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Volume XVIII, Number 2, 2014 - Therapeutics Pharmacology and Clinical Toxicology

Review


The European HIV AIDS & Infectious Diseases Academy 5 Years and on-going!

Abstract: The European HIV/AIDS & Infectious Diseases Academy launched in Bucharest/Romania in the summer of 2009 celebrates its fifth anniversary. The Academy has been created as an educational and research institution for defining clinical, epidemiological and logistic particularities in HIV infection for Central and South-East Europe, aiming to optimize its management.

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Influenza infection and neurologic complications

Visan Angelica, Luminos Monica, Negulescu Cristina, Draganescu Anca, Bilasco Anuta, Vasile Magdalena, Mantescu Ruxandra, Merisescu Madalina, Slavu Diana, Dogaru Cornelia, Streinu-Cercel A.
Abstract: Purpose: Influenza infection is associated with a wide range of neurologic complications, that imposes a recognized burden of central nervous system diseases. The emergence of influenza A H1N1 virus has been linked to important neurological involvement. Scope: Our objective with this paper was to make a review of the neurological manifestations related to influenza A H1N1 virus in different countries of the world, so as to highlight the variety of clinical aspects of the pandemic virus. We will present the investigations used, but also the hypothesis of the pathogenic mechanisms involved in each case. Conclusions: Neurological manifestations of influenza A H1N1 virus infection appear to be variable in severity, from febrile seizures to encephalitis with malignant clinical course, complicated by high morbidity and mortality. Since the H1N1 influenza virus was not detected in the cerebrospinal fluid of the patients with this diagnosis, the emerging view is that the host immune response plays a key role in pathogenesis. This review can contribute to establish future management of neurological complications, especially when influenza continues to be a real threat in our life.

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Original Papers


Inappropriate use of PPIs to patients admitted into a non ICU gastroenterology department

Neag Maria, Boc.an Corina, Popa Adina, Campean R., Mircea P.A.
Abstract: It is a fact that more frequent evidences are showing that proton pump inhibitors (PPIs) are used improperly. This contributes, on one hand, to the increase of the cost of health care services, and on the other hand, is impairing the safety and quality of patients lives. The aim of this study was to identify whether, in a non ICU ward, PPIs are used with respect for the current clinical guidelines. The research is based on the assessment of therapeutic schemes of 98 patients which were hospitalized in a non-ICU ward, summarizing 236 days of treatment with PPIs. PPI administration was analyzed in related to indication, dose, route of administration and drug interactions. We also tried to determine if there is a potential cost of PPI therapy which could, potentially, be saved. We have found that that PPIs were unnecessarily administered in 8.05% of days, having inadequate doses in 21.61% of days, there have been interactions for 1.69% of days, and route of administration was inadequate for 10.17 % of days. By comparing the total cost with the potential total cost, the first was found as significantly higher. So, PPIs are being used inappropriately to some of the patients admitted to non-ICU ward. A solution for improving PPI therapy might be to include a clinical pharmacologist as part of the medical team and follow minimal prescribing rules.

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Assessing the effectiveness and safety of pharmacological therapy in children diagnosed with attention deficit and hyperactivity disorders

Davitoiu Ana Maria, Truta Elena, Negulescu Cristina, Constantin Laura, Stoica Alexandra, Plesca Anca Doina
Abstract: Deficit Hyperactivity Disorder (ADHD) is considered to be a neurodevelopment condition with a worldwide prevalence between 3-10 % in children1 with symptoms that could continue into adolescence for 50-80% of cases and into adulthood for as many as 30 - 50 % of cases. The purpose of the research was to evaluate the efficacy and safety of pharmacological treatment in attention deficit hyperactivity children. A retrospective clinical research in 73 patients was designed and carried out at ″Victor Gomoiu″ Clinical Pediatric Hospital. The data was obtained from patients medical records. The study duration was 15 months from Jan 2013 to March 2014. The medical treatment was analysed: type of drugs given, dosage, pharmaceutical formulation, length of treatment. We also analysed the types of non-medical treatments associated: psychological therapy, logopedic therapy, occupational and cognitive stimulation therapy, other types of therapy. Monthly monitoring and identification of adverse events was done for each patient by analysing the type of medication given, adverse event onset, severity, dose optimization, withdrawal from treatment or change of medication. Data was stratified for three age groups: preschool children (< 7years old), 12 to 18 - year-olds and 7 to 11 - year- olds. Combined therapy (both medical and psychological) gave results but without being able to determine the measure in which either the psychological, pharmacological or combined treatment have influenced the end result. Early detection and management of side effects (dose optimization, change of medication, drug combinations that diminish or even eliminate the side effects, treatment interruption) improve compliance and adherence towards the given medical treatment but also improve the quality of life.

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Therapeutical Practice


Prediction scores and complexity of physical therapy approach in the Intensive Care Unit of the Clinical Emergency Hospital Bucharest

Popescu G., Macovei R.Al., Ilie Madalina, Constantinescu G., Stanciulescu Elena-Luminita, Patru Cristina, Paun M.Al., Grinsescu Ioana Cristina, Grinsescu Ioana Marina
Abstract: Evaluation scores of critically ill patients began to develop in the ′70s, in an attempt to create a real model to allow the quantification of disease severity, outcomes, prognosis and mortality rate of hospitalized patients in ICU. Over time many such scores were developed, some of them have lost practical value, being no longer in use, others are important tools in assessing critically ill patients.There are basically four areas of application of these scores: research and clinical trials - for this purpose, scores serve as common, standardized tools of patient comparison, as a common language for researchers and clinicians, who may thus decide how the results of clinical research can influence their daily practice; administrative field - refers to the capital allocation depending on the disease severity, to cost-effectiveness analysis; performance assessment field: comparative performance assessment of ICU from year to year is important, as well as, individual performance assessment; assessment of individual prognosis and treatment protocols or decisions. There are four known validated prediction scores: APACHE (Acute Physiology and Chronic Health Evaluation), SAPS (Simplified Acute Physiology Score), MPM (Mortality Prediction Model) and SOFA (Sequential Organ Failure Assessment) score. A prediction score (severity score) represents a numerical value, composed of a variety of clinical parameters, quantifying the severity of the disease. This can be introduced into a mathematical equation, the result reflecting the probability of clinical course, usually the mortality rate. There is an obvious correlation between the severity of the prediction score, length of ICU stay and the complexity of physical therapy. This study aims to demonstrate the importance of starting prompt physical therapy in critically ill patients with high severity scores, significantly influencing individual recovery and prognosis.

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Assessment of prognostic factors in myelodysplastic syndromes

Georgescu Daniela, Patrinoiu Oana, Popescu Mihaela, Ciuhu Anda Natalia
Abstract: Myelodysplastic syndromes (MDSs) represent a heterogeneous group of bone marrow conditions characterized by peripheral blood cytopenias and increased risk for evolution to acute leukemia. An accurate risk group classification constitutes the start point for the establishment of the therapeutic attitude in MDS pathology. The prognostic relies on different risk models, some of them being disease related: French-American-British system (FAB), World Health Organization classification, International Prognostic Scoring System (IPSS), WHO Prognostic Scoring System (WPSS), MD Anderson Scoring System (MDACC), while others being patient and comorbidities related: MDS- specific Comorbidity Index (MDS-CI). In 2012, Peter L. Greenberg and collaborators published in Blood the Revised International Scoring System (R-IPSS) that included MDS patients in five risk groups, based on cytogenetic changes. The evolution of patients with low risk MDS is heterogeneous and in most cases influenced by an associated pathology, considering that myelodysplasia occurs more frequently in elder people. By correlating the data in literature, a risk group classification was applied in the case of a 65 years old male patient, based on several of the above mentioned models. The patient was diagnosed with MDS in 2009 - refractory cytopenia with multilineage dysplasia and ringed sideroblasts (WHO 2008) in the Haematology Clinic of ″Colentina″ Hospital, Bucharest. At admission the patient presented a normal karyotype and he was classified in Intermediate 1 risk group (IPSS Int-1); Intermediate risk (WPSS); Low risk (MDACC); Low risk (MDS-CI). Our patient soon became transfusion dependent, with a requirement of 3 units of packed red blood cells per month and repeated hospital admissions. He also developed progressive left-ventricular dysfunction secondary to severe anaemia and recurrent transfusions. After approximately four years, in May 2013, the patients reclassification based on risk models indicated an intermediate risk (WPSS), the same as that at the moment of the diagnosis, but the associated comorbidities (transfusion dependency and heart failure) shifted him to a higher risk group, according MDS Co-morbidities Index (MDS-CI Int-High Risk), with low chances of survival, confirmed by his death shortly after, due to staphylococcal endocarditis but no leukemic transformation. Considering these events it becomes clearer that for MDS patients staged in low and intermediate risk groups, comorbidities represent an independent risk factor which entails a reassessment of the current prognostic systems.

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Case Report


Gastrointestinal stromal tumour: predicting the risk of recurrence of primary tumours

Savulescu F., Dutu C., Trifu V., Darmanescu Monica, Surdeanu D., Merticariu B., Cirlan C.
Abstract: Even if they have a low incidence (0.1-3% of gastrointestinal tumours), the stromal tumours located in the digestive tract raise important issues in predicting the risk of recurrence. Their diagnosis and treatment have evolved over the last 20 years, particularly in etiopathogenic terms, due to the arsenal of laboratory investigations like imunohistochemistry and mutational analysis techniques. The main factors that determine the risk of recurrence, initially evaluated by Mietinen (2006) and subsequently clarified by Joensuu (2008, 2011) are the size, the number of mitoses, the tumour location and the intrusion capsule.The main pillars of treatment are surgery and therapy with Imatinib. Three representative cases for the factors described and well coded as diagnosis, treatment and postoperative monitoring are presented in this article: a bulky gastric tumour and one giant gastric intestinal (resected by laparotomy) and cecal gastrointestinal stromal tumour (GIST) (rarerly concerning the location) incidentally discovered during an appendectomy, laparoscopically resolved.The review of literature in this field combined with the clinical experience highlight the characteristics of these tumours, and, ultimately, guide the therapeutic approach in similar situations.

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Therapeutic success in chronic myeloid leukaemia - accelerated phase at onset

Patrinoiu Oana, Georgescu Daniela
Abstract: Tyrosine kinase inhibitors based therapy has completely changed the prognosis for patients with chronic myeloid leukaemia in the sense that most of them have a life expectancy almost similar with the healthy population. The best responses occur in patients diagnosed while in chronic phase of the disease, with a 60-65% probability to maintain a complete cytogenetic response up to five years. For the cases whose illness begins already in an advanced phase (accelerated or blastic) and who present new unfavourable cytogenetic or molecular prognosis factors, complete cytogenetic response under therapy with tyrosine kinase inhibitors (TKIs) is obtained rather late or it is not obtained at all, making allotransplant a curative therapy. The current paper describes the case of a female patient, diagnosed with accelerated phase chronic myeloid leukaemia, high risk group, who lost the complete cytogenetic response with first generation TKIs therapy and presented trisomy 8, clonal cytogenetic abnormality and unfavourable prognosis marker in Ph + cells. Despite this evolution our patient has been under oral therapy with Dasatinib for six years (IInd generation TKIs) and for the past four years in complete molecular remission, in other words the disease is currently undetectable.

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