Сопутствующие заболевания при подагре: изучение клинического полиморфизма, диагностика, стратегии лечения и прогноз

Structura tezei. Lucrarea a fost expusă pe 256 de pagini de text electronic și se compartimentează în: introducere, 5 capitole, discuții, 8 concluzii și 12 recomandări, indice bibliografic (240 de titluri), 36 de figuri, 45 de tabele, 13 anexe. Rezultatele cercetării au fost prezentate în 62 de publicații. Cuvinte-cheie: acid uric, hiperuricemie, gută, boli metabolice, comorbidități, diagnostic, scorul de severitate. Domeniul de studiu. Reumatologie Scopul studiului. Evaluarea comorbidității pacienților de diferite vârste afectați de gută cu argumentarea clinică și economică privind îmbunătățirea managementului de evaluare clinico-paraclinică în acordarea asistenței medicale acestor pacienți. Obiectivele studiului. 1. Evaluarea statutului comorbid la pacienții suferinzi de gută de diferite vârste. 2. Analiza evoluției procesului inflamator și a progresiei bolii la pacienții cu gută prin prisma diferitor decade ale vârstei. 3. Specificarea modificărilor patologice ale organelor interne și a particularităților evolutive ale afectărilor extraarticulare la pacienții cu gută. 4. Determinarea factorilor provocatori și a influenței lor asupra debutului, caracteristicilor și evoluției gutei la persoanele vârstnice. 5. Analiza posibilității corecției factorilor provocatori la pacienții vârstnici prin ajustarea tratamentului non-farmacologic și farmacologic. 6. Determinarea fezabilității economice exprimate prin analiza costurilor medicale directe în funcție de vârstă și comorbiditate, cu elaborarea principiilor de eficientizare a cheltuielilor. 7. Analiza economică a costurilor unui caz tratat staționar, cu elaborarea principiilor de eficientizare a cheltuielilor în funcție de evoluție. 8. Elaborarea recomandărilor pentru eficientizarea managementului clinic și fezabilității economice de acordare a asistenței medicale pacienților vârstnici cu gută. Noutatea și originalitatea științifică. În cadrul unui studiu observațional, descriptiv, transversal, pacienții cu gută au fost cercetați multidimensional. Au fost evaluate factorii provocatori, debutul și evoluția, frecvența comorbidităților la pacienții vârstnici cu gută în comparație cu indicatorii similari ai pacienților din alte grupuri de vârstă. A fost efectuată o evaluare a conformității „practicii tipice” de gestionare a pacienților vârstnici cu gută într-un cadru spitalicesc, ținând cont de recomandările internaționale valabile pentru perioada studiului. Sa demonstrat importanța factorilor controlabili dobândiți care afectează severitatea gutei la pacienții vârstnici, dintre care: administrarea diureticelor și dozelor mici de acidul acetilsalicilic, obezitatea, respectarea dietei și consumul excesiv de alcool. S-au analizat recomandările pentru îmbunătățirea metodologiei de analiză clinică și economică a costurilor de acordare a asistenței medicale pacienților vârstnici cu gută, luând în considerare corectarea contextului comorbid, acestea fiind fundamentate și testate științific. Problema științifică importantă soluționată în teză. Pe baza analizei factorilor provocatori care cauzează guta la vârstnici, au fost identificate principalele metode de abordare optimă a prevenirii și tratamentului acesteia, care includ medicamente (diuretice, acidul acetilsalicilic), nerespectarea regimului alimentar, consumul de alcool și prezența sindromului metabolic. În baza datelor obținute, a fost determinat rolul semnificativ al comorbidităților în formarea costurilor pentru furnizarea de asistență medicală pacienților vârstnici cu gută. În special, prezența HTA, CPI, BCR crește semnificativ aceste costuri. Sunt prezentate recomandări metodice pentru optimizarea metodologiei de modelare a costurilor de acordare a îngrijirilor medicale unui pacient vârstnic cu gută, ținând cont de comorbidități, care includ revizuirea numărului de examinări, atât de laborator, cât și instrumentale, pentru fiecare boală comorbidă. Semnificația teoretică. Datele epidemiologice obținute privind distribuția frecvenței factorilor provocatori de gută la pacienții vârstnici vor permite stratificarea determinată științific a riscurilor la anumiți pacienți și vor fi utilizate în mod activ la crearea recomandărilor pentru prevenirea și tratamentul bolii. Caracteristicile debutului și ale evoluției gutei la pacienții vârstnici identificați pe parcursul studiului în comparație cu pacienții de vârstă medie vor optimiza desfășurarea măsurilor diagnostice și terapeutice la pacienții din acest grup de vârstă. Valoarea aplicativă. Analizându-se factorii provocatori pentru dezvoltarea gutei la vârstnici, au fost identificate principalele cauze care afectează lipsa unei abordări optime a prevenirii și tratamentului acesteia. În baza datelor obținute, a fost determinat un rol semnificativ al patologiei comorbide în formarea costurilor pentru furnizarea de asistență medicală pacienților vârstnici cu gută. Sunt prezentate recomandări metodice pentru optimizarea metodologiei de modelare a costurilor de acordare a îngrijirilor medicale unui pacient vârstnic cu gută, ținând cont de patologia concomitentă. Implementarea rezultatelor. Rezultatele studiului au fost incluse în Protocolul Clinic Național „Guta la adult”, se aplică în procesul didactic al Departamentului Medicină Internă, în practica Disciplinei de reumatologie și nefrologie a IP USMF „Nicolae Testemițanu” și în secția de Artrologie a IMSP SCR „Timofei Moșneaga”.Thesis structure. The work was exposed on 256 pages of electronic text and is divided into: introduction, 5 chapters, discussions, 8 conclusions and 12 recommendations, bibliographic index (240 titles), 36 figures, 45 tables, 13 annexes. The results of the research were presented in 62 publications. Keywords: uric acid, hyperuricemia, gout, metabolic diseases, comorbidities, diagnosis, severity score. Domain of research. Rheumatology Aim of the study. Assessment of the comorbidity of patients of different ages affected by gout with clinical and economic rationale for improving the management of clinical-paraclinical assessment in providing care to these patients. Study objectives. 1. Assessment of comorbid status in gout patients of different ages. 2. Analysis of the evolution of the inflammatory process and disease progression in patients with gout in the different decades of age. 3. Specify the pathological changes of internal organ pathology and the evolutionary peculiarities of extraarticular damage in patients with gout. 4. Determine the triggering factors and their influence on the onset, characteristics and evolution of gout in the elderly. 5. Analysis of the possibility of correcting modifiable risk factors in elderly patients by adjusting non-pharmacological and pharmacological treatment. 6. Determination of economic feasibility expressed by analysis of direct medical costs according to age and comorbidity, with elaboration of principles of cost efficiency. 7. Economic cost analysis of an inpatient case, with development of cost efficiency principles according to evolution. 8. Development of recommendations for streamlining clinical management and economic feasibility of providing care to elderly patients with gout. Scientific novelty and originality. In an observational, descriptive, cross-sectional study, patients with gout were investigated multidimensionally. Challenging factors, onset and progression, frequency of comorbidities in elderly patients with gout were assessed in comparison with similar indicators of patients in other age groups. An assessment of the compliance of the „typical practice” management of elderly patients with gout in a hospital setting was performed, taking into account the international guidelines valid for the study period. The importance of acquired controllable factors affecting the severity of gout in elderly patients was demonstrated, including: the administration of diuretics and low doses of acetylsalicylic acid, obesity, dietary compliance and excessive alcohol consumption. Recommendations for improving the methodology of clinical and economic cost analysis of healthcare delivery for elderly patients with gout, taking into account the correction of the comorbid context, have been reviewed and are scientifically substantiated and tested. The scientific problem solved in the thesis. Based on the analysis of the factors that cause gout in the elderly, the main methods of optimal approach to its prevention and treatment have been identified, which include drugs (diuretics, acetylsalicylic acid), dietary non-compliance, alcohol consumption and the presence of metabolic syndrome. Based on the data obtained, the significant role of comorbidities in shaping the costs of providing care to elderly patients with gout was determined. In particular, the presence of ischemic heart disease, chronic heart failure, chronic renal failure significantly increases these costs. Methodological recommendations are presented for optimizing the methodology for modeling the costs of providing health care to an elderly patient with gout, taking into account comorbidities, which include reviewing the number of examinations, both laboratory and instrumental, for each comorbid disease. Theoretical significance. The epidemiological splints obtained on the distribution of the frequency of gout risk factors in elderly patients will allow scientifically determined stratification of risks in certain patients and will be actively used to create recommendations for the prevention and treatment of the disease. The characteristics of the onset and development of gout in elderly patients identified during the study compared to middLe-aged patients will optimize the conduct of diagnostic and therapeutic measures in patients in this age group. Applicative value of the study. When analyzing the factors that cause the development of gout in elderly, the main causes affecting the lack of an optimal approach to its prevention and treatment have been identified. Based on the data obtained, a significant role of comorbid pathology in the formation of costs for the provision of medical care to elderly patients with gout was determined. Methodical recommendations are presented for optimizing the methodology for modeling the costs of providing medical care to an elderly patient with gout, taking into account the concomitant pathology. Results implementation. The results of the study were included in the National Clinical Protocol „Gout in adult”, is applied in the didactic process of the Department of Internal Medicine, in the practice Department of Rheumatology and Nephrology of „Nicolae Testemitanu” SMPhU and in the Clinical Department of Arthrology of Republican Clinical Hospital „Timofei Moşneaga”.Структура диссертации. Работа представлена на 256 страницах электронного текста и состоит из: введения, 5 глав, обсуждение, 8 выводов, 12 практических рекомендаций, библиографии (240 источника), 36 рисунков, 45 таблиц, 13 приложений. Результаты исследования были опубликованы в 62 научных работах. Ключевые слова: мочевая кислота, гиперурикемия, подагра, метаболические заболевания, сопутствующие заболевания, диагностика, оценка тяжести. Область исследования. Ревматология Цель исследования. Оценка коморбидности пациентов разного возраста, страдающих подагрой, с клиникоэкономическим обоснованием для улучшения управления клинико-параклинической оценкой при оказании помощи этим пациентам. Задачи исследования. 1. Оценка коморбидного статуса у больных подагрой разного возраста. 2. Анализ эволюции воспалительного процесса и прогрессирования заболевания у пациентов с подагрой в разных возрастных категориях. 3. Уточнить патологические изменения внутренних органов и эволюционные особенности внесуставного поражения у больных подагрой. 4. Определить триггерные факторы и их влияние на возникновение, характеристики и эволюцию подагры у пожилых людей. 5. Анализ возможности коррекции модифицируемых факторов риска у пациентов пожилого возраста путем корректировки нефармакологического и фармакологического лечения. 6. Определение экономической целесообразности, выраженной в анализе прямых медицинских затрат в зависимости от возраста и коморбидности, с разработкой принципов экономической эффективности. 7. Анализ экономических затрат на стационарный случай с разработкой принципов эффективности затрат в зависимости от эволюции. 8. Разработка рекомендаций по оптимизации клинического менеджмента и экономической целесообразности оказания помощи пожилым пациентам с подагрой. Научная новизна. В обсервационном, описательном, перекрестном исследовании пациентов с подагрой были комплексно обследованы. Были оценены провоцирующие факторы, дебют и эволюция заболевания, частота сопутствующих заболеваний у пожилых пациентов с подагрой в сравнении с аналогичными показателями пациентов других возрастных групп. Проведена оценка соответствия „типичной практики” ведения пожилых пациентов с подагрой в условиях стационара с учетом международных рекомендаций, действующих на период исследования. Показана важность приобретенных контролируемых факторов, влияющих на тяжесть подагры у пожилых пациентов, в том числе: прием диуретиков и низких доз ацетилсалициловой кислоты, ожирение, соблюдение диеты и чрезмерное употребление алкоголя. Рассмотрены и научно обоснованы рекомендации по совершенствованию методологии анализа клиникоэкономических затрат на оказание медицинской помощи пожилым пациентам с подагрой с учетом коррекции коморбидных заболеваний. Важность решенной научной проблемы. На основе анализа факторов, вызывающих подагру у пожилых, определены основные методы оптимального подхода к ее профилактике и лечению, к которым относятся лекарственные препараты (диуретики, ацетилсалициловая кислота), несоблюдение диеты, употребление алкоголя и наличие метаболического синдрома. На основании полученных данных, была определена значительная роль сопутствующих заболеваний в формировании затрат на оказание помощи пожилым пациентам с подагрой. В частности, наличие ишемической болезни сердца, хронической сердечной недостаточности, хронической почечной недостаточности значительно увеличивает эти затраты. Представлены методические рекомендации по оптимизации методики моделирования затрат на оказание медицинской помощи пожилому пациенту с подагрой с учетом коморбидных заболеваний, которые включают пересмотр количества обследований по каждому коморбидному заболеванию. Теоретическая значимость. Полученные эпидемиологические данные по распределению частоты провоцирующих факторов при подагре у пациентов пожилого возраста позволили определить стратификацию рисков у отдельных пациентов и были использованы для создания рекомендаций по профилактике и лечению заболевания. Выявленные в ходе исследования особенности возникновения и развития подагры у пациентов пожилого возраста по сравнению с пациентами среднего возраста позволили оптимизировать проведение диагностических и лечебных мероприятий у пациентов этой возрастной группы. Прикладная значимость. При анализе провоцирующих факторов развития подагры в старческом возрасте выявлены основные причины, влияющие на отсутствие оптимального подхода к ее профилактике и лечению. На основании полученных данных определена значительная роль коморбидной патологии в формировании затрат на оказание медицинской помощи пожилым пациентам с подагрой. Представлены методические рекомендации по оптимизации методики моделирования затрат на оказание медицинской помощи пожилому пациенту с подагрой с учетом сопутствующей патологии. Внедрение в практику. Результаты исследования были включены в Национальный Клинический Протокол „Подагра у взрослых”, были внедрены в дидактическом процессе и в практику Дисциплины ревматологии и нефрологии, Департамента Внутренних Болезней, ГУМФ „Николае Тестемицану” и в отделении Артрологии Республиканской Клинической Больницы „Тимофей Мошняга”

Analysis of clinical-biological markers and scoring of patients with liver cirrhosis in the liver transplant program: Summary of doctoral thesis in medical sciences: 321.24 – Transplantology

Actuality and importance of the researched problem: Although recent years have seen a steady increase in the incidence of liver disease, which is a serious problem in modern medicine, viral liver cirrhosis is still certainly underestimated both nationally and globally. Currently, worldwide 844 million people are registered with chronic liver disease, with a mortality rate of 2 million deaths per year, including 1 million deaths due to complications of cirrhosis and 1 million due to viral hepatitis and hepatocellular carcinoma [1]. Liver disease is becoming more and more common lately and more alarming worldwide, as well as in the Republic of Moldova, 75% of deaths caused by pathology of the digestive system are due to liver cirrhosis [2]. Epidemiological analysis of viral liver cirrhosis showed a 3-fold increase in morbidity in 2019 compared to 2000. As a result of which, the number of patients with liver cirrhosis of viral etiology increased in 2019 to 5482 patients. Also, in the case of chronic viral hepatitis, the majority of patients were detected with hepatitis B virus. In the multi-year dynamics the prevalence index of HBV morbidity increased from 655 cases (15.3 cases per 100 thousand inhabitants) in 2000 to 2422 cases (68.32 cases per 100 thousand inhabitants) in 2019. The prevalence rate in liver cirrhosis caused by C virus increased practically 9-fold, from 229 cases (5.4 cases per 100 thousand inhabitants) in 2000 to 2240 cases (63.19 cases per 100 thousand inhabitants) in 2019. Viral liver cyonoses, other etiologies and those not specified, showed a slight decrease from 522 cases (12.2 cases per 100 thousand inhabitants) in 2000 to 420 cases (11.85 cases per 100 thousand inhabitants) in 2019 [3]. Thus, at this stage, viral liver cirrhosis and primary liver cancer represent one of the most serious problems for the population, due to their global spread, increased morbidity and mortality, and the high degree of disability caused by the rapid progression of these pathologies. Globally, approximately 257 million people are infected with chronic viral hepatitis B, while 71 million people are infected with chronic viral hepatitis C, mainly in less developed countries. In 2019, 10 thousand patients with liver cirrhosis were registered in the Republic of Moldova, as a result of which 70% of patients with cirrhosis developed primary liver cancer. Morbidity for viral etiology liver cirrhosis, caused by virus D, increased from 183 cases (4.3 cases per 100 thousand inhabitants) in 2000 to 400 cases (11.28 cases per 100 thousand inhabitants) in 2019. What denotes a higher prevalence for the Republic of Moldova is HDV viral liver cirrhosis, which has a more aggressive and rapid evolution compared to other viral liver cirrhosis [3]. Over the past two decades, efforts have focused on reducing mortality on the liver transplant waiting list without compromising post-transplant outcomes. However, it can be 5 difficult to identify candidates who are too ill for HT to prevent unnecessary transplants [39]. The implementation of the MELD score was the first and most important change in liver allocation, redirecting donor organs to the sickest patients and aiming to reduce waiting list mortality [4]. Notwithstanding the fact, that there is a need for continuous consolidation and development of new prognostic scores for the end-stage liver disease population on the waiting list for liver transplantation in the Republic of Moldova, the validation of new scores and in fact what defines the research problem at hand, which is predestined to improve and prolong the quality of life of patients on the waiting list within the national liver transplantation system. Thus, based on the above, the aim of the scientific work is to: study the clinical-biological landmarks and analyze different prognostic scores on the population with viral liver cirrhosis from the waiting list for liver transplantation in the Republic of Moldova. The following general research objectives were stipulated to achieve the aim: 1. Evaluation of clinical-biological landmarks in patients on the waiting list for liver transplantation 2. Analysis of prioritization factors of recipients for liver transplant waiting list 3. Comparison of predictive accuracy between MELD score, MELD Na, MESO-index on mortality in the first 3 months after liver transplant listing 4. Validation of the MELD 3.0 prognostic score for mortality in the first 3 months of recipients on the liver transplant waiting list 5. Development of the algorithm for enrolling patients with decompensated viral liver cirrhosis on the liver transplant waiting list based on the validated maximum predictive accuracy prognostic score Scientific research methodology The present work represents a stepwise, retrospective and analytical clinical study focused on the evaluation of clinical parameters, results of instrumental methods of diagnosis and monitoring of 265 patients with viral liver cirrhosis included in the waiting list for liver transplantation. With the application of prognostic scores to predict mortality rate in the first 90 days after listing for liver transplantation. Statistical analysis was performed using SPSS software, version 23.0. Data are reported as mean±SD. Gaussian normal distribution was tested by applying normality tests (ShapirkoWilk test); and homogeneity of variance was checked by Levene's test. Differences between groups were detected by performing the independent t-test for normally distributed homogeneous values and the Welch test for non-homogeneous normally distributed values. The Mann-Whitney 6 U test was applied for non-parametric data or for parametric data not following the normal distribution. Differences were considered significant at a p-value less than 0.05. The PhD scientific project was favourably approved by the Research Ethics Committee of the IP USMF "Nicolae Testemitanu" (no. 47 of 17.06.2019). Novelty and scientific originality of the results obtained: Taking into account the increasing number of patients on the waiting list with viral liver cirrhosis, the long waiting time, the rapid progression of the disease with increased mortality rate of patients, for the first time an interdisciplinary clinical and paraclinical study was conducted, with a complex evaluation of prognostic scores predicting mortality in the first 90 days of listing, with the creation of a monitoring system validated and adapted for the Republic of Moldova. Careful monitoring and re-evaluation of candidates at regular intervals has been implemented which can improve the success of the liver transplant programme and the overall patient outcome. Scientific and practical problem solved The scientific-practical problem solved in the research is the development of the rational algorithm for evaluation and triage of patients with liver cirrhosis of viral aetiology from the waiting list in various clinical situations and greater accessibility in the view of the liver transplant coordinator team. Theoretical importance and applicative value of the study The applicative value of the study is reflected in the scientific work - the analysis of the concepts of scientists in the country and abroad, the hypotheses and problematizations made, as well as the knowledge we have gained through our PhD research, will broaden the horizon of research of clinical-paraclinical features in patients with liver cirrhosis of viral etiology and the assessment of prognostic scores of short-term mortality risk for patients included in the waiting list for liver transplantation. New scores have been proposed that exceed the predictive value of the MELD score and would facilitate the inclusion of patients on the liver transplant waiting list depending on the severity of the disease, so that patients with end-stage liver disease in severe disease are given priority for liver transplantation. Also in teaching activity - the conclusions and recommendations presented in the paper can be used in the training process of students/residents; practical activity - the acquired knowledge and the proposed recommendations will improve the work of clinics. Implementation of research results. The practical impact of the present study is the external validation of the new MELD 3.0 score on the population with viral liver cirrhosis from the waiting list for liver transplantation in the Scientific Surgical Laboratory ,,Reconstructive Surgery of the Digestive Tract'' Nicolae 7 Testemitanu State University of Medicine and Pharmacy, Chisinau, Republic of Moldova. In addition, the results obtained (validation of the new prognostic mortality score in the first 90 days after listing) were presented to medical students during the classes at the Department of Surgery No. 2. Approval of scientific results. The results obtained were discussed and presented at the following scientific forums: the National Congress of Surgery, Sinaia, 2022, the National Congress of the Romtransplant Association, edition 2022, the scientific-practical conference with international participation ,,Hepatobiliary-pancreatic surgery, abdominal parietal defects, advanced laparoscopic surgery'', Chisinau, 2022, the annual scientific conference ,,Research in biomedicine and health: Quality, Excellence and Performance'' dedicated to the 77th anniversary of the founding of Alma Mater. National Conference ,,Days of the CF Clinical Hospital Iasi'', edition 2022, Scientific Conference with international participation dedicated to the Medical Days of the Municipal Clinical Hospital ,,Saint Archangel Michael'' 1st edition, 21.11.2022, International Scientific Conference ,,Tissue and Cell Transplantation. Actualități și perspective'', National Scientific Conference on BPH Surgery, 20.04.2023 - 23.04.2023, Bucharest, Congress Balkan Medical Week, XXXVII edition Perspectives of Balkan Medicine in the post COVID-19 era, 7-9 June 2023, Chisinau, Republic of Moldova, National Congress of Surgery. The XIVth Congress of the Association of Surgeons ,,Nicolae Anestiadi'' of the Republic of Moldova. 21-23 September 2023. Publications on the research topic. 29 scientific papers have been published on the subject of the thesis, of which: 10 articles in scientific journals, 9 theses, 1 abstract in SCOPUS journal. 1 patent, active participations in national and international scientific conferences and congresses in total 10 participations confirmed by programs and certificates of participation. Of which, international communications - 2, national - 8. Thesis structure. Thesis includes annotations in Romanian, Russian and English, list of abbreviations, introduction, 4 chapters with general conclusions, practical recommendations. The paper is followed by the list of bibliographical references with 222 sources and the author's CV. The introduction part of the paper reflects the topicality and scientific-practical importance of the problem addressed in the thesis, the aim, objectives, scientific novelty, theoretical importance and applied value of the research, approval of the results of the study

Cartografierea consumului de antibiotice în Republica Moldova

Introduction. Antibiotic consumption represents a crucial aspect of modern healthcare. Abuse and inappropriate use of antibacterial agents contribute to the phenomenon of bacterial resistance. The aim of the study was to determine antibiotic consumption in hospital conditions and map the results in order to highlight regions in the country with the highest levels of antibiotic consumption and the classes of antibiotics used. Material and methods. Antibiotic consumption in hospitals (64 facilities) over a 4-year period (2018-2021) was determined using the defined daily dose (DDD) as the unit of measurement. The quantity of antibiotics consumed was expressed in DDD/1000 patient-days (hospitalization days), followed by mapping the results. Results. A "very high" level of antibiotic consumption, expressed in DDD/1000 patient-days, was observed in the Falesti district, while a "medium" level of antibacterial agent consumption was observed in the Taraclia, Comrat, Ialoveni, Singerei, Glodeni, and Donduseni districts. The total consumption per antibiotic class revealed an increased use of Cephalosporins, Imidazole derivatives, Macrolides, Tetracyclines, Fluoroquinolones, and Aminoglycosides. Conclusions. Mapping antibiotic consumption is an efficient tool in highlighting administrative-territorial regions with high antibiotic consumption and identifying the most frequently used antibiotic classes. Providing this information is useful for developing policies aimed at optimizing antibiotic use and minimizing resistance.Introducere. Consumul de antibiotice reprezintă un aspect crucial al asistenței medicale moderne. Abuzul și utilizarea necorespunzătoare a preparatelor antibacteriene favorizează fenomenul de rezistență bacteriană. Scopul studiului a fost determinarea consumului de antibiotice în condiții de staționar în Republica Moldova și cartografierea rezultatelor obținute. Material și metode. În acest studiu a fost determinat consumul de antibiotice în condiții de staționar (64 de spitale), pe o perioadă de patru ani (2018-2021), folosind ca unitate de măsură doza zilnică definită (DDD). Cantitatea de antibiotice consumată a fost exprimată în DDD/1000 zile-pacient (zile de spitalizare), ulterior fiind efectuată cartografierea rezultatelor. Rezultate. Rezultatele înregistrate atestă un nivel „foarte mare” de consum de antibiotice exprimat în DDD/1000 zile de spitalizare în raionul Fălești și un nivel „mediu” de consum de preparate antibacteriene în raioanele Taraclia, Comrat, Ialoveni, Sîngerei, Glodeni, Dondușeni. Consumul total per clase de antibiotice a scos în evidență un consum sporit de cefalosporine, de derivați de imidazol, de macrolide, de tetracicline, de fluorochinolone și de aminoglicozide. Concluzii. Cartografierea consumului de antibiotice reprezintă un instrument eficient de evidențiere a regiunilor administrativ-teritoriale în care consumul de antibiotice este ridicat, și a claselor de antibiotice cel mai frecvent utilizate. Aceste informații sunt utile pentru elaborarea de politici menite să optimizeze utilizarea antibioticelor și să minimizeze rezistența acestora

Immunostimulation of local immunity in the complex treatment of chronic tonsillitis in children

Background. After healing the palatine tonsils in the complex conservative treatment of chronic tonsillitis, an important role is the stimulation of local immunity by applying autologous mononuclear cells. This is done by introducing these activated cells into the peritonsillar space. The application of this method does not produce immune conflict, transmission is excluded hemotransmissible pathologies, the bioethical problem is missing. Objective. To examine the effect of applying local immunostimulation with activated autocells in chronic tonsillitis in children without complications at the distance. Materials and methods. Clinical and immunological studies of the treatment of children with chronic tonsillitis without complications of other organs and (74 children) were investigated in the IP Mother and Child Center, Emilian Cotaga Clinic, ENT Department. The method of local immunostimulation (autologous mononuclear cells) was developed in the Tissue Engineering and Cell Cultures Laboratory of Nicolae Testemițanu SUMPh. Results. After more than 2 months of treatment were highlighted decreases in IgE content, decreases in sensitization of T lymphocytes to Streptococcus pyogenes and pneumococcal antigens, decreases in IgG titers, decreases in the level of pro-inflammatory cytokines TNF-alpha, IL-1-8 beta, increases in cytokines anti-inflammatory Il-4. The presence of Streptococcus pyogenes in tonsillar surface smears was significantly reduced after treatment. Over the course of a year, the number of acute respiratory infections decreased in these children, as well as indications for antibiotic therapy, signs of chronic inflammation of the palatine tonsils (caseous masses in the hollows, hyperemia of the tonsil pillars, etc) Conclusion. The method of local immunostimulation (with autologous mononuclear cells) in the case of chronic tonsillitis has a positive clinical impact, exerting a positive complex action on the reactivity of immune indices

Autolog tranplantation of platelet rich fibrin in inguinal hernia repair in liver cirrhosis

Background. The objective of this study is to provide autologous platelet-rich fibrin transplantation in inguinal hernia repair in liver cirrhosis with ascites. Materials and methods. A study was conducted on 28 patients with inguinal hernia combined with liver cirrhosis and massive ascites-peritonitis. Group I: 14 patients with inguinal hernia associated with liver cirrhosis and massive ascites peritonitis underwent Lichtenstein type hernioplasty. Group II: 14 patients with inguinal hernia associated with liver cirrhosis and massive ascites peritonitis underwent Lichtenstein type hernioplasty with the application of autologous fibrin transplantation rich in platelets. All patients in both groups underwent laparoscopic lavage of the abdominal cavity with antibacterials and postoperative drainage with lavage. Results. Seroma wounds postoperative wounds I group 3 cases, II group 0 cases. Postoperative wound suppuration I group 1 case, In group II – 0 cases. Recurrence of the hernia at 1 year was not observed in both groups. Mortality consists of 2 patients, who developed liver failure after 2 months of hospitalization, 1 patient from group I. Conclusion. In patients with inguinal hernia and liver cirrhosis and ascites-peritonitis, the application of Lichtenstein-type surgical treatment with the application of autologous platelet-rich fibrin transplantation ensures safe local results, without postoperative complications in the postoperative wound (lack of seromaler and wound suppuration). Postoperative mortality does not determine a significant difference, being caused by liver reserves and liver failure. Surgical treatment without the application of autologous platelet-rich fibrin transplantation has an increased incidence of postoperative complications

Organizarea asistenței medicale victimelor violenței sexuale

Scopul: Evaluarea practicilor de organizare a asistenței medicale victimelor violenței sexuale pentru elaborarea recomandărilor menite să îmbunătățească structura și procesele instituționale în domeniu. Obiective: Analiza practicilor internaționale și naționale privind organizarea asistenței medicale victimelor violenței sexuale; evaluarea practicilor existente de organizare a serviciilor medicale și medico-legale pentru victimele violenței sexuale; identificarea barierelor și provocărilor în organizarea asistenței medicale victimelor violenței sexuale; elaborarea unor recomandări privitor la îmbunătățirea serviciilor medicale și medico-legale acordate victimelor violenței sexuale. Material și metode: Tipul de studiu: transversal, descriptiv, mixt (cantitativ și calitativ), efectuat prin chestionarea a 240 de medici ginecologi și interviuri în profunzime cu diferite categorii de profesioniști, precum: manageri de spitale, șef Centru Perinatal, reprezentant al Inspectoratului de Poliție, medic-legist. Datele au fost colectate în perioada noiembrie 2022- martie 2023. Chestionarul a fost realizat în Google Forms și distribuit online. Metodele studiului – grafică, statistică, sociologică. Rezultate obținute: În studiul cantitativ, caracteristicile social-demografice ale respondenților sunt după cum urmează: 165 (68,70%) sunt femei și 75 (31,30%) bărbați; stagiul de muncă de 5 ani a fost indicat de 6,2%, 10-15 ani – 12,5%, peste 20 de ani – 81,3 %. După regiunea geografică a țării, din centru au răspuns 18,8%, sud – 37,4%, nord – 43,8%. Datele studiului relatează că medicii ginecologi în proporție de 100% sunt total de acord că serviciile de sănătate acordate victimelor violenței sexuale trebuie să fie furnizate concomitent cu serviciile medico-legale, în același loc și timp. Medicii ginecologi din cadrul spitalului, de altfel, foarte rar participă la expertiza medico-legală efectuată de către medicul legist în UPU, deoarece nu este solicitat/invitat. Cu faptul că fenomenul de violență sexuală este o problemă majoră de sănătate publică au fost de acord jumătate din respondenți, total de acord au fost 31,3% și nu sunt de acord – 18,7%. Frecvența fenomenului violenței sexuale în practica medicului ginecolog se întâlnește rar conform opiniei a 37,5%, frecvent – 25%, foarte rar – 25%, iar pentru opțiunea greu de răspuns optează 12,5% dintre respondenți. Răspunsul sistemului de sănătate la cazurile de violență sexuală este fragmentar și sunt oferite de diferite unități în cadrul spitalului (UPU, AMSA, cât și centrele de sănătate). Conform datelor studiului, în 37,5% din cazuri asistența medicală este acordată în cadrul spitalelor și în 25% – AMSA. Medicii din UPU și medicii obstetricieni ginecologi au acces la contracepție de urgență care se oferă 100% datorită donațiilor din partea UNFPA. Formarea profesională a medicilor implicați în acordarea asistenței medicale victimelor violului a inclus instruiri sporadice în managementul cazurilor de viol. În cadrul cursurilor de educație continuă nu există cursuri tematice dedicate exclusiv gestionării cazurilor de violență sexuală. Conform datelor studiului au beneficiat de instruiri 68,8%, pe când 31,3% nu au beneficiat. Oferirea suportului psihosocial victimei este deosebit de importantă la adresarea în instituția medicală. Nevoia de instruire a furnizorilor de servicii cu privire la ajutorul psihosocial și consiliere pentru victimele violenței sexuale a fost raportat de 87,5% din respondenți, pe când doar 31,2% au beneficiat de asemenea instruiri. Frecvent în instituțiile medicale se încalcă principiul de confidențialitate, dreptul de a primi îngrijiri și tratament într-un mediu privat și sigur. Rezultatele studiului calitativ confirmă că răspunsul sistemului de sănătate la cazurile de violență sexuală nu corespunde „standardului de aur” al OMS, care prevede acordarea serviciilor medicale și medico-legale victimelor violului concomitent. Majoritatea specialiștilor optează pentru o comunicare mai eficientă care va fi posibilă prin formarea centrelor/serviciilor multidisciplinare de asistență a victimelor violenței sexuale. Concluzii: La momentul actual, în pofida existenței cadrului legal în domeniu, acordarea asistenței medicale victimelor violenței sexuale este fragmentară și neuniformă. Un rol important revine acțiunilor de informare și prevenire. Instruirea personalului implicat nu este suficientă pentru o schimbare durabilă, fiind necesar de a îmbunătăți infrastructura, comunicarea între diferiți actori, elaborarea procedurilor standard operaționale și a procedurilor de confidențialitate, mobilizare comunitară. Se constată necesitatea creării unui serviciu specializat multidisciplinar amplasat cât mai aproape de beneficiari, ce va permite examinarea medicală și medico-legală, consiliere psihologică, servicii sociale și asistență juridică sub același acoperiș

Complications associated with fixation method of orthopedic constructions on implant support

Rezumat. Articolul examinează complicațiile asociate cu metodele de fixare a construcțiilor protetice pe suport implantar, comparând cimentarea și înșurubarea. Studiul a relevat că fixarea prin cimentare prezintă un risc mai mare de complicații biologice, cum ar fi periimplantita și pierderea osoasă, în timp ce fixarea prin înșurubare este asociată cu un risc crescut de complicații tehnice, cum ar fi slăbirea sau fracturarea șuruburilor. Ambele metode au avantaje și dezavantaje distincte, dar necesită luarea în considerare a complicațiilor posibile pentru a alege metoda optimă.Abstract. The article examines the complications associated with methods of fixing prosthetic constructions on implant support, comparing cementation and screwing. The study revealed that cementation fixation presents a higher risk of biological complications, such as peri-implantitis and bone loss, while screw fixation is associated with an increased risk of technical complications, such as screw loosening or fracturing. Both methods have distinct advantages and disadvantages, but require consideration of possible complications to choose the optimal method

Osteo-cellular graft in the wrist instability. Clinical case

Background. The wrist or carpal instability means any disturbance of the static and dynamic balance of forces at the wrist under the conditions of daily living [Linscheid, 1972]. The cause of wrist instability in 95% is of post-traumatic origin, the most of cases are around scaphoid bone [Watson, 1984]. The instability of the wrist joint causes the deforming osteoarthritis of the joint which in turn leads to chronic pain and disability [AzÛcar, 2021]. Wrist arthrodesis is a procedure performed in advanced arthritis with painful movement in wrist joint [Chhabra, 2010]. This surgery is a rescue one, and is made in order to remove the pain syndrome and increase the strength of the hand [Gelberman, 2000]. Aim of study was presentation the clinical case of scaphoid pseudarthrosis with deforming osteoarthritis of the wrist joint treated by arthrodesis using osteo-cellular graft (OCG). Material and methods. Anamnesis, clinical and paraclinical data were taken from the hospital patient record. Were analyzed the laboratory examinations, radiography and MRI of the wrist joint of the patient. Results. A 39-year-old man suffered repetitive fall trauma in the left hand: first time it was about 20 years ago and was performed conservative treatment, but 6 years later the pains started to appear. After another trauma 5 years ago, it was diagnosed scaphoid pseudarthrosis, but it was neglected. Now the patient presented at the Clinical Hospital of Traumatology and Orthopedics with severe pain, limitation of movements and deformity of the left wrist joint, he was admitted to the Division of Hand Surgery. The patient’s radiological images and MRI reports - Scaphoid pseudarthrosis of the left hand with 2nd degree deforming osteoarthritis of the wrist joint. Together with patient it was decided to perform surgical treatment – scaphoidectomy and arthrodesis using osteo-cellular graft (OCG). Before surgery, harvesting of autologous mesenchymal stem cells and enrichment by tissue-engineering was carried out, which were combined with demineralized allograft obtaining OCG. According to preoperative planning, scaphoidectomy and 4-corner arthrodesis (capitate-lunate and triquetrum-hamatum) using OCG was performed. Remote imaging and clinical examinations showed a satisfactory outcome. The patient completely got rid of pain and began to work again. Conclusion. The use of osteo-cellular graft in arthrodesis of wrist instability is a safe method with good results, the clinical study of this topic is imperative and needs to be researched further

The use of autotransplanted and homotransplanted septal cartilage in rhinoplasty and rhinoseptoplasty surgeries

Background. Surgical interventions for nasal reshaping, such as rhinoplasty and rhinoseptoplasty, have gained significant popularity among the population. Currently, these procedures are increasingly performed using both autotransplants and homotransplants. These surgical procedures are now enhanced through the use of advanced surgical techniques, specialized equipment, and high- performance instruments. Rhinoplasty surgeons have embraced a modern approach, abandoning traditional methods of dorsum nasi bone resection with chisel and hammer. Instead, a piezotome is used to perform median and lateral osteotomies, allowing for controlled fracturing of nasal bones along the greenstick fracture lines to obtain mobile fragments without displacement, and adjusting only the insertion angle. These aspects are crucial moments that previously presented multiple difficulties for surgeons. In many cases, it is necessary to fill depressions or tissue deficiencies on the nasal pyramid or adjust the position of the nasal tip using cartilaginous tissues. In such cases, nasal septal cartilage is a valuable resource. Rhinoplasty surgeons prefer to use the patient's own nasal septal cartilage whenever possible, but it is not always sufficient or may be absent, especially after previous nasal septal surgeries. In these cases, rib cartilage can be used, but some patients may refuse its harvesting or there may be contraindications. Consequently, the question arises regarding the use of homotransplanted nasal septal cartilage.This technique is well-known and successfully used by rhinoplasty surgeons. To benefit from homotransplanted cartilage, collaboration with a specialized tissue bank for human tissue transplants is necessary. The aim of the study. Is to conduct comprehensive literature studies regarding the use of autotransplanted and homotransplanted nasal septal cartilage in rhinoplasty and rhinoseptoplasty surgeries. Materials and methods. In the analysis process, a total of 50 sources of information were evaluated, including those available on medical platforms such as Medlife, PubMed, Google Scholar, and ResearchGate. Among the highly relevant sources, several were highlighted, considered significant for this research domain, providing varied and detailed perspectives on the use of nasal septal cartilage in nasal aesthetic surgery and contributing to the comprehensive analysis of the subject. To achieve an advanced selection of bibliographic sources, several filters and criteria were applied. Full-text articles published in English and Russian between 2000 and 2024 were sought. After a preliminary analysis of the titles, original articles, editorials, and narrative, systematic, and meta- analysis synthesis articles were selected. These types of articles were chosen because they provide relevant information and contemporary concepts regarding the use of autotransplanted and homotransplanted nasal septal cartilage in rhinoplasty and rhinoseptoplasty surgeries. Additionally, a supplementary search was conducted in the bibliographic reference lists of the initially identified sources to find additional relevant publications not included in the consulted databases. Information from the publications included in the bibliography was gathered, classified, evaluated, and synthesized to highlight the main aspects of contemporary views on the practices mentioned in the field of using nasal septal cartilage in aesthetic and reconstructive nasal surgeries. This approach allowed for exhaustive and updated research in the field of rhinoplasty and rhinoseptoplasty. Results and discussions. According to the results obtained in these studies, in rhinoplasty and rhinoseptoplasty interventions, it was found that autotransplanted nasal septal cartilage was most commonly used, while homotransplanted cartilage, collected from other patients, and previously preserved at a human tissue bank for transplantation, was used less frequently. Overall, the results were promising, with good integration and revitalization observed in both autotransplants and homotransplants. Conclusions. The use of transplants, both autotransplants and homotransplants, represents the most efficient and commonly used method in rhinoplasty and rhinoseptoplasty surgeries. In rhinoplasty and rhinoseptoplasty surgeries, it was found that nasal septal cartilage is most frequently used compared to other types of transplants, such as auricular cartilage or costal cartilage. These transplants have the advantage of not being resorbed, maintaining their shape over time, and not causing inflammatory or allergic reactions, contributing to the success and durability of surgical interventions in these areas

Hepatic veins in anatomical-surgical aspect

Background. Currently, complex liver pathology has imposed an increased need for surgical interventions at this level, which has required a detailed knowledge of hepatic blood circulation. An important place in this study belongs to the efferent venous circulation. Under normal conditions, the liver accumulates about 20% of the circulating blood volume and directs up to 1,200 ml of blood per minute into the inferior vena cava, which represents 50% of the breast volume returned through this vein. The advances made lately in knowing the anatomical distribution of the components of the hepatic, arterial and venous vascular tree have allowed a systematization of knowledge in the field of liver segmentation.The purpose of the present paper is to study the anatomical and surgical peculiarities of hepatic veins. Material and methods. To establish the morphology of hepatic veins, the study was performed on a number of 11 macroscopic liver preparations. Macropreparations were taken from cadavers of both sexes who died at different ages, in which no diseases of the hilar or cavale area of the liver. As working methods were used: plastic injection, which has solvent dust and green, yellow, blue and red paint, and corrosion step in hydrochloric acid solution. Results. The trunks of the hepatic veins in all given cases are located intraorganically and flow into the inferior vena cava in its subdiaphragmatic portion. Depending on the size of the veins, large hepatic veins with a diameter of 7-18 mm and small diameters of 2-6 mm can be highlighted. The number of hepatic veins flowing into the inferior vena cava is variable. Conclusions. The casts of the venous elements of the liver, obtained by polychrome injection and corrosion are very informative