Med. čas.

Основан 1961. Годиште 55 Свеска 1 Стране 1-50.

Founded 1961. Volume 55 Issue 1 Pages 1-50.

21 21
MEDICINSKI ČASOPIS MEDICAL JOURNAL
Srpsko lekarsko društvo Serbian Medical Society
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 SADR@AJ
A. ORIGINALNI NAUČNI ČLANAK
1. POREĐENJE EFIKASNOSTI UKLANJANJA
UREMIJSKIH TOKSINA SREDNJE MOLEKULSKE
MASE IZMEĐU VISOKOPROPUSNE
HEMODIJALIZE I POSTDILUCIONE ONLINE
HEMODIJAFILTRACIJE
Marko Nenadović, Aleksandra Nikolić,
Milica Kostović, Branislava Drašković,
Milena M. Jovanović, Tomislav Nikolić,
Dejan D. Petrović
2. MIKROCIRKULATORNOM KAPILARNOM
KORITU PACOVA SA DEMENCIJOM
ALCHAJMEROVOG TIPA INDUKOVANOG
NITRITOM NA TERENU MEZENHIMALNIH
MATIČNIH ĆELIJA
Jevgenija Zorenko, Galina Gubina-Vakulik,
Olena Pavlova, Tatjana Gorbah, Elena Šegelskaja,
Elena Omelčenko
B. STRUČNI ČLANAK
3. BOL U GRUDIMA I PREHOSPITALNO
KAŠNJENJE
Marija Stevanović, Slavoljub R. Živanović
C. PREGLEDNI ČLANAK
4. POREMEĆAJI GUTANJA U TOKU I NAKON
LEČENJA KARCINOMA LARINKSA
Mirna Zelić, Mirjana Petrović Lazić,
Dragan Pavlović
D. PRIKAZ SLUČAJA
5. PRIKAZ SLUČAJA MELANOMA REKTUMA U
HEMOROIDU
Vladimir Selaković, Milan Ranisavljević,
Tijana Vasiljević, Bratislav Stoiljković,
Biljana Kukić
CONTENTS
A. ORIGINAL SCIENTIFIC ARTICLE
1. COMPARISON OF EFFICIENCY OF MEDIUM
MOLECULAR WEIGHT UREMIC TOXIN
REMOVAL BETWEEN HIGH-FLUX
HEMODIALYSIS AND POSTDILUTION ONLINE
HEMODIAFILTRATION
Marko Nenadovic, Aleksandra Nikolic,
Milica Kostovic, Branislava Draskovic,
Milena M. Jovanovic, Tomislav Nikolic,
7 Dejan D. Petrovic 7
2. DYNAMICS OF INDICATORS OF THE
ENDOTHELIUM MORPHOFUNCTI-ONAL STATE
OF THE BRAIN MICROCIRCULATORY BED
VESSELS IN RATS WITH NITRITE-INDUCED
ALZHEIMER'S TYPE DEMENTIA ON THE
BACKGROUND OF MESENCHYMAL STEM CELL
ADMINISTRATION
Yevgeniya Zorenko, Galina Gubina-Vakulyck,
18
Olena Pavlova, Tatyana Gorbach,
Elena Shchegelskaya, Elena Omelchenko 18
B. PROFESSIONAL ARTICLE
CHEST PAIN AND PREHOSPITAL DELAY
27
Marija Stevanovic, Slavoljub R. Zivanovic 27
C. REVIEW ARTICLE
4. SWALLOWING DISORDERS DURING AND
AFTER THE TREATMENT OF LARYNX CANCER
Mirna Zelic, Mirjana Petrovic Lazic,
33
Dragan Pavlovic 33
D. CASE REPORT
5. A RARE CASE OF MELANOMA OF THE
RECTUM HEMORRHOID NODULE
Vladimir Selakovic, Milan Ranisavljevic,
Tijana Vasiljevic, Bratislav Stoiljkovic,
40
Biljana Kukic 40
 LISTA RECENZENATA U 2020. GODINI

THE LIST OF PEER-REVIEWERS IN 2020

Медицински часопис је захвалан за допринос рецензената током 2020. године, који су

великодушно посветили своје време и уложили напор у евалуацију и унапређење квалитета
поднетих рукописа.
Medical Journal is grateful for contributions of the peer reviewers during 2020. who generously
devoted their time and made efforts to assessing and improving quality of submitted manuscripts.

Мирослав Васовић Љиљана Новковић

Радмила Величковић Радовановић Јусуф Нуковић
Радиша Војиновић Слађана Павловић
Биљана П. Вулетић Ана Пејчић
Татјана Вуловић Дејан Петровић
Александар Гавриловић Марина Петровић
Владимир Гајић Зоран А. Поњавић
Нела Ђоновић Биљана Поповска Јовичић
Наташа Здравковић Ана Равић
Драгана Игњатовић Ристић Светлана Р. Радевић
Мирјана А. Јанићијевић Петровић Драгче Радовановић
Слободан Јанковић Дејана Т. Ружић Зечевић
Владимир Јањић Марија Р. Секулић
Невена Јеремић Иван Симић
Зорица Јовановић Александра Симовић
Сања Коцић Марко Б. Спасић
Биљана П. Мијовић Јасмина Сретеновић
Момир Миков Миодраг Ј. Срећковић
Светлана Д. Милетић Дракулић Јасмина Стојановић
Весна Миличић Александра Стојановић
Драган Р. Миловановић Милош Тодоровић
Драган Милојевић Јовица М. Томовић
Милош Милосављевић Војислав Ћупурдија
Оливера Милошевић Ђорђевић Иван Чекеревац
Горан Михајловић Јовица Шапоњски
Јасмина Недовић
 doi: 10.5937/mckg55-31062
COBISS . SR - ID 44211721
Med. čas. 2021; 55(1): 7-17. ORIGINALNI NAUČNI ČLANAK UDK. 616.61-78

POREĐENJE EFIKASNOSTI UKLANJANJA UREMIJSKIH TOKSINA

SREDNJE MOLEKULSKE MASE IZMEĐU VISOKOPROPUSNE
HEMODIJALIZE I POSTDILUCIONE ONLINE HEMODIJAFILTRACIJE
Marko Nenadović1, Aleksandra Nikolić2, Milica Kostović3, Branislava Drašković3,
Milena M. Jovanović3, Tomislav Nikolić1,3, Dejan D. Petrović1,3
1Fakultet medicinskih nauka, Univerzitet u Kragujevcu, Kragujevac
2Klinika za internu medicinu, UKC Kragujevac, Kragujevac
3Klinika za urologiju, nefrologiju i dijalizu, UKC Kragujevac, Kragujevac

COMPARISON OF EFFICIENCY OF MEDIUM MOLECULAR WEIGHT

UREMIC TOXIN REMOVAL BETWEEN HIGH-FLUX HEMODIALYSIS AND
POSTDILUTION ONLINE HEMODIAFILTRATION
Marko Nenadovic1, Aleksandra Nikolic2, Milica Kostovic3, Branislava Draskovic3,
Milena M. Jovanovic3, Tomislav Nikolic1,3, Dejan D. Petrovic1,3
1Faculty of Medical Sciences, University of Kragujevac, Kragujevac, Serbia
2Clinic for Internal Medicine, University Clinical Centre of Kragujevac, Kragujevac, Serbia
3Clinic for Urology, Nephrology and Dialysis, University Clinical Centre of Kragujevac, Kragujevac, Serbia

SAŽETAK
Uvod. Konvencionalna visokopropusna hemodijaliza
efikasno uklanja uremijske toksine srednje molekulske mase
0,5–15 (20) kDa, dok postdiluciona online hemodijafiltracija
efikasno uklanja uremijske toksine srednje molekulske mase
u rasponu 0,5–60 kDa.
Cilj. Rad je imao za cilj da uporedi efikasnost uklanjanja
β2-mikroglobulina iz seruma bolesnika u toku pojedinačne
sesije konvencionalne visokopropusne hemodijalize i
postdilucione online hemodijafiltracije.
Metod. Ispitano je 85 bolesnika koji su lečeni
konvencionalnom visokopropusnom hemodijalizom i 30
bolesnika koji su lečeni postdilucionom online
hemodijafiltracijom. Glavni parametar za procenu
efikasnosti uklanjanja uremijskih toksina srednje molekulske
mase bila je koncentracija β2-mikroglobulina u serumu pre i
nakon pojedinačne sesije konvencionalne visokopropusne
hemodijalize i postdilucione online hemodijafiltracije. Za
statističku analizu korišćeni su: Kolmogorov–Smirnov test,
Studentov T test i Mann–Whitney U test.
Rezultati. Kod bolesnika koji su lečeni postdilucionom
online hemodijafiltracijom prosečan ukupni konvektivni
volumen iznosio je 21,38  2,97 litara po sesiji. Indeks
redukcije β2-mikroglobulina za dijaliznu membranu FX
CorDiax 600 iznosio je 61,76  7,32%, za dijaliznu
membranu FX CorDiax 800 74,69  6,51%. Indeks redukcije
albumina za membranu FX CorDiax 600 iznosio je 3,48 
1,28%, za dijaliznu membranu FX CorDiax 800 6,01 
2,97%. Između indeksa redukcije β2-mikroglobulina i
albumina, za dva različita dijalizna modaliteta i dve različite
dijalizne membrane, postoji visoko statistički značajna
razlika (p  0,01).
Zaključak. Postdiluciona online hemodijafiltracija je
efikasnija u uklanjanju β2-mikroglobulina iz seruma
ABSTRACT
INTRODUCTION. Conventional high-flux hemodialysis
effectively removes uremic toxins of medium molecular
weight of 0.5-15 (20) kDa, while postdilution online
hemodiafiltration effectively removes uremic toxins of
medium molecular weight in the range of 0.5-60 kDa.
AIM. The aim of the study was to compare the efficacy of
β2-microglobulin removal from the patient serum during a
single session of conventional high-flux hemodialysis and
postdilution online hemodiafiltration.
METHOD. Eighty-five patients treated with conventional
high-flux hemodialysis and thirty patients treated with
postdilution online hemodiafiltration were examined. The
main parameter for assessing the removal efficiency of
medium molecular weight uremic toxins was serum β2-
microglobulin concentration before and after a single session
of conventional high-flux hemodialysis and postdilution
online hemodiafiltration. The following were used for
statistical analysis: Kolmogorov-Smirnov test, Student's T
test and Mann-Whitney U test.
RESULTS. In patients treated with postdilution online
hemodiafiltration, the average total convective volume was
21.38  2.97 liters per session. The β2-microglobulin
reduction index for the FX CorDiax 600 dialysis membrane
was 61.76  7.32%, while for the FX CorDiax 800 dialysis
membrane it was 74.69  6.51%. The albumin reduction
index for the FX CorDiax 600 membrane was 3.48  1.28%,
and for the FX CorDiax 800 dialysis membrane it was 6.01
 2.97%. There is a highly statistically significant difference
between the reduction index of β2-microglobulin and
albumin, for two different dialysis modalities and two
different dialysis membranes (p  0.01).
CONCLUSION. Postdilution online hemodiafiltration is
more efficient in removing β2-microglobulin from patient

Primljen/Received: 25.02.2021. 7 Prof. dr Dejan Petrović

Prihvaćen/Accepted: 09.06.2021. Klinika za urologiju, nefrologiju i dijalizu, UKC Kragujevac
Zmaj Jovina 30, 34000 Kragujevac
e-mail: dejan.petrovic@medf.kg.ac.rs, dejan.petrovic@kc-kg.rs
+381 64 806 5102

Med. čas. 2021; 55(1): 7-17.
bolesnika od konvencionalne visokopropusne hemodijalize.
Gubitak albumina u toku pojedinačne sesije visokopropusne
hemodijalize manji je od pojedinačne sesije postdilucione
online hemodijafiltracije. Kod oba modaliteta dijalize
gubitak albumina je manji od 4,0 g/4h. Visokopropusna
hemodijaliza efikasno sprečava razvoj amiloidoze povezane
sa dijalizom, dok postdiluciona online hemodijafiltracija
efikasno sprečava ne samo razvoj amiloidoze povezane sa
dijalizom već i razvoj rezistencije na dejstvo eritropoetina i
aterosklerotskih kardiovaskularnih bolesti u populaciji
bolesnika koji se leče redovnom dijalizom.
Ključne reči: hemodiafiltracija; bubrežna dijaliza;
toksini, biološki; albumini; β2-microglobulin.
UVOD
Kardiovaskularne bolesti su vodeći uzrok smrti
bolesnika koji se leče redovnom hemodijalizom (1, 2).
Uremijski toksini imaju značajnu ulogu u razvoju
amiloidoze, ubrzane ateroskleroze i kardiovaskularnih
bolesti u ovoj populaciji bolesnika. Prema preporukama
EUTox (engl. European Union Toxin Working Group)
uremijski toksini se mogu podeliti u tri grupe. Prvu grupu
čine uremijski toksini male molekulske mase (MW  500
Da). Ovi toksini su rastvorljivi u vodi i efikasno se
uklanjaju konvencionalnom visokopropusnom „high-
flux“ hemodijalizom. Drugu grupu čine uremijski toksini
koji se u visokom procentu vezuju za protein plazme
(stepen vezivanja za protein plazme  90%). Oni su
uglavnom male molekulske mase (MW  500 Da) i
efikasno se uklanjaju hemodijalizom sa membranama koje
imaju sposobnost adsorpcije. Uremijski toksini srednje
molekulske mase (MW = 0,5–60 kDa) spadaju u treću
grupu uremijskih toksina. Ovi uremijski toksini se
efikasno uklanjaju konvencionalnom visokopropusnom
hemodijalizom (0,5–20 kDa), postdilucionom online
hemodijafiltracijom (0,5–60 kDa) i proširenom
hemodijalizom – ED (0,5–60 kDa) (engl. Expanded
Dialysis) (3, 4). U uremijske toksine srednje molekulske
mase spadaju proteini (β2-mikroglobulin), prozapaljenski
citokini (interleukin-1β, interleukin-6, interleukin-18,
faktor nekroze tumora alfa – TNF), proteini zapaljenja
(pentraxin-3, YKL-40) i adipokini (leptin) (4). Povećanje
koncentracije 2 mikroglobulina u serumu za posledicu
ima nastanak sindroma karpalnog tunela – CTN (engl.
Carpal Tunnel Neuropathy) i razvoj artropatije povezane
sa deponovanjem 2 mikroglobulina (amiloidoza
povezana sa dijalizom) (4, 5). Prozapaljenski citokini i
proteini imaju značajnu ulogu u razvoju mikroinflamacije,
dok leptin ima značajnu ulogu u razvoju neuhranjenosti
kod bolesnika koji se leče redovnom hemodijalizom (4, 5).
Mikroinflamacija, neuhranjenost i oksidacioni stres
značajni su netradicionalni faktori rizika, koji za posledicu
imaju razvoj ubrzane ateroskleroze (aterosklerotske
kardiovaskularne bolesti), amiloidoze povezane sa
8
doi: 10.5937/mckg55-31062
COBISS . SR - ID 44211721
UDK. 616.61-78
serum, compared to conventional high-flux hemodialysis.
Albumin loss during a single session of high-flux
hemodialysis is lower compared to a single session of
postdilution online hemodiafiltration. With both dialysis
modalities, albumin loss is less than 4.0 g/4h. High-flux
hemodialysis effectively prevents the development of dialysis-
related amyloidosis, while postdilution online
hemodiafiltration effectively prevents not only the
development of dialysis-related amyloidosis, but also the
development of resistance to erythropoietin and
atherosclerotic cardiovascular diseases in the population
treated with regular dialysis.
Key words: hemodiafiltration; renal dialysis; toxins,
biological; albumins; β2-microglobulin.
hemodijalizom, rezistencije na dejstvo eritropoetina i
anemije (4–12).
Konvencionalna visokopropusna hemodijaliza je
metoda lečenja kojom se kroz selektivno propustljivu
dijaliznu membranu („high-flux“ membrana za
hemodijalizu) iz krvi uklanjaju nakupljeni uremijski
toksini i istovremeno iz rastvora za dijalizu preuzimaju
supstance neophodne za organizam bolesnika i korekciju
acido-baznog i elektrolitskog sastava krvi (13). Membrane
za dijalizu imaju centralnu ulogu u procesu hemodijalize i
hemodijafiltracije. Parametar za procenu efikasnosti
dijalizne membrane je koeficijent masenog prenosa –
KoA. Predstavlja proizvod koeficijenta prenosa (Ko) i
površine membrane (A). KoA membrane zavisi od gustine
(distribucije) i veličine pora. U zavisnosti od KoA,
dijalizatori mogu biti nisko efikasni (KoA  300),
umereno efikasni (KoA = 300–600) i visoko efikasni
(KoA  600–700). Ultrafiltracioni kapacitet dijalizatora
(kapacitet propustljivosti za vodu, obezbeđuje klirens
uremijskih toksina srednje molekulske mase) kvantifikuje
se na osnovu koeficijenta ultrafiltracije – Kuf. U
zavisnosti od koeficijenta ultrafiltracije dijalizne
membrane mogu biti: „low-flux“ (Kuf  10 ml/h x mmHg)
i „high-flux“ (Kuf  20 ml/h x mmHg) (13, 14).
Propusnost dijalizne membrane procenjuje se na osnovu
klirensa β2-mikroglobulina. U zavisnosti od klirensa β2-
mikroglobulina razlikujemo pet tipova membrana za
dijalizu. Kod tipa 1, klirens β2-mikroglobulina iznosi 10
ml/min, kod tipa 2 10–20 ml/min, kod tipa 3 30–50
ml/min, kod tipa 4 50–70 ml/min, a kod tipa 5 ≥ 70
ml/min. Od 2016. godine u ovu klasifikaciju je uključen i
koeficijent prosejavanja za albumin. U zavisnosti od
klirensa β2-mikroglobulina i koeficijenta prosejavanja za
albumin – SC (engl. Sieving Coefficient) razlikujemo
četiri tipa membrana za hemodijalizu. Kod tipa 1 klirens
β2M je manji od 70 ml/min, a kod tipa 2 klirens 2M je ≥
70 ml/min. U zavisnosti od koeficijenta prosejavanja za
albumin, tip 1 ima dva podtipa, podtip 1a (SC za albumin
 0,03) i podtip 1b (SC za albumin ≥ 0,03). Kod tipa 2a
koeficijent prosejavanja za albumin je < 0,03, a kod tipa
2b, SC za albumin je ≥ 0,03 (13, 14).

Med. čas. 2021; 55(1): 7-17.
Postdiluciona online hemodijafiltracija (OL-HDF)
jeste metoda lečenja za zamenu funkcije bubrega koja
zaštitno deluje na kardiovaskularni sistem i znatno
popravlja ishod bolesnika sa završnim stadijumom
hronične bolesti bubrega (15–19). Ona kombinuje difuziju
i konvekciju. Procesom difuzije uklanjaju se uremijski
toksini male i srednje molekulske mase, dok se procesom
konvekcije (konvektivni transport) uklanjaju uremijski
toksini srednje molekulske mase. Jačina difuzije zavisi od
jačine protoka krvi (Qb) i jačine protoka rastvora za
dijalizu (Qd), dok jačina konvekcije zavisi od jačine
protoka krvi (Qb) i jačine ultrafiltracije (Quf) (15–19).
Jačina konvektivnog protoka predstavlja zbir jačine
protoka rastvora za supstituciju (Qsubs) i jačine neto
ultrafiltracije (Qnuf). Jačina neto ultrafiltracije je stvarni
gubitak tečnosti iz organizma bolesnika u toku tretmana
postdilucione online hemodijafiltracije (15–19).
Postdiluciona online hemodijafiltracija efikasno
uklanja uremijske toksine srednje molekulske mase, a
njena efikasnost zavisi od ukupnog konvektivnog
volumena (Vconv), odnosno od protoka krvi kroz
vaskularni pristup za hemodijalizu (Qavf ≥ 600 ml/min),
jačine protoka krvi (Qb ≥ 350 ml/min) i karakteristika
dijalizatora (15–19). Dijalizne membrane imaju centralnu
ulogu u lečenju bolesnika postdilucionom online
hemodijafiltracijom. Glavne karakteristike membrana su:
visok koeficijent ultrafiltracije (Kuf  40 ml/h x mmHg),
koeficijent prosejavanja za 2-mikroglobulin veći od 0,60,
koeficijent prosejavanja za albumin manji od 0,01
(gubitak albumina po sesiji manji od 4,0 g), gustina
kapilara veća od 11.000 po površini preseka omogućava
protok rastvora za dijalizu – Qd = 400–500 ml/min,
unutrašnji dijametar kapilara dijalizatora veći od 200 µm,
sterilizacija bez etilen-oksida, odsustvo bisfenola A – BPA
(engl. Bisphenol A) i dobra biokompatibilnost. Za
optimizaciju frakcije filtracije treba koristiti dijalizatore s
dijaliznim membranama površine ≥ 2,0 m2 (15–19).
U kliničkoj praksi za procenu efikasnosti uklanjanja
uremijskih toksina srednje molekulske mase u toku
pojedinačne sesije konvencionalne visokopropusne
hemodijalize i postdilucione online hemodijafiltracije
koristi se merenje koncentracije β2-mikroglobulina i
albumina u serumu, pre i posle sesije. Na osnovu
koncentracije β2-mikroglobulina u serumu pre i posle
sesije konvencionalne visokopropusne i postdilucione
online hemodijafiltracije izračunava se indeks redukcije za
β2-mikroglobulin – RR (engl. Reduction Ratio). On se
izračunava iz formule: RR (%) = 1 – (Cpost/Cpre) x 100,
gde su: Cpre – koncentracija β2-mikroglobulina u serumu
pre sesije dijalize (mg/l), Cpost – koncentracija β2-
mikroglobulina u serumu posle sesije dijalize (mg/l)
(15–21).
BOLESNICI I METODE
U radu je ispitano 85 bolesnika koji se leče redovnom
konvencionalnom visokopropusnom hemodijalizom i 30
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bolesnika koji se leče postdilucionom online
hemodijafiltracijom u Centru za nefrologiju i dijalizu
Kliničkog centra Kragujevac. Ispitivanje je sprovedeno uz
poštovanje Helsinške deklaracije o medicinskim
istraživanjima, dobijenu saglasnost Etičkog odbora
Kliničkog centra Kragujevac (odluka Etičkog odbora broj:
01-20-765) i saglasnost bolesnika.
Ispitivani su bolesnici koji se leče redovnom
konvencionalnom visokopropusnom hemodijalizom i
postdilucionom online hemodijafiltracijom, tri puta
nedeljno po četiri časa (12 h nedeljno), u periodu od
najmanje tri meseca, „high-flux“ biokompatibilnim
dijaliznim membranama (tabela 1), na mašinama sa
kontrolisanom ultrafiltracijom tipa Fresenius 5008S,
Gambro Artis i BBraun. Prosečna jačina protoka krvi za
bolesnike koji se leče konvencionalnom visokopropusnom
hemodijalizom iznosi – Qb = 225,41  22,44 ml/min, a za
bolesnike koji se leče postdilucionom online
hemodijafiltracijom Qb = 257,00  18,65 ml/min, dok
prosečna jačina protoka dijalizata za oba modaliteta
dijalize iznosi – Qd = 500,00  0,00 ml/min. Korišćen je
standardni ultračist rastvor za dijalizu (broj kolonija
bakterija  0.1 CFU/ml i koncentracija endotoksina – E 
0,03 EU/ml), sa koncentracijom kalcijuma 1,75 mmol/l
(PGS21), 1,50 mmol/l (PGS25) i 1,25 mmol/l (PGS27).
Koncentracija natrijuma Na+ u rastvoru za dijalizu iznosila
je 140 mmol/l, koncentracija bikarbonata 35 mmol/l, a
koncentracija K+ 2,0 mmol/l. Kod bolesnika koji se leče
postdilucionom online hemodijafiltracijom prosečni
ukupni konvektivni volumen iznosio je Vconv = 21,38 
2,97 litara po sesiji (tabela 2). Za antikoagulaciju
vantelesne cirkulacije korišćen je nefrakcionisani heparin.
Prosečna mesečna doza nefrakcionisanog heparina kod
konvencionalne visokopropusne hemodijalize iznosila je
4432,35  396,00 IU, a kod postdilucione online
hemodijafiltracije 4508,32  541,92 IU. Svi bolesnici su
lečeni agensima koji stimulišu eritropoezu
(kratkodelujući: epoetin-, epoetin-β; dugodelujući:
darbepoetin-). Ispitivanje nije uključilo bolesnike sa
aktivnom infekcijom (prosečan broj leukocita iznosio je
6,96  1,82 x 109/l i 6,25  2,00 x 109/l), dokazanim
aktivnim krvarenjem, nekontrolisanim malignim
bolestima, kao ni bolesnike koji su lečeni
imunosupresivnim medikamentima.
Uzorak krvi za određivanje laboratorijskih analiza
uziman je pre započinjanja i nakon završetka srednje
nedeljne pojedinačne konvencionalne visokopropusne
hemodijalize i postdilucione online hemodijafiltracije za
svaku dijaliznu membranu (srednja nedeljna dijaliza), pre
davanja heparina. Rutinske laboratorijske analize su
određivane standardnim laboratorijskim testovima i
izračunate su kao prosečna vrednost tri merenja u toku tri
uzastopna meseca.
Radi procene uticaja dva modaliteta dijalize i dve
različite dijalizne membrane na stepen uklanjanja

Med. čas. 2021; 55(1): 7-17.
uremijskih toksina srednje molekulske mase i stepen
gubitka albumina u toku pojedinačne sesije
konvencionalne visokopropusne hemodijalize i
postdilucione online hemodijafiltracije ispitivana je
koncentracija β2-mikroglobulina i albumina u serumu.
Koncentracija β2-mikroglobulina i albumina u serumu
merena je pre i posle pojedinačne sesije konvencionalne
visokopropusne hemodijalize i postdilucione online
hemodijafiltracije, u toku srednje nedeljne dijalize.
Koncentracija β2-mikroglobulina u serumu određivana
je turbidimetrijskom metodom, na aparatu Beckman
Coulter AU680. Kod bolesnika koji se leče redovnom
dijalizom, predijalizna koncentracija β2-mikroglobulina u
serumu treba da iznosi manje od 25 mg/l. Na osnovu
izmerene koncentracije β2-mikroglobulina izračunat je
indeks redukcije – RR (engl. Reduction Ratio) uz pomoć
formule: RR(%) = 1 – (Cpost/Cpre) x 100, gde su: Cpre
– koncentracija β2-mikroglobulina u serumu pre sesije
dijalize (mg/l), Cpost – koncentracija β2-mikroglobulina u
serumu posle sesije dijalize (mg/l).
Koncentracija albumina u serumu određivana je
turbidimetrijskom metodom, na aparatu Beckman Coulter
AU680. Kod bolesnika koji se leče redovnom dijalizom
hipoalbuminemija se definiše kao koncentracija albumina
u serumu manja od 35 g/l.
Na osnovu izmerene koncentracije albumina izračunat
je indeks redukcije – RR (engl. Reduction Ratio) uz
pomoć formule: RR(%) = 1 – (Cpost/Cpre) x 100, gde
su: Cpre – koncentracija albumina u serumu pre sesije
dijalize (g/l), Cpost – koncentracija albumina u serumu
posle sesije dijalize (g/l).
Koncentracija albumina u serumu posle sesije
postdilucione online hemodijafiltracije izračunata je uz
pomoć formule: Albuminpost = Calb post/1 + (UF)/0,2 x
(BWpre – UF), gde su: UF = BWpre – BWpost. BWpre
– telesna masa bolesnika pre dijalize (kg), BWpost –
telesna masa bolesnika posle dijalize (kg), Calb post –
koncentracija albumina u serumu posle dijalize (g/l), UF –
jačina neto ultrafiltracije (l/4h).
Koncentracija feritina u serumu određivana je
turbidimetrijskom metodom, na aparatu Beckman Coulter
AU680. Kod bolesnika koji se leče redovnom dijalizom
normalna koncentracija feritina u serumu iznosi 100–500
ng/ml.
Koncentracija CRP u serumu određivana je
turbidimetrijskom metodom, na aparatu Olympus AU680,
a izračunata je kao prosečna vrednost dva merenja u toku
dva uzastopna meseca. Normalna koncentracija CRP u
serumu iznosi  5 mg/l. Mikroinflamacija se definiše kao
koncentracija CRP u serumu veća od 5 mg/l.
Koncentracija vitamina D u serumu određivana je
metodom elektrohemiluminiscencije, na aparatu Cobas e
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411. Normalna koncentracija vitamina D u serumu iznosi
20–40 ng/ml. Kod bolesnika koji se leče redovnom
dijalizom normalna koncentracija vitamina D iznosi ≥ 30
ng/ml (30–80 ng/ml). Težak deficit se definiše kao
koncentracija vitamina D  10 ng/ml, deficit vitamina D
postoji ako je koncentracija 10–20 ng/ml, a insuficijencija
se definiše kao koncentracija vitamina D u serumu 20–30
ng/ml.
Koncentracija intaktnog parathormona u serumu
određivana je imunoradiometrijskom metodom (IRMA),
na gama brojaču WALLAC WIZARD 1470. Normalna
koncentracija intaktnog parathormona u serumu iznosi
11,8–64,5 pg/ml. Kod bolesnika koji se leče redovnom
dijalizom gornja normalna granica iznosi 300 pg/ml.
Koncentracija prealbumina i transferina određivana je
imunoturbidimetrijskom metodom, na analizatoru Abbott
Architect. Kod bolesnika koji se leče redovnom dijalizom
normalna koncentracija prealbumina u serumu iznosi ≥
0,30 g/l (≥ 30 mg/dl).
Normalizovan stepen razgradnje proteina – nPCR
izračunat je na osnovu formule: nPCR = (PCR x 0,58)/Vd,
gde su: PCR – stepen razgradnje proteina, a Vd – volumen
tečnosti u organizmu. PCR se izračunava iz formule: PCR
= (9,35 x G) + (0,29 x Vd), gde su: G – stepen stvaranja
uree, a Vd – zapremina tečnosti u organizmu. Stepen
stvaranja uree izračunava se iz formule – G=(C1 –
C2)/Id x Vd, gde su: C1 – koncentracija uree u serumu
pre dijalize (mmol/l), C2 – koncentracija uree u serumu
posle dijalize (mmol/l), Id – vreme između dve dijalize
(h). Volumen tečnosti u organizmu se izračunava iz
formule: Vd = 0,58 x DW, gde je DW – suva telesna masa
bolesnika posle dijalize (kg).
Procenat interdijaliznog prinosa u telesnoj masi
bolesnika – %IDWG izračunat je pomoću formule:
%IDWG = (telesna masa bolesnika pre dijalize (kg) –
„suva telesna masa“ bolesnika) (kg)/„suva telesna masa“
bolesnika (kg) x 100.
Adekvatnost dijalize procenjivana je na osnovu single-
pool Kt/Vsp indeksa izračunatog prema Daugridas
second-generation formuli: Kt/Vsp = -ln(C2/C1 – 0,008 x
T) + (4 – 3,5 x C2/C1) x UF/W, gde su: C1 – vrednost uree
pre dijalize, C2 – vrednost uree posle dijalize (mmol/l), T
– trajanje hemodijalize (h), UF – interdijalizni prinos (l),
W – telesna težina posle hemodijalize (kg). Prema
K/DOQI smernicama hemodijaliza je adekvatna ukoliko
je Kt/Vsp  1,2.
Stepen smanjenja uree – URR indeks izračunat je
pomoću sledeće formule: URR = (1–R) x 100%, gde R
predstavlja odnos koncentracije uree u serumu posle i pre
tretmana dijalize. Dijaliza je adekvatna ukoliko je URR
indeks = 65–70%.
Protok krvi kroz vaskularni pristup – Qavf određivan
je Color Doppler ultrazvučnim pregledom, na aparatu

Med. čas. 2021; 55(1): 7-17.
Logic P5, korišćenjem sonde od 7,5 MHz. Protok krvi
kroz vaskularni pristup koji obezbeđuje adekvatnu
hemodijalizu iznosi 500–1000 ml/min.
Za statističku analizu dobijenih podataka korišćeni su
Kolmogorov–Smirnov test, Studentov T test i
Mann–Whitney U test . Prag značajnosti bila je
verovatnoća od 0,05 i 0,01.
REZULTATI
U Centru za nefrologiju i dijalizu KC Kragujevac
sprovedena je studija preseka, koja je uključila bolesnike
lečene konvencionalnom visokopropusnom hemodija-
lizom i postdilucionom online hemodijafiltracijom, tri
puta nedeljno po 4 h, u periodu od tri meseca, korišćenjem
dve različite dijalizne membrane (tabela 1). Ispitano je 85
bolesnika koji su lečeni konvencionalnom
visokopropusnom hemodijalizom (47 muškaraca, 38
žena), prosečne starosti 66,61  8,86 godina, prosečne
dužine lečenja hemodijalizom 3,29  4,59 godina,
prosečne uhranjenosti 26,02  4,57 kg/m2 i prosečnog
indeksa adekvatnosti – spKt/V = 1,37  0,34. Dodatno,
ispitano je 30 bolesnika koji su lečeni postdilucionom
online hemodijafiltracijom (23 muškarca, 7 žena),
prosečne starosti 54,87  11,66 godina, prosečne dužine
lečenja hemodijalizom 4,95  5,40 godina, prosečne
uhranjenosti 23,49  3,75 kg/m2 i prosečnog indeksa
adekvatnosti – spKt/V = 1,41  0,25. Opšti podaci o
bolesnicima prikazani su u tabeli 2. Glavni uzroci razvoja
završnog stadijuma hronične bolesti bubrega u grupi
bolesnika koji su lečeni konvencionalnom
visokopropusnom hemodijalizom jesu hipertenzivna i
dijabetesna nefropatija, a u grupi bolesnika koji su lečeni
postdilucionom online hemodijafiltracijom glomerulske
bolesti bubrega i hipertenzivna nefropatija. Osnovni
parametri postdilucione online hemodijafiltracije
prikazani su u tabeli 3.
Tabela 1. Karakteristike membrana za konvencionalnu visokopropusnu hemodijalizu (HF-HD) i postdilucionu online
hemodijafiltraciju (OL-HDF)
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Za lečenje anemije ispitivanih bolesnika koristili su se
kratkodelujući i dugodelujući eritropoetini, i. v. gvožđe, i.
v. preparat vitamina B i folna kiselina (per os). U grupi
bolesnika koji su lečeni konvencionalnom
visokopropusnom hemodijalizom, prosečna mesečna doza
kratkodelujućeg eritropoetina iznosila je 22.000,00 
11.391,05 IU, dugodelujućeg eritropoetina 165,00  94,88
g, dok je prosečna mesečna doza intravenskog gvožđa
iznosila 237,50  228,25 mg. U grupi bolesnika koji su
lečeni postdilucionom online hemodijafiltracijom
prosečna mesečna doza kratkodelujućeg eritropoetina
iznosila je 18.857,14  8.234,65 IU, dugodelujućeg
eritropoetina 102,94  52,54 g, dok je prosečna mesečna
doza intravenskog gvožđa iznosila 244,44  104,16 mg.
Za obe grupe bolesnika prosečna mesečna doza i. v.
vitamina C iznosila je 6.000,00  0,00 mg, a prosečna
mesečna doza vitamina B12 2.500,00  0,00 g. Kod
bolesnika koji su lečeni konvencionalnom
visokopropusnom hemodijalizom prosečna mesečna doza
folne kiseline iznosila je 176,47  57,52 mg, a kod
bolesnika koji se lečeni postdilucionom online
hemodijafiltracijom 180,00  60,00 mg. Sekundarni
hiperparatireoidizam ispitivanih bolesnika lečen je
vezačima fosfata koji sadrže kalcijum, aktivnim
metabolitima vitamina D i parikalcitolom. Za lečenje
arterijske hipertenzije korišćena je kombinacija blokatora
konvertaze angiotenzina I, blokatora receptora za
angiotenzin II, beta blokatora, blokatora kalcijumskih
kanala i diuretika Henleove petlje.
Prosečne vrednosti parametara anemije, statusa
gvožđa, mikroinflamacije, malnutricije, sekundarnog
hiperparatireoidizma prikazani su u tabeli 4. Bolesnici
lečeni postdilucionom online hemodijafiltracijom imaju
statistički visoko značajnu veću jačinu protoka krvi (Qb),
koncentraciju ukupnih proteina, albumina i prealbumina u
serumu, kao i statistički visoko značajnu (p  0,01) manju
koncentraciju C-reaktivnog proteina u serumu u odnosu na
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bolesnike lečene konvencionalnom visokopropusnom β2-mikroglobulina u serumu pre sesije manja od 25 mg/l
hemodijalizom (tabela 4). utvrđena je kod 11 (36,67%) bolesnika, a manja od 30
Koncentracija β2-mikroglobulina u serumu pre mg/l kod 21 (70,00%) bolesnika. Prosečan indeks
pojedinačne sesije konvencionalne visokopropusne redukcije β2-mikroglobulina u toku pojedinačne sesije
hemodijalize manja od 25 mg/l utvrđena je kod 35 konvencionalne visokopropusne hemodijalize za dijaliznu
(41,18%) bolesnika, manja od 30 mg/l kod 25 (29,41%) membranu FX CorDiax 600 iznosio je 61,76  7,32%, a
bolesnika, a kod 25 (29,41%) bolesnika veća od 30 mg/l. kod postdilucione online hemodijafiltracije za dijaliznu
Kod postdilucione online hemodijafiltracije, koncentracija membranu FX CorDiax 800 74,69  6,51%. Između
Tabela 2. Opšti podaci o bolesnicima

Tabela 3. Podaci o lečenju bolesnika postdilucionom online hemodijafiltracijom

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indeksa redukcije β2-mikroglobulina u toku pojedinačne
sesije konvencionalne visokopropusne hemodijalize i
postdilucione online hemodijafiltracije, između dve
različite dijalizne membrane, postoji statistički visoko
značajna razlika (p  0,01) (tabela 5).
Svi ispitivani bolesnici su pre i posle sesije
konvencionalne visokopropusne hemodijalize i
postdilucione online hemodijafiltracije imali
koncentraciju albumina u serumu veću od 35 g/l. Prosečno
smanjenje koncentracije albumina u serumu u toku
pojedinačne sesije konvencionalne visokopropusne
hemodijalize za dijaliznu membranu FX CorDiax 600
iznosilo je 1,36  0,52 g/l (indeks redukcije albumina
iznosio je 3,48  1,28%). Prosečno smanjenje
koncentracija albumina u serumu u toku pojedinačne
sesije postdilucione online hemodijafiltracije za dijaliznu
membranu FX CorDiax 800 iznosilo je 2,40  1,28 g/l
(indeks redukcije albumina iznosio je 6,01  2,97%).

Tabela 4. Prosečne vrednosti parametara ispitivanja: HF-HD naspram OL-HDF

Tabela 5. Poređenje efikasnosti dve dijalizne membrane: indeks redukcije β2-M i albumina

13

Med. čas. 2021; 55(1): 7-17.
Između indeksa redukcije albumina, za dva različita
dijalizna modaliteta i dve različite dijalizne membrane,
postoji statistički visoko značajna razlika (p  0,01)
(tabela 5).
DISKUSIJA
Kardiovaskularne bolesti su vodeći uzrok smrti
bolesnika koji se leče redovnom dijalizom. Uremijski
toksini, mikroinflamacija, neuhranjenost, oksidacioni
stres, poremećaj funkcije endotela, rezistencija na dejstvo
eritropoetina i anemija značajni su netradicionalni faktori
rizika za razvoj kardiovaskularnih bolesti. Rano otkrivanje
i optimalna kontrola netradicionalnih faktora rizika imaju
ključnu ulogu u sprečavanju razvoja kardiovaskularnih
bolesti u ovoj populaciji bolesnika (22–28).
β2-mikroglobulin je uremijski toksin srednje
molekulske mase (MW – 11,8 kDa), rastvorljiv u vodi, a
povećanje njegove koncentracije u serumu za posledicu
ima razvoj amiloidoze povezane sa dijalizom – DRA
(engl. Dialysis-Related Amyloidosis) (29–31). Kod
bolesnika koji se leče redovnom dijalizom, koncentracija
β2-mikroglobulina u serumu pre pojedinačne sesije
dijalize treba da iznosi  30 mg/l (29–31). Kod ispitivanih
bolesnika, koncentracija β2-mikroglobulina u serumu pre
pojedinačne sesije konvencionalne visokopropusne
hemodijalize manja od 25 mg/l prisutna je kod 35
(41,18%) bolesnika, manja od 30 mg/l kod 25 (29,41%)
bolesnika, a kod 25 (29,41%) bolesnika veća od 30 mg/l.
Kod bolesnika koji su lečeni postdilucionom online
hemodijafiltracijom, koncentracija β2-mikroglobulina u
serumu pre pojedinačne sesije bila je manja od 25 mg/l
kod 11 (36,67%) bolesnika, a manja od 30 mg/l kod 21
(70,00%) bolesnika. Prosečan indeks redukcije β2-
mikroglobulina u toku pojedinačne sesije konvencionalne
visokopropusne hemodijalize i postdilucione online
hemodijafiltracije za dijaliznu membranu FX CorDiax 600
iznosio je 61,76  7,32%, a za dijaliznu membranu FX
CorDiax 800 74,69  6,51%. Rezultati do sada učinjenih
istraživanja pokazali su da u toku pojedinačne sesije
visokopropusne „high-flux“ hemodijalize indeks
redukcije za β2-mikroglobulin iznosi 50–60%, kod
proširene MCO hemodijalize („medium cut-off“ dijalizna
membrana) 70%, a kod visokovolumenske (Vconv  22
litara po sesiji) postdilucione online hemodijafiltracije
80–85% (RR ≥ 80%) (29–31). Bolesnici koji su lečeni
postdilucionom online hemodijafiltracijom imaju
statistički visoko značajan veći stepen uklanjanja β2-
mikroglobulina u poređenju s bolesnikima koji su lečeni
konvencionalnom visokopropusnom hemodijalizom. To
se može objasniti statistički visoko značajnom većom
jačinom protoka krvi (p  0,01), kao i doprinosom
konvektivnog transporta uklanjanju uremijskih toksina
srednje molekulske mase. Kod ispitivanih bolesnika koji
14
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COBISS . SR - ID 44211721
UDK. 616.61-78
su lečeni postdilucionom online hemodijafiltracijom
prosečni ukupni konvektivni volumen iznosio je Vconv =
21,38  2,97 litara po sesiji, a jačina protoka krvi – Qb =
257,00  18,65 ml/min. Jačina protoka krvi kod bolesnika
lečenih konvencionalnom visokopropusnom hemo-
dijalizom iznosila je Qb = 225,41  22,44 ml/min.
Rezultati sprovedenog istraživanja ukazuju na veću
efikasnost postdilucione online hemodijafiltracije u
uklanjanju β2-mikroglobulina iz krvi bolesnika od
konvencionalne visokopropusne hemodijalize, što je u
saglasnosti s rezultatima drugih istraživača (32, 33).
Bolesnici sa ukupnim konvektivnim volumenom – Vconv
 22 litara po sesiji imaju statistički značajno manju jačinu
protoka krvi (Qb) i veću frakciju filtracije (FF) u odnosu
na bolesnike kod kojih se ostvaruje Vconv ≥ 22 litara po
sesiji. Ukupni konvektivni volumen – Vconv ≥ 22 litara po
sesiji ostvarljiv je u kliničkoj praksi kod 75% bolesnika.
Visokovolumenska postdiluciona online
hemodijafiltracija efikasno uklanja uremijske toksine
srednje molekulske mase, prvenstveno zbog visokog
konvektivnog transporta, bez značajnog gubitka albumina.
Kod ispitivanih bolesnika prosečno smanjenje
koncentracije albumina u toku pojedinačne sesije
konvencionalne visokopropusne hemodijalize za dijaliznu
membranu FX CorDiax 600 iznosilo je 1,36  0,52 g/l, a
kod postdilucione online hemodijafiltracije za dijaliznu
membranu FX CorDiax 800 2,40  1,28 g/l.
Konvencionalna visokopropusna hemodijaliza sa
dijaliznom membranom FX CorDiax 600 ima manji
gubitak albumina u toku pojedinačne sesije nego
postdiluciona online hemodijafiltracija sa membranom FX
CorDiax 800. To se može objasniti karakteristikama
dijaliznih membrana (površina, koeficijent ultrafiltracije) i
modaliteta dijalize (konvektivni transport). Dijalizna
membrana FX CorDiax 600 ima manju površinu i manji
koeficijent ultrafiltracije od dijalizne membrane FX
CorDiax 800, dok su kod postdilucione online
hemodijafiltracije značajan konvektivni transport i
frakcija filtracije. Kod ispitivanih bolesnika koji su lečeni
postdilucionom online hemodijafiltracijom frakcija
filtracije iznosila je FF = 36,00  5,00% i bila je nešto veća
od optimalne FF = 25–30% (FF  25%). Zbog povećane
frakcije filtracije povećan je transmembranski pritisak –
TMP (ciljni TMP treba da bude manji od 400 mmHg), a
ispitivanja su pokazala statistički značajnu pozitivnu
povezanost između transmembranskog pritiska i gubitka
albumina u toku sesije pojedinačne postdilucione online
hemodijafiltracije (29–34). Kod ispitivanih bolesnika
indeks redukcije albumina (RR-Alb) za obe dijalizne
membrane manji je od 11%, što ukazuje na gubitak
albumina dijalizatom u količini manjoj od 3,5 g / 4 h
(29–34). Posle pojedinačne sesije konvencionalne
visokopropusne hemodijalize i postdilucione online
hemodijafiltracije koncentracija albumina u serumu bila je

Med. čas. 2021; 55(1): 7-17.
kod svih bolesnika veća od 35 g/l. U toku pojedinačne
sesije konvencionalne visokopropusne hemodijalize i
postdilucione online hemodijafiltracije gubi se manje od
4,0 g albumina (≤ 4,0 g/4h), što je od velikog značaja za
sprečavanje razvoja neuhranjenosti (29–35). Značajnu
ulogu u razvoju neuhranjenosti imaju mikroinflamacija i
povećana koncentracija leptina u serumu. Leptin je
adipokin srednje molekulske mase (MW – 17 kDa), koji
smanjuje apetit bolesnika koji se leče redovnom dijalizom
(energetski unos  30 Kcal/kg/dan, unos proteina manji od
0,8 g/kg/dan). Indeks telesne mase – BMI  20 kg/m2,
koncentracija albumina u serumu  35 g/l, koncentracija
prealbumina u serumu manja od 0,30 g/l i normalizovan
stepen razgradnje proteina – nPCR  1,0 g/kg/dan faktori
su rizika za nepovoljan ishod bolesnika koji se leče
redovnom dijalizom (36–38). Ispitivanja pokazuju da
visokovolumenska postdiluciona online hemodijafiltracija
efikasno uklanja prozapaljenske citokine i leptin, smanjuje
mikroinflamaciju, smanjuje koncentraciju leptina u
serumu, sprečava razvoj neuhranjenosti i popravlja ishod
ovih bolesnika (36–38).
Uremijski toksini podstiču razvoj mikroinflamacije
kod bolesnika koji se leče redovnom dijalizom.
Prozapaljenski citokini (interleukin-6) stimulišu sintezu
hepcidina u ćelijama jetre. Hepcidin je uremijski toksin
srednje molekulske mase (MW – 2,7 kDa), koji blokira
oslobađanje gvožđa iz ćelija retikuloendotelnog sistema.
To za posledicu ima razvoj funkcionalnog nedostatka
gvožđa, rezistencije na dejstvo eritropoetina i razvoj
anemije. Visokovolumenska postdiluciona online
hemodijafiltracija efikasno uklanja hepcidin, smanjuje
rezistenciju na dejstvo eritropoetina i omogućava
optimalnu kontrolu anemije (postizanje i održavanje ciljne
vrednosti hemoglobina u krvi bolesnika koji se leče
redovnom dijalizom) (39, 40).
Optimizacija ukupnog konvektivnog volumena
(Vconv) zavisi od faktora povezanih sa bolesnikom
(hematokrit, koncentracija ukupnih proteina u serumu) i
faktora povezanih sa sesijom postdilucione online
hemodijafiltracije, kao što su: jačina protoka krvi (Qb),
dužina trajanja pojedinačne sesije postdilucione online
hemodijafiltracije (T) i tip dijalizne membrane (41, 42).
Ciljna jačina protoka krvi treba da iznosi – Qb ≥ 350
ml/min. Jačina protoka krvi zavisi od protoka krvi kroz
vaskularni pristup za hemodijalizu (Qavf  600 ml/min) i
dijametra arterijske i venske igle (15G/16G) (41, 42).
Visok hematokrit i povećana koncentracija ukupnih
proteina u serumu povećavaju frakciju filtracije i smanjuju
ukupni konvektivni volumen (Vconv). Visokovolumenska
postdiluciona online hemodijafiltracija (Vconv ≥ 22 litara
po sesiji) zahteva stalnu edukaciju i trening medicinskih
tehničara (41, 42).
15
doi: 10.5937/mckg55-31062
COBISS . SR - ID 44211721
UDK. 616.61-78
ZAKLJUČAK
Konvencionalna visokopropusna hemodijaliza uklanja
uremijske toksine molekulske mase u rasponu 0,5–15
kDa, dok postdiluciona online hemodijafiltracija efikasno
uklanja uremijske toksine srednje molekulske mase u
rasponu 0,5–60 kDa. Stepen uklanjanja uremijskih toksina
srednje molekulske mase iz krvi bolesnika zavisi od jačine
protoka krvi, ukupnog konvektivnog volumena i tipa
dijalizne membrane. Postdiluciona online
hemodijafiltracija efikasnije uklanja β2-mikroglobulin iz
krvi bolesnika od konvencionalne visokopropusne
hemodijalize. Visokovolumenska postdiluciona online
hemodijafiltracija (ukupni konvektivni volumen ≥ 22
litara po sesiji) smanjuje mikroinflamaciju, oksidacioni
stres, pothranjenost, rezistenciju na dejstvo eritropoetina,
sprečava razvoj amiloidoze povezane sa dijalizom,
ubrzane ateroskleroze i popravlja ishod bolesnika koji se
leče redovnom dijalizom.
ZAHVALNICA
Autori zahvaljuju Ministarstvu prosvete, nauke i
tehnološkog razvoja Republike Srbije na projektu No
175014 kao i Fakultetu medicinskih nauka Univerziteta u
Kragujevcu na junior projektima No 02/19 i No 22/20,
koji su delom pomogli finansiranje ovog rada.
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DYNAMICS OF INDICATORS OF THE ENDOTHELIUM MORPHOFUNCTI-

ONAL STATE OF THE BRAIN MICROCIRCULATORY BED VESSELS IN
RATS WITH NITRITE-INDUCED ALZHEIMER'S TYPE DEMENTIA ON
THE BACKGROUND OF MESENCHYMAL STEM CELL ADMINISTRATION
Yevgeniya Zorenko1, Galina Gubina-Vakulyck2, Olena Pavlova1, Tatyana Gorbach3, Elena Shchegelskaya4, Elena Omelchenko5
1Kharkiv National Medical University, Department of Physiological Pathology, Kharkiv, Ukraine
2Kharkiv National Medical University, Department of Pathological Anatomy, Kharkiv, Ukraine
3Kharkiv National Medical University, Department of Biochemistry, Kharkiv, Ukraine
4Kharkiv National Medical University, Department of Neurosurgery, Kharkiv, Ukraine
5Kharkiv Medical Academy of Postgraduate Education, Kharkiv, Ukraine

MIKROCIRKULATORNOM KAPILARNOM KORITU PACOVA SA

DEMENCIJOM ALCHAJMEROVOG TIPA INDUKOVANOG NITRITOM NA
TERENU MEZENHIMALNIH MATIČNIH ĆELIJA
Jevgenija Zorenko1, Galina Gubina-Vakulik2, Olena Pavlova1, Tatjana Gorbah3, Elena Šegelskaja4, Elena Omelčenko5
1Nacionalni medicinski univerzitet Harkov, Katedra za patofiziologiju, Harkov, Ukrajina
2Nacionalni medicinski univerzitet Harkov, Katedra za patološku anatomiju, Harkov, Ukrajina
3Nacionalni medicinski univerzitet Harkov, Katedra za biohemiju, Harkov, Ukrajina
4Nacionalni medicinski univerzitet Harkov, Katedra za neurohirurgiju, Harkov, Ukrajina
5Medicinska akademija za postdiplomske studije Harkov, Harkov, Ukrajina

ABSTRACT
Objective. The aim of this study was to assess the vascular
endothelium morphofunctional state of the brain
microcirculatory bed in rats with nitrite-induced Alzheimer's
type dementia on the background of stem cells administration.
Methods. 14 days after the experiment’s end, the
endothelin-1, VEGF-A, eNOS, von Willebrand factor were
determined in blood serum by the enzyme immunoassay and
photometric methods in rats with a model of nitrite-induced
dementia (14 and 28 days of sodium nitrite intraperitoneal
introduction) with and without mesenchymal stem cells
(MSCs) administration. The brain slices were stained
according to the Einarson’s method and
immunohistochemically by staging the reaction with
antibodies to VEGF.
Results. With an increase in the sodium nitrite
administration period, the degree of damage of brain
capillaries and neurons increased, dystrophy of “surviving”
neurons developed and ability to produce VEGF decreased.
After 14 days of “regeneration period” in groups without
MSCs administration, further stimulation of VEGF
production by endotheliocytes, cortex and hippocampus
neurons of varying degrees was observed. In groups where
stem cells were introduced, the number of capillaries
increased, with endothelial hyperplasia in some cases.
Conclusion. In animals with nitrite-induced dementia,
dose-dependent damage to the endothelium of the capillary
bed is noted. From the first day damage the vascular
regeneration can be proved by VEGF expression. The stem
cells administration more effectively stimulates capillary
regeneration, as evidenced by a noticeable increase of the
number of brain capillaries.
Key words: Alzheimer disease; sodium nitrite;
mesenchymal stem cells.
SAŽETAK
Cilj. Cilj ove studije bio je da se proceni
morfofunkcionalno stanje vaskularnog endotela u
mikrocirkulacijskom sloju mozga kod pacova s demencijom
Alzheimerovog tipa izazvanom nitritima na terenu
administracije matičnih ćelija.
Metode. Četrnaest dana po završetku eksperimenta
određivani su endotelin-1, VEGF-A, eNOS, Fon Vilebrandov
faktor u krvnom serumu, imunoanalizom enzima i
fotometrijskim metodama kod pacova s modelom demencije
izazvane nitritima (14 i 28 dana intraperitonealne indukcije
natrijum nitrita) s primenom mezenhimskih matičnih ćelija
(MSC) i bez nje. Moždani preseci su obojeni prema
Ejnarsonovoj metodi i imunohistohemijski postavljanjem
reakcije antitela na VEGF.
Rezultati. S povećanjem perioda primene natrijum nitrita
povećava se stepen oštećenja moždanih kapilara i neurona,
razvija distrofija „preživelih“ neurona i smanjuje sposobnost
stvaranja VEGF. Nakon 14 dana „perioda regeneracije“ u
grupama bez administracije MSC primećuje se dalja
stimulacija proizvodnje VEGF endoteliocitima, korteksom i
hipokampusom neurona različitog stepena. U grupama gde
su uvedene matične ćelije broj kapilara se povećava,
ponegde s endotelnom hiperplazijom.
Zaključak. Kod životinja s demencijom izazvanom
nitritima primećuju se oštećenja endotela kapilarnog korita
zavisna od doze. Od prvog dana oštećenja vaskularna
regeneracija može se dokazati ekspresijom VEGF.
Administracija matičnih ćelija efikasnije stimuliše
regeneraciju kapilara, što dokazuje primetno povećanje
broja moždanih kapilara.
Ključne reči: Alchajmerova bolest; natrijum nitrit;
mezenhimske matične ćelije.

Primljen/Received: 10.04.2021. 18 Yevgeniya M. Zorenko,

Prihvaćen/Accepted: 16.07.2021. Boyova street, 52, 61051, Kharkiv, Ukraine
+380675723294, zeekmail@ukr.net,.

Med. čas. 2021; 55(1): 18-26.
INTRODUCTION
The attention of many researchers has been focused on
the study of the interconnection between neuropathy and
vasculopathy in the brain. After all, the role of vascular
factors is decisive in the mechanisms of neuronal function
damage in neurodegenerative diseases. The study of
Alzheimer's disease (AD) etiopathogenesis remains an
urgent issue, which is associated with the need to search
for new, effective means of combating the progression of
this pathology. Every year the number of AD patients all
over the world is growing steadily. Perhaps this is the
result of a combined negative influence of different
exogenous factors that can cause genetic mutations in the
human body, and subsequently lead to the development of
neurodegenerative processes.
Back in 2009, Suzanne M. de la Monte et al. (1)
established the fact of an increase of AD cases with
excessive accumulation of nitrosamines, which are formed
in the body during the interaction of sodium nitrite with
proteins after its entering into the body with water, food,
etc. Besides their carcinogenic effect, nitrosamines
reinforce the oxidative stress, have a mutagenic effect,
which plays an important role in the development of
neurodegenerative changes. The role of this exogenous
factor in the development of Alzheimer's type dementia
was proven in our previous studies on the created nitrite-
induced model, where after prolonged intraperitoneal
administration of aqueous solution of sodium nitrite rats
developed cognitive deficit, changed behavioral reactions,
and, along with this deposition of congophilic masses in
the arteries’ walls of the brain and focal - in the white
matter of the hemispheres (2).
It has also been previously experimentally stated, but
on the scopolamine model of dementia, that animals
simultaneously developed insulin resistance and energy
deficiency in the brain (3, 4). Other studies also revealed
similar changes (mitochondrial dysfunction, ATP
deficiency, oxidative stress) in combination with the
development of cognitive impairment in animals after the
administration of low doses of streptozotocin, which is
close to nitrosamine in chemical structure (5).
Amyloidosis of the brain has several hypotheses. Thus,
the hypothesis of “amyloid cascade” provides for the
excessive formation of β-amyloid by neuronal and glial
cells as a result of pathological proteolysis of APP-
amyloid precursor protein, which causes the accumulation
of amyloid plaques and the development of
neurodegenerative processes (6). Some authors believe
that a mandatory stage in the accumulation of amyloid and
the formation of cognitive impairment is cerebrovascular
dysfunction due to vascular damage and the development
of chronic ischemia (7). Possibly, neurodegeneration
without previous impairment of endothelial function does
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not occur in AD patients (8).
The aim of the paper was to study of indicators
characterizing the vascular endothelium morphofunctional
state of the brain microcirculatory bed in rats with nitrite-
induced Alzheimer's type dementia on the background of
stem cells administration.
MATERIAL AND METHODS
1. Animals and groups
The experiment involved 48 male Wistar Albino Glaxo
(WAG) rats weighing 180-250 g, which were divided into
5 groups. Animals of group N-14 (nitrite 14 days, n = 8)
and group N-28 (nitrite 28 days, n = 8) received
intraperitoneal injections of an aqueous solution of sodium
nitrite (NaNO2) in a dose of 50 mg/kg for 14 days and 28
days, respectively. Animals of group N-14-SC (nitrite 14
days + stem cells, n = 8) and group N-28-SC (nitrite 28
days + stem cells, n = 8) received single intravenous
injections of mesenchymal stem cells (MSCs) in a dose of
500,000 cells per each rat at the appropriate time after
sodium nitrite injections (Figure 1). Animals of the control
group (C, n = 16) received injections of 0.9% sodium
chloride solution at the same time and in the same way. All
animals were housed in 41x41x20 cm cages (4 rats in each
cage) at a controlled temperature of 20±2°C and humidity
of 60±10% under standard vivarium conditions. The rats
were removed from the experiment 14 days after the last
day of injections in order to assess both the degree of
damage and the regenerative capabilities of the cerebral
vessels in rats. This period is conventionally called by us
“the regeneration period” as the regeneration begins after
the first day of damage, and in the period from 14 to 28
days the damaging factor was removed and regeneration
continued. Blood was collected in sterile EDTA
VACUTAINER tubes, the brain was removed for the
preparation of histological sections.
All institutional and national guidelines for the care
and use of laboratory animals were followed. When
working with experimental animals, we were guided by
the provisions of the European Convention for the
Protection of Vertebrate Animals (Strasbourg, 03/18/1986,
revised and supplemented in 2006), Law of Ukraine No.
3447-IV, Art. 26, 31 “Animal Protection Law”, “General
Ethical Principles of Animals Experimentation”, adopted
by the Fifth National Congress on Bioethics (Kyiv, 2013).
The Commission on Ethics and Bioethics of KhNMU at
its 8th meeting on 10/10/2018 approved that this
experiment complied with the bioethical requirements of
the EU Directive 2010/63/EU on the protection of
animals, the Council of Europe Convention for the
Protection of Vertebrate Animals (ETS123) and did not
violate ethical standards in science and standards for
conducting biomedical research.

Med. čas. 2021; 55(1): 18-26.
2. Obtaining stem cells
Primary culture of mesenchymal stem cells was
obtained from the bone marrow of the femur. The
suspensions were washed with Hank’s saline solution,
centrifuged at 450 g for 10 min and placed in cultivation
flasks with a capacity of 75 cm2 at a density of 4x105
cells/cm2 in Dulbecco's Modified Eagle's Medium
DMEM/F12 (1/1) medium containing 2 mM L-Glutamine,
10% fetal bovine serum (FBS) (SIGMA-ALDRICH,
F7524) and 2 μl/ml antibiotic antimycotic solution
(SIGMA-ALDRICH, A5955). The medium with non-
adherent cells was discarded after 24 hours of cultivation
and fresh medium was added to adhered fibroblast-like
MSCs. They were cultured at 37ºC and 5% CO2 in air in
a CO2-incubator for 14 days, the medium was changed
every 3 days (9). All reagents were purchased from
SIGMA-ALDRICH (USA).
3. Endotelin -1(ET-1), vascular endothelial growth
factor A (VEGF-A), endothelial NO-synthase (eNOS), von
Willebrand factor (vWF) determination in blood serum
Concentrations of ET-1, VEGF-A and eNOS in blood
serum were determined by enzyme immunoassay using a
standard set of reagents on a semi-automatic enzyme
immunoassay analyzer STAT FAX 303+ (Elabscience,
Wuhan, Hubei, China, 2019).
Determination of the vWF level was based on the
aggregation of formalin-fixed platelets obtained from rats
by ristomycin by a photometric method using a Solar
PV12521 spectrophotometer (Belarus).
4. Obtaining morphological preparations and
immunohistochemical determination of vascular
endothelial growth factor (VEGF)
The brain immediately after decapitation of the
animals was fixed in 10% neutral formalin, followed by
preparation of slices using gallocyanine chromium alum
staining according to the Einarson’s method to assess the
state of DNA and RNA of various cells. For
immunohistochemical studies sections with a thickness of
3-4 microns were prepared which were applied to glass
slides with high adhesive ability SuperFrost (Thermo
Scientific, USA). After dewaxing and standard processing
in xylene and ethanol the samples were boiled in a water
bath in citrate buffer (pH = 6) at a temperature of 95-98°C.
A detection system “Ultra Vision Quanto Detection
System HRP DAB Chromogen” (Thermo scientific, USA)
was used to detect the antigen-antibody VEGF interaction
reaction (10). The study of histological and
immunohistochemical preparations of the brain was
carried out using Zeiss Axiostar plus binocular microscope
with ProgRes C10Plus digital camera (Germany). The
expression of VEGF antigen in neurons of the parietal lobe
cortex, CA1 zone of the hippocampus, in vascular
endotheliocytes of microcirculatory bed (MCB) and in
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UDK. 616.892.3-085 602.9
venous blood plasma was studied. The mean values of the
levels of optical density of VEGF-tagged cells cytoplasm
(I) and the background (I0) were determined in the
program of the raster graphic editor GIMP (GNU Image
Manipulation Program). Optical density (D) of VEGF was
calculated by the formula D=lg I0/I (11).
5. Statistical analysis
Normal distribution of the sample was assessed using
the Shapiro-Wilk test. Based on its results, non-parametric
tests were used to compare the independent groups of
variables. The study selected one-way Kruskal-Wallis
analysis and Dunn's multiple comparison test to assess the
differences between five independent groups. If p-values
were below 0.05, the difference was considered to be
statistically significant. All numerical data were analyzed
using GraphPadPrism 5.0 (GraphPad Software Inc.,
California, USA) and the Social Science Statistical
Package (SSPS).
RESULTS
As described in the previously published articles, 2
weeks after completing a course of 14-day sodium nitrite
injections, in addition to the development of motor
protective inhibition in rats, and a decrease in exploratory
activity and cognitive deficit, the following changes were
noted morphologically in the cerebral vessels: amyloid
deposition in the walls’ arteries; the formation of blood
clots, both parietal in large vessels and obstructing in
small vessels; infiltration of blood vessels by macrophages
and lymphocytes (vasculitis); presence of pronounced
perivascular edema and areas of “empty spaces” that
follow the contours of capillaries (12, 13).
In this article, the morphofunctional state of the MCB
vascular endothelium in animals of the experimental
groups was assessed more deeply. In a microscopic
survey, in rats of group N-28, the damage to the cerebral
vessels is more pronounced than in group N-14 (Figure 2).
At the same time, the signs of endothelial recovery and
growth of new capillaries were observed in all groups for
14 days of regeneration, and in groups with stem cells –
multiple areas of endothelial hyperplasia (Figure 3, 4).
Among the biochemical indicators assessing the state
of the endothelium, two indicators characterizing the level
of damage and endothelial dysfunction (ET-1 and vWF)
were studied, one of the factors reflecting the
compensatory capabilities of endothelial cells (eNOS),
and the factor indicating the regenerative capabilities of
the endothelium (VEGF-A) (Table 1). Thus, the average
level in ET-1 in the blood serum of animals of group N-14
was 3.8 times higher than in group C. After stem cells
administration at the beginning of the recovery period, the
level of ET-1 became significantly lower than in group N-
14, but did not reach the level of group C.

Med. čas. 2021; 55(1): 18-26.
In animals of group N-28 the mean value of ET-1
concentration became approximately 7 times higher than
in rats of group C. At the same time, the administration of
stem cells to rats of group N-28-SC contributed to a
significant decrease in ET-1 by 3.5 times compared to
group N-28, which, however, was higher than that in
group C.
Changes similar in direction were observed in the
study of von Willebrand factor level (marker of
endothelial dysfunction) in all experimental groups. It
should be mentioned that in animals of groupN-28-SC,
vWF concentration practically reached control values.
It was found that the administration of sodium nitrite to
rats for 2 weeks caused a significant increase in the
activity of endothelial NO synthase (1.4 times higher than
Table 1. Biochemical parameters of endothelial state
Table 2. Optical density of VEGF expression in different cells of brain tissue
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in group C), and the administration of stem cells into
group N-14-SC caused decrease in enzyme activity almost
to the level of that in group C.
In group N-28, in contrast to group N-14, the eNOS
activity insignificantly exceeded that in group C. Stem cell
injections in group N-28-SC caused a statistically
insignificant (almost 1.1-times compared to group N-28)
decrease in eNOS activity, while at the same time, the
level of enzyme activity did not practically differ from the
control.
As it was seen from the data obtained, the
concentration of VEGF A increased under the influence of
prolonged administration of sodium nitrite after 2 weeks
of the regeneration period: in group N-14 - 1.4 times, and
in group N-28 - reliably 3.8 times compared to the control.
 doi: 10.5937/mckg55-31775
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Med. čas. 2021; 55(1): 18-26. UDK. 616.892.3-085 602.9

Figure 1. Experimental design. Groups N-14 - nitrite 14 days, N-28 - nitrite 14 days, N-14-SC-nitrite 14 days+stem
cells (SC), N-28-SC- nitrite 28 days+stem cells, NaNO2 – sodium nitrite.

Figure 2. A – presence of “empty space”, repeating the

contour of the dead vessel. B – capillary with flat
hyperchromic nuclei of endothelial cells and expressed
peri-vascular edema. Staining according to the
Einarson’s method. Group N-28. x400

Figure 4. Endothelial hyperplasia. Hippocampal neurons

are light, rounded shaped. Staining according to
Einarson’s method. Group N-28-SC. x400

Figure 5. Immune hystochemical reaction with

antibodies to VEGF. СА1 hippocampal zone. a – diffused
Figure 3. A great number of “young” endothelial cells weak color of neurons of groupN-28. b – intensely
(cells with large elongated oval nucleus). Staining tagged neurons of groupN-28-SC. Presence of “empty”
according to Einarson’s method. Group N-14-SC. x400 spaces between neurons in both groups. x400

22

Med. čas. 2021; 55(1): 18-26.
After the administration of stem cells to rats of group N-
14-SC there was a slight increase in VEGF A synthesis,
and in group N-28-SC there was a sharp decrease in VEGF
A synthesis (2.5 times compared to group N-28).
Nevertheless, its concentration remained reliably higher
than in the rats of the control group.
Simultaneously with the change of VEGF level in the
blood serum, the production of this peptide regulating the
proliferation of endothelium change in the cytoplasm of
neurons in the cerebral hemispheres, in the neurons of the
hippocampus (CA1 field), in the endotheliocytes of
capillaries, in the blood plasma of cerebral venules, which
is assessed by staging immunohistochemical reaction on
VEGF, study of the total number of tagged cells in the
field of view of the microscope and the optical density of
the cytoplasm of these cells (Table 2). Thus, in group N-
14 the number of VEGF-tagged endothelial cells was
higher and the optical density of the cytoplasm was 1.5
times higher than in the control group. At the same time,
in group N-28 where the endothelial damage was more
significant compared to group N-14, the number of tagged
endothelial cells in the field of view was smaller, and the
average optical density of the cytoplasm of tagged
endothelial cells did not differ from that in group N-14.
The administration of stem cells promoted a decrease in
the number of tagged endothelial cells in groupN-14-SC,
which contained a small amount of VEGF granules in the
cytoplasm, and the optical density of their cytoplasm was
reliably reduced. In group N-28-SC changes were of the
opposite nature: an increase in the number of capillaries in
the brain tissue with intensely tagged endothelial cells and
their optical density was reliably higher (1.4 times)
compared to group N-28.
In the CA1 field of the hippocampus in all main groups
the number of neurons decreased, which was especially
pronounced in the groups with 28 days of sodium nitrite
administration. In this context the following picture was
observed at the end of the regeneration period: in group N-
14 – an increase in the number of tagged neurons and a
low (as in group C) optical density of the cytoplasm; in
group N-14-SC in comparison to group N-14 – a decrease
in the number of tagged neurons and a decrease in the
optical density of their cytoplasm; in group N-28
hippocampal CA1 field was strongly atrophied and the
remaining neurons contained a label where optical density
of the cytoplasm was low; in group N-28-SC on the
background of a similar atrophization of hippocampus
CA1 field the optical density of the cytoplasm of tagged
neurons significantly increased compared to group N-28
(2.5 times) (Figure 5).
Optical density of VEGF in the neurons of the cerebral
cortex in all studied groups was higher than in the control
group. At the same time, visually, in group N-14-SC the
greater number of neurons were tagged in comparison to
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UDK. 616.892.3-085 602.9
group N-14. However, the level of VEGF expression in
neurons of the cerebral cortex of rats of group N-14 and
group N-14-SC practically did not differ from each other.
In animals of group N-28, the number of neurons in the
cerebral cortex was noticeably reduced, there were
“empty” gaps between neurons which indicated that
atrophization of the cortex had occurred, the remaining
neurons had a less intense label than in group N-14. After
the administration of stem cells in groupN-28-SC, the
VEGF expression did not statistically differ in comparison
to group N-28.
Determination of VEGF content in venous blood
plasma allows: to assess the level of its synthesis by brain
cells and the degree of reception by endothelial cells to
stimulate their division. This indicator significantly differs
from the one in blood serum (biochemically determined)
and reflects the general organism level of synthesis and
use of this peptide. Compared to the control group, optical
density of tagged plasma in animals of group N-14
increased reliably by 2.4 times, and in group N-28 it
decreased by 2.5 times. After the administration of stem
cells in group N-14-SC a significant decrease in the
content of the label was observed in the plasma as
compared to group N-14 and in group N-28-SC the plasma
optical density was reliably higher – 8 times, compared to
group N-28.
DISCUSSION
Currently, the point of view about significant
contribution of cerebrovascular dysfunction to the
development of Alzheimer's disease (AD) has been
gaining increasing recognition. Thus, in the study by
Verclytte S. et al. (14), a decrease of cerebral circulation in
the cortex of the frontal and parietal lobes of the brain of
patients with early stages of AD was found. It was
revealed that hypoperfusion and ischemic brain damage
were accompanied by the activation of enzymes involved
in the proteolysis of the APP amyloid precursor protein,
thereby increasing the accumulation of beta-amyloid both
in the vascular wall (the development of cerebral amyloid
angiopathy (CAA) and in the brain tissue) (15). At the
same time signs of endothelial mitochondrial dysfunction
were observed, which could be primary regarding the
appearance of amyloid in the vessels wall (16).
In our work, when simulating dementia of the
Alzheimer's type of vascular origin by daily
intraperitoneal injection of an aqueous solution of sodium
nitrite for 14 days, this substance, circulating in blood, had
a damaging effect on the vascular endothelium. Indeed, in
group N-14 and, especially, in group N-28 a decrease in
the number of capillaries and endothelial cells in them, an
increase in the number of pericytes and a decrease in the
size of the remaining hyperchromic endothelial cells were

Med. čas. 2021; 55(1): 18-26.
noted during morphological examination of the brain in
the MCB vessels (13). These changes occurred despite the
fact that the course of sodium nitrite injections had been
completed and 14 days had already passed, when only the
regeneration of the endothelium was taking place without
damaging it.
The study of biochemical parameters characterizing
the state of the endothelium in this study demonstrated
that the administration of sodium nitrite caused a
significant increase of ET-1 and vWF content in blood
serum, which confirms the violation of the integrity of the
endotheliocyte monolayer and vasoconstriction and
thrombosis increase in the vessels. The data obtained are
consistent with the results of Savitskiy I. et al. (17), where
animals developed endothelial dysfunction on the
background of chronic nitrate load (daily intake of 0.03%
nitrate solution instead of drinking water, which is
converted into nitrite in the body). Moreover, the increase
of the dose of sodium nitrite received by the animals
(group N-28 compared to group N-14) was accompanied
by a significant increase of the values of these two
indicators. Taking into account that these biochemical
parameters reflected the reaction of the endothelium in the
entire bloodstream of the body, a histological examination
of the brain carried out in parallel demonstrated that the
capillaries of the brain tissue in animals of group N-28
were damaged more than in group N-14.
The eNOS enzyme responds to endothelial damage by
performing, to a certain extent, a compensatory role,
catalyzing the formation of nitric oxide (NO). Besides
vasodilation, NO has an anti-thrombogenic, anti-
inflammatory effect and promotes transendothelial
migration of progenitor endothelial cells (18). A slight
increase of eNOS activity after 2 weeks of the
regeneration period in animals of groupN-28, in contrast
to the significant activity of endothelial NO synthase in
animals of groupN-14, proved a stronger damage of
endothelial cells and, apparently, a decrease in their
compensatory capabilities in general.
The histologically observed regeneration of capillaries,
the proliferation of endothelial cells in group N-28
developed on the background of a more significant
damage of capillaries than in group N-14, as mentioned
earlier, therefore show that, indeed, capillaries
endothelium of the brain tissue in group N-28 recovered to
a lesser extent than in group N-14, i.e. the estimated
explanation of eNOS lower activity in group N-28
compared to group N-14 can be considered convincing.
The VEGF content in arterio-venous blood was
significantly increased in group N-14 and in group N-28,
but in group N-28 it was almost 3 times higher than in
group N-14. Obviously, high VEGF index in blood of
group N-28 could be formed due to high possibilities of
cell regeneration of many parenchyma cells, which
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suffered due to disturbed blood supply during endothelial
death and capillaries destruction; new cells of such tissues
actively synthesized VEGF. Maximum endothelial death
is observed only in group N-28 (judging by the histology
of the brain), the restoration of which is not completed
until the moment of withdrawal from the experiment, and
in group N-14, apparently, the degree of endothelial cell
division stimulation by this active protein decreased by the
end of 14-day regeneration period, i.e. there was a
significant, but not yet complete restoration of the
endothelial layer in the bloodstream vessels.
There was an increase in the number of tagged
corresponding cells in comparison to group C and at the
same time an increase in the optical density of the label,
i.e. content of this protein in the cytoplasm, were found
during immunohistochemical determination of VEGF
content (i.e. production) in hippocampus neurons, cerebral
cortex and capillary endotheliocytes in groupN-14. In
group N-28, as mentioned earlier, damage to the capillary
endothelium was more pronounced and was accompanied
by cerebral cortex and CA1 zone atrophy of the
hippocampus, whereas almost all neurons were tagged,
but optical density of the cytoplasm was less than in group
N-14, which can be due to dystrophy of the “surviving”
neurons and their reduced ability to produce VEGF.
The number of tagged cells in the capillary bed of the
brain in group N-14 and group N-28 had sharply increased
in comparison to group C, and the optical density of the
cytoplasm in such endotheliocytes increased equally. To
assess the VEGF level in brain blood the optical density of
blood plasma in veins was examined. We have never seen
publications with such studies. But this indicator can
really be regarded as an indicator reflecting VEGF
concentration in the venous blood of the brain. The
interpretation of the results of this indicator is based on the
point of view that VEGF plasma concentration in the brain
veins is the result of two divergent processes occurring
with VEGF in the brain: VEGF production by different
cells and “consumption”, i.e. the reception by
endotheliocytes. It turned out that significantly more
VEGF was removed from the brain tissue with venous
blood in group N-14 than in group N-28, apparently
because much more of this protein was consumed in group
N-28, as endothelial regeneration was not yet completed.
These results do not contradict the data obtained by Li
Huang et. al. (19), when the VEGF level was significantly
lower in patients with AD than in patients with mild
cognitive impairment.
Thus, our experiment has demonstrated that cortex and
hippocampus neurons reacted to the damage of the
capillary endothelium and stimulated the production of
vascular growth factor. In the study of K. Okabe et. al.
(20), it was also demonstrated that VEGF secreted by
cortex and hippocampus neurons induced the blood

Med. čas. 2021; 55(1): 18-26.
vessels growth, which was important for the blood supply
to areas of the brain with dystrophic changes.
When stem cells were used in both groups (N-14-SC,
N-28-SC), a sharp decrease of both ET-1 and vWF content
in blood serum was observed, which indicates that to the
blood vessels endothelium damage in the body decreased
to the values of group C due to stem cells administration.
Accordingly, eNOS content in these groups decreased as
this enzyme was activated in response to endothelial
damage. Histological examination of brain tissue directly
demonstrated that in these groups there was a sharp
increase in the number of capillaries, with areas of
endothelial hyperplasia in some places.
Despite this, the VEGF content in total blood remained
slightly higher than in group C, while the administration of
stem cells did not significantly change the VEGF content
in blood during the 14-day course of sodium nitrite
administration, and after 28 days of administration it
significantly decreased, approximately 2.5 times.
Decreased VEGF circulation and improved angiogenesis
were obtained in people with heart failure and advanced
endothelial dysfunction who received allogeneic (from a
compatible donor) mesenchymal stem cells (21). It can be
assumed that in the tissues of the body as a whole (on
average) the need to stimulate angiogenesis in group N-
14-SC after a preliminary short activation (not studied by
us) decreased due to the end of the period of active
regeneration of the damaged endothelium. And in group
N-28-SC, in comparison to group N-28, acceleration of
regenerative processes was obvious and in this connection
the decrease in VEGF content in total blood serum. An
analysis of plasma optical density in the lumen of small
veins (immunohistochemical reaction for VEGF) fully
confirmed this assumption, as a small amount of this
peptide was removed from the brain tissue in the N-14-SC
group with venous blood (at the level of group C), and in
group N-28-SC its plasma concentration was very high,
i.e. it remained unclaimed.
A significant decrease in the cytoplasm optical density
of the capillary endothelium and CA1 neurons of the
hippocampal field, proved already completed (or ending)
endothelial regeneration in the vessels of the brain tissue
in groupN-14-SC, as only the neurons of the cerebral
cortex still produced VEGF at the same level as without
the administration of stem cells, but at the same time the
cortex showed signs of atrophization. But in group N-28-
SC, VEGF synthesis remained increased relative to group
N-28 in endotheliocytes and in neurons of the cerebral
cortex and in neurons of the hippocampus, i.e. stimulation
of the endothelial cells division continued, as their damage
by sodium nitrite was more significant.
Thus, using the NaNO2 model of Alzheimer's type
dementia, dose-dependent endothelial damage with a
reduction in the capillary network in the brain tissue with
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UDK. 616.892.3-085 602.9
biochemically proved signs of endothelial cell destruction
is demonstrated. Stimulation of endothelial cell
regeneration studied by the VEGF content both in blood
(plasma) and in neurons and endothelial cells cytoplasm,
as well as by the histological picture of the brain tissue, is
more active in animals that received one-time
mesenchymal stem cells. It can be assumed that damage of
the capillary wall followed by hypoxia and tissue nutrition
disturbance is one of the primary stages in the formation
of amyloid in the brain tissue due to the activation of
pathological breakdown of APP protein.
CONCLUSION
In experimental animals with a nitrite-induced model
(14 daily injections) of Alzheimer's type dementia,
biochemical and morphological evidence of significant
damage of the vascular endothelium both in the body as a
whole and in the brain tissue is revealed after 14 days of
the “regeneration” period. Intensive VEGF production is
observed with ongoing restoration of the endothelial layer
in vessels, which is clearly seen in the vessels of the brain
tissue microcirculatory bed. With an increase in the
duration of sodium nitrite administration, the degree of
endothelial damage increases significantly both in the
body as a whole and in the brain tissue with
simultaneously more reduced production of VEGF.
Stem cells therapy the next day after the end of sodium
nitrite administration promotes the acceleration of the
regeneration of the endothelial lining of blood vessels, as
evidenced by a noticeable increase in the number of
capillaries in the brain tissue. Comparison of the observed
changes in the indicators of the endothelial
morphofunctional state suggests that the state of
endothelial regeneration is closer to completion after a 14-
day administration of sodium nitrite compared to 28-day
administration.
ACKNOWLEDGMENTS.
The corresponding author would like to express
gratitude to Galina Gubina-Vakulyck and Tatyana
Gorbach for carrying out a morphological and
biochemical analysis, Elena Shchegelskaya and Elena
Omelchenko – for mesenchymal stem cells obtainment.
DECLARATION OF COMPETING INTEREST
The authors declare that they have no conflict of
interests.
FUNDING STATEMENT
The authors received no specific funding for this work.

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ABBREVIATIONS
AD - Alzheimer's disease; C – control; CAA - cerebral
amyloid angiopathy; DMEM - Dulbecco′s Modified
Eagle′s Medium; eNOS - endothelial NO-synthase; ET-1-
Endotelin -1; EU – European Union; FBS - fetal bovine
serum; KhNMU – Kharkiv National Medical University;
MSCs - mesenchymal stem cells; N-14 - nitrite 14 days;
N-14-SC - nitrite 14 days + stem cells; N-28 - nitrite 28
days; N-28-SC - nitrite 28 days + stem cells; NaNO2 -
sodium nitrite; SC - stem cells; VEGF-A - vascular
endothelial growth factor A; vWF - von Willebrand factor;
WAG - Wistar Albino Glaxo
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Med. čas. 2021; 55(1): 27-32. STRUČNI CLANAK
BOL U GRUDIMA I PREHOSPITALNO KAŠNJENJE
Marija Stevanović1, Slavoljub R. Živanović1
1Gradskizavod za hitnu medicinsku pomoć, Beograd
CHEST PAIN AND PREHOSPITAL DELAY
Marija Stevanovic1, Slavoljub R. Zivanovic1
1Emergency Medical Department, Belgrade, Serbia
SAŽETAK
Cilj. Cilj rada bio je da se za pacijente sa anginom
pektoris (AP) i akutnim koronarnim sindromom (AKS)
prikažu vreme trajanja bola u grudima pre javljanja u
ambulantu hitne pomoći i način na koji su pacijenti pokušali
sami sebi da pomognu.
Materijal i metode. Istraživanje je rađeno od avgusta
2014. do oktobra 2018. u ambulanti Gradskog zavoda za
hitnu medicinsku pomoć (GZZHMP) u Beogradu. Istraživanje
obuhvata 161 bolesnika od ukupno 9.437 pregledanih
pacijenata jednog lekara kojima je postavljena dijagnoza
AKS i AP ili se na nju posumnjalo.
Rezultati. Najveći procenat pacijenata sa AP čekao je
između dva i 24 h, dok je kod bolesnika sa AKS to bilo < 1 h
od početka tegoba do trenutka javljanja. Najveći broj
bolesnika kako sa AKS (17), tako i sa AP (79) nije uzeo
nikakvu terapiju, dok su pojedinci primenili jedan ili više
lekova. Kod pacijenata sa AP u većini slučajeva (17,42%)
primenjeni su lekovi za lečenje povišenog pritiska, a kod AKS
najčešće Ntg i analgetici (31,03%). Kod svih pacijenata (AP
i AKS) Ntg je ukupno primenjen u 12,42% slučajeva.
Zaključak. Pacijenti s postavljenom dijagnozom AP duže
trpe tegobe u grudima od onih sa AKS, a najčešće kao
samopomoć uzimaju lekove iz grupe antihipertenziva. Kao lek
prvog izbora prema mnogim preporukama nitroglicerin se
ređe koristi i pacijenti ga u većini slučajeva nemaju kod sebe.
Ključne reči: bol u grudima, primarna zdravstvena
zaštita, samomedikacija.
UVOD
Bol u grudima je jedan od najčešćih simptoma zbog
kojih se bolesnici obraćaju službama hitne pomoći i
urgentne medicine (1). Po poreklu bol u grudima u osnovi
možemo podeliti na visceralni i somatski. Visceralni bol je
poreklom iz površinskih struktura ljudskog organizma,
dok somatski vodi poreklo iz unutrašnjih organa (2).
Glavni zadatak lekara prilikom pregleda bolesnika s
bolom ili tegobom u grudima jeste da brzim, i
sistematskim pristupom ustanove moguće životno
ugrožavajuće uzroke bola, a to su najčešće infarkt
miokarda (IM), plućna embolija, disekcija aneurizme
aorte, ruptura aneurizme aorte i tenzioni pneumotoraks
(3). Među navedenim, kardiovaskularne bolesti (KVB), na
čelu sa IM, predstavljaju jedan od najčešćih uzroka bola u
grudima, sa učestalošću od oko 22% (4). KVB
predstavljaju jedan od najčešćih uzroka morbiditeta i
Primljen/Received: 08.04.2020. 27
Prihvaćen/Accepted: 27.04.2021.
doi: 10.5937/mckg55-26065
COBISS . SR - ID 44237833
UDK. 616.1/.2-083.98(497.11)"2014/2018"
ABSTRACT
Aim was to show the duration of chest pain in patients
with Angina pectoris (AP) and acute coronary syndrome
(ACS) prior to reporting to the ambulance as well as the
patients' self management of the pain.
Materials and methods. The study was done between 1st
August 2014th and 1st October 2018th in the infirmary of
EMS in Belgrade. The study involved 161 patients, out of
9437 patients in total, who were treated by one doctor and
with confirmed or suspected diagnosis of an ACS or AP.
Results. Patients with AP most commonly waited between
2-24 hours, while the patients with ACS waited <1h from the
pain onset until contacting EMS. Most patients with MI (17)
as well as with AP (79) did not take any kind of therapy, while
some patients administered one or more drugs in order to
relieve the pain. In patients with AP, the drugs of choice were
antihypertensive medications (17.42%) and in MI patients
Nitroglycerin and analgesics (31.03%). All patients
previously diagnosed with MI and AP have self-administered
Nitroglycerin in 12.42% of cases.
Conclusion. Patients with AP wait longer when having
chest pain before calling EMS from patients with ACS, but
their self-administered drugs of choice were antihypertensive
medications. Nitroglycerine as the first appropriate drug of
choice is used less and in most cases patients even do not
have it readily available.
Key words: chest pain, primary healthcare, self
medication.
mortaliteta u celom svetu, a prema izveštaju Instituta za
javno zdravlje Srbije „Dr Milan Jovanović Batut“ za 2017.
godinu (5) KVB predstavljaju vodeći uzrok smrti i među
obolelima u Srbiji, sa učestalošću od 52%, pri čemu je
17,4% smrtnih ishoda bilo uzrokovano ishemijskom
bolešću srca. Pravovremeno diferenciranje bola i
postavljanje dijagnoze veoma je važno jer omogućava
sprovođenje odgovarajućih metoda lečenja, pa i
revaskularizacionih metoda ukoliko je reč o akutnom
koronarnom sindromu (AKS), ali i smanjuje mogućnost
razvoja komplikacija ishemije i umnogome poboljšava
prognozu ovih bolesnika (1). S druge strane, prehospitalno
kašnjenje u postavljanju dijagnoze, bilo usled odloženog
javljanja obolelih službama hitne pomoći od trenutka
nastupanja tegoba (vreme kašnjenja u javljanju) bilo
kašnjenja usled produženog vremena transporta službama
hitne medicinske pomoći, smanjuje mogućnost
Marija M. Stevanović,
Devet Jugovića 14/18, Čačak,
tel 066/341549
st.maja.93@gmail.com,

Med. čas. 2021; 55(1): 27-32.
revaskularizacije i povećava mortalitet bolesnika (5–8).
Gradski zavod za hitnu medicinsku pomoć u Beogradu je
ustanova primarne zdravstvene zaštite i, osim što radi na
terenu, ima i svoje ambulante u kojima rade uglavnom
specijalisti opšte i urgentne medicine. Ambulante rade u
više krajeva grada noću, a ambulanta u centrali GZZHMP,
u kojoj je rađeno istraživanje, radi 24 sata dnevno bez
prekida u smenama od 12 časova. U ambulantu dolaze
građani koji ili smatraju da su tegobe koje imaju takvog
karaktera da nije razumno čekati ili imaju zdravstvene
potrebe zbog kojih nisu stigli da se jave svom lekaru u
ambulanti doma zdravlja.
Cilj rada je bio da se kod pacijenata kod kojih je
ambulantnim pregledom postavljena dijagnoza akutnog
koronarnog sindroma (AKS) ili angine pektoris (AP)
prikažu vreme trajanje bola u grudima pre javljanja u
ambulantu hitne medicinske i kojom su terapijom
bolesnici pokušali sami sebi da pomognu.
MATERIJAL I METODE
Istraživanje je rađeno u periodu od 1. avgusta 2014. do
1. oktobra 2018. u ambulanti Gradskog zavoda za hitnu
medicinsku pomoć (GZZHMP) u Beogradu. Istraživanje
je obuhvatilo 169 od ukupno 9.437 pregledanih bolesnika,
kojima je u ambulanti postavljena dijagnoza angine
pektoris ili akutnog koronarnog sindroma. Anamnestičkim
ispitivanjem bolesnika dobijeni su podaci o dužini trajanja
bola u grudima kod 161 bolesnika, dok za njih osam, koji
nisu ušli u statističku obradu podataka, nedostaje podatak.
Sve preglede je uradio jedan lekar, specijalista opšte
medicine. Anamnestički podaci o trajanju bola, njegovom
karakteru i propagaciji u druge delove tela, zajedno sa
objektivnim nalazom, prikupljani su prospektivno
unošenjem u bazu podataka, a potom je izvršena njihova
retrospektivna analiza. Objektivni nalaz obuhvata podatke
dobijene fizikalnim pregledom, snimanjem i analizom
elektrokardiografskog (EKG) zapisa, merenjem arterijske
tenzije. Diferencijalna dijagnoza AKS postavljena je
prema univerzalno prihvaćenoj definiciji, i to na osnovu
simptoma infarkta miokarda, karakterističnih promena na
EKG-u (ST elevacija / ST depresija [plića ili dublja]), ili
na osnovu novonastalog bloka leve grane, a u prisustvu
tegoba koje bi mogle da ukazuju na IBS (ishemijsku bolest
srca), dok povišenje vrednosti kardiospecifičnih enzima
nije bilo moguće odrediti u ambulantnim uslovima
GZZHMP. Kako u poslednjoj verziji MKB 10 ne postoji
šifra za entitet akutni koronarni sindrom (AKS), svi
pacijenti za koje se posumnjalo da imaju dati sindrom
poslati su u ustanovu sekundarnog/tercijarnog nivoa pod
šifrom I21 (akutni infarkt miokarda – AIM), dok su
pacijenti čije su tegobe odgovarale stabilnoj angini
upućeni dalje pod dijagnozom I20 (angina pektoris).
Deskriptivna statistika prikupljenih podataka urađena
28
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je u programu Spss11 for Windovs. Za ispitivanje nivoa
značajnosti korišćen je χ2 test, a nivo značajnosti iznosio
je 0,05. Rezultati su prikazani grafički i tabelarno.
REzULTATI
Ispitivana populacija obuhvata 103 osobe muškog pola
i 58 osoba ženskog pola starosti od 31 godine do 85
godina. Prema vrednostima χ2 = 13,64 (p < 0,01), veći je
udeo osoba muškog pola. Prosečna starost ispitivane
populacije iznosi 58,26 ± 11,86. Procentualna
zastupljenost bolesnika prema starosnim kategorijama
prikazana je u tabeli 1.
Nakon detaljnog fizikalnog pregleda i analize EKG-a
kod 29 (17,16%) bolesnika postavljena je diferencijalna
dijagnoza akutnog koronarnog sindroma (AKS), i to kod
pet osoba ženskog i 24 osobe muškog pola, dok je kod
preostala 132 bolesnika postavljena diferencijalna
dijagnoza Angina pectoris.
Kako su podaci o vremenskim intervalima čekanja pre
javljanja u ambulantu GZZHMP u Beogradu bili veoma
varijabilni, sva vremena smo podelili u četiri vremenske
kategorije (tabela 2) i izračunali njihovu učestalost kod
bolesnika kod kojih je postavljena dijagnoza AP, odnosno
AKS. Tom prilikom nađeno je da je među pacijentima sa
AP najveći procenat bolesnika čekao između dva i 24 h,
dok je kod bolesnika sa AKS najveći procenat čekao
između pet minuta i jednog sata od početka tegoba do
trenutka javljanja u ambulantu GZZHMP. Dobijeni
rezultati prikazani su tabelarno (tabela 3) i grafički (slika
1). Najkraće vreme čekanja kod svih bolesnika iznosilo je
pet minuta, a najduže deset i više dana.
Postoji statistički značajna razlika u učestalosti između
grupa pacijenata klasifikovanih po intervalima trajanja
tegoba (χ2 = 25,59), tj. najviše je pacijenata u grupi
pacijenata koji su pre javljanja lekaru čekali 2–24 sata (p
< 0,01).
Na osnovu anamnestičkih podataka o primenjenoj
terapiji od trenutka javljanja tegoba utvrđeno je da najveći
broj bolesnika kako sa AKS 17 (10,56%), tako i sa AP 79
(49,07%), nije uzeo nikakvu terapiju, dok su neki
bolesnici primenili jedan ili više lekova radi smanjenja
tegoba. Vrste primenjenih lekova podeljene po grupama i
učestalost njihove primene prikazani su u tabeli 4.
Od ukupnog broja bolesnika, njih 19 u svojoj
anamnezi ima dijagnozu prethodne AP. Od njih samo šest
pacijenata (14,64%) u svojoj terapiji ima propisan
nitroglicerin (slika 2) kao lek prvog izbora prilikom
javljanja bola u grudima srčanog porekla. Od 21 bolesnika
koji u anamnezi ima preležan infarkt miokarda samo njih
četiri imaju u terapiji propisan nitroglicerin (slika 2). Od
31 navedenog bolesnika sa pozitivnom anamnezom na
prethodne IBS, a bez propisane terapije nitroglicerinom,

Med. čas. 2021; 55(1): 27-32.
njih sedam (22,6%) ipak je primenilo Ntg
samoinicijativno ili im je Ntg kao pomoć dalo drugo lice.
Osim navedenog, u trenutku postavljanja dijagnoze
kod nekih bolesnika su postojala i patološka stanja poput
poremećaja ritma i provođenja, povišene vrednosti krvnog
pritiska u toku pregleda itd. U tabeli 5 su prikazane sve
pridružene dijagnoze kod ispitivanih bolesnika.
Deskriptivnom statističkom metodom dobijen je
podatak o prosečnoj starosti pacijenata prema polu,
Tabela 1. Zastupljenost pacijenata prema starosnim
kategorijama i polu
Tabela 2. Grupe pacijenata prema dužini trajanja
vremenskih intervala
Tabela 3. Čekanje u odnosu na postavljenu dijagnozu
AKS (I21) ili AP (I20)
Tabela 5. Pridružene dijagnoze
29
doi: 10.5937/mckg55-26065
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UDK. 616.1/.2-083.98(497.11)"2014/2018"
grupama sa različitim intervalima čekanja, kao i
postavljenim diferencijalnim dijagnozama. Dobijeni
podaci prikazani su grafički (grafici 3–5).
Nakon završene evaluacije i primenjene terapije svih
29 bolesnika sa AKS, kao i 115 sa AP upućeno je
specijalisti interne medicine u višoj nadležnoj
zdravstvenoj ustanovi na dalju dijagnostiku i terapiju.
Među bolesnicima sa AP u nadležnu zdravstvenu
ustanovu višeg nivoa na dalju opservaciju, dijagnostiku i
terapiju njih 17 je upućeno u pratnji lekarske ekipe, jedan
u pratnji transportne ekipe, dok su ostali po primenjenoj
terapiji i smanjenju ili gubitku tegoba upućeni u pratnji
porodice ili osoba s kojima su došli na pregled (slika 3).
Tabela 4. Terapija primenjena pre javljanja u ambulantu
 doi: 10.5937/mckg55-26065
COBISS . SR - ID 44237833
Med. čas. 2021; 55(1): 27-32. UDK. 616.1/.2-083.98(497.11)"2014/2018"

Slika 1. Vreme čekanja prema postavljenoj Slika 3. Grafički prikaz prosečne starosti pacijenata
diferencijalnoj dijagnozi prema polu

Slika 2. Prethodni IM, AP ili stent i terapija Ntg

Slika 4. Prosečna starost pacijenata prema vremenu Slika 5. Prosečna starost pacijenata prema postavljenim
čekanja diferencijalnim dijagnozama

Slika 6. Dalje upućivanje bolesnika s bolom u grudima i dijagnozom AP

30

Med. čas. 2021; 55(1): 27-32.
DISKUSIJA
U našem istraživanju bol u grudima se javljao češće
kod muškaraca (p < 0,01) (tabela 1), što je u skladu sa
studijom koju su sproveli N. J. Fothergill i sar., ali ne i sa
studijom C. C. Liaudat i sar., čije je istraživanje pokazalo
da se bol u grudima češće javlja kod osoba ženskog pola
(52,4%) (1, 9), kao i u radu Milovanović i sar., gde je nešto
više osoba ženskog pola ali bez statističke značajnosti
(10). Prosečna starost ispitivane populacije iznosi 58,26 ±
11,86 godina, što je u skladu sa istraživanjem M. Geyser i
sar., kojim je pokazana približno ista prosečna starost kod
ljudi s kardiogenim bolom u grudima, a koja je bila nešto
viša u odnosu na starosnu distribuciju bola u grudima
druge etiologije (4). Analizom podataka dobijeni su
rezultati koji upućuju na to da je ukupna učestalost bola u
grudima među osobama oba pola najveća kod pacijenata
starijih od 60 godina. Međutim, ukoliko analiziramo ovu
učestalost među različitim polovima, kao što su to učinili
N. J. Fothergill i sar., dobijamo podatak da je kod osoba
muškog pola najveća učestalost pojave bola u grudima
između 51. i 60. godine života (30,09%), dok se kod osoba
ženskog pola bol najčešće pojavljuje u starosnoj kategoriji
preko 60. godine (36,20%), što je u saglasnosti s
prethodno pomenutom studijom (1).
Kada je reč o dužini trajanja bola u grudima pre
javljanja u ambulantu GZZHMP, većina bolesnika s
bolom u grudima, a kasnije postavljenom dijagnozom AP
(37,12%), čekala je između dva i 24 h, što se razlikuje od
rezultata istraživanja Milovanović i sar., gde je najveći
procenat onih koji su zbog bola/tegoba u grudima najčešće
čekali do jedan čas da pozovu hitnu medicinsku pomoć iz
svog stana (10). U našem istraživanju je čekanje do jednog
sata bilo najizraženije u grupi bolesnika s kasnije
postavljenom dijagnozom AKS (37,93%). Vreme trajanja
tegoba kod bolesnika u našem istraživanju sa AKS u
korelaciji je s rezultatima koje su dobili Nilsson i sar. (11),
u okviru čijeg istraživanja je prosečno vreme
prehospitalnog kašnjenja iznosilo oko 5 h. Vreme
prehospitalnog kašnjenja, odnosno vreme trajanja tegoba
pre javljanja u zdravstvenu ustanovu u ovoj, ali i nekim
drugim studijama deli se na kašnjenje usled odloženog
javljanja i kašnjenje u transportu. Nemamo podatke o
tome kolika je bila udaljenost njihovih stanova od
GZZHMP, te samim tim ni koliko je bilo vreme kašnjenja
usled transporta do naše ustanove, te iz tog razloga nismo
diferencirali ove dve vrste kašnjenja, a transport iz
ambulante GZHMP do nadležnog Urgentnog centra traje
manje od 5–10 minuta sanitetskim automobilom. I u tom
smislu pacijenti dostižu moguću granicu za reperfuzionu
terapiju 90–120 minuta posle medicinskog kontakta (12).
Kada je reč o bolesnicima sa AP i njihovim prehospitalnim
kašnjenjem, pretraživanjem literature nismo uspeli da
nađemo podatke drugih studija o prehospitalnom
kašnjenju ove populacije. Pacijenti često izjavljuju da su
31
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se nadali da će bol proći sam od sebe ili usled
samoprimenjene terapije.
Od ukupnog broja bolesnika koji su uključeni u naše
istraživanje samo kod 18,01% postavljena je dijagnoza
AKS, dok je kod 81,99% obolelih postavljena dijagnoza
AP, te prema tome postoji statistički značajna razlika
između ove dve grupe (χ2 = 111,55 [p < 0,01]). Naši
rezultati nisu bili u skladu sa istraživanjima koje su
objavili A. Almas i sar. (12), kao i M. Geyser i sar. (4),
koja su među kardiogenim uzrocima bola u grudima
pokazala veću učestalost bolesnika sa IM u odnosu na AP.
Ovakve rezultate možemo objasniti činjenicom da su u
obe pomenute studije ispitanici pored rutinskog protokola
u ambulantnim uslovima (EKG, fizikalni pregled) bili
podvrgnuti i dodatnim analizama kao što su utvrđivanje
vrednosti kardiospecifičnih enzima, koronarografija,
ultrazvučni stres testovi, te je dijagnoza IM postavljena na
osnovu svih ovih parametara. Međutim, u našoj ispitivanoj
populaciji od svih bolesnika sa AP čak 87,12% upućeno je
specijalistima interne medicine radi dalje opservacije i
evaluacije, ali kako su upućeni u druge ustanove nismo
imali raspoložive povratne informacije o njihovoj
konačnoj dijagnozi (13).
Analizom anamnestičkih podataka o primenjenoj
terapiji pre javljanja u ambulantu HP uočili smo da većina
bolesnika kako sa postavljenom dijagnozom AP (59,85%),
tako i sa dijagnozom AKS (58,62%) nije uzela nikakav
oblik terapije. Deo njih je primenio nitroglicerin, potom
sedative, a onda i analgetike. Ovo je neobično i ne slaže se
sa istraživanjem koje su sproveli Petrov-Kiurski Milorank
i sar., gde se navodi da skoro 80% našeg stanovništva
primenjuje neke postupke samolečenja, tj. samopomoći u
raznim zdravstvenim stanjima (14).
U našem istraživanju lekove su najčešće uzimali
pacijenti s anginom pektoris, i to lekove za povišen krvni
pritisak – u 23 slučaja ili 17,42% od ukupno primenjene
terapije, što ukazuje na to da pacijenti pretpostavljaju da je
uzrok njihove tegobe u grudima povišeni krvni pritisak. U
literaturi se navodi da dobro upravljanje svojom bolešću
kod stabilne angine pektoris smanjuje učestalost pojave
angine, kao i upotrebu Ntg u svakodnevnim aktivnostima.
U našem slučaju najveći procenat pacijenata koji u
anamnezi imaju preležani infarkt miokarda, anginu
pektoris ili ugrađene koronarne stentove nema
nitroglicerin u svojoj terapiji, a i kada ga ima, koristi ga u
manjem procentu slučajeva za kontrolu bola u grudima
(slika 2) (15, 16).
Iako bolesnici s koronarnom bolešću imaju višestruko
veći rizik za nastanak IM i veću smrtnost od ostale
populacije, iz našeg istraživanja se ne vidi da ih lekari koji
ih kontrolišu dobro vode. Većina njih u terapiji nema
propisan nitroglicerin kao neophodan lek, niti ga
primenjuje za bol u grudima kada ga ima, kao što bi
trebalo. U istraživanju Sheikh-Taha M. i sar. o terapiji na

Med. čas. 2021; 55(1): 27-32.
otpustu iz bolnice, a kod bolesnika sa AKS, navodi se da
je, kao dalja terapija, samo za nepunih 20% pacijenata
propisan Ntg (17), tj. lek kojim bi kod tegoba u grudima
mogli sebi da pomognu.
zAKLJUčAK
Većina pacijenata s bolom u grudima javlja se u
zdravstvenu ustanovu u periodu 2–24 h od početka tegoba.
Najveći broj pacijenata sa AKS čeka do 1 h pre nego što
se javi u ambulantu, a sa AP 2–24 sata. Prilikom pojave
bola u grudima pacijenti pre javljanja lekaru najčešće kao
samopomoć uzimaju lekove koji pripadaju grupama
antihipertenziva. Nitroglicerin kao prvi lek, primeren za
ova stanja, koristi se u manjoj meri i pacijenti, pa ga ni i
oni s koronarnom bolešću u većini slučajeva nemaju.
LITERATURA
1. Fothergill NJ, Hunt MT, Touquet R. Audit of patients
with chest pain presenting to an accident and
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2. Stochkendahl MJ, Christensen HW. Chest pain in focal
musculoskeletal disorders. Med Clin North Am 2010;
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3. Opolot J. Chest pain: an approach for family practice.
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4. Geyser M, Smith S. Chest pain prevalence, causes, and
disposition in the emergency department of a regional
hospital in Pretoria. Afr J Prm Health Care Fam Med
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5. Jovanović V, ur. Zdravstveno-statistički godišnjak
Republike Srbije 2017. Beograd: Institut za javno
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7. Kushner FG, Hand M, Smith SC Jr, et al. 2009 focused
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patients with ST-elevation myocardial infarction
(updating the 2004 guideline and 2007 focused update)
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hospital delay in patients with first time myocardial
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strategic reperfusion early after myocardial infarction
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13. Almas A, Parkash O, Hameed A, Islam M. Emergency
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Dimitrijević Z, Akulov D, Radosavljević N, Kondić-
Jovanović N, et al. Studija o samolečenju pacijenata u
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2010; 16: 9–20.
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Med. čas. 2021; 55(1): 33-39. PREGLEDNI ČLANAK uDK. 616.22-006.4-06 616.32-008.1

SWALLOWING DISORDERS DURING AND AFTER THE TREATMENT OF

LARYNX CANCER
Mirna Zelic1, Mirjana Petrovic Lazic2, Dragan Pavlovic2
1Institute for Psychophysiological Disorders and Speech Pathology “Prof. dr Cvetko Brajović”, Belgrade, Serbia
2Faculty for Special Education and Rehabilitation, University in Belgrade, Belgrade, Serbia

POREMEĆAJI GUTANJA U TOKU I NAKON LEČENJA KARCINOMA

LARINKSA
Mirna Zelić1, Mirjana Petrović Lazić2, Dragan Pavlović2
1Zavod za psihofiziološke poremećaje i govornu patologiju „Prof. dr Cvetko Brajović“, Beograd
2Fakultet za specijalnu edukaciju i rehabilitaciju Univerziteta u Beogradu, Beograd

ABSTRACT
Dysphagia is a swallowing disorder that is characterized
by difficulty to swallow and to control saliva as well as by
feeding difficulties. Dysphagia is a common symptom of
laryngeal cancer, or a consequence of surgical treatment as
well as radiotherapy and chemotherapy of this neoplasma.
The patients after laryngectomy are at risk of developing
malnutrition, and aspiration pneumonia. Removal of
anatomical structures and reorganization of remaining
tissues has a significant impact on the physiology of
swallowing. For most patients, safe swallowing is the main
feature of a positive treatment outcome. Swallowing therapy
is important before, during and after treatment of larynx
cancer. The aim of this paper is to explore a correlation
between swallowing disorders and laryngeal cancer
treatment, and to understand the anatomical and
physiological bases of dysphagia treatment.
Key words: deglutition disorders; laryngeal neoplasms;
therapeutics.
INTRODUCTION
Dysphagia is defined as a swallowing disorder
including difficulty to swallow and control saliva as well
as by feeding difficulties. In the most general terms,
dysphagia encompasses all behavioral, sensory, and
preliminary motor actions in preparation for swallowing,
including the awareness of the impending feeding
situation, visual recognition of food, and increased saliva
production as a physiological response to food (1, 2).
Laryngeal cancer accounts for 40% of all head and
neck cancers, and 2% of all cancers in the body (3).
Statistics indicate that laryngeal cancer is four to five
times more common in men. In relation to localization, it
can be supraglottic, glottic and subglottic. The glottis is
affected in 60% of cases, the supraglottic in 35%, and the
other 5% includes subglottic structures (1, 4). Exogenous
risk factors influencing the occurrence of laryngeal cancer
are smoking, alcohol consumption, ionizing radiation,
mechanical and thermal damage to the laryngeal mucosa
as well as chronic laryngitis (5).
The symptoms of laryngeal cancer depend on their
location. Supraglottic carcinoma spreads rapidly and
SAŽETAK
Disfagiju definišemo kao poremećaj gutanja. Poremećaji
gutanja obuhvataju kako teškoće u gutanju i kontrolisanju
pljuvačke, tako i teškoće u hranjenju. Disfagija podrazumeva
čest simptom karcinoma larinksa, ali i posledicu hirurškog
lečenja kao i radioterapije i hemoterapije ove neoplazme.
Laringektomirani bolesnici su u riziku za malnutriciju i
pneumoniju. Uklanjanje ključnih anatomskih struktura i
reorganizacija preostalih tkiva ima značajan uticaj na
fiziologiju gutanja. Izbor tretmana lečenja za očuvanje
funkcije gutanja najvažnije je pitanje. Za većinu pacijenata
bezbedno gutanje je glavna odlika pozitivnog ishoda lečenja.
Tretman poremećaja gutanja je važna karika pre, u toku i
nakon lečenja. Cilj rada bio je da se utvrdi korelacija između
poremećaja gutanja, lečenja karcinoma larinksa,
laringektomije kao izbora lečenja, odnosno razumevanje
anatomskih i fizioloških osnova tretmana disfagija.
Ključne reči: poremećaji gutanja; tumori grkljana;
terapija.
metastasizes locally. The most significant symptom is
hoarseness, but it is not the earliest. The earliest symptom
is difficulty swallowing. In glottic carcinoma, hoarseness
of variable intensity is the earliest symptom, while
subglottic carcinoma does not give early symptoms,
except for difficulty breathing, i.e. inspiratory stridor and
later respiratory insufficiency. Carcinomas of the glottic
region have the best prognosis precisely because of the
appearance of early symptoms (5, 6).
Two primary approaches to the treatment of laryngeal
cancer are surgical treatment and radiotherapy and they
can be combined. Primary radiotherapy is less destructive
to tissue and can be used in early glottic cancer (7). If the
tumor is in the earliest stage, there are almost no side
effects, but if there is a larger amount of radiotherapy
(6,000-7,000 Gy), the side effects of radiotherapy are
related to phonation and swallowing problems due to
xerostomia, mucosal damage, thick saliva, loss of sense of
taste and smell, edema, inflammatory processes of the
gums and oral cavity. Chemotherapy is also applied before
surgical treatment or radiotherapy, i.e. as a combination
therapy with surgery. Despite the development of non-
surgical therapy to preserve organs, laryngectomy, total or

Primljen/Received: 02.03.2021. 33 Mirna Zelić

Prihvaćen/Accepted: 08.06.2021. Dragana Rakića 47, 11080 Beograd
Phone: +381 63 8295812
e-mail: mirnabzelic@gmail.com

Med. čas. 2021; 55(1): 33-39.
partial is still the optimal therapy for advanced disease as
the only option after unsuccessful radiotherapy.
Laryngectomy as such significantly changes the quality of
life with significant consequences for swallowing and
speech. The first laryngectomy was performed 150 years
ago, and while only a few ablative aspects have changed,
reconstructive techniques have undergone radical
evolution (8). The choice of treatment to preserve
swallowing function is the most important issue. For most
patients, safe swallowing is the main feature of a positive
treatment outcome.
This paper aims to explore the correlation between
swallowing disorders and laryngeal cancer treatment, with
its anatomical and physiological bases. A brief overview
of the normal physiology of swallowing is necessary to
further analyze the impact of laryngeal cancer on the
anatomical structures and functional basis of swallowing.
PHYSIOLOGY OF SWALLOWING
Eating and swallowing are complex motor actions and
include voluntary and reflex activities of as many as 30
muscles and five cranial nerves and have two biological
roles: 1) food transfer from the oral cavity to the stomach
and 2) respiratory protection (9).
Different authors point to different divisions of
swallowing phases. According to Logeman (1),
swallowing has four phases: a) preparatory oral, b) oral, c)
pharyngeal and e) esophageal. Other authors further break
down the oral phase into three more levels: food transfer
through the oral cavity, food processing by chewing and
saliva, and food transfer to the oropharynx. A rough
division into only three phases can be found in the
literature, namely oral, pharyngeal and esophageal (10).
Eating, swallowing, and breathing are closely related.
In healthy adults, breathing is interrupted during
swallowing due to both the physical closure of the airways
by lifting the soft palate and the closure of the epiglottis
and the neural control of respiration in the brainstem.
When sucking, the newborn swallows and breathes at the
same time. understanding the physiology and
pathophysiology of eating and swallowing are key to the
evaluation and treatment of swallowing disorders (11).
Preparatory oral phase
The patterns of movement in the preparatory oral
phase vary depending on the viscosity of the food, its
quantity as well as the degree of pleasantness (subjective
sense of taste). At the moment when the liquid is placed in
the mouth, the lips close, which requires nasal breathing,
and the posterior soft palate and tongue prevent premature
leakage of fluid into the pharynx. In the case of solid food,
the tongue rotates laterally by placing food on the teeth
due to chewing. At this stage, the food bolus is softened by
saliva (1, 9, 11).
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Oral phase
During the oral phase, the tip of the tongue is raised,
touches the alveolar ridge and the posterior part is lowered
and opens the passage to the pharynx. The dorsal surface
of the tongue moves upwards, expanding the area of
contact with the palate and pressing the fluid against the
palate. In the case of solid foods, the oral phase has the
role of completely preparing food and facilitating the
pharyngeal phase (1, 11).
Pharyngeal phase
The pharyngeal phase begins with the trigger of the
pharyngeal swallowing reflex. The velopharyngeal
sphincter rises and closes the path to the epipharynx, while
the suprahyoid muscles push the larynx up and forward,
and the epiglottis closes. Pushing the larynx forward and
under the base of the tongue also causes the adduction of
the vocal cords, which closes the glottis and thus prevents
the penetration of food inside the larynx and further into
the airways. These actions achieve separation of the
digestive and respiratory pathways, pharyngeal filling, its
passive emptying, and active pharyngeal muscle
peristalsis (1, 11)
Esophageal phase
The esophagus consists of striated and smooth muscles
and its role is to transfer food to the stomach. With
peristaltic movements, the food goes down. This is an
involuntary phase of swallowing and is slower than the
pharyngeal phase (1, 9, 11).
PATOPHYSIOLOGY
Normal swallowing physiology is achieved by changes
in pressure dynamics, tongue base and pharyngeal
contraction exerts positive pressure on the bolus while
simultaneously lifting the larynx anteriorly and superiorly
opening the pharyngoesophageal segment allowing the
bolus to pass into the esophagus. In patients with
laryngotomy, the interaction of the base of the tongue and
the contraction of the pharynx must compensate for the
pressure of the closed pharyngoesophageal segment in
order for the bolus to pass into the esophagus. This change
in the physiology of swallowing leads to a slowing of
bolus transit as well as to the accumulation of bolus
remnants in the pharynx and is more common in patients
who have also received chemotherapy (12).
Depending on the place of origin, we distinguish two
basic forms of dysphagia: oropharyngeal and esophageal
(13). Oropharyngeal dysphagia is an anatomically limited
term and implies difficulties in the transit of food from the
oral cavity to the pharynx and esophagus, where the

Med. čas. 2021; 55(1): 33-39.
spontaneous process of swallowing is initiated. As
swallowing is one of the vital functions in which the
larynx is involved, in order for the outcome of laryngeal
cancer treatment to be considered positive, the patient
needs to swallow efficiently and safely. Preservation of
swallowing functionality is usually the most important
goal of various surgical techniques (14).
Oropharyngeal dysphagia can be caused by damage to
the oral cavity, pharynx and larynx, and the damage can be
anatomical and functional. The location of the primary
tumor will determine the changes in the different phases of
swallowing. The larynx plays a central role in swallowing,
but lesions in the oral cavity will interfere with the
preparation of the bolus, its retention and transport to the
pharynx. Lesions in the pharynx and larynx can lead to
food aspiration (8).
INFLUENCE OF RADIOTHERAPY AND
CHEMOTHERAPY ON SWALLOWING
FUNCTION
Radiotherapy can cause mucositis and further
ulcerative changes and pain. These symptoms are mostly
temporary and will appear immediately in the first phase
of radiotherapy treatment. Xerostomia is the most frequent
and can last for years after radiotherapy, and fibrosis of the
neck tissue can also develop (15). The study showed that
radiotherapy (6500Gy) affects the following substructures
of the larynx: thyroid cartilage, cricoid cartilage,
epiglottis, suprahyoid epiglottis, infrahyoid epiglottis,
supraglottic and subglottic part of the larynx, arytenoid
cartilage, and arytenoid cartilage. Damage to these
structures even 12 months after radiotherapy can lead to
aspiration and swallowing disorders (16).
On the other hand, a study of the incidence of
swallowing disorders in patients treated with radiotherapy
alone showed that there were no significant changes in
swallowing function compared to patients treated with
both radiotherapy and chemotherapy (17). In patients
treated with radiotherapy and chemotherapy, the incidence
of swallowing disorders increased significantly over time
through reduced mobility of the base of the tongue, limited
movement of the tongue back and forth, reduced laryngeal
closure, reduced laryngeal elevation, bilateral pharyngeal
weakness, cricopharyngeal dysfunction (16). The study
also indicated that 3 months after the end of
chemotherapy, significant elements of swallowing
disorders still remain, such as limited tongue movements
back and forth and reduction of laryngeal elevation, and
that they persist for up to 12 months after the end of
chemotherapy. The amount of saliva dropped significantly
as a result of chemotherapy, from 5.68 g at the beginning
to 1.99 g after 3 months after the therapy and remained at
the same amount for 12 months after the therapy (1, 18).
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The latest study from 2020 included patients with
laryngeal cancer who were treated only with radiotherapy
and those treated with radiotherapy and chemotherapy.
Swallowing function was examined at the beginning,
followed by the examination after 6 weeks and three
months after the end of therapy. The study showed that
swallowing function decreased significantly both after 6
weeks and three months compared to the baseline status (19).
Studies on persistent symptoms of neck dysphagia,
xerostomia, and fibrosis over a period of 8 years in
patients after laryngeal cancer treatment with radiotherapy
and chemotherapy indicate that 60% of patients had
symptoms of dysphagia in the first year of therapy. That
percentage was reduced to 36% after the fifth year and
again increased to 48% after 8 years of follow-up.
Xerostomia was recorded in 87% of patients during the
first year, decreasing to 65% after 8 years of therapy,
generally remaining stable after the second year. Neck
fibrosis was recorded in 58% of patients one year after
therapy. The percentage decreased slightly to 54 during
the third year and increased again after 8 years. The results
of this study indicated delayed effects of toxins after
radiotherapy and chemotherapy (15).
INFLUENCE OF SURGICAL TREATMENT
OF LARYNGEAL CANCER ON
SWALLOWING FUNCTION
Surgical treatment of laryngeal cancer affects the
physiology of swallowing, depending on the type of
surgery that needs to be performed. Laryngectomies in the
broadest sense are divided into total and partial (19, 20).
PARTIAL LARYNGECTOMIES
Partial laryngectomies consist of partial vertical
laryngectomies, partial horizontal laryngectomies, and
atypical laryngectomies. Partial vertical laryngectomies
are used today in invasive glottic tumors. This group of
laryngectomies includes: transcervical chordectomy,
frontal partial laryngectomy, hemilaryngectomy, lateral
partial laryngectomy, frontolateral partial laryngectomy
and extended frontolateral partial laryngectomy (21).
Vertical partial laryngectomies are operations in which
one side of the larynx remains spared from resection or is
less resected, so it is possible that the laryngeal phase of
swallowing is delayed. The epiglottis, although a
supraglottic structure, is often used in the reconstruction of
defects made by resection of tumor tissue. The
relationship between the base and the tongue and the
vestibule is not disturbed, and one intact side of the larynx
retains its sphincter function. Patients with vertical partial
laryngectomy do not have significant swallowing
problems (7, 18).

Med. čas. 2021; 55(1): 33-39.
Swallowing problems in subtotal laryngectomies are
pronounced. According to Jović (18), the basic principles
of protection of the airway from bolus penetration, i.e.
lowering of the epiglottis through the entrance to the
larynx, sphincter closure and redirection of the bolus were
violated. The pharyngeal phase of swallowing is disturbed
and the patients aspirate their own saliva in the early
postoperative period. Feeding in the first 8 days is done
through a nasogastric tube and the rehabilitation begins
after that period. The rehabilitation is significantly longer
and amounts to 28.5 days.
Horizontal partial laryngectomy is applicable when the
tumor is limited to the supraglottis. This type of surgery
leads to laryngeal dysfunction. Supracricoid laryngectomy
involves resection of both vocal cords, paraglottic space
and thyroid cartilage. It is performed within the treatment
of early-stage cancer or localized advanced glottic and
transglottic cancer, while preserving the function of the
larynx, more precisely swallowing, breathing and
phonation (22).
There are two types of supracricoid partial
laryngectomy (SKL). The first involves resection of the
epiglottic and preepiglottic space and the second, which is
based on sparing them. The main principle is resection of
the vocal cords and ventricular folds as well as the entire
thyroid cartilage while sparing at least one arytenoid
cartilage. The first type of SKL refers to glottic tumors and
the epiglottis and preepiglottic space are spared, and the
space is reconstructed by suturing the cricoid cartilage to
the epiglottis, hyoid bone and the base of the tongue. This
procedure is called cricochiodoepiglotopexy. The second
type of SCL is used in supraglottic and transglottic tumors
where resection of the epiglottis and preepiglottic space is
performed and is reconstructed by suturing the cricoid
cartilage to the hyoid bone and the base of the tongue. This
procedure is called cricochiodopexy (7, 22).
Extended supraglottic laryngectomies are
interventions with the most intense swallowing disorder in
the postoperative period. Resection of the arytenoid or
resection of the base of the tongue are the most difficult
operative supraglottic procedures from the aspect of
postoperative functional problems with swallowing. The
authors state that partial resection of the base of the tongue
does not interfere with swallowing and that good
reconstruction makes the movements of the base of the
tongue and the rest of the larynx unrestricted. The average
length of swallowing rehabilitation of operated patients
with supraglottic laryngectomy is 5.6 days and the average
time of achieving good swallowing is 18.6 days, although
they state that recovery of swallowing function lasts up to
6 months after surgery (18).
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TOTAL LARYNGECTOMY
Total laryngectomy involves the removal of all the
structures that make up the anterior wall of the upper
digestive tract, including all the cartilage of the larynx,
epiglottis, hyodic bone, parts of the base of the tongue
together with the neck muscles. The remaining tissue
contains the pharyngeal mucosa and constrictor muscles.
The most common types of laryngectomy closure are T
closure and vertical closure. The direct relationship
between the type of closure and swallowing disorders is
not clearly defined, but the relationship between the type
of closure and pressure in the middle part of the pharynx
during swallowing is mentioned, as well as the presence of
pseudoglottis (14, 23).
Removal of key anatomical structures and
reorganization of remaining tissues has a significant
impact on the physiology of swallowing. The absence of
the larynx prevents the pharynx from shortening, the
esophagus opening and the development of negative
pressure, which helps the transit of the bolus. Bolus transit
is hampered by pharyngeal reconstruction. Studies
indicate increased intrabolic pressure in patients after total
laryngectomy which reflects increased resistance to bolus
transit through the newly reconstructed pharyngeal
segment (23). Studies indicate the presence of obstructive
structures such as a narrow lumen of the pharynx, the
formation of pseudoglottis, cricopharyngeal dysfunction
and strictures and stenosis, all of which interfere with the
transit and flow of bolus. Changes in esophageal motility
may be an additional factor in swallowing disorders in
patients with total laryngectomy (24). During total
laryngectomy, resection of the cricopharyngeal muscle is
performed, which is the main muscular component of the
upper esophageal sphincter, which after the procedure
affects the reduction of maximum pressure and the
duration of contractions during swallowing. By removing
the larynx, the upper esophageal sphincter changes shape
into a symmetrical ring, changing the ability to contract.
Since cricopharyngeal contraction initiates esophageal
peristalsis, changes in its function may explain the
reduction and duration of esophageal contraction. Some
authors believe that damage to the pharyngeal plexus,
which is responsible for motor innervation of the
esophagus, is also responsible for this (25).
Immediately after the intervention, additional
conditions occur that complicate the physiology of
swallowing. The study showed that 27% of total
laryngectomized patients experience additional
complications after surgical treatment, namely 1) edema
of the pharyngeal mucosa, which usually resolves
spontaneously within a few months of surgery; 2) fistulas
whose incidence varies from 4 to 75% of laryngectomized
patients; 3) functional barriers to bolus transit such as
stenosis, strictures, obstruction, the presence of

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pseudoepiglottis or areas of excess tissue "pockets" where
food and fluid accumulate, 4) return of nasal contents
reported in 9% of patients after laryngectomy and
explained is velopharyngeal incompetence; 5) poor
motility of the esophagus; 6) reflux; 7) changes in
language mobility in the region of the base (26, 27).
CRANIAL NERVE DAMAGE AND
SWALLOWING DISORDERS
Five cranial nerves are involved in the swallowing
process during the oral and pharyngeal phases:
n.trigeminus (V), n. facialis (VII), n. glossopharingeus
(IX), n.vagus (X) and n.hypoglossus (XII). If the listed
nerves are affected by tumors or damaged due to the
nature of the surgical intervention, they may be associated
with swallowing disorders (9). Cranial nerves involved in
swallowing send sensory information in nucleus Tractus
Solitarius. Motor components are organized in the
Nucleus Ambiguus, and together, Nucleus Tractus
Solitarius and Nucleus Ambiguus comrise the swallowing
center located in the medula in the brainstem, central
pattern generator (28).
The N.trigeminus (V) has a motor and sensory branch.
Motor innervation is directed to the masticatory
musculature (m.temporalis, m.masseter, m. Medialis
pterygoid, m.lateralis pterygoid), m. tensor tympani,
m.tensor veli palatini, m. digastricus (venter anterior), m.
mylohyoideus. The mandibular branch receives impulses
from the lower lip, tongue, lower teeth and cheek mucosa.
Damage to this nerve will significantly affect the function
of chewing and opening the mouth (11, 29, 30).
N.facialis (VII) innervates m.frontalis, m. orbicularis
oculi, m.orbicularis oris, m.patysma, has a function in
guttural innervation of the anterior two-thirds of the
tongue and sensibility of the eardrum. In case of damage,
it will give inadequate lip occlusion and salivation (11, 29).
N. glossopharingeus (IX) contains motor, sensitive
and parasympathetic fibers. Motor fibres innervate the
muscles of the soft palate and pharynx. They sensitively
innervate the mucous membrane of the last third of the
tongue, soft palate, pharynx, palatine tonsil and middle
ear and transmit stimuli to the senses of taste.
Parasympathetic fibers innervate the parotid salivary
gland. The nerve belongs to the pharyngeal plexus, which
controls the movement and constriction of muscles during
bolus flow (29).
The N. vagus (X) contains motor, sensory, and
parasympathetic fibers. It has a vegetative role and is
characterized by a wide innervation field. Motor fibers
innervate the transverse striated muscles of the soft palate,
pharynx and larynx. Sensitive fibers innervate the skin of
the external auditory canal, the mucous membrane of the
pharynx, epiglottis, larynx, trachea and digestive organs
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this nerve courses through the pharygeal and laryngeal
areas and can be injured during neck surgery. Recurrent
laryngeal nerve innervates upper Esophageal Sphincter
and several portions of superior pharingeal constrictors
(29, 30).
N. hypoglossus (XII) innervates the musculature of the
tongue and m.geniohyoideus. With unilateral paralysis of
the nerve, difficult tongue movements occur, while with
bilateral paralysis, it is completely immobile and chewing
is difficult (11, 29).
SCREENING AND DIAGNOSIS OF
SWALLOWING DISORDERS
Screening for dysphagia includes early detection of
signs and symptoms in patients who are at high risk of
developing swallowing disorders. Screening procedures
provide information on the presence of aspiration,
inadequate swallowing, the presence of food debris in the
mouth and pharynx, the presence of a hoarse voice, and
coughing during or immediately after a meal. The purpose
of screening is to determine the likelihood that swallowing
disorder exists as well as the need for further assessment
of swallowing (14, 31).
Examination methods can be instrumental or non-
instrumental. For patients with signs and symptoms of
pharyngeal dysphagia, instrumental examination methods
provide more objective findings. Instrumental techniques
are used to evaluate oral, pharyngeal, laryngeal, and
esophageal functions as well as to determine the
appropriateness and efficacy of treatment strategies (14).
Videofluoroscopy or modified ingestion of barium is a
radiological procedure that provides insight into oral,
pharyngeal and esophageal function. The most
comprehensive assessment of swallowing disorders and
the recognized gold standard is modified barium
ingestion. Fiberoptic endoscopic assessment of
swallowing is a procedure that can be performed in the
field but does not allow visualization of swallowing
phases such as video fluoroscopy. A pressure gauge that
monitors bolus pressure and creates pressure due to
contractions at different points of swallowing is combined
with video fluoroscopy for more accurate assessment and
is the most important procedure that can identify the exact
site of obstruction after laryngectomy (31-33).
TREATMENT OF DYSPHAGIA AND
QUALITY OF LIFE AFTER LARYNGEAL
CANCER TREATMENT
Swallowing disorders that affect 17-70% of patients
treated for laryngeal cancer occur due to the presence of
tumors and as a consequence of the treatment (34, 35). The
swallowing disorder is the main concern of patients after

Med. čas. 2021; 55(1): 33-39.
laryngeal cancer treatment because it affects the quality of
life. Improvement of swallowing function can be achieved
by treatment and swallowing exercises. Studies indicate a
correlation between the outcome of dysphagia treatment
and smoking as well as a correlation with different types
of surgery, after laser interventions dysphagia persisted for
a short time (36). The speech pathologist is an important
member of the multidisciplinary team in the treatment and
rehabilitation of people with laryngeal cancer and the field
of speech and swallowing therapy includes screening and
initial assessment, diagnosis and pre-treatment planning,
then treatment during the treatment and after the discharge
and patient education. Compensatory and strategic
techniques are used in the treatment of swallowing
disorders, while surgical intervention is rarely an option (9).
In this chapter, we will try to connect physiological
deficiencies, impaired swallowing function, compensatory
techniques and strategies, therapeutic maneuvers and
exercises after the laryngectomy (9, 32).
With total laryngectomy, we have no respiratory
problems, the airway is redirected, but due to obstruction
in case of stenosis, lack of pharyngoesophageal segment
and altered peristalsis, we use compensatory strategies:
changing posture, modifying the size and texture of the
bolus, lying on its side, swallowing more. Therapeutic
techniques and maneuvers used are opening the jaw while
providing resistance, swallowing with effort (9, 14).
Supraglottic laryngectomies are characterized by
incomplete movement of the base of the tongue, limited
movement of the arytenoids, partial closure of the airways,
impaired sensory function of the larynx. Swallowing is
impaired in terms of delayed bolus transit, difficulty in
lifting the structures involved in swallowing, reduced
airway protection, reduced glottis closure, reduced
pharyngeal clearance, weaker range of motion of the
tongue base. Compensatory techniques are tilting the
head, turning the head, lying sideways, modifying the
texture and size of the bolus. Therapeutic maneuvers and
exercises used are tongue retraction exercises, swallowing
with effort, Masako maneuver, supraglottic swallowing,
supersupraglottic swallowing (1, 32).
Supracricoid laryngectomies are characterized by a
loss of piriform sinus volume, a vocal cord membrane that
would close the anterior glottis, and a loss of ariepiglottic
and ventricular folds. Swallowing is impaired at the level
of bolus transit delay, dysfunction of lifting structures that
participate in swallowing, reduction of airway protection,
reduction of pharyngeal clearance. Compensatory
strategies are tilting the head, turning the head, modifying
the texture and size of the bolus, lying sideways.
Therapeutic techniques and maneuvers used are
supraglottic swallowing, supersupraglottic swallowing,
effort swallowing, tongue base retraction exercises (9, 14).
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In patients with hemilaryngectomy, there is unilateral
resection of the larynx and partial closure of the
respiratory organs. Impaired swallowing is at the level of
unilateral weakness of the pharynx, reduced protection of
the respiratory organs. Compensatory strategies are tilting
the head, turning the head, modifying the texture and size
of the bolus, lying sideways. Therapeutic techniques and
maneuvers used are muscle strength training during
expiration, vocal cord adduction exercises,
thyropharyngeal strengthening through phonation,
supraglottic swallowing, supersupraglottic swallowing,
swallowing with effort (14, 18).
CONCLUSION
The human larynx achieves a complex function united
through respiration, phonation and swallowing. Ingestion
is complicated by loss or damage to the larynx or damage
to motor and sensory function in addition to the side
effects of radio and / or chemotherapy. Screening
dysphagia after laryngectomy is often a missing link in the
postoperative course of rehabilitation. Complications with
partial laryngectomies can be silent aspiration and
recurrent pneumonia, while in half of the patients with
total laryngectomy, strictures, fistulas, and motility
disorders significantly affect their quality of life.
Swallowing treatment is important for patients undergoing
laryngectomy, they should be advised before surgery and
they should have a pretreatment of swallowing.
Prophylactic exercises can enable a better recovery. The
most important is the treatment after the surgery with
periodic evaluation in order to achieve optimal outcomes,
with possible education in the field of dietary
modification.
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A RARE CASE OF MELANOMA OF THE RECTUM HEMORRHOID NODULE

Vladimir Selakovic1, Milan Ranisavljevic1,2, Tijana Vasiljevic2,3, Bratislav Stoiljkovic3, Biljana Kukic2,4
1Oncology Institute of Vojvodina, Department for Operative Oncology, Novi Sad, Serbia
2Medical Faculty, University of Novi Sad, Novi Sad, Serbia
3Oncology Institute of Vojvodina, Department for Pathology Novi Sad, Serbia
4Oncology Institute of Vojvodina, Department for Internal Oncology, Novi Sad, Serbia

PRIKAZ SLUČAJA MELANOMA REKTUMA U HEMOROIDU

Vladimir Selaković1, Milan Ranisavljević1,2, Tijana Vasiljević2,3, Bratislav Stoiljković3, Biljana Kukić2,4
1Institut za onkologiju Vojvodine, Klinika za operativnu onkologiju, Novi Sad
2Medicinski fakultet, Univerzitet u Novom Sadu, Novi Sad
3Institut za onkologiju Vojvodine, Zavod za patologiju, Novi Sad
4Institut za onkologiju Vojvodine, Klinika za internu onkologiju, Novi Sad

ABSTRACT
Anorectal melanoma (AM) is an aggressive and very rare
malignancy. The aim of this case report is to present a case
of anorectal melanoma that occured in hemorrhoidal node
after a colorectal surgery.
A patient aged 69 years was treated at the Oncology
Institute of Vojvodina for histopathological (HP) verified
melanoma of the anorectum (S100, HMB45 and Melan A
positive) localized in the hemorrhoidal node. Wide local
excision was made. Three months after the operation
secondary deposits ocurred at the site of the colorectal
anasthomosis, stomach, lung and brain. Polymerase chain
reaction analysis of tumor DNA found no mutation in the
BRAF V600 gene. Five months after the operation the patient
is still alive and on supportive and symptomatic therapy.
Despite its rarity, AM should always be considered in
unusual anorectal lesions first at all in hemorrhoid nodules.
Key words: melanoma; rectum; haemorrhoids.
SAŽETAK
Anorektalni melanom je agresivan i redak tumor. Cilj ovog
prikaza slučaja bio je da se predstavi izuzetno redak slučaj
anorektalnog melanoma lokalizovanog u hemoroidu.
Pacijentkija stara 69 godina lečena je na Institutu za
onkologiju Vojvodine zbog patohistološki verifikovanog
melanoma anorektuma (S100, HMB45 I Melan A pozitivan)
lokalizovanog u hemoroidu. Operativno lečenje sastojalo se
od široke lokalne ekscizije. Tri meseca nakon operacije dolazi
do razvoja sekundarnih depozita na mestu kolorektalne
anastomoze, u želucu, plućima i mozgu. Analizom tumorske
DNK polimeraza lančanom reakcijom nije pronađena
mutacija BRAF V600 gena. Pet meseci nakon operacije
pacijentkinja je živa i na suporativnoj i simptomatskoj terapiji.
Uprkos malom broju slučajeva, uvek treba razmišljati o
anorektalnom melanomu kod nespecifičnih anorektalnih lezija,
prvenstveno hemoroida.
Ključne reči: melanom; rektum; hemoroidi.

INTRODUCTION CASE REPORT

Anorectal melanoma (AM) is an aggressive and rare
malignancy (1.7 cases per 1 million), despite the fact that
anorectum is the third most common mucosal site for
melanoma (1-3). Many authors have published multiple
isolated case reports, but clinical management strategies
do not exist because of the lack of randomized clinical
trials and its rarity.
Histological subtypes of AM are as follows: 44%
epitheloid, 31% mixed type, and 25% spindle cell
melanoma (4-6). Yap and Neary categorize AMs in the
following way: anal - if situated below the dentate line,
rectal - if located above the dentate line, and anorectal- if
located around the dentate line (7).
The aim of this case report is to present a rare case of
anorectal melanoma that occured in hemorrhoid node after
a colorectal surgery at the Oncology Institute of
Vojvodina.
Patient aged 69 years was treated at Oncology Institute
of Vojvodina for histopathological (HP) verified
melanoma of the anorectum in the period from 29th
September to 1st October 2020.
Initial colonoscopy of the patient was done on 24th
May 2019 where 15 centimeters (cm) from the
anocutaneous line (ACL) exophytic (saddle shaped) tumor
with broad base was seen, about 5 cm in diameter that
almost completely closed the intestinal lumen. HP analysis
confirmed well differentiated adenocarcinoma of the
colon. Magnetic resonance imaging (MRI) of the pelvis
was performed on 27th October 2019 and it described the
tumor (dimensions 3x2.9x2.7 cm) at the initial part of
sigmoid colon which completely filled the intestinal
lumen and highly infiltrated the muscular layer of the
anterior and right lateral wall with rare oval lymph nodes
in mesocolon. Computed tomography (CT) scans of the
chest and abdomen were without dissemination of the
primary disease.

Primljen/Received: 03.03.2021 40 Vladimir Selaković

Prihvaćen/Accepted: 04.07.2021. Adress: Put doktora Goldmana 4;21204 Sremska Kamenica; Serbia
Phone: +381 (0)21 480 5100
E-mail: selakovicvanja@gmail.com
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Operative treatment was performed on August 20 2019
when an anterior high resection of the rectum was
performed with the creation of termino-terminal
anasthomosis using double stapling technique. HP
analysis of specimen was adenocarcinoma at tubulovilous
adenoma (low grade), without metastases in lymph nodes
(0/12). TNM classification at the moment of operation was
pT1N0M0. The operative and postoperative course passed
without complications and the patient was discharged for
further home treatment on the 6th postoperative day. A
multidisciplinary team after the operation indicated
regular follow-up by the surgeon and an oncology
internist.
The patient was very well until July 2020, when she
come to the surgeon with the history of bleeding per
rectum. Control imaging finding (abdominal and thorax
CT performed on June 2020) was without the sings of
metastases. Control colonoscopy from 20/06/2020
described intact colorectal anasthomosis without sings of
local recurrence and/or rest of the tumor. One
thrombosishemorrhoid nodule above the ACL was
described. The surgeon performed digitorectal
examination and his finding was that patient
hasthrombosis hemorrhoid at the fingertips behind the
ACL and the patient was suggested surgical treatment
(hemorrhoidectomy) due to the pain in the rectum during
the examination as well as the presence of a larger amount
of fresh blood in the stool.
The patient underwent a hemorrhoidectomy in a
private health institution (July 24, 2020). The finding from
HP analysis of the specimen spoke in favor of partially
ulcerated melanoma of the anorectal mucosa (invasion

A B

Figure 1. Macroscopic findings. A – tumor prolapsed trough rectum; B – Surgical specimen

1 2

Figure 2. Microscopic findings. 1 - Histopathological analysis of the tumor showed nested spindle-shaped melanocites
with melanin rich cytoplasm (hematoxylin-eosin staining x 50); 2 - Immunohistochemistry confirmed melanocytic
nature of tumor cells, Melan A+ (immunohistochemical staining x 50).

41

Med. čas. 2021; 55(1): 40-44.
depth of up to 5 millimeters (mm)). Immunohistochemical
analysis registered tumor cells that are S100, HMB45 and
Melan A positive, which confirmed the HP diagnosis.
After the operative treatment, the patient contacted the
surgeon at the Vojvodina Institute of Oncology
(September 4, 2020) and still complained about the
bleeding from the rectum. Digitorectal examination
revealed a rest of the tumor localized at 8 h which is darker
stained and prolapsed through the rectum. A reoperation
was performed 30th September 2020. when a local
excision was made and HP analysis confirmed the
diagnosis of exulcerated and infiltrative melanoma. After
the discharge, the patient was clinically monitored by a
surgeon and an oncology internist and was without any
problems for some period.
Macroscopic and microscopic findings are shown on
Figures 1 and 2.
Three months after the reoperation, the patient came to
the surgeon due to profuse bleeding from the anus,
haemathemesis and general weakness. Digitorectal
examination was without sings of local relapses, so the
surgeon requested to for colonoscopy, gastroscopy, as well
as CT scans of the pelvis, abdomen, chest and head to be
performed.
Gastroscopy and colonoscopy were performed
(December 2, 2020) - the findings of gastroscopy
indicated at least 5 darker pigmented ulcerations up to 15
mm in diameter localized on the funds, currently without
signs of active bleeding. Two polypoid changes with a
diameter of about 20 and 30 mm were identified
colonoscopically in the area of the anasthomosis from
colorectal surgery (with the same characteristics like in the
stomach). The HP findings indicated that they were
melanoma metastases. Polymerase chain reaction analysis
of tumor DNA found no mutation in the BRAF V600
gene. Imaging diagnostics were performed on January 6,
2021. CT scans indicated a high number of newly formed
secondary deposits (the largest 25 mm in size) in lungs. In
abdomen, there were at least 4 nodular thickenings of the
gastric wall localized in the fundus region with
endoluminal propagation. CT of the small pelvis showed
significant wall thickening in the anastomotic region with
multiple regional lymph nodes. In head, there were at least
7 hyper dense changes with vasogenic perifocal edema
(secondary deposits) localized in the frontal, parietal and
occipital cortex.
Patient is still alive (five months after the operation)
and he is on supportive and symptomatic therapy.
DISCUSSION
Tumor thickness of more than 4 mm (Breslow
classification) is associated with more aggressive disease
forms in cases of cutaneous melanoma, but in cases of AM
42
doi: 10.5937/mckg55-31144
COBISS . SR - ID 44245513
UDK. 616.147.17-007.64-006.81
the data are inconsistent (4). The 5-year disease-specific
survival (DSS) is < 10% and the mean survival time is 12-
18 months in cases of AM.
Anal melanoma occurs mostly among females of older
age (≤55 years). Clinical presentation of the disease is
primarily hematochezia (primary symptom), pain and anal
mass. Anal melanoma is mostly located around the ACL,
including the ACL and the anal canal (4-6).
Zhang et al reported 216 cases of AM and concluded
that AM was more likely to be clinicaly benign. The
maximum diameter of the tumor was relatively small;
43.6% were polypoid and only 23.6% of the tumors were
invading the surrounding tissues. Many such tumors
produce melanin (70-80%) (8).
One additional problem with AM diagnosis is that a
high number of tumors (20-30%) is amelanotic and no
publication has compared pigmented with amelanotic
lesions due to the small number of cases. In the study from
Hillenbrand it is highlighted that “while not every dark
anorectal swelling is a malignant melanoma, not every
malignant melanoma is pigmented” and
immunohistochemical staining can be very useful in
diagnosing questionable lesions. Melanoma is positive for
S-100 protein, HMB-45 and vimentin. It is negative for
CEA, cytokeratin, and epithelial membrane antigen (3, 4,
6, 9, 10).
The appropriate evaluation of AM is minimally
detailed in the literature, but opinion is to make CT
scanning of the head, chest, abdomen, and pelvis (6, 10).
PET scanning can be reserved for lesions of indeterminate
nature on the CT scan, because its sensitivity tends to be
low otherwise (11). Endoluminal ultrasound and magnetic
resonance imaging could be useful when evaluating the
degree of rectal sphincter involvement and making
operative treatment decision (12). The value of endoscopy
in visualizing and sampling AM is obvious, and recent
publications have described endoscopic therapeutic
approaches (13).
Despite the fact that AM is a rare tumor with poor
diagnosis, patients are commonly misdiagnosed as heaving
haemorrhoids, like in our case, which is not an isolated
case (14-16). The early symptoms of AM resemble some
anorectal benign diseases, such as thrombosis
hemorrhoids, mixed hemorrhoids and rectal adenomas. In
the advanced stage, AM is similar to rectal cancer. Better
prognosis for AM is given when the tumor is located in the
mucosa and submucosa, and in such cases the tumor can be
treated by wide local excision (WLE) and in other cases
with abdominoperineal amputation (APR) (17).
AM is not sensitive to radiotherapy/chemotherapy and
surgical excision remains the only possible therapeutic
treatment. Data from different studies show no difference
in long-term survival and overall quality of life (2, 5-7, 13,

Med. čas. 2021; 55(1): 40-44.
17). In analysis from Yeh et al. who has compared APR
and WLE, the rates of local recurrence were 21% (APR)
and 26% (WLE) and the disease specific survival was
34% and 35%, respectively with no statistical differences.
Conclusion of the study was that the range of surgical
excision was not correlated with the prognosis (2).
In our cases we have decided to make WLE because it
has many advantages such as minor surgical trauma, quick
recovery, less effect on the function of the intestinal tract
and preservation of anal function. Our opinion is that
WLE should be the first choice of treatment, and APR can
be performed when WLE is impossible, when the surgical
margins of the specimen are positive, or in the cases of
tumor recurrence.
Biotherapy and chemotherapy are necessary
postoperative procedures, while AM is highly invasive
and metastases in lymph nodes or/and distal metastases
may occur. Cisplatin, catharanthine, or dacarbazine
combined with immunomodulators (interleukin-2 and
interleukin-α) can improve the survival status of some
patients (18).
In patients with positive lymph nodal status and
distand metastases, α-interferon and Interleukin-2 (IL-2)
have demonstrated a significant prolongation of relapse-
free-survival and overall survival, but with expressed
systematic side effects (haematological, autoimmune and
neuropsychiatric disorders) (19).
Novel immunotherapeutic strategies for metastasis are
having promising results and they are focused on immune
checkpoints. The patients with KIT-mutated metastatic
melanomas are amenable to single-agent therapy with one
of the kit inhibitors imatinib, dasatinib, sunitinib or
sorafenib (20).
Dabrafenib, vemurafenib and encorafenib are
classified as reversible ATP-competitive inhibithors with
selective inhibition on BRAF, MEK and MAP genes. In
approximately 50–70% of patients with mutation in BRAF
V600E or in V600K, these medications have demonstrated
their efficacy (21). Studying mutations in melanoma may
allow finding new target molecules to develop specific
treatments with better response. At melanomas with the
absence of BRAF V 600 mutation, the treatment of choice
in advanced, refractory forms is based on the use of
ipilimumab, alone or in combination with standard
chemotherapy (21).
Melanoma is a highly angiogenic tumor and in some
cases the antiangiogenetic treatment (bevacizumab
combined with nab-paclitaxel) has been proven to be a
potential strategy (22).
Despite its rarity, AM should always be considered in
unusual anorectal lesions, first at all in hemorrhoid nodule.
First line surgical method should be WLE, while in cases
of local relapses APR.
43
doi: 10.5937/mckg55-31144
COBISS . SR - ID 44245513
UDK. 616.147.17-007.64-006.81
REFERENCES
1. Weinstock MA. Epidemiology and prognosis of
anorectal melanoma. Gastroenterology 1993; 104:
174–8.
2. Yeh JJ, Shia J, Hwu WJ, et al. The role of
abdominoperineal resection as surgical therapy for
anorectal melanoma. Ann Surg 2006; 244: 1012–7.
3. Kohli S, Narang S, Singhal A, Kumar V, Kaur O,
Chandoke R. Malignant melanoma of the rectum. J
Clin Imaging Sci 2014; 4: 4.
4. Kobakova I, Stoyanov G, Popov H, et al. Anorectal
melanoma - a histopathological case report and a
review of the literature. Folia Med (Plovdiv) 2018; 60:
641-6.
5. Atak I. Anorectal malignant melanoma: retrospective
analysis of six patients and review of the literature.
Prague Med Rep 2018; 119: 97-106.
6. Pantalone D, Taruffi F, Paolucci R, Liguori P, Rastrelli
M, Andreoli F. Malignant melanoma of the rectum. Eur
J Surg 2000; 166: 583-4.
7. Yap LB, Neary P. A comparison of wide local excision
with abdominoperineal resection in anorectal
melanoma. Melanoma Res 2004; 14: 147–50.
8. Zhang S, Gao F, Chen LS, Tang ZJ, Liang JL, Wu Q.
Clinical analysis of anorectal malignant melanoma.
Zhonghua Weichang Waike Zazhi 2005; 8: 309–11.
9. Hillenbrand A, Barth TF, Henne-Bruns D, Formentini
A. Anorectal amelanotic melanoma. Colorectal Dis
2008; 10: 612–5.
10. Nunez Herrero L, Chaucer B, Zafar W, Davalos F,
Salman S, Naing S. Primary malignant melanoma of
the rectum: a case report of an extremely rare
gastrointestinal cancer. J Gastrointest Cancer 2016; 47:
494-6.
11. Maubec E, Lumbroso J, Masson F, et al. F-18
fluorodeoxy-D-glucose positron emission tomography
scan in the initial evaluation of patients with a primary
melanoma thicker than 4 mm. Melanoma Res 2007;
17: 147–54.
12. Li XT, Sun YS, Tang L, Cao K, Zhang XY. Evaluating
local lymph node metastasis with magnetic resonance
imaging, endoluminal ultrasound and computed
tomography in rectal cancer: a meta-analysis.
Colorectal Dis 2015; 17: 129-35.
13. Tanaka S, Ohta T, Fujimoto T, Makino Y, Murakami I.
Endoscopic mucosal resection of primary anorectal
malignant melanoma: a case report. Acta Med
Okayama 2008; 62: 421–4.
14. Liptrot S, Semeraro D, Ferguson A, Hurst N.
Malignant melanoma of the rectum: a case report. J
Med Case Rep 2009; 3: 9318.

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15. Turner G, Abbott S, Eglinton T, Wakeman C, Frizelle
F. Anorectal melanoma: not a haemorrhoid. N Z Med J
2014; 127: 73-81.
16. Zhang S, Gao F, Wan D. Effect of misdiagnosis on the
prognosis of anorectal malignant melanoma. J Cancer
Res Clin Oncol 2010; 136: 1401–5.
17. Che X, Zhao DB, Wu YK, et al. Anorectal malignant
melanomas: retrospective experience with surgical
management. World J Gastroenterol 2011; 17: 534–9.
18. Joyce T, Oikonomou E, Kosmidou V, et al. A
molecular signature for oncogenic BRAF in human
colon cancer cells is revealed by microarray analysis.
Curr Cancer Drug Targets 2012; 12: 873-98.
19. Malaguarnera G, Madeddu R, Catania VE, et al.
Anorectal mucosal melanoma. Oncotarget 2018; 9:
8785-800.
44
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UDK. 616.147.17-007.64-006.81
20. Perfetti V, Laurini E, Aulić S, et al. Molecular and
functional characterization of a new 3′ end KIT
juxtamembrane deletion in a duodenal GIST treated
with neoadjuvant imatinib. Oncotarget 2017; 8:
56158–67.
21. Ascierto PA, Minor D, Ribas A, et al. Phase II trial
(BREAK-2) of the BRAF inhibitor dabrafenib
(GSK2118436) in patients with metastatic melanoma.
J Clin Oncol 2013; 31: 3205–11.
22. Cui C, Mao L, Chi Z, et al. A phase II, randomized,
double-blind, placebo-controlled multicenter trial of
Endostar in patients with metastatic melanoma. Mol
Ther 2013; 21: 1456–63.
Med. čas. 2021; 55(1): 45-48.
INSTRUKCIJE AUTORIMA ZA PRIPREMU RUKOPISA
MEDICINSKI ^ASOPIS objavljuje na srpskom i
engleskom jeziku originalne nau~ne i stru~ne ~lanke, prikaze
slu~aja, revijske radove, pisma uredniku, prikaz objavljenih
knjiga i druge sadr`aje iz medicine i srodnih nauka.
Adresa za korespondenciju:
Medicinski ~asopis
SLD Podru`nica Kragujevac
Zmaj Jovina 30, 34000 Kragujevac
Tel. 034 372 169, tel./faks: 034 337 583
E-mail: medicinskicasopis@gmail.com
(slfskckg@nadlanu.com)
Rukopise treba pripremiti u skladu sa "Recommendations
for the Conduct, Reporting, Editing and Publication of
Scholarly Work in Medical Journals" (www.icmje.org) koje je
propisao Me|unarodni komitet izdava~a medicinskih ~asopsa.
Originalni rukopisi }e biti prihva}eni podrazumevaju}i da
su poslati samo MEDICINSKOM ^ASOPISU. Rukopisi koji
su prihva}eni za stampu postaju vlasni{tvo MEDICINSKOG
^ASOPISA i ne mogu se publikovati bilo gde bez pismene
dozvole izdava~a i glavnog urednika. MEDICINSKI
^ASOPIS ne objavljuje rukopise koji sadr`e materijal koji je
ve} bio objavljivan na drugom mestu, izuzev ako je u pitanju
sa`etak od 400 re~i najvi{e. Podneti radovi podle`u
nezavisnim, anonimnim recenzijama.
Rukopis
Rukopisi se podnose u elektronskoj formi putem
sistema ASEESTANT (SouthEast European Journals
Production Assistant) pristupom na link
http://aseestant.ceon.rs/index.php/mckg/login a samo
izuzetno na e-mail adresu ~asopisa. Rukopis treba da bude
pripremljen kao tekstualna datoteka (Word for Windows),
veli~ine A4 sa dvostrukim proredom (uklju~uju}i reference,
tabele, legende za slike i fusnote) i sa marginama 2 ili 2,5 cm.
Slo`eni grafi~ki prilozi (grafikoni, slike) mogu da se prilo`e
kao posebni, dopunski fajlovi.
Rukopis originalnog rada mora biti organizovan na
slede}i na~in: naslovna strana na srpskom jeziku, sa`etak na
srpskom jeziku, naslovna strana na engleskom jeziku, apstrakt
na engleskom jeziku, uvod, bolesnici i metode/ispitanici i
metode/materijal i metode, rezultati, diskusija, literatura,
tabele, slike, legende za i slike. Ako je potrebno zahvalnost,
napomene i konflikt interesa upisati na stranicu iza diskusije.
Struktura glavnog teksta drugih tipova rukopisa (pregledi,
prikazi slu~ajeva, seminari i drugo) se formira kako je
primenljivo.
Svaki deo rukopisa (naslovna strana, itd.) mora po~eti na
posebnoj strani. Sve stranice moraju biti numerisane po
redosledu, po~ev od naslavne strane.
Obim rukopisa. Celokupni rukopis rada, koji ~ine
naslovna strana, kratak sadr`aj, tekst rada, spisak literature,
svi prilozi, odnosno potpisi za njih i legenda (tabele, slike,
grafikoni, sheme, crte`i), naslovna strana i sa`etak na
engleskom jeziku, treba najvi{e da iznosi za originalni rad,
saop{tenje, rad iz istorije medicine i pregled literature od
45
5.000 do 7.500 re~i, a za prikaz bolesnika, rad za praksu,
edukativni ~lanak od 3.000 do 5.000 re~i; ostali radovi mogu
imati od 1.500 do 3.000 re~i; ostali prilozi mogu imati do 1.500
re~i.
Sva merenja, izuzev krvnog pritiska, moraju biti izrazena
u internacionalnim SI jedinicama, a ako je neophodno, i u
konvencionalnim jedinicama (u zagradi). Za lekove se moraju
koristiti generi~ka imena. Za{ti}ena imena se mogu dodati u
zagradi.
Naslovna strana
Naslovna strana sadr`i naslov rada, puna prezimena i
imena svih autora, naziv i mesto institucije u kojoj je rad
izvrsen, zahvalnost za pomo} u izvr{enju rada (ako je ima),
obja{njenje skra}enica koje su kori{}ene u tekstu (ako ih je
bilo) i u donjem desnom uglu ime i adresu autora sa kojim }e
se obavljati korespondencija.
Naslov rada treba da bude sa`et, ali informativan.
Ako je bilo materijalne ili neke druge pomo}i u izradi
rada, onda se mo`e sa`eto izre}i zahvalnost osobama ili
institucijama koje su tu pomo} pru`ile.
Treba otkucati listu svih skra}enica upotrebljenih u tekstu.
Lista mora biti ure|ena po azbu~nom redu (ili abecednom,
ako se koristi latinica) pri ~emu svaku skra}enicu sledi
obja{njenje. Uop{te, skra}enice treba izbegavati, ako nisu
neophodne.
U donjem desnom uglu naslovne strane treba otkucati
ime i prezime, telefonski broj, broj faksa i ta~nu adresu autora
sa kojim ce se obavljati korespodencija.
Stranica sa sa`etkom
Sa`etak sadr`i do 250 re~i. Za radove sa originalnim
podacima (originalni nau~ni rad, stru~ni rad i dr.) sa`etak
treba da je strukturisan sa slede}im paragrafima: cilj, metode,
rezultati, zaklju~ak. Za ostale tipove radova (pregledni
~lanak, pregled literature i dr.) sa`etak se dostavlja kao
jedinstveni paragraf. Na kraju sa`etka navesti najmanje 3
klju~ne re~i, prema terminima datim u MESH klasifikaciji.
Stranica sa sa`etkom na engleskom jeziku
Treba da sadr`i pun naslov rada na engleskom jeziku,
kratak naslov rada na engleskom jeziku, naziv institucije gde
je rad ura|en na engleskom jeziku, tekst sa`etka na
engleskom jeziku i klju~ne re~i na engleskom jeziku.
Stranica sa uvodom
Uvod treba da bude sa`et i da sadr`i razlog i cilj rada.
Bolesnici i metode/materijal i metode
Treba opisati izbor bolesnika ili eksperimentalnih
`ivotinja, uklju~uju}i kontrolu. Imena bolesnika i brojeve
istorija ne treba koristiti.
Metode rada treba opisati sa dovoljno detalja kako bi
drugi istra`iva~i mogli proceniti i ponoviti rad.
Med. čas. 2021; 55(1): 45-48.
Kada se pi{e o eksperimentima na ljudima, treba prilo`iti
pismenu izjavu u kojoj se tvrdi da su eksperimenti obavljeni
u skladu sa moralnim slandardima Komiteta za eksperimente
na ljudima institucije u kojoj su autori radili, kao i prema
uslovima Helsin{ke deklaracije. Rizi~ne procedure ili
hemikalije koje su upotrebljene se moraju opisati do detalja,
uklju~uju}i sve mere predstro`nosti. Tako|e, ako je ra|eno
na `ivotinjama, treba prilo`iti izjavu da se sa njima postupalo
u skladu sa prihva}enim standardima.
Treba navesti statisti~ke metode koje su kori{}ene u
obradi rezultata.
Rezultati
Rezultati treba da budu jasni i sa`eti, sa minimalnim
brojem tabela i slika neophodnih za dobru prezentaciju.
Diskusija
Ne treba ~initi obiman pregled literature. Treba
diskutovati glavne rezultate u vezi sa rezultatima objavljenim
u drugim radovima. Poku{ti da se objasne razlike izme|u
dobijenih rezultata i rezultata drugih autora. Hipoteze i
spekulativne zaklju~ke treba jasno izdvojiti. Diskusija ne
treba da bude ponovo izno{enje zaklju~aka.
Literatura
Reference se u tekstu oznacavaju arapskim brojevima u
zagradama. Brojeve dobijaju prema redosledu po kome se
pojavljuju u tekstu. Personalna pisma i neobjavljeni rezultati
se ne citiraju, ali se mogu pomenuti u tekstu u zagradi.
Skra}enice imena ~asopisa treba na~initi prema
skra}enicama koje se koriste u PubMed/MEDLINE-u.
Reference treba navoditi na slede}i na~in:
^lanak (svi autori se navode ako ih je {est i manje; ako ih
je vi{e, navode se samo prva tri i dodaje se "et al.")
12 - Talley NJ, Zinsmeister AR, Schleck CD, Melton LJ
3rd. Dispepsia and dyspeptic subgroups: A population -
based study. Gastroenterology 1992; 102: 1259-68.
Knjiga
17 - Sherlock S. Disease of the liver and biliary system.
8th ed. Oxford: Blackwell Sc Publ, 1989.
Glava i1i ~lanak u knjizi
24 - Trier JJ. Celiac sprue. In: Sleisenger MH, Fordtran
JS, eds. Gastrointestinal disease. 4th ed. Phil¬adelphia: WB
Saunders Co, 1989: 1134-52.
Podaci sa interneta
Citirati samo ako je neophodno na slede}i na~in: autor
(ako je poznat), naslov sadr`aja, grad u kome je sedi{te
autora/vlasnika internet stranice/sadr`aja, naziv autora/
vlasnika internet stranice/sadr`aja, godina kreiranja internet
stranice/sadr`aja i internet adresa (u zagradi). Podatke o
autoru/vlasniku preuzeti iz rubrike kontakt ili odgovaraju}e.
Autori su odgovorni za ta~nost referenci.
46
Tabele
Tabele se kucaju na posebnim listovima, sa brojem tabele
i njenim nazivom iznad. Ako ima kakvih obja{njenja, onda se
kucaju ispod tabele.
Slike i legende za slike
Sve ilustracije (fotografije, grafici, crte`i) se smatraju
slikama i oznacavaju se arapskim brojevima u tekstu i na
legendama, prema redosledu pojavljivanja. Treba koristiti
minimalni broj slika koje su zaista neophodne za
razumevanje rada. Slike nemaju nazive. Slova, brojevi i
simboli moraju biti jasni, pro-porcionalni, i dovoljno veliki da
se mogu reprodukovati. Pri izboru veli~ine grafika treba
voditi ra~una da prilikom njihovog smanjivanja na {irinu
jednog stupca teksta ne}e do}i do gubitka ~itljivosti. Legende
za slike se moraju dati na posebnim listovima, nikako na
samoj slici.
Ako je uveli~anje zna~ajno (fotomikrografije) ono treba
da bude nazna~eno kalibracionom linijom na samoj slici.
Du`ina kalibracione linije se unosi u legendu slike.
Treba poslati dva kompleta slika, u dva odvojena koverta,
za{ti}ene tvrdim kartonom. Na pozadini slika treba napisati
obi~nom olovkom prezime prvog autora, broj slike i strelicu
koja pokazuje vrh slike.
Uz fotografije na kojima se bolesnici mogu pre-poznati
treba poslati pismenu saglasnost bolesnika da se one objave.
Za slike koje su ranije ve} objavljivane treba navesti ta~an
izvor, treba se zahvaliti autoru, i treba prilo`iti pismeni
pristanak nosioca izdava~kog prava da se slike ponovo
objave.
Pisma uredniku
Mogu se publikovali pisma uredniku koja se odnose na
radove koji su objavljeni u MEDICINSKOM ^ASOPISU, ali
i druga pisma. Ona mogu sadr`ati i jednu tabelu ili sliku, i do
pet referenci.
Propratno pismo. Uz rukopis obavezno prilo`iti pismo
koje je potpisao korespondiraju}i autor, a koje treba da
sadr`i: izjavu da rad prethodno nije publikovan i da nije
istovremeno podnet za objavljivanje u nekom drugom
~asopisu, te izjavu da su rukopis pro~itali i odobrili svi autori
koji ispunjavaju merila autorstva. Tako|e je potrebno
dostaviti kopije svih dozvola za: reprodukovanje prethodno
objavljenog materijala, upotrebu ilustracija i objavljivanje
informacija o poznatim ljudima ili imenovanje ljudi koji su
doprineli izradi rada.
Napomena. Rad koji ne ispunjava uslove ovog uputstva
ne mo`e biti upu}en na recenziju i bi}e vra}en autorima da
ga dopune i isprave. Pre {tampanja prihva}enog rada svaki od
autora mora da dostavi izjavu o radu i prenosu izdava~kih
prava, svojeru~no potpisanu i datiranu, u skladu sa
uputstvima uredni{tva. Autori snose odgovornost za stavove
u svom radu. Srpsko lekarsko dru{tvo Okru`na podru`nica
Kragujevac odri~e svaku odgovornost za eventualnu {tetu
nastalu upotrebom informacija publikovanih u Medicinskom
~asopisu.
Med. čas. 2021; 55(1): 45-48.
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MEDICAL JOURNAL publishes original papers, case
reports, multi-center trials, editorials, review articles, letters
to the Editor, other articles and information concerned with
practice and research in medicine and related sciences,
written in the English or Serbian language.
Address for correspondence:
Medical Journal
Serbian Medical Society Section Kragujevac
Zmaj Jovina 30, 34000 Kragujevac, Serbia
Tel.: *381 34 372 169, Fax: *381 34 337 583
e-mail: medicinskicasopis@gmail.com,
(slfskckg@nadlanu.com)
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Publication of Scholarly Work in Medical Journals" developed
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The manuscript of the original article should be organized
in the following sections: title page, abstract, introduction,
patients and methods / subjects and methods / material and
methods, results, discussion, references, tables, figures, figure
legends. If necessary acknowledgement, notes and conflict of
interest should be written on a page after discussion. The
structure of the body text of other types of manuscripts
(reviews, case reports, seminars, etc.) is formed as applicable.
Each manuscript component (title page, etc.) begins on a
separate page. All pages are numbered consecutively
beginning with the title page.
Manuscript volume. The complete manuscript, which
includes title page, short abstract, text of the article, literature,
all figures and permisions for them and legends (tables,
images, graphs, diagrams, drawings), title page and abstract in
English, can have the length from 5000 to 7500 words for
original paper, report, paper on the history of medicine and
literature overview, while for patient presentation, practice
paper, educative article it can be from 3000 to 5000 words;
other articles could be from 1.000 to 3.000 words; other
contributions could be up to 1.500 words.
47
All measurements, except blood pressure, are reported in
the System International (SI) and, if necessary, in
conventional units (in parentheses). Generic names are used
for drugs. Brand names may be inserted in parentheses.
Title page
The title page contains the title, full names of all the
authors, names and full location of the department and
institution where work was performed, acknowledgments,
abbreviations used, and name of the corresponding author.
The title of the article is concise but informative, and it
includes animal species if appropriate.
A brief acknowledgment of grants and other assistance, if
any, is included.
A list of abbreviations used in the paper, if any, is
included. List abbreviations alphabetically followed by an
explanation of what they stand for. In general, the use of
abbreviations is discouraged unless they are essential for
improving the readabillity of the text.
The name, telephone number, fax number, and exact
postal address of the author to whom communications and
reprints should be sent, are typed at the lower right corner of
the title page.
Abstract page
Abstract contains up to 250 words. Manuscripts with
original data (original scientific work, professional work,
etc..) have the abstract structured with the following
paragraphs: objective, methods, results and conclusion. For
other types of papers (review article, literature review, etc.).
abstract is provided as a single paragraph. At the end of the
abstract at least 3 key words, should be provided, according
to the terms set out in the MESH classification.
Introduction page
The introduction is concise, and states the reason and
specific purpose or the study.
Patients and methods / Material and methods
The selection of patients or experimental animals,
including controls is described. Patients' names and hospital
numbers are not used.
Methods are described in sufficient detail to permit
evaluation and duplication of the work by other investigators.
When reporting experiments on human subjects, it
should be indicated whether the procedures followed were in
accordance with ethical standards of the Committee on
human experimentation of the institution in which they were
done and in accordance with the Declaration of Helsinki.
Hazardous procedures or chemicals, if used, are described in
detail, including the safety precautions observed. When
appropriate, a statement is included verifying that the care of
laboratory animals followed the accepted standards.
Statistical methods used, are outlined.
Results
Results are clear and concise, and include a minimum
number of tables and figures necessary for proper
presentation.
Med. čas. 2021; 55(1): 45-48.
Discussion
An exhaustive review of literature is not necessary. The
major findings should be discussed in relation to other
published works. Attempts should be made to explain
differences between results of the present study and those of
the others. The hypothesis and speculative statements should
be clearly identified. The discussion section should not be a
restatement of results, and new results should not be
introduced in the discussion.
References
References are identified in the text by Arabic numerals
in parentheses. They are numbered consecutively in the
order in which they appear in the text. Personal
communications and unpublished observations are not cited
in the reference list, but may be mentioned in the text in
parentheses. Abbreviations of journals conform to those in
PubMed/MEDLINE. The style and punctuation conform to
the Medical Journal style requirements. The following are
examples:
Article (all authors are listed if there are six or fewer;
otherwise only the first three are listed followed by "et al.")
12 - Talley NJ, Zinsmeister AR, Schleck CD, Melton LJ
3rd. Dyspepsia and dyspeptic subgroups: A population-based
study. Gastroenterology 1992; 102: 1259-68.
Book
17 - Sherlock S. Diseases of the liver and biliary system.
8th ed. Oxford: Blackwell Sc Publ. 1989.
Chapter or article in a book
24 - Trier JJ. Celiac sprue. In: Sleisenger MH, Fordtran
J5, eds. Gastro-intestinal disease. 4 th ed. Philadelphia: WB
Saunders Co, 1989: 1134-52.
Data from the Internet
Quote only if necessary as follows: author (if known), the
title of the content, the city where the headquarters of the
author/owner of the website/content is located, the name of
the author / name of the owner of the website/content, the
year of creating web pages/content and internet address (in
parentheses). Information about the author/owner of the
sections should be taken from the contact or other
appropriate section.
The authors are responsible for the exactness of
reference data.
Tables
Tables are typed on separate sheets with figure numbers
(Arabic) and title above the table and explanatory notes, if
any, below the table.
Figures and figure legends
All illustrations (photographs, graphs, diagrams) are to
be considered figures, and are numbered consecutively in the
text and figure legend in Arabic numerals. The number of
figures included is the least required to convey the message
of the paper, and no figure duplicates the data presented in
the tables or text. Figures do not have titles. Letters,
numerals and symbols must be clear, in proportion to each
other, and large enough to be readable when reduced for
publication. Figures are submitted as near to their printed
48
size as possible. Figures are reproduced in one of the
following width sizes: 8 cm, 12 cm or 17 cm, and with a
maximal length of 20 cm. Legends for figures should be given
on separate pages.
If magnification is significant (photomicrographs), it is
indicated by a calibration bar on the print, not by a
magnification factor in the figure legend. The length of the
bar is indicated on the figure or in the figure legend.
Two complete sets of high quality unmounted glossy
prints are submitted in two separate envelopes, and shielded
by an appropriate cardboard. The backs of single or grouped
illustrations (plates) bear the first author's last name, figure
number, and an arrow indicating the top. This information is
penciled in lightly or placed on a typed self-adhesive label in
order to prevent marking the front surface of the illustration.
Photographs of identifiable patients are accompanied by
written permission from the patient.
For figures published previously, the original source is
acknowledged, and written permission from the copyright
holder to reproduce it is submitted.
Color prints are available by request at the author's
expense.
Letters to the Editor
Both letters concerning and those not concerning the
articles that have been published in Medical Journal will be
considered for publication. They may contain one table or
figure and up to five references.
Cover letter. The letter which is signed by corresponding
author must be attached with the manuscript. The letter
should consist of: the statement that the paper has not been
published previously and that it is not submitted for
publication to some other journal, the statement that the
manuscript has been read and approved by all the authors
who fulfill the authorship criteria. Furthermore, authors
should attach copies of all permits: for reproduction of
previously published materials, for use of illustrations and for
publication of information about publicly known persons or
naming the people who contributed to the creation of the
work.
Note. The paper which does not fulfill the conditions set
in this instruction cannot be set to reviewers and will be
returned to the authors for amendments and corrections.
Before publishing of accepted paper each of the authors
must provide the statement about manuscript and copyright
transfer, personally signed and dated, according to the
instructions of the editorial office. Authors are responsible
for the statements in their article. Serbian Medical Society
Section Kragujevac disclaim any responsibility for any
damage caused by the use of information published in the
Medical Journal.
Proofs
All manuscripts will be carefully revised by the publisher's
desk editor. Only in case of extensive corrections will the
manuscript be returned to the authors for final approval. In
order to speed up the publication no proof will be sent to the
authors but will be read by the editor and the desk editor.
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Народна библиотека Србије, Београд

61
MEDICINSKI časopis = Medical journal /
glavni i odgovorni urednik Radiša Vojinović. -
God. 1, br. 1/2 (1961)- . - Kragujevac : Srpsko
lekarsko društvo, Okružna podružnica, 1961-
(Kragujevac : Spektar 7). - 30 cm

Dostupno i na: http://www.medicinskicasopis.org.

- Tromesečno. - Tekst na srp. (ćir. i lat.) i na engl.
jeziku
. - Drugo izdanje na drugom medijumu:
Medicinski časopis (Online) = ISSN 2406-0380
ISSN 0350-1221 = Medicinski časopis
COBISS.SR-ID 81751559
 ISSN 0350 - 1221

9 770350 122004

ISSN 0350-1221 = Medicinski časopis

COBISS.SR-ID 81751559