The Journal of Bucharest College of Physicians and the Romanian Academy of Medical Sciences

Florin Bobirca

Florin Bobirca

The Outcome of Rectal Cancer Patients During SARS-CoV-2 Pandemic

Introduction: Rectal cancer is a complex pathology that requires a multidisciplinary approach according to current guidelines, and surgery is one of the main stages of treatment, the type of intervention being established in relation to the location of the tumor at the rectal level. Material and method: The present study aims to analyze the diagnostic features, study the evolution, treatment and complications of patients with rectal cancer in a period marked by the SARS-CoV-2 pandemic. After completing the inclusion criteria, but also the exclusion group, the remaining group consisted of 55 patients with rectal cancer. Results: For the 55 patients, abdominal-pelvic rectal amputation was performed in 17 cases, rectosigmoid resection with colostomy in 13 cases, and rectosigmoid resection with anastomosis in 25 cases. It was also taken into account that the access to medical services was delayed compared to the pre-pandemic period, the increase of the time interval between the treatment stages being an important aspect of the study. Complications associated with surgery have been reported in 13 patients, the most common being the pelvic abscess. Conclusions: The results of the study show a high incidence rate in the age group 60-69 years, with a predominance of males, a delay in making the diagnosis of certainty, an extension of the period from the beginning of neoadjuvant treatment to access to surgery, and the rate of postoperative complications is similar to that described in other studies conducted during the SARS-CoV-2 pandemic, but also outside it.

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Mesenteric Lymphangioma – a Rare Tumor of the Abdomen

Mesenteric lymphangioma (ML) is a cystic tumor developed at the base of the mesentery, which occurs frequently in children, rarely in adults, with nonspecific symptoms, often diagnosed late. The diagnosis is made by computer tomography and the curative treatment is the surgical one with good results and with optimal postoperative outcome. A 44-year-old patient for whom mesh surgery for incisional hernia post appendectomy has been performed was admitted to our clinic for non-specific gastrointestinal symptoms for which he has also been investigated multiple times in other services. On the right flank and iliac fossa, a tumor of firm-elastic consistency is detected, relatively well delimited. Computed tomography (CT) describes the lesion as a mesenteric tumor. Intraoperatively, a cystic tumor is detected, which is punctured, the biochemical result highlighting the lymphatic character. The surgical treatment was represented by segmental intestinal resection with entero-enteroanastomosis. No postoperative events were
reported.

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Personalized Treatment in Rectal Cancer – a Single Center Study

The study aims to evaluate the incidence, characteristics of diagnosis and treatment for patients with rectal cancer, but also the evolution of patients diagnosed with this neoplasia, so that a personalized treatment can be applied and followed, adapted to the patient’s clinical-imaging picture. The study included 127 patients operated on between January 2018 and November 2021. Dixon resection was performed in 63 patients, rectal amputation (Miles) in 42 patients, and Hartmann resection in 22 patients. For the Miles-type intervention, the patients in a more advanced stage were selected, which represented a percentage of 33.07% of the total. This type of intervention involves a permanent colostomy and has a strong impact on the patient’s life. Of the total of 127 patients, the presence of complications was relatively rare, occurring in only 14 patients. Of the 14 patients, the most common complication was abscess, which occurred in 6 patients, while peritonitis and occlusion occurred in only 4 patients. After analyzing the data obtained, it can be seen that the results coincide with world statistics, the highest incidence of rectal cancer occurring in the age range 60-69 years, with an increased incidence among male patients.

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Comparison between Young and Elderly Onset of Rheumatoid Arthritis in a Romanian Cohort

Rheumatoid arthritis (RA) is a chronic inflammatory disease that predominantly affects middle-aged adults in the third to fifth decades of life, but can also occur at any age. Significant differences were observed between patients with the diagnose of the disease under the age of 65 years – young- onset of RA (YORA) and those with the onset over the age of 65 years -elderly-onset of RA (EORA). The literature has shown that patients in the EORA group, in comparison to the young, have more severe onset, shorter duration of morning stiffness, lower frequency of seropositivity and a more important biological inflammatory syndrome.

Objective: Describe and compare the clinical characteristics, laboratory features, functional status, therapeutic approach and disease progression in elderly-onset and young-onset rheumatoid arthritis (RA) patients.

Materials and Methods: This retrospective, transversal study included 102 patients diagnosed with rheumatoid arthritis according to the ACR / EULAR criteria and who had at least 3 visits to our clinic, the last one during 2019-2020. Depending on the age at disease onset, we divided them into 2 groups- EORA and YORA and analyzed them comparing the clinical, laboratory and treatment data obtained at diagnosis. Subsequently we studied the evolution of the disease activity and the therapy efficiency at 6 months of follow-up and at the last hospitalization for each group.

Results: The percentage of women is similar and predominant in both groups, YORA and EORA (68.3% and 71.8%). YORA was associated with a longer disease length and a prolonged symptom duration prior to the diagnosis in comparison to EORA (p<0.001 and P=0.002). Extra-articular manifestations were more frequent in elderly-onset RA patients at diagnosis, especially the presence of rheumatoid nodules (46.2% vs 22.2%. p=0.011) and weight loss (82.1% vs 34.9%, p<0.001). Anemia was statistically associated with the EORA group (p=0.037). Analyzing the radiological findings, there was a greater number of patients who showed erosions (48.7%) and geodes (28.2%) in EORA, than in YORA group (33.3% and 19.0%). The prevalence of specific auto-antibodies positivity as anti-CCP was higher in YORA (76.2% vs 53.8%, p=0.019), as well as the positivity of Rheumatoid factor (RF) (84.1% vs 61.5%, p=0.010). The majority of patients began treatment with synthetic DMARD monotherapy, 54.0% of YORA and 64.1% of EORA. Methotrexate was the main drug administrated in both groups (61.5% in EORA and 54.0% in YORA, p-value= 0.602). Other medications, such as Sulfasalazine and Leflunomide, were less preferred in the two groups. Biologic therapy was preferred in younger patients than in those with RA at 65 years of age or over (69.8% vs 35.9%, p=0.001). Disease activity measured with DAS28(CRP) score was similar between the two groups at baseline, but significantly lower for YORA patients measured at the last hospitalization (p=0.020), treat to target (low disease activity and remission) being achieved in 53% of cases in the YORA group versus 23% of EORA patients (p=0.002).

Conclusions: The definite diagnosis of RA was delayed in YORA patients in comparison to EORA patients and the extra-articular manifestations of the disease were more frequently found in the EORA group. Seropositivity was statistically significantly associated with the YORA group. Anemia was predominant in patients with disease onset over 65 years old. Both groups underwent DMARDs therapy in the early stages of the disease, but biologic therapy was more often administered in younger patients. Disease activity at diagnosis was similar in both groups, but in dynamic, the treat to target endpoint was achieved more frequent in YORA population.

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Evaluation of Treatment Response in Lupus Nephritis

Objectives: To evaluate the effectiveness of the treatment reflected by the rate of response to therapy at 6 months and 12 months of follow-up respectively. Methods: We retrospectively analyzed clinical, laboratory data, treatment regimens, the type of response and relapse rate of 51 patients diagnosed with LN between January 2017 and February 2020. Results:47.06% of the patients underwent renal biopsy, classes III and IV being the most common lupus nephritis types (totaling 35.3% of biopsied patients). All induction therapy choices analyzed in the study- CYC, Glucocorticoids (GCs) and MMF- proved effective at reducing the proteinuria of the patients (p=0.001, p=0.012 and p=0,019 respectively. The 12 months evaluation demonstrated an ascending trend of the complete response, starting from 27.45% at 6 months and almost doubling at 1 year (56.86%). Almost half of patients (49.02%) did not relapse, while most of them (27.45%) had only 1 relapse. Analyzing the risk of relapse for each induction drug used, CYC had the highest rate of recurrence (62.07%). The use of MMF as a maintenance drug associated the lowest degree of recurrence. Conclusions: Both CYC and MMF as induction therapy are significantly effective in reducing proteinuria. The complete response was more frequently identified as an endpoint at 12 months of follow-up.

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Particularities of Surgical Treatment for the Neuropathic Diabetic Foot

Diabetic neuropathy is one of the chronic complications of diabetes and along with other complications causes a pathology called diabetic foot. The present study analyzed a group of 164 patients admitted to the surgery department of the Clinical Hospital “Doctor Ioan Cantacuzino” Bucharest, between September and December 2019. The results of the study highlight the potential for contamination of neuropathic lesions and the need for curative surgery, most conservative. The conclusion of the analysis emphasizes that the imbalance of the underlying disease changes, in a negative sense, the prognosis of any complication of it.

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Screening Criteria for Colorectal Cancer for Patients with Type II Diabetes Mellitus

Colorectal cancer and diabetes mellitus represent a major public health issue, first, by the number of new cases which are at an alarming rate. Secondly, by the negative effect over the quality of life, socio-economic status and lifespan, representing high morbidity and mortality causes. Diabetes Mellitus is the disease of the century with a global prevalence (standardised-age) which doubled since 1980, rising from 4.7% to 8.5% in adult population. In 2012, the estimated number of fatalities caused by diabetes mellitus and other related complications were at 3.7 million, out of which 43% were patients under the age of 70. Neoplasia represents the second cause of death, after cardiovascular disease. Colorectal cancer (CRC) ranks the 3rd regarding the global neoplasia incidence (10.2%) and the second regarding the mortality (9.5% of all cancer deaths). Colorectal cancer screening refers to the periodic evaluation of asymptomatic patients at risk of developing this neoplasia. Colorectal cancer has a number of peculiarities that make it ideal for screening. Since the end of the 19th century, the suspicion has been raised that diabetes mellitus has been involved, through directly etiological mechanisms, in carcinogenesis (breast, endometrium, colorectal, pancreas, liver, non-Hodgkin lymphoma). At the moment, there is already a consensus in the literature on the role of diabetes as an independent risk factor for colorectal cancer. However, despite the existence of numerous experimental evidence, epidemiological studies and meta-analyses, there is currently no adaptation of colorectal cancer screening for these patients. Material and method: Prospective case-control study conducted over a 2-year period including a number of 442 patients presented at „Dr. I Cantacuzino” Clinical Hospital, asymptomatic, who underwent lower digestive endoscopies in order to assess and define using anamnestic, clinical and paraclinical criteria, the profile of the patient with type II diabetes mellitus that should be given an endoscopic examination because diagnosing precursor lesions or even CRC is likely probable. Results: In the analyzed group, statistically significant correlations (p<0.05) were recorded between positive colonoscopy results (defined as precursor lesions - polyps - or tumors) and certain clinical characteristics (age, sex, BMI, duration of diabetes, type of antidiabetic treatment) and also paraclinical (reactive C protein and glycated hemoglobin). Conclusions: Criteria of patients with type II diabetes who have the maximum probability of developing colorectal cancer have been outlined. Thus this patient is more likely male, with a BMI > 25, aged over 60 years, with an unbalanced diabetes mellitus counted by HbA1c > 7 mg/dL, with over 5 years of diabetes evolution, in treatment with insulin most likely or combined insulin with oral antidiabetics and with an inflammatory biological profile expressed by PCR> 2 mg/dL threshold values.

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