The Role of Neutrophil to Lymphocyte Ratio in the Assessment and Rehabilitation of Knee Osteoarthritis Patients.

Osteoarthritis (OA) is considered to be a real problem for many people. The last decade is characterized through an increased interest in using a non-specific, simply and readily available marker of inflammation-neutrophil to lymphocyte ratio (NLR)-to predict various chronic diseases (gastrointestinal and colorectal cancers, lung cancer, cardiovascular events, sarcoidosis, arthritis). The aim of our study is to establish the correlation between NLR and other parameters of clinical and functional status in KOA patients and to compare the NLR values before and after rehabilitation program. 90 patients, aged 40 to 82 years, diagnosed with mild (8 patients), moderate (70 patients) and severe (12 patients) KOA, in accordance with Kellgren and Lawrence score. Statistical assessment showed different values for the erythrocyte sedimentation (ESR) rate at 1-hour, Visual Analogue Scale (VAS), and Lequesne index in the studied group. NLR regression was significant for ESR at 1 and 2 hours. As an independent diagnostic marker, NLR has limited value, however it can be considered an inexpensive additional biomarker for the diagnosis of KOA and for monitoring the rehabilitation program.

Osteoarthritis induces gender-related changes in the knee range of motion.

In time, osteoarthritis (OA) generates the misalignment of the affected joint structures. However, due to the nature of bipedal gait, OA in the lower limb can also cause pathological gait patterns, which can generate instability and falls, with great consequence, especially in the aged population. With goniometry used to evaluate the range of motion (ROM) of joints, we wanted to evaluate how gender impacts gait dynamics in OA patients. For this study, we have compared 106 OA patients (74 females and 32 males) to age matched controls. All participants had their right leg as dominant. Video recording of normal gait was analyzed with a digital goniometry tool phone application, and the knee's ROM was measured in midstance and midswing moment of the gait. During midstance, significant extension and flexion of the knee excursion have been observed in both males and females. During midswing, knee OA presents more differences, whereas subjects with hip and knee OA present changes on the dominant knee. Midstance changes suggest that the knee's joint degenerative changes, such as synovitis, can be linked to hip OA secondary changes. Midswing changes in lower limb OA suggest a connection to the activities of daily life. Gender differences generated by OA must furthermore be studied in both lower limbs so that the best therapeutic approach can be chosen.

Fetal-maternal incompatibility in the Rh system. Rh isoimmunization associated with hereditary spherocytosis: case presentation and review of the literature.

Next to A and B antigens, agglutinogen D exhibits the highest immunogenicity. Following the transfusion of D-positive red blood cells (RBCs), almost 80% of D-negative recipients develop anti-D antibodies (Abs). Subsequently, anti-D immunization further promotes the synthesis of Abs towards other blood group antigens in or outside the Rh system. The D antigen is also involved in 95% of cases of hemolytic disease of the newborn. Transfusions, hemotherapy, grafts, and obstetric history (abortions, ectopic pregnancy, births) are all risk factors for Rh isoimmunization. In the case of ABO compatibility between mother and fetus, Rh-positive fetal RBCs that have reached the maternal bloodstream are not destroyed by group agglutinins, and Rh antigenic sites are not hidden by the maternal immune system. But a Rh-negative mother with a homozygous Rh-positive husband will certainly have a Rh-positive fetus. As it has an irreversible evolution, the Rh isoimmunization once installed cannot be influenced in the sense of decreasing the Ab titer, therefore, injectable globulin has no effect. A particular case was that of a newborn with Rh system incompatibility associated with hereditary spherocytosis The clinical balance at birth reflects the severe jaundice of the female newborn of 3140 g, gestational age 38∕39 weeks, extracted by lower-segment transverse Caesarean section, with a double loop nuchal cord, Apgar score 8. Because the jaundice was severe and atypical (face and upper chest), we considered the possibility of coexistence of hemolytic disease of the newborn by Rh blood group incompatibility associated with hereditary spherocytosis, as it turned out to be true and mentioned. Changes in genes encoding proteins in the structure of the RBC membrane have amplified hemolysis induced by maternal-fetal isoimmunization in the Rh system. Massive hemolysis accentuated by congenital spherocytosis, confirmed later, imposed blood transfusion and dynamic monitoring.

Positive Effects of Pulmonary Rehabilitation Among Patients with Obstructive Ventilatory Dysfunction Post COVID-19.

BACKGROUND: SARS-CoV-2 (Severe Acute Respiratory Syndrome Coronavirus-2) infection appeared for the first time in Wuhan, China in December 2019, and in March 2020 it was declared a pandemic by the World Health Organization (WHO). Thus, a new disease was registered-COVID-19 (Coronavirus Disease 2019). Our study followed the patients who had the diagnosis of obstructive ventilatory dysfunction in their personal pathological antecedents, who tested positive for SARS-CoV-2 infection. The patients were in the hospital records with chronic obstructive pulmonary disease (COPD) or asthma. After discharge, patients had a number of outstanding symptoms: fatigue, cough, dyspnea, mental and cognitive disorders, palpitations, headaches, dysfunctions of taste and smell. All patients underwent pulmonary rehabilitation after hospitalization. AIMS: In this study, we looked at the benefits of respiratory rehabilitation over a period of six months after SARS-CoV-2 infection. The medical rehabilitation program included physical training, muscle training, nutritional support, psychological support and patient education. METHODS: A retrospective study was defined between April 2021-December 2021, including 72 patients who had SARS-CoV-2 infection and who presented various symptoms on discharge. The study was carried out at the Clinical Hospital of Infectious Disease and Pneumoftiziology "Victor Babeș" from Craiova-Pulmonology Department. These patients had a history of obstructive ventilatory dysfunction: asthma or COPD. Patients were monitored during the respiratory rehabilitation program at 3 and 6 months after discharge. RESULTS: An improvement in clinical and functional parameters was obtained as a result of the pulmonary rehabilitation. CONCLUSIONS: Patients with COPD are increase risk to develop severe forms of COVID-19. Smoking is an important risk factor for SARS-CoV-2 infection and obstructive ventilatory dysfunction. Vaccination against SARS-CoV-2 infection is effective, being associated with mild forms of COVID-19. Pulmonary rehabilitation is a key point in the management of patients with COVID-19, improving exercise capacity, reducing dyspnea, improving health, increasing oxygen saturation and quality of life.

Bimalleolar pathological fracture in a patient with chronic tophaceous gout.

Gout is one of the most common types of inflammatory arthritis. Four stages have been described in its evolution: asymptomatic hyperuricemia, acute gouty arthritis, intercritical gout and chronic tophaceous gout. Monosodium urate crystals deposits are more frequently encountered in hyaline cartilage, tendon sheaths, articular bursae, bone epiphysis, synovium, and skin. Pathological fractures that occur at the formation sites of gout tophi have been rarely described in gout. Bimalleolar fractures often occur following a trauma. We present the case of a 56-year-old patient, diagnosed with chronic gout for over 12 years, with tophi in the upper and lower limbs, who presented accusing mechanical pain in the left tibio-tarsal joint and impaired function of the hands. The clinical examination showed bilateral multiple destructive gout tophi in the hands, forearms, elbows, feet, ankles, and lower legs, while the left ankle exhibited an important varus deformity. Computed tomography examination of the left ankle showed multiple gout tophi with bone erosions and a bimalleolar pathological fracture. The patient underwent pharmacological treatment, physical therapy and the ankle was immobilized in a knee-ankle-foot orthosis, with subsequent orthopedic surgical treatment for fracture fixation, to improve functional status. We have chosen to present this case given the multiple disabilities of the patient, which have improved following the rehabilitation treatment.

The procoagulant status. Hypercoagulability as a risk factor of primary and secondary infertility.

Thrombophilia is a disorder that makes patients susceptible to intravascular thrombosis that may increase the risk of developing a pregnancy on a known pathology. The female patient diagnosed with hypoplastic uterus and hereditary thrombophilia had a favorable evolution under properly administered anticoagulant treatment. The homozygous status for the C677T mutation may lead to an increase in plasma homocysteine levels, especially in pregnant women, being an associated risk factor for thrombosis. The risk of developing intravascular thrombosis requires primary prevention measures by adding D-dimers in the early diagnostic algorithm, being the most accurate marker of hypercoagulability and endogenous fibrinolysis. The corroboration of the hypercoagulability status with the results of genotyping, the frequencies of the minor/major alleles studied, single mononucleotide polymorphisms (SNPs) and the establishment of preventive therapy, aims to prevent intravascular thrombosis and thromboembolic phenomena.

Managing Low Back Pain in Primary Care.

Low back pain (LBP) is one of the most common pathologies for which patients present for consultation in primary medical practice. The objective of the study was to determine the number of patients with LBP who presented to the general practitioner 's (GP) office between October 2019 and March 2020, to determine risk factors, favoring factors and their correlation with clinical data obtained after performing the clinical examination, with paraclinical data obtained by imaging investigation. 347 patients, aged between 17 and 82 years, were included in the study, presenting a sex ratio of men: women of approximately 2: 1. The main pain symptoms of the patients were: localized pain in the lumbar spine, radicular pain, referred to the lower limbs, subjective sensitivity disorders felt in the lower limbs, distal motor deficit in the lower limbs, paravertebral muscle contractions and the feeling of instability in the low back. The main risk factors were smoking, the existence of a trauma to the lumbar spine, sedentary lifestyle, maintaining a prolonged fixed position and intense physical exercise, either occasionally or daily. Among the patients included in the study, a number of 93 patients required the granting of medical leave both by the attending GP and by other specialists. Regardless of the etiology and pathophysiological mechanisms involved in the occurrence of LBP, therapeutic management should aim to stop pain symptoms and prevent recurrences.

Complex regional pain syndrome as a paraneoplastic disorder associated with metatypical basal cell carcinoma.

Metatypical basal cell carcinoma (MTBCC) is a rare form of tumor, which associates the clinical and histopathological (HP) characteristics of both basal cell carcinoma (BCC) and squamous cell carcinoma (SCC), with a 5% chance for the development of metastases. The reference diagnosis remains the HP confirmation from the lesional tissue. The current report illustrates the case of a 74-year-old patient, diagnosed with MTBCC consequently to the biopsy from the clinically malignant lesion with HP and immunohistochemical examination, currently in clinical remission following surgical treatment. The musculoskeletal symptoms represent the patient's admission reason to the Clinic of Rheumatology, where he was diagnosed with paraneoplastic type I complex regional pain syndrome (CRPS-I). The onset was six weeks prior with intense pain in the upper limb, burning sensation and nondermatomal distribution, exacerbated by lowering the position of the upper limb. The clinical evaluation revealed vasomotor disorders: color changes on the skin of the upper limb, venous turgescence on the back of the hands, and local increased temperature. Also, there were evident sudomotor modifications with hyperspiration and fluffy edema. The presence of clinical manifestations associated with the HP confirmation of MTBCC and the information provided by the imaging tests regarding the evaluation of tumor extension advocates for the diagnosis of paraneoplastic CRPS, consequently to both the primary tumor and the pulmonary metastasis. Diagnosis of CRPS-I is generally established on the basis of clinical criteria after excluding other conditions that may explain the degree of pain and the existing dysfunction. The therapist should be aware of the clinical manifestation of CRPS, as early recognition and aggressive treatment often leads to the best response.

Complex evaluation in patients with knee osteoarthritis.

Knee osteoarthritis (KOA) is a very common, slowly progressive and incurable articular disease resulting in the breakdown of cartilage and bone in the joint, which causes significant discomfort, pain and disability, with a significant socio-economic impact. The aim of our observational study for patients with symptomatic KOA was to investigate the changes of C-terminal telopeptide of type II collagen (CTX-II) in serum pre and post a complex rehabilitation program and to establish the correlation between all studied parameters [clinical, functional, serum CTX-II (sCTX-II) and histological aspects obtained through arthroscopy]. During 2016-2017, we performed an observational study including 24 patients, between 59 and 76 years old, diagnosed with KOA. Studied patients were completely assessed before (T1) and four months after a complex rehabilitation program (T2). The measured parameters were stiffness, pain, and physical function and we used the Visual Analogue Scale (VAS) for pain, with Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), sCTX-II value obtained by enzyme-linked immunosorbent assay (ELISA) test, histological assessment of knee cartilage after arthroscopy. In the histological assessment of our patients, we observed that the cells of the superficial areas were round and hypertrophic, the cartilage tissue had few proteoaminoglycans and glycosaminoglycans, with an airy aspect of the matrix and degenerate cells, numerically reduced. After positive diagnosis, the complete treatment, including the rehabilitation program, seems to be the ideal option for improving the CTX-II values, as well as the quality of life in KOA patients.

Frostbite arthropathy - a rare case of osteoarthritis, review of the literature and case presentation.

Frostbite affects more commonly the northern population then it was suspected earlier, but wherever cold winter occurs, cold caused lesions are reported. Most often, it is described as soft tissue lesions, but deeper structures like tendons, ligaments, muscles, cartilage or bones can be affected. All extremities can be involved; lesions can lead to necrosis and amputations. First documented cases were described during military actions, but occupational or recreational activities can also be a risk factor for frostbite. Frozen or frostbite arthropathy is a rare cause of osteoarthritis. Usually, arthritis appears after a long time after frostbite, it can be decades apart. Frostbite arthropathy can result in different debilitating conditions. The current review describes the most important changes in frostbite and a rare but very serious late complication, which lead to arthropathy.

Immunohistochemical analysis of bone metabolism in osteonecrosis of the femoral head.

Osteonecrosis of the femoral head occurs because of the suppression of blood circulation. At the level of the area affected by the ischemic phenomenon, there are two types of events, in the first stage there is necrosis of the cellular elements, followed by a reparatory phase of the spongy bone tissue. The objective of the study was the histological and immunohistochemical (IHC) analysis of bone metabolism in the repair phase. We observed the action of the main cells involved in the remodeling, the osteoblasts and the osteoclasts, following the reaction of the markers of their activity: osteoprotegerin, osteonectin, osteopontin. We included 23 patients diagnosed with femoral head osteonecrosis, stage II, Ficat and Arlet classification, biological material required for histological and IHC analysis being obtained during hip arthroplasty. Regardless of the age or presence of risk factors, the reaction to osteoprotegerin was mildly positive, being only highlighted at the level of the reactive dividing line, being absent in the other areas, indicating a reduced activity of inhibiting differentiation and activation of osteoclasts, also highlighted with classical histology methods, the affected area being well-defined and we could observe the necrotic tissue resorption by osteoclasts. The intense positive reaction of osteopontin and osteonectin, especially at the line of demarcation, is due to the increase in the number of osteoblasts required for the synthesis of neoformation bone tissue. We believe that the aspects revealed by our study can be a track in finding new-targeted therapies useful in stopping the development of the disease.

Hand enchondroma - complete evaluation and rehabilitation.

Enchondroma, the most frequently reported primary tumor in the long bones of the hand, is a common benign cartilaginous tumor, defined more exactly as a benign mature hyaline cartilaginous tumor that is located into the medullar space of the tubular bones. Between 2012 and 2018, we performed an observational study on six patients (two males and four females), aged 16 to 49 years old (mean 29.5 years), who were diagnosed during routine physical examinations with isolated enchondroma in their hand. The tumor was more frequently located in their proximal phalanges (four patients), while two patients had middle phalange tumors. The most common digit involved was the little finger (five patients), followed by the ring finger (one patient). The symptoms, which prompted surgical interventions, were: enlargement without fracture (two patients), pain or limitation of mobility (four patients), pain without pathological fracture (six patients). Studied patients were completely assessed before the treatment program (surgical intervention and rehabilitation program). The measured parameters and scales used were Visual Analogue Scale (VAS), Health Assessment Questionnaire (HAQ) scale for functional status and histological exam. For both VAS and HAQ, we observed a statistically significant difference between the initial and final evaluations, with p=0.03 and p=0.035, respectively. Histological assessment and differential diagnosis are essential for the post-surgical treatment and rehabilitation program.

Cervical adenocarcinoma generator of procoagulant status and ischemic stroke.

The procoagulant status of neoplastic patients is well known in medical literature, but in the last years there is attempted a correlation between the histological types of neoplasia and the risk for thrombotic strokes. We present the case of a 44-years-old patient undergoing early menopause, who was diagnosed with cervical tumor of the serous adenocarcinoma type. The patient underwent external radiotherapy, and, in the seventh day of treatment, she suffered a frontal-temporal-parietal ischemic stroke with left hemiplegia. The blood testing highlighted procoagulant products (double fibrinogen compared to normal values, deficit of antithrombin and a high number of thrombocytes). The patient received neurological and rehabilitation treatment, at first with Heparin, followed by the administration of an antiaggregant. During this treatment, the deficit remained unchanged. She continued the neurological and rehabilitation treatment, followed by radiotherapy, with a good evolution. Six months after the stroke, it was decided the surgical tumor ablation of cytoreduction. The post-surgery histological examination highlighted specific changes due to post-surgery radiotherapy, without the presence of any neoplastic cells. The imagistic evaluation, computed tomography (CT) every three months after surgery, did not highlight any suggestive dissemination elements. The occurrence of an ischemic stroke in a patient with endocervical neoplasm of the adenocarcinoma type during radiotherapy imposed the discharge of chemotherapy, with subsequent imaging, biological and histopathological monitoring after surgery. The cause of stroke in this case is determined by the hypercoagulant status in the context of the developed neoplasia, the patient being free of any other risk factors.

Predictive model of synovial membrane degradation using semi-automated morphometry and artificial neural networks.

Gonarthrosis is a degenerative disease that affects mainly older people, but whose incidence has increased significantly in the last decade in population under the age of 65. The main objective of this study was developing a predictive model of synovial membrane degradation in relation to local nerve structures in patients with knee osteoarthritis, based on advanced morphometry and artificial neural networks (ANNs). We present here a pilot test of the method, describing preliminary findings in analyzing a pre-set number of images. We tested the system on a pre-defined set of 50 images from patients suffering of gonarthrosis in different stages. Biological material used for the histological study was synovial membrane fragments. We included 50 anonymized images from 25 consecutive patients. We found significant differences between mean fractal dimensions (FDs) of histological elements of normal and pathological tissues. In the case of immunohistochemistry, we found statistically relevant differences for mean FDs of all antibodies. We fed the data to the ANN system designed to recognize pathological regions of the examined tissue. We believe that further study will have an important contribution to the development and will bring new local targeted therapies. These could slow or reverse joint damage and pain relief in patients with osteoarthritis.

Postmenopausal osteoporosis - clinical, biological and histopathological aspects.

Osteoporosis is one of the most common disorders in postmenopausal women, affecting the quality of life and increasing the risk for fractures in minor traumas. Changes in the bone microarchitecture causes static changes in the body and affects motility. In this study, we analyzed two groups of women, one with physiological menopause and one with surgically induced menopause. The diagnosis of osteoporosis was suspected based on the clinical symptoms and confirmed by assessing bone mineral density by the dual-energy X-ray absorptiometry (DEXA). Comparing some clinical and biological aspects there was noted that a much higher percentage of women with surgically induced menopause exhibited increases in body mass index, changes in serum lipids, cholesterol, triglycerides, blood glucose, serum calcium, magnesemia and osteocalcin. In contrast, no significant differences were observed in the histopathological aspects of bone tissue examined from these two groups. In all patients, there was identified a significant reduction in the number of osteocytes and osteoblasts, the expansion of haversian channels, reducing the number of trabecular bone in the cancellous bone with wide areola cavities often full of adipose tissue, non-homogenous demineralization of both the compact bone and the cancellous bone, atrophy and even absence of the endosteal, and the presence of multiple microfractures. Our study showed that early surgically induced menopause more intensely alters the lipid, carbohydrate and mineral metabolism, thus favoring the onset of osteoporosis.

Rheumatoid nodules and quality of life in rheumatoid arthritis females - complex assessment.

Rheumatoid arthritis (RA) represents the most commonly diagnosed arthropathy that affect many tissue types and organs, characterized by a clinical, functional and therapeutic pathogenic complexity and it affects especially diarthroidal joints. Rheumatoid nodules (RNs) are one of the most frequent extra-articular manifestations of RA, and usually reflect an advanced stage of the disease and a poor prognosis. The complexity of histological, clinical and functional aspects in RA has a real impact on the quality of life in all patients diagnosed with this disorder. Our prospective study presents the RNs involvement in the rehabilitation program performed in order to enhance the quality of life in the 25 RA female patients. We made a complex assessment and realized a correlation between pain, disability and histological aspect of RN, before and after the rehabilitation program. Also, we evaluated the clinical and functional effectiveness of a complex rehabilitation program and changes in impairment and activity limitation in women with RA and RNs. The immunohistological complexity of RNs reflects the intensity of the inflammatory-immune process and completes the assessment of RA patients with RNs. It allows for medical assistance quantification, even for patients that have a poor evolution prognosis.

Imaging and histopathological aspects in aseptic osteonecrosis of the femoral head.

Aseptic osteonecrosis causes various clinical manifestations, depending on its location, but has in common a histopathological and radiological substrate. Aseptic osteonecrosis of the femoral head is a condition whose pathogenesis remains unclear despite many theories developed so far, and the discovery of numerous risk factors. The objective of this study is to emphasize the role of imaging techniques and correlating histology and immunohistochemistry methods in order to more accurately stage the disease. This retrospective study was performed on a total of 103 patients with clinical and radiological suspicion of unilateral or bilateral osteonecrosis. For the diagnosis criteria, we used clinical information, pelvic X-ray images, magnetic resonance imaging (MRI) or computed tomography (CT). For the inclusion of patients in a disease stage, we used the Association Research Circulation Osseous (ARCO) classification system. For patients diagnosed at an advanced stage, who underwent hip arthroplasty, we harvested biological material necessary for the histopathological study. There were differences in the appearance and extent of the lesion on the histological samples compared to macroscopic examination and even those obtained through imaging means, particularly for patients in evolutionary stage III. Aspects such as the extension of the area of fibrosis, bone tissue remodeling, the density of the newly formed vascular network and degree of impairment of the cartilage, are determined more accurately using histology and immunohistochemistry techniques. Before classifying patients in a certain stage, after correlating clinical and imaging data, histopathological aspects have to be considered, particularly in patients in stages III and IV, in which total hip arthroplasty could be delayed.