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Fiziologia - Physiology  2009.19.1(61)CONTENTS

1. Ethanol Suppresses Seizure Incidence in Both Metaphit and Lindane Models of Generalized Epilepsy in Rats
Dragan Hrnčić, Aleksandra Rašić-Marković, Dragan Djuric, Veselinka Šušić, Olivera Stanojlović, Adela Joanta,
Manole Cojocaru................................................................................................................................................................................................4
2. Sensibility of Fungi Isolated from High Risk Wards
Liliana Dragomirescu, Monica Licker, Elena Hogea, Roxana Zugravu, Marcela Adămuţ, Carmen Tatu, Delia
Berceanu-Văduva, Ramona Pîrvan, Delia Muntean, Roxana Moldovan............................................................................................8
3. REVIEW: New Looks on the Biological Markers for Atherosclerosis in Coronary Patients
Adriana S. Potra, Virgil M. Luca, Constantin O. Luca ................................................................................................................. 13
4. Use of EMG Biofeedback as a Method of Muscular Training during Physical Exercise in Elders
Elena Butariu, Stelian Butariu, Andor Minodora, Lavinia Noveanu, Georgeta Mihalas ........................................................ 16
5. Smoking and Salivary Antioxidant Capacity
Gotia Smaranda Laura, Gotia Smaranda Rodica ..................................................................................................................... 21
6. MINIREVIEW: From Autologous Bone Transplantation to Tissue Engineering in Bone Grafting Orthopedic Surgery
Rares Bredicianu .......................................................................................................................................................................... 25
7. Milk and Acid Dairy Products Consumption in Timis County Adolescents. Evaluation of Some Risk Factors
Oana Suciu, Brigitha Vlaicu, Sorina Doroftei, Cristina Petrescu, Corneluţa Fira-Mladinescu, Salomeia Putnoky,Radu Bagiu, Delia Cheptănariu ................................................................................................................................................. 28
8. Associated Risks to the Sexual Act in Adolescents from Timis County
Bagiu Radu, Suciu Oana, Putnoky Salomeia, Vlaicu Brigitha, Rotaru Iulia ............................................................................ 32
9. The Eﬀect of the Long Term High Doses of Atorvastatin Therapy on the Recurrent Events in Acute Coronary Patients
Adriana S. Potra, Virgil M. Luca, Constantin O. Luca ................................................................................................................ 35
10. Capsule Endoscopy: Indications and Future Advances
Calin Cernescu, Ioan Sporea, Luminita Cernescu, Alina Popescu ............................................................................................ 40
CUPRINS
1. Etanolul reduce incidenta crizelor in modelele experimentale de epilepsie generalizata la sobolan cu metaﬁtati si lindan ethanol
Dragan Hrnčić, Aleksandra Rašić-Marković, Dragan Djuric, Veselinka Šušić, Olivera Stanojlović,
Adela Joanta, Manole Cojocaru ................................................................................................................................................... 7
2. Sensibilitatea fungilor izolati din sectiile spitalicesti cu risc crescut
Liliana Dragomirescu, Monica Licker, Elena Hogea, Roxana Zugravu, Marcela Adămuţ, Carmen Tatu,
Delia Berceanu-Văduva, Ramona Pîrvan, Delia Muntean, Roxana Moldovan ...................................................................... 12
3. REVIEW: Noi perspective asupra markerilor biologici ai aterosclerozei la pacientii coronarieni
Adriana S. Potra, Virgil M. Luca, Constantin O. Luca ................................................................................................................. 15
4. Utilizarea biofeedback-ului EMG ca metodă de antrenament muscular în cadrul exerciţiilor ﬁzice la vârstnici
Elena Butariu, Stelian Butariu, Andor Minodora, Lavinia Noveanu, Georgeta Mihalas ........................................................ 20
5. Fumatul si capacitatea antioxidanta salivara
Gotia Smaranda Laura, Gotia Smaranda Rodica ..................................................................................................................... 24
6. MINIREVIEW: De la transplantul osos autolog la ingineria tisulară în chirurgia ortopedică de grafare osoasă
Rares Bredicianu .......................................................................................................................................................................... 27
7. Consumul de lapte si produse lactate acide in randul adolescentilor di judetul timis. Evaluarea unor factori de risc
Oana Suciu, Brigitha Vlaicu, Sorina Doroftei, Cristina Petrescu, Corneluţa Fira-Mladinescu,
Salomeia Putnoky, Radu Bagiu, Delia Cheptănariu ...............................................................................................................................31
8. Riscuri asociate actului sexual la adolescenţi timişeni
Bagiu Radu, Suciu Oana, Putnoky Salomeia, Vlaicu Brigitha, Rotaru Iulia......................................................................................34
9. Efectele utilizarii pe termen lung a terapiei cu doze crescute de Atorvastatin in cazul evenimentelor recurentela pacientii coronariei acuti
Adriana S. Potra, Virgil M. Luca, Constantin O. Luca ......................................................................................................................................... 39
10. Capsula endoscopica: indicatii si perspective
Calin Cernescu, Ioan Sporea, Luminita Cernescu, Alina Popescu .......................................................................................................42
2009.19.1(61)  Fiziologia - Physiology

3

ETHANOL SUPPRESSES SEIZURE INCIDENCE IN BOTH
METAPHIT AND LINDANE MODELS OF GENERALIZEDEPILEPSY IN RATSDRAGAN HRNČIĆ1, ALEKSANDRA RAŠIĆ- MARKOVIĆ1, DRAGAN DJURIC1, VESELINKA
ŠUŠIĆ 2, OLIVERA STANOJLOVIĆ1 , ADELA JOANTA3, MANOLE COJOCARU4
1Laboratory of Neurophysiology, Institute of Medical Physiology “Richard Burjan”, School of Medicine, University of Belgrade, 11000 Belgrade, Serbia
2Serbian Academy of Sciences and Arts, 11000 Belgrade, Serbia
3Physiology Department, University of Medicine and Pharmacy, Cluj-Napoca, Romania
4Colentina Clinical Hospital, Clinical Immunology Department, Bucharest, Romania

ABSTRACTIn diﬀerent experimental epilepsy models, ethanol may have either proconvulsive or anticonvulsive eﬀects on epileptic activity. The aim of the present study
was to determine and compare the inﬂuence of ethanol on seizure incidence, main parameter of convulsive behavior, in models of generalized epilepsy inducedby lindane and methaphit. Adult male Wistar albino rats were randomly divided into following groups: control, saline – injected, dimetilsulfoxide – treated,ethanol (2 g/kg, i.p.), lindane (8 mg/kg, i.p.), ethanol (2g/kg, i.p.) + lindane (8mg/kg, i.p) in experiment I and metaphit (10 mg/kg, i.p.) and ethanol (2 g/kg,
i.p.) + metaphit (10 mg/kg, i.p.) groups in experiment II. Seizure incidence was deﬁned as percentage of animals with seizure out of total number of animals
in group. No signs of seizure behavior were observed in control and ethanol groups. Seizure incidence was signiﬁcantly lower in groups that received ethanol
in comparison with those received convulsive drug (either lindane or metaphit). These results indicate prominent anticonvulsive activity of acute ethanol inhigh dose in models of generalized seizures induced by lindane and metaphit.
Key words: ethanol, seizure incidence, metaphit, lindane, generalized epilepsy, rats

INTRODUCTION
In diﬀerent experimental epilepsy models, ethanol may have either proconvulsive or anticonvulsive eﬀects on epileptic activity (15). Chronic ethanol consumption
has been considered as major risk factor for epilepsy (4). It is also known that evenseizure series may occur during the withdrawal period (8). On the other hand, acuteadministration of high doses of ethanol exerts an inhibitory eﬀect on central nervous
system and increases the threshold of seizure activity (5, 19, 8).
The molecular mechanisms involving these interactions are still not wellknown since an ideal model for their study is currently unavailable. Ethanol exerts
its behavioral eﬀects largely by interacting with receptors of brain neurotransmitters(31). In particular, it has been shown that ethanol directly modulate the gammaaminobutyric acid type A (GABAA), N-methyl-D-aspartate (NMDA), glycine (32),neuronal nicotinic (3) and 5-hydroxytryptamine type 3 (5-HT3) receptors (20).
Namely, acute ethanol exposure potentiates ion currents at GABAA and glycine
receptors (21) but inhibits them at NMDA receptors (9).
Metaphit (1-[1-(3-isothiocyanatophenyl)-cyclohexyl]-piperidine), a
phencyclidine (PCP) analog (23) is known to induce audiogenic seizures in smallrodents (29). Metaphit model of generalized, reﬂex audiogenic seizures in rats
has been shown valuable for studying anticonvulsive proﬁle of numerous drugs(10, 26, 27).
Lindane (γ-1,2,3,4,5,6-hexachlorocyclohexane), an organochloride pesticide,is extensively used in agriculture and in human and veterinary medicines. Lindane
is postulated to interact with the picrotoxin site within the GABAA receptor chloride
channel and to suppress the GABA-induced chloride ﬂux into cells (1, 28). Modelof generalized epilepsy induced by lindane may be used as a suitable model for
testing new antiepileptic drugs (33). The aim of the present study was to determine
and compare the inﬂuence of ethanol on seizure incidence, main parameter ofconvulsive behavior, in models of generalized epilepsy induced by lindane andmethaphit.

MATERIALS AND METHODS
Animals
Adult 2-month-old Wistar rat males (180 - 220 g), raised at Military Medical
Academy Breeding Laboratories, Belgrade (Serbia) were used. They were kept
under controlled environmental conditions (22±1 °C, 50% relative humidity and12/12 h light/dark cycle with light switched on at 9 AM) and housed individuallywith free access to standard laboratory animal chow and tap water. Each animal
was used only once.
All experimental procedures were in full compliance with The European Council
Directive (86/609/EEC) and approved by The Ethical Committee of the Universityof Belgrade (Permission No 298/5-2).
Experiment I
A total of 48 animals were divided into ﬁve groups: 1. control, saline-injected(n=8); 2. dimethylsulfoxide (DMSO)-treated (n=8); 3. Lindane-administered (L,8 mg/kg; n=11), 4. Ethanol-treated group (E, 2 g/kg; n=8); 5. group received
ethanol (2g/kg) 30 min prior to lindane (8 mg/kg), EL (n=16). For intraperitoneal(i.p.) administration lindane was dissolved in DMSO.
Behavioral changes were observed during 30 minutes after lindane administration. Seizure incidence was deﬁned as percentage of animals with seizure out of
total number of animals in group.
Experiment II
A total of 19 animals was divided into following groups: metaphit administered (M, 10 mg/kg; n = 12) and metaphit + ethanol administered (EM, 10 mg/
kg metaphit + 2g/kg ethanol; n = 7). Ethanol was injected 8h after metaphit

Address for correspondence: Prof. Dr. Olivera Stanojlović, MD PhD, Institute of Medical Physiology, School of Medicine, University of Belgrade, Višegradska 26/II, 11000 Belgrade, Serbia, Phone/ Fax: ++38111-3607-085, e-mail: solja@afrodita.rcub.bg.ac.yu

4

Fiziologia - Physiology  2009.19.1(61)administration, when metaphit audiogenic seizures were fully developed.
None of the untreated animals screened for audiogenic susceptibility expressed
seizure activity. Audiogenic stimulation (AGS) was applied for 60 s using an electricbell (on the top of the cage) generating 100 ± 3 dB and frequency of 5-8 kHz. The
ﬁrst stimulation was applied 60 min after metaphit administration and thereafter
at hourly intervals during the experiment. Seizure incidence was deﬁned as inprevious experiment.
Drugs
Injected solutions given i.p. in a total volume of 0.1 ml were freshly prepared insterile physiological saline. Metaphit methanesulphonate, lindane and DMSO werepurchased from Sigma-Aldrich Chemical (St Louis, MO, USA). Absolute ethanol wasa product of Merck KGaA, Germany.
Data analyses
Signiﬁcance of the diﬀerences in the incidence of seizures between groups
was evaluated by Fisher’s exact probability test.

RESULTSNo signs of seizure behavior were observed in control and DMSO-treatedgroups, as well as in group of ethanol-treated animals (E). Seizure incidence in EL
group was signiﬁcantly lower in comparison with L group (p<0.05, Fig.1)
80

70

60

Seizure incidence (%)

50

40

30

*

20

10

0
L

EL
experimental groups

Fig. 1. Seizure incidence in lindane group (L, 8 mg/kg, i.p.) and group received
ethanol (2g/kg, i.p.) 30 min prior to lindane (8 mg/kg, i.p.) (EL). Signiﬁcance of thediﬀerences in the incidence of seizures between groups was evaluated by Fisher’s
exact probability test (*p<0.05)
Behavioral observation showed that the incidence of seizure responses on
AGS were the highest 7-12 h after metaphit injection. About 25% of metaphittreated animals never responded to AGS and behaved normally during this criticaltime period.
90
M

EM

80

70

Seizure incidence (%)

60

50

40

30

20

10

0
1

2

3

4

5

6

7

8

9

10

11

**

**

**

12

13

14

2009.19.1(61)  Fiziologia - Physiology

15

16
time (h)Time course study revealed high incidence reduction of all convulsive componentsof metaphit seizures occurring for 3 h after ethanol injection. Incidence of seizures
in EM group was signiﬁcantly reduced in comparison with group M in the threetime points 9h (p < 0.01), 10h (p < 0.01) and 11h (p < 0.01) (Fig. 2).
Figure 2: Time course of seizure incidence of metaphit-induced seizure followedby ethanol injection after 8 h. All animals were exposed to an intense AGS (100 ±3dB, 60 s) at hourly intervals after metaphit (10 mg/kg, i.p) injection during theexperiment. Incidence of seizures in metaphit + ethanol-treated group (EM) was
signiﬁcantly reduced in comparison with only-metaphit-treated group (M) as
indicated. Y-axis: seizure incidence (%) X-axis: time (h) after metaphit administration. Signiﬁcance of the diﬀerences in the incidence of seizures between groups
was evaluated by Fisher’s exact probability test (**p<0.01).

DISCUSSIONSIn the present experiments, we showed that ethanol (2 g/kg, i.p.) signiﬁcantly
suppressed seizure incidence in models of epilepsy induced by lindane (8 mg/kg,
i.p.) and metaphit (10 mg/kg, i.p +AGS).
Molecular mechanisms underlying the metaphit seizure are still unclear
and there are several hypotheses on its convulsive activity. Metaphit irreversibly
binds to the ligand-gated ion channels of the NMDA receptor complex, opening
it for Na+ and Ca2+ inﬂux and/or upregulating NMDA receptors and increasing
receptor aﬃnity for the binding of natural ligands, such as glutamate and aspartate(29). It is possible that metaphit inhibits the back-inﬂux mechanism transportsystem for glutamate at the luminal side of the brain capillaries, resulting in an
over-accumulation of glutamate in the brain, as suggested by Lipovac et al. (18),
who hypothesized a metaphit related inhibition of the glial uptake of glutamate
resulting in an increase in extracellular glutamate levels in the brain. Similarly,
metaphit aﬀects numerous neurotransmitter systems and receptors, such as serotonergic, dopaminergic, voltage-dependent sodium channels (24) and sigma
receptors (34). Ishida et al. (12) demonstrated that audiogenic seizures induced byhigh-intensity sound stimulation in genetically suspectible mice and rats expressed
typical and characteristic signs of epilepsy (running, clonus and tonus). In thismodel, convulsions were triggered by creating an imbalance between excitatory
and inhibitory brain activities, mainly by increasing excitatory inﬂuences related
to glutamate activity.
Lindane induces convulsions through diﬀerent neuronal mechanisms. Some ofthem include modiﬁcations in neurotransmitter levels in diﬀerent brain structures.
Pro-convulsive eﬀect of lindane may be explained by direct inﬂuence on GABA-ergic
system. Namely, lindane was postulated to interact with picrotoxin binding site
within the GABAA receptor chloride channel as well as to suppress GABA-induced
chloride ﬂux into cells (28), leading subsequently to seizure induction. Furthermore,
excitatory amino acid antagonists reduced pro-convulsive properties and toxicity
of lindane (2). Calcium mobilization may be an additional mechanism of lindaneinduced convulsions (25).
Other authors reported a similar data that provide evidence of anticonvulsive
eﬀect of ethanol (15). Namely, ethanol was found to act as lindane antagonist and its
central depressive eﬀects were predominant (14, 15, 36). The ethanol doses used in
the present experiment were similar to those applied in experiments of anticonvulsant eﬀects of ethanol against NMDA-, kainic acid- and picrotoxin-induced convulsions in rats reported by other authors (16). Ethanol (2 g/kg, i.p.) oﬀered protection
against these agents, and it was most eﬀective against picrotoxin and least eﬀective
against kainic acid. In co-medication with valproate and carbamazepine, ethanol
signiﬁcantly increased the anticonvulsant eﬀectiveness of both antiepileptic drugs(6). Furthermore, a number of previous in vivo studies in the pentylenetetrazol
5

(PTZ)-kindling and ferric chloride models in rats also suggest anticonvulsant andantiepileptic eﬀects of ethanol after acute application (7, 11).
The results of Rabe CS et al. (22) demonstrate that in vivo actions of ethanol on
the NMDA systems may be dependent on glycine concentrations at these receptor
sites. Hoﬀman PL et al.(9) suggested in diﬀerent studies using various concentrations of NMDA, as well as phencyclidine (PCP) and glycine, that ethanol aﬀected
the co-agonist binding site of the NMDA receptor-channel complex, rather than the
PCP recognition site. Yaka et al. (35) results suggest that the interaction between
tyrosine kinase Fyn and the NR2B subunit of the NMDA receptor mediates the acutesedative eﬀects of ethanol.
GABA systems have been also implicated as targets for ethanol at the cellular,
molecular and behavioural level (13). Ethanol acutely enhances Cl- transport
through the GABAA receptor channel (30). While much eﬀort concentrated on theeﬀects of ethanol on GABAA receptor-mediated synaptic transmission, GABAB
receptors are acknowledged as targets for ethanol (17).
These ﬁndings suggested that the anticonvulsant actions of ethanol may be
attributed to its ability to antagonize NMDA-mediated excitatory responses andfacilitate the GABAergic transmission.
Based on our results it could be concluded that ethanol has signiﬁcant andcomparable anticonvulsant activity in metaphit model of seizures and model ofseizure induced by lindane.

ACKNOWLEDGEMENTS
This work was supported by the Ministry for Science, Technology and Environment Protection of Serbia (Grant N#145029B).

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23:23–28

ETANOLUL REDUCE INCIDENTA CRIZELOR IN MODELELE EXPERIMENTALE DE EPILEPSIE GENERALIZATA LA SOBOLAN CU METAFITATI SI
LINDAN ETHANOLREZUMATIn diferite modele experimentale de epilepsie, etanolul are ﬁe efecte proconvulsivante, ﬁe anticonvolsivante asupra activitatii epileptice. Scopul acestui studiu
a fost sa determine sis a compare inﬂuenta etanolului in incidenta convulsiilor, cel mai important parametru al comportamentului convulsivant, la modelele
de epilepsie generalizata indusa de lindan si metaﬁtati. Sobolani adulti, masculi rasa Wistar albino au fost impartiti in urmatoarele grupuri: control, solutiesalina – injectare, dimetilsulfoxid – tratati, etanol (2 g/kg, i.p), etanol (2 g/kg, i.p.), lindane (8 mg/kg, i.p.), etanol (2g/kg, i.p.) + lindane (8mg/kg, i.p) inexperimentul I si grupurile cu metaﬁtati (10 mg/kg, i.p.) si etanol (2 g/kg, i.p.) + metaﬁti (10 mg/kg, i.p.) in experimentul II. Incidenta crizelor epileptice a fostdeﬁnita procentual in functie de numarul de animale cu crize, raportat la numarul total de animale din grupul respectiv. Nu au fost observate comportamente
convulsive la grupurile de control si la cele in care s-a folosit etanolul. Incidenta crizelor a fost semniﬁcativ mai scazuta in grupurile tratate cu etanol, comparativ
cu cele in care a fost administrate medicamente convulsive (ﬁe lindan, ﬁe metaﬁtati). Aceste rezultate indica activitatea anticonvulsivanta proeminenta aetanolului administrat in doze crescute la modelele animale de crize epileptice generalizate induse de lindan si metaﬁti.
Cuvinte cheie: etanol, incidenta crizelor, metaﬁtati, lindan, epilepsie generalizata, sobolani

2009.19.1(61)  Fiziologia - Physiology

7

SENSIBILITY OF FUNGI ISOLATED FROM HIGH RISKWARDSLILIANA DRAGOMIRESCU1, MONICA LICKER1, ELENA HOGEA1, ROXANA ZUGRAVU1, MARCELA ADĂMUŢ1, CARMEN TATU2, DELIA BERCEANU-VĂDUVA1, RAMONA PÎRVAN1, DELIA
MUNTEAN1, ROXANA MOLDOVAN1
1Department of Microbiology, University of Medicine and Pharmacy “Victor Babes”Timisoara
2Department of Physiology, University of Medicine and Pharmacy “Victor Babes”Timisoara

ABSTRACT
Background: The aim of this study was to establish the antifungal sensitivity of possible nosocomial fungi isolated from high-risk wards of County Emergency
Hospital Timisoara.
Material and method: The study took place during January 8, 2007 – June 15, 2008. During this period we have collected 564 biological samples
from the patients hospitalized in County Emergency Hospital Timisoara wards. Isolated pathological samples were striked on chloramphenicol and gentamicin
supplemented Sabouraud agar. API 20 C AUX kits were utilized for fungal identiﬁcation. Antifungal sensitivity was performed both by disk diﬀusion classicalmethod and ATB fungus.
Results: Mycology analysis of the pathological samples lead up to 314 Candida sp. strains, 28 Cryptococcus neoformans strains, 19 Aspergillus sp. strains.
Antifungal tests revealed a high resistance to amphotericin B for a number of isolates: C.albicans-27, C.non-albicans-13, Cryptococcus neoformans-8. Fluconazole resistance was present for: 51 C. albicans strains, 27 C.non-albicans strains and 4 Cryptococcus neoformans strains. High resistance to clotrimazole
had: 61 C. albicans strains, 37 C. non-albicans strains, and 3 Cryptococcus neoformans strains. 8 from Aspergillus fumigatus strains showed resistance toﬂuconazole and miconazole.
Conclusions: The number of resistant fungi is continuously increasing in hospitals around the world and nocomial infections treatment for these microorganisms requires high costs, it’s implied to introduce some guides and protocols for prevention and control of resistant fungal strains spreading.
Key words: antifungal sensitivity, nosocomial fungi, fungal diseases, biological samples, intensive care unit

INTRODUCTION
Fungal infections represent an important acute problem especially in hospital’s high-risk wards. In the USA, fungi are thought to be the fourth in place as
nosocomial infectious agent and these germs are responsible of more than 5% of
all sepsis cases (5).
Fungi are causing nosocomial infections, especially in Intensive Care Wards
where the number of immunocompromised patients is high. The importance offungi in nosocomial infections etiology has increased during the last two decades
and there have been reported worldwide nosocomial outbreaks. Candida species
have become dominant germs for many immunosupressed patients. Localized orsystemic, Candida infections can be found in neutropenic patients, in patients withimmunosuppressive therapy, in patients of Intensive Care Units. Fungi are more
frequently isolated in Intensive Care Wards, due mainly to the increased number oftherapeutic and diagnostic invasive procedures used in Intensive Care during the lastyears and to the microorganisms’ ability to survive long periods in the environmentand on the skin of medical staﬀ (13). The risk factors for fungal nosocomial infection are represented by previous hospitalization, immunosupressed patient status,
mechanic ventilation, respiratory or cardiac failure, previous infections and anti
infectious therapy and by the presence of central or urethral catheters.
From all human pathogen fungi, Candida albicans, Candida non albicans species and Cryptococcus neoformans are producing most of the infections, often very
severe, which require prolonged treatment and secondary prophylaxis (3).
For many decades, only the polyenes, represented by amphotericin B, were used
for systemic infection treatment. Amphotericin B has preserved its eﬃciency for along time, together with its adverse eﬀects, especially nephrotoxicity (4). The

progress in antifungal therapy led to the rise of new and more eﬀective derivates,
less nephrotoxic, more expensive.
Dermato-therapy was marked by the presence of azole antifungals. Introducerea antifungicelor azolice a marcat dezvoltarea dermatoterapiei. The azoles
are distinctive by their wide spectrum, being active on dermatophytes, yeasts anda large number of human pathogenic molds.
In 1969 under the name of imidazole derivatives clotrimazole and miconazole
appeared, followed by econazole and ketoconazole used for topic treatment ofskin mycoses. Ketoconazole was the ﬁrst wide spectrum systemic antifungal fromthis group.
Systemic treatment of mycoses has been improved by the discovery of
ﬂuconazole and itraconazole, antifungal drugs from the class of imidazole derivatives (5, 9).
Amorolﬁne belongs to a new class (morolphine derivatives) – topic antifungal. It’s fungistatic or fungicide eﬀect is based on fungal membrane allteration,
primary target being sterols biosynthesis. Terbinaﬁne, an oral systemic antifungal
belongs to the group of allylamines.
Voriconazole is a new wide spectrum triazole, available as an oral
or intravenous drug. It is used in treatment of Fusarium spp infections of patients
who do not tolerate other antifungal agents or of patients with resistant infections
to other antifungals. It has been proved that voriconazole is more eﬀective thanamphotericin B (partial or complet response 53% versus 32% in treatment week
12, survival rate 71% versus 58%) in primary treatment of invasive aspergillosis.
Like other triazoles, voriconazole is generally well tolerated (2, 7).

Received December 2008. Accepted January 2009. Address for correspondence: Dr. Liliana Dragomirescu, Microbiology Department, “Victor Babes” University of Medicine and Pharmacy Timisoara, Eftimie Murgu
Square No. 2A, 300041, Timisoara

8

Fiziologia - Physiology  2009.19.1(61)The newest antifungal agents are from Echinocandins class – a new semi
synthetic lipopeptides with a selective antifungal activity. Capsofungin is used inprimary therapy of invasive candidosis, including candidemia, therapy of patientswith resistant aspergillosis (or intolerant ones) to other antifungals. It has been
proved that capsofungin has similar activity with amphotericin B in treatment ofpatients with candidemia. A good therapeutic response was obtained on 73.4%of the patients treated with capsofungin and on 61.7% of the patients treated withamphotericin B. Capsofungin was well tolerated besides amphotericin B (1).
Now there are diﬀerent antifungal agents to study: a liposomal form of nystatin,
new triazoles (posaconazole and ravoconazole), echinocandins (anidulafungin andmicafungin) etc. So far it is known that: new agents of the respective class have a lower
toxicity, drug interactions are less, pharmacokinetics and pharmacodynamic properties are more in favor, and possible a better activity on resistant pathogens (7).

RESULTS AND DISCUSSIONS
During January 8, 2007 – June 15, 2008, 361 fungi strains were isolated
from 191 patients. Fungal infections were proved on 71 women (37.17%) and
120 men (62.82%) with ages between 15 and 81 years old. (Figure 1) Pathological samples most frequent isolated were pharyngeal swabs (23.82%), blood(17.45%), bronchial aspirates (14.95%), urines (8.86%), wound secretions(8.58%) and lingual secretions (7.20%) (Table I).
37%

37%

63%
Fig. 1. Gender distribution of patients

MATHERIAL AND METHODSThis study took place in Clinical Emergency County Hospital Timisoara (SCJUT)
and isolation and antifungal activity tests were performed at the Bacteriology Department of the Central Analysis Laboratory of SCJUT. Between January 2007- June
15th 2008, 564 biological samples were collected from the patients admitted in
diﬀerent wards of Clinical Emergency County Hospital Timisoara. Patients included inthis study belong to both genders and are over 15 years old. Before including themin this study, all the patients were hospitalized at least 48 hours, so the nosocomial
infection criterion was fulﬁlled.
Collected pathological samples were represented by: bronchial aspirates,
sputum, wound secretions, blood for blood culture, urine, peritoneal ﬂuid etc. Pathological samples were striked on Sabouraud with chloramphenicol and gentamicin
media. The plates were incubated in aerobiosis environment, on 35-37° C, 24-48
h (up to 4 days).Gram stained smears were done from the pathological samples.
Mycology diagnosis was based on colony appearance on culture media: Sabouraud
and Chromagar (agar, peptone, special chromogenic mixture, chloramphenicol)(6, 8). For fungal identiﬁcation we have used API 20 C AUX kits. Api Candida kits(sugar fermentation) allow quick identiﬁcation (18-24 hours) of 14 yeasts species:
C. albicans, C. famata, C. glabrata, C. guilliermondii, C. kefyr, C. krussei, C. lusitaniae,
C. parapsilosis, Candida tropicalis, Cryptococcus neoformans, Geotrichum (candidumşi capitatum), Saccharomyces cerevisiae and Trichosporon sp.
Microscopy of culture smears was a method to conﬁrm mycology diagnosis.
Microscopicallly examined, A. fumigatus presents sporulare ends with vesicles anda chain of philides on the external two thirds of the surface. Conidia are disposed inparallel chains. A. niger has sporulare ends with conidiophores, globular vesicles andphilides disposed in one or two rows all over the surface (10, 12).
Also, the antifungal sensitivity was determined, both by classical method of
disk diﬀusion and by ATB fungus.

males

males

femalesfemales63%

Table I. Fungal strains distribution according to thepathological samples from where it have been isolated
Pathological sample
Pharyngeal swab
Blood
Bronchial aspirate
Urine
Wound secretion
Lingual secretion
SputumCatheter tip
Vaginal discharge
Peritoneal fluid
Ear discharge
Vomit liquid
Total

Number of strains
86
63
54
32
31
26
25
15
12
8
6
3
361

Percent
23,82
17,45
14,95
8,86
8,58
7,20
6,92
4,15
3,32
2,21
1,66
0,83
100%

Mycology analysis of the pathological samples allowed us the isolation of 361
fungi strains: 314 Candida sp. strains, 28 Cryptococcus neoformans strains, 19 strains ofAspergillus sp.
From 314 Candida sp. strains, 213 were Candida albicans and 101 Candida non albicans(C. tropicalis-46 strains, C. krussei-27 strains, C. glabrata-19 strains, and C. parapsilosis-9
strains). From 19 Aspergillus sp. strains, 12 were Aspergillus fumigatus, 4 Aspergillus

ﬂavus and 3 Aspergillus niger strains (Table II, III and IV).
Table II. Candida sp. strain distribution according to isolated pathological samples

Pathological sample
Pharyngeal swab
Blood
Bronchial aspirate
Urine
Wound secretion
Lingual secretion
SputumCatheter tip
Vaginal discharge
Peritoneal fluid
Ear discharge
Vomit liquid
Total

C. albicans
49
35
29
13
22
20
19
10
9
2
2
3
213

2009.19.1(61)  Fiziologia - Physiology

C. tropicalis
15
7
6
3
5
2
4
1
2
1

C. krussei
9
4
5
5

46

27

1
1
1
1

C. glabrata
5
3
4
1
2
1
1
1
1
19

C. parapsilosis
4
2
2

1
9

9

Table III. Cryptococcus neoformans strain
distribution according to isolated pathological samples
Pathological sample
Pharyngeal swab
Blood
Bronchial aspirate
Urine
Wound secretion
Lingual secretion
SputumCatheter tip
Vaginal discharge
Peritoneal fluid
Ear discharge
Vomit liquid
Total

Cryptococcus neoformans
4
6
6
4
2
2
1
2
1

In some pathological samples we have identiﬁed fungal and microbial association, especially Staphylococcus aureus, Klebsiella pneumoniae, Escherichia coli,
Pseudomonas aeruginosa, Acinetobacter calcoaceticus baumannii complex. The
most frequent associations were represented by Candida albicans + Staphylococcus
aureus - 25 cases, Candida tropicalis + S. aureus- 11 cases, Candida albicans +Acinetobacter calcoaceticus baumannii complex – 7 cases, Aspergillus fumigatus+ Pseudomonas aeruginosa – 6 cases, Cryptococcus neoformans + S. aureus– 5 cases, Aspergillus ﬂavus + Escherichia coli – 2 cases, Aspergillus niger +Pseudomonas aeroginosa – 2 cases, Aspergillus niger + Klebsiella pneumoniae– 1 case (Figure 3).

28

Table IV. Aspergillus sp. strains distribution according
to isolated pathological sample
Pathological sample
Pharyngeal swab
Blood
Bronchial aspirate
Urine
Wound secretion
Lingual secretion
SputumCatheter tip
Vaginal discharge
Peritoneal fluid
Ear discharge
Vomit liquid
Total

Aspergillus
fumigatus

Aspergillus flavus

Aspergillus niger

4
2
3

1
2
1

1

1
1

Fig. 3. Fungal and microbial association

1
12

4

2

200

3

150

During this study we have isolated 85 strains from the ICU ward of Clinical
Emergency County Hospital Timisoara, 124 strains from the surgical wards of
SCJUT (Reconstructive surgery – 31 strains, Surgical wards I, II and III – 17 strains,
Orthopedics – 22 strains, Urology – 19 strains, Brain surgery – 18 strains, Vascularsurgery – 17 strains), 33 strains in Nephrology department, Internal Medicine – 27
strains, Neurology – 10 strains, Gastroentrology - 18 strains, Cardiology – 18 strains,
Endocrinology– 21 strains, Traumatology – 12 strains, Hemodialysis – 13 strains.
.
These aspects are revealed in Figure 2

186

100
50

39

27
7

0

22
5

18

8

1

20

C.
C.
C.
C.
C.
alb
kru
gla
tro
neo
pic
i ca
bra
sse
f or
ali
ns
i
ma
t
a
s
ns

ResistantSensitive

Fig. 4. Isolated fungal strains resistance to amphotericin B
13

Hemodialysis

250

12
21
18

Traumatology
Endocrinology
Cardiology

200

18
10

Gastroenterology
Neurology

150
162

27
33

Internal Medicine
Nephrology

100

124

Surgical wards

85

ICU

50
51

0

50

100

150

Fig. 2. Comparison between isolated strain numbers in SCJUT wards

18
14

0

9

17
2

7
2

24
4

4
8

2
2

s
vu
fla tus
A.
ga
s
mi
fu
an
A. formoisne ilos
C.
ps
ra
pa ta
C.
a
br
gla
i
C.
se
us s
kr
i
C. icalp
tro s
C. canialbC.

No of Isolated Strains

32

Resistant strains

Sensitive strains

Fig. 5. Isolated fungal strains resistance to ﬂuconazole

10

Fiziologia - Physiology  2009.19.1(61)An important objective of this study was the antifungal sensitivity testing. Thiswas performed for all 361 isolated fungal strains.
Disk diﬀusion test revealed a high resistance to amphotericin B for a number ofisolates: C.albicans-27, C.non-albicans-13 (7 C. tropicalis strains, 5 C. krussei strains
and 1 C. glabrata strain), Cryptococcus neoformans-8. Fluconazole resistance waspresent for: 51 strains of C. albicans, 27 C. non-albicans (14 C. tropicalis strains, 9 C.
krussei strains, 2 C. glabrata strains and 2 strains of C. parapsilosis) and 4 Cryptococcus neoformans. High resistance to clotrimazole had: 61 strains of C. albicans, 37
strains of C. non-albicans (8 strains of C. tropicalis, 13 strains of C. krussei, 14 strainsof C. glabrata, 2 strains of C. parapsilosis) and 3 Cryptococcus neoformans. 8 from
Aspergillus fumigatus strains showed resistance to ﬂuconazole and miconazole and2 strains of A. ﬂavus were resistant to ﬂuconazole.
C. albicans strains were also tested to voriconazole. Form 213 C. albicans strains,
58 were resistant to voriconazole.
In this study were include patients hospitalized in diﬀerent wards of Clinical
Emergency County Hospital Timisoara, some of them being the second or the thirdtime hospitalized. Blood cultures were performed only for febrile patients. 63 blood
cultures were positive (51 Candida sp. strains, 6 Cryptococcus neoformans strains
and 6 strains of Aspergillus sp.). In our study the oral candidosis was the mostfrequent infection, which led to isolation of 82 Candida sp. strains from pharyngeal
swabs and 23 Candida sp. strains from lingual secretions. So it can be explained
why repeated and often long treatment led to antifungal resistance. There are a lotof studies which proved that long time usage of ﬂuconazole for oro-pharyngeal
candidosis can led to ﬂuconazole resistance by selective pressure, phenomenon
which appears after using this drug for prophylaxis (5).
Like in other studies, Aspergillus sp. strains remained sensitive to amphotericin
B, 10 Aspergillus sp. strains being resistant to ﬂuconazole. Bronchial colonization
with Aspergillus sp. was less frequent – 4 isolated strains from bronchial aspirates(2, 11).
Literature data show a marked and alarmed increasing of fungal strains number
with resistance to antifungals. Thus, in Europe, similar studies have showed this,although resistance percent vary from country to country, partial because sensitivity
data are obtained through diﬀerent methods. Therefore it’s implied to establish astandard method for antifungal sensitivity testing and a breakpoint for MIC, for abetter observation of resistance tendencies. Antifungal resistance surveillance, studyof resistance mechanisms, using in medical practice of some other antifungal classes
to which the fungi are still sensitive, introducing in therapy of new antifungals(new triazoles: posaconazole, ravuconazole, echinocandins: anidaulafungin andmicafungin) and preventing the spread of resistant strains are important measuresrequired for impact control of these multiresistant microorganisms (11).

ﬂuconazole, clotrimazole, miconazole and a good sensitivity to amphotericin B.
5.
An alternative to the actual treatment of fungal nosocomial infections
is the use in medical practice of some antifungals to which the fungal strains are
sensitive (voriconazole, capsofungin etc.).
6.
The number of resistant fungi is continuously increasing in hospitals
around the world and nocomial infections treatment for these microorganisms
requires high costs, it’s implied to introduce some guides and protocols for prevention
and control of resistant fungal strains spreading.

REFERENCES
1.Denning DW. Echinocandin antifungal drugs, Lancet, 2003, 362, 1142-1151
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CONCLUSIONS
1.
361 fungal strains have been isolated from the hospitalized patientsof SCJUT wards, during January 8 2007 – June 15 2008. Out of these, Candida sp.
strains were 314, most of the strains being isolated from pharyngeal swab, bloodand bronchial aspirates.
2.
We have isolated 85 fungal strains in ICU ward of SCJUT, 124 strainsfrom Surgical wards, 33 strains in Nephrology, Internal Medicine – 27 strains,
Neurology – 10 strains, Gastroenterology – 18 strains, Cardiology – 18 strains, Endocrinology – 21 strains, Traumatology – 12 strains, Hemodialysis – 13 strains.
3.
The most frequent fungal and microbial associations were represented
by Candida albicans + Staphylococcus aureus - 25 cases, Candida tropicalis +S. aureus- 11 cases, Candida albicans + Acinetobacter calcoaceticus baumannii
complex – 7 cases, Aspergillus fumigatus + Pseudomonas aeruginosa – 6 cases.
4.
For some fungi strains we have pointed out an increased resistance to2009.19.1(61)  Fiziologia - Physiology

11

SENSIBILITATEA FUNGILOR IZOLATI DIN SECTIILE SPITALICESTI CU
RISC CRESCUTREZUMAT
Scop: Scopul urmărit în acest studiu a fost determinarea sensibilităţii la antifungice a speciilor de fungi cu potenţial nosocomial izolate în secţiile cu risc crescut
ale Spitalului Clinic Judeţean de Urgenţă din Timişoara.
Material şi metoda: Studiul a fost efectuat în perioada 8 ianuarie 2007-15 iunie 2008. În acestă perioadă am recoltat un număr de 564 de probe biologice dela pacienţii internaţi în secţiile Spitalului Clinic Judeţean de Urgenţă Timişoara. Produsele patologice izolate de la pacienţii internaţi au fost însămânţate pe
mediul Sabouraud cu adaus de cloramfenicol şi gentamicină. Am utilizat pentru identiﬁcarea fungilor galerii API 20 C AUX. S-a determinat de asemenea şisensibilitatea la antifungice atât prin metoda clasică a antifungigramei difuzimetrice cât şi prin utilizarea ATB fungus.
Rezultate: Analiza micologică a produselor patologice ne-a permis izolarea unui număr de 314 tulpini de de Candida sp., 28 tulpini de Cryptococcus neoformans,
19 tulpini de Aspergillus sp. Antifungigrama a arătat rezistenţă crescută la amfotericină B pentru un număr de izolate: C.albicans-27, C.non-albicans-13,
Cryptococcus neoformans-8. Rezistenţă la ﬂuconazol au avut: 51 tulpini de C. albicans, 27 C.non-albicans şi 4 Cryptococcus neoformans.
Concluzii: Numărul tulpinilor de fungi cu rezistenţă la antifungice ﬁind în continuă creştere în instituţiile spitaliceşti din întreaga lume, iar tratamentul
infecţiilor nosocomiale cu aceste microorganisme implicând costuri mari, se impune implementarea unor ghiduri şi protocoale de prevenire şi control arăspândirii tulpinilor de fungi rezistente.
Cuvinte cheie: sensibilitate la antifungice, fungi cu potenţial nosocomial, infecţii fungice, probe biologice, secţia de terapie intensivă

12

Fiziologia - Physiology  2009.19.1(61)REVIEW NEW LOOKS ON THE BIOLOGICAL MARKERS FORATHEROSCLEROSIS IN CORONARY PATIENTSADRIANA S. POTRA, VIRGIL M. LUCA, CONSTANTIN O. LUCA
Institute of Cardiovascular Medicine Timisoara, "Victor Babes" University of Medicine and Pharmacy, Timisoara, Romania

ABSTRACTAt this moment, there are several models for the evaluation of the cardiovascular risk in the general population. These models include the classical cardiovascular risk factors: dislipidemy, high arterial essential blood pressure, diabetes, smoking, etc. Such models are not perfect, that is why, in the last years, alarge number of biochemical parameters have been evaluated in several studies. The data existing today allows us to centralise these biological markers foratherosclerosis in ﬁve groups according to the pathogenetic mechanism: inﬂammation markers, lipoproteic markers, haemostasis markers, oxidation markers
and other markers, all of these biological markers for atherosclerosis being presented in this paper.
Key words: risk factors, markeri, dyslipidemia, hypertension, atherosclerosis

INTRODUCTION
The classical factors of cardiovascular risk ( dislipidemy, arterial blood pressure,diabetes and smoking, etc) have been integrated in multiple models for the evaluation of cardiovascular events risk in the general population (1). This concept ofglobal estimation of the risk allows a more accurate prediction of the cardiovascularrisk in coronary patients (9).
As it has been demonstrated in multicentric studies (7), the traditional risk
factors explain over 90% of the myocardial infarct (7). The algorithms developed on
the basis of these classical risk factors allow a classiﬁcation of the individuals

into three risk categories: low, medium and high (8). Nevertheless, one has totake into account the fact that these models are not perfect. It is demonstrated that
one third of the patients initially classiﬁed as having a medium cardiovascular risk
were the victims of a myocardial infarct. Therefore, during the last years a large number of biochemical parameters were evaluated as having potential cardiovascular risk
(5). It were established the following biological parameter in order to determine its
use in the clinical practice as a cardiovascular risk factor (Table I).

Table I. The Biological markers for atherosclerosis in coronary patients

Inflammation markers

Lipoproteic markers

Haemostasis markers

Oxidation markers

Other markers

Ultrasensitive PCR

Lp

fibrinogen

ADMA (asimetric dimethilarginina)

microalbuminuria

Seric Amiloid A (SAA)

LDL

plasma D-dimers

Lp-PLA2

natriuretic peptide

cytokine (IL6, IL8)

Residual lipoproteins

fibrinopeptides

homocystheina

adiponectina

Cell Adhesion molecules

oxidized particles of
LDL

Plasminogen Activator
Inhibitor-I (PAI-I)( VCAM-I, ICAM-I)

genotypes of Apolipoproteina E

Tissue Plasminogen Activator (TPA)

LP-PLA2 (lipoprotein asociated to A2)

Coagulation Factors V, VII,
VIII

CD4 solubil ligand

activation and aggregationof thrombicytes

number of leucocytes

Received January 2009. Accepted February 2009. Address for correspondence: Dr. Adriana Potra, Institute of Cardiovascular Medicine Timisoara, “Victor Babes” University of Medicine and Pharmacy Timisoara,
Eftimie 2A Murgu Square, 300041, phone/fax: 0256490507

2009.19.1(61)  Fiziologia - Physiology

13

The evaluation of these biological markers is precise and reproducible bymeans of standard international measures and they are better correlated withthe evolution of patients in comparison with the old cardiovascular risk factors(3). The amelioration of the predictive value of the new cardiovascular risk factors
has also greater importance, especially in subgroups of patients (e.g. women,
kidney disease, cardiovascular disease, etc) as well as for therapy and ﬁnally forthe knowledge of the psychopathological mechanism witch explains its role in
the process of atherogenesis.

INFLAMMATION MARKERS
Ultrasensitive PCR and lipoprotein associated to phospholipase A (Lp-PLA2)
are the two markers of inﬂammation with prognostic value in ATS (atherosclerosis)(3). There is a major interest in the ultrasensitive PCR, because its major role in thepathogeny of ATS is already known, representing an independent RF (risk factor). PCR
with values over 1mg/l are considered to be associated with the moderate increase ofrisk, which becomes high with values over 3 mg/l. Numerous studies show that thedecrease of ultrasensitive PCR induced by therapy with satins, besides the reductionof cholesterol LDL, determines additional clinical beneﬁts(1). The patients with themost reduced levels of LDL cholesterol and of the ultrasensitive PCR beneﬁt most of
the treatment with satins (PROVEIT TIMI 22). The completion of the JUPITER study(for primary prevention) will bring decisive information to the patients with normalcholesterol, but with increased values of the ultrasensitive PCR(7).
Lp-PLA2, secreted by the inﬂammatory cells, monocytes, T cells and mastocytes is associated with high risk for cardiovascular events, independent of traditional
RF and other inﬂammatory RFs. In addition, Lp-PLA2 is a RF for the relapse of thecoronary accident.

LIPOPROTEIC MARKERS
The lipoproteic markers are numerous and many of them are known, but a
special importance in the ATS process have the lipoprotein A (Lp A), small dense
particles of LDL cholesterol and the apoliprotein E(2).
Lp A is the form under which the total cholesterol is transported in the blood,
only 6% is transported in the form of Lp B. There are already many studies whichhave proved the connection between the blood level of Lp A and the coronary risk.
Most laboratories have ﬁxed the level of 300 mg/l as the threshold for cardiovascularrisk. The fact that Lp A is a risk factor for stroke with elderly and young persons isalready known. Unfortunately, medication does not inﬂuence the blood level of
Lp A, with the exception of niacin (it reduces by 25% the Lp A level in the blood)and of anabolisant steroids(4).
The small and dense particles of LDL cholesterol are always present in trigliceridemy and type 2 diabetes. The macrophages in the arterioles phagocyte theseparticles and become yeasty cells, characteristic for the incipient phase of ATS(7).
The biological eﬀect of these small and dense particles of LDL cholesterol are theendothelial dysfunction, the recruitment of monocytes, the molecular expressionof adhesion molecules at the surface of endothelial cells and the formation ofyeasty cells.
The apolipoprotein E has a multifunctional role: it is involved in the lipidic
metabolism and it has also a neurobiological function. In the plasma, it is present
in three isoform: apo E2, E and E4. The most frequent isoform of the apolipoprotein
E is apoE3, with an important role in the lipidic homeostasis. It seems that apo E4
has an important role in the pathogeny of Alzheimer disease, and apo E2 is involvedin the pathogeny of the Fredrichson disease (8).

14THE HAEMOSTASIS MARKERS
The ﬁnal event in the pathogeny of ATS is thrombosis, which lies at the basisof myocardial infarct and of the ischemic stroke (4). This is the reason why great
accent was put on the study of the coagulation factors, out of which the ﬁbrinogen
has an important role.
In many studies the ﬁbrinogen was identiﬁed as an independent cardiovascular RF. Just like PCR, the ﬁbrinogen is an acute phase reactive (2). Therefore, theﬁbrinogen is not useful in the estimation of the cardiovascular risk in the case of
acute phase diseases. Currently, the serum value of the ﬁbrinogen is not establishedconsensually, but most clinical studies established the value of 3.5 g/l as thethreshold from which the cardiovascular risk increases.
D-dimer is a marker of the activation of coagulation and the formation of theﬁbrin, as opposed to ﬁbrinogen. With coronary patients, the increase of D-dimerics
is associated with the increase of the cardiovascular risk (3).

THE OXIDATION MARKERS
An important process in the ATS pathogeny is the oxidative lipidic stress. The
best studied markers are the already discussed Lp A, ADMA (asymmetric dimethyl
arginine) or homocysteine (5). ADMA is an endogen inhibitor of all the major
isoform of the endothelial synthesis of ON, thus contributing to the endothelial
dysfunction. The ADMA values are higher in the case of IR, hypercholesteromy,
hypertrigliceridemy, insulin resistance, diabetes, hyperhomocysteinemy, andhigh blood pressure. ADMA was identiﬁed as an independent cardiovascular RFof the ATS progression and of the cardiovascular mortality, of the total mortality
in coronary patients (6).
Homocystein is an independent cardiovascular RF with a lower predictive
value than the traditional RF, or than PCR and ﬁbrinogen. Homocystein increases
the cardiovascular risk of the subjects with higher global risk. The limit values of
the homocystein vary between 10-16 ÷mol/l. The folic acid or its association withvitamin B6 and B12 reduce the value of the homocystein, but the studies concerning
the decreasing of the level of homocystein are not conclusive yet (8).

OTHER MARKERS
Microalbuminuria (30-300 mg/24 hours) is considered a micro or macrovascular lesion marker in diabetes patients. Because of this reason and of the therapeutic
beneﬁt proved by IECA and the antagonists of the angiotensine II reception in thepresence of albuminuria, certain recommendations suggest the identiﬁcation ofthese urinary parameters for the prediction of the cardiovascular risk with diabetes
and high blood pressure patients(8). It has been demonstrated in the specialized
literature that microalbuminuria is a cardiovascular risk marker, going beyond the
traditional RFs, but the use of this fact is limited because there is no clear consensus
concerning the values of this marker.
The albumen concentration in the spontaneous urine has a good correlation
with the urinary secretion/24 hours, only if the urine is collected in a well deﬁned
way (the second urine in the morning). The value of this parameter is strengthenedby the ratio between urinary albumen and creatinine, ratio which depends on themuscle mass and requires reference to age and sex (2).
The association between advanced chronic kidney failure and the cardiovascular risk has been known for years. In the Rotterdam study it was proved that the
cardiovascular risk is already increased in the case of deteriorated kidney function
with normal creatinine, but also with increased C cyctatine (kidney function marker
more sensitive than creatinine). The increase of the C cyctatine value is associatedin many studies with the cardiovascular risk (11).
Fiziologia - Physiology  2009.19.1(61)The adiponectine is a new marker which has a antiaterogenetic activity andis produced solely by the white adipose tissue. The adiponectine is reversely correlated with the resistance to insulin and the endothelial dysfunction (10). Low
values of the adiponectine are associated with NO in low concentrations and with
angiotensine II with high values. Knowing this, we can say that the adiponectine
has an important role in the prediction of the cardiovascular risk. Currently, there
is only one prospective study performed in the USA, with evidence concerning thesigniﬁcant reduction of the myocardial infarct risk associated with high levels of
adiponectine(11).
BNP and pro-BNP is a peptide secreted by the cardiac muscle cells, as a responseto the increase of the pressure consecutive to the ventricular volumetric increase andsecondary to a pressure overcharge(9). Active BNP is secreted in the circulation inassociation with an inactive amono-terminal peptide (NT pro-BNP).
REFERENCES
1.
The Heart Protection Study Investigators. MRC/BFT Heart Protection
Study of cholesterol lowering with simvastatin in 20536 high-risk individuals: a
randomised placebo-controlled trial. Lancet 2002;360:7-22.
2.
2. Pitt B, Waters D, Brown WV, van Boven AJ, Schwarts L, Title LM,
Eisenberg D, Schurzinske L, McCormick LS. Aggressive lipid-lowering therapy
compared with angioplasty in stable coronary artery disease. Atorvastatin versus
revascularisation Treatment Investigators. N ENGL J Med 1999; 341:70-76.
3.
Schwarts GG, Olsson AG, Ezekowitz MD, Ganz P, Oliver MF, Waters D,
Zeiher A, Chaitman BR, Leslie S, Stern T. Eﬀects of atorvastatin on early recurrent

ischaemic events in acute coronary syndromes: the MIRACL study: a randomized
controlled trial. JAMA 2001; 285:1711-1718.
4.
Cannon CP, Murphy SA, Braunwald E. Intensive lipid lowering withatorvastatin in coronary disease (authyor reply). N Engl J Med 2005;353:93-96
5.
Paoletti R, Gotto AM Jr, Hajjar DP. Inﬂammation in atherosclerosis andimplication for therapy. Circulation 2004;109(suppl. 1):III20-III26.
6.
Apple FS, Wu AH, Mair J, Ravkilde J, Panteghini M, Tate J, Pagani F, Christenson RH, Mockel M, Danne O, Jaﬀe AS. Future biomarkers for detection of ischemia
and risk stratiﬁcation in acute coronary syndrome. Clin Chem 2005;51:810-824
7.
Davingnon J. Beneﬁcial cardiovascular pleiotropic eﬀects of statins.
Circulation 2004;109(suppl. 23):III39-III43.
8.
Ridker PM, Morrow DA, Rose LM, Rifain N, Cannon CP, Braunwald E.
Relative eﬃcacy of atorvastatin 80mg and pravastatin 40mg in achieving the dual
goals of low-density lipoprotein cholesterol ,70mg/dl and C-reactive protein <2mg/l:
an analysis of the PROVE IT TIMI-22 trial. J Am Coll Cardiol 2005;45:1644-1648.
9.
Waters DD. Safety of high dose atorvastatin therapy. Am J Cardiol
2005;96:69F-75F.
10.
Wiviot SD, Cannon CP, Morrow DA, Ray KK, Pfeﬀer MA, Braunvald E. Can
low-density lipoprotein be too low? The safety and eﬃcacy of achieving veru low
low-density lipoprotein with intensive statin therapy: a PROVE IT-TIMI 22 substudy.
J Am Coll Cardiol 2005;46:1411-1416
11.
Bavry AA, Mood G, Kumbhani DJ, Borek PP, Askari AT, Bhatt DL. Long
term beneﬁt of statin therapy initiated during the hospitalisation for an acute coronary syndrome: a systematic review of randomized trials. Am J Cardiovasc Drugs, inpress.

NOI PERSPECTIVE ASUPRA MARKERILOR BIOLOGICI AI ATEROSCLEROZEI LA PACIENTII CORONARIENIREZUMATIn prezent, se cunosc cateva modele de evaluare a factorilor de risc cardiovasculari in populatia generala. Aceste modele include factorii clasici de risc cardiovascular: dislipidemia, hipertensiunea arteriala, diabetul zaharat, fumatul, etc. Insa aceste modele nu sunt perfecte si de aceea, in ultimii ani, s-a studiat unnumar foarte mare de parametric biologici. Datelor existente astazi ne permit centralizarea markerilor biologici aterosclerotici in cinci grupe, dupa mecanismul
pathogenic presupus: markerii aterosclerotici inﬂamatori, markerii aterosclerotici lipoproteici, markeri aterosclerotici ai hemostazei, markeri biologici si alti
markeri aterosclerotici importnanit, toti acesti markeri ﬁind prezentati in lucrarea de fata.
Cuvinte cheie: factori de risc, markeri, dislipidemie, hipertensiune, ateroscleroza

2009.19.1(61)  Fiziologia - Physiology

15

USE OF EMG BIOFEEDBACK AS A METHOD OF MUSCULARTRAINING DURING PHYSICAL EXERCISE IN ELDERSELENA BUTARIU1, STELIAN BUTARIU1, ANDOR MINODORA2, LAVINIA NOVEANU3, GEORGETA MIHALAS3
1Physiodynamic Cabinet, Physiotherapy and Rehabilitation, Baile Calacea, Timis
2University of Medicine and Pharmacy "Victor Babes", Department of Medical Semiology II, Timisoara
3University of Medicine and Pharmacy "Victor Babes", Department of Physiology, Timisoara

ABSTRACT
Objectives: Starting from the premise that physical exercise plays an important role in the maintenance of the clinical and functional status at elderly persons,
we have proposed in the present study to follow the way in which associating the physical exercise program to the EMG biofeedback (EMGBF) as a muscle
training method, can qualitatively and quantitatively inﬂuence its eﬃciency.
Methods: We performed a study on 30 patients aged > 65, divided in a randomized way into two groups. They were submitted to an identical force andresistance training program during 10 weeks. The EMGBF training was added to the experimental group. The patients were functionally (The Fullerton ﬁtness test for seniors, global functional level through the ADL scale and the HAQ – DI scale, the Geriatric Depression Scale - GDS) and electrophysiologically(through surface EMG measuring the amplitude of contraction, of relaxation, the rise time, the drop time) evaluated. Such evaluations were performed at
the beginning and at the end of the training period.
Results: There were no signiﬁcant diﬀerences of the functional and electrophysiological parameters between the studied groups, before the beginning of theexercise program. After 10 weeks, all the functional and electrophysiological parameters increased on both groups, signiﬁcant diﬀerences being recordedwith the muscle force, balance, coordination, walking speed, in favor of the group which had BFEMG training.
Conclusions: Physical exercise has beneﬁc eﬀects on the ﬁtness level, on the global functional status and on the depression condition, at elderly persons. Associating EMGBF to the training program provides several important advantages: objective diagnosis, targeted training, good control over the muscle activity
phases, customized protocols, close communication patient-therapist, inciting, ludic therapy modality.
Key-words: elders, physical exercise, EMG biofeedback

INTRODUCTION
Physical activity is the factor with a determining role in the preservation aslong as possible of the best functional status (ﬁtness), and also in preventing/
improving most of the chronic diseases on elderly persons (1). The regular practice ofphysical exercise ensures the increase of functional capacity, prevents osteoporosis,
cardiovascular diseases, diabetes, obesity and depression, improves neuromuscularbalance and coordination, and reduces mortality (2).
In general, exercise is practiced at a moderate intensity level. This can bemonitored through a heart frequency level of 60-79% of the maximum frequency
and a blood pressure under the risk values, or 11-13 quotation on the physical eﬀort
perception Borg scale. The exercise rhythm varies with each patient, according to the
pursued objective and to the exercise type. The average rhythm is 3 times/week.
Unfortunately, elderly persons are rather reticent when it comes to regular
practice of physical exercise, both as a therapeutic method, but mostly as a meansof maintaining the good health. That is why we have proposed to introduce in thetherapy "unit" an unconventional method – therapy through EMG biofeedback.
Biofeedback is a technique using an electronic equipment, in order to reveal
to a certain person a part of his own physiological events, normal or pathological,
as audio and/or visual signals, with a view to teach the person to manipulate such
events, otherwise involuntary, by manipulating the displayed signals (3).
EMG biofeedback (EMGBF) is based on collecting the muscular bioelectric potentials through global electromiography, through the means of surface
electrodes, their magniﬁcation and integration. This surface EMG, provides us anindirect measure of the subjacent striated muscles activity. The number of activatedmotor units increases gradually, with the increase of the developed force, achieving
the spatial sumation or recruitment. Reversely, muscular relaxation is characterized
by a reduction of motor units’ electric discharges. EMG signals have three-phasemorphology, its constituents being situated on both sides of the zero line. In order tobeneﬁt from all such constituents, all interchanges situated on one side of the zeroline are redressed, resulting in the redressed EMG curve (full - wave rectiﬁcation).
The global surface of the redressed potentials is then automatically calculated andproduces a curve with amplitude quantifying the muscular activity degree (signal
integration). The muscular contraction is then acknowledged by the patient, throughaudio or visual signals, with an intensity which is directly proportional with thecompleted activity. The parameters of such signals can be introduced into thecomputer, thus facilitating the pursuit in time of the patients’ evolution (4).
In the present paper we have approached the EMGBF use as a means ofmuscular training on elderly persons, within a complex program of physical exercise,
conceived according to the needs established through a clinical and functional
evaluation. We have followed the way in which associating EMGBF as a method ofphysical and behavior therapy to the exercise program can inﬂuence its eﬃciency
from a qualitative and quantitative point of view (better results in a shorter periodof time), and also the inﬂuence of such method on some psychical parameters like
depression, attention, participation.

Received November 2008. Accepted January 2009. Adress for correspondence: Dr. Elena Butariu, Timisoara, Labirint Street No. 9, 300660, e-mail: physiodinamic@yahoo.com

16

Fiziologia - Physiology  2009.19.1(61)MATERIAL AND METHOD
The study was performed on thirty patients, who showed themselvesat the specialty medical oﬃce in Baile Calacea Resort during June 2008 - January
2009, for balneal-physiotherapy treatment. The criteria according to which thepatients were included in the study were represented by the age of > 60 years
old, the absence of cognitive troubles and of some absolute counter indications
for physical exercise performance. Such counter indications are: unstable pectoral
angina, uncompensated cardiac insuﬃciency, symptomatic severe aortic stenosis,
hypertrophic cardiomyopathy, severe pulmonary hypertension, rest systolic tension> 200 mm Hg, rest diastolic tension > 110 mm Hg, pericarditis or acute myocarditis,
dissecting aneurysm, thrombophlebitis, recent systemic or pulmonary emboli.
The patients’written approval was obtained, after they had been explained
the study purpose, the performed measurements, the used means of treatment, thebeneﬁc eﬀects and the existent risks. Anonymity was guaranteed.
The 30 patients were divided in a randomized way into 2 groups, madeof 15 subjects: group A, as a control group and group B, for study. The allocation ofpatients in the 2 groups according to demographic parameters (age, sex, provenanceenvironment and degree of education), is the following (Table I):

Table I. Structure of study groups based on demographyc parameters
Parameter
60 - 75 years (youg old)
AgeGroup A (control)
13 (86.66%)

Lot B (study)

Total

14 (93.33%)

27 (90%)76 - 85 ani (middle old)Male

2 (13.33%)
7 (46.66%)

1 (6.66%)
6 (40%)

3 (10%)
13 (43.33%)

Residence

FemaleUrban
Rural
Primary school

8 (53.33%)
5 (33.33%)
10 (66.66%)
5 (33.33%)

9 (60%)
4 (26.66%)
11 (73.33%)
6 (40%)

17 (56.66%)
9 (30%)
21 (70%)11 (36.66%)

Education

High school

8 (53.33%)

7 (46.66%)

15 (50%)

Faculty

2 (13.33%)

2 (13.33%)

4 (13.33%)

Gender

The main aﬀection that the patients came at the medical oﬃce for was
represented by osteoarthritis with diﬀerent locations (vertebral - spondylosis andperipheral - coxarthrosis, gonarthrosis), light and medium forms (the advanced
ones being recommended for surgery treatment). The patients also presented otherassociated diseases like: osteoporosis, cardiovascular diseases (ischemic cardiopathy,
AH, varicose disease), pulmonary diseases (chronic bronchitis), metabolic diseases(hyperglycemia, dislipidemies, and obesity), and light visual deﬁciencies. Such associated diseases were evenly allocated within both groups, being in compensatedstates, under treatment. Their existence does not inﬂuence the study results.
The patients’ evaluation was performed from a functional and electrophysiological point of view in two moments: before the beginning of the treatment
and at the end of the proposed exercise program. The obtained values were compared one to the other, both within the same group (initial score – ﬁnal score), andbetween groups. The initial scores were compared among them in order to avoid
too big diﬀerences between the groups, while the ﬁnal scores were compared inorder to ﬁnd out whether there was a statistically signiﬁcant diﬀerence between
the eﬃciency of the two practice methods.
The initial clinical evaluation comprised a general clinical exam, themeasurement of the heart rate (HR) and of the rest TA, of the body weight (W)and the calculation of the body mass index (BMI). This evaluation was performed
in order to identify the patients with possible counter indications for physicalexercise and to evenly allocate the subjects in the two groups according to theassociated pathology.
The functional evaluation comprised:
1. The global evaluation of the ﬁtness level with the Fullerton ﬁtness Test forseniors (5), which consists of 6 tests evaluating:- the ﬂexibility (expressed in centimeters) of the body upper extremity: "back2009.19.1(61)  Fiziologia - Physiology

scratch" and lower extremity respectively: "sit and reach"- the muscular force (expressed in number of repetitions) of the body upper
extremity: "arm curl" and lower extremity respectively: "30 second chair stand"- the moving abilities and the dynamic balance: the "up and go" test (expressedin seconds)- the aerobic resistance (expressed in number of repetitions): "2 minutemarching step".
2. The estimation of the general functional status through a general score, with
the ADL sheet: activities of daily living, of the Illinois University, short form (ADLscore) (6), and also through the Health Assesment Questionnaire Disability Index: HAQ - DI (HAQ – DI score) (7) .
3. Depression was evaluated using the Yesavage's Geriatric Depression Scale,
short form (with 15 items) (8), the evaluation result being under the form of a
global score (GDS score).
Before beginning the study, the tolerance of patients to eﬀort wasalso tested, in order to establish the initial intensity level of physical exercise. The
six-minute walk test (6MWT) was used, well tolerated and easy to perform byelders, which measures the distance that the subject can cover walking on a ﬂat,
hard surface, during 6 minutes. This test is performed at a submaximal level of thefunctional capacity, in accordance with the level at which most of the daily activities
are performed (ADLs) (9).
The electrophysiological evaluation consisted of measuring some parameters obtained as a result of the surface EMG (EMGs) recording. In the present study
we used the Myomed 134 appliance manufactured by the company Enraf-Nonius.
This appliance recorded the EMGs and it facilitated the practice through EMG
biofeedback. The appliance was connected to a computer, thus the records weregraphically presented and kept in the PC memory.
17

The EMG signal detection was accomplished through some self-adhesive
single-use electrodes (Blue sensor Ambu - Denmark). The detection electrodes wereplaced in parallel with the muscular ﬁbers, on both sides of the motor points, compared to the position that the muscle has during the contraction phase. The distance
between the electrodes was 10 mm (10). Recordings were performed on two groups
of muscles: for the upper member on the brachial biceps (the dominant arm) andfor the lower member on the quadriceps muscle (the dominant member).
The evaluation protocol consisted of the following stages, each of themestimating a certain phase of the muscular activity:
1.) 60 sec. of pause – evaluation of the muscular relaxation (normal
values = 1 - 2 μV or < 10 % of the maximum developed force);2.) 5 contractions of 1 sec. with 10 sec pauses between contractions –evaluation of the phasic contraction;3.) 5 contractions of 1 sec (during 10 sec.) = quick ﬂicks – evaluationof the coordination;4.) 5 contractions of 10 sec. with 10 sec. pause between contractions –evaluation of the tonic contractions;5.) 3 submaximal contractions of 20 sec. with 20 sec. pause between
contractions – evaluation of the muscular resistance (in case of muscular fatigue,
or of decrease of muscular resistance, a great variability is recorded in the maximum
amplitude) ;6.) 60 sec. of pause.
After the EMGs recording the following were determined: the amplitudeof the integrated signal (expressed in μV) and the standard deviation for eachcontraction and relaxation period (the appliance directly providing an average of
the EMG signal amplitude for such phases), "rise time" (the rise time at contraction
beginning), "drop time" (the return time at contraction end), expressed in seconds(normal values ≤ 2 sec.) and the variability coeﬃcient (the ratio standard deviation/
amplitude). Electrophysiological recordings were also performed in two moments– at the beginning and at the end of the study, the data being compared among
them. It was considered that a good evolution of the muscular function is given
both by the increase of the contraction amplitude and the decrease of the relaxation
amplitude, but mostly by the decrease of the contraction variability coeﬃcient andby the value decrease of the "rise time" and "drop time", respectively (11).
After the completion of individual evaluations, the patients have started
the exercise program. It was performed during 10 weeks, with a rhythm of 3 times/
week, at a moderate intensity level, relevant for a HR representing 75% of the max.
HR (calculated according to the formula 220 - age) or for a 12 - 13 level on thephysical eﬀort perception Borg scale (RPE).
For group A (control), each exercise session lasted for approximately
55 minutes and consisted of the following protocol: 3 - 5 min. of warming up(light pedaling on the ergometric bicycle), 20 min. of exercise for muscular force
strengthening, 5 min. of pause, 20 min. of endurance exercise, 5 min. of cooling(free walking or stretching exercise performed in a very slow rhythm). The force
exercise was customized according to the evaluations, but they especially followed
to train the hip ﬂexors, extensors and abductors, the knee ﬂexors and extensors and18

the plantar ﬂexors, such muscles also being involved in the accomplishment of agood balance. The MS ﬂexors were also trained. Resistance was set at 50% of the
maximum level. 3 sets of 10 repetitions were performed for each muscle group.
Progressivity was accomplished by increasing the lifted weight (evaluation at every
2 weeks of practice). Endurance exercise was performed on the ergometric bicycle,
starting with a load of 25 W (according to the eﬀort capacity), the intensity level
being controlled by permanently monitoring the target HR (electronically displayedon the bicycle LCD screen). The BP was measured at the beginning an dat the endof each practice session.
Group B (study) was submitted to the same therapy protocol, to the exercise
for muscular force strengthening being associated the EMG biofeedback practice.
For the biofeedback practice there have been selected the same muscle
groups like in the force practice of group A: the quadriceps muscle, the middle
buttock, the femoral biceps, the femoral triceps, the brachial biceps. The electrodes
for the EMG potentials recording were located according to Zipp’s recommendations,related to the indicated anatomic marks (12).
The speciﬁc EMG biofeedback practice was initially performed on an EMG
channel for each muscle group, then, as the patient became more acquainted withthe therapy, two EMG channels were used for the concurrent practice of two symmetric (right – left) muscle groups. The following protocols were used:- Protocol 1: 5 sec. of contraction, 10 sec. of relaxation (protocol work - rest);
repeated for 10 times for each muscle group (isotonic contraction);- Protocol 2: progressive contraction, 20 sec. of maintenance, progressive
relaxation (isometric contraction)- Protocol 3: 5 rapid contractions in 10 seconds (quick ﬂiks) – coordination
practice- Protocol 4: pattern type: graphics of various shapes appear on the screen,
the patient has to maintain his level of muscle activity so that a slider present on
the screen should follow the proﬁle of such graphics.
Protocos 1 and 2 were used at the beginning of the practice program,then protocols 3 and 4 will be introduced after 2 weeks of practice.
These protocols were introduced into a program customized for eachpatient and stored in the appliance memory.
In addition to the visual biofeedback, an audio one was also used, the one
generally used being a continuous sound appearing at a contraction intensity overthe limit value. This value was determined by making the patient perform a maximal
contraction. During the sessions, the limit value changed (increased).
The total duration of the EMGBF practice was 20 minutes.

RESULTSThe following tables present the ﬁnal values (the arithmetic average)of the parameters obtained as a result of the functional and electrophysiologicalevaluations on the two groups under study. These values, compared with theunpaired t-test are presented bellow

Fiziologia - Physiology  2009.19.1(61)(tab. 2, 3, 4).
Table II. Comparison between functional parameters at the two groups
EVALUATIONFITNESSFUCTIONALSTATUS
DEPRESSIONGROUP AGROUP Bback scratch (cm)sit and reach (cm)
30 sec. chair stand (no of repetition)
arm curl (no of repetition)

8.4 ± 2.3
1.4 ± 0.9
14.8 ± 2.3

8 ± 1.3
1.2 ± 0.918 ± 20.88 (NS)0.88 (NS)0.046 (< 0.05)

13.8 ± 1.3

17.6 ± 0.8

0.049 (< 0.05)

up and go (seconds)
2 minute marching step (no of repetition)
ADL score
HAQ - DI score

9.8 ± 3.1
93 ± 9.7

6.2 ± 1
107.8 ± 9.7

0.049 (< 0.05)
0.042 (< 0.05)

168.6 ± 6.6
23.2 ± 1

171.4 ± 3.5
23.8 ± 0.4

0.47 (NS)0.38 (NS)5.2 ± 0.8

4.6 ± 1.1

0.37 (NS)GDS score

P

Table III. Comparison between electrophysiological parameters of quadriceps muscle at two groups
PARAMETER
Contraction amplitude - mean (μV)
Relaxation amplitude - mean (μV)
Rise time (sec)Drop time (sec)

GROUP A34.8 ± 14.1
4.2 ± 0.8
3.2 ± 0.7
2.76 ± 0.4

GROUP B
49.4 ± 11.9
2.4 ± 0.4
1.8 ± 0.2
1.82 ± 0.1

P0.11 (NS)0.005 (< 0.01)
0.01 (< 0.05)
0.005 (< 0.01)

Table IV. Comparison between electrophysiological parameters of brachial biceps at two groups
PARAMETER
Contraction amplitude - mean (μV)
Relaxation amplitude - mean (μV)
Rise time (sec)Drop time (sec)

DISCUSSIONS
Comparing the initial values of the functional and electrophysiologicalparameters on the two groups, no signiﬁcant diﬀerence was identiﬁed among
them.
Comparing the evolution of the functional parameters, we observed
the following:- the evolution of parameters within the same group shows us a signiﬁcant
increase, both for the witness lot and for the experimental one, on all the followed
parameters (p < 0.05).
- there is a statistically signiﬁcant diﬀerence (a better evolution on the EMGBF
group) in the evolution of ﬁtness parameters: 30" chair stand, arm curl, up andgo and 2 minute marching step. This shows a better increase of the muscle force(especially on the lower body), of the balance, coordination and walking speed.
- among the ﬁnal values of the parameters estimating ﬂexibility, the global
functional status and depression, no statistically signiﬁcant diﬀerences were observed between the two groupss (p > 0.05).
2009.19.1(61)  Fiziologia - Physiology

GROUP A
46.35 ± 15.3
4.3 ± 0.5
3.35 ± 0.8
2.7 ± 0.5

GROUP B
55.7 ± 12.4
2.15 ± 0.3
1.82 ± 0.2
2 ± 0.2

P
0.06 (NS)0.03 (< 0.05)
0.03 (< 0.05)
0.049 (< 0.05)

Comparing the evolution of electrophysiological parameters both in therecording performed on the brachial biceps muscle and on the lower right muscle,
we observed:- there are signiﬁcant diﬀerences between the initial and ﬁnal values withinboth lots, on all the followed parameters (p < 0.05).
- no signiﬁcant diﬀerences were recorded between the lots regarding theincrease of the muscle contraction amplitude (p > 0.05).
- there are, though, statistically signiﬁcant diﬀerences in the evolution of theother electrophysiological parameters (relaxation, rise time, drop time) in favorof group B, such parameters showing an improvement of the contraction quality(increase of the muscle ﬁbers recruitment, increase of the reaction speed, coordination improvement, muscle resistance improvement).
CONCLUSIONS
After the study it was proved the beneﬁc eﬀect of physical exercise on
19the ﬁtness level, on the global functional status and on the depression condition,
at elderly persons.
Associating EMGBF to the training program provides several important
advantages:- it allows an objective diagnosis of the muscle function, determining certain
well established recovery objectives and objectively estimating the ﬁnal results(3).
- it permanently ensures the control of the muscle activity, providing us thepossibility to follow the performance correctness, the exact moment of settlementof muscle fatigue (13).
- it allows the accomplishment of progress not only due to the quantitative
aspect, but also to the qualitative one (which can be more rapidly observed), by
acknowledging the action that must be performed and by diﬀerentiating therelaxation – contraction phases (12).
- it provides the possibility to establish some customized protocols, to memorize them and to record them for comparison.
- it can be even used at lower values of the muscle functional capacity, by
establishing lower levels of the limit activity value and by gradually increasing it(better control over exercise progress).
- a closer communication is accomplished between the patient and his
therapist.
- it is a modern method, the patient being involved in an inciting, even ludicway.

and Aplications in
Medical Rehabilitation. Bucharest , Carol Davila, 2006
4. Sella GE. Neuromuscular Testing with Surface Electromyography. GENMED Publishing, 1995
5. Rikli RE, Jones CJ. Senior Fitness Test Manual. Champaign, Illinois:Human Kinetics,
2001
6. Nemeş ID. Exploration and Evaluation Methods in Kinetotherapy.Timişoara, Orizonturi
Universitare 2001
7. Bruce B, Fries JF. The Stanford Health Assesment Questionnaire: A Review of its History,
Issues, Progress and Documentation. J Rheumatol, 2003; 30: 167 - 178
8.Mcphee SJ, Papadakis MA, Tierney Jr. LM. Current Medical Diagnosis and Treatment.
Geriatric Disorders. Mc Graw Hill's Lange, 2008
9. ATS Statement: Guidelines for the Six – Minute Walk Test. Am J Respir Crit Care Med
2002; 166:111-117
10. Soderberg GL et al. Selected Topics in Surgace Electromyography for Use in the Occupational Setting:Expert Perspectives. U.S. Department of Health and Human Services,
Public Health Sesvice Center for Disease Control National Institute for Occupational
Safety and Health, 1992
11. Zipp P et al. Recommandations for the standardiyation of lead positions in surface
electromyography. Eur J Appl Physiol, 1982; 50: 41-54
12. Woolner B, Corcos J, Drews S. The use of Electromyographic Biofeedback for Training
Pelvic Floor Musculature: The Biofeedback Foundation of Europe, Copyright, 1997
13. Middaugh SJ, Miller MC, Foster G, Ferdon MB. Electromyographic feedback: eﬀects
on voluntary muscle contractions in normal subjects. Arch Phys Med Rehabil 1982;
63(6) :412

REFERENCES
1. Bălăceanu-Stolnici C. Practical Geriatry, Bucharest, Amalteea, 1998
2. Beers MH, Berkwits M, Kaplan JL et al. Aging and Musculoskeletal Disorders. In: The
Merck Manualof Geriatrics, 3rd, Ch.48, update on line 2005
3. Berteanu M. Electromyographic Biobeedback. In Neurophysiopathological BasesUTILIZAREA BIOFEEDBACK-ULUI EMG CA METODĂ DE ANTRENAMENT MUSCULAR ÎN CADRUL EXERCIŢIILOR FIZICE LA VÂRSTNICIREZUMAT
Obiective: Pornind de la premiza că exerciţiul ﬁzic joacă un rol important în menţinerea statusului clinico-funcţional la persoanele în vârstă, în studiul defaţă ne-am propus să urmărim modul în care asocierea la programul de exerciţii ﬁzice a biofeedback-ului EMG (BFEMG) ca metodă de antrenament muscular,
poate să inﬂuenţeze eﬁcienţa acestuia din punct de vedere calitativ şi cantitativ.
Metode: Am efectuat un studiu pe 30 de pacienţi cu vârste > 65 ani, împărţiţi în mod randomizat în două loturi. Aceştia au fost supuşi unui program identic
de antrenament de forţă şi rezistenţă pe o perioadă de 10 săptămâni. La lotul experimental s-a adăugat antrenamentul prin BFEMG. Pacienţii au fost evaluaţi
din punct de vedere funcţional (Testul de ﬁtness Fullerton pentru vârstnici, nivel funcţional global prin scala ADL şi scala HAQ - DI, Scala Geriatrică pentru
Depresie - GDS) şi electroﬁziologic (prin EMG de suprafaţă măsurând amplitudinea contracţiei, a relaxării, rise time, drop time, coeﬁcientul de variabilitate acontracţiei). Aceste evaluări s-au făcut iniţial şi la sfârşitul perioadei de antrenament.
Rezultate: Nu au existat diferenţe semniﬁcative ale parametrilor funcţionali şi electroﬁziologici între grupele studiate, înainte de începerea programuluide exerciţii. După 10 săptămâni, toţi parametrii funcţionali şi electroﬁziologici au crescut la ambele grupuri, diferenţe semniﬁcative înregistrându-se în ceea
ce priveşte forţa musculară, echilibrul, coordonarea, viteza de mers, în favoarea grupului ce a făcut antrenament prin BFEMG.
Concluzii: Exerciţiului ﬁzic are efecte beneﬁce asupra nivelului de ﬁtness, statusului funcţional global şi a stării de depresie, la persoanele în vârstă.
Asocierea BFEMG la programul de antrenament oferă câteva avantaje importante: diagnostic obiectiv, tratament ţintit, bun control asupra fazelor activităţii
musculare, protocoale individualizate, comunicare strânsă pacient-terapeut, modalitate incitantă, ludică de terapie.
Cuvinte cheie: vârstnici, exerciţii ﬁzice, biofeedback EMG

20

Fiziologia - Physiology  2009.19.1(61)SMOKING AND SALIVARY ANTIOXIDANT CAPACITY
GOTIA SMARANDA LAURA, GOTIA SMARANDA RODICA
Department of Physiology, University of Medicine and Pharmacy “Victor Babes”, Timisoara, Romania
ABSTRACT
Cigarette smoke contains a large amount of oxidative species, and therefore smoking represents a signiﬁcant source of oxidative stress. Saliva possesses
protection mechanisms from oxidative attack. Smoking is one of the main and most prevalent, risk factor for chronic periodontitis and oral tumors.
The purpose of the study was to investigate the smoking eﬀect on salivary antioxidant capacity, appreciated by glutathione level (GSH).
Material: There were recruited 10 persons (non-smoker group) and into the smoker group 14 healthy subjects who reported smoking more than 10
cigarette/day, for more than 2 years. Un-stimulated whole saliva samples were obtained in the morning, after two hours of tooth brushing and smoking.
Salivary ﬂow was noted. Salivary glutathione was performed by dithio-bisnitro-benzoic acid method (DTNB), in 1-2 hours after saliva collection, in order toavoid the release of GSH from destroyed cells.
Results: GSH level into the non-smoker group was higher (63.43 ± 32.64 microM/L), than into the smoker group (60.44 ± 28.83 microM/L). Salivary
ﬂow was 0.414 ± 0.171 ml/min. to non-smoker compared with 0.55 ± 0.14 ml/min. in smoker group. Also, in smoker group was observed high levels ofdesquamated epithelial cells and the decrease of cell viability under 90%. Early after one cigarette smoking the salivary ﬂow and GSH increased.
Conclusion: Smoking modiﬁed the GSH levels and can produced noxious eﬀects on oral cavity.
Key words: smoking, salivary GSH, antioxidant capacity

INTRODUCTION
Smoking is undoubtedly one of the main, most prevalent, risk factor
for tumors. Tobacco smoking certainly modiﬁes oral response to any injuries, suchas microbial challenge or malignant transformation of cells. Smoking inﬂuences
angiogenesis, adhesion molecule proﬁles, leucocytes recruitment, and multiple
aspects of leucocytes development and function (1, 2).
Reactive oxygen species (ROS) play an important role in cell signaling
and metabolic processes, but also contribute to pathogenic processes in a variety
of inﬂammatory disorders and cancers by DNA base alterations, strand breaks,
and an enhanced expression of protooncogenes (3). Oxidative stress is deﬁned as
the disturbance of the pro-oxidant-antioxidant balance in favor of former (4). It is
well known that cigarette smoke contains a large amount of oxidative species, andtherefore smoking represents a signiﬁcant source of oxidative stress. In addition tothis pro-oxidant burden, tobacco smoke can contribute to reactive oxygen speciesmediated tissue damage through depletion of systemic endogenous antioxidant
capacity (5).
Large amounts of pro-oxidants are produced by activation of leucocytes
in prolonged inﬂammatory responses. Therefore, both tobacco smoke and inﬂammation are sources of reactive oxygen species and can compromise the antioxidant
capacity of serum and tissues (6). Saliva possesses elaborate antioxidant defense
systems (including superoxide dismutase, catalase, uric acid, vitamin C, glutathione,
and others) to prevent oxidative damage in oral cavity (7, 8).
Thus, the aim of our study was to investigate the smoking eﬀect onsalivary antioxidant capacity, appreciated by glutathione level (GSH), correlatedwith ROS formation in salivary leucocytes.

MATHERIAL AND METHOD
In order to investigate smoking eﬀects on oral environment there werestudied physical, chemical and biological salivary parameters, in comparison smokers and non- smokers. 24 patients, 14 smokers and 10 non-smokers, aged between
30 and 60, who don’t work in a polluted environment, were investigated.

The patients were questioned about the last oral hygiene, drugs usedat the time of the study, eating after tooth brush, type of alimentation, and dental
status. The smokers group was also questioned about the number of cigarettes
smoked per day, and how long they smoked.
Lot distribution:•
Non-smokers: 10 healthy subjects, aged between 30-60, 7 females
and 3 males,•
Smokers: 14 healthy subjects, aged 30-45, 12 females and 2 males,
who smokes over 10 cigarettes daily, over 2 years.
Sampling
Sampling was performed at approximately 9.00 a.m. after a 10 hours fasting
and avoidance of physical stress and cigarette smoking. Sampling also took place
2 hours after teeth brushing, food and liquids intake, chewing gum.
Salivary samples were taken from the subjects as follows: resting saliva samples
were collected for almost 5 minutes in plain containers. Salivary gland ﬂow rateare expressed as volume of saliva (ml) secreted per minute. In smokers saliva was
obtained before and 30 min after one cigarette smoking.
Saliva samples were performed in 15-30 minutes after collection, inorder to minimize the enzymatic degradation of the saliva. Saliva was centrifuged
for 5 min at 2000-2500 rpm. It was separated salivary sediment and supernatant.
Samples were stored at +4o C untill tests were performed.
GSH: from the supernatant it was determined salivary GSH byspectrophotometric dithiobis- nitrobenzoic acid method. GSH microMoles/L= Absorption x 2020.
Salivary cells study
From salivary sediment were determined leucocytes and epithelial cells number with Burker camera. Results were noted as number of cells/μl. Cellular viability
was determined with tripan blue vital dye, at the microscope, and were quantiﬁed
the cells which exclude the dye (uncolored, live cells). Phagocytic capacity was ap-

Received December 2008. Accepted January 2009. Address for correspondence: Dr. Gotia Smaranda Laura, Department of Physiology, UMF “Victor Babes”Timisoara, 2 Eftimie Murgu Square 300041, phone/fax :0256490507, e-mail: lauragotia@yahoo.com

2009.19.1(61)  Fiziologia - Physiology

21preciated by latex particle incorporation (IFL%), and by basal nitrobluetetrazolium
test (NBT%) and stimulated (NBTs%) (9, 10).
Statistical analysis
The results were statistical analysed and were determined mean and standard
deviation. In order to compare the results was used t Student test. Were compared
the values of the investigted parameters before and after smoking, also, between

smoking and non-smoking groups.
RESULTSThe results of investigated salivary parameters are showed in thetables. The variation of salivary rate at smoker’s group, of salivary GSH, salivary
cells parameters before and after smoking is extremely signiﬁcant, compared with
unsmoker’s group (Table I).

Tabel I. Age, salivary ﬂow/min, and GSH in non-smokers and smokers, before and 30 min. after smoking (M ± DS)

GROUP

Nr. cases
Non-smokers (1)10
Smokers (2)14
Smokers 30 min after smoking 14(3)
Lot 1- Lot 2 comparedLot 2- Lot 3 comparedLot 1- Lot 3 compared

Age(years)54.4 ± 17,22
37.14 ± 5,89

Salivary flow ml/
min.
0.414 ± 0,171
0.55 ± 0.14
0.71 ± 0.1

GSH
microM/L
63.43 ± 32.64
60.44 ± 28.83
104.86 ± 22.70

p = 0.002 VS

p = 0.0436 S
p = 0.0018 VS
p < 0.0001 ES

p = 0.808 NS
p < 0.0001 ES
p = 0.001 VS

p = 0.002 VS

NS=Not signiﬁcant; S=Signiﬁcant; VS=Very signiﬁcant; ES=Extremely signiﬁcant

Salivary leucocytes and epithelial cells were signiﬁcant increased, but cells’ viability was decreased in smokers compared with non-smokers (Table II).
Table II. Salivary cells parameters: salivary leucocytes, epithelial cells, cellular viability, in smoking and non-smoking group (M ± DS)

GROUP

Nr. cases
Non-smokers (1)10
Smokers (2)14
Smokers 30 min after smo- 14
king (3)
Lot 1- Lot 2 compared

Salivary leucocytes/μl1380 ± 657.26
7000 ± 4082.48
8357.14 ± 3902.07

Epithelial cells/μl4000 ± 3674.23
10742. 86 ±4375.63
12257.14 ± 4492.16

Cells viability %p = 0.0003 ES

p = 0.0007 ES

p = 0.0005 ES

Lot 2- Lot 3 comparedp = 0.378 NS

p = 0.374 NS

p < 0.0001 ES

Lot 1- Lot 3 comparedp < 0.0001 ES

p < 0.0001 ES

p < 0.0001 ES

92.4 ± 2.509
88.14 ± 2.54
83.28 ± 2.42

NS=Not signiﬁcant; S=Signiﬁcant; VS=Very signiﬁcant; ES=Extremely signiﬁcant
The variation of salivary leucocytes phagocytosis tests before and after smoking is signiﬁcant, in comparison with unsmoker’s group (table III).

GROUP

Tabel III. Mean values of salivary leucocytes phagocytosis tests (M ± DS).

Nr. cases

IFL test %NBT test %NBTs test %Non-smokers (1)10
Smokers (2)14
Smokers 30 min after smo- 14
king (3)
Lot 1- Lot 2 compared19.4 ± 0.894
19.14 ± 1.67
16.57 ± 1.71

2.2 ± 0.83
2.14 ± 0.69
1.57 ± 0,53

3.4 ± 1.14
3.71 ± 0.95
3.28 ± 0.48

p = 0.659 NS

p = 0.818 NS

p = 0.475 NS

Lot 2- Lot 3 comparedp = 0.0003 ES

p = 0.0213 S

p = 0.142 NS

Lot 1- Lot 3 comparedp < 0.0001 ES

p = 0.0331 S

p = 0.726 NS

NS=Not signiﬁcant; S=Signiﬁcant; VS=Very signiﬁcant; ES=Extremely signiﬁcant22

Fiziologia - Physiology  2009.19.1(61)Increased salivary GSH after one cigarette smoking (Figure 1) was correlatedwith transitory high levels of salivary ﬂow.
Salivary GSH in non-smoking, smoking person and 30 minutes
after one cigarette smoking
104,86

120
100
80

63,43

60,44560
40
20

study can decrease the oral mucosa barrier and can amplify local lesions induced by
tobacco use. One potential mechanism is through tissue damage mediated by oxidative species originating from tobacco smoke and tobacco induced inﬂammation, in
addition to the direct cigarette smoke-mediated depletion of antioxidants.
Abundant cross-sectional data support the adverse relationship between
smoking and inﬂammatory modiﬁcations (1, 16, 17). A strong dose–response
relationship between the amount smoked and the severity of inflammatory
modiﬁcations has also been shown, further supporting the role of smoking as arisk factor for periodontitis (18).

0Nonsmoking

Smoking

30 min. after 1
cigarette smoking

Fig. 1. Salivary GSH levels in non-smokers and smokers

DISCUSSIONS
According to Chiappin study we used un-stimulated whole saliva specimen
for investigation of GSH and leucocytes function (11). Several methods of saliva
collection are available, including the collection of un-stimulated whole saliva;
whole saliva stimulated with, typically, paraﬃn wax, gum base or citric acid; orthe collection of saliva from speciﬁc salivary glands.
For the purpose of analyzing salivary antioxidant status, whole saliva is the most
relevant, as it contains gingival crevicular ﬂuid, immune cells, and tissue metabolites(12) and reﬂects most closely the predominant intra-oral condition. Stimulation,on the other hand, may increase the ﬂow of gingival crevicular ﬂuid and this may
result in false increases in the concentration of antioxidants in the saliva.
In our study salivary ﬂow was signiﬁcantly increased (p < 0.05) in smokers
group (0.55 ± 0.14 ml/min) compared with non-smokers, and the elevated values(0.71 ± 0.1ml/min) was mentained after one cigarette smoking (p < 0.001). The
variation of salivary ﬂow was correlated with increased values of salivary GSH.
Pre smoking salivary GSH level was decreased. This may indicate that excesive
ROS production in smokers individuals is leading to the situation of excessive oxidative stress which may be an important factor contributing to the destruction of oral
tissues. After smoking GSH value was increased that can indicate mobilization ofsalivary antioxidant capacity.
Antioxidants, by counteracting the harmful eﬀects of free radicals, protect
structural and tissue integrity (13). Individuals with already low pre smoking glutathione concentrations are most prone to the noxious eﬀects of cigarette smoking. The
decreased antioxidant capacity may indicate either inherently low bazal antioxidant
defence status or may result from an increase in oxidative stress (14).
Salivary cells were signiﬁcantly increased in smokers and after one cigarettesmoking (p < 0.001) associated with decreased cells viability, observed in present study.
It seems that tobacco use ampliﬁed expholiation of oral mucosa cells. The
glutathione can be released from dead cells and for this reason the samples were
performed in short time after salivary samples collection.
The resting saliva ﬂow rate in young healthy smokers was 0.31 ± 0.18 ml/
min and increased to 0.34 ± 0.22 ml/min after smoking associated with increased
GSH concentration in a Charalabopoulos study (15).
Phagocytosis assays of salivary leucocytes performed in the present study
showed the reduced values of NBT test in smokers. NBT reduction dye indirectly
revealed ROS generation during phagocytosis. ROS are generated in vivo by multiple
mechanisms including the respiratory redox chain in mitochondria, the respiratory
burst in phagocytes, and the activity of various oxidase.
Low levels of salivary leucocytes phagocytosis in smokers group, reduced cells
viability associated with high values of epithelial cells desquamation found in our
2009.19.1(61)  Fiziologia - Physiology

CONCLUSIONSSaliva samples may be used for smoking eﬀects investigation on oral cavity.
The measurement of salivary GSH in human saliva might be useful for estimating
the level of oxidative stress on smoking habits.
Smoking modiﬁed the GSH levels and can produced noxious eﬀects on oralcavity. GSH increased levels can be compensating defense mechanisms in saliva inorder to withstand the oxidative stress imposed by smoking.
Low levels of salivary leucocytes phagocytosis in smokers group, reduced cells
viability associated with high values of epithelial cells desquamation found in ourstudy can decrease the oral mucosa barrier and can amplify local lesions induced
by tobacco use.
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related to caries, age, and gender. Internat J Paediatric Dentistry. 2006; 16: 186-191
14. Brock GR, Butterworth CJ, Matthews JB, Chapple ILC. Local and systemic total
antioxidant capacity in periodontitis and health. J Clin Periodontol. 2004; 31, 515-521.

23

Blackwell Munksgaard
15. Charalabopoulos K, Assimakopoulos D, Karkabounas S, Danielidis V, Kiortsis D,
Evangelou A. Eﬀects of cigarette smoking on the antioxidant defence in young healthy
male volunteers. Int J Clin Pract. 2005; 59, 1, 25-30, Blackwell Publishing Ltd
16. Johnson GK, Hill M. Cigarette smoking and the periodontal patient. J Periodontol.

2004; 75, 196–209
17. Palmer RM, Wilson RF, Hasan AS, Scott DA. Mechanisms of action of environmental
factor – tobacco smoking. J Clin Periodontol. 2005; 32, S180–S195
18. Calsina G, Ramon JM, Echeverria JJ. Eﬀects of smoking on periodontal tissues. J Clin
Periodontol. 2002; 29, 771–776

FUMATUL ŞI CAPACITATEA ANTIOXIDANTĂ SALIVARĂREZUMAT
Fumul de ţigară conţine o cantitate mare de specii oxidative, de aceea fumatul reprezintă o sursă semniﬁcativă de stres oxidativ. Saliva posedă mecanisme deprotecţie împotriva stresului oxidativ. Fumatul este factorul de risc cel mai întâlnit pentru parodontită cronică şi tumori maligne orale.
Scopul studiului a fost să investigăm efectele fumatului asupra capacităţii antioxidante salivare, apreciată prin nivelul de glutation (GSH).
Material: au fost selectate două loturi 10 nefumători, 14 fumători a peste 10 ţigări/zi de peste 2 ani.
S-au recoltat probe de salivă nestimulată, dimineaţa, la 2 ore de la periajul dinţilor şi fumat.
S-a notat debitul salivar. S-a determinat glutationul salivar prin metoda cu acid dithio-bisnitro-benzoic (DTNB), la 1-2 ore de la recoltare, pentru a evita
eliberarea de GSH din celulele distruse.
Rezultate: Nivelul de GSH a fost mai crescut la grupul de nefumători (63,43 ± 32,64 microM/L), decât la grupul de fumători (60,44 ± 32,64 microM/L).
Debitul salivar a fost de 0,414 ± 0,171 ml/min la grupul de nefumători comparativ cu 0,55 ± 0,41 ml/min la grupul de fumători. De asemenea, la grupul defumători s-a observat creşterea celulelor epiteliale descuamate şi o scădere a viabilităţii celulare sub 90%. Imediat după fumatul unei ţigări debitul salivar
şi GSH-ul au crescut.
Concluzie: fumatul a modiﬁcat nivelul de GSH salivar şi prin acesta poate avea efect nociv asupra cavităţii orale.
Cuvinte cheie: fumat, GSH salivar, capacitate antioxidanta

24

Fiziologia - Physiology  2009.19.1(61)Minireview From autologous bone transplantation to tissue
engineering in bone grafting orthopedic surgery
RARES BREDICIANU
Department of Trauma-Orthopedics Clinic I, Timisoara County Emergency Hospital

ABSTRACT
Despite the many discoveries in bone grafting surgery, new materials and approaches to bone healing in bone defect continue to be investigated. One exciting
area is tissue engineering, which can be deﬁned as the application of biologic, chemical and engineering principles to the repair, restoration or regenerationof living tissues by using biomaterials, cells and growth factors, alone or in combination. In this review article is presenting the evolution of bone grafting
used in orthopedic surgery, kinds, some remarks presented at the last congresses in this speciality and some aspects for future.
Key words: bone grafting, scaﬀold, mesenchymal stem cells, tissue engineering

INTRODUCTION
Large traumatic bone defects can be covered by soft tissues but reconstructionof the bone itself may be diﬃcult. The use of autogenous bone has remained thegolden standard in restoring bone defects, but it is not always possible to obtainenough bone.
Despite the evolution of surgical techniques, the reconstruction of large bone
defects remains a major challenge for which a tissue engineering approach canprovide a solution.
Bone defects and bone loss are a relatively frequent occurence in orthopedic
and trauma surgery as in bone fractures, mal unions, non-unions, tumors, infections,primary or revision joint replacement procedures, spinal surgery.
The use of bone grafts is essential for bone reconstruction and restauration ofbone functional integrity in a variety of clinical situations.
Bone grafts are second only to blood transfusions on the list of transplantedmaterials worldwide. The total USA bone graft market revenues were at 1.3 billions$ in 2006. The revenue for this market are expected to reach 3.3 billion $ in 2013.
The total European bone graft substitute market alone is expected to reach 120
million $ by 2010(11).
In literature are discribed many methods for bone grafting. The conventional
methods are autologous bone transplantation, allotransplant of bone and artiﬁcialbone graft materials(12). Even if autogenous bone grafts had been used before,
Leopold Ollier was the ﬁrst to study bone transplantation systemically (14). He also
pointed out the diﬀerence between auto-, allo- and xenografts.

THE AUTOLOGOUS BONE TRANSPLANTA
TION
The autologous bone transplantation (patient’s own tissue: cancellous bone,cortical -compact bone, microvascular grafts, the periosteum) has potential forbone regeneration, easy to model, bone harvesting damages healthy body parts,
a secondary operation, the limited availability of bone. The autograft tissue bone
grafts is harvested from the patient, usually from the iliac crest, but possibly fromthe distal femur or the proximal tibia. This tissue is ideal as a bone graft because it
possesses all of the characteristics necessary for new bone growth- osteoconductivity, osteogenicity and osteoinductivity.

Osteoconductivity refers to the situation in which the graft supports theattachment of new osteoblasts and osteoprogenitor cells, providing an interconnected structure through which new cells can migrate and new vessels can form.
Osteogenicity means the situation when the osteoblasts, that are at the site of
new bone formation, are able to produce minerals to calcify the collagen matrix
that forms the substrate for new bone. Osteoinductivity refers to the ability of agraft to induce nondiﬀerentiated stem cells or osteoprogenitor cells to diﬀerentiate
into osteoblasts.
In 1914 Phemister described clinically the healing of autogenous bone grafts
and stressed the importance of vascularization, the various tissue components
involved in bone healing and creeping substitution (16). In particular after theSecond World War, when there were a great number of victims with severe bone
defects, the research into bone grafting increased.
THE allotransplant oF bone
Comparative, the allotransplant of bone (donor tissue) is characterised throughlarge quantities available, easy to model, nonuniformity of products (sex, age)
and issues of antigenicity, infection through transmitting diseases and a lower
osteogenic capacity. (12)The xenogenic bone graft (from another species) presents similar problems
to the allograft: acute antigenic response, a high failure rate and from this reasons
indeed rarely used (7).

BIOMATERIALSThe artiﬁcial bone graft materials are uniform in quality, have no limit to amountof use and no capability of new bone formation. Approximately 60% of the bone
graft substitutes currently available involve ceramics, either alone or in combination
with another material. Ceramics together metal (titanium, vitallium, aluminium andstainless steel) and polymer (methyl methacrylate, polyhydroxyethylmethacrylatewith calcium hydroxide coating) are biomaterials. A biomaterial can be deﬁned as“amaterial intended to interface with biological systems to evaluate, treat, augment,or replace any tissue, organ, or function of the body” (18).
Ceramics family include calcium sulfate (the ﬁrst material used in bone defect),
bioactive glass and calcium phosphate. Nowadays, the last class-the calcium

Received January 2009. Accepted February 2009. Address for correspondence: Dr. Rares Bredicianu, Department of Trauma-Orthopedics, Timisoara County Emergency Hospital, Iosif Bulbuca Street, Timisoara,
Romania, phone/fax: 0256220479, e-mail:2009.19.1(61)  Fiziologia - Physiology

25phosphate ceramics (hydroxiapatite: TRANS-OSSATITE, TECMA-FIXR, tricalcium
phosphate: BIO-TECMAR, CALCIRESORB R , CEROSR TCP, CyclOS TM, biphasic calcium
phosphate: BONE’X, EUROS SSBS, EUROCERR 400, ATLANTIKR , ATLANTIKR Genta)
are frequent used in orthopedic surgery(10). They are bioactive, biocompatible,
bioresorbable, osteoconductive and occasionally osteoinductive. The use of calcium
phosphates as biomaterials is based upon their similarity with the mineral phase ofbone and teeth. Biomaterials of calcium phosphates are available in various physicalforms: particles, blocks (dense or porous), injectable compositions, coatings on
metal implants, self-setting cements, composites with polymers(10).

TISSUE ENGINEERING
Since 1970 , the combination of cells and scaﬀolds has been investigated as
an alternative for the autologous bone graft. This technology is now referred to as
tissue engineering, popularized and deﬁned in 1993 as“the application of principles
of engineering and life sciences toward the development of biological substitutes
that restore, maintain or improve tissue function”(8).
In 2002 tissue engineering has been deﬁned as “the application of scientiﬁcprinciples to the design, construction, modiﬁcation and growth of living tissues
using biomaterials, cells and factors, alone or in combination”(6).
The main aim of tissue engineering is to fabricate artiﬁcial tissues or organs thatcan replace damaged or missing tissue in patients(9). One of the biggest advantagesof tissue engineering is that new tissue, which is fabricated in vitro, is based on cells
that originate from the patient that will receive the implant. This approach reduces
the probability of rejection and bypasses the lack of organ and tissue donors.
The main components required for tissue engineering are cells, scaﬀolds,
growth factors and proteins.
Stem cells are the cells which can be used in bone tissue engineering.
They have extensive proliferation as well as diﬀerentiation capability. There are
two types of stem cells, one is embryonic and the other is adult stem cells. The
embryonic cells can be isolated from inner cell mass of blastocyst during the stageof embryonic development. But due to the cell source, are many ethical issues,possible transplantation rejection and teratoma formation for their use in clinicalcases. In contrast to the embryonic cells, certain kinds of adult stem cells have thecapability to diﬀerentiate into a number of diﬀerent cell types. Also, there are themulti-diﬀerentiation capability of mesenchymal stem cells (MSCs) found in adultbone marrow and other tissues (12).
MSCs are bone marrow populating cells, diﬀerent from hematopoietic stem cells, which possess an extensive proliferative potential and ability to diﬀerentiate into
various cell types, including: osteocytes, adipocytes, chondrocytes, cardiomyocytes,
myocytes and neurons. MSCs play a key role in the maintenance of bone marrow
homeostasis and regulate the maturation of both hematopoietic and non-hematopoietic cells. The cells are characterized by the expression of numerous surface
antigens, but none of them appears to be exclusively expressed on MSCs. Apartfrom bone marrow, MSCs are located in other tissues, like: adipose tissue, peripheral
blood, cord blood, liver and fetal tissues. MSCs have been shown to be powerful tools
in gene therapies and can be eﬀectively transduced with viral vectors containing atherapeutic gene, as well as with DNA for speciﬁc proteins, expression of which isdesired in a patient. Due to such characteristics, the number of clinical trials basedon the use of MSCs increase. These cells have been successfully employed in graft
versus host disease treatment, heart regeneration after infarct, cartilage and bone
repair, skin wounds healing, neuronal regeneration and many others(3).
Presently, one basic research in tissue engineering is the development of“smart”
multifunctional scaﬀolds for supporting and guiding the growth of cells.
Ideally, a scalfold should have the following characteristics (5) three-dimensional and highly porous with an interconnected pore network for cell growth and26

ﬂow transport of nutrients and metabolic waste; biocompatible and bioresorbablewith a controllable degradation and resorption rate to match cell/tissue growth invitro and/or in vivo; suitable surface chemistry for cell attachment, proliferation,and diﬀerentation and mechanical properties to match those of the tissues at thesite of implantation.
In a scaﬀold based tissue engineering approach, the following aspects
must be considered: architecture-the scaﬀold must be porous with pore sizes
suﬃcient for the ingrowth and vascularization of new tissue; structural mechanics,
strength and stiﬀness of the scaﬀold must be as close as possible to the host tissue
and the scaﬀold must resist traction and contraction forces; degradation- whencancellous bone is considered, scaﬀolds must retain their integrity for one until
three months for cell seeding and culturing plus one -three months once they areplaced in the location to repair. Then, the scaﬀold must be reabsorbed without
foreign body reaction for another 12-14 months. Cortical bone regeneration
requires that the scaﬀold maintain its integrity for 6-12 months. Materials surface
should be favourable to protein adhesion and promote cellular proliferation anddiﬀerentiation(17). No single material appears to be with the complex requirements
needed for bone regeneration, thus the necessity of developing hybrid scaﬀolds.
The factors and proteins that exist in bone are responsible for regulating
cellular activity. Growth factors bind to receptors on cell surfaces, stimulating theintracellular environment to act. This activity translates to a protein kinase thatinduces a series of events resulting in the transcription of messenger ribonucleic acidand then into the formation of a protein to be used intracellularly or extracellularly.
The combination and simultaneous activity of many factors result in the controlled
production and resorption of bone. These factors, residing in the extracellular matrix
of bone, include TGF-beta, insulinlike growth factors I and II, PDGF, FGF, and BMPs.
Researchers have been able to isolate and, in some cases, synthesize these factors.
Much work continues in the research setting, and some products for clinical use
have appeared on the market (4)Transforming growth factor beta (TGF-ß) is an important regulator of bonedevelopment, induction, repair and remodelling. Beck showed in rabbits that asingle application of TGF-ß1 leads to new bone formation (2).
Bone morphogenetic proteins (BMPs) play a key role in bone formation andrepair. They have been demonstrated to elicit new bone formation both at orthotopic and ectopic sites in experimental animal models. Because of their osteogenic
potentials, recombinant BMPs hold great promise for healing bone fractures (15).
The improvement of bone healing properties of calcium phospates ceramics canbe obtained through their association with osteoinductive growth factors such
as BMP-2 or BMP -7 and/or bone progenitor cells.The adsorption of rhBMP-2 onsintered calcium phosphate ceramics can be signiﬁcantly improved by coating theceramic surface with apatite nanocrystals. It should certainly contribute to improve
the osteoinductive properties of these materials. (1)CONCLUSIONSIn long term the goal of the tissue engineering is the development of newclinical therapies and treatments in orthopedics surgery and not only(13).
At the beginning of the 21st century it is clear that the medical paradigm oftissue substitution must be replaced with tissue regeneration. Tissue engineeringbone may represent a suitable alternative to the scarcely available autologous bone
tissue and to allografts.
REFERENCES
1. Autefage H, Briand-Mesange F, Combes C, Cazalbou1 S, Drouet C, Fourmy D, Gonçalvès
S, Salles JP, Swider P, Rey C, Improvement of rhBMP-2 Adsorption on Calcium Phosphate
Ceramics Coated with Nanocrystalline Apatite, presented at 8th World Biomaterials
Congress, Amsterdam, 28.05- 1.06.2008, 1524

Fiziologia - Physiology  2009.19.1(61)2. Beck LS, Ammann AJ, Aufdemorte T B, Deguzman L, Xu Y, Lee WP, McFatridge LA,
Chen TL, In vivo induction of bone by recombinant human transforming growth factor
beta 1. J Bone Miner Res,1991; 6(9): 961-8
3. Bobis S, Jarocha D, Majka M, Mesenchymal stem cells: characteristics and clinicalapplications, Folia Histochem Cytobiol. 2006; 44(4):215-30
4. Bostrom MP, Saleh KJ, Einhorn TA. Osteoinductive growth factors in preclinical fracture
and long bone defects models. Orthop Clin North Am,. Oct 1999;30(4):647-58
5. Dietmar W. Hutmacher. Scaﬀolds in tissue engineering bone and cartilage. Biomaterials 21, 2000, 2529-2543.
6. Felicity R, Rose AJ, Oreﬀo ROC. Bone Tissue Engineering: Hope vs Hype. Biochemical
and Biophysical Research Communications, 2002; 292, 1–7
7. Heiple KG, Kendrick RE, Herndon CH, Chase SW, A critical evaluation of processed calfbone. J Bone Joint Surg , 1967; 49A(6): 1119-27
8. Kruyt M, Wilson C, Dhert W, The role of osteogenesis, osteoinduction and osteoconduction in cell-based bone tissue engineering, presented at 8th World Biomaterials Congress,
Amsterdam, 28.05- 1.06.2008, 1856
9. Langer, R., Vacanti, J.P. Tissue Engineering. Science, 1993; 260:920
10. Mainard D., Gouin F, Chauveaux D, Loty B, Massin Ph, Les substitutes osseux et du
cartilage en 2007, GESTO, Edition Romillat, 2007, Vol VIII :9-12
11. Meani E, Romano CL, Trezza P, Bone defect and bone loss: an emerging problem,

The International Meeting Bone Defect 23-25.10.2008, Milano, 5
12. Muraki K, Hirose M, Kotobuki N, Kato Y, Machida H, Takakura Y, Ohgushi H, Assessment of viability and osteogenic ability of human mesenchymal stem cells after being
stored in suspension for clinical transplantation. Tissue Eng. 2006 Jun;12(6):1711-9.
13. Nerem RM. Tissue Engineering and Stem Cell Technology, presented at 8th World
Biomaterials Congress, Amsterdam, 28.05 - 1.06.2008, 1090
14. Ollier L. De la production artiﬁcielle des os, an moyen de la transplantation depérioste et des greﬀes oseuses. C.r. Soc. Biol., 1858;5: 145-191
15. Park DJ, Kim HL, YI Woo, Lee MH, Lee DH, Park J.C, Enhancement of osteogenesisby rhBMP-7/PLGA composite scaﬀold, presented at 8th World Biomaterials Congress,
Amsterdam, 28.05- 01.06.2008, 214
16. Phemister DB, The fate of transplanted bone and regenarative power of its various
constituents. Surg Gyn 1914; 19: 303-33
17. Rodríguez-Lorenzo LM, García-Carrodeguas R, Rodríguez MA, Aza S , Román JS,
Modulation of porosity in ceramic/bioresorbable polymer hybrid scaﬀolds for boneengineering, presented at 8th World Biomaterials Congress, Amsterdam, 28.051.06.2008, 2039
18. Williams DF, Black J, Doherty PJ, Second consensus conference of deﬁnitions inbiomaterials. 525-33. In: Williams D F, Black J, Doherty P J ed. Advances in biomaterials
10. Elsevier, Amsterdam-London-New York-Tokyo, 1992

DE LA TRANSPLANTUL OSOS AUTOLOG LA INGINERIA TISULARĂ ÎN CHIRURGIA
ORTOPEDICĂ DE GRAFARE OSOASĂREZUMATIn ciuda numeroaselor descoperiri din chirurgia grefării osoase, noile materiale şi tehnici în tratamentul defectelor osoase continuă să ﬁe cercetate. Unul din
domeniile ce suscita interes în prezent este ingineria tisulară, care poate ﬁ deﬁnită ca o aplicaţie biologică, chimică şi principii de inginerie pentru repararea,
restaurarea sau regenerarea ţesuturilor vii ce folosesc biomateriale, celule şi factori de creştere, utilizate separat sau în combinaţie. În acest articol review este
prezentată evoluţia transplantului de grefă osoasă din chirurgia ortopedică, modalităţile de grefare, câteva aspecte punctate la ultimile congrese internaţionale
ale acestei specialităţi, precum şi unele aspecte ce se preﬁgurează în viitor.
Cuvinte cheie: grefare osoasă, matrice, celule stem mezenchimale, inginerie tisulară

2009.19.1(61)  Fiziologia - Physiology

27

MILK AND ACID DAIRY PRODUCTS CONSUMPTION IN TIMIS COUNTY ADOLESCENTS. EVALUATION OF SOME RISKFACTORSOANA SUCIU1, BRIGITHA VLAICU1,2, SORINA DOROFTEI1, CRISTINA PETRESCU1, CORNELUŢAFIRA-MLADINESCU1, SALOMEIA PUTNOKY1, RADU BAGIU1, DELIA CHEPTĂNARIU3
1 “Victor Babes” University of Medicine and Pharmacy Timisoara, Romania
2 Institut of Public Health “Prof.Dr. L. Georgescu”, Timisoara, Romania
3 Omnisan Polyclinic, Timisoara

ABSTRACT
Milk and acid dairy products are foods with high nutritional value especially due to the phospho-calcium complex and proteins. Reported to the caloric valueof the food intake during adolescence, this animal origin nutrient cathegory will represent 15-20%.
The study was performed on a representative population of adolescents in high schools, postagraduate and vocational schools in Timiș County, in urban
areas, including 2908 pupils.
We investigated the frequency of milk and acid dairy products consumption in adolescents, and the results showed that 31.7% of the young subjects had
consumed milk and acid dairy products on a daily basis during the previous week, the boys/girls ratio being 1.3/1, and the daily milk intake decreased
with age. Acid dairy products were consumed daily by 24.1% of the adolescents, the report between boys and girls being 1.1/1 and the proportion of daily
consumers decreased with age.
We found that reported to the hygiene recommendation of daily intake of milk and acid dairy products, Timiș county adolescents may present a susceptibility
towards retarded development and maturation, to harmful environmental agents and to osteomalacia.
Key words: adolescents, milk and acid dairy products, risks

INTRODUCTIONMETHODS
The study was performed on a representative population of adolescents in highschools, postgraduate and apprentice schools in Timis county, urban areas, and it included
a total of 2908 pupils aged between 14-25 years (99% for the 15-19 years age group),
51.5% girls and 48.5% boys.
The work method was the transversal populational study, by group and anonimous
use of the CORT 2004 questionnaire for investigating some health risk behaviours inyoung subjects, as concieved by a CNCSIS accredited research, based upon the adaptationof some international questionnaires (ESPAD, YRBSS) to Romanian realities, during theperiod 2003 - 2005 (8).

RESULTS AND DISCUSSIONS
1. Milk consumption (Figures 1 and 2)
35
%

31.1

28.3

30
25

23.6
17.8

19.5

20

22.5

18.5

10

16.5

14.2

15

Boys
Girls

8.1

5
Did not
consumemilk

Between 1
and 3
glasses a
week

Between 4
and 6
glasses aweek

At least
one glassof milk aday

0More than
two glasses
a day

Milk is a complete aliment, with a high nutritional value, given by the presence oftrophines which are indispensable for human nutrition at all ages. The most valuable
trophines are the phospho-calcium complex and the proteins, involved in growth andmaturation, in bone and teeth mineralization – antirachitic/antidecalciﬁant (4).
The main calcium source is represented by milk and its derivates. The calcium
concentration in milk is 120mg/100ml. The digestive use of milk calcium is also supported by some factors: Ca/P ratio over 1, 1.4 similar to the ratio in the human organism;
the presence of natural D3 vitamin, lactose and lactic acid, citric acid and citrates, ﬁrst
class proteins. At the same time, some calcium inhibiting factors, such as the phitic
and oxalic acids, are absent.
Milk proteins, 3.5g % on the average, are mainly represented by casein, 3 g%(2). Having a high biological value, milk proteins are proteinogenetic, they determine
growth and a positive azotate balance, increase the resistence of the organism to biotic
and abiotic aggressions.
Acid dairy products, obtained by milk fermentative processes (lactic, alcoholic
fermentation) are recommended for daily alimentation, being characterized by: digestibility of proteins and lipids, 20-25% higher as compared to milk; high content of
B complex vitamins (1).
The need of milk and acid dairy products in adolescence: 500 ml milk/day (2 cupsof 250 ml or 3-4 glasses of 150 ml); 100 ml acid dairy products/day (1/2 cup or one
glass). Reported to the caloric value of the portion, this animal origin food cathegory
will represent 15-20% (7).

Fig. 1. Percent distribution of boys and girls depending on the frequency of a single milk
glass consumption during one week
Received November 2008. Accepted January 2009. Address for correspondence: Dr. Oana Suciu, „Victor Babes” University of Medicine and Pharmacy Timisoara, 2A Eftimie Murgu Square, 300041, Timisoara,
Romania, phone/fax: 0256220479

28

Fiziologia - Physiology  2009.19.1(61)10.53
Did not consume
milk

23.6
15.4

10.53
Be twe e n 1 and 3
glasse s a we e k>20 ye ars
19 ye ars
18 ye ars
17 ye ars
16 ye ars
15 ye ars
14 ye ars

24.7

7.7

31.58

Be twe e n 4 and 6
glasse s a we e k

20.1
30.8
26.31

At le ast one glassof milk a day

18.4

38.5

10.53

21.05

More than two
glasse s a day

Did not consume milk

13.1
7.7

0

10

20

Fig. 3. Percentual distribution of boys and girls depending on the frequency of one glass ofacid dairy products during one week

30

40

10.53 15.4

Be twe e n 1 and 3 glasse s a we e k%

Out of the questioned adolescents, only 12.8% consumed more than
two glasses of milk a day, and 31.7% consumed at least one glass of milka day, 18.7% of the young subjects consumed between 4 and 6 glasses a
week, and 27% consumed between 1 and 3 glasses a week. The percent of
those who did not consume milk is 22.6%.
We observed that boys had a better milk intake than girls, 17.8%
consumed more than two glasses a day, as compared to 8.1%, and 22.5% of
the boys and 31.1% of the girls consumed between one and three glasses ofmilk during one week. The percent of young subjects who consumed at least
one glass of milk a day was low, 37.3% of the boys and 26.6% of the girls,
given the importance of this aliment for adolescent nutrition (Figure 1).
The diference is statistically signiﬁcant (χ2) as reported to gender, being
152.4, with a probability cutoﬀ p<0.001, in favour of the boys who consume
milk more frequently than girls.
Analyzing milk consumption in adolescents, by age groups, we foundthat almost half of the the 14 years olds, 46.2%, and 35.8% of the 15 year
olds, consumed at least one glass of milk a day, and that the frequency ofdaily milk consumption decreases with age, namely only 22.3% of the 19
year old adolescents have a daily milk intake (Figure 2).
The age diﬀerence regarding milk consumption is statistically signiﬁcant(χ2), 89.63%, with a probability p<0.001, the highest milk consumption
being found in 16-17 year old adolescents.

2. Acid dairy product consumption (Figures 3 and 4)
43.1
35.2
24.7
15.5

16.0

10.6

25.3

Did not
consume

Between 1
and 3
glasses a
week

Between 4
and 6
glasses a
week

6.3

At least
one glass
a day

Boys
Girls

14.1
9.3

More thantwo
glasses a
day

40
35
30
25
20
15
10
5
0

2009.19.1(61)  Fiziologia - Physiology

31.58

20.1

30.8
26.31
38.5
18.4

At le ast one glass of milk a day
More than two glasse s a day

% 45

24.7

7.7

Be twe e n 4 and 6 glasse s a we e k

Fig. 2. Percentual distribution of adolescents by age groups depending on the frequency of
one glass of milk during one week

23.6

7.7

0

10

21.05
13.1

20

30

40

>20 ye ars
19 ye ars
18 ye ars
17 ye ars
16 ye ars
15 ye ars
14 ye ars%Fig. 4. Percentual distribution of adolescents by age groups depending on the frequency
of consumption of one glass of acid dairy products (sana, keﬁr, yoghurt, sour milk) during one
week

Considering the extremely valuable qualities of milk derivates, regarding theircontent of high quality nutrients, in an optimal combination for the develpomentand support of body functions, these have a great importance for adolescent nutrition as an alternative to milk consumption (5). Their nutritional value is similar tothat of milk, but they have the advantage of presenting nutritional factors in aneasier assimilable form (3).
The studied group had an acid dairy product consumption lower than milk
consumption. Only 8.4% of adolescents consumed 2 or more glasses a day, 15.7%
consumed one glass a day, and for 11.6% of the young subjects, the frequency
of consumption was between 4 and 6 glasses a week. Most of the questioned
adolescents, 39.2%, very rarely consumed milk derivates, namely, between 1 and3 glasses a week.
Of the adolescents consuming at least one glass of acid dairy products a day,the highest proportion was represented by boys, 26.1%, as compared to girls,
22.3%. Only 6.3% of girls, as compared to 10.6% of boys, had a daily intake overtwo glasses. About one quarter of the young subjects, 24.7%, boys and 25.3%
girls, do not consume milk derivates (Figure 3).
By gender, the diference is statistically significant (χ2), 32.6, in favourof boys, with a probability p<0.01, boys having a higher intake of acid dairy
products because they are more preoccupied of increasing their muscular mass.
By frequency hierarchy in consumption of acid dairy products, there is an identity
between boys and girls.
We observed that the frequency of young subjects who rarely consumed aciddairy products is increasing from the age of 14, 30.8%, to the age of 19, 44.9%,
as compared to those who had a daily intake of at least one glass, for whom theconsumption frequency decreases from 14 years of age, 46.2% to the age of 19,
14.5% (Figure 4).
The diﬀerence between the frequency of consumption of acid dairy products,
by age, is statistically signiﬁcant, (χ2), 26.14, with a probability p<0.01.
3. Evaluation of risk factors for milk and acid dairy products (Table I)
We selected individual and family factors, possible predictors for insuﬃcient milk anddairy products consumption in adolescents, by multivariated logistic regression.

29

Table I. Risk factors for daily consumption of milk and acid dairy products. Multivariated logistic regression analysis

Variable

Odds Ratio
OR

Statistical significance cutoff
p

Minim

Maxim

0.007

0.67

0.94

0.756
0.016

0.59
1.05

1.47
1.65

Individual Factors
Masculine Gender

0.80

95% C.I. for OR

ResidenceTown

1(ref)

Village
Municipium
Perceived Weight
Under normal value

0.93
1.32
1(ref)

Around the normal value
A little over the normal value
Much over the normal value
School situation (average grade in thelast semester)
Very good (average 9-10)
Good (average 8-8.99)

1.07
1.38
1.80

0.494
0.012
0.012

0.88
1.07
1.14

1.30
1.76
2.86

1(ref)
0.87

0.184

0.70

1.07

Medium (average 6-7.99)

0.65<0.0010.52

0.81

Low (average 5-5.99)

0.91

0.693

0.58

1.43

Class
The IX-th class1(ref)The X-th Class

1.03

0.781

0.84

1.26

The XI-th Class

1.14

0.231

0.92

1.40

The XII-th Class
Education level of the mother

1.62<0.001

1.27

2.06

Faculty1(ref)

Postgraduate school

1.03

0.865

0.76

1.39

High school
Apprentice school
Gymnasium or less

1.34
1.48
1.30

0.009
0.005
0.108

1.08
1.12
0.94

1.66
1.95
1.80

By multivariated regression analysis, weak predictors (OR between 1-2, p<0.005) were revealed for daily lack of consumption of milk and acid dairy products in adolescents:-the situation of XII-th class high school pupil (OR=1.62, p<0.001)-the mother’s average level of education (graduate of apprentice school) (OR=1.48, p<0.005).
The statistical behavioural model for daily lack of consumption of milk and acid dairy products in adolescents reunites the two signiﬁcant predictors mentioned above.
CONCLUSIONS
Milk and acid dairy products are foods with high nutritional value especiallygiven by the phospho-calcium complex and proteins.
Daily milk consumption during the previous week was declared in 31.7% of
adolescents, boys more frequently being daily consumers, with a boys/girls ratio of
1.3/1. The daily milk consumption decreases with age from 35.8% at the age of 15,
to 22.3% at the age of 19. Acid dairy products, deﬁned by a higher digestability ofproteins and lipids and a higher content of B complex vitamins, are consumed daily30

by 24.1% of the adolescents aged between 15-19 years, the boys/girls consumer
ratio being 1.1/1. The daily consumption decreases with age, from 30.1% at theage of 15, to 14.5% at 19.
The statistical behavioural model for daily lack of milk and acid diary products
consumption in adolescents reunites the two signiﬁcant predictors: the XII-thclass high school pupil status, the educational level of the mother (graduate ofapprentice school).
Reported to the hygiene recommendation for daily consumption of milk andFiziologia - Physiology  2009.19.1(61)acid dairy products, adolescents present susceptibility to osteomalacia, to developmental and maturation retardation, and to environmental harmful agents (6).

REFERENCES
1.
Bandini LG, Colclough-Douglas S, Naumova E, et al. Dairy food consumption and body weight and fatness studied longitudinally over the adolescent period.
International Journal of Obesity, 2003, 27(9):1106-1113
2.
Doroftei S, Vlaicu B, Petrescu C, et al. Environmental Hygiene. Food
Hygiene. Hygiene of children and adolescents, Eurobit Publishing, Timişoara, 2000,
126-142
3.
Huth PJ, DiRienzo DB, Miller GD, Major Scientiﬁc Advances with Dairy
Foods in Nutrition and Health. J Dairy Sci, 2006, vol. 89: 1207-1221
4.
Ionuţ C, Popa M, Laza V, et al. Compendium of Hygiene, Medical Uni-

versity Publishing House „Iuliu Haţieganu” Cluj-Napoca, 2004, 327- 380
5.
Negrişanu G. Treaty of nutrition. Brumar Publishing, Timişoara, 2005,
259-277
6.
Williams AC, Penﬁeld MP, Development and validation of an instrument for characterizing food-related behavior. Journal Am. Dietetic Assoc., 1989,
85(6):685-97.
***, WHO, Childhood nutrition and progress in implementing theInternational Code of Marketing of Breast-milk Substitutes. Geneva (document
A55/14). Obesity: preventing and managing the global epidemic. Report of a WHO
Consultation. Geneva, 2002, (WHO Technical Report Series, No. 894)8.
***, Grant A CNCSIS code 1167, 2003-2005, Assessing the size of risk
behaviors in high school and young people in secondary education, post, professional
and academic Timiş County, 2004.

CONSUMUL DE LAPTE SI PRODUSE LACTATE ACIDE IN RANDUL ADOLESCENTILOR DI JUDETUL TIMIS. EVALUAREA UNOR FACTORI DE RISC
REZUMAT
Laptele şi produsele lactate acide sunt alimente cu valoare nutritivă superioară dată mai ales de complexul fosfo-calcic şi proteine. Raportat la valoarea
calorică a raţiei în adolescenţă, această categorie de alimente de origine animală va reprezenta 15-20%. Studiul a fost efectuat pe o populaţie reprezentativă
de adolescenţi liceeni din licee, şcoli postliceale şi profesionale din judeţul Timiş, mediul urban, care a totalizat 2908 elevi. S-a investigat frecvenţa cu careadolescenţii consumă lapte şi produse lactate acide, iar rezultatele au evidenţiat faptul că 31,7% dintre tineri au consumat zilnic lapte în ultima săptămână,raportul băieţi/fete ﬁind de 1,3/1, iar cu vârsta, consumul zilnic de lapte scade. Produsele lactate acide au fost consumate zilnic de 24,1% dintre adolescenţi,raportul consumatorilor băieţi/fete ﬁind de 1,1/1 şi proporţia consumatorilor zilnici scade cu vârsta. Se constată că faţă de recomandarea igienică de consum
zilnic de lapte şi produse lactate acide, adolescenţii timişeni pot prezenta susceptibilitate pentru retard în dezvoltare şi maturizare, faţă de noxele din mediulînconjurător şi pentru osteomalacie.
Cuvinte cheie: adolescenţi, lapte şi produse lactate acide, riscuri

2009.19.1(61)  Fiziologia - Physiology

31

ASSOCIATED RISKS TO THE SEXUAL ACT IN ADOLESCENTS
FROM TIMIS COUNTYBAGIU RADU1, SUCIU OANA1, PUTNOKY SALOMEIA1, VLAICU BRIGITHA1, ROTARU IULIA2
1Victor Babes University of Medicine and Pharmacy Timisoara, Romania
2Emergency Public Hospital Timisoara

ABSTRACT
Risks associated with sexual act, such as the debut of sexual life under 13 years old, the lack of using contraception, sex with one-night partners, alcohol anddrug consumption associated with intercourse, group sex, homosexual experiences are realities in adolescence. The study was conducted on a representative
population of highschool students in Timis county, 2908 students from urban area of 15-19 years. The used work method was a cross sectional study. Results
show: 3.1% of adolescents have started their sex life under the age 13.41.2% of boys and 10.4% of girls listed 4 or more sexual partners; 43.5% of boys and
21% of girls never use or only rarely condom with casual partners, 98.8% of the adolescents associated intercourse with diﬀerent experiences. Promoting
healthy sexual behavior as concept along lifetime is fundamental.
Keywords: adolescents, sexuality, risks

INTRODUCTION
Sexual freedom after puberty seems to be natural. In reality in this period sexual
life hides many risks: sexual transmitted diseases, AIDS, abortions, unwanted childor born outside marriage, family conﬂicts (1).
Approximately 25% of sexually active young people in the U.S. get a sexuallytransmitted disease each year and 80% of infected young people do not even know
they are infected, transmitting the disease to the partners. Factors contributing tosuch situations are combination of the intercourse with the consumption of alcoholor drugs in 23% of highschool students, intercourse in wich at 34% of them isunprotected by contraception. Some 14% of adolescents have had four or moresexual partners from the onset of their sexual life (7).
In multiple studies, adolescents have reported an early debut of sexual activity, multiple sexual partners, use of psychoactive substances, and sexual abuse inchildhood. A relatively low percentage stated a condom was used at last intercourse.
Unprotected sex was associated with lack of behavioral intentions to use condoms,
pregnancy, having occasional partner and persons who practiced anal sex (3). Ina study on a randomized group of 3000 adolescents of 17-19 years in Norway,
during the recent intercourse, every ﬁfth adolescent did not use any contraception;
one in three used a condom and approximately 40% reported having used the pill.
Multiple logistic regression analysis showed that among both girls and boys non-use
of contraception increased with alcohol consumption prior to intercourse. Use of acondom most frequently occurred in standing relationships (4). Sexual orientation
plays an important part in building identity during adolescence.
For a realistic understanding of sexual orientation in adolescents, is necessary
a diﬀerential view on the dimension of sexual orientation. Thus, it can describe
patterns of sexual orientation, including sexual attraction, fantasies, aﬃliations
and behavior (5).
Sexual violence is all over the world. Childhood sexual abuse may weaken self
esteem, self awareness, interpersonal relations and trust. Impact of sexual abuseon cognitive and emotional development of children is very important because thechild feels betrayed, without force, stigmatized. The emotional response includes
the anxiety, fear, depression, anger, self blame, low self esteem, poor capacity tomake intimate relationships.
Fear of reprisals, attitude against homosexuality, and loss of self esteem they
make boys to be less willing to confess abuse than girls. Studies on adolescent boys
reported an association between sexual abuse and drug abuse, violent behavior,school absenteeism and theft. Even girls are included as sexual aggressors: sexual
violence includes blackmail, intimidation, threats as forms of coerrction to compel
to intercourse.
It may be taken into account the fact that sexual violence can occur on an
individual who is unable to express consent, for example, drunk or under theinﬂuence of drugs (8, 9).

METHODOLOGY
Material
The study was conducted on a representative population of adolescents fromhigh schools, post secundary schools and profesional schools in Timis county, urban
area, and totalized 2908 students of 14-25 years (99% for the group of adolescentsof 15-19 years), 51.5% girls and 48.5% boys.
MethodThe method of the study was a cross sectional study through application ofanonymous group questionnaire CORT 2004 of investigation risk behaviors for healthto young people, designed by a team of an research project accredited CNCSIS,
through adjustment of international surveys (ESPAD, YRBSS) to the reality of life in
Romania during the period 2003-2005 (2, 10).

Received January 2009. Accepted February 2009. Address for correspondence: Dr. Radu Bagiu, “Victor Babes” University of Medicine and Pharmacy Timisoara, 2A Eftimie Murgu Square, 300041, phone/fax:
0256220479, e-mail:32

Fiziologia - Physiology  2009.19.1(61)3. Condom use in intercourse with casual partners (Figure 3).
1. Beginning of sexual life under the age of 13 years (Figure 1).

Fig. 1. Percentage distribution of adolescents who started sexual life, depending on age
debut of sexual relations

A percentage of 43.8% adolescents between 15-19 years said they started
sex life.
For both sexes, 54.2% of boys and 33.8% of girls have intercourse. On age
groups at both sexes, the presence of sexual relations register increase percentage,
from 11 years to 17 years or more. It is observed a beginning of sexual life at theage of 11 years or even earlier to a number of 1.5% subjects, 2.8% being boys
and 0.3% girls.
Among boys, 3.3% began sex life from the age of 12 years, 3.8% from 13
years, 9.8% from 14 years, 12.5% from 15 years, 12.7% from 16 years and 9.4%
from 17 years or more.
Girls at all age groups register lower percentages than boys in terms of debutof sexual life.
At the age of under 13 years, 3.1% of adolescents from Timis county began
sex life, 2.8% boys and 0.3% girls.

Fig. 3. Percentage distribution of adolescents who started sexual life, depending on thefrequency of condom use with the occasional partner

The condom is used by a percentage of 87.4% boys and 66.4% girls who
indicate casual sex partners. Among boys, 63.2% always use it, 14.3% often, 9.9%
rarely and 12.6% never.
A percentage of 44.8% of young women who have answered the question,
always indicate condom use, 13.1% often, 8.4% rarely and 33.6% never.
Never use a condom or only rarely in relations with casual partners, 43.5%
of boys and 21% of girls.
4. Associated experiences to intercourse (Figure 4).

2. The number of sexual partners, 4 or more (Figure 2).

Fig. 4. Percentage distribution of adolescents who started sexual life, depending on theuse of risk experiences associated with intercourse

Fig. 2. Percentage distribution of adolescents who maintained sexual relations, according
to the number of sexual partners

The most boys with sexual life, 33.5% indicated ﬁve or more partners before,
7.7% stated they had intercourse with four persons, 16.2% with three, 16.5% withtwo persons and 25.5% boys indicated one partner so far.
The most girls, 64.1% declare a single sexual partner, 16.1% stated they hadintercourse with two persons, 8.8% with three, 4.7% with four and 5.7% with ﬁve
or more partners until now.
A number of 4 or more sexual partners was mentioned by 41.2% of boys
and 10.4% of girls.
2009.19.1(61)  Fiziologia - Physiology

A large proportion of adolescents with sexual life, 98.8%, of which 60.7%
boys and 39.3% girls, answered the question concerning the association of sexual
act with diﬀerent experiences:- 26.0% of them indicate sex with one night partners,- 15.3% associate alcohol consumption and 1.4% drug consumption tointercourse,- 6.9% of young people have practiced group sex,
- 1,1% had homosexual experiences.
The most boys, 38.2%, indicate sex with one night partners, 18.0% associatealcohol consumption and 1.8% drug consumption to intercourse, 9.9% practicegroup sex, and 0.6 % adolescents had homosexual experiences.
Among adolescent girls with sexual life, 11.0% associate alcohol consumption and 0.8% drug consumption to intercourse, 7.4% practice sex with one night
partners and 2.4% group sex, while 1.7% of the young girls had homosexual
experiences.

33

5. Sexual coercion of adolescents and coercion of other persons to sex relations byadolescents (Figure 5).

capable to address those groups of adolescents not using contraception remains
important (4).
Monitoring sexual behavior of the general population, focusing on risk behavior, rather than on the risk groups, is vital in promoting healthy sexual behavior
as concept of lifetime (6).

REFERENCES

Fig. 5. Percentage distribution of girls and boys in terms of sexual coercion, supported orcommitted

In the CORT 2004 study, 5.5% of girls and 3% of boys reported that they wereforced to sexual relations.
In turn, 3.6% of boys and 0.4% of girls admitted that they forced someone tomaintain sexual relations with them.

CONCLUSIONS
A number of risks associated with sexual act, such as the debut of sexual life
under 13 years, the lack of recourse to contraception, sex with one-night partners,
alcohol and drugs consumption associated with sexual act, group sex, homosexual
experiences, have been highlighted in the study of risk behaviors in adolescentsfrom Timis county.
A substantial proportion of adolescents are at risk practices for unwanted
pregnancies and sexually transmitted diseases. Despite the priority given to issuesof sexuality in schools and health centers in recent decades, the percentage of
those not using contraception is high. Development of health promoting activities

1.Fiske B. The sexual brain. Nature Neuroscience, 2004, 7:1029
2.Hibell B, Andersson B, Bjarnason T et al. The ESPAD Report - Alcohol and Other Drug
Use Among Students in 35 European Countries, The Swedish Council for Information
on Alcohol and Other Drugs, The Pompidou Group at the Council of Europe and theauthors, Sweden, Modintryckoﬀset AB, Stockholm, 2004
3.Koniak-Griﬃn D, Lesser J, Uman G et al. Teen pregnancy, motherhood, and unprotected sexual activity. Research in Nursing & Health, 2003; 26 (1):4-19
4.Kraft P, Rise J. Contraceptive behavior of Norwegian adolescents. Health Education
Research, 1991; 6(4):431-441
5.Narring F, Stronski Huwiler SM, Michaud PA. Prevalence and dimensions of sexual
orientation in Swiss adolescents: a cross-sectional survey of 16 to 20-year-old students. Acta Paediatrica, 2007;92(2):233 - 239
6.Signorelli C, Pasquarella C, Limina RM et al. Third Italian national survey on knowledge, attitudes, and sexual behaviour in relation to HIV/AIDS risk and the role of healtheducation campaigns. The European Journal of Public Health, 2006;16(5):498-504
7.***, CDC. Youth Risk Behavior Surveillance-United States. Morbidity & Mortality
Weekly Report, 2006;55(SS-5):1–108
8.***, World Health Organisation, Geneva, World report on violence and health,2002
9.***, WHO, The Health of Children and Adolescents in Europe, Copenhagen, Bucharest, 12 september 2005, http://www.euro.who.int./childhealthdev
10.***, The Youth Risk Behavior Surveillance System (YRBSS), Department of Healthand Human Services, Center for Disease Control and Prevention, 2005

RISCURI ASOCIATE ACTULUI SEXUAL LA ADOLESCENŢI TIMIŞENIREZUMAT
Riscuri asociate actului sexual, cum ar ﬁ debutul vieţii sexuale sub 13 ani, lipsa de recurgere la contracepţie, sexul cu parteneri de o noapte, consumul dealcool şi droguri asociat actului sexual, sexul în grup, experienţele homosexuale sunt realităţi în adolescenţă. Studiul s-a efectuat pe o populaţie reprezentativă
de liceeni din judeţul Timiş, mediul urban, 2908 elevi de 15-19 ani. Metoda de lucru a fost studiul populaţional transversal. Rezultatele indică: 3,1% dintre
adolescenţi au început viaţa sexuală sub 13 ani; 4 parteneri sexuali sau mai mult, au fost menţionaţi de 41,2% dintre băieţi şi 10,4% dintre fete; nu folosesc
niciodată sau doar rareori prezervativul cu parteneri ocazionali, 43,5% dintre băieţi şi 21% dintre fete; 98,8%, dintre adolescenţi asociază actul sexual cudiferite experienţe. Promovarea comportamentului sexual sănătos ca şi concept de-a lungul vieţii este fundamentală.
Cuvinte cheie: adolescenţi, sexualitate, riscuri

34

Fiziologia - Physiology  2009.19.1(61)THE EFFECT OF THE LONG TERM HIGH DOSES OF ATORVASTATIN THERAPY ON THE RECURRENT EVENTS IN ACUTE
CORONARY PATIENTSADRIANA S. POTRA, VIRGIL M. LUCA, CONSTANTIN O. LUCA
Institute of Cardiovascular Diseases Timisoara, Romania
University of Medicine and Pharmacy “Victor Babes”Timisoara, Romania

INTRODUCTION
The statins has shown beneﬁt in acute coronary patients. The long term highdoses atorvastatin therapy has been very eﬀective in improving outcomes of acutecoronary patients with severe instable angina and acute myocardial infarction.
There are only few studies of the eﬀects of statins in acute coronary patients who
hospitalised late in a specialised coronary unit. This study evaluates major andminor end points during a long period of time after acute coronary patients havebeen hospitalised.

MATERIAL AND METHOD
The present observational study is undertaken on acute coronary patients,
adults (above 18 years), that hospitalized relatively tardy, 8-12 hours after the onsetof the myocardial infarct, regardless of the presence or absence of dyslipidemia.
We excluded the coronary patients that were scheduled for revascularizationinterventions, the myocardial infarct patients with Q wave in the last 4 weeks,coronary by pass undertaken in the last 3 months, PTCA in the last 6 months, severe
anaemia (Hb<8mg/%), dialysis patients (IRC stadium IV), insulin-dependent
diabetes, pregnancy and nursing.
The present observational study is undertaken in accordance with all valid
ethical principles, all the patients included beneﬁted from pharmaceutical therapy
conformable with the current therapeutic guides. Written informed consens was
obtained from all patients. The hospitalized patients, with acute myocardial infarct(with or without pre-hospital thrombolysis) and severe unstable angina, weretreated and monitored adequately during the hospitalization period and received
high doses of atorvastatin (80mg/day) after which they were attentively monitored
both clinically and biologically at 6 months, 12 months and 24 months. All thepatients received recommendations for hygieno-dietethical regime, conformablewith the current therapeutic guides.
After 24-96 hours of hospitalization, the acute coronary patients received
atorvastatin in maximum dose of 80mg/day; the clinical and paraclincal monitoringof the patients has been duly undertaken, both during the hospitalization period
and after the hospitalization at 6, 12 and 24 months. The clinical and paraclinicalevolution of these patients was compared with hospitalized patients with similar
characteristics who received usual pathology speciﬁc treatment, except the maximum atorvastatin dose administered just after admission in the study. Preliminary
analyses of the results at 6 months, 12 months and 24 months from the hospitalization of acute myocardial infarct patients were eﬀectuated.

END POINTSAll the patients were monitored for major and minor ischemic events (endpoints), immediately after the onset of the acute coronary event: acute myocardial
infarction or severe unstable angina.
The default primary end-points are the death, non-fatal acute myocardial
infarct, cardiac arrest with resuscitation, or recurrent symptomatic myocardial ischemia with objective evidence requiring emergency re-hospitalization. Electrocardiographic entry criteria and the diagnosis of acute myocardial infarction included
cardiac enzyme data criteria are for each patient.. Cardiac arrest with resuscitation
and recurrent symptomatic myocardial infarction
The traced secondary end-points are the period of time until the occurrence ofthe primary end-points, the occurrence of fatal and non-fatal AVC, revascularizations (PTCA and by pass), re-hospitalization (aggravated angina, newly diagnosed
or aggravated congestive cardiac insuﬃciency that needed hospitalization), theperiod of time until the occurrence of primary and secondary end-points and theseric level of the lipids in comparison with moment zero when the patients wereadmitted into the study.
All patients were monitored clinically and paraclincal: seric lipids (total cholesterol, triglycerides, LDL, HDL), PRC, ﬁbrinogen, VSH, glycaemia, hemoleucograma,
LDH, urea, creatinine, ionograma, ECG, echocardiography.
STATISTICAL ANALYSISTime to ﬁrst occurrence or ﬁrst primary or secondary cardiovascular event
was analysed using stratiﬁed Cox proportional hazards models and were displayedusing Kaplan-Meier curves. The Cox proportional hazards analyses were stratiﬁed bysubgroups and index event ( unstable severe angina or acute myocardial infarction).
Stepwise regression analyses were performed to determine predictors of nonfatal
myocardial infarction. The stratiﬁed Cox proportional hazards model that was used
for the original analyses was used as the starting point for the stepwise analyses.
Baselines variables (Table 1) were added one by one to the original Cox model in the
stepwise analysis, beginning with the variable with the smallest probability value.
The stepwise process ended when none of the variables outside the model had aprobability value <0,05 and every variable in the model had a p<0,10.

RESULTS
From a total of 584 acute coronary patients, we included 352 patients withacute myocardial infarction and severe unstable angina in the study, in accordancewith the preset inclusion criteria, the period of the inclusion of the patients being

Received January 2009. Accepted February 2009. Address for correspondence: Dr. Adriana Potra, Institute of Cardiovascular Medicine Timisoara, “Victor Babes” University of Medicine and Pharmacy Timisoara,
Eftimie 2A Murgu Square, 300041, phone/fax: 0256490507

2009.19.1(61)  Fiziologia - Physiology

35February 2004-December 2005. The moment of the admission of the patients tothe study overlapped with the moment of their hospitalization. The maximum daily
dose of atorvastatin (80mg/zi) was administered to a lot of 179 patients, the rest of
the patients received the usual treatment according to the valid therapeutic guides(other statins in usual doses), meaning the control lot was composed of 173 patients.
The clinical and paraclinical monitoring of all the patients was undertaken at 6, 12
and 24 months from the inclusion to the study. The clinical and demographical dataof the patients from the two groups were similar at the moment of the inclusion
to the study (Table 1).
Table 1. The baselines characteristics of the acute coronary patientsAge (years)
Men
White raise
Time from the onset(hours)Cardiovascular history* Heart failure

65 _
224
64%
350
100%
9 _
30

8.50%

30

8.50%

34
88

9.60%
25.00%

11

3.00%

25

7.30%

* Smoking98

28.00%* HTA

193

55.00%* diabetes melitus

81

23.00%* dislipidemia

147

42.00%* Cerebrovascular disease* Periferic vascular disease* Miocardial Infarction* PTCA revascularisation* BY PASS revascularisation
Cardiovascular Risk Factors

Values are mean ±SD or number of patients (%).

We have split the acute coronary patients 3 groups corresponding to the twolots of patients (the control lot and the lot with acute myocardial infarct patientstreated with atorvastatin 80mg/day) and in accordance with the ECG diagnosis.
Group I includes 145 patients with severe unstable angina (Table 2). Group II
includes 110 patients with acute myocardial infarction (AMI) without ST segment
denivelation, group III includes 97 patients with AMI with ST segment denivelation (Table 2).

36

Table 2. Groups of acute coronary patients evaluated for 24 months
Lot Atorvastatin
Lot
ConTo80mg/zi
trol
tal
nr
nr papaPatientstients%tients%Group
I: Severe
Unstable
Angina

72

40%

73

42%

145

Group II:Non ST
Denivelation IMA(NSTD)

57

32%

53

31%

110

Group IIIST Denivelation IMA
(STD)

50

28%

47

27%

97

Total

179

173

352

As a percentage, group I (patients with Severe Unstable Angina)
comprises 41% of the patients, group II (Non ST Denivelation Myocardial
Infarct) comprises 32% of the total patients and group III ( ST Devinvelation
Myocardial Infarct) comprises 27% of the total patients with IMA includedin the study.
The average time between the hospitalization of the patients and theadministration of the dose of 80mg/day of atorvastatin was 63 hours. The
planning for the clinical monitoring of the patients was scheduled at 6, 12
and 24 months from the inception of the acute myocardial infarct. All thedata about the patients was centralized in accordance to the preset planning, with the exception of 8 patients that got lost in the lot of patients thatreceived atorvastatin 80mg/day (0,3%), respectively 3 patients that got
lost in the control lot (0,1%). We considered as a “lost patient” the patientthat could not be contacted at the domicile declared at the inclusion to
the study and that could not be contacted using any of the data detained(administrative matters).
The compliance of the patients to the prescribed treatment, deﬁned
by the number of days in which the patient strictly followed the prescribed
medication, was 86% in the atorvastatin lot and 87% in the control lot. The
medication of the acute myocardial infarct patients was in accordance withthe valid therapeutic guides, individualized according to the clinical andparaclinical diagnosis of each patient (table 3). Aspirin, heparin, nitrates
and beta-blockers were administered to most of the patients included in
the study.

Fiziologia - Physiology  2009.19.1(61)Aspirin

318

91.00%

Antiplatelet agents

42

12.00%

Heparin263

75.00%

Oral anticoagulants

28

8.00%

Fibrinolitic Agents

24

7.00%

Nitrates

315

90.00%

Beta blockers
Ca Chanel Blockers

273

78.00%

168

48.00%

ACE Inhibitors

168

48.00%

Digoxin
Statins (atorvastatin 80mg)

42

12.00%

179

100.00%

By the end of the study, in the control group of patients, the seric level of the
LDL cholesterol increased by 12% (average 135mg/dl), comparing to the atorvastatin lot where the seric level of the LDL cholesterol decreased by 40% (average
78mg/dl). Triglycerides increased by 8% (average 187mg/dl) in the control lot,compared to the decrease of 16% (average 142mg/dl) of the triglycerides level in
the atorvastatin lot. In the control lot the seric level of HDL cholesterol decreased
by 6% (average 41mg/dl) comparing to the atorvastatin lot where the seric levelof HDL increased by 8% (average 50mg/dl).
Figure 1. The evolution of PCR inflamation markerof the acute coronary patients treated with 80 mg atorvastatincomparative with control group
14

10

11.5

11

6

-74%

P<0,01

2.9

At the moment of the onset of the acute myocardial infarction, the level ofseric lipids was similar for both lots of patients with an average level of the LDLcholesterol of 124mg/dl, triglycerides 184mg/dl and HDL 46mg/dl. At 6 months
the reduction of the level of total cholesterol, of the LDL and of the triglycerides wascomplete in the lot of patients with high dose of atorvastatin; this fact maintained
at 12 months and at 24 months (Table 4).

Table 4. The evolution of the lipidic markers of theacute coronary patients treated with 80mg atorvastatincomparative with the control group
Lipid markers (mg/dl) :control
IMA
debut
After
24
Results(%)

TGL
control

124

atorvastatin
184

HDL
control
84

135

78

187

142

41

- 12%

40%*

+18%

16%*

- 6%

* P<0,001

2009.19.1(61)  Fiziologia - Physiology} -34%*
1.9

0

PARACLINICAL RESULTS

atorvastatin

-83%

4

control

LDL

24 months.

8

2Values are number of patients (%).

0 debut

12

PCR (mg/l)

Table 3. Medications During Hospitalization of the acute coronary patients

Atorvastatin 80mg

In the patients with IMA treated with atorvastatin 80mg/day for 24 months,
PCR decreased from an average value of 11,5mg/l to 1,9mg/l, representing adecrease of 83% compared to 79% in the control lot, at the debut PCR having an
average value of 11mg/l and after 24 months 2,9g/l.
RESULTS OF THE ENDPOINTSOver the six-months period of the study, in the lot of acute myocardial infarctpatients treated with 80mg atorvastatin, major events (primary end-points) took
place for 27 patients (14.8%) compared with 31 patients (18%) in the control lot(Figure 2). The administration of 80mg/day of atorvastatin diminished the risk for the
combined primary end-point (Relative Risk RR) from 0.84 to 0.70-1.00, p=0.049,
after 6 months of treatment from the debut. No statistical diﬀerences were registered
between the control lot and the lot of patients treated with 80mg/day atorvastatin,
regarding the death risk or the cardiovascular resuscitations with re-hospitalization
after 6 months. However, in the patients from the lot with 80mg/day atorvastatin, alower risk of the recurrent ischemic events with emergency re-hospitalization was
registered at 6 months (RR, 0.74, 95% CI, 0.57-0.95, P=0.02).
At 12 and 24 months the recorded diﬀerences between the two lots weresigniﬁcant from a statistical point of view, regardless of the ECG diagnosis of the
IMA at the debut (group I, group II and group III).
Over the 12 months period of the study, in the lot of acute myocardial infarctpatients treated with 80mg atorvastatin, major events (primary end points) took
place for 31 patients (17.4%) compared to 38 patients (22%) in the control lot.
Over the 24 months period of the study, in the lot of acute myocardial infarctpatients treated with 80mg atorvastatin major events (primary end points) were registered in 35 patients (19.6%) compared to 44 patients (25%) in the control lot.
At 24 months the treatment with atorvastatin (80mg/day) signiﬁcantly reduces
the risk of the combined primary end points by 26%, p<0.5, Figure 2.

37

Figure 2. Results if the primary cumulative end points

Cumulative incidence, (%)

of the acute coronary patients treated with atorvastatin 80mg
comparative with the control group

20
22 %

15

control26%

18 %17,4 %

10

Atorvastatin 80mg

14,8 %

5
0

Risc relativ = 0,84
p=0,0480

612Time Since Admission ( months )24

Signiﬁcant statistical diﬀerences of the combined secondary end point wereregistered between the lot of patients treated with atorvastatin 80mg/day from thedebut and the control lot at 24 months (Figure 3).

Figure 3. Results of secondary cumulative endpointsof acute coronary patients treated with atorvastatin 80mg
comparative with the control group

Incidenţă cumulată (%)

15

control

33%
10

Atorvastatin 80mg

5

prognostic in the post-infarct evolution.
The prognostic of acute coronary syndrome patients in general, and the acute
myocardial infarct in particular, with or without ST segment denivelation, proved
to have the most beneﬁcial eﬀects if the total cholesterol level is signiﬁcantly
reduced below the normal values and the decrease of the LDL at values below
70mg%. These changes were demonstrated in the MIRACL study on a number of
3086 cases of acute myocardial infarct who received 80mg/day of atorvastatin, for
16 weeks: is has been demonstrated that the early administration of 80mg/day of
atorvastatin reduces the risk for major cardiovascular events at 16 weeks by 16%,it also reduces the risk for re-hospitalization due to recurrent myocardial ischemia
by 26%, as well as the LDL cholesterol level below 80mg%, with or without PTCA
or other interventional procedures.
The trials existing up to date illustrate to a lesser extent the evolution of somegroups of acute coronary patients, who arrive belated to specialized medical assistance speciﬁc for acute myocardial infarct for early coronary unobstruction. Suchemergencies require emergency therapy insuﬃciently prompt, but in accordancewith valid therapeutic guides. For this reason, we considered necessary such a lotof acute coronary patients, to whom a maximum daily dose of atorvastatin was
administered, for a period of 24 months, with the monitoring of the clinical andparaclinical evolution.
In this trial, early treatment with 80mg atorvastatin of acute coronary patientswith acute myocardial infarction and severe unstable angina, reduced major recurrent ischemic events with 26% after 24 motnhs, and with 33% minor recurrent
ischemic events. The lipid markers evolution was very good: the seric level of the
LDL cholesterol decreased with 40%, triglycerides decreased with 16% and theseric level of HDL cholesterol increased by 8%.

Risc relativ = 0.74
P=0.081

0
0

6

12

24

Timp de la debutul infarctului (luni)

Over the 24 months period of the study, in the lot of acute coronary patientstreated with 80mg atorvastatin, the cumulative senondary endpoint was reducedwith 33%, p=0.081. The administration of 80mg/day of atorvastatin diminished therisk for the combined primary end-point (Relative Risk RR) from 0.84 to 0.70-1.00,
p=0.049, after 24 months of treatment from the debut.
In the lot of patients treated with atorvastatin 80mg/day, 13 fatal and nonfatal cerebrovascular events were registered (in 15 patients): 4 recurrent IMA, 3
hemorrhagic AVC, 1 embolic AVC, 4 of systemic tromboembolic nature, 1 case of
unspeciﬁed etiology, compared with a total of 39 events the control lot.
Non-fatal recurrent AVC (stroke) was registered in 4 patients from the lot of
patients treated with atorvastatin 80 mg (2.3%) and in 9 cases from the control lot(5.3%) with signiﬁcant diﬀerences between the lots, p<0.01 (RR 0.41).
SAFETYNo serious adverse eﬀects appeared in more than 1% of the patients. Increased
hepatic transaminases (three times the normal value) appeared in 8 patients (4.5%),
for whom the treatment with atorvastatin was stopped and who where excluded
from the study. No case of documented myositis was registered.
DISCUSSIONSThe control of the hypercholesterolemia in coronary patients is in general
well documented, both in the primary prevention and the secondary prevention,
especially in the acute coronary syndromes and the acute myocardial infarct. For
the latter ones, the decrease of the cholesterol values is correlated with a favourable
38

CONCLUSIONSThe present study proves that the early administration of 80mg/day atorvastatin in acute coronary patients late hospitalised, with or without ST segment
denivelation, is necessary immediately after the ischemic event and in the long run,because it reduces the recurrence of the ischemic events in long term evolution andespecially the ischemic cardiovascular recurrences that require hospitalization.
The aggressive decrease of the values of the seric lipids and of the PCR (atherosclerotic inﬂammation marker) at the administration of atorvastatin in maximum
dose of 80mg/day, for 24 months, reduced the major cardiovascular events by 26%
and the secondary cardiovascular events by 33%.
Atorvastatin was generally well tolerated in this patient population. There
were no documented cases of myositis, witch is the most serious adverse eﬀect ofstatins. Levels of serum transaminases exceeding 3 times the ULN were detected
in 8 patients, but these patients were excluded.
In conclusion, the results of this trial indicate that the treatment with highdoses atorvastatin the late hospitalised patients with acute myocardial infarction
and unstable angina reduces the early and long term risk of major and minor
cardiovascular events.

REFERENCES
1 Scandinavian Simvastatin Survival Study Group. Randomized trial of cholesterol
lowering in 4444 patients with coronary heart disease: the Scandinavian Simvastatin
Survival Study (4S). Lancet. 1994;344:1383-1389
2 Sacks FM, Pfeifer MA, Moye LA, et al. The eﬀect of pravastatin on coronary events
after myocardial infarction in patients with average cholesterol levels. N. ENgl. J

Fiziologia - Physiology  2009.19.1(61)Med. 1996;335:1001-1009
3 The long term intervention with pravastatin in Ischemic Disease (LIPID) Study
Group. Prevention of cardiovascular events and death with pravastatin in patientswith coronary heart disease and broad range of initial cholesterol levels. N. Engl. J
Med. 1998;339:1349-1357
5 Fragmin and Fast Revascularization During Instability in Coronary Artery Disease(FRISC II) Investigators. Invasive compared with non-invasive treatment in unstablecoronary-artery disease: FRISC II prospective randomized multicentre study. Lancet
1999;354:708-715
6 Gotto AM, Whitney E, Stein EA. Et al. Relation between baseline and on-treatment
lipid parameters and ﬁrst acute major coronary events in the Air Force/Texas Coronary
Atherosclerosis Prevention Study (AFCAPS/TexCAPS). Circulation. 2000;101:477484

2009.19.1(61)  Fiziologia - Physiology

7 Knatterud GL, Rosenberg Y, Campeau L, et al, for the Post CABG Investigators. Long
Term eﬀects on clinical outcomes of aggressive lowering of low density lipoproteincholesterol levels and low-dose anticoagulation in the Post Coronary Artery Bypass
Graft Trial. Circulation. 2000;102:157-165
8 Laufs U, Endres M, Huang Z, et al. Atrovastatin upregulates type III nitric oxide
syntheses in trombocytes, decreases platelets activation and protects from cerebral
ischemia in normocholesterolemic mice. Stroke. 2000;31:2437-2449
9 Guyant G, Jaeschke R, Heddle N, Cook D, Shannon H, Walter S, et al. Interpreting
study results: conﬁdence intervals. Basic statistics for clinicians. 1995; 152:169-173
10. G.G. Schwats, A.Olsson, M.Ezekowitz et all. Eﬀects of atorvastatin on the early recurrent ischemic events in acute coronary syndromes. Jama.2001;285;1711-1718.

39

CAPSULE ENDOSCOPY: INDICATIONS AND FUTURE
ADVANCES
Calin Cernescu1 , Ioan Sporea1, Luminita Cernescu2, Alina Popescu1
1. Department of Gastroenterology and Hepatology, University of Medicine and Pharmacy “Victor Babes”Timisoara, Romania
2. University of Medicine and Pharmacy “Victor Babes”Timisoara, Romania

ABSTRACT
For many years the small bowel has been the least accessible portion of the gastrointestinal tract for endoscopic evaluation. Introduced for clinical use in 2001,
capsule endoscopy has revolutionized the diagnosis and management of multiple small bowel lesions. The main indication of the wireless capsule endoscopy
is the obscure gastrointestinal bleeding, where the upper digestive endoscopy and the colonoscopy did not ﬁnd the source of blood loss. It can be useful tool
in diagnosis and surveillance of intestinal tumors, Crohn’s disease, celiac disease and polyposis, but the indications are continuously to be deﬁned.
Key words: capsule endoscopy, gastrointestinal tract, evaluation, diagnostic

INDICATIONS
Capsule endoscopy (CE) represents a great advance of investigation methods
for digestive tract, thus standing for revolutionary endoscopic modern techniques
and providing the possibility to explore the digestive tract segments previously
diﬃcult to be visualized. Capsule endoscopy is presently unanimously accepted as
diagnostic method, enterocapsule examination being considered the gold standard
for exploring the small intestine, proving to be of superior or comparable value tothe other methods presently available (barium tracking exam, push enteroscopy,
entero-CT or entero-RMN, double balloon endoscopy). This new technique, easy
to be performed and well accepted by the patients, is the only one that allows
minimum invasive endoscopic evaluation of small intestine, without requiring
sedation of patient and providing a great comfort to the patient.
Necessity to explore diﬃcult accessible areas of digestive tract determined, evenfrom the beginning of the nineties, initiation of studies regarding miniature video
cameras, which could be swallowed and transmit images from these levels, using awireless system. After a long period of research in this ﬁeld, in 1999 administrationof the ﬁrst CE was decided to a human subject represented by the researcher C. Paul
Swain (2). The success was extraordinary, and as a result of numerous clinical trials
on patients developed during the following two years, in 2001 US Food and Drug
Administration patented CE as investigation method for small intestine in adults,
while the CE for pediatric use was released in 2003 (11).

INDICATIONS
1. Obscure gastrointestinal hemorrhages
According to the indited consensus (6), the main indication of enterocapsuleis obscure gastrointestinal bleeding (imprecisely located) franc or occult, as well asiron deﬁciency anemia. Gastrointestinal hemorrhages are deﬁned as persistent orrecurrent gastrointestinal bleeding, whose source remains undetermined as a resultof usual investigation techniques (gastroscopy and colonoscopy with ileoscopy).
Under these circumstances, CE represents the third investigation method, following
superior endoscopy and colonoscopy, except for massive hemorrhages, when an
angiographic evaluation is required.
The ﬁrst study performed on human subjects in 2001 showed that the bleeding
sources were revealed in 100% as a result of standard investigation methods using

CE. In addition to these, CE use helped in identifying other supplementary bleeding
sources in 56% of the investigated patients (9).
Another study performed on 100 patients presenting obscure gastrointestinal
bleeding showed that the CE accuracy is 91% in diagnosis of any hemorrhage,
having 88.9% sensitivity and 95% speciﬁcity (7). According to this study, the mostfrequent revealed cause of hemorrhage seemed to be angiodisplasia in 29% of thecases, followed by inﬂammatory bowel disease in 6% of the cases.
2. Small intestine tumors
Before the CE entered in current clinical practice, the small intestine tumors
were considered to have a low incidence, being incidentally diagnosed during
laparotomies or some other investigations or therapeutically maneuvers. They werereported as 1%-2% from total tumors of digestive tract.
Recent studies showed that prevalence of small intestine tumors is muchhigher than thought before, clinical data from international studies showing an
incidence between 5.4%-8.9%, while the malignity rate was estimated at 66%.
The most frequent malignant tumor was adenocarcinoma, followed by carcinoma,
lymphoma, and sarcoma (8).
3. Intestinal inﬂammatory bowel diseases
Numerous prospective studies referring to CE use in Crohn disease suspicion
generally showed an increased rate of revealing the precocious inﬂammatory lesions
in small intestine, comparative to other diagnostic methods (10). This investigation technique is much more sensitive than any other imaging technique, being
useful in patients with Crohn disease suspicion and previous negative endoscopic
evaluations.
CE is recommended both in Crohn disease suspicion as initial diagnostic
method, as well as in monitoring of post-therapeutic tissue repair, and detectionof extent and severity of disease at the level of small intestine for evaluation of
disease activity and prognostic.
Nevertheless, there is a great problem represented by over-diagnosis of Crohndisease in cases of non-speciﬁc colitis or other lesions induced by AINS, due to

Received December 2008. Accepted January 2009. Address for correspondence: Dr. Calin Cernescu, Gastroenterology Department, „Victor Babes” University of Medicine and Pharmacy Timisoara, Iosif Bulbuca
Street No. 9, Timisoara, e-mail:40

Fiziologia - Physiology  2009.19.1(61)impossibility to harvest mucosa biopsy for histological diagnostic. As consequence,
AINS administration should be stopped 2 weeks before the capsule investigationis performed (8).
In a study performed on 30 patients having undetermined colitis symptoms
and negative ASCA/p-ANCA antibodies, CE was able to diagnose presence of Crohndisease in 5 patients and had false negative results in other 5 patients, which werediagnosed consequently based on the biopsy performed during ileo-colonoscopy(5). This is one of the reasons why CE is not yet, unfortunately, an ideal diagnosis
method for this pathology.
4. Celiac disease
Indication of CE use is made in cases of patients having positive serologic
markers of celiac disease, but which do not want to have a superior endoscopy, or inwhich the endoscopic characteristic aspect is diﬃcult to be visualized or irrelevant.
Studies involving symptomatic patients, with positive serologic markers, showed agood sensitivity, as well as a good speciﬁcity for CE, with the only mention that theendoscopic signs are less speciﬁc comparative to the histological exam, consideredas the gold standard in diagnosis of this disease (3).
CE is also indicated to patients known as having celiac disease which present
alarm symptoms such as weight loss, abdominal pain, and fever.
5. Familial intestinal polyposis syndrome
According to a study in 2005, rate of polyps detection using CE is a lot more increased compared to the barium exam (4). Another study involving CE use in polyps
detection ability in patients presenting familial polyposis compared to MRI, showedthat polyps having more that 15 mm in size were detected with similar accuracy.
In contrast, the detection rate of polyps with 5-15 mm in size was increased in CE
compared to MRI, while the polyps less that 5 mm were better detected using MRI(1). As conclusion, this technique proved to be very useful in precocious evaluationof patients with family history of polyposis, which also present an increased riskof developing this disease.
6. Less frequent indications
Less used in current medical practice, CE can also be indicated in cases ofmonitoring the lesions of superior and inferior digestive tract (esophagitis, Brrett
esophagus), polyps, malabsorbtion syndrome, and abdominal pains of undetermined origin, but these indications remain to be established in the future.
Table I. The main indications of wireless capsule endoscopy

I.

Obscure gastrointestinal hemorrhages and Irondeﬁciency anemia of undetermined cause

II.

Small intestine tumor suspicion

III.

Familial intestinal polyposis syndrome
1. Evaluation of patients with family history
2. Diagnosed patients monitoring
Inﬂammatory bowel disease
1. Diagnostic of patients with Chron disease suspicion
2. Chron disease extent monitoring
Celiac disease
1. Diagnostic of patients with celiac disease suspicion
2. Monitoring of patients diagnosed with celiac
diseaseIV.

V.

2009.19.1(61)  Fiziologia - Physiology

DISADVANTAGES (LIMITATIONS) OF CE
CE is an investigation technique very useful in diagnosis of diﬀerent
disorders of small intestine, which still has some disadvantages, thus limiting its
use. The most important disadvantage is the impossibility to perform therapeutic
maneuvers when the intestinal lesions are discovered, CE being only a mean ofdiagnosis, not a therapeutic one. Also, this capsule does not allow air inﬂating
within the gastrointestinal tract for an increased visualization of the mucosa, thus
the exact anatomic location of the revealed lesions cannot be determined.
The risk of capsule impastation at the level of diverticula’s or narrowed areas
must be also taken into consideration, due to the further possible consequences.
Sometimes, CE is not able to pass through the entire small intestine during the
8 hours of battery power, thus the investigation remaining incomplete. The relative
cost of this investigation is increased (approximately 600 euros) and represents animportant disadvantage, thus limiting its use in well selected cases.

CONTRAINDICATIONS
CE is generally very well tolerated by the patients, but its use is contraindicatedin case of presence or even suspicion of obstruction/narrowing of intestine lumen,
due to retention risk. This risk is deﬁned by capsule stopping above the narrowed
area, for over 2 week period, requiring removal of CE using medical, endoscopic
or surgical procedures.
Presence of diverticulum’s Zenker, or other sub-occlusive syndrome arecircumstances which also contraindicate the use of CE because of the impastation
risk of the capsule.
Passage disorders such as acute diarrhea in the moment of examination orin the last 30 days before the examination can also impair a good visualization ofsmall intestine, due to an increase passage of the CE. Cardiac pacemaker implant,deﬁbrillator or electro-mechanic devices also contraindicate administration ofcapsule due to interference risk in image transmission.

Table II. The contraindications of wirelesscapsule endoscopy
1.
2.
3.
4.
5.
6.
7.
8.

Suspicion/presence of narrowed or partial/total
obstructed intestine areas
Deglutition disorders
Severe motility disorders of digestive tract
Sub-occlusive syndrome
Zenker diverticulum
Recent surgical procedure/resection of small
intestine
Cardiac pacemaker implant, deﬁbrillator
Pregnancy

CONCLUSIONS
CE represents a great advance of investigation techniques developed fordigestive tract, developing into the standard evaluation procedure of small intestine.
Similar to a large antibiotic capsule or a vitamin tablet, CE is small enough to be
swallowed, is single use and do not require air inﬂation of the digestive tract. This
capsule represents the non-invasive and non-harmful procedure for the digestive
tract, providing the possibility of increased precision examination even in ambulatory
conditions. Images obtained using this capsule have a high resolution, thus being
possible to detect the lesions present on diﬃcult access anatomic areas.

41

VIITOARE DIRECTIIThe esophageal capsule is used in practice since 2004, indicated forpatients with esophageal pathology, especially gastro-esophageal reﬂux andBarett esophagus. Due to a slower passage time, this capsule was coupled withtwo miniature sensors at both ends, so that the quality of the image obtained was
improved.
In 2007 the colonic capsule was launched on the clinical market,
having as indication the patients with incomplete colonoscopy and those having
contraindications for colonoscopy. The advantage of this capsule is represented by
the fact that does not require sedation or air inﬂating.
Possible future directions could be the necessity to implement a guiding
system for the capsule and electric stimuli for movement control inside the intestine,
as well as for improved visualization of intestine mucosa. In order to endow the CEwith a therapeutic function, it can beneﬁt of a delivery system for diﬀerent drugs
in certain anatomic areas.
Moreover, it becomes necessary that the CE would have a wirelesspower supplying system, due to the low power cycle of the batteries now in useof only 8 hours, which impairs visualization of the entire digestive tract, in casesof prolonged passage time. The technologic advance will improve in the future
all present limitations of CE, the greatest challenge being the capsule having thepossibility of sonography, thus enlarging even further the range of its use.

REFERENCES
1. Caspari R, Von Falkenhausen M, Krautmacher C et al. Comparison of capsuleendoscopy and magnetic resonance imaging for the detection of polyps of the small
intestine in patients with familial adenomatous polyposis or with Peutz-Jeghers’

Syndrome. Endoscopy 2004; 36:1054-1059
2. Iddan GJ, Swain CP. History and development of capsule endoscopy. Gastrointest
Endosc Clin N Am. 2004;14:19
3. Lee SK, Green PH. Endoscopy in celiac disease. Curr Opin Gastroenterol 2005; 21:589-594
4. Mata A, Liac J, Castells A et al. A prospective trial comparing wireless capsuleendoscopy and barium contrast series for small bowel surveil− lance in hereditary
GI polyposis syndrome. Gastrointest Endosc 2005;61: 721-725
5. Maunoury V, Savoye G, Bourreille A et al. Value of wireless capsule endoscopy inpatients with indeterminate colitis (inﬂammatory bowel disease type unclassiﬁed).
Inﬂamm Bowel Dis 2007; 13: 152-155
6. Mergener K. et al, Consensue statements for small-bowel capsule endoscopy,
2006/2007, Endoscopy Oct 2007; 39:895-909
7. Pennazio et al, Outcome of patients with obscure gastrointestinal bleeding after
capsule endoscopy: Report of 100 consecutive cases, Gastroenterology, 2004 Mar;
126(3):643-53
8. Rey JF, Ladas S, Alhassani A, Kuznetsov K and the ESGE Guidelines Committee,
European Society of Gastrointestinal Endoscopy (ESGE) Video capsule endoscopy:
Update to guidelines, Endoscopy 2006; 38 (10): 1047-1053
9. Tilson M, Saltzman JR. Small bowel bleeding and capsule endoscopy, Brigham and
Women's Hospital, Harvard Medical School, Boston, Massachusetts, The American
College of Gastroenterology, Avaible at: http://www.gi.org/patients/gihealth/smallbowel.asp, 2006
10. Triester SL, Leighton JA et al. A meta-analysis of capsule endoscopy (CE) comparedto other modalities in patients with non-stricturing small bowel Crohn’s disease. Am
J Gastroenterol 2006; 101: 954-964
11. US Food and Drug Administration. Center for Devices and Radiological Health.
150(k)s Final Decision Rendered for August 2001. Available at: http://www.fda.gov/
drh/510/sumaug01.html Accessed October 7, 2005

CAPSULA ENDOSCOPICA: INDICATII SI PERSPECTIVEREZUMAT
De-a lungul timpului intestinul subtire a fost portiunea tractului gastrointestinal cea mai putin accesibila evaluarii endoscopice. Introdusa, in scopul utilizarii
clinice, in anul 2001, capsula endoscopica a revolutionat metodele de explorare si diagnosticare a leziunilor prezente la acest nivel. Principala indicatie a capsulei
endoscopice este hemoragia gastrointestinala obscura, atunci cand sursa de sangerare nu a fost decelata la endoscopia digestiva superioara si colonoscopie.
Ea poate ﬁ, de asemenea, utila in diagnosticarea si supravegherea tumorilor intestinale, boala Crohn, boala celiaca si polipoza intestinala, indicatiile saleurmand a ﬁ deﬁnite in continuare.
Cuvinte cheie: capsula endoscopica, tract gastrointestinal, evaluare, diagnostic

42

Fiziologia - Physiology  2009.19.1(61)XIIth International Magnesium Symposium
Iasi, Romania, 22-25 September 2009
President of Congress
MIHAI NECHIFOR – Romania
Honorary President
YVES RAYSSIGUIER – France
Organizing Committee
Manole Cojocaru
Victor Cristea
Felicia Gradinaru
Ioan Gutiu
Nicolae Miu

Mihai Nechifor
Victoria Papadopol
Paul J Porr
Dragomir Serban
Corneliu Zeana

Scientiﬁc Committee

Invited Speakers
Burton Altura - USA
Manfred Anke - Germany
Mario Barbagallo - Italy
Fu-Chou Cheng - Taiwan
Ivana Djujic - Serbia
Jean Durlach, Past President - France
Jessus Escanero - Spain
Peter W. Flatman - United Kingdom
Fernando Guerrero-Romero - Mexico
Stefano Iotti - Italy
Mieko Kimura - Japan
Sandor Kiss - Hungary
Maria Jose Laires - Portugal
Andrzej Lewenstam - Poland
Gousong Liu -USA
Jeanette Maier - Italy
Andrzej Mazur - France
Yoshichi Nishizawa - Japan
Paul J Porr - Romania
Andrea Rosanoﬀ - USA
Ragnar Rylander -Sweden
Rudolf Schweyen - Austria
Michael Shechter - Israel
Ronald Smetana - Austria
Theophile Theophanides - Greece
Keichi Torimitsu - Japan
Rhian M. Touyz - Canada
Jurgen Vormann - Germany
William Weglicki - USA
Frederica Wolf - Italy

Jean Durlach, Past President - France
Burton Altura - USA
Manfred Anke - Germany
Mario Barbagallo - Italy
Fu-Chou Cheng - Taiwan
Ivana Djujic - Serbia
Jessus Escanero - Spain
Peter W. Flatman - United Kingdom
Fernando Guerrero-Romero - Mexico
Mieko Kimura - Japan
Sandor Kiss - Hungary
Maria Jose Laires - Portugal
Andrzej Lewenstam - Poland
Andrzej Mazur - France
Yoshichi Nishizawa - Japan
Paul J Porr - Romania
Ragnar Rylander - Sweden
Rudolf Schweyen - Austria
Ronald Smetana - Austria
Theophile Theophanides - Greece
Keichi Torimitsu - Japan
Robert Vink - Australia
Jurgen Vormann - Germany
William Weglicki - USA
Frederica Wolf - Italy

TopicsMagnesium in water and soil
Magnesium in microorganisms
Magnesium in plants
Magnesium in veterinary medicine
Magnesium in physiology
Magnesium in pathology
Magnesium in neurology
Magnesium in psychiatry
Magnesium in immunity
Magnesium in reproductive system

2009.19.1(61)  Fiziologia - Physiology

Magnesium in gastrointestinal system
Magnesium in oro-maxilar area
Magnesium in nutrition
Magnesium in therapy
Magnesium's mechanisms of action at cellular level
Synthesis and biochemistry of new magnesium compounds
Pharmacology and toxicology ofMagnesium's sources
Other involvements of magnesium in biology

43