according to position. If the object’s top edge goes under the infrared led, the detector makes sure to send a signal to the power supply and then the voltage will be increased and if it goes above the infrared led the voltage decreases.
Objective: The objective is to create an advanced electronic regulator circuit with the capability to achieve levitation of small metal objects.
Material and Method: An infrared tracking system (containing one infrared emitter and two receivers) is used, which contains an operational amplifiers-based regulator circuit. The regulator circuit includes a differential amplifier that adjusts its output according to a reference signal and a dedicated power amplifier for controlling the electromagnet. This comprehensive setup is integrated into a mechanical framework housed within a robust wooden structure.
Results: The meticulously crafted system seamlessly achieves levitation, demonstrating efficiency in suspending various small metal objects effortlessly. Despite its remarkable performance, the circuit's power consumption remains minimal, underscoring its useability.
Conclusions: The circuit surpasses expectations, delivering exemplary results in achieving levitation objectives. Its versatility extends beyond mere functionality, as it exhibits adaptability to diverse objects and potential for further refinement. Moreover, the circuit's innovative design facilitates the inversion of the electromagnet, enabling suspension of objects in unconventional orientations, thus broadening its applicability and potential impact. 

THE SURGICAL MANAGEMENT OF RECURRENT ADULT GRANULOSA CELL TUMOR OF THE OVARY-A CASE REPORT

First author: Raul-Ioan Gârbacea

Coauthors: Ana-Ilinca Gherghe Bianca Forna Bianca-Alexandra Savin Ioana-Alexandra Burghelea

Coordinator(s): Lecturer Bogdan Stancu

Keywords: Adult granulosa cell tumor of ovary Radical surgery Giant tumor

Introduction: Adult granulosa cell tumor of ovary is the most common type of ovarian granulosa cell tumor, accounting for 95% of cases. Radical surgery is the primary treatment for patients diagnosed with this type, given its resistance to chemotherapy. However, recurrence occurs in 25%-30% of patients. Tumor recurrences typically average around 7.1cm, but in certain cases, these recurrences can greatly increase, affecting the surrounding anatomical structures.
Case Report: We report the case of a 55 year-old female known with total hysterectomy with bilateral adnexctomy in 2015, the histopathological diagnosis at that time indicates an ovarian adult granulosa cell tumor and endometrioid adenocarcinoma with squamous differentiation of the uterine body. The patient presents with mid-abdominal pain, slowed digestive transit, asthenia, and fatigue. Upon physical examination, mid-abdominal tenderness with a parietal defect at the site of the old postoperative scar with an irreducible incisional hernia is noted. CT and PET CT examinations performed prior to hospitalization reveal a left abdominopelvic tumor formation measuring 20x25cm with infiltrative characteristics involving intestinal elements: ileal loops and the descending colon, as well as the antral portion of the stomach. After surgical intervention, the histopathological examination of the extracted specimen categorized it according to the TNM classification as stage T2N0M0R0.
Discussions: The surgical intervention is the first-line treatment, and the location of tumor recurrence can vary. The most frequent sites of tumor recurrence are the abdominal cavity and the pelvis; additionally, the tumor most commonly metastasizes to the pelvic area, followed by the liver and small intestine. The patient underwent a xiphopubic laparotomy, during which a recurrent giant retroperitoneal tumor (20x25cm) was identified, intimately adherent to surrounding anatomical structures at the abdominal level: the descending colon, the left ureter, and the left iliac vessels. A left hemicolectomy with latero-terminal anastomosis was performed en bloc with the retroperitoneal tumor, which was previously adherent to the left iliopsoas muscle.
Conclusions: The presented case highlights the importance of surgical treatment in the recurrence of an adult ovarian granulosa cell tumor, aiming to prevent the development of distant metastases, but most importantly, to improve the patient's quality of life.

Navigating Complexities in Ischemic Stroke Management: A Case Study of Tandem Arterial Occlusions and Endovascular Intervention

First author: Septimiu Cioloboc

Coauthors: Jasmina Cioloboc Stefan Vunvulea

Coordinator(s): Medical Doctor Lucian Mărginean , Medical Doctor Vlad Vunvulea

Keywords: ischemic stroke tandem arterial occlusions endovascular thrombectomy aspiration thrombectomy

Introduction: Stroke is a common medical condition where the blood flow of the brain is suddenly stopped, leading to different neurological deficits. It mostly affects individuals aged 55 or above, but it can occur at any age. The stroke can come as an ischemic stroke, hemorrhagic stroke or even transient ischemic stroke. The most common type is the ischemic stroke, which can further come as large artery atherosclerosis, cardioembolic, small vessel disease, or other forms.
Case Report: We present the case of a 37-year-old male patient who suffered an ischemic stroke. The patient underwent a comprehensive treatment protocol, including endovascular thrombectomy, following the identification of an obstruction of the internal carotid artery. Prior to the intervention, the patient underwent radiological and imaging investigations at the radiology department, where several CT scans were performed. The patient was referred to our clinic after a thorough neurological examination, with tandem stroke, trough simultaneous occlusion of the cervical segment of the internal carotid artery, and middle cerebral artery. Initially, aspiration thrombectomy was attempted using an aspiration catheter, yielding only partial success. Eventually, combined thrombectomy was performed, where an aspiration catheter alongside a stent retriever was deployed, to capture the thrombus. The procedure was complicated by the thrombus fragmentation and migration into the upper trunk of the middle cerebral artery. After numerous attempts, successful recanalization was obtained, with the ischemic stroke attributed to an embolic thrombus originating from the heart, associated with the patient's atrial fibrillation.
Discussions: The presented case highlights the complexity often encountered in managing ischemic strokes, particularly in younger patients. The use of a comprehensive treatment approach, including endovascular thrombectomy, highlights the evolving landscape of stroke management, where timely intervention is crucial to mitigate potential long-term neurological deficits. The tandem occlusion of the cervical segment of the internal carotid artery and middle cerebral artery poses an incredible challenge, employing innovative strategies such as combined thrombectomy to address the obstruction effectively.
Conclusions: In conclusion, this case highlights the challenges and complexities in managing ischemic strokes, particularly when tandem arterial occlusions occur with embolic origin. Despite procedural difficulties, successful recanalization was achieved, emphasizing the importance of strategizing, adaptability and perseverance in stroke interventions. 

Logarithmic scale display system

First author: Homorozan Mihai-Daniel

Coordinator(s): Associate Professor Zoltan German-Sallo

Keywords: Logarithmic display system LED display driver Data visualization

Background: In the context of increasing data volume, it is essential to develop effective visualization tools. This abstract presents an innovative logarithmic display system extended to 19 LEDs, which aims to simplify the interpretation of complex data and improve decision making. 
Objective: The purpose of this project is to obtain an universal indicating tool which can be used in different measuring applications. The display should be at logarithmic scale and at a good resolution. This tool will optimize data visualization, its accuracy facilitates the interpretation of different data. 
Material and Method: This logarithmic display system is based on a LED display driver. This driver is a monolithic integrated circuit that senses analog voltage levels and drives ten LEDs providing a logarithmic 3 dB/step analog display. In order to obtain a better resolution, the number of driven LEDs is extended to nineteen. The assembly is composed of a total of 19 various colored LEDs, the colors can be chosen according to the type of measurement. The construction and expansion of this LED display is carried out using the integrated circuit LM3915. 
Results: The obtained circuit is able to display various measured parameters, if they were converted before in an electrical signal of a certain voltage and frequency domain. The most important parameters could be temperature, humidity, sound level. 
Conclusions: The extension of the LED display drivers domain offers a better and accurate resolution of the measured parameters. Using different analog interfaces, this LED driver can be adapted for other types of measurements. 

The importance of the Helkimo Index in assessing TMJ involvement in dento-maxillary anomalies

First author: Khaled Madani

Coauthors: Mădălina-Nadina Rotaru

Coordinator(s): Professor Mariana Păcurar

Keywords: Helkimo index Anomalies TMJ dysfunction Orthodontic

Background:  Dento-maxillary anomalies are characterized by changes in the size, shape, position and inclination of the morphological elements that make up the stomatognathic system. Recent studies demonstrate the fact that not only traumatic occlusion (OT) is the etiological factor of TMJ dysfunction. Created by the M. Helkimo in 1972 to investigate the prevalence and severity of signs and symptoms of temporomandibular dysfunction.
Objective: The aim of the study was to evaluate the prevalence of TMJ pathology using the Helkimo's index in patients in the Orthodontic department with clinical examination and anamnestic data.
Material and Method: The study was carried out on a group of 78 patients from the belong to Orthodontic department case with various dento-maxillary anomalies and TMJ suffering. We statistically processed the data obtained from the clinical examination, in order to analyize the situation of patients with temporomandibular dysfunction compared to that of patients without joint disorders at the time of the initial examination. 
Results: Most patients with class II/2 anomalies: 42.86% presented an anamnestic index of I, and a percentage of 20.69% had a Helkimo anamnestic index of II. So with this type of anomaly, the patients indicated obvious signs of TMJ dysfunction. The Helkimo anamnestic index had the highest scores in the II/2 Angle anomaly in the female sex, followed by class II/1 Angle anomalies in the male gender. 
Conclusions: The most important examination in the case of TMJ pathology is represented by the thorough clinical examination. There is a directly proportional relationship between the degree of severity of the malocclusion and the Helkimo index points.  

A RARE CASE OF HYDATID CYST WITH CENTRAL NERVOUS SYSTEM INVOLVEMENT

First author: Paul Frigură

Coauthors: Cansu Özcan Teodora- Karin Gligor Vasileios- Aiakos Lykouris Mihai Roman

Coordinator(s): Professor Ata Nevzat Yalçin , Medical Doctor Seval Yalçin

Keywords: Hydatid cyst Albenzdazole Central nervous system

Introduction: Hydatid cyst is a very rare disease in our days and furthermore central Nervous system involvement is uncommon.
Case Report: We present the case of a 46 years old patient that was admitted to the emergency department with complaints of new onset of nonsensical movements, speech and inability to recognize his relatives. He had no known comorbidities. He had been on oral ornidazole and naproxen for two weeks for hydatid cyst and an operation was planned. On physical examination, he was unoriented and incoherent. In laboratory results, hemoglobin level was low; platelets were normal; leukocytes, CRP, ALT, AST, ALP, GGT, bilirubins were elevated. The preliminary report of brain CT imaging was interpreted as normal and In the preliminary report of brain MRI Hydatid cyst was interpreted as central involvement . Lumbar puncture could not be performed in the emergency department because of high INR. Two sets of blood cultures were obtained, Albendazole 2*400 mg; ceftriaxone 2*2000 mg iv and vancomycin 4*500 mg iv were started. Infective endocarditis screening tests were requested. He was hospitalized in the intensive care unit and follow-up was started. He developed a fever in the intensive care unit. Brain MRI report was evaluated in favor of foreground abscess foci. Metronidazole 4*500 mg iv was added to the treatment. Also Streptococcus intermedius was found in the blood culture and gentamicin 5mg/kg was started. The dynamic CT imaging of the liver revealed that intra-abdominal ascites was observed in the preliminary interpretation. The patient underwent paracentesis and leukocytosis was present in the  sample cell count. Radiology was consulted again and rupture of one of the abscess foci in the left liver was suspected. The patient underwent emergency operation and five liters of intra-abdominal abscess material was drained . Fluconazole 1*400 mg iv was added. Echocardiography performed for  endocarditis revealed no vegetation. The patient was transferred from ICU to gastroenterology clinic.  
Discussions: The presence of multiple infections in a patient with a Hydatid Cyst can pose challenges in treatment and selecting the appropriate medication. Effective management requires a multidisciplinary approach involving medical specialties such as Infectious Diseases, Intensive Care, Gastroenterology, General Surgery and Radiology.
Conclusions: During the follow-up, ESBL positive Klebsiella pneumonıae was grown in sputum culture. Ceftriaxone was discontinued and changed with meropenem 3*2000 mg iv. The patient was evaluated with control tomography imaging and discharged with completely healing. 

Preliminary nutritional insights on high fat diet in animal models for MAFLD/NAFLD preclinical studies

First author: Rodica TALMACI

Coordinator(s): Lecturer Irina Mihaela MATRAN

Keywords: MAFLD/NAFLD animal models Sprague-Dawley rats high fat diet

Background: Non-alcoholic fatty liver disease (NAFLD) or the newly changed name Metabolic dysfunction-associated fatty liver disease (MAFLD) is a growing global health problem driven by high fat and sugar diet and a sedentary lifestyle. Untreated severe forms of NAFLD can lead to cirrhosis and hepatic carcinoma. There is a lack of clinically relevant preclinical models for fatty liver disease. This problem has led to most drug candidates that were successful in preclinical development failing once they reach clinical trials. Animal models are crucial for improving our understanding of human pathogenesis, enabling researchers to identify therapeutic targets and test novel drugs and nutraceutical products. The only recommendations for NAFLD are a healthy diet, lifestyle and food supplements.
Objective: It is crucial to test new drugs or food products on animal models that reflect the biology of the conditions we wish to treat in humans. As MAFLD defines a new pathological condition, there is an urgent need to create new animal models that reflect MAFLD and its subtypes: overweight/obese MAFLD, diabetes MAFLD and metabolic syndrome MAFLD. Development of food product for special nutritional states, adjuvant in the treatment of non-alcoholic hepatic steatosis and preclinical verification of its effectiveness are the study objectives. Recognition of these three subtypes of MAFLD will be translated into clinical trial design in the future to test innovative food product in more homogenous patient populations in terms of pathological processes. Material and Method: The present study is an experimental, preclinical study, carried out on laboratory animal models represented by thirty-two Sprague-Dawley rats, both males and females of 6 months of age, hosted in individual cages. Animals were fed with either standard nutrition or a high-fat diet, containing a high proportion of fat calories. Body weight, urine, blood sugar, and 11 hepatic parameters were analyzed at the end of the adaptation period and induction period.
Results: Sprague-Dawley rats showed overweight/obese status in 10% of rats. No significant differences in biochemical, glycemic and urine parameters have been observed in the first month of induction. The more significant differences have been observed between female and male rats.
Conclusions: We focus on issues such as reproducibility and practicality, discussing the advantages and weaknesses of available models for the future animal studies on MAFLD/NAFLD. In conclusion, the strain of the animals included in the research, individual differences, gender, diet and microclimate conditions should be taken into account when designing a study that may provide new ways to advance therapeutic strategies.

EXPLORING THE IN SILICO PRO-APOPTOTIC POTENTIAL OF TRITERPENE-TRIAZENE DERIVATIVES

First author: Elisabeta Atyim

Coauthors: Marius Mioc

Coordinator(s): Professor Codruța Șoica

Keywords: pentacyclic triterpenes triazene derivatives pro-apoptotic molecular docking

Background: Lupane-derived triterpenes are naturally occurring chemicals researched as fundamental frameworks for the synthesis of various semisynthetic compounds. Numerous such structures were reported as potential active agents, particularly against cancer. These structures have been found to primarily induce apoptosis in cancer cells by blocking the function of anti-apoptotic proteins (Bcl-2 and Bcl-XL). Triazenes are chemical structures that contain the -N=N-N- group. A wide range of compounds incorporating this functional group have been extensively investigated for their potential as anticancer agents in various tumour types.
Objective: Our current project aims to develop a range of triterpene-triazene hybrid compounds that can theoretically inhibit the anti-apoptotic proteins Bcl-2 and Bcl-XL. 
Material and Method: Triterpene-triazene hybrids were generated by linking triazene functional groups to C30 of lupane-derived compounds such as lupeol (Lup), betulin (Bet), and betulinic acid (BA) (30-(Aryl-azo-R-amino)-triterpene; Aryl: phenyl, 1-naphtyl, or p-substituted phenyl rings; R: n-propyl, iso-propyl, n-butyl, iso-butyl, or H; triterpene: lupeol (Lup), betulin (Bet) or betulinic acid (BA)). The structure of Bcl2 and Bcl-Xl was obtained from https://www.rcsb.org/ (PDB IDs: 2W3L, 2YXJ). Molecular docking was employed using PyRX with Vina’s scoring function. The triazene-triterpene hybrids, their parent compounds, and the native ligands (NL) were docked in the active binding site of each protein. The results were expressed as binding affinities (kcal/mol). The NL for each protein was employed as the primary positive control, with Lup, Bet, and BA serving as secondary controls for each subgroup.
Results: In the case of Bcl-XL, some compounds showed higher binding affinities than their parent molecule or the NL (-10.8 kcal/mol). These include the 30-(1-naphtyl-azo-isopropylamino) (-11.6(BA), -11(Bet), -11.2(Lup) kcal/mol) and 30-(1-naphtyl-azo-amino) derivatives (-11(BA), -11.5(Bet), -12.1(Lup) kcal/mol) of all three triterpenes. Other BA hybrids that outperformed the NL were 30-(1-p-chloro-pheny-lazo-amino)-BA (-11 kcal/mol) and 30-(1-naphtyl-azo-isobutylamino)-BA) (-11.1 kcal/mol). In the case of Bcl-2, triterpene derivatives containing the 1-naphtyl-azo-isobutylamino group exhibited binding affinities close to the NL. A similar trend was observed for these compounds in the previous case (Bcl-XL), demonstrating that these structures have the potential to act as dual Bcl2/Bcl-XL inhibitors.
Conclusions: Triterpene-triazene hybrids represent a promising scaffold for the development of new semisynthetic triterpenoids with increased pro-apoptotic-based antiproliferative activity. Future research will focus on the synthesis and biological evaluation of the most theoretically active compounds reported here.

Complete remission of Vein of Galen aneurysmal malformation: a case report

First author: Maria Pîrcălabu

Coauthors: Oana Maria Popescu Florin-Alexandru Popa Cristiana Petrus

Coordinator(s): Professor Ștefania Tudorache

Keywords: Vein of Galen aneurysmal malformation Doppler technique complete spontaneous remission

Introduction: Vein of Galen aneurysmal malformation (VGAM) has an incidence of 1% of all fetal arteriovenous vascular abnormalities. The first-choice method for the diagnosis is two-dimensional real-time ultrasound (US), and the Doppler mode confirming the vascular nature of the malformation. Two methods that are currently used for treatment are: endovascular transarterial embolization and direct surgical removal. The mortality remains around 50%.
Case Report: A 24-year-old woman was referred to the Prenatal Diagnosis Unit of the Emergency University County Hospital of Craiova at 34 weeks and 5 days of gestation, with a suspicion of fetal cerebral vascular malformation. All clinical data and fetal US parameters were within normal limits, except for the presence of a hypoechogenic structure containing a turbulent arterial and venous flow. The structure was located in the midline of the posterior part of the third ventricle. The dilatation of the straight sinus was observed. Three-dimensional multiplanar images were instrumental in localizing the abnormal structure. A magnetic resonance imaging (MRI) exam was performed at 36 weeks, confirming the sonographic findings and no associated brain parenchyma abnormalities. Despite the isolated aspect of the malformation, the parents were informed about the poor postnatal outcome. At 37 weeks and 3 days a female neonate was delivered by cesarean section, with an Apgar score of 9 and weighing 2720 g. The transfontanellar US confirmed the diagnosis of VGAM. Mild cardiac complications and pulmonary hypertension were noted during the immediate postnatal period. At 3 months of age, a subsequent MRI revealed partial closure of the aneurysm and a normal ventricular system. At 32 months, an angio-MRI showed an entirely normal intracerebral vascular system. Currently, the child is completely asymptomatic at 5 years of age, having normal neurodevelopment.
Discussions: The VGAM is characterized by the presence of numerous arteriovenous shunts linking the vein of Galen with the choroidal arteries. This pathology occurs more in male than female patients. The possible consequences of the pathology are the “vascular steal effect” and the overload of the right heart. Heart failure and cerebral damage are commonly seen. This congenital malformation has usually an ominous outcome.
Conclusions: To our knowledge, this is the first documented case of spontaneous, complete remission of the VGAM, occurring at approximately 32 months post-birth. The single medical intervention was careful monitoring.

Signal synthesizer

First author: Vultur Cristina - Gabriela

Coauthors: Pilca Denis-Cristian Murar David

Coordinator(s): Associate Professor Zoltán Germán-Salló

Keywords: Signal synthesizer electronics frequency stability communications

Background: Sinusoidal signal synthesizers are crucial for electronic engineering and communications as they generate precise and stable signals required for various applications. These circuits operate by generating elementary waveforms through voltage or frequency controlled oscillators, which are then combined, amplified, and filtered to produce the desired waveform.  
Objective: This presentation is intended to provide a thorough explanation of the operating principles of sinusoidal signal synthesizers and emphasize their significance in electronics and communications. It also proposes analyzing the advantages and applications of these synthesizers in engineering and science while evaluating their performance within a specific context to understand their capabilities and limitations.  
Material and Method: The research method involves a blend of theoretical analysis and practical experiments to evaluate the performance of sinusoidal signal synthesizers. Analog circuits that use operational amplifiers are used to synthesize digital signal sources created with numerical circuits. The use of components such as logic gates, binary counters, decoders, and operational amplifiers occur. Altering the frequency of elementary signals allows for the synthesis of a wide range of signals. The project implementation encompasses theoretical study, computer simulation, and practical realization.
Results: The results of the experiments demonstrated that the synthesizer is capable of producing signals with high frequency stability and low harmonic distortion under normal operating conditions. The performance of the device was consistent with the technical specifications and met the requirements of the application. The voltage and frequency ranges obtained correspond to the parameters required for these electronic equipment. Possible limitations of the signal synthesizer in certain usage scenarios were also identified and discussed.  
Conclusions: In conclusion, signal synthesizers are essential tools in the field of electronics and communications, providing a stable and accurate signal source for a variety of applications. Understanding their operating principles and assessing their performance are important for ensuring the correct and reliable operation of electronic systems. At the same time, the continuation of research and the development of technologies associated with sinusoidal signal synthesizers can bring significant benefits in the field of engineering and science. This principle can also be transposed into programmable devices (microcontrollers, FPGA structures, reconfigurable hardware).

Epigenetic dysregulation in liver cells after Hepatitis C Virus eradication

First author: Carmen-Elena Chiferiuc

Coordinator(s): Lecturer Liliana Vecerzan

Keywords: Epigenome Hepatitis C Virus Direct-acting antiviral Hepatocellular carcinogenesis

Background: Direct-acting antiviral agents (DAA) had a profound impact regarding the treatment of hepatitis C infection, resulting in sustained virological response (SVR) in over 90% of patients that use DAA therapy. Although obtaining SVR was associated with a decreased risk of developing hepatocarcinoma (HCC), there are still direct (virus-induced) and indirect (fibrosis, inflammation related) factors that influence this possibility, even after HCV eradication.
Objective: The aim of this study is to highlight the importance of epigenetic dysregulations that persist after using DAA and obtaining SVR, therefore explaining a part of the molecular pathway involved in hepatocellular carcinogenesis.
Material and Method: An advanced search of the PubMed database was conducted, using Boolean querying: (hepatocarcinoma) OR (hepatocellular cancer) AND (epigenetic) AND (hepatitis C) NOT (hepatitis B) AND (direct-acting antivirals). The research resulted in 15 articles, out of which four did not meet the inclusion criteria. 
Results: Experiments using patient liver biopsies, cell cultures and chimeric animal models consistently found persistent changes in DNA methylation of cytosine-phospho-guanine (CpG) dinucleotides in regulatory gene elements, histone modifications and involvement of noncoding RNAs. HCV infection influences the expression of key genes that promote carcinogenesis: the inactivation of tumor suppressor genes by hypermethylation and hyperexpression of oncogenes by hypomethylation. Another change persistently found was acetylation of histone H3 at position lysine 27 (H3K27Ac), which is an activation marker for transcription that is considered to be an important causal factor for developing HCC after SVR. Other persistent histone changes were found: H3K9Ac, H3K4Me3, H3K4Me1, H3K27Ac,H3K27Me3, H3K9Me3. One of the mechanisms that is involved in these processes is related to the elevated expression of DNA methyltransferase 1 and 3b and histone deacetylase 1 induced by HCV core protein. HVC infection also deregulates non-coding RNA expression, which in turn affects gene expression and is linked to carcinogenesis. Importantly, it was found that more than half of the epigenomic modifications were persistent after treatment with DAA and obtaining SVR. 
Conclusions: HCV infection alters the epigenetic memory of hepatocytes, changes that persist even after obtaining SVR. These findings suggest that chemoprevention research should focus on finding ”epidrugs” that would reverse the epigenetic imprinting left on liver cells, considering even personalized medicine. It is also important to acknowledge that the detection of patients with significant epigenomic dysregulations after DAA treatment might be a predictive tool for developing HCC. 

Operating Principles and Significance of Signal Synthesizers in Electronics and Communications

First author: Pilca Denis-Cristian

Coauthors: Vultur Cristina - Gabriela Murar David

Coordinator(s): Lecturer Germán-Salló Zoltán

Keywords: Signal synthesizer electronics communications harmonic distortion

Background: Signal synthesizers are a crucial component in electronic engineering and communications. These circuits can generate precise and stable signals of various forms, playing essential roles across a wide array of applications. These include testing and troubleshooting electronic equipment, scientific research, and applications within the communications industry. The underlying principle of a signal synthesizer lies in generating elementary waveforms through voltage or frequency-controlled oscillators. These waveforms are subsequently combined, amplified, and filtered to attain the desired signal waveform.
Objective: This presentation endeavors to offer a thorough and all-encompassing comprehension of the operational principles governing signal synthesizers, thereby emphasizing their paramount importance within both the realms of electronic engineering and communication technologies. Moreover, it aspires to delve into a detailed analysis of the myriad advantages and pragmatic applications of signal synthesizers across a diverse spectrum of engineering and scientific disciplines. Additionally, it aims to conduct an exhaustive performance evaluation of a signal synthesizer within a specific context, thereby endeavoring to attain profound insights into its multifaceted capabilities and inherent limitations.
Material and Method: The research methodology encompasses a blend of theoretical analysis of signal synthesizer operational principles and practical experiments aimed at assessing their performance. Basic signal sources (digital signals) generated using numerical circuits are utilized and then synthesized using analog circuits based on operational amplifiers. Electronic components such as logic gates, binary counters, decoders, and operational amplifiers are employed. By altering the frequency of elementary signals and the synthesis mode, a diverse range of signals can be obtained. The project implementation stages involve theoretical study, computer simulation, and practical realization.
Results: Experimental findings demonstrate that the synthesized signal generator exhibits high frequency stability and low harmonic distortion under normal operating conditions. The device's performance aligns with technical specifications and meets application requirements. The voltage and frequency domains achieved align with the parameters necessary for electronic equipment. Additionally, potential limitations of the signal synthesizer in specific usage scenarios are identified and discussed.
Conclusions: In conclusion, signal synthesizers play a crucial role in both electronic and communication domains, serving as stable and precise signal sources for a multitude of applications. Understanding their operational principles and evaluating their performance are essential for ensuring the accurate and reliable functioning of electronic systems. Furthermore, continued research and development of technologies associated with signal synthesizers hold substantial promise for advancements in engineering and science. This principle can also extend to programmable devices such as microcontrollers, FPGA structures, and reconfigurable hardware.

Pneumosepsis in a Young Patient with Systemic Lupus Erythematosus

First author: Teodora- Karin Gligor

Coauthors: Vasileios- Aiakos Lykouris Paul Frigură Seval Yalçın Tudor Dima

Coordinator(s): Professor Ata Nevzat Yalçin , Medical Doctor Cansu Özcan

Keywords: systemic lupus erythematosus (SLE) pneumosepsis infections immunosuppressed

Introduction: Systemic lupus erythematosus (SLE) is characterized by immune system dysfunction and is clinically heterogeneous, exhibiting variable and multisystemic symptoms. Pneumonia is a common clinical entity, especially of concern in immunocompromised individuals who have worse outcomes than seen in the general population.
Case Report: A 29-year-old man diagnosed with Systemic Lupus Erythematosus and Hereditary Angioedema was admitted to the nephrology service, due to anemia and acute renal failure, which was confirmed to be Class IV Lupus Nephritis. After treatment with pulse steroids, he was discharged with oral prednisolone and mycophenolate mofetil (MMF). The next day, he presented to the rheumatology outpatient clinic with a deteriorating general condition, fever, and cough, and was subsequently admitted to the ward. He was transferred to the intensive care unit (ICU) the following day due to respiratory distress, hypotension, and the need for positive inotropes and vasopressors. The infectious diseases consultant recommended meropenem 2g IV q12h, vancomycin 1g IV q24h, a PCR examination for viral respiratory tract agents, chest radiography, blood culture, sputum culture and smear examination, complete urinalysis, and urine culture examination. High-resolution CT of the lungs showed nodular densities tending to consolidate in both lungs, more pronounced in the lower lobes, suggestive of infection. A day later, due to persistent fever, rales on lung examination, and increased CRP and lactate levels, amikacin 7.5 mg/kg IV was added to the antibiotic therapy for suspected pneumosepsis. The antibiogram of peripheral blood culture revealed Pseudomonas aeruginosa susceptible to meropenem, tobramycin, and amikacin; intermediate to imipenem and piperacillin/tazobactam; resistant to levofloxacin, cefepime, and ceftazidime. The patient showed improvement and was transferred to the rheumatology service continuing his treatment. Intravenous antibiotic therapy was completed with meropenem, vancomycin, and amikacin. In the follow-up, there was improvement in acute phase reactants, renal function tests, and clinical status. Control tests showed no microorganisms in the smear and the patient was discharged.
Discussions: Immunocompromised patients such as SLE patients are vulnerable to opportunistic infections. To avoid the high morbidity and mortality associated with pneumonia in such patients, it must be diagnosed and treated early on in the disease process. Conclusions: Although pneumonia is rare in patients diagnosed with lupus (1-10%), it is a clinical condition with mortality. Broad-spectrum antibiotics and immunosuppressive treatment should be started earlier, and necessary precautions should be taken to avoid other complications and close follow-up should be done.

SURGICAL APPROACH IN AN ULCERATIVE COLITIS PATIENT UNRESPONSIVE TO MAXIMAL THERAPY

First author: Sofia Larrea Sánchez-Monge

Coauthors: Carla Forne Navarro Maria Victoria Gonzalez Giuseppe Biagio Robillotta Natalia Fornells Gómez

Coordinator(s): Assistant Professor Adina Roman

Keywords: Ulcerative colitis Refractory UC Surgical management

Introduction: Ulcerative colitis (UC) is an inflammatory bowel disease (IBD) characterized by chronic mucosal inflammation of the rectum, colon, and cecum. Symptomatically it is characterized by bloody diarrhea and fecal urgency. Long-term risk for colon cancer is elevated, being one of the most common causes of mortality in IBD, together with infections and surgery complications. A colonoscopy is required for definitive diagnosis, and laboratory findings such as inflammatory markers and fecal calprotectin are useful to assess the disease severity. Medical treatment must be individualized, following a step-up pattern with the goal of achieving remission. Surgery can be considered if medical therapy is unsuccessful.
Case Report: A 26 year-old man is diagnosed with ulcerative pancolitis in March 2022, receiving as initial treatment 5-ASA and Azathioprine without success. In October 2022 he presents in the Gastroenterology clinic with fecal calprotectin 6000mcg/g, elevated inflammatory markers, and a positive result for Clostridium Difficile A+B toxins. One month later he is admitted in the department with similar laboratory values. Endoscopy is performed showing an edematous, hemorrhagic, friable mucosa with inflammatory polyps throughout the entire colon. He is diagnosed with a severe active pancolitis, MAYO score 10 and given as treatment corticosteroids, 5-ASA, and Adalimumab. Clinical remission is achieved for 7 months. In June 2023 the patient presents 4 semisolid stools with rectorrhagia, Hgb 10.4mg/dl, fecal calprotectin 7329mcg/g and same endoscopic aspect. Previous treatment is modified with Infliximab, with good response for one month, after which fecal calprotectin elevates to 7000mcg/g.
Discussions: Long-standing UC leads to complications such as toxic megacolon, colonic perforation, infections and increased colorectal cancer risk, the last one directly correlated with the duration, extension, and presence of inflammatory pseudopolyps. Long-term management of the disease includes colorectal cancer screening, performed by a colonoscopy with biopsies every 1-5 years. However, given the condition of our patient, having pseudopolyps throughout the whole colon, dysplasia cannot be properly assessed. Moreover, medically refractory UC represents one of the main indications for surgical treatment. This includes steroid-dependency and immunomodulator or biologic-refractory disease. The absolute contraindication for surgical treatment of UC is anal sphincter dysfunction and suspected Crohn's disease. The procedures of choice are proctocolectomy with an ileal pouch-anal anastomosis or total proctocolectomy with end-ileostomy
Conclusions: Considering the patient's age, lack of comorbidities, treatment refractoriness, endoscopic findings, and the risk of complications from uncontrolled disease activity, surgical intervention should be considered.

"Enhancing Longevity of Total Hip Arthroplasty in Paprosky Type II and III Acetabular Defects: A Study on the Efficacy of Reinforcement Devices and Bone Grafting"

First author: Dobrin Alexandru

Coordinator(s): Professor Pop Tudor-Sorin

Keywords: revision reinforcement device bone graft Paprosky defects

Background: The long-term success of total hip arthroplasty (THA) is contingent upon effective management of acetabular defects, which represent a substantial challenge in reconstructive orthopedic surgery. Complexity of these defects, particularly Paprosky type II and III, requires innovative approaches to ensure the stability and longevity of the prosthetic joint. Use of reinforcement devices (RD) combined with bone grafting has emerged as a promising technique to address this issue, aiming to restore the hip's anatomical structure and function. Objective: This study was designed to evaluate the radiological outcomes of acetabular reconstruction using RD and autologous bone grafting in patients with Paprosky type II and III acetabular defects. We aimed to assess the effectiveness of this combined approach in achieving resilient hip function and reducing the need for subsequent revision surgeries. Material and Method: A comprehensive retrospective analysis in a time span of 10 years was conducted on a cohort of patients 18 (18 hips), out of which 4 patients underwent acetabular reconstruction with RD and bone grafting. Patients were followed for an average of 1.7 years. Radiographic evaluations were performed to monitor the stability of the hip center of rotation, integrity of the medial acetabular wall, and the integration of the bone grafts. Results: The study demonstrated that acetabular reconstruction with RD and bone grafting achieved stable reconstruction outcomes, evidenced by the osseointegration of bone grafts and RD devices postoperatively in surrounding tissue at the final follow-up. Only one patient had implant mobilization due to trauma at the five-year mark, but not due to osteolysis. Conclusions: Our findings suggest that acetabular reconstruction using RD and bone grafting offers a reliable and effective treatment option for significant acetabular defects. This approach provides satisfactory mid-term outcomes, enhancing the prospect of achieving long-term prosthetic joint stability and reducing the incidence of revision surgeries