CLINICAL ASPECTS

STUDY REGARDING THE ACTIVITY OF THE EMERGENCY

DENTAL OFFICE WITHIN THE EMERGENCY ROOM OF
MOBILE EMERGENCY SERVICE FOR RESUSCITATION AND
EXTRICATION (UPU-SMURD) SIBIU

CRISTIAN ALEXANDRU ȚÂNȚAR1, CARMEN DANIELA DOMNARIU2

1
Phd Candidate “Lucian Blaga” University of Sibiu, 2“Lucian Blaga” University of Sibiu

Keywords: UPU, Abstract: Our study is a retrospective one and it is related to the analysis of registration data of patients
SMURD, emergency who addressed the dental emergency office of Sibiu County during 2011-2015. We aimed at identifying
dental office, the number of patients coming to the emergency dental office, its trend for the period under study and at
retrospective study analysing the activity of this office in relation to other similar centers. After analysing the data, it was
found a total number of 32 165 patients, the number of males being of 13.4%, more than females and
from the urban areas, there were 36.2% patients, more than those from rural areas. The average number
of patients per dental office was 536 (SD = 62.55) patients /month with an average number per day of
about 18 patients while the average age of patients was approximately 38 years (SD = 19.02). The study
concluded that the age of addressability to Sibiu dental emergency service drops significantly
throughout the 5 years of study, and the months with high activity under study were December, January
and August. The results were compared with data found in the literature about similar dental centres in
Romania, namely Bihor and Mureş counties’ centres. It was found that the average number of patients
per month in Sibiu was similar to that of Mureş and twice higher than in Bihor.

INTRODUCTION  Pericoronaritis, anti-inflammatory treatment, incision,

The department of the emergency room within the
Romanian Mobile Emergency Service for Resuscitation and
Extrication (UPU-SMURD) contains since 2007 an emergency
dental office dealing with dental emergencies 24 hours per day.
The type of activity and protocol is stipulated in the Romanian
health policy.
In year 2007, along with the publication of the Order
no.1706 from 2 October 2007, regarding the management and
organization of the emergency departments, hospitals having
―emergency‖ title are obliged to establish dental offices that
provide dental care for emergency dental pathologies.(1,2)
The same Order stipulates that ―In UPU-SMURD
structures from the county emergency hospitals, dental offices
will also operate providing dental medical emergency care‖.(3)
The following diagnoses are considered emergencies
and need urgent procedures:
 Acute stomatitis, necrotic ulcerative gingivitis-lavage and
collutoria;
 Acute pulpitis - calming bandage, pulp extirpation;
 Acute apical periodontitis - treatment of acute apical
periodontitis, transosseous drainage;
 Abscess: vestibular, palatinal, and marginal periodontal -
incision, drainage;
 Post-extraction dry socket - lavage, cones with antibiotics,
possibly curettage;
 Post-extraction bleeding: sutures, possibly curettage or
conformators of thermoplastics;
 Dento-alveolar trauma: luxations, subluxations - reduction,
immobilization of fractures, tooth extraction;
drainage;
 Maxilo-facial trauma - emergency treatment - hemostasis,
temporary splinting;
 Temporomandibular joint dislocations - reduction and
immobilization.(3)
Most often, this service is underfunded, regarded as a
dispensable service and supposedly, not important as the other
medical specialties.
PURPOSE
Identifying the number of patients who come to our
office and the trend for the period under study.
Comparative analysis of the activity of the dental
office in relation to other similar centers for which there is data
published in the literature.
MATERIALS AND METHODS
The study is a descriptive, retrospective one and was
conducted over a 5-year period between 01.01.2011 and
31.12.2015 and targeted non personal data of the patients who
addressed the dental emergency office from UPU-SMURD
Sibiu within the Clinical County Emergency Hospital of Sibiu.
The database contained information about age, gender,
date and time of arrival, date and time of departure, diagnosis,
treatment conducted and medical indications.
Study patients who were presented to the emergency
dental office within the University Dental Centre of Sibiu
received clinical check-up and were diagnosed with an
emergency pathology for which they received emergency
treatment.

1
Corresponding author: Cristian Alexandru Țânțar, Str. Ștefan cel Mare, Nr. 75 B, Ap. 5, Sibiu, România, E-mail: tantarcristian@yahoo.com, Phone:
+40744 369508
Article received on 12.01.2017 and accepted for publication on 27.02.2017
ACTA MEDICA TRANSILVANICA March 2017;22(1):1-3
AMT, vol. 22, no. 1, 2017, p. 1
 PUBLIC HEALTH AND MANAGEMENT
Data processing (4) and graphical representations
were done using Microsoft Office Excel 13 program. Data
analysis was performed using IBM SPSS Statistics 20.
Categorical data of gender and area of origin were
presented as frequencies and percentages and in order to
compare them, Chi-Square test was used.(5,6)
For continuous data, the number of patients per year,
the number of patients per month, both frequencies and
percentages and indicators of central tendency such as mean and
standard deviation were determined.
For age, there were determined the values of central
tendencies and comparisons between years were performed
using ANOVA test. For the analysis of differences in the
number of patients between the origin areas and gender, t-test
was used.(7,8)
RESULTS AND DISCUSSIONS
During the five years of the study, 32165 patients
were presented to the dental emergencies office within the
University Dental Clinic.
The number of patients who presented each year was
6340 (19.7%) in 2011, 6314 (19.6%) in 2012, 5983 (18.6%) in
2013, 7003 (21.8%) in 2014 and 6525 (20.3 %) patients in 2015
(Chi-Square test, χ2 = 86.845, df = 4, p = 0.000).
Analysing the collected data, we noticed that the
average number of cases per year was M = 6433 (SD = 373.72)
patients, the greatest difference being recorded between 2014
and 2013 in 2014, 1020 more patients were presented than in the
year 2013.
The number of patients seeking emergency dental
treatment varied between a minimum of 422 patients /month in
October 2013 and a maximum of 704 patients /month (in
December 2014) with an average of 536 (SD = 62.55) patients
/month.
During the 5 years of study, the average number of
patients who were sent daily to this office was 17.65. The
maximum number of patients examined and treated over 24
hours was 56 (December 2012). For each of the five years, the
highest value was observed in December, probably due to winter
holidays, period of time during which the private practice
offices were closed in Sibiu.
The average age of the study patients was M = 38.19
(SD = 19.02). In 2011, the average age was 40.55 years (SD =
18 732) in 2012 - 39.16 years (SD = 18 728), in 2013 - 38,57
years (SD = 18.816), in 2014 -37.09 years (SD = 19 244) and in
2015- 35.90 years (SD = 19.174). It appears that over the study
period, between 2011 and 2015, the average age has decreased
significantly (F = 57.859, df = 4, p = 0.000) (figure no. 1).
Figure no. 1. Distribution of patients’ age during the five
years of study
AMT, vol. 22, no. 1, 2017, p. 2
Regarding the origin environment, the patients were
divided as follows: 21904 (68.1%) came from urban area and
10261 patients (31.9%) came from rural areas (p = 0.000).
During the five years of study, limits under which the
percentages of patients vary were: 67-68% from urban area and
31-32% from rural area (figure no. 2).
The minimum number of patients per month in urban
areas was 266 (February 2011), the maximum number was 473
(March 2014) with an average M = 365.07 (SD = 38.87). The
minimum number of patients per month in rural areas was 108
(February 2012), the maximum number was 473 (December
2014) with an average M = 171.02 (SD = 22.30).
Figure no. 2. The distribution of patients regarding the area
of origin during the five years of study
In terms of gender, most patients were males 18242
(56.7%), while 13923 (43.3%) were females (p = 0.000).
During the five years of study, the limits under which
the number of patients varied were as follows: 38% -47% for the
female gender and 52%-61% for the male gender (figure no. 3).
The minimum number of patients per month of the
male gender was 221 (October 2013), the maximum number
was 404 (December 2011) with an average M = 304.03 (SD =
34.61). The minimum number of patients per month for the
female gender was 163 (June 2012), the maximum number was
329 (August 2014) with an average M = 232.05 (SD = 39.36).
Figure no. 3. Gender distribution of patients during the five
years of study
According to the available data in the literature, we
could make a comparison between the three emergency centres:
Sibiu, Oradea and Tîrgu-Mureş regarding the fluctuation of the
number of patients who addressed this service between 2011 and
2012.
According to a similar retrospective study on just two
years (2011-2012), of the patients who addressed the emergency
dental office of Oradea, 63% were from urban area and 37%
from rural area. Gender distribution was as follows: 54% males
and 46% females.(9)
 PUBLIC HEALTH AND MANAGEMENT
In the emergency dental office from Tîrgu-Mureş, the
percentages were completely reversed, 47% were from urban
area and 53% from rural area, while the distribution by gender
was in favour of the female gender with 62% and 38% for the
males.(9)
Figure no. 4. Fluctuation of the number of patients in the
emergency dental offices in Sibiu, Oradea and Tîrgu-Mureş
for a period of two years, depending on origin area
Figure no. 5. Fluctuation of the number of patients in
emergency dental offices in Sibiu, Oradea and Tîrgu-Mureş
for a period of 2 years, by gender
In Sibiu, during 2012-2013, the average number of
cases per month was M = 511.66 (SD = 58.89), in Bihor centre,
the average was M = 194.87 (SD = 29.05) and in Mureş, M =
534.29 (SD = 130.85).
Regarding the number of patients per month, there can
be noticed a greater resemblance with Mureş County, but the
number of cases in terms of evolution in time is more constant
in Sibiu, the evolution being similar with the emergency dental
office in Oradea (figure no. 6).
Figure no. 6. Fluctuation of the number of patients in
emergency dental offices in Sibiu, Oradea and Tîrgu-Mureş
for a period of 2 years
AMT, vol. 22, no. 1, 2017, p. 3
CONCLUSIONS
1. The age of addressability in Sibiu dental emergency service
drops significantly throughout the 5 years of study.
2. The average number of patients per month is two times
higher in urban areas compared to rural areas (t = 18.66, p
= 0.000). Also, during the 5 years studied, the fluctuation in
the number of patients in urban areas was higher than in
rural areas, which had a much constant evolution
throughout the 5 years of study.
3. The average number of patients per month is 1.5 times
higher in male people compared to female persons (t =
7.47, p = 0.000). Also, during the five years studied, there
was a 5% increase in the number of female patients
addressing the emergency dental office.
4. Of the three emergency dental offices studied, the one in
Sibiu had the largest number of patients per year. It was
found that the average number of patients per month in
Sibiu was similar to that of Mureş (t = -0.772, p = 0.446)
and more than two times higher than in Bihor (t = 23.63, p
= 0.000).
5. Analysing the evolution of the number of patients who
address the emergency dental office, there are highlighted a
number of issues that would need to be optimized through a
pragmatic and operational approach.
6. In the months with very high activity according to the study
(December, January and August), there should be
employed physicians (paid by the hour) from the outside to
supplement the need for medical personnel.
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1. Voroneanu M, Bucur A, Iordache N, B lan H. Urgențe
medico-chirurgicale n cabinetul de medicin dentar .
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2. Colojoar C. Curs de reabilitare oral i urgențe
stomatologice, Volumul 1. Lito UMFT, Timi oara; 200 . p.
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3. Ordinul ministrului s n t ii publice nr. 706 2007 privind
conducerea şi organizarea unit ilor şi compartimentelor de
primire a urgen elor. Online. 2007 [cited 2016 July 4].
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Stoica E. Manual de inițiere n birotic , Ed. Univ. Lucian
Blaga, Sibiu ISBN 978–973–739-388-3; 2007.
5. Anderson L, Cherala S, Traore E, Martin N. Utilization of
Hospital Emergency Departments for Non-Traumatic
Dental Care in New Hampshire, 2001–2008. J Community
Health. 2011;36:513-516.
6. Shortridge E, Moore E. Use of emergency departments for
conditions related to poor oral healthcare: Implications for
rural and low-resource urban areas for three states. Journal
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2009;15(3):238-245.
7. Mocan I. SPSS Introducere în analiza datelor, Ed. Univ.
Lucian Blaga, Sibiu, ISBN 973–739–189–6; 2005. p. 9-
100.
8. Maniu I. Tehnici de analiz a datelor: statistica, Ed. Univ.
Lucian Blag, Sibiu, ISBN 978–606–12–0891–3; 2014. p.
93-98.
9. Dörner K, Boeriu C, Vass H, Nagy M, Koszta Z, Iurcov R,
Székely M. Comparative Study Regarding Activity of
Emergency Dental Offices în Tîrgu Mures and Oradea.
Acta Medica Marisiensis. 2015;61(2):120-123.
 PUBLIC HEALTH AND MANAGEMENT

STATUS OF HUMAN PAPILOMA VIRUS IN A COHORT OF

ROMANIAN WOMEN

GABRIELA ADRIANA DINCA1, DANIELA NUTI OPRESCU2,

FLORENTINA LIGIA FURTUNESCU3, MATEI DUMITRU4
1,2,4
National Institute for Mother and Child Health Alessandrescu – Rusescu, Bucharest,
2,3,4
University of Medicine and Pharmacy “Carol Davila”, Bucharest

Keywords: human Abstract: Cervical cancer is the fourth most frequent type of cancer in women worldwide and its
papillomavirus, occurrence is strongly associated to high risk genotypes 16/18/31/33/35/39/45/51/52/56/58/59/66 of
cervical cancer, human papillomavirus (HPV). This observational study aimed to investigate the status of HPV infection
screening in a cohort of 725 Romanian women requesting specialty services in a clinic of gynaecology from
Bucharest. In our cohort, the HPV genotype 16 was by far most frequently identified and it was followed
by genotypes 51, 31, 52 and 18 (prevalence of 37.5; 13.9; 13.4; 11.8; 10.6% respectively). Its presence
increased significantly in women having HSIL cytology, compared to cases with less severe cytology
results. We found also very low use of vaccination and HPV testing. Due to methodologic limitations,
our results cannot be generalised in the Romanian women population and further research is needed for
this purpose. However, our results suggest the need for a stronger public health approach for prevention
and control of cervical cancer in Romania.

INTRODUCTION cancer are considered amenable, the standardised mortality rate

Cervical cancer is the fourth most frequent type of
cancer in women worldwide, with an estimated of 528000 new
cases and 260000 deaths reported for the year 2012.(1) This
cancer is a source of major health inequities because 85% of the
total cases occur in less developed regions of the world,
meanwhile the three preceding most common tumours (breast,
colorectal and lung) do occur with quite similar frequency in
developed and less developed regions.(1,2)
By another hand, the deaths by cervical cancer are
considered both amenable and preventable (potentially
avoidable through good quality of health care services and
adequate public health interventions respectively).(3)
Historically, main causes of cervical cancer were
related to the age of starting the sexual life or to the number of
partners, but, in the last two decades, strong evidence showed
that human papillomavirus (HPV) is a necessary cause for this
severe disease. The virus has over 200 genotypes which are
classified as low and high risk respectively.(4) The virus has
over 30 genotypes sexually transmitted and thirteen high risk
genotypes, which were found to be responsible of 99.7% of the
total cases of cervical cancer (HPV
16/18/31/33/35/39/45/51/52/56/58/59/66).(4-6) Among these
genotypes HPV-16 and HPV-18 are the most common, being
responsible of around 70% of all cervical cancers worldwide.(7)
Strategies for primary and secondary preventions are
available for controlling the burden of cervical cancer, as
programs for vaccination against HPV and populational
screenings, either for cervical cancer (cytology based) or for
HPV, last one bringing 70% more protection against invasive
cervical cancer compared to cytology.(8)
Cervical cancer is a major public health problem in
Romania, each year being reported over 3,500 new cases and
2400 deaths.(9,10) Even though at EU level deaths by cervical
in Romanian women is more than three times higher compared
to EU average (11.9 versus 3.1 deaths per 100,000 inhabitants
respectively).(9,11) As regard the preventive strategies, they
have limited availability. An attempt to initiate a program for
vaccination against HPV targeting the girls of 9 – 11 years old
was rejected by the civil society in 2008-2009, due to
insufficiently analysed reasons. Apparently, the parents of the
girls perceived the vaccine as risky or experimental and only
2.5% of the direct beneficiaries were vaccinated at that time.(12)
The screening for cervical cancer using cytology is subject of a
national health program since many years, but despite the
gradual increase in number of beneficiaries, the at-risk
population coverage remains still low, and with high disparities
among regions (national coverage for period 2012 – 2015:
14.5% of eligible population, varying among regions from 7.4%
to 22.6%).(13) Screening for HPV is not reimbursed by the
health insurance, being available with full payment from the
patient.
In this context, the prevalence of HPV infection and
the distribution of different genotypes are not known in
Romania, even though these data would be very necessary for
monitoring the epidemiologic context and the impact of
prophylactic vaccination.
PURPOSE
Our study aimed to investigate the status of HPV
infection in a cohort of Romanian women requesting specialty
services in a clinic of gynaecology from Bucharest.
MATERIALS AND METHODS
The presented study is a prospective cohort. All
consecutive women seeking specialty gynaecologic services for
cervical abnormalities during five years, since 1 st of January

1
Corresponding author: Gabriela Adriana Dinca, B-dul Lacul Tei, Nr. 20, Sector 2, Bucureşti, România, E-mail: toyamed.gaby@yahoo.com, Phone:
+4074 4347188
Article received on 17.01.2017 and accepted for publication on 27.02.2017
ACTA MEDICA TRANSILVANICA March 2017;22(1):4-7
AMT, vol. 22, no. 1, 2017, p. 4
 PUBLIC HEALTH AND MANAGEMENT

2010 – 31st of December 2014 were enrolled. proportion of smokers was almost double (27.9% compared to
The inclusion criteria were: 16.7% in general female population respectively).(16)
a. Age over 18 years;
b. Woman seeking specialty gynaecologic services for Table no. 1. Personal characteristics of the patients
cervical abnormalities Personal Characteristic Value
c. New case for the clinic at first visit. Age (years): mean±SD (min; max) 33.9±8.17 (18, 71)
We excluded pregnant women seeking pre-natal services. Weight (kg): mean±SD (min; max) 61.3±9.34 (43; 106)
The study is observational and it has been approved by Height (cm): mean±SD (min; max) 165.7±5.36 (150; 185)
the Ethical Committee of the Clinic. Body mass index: % (n)
We planned to have a two years’ follow-up period. underweight 8.4% (n=61)
normal weight 73.4% (n=532)
Within this interval each woman was invited to new visits
overweight 14.3% (n=104)
depending on her clinical status and in accordance to the
obese 3.9% (n=28)
corresponding clinical protocols. Education*: % (n)
All the women have been investigated at enrolment Lower secondary or less: 1.7% (n=12)
following the medical protocol of the clinic, by receiving Upper seconday 25.7% (n=186)
cytology, colposcopy and, if needed, recommendation for HPV Tertiary 70.3% (n=510)
testing. HPV testing was recommended at first visit to patients Urban living environment: % (n) 91.3%(n=662)
with abnormal cytology, or to patients with normal cytology and Prevalence of current smokers: % (n) 27.9% (n=202)
cervical lesion identified by colposcopy. * Data available for 708 women
We collected data regarding personal characteristics
(age at first visit, weight, height, education, living environment, Personal antecedents of the patients are presented in
smoking), personal antecedents (age of starting the sexual life, table no. 2.
number of previous births or abortions, use of oral
contraceptives, number of sexual partners, previously performed Table no. 2. Personal antecedents of the patients
cytology, previously documented HPV infection and vaccination Personal Antecedents Value
against HPV), clinical status at the enrolment visit (cytology, Age of starting the sexual life (years): 19/2 (14; 38)
colposcopy, HPV testing) and therapeutic approach. median/IQR (min; max)
Cytology results were interpreted following the Previous births:
Bethesda reporting system as: NILM (Negative for Yes: % (n) 50.8% (n=368)
Births/person: median/IQR (min; max) 1/1 (0; 6)
Intraepithelial Lesion or Malignancy), ASCUS (Atypical
Previous abortions:
squamous epithelial cells of uncertain significance)/ASC-H
Yes: % (n) 43.6% (n=315)
(Atypical Squamous Cells, Cannot Rule Out High-Grade Abortions/person: median/IQR (min; max) 0/1 (0; 15)
Squamous Intra-epithelial Lesion), LSIL (Low-grade squamous Use of oral contraceptives*:
intraepithelial lesion) and HSIL (high-grade squamous All ages: Yes % (n) 15.8% (n=111)
intraepithelial lesion). Colposcopy results were classified as: 18 – 29 years: Yes % (n) 25.7% (n=63)
normal (without lesions), atypical transformation grade 1 30 – 39 years: Yes % (n) 13.9%(n=41)
(ATG1) and grade 2 (ATG2) areas. 40 – 49 years: Yes % (n) 5.1% (n=7)
For HPV testing we followed the presence of any of 50+ years: Yes % (n) 0% (n=0)
the thirteen known high risk genotypes Number of sexual partners:
16/18/31/33/35/39/45/51/52/56/58/59/66, as single infection or Partners/person: median /IQR (min; max) 3/2 (0; 20)
coinfection. Previous cytology
The therapeutic approach included different pathways Yes: % (n) 13.7% (n=99)
in accordance to clinical status of the patient, from the Previously documented HPV infection
recommendation for a follow-up visit to histopathologic Previous documented testing: % (n) 12.4% (n=90)
Positive results for HPV infection: % (n) 11.4% (n=82)
examination, associated or not to immunohistochemistry or
Positive results for high risk HPV genotype: 9.5% (n=69)
surgical treatment. This paper presents only the clinical status % (n)
and the status of HPV infection at the enrolment visit. **Single infection: % (n) 59.8% (n=49)
Data analysis: The scale variables were discussed as **Coinfection: % (n) 40.4% (n=33)
meadSD or median and interquartile range. They were assessed **Genotype 16: % (n) 41.5% (n=82)
for normality using the Kolmogorov-Smirnov test. A p-value **Genotype 18: % (n) 17.1% (n=14)
<0.05 was considered for statistical significance (two tailed **Genotype 31: % (n) 14.6% (n=12)
test). Categorical data were presented as proportions with one **Genotype 33: % (n) 6.1% (n=5)
decimal. Proportions were compared by using Chi square test **Genotype 35: % (n) 1.2% (n=1)
(p<0.05). Statistical analyses were performed using SPSS 23.0 **Genotype 39: % (n) 1.2% (n=1)
and Open Epi. **Genotype 45: % (n) 4.9% (n=4)
**Genotype 51: % (n) 4.9% (n=4)
RESULTS **Genotype 52: % (n) 4.9% (n=4)
**Genotype 56: % (n) 0% (n=0)
We included in our cohort 725 women, seeking
**Genotype 58: % (n) 6.1% (n=5)
gynaecologic services during 2010 – 2014. The personal
**Genotype 59: % (n) 1.2% (n=1)
characteristics of the patients are shown in table no. 1. **Genotype 66: % (n) 12.2% (n=10)
Analysis of personal characteristics of the cohort Previous vaccination
reveals important differences compared to the general Total cohort: % (n) 6.3% (n=46)
population, suggesting more favourable socio-economic Patients with documented infection: % (n) 23.2% (n=19)
determinants for the cohort. Most of our patients came from Patients without documented infection: % (n) 4.3% (n=27)
urban environment (91.3% vs. 55.1% in general population) and * Data available for 705 women
had tertiary education (70.3% vs. 26.8%).(14,15) Also the ** Proportion was calculated among the positive results

AMT, vol. 22, no. 1, 2017, p. 5

 PUBLIC HEALTH AND MANAGEMENT

Among the personal antecedents, we noticed that half More frequent genotypes were 16/51/31/52/18.
of the patients started their sexual life till the age of 19. Also In our study recommendation for HPV testing has
half of them had already at least a birth, but 43.6% had at least been addressed to patients with abnormal cytology or cervical
an abortion in their past. Overall, 691 abortions and 522 births lesion identified by colposcopy. However, only two thirds of
were registered among the study subjects, meaning a ratio patients with abnormal cytology have been tested (table no. 5).
abortion/birth of 1.3. These results suggest that abortion still Most frequent HR genotypes in abnormal cytology
remained popular as birth control method. These data are in line cases are shown in table no. 6.
with the reduced proportion of oral contraceptive users. The use
of gynaecology services was also limited, only 13.7% and Table no. 5. HPV testing associated to cytology results
12.4% of the patients having a previous cytology and HPV Total Tested
documented testing respectively. As regard the HPV Cytology
no no %
epidemiology, among the 82 cases with previous positive
results, 59.8% had a single genotype and the rest had Normal 214 100 46.7%
associations. Among the high-risk genotypes, 16, 18 and 31 Abnormal 507 322 63.5%
were isolated most frequently. 6.3% of the patients were already ASCUS/ASC-H 278 181 65.1%
vaccinated against HPV at the firs visit. LSIL 140 83 59.3%
HSIL 89 58 65.2%
Clinical status at enrolment visit
Missing 4 2 NA
At enrolment visit, the patients received cytology,
Total 725 424 58.5%
colposcopy and, if needed, recommendation for HPV testing.
Overall 721 and 715 patients received cytology and colposcopy
Table no. 6. Most frequent high risk HPV genotypes in
respectively. The results are shown in table no. 3.
abnormal cytology
ASCUS
Table no. 3. Results for cytology and colposcopy HPV
/ ASC- LSIL HSIL p* p** p***
Colposcopy genotype
Cytology H
Normal ATG1 ATG2 Total 16 no 55 29 34 <
no 69 107 35 211 0.46 0.005
Normal % 30.4% 34.9% 58.6% 0.001
% 32.7% 50.7% 16.6% 100.0% 51 no 29 14 6
ASCUS/ no 28 213 34 275 0.86 0.28 0.29
% 16.0% 16.9% 10.3%
ASC-H % 10.2% 77.5% 12.4% 100.0% 31 no 27 9 7
no 4 95 41 140 0.37 0.57 0.82
LSIL % 14.9% 10.8% 12.1%
% 2.9% 67.9% 29.3% 100.0% 52 no 26 14 2
no 0 14 75 89 0.6 0.01 0.02
HSIL % 14.4% 16.9% 3.4%
% 0.0% 15.7% 84.3% 100.0% 18 no 18 11 7
no 101 429 185 715 0.43 0.83 0.1
Total % 9.9% 13.3% 12.1%
% 142% 60.0% 25.9% 100.0% * Chi2 for ASCUS/ LSIL
As can be noticed, colposcopy confirmed in high ** Chi2 for LSIL/ HSIL
proportion the severity of the HSIL lesions. 89.7% of the *** Chi2 for ASCUS/ HSIL
investigated patients (n=637) receive the recommendation for
HPV testing, but only 78.2% of them (n=498) did perform the DISCUSSIONS
test. The results of the HPV testing are presented in table no. 4. This study is a non-interventional cohort, aiming to
provide real-world data from the medical practice. The main
Table no. 4. Results of the HPV testing goal was to analyse the status of HPV infection in 725 women
HPV testing characteristic Value seeking specialty gynaecologic services for cervical
*HPV testing: abnormalities.
Negative: % (n) 14.9% (n=74) Our subjects had a more privileged social statute
Positive: % (n) 85.1% (n=424) compared to the general population of Romanian women, but
**Type of infection: despite this, we found high proportion of abortions and low use
Positive – single infection: % (n) 49.8% (n=211) of oral contraception. Also very few women had a previous
Positive – coinfection: % (n) 50.2% (n=213) cytology or a documented HPV testing previous to the
Positive – high risk HPV genotype: % (n) 89.9% (n=381) enrolment in the study and only 6.3% had been vaccinated
**High risk HPV genotypes against HPV. At enrolment, two thirds of the subjects had
Genotype 16: % (n) 37.5% (n=159)
abnormal cytology and 84.3% of those having HSIL at cytology
Genotype 18: % (n) 10.6% (n=45)
had been confirmed as ATG 2 by colposcopy. Despite the
Genotype 31: % (n) 13.4% (n=57)
Genotype 33: % (n) 6.1% (n=26)
favourable social position, more than one fifth of the women
Genotype 35: % (n) 5.2% (n=22) with medical recommendation for HPV testing were not able to
Genotype 39: % (n) 2.8% (n=12) perform it, due to limited affordability.
Genotype 45: % (n) 2.6% (n=11) The study has important limitations because we
Genotype 51: % (n) 13.9% (n=51) analysed a particular cohort, seeking specialty services for a
Genotype 52: % (n) 11.8% (n=50) previously known cervical lesion or abnormality. In addition,
Genotype 56: % (n) 4.0% (n=17) almost a quarter of the eligible women did not perform the HPV
Genotype 58: % (n) 4.0% (n=17) testing, so our conclusions refer only to the investigated women,
Genotype 59: % (n) 3,3% (n=14) but not to the overall cohort. From these reasons our conclusions
Genotype 66: % (n) 5.0% (n=21) cannot be generalized. However, the high-risk HPV genotypes
**Most frequent result 16/51/31/52/18 were most common in our subjects and this
Genotype 16 – single infection: % (n) 18.9% (n=80) result seems to be consistent to other studies in European
* proportions calculated to N=498 (total tests) population, except for genotype 51, which was secondly most
** proportions calculated to N=424 (positive tests)
frequent in our subjects (table no. 7).
AMT, vol. 22, no. 1, 2017, p. 6
 PUBLIC HEALTH AND MANAGEMENT

Table no. 7. HPV genotypes prevalence in different studies M, Gómez D, Muñoz J, Bosch FX, de Sanjosé S. ICO
Study 16 51 31 52 18 Information Centre on HPV and Cancer (HPV Information
Our study % 37.5 13.9 13.4 11.8 10.6 Centre). Human Papillomavirus and Related Diseases in
rank 1 2 3 4 5 the World. Summary Report 15 December 2016. Available
Anderson et % 37.4 3.9 8.2 6.8 5.1 at: http://www.hpvcentre.net/statistics/reports/XWX.pdf
al. 2016 (17) rank 1 5 2 3 4 [accessed 20 of February 2017].
Castellague et % 2.9 1.6 1.3 1.8 NA 8. Ronco G et al. Efficacy of HPV-based screening for
al (2012) (18) rank 1 3 4 2 NA
prevention of invasive cervical cancer: follow-up of four
Kjaer et al % 5.4 3.4 3.8 3.9 2.4
(2014) (19)
European randomised controlled trials. Lancet.
rank 1 4 3 2 5
2013;383(9916):524 -32.
The genotype 16 was by far most frequently identified
9. World Health Organization Regional Office for Europe.
either single or in coinfections. Its presence increased
European Health for All Database (HFA-DB) WHO
significantly in women having HSIL cytology. Per contrary, the
Europe. Available at: http://data.euro.who.int/hfadb/
presence of genotype 52 has decreased significantly in HSIL
[accessed 15 of February 2017].
cases, but this result should be interpreted with caution due to
10. National Institute of Public Health. Mortality in women,
the study limitations.
Romania, 2014. Available at request.
Despite the limitations, our results suggest that more
11. Eurostat. Statistics explained. Amenable and preventable
importance should be awarded to cervical cancer as a public
deaths statistics. Available at:
health problem, due to many reasons: very high mortality, very
http://ec.europa.eu/eurostat/statistics-
low coverage of the screening program, very low use of
explained/index.php/Amenable_and_preventable_deaths_st
vaccination against HPV and limited access to testing (paid
atistics#Data_sources_and_availability [accessed 17 of
100% by the patient).
February 2017].
12. Craciun C, Baban A. ―Who will take the blame?‖:
CONCLUSIONS
Understanding the reasons why Romanian mothers decline
Cervical cancer is a public health problem worldwide
HPV vaccination for their daughters. Vaccine.
and in Romania. Our analysis of a cohort of 725 women seeking
2012;30:6789-93.
specialty gynaecologic services for cervical abnormalities
13. National Institute of Public Health Activity Report for year
revealed that HPV high risk genotypes 16, 51, 31, 52 and 18
2015. Available at:
were most common. Genotype 16 was by far the most frequent
http://www.insp.gov.ro/index.php/informatii-
and its presence increased significantly in women having HSIL
publice/send/7-informatii-publice/345-raport-de-activitate-
cytology. In addition, we found very low use of vaccination and
2015 [accessed 22 of January 2017].
HPV testing. Due to methodologic limitations, our results
14. National Institute of Statistics. Tempo online database.
cannot be generalised in the Romanian women population and
Resident population by gender and residence. Available at:
further research is needed for this purpose. However,
http://statistici.insse.ro/shop/?lang=ro [accessed 28 January
considering that in Romania the screening for cervical cancer
2017].
has a very low coverage and the vaccination is available only
15. Population and households census 2011. Volume 3.
with full direct payment from the beneficiary, the existing
Resident population- socio-economic structure. Available
epidemiologic context requires planning a public health
at: http://www.recensamantromania.ro/noutati/volumul-iii-
approach more focused on systematic prevention and control of
populatia-stabila-rezidenta-structura-social-economica/
cervical cancer.
[accessed 28 January 2017].
REFERENCES 16. Ministry of Health, Romania. Global Adult Tobacco
1. Globocan. Cervical Cancer. Estimated Incidence, Mortality Survey, Romania 2011. Eikon 2012, Cluj Napoca. ISBN
and Prevalence Worldwide in 2012. Available at: 978-973-757-571-5.
http://globocan.iarc.fr/Pages/fact_sheets_cancer.aspx 17. Anderson LA, O'Rorke MA, Wilson R, Jamison J, Gavin
[accessed 10 of February 2017]. AT; Northern Ireland HPV Working Group. HPV
2. Samarasekera U, Horton R. Women’s cancers: shining a prevalence and type-distribution in cervical cancer and
light on a neglected health inequity. Lancet. 2017;389:771- premalignant lesions of the cervix: A population-based
3. study from Northern Ireland. J Med Virol.
3. Nolte E. and M. McKee: Does Health Care Save Lives? 2016;88(7):1262-70.
Avoidable Mortality Revisited", Nuffield Trust, London; 18. Castellague X et al. Prevalence and Genotype Distribution
2004. p. 1-93. of Human Papillomavirus Infection of the Cervix in Spain:
4. Bouvard V, Baan R, Straif K, Grosse Y, Secretan B, El The CLEOPATRE Study. J Med Virol. 2012;84(6):947-56.
Ghissassi F, et al. A review of human carcinogens-part B: 19. Kjaer S, Munk C, Junge J, Iftner T. Carcinogenic HPV
biological agents. Lancet Oncol. 2009;10:321-2. prevalence and age-specific type distribution in 40,382
5. Walboomers JM, Jacobs MV, Manos MM, Bosch FX, women with normal cervical cytology, ASCUS/LSIL,
Kummer JA, Shah KV, et al. Human papillomavirus is a HSIL, or cervical cancer: what is the potential for
necessary cause of invasive cervical cancer worldwide. J prevention? Cancer Causes Control. 2014;25:179-89.
Pathol. 1999;189:12-9.
6. World Health Organization and International Agency for
Research on Cancer. IARC Monographs on the evaluation
of carcinogenic risks to humans. Biological agents. Volume
100B. A review of human carcinogens. Lyon: France;
2012. Available at:
http://monographs.iarc.fr/ENG/Monographs/vol100B/mono
100B.pdf [accessed 10 of February 2017].
7. Bruni L, Barrionuevo-Rosas L, Albero G, Serrano B, Mena
AMT, vol. 22, no. 1, 2017, p. 7
 PUBLIC HEALTH AND MANAGEMENT

CONTEMPORARY PROFILE OF THE PATIENT WITH

POLYCYSTIC OVARY SYNDROME (PCOS)

VICTORIA VOLOCEAI1
1
“Nicolae Testemițanu” State University of Medicine and Pharmacy, Chişinău

Keywords: polycystic Abstract: Background: The aim of our research included identifying the medical and social specifics of
ovary syndrome, contemporary profile in PCOS patients in the Republic of Moldova in order to improve the diagnose and
patient profile, medical the management of treatment of this disease. Materials and Methods: There were analysed 138 patients
determinants who were selected according to the Rotterdam criteria regarding PCOS, who were hospitalized in the
Department of Aseptic Gynecology at the Municipal Clinical Hospital Nr.1 of Chişinău city. Results: Some
medical and social determinants had either a direct or indirect role in the evolution of PCOS. In the current
study, we determined that the main impact had the body mass index (BMI), irregular menstrual cycle,
family history, the hormonal level, the duration of treatment and infertility. Conclusions: We have compiled
the contemporary profile of PCOS patients - young women in reproductive age, usually overweight, who
have irregular menstrual cycle, a family history of PCOS and infertility for nearly 1 year of regular sexual
life.

INTRODUCTION in 89 (64,5 ± 4,1%) cases, the most optimal period for

Polycystic ovarian syndrome (PCOS) is the reproduction. We found out that in the last years, there were
commonest cause of anovulatory infertility in about 75% of hospitalized and treated more than 6 patients (4,3 ± 1,7%) older
women of reproductive age group.(1) The syndrome first than 37 years.
defined by Stein and Leiventhal in 1935 consisted of irregular
anovulatory bleeding, obesity, hyperandrogenism, abnormal Figure no. 1. Distribution of laparoscopic outcome in PCOS
ovarian morphology and atypical gonadotrophin secretions.(2,3) patients
Clomiphene Citrate (CC) remains the first choice of treatment in
management of anovulatory amenorrhea but achievement of
pregnancy occurs in about 35–40% of cases.(4) Failure to
respond to CC and other drug therapies resulted in more
invasive procedures such as wedge resection of ovaries, multiple
ovarian biopsies and others and depend on the main criteria of
PCOS.(5)

PURPOSE
The aim of our research included identifying the
medical and social specifics of contemporary profile in PCOS
patients in the Republic of Moldova in order to improve the
diagnose and the management of treatment of this disease.

MATERIALS AND METHODS

There were analysed 138 clinical cases of patients
who have followed Rotterdam criteria regarding PCOS, who Figure no. 2. The structure of PCOS patients according to
were hospitalized at the Department of Aseptic Gynecology no. the age criteria, (%)
1 of the Municipal Clinical Hospital of Chişin u. As criteria for
selecting the patients, we have used the Rotterdam criteria:
irregular menstrual cycle, biochemical or clinical
hyperandrogenia and USG criteria for PCOS.

RESULTS AND DISCUSSIONS

In order to be able to highlight some correlation
between the age of the patients and the occurrence of PCOS, the
patients were divided according to the age criteria. Regarding
the distribution of the age group, we can conclude that the
gathered data showed that most frequently patients with PCOS
and infertility were in the age group of 23-30 years, established

1
Corresponding author: Victoria Voloceai, B-dul. Ștefan cel Mare i Sf nt, Nr. 165, Chi in u, Republica Moldova, E-mail:
victoriavoloceai@gmail.com, Phone: 06918216
Article received on 17.01.2017 and accepted for publication on 27.02.2017
ACTA MEDICA TRANSILVANICA March 2017;22(1):8-10
AMT, vol. 22, no. 1, 2017, p. 8
 PUBLIC HEALTH AND MANAGEMENT

The age of starting the menarh for the patients from after 3 months – 45 (32,6 ± 3,4%) cases, regular after 2 months
the study was the following: up to 10 years in 1 (0,7 ± 0,7%) in 25 (18,1 ± 3,2%) cases and only in 23 cases it became regular
case, 11 - 13 years in 3 (26,16 ± 3,7%) cases, 14 -16 years– 66 immediately and maintained regular during the period of
cases (47,8 ± 4,2%), more than 17 years in 35 (25,4 ± 3,7%) research – (16,7 ± 3,2%).
cases. This criterion was available in 101 medical histories.
We appreciated that 129 patients had irregular Figure no. 4. The effect of LOD on menstrual cycle, (%)
menstrual cycle, I place oligomenorea – 79 (57,9 ± 3,5%) cases,
II – amenorea – 50 (36,23 ± 4,3%) cases. But there were
diagnosed 9 (5,8 ± ,6%) cases (χ ²=11,8 p<0,01) of PCOS with
regular menstrual cycle. Regarding the BMI criteria, our
analysis showed that most of the patients had a BMI less than 25
in 76 ( 55,1 ± 4,2%) cases, between 26 – 30 in 32 ( 23,2 ± 3,6%)
cases, and a BMI more than 31- 35 – 30 ( 21,7 ± 3,5%).

Table no. 1. Clinical criteria of PCOS patients who were

analysed
Clinical criteria PCOS patients (n=138)
Age, years 27,4 ± 3,1
BMI (kg/ m2) 27,6 ± 2,4
Menarch 14,7 ± 2,5 The effect of LOD on ovulation was absent in 40
Characteristics of menstrual cycle N %±Δ% patients – (29 ± 3,8%), spontaneous ovulation after LOD – 13
- Oligomenoreea 79 57,9 ± 3,5% (9,4 ± 2,5%) cases, after 2 months– 34 cases (24,6 ± 3,6%), 3
- Amenoreea 50 36,23 ± 4,3% months – 26 cases (18,8 ± 3,3%), 4 – 5 months – 19 cases (13,8
- Regular 9 5,8 ± 1,6% ± 2,9 %), 6 months and more – 6 cases (4,3 ± 1,7%).
As it was demonstrated in our analysis, the family
history established: on the first place - mothers with PCOS – 65 Figure no. 5. Pregnancy rates after LOD in PCOS patients,
(47,1 ± 4,2%), II – diabetes – 26 (18,8 ± 3,3%), on the third – (%)
arterial hypertension - 10 (7,2 ± 2,4%) cases, IV- obesity – 8
(5,8 ± 3,2%), uncomplicated – 29 (21,0 ± 2,9%).
The amount of blood loss per menstra: I place – more
than 150 ml – 50 (36,2 ± 4 ,1%), II – 101- 150 ml – 41 (29,7 ±
3,9%),III – 30 – 100 ml – 40 (29,0 ± 3,9%), and less de 30 ml –
7 ( 5,1 ± 2,3%). The length of menstra I place – 3 – 7 days – 88
(63,8 ± 4,1%) cases, II – more than 7 days – 45 (32,6 ± 4,0%),
III – less than 3 days – 5 cases (3,6 ± 1,2 %).
Our analysis showed that infertility criteria varied
from 1 year – 8 (5,8 ± 2,0 %) cases and more than 10 years – 23
(16,7 ± 3,2 %) cases, the most frequent being between 1,6 -3
years – 42 (30,4 ± 3,9 %) cases (figure no. 3.). Pregnancy rate after LOD was - spontaneous in 45
(32,6 ± 4,0%) cases, after CC induction – 35 (25,4 ± 3,7%)
Figure no. 3. The structure of PCOS patients according to cases, in association with CC + HMC – 1 (0,7 ± 0,7%), without
the infertility criteria, (%) pregnancy in 27 cases (19,6 ± 3,4%). Pregnancy rate after IVF –
in 30 de cases (21,7 ± 3,5 %) (figure no. 5).
Pregnancy evolution of the patients included in our
study had a symptomatic evolution in 127 patients,
asymptomatic in - 11 (8,0 ± 2,3%) cases.

Figure no. 6. Pregnancy evolution of PCOS patients, (%)

The length of ovulation induction criteria with CC

showed: I place – more than I year 66 (47,8 ± 4,2%) cases, II
place – 6 months - 28 (20,3 ± 3,4%) cases, III – more than 3
years – 17 (12,3 ± 2,8%) cases, IV – 3 months – 11 (8,0 ± 2,3%)
cases.
All of the patients were declared dexamethasone- So, pregnancy evolution was complicated especially
clomiphene citrate (CC) – resistant, and were treated with with imminent spontaneous abortion in 69 (62,1 ± 4,1%) cases,
laparoscopic ovarian drilling (LOD) as a second line of pregnancy arterial hypertension – 21 (18,9 ± 3,1%) cases,
treatment of PCOS patients. We established that: irregular premature labour – 9 (8,1 ± 2,1%) cases, restriction of intra -
menstrual cycle was in 45 (32,6 ± 3,9%) cases, became regular uterine development 3 (2,7 ± 1,2%) cases.
AMT, vol. 22, no. 1, 2017, p. 9
 PUBLIC HEALTH AND MANAGEMENT

Unfortunately, spontaneous abortion was in 9 (7,5 ±

2,1%) cases. Patients delivered by natural labour - 93 (83,7% ±
4,0), cesarean section– 33 cases (29,7 ± 3,8%), lack of data in -
6 cases (3,6 ± 1,7%).

CONCLUSIONS
1. The results of the study have allowed us to establish the
profile of the PCOS patients: young women, in the
reproductive age between 23-30 years (64,5 %), with a
beginning of menarche between 14-16 years (47,6%), with
a BMI less than 25 in ( 55,1%), irregular menstrual cycle
(95,2%). Nearly ½ have a family history of PCOS and
suffer of endocrine infertility till 3 years.
2. LOD outcome shows that this II line treatment is an
effective procedure in PCOS patients, and should be always
considered in PCOS CC resistant patients.

REFERENCES
1. Adam J, Polson DW, Franks S. Prevalence of polycystic
ovaries in women with anovulation and idiopathic
hirsutism. Br Med J. 1986;293:355-9.
2. Stein IF, Leventhal UL. Amenorrhea associated with
bilateral polycystic ovaries. Am J Obstet Gynecol.
1935;29:181-91.
3. Adams J, Franks S, Polson DW, Mason HD, Abdulwahid
N, Tucker M, et al. Multi-follicular ovaries: clinical and
endocrine features and response to pulsatile Gonadotropin
releasing hormone. Lancet. 1985;2(8469–70):1375-9.
4. Gysler M, March CM, Mishell DR, Bailey EJ. A decade’s
experience with an individualized clomiphene treatment
regime including its effect on post coital test. Fertil Steril.
1982;37:161-7.
5. Lunde O. Polycystic Ovarian Syndrome: a retrospective
study of the therapeutic effect of ovarian wedge resection
after unsuccessful treatment with clomiphene citrate. Ann
Chir Gynaecol. 1982;71:330-3.
6. Weinstein D, Polishuk WC. The role of wedge resection of
ovary as a cause for mechanical sterility. Surg Gynecol
Obstet. 1975;141:417-8.

AMT, vol. 22, no. 1, 2017, p. 10

 PUBLIC HEALTH AND MANAGEMENT

THE PSYCHOLOGICAL IMPACT OF THE PRENATAL DOWN

SYNDROME DIAGNOSTIC TEST

MELANIA ELENA (POP) TUDOSE1, PETRU ARMEAN², VICTOR IOAN POP³

1,3
“Iuliu Hațieganu” University of Medicine and Pharmacy, ²“Carol Davila” University of Medicine and Pharmacy

Keywords: Down Abstract: Background: Prenatal Diagnostics Testing is the only current method of clarifying suspicions
syndrome, prenatal on Down syndrome obtained as a result achieved through the increased risk screening. The pregnancy,
diagnosis, by definition, is a period of great transformation, with multiple organic and psychological adaptation
psychological effects processes, while sensitivity touches high peaks and anything, as small as it could be, may disturb the
equilibrium and cause psycho-emotional imbalances. Most often the diagnostic result of the screening is
most likely to infirm the screening and will most probably reinstall the psycho-emotional stability, but
mother’s already anxious attitude may have already affected the child’s future emotional development
and behaviour. Methods: The present study is a narrative analysis, based on a collection of data from
studies published in the databases of PubMed / Medline, SpringerLink, EBSCOhost, Elsevier and
ResearchGate. Results: From reviewing the studies, there have been highlighted three themes:
associated psychological effects, consequences and coping methods and practices and methods that can
influence the psychological effects. Conclusion: The consequences and psychological effects, closely
linked to the necessary diagnostic procedures and possible outcomes, require more interest from
specialists which are now more focused on the diagnostic component.

INTRODUCTION duration to obtain the result. Faster results can be obtained

Pregnancy is a natural and profound physiological
stage of a woman’s life which takes place in normal conditions
for most women.(1) However, its completion involves a lot of
investigation in order to detect in time the emergence of
potential health problems of mother and fetus. One of the
investigations related to the fetus is the prenatal genetic testing
for fetal aneuploidy is the case for the Down Syndrome (DS) in
this case, an important technological acquisition in modern
obstetrics. This may bring many answers but can also generate
many questions, controversial decisions and ethical
dilemmas.(2,3)
DS is a consequence of the presence of an extra
chromosome 21 (most common) or just supplementing critical
region 21q22, both producing the over dosage gene effect. It is
the most common genetic cause of mental retardation (from
moderate to severe), the most common chromosomal damage of
the newborn and the most compatible autosomal trisomy with
survival. DS incidence is 1/700 live births.(4,5,6) Current
diagnostic algorithm includes both DS prenatal stage and the
diagnostic screening, specifying that screening tests relate to
prediction, indicating a suspicion, while the detection and
diagnosis refers to the actual certification and it is the only way
to certify the suspicion.(6,7)
In order to obtain the necessary material for fetal
genetic analysis, diagnostic testing uses invasive procedures
such as Amniocentesis (AC) and Chorionic Villus Biopsy
(CVB). CVB can be performed between the 10th and 13th week
of amenorrhea and carries a risk of miscarriage of 2-3%, while
classical AC can be performed starting with the 15 th – 16th week
of amenorrhea and carries a risk of miscarriage by 0.7%.(8,9)
Conventional Karyotyping is still considered the gold standard
for prenatal diagnosis of DS but has the disadvantage of a longer
through the FISH or QF-PCR tests, but given that these are
specific techniques with low sensitivity, experts recommend
complete cytogenetic evaluations through the classic
Karyotyping that has the advantage of 100%
accuracy.( 0, , 2, 3). The pregnant woman’s strong
emotionally reactions to any potential threat of pregnancy or
fetal status apply to invasive diagnostic procedures, too (AC and
CVB).(14,15,16,17,18)
Associated psychological effects
Pregnant women who performed prenatal diagnostic
procedures are experiencing much higher levels of stress and
anxiety, sometimes with depressive disorders compared with
pregnant women whose task performed within normal
parameters and do not require any additional intervention for
possible diagnoses.(17,18,19,20) Stress occurs since the blood is
collected for screening and gets higher with achieving an
increased risk and suspicion of abnormality. The decision itself
to perform an invasive procedure is difficult, complex and the
short time decision pressure further increases the stress levels
and anxiety.(21) Anxiety before the procedure was identified by
reference to invasiveness, during and immediately after the
procedure with regard to child endangerment and whilst
awaiting the results referring to the result.(14,15,16,17,18,20) It
can fluctuate over time, without permanently disappearing and
showing maximum levels immediately after the invasive
procedure and during the awaiting the results of diagnoses.(21)
Most researches focused mainly on anxiety and
negative emotions related to the procedure itself and possible
adverse effects on the fetus or pregnancy, so there are few
studies focused on the emotions experienced during the period
of time for the results to be ready.(16) It seems that stress and
anxiety related to the procedure itself, however, is not a clinical

Corresponding author: Melania Elena (Pop) Tudose, B-dul. N.

1
B lcescu, Bl. Camelia, Ap. 6, Buz u, România, E-mail:
melaniaelena_tudose@yahoo.ro, Phone: +40721 751 540
Article received on 15.12.2016 and accepted for publication on 23.02.2017
ACTA MEDICA TRANSILVANICA March 2017;22(1):11-14
AMT, vol. 22, no. 1, 2017, p. 11
 PUBLIC HEALTH AND MANAGEMENT
problem.(17) Pending time after an AC may extend to 3 weeks,
during which uncertainty related to child health intensify
obsessive thoughts about possible abnormal results would entail
a decisional moment of existential importance. Frequently, this
period associates psycho-emotional feelings such as anger, guilt,
worry, anxiety and sometimes depression, for many women,
hard to cope with or to manage.(16) This situation prone to
choosing extreme coping mechanisms, opposite reactions, denial
or defensive reactions.(15)
Consequences and coping methods
Psycho-emotional imbalance may affect fetal-maternal
attachment with possible consequences for mental and
behavioural development of their child, even if subsequently
refuted result.(17,20) Mother and fetus have a symbiotic
relationship, so that if a disease affecting one of the two most
likely will affect the other one. Psychologically, it was found
that the level of stress and anxiety is much greater when the test
results have altered fetal health, compared with altered test
results related to maternal health. (1)
During the waiting for the results period, some
pregnant women are focusing predominantly on what could be
wrong with their fetus, an attitude that enhances anxiety and
cortisol release. Excessive exposure of the fetus to high levels of
cortisol may promote development of type II diabetes and
obesity in adulthood but also learning and memory disorders, up
to and including the functional impairment of the frontal lobe
executive.(20,22) Generally, anxious pregnant woman is
associated with negative effects both on her and on the baby,
effects whose consequences may be short-termed, materialized
only through an increase in symptoms related to pregnancy or
intensification of vices harmful in the medium term by the
appearance of obstetrical complications, including birth, as well
as on long-term by stimulating post-partum maternal depression
post-partum or worse, by impaired development of
neuropsychiatric fetus that would become a child with psycho-
behavioural issues later.(23)
Coping is a very important process in situations of
stress and anxiety. There are studies that have shown that
optimism and positive attitude of women attending stage
diagnosis lowers stress levels and keeps the situation under
control, unlike avoidant women, addressing a maladaptive
attitude.(15) An example of maladaptive coping can be
considered the imposition of an emotional distance up to mental
pregnancy rejection of their child, mental abandonment and lack
of communication with him throughout the period of waiting for
the results. After receiving favourable outcome, the return to the
mental status of pregnant woman attitude occurs and thus
resume mother-child bond, but the psychological status of fetal
damage may already have occurred.(24,20) Some pregnant
women cope by mentally imposing to themselves that they bear
a healthy child and that the procedure will only bring this
confirmation. It is an instinctive protective attitude based on the
suppression of fears that aim to avoid the feeling of anxiety. Not
based on conviction, sliding to clinical anxiety is easy to be
done.(17)
Practices and methods that can prevent or
influence the psychological effects
For a less intense emotional involvement, women
think that the diagnosis should be as early in pregnancy as
possible and the information has to be complete, adequate,
interactive, personalized and to take place in the prescreening
period.(17,21) Both AC and associated CVB score for anxiety
and depression.(16,17,20,18,19,24) Unlike AC, CVB has the
advantage that it can be done earlier in pregnancy when we are
still talking about embryo and not fetus and the result can be
obtained in a few days.(14) But CVB is associated with a higher
AMT, vol. 22, no. 1, 2017, p. 12
risk of miscarriage than AC, which causes higher levels of
depression.(25) With regard to genetic analysis, it was found
that providing early results significantly decreases the level of
maternal anxiety. This is possible by making besides classical
Karyotyping, a rapid molecular test (FISH, QF-PCR), too.(16)
The Non-invasive Prenatal Testing (NIPT), considered the
technological cutting edge revelation, can analyze early fetal
DNA in the mother’ blood, from 9-10 weeks of pregnancy.
NIPT can only be used as a screening test, not a diagnostic test,
confirmation of a positive result also belonging to obtaining
fetal material by the known invasive procedures.(26) Using
NIPT as a second contingent of screening for all pregnant
women at risk (1-150) significantly decreases the percentage of
AC candidates.(27)
Information and counselling even before proceedings
are efficient and handy method that can help women to cope
with emotional difficulties related to the procedure and concerns
about the results.(15,17) Increased intake of information through
the use of written materials and presentations including video to
increase the level of knowledge, reduce decisional conflict and
increases the satisfaction of an informed choice.(28,29) There is
question whether too much information could cause an
increasing anxiety if extensive knowledge about the negative
implications and limitations associated tests can influence a
woman’s decision making and can lead to an overestimation of
risk associated with the abortion procedure and an
underestimation of the rate of detection.(30) The opposite pole
demonstrated that anxiety enhances the minimization of
information.(31).
Using Decision Support Technologies (DSTs) as
supplementary educational materials that complement
interactions with professionals could have an important decision
not only in mitigating conflict but also in lowering anxiety.
Unfortunately, it was found that the amniocentesis procedure
used DSTs little compared to other medical conditions
associated with decisional conflicts.(32,21,33) The use of
cognitive therapy techniques adapted to the pregnancy would be
useful not only to reduce the diagnostic testing related anxiety,
but to an increase in psychological well-being of both mother
and unborn child and the relationship between the two.(23)
Emotional support and involvement of partners in the
implementation of this step decreases stress and anxiety of
pregnant women but not related to the procedure, too.(18)
Discussion and Conclusions
DS prenatal testing involves a variety of sensitive and
specifics, as well as risks of invasive procedures, an important
potential to trigger a series of consequences with long lasting
effects. Definitely, prenatal testing needs to be addressed and
understood as an option and not an obligation to inform women
since the first recommendation of screening. Trying to spare the
pregnant and not to tell that from a prenatal test screening can
lead to termination of pregnancy, besides violating the rule of
informed consent is a mistake that can have serious psycho-
emotional repercussions over that person. The development of
such a scenario must not be maximized nor ignored or
minimized.(15,31,21) Failure to provide necessary information,
inadequate skills processing and rendering specialists, poor
communication, lack of segregation, ignorance, fears,
psychological reactions adjacent informed consent, decision
making and facilitating its tactics in latter are gaps and
weaknesses that can cause cognitive distortions affecting the
reasoning of those directly involved.(31,34)
Psychological stress could be minimized by widening
maternal-fetal care team and other specialists’ inclusion in
providing information and psychological support, including the
time spent awaiting the results of diagnoses.(20,31,35)
 PUBLIC HEALTH AND MANAGEMENT
Prenatal diagnostic technologies are currently
performing and there is a concentration of researchers carried to
the extreme in this regard, but their effectiveness in practice will
never be as powerful there will not be paid similar attention to
issues and implications associated especially to the psycho
emotionally ones.(25,18)
Monitoring pregnant women should not be purely
obstetric parameters and directed only toward physical status but
also an emotional assessment of the level of stress, anxiety and
depression especially in covering the distance of achieving a
screening and final output after invasive procedure.(15,18,25)
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1. Harris JM, Franck L, Michie S. Assessing the
psychological effects of prenatal screening tests for
maternal and foetal conditions: a systematic review. J
Reprod Infant Psychol. 2012;30(3):222-46.doi:
10.1080/02646838.2012.710834.
2. Skirton H, Goldsmith L, Jackson L, Lewis C, Chitty L.
Offering prenatal diagnostic tests: European guidelines for
clinical practice. Eur. J. Hum. Genet. 2014 May;22(5):580-
6. doi: 10.1038/ejhg.2013.205.
3. Binns V, Hsu N. Prenatal Diagnosis. Encyclopedia of Life
Sciences. 2001 Jun;1-17.doi: 10.1038/npg.els.0002291May
4. Online Mendelian Inheritance in Man, OMIM (TM). Down
Syndrome. Johns Hopkins University, Baltimore, MD.
Number:#190685: Updated 23 November 2016: Available
from http://www.ncbi.nlm.nih.gov/omim/.
5. CDC, Division of Birth defects and Developmental
Disabilities. Data and Statistics-Occurrence of Down
Syndrome; 2014.
http://www.cdc.gov/ncbddd/birthdefects/downsyndrome/da
ta.html.
6. Palomaki GE, Lee JE, Canick JA, McDowell GA,
Donnenfeld AE. Technical standards and guidelines:
Prenatal screening for Down syndrome that includes first-
trimester biochemistry and/or ultrasound measurements.
Genet Med. 2009;11(9):669-81.
7. Agnieszka S, Slezak R, Pesz K, Gil J, Sasiadek MM.
Prenatal diagnosis - principles of diagnostic proceduresand
genetic counseling. Folia Histochem Cyto. 2007;45:11-16.
8. Anderson CL, Brown CE. Fetal chromosomal
abnormalities: antenatal screening and diagnosis. Am Fam
Physician. 2009 Jan 15;79(2):117-123. PMID: 19178062.
9. ACOG Committee on Practice Bulletins. ACOG practice
bulletin no. 88: invasive prenatal testing for aneuploidy.
Obstet Gynecol. 2007 Dec;110(6):1459-67.
10. Hahn S, Jackson LG, Zimmermann BG. Prenatal diagnosis
of fetal aneuploidies: post‑ genomic developments.
Genome Med. 2010;2(1):171-175 DOI: 10.1186/gm171.
11. Dastur AE. Changing paradigm in prenatal management. J
Prenat Diag Ther. 2010 Jan-June;1(1):1-2. doi:
10.4103/0976-1756.62131.
12. Gorduza EV, Popescu R, Caba L, Ivanov I, Martiniuc V,
Nedelea F, et al. Prenatal diagnosis of 21 trisomy by
quantification of methylated fetal DNA in maternal blood:
study on 10 pregnancies. RJLabMR. 2013 Sept;21:3,4. doi:
10.2478/rrlm-2013-0030.
13. ACOG Committee on Practice Bulletins. ACOG practice
bulletin no.162:Prenatal Diagnostic Testing for Genetic
Disorders. Obstet Gynecol. 2016 May;127(5):108-22.
14. Sjogren B, Uddenberg N. Prenatal Diagnosis and
Psychological Distress: Amniocentesis or Chorionic Villus
Biopsy? Prenatal Diagnosis. 1989;9:477-87.
15. Nakić Radoš S, Košec V, Gall V. The psychological effects
of prenatal diagnostic procedures: maternal anxiety before
AMT, vol. 22, no. 1, 2017, p. 13
and after invasive and noninvasive procedures. Prenatal
Diag. 2013; 33:1194–1200. doi: 10.1002/pd.4223.
16. Hewison J, Nixon J, Fountain J, Cocks K, Jones C, Mason
G, et al. Amniocentesis results: investigation of anxiety.
The ARIA trial. Health Technol Assess. 2006 Apr;10(50).
doi: http://dx.doi.org/10.3310/hta10500.
17. Kowalcek I, Mühlhoff A, Bachmann S, Gembruch U.
Depressive reactions and stress related to prenatal medicine
procedures. Ultrasound Obst Gyn. 2002 Jan 19(1):18-23.
doi: 10.1046/j.0960-7692.2001.00551.x.
18. Brajenović-Milić B, Dorcić T, Kuljanić K, Petrović O.
Stress and Anxiety in Relation to Amniocentesis: Do
Women Who Perceive Their Partners To Be More Involved
in Pregnancy Feel Less Stressed and Anxious? Croat Med
J. 2010 Apr;51(2):137-143.
19. El-Hage W, Leger J, Delcuze A, Giraudeau B, Perrotin F.
Amniocentesis, Maternal Psychopathology and Prenatal
Representations of Attachment: A Prospective Comparative
Study. PLoS ONE. 2012;7(7):e41777.
doi:10.1371/journal.pone.0041777.
20. Allison SJ, Stafford J, Anumba D. The effect of stress and
anxiety associated with maternal prenatal diagnosis on feto-
maternal attachment. BMC Women’s Health.
2011;11(1):33-40. doi: 10.1186/1472-6874-11-33.
21. Durand MA, Stiel M, Boivin J, Elwyn G. Information and
decision support needs of parents considering
amniocentesis: interviews with pregnant women and health
professionals. Health Expect. 2010 Jun;13(2):125-138. doi:
10.1111/j.1369-7625.2009.00544.x.
22. Kaasen A, Helbig A, Malt U, Næs T, Skari H, Haugen G.
Acute maternal social dysfunction, health perception and
psychological distress after ultrasonographic detection of a
fetal structural anomaly. BJOG. 2010 Aug; 117(2):1127-
1138. doi:10.1111/j.1471-0528.2010.02622.x.
23. Goodman J, Guarino A, Chenausky K, Klein, Lauri Prager
J, Petersen R, et al. Calm Pregnancy: results of a pilot study
of mindfulness-based cognitive therapy for perinatal
anxiety. Arch Womens Ment Health. 2014 Oct;17(5):373-
387. doi: 10.1007/s00737-013-0402-7.
24. Georgsson Ohman S, Saltvedt S, Waldenstrom U,
Grunewald C, Olin-Lauritzen S. Pregnant Women’s
Responses to Information About an Increased Risk of
Carrying a Baby with Down Syndrome. Birth: Issues in
Perinatal Care. 2006 Mar;33(1):64-73. doi: 10.1111/j.0730-
7659.2006.00075.x.
25. Sanhal CY, Mendilcioglu I, Ozekinci M, Simsek M,
Bozkurt S. Comparison of pre-procedural anxiety and
depression scores for patients undergoing chorion villus
sampling and amniocentesis: An alternative perspective on
prenatal invasive techniques. Pak J Med Sci. 2015
Sep/Oct;31(5):1-5 doi: 10.12669/pjms.315.7477.
26. Allyse M, Minear M, Berson E, Sridhar S, Rote M, Hung
A. Non-invasive prenatal testing: a review of international
implementation and challenges. Int J Women’s
Health.2015;7:113-126. PMC4303457.
27. UK NSC. The UK NSC recommendation on Fetal anomaly
screening in pregnancy.
https://legacyscreening.phe.org.uk/fetalanomalies.
28. Björklund U, Marsk A, Öhman SG. Does an information
film about prenatal testing in early pregnancy affect
women's anxiety and worries? J Psychosom Obstet. 2013
Mar;34(1):9-14. doi: 10.3109/0167482X.2012.756864.
29. Say R, Robson S, Thomson R. Helping pregnant women
make better decisions: a systematic review of the benefits
of patient decision aids in obstetrics. BMJ Open. 2011 Jan;
1:e000261. doi:10.1136/bmjopen-2011-000261.
 PUBLIC HEALTH AND MANAGEMENT

30. Dahl K, Hvidman L, Jorgensen FS, Henriques C, Olesen F,

Kjaergaard H, et al. First-trimester Down syndrome
screening: pregnant women’s knowledge. Ultrasound
Obstet Gynecol. 2011;38(2):145-51.doi:10.1002/uog.8839.
31. Sahin NH, Ilkay G. Congenital anomalies: parents’ anxiety
and women’s concern before prenatal testing and women’s
opinion towards the risk factors. J Clin Nurs. 2008
Mar;17(6):827-36 doi: 10.1111/j.1365-2.
32. Rowe HJ, Fisher JR, Quinlivan JA. Are pregnant
Australian women well informed about prenatal genetic
screening? A systematic investigation using the
Multidimensional Measure of Informed Choice. Aus NZ J
Obstet Gynaecol. 2006 Oct;46(5):433–39.doi:
10.1111/j.1479-828X.2006.00630.x.
33. Durand MA, Boivin J, Elwyn G. A review of decision
support technologies for amniocentesis. Hum Reprod
Update. 2008 Nov-Dec;14(6):659–68.
doi:10.1093/humupd/dmn037.
34. Segal I, Shahar Y. A distributed system for support and
explanation of shared decision-making in the prenatal
testing domain. J Biomed Inform. 2009 Apr;42(2):272-86.
doi: 10.1016/j.jbi.2008.09.004702.2007.02023.x.
35. Kukulu K, Buldukoglu K, Keser I, Simşek M,
Mendilcioğlu I, Lüleci G et al. Psychological effects of
amniocentesis on women and their spouses: importance of
the testing period and genetic counseling. J Psychosom
Obstet Gynecol. 2006 March; 27(1):9-15.

AMT, vol. 22, no. 1, 2017, p. 14

 PUBLIC HEALTH AND MANAGEMENT

THE NEUROLOGIST’S RESPONSIBILITIES IN DECLARING

THE TIME OF BRAIN DEATH AND ORGAN DONATION

MIHAELA LUNGU1, MARY NICOLETA LUPU2, CARINA DOINA VOINESCU3

1,2
Emergency Clinical Hospital Galaţi, 1,2,3“Dunărea de Jos” University Galaţi

Keywords: brain death, Abstract: Declaring brain death and identifying the potential organ donors requires the existence of a
organ donor, the multidisciplinary team, but the neurologist has the responsibility of establishing the irreversibility of the
neurologist’s role brain damage. This responsibility, which is not a simple one, implies elements of medical ethics, but also
emotional participation of the neurologist.

Brain death is defined as a non-responsive status
associated with abolition of all brain reflexes which represents the
most severe grade of brain hypoxia, frequently determined by lack
of circulation.(1)
The first definition of brain death was given in 1950, as
being the state in which the brain is irreversibly damaged but heart
and lung functions can be artificially maintained: exceeded
coma.(2)
In 1968 Harvard Medical School introduces the concept
of brain death as being the brain state non-responsive to any type
of stimulus, stopping breathing and absence of electrical activity
on electroencephalography (EEG) for 24 hours.(2)
The equating between brain death and the patient’s
death involved, in the years that followed, performing complex
ethical and moral analysis with social, religious implication, the
justification for this equivalence being given by the association of
brain death with irreversible heart – respiratory insufficiency.(3)
The essential criteria for brain death’s diagnosis include
absence of all brain functions associated with the absence of vital
functions that are under brain control, modifications being
irreversible, in other words nonreactive coma, absence of brain
stem reflexes and apnea.(4,5)
In declaring brain death it is absolutely mandatory for
the determining cause of the irreversible brain damage to be
known: subarachnoid hemorrhage, traumatic brain injury (6),
cardiac arrest.(7,8) etc, imposing differential diagnosis with drug
intoxications, anesthesia, hypothermia (body temperature over 32
degrees), vegetative status, ―locked-in‖ syndrome, for which
clinical tests and repeated laboratory analysis are required.(9)
Clinically the brain dead patient is in a profound coma,
no spontaneous movements, without motor or verbal response to
visual, cutaneous, auditory stimulus. Spinal reflexes of triple
flexion may be present with or without the presence of the
Babinski sign (its existence does not rule out brain death).(10) But
there may be positions in flexion or extension which require
timing of declaring this status. The eyeballs are in middle position,
the pupils are nonreactive with sizes between 4-9 mm. Bulbar
muscles are paralyzed, facial movements, coughing and
swallowing reflexes, suction reflex, and corneal reflex being
absent. There is no motor or autonomic response to noxious
stimulus, there are no respiratory movements.(11)
Diagnosing the bulbar condition is performed through
apnea test which shows the absence of the bulbar response to
increasing CO2 concentration: disconnection from ventilation
equipment for 3-5 minutes up to 8-10 minutes is associated with
absence of respiratory movements in CO2 pressure values >= 50-
60mmHg (formal criteria 60 mm Hg) or causes increasing CO2
pressure up to >=20mmHg more than the normal value.(4)
Another important element is the presence of diabetes
insipidus in a brain dead patient, its absence imposing diagnosis
delay. Tachycardia response to atropine injection shows loss of
cardiac innervation through bulbar vagal neurons. Neurological
examination protocol includes pupil examination (which has to be
between 4-9 mm with abolished photo-motor reflex), eyeball
movements (which must be absent), corneal reflex – absent,
spontaneous blinking – absent, facial movements – absent,
spontaneous muscle movements – absent, ocular-vestibular reflex,
ocular-cephalic reflex, glossopharyngeal reflex, coughing reflex –
absent associated with the absence of spontaneous breathing and
response to atropine.(12)
Monitoring the eventual organ donor is done for at least
6 hours in cases of primary brain damage and for 24 hours in
cases of secondary brain damage. Clinical evaluation of potential
donors may be difficult, as each patient can be the ideal donor for
a particular organ and donor with some drawbacks for another
organ. The donor’s age correlates with other conditions, for
example hypertension, diabetes.
The cause of death must be well established, suspicions
related to central nervous system (CNS) infections, neoplastic
diseases must be eliminated.(13) Laboratory evaluations include
serology, chemistry, hematology an microbiology
examinations.(14,15,16) For example the existence of piercings
and tattoos may raise suspicion for infections with hepatitis
viruses, human immunodeficiency virus (HIV), and therefore in
situations in which this type of actions on the skin occurred in less
than 3 months before the patient can be excluded from
donation.(1) After clinical establishment of the existence of a
potential donor, after following all the previously mentioned steps
which were well established by examination protocols there are
also necessary laboratory confirmations (14), which are carried
out through several methods: EEG, brain angiography, brain
scintigraphy, Doppler examination, echocardiography.(17,18,19)
Electroencephalography aspect is extremely important
in the confirmation of the brain death, although in United States
most medical institutions do not require EEG as an indispensable
criteria for the diagnosis.(5)
In brain death, EEG does not present electrical
potentials that are over 2mV for a period of 30 minutes

Corresponding author: Doina Carina Voinescu, Str. Al. I. Cuza, Nr. 35, Gala i, România, E-mail: carinavoinescu@gmail.com, Phone: +40757 644226
3

Article received on 14.11.2016 and accepted for publication on 23.02.2017

ACTA MEDICA TRANSILVANICA March 2017;22(1):15-16
AMT, vol. 22, no. 1, 2017, p. 15
 PUBLIC HEALTH AND MANAGEMENT
(isoelectric aspect). However reaching the moment in which an
isoelectric line is registered is purely theoretical, as the artifacts
determined by the interference of the surrounding equipment
appear on the route: ventilation equipment, electrocardiography
(EKG) equipment, other electrical devices.
Moreover, the absence of these artifacts indicates a
possible technical problem regarding the EEG recording
equipment.(1)
The EEG registration is performed after 6 hours since
the causal event, and then it is repeated up to 24 hours before
declaring brain death. The route must show the absence of the
electrical activity for at least 30 minutes, while registering it on 16
channels with electrodes placed at a distance of 10 cm from each
other, frontal, temporal, occipital and parietal including during
painful stimulus. Sometimes, on the EEG route there can be EKG
aspects recorded, with the appearance of a QRS complex.
The ideal aspect – isoelectric – of the EEG is influenced
by artifact given by the ventilation equipment, by the
electrocardiograph and by all the other electrical devices that are
around. Moreover, the absence of these artifacts and the obtaining
of an ideal isoelectric line raises high suspicions about the well
functioning of the encephalograph. The EEG route will be
monitored for 24 hours.
We exemplify an EEG aspect in a patient that was brain
dead, due to a brain hemorrhage, caused by a brain aneurysm: no
electrical potentials that are over 2mV (the absence of the
electrical activity), with artifacts determined by the interference of
the surrounding equipment (figure no. 1).
Figure no. 1. EEG route in a brain dead patient
Evoked visual potentials are not a criterion that is worth
following because they may show various abnormalities.
Some medical centers use brain scintigraphy or brain
angiography to demonstrate the absence of intracranial circulation,
though clinical diagnosis is preferred, because false – negative
results may appear.
Arteriography on 4 vessels shows the absence of
intracranial circulation: total suppression of all arterial contrast
and the absence of venous flow, full suppression of the blood flow
in the polygon of Willis, delayed circulation (its extending over 15
seconds is not compatible with the preservation of brain function).
However, the administration of contrast substance may lead to the
alteration of renal function for the potential donor.
Brain scintigraphy evaluates the blood flow through the
brain and of the Tc99 tracer towards the brain parenchyma.
Through Doppler examination, temporal and foramen
magnum, we highlight the absence of intracranial blood flow. But
in 10% of the cases the time gap is missing and because of this,
the initial absence of the Doppler sign is not equivalent with brain
death. Low systolic peaks at the start of the systole, with no
diastolic flow or turbulent flow indicate the high vascular
resistance associated with exceeded intracranial pressure.(20)
AMT, vol. 22, no. 1, 2017, p. 16
In other words, laboratory investigations used in the
diagnosis of brain death have pro and con arguments, which make
the neurological clinical examination to become essential in this
situation.
So, the neurologist has a major moral, legal and medical
responsibility to declare a patient a possible organ donor and to
allow the rest of medical team to harvest the organs.
REFERENCES
1. Adams and Victor's Principles of Neurology - Tenth Edition,
McGraw-Hill Education, USA; 2014.
2. Harvard Criteria. Report of the AdHoc Committee of the
Harvard Medical School to Examine the Definition of Brain
Death. A definition of irreversible coma. JAMA.
1968;205:337-340.
3. Randell TT. Medical and legal consideration of brain death.
Acta Anaesthesiologica Scandinavica. 2004;48(2):139-144.
4. Evaluare. Diagnostic. Management. Donare/transplant.
Legisla ie: OMS 1246.
5. Guidelines for the Determination of Death, JAMA
11/13/1981;246 (19):2184-2186.
6. Greenberg MS. Handbook of neurosurgery- Fourth Edition,
Greenberg Graphics, Florida; 1997. p. 564-570.
7. Dujardin KS, McCully RB, Wijdicks EF, et al. Myocardial
dysfunction associated with brain death: clinical,
ecocardiographic and pathologic features, J. Heart Lung
Transplant. 2001;20:350.
8. Cooper DK, Novitzky D, Wicomb WN. The
pathophysiological effects of brain death on potential donor
organs, with particular reference to the heart. Ann R Coll
Surg Engl. 1989;71:261.
9. Popa C. Moartea cerebral şi managementul transplantului
de organe, vol. A XIV-a Conf. Nat. de Stroke: Sinteze si
rezumate; 2013. p. 75-91.
10. Popa C. Moartea cerebral , in vol. A-XIV-a Conf. Nat.de
Stroke- Sinteze şi rezumate; 20 3. p. 49-56.
11. Canadian Neurocritical Care Group. Guidelines for diagnosis
of brain death. Can J Neurol. Sci. 1999;26:64-66.
12. Report of the Quality Standards Subcommitte of the
American Academy of Neurology. Practice parameters for
determinating brain death in adults. Neurology.
1995;45:1012-1014.
13. Rosendale JD, Chabalewski FL, McBride MA, et. al.:
Increased transplanted organs from the use of a standardized
donor management protocol. Am J Transplant. 2002;2:761.
14. Hufschmidt A, Lucking CH. Neurologie integrala, de la
simptom la tratament, Ed. Polirom; 2002. p. 348-350.
15. Totsuka E, Fung JJ, Ishii T, et al. Influence of donor
condition on postoperative graft survival and function in
human liver transplantion. Transplant Proc. 2000;32:322.
16. Wijdicls EFM. Determinating brain death in adults.
Neurology. 1995;45:1003.
17. Rosendale JD, Chabalewski FL, McBride MA, et. al.:
Aggressive pharmacologic donor management results in
more transplanted organs. Transplantation. 2003;75:482.
18. Cooper DK, Novitzky D, Wicomb WN. The
pathophysiological effects of brain death on potential donor
organs, with particular reference to the heart. Ann R Coll
Surg Engl. 1989;71:261.
19. Zaroff J. Echocardiographic evaluation of the potential
cardiac donor. J Heart Lung Transplant. 2004;23:250.
20. Tiu C, Antohi F. Neurosonologie, Ed. SemnE, Buc.; 2006. p.
219- 228.
 PUBLIC HEALTH AND MANAGEMENT

STUDY REGARDING PATIENT SATISFACTION WITHIN THE

EMERGENCY DENTAL OFFICE OF THE EMERGENCY ROOM
OF MOBILE EMERGENCY SERVICE FOR RESUSCITATION
AND EXTRICATION (UPU-SMURD) SIBIU

CRISTIAN ALEXANDRU ȚÂNȚAR1, CARMEN DANIELA DOMNARIU2

1
Phd Candidate “Lucian Blaga” University of Sibiu,2“Lucian Blaga” University of Sibiu

Keywords: Abstract: Our study is based on an opinion survey applied in the emergency dental office from Sibiu
questionnaire, County. An important factor taken into account when we plan to streamline the medical service is the
satisfaction, UPU level of satisfaction patients have towards the service provider. The questionnaire which we applied is
SMURD, emergency an adapted version of a validated form used in 2006 by the National Health Insurance Service in
dental office Englant (NHS) for the implementation of measures to streamline the emergency dental system. The
group of patients to whom we applied the questionnaire consists of 60 patients. The questionnaire
contains questions about the level of satisfaction of patients, addressability aiming to identify the
reasons for which patients resort to such services in Romania. According to the results, 65% of patients
were very satisfied with the treatment offered, 96% were satisfied with the attitude of the staff towards
them and 91% said they trust the medical staff. A large percentage (40%) said that the equipment in the
dental office can be improved. The conclusion of this study is that the emergency dental office is highly
appreciated by patients and despite the poor equipment, doctors are trying to cope with increased
addressability of the dental office.

INTRODUCTION The questionnaire was applied to persons who were

The emergency dental office from Sibiu develops its
activity inside the University Dental Clinic and is part of the
Emergency Room of the Mobile Emergency Service for
Resuscitation and Extrication (UPU-SMURD) department
within the Clinical County Emergency Hospital of Sibiu. It is
designed to treat acute dental pathologies operating in this form
for nearly 11 years. It provides permanent emergency dental
care. Addressability to this office is quite high, above the
average of other centres of this kind in the rest of the country.(1)
We believe that any attempt to streamline a medical
system should have as a starting point quantifying the impact tit
has on patients.(2,3) One of the indicators is undoubtedly the
patient satisfaction regarding the medical services, in our case,
the treatment offered by the Sibiu emergency dental office.
PURPOSE
The purpose for continuous improvement has led to
the design of this study of the impact of emergency medical
services on patients with a view to identify the level of trust and
patient satisfaction in terms of this emergency service.
MATERIALS AND METHODS
This study is based on the application of a self-
administered questionnaire of satisfaction and addressability, to
patients who have addressed the emergency dental service
within UPU-SMURD during 1 September 2016- October 30,
2016.
The source of the instrument used was a questionnaire
applied by the National Health Service (NHS) in England and
Wales.(4,5)
The questionnaire was applied during the period:
March 2006-October 2006 following a change in the legislative
conditions for dentists’ accession to the NHS.
sent to the emergency dental service in several areas of
London.(6) The questionnaire was designed to have two main
parts. A part of addressability and a part focused on measuring
the level of patients presenting in this service.
The questionnaire explores many characteristics and
opinions of patients: reasons of presentation, registration data,
knowledge about this emergency service, satisfaction with
services, items on the future development of the service etc. The
questionnaire has been validated on a number of 20 subjects
who were not included in the study.(2)
The sample is represented by a group of 60 patients
who addressed the emergency dental office with various
complains.
The inclusion criteria regarded all patients who were
willing to fill out the questionnaire, who were over 18 and had
no clinical psychiatric disorders.
The exclusion criteria referred to patients aged under
18, with insubordinate behaviour in the emergency service,
verbal or physical aggression or they just did not want to fill out
the questionnaire.
All questionnaires were filled out by patients after
completing the medical emergency treatment by the physician,
namely before leaving the office. The study complied with the
ethical rules of individual and scientific research, the research
being approved by the Ethics Committee of the Clinical County
Emergency Hospital of Sibiu.
Data analysis was performed using SPSS IBM
Statistics 20 software, the results for each of survey questions
being presented in the form of their points, and for comparisons
the Chi-Square test was used.(7,8) Microsoft Office Excel 13
software was used for data processing (9) and graphical
representations.

1
Corresponding author: Cristian Alexandru Țânțar, Str. Ștefan cel Mare, Nr. 75 B, Ap. 5, Sibiu, România, E-mail: tantarcristian@yahoo.com, Phone:
+40744 369508
Article received on 12.01.2017 and accepted for publication on 27.02.2017
ACTA MEDICA TRANSILVANICA March 2017;22(1):17-19
AMT, vol. 22, no. 1, 2017, p. 17
 PUBLIC HEALTH AND MANAGEMENT

RESULTS AND DISCUSSIONS Figure no. 4. Distribution of patients according to the level
After analyzing the results we obtained the following of satisfaction with the information received on health status
values: 65% of patients in the present study say they are very
satisfied with the treatment offered in the emergency dental
office, 30% were satisfied and almost satisfied, 5% (figure no.
1).

Figure no. 1. Distribution of patients regarding the level of

satisfaction of the treatment

Patients’ level of satisfaction on whether the doctor

took into account their opinions in setting the treatment is very
high, 90% of patients saying that the doctor took account of this
(figure no. 5).

Figure no. 5. Distribution of patients depending on their

level of satisfaction with the importance of their opinion in
choosing the treatment

A very high percentage, 90% said they had received

satisfactory information on the risk of surgery and prescribed
treatment (figure no. 2).

Figure no. 2. Patients’ distribution regarding the level of

satisfaction with the information received, related to the risk
of intervention

A very high percentage of patients (96%) say they are

very satisfied with the attitude of the medical staff towards them
(figure no. 6), one proof being the very high confidence that
patients have towards the medical staff (91%) (figure no. 7).

Figure no. 6. Distribution regarding patients’ satisfaction

towards the medical staff’s attitude

Regarding the patients’ consent before performing

dental emergency intervention, 83% of patients said that they
had been asked about their consent, 6.7% partially and 10%
replied that they were not asked about this (figure no. 3).

Figure no. 3. Distribution of patients according to the level

of satisfaction with the consent given for dental intervention
Figure no. 7. Distribution of patients according to the level
of confidence of the medical staff

As for the information that patients have received

related to health and treatment possibilities, 90% of patients Finally, we found it necessary to find out patients’
were satisfied (figure no. 4). opinion about the material resources which this emergency
AMT, vol. 22, no. 1, 2017, p. 18
 PUBLIC HEALTH AND MANAGEMENT

dental office holds. Of the patients included in the study, 23%
consider the dental office is very good equipped, a rate of 12%
higher (35%) consider the dental office is good equipped (Chi-
square = 1.400, p = 0.237) and a rate about twice as high (40%)
believe that the equipment can be optimized (Chi-square =
2.632, p = 0.105) (figure no. 8.).
Figure no. 8. Distribution of patients according to the
satisfaction level with the office’s equipment
one possible local solution. British Dental Journal.
2001;191(10):550-554.
5. Gibbons DE, West BJ: Dentaline: an out-of-hours
emergency dental service in Kent. British Dental Journal.
1996;180(2):63-66.
6. Austin R, Jones K, Wright D, Donaldson N, Gallagher J.
Use of the out-of-hours emergency dental service at two
south-east London hospitals. BMC Oral Health.
2009;9(19).
7. Mocan I. SPSS Introducere în analiza datelor, Ed. Univ.
Lucian Blaga Sibiu, ISBN 973–739–189–6; 2005. p. 9-100.
8. Maniu I. Tehnici de analiz a datelor: statistica, Ed. Univ.
Lucian Blaga, Sibiu, ISBN 978–606–12–0891–3; 2014. p.
93-98.
9. Popa EM, Hunyadi D, Muşan M, Maniu I, Brumar B,
Stoica E. Manual de inițiere n birotic , Ed. Univ. Lucian
Blaga, Sibiu ISBN 978–973–739-388-3; 2007.
10. D ncil A, Iona M. The evaluation of the satisfaction
degree in a dental practice in Sibiu. Acta Medica
Transilvanica.2016;4(21):108.

Interestingly, a similar study done in the area of

private practice in Sibiu (10), the same year, reveals percentages
smaller in terms of the satisfaction on the level of information
received from the doctor (80%), compared to (90%) how the
emergency dental office records.(10)
Also, in this study it is reported that 92% were
satisfied with the treatment and medication prescribed by a
physician, a percentage similar to that in our study.(10)
From the study done by the NHS in London in 2007
we find that a very similar percentage (95%) was obtained in
assessing patients’ satisfaction regarding the services of the
emergency dental system, a percentage very similar to that
obtained in our study.(6)

CONCLUSIONS
1. Large percentages of patients who reported high levels of
satisfaction of their treatment, of what information they
were given and regarding the attitude of the medical staff
towards patients’ needs show a professional and ethical
behaviour of the medical staff employed in the emergency
dental office of UPU-SMURD Sibiu.
2. However, patients’ impression that material and technical
resource could be improved in this dental office is correct,
this office benefiting from technical material of 50-60 years
old, which is worn and overused.
3. The high level of satisfaction compared to the private
sector show probably a lower expectation of patients
presenting to the emergency dental office.

REFERENCES
1. Țânțar CA, Domnariu CD. Studiu privind activitatea
Cabinetului de urgențe dentare din cadrul Upu Smurd
Sibiu. Acta Medica Transilvanica [ahead of publishing].
2. Dickinson TM, Guest PG. An audit of demand and
provision of emergency dental treatment. British Dental
Journal. 1996;181(3):86-87.
3. Anderson R, Thomas DW, Phillips CJ. The effectiveness of
out-of- hours dental services: II. patient satisfaction. British
Dental Journal. 2005;198(3):151-156.
4. Evans DJ, Smith MP, Grant SMB, Crawford MA, Bond J.
Out-of- hours emergency dental services – development of

AMT, vol. 22, no. 1, 2017, p. 19

 PUBLIC HEALTH AND MANAGEMENT

NURSE STUDENTS CLINICAL PRACTICE – TRAINERS’

PERCEPTIONS

GHEORGHE CUCU1, PETRU ARMEAN2, ALEXANDRA CUCU3, ILEANA PAULA IONEL4

1
The Romanian Parliament, Chamber of Deputies, 2,3,4 “Carol Davila” University of Medicine and Pharmacy Bucharest

Keywords: nurse Abstract: Descriptive transversal study aiming to identify the perceptions, barriers and needs for future
clinical practice, nurse training of nurses involved in clinical practice of the students of the Faculty of Nursing and Midwifery from
perceptions, teaching “Carol Davila” University of Medicine and Pharmacy from Bucharest. The study results identify the
barriers positive approach and commitment of nurses from the Burghele Clinical Hospital towards fulfilling their
roles and mission in guiding the students practice. Some barriers and future needs were also revealed by
the study, providing clues for future direction for improvement in nurse student’s clinical practice.

INTRODUCTION replacing the former GD 1477/2003, creates the national frame

In Europe currently, nurse education is organized in a
diversity of settings either at the higher educational level, in
universities or in nursing schools or colleges.(1)
Nursing practice, as the whole health service delivery,
in order to respond to the main challenges the health system are
facing in present in almost all the countries, in Romania as well,
mainly: the technological development, economic and personnel
shortage, the patient current profile in relation with demographic
characteristics, information and increased expectation, should
continuously evolve. These developments lead to an increased
demand with respect to nurses’ whole range of competences.
Recent studies suggest that graduating students often lack the
knowledge and skills needed to practice effectively in the 21 st
century.(2)
Consequently, a change in nurse education, including
solid skills for continuous professional development, in order to
make them capable to meet the modern professional
environment, should be set up.
In order to meet these developments and create the
theoretical and practical competencies for modern nurses, in the
European Union, within the frame of Bologna process, through
the Directive 2005/36/EC (the Recognition of Professional
Qualifications, modernized by the new 2013/55/EU Directive,
set up minimum requirements on length and content for nurse
education. In this context higher education institutions for nurse
education, which are obliged to meet those requirements by the
accreditation process are challenged to provide training for
nurses capable to practise with awareness, compassion and
competence and endowed with a high level of independent
learning skills.(1,2) According to these legal provisions, the
nurse clinical practical training is one of the most important
parts of the modern nurse education. The simple fact that it
should count for one half of total number of training hours, 2300
of the total of 4600, is expressing the importance of practical
training in nurse competence equation.(3,4,5)
The national legislation, transposing the Directive
provision, represented by the Government Decision 469/2015 on
approval of minimum criteria for authorization and accreditation
of study programmes on Medicine, Dental medicine, Pharmacy,
nursing, midwifes, veterinary medicine and architecture,
for the adequate and standardized nurse curriculum at national
level. According to this normative act the clinical training is
―that part of nurse training in which trainee nurses learn, as part
of a team and in direct contact with a healthy or sick individual
and/or community, to organize, dispense and evaluate the
required comprehensive nursing care, on the basis of the
knowledge, skills and competences which they have acquired.
The trainee nurse shall learn not only how to work in a team, but
also how to lead a team and organize overall nursing care,
including health education for individuals and small groups,
within health institutes or in the community ‖. The knowledge
and skills acquired related to this training, defined as adequate
clinical experience, comprising in ‖such experience, which
should be selected for its training value, should be gained under
the supervision of qualified nursing staff and in places where the
number of qualified staff and equipment are appropriate for the
nursing care of the patient‖.(5,6)
Summarizing, according to above prerequisites,
contemporary qualified nurse are expected to take initiative not
only for health services delivery but also for their own
development as active, long life learners. Consequently, the
mode how they are trained, how the clinical practice contribute
to reach these goals should be carefully planned.
PURPOSE
The university clinical training, including at least 2300
hours, distributed in 4 years of study, are performed in clinical
hospitals under the supervision of the existing nurses. The
successful organization of stages requires collaboration and
coordination of hospital management, academic teaching staff,
nurses’ team, students and finally, patients, requiring not only
staff commitment but also a climate supportive for clinical
teaching. In the actual context of increasing number of students,
complex demands for new competences, that have to be reached
through clinical practice and the personnel overload due to
already chronic staff shortage in our hospitals, the way how the
clinical training is organized and perceived is crucial for the
professional development of the future nurses.
How is this training organized, what are the attitudes
of the nurses supplementary charged with teaching roles, how

4
Corresponding author: Ileana Paula Ionel, Str. Gh T t raşcu, Bl. P2, Ap. 34, Bucureşti, România, E-mail: ionelileanapaula@yahoo.com, Phone:
+40723 369027
Article received on 28.12.2016 and accepted for publication on 23.02.2017
ACTA MEDICA TRANSILVANICA March 2017;22(1):20-23
AMT, vol. 22, no. 1, 2017, p. 20
 PUBLIC HEALTH AND MANAGEMENT
they perceive these tasks, as factors contributing to a competent,
skilled and self confident future nurse, were the main study
questions of the study. Also the managerial, organizational
aspects were targeted by a group of three questions. Based on
the received answers a future better coordination and support for
an effective clinical practice will be elaborated and
implemented. In this context the objectives of the study were:
 Identifying the nurse perceptions on opportunities offered
by involvement in clinical practice,
 Assessment of models, attitudes and practices regarding
nurse students clinical practice,
 Identifying the main further educational needs of the nurses
involved in clinical practice of students.
MATERIALS AND METHODS
The study is based on a descriptive approach. The
evaluation of the way how the clinical training is organized,
perceived and guided in order to ensure competence and value
gain for the students was carried out through a quantitative
method, by a self-completed questionnaire, administrated in
Burghele Clinical Hospital Bucharest, one of the main hospitals
were the nurses of are performing clinical practice. The target
audience was represented by the team of nurses involved in
clinical practice of students from the Faculty for Midwife and
Nursing of University of Medicine and Pharmacology Carol
Davila Bucharest.
The sample selection was made based on the nursing
staff present at work in the hospital in the ten days period for
data collection, during February 2016.
The questionnaire ―Knowledge, attitude, and practice
as trainer for the nurse students― was designed to collect
information on factual aspects as age, experience and on six
areas of importance for the clinical teaching process: main
activities, methods used, values transmitted, process perception,
difficulties encountered and training needs. The questionnaire
consisted of closed questions with single or multiple answers,
and two questions based on a Likert scale from 1-5.
The self-administered questionnaire was anonymous
and confidential, and the statistical analysis was done with no
personal reference.
RESULTS AND DISCUSSIONS
The socio demographic characteristics of the study
sample reveal a profile of respondents dominated by women: 40
(93%) of the 43 respondents, corresponding to the normal stuff
distribution in health care facilities were the women are
predominating. From the clinical department affiliation
perspective, most of the respondents work on the Urology
Department (I, II, III-20) followed by internal medicine (10) and
Cardiology.(9)
Related to the professional qualification most of the
nurses, 27 (62,9%) were graduated from the post high school
colleges, followed by the university degree graduates, 13 (30%)
and only 3 persons trained by the nurse high school that
functioned in Romania during the `80`s.
From the age distribution perspective the sample mean
age were 41, 32 years (min 23 years, max 60, SD ±8.03 years).
Consequently the associated work experience was quite
important, with a mean of 17.58 years (min=0.3, max=39,
SD±10.10). Among those, the most of the respondents, 39% are
included in the work experience share of 10-20 years and 17 %
of them have even more than 21 years of experience. Of these
only 6 (14 %) of nurses considered that they have experience in
clinical practice, the trainer experience practicce being less
extensive that the professional one, ranking from 2 to 15 years.
AMT, vol. 22, no. 1, 2017, p. 21
The answers related to the overall perception on
personal participation in the clinical practice of the nurse
students reveals that most of the respondents 55% (24)
considered their involvement as a personal opportunity not as an
obligation, as perceived by 34%, the rest of them being not
decided. In addition, further asked on what type of opportunities
the clinical practice creates for their professional life they
perceived that as a chance for exercising their organizational
skills 72%, planning the clinical practice in such a way that the
most important techniques and cases to reach the students
without prejudice to the normal care flow is really important.
Other types of opportunities identified were:
knowledge transfer 69%, the challenge of assuming new roles
and responsibilities (69%) as well as the challenge to be
connected to the professional news (65%). Interesting is the fact
that the clinical practice is seen as a condition for improving the
patient centeredness of the medical care act for the patient, in
order to represent a model for the students for more 60% of the
respondents. Also, participating in this activity is perceived as a
chance to improve self esteem 58%. About the mentorship
chance, that summarize and extend the professional guidance it
reach agreement for less than half of the respondent (42%).
(figure no. 1).
Figure no. 1. Respondent distribution by perceived
opportunities offered by the student’s clinical practice
mentorhip
self esteem improuvment
improuving patient centerdness
staying connected to professional news
assuming new responsabilities
knowledge transfer
organizational skills
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
agreement disagreement missing
From their mission perspective in the clinical training
process, the practice nurses identified the most important roles as
following: development of practical skills, 74%, supporting the
exercise of theoretical knowledge gained during the clinical
nursing classes, guiding the collaboration and communication
with the patient (65%) and health care team (67%), guidance for
the self learning process (62%) and the last one, the information
and theoretical knowledge transfer function (53%). (figure no. 2).
Figure no. 2. Respondent distribution on nurse role
perception in the nurse student’s clinical training
knowledge transfer
guding self learning process
mediating patient-student relation
guiding health team collaboration
knowledge valorization
practical aptitudes and skills development
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100
%
agreement disagreement missing
 PUBLIC HEALTH AND MANAGEMENT
Related to the managerial, organizational aspects of
clinical practice main features revealed by the responders were:
 Only a relatively small percent 23% of nurses are involved
in the process of planning the clinical activities for the
nurse’s practice, a result somehow confirming the fact that
the clinical practice is perceived as an organizational
challenge.
 The main training model adopted are the whole team of
nurses-whole group of students model (42%) followed by
the medial act cantered method (18%) and by 1 nurse-
small team of allotted students (12%).
 The main teaching methods used were: demonstration
(67%), active observation (58%), group teaching (30%),
active learning and case studies (11%).
The main disturbing factors influencing the process of
students clinical practice identified by the respondents were:
 Time constraint was mentioned by 88% of respondents as
the main factor negatively influencing the quality of
clinical practice. On the background of the chronic
personnel shortage granting enough attention to both
normal tasks and the teaching process is perceived as
difficult for most of respondents.
 The students attitude, the lack of interest and motivation in
practising and developing skills based on the theoretical
knowledge is identified as the second important barriers by
33% of responders.
 The patient refusal together with the limited teaching
resources as instructional materials or even teaching spaces
during the clinical practices are perceived as important by
about one quarter (22%, 23%) of all respondents.
 The less important, still present, is the institutional support,
mentioned by 3% of respondents, identifying one of the
prerequisites for a well organized clinical training (figure
no. 3).
Figure no. 3. Respondent distribution on the main barriers
in nurse student’s clinical training
institutional support
limited teaching skills
teaching resources
patient refusal
students atitude
time constraints
0% 20% 40% 60%
agreement disagreement missing
In order to identify another direction of future
improvement intervention, a Likert scale questions from 1-5,
from very useful- to useless, contribute to identify the hierarchy
of future training needs for the nurses involved in students
clinical practice. The main direction identified were: content of
the health care protocols and clear establishment of the nurse
roles in the health care process (70%); updated knowledge on
ethics and patient rights (69%), evidence based nursing (67%),
legislative framework requirements, (65%) or teaching methods
(63%) (figure no. 4).
Those answers are in concordance with the ending
overall appreciation question on being a good tutor for the nurse
AMT, vol. 22, no. 1, 2017, p. 22
students where only 34% answer yes, I am a good teacher, while
only 2% answer no. The rest of them, the majority, 55%, choose
the unconfident, ―don’t know‖ answer.
Figure no. 4. Future training nurse for nurses involved in
nurse student’s clinical training
teaching methods
legal requirements
evidence based
nursing
ethics, patient rights
health care protocols
0% 20% 40% 60% 80% 100%
very useful usefull less useful usless don t know
CONCLUSIONS
Based on the study information results, we can stress
the following aspects:
 The nurse student clinical practice is a complex process
involving at least tree actors: the student, the patient and
the health care team. Their involvement and collaboration
is crucial for attracting, guiding and empowering the
student in reaching the necessary competences.
 The majority of nurses positively appreciate their role in
the student clinical practice, perceived in most cases as a
personal opportunity not a professional obligation. By their
roles they fulfil a very important task, that one to connect
theory with practice completed by guidance and support for
collaborating with the health care team and patients. They
also contribute to set the coordinates for professional ethics
of the future professionals and guiding students in self
learning and personal development.
 Their mission is often jeopardized by multiple and complex
factors, as student attitudes, patient refusal or resource
limitation, all of them on the background of time
constraints that also pose serious challenges to even the
most committed teaching nurses.
Consequently, in order to reform, improve the
transition process of a nursing student in a proficient
professional nurse it is important to establish clear outcomes and
competences for each of the clinical practice training, specific
protocols on effective methods and tools for teaching nurses,
80% 100%
completed with adequate organizational, staffing and resource
allocation.
REFERENCES
1. Buscher A, Sievertsen B, White E, Nurses and midwifes, a
force for health, survey on the situation of nursing and
midwifery in the member states of the European Region of
the World Health Organization 2009, WHO Regional
office for Europe, Copenhagen, Denmark; 2010.
2. DaRosa DA, Skeff K, Friedland JA, Coburn M, Cox S,
Pollart S, O’connell M, Smith S, Barriers to effective
teaching, Acad Med. 2011 Apr; 86(4):453-9. doi:
10.1097/ACM.0b013e31820defbe.
3. Keighley T. European Union Standards for nursing and
midwifery - information for accession countries, WHO
Regional office for Europe, Copenhagen, Denmark; 2009.
 PUBLIC HEALTH AND MANAGEMENT

4. Directive 2005/36/EC of the European Parliament and of

the Council of 7 September 2005 on the recognition of
professional qualifications Official Journal of the European
Union L 255, 30.9.2005.
5. Directive 2013/55/EU of the European Parliament and of
the Council of 20 November 2013 amending Directive
2005/36/EC on the recognition of professional
qualifications and Regulation (EU) No 1024/2012 on
administrative cooperation through the Internal Market
Information System (the IMI Regulation), published in
Official Journal of the European Union, L nr. 354 din 28
decembrie 2013.
6. Hot rârea Guvernului nr. 469 2 5 pentru aprobarea
criteriilor minime obligatorii de autorizare şi acreditare
pentru programele de studii universitare de Medicin ,
Medicin dentar , Farmacie, Asisten medical general ,
Moaşe, Medicin veterinar , Arhitectura. M.Of.Nr.511 din
9 iulie 2015.
7. Hot rârea Guvernului nr. .477 2003 pentru aprobarea
criteriilor minime obligatorii de autorizare şi acreditare
pentru instituțiile de înv mânt superior din domeniile:
medicin , medicin dentar , farmacie, asisten i medicali,
moaşe, medicin veterinar , arhitectur , precum şi pentru
colegiile de asistenți medicali generali ti. M.Of.Nr. 0 din
8 ianuarie 2004.

AMT, vol. 22, no. 1, 2017, p. 23

 PUBLIC HEALTH AND MANAGEMENT

TIBIAL PLATEAU FRACTURES - EPIDEMIOLOGICAL

ANALYSIS

MIHAI ROMAN1, ADRIAN BOICEAN2, RADU FLEACĂ3

1,2,3
“Lucian Blaga” University of Sibiu

Keywords: tibial Abstract: Tibial plateau fractures are a constant challenge for the trauma surgeon, both for their
plateau fractures complexity and for their great variability. Purpose: Evaluation of the epidemiological characteristics in
tibial plateau fractures treated in the County Hospital Sibiu. Material and methods: 210 patients with
tibial plateau fractures, treated between 1.01.2009 -31.12.2015 were evaluated. Several epidemiological
variables were assessed. Results and discussions: The mean age of the patients was 54.5 years. The
incidence of these fractures is higher, between 51-70 years. There was a slightly greater incidence in the
male population. No difference between dominant and non-dominant limb was found. The majority of
these fractures were produced by falling. There is a high prevalence of associated injuries - menisci,
collateral/cruciate ligaments and fibula - and hemartrosis is present in a high percentage. Conclusion:
Correct evaluation of epidemiological factors is mandatory for a proper understanding of the complexity
of tibial plateau fractures.

INTRODUCTION
Tibial plateau fractures raises therapeutic challenges
and have to be well treated because of the potential
complications. Understanding the whole picture of these
fractures and judging each case individually increases the
quality of final results. The correct evaluation of these fractures
is essential for reducing the risk of complications.(1,2)
PURPOSE
The purpose of this paper is to evaluate the
epidemiological characteristics in tibial plateau fractures treated
in the Clinic of Orthopaedics and Trauma in the County
Hospital Sibiu.
MATERIALS AND METHODS
We evaluated retrospectively a total of 210 patients
with tibial plateau fracture who were treated in the Clinic of
Orthopaedics and Trauma Sibiu in the period 1.01.2009-
31.12.2015.
We analysed the following documents: inpatient
observation sheets, operation protocols, patient discharge data
from the Statistical Office of the Hospital.
This study included patients of both sexes, aged
between 18 and 100 years, suffering fractures of the tibial
plateau of any kind (AO and Schatzker Classification).(3,4)
This study did not include patients with open
fractures.
Detailed evaluation before treatment included history
(mechanism of production) and the presence of comorbidities or
other secondary traumatic lesions.
Several variables were assessed: gender, age,
environment, diagnosis, mechanism of action, date of admission
and discharge.
RESULTS AND DISCUSSIONS
We studied a total of 210 patients who underwent
tibial plateau fractures, of which 93 were women and 117 were
men.
Fractures of the tibial plateau are distributed
approximately equally between the two limbs. Frequency of the
lesion of a specific limb has no connection with the limb being
dominant or not.
It was found an incidence of 7.5 cases per 100 000
inhabitants per year (30 cases- to about 400 000 inhabitants -
county population), lower than the international literature
studies (10.3).
The incidence of these fractures is higher (68%) in the
age groups 41-50 years, 51-60 years, 61-70 years, with the peak
age group 51-60 years. The average age in these patients is 54.5
years compared to 44.5 in international studies.
These results are explained by a certain decrease of
bone quality at this age. In the groups below 50 years, albeit
with better bone strength, these fractures occur by mechanisms
of greater energy.
It can be seen that in the patients category between 51-
60 years, tibial plateau fractures are more common in males
Then, after this age, fractures are more common in females. This
is explained by the participation of men in the more intense
events and physical activities with high risk.
142 patients are of urban origin (68%) and only 68
patients come from rural areas (32%). This difference is
probably explained by the fact that the urban population is
numerically larger.
In terms of the mechanism of production, there is a
high percentage of falling - at the same level or from one level
to another (58%) - compared to other mechanisms such as car
accidents or direct trauma. Analysing the fractures caused by
accidents, an increased incidence among pedestrians (15%) can
be seen.
Patients who have this mechanism of falling are
usually of more advanced age (average - 57 years). These
fractures are due to low bone strength, a large number of these
fractures being found in women.(5,6,7)
Fractures of the tibial plateau which have, as a

2
Corresponding author: Adrian Boicean, Str. Lucian Blaga, Nr. 2A, Sibiu, România, E-mail: adrian.boicean@yahoo.com, Phone: +40722 304379
Article received on 27.01.2017 and accepted for publication on 27.02.2017
ACTA MEDICA TRANSILVANICA March 2017;22(1):24-25
AMT, vol. 22, no. 1, 2017, p. 24
 PUBLIC HEALTH AND MANAGEMENT

mechanism of production, horse and cart accidents are more 847.

common in rural areas, males with a mean age 57 years being
the most incriminated.
Analysing the frequency of fractures by the year time,
we found that the majority of the tibial plateau fractures
occurred in winter with a total of 67 cases (32%). This is
explained by the adverse weather conditions, most of these
fractures being produced by falling at the same level by
dropping or sliding on snow and ice. During summer, we have
found a total of 60 cases (29%), approaching that of the winter
period. In the warm seasons, fracture mechanisms are variable,
but a majority of them occurred after car accidents, cyclists and
motorcyclists being often involved. During spring, there were a
total of 47 cases. Of all the seasons, it was found that in autumn,
the fewest cases were recorded - 36 (17%).
In terms of simultaneous association with other
injuries, we can see that a large percentage of the fractures
(84%) are isolated. Only 16% of cases were multilesional.
Although polytrauma patients represent only 12%, this group is
of particular importance from a therapeutic standpoint.(8,9,10)
The most common associated fractures are the ones of
the fibula because of the very close situation to the tibial
plateau. Thus, when the energy of the traumatic event is very
high, those associated fractures occur. Other associated fractures
such as clavicle, rib and vertebrae fractures, fractures of the
upper limbs, patella and calcaneus fractures occur typically in
the context of polytrauma.(11,12)
Meniscus injuries are common in tibial plateau
fractures, accounting for 35% of cases, and are usually produced
by a medium-energy trauma. Ligament injuries are found in
23% of all cases. Most frequently, they occur in the collateral
and cruciate ligaments of the knee, produced by high-energy
mechanisms. These lesions are diagnosed through clinical
examination, imaging and intraoperative assessment.(13)
Hemartrosis is present in a high percentage of tibial
plateau fractures (57%) and compartment syndrome has a
frequency of 2% and usually requires emergency fasciotomy.
Medical history of the patient should be considered
before starting treatment of a tibial plateau fracture. Thus, we
see that the incidence of heart diseases is the highest, accounting
for 40%. Among the most common associated heart diseases
are: angina pectoris, chronic ischemic heart disease, congestive
heart failure, hypertension, arrhythmias and arytmia.
Metabolic disorders are the second, after heart
diseases (24%). Obesity is the leader of metabolic disorders
which accompanies these fractures.
4. Schatzker J. Fractures of the tibial plateau. In: Schatzker J,
Tile M, eds. The Rationale of Operative Fracture Care.
Berlin: Springer-Verlag; 1987. p. 279-295.
5. Muller M. The comprehensive classification of long bones.
In: Muller ME, Allgower M, Schneider R, Willenegger H,
eds. Manual of Internal Fixation. Berlin: Springer-Verlag;
1995. p. 118-158.
6. Orthopaedic Trauma Association. Fracture and dislocation
compendium: introduction. J Orthop Trauma.
1996;10[Suppl 1]:5-9.
7. Koval KJ, Sanders R, Borrelli J, et al. Indirect reduction
and percutaneous screw fixation of displaced tibial plateau
fractures. J Orthop Trauma. 1992;6(3):340-346.
8. Asik M, Cetik O, Talu U, et al. Arthroscopy-assisted
operative management of tibial plateau fractures. Knee
Surg Sports Traumatol Arthrosc. 2002;10(6):364-370.
9. Buchko GM, Johnson DH. Arthroscopy assisted operative
management of tibial plateau fractures. Clin Orthop.
1996;(332):29-36.
10. Young MJ, Barrack RL. Complications of internal fixation
of tibial plateau fractures. Orthop Rev. 1994;23(2):149-
154.
11. Touliatos AS, Xenakis T, Soucacos PK, et al. Surgical
management of tibial plateau fractures. Acta Orthop Scand
1997;275:92-96.
12. Karunakar MA, Egol KA, Peindl R, et al. Split depression
tibial plateau fractures: a biomechanical study. J Orthop
Trauma. 2002;16(3):172-177.
13. Koval KJ, Polatsch D, Kummer FJ, et al. Split fractures of
the lateral tibial plateau: evaluation of three fixation
methods. J Orthop Trauma. 1996;10(5):304-308.

CONCLUSIONS
Fractures of the tibial plateau represent a complex
pathology that must be addressed properly to prevent
complications. Men have a slightly higher incidence, and the
most affected age group is 51-60 years followed by 61-70 years
decade. The average age of patients with tibial plateau fractures
is 54.5 years. They are produced in 55% of the cases in the left
knee. This type of fracture occurs more frequently in urban areas
with a higher-frequency during the winter. Correct evaluation of
epidemiological factors is mandatory for a proper understanding
of the complexity of tibial plateau fractures.

REFERENCES
1. Rockwood & Green's Fractures in Adults, 6th Edition,
Lippincott Williams & Wilkins; 2006.
2. Gray H. Anatomy of the Human Body. Philadelphia: Lea &
Febiger, 1918; Bartleby.com; 2000.
3. Honkonen SE, Jarvinen MJ. Classification of fractures of
the tibial condyles. Br J Bone Joint Surg. 1992;74(6):840-
AMT, vol. 22, no. 1, 2017, p. 25
 PUBLIC HEALTH AND MANAGEMENT

DENTAL CARE AWARENESS AMONG MOTHERS OF

CHILDREN FROM DISADVANTAGED SOCIOECONOMIC
BACKGROUNDS IN ROMANIA

MONA IONAŞ1, ADELA DĂNCILĂ2

1,2
“Lucian Blaga” University of Sibiu

Keywords: dental care, Abstract: With recent trends in European child welfare policies moving towards shifting more
mother, children, responsibility for children health to parents, this study was intended to learn about parents’ knowledge
socioeconomic factor of dental hygiene and the impact of education on oral health practices in economically disadvantaged
families in Romania. Data about parent’s education, tooth brushing practices, and visits to a dental
practice were collected from 64 participants. Data analysis using non-parametric statistical tests
suggests that parents from this disadvantaged socio-economic category do not pay appropriate attention
to their children’s dental hygiene. Activities aimed at increasing awareness are recommended alongside
existing community support.

INTRODUCTION
A recent trend in European child welfare policies is to
shift responsibility for the child’s health, education and welfare
from the state to the parents and families (1,2,3) suggest, the
sphere of parenting competence should also include the
activities and behaviours related to primary care, carried out
with the purpose of giving children autonomy.
The patterns of behaviour learned in early childhood
are deeply rooted and are resistant to change. Attempts to
change the behaviour at a later stage of development may be
difficult because of the earlier indoctrination at home.(4)
Parental attitudes have a significant impact on the establishment
of positive dental health habits.(5,6,7)
Dental cavities, is one of the most prevalent chronic
diseases worldwide which can occur anytime during a person’s
life.(8) Children from disadvantaged socioeconomic
backgrounds have a higher risk of dental cavity incidence.(9)
For the purpose of this paper, a socioeconomic disadvantaged
background is defined by low-income (10) and low educational
levels.(11,12) The parental attitude towards oral hygiene,
indulgence, awareness, habits, behaviour and the poor oral
health of parents (13) tend to lead to higher cavity incidence in
children.(14,15,16)
Dental health prevention aims to decrease the number
of dental cavities. Prevention of dental cavities, which attempts
to ensure the teeth health, includes a host of methods designed
to help increase dental hard tissue resistance and fight against
the cariogenic aggressor factors.(17,18) Dental health
prevention includes three stages: primary, secondary and
tertiary. The primary prevention covers prevention from
diseases of the dentomaxillary apparatus. The secondary
prevention covers the identification and cessation of the
pathogenic process in its early phases. The tertiary prevention
includes correction and compensatory measures of the
functional consequences.(19) In medicine, primary prevention
starts at home, where the rules of hygiene and the habit of going
to regular medical check-ups are introduced and fostered. While
the parents are the ones who introduce their children to the first
hygiene rules, as the child grows, these habits are further
developed in school and through special programs.
PURPOSE
This study was intended to learn about parents’
knowledge of dental hygiene and the impact of education on
oral health practices in economically disadvantaged families in
Romania.
MATERIALS AND METHODS
While there are many factors that can affect the
incidence of dental cavities, for the purpose of this study, the
following factors are considered:
 Tooth brushing frequency, because proper tooth brushing,
as an effective mechanical method of removing dental
plaque, the main cause of cavities, is the most important
component in dental hygiene.(20)
 Age at which the child has started tooth brushing.(21)
 Parental supervision of the child’s tooth brushing
technique.(20)
Beginning and frequency of dental checkups,
considering that it requires specialized expertise to detect the
onset of dental cavities early, in stages where parents and
patients would not notice them.(22)
Research Questions:
1. What is the habitual oral hygiene behaviour of children
from families from disadvantaged backgrounds?
2. How does the parents’ education level impacts the child’s
tooth brushing frequency, the age at which the child started
brushing his or her teeth, the amount of supervision the
child received during tooth brushing, and the frequency of
dental check-ups.
The study was performed with support from the SOS
Children’s Villages Association Romania through its Center for
Conciliation and Support for Children and Parents in Cisn die,
Sibiu County, Romania, which helped to define the target
population and the selection and recruitment of the study
participants. The center provides support to children from
families in need coming from urban areas, with a high risk of
being institutionalized.
A combination of the following selection criteria was
used:
 Families with increased risk of divorce;

1
Corresponding author: Mona Iona , Str. Lucian Blaga, Nr. 2A, Sibiu, Romania, E-mail: stomatologmonaionas@yahoo.com, Phone: +40269 436777
Article received on 09.10.2016 and accepted for publication on 22.02.2017
ACTA MEDICA TRANSILVANICA March 2017;22(1):26-29
AMT, vol. 22, no. 1, 2017, p. 26
 PUBLIC HEALTH AND MANAGEMENT

 Low income families no. 1).

o With an average of three children
o Sporadic income Figure no. 1. Brushing starting age of studied children
 Families with children who dropped out of school or with
children with increased risk of school dropout.
 Single parent families;
 Underage mothers;
 Families which solicited council about child rearing;
 Families with low education level;
 Families with unemployed parents.
 Families with members suffering from poverty-generated
health issues.
Of the over 100 invitations extended to potential
participants in this study, we received a number of 64 answers,
all mothers. After informing the participant of her rights and
obtaining her written consent, the participant was instructed to
answer the survey questions. This process took place at the local
Social Work offices of the Center for Conciliation and Support
for Children and Parents in Cisn die, Sibiu County, Romania,
part of SOS Children’s Villages Association Romania where the
available personnel provided guidance and support to help
improve response accuracy. The survey questions are presented
in table no. 1.
The question regarding supervision of dental hygiene
Table no. 1. Relevant survey questions in children was answered positively by only 43.8% of the
Question Answer Options
participants. Analysis of the data related to frequency of dental
What is your level of No education;
education? Primary school; checkups reveals that for this study group the vast majority
Secondary school; (84.4%) of the participants visit the dentist office with their
High school; children occasionally, for treatment. 1.6% of the respondents
Professional (Technical) education stated that they never visited a dentist’s office while 4. % do it
How often is your child Less than once per day; on a regular basis.
brushing his or her teeth? Once per day; On the question about the mother’s level of education,
Twice per day; data analysis revealed that 32.8% have secondary education (8
More than two times per day
classes), 12.5% indicate no education at all, while 14.1% of the
At what age did your child start < 2 years of age;
participants had only primary school education (4 classes).
brushing his or her teeth? 2-3 years of age;
4-5 years of age; 15.6% and 25.0% of the participants indicated high school and
> 5 years of age technical studies (professional school) respectively.
Do you supervise your child Yes The second research question was aimed at finding
during tooth brushing? No more about the relation between the participant’s education level
For what reason do you go to I have never been at the dentist; and the four variables considered for this study: the child’s tooth
the dentist with your child? When his/her teeth hurt brushing frequency, the age at which the child started brushing
On a regular basis, for checkups his or her teeth, the amount of supervision the child received
Descriptive statistics and nonparametric tests during tooth brushing, and the frequency of dental checkups.
(Kruskal-Wallis and Mann-Whitney U) were used to analyse the In this respect the Kruskal-Wallis statistical test, using
data. Study variables were mother’s educational level, tooth the mother’s education level as grouping variable (used
brushing frequency, brushing starting age, brushing supervising, throughout), indicated no statistically significant relationship
and the reason the mother takes her children to the dentist, all between the mothers’ level of education and the frequency of
categorical variables. tooth brushing (χ2 (4, N=64)= .83, p= 0.767 > 0.05).
Alternatively, the same statistical test applied to the child’s age
RESULTS when starting tooth brushing shows a significant relationship
We will first present descriptive statistics of our with the mother’s level of education (χ2 (4, N=64)= . 5, p =
findings about habitual oral hygiene behaviour of children from 0.025 < 0.05).
families from disadvantaged backgrounds. In the second part we The participants’ level of education was found to have
will present the observed relationship between mother a significant relationship with the supervision of the children’s
educational levels and answers to other survey questions. tooth brushing as well, as indicated by the results provided by
Of the 64 participants in this study a majority of the Kruskal-Wallis test (χ2 (4, N=64)= 8.03 p = 0.00 < .05). A
60.9% stated that their children brush their teeth only once a day statistically significant relationship was also found between the
while only a minority of 3.1% stated that their children brush frequency of dental checkups and the participants’ education
their teeth less than once a day. The ―twice a day‖ and ―several level (Kruskal-Wallis χ2 (4, N=64) = 5.38, p = 0.004 < .05).
times a day‖, the desired answers, were provided by 8.8% and The Mann-Whitney U statistical test was used to provide
17.2% of the participants, respectively. between-groups analysis in situations where Kruskal-Wallis test
The data collected about the age at which children revealed significant differences. While some statistically
start brushing their teeth reveals that the majority of children significant differences were found, we consider them inadequate
included in this study start brushing at age 4 or older, indicating to clearly single out an educational level group (table no. 2).
a delay from the expected ideal age of first tooth eruption (figure

AMT, vol. 22, no. 1, 2017, p. 27

 PUBLIC HEALTH AND MANAGEMENT
Table no. 2. Significant Mann-Whitney U test results
Question
At what age did your child start brushing his or her teeth?
Do you supervise your child during tooth brushing?
For what reason do you go to the dentist with your child?
DISCUSSIONS
Over the years, studies in this field reveal a rather low
level of knowledge of oral health prevention among the parents
from Romania.(23,24,25) The recommended tooth brushing
frequency is twice a day.(26) Only 36 percent of the participants
in our study (17.2% several times per day and 18.8% twice a
day), coming from disadvantaged backgrounds, indicated that
their child or children brush their teeth twice or more every day.
In comparison, a study performed in Romania in 2009 on
children and parents without accounting for social background
revealed percentages of 23.9% and 35.9% respectively for the
same brushing frequencies.(15) Another study, which measured
the two brushing frequency groups together (brushing twice a
day or more often) indicated a percentage of 69% of positive
answers.(27) While a significant relationship was not found
between the level of education of the participants included in
this study and the frequency with which their children brush
their teeth, when compared to other studies, the percentage of
the population of participants coming from disadvantaged
backgrounds who follow the recommended tooth brushing
frequency seems to be significantly lower.
Another possible explanation of this finding is
population homogeneity, as the participants where purposefully
selected based on low income and education levels. As House
and Goesling (28) suggest, parents’ education level can help
improve children health in three ways: work and occupation,
lifestyle, and social relationships.
Along with the obligations from school, parents are
expected to monitor their children’s general hygiene and in
particular their oral hygiene. Our study on children from
disadvantaged backgrounds indicates that only 43.8 % of the
mothers supervise them while brushing. In comparison, a similar
study found that 96.49% of the parents of preschool children
agreed that children should be guided and supervised by parents
while brushing their teeth. Thakare, Ajith Krishnan &
Chaware.(29) Kuriakose and Joseph (30) also found that the
incidence of dental cavities is significantly lower in children
who are assisted by their parents during tooth brushing.
The best age to start tooth brushing is with the
eruption of the first tooth.(31) Research shows that people from
disadvantaged backgrounds do not seem to be familiar with this
recommendation. For example, a study by Akpabio et al., (2008)
finds that in the USA only 32,4% of the mothers are aware it.
Our study indicates an even more dire situation, with only
14.1% of the participants having started tooth brushing with
their children when they were one year of age or younger.
Overall, studies in the USA show a direct significant
relationship between family income and the mothers’ knowledge
of the dental care and oral health-related behaviour.(21) The
same study also shows that higher levels of education (more
years of education) the respondents had was directly correlated
with the level of knowledge of the consequences of poor oral
health. That is, the higher the education level, the more they
knew about the consequences of poor oral health. Another study,
by Skeie et al. ( 6), suggests that Norway’s immigrant
population faces the same problems, indicating that the lack of
AMT, vol. 22, no. 1, 2017, p. 28
Test values
Educational level
U p (<0.05)
No education Professional education 19.50 0.005
Secondary school Professional education 84.50 0.009
Primary school Secondary school 40.50 0.012
Primary school Professional education 18 0.001
Primary school High school 36.00 0.020
Secondary school Professional education 98.00 0.032
higher education and having a non-western background were
associated with their inclusion in an ―attitudinal risk group‖,
prompting to the fact culturally tailored programs for dental
health education are necessary to promote more positive
attitudes towards oral health.
The children are recommended to have periodical
medical check-ups performed starting from age 1 or when their
first tooth erupts.(31) The American Academy of Pediatric
Dentistry (32) recommends the parents to take children to the
dentist twice every year, fact known to only a small extent
among people from disadvantaged families in the USA.(21)
When periodical medical check-ups are performed, the pain
symptoms will be avoided. A study performed in India revealed
that parents take their children to emergency treatments to an
extent of 58.07%.(29) Unfortunately 84.4% of the mothers from
our study indicate that they take their children to the dentist only
for emergency treatments.
Experts in various fields related to child welfare
consider the parents as partners, actively collaborating with
various types of specialists in schools, social services, legal
services etc.(2) By participating in educational programs,
parents gain new abilities and competencies, which help them
further in their relationship with their children. Studies show
that parents prefer practical and the group activities, with
mothers being more open to such programs.(2)
Prevention courses should be performed in mixed
groups of children and parents in order to determine together
where the problems are and to learn effectively how to solve
them. Dental health education proved to be effective in
increasing the knowledge level of children from disadvantaged
backgrounds.(18,33)
CONCLUSIONS
We came to the conclusion that mothers from
disadvantaged backgrounds do not pay sufficient attention to
their children’s learning about the principles of dental hygiene.
Their monitoring of the process of dental hygiene as well as the
age of starting tooth brushing among their children is
unsatisfactory. Our recommendation would be for them to
participate in special courses learn more about dental hygiene
and to increase awareness of the importance of dental hygiene in
their children.
Future work will attempt to include additional factors
related to the etiology of dental cavities in children, additional
hygiene factors, food, as well as specific cavity prevention
options only available in dental practices. It will also be
extended to cover a larger geographical area and additional
organizations supporting children coming from socioeconomic
disadvantaged environments.
Acknowledgment:
The authors would like to thank Maria Magher,
coordinator of the Counselling and Support Centre for Children
and Parents of Cisnădie - SOS Children’s Villages Association
of Romania for her support in the project and the company
Procter&Gamble Romania that supplied the materials of dental
hygiene.
 PUBLIC HEALTH AND MANAGEMENT
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6. Sab u M, Fr il A, Ionaş M. Profilaxia în medicina
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Winickoff JP, Perrin JM. Association Between Parents' and
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11. Jiang EM, Lo ECM, Chu CH, Wong MCM. Prevention of
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13. Dye BA, Vargas CM, Lee JJ, Magder L, & Tinanoff N,
Assessing the relationship between children’s oral health
status and that of their mothers. The Journal of the
American Dental Association. 2011;142(2):173-183.
14. Chandra Shekar BR, Reddy C, Manjunath BC, Suma S.
Dental health awareness, attitude, oral health-related habits,
and behaviors in relation to socio-economic factors among
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15. Nuca C, Amariei C, Badea V, Jipa I. Relationships between
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 PUBLIC HEALTH AND MANAGEMENT

PRELIMINARY STUDY CONCERNING LABOR CAPACITY

ENHANCEMENT THROUGH KINETOTHERAPY OF DENTAL
TECHNICIANS

CLAUDIA CAMELIA BURCEA1, VIOREL ȘTEFAN PERIEANU2, NICOLETA MĂRU3,

MĂDĂLINA VIOLETA PERIEANU4, MIHAI AUGUSTIN5, GABRIELA TĂNASE6,
MIHAI BOGDAN BUCUR7, VICTOR TRĂISTARU8, ANCA NICOLETA TEMELCEA9,
MIHAI BURLIBAȘA10
1,2,3,4,5,6,7,8,9,10
“Carol Davila” University of Medicine and Pharmacy Bucharest

Keywords: effort Abstract: Dental technician profession and working conditions are very difficult. Harsh working
capacity, kinetotherapy, conditions (working position, extended static physical effort etc.) and living environment (climate) orient
aerobic exercise, dental us toward explaining the occurrence of some physical deficiencies, occupational diseases caused by
technician pollutants from work, which can lead to cardiovascular, respiratory, digestive, mental and other
diseases. Considering the need to undertake such a study, we proposed the assessment of effort capacity
of this professional category (dental technician), as it enables testing of multiple functions of the body:
cardiovascular, respiratory, metabolic, muscular strength and endurance, articular amplitude, psycho-
volitional states. The engagement of body in various dynamic and sustained efforts through application
and compliance of strategies for practicing physical training, proved to be crucial for improving the
cardio-respiratory functional performance, respectively improve aerobic fitness of dental technicians.

INTRODUCTION
It is well known that the dental technician is the
provider of a professional activity carried out most of the time in
a seated position with static physical effort (labor), for long
periods.
This is a very complex situation and it is doubled by
the effective work in some very unfavorable ambient conditions.
Temperature and high humidity of air, the presence of various
physico-chemical factors (professional powders, biological
pathogenic factors passed on through various tray, occlusal rims,
dental wax templates between clinical compartment and dental
laboratory), and also exposure to vibrations make the dental
technician to be at risk of disease and body related decline.(1-5)
Thus, in the last two decades, the increase of
respiratory morbidity and cardiac disease among dental
technicians generated a continuous concern of specialists in the
field to reduce them. Specifically, latest advancements in
Kinesiology, managed to keep up with the dynamics of
morbidity, in the history of this medical specialties being
mentioned discoveries that have revolutionized in their time this
quite controversial field through efficiency, both prophylactic
and therapeutic.
In order to combat the body deterioration among
dental technicians due to sedentary lifestyle, work under certain
adverse conditions related to the environment, as well as
growing older, it requires the implementation of an active and
healthy lifestyle. In this regard, by its basic means - physical
exercise (aerobic exercise), Kinetotherapy accomplished an
important objective in improving respiratory and cardiac
functions, improve strength and duration of muscle contraction
and body immunity.(6,7) The purpose of this study is to
establish efficient and effective methodology for evaluation and
monitoring of dental technicians as well as complex physical
training individualized to each subject.
PURPOSE
The aim of this study, presenting a preliminary
character, is represented by finding methods to help improve
health and enhancing performance at work of dental technicians
by improving motor skills and effort capacity.
MATERIALS AND METHODS
Research hypotheses addressed in this study are
described as follows:
 Hypothesis 1: We believe that physical training is vital for
improving aerobic fitness of specialists in dental
technology, with important contributions in improving their
health.
 Hypothesis 2: We consider that practicing aerobic
workouts on a regular basis is a means with significant
neuro-psychic valence through important decrease of
mental tension, educating the will, increase motivation,
substantially contributing to improve the quality of life of
practitioners from dental laboratory.
Specific research methods of applied kinesiology and
the purpose of their use are:
 Conversation method (anamnesis interview) - to obtain
important information regarding the living and working
conditions, the number of hours assigned for professional
activity, physical activity level of the subject, the type of
physical activity practiced, the psycho-emotional state,
elements that have decreased effort capacity of subjects in
certain daily activities;
 Observation method - sensing characteristic aspects such as
attitude, anthropometric and somatoscopic characteristics,
constitutional type, participation in kinetic programs of
subjects;
 Experimental method - confirmation or rejection of the
assumptions related to the effects of chosen kinetic

Corresponding author: Gabriela T nase, Str. Plevnei, Nr. 9, Sector 5, Bucureşti, România, E-mail: mburlibasa@gmail.com, Phone: +40723 472632
6

Article received on 30.01.2017 and accepted for publication on 27.02.2017

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AMT, vol. 22, no. 1, 2017, p. 30
 PUBLIC HEALTH AND MANAGEMENT

programs and comparison between the two study groups Table no. 2. Table with descriptive statistical indicators -
through the effects on established parameters; Age of subjects
 Statistical and mathematical method - highlighting the Experimental Control
Indicator
functional gain obtained by dental technicians, the Group Group
effectiveness of programs proposed by us versus achieved Average 44,6 38,6
benefits, as well as comparative analysis of the two groups
Median 36,5 40,5
- control and experimental;
 Graphical method - comparative evolution representation Standard deviation 7,5 8,8
of both experimental and control groups. Minimum 26 24
Presenting the study group Maximum 49 49
The study group submitted to research consisted of 40
dental technicians, divided into two groups, experimental and
control group, each group consisted of 20 subjects each. The Regarding living environment, most subjects, in both
selection of subjects was based on the agreement for inclusion in groups, have originated in urban areas (table no. 3).
one of the research groups (experimental or control).
The differentiation between the experimental group Table no. 3. Table of Frequency - The living area of the
and the control group was made through the different kinetic subjects
program applied: the control group was implemented a Classic Experimental Group Control Group
program at gyms, with a frequency of 2 times a week, and a new
Relative Relative
built kinetic program was applied to the experimental group, Absolute
frequency
Absolute
frequency
with a frequency of 3 times a week. The differences of aerobic frequency frequency
(%) (%)
workout applied to experimental group consisted of both the
Urban 17 85% 15 75%
grading of effort and the types and modalities of application of
exercises, after establishing certain functional parameters of the Rural 3 15% 5 25%
subjects. Total 20 100% 20 100%
The main kinetic operational objectives are presented
as follows: muscle toning, blood circulation stimulation, Evolution of chest perimeter measurement
increase of respiratory capacity, increased of effort capacity, Relaxed thoracic perimeter in both groups is presented
increased participatory role and active involvement, improved as follows:
quality of life, and improve overall health.  for to experimental group, the mean of the relaxed chest
In creating exercise programs with the main specific objective of perimeter was in the initial testing, 92.3 cm, with a
developing aerobic capacity of the dental technician body , was minimum of 84 cm and a maximum of 100 cm and a
taken into account their professional activity and thus we standard deviation of 5.2, and in the final testing was 93.2
considered useful the combination of exercises for postural cm, with a minimum of 85 cm and a maximum of 101 cm
muscles toning with a role in keeping the spine straight and to and a standard deviation of 5.2;
stabilize the body. Regarding aerobic training modalities, most  for the control group, the mean of the relaxed thoracic
commonly used were the exercises of walking, running, perimeter was in the initial testing, 89.3 cm, with a
exercises stepper, bicycle and treadmill. minimum of 82 cm and a maximum of 96 cm and a
standard deviation of 4.2, and in the final testing was 89.9
RESULTS cm with a minimum of 83 cm and a maximum of 96 cm
Description of study groups and a standard deviation of 4.3.
Both control and experimental group were each Comparative analysis of the difference between the
consisting of 20 subjects, dental technicians. means of the two groups revealed that the evolution of
Analysis of demographic characteristics experimental group was better, the difference between the
Regarding gender feature, the experimental group experimental group average being 0.9 and 0.6 for the control
consisted of 11 female subjects and 9 male subjects and the group (figure no. 1).
control group consisted of 13 female subjects and 7 male (table
no. 1).
Figure no. 1. Relaxed chest perimeter
Table no. 1. Table of Frequency - Gender of subjects
Experimental Group Control Group 1 0,9
Absolute Relative Absolute Relative
0,8
frequency frequency frequency frequency 0,6
(%) (%) 0,6

Male 9 45% 7 35% 0,4

0,2
Female 11 55% 13 65%
0
Total 20 100% 20 100%
experimental group control group
Regarding the age of subjects, for to experimental
group the age was between 26 and 49 years, with an average of Further, to understand the sequence conducted in this
36.5 years and a standard deviation of 7.5, and in the control preliminary study, the term of ―chest elasticity‖ must be
group between 24 and 49 years with a mean of 38.6 years and a described. This represents the difference between the chest
standard deviation of 8.8 (table no. 2). perimeter in maximum inspiration and in maximum exhalation.
AMT, vol. 22, no. 1, 2017, p. 31
 PUBLIC HEALTH AND MANAGEMENT
Chest perimeter in maximum inspiration and
maximum exhalation
 Experimental group:
 The average for the chest perimeter in the maximum
inspiration was in the initial testing, 94.9 cm, with a
minimum of 85 cm and a maximum of 103 cm, and in
final testing was 95.9 cm, with a minimum of 86 cm and
a maximum of 104 cm;
 The average for the chest perimeter in maximum
exhaling was in the initial testing 90.3 cm, with a
minimum of 82 cm and a maximum of 98 cm, and in the
final testing, was 90 cm, with a minimum of 81 cm and a
maximum of 98 cm.
 Control group:
 The average for the chest perimeter in maximum
inspiration was in the initial testing, 92.4 cm, with a
minimum of 84 cm and a maximum of 98 cm, and in the
final testing was 93 cm, with a minimum of 84 cm and a
maximum of 98 cm;
 The average for the chest perimeter in maximum
exhalation in the initial testing was 87.8 cm, with a
minimum of 80 cm and a maximum of 94 cm and in the
final testing, remained unchanged at 87.7 cm, with a
minimum of 80 cm and a maximum of 94 cm.
Comparing the difference between the means of the
two groups revealed that a better evolution was recorded in the
experimental group, respectively:
 For chest perimeter in maximum inspiration the difference
between the means for the experimental group was 1, and
for the control group was 0.6 (figure no. 2);
 For chest perimeter in maximum exhalation, the difference
between the means for the experimental group was 0.3,
while for the control group was 0.1 (figure no. 3).
Figure no. 2. Chest perimeter in maximum inspiration
1.0 1.0
0.8
0.6 0.6
0.4
0.2
0.0
experimental group control group
Figure no. 3. Chest perimeter in maximum exhalation
0.35
0.3
0.3
0.25
0.2
0.15
0.1
0.1
0.05
0 0
experimental group control group
AMT, vol. 22, no. 1, 2017, p. 32
Making the difference between the chest perimeter in
maximum inspiration and maximum exhalation, we obtained the
following:
 for the experimental group, in the initial testing, the
average of chest elasticity was 4.6 cm with a minimum of 3
cm and a maximum of 5 cm, and in the final testing the
average was 5.8 cm with a minimum of 4 cm a maximum
of 7 cm;
 for the control group, in the initial testing the average for
the chest elasticity was 4.6 cm, with a minimum of 3 cm
and a maximum of 6 cm, and in the final testing the
average was 5.3 cm, with a minimum of 4 cm a maximum
of 7 cm.
The comparative analysis of the difference between
the means of the two groups resulted in a better evolution of the
experimental group. This difference was 1.2 in the experimental
group and 0.7 in the control group (figure no. 4).
Figure no. 4. Chest elasticity
1.4
1.2
1.2
1
0.8 0.7
0.6
0.4
0.2
0
experimental group control group
The efficiency of cardiovascular system index
(Ruffier test index) was described as follows:
 For the experimental group, in the initial testing the
average for cardiac resistance index was 8.7, with a
minimum of 5.5 to a maximum of 13.2, and in the final
testing the average was 6.3, with a minimum of 3.6 to a
maximum of 10.6;
 For the control group, in the initial testing the average for
cardiac resistance index was 8.7, with a minimum of 5.5 to
a maximum for 13.2, and in the final testing average was
7.6, with a minimum of 5 and a maximum 11.6.
Comparative analysis of the averages of the two
groups shows that, for cardiac resistance index, the
experimental group had a better evolution. The difference
between the means for the experimental group was 2.4, and for
the control group 1.1 (figure no. 5).
Figure no. 5. Cardiac resistance index
3
2.4
2.5
2
1.5 1.1
1
0.5
experimental group control group
 PUBLIC HEALTH AND MANAGEMENT

DISCUSSIONS Popovici I.A., Com nescu C. (coordonatori), Probleme în

Based on the results, we bring the following aspects: medicin i biologie, Vol.3, Editura Ars Docendi,
1. The engagement of body in various dynamic and lasting Bucureşti. 2014;3:95-141.
efforts through implementation and compliance of 7. Marcu V, Dan M. (coordonatori). Kinetoterapie /
strategies for practicing the physical training, has been Physiotherapy, Editura Universit ții din Oradea; 2006. p.
crucial in improving the cardiac-respiratory functional 249-252.
performance, as evidenced by qualitative and quantitative
leap, statistically significant, recorded from one stage to
another of cardiac resistance index (increase the quality of
aerobic fitness) in the experimental group of dental
technicians, which are verifying the assumption No. 1.
2. Practicing physical training regularly has a favorable
influence on health of the cardiovascular system with
substantial contributions in improving the quality of life of
dental technicians, which are verifying the hypothesis No.
2.
3. In this study, even if it has a preliminary character, no
significant differences in improving effort capacity were
found by gender of subjects.
4. To obtain favorable effects in implementing programs of
kinesiology among dental technicians practitioners it
should be take into account their professional activity,
which involve decreased of physical activity, vicious
positions, as well as clinical and functional status of each
subject.
5. The education and regular physical activity contribute to
the primary prevention of many chronic conditions such as
cardiovascular diseases, hypertension, obesity, depression
and osteoporosis, being associated with a lower risk of
premature death.

CONCLUSIONS
Finally, it should be appreciated that the profession of
dental technician, even if at first glance offers many advantages,
particularly financial, in terms of health; it is extremely
deficient, cardiac-respiratory affections among this professional
category, being extremely frequent.
Thus, to combat body deterioration among dental
technicians due to sedentary lifestyle, stress, work under certain
adverse conditions related to the environment, as well as
growing older, it requires the implementation of an active and
healthy lifestyle. Specifically, we believe that physical training
of any kind is vital for improving aerobic fitness of specialists in
dental technology, with major contributions in improving their
health status.

REFERENCES
1. Jacobsen N, Derand T, Hensten-Pettersen A. Profile of
work-related health complaints among Swedish dental
laboratory technicians. Community Dent Oral Epidemiol.
1996 Apr. 24(2):138-144.
2. Torbica N, Krstev S. World at work: Dental laboratory
technicians. Occup Environ Med Feb. 2006;63(2):145-148.
3. David GC. Ergonomic methods for assessing exposure to
risk factors for work-related musculoskeletal disorders.
Occup Med (Lond) May. 2005;55(3):190-199.
4. Tiric-Campara M, Krupuc F, Biscevic M, et al.
Occupational overuse syndrome (technological diseases):
Carpal tunnel syndrome, a mouse shoulder, cervical pain
Syndrome. Acta Inform Med Oct. 2014;22(5):333-340.
5. Rom WN. Environmental and occupational medicine.
Lippincott-Raven Publishers, Philadelphia, New York;
1998. p. 79-95,11-17.
6. Burcea CC, Georgescu L, Popovici IA, et al. Chestionar
test de identificare a nivelului de fitness a speciali tilor din
domeniul tehnicii dentare. În: Bodnar D.C., Burcea C.C.,
AMT, vol. 22, no. 1, 2017, p. 33
 CLINICAL ASPECTS

EVOLUTION OF SURGICAL TECHNIQUES FOR CORRECTION

OF LEFT VENTRICULAR ANEURYSM AFTER ACUTE
MYOCARDIAL INFARCTION

RADU BĂLĂU1, HORAŢIU SUCIU2, KLARA BRÎNZANIUC3, RADU DEAC4, MIHAELA OPRIŞ5,
MARIUS HARPA6
1,2,3,4,5,6
University of Medicine and Pharmacy Tîrgu-Mureş, Institute for Cardiovascular Diseases and Transplantation Tîrgu-Mureş

Keywords: ventricular Abstract: Evolution in the surgical treatment of left ventricular aneurysm post myocardial infarction
aneurysm, linear resulted in considerable decrease of intra and postoperative mortality in these patients, but the optimal
reconstruction, technique for correction remains questionable, each technique presenting advantages and
ventriculoplasty disadvantages. The purpose of this study was to carry out a review of publications on left ventricular
reconstruction techniques for left ventricular aneurysm after acute myocardial infarction, from the first
attempts to currently used techniques.

One of the most common sequelae of transmural
myocardial infarction is the development of an aneurysm of the
left ventricular wall. The most common location of the left
ventricular aneurysm is the anterolateral wall of the left ventricle
and the anterior portion of the septum, which is territory of the
left anterior descending coronary artery. Less frequent is the
posterior location of the left ventricular aneurysm caused by a
dominant right coronary artery infarction associated with lesions
of the circumflex artery.
Evolution in the surgical treatment of left ventricular
aneurysm post myocardial infarction resulted in considerable
decrease of intra and postoperative mortality in these patients,
but the optimal technique for correction remains questionable,
each technique presenting advantages and disadvantages.
The purpose of this study was to carry out a review of
publications on left ventricular reconstruction techniques for left
ventricular aneurysm after acute myocardial infarction, from the
first attempts to currently used techniques.
First steps
The first step in the surgical treatment of left
ventricular aneurysm was made by Beck, who in 1944 used
"fascia lata" aponeurosis to strengthen the aneurysmal wall of
the left ventricle, in an attempt to prevent excessive expansion
and avoid aneurysm rupture.(1) This technique was palliative
and was fairly quickly abandoned. In 1955, Likoff and Bailey
suggested a more radical technique, doing a closed
ventriculoplasty by applying a large lateral vascular clamp on
the beating heart, right on the base of the left ventricular
aneurysm, followed by aneurysm resection and suture of the
edges of the remaining ventricular wall.(2) This type of
procedure is the precursor of linear correction of left ventricular
aneurysm.
The two techniques mentioned above represent
pioneering attempts in this field. The techniques used later in
surgical correction of left ventricular aneurysm can be classified
into two categories: direct suture techniques and patch
ventriculoplasty techniques.
Direct suture techniques
Development of extracorporeal circulation and
cardiopulmonary bypass allowed first left ventricular aneurysm
resection, followed by linear suture, first performed by Cooley
in 1958. The surgery is performed through median sternotomy.
Cardioplegic cardiac arrest is used especially if associated
procedures are required, such as myocardial revascularization
surgery or mitral valve procedure. In situations where left
ventricular aneurysm resection is not accompanied by other
procedures, cardioplegic arrest is not necessary and surgery can
be performed on the beating or induced fibrillating heart, if the
aortic valve is competent. This technique involves a linear
incision in the aneurysmal territory at the front or rear wall of
the left ventricle, parallel to the interventricular septum. The
ventricular aneurysm is excised leaving in place a margin of
about 1 cm of scar tissue to allow suture of the ventricular wall.
Closing of the defect thus created is done in two layers.(3)
In aneurysms of the anterior wall, interventricular
septum is almost always involved in the scar, causing a
paradoxical movement of the septum, and thus affecting the left
ventricle contractility. Resection and direct suture technique
does not solve the problem, therefore, left ventricular
functionality remains impaired by the paradoxical movement of
the interventricular septum, so different techniques of
septoplasty have been tried.
Two of the septoplasty techniques experimented by
Cooley have become very popular: septal folding with separated
stitches and reinforcing aneurysmal septum with a patch of
Dacron (technique indicated especially in cases with extremely
thinned ventricular septum, to prevent septal rupture).(4,5) In
both cases, the dyskinetic septum is transformed into an akinetic
one, with good immediate results, but this affects late results,
akinetic septal area contributing to the worsening of congestive
heart failure phenomena.
As a result of that finding, in 1973, Stoney proposed
an amendment to the technique of resection and linear suture of
anteroseptal aneurysms, which contains inclusion of septal scar
into the correction procedure. After resection of aneurysmal
wall, it is essential to examine the interventricular septum to
identify the limit between the scar and the viable myocardium.
The lateral edge of the excision area is sutured to the
interventricular septal aneurysm in the transition area between
the scar and the viable septum. The suture is armed with teflon

2
Corresponding author: Hora iu Suciu, Str. Gheorghe Marinescu, Nr. 50, T rgu-Mureş, România, E-mail: suciu.horatiu@umftgm.ro, Phone: +40744
701530
Article received on 03.12.2016 and accepted for publication on 03.01.2017
ACTA MEDICA TRANSILVANICA March 2017;22(1):34-36
AMT, vol. 22, no. 1, 2017, p. 34
 CLINICAL ASPECTS
strip into the ventricular free wall and wires are passed through
the septum to the anterior wall of the right ventricle. The
correction is completed with a second suture that connects the
scar tissue located along the left anterior descending artery with
viable myocardium of the side wall of the left ventricle.(6) This
technique makes bypass to the left anterior descending artery
impossible, because it is included in the suture line.
Another option for linear correction was introduced by
Cabrol in 1974. This technique consists of cappitonage and
exclusion of fibrous unresectable area, creating a new left
ventricular cavity bordered only by contractile walls.
Cappitonage is made with three layers of continuous suture.
First, the deepest connects the free wall of the left ventricle to
the interventricular septum in the border zone between the scar
and the viable myocardium, the second layer connects the
portion of ventricular free wall with the fibrous septum, and the
third is shallow, epicardial.(7)
In 1984, Guilmet proposed the technique of septal
exclusion, indicated in large aneurysms with septal involvement.
This technique involves partial resection of the aneurysmal sac
and exclusion of septal scar from the new ventricular cavity.
Two layers of suture are applied, first connecting the left edge of
the aneurysmectomy with the border zone of the septal scar,
thereby excluding 2/3 of the septal dyskinesia. The second layer
suture unites the right edge of the aneurysmectomy with the
anterior left ventricular wall, providing hemostasis.(8)
Figure no. 1. Linear left ventricular aneurysm repair
Patch ventriculoplasty techniques
In 1979, Levinsky described a technique of
reconstruction of the left ventricle using a Dacron patch after
resection of post myocardial infarction aneurysm. As a result of
complications due to the fact that linear sutures were cutting into
necrotic tissue, a wider resection up to the viable myocardium
was needed. Since a 12/6 cm defect is impossible to close by
direct suture, Levinski used a Dacron patch for its closure.(9)
This technique is precursor of the current ventriculoplasty patch
techniques.
In 1985, Jatene and Dor independently reported a new
method, called anatomical reconstruction of the left ventricle
with circular endoventricular reduction and closure by patch
suture of the ventricular wall defect. The purpose of these
methods was to recreate normal left ventricular geometry so that
AMT, vol. 22, no. 1, 2017, p. 35
normal myocardial fibers have initial orientation.
In his technique, after ventriculotomy, aneurysm
resection and thrombectomy of the left ventricular cavity, Jatene
performed one or two purse string sutures at the junction
between normal and fibrous myocardium. These sutures are
tight, carefully reconstructing the left ventricular cavity and
reducing its size. Afterwards, ventriculotomy closure is
performed with or without patch. If ventricular cavity volume is
close to the desired one, ventriculotomy is closed with isolated
stitches reinforced with Teflon patches. In such cases,
longitudinal suture length is significantly shorter than for
conventional linear suture. When the defect resulted from
anevrismectomy is large, double Dacron patch is used to close
ventriculotomia. Endoventricular circular patch suture reduces
patch surface and thus the akinetic area in the newly formed left
ventricular cavity.(10)
In Dor’s technique of circular endocavitary plasty, the
procedure is performed under cardioplegic arrest.
Ventriculotomy is performed in the dyskinetic area, the
thrombus is removed, and if there are documented episodes of
ventricular tachycardia, endocardic subtotal resection is
performed. Cooley performs a circular endoventricular suture at
1 cm from the edge of viable myocardium to allow recreation of
a normal shape of the left ventricle. A balloon is inserted into
the left ventricular cavity and inflated to a theoretically diastolic
volume of 50-70 ml/m², then circular suture is tightened and
knotted. Subsequently, ventriculotomy is closed with a patch of
appropriate size. Excluded scar tissue is sutured above,
contributing to local hemostasis.(11,12,13,14)
Figure no. 2. Patch ventriculoplasty
In 1989, Cooley promoted the ventricular
endoanevrismoraphy technique as a modified version of patch
reconstruction. The surgery is performed under conditions of
continuous hypothermic cardioplegia. The apical aneurysm is
opened through an incision parallel to the interventricular
sulcus, avoiding left anterior descending artery. After left
ventricular thrombectomy and identification of the border zone,
defect size measurement is performed. An elliptical Dacron
patch of appropriate size is used to close the defect, with the
purpose of recreating normal ventricular shape, the scar tissue
remaining outside. Ventriculotomy is closed above the patch,
providing an additional hemostasis.(15,16)
 CLINICAL ASPECTS

The major advantage of ventricular patch plasty is 13. Dor V. Left ventricular aneurysms: the endoventricular
recreation of the left ventricular geometry, eliminating circular patch plasty. Semin Thorac Cardiovasc Surg.
paradoxical movement and reducing akinetic surface. 1997;9:123-130.
Complementary surgical procedures may be required 14. Dor V. The endoventricular circular patch plasty (Dor
on a case by case basis, associated myocardial revascularization procedure) in ischemic akinetic dilated ventricles. Heart
being considered an almost indispensable procedure. Mitral Failure Rev. 2001;6:187-193.
valve repair procedures, closing a post infarct ventricular septal 15. Cooley DA. Ventricular endoaneurysmorrhaphy: a
defect, and surgery of ventricular arrhythmias may be necessary simplified repair for extensive postinfarction aneurysm. J
in some cases.(17-23) Cardiac Surg. 1989;4:200-205.
Conclusions 16. Cooley DA, Frazier OH, Duncan JM, Reul GJ, Krajce
In conclusion, evolution of surgical techniques for Z. Intracavitary repair of ventricular aneurysm and regional
correction of left ventricular aneurysm post myocardial dyskinesia. Ann Surg. 1992;215:417-424.
infarction resulted in a significant decrease in mortality in 17. Vicol C, Rupp G, Fischer S, Summer C, Dietrich Bolte H,
patients with this type of pathology, but left open the discussion Struck E. Linear repair versus ventricular reconstruction for
on the optimal technique used for each patient. Since all treatment of left ventricular aneurysm: a 10-year
techniques have their advantages and disadvantages and due to experience. J Cardiovasc Surg (Torino). 1998;39:461-467.
anatomical and pathophysiological aspects of each case, most 18. Antunes PE, Silva R, de Oliveira JF, Antunes MJ. Left
often the choice of a particular technique is up to the surgeon. ventricular aneurysms:early and long-term results of two
types of repair. Eur J CardiothoracSurg. 2005;27:210-5.
REFERENCES 19. Lange R, Guenther T, Augustin N, Noebauer C,Wottke M,
1. Beck CS. Operation for aneurysm of the heart. Ann Surg. Busch R, Mayr N,Meisner H, Holper K. Absent long-term
1944;120:34. benefit of patch versus linear reconstruction in left
2. Likoff W, Bailey CP. Ventriculoplasty: excision of ventricular aneurysm surgery. Ann Thorac Surg.
myocardial aneurysm; report of a successful case. JAMA. 2005;80:537-42.
1955;158:915-920. 20. Minami K, Amin-Parsa MH, Reiss N, Schulte-Eistrup S,
3. Cooley DA, Collins HA, Morris GC Jr, Chapman DW. Coskun O, Koerfer R. Left ventricular aneurysmectomy, a
Ventricular aneurysm after myocardial infarction: surgical 10-year experience in 269 patients. J Cardiovasc Surg.
excision with use of temporary cardiopulmonary bypass. 2003;44(5 Suppl. 1):64 [abstract].
JAMA. 1958;167:557-560. 21. Tavakoli R, Bettex D, Weber A, Brunner H, Genoni M,
4. Cooley DA, Walker W E Technique of ventricular Pretre R, Jenni R, Turina M. Repair of postinfarction
septoplasty In: Moran JM, Michaelis LL, editors. Surgery dyskinetic LV aneurysm with either linear or patch
for the complications of myocardial infarction. Grune & technique. Eur J Cardiothorac Surg. 2002;22:129-34.
Stratton, Inc; 1980. p. 279. 22. Lundblad R, Abdelnoor M, Svennevig JL. Surgery for left
5. Reddy SB, Cooley DA, Duncan JM, Norman JC. Left ventricular aneurysm: early and late survival after simple
ventricular aneurysm: twenty-year surgical experience with linear repair and endoventricular patch plasty. J Thorac
1572 patients at the Texas Heart Institute. Cardiovascular Cardiovasc Surg. 2004;128:449-56.
diseases. Bull Texas Heart Inst. 1981;8:165-186. 23. Shapira OM, Davidoff R, Hilkert RJ, Aldea GS, Fitzgerald
6. Stoney WS, Alford WC, Burrus GR, Thomas CS. Repair of CA, Shemin RJ. Repair of left ventricular aneurysm: long-
anteroseptal ventricular aneurysm. Ann Thorac Surg. term results of linear repair versus endoaneurysmorrhaphy.
1973;15:394-404. Ann Thorac Surg. 1997;63:701-5.
7. Cabrol A, Guiraudon G, Laughlin L, Mattei S, Luciani J,
Leon L, Renou J. Resection of left ventricular aneurysms
and fibrous plaques. J Cardiovasc Surg. 1974;15:72-73.
8. Guilmet D, Popoff G, Dubois C, Tawil N, Bachet J, Goudot
B, Guermonprez JL, Brodaty D, Schlumberger S. Nouvelle
technique chirurgicale pour la cure des anévrysmes du
ventricule gauche: l’anévrysmoplastie en paletot. Résultats
préliminaires. 11 observations. Arch Mal Coeur Vaiss.
1984;77:953-958.
9. Levinsky L, Arani DT, Raza ST, Kohn R, Schimert G.
Dacron patch enlargement of anterior wall of left ventricle
after aneurysmectomy with concomitant infarctectomy. J
Thorac Cardiovasc Surg. 1979;77:753-756.
10. Jatene A. Left ventricular aneurysmectomy. Resection or
reconstruction. J Thorac Cardiovasc Surg. 1985;89:321-
331.
11. Dor V, Kreitmann P, Jourdan J, Acar C, Saab M, Coste P,
Viglione J. Interest of physiological closure
(circumferential plasty on contractile areas) of left ventricle
after resection and endocardectomy for aneurysm or
akinetic zone comparison with classical technique about a
series of 209 left ventricular resections. J Cardiovasc Surg.
1985;26:73. [abstract].
12. Dor V, Saab M, Coste P, Kornaszewska M, Montiglio F.
Left ventricular aneurysm: a new surgical approach. J
Thorac Cardiovasc Surg. 1989;37:11-19.
AMT, vol. 22, no. 1, 2017, p. 36
 CLINICAL ASPECTS

ABNORMAL HEART RATE RECOVERY AS A MARKER FOR

AUTONOMIC NERVOUS SYSTEM DYSFUNCTION

ELENA CRISTINA ENCIU1, SILVIU STANCIU2, LEVAI LAZLO3, DUMITRU MATEI4

1,2
Central Military University Hospital Bucharest, 3Head of Cardiology Department CH Colmar, France, 4Mother and Child Institute Bucharest,
“Carol Davila” University of Medicine and Pharmacy Bucharest

Keywords: heart rate Abstract: Introduction: Heart rate recovery (HRR) immediately after the exercise stress test is
recovery, autonomic considered a reflection of the vagal reactivation and a marker for autonomic imbalance. Materials and
nervous system, stress methods: We performed a retrospective analysis on 31 patients with abnormal HRR studying the
test influence of the most important cardiovascular risk factors: smoking, diabetes, obesity and hypertension
as determinants for autonomic imbalance. Results: There was no association between the major risk
factors with the ∆HR1, which only seems to be correlated with the maximal load of the stress test. For
sub-groups with lower cut-off values for HRR and aged above 75 we obtained several correlations with
smoking status, diastolic blood pressure and obesity. Conclusions: Even though our study group is
small, our findings still raise the question if we should be more strict when considering the HRR
abnormality with a possible cut-off value of 8/9 for each of the minutes of recovery.

INTRODUCTION atrial fibrillation, the presence of a pacemaker or with other

The important role of the nervous autonomic system
on cardiovascular activity regulation has been well known since
the beginning of the 20th century, and a shift towards a
sympathetic predominance is associated with an overall
increased cardiovascular risk (1-4) by elevated heart pressure,
tachycardia and arrhythmias.
Heart rate recovery (HRR) immediately after stopping
the exercise stress test is considered as a reflection of the
balance between sympathetic and parasympathetic tone; the
inability of the activation of the vagal tone represents a failure in
descending the heart rate in the first minute at least 12 beats per
minute from peak heart rate with an active recovery, and another
12 beats in the second minute.
Slow HRR has been associated with atherosclerosis
and ischemic heart disease.(5,6,7) Also, HRR is a prognostic
marker among heart failure patients (FEVG <40%) and
hyperactivity of the sympathetic nervous system may be a
pathogenesis factor.(8,9)
PURPOSE
The aim of this study was to evaluate HRR after
ergometer exercise testing as a marker of impaired autonomic
balance and the possible correlation between a slow HRR and
cardiovascular risk factors (smoking, diabetes, age and
hypertension).
MATERIALS AND METHODS
We have conducted a retrospective analysis of the
patients referred for exercise stress test in our department
between January 2015 – December 2015; from all the tests
performed we only selected 31 patients who fulfilled the
inclusion criteria: abnormal heart rate recovery defined as: heart
rate (HR) minute 1 (∆HR ) < peak heart rate -12; HR minute
2(∆HR2) < ∆HR - 2; HR minute 3 (∆HR3) < ∆HR2 minute-12.
We excluded the patients with left bundle branch,
extracardiac conditions incompatible with accomplishing at least
sub-maximal stress test (inferior member arteriopathy, sciatics,
arthrosis of the knee or hip). Beta-blockers and calcium channel
antagonists were discontinued at least 48 hours before the
exercise test in all patients. All patients signed consent forms
and answered a questionnaire about the presence of symptoms,
treatment, risk factors for coronary artery disease, and cardiac
history. Maximal predicted HR was calculated as 220 – age
(years).
The reasons for terminating the test were: achievement
of > 85% of age predicted maximum HR; systolic blood
pressure > 250 mm Hg; typical angina; severe arrhythmias and
more than 1 mm of horizontal or descending ST segment
depression. In the recovery phase the patients spent 3 minutes
performing a 0-30W workload effort (active recovery).
In our study we used as parameters some of the most
important risk factors: smoking, diabetes, obesity and
hypertension. Statistical analysis was performed using the
software RStudio Version 1.0.44 performing a multivariate
regression and a p value ≤ 0.05 was considered statistically
significant.
RESULTS
A group of 31 patients met the inclusion criteria (18
men and 13 women) aged between 51 and 83 (67.7 +/- 9.21
mean age). 13 patients had an abnormal HRR minute 1, 22 an
abnormal HRR minute 2, 20 minute 3; 12 of the individuals had
an abnormal HRR for minute 1 and 2 and 5 for minutes 1,2 and
3. A summary of the characteristics of the variables in the study
group is shown in table no. 1.
Surprisingly, there was no association found between
the presence of the major risk factors with the ∆HR (table no.
2), which only seems to be correlated with the maximal load of
the stress test (IMC p=0.6 r=-0.05; Diabetes p=0.4 r=-14;
Hypertension p=0.7 r=-18; Smoking p=0.8 r=0.32) R=0.41

1
Corresponding author: Elena Cristina Enciu, Str. Mircea Vulc nescu, Nr. 88, Bucureşti, România, E-mail: enciucristinacardio@yahoo.com, Phone:
+4073 3044129
Article received on 26.01.2017 and accepted for publication on 27.02.2017
ACTA MEDICA TRANSILVANICA March 2017;22(1):37-39
AMT, vol. 22, no. 1, 2017, p. 37
 CLINICAL ASPECTS

p=0.01. When defining subgroups with: Figure no. 2. Correlation between ∆HR1and resting HR
- HR <9 (∆HR ’) association found with the heart rate at
rest (p=0.004, R=0.7)
- HR <8 (∆HR ‖) a negative correlation of DHR3 with
age(p=0.01 R=-0.96) and with the number of ESV (p=0.05
R=-0.88); positive correlation between ∆HR2 and peak
diastolic arterial pressure (p=0.03 R=0.93)
When taking into consideration only patients aged
more than 75, ∆HR2 proves a negative correlation with the
smoking status (p=0.001 R=-0.84).
Old age (>80) has a stronger negative correlation
between ∆HR2 and smoking status (p=0.004 R= -0.93), with
IMC (p=0.09 R=-0.92) and with maximal load (p=0.03 R=-
0.82).

Table no. 1. Study group characteristics DISCUSSIONS

Age 67 years (51-83) Age is probably the most important determinant in
Sex 18 males/13 female our analysis, the older the patient the slower he will recover
IMC (kg/m2) 28 (19-50) from the 3rd minute, our findings corresponding with the
Diabetics 11 patients
findings of previous studies available in literature.(10)
Hypertension 24 patients
Smoking was already established to be correlated
Smoking 10 patients
LVEF (%) 60 (47-76) with an abnormal heart rate recovery in coronary artery
FMT (%) 87 (64-100) disease (6) and dyslipidemic patients.(11) Our smoking
∆HR :Frecvmin -Frecvmax 16(0-31) patients over 75-80 years old have slower heart rate recovery
∆HR2:Frecvmin2-Frecvmin1 10 (-20-30) from minute 2 and they are less capable to reach higher
∆HR3:Frecvmin3-Frecvmin2 4.5 (-4-11) maximal loads.
HR at rest 74 (52-106) The main limitation of our study is the small number
HR peak exercise 135 (102-165) of patients who were recruited in a single centre university
TAS max 180 (129-197) hospital. Another concern and maybe a source of error is that
TAD max 101 (70-124) there is no consensus worldwide for standardised cut-off
Positive stress test 11 values for abnormal heart rate recovery for each minute after
stopping the test and neither for the duration to measure, some
Table no. 2. Predictors of abnormal HRR in multivariate authors consider up to 5 minutes (12), others stop at 2. Others
regression analysis have proposed taking into consideration HRR at 30, 60 and 90
P value P value P value seconds as a predictor for responding to resynchronisation
∆HR1 ∆HR2 ∆HR3 therapy.(13) Also there are no recommendations for using an
Age 0.9651 0.0813 0.742 active recovery (with a low workload exercise) or passive one
(14) and which should be the cut-off values in each case.
IMC 0.6107 0.3489 0.481
These differences make it very difficult to compare the studies.
Diabetic 0.4254 0.8273 0.882
Hypertension 0.7642 0.5102 0.325 CONCLUSIONS
Smoking 0.8675 0.3992 0.721 Even though our study group is small, our findings
FMT 0.3583 0.1241 0.816 still raise the question if we should be more strict when
HRatrest 0.9499 0.7261 0.529 considering the HRR abnormality with a possible cut-off value
of 8/9 for each of the minutes of recovery.
HRpeak 0.2459 0.7838 0.190
TASmax 0.1921 0.0578 0.248 REFERENCES
TADma 0.1336 0.8070 0.806 1. Carroll D, Smith D, Shipley MJ, Steptoe A, Brunner EJ
Maxload * 0.0140 0.0603 0.324 and Marmot MG Blood pressure reactions to acute
psychological stress and future blood pressure status: a
Figure no. 1. Comparison of HRR at minutes 1, 2 and 3 10-year follow-up of men in the Whitehall II study.
Psychosom Med. 2001;63:737-743.
2. Thayer JF, Lane RD The role of vagal function in the risk
for cardiovascular disease and mortality. Biol Psychol.
2007;744:224-242.
3. Treiber FA, Kamarck T, Schneiderman N, Sheffield
D, Kapuku G, Taylor T. Cardiovascular reactivity and
development of preclinical and clinical disease states.
Psychosom Med. 2003;655:46-62.
4. O’Connor MF, Gundel H, Mcrae K, Lane RD Baseline
vagal tone predicts bold response during elicitation of
grief. Neuropsyhopharmacology. 2007;322:2184-2189.
5. Kizilbash MA, Carnethon MR, Chan C, Jacobs DR,
Sidney S, Liu K. The temporal relationship between heart
AMT, vol. 22, no. 1, 2017, p. 38
 CLINICAL ASPECTS

rate recovery immediately after exercise and the

metabolic syndrome: The CARDIA Study. Eur Heart J.
2006;27:1592–1596.
6. GhaffariS, Kazemi B, Aliakbarzadeh P Abnormal heart
rate recovery after exercise predicts coronary artery
disease severity Cardiology Journal. 2011;18:47-5.
7. Morshedi-Meibodi A, Larson MG, Levy D, O’Donnell
CJ, Vasan RS. Heart rate recovery after treadmill exercise
testing and risk of cardiovascular disease events (The
Framingham Heart Study). Am J Cardiol. 2002;90:848-
852.
8. Bilsel T, Terzi S, Akbulut T Sayar N, Hobikoglu
G, Yesilcimen K. Abnormal Heart Rate Recovery
Immediately After Cardiopulmonary Exercise Testing in
Heart Failure Patients Int Heart J. 2006;47:431-440.
9. Wolk R, Sommers VK, Gibbons T, O’Malley K, Johnson
BD Pathophysiological characteristics of heart rate
recovery in heart failure Med Sci Sports. 2006;38:1367-
1373.
10. Kligfield P, McCormick A, Chai A, Jacobson A,
Feuerstadt P, Hao SC. Effect of age and gender on heart
rate recovery after submaximal exercise during cardiac
rehabilitation in patients with angina pectoris, recent
acute myocardial infarction, or coronary bypass surgery.
Am J Cardiol. 2003;92:600-603.
11. Ueda H, Kuroda N, Ogura M, Miyamoto K, Hashiramoto
M, Kato J, et al. Importance of serum cholesterol level in
development of diabetic autonomic neuropathy. Diabetes
Res Clin Pract. 1993 Aug-Sep;21(2-3):123-6.
12. Antelmi I, Chuang YE, Grupi CJ, Latorre Mdo R, Mansur
AJ Heart Rate Recovery after Treadmill
Electrocardiographic Exercise Stress Test and 24-Hour
Heart Rate Variability in Healthy Individuals Arq Bras
Cardiol. 2008;90(6):380-385.
13. Okutucu S, Aytemir K, Evranos B, Aksoy H, Sabanov C,
KaraulaK UN et al. Cardiac resynchronisation therapy
improves exercise heart rate recovery in patients with
heart failure Europace. 2011;13:526-32.
14. Watanabe J, Thamilarasan M, Blackstone EH, Thomas
JD, Lauer MS. Heart Rate Recovery Immediately After
Treadmill Exercise and Left Ventricular Systolic
Dysfunction as Predictors of Mortality The Case of Stress
Echocardiography Circulation. 2001;104:1911-1916.

AMT, vol. 22, no. 1, 2017, p. 39

 CLINICAL ASPECTS

RARE CASE REPORT OF LATE IDENTIFICATION OF CORPUM

CALLOSUM DYSGENESIS IN A CHILD WITH BILATERAL
HEARING LOSS

SIMONA ȘERBAN1, ANDREEA RUSESCU2, ANA DRAGU3, MARIAN RĂDULESCU4

1,4
“Carol Davila” University of Medicine and Pharmacy, Bucharest
1,2,3,4
“Prof. Dr. D. Hociotă” Institute of Phonoaudiology and Functional ENT Surgery, Bucharest

Keywords: dysgenesis, Abstract: The corpus callosum is the most important relay connection between the two hemispheres. The
corpus callosum, malformation of the corpus callosum manifests as total agenesis or dysgenesis of various degrees and
bilateral hearing loss, these afflictions have highly variable clinical expression. Current imaging investigative possibilities
retrocochlear allow the early detection of any malformations even in the fetal period. The cases in which brain
malformation, either solitary or within a syndrome, associates with sensory or neural hearing loss are
very rare. The authors present the case of a child with severe bilateral hearing loss and dysgenesis of
the corpus callosum. The retrocochlear feature of hearing loss and the late identification of the
malformative pathology of the brain is what gives the case its particularities.

INTRODUCTION
The corpus callosum (CC) is the largest structure of
the white matter of the brain, gathering more than 190 million
axons. From an anatomic point of view, from the anterior to the
posterior, there are four parts in its structure: rostrum, genu,
body and splenium. Its dimensions vary between genders and
races, but there is evidence that women are more developed in
this aspect. The transverse fiber tracts of the CC structure
connect the two hemispheres and play a role in the integration of
the motor, sensory and cognitive functions. The literature
indicates the presence of distinct specializations of the two
cerebral hemispheres but also an interhemispheric
communication made possible by the key structure, represented
by the corpus callosum.(1) The existence of this neural bridge
allows the transmission of information to the hemisphere that
was not stimulated. Due to this structure, the inhibitory function
of a hemisphere over the other one develops and creates
asymmetry between the cerebral hemispheres (i.e. for right-
handed people, the left hemisphere is dominant, with an
inhibitory function on the right hemisphere). The presence of
this structure makes possible the lateralization of functions such
as speech, for which the left hemisphere is responsible in most
people. The structures involved in this process are the lower part
of the frontal lobe and the posterior left temporal lobe.
The corpus callosum is involved in gnosis and praxic
processes, but also in mechanisms of memory and
consciousness. Recent studies have revealed a differential
specialization of the two hemispheres in processing linguistic
features (2), the right hemisphere is involved in speech
processing and suprasegmental features of speech, while the left
hemisphere in segmental analysis of syntax and lexical
semantics.(3) Corpus callosum plays an important role in
complex processes such as understanding and speech
production, with a syntax and prosodic information exchange
between the two hemispheres. The malformation of this
structure is generally described in the literature as dysgenesis of
the corpus callosum, including both total agenesis of corpus
callosum (its absence) and partial agenesis with varying degrees
of atrophy and even the absence of parts of the corpus callosum
morphology. Regarding the incidence of the disease, in the
general population it is below 1% and for population with
cognitive disabilities it is around 2.3% (4), having a predilection
for males.(5,6,7)
Agenesis of the corpus callosum (ACC) causes can be
multiple: rubella infection, alcohol, cocaine, genetic factors such
as those involved in trisomy 8, 13 and / or 18, Andermann
syndrome, Aicardi syndrome.
ACC can be solitary or associated with other
malformations of the brain, and from a clinical point of view,
cognitive dysfunction may be present varying from mild to
pervasive disorders. Epileptic seizures occur in approximately
50% of cases. Some subjects may have normal intelligence (8),
but most do not.
Genetic counseling in such cases remains difficult
given that radiological and genetic markers can not distinguish
between symptomatic and asymptomatic subjects.
Prenatal diagnosis is routine ultrasound (week 20) and
magnetic resonance imaging (MRI) scan (week 30).
Treatment is symptomatic, including psychotherapy,
speech therapy and anticonvulsant treatment for epileptic
seizures.
Questions that have no answers refer to the fact that
although this isolated malformation of the brain, total or partial,
can be detected prenatally by ultrasound or MRI, it is impossible
to predict the degree of functional impairment. Future
multicenter studies will probably find the answer to which genes
are responsible for this abnormality of the brain.
CASE PRESENTATION
The authors present the case of a male child, aged 7
years, who has developed bilateral deafness since early
childhood, for which bilateral hearing aid were fitted by age 3.
The child was admitted to the audiology department for second
opinion due to the absence of any progress in speech
development and inconsistent use of hearing aids.
Clinically, it was noticed a child with a slight mental

1
Corresponding author: Simona Şerban, Str. Mihail Cioranu, Nr. 21, Sector 5, Bucureşti, România, E-mail: s_serban@hotmail.com Phone: +4021
4102170, extension 152
Article received on 12.01.2017 and accepted for publication on 27.02.2017
ACTA MEDICA TRANSILVANICA March 2017;22(1):40-42
AMT, vol. 22, no. 1, 2017, p. 40
 CLINICAL ASPECTS

retardation, hyperkinetic, with an extremely poor vocabulary did not reveal the presence of any tumor mass in the left internal
including words composed of repeating syllables or incomplete auditory canal or pontocerebelos angle, but showed severe
words. The child had reduced ability to understand speech and dysgenesis of the corpus callosum, internal hydrocephalus with
communication with other people was possible mostly gestual. the dilatation of the lateral, third and fourth ventricles. The
The audiology examination consisted in acoustic morphology of the cochleea and eight nerve was normal on both
immittance, behavioral audiometry through the observational sides (figure no. 2).
method and auditory brainstem evoked response under general
anesthesia. Figure no. 2. T2-weighted axial flair acquisition shows
Tympanometry showed flat tympanograms (type B), normal content of internal auditory canal and cochleea on
which were consistent with serous effusion in both middle ears. both sides
Clinical examination of the ear showed bilateral retracted
tympanic membrane with amputated light reflex. Due to the
hyperkinetism of the child and his refusal to accept supraaural
audiometric headphones, behavioral audiometry was possible in
a free field arrangement with the loudspeaker located at 0
degrees azimuth. The minimum level responses ranged between
55 and 70 dB HL from 500 to 4000 Hz.
Electrophysiological assessment through brainstem
auditory evoked response (BAER) was performed in the
operating room under general anesthesia. To remove the
conduction component of hearing loss, represented by serous
effusion in the middle ears, a tympanostomy fluid drainage was
carried out, followed by insertion of tympanostomy tube into the
eardrum bilaterally. On the sagital T1 weighted view it was noticed corpus
The BAER test was performed with Eclipse 25 callosum abnormality with severe atrophy of the rostrum, genu,
equipment (from Interacoustics), through air conduction, with body and absence of the splenium (Figure 3).
ER3A intraaural transducers, collecting the evoked response in a
two channel montage, the placing of the electrodes being FPz Figure no. 3. T1 weighted mid sagital view shows severe
(high forehead), M1 (right mastoid) and M2 (left mastoid). atrophy of the rostrum (a), genu (b), body (c) and the
The stimulation parameters were short clicks in absence of the splenium (d)
rarefaction polarity with a stimulation rate of 20.1 cicles/sec and
bandpass filtering of the recording system from 150 to 3000 Hz.
The results showed a moderate hearing loss with the objective
threshold of wave V at 60 dB HL for the right ear and 50 dB HL
for the left ear. The BAER recording analysis showed evidence
of neural (retrocochlear) damage, by prolongation of I-V
interval (4.77 msec compared to 4.4 msec maximum allowed)
on the left side (figure no. 1).

Figure no. 1. click ABR recordings with prolonged I-V

interval on the left ear (4.77 msec) and interaural I-V
difference of 0.4 msec; I-V interval within norms on the
right ear (4.37 msec); click tresholds at 50 dB HL on the left
ear and 60 dB HL on the right ear
Images from a T2-weighted FLAIR coronal sequence
showed enlarged lateral ventricles, third ventricle (Figure 4) and
fourth ventricle (figure no. 5).

Figure no. 4. T2-weighted Coronal Flair slice showing

hypertrophy of the lateral ventricles (a) and third ventricle
(b)

The interaural difference of I-V intervals was 0.4

msec. (0.3 msec maximum allowed). Given the suspicion of a
left retrocochlear injury, the patient was referred for a brain
magnetic resonance imaging (MRI) scan. The examination was
performed on a Siemens Magnetom Avento MRI machine, with
a magnetic field strength of 1.5 T and 0,8 mm slice thickness. It

AMT, vol. 22, no. 1, 2017, p. 41

 CLINICAL ASPECTS
Figure no. 5. T2-weighted Coronal Flair slice showing
hypertrophy of the fourth ventricle (c)
DISCUSSIONS
The authors reported an interesting case of severe
dysgenesis of the corpus callosum with behavioral disorders and
cognitive deficit associated with bilateral hearing involving
permanent damage of the cochlea in both sides but also neural
(retrocochlear) dysfunction in one ear.
This pattern of retrocochlear damage can be attributed
to the compresive effect of the cerebrospinal fluid within the
pontocerebellar cistern on the auditory nerve, but it can not be
ruled out an intrinsec characteristic of the hearing loss
associated to the malformation of the most important structure
of the white matter in the brain.
Unfortunately, the malformation was not evidenced in
utero, and the late diagnosis was detrimental to the possibility of
applying specific recovery therapies until the age of 6 when the
cerebral plasticity starts to decline significantly. Regarding the
benefit of hearing aids, it is extremely limited, on the one hand
due to the characteristic of neural deafness on the left ear, on the
other hand because of the absence of communication between
brain hemispheres that limits speech understanding but also its
production. Other consequences of central auditory processing
deficit are related to the difficulties that the child has on spatial
localization tasks and dichotic listening.
These issues must be explained to the family in a
manner that makes their expectations of hearing aids benefit and
child’s recovery be more realistic. Provision of conventional
hearing aids may increase the child awareness to the sounds but
the associated behavioral disorders disrupt a systematic wearing
of the devices.
Concerning the prevalence of hearing loss in
newborns with corpus callosum agenesis, there are no
conclusive data reported in the literature so far. Some authors
published isolated cases of association between agenesis of the
corpus callosum and Mondini dysplasia (9) or congenital
hearing loss in combination with partial agenesis of corpus
callosum with hydrocephalus and arachnoid cyst.(10) For the
central processing of auditory information that refers to specific
tasks like attention, detection and understanding of sounds it is
required integrity of structures of the brainstem to the cortex.
Audiological monitoring of central auditory pathways is
recommended in all cases of children with dysgenesis of corpus
callosum even if they have a normal function of inner ears
detected by otoacoustic emissions screening technique at birth.
AMT, vol. 22, no. 1, 2017, p. 42
CONCLUSIONS
Although this malformation may be solitary, related to
maternal consumption of alcohol and cocaine mostly, or
syndromic appearance in 25-32% of patients (11), there are very
few cases reported in literature with clinical manifestation of
bilateral sensorineural hearing loss. This is a very rare case
reporting the association of severe corpus callosum dysgenesis,
internal hydrocephalus and bilateral hearing loss involving
malfunction of both cochlea and brainstem audithory pathways.
The pattern of inheritance is probably autosomal recessive.
REFERENCES
1. Gazzaniga MS. Cerebral specialization and
interhemispheric communication: Does the corpus
callosum enable the human condition? Brain.
200;123:1293-1326.
2. Poeppel D, Idsardi WJ, van Wassenhove V. Speech
perception at the interface of neurobiology and linguistics.
Philosophical Transactions of the Royal Society of London
B Biological Sciences. 2008;363(1493):1071-86.
3. Hagoort P. On Broca, brain, and binding: a new
framework. Trends in Cognitive Sciences. 2005;9:416-23.
4. Jeret JS, Serur D, Wiesniewski KE, Lubin RA.
Clinicopathological findings associated withagenesisof the
corpus callosum. Brain and Development. 1987;9(3):255-
64.
5. Bedeschi MF, Bonaglia MC, Grasso R, Pellegri A,
Garghentino RR, Battaglia MA, et al.. Agenesis of the
corpus callosum: Clinical and genetic study in 63 young
patients. Pediatric Neurology. 2006;34:186-93.
6. Taylor M, David AS. Agenesis of the corpus callosum: A
United Kingdom series of 56 cases. J Neurol Neurosurg
Psychiatry. 1998;64:131-4.
7. Serur D. Agenesis of the corpus callosum: clinical,
neuroradiological and cytogenetic studies. Neuropediatrics.
1988;19:87-91.
8. Blum A, André M, Droulle P, Husson S, Leheup B.
Prenatal diagnosis of the corpus callosum agenesis. The
Nancy experience, 1982-1989. Genetic Counselling.
1990;38:115-26.
9. Smith LP, Karimi K, Angeli SI. Cochlear dysplasia with
agenesis of the corpus callosum.Inter. J. Pediatr.
Otorhinolaryngol. 2006;70:1985-8.
10. Hendriks YM1, Laan LA, Vielvoye GJ, van Haeringen A.
Bilateral sensorineural deafness, partial agenesis of the
corpus callosum, and arachnoid cysts in two sisters. Am J
Med Genet. 1999;10;86(2):183-6.
11. Schell-Apacik CC, Wagner K, Bihler M, Ertl-Wagner B,
Heinrich U, Klopocki E, et al. Agenesis and dysgenesis of
the corpus callosum: clinical, genetic and neuroimaging
findings in a series of 41 patients. Am J Med Genet A.
2008;146A(19):2501-11.
 CLINICAL ASPECTS

THE FEATURES OF DIAGNOSIS AND TREATMENT IN THE

CASE OF CHRONIC OBSTRUCTIVE PULMONARY DISEASE
COMPLICATED BY CLOSTRIDIUM DIFFICILE
MAGDALENA DIACONU1, ANDREI TICA2, CRISTIAN GEORGESCU3, ALICE DRĂGOESCU4,
FLORENTINA CRISTINA PLEŞA5, MONICA MARILENA ŢÂNŢU6
1,2,3,4
University of Medicine and Pharmacy Craiova, Craiova Emergency County Hospital,
5
Central Military Emergency University Hospital “Carol Davila”, Bucharest, 6Pitesti University

Keywords: COPD, Abstract: Clostridium Difficile infection (CDI) is located in the abdomen which can have a low healing rate
DCI, antibiotic and an adverse outcome. The patients complain about specific abdominal symptoms, with unpredictable
therapy, respiratory evolution and various complications, sometimes fatal. The occurrence of respiratory decompensation in the
failure lungs, in a bronhopat patient, as well as the occurrence of other infections such as CDI, in our case, when
antibiotic therapy is needed and cannot be interrupted, is a rare complication, which raises issues of
differential diagnosis and treatment. We present the case of a man known of having been suffering from
chronic obstructive pulmonary disease (COPD) for many years, an outpatient with intermittent
bronchodilator treatment with cardiac pathology, Madelung disease with surgery in history, complicated by
infectious diarrhea syndrome, dyspnea with severe orthopnea, bilateral pleurisy, renal dysfunction and
undiagnosed anemia. The chest computer tomograph examination revealed bilateral pleural effusion,
pulmonary radiography showed increased cord whereas the cultures taken from tracheobronchial secretions
and stool have identified methicillin-resistant Staphylococcus aureus (MRSA), Candida sp. and Clostridium
Difficile, as etiologic agents of abdominal and lung infection. The optimal antibiotic treatment, to maintain
respiratory function, represented the touchstone, taking into account the abdominal infectious complication.

INTRODUCTION CASE PRESENTATION

Clostridium Difficile infection is one of the most
common infections in hospitals lately, with fatal high-risk, being
caused by three important triggers:
a) hospitalization – the contact with other patients;
b) antibiotics, proton pump inhibitors, H2 antagonists;
c) the age over 65 years, comorbidities, obesity etc.(1,2,3)
Various studies have shown that infectious diarrhea,
caused by the most common germ, Clostridium Difficile (CD), in
a young patient, leads to increased morbidity and mortality. The
causes that worsen even more the state of health of an infected
patient in intensive care are: dehydration, malnutrition,
hemodynamic instability, hidro-electrolyte disturbances etc.
For preventing the spread of hospital-acquired
infections, responsible for mortality and morbidity of patients in
intensive care units, strict measures must be taken among which
are worth mentioning: gowns, gloves, face masks, used in aseptic
conditions, washing hands with water and soap, hand disinfection
which is primarily essential in reducing the transmission of this
infection. Of these infections, methicillin-resistant Staphylococcus
aureus (MRSA), Clostridium Difficile’s (CDs), multi-drug
resistant Gram negative bacterium (MDR) are often most
common. The most dramatic association is CDI and MRSA, in
which cases the rate of survival is very low.(4)
Besides the preventive measures of medical staff, we
must offer prevention and treatment of pneumonia associated with
mechanical ventilation (VAP) when the patient is intubated, the
sterilization of circuits fan, keep clean, change under strict aseptic
conditions, disinfection of renal probe, of central venous catheters
etc.(4) Chronic obstructive pulmonary disease (COPD) is the
fourth cause of mortality among other pathologies with fatal
impact affecting the heart, neoplasms and brain disorders, more
and more common in the population lately.(2)
Male, aged 53, with factors of cardiovascular risk
(smoker, arterial hypertension, congestive heart failure class
NYHA III) with intermittent treatment in outpatients, with COPD,
bronchodilator treatment and chronic consumer of alcohol, came
to the emergency room, on the 22nd of January 2017, with
dyspnea and orthopnoea, complaining of increasing volumes of
legs, bilaterally, diarrhea emission (5-6 a day), symptoms which
had started a week before and he is hospitalized in medical
sectors. His personal pathological history reveals symmetrical
benign lipomatosis, asymptomatic hyperuricemia, obesity grade
III, undiagnosed anemia.
Objective: malaise, afebrile, dehydrated pale skin,
important bilateral ankle edema, jugular, cervical level and
posterior chest large lipomatous masses which were mobile on
deep plans. On admission, abdominal ultrasound reveals the liver
having anterior-posterior diameter: left lobe (LL) = 6.7 cm, right
lobe (RL) = 15 cm, empty bladder, left kidney = 11.4 cm, regular
shape, parenchymal index = 2cm, without fluid in peritoneal
quantity.
Two days after admission, liver tests started to increase,
urea values reaching a level of 82 mg/dl, creatinine having a value
of 5,11mg/dl, leukocytes 11,600 / mm3, potassium = 5.7 mmol/l.
The patient received treatment on medical department with
intestinal anti-infectives, proton pump inhibitors, diuretics,
selective beta-blockers, angiotensin II receptor antagonists,
bronchodilator, antidiarrhea, corticosteroids.
Infectious diseases examination raised the suspicion of
infection with Clostridium Difficile and recommended stool,
hydro-electrolyte balance, general surgery check-up.
Renal examination (on 25th of January 2017) raised the
suspicion of renal dysfunction (possible renal injury stage 3), mild
hyperkalemia and recommended monitoring of urine output,

1
Corresponding author: Diaconu Magdalena, Str. Ion I. Argetoaia, Nr. 6, Bl. C2, Sc. 1, Ap. 11, Cod postal 200642, Phone: +407222 97755, E-mail:
diaconumagda@yahoo.com
Article received on 22.01.2017 and accepted for publication on 27.02.2017
ACTA MEDICA TRANSILVANICA March 2017;22(1):43-45
AMT, vol. 22, no. 1, 2017, p. 43
 CLINICAL ASPECTS
interruption of anti-diarrhea treatment, angiotensin II receptor
antagonists, proton pump inhibitors, administration of intestinal
anti-infectives, anti-acids, diuretics, selective beta-blockers, with
immediate repeated urea and creatinine, serum iconogram and
transfer in the intensive care unit.
On admission in the intensive care unit (ICU), on 27th
of January 2017, the patient presents severe general condition, he
is conscious, cooperative, with bilateral basal decreased vesicular
murmur, lung crackles disseminated in both bronchial areas,
afebrile, an intense diuresis urine, in the amount of about 100
milliliters, bilateral leg edema, multiple diarrhea episodes.
Immediate stool was proceeded in order to test the existence of
Clostridium Difficile, and the results came out positive. The Adler
test was also carried out, which came out negative, whereas the
digestion sample shows: rare fat droplets, very frequently
undigested starch, absorbed muscle fibers, so the occult bleeding
test does not indicate a bleeding. Tracheobronchial sample was
collected and, 5 days later, it pointed out pulmonary infection with
MRSA and Candida spp., the patient being a carrier of the germs.
The values of all tests were normal, except: urea = 178
mg/dl, creatinine = 8.99 mg/dl, leukocytes 11 330 /mm3,
neutrophils = 84,500/mm3, hemoglobin 6.97 g / l, sodium (Na) =
125 mmol/l potassium (K) = 5.60 mmol/l. These values were
measured immediately at admission to IC.
It was immediately proceeded the treatment for
Clostridium Difficile orally as prescribed by the infectious disease
physician, with antiprotozoals (500 mg every 8 hours).
On the 2nd of February 2017, a new abdominal
ultrasound was performed, which, compared to the previous
examination, revealed stasis hepatomegaly, normal kidneys, with
parenchymal index -2, dilated intestinal loops, with abundant
content, possibly ascites liquid between the intestines. Chest X-ray
was performed which revealed no pleuro-pulmonary lesions, only
increased heart.
Thorax and abdominal tomography was performed, on
the 2nd of February 2017, (natively performed tomography, due to
the increased values of cleareance), which highlighted: bilateral
basal pleural fluid with maximum thickness of 6.8 cm on the right
and 3.4 cm on the left. Without areas of compression or suspect
bilateral pulmonary nodules. The abdominal results are: the right
lobe of the liver = 19 cm and the left lobe = 7 cm without
computed tomography changes, without dilatation of lower biliar
ducts. The spleen is natively homogeneous, the bipolar spindle =
13cm. Pancreas heads without ductal dilatation or parenchymal
calcifications. The adrenal glands are normally complied. The
kidneys have normal size, sustained parenchymal index without
computer images of kidney stones, without dilatation of the upper
urinary tract. Atheromatous parietal calcifications of abdominal
aorta. Without abdominal fluid. Highlighted infiltration of
subcutaneous tissue, accompanied by fluid density areas in the
bilateral abdominal wall, predominantly on the right side.
Atheromatous parietal calcifications in the aortic arch and
descending intrathoracic aorta.
Bioassays were performed in dynamic and interclinic
check-ups.
The lung examination shows a serious state of the
patient, with recommendations of bronchodilators and
nebulization for improving the respiratory function. After
performing a computer tomography scan of the thorax, thoracic
surgery consultation was performed, which decided bilateral
pleural puncture, being evacuated on either sides about 500 ml of
serocitrin liquid and it recommended samples for cytology,
biochemistry, culture.
Cardiology consultation with cardiac ultrasound,
describes a right ventricle of 45 mm, left ventricle of 31 mm,
ventricular septal of 13.5, left ventricle posterior wall = 13.5,
AMT, vol. 22, no. 1, 2017, p. 44
normal contractions of the left ventricle walls, ejection fraction =
55%, expansion of the right cavity, right atrium = 49 mm, left
atrium = 47 mm, not being able to examine tricuspid
regurgitation, recommending heparin with low molecular weight,
loop diuretics, potassium saver diuretics, the electrocardiogram
(ECG) highlighting the sinus rhythm.
Surgical consult describes that the rectal examination
does not recommend melena, this case not being an acute surgical
case.
Regarding the evolution of biological parameters, they
had a favourable outcome, namely:
 creatinine, from the value of 8.99 mg/dl it was normalized,
reaching a value of 1.2 mg/dl;
 urea, from the value of 178 mg/dl on admission, it reached a
value of 117 mg/dl;
 hemoglobin, from the value of 6.97 g/l after the
administration of 4 units of packed red blood cells,
administered one at a day, it reached the value of 8.8 g/l;
 albumin, from the value of 2.8 g/dl after the administration of
human albumin daily, it reached a normal value;
 sodium, potassium through fluid and electrolyte balancing,
had normal values;
 p-sepsine from 527 increased to 708 on the 13th day;
 NT-proBNP (N-terminal brain-Type Netriuretic Peptide)
from 12.377, fell to 8468 (being a severe heart failure);
 D-dimer from the value of 4.48, increased to a level> 5;
 white blood cells (WBC) normalized, as well as neutrophils,
so from a neutrophilic leukocytosis were obtained normal
values, but in the 13th day, they had a significant increase,
reaching leukocytes = 28 160 /mm3 with neutrophils = 97
190 /mm3.
Regarding the temperature curve, the patient was
afebrile during hospitalization, recording one episode of low grade
fever, a temperature of 37.4 °C on the 14th day. Diuresis, from an
amount of about 500 ml/day, intensively coloured, after the first 2
days of hospitalization in intensive care it was normochromic and
its amount reached 2400-3000 ml/day.
Diarrhea episodes after three days of administration,
antiprotozoals 500 mg every 8 hours orally, did not diminish, the
patient still presenting the same diarrhea syndrome, in addition to
presenting a melena case. It was thus decided to change the oral
administration of antibiotic with glycopeptide antibiotics, which
are administered for the treatment of severe infections resistant to
other antibiotics. The dose established by the infectious disease
doctor was 125 mg every 6 hours orally. From the 5th day the
diarrhea and melena episodes were not repeated, the result of
tracheobronchial culture being lung infection with MRSA and
Candida spp. It was thus initiated the treatment with tigecycline,
taking into account associated infections, these bacteria being
sensitive to this antibiotic. Antifungal treatment was administered
for candidiasis. After this combination, leukocytosis with
neutrophil normalized. Throughout the admission in ICU,
medication was administered according to antibiogram, the
adjustments of drugs being made according to creatinine
clearance, the infusion according to diuresis, with fluid electrolyte
balance aiming at daily requirements plus or minus deficits.
Painkillers were given, if required, as well as expectorant, digital
benzodiazepine, diuretics, selective beta-blockers, heparins with
low molecular weight, substances that favour increased nutritional
intake at the cellular level, nebulization with bronchodilators and
polymyxin.
Regarding respiratory function, it did not have a
favourable evolution. Whereas at admission to IC the patient was
breathing spontaneously with additional Oxygen (O2), on the
facial mask on the 6th day breaths were ineffective, SpO2 = 79%
 CLINICAL ASPECTS
(peripheral oxygen saturation), perioronasal cyanosis and
extremities, leading to the oro-tracheal intubation, with evident
hypercapnia encephalopathy. On the 7th day the patient was
conscious, it was attempted extubation, but during the guard he
was intubated and put back on ventilator, O2 saturation wasn’t
maintained within favorable limits, thus the patient underwent
decay breathing again. Regarding the mode of ventilation, if only
for a short period of time (for an hour), it was under cotrol all the
time, while the patient was intubated, the ventilation was assisted
with intermittent periods when breathing alone on probe
intubation, on T-tube. Starting on day 10, mechanical ventilation
was totally controlled, the patient's condition got worse and on the
11th day, the patient had an irresuscitator cardiac arrest.
DISCUSSIONS
CDI treatment associated with COPD is complex,
requiring multidisciplinary involvement and intervention at the
etiological, symptomatic and complication level. Regarding the
CDI treatment, for a long time, it was used Vancomycin and
Metronidazole, proving its efficacy, treatment which does not
suppress the risk factors of the host.(9) In addition to this therapy,
which is preferred, it can also be used intravenous administration
of tigecycline, as an alternative therapy.(10)
When a patient shows decompensation of COPD, they
have three symptoms: dyspnea emphasis, increasing the amount
of phlegm and infection of tracheobronchial secretions. As
treatment of first intention, worsening COPD initiates:
a) O2 therapy, whose target is (oxygen arterial pressure) PaO
2≥ 60 mmHg or SpO2≥ 90-92%;
b) Bronchodilators. It has been scientifically proven that their
administration by inhalation was superior to the intravenous
one;
c) Corticosteroids, administered intravenously, have a clear
benefit in COPD exacerbation site;
d) Antibiotics are used in patients with moderate and severe
COPD community, the majority of germs from COPD being:
b Streptococ pneumoniae, Moraxella, Moraxella,
Haemophilus influenzae MRSA.(2)
In our case, although the evolution of biological
parameters was toward normalization, the morbid condition of the
patient, obesity, COPD, smoking, chronic alcohol consumption,
lifestyle inadequate to chronic diseases have had a negative
impact on the patient, as literature itself describes the three
important factors in triggering CDI:
a) hospitalization, contact with other patients;
b) antibiotics, proton pump inhibitors, H2 antagonists;
c) age over 65 years, comorbidities, obesity, etc.(1,2,3)
In the case of CDI, the first symptom is watery diarrhea,
with daily episodes from 3 to even 20 episodes a day in the most
severe cases. The symptoms are common: abdominal pain, fever,
leukocytosis, hypoalbuminemia.(5,6) In our case these symptoms
were present and remitted after treatment. As laboratory diagnosis
there are worth mentioning a few ways: stool, with the presence or
absence of toxins A and B in the stool, colonoscopy (when the test
is negative, with doubtful diagnosis), abdominal ultrasound,
which may reveal ischemia or distension, abdominal tomography
that can describe thickening of the intestinal wall, when the
disease is very advanced.(7,8) Therefore, according to the
protocols, the first analysis that was collected was a stool to test
for CD, and when their condition worsened it was performed
abdominal tomography to exclude intestinal occlusion or
ischemia, abdominal ultrasound being performed several times.
The presence of multiple pathologies associated with
strict therapeutic indications, makes the course of treatment
difficult. In the case of our patient, where intravenous antibiotics
require respiratory pathology, according to the studies while
AMT, vol. 22, no. 1, 2017, p. 45
abdominal pathology indicates administration of the antibiotic
orally, it is essential to maintain normal biological parameters. So,
as a measure of prevention of lung superinfection, we applied
nebulizer with polymyxin and intravenous tigecycline.
In the case of a complicated COPD, also of a CDI,
where for the first infection the antibiotic is by choice, but in the
second case the antibiotic was contraindicated as the major cause
in triggering this condition, nebuliser with polymyxin E until the
result of tracheobronchial culture, has resulted in improving the
patient's condition, WBC reaching the normal amount. This
therapeutic approach we took after studies showed that
administration of intravenous antibiotics should be stopped as
recurrences occur and the treatment with metronidazole or
vancomycin must absolutely be initiated, with examination, in
advance of infectious diseases and surgical consultation, in order
to perform therapeutic colectomy if it is considered
appropriate.(2) Tigecycline is active on both CDI and MRSA
infection.(10)
CONCLUSIONS
The experience of this case supports the idea that
clostridium difficile infection and chronic obstructive pulmonary
disease are two major causes of death. Therapeutic conducts for
these diseases come in contradiction at the expense of the patient,
stressing the fact that their association is dramatic. Therapeutic
orientation by inhalation of polymyxin and bronchodilators had
remarkable effects, worthy to consider for further cases. In the
present situation, preexisting disease has increased susceptibility
to infectious complications, interfered with treatment response,
leading to an adverse evolution compared with other hospitalized
patients with the same diagnosis.
REFERENCES
1. Le Monnier A, Zaharc JR, Barbut F. Update on Clostridium
difficile. Medicine et maladies infectieuses. 2014;44:352-
367.
2. Khanna S, Pardi DS.Clostridium difficile infection:
management strategies for a difficult disease. Ther Adv
Gastroenterol. 2014;7(2):71-88.
3. Bobo LD, Dubberke ER, Kollef M. Clostridium difficile in
the ICU. CHEST. 2011;140(6):1643-1654.
4. Wittand CA, Kollef MH. The Washington Manual of Critical
Care, second edition, ed. Wolters Kluwer/Lippincott
Williams and Wilkins; 2012. p. 76-78,337,338,343-346.
5. Lubbert JT. John E, von Muler L. Clostridium difficile
infection in adults: Clinical manifestation and diagnosis,
guideline-base diagnosis and treatment. Dtsch Arztebl Int.
2014, Oct 24;111(43):723-31.
6. Christine WA, Crobach MJT, Dekkers OM, Wilcox MH,
Kuijper EJ. European Society of Clinical Microbiology and
Infections Disease (ESCMID). Data review and
recommendations for diagnosing Clostridium difficile
infection, Epidemiology and causes of acute diarrhea.
2009;15:1053-1066.
7. Khan FY, Elzonki AN. CDI: a review of the literature; 2014.
8. Stuart J. Recurrent CDI: A review of risk factors, treatments,
and outcomes; 2009.
9. Musgrave CR, Bookstaver PB, Sutton SS, Miller AD. Use of
alternative or adjuvant pharmacologic treatment strategies in
the prevention and treatment of CDI. International Journal of
Infectious Diseases. 2011;15:431-449.
10. Cunha BA. Antibiotic essentias, ed. Jonesand Bartlet
Learning; 2013. p. 14,238.
 CLINICAL ASPECTS

OSTEOARTICULAR PARANEOPLASTIC SYNDROMES

ASSOCIATED TO LUNG CANCER

LIVIA MIRELA POPA1

1
“Lucian Blaga” University of Sibiu, GinekoPro Medical, Sibiu

Keywords: Abstract: Paraneoplastic syndromes are a group of disorders associated with malignancies, independent
paraneoplastic of the location or size of the tumor. They are mediated by soluble mediators such as hormones and
syndromes, digital cytokines released by tumor tissue. In the case of paraneoplastic rheumatologic syndromes, symptoms
clubbing, hypertrophic occur in joints, muscles, boness, fascia, generally not more than 2 years before the diagnosis of cancer,
pulmonary and therefore, can be of great clinical importance through early detection and initiation of appropriate
osteoarthropathy therapy.

INTRODUCTION aspartate aminotransferase, alanine aminotransferase,

Paraneoplastic syndromes are described as non-
specific clinical and biological manifestations occurring in
patients with malignancies, and those that accompany lung
cancer are numerous and extremely varied. These manifestations
can precede the symptoms of tumour, occur simultaneously or
afterwards.(1,2,3)
PURPOSE
The work aimed at evaluating the incidence of
osteoarticular paraneoplastic syndromes in patients diagnosed
with lung cancer in our geographical region, both at the time of
diagnosis and during disease progression.
Another objective was to study the characteristics of
these paraneoplastic syndromes according to histology and
evolution of pulmonary neoplasia.
MATERIALS AND METHODS
I conducted a prospective study including patients
diagnosed with lung cancer, with or without treatment, and
patients who presented with symptoms of a paraneoplastic
syndrome and subsequently diagnosed with this condition.
The group was selected from patients consecutively
admitted within the Oncology Clinic, Internal Medicine Clinics,
Neurology, Nephrology, Hematology Clinics of the County
Clinical Emergency Hospital of Sibiu and patients diagnosed in
Sibiu Pneumology Clinic and referred to the Oncology Clinic
for specialized treatment.
Data was collected from both, the observation sheets,
medical history and physical examination of patients.
The following examinations were aimed at:
 The detailed objective examination focusing on certain
modifications characteristic of paraneoplastic diseases
(hyppocratic fingers, hypertrohphic osteoarthropathy,
facies ―in full moon‖ etc.), nutrition score assessment etc.
 Laboratory examinations:
1. Complete blood count, differential blood count and
erythrocytes morphology in case of changes in blood
count, sideremia;
2. Na, K, Ca, Mg, P;
3. Astrup of venous blood;
4. Serum alkaline phosphatase, creatine phosphokinase,
blood sugar;
5. CIC, C3, IgA, IgM, IgG, cryoglobulins, rheumatoid
factor, antinuclear antibodies;
6. Inflammatory tests: erythrocyte sedimentation rate
(ESR), fibrinogen, C-reactive protein (CRP);
7. Serum urea, serum creatinine, uric acid, proteinuria,
urinalysis, urine sediment calcium excretion,
phosphaturia;
8. Complete lipidogram;
9. Determination of plasma cortisol and urinary 17-
ketosteroids;
10. Determination of parathyroid hormone (PTH);
 Bone radiographs in case of complaints or changes in the
osteoarticular system;
 Abdominal ultrasound to highlight any liver metastases,
tumours of the adrenal gland; ultrasound of the neck in
cases diagnosed with hypercalcemia, ultrasound of other
organs depending on the symptoms;
 Electroencephalogram, electromyography in patients with
neurological symptoms;
The data was processed and analysed, followed by
drawing conclusions.
RESULTS
Regarding the study group, I have selected two types
of osteoarticular paraneoplastic syndromes.
Digital hypocratism
Digital clubbing had a higher incidence among the
study patients; in 68 (28.09% of all lung cancer cases) this sign
has been highlighted. 3 (1.23%) patients had this sign at time of
diagnosis of lung cancer, while in the remaining patients
(26.85%), it occurred during disease progression. This type of
paraneoplastic syndrome appeared simultaneously with other
paraneoplastic syndromes, its single presence being rare.
These patients’ nails were curved longitudinally,
others were transversely and others presented a mixed curvature
being associated with hypertrophy of fingers pulp, elastic, with
pink burelet. In some patients, similar changes, but at a smaller
scale were present in toes, as well.
Association with the histopathological type was made
as follows: 44 digital clubbings were found in patients

Corresponding author: Livia Mirela Popa, Str. Distribu iei, Nr. 32, Sibiu, România, E-mail: liviamirelapopa@yahoo.com, Phone: +40754 992580
1

Article received on 03.10.2016 and accepted for publication on 23.02.2017

ACTA MEDICA TRANSILVANICA March 2017;22(1):46-48
AMT, vol. 22, no. 1, 2017, p. 46
 CLINICAL ASPECTS
diagnosed with epidermoid carcinoma simultaneously, 7 patients
with adenocarcinoma, 5 patients with small cell carcinoma, the
remaining 12 patients having no histological confirmation.
Table no. 1. Distribution of patients with digital clubbing
depending on the histopathological type of lung cancer
Histopathological type No. of patients with digital clubbing
Epidermoid carcinoma 44
Adenocarcinoma 7 osteoarthropathy
Small cell carcinoma 5 Epidermoid carcinoma
Undetermined
12
histopathologic type
Figure no. 1. Distribution of patients with digital clubbing
depending on the histopathological type of lung cancer
Table no. 2. Distribution of patients with digital clubbing
depending on the time of diagnosis of lung cancer
The time when digital clubbing signs occurred No. of patients
Upon diagnosis of lung cancer 3 syndromes associated to this (numerous and extremely varied)
During disease progression 65
Figure no. 2. Distribution of patients with digital clubbing
depending on the time of diagnosis of lung cancer
Hypertrophic pulmonary osteoarthropathy
Hypertrophic pulmonary osteoarthropathy, in its
complete form, was present in 11 patients (4.54% of all lung
cancer cases). Two of the patients went to the doctor for
rheumatoid syndrome manifested by pain and swelling joints,
symmetrical at the level of radiocarpal joints, knees or ankles.
Associated, they presented digital clubbing, excessive growth of
the soft tissues of the extremities accompanied by vasomotor
disturbances at this level. Subsequently, chest radiograph
examination revealed lung cancer, confirmed by chest CT scan
and bronchoscopy with histopathological type determination. In
9 patients, this kind of events has occurred subsequently to the
diagnosis of lung cancer, in different stages of the disease.
Association with the histopathological type was made
as follows: 8 patients were diagnosed with epidermoid
AMT, vol. 22, no. 1, 2017, p. 47
carcinoma, 1 with adenocarcinoma, 1 with small cell carcinoma,
and in 1 patient, no histopathological type was revealed.
Table no. 3. Distribution of patients diagnosed with
hypertrophic pulmonary osteoarthropathy according to
histopathological type of lung cancer
Histopathological type No. of patients with
hypertrophic pulmonary
8
Adenocarcinoma 1
Small cell carcinoma 1
Undetermined histopathologic
1
type
Figure no. 3. Distribution of patients diagnosed with
hypertrophic pulmonary osteoarthropathy according to
histopathological type of lung cancer
DISCUSSIONS
Although lung cancer is a cause of severe illness and
its incidence is continuously increasing, paraneoplastic
are insufficiently studied. These paraneoplastic syndromes may
precede the occurrence of clinical manifestations of cancer.
Their knowledge is very important in setting an early diagnosis.
Symptoms may occur once the clinical externalization of the
tumour or at any other time of its progression. Within these
conditions, paraneoplastic syndrome can dominate the clinical
stage and the neoplasm can be ignored, hence the mistakes of
diagnosis and treatment. When the syndrome occurs during the
progression of an already known cancer, it can be erroneously
misinterpreted as in connection with a metastasis, which can
lead to serious errors. It can regress after tumour resection and
reoccur in case of metastasis or relapses.
Their incidence is not exactly known. Today, it is
accepted that they are present in up to 15% of patients with
cancer diagnosis and up to 70% of patients with lung cancer
may have one of these syndromes during the course of the
disease.(4,5,6)
Some of the few cohort studies were those of Croft and
Wilkinson on paraneoplastic neurologic syndromes, in which
more than 1400 study patients had an incidence ranging between
0.5 and 16.4%, with the average of 6.6 %. In a control group,
these authors have found neurological changes between 1 and
2%. It their etiology, the first place was held by lung cancer. In
another study, these syndromes were detected in 7% of almost
1500 patients with tumours. Tumours that are most frequently
associated with paraneoplastic neurologic syndromes are lung
cancer (47%), gastric (12%), breast (12%), ovarian (9%), and
colon cancer (6%).(6,7,8)
Another published study show that isolated monoarthritis
of the knee is a paraneoplastic syndrome previously described
that evokes lung cancer without small cells in an early stage.(9)
 CLINICAL ASPECTS

While paraneoplastic syndromes are found in approximately 10- carcinoma of the lung. Cancer Control. 2006;13:270-275.
20% of cases of small cell lung cancer, monoarthritis of the knee 8. Gherasim L. Tumorile bronho-pulmonare. În Medicinã
are more common in lung cancer without small cells.(10,11) Internã, Vol. I, ediția a II-a. Ed. Medicalã, Bucure ti; 2002.
Osteoarticular manifestations were the most frequently p. 433-479.
encountered among the study population, digital clubbing 9. Ghilezan N. Oncologia generalã. Ed. Medicalã, Bucure ti;
occupying the first place, both regarding the osteoarticular 1992. p. 15-31.
manifestations and in paraneoplasia. 10. Gherman G. Paraneoplaziile-Dificultãți de diagnostic ȋn
The data is compared with that existing in the cancer. Editura Dacia. Cluj-Napoca; 1986.
literature.(12) Digital clubbing was manifested clinically in 68 11. Ghozlani Imad, Ghazi Mirieme, Niamane Radouane. Les
patients (28.09% of all lung cancer cases), in 3 of them it was an syndromes paranéoplasiques en rhumatologie.
inaugural sign and in the rest of the patients it occurred during Paraneoplastic syndromes in rheumatology. Revue
disease progression. It was found in all histopathological types Marocaine de Rhumatologie. 2016;35:22-8.
of lung cancer without any of them to prevail. 12. http://www.boloncol.com/index2.php?option=com_content
Hypertrophic pulmonary osteoarthropathy was &task=view&id=20&pop=1&pa. Accessed 10.08.2016.
diagnosed in its complete form in 11 patients (4.54%).
The predominant histopathological type of lung cancer
was the epidermoid carcinoma, data confirmed by that in the
literature.
In 2 patients, the syndrome preceded the diagnosis of
pulmonary neoplasia, in the remaining 9 patients this event
occurring during the course of the disease.
Rheumatic paraneoplastic syndromes were diagnosed
in 22 patients (9.09%).
In 9 patients, symptoms were visible before the
diagnosis of cancer, joint pain being the reason for which the
patients went seeing a doctor. 13 patients evidenced a form more
or less severe of rheumatoid syndrome during the course of the
disease. 18 of them had bilateral pain, largely symmetrical,
localized especially in the large joints of the limbs, only 4 were
diagnosed with knee monoarthritis (1.65%). The percentages are
comparable to those found in the literature.

CONCLUSIONS
1. 2.06% of patients (n = 5) were diagnosed with
dysacromelia-gynecomastia syndrome consisting of a
combination of digital clubbing and gynecomastia.
2. The most common paraneoplastic manifestation is
represented by digital clubbing, being encountered in 68
patients (28.09%).
3. The predominant histopathological type in hypertrophic
pulmonary osteoarthropathy and rheumatoid syndromes is
represented by the epidermoid carcinoma, 8 patients,
respectively 14 patients being diagnosed with this
histopathological type.
4. Paraneoplastic syndromes are numerically important since
the diagnosis of lung cancer.
5. It is noted an association of one or more paraneoplastic
syndromes in the same patient.

REFERENCES
1. Anastasatu C, Eskenasy A. Cancerul bronhopulmonar. În
Colec ia Enciclopedia Oncologicã, Cluj-Napoca; 1986.
2. Azar L, Khasnis A. Paraneoplastic rheumatologic
syndromes. Curr Opin Rheumatol. 2013;25(1):44-9.
3. Bojinca V, Janta I. Rheumatic Diseases and Malignancies.
Mædica. 2012;7(4):364-71.
4. Brown RH. Sindroame neurologice paraneoplazice. Ȋn
Principiile Medicinei Interne. Harrison. Vol. I. 14th edition.
Ed. Teora. Bucure ti; 200 . p. 680-685.
5. DeLellis RA, Xia L. Paraneoplastic Endocrine Syndromes:
A review. Endocrine Pathol. 2003;14:303-317.
6. Edelman MJ, Gandar DR. Lung Cancer; In Manual of
Clinical Oncology, 4th edition, eds. Casciato DA Lowitz
BB – Lippincott, Williams and Wilkins Philadelphia; 2000.
p. 157-171.
7. Fernandez FG, Battafarano RJ. Large-cell neuroendocrine

AMT, vol. 22, no. 1, 2017, p. 48

 CLINICAL ASPECTS

BASAL CELL CARCINOMA: HISTOLOGIC DIAGNOSTIC

PITFALLS – CASE REPORT

ZAMFIR RADU IONESCU1, GEORGE MIHAIL MAN2, MIHAI POPESCU3

1
The Pediatric Hospital of Piteşti, 2,3The Emergency County Hospital Pitești, 1,2,3The State University of Pitești

Keywords: basal cell Abstract: Basal cell carcinoma (BCC), although a very often dermatological issue, may embrace
carcinoma, ionizing various morphological forms that the pathologist is required to accurately diagnose. We present the
radiation exposure, case of a 15 years old girl with a nodular tumor observed, on skin, in a subclavian area, with dimensions
tumor immunogenicity within 0,7/0,7/0,4 cm. The microscopic appearance of the tumor resembles a BCC, with basaloid and
rare scuamoid features, but no atypia or peripheral clefting, within a normal dermis with marked
plasocytic inflammation and reticular areas; differential diagnosis included trichoepithelioma, Merkel
cell carcinoma, trichoblastoma and microcystic adnexal carcinoma. The final diagnosis proved to be a
trichoepithelioma. Therefore, the importance of differential diagnosis in BCC and BCC-like conditions
requires mainly classical histologic criteria, with, depending on case, subsequent molecular
confirmation techniques. The article depicts the required attitude in such a situation, allowing an
illumination on the matter.

INTRODUCTION microscopic examination.

Basal cell carcinoma (BCC) is a very often
dermatological diagnosis, regarded almost as a common primary Figure no. 1. Macroscopic appearance of excised nodule
malignancy within the skin, constituting almost 80% of all (formalin 4%)
cutaneous primary cancers. Around 900.000 new patients are
diagnosed with a form of BCC during one year’s time, in the
United States, with occurrence in all races having a slight
predominance for fair or blond skinned people. Almost 85% of
BCCs are encountered on the skin of the face, neck or head and
scalp, while other may appear on the extremities and rarely on
hands. Sometimes, BCCs might be develop in the periocular
regions, like in the lower eyelid, medial or lateral canthus.(1) Figure no. 2. Dispersed basaloid cells around a follicular
The tumor grows in an indolent fashion, and if left untreated, it area in the presented case (HE, 400x)
may involve profound structures like the hypoderm, skeletal
muscles and bones. Clinically, the BSCs is divided in the
following types: nodular, ulcerative, superficial, multicentric,
erythematous, sclerosing and morphea-like. The median patients
age is 40 years old, having a fair skin that are prone to sunburns.
Treatment consists of topical application of imiquimod, surgical
excision and irradiation.(2,3) Metastatic disease is very rare and
might be detectable in neglected BCCs with prolonged evolution
and profound spreading.(4)

CASE REPORT
Figure no. 3. Basaloid areas with intermingled haematic
We present the case of a 15-year old girl with a nodular
infiltrates and surrounding dermis oedema; no visible atypia
tumor observed in the left subclavian area with surrounding
(H&E, 400x)
erythema that has been resected by our surgical team. The
excised fragment consisted of a round – ovoid, white to tan,
elastic structure with dimensions within 1 cm (0,7/0,7/0,4 cm)
and inconspicuous ulcerations (figure no. 1). The fragment was
fixed in a 4% formalin solution for 24 hours, in order to preserve
any immunogenicity. Afterwards, histologic processing included
the use of successive ethanol concentrations, i.e 70, 80 and three
successive baths of 96, 99 degrees, izopropylic alcohol and
acetone submersion in order to freeze any decaying on the
tissue. Subsequent paraffin embedding and sectioning in 2-3 µm
followed with standard haematoxylin and eosin staining and

Corresponding author: George Mihail Man, Aleea Spitalului, Nr. 36, Piteşti, România, E-mail: georgemihail@yahoo.com, Phone: +40749 192291
2

Article received on 18.01.2017 and accepted for publication on 23.02.2017

ACTA MEDICA TRANSILVANICA March 2017;22(1):49-51
AMT, vol. 22, no. 1, 2017, p. 49
 CLINICAL ASPECTS
Figure no. 4. Scuamoid pearls inside basaloid cell areas, with
hyaline depositions and brisk inflammatory infiltrates (HE,
100x)
Figure no. 5. Basaloid areas with a whorle appearance
pattern, brisk plasmocytic infiltrates and edem with
incoscpicous peripheral clefting (H&E, 400x)
The microscopic examination revealed a dermis with
frequent hair follicles that surrounds an almost necrotic area
with bluish, polygonal, basaloid cells (figure no. 2) with visible
nuclei and scant mitosis, intermingled with epidermal and
scuamoid areas (figure no. 4), oedema and brisk plasmocytic
inflammation (figures no. 3 and 5). There were present pearl-
like structures scattered in the basaloid cell population. It is
important to note that no peripheral clefts are observable
between basaloid areas and healthy dermis (figure no. 4).
Regarding histologic criteria, the established diagnosis was that
of a trichoepithelioma with areas resembling basal cell
carcinoma. The archived tissue and sections were referred for
immunohistochemical analysis.
DISCUSSIONS
Ultraviolet radiation exposure is general accepted as
the main risk factor for the initiation of BCC. It seems that day-
light timing, pattern of distribution and duration of exposure to
UV emissions would influence in a significant way the BCC
onset. Therefore, recreational exposure of individuals during
childhood and adolescence of a individual would have
eventually a tremendous influence towards the evolution of
BCCs. The presence of any ionizing radiation, oral psoralen,
arsenic and ultraviolet A rays could be incriminated in the
etiopathogeny of BCCs. Transplant recipients and
immunosupression predisposes individuals for BCCs. For
example, it has been documented that renal transplant patients
have a ten-fold incidence for BCCs than those patients who have
not received any renal transplants.(5) Genetic studies have
identified that mutations in p53 and PTCH tumor suppressor
genes for BCC, in sun-exposed Korean patients, are linked with
sporadic cases of BCC. Heterozygocity loss of 9q22 for PTCH
loci was found in 53% of cases. Therefore, it is suggested that
UV-induced DNA lesions might interfere with the production of
different BCC morphologic racial subtypes.(6) Some authors
designate BCCs as a trichoblastic carcinoma (TCC), due to its
predominant follicular differentiation and a possible follicular
AMT, vol. 22, no. 1, 2017, p. 50
origin. It is known that TCC is a rare entity, thought to arise
from within a benign trichoblastoma, presenting as a painless
mass for a several years period before malignant transformation.
However, there are similarities and differences between the
morphologies of TCC and BCC: the TCCs may develop
clinicopathologic criteria akin to BCC, histological diagnosis is
difficult as it must be excluded from the benign counterpart.(7)
Although difficult to identify or speculate a hair follicle origin
for BCCs on standard haematoxylin-eosin stains, in superficial
forms of BCCs this may become conspicuous, however, towards
embryonic human hair. It was observable that vellus hair has
intense Ep-CAM or epithelial cell adhesion molecule staining.
In the terminal stage of hair follicle, only the secondary germ
hair becomes the starting point of a new hair cycle with active
cellular proliferation with no morphological signs towards any
differentiation.
In this stage, the molecular immunohistochemical
expression of Ep-CAM is visible, while, in the end of the cell
differentiation this becomes inconspicuous. In some studies,
most of the BCC variants – morpheiform, nodular, infiltrative,
cystic, adenoid or granular consistently express Ep-CAM
immunogenicity together with Ber-EP4. Further research prove
that Ep-CAM may be involved in the generation of the oblique
angle of the hair follicle during development, which is important
for proper layering of the shaft and thermoregulation in fur-
bearing organisms, thus offering solid evidence for BCC
etiology as the most primitive hair follicle tumor.(8) Thus,
microscopic appearance for BCC requires the presence of
basaloid cells with scant cytoplasm and elongated
hyperchromatic nuclei, peripheral palisading with peritumoral
clefting and mucinous alteration of intermingled stroma, the
latter two being the most important differential features against
basaloid or BCC-like tumors. Amiloyd presence, distrophic
calcifications and regressive brisk inflammatory infiltrate may
be detectable on standard haematoxylin and eosin stains.
Tumors with signed ring morphology , Pinkus tumor or
fibroepithelioma, granular or infundibulocystic BCC variants
might be encountered, although irrelevant to the prognostic
factors.(9)
Most disputed differentials are Merkel cell carcinoma,
microcystic adnexal carcinoma, squamous cell carcinoma with
basaloid feature and trichoblastoma and trichoepithelioma.
Merkel cell carcinoma (MCC) is confirmed histopathologically
and is classified as trabecular, small cell or intermediate,
proving to be a tumor with small, round, bluish cells with large
nuclei that stain in a dot-like pattern with CK-20. MCC may be
deceptive and misinterpreted in early stages as a BCC,
amelanotic melanoma, keratoacanthoma or cutaneous metastatic
disease, especially when overlying epidermis is not ulcerated
until present in a late stage. Despite BCCs similiraties the MCC
has a rapid growth rate with early metastastic disease.The best
clue for MCC diagnosis is furnished by the AEIOU acronym,
i.e. asymptomatic – lack of tenderness, expanding rapidly,
immunosuppression, patient over 50 years of age and site
exposed to ultraviolet rays.(10) Microcystic adnexal carcinoma
(MAC) is an unusuall, malignant adnexal neoplasm, designated
also as a malignant syringoma or syringoid carcinoma – i.e, a
low grade sweat gland carcinoma. Grossly, it presents as a
smooth, flesh colored to yellow, bulging firm plaque or cystic
tumor, with a diameter between 2 to 3 cm, that evolves in a 3 to
5 years period, with initial site on head or neck, including lips.
Histologically, MAC is a deep infiltrating tumor with assimetry,
with desmoplastic stroma and keratin horn cysts intermingled
with basaloid cells nests and tadpole shaped ducts filled with a
eosinophilic amorphous substance. Perineural invasion is
characteristic, while cords and strands may become very thin
 CLINICAL ASPECTS

and may have anindian file pattern. The immunohistochemistry
panel in MAC may prove the most reliable CK19 positive
expression in malignant transformation, along with broad
spectrum antikeratin AE1-AE3 antibodies and carcinoembryonic
antigen (CEA) positivity. Syringomatous carcinoma as a variant
of MAC may be distinguished due to a higher amount of
basaloid cells and nests, within a more sclerotic dermis.(11)
Trichoblastoma (TCB) is a rare, benign, tumor with origins in
rudimentary hair follicles, frequent in pediatric pathology, that
arises secondary to another benign lesion, known as nevus
sebaceous, due to a rapid development on the scalp or another
hairy region during adolescence. Clinically it presents as a skin-
colored, large, nodular lesion. The histopathological appearance
of TCB may encounter various forms described as small, large
nodular, retiform, cribriform, racemiform or columnar. The
main feature is characterized by the presence of basaloid
follicular germinative cells.(12) Trichoepitheliomas (TES)
present as a solitary, fleshy nodule, nonulcerated with raised
margins, usually on the upper eyelid margin, in patients with age
ranging from 3 to 75 years old. Sometimes, TES present
surrounded by milia-like lesions. The pathologic examination
reveals that TES occur in 3 varietes: solitary, multiple or
desmoplastic. Solitary lesions are non-inherited, while multiple
TES may be associated with cylindromas and syringomas
known as the Spiegel-Brooke syndrome, determined by a
recessive suppressor oncogene located on the chromosome
16q12-13. The desmoplastic form of TES require the presence
of concentric laminated keratinous horn cysts with a conspicous
desmoplastic stroma and clusters of epithelial cells.(13)
Dermatol. 2008 Jan;58(1):158–67.
9. Roldán-Marín R, Ramírez-Hobak L, González-de-Cossio
AC, Toussaint-Caire S. Fibroepithelioma of Pinkus in
continuity with a pigmented nodular basal cell carcinoma
(BCC): A dermoscopic and histologic correlation. Vol. 74,
Journal of the American Academy of Dermatology. 2016.
10. Patel M, Newlands C, Whitaker S. Single-centre
experience of primary cutaneous Merkel cell carcinoma of
the head and neck between 1996 and 2014. Br J Oral
Maxillofac Surg. 2016;54(7):741–5.
11. Hamed NS, Khachemoune A. Microcystic adnexal
carcinoma: A focused review and updates. J Dermatology
Dermatologic Surg. 2015;19(2):80–5.
12. Zeller KA, Billmire DF. Trichoblastoma: management of a
rare skin lesion. J Pediatr Surg. 2012;47(1):250–2.
13. Kuo DS, Nyong’o OL. Congenital solitary eyelid
trichoepithelioma. Vol. 14, Journal of American
Association for Pediatric Ophthalmology and Strabismus.
2010.

CONCLUSION
In an ever increasing skin primary neoplasm
incidence, the attention focused towards the early detection of
BCC may offer an additional genetic syndrome diagnose and
avoidance of later unfavorable evolution of BCC, regarding
deep penetration muscles and bones or esthetic difficulties for
face or visible skin localization, especially in young patients.

REFERENCES
1. Loh TY, Rubin AG, Brian Jiang SI. Basal Cell Carcinoma
of the Dorsal Hand: An Update and Comprehensive
Review of the Literature. Dermatol Surg. 2016
Apr;42(4):464-70.
2. A Gaspari A, Tyring SK, Rosen T. Beyond a decade of 5%
imiquimod topical therapy. J Drugs Dermatol.
2009;8(5):467–74.
3. Mosterd K, Arits AHMM, Thissen MRT, Kelleners-Smeets
NWJ. Histology-based treatment of basal cell carcinoma.
Acta Derm Venereol. 2009;89(5):454–8.
4. LeBoit P, Burg G, Weedon D, Sarasin A. World Health
Organization Classification of Tumors. Pathology and
Genetics of Skin Tumors. 3rd ed. Lyon: IARC Press; 2006.
5. Rubin AI, Chen EH, Ratner D. Basal-cell carcinoma. N
Engl J Med. 2005;353(21):2262
6. Kim M-Y, Park HJ, Baek S-C, Byun DG, Houh D.
Mutations of the p53 and PTCH gene in basal cell
carcinomas: UV mutation signature and strand bias. J
Dermatol Sci. 2002;29(1):1–9.
7. Parbhoo A. The ―rare‖ trichoblastic carcinoma – a rare
entity with mixed presentation – lessons for the future. Br J
Oral Maxillofac Surg. 2016;54(10).
8. Sellheyer K, Krahl D. Basal cell (trichoblastic) carcinoma:
Common expression pattern for epithelial cell adhesion
molecule links basal cell carcinoma to early follicular
embryogenesis, secondary hair germ, and outer root sheath
of the vellus hair follicle: A clue to the adnex. J Am Acad
AMT, vol. 22, no. 1, 2017, p. 51
 CLINICAL ASPECTS

CUTANEOUS LARVA MIGRANS – DIAGNOSTIC DIFFICULTIES

IN THE NON-ENDEMIC AREA. CASE REPORT

ANA-MARIA PELIN1, COSTINELA GEORGESCU2, VICTORIŢA ŞTEFĂNESCU3,

GABRIELA BĂLAN4
1,2,3,4
“Dunărea de Jos” University of Galaţi

Keywords: cutaneous Abstract: Patient aged 68 years, chronic hypertensive, came to the medical office due to an intensely
larva migrans, pruritic, serpiginous lesion that had occurred within the hand’s thenar eminence approximately 10 days
albendazole, before. The patient recounts that further to the agricultural works (vineyard harvesting) he noticed the
doxycycline occurrence of a 2-3 mm papule within his hand’s thenar eminence accompanied by intense itching. An
inflammatory, serpiginous tract subsequently occurred which grew by approximately 1 cm per day.
Further to the clinical examination performed by the family physician, the dermatologist and the
infectious diseases consultant, on the basis of the clinical manifestations and the lesion progression,
combined with the paraclinical examination, the cutaneous larva migrans diagnostic was established.
Conclusions: The presentation of the cutaneous larva migrans cases would contribute to an early and
correct diagnostic of such cases of parasitosis that are specific to tropical areas and which are
occasionally encountered in non-endemic areas such as Europe.

INTRODUCTION
The Cutaneous Larva Migrans is an eruption having a
characteristic clinical aspect caused by the hookworms from
animals and humans such as Ancylostoma caninum and
Ancylostoma braziliense.(1) The Cutaneous Larva Migrans
(CLM) is clinically characterized by the erythematous,
serpiginous and intensely pruritic tracts, but also by
disseminated or eczematized eruptions mainly located in the
feet.(2) Although the cutaneous larva migrans especially appears
in the tropical areas, isolated cases have been described in
Europe with the travellers coming from such areas. The disease
is also likely to be caused by the climatic changes occurring in
non-endemic areas.(3) The treatment is based on oral medicines
(Albendazole or Ivermectin) or topical application of
Thiabenzadole.(4-7) Larvas cannot penetrate the basal
membrane of the human skin but remain confined to the
epiderma and thus do not complete their lifecycle. Although
CLM is a self-confining disease, it might last for months unless
promptly treated.(8-9) In Europe, cases are rare and occur in
patients after having worked in agriculture or sunbathed on the
river bank.(10-15)
The Cutaneous Larva Migrans infections may be
grouped into several types, depending on the species responsible
for the lesions and their clinical aspect.(16)
Type 1: Animal hookworms: CLM caused by the
Ancylostoma duodenale and Ancylostoma caninum is
characterized by well-defined tracts extending a few centimetres
from their point of origin. These larvae migrate at a rate of 3.5 to
5 cm per day. The infection may be chronic and last for
months.(16)
Type 2: Human Hookworms: Ancylostoma duodenale
and Necator americanus cause short tracts and intense itching.
This type of larva migrans is also known as the ―ground itch‖.
The parasites might migrate to the lungs and digestive tube
where they turn into adults.(16,17)
Type 3 Strongyloides stercoralis: Human
strongyloides cause a CLM type known as ―currens larva‖.(18)
The lesions start in the perineum and advance towards the
extremities and other areas.(18,19)
Type 4 Animal Strongyloides: CLM caused by animal
strongyloides is variable. Certain lesions are similar to the ones
noticed in the Strongyloides stercoralis infection. Infections
caused by Strongyloides myopotomi and Strongyloides
procyonis cause lesions resembling a typical polymorphic
erythema under indirect light examination.
Type 5 Gnathostoma: CLM caused by Gnathostoma is
usually confined to Japan, Thailand and more rarely to other
South-East Asia countries. It might occur as a result of the
migration of the ingested larva from the intestine to the skin or
by the direct penetration of the parasite while handling animal
meat.
Type 6 Insects larvae: Certain species of Gastrophi
and Hypoderma might migrate by causing linear lesions
sometimes called ―myiasis linearis‖. Larvae may easily be
viewed by whitening the skin by slight pressure with a
magnifying glass or by rubbing the skin with mineral oil.
CASE REPORT
Patient aged 68 years, chronic hypertensive, came to the
medical office due to a intensely pruritic serpiginous lesion that
had occurred within the hand’s thenar eminence approximately
10 days before. The patient recounts that further to the
agricultural works (vineyard harvesting) he noticed the
occurrence of a 2-3 mm papule within his hand’s thenar
eminence accompanied by intense itching. An inflammatory,
serpiginous tract subsequently occurred, which grew by
approximately 1 cm per day. During the dermatological
examination the patient had an eczematized, inflammatory,
painful and linear eruption measuring approximately 10 cm
(figure no. 1). The general clinical examination performed on
the equipment was normal, tension values ranged within normal
values. Routine blood and biochemical tests were normal.
Coproparasitological exam tested negative for parasites and the
pulmonary X-ray was normal.

2
Corresponding author: Costinela Georgescu, Str. R zboieni, Nr. 19A, Cod 800114, Gala i, Jude ul Gala i, România, E-mail: costinelag@gmail.com,
Phone: +40745 384969
Article received on 18.01.2017 and accepted for publication on 23.02.2017
ACTA MEDICA TRANSILVANICA March 2017;22(1):52-53
AMT, vol. 22, no. 1, 2017, p. 52
 CLINICAL ASPECTS
Figure no. 1. Serpiginous linear eruption located on the
thenar eminence
Figure no. 2. Lesion appearance after medicine treatment
The diagnostic of Cutaneous Larva Migrans was
established on the basis of anamnesis and clinical examination.
The patient was treated with Albendazole 400 mg/day for 5 days
and required treatment continuation for another five days with
Doxycycline because, despite the gradual disappearance of the
serpiginous tract, the area remained intensely eczematized due
to the itch and to attempts made by the patient to find the larva
(figure no. 2).
DISCUSSIONS
Cutaneous Larva Migrans is frequent in the tropical
and subtropical countries, yet isolated cases might occur in non-
endemic areas such as Europe. The specific host is the dog or
the cat who eliminated via faecal the nematode eggs. Under
moisture and heat the eggs turn into larvae and penetrate the
epiderma. The nematode larvae penetrate the epiderma but they
are unable to pass by the dermoepidermic junction and go
deeper, systemic complications being absent. The disease is self-
confining in the absence of treatment to weeks or months since
humans are not the usual host of the nematode, which cannot
complete its lifecycle. Cutaneous biopsy is not considered
necessary as the larva advances beyond the end of the eruption.
Treatment is required due to the long evolution periods and
itching.
CONCLUSIONS
The Cutaneous Larva Migrans is a rare disease in
Europe. The presentation of the cutaneous larva migrans cases
would contribute to an early and correct diagnostic of such cases
of parasitosis that are specific to tropical areas and they are
occasionally encountered in Romania.
REFERENCES
1. Baple K, Clayton J. BMJ Case Rep. Hookworm-related
cutaneous larva migrans acquired in the UK. 2015 Nov
13;2015. pii: bcr2015210165. doi: 10.1136/bcr-2015-
210165.
2. Veraldi S, Persico MC, Francia C, Nazzaro G, Gianotti R.
Follicular cutaneous larva migrans: a report of three cases
and review of the literature. Int J Dermatol. 2013
AMT, vol. 22, no. 1, 2017, p. 53
Mar;52(3):327-30. doi: 10.1111/j.1365-4632.2012.05723.x.
3. Oanta MI, Oanta S. Cutaneous larva migrans,
DermatoVenerol. (Buc.). 2011:56:183-190.
4. Vanhaecke C, Caumes É. Treatment of hookworm-related
cutaneous larva migrans: albendazole or ivermectin? Ann
Dermatol Venereol. 2012 Aug-Sep;139(8-9):518-20. doi:
10.1016/j.annder.2012.05.022. Epub 2012 Jul 3.
5. Heukelbach J, Feldmeier H. Epidemiological and clinical
characteristics of hookworm-related cutaneous larva
migrans. Lancet Infect Dis. 2008 May;8(5):302-9. doi:
10.1016/S1473-3099(08)70098-7.
6. Schuster A, Lesshafft H, Reichert F, Talhari S, de Oliveira
SG, Ignatius R, Feldmeier H. Hookworm-related cutaneous
larva migrans in northern Brazil: resolution of clinical
pathology after a single dose of ivermectin. Clin Infect Dis.
2013 Oct;57(8):1155-7. doi: 10.1093/cid/cit440. Epub 2013
Jun 27.
7. Shoop WL, Michael BF, Soll MD, Clark JN. Efficacy of an
ivermectin and pyrantel pamoate combination against adult
hookworm, Ancylostoma braziliense, in dogs". Aust Vet J.
1996;73(3):84–85.doi:10.1111/j.1751-0813.1996.tb09981.x.
PMID 8660218.
8. Veraldi S, Persico MC, Francia C, Schianchi R. Chronic
hookworm-related cutaneous larva migrans. Int J Infect Dis.
2013 Apr;17(4):e277-9. doi: 10.1016/j.ijid.2012.11.002.
Epub 2012 Dec 5.
9. Tomich EB, Knutson T, Welsh L Hookworm-related
cutaneous larva migrans. CJEM. 2010 Sep;12(5):446.
10. Müller-Stöver I, Richter J, Häussinger D(Cutaneous larva
migrans (creeping eruption) acquired in Germany). Dtsch
Med Wochenschr. 2010 Apr;135(17):859-61. doi:
10.1055/s-0030-1253669. Epub 2010 Apr 20.
11. Zimmerman RF, Belanger ES, Pfeiffer CD. Skin infections
in returned travelers: an update. Curr Infect Dis Rep. 2015
Mar;17(3):467. doi: 10.1007/s11908-015-0467-8.
12. Landolt L, Kovari H. (CME. Larva migrans). Praxis (Bern
1994). 2014 Dec 10;103(25):1491-8. doi: 10.1024/1661-
8157/a001859.
13. Romero-Callejas E, Rendón-Franco E, Villanueva-García
C, Osorio-Sarabia D, Muñoz-García CI. Risk of cutaneous
larva migrans and other zoonotic parasites infections due to
feral cats from a touristic tropical park. Travel Med Infect
Dis. 2014 Nov-Dec;12(6 Pt A):684-6. doi:
10.1016/j.tmaid.2014.10.018. Epub 2014 Nov 1.
14. Criado PR1, Belda W Jr, Vasconcellos C, Silva CS.
Cutaneous larva migrans: a bad souvenir from the vacation.
Dermatol Online J. 2012 Jun 15;18(6):11.
15. Gutierrez Y. Diagnostic Pathology of Parasitic Infections
with Clinical Correlations, Second edn, New York: Oxford
University Press; 2000. p. 343-353.
16. Gilman RH. Intestinal nematodes that migrate through skin
and lung. In: Strickland GT ed. Hunter's Tropical Medicine
and Emerging Infectious Disease, 8th edn. Philadelphia:
Sounders; 2000. p. 730-735.
17. Bryceson ADM, Hay RJ. Parasitic worms and protozoa. In:
Champion RH, Burton JL, Burns DA, et al eds. Rook/
Wilkinson / Ebling Textbook of Dermatology, 6th edn. Vol
2, Oxford: Blackwell Sciences; 1999. p. 971-972.
18. Arthur RP, Shelly WB. Larva currens. A distinctive variant
of cutaneous larva migrans due to Strongyloides stercoralis.
Arch Dermatol. 1958;78:186-190.
19. Stone OJ, Newell GB, Mullins JF. Cutaneous
Strongyloidiasis: larva currens. Arch Dermatol.
1972;106:734-736.
 CLINICAL ASPECTS

AQUEOUS HUMOR: PHYSIOLOGY AND DYNAMICS

GABRIELA DENISA CĂILEANU1, ADRIANA STĂNILĂ2

1
County Hospital Piatra Neamț, 1,2“Lucian Blaga” University of Sibiu, 1Fellow of the European Board of Ophthalmology,
2
Emergency County Hospital Sibiu

Keywords: aqueous humor, Abstract: This article reviews the anatomy and physiology of aqueous humor circulation, from
outflow, trabecular secretion to drainage. There are also highlighted the secretory mechanisms of the ciliary body, the
meshwork, Schlemm’s canal blood-aqueous barrier, the pathways of aqueous flow within the eye and the aqueous outflow
system.

Aqueous humor is a transparent colourless solution
that fills the anterior chamber of the eye, being produced by the
nonpigmented cells of the ciliary epithelium. It has several
important functions in ocular physiology: nutritive, optical and
mechanical. At the beginning of the 20 th century, aqueous
humor was considered a stagnant fluid. This idea was revoked
after several experiments designed to investigate it and other
aspects of the anatomy and physiology of aqueous drainage
were discovered later. Aqueous humor is secreted into the
posterior chamber, passes through the pupil in the anterior
chamber and drains mostly into venous circulation through the
conventional (pressure dependent) pathway. This is composed
of trabecular meshwork, Schlemm’s canal, scleral collector
channels and aqueous and episcleral veins. The remainder goes
into the orbit through the uveo-scleral (non-conventional,
pressure independent pathway), composed of interstices of the
ciliary muscle, ciliary body lymphatics, the suprachoroidal space
and the sclera.
Formation and secretion of aqueous humor
Aqueous humor is continuously formed by the cells of
the non-pigmented ciliary epithelium. Three physiologic
processes are involved in aqueous humor formation: diffusion,
ultra filtration and active secretion. The first two are passive
processes, requiring no active cellular participation. Diffusion
takes place down a concentration gradient. High-lipid solubility
substances can easily penetrate biological membranes in this
way. The process of ultra filtration takes place because of
gradients in fluid pressure between the different compartments
of the eye. This process controls the flow of blood plasma across
the fenestrated ciliary capillary endothelia, driven by hydrostatic
pressure. It is responsible for the formation of the reservoir of
plasma ultra filtrate in the stroma, from which aqueous humor is
derived through active secretion. There is a limited influence of
systemic blood pressure on intraocular pressure (IOP) and
increased IOP reduces aqueous inflow, showing a
responsiveness of aqueous inflow to altered hydrostatic pressure
gradients. The mechanism of cellular secretion is better
understood than that of ultra filtration.
The concentration of Na+, K+, Cl-, bicarbonate,
glucose, some amino acids and other organic compounds in
aqueous humor are maintained by specific transport systems in
the ciliary epithelium. Active secretion requires energy,
provided by hydrolysis of ATP. This energy is used to secrete
substances against a concentration gradient. Active secretion
accounts for 80-90% of total aqueous humor formation. Through
active secretion substances are moved in a direction opposite to
that which would be expected by passive mechanisms alone.
Aqueous humor exhibits increased lactate, ascorbate and certain
amino acid concentrations as compared to plasma, as a
consequence of active secretion.
In the ciliary epithelium, there have been identified
several membrane active transport systems, including Na+
K+ATP-ase, carbonic anhidrase, Na+K+-2Cl- symport parallel Cl-
/HCO3- and Na+/H + antiports as well as amino acid membrane
transporters.(1) The evidence for active secretory processes in
the ciliary epithelium is provided by the inhibition of aqueous
humor inflow by the inhibitors of cellular enzymes. There is a
reduction of IOP after experimental topical and intravitreal
administration of Na+K+ATP-ase inhibitors, ouabain and
vanadate. Vanadate ion reduces IOP in rabbits but does not
lower IOP in ocular hypertensive patients.(2) An active transport
system is characterized by a limit beyond which an increase in
substrate produces no further increase in transport.
When this limit is reached the system is saturated. For
instance, ascorbate transport system in the eye is saturable.
Electrophysiological studies of the isolated ciliary epithelium
have demonstrated the need for Na+ and HCO3- for the
maintenance of indices of ion transport or secretion across the
membranes (transepithelial potential difference and short-circuit
current).(1) The anionic transport systems of the anterior uvea
have a strong relationship to those of the kidney and liver. The
process of aqueous humor formation is very much alike to the
formation of the cerebrospinal fluid.
Aqueous humor composition
Aqueous humor has a refractive index of 1.336, lower
than that of the cornea. Because of this fact, there is a slight
divergence of the light rays as they pass the cornea-aqueous
interface. The density and the viscosity of the aqueous humor
are lower than that of water and the osmolality is slightly higher
of that of plasma. The volume of human anterior chamber is
approximately 200 μL, whereas that of the posterior chamber is
approximately 60μL. The main difference between aqueous and
plasma is found in the very low protein content of the aqueous
which is in the region of 0.5% of plasma.(1)
The composition of protein in the aqueous is also
different from that in plasma. There are far less high molecular
weight proteins such as beta lipoproteins and immunoglobulin in
the aqueous than in the plasma. IgG is present in aqueous at a

1
Corresponding author: Gabriela Denisa C ileanu, Str. Decebal, Nr. 3 , Bl. C1, Sc. B, Ap. 29, Piatra Neam , România, E-mail:
dcaileanu@yahoo.com, Phone: +047455 26842
Article received on 14.10.2016 and accepted for publication on 23.02.2017
ACTA MEDICA TRANSILVANICA December 2016;21(4):54-56
AMT, vol. 22, no. 1, 2017, p. 54
 CLINICAL ASPECTS
concentration of 3mg per 100ml, whereas IgM, IgA and IgD are
absent.(3) In eyes with uveitis, the level of IgG increases and
IgA and IgM also appear. There also have been reported
elevated levels of aqueous matrix metalloproteinase (MMP-2)
and tissue inhibitors of MMP (TIMP-1, TIMP-2 and TIMP-3 in
p with myopia in a stationary stage and with an axial length
greater than 26 mm.(4) In aqueous humor there are also trace
quantities of complement proteins and of components of
fibrinolytic and coagulation systems, excepting plasminogen and
plasminogen proactivator which are present at more significant
levels. Only traces of the inhibitors of plasminogen activator are
present, ensuring that the aqueous outflow pathway remain free
of fibrin.
There are also in aqueous humor small quantities of
mono- and dinucleotide that play a role in the control of corneal
endothelium ion transport. α and γ-lens crystallins are also
present in small quantities in healthy eyes and their levels
increase in cataract. The amino acid concentration is frequently
higher in the aqueous than in the plasma. It has been suggested
the existence of six transport systems for amino acid in the
ciliary epithelium: three independent for neutral amino acids and
separate mechanisms for basic aminoacids, acidic amino acids
and urea. Proteomic analysis of the human aqueous humor
indentified 676 nonredundant proteins.(5) The elucidation of
aqueous proteome will establish a foundation for protein
function analysis and identification of differentially expressed
markers associated with diseases of the anterior segment. Open
angle glaucoma patients (primitive and pseudoexfoliative type)
have elevated levels of multiple biomarkers of Alzheimer
disease in aqueous humor, compared with cataract patients.
They have elevated levels of apolipoprotein Al, Apolipoprotein
CIII, transthyretin (TTR), complement factor H, and
complement C3 and α2 macroglobulin.(6)
In aqueous humor there are very high concentrations
of ascorbate and lactate. Ascorbate is actively secreted in
aqueous humor and its production depends on the presence of
ATP and Na + gradient. Ascorbate is concentrated mainly by the
lens epithelium and has a protective effect against UV-induced
DNA damage to this tissue. Ascorbate has an antioxidant role,
partially absorbs UV radiation and regulates the sol-gel balance
of mucopolysaccharides in the trabecular meshwork. Lactate
accumulates in the anterior chamber, being produced by both
ciliary body and retina. In anterior chamber lactate concentration
is considerably higher than in plasma.
Aqueous humor also contains hydrogen peroxide, as a
result of reactions between ascorbic acid and trace metals.
Human trabecular cells exposed to 1 mM hydrogen peroxide
show reduced adhesiveness to the extracellular matrix proteins
fibronectin, laminin and collagen types I and IV.(1) Repeated
oxidative stress in vivo may result in reduced trabecular
meshwork cells adhesion leading to cell loss, one of the major
histopathologic changes in glaucoma. Glucose concentration in
aqueous humor is slightly less than that in plasma. Glucose
diffuses into the aqueous and also in the cornea. Its
concentration in the corneal endothelium is half of that in
aqueous.
Oxygen is also present in aqueous humor as well as
transforming growth (TGF) β2 factor that may play a role in
glaucoma pathogenesis. The intrinsic activity of TGF β 2
contributes to the maintenance of the anterior chamber
associated immune deviation. Many physiologic systems,
including the central nervous system, endocrine and
cardiovascular systems, as well as change in metabolic activity
influence the secretion of aqueous humor. The aqueous
production shows a diurnal cycle, decreasing by as much as 50%
at night.(8) The aqueous diurnal cycle is influenced by
AMT, vol. 22, no. 1, 2017, p. 55
circulating cathecolamines, epinephrine and norepinephrine, and
by the activity of the subject. Aqueous production diminishes
slightly with age and by now there is no report of an age-
dependent loss of ciliary epithelial cells. Hypothermia leads to a
decrease in aqueous humor formation, reflecting a deactivation
of metabolic processes necessary to maintain active secretion.
The ultrafiltration component of aqueous formation is
pressure sensitive, decreasing with increasing IOP. This
phenomenon is called pseudofacility and is quantifiable.
Decreased plasma osmolality reduces aqueous formation, and
also does uveitis, especially iridocyclitis. There are also
hormonal influences on aqueous secretion and many
pharmacologic agents reduce aqueous secretion and thus IOP.
They are largely used in glaucoma treatment, including β-
adrenoceptor antagonists such as timolol, betaxolol and others,
carbonic anhydrase inhibitors, and α2-adrenoceptor agonists
such as brimonidine. Thicker corneas may be associated with
lower aqueous production and lower uveo-scleral outflow.(9)
Blood aqueous barrier
Large molecules such as protein are present in
aqueous in small quantities although their plasma concentration
is high. In humans, normal plasma total protein levels are 6g per
100 mL, and in aqueous humor there are less than 20 mg protein
per 100 mL (less than 0.5% of plasma concentration). This is
due to the existence of blood-aqueous barrier, an epithelial
barrier formed by the nonpigmented ciliary epithelium and the
posterior iridial epithelium and by the endothelium of the iridial
vessels. Both these compounds have tight junctions of the
―leaky‖ type. There is some evidence indicating that the tight
junctions of the ciliary epithelium have few sealing strands,
these being responsible for a low transepithelial resistance
characteristic of the less tight and somewhat more ―leaky‖
epithelia.(7) Thus, the blood-aqueous barrier is not absolute. The
greater the lipid solubility of a molecule, the greater its ability to
penetrate the barrier and to pass into the posterior chamber.
Certain substances, such as urea, creatinine and some sugars
penetrate the blood-aqueous barrier but they are slower than
across capillary walls. The blood–aqueous barrier is fragile and
may be disrupted by various stimuli such as corneal abrasions,
uveal inflammation, intraocular infections, paracentesis,
intraocular surgery, topical applied drugs (anticholinesterase
agents). The resultant aqueous produced is the ″secondary″
aqueous with a marked increase in protein concentration.
Certain substances as mannitol penetrate poorly the blood-
aqueous barrier and are used clinically to reduce IOP. They
accumulate in the extacellular spaces of the body, producing a
high osmotic pressure that draws water from cells and ocular
fluids leading to a reduction of IOP.
Aqueous humor outflow
Aqueous humor produced in the ciliary body and
released in the posterior chamber passes through the pupil in the
anterior chamber and then through trabecular meshwork,
Schlemm’s canal and aqueous veins. The fluid movement is
directed by pressure change. In the eye normal IOP is 15 Hg, but
pressure drops to 9 mm Hg in SC and further to 7-8 mm Hg in
aqueous veins.(10)
There is a mechanosensing activity in trabecular
meshwork and Schlemm’s canal, including ways in which cells
transfer mechanical changes into biologic signals. There is no
direct evidence of baroreceptor activity in the eye but some
evidence for an ―ocular baroreflex‖ is given by the fact that eye
pressure is tightly regulated over the entire life and eyes exposed
to stretching and increased fluid flow return to starting IOP
levels. The most likely site for this baroreceptor activity in the
conventional outflow pathway appears to be the interface
between the juxtacanalicular region of the trabecular meshwork
 CLINICAL ASPECTS
and the Schlemm’s canal.( 0) The cells and extracellular matrix
in this region are considered the site of outflow resistance in
glaucoma.
The Schlemm’s canal inner wall has two diametrically
opposed functions. First, it must allow aqueous to pass in a basal
to apical direction, facilitating entry into the canal lumen.
Second, the Schlemm’s canal is part of the blood aqueous
barrier along with the ciliary epithelium, the iris vascular
endothelium and the posterior iris epithelium.(11) This barrier
formed by the tight junctions between the endothelial cells of
the inner wall of the canal prevents blood products from
entering the eye when elevated episcleral venous pressure
exceeds IOP. The factors that regulate the blood aqueous barrier
at the level of Schlemm’s canal are poorly understood.
Schlemm’s canal endothelium stretches and expands as a
response to pressure, in both size and contractile ability.
Canalicular endothelial cells form more giant vacuoles and
pores increased in size as a response to pressure. Schlemm’s
canal cells undergo shear stress much alike to that in large
arteries and act by aligning in the direction of flow.
The pressure in the outflow system is influenced by
pulse, blinking and head movement, indicating that fast and
slow adaptation mechanisms may be present to respond to rapid
pressure change. Tissue and cell stiffness are factors that may
alter the responsiveness of trabecular meshwork and Schlemm’s
canal to fluid flow, shear stress and pressure. There are changes
in cytoskeleton, morphology, protein and gene expression
produced in trabecular meshwork cells as a result of changing
substrate stiffness.(10) It is well known that trabecular
meshwork stiffness increases in primitive open angle glaucoma
with regional variability.
It has been proved that drug treatments also modify
Schlemm’s canal stiffness. If drug treatment increased
Schlemm’s canal stiffness, resistance to outflow also increased.
If drug treatment relaxed the cells, resistance decreased. In
Schlemm’s canal cells vacuole and pore formation is pressure
dependent and is influenced by stiffness. The number of pores is
reduced in glaucoma tissue. Increased trabecular and canal
stiffness with age or primitive open angle glaucoma could
reduce baroreceptor activity and pore formation, increasing
outflow resistance. Thus drugs that modify cytoskleton directly
or indirectly, such as Rho Kinase inhibitors and latrunculins,
may decrease cell stiffness and reduce outflow resistance.
Defining the mechanosensing activity of the
conventional outflow pathway may be the clue for new
therapeutic options in primitive open angle glaucoma.
Latrunculins A and B significantly reduced IOP ade were
consistent in their facility increasing effect in living cynomolgus
monkey.(12) This indicates that active disorganization of the
actin cytoskeletoninthe trabecular meshwork by latrunculins
may be an useful antiglaucoma strategy. Effects on corneal
endothelium or ciliary epithelium (pseudoguttata, increased
central corneal thickness) are a potential safety issue.
The extracellular matrix in the juxtacanalicular region
of the trabecular meshwork is responsible for a large part of
outflow resistance in glaucoma. It is composed of elastin,
collagens, laminin, fibronectin and fibrillin and increases with
age and in primitive open angle glaucoma. This increase is
primarily seen in ″sheath-derived plaque material″ which
correlates with axonal damage in glaucoma. Matrix
metalloproteinases, tissue inhibitors of matrix
metalloproteinases and other inhibitors of these substances are
involved in remodeling and maintaining of extracellular matrix.
Another important factor in modulating outflow resistance is the
presence of various glycosaminoglycans that are present in the
intertrabecular spaces. Changes in the extracellular matrix bring
AMT, vol. 22, no. 1, 2017, p. 56
the cells in contact with integrins that activate integrin-signaling.
This outside-in signalling affect outflow facility by regulation of
cell contractility. In addition, inside-out signaling can be
initiated by growth factor receptor pathways or by G-protein-
coupled receptors that induce activation of the integrin. Eleven
integrins are expressed by the TM cells.(10)
In addition, an uveo-scleral outflow pathway exists,
that accounts for nearly half of total aqueous drainage in young
human eyes. New evidence suggest ocular lymphatics, formerly
believed to be absent in the eye, may represent an
uveolymphatic exit route for fluid and proteins retained in the
uveo-scleral tissue. A minimal amount of fluid leaves the
anterior and posterior chambers through the iris and through the
vitreous to the optic nerve and retinal vessels.(1)
CONCLUSIONS
Aqueous humor is a liquid of paramount importance in
the homeostasis of normal human eye. Apart of maintaining the
IOP and the internal alignment of intraocular structures, it
nourishes the ocular structures that are necessarily avascular, the
posterior cornea, the crystalline lens and the anterior vitreous.
During ocular diseases treatment very effort must be made for
its normal production and existence inside the eye.
REFERENCES
1. Gabelt BT, Kiland JA, Tian B, Kaufmann PL. Aqueous
Humor: Secretion and Dynamics, in Duane’s Foundation of
Clinical Ophthalmology. 2013;2:12957-13018.
2. Green K. Physiology and Pharmacology of Aqueous
Humor Inflow. Surv Ophthalmol. 1984;29:208-14.
3. Sen DK, Sarin GS, Saha K. Immunoglobulin in human
aqueous humor. Br.J. Ophthalmol. 1977;61:216-7.
4. Jia Y, Hu DN, Zhu D, Zhang L,Gu P, Fan X,et al. MMP-2,
MMP-3, TIMP-1, TIMP-2, and TIMP-3 Protein Levels in
Human Aqueous Humor: Relationship with axial length.
Invest Ophthalmol Vis Sci. 2014;55(6):3921-28.
5. Chowdry UR, Madden BJ, Charlesworth MC, Fautsch MP.
Proteome analysis of Human Aqueous Humor. Invest
Ophthalmol Vis Sci. 2010;51:4921-31.
6. Inoue T, Kawaji T, Tanihara H. Elevated Levels of
Multiple Biomarkers of Alzheimer Disease in the Aqueous
Humor of Eyes with Open Angle Glaucoma. Invest
Ophthalmol Vis Sci. 2013;54:5353-58.
7. Cunha-Vaz J. The Blood-Ocular Barriers. Surv
Ophthalmol. 1979; 23:279-96.
8. Nau CB, Malihi M, McLaren JW, Hodge DO, Sit AJ.
Circadian Variation of Aqueous Humor Dynamics in Older
Healthy Adults. Invest Ophthalmol Vis Sci.
2013;54(12):7623-9.
9. Gulati V, Ghate DA, Camras CB, Toris CB. Correlations
Between Parameters of Aqueous Humor Dynamics and the
Influence of Central Corneal Thickness. Invest Ophthalmol
Vis Sci. 2011;52:920-926.
10. Chowdhury UR, .Hann CR, .Stamer WD, Fautsch MP.
Aqueous Humor Outflow: Dynamics and Disease. Invest
Ophthalmol Vis Sci. 2015;56(5):2993-3003.
11. Rosman M, Skaat A, Park SC, Chien JL ,Ghassibi M, Rathi
S, et al. Cyclopentolate 1% Decreases Schlemm’s Canal
Dimensions in Healthy Subjects. Invest Ophthalmol Vis
Sci. 2013;54(15):485.
12. Peterson JA, Tian B, McLaren JW, Hubbard WC, Geiger
B, Kaufman PL. Latrunculins Effects on Intraocular
Pressure, Aqueous Humor Flow and Corneal Endothelium.
Invest Ophthalmol Vis Sci. 2000;41:1749-58.
 CLINICAL ASPECTS

THE EFFICACY OF THE ALVARADO SCORE IN PEDIATRIC

POPULATION OF MUREȘ REGION

RADU PRIȘCĂ1, TAMAS TOTH2, ANA MARIA PRIȘCĂ3, ZOLTAN DERZSI4, HOREA GOZAR5
1,4,5
University of Medicine and Pharmacy Tîrgu-Mureș, 2Student, University of Medicine and Pharmacy Tîrgu-Mureș,
3
County Hospital of Tîrgu-Mureș

Keywords:
appendicitis, Alvarado
score, diagnosis
Abstract: Appendicitis diagnosis may be difficult in pediatric population, despite the developed imaging
techniques and laboratory tests. Considering this fact, many authors have attempted to develop
predictive scores for this pathology. One of the most popular is the Alvarado score, which uses both
physical examination and laboratory findings and was quoted by multiple studies as having a great
value of sensitivity and specificity. The aim of our study is to check the applicability of the Alvarado
score in our pediatric population. Our retrospective study comprised 133 patients aged between 2 and
18 years who had been presented with suspected appendicitis at the Department of Pediatric Surgery
and Orthopedics, Emergency Clinical County Hospital of Tîrgu-Mureş between 1st of April 2012 and
30th of July 2014. We found that in different age groups the cut off value and the accuracy of the
Alvarado score varied, which leads us to say that the Alvarado score can be of assistance in setting the
diagnosis of acute appendicitis, but it cannot be used as an exclusive standard, the final decision being
in the hand of the treating surgeon.

INTRODUCTION complication of acute appendicitis, which includes perforation,

Appendicitis is a version of diverticulitis in which the
appendix represents a diverticulum with a narrow lumen.
Inflammation of the appendix is initiated as the result of an
obstructive process within the lumen.(1) The etiology of the
obstruction is not always clear. It can be caused by lymphoid
hyperplasia as a consequence of bacterial infection or the
presence of a feacoltih, a calculus, a foreign body (for example
fruit seed) in the lumen of the appendix.(2)
Despite the developed imaging techniques and
laboratory tests the diagnosis of acute appendicitis is based on
the patient’s history and the physical examination. The signs and
symptoms develop in 24 to 36 hours. The pain classically begins
as a poorly defined continuous periumbilical pain that migrates
to the right lower quadrant over a period of hours. Other major
symptoms which are frequently present in the early stages are
fever, anorexia, nausea/vomiting. Physical examination shows
localized tenderness to palpation and occasionally rebound pain.
There are some difficulties in diagnosing acute
appendicitis in the new-born and the preschooler population.
The rate of negative appendectomy in children is in the range of
4-50% in various reports. It gives symptoms similar to other
childhood diseases like mesenteric lymphadenitis, pneumonia,
gastroenteritis. Infants present only lethargy, irritability, and
anorexia in the early stages, but may develop vomiting, fever
and pain as the disease progresses. They can present atypical
symptoms. Usually the whole abdomen is swollen and painful.
The perforation can occur in 6 to 12 hours from the appearance
of the first symptoms. If the patient does not speak, we may get
the history from the parents, but this can be subjective. Young
children have less ability to tell about their developing
symptomatology compared to adolescents. Sometimes children
may conceal their symptoms because of fear. They might make
the physical examination impossible with their behavior. If the
presentation is further delayed, the patient may present with a
peritonitis, and abscess. Approximately one-third of children
with acute appendicitis have perforation by the time of
operation. Complications can exacerbate the patient’s status.
Clinical scoring systems can be of assistance in setting
the diagnosis of acute appendicitis in time. The Alvarado score,
which uses both physical examination and laboratory findings,
has a great value of sensitivity and specificity. Many studies
have recommended that patients with a score of less than 4 can
be discharged, while those with scores between 5 and 7 should
be kept under observation, and those with a score greater than 7
should undergo surgery.(3,4,5,6,7)
PURPOSE
The aim of this study is to check the applicability of
the Alvarado score in our pediatric population.
MATERIALS AND METHODS
Our retrospective study comprised 133 patients aged
between 2 and 18 years who had been presented with suspected
appendicitis at the Department of Pediatric Surgery and
Orthopedics, Emergency Clinical County Hospital of Tîrgu-
Mureş between st of April 2012 and 30th of July 2014. The
Alvarado score was calculated form variables such as pain in the
right lower quadrant, anorexia, nausea or vomiting, tenderness
in the right lower quadrant, rebound pain, pyrexia, leukocyitosis,
and neutrophilic leukocyitosis left shift. Patients were divided
into three groups according to the Alvarado score: AS<4, AS 5-
7, AS 8-10. Another division was made as follows: patients
younger than 7 years (preschooler group), aged between 7 and
11 (elementary school group), aged between 12-15 (middle
school group) and aged between 16-18 (high school group).
Statistical data were evaluated with SPSS software to
calculate means, frequencies, sensitivity, specificity and the area
under the ROC curve.

2
Corresponding author: Tamas Toth, Str. Gh Marinescu, Nr. 50, Tîrgu-Mureş, România, E-mail: tamas.toth@yahoo.com, Phone: +40265 212111
Article received on 13.01.2017 and accepted for publication on 27.02.2017
ACTA MEDICA TRANSILVANICA March 2017;22(1):57-59
AMT, vol. 22, no. 1, 2017, p. 57
 CLINICAL ASPECTS
RESULTS
In the study, there were included 78 (58.64%) boys
aged between 2 and 17 years (mean age: 10.02) and 55 (47.35%)
girls aged between 3 and 17 years (mean age: 11.85). The
overall mean Alvarado score was 7.36 ± 1.96. In 11 cases
(8.27%) the score was less than 4. The most frequent symptom
in 45.45% of the cases was migration of pain in the right lower
quadrant (RLQ). In this group the rate of perforation was low, it
occurred in 9.09%. The average of the days spent in the hospital
was 4.90.
In 54 cases (40.60%), the score was between 5 and 7,
with a rate of perforation of 1.85% and an average
hospitalization of 5.16 days. In this group, the most frequent
symptoms were migration of pain to the RLQ (87.04%) and
tenderness in the RLQ (83.33%).
In 68 cases (51.12%) the score was higher than 7. The
most frequent symptoms were the same as in the other group:
95.59% tenderness in the RLQ and leukocytosis with 94.12%.
The rate of perforation was higher, with a rate of 18 (26.47%)
cases. 12 of the perforated cases came from the rural area and 6
from the urban area.
According to the statistical analyses the cut off value
was 7, where the specificity was 93.3% and the sensitivity was
56.8% with a positive predictive value (PPV) of 0.985 and a
negative predictive value (NPV) of 0.215. We found a
significant correlation at the 0.01 level (r= -0.909). The analysis
of the ROC curve demonstrated an area under the curve of
81.1% (figure no. 1). We did not find a significant correlation
between the Alvarado score and the type of the appendicitis.
Figure no. 1. ROC curve
We found that in different age groups the cut off value
and the accuracy of the Alvarado score varied.
In the preschooler group with 6 girls and 14 boys, the
mean age was 4.78, and the mean AS was 7.7. The most
frequent symptoms were migration of the pain to the RLQ, and
nausea or vomiting in 80% of the cases. The specificity was
100% and the sensitivity was 58.8% with a PPV of 1.00 and a
NPV of 0.30. In this group we didn’t find a correlation between
the sensitivity and specificity at the cut off value of 8.
In the elementary schooler’s group the mean age was
9.05 with 17 girls and 38 boys. They have been presented most
frequently with migration of the pain to the RLQ in 89.09% of
the cases, tenderness, and nausea/vomiting in 85.45%. We found
at the cut off value of 5 a specificity of 66.7% and sensitivity of
98.1% with a PPV of 0.981 and NPV of 0.667. The correlation
between specificity and sensitivity was significant at 0.05 level
(r= 0.021). The accuracy in this case was 96.5%.
In 21 girls and 20 boys with a mean age of 13.51 were
included in the middle scholar group with a mean of AS 7.17. In
this group the most frequent symptom was also the migration of
the pain and tenderness in the RLQ, both with 87.80%. The
AMT, vol. 22, no. 1, 2017, p. 58
specificity was 100% and the sensitivity was 61.1% at a cut off
value of 8. A PPV of 1.00 and a NPV of 0.263 showed an
accuracy of 65.9%. The correlation between the specificity and
sensitivity was significant at 0.05 level (r= 0.011).
The high-schooler’s group was formed by 2 girls and
5 boys with a mean age of 16.47, and a mean of AS of 6.29. In
94.12%, they have presented migration of the pain and
tenderness in the RLQ. The specificity was 100% and the
sensitivity was 50% at a cut off value of 7. A PPV of 1.00 and a
NPV of 0.300 showed an accuracy of 58.8%. The correlation
between the specificity and sensitivity was significant at 0.01
level (r= 0.003).
DISCUSSIONS
Acute appendicitis is a common cause of abdominal
pain and can be difficult to diagnose, especially during the early
stages. There is still appreciable morbidity and occasionally
mortality which may be related to failure of making an early
diagnosis. Clinical scoring systems were developed in order to
sustain the clinical diagnosis. The Alvarado scoring system was
developed in 1986. Alvarado conducted a retrospective study on
305 patients admitted for suspected appendicitis and he
evaluated common clinical and laboratory findings in relation to
pathologically proven acute appendicitis. The initial study
included adults and children, with an age range of 4 to 80 years.
An Alvarado score above 7 was considered high risk for
appendicitis with a sensitivity of 81% and a specificity of 74%.
Yildirim(8) et al. performed surgery on 14 patients
with AS<4, and detected AA in 13 (92.8%) cases. Yücel et al.(7)
found 13 (56.5%) AA cases out of 23. Winn et al.(9) discharged
12 patients, but 4 were re-admitted and 2 of them underwent
surgery, but appendicitis was not found. In our study, 11 patients
underwent surgery with an AS<4 and AA was found in 6 cases
(54.5%). According to these results, patients with a score less
than 4 should be reexamined if the pain increases. A low
Alvarado score does not exclude a possible acute appendicitis.
Reexamination can prevent the complications of appendicitis.
AS between 5 and 7 was calculated in 54 cases in our
study and AA was found in 45 (83.3%) cases. Yücel et al(7)
detected AA in 75.9%, and Yildirim et al.(8) in 84.2% of their
patients. Patients with AS between 5 and 7 should be monitored
and AS should be calculated at certain intervals.
Yildirim et al.(8) detected AA in 91% of the patients
with a score between 8 and 10. We found AA in 67 (98.5%) out
of 68 cases. Patients who belong to this group should undergo
surgery without the need of other examination in order to
prevent the complications.
Bond et al.(10) found that AS to be least accurate in
preschool children. In our study were included 20 patients from
this age group and in 17 cases (85%) had AA. In this group of
patients we can consider a lower AS as a cut off value because
the data obtained from the anamnesis can be false negative. If
the AA is not treated in time the appendix can perforate. The
general perforation rate of AA was 20% according to Mentes et
al.(11) The prevalence of perforation increases as the AS
increases. Yücel et al (7) found perforation in 7.7% of the cases
in the AS<4 group, 27% in the AS 5-7 group, and 27% in the
AS 8-10 group. In our study, the perforation occured in one case
(9.09%) in AS<4 group, one case (1.85%) in AS 5-7 group, and
26.47% in AS 8-10 group. Douglas et al.(12)suggested that
surgery is not necessary if the Alvarado score is less than 4. Our
study and the data from literature (ex. Yücel et al(7) ) showed
that perforation cannot be correlated with the Alvarado score,
the risk of perforation is there even when the AS is low.
However, it is more likely in patients with high AS. When there
is a chance of perforation we suggest reevaluation of the case,
 CLINICAL ASPECTS

since the perforation may not be determined based on the AS.

Sometimes, from the clinical signs and laboratory findings we
can suspect acute appendicitis, but as a result we have negative
appendectomy. In the litearature, the negative appendectomy
rate is between 15 and 40%, in our study we found 11%.
No study has investigated the efficacy of the Alvarado
score just in the pediatric population. In comparison to the data
from the literature, we have achieved better results. We can use
the Alvarado score in predicting acute appendicitis in pediatric
population with a higher confidence.

CONCLUSIONS
The Alvarado score can be of assistance in setting the
diagnosis of acute appendicitis, but it cannot be used as an
exclusive standard. It can be used with a higher confidence in
pediatric population. However, a low score does not exclude the
possibility of a perforated appendix. The perforation may not be
determined based on this score. As a clinical scoring system it
can be repeated during active observation and influence the
decision to operate. It can also be used by general practitioners;
they could estimate the surgical indication. The final decision
has to be based on the surgeon’s opinion.

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3. Owen TD, Williams H, Stiff G, et al. Evaluation of the
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4. Gonçcalves JP, Cerqueira A, Martins S. Validação do score
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6. Kariman H, Shojaee M, et al. Evaluation of the Alvarado
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7. Yücel Y, Dinç D, et al. How reliable is the Alvarado score
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Trauma&Emergency Surgery. 2014;20(1):12-18.
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9. Winn RD, Laura S, Douglas C, Davidson P, Gani JS.
Protocol-based approach to suspected appendicitis,
incorporating the Alvarado score and outpatient antibiotics.
ANZ J Surg. 2004;74:324-9.
10. Bond GR, Tully SB, Chan LS, Bradley RL. Use of the
MANTRELS score in childhood appendicitis: a prospective
study of 187 children with abdominal pain. Annals of
Emergency Medicine. 1990;19(9):1014-1018.
11. Mentes O, Eryilmaz M, Yigit T, Tasci S, Balkan M,
Kozak O, et al. Retrospectively analysis of appendectomies
which performed elderly cases. Akademik Acil Tip Dergisi.
2008;7:36-41.
12. Douglas CD, Macpherson NE, Davidson PM, Gani JS.
Randomised controlled trial of ultrasonography in
diagnosis of acute appendicitis, incorporation the Alvarado
score, BMJ. 2000;321:919-22.

AMT, vol. 22, no. 1, 2017, p. 59

 CLINICAL ASPECTS

POSTPUBERTAL YOLK SAC TUMOUR OF THE TESTIS. THE

HISTOPATHOLOGIST’S POINT OF VIEW

ZAMFIR-RADU IONESCU1
1
Paediatric Hospital Pitești, University of Pitești

Keywords: yolk sac Abstract: Yolk sac tumour of testis (YSTT) is an aggressive neoplasm that resembles the allantois of the
tumour, hepatoid, embryo and becomes a difficult diagnosis in children, even in a pure form. We present the case of a- 16
prepubertal testis, year-old boy with a right scrotal swelling and haematocele that revealed due to microscopic
pediatric, examination a hepatoid – microcystic YSTT on a small testicular biopsy. The serum alpha-feto-protein
histopathology (AFP) showed detectable levels as high as 3,7 ng/L, with negative values for β-hCG and CEA 125.
Immunohistochemistry requires AFP, SALL4, Glypican 3 and cytokeratins.

INTRODUCTION scheduled, with epidural anaesthesia.

Yolk sac tumour of testis (YSTT), also called
endodermal sinus tumour of Teilum, the endoderm being the Figure no. 6. Echographic aspect of the right testicle (TD). A
most inner layer of the yolk sac of the embryo, thus, resembling septate, multicystic aspect of an enlarged, bulging mass can
the yolk sac, the extraembryonic mesenchyme and the allantois. be observed
Pure YSTT is seen in children and infants, classified as
malignant, representing almost 70% all testicular germ cell
tumours. Increased serum α-fetoprotein is the most frequent
preclinical clue to the diagnosis, while, clinical presentation is
represented by testicular, painless, enlargement, sometimes as a
frank, pseudo-traumatic, haematocele.(1) Although appearing as
a benign condition, a scrotal, painless swelling, might be
overlooked, the clinician should take in account that 15-50% of
cases are associated with a testicular tumour and a thorough
examination for a malignant pathology becomes mandatory.(2)

PURPOSE
The purpose of this article is to attract the clinician
attention towards diagnostic issues frequently encountered in
histological assessment of testicular germ cell tumours,
especially in paediatric pathology, within small surgical
biopsies.
MATERIALS AND METHODS
A 16-years old male patient was admitted with an
enlarged painful, right testicle at the Surgery Department of our
Hospital. During close inspection, the scrotum had a bluish,
elastic appearance, with a liquid-like consistency during
palpation. Screening laboratory tests proved negative for any
acute inflammatory condition, although ultrasonography shows
a tumour, apparently, as a extratesticular mass, with a
multicystic appearance (figure no. 2), with maximum
dimensions of 4/10,4 cm, that compressed the testis parenchyma
(1,5/3,6 cm). Subsequently, blood samples were obtained for
analysis of β-hCG, AFP (α-fetoprotein) and CEA 125
(carcinoembrionic antigen). Doppler ultrasonography proved
intraparenchymal signal, raising the diagnostic suspicion of a
YSTT. The left testis proved a homogenous structure, with
dimensions within 2,7/4 cm, and a positive Doppler signal. No
other clinical or radiologic anomalies were detected during
immediate clinical follow-up. A surgical intervention was
Thus, a testicular mass was discovered, with no gross
clues for albuginea or vaginalis invasion. Afterwards, a quantity
of 20 cc of haemorrhagic liquid inside the vaginalis exteriorised
after incision, in a volume of 10-12 cc. Biopsies were sampled,
from vaginalis, albuginea and parenchymal testis, and referred
to the Pathology department in our hospital. The first biopsy (a)
comprises an area of testicular parenchyma as well as albuginea
testis with dimensions within 2,5/0,5 cm. The second (b)
consists of thickened, loose, elastic, testicular vaginalis – 5/5/0,3
cm – with a brown, homogeneous colour. The latter fragment (c)
from cremasteric muscle, with a brown colour and fragile
appearance, had dimensions of 1/0,5 cm (figure no.1). These
fragments were fixed in buffered formalin 4%, in order to
preserve any lymphocytic distribution or molecular antigenicity.
Afterwards, the fragments were processed in alcohol in
successive grades, i.e. 70 and 80% concentration in the first day,
three subsequent baths of 96% concentration alcohol, and the
latter two baths of 99,96% and, respectively, another two
isopropyl alcohol. Paraffin and wax impregnations were
performed, followed by embedding and thin sections, 2-3 µm in

1
Corresponding author: Zamfir-Radu Ionescu, B-dul Eroilor, Nr. 1, Pite ti, Arges, România, E-mail: dr.raduionescu@yahoo.com; Phone: +40769
718748
Article received on 07.12.2016 and accepted for publication on 23.02.2017
ACTA MEDICA TRANSILVANICA March 2017;22(1):60-62
AMT, vol. 22, no. 1, 2017, p. 60
 CLINICAL ASPECTS
thickness. The obtained samples were stained with haematoxylin
and eosin.
Figure no. 7. Macroscopic appearance of the tissue samples
from the case: (a) testicular parenchyma; (b) testicular
vaginalis; (c) cremasteric muscle
RESULTS
On the resulting slides we have observed a thickened
albuginea testis with slight inflammation and scattered
lymphocytes, fatty tissue areas with adipocytes and a thickened,
haemorrhagic vaginalis. In the sampled testicular parenchyma
we detected sarcoid, large-cell, polygonal shaped eosinophilic
cells organised in inter-tubular sheets (figure no. 3), mostly
arranged in a hepatoid fashion, with a perivascular distribution,
focally solid and, eventually, reorganising in honeycomb-like
laces, towards the albuginea, with epithelioid cell proliferation
and capilar hyperaemia. Some cells proved to have a signet ring
appearance.
Figure no. 8. Microscopic appearance of the testicular
biopsy: diffuse spreading epitheliod cells between the tubuli;
basal compartment of the tubuli with cells and vacuolization
of Sertoli cells; central mitosis is visible (personal collection,
100x, H&E)
In the tumour aspect between the intermingled
tubules, Leydig cells were appearing hyperplastic, almost with
an invasive tendency in the basal compartment of the tubules
(figure no. 4). The pampiniform plexus proved to be hyperaemic
and having no signs of any vascular refraction whatsoever.
However the plexiform appearance in some areas pleads for a
mixed testicular tumour, either with a Yolk sac component, a
non-germinative component. The blood samples revealed a
negative β-hCG component, with a AFP level of 3,7 ng/L. This
value, although indifferent from the laboratory point of view
(normal value limit below 7 ng/L) cannot be ignored, regarding
AMT, vol. 22, no. 1, 2017, p. 61
the spontaneous haematocele with no local traumatic or heavy
effort history. Although Schiller-Duval bodies were not present,
elements of intratubular germ cell neoplasia – like
polychromasia, bland, vesicular, excentric nuclei – were
encountered with a reticular and cord-like pattern, and
moderately raised AFP, the diagnosis concluded to hepatoid –
microcystic Yolk sac tumour.
Figure no. 9. Microscopic aspects of the tumour in case:
sheets of cells with bland, vesicular nuclei, arranged in a
perivascular fashion, with, areas of sarcoid differentiation;
two tubuli with elements of intratubular germ cell neoplasia
(100x, HE, personal collection)
DISCUSSIONS
Macroscopic aspect of YSTT is that of a
nonencapsulated tumour, with a tan-white to yellow colour, soft
texture and a gritty, friable on the cut surface, with frequent
cystic change and gelatinous or mucoid appearance. The
microcystic pattern seems to be the most frequent histological
aspect, among the others aspects: macrocystic, glandular-
alveolar, endodermal sinus, solid, myxomatous, spindled,
hepatoid, papillary, parietal and polyvesicular or vitelline.(3)
Sometimes, histological differentiation between sarcoid YSTT
and choriocarcinoma testis might be difficult. It is generally
accepted that choriocarcinoma of testis is a malignant germ cell
neoplasm that might exhibit trophoblastic differentiation.
Usually, it is detected as a component of a mixed TGCT, in pure
form, comprising from 0,2% to 0,6% of all primary testicular
tumours. The metastatic spread of the tumour would become,
frequently, the first clinical sign either due to back pain – in
retroperitoneal spread – gastrointestinal bleeding, neurological
symptoms or haemoptysis in pulmonary metastasis. In
laboratory screening, an elevated hCG would point to the
diagnosis, extremely high levels leading to thyrotoxicosis, due
to molecular similarities with thyroid stimulating hormone.
Often, hCG levels are greater than 100,000 IU/litre. The average
dimensions of a testicular tumour, in a study of 13 patients
ranges from 1,5 cm to 10 cm, with a median of 7 cm, with
haemorrhage and necrosis on cut-surface, also with
haemorrhagic liquid in the vaginalis testis, being firstly
diagnosed as a haematocele.(4) Microscopic diagnostic criteria
in YSTT require the presence of polygonal cells, with
eosinophilic cytoplasm, bland nuclei arranged in different
patterns – reticular, papillary or cord-like. In some situation,
Schiller-Duval bodies might be encountered, resembling
primitive glomeruli having central capillaries surrounded by a
visceral and parietal layer of cells, thus, similar to endodermal
sinuses. Some authors report that YSTT, in childhood, have no
mixed histologic pattern but rather a pure one, therefore, not
becoming involved with any mixed germ cell tumour, like the
 CLINICAL ASPECTS

case of adults, however, in a postpubertal situation, it resembles

more with the adult type.(5) Regarding tumour markers, serum
alpha-feto-protein becomes a useful marker for early diagnosis
of YSTT, used to check for complete remission or recurrence.
Studies suggest that positive values of serum AFP are found in
all patients with tumours that contain a YSTT area. However, it
is speculated that preoperative serum AFP levels before initial
resection surgery have no prognostic importance, while
postoperative follow-up for AFP remain a good indicator for
residual stages of neoplasia. Chemotherapeutic treatment with a
good response would determine a lowering of AFP levels to a
normal status. Elevation of β-hCG implies the presence of a
germinal counterpart, probably choriocarcinoma, but values tend
to become very high.
Immunohistochemistry requires AFP that becomes
diffuse trough the cytoplasm and hyaline globules, although
pediatric tumors are often AFP negative, with an almost
indifferent serum AFP.(6) Cytokeratins, SALL4, Glypican 3,
with a variable PLAP positivity might be helpful, when AFP
remain negative, while intense CD117 is positive in the solid
histological pattern of YSTT.(7,8)

CONCLUSIONS
Yolk sac tumour of testis, although with a rare
incidence in scrotal pathology, is a very important condition that
could be overlooked in current clinical practice, by the surgeon,
paediatrician or pathologist. Differential diagnosis with other
testicular tumours is mainly achieved through corroboration
between histological and laboratory findings. A rapid
involvement of a complete and competent medical team should
avoid stage progressing or metastasis and, thus, an unfavourable
prognosis.

REFERENCES
1. Cao D, Humphrey PA. Yolk Sac Tumor of the Testis. The
Journal of Urology. 2011;186 (4):1475-1476.
2. Ahmed HU, Arya M, Muneer A, Mushtaq I, Sebire NJ.
Testicular and paratesticular tumours in the prepubertal
population. Lancet Oncol. 2010;11(5):476-83.
3. Cao D, Humphrey PA, Allan RW. SALL4 is a novel
sensitive and specific marker for metastatic germ cell
tumors, with particular utility in detection of metastatic
yolk sac tumors. Cancer. 2009;115(12):2640-51.
4. Alvarado-Cabrero I, Hernandez-Toriz N, Paner GP.
Clinicopathologic analysis of choriocarcinoma as a pure or
predominant component of germ cell tumor of the testis.
Am J Surg Pathol. 2014;38(1):111-8.
5. Nagasawa M, Johnin K, Hanada E, Yoshida T, Okamoto K,
Okada Y, et al. Advanced Childhood Testicular Yolk
Sac Tumor With Bone Metastasis: A Case Report,
Urology. 2015;85(3):671-673.
6. Dällenbach P, Bonnefoi H, Pelte M-F, Vlastos G. Yolk sac
tumours of the ovary: an update. Eur J Surg Oncol.
2006;32(10):1063-75.
7. Kao C-S, Idrees MT, Young RH, Ulbright TM. Solid
pattern yolk sac tumor: a morphologic and
immunohistochemical study of 52 cases. Am J Surg Pathol.
2012;36(3):360-7.
8. Zynger DL, Dimov ND, Luan C, Teh BT, Yang XJ.
Glypican 3: a novel marker in testicular germ cell tumors.
Am J Surg Pathol. 2006;30(12):1570-5.

AMT, vol. 22, no. 1, 2017, p. 62

 CLINICAL ASPECTS

CORRELATIONS BETWEEN BLOOD GROUPS AND INCIDENCE

OF CERVICAL CANCER

GEORGETA GÎNFĂLEAN1
1
“Lucian Blaga” University of Sibiu

Keywords: blood Abstract: Current knowledge about cervical cancer and its etiology showed a remarkable development.
groups, cervical For many years, the idea that blood groups may have other medical meanings besides the role they play
cancer, incidence, in making transfusion was discredited by scientists.(1) However, the link between the blood groups and
epidemiological feature the risk of certain diseases has been proven by researchers and epidemiologists.

INTRODUCTION Gynecology within the Clinical County Emergency Hospital of

Oncobiology recent discoveries have shown that there
is a correlation between blood type and susceptibility to the
occurrence of certain cancers.(2,3) In reality, cancer is a generic
name of some diseases based on the deregulation of the process
of exaggerated multiplication of ―defect‖ cells. British
oncobiologists examined the relationship between blood groups
and the statistical probability of the occurrence of various forms
of cancer. Oncobiologists practically proved that cancer
incidence did not differ according to blood group.(4,5) This was
known to anthropology healthcare and medicine, fairly
empirically, until there was discovered (yet, partially) the secret
of the human genome (genetic map of man), showing the ―real
truth about the destiny of human health evolution‖.(2)
Blood type 0I was found by a recent study that in
Iceland, with blood type 01 is predominant, the risk of cancer of
the cervix, rectum, skin is extremely high in women. Research
has shown statistically that all those who have blood type0I as
well as those in other areas like Chile, the US, Denmark and
some regions in Romania (such as Oltenia) has the same risk of
uterine cancer and skin.(5,6)
Blood type AII is the most common blood type in
Europe, including in Romania (82%) and quite vulnerable to the
emergence of many types of cancer. British oncobiologists
consider group A the most sensitive type to cancerous diseases,
40% of the Europeans with this group having a higher risk
factor.(6,7)
PURPOSE
Although blood type of patients is not a risk factor for
the occurrence of cervical cancer, as happens in ovarian cancer,
I studied this issue to see whether this hypothesis is confirmed.
Based on these considerations, the purpose of the
research was to demonstrate the correlation between blood
groups and the incidence of cervical cancer. In order to do this,
there was studied the global analysis of casuistry in relation to
the blood groups: analysis of casuistry in relation to living
conditions (smoking), age groups, origin (urban/rural),
educational level, obstetric history and degree of parity.
Sibiu, between 1 January 2002 and 31 December 2016 including
about 200 patients diagnosed and treated surgically from
neoplasm of the cervix during this period.
Statistical analysis of data was performed using the
Statistical Program for Social Science (SPSS) version 19.(8) For
the descriptive analysis of data we used frequency tables,
measures of central tendency and of dispersion and to determine
significant differences between groups, there were used
statistical parametric and non-parametric tests (binomial test,
chi-square test, T test, Kruskal – Wallis test). For data
representation, we used Microsoft Excel software.(8)
RESULTS AND DISCUSSIONS
Statistical analysis of data based on this parameter
(blood groups) showed the increased share of those with blood
type AII, a total of 78 persons representing 39%, followed by
group 0I with a number of 65 persons, representing 32.5%,
group BIII with a total of 34 persons, representing 17% and
group ABIV with a total of 23 persons, representing 11.5% of the
studied cases. There is a higher incidence of cervical cancer (p
<0.05) for blood groups AII and 0I as compared with blood
group BIII and ABIV, in the patients under study.
The table no. 1 and figure no. 1 show the number and
percentage incidence of the operated cases according to blood
type.
Table no. 1. Numerical and percentage incidence of the
operated cases according to blood types
Statistical
Blood type Number Percentage
significance
Group 0I 65 32.5%
Group AII 78 39%
p<0.05
Group BIII 34 17%
Group ABIV 23 11.5%
Total of cases 200 100%

MATERIALS AND METHODS The analysis of this aspect showed that maximum
The study material of this paper consists of the incidence of cervical cancer was in the patients with blood
observation sheets and surgery registers of the Department of group AII.

1
Corresponding author: Georgeta Gînf lean, Str. Moreni, Nr. 19, Sibiu, România, E-mail: rezultatemedicina@yahoo.com, Phone: +04723 254897
Article received on 13.01.2017 and accepted for publication on 27.02.2017
ACTA MEDICA TRANSILVANICA March 2017;22(1):63-66
AMT, vol. 22, no. 1, 2017, p. 63
 CLINICAL ASPECTS

Figure no. 1. Numerical incidence of the operated cases Figure no. 3. Distribution of casuistry according to blood
according to blood type type and age group

From the distribution of the cases in relation to blood

types, we mention the following: for blood group 0I, the
youngest patient was 25 years old and the eldest 71 years, with
an average of M = 49.65 (SD = 11.97). For blood group AII, the
youngest patient was 18 years old and the eldest 81 years, with
an average of M = 50.42 (SD = 12.47). For blood group BIII, the
youngest patient was 30 years old and the eldest 77 years, with
an average of M = 50.65 (SD = 12.79). For ABIV blood group,
the youngest patient was 26 years old and the oldest 59 years
old, with an average of M = 43.25 (SD = 11.03).
All these means between blood groups and age are
plotted in figure no. 2. Lower values can be observed for the Of the total cases of cervical cancer in relation to the
average age in the blood group ABIV in comparison to other blood groups and educational level, we mention that for all
blood groups (Kruskal - Wallis test, chi-square = 0.225, p = blood types, the largest share was recorded in the patients with a
0.386). basic level of education, so there were 41% of cases for blood
type 0I, 52% of cases for group AII, 50% of cases for blood
Figure no. 2. Distribution of the operated cases according to group BIII and 67% of cases were registered for blood type
blood type and age ABIV, as shown in figure no. 4.

Figure no. 4. Distribution of operated cases according to

blood type and education level

By analyzing the operated cases according to age

groups, it is observed that in the blood group 0I most patients
belong to the age groups of 41-45 years, 51-55 years, 61-65
years (14.5%), respectively in the age range 36- 65 years being
80% of patients with this blood type.
For blood group AII most patients belong in the age
group 36-40 years (20.9%), 56-60 years (17.9%) and in the age
range 36-60 years, there were 74.6% of patients with this blood
type.
For blood group BIII most patients belong to the age
group 46-50 years, 51-55 years (21.7%) and in the age range 46-
55 years there were 43.4% of patients with this blood type.
For blood group ABIV most patients belong to the age
groups of 46-50 years (25%), 24-30 years, 36-40 years, 51-55
years (16.7%) and in the age range 24-60 years, there 100% of
patients with this blood type.
All these results on the distribution of the operated cases
according to blood groups and age groups are presented in
figure no. 3.
Regarding the distribution of cases of cervical cancer
related to the blood groups and area of origin, it is noticed that
for blood group 0I, 50.9% of cases were from urban areas and
49.1% from rural areas (p = 0.893).
For blood group AIII, a percentage of 61.2% of cases
were coming from urban areas and 38.3% from rural areas (p =
0.067).
For the blood type ABIV, a rate of 58.3% were from
urban area and 41.7% from rural area (p = .532), while for the
blood group BIII, 56.5% were from rural areas and 43.5% of
cases from urban areas (p = 0.564), as represented in table no. 2.

AMT, vol. 22, no. 1, 2017, p. 64

 CLINICAL ASPECTS

Table no. 2. Distribution of cases of cervical cancer Figure no. 5. Distribution of cases of cervical cancer in
according to blood type and origin area relation to blood type and abortions

From the results obtained in the study, based on these

two parameters, there is noticed a hierarchy of blood groups in From the literature it is known that cervical cancer is
urban areas as: blood group AII with 47.7%, blood group 0I with particularly found in female patients with a history of multiple
32.6%, blood group BIII with 11.6% and blood group ABIV with births, abortions and ―agitated‖ sexual life. It is known that
8.1%, while a hierarchy of blood groups reported in rural areas nulliparous rarely get cervical cancer, and women without
is as follows: 38% for blood type 0I, 36.6% for blood group A II, sexual life, quite exceptionally.(9,10)
18.3% for blood group BIII group and 7% for blood type ABIV. Study results obtained can be considered significant in
Regarding the smoker patients, the distribution of the terms of blood groups as a risk factor, as 39% of the patients
cases according to this parameter was as follows: for blood under study had blood group AII and 32.5% had blood type 0 I,
group 0 I, there were 67.3% smoker patients (32.7% non- indicating an increased incidence of cancer cervical in those
smokers, p = 0.010), for blood group AII, there were 67.2% groups, data which corresponds to that in the literature.(11)
smoker patients (32.8% non-smokers, p = 0.005), while for the Statistical analysis of epidemiological characteristics
blood type BIII, there were 82.6% smokers (17.4% non-smokers, allows us to outline the most representative profile of patients
p = 0.002) and for the blood group AB IV, there were 75% of who presented for surgical treatment of cervical cancer in the
smokers (25% non-smokers, p = 0.083), as shown in table no. 3. Gynecology Clinic within the County Clinical Emergency
A hierarchy of blood groups in relation to this Hospital of Sibiu.
parameter is as follows: blood type AII with 40.9% of cases, Table no. 4 shows the profile of cervical cancer patients
blood type OI with 33.6% of cases, blood type BIII with 17.3% under study.
of cases and blood type AB IV with 8.2% of cases out of the total
smoker patients (70.1%). Table no. 4. Profile of the patients with cervical cancer
under study
Epidemiological Profile %
Table no. 3. Distribution of cases of cervical cancer
characteristic
according to blood type and smoking Age group 46-50 18%
Origin area Urban 63%
Educational level Elementary 48%
education
Obstetric history Spontaneous 86,5%
abortions or upon
request
No. of births 3 births 31,5%
Living conditions Smokers 70,5%
Blood type AII 39%

The number of pregnancies seems to influence the
incidence of cervical cancer, too. This can be considered a risk
factor both in terms of endocrine changes induced by pregnancy
and in terms of the indications we give on the early debut of
sexual activity. This was another aspect I aimed at in this study.
Therefore, regarding the patients with abortions, for the blood
type 0I, there were 49.1% of cases, (50.9% without abortions, p
= 0.893), for blood group AII, there were 59.7% (40.3% without
abortions, p = 0.112) and for blood group B III, 65.2% (34.8%
without abortions, p = 0.144). For the blood group ABIV, there
were 66.7% (33.3% without abortions, p = 0.248).
A hierarchy of blood groups in relation to abortions is:
the following: blood type IIA, 44.4% cases, blood type 0I, 30%
cases, blood group BIII, 16.7% cases, blood group ABIV with
8.9% cases of all patients who had a history pathological
abortions (53.7%), as shown in figure no. 5.
CONCLUSIONS
Increased incidence of cervical cancer in combination
with increasing parity was considered to be a reflection of
sexual activity and age at first sexual intercourse.
We should note that this study reveals absolutely
unsatisfactory aspects that should put on alert public health
professionals.
REFERENCES
1. Adelusi B. Haemoglobin genotype, ABO blood groups and
carcinoma of the cervix. J Trop Med Hyg. 1977;80(7):152–
154.
2. Cui Y, Noguchi H, Kiguchi K, Aoki D, Susumu N, Nozawa
S, Kawakami H, Hirano H, Iwamori M. Human cervical
epidermal carcinoma-associated intracellular localization of
glycosphingolipid with blood group A type 3 chain. Jpn J
Cancer Res. 1993;84:664-672.

AMT, vol. 22, no. 1, 2017, p. 65

 CLINICAL ASPECTS

3. Gates MA, Xu M, Chen WY, Kraft P, Hankinson SE,

Wolpin BM. ABO blood group and breast cancer incidence
and survival. Int J Cancer. 2012;130(9):2129–2137.
4. Iodice S, Maisonneuve P, Botteri E, Sandri MT, Lowenfels
AB. ABO blood group and cancer. Eur. J. Cancer.
2010;46(18):33453350.
5. Kaur I, Singh IP, Bhasin MK. Blood groups in relation to
carcinoma of cervix uteri. Hum. Hered. 1992;42(5):324–
326.
6. Loddenkemper R, Minks T, Nitz M, Otte F, Koch M: ABO
blood groups as genetic host factors of lung cancer risks.
Institute for Klinische Pharmakologie, Freie Universitat,
Berlin. 2002;20:114-117.
7. Yuzhalin AE, Kutikhin AG. ABO and Rh blood groups in
relation to ovarian, endometrial and cervical cancer risk
among the population of South-East Siberia. Asian Pac J
Cancer Prev. 2012;13(10):5091-6.
8. Maniu I. Tehnici de analiz a datelor: statistica, Ed. Univ.
„Lucian Blaga‖ Sibiu, ISBN 978 – 606 – 12 – 0891 – 3;
2014. p. 93-98.
9. Marinaccio M, Traversa A, Carioggia E, Valentino L,
Coviello M, Salamanna S, Dragone DC, Marinaccio L.
Blood groups of the ABO system and survival rate in
gynecologic tumors. Minerva Ginecol. 1995;47:69-76.
10. Segi M, Fujisaku S, Kurihara M, Moniwa H. Cancer of
cervix uteri and ABO blood groups. Tohoku J Exp Med
1957;66(1):50.
11. Xie J, Qureshi AA, Li Y, Han J. ABO blood group and
incidence of skin cancer. PLoS One. 2010;5(8):e11972.

AMT, vol. 22, no. 1, 2017, p. 66

 CLINICAL ASPECTS

MANAGEMENT OF ABNORMAL PAP SMEARS

GEORGETA GÎNFĂLEAN1
1
“Lucian Blaga” University of Sibiu

Keywords: Abstract: Screening programmes using the Pap test have significantly reduced the number of invasive
management, cytology cancer cases through early diagnosis and treatment of precancerous lesions. Starting from the main
screening, HPV purpose of cervical cytological screening - preventing the development of invasive carcinoma –HPV
infection, colposcopy testing really speeds up the diagnosis of CINII-IIII and allows immediate treatment.

Screening programmes using the Pap test have
significantly reduced the number of invasive cancer cases
through early diagnosis and treatment of precancerous lesions.
When precancerous lesions are diagnosed before they develop
into cancerous lesions and early and appropriate treatment is
established for each grade, the survival rate can reach almost
100%. However, in the case of invasive cancer, prognosis
depends on the time of diagnosis of precancerous lesion.
Introduction of the Pap test as a screening method for
cervical cancer has reduced the mortality from this disease, but
consecutively, the number of diagnoses of preinvasive lesions of
the cervix has increased. Papanicolau cervical cytology
screening is the most appropriate current method for the early
detection of cervical lesions.(1,2)
Screening should be initiated 3 years after the start of
sexual activity; rotation interval to repeat cytology must be
annually until obtaining 3 consecutive negative results and then,
every 3 years. Women who have not been tested in the past 5
years, re-enter in the annual screening programme. Pap smear
screening continues until the age of 70 years if the last decade
history registers negative tests.(1,2)
The ideal method to perform a Pap smear is
represented by liquid-based cytology (LBC), which provides a
uniform fixation of artefacts and of uninterpretable elements
comparative with conventional cytology.
HPV infection causes an insufficient immunologic
response from the body to be detected by antibody
determination. As a result, the diagnosis of HPV infection is
determined by detection of HPV-DNA in cervical cells from the
cells harvested by cytological examination through LBC
technique or by a new harvesting. To determine HPV-DNA, it is
used either the hybridization technique or the polymerase chain
reaction (PCR) method. Currently, the most commonly used
method is the hybridization (HC2-Hybrid Capture 2) by using
enzyme-linked immunosorbent assay (ELISA). An important
role is assigned to determine the types of high-risk HPV
strains.(3,4)
Motivated by the high frequency of HPV infection,
especially in the young population and by the lack of specificity
of infection for the cervical cancer screening, its highlighting is
not indicated as initial screening method. This method is
recommended to clarify abnormal Pap cytology methods.
Highlighting HPV infection associated with the Pap
test has a sensitivity of 96-100% in detecting cervical
intraepithelial neoplasia (CIN) and cervical cancer.
Management of abnormal Pap smears
1. ASC-US – The term of ASC-US (Atypical squamous
Cells of Undetermined Significance) is used by cytologists to
define the cellular changes more noticeable than the reactive
changes, but insufficient to diagnose a squamous intraepithelial
lesion.(4)
Special circumstances occur in the presence of an
infection or atrophy. In such cases, treatment of the infection is
indicated and to repeat cytology at an interval of 4-6 months
after treatment.
HPV testing can be used to triage patients with
indication for colposcopy, this one having a much greater
sensitivity than repeating cytology in the detection of possible
squamous intraepithelial lesions.(5)
A positive test means a 15-27% risk for CIN 2/3
lesion and requires colposcopy with biopsy. A negative test is
associated with a risk of CIN below 2%, but it may be also
determined by an infection with HPV with lower titres or HPV
types not included in the test. Repeating cytology is justified
after 1 year.(1,2)
In HPV-positive women in whom biopsy does not
indicate a CIN lesion, it is recommended to observe Pap test at 6
and 12 months with colposcopy and biopsy in case of persistent
or worsening ASC-US lesion.
In the conditions in which HPV testing is not
available, it is recommended to repeat Pap cytology every 6
months. Two negative Pap tests signify one negative HPV test
and under these circumstances, patients’ surveillance is achieved
through annual screening programmes.
In the case of an abnormal smear result (ASC-US
persistent or worsened), colposcopy or biopsy is necessary
(figure no. 1).(6,7)
Figure no. 1. ASC-US cases cytologic exam

Corresponding author: Georgeta G nf lean, Str. Moreni, Nr. 9, Sibiu, România, E-mail: rezultatemedicina@yahoo.com, Phone: +04723 254897
1

Article received on 19.11.2016 and accepted for publication on 23.02.2017

ACTA MEDICA TRANSILVANICA December 2016;21(4):67-69
AMT, vol. 21, no. 4, 2016, p. 67
 CLINICAL ASPECTS
2. ASC-H (Atypical Squamous Cells: cannot exclude High-grade
squamous intraepithelial lesion) has a predictive value in
detecting a possible CIN 2/3 lesions of about 48-56%, which
requires colposcopy and biopsy.(4)
In case of a negative biopsy, it is indicated to repeat
Pap test at 6 and 12 months respectively, associated with
colposcopy in case of persistent or worsened lesion.(6,7)
3. AGUS - Atypical Glandular Cells of Uncertain Significance
may be the expression of an inflammation, hyperplasia,
dysplasia or endometrial or endocervical
adenocarcinoma.(4)
Due to the risk of endocervical neoplasia or cervical
dysplasia of high grade, it is required to perform endocervical
biopsy from the junction area and complete biopsy with
endometrial and endocervical curettage.
In case of a negative biopsy, it is indicated to follow
Pap cytology for 2 years every 6 months for the diagnosis of a
possible lesion previously undetected. If the result of Pap test
does not return to normal, more aggressive assessment of the
case is required, with no consensus in this situation, conisation
is usually required in this situation.(8)
4. L-SIL - Low Grade Squamous Intraepithelial Lesion requires
careful monitoring and compliance to Pap examination every 6
months. The persistence of abnormal Pap smear requires
performing colposcopy with biopsy, in these circumstances
determining HPV infection does not bring additional benefits,
about 83% of these women being HPV positive.
The exception to this conduct is represented by the
cases of L-SIL lesions that occur in adolescents, mostly
representing the expression of a HPV infection with self-
limiting evolution, frequently followed by spontaneous
regression of the lesion.(9) In this situation, cytology
examination will be repeated at 6 and 12 months, colposcopy
being necessary only if obtaining a new abnormal Pap
result.(9,10)
In case of a negative biopsy, it is recommended to
repeat cytology at 6, respectively at 12 months completed with
colposcopy and biopsy in case of abnormal Pap result.(8)
5. H-SIL - High Grade Squamous Intraepithelial Lesion
gathers the moderate and severe dysplasia of the cervix and
carcinoma in situ. Standard practice requires colposcopy with
biopsy, subsequent management being determined by its
outcome. In case of a negative biopsy, it is recommended the
excisional diagnostic method, that is conisation.
Endocervical curettage must be performed, if at
colposcopy, transformation area is not visible in women with
altered Pap smear changed that is with atypical glandular cells
(AGC) and in women with abnormal cytology of high – grade
type (H-SIL), particularly for those more than 45 years old. The
recommendation is: the patient’s age can influence management,
age being correlated with lesion regression or persistence of
infection.(11)
The algorithm in the case of H-SIL persistence in teen
girls: Frequently, this type of lesion is spontaneously regressive,
cytologic and colposcopic follow-up at 4-6 months can be
recommended, so as to avoid the complications of an excisional
treatment, with possible repercussions on the reproductive
prognosis and obstetrical future. If after this period, H-SIL
cervical cytology persists, the teen girl will be a candidate for an
excisional biopsy.(12)
H-SIL presence in the particular context of pregnancy
requires the following management:
 a colposcopy should be carried out and if the result is not
satisfactory, it should be repeated 6-12 weeks later. Target
biopsy is aimed at if the lesion has an evolutionary
character and possibly invasive. If the H-SIL cytology is
AMT, vol. 21, no. 4, 2016, p. 68
revealed in the third quarter of pregnancy, cytological and
colposcopic reassessment is recommended at 6 weeks
postpartum. (12)
Conclusions:
 Pap test is one of the easiest medical investigations, is
cheap, fast, but very effective in detecting cervical cancer.
However, too few women are periodically tested. The proof
is the sad top place that Romania has in Europe regarding
cervical cancer mortality.
 Without minimizing the undeniable progress concerning
the etiology, the diagnostic and therapeutic means and the
ways of prevention and early detection, I believe that
modern medicine owes in this area, where stronger actions
should be taken in order to improve the incidence and
treatment in curable stages of the disease.
 When Pap test is regularly performed, it can early detect
abnormal cells in the cervix, before they turn into cancer
cells.
 The main conclusion is the belief that a good
discrimination can be achieved by combining the detection
and viral typing with cytology. In different analyses, lesion
progression was correlated to HPV detection or with the
presence of moderate or severe dysplasia.
 Screening of cervical carcinoma is based on Pap smear (in
countries that it became available, mortality was reduced
by 40-80%).
 Cytology is closely related to HPV typing (cytology is
recommended in association with HPV testing every two
years in women over 20 years old).
 Endocervical curettage will be performed if at colposcopy,
the transformation area is not visible in women with altered
Pap smear, that is with atypical glandular cells (AGC) and
in women with abnormal cytology of high – grade type (H-
SIL), particularly above 45 years old. The recommendation
is: the patient’s age can influence the diagnostic algorithm.
 Women aged 30 years and over (in whom frequently, HPV
infection is persistent) who as a result of phenotyping,
presence of HPV strains - HR (high-risk) is noticed in the
context of an unchanged cytology, cyto-oncologic
examination will be repeated 12 months later at the same
time with a colposcopy.
 Abnormal cervical cytology management in the context of
pregnancy with the presence of abnormal cytology of ASC-
US or LSIL type will require repeating the cyto-oncologic
examination 3 months postpartum. Pregnant women with
H-SIL, ASC-H or AGC Pap result will benefit from
colposcopic evaluation. Pregnant women in whom CIN 2
or CIN 3 is suspected or is histologically confirmed
presence will benefit from colposcopic reassessment and
treatment 8-12 weeks postpartum. Endocervical curettage is
prohibited during pregnancy.
 Statistics rank Romania first in Europe in terms of
mortality from cervical cancer and third, regarding the
incidence. The increasing incidence of the disease in the
recent years, especially in people of young age, requires
raising the health education level of the population and the
establishment of effective screening programmes to include
all female population at risk.
REFERENCES
1. ACOG Practice Bulletin No. 109. Cervical cytology
screening. Obstetr & Gynec. 2009;114(6):1409-1420.
2. Iancu D, Crauciuc E, Toma O, Crauciuc D. The cytological
diagnostic of the cervical cancer. Scientific Annals of
Alexandru Ioan Cuza University, Department of Genetics
 CLINICAL ASPECTS

and Molecular Biology. 2010;XI(1):49-55.

3. Gottlieb S. Persistence of HPV increases risk of cervical
cancer, BMJ. Jan 2002;324:69,
Doi:10.1136/bmj.324.7329.69/b.
4. Velenciuc N, Velenciuc I, Lunc S. Considera ii asupra
factorilor de risc şi a preven iei n cancerul de col uterin.
Revista Medico-chirurgical a Societ ii de Medici şi
Naturalişti Iaşi. 2009;2:434-439.
5. Inoue M, Okamura M, Hashimoto S, Tango M, Ukita T.
Adoption of HPV testing as an adjunct to conventional
cytology in cervical cancer screening in Japan. Int J
Gynaecol Obstet. 2010 Aug 11.
6. Ball C, Madden JE. Update on cervical cancer screening.
Current diagnostic and evidence-based management
protocols- Postgraduate Medicine. 2003;113(2).
7. Ministerul S n t ții. Normele pentru aplicarea programului
de screening pentru cancerul de col uterin,- publicat în
Monitorul Oficial al României, Partea I, nr. 547 din 6
august 2009.
8. Iancu D, Crauciuc E, Toma O, Crauciuc D. Histopathologic
diagnostic of the cervix neoplasma. Scientific Annals of
Alexandru Ioan Cuza University, Department of Genetics
and Molecular Biology. 2010; XI(1):55-61.
9. ACOG Committee Opinion No. 463:- Cervical cancer in
adolescents: screening, evaluation, and management -
Obstet Gynecol. 2010;116(4):69-72.
10. Iancu D, Crauciuc E, Pricop F. Cervical neoplasia and the
early debut of the sexual life. Bul Perinatol, Chişin u.
2001;4:17-20.
11. Society of Obstreticians and Gynaecologists of Canada.
Colposcopic management of abnormal cervical cytology
and histology; 2012.
12. Peltecu G. Tratat de chirugie, Vol I, Editura Academiei
Române Bucureşti; 20 4.

AMT, vol. 21, no. 4, 2016, p. 69

 CLINICAL ASPECTS

TREATMENT OF THE TIBIAL PLATEAU FRACTURES

MIHAI ROMAN1, ADRIAN BOICEAN2, RADU FLEACĂ3

1,2,3
“Lucian Blaga” University of Sibiu

Keywords: tibial Abstract: Appropriate assessment and treatment of tibia plateau fractures are critical for obtaining
plateau fractures improved functional outcomes and reduced risk of complications. Purpose: Evaluating tibial plateau
fracture treatment in two distinct periods: 2009-2011 vs. 2012-2015. Material and methods: 210
patients with tibial plateau fractures, treated between 1.01.2009 and 31.12.2015 were evaluated.
Treatment methods and hospitalisation days were evaluated. Results and discussions: The majority of
fractures (62%) were treated surgically. Plate and screw fixation is the method of choice (56%). The
number of hospitalisations days was reduced by half in the last 4 years in comparison to 2009.
Conclusion: The last four years revealed a strong trend in using modern treatment protocols with better
results and less complications

INTRODUCTION locked intramedullary nail or with external fixators). For an

Appropriate assessment and treatment of tibia plateau effective treatment we considered the type of fracture, age,
fractures are critical for improved functional outcomes and general condition of the patient, associated diseases, if the
reduced risk of complications.(1,2) Apart from the fracture, soft fracture is part of a polytrauma, and also the surgeons preference
tissues (skin, muscle, nerves, blood vessels, ligaments) may be and the facilities of the department. Fracture treatment in tibial
injured at the time of the trauma, therefore the appropriate plateau may differ from patient to patient, all these details
treatment is aimed at both, fracture and soft tissues injuries.(3,4) having a role in the final outcome.
The management of these fractures requires special Out of the 210 cases of tibial plateau fractures, 80
attention during the reduction and fixation. Posttraumatic cases (38%) were treated conservatively and 130 cases (62%)
arthritis, malalignament and infection are complications that can were treated surgically.
compromise the results of these fractures.(4,5)
Figure no. 1. Type of treatment 2009-2011
PURPOSE
The purpose of this paper is to evaluate the tibial
plateau fracture treatment in the Clinic of Orthopaedics and
Trauma of the County Hospital Sibiu. Techniques of treatment
(surgical or orthopaedic), applied to patients with tibial plateau
fracture were evaluated, number of hospitalisation days were
recorded. A comparative analysis of the treatment of tibial
plateau fracture in two distinct periods: 2009-2011 and 2012-
2015 was performed.

MATERIALS AND METHODS

We conducted a retrospective study over two distinct
intervals: 1.01.2009 - 31.12.2011 and 1.01.2012 –31.12.2015. A
total of 210 tibial plateau fracture patients were treated. We Figure no. 2. Type of treatment 2012-2015
analyzed the following documents: inpatient observation sheets,
operation protocols, patient discharge data from the Statistical
Office of the Hospital. This study included patients of both
sexes, aged between 18 and 100 years, suffering fractures of the
tibial plateau of any kind (AO and Schatzker Classification).
This study did not include patients with open fractures. Several
variables were assessed: treatment method, number of
hospitalisation days.

RESULTS AND DISCUSSIONS

Treatment of tibial plateau fractures is complex,
orthopaedic (cast immobilisation) or surgical (osteosynthesis The operating indications were made using
with plate and screws. with screws and washers, pins, with Schatzker and AO classification.(6) Fractures with displacement

Corresponding author: Radu Fleac , Str. Lucian Blaga, Nr. 2A, Sibiu, 550169, România, E-mail: rfleaca@yahoo.com, Phone: +40722 604405
3

Article received on 27.01.2017 and accepted for publication on 27.02.2017

ACTA MEDICA TRANSILVANICA March 2017;22(1):70-71
AMT, vol. 22, no. 1, 2017, p. 70
 CLINICAL ASPECTS

(clogging or separation) have absolute indication for surgery,
orthopaedic treatment is not enough. These fractures usually
require reconstruction of menisci and ligaments if
necessary.(7,8) Type of fixation varies depending on the type of
fracture and surgeon preference. As it can be seen, 130 cases
required surgery. Osteosynthesis with plates and screws was the
most common method (39% + 17% = 56%) having the
advantage of providing a stable construct, allowing early
mobilization and faster functional recovery. Fixation with
screws (plus washers or pins) was used in 32% of cases - mostly
in fractures with little or no displacement movement.
was 16. After this year, there was a progressive decrease to 9.6
days in 2012 and then to 8.3 days in 2015. The average number
of hospitalisation days during the 7 years of the study was
reduced by 50%. This is very good, both for the patient and for
the hospital. Better numbers can be obtained, but only if the
administrative policy of the hospital management will improve.
Figure no. 3. Average hospitalisation (days)

Table no. 1. Type of fixation

Fixation type Number %

plates and screws 50 39%

plates and screws and wires 22 17%

screws and washers 25 19%

screws and wires 17 13%

intramedulary nail 11 8%

external fixation 5 4% CONCLUSIONS

Recent years revealed an increased tendency
Intramedulary nail fixation is rarely used and
towards an implementation of international protocols and
represents only 8% of cases. This method is used in cases of
modern approaches in the treatment of tibial plateau fractures
fractures of the tibial plateau and the tibial diaphysis. External
There was an evident decrease of the conservative treatment
fixation is rarely used - only in cases of open fractures or
correlated with an increased tendency of the surgical treatment.
―floating knee‖.
This is much more efficient and gives better end results. This
To assess the evolution of our orthopaedics service in
trend was associated with improved management. This was best
time, we made a comparative analysis of tibial plateau fracture
proved by a decrease to half, of the number of hospitalisation
treatment comprising the years 2009-2011 and 2012-2015.
days.
Between 2009 and 2011, 106 cases were treated. Of
these, 47 were treated conservatively, while the remaining 59
were treated surgically. In the period 2012-2015, 104 patients REFERENCES
with tibial plateau fracture were treated. Of these, 33 were 1. Rockwood & Green's Fractures in Adults, 6th Edition,
treated non-operative and the remaining 71 were treated Lippincott Williams & Wilkins; 2006.
surgically. The number of tibial plateau fractures in these two 2. Gray H. Anatomy of the Human Body. Philadelphia: Lea &
periods is nearly equal and that permits a comparison between Febiger, 1918; Bartleby.com; 2000.
the two periods. 3. Baciu C. Aparatul Locomotor(Anatomie funcțional ,
A decrease of orthopaedic treatment as treatment of biomecanic , semiologie clinic , diagnostic diferențial),
choice was noted: - while between 2009 and 2011, 45% of the Editura Medical , Bucure ti; 1981.
fractures were treated conservatively, in 2012-2015 the 4. Baciu C. Anatomia func ional şi biomecanica aparatului
percentage decreased to 32% of cases. This is explained by a locomotor, Editura Stadion, Bucureşti; 1972.
different treatment approach, in which modern and current 5. Trosc P, Radu D. Genunchiul instabil dureros, Editura
trends represent the actual standard of treatment. The same trend Junimea, Iaşi; 978.
is underlined by the observation that modern fixation techniques 6. Ifrim M, Iliescu A. Anatomia şi biomecanica educa iei
with plates and screws were applied to a greater number of cases fizice şi sportului, Editura Didactic şi Pedagogic ,
in 2012-2015. Bucureşti; 1978.
The average hospitalisation was influenced by 7. Martin J, Marsh JL, Nepola JV, et al. Radiographic fracture
several factors such as patient age, health outcomes, disease assessments: which ones can we reliably make? J Orthop
related complications. Thus, with the advent of the factors listed Trauma. 2000;14(6):379-385.
above, hospitalisation days were extended above the average. 8. Moore TM, Harvey JP. Roentgenographic measurement of
47% of patients had under 10 days of hospital stay. tibial plateau depression due to fracture. J Bone Joint Surg
The majority of these patients had a favourable Am. 1974;56:155-160.
evolution, they were young and with a good health status. On
the other hand, we observed a fairly large number of patients
who required hospitalisation between 10 and 20 days (43%).
The remaining patients (10%) were hospitalised more then 20
days. This group is represented by those who suffered
polytrauma and therefore have required a complex,
multidisciplinary treatment. We noticed a great improvement of
the hospitalisation days number in the last four years. Now, we
can see that this number tends to be constant under 10 days. We
can see that in 2009 the average number of hospitalisation days
AMT, vol. 22, no. 1, 2017, p. 71
 CLINICAL ASPECTS

PRELIMINARY STUDY REGARDING IDENTIFICATION AND

EVALUATION OF CLINICAL AND FUNCTIONAL PARAMETERS
COMMON IN DENTAL TECHNICIANS WITH PROFESSIONAL
OVERLOAD CERVICAL PAIN SYNDROMES

CLAUDIA CAMELIA BURCEA1, VIOREL ȘTEFAN PERIEANU2, NICOLETA MĂRU3,

MĂDĂLINA VIOLETA PERIEANU4, MIHAI AUGUSTIN5, GABRIELA TĂNASE6,
MIHAI BOGDAN BUCUR7, VICTOR TRĂISTARU8, ANCA NICOLETA TEMELCEA9,
MIHAI BURLIBAȘA10
1,2,3,4,5,6,7,8,9,10
“Carol Davila” University of Medicine and Pharmacy Bucharest

Keywords: dental Abstract: Occupational overload syndromes represent a significant occupational problem for dental
technician, working technicians. The aim of this study is represented by optimization of intervention strategies specific for myo-
position, occupational arthropod-kinetic pathology of dental technicians in order to improve stability and mobility of the spine,
overload syndromes and increase the quality of life of these subjects. Subjects were included in two groups (experimental and
control), experimental group benefit of a physical exercise program adapted to dental technician
profession. Results demonstrate an improvement of all functional parameters for the experimental group
and the quality of life of these subjects. A suitable kinetic program will reduce the negative effects created
by prolonged improper working positions, which a dental technician is obliged to adopt in its activity.

INTRODUCTION intervention in cervical-brachial syndromes must be focused on

The most common diseases that appear and develop in
the case of dental technicians, are usually those at the level of
myo-artro-kinetic system, caused by muscle imbalances
produced, most often due to a prolonged kyphosis position. This
position increases the forces exerted on the upper neck and back
muscles and on intervertebral discs, these aspects leading to
muscle necrosis, pain and muscle contractures. Increased
pressure within the intervertebral disc leads over time to
degenerative changes, increasing the risk damaging the disc.(1)
This fact has been confirmed by numerous studies
conducted on the health of dental technicians, studies that
revealed that the most common problems encountered were
identified at the spine and upper limb. Studies conducted over
time have shown that there is a correlation between the age and
the health of dental technicians, but regarding the myo-
arthropod-kinetic system affections, they are more common in
women.(2,3) These conditions are classified as occupational
overload syndromes, because of interactions between different
professional risks factors.(4,5)
Generally, occupational overload syndromes have
become one of the most frequent cause in general morbidity,
representing a significant occupational problem, due to
increased costs of compensation and health, low productivity,
and a lower quality of life among dental technicians. In different
studies developed over time of this occupational segment, for
practitioners with cervical pain syndromes, were reported:
absence from work, reduced work capacity, transfer to another
workplace or even disability.(6) Overloads during work of
dental technician, can be influenced by organizing changes
related to working conditions, rhythm, intensity and duration of
work. Dysfunctions of myo-arthropod-kinetic system must be
corrected through therapy, respectively by performing regular
and consistent physical exercises, to improve the tissues
structure, and prevent damages that inherently occur due to
maintaining a working position for a long time and work in
certain environmental conditions.(7-9) Kinetic specific
the muscles involved, namely the muscles of the spine and the
upper limb.(10,11)
PURPOSE
The aim of this study is represented by optimization of
intervention strategies specific for myo-arthropod-kinetic
pathology of dental technicians in order to improve stability and
mobility of the spine, and increase the quality of life of these
subjects.
The objectives of this research is to identify the most
efficient operational structures, elaborating kinetic programs to
improve clinical and functional status of the subjects involved in
research, experimenting, recording and statistical interpretation
of the results.
MATERIALS AND METHODS
The study consists of two separate parts, as follows:
 In the first part, adapting the content of kinetic program to
subject’s possibilities will significantly increase
interventional process efficiency;
 In the second part, focusing the kinetic intervention on the
muscles involved, clinical and functional indexes of
subjects will be improved and thus the quality of life of
these subjects will increase significantly.
The working groups, place and conditions of the
research: There were formed of two groups of 20 dental
technicians each, who had cervical pain syndromes, the
selection of subjects based on inclusion agreement in one of the
research groups (experimental or control).
The differentiation between the experimental group
and the control group was made as follows:
 To the control group applied a program based on exercises
and massage at work;
 To the experimental group we applied, in addition to
exercises and massage program at work, and individualized
kinetic program at home with grading of effort and

Corresponding author: Gabriela T nase, Str. Plevnei, Nr. 9, Sector 5, Bucureşti, România, E-mail: mburlibasa@gmail.com, Phone: +40723 472632
6

Article received on 30.01.2017 and accepted for publication on 27.02.2017

ACTA MEDICA TRANSILVANICA March 2017;22(1):72-74
AMT, vol. 22, no. 1, 2017, p. 72
 CLINICAL ASPECTS

implementing procedures for exercises, depending on  Control group: 14 subjects were married, 2 singles and 4
subject capabilities. divorced (figure no. 4).
The main kinetic operational objectives were:
 Reduce / prevent cervical pain syndrome; Figure no. 4. Marital status – Control group
 Increasing the mobility of the spine;
 Preventing vicious positions of the spine;
 Increasing paravertebral musculature tone;
 Obtaining stability of the spine.

RESULTS
The interpretation of results was performed using
classical statistical analysis, represented by conclusive figures
and charts.
The experimental group consisted of 14 women and 6
men and control group was composed of 17 women and 3 men
(figure no. 1 and figure no. 2).
Figure no. 1. Subjects gender - the experimental group
Analyzing data on the number of hours allocated to
professional activity the following were observed:
 For the experimental group: 11 subjects assigned for
professional work more than 8 hours a day, 6 subjects
assigned for professional work 8 hours a day, 3 subjects
assigned for professional work less than 8 hours a day
(figure no. 5);
 For control group: 7 subjects assigned for professional
work more than 8 hours a day, 7 subjects assigned for
professional work 8 hours a day, 6 subjects assigned for
professional work less than 8 hours a day (figure no. 6)

Figure no. 5. Number of hours assigned for professional work

(experimental group)
Figure no. 2. Subjects gender - the control group

Figure no. 6. Number of hours assigned for professional work

(control group)
Age of the subjects in experimental group ranged from
29 to 58 years, averaging 44.6 years old, and that of the control
group ranged between 28 and 55 years, with a mean of 42.5
years old (table no. 1).

Table no. 1. Descriptive statistical indicators - age of subjects

Experimental Group Control Group
Indicator Indicator Evolution of joint mobility
Average 44,6 Average 42,5 It was performed initially the difference between the
Median 45,5 Median 45 value obtained in the final testing and the one obtained in the
Standard deviation 8,1 Standard deviation 9,7 initial testing for each subject, which represented functional gain
Minimum 29 Minimum 28 for tested characteristic of the subject and subsequently was
Maximum 58 Maximum 55 calculated the average gain for the same functional characteristic
Data analysis of marital status of the subjects of the for the whole group.
two groups revealed the following: The calculation formula:
 The experimental group: 15 subjects were married, 4 Functional gain = final testing - initial testing
singles and 1 divorced (figure no. 3); Flexion functional gain
The experimental group had an average value of
Figure no. 3. Marital status – Experimental group functional gain of 6.9º, with a minimum of 4º and a maximum of
10º, and the control group had an average of functional gain of
4.1º, with a minimum of 3º and a maximum of 6º (table no. 2).

Table no. 2. Descriptive statistical indicators – Flexion functional

gain
Standard
Average Minimum Maximum
Deviation
Experimental Group 6,9º 2,3 4º 10º
Control Group 4,1º 1 3º 6º
Extension functional gain
The experimental group showed an average of
AMT, vol. 22, no. 1, 2017, p. 73
 CLINICAL ASPECTS

functional gain in extension testing of 6.3º, with a minimum of quantitative and qualitative bounce recorded in the
4º and a maximum of 8º, while the control group had an average experimental group, which are verifying the assumption
of functional gain of 4º, with a minimum of 3º and a maximum from the beginning of the study.
of 6º (table no. 3).  By focusing kinetic intervention procedures on involved
muscles and correlation with evaluating tests of the quality
Table no. 3. Descriptive statistical indicators – Extension functional and efficiency of interventional process, is actually
gain demonstrate an improvement of all functional parameters
Standard
Average
Deviation
Minimum Maximum for the experimental group and the quality of life of these
Experimental Group 6,3º 1,5 4º 8º subjects, which are verifying the assumption from the
Control Group 4º 1 3º 6º second part of the study.
Right lateral tilt functional gain
The experimental group had an average value of CONCLUSIONS
functional gain of 6.4º, with a minimum of 3º and a maximum of Poor management of working position in the
10º, and the control group had an average functional gain of professional activity from dental laboratories entails the
3.5º, with a minimum of 3º and a maximum of 5º (table no. 4). development of pathology by musculo-osteo-articular
overloading, pathology whose symptoms will gradually
Table no. 4. Descriptive statistical indicators – Right lateral tilt intensify without a proper treatment on right time, and could
functional gain. finally get to reduced work capacities or even stop working.
Average
Standard
Minimum Maximum Physical exercise programs carried out regularly by dental
Deviation technicians prevents some diseases caused by stress produced in
Experimental Group 6,4º 2,7 3º 10º
wrong working positions. Education and regular physical
Control Group 3,5º 0,7 3º 5º
activities of dental technicians will help to primary prevention of
Left lateral tilt functional gain
cervical painful syndromes.
The experimental group had an average functional
gain 9.7º, with a minimum of 4º and a maximum of 20º, and the
REFERENCES
control group had an average functional gain of 3.5º, with a
1. Peios L, Chiru A. Afecțiunile musculoscheletice
minimum of 3º and a maximum of 5º (table no. 5).
profesionale în domeniul stomatologic. Lucr rile
Conferin ei S pt mâna European a Securit ii i S n t ii
Table no. 5. Descriptive statistical indicators – Left lateral tilt
functional gain n Munc , Vaslui. 25-26 Oct., 2007. p. 103.
Standard 2. Jacobsen N, Derand T, Hensten-Pettersen A. Profile of
Average Minimum Maximum
Deviation work-related health complaints among Swedish dental
Experimental Group 9,7º 7 4º 20º laboratory technicians. Community Dent Oral Epidemiol.
Control Group 3,5º 0,7 3º 5º 1996; Apr. 24(2):138-144.
Right rotation functional gain - cervical segment 3. Torbica N, Krstev S. World at work: Dental laboratory
The experimental groups had a mean functional gain technicians. Occup Environ Med Feb. 2006;63(2):145-148.
of 32.5º with a minimum of 25º to a maximum 40º, and the 4. David GC. Ergonomic methods for assessing exposure to
control group had an average functional gain of 25.5º, with a risk factors for work-related musculoskeletal disorders.
minimum of 20º and a maximum of 32º (table no. 6). Occup Med (Lond). 2005;May 55(3):190-199.
5. Tiric-Campara M, Krupuc F, Biscevic M, et al.
Table no. 6. Descriptive statistical indicators – Right rotation Occupational overuse syndrome (technological diseases):
functional gain. Carpal Tunnel syndrome, a mouse shoulder, cervical pain
Standard
Average
Deviation
Minimum Maximum syndrome. Acta Inform Med Oct. 2014;22(5):333-340.
Experimental Group 32,5º 5,7 25º 40º 6. Aptel M, Aublet-Cuvelier A, Cnockaert JC. Work-related
Control Group 25,5º 4,5 20º 32º musculoskeletal disorders of the upper limb. Joint Bone
Left rotation functional gain - cervical segment Spine Dec. 2002;69(6):546-555.
The experimental groups had a mean functional gain 7. Rom WN. Environmental and occupational medicine.
of 32.5º, with a minimum of 25º and a maximum 40º, and the Lippincott-Raven Publishers, Philadelphia – New York;
control group had an average functional gain of 24.2º, with a 1998. p. 79-95,11-17.
minimum of 20º and a maximum of 32º (table no. 7). 8. Cocârl A. Medicina ocupa ional . Editura Medical
Universitar ‖Iuliu Ha ieganu‖, Cluj-Napoca; 2009. p. 106-
Table no. 7. Descriptive statistical indicators – Left rotation 117,229-237.
functional gain. 9. Luan S, Wan Q, Luo H, et al. Running exercise alleviates
Standard pain and promotes cell proliferation in a rat model of
Average Minimum Maximum
Deviation
Experimental Group 32,5º 5,8 25º 40º
intervertebral disc degeneration. Int J Mol Sci Jan.
Control Group 24,2º 4,8 20º 32º 2015;16(1):2130-2144.
Comparative analysis of the average gains of the two 10. Burcea CC, Georgescu L, Burliba a M, et al. Chestionar
groups revealed that the experimental group had a better destinar orient rii strategiei de intervenție profilactic i
outcome for all measurements regarding functional gain for terapeutic n scopul cre terii performanței la locul de
cervical segment. munc a speciali tilor din domeniul tehnicii dentare. În:
Burcea C.C., Ionescu C., Cristache C.M., Burliba a L.
DISCUSSIONS (coord.). Probleme n medicin i biologie. Vol.2, Editura
Within this interesting study, are brought into Ars Docendi, Bucureşti; 2014. p. 11-62.
discussion the following issues: 11. El-Rifai N. Optimizarea statusului funcțional mio-artro-
 By creating and adapting the content of kinetic program to kinetic prin kinetoterapie la speciali tii din domeniul
subjects’ possibilities, was obtained an improvement in tehnicii dentare, (coord. Burliba a M., Burcea C.); 2016.
joint mobility as proven by statistically significant
AMT, vol. 22, no. 1, 2017, p. 74
 CLINICAL ASPECTS

PARTICULARITIES OF TREATMENT WITH BULK FILL FLOW

COMPOSITES

MONA IONAŞ1
1
“Lucian Blaga” University of Sibiu

Keywords: composite Abstract: Composite materials are used in the everyday practice in dentistry. The work technique that
material, bulk fill flow, uses composites has been developed to counteract the high contraction inlet. The development of
stress composites with increased elasticity has triggered changes in the work technique. When using the bulk-
fill flow composite a thick layer of material can be placed on the floor of class I&II cavities with the
intention to reduce the internal structural stress of the tooth and of the filling material.

INTRODUCTION  Uses etch&rinse or self-etch adhesive systems.

The composite materials are the most common
materials used in direct restoration. They have become the
material of choice for fillings even for the lateral region of the
dental arches.(1) Under these conditions the limits of the
materials have become obvious. The problem with the solid
composites is the formation of gaps at the insertion of material
and the polymerization shrinkage.(2,3)
The polymerization shrinkage will induce stress to the
tooth walls, especially there where these are thin such as the
cuspal region of the cavities of class II-a.(4,5)
The effects of the polymerization shrinkage occur
immediately or later. Among the immediate reactions we can
enumerate the postoperative sensitivity and the pulp
inflammatory reactions, among the late reactions we can
enumerate the marginal microinfiltration, secondary caries,
cuspal fracture, necrosis.(6)
Several approaches have been applied over the years
in order to diminish the polymerization shrinkage of the
composite resins, such as the raise of the inorganic fillings and
the modification of the organic matrix, the removal of
triethylene glycol dimethacrylate (TEGDMA) from the
composition of the monomers, the appearance of the silorane-
based composites.(7,8,9) A new solution to the same old
problem of the polymerization shrinkage represents the bulk-fill
flow composite materials.(10,11,12)
 Up to a 4mm thick layer of bulk-fill flow material can be
applied in the cavity followed by a solid composite layer of
min 2mm.(14,15)
The used materials are:
 the adhesive system,
 the bulk-fill flow composite,
 a compactable composite.
CLINICAL CASE
The tooth 1.6 had a root canal treatment performed
prior to the restoration treatment (figure no. 1). A preformed
matrix was used to define the proximal wall. Glass-ionomer
cement was applied on the pulp chamber floor to make the
identification of the root canals openings easier in case that a
future endodontic retreatment becomes necessary (figure no. 2).
The next step was the application of the adhesive
system. In the vertical and the horizontal cavity a bulk-fill flow
composite material was applied (figure no. 3). The last applied
layer was the compactable composite material (figures no. 4,5).
Figure no. 1. Tooth 16 prepared for filling. Gutapercha is
visible on pulp chamber floor and root canal entrance.
Cuspal reduction can be seen at the level of mezio-vestibular
cusp

PURPOSE
The aim of this article is to present the work technique
with the bulk fill flow composites and the advantages of such
material.

MATERIALS AND METHODS

The working method applied for bulk-flow materials
are:
 The steps for the preparation of the decay process are
classical: defining the marginal contour, reducing the thin
walls, preparing a convenience form, removing the altered
dentine.(13)
 As we have to deal with direct restorations, the application
of a rubber dam is recommended. The neighboring teeth
are isolated too, when the contact point between two teeth
must be re-created.

Corresponding author: Mona Iona , Str. Lucian Blaga, Nr. 2A, Sibiu, Romania, E-mail: stomatologmonaionas@yahoo.com, Phone: +40269 436777
1

Article received on 09.10.2017 and accepted for publication on 22.02.2017

ACTA MEDICA TRANSILVANICA March 2017;22(1):75-77
AMT, vol. 22, no. 1, 2017, p. 75
 CLINICAL ASPECTS
Figure no. 2. Glass ionomer cement applied on the pulp
chamber floor
Figure no. 3. Bulk-fill flow composite applied in the vertical
cavity in the gingival floor area
Figure no. 4. Insertion of the compactable composite in the
cavity
Figure no. 5. Tooth 16 before finishing. One can observe the
restoration with cuspal coverage in the vestibular wall area
AMT, vol. 22, no. 1, 2017, p. 76
By means of these bulk-fill flow composites I
provided a fast, aesthetic restoration, with an increased elastic
infrastructure and resistance to occlusal stress.
DISCUSSIONS
The use of bulk-fill flow material has been discussed
in the specialist literature of the past years with regard to the
depth of polymerization, material hardness and physical
properties.(10,11, 2) From the clinician’s point of view the
work flow and the way in which the dental tissues are prepared
for this new material are very important in order to obtain
durable results.
For composite materials dental fillings, a serious
problem is the frequent replacement of the fillings.(16) By
selecting a suitable work technique and choosing modern
materials such as the ones of the type bulk-fill flow, the frequent
replacing of the fillings can be reduced. Their use can also lead
to a reduction of the frequent dental fractures caused by the
incorrect modelling of the remaining dental tissues during cavity
preparation.
Currently, in the specialist literature you will find
discussions on layering of composite materials in the lateral area
of the dental arch, on the use of the oblique or horizontal
layering technique with reduced thickness of 2 mm according to
the width and the depth of the cavity.(17,18,19,20) The layering
is time consuming and may include air gaps with high risk of
fracture.(21) These materials transmit the stress to the dental
walls.(22)
The bulk-fill flow materials are known to have an
increased elasticity and offer the possibility to be applied in
layers with a greater thickness than the compactable
composites.(23) They can be applied with a thickness higher
than 4 mm, thus leaving only a small part of depth of the cavity
filled with compactable composite material.(2,17,23,24,25,26)
The increased elasticity of bulk fill flow type composites may
reduce the tensions at the cuspal level.
The final layer of solid composite material is applied
over this material with increased elasticity. The cuspal reduction
and the restoration with composite materials increase the life of
the tooth rather than the technique which does not use cuspal
protection.(27)
CONCLUSIONS
The use of composite materials of the bulk-fill flow
is a very much up to date theme in the specialist literature of
dental medicine. A deeper understanding of the work technique
is required for this type of materials which is not standardized at
present. These materials introduce a new concept, that of elastic
composite materials, but they require a final layer of a
compactable composite material.
REFERENCES
1. Sunnegårdh-Grönberg K, van Dijken JW, Funegårdh U,
Lindberg A, Nilsson M. Selection of dental materials and
longevity of replaced restorations in Public Dental Health
clinics in northern Sweden, Journal of Dentistry.
2009;37:673–678.
2. van Dijkena JW, Pallesen U. A randomized controlled
three year evaluation of ―bulk-filled‖ posterior resin
restorations based on stress decreasing resin technology,
Dental Materials. 2014;30(9):e245–e251.
3. Versluis A, Tantbirojn D, Pintado MR, DeLong R, Douglas
WH. Residual shrinkage stress distributions in molars after
composite restoration, Dental Materials. 2004;20:554–564.
4. Causton BE, Miller B, Sefton J. The deformation of cusps
by bonded posterior composite restorations: an in vitro
 CLINICAL ASPECTS

study, British Dental Journal. 1985;159:397–400. Bulk Fill Composites, Compendium. 2010;31(special issue
5. Suliman AA, Boyer DB, Lakes RS. Cusp movement in 5):14-17.
premolars resulting from composite polymerization 25. Ilie N, Hickel R. Investigations on a methacrylate-based
shrinkage, Dental Materials. 1993;9:6–10. flowable composite based on the SDR™ technology,
6. Lutz F, Krejci I, Barbakow F. Quality and durability of Dental Materials. 2011;27:348–355.
marginal adaptation in bonded composite restorations, 26. Garoushi S, Säilynoja E, Vallittu PK, Lassila L. Physical
Dental Materials. 1991;7:107–113. properties and depth of cure of a new short fiber reinforced
7. Braga RR, Ferracane JL. Alternatives in polymerization composite, Dental Materials. 2013;29:835–841.
contraction stress management, Critical Reviews in Oral 27. Niek JM. Opdam, Joost JM. Roeters, Bas AC. Loomans,
Biology and Medicine. 2004;15:176–184. Ewald M. Bronkhorst. Seven-year Clinical Evaluation of
8. Stansbury JW, Trujillo-Lemon M, Lu H, Ding X, Lin Y, Painful Cracked Teeth Restored with a Direct Composite
Ge J. Conversion-dependent shrinkage stress and strain in Restoration, Journal of Endodontics. 2008;34(7):808-811.
dental resins and composites, Dental Materials.
2005;21:56–67.
9. Papadogiannis D, Kakaboura A, Palaghias G, Eliades G.
Setting characteristics and cavity adaptation of low-
shrinking resin composites, Dental Materials.
2009;25:1509–1516.
10. Alrahlah, N. Silikas, DC. Watts, Post-cure depth of cure of
bulk fill dental resin-composites Original Research Article,
Dental Materials. 2014;30(2):149-154.
11. Flury S, Peutzfeldt A, Lussi A. Influence of increment
thickness on microhardness and dentin bond strength of
bulk fill resin composites, Dental Materials.
2014;30(10):1104-1112.
12. Esquibel K, Gonzalez A, Bracho-Troconis C. Physical
properties of a new bulk fill flowable composite, Dental
Materials. 2014; 30 (Supp. 1):e49-e50.
13. Iliescu A, Gafar M. Cariologie i odontoterapie
restauratoare, Ed. Medical , Bucure ti; 2002.
14. Ferracane JL. Placing dental composites—a stressful
experience, Operative Dentistry. 2008;33:247–257.
15. Ilie N, Hickel R. Investigations on a methacrylate-based
flowable composite based on the SDR™ technology,
Dental Materials. 2011;27:348–355.
16. Sharif MO, Merry A, Catleugh M, Tickle M, Brunton P,
Dunne SM, Aggarwal VR. Replacement versus repair of
defective restorations in adults: amalgam. Cochrane
Database of Systematic Reviews 2010, Issue 2. Art. No.:
CD005970. DOI: 10.1002/14651858.CD005970.pub2.
17. Flury S, Hayoz S, Peutzfeldt A, Hüsler J, Lussi A. Depth of
cure of resin composites. Is the ISO 4049 method suitable
for bulk fill materials?, Dental Materials. 2012;28:521–528.
18. Brenna F, Breschi L, Cvalli G, et al. Restorative Dentistry:
Treatment Procedures and Future Prospects, Elsevier
Mosby (Elsevier Inc), St. Louis; 2009. p. 294-327,366-455.
19. Mangani F, Putignano AM Cerutti A. Guidelines for
Adhesive dentistry. The Key to Success Quintessenca
Publishing Co. LTD, London, Berlin, Chicago; 2009. p.
173-194,231-254.
20. Tery DA, Leinfelder KF, Geller W. Aesthetic and
Restorative Dentistry: Material Selection and Technique
Everest Publishing Media; 2011. p. 43-79,81-140, 454-483.
21. El-Safty S, Silikas N, Watts DC. Creep deformation of
restorative resin-composites intended for bulk-fill
placement, Dental Materials. 2012;28:928–935.
22. Sengul F, Gurbuz T, Sengul S, Finite element analysis of
different restorative materials in primary teeth restorations.
European Journal of Paediatric Dentiustry. 2014;15(3):317-
22.
23. Moorthy A, Hogg CH, Dowling AH, Grufferty BF, Benetti
AR, Fleming GJP. Cuspal Deflection and Microleakage in
Premolar Teeth Restored with Bulk-Fill Flowable Resin-
Based Composite Base Materials, Journal of Dentistry.
2012;40(6):500-505.
24. Ruiz JR. Dental Technique: Restorations with Resin-Based,
AMT, vol. 22, no. 1, 2017, p. 77
 CLINICAL ASPECTS

PAPILLARY PROPORTION – AN OBJECTIVE FACTOR IN THE

AESTHETICS ASSESSMENT OF THE FRONTAL MAXILLARY
AREA

LUMINIȚA OANCEA1, ALIN POENARU2, MIHAELA PANTEA3, NICOLETA MĂRU4,

MIHAI BURLIBAȘA5
1,2,3,4,5
“Carol Davila” University of Medicine and Pharmacy Bucharest

Keywords: aesthetics, Abstract: The mathematical quantification of the relationship between the size of the inter-dental papilla
proportion, papilla and the heights of the clinical crown of the adjacent teeth. The pictures were analyzed in Photoshop CS5
Extended, resulting 512 measurements of the 5 papillae from the front maxillary area, with the following
referring points: gingival zenith, tip of inter-dental papilla and the incisal edge. The papillary
proportion is a quantifiable factor worth taking into account in the objective evaluation of aesthetics in
the frontal maxillary area. The average mathematical value of the ratio between the heights of the
papilla and of the adjacent tooth is more important as a reference factor than the average values of their
heights, as the aspect consisting of the papillary proportion is not influenced by the individual variations
in height, the ratio of sizes remaining the same.

INTRODUCTION contact is not present, it shall be approximated an ideal virtual

A positive prognosis of an aesthetic oral rehabilitation
in the front area is influenced to a considerable extent by the
clinical crown relation with the periodontium, whether a natural
tooth, a bridge or an implant are involved.(1) Regarding the
periodontal aspect, the keys elements in the aesthetic treatment
of the frontal area are the preservation of the inter-dental
papillae and the avoidance of formation of black triangles (2),
the relationship between the shape, form, colour, position,
arrangement of teeth and the aspect of the marginal
periodontium, providing the harmonious appearance of a
smile.(3)
The height of the inter-dental papilla is influenced by
three factors: the level of the alveolar ridge, the biological
width, characteristics of size and shape of the gum
embrasure.(4,5) The decrease of the inter-dental papilla is
frequently a consequence of the periodontal disease, associated
with gingival inflammation, loss of epithelial junction and inter-
proximal bone resorption. The absence of inter-dental papilla
may be determined by the periodontal surgical interventions, the
soft tissues usually losing volume during the healing period.(4)
From a biological perspective the papilla volume variations
depend mainly on the distance between the inter-dental contact
and the inter-proximal bone crest.(6)
The therapeutic solutions to rehabilitate an open
gingival embrasure come from an interdisciplinary approach:
prosthetics, orthodontics and periodontal therapy. The papillary
defect correction interventions must be done after an objective
assessment made by clinicians. In this respect, it became
imperative the use of a system to quantify the variations of the
inter-dental papilla, to help establish a diagnostic and also to
monitor the post-therapeutic results, thus improving
communication between clinicians. One of the proposed
instruments is the papilla presence index - PPI (Papilla Presence
Index) (4), based on the relationship between the inter-dental
papilla, the cement enamel junction and the adjacent teeth; this
system describes four degrees of retraction. If the inter-dental
level, and the contra-lateral inter-dental papilla is used as a
comparison element. Chu and its collaborators (7) intended to
find a numerical correlation between the height of the papilla
and the height of the teeth that frame it (papillary proportion) in
the frontal maxillary area, and they concluded that the papillary
proportion is almost 40% regardless of the location of the inter-
dental papilla in the front maxillary area.
PURPOSE
The purpose of this study is to verify the existence of a
relationship between the size of the inter-dental papilla and the
height of the clinical crown of the adjacent teeth, and to
compare the results with the ―papillary proportion‖ described by
Chu.(7)
MATERIALS AND METHODS
This study has been conducted on a population group
represented by students from the Faculty of Dentistry, ―Carol
Davila‖ University of Medicine and Pharmacy, Bucharest,
Romania.
The inclusion criteria were:
 full dental arcade in frontal area;
 periodontally stabilised or free of periodontal diseases
dental arcades;
 mesio-distal and vestibular-palatal space correlated with the
dimensions of the teeth in the maxillary front area;
 absence of carious lesions in frontal maxillary teeth.
The exclusion criteria were:
 edentations;
 gum diseases;
 loos of tough dental structure due to attrition, caries,
fractures;
 frontal direct or indirect restorations;
 dental-maxillary anomalies associated with dental
crowding or spacing.

3
Corresponding author: Mihaela Pantea, Str. Rahmaninov, Nr. 25A, Ap 2, Sect 2, Bucharest, România, E-mail: trili_poli@yahoo.com, Phone: +40722
387969
Article received on 03.10.2016 and accepted for publication on 27.02.2017
ACTA MEDICA TRANSILVANICA March 2017;22(1):78-81
AMT, vol. 22, no. 1, 2017, p. 78
 CLINICAL ASPECTS
Using these criteria, the selected group consisted in 32
subjects, 22 females and 10 males (figure no. 1), aged between
21 and 28 years old (figure no. 2). Their average age was 22.65
years and their median, 22 years.
Figure no. 1. Sex distribution of the study group
M adjacent teeth not be at the same level, there were determined
31%
F papilla. For the inter-incisive papilla, there were described two
69%
Pictures of the subjects were taken in front norm, with
lips apart (using monoblock retractors – ―Directa‖, with dental
arches in occlusion. The standard conditions of the pictures were
represented by:
 50 mm focal length;
 when the pictures were taken, each subject had a facial
arch mounted on, with clinometer (―behrend‖), thus
assuring the guidance in setting the measuring electronic
ruler the guide shall be represented by the distance
between two consecutive vertical lines which is 5 mm;
 All photos were taken by the same person in order to
standardize the obtained data;
 The digital used in study was represented by Pentax kc
DSLR camera with 18-55 mm lens attached by a quick
attach-release plate to a Silk Able 300DX tripod, at a
distance of 120 cm from the examined subject;
 The shooting was performed with a 2-second delay after
pushing the shutter button.
The pictures were analyzed with a laptop (MSI CR
6200), being processed in Microsoft Paint, Adobe Lightroom 3.6
and Adobe Photoshop CS5 Extended respectively (Adobe
Systems Inc.). The results were processed in Microsoft Excel
2010 (Microsoft Corporation). Measurements are made on the
vestibular side of the teeth, into mm (figure no. 2). The heights
of the papillae in the front maxillary area were measured (50),
relying on the referring points of the gingival zenith, the tip of
the interdental papilla and the incisal edge. For a better view of
the less visible areas (gingival zenith and papilla tip) this were
marked by horizontal lines, parallel to each other and to the
incisal plan. 512 measurements were performed.
Figure no. 2. The horizontal lines marked on photographs
Trying to set the association between the height of the
papilla and the height of the adjacent teeth, we used the papilla
height/tooth height x 100% formula, also known as the
―papillary proportion‖ relation (PP).
AMT, vol. 22, no. 1, 2017, p. 79
The papillary proportion is a mathematical
quantification of the relation between the size of the interdental
papilla and the height of the clinical crown of the adjacent teeth.
The papilla is placed between two teeth, one distal and
one medial (except for the central incisors which are distal to the
right and distal to the left), so the measurements made were
reported to two zeniths (of the two adjacent teeth). Thus, we
defined a distal papillary proportion and a mesial papillary
proportion. Since it is possible for the zeniths of the two
for the same papilla, two different papillary proportions
according to the adjacent tooth we refer to. To refer to a unique
papillary proportion, there was calculated the average of the two
papillary proportions, namely mesial and distal of the same
distal papillary proportions (right and left) which are averaged.
The dental arch is viewed through the digital photo-
sensor. This is located in the front on the median line. Due to its
position and to the vestibular curve of the superior dental arch,
we considered that the progressive modification of the image
may be noticed equally for the papillae and the adjacent teeth,
therefore the papillary proportion shall be the same.
Example: the papilla between teeth 1.1.and 1.2. The
heights of the papilla is first measured by taking as referring
point the zenith of tooth 1.1, afterwards we shall measure the
height of the same papilla vs. the zenith of tooth 1.2. As it is
very likely to have different heights for the same papilla due to
the reference to different adjacent teeth, two different papillary
proportions for the same papilla will result. Therefore, we can
conclude that the average between the two measurements
represents the average papillary proportion. The height of the
inter-incisive papilla is no exception to the rule, but it is much
more likely that zeniths of the central incisors be at the same
level, so the height may be the same for both distal referring
points (zenith 1.1. and zenith 2.1.)
In order to make, record and analyze the
measurements, the gum zeniths and the tips of the papillae were
marked by narrow horizontal lines, and adjacent notes were
made:
 papilla between 1.3. and 1.2. = papilla 3 right
 papilla between 1.2. and 1.1. = papilla 2 right
 papilla between 1.1. and 2.1. = papilla 1
 papilla between 2.1 and 2.2 = papilla 2 left
 papilla between 2.2. and 2.3 = papilla 3 left
 height of 1.3. = canine right
 the height of the papilla between 1.3. and 1.2. measured
from the zenith level of 1.3. = papilla 3 distal right
 the height of the papilla between 1.3. and 1.2. measured
from the zenith level of 1.2. = papilla 3 mesial right
 height of 1.2. = lateral right incisive
 the height of the papilla between 1.2 and 1.1. measured
from the zenith level of 1.2. = papilla 2 distal right
 the height of the papilla between 1.2. and 1.1. measured
from the zenith level of 1.1. = papilla 2 mesial right
 height of 1.1. = central right incisive
 the height of the papilla between 1.1. and 2.1. measured
from the zenith level of 1.1. = papilla 1 distal right
 the height of the papilla between 1.1. and 2.1. measured
from the zenith level of 2.1. = papilla 1 distal left
 the height of the papilla between 2.1. and 2.2. measured
from the zenith level of 2.1. = papilla 2 mesial left
 the height of the papilla between 2.1. and 2.2. measured
from the zenith level of 2.2. = papilla 2 distal left
 height of 2.1. = central left incisive
 the height of the papilla between 2.2. and 2.3. measured
 CLINICAL ASPECTS

from the zenith level of 2.2. = papilla 3 mesial left Figure no. 4. Calculated average PP for the papilla adjacent
 the height of the papilla between 2.2. and 2.3. measured to the superior lateral incisive and the central incisive
from the zenith level of 2.3. = papilla 3 distal left
 height of 2.3. = left canine
 distal = D, mesial = M, right = dr., left = stg.
 papillary proportion = P = papilla height/adjacent tooth
height x 100%
Example: PP3Ddr = papillary proportion calculated by
the ratio between the height of papilla 3 measured from the
zenith of the adjacent tooth located distally from the papilla
(papilla 3 distal right) and the height of that tooth (right canine),
this ratio being multiplied by 100%.
The protocol followed for the measurement of the
picture is:
 The area of interest is framed in raw format photography Figure no. 5. PP calculated average PP for the papilla
(digital negative) and saved in tiff format; the processing is adjacent to the central incisors
made with adobe light room 3.6;
 The picture is opened in Microsoft paint and horizontal
lines are drawn by the gingival zeniths and by the tip of the
inter-dental papillae of the maxillary front area (1.3.-2.3.)
And then is saved;
 The new picture is opened with Photoshop cs5 extended;
using the 5 mm distance between two consecutive vertical
lines of the clinometer, we set the scale of the electronic
ruler (―ruler tool‖); the measurements are made starting
from the referring points by pressing "shift" button in order
to maintain the electronic rulers parallel during the
measurements.
 The data are exported in Microsoft excel 2010 in a-p Figure no. 6. PP average of the 5 papillae in the front
columns. maxillary area
RESULTS
We analyzed the results in ―Microsoft Excel 20 0‖,
using four statistical functions: minimum, average, maximum,
standard deviation (Annex ). The ―p‖ value was calculated by
an independent source. As follows:
 calculated average PP for the papilla adjacent to the
superior canine and to the superior lateral incisive is 41% ,
standard deviation = 7%, p<0.001 (figure no. 3)
 calculated average PP for the papilla adjacent to the
superior lateral incisive and to the central incisive is 42% ,
standard deviation = 6%, p<0.001 (figure no. 4)
 calculated average PP for the papilla adjacent to the central
incisors is 44%, standard deviation = 6%, p<0.001 (figure
no. 5)
 the average PP of the 5 papillae in the front maxillary area The extreme measured limits of the PP were:
for the 32 subjects analyzed is 41%, standard deviation = minimum - 20% and maximum - 60%. The average papillary
6%, p<0.001 (figure no. 6) proportion in the frontal maxillary area decreases toward the
distal which can be explained by a more apical placement of the
Figure no. 3. Calculated average PP for the papilla adjacent tips of the inter-dental papillae from the median to the distal;
to the superior canine and to the lateral incisive p<0.001 (figure no. 7).

Figure no. 7. Average papillary proportion in the frontal

maxillary area decreases toward the distal

AMT, vol. 22, no. 1, 2017, p. 80

 CLINICAL ASPECTS

DISCUSSIONS
The purpose of this study was to mathematically
quantify the relationship between the size of the inter-dental
papilla and the heights of the clinical crown of the adjacent
teeth, a relation also known as ―Papillary proportion‖.
The paillary proportion is clinically relevant for
practitioners wishing to obtain a natural esthetic restoration of
the maxillary frontal area, for periodontologists and - in
planning the surgical procedures involving the vertical
placement modification of the gingival tissue.
We consider important the specification that the
average mathematical value of the ratio between the height of
the papilla and of the adjacent tooth is more important as a
referral aspect than the average values of their heights because
the aspect consisting of the papillary proportion is not
influenced by the individual variations of height, the ratio
between the dimensions remaining the same.
The study conducted by Chu and his collaborators (7)
is the pilot study which analyzed and mathematically quantified
the relationship between the interdental papilla and the adjacent
teeth at the front maxillary area. Although we used a design with
major differences in terms of materials and method compared to
the design of the study conducted by Chu and his collaborators,
the obtained result (papillary proportion) was nearly identical -
41% vs. 40% .

CONCLUSIONS
The similarity of the values of the papillary
proportions resulted from the two studies may be considered as
argument for suggesting (regarding the imposing of) the
papillary proportion as an important factor in the objective
assessment of the front maxillary area.
The perception of dental aesthetics is subjective, being
influenced by various factors.
This study provides a mathematical constant which
describes the normal percentage ratio between the height of the
interdental papilla and of the adjacent teeth. If the ideal is the
natural, then, the results of this study may be considered as a
valuable and objective referral.

REFERENCES
1. Gurel G. The Science and Art of Porcelain Laminate
Veneers. Hanover Park, IL: Quintessence Pub; 2003. p. 19-
51.
2. Buduneli N. Pathogenesis and treatment of periodontitis.
InTech. Publish; 2012. p. 113-122.
3. Bichacho N. Controlled restorative treatment of
compromised anterior dentition. Pract Periodontics Aesthet.
Dent. 1998;10(6): 723-727.
4. Cardaropoli D, Re S, Corrente G. The papilla presence
index (PPI): a new system to assess interproximal papillary
levels. Int J Periodontics Restorative Dent. 2004;24(5):488-
92.
5. Spear F. Embrasure and papilla form in anterior aesthetics.
www.SPEREDUCATION.com.
6. Dennis T, Magner AW, Fletcher P. The effect of the
distance from the contact point to the crest of bone on the
presence or absence of the interproximal dental papilla, J
Periodontol. 1992;63:995-996.
7. Chu SJ, Tarnow DP, Tan Jo. HP, Stappert CFJ. Papilla
proportion in the maxillary anterior dentition. The
International Journal of Periodontics & Restorative
Dentistry. 2009;29(4):385-393.

AMT, vol. 22, no. 1, 2017, p. 81

 CLINICAL ASPECTS

THE SILENT SINUS SYNDROME: A MISDIAGNOSED

PTERYGO-MAXILLARY FOSSA TUMOUR - CASE REPORT

DOINEL RĂDEANU1, ALMA MANIU2, HORAŢIU ROTARU3, IULIAN FĂGEŢAN4

1,2,3
“Iuliu Haţieganu” University of Medicine and Pharmacy Cluj-Napoca, 4“Lucian Blaga” University of Sibiu

Keywords: silent Abstract: This entity is relatively new in sino-nasal pathology, characterized by a chronic unilateral
sinus syndrome, SSS, maxillary sinusitis, without specific symptoms. Like atelectatic otitis caused by the middle ear negative
enophthalmos pressure dysfunction of the Eustachion tube, in silent sinus syndrome, a slight thickening of the sinus walls
appears, caused by chronic inflammation and negative intrasinusal pressure due to the osteo-meatal
dysfunction, with the onset of indolent enophthalmos. Materials and methods: We present a 38-year-old man
misdiagnosed with right pterygomaxillar fossa tumor, suffering from fluctuant migrena, partial nasal
obstruction onset 3 years earlier, associated in the last 3 months with unilateral indolent enophtalmia,
unilateral vision problem and facial asymmetry. Clinic and paraclinic examinations showed a likely silent
sinus syndrome. In this case we performed sino-nasal surgical treatment. Conclusion: SSS is a rare
pathology, characterised by lack of pain and progressive enophtalmos, being necessary a multidiscipline
outcome.

INTRODUCTION revealed right maxillary sinus volume loss, with opacity, thinned
The silent sinus syndrome (SSS) is a relatively new sinus wall, especially the posterolateral wall and the superior
entity, first described in 1964 as the chronic maxillary wall. The nasal endoscopy results were indicative of chronic
atelectasis by Montgomery (1), but named as such by Soparkar hypertrophic nasal mucosa, lateralization of the middle turbinate
in 1994.(2) This disease is characterized by painless and obstruction of the air space reduced on the right side.
enophtalmos, sometimes the onset of diplopia, with facial
deformity and signs of chronic maxillary sinusitis on paraclinic Figure no. 1. Frontal view of the patient shows enophtalmos,
examination. These symptoms are caused by the unaerated facial asymmetry and deep upper lid sulcus on right side
unilateral maxillary sinus due to trauma, anatomic development,
post-surgery or other unknown factors. Brandt et al (3) found
105 cases from 1964-2006, some of them under the name of
chronic maxillary atelectasis (CMA), and proposed that the
name of silent sinus syndrome is a stage of the CMA.
We found no reports regarding misdiagnosed silent
sinus syndrome (SSS) with pterygo-maxillary fossa tumour, so
be believed it would be interesting to present the case in order to
clarify the entity and specify the symptomatology and treatment.

CASE REPORT The CT scan revealed right maxillary sinus volume

A 38-year old man was sent to our clinic for suspicion loss, with opacity, thinned sinus wall especially the
of right pterygomaxillary fossa tumour. He complained of posterolateral wall and the superior wall, increased volume of
headache for about 3 years, treated with anti-inflammatory once the orbit due to retraction of the sinusal walls and increased fat
in a while and right painless progressive enophtalmos for the tissue in the pterygomaxillar fossa.
last 3 months with inconstant vision disturbances. The patient
did not complain of mucopurulent rhinorhea, teeth pain, diplopia Figure no. 2. Axial CT scan shows sinus volume loss, with
or hemi facial pressure. He remembered a minor facial trauma opacity, thinned sinus wall especially the posterolateral wall
20 years ago during a football game, which did not require any
treatment. He has worked for 15 years in a factory with
exposure to pollutants. He is a non-smoker, with a history of
general rush after antibiotic administration. The clinic
examination revealed right painless enophtalmia, with upper lid
downward, deepened upper lid sulcus and facial asymmetry.
The patient was seen by an ophthalmologist, who noticed no
vision disturbances or diplopia. He also consulted a neurologist
for his headache, who decided to perform an MRI and
discovered a right pterygomallar fossa tumour sending him to an We diagnosed the patient with silent sinus syndrome on
OMF surgeon. The latter decided to make a CT scan which the right side and excluded the tumour suspicion based on the

Corresponding author: Iulian F ge an, Str. Axente Sever, Nr. 6, Sibiu, România, E-mail: imfagetan@yahoo.com, Phone: +40744 564898
4

Article received on 31.01.2017 and accepted for publication on 27.02.2017

ACTA MEDICA TRANSILVANICA March 2017;22(1):82-84
AMT, vol. 22, no. 1, 2017, p. 82
 CLINICAL ASPECTS
characteristics on the CT (the same density as fat on the IRM
localised in the pterygomaxillar fossa).
The patient was processed for surgery and we conducted a
functional endoscopy sinus surgery with medialization of the
middle turbinate, uncinectomy, large antrostomy extended to
anterior part of the internal sinus wall, lavage of the sinus cavity
(dark-yellow viscous mucus, with black centre). Using a 45-
degree endoscope, we visualised the interior cavity of the sinus -
smaller than on the opposite side, with central retraction of the
posterior and superior wall and no changes to the mucosa.
Figure no. 3. Frontal view of the patient shows enophtalmos,
facial asymmetry, deep upper lid sulcus
All tissues were sent to an anatomopathologyst. The
microscopic alterations were chronic inflammatory on the
mucosa of sinonasal mucosa. There was no bacteria culture
present. Regarding the enophtalmos, we performed no surgery,
but waiting for the results of the 6 month - recovery.
The 3-month follow-up revealed significant changes:
reduced asymmetry of the face, no visual complaints and
reduced enophtalmia. The rhinoscopy showed large osteomeatal
complex formed after surgery with normal discharged maxillary
cavity.
Figure no. 4. Intraoperative images from the middle meatus
and the dark-yellow viscous mucus from the sinus
DISCUSSIONS
Misdiagnosing a silent sinus syndrome changes the
course of treatment. A pterygopalatine fossa tumour comes with
late presentation at the physician because of absence of
symptoms and usually, imaging showing extension in the area
around, cases when surgery is impossible to perform.(4)
Differential diagnosis is made with other cause of indolent
enophtalmia, appearance of hipoplastic sinus (in syndromic
pacients), sdr. Parry Romberg, linear scleroma, trauma, tumours,
diffuse facial lipodistrophy.(5)
In the literature, there is described the confusion of
painless enophtalmos and facial asymmetry with Bell’s palsy.
The patient underwent specific treatment with no response.
After CT examination the maxillary sinus was hypoplastic, with
centripet modification of the superior and posterior wall,
enophtalmos, being diagnosed with silent sinus syndrome.(6)
AMT, vol. 22, no. 1, 2017, p. 83
The medical history plays an important role in the
appearance of SSS; it is known that facial trauma, surgery for
sinonasal malignancies, history of chronic rhinosinusitis and
orbital decompression produce changes in sinonasal anatomy
predisposing to develop SSS.(7)
There is no gender predilection, the typical patient is in 3-
rd to 4-th decade, non-smoker, apparently with no history of
trauma or chronic sinuses discharge.
Hobbs et al described a 27-year old female who developed
this condition after nasotracheal intubation for a routine general
anaesthesia. Also, iatrogenic version of the disease occurring
after bilateral orbital decompression is described. Usually, it is
unilateral, but bilateral iatrogenic SSS was described (7) as well.
Usually, an anatomical condition is necessary to appear in
this disease like septal deviation, big Haller cell, concha bullosa,
medialisation of middle turbinate (which moves the uncinate
process blocking the ostium, even in the presence of an accesory
ostium), presence of mucocel, nasal polyps. Some of them are
visible on CT scan or MRI, which are the main investigations
necessary to confirm the disease.(8)
The pathogenesis of SSS is still unknown, but some
theories argue that the hypoventilation of the sinus, due to the
anatomical middle meatus modification, causes sinus atelectasis.
Other specialists maintain the idea that chronic sinusitis with
anaerobe bacteria causes viscous mucus accumulation,
osteoclastic modification to the sinus walls and onset sinus
atelectasis.(9)
The surgical treatment is the best option for this kind of
patients: large antrostomy with drainage of the mucous. The
dilemma is if we have to repair the inferior orbital wall or we
should wait and see (but how long should we wait?). Sesenna et
al presented three cases treated with a single stage procedure,
endoscopy and subcilliar approach, obtaining very good results,
with no relapse of the disease.(8) Numa et al presented a SSS
case who underwent surgical treatment, and 14-th month follow-
up revealed normal eye line.(10) Some authors had good results
in resolving the aeration of the sinus and the follow-up for
resolution of the enophtalmos from 2 to 2 year.(11) We chose to
wait for 6 months for the resolution of the enophtalmos, but at
the 3 month-follow-up, there was a very good improvement.
Children are not predisposed to develop SSS, but
nonsyndromic pediatric patients can develop SSS due to
maxillary sinus hypoplasia, even if the sinus is not fully
developed until 15-18 years of age. It is difficult to diagnose
SSS in a maxillary sinus hypoplasia without any previous
imaging studies.(12)
Figure no. 1. Mangussi classification of chronic maxillary
atelectasis
Chronic Maxillary Atelectasis
Terminology Stage I Stage II Stage III SSS
Deformity Membranous Bony Clinical
(soft medial (osseous (enophthalmos,
wall) walls) hypoglobus, facial
asymmetry)
Nasosinusal +++ ++ + –
symptoms
Mangussi et al proposed a classification of Chronic
Maxillary Atelectasis and SSS, considering that the latter is a
stage of first. Also Hypoplastic maxillary sinus should be
differentiate from SSS.(13,14)
CONCLUSIONS
Differential diagnosis between silent sinus syndrome and
 CLINICAL ASPECTS

pterygopalatine fossa is very important, because the course of

treatment is different. The scan imaging and clinical complaints
showed are very useful, aiding the clinician to propose the
specific treatment. Being a new entity, SSS should be taken into
consideration when patients come with progressive
enophtalmos, subclinical signs of rinosinusitis and specific scan
imaging.
The endoscopic treatment associated with the subcilliar
approach for enophtalmos (15) should be individualised for
every patient, depending on his wishes.

REFERENCES
1. Montgomery WW. Mucocele of the maxillary sinus
causing enophtalmos. Eye Ear Nose Throat Monthy. May
1964;43:41-44.
2. Sopakar CNS, Ptrinely JR, Cuaycong MJ, et al. The silent
sinus syndrome: a cause of spontaneous enophtalmos.
Ophtalmology. 1994;101:772-778.
3. Brandt MG, Wright ED. The silent sinus syndrome is a
form of chronic maxillary atelectasis: a systematic review
of all reported cases. American Journal of Rhinology. 2008
Jan-Feb;22(1):68-73.
4. Chawla A, Prashant S, Naphade A, Raut A; Imaging of
skull base: Pictorial essay, Indian Journal of Radiology and
Imaging. 2012;22(4):305-316.
5. Monos T, Levy J, Lifshitz T, Puterman M. The silent sinus
syndrome. Isr Med Assoc J. 2005 May;7(5):333-5.
6. Joseph B, Van der Meer BS, Harris G, Toohill RJ, Smith T
L. The Silent Sinus Syndrome: A Case Series and
Literature Review. 2011;111(6):975-978.
7. Hobbs CGL, Saunders MW, Potts MJ. ―Imploding
Antrum‖ or Silent Sinus Syndrome Following Naso-
Tracheal Intubation. The British Journal of Ophthalmology.
2004;88(7):974-975.
8. Sesenna E, Oretti G, Anghinoni ML, Ferri A. Simultaneous
management of the enophthalmos and sinus pathology in
silent sinus syndrome: a report of three cases; J
Craniomaxillofac Surg. 2010 Sep;38(6):469-72. doi:
10.1016/j.jcms.2009.12.003
9. Numa WA, Desai U, Gold DR, et al.; Silent sinus
syndrome: a case presentation and comprehensive review
of all 84 reported cases. AnnOtol Rhinol Laryngol
2005;114:688–694.
10. Hourany R1, Aygun N, Della Santina CC, Zinreich SJ.;
Silent sinus syndrome: an acquired condition, AJNR Am J
Neuroradiol. 2005 Oct;26(9):2390-2.
11. George J, Durr M, Pletcher S. T Endoscopic Treatment of
Silent Sinus Syndrome with Dramatic Resolution The
Laryngoscope. 2011;121 Suppl S4:S230.
12. Price DL, Friedman O. Facial asymmetry in maxillary
sinus hypoplasia.; Int J Pediatr Otorhinolaryngol. 2007
Oct;71(10):1627-30. Epub 2007 Aug 9.
13. Erden T, Aktas D, Erden G, Miman MC, Ozturan O.
Maxillary sinus hypoplasia. Rhinology. 2002;40:150-153.
14. Mangussi-Gomes J, Nakanishi M, Chalita MR, Damasco F,
Augusto C, Pires De Oliveira C. Stage II Chronic Maxillary
Atelectasis Associated with Subclinical Visual Field
Defect; Int Arch Otorhinolaryngol. 2013;17(4).
15. Se-Hyung K. Successful Treatment of Silent Sinus
Syndrome with Combined Endoscopic Sinus Surgery and
Blepharoplasty Without Orbital Floor Reconstruction, The
Journal of craniofacial surgery; 2016.

AMT, vol. 22, no. 1, 2017, p. 84

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