Cardiovascular Safety of Anti-TNF and Non-TNF Biological Therapy in Patients with Rheumatoid Arthritis

The association between cumulative inflammatory burden and increased cardiovascular (CV) risk in patients with immune-mediated inflammatory rheumatic disorders, particularly rheumatoid arthritis (RA), is widely recognized. Furthermore, the complex and dynamic interrelation between traditional cardiovascular risk factors, systemic inflammation, early accelerated atherosclerosis, and RA-related factors remains a challenge in routine practice. New European League Against Rheumatism (EULAR) 2016 recommendations have recently highlighted three key trends in cardiovascular risk assessment and management in patients with RA including optimal disease control (early diagnosis, treat-to-target strategy with the dynamic use of antirheumatic synthetic and biologic drugs) and non-pharmacological as well as pharmacological management of risk factors. The present chapter will emphasize excessive cardiovascular morbidity in RA, the optimal strategy to identify and stratify the cardiovascular risk profile, the prime selection of medication from the whole spectrum of non-biologic and biologic (TNF and non-TNF) drugs according to their cardiotoxicity

Rheumatoid Arthritis and Periodontal Disease: A Complex Interplay

Recent advances in understanding the dynamic pathways involved in the pathogenesis of rheumatoid arthritis have emphasized the pivotal role of pro-inflammatory cytokines, inflammatory cells, endothelial cell activation and matrix degradation, acting in a genetically predisposed environment. On the other hand, there are significant amounts of data highlighting the potential role of bacteria (leading periodonthopatic pathogen Porfiromonas gingivalis) in promoting different types of arthritis, as well as the influence of periodontis (an infectious-inflammatory condition) as etiological or modulating factor in different pathologies, including cardio-vascular disorders, diabetes, respiratory disease and inflammatory rheumatic disorders (such as rheumatoid arthritis, ankylosing spondylitis and lupus). The present chapter deals with the possible association between rheumatoid arthritis and periodontitis as entities with common pathological events

BAFF System in Rheumatoid Arthritis: from Pathobiology to Therapeutic Targets

Recent advances in understanding the multifaceted pathobiology of rheumatoid arthritis have highlighted the pivotal role and continuing crosstalk between activated immune cells, pro-inflammatory cytokines, and matrix-degrading mediators, promoting chronic inflammation as well as irreversible tissue damage within an autoimmune background. B cells are widely recognized as leading players in immune-mediated pathology based on their ability to produce not only different patterns of autoantibodies and driving cytokine synthesis but also as independent antigen-presenting cells and by modulating the specific activation of T cells. Overwhelming evidence emphasized the role of BAFF, a B-cell-activating factor, and BAFF receptors (TACI, BCMA, BAFF-R) in promoting B-cell homeostasis, proliferation, and survival under normal and autoimmune systemic disorders. We systematically reviewed data from literature focusing on BAFF, its homolog molecule APRIL, and BAFF-binding receptors biology, dysregulation of BAFF/BAFF receptor signaling in autoimmune settings, and current status of targeting BAFF/BAFF receptor pathway for rheumatoid arthritis

Colposcopic Assessment Among Women with Lower Genital Tract Pathology

A broad spectrum of conditions classically requires a colposcopic assessment for either diagnostic or treatment means, including atypical changes in the cervix-vagina and vulva, abnormal Pap tests, cervicitis, polyps, cervical warts, genital warts, and bleeding. Although the procedure is commonly considered as criteria for the management of cervical cancer, the sensitivity of colposcopy is quite limited as its ability to discriminate among dysplasia and microinvasive carcinoma is difficult. Most professional societies and international health organizations have already released guidelines and recommendation for the management for woman with abnormal cervical pathology (e.g., cervical intraepithelial neoplasia and cervical cancer); only women with positive human papillomavirus (HPV) tests, low-grade squamous intraepithelial lesion (LSIL), or severe cytology have clear indication for referral to a colposcopic evaluation. While most guidelines recommend colposcopy for any abnormal cytology or any positive HPV test, others apply only for woman with two consecutive unsatisfactory Pap tests or for those with some abnormalities. In conclusion, cervical cancer risk remains high; thus, the potential benefit of colposcopy examination should be balanced against the risk

Psychosocial Aspects of Colposcopic Assessment: Perspectives and Strategies for Physicians

The purpose of this work is to determine perspectives, misconceptions, psychology adjustments and useful strategies of women living with dilemmas about their malignant lesions which can be detected through the colposcopy. Colposcopic assessment following abnormal Pap test has resulted in a long list of concerns: fear of having cancer, periodic obligations related to follow-up, balancing treatment of premalignant disease with quality of life, pain or discomfort and long-term impact on their families or limited social support. How prepared are they to adapt to their diagnosis? New diagnosis results in patient not being able to listen well or to understand her medical situation. The success of the outcome and procedure takes time to deduce the concerns she has regarding her diagnosis, treatment and appropriate follow-up. Several physicians endorse a wide range of barriers with respect to diagnosis and management of the disease: organizational or patient issues. Furthermore, patient appears to be important for the effective treatment than to identify and assess psychosocial problems among women diagnosed with cancer. In conclusion, physician provides effective treatment, but fails to address psychosocial issues associated with the illness. It is necessary to define the condition more clearly by studying patients and their psychosocial problems

Low grade endometrial stromal sarcoma – case study

Scopul lucrării. Prezentarea unui caz complex de diagnostic diferențiat și tratament al sarcoamelor endometriale de stromale de grad scăzut SESGS. Materiale și metode. Pacienta 42 ani a fost supusă mai multor chiuretaje endometriale pe motiv de polipi endometriali, ultimul în 2017. A fost monitorizată, tratată conservativ cu progestine, anticoncepționale orale. Clinic s-a agravat incluzând simptome digestive și urinare. La IRM din 03.10.2020 se constată: formațiuni policamerale solid-chistice în ovare bilateral (82x60x54 mm pe dreapta, 56x116x67 mm pe stânga) paternul imagistic suspect. Endometrul – formațiune neomogenă 24x38 mm, restricția difuziei și acumularea lentă a contrastului. Imunohistochimia stabilește diagnosticul SESGS în urma reevaluării raclajului histologic endometrial efectuat în 2017. Pe 26.10.2020: Histerectomie totală abdominală cu salpingo-ovarectomie bilaterală cu disecția ganglionilor limfatici regionali cu omentectomie supra- și infracolică + rezecție anterioară de rect cu anastomozare. Rezultate. A fost obținut un rezultat citoreductiv optim - tumoare restantă - zero. Hemoragii 190 ml,zile-pat 4. Stadiul pT3b (FIGO IIIB); pN0, LV1; R0. Postoperator pacienta a urmat radioterapie externă/internă și hormonoterapie. Follow up imagistic 40 luni – fără recidive. Concluzii. Histerectomia cu anexectomie bilaterală ramâne prima linie de tratament pentru SEGS. Beneficiile limfadenectomiei, operațiilor citoreductive sunt neclare. Examenul histopatologic poate fi neclar; imunohistochimia și IRM sunt necesare pentru a completa ecografia uzuală și histologia.Aim of study. Complex case of differential diagnosis and treatment of low-grade SESGS endometrial stromal sarcoma. Materials and methods. A 42-year-old patient underwent several endometrial curettages due to endometrial polyps, the last one in 2017. She was treated conservatively with progestins /contraceptives. At the time of addressing MedPark International Hospital, the clinic worsened, including digestive/urinary symptoms. The MRI of 03.10.2020 shows: Polycameral solid-cystic formations in bilateral ovaries (82x60x54 mm on the right, 56x116x67 mm on the left) cancer pattern suspicious. Endometrium – inhomogeneous formation 24x38 mm, diffusion restriction and slow contrast accumulation; the histological block performed in 2017 reevaluated, subjected to immunohistochemistry. The diagnosis of SESGS was established. On 26.10.2020 the patient underwent total abdominal hysterectomy with bilateral salpingo-ovariectomy, regional lymph node dissection, supra- and infracolic omentectomy, anterior rectal resection with anastomosis. Results. Cytoreductive result: no residual tumor. Blood loss 190 ml,stay days 4. (pT3b stage, FIGO IIIB; pN0, LV1; R0). Postoperatively, adjuvant external/endovaginal radiotherapy, hormone therapy. On an imagistic follow-up after 40 months there were no signs of tumour relapse. Conclusions. Total hysterectomy and adnexectomy is the first line treatment of SEGS. The benefit of lymphadenectomy and cytoreductive surgery is unclear. Histopathology report, immunohistochemistry, MRI can be avoided in favor of routine ultrasonography. Histopathology report if unclear has to be completed by immunohistochemistry and MRI added to routine ultrasonography

Challenges in the Delivery Room: Integrated Analysis of Biomarkers Predicting Complications in Lupus Pregnancy

Pregnancy in autoimmune rheumatic diseases remains a real challenge in clinical practice due to complex interplay between disease activity, pregnancy and drugs, and account for potential influence of pregnancy on rheumatic condition and the impact of disease on pregnancy outcomes. Indeed, innovative and successful therapies have dramatically improved the quality of life in immune-mediated rheumatic conditions and, subsequently, allowed more patients of reproductive age to plan a pregnancy/to conceive. The purpose of this chapter is to discuss emerging data about the interaction of pregnancy and systemic erythematosus lupus (SLE) focusing on modulation of the immune system by pregnancy, pregnancy outcomes in women with active lupus, biomarkers of adverse pregnancy outcomes (APO) including predictors of pre-eclampsia, predictors of obstetric complications in SLE, the influence of autoantibodies on fetal health, and, finally, evidence about rheumatologic and obstetric follow-up. There are still unmet needs in this new field of reproductive rheumatology and it becomes crucial that researchers, physicians (rheumatologists, specialists in maternofetal medicine, obstetricians) and midwifes share their knowledge and expertise in counseling women with SLE wishing to conceive, assisting pregnancy and managing different issues related to APO as well as drug optimization in preconception, during pregnancy and postpartum period

Stage IV advanced endometrial cancer - case study

Scopul lucrării. Caz clinic ce confirmă că cancerul endometrial este o maladie potențial-operabilă în orice stadiu clinic. Materiale și metode. Pacienta 71 ani, diagnosticată clinic, paraclinic și prin stadializare chirurgicală. Histologia preoperator - adenocarcinom endometrial moderat-diferențiat G2. ECOG 0-1. Indicele masei corporale > 30. Pacienta a fost operată în cadrul Spitalului Internațional MedPark, Chișinău, Moldova: Histerectomie totală, anexectomie bilaterală, omentectomie supra- și infracolică, limfadenectomie pelvină și paraaortică, biopsie peritoneală. Tratament adjuvant: radioterapie externă/brahiterapie, 6 cure polichimioterapie carboplatin/taxane. Rezultate. Histologie postoperator - adenocarcinom mixt (endometrioid 60% și seros de grad înalt G3 40%), infiltrează tot miometrul la seroasă, trecere pe stroma cervixului, trompele uterine; afectează metastatic 24 din 55 ganglioni limfatici pelvini și paraaortali înlăturați; metastaze în oment și peritoneul parietocolic drept (M1). Încadrare TNM: pT3a (FIGO IVB), pN2a, LV1, Pn1, R0, M1. Concluzii. Supraviețuirea la 5 ani a cancerului endometrial în stadiile avansate este de 20%. Follow –up imagistic 34 luni – date de recidivare a patologiei nu se atestă. Deși tratamentul chimio/radioterapic este indicat în majoritatea cazurilor de cancer endometrial avansat, intervenția chirurgicală efectuată de o echipă multidisciplinară calificată într-un centru oncologic de specialitate este o opțiune dezirabilă de tratament, urmată de alte tratamente specifice.Aim of study. Case confirming that advanced endometrial cancer is a potentially operable disease in any stage. Materials and methods. 71 years old female with advanced endometrial cancer, clinically and surgically diagnosed. Preoperative histology - G2 moderately-differentiated endometrial adenocarcinoma. ECOG 0-1; body mass index > 30. Total hysterectomy with bilateral adnexectomy, omentectomy, pelvic and para-aortic lymphadenectomy, peritoneal biopsy performed in MedPark International Hospital, Chisinau, Moldova. Adjuvant treatment: external radiotherapy (DS 46Gy) and brachytherapy (DS 15Gy), 6 courses of carboplatin taxane polychemotherapy. Results. According to the postoperative histological result, a mixed adenocarcinoma was identified (endometrioid 60% and high-grade serous G3 40%) infiltrating the entire myometrium up to the serous and crossing the stroma of the cervix, fallopian tubes; metastatic 24 of 55 removed pelvic and para-aortic lymph nodes; metastases in omentum, right parietocolic peritoneum (M1). TNM classification: pT3a (FIGO IVB), pN2a, LV1, Pn1, R0, M1. Conclusions. The 5-year survival of patients with endometrial cancer in advanced stages is 72% in localized and 20% in metastasis, respectively. Imagistic Follow-up at 34 months – no recurrence of the pathology. Although chemotherapy/radiotherapy is indicated in most cases of advanced endometrial cancer, surgery performed by a qualified multidisciplinary team in a specialist oncology center is a desirable treatment option, followed by other specific treatments