APPROACHING DEPRESSION IN FAMILY DOCTOR PRACTICE

Depression is a common condition, especially among people suffering from chronic diseases. Some people with depression do not realize that they suffer from this condition and therefore do not seek professional help. The family doctor is the first to come in contact with these patients, and he is the one who monitors their progress. The attitude of the family doctor to depression can influence both the attitude of the patient to depression and his attitude toward treament

Epigenetica şi determinismul bolilor nutriţionale

Universitatea de Medicină şi Farmacie Carol Davila, Bucureşti, Institutul Naţional pentru Sănătatea Mamei şi Copilului Alessandrescu-Rusescu, Bucureşti, Universitatea Bioterra, Bucureşti, Universitatea Ovidius, Constanţa, cabinet medical individual, Al IV-lea Congres al medicilor de familie din Republica Moldova cu participare internaţională 16-17 mai 2018 Chișinău, Republica MoldovaPrevenirea apariţiei bolilor, prevenţia primară, se extinde – pe lângă conceptul de promovare a sănătăţii – şi asupra perioadei prenatale, când au loc procesele de creştere şi diferenţiere, asociate cu o serie de posibile modificări epigenetice la nivelul fătului, cu răsunet asupra patologiei ulterioare a viitorului adult. Factorii de mediu, prin intermediul epigeneticii, pot predispune la apariţia unor boli nutriţionale. Mecanismele principale implicate sunt reprezentate de metilarea ADN, acetilarea şi metilarea histonelor, remodelarea cromatinei şi inactivarea ARNm. Uneori mecanismele epigenetice se întrepătrund cu cele genetice: se blochează anumite gene patogene sau determină hiperactivitatea unor gene normale, care sunt implicate astfel în apariţia diferitelor boli [1]. Legătura stabilită între mamă şi copil nu este numai una afectivă, comportamentul matern se reflectă şi în sănătatea şi dezvoltarea ulterioară a copilului, încă din perioada preconcepţională. Modificarea comportamentului alimentar prin creşterea consumului de glucide, prin alimentaţie hipercalorică, sedentarismul, fumatul sau expunerea la diferite noxe a viitoarei mame determină apariţia obezităţii şi a diferitelor tulburări metabolice nu doar la mamă, dar şi la viitorii copii [2]. Greutatea părinţilor în momentul concepţiei, precum şi existenţa unor boli cronice ca, de exemplu, diabetul zaharat de tip II, obezitatea, dislipidemia sau maladiile cardiovasculare în antecedentele eredocolaterale ale părinţilor condiţionează patologia nutriţională a viitorului copil. Dacă expunerea la diferiţi factori de risc are loc în anumite perioade ale evoluţiei, denumite „ferestre epigenetice”, efectele asupra fenotipului se vor manifesta la viitorul copil în diferite etape ale vieţii. Influenţa timpurie a epigeneticii determină starea de sănătate sau de boală a individului şi a urmaşilor lui [3]. În primele 20 de zile are loc prima fereastră epigenetică – expresia specifică, aleatoare a genelor de la cei doi genitori – genomic imprinting, cu efect asupra dezvoltării fetale, determinând apariţia tulburărilor neurologice, de dezvoltare sau metabolice. Al doilea moment important al modificărilor epigenetice este în perioada intrauterină, sub acţiunea elementelor lichidului amniotic (toxice, matale grele). Pe lângă această perioadă sensibilă, numită „perioada primelor 1000 de zile din momentul concepţiei”, se mai descriu ferestre epigenetice la pubertate sau menopauză. Fiecare boală cronică are propria ei fereastră epigenetică. În timpul perioadei de adult, factorii de risc acţionează pe gene sensibilizate anterior de factorii epigenetici implicaţi în primele ferestre epigenetice. Mecanismele epigenetice au anumite limite, nevoi şi sensibilităţi în diferite etape ale vieţii [4]. Există tot mai multe dovezi că obezitatea şi bolile metabolice care apar mai târziu au ca punct de plecare o primă expunere la nutrimente inadecvate înainte de naştere sau în copilăria timpurie. În perioada intrauterină, o alimentaţie inadecvată predispune la naşterea unor copii cu risc crescut de a dezvolta obezitate, ca urmare a activării genelor obezităţii sub acţiunea factorilor epigenetici încă din perioada de dezvoltare intrauterină [2]. Studiile pe animale au arătat transmiterea transgeneraţională a acestor modificări epigenetice, determinate de expunerea inadecvată la anumite nutrimente [5]. În scopul evaluării clinice a acestor influenţe, am monitorizat 78 de copii cu exces ponderal (39 fete, 39 băieţi), analizând antecedentele eredocolaterale comparativ cu un lot de 78 de copii normoponderali, aflaţi în evidenţele cabinetului de medicină de familie în perioada 2013-2015. Vârsta medie a întregului lot a fost de 11,6±04 ani (6–18 ani), în lotul copiilor cu exces ponderal vârsta medie a fost de 12,6±03 ani versus 11,6±03 ani în lotul celor normoponderali. S-a constatat ca prezenţa în antecedentele eredocolaterale a obezităţii reprezintă un factor de risc pentru apariţia obezităţii în copilărie, corelându-se pozitiv cu IMC (risc estimat de 1,26 (95% CI 0,9-1,7), precum şi prezenţa diabetului zaharat de tip II în antecedentele eredocolaterale creşte riscul apariţiei obezităţii la copii (riscul estimat 2,16 (95% CI 1,7-2,7). Toate aceste modificări au un grad de reversibilitate, astfel încât, dacă se intervine pe o anumită perioadă de timp prin revenirea la o alimentaţie echilibrată, factorii epigenetici vor acţiona prin inactivarea genelor ce predispun la obezitate, efectul fiind revenirea la normal a greutăţii urmaşilor. Dieta hiperlipidică determină hipermetilarea ADN-ului la nivelul genelor ce controlează activitatea celulelor adipoase şi a ţesutului muscular, determinând apariţia obezităţii. O dietă hipolipidică la pacienţii obezi determină hipometilarea ADN-ului la nivelul aceloraşi gene, având drept efect scăderea ponderală. Prin urmare, alimentaţia dezechilibrată şi obezitatea genitorilor pot predispune la obezitatea viitorilor descendenţi, încă din faza de preconcepţie

Management of macrovascular diabetic complications: a single-center case series analysis of consecutively attending patients in primary care

Introduction. The prevalence of diabetes mellitus is increasing, with type 2 diabetes (T2DM) being a major health priority for any public health system. Increased arterial stiffness in patients with diabetes will lead to the appearance of vascular complications. Increased arterial stiffness in patients with diabetes usually leads to vascular complications. Any earlier diagnosis of impaired macrovascular evidence may lead to improved outcomes in patient care. The objective of our study was to assess and evaluate the finger-toe pulse wave velocity (ftPWV), as a measure of arterial stiffness, in order to assist with early detection of macrovascular diabetic complications. Materials and Methods. The observational case series included 140 patients who are registered in a primary care office, of whom 73 were previously diagnosed with diabetes mellitus (study group). The age-matched non-diabetic group included 67 consecutive registered patients who visited the practice for other reasons. Results. The mean age of all patients was 51.42±11.57 years, with DM patients being with 4.5 years older than the non-DM patients (CI 95% and CI 95%). There was a significantly higher mean value of ftPWV in the DM group (p = 0.0039) although the study presented some limitations. Conclusions. The mean value of ftPWV was statistically significant higher in diabetic patients. The assessment of ftPWV is a non-invasive test, and the data can be used as a useful marker of vascular stiffness in primary care, thus providing an early diagnosis of macrovascular complications during the monitoring and care of the diabetic patient

Pregnancy implanted in the scar of caesarean section and the role of the general practitioner

The increase in the number of cesarean sections led to severe complications, such as the ectopic scar pregnancy and the morbidly adherent placenta. The incidence of scar pregnancy is 1/2000 of pregnancies, the more frequently associated with the higher the number of cesarean sections. These can cause severe bleeding, rupture of the uterus, bladder or digestive injury or maternal mortality. The general practitioner has an important role in the diagnosis and monitoring of these patients. He knows the patient's history, is asked in permanent by it and sometimes is in the situation of being the only one checking pregnancy. This work aims to review the diagnostic and monitoring criteria for ectopic scar pregnancy helpful to family physicians. Addressing all patients with a scarred uterus for early screening ultrasound may increase the rate of diagnosis. The family doctor is an essential partnership in monitoring these high risk cases

CONDYLOMATA ACUMINATA AND CANDIDA VULVOVAGINITIS DURING PREGNANCY – CURRENT FACTS AND THERAPEUTIC POSSIBILITIES

Condylomata acuminata during pregnancy represents genital, perineal and perianal hyperplasia as a result of infection with human papillomavirus during pregnancy. Candida vulvovaginitis is a symptomatic vaginitis (inflammation of the vagina and / or vulva) caused by Candida infection, with 10% of women being asymptomatic. These diseases present some particularities and therapeutical problems during pregnancy

New oral anticoagulants and their reversal agents

Atrial fibrillation is a commonly encountered pathology in medical practice, and its prevalence has shown a continuous rise over the past years. Atrial fibrillation has a significant impact on patients' quality of life, not only due to the standard anticoagulant treatment with vitamin K antagonists that require close monitoring and dose adjustment, but also due to the fragile equilibrium between hemorrhagic and thrombotic risks. The introduction of new oral anticoagulants (NOACs) in the treatment guidelines for atrial fibrillation has improved the quality of life, as NOACs do not require close monitoring or dose adjustments. However, even if the safety profile of the NOACs regarding the hemorrhagic risk is superior to vitamin K antagonists, the problem raised by an unexpected hemorrhage (e.g. severe hemorrhage after an accident) and the need for efficient hemostasis in a chronic anticoagulated patient has remained unsolved. To find a solution for this problem, reversal agents for NOACs have been developed and tested, and two of them, idarucizumab and andexanet-alpha, have already been approved by the FDA, thus making NOACs increasingly appealing as a choice of anticoagulation treatment

Translation of the Fugl-Meyer assessment into Romanian: Transcultural and semantic-linguistic adaptations and clinical validation

PurposeThe Fugl-Meyer Assessment (FMA) scale, which is widely used and highly recommended, is an appropriate tool for evaluating poststroke sensorimotor and other possible somatic deficits. It is also well-suited for capturing a dynamic rehabilitation process. The aim of this study was to first translate the entire sensorimotor FMA scale into Romanian using the transcultural and semantic-linguistic adaptations of its official afferent protocols and to then validate it using the preliminary clinical evaluation of inter- and intra-rater reliability and relevant concurrent validity.MethodsThrough three main steps, we completed a standardized procedure for translating FMA's official afferent evaluation protocols into Romanian and their transcultural and semantic-linguistic adaptation for both the upper and lower extremities. For relevant clinical validation, we evaluated 10 patients after a stroke two times: on days 1 and 2. All patients were evaluated simultaneously by two kinesi-physiotherapists (generically referred to as KFT1 and KFT2) over the course of 2 consecutive days, taking turns in the roles of an examiner and observer, and vice versa (inter-rater). Two scores were therefore obtained and compared for the same patient, i.e., being afferent to an inter-rater assay by comparing the assessment outcomes obtained by the two kinesi-physiotherapists, in between, and respectively, to the intra-rater assay: based on the evaluations of the same kinesi-physiotherapist, in two consecutive days, using a rank-based method (Svensson) for statistical analysis. We also compared our final Romanian version of FMA's official protocols for concurrent validity (Spearman's rank correlation statistical method) to both of the widely available assessment instruments: the Barthel Index (BI) and the modified Rankin scale (mRS).ResultsSvensson's method confirmed overall good inter- and intra-rater results for the main parts of the final Romanian version of FMA's evaluation protocols, regarding the percentage of agreement (≥80% on average) and for disagreement: relative position [RP; values outside the interval of (−0.1, 0.1) in only two measurements out of the 56 comparisons we did], relative concentration [RC; values outside the interval of (−0.1, 0.1) in only nine measurements out of the same 56 comparisons done], and relative rank variation [RV; all values within an interval of (0, 0.1) in only five measurements out of the 56 comparisons done]. High correlation values were obtained between the final Romanian version of FMA's evaluation protocols and the BI (ρ = 0.9167; p = 0.0002) for FMA–upper extremity (FMA-UE) total A-D (motor function) with ρ = 0.6319 and for FMA-lower extremity (FMA-LE) total E-F (motor function) with p = 0.0499, and close to the limit, with the mRS (ρ = −0.5937; p = 0.0704) for FMA-UE total A-D (motor function) and (ρ = −0.6615; p = 0.0372) for FMA-LE total E-F (motor function).ConclusionsThe final Romanian version of FMA's official evaluation protocols showed good preliminary reliability and validity, which could be thus recommended for use and expected to help improve the standardization of this assessment scale for patients after a stroke in Romania. Furthermore, this endeavor could be added to similar international translation and cross-cultural adaptations, thereby facilitating a more appropriate comparison of the evaluation and outcomes in the management of stroke worldwide

LYSYL OXIDASE (LOX) – A FUTURE NEW ALLY ON THE STAGE OF THE FIGHT AGAINST CANCER

The local extracellular matrix (EM) remodelling is considered one of the critical events in metastasis, both at primary and the secondary sites. One of the main actors on the EM remodelling is lysyl oxidase (LOX). In this connection, the aim of this paper is to bring to light a possible future systemic (and why not, salivary) biomarker of the metastatic process. LOX best-characterized role is in the EM remodelling by oxidative deamination of collagens and elastin peptidyl lysine residues, in order to facilitate covalent cross-linking. The LOX family members seem to play extremely important roles in these extracellular matrix interactions. Future research is needed to confirm whether simple LOX blocking or its downstream actions control could be regarded as target of preventive treatment in patients at a higher risk of metastasis. This is how the portrait of the future biomarker of LOX is becoming more and more outlined

VITAMIN D DEFICIENCY AND INSULIN RESISTANCE

Vitamin D or cholecalciferol is active in the human body after two hydroxylation reactions. Once activated, it is involved in bone metabolism, but can also influence other biological processes such as cell growth and proliferation or angiogenesis. Studies conducted so far suggest a link between vitamin D deficiency and insulin resistance. The purpose of this review is to analyze the effects of hypovitaminosis D as well as the administration of vitamin D rich supplements on the insulin resistance provided by the specialized literature

HYPERLEPTINEMIA AND CARDIOVASCULAR SYSTEM

Leptin is the satiety hormone, synthesized in the adipose tissue that reduces food intake, being involved in glucose and lipid metabolism. Hyperleptinemia correlates with obesity and represents a risk factor in the pathology of the cardiovascular system. Increased concentrations of leptin have been observed in patients with hypertension or atherosclerosis. In vitro studies suggest the angiogenic role of leptin. The purpose of this review is to present the metabolic effects of hyperleptinemia in the cardiovascular system