An Update on Obstructive Sleep Apnea Syndrome-A Literature Review.

Obstructive sleep apnea syndrome (OSAS) is the most common breathing-related sleep disorder. It is characterized by recurrent episodes of partial or complete airway obstruction during sleep, resulting in a reduction in or the total cessation of airflow, despite ongoing respiratory efforts, leading to oxygen desaturation and arousal. The purpose of this literature review is to evaluate the most common characteristics of this pathology, as well as to investigate the most effective treatment options, providing an update on the management of OSA patients.

TECHNICAL DIFFICULTIES AND PROCEDURAL COMPLICATIONS IN CLOSING MALIGNANT ESOPHAGEAL-RESPIRATORY FISTULAS.

The aim of the study was to outline technical difficulties and procedural complications of using partially covered esophageal self-expandable metal stents (SEMSs) in malignant esophageal respiratory fistulas (ERFs) as a palliative treatment option. In this study, 150 patients with malignant dysphagia underwent treatment with SEMSs. A total of 36 ERFs were detected through endoscopic or clinical assessment. Complete fistula sealing with SEMSs was possible in 35 of the 36 patients. The majority of fistulas were diagnosed in male patients with advanced esophageal cancer. All of them presented with prolonged dysphagia and cachexia. Stent migration or tumoral overgrowth was identified in 6 cases with recurrent dysphagia, and required a second stent insertion. SEMSs were highly efficient in 98% of the patients studied with ERFs, with successfully sealed ERFs after the first attempt, with an overall median survival rate of 92 days. The technique of esophageal SEMS placement is simple and can be rapidly mastered. Patients with ERFs have a respiratory shunt that makes intubation difficult and is often avoided. Restoring oral feeding increased the patient quality of life. SEMS placement is generally safe, but has few associated postoperative complications.

Outcome Predictive Value of Serum Ferritin in ICU Patients with Long ICU Stay.

Background and Objectives: The simplified interpretation of serum ferritin levels, according to which low ferritin levels indicate iron deficiency and high levels indicate hemochromatosis is obsolete, as in the presence of inflammation serum ferritin levels, no longer correlate with iron stores. However, further data are needed to interpret serum ferritin levels correctly in patients with ongoing inflammation. Our study aimed to assess serum iron and ferritin dynamics in patients with long ICU stay and the possible correlations with organ dysfunction progression and outcome. Materials and Methods: We conducted a prospective study in a university hospital intensive care unit (ICU) over six months. All patients with an ICU length-of-stay of more than seven days were enrolled. Collected data included: demographics, Sequential Organ Failure Assessment (SOFA) score, admission, weekly serum iron and ferritin levels, ICU length-of-stay and outcome. Interactions between organ dysfunction progression and serum iron and ferritin levels changes were investigated. Outcome predictive value of serum ferritin was assessed. Results: Seventy-two patients with a mean ICU length-of-stay of 15 (4.4) days were enrolled in the study. The average age of patients was 62 (16.8) years. There were no significant differences between survivors (39 patients, 54%) and nonsurvivors (33 patients, 46%) regarding demographics, serum iron and ferritin levels and SOFA score on ICU admission. Over time, serum iron levels remained normal or low, while serum ferritin levels statedly increased in all patients. Serum ferritin increase was higher in nonsurvivors than survivors. There was a significant positive correlation between SOFA score and serum ferritin (r = 0.7, 95%CI for r = 0.64 to 0.76, p < 0.01). The predictive outcome accuracy of serum ferritin was similar to the SOFA score. Conclusions: In patients with prolonged ICU stay, serum ferritin dynamics reflects organ dysfunction progression and parallels SOFA score in terms of outcome predictive accuracy.

Cerebellar Abscess Secondary to Cholesteatomatous Otomastoiditis-An Old Enemy in New Times.

Chronic otitis with cholesteatoma is a potentially dangerous disease that can lead to the development of intracranial abscesses. Although cerebellar abscess is half as common as cerebral abscess, it is known for its particularly difficult diagnosis, which requires the visualization of the pathological process continuity from the mastoid to the posterior fossa. In this article, we present an extremely rare case from the literature of cholesteatomatous otomastoiditis complicated with meningitis and cerebellar abscess, along with the description of technical surgical details for the plugging of the bony defect between the mastoid and posterior fossa with muscle and surgical glue. The particularity of this case lies in the late presentation to the doctor of an immunocompetent patient, through a dramatic symptomatology of life-threatening complications. We emphasize the importance of responsibly treating any episode of middle ear infection and considering the existence of underlying pathologies. In such cases, we recommend additional neuroimaging explorations, which can prevent potentially lethal complications. The treatment of such intracranial complications must be carried out promptly and requires collaboration between a neurosurgeon and an ENT surgeon.

Analysis of emergency head computed tomography in critically ill oncological patients.

BACKGROUND: Critically ill cancer patients have an increased risk of developing acute neurological signs. The study objective was to evaluate the use and the usefulness of emergency head computed tomography (EHCT) in this category of patients. PATIENTS AND METHODS: This retrospective, single-centre, cohort study included patients with EHCT performed during Intensive Care Unit (ICU) admission for a period of three years. Indications, imagistic findings, type of malignancy, and outcome were evaluated to identify diagnostic yield and correlations between abnormal findings on positive scans, malignancy type, and mortality rate. RESULTS: Sixty-four EHCTs were performed in 54 critically ill cancer patients, with 32 scans (50%) showing previously unknown lesions and considered to be positive. The most frequent abnormal findings were ischemic (15 EHCTs, 47%) and haemorrhagic (13 EHCTs, 40%) lesions. Thirty-eight EHCTs (59%) were indicated for altered mental status, with a positivity rate of 50%. Eighteen EHCTs (48%) were performed in hematological malignancy patients: 9 (50%) of which were positive with 8/9 (89%) displaying hemorrhagic lesions. Twenty EHCTs were performed in solid tumour patients, 10 (50%) of which were positive, with 9/10 (90%) displaying ischemic lesions. Out of 54 patients, 30 (55%) died during ICU stay. The mortality rate was higher in patients with hematological malignancies and positive EHCT (78% vs. 58%). CONCLUSIONS: Diagnostic yield of EHCT in critically ill cancer patients is much higher than in other categories of ICU patients. We support the systematic use of EHCT in critically ill, mainly hemato-oncological patients with nonspecific neurological dysfunction, as it may lead to early identification of intracranial complications.

[The evaluation of mortality in abdominal surgery of patients aged over 75. A retrospective study on a series of 111 cases]. / Evaluarea mortalitatii în patologia chirurgicala abdominala la pacientii peste 75 de ani. Studiu retrospectiv.

UNLABELLED: Abdominal surgery of patients aged over 75 is a real challenge, regarding the risk-benefit ratio, especially in emergency cases. The aim of the study was to assess the mortality in elderly patients admitted for abdominal surgical conditions. MATERIAL AND METHODS: A retrospective study was carried out on a series of 111 patients aged over 75 that died during hospitalization for abdominal diseases in the 3rd Surgical Unit during the period 2007-2010. Data from the medical files, operating books and pathology reports were collected and analyzed. RESULTS: Of the 61 cases admitted for benign conditions, 11 deceased prior to surgery due to high ASA risk. 50 patients underwent surgery, mainly on emergency basis (42 cases). Most of the patients in this group suffered from intestinal infarction (22), followed by abdominal sepsis (16), intestinal obstruction (12) and digestive bleeding (10). Resection followed by anastomosis was performed in 17 cases; of these, anastomotic fistula with sepsis developed in 7 cases (41%). Malignant abdominal diseases were diagnosed in 50 patients, most frequently colorectal cancer (25) followed by gastric cancer (14), pancreatic cancer (5), billiary duct carcinoma (3), malignant ampuloma (2) and hepatoma (1). In this group, 46 patients were operated on, mainly in emergency (35). Of the 32 cases where resection was performed, anastomostic fistula with sepsis developed in 21 (65,6 %). CONCLUSIONS: the main cause of death was abdominal sepsis due to anastomotic fistula following resections, for both benign and malignant condition.

[The assessment of empiric antibiotherapy in acute secondary peritonitis]. / Evaluarea tratamentului antibiotic empiric în peritonitele acute secundare de cauza, digestiva.

UNLABELLED: The adequate use of antibiotics, according to the international guidelines of antimicrobial therapy, is, in addition to surgery, an important part of the management of intra-abdominal infections. The aim of the study was to assess the efficacy of empiric antibiotherapy in acute peritonitis of digestive cause. MATERIAL AND METHODS: A retrospective study was carried out on a series of 75 cases of acute peritonitis, admitted in the IIIrd Surgical Unit, in the period 2003-2005. Perforated duodenal ulcer was the cause of diffuse peritonitis in 46 % of the cases, followed by acute appendicitis (31%) and traumatic perforation of the small bowel (11 %). The most frequent bacteria encountered was E. coli (62 %), while Klebsiella, Enterobacter and Acinetobacter were present in nearly 8% of the cases. Ertapenem as single agent was preferred in 36.8% of the patients and an association of third generation cephalosporins or aminoglycoside with metronidazole in 33.4%. RESULTS: the efficiency of the treatment was assessed in regard to clinical (fever) and laboratory (leucocytosis) data, the duration of treatment and hospital stay. The outcome was appreciated as good in almost 73% of the patients treated with ertapenem, and 52% respectively for combined therapy. CONCLUSION: the authors recommend the use of penems as monotherapy in the empiric treatment of acute peritonitis following digestive perforation.

[Acute surgical pathology in elderly patients]. / Aspecte ale chirurgiei de urgenta la pacientul vârstnic.

The consequence of demographic aging is an increase of surgical pathology of the elderly, concerning both number and complexity of the cases. To asses the nature of geriatric surgical pathology and the effect of co-morbidities on surgical outcome, a retrospective study was carried out on a series of 401 patients aged over 75, treated in the IIIrd Surgical Unit in the period 2002-2003. 132 patients were admitted as acute cases and 94 of them were operated: 62 required immediate surgery and 32 required delayed operations. According to the nature of the diseases, benign surgical conditions were encountered in majority of the cases (78 cases). The diagnostics requiring immediate operations were: complicated hernias, perforated peptic ulcer, lower limb acute ischemia. Delayed emergency operations were performed for: acute cholecystitis, biliary lithiasis with angiocholitis and complicated gastric cancer. Cardiovascular pathology was recorded as the most frequent co-morbidity. Hospital mortality rate of 32.9% resulted mainly from cases with mesenteric infarction and generalized peritonitis, as well as from delayed emergencies such as complicated gastric and colon cancer. The most frequent causes of death following surgery were: cardiac failure, sepsis and multiple organ failure.