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Volume XIV, Number 1, 2010 - Therapeutics Pharmacology and Clinical Toxicology

Review



Emerging infectious diseases and travel medicine

Adriana Hristea, Iulia Niculescu, Ruxandra Moroti, Arthur Istvan Luka, Victoria Arama, Anca Streinu-Cercel, Mihaela Ion, Raluca Mihailescu
Abstract: The term -emerging infectious diseases- (EID) is a broad one that covers newly recognized human diseases caused by pathogens that have recently jumped species, older pathogens that have emerged in new populations due to humans behaviors or modifications to natural habitats, and older pathogens that are exhibiting resurgence in area once brought under control. EID are those with increasing incidence at local, regional or international scales and are spreading from epicenters to new geographic area. Travelers are important factor in the global dissemination of EID due to the increased frequency and speed of both local and international travel. Numerous epidemiologic studies suggest an upward trend in the incidence of reported cases of zoonoses over the past decade. Many of the diseases caused by emerging infections are vectored diseases (West Nile, chikungunya, malaria, Lyme borreliosis). Pathogens that are transmitted through aerosolized droplets have huge potential for rapid global spread. Exemples of pathogens in this group are avian (H5N1) influenza, and recently the new H1N1 swine influenza virus, extremely drug-resistant tuberculosis and severe acute respiratory syndrome (SARS) coronavirus. Changes in animal production system and in the food production chain are thought to be among the main factors causing emergence of food-borne zoonoses. The worlds holy places can be a magnet for the ailing, the disabled and the infirm. Each year millions of men and women go on pilgrimages. Problems of sanitation and disease transmission in large groups put pilgrims at high risk from gastrointestinal and respiratory illnesses, with variable risks according to the geographical location and specific religious customs. Travelers should know that the basic principles of food and water hygiene apply even in this context.

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Clinical, evolutive and therapeutic aspects of recurrent respiratory papillomatosis

Doina Anca Plesca, Victoria Hurduc, Iulia Ioan
Abstract: HPV infection is one of the most common sexually transmitted diseases. The majority of infections cause no symptoms and are self limiting, being cleared without sequelae. Persistent infections are associated with various clinical aspects (cervical cancer, genitoanal warts, recurrent respiratory papillomatosis). Recurrent respiratory papillomatosis (RRP) is a rare but possible clinical outline. This article provides updates on the epidemiology, pathology, clinical and imaging features, treatment and evolution of RRP. Sexual education and HPV vaccines represent the most important tools against HPV infection.

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Community-acquired pneumonia

A. Cupsa, Irina Niculescu, Florentina Dumitrescu, Andreea Stoian, L. Giubelan
Abstract: Acute pneumonia was and still is one of the most important causes of morbidity and mortality. A patient with typical CAP presents sudden onset with chill, fever, pleural pain, cough, expectoration, dyspnea. Elderly patients may present an atypical clinical presentation: confusion, decompensation of underlying diseases. Chest radiography is recommended to patients suspected of having CAP. It is important to perform a severity assessment of CAP in order to decide whether to treat the patient with CAP as outpatient or as inpatient, in the ward or in the ICU. A lot of patients with CAP could be correctly treated with oral antimicrobial drugs.

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Original Papers


Hepatitis C virus superinfection in individuals with chronic hepatitis B virus infection.

Anca Streinu-Cercel, Ileana Rebedea, Oana Streinu-Cercel; A. Streinu-Cercel, Liliana Preotescu, Daniela Manolache
Abstract: Hepatitis B virus (HBV) is known to infect over 500 million people worldwide while WHO estimates that there are more than 170 million chronic HCV carriers. A study conducted in 2009 in Romania revealed a seroprevalence of HBV infection of 5.59% and of 4.56% for HCV infection [ASRF, 2009]. HBV and HCV coinfection is one of the leading problematics in the area of infectious diseases. The National Institute for Infectious Diseases ″Prof. Dr. Matei Bals″, Bucharest is one of the excellence centers. in Eastern Europe for diagnosing and treating hepatitis B and C. During 2009, the National Institute for Infectious Diseases ″Prof. Dr. Matei Bals″ monitored 3027 patients with chronic HBV hepatitis, out of which 402 patients presented chronic HBV HDV coinfection, 256 patients presented acute HBV hepatitis without comatose state and 3 presented acute HBV hepatitis with comatose state. In 2009, we also monitored 6012 patients with chronic HCV hepatitis and we admitted 26 cases of acute HCV hepatitis and 3 cases of HEV acute hepatitis. Out of the total number of patients monitored in our clinic almost 3% represent HBV and HCV coinfections. This article compares the evolution of 5 cases of HCV superinfection in patients with chronic HBV infection. All of the patients were diagnosed within the National Institute for Infectious Diseases ″Prof. Dr. Matei Bals″ and 4 out of the 5 cases were treated with specific antiviral therapy. Patients 1 through 4 attained and maintained undetectability for HCV-RNA while patient 5, who refused antiviral treatment, developed a chronic HCV hepatitis with fluctuating viral load values. All patients treated with Peg IFN and ribavirin for HCV hepatitis responded well to therapy, with undetectability of viral load at 2 weeks of treatment. One treated patient positivated the HCV viral load 5 years after the initial HCV hepatitis. We suspect this may be associated with administration of hepato-toxic drugs. We also present an illustrative case report of a patient with a particular evolution under HBV antiviral treatment with lamivudine and successive HCV treatment with Peg IFN and ribavirin, discussing the possible role of the chronology of HBV and HCV infection on the evolution of the hepatic disorder.

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Eustachian tube dysfunction of adenoid origin

C. Sarafoleanu, Raluca Enache, D. Sarafoleanu
Abstract: Objective: Eustachian tube dysfunction is one of the most frequent otic pathologies, being the starting point in most local inflammatory processes. Within the pediatric population, the adenoidal hypertrophy is the most frequent cause of tubal dysfunction. The purpose of this study was to show the implications of adenoid tissue hypertrophy in the genesis of Eustachian tube dysfunction. Methods: The study covered 18 months and included 126 child patients, between 3 and 6 years of age, diagnosed with chronic rhinoadenoiditis. All patients were carefully investigated, clinically and paraclinically (nasal and otic endoscopy, tympanogram, tubal manometry). Results: 98 patients presented otic and rhinologic moderate or severe symptoms and in these cases an adenoidectomy was performed. The other 28 children with low intensity symptoms received medical treatment. The re-evaluation made after four weeks revealed a very good evolution of symptoms after the surgery. Conclusions: Adenoid hypertrophy is the first cause of Eustachian tube dysfunction in children. To ensure a normal function of the auditory tube, in these cases an adenoidectomy must be performed, followed by a periodic reassessment.

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Considerations about susceptibility to antibiotics of uropathogenics Klebsiella Pneumoniae strains

Andreea Cristina Stoian, A. Cupsa, Florentina Dumitrescu, Elena Stefan, L.Giubelan, Irina Niculescu, Cristina Iocu, I. Diaconescu, Livia Dragonu, Maria Marinescu
Abstract: This study aimed to determine and analyze the antibiotic sensitivity of Klebsiella pneumoniae strains isolated from urine cultures. Material and methods: Retrospective, comparative study, performed within the Craiova Clinical Hospital for Infectious Diseases -Victor Babes, determining the evolution of the chemosensitivity of uropathogenic Klebsiella pneumoniae in urinary tract infections, during 2000-2004 and 2005-2008. Results: During 2000-2004, we identified 161 pathologic urine samples bacteriologically positive for Klebsiella pneumoniae (15,01% of the total positive urocultures) and we analyzed them through antibiogram testing. Between 2005-2008, we identified 127 pathological bacteriologically positive urine samples (13.23% of all positive urine cultures). The rates of susceptibility to antibiotics tested in the first period of the study were: 33.7% for amoxicillin/clavulanic acid, 77.15% for aztreonam, 89.46% for cefoperazone-sulbactam, 85% for ceftazidime, 84% for amikacin, 79.91% for gentamicin, 74.13% for ofloxacin, 84.25% for norfloxacin, 67.16% for nalidixic acid, 62.71% for colistin and 96.59% for meropenem. During the second studied period, the rates of susceptibility to antibiotics were: 22.22% for amoxicillinclavulanic acid, 62.65% for aztreonam, 62.51% for cefoperazone-sulbactam, 76% for ceftazidime, 84.31% for amikacin, 70% for gentamicin, 69,69% for ofloxacin, 65.82% for norfloxacin, 57.14% for nalidixic acid, 80.35% for colistin and 95.96% for meropenem. Conclusions: Increased susceptibility of K. pneumoniae to meropenem and certain aminoglycosides (amikacin) is maintained. We noticed an increasing trend in the sensitivity to colistin and a declining trend in that to quinolones and certain IIIrd generation cephalosporins (ceftazidime, cefoperazone-sulbactam).

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A morphological study of the mandibular canal in partially edentulous patients

M. Sandulescu, M. Traistaru, Mihaela Nitescu, I. Sirbu
Abstract: The inferior alveolar nerve is the one of the largest branches of the mandibular division of the trigeminal nerve and it is vulnerable during surgical procedures of the mandible, especially during impacted third molar removal and implant placement procedures. Purpose: The present study aims to clarify the 3-dimensional positioning of the mandibular canal in partially edentulous patients by evaluating a series of Cone-Beam Computed Tomography (CBCT) data. Material and method: For this study we evaluated 136 patients (66 women, 70 male), aged 18-86, who consecutively presented to the Oral Implantology Clinic from the Central Clinical Emergency Military Hospital, Bucharest, Romania, between November 2008 - December 2009 for various dental treatments. The inclusion criteria were: presence of terminal bilateral mandibular edentations (group 1) or presence of lateral edentations on one side of the mandible associated with terminal edentations on the opposite side (group 2). Within the two groups, we analyzed the shape of the mandibular body, dividing it into two mandibular morphological types, and we determined the mandibular canals position through the quantification of the distances to the superior border of the alveolar process, to the buccal cortical plate and to the oral plate. Results: In group 1, the average bone height above the mandibular canal was 11.98 mm, while in group 2 it was 13.07 mm for the mandibular morphological type 1 and 16.88 for the mandibular morphological type 2. Regarding the bucco-lingual position of the mandibular canal, in group 1, the mean distance from the mandibular canal to the buccal plate was 4.14 mm, while the mean distance to the lingual plate was 3.20 mm. In group 2 we found slightly higher distances. Conclusions: In order to avoid injury of the inferior alveolar neurovascular bundle during surgical implant placement procedures, both the vertical distance to the mandibular canal and the buccal-oral positioning of the mandibular canal need to be determined pre-operatively. Patients with termino-terminal mandibular edentations present a significant vertical bony resorption compared to the patients with latero-terminal edentation. This study provides essential data for developing a clinical algorithm of preoperative risk assessment in patients undergoing implant surgery within both the posterior and the anterior mandible, in order to minimize intra- or post-operative complications, such as inferior alveolar nerve damage.

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Research on the influence of Biguanides treatment on Copper concentration in non-insulin-dependent diabetes mellitus patients

Monica Daniela Dosa, Doina Catrinoiu, L. T. Hangan, Cristina Gales, M. Nechifor
Abstract: We have studied the plasmatic and urinary concentration of copper in a group of adult patients with non-insulin-dependent diabetes mellitus (NIDDM). Our study enrolled 30 patients with NIDDM, naive for antidiabetic medication, recruited from the Diabetes, Nutritional and Metabolic Diseases Clinic of Faculty of Medicine Constanta. The patients received treatment with Metformin, 1000 mg/day. We measured the plasmatic and urinary concentration of copper (Cu) and the concentrations of: glucose (Gl), HDL, LDL, cholesterol (Col), triglycerides (Tg), glycosylated hemoglobin (HbA1c), before and after 3 months of treatment. The same measurements were performed on a control group (CG) of healthy adults of both genders. The results were statistically interpreted. The data revealed a significant difference in the plasmatic concentration of copper, the NIDDM group displaying higher values than those in the control group (111,91+/-20,98 vs. 96,33+/- 8,56 µg/dl, p<0,001) prior to the administration of Metformin. The treatment with Metformin for 3 months did not significantly modify the plasmatic concentration of copper (111,91+/-20,98 vs. 101,23+/-21,73 µg/dl) nor the urinary concentration of this cation (53,35+/-23,79 vs. 51,70+/- 22,13 µg/24h). The plasmatic concentration of copper positively correlated with the levels of HbA1c, triglycerides and cholesterol.

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Intradialytic hypotension - mechanisms and therapeutic implications

Mihaela-Elisabeta Stafie, I. Al. Checherita, A. Niculae, Gabriela Lupusoru, Cristiana David, Al. Ciocalteu
Abstract: Background Intradialytic hypotension continues to be a major problem in hemodialysis treatment today, despite technical improvements. Its origin is still a subject of extensive research. The aim of the study was to identify the cause of intradialytic hypotension, measuring hemodynamic parameters during a hemodialysis session. This strategy provides the opportunity of classifying the patients into different risk categories and may lead to an individualized dialysis protocol. Methods The variations in arterial blood pressure, cardiac stroke volume, heart rate, cardiac output and systemic vascular resistance were monitored during a hemodialysis session in sixty-two patients on chronic intermittent hemodialysis. Results Seventeen patients experienced an episode of intradialytic hypotension. Based on the predominance of systemic vascular resistance (SVR) or stroke volume (SV) decrease at the time of hypotension, two groups could be differentiated. Six patients showed a fall in SVR (HID_svr group) whereas eleven patients showed a more pronounced decrease in cardiac output, caused by a decline in stroke volume. In the HID_sv group, Pearson`s correlation revealed a predominant relationship between cardiac output variations and mean arterial pressure variations (R=0.59, p=0.001). No correlation was found between systemic vascular resistance and mean arterial pressure variations in this group. In the HID_svr group, the mean arterial pressure variations showed a strong correlation with systemic vascular resistance variations (R=0.71, p=0.002) and a poor correlation with stroke volume (R=0.21, p=0.001) and cardiac output variations (R=0.11, p=0.0012). Conclusion Based on the hemodynamic response, intradialytic hypotension is due to cardiac filling failure caused by hypovolemia in one group, while in another group a fall in systemic vascular resistance, independent of cardiac function, is the cause of this complication. Different preventive strategies are proposed for the different subgroups.

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Therapeutical Practice


Severe influenza caused by the new virus, A H1N1

Smaranda Gliga, Cristina Popescu, Victoria Arama, Mihai Ionescu
Abstract: From november 2009, an outbreak of severe pneumonia was reported in Romania, in conjunction with the concurrent isolation of a novel swine-origin influenza virus. A(H1N1) virus was causing the first influenza pandemic of this century, that caused variable mortality depend on the development of severe pneumonia. The decision about antibiotic treatment in severe cases of influenza is very difficult. For the child or adult admitted to a hospital intensive care unit in respiratory distress, it was accepted that empirical initial therapy with broad-spectrum antibiotics to include coverage for MRSA, as well as Streptococcus pneumoniae and other common respiratory pathogens, is appropriate. We presented a case of severe influenza with pneumonia complicated with pulmonary fibrosis.

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The psychological impact of medicines on children

Maria Dorina Pasca
Abstract: Starting from -Primum non nocere-, the patients perception and observation, particularly through their inherent psychological effects, need to be taken into account by the doctor and pharmacist. The patients perception on medication determines a need for finding a new methodological strategy concerning its impact on the child. Objectives. In this context, the doctor and the pharmacist need to be aware of the age particularities of children and also of the child patients attitude towards medicine administration (which generally is not a positive one), in order to determine a new attitudinal-behavioral structure which would prevent or heal the health problem appeared at a certain point. Material and methods. We stress on the importance of psychotherapy, illustrated through the therapeutical and behavioral story of verbal expressions and its role in the educational therapy. Starting from administrating medicines to the child, a therapeutic story as -The Syrup and the Little Pill- can be capable of generating an optimistic attitude, mainly a positive manner of thinking on health, by emphasizing the role of medicine in sustaining it. Conclusions: It is important to find a timely solution to each problem together, doctor/pharmacist and patient. The problem which occurred at a certain moment can be solved by amending the manner of perceiving and administrating medicine and by eliminating the difficulties and psychological traumas that may appear during childhood. This is the starting point of health education and its maintenance.

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Case Report


Idiopathic heterotopic ossification in soft tissues around ankle joint

C. Socoliuc, Sabina Zurac, Gianina Micu, Cristiana Popp, Luciana Nichita, Adina Ene, Alina Slavnea, Florica Staniceanu, R. Fundulea
Abstract: Acute pneumonia was and still is one of the most important causes of morbidity and mortality. A patient with typical CAP presents sudden onset with chill, fever, pleural pain, cough, expectoration, dyspnea. Elderly patients may present an atypical clinical presentation: confusion, decompensation of underlying diseases. Chest radiography is recommended to patients suspected of having CAP. It is important to perform a severity assessment of CAP in order to decide whether to treat the patient with CAP as outpatient or as inpatient, in the ward or in the ICU. A lot of patients with CAP could be correctly treated with oral antimicrobial drugs.

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Encapsulating peritoneal sclerosis: complication of peritoneal dialysis

M. Daniliuc, I. Gutu, C. David, I. Checherita, Al.Ciocalteu
Abstract: Encapsulating peritoneal sclerosis (EPS) is a rare but devastating complication of long-term peritoneal dialysis (PD) therapy. EPS is characterized by peritoneal membrane inflammation, followed by progressive peritoneal membrane fibrosis and intestinal encapsulation. Clinical manifestations include ascites and small bowel obstruction. The exact causes of EPS remain unknown but EPS is frequently seen after an increased duration of PD therapy. The prognosis of EPS is poor. Early diagnosis and prompt initiation of treatment is essential. We report a case of EPS following bacterial peritonitis in a peritoneal dialysis patient.

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