Myasthenia Gravis Triggered by a COVID-19 Infection: A Case Report and Literature Review.

Myasthenia gravis (MG) is an autoimmune disease that induces skeletal muscle weakness, affecting different muscle groups. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the cause of coronavirus disease 2019 (COVID-19), became both a diagnostic and a therapeutic challenge during the pandemic. The effects of COVID-19 are not only limited to the acute symptoms but also to the post-infectious sequelae. We present the case of a 30-year-old Caucasian woman, with no significant medical history, who presented to the emergency room with acute respiratory failure. The patient tested positive for SARS-CoV-2 with a rapid antigen test and during hospitalization developed a myasthenic crisis, ultimately being diagnosed with seropositive MG.

Relationship between Climate Change, Air Pollution and Allergic Diseases Caused by Ambrosia artemisiifolia (Common Ragweed).

Objective: Influence of climate change and outdoor air pollution (through anthropogenic factors, including heavy traffic, industry and other human activities polluting the environment), which contribute to global warming and increase the allergenicity of some plants (common ragweed) on allergenic patterns, with a direct negative impact on human health, causing or exacerbating allergic respiratory diseases such as bronchial asthma and allergic rhinitis, changing the pattern of respiratory tract infections and premature deaths in Europe. The present study aims to highlight the link between climate change, outdoor air pollution, altered allergenicity of palms and possible behavioural risk factors in the environment. Methods:The clinical studies selected in this research highlighted the links between climate change, air pollutants and the occurrence/exacerbation of aeroallergen-induced respiratory disease; climate change (as an inducer of allergic respiratory disease), increasing global mean ambient air temperature and aeroallergens; climate change, global warming, [CO2] concentration and aeroallergens; climate change, atmospheric humidity, dust storms and aeroallergens; urbanisation (anthropogenic influence), air pollution and aeroallergens; potential of different plant species (common ragweed) for Ni accumulation and possible effects on the human body. Results:The medical implications of increased atmospheric [CO2] concentration are either direct (effect of [CO2] on human physiology and pathophysiology) or indirect (alteration of plant physiology associated with human disease). In an urban area with high [CO2] concentrations, ragweed grows faster, flowers earlier and more intensively, which will lead to increased pollen production compared to rural areas. Over time, climate change leads to changes in allergen (common ragweed) patterns, followed by effects on human health (causing or exacerbating allergic respiratory diseases such as bronchial asthma and allergic rhinitis and changing the pattern of respiratory tract infections). Conclusion:Climate change is changing air pollution patterns, particularly in urbanised areas of the world, with a significant effect on human health. Allergen patterns are also changing in response to climate change. Lifestyle adjustments are important to mitigate the health effects of air pollution and reduce the occurrence and progression of respiratory diseases.

Algorithm for Forecasting the Number of Hospital Beds by Specialty Using Regression Equations.

Introduction:Planning the hospital beds according to population needs is still in focus. Objective: To develop an algorithm for designing the number of beds Per hospital and specialty wards according to local needs. Materials and methods: The present study was designed as a retrospective analysis based on hospital utilisation data, demographic data and morbidity recorded by GPs in J2 county, testing the variation in dependent variable (number of beds) due to independent variables, using linear regression analysis. Results:Three models were tested, of which model 3 version 2 was considered the most relevant one, providing a general regression equation for type I hospitals, but also for different hospital wards, taking into account local data regarding morbidity on specialty wards and local demographic data; when uploaded with own data of type I and IV hospitals, the number of beds forecasted by regression equations provided differences in specialty ward bed numbers, comparing with the approved structure. Conclusions:The algorithm for planning the hospital beds on specialty wards provided by the present study can be used to either forecast the structure of hospital beds for new hospitals or redesign the current ones according to the population needs.

Validation of a Quality of Life Assessment Questionnaire for Patients with Infantile Hemangioma and Their Families - the IH-QOL-RO.

Introduction:Despite the fact that infantile haemangioma is one of the most common benign tumour of the child, the impact of this pathology on the quality of life of patients and their families has not aroused much interest in health services research. Several tools have been proposed to date to assess this, but there is no Romanian standardised instrument yet. Taking as a model the questionnaire developed and validated in English by Chamlin et al (2015), we translated, culturally adapted and piloted this instrument into Romanian. The questionnaire was administered during two years, between August 2019 and August 2021, to the parents of children with a diagnosis of infantile hemangioma who attended "M. S. Curie" Children's Emergency Hospital, Bucharest, Romania. Inclusion criteria were the diagnosis of infantile hemangioma and children under the age of 24 months. Other comorbidities which may have caused other health impairments were considered as exclusion criteria. Response rate was 100% for all items in the questionnaire. A total of 112 family respondents were included for analysis. Classic psychometric tests were used. Results:Based on the 29 standardized original items, the four scales have Cronbach-alpha values ranging from 0.489 (CSI), 0.609 (PSF), 0.689 (PEF) to 0.719 (CPS). The proposed final Romanian version includes 26 standardised items. The Cronbach-alpha values improve marginally: 0.63 (PSF), 0.67 (CSI), 0.72 (PEF) and 0.733 (0.78) (CPS). Conclusion:We propose the 21-item scale of the IH-QOL-RO as the Romanian version of the IH-QOL®. The instrument has been culturally adapted and is ready to use in paediatric clinics. We recommend the use of IH-QOL-RO in a longitudinal study design as a measure of health-related quality of life and to complete the classical set of psychometric tests with the 48-hour test-retest reliability.

Infantile Haemangioma in the Romanian Paediatric Population-Characteristics and Therapeutic Approaches.

Infantile haemangioma (IH) is the most common benign tumour in childhood, with an incidence of 4% to 12%. Aim: to describe the characteristics of infantile haemangioma in a sample of Romanian children <2 years old at diagnosis, types of treatment applied, recorded complications and the response to the therapeutic approach. A two-year prospective case series study (August 2019 to August 2021) was carried out. Sample: 117 patients <24 months of age diagnosed with IH at the Emergency Hospital for Children "Marie Sklodowska Curie", in Bucharest, Romania. Five therapeutic approaches were used: oral treatment with propranolol, local treatment with timolol, surgical treatment, topical treatment with steroids and no treatment ("wait and see"). Recorded factors mentioned in the literature were also present in this study population: female patients-68.4%; phototype I-58%. In 53% of cases, IHs had a head and neck location and 10% developed local complications (traumatic bleeding). The majority of patients (86%) required one type of therapy: oral propranolol (51%). A low relapse rate was recorded (4%). We consider that any child with a vascular anomaly should be referred to a highly specialised medical service for therapeutic approach.

Quality of life in parents of autistic children: A transcultural perspective.

Introduction: The concepts of health, illness, and disability as well as the perceptions of autism and quality of life (QoL) vary greatly across cultures and across time. This study sought to explore the interplay of culture on QoL and impact on parents caring for autistic children. Methods: We used a transcultural dataset from seven countries (Australia, Hungary, Malaysia, Romania, Singapore, Spain, and the United Kingdom) with participating parents/carers reporting on the Quality of Life in Autism (QoLA) questionnaire. The QoLA questionnaire is a validated measure of QoL for parents of autistic children, with Part A subscale measuring parental QoL and part B subscale assessing the parental impact of the child's autism spectrum disorder (ASD) symptoms or features. We used the Quade's ranked analysis of covariance to determine significant differences between the countries in relation to QoLA Part A and Part B scores while adjusting for baseline differences using covariates such as parents' gender, child's age, and gender. Additionally, a post-hoc analysis with Bonferroni correction was also conducted to examine multiple pairwise comparisons. Results and conclusion: We found that while the effect of features of ASD (Part B subscale) stayed strongly comparable between cultures, the self-reported parental QoL was most likely determined by different aspects of culture in different countries. It is concluded that while the ASD symptoms or features appear to affect parents in the same way across different countries, the parental QoL may be a culturally informed construct.

Accessory renal arteries - a source of hypertension: A case report.

BACKGROUND: Secondary hypertension is a relatively rare condition most commonly caused by renovascular disease due to atherosclerotic vascular disease or fibromuscular dysplasia. Although accessory renal arteries are frequent, to date, only six cases of secondary hypertension determined by their existence have been reported. CASE SUMMARY: We describe a case of a 39-year-old female who came to the emergency department with an urgent hypertensive crisis and hypertensive encephalopathy. Despite normal renal arteries, the computed tomography angiography revealed an inferior polar artery with 50% stenosis of its diameter. Conservative treatment with amlodipine, indapamide and perindopril was adopted, leading to blood pressure control within one month. CONCLUSION: To the best of our knowledge, there are controversies regarding accessory renal arteries as a potential etiology for secondary hypertension, but the seven similar cases already described, along with the current case, could reinforce the necessity of more studies concerning this subject.

Infantile Haemangioma - Elaboration and Piloting a Specific Quality of Life Questionnaire.

Backround:Infantile haemangiomas are the most common benign tumours of the child with clinical manifestations in the first two years of life, which is an additional cause of parents' concerns. Objective:This study describes the first stage in elaborating a specific instrument to evaluate the quality of life of both patients with infantile haemangioma under two years of age and their parents, adapted to the reality of the Romanian context. Methods:Items were generated from a literature review - from both the current generic pediatricians' instruments and specific tools in dermatology for assessing quality of life and the existing consensus among experts - as well as from a qualitative analysis of parents' concerns. The instrument was piloted on a group of patients' relatives. Results:We have developed a 28-item specific infantile haemangioma quality of life questionnaire with four sub-scales to assess physical health, the social function of the child, parents' emotional health and the social function of parents. Demographic data and clinical features (meanings of symptoms and outcomes) that have an impact on the quality of life were obtained. Conclusion:It is important to be able to measure and compare the quality of life of both patients with infantile haemangioma and their parents for adapting the treatment to the specific needs of patients and their family. The effectiveness of new therapeutic options which are especially useful for infants with haemangiomas can be checked by using the questionnaire as a measure of patient-reported outcome. The questionnaire developed by us was well accepted by the patients' parents.

Uncommon onset manifestations without renal involvement in microscopic polyangiitis: A case report.

Microscopic polyangiitis (MPA) is a rare, idiopathic, autoimmune, systemic disease that most frequently involves the kidneys. The present study reports the case of a 48-year-old female patient who presented with diffuse myalgia, arthralgia of both hands and feet for 2 weeks before being admitted to the hospital. The patient exhibited involuntary loss of weight and occasional slight fever. Physical examination noted microstomia and perioral radial furrows, slight skin induration of the hands, discrete cyanotic skin areas on the dorsal side of both feet. The patient also presented bilateral crepitant rales. Laboratory findings at admission revealed non-specific biological inflammatory syndrome consisting of high erythrocyte sedimentation rate and high C-reactive protein. The patient was initially suspected of systemic sclerosis due to the appearance of microstomia and the slight skin induration of the hands with diffuse arthralgia and myalgia, although with negative immune tests (anti-SCL70 and anti-centromere B antibodies) and normal nailfold capillaroscopy. Instead, a high titer of MPO-ANCA was detected. The computerized tomography scan revealed early diffuse interstitial lung disease (ILD). Cases of MPA with pulmonary involvement, such as ILD before the onset of vasculitis or kidney involvement, are known. Therefore, the diagnosis of MPA was formulated considering the symptoms, the clinical examination and the high titer of MPO-ANCA. The particularity of the present case consists in the uncommon onset with atypical skin changes, positivity to MPO-ANCA, absent renal dysfunction and ILD involvement.

PM10 and NO2 Air Pollution and Evolution of COVID-19 Cases in Romania.

Objectives:Based on the correlation between air pollution and COVID-19 incidence/mortality already existing in the literature, we aimed to develop a study to investigate the link between the average level of PM10 (particulate matter 10 - particulate matter 10 microns in diameter) and NO2 (nitrogen dioxide) concentration over five years and the cumulative incidence of COVID-19 cases per 1000 people in Romania. Methods: To assess PM10 and NO2 exposure, we determined the average value of annual PM10 and NO2 concentration for each city over five years (2015-2019). For this purpose, the average of annual PM10 and NO2 concentrations collected from monitoring stations in selected cities was calculated. Then, the annual values over five years were averaged to finally obtain the average PM10 and NO2 concentration for each city. Data on the cumulative number of confirmed cases of COVID-19 up to the 28th of September 2020 were provided by the National Centre for Surveillance and Control of Communicable Diseases (CNSCBT) of the National Institute of Public Health (INSP). The study used the cumulative incidence/hour per 1000 population on 28.09.2020. Results:According to Law no. 104/2011, the annual permissible limit value of PM10 concentration of 40 µg/m³ was not exceeded in any of the 43 cities in our study. The average for all cities was 24.0±4.8 ìg/m³, with a minimum value of average PM10 concentration of 13.9 µg/m3 measured in Alba Iulia and a maximum value of 39.1 µg/m³ in Iasi. The regression model shows that, in Bucharest, 77.9% of the variation in case incidence is explained by the variation in PM10 concentration. In order to find the number of new cases that would correspond to a cumulative incidence of 0.166, taking as an example one of the districts with a population of 259,084, the above regression model shows that an increase in the average PM10 concentration by one unit is associated with 43 new cases. Conclusion:The study demonstrates that an exposure of the population to particulate matter in atmospheric air, at low values, below the permissible limit values but for a long time (the follow-up period in our study was five years, between 2015 and 2019), can have effects on the health status of the population, which becomes much more vulnerable to external agents, in our case pathogenic microorganisms (viruses).

Cost-Effectiveness Analysis of Treatment for Metastatic Renal Carcinoma in Romania.

Rationale: In recent years, the cost of several treatment options for renal cancer have been supported by the Romanian healthcare system for both first- and second-line therapies. First-line alternatives through real-life efficacy and amplitude of adverse reactions may influence the efficacy and costs of patients treated with second-line treatment. Objective: Estimation of the cost-effectiveness and cost-benefit ratio for first-line treatment alternatives: Sunitinib and Pazopanib from the payer's perspective in the Romanian healthcare system. Methods and Results: We developed a Markov model to calculate the cost-effectiveness and cost-benefit ratio for 2 cohorts of patients using the results from the COMPARZ study for efficacy (progression-free survival, general survivability and quality of life) and safety and costs from national hospital databases. For an estimated population of 800 patients, Pazopanib has a quantified benefit of 7.19 years in progression-free survival, 11.71 life years gained and 8.97 years of quality-adjusted life-years compared to Sunitinib. The analysis is limited by the accuracy of the national data used and the transposition of general data on efficacy and safety at the local level.

Recent trends of cancer mortality in Romanian adults: mortality is still increasing, although young adults do better than the middle-aged and elderly population.

We analysed the mortality trends (1986-2009) for all cancers combined and selected cancers in adult Romanians by three age groups (15-49, 50-69 and older than 70 years of age) in comparison with 11 other European countries. We extracted mortality data from the WHO database and grouped the countries into four regions: central and eastern Europe (Romania, Bulgaria, the Czech Republic, Hungary), Baltic countries (Estonia, Latvia and Lithuania), western and northern Europe (Austria, the Netherlands and Finland), and southern Europe (Croatia and Slovenia). Mortality rates were age-standardized against the standard European population. Significant changes in mortality trends were identified by Joinpoint regression and annual percentage changes (APCs) were calculated for periods with uniform trends. Cancer mortality in Romania was among the lowest in Europe in 1986, but was higher than most countries by 2009. Despite the declining mortality (APC) in younger Romanians for all cancers combined (men-1.5% from 1997, women-1.2% 1997-2004 and -3.8% 2004-2009), male lung cancer (-2.8% from 1997), female breast (-3.5% from 1999) and cervical (-5.4% from 2004) cancers, mortality has increased in middle-aged and elderly patients for most cancers analysed. The exception was declining stomach cancer mortality in most Romanians, except elderly men. For most cancers analysed, mortality declined in the Baltic countries in young and middle-aged patients, and in western and northern countries for all ages. Lung cancer mortality in women increased in all countries except Latvia. We urge immediate steps to reverse the alarming increase in cancer mortality among middle-aged and elderly Romanians.

Reflections on fertility dynamics in Romania.

Aims to highlight the changes occurred in the evolution of the fertility phenomenon in Romania, focusing on developments in the general fertility rate, total fertility rate, number of live births, and on the construction of specific indicators to reveal the source of demographic change. Several theories on the factors that may cause fertility decline it were outlined, underlining the presence of these factors during fertility dynamics in our country. After 1990, population decline may be explained by a close inter-relationship between economic theories (worsening economic conditions lead to decreased fertility) and the second demographic transition (postponement of births, fertility change model).

Analysis of traffic accidents in Romania, 2009.

UNLABELLED: This paper aimed to underline the main consequences of traffic accidents in Romania 2009 and their associated causes or circumstances. We identified some problematic geographic areas, some critical months or moments of the day and also the most frequent causes; all these should become targets for the future planning. The current analysis provides some priority criteria for public health interventions. So, the future national road safety strategy should be in line with the EU objectives, but also with the national priorities. BACKGROUND: Romania is far away from the average EU target for 2010 of halving the death by traffic accidents registered in 2001. AIM: To describe the circumstances and the consequences related to traffic accidents registered in Romania, for the year 2009. METHODS: An ecological study was conducted. The traffic accidents circumstances were analyzed in terms of magnitude, geographic space, time and cause. The consequences were analyzed as affected people and damaged cars. RESULTS: A total of 28,627 traffic accidents were registered in Romania during the year 2009. 2,796 people were killed and 27,968 were hospitalized and 42,443 cars were damaged. 3 of 4 accidents were caused by violations on behalf of the car drivers. Most common violations in car drivers were excess of speed and priority violations (52.4%). Among the pedestrians, 7 of 10 accidents were caused by illegal crossing. A higher number of accidents occurred during the summer months and during the evening hours (from 5.00 pm till 8.00 pm). CONCLUSIONS: The traffic accidents represent a real public health problem in Romania and a serious burden for the health system. The gap between Romania and the other EU member states needs to be diminished in the next decade. In this purpose, the future national road safety strategy should be in line with the EU objectives, but also with the national priorities. Research is needed to understand the causes and the socio-economical impact of traffic accidents and to define appropriate national objectives.

B1 versus B2 Dukes stage rectal cancer: prospective evaluation of 87 patients in a single institution and quest for re-evaluation of the current protocol.

BACKGROUND/AIMS: Current protocols indicate surgery as single modality of therapy for B1 stage rectal cancer and surgery with adjuvant therapy for B2 stage. The aim of our study was to analyze the five-year survival rate for patients with surgically treated B1 and B2 rectal cancer and to assess the impact of adjuvant therapy on overall survival. METHODOLOGY: Our epidemiological clinical study was based on a prospective analysis of 87 cases of B1 (n=32) and B2 (n=55) rectal cancers operated between 2000 and 2003. Survival evaluation was done through a prospective cohort followup study. RESULTS: There were 33 female and 54 males with a median age of 60 years (IQR 39-74). Tumor location was low rectum for 23 patients (26.4%), medium rectum for 30 patients (34.5%) and high rectum at 34 patients (37.9%). We performed Miles operation in 42 cases, Dixon resection in 26 cases and Hartmann operation in 18 patients. There was no difference in the number and type of postoperative complications between groups. There were no local recurrences in the B1 stage group but 7 cases (12.7%) in the B2 stage group. Distant metastases were recorded in 8 patients (25%) in the B1 group and 2 patients (3.6%) in the B2 group. The survival rate at 5 years (S5) was better for the B2 stage S5=69.9% than B1 stage S5=53.5% (p=0.001). CONCLUSIONS: Patients with B1 stage rectal cancer might benefit from adjuvant/neoadjuvant therapy.

[Postoperative pain management in elderly patient]. / Managementul durerii postoperatorii la pacientul vârstnic.

Pain is a common occurrence for the hospitalized elderly, and may often be under recognized and inadequately managed. Insufficient pain management can lead to the sequelae of emotional distress and depression, delirium, anxiety, sleep disturbances, and physical disabilities, as well as increased health care costs. Effective pain management of the older adult begins with pain assessment using the proper tools. Morphine is the analgesic of choice for the older adult, and is appropriate for the postoperative period. It is important to maintain a therapeutic serum level of opioids to prevent inadequate management of the acute pain. Side effects of opioids include hypotension, nausea, mood disturbances, ileus, histamine production, and respiratory depression. The adage for pain treatment in the elderly is "start low and go slow". Paracetamol is commonly prescribed and may be the drug of choice for mild to moderate postoperative pain. Older adults may enjoy the benefits of Patient-Controlled Analgesia and Patient Controlled Epidural Analgesia in the postoperative period; however, thorough and ongoing teaching must occur to ensure understanding and compliance with the therapy. Treating post-procedure pain in the elderly patient requires an understanding of the normal changes associated with aging and the impact on medications, and multimodal analgesia can be the best approach.

[Survival in a cohort of patients with rectal cancer]. / Evaluarea supravietuirii într-o cohorta de bolnavi cu cancer de rect.

BACKGROUND: The aim of our study is to analyze the five-year survival for patients with operated rectal cancer in our clinic during a five-year period (1997-2001). METHODS: Our epidemiological clinical study is based on prospective analysis of 196 cases of rectal cancer operated between 1997 and 2001. Survival evaluation was prospective cohort follow-up study. We have used Epiinfo 2000 software package for data analysis. RESULTS: The five-year survival was 54.08% if we take into account all deceases including other causes and 64.28% for exclusive deaths caused by rectal cancer and metastasis. The survival at 5 years (S5) was: stage A S5 = 85.3%; stage B1 S5 = 76.6%; stage B2 S5 = 71%; stage C S5 = 68.7% and stage D S5 = 8.6%. The follow-up in month (e5) was: stage A e5 = 58, stage B1 e5 = 46; stage B2 e5 = 36, stage C e5 = 20 and stage D e5 = 6. The values for S5 and e5 are in accordance with the literature. CONCLUSIONS: Despite progresses of rectal cancer management, the five-year survival doesn't transcend much over 50%. Because the five-year survival for A stage is 85.3% in our study, we may conclude that at present introducing of screening program represents the only chance for improvement of results.