Updates in the pathogenesis and diagnosis of hepatic encephalopathy.

In the pathophysiology of hepatic encephalopathy (HE), a serious complication of liver cirrhosis, different hypotheses, including increased blood ammonia levels, increased production and absorption of intestinal bacterial products are discussed. Recent studies demonstrated that Helicobacter pylori infection is associated with elevated blood ammonia levels. Inflammatory mediators and cytokines also play important roles along with hyperammonia in the pathogenesis of HE, while recent studies revealed correlations between CRP levels and length of hospital stay. Neuropsychological diagnostic tests, such as Psychometric Hepatic Encephalopathy Score, were especially designed for detecting minimal HE. Imaging investigations, like Computed Tomography or Magnetic Resonance Imaging, show characteristic aspects in advanced stages of liver disease. Recent studies revealed that Mini-Mental State Examination (MMSE) can show significant changes mostly in advanced stages of overt HE, but that it is not an appropriate tool in defining an encephalopathy-related status of patients with cirrhosis.

Butyrylcholinesterase activity-biomarker for predicting the outcome in acute cholinesterase inhibitor poisoning--a 30-year retrospective analysis.

AIM: To assess the role of butyrylcholinesterase (BuChE) activity as a predictive biomarker in acute cholinesterase inhibitor poisoning in a cohort from a regional tertiary care hospital. MATERIAL AND METHODS: Plasma butyrylcholinesterase activity on admission and at regular intervals during admission and clinical outcomes of cases admitted to the Toxicology Clinic of "Sf. Spiridon" Emergency Hospital Iasi, Romania between 1983 and 2013 were evaluated. RESULTS: A total number of 606 patients were included in the study. The mean BuChE-activity level on admission was 1.54 ml NaOH N/100. A correlation between the amount of ingested organophosphates/carbamates (OPs/CMs) and low cholinesterase activity on admission was found. 66.66% of the patients were admitted to hospital within 8 hours after poisoning. The initial, daily and mean total atropine doses administrated were 9.65 mg, 10.51 mg and 69.39 mg, respectively. 67.16% of the investigated patients received Toxogonin for 6.41 days showing a slow increase in BuChE activity afterwards. The average number of hospital days was 11.22. The study revealed that complications occurred in patients with BuChE-activity levels below 1.4 mL NaOH N/100. A positive correlation between mortality rate (3.8% of patients) and the lowest BuChE-activity level on admission (0.89 mL NaOH N/100) was found. CONCLUSIONS: BuChE activity on admission and its level during hospital stay represent an important predictive factor for acute cholinesterase inhibitors poisoning.

Unmasking a young adult migratory deep venous thrombosis--case report.

Venous thromboembolism is a known complication of cancer which impacts on patient mortality and quality of life. The primary site of cancer is an important risk factor, with highest rates observed in patients with brain, pancreas, gastric, kidney, ovary and lung cancers. The extent of metastatic spread further adds to the risk. In this article, we present the case of a young patient who was diagnosed with an aggressive form of pancreatic neoplasm with secondary determinations, without any previous digestive symptoms, with the occasion of a recurrent and migratory deep venous thrombosis (DVT).

[The effects of ethanol on the evolution of the acute benzodiazepine poisoning]. / Efectele etanolului asupra evolutiei intoxicatiilor acute cu benzodiazepine.

UNLABELLED: The depressing effects on the nervous central system (NCS) induced by benzodiazepines and ethanol are similar. The complications are rare in the benzodiazepine poisoning, but are a lot more frequent in association with other depressing drugs for the NCS (especially alcohol). MATERIAL AND METHODS: We analyzed retrospectively patients with benzodiazepine poisoning admitted in the Internal Medicine Clinic - Toxicology during 2003 - 2009.The study attempted a complex evaluation of the consequences of acute and chronic alcoholism on the evolution of acute benzodiazepinepoisoning and the description of the clinic evolution and paraclinical particularities of the patients under investigation. RESULTS: 343 patients with benzodiazepine poisoning were admitted, 150 were tested through measurement of alcohol level, leading to values between 1 - 415 mg/dl. Chronic alcoholism in personal pathological antecedents of the patients determined a relative risk of intoxication 1.46 times higher. The hospitalization period varied from 1 to 8 days for patients with chronic alcoholism and from 1 to 14 days for patients with acute alcoholism, a statistically important difference. CONCLUSIONS: During the period under investigation, from the total of patients admitted for acute benzodiazepine poisoning, 2 deaths were registered. Of the two deaths, one patient showed ethanol coingestion.

[Intentional poisoning with ACE inhibitors. Emergeny Hospital Iasi]. / Toxicitatea acuta a inhibitorilor enzimei de conversie a angiotensinei. Experienta clinicii de medicina interna si toxicologie, spitalul clinic de urgente "SF Ioan" Iasi.

UNLABELLED: Regarding angiotensin-converting enzyme inhibitors (ACEI) poisoning, only few data are available in the last decade literature. In the previous couple of years especially isolated case reports were published. MATERIAL AND METHOD: We analyzed retrospectively all the patients with acute ACEI poisoning admitted in Iasi Internal Medicine and Toxicology Clinic between 2004 and 2009. RESULTS: 17 cases of poisoning were recorded (enalapril-9 cases, captopril-3 cases, perindopril-3 cases, lisinopril-2 cases). All the poisonings were intentional. A favorable outcome was consistently observed, and were recorded no sequelae or death in this study. The main complain was hypotension, required fluid administration, only one case with 500 mg enalaprilum and severe hypotension required injection of vasopressive amines. No abnormal renal function and no angioedema were noted.

New original in vitro method to assess cholinesterase reactivity in organophosphate poisoning.

Assessment of organophosphate poisoning could benefit from a safe, non-expensive, easy to perform, quick (< 1 hour) test, which evaluates the level of cholinesterase activity "in vitro" regarding to the capability of oximes to reactivate OF-blocked cholinesterase. In the proposed protocol, 0.5 mL of sample serum is incubated, prior to the evaluation of level of cholinesterase activity, with 5 microL of a Toxogonin dilution (0.125 mg) for 30 minutes at 37 degrees C. For the standardization of the newly proposed protocol, several important issues were documented in the present article. The new original method of assessing cholinesterase reactivability will consist in an advantage for the diagnosis, prognostic evaluation and therapeutic orientation in OF intoxication.

[Non-traumatic rhabdomyolysis in medical practice]. / Rabdomioliza non-traumatica in practica medicala.

UNLABELLED: Rhabdomyolysis, meaning "disintegration of striated muscle", is a potentially life-threatening syndrome resulting from release of muscular cell constituents into the circulation. The aim of this study is to determine frequence and causes of rhabomyolysis in internal medicine practice, as well as diagnostic and therapeutic discussions, based on a retrospective study in patients addressed to a medical clinic of an universitary emergency hospital. RESULTS: The most common causes of rhabdomyolysis in general practice are represented by muscular trauma, muscle enzyme deficiencies, electrolyte abnormalities, infections, drugs, toxins and endocrine disorders. Frequent encountered clinical manifestations are weakness, myalgia and tea-colored urine, and the most sensitive laboratory finding of muscle injury is an elevated plasma creatine kinase level. The management of patients with rhabdomyolysis includes early vigorous hydration, together with specific measures (urine alkalinization, mannitol, hemodialysis).

A computerized data analysis method for electrogastrographic signals.

UNLABELLED: Many recent studies showed that EGG signal can be used to diagnose and monitor patients with gastric motility disorders. MATERIAL AND METHOD: This paper presents the way to record and process the EGG signal, and the results of study on a sample of 10 patients. These patients are initially evaluated by upper endoscopy were are normal without gastric motility dysfunction or some gastric lesions. The EGG signals are obtained with the surface electrodes placed along the projection of the stomach axis on the abdomen, amplified with an electrogastrogram amplifier module and analyzed on a personal computer. The used signal analysis method is based on spectral analysis of EGG signals. RESULTS: This method showed a normal gastric activity for seven patients of the sample and a gastric dysryhthmia for three of them. CONCLUSION: The computerized spectral analysis of electrogastrography signals proves to be a non-invasive, high sensitive, reproducible and cost-effective method for the diagnosis of gastric dysrhythmias and normal gastric electrical rhythm even in sub clinical patients.

[Self-administration of intravenous drugs--a rare cause of respiratory arrest in medical practice]. / Auto-administrarea de medicamente intravenos-- cauza rara de stop respirator in practica medicala.

Respiratory arrest is a major emergency in medical practice, which implies prompt intervention from the physician assisting such case. Respiratory arrest can be classified into primary respiratory arrest, caused by airway obstruction, decreased respiratory drive, or respiratory muscle weakness and secondary respiratory arrest, as a result of circulatory insufficiency. Among important causes of respiratory arrest, acute poisonings are to remember. We present a case of respiratory arrest following intravenously self-administration of opiates in attempted suicide. Patient required rapidly orientated etiologic diagnostic, and had a favorable outcome, with complete recovery, after applying CPR protocol, as well as antidote.

[Electrocardiographic changes in acute organophosphate poisoning]. / Modificari electrocardiografice in intoxicatia acuta cu pesticide organofosforice.

Cardiac complications often accompany poisoning with organophosphates. These may be serious and often fatal, being represented by cardiac arrhythmias, electrocardiographic abnormalities and conduction defects, as well as myocardial infarction, a rarely reported complication of acute pesticide poisoning. The extent and pathogenesis of cardiac toxicity from these compounds is not yet clearly defined. We report the case of a 57-year-old woman who presented to our emergency department with coma and acute non-cardiogenic pulmonary edema, as a result of organophosphates ingestion. She was resuscitated for asystole presented shortly after admission; prolonged QTc interval, ST-T changes, right bundle branch block, ventricular tachycardia were recorded. Finally she developed acute anteroseptal myocardial infarction and died despite serum cholinesterase normalization. We believe that admission in an intensive care unit, careful electrocardiographic and enzymatic monitoring of all patients is important for the diagnosis and treatment of cardiac complications of organophosphates poisoning.

Toxic-induced hypoglycemia in clinical practice.

UNLABELLED: Toxic induced hypoglycemia is usually caused by the anti-diabetic treatment and excessive alcohol consume. Hypoglycemia in diabetics treated with insulin or anti-diabetic oral agents is far the most studied form of hypoglycemia. Less information is available on toxic-induced hypoglycemia in non-diabetic subjects with acute exogenous poisoning. MATERIAL AND METHODS: We retrospectively studied adult non-diabetic patients admitted in Emergency Clinic Hospital of Iasi with hypoglycemia caused by an acute poisoning, over a period of 10 years. Then we performed a prospective study in those poisoning associated with hypoglycemic risk, to assess the prevalence of toxic-induced hypoglycemia. RESULTS: We identified 15,497 patients with acute poisoning in our retrospective study, 4,005 of whom presented poisoning associated with hypoglycemic risk (40% acute ethanol poisoning, 29% wild mushroom poisoning, 23% beta-blocker poisoning, 7% salicylate poisoning and 1% patients with anti-diabetic agents acute poisoning). The prospective study identified 1,034 patients with acute poisoning, 20.11% of whom had ethanol poisoning, 11.79% had beta-blocker poisoning, 5.89% had wild mushroom poisoning, 1.74% had salicylate poisoning and the rest of 60.47% had other acute poisoning, without hypoglycemic risk. Attempted suicide with anti-diabetic agents in non-diabetic subjects produced the most severe and prolonged form of hypoglycemia in acute poisoning. 23 patients in retrospective study and 6 patients in prospective study died, but in only one situation, the death was the direct consequence of hypoglycemia. CONCLUSIONS: In non-diabetic subjects with acute poisoning, prevalence of toxic-induced hypoglycemia depends on the poison itself, the mechanism of poisoning, also depends on the association between toxics and the severity of toxic- induced liver disease. A useful test to assess toxic-induced hypoglycemia is standard 6 hour oral glucose tolerance test (OGTT). Factors predicting a negative outcome in toxic-induced hypoglycemia are association of toxins, cardiac and hepatic complications, and age (>65 years).

[Respiratory syndromes in acute poisoning]. / Sindroame respiratorii în patologia toxica.

Respiratory syndromes in acute poisoning can refer to a wide range of specific clinical syndromes, from acute tracheobronchitis to acute pulmonary edema, chemical pneumonia, acute respiratory distress syndrome and respiratory failure, that occur as a result of direct or indirect effect of chemical substances, drugs and toxins on lungs and airways. Our study attempt to identify, during one-year retrospective study on patients diagnosed with acute poisoning, addressed to Medical Clinic of Emergency Clinic Hospital of Iasi, the respiratory syndromes commonly associated with acute poisoning. We found that the association of toxins, inhalation of gases or volatile substances have a high risk for appearance of respiratory syndromes. The outcome of these patients is influenced by the duration of exposure or the delay of presentation to the hospital after ingestion, and depends on the rapid and aggressive measures for basic life support and intensive care.

[Diagnostic problems in a case of chronic expanding hematoma]. / Probleme de diagnostic într-un caz rar de hematom cronic expansiv.

We present a case of chronic expanding hematoma occurring in the right medial thigh. The patient was an 86 year-old woman who had this mass with slowly growth 3 years before. Ultrasonography showed a multilocular cyst and computed tomography an image of heterogeneous mass with capsule formation. A diagnose was unable to perform through both methods, which was confirmed by histopathological exam after successful surgical treatment. Microscopically, a fibrous pseudocapsule and in the central cavities blood clot, fibrin and necrotic debris were described.

[A rare cause of non-Q myocardial infarction--acute carbon monoxide poisoning]. / O cauza rara de infarct miocardic non-Q intoxicatia acuta cu oxid de carbon.

Myocardial infarction is a rarely reported complication of acute carbon monoxide (CO) poisoning. We report the case of a 77 years old woman who presented to our emergency department with altered consciousness as a consequence of exposure to CO. The patient didn't experience any chest pain, but the electrocardiogram showed a non-Q-wave antero-septal acute myocardial infarction, with typical elevation in troponin T and creatine-phosphokinase MB levels. The patient recovered completely after specific treatment of poisoning with no major cardiac complication. We consider that careful electrocardiographic and enzymatic monitoring of all patients, especially elderly patients, in the first hours after CO exposure is important for early diagnosis and treatment of this rare complication of CO poisoning, and can improve the outcome of these patients.

Chronic inflammatory rheumatismal diseases--paraclinical diagnosis.

The rheumatismal diseases constitute a major problem of public health, the pathology of the locomotor system representing today the main cause of invalidity in the world. The inflammatory chronic rheumatisms affect the young population, and, between the onset of the disease and diagnosis (approximately one year), the patient does not accuse major clinical complaints. In this context, the present work proposes a presentation of the main paraclinic methods and techniques, which may direct the clinician in giving a correct and early diagnosis of the main chronic inflammatory rheumatismal disorders. The paraclinic methods and techniques for assessing the intensity and evolution of the chronic rheumatismal inflammatory processes may be classified as follows: genetic, biological, histological, and imagistic. The inflammatory reaction is a nonspecific long-term reaction of the body defense systems, as response to the continuous and recurrent aggression. It is characterized by the predominance of the lymphocytes and macrophages at the level of the focus infectious and an intense process of neoangiogenesis and fibroblastic proliferation accompanies it. The paraclinic methods and techniques for assessing the intensity and evolution of the chronic rheumatismal inflammatory processes may be classified as follows: genetic, biological, histological, and imagistic.

[Anatomical and surgical considerations concerning the segmentation of the pancreas]. / Consideratii asupra segmentatiei anatomo-chirurgicale a pancreasului.

Pancreatic vascularization, especially the right segment (the head of the pancreas) has great surgical importance, due to its anatomical variety. From this practical point of view, establishing the type of the patient's pancreatic vascular pattern is highly recommended not just diagnosis purposes, but especially for its indispensable role in surgical decision. Selecting the appropriate technique, based on the imagistic evidences must consider the anatomical studies, which propose a systematic vision of the cephalic area vascularization, detecting two major types of arterial distribution. The first type is especially anastomotic; meanwhile the second one is terminal, these two varieties leading to a different surgical technique, best adapted for avoiding hemorrhages or ischemic necroses. Between the classic two segments of the pancreas (cephalic and caudal parts) there is a less vascularized area, which includes just an intersegmentary artery and the pancreatic duct, surgically sectioned during the separation operation of the two pancreatic segments. Vascular variety of the pancreas may be related to both embryological development of the pancreatic tissue, and that of the abdominal aortic branches.

[Renal cell carcinoma- diagnosis by computed tomography]. / Rolul tomografiei computerizate în diagnosticul cancerului renal chistic.

In approximately 10% of cases, renal cell carcinoma (RCC) could present as a fluid- filled cystic mass. There are three mechanisms by which RCC may become cystic: extensive cystic necrosis, intrinsic cystic growth and origin from the epithelium lining a simple renal cyst. Simple renal cysts are very common. Uncommonly these cysts are complicated by hemorrhage, infection and possibly ischemia. The goal of the radiologist in evaluating these cystic lesions is to distinguish malignant neoplastic cystic masses from non-neoplastic complicated cysts so that appropriate management can be undertaken: RCC is best treated by surgical excision while non-neoplastic complicated cysts do not require surgery. The radiologic findings in these cystic masses which must be carefully evaluated include calcification, abnormal density, septations, nodularity, wall thickening and enhancement.

[Staging and diagnosis in accidental hypothermia]. / Stadializarea si diagnosticul urgentelor hipotermice.

Core body temperature below 35 degrees C is defining arbitrarily hypothermia. There is no worldwide consensus concerning the staging and resuscitation strategies in such a vital emergency, not even in rewarming strategy. Accidental hypothermia has its own "survival chain", modifying some steps or the timing in the common cardiopulmonary resuscitation protocol, according to some particularities of the metabolism in such an accident. Taking into account the two major events during hypothermic conditions (ventricular fibrillation and coma), we have proposed a better borderline between the three severity classes, based on clinical, paraclinical and prognostic arguments. The interest in this special environmental emergency situation is coming not only from its incidence, but especially from its particular long time period in which the resuscitation maneuvers could be effective, so that a literature review mixed with our practical observations may be of didactical and legal benefit also.

[Cajal interstitial cells identification]. / Identificarea celulelor interstitiale Cajal si plasarea lor in contextul structural al peretelui intestinal.

Cajal interstitial cells are cells that are found in the abdominal digestive system wall, between neurons and smooth muscular tissue. They are considered to be pacemakers for slow intestinal waves. The paper discuss about the electron-microscopic identification of Cajal interstitial cells in the rat small intestine wall, cell morphology, placement of these cells in the muscular layer and the relation between Cajal interstitial cells and the components of the nervous plexus. Fragments of rat small intestine have been prepared for electron microscopy examination. Cajal interstitial cells have been found in different locations: in the circular muscular layer, around the nervous nodes and between the muscular layers (longitudinal and circular). The main morphologic characteristic of these cells is the aspect of cytoplasm, with numerous vacuoles and long extensions, some of them very thin, with a tendency to divide. Some Cajal interstitial cells form a network that surrounds the nervous nodes. Other form junctions with the muscular cells and with the interstitial neurons.

[Consideration on serotoninergic syndrome based on a clinical situation ]. / Consideratii asupra sindromului serotoninergic pornind de la un caz clinic.

The diagnosis criteria for serotoninergic syndrome was first time proposed in 1991 by Sternbach, mixing clinical, biological and historical features. Drugs inducing serotonin accumulation by decreasing the synaptic recapture or increasing the serotoninergic transmission are responsible for the onset of this syndrome even in small amounts. We are describing a case of a young patient developing a comatose stage of serotoninergic syndrome as a result of Amitriptylinum and Sertralinum poisoning.