founded 1897 vol. cxvii romanian journal of no. 1 …...vol. cxvii • new series • no. 1-2/2014...

• Reconsidering the importance of military medicine at the level of National Ministry of

Defence and into society

• Clostridium difficile – emergent hospital flora

• Stress management for optimization of organizational activity

• New quaternary ammonium salts based decontaminants

• News and perspectives on treatment of normal pressure internal hydrocephalus

• Nonalcoholic fatty liver disease – an etiological approach

• An unusual cause for cerebellar syndrome

• Past and future

www.amfmr.ro

Founded 1897 • Vol. CXVII

New series • No. 1-2/2014

REVISTA DE MEDICINĂ MILITARĂ

Military Medicine

Romanian Journal of

Editorial Board of Romanian Journal of Military Medicine

Under the patronage Romanian Association of Military Physicians and Pharmacists

Honorary Editor Victor Voicu MD, PhD

Editor-in-Chief Daniel O. Costache MD, PhD, MBA Dragoș Cuzino MD, PhD

Executive Editor Florentina Ioniță Radu MD, PhD, MBA

Associate Editors Mariana Jinga MD, PhD, MBA Silviu Stanciu MD, PhD

Advisory Board Dan Mischianu MD, PhD Dragoș Vinereanu MD, PhD, EC, FESC

Redactors Doina Baltaru MD, PhD – Cluj Napoca Ovidiu Bratu MD, PhD – Bucharest Ciprian Constantin MD, PhD – Balkan Military Medical Committee Florin Miclea MD, PhD – Timișoara Constantin Ștefani MD – Bucharest

Editorial Assistants Dan Dobre MD Cristina Solea Claudia Țiglea

Technical Secretary Oana Ciobanu

International Editorial Board

Natan Bornstein (Israel) Raluca Ciornei MD (UK)

Mihai Coculescu MD, PhD (Romania) Cris S. Constantinescu MD, PhD, FRCP (UK)

Daniel Dănilă MD, PhD (USA) Mihai Moldovan (Denmark)

Ioan Opriș BS, PhD (USA) Gerard Roul MD, PhD (France)

Adrian Săftoiu (Denmark)

Ioanel Sinescu MD, PhD (Romania) Ionescu Târgovişte MD, PhD (Romania)

Radu Ţuţuian (Switzerland) Victor Voicu MD, PhD (Romania)

Scientific Publishing Committee

drian Barbilian MD, PhD Anda Băicuş MD, PhD

Cristian Băicuş MD, PhD Andra Bălănescu MD, PhD

Silviu Brad MD, PhD Daciana Brănișteanu MD, PhD

Marian Burcea MD, PhD Sofia Colesca PhD, MBA

Gabriel Constantinescu MD, PhD Dan Corneci MD, PhD

Raluca S. Costache MD, PhD, MBA Mircea Diculescu MD, PhD Cosmin Dobrin PhD, MBA

Gabriela Droc MD, PhD Silviu Dumitrescu MD, PhD Cristian Gheorghe MD, PhD Mihai E. Hinescu MD, PhD Codorean Ioan MD, PhD

Florentina Ioniţă Radu MD, PhD Mariana Jinga MD, PhD

Viorel Jinga MD, PhD Ruxandra Jurcuţ MD, PhD Dan Mischianu MD, PhD Ovidiu Nicodin MD, PhD Tudor Nicolaie MD, PhD

Emilian A. Ranetti MD, PhD Corneliu Romanițan MD, PhD

Carmen Adella Sîrbu MD, PhD, MPH Sorin Țiplică MD, PhD

Dragoş Vinereanu MD, PhD, EC, FESC

REDACȚIA Str. Institutul Medico-Militar nr. 3-5, sector 1, București, R-010919, Tel/fax 021.321.5386

Romanian Journal of Military Medicine (RJMM) is included in Romanian College of Physicians Medical Publications Index and

credited with 5 CME credits. RJMM is recognized by CNCSIS in the category C.

www.amfmr.ro

Romanian Journal of Military Medicine, vol. CXVII, New Series, No 1-2/2014

ISSN 1222-5126

Vol. CXVII • New Series • No. 1-2/2014 • Romanian Journal of Military Medicine

1

Founded 1897 • Vol. CXVII

New Series • No. 1-2/2014

Edited by the Romanian Army Medical Directorate and Romanian Association of Military Physicians and Pharmacists.

Contents

EDITORIAL Ioan Sîrbu

Reconsidering the importance of military medicine at the level of National Ministry of Defence and into society 3

REVIEW ARTICLE Gabriela V. Dumitrescu, Viorel Ordeanu, Simona Bicheru, Lucia Ionescu, Diana Popescu, Marius Necşulescu

Clostridium difficile – emergent hospital flora 5

SYSTEMATIC REVIEWS, META-ANALYSIS Iuliana Guiţă – Alexandru

Stress management for optimization of organizational activity

Diana M. Popescu, Viorel Ordeanu, Lucia E. Ionescu, Gabriela V. Dumitrescu, Simona N. Bicheru, Marius Necşulescu

New quaternary ammonium salts based decontaminants

13

18

ORIGINAL ARTICLES Cristian Năstase, Marian Mitrică, Cristian Popescu

News and perspectives on treatment of normal pressure internal hydrocephalus

Florentina Ioniță Radu, Mariana Jinga, Petruț Nuță, Raluca S. Costache, Sandica Bucurica, Bogdan Macadon, Vasile Balaban, Mihăiță Pătrășescu

Nonalcoholic fatty liver disease – an etiological approach

24

33

CLINICAL PRACTICE Carmen A. Sîrbu, Octavian M. Sîrbu, Anca M. Sandu, Cristina P. Sandu, Marian Ștefănescu

An unusual cause for cerebellar syndrome

39

VARIA Andrei Necșulescu

Past and future 42

ADMINISTRATIVE ISSUES Guidelines for authors 45

RJMM Romanian Journal of Military Medicine


3

Reconsidering the importance of Military

Medicine at the level of National Ministry of

Defense and into society

Ioan Sîrbu

This goal can be achieved through the

implementation of a modern management both of

the Medical Directorate and of the subordinate units,

which basically involves a reform of these

institutions, keeping them out of the incertitude of

annual budgetary provision, looking for contractual

stability with National Defence, Internal Affaires,

National Security and Justice Authority Health

Insurance Company (C.A.S.A.O.P.S.N.A.J) and placing

them on the right path for institutional performance.

The reform of the military medical institution is an act

of courage that has to be accomplished with great

determination.

The first step would be submitting to the Supreme

Council of National Defence (CSAT) the concept of the

modernization of the military medical system

including elements of innovative vision on the

military medical phenomenon. One of these issues is

the need for modernisation of medical equipment

and hospital infrastructure in order to allow the

treatment in national military hospitals of soldiers

injured in combat theaters and of civilians after

natural disasters or industrial accidents with multiple

victims.

Another goal is to create a fully equipped base for

physical and neuropsychological recovery of military

personnel executing missions in operation theaters

and of their family members, allowing a fast and

complete social and family reintegration.

A particular attention

should be paid to hero

combatants, wounded in

combat theaters; they will

take benefit from the best

specialists in health care in

the new social-medical

edifice which will be

available since 2015.

In 2015 also, the construction of the new Emergency

Universitary Central Military Hospital will begin in

Bucharest in Garrison 867, part of the Ministry of

National Defense estate patrimony, under

Government Decision no 1594/04.12.2008.

This investment is the natural consequence of the

need to be aligned with the realities of modern

medicine promoted by North Atlantic Alliance

through ROL 4 level hospital units, covering all

medical and surgical specialties required for complete

rehabilitation and recovery of military personnel

wounded in the operation theaters or in the current

training activities, on national territory.

In the same time with updating of the clinical basis,

we should concentrate our attention on improving

the continuous training of our healthcare staff

regarding the achievement of new treatment

techniques and solutions. Continuous professional

training is an asset that our physicians are providing

to the military personnel in distress.

EDITORIAL

Major General IOAN SÎRBU

Chief of Medical Directorate, Ministry of National Defence,

Romania Professor, Head of Oral

Implantology Department of the Faculty of Dental

Medicine, Bucharest, Romania

4

From the experience of some colleagues, who have

chosen to leave the system, the main reasons for

discontent were: the working environment and the

lack of modern investigation means; to the surprise of

many, the financial reason was the last one.

Promoting team spirit and preserving the values in

the system has been a permanent concern of the

Medical Directorate Management.

All these contribute to achieving outstanding results

in our activity, leading to increasing satisfaction for

patients and doctors.


5

Article received on October 1, 2013 and accepted for publishing on December 13 2013.

Clostridium difficile – emergent hospital flora

Gabriela V. Dumitrescu, Viorel Ordeanu, Simona Bicheru, Lucia Ionescu, Diana Popescu, Marius Necşulescu1

Abstract: Clostridium difficile (C. difficile) is a Gram-positive sporogenous bacillus strictly anaerobic, which in the last decade has became the most important anaerobic bacterium in nosocomial human pathology. Cl.dificile is the etiological agent of more than 20% of diarrhea postantibiotics, over 95% of pseudomembranous colitis and the first cause of nosocomial infectious diarrhea in adults. Although this bacterium usually colonizes the intestine of vertebrates (the normal microbiota), the toxinogenic strains (tcdA and tcdB) are pathogenic in the digestive tract. Given the excessive use of antibiotics and the increased spores resistance, it is possible an environment contamination, with strains which may already be resistant to antibiotics. The main causes of this infection are decreased resistance to antibiotic-induced colonization, contamination with a pathogenic strain of Cl.difficile, secretion of A and/or B toxins and deficient immune response. Due to the increasing worldwide incidence of infections with C. difficile on one hand and to the discovery of new ways of transmitting the infection according with some studies regarding the genetic diversity of bacterium strains on the other hand, a new approach is necessary for C. difficile related topics..

Keywords: antibiotics, Clostridium difficile, epidemiology, nosocomial infection, toxins.

INTRODUCTION

Clostridium difficile (C. difficile) is a Grampositive

sporogenous bacillus strictly anaerobic, which in the

last decade has became the most important

anaerobic bacterium in nosocomial human pathology.

Cl.dificile is the etiological agent of more than 20% of

diarrhea postantibiotics, over 95% of pseudo-

membranous colitis and the first cause of nosocomial

infectious diarrhea in adults.

Although this bacterium usually colonizes the

intestine of vertebrates (the normal microbiota), the

toxinogenic strains (tcdA and tcdB) are pathogenic in

the digestive tract. Given the excessive use of

antibiotics and the increased spores resistance, it is

possible an environment contamination, with strains

which may already be resistant to antibiotics.

The main causes of this infection are decreased

resistance to antibiotic-induced colonization,

contamination with a pathogenic strain of Cl.difficile,

secretion of A and/or B toxins and deficient immune

response.

Microbiological diagnosis is made by several methods

and techniques for bacteria or toxins identification.

Cytotoxicity test reveals the cytopathic effect of fecal

filtrate with pg sensitivity. Immunoenzymatic assay

REVIEW ARTICLE

1 Military Medical Research Center (CCSMM), Bucharest

6

enables a rapid diagnosis, first generation with ELISA,

the second generation by immuno-enzymatic or

immuno-chromatography cassette. Molecular biology

techniques based on quantitative real-time PCR

detect tcdA and tcdB genes in stool, responsible for

toxigenesis with very good sensitivity and specificity.

Through cultivation and microscopy Cl. difficile can be

revealed in the stool or on contaminated surfaces;

spores are resistant in the environment and are

found in nosocomial flora. A characteristic enzyme,

glutamate dehydrogenase (GDH) can be revealed in

stool by immuno-enzymatic assay correlated with the

outcome of cultivation, or latex agglutination test

with antiGDH antibody.

Due to the increasing worldwide incidence of

infections with C. difficile on one hand and to the

discovery of new ways of transmitting the infection

according with some studies regarding the genetic

diversity of bacterium strains on the other hand, a

new approach is necessary for C. difficile related

topics.

CLINICAL

Clostridium difficile (C. difficile) is a Grampositive,

spore forming bacteria, spread by the fecal-oral

route. It is non-invasive, produces toxins A and B,

which cause disease, ranging from asymptomatic

carriage, to mild diarrhea, to colitis, or pseudo-

membranous colitis. Clostridium difficile infection

(CDI) is defined as the acute onset of diarrhea with

toxigenic C. difficile or its toxin and no other cause for

diarrhea.

Since 2000 the rate of CDI has been increasing,

especially in the elderly with a recent hospitalization

or residing in long-term care facility (LTCF).

Carriage of C. difficile occurs in 5– 15% of healthy

adults, up to 57 % in residents in LTCF and can reach

84.4 % in newborns and healthy infants.

In simple diarrhea cases, the classic symptoms may

not occur and the endoscopic examination shows

normal or ulcerated mucous; in 25% of cases ending

the antibiotic therapy was followed by clinical

recovery in 2-3 days. Further on antibiotheraphy is a

prolonging factor of diarrhea relapse.

Pseudomembranous colitis represent up to 9% of CDI

and starts with abundant watery diarrhea, over 7

stools a day, with heterogenic no bleeding aspect.

They are accompanied by fever in 75% of cases and

abdominal pains in 70% cases. The symptoms are

non-specific, leukocytolysis up to ex 80.000 PMN/I¼l,

extracellular dehydrating caused by exudative

enteropathy.

Digestive endoscopy confirms the diagnosis, allowing

canker yellowish sores visualization, named

pseudomembrane, on mucous colon membrane. In

the first stage they are isolated, afterwards they

come together. In CDI forms with severe onset and

no obvious etiology of diarrhea an endoscopy is

recommended, but this test is difficult to perform on

aged and fragile patients. Complications such as

septic shock and toxic megacolon may occur, septic

shock and toxic megacolon occur and provoke the

colon perforation (colectomy required) and even

death.

The ratio of severe forms differs (7-18%), depending

on the studies we consider. Consecutive mortality

with C. difficile varies 0,6-3% and when complications

occur is 35-50%. Some studies show increased

mortality in North America, a double no. of cases in

EU, heading to 24/milion, C. difficile being involved in

death cases three times more frequent than

Staphilococcus aureus MRSA. In 20% of cases,

relapses appear in the first two months after the

initial episode. In over 50% of cases they are

connected with the persistence of pathogen strain

(spores) inside digestive tract; a new stain could

appear and provoke reinfection especially during

hospital admission. Multiple strains have been

identified during one episode of infection.

Approximately 3% of adults are asymptomatic

carriers and often with toxin-free strains and

sometimes specific toxins may be identified in some

asymptomatic patients stool. The asymptomatic

transmission of toxinogen strains in neonates is 5-

70%, but there is no explanation what so ever.

Although nosocomial infections are the most

frequent, some of them could be communal. There

are recorded 17.5% postantibiotics diarrhea in EU,


7

from which 66% have one day manifestation. After

two weeks antibiotherapy, the frequency becomes

3.8%, from which 70% are toxic. In North America

were identified a lot of cases but no strain high

pathogen 027 had been isolated in communal

infectious. Differential diagnosis will be made with

other infectious diarrhea: bacterial, viral, fungus and

parasitic or non-infectious causes; for example, the

outcome of some ”cool” drugs is in reality laxative

ones (supplements for straitening the immunity,

sugar free sweets, food with magnesium and decaf

products) with no connection with CDI etiology.

[Duker Freuman T., 2014]

Figure 1. Pathogenesis of Clostridium difficile – associated disease

(http://bioweb.uwlax.edu/bio203/s2009/kumm_jakl/pathology.htm)

MICROBIOLOGICAL DIAGNOSTIC

CDI diagnostic is based on revealing the toxins in

stool or isolating a toxinogenic strain of Cl.difficile,

this being the only pathogenic strain. Diagnostic

testing for C. difficile has rapidly evolved in the past

decade. Previously, toxin A + B EIAs were the most

widely used diagnostic tests because of ease of use

and objective interpretation.

However, EIA tests have substantially reduced

sensitivities compared with reference standards.

Moreover, toxin A immunoassays (without toxin B)

lack detecting the small number of pathogenic strains

that only produce toxin B. Two major advances in the

laboratory diagnosis are the use of GDH detection in

stools as a means of screening for CDI and the

development of Nucleic acid amplification tests

(NAATs) such as PCR to detect toxigenic strains of C.

difficile. Glutamate dehydrogenase (GDH) screening

tests for C.difficile can be used in two- or three-step

algorithms with subsequent toxin A + B EIA testing,

but the sensitivity of such strategies is lower than

NAATs [Surawicz et al., 2013] (fig 2).

Testing the toxigenic C. difficile should be limited to

patients with > 3 nonformed stool specimens per 24

hr period, unless ileus (obstruction) is suspected.

Repeat testing following a positive test (test of cure)

is not recommended since patients may carry

toxigenic C. difficile for months after clinical cure.

Repeated testing following a positive test is

appropriate if the patient improves with therapy and

relapses after the completion of a treatment regimen

(clinical relapse). Testing a second specimen from a

negative patient is more likely to be a false positive

[American Society for Microbiology, 2010].

The optical microscopy swab is pathognomonic,

revealing long gram-positive bacilli with a bulge at

8

terminal ends, with long terminal and isolated spores,

visible with Gray coloration. While the presence of C.

difficile can be suspected, we cannot differentiate the

pathogencal strains from the nonpathogencal ones,

therefore the examination should be supplemented

with toxigenical and molecular biology tests. In the

last years, a very pathogenical and virulent strain, C.

difficile 027, has been identified, that causes severe

epidemic episodes (Fig 3).

Figure 2. Diagnostic algorithm of Clostridium difficile (Surawicz et al., 2013)

The epidemic strain currently described in North

America and EU, has the following features: PCR

ribotype 027 in accordance with Anaerobe Reference

Laboratory surveillance data [ECDC, 2006], pulsotype

NAP 1 on pulsed-field electrophoresis, enzymatic

restriction-profile BI, toxinotype III by Rupnik

toxinotyping method, positive for binary toxin actinia-

specific ADPribozyltransferase, deletion of 18 bp in

tcdC gene controlling the expression of toxins A and

B, hyperproduction of toxins A and B (Ax16 and Bx23)

in comparison with strains of other genotypes,

resistant to macrolides (erythromycin) and la

flororquinolones (moxifloxacin, gatifloxacin and

levofloxacin).

Only specialised laboratories are able to perform the

techniques for identifying these features and a two

weeks period is required for confirmation [INVS,

2006].

In practice, CDI diagnostic is based on toxin B

detection in stool or revealing the toxigen strain. A-

and B+ strains cannot be detected by current

imunoenzymatic assays which detect only A stain.


9

Figure 3. Analysis of anaerobic bacterial isolates in the microbiology laboratory of CCSMM

The strain isolation through culture is a necessary

stage for epidemic clone 027 characterisation; PCR

profile identification provides the certainty diagnosis.

This clone presence is clinically suspected if a severe

form of the disease is diagnosed, epidemiologically

suspected if several cases occur, or microbiologically

suspected if the isolated strain is resistant to new

fluoroquinolones (moxifloxacin CMI > 4 mg/l) or to

erythromycin (CMI > 256 mg/l).

These characteristics are not specific to clone 027,

but justify the stool culture in anaerobiosis in order to

isolate the responsible stain and to send it to a

specialised reference laboratory for further

examination.

The genes encoding TcdA and TcdB, tcdA and tcdB,

respectively, have been sequenced and are found in

single open reading frames located within a 19.6-kb

pathogenicity locus (8, 38).

As expected, both open reading frames are large,

with tcdA found within an 8,133-nucleotide region

and tcdB is 7,098 nucleotides in length (fig. 4).

Both tcdA and tcdB are low-G C (28%) genes, which

are comparable to the G C content (29%) of the C.

difficile genome, and the toxins exhibit a high degree

of overall similarity (66%).

Given the proximal locations of tcdA and tcdB and the

high sequence and functional homology between the

two proteins, it has been proposed that the two

genes may have arisen as the result of a gene

duplication event.

Furthermore, the similarity in the biochemical activity

of TcdA and TcdB, wherein both toxins use a highly

conserved N-terminal domain to modify identical

substrates, supports the notion of gene duplication.

The major regions of homology between TcdA and

TcdB fall within the enzymatic and receptor-binding

domains of the two toxins. The N-terminal domains

of TcdA and TcdB show 74% homology, and this

homology provides a basis for the similar substrate

specificity of these two toxins.

The C terminus of TcdA and TcdB show a number of

short, homologous regions termed combined

repetitive oligopeptides (CROPs). TcdA encodes five

groups of CROPs, which range in size from 21 to 50

residues and can be repeated throughout the C

terminus of the protein. TcdB also encodes five

groups of CROPs, four of which show homology to the

CROPs of TcdA.

Yet the CROPs found in TcdB are more divergent and

less frequent than those found in TcdA. CROPs

appear to play a putative role in initial target cell

interaction and receptor binding, but the mechanism

explaining the necessity for these repeats in cell

binding remains unclear [Daniel E. Voth, 2005].

10

Figure 4. Genetic arrangement of the C. difficile pathogenicity locus and proposed protein domain structures of TcdA and TcdB. Both TcdA and TcdB are encoded on the 19.6-kb pathogenicity locus. In addition to the two toxin genes tcdA and tcdB,

three additional regulatory open reading frames are located on this island. tcdD is a proposed positive regulator, tcdE is a putative holing protein, and tcdC is a proposed negative regulator of toxin gene expression. Through deletion mutagenesis, research combined from multiple research groups has revealed a three-domain structure of the large clostridial toxins. The glycosyltransferase activity is located at the N terminus of the protein, and the C terminus is involved in receptor binding.

Located in the middle domain of the protein is a putative transmembrane segment that is thought to be involved in membrane translocation. [Daniel E. Voth, 2005]

EPIDEMIOLOGY

C. difficile transmission is made by fecal-oral route, by

hands and contaminated objects or environment. The

fast transmission in healthcare environments is a

result of several factors: strain dissemination in CDI

patients, half of samples from patients rooms being

positive; high resistance of spores on inert supports

for several months; too many patients crowded in

common healthcare settings; numerous healthcare

maneuvers creating a high possibility of

contamination by the medical personnel hands;

inadequate usage of antibiotics which diminishes the

resistance to colonization and facilitates C. difficile

development.

The main individual risk factors are the advanced age

and antibiotherapy. There are several studies which

correlate the consumption of some classes of

antibiotics with CDI incidence: clindamicyn, 3-rd

generation cephalosporins, macrolides, and

amoxicillin with clavulanic acid, 1-st generation

cephalosporins and fluoroquinolones. It seams that

the role of fluoroquinolones in C. difficile 027strains

emergence and spreading is connected to the

resistance level towards them [INVS, 2006].

All factors stimulating the digestive ecosystem

alteration, like laxatives, antacids, antisecretors,

transit retarders, baritosis transit, gastrointestinal

surgery, etc. may facilitate this infection [Duker

Freuman, 2014].

In March 2014, an epidemic episode with 31 cases of

postantibiotic C. difficile infection was recorded in

Ploiesti Emergency Hospital (Romania) and the

patients were isolated and treated. Most of them

were aged people from Neurology, Nephrology and

Intensive Care Unit [Libertatea newspaper, 2014].

In May 2014 the Ministry of Health of Romania gave

the alert for C.difficile in Vaslui and Bucharest

hospitals. The beginning of the year is worrying, in

only 4 months, in Bucharest health facilities were

registered 462 infected patients [Pro TV, 22 Mai

2014].


11

In accordance with Annual epidemiological report:

Reporting on 2011 surveillance data and 2012

epidemic intelligence data, 2013, uttered by

European Centre for Disease Prevention and Control

(ECDC), 48% cases of HAI (Healthcare-Associated

Infections) associated with gastro-intestinal infections

were connected with C. difficile, and from all HAI

(15.000 cases) in 3 only 5,4% of cases the Clostridium

difficile has been isolated. Taking into consideration

that in Romania over 92.3% of patients were the

beneficiary of an antimicrobial prophylaxis during

more than a day surgeries, the HAI risk associated

with C. difficile is very high [ECDC, 2013]

TREATMENT

There is worldwide observed natural resistance

and/or acquired to the medicines of the quinolone

group.

A mild CDI can usually be controlled by withdrawing

treatment with the antibiotics causing the infection

(25% of patients could recover in 2-3 days). More

severe cases can be treated using an oral specific

treatment with metronidazole (1 g/day) or

vancomycin (1-2 g/day) for 10 days. The

metronizadole is a better choice, being a less

expensive treatment with no risk of selecting

glycopeptides resisting germs like golden

enterococcus and staphylococcus.

Failure to respond to metronidazole therapy within 5

– 7 days should prompt consideration of a change in

therapy to vancomycin at standard dosing. For mild-

to-moderate CDI in patients who are intolerant/

allergic to metronidazole and for pregnant/

breastfeeding women, vancomycin should be used at

standard dosing. In patients in whom oral antibiotics

cannot reach a segment of the colon, such as with

Hartman’s pouch, ileostomy, or colon diversion,

vancomycin therapy delivered via enema should be

added to treatments (500 mg in 100 – 500 ml of

normal saline every 6 h) until the patient improves.

However, relapse is common and requires further

treatment with repeated series of metronidazole or

vancomycin, in high doses first and smaller doses

associated with probiotics (i.e. Saccharomyces

boulardii) after improvement. Severe cases may need

intensive care for maintaining the vital functions and

even surgical treatment for colectomy (in case of

toxic megacolon or colon perforation).

CT scanning is an important technique for perforation

diagnosis in comparison with colonoscopy technique

which presents a perforation risk due to gas inflation.

The antibiotic treatment for healthy individuals

colonized with C. difficile is not recommended, being

inefficient for eradicating for good this bacteria in

digestive tract. [Ordeanu, 2010; Ordeanu 2012]

Considering the antibiotherapy limitations, there has

been designed the fecal bacteriotheraphy, known as

“stool transplant”/fecal microbiota transplant (FMT)

of bacterial flora acquired from the feces of a healthy

donor to reverse the bacterial imbalance responsible

for the recurring nature of the infection, with good

results [ASGE, 2013].

This “synthetic stool” is a super-biotic obtained using

several cultures of saprophyte intestinal culture

[Allen-Vercoe, 2013]. Studies show that patients with

recurrent CDI (RCDI) have abnormally proportioned

colon microbiota, and that reintroduction of normal

bacteria via donor feces corrects this imbalance,

restoring phylogenetic richness and colonization

resistance.

There is no international consensus for defining and

surveillance CDI, but we have to consider local

(regional and national) epidemiology conditions and

possibilities. ECDC created a working group for early

detection and monitoring the CDI. They have

suggested recorded signals criteria for severe and

grouping cases of CDI.

C. difficile infectious can usually be prevented by

practicing good hygiene in healthcare environments,

such as: individual bed space, washing hands

regularly (mechanical action of washing after gloves

removal), using gloves, protection mask, glasses and

gown in bed space area and in contact with patients,

using medical supplies for one usage only, cleaning

surfaces using bleach wipes of sodium hypochlorite

containing 0.5 % active chlorine, and patient removal

limitation. [CCLIN, 2013]

12

COMMENT


infections with C. difficile on one hand, and to the



diversity of C. difficile strains on the other hand,

(http://www.pharmacypracticenews.com) a new

approach is necessary for C. difficile related topics It

is important to adopted NAAT testing alone or a 2 or

3 step algorithm for CDI diagnosis.

If the C. difficile is confirmed and classified as a

severe form or in an epidemic context it should be

reported to Public Health Territorial Authorities and

to The Anaerobe Reference Laboratory from INCDMI

Cantacuzino, for a clear diagnosis and adequate

measures.

CONCLUSION


infections with C. difficile on one hand and to the



diversity of bacterium strains on the other hand, a

new approach is necessary for C. difficile related

topics.

References:

1. Allen-Vercoe E. “Syntetic stool can cure clostridium difficile infection” University of Guelph, Science Daily, 2013

2. Coignard B., Barbut F. “Conduite a tenir: diagnostic, investigation, surveillance, et principes de prevention et de maitrise des infections a Clostridium difficile” INVS, RAISIN, France, 2006

3. Duker Freuman T. “Surprise! It’s a laxative” blog www.tamaraduker.com, 2014

4. Hemker Oliva, Hourigan Suchitra “Fecal Microbiota Transplantation” www.news-medical.net/health, 2014

5. Ordeanu V. et all. “Elements of pharmaceutical microbiology” 2nd edition, Universitary Publishing House “Carol Davila” Bucharest, 2010

6. Ordeanu V. “ Antibiotheraphy individualisation” UMF conference, 2012

7. Ordeanu V. et all. “Clostridium difficile a threat emerging in zooantroponotic pathology”, Book of abstracts, Scientific Conferences, 2nd Edition 2014, Timisoara, pg. 112-113”

8. Stoica O. “31 cases of postantibiotic C. difficile infection recorded in Ploiesti” Libertatea newspaper, 7 March 2014

9. Surawicz Christina M., Brandt Lawrence J., Binion David G., Ananthakrishnan Ashwin N., Curry Scott R., Gilligan Peter H., McFarland Lynne V., Mellow Mark, and Zuckerbraun Brian S. “Guidelines for Diagnosis, Treatment,

and Prevention of Clostridium diffi cile Infections”, The American Journal of GASTROENTEROLOGY, Guidelines for CDI, 2013

10. Voth Daniel E. and Ballard Jimmy D. “Clostridium difficile Toxins: Mechanism of Action and Role in Disease”, Clin. Microbiol. Rev. 2005, 18(2):247.

11. http://www.pharmacypracticenews.com/ViewArticle.aspx?d=Clinical&did=50&i=January+2014&iid=1029&aid=24792

12. *** American Society for Microbiology “A Practical Guidance Document for the Laboratory Detection of Toxigenic Clostridium difficile”, September 21, 2010

13. *** CDC “Clostridium difficile - information for healthcare providers”, Atlanta, USA, 2005

14. *** CCLIN “Conduite a tenir devant un ou plusieurs cas de diarhee a Clostridium difficile” France, 2013

15. *** ECDC “027 Clostridium difficile - An emerging epidemic in European Health Care”, Stockholm, Sweden, 2006

16. *** ECDC ’’Annual epidemiological report: Reporting on 2011 surveillance data and 2012 epidemic intelligence data”, 2013

17. *** Pro TV, 22 May 2014.


13

Article received on August 12, 2013 and accepted for publishing on October 9 2013.

Stress management for optimization of organizational

activity

Iuliana Guiţă – Alexandru1,2

Abstract: Stress is a constant presence in our lives, whether we analyze it in professional, social or family terms. This daily reality creates a state of tension, strain and discomfort, causing significant changes in physical and mental health. Stress at work can affect anyone, at any level, in any sector and in organizations of any size. Stress affects health and safety of individuals and also organizations’ welfare and national economies. There is a definite correlation between the level of stress at work and the changes in organization’s productivity.

Keywords: stress management, organizational optimization, occupational stress, organizational culture, psychological contract

STRESS: DEFINITION, TYPES AND CAUSES OF ITS

OCCURRENCE

We meet every day people who are overworked,

overwhelmed or underpaid. We wonder what to do

to cope with the stress in our life. Often we forget to

put on paper all the endless tasks we have to do

during the day, and paradoxically we receive other

new tasks to fulfill.

According to Peter Drucker, we have to make a clear

distinction regarding those who are accomplishing an

intellectual work today, the situation being more

complicated for them than for production line

workers of the past, who knew what they have to do.

Instead, those involved in intellectual work should

not only execute the plan, but also to conceive it. This

puts an important pressure on the human brain so in

case you see a doctor, one of the question is: “How

stressed are you?” Certainly, stress at work can affect

anyone at any level. It is produced in no matter what

do main and in organizations of any size. Stress

affects the health and safety of individuals and also

welfare of organizations and national economies.

Stress was introduced by Hans Hugo Bruno Selye,

professor of histology, who sets up the foundation of

International Institute of Stress with Alvin Tofler in

1977. He believes that stress is related to adaptation

syndrome as a reaction of individual against

environmental aggressions. Hans Selye defines stress

as “the set of reactions of the body to the external

action of the causative agents (physical, chemical,

biological and psychological) consisting in

morphofunctional changes, most often endocrine”.

According to the Romanian Language Explanatory

Dictionary (1998), stress is “the name given to any

environmental factor (or set of factors) causing an

SYSTEMATIC REVIEW

1 Military Emergency Hospital “Dr. Ion Jianu “, Pitești, Romania 2 Researcher in the Research Center for the Promotion of Excellence in Training - University of Pitești

14

abnormal reaction to human body; adverse effect on

the human body produced by an environmental

factor.”

According to Terry Looker, Olga Gregson (2009, p.

31), “Stress is seen as a reaction of the organism

against changes occured in our environment.”

All mentioned authors consider that “stress can be

defined as the condition that we feel when we

perceive a discrepancy between perceived demands

and ability to cope with them.”

Lazarus and Folkman (1984) define stress as “a

cognitive and behavioral effort (with obvious

emotional expression) to reduce, control or tolerate

external or internal demands that exceed personal

resources.”

Ioan Bratu Iamandescu (2002) believes that mental

stress is a syndrome consisting of exacerbation

beyond the level of simple homeostatic adjustments,

certain psychic reactions and their somatic

connections (affecting almost all body components),

in connection with external and internal excitement

exerted by triggering factors (stressor factors) acting

intense, surprisingly, sudden and/or persistent and

having a symbolic nature, “threating”, or, othertime,

extremely favorable to the subject (perceived or

anticipated by the subject). In other cases, stressor

factors could be psychical excitants with major

affective resonance (positive – eustress or negative –

distress) or overloading factors of cognitive

(attention, thinking, etc) and volitional process,

mentioning that mental stress is mainly based on a

major emotional involvement.”

The definition given by Golu M. (1981) should also be

taken into consideration: “state of tension, tightness,

discomfort, caused by affective agents with negative

significance (or positive, in case of eustress),

frustration or repression of some motivations (needs,

desires, aspirations – including underloading),the

difficulty or impossibility of solving problems”.

However, Paul Popescu Neveanu, in the “Dictionary

of Psychology “ (1978), defines stress in terms of two

meanings: “a) situation, stimulus which puts the body

into a state of tension ; b) the special tension state,

itself, of the body as an activation of all its resources

to cope with physical or psychical aggression (strong

emotion)”.

“Stress is an individual reaction and the result of

interaction between environmental demands on one

hand and the resources, capabilities and

opportunities of the individual on the other hand.”

It is certain that stress is characterized by intense

hormonal changes, massive secretion of adrenaline.

There are also morbid changes (hypertension, gastric

ulcer etc). Psychical stress is caused by prolonged

emotions primarily mainly due to frustration, conflict

and anxiety. There is stress of overload and also

stress of underload. A moderate stress boosts and

stimulates the body vitality. The harmful feature of

stress occurs when the damage is too large,

exceeding the individual adaptive capacity.”

Doctor Ioan Bratu Iamandescu, in his book “Psychical

stress and internal diseases” (1993), believes that

stress can be positive (eustress) or negative (distress).

Eustress (“positive stress“) has beneficial effects on

the human body, occurring when the stress agents

have positive significance for the individual.

These triggers positive emotions (intense joy, ecstasy,

triumph, laugh out loud), and positively affect the

body’s organs and apparatus. Eustress appears in the

course of positive emotional states or coupled with

moderate exercise (eg sex or jogging). Eustress is

essentially acute. Frequent repetition of eustress

contributes to increase antiinfection and antitumor

immunity, becoming a longevity premise.

Distress (“negative mental stress“) is widely

recognized as pathological. It usually produces pain

and inadaptation as a result of contact with a stressor

agent.

Situations generating mental stress:

• the existence of unusual circumstances for the

individual, which find him unprepared to deal with

them

• the significance of an event

• engaging the individual into an exaggerated action

or relation

• peculiarities of the social context


15

• lack of internal conditions

• subjective way of perceiving environmental

demands

• underload / overload

• existing conflictual situations in the family,

profession or intellectually related

• lack of time

• isolation

• the emergence of a physical or mental obstacle in

the way of a goal that leads to frustration

• disturbing circumstances arising from physical

agents (noise, vibration, temperature fluctuations).

STRESS AND HEALTH AT WORKPLACE

MANIFESTATIONS OF STRESS AT WORKPLACE

Stress at work can affect anyone, at any level.

It is produced in every sector and in organizations of

any size. Stress affects the health and safety of

individuals and also welfare of organizations and

national economies.

Workplace stress occurs when job demands exceed

the available resources of human beings. Stress is not

only the result of major adverse events, but also is

the result of stress and daily pressures. The latter, by

their frequency, have an important role in the

professional environment and affect more individuals

than major adverse events, which are rare.

Andreescu Anghel, Liţă Ştefan (2006), states that

“sometimes, professional stress is considered as a

positive, beneficial factor on performance.

This refers to eustress which means activation,

mobilization of individual resources. It is important to

distinguish between eustress and distress, one as a

state of stress with beneficial effects, the other with

adverse health effects.”

Today’s world, more dynamic in work field

perspective, brings in the foreground workers,

personnel reductions and services externalization,

increased flexibility in terms of position and

competencies, the growth in number of determined

time job contracts, growing uncertainty of jobs and

intensity of work (overload and higher pressure), and

unstable balance of life and work.

That is why stress can bring disease and pain to

individuals, both at work and at home.

Stress can compromise safety at work too, thus

contributing to other health issues related to work,

such as musculoskeletal disorders.

Stress greatly affects the image of an organization.

Reducing stress associated with work and

psychosocial risks is not only a moral imperative but

also a legal one. It is also an important problem of

economic efficiency. The good news is that stress

associated with work can be approached in the same

logical and systematic way as other health and safety

issues.

There is an abundance of practical examples to cope

this problem in the area of Eurpean Union countries.

Using the appropriate method, workers may be stress

protected.

Considering the example of a person who feels great

pressure meaning job demands (work time, liability)

larger than individual capabilities and corroborated

by conflicts with colleagues/leaders, frequent

changes or threats on job security – such as the

possible personnel downsizing; all these could be

perceived as a stressful situation by someone or

challenging by another. What makes the difference in

perception depends on job nature, the psychological

profile of individuals, as well as physical health or

health, in general.

Manifestations of stress at workplace can lead to:

depression, anxiety, feelings of being overwhelmed

and unable to cope with them, a decrease in

professional performance, an increase in the number

of days for sickness treatment, absenteeism,

insomnia, cognitive difficulties (reduced ability to

concentrate or make decisions), fatigue, headache,

palpitations, gastrointestinal problems, increased

aggressivity, etc.

All these lead to the following consequences:

• a decrease in productivity

• an increased risk of having an accident at work

• damage in personal relationships

• an increased risk of health problems (cardiovascular

disease, digestive problems, cervical pain, etc.)

16

STRATEGIES TO ELIMINATE AND PREVENT

STRESS AT WORK

Recent studies of the so-called “healthy

organizations” suggest that policies for employee

health lead to benefits for organizations.

A healthy organization is defined as an organization

with a low rate of illness or disability in working

personnel.

That means an increased competitivity. Researchers

have identified that a minimum stress at work leads

to a higher level of productivity as definition for a

healthy organization.

These relate to:

• Recognizing employee’s performance

• Opportunities for career development

• Organizational culture that values employee

• Managerial actions in concordance with the values

of the organization.

Strategies to reduce stress at work include:

a) psychological assistance for employees is an

occupational health service; that is provided by

organization in order to reduce or eliminate the

decreasing performance at workplace;

b) training services for employees: performance

management, time management, stress

management, career management, etc. ;

c) educational workshops: parenting, work life

balance, time management, stress management,

emotional control, anger management, decision

making and problem solving, alertness,

communication in couple, smoking quittance, weight

control, etc.;

d) online educational resources: newsletter, access to

educational information for the employee and his

family (web resources, brochures);

e) career management services;

f) services for managers and professionals in human

resources departments are:

- management of critical incidents ;

- assistance for enhancing skills in control of

inadequate behaviors of employees;

- assistance and training in management of

employees capabilities;

- development and implementation of employee

assistance programs in the company.

STRESS PREVENTION AT WORKPLACE

There is no standardized approach or a manual for

developing stress prevention programs. Design

programs and solutions will be influenced by many

factors: the size and complexity of the organization,

available resources, and in particular the type of

problems the organization faces.

For example, in some companies the main problem is

overloading employees and others, an inflexible

program or lack of communication with the public. In

other words, it is not possible to find a universal

prescription for stress prevention in the workplace,

but it is possible to provide some guide lines for the

prevention of stress in organizations.

In all cases, the process of stress prevention

programs involves three distinct approaches:

problem identification, intervention and evaluation.

Organizations must be prepared properly to lead this

process successfully.

A minimum level in preparing a stress prevention

program should include the following:

• workplace stress awareness (causes, costs, control);

• ensuring a quality management and support for the

program;

• employee involvement in all phases of the program;

• establishing the technical capability of program

management (specific training for members or

consultants involvement).

Assembling employees or employers and managers in

the same committee or “solving problem group” can

be a very useful approach for developing a stress

prevention program.

Researches show that these participatory efforts

were successfully achieved on ergonomic issues in

the workplace, partialy due to the capitalization of

direct knowledge of employees about the problems

encountered in their workplace.

The “psychological contract” as a mean of preventing

and combating stress is today a frequent approach. In

the literature the term “psychological contract” is

commonly used in the sense of mutually shared set of


17

expectations between the employee and the

organization.

The author Denise Rousseau defines the

psychological contract as “individual beliefs shaped

by an organization, in terms of exchange between the

individual and the organization”.

Psychological contract can be accepted as a mental

model that employees use to inframe and interpret

organizational phenomena. Its terms shall constitute

a reference system to which employees report their

work and the attitude of employers towards

employees is also very important.

Characteristics of the psychological contract:

• represents, essentially, a subjective perception that

differs from one individual to another;

• psychological contract is dynamic, that means it is

changing over time, during the relationship between

employer and employee;

• refers to the mutual obligations based on

investment in promises made by both parties, with

the hope of a positive outcome for each party;

• is closely linked to the context of labor relationship,

the psychological contract can not be created by

individual or organization only.

The main functions of the psychological contract:

• reduces incertitude, because not all possible

aspects of the employment relationship may be

covered by a formal written contract between the

two parts: employer and employee;

• dictates employee behaviors - like a system, the

employee weighs their commitment to the

organization and the organization’s obligations to

themselves and change their behavior in relatation

with critical company outcomes;

• the third function of psychological contract, gives to

employee a sense of influence on what happens to

him, in the organization.

To conclude, stress is a “disease” of our time,

affecting people no matter of their lifestyle.

Stress is found everywhere, more obvious and more

frequent in advanced countries. To find the way to

manage stressful situations is up to each of us.

References:

1. Labor Safety and Health Agency – https://osha.europa.eu/ro/topics/stress index_ html

2. Anderson, N.; Schalk, R., The psychological contract in retrospect and prospect. Journal of Organizational Behavior, vol. 19, 1998, p. 640

3. Aradavoaice Gheorghe, (2010), Stres, eustres, distres, Antet Publishing House, Bucharest

4. Băban, A. (1998), Stress and personality, Dacia Publishing House, Cluj-Napoca

5. Charly, C. (2003), How to face stress, Polirom Publishing House, Iași

6. Cocoară, Mihai (2005), Stress-definition, manifestation, prevention, Category: Medicine for all. ISBN: 973-87431-2-5

7. Derevenco, P., Anghel, I., Baban, A. (1992), Stress in health and illness – from theory to practice, Dacia Publishing House, Cluj-Napoca

8. Floru, R. (1974), Mental stress, Enciclopedic Publishing House, Bucharest

9. Gherman L., Pănoiu, L., Răcăşan M (2010), Human resource and career management, “Independenţa Economic” Publishing House, Piteşti

10. Holdevici, I. (1995), Autosuggestion and relaxation, Ceres Publishing House, Bucharest

11. Holdevici, I. (1995), Suggestion and suggestive psychotherapy, Victor Publishing House, Bucharest

12. Horney, K. (1998), Our inner conflicts, IRI Publishing House, Bucharest

13. Iamandescu, I.B. (1993), Psychical stress and internal diseases, All Publishing House, Bucharest

14. Iamandescu, I.B. (1995), Manual of Medical Psychology, InfoMedica Publishing House, Bucharest

15. Iamandescu, I.B. (2002), Mental stress, InfoMedica Publishing House, Bucharest

16. Ionescu, G. (1980), Normal and pathological mental life, Academic Publishing House, Bucharest

17. Lacombe F. (2005), Solving communication difficulties, Polirom Publishing House, Iasi

18. Lăzărescu, M. (1994), Clinical psychopathology, Helicon Publishing House., Timisoara

19. Rousseau, D. M.( 1996), Psychological Contracts in Organizations: Understanding Written and Unwritten Agreements. Newbury Park, CA: Sage

18

Article received on October 1, 2015 and accepted for publishing on October 9 2015.

New quaternary ammonium salts based decontaminants

Diana M. Popescu1, Viorel Ordeanu1, Lucia E. Ionescu1, Gabriela V. Dumitrescu1, Simona N. Bicheru1, Marius

Necşulescu1

Abstract: Decontamination after terrorist attacks or industrial accidents with biological and/or chemical agents („bio-chem“) must be fast and efficient, in order to reduce the number of victims and to eliminate the consequent damages. The decontamination of living biological agents (bacteria, viruses) or nonliving ones (toxins, regulators) and toxic chemicals could be accomplished by reactions of hydrolysis in various experimental conditions, in particular in alkaline medium, reactions with amines or ammonia, alcohols, phenols etc. and by their transformation into less toxic degradation products. “Bio-chem” intentional or unintentional contamination is a real risk, towards which an effective management must be available to prevent and control it. Decontamination is an essential measure to protect the personnel and the environment. Synthesis and testing of new „bio-chem“ decontaminants, based on quaternary ammonium salts, complete the arsenal of protection against chemical and biological agents. The most effective selected substances could be produced and used for decontamination in accordance with legal procedures.

Keywords: „bio-chem“ contamination, decontaminants, disinfectant, quaternary ammonium salts, chemical synthesis

DECONTAMINATION

After terrorist attacks, biological and/or chemical

attacks or industrial hazards with bio-chem agents,

the decontamination must be prompt and efficient, in

order to reduce the number of victims and to

eliminate the consequent damages. The

decontamination of the living biological agents

(bacteria, viruses, fungus, and parasites) or of the

nonliving agents (toxins, regulators) and of the toxic

chemicals could be accomplished by hydrolytic

reactions in various experimental conditions

(especially in alkaline medium), reactions with amines

or ammonia, with alcohols and phenols etc. or by

their transformation in less toxic degradation

products.

The biological contamination refers to bacteria and

viruses generating diseases as anthrax, plague,

smallpox, botulism etc. From the chemical structure

point of view, the range of the products used in

microbial decontamination is wide but very few fulfill

the conditions of a good decontaminant.

In this paper there are taken into account the

quaternary ammonia salts obtained by treating the

tertiary amines with alkyl halogen, particularly alkyl

chlorides or benzyl chlorides. These compounds are

SYSTEMATIC REVIEW

1 Military Medical Research Center (CCSMM), Bucharest


19

the most important agents having a biocide action.

Synthesis and conditioning decontaminant by

Mechanical Engineering and Research Institute,

Bucharest (ICTCM) in different forms with the

chemical structure of quaternary ammonium salt

soluble in water was carried out in accordance with

national and European Union legislation related to

ecology and environmental protection.

Figure 1. Microbiological testing of decontaminating substances, in vitro, in CCSMM microbiology laboratory

Figure 2. Microbiological testing of decontaminating substances in various materials, CCSMM minipolygon biological testing

Spectrum of activity and penetrating ability of

decontaminating substance is enhanced by a

surfactant that is designed to reduce surface tension

thus facilitating contact between the microbian cell

and decontaminant compound.

Decontaminant qualities of each product are

determined by the choice of the active substance and

should take account of its antimicrobial qualities, the

purpose, and the conditions that will be used in.

Decontamination efficiency is determined by the

contact time of each decontaminant product,

decontaminating solution concentration, the amount

of solution used per unit area and, not the last, by the

decontaminant agent application mode.

SCREENING TEST

Screening of potential decontaminating substances

was performed in the Laboratory of Microbiology-

20

Epidemiology, in diagnosis laboratory for biological

agents, ranked by P2+ biosafety level for the

pathogen microorganisms.

Bacterial sensitivity assays were performed (the

antibiotic disc diffusion method on several lots),

according to the following parameters: cultivation on

solid culture medium Mueller-Hinton, 72 hours

aerobic incubation at 37° C, with daily reading.

The following bacterial species were tested:

Staphylococcus aureas, Bacillus anthracis, Escherichia

coli, Pseudomonas aeruginosa, Vibrio cholerae.

Results were quantified by measuring with 0.1 mm of

accuracy (caliper and magnifier), comparatively, on

many tests, to calculate the average of each

substance on each species.

Product code DC-3 and code DC-7 was carried out on

quaternary ammonium salts and Nalkylpyridinium

basis. Their testing revealed that the best

microbiological activity was recorded in the product

code DC-7. The possible synergistic effect with

oxidizing compounds was tested in order to achieve

possible decontaminating mixtures.

The bactericidal effect of the substance was tracked

for a set of standard bacterial (gram-positive and

gram-negative, anaerobic bacterial and spores) and

other pathogenic microorganisms; bacterial

sensitivity results were read after 24 and 48 hours of

incubation and then, after storage at room

temperature 48 hours, to watch the effect in time.

The antimicrobial effect was quantified by calculating

the average diameter of bacterial inhibition zone and

bactericidal concentration (g/liter), calculated as the

quantity of substance (20 mg) divided by the volume

in which the antimicrobial diffusion was effective.

(figure 1, 2).

Figure 3. Microbiological testing of decontaminating substances in various materials, CCSMM minipolygon biological testing

TOXICOLOGICAL TESTING

Toxicological screening for acute toxicity aimed to

confirm that these substances are not highly toxic

and are not dangerous to operators.

To demonstrate, 0.5 ml of each substance was

injected in mice (approx. 20 g weight, young adult),

tracking morbidity and mortality for three days. The

test results have enabled experiment achievements

under conditions of a specially arranged experimental

minipolygon.

Experiencing decontaminating products

Representative microbial strains were used for the

main groups of pathogenic bacteria: gram-positive

cocci: Staphylococcus aureus, Streptococcus

pneumoniae, Enterococcus fecalis; gram-positive

bacilli: Bacillus anthracis (vaccine strain), Bacillus


21

cereus, Bacillus subtilis; gram-negative bacilli:

Escherichia coli, Proteus vulgaris, Klebsiella

pneumoniae, Pseudomonas aeruginosa; vibrio: Vibrio

cholerae.

The experimental contamination and

decontamination have been carried out on an out of

service military vehicle, representing the “target”

(figure 3, 4) marked with numbered areas of

approximately 0.1 square meters on which have been

implemented operating procedures for CBRN

(chemical, biological, radiological and nuclear)

contamination control.

Areas were chosen as follows: vertical painted metal

sheet, for aqueous solution decontaminants; glass

window for aqueous solution decontaminants; rubber

tires for aqueous solution decontaminants and

horizontal painted metal sheet for supplied powder

decontaminants as a positive control.

Microbial contamination was done by spraying the

allocated surface, separately, with every microbial

strain and with a mixture of them also. A microbial

suspension culture in a liquid medium was used, with

approximately 1 million live bacteria per ml. Also, it

was sprayed 1 ml of suspension per square

decimeter, enough to create a uniform contaminant

film. For liquid decontaminating substances, the

aqueous solution (conc. 10%) was sprayed to cover

the contaminated area until the excess liquid begun

to tear, about, 10 ml/sqdm on smooth surfaces (glass,

metal sheets) and about 20 ml/sqdm on rough

surfaces (peeling metal sheet, tires).

Figure 4. Microbiological testing of decontaminating substances on combat vehicle with Biological Mobile Intervention Team of CCSMM in CBRN training area from Campulung

Microbiological samples were collected by means of

hygienic-sanitary pad, as follows:

0. before contamination (to establish a baseline level

of natural contamination);

1. immediately after contamination (to check the

level of contamination experiment);

2. after decontamination for each decontaminant

upon each biological agent within 10 min (as required

for military using decontaminant);

3. at every 45 min (as for general household

disinfectant).

In addition, at the end of the experiment, samples

were collected from different parts of the operator’s

protective equipment and from the environment to

detect any residual contamination. All samples were

immediately transported under biosafety conditions

and tested in the microbiology P2+ laboratory.

Decontamination achieved results after 45 min are

shown in Table 1.

22

Table 1. Contamination level after decontamination by 10% aqueous solution

No. Decontaminant Biological

agent Surface

Time (min.)

Growth (tube)

Growth (pane)

Remarks

1 DC 17 ICTCM Mixture Glass 45 - ++hem. Contaminated

2 DC 17 ICTCM B. cereus Glass 45 - - Uncontaminated

3 DC 17 ICTCM Mixture vertical

metal sheet 45 +dep. - Contaminated

4 DC 17 ICTCM B. cereus vertical

metal sheet 45 +/- - Uncontaminated

5 DC 18 ICTCM Mixture Glass 45 - - Uncontaminated

6 DC 18 ICTCM B. cereus Glass 45 +/- - Uncontaminated





9 DC 19 ICTCM Mixture Glass 45 - - Uncontaminated

10 DC 19 ICTCM B. cereus Glass 45 +/- - Uncontaminated




metal sheet 45

+veil, dep.

+ Contaminated

- or +/-: no microbial growth; dep.: bacterial deposit at medium bottom; veil: bacterial population at medium top; hem.: hemolytic colonies.

COMMENTS

The antimicrobial effect remains and is more obvious

after 45 min, suggesting that these products can be

proposed as potential disinfectants for medical or

hygienic-sanitary use, according with Drug Law.

The decontamination with powder is less effective in

all cases, compared with the laboratory control

sample, because of weak contact between micro-

organism and decontaminant, so a residual

contamination remains on surfaces.

In all cases, the final stage of decontamination should

be washing with water because the substances used

can be corrosive upon certain materials or irritating

for personnel.

After the final washing action, a microbiological

analyze was made to determine residual

contamination of surfaces, waste water or protection

equipment, but a significant contamination was not

recorded, so it can be concluded that there is no risk

to the environment.

CONCLUSIONS

A number of potential decontaminating substances

were synthesized and tested, eight of which were

selected and recommended as decontaminating

agents because these can be characterized by high

chemical stability. These products are soluble in

water and various organic solvents. These biocidal

products have bactericidal and fungicidal capabilities,

with a large spectrum of usability. The substances are

characterized by low toxicity on animals.

Theoretical and experimental scientific research has

been made to design and implement polyvalent “bio-

chem” decontaminants for destruction of biological

and toxic chemical agents, hazardous to health.

Technologies have been developed for obtaining

polyvalent decontaminants, selected by efficiency

assays, in laboratory. The experimental polyvalent

model for chemical and biological decontamination

with decontaminants of quaternary ammonium salts

types was developed.


23

Among the tested products, the best antimicrobial

activity is achieved by products based on mixture of

oxidizing compounds and quaternary ammonium

salts, which also have a synergic effect when used,

expanding the action spectrum.

References:

1. Ordeanu V., Luta N., Voicu V., Taralunga Gh., Mircioiu Ctin., Neamtu Ctin., Andries A., Irimia Adriana, Alkyl-Phosphates as New Substances for Disinfection and Decontamination “Bio-Chem”, Chemistry Mag. Bucharest, 59, no. 6, 2008.

2. Luta N., Ordeanu V., Taralunga Gh., Chiraleu E., Popescu M., Neamtu C., Hanganu M., Polyvalent decontaminants for the terrorist attacks combat BIO-CHEM, International Forum “The priorities of chemistry for a durable development”, 20-21 Oct. 2005, ICECHIM Bucharest, Romania.

3. Ordeanu V., Luta N., Voicu V., Taralunga Gh., Mircioiu C., Andries A., Neamtu Ctin., Irimia Adriana, New substances for disinfection and decontamination “bio-chem”, The XIII National Congress of Pharmacy, 28-30 Sept. 2006, Cluj-Napoca, Romania.

4. Stepan E., Neamtu C., Enascuta C., Ordeanu V., Necsulescu M., Andries A., Irimia Adriana, N,N,N’,N’-tetraacetyletylenedyamine (TAED) as an activator for persodiums, in modern compositions of detergents and

disinfectants, Chemistry Mag. (Bucharest) 59, No. 5, 2008, p.558.

5. Stoica L., Irimia Adriana, Oproiu G.C., Ordeanu V., Kinetic modeling of As(V) Separation by dissolved air flotation, Chemistry Mag. (Bucharest) 59, No. 4, 2008, p.379.

6. Craciunoiu S., Barbulescu Emilia, Raducanu Carmen, Ordeanu V., Necsulescu M., Decontaminants BIO-CHEM based on oxidizing compounds and quaternary ammonium salts, Innovative Technology Mag., No. 3, 2008.

7. Voicu V., Luta N., Ordeanu V., Andries A., Research for the development of decontaminating products to combat the effects of terrorist, chemical and biological attacks, Defense NBC Mag., No. 17, 2009, p. 31.

8. Jungerman E., Cationic Surfactants, Marcel Dekker Inc. New York 1970

9. Jackson J.B., Decontaminating solution, Brevet SUA no.3.079.346, 1963

10. *** Antiseptics and disinfectants, AFNOR, ed. 2, AFNOR 1989

24

Article received on December 10, 2013 and accepted for publishing on January 5, 2014.

News and Perspectives on Treatment of Normal Pressure

Internal Hydrocephalus

Cristian Năstase1, Marian Mitrică1, Cristian Popescu1

Abstract: Many patients, usually over 60 years old, presenting presenile dementia associated with marked gait disorders, impaired balance, urinary incontinence, have been shown to have enlarged ventricles associated with relatively small cortical atrophy. Intracranial pressure monitoring indicates normal values, or subject to only minor peaks, usually at night. Because some of these patients improve markedly after ventricular shunting procedures it has been suggested that their neurological dysfunction may be caused by a pressure effect on the brain from the increased internal surface of the ventricles. Many of these patients do benefit from surgery, and a lot of them have a history of subarachnoid hemorrhage, traumatic brain injury or meningitis which might have impaired the CSF absorption.

INTRODUCTION

We would like to present the experience of our clinic

over the last five years regarding the treatment of

normal pressure internal hydrocephalus (28 patients

operated between January 2009 and December

2013), to report our results and compare them with

the statistics and results from the international

literature. Normal pressure internal hydrocephalus

(NPIH) represents an increase of CSF volume, with

different etiology, that causes an enlargement of the

ventricular system as a consequence of the

hydrodynamic CSF circulation disorders.

The cause of this disease cannot be identified in 60%

of cases. It was described in 1965 with the Hakim &

Adams triad: gait disorders and impaired balance,

cognitive disorders (progressive dementia), sphincter

disorders (8). The imagistic explorations (CT scan)

indicate the size of hydrocephalus; ICP < 15 mmHg

and the pressure gradient between the ventricles and

subarachnoid space is very low. For treatment there

are extrathecal shunts (particularly ventriculo-

peritoneal shunt) and intrathecal shunts (particularly

endoscopic ventriculocisternostomy).

Both methods have been practiced successfully in our

clinic.

The ideal treatment method for hydrocephalus still

does not exist. None of the surgical techniques is

perfect and no shunting device gave total satisfaction

(4, 7).

Hydrocephalus represents the enlargement of one or

more parts of the CSF containing anatomic structures.

The CSF total volume is about 150 ml in adult; the

ventricular system contains 25-30 ml, the spinal

subarachnoid space contains 30 ml and the rest of

CSF is contained by the cranial subarachnoid space

ORIGINAL ARTICLES

1 Carol Davila Central Emergency Military Hospital, Bucharest


25

and basal cisterns (1).

Figure 1. The ventricular enlargement shown on CT scan

The total production of CSF is about 600 – 700 ml/24

hours, approximately 0,35 ml/min. The CSF

participates in maintaining the endocranial volume

constant by adjusting the production/absorption ratio

depending on the cerebral parenchyma volume and

the intracranial blood volume variations according to

the Monro-Kellie relationship. Changing the volume

of one of the three intracranial components (brain

tissue, blood, CSF) is followed by a compensatory

reaction from the other two components in order to

maintain inside an inextensible space the endocranial

volume constant (9).

Based on its underlying mechanisms, hydrocephalus

can be classified into obstructive and communicating.

The obstructive hydrocephalus is defined by any

condition that restricts the CSF flow to and from the

ventricular system. Any CSF flow interruption outside

the ventricular system defines the communicating

hydrocephalus (5).

Figure 2. Lateral ventricles puncture

The NPIH etiology is not fully known. There are many

possible congenital or acquired causes, but the most

important are the subarachnoid hemorrhages (20%),

meningitis (1%), parasite infections, traumatic brain

injuries, neurosurgical procedures with open

26

ventricular system, intoxications, Alzheimer disease

(15%).

Hydrocephalus of the adult patients is a

communicating, chronic and normal pressure

hydrocephalus (3).

DIAGNOSTIC

The CT scan and the MRI revolutionized the diagnosis

and the postoperative follow-up of the

hydrocephalus. The CT scan is the first stage of

diagnosis.

It highlights an obstructive cause, evaluates the

ventricular enlargement, appreciates the cerebral

parenchyma condition (periventricular hypodensity)

and the subarachnoid spaces condition (basal

cisterns, sylvian fissures, interhaemispheric fissure,

cortical sulci).

Bifrontal index measuring (the distance between

frontal horns / intracranial distance ratio, on the

same CT slice) > 50% is suggestive for a possible

decompensation of hydrocephalus.

The Evans index > 30% has the same meaning (the

frontal horns size/ the maximum biparietal diameter

ratio). It suggests an active hydrocephalus. The MRI

completes the CT scan by describing the obstructive

lesions accurately and obtaining dynamic information

over the CSF flow (the absence of CSF flow through

Sylvius aqueduct).

The preventing treatment is important because of the

existing risk of postoperative hydrocephalus after any

neurosurgical procedure. Cisternograms with

radioactive markers (99Tc-DTPA) remain

controversial and rarely used.

The radionuclide is injected into the subarachnoid

space by a lumbar puncture and serial images are

taken by planar scintigraphy 3, 6 and 24 hours after

the injection. In case of NPIH intraventricular

radioactivity can be obtained even 48 hours after the

injection. Serial lumbar punctures with repeated

evacuation of 15 – 30 ml CSF associated with clinical

improvement can predict a favorable response to

shunting procedures. Patients with initial measured

CSF pressure >15 mmHg responded favorably after

ventriculo-peritoneal shunting (6, 8, 9).

TREATMENT

The treatment of hydrocephalus depends on the

moment of diagnosis, etiology, age and clinical

condition of the patient (particularly the acute form)

and the complementary investigations results.

The treatment with acetazolamide, a carbonic

anhydrase inhibitor has favorable effects

predominantly by inhibiting the chorioid plexus

secretion and less by the diuretic effect.

The acetazolamide dose is 25 mg/kg/day with

simultaneously administration of furosemide 1

mg/kg/day.

The treatment of obstructive hydrocephalus is

removing the obstacle (excision of tumors). The

surgical treatment seeks not returning to normal size

of ventricles but regaining most of the lost

neurological functions.

The diuretic and corticosteroid therapies complete

the CSF evacuation by lumbar punctions. The CSF

lumbar drainage will be performed only after the

confirmation of communicating chronic

hydrocephalus by imagistic methods.

There are several types of extrathecal derivations of

CSF: controlled external ventricular drainage,

ventriculoperitoneal drainage, ventriculoatrial

drainage, ventriculopleural drainage.

The currently used valves are predetermined opening

pressure valves (low, medium and high pressure),

modular opening valves and programmable valves

with variable resistances, self-regulating valves etc.

The intrathecal derivation (particularly the

endoscopic ventricular cysternostomy) represents an

alternative treatment method. Both extra- and

intrathecal derivations have been successfully

performed in our clinic.

The intrathecal CSF derivations consist of endoscopic

ventriculostomy through the 3rd ventricle floor

aiming to restore the communication between


27

intraventricular and subarachnoid liquidian

compartments.

MATERIAL AND METHODS

We retrospectively studied 28 patients admitted to

our clinic between January 2009 and December 2013.

The patients were all neurological and imagistic

diagnosed with normal pressure internal

hydrocephalus.

Only in 18 cases, a cause for impaired CSF absorption

and ventricular enlargement could be detected. 8

patients had a history of traumatic brain injury, 4

patients had a history of subarachnoid hemorrhage

(First and second grade on Hunt and Hess scale) with

normal “4 vessels” cerebral angiogram, 2 patients

were diagnosed with Alzheimer disease prior to

admission and 4 patients had a history of ischemic

stroke.

3 of the patients with NPIH after subarachnoid

hemorrhage underwent endoscopic procedures with

intrathecal derivations (ventriculocisternostomy).

On the other 15 patients were performed ventriculo-

peritoneal shunts using various valves (most of them

were low pressure valves). The most frequently used

were the Delta (Medtronic), Spitz – Holter, Heyer –

Schulte, Pudenz, Cordis – Hakim valves. In 10 cases, a

cause for NPIH was not revealed and these patients

were diagnosed with idiopathic NPIH. They have also

been performed ventriculoperitoneal shunts with low

pressure valves.

Clinical improvement was significant in most patients,

but only partial in the patients diagnosed with

Alzheimer disease.

According to statistics from literature, urinary

incontinence is the main symptom that resolves after

shunting procedures.

Gait disorders and impaired balance are subsequently

remitted and dementia is the last that improves (3, 4,

8).

Black and collaborators established few criteria that

can predict the favorable clinical course after

shunting procedures:

- clinical: the presence of symptomatic triad;

approximately 77% of the patients presenting gait

disorders as primary symptom improve their

locomotor function after shunting; the patients with

dementia without gait disorders rarely improve after

drainage;

- patients with CSF pressure >18 mmHg on lumbar

puncture or continuous monitoring improve their

neurological status after ventriculoperitoneal

drainage;

- patients with CT or MRI showing large ventricles

with minimal cortical atrophy have favorable

evolution after shunting procedures.

The response to drainage is especially good as the

symptoms started recently (1, 5).

ILLUSTRATIVE CASES

Case 1.

66 year old male patient complaining of gait

disorders, impaired balance, cognitive impairment

(occasionally) and sphincter disturbances (imperious

need to urinate) which started about a year ago,

slowly progressive despite of conservative treatment.

We decided to install ventriculoperitoneal drainage

with self-regulating valve. Postoperative evolution

was favorable, symptoms thereby improving

considerably about 3 months after the procedure.

Case 2.

59 year old male patient complaining of headache,

nocturnal insomnia, depressive syndrome, cognitive

impairment, gait disorders and locomotor’s

instability.

Case 3.

68 year old female patient hospitalized for memory

disorders, sphincter disturbances (imperious need to

urinate), gait disorders, vertigo, occasional headaches

and depressive syndrome. The CT scan reveals

28

enlarged ventricular system. It was decided to install

VP drainage with Delta low pressure valve. The

symptoms improved partially after one month with

significant improvement 6 months after the

procedure.

Figure 3. The ventricular catheter placed inside the right lateral ventricle and the selfregulating valve placed in the right parietal region, under the scalp.

Figure 4. The ventricular catheter placed inside the frontal horn of the right lateral ventricle, near septum pellucid; VP drainage with Delta (Medtronic) low pressure valve.

Case 4.

64 year old male patient facing important balance

disorders, persistent vertigo, extremely difficult gait,

urinary incontinence (and incipient stercoral), onset

of Alzheimer disease (after neurological and

psychiatric examinations). It was inserted a Delta low

pressure valve. The symptoms improved partially

after 3-4 months; the gait has become easier,

sphincter disturbances have improved and the

cognitive impairment still exist, but more tolerable.

Case 5.

72 year old female patient hospitalized for walking

difficulties, balance disorders, persistent vertigo and

vomiting, dehydration. A central venous catheter was

inserted into the right subclavian vein and VP

drainage with a Delta low-pressure valve was inserted

on the left side; intraoperative CSF pressure was 15

mmHg.

Case 6.

66 year old male patient with memory disorders,

impaired balance and gait disorders, cognitive

impairment, urinary incontinence (occasionally),

started over a year ago, with progressive evolution.

Intraoperative measured ICP was 18 mmHg.

Ventriculoperitoneal drainage with Holter low


29

pressure valve was installed. The symptoms improved

after one month with the complete remission of gait

disorders, impaired balance and sphincter

disturbances.

Figure 5. The ventricular catheter placed inside right lateral ventricle (functional drainage).

CONCLUSIONS

The ventricular enlargement and the pressure on the

frontal lobes are probably responsible for the

occurrence of cognitive disorders and dementia.

The pressure on the regulator centers of the

sphincter functions located in the paracentral lobule

may be responsible for the urinary incontinence. The

ventricular dilatation may compress the internal

capsule and secondary the pyramidal tract,

responsible for the gait disorders, impaired balance

and pyramidal syndrome (4, 5, and 9).

To determine the surgical indication and to anticipate

the subsequent postoperative evolution, several

clinical and imaging criteria must be established:

• the obstructive causes for hydrocephalus must be

excluded; it must be a communicating form;

• a periventricular hypodensity on CT scan or

hyperintensity on T2 sequence (MRI) might be

transependimar CSF resorption and might anticipate

a favorable evolution after the shunt procedure;

• the rounding and symmetrical ballooning of the

frontal horns;

• dilated focal of convexity sulci may be revealed by

imaging studies and they are atypical CSF reservoirs

which subsequently decrease after drainage and they

should not be confused with cortical atrophy; typical

cortical atrophy (ex vacuo hydrocephalus) occurs

frequently with Alzheimer disease, and there is a

limited response to ventriculoperitoneal drainage

(11).

30

Figure 6. Preoperative MRI (T2 sequence) and postoperative CT scan; right ventricular catheter;prominent convexity sulci; incipient cortical atrophy

Figure 7. Preoperative and postoperative CT images; the catheter has been placed inside the left lateral ventricle because a central venous catheter was inserted into the right subclavian vein (functional drainage).


31

Figure 8. Important hydrocephalus with cortical sulcus persistent; catheter placed inside the left lateral ventricle (coronal section).

Maintaining good results depends on periodic

medical checks, immediate recognition and

treatment of complications (insufficient drainage

should be suspected first). There is no ideal method

for the treatment of hydrocephalus. None of the

surgical techniques is perfect and no device gave total

satisfaction.

The accelerated development of technology and the

practical experience in CSF intra- and extrathecal

drainage allow overcoming the current difficulties.

The world population undergoes a pronounced aging

process, the number of people aged over 60,

increasing to 400 million over the last 40 years. The

ratio of the elderly population has been modified,

representing over 50% in developed countries, with

the European zone being the aged (10).

References:

1 Black P., Kaye A. - Operative Neurosurgery. Churchill Livingstone. 2000, pp. 1235-1247.

2 Connelly S., Mc Khann G., Huang J., Chondhry T. – Fundamentals of Operative Techniques in Neurosurgery. Thieme 2001, pp. 345 - 355

3 Constantinovici A., Ciurea A.V. – Practical Guide of Neurosurgery, Medical Publishing House 1998, pp. 353-414

4 Jennett B., Lindsay K. – Neurosurgery; Fifth Edition; Springer-Verlag 1996 ; pp.283-289;

5 Greenberg M. – Handbook of Neurosurgery, fifth edition,

Thieme 2001, pp. 191-195;

6 Gorgan R. M. – Handbook of Surgery (Prof. Irinel Popescu), II, Romanian Academy Publishing House, 2007, pp. 114 – 120;

7 Kempe G. L. - Operative Neurosurgery, Springer – Verlag 1968, pp. 203-214;

8 Karaguiosov L. - Operative Neurosurgery, Medicina I Fizkultura, Sofia 1982, pp. 159-166;

9 Wilkins R.H. – Principles of Neurosurgery, McGraw Hill inc.1985.pp. 2341 – 2356.

32

10 Yasargil M.G. – Microsurgery vol II, Clinical Considerations Surgery of Intracranial Aneurysms and Results. New York. Georg Thieme Verlag 1984, pp. 232-295

11 Youmans J.R. - Neurological Surgery, Fourth Edition, W. B. Saunders Company, 2000.


33

Article received on November 12, 2013 and accepted for publishing on December 15 2013.

Nonalcoholic fatty liver disease – an etiological approach

Florentina Ioniță Radu1, Mariana Jinga1,2, Petruț Nuță1, Raluca S. Costache1,2, Săndica Bucurică1,2, Bogdan

Macadon1, Vasile Balaban1,2, Mihăiță Pătrășescu1

Abstract: Nonalcoholic fatty liver disease (NAFLD) is defined as the presence of fat in the liver (hepatic steatosis) either on imaging or on liver histology only after the exclusion of secondary causes of fat accumulation in the liver (e.g. high alcohol drinking, drugs and other medical ailments). Considering the fact that there are many causes of hepatic steatosis, the term NAFLD is reserved for the liver disease that is predominantly associated with obesity and metabolic syndrome. The presence of inflammation and cell injury defines steatohepatitis (NASH) which has the potential to evolve into cirrhosis and hepatocarcinoma, being, therefore, the stage of NAFLD most amenable to treatment. Among the treatments available, the most important are: weight loss, vitamin E and, last but not least, probiotics.

INTRODUCTION

Excessive alcohol consumption must be excluded

(>21 drinks per week in men and >14 drinks per week

in women over a 2-year period before the baseline

liver biopsy).

Insulin resistance (figure 1) is, therefore, central to

the development of NAFLD, as it is central to

metabolic syndrome (MS). The Adult Treatment Panel

III defines MS as the presence of three or more of the

following features:

1. Waist circumference greater than 102 cm in men

or greater than 88 cm in women,

2. Triglyceride level greater than or equal to 150

mg/dL,

3. High-density lipoprotein cholesterol level less than

40 mg/dL in men and less than 50 mg/dL in women,

4. Systolic blood pressure greater than or equal to

130 mm Hg or a diastolic pressure greater than or

equal to 85 mm Hg, and

5. Fasting plasma glucose level greater than or equal

to 110 mg/dL.

Patients with features of MS are at high risk for

NAFLD.

The gold standard for the diagnosis of NAFLD is

hepatic biopsy which further characterizes the

ailment deriving two stages of histological evolution:

nonalcoholic fatty liver (NAFL) (this may be the plain

hepatic steatosis) and nonalcoholic steatohepatitis

(NASH).

NAFL is defined as hepatic steatosis with no evidence

of hepatocellular injury in the form of hepatocyte

ballooning. NASH is defined as the presence of

hepatic steatosis and inflammation with hepatocyte

injury (ballooning) with or without fibrosis. Although

NAFL may be proportionally more common than

CLINICAL PRACTICE


2 Carol Davila University of Medicine and Pharmacy, Faculty of Medicine, Bucharest

34

NASH, only patients with NASH have the potential to

progress to cirrhosis. The presence of the

characteristic ballooning injury is considered to be

the key to the diagnosis.

Figure 1: Insulin resistance – central to metabolic syndrome

Ballooning injury results in enlarged vacuolated cells,

classically containing Mallory-Denk bodies, which are

eosinophilic cytoplasmic inclusions near the nucleus.

The most important injury may be identified in zone 3

(around the central venule of the hepatic lobule) and

this pattern of distribution is also characteristic of

NAFLD.

The cardinal histologic feature of NAFLD is the

presence of an excessive accumulation of

triacylglycerols (TAG) and in hepatocytes. The

presence of obesity and insulin resistance lead to an

increased hepatic free fatty acid (FFA) flux creating an

environment appropriate for the development of

NAFLD/NASH.

The resultant net increase in hepatic FFA is

hepatotoxic unless it is converted to nontoxic

intracellular triglyceride (TG). When the synthesis of

TG is impaired, the level of FFA in the liver is

increased with subsequent augmentation of hepatic

fatty acid oxidation resulting in the overproduction of

reactive oxygen species (ROS) also known as free

radicals causing hepatocellular injury.

Based on this biochemical knowledge, a two-hit

hypothesis for the pathogenesis of NASH has been

proposed. The first hit involves the accumulation of

excess triglyceride and particularly FFA in

hepatocytes. The second hit is the generation of toxic

reactive oxygen species with the production of

hepatic injury and inflammation as a consequence of

FFA oxidation which ultimately leads to the initiation

and progression of fibrosis [1].

Hence, steatosis is mandatory for the diagnosis of

NAFLD but alcohol consumption and chronic hepatitis

C should be taken into account as two of the most

important alternative causes amenable to different

treatments.

The diagnosis of NAFLD requires the following:

(1) Hepatic steatosis according to imaging or

histology

(2) No significant alcohol consumption

(3) No competing etiologies for hepatic steatosis

(table 1)

and

(4) No coexisting causes for chronic liver disease.

NAFLD is the most common cause of abnormal liver

chemistry, so other causes, like those in table 1,

should be ruled out. The majority of patients with

NAFLD are asymptomatic. The most frequently

encountered symptoms are: vague right upper

quadrant dull ache or discomfort. Hepatomegaly is

the most common physical finding. Other clinical

symptoms and physical findings are, also, nonspecific:

general malaise, abdominal discomfort, nausea.

Celiac disease always should be ruled out in

suspected individuals considering the fact that this

disease is often underdiagnosed and seldom to be

taken into account as a differential diagnosis of

hipertransaminasemia.


35

Table 1. Conditions associated with the risk of hepatic

steatosis

STEATOSIS

• Insulin resistance • Obesity • Type 2 diabetes mellitus • Dyslipidemia • Hypertension • Sedentary lifestyle • Corticosteroids • Estrogens • Amiodarone • Antiretroviral medications • Obesity surgery (e.g., jejunoileal bypass) • Rapid weight loss • Carbohydrate excess (e.g., diet and total parenteral nutrition) • Chronic hepatitis C virus, mainly genotype 3 • Hypothyroidism • Polycystic ovarian syndrome

Once NAFLD is diagnosed, the next step is to

determine the severity as it is necessary to establish

the prognosis. Clinical examinations and laboratory

and imaging studies in combination lack the

sensitivity and specificity for distinguishing NAFL from

NASH and for determining the presence and stage of

fibrosis, which is the most important determinant for

the severity and progression of disease.

Circulating levels of cytokeratin 18 fragments have

been investigated extensively as novel biomarkers for

the presence of steatohepatitis in patients with

NAFLD, but this testing is not routinely

recommended. Other noninvasive tests are emerging;

however, these are not yet ready for prime time. [1,

2, 3]

Liver biopsy still remains the most reliable approach

for identifying the presence of steatohepatitis and

fibrosis in patients with NAFLD.

The recommendations for liver biopsy are as follows

(figure 2):

1. Patients at increased risk for steatohepatitis and

advanced fibrosis according to the presence of

features of MS and possibly the NAFLD fibrosis score.

2. Patients with suspected NAFLD for whom

competing etiologies of hepatic steatosis and

coexisting chronic liver diseases cannot be excluded

without liver biopsy.

There is a general consensus that patients with NAFL

have a very slow progression (if any). On the other

hand, patients with NASH can exhibit histological

progression and can develop fibrosis (37%-41%) and

cirrhosis (Approximately 5%) [3]. Importantly, hepatic

cancer can occur in NASH in the absence of cirrhosis.

This is why every effort should be made to identify

patients with NASH as they are the ones to progress

to more severe forms of disease. The presence of

NASH can be associated with higher liver-specific

mortality in comparison with the general population.

Cardiovascular ailments associated with NASH (as

metabolic syndrome) contribute significantly to

mortality and morbidity. Patients with NAFLD are also

at increased risk for hepatocellular carcinoma, but

this risk is likely limited to those with advanced

fibrosis and cirrhosis (1%-42%) [2]. Furthermore, a

comparison of the natural history of NASH cirrhosis

with hepatitis C cirrhosis reveals that patients with

NASH cirrhosis have a significantly lower risk of

hepatocellular carcinoma. [2]

NAFLD is typically characterized by a hepatocellular

pattern of liver-related enzymes with mild elevations

(1-2 times the upper limit of normal) in serum alanine

aminotransferase (ALT) and aspartate amino-

transferase (AST). Up to 50% of NAFLD patients have

normal liver biochemistry. Therefore, several

biomarkers may aid in the diagnosis. The diagnosis of

NASH without a liver biopsy remains the most

significant clinical challenge in the evaluation of a

patient with hepatic steatosis. Several biomarkers

may distinguish between simple steatosis and NASH.

Some of the inflammatory markers include serum C-

reactive protein, interleukin-6, ferritin, hyaluronic

acid (HA), tumor necrosis factor a, leptin,

adiponectin, and resistin.

Apoptosis plays a key role in the pathogenesis of

NASH. Among the markers of apoptosis, plasma

cytokeratin 18 (CK-18) is emerging as one of the

promising biomarkers for the noninvasive detection

of NASH. Since oxidative stress also plays an

important role in the pathogenesis of NASH, several

biomarkers of oxidative stress have been

investigated. Among these, oxidized low-density

lipoprotein, thiobarbituric acidreacting substances,

superoxide dismutase, and glutathione peroxidase

36

dismutase have been examined. The NASH test

combined 13 variables [age, sex, height, weight, and

serum levels of triglycerides (TGs), cholesterol, a2-

macroglobulin, apolipoprotein A1, haptoglobin,

gammaglutamyl transpeptidase (GGT), ALT, AST, and

total bilirubin] to achieve positive predictive value,

and negative predictive value of 66%, and 81%,

respectively. [2, 3, 4]

Figure 2: Algorithm for liver biopsy in NAFLD

Two of the most promising tests for diagnosing

advanced fibrosis in NAFLD are the European Liver

Fibrosis (ELF) score and the NAFLD fibrosis score. The

ELF score includes HA, tissue inhibitor of

metalloproteinase 1 (TIMP1), aminoterminal peptide

of procollagen 3, and age. The NAFLD fibrosis score is

helpful in the clinical setting because it uses routinely

available variables in the clinical setting, including

age, BMI, hyperglycemia, platelet count, serum

albumin, and AST/ALT ratio. We use routinely

available models or markers that increase the pretest

likelihood of finding more advanced liver disease on

liver biopsy. These tests can aid in clinical decision

making for patients with NAFLD.

Some of these markers are a high AST/ALT ratio, a

high AST/platelet ratio, low albumin levels, and low

platelet levels. [2, 3]

TREATMENT LANDMARKS

Among patients suffering from NAFLD (more than

50% of them being asymptomatic) treatment is

mandatory only in NASH patients because only those

have the potential to evolve into more severe

diseases (cirrhosis, hepatocarcinoma) [5].

Because NASH is linked to excess body weight and

resulting insulin resistance, diet and lifestyle

measures are the recommended first-line therapy.

YES

Presence of any of the following (emerging): 1. Elderly (> 65 years old) 2. Family history of diabetes 3. Family history of cirrhosis

Elevated AST and/or ALT and evidence of steatosis on imaging

Presence of co-existing liver diseases or bio-chemical tests favoring an alternative diagnosis

NO

Presence of diabetes or metabolic syndrome

Work-up for co-existing liver diseases and liver biopsy if needed

YES NO

Liver biopsy Presence of any of the following: 1. AST > ALT 2. Low serum albumin 3. Low platelet count

YES

Liver biopsy

NO

YES NO

Consider liver biopsy Reassess every 6 months to 1 year


37

Optimal treatment begins with weight loss and

physical exercise. A tangible target for patients with

NAFLD is a weight loss of 5% to 10% of total body

weight over a 6- to 12-month period [6]. Those

measures may improve insulin sensitivity, increase

adiponectin expression, lipid profiles, and liver

biochemistry. The improvement in liver enzyme does

not always correlate with improvement in hepatic

histology, unfortunately. As it is already

demonstrated, weight loss by dietary changes may be

beneficial even without physical exercise; although

physical exercise may lead to further improvement in

insulin sensitivity. The initiation of increased physical

activity must be the first step to the treatment of

NAFLD; vigorous exercise and resistance training are

more helpful than aerobic exercises. The intensity

may be more important than the duration or total

volume of exercise. [7, 8, 9]

Current guidelines do not recommend the use of

hepaticopharmacological therapy in patients with

steatosis alone. Instead, patients with NASH and

significant liver disease (bridging fibrosis) are good

candidates for this type of therapy. According to the

clinical practice guidelines of the American

Association for the Study of Liver Diseases, the first

choice of therapy is vitamin E (preferably 800 IU/day).

A 2-year treatment in the PIVENS trial (800

IU/day) reversed steatohepatitis and improved all

histological features of NASH (except fibrosis) in

comparison with a placebo. This beneficial effect of

vitamin E was not associated with an improvement in

insulin sensitivity. Recent studies and meta-analyses

showed increased mortality, a risk of hemorrhagic

stroke, and a risk of prostate in long term vitamin E

treatments. [10, 11]

Animal studies have shown that omega-3

polyunsaturated fatty acids promote insulin

sensitivity, reduce intrahepatic triglyceride content,

and ameliorate steatohepatitis. [10, 11]

The drugs to increase insulin sensitivity (glitazone,

metformin) may be indicated as a treatment

alternative in NASH 16. Ursodesoxicholic acid and

pentoxifilin, which may benefit marginally. [6]

Probiotics and NAFLD

The newest topic in treatment of NAFLD is that of the

involvement of gut microbiota in the pathogenesis of

liver steatosis and inflammation.

Intestinal microbiota plays an important role in health

and disease. The gut-liver axis involves an interaction

between bacterial components like lipopolysaccha-

ride and hepatic receptors (Toll-like receptors). Our

gut has approximately 100 trillion (1014) microbes,

which make up approximately 1 to 2 kilograms of our

weight. Gut microbiota perform diverse immunologic,

digestive, and metabolic functions. [11]

Changes in microbiota may be involved in various

disease pathogenesis (nonalcoholic fatty liver disease

(NAFLD), hepatic encephalopathy, alcohol-related

liver disease, and hepatocellular carcinoma). Gut

microbiota may cause NAFLD by luminal ethanol

production by metabolization of carbohydrates, cau-

sing an increased intestinal permeability (“leaky gut”)

just like in alcohol associated steatohepatitis (ASH).

[12, 13]

In 2009 Miele was the first author to provide

evidence of increased intestinal permeability in

patients suffering from NAFLD and this fact was

associated with increased prevalence of small bowel

bacterial overgrowth (SIBO) in those patients [14].

The increased permeability appears to play an impor-

tant role in the pathogenesis of NAFLD. Loguercio

demonstrated in 2005 that probiotics may improve

NAFLD histology and biochemistry [15]. In October

2013 Yan-Yan Ma et al published a meta-analysis in

World Journal of Gastroenterology to conclude that

the treatment with probiotics and prebiotics may

definitely benefit patients with NASH [11].

Probiotics can inhibit the proliferation of harmful

bacteria, reduce SIBO, restore gastrointestinal barrier

function and modulate the immune system, all of

which contribute to the improvement of NAFLD. This

meta-analysis showed that probiotics significantly

reduced ALT, AST, T-chol, TNF-α and insulin resis-

tance, which are all related to the process and con-

sequences of NAFLD. Regular consumption of probi-

otics reduced, also, cholesterol levels which is part of

metabolic disturbances in NAFLD patients. [11]

38

A high fat diet that induces obesity, insulin resistance

and hepatic steatosis also leads to hepatic NKT cell

depletion. The hepatic NKT cell is the key mediator of

HF diet-induced metabolic abnormalities. Moreover,

recently, Cani and colleagues reported that a high-fat

diet increases plasma lipopolysaccharide (LPS) level,

which also contributes to the pathogenesis of insulin

resistance and increased liver triglyceride content. It

is possible that this bacterial endotoxinemia caused

by high fat diet reduces intrahepatic NKT cells and

leads to worsened or amplified insulin resistance. The

ability of probiotics to restore hepatic NKT cells and

improve HF diet-induced insulin resistance and fatty

liver are novel findings and intriguing. [12, 13]

These data suggest that strategies designed to down

regulate inflammatory mediators with probiotics

have promising potential in patients with NAFLD.

CONCLUSIONS

NAFLD/NASH is a prevalent health problem in general

population in close proximity with the same

increased rate of obesity, diabetus mellitus and

metabolic syndrome to which it is pathogenically

related. Proper management of insulin resistance by

diet, weight loss and physical exercise may provide

the patients with strong tools to fight the disease.

The increasing evidence of the role of gut microbiota

in disease pathogenesis and the role of probiotics in

decreasing hepatic steatosis and inflammation points

firmly towards new and handy solutions in the

nearest future.

References:

1. Sanyal AJ, Banas C., Sargeant C., Luketic VA et al; .Similarities and differences in outcomes of cirrhosis due to nonalcoholic steatohepatitis and hepatitis C. Hepatology 2006;43:682-689.

2. Adams LA, Lymp JF, St Sauver J, Sanderson SO et al; The natural history of nonalcoholic fatty liver disease: a population-based cohort study. Gastroenterology 2005; 129: 113-121.

3. Bashar M. and David H. ; Van Thiel Current Concepts and Management Approaches in Nonalcoholic Fatty Liver Disease ScientificWorldJournal. 2013; 2013: 481893. Published online 2013 March 20

4. Rafiq N., Bai C., Fang Y., Srishord M., McCullough A., Gramlich T. Et al; Longterm follow-up of patients with non-alcoholic fatty liver. Clin Gastroentrol Hepatol 2009;7:234-238.

5. Ong JP, Pitts A, Younossi ZM.; Increased overall mortality and liver-related mortality in nonalcoholic fatty liver disease. J Hepatol 2008;49:608-612.

6. Zein CO, Yerian LM, Gogate P., Lopez R, Kirwan JP, Feldstein AE et al; Pentoxifylline improves nonalcoholic steatohepatitis: a randomized placebo-controlled trial. Hepatology 2011;54:1610-1619

7. Huang MA, Greenson JK, Chao C., Anderson L., et al; One-year intense nutritional counseling results in histological improvement in patients with non-alcoholic steatohepatitis: a pilot study. Am J Gastroenterol 2005; 100:1072-1081.

8. Harrison SA, Fecht W, Brunt EM, Neuschwander-Tetri BA.et al; Orlistat for overweight subjects with nonalcoholic steatohepatitis: a randomized, prospective trial. Hepatology

2009;49:80-86.

9. Levy JR, Clore JN, Stevens W.; Dietary n-3 polyunsaturated fatty acids decrease hepatic triglycerides in Fischer 344 rats. Hepatology 2004;39:608-616.

10. Williams CD, Stengel J, Asike MI, Torres DM, et al; Prevalence of nonalcoholic fatty liver disease and nonalcoholic steatohepatitis among a largely middle-aged population using ultrasound and liver biopsy: a prospective study. Gastroenterology 2011;140:124-131.

11. Yan-Yan Ma, Lin Li, Chao Hui Yu, Zhe Chen et al; Effects of probiotics on nonalcoholic fatty liver disease: A meta-analysis World J Gastroenterol. 2013 October 28; 19(40): 6911–6918. Published online 2013 October 28.

12. Cani P., Amar J, Iglesias M., Poggi M., et al. Metabolic Endotoxemia Initiates Obesity and Insulin Resistance. Diabetes. 2007;56:1761–1772.

13. Vishal Sh., Shashank G. , Sourabh et al ; Probiotics and Liver Disease Perm J 2013 Fall;17(4):62-67

14. Miele L, Valenza V, La Torre G, Montalto M et al; Increased intestinal permeability and tight junction alterations in nonalcoholic fatty liver disease. Hepatology. 2009 Jun;49(6):1877-87.

15. Loguercio C., Alessandro F., Tuccillo C., Terracciano F. et al; Beneficial Effects of a Probiotic VSL#3 on Parameters of Liver Dysfunction in Chronic Liver Diseases; J Clin Gastroenterol 2005;39:540–543

16. Boettcher E., Csako G., Pucino F., Wesley R., and Loomba R.; Metaanalysis: pioglitazone improves liver histology and fibrosis in patients with non-alcoholic steatohepatitis; Aliment Pharmacol Ther. 2012 January; 35(1): 66–75.


39

Article received on January 12, 2014 and accepted for publishing on February 15 2014.

An unusual cause for cerebellar syndrome – case report

Carmen A. Sîrbu1, Octavian M. Sîrbu2, Anca M. Sandu2, Cristina P. Sandu1, Marian Ștefănescu1

Abstract: A male from rural area, S.M., aged 77 years, was admitted in our department for discontinuous headache. His medical history was irrelevant. He has been experiencing intermittent right parietal-occipital headaches during the last 3 months. Neurologic exam revealed a slight right limb ataxia. Initial laboratory findings revealed a white blood cell count of 6500/mm3 with 75% polymorphonuclear leukocytes, 15% lymphocytes and 8% monocytes. His serum glucose was 90 mg/dL. Non Gadolinium CT scan shows rounded, inhomogenous spontaneous hyperdense area (40-45 UH) between 5-12 mm diameter, localized frontal, temporal, occipital and cerebellar bilaterally. The question was whether the lesions were metastasis or parasitic infection?

Cerebral MRI showed unenhanced, well defined,

multiple lesions between 3-17 mm, with iso-

hyperintensity T1, T2, and FLAIR, spread out

periventriculary, subcortically, in frontal, temporal,

parietal lobes and subtentorially, right and left

cerebellum (figure 2). After serological tests from

blood and CSF the diagnostic of neurocysticercosis

was certified (an enzyme-linked immunosorbent

assay of the CSF was positive for immunoglobulin G

cysticercosis antibody, with 1.32 optical density units

(OD) (positive result > 0.50 OD); his serum IgG

cysticercosis antibody was positive with 5.12 OD).

CT findings are depending on the stage of evolution:

• Vesicular stage (viable larva): hypodense,

nonenhancing lesions

• Colloidal stage (larval degeneration): hypodense/

isodense lesions with peripheral enhancement and

edema

• Nodular-granular stage: nodular-enhancing lesions

• Cysticercotic encephalitis: diffuse edema, collapsed

ventricles, and multiple enhancing parenchymal

lesions

• Active parenchymal stage: the scolex within a cyst

may appear as a hyperdense dot

• Calcified stage: when the parasite dies, nodular

parenchymal calcifications are seen.

Our patient has multiple lesions in different phases of

evolution (active and calcified).

DISCUSSIONS

Neurocysticercosis is a parasitic brain infection,

caused by larval cysts of the tapeworm Taenia solium

by accidental ingestion of eggs.

It is the most common parasitic disease of the

nervous system and it is the main cause of acquired

epilepsy mainly in developing countries. Once in the

human intestine, Taenia eggs evolve to oncospheres

CLINICAL PRACTICE


2 Carol Davila University of Medicine and Pharmacy, Faculty of Medicine, Bucharest

40

that cross the intestinal wall and lodge in the brain

where cysticerci develop.

Time from infestation until first symptoms is between

days and many years (30).This extremely long

incubation is due to hipnobiosis. They may be located

in subarachnoid space, ventricular system, or spinal

cord too, causing a clinical heterogeneity.

Figure 1. Non Gadolinium CT scan shows rounded, inhomogenous spontaneous hyperdense area (40-45 UH) between 5-12

mm diameter, localized frontal, temporal, occipital and cerebellar bilaterally.

Figure 2. Cerebral MRI showed unenhanced, well defined, multiple lesions between 3-17 mm, with iso-hyperintensity T1, T2,

and FLAIR, spread out periventriculary, subcortically, in frontal, temporal, parietal lobes and subtentorially, right and left

cerebellum


41

Onset of most symptoms is usually insidious to

chronic, with seizures (most common presentation),

headache, dizziness, stroke, neuropsychiatric

dysfunctions. Almost every neurological sign or

symptom may be present but physical findings occur

in less than 20% of the cases.

There is a pleomorphism of the immune response

against Taenia solium. In some cases, cysticerci are

destroyed by immunological attack, while in others,

parasites may live unchanged for years. CT scan

shows a rounded, homogeneous hyperdense area

with no enhancement with contrast medium. This

phase corresponds to the inactive parenchymal form

of the disease.

References:

1. Baccari P, Civilini E, Dordoni L, Melissano R: Celiac artery

compression syndrome managed by laparoscopy. Journal of

vascular surgery, vol. 50 pp.134-139 2009.

2. Muqeetadnan M, Amer S, Rahman A, Nusrat S, Hassan S:

Celiac artery compression syndrome. Case reports in

gastrointestinal Medicine, vol.2013, article ID 934052, 3

pages, 2013.

3. Radiopaedia.org (internet).UBM Medica network; c2005-

2015 rID:1143 Accesed at http://radiopaedia.org/articles/

coeliac artery compression syndrome.

4. Schaan de Quadros A, Sarmento-Leite R, Moraes C. Stent

Implantation in Critical Stenosis of Celiac Trunk: Enlarging

the Frontiers of Percutaneous Vacular Interventio. Arquivos

Brasileiros de Cardiologia, vol 83, no.5 pp. 445-447, 2004.

42

Past and future

Andrei Necşulescu1

Abstract: I was thinking a lot about choosing this title which at first glance doesn’t seem not to be related to the main topic of this article. However, I think these two opposites have the ability to describe in the most subtle form my journey in Istanbul, the city on two continents. The streets covered with history invites you to discover them step by step and the congress showed me a picture of my future when I will have the opportunity to present important projects in front of a selected audience.

The 18th edition of the Balkan Military Medical

Committee Congress was the start point. I can say

that it remains, so far, the most important scientific

event I have participated.

I also had the opportunity to visit Istanbul, a city like a

story that I truly recommend everyone to visit.

Novelty began for me at the military airport Baneasa

when, in a cold morning, I had

the chance to see a C17 Spartan

military transport aircraft for the

first time. I was curious because

that type of military aircraft had

to take me to destination

offering me a unique

experience. First flight was quiet and we were

greeted in Istanbul by friendly hosts and a beautiful

weather. Coach riding to the hotel in the bustling

metropolis gave me a chance to admire the

panorama for the first time especially because there

was quite a distance between the airport and our

hotel, the complex where we were accommodated

being in Asia. When I reached the destination I had

the honor to admire one of the most beautiful hotels

in Istanbul, a true pride of the Turkish army and also a

proof of their elite role in society. Beyond the luxury

and good taste I noticed again the perfect planning of

every detail, starting with accommodation. The

Congress began. In the first evening I started meeting

my colleagues from other countries during an elegant

and discreet reception.

That was the first time I

changed impressions with my

fellow military students from

the other participating

countries. We linked friendships

that I’m sure will be long-lasting

and we set up a future

collaboration for the upcoming congresses,

everything in a festive and friendly atmosphere.

Beyond the congress I ventured for the first time into

crowded Istanbul with my colleague Robert Popescu.

In the second day of the congress I went for the first

VARIA

1 Carol Davila University of Medicine and Pharmacy, Faculty of Military Medicine, Bucharest

Beyond the speeches from heads of delegations I was very happy to see

that the prize for the best project was awarded to Romania. It was a pride

for the whole delegation and we returned to the hotel very happy.


43

time at the Military Museum from Istanbul where I

attended the opening ceremony. After visiting the

museum, my colleague and I were invited in the hall

where the presentations were kept. In front of a huge

picture of Mustafa Kemal Ataturk I attended military

medical exposures from Serbia, Greece, Turkey,

Bulgaria and Romania. I started to get ready for my

first speech in front of an audience composed mostly

of doctors.

Day three was the highlight of the congress for me.

Although I knew Robert Popescu was going to present

the project with doctors and university students, I

was told that my poster will be exhibited in the

museum lobby where I should provide clarifications

for the numerous questions that might be asked. I

admit that things for me were much more effortless

but I was kept up-to-date with the events of the

congress thank to my colleague who was getting

ready to present his project. I appreciated the

presentations of my colleagues from other countries

and together we agreed to collaborate in the

future and gather together at these conferences with

bigger projects that will integrate more teamwork. I

left there convinced that at the next congress I will

come with an oral presentation. I gathered the

minimum necessary experience to deal with future

congress work and I hope I managed to fit in that

great atmosphere provided by the hosts. The

presentation of my colleague was praised; his

experience at previous congresses he attended made

a difference. I left there thinking that I fulfilled the

task of coping with challenges and building the idea

that I can come up with a lot more and improve

myself.

Day four was great. It was time to visit the impressive

Dolmabahce, a true monument and one of the most

spectacular buildings in Istanbul. That day it was

warm, summer was definitely approaching. Many

people were gathered in front of the palace, a sign of

the importance of that particular place. Huge halls,

sophisticated architecture, historical significance and

opulence made me think about what many years ago

was considered absolute luxury. I recommend visiting

the palace along with other major sights of Istanbul.

The evening was one of the most important moments

of the congress due to the cruise on the Bosphorus.

The boat that was waiting for us was state-of-the-art,

impressive and equipped with a luxury dining room.

As already expected, we were welcomed aboard with

friendship. It was the last moment when I changed

impressions about congress with my colleagues from

other countries. There were five delegations in the

debut of the party but at the end we were a single

group with many things in common. That was the

moment when we had the chance to know us better

than we did before. Seen from the Bosphorus,

Istanbul was like a fairytale. I think one of the most

spectacular city’s overall images can be seen at night.

Picture of opulence was reflected in every detail

when I saw the most famous clubs from the city

during the cruise.

44

I went back to the hotel thinking that an experience

like that was unique and I rarely had the opportunity

to see so much luxury gathered in a single place. Last

day brought me back at the military museum which

hosted the closing ceremony. Beyond the speeches

from heads of delegations I was very happy to see

that the prize for the best project was awarded to

Romania.

It was a pride for the whole delegation and we

returned to the hotel very happy. Those were already

the last hours in Turkey. We started preparing to go

back home so we had lunch and then we started

packing the luggage. At the airport our plane was

waiting for us. After a turbulent flight we arrived back

in Romania on a cold and rainy weather, a lot

different than the sun and the heat from Turkey.

The experience was unforgettable. I recommend

everyone to take part in this kind of event even if

they have to deal with oral presentations. I think that

what matters the most is participation and the

numerous things that you can learn. Since little, brick

by brick, experience accumulates and allows

overcoming new limits. I hope I gave a good read and

I want to thank you for the time you have given me.


45

Guidelines for authors

Thank you for your interest in Romanian Journal of Military Medicine. Please read the complete Author Guidelines carefully prior to submission, including the section on copyright. To ensure fast peer review and publication, manuscripts that do not adhere to the following instructions will be returned to the corresponding author for technical revision before undergoing peer review. Note that submission implies that the content has not been published or submitted for publication elsewhere except as a brief abstract in the proceedings of a scientific meeting or symposium. Once you have prepared your submission in accordance with the Guidelines, manuscripts should be submitted online at [email protected]. We look forward to your submission.

EDITORIAL AND CONTENT CONSIDERATIONS Aims and Scope Romanian Journal of Military Medicine (RJMM) is the official journal of the Romanian Association of Military Physicians and Pharmacists. The Journal publishes peer-reviewed original papers, reviews, metaanalyses and systematic reviews, and editorials concerned with clinical practice and research in the fields of medicine. Papers cover the medical, surgical, radiological, pathological, biochemical, physiological, ethical and historical aspects of the subject areas. Clinical trials are afforded expedited publication if deemed suitable. RJMM also deals with the basic sciences and experimental work, particularly that with a clear relevance to disease mechanisms and new therapies. Case reports and letters to the Editor will not be considered for publication. Editorial Review and Acceptance The acceptance criteria for all papers and reviews are based on the quality and originality of the research and its clinical and scientific significance to our readership. All manuscripts are peer reviewed under the direction of an Editor. The Editor reserves the right to refuse any material for review that does not conform to the submission guidelines detailed throughout this document, including ethical issues, completion of an Exclusive License Form and stipulations as to length.

ETHICAL CONSIDERATIONS Principles for Publication of Research Involving Human Subjects Manuscripts must contain a statement to the effect that all human studies have been reviewed by the appropriate ethics committee and have therefore been performed in

accordance with the ethical standards laid down in an appropriate version of the Declaration of Helsinki (as revised in Brazil 2013), available at http://www.wma.net/ en/30publications/10policies/b3/index.html. It should also state clearly in the text that all persons gave their informed consent prior to their inclusion in the study. Details that might disclose the identity of the subjects under the study should be omitted. Photographs need to be cropped sufficiently to prevent human subjects being recognized (or an eye bar should be used). Registration of Clinical Trials We strongly recommend, as a condition of consideration for publication, registration in a public trials registry. Trials register at or before the onset of patient enrolment. This policy applies to any clinical trial. We define a clinical trial as any research project that prospectively assigns human subjects to intervention or comparison groups to study the cause-and-effect relationship between a medical intervention and a health outcome. Studies designed for other purposes, such as to study pharmacokinetics or major toxicity (e.g., phase 1 trials) are exempt. We do not advocate one particular registry, but registration with a registry that meets the following minimum criteria: (1) accessible to the public at no charge; (2) searchable by standard, electronic (Internet-based) methods; (3) open to all prospective registrants free of charge or at minimal cost; (4) validates registered information; (5) identifies trials with a unique number; and (6) includes information on the investigator(s), research question or hypothesis, methodology, intervention and comparisons, eligibility criteria, primary and secondary outcomes measured, date of registration, anticipated or actual start date, anticipated or actual date of last follow-up, target number of subjects, status (anticipated, ongoing or closed) and funding source(s). Plagiarism Detection The journal employs a plagiarism detection system. By submitting your manuscript to this journal you accept that your manuscript may be screened for plagiarism against previously published works. Committee on Publication Ethics The journal subscribes to the principles of the Committee on Publication Ethics (COPE).

ADMINISTRATIVE ISSUES

46

MANUSCRIPT CATEGORIES AND SPECIFICATIONS All articles, with the exception of Editorials, must contain an abstract of no more than 250 words. Abstracts for original articles should be formatted into subheadings, as detailed below. Titles must not be longer than 120 characters (including spaces). Editorials These are invited by the Editor-in-Chief or their delegated editor, and should be a brief review of the subject concerned, with reference to and commentary about one or more articles published in the same issue of RJMM. Editorials are generally 1200–1500 words, may contain one table or figure and cite up to 15 references, including the source article [this should be cited as Military Med. Today (year); (vol): [this issue]. Review Articles RJMM welcomes reviews of important topics across the scientific basis of medicine, and advances in clinical practice. Most published reviews are in response to editorial invitation, including thematically related “mini-series” of reviews. Authors considering submitting a review for RJMM are advised to canvas their possible review with the Editor-in-Chief or a colleague editor; this avoids early rejection if the subject matter is not deemed a high priority for the Journal at the time of submission. Reviews are limited to 3500–5000 words, with an abstract of up to 250 words and up to 75 references and 3–7 figures or tables. Meta-Analyses or Systematic Reviews RJMM particularly welcomes submission of Meta-Analyses and Systematic Reviews, which underpin evidence-based medicine. Guidelines for preparation of Meta-Analysis and Systematic Reviews are similar to other reviews, and articles are subject to the usual peer review process. Meta-Analyses and Systematic Reviews have a word limit of 3500–5000 words, with an abstract of up to 250 words and up to 75 references and 3–7 figures or tables. Original Articles (including clinical trials) RJMM welcomes original articles concerned with clinical practice and research in the fields of medicine. Papers can cover the medical, surgical, radiological, pathological, biochemical, physiological, ethical and/or historical aspects of the subject areas. Clinical trials are afforded expedited publication if deemed suitable. RJMM also deals with the basic sciences and experimental work, particularly that with a clear relevance to disease mechanisms and new therapies. Original articles are limited to 3000 words, with an abstract of up to 250 words and up to 50 references and 3–7 figures and tables. Education and Imaging The Editors welcome contributions to the Education and Imaging section. The purpose is to present imaging for the evaluation of unusual features of common conditions or diagnosis of unusual cases. Contributions will be reviewed by the Education and Imaging Coordinating Editors. The format of the Images pages involves two parts, each of which will occupy up to one journal page. In part 1, a case will be described briefly, including a summary of the presentation, clinical features and key laboratory results. One to two key images will then be presented. It is helpful

to the reader if the author responds to questions that follow from the images of the case, such as ‘What is your diagnosis? What are the features indicated on the CT scan? What is the differential diagnosis?’ Part 2 will briefly describe the imaging features, particularly those that lead to diagnosis or which are critical for management. Differential diagnosis should be mentioned. It will be useful to include either further images or pathological details that validate the imaging diagnosis. Occasionally, presentation of analogous cases or related images from a similar case might be appropriate. Please include between one and three references to definitive studies and appropriate reviews of the subject. The format of the Images page involves a brief background to and description of the disorder of interest together with two figures of high quality. Colored photographs are encouraged. The submission may take the form of a case report or may illustrate particular features from more than one patient.

MANUSCRIPT PREPARATION Style Manuscripts should follow the style of the Vancouver agreement detailed in the International Committee of Medical Journal Editors’ revised ‘Uniform Requirements for Manuscripts Submitted to Biomedical Journals: Writing and Editing for Biomedical Publication’, as presented at http://www.ICMJE.org/. Spelling. The journal uses US spelling and authors should therefore follow the latest edition of the Merriam-Webster’s Collegiate Dictionary. Units. All measurements must be given in SI units as outlined in the latest edition of Units, Symbols and Abbreviations: A Guide for Biological and Medical Editors and Authors (Royal Society of Medicine Press, London). Abbreviations should be used sparingly and only where they ease the reader’s task by reducing repetition of long technical terms. Initially use the word in full, followed by the abbreviation in parentheses. Thereafter use the abbreviation. Trade names should not be used. Drugs should be referred to by their generic names, rather than brand names. Parts of the Manuscript The manuscript should be submitted in separate files: title page; main text file; figures. Title page The title page should contain (i) a short informative title that contains the major key words. The title should not contain abbreviations; (ii) the full names of the authors (if possible, not more than 5 authors per title); (iii) the author's institutional affiliations at which the work was carried out; (iv) the full postal and email address, plus telephone number, of the author to whom correspondence about the manuscript should be sent; (v) disclosure statement; and (vi) acknowledgements. The present address of any author, if different from that where the work was carried out, should be supplied in a footnote. Disclosure statement The source of financial grants and other funding should be acknowledged, including a frank declaration of the authors’


47

industrial links and affiliations. In the case of clinical trials or any article describing use of a commercial device, therapeutic substance or food must state whether there are any potential conflicts of interest for each of the authors: failure to make such a statement may jeopardize the article being sent out for peer-review. Acknowledgments The contribution of colleagues or institutions should also be acknowledged. Thanks to anonymous reviewers are not allowed. Main text As papers are double-blind peer reviewed the main text file should not include any information that might identify the authors. The main text of the manuscript should be presented in the following order: (i) abstract and key words, (ii) text, (iii) references, (iv) tables (each table complete with title and footnotes), (vii) figure legends. Figures and supporting information should be submitted as separate files. Footnotes to the text are not allowed and any such material should be incorporated into the text as parenthetical matter. Abstract and keywords Original articles must have a structured abstract that states in 250 words or less the purpose, basic procedures, main findings and principal conclusions of the study. Divide the abstract with the headings: Background and Aim, Methods, Results, Conclusions. The abstracts of reviews need not be structured. The abstract should not contain abbreviations or references. Three to five keywords should be supplied below the abstract and should be taken from those recommended by the US National Library of Medicine’s Medical Subject Headings (MeSH) browser—(http://www.nlm.nih.gov/mesh/meshhome.html). Text Authors should use subheadings to divide the sections of their manuscript: Introduction, Methods, Results, Discussion, Acknowledgments and References. References The Vancouver system of referencing should be used. In the text, references should be cited using superscript Arabic numerals in the order in which they appear. If cited only in tables or figure legends, number them according to the first identification of the table or figure in the text. In the reference list, the references should be numbered and listed in order of appearance in the text. Cite the names of all authors when there are six or less; when seven or more list the first three followed by et al. Names of journals should be abbreviated in the style used in MEDLINE. Reference to unpublished data and personal communications should appear in the text only. References should be listed in the following form: Number references in the order cited as Arabic numerals in parentheses on the line. Only literature that is published or in press (with the name of the publication known) may be numbered and listed; abstracts and letters to the editor may be cited, but they must be less than 3 years old and identified as such. Refer to only in the text, in parentheses, other material (manuscripts submitted, unpublished data, personal communications, and the like) as in the following

example: (Chercheur X, unpublished data). If the owner of the unpublished data or personal communication is not an author of the manuscript under review, a signed statement is required verifying the accuracy of the attributed information and agreement to its publication. Use Index Medicus as the style guide for references and other journal abbreviations. List all authors up to six, using six and "et al." when the number is greater than six. Tables Tables should be self-contained and complement, but not duplicate, information contained in the text. Number tables consecutively in the text in Arabic numerals. Type tables on a separate page with the legend above. Legends should be concise but comprehensive – the table, legend and footnotes must be understandable without reference to the text. Vertical lines should not be used to separate columns. Column headings should be brief, with units of measurement in parentheses; all abbreviations must be defined in footnotes. Footnote symbols: †, ‡, §, ¶ should be used (in that order) and *, **, *** should be reserved for P-values. Statistical measures such as SD or SEM should be identified in the headings. Figure legends Type figure legends on a separate page. Legends should be concise but comprehensive – the figure and its legend must be understandable without reference to the text. Include definitions of any symbols used and define/explain all abbreviations and units of measurement Indicate the stains used in histopathology. Identify statistical measures of variation, such as standard deviation and standard error of the mean. Figures All illustrations (line drawings and photographs) are classified as figures. Figures should be numbered using Arabic numerals, and cited in consecutive order in the text. Each figure should be supplied as a separate file, with the figure number incorporated in the file name. Preparation of Electronic Figures for Publication: Although low quality images are adequate for review purposes, publication requires high quality images to prevent the final product being blurred or fuzzy.

SUBMISSION REQUIREMENTS Manuscripts should be submitted online at [email protected] A cover letter containing an authorship statement should be included. The cover letter should include a statement covering each of the following areas: 1. Confirmation that all authors have contributed to and agreed on the content of the manuscript, and the respective roles of each author. 2. Confirmation that the manuscript has not been published previously, in any language, in whole or in part, and is not currently under consideration elsewhere. 3. A statement outlining how ethical clearance has been obtained for the research, particularly in relation to studies involving human subjects, and animal experimentation. The institutional ethics committees approving this research

48

must comply with acceptable international standards (such as the Declaration of Helsinki) and this must be stated. 4. For research involving pharmacological agents, devices or medical technology, a clear Conflict of Interest statement in relation to any funding from or pecuniary interests in companies that could be perceived as a potential conflict of interest in the outcome of the research. 5. For clinical trials, that these have been registered in a publically accessible database (see more under 'ETHICAL CONSIDERATIONS (Further Information)' later in these guidelines). If the above items are not included in the cover letter, manuscripts cannot be sent for review. Please also note that the cover letter does not require a detailed or lengthy description of the content or structure of the manuscript itself. Two Word-files need to be included upon submission: A title page file and a main text file that includes all parts of the text in the sequence indicated in the section 'Parts of the manuscript', including tables and figure legends but excluding figures which should be supplied separately. The main text file should be prepared using Microsoft Word, doubled-spaced. The top, bottom and side margins should be 30 mm. All pages should be numbered consecutively in the top right-hand corner, beginning with the first page of the main text file. Each figure should be supplied as a separate file, with the figure number incorporated in the file name. For submission, low-resolution figures saved as .jpg or .bmp files should be uploaded, for ease of transmission during the review process. Upon acceptance of the article, high-resolution figures (at least 300 d.p.i.) saved as .eps or .tif files will be required.

PUBLICATION PROCESS AFTER ACCEPTANCE Accepted papers will be passed to production team for

publication. The author identified as the formal corresponding author for the paper will receive an email, being asked to complete an electronic license agreement on behalf of all authors on the paper. Accepted Articles The accepted ‘in press’ manuscripts are published online very soon after acceptance, prior to copy-editing or typesetting. Accepted Articles are published online a few days after final acceptance, appear in PDF format only, are given a Digital Object Identifier (DOI), which allows them to be cited and tracked. After print publication, the DOI remains valid and can continue to be used to cite and access the article. Given that copyright licensing is a condition of publication, a completed copyright form is required before a manuscript can be processed as an Accepted Article. Proofs Once the paper has been typeset, the corresponding author will receive an e-mail alert containing instructions on how to provide proof corrections to the article. It is therefore essential that a working e-mail address is provided for the corresponding author. Proofs should be corrected carefully; the responsibility for detecting errors lies with the author. The proof should be checked, and approval to publish the article should be emailed to the Publisher by the date indicated; otherwise, it may be signed off on by the Editor or held over to the next issue. Offprint A PDF reprint of the article will be supplied free of charge to the corresponding author. Additional printed offprint may be ordered for a fee.

COPYRIGHT, LICENSING AND ONLINE OPEN Details are on the Copyright Agreement Form that must be completed and signed when the Article is accepted.

Romanian Journal of Military Medicine

Vol. CXVII, New Series, No 1-2/2014

ISSN 1222-5126

founded 1897 vol. cxvii romanian journal of no. 1 …...vol. cxvii • new series • no. 1-2/2014...

Documents