The Safety Profile of Sodium-Glucose Cotransporter-2 Inhibitors and Glucagon-like Peptide 1 Receptor Agonists in the Standard of Care Treatment of Type 2 Diabetes Mellitus.

AIM: We evaluated the safety of sodium-glucose cotransporter-2 inhibitors (SGLT2i) and glucagon-like peptide 1 receptor agonists (GLP-1 RAs) for their use with other glucose-lowering drugs and drugs for the treatment of type 2 diabetes mellitus (T2DM), in a standard-of-care regimen with maximum tolerated doses, and, respectively, when compared with metformin. METHODS: We conducted a retrospective, observational study on 405 patients that were seen in the outpatient clinic of the N Paulescu National Institute for Diabetes Mellitus, Bucharest, Romania, in 2019. Their demographics, metabolic parameters, and medication safety were evaluated at three follow-up visits, from baseline, six months, and twelve months. RESULTS: Both SGLT-2is and GLP-1 RAs are safe regarding creatinine, eGFR, urea, GOT, and GPT upon the comparison of the data from the six- and twelve-month visits with the initial visit, and also the twelve-month visit with the six-month visit. Moreover, when comparing SGLT-2is and GLP-1 RAs with metformin, there are safety data only for urea. CONCLUSIONS: In this retrospective analysis, both SGLT-2is and GLP-1 RAs, when used in conjunction with other glucose-lowering, blood-pressure-lowering, and lipid-lowering medications, appeared to be safe for the management of T2DM.

The Cumulative Detrimental Effect of COVID-19 Pneumonia in a Patient with Myasthenic Crisis: A Case Report and Overview of the Literature.

BACKGROUND: As the COVID-19 pandemic reached its peak, it became unavoidable that patients with other risk factors for severe pulmonary impairment (such as neuromuscular illnesses) would become afflicted. While the subject of myasthenic crisis secondary to COVID-19 pneumonia represents an interesting topic in the literature, we could not find consistent data that include, as a novel therapeutic approach, both intravenous immunoglobulin and plasma exchange therapy for the treatment of these two concurrent diseases. CASE SUMMARY: A 69-year-old man with known seropositive generalized myasthenia gravis, hypertension, ischaemic heart disease, NYHA class II-III heart failure, cerebrovascular disease, and recurrent urinary tract infections, was admitted to the ICU for mixed acute respiratory failure, elevated serum lactate and liver function enzymes, and severe thrombocytopenia. A SARS-CoV-2 PCR test was positive, despite a previous COVID-19 pneumonia episode, 10 months prior to the current one. The patient had a recent ICU admission for a myasthenic crisis, which required non-invasive mechanical ventilation and intravenous immunoglobulin therapy. He received supportive therapy, as well as etiological (intravenous remdesivir, plasmapheresis and intravenous dexamethasone). Fifteen days after admission, the patient was transferred to the neurological ward, whence he left 20 days later, with no apparent sequelae. CONCLUSIONS: Subsequent intravenous immunoglobulins and plasma exchange therapy appear to be effective and safe in patients with simultaneous acute myasthenic episode and COVID-19 pneumonia.

What Is Different in Acute Hematologic Malignancy-Associated ARDS? An Overview of the Literature.

Background and Objectives: Acute hematologic malignancies are a group of heterogeneous blood diseases with a high mortality rate, mostly due to acute respiratory failure (ARF). Acute respiratory distress syndrome (ARDS) is one form of ARF which represents a challenging clinical condition. The paper aims to review current knowledge regarding the variable pathogenic mechanisms, as well as therapeutic options for ARDS in acute hematologic malignancy patients. Data collection: We provide an overview of ARDS in patients with acute hematologic malignancy, from an etiologic perspective. We searched databases such as PubMed or Google Scholar, including articles published until June 2022, using the following keywords: ARDS in hematologic malignancy, pneumonia in hematologic malignancy, drug-induced ARDS, leukostasis, pulmonary leukemic infiltration, pulmonary lysis syndrome, engraftment syndrome, diffuse alveolar hemorrhage, TRALI in hematologic malignancy, hematopoietic stem cell transplant ARDS, radiation pneumonitis. We included relevant research articles, case reports, and reviews published in the last 18 years. Results: The main causes of ARDS in acute hematologic malignancy are: pneumonia-associated ARDS, leukostasis, leukemic infiltration of the lung, pulmonary lysis syndrome, drug-induced ARDS, radiotherapy-induced ARDS, diffuse alveolar hemorrhage, peri-engraftment respiratory distress syndrome, hematopoietic stem cell transplantation-related ARDS, transfusion-related acute lung injury. Conclusions: The short-term prognosis of ARDS in acute hematologic malignancy relies on prompt diagnosis and treatment. Due to its etiological heterogeneity, precision-based strategies should be used to improve overall survival. Future studies should focus on identifying the relevance of such etiologic-based diagnostic strategies in ARDS secondary to acute hematologic malignancy.

Inguinal Hernia - Is There Any Room Left for Classical Procedures?

Background: Nowadays, the repair of inguinal hernias is mostly achieved through a minimally invasive approach (TAPP or TEP) which has well-known advantages. However, the Lichtenstein mesh technique still has some particular indications. Methods: We reviewed 256 consecutive patients who underwent a Lichtenstein procedure during 5 years (2015-2019) in the Department of General Surgery of "Dr. I. Cantacuzino" Clinical Hospital. The vast majority of them - 180 (74%) were 60 or older and 105 (41%) were over 70. Severe cardiovascular diseases, diabetes mellitus and other significant co-morbidities were recorded in 128 patients (50%). Results: 240 patients had a favorable evolution, 12 experienced local complications, while in 4 we recorded severe cardiac post-operative events.1 patient died due to a massive myocardial infarction. Conclusions: The surgical treatment of inguinal hernias should be adapted to the age and biological status of the patient; surgical departments must be able to provide both a laparoscopic and an open-surgery approach.

Diabetes Mellitus as a Risk-factor for Colorectal Cancer Literature Review - Current Situation and Future Perspectives.

Colorectal cancer and Diabetes Mellitus represent a major public health issue, first, by the number of new cases which are at an alarming rate. Secondly, by the negative effect over the quality of life, socio-economic status and lifespan, representing high morbidity and mortality causes. Diabetes Mellitus is the disease of the century with a global prevalence (standardised-age) which doubled since 1980, rising from 4,7% to 8,5% in adult population. In 2012, the estimated number of fatalities caused by Diabetes Mellitus and other related complications was at 3,7 million, out of which 43% were patients under the age of 70. Neoplasia represents the second cause of death, after cardiovascular disease. The occurrence of Colorectal cancer (CRCA) is rated for men and women at 3rd and 2nd place. However, the rate of mortality from CRCA is in the 4th place, representing 8,5% out of the total cancer related deaths. 52% of these cases are recorded in underdeveloped countries, considering their level, this reflects a very low survival rate. Moreover, every year, approximately 1.4 million cases are being diagnosed out of which 55% appear in overdeveloped countries. Screening for colorectal cancer refers to the periodical evaluation of the asymptomatic patients who are at a risk of developing this type of neoplasia. The colorectal cancer contains a series of particularities which makes it ideal for screening. Since the end of the 19th century there has been a high suspicion that type II diabetes, through direct etiological mechanisms, may play a part in carcinogenesis (breast, endometrium, colorectal, pancreas, liver, non-Hodgkin's lymphoma). At the moment, the relevant published literature presents type II diabetes as an independent risk factor for colorectal cancer. Although, despite experimental proof, many epidemiological studies, case-controlled studies and meta-analysis, there still is the necessity for prospective studies which can intensify the existing results and can allow the colorectal cancer screening to adapt to these patients.

Soft Tissue Infections in Diabetic Patients.

Background: the patient with diabetes has an increased susceptibility to infections, with negative evolutionary potential leading to increased morbidity and mortality compared to the general population. The cause is the alteration of immune defense mechanisms, the hyperglycemic environment leading to alteration of neutrophil function, suppression of the antioxidant system and humoral activity, systemic micro and macroangiopathy, neuropathy, depression of antibacterial activity of the genitourinary and digestive tract. Infections localized at the soft tissue (skin, fascia and aponeurosis, subcutaneous tissue, muscles) in the diabetic patient require a complex medico-surgical approach in which aggressive surgical treatment should be complemented by metabolic balancing and sustained antibiotic therapy. Materials and methods: these peculiarities will be exposed and analyzed in a retrospective descriptive study performed at the General Surgery Clinic. Juvara of the clinical hospital Dr. I. Cantacuzino, during the period of Jan. 2013- Dec.2017, which followed the type of lesions, their localization, the germs involved, the comorbidities, the biologic parameters, the antibiotic and surgical treatment as well as the postoperative evolution. The study does not include patients with localized infections in the diabetic foot, a particular pathological entity that will be analyzed separately in a separate study. Results: 150 diabetic patients with soft tissue infections localized in the upper limb, calf, thigh, perineum, abdominal and thoracic wall were identified. The most frequent localization was found in the lower limb (54%). The incidence of these infections was higher in males (55%), and the most affected age group was 60-69 years (38%). Most patients had type II diabetes (93%). Among the associated comorbidities, cardiovascular diseases and obesity are the most common, explaining to a large extent the complicated evolution, potentially lethal of this pathology. From the bacteriological perspective, a plurimicrobian flora is identified, staphylococcus aureus being most frequently encountered. The antibiotic treatment was initiated immediately empirically, subsequently according to the antibiogram; the most commonly used antibiotic classes being cephalosporins and carbapenems. Surgical interventions were in their majority of debridement and necrectomy, but in a few cases limb amputation was necessary. In particular, the number of surgical interventions performed in the same patient and in the same hospital stay was between 1 and 7 interventions. Conclusions: Soft tissue infections in the diabetic patient have a heterogeneous aspect with specific particularities requiring careful clinical examination, multidisciplinary treatment including rapid, serial surgical interventions to control the growing aggression of the germs involved. Fast and caseadapted therapeutic decisions, careful observation of the patient's general condition and of the wound several times a day are essential to achieving favorable postoperative outcomes.

Synchronous Locally Advanced Rectal Cancer with Clinical Complete Remission and Important Downstaging after Neoadjuvant Radiochemotherapy - Personalised Therapeutic Approach.

Introduction: The current practice for patients with good response, important downstaging or complete remission after preoperative chemoradiation, is to perform surgery on the basis of initial pretherapeutical staging. In literature, varying approaches, like transanal endoscopic microsurgery and even "wait and see", are described for patients with good response after chemoradiation. However, considering the present level of available evidence, the wide-spread adoption of a "watch and wait" policy in those achieving a complete clinical remission cannot be justified. CASE REPORT: It is presented the case of a 63 years old patient, investigated and diagnosed with synchronous rectal cancer, inferior rectal cancer invading the perianal region and medium rectal cancer, located between 8 and 14 cm from the anal verge, pretheraputically staged cT4N2M0. The oncological board decides neoadjuvant radiochemotherapy. Restaging shows complete remission of inferior rectal tumor and ulcerative infiltrative remnant lesion in the medium rectum. The patient firmly declines colostomy, assuming recurrence risks. A TME low rectal resection with colorectal mechanical anastomosis is performed, postoperative evolution being favorable. Conclusions: Although, the radical surgery to be done would have been an abdomino-perineal resection, the patient's option to decline the colostomy imposed a radical intervention just for the proximal tumor. The inferior rectal tumor, with complete remission after neoadjuvant therapy was submitted to "wait and see" approach.