Category Archives: JCCM 2018

Hospital Resilience: A Recent Concept in Disaster Preparedness

DOI: 10.2478/jccm-2018-0016

Planning for a disaster must anticipate how demands imposed by a disaster equate with the capacity of the available facilities. Resources must be organized before an event occurs so that they are best prepared in every way to treat as many victims as possible. The actual number of victims is less relevant than the extent receiving facility can be adjusted to meet the appropriate requirements of victims. Multiple casualty incidents (MCIs) are defined as a large number of casualties generated over a short period that are appropriately managed with existing or extended resources. Mass casualty events (MCEs), in contrast, are major medical disasters that erode organized community support mechanisms and result in casualty numbers which overwhelm resources [1].
Due to the increased frequency and impact of disasters, including natural disasters, pandemics and terrorism, the concept of disaster resilience is accepted as being of increasing importance.
The notion of resilience can be defined as the capacity to adapt to unexpected challenges and the flexibility to revert to normality. Additionally, the issues learned from the experience should be incorporated into protocols which would allow for better preparedness for future challenges [2,3]. [More]

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Acute Pulmonary Embolism in a Teenage Female – A Case Report

DOI: 10.2478/jccm-2018-0015

Thrombophilia represents a tendency towards excessive blood clotting and the subsequent development of venous thromboembolism (VTE). VTE is a rare condition in children that comprises both deep venous thrombosis (DVT) and pulmonary embolism (PE). This paper reports the case of a 16-year-old girl, admitted to the Pediatrics Clinic No. 1, Tîrgu Mureș, Romania, for dyspnea, chest pain and loss of consciousness. Her personal history showed that she had had two orthopedic surgical interventions in infancy, two pregnancies, one spontaneous miscarriage and a recent caesarian section at 20 weeks of gestation for premature detachment of a normally positioned placenta associated with a deceased fetus. Laboratory tests showed increased levels of D-dimers. Angio-Computed Tomography (Angio-CT) showed multiple filling defects in both pulmonary arteries, establishing the diagnosis of PE. The laboratory tests were undertaken to assist in the diagnoses of a possible thrombophilia underlined a low level of antithrombin III. Antiphospholipid syndrome was ruled out and genetic tests revealed no specific mutation. Anticoagulant therapy was initiated with unfractionated heparin and afterwards subcutaneously low molecular heparin was prescribed for three months. Later it has been changed to oral therapy with acenocoumarol. The patient was discharged in good general status with the recommendation of life-long anticoagulation therapy. Thrombophilia is a significant risk factor for PE, and it must be ruled out in all cases of repeated miscarriage.

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Transplant Critical Care: Is There A Need for Sub-specialized Units? — A Perspective

DOI: 10.2478/jccm-2018-0014

The critical care involved in solid-organ transplantation (SOT) is complex. Pre-, intra- and post-transplant care can significantly impact both – patients’ ability to undergo SOT and their peri-operative morbidity and mortality. Much of the care necessary for medical optimization of end-stage organ failure (ESOF) patients to qualify and then successfully undergo SOT, and the management of peri-operative and/or long-term complications thereafter occurs in an intensive care unit (ICU) setting. The current literature specific to critical care in abdominal SOT patients was reviewed. This paper provides a contemporary perspective on the potential multifactorial advantages of sub-specialized transplant critical care units in providing efficient, comprehensive, and collaborative multidisciplinary care.

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Emerging Infection with Elizabethkingia meningoseptica in Neonate. A Case Report

DOI: 10.2478/jccm-2018-0013

Background: Elizabethkingia meningoseptica are Gram-negative rod bacteria which are commonly found in the environment. The bacteria have also been associated with nosocomial infections, having been isolated on contaminated medical equipment, especially in neonatal wards.
Case report: Here, we present the case of a premature female infant born at 33 weeks’ gestational age, with neonatal meningitis. The onset was marked by fever, in the 5th day of life, while in the Neonatal Intensive Care Unit. The patient was commenced on Gentamicin and Ampicillin, but her clinical condition worsened. Psychomotor agitation and food refusal developed in the 10th day of life, and a diagnosis of bacterial meningitis was made based on clinical and cerebrospinal fluid findings. A strain of Elizabethkingia meningoseptica sensitive to Vancomycin, Rifampicin and Clarithromycin was isolated from cerebrospinal fluid. First-line antibiotic therapy with Meropenem and Vancomycin was adjusted by replacing Meronem with Piperacillin/Tazobactam and Rifampicin. The patient’s clinical condition improved, although some isolated febrile episodes were still present. The cerebrospinal fluid was normalized after 6 weeks of antibiotic treatment, although periventriculitis and tetraventricular hydrocephalus were revealed by imaging studies. Neurosurgical drainage was necessary.
Conclusion: Elizabethkingia meningoseptica can cause severe infection, with high risk of mortality and neurological sequelae in neonates. Intensive care and multidisciplinary interventions are crucial for case management.

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Endotracheal Tube Biofilm and its Impact on the Pathogenesis of Ventilator-Associated Pneumonia

DOI: 10.2478/jccm-2018-0011

Ventilator-associated pneumonia (VAP) is a common and serious nosocomial infection in mechanically ventilated patients and results in high mortality, prolonged intensive care unit- (ICU) and hospital-length of stay and increased costs. In order to reduce its incidence, it is imperative to better understand the involved mechanisms and to identify the source of infection. The role of the endotracheal tube (ET) in VAP pathogenesis became more prominent over the last decades, along with extensive research dedicated to medical device-related infections and biofilms. ET biofilm formation is an early and constant process in intubated patients. New data regarding its temporal dynamics, composition, germ identification and consequences enhance knowledge about VAP occurrence, microbiology, treatment response and recurrence.
This paper presents a structured analysis of the medical literature to date, in order to outline the role of ET biofilm in VAP pathogenesis and to review recommended methods to identify ET biofilm microorganisms and to prevent or decrease VAP incidence.

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Incidental Finding of a Left Atrial Myxoma while Characterising an Autoimmune Disease

DOI: 10.2478/jccm-2018-0009

Although cardiac tumours are uncommon, cardiac myxomas account for more than fifty percent of all cases and are the most frequent primary cardiac tumour. They have a broad clinical spectrum, usually related to cardiac symptoms, peripheral embolic events or systemic manifestations. We present a case report of a 68-year-old man who presented with systemic symptoms and analytical features suggestive of an autoimmune disease. In the ensuing diagnostic procedures, a cardiac myxoma was found, and after surgical resection, both the systemic manifestations and the analytical abnormalities disappeared.

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Resistance to Antimicrobians – A Global Problem with Sectoral Resolution

DOI: 10.2478/jccm-2018-0010

Mankind has been and still is constantly threatened by infectious diseases. Antimicrobials, used to treat infections, are considered one of the greatest discoveries of the 20th century because they saved millions of lives from diseases that had a high mortality rate. Mankind has been and is still constantly threatened by infectious diseases. Antimicrobials, used to treat infections, are considered one of the greatest discoveries of the 20th century because they saved millions of lives from diseases that had a high mortality rate. Current infectious pathology is worryingly extending due mainly to “globalization”, which confirms the current concept of “Infections Without Borders”. In this context, both the consumption of antimicrobial substances and, inherently, the resistance of the main pathogens involved have increased. Unfortunately, antimicrobials have become victims of their success because their abusive use in humans and animals has led to the emergence of resistance among clinically important pathogens. Each dose of antibiotic creates selective evolutionary pressures, resulting in pandemic spread of highly resistant bacterial clones. Resistance to antibiotics is one of the greatest threats to human health. A return to the pre-antibiotic era would not only make possible the development of epidemics caused by multidrug-resistant bacteria, a major threat to the population, but would also jeopardize some of the most valuable therapies in modern medicine, such as transplantation and immunosuppressive chemotherapy programmes –dependent on supportive antimicrobial treatments. [More]

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Perioperative Stress-Induced (Takotsubo) Cardiomyopathy in Liver Transplant Recipients

DOI: 10.2478/jccm-2018-0006

A comprehensive analysis of published cases of Takotsubo cardiomyopathy, occurred in liver transplant recipients in the perioperative period, has been attempted in this review. Predisposing factors, precipitating events, potential physiological mechanisms, acute and post-event management have been discussed.

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Severe Fatal Systemic Embolism Due to Non-Bacterial Thrombotic Endocarditis as the Initial Manifestation of Gastric Adenocarcinoma: Case Report

DOI: 10.2478/jccm-2018-0008

Introduction: Nonbacterial thrombotic endocarditis (NBTE), also known as marantic endocarditis, is a rare, underdiagnosed complication of cancer, in the context of a hypercoagulable state. NBTE represents a serious complication due to the high risk of embolisation from the sterile cardiac vegetations. If these are not properly diagnosed and treated, infarctions in multiple arterial territories may occur.
Case presentation: The case of a 47-year-old male is described. The patient was diagnosed with a gastric adenocarcinoma, in which the first clinical manifestation was NBTE. Subsequently, a hypercoagulability syndrome was associated with multi-organ infarctions, including stroke and eventually resulted in a fatal outcome.
Conclusions: NBTE must be considered in patients with multiple arterial infarcts with no cardiovascular risk factors, in the absence of an infectious syndrome and negative blood cultures. Cancer screening must be performed to detect the cause of the prothrombotic state.

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