Spontaneous Atraumatic Rupture of a Liver Hemangioma as a Rare Cause of Syncope.

BACKGROUND Syncope is common in emergency medicine, but only a minority of syncopes is caused by hemorrhage. Liver hemangioma is the most frequent benign liver tumor, and they rarely lead to symptoms or complications. Case Presentation. We describe the case of an 81-year-old man with hemorrhagic shock due to an atraumatic rupture of a hepatic hemangioma while on oral anticoagulation. The patient presented to the emergency department after three episodes of syncope before admission, nausea, vomiting, mild epigastric abdominal pain, but with clinical signs of peritonitis. On admission, the patient had a mild tachycardia with a heart rate of 107/min and a blood pressure of 102/83 mmHg. Initial hemoglobin was 122 g/L, and lactate was slightly elevated (2.5 mmol/L). Bedside sonography revealed free intraabdominal fluid. The subsequent computed tomography showed a ruptured hemangioma of the liver with ongoing hemorrhage. After the CT scan, the patient became increasingly tachycardic and the blood pressure dropped to 94/62 mmHg. After administration of blood products and intravenous fluids, the patient responded with improved hemodynamics and was transferred to angiology for emergency embolization. After the intervention, the patient spent two days in the intermediate care unit and was discharged after 10 days of hospitalization. CONCLUSION Atraumatic rupture of a hemangioma with consecutive hemorrhagic shock is extremely rare. In selected cases of spontaneously ruptured hemangiomas with hemoperitoneum, endovascular embolization can be an alternative to surgery. Furthermore, this case emphasizes the importance of sonographic examination as an additional diagnostic tool in syncope and concomitant abdominal pain

Surgical treatment of abdominal aortic aneurisms

Secția Chirurgie Vasculară IMSP SCR, Al XI-lea Congres al Asociației Chirurgilor „Nicolae Anestiadi” din Republica Moldova și cea de-a XXXIII-a Reuniune a Chirurgilor din Moldova „Iacomi-Răzeșu” 27-30 septembrie 2011În secția chirurgie vasculară a IMSP SCR, pe parcursul anilor 1988-2010 au fost operați 224 pacienți cu anevrisme ale aortei abdominale. SCa criteriu diagnostic pentru anevrism s-a considerat dilatarea aortei abdominale cu două diametre şi mai mult. Vârsta pacienților a fost cuprinsă între 15 şi 89 ani. Din totalul de pacienți 79,5%(178) au fost bărbați şi 20,5%(46) femei. La 18,75%(42) pacienți anevrismele au fost complicate prin ruptură completă sau incompletă, fiind operați în regim de urgență imediată. Etiologia a fost: ateroscleroza - 94,65% (212), aortoarteriita nespecifică - 3,57% (8), sindromul Marfan - 1,78% (4). Diagnosticul a fost stabilit clinic, ultrasonografic, prin Duplex vascular, angio-CT, aortografie, RMN. În 3 cazuri (1,34%) anevrismul implica şi arterele renale. Doi pacienți, neincluşi în studiu, au decedat preoperator prin hemoragie masivă cauzată de ruptura spontană a anevrismului în duoden şi cavitatea abdominală liberă. Toți pacienții au fost supuşi rezecției anevrismului aortal cu protezare aorto-distală (aortală, biiliacă, ilio-femurală, bifemurală), iar în 3 cazuri cu replantarea arterelor renale şi viscerale. Mortalitatea în anevrismele rupte a fost 57% (24), iar în cele complicate - 8% (18). Concluzii: pe parcursul ultimilor 5 ani a crescut ponderea pacienților cu anevrisme simptomatice sau deja complicate prin ruptură, astfel că toți pacienții cu factori de risc trecuți de 50 ani trebuie supuşi screening-ului prin USG sau Dopplerografie. Mortalitatea postoperatorie în anevrismele rupte s-a micşorat cu 13 %, iar în cele operate programat cu 7,55%. Implimentarea metodei endovasculare ar permite reducerea substanțială a acestui indice, mai ales în cazul anevrismelor complicate prin ruptură.During the period of 1988 - 2010, 224 patients underwent surgery for abdominal aortic aneurisms. The main diagnostic criteria was dilatation of the abdominal aorta by two diameters and more. All patients were aged between 15 and 89. Of all patients 79,5% (178) were males and 20,5% (46) were female. In 18,75% (42) cases, a complete or incomplete rupture of the aneurisms occurred. These patients underwent urgent surgery. Etiology: atherosclerosis – 94,65% (212), nonspecific aortoarteritis – 3,57% (8), Marfan syndrome – 1,78% (4). The diagnosis was made by clinical findings, vascular Duplex scanning, angio-CT and MRI. In 3(1,34%) cases the aneurism involved the renal arteries. There were two lethal outcomes, one caused by spontaneous rupture of the aneurism in the duodenum and the second caused by rupture into the peritoneal cavity. These cases were not included in the study. All patients underwent aneurism resection with aortal –distal (aortic, biiliac, ilio-femural, bifemural) allografting, while in three cases reimplantation of the renal arteries was necessary. The mortality in cases of ruptured aneurisms consisted 57% (24), and in cases of uncomplicated aneurisms – 8% (18).Conclusions: During the last 5 years we observed a raise in the rate of symptomatic aneurisms, including those complicated with rupture. Aortic ultrasonography or dopplerography should be used as screening methods in all patients, with risk factors, that are aged 50 and more. Postoperative mortality in cases of ruptured aneurisms has decreased by 13%, while in cases of planned aneurism surgery by 7,55%. Implementation of endovascular techniques would reduce substantially these indices

Optimizing surgical techniques in extra-anatomical ilio-femoral bypasses

Scopul lucrării. Bypass-ul extraanatomic ilio-femural crossover este o procedura chirurgicala utilizată pentru revascularizarea segmentului aorto-femural, când intervențiile endovasculare nu sunt posibile, iar aplicarea unui bypass aorto sau ilio-femural este dificilă sau chiar imposibilă din cauza condițiilor tehnice sau a stării pacientului. Scopul este studierea rezultatelor precoce și tardive pentru favorizarea unor schimbări și implementarea unor gesturi tehnice în aplicarea bypass-urilor crossover ilio-femural, pentru a crea o geometrie cât mai fiziologică ce poate oferi o soluție durabilă pe termen lung. Materiale și metode. Pe parcursul anilor 2001-2022 au fost efectuate 142 bypass-uri crossover ilio-femurale. Rezultate. În perioada postoperatorie a fost un singur deces și s-au efectuat 3 amputații. Au fost analizate duplex scanările și CT angiografiile în primele 12 luni postoperatorii, pentru aprecierea altor leziuni aterosclerotice, care ar necesita revascularizare deschisă s-au endovasculară atît in bazinul recipient cât și cel donator. Totodată, a fost apreciata poziția și forma bypass-ului ce a dus la folosirea ulterioară a unor noi procedee tehnice ce diferă de cele descrise anterior. Concluzii. Optimizarea tehnicilor chirurgicale creând o geometrie cât mai fiziologică, excluderea maximală a angulărilor stenozante ale grefei poate oferi bypass-ului extraanatomic crossover ilio-femural o durabilitate îndelungată. Acest lucru poate favoriza creșterea frecvenței indicațiilor la folosirea bypass-urilor crossover ilio-femural.Aim of study. The extra-anatomic ilio-femoral crossover bypass is a surgical procedure used for revascularizing the aorto-femoral segment when endovascular interventions are not possible, and when applying an aorto- or ilio-femoral bypass is difficult or even impossible due to technical conditions or the patient's condition. The aim was to study the early and late outcomes to promote changes and implement technical gestures in the application of ilio-femoral crossover bypasses, aiming to create a more physiological geometry that can provide a durable long-term solution. Materials and methods. Between 2001 and 2022, a total of 142 ilio-femoral crossover bypasses were performed. Results. There was one death and three amputations in the postoperative period. Duplex scans and CT angiography were analyzed in the first 12 months postoperatively to assess other atherosclerotic lesions that would require open or endovascular revascularization in both the recipient and donor areas. Additionally, the position and shape of the bypass were evaluated, leading to the subsequent use of new technical procedures that differ from those previously described. Conclusions. Optimizing surgical techniques by creating a more physiological geometry and minimizing stenotic angles of the graft can provide the extra-anatomic ilio-femoral crossover bypass with long-lasting durability. This may increase the frequency of indications for using ilio-femoral crossover bypasses

Results and prospects of the National Immunization Program in Moldova

The analysis of the incidence of some infectious diseases, included in the National Immunization Program (NIP) in the period of 2003-2012 compared with the period of 1993-2002 and the data on the level of vaccination coverage of target age groups of children are presented. Thanks to the multiannual NIP realization, the epidemiological situation in Moldova concerning the infectious diseases that can be controlled by vaccination remains favorable. However, in the recent years the level of vaccination coverage has been reduced in connection with the numerous vaccination refusals, due to the erroneous information in the media and internet supported by some religious groups. One of the main objectives of the NIP is the vaccination coverage of 95% or more percent of the population at the national and local levels. The analysis has showed that from 16 positions it has not been achieved for six that is 37.5%. Even in the cases where the national level of vaccination coverage has been equal or more than 95%, in some areas, within 11.4-27.3%, this objective has not been achieved. All the above requires that the medical workers, involved in the NIP implementation, should develop and realize the measures to increase the vaccination coverage

Data on the safety of immunizations included in the National Immunization Program in Moldova

The purpose of this article is epidemiological analysis of adverse events following immunization (AEFI) registered in the Republic of Moldova in 2007-2012 on the basis of registration forms. In total there were 534 AEFI, mostly reactions after BCG (409-76.6 ± 3.7%) compared to the DTP, Penta (104-19.5 ± 3.4%) and MMR (21-3.9 ± 1.7%). AEFI after the introduction of hepatitis B vaccine, OPV and Td for adults and adolescents have not been registered. After BCG most AEFI are lymphadenitis, 82.4 ± 3.8%, often in the first two months after vaccination, significantly higher after the first dose compared to the second. Other reactions were cold abscesses – 8.3 ± 2.7%, ulceration – 6.1 ± 2.4%, scars – 1.7 ± 1.2% and osteitis – 1.5 ± 1.2%, occurring more often after the second dose of vacсine. It should be stated improper introduction of BCG. The vast majority of AEFI after the DPT and the pentavalent vaccine are systemic reactions, 90.7 ± 5.6% compared to local, 9.3 ± 5.6%, p < 0001, and it is possible to state the underdiagnosis of local AEFI. The greatest number of AEFI after DTP and pentavalent vaccine occur within the first 1-10 hours, 78.5 ± 8.1%, often within 1-6 hours, 49.6 ± 9.8%. Thus, more active monitoring of vaccinated children should be carried out during this period of time. Surveillance system for AEFI requires standardization in reporting and harmonization of registration forms

Skin fragility with mottled pigmentation by transport protein Slac2-b anomaly

Epidermolysis bullosa (EB) caused by EXPH5 mutations, is an recently identified and extremely rare subtype. We describe a novel homozygous nonsense mutation in the EXPH5 gene in a 15-year-old woman. EXPH5 encodes the vesicle transport protein &amp;#39;synaptotagmin-like homologue lacking C2 domains B&amp;#39; (Slac2-b, also known as exophilin- 5) and is involved in epidermolysis bullosa simplex with cleavage in the basal cell layer. The phenotype of this case was characterized by mottled pigmentation (MP), which developed when the patient was ten years old. By means of electron microscopy image analysis, we propose a hypothesis for the pigmentary changes associated with Slac-2b anomaly. This patient that we have described is one of the oldest with EXPH5 mutations reported up to now, which possibly allowed for the &amp;#39;lateonset&amp;#39; MP.</p

Acute flaccid paralysis in the children free of poliomyelitis caused by the wild virus during the postcertification period in the Republic of Moldova

In 2002 the European Regional Certification Commission of the World Health Organization declared Europe a zone free of poliomyelitis caused by the wild virus. The postcertification program [4] provides identification, informing, epidemiological and laboratory investigation of each case of acute flaccid paralysis (AFP) with the subsequent establishing of the final diagnosis to globally complete the eradication of polio. From 2008 to 2012 in the Republic of Moldova 45 cases of the AFP in children were registred, from which 92 feces samples were collected and studied. All the identified poliomyelitis viruses had a vaccination nature. In this work the results of the monitoring of epidemiological and laboratory cases of AFP, including the people who were contacting those ones having this disease in the last 5 years (2008-2012), have been discribed. The isolation of the viral strains and their identification in the reaction of neutralization has been held in the cultures of the cells RD and L-20B received from WHO using standard specific immune serums against polio- and enteroviroses (Bilthoven, Netherlands) in the national laboratory of poliomyelitis and enteroviroses, which is a part of the European network of laboratories for the diagnosis of these diseases (the laboratory is accredited annually by the profile experts of WHO)

The characteristics of the completeness of the primary cycle of immunization for children aged 15-26 months in the Republic of Moldova

The article includes an analysis of the data on the primary cycle vaccination coverage (VC) of children aged 15-26 months (N 1341) with the vaccines in the framework of the National Immunization Program (NIP) from 34 localities of Moldova in accordance with the criteria recommended by the WHO. The values of the general VC and ones referring to the age of 12 months (MMR – 15 months) have been calculated as well as the proportion of children who have not completed the immunization program. The level of the general VC has been uneven, and it is the lowest in the city of Chisinau (MMR – 86.1 ± 3.0%, DPT – 90.0 ± 2.6%) compared with the other urban and rural areas. Nationwide, this figure for the most vaccines is at the level envisaged by NIP (≥ 95%), with the exception of the MMR and Hib vaccines, whose figures are 89.3 ± 1.7% and 68.7 ± 2.5% respectively. The analysis of the VC up to target age of 12 months shows that on many issues its level set by the NIP has not been reached, and there is a significant number of susceptible children that may contribute to the spread of infectious diseases when a source of infection emerges. A complex of organizational and methodical measures is needed for immunization strictly according to the national immunization schedule