Introduction. Multisystem inflammatory syndrome in adults (MIS-A) is a rare but potentially life-threatening sequel of SARS-CoV-2 infection, requiring early recognition and treatment. Nevertheless, it is often hard to distinguish MIS-A from other COVID-19-related hyperinflammatory complications. Case presentation. A 74-year-old male presented to the emergency department with persistent fever, diarrhea, altered consciousness, polymorphous rash with oral lesions and erythema of the palms and soles, with progressive exfoliation. The patient had been hospitalized for COVID-19 four weeks before and was suffering from chronic lymphocytic leukemia, diabetes and hypertension. During his recent hospital stay he received multiple courses of antibiotics and was discharged home with instructions to add sitagliptin and re-initiate therapy with ibrutinib. Upon re-admission, polymerase chain reaction test for SARS-CoV-2 was still positive and inflammatory markers were markedly elevated. Although MIS-A could not be excluded, a presumptive diagnosis of Stevens-Johnson Syndrome (SJS) was made, and the patient was treated empirically with intravenous immunoglobulin and high-dose methylprednisolone. SJS is usually considered an adverse drug reaction that affects the skin and mucous membranes. In this patient, MIS-A was also initially included in the differential diagnosis due to previous COVID-19, despite the patient’s advanced age and lack of cardiac involvement or conjunctivitis. The patient only partially fulfilled current diagnostic criteria for MIS-A. Conclusions. SJS results from a dysregulated immune response and can have a similar presentation to MIS-A. A better characterization of both conditions is required particularly in older adults with comorbidities, to facilitate timely diagnosis and management and to reduce mortality.

Introduction. Acalculia is defined as a form of cognitive impairment, manifested by the loss of ability to perform calculations and use arithmetical concepts because of the damage to some parts of the cerebral cortex, with a subcortical extension. Case presentation. We present a unique case of a 74-year-old right-handed patient with isolated acalculia on a background of ischaemic stroke in the right parietal lobe. Physical examination, laboratory tests, and various instrumental and neurological investigations including electroencephalogram and magnetic resonance imaging (MRI) were performed. Brain MRI showed a subacute infarct in the area of the right temporo- parieto-occipital junction and multiple subcortical lesions of vascular origin in the frontal and parietal lobes. The patient was treated with aspirin, enalapril, and atorvastatin, along with cognitive rehabilitation therapy. During subsequent follow-up visits, a decrease in the severity of acalculia was noticed, but complete recovery was yet to be achieved. Conclusions. Acalculia is a form of cognitive impairment, which may either be part of Gerstmann syndrome, or an isolated symptom of cognitive decline in stroke, tumours, Binswanger’s disease, several types of dementia, epilepsy, and some other diseases. However, a subacute isolated presentation is rare.

Introduction. Intrahepatic cholestasis of pregnancy (ICP) is a disorder characterized by pruritus and elevated liver function tests and is associated with a high incidence of adverse perinatal outcomes. Multi-disciplinary cooperation is critical for managing the condition and ensuring better pregnancy outcomes. The objective of the study was to assess the clinical symptoms and intensity of cutaneous pruritus in women with intrahepatic cholestasis of pregnancy. Material and methods. The study group included 71 women with ICP. The patients were asked about their symptoms and intensity of itching. The intensity of cutaneous pruritus was assessed according to two scales. SPSS 21 software was used to conduct the statistical analysis. Results. On the onset of symptoms women had indicate the intensity of itching at 5.1±2.3 points on average, according to visual analog scale. 53.5% women indicated the symptom to be occasional or discontinuous. By the moment of the survey, 66.2% women indicated the intensity of the pruritus more or equal to 8 points, being continuous in 52.1% of cases. In the post-partum period, the intensity of the pruritus decreased, being assessed on the third day after delivery as less or equal with 5 points in 93.1% of cases, being occasional or discontinuous in 90.1% of cases. Conclusions. Pruritus is the most prevalent clinical sign of ICP and it should not be ignored, being considered as a call for follow-up.

Heart failure (HF) is a heterogeneous syndrome, with progressive evolution and negative impact on quality of life and mortality of patients. The incidence of HF in Europe and the United States of America varies between 1 to 9 cases per 1000 inhabitants, depending on the population studied and the diagnostic criteria used1. Currently, it is estimated that approximately 64.3 million people suffer from HF world-wide2. One of the most important therapeutic goals for patients with HF is represented by maintaining and improving the quality of life. Many patients value functional status and quality of life more than longevity. The most important predictors of the quality of life in HF are the presence of symptoms and their severity, functional status and depression3. Current guidelines recommend the combined use of medical and behavioural interventions to improve the functional status of these patients3.

Introduction. Performing surgical manipulations and interventions on neurovascular bundles located in the anterior brachial region of human fetuses and newborns requires comprehensive knowledge of their topographical and anatomical features. The objective of the study was to establish the fetal topography peculiarities of both nerves and vessels in the anterior brachial muscle region. Materials and methods. The study was carried out on 32 human fetuses of 4-8 months with 81.0-310.0 mm crown-rump length (CRL) using macro microscopic dissection, vascular injections and morphometry. Results. We describe the main and additional sources of muscle blood supply and innervation of the anterior brachial region in human fetuses. Two to 4 branches of the musculocutaneous nerve take part in the innervation of both coracobrachialis and brachialis muscles, as well as the biceps brachii muscle. Some fetuses possess additional sources of innervation: for the coracobrachialis muscle there is a branch of the lateral bundle of the brachial plexus, the biceps brachii muscle has median nerve and for the brachialis muscle there is radial nerve. The largest number of arterial and nerve branches goes to the proximal and middle parts of the coracobrachialis and brachialis muscles, as well as the biceps brachii muscle. Conclusions. The established neurovascular correlations and features of the fetal anatomy of the anterior brachial muscle region determine the presence of relatively favourable conditions for cutting muscle flaps that are well innervated and supplied with blood.

Introduction. Leptospirosis is a re-emerging illness with a wide spectrum of clinical manifestations, from asymptomatic or moderate to severe and lethal results. Leptospirosis can be adequately treated if detected early; however, comparable clinical presentations with various other febrile illnesses or co-infections, as well as laboratory diagnosis problems can result in misdiagnosis, leading to severe illness. Identifying clinical predictors for the severe form of the disease is critical to reduce the disease complications and mortality. The objective of the study was to establish the risk factors for mortality in patients with leptospirosis. Materials and methods. A retrospective study of 102 medical records of patients diagnosed with leptospirosis in the period from 2009 to 2019 was conducted. Quantitative variables in the presence of normal distribution were compared using a paired Student’s t-test, and in the case of an abnormal distribution, the Mann–Whitney U test was used. The criterion ?2 was used for qualitative variables. A two-step cluster analysis was also performed. Results. The following factors associated with death from leptospirosis have been identified: oliguria (OR, 13.5; 95% confidence interval [CI], 2.56-71.12), serum creatinine and urea levels, direct and total bilirubin, platelets, and white blood cells count. Conclusions. These „red flag” laboratory and clinical characteristics will aid medical personnel in rapidly identifying a patient at risk of death, which is critical in determining the severity of the condition and the need for early intensive care and therapy adjustment.

Introduction. Evidence on disparities of mortality by place of residence based on reliable data is needed for appropriate public health programmes aimed at reducing high mortality in Moldova. The objective of the study was to determine changes in mortality disparities for all causes and major groups of causes of death between rural and urban populations of the Republic of Moldova after independence. Material and methods. The data were analysed by sex and place of residence for all causes and seven main groups of causes of death for two periods: 1991-93 and 2017-19. Abridged life tables and standardised death rates with 95% confidence intervals were computed. Mortality inequities between rural and urban areas were analysed in absolute and relative terms. Results. Cardiovascular diseases and digestive system diseases in both sexes and external causes and respiratory system diseases among men accounted for the rural mortality disadvantage. Cancer mortality had a negative rural-urban gradient. During independence, the rural-urban gradient of all-cause mortality declined among women, but not among men. A more rapid reduction in mortality from circulatory system diseases and a more rapid growth of neoplasm mortality in rural areas than in urban areas narrowed the rural-urban disparities. For external causes and diseases of the respiratory system, inequalities in mortality between rural and urban areas increased over the study period. Conclusions. Public health programmes aimed at reducing elevated cardiovascular mortality in rural areas are a key strategy for addressing mortality disparities between rural and urban populations.

One of the most frequent types of dementia is the Alzheimer’s disease (AD). The fundamental concepts of pharmacotherapy valid for AD are substances that increase the cerebral acetylcholine level, intervening in cholinergic neurotransmission through cholinesterase inhibition and N-methyl D-aspartate receptor antagonists. These drugs have the role of slowing down the further evolution of the disease, providing at the same time a symptomatic improvement. The effectiveness of these drugs is clearly limited, both because of several negative side effects and their inefficiency to cure the disease. The therapeutic management is therefore a major challenge in AD, and the non-adherence to treatment often constitutes a serious barrier to an effective therapy. Doctors and pharmacists play a vital role in the pharmacotherapeutic management of AD, contributing to improved clinical results and quality of life of the patient. The current review analysed the challenges in therapeutic management, especially those related to treatment adherence and pharmacist involvement.

Introduction. Heart failure (HF) is a clinical syndrome caused by structural and/or functional cardiac abnormalities, resulting in a reduced cardiac output and/or elevated intracardiac pressures at rest or during stress. It is a progressive disease with a high risk of death in the first 6-12 months after the diagnosis of end stage HF. Cases presentation. We present the successful implantation of a left-ventricular assist device (LVAD) HEART MATE III in a 54-year-old male with ischemic cardiomyopathy and end stage HF, and a heart transplant in a 31-year-old male with non-ischemic dilated cardiomyopathy and end stage HF. Both procedures were guided by experienced surgeons and the overall management Conclusions. HF is one of the leading causes of death world-wide. The effort to stabilize and effectively treat patients with ventricular assist devices and/or orthotopic heart transplant is increasing. One of the few drawbacks is the complex Heart Team training, a difficult process that involves each member acquiring the necessary skills and knowledge. The end stage HF Team is composed of a large variety of members, such as cardiologists, cardiac surgeons, anaesthetists and intensive care doctors, interventional cardiology doctors, and nurses.

Introduction. The risk factors for multiple sclerosis (MS) and cancer overlap to a large extent. The objective of our study was to estimate the prevalence and risk ratios (RR) of cancers in patients with MS and to identify which types of cancer have the lowest frequency. Materials and methods. We carried out research of the literature in the PubMed, Medline, and Google Academic databases, with the aim of identifying large-scale studies addressing the link between different cancers and MS. From 411 relevant articles, we selected 13 scientific papers for further analysis, comprising 109,276 patients diagnosed with MS from different countries. Results. Of all MS patients, 5.1% were diagnosed with a certain type of cancer compared to 5.5% in the general population; the cancers with the lowest incidence were respiratory, digestive, and blood cancers. Conclusions. The results of our analysis suggested that MS patients are less exposed to respiratory, digestive, and blood cancers, but more research is needed to understand if some disease-modifying therapies play a role in this regard.

Anaemia is a pathology encountered very often among geriatric patients and mostly it is secondary to a chronic disease or an acute/ chronic loss of blood. Therefore, it should not be considered as a possible physiological consequence of aging. Anaemia is recognized as a risk factor for a series of effects with a negative impact on the subsequent evolution of geriatric patients, such as a prolonged duration of hospitalization, higher morbidity, and mortality. In most cases, geriatric patients have a series of cardiovascular comorbidities which, in association with anaemia, can further increase the risks. Most geriatric patients with severe anaemia present to the emergency room for upper digestive hemorrhage. This article will focus especially on this pathology, with a complete description of the causes and treatment methods in these patients.

Introduction. The presence of blood in the semen is called haematospermia or haemospermia. The condition is always accompanied by patients’ fear and anxiety and in most cases is intermittent and on short-term. In cases when haematospermia is continuing for long time or associates other symptoms it requires diagnostic evaluation for the numerous possible causes – inflammatory, neoplastic, iatrogenic and obstructive. Case presentation. We present a case of coitus reservatus – an unpopular practice of sexual intercourse and a contraceptive method which is clinically manifested with haematospermia. A 38-year-old male patient, married, with one 6-year-old child, has been consulted for persistent haematospermia after each ejaculation in the last 5 years. The physical, laboratory and imaging examinations identified the cause of haematospermia as being coitus reservatus. Conclusions. Haematospermia is a relatively rare and typically harmless condition, with a multifactorial aetiology. The presented case of coitus reservatus is an unpopular practice of sexual intercourse and a contraceptive method which is clinically manifested with haematospermia.

Introduction. Platelet-rich plasma (PRP) is a novel treatment of lichen sclerosus vulvae. Case presentation. We describe a case of lichen sclerosus vulvae in a 25-year-old woman treated with PRP. The diagnosis was confirmed by the histological examination. The patient’s symptoms were evaluated using Female Sexual Function Index (FSFI) questionnaire. PRP was prepared using Regen lab Cellular Matrix Kit and administered every two weeks, three times. The lesions disappeared at the visual examination. Conclusions. Our case confirms the effectiveness of PRP treatment for lichen sclerosus vulvae reported by other case reports. Nevertheless, future randomized controlled studies are needed to evaluate the safety of PRP treatment and to establish effective clinical protocols for its use in lichen sclerosus vulvae.

Introduction. Melanomas are the most aggressive skin carcinomas and a major cause of premature death from cancer. The risk factors for melanomas are UV rays, personal or family history of melanoma, large numbers of naevi, fair complexion, immunodeficiency, solar-damaged skin, etc. The scars from malignant melanoma on the face are serious challenge for the surgeons, so the successful plastic reconstruction of skin defects is very important for the normal life of the patient after surgery. Case presentation. A 82-year-old patient with a large malignant melanoma of the left cheek was admitted to the Clinic of Maxillo-facial Surgery, University Hospital „St. George”, Medical University of Plovdiv, Bulgaria, for treatment. The preoperative examination revealed the presence of a sloping heterogonic tumour, with axial dimensions of 55/28 mm, penetrating and engaging the dermis, subcutaneous tissue, levator oris and muscular orbicularis oris. Surgery was performed, under general anaesthesia. The tumour was removed, and the defect was repaired using several skin flaps, to use the adjacent tissues. The final outcome was favourable and the surgery was functionally successful. Conclusions. This case highlights the importance of an accurate diagnosis of malignant melanoma, that is essential for an adequate management and follow-up, considering its potentially aggressive behaviour.