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

Corresponding author: Cristian Alexandru Țânțar, Str. Ștefan cel Mare, Nr. 75 B, Ap. 5, Sibiu, România, E-mail:, Phone:
+40744 369508
Article received on 12.01.2017 and accepted for publication on 27.02.2017
AMT, vol. 22, no. 1, 2017, p. 1

Data processing (4) and graphical representations Regarding the origin environment, the patients were
were done using Microsoft Office Excel 13 program. Data divided as follows: 21904 (68.1%) came from urban area and
analysis was performed using IBM SPSS Statistics 20. 10261 patients (31.9%) came from rural areas (p = 0.000).
Categorical data of gender and area of origin were During the five years of study, limits under which the
presented as frequencies and percentages and in order to percentages of patients vary were: 67-68% from urban area and
compare them, Chi-Square test was used.(5,6) 31-32% from rural area (figure no. 2).
For continuous data, the number of patients per year, The minimum number of patients per month in urban
the number of patients per month, both frequencies and areas was 266 (February 2011), the maximum number was 473
percentages and indicators of central tendency such as mean and (March 2014) with an average M = 365.07 (SD = 38.87). The
standard deviation were determined. minimum number of patients per month in rural areas was 108
For age, there were determined the values of central (February 2012), the maximum number was 473 (December
tendencies and comparisons between years were performed 2014) with an average M = 171.02 (SD = 22.30).
using ANOVA test. For the analysis of differences in the
number of patients between the origin areas and gender, t-test Figure no. 2. The distribution of patients regarding the area
was used.(7,8) of origin during the five years of study


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 In terms of gender, most patients were males 18242
treatment varied between a minimum of 422 patients /month in (56.7%), while 13923 (43.3%) were females (p = 0.000).
October 2013 and a maximum of 704 patients /month (in During the five years of study, the limits under which
December 2014) with an average of 536 (SD = 62.55) patients the number of patients varied were as follows: 38% -47% for the
/month. female gender and 52%-61% for the male gender (figure no. 3).
During the 5 years of study, the average number of The minimum number of patients per month of the
patients who were sent daily to this office was 17.65. The male gender was 221 (October 2013), the maximum number
maximum number of patients examined and treated over 24 was 404 (December 2011) with an average M = 304.03 (SD =
hours was 56 (December 2012). For each of the five years, the 34.61). The minimum number of patients per month for the
highest value was observed in December, probably due to winter female gender was 163 (June 2012), the maximum number was
holidays, period of time during which the private practice 329 (August 2014) with an average M = 232.05 (SD = 39.36).
offices were closed in Sibiu.
The average age of the study patients was M = 38.19 Figure no. 3. Gender distribution of patients during the five
(SD = 19.02). In 2011, the average age was 40.55 years (SD = years of study
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

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
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)

AMT, vol. 22, no. 1, 2017, p. 2


In the emergency dental office from Tîrgu-Mureş, the CONCLUSIONS

percentages were completely reversed, 47% were from urban 1. The age of addressability in Sibiu dental emergency service
area and 53% from rural area, while the distribution by gender drops significantly throughout the 5 years of study.
was in favour of the female gender with 62% and 38% for the 2. The average number of patients per month is two times
males.(9) higher in urban areas compared to rural areas (t = 18.66, p
= 0.000). Also, during the 5 years studied, the fluctuation in
Figure no. 4. Fluctuation of the number of patients in the the number of patients in urban areas was higher than in
emergency dental offices in Sibiu, Oradea and Tîrgu-Mureş rural areas, which had a much constant evolution
for a period of two years, depending on origin area 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
Figure no. 5. Fluctuation of the number of patients in pragmatic and operational approach.
emergency dental offices in Sibiu, Oradea and Tîrgu-Mureş 6. In the months with very high activity according to the study
for a period of 2 years, by gender (December, January and August), there should be
employed physicians (paid by the hour) from the outside to
supplement the need for medical personnel.

1. Voroneanu M, Bucur A, Iordache N, B lan H. Urgențe
medico-chirurgicale n cabinetul de medicin dentar .
Editura Medical , Bucure ti; 20 4. p. 12- 13.
2. Colojoar C. Curs de reabilitare oral i urgențe
stomatologice, Volumul 1. Lito UMFT, Timi oara; 200 . p.
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].
4. Popa EM, Hunyadi D, Muşan M, Maniu I, Brumar B,
In Sibiu, during 2012-2013, the average number of Stoica E. Manual de inițiere n birotic , Ed. Univ. Lucian
cases per month was M = 511.66 (SD = 58.89), in Bihor centre,
Blaga, Sibiu ISBN 978–973–739-388-3; 2007.
the average was M = 194.87 (SD = 29.05) and in Mureş, M =
5. Anderson L, Cherala S, Traore E, Martin N. Utilization of
534.29 (SD = 130.85). Hospital Emergency Departments for Non-Traumatic
Regarding the number of patients per month, there can Dental Care in New Hampshire, 2001–2008. J Community
be noticed a greater resemblance with Mureş County, but the
Health. 2011;36:513-516.
number of cases in terms of evolution in time is more constant
6. Shortridge E, Moore E. Use of emergency departments for
in Sibiu, the evolution being similar with the emergency dental conditions related to poor oral healthcare: Implications for
office in Oradea (figure no. 6). rural and low-resource urban areas for three states. Journal
of Public Health Management and Practice.
Figure no. 6. Fluctuation of the number of patients in 2009;15(3):238-245.
emergency dental offices in Sibiu, Oradea and Tîrgu-Mureş 7. Mocan I. SPSS Introducere în analiza datelor, Ed. Univ.
for a period of 2 years Lucian Blaga, Sibiu, ISBN 973–739–189–6; 2005. p. 9-
8. Maniu I. Tehnici de analiz a datelor: statistica, Ed. Univ.
Lucian Blag, Sibiu, ISBN 978–606–12–0891–3; 2014. p.
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.

AMT, vol. 22, no. 1, 2017, p. 3





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

Corresponding author: Gabriela Adriana Dinca, B-dul Lacul Tei, Nr. 20, Sector 2, Bucureşti, România, E-mail:, Phone:
+4074 4347188
Article received on 17.01.2017 and accepted for publication on 27.02.2017
AMT, vol. 22, no. 1, 2017, p. 4

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


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
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

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:
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:
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
low coverage of the screening program, very low use of
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?‖:
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
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
and its presence increased significantly in women having HSIL
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, [accessed 28 January
considering that in Romania the screening for cervical cancer
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
approach more focused on systematic prevention and control of
cervical cancer.
[accessed 28 January 2017].
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[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
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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
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7. Bruni L, Barrionuevo-Rosas L, Albero G, Serrano B, Mena
AMT, vol. 22, no. 1, 2017, p. 7



“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

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

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.


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.


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

Corresponding author: Victoria Voloceai, B-dul. Ștefan cel Mare i Sf nt, Nr. 165, Chi in u, Republica Moldova, E-mail:, Phone: 06918216
Article received on 17.01.2017 and accepted for publication on 27.02.2017
AMT, vol. 22, no. 1, 2017, p. 8

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

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%)
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

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%).

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.

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.
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.
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





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

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

B lcescu, Bl. Camelia, Ap. 6, Buz u, România, E-mail:, 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

problem.(17) Pending time after an AC may extend to 3 weeks, risk of miscarriage than AC, which causes higher levels of
during which uncertainty related to child health intensify depression.(25) With regard to genetic analysis, it was found
obsessive thoughts about possible abnormal results would entail that providing early results significantly decreases the level of
a decisional moment of existential importance. Frequently, this maternal anxiety. This is possible by making besides classical
period associates psycho-emotional feelings such as anger, guilt, Karyotyping, a rapid molecular test (FISH, QF-PCR), too.(16)
worry, anxiety and sometimes depression, for many women, The Non-invasive Prenatal Testing (NIPT), considered the
hard to cope with or to manage.(16) This situation prone to technological cutting edge revelation, can analyze early fetal
choosing extreme coping mechanisms, opposite reactions, denial DNA in the mother’ blood, from 9-10 weeks of pregnancy.
or defensive reactions.(15) NIPT can only be used as a screening test, not a diagnostic test,
Consequences and coping methods confirmation of a positive result also belonging to obtaining
Psycho-emotional imbalance may affect fetal-maternal fetal material by the known invasive procedures.(26) Using
attachment with possible consequences for mental and NIPT as a second contingent of screening for all pregnant
behavioural development of their child, even if subsequently women at risk (1-150) significantly decreases the percentage of
refuted result.(17,20) Mother and fetus have a symbiotic AC candidates.(27)
relationship, so that if a disease affecting one of the two most Information and counselling even before proceedings
likely will affect the other one. Psychologically, it was found are efficient and handy method that can help women to cope
that the level of stress and anxiety is much greater when the test with emotional difficulties related to the procedure and concerns
results have altered fetal health, compared with altered test about the results.(15,17) Increased intake of information through
results related to maternal health. (1) the use of written materials and presentations including video to
During the waiting for the results period, some increase the level of knowledge, reduce decisional conflict and
pregnant women are focusing predominantly on what could be increases the satisfaction of an informed choice.(28,29) There is
wrong with their fetus, an attitude that enhances anxiety and question whether too much information could cause an
cortisol release. Excessive exposure of the fetus to high levels of increasing anxiety if extensive knowledge about the negative
cortisol may promote development of type II diabetes and implications and limitations associated tests can influence a
obesity in adulthood but also learning and memory disorders, up woman’s decision making and can lead to an overestimation of
to and including the functional impairment of the frontal lobe risk associated with the abortion procedure and an
executive.(20,22) Generally, anxious pregnant woman is underestimation of the rate of detection.(30) The opposite pole
associated with negative effects both on her and on the baby, demonstrated that anxiety enhances the minimization of
effects whose consequences may be short-termed, materialized information.(31).
only through an increase in symptoms related to pregnancy or Using Decision Support Technologies (DSTs) as
intensification of vices harmful in the medium term by the supplementary educational materials that complement
appearance of obstetrical complications, including birth, as well interactions with professionals could have an important decision
as on long-term by stimulating post-partum maternal depression not only in mitigating conflict but also in lowering anxiety.
post-partum or worse, by impaired development of Unfortunately, it was found that the amniocentesis procedure
neuropsychiatric fetus that would become a child with psycho- used DSTs little compared to other medical conditions
behavioural issues later.(23) associated with decisional conflicts.(32,21,33) The use of
Coping is a very important process in situations of cognitive therapy techniques adapted to the pregnancy would be
stress and anxiety. There are studies that have shown that useful not only to reduce the diagnostic testing related anxiety,
optimism and positive attitude of women attending stage but to an increase in psychological well-being of both mother
diagnosis lowers stress levels and keeps the situation under and unborn child and the relationship between the two.(23)
control, unlike avoidant women, addressing a maladaptive Emotional support and involvement of partners in the
attitude.(15) An example of maladaptive coping can be implementation of this step decreases stress and anxiety of
considered the imposition of an emotional distance up to mental pregnant women but not related to the procedure, too.(18)
pregnancy rejection of their child, mental abandonment and lack Discussion and Conclusions
of communication with him throughout the period of waiting for DS prenatal testing involves a variety of sensitive and
the results. After receiving favourable outcome, the return to the specifics, as well as risks of invasive procedures, an important
mental status of pregnant woman attitude occurs and thus potential to trigger a series of consequences with long lasting
resume mother-child bond, but the psychological status of fetal effects. Definitely, prenatal testing needs to be addressed and
damage may already have occurred.(24,20) Some pregnant understood as an option and not an obligation to inform women
women cope by mentally imposing to themselves that they bear since the first recommendation of screening. Trying to spare the
a healthy child and that the procedure will only bring this pregnant and not to tell that from a prenatal test screening can
confirmation. It is an instinctive protective attitude based on the lead to termination of pregnancy, besides violating the rule of
suppression of fears that aim to avoid the feeling of anxiety. Not informed consent is a mistake that can have serious psycho-
based on conviction, sliding to clinical anxiety is easy to be emotional repercussions over that person. The development of
done.(17) such a scenario must not be maximized nor ignored or
Practices and methods that can prevent or minimized.(15,31,21) Failure to provide necessary information,
influence the psychological effects inadequate skills processing and rendering specialists, poor
For a less intense emotional involvement, women communication, lack of segregation, ignorance, fears,
think that the diagnosis should be as early in pregnancy as psychological reactions adjacent informed consent, decision
possible and the information has to be complete, adequate, making and facilitating its tactics in latter are gaps and
interactive, personalized and to take place in the prescreening weaknesses that can cause cognitive distortions affecting the
period.(17,21) Both AC and associated CVB score for anxiety reasoning of those directly involved.(31,34)
and depression.(16,17,20,18,19,24) Unlike AC, CVB has the Psychological stress could be minimized by widening
advantage that it can be done earlier in pregnancy when we are maternal-fetal care team and other specialists’ inclusion in
still talking about embryo and not fetus and the result can be providing information and psychological support, including the
obtained in a few days.(14) But CVB is associated with a higher time spent awaiting the results of diagnoses.(20,31,35)
AMT, vol. 22, no. 1, 2017, p. 12

Prenatal diagnostic technologies are currently and after invasive and noninvasive procedures. Prenatal
performing and there is a concentration of researchers carried to Diag. 2013; 33:1194–1200. doi: 10.1002/pd.4223.
the extreme in this regard, but their effectiveness in practice will 16. Hewison J, Nixon J, Fountain J, Cocks K, Jones C, Mason
never be as powerful there will not be paid similar attention to G, et al. Amniocentesis results: investigation of anxiety.
issues and implications associated especially to the psycho The ARIA trial. Health Technol Assess. 2006 Apr;10(50).
emotionally ones.(25,18) doi:
Monitoring pregnant women should not be purely 17. Kowalcek I, Mühlhoff A, Bachmann S, Gembruch U.
obstetric parameters and directed only toward physical status but Depressive reactions and stress related to prenatal medicine
also an emotional assessment of the level of stress, anxiety and procedures. Ultrasound Obst Gyn. 2002 Jan 19(1):18-23.
depression especially in covering the distance of achieving a doi: 10.1046/j.0960-7692.2001.00551.x.
screening and final output after invasive procedure.(15,18,25) 18. Brajenović-Milić B, Dorcić T, Kuljanić K, Petrović O.
Stress and Anxiety in Relation to Amniocentesis: Do
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Kjaergaard H, et al. First-trimester Down syndrome
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AMT, vol. 22, no. 1, 2017, p. 14





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 equipment for 3-5 minutes up to 8-10 minutes is associated with
associated with abolition of all brain reflexes which represents the absence of respiratory movements in CO2 pressure values >= 50-
most severe grade of brain hypoxia, frequently determined by lack 60mmHg (formal criteria 60 mm Hg) or causes increasing CO2
of circulation.(1) pressure up to >=20mmHg more than the normal value.(4)
The first definition of brain death was given in 1950, as Another important element is the presence of diabetes
being the state in which the brain is irreversibly damaged but heart insipidus in a brain dead patient, its absence imposing diagnosis
and lung functions can be artificially maintained: exceeded delay. Tachycardia response to atropine injection shows loss of
coma.(2) cardiac innervation through bulbar vagal neurons. Neurological
In 1968 Harvard Medical School introduces the concept examination protocol includes pupil examination (which has to be
of brain death as being the brain state non-responsive to any type between 4-9 mm with abolished photo-motor reflex), eyeball
of stimulus, stopping breathing and absence of electrical activity movements (which must be absent), corneal reflex – absent,
on electroencephalography (EEG) for 24 hours.(2) spontaneous blinking – absent, facial movements – absent,
The equating between brain death and the patient’s spontaneous muscle movements – absent, ocular-vestibular reflex,
death involved, in the years that followed, performing complex ocular-cephalic reflex, glossopharyngeal reflex, coughing reflex –
ethical and moral analysis with social, religious implication, the absent associated with the absence of spontaneous breathing and
justification for this equivalence being given by the association of response to atropine.(12)
brain death with irreversible heart – respiratory insufficiency.(3) Monitoring the eventual organ donor is done for at least
The essential criteria for brain death’s diagnosis include 6 hours in cases of primary brain damage and for 24 hours in
absence of all brain functions associated with the absence of vital cases of secondary brain damage. Clinical evaluation of potential
functions that are under brain control, modifications being donors may be difficult, as each patient can be the ideal donor for
irreversible, in other words nonreactive coma, absence of brain a particular organ and donor with some drawbacks for another
stem reflexes and apnea.(4,5) organ. The donor’s age correlates with other conditions, for
In declaring brain death it is absolutely mandatory for example hypertension, diabetes.
the determining cause of the irreversible brain damage to be The cause of death must be well established, suspicions
known: subarachnoid hemorrhage, traumatic brain injury (6), related to central nervous system (CNS) infections, neoplastic
cardiac arrest.(7,8) etc, imposing differential diagnosis with drug diseases must be eliminated.(13) Laboratory evaluations include
intoxications, anesthesia, hypothermia (body temperature over 32 serology, chemistry, hematology an microbiology
degrees), vegetative status, ―locked-in‖ syndrome, for which examinations.(14,15,16) For example the existence of piercings
clinical tests and repeated laboratory analysis are required.(9) and tattoos may raise suspicion for infections with hepatitis
Clinically the brain dead patient is in a profound coma, viruses, human immunodeficiency virus (HIV), and therefore in
no spontaneous movements, without motor or verbal response to situations in which this type of actions on the skin occurred in less
visual, cutaneous, auditory stimulus. Spinal reflexes of triple than 3 months before the patient can be excluded from
flexion may be present with or without the presence of the donation.(1) After clinical establishment of the existence of a
Babinski sign (its existence does not rule out brain death).(10) But potential donor, after following all the previously mentioned steps
there may be positions in flexion or extension which require which were well established by examination protocols there are
timing of declaring this status. The eyeballs are in middle position, also necessary laboratory confirmations (14), which are carried
the pupils are nonreactive with sizes between 4-9 mm. Bulbar out through several methods: EEG, brain angiography, brain
muscles are paralyzed, facial movements, coughing and scintigraphy, Doppler examination, echocardiography.(17,18,19)
swallowing reflexes, suction reflex, and corneal reflex being Electroencephalography aspect is extremely important
absent. There is no motor or autonomic response to noxious in the confirmation of the brain death, although in United States
stimulus, there are no respiratory movements.(11) most medical institutions do not require EEG as an indispensable
Diagnosing the bulbar condition is performed through criteria for the diagnosis.(5)
apnea test which shows the absence of the bulbar response to In brain death, EEG does not present electrical
increasing CO2 concentration: disconnection from ventilation 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:, Phone: +40757 644226

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

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





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

Corresponding author: Cristian Alexandru Țânțar, Str. Ștefan cel Mare, Nr. 75 B, Ap. 5, Sibiu, România, E-mail:, 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

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.

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

dental office holds. Of the patients included in the study, 23% one possible local solution. British Dental Journal.
consider the dental office is very good equipped, a rate of 12% 2001;191(10):550-554.
higher (35%) consider the dental office is good equipped (Chi- 5. Gibbons DE, West BJ: Dentaline: an out-of-hours
square = 1.400, p = 0.237) and a rate about twice as high (40%) emergency dental service in Kent. British Dental Journal.
believe that the equipment can be optimized (Chi-square = 1996;180(2):63-66.
2.632, p = 0.105) (figure no. 8.). 6. Austin R, Jones K, Wright D, Donaldson N, Gallagher J.
Use of the out-of-hours emergency dental service at two
Figure no. 8. Distribution of patients according to the south-east London hospitals. BMC Oral Health.
satisfaction level with the office’s equipment 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.
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

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)

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.

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





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

Corresponding author: Ileana Paula Ionel, Str. Gh T t raşcu, Bl. P2, Ap. 34, Bucureşti, România, E-mail:, 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

they perceive these tasks, as factors contributing to a competent, The answers related to the overall perception on
skilled and self confident future nurse, were the main study personal participation in the clinical practice of the nurse
questions of the study. Also the managerial, organizational students reveals that most of the respondents 55% (24)
aspects were targeted by a group of three questions. Based on considered their involvement as a personal opportunity not as an
the received answers a future better coordination and support for obligation, as perceived by 34%, the rest of them being not
an effective clinical practice will be elaborated and decided. In addition, further asked on what type of opportunities
implemented. In this context the objectives of the study were: the clinical practice creates for their professional life they
 Identifying the nurse perceptions on opportunities offered perceived that as a chance for exercising their organizational
by involvement in clinical practice, skills 72%, planning the clinical practice in such a way that the
 Assessment of models, attitudes and practices regarding most important techniques and cases to reach the students
nurse students clinical practice, without prejudice to the normal care flow is really important.
 Identifying the main further educational needs of the nurses Other types of opportunities identified were:
involved in clinical practice of students. knowledge transfer 69%, the challenge of assuming new roles
and responsibilities (69%) as well as the challenge to be
MATERIALS AND METHODS connected to the professional news (65%). Interesting is the fact
The study is based on a descriptive approach. The that the clinical practice is seen as a condition for improving the
evaluation of the way how the clinical training is organized, patient centeredness of the medical care act for the patient, in
perceived and guided in order to ensure competence and value order to represent a model for the students for more 60% of the
gain for the students was carried out through a quantitative respondents. Also, participating in this activity is perceived as a
method, by a self-completed questionnaire, administrated in chance to improve self esteem 58%. About the mentorship
Burghele Clinical Hospital Bucharest, one of the main hospitals chance, that summarize and extend the professional guidance it
were the nurses of are performing clinical practice. The target reach agreement for less than half of the respondent (42%).
audience was represented by the team of nurses involved in (figure no. 1).
clinical practice of students from the Faculty for Midwife and
Nursing of University of Medicine and Pharmacology Carol Figure no. 1. Respondent distribution by perceived
Davila Bucharest. opportunities offered by the student’s clinical practice
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. mentorhip

The questionnaire ―Knowledge, attitude, and practice self esteem improuvment

as trainer for the nurse students― was designed to collect improuving patient centerdness
information on factual aspects as age, experience and on six
staying connected to professional news
areas of importance for the clinical teaching process: main
activities, methods used, values transmitted, process perception, assuming new responsabilities

difficulties encountered and training needs. The questionnaire knowledge transfer

consisted of closed questions with single or multiple answers,
organizational skills
and two questions based on a Likert scale from 1-5.
The self-administered questionnaire was anonymous 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

and confidential, and the statistical analysis was done with no

personal reference. agreement disagreement missing

RESULTS AND DISCUSSIONS From their mission perspective in the clinical training
The socio demographic characteristics of the study process, the practice nurses identified the most important roles as
sample reveal a profile of respondents dominated by women: 40 following: development of practical skills, 74%, supporting the
(93%) of the 43 respondents, corresponding to the normal stuff exercise of theoretical knowledge gained during the clinical
distribution in health care facilities were the women are nursing classes, guiding the collaboration and communication
predominating. From the clinical department affiliation with the patient (65%) and health care team (67%), guidance for
perspective, most of the respondents work on the Urology the self learning process (62%) and the last one, the information
Department (I, II, III-20) followed by internal medicine (10) and and theoretical knowledge transfer function (53%). (figure no. 2).
Related to the professional qualification most of the Figure no. 2. Respondent distribution on nurse role
nurses, 27 (62,9%) were graduated from the post high school perception in the nurse student’s clinical training
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 knowledge transfer

age were 41, 32 years (min 23 years, max 60, SD ±8.03 years). guding self learning process

Consequently the associated work experience was quite mediating patient-student relation
important, with a mean of 17.58 years (min=0.3, max=39, guiding health team collaboration
SD±10.10). Among those, the most of the respondents, 39% are knowledge valorization
included in the work experience share of 10-20 years and 17 % practical aptitudes and skills development
of them have even more than 21 years of experience. Of these
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100
only 6 (14 %) of nurses considered that they have experience in %
clinical practice, the trainer experience practicce being less
agreement disagreement missing
extensive that the professional one, ranking from 2 to 15 years.

AMT, vol. 22, no. 1, 2017, p. 21


Related to the managerial, organizational aspects of students where only 34% answer yes, I am a good teacher, while
clinical practice main features revealed by the responders were: only 2% answer no. The rest of them, the majority, 55%, choose
 Only a relatively small percent 23% of nurses are involved the unconfident, ―don’t know‖ answer.
in the process of planning the clinical activities for the
nurse’s practice, a result somehow confirming the fact that Figure no. 4. Future training nurse for nurses involved in
the clinical practice is perceived as an organizational nurse student’s clinical training
 The main training model adopted are the whole team of teaching methods
nurses-whole group of students model (42%) followed by
the medial act cantered method (18%) and by 1 nurse- legal requirements
small team of allotted students (12%).
 The main teaching methods used were: demonstration evidence based
(67%), active observation (58%), group teaching (30%),
active learning and case studies (11%). ethics, patient rights
The main disturbing factors influencing the process of
students clinical practice identified by the respondents were: health care protocols
 Time constraint was mentioned by 88% of respondents as
the main factor negatively influencing the quality of 0% 20% 40% 60% 80% 100%
clinical practice. On the background of the chronic
personnel shortage granting enough attention to both very useful usefull less useful usless don t know
normal tasks and the teaching process is perceived as
difficult for most of respondents.
 The students attitude, the lack of interest and motivation in CONCLUSIONS
practising and developing skills based on the theoretical Based on the study information results, we can stress
knowledge is identified as the second important barriers by the following aspects:
33% of responders.  The nurse student clinical practice is a complex process
 The patient refusal together with the limited teaching involving at least tree actors: the student, the patient and
resources as instructional materials or even teaching spaces the health care team. Their involvement and collaboration
during the clinical practices are perceived as important by is crucial for attracting, guiding and empowering the
about one quarter (22%, 23%) of all respondents. student in reaching the necessary competences.
 The less important, still present, is the institutional support,  The majority of nurses positively appreciate their role in
mentioned by 3% of respondents, identifying one of the the student clinical practice, perceived in most cases as a
prerequisites for a well organized clinical training (figure personal opportunity not a professional obligation. By their
no. 3). roles they fulfil a very important task, that one to connect
theory with practice completed by guidance and support for
Figure no. 3. Respondent distribution on the main barriers collaborating with the health care team and patients. They
in nurse student’s clinical training 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
institutional support limitation, all of them on the background of time
limited teaching skills
constraints that also pose serious challenges to even the
most committed teaching nurses.
teaching resources
Consequently, in order to reform, improve the
patient refusal transition process of a nursing student in a proficient
professional nurse it is important to establish clear outcomes and
students atitude
competences for each of the clinical practice training, specific
time constraints protocols on effective methods and tools for teaching nurses,
0% 20% 40% 60% 80% 100%
completed with adequate organizational, staffing and resource
agreement disagreement missing
In order to identify another direction of future 1. Buscher A, Sievertsen B, White E, Nurses and midwifes, a
improvement intervention, a Likert scale questions from 1-5, force for health, survey on the situation of nursing and
from very useful- to useless, contribute to identify the hierarchy midwifery in the member states of the European Region of
of future training needs for the nurses involved in students the World Health Organization 2009, WHO Regional
clinical practice. The main direction identified were: content of office for Europe, Copenhagen, Denmark; 2010.
the health care protocols and clear establishment of the nurse 2. DaRosa DA, Skeff K, Friedland JA, Coburn M, Cox S,
roles in the health care process (70%); updated knowledge on Pollart S, O’connell M, Smith S, Barriers to effective
ethics and patient rights (69%), evidence based nursing (67%), teaching, Acad Med. 2011 Apr; 86(4):453-9. doi:
legislative framework requirements, (65%) or teaching methods 10.1097/ACM.0b013e31820defbe.
(63%) (figure no. 4). 3. Keighley T. European Union Standards for nursing and
Those answers are in concordance with the ending midwifery - information for accession countries, WHO
overall appreciation question on being a good tutor for the nurse Regional office for Europe, Copenhagen, Denmark; 2009.

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


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





“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.

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

Corresponding author: Adrian Boicean, Str. Lucian Blaga, Nr. 2A, Sibiu, România, E-mail:, 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

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

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

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.

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;; 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




“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.

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

Corresponding author: Mona Iona , Str. Lucian Blaga, Nr. 2A, Sibiu, Romania, E-mail:, 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

 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


Table no. 2. Significant Mann-Whitney U test results

Test values
Question Educational level
U p (<0.05)
No education Professional education 19.50 0.005
At what age did your child start brushing his or her teeth?
Secondary school Professional education 84.50 0.009
Primary school Secondary school 40.50 0.012
Do you supervise your child during tooth brushing? Primary school Professional education 18 0.001
Primary school High school 36.00 0.020
For what reason do you go to the dentist with your child? Secondary school Professional education 98.00 0.032

DISCUSSIONS higher education and having a non-western background were

Over the years, studies in this field reveal a rather low associated with their inclusion in an ―attitudinal risk group‖,
level of knowledge of oral health prevention among the parents prompting to the fact culturally tailored programs for dental
from Romania.(23,24,25) The recommended tooth brushing health education are necessary to promote more positive
frequency is twice a day.(26) Only 36 percent of the participants attitudes towards oral health.
in our study (17.2% several times per day and 18.8% twice a The children are recommended to have periodical
day), coming from disadvantaged backgrounds, indicated that medical check-ups performed starting from age 1 or when their
their child or children brush their teeth twice or more every day. first tooth erupts.(31) The American Academy of Pediatric
In comparison, a study performed in Romania in 2009 on Dentistry (32) recommends the parents to take children to the
children and parents without accounting for social background dentist twice every year, fact known to only a small extent
revealed percentages of 23.9% and 35.9% respectively for the among people from disadvantaged families in the USA.(21)
same brushing frequencies.(15) Another study, which measured When periodical medical check-ups are performed, the pain
the two brushing frequency groups together (brushing twice a symptoms will be avoided. A study performed in India revealed
day or more often) indicated a percentage of 69% of positive that parents take their children to emergency treatments to an
answers.(27) While a significant relationship was not found extent of 58.07%.(29) Unfortunately 84.4% of the mothers from
between the level of education of the participants included in our study indicate that they take their children to the dentist only
this study and the frequency with which their children brush for emergency treatments.
their teeth, when compared to other studies, the percentage of Experts in various fields related to child welfare
the population of participants coming from disadvantaged consider the parents as partners, actively collaborating with
backgrounds who follow the recommended tooth brushing various types of specialists in schools, social services, legal
frequency seems to be significantly lower. services etc.(2) By participating in educational programs,
Another possible explanation of this finding is parents gain new abilities and competencies, which help them
population homogeneity, as the participants where purposefully further in their relationship with their children. Studies show
selected based on low income and education levels. As House that parents prefer practical and the group activities, with
and Goesling (28) suggest, parents’ education level can help mothers being more open to such programs.(2)
improve children health in three ways: work and occupation, Prevention courses should be performed in mixed
lifestyle, and social relationships. groups of children and parents in order to determine together
Along with the obligations from school, parents are where the problems are and to learn effectively how to solve
expected to monitor their children’s general hygiene and in them. Dental health education proved to be effective in
particular their oral hygiene. Our study on children from increasing the knowledge level of children from disadvantaged
disadvantaged backgrounds indicates that only 43.8 % of the backgrounds.(18,33)
mothers supervise them while brushing. In comparison, a similar
study found that 96.49% of the parents of preschool children CONCLUSIONS
agreed that children should be guided and supervised by parents We came to the conclusion that mothers from
while brushing their teeth. Thakare, Ajith Krishnan & disadvantaged backgrounds do not pay sufficient attention to
Chaware.(29) Kuriakose and Joseph (30) also found that the their children’s learning about the principles of dental hygiene.
incidence of dental cavities is significantly lower in children Their monitoring of the process of dental hygiene as well as the
who are assisted by their parents during tooth brushing. age of starting tooth brushing among their children is
The best age to start tooth brushing is with the unsatisfactory. Our recommendation would be for them to
eruption of the first tooth.(31) Research shows that people from participate in special courses learn more about dental hygiene
disadvantaged backgrounds do not seem to be familiar with this and to increase awareness of the importance of dental hygiene in
recommendation. For example, a study by Akpabio et al., (2008) their children.
finds that in the USA only 32,4% of the mothers are aware it. Future work will attempt to include additional factors
Our study indicates an even more dire situation, with only related to the etiology of dental cavities in children, additional
14.1% of the participants having started tooth brushing with hygiene factors, food, as well as specific cavity prevention
their children when they were one year of age or younger. options only available in dental practices. It will also be
Overall, studies in the USA show a direct significant extended to cover a larger geographical area and additional
relationship between family income and the mothers’ knowledge organizations supporting children coming from socioeconomic
of the dental care and oral health-related behaviour.(21) The disadvantaged environments.
same study also shows that higher levels of education (more Acknowledgment:
years of education) the respondents had was directly correlated The authors would like to thank Maria Magher,
with the level of knowledge of the consequences of poor oral coordinator of the Counselling and Support Centre for Children
health. That is, the higher the education level, the more they and Parents of Cisnădie - SOS Children’s Villages Association
knew about the consequences of poor oral health. Another study, of Romania for her support in the project and the company
by Skeie et al. ( 6), suggests that Norway’s immigrant Procter&Gamble Romania that supplied the materials of dental
population faces the same problems, indicating that the lack of hygiene.

AMT, vol. 22, no. 1, 2017, p. 28


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AMT, vol. 22, no. 1, 2017, p. 29




“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.

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

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

Article received on 30.01.2017 and accepted for publication on 27.02.2017

ACTA MEDICA TRANSILVANICA March 2017;22(1):30-33
AMT, vol. 22, no. 1, 2017, p. 30

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
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
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
frequency frequency frequency frequency 0,6
(%) (%) 0,6

Male 9 45% 7 35% 0,4

Female 11 55% 13 65%
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

Chest perimeter in maximum inspiration and Making the difference between the chest perimeter in
maximum exhalation maximum inspiration and maximum exhalation, we obtained the
 Experimental group: following:
 The average for the chest perimeter in the maximum  for the experimental group, in the initial testing, the
inspiration was in the initial testing, 94.9 cm, with a average of chest elasticity was 4.6 cm with a minimum of 3
minimum of 85 cm and a maximum of 103 cm, and in cm and a maximum of 5 cm, and in the final testing the
final testing was 95.9 cm, with a minimum of 86 cm and average was 5.8 cm with a minimum of 4 cm a maximum
a maximum of 104 cm; of 7 cm;
 The average for the chest perimeter in maximum  for the control group, in the initial testing the average for
exhaling was in the initial testing 90.3 cm, with a the chest elasticity was 4.6 cm, with a minimum of 3 cm
minimum of 82 cm and a maximum of 98 cm, and in the and a maximum of 6 cm, and in the final testing the
final testing, was 90 cm, with a minimum of 81 cm and a average was 5.3 cm, with a minimum of 4 cm a maximum
maximum of 98 cm. of 7 cm.
 Control group: The comparative analysis of the difference between
 The average for the chest perimeter in maximum the means of the two groups resulted in a better evolution of the
inspiration was in the initial testing, 92.4 cm, with a experimental group. This difference was 1.2 in the experimental
minimum of 84 cm and a maximum of 98 cm, and in the group and 0.7 in the control group (figure no. 4).
final testing was 93 cm, with a minimum of 84 cm and a
maximum of 98 cm; Figure no. 4. Chest elasticity
 The average for the chest perimeter in maximum
exhalation in the initial testing was 87.8 cm, with a 1.4
minimum of 80 cm and a maximum of 94 cm and in the 1.2
final testing, remained unchanged at 87.7 cm, with a
minimum of 80 cm and a maximum of 94 cm. 1
Comparing the difference between the means of the 0.8 0.7
two groups revealed that a better evolution was recorded in the 0.6
experimental group, respectively:
 For chest perimeter in maximum inspiration the difference
between the means for the experimental group was 1, and 0.2
for the control group was 0.6 (figure no. 2); 0
 For chest perimeter in maximum exhalation, the difference experimental group control group
between the means for the experimental group was 0.3,
while for the control group was 0.1 (figure no. 3).
The efficiency of cardiovascular system index
(Ruffier test index) was described as follows:
Figure no. 2. Chest perimeter in maximum inspiration
 For the experimental group, in the initial testing the
average for cardiac resistance index was 8.7, with a
1.0 1.0 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
0.8 maximum of 10.6;
 For the control group, in the initial testing the average for
0.6 0.6
cardiac resistance index was 8.7, with a minimum of 5.5 to
0.4 a maximum for 13.2, and in the final testing average was
7.6, with a minimum of 5 and a maximum 11.6.
0.2 Comparative analysis of the averages of the two
groups shows that, for cardiac resistance index, the
0.0 experimental group had a better evolution. The difference
experimental group control group between the means for the experimental group was 2.4, and for
the control group 1.1 (figure no. 5).

Figure no. 3. Chest perimeter in maximum exhalation Figure no. 5. Cardiac resistance index

0.35 3
0.3 2.4
0.3 2.5
0.25 2
0.2 1.5 1.1
0.1 1
0 0
experimental group control group experimental group control group

AMT, vol. 22, no. 1, 2017, p. 32


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.
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
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.

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.

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work-related health complaints among Swedish dental
laboratory technicians. Community Dent Oral Epidemiol.
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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



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

Corresponding author: Hora iu Suciu, Str. Gheorghe Marinescu, Nr. 50, T rgu-Mureş, România, E-mail:, Phone: +40744
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

strip into the ventricular free wall and wires are passed through normal myocardial fibers have initial orientation.
the septum to the anterior wall of the right ventricle. The In his technique, after ventriculotomy, aneurysm
correction is completed with a second suture that connects the resection and thrombectomy of the left ventricular cavity, Jatene
scar tissue located along the left anterior descending artery with performed one or two purse string sutures at the junction
viable myocardium of the side wall of the left ventricle.(6) This between normal and fibrous myocardium. These sutures are
technique makes bypass to the left anterior descending artery tight, carefully reconstructing the left ventricular cavity and
impossible, because it is included in the suture line. reducing its size. Afterwards, ventriculotomy closure is
Another option for linear correction was introduced by performed with or without patch. If ventricular cavity volume is
Cabrol in 1974. This technique consists of cappitonage and close to the desired one, ventriculotomy is closed with isolated
exclusion of fibrous unresectable area, creating a new left stitches reinforced with Teflon patches. In such cases,
ventricular cavity bordered only by contractile walls. longitudinal suture length is significantly shorter than for
Cappitonage is made with three layers of continuous suture. conventional linear suture. When the defect resulted from
First, the deepest connects the free wall of the left ventricle to anevrismectomy is large, double Dacron patch is used to close
the interventricular septum in the border zone between the scar ventriculotomia. Endoventricular circular patch suture reduces
and the viable myocardium, the second layer connects the patch surface and thus the akinetic area in the newly formed left
portion of ventricular free wall with the fibrous septum, and the ventricular cavity.(10)
third is shallow, epicardial.(7) In Dor’s technique of circular endocavitary plasty, the
In 1984, Guilmet proposed the technique of septal procedure is performed under cardioplegic arrest.
exclusion, indicated in large aneurysms with septal involvement. Ventriculotomy is performed in the dyskinetic area, the
This technique involves partial resection of the aneurysmal sac thrombus is removed, and if there are documented episodes of
and exclusion of septal scar from the new ventricular cavity. ventricular tachycardia, endocardic subtotal resection is
Two layers of suture are applied, first connecting the left edge of performed. Cooley performs a circular endoventricular suture at
the aneurysmectomy with the border zone of the septal scar, 1 cm from the edge of viable myocardium to allow recreation of
thereby excluding 2/3 of the septal dyskinesia. The second layer a normal shape of the left ventricle. A balloon is inserted into
suture unites the right edge of the aneurysmectomy with the the left ventricular cavity and inflated to a theoretically diastolic
anterior left ventricular wall, providing hemostasis.(8) volume of 50-70 ml/m², then circular suture is tightened and
knotted. Subsequently, ventriculotomy is closed with a patch of
Figure no. 1. Linear left ventricular aneurysm repair appropriate size. Excluded scar tissue is sutured above,
contributing to local hemostasis.(11,12,13,14)

Figure no. 2. Patch ventriculoplasty

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 In 1989, Cooley promoted the ventricular
complications due to the fact that linear sutures were cutting into endoanevrismoraphy technique as a modified version of patch
necrotic tissue, a wider resection up to the viable myocardium reconstruction. The surgery is performed under conditions of
was needed. Since a 12/6 cm defect is impossible to close by continuous hypothermic cardioplegia. The apical aneurysm is
direct suture, Levinski used a Dacron patch for its closure.(9) opened through an incision parallel to the interventricular
This technique is precursor of the current ventriculoplasty patch sulcus, avoiding left anterior descending artery. After left
techniques. ventricular thrombectomy and identification of the border zone,
In 1985, Jatene and Dor independently reported a new defect size measurement is performed. An elliptical Dacron
method, called anatomical reconstruction of the left ventricle patch of appropriate size is used to close the defect, with the
with circular endoventricular reduction and closure by patch purpose of recreating normal ventricular shape, the scar tissue
suture of the ventricular wall defect. The purpose of these remaining outside. Ventriculotomy is closed above the patch,
methods was to recreate normal left ventricular geometry so that providing an additional hemostasis.(15,16)

AMT, vol. 22, no. 1, 2017, p. 35


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.
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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,
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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.
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-
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




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

Corresponding author: Elena Cristina Enciu, Str. Mircea Vulc nescu, Nr. 88, Bucureşti, România, E-mail:, 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

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=-

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.
3. Treiber FA, Kamarck T, Schneiderman N, Sheffield
D, Kapuku G, Taylor T. Cardiovascular reactivity and
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Psychosom Med. 2003;655:46-62.
4. O’Connor MF, Gundel H, Mcrae K, Lane RD Baseline
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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

rate recovery immediately after exercise and the

metabolic syndrome: The CARDIA Study. Eur Heart J.
6. GhaffariS, Kazemi B, Aliakbarzadeh P Abnormal heart
rate recovery after exercise predicts coronary artery
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CJ, Vasan RS. Heart rate recovery after treadmill exercise
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Framingham Heart Study). Am J Cardiol. 2002;90:848-
8. Bilsel T, Terzi S, Akbulut T Sayar N, Hobikoglu
G, Yesilcimen K. Abnormal Heart Rate Recovery
Immediately After Cardiopulmonary Exercise Testing in
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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-
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
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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
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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





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

Corresponding author: Simona Şerban, Str. Mihail Cioranu, Nr. 21, Sector 5, Bucureşti, România, E-mail: 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

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

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


Figure no. 5. T2-weighted Coronal Flair slice showing CONCLUSIONS

hypertrophy of the fourth ventricle (c) 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.

1. Gazzaniga MS. Cerebral specialization and
interhemispheric communication: Does the corpus
callosum enable the human condition? Brain.
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
DISCUSSIONS framework. Trends in Cognitive Sciences. 2005;9:416-23.
The authors reported an interesting case of severe 4. Jeret JS, Serur D, Wiesniewski KE, Lubin RA.
dysgenesis of the corpus callosum with behavioral disorders and Clinicopathological findings associated withagenesisof the
cognitive deficit associated with bilateral hearing involving corpus callosum. Brain and Development. 1987;9(3):255-
permanent damage of the cochlea in both sides but also neural 64.
(retrocochlear) dysfunction in one ear. 5. Bedeschi MF, Bonaglia MC, Grasso R, Pellegri A,
This pattern of retrocochlear damage can be attributed Garghentino RR, Battaglia MA, et al.. Agenesis of the
to the compresive effect of the cerebrospinal fluid within the corpus callosum: Clinical and genetic study in 63 young
pontocerebellar cistern on the auditory nerve, but it can not be patients. Pediatric Neurology. 2006;34:186-93.
ruled out an intrinsec characteristic of the hearing loss 6. Taylor M, David AS. Agenesis of the corpus callosum: A
associated to the malformation of the most important structure United Kingdom series of 56 cases. J Neurol Neurosurg
of the white matter in the brain. Psychiatry. 1998;64:131-4.
Unfortunately, the malformation was not evidenced in 7. Serur D. Agenesis of the corpus callosum: clinical,
utero, and the late diagnosis was detrimental to the possibility of neuroradiological and cytogenetic studies. Neuropediatrics.
applying specific recovery therapies until the age of 6 when the 1988;19:87-91.
cerebral plasticity starts to decline significantly. Regarding the 8. Blum A, André M, Droulle P, Husson S, Leheup B.
benefit of hearing aids, it is extremely limited, on the one hand Prenatal diagnosis of the corpus callosum agenesis. The
due to the characteristic of neural deafness on the left ear, on the Nancy experience, 1982-1989. Genetic Counselling.
other hand because of the absence of communication between 1990;38:115-26.
brain hemispheres that limits speech understanding but also its 9. Smith LP, Karimi K, Angeli SI. Cochlear dysplasia with
production. Other consequences of central auditory processing agenesis of the corpus callosum.Inter. J. Pediatr.
deficit are related to the difficulties that the child has on spatial Otorhinolaryngol. 2006;70:1985-8.
localization tasks and dichotic listening. 10. Hendriks YM1, Laan LA, Vielvoye GJ, van Haeringen A.
These issues must be explained to the family in a Bilateral sensorineural deafness, partial agenesis of the
manner that makes their expectations of hearing aids benefit and corpus callosum, and arachnoid cysts in two sisters. Am J
child’s recovery be more realistic. Provision of conventional Med Genet. 1999;10;86(2):183-6.
hearing aids may increase the child awareness to the sounds but 11. Schell-Apacik CC, Wagner K, Bihler M, Ertl-Wagner B,
the associated behavioral disorders disrupt a systematic wearing Heinrich U, Klopocki E, et al. Agenesis and dysgenesis of
of the devices. the corpus callosum: clinical, genetic and neuroimaging
Concerning the prevalence of hearing loss in findings in a series of 41 patients. Am J Med Genet A.
newborns with corpus callosum agenesis, there are no 2008;146A(19):2501-11.
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



University of Medicine and Pharmacy Craiova, Craiova Emergency County Hospital,
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.


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

Corresponding author: Diaconu Magdalena, Str. Ion I. Argetoaia, Nr. 6, Bl. C2, Sc. 1, Ap. 11, Cod postal 200642, Phone: +407222 97755, E-mail:
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

interruption of anti-diarrhea treatment, angiotensin II receptor normal contractions of the left ventricle walls, ejection fraction =
antagonists, proton pump inhibitors, administration of intestinal 55%, expansion of the right cavity, right atrium = 49 mm, left
anti-infectives, anti-acids, diuretics, selective beta-blockers, with atrium = 47 mm, not being able to examine tricuspid
immediate repeated urea and creatinine, serum iconogram and regurgitation, recommending heparin with low molecular weight,
transfer in the intensive care unit. loop diuretics, potassium saver diuretics, the electrocardiogram
On admission in the intensive care unit (ICU), on 27th (ECG) highlighting the sinus rhythm.
of January 2017, the patient presents severe general condition, he Surgical consult describes that the rectal examination
is conscious, cooperative, with bilateral basal decreased vesicular does not recommend melena, this case not being an acute surgical
murmur, lung crackles disseminated in both bronchial areas, case.
afebrile, an intense diuresis urine, in the amount of about 100 Regarding the evolution of biological parameters, they
milliliters, bilateral leg edema, multiple diarrhea episodes. had a favourable outcome, namely:
Immediate stool was proceeded in order to test the existence of  creatinine, from the value of 8.99 mg/dl it was normalized,
Clostridium Difficile, and the results came out positive. The Adler reaching a value of 1.2 mg/dl;
test was also carried out, which came out negative, whereas the  urea, from the value of 178 mg/dl on admission, it reached a
digestion sample shows: rare fat droplets, very frequently value of 117 mg/dl;
undigested starch, absorbed muscle fibers, so the occult bleeding  hemoglobin, from the value of 6.97 g/l after the
test does not indicate a bleeding. Tracheobronchial sample was administration of 4 units of packed red blood cells,
collected and, 5 days later, it pointed out pulmonary infection with administered one at a day, it reached the value of 8.8 g/l;
MRSA and Candida spp., the patient being a carrier of the germs.  albumin, from the value of 2.8 g/dl after the administration of
The values of all tests were normal, except: urea = 178 human albumin daily, it reached a normal value;
mg/dl, creatinine = 8.99 mg/dl, leukocytes 11 330 /mm3,  sodium, potassium through fluid and electrolyte balancing,
neutrophils = 84,500/mm3, hemoglobin 6.97 g / l, sodium (Na) = had normal values;
125 mmol/l potassium (K) = 5.60 mmol/l. These values were  p-sepsine from 527 increased to 708 on the 13th day;
measured immediately at admission to IC.
 NT-proBNP (N-terminal brain-Type Netriuretic Peptide)
It was immediately proceeded the treatment for
from 12.377, fell to 8468 (being a severe heart failure);
Clostridium Difficile orally as prescribed by the infectious disease
 D-dimer from the value of 4.48, increased to a level> 5;
physician, with antiprotozoals (500 mg every 8 hours).
 white blood cells (WBC) normalized, as well as neutrophils,
On the 2nd of February 2017, a new abdominal
so from a neutrophilic leukocytosis were obtained normal
ultrasound was performed, which, compared to the previous
values, but in the 13th day, they had a significant increase,
examination, revealed stasis hepatomegaly, normal kidneys, with
reaching leukocytes = 28 160 /mm3 with neutrophils = 97
parenchymal index -2, dilated intestinal loops, with abundant
content, possibly ascites liquid between the intestines. Chest X-ray 190 /mm3.
Regarding the temperature curve, the patient was
was performed which revealed no pleuro-pulmonary lesions, only
afebrile during hospitalization, recording one episode of low grade
increased heart.
fever, a temperature of 37.4 °C on the 14th day. Diuresis, from an
Thorax and abdominal tomography was performed, on
the 2nd of February 2017, (natively performed tomography, due to amount of about 500 ml/day, intensively coloured, after the first 2
days of hospitalization in intensive care it was normochromic and
the increased values of cleareance), which highlighted: bilateral
its amount reached 2400-3000 ml/day.
basal pleural fluid with maximum thickness of 6.8 cm on the right
Diarrhea episodes after three days of administration,
and 3.4 cm on the left. Without areas of compression or suspect
bilateral pulmonary nodules. The abdominal results are: the right antiprotozoals 500 mg every 8 hours orally, did not diminish, the
patient still presenting the same diarrhea syndrome, in addition to
lobe of the liver = 19 cm and the left lobe = 7 cm without
presenting a melena case. It was thus decided to change the oral
computed tomography changes, without dilatation of lower biliar
administration of antibiotic with glycopeptide antibiotics, which
ducts. The spleen is natively homogeneous, the bipolar spindle =
13cm. Pancreas heads without ductal dilatation or parenchymal are administered for the treatment of severe infections resistant to
other antibiotics. The dose established by the infectious disease
calcifications. The adrenal glands are normally complied. The
doctor was 125 mg every 6 hours orally. From the 5th day the
kidneys have normal size, sustained parenchymal index without
diarrhea and melena episodes were not repeated, the result of
computer images of kidney stones, without dilatation of the upper
urinary tract. Atheromatous parietal calcifications of abdominal tracheobronchial culture being lung infection with MRSA and
Candida spp. It was thus initiated the treatment with tigecycline,
aorta. Without abdominal fluid. Highlighted infiltration of
taking into account associated infections, these bacteria being
subcutaneous tissue, accompanied by fluid density areas in the
sensitive to this antibiotic. Antifungal treatment was administered
bilateral abdominal wall, predominantly on the right side.
Atheromatous parietal calcifications in the aortic arch and for candidiasis. After this combination, leukocytosis with
neutrophil normalized. Throughout the admission in ICU,
descending intrathoracic aorta.
medication was administered according to antibiogram, the
Bioassays were performed in dynamic and interclinic
adjustments of drugs being made according to creatinine
The lung examination shows a serious state of the clearance, the infusion according to diuresis, with fluid electrolyte
balance aiming at daily requirements plus or minus deficits.
patient, with recommendations of bronchodilators and
Painkillers were given, if required, as well as expectorant, digital
nebulization for improving the respiratory function. After
performing a computer tomography scan of the thorax, thoracic benzodiazepine, diuretics, selective beta-blockers, heparins with
surgery consultation was performed, which decided bilateral low molecular weight, substances that favour increased nutritional
intake at the cellular level, nebulization with bronchodilators and
pleural puncture, being evacuated on either sides about 500 ml of
serocitrin liquid and it recommended samples for cytology,
biochemistry, culture. Regarding respiratory function, it did not have a
Cardiology consultation with cardiac ultrasound, favourable evolution. Whereas at admission to IC the patient was
breathing spontaneously with additional Oxygen (O2), on the
describes a right ventricle of 45 mm, left ventricle of 31 mm,
facial mask on the 6th day breaths were ineffective, SpO2 = 79%
ventricular septal of 13.5, left ventricle posterior wall = 13.5,
AMT, vol. 22, no. 1, 2017, p. 44

(peripheral oxygen saturation), perioronasal cyanosis and abdominal pathology indicates administration of the antibiotic
extremities, leading to the oro-tracheal intubation, with evident orally, it is essential to maintain normal biological parameters. So,
hypercapnia encephalopathy. On the 7th day the patient was as a measure of prevention of lung superinfection, we applied
conscious, it was attempted extubation, but during the guard he nebulizer with polymyxin and intravenous tigecycline.
was intubated and put back on ventilator, O2 saturation wasn’t In the case of a complicated COPD, also of a CDI,
maintained within favorable limits, thus the patient underwent where for the first infection the antibiotic is by choice, but in the
decay breathing again. Regarding the mode of ventilation, if only second case the antibiotic was contraindicated as the major cause
for a short period of time (for an hour), it was under cotrol all the in triggering this condition, nebuliser with polymyxin E until the
time, while the patient was intubated, the ventilation was assisted result of tracheobronchial culture, has resulted in improving the
with intermittent periods when breathing alone on probe patient's condition, WBC reaching the normal amount. This
intubation, on T-tube. Starting on day 10, mechanical ventilation therapeutic approach we took after studies showed that
was totally controlled, the patient's condition got worse and on the administration of intravenous antibiotics should be stopped as
11th day, the patient had an irresuscitator cardiac arrest. recurrences occur and the treatment with metronidazole or
vancomycin must absolutely be initiated, with examination, in
DISCUSSIONS advance of infectious diseases and surgical consultation, in order
CDI treatment associated with COPD is complex, to perform therapeutic colectomy if it is considered
requiring multidisciplinary involvement and intervention at the appropriate.(2) Tigecycline is active on both CDI and MRSA
etiological, symptomatic and complication level. Regarding the infection.(10)
CDI treatment, for a long time, it was used Vancomycin and
Metronidazole, proving its efficacy, treatment which does not CONCLUSIONS
suppress the risk factors of the host.(9) In addition to this therapy, The experience of this case supports the idea that
which is preferred, it can also be used intravenous administration clostridium difficile infection and chronic obstructive pulmonary
of tigecycline, as an alternative therapy.(10) disease are two major causes of death. Therapeutic conducts for
When a patient shows decompensation of COPD, they these diseases come in contradiction at the expense of the patient,
have three symptoms: dyspnea emphasis, increasing the amount stressing the fact that their association is dramatic. Therapeutic
of phlegm and infection of tracheobronchial secretions. As orientation by inhalation of polymyxin and bronchodilators had
treatment of first intention, worsening COPD initiates: remarkable effects, worthy to consider for further cases. In the
a) O2 therapy, whose target is (oxygen arterial pressure) PaO present situation, preexisting disease has increased susceptibility
2≥ 60 mmHg or SpO2≥ 90-92%; to infectious complications, interfered with treatment response,
b) Bronchodilators. It has been scientifically proven that their leading to an adverse evolution compared with other hospitalized
administration by inhalation was superior to the intravenous patients with the same diagnosis.
c) Corticosteroids, administered intravenously, have a clear REFERENCES
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COPD community, the majority of germs from COPD being: 367.
b Streptococ pneumoniae, Moraxella, Moraxella, 2. Khanna S, Pardi DS.Clostridium difficile infection:
Haemophilus influenzae MRSA.(2) management strategies for a difficult disease. Ther Adv
In our case, although the evolution of biological Gastroenterol. 2014;7(2):71-88.
parameters was toward normalization, the morbid condition of the 3. Bobo LD, Dubberke ER, Kollef M. Clostridium difficile in
patient, obesity, COPD, smoking, chronic alcohol consumption, the ICU. CHEST. 2011;140(6):1643-1654.
lifestyle inadequate to chronic diseases have had a negative 4. Wittand CA, Kollef MH. The Washington Manual of Critical
impact on the patient, as literature itself describes the three Care, second edition, ed. Wolters Kluwer/Lippincott
important factors in triggering CDI: Williams and Wilkins; 2012. p. 76-78,337,338,343-346.
a) hospitalization, contact with other patients; 5. Lubbert JT. John E, von Muler L. Clostridium difficile
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c) age over 65 years, comorbidities, obesity, etc.(1,2,3) guideline-base diagnosis and treatment. Dtsch Arztebl Int.
In the case of CDI, the first symptom is watery diarrhea, 2014, Oct 24;111(43):723-31.
with daily episodes from 3 to even 20 episodes a day in the most 6. Christine WA, Crobach MJT, Dekkers OM, Wilcox MH,
severe cases. The symptoms are common: abdominal pain, fever, Kuijper EJ. European Society of Clinical Microbiology and
leukocytosis, hypoalbuminemia.(5,6) In our case these symptoms Infections Disease (ESCMID). Data review and
were present and remitted after treatment. As laboratory diagnosis recommendations for diagnosing Clostridium difficile
there are worth mentioning a few ways: stool, with the presence or infection, Epidemiology and causes of acute diarrhea.
absence of toxins A and B in the stool, colonoscopy (when the test 2009;15:1053-1066.
is negative, with doubtful diagnosis), abdominal ultrasound, 7. Khan FY, Elzonki AN. CDI: a review of the literature; 2014.
which may reveal ischemia or distension, abdominal tomography 8. Stuart J. Recurrent CDI: A review of risk factors, treatments,
that can describe thickening of the intestinal wall, when the and outcomes; 2009.
disease is very advanced.(7,8) Therefore, according to the 9. Musgrave CR, Bookstaver PB, Sutton SS, Miller AD. Use of
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abdominal tomography to exclude intestinal occlusion or Infectious Diseases. 2011;15:431-449.
ischemia, abdominal ultrasound being performed several times. 10. Cunha BA. Antibiotic essentias, ed. Jonesand Bartlet
The presence of multiple pathologies associated with Learning; 2013. p. 14,238.
strict therapeutic indications, makes the course of treatment
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require respiratory pathology, according to the studies while
AMT, vol. 22, no. 1, 2017, p. 45




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

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

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

diagnosed with epidermoid carcinoma simultaneously, 7 patients carcinoma, 1 with adenocarcinoma, 1 with small cell carcinoma,
with adenocarcinoma, 5 patients with small cell carcinoma, the and in 1 patient, no histopathological type was revealed.
remaining 12 patients having no histological confirmation.
Table no. 3. Distribution of patients diagnosed with
Table no. 1. Distribution of patients with digital clubbing hypertrophic pulmonary osteoarthropathy according to
depending on the histopathological type of lung cancer histopathological type of lung cancer
Histopathological type No. of patients with digital clubbing Histopathological type No. of patients with
Epidermoid carcinoma 44 hypertrophic pulmonary
Adenocarcinoma 7 osteoarthropathy
Small cell carcinoma 5 Epidermoid carcinoma 8
Undetermined Adenocarcinoma 1
histopathologic type Small cell carcinoma 1
Undetermined histopathologic
Figure no. 1. Distribution of patients with digital clubbing type
depending on the histopathological type of lung cancer
Figure no. 3. Distribution of patients diagnosed with
hypertrophic pulmonary osteoarthropathy according to
histopathological type of lung cancer

Table no. 2. Distribution of patients with digital clubbing DISCUSSIONS

depending on the time of diagnosis of lung cancer Although lung cancer is a cause of severe illness and
The time when digital clubbing signs occurred No. of patients its incidence is continuously increasing, paraneoplastic
Upon diagnosis of lung cancer 3 syndromes associated to this (numerous and extremely varied)
During disease progression 65 are insufficiently studied. These paraneoplastic syndromes may
precede the occurrence of clinical manifestations of cancer.
Figure no. 2. Distribution of patients with digital clubbing Their knowledge is very important in setting an early diagnosis.
depending on the time of diagnosis of lung cancer 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
Hypertrophic pulmonary osteoarthropathy disease.(4,5,6)
Hypertrophic pulmonary osteoarthropathy, in its Some of the few cohort studies were those of Croft and
complete form, was present in 11 patients (4.54% of all lung Wilkinson on paraneoplastic neurologic syndromes, in which
cancer cases). Two of the patients went to the doctor for more than 1400 study patients had an incidence ranging between
rheumatoid syndrome manifested by pain and swelling joints, 0.5 and 16.4%, with the average of 6.6 %. In a control group,
symmetrical at the level of radiocarpal joints, knees or ankles. these authors have found neurological changes between 1 and
Associated, they presented digital clubbing, excessive growth of 2%. It their etiology, the first place was held by lung cancer. In
the soft tissues of the extremities accompanied by vasomotor another study, these syndromes were detected in 7% of almost
disturbances at this level. Subsequently, chest radiograph 1500 patients with tumours. Tumours that are most frequently
examination revealed lung cancer, confirmed by chest CT scan associated with paraneoplastic neurologic syndromes are lung
and bronchoscopy with histopathological type determination. In cancer (47%), gastric (12%), breast (12%), ovarian (9%), and
9 patients, this kind of events has occurred subsequently to the colon cancer (6%).(6,7,8)
diagnosis of lung cancer, in different stages of the disease. Another published study show that isolated monoarthritis
Association with the histopathological type was made of the knee is a paraneoplastic syndrome previously described
as follows: 8 patients were diagnosed with epidermoid that evokes lung cancer without small cells in an early stage.(9)
AMT, vol. 22, no. 1, 2017, p. 47

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.
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
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.

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.

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





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)

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:, Phone: +40749 192291

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

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

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

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.

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
2. A Gaspari A, Tyring SK, Rosen T. Beyond a decade of 5%
imiquimod topical therapy. J Drugs Dermatol.
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




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

Corresponding author: Costinela Georgescu, Str. R zboieni, Nr. 19A, Cod 800114, Gala i, Jude ul Gala i, România, E-mail:,
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

Figure no. 1. Serpiginous linear eruption located on the Mar;52(3):327-30. doi: 10.1111/j.1365-4632.2012.05723.x.
thenar eminence 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:
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.
Figure no. 2. Lesion appearance after medicine treatment
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.
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.
The diagnostic of Cutaneous Larva Migrans was 9. Tomich EB, Knutson T, Welsh L Hookworm-related
established on the basis of anamnesis and clinical examination. cutaneous larva migrans. CJEM. 2010 Sep;12(5):446.
The patient was treated with Albendazole 400 mg/day for 5 days 10. Müller-Stöver I, Richter J, Häussinger D(Cutaneous larva
and required treatment continuation for another five days with migrans (creeping eruption) acquired in Germany). Dtsch
Doxycycline because, despite the gradual disappearance of the Med Wochenschr. 2010 Apr;135(17):859-61. doi:
serpiginous tract, the area remained intensely eczematized due 10.1055/s-0030-1253669. Epub 2010 Apr 20.
to the itch and to attempts made by the patient to find the larva 11. Zimmerman RF, Belanger ES, Pfeiffer CD. Skin infections
(figure no. 2). in returned travelers: an update. Curr Infect Dis Rep. 2015
Mar;17(3):467. doi: 10.1007/s11908-015-0467-8.
DISCUSSIONS 12. Landolt L, Kovari H. (CME. Larva migrans). Praxis (Bern
Cutaneous Larva Migrans is frequent in the tropical 1994). 2014 Dec 10;103(25):1491-8. doi: 10.1024/1661-
and subtropical countries, yet isolated cases might occur in non- 8157/a001859.
endemic areas such as Europe. The specific host is the dog or 13. Romero-Callejas E, Rendón-Franco E, Villanueva-García
the cat who eliminated via faecal the nematode eggs. Under C, Osorio-Sarabia D, Muñoz-García CI. Risk of cutaneous
moisture and heat the eggs turn into larvae and penetrate the larva migrans and other zoonotic parasites infections due to
epiderma. The nematode larvae penetrate the epiderma but they feral cats from a touristic tropical park. Travel Med Infect
are unable to pass by the dermoepidermic junction and go Dis. 2014 Nov-Dec;12(6 Pt A):684-6. doi:
deeper, systemic complications being absent. The disease is self- 10.1016/j.tmaid.2014.10.018. Epub 2014 Nov 1.
confining in the absence of treatment to weeks or months since 14. Criado PR1, Belda W Jr, Vasconcellos C, Silva CS.
humans are not the usual host of the nematode, which cannot Cutaneous larva migrans: a bad souvenir from the vacation.
complete its lifecycle. Cutaneous biopsy is not considered Dermatol Online J. 2012 Jun 15;18(6):11.
necessary as the larva advances beyond the end of the eruption. 15. Gutierrez Y. Diagnostic Pathology of Parasitic Infections
Treatment is required due to the long evolution periods and with Clinical Correlations, Second edn, New York: Oxford
itching. University Press; 2000. p. 343-353.
16. Gilman RH. Intestinal nematodes that migrate through skin
CONCLUSIONS and lung. In: Strickland GT ed. Hunter's Tropical Medicine
The Cutaneous Larva Migrans is a rare disease in and Emerging Infectious Disease, 8th edn. Philadelphia:
Europe. The presentation of the cutaneous larva migrans cases Sounders; 2000. p. 730-735.
would contribute to an early and correct diagnostic of such cases 17. Bryceson ADM, Hay RJ. Parasitic worms and protozoa. In:
of parasitosis that are specific to tropical areas and they are Champion RH, Burton JL, Burns DA, et al eds. Rook/
occasionally encountered in Romania. Wilkinson / Ebling Textbook of Dermatology, 6th edn. Vol
2, Oxford: Blackwell Sciences; 1999. p. 971-972.
REFERENCES 18. Arthur RP, Shelly WB. Larva currens. A distinctive variant
1. Baple K, Clayton J. BMJ Case Rep. Hookworm-related of cutaneous larva migrans due to Strongyloides stercoralis.
cutaneous larva migrans acquired in the UK. 2015 Nov Arch Dermatol. 1958;78:186-190.
13;2015. pii: bcr2015210165. doi: 10.1136/bcr-2015- 19. Stone OJ, Newell GB, Mullins JF. Cutaneous
210165. Strongyloidiasis: larva currens. Arch Dermatol.
2. Veraldi S, Persico MC, Francia C, Nazzaro G, Gianotti R. 1972;106:734-736.
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



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

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

Corresponding author: Gabriela Denisa C ileanu, Str. Decebal, Nr. 3 , Bl. C1, Sc. B, Ap. 29, Piatra Neam , România, E-mail:, 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

concentration of 3mg per 100ml, whereas IgM, IgA and IgD are circulating cathecolamines, epinephrine and norepinephrine, and
absent.(3) In eyes with uveitis, the level of IgG increases and by the activity of the subject. Aqueous production diminishes
IgA and IgM also appear. There also have been reported slightly with age and by now there is no report of an age-
elevated levels of aqueous matrix metalloproteinase (MMP-2) dependent loss of ciliary epithelial cells. Hypothermia leads to a
and tissue inhibitors of MMP (TIMP-1, TIMP-2 and TIMP-3 in decrease in aqueous humor formation, reflecting a deactivation
p with myopia in a stationary stage and with an axial length of metabolic processes necessary to maintain active secretion.
greater than 26 mm.(4) In aqueous humor there are also trace The ultrafiltration component of aqueous formation is
quantities of complement proteins and of components of pressure sensitive, decreasing with increasing IOP. This
fibrinolytic and coagulation systems, excepting plasminogen and phenomenon is called pseudofacility and is quantifiable.
plasminogen proactivator which are present at more significant Decreased plasma osmolality reduces aqueous formation, and
levels. Only traces of the inhibitors of plasminogen activator are also does uveitis, especially iridocyclitis. There are also
present, ensuring that the aqueous outflow pathway remain free hormonal influences on aqueous secretion and many
of fibrin. pharmacologic agents reduce aqueous secretion and thus IOP.
There are also in aqueous humor small quantities of They are largely used in glaucoma treatment, including β-
mono- and dinucleotide that play a role in the control of corneal adrenoceptor antagonists such as timolol, betaxolol and others,
endothelium ion transport. α and γ-lens crystallins are also carbonic anhydrase inhibitors, and α2-adrenoceptor agonists
present in small quantities in healthy eyes and their levels such as brimonidine. Thicker corneas may be associated with
increase in cataract. The amino acid concentration is frequently lower aqueous production and lower uveo-scleral outflow.(9)
higher in the aqueous than in the plasma. It has been suggested Blood aqueous barrier
the existence of six transport systems for amino acid in the Large molecules such as protein are present in
ciliary epithelium: three independent for neutral amino acids and aqueous in small quantities although their plasma concentration
separate mechanisms for basic aminoacids, acidic amino acids is high. In humans, normal plasma total protein levels are 6g per
and urea. Proteomic analysis of the human aqueous humor 100 mL, and in aqueous humor there are less than 20 mg protein
indentified 676 nonredundant proteins.(5) The elucidation of per 100 mL (less than 0.5% of plasma concentration). This is
aqueous proteome will establish a foundation for protein due to the existence of blood-aqueous barrier, an epithelial
function analysis and identification of differentially expressed barrier formed by the nonpigmented ciliary epithelium and the
markers associated with diseases of the anterior segment. Open posterior iridial epithelium and by the endothelium of the iridial
angle glaucoma patients (primitive and pseudoexfoliative type) vessels. Both these compounds have tight junctions of the
have elevated levels of multiple biomarkers of Alzheimer ―leaky‖ type. There is some evidence indicating that the tight
disease in aqueous humor, compared with cataract patients. junctions of the ciliary epithelium have few sealing strands,
They have elevated levels of apolipoprotein Al, Apolipoprotein these being responsible for a low transepithelial resistance
CIII, transthyretin (TTR), complement factor H, and characteristic of the less tight and somewhat more ―leaky‖
complement C3 and α2 macroglobulin.(6) epithelia.(7) Thus, the blood-aqueous barrier is not absolute. The
In aqueous humor there are very high concentrations greater the lipid solubility of a molecule, the greater its ability to
of ascorbate and lactate. Ascorbate is actively secreted in penetrate the barrier and to pass into the posterior chamber.
aqueous humor and its production depends on the presence of Certain substances, such as urea, creatinine and some sugars
ATP and Na + gradient. Ascorbate is concentrated mainly by the penetrate the blood-aqueous barrier but they are slower than
lens epithelium and has a protective effect against UV-induced across capillary walls. The blood–aqueous barrier is fragile and
DNA damage to this tissue. Ascorbate has an antioxidant role, may be disrupted by various stimuli such as corneal abrasions,
partially absorbs UV radiation and regulates the sol-gel balance uveal inflammation, intraocular infections, paracentesis,
of mucopolysaccharides in the trabecular meshwork. Lactate intraocular surgery, topical applied drugs (anticholinesterase
accumulates in the anterior chamber, being produced by both agents). The resultant aqueous produced is the ″secondary″
ciliary body and retina. In anterior chamber lactate concentration aqueous with a marked increase in protein concentration.
is considerably higher than in plasma. Certain substances as mannitol penetrate poorly the blood-
Aqueous humor also contains hydrogen peroxide, as a aqueous barrier and are used clinically to reduce IOP. They
result of reactions between ascorbic acid and trace metals. accumulate in the extacellular spaces of the body, producing a
Human trabecular cells exposed to 1 mM hydrogen peroxide high osmotic pressure that draws water from cells and ocular
show reduced adhesiveness to the extracellular matrix proteins fluids leading to a reduction of IOP.
fibronectin, laminin and collagen types I and IV.(1) Repeated Aqueous humor outflow
oxidative stress in vivo may result in reduced trabecular Aqueous humor produced in the ciliary body and
meshwork cells adhesion leading to cell loss, one of the major released in the posterior chamber passes through the pupil in the
histopathologic changes in glaucoma. Glucose concentration in anterior chamber and then through trabecular meshwork,
aqueous humor is slightly less than that in plasma. Glucose Schlemm’s canal and aqueous veins. The fluid movement is
diffuses into the aqueous and also in the cornea. Its directed by pressure change. In the eye normal IOP is 15 Hg, but
concentration in the corneal endothelium is half of that in pressure drops to 9 mm Hg in SC and further to 7-8 mm Hg in
aqueous. aqueous veins.(10)
Oxygen is also present in aqueous humor as well as There is a mechanosensing activity in trabecular
transforming growth (TGF) β2 factor that may play a role in meshwork and Schlemm’s canal, including ways in which cells
glaucoma pathogenesis. The intrinsic activity of TGF β 2 transfer mechanical changes into biologic signals. There is no
contributes to the maintenance of the anterior chamber direct evidence of baroreceptor activity in the eye but some
associated immune deviation. Many physiologic systems, evidence for an ―ocular baroreflex‖ is given by the fact that eye
including the central nervous system, endocrine and pressure is tightly regulated over the entire life and eyes exposed
cardiovascular systems, as well as change in metabolic activity to stretching and increased fluid flow return to starting IOP
influence the secretion of aqueous humor. The aqueous levels. The most likely site for this baroreceptor activity in the
production shows a diurnal cycle, decreasing by as much as 50% conventional outflow pathway appears to be the interface
at night.(8) The aqueous diurnal cycle is influenced by between the juxtacanalicular region of the trabecular meshwork
AMT, vol. 22, no. 1, 2017, p. 55

and the Schlemm’s canal.( 0) The cells and extracellular matrix the cells in contact with integrins that activate integrin-signaling.
in this region are considered the site of outflow resistance in This outside-in signalling affect outflow facility by regulation of
glaucoma. cell contractility. In addition, inside-out signaling can be
The Schlemm’s canal inner wall has two diametrically initiated by growth factor receptor pathways or by G-protein-
opposed functions. First, it must allow aqueous to pass in a basal coupled receptors that induce activation of the integrin. Eleven
to apical direction, facilitating entry into the canal lumen. integrins are expressed by the TM cells.(10)
Second, the Schlemm’s canal is part of the blood aqueous In addition, an uveo-scleral outflow pathway exists,
barrier along with the ciliary epithelium, the iris vascular that accounts for nearly half of total aqueous drainage in young
endothelium and the posterior iris epithelium.(11) This barrier human eyes. New evidence suggest ocular lymphatics, formerly
formed by the tight junctions between the endothelial cells of believed to be absent in the eye, may represent an
the inner wall of the canal prevents blood products from uveolymphatic exit route for fluid and proteins retained in the
entering the eye when elevated episcleral venous pressure uveo-scleral tissue. A minimal amount of fluid leaves the
exceeds IOP. The factors that regulate the blood aqueous barrier anterior and posterior chambers through the iris and through the
at the level of Schlemm’s canal are poorly understood. vitreous to the optic nerve and retinal vessels.(1)
Schlemm’s canal endothelium stretches and expands as a
response to pressure, in both size and contractile ability. CONCLUSIONS
Canalicular endothelial cells form more giant vacuoles and Aqueous humor is a liquid of paramount importance in
pores increased in size as a response to pressure. Schlemm’s the homeostasis of normal human eye. Apart of maintaining the
canal cells undergo shear stress much alike to that in large IOP and the internal alignment of intraocular structures, it
arteries and act by aligning in the direction of flow. nourishes the ocular structures that are necessarily avascular, the
The pressure in the outflow system is influenced by posterior cornea, the crystalline lens and the anterior vitreous.
pulse, blinking and head movement, indicating that fast and During ocular diseases treatment very effort must be made for
slow adaptation mechanisms may be present to respond to rapid its normal production and existence inside the eye.
pressure change. Tissue and cell stiffness are factors that may
alter the responsiveness of trabecular meshwork and Schlemm’s REFERENCES
canal to fluid flow, shear stress and pressure. There are changes 1. Gabelt BT, Kiland JA, Tian B, Kaufmann PL. Aqueous
in cytoskeleton, morphology, protein and gene expression Humor: Secretion and Dynamics, in Duane’s Foundation of
produced in trabecular meshwork cells as a result of changing Clinical Ophthalmology. 2013;2:12957-13018.
substrate stiffness.(10) It is well known that trabecular 2. Green K. Physiology and Pharmacology of Aqueous
meshwork stiffness increases in primitive open angle glaucoma Humor Inflow. Surv Ophthalmol. 1984;29:208-14.
with regional variability. 3. Sen DK, Sarin GS, Saha K. Immunoglobulin in human
It has been proved that drug treatments also modify aqueous humor. Br.J. Ophthalmol. 1977;61:216-7.
Schlemm’s canal stiffness. If drug treatment increased 4. Jia Y, Hu DN, Zhu D, Zhang L,Gu P, Fan X,et al. MMP-2,
Schlemm’s canal stiffness, resistance to outflow also increased. MMP-3, TIMP-1, TIMP-2, and TIMP-3 Protein Levels in
If drug treatment relaxed the cells, resistance decreased. In Human Aqueous Humor: Relationship with axial length.
Schlemm’s canal cells vacuole and pore formation is pressure Invest Ophthalmol Vis Sci. 2014;55(6):3921-28.
dependent and is influenced by stiffness. The number of pores is 5. Chowdry UR, Madden BJ, Charlesworth MC, Fautsch MP.
reduced in glaucoma tissue. Increased trabecular and canal Proteome analysis of Human Aqueous Humor. Invest
stiffness with age or primitive open angle glaucoma could Ophthalmol Vis Sci. 2010;51:4921-31.
reduce baroreceptor activity and pore formation, increasing 6. Inoue T, Kawaji T, Tanihara H. Elevated Levels of
outflow resistance. Thus drugs that modify cytoskleton directly Multiple Biomarkers of Alzheimer Disease in the Aqueous
or indirectly, such as Rho Kinase inhibitors and latrunculins, Humor of Eyes with Open Angle Glaucoma. Invest
may decrease cell stiffness and reduce outflow resistance. Ophthalmol Vis Sci. 2013;54:5353-58.
Defining the mechanosensing activity of the 7. Cunha-Vaz J. The Blood-Ocular Barriers. Surv
conventional outflow pathway may be the clue for new Ophthalmol. 1979; 23:279-96.
therapeutic options in primitive open angle glaucoma. 8. Nau CB, Malihi M, McLaren JW, Hodge DO, Sit AJ.
Latrunculins A and B significantly reduced IOP ade were Circadian Variation of Aqueous Humor Dynamics in Older
consistent in their facility increasing effect in living cynomolgus Healthy Adults. Invest Ophthalmol Vis Sci.
monkey.(12) This indicates that active disorganization of the 2013;54(12):7623-9.
actin cytoskeletoninthe trabecular meshwork by latrunculins 9. Gulati V, Ghate DA, Camras CB, Toris CB. Correlations
may be an useful antiglaucoma strategy. Effects on corneal Between Parameters of Aqueous Humor Dynamics and the
endothelium or ciliary epithelium (pseudoguttata, increased Influence of Central Corneal Thickness. Invest Ophthalmol
central corneal thickness) are a potential safety issue. Vis Sci. 2011;52:920-926.
The extracellular matrix in the juxtacanalicular region 10. Chowdhury UR, .Hann CR, .Stamer WD, Fautsch MP.
of the trabecular meshwork is responsible for a large part of Aqueous Humor Outflow: Dynamics and Disease. Invest
outflow resistance in glaucoma. It is composed of elastin, Ophthalmol Vis Sci. 2015;56(5):2993-3003.
collagens, laminin, fibronectin and fibrillin and increases with 11. Rosman M, Skaat A, Park SC, Chien JL ,Ghassibi M, Rathi
age and in primitive open angle glaucoma. This increase is S, et al. Cyclopentolate 1% Decreases Schlemm’s Canal
primarily seen in ″sheath-derived plaque material″ which Dimensions in Healthy Subjects. Invest Ophthalmol Vis
correlates with axonal damage in glaucoma. Matrix Sci. 2013;54(15):485.
metalloproteinases, tissue inhibitors of matrix 12. Peterson JA, Tian B, McLaren JW, Hubbard WC, Geiger
metalloproteinases and other inhibitors of these substances are B, Kaufman PL. Latrunculins Effects on Intraocular
involved in remodeling and maintaining of extracellular matrix. Pressure, Aqueous Humor Flow and Corneal Endothelium.
Another important factor in modulating outflow resistance is the Invest Ophthalmol Vis Sci. 2000;41:1749-58.
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



University of Medicine and Pharmacy Tîrgu-Mureș, 2Student, University of Medicine and Pharmacy Tîrgu-Mureș,
County Hospital of Tîrgu-Mureș

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

Corresponding author: Tamas Toth, Str. Gh Marinescu, Nr. 50, Tîrgu-Mureş, România, E-mail:, 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

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

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.

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.

1. Whitfield Holcomb III G, Murphy JP. Ashcraft’s pediatric
surgery. 5th ed. Philadelphia: Saunders Elsevier; 2010.
2. Doherty GM. Current Diagnosis & Treatment: Surgery.
Fourteenth Edition. New York: Mc Graw Hill; 2015.
3. Owen TD, Williams H, Stiff G, et al. Evaluation of the
Alvarado score in acute appendicitis. Journal of the Royal
Society of Medicine. 1992;(85):87-88.
4. Gonçcalves JP, Cerqueira A, Martins S. Validação do score
de Alvarado no diagnostico de apendicite aguda em
crianças e adolescents no Hospital de Braga. Acta Med
Port. 2011;24(S2):583-588.
5. de Castro, Ünlü Ç, Steller E Ph, et al. Evaluation of the
Appendicitis Inflammatory Response Score for Patients
with Acute Appendicitis. World J. Surgery. 2012;36:1540-
6. Kariman H, Shojaee M, et al. Evaluation of the Alvarado
score in acute abdominal pain. Turkish Journal of
Trauma&Emergency Surgery. 2014;20(2):86-90.
7. Yücel Y, Dinç D, et al. How reliable is the Alvarado score
in acute appendicitis. Turkish Journal of
Trauma&Emergency Surgery. 2014;20(1):12-18.
8. Yildirim E, et al. Alvarado scores and pain onset in relation
to multiclice CT findings in acute appendicitis. Diagn
Interv Radiol. 2008;14:14-8.
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.
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




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)

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

Corresponding author: Zamfir-Radu Ionescu, B-dul Eroilor, Nr. 1, Pite ti, Arges, România, E-mail:; Phone: +40769
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

thickness. The obtained samples were stained with haematoxylin the spontaneous haematocele with no local traumatic or heavy
and eosin. effort history. Although Schiller-Duval bodies were not present,
elements of intratubular germ cell neoplasia – like
Figure no. 7. Macroscopic appearance of the tissue samples polychromasia, bland, vesicular, excentric nuclei – were
from the case: (a) testicular parenchyma; (b) testicular encountered with a reticular and cord-like pattern, and
vaginalis; (c) cremasteric muscle 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)

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 DISCUSSIONS
laces, towards the albuginea, with epithelioid cell proliferation Macroscopic aspect of YSTT is that of a
and capilar hyperaemia. Some cells proved to have a signet ring 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
Figure no. 8. Microscopic appearance of the testicular
aspect, among the others aspects: macrocystic, glandular-
biopsy: diffuse spreading epitheliod cells between the tubuli;
alveolar, endodermal sinus, solid, myxomatous, spindled,
basal compartment of the tubuli with cells and vacuolization
hepatoid, papillary, parietal and polyvesicular or vitelline.(3)
of Sertoli cells; central mitosis is visible (personal collection,
Sometimes, histological differentiation between sarcoid YSTT
100x, H&E)
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
In the tumour aspect between the intermingled haemorrhagic liquid in the vaginalis testis, being firstly
tubules, Leydig cells were appearing hyperplastic, almost with diagnosed as a haematocele.(4) Microscopic diagnostic criteria
an invasive tendency in the basal compartment of the tubules in YSTT require the presence of polygonal cells, with
(figure no. 4). The pampiniform plexus proved to be hyperaemic eosinophilic cytoplasm, bland nuclei arranged in different
and having no signs of any vascular refraction whatsoever. patterns – reticular, papillary or cord-like. In some situation,
However the plexiform appearance in some areas pleads for a Schiller-Duval bodies might be encountered, resembling
mixed testicular tumour, either with a Yolk sac component, a primitive glomeruli having central capillaries surrounded by a
non-germinative component. The blood samples revealed a visceral and parietal layer of cells, thus, similar to endodermal
negative β-hCG component, with a AFP level of 3,7 ng/L. This sinuses. Some authors report that YSTT, in childhood, have no
value, although indifferent from the laboratory point of view mixed histologic pattern but rather a pure one, therefore, not
(normal value limit below 7 ng/L) cannot be ignored, regarding becoming involved with any mixed germ cell tumour, like the
AMT, vol. 22, no. 1, 2017, p. 61

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)

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

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.
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.
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




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

Corresponding author: Georgeta Gînf lean, Str. Moreni, Nr. 19, Sibiu, România, E-mail:, 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

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

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


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
according to blood type and smoking Age group 46-50 18%
Origin area Urban 63%
Educational level Elementary 48%
Obstetric history Spontaneous 86,5%
abortions or upon
No. of births 3 births 31,5%
Living conditions Smokers 70,5%
Blood type AII 39%

The number of pregnancies seems to influence the Increased incidence of cervical cancer in combination
incidence of cervical cancer, too. This can be considered a risk with increasing parity was considered to be a reflection of
factor both in terms of endocrine changes induced by pregnancy sexual activity and age at first sexual intercourse.
and in terms of the indications we give on the early debut of We should note that this study reveals absolutely
sexual activity. This was another aspect I aimed at in this study. unsatisfactory aspects that should put on alert public health
Therefore, regarding the patients with abortions, for the blood professionals.
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 REFERENCES
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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
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



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

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

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

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

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

3. Gottlieb S. Persistence of HPV increases risk of cervical
cancer, BMJ. Jan 2002;324:69,
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.
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




“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
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.


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.


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:, Phone: +40722 604405

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

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

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.
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;; 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




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

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

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

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.

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

Average Minimum Maximum
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

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
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.
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
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
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
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



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

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


The working method applied for bulk-flow materials
 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
 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:, Phone: +40269 436777

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

Figure no. 2. Glass ionomer cement applied on the pulp By means of these bulk-fill flow composites I
chamber floor provided a fast, aesthetic restoration, with an increased elastic
infrastructure and resistance to occlusal stress.

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
Figure no. 3. Bulk-fill flow composite applied in the vertical to a reduction of the frequent dental fractures caused by the
cavity in the gingival floor area incorrect modelling of the remaining dental tissues during cavity
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
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.
Figure no. 4. Insertion of the compactable composite in the The final layer of solid composite material is applied
cavity 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

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.

1. Sunnegårdh-Grönberg K, van Dijken JW, Funegårdh U,
Lindberg A, Nilsson M. Selection of dental materials and
Figure no. 5. Tooth 16 before finishing. One can observe the longevity of replaced restorations in Public Dental Health
restoration with cuspal coverage in the vestibular wall area clinics in northern Sweden, Journal of Dentistry.
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
AMT, vol. 22, no. 1, 2017, p. 76

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.
9. Papadogiannis D, Kakaboura A, Palaghias G, Eliades G.
Setting characteristics and cavity adaptation of low-
shrinking resin composites, Dental Materials.
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.
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.
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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-
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AR, Fleming GJP. Cuspal Deflection and Microleakage in
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Based Composite Base Materials, Journal of Dentistry.
24. Ruiz JR. Dental Technique: Restorations with Resin-Based,
AMT, vol. 22, no. 1, 2017, p. 77




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

Corresponding author: Mihaela Pantea, Str. Rahmaninov, Nr. 25A, Ap 2, Sect 2, Bucharest, România, E-mail:, Phone: +40722
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

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

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
 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
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


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% .

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.

1. Gurel G. The Science and Art of Porcelain Laminate
Veneers. Hanover Park, IL: Quintessence Pub; 2003. p. 19-
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-
5. Spear F. Embrasure and papilla form in anterior aesthetics.
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





“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

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:, Phone: +40744 564898

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

characteristics on the CT (the same density as fat on the IRM The medical history plays an important role in the
localised in the pterygomaxillar fossa). appearance of SSS; it is known that facial trauma, surgery for
The patient was processed for surgery and we conducted a sinonasal malignancies, history of chronic rhinosinusitis and
functional endoscopy sinus surgery with medialization of the orbital decompression produce changes in sinonasal anatomy
middle turbinate, uncinectomy, large antrostomy extended to predisposing to develop SSS.(7)
anterior part of the internal sinus wall, lavage of the sinus cavity There is no gender predilection, the typical patient is in 3-
(dark-yellow viscous mucus, with black centre). Using a 45- rd to 4-th decade, non-smoker, apparently with no history of
degree endoscope, we visualised the interior cavity of the sinus - trauma or chronic sinuses discharge.
smaller than on the opposite side, with central retraction of the Hobbs et al described a 27-year old female who developed
posterior and superior wall and no changes to the mucosa. this condition after nasotracheal intubation for a routine general
anaesthesia. Also, iatrogenic version of the disease occurring
Figure no. 3. Frontal view of the patient shows enophtalmos, after bilateral orbital decompression is described. Usually, it is
facial asymmetry, deep upper lid sulcus 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
All tissues were sent to an anatomopathologyst. The atelectasis.(9)
microscopic alterations were chronic inflammatory on the The surgical treatment is the best option for this kind of
mucosa of sinonasal mucosa. There was no bacteria culture patients: large antrostomy with drainage of the mucous. The
present. Regarding the enophtalmos, we performed no surgery, dilemma is if we have to repair the inferior orbital wall or we
but waiting for the results of the 6 month - recovery. should wait and see (but how long should we wait?). Sesenna et
The 3-month follow-up revealed significant changes: al presented three cases treated with a single stage procedure,
reduced asymmetry of the face, no visual complaints and endoscopy and subcilliar approach, obtaining very good results,
reduced enophtalmia. The rhinoscopy showed large osteomeatal with no relapse of the disease.(8) Numa et al presented a SSS
complex formed after surgery with normal discharged maxillary case who underwent surgical treatment, and 14-th month follow-
cavity. up revealed normal eye line.(10) Some authors had good results
in resolving the aeration of the sinus and the follow-up for
Figure no. 4. Intraoperative images from the middle meatus resolution of the enophtalmos from 2 to 2 year.(11) We chose to
and the dark-yellow viscous mucus from the sinus 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

Chronic Maxillary Atelectasis
Misdiagnosing a silent sinus syndrome changes the Terminology Stage I Stage II Stage III SSS
course of treatment. A pterygopalatine fossa tumour comes with
late presentation at the physician because of absence of Deformity Membranous Bony Clinical
(soft medial (osseous (enophthalmos,
symptoms and usually, imaging showing extension in the area
wall) walls) hypoglobus, facial
around, cases when surgery is impossible to perform.(4) asymmetry)
Differential diagnosis is made with other cause of indolent
enophtalmia, appearance of hipoplastic sinus (in syndromic Nasosinusal +++ ++ + –
pacients), sdr. Parry Romberg, linear scleroma, trauma, tumours, symptoms
diffuse facial lipodistrophy.(5) Mangussi et al proposed a classification of Chronic
In the literature, there is described the confusion of Maxillary Atelectasis and SSS, considering that the latter is a
painless enophtalmos and facial asymmetry with Bell’s palsy. stage of first. Also Hypoplastic maxillary sinus should be
The patient underwent specific treatment with no response. differentiate from SSS.(13,14)
After CT examination the maxillary sinus was hypoplastic, with
centripet modification of the superior and posterior wall, CONCLUSIONS
enophtalmos, being diagnosed with silent sinus syndrome.(6) Differential diagnosis between silent sinus syndrome and
AMT, vol. 22, no. 1, 2017, p. 83

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
The endoscopic treatment associated with the subcilliar
approach for enophtalmos (15) should be individualised for
every patient, depending on his wishes.

1. Montgomery WW. Mucocele of the maxillary sinus
causing enophtalmos. Eye Ear Nose Throat Monthy. May
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
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.
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:
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
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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