Professional Documents
Culture Documents
January/March 2015
Volume 21
Volume 21, Number 1, pp 1 - 80 January/March 2015
3
PUBLISHER Editor-in-Chief
Institute for Research and Development Mirza Dilić
Clinical Center University of Sarajevo
71000 Sarajevo, Bolnička 25 Editorial Board
Bosnia and Herzegovina
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500 copies Society of Cardiology
Content Medical Journal (2015) Vol. 21, No. 1
Original article
Evaluation of the intraoperative risk factors for deep vein thrombosis after knee arthroplasty ........................ 9
Amel Hadžimehmedagić, Ismet Gavrankapetanović, Đemil Omerović, Haris Vranić, Nermir Granov,
Faris Gavrankapetanović, Faruk Lazović
Relationship between nonenzymatic antioxidant component and free radical nitric oxide in patients with
schizophrenia ............................................................................................................................................................................... 17
Amra Memić, Abdulah Kučukalić, Lilijana Oruč, Jasminko Huskić, Lejla Burnazović, Nafija Serdarević
Professional article
Sarcopenia ................................................................................................................................................................................... 43
Ksenija Miladinović
Major trauma care at Clinic of Emergency Medicine of the Clinical Center University of Sarajevo ................. 47
Gjulera Dedović Halilbegović, Zoran Hadžiahmetović, Adnana Talić-Tanović, Samra Halilović, Lejla Aldžuz
Outcome of the surgical repair of high and intermediate anorectal malformations in children ........................ 51
Sejdi Statovci, Nexhmi Hyseni, Islam Rashiti, Murat Berisha, Antigona Hasani, Butrint Xhiha, Ali Aliu
Review article
European sterilization standards in the Clinical Center University of Sarajevo ...................................................... 59
Adnana Talić-Tanović, Aida Pitić, Mahir Trnka, Azra Muzurović
Case report
Recurrent aphthous ulceracions as an initial clinical and patohistological biomarker of Crohn’s disease ........ 66
Amira Dedić, Mersiha Avdić-Saračević, Ljiljana Kesić, Mia Hodžić, Alma Kantardžić
Heroin overdose caused by intranasal administration (sniffing) causes coma, rhabdomyolysis, acute kidney
failure and diffuse hepatopathy .......................................................................................................................................... 70
Amina Godinjak, Amer Iglica, Selma Jusufović, Anes Ajanović, Ira Tančica, Adis Kukuljac, Senad Pešto
Long term survival of unoperated patient with the left ventricular pseudoaneurysm .......................................... 73
Zlatko Šantić, Slobodan Kožul, Katica Mustapić-Šantić
* Corresponding author
ABSTRACT SAŽETAK
We researched the association between incidence of deep vein Istraživali smo povezanosti između incidence (DVT) nakon ar-
thrombosis (DVT) after knee arthroplasty and several intraoperative troplastike koljena sa jedne strane i izmjene promjera (mm) i brzina
risk factors: changes of diameter (mm) and flow velocity in posterior tib- protoka (cm/sec) u veni tibialis posterior (PTV) u simuliranim opera-
ial vein (PTV) in simulated operative positions; anesthesia duration, and tivnim položajima, te dužine trajanja anestezije i ukupne dužine trajanja
total duration of operative forced positions (min.). Average values of the prinudnih operativnih položaja (min.) sa druge strane. Prosječne vri-
ranges of PTV diameter were the greatest in simulated position 90°+ jednosti rangova dijametara PTV bile su najveće u simuliranom položa-
(3.9725) with statistical significant difference compared to other three ju 90°+ (3.9725) sa značajnom razlikom u odnosu na mjerenja u ostala
measurements (p<0,05). Average values of the ranges of flow veloci- tri položaja (p<0.05). Prosječne vrijednosti rangova brzina u PTV bile
ty in PTV were the greatest in simulated position „90°+“ (1.0000) with su najveće u simuliranoj poziciji „90°+“ (1.0000) sa značajnom razlikom
statistical significant difference compared to other three measurements u odnosu na ostala tri mjerenja (p<0.05). Analizom DVT i non-DVT
(p<0.05). Analysing DVT and non-DVT cases through receiver operat- slučajeva kroz receiver operating characteristic (ROC) odredili smo
ing characteristic (ROC) we got critical value of PTV diameter (cut-off: granične vrijednosti promjera (cut-off: >2.96 mm), i brzine protoka u
>2.96 mm), critical value for flow velocity (cut-off: ≤11.71 cm/sec), critical PTV (cut-off: ≤11.71 cm/sec), te granične vrijednosti trajanja anestezije
value for anestesia duration (cut-off: >185 min), and critical value for total (cut-off: >185 min), kao i ukupnog trajanja prinudnog položaja (cut-
duration of forced position (cut-off: >80 min). The greatest relative risk off: >80 min). Najveći relativni rizik (RR) za nastanak DVT RR=3.789
(RR) for DVT occurence RR=3.789 (p<0.0001) have had the patients (p<0.0001) imali su pacijenti kojima je operacija trajala duže od 185
with anesthesia duration more than 185 minutes. RR was very high at the minuta. RR je bio vrlo visok kod pacijenata kojima je prinudni položaj
patients with forced position duration more than 80 minutes (RR=2.992, trajao više od 80 minuta (RR=2.992, p<0.0001). RR je bio visok kod
p<0.0001). RR was moderately high at the patients with flow velocity in ispitanika kojima je protok u simuliranim pozicijama bio ≤11.71 cm/sec
simulated position „90°+” ≤11.71 cm/sec (RR=2.091, p<0.0001). We also (RR=2.091, p<0.0001). Također, značajan rizik imali su i pacijenti koji
noted a signifficant relative risk for vein diameter <2.96 mm in maximal su u maksimalnoj fleksiji imali dijametar PTV <2.96 mm (RR=1.312,
flexion (RR=1.312, p=0.0028). By the direct logistic regression we made p=0.0028). Direktnom logističkom regresijom napravili smo model
model to estimate influence of observed parameters on DVT occurence za procjenu uticaja posmatranih parametara na nastanak DVT koji je
which precisely classified 83.52% of patients. percizno klasificirao 83.52% pacijenata.
Key words: deep vein thrombosis, haemodynamics, knee arthro- Ključne riječi: duboka venska tromboza, hemodinamika, artroplas-
plasty, risk factors tika koljena, riziko- faktori
INTRODUCTION ready known. However, analyzes build upon the Virchow’s triad still
do not have a direct answer to the question whether the occurrence
We are witnesses of a daily progress in optimising surgical tech- of DVT is a result of dominant influence of one factor, or a result of
niques and strategics, anesthesiological improvements, and postop- cumulative action of several of them for long enough duration.
erative treatment progress. Intensive dynamics in practice requires It has already been proven that certain operative positions are
equal dynamics in research activities. Thus, the research of surgically leading to a complete interruption of venous flow (1). Also, there is
induced deep vein thrombosis (DVT) and its complications has be- well known evidence of association between increased age, obesity,
come a kind of a moving target. All the risk factors for DVT are al- a history of thromboembolism, varicose veins, contraceptive thera-
10 A. Hadžimehmedagić et al.
py, malignancy, Factor V Leiden gene mutation, general anaesthesia Average values of the ranges were the greatest in simulated po-
and orthopaedic surgery, with higher rates of postoperative DVT (2). sition 90°+ (3.9725) with statistical significant difference compared
We have researched the association between incidence of DVT to other three measurements (p<0.05).
after knee arthroplasty and several independent variables that we Analysing DVT and non-DVT cases through receiver operating
consider as intraoperative risk factors: changes of diameter (mm) characteristic (ROC curve) we got critical value of posterior tibial
and flow velocity in posterior tibial vein (PTV) in simulated operta- vein diameter (cut-off: >2.96mm). Sensitivity for cut off >2.96mm
tive positions; anesthesia duration, and total duration of intraopera- of posterior tibial vein in simulated position „900+“ (maximal flex-
tive forced positions (min.). ion) was 94.7%, specificity 27.8%, positive predictivity 25.7%, and
negative predictivity 95.2%. Accuracy was 41.8%, confidence in-
terval 0.400-0.613, and probability p<0.916. Area under the curve
MATERIALS AND METHODS (AUC) was 0.507 (Figure 1).
The longest forced position duration was 149 minutes, and the
shortest 46 minutes. Arithmetical middle values are presented in Ta-
ble 4.
FORCED POSITION N = 91 Na = 53 Nb = 38
The longest anesthesia duration was 271 minutes, and the short-
est was 92 minutes. Arithmetical middle values are presented in Ta-
ble 3.
ANEST. DURAT. N = 91 Na = 53 Nb = 38
DISCUSSION REFERENCES
There are several models of DVT risk assessment both for sur- 1. Warwick D. Thromboembolism in orthopaedics-observation and experiment. Ann
gical and nonsurgical patients. The most commonly used is Caprini R Coll Surg Engl. 2002;84(2):118-121.
score system which covers a risk assessment based on generalized in- 2. Edmonds MJ, Crichton TJ, Runciman WB, Pradhan M. Evidence-based risk factors
for postoperative deep vein thrombosis. ANZ J Surg. 2004;74:1082–97.
dividual characteristics (3). However, the specific intraoperative risk
3. Caprini JA. Risk assessment as a guide for the prevention of the many faces of
factors are still under-researched. Some of them should be consid-
venous thromboembolism. Am J Surg. 2010;199(1):3-10.
ered through the so-called dominant influence period of their dura- 4. Australian Government NHMRC. Clinical Practice Guideline for the Prevention of
tion (4). There are several studies that emphasize the influence of the Deep Vein Thrombosis and Pulmonary Embolism in Patients Admitted to Australian
duration of exposure to a particular risk factor for the occurrence of Hospitals. Commonwealth of Australia 2009.
postoperative DVT. Thus, the group of authors from the University 5. Hernandez AJ, De Almeida AM, Fávaro E, Sguizzato GT. The influence of tourni-
Hospital of Sao Paulo presented the fact that in 75% of patients with quet use and operative time on the incidence of deep vein thrombosis in total knee
arthroplasty. Clinics. 2012;67(9):1053-7.
DVT after total knee arthroplasty, surgery lasted more than 150 min-
6. Chann M, Hamza N, Ammori BJ. Duration of surgery independently influences
utes (5,6).
risk of venous thromboembolism after laparoscopic surgery. Surg Obes Relat Dis.
Study from the Clinic of Gynecology and Obstetrics in North 2013;9(1):88-93.
Carolina conducted on a sample of 411 patients showed that in- 7. Clarke-Pearson D, Maxwell L. Deep vein thrombosis in gynecologic surgery (Chap-
terventions completed within 120 minutes carry a 5% risk of DVT ter 95) in: Gynecology and Obsterics; Lippincot Williams&Wilkins 2004.
occurrence. Operations completed within 120-300 minutes carry a 8. Levine A, Huber J, Huber D. Changes in popliteal vein diameter and flow velocity
14% risk of DVT occurrence, and those longer than 300 minutes with knee flexion and hyperextension. Phlebology. 2011;26(7):307-10.
9. Westrich GH, Winiarsky R, Betsy M, Maun L, Sculco TP. Effect on deep vein throm-
carry 32% risk of postoperative DVT occurrence (7). The fact is
bosis with flexion during total knee arthroplasty. HSS J. 2006;2(2):148-53.
that postoperative DVT developed even when the risks according to
10. Huber DE, Huber JP. Popliteal vein compression under general anestesia. Eur J Vasc
existing scales of assessment are minimal, so we can discuss about Endovasc Surg. 2009;37(4):464-9.
the presence of insufficiently explored or incorrectly assessed risk
factors.
There are reports concerning the mechanical impact of joint po-
sitions on the morphologic and hemodynamic changes in the vein
(8,9,10). Reports of the cumulative impact of all known factors of
DVT initiation and occurrence of its manifest forms are expected.
CONCLUSIONS
*Corresponding author
ABSTRACT SAŽETAK
In some patients, dermatomyositis (DM) appears as a paraneo- Dermatomiositis (DM) se kod nekih bolesnika javlja kao parane-
plastic syndrome, however the incidence and factors that indicate the oplastični sindrom, međutim njegova učestalost i faktori koji ukazuju
coexisting malignancy still remain unclear. The purpose of our study na postojeći malignitet i dalje su nejasni. Svrha našeg istraživanja bila
was to investigate the connection of DM and malignancy and to iden- je ispitati povezanost DM i maligniteta i utvrditi faktore rizika koji
tify risk factors associated with cancer in this group of patients. Clin- su povezani sa tumorom u ovoj skupini bolesnika. Retroaktivno su
ical and laboratory data of 40 patients with DM, treated over a 30 pregledani klinički i laboratorijski podaci o 40 bolesnika s DM, koji su
year period (from 1985 to 2014) at the Clinic of Dermatovenerology liječeni u razdoblju od 30 godina (1985-2014) na Klinici za Dermato-
were reviewed retrospectively. The main recorded parameters in- venerologiju. Zabilježeni podaci obuhvaćali su: povezanost s tumor-
cluded: association with cancer, age, gender, presence of some clinical om, dob, spol, prisutnost nekih kliničkih znakova i biološke testove.
signs and biological tests. Statistical analysis was performed to inves- Statistička analiza je sprovedena s ciljem da se utvrde razlike između
tigate differences between patients with and without associated ma- bolesnika sa i bez postojećeg maligniteta. Prosječna dob bila je 55
lignancy. The mean age was 55 years and the sex ratio (female/male) godina, a omjer spolova (žene/ muškarci) iznosio je 1,2. Maligni tumori
was 1.2. Malignant tumors were detected in 10 (25%) patients (mean su otkriveni kod 10 (25%) bolesnika (srednja dob: 63,7 godina, odnos
age: 63.7 years, sex ratio=1). Malignancies related to colon cancer (3 spolova = 1). Maligne bolesti obuhvatale su tumor kolona (3 paci-
patients), ovarian cancer (3 patients) and the remaining cancers were jenta), tumor jajnika (3 pacijenta), dok su preostali maligni tumori bili
those of lung, breast, pancreas and prostate. Factors significantly as- tumori pluća, dojke, gušterače i prostate. Faktori značajno povezani
sociated with malignancy were cutaneous necrosis and elevation in s malignitetom su postojanje kožnih nekroza i povišene vrijednosti
muscle enzymes. Our data indicate that necrotic skin ulcerations and mišićnih enzima. Naši podaci pokazuju da su nekrotične ulceracije
high muscle enzyme levels are highly associated with a concomitant kože i visok nivoi mišićnih enzima značajno povezani s postojećim ma-
malignancy. An extensive search for malignancy should be provided lignitetom. Opsežno traganje za malignitetom trebao bi biti osiguran
in a subset of patients with DM, and predictive factors of malignancy. u podskupini bolesnika s DM i prediktivne čimbenike malignosti.
Key words: dermatomyositis, malignancy, risk factors, cutaneous ne- Ključne riječi: dermatomyositis, malignitet, faktori rizika, kožne
crosis, muscle enzymes nekroze, mišićni enzimi
INTRODUCTION tantly with DM and is discovered on the basis of clinical signs, symp-
toms or abnormal routine blood tests.
Dermatomyositis (DM) is an idiopathic inflammatory myopathy The association of DM and malignancy is greater than that in the
with characteristic cutaneous manifestations and proximal muscle general population (1,3-7) and in the first years following the disease
myopathy (1). A clinically distinct amyopathic variant with typical diagnosis (4,5).
skin signs but without muscle inflammation has been described as Many different clinical and serological signs have been suggested
well (2). as possible predictive factors for DM malignancy: older age (8-17),
However, due to a paraneoplastic syndrome DM may also be male gender (10,12,13,17), rapid onset of the disease (18), presence
associated with malignant disease, in particular ovarian, lung, pan- of cutaneous necrosis and periungual erythema (19-23), signs of se-
creatic, stomach, colorectal cancers and non-Hodgkin’s lymphoma verity (10,¸15,24), elevated erythrocyte sedimentation rate (ESR)
(3-7). In most cases, malignant disease precedes or occurs concomi- (17-19,25), rapid progression to muscle weakness (12,19,21,25),
14 A. Prohić et al.
Collected data was compared between patients with and with- 6 F 65 Definite Ovary Concomitant 18
Table 2 Comparison of demographic, clinical, and laborato- As suggested by some authors, the increase in risk of harboring
ry between DM with malignancy and without malignancy. a cancer is highest in the first year after diagnosis but can persist up
VARIABLE DM with malignancy DM without malignancy P value to five years (4,5). András et al. (34) have reported that neoplasias
(n = 10) (n = 30)
may precede myopathy by two years, while Maoz et al. (35) have
Mean age at DM diagnosis 63.7 ± 6.05 53.2 ± 6.92 0.248
Gender (F/M) 5/5 17/13 0.966 described malignancy in DM even after five years of disease.
Cutaneous manifestations
Photodistributed rash 10 (100%) 28 (93.3%) 0.836 These results support some propositions that patients with DM,
Gottron’s papule 9 (90%) 28 (93.3%) 0.790
Heliotrope rash 8 (80%) 26 (86.7%) 0.835
especially with a history of cancer should be subjected to a more
Cutaneos necrosis 8 (80%) 3 (10%) 0.001 aggressive cancer screening which may be difficult and expensive
Poikiloderma 6 (60%) 25 (83.3%) 0.896
Periungual erythema 6 (60%) 15 (50) 0.654 (2,18,32). Therefore, it might be important to define some risks fac-
Calcinosis 2 (20%) 11 (36.7%) 0.822
Vasculitis lesions 2 (20%) 7 (23.3%) 0.758 tors that indicate the coexisting malignancy in DM patients. Some
Muscle involvement
Clinical muscle involvement 9 (90%) 26 (86.7%) 0.792
authors have pointed out that paraneoplastic DM has specific clinical
Laboratory evidence of myositis signs and serologic evaluations compared with idiopathic form, sug-
CK 1236.2 ± 411.53 382.5 ± 139.61 0.001
LDH 684 ± 123.16 510.3 ± 80.51 0.046 gesting an association with cancer (7-27).
AST 188.2 ± 42.98 129.0 ± 20.26 0.032
ALT 169.4 ± 36.11 120.2 ± 16.24 0.019 We found that the age at diagnosis of paraneoplastic DM (64
Rapid onset
Signs of severity
4 (40%) 14 (46.7%) 0.875
years) was higher than that of idiopathic DM (53 years), but the dif-
Dysphagia 4 (40%) 14 (46.7%) 0.875 ference was not statistically significant, which may be due to the small
Dyspnoea 2 (20%) 11 (36.7%) 0.834
Arthritis/arthralgia 6 (60%) 14 (46.7%) 0.606 sample size. However, all patients with malignancy were over the
Laboratory findings
ESR (>40 mm/h) 8 (80%) 15 (50%) 0.179 age of 57, confirming that the risk of malignancy increased with age
CRP (>10 mg/L)
Positive ANA
5 (50%)
5 (50%)
14 (46.7%)
12 (40%)
0.791
0.588
(8-17). Moreover, only in multivariate analysis, older age at onset
(>45 years) has been proposed as predictive factor for developing
Data are given as number (percentage) of cases or mean value malignancy in DM with significant difference (12).
± 2 SD (Standard deviation), DM = dermatomyosits, CPK = cre- Malignancies were found in equal number in female and male, in
atine phosphokinase (normal values 10 - 120 IU/L), LDH = lactate agreement with a previous report (23), although majority of authors
dehydrogenase (normal values 105 - 333 IU/L) , AST = aspartate reported paraneoplastic DM more frequently in male gender, even
aminotransferase (normal values 10 to 34 IU/), ALT = alanine ami- as predictive factor for developing cancer (10,12,13,17). Contrary
notransferase (normal values 10 to 40), CRP = C-reactive protein; to these findings, Sigurgeirsson et al. (4) showed that the neoplasias
ESR = erythrocyte sedimentation rate. affect predominantly women.
Although the development of necrotic lesions in the context of
DM is a rare occurrence, some previously published studies indi-
DISCUSSION cated that DM patients with cutaneous necrosis faced a significantly
higher risk of malignancy (19, 21-23). Including our trial, cutaneous
An association between DM and malignancy was first suggested necrosis is thought to increase the probability of occult malignancies
in 1916 (29) and since than some population-based cohort (3-5) and in 80% of cases associated with cancer, opposite to 10% cases of DM
many retrospective studies (6-27) variously reported an incidence without cancer. The results of our study highlight this clinical parame-
of malignancy. Large population-based epidemiologic studies from ter, which can be easily identified by a dermatologist, and is probably
Sweden, Finland, Denmark, Scotland, Australia, and Taiwan have one of the most important indications for a detailed investigation
shown an overall increased incidence for malignancies at the same of underlying cancer in DM. Other skin findings such as periungal
time or after the diagnosis of myositis with a frequency from 9% to erythema, hyperkeratotic follicular papules and vesiculo-bullous le-
42% (30). In our study, malignancies were found in 25% of patients, sions have been proposed as markers of underlying cancer, even as a
in accordance with a study of Whitmore et al. (2), and compara- marker of poor prognosis and aggressive internal malignancy, partic-
ble to many other studies, reporting frequencies between 22-28% ularly in gynaecological malignancies (36).
(6,15,17,20,21,24,25,27). Some authors have reported higher fre- We found that DM patients with malignancy had elevated mus-
quencies of underlying cancers which may be explained by a large cle enzyme levels, especially elevated level of CPK. The validity of
number of patients with DM included in large population based stud- this criterion has been confirmed by most formerly published trials
ies (3-5). On the contrary, two studies conducted in Brazil reported (18,23) but is contrary to some studies that normal muscle enzyme
a significantly lower incidence of malignancy in DM with frequency of levels tend to be a risk factor in developing cancer (2,3,7). Although
6.8% and 6.4%, respectively (31,32). the number of patients included in our study was small, this may give
The type of malignancy also varies depending on the age, gender a tantalizing clue as to serum markers for predicting malignancy in
and geographical location. DM patients.
According to Western literature, the malignancies most strongly Identifying DM patients who face a high risk for malignancy is
associated with DM are ovarian and breast carcinoma in women and important from a public health and clinical perspective as this identi-
lung and prostate carcinoma in men (3-5). However, nasopharyngeal fication would facilitate early detection of malignancy and treatments
carcinoma has been reported as the predominant cancer associated as well. Therefore, further prospective studies with larger sample
with DM in many Asian countries (11,12,17). We observed that the are needed to clarify which clinical and biological examination is fre-
types of malignancies found in association with DM parallel those quently considered predictive of cancer. Depending on these results,
previously described in an age-matched general population in our dermatologists will be able to perform more comprehensive cancer
country (33). screening to detect malignancy in an early, potentially treatable stage.
16 A. Prohić et al.
*Corresponding author
ABSTRACT SAŽETAK
Findings in schizophrenia (Sch) include elevated nitric oxide (NO) Kod shizofrenije (Sch) je dokazana povećana razina nitričnog
production and imbalanced serum level of bilirubin as an indicator of oksida (NO) i neuravnotežen nivo bilirubina u serumu, kao in-
nonenzymatic antioxidant component. The aim of this study was to in- dikatora ne-enzimskih antioksidativnih komponenti. Cilj ovoga
vestigate possible interaction between NO and bilirubin. The study was rada bio je istražiti moguću interakciju između NO i bilirubina.
consisted of 50 patients with Sch and 50 healthy controls. In both of Istraživanje je uključilo 50 pacijenata oboljelih od Sch i 50 zdravih
groups we investigated the levels of NO which is determined by conver- kontrola. U obje grupe određen je nivo NO, konverzijom nitra-
sion of nitrate to nitrite using elemental zinc and then measuring con- ta u nitrite koristeći elementarni cink, a zatim mjerenje koncen-
centration with Greiss reagent. However, in the group of patients who tracije s Greiss reagensom, a u grupi pacijenata koji boluju od
are suffering from Sch we measured the mean levels of total bilirubin Sch određen je nivo ukupnog bilirubina (TBI) pomoću Dimension
(TBI) using Dimension (Siemens) clinical chemistry system, within the (Siemens) kliničkog hemijskog sistema, u odnosu na tok bolesti.
course of illness. Statistically significant differences are present between Statistički signifikantna razlika je prisutna između toka oboljen-
the course of illness and total bilirubin, where the maximum value is ja i nivoa bilirubina, gdje su najviše vrijednosti u vezi sa prvom
presented with respect to first hospitalization. Correlation between hospitalizacijom. Korelacija između ukupnog bilirubina i NO kod
total bilirubin and NO for patients with Sch was small (R2= 0.12758), pacijenata sa Sch bila je mala (R2 = 0,12758), a umjerena (R2
while for patients with positive psychotic symptoms that we accrued = 0,3068) kod pacijenata sa pozitivnim psihotičnim simptomima
using the scale for the assessment of positive and negative symptoms koje smo dobili upotrebom skale za procjenu pozitivnih i nega-
(PANSS) the correlation is moderate (R2=0.3068). Our results confirm tivnih simptoma (PANSS). Naši rezultati potvrđuju hipotezu da se
the hypothesis that the antioxidant capacity in patients with Sch decreas- antioksidativni kapacitet kod pacijenata sa Sch smanjuje sa napre-
es with the progress of the disease. Increased bilirubin consumption may dovanjem bolesti. Povećana potrošnja bilirubina može biti rezul-
be resulting from increased oxidative stress that accompanies sch. Possi- tat povećanja oksidativnoga stresa koji prati Sch. Kod Sch moguća
bility of relationship between NO and bilirubin participates in Sch. je povezanost između NO i bilirubina.
Key words: schizophrenia, nitric oxide, total bilirubin Ključne riječi: shizofrenija, nitrični oksid, ukupni bilirubin.
INTRODUCTION a large number of articles that investigate oxidative stress, and the
potential role of nitric oxide (NO) in the pathophysiology of Sch
Schizophrenia (Sch) is a serious mental disorder consisting of and a lot of evidence of altered antioxidant capacity in patient who
specific psychopathological symptoms that are consequence of dis- suffer from Sch (1, 2, 3). Nitric oxide is a simple, gas permeable
turbed biochemical processes of the brain. This implies a general membrane, a distinctive chemistry that transmits signals in the in-
tendency toward disorganization and deterioration of personality. tra and intercellular space, synthesized under the influence of nitric
The findings confirm the participation of biological factors in the oxide synthase enzyme that catalyzes the oxidation of L-arginine to
pathogenic processes that underlie this serious and complex disor- L-citrulline and nitric oxide (4, 5, 6). In the brain, the neurotrans-
der but etiopathogenic process remains unknown. Today we have mitter actions of NO are believed to impact the processes of
18 A. Memić et al.
learning and memory. There are enormous proofs in recent years MATERIALS AND METHODS
that nitric oxide plays an important role in the pathophysiology of
schizophrenia. NO has a neuroprotective role in excess neurotox-
The study was consisted of inpatients (n=50) who suffering from
ic because free-radical mediated abnormalities may play a role for
Schizophrenia (Sch) according to DSM-IV diagnostic criteria con-
the progress of a number clinically significant consequences includ-
firmed by Structured Clinical Interview (SCID 1) treated in Psychiat-
ing well-known negative symptoms (7). Surplus, NO production
ric Clinic, Clinical Centre University of Sarajevo (KCUS) and healthy
further leads to alteration of neuron structure and function that
controls (n=50). To assess the presence of positive and negative
includes neuronal membrane damage and increased appearance of
psychopathology symptoms, Positive and Negative Syndrome Scale
lipid peroxidation. Akyol et all. (8) show important role of oxy-
was also applied to each patient. Exclusion criteria from the study
gen free radicals in the pathophysiology of the abovementioned
were: individuals younger than 18 years and older than 65, any infor-
disorder. At the same time they do not exclude the potential role
mation in the history of past or current psychiatric comorbidity, and
of antioxidants in therapeutic purposes (8, 9). Until recently, biliru-
information about substance abuse, chronic somatic disease, diabe-
bin was considered a degradation product of hem, but in the last
tes mellitus, hypertension, gastrointestinal disorders, impaired renal
twenty years many papers claim that the bile pigments with strong
or pancreatic function, neurological disorder, cataract, inflammatory
antioxidant activity are able to prevent cell damage caused by reac-
or autoimmune disease. The study was carried out with the approval
tive nitrogen species as well as better known peroxynitrite result-
of the local Ethic Committee of KCUS and both of groups had con-
ing in excess NO that undergoes oxidation /reductive reactions
firmed their voluntary participation by signing an informed consent
(6). Interesting scientific fact is that bilirubin acts as an endogenous
after being given a complete description and protocol of the study.
scavenger of NO and RNS and the protective role of it induces
other reactive species within the cellular milieu, giving him the role
Laboratory investigation
of antioxidant that is reduced in patients suffering from schizophre-
nia (10, 11, 12), as the total antioxidant capacity is impaired as well.
The samples of patient blood were collected in serum separa-
Several studies have recently investigated the interaction of biliru-
tor Vacutainer test tubes (Becton Dickinson, Rutherford, NJ 07,070
bin, the final product of hem catabolism, which plays a crucial role
U.S.) in volume of 3.5 mL. We used test tubes with gel. Serum sam-
in protecting cells from oxidative and nitric repetitive stress, and
ples were obtained by centrifugation at 3000 rpm using centrifuge
NO, the gas involved in many psychological functions that is able to
(Sigma 4-10). The patients and controls were fasting 12 hours be-
induce cytotoxicity and cell death if produced in excess. Donors of
fore laboratory testing. After centrifuging, serum concentration of
nitric oxide induced expression of hem oxygenase-1 in endotheli-
total bilirubin was determined. The total bilirubin (TBI) levels were
al cells (13). The specific nitric oxide scavenger hydroxocobalamin
measured using Dimension (Siemens) clinical chemistry system. It is
reduces the activity of endothelial hem oxygenase. Moreover, nitric
an in vitro diagnostic test intended to quantitatively measure TBI in
oxide-mediated induction of hem oxygenase-1 was significantly re-
human serum. Bilirubin (unconjugated) in the sample is solubilized
duced with N-acetyl-cysteine precursor of glutathione syntheses
by dilution in a mixture of caffeine/benzoate/acetate/EDTA. Upon
by stabilizing nitric oxide through the formation of S-nitrosothi-
addition of the diazotized sulfanilic acid, the solubilized bilirubin
ol group. These results indicate that reactive derivative of nitric
including conjugated bilirubins (mono and diglucoronides) and the
oxide is associated with nitric oxide mediated induction of hem
delta form (biliprotein-bilirubin covalenty bound to albumin) is con-
oxygenase-1. Accordingly, peroxynitrite (ONOO-) strong oxidant
verted to diazo-bilirubin, a red chromophore representing the total
formed in the reaction of nitric oxide with superoxide anion was a
bilirubin which absorbs at 540 nm and is measured using bichromatic
powerful inducer of expression of hem oxygenase-1. Peroxynitrite
(540,700 nm) endpoint technique (16). The serum TBI was mea-
also increases apoptosis and induces cytotoxicity, while a scavenger
sured at Institute for Chemistry and Biochemistry, Clinical Centre
of peroxynitrite reduces this effect. It is interesting that pretreat-
University of Sarajevo.
ment of endothelial cells with hemin inducer of hem oxygenase-1
increased the production of UCB and reduced apoptosis mediated
The determination of nitric oxide
peroxynitrite. Furthermore, the resources that released nitric ox-
ide and peroxynitrite are causing decay in plasma concentration of
The concentration of NO in blood was done with measure-
direct bilirubin and biliverdin. These findings suggest that UCB and
ment of nitrate and nitrite using colorimetric Greiss reaction (17).
biliverdin protects cells from damage caused by the uncontrolled
The concentration of NO in serum was determined by conversion
creation of nitric oxide (14).
of nitrate (NO¯3) to nitrite (NO¯2) using elemental zinc and then
The formation of bilirubin-nitric oxide compound has not
colorimetric measurement of nitrite (NO¯2) (µmol/L). We took 1
happened only in the reconstituted system, but was confirmed in
mL of blood, added 8 mg of elemental zinc solved in 0.4 mL of de-
fibroblasts of rats exposed to pro-oxidant stimuli. These results
ionized water, after this we added 0.032 ml 5% CH3COOH (acetic
provide insight into the antioxidant properties of bilirubin through
acid) and tilled 2 ml deionized water. We mixed the sample for 5 min
its interaction with the gaseous neurotransmitter nitric oxide with
using vortex at room temperature and centrifuged it for 2.5 min at
well-known dual effect, the neuroprotective under physiological
700 rpm. We took 1 mL of supernatant and 1 mL of Greiss reagent
conditions, or if produced in excess of neurotoxic effects, and pro-
and mixed it for 10 min in vortex at room temperature. After 10 min
pose that bilirubin-nitric oxide as a new biomarker of oxidative/
of mixing we have measured light absorption (optical density) with
nitrosative stress (15).
spectrophotometer at 546 nm. The concentration of nitrate and ni-
Relationship between nonenzymatic antioxidant component and free radical nitric oxide in patients with schizophrenia 19
Statistical analysis
N 50 50
Age 38.4±1.77 34.56±1.53 Figure 2 Correlation between the levels of total bilirubin
Sex 15M/35F 18M/32F and NO concentration in the blood of patients suffering
from schizophrenia.
SANS-Total (mean ±S.D) 23.82(±9.962) -
gether with the total antioxidant capacity. From the results obtained, CONCLUSION
we can conclude that there are serious deregulation of oxidative
and antioxidative metabolism system during schizophrenia and in- Increased bilirubin consumption may be resulted from an in-
creased oxidative stress and decreased bilirubin which is endowed creased oxidative stress which is accompanying sch. Future research
with a strong antioxidant activity, both of which may be relevant to should analyze blood samples and compare values of NO and bili-
the pathophysiology of Sch which is quite consistent with the work rubin depending on clinical symptoms, psychopharmacotherapy and
of Mancuso et al. (11) who explained this mechanism in some other consist out of larger sample sizes.
illnesses, such as atherosclerosis, liver disease and neurodegenera-
tive disorders. Our results are consistent with the results of Hui- Conflict of interest: none declared.
chun et al (18) who found increased levels of nitric oxide in patients
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*Corresponding author
ABSTRACT SAŽETAK
Osteoporosis is a thinning of the bones that occurs over time Osteoporoza je smanjenje mase koštanog tkiva koji se javlja tokom
for most people. Building and maintaining bone mass requires a vremena za većinu ljudi. Izgradnja i održavanje koštane mase zahtijeva
combination of nutrients and physical activity. Building bone den- kombinaciju hranjivih tvari i fizičku aktivnost. Izgradnja gustoće kostiju u
sity in early childhood is the best way to prevent osteoporosis lat- ranom djetinjstvu je najbolji način za sprečavanje osteoporoze kasnije.
er. Risk factors are numerous and there is no unique cause of the Faktori rizika su mnogobrojni, a nema jedinstvenog uzroka bolesti. Ciljevi
disorder. The aim of this study was to determine the influence of istraživanja: utvrditi uticaj bavljenja sportom, pojave sniženih vrijednosti
sports, the occurrence of vitamin D deficiency and low calcium on D vitamina i kalcija na mineralnu gustoću kostiju i pojavu osteoporoze.
bone mineral density and occurrence of osteoporosis. Patients and Pacijent i metode rada: studija je uključivala grupu od 286 pacijenata sa
methods: the study involved a group of 286 patients diagnosed with dijagnozom osteoporoze i osteopenije na Klinici za nuklearnu medici-
osteoporosis and osteopenia at the Clinic of Nuclear Medicine of nu Kliničkog centra Univerziteta u Sarajevu, starosti 30-65 u periodu
the Clinical Center University of Sarajevo (CCUS), age 30 to 65 od 12 mjeseci. Studija je bila prospektivna. Svakom pacijentu su uzeti
over a 12 months period. The study was designed as prospective. anamnestički podaci, te se pristupilo dijagnostičkoj proceduri: mjeren-
For each patient we did personal history and diagnostic procedure: je mineralne gustoće kostiju (BMD) na lumbalnoj kičmi i proksimalnom
bone mineral density (BMD) at lumbar spine and proximal femur, femuru, tjelesna težina i indeks tjelesne mase (BMI), deficijencija D vita-
weight and body mass (BMI) presence of risk factors for osteopo- mina i hipokalcemija, prisutnost faktora rizika za osteoporozu i tjeles-
rosis, mineralogram and physical activity. Results of investigation: no vježbanje-fizička aktivnost. Rezultati istraživanja: mineralna gustoća
low bone mineral density (BMD) is independent predictor of hip kostiju (BMD) predstavljaju nezavisne prediktore rizika fraktura kuka i
fracture risk and spinal column or other fractures. BMD depends kičmenog stuba ili drugih fraktura. BMD je u zavisnosti od vrijednosti
on the value of minerals and vitamin D. Weight and body mass minerala i vrijednosti vitamina D. Tjelesna težina i indeks tjelesne mase
(BMI) are associated with low bone mineral density and may af- (BMI) su povezani s niskom mineralnom gustoćom kostiju te mogu
fect the bone structure or bone degradation. Risk factors for the utjecati na strukturu kostiju ili degradaciju istih. Kod mlađih pacijenata
prediction of osteoporosis and fractures have been less thorough- pojava osteoporoze i prijeloma se manje temelji na prisustvu faktora
ly studied in younger patients. In patients who are still actively in- rizika. Pacijenti koji se još uvijek aktivno bave tjelesnim vježbanjem pojava
volved in sports osteoporosis is uncommon, and occurs in 8% of osteoporoze je mala, kod 8% pacijenata. Za razliku od pacijenata koji
patients, while it occurs in 57% of patients lacking physical activity nemaju fizičku aktivnost 57% ili se umjereno bave tjelesnim vježbanjem
and in 35% of patients with moderate physical activity. We evaluat- osteoporoza se javlja u 35% slučajeva. Evaluirali smo povezanost između
ed the connection between weight and body mass index (BMI). Ac- tjelesne težine i indeksa tjelesne mase (BMI). Aktivno bavljenje fizičkim
tive sports, maintenance of body weight, varied nutrition, sufficient aktivnostima, održavanje tjelesne težine, raznovrsna ishrana, dovoljno
intake of calcium and vitamin D, and sun exposure can increase unošenje kalcija i D vitamina, te izlaganje suncu mogu povećati gustoću
bone density and prevent fractures. kostiju i spriječiti frakture.
Key words: bone mineral density, osteoporosis, BMI, physical activ- Ključne riječi: mineralna gustoća kostiju, osteoporoza, BMI, fizička
ity, vitamin D deficiency aktivnost, nedostatak vitamina D
INTRODUCTION and hip, although any bone can be affected (1). The current opinion
is that childhood and adolescence are critical periods for building up
bone mineral density. It is also known that life style factors, such as
The skeletal disease of bone thinning and compromised bone physical activity, may influence the accrual of bone mineral density
strength, osteoporosis, continues to be a major public health issue (2). Mechanical loading has been shown to be one of the best stimuli
as the population ages. This disease is characterized by bone fragility to enhance not only bone mass but also structural skeletal adapta-
and an increased susceptibility to fractures, especially of the spine tions, both independently contributing to bone strength (Figure 1).
Osteoporosis and physical activity 23
According to the World Health Organization (WHO) T-score Prevalence of osteoporosis in physical activity according to the
Means are as follows: BMI.
• T-score of -1.0 or above is normal bone density. I group: physical activity was registered in 58% (n=165) of patients,
• T-score between -1.0 and -2.5 means you have low bone diagnosed osteopenia in 95%, osteporosis in 5% of patients.
density or osteopenia II group: moderate active was registered in 23% (n=65) patients,
• T-score of -2.5 or below is a diagnosis of osteoporosis. diagnosed osteopenia in 68%, osteporosis in 32% of patients.
Body Mass Index (BMI) is a number calculated from a person’s III group: lack of physical activity was registered in 19% (n=56) of
weight and height. Body mass index (BMI) is a predictor of fracture patients, diagnosed osteopenia in 11%, osteporosis in 89% of pa-
risk. Body Mass Index is a number calculated from a person’s weight tients (Figures 4 and 5).
and height. BMI is a reliable indicator of body fatness for most peo-
ple and is used to screen for weight categories that may lead to
health problems. The values of the recommended BMI are the same
for both sex, it is 18.5 to 24.9 kg /m2.
Patients were divided in three groups based on duration of their
physical activity:
Group I: Three times a week or more,
Group II: Once a week,
Group III: No physical activity
Serum calcium and D vitamin were measured using standard
methods. The normal adult value for calcium is 2.10-2.55 mmol/L. Figure 4 Physical activity.
Hypocalcemia is an electrolyte imbalance and is indicated by a
low level of calcium in the blood. The normal range of vitamin D
(25(OH)D) is 30–50 ng/ml.
RESULTS
The study included 286 patients, 189 women and 97 men, divid-
ed into three age groups: 30-40, 40-50 and 50-65 years (Table 1).
DISCUSSION
With regard to physical activity, 165 (58%) patients were active, by age 30, therefore, physical activity and obtaining the recommend-
65 (23%) patients were moderately active and 56 (19%) patients ed doses of calcium and vitamin D in adolescence and young adult
were not active. will ensure peak bone mass development (24). In the daily reference
Prevalence of osteoporosis at physical activity according to the intake should be 800–2000 i.j. per day. The normal range of vitamin
BMI was as follows: I group: physical activity was registered in 165 D (25(OH)D) is 30–50 ng/ml (9, 25).
(58%) patients, osteopenia was diagnosed in 95%, and osteporosis The amount of these bone minerals within our bones is referred
in 5% of patients. II group: moderate active was registered in 65 to as our bone mineral density (BMD). Our BMD is highest when we
(23%) patients, osteopenia was diagnosed in 68%, and osteporosis are aged in our 20s, and then as we get older we gradually lose some
in 32% of patient. III group: lack of physical activity was registered in of the important minerals, causing our BMD to decline. If this loss
56 (19%) patients, osteopenia was diagnosed in 11%, and osteporo- of minerals is excessive, our BMD will become very low, and we will
sis in 89% of patients. develop osteoporosis (26).
BMI 17-19: there were 58% (n=165) of physically active pa- Characterized by weak and brittle bones, osteoporosis and its
tients, the frequency of osteopenia was registered in 95% (n=157) precursor osteopenia affect 44 million patients bone fractures ev-
while the occurrence of osteoporosis was registered in 5% (n=8) of ery year. Life Health care providers are vital to identify patients at
patients. BMI 23- 26: there were 23% (n=65) of moderately active risk for bone loss and diagnose bone thinning so that prevention
patients, the frequency of osteopenia was registered in 68% (n=44) and treatment strategies are effective. Prevention of falls with main-
while the osteoporose was registered in 32% (n=21) of patients. tenance of bone health through adequate calcium, vitamin D, and
BMI 26-30: in (n=56) 19% of inactive patients occurrence of osteo- physical activity represent the base of the pyramid for all individuals,
penia was registered in 11% (n=7) of cases, and the occurrence of including those with bone disease (27, 28). Peak bone mass is usually
osteoporosis in 89% (n=49) of patients. achieved by age 30, therefore, physical activity and obtaining the
In our study value of D vitamin was 14,1 to 42,12 ng/ml de- recommended doses of calcium and vitamin D in adolescence and
pending on the BMI, diet and physical activity. The calcium values young adulthood will ensure peak bone mass development (29).
ranged from 2,0 to about 2.355 mmol/L, depending on osteoporo-
sis or osteopenia.
A primary factor associated with risk of osteoporosis is the CONCLUSION
maximal BMD of the skeleton (peak bone mass) developed during
childhood and early adult years (11). The age of bone mineralization We concluded that the low BMI is a risk of substantial impor-
onset and the age of attainment of peak bone mass vary, according tance for all fractures that is largely independent of age and sex, but
to gender and the bone region being studied. Peak bone mass usual- dependent on BMD. The significance of BMI as a risk factor varies
ly occurs before the third decade (14). Peak bone mass is dependent based on the BMI level Patients with low BMI are at increased risk
primarily on genetic factors (70-80%), but it is also considerably in- of osteoporosis. To help reduce the risk of osteoporosis, patients
fluenced by physical activity and dietary calcium intake during ado- should be advised to maintain a normal weight. Significant associa-
lescence (7,17). The age-related decrease of bone mass (regardless tion with serum level is use of multivitamins and physical activity.
of gonadal hormone levels) generally is starting some time after the Evidence show that exercise may help building and maintenance of
age of 50. The age-related bone loss is about 0.5% per year during bone density at any age. Studies have seen bone density increase by
the sixth and seventh decades, but accelerates substantially with ad- doing regular resistance exercises three times a week or more, such
vancing ages. In women there is an increased acceleration of bone as weight lifting. This type of weight bearing exercise appears to
loss at menopause (4,18). stimulate bone formation, and the retention of calcium in the bones
The individuals who do not obtain enough calcium from foods bearing the load. A bone health through adequate intake of calcium,
should take a supplement, less than the recommended 1000 mg dai- vitamin D, and physical activity represent the base of the pyramid
ly. The normal range of Calcium is 2,10-2,55 mmol/L. Low forearm for all individuals with bone disease.
bone mineral density (BMD) is a risk factor for sustaining a fore-
arm fracture in both genders and it might be a predictor of a later Conflict of interest: none declared.
vertebral and/or hip fracture. The increased incidence results from
a combination of decreasing BMD and an increased propensity of
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Medical Journal (2015) Vol. 21, No. 1, 27 - 29 Original article
*Corresponding author
ABSTRACT SAŽETAK
The authors of this study will show experimental development Autori će u radu prikazati eksperimentalni razvoj, a zatim i kliničku
followed by clinical application of bioelastic extramedullary osteo- aplikaciju bioelastične ekstramedularne osteosinteze (BEO) - premos-
synthesis (BEO). The main reason for work on BEO developement nioce. Osnovni problem koji je uvjetovao rad na razvoju BEO jeste ne-
was the inability of proper bone fixation in small diaphysis in case mogućnost odgovarajuće fiksacije kosti kod malih dijafiza u situacijama
of proclaimed osteosynthesisa absence. In that regard, following the nedostatka proklamirane osteosinteze. U tom smislu nakon PC pro-
computerized material estimation the basic task of the experimental računa materijala koji je upotrebljen postavljen je osnovni zadatak eks-
research was set, that was to determine the effect or reliability of perimentalnog istraživanja, a to je utvrditi efekat odnosno pouzdanost
BEO as an extramedullary binder in simple and complex fractures of BEO kao ekstramedularnog bindera kod jednostavnih i kompleksnih
small animals (13 dogs and 19 cats). By default the parameters of the prijeloma malih životinja (13 pasa i 19 mačaka). Prema zadanim para-
research showed a wide segmental bioelasticity of BEO reflected in metrima istraživanja utvrđen je širok segmentni bioelasticitet BEO koji
the prevention of shear, rotation, contraction and distraction. In 2006 se ogledao u prevenciji: striga, rotacije, kontrakcije i distrakcije. Metoda
this method was introduced as original surgical technique for the je kao originalna operativna tehnika uvedena u kliničku praksu 2006.
chosen indicated field. Final results compared with other alternative godine u biranom indikacionom području. Konačni rezultati kompar-
methods were in favor of BEO application. The bone osteosynthe- irani sa drugim alternativnim metodama idu u prilog primjene BEO.
sis has shown its strong foundation in serious comminuted fractures, Premosnica je pokazala svoje snažno uporište kod jakih kominutivnih
necessary interphalangeal and metacarpophalangeal arthrodesis, and prijeloma, neophodnih interfalangealnih i metakarpofalangealnih artro-
in the installation of intercalary bone grafts in 12 applications (10 pa- deza i pri ugradnji interkalarnih koštanih presadaka kostiju šake kod 12
tients) at the Clinical Center University of Sarajevo (CCUS). aplikacija (10 pacijenata) u Kliničkom centru Univerziteta u Sarajevu.
Key words: bioelastic osteosynthesis, fractures, bone defects, ar- Ključne riječi: bioelastična osteosintreza, prijelom, koštani defekt,
throdesis artrodeza
INTRODUCTION require use of special instruments and have a high purchase price.
With a view of achieving better bone elasticity and wide bridging
The main problem in the fixation of small bone fractures in of a bone fracture computer calculation was used, specifically indi-
the locomotor surgical system is the selection of adequate fixation. vidual analysis of mechanical load of one and subsequently of two
This is especially emphasized in case of small diaphysis defects. K-wires of 12,0/24,0 gram weight, and Ø 2,0 mm, L= 150 mm
The question is which bone implant or osteosynthesis is to be dimension. The force of Kg/N = 3/29,41, 5/49,03, 7/68.64 was
applied. applied in the simulation. The analysis related to twisting defor-
In case of a small plate and screws, frequent problems relate mation: static mo-ment (M) Ncm and achieved angle (α°), as well
to inadequate size, voluminous, rig-idness, use of special instru- as to deformation caused by twisting without longitudi-nal force
ments and high implant prices. In case of Kirschner wire (K-wire) (KI/mm). Axial load (compression-distraction) of the K-wire, and
and in-tramedullary and/or transcortical screw fixation, percutan rigidness and elasticity of the structural model interconnection re-
use causes frequent infections around wires, loose of fixation, frac- spectively were not measures given that they were in collision with
ture, bending, dislocation or spilling. External fixators are extremely the specific characteristics of the experimental research. It was es-
large and their use is limited to a narrow indicated area. They also tablished that the minimum de-formation with twisting and bending
28 Z. Hadžiahmetović et al.
occurred with the creation of a structural binder consisting of two • To which extent is BEO wildly uniform and provide better bio-
K-wires arranged under the angle of 54° with four cerclage wires chemical basis within the bone fu-sion (arthrodesis), and to which
on two levels in each main bone fragment (1). extent is it more reliable in respect to intramedullary fixation with
This simulation presented basis for the experimental research K-wires;
of bone wire complex on small an-imal bones (dogs and cats). In • Whether the stabilization and final intercalary bone graft fusion
that regard we simultaneously applied intramedullary and extra- are in direct correlation with the implant selection (6,7).
medullary bridging of the fracture with K-wire and cerclage. The
additional aim of the analysis was to determine the strength of
bond between the two interconnected K-wires and cerclage in a MATERIALS AND METHODS
routine procedure only in an extreme version, without additional
intramendullary support in simple and complex fractures. In the period from 2007 to 2012 ten (10) patients diagnosed
Following very good initial results the further application was with bony defect in metacarpal or phalanges fractures were surgi-
exclusively exstramendullary and was called Extramedullary Fixa- cally treated at the Clinic of Plastic and Reconstructive Surgery and
tion with Kirschner Wires and Cerclage (EFIKS). This research on the Clinic of Emergency Medicine of the CCUS. All cases related
ani-mals was conducted in the period from 2001 to 2005. Over to trauma substrate, except for two defects which occurred after
that period 13 dogs and 19 cats with trauma fractures were sur- tumor extirpation, specifically the bone cyst extirpation (Table 1).
gically treated at the Cantonal Veterinary Station in Sarajevo. The
following parame-ters were monitored: fracture healing (radiogra- Table 1 1 Double phalange defect, 4 open defect *
phy), implant fixation (specifically alenthesis – bone – soft tissues),
No /Ost Trauma/Tumor/ Arthrodesis Bone graft
infection development, deformities, joint movements and everyday Cyst
activities of the animals (Figure 1). It was established that EFIKS
1/1. Phal.prox.pollicis MTCP + IP I liac bone (3 cortical )
was: firm fractural osteosynthesis with wide segmental bioelasticity (osteid osteoma)
in unstable fractures, good prevention from rotation, shear, angu- 2/2.* Phal.prox.dig.IV, MTCP + PIP + II meta carpal
lations and distraction, with good adoption of fractural fragments, V (trauma) (cylindric )
and very cheap. Furthermore, the evident was a high level of osteo- 3/1. Phal.med.dig.III PIP Free fibula
(cyst ) (cylindric )
synthesis elasticity, specifically a direct correlativity of bioelasticity
4/1.* Phal.dist.indicis DIP I liac bone
with the established balance among the bone contact, size and di- (trauma) (cortico-spongiosa )
mension of the bone-position of implant (1). 5/1.* Phal.prox.indicis MTCP + PIP I liac bone (2 cortical )
(trauma)
2/1. Metacarpal.V Free fibula
(trauma) (cylindric )
6,7/2. Phal.med.dig.IV PIP + DIP I liac bone
(trauma) (cortico-spongiosa )
8/1.* Metacarpal. III Radi al
(trauma) (cortico-spongiosa )
9,10/2. Phal.med. dig. III PIP + DIP I liac bone
(trauma) (cortico-spongiosa )
Post operative bone infection was not registered in any of the CONCLUSION
patients. Five (5) patients were subjected to a primary bone and soft
tissue defect treatment, and based on the antibiogram they were The created BEO proved as a good choice in stabilization of
treated with antibiotics pre and post operatively. bone grafts and metacarpal bone phalanges grafts, and simple and
complex diaphyseal fractures of short and middle bones especially
of upper extremities. The implementation of the method is simple
and BEO is elastic enough to create large rigid diaphyseal bone seg-
ments. It satisfies all contemporary principles of „biological fixation“
of fractures and except for surgical cerclage set it does not require
purchasing of special instruments.
In certain cases it is necessary to prevent the bone lever phe-
nomena, especially if the bone defect or fracture line is outside of
Figure 2 Aneurysmal bone cyst of middle phalanx of the middle diaphysel segment or in a situation of inadequate contact
third finger. Substitution of phalanx with fibula graft, BEO, bracing. This can influence the need for additional use of cerclage
proximal interphalangeal (PIP) and distal interphalangeal wires. However, reduction of micro movements can be achieved
(DIP) transient joint stiffness - the 2007 surgery (x-ray) with the increase of number and thickness of K-wires, especially if
stronger muscle activity is expected.
REFERENCES
*Corresponding author
ABSTRACT SAŽETAK
Thyroid cancers are the most common malignant tumour of the Karcinomi štitnjače su najčešći zloćudni tumori endokrinog
endocrine system, with an incidence that is growing every year. Thyroid sistema, s učestalošću koja raste svake godine. Čvorovi štitne žli-
nodule with suspicious US features (hypoechoic, increased nodular vas- jezde sa sumnjivim karakteristikama na UZ-u (hipoehogene, pov-
cularity, infiltrative margins, microcalcifications and size), abnormal cer- ećane prokrvljenosti, sumnjive inflitrativne margine, mikrokalcifikati
vical lymph nodule, and scyntigraphic signs (cold nodule) require further i veličina), abnormalni limfni čvorovi i scintigrafskih znakova (hladni
diagnostics. The fine-needle aspiration (FNA) is the most accurate and čvorovi) zahtijevaju daljnju dijagnostiku. Citološka punkcija (FNA) je
cost-effective method for evaluating thyroid nodules. Patients whose cy- najprecizniji i ekonomičan način za procjenu strukture čvorova štitn-
tology results were malignant or suspicious for malignancey and patients jače. Pacijenti čiji su citolološki rezultati bili maligni ili sumnjivi za ma-
whose cytology results showed signs of marked atypia, are referred lignost i pacijenti čiji je citološki nalaz ukazivao na atipiju su upućeni na
to surgery. The aim of our study is to evaluate the FNA results and to operaciju. Cilj našeg rada bio je ocijeniti rezultate FNA i usporediti
compare them to hystopathology in diferentiated thyroid carcinoma. histopatologiju diferenciranih karcinoma štitnjače. U našoj retrospek-
Our retrospective study included 65 patients who were referred to the tivnoj studiji bilo je 65 pacijenta koji su upućeni na Kliniku za nuklear-
Clinic of Nuclear Medicine, Clinical Centre University of Sarajevo. All nu medicinu, Kliničkog centra Univerziteta u Sarajevu. Svi pacijenti
patients underwent FNA and thyroid surgery and they were divided su podvrgnuti FNA i operaciji štitnjače. Svi pacijenti su podijeljeni u 5
into 5 groups based on the results of the FNA findings (National Can- skupina na temelju rezultata FNA nalaza (Nacionalni Institut za kar-
cer Institute Thyroid Fine-Needle Aspiration Guidelines Committee cinome štitnjače-Smjernice za aspiracionu punkciju IV). Na temelju
IV). Based on the patohystological findings the results were divided in 2 patohistoloških nalaza, rezultati su bili podijeljeni u 2 skupine (pap-
groups (papillary and follicular thyroid cancer). Data is presented in the illarni i folikularni karcinom štitnjače). Podaci su prikazani u obliku ta-
form of tables and graphs, using classical methods of descriptive statis- blica i grafova, korištene su klasične metode deskriptivne statistike,
tics, sensitivity and false-negative and positive rates and positive predic- osjetljivost i lažno-negativnih i pozitivne stope i pozitivne prediktivne
tive value, depending on the nature and scale of the measurement data. vrijednosti, ovisno o prirodi i opsegu mjerenja podataka. Ispitivanje
Sensitivity test (SN) was 67.0%, The positive predictive value (PPV) was osjetljivosti (SN) je 67,0%, pozitivna prediktivna vrijednost (PPV) je
97.0%, false negative rate was 21,5 % and false postive 0%. Fine-needle 97,0%, lažno negativnih stopa je 21,5%, a lažno pozitivna je 0%. Aspir-
aspiration (FNA) biopsy of the thyroid gland is an accurate diagnostic test aciona punkcija iglom (FNA) štitnjače je tačan dijagnostički test koji se
used routinely in the initial evaluation of nodular thyroid disease. Results koristi rutinski u početnoj procjeni nodularne bolesti štitnjače. Rezu-
from the study were comparable to those from literature with a special ltati ovog istraživanja su usporedivi sa onima iz literature, ali poseban
reference to false negative results. oprez treba posvetiti lažno negativnim rezultatima.
Key words: thyroid carcinoma, fine-needle aspiration, cytology, his- Ključne riječi: karcinom štitnjače, citološka punkcija, citologija, his-
topathology topatologija
INTRODUCTION pending on the type of cell origin they are classified as: differentiated
(papillary and follicular), undifferentiated and rare tumours of the
Thyroid cancers are the most common malignant tumour of the thyroid gland (lymphoma, sarcoma, fibrosarcoma and metastatic
endocrine system, with an incidence growing every year (1). De- tumours). Papillary thyroid carcinoma is known to frequently metas-
Relevance of fine-needle aspiration cytology compared to histopathology in differentiated thyroid carcinoma 31
Of the total number of patients (n = 65), 37 patients (56.9%) ter techology support is needed for better correlation between the
had papillary carcinoma of the thyroid gland, while 28 patients FNA and PHD.
(43.1%) had follicular carcinoma of the thyroid gland. Sensitivity test (SN) is defined as the ability of a test to identi-
fy people who actually have the disease. Sensitivity test (SN) was
Table 4 Diagnostic results based on histological findings
(PHD) (n = 65). 67.0%, namely by means of the FNAB (fine needle aspiration bi-
opsy) it was possible to detect 67.0% of patients who actually had
Valid
Frequency Percent percent Cumulative
percent thyroid gland cancer. The positive predictive value (PPV) was 97.0%,
i.e., the probability that a patient with a positive FNA findings of
Ca papillare 37 56.9 56.9 56.9 thyroid carcinoma really has the thyroid gland cancer is 97.0% . False
negative rate was 21,5 % ie. number of patients that have negative
Valid Ca folliculare 28 43.1 43.1 100.0
FNA and positive PHD and false positive is 0% is patients that have
Total 65 100.0 100.0 positive FNA and negative on surgery. Other results are comperable
to those from litereature.
Sensitivity, 67 Likelihood that patient who has disease has positive test results
Positive predictive value, % 97 Fraction of patients who have positive test (who have disease)
DISCUSSION
CONCLUSION
*Corresponding author
ABSTRACT SAŽETAK
Pathological pregnancies in the first trimester and unwanted Patološke trudnoće u prvom trimestru i neželjene trud-
pregnancies in general present a big clinical problem. It is necessary noće uopšte, predstavljaju veliki klinički problem. Potrebno je
to protect the health of the future mothers and their reproductive očuvati zdravlje budućih majki i njihovu reproduktivnu sposob-
ability. Classical methods (dilatation of the cervical canal, aspiration, nost. Klasične metode (dilatacija cervikalnog kanala, aspiracija i
and curettage) are gradually withdrawing from the practice given that kiretaža) polako izlaze iz prakse jer se u svijetu sve više koristi
„medical abortion“ in combination with mifepriston (a progesterone „medikamentozni pobačaj“ i to kombinacija mifepristona (blo-
receptor antagonist) and misoprostol (synthetic analogue of pros- kator progesteronskih receptora) i misoprostola (sintetski an-
taglandin E1) has been accepted worldwide. Our Clinic conducted alog prostaglandina E1). Naša klinika je uradila obimnu kliničku
a comprehensive study related to treatment of pathological preg- studiju tretmana patoloških trudnoća u prvom trimestru me-
nancies in the first trimester, and among the first ones in the region dikamentima, te prva na našim prostorima ukazala na prednosti
pointed to the advantages of medical abortion over the classical ap- medikamentoznog pobačaja u odnosu na klasični pristup. Studija
proach. The study included 90 patients with pathological pregnancies je urađena na 90 pacijenatica sa patološkim trudnoćama u pr-
in the first trimester and it was established that medical pregnancy vom trimestru, te je ustanovljeno da je medikamentozni prekid
termination was better, more efficient and with less complications trudnoće bolji, efikasniji i sa manje komplikacija i nus pojava od
and side effects than the classical approach. klasičnog načina.
Key words: medikamentous abortion, misoprostol, mifepriston Ključne riječi: medikamentozni abortus, misoprostol, mifepriston
INTRODUCTION infection (and possible sterility) and injuries of genital and other or-
gans during the intervention. Psychological aspects of abortion are
An estimated 46 million abortions are performed globally each also important as well as dislike of women for surgical interventions,
year (1), although the latest data points to the fact that their number which certainly include abortion.
is reducing and amounts to 41 million (2). Out of that total, 48%
relates to unsafe abortions performed by persons lacking the nec-
essary skills, with unsafe abortion methods, and in an environment MATERIALS AND METHODS
lacking the minimal medical standards (3). The unsafe abortions
mainly occur in the countries in which abortions are prohibited or A prospective study was conducted at the Clinic of Gynecol-
limited to certain medical indications, and as such they always result ogy and Obstetrics of the Clinical Center University of Sarajevo.
in a high rate of female morbidity and mortality. Unwanted preg- It included 90 patients with pathological pregnancies in the first tri-
nancies will occasionally occur regardless of adherence to adequate mester and was conducted over the period of two years. Patients
contraception methods, and in such cases a legal option of pregnan- diagnosed with pathological pregnancy in the first trimester were
cy termination should exist at the request of the woman and under divided in three groups of 30 patients. The first 30 patients were
the best possible conditions. Optimal contemporary abortion meth- tested with 600 mg of mifepriston administered orally and subject-
ods imply the instrumental methods and medical abortions conduct- ed to ultrasound monitoring in order to determine if abortion oc-
ed according to certain schemes and protocols depending on weeks curred (complete or incomplete). If abortion was incomplete it was
of gestation, available methods and some other conditions related completed surgically (vacuum aspiration). In the other 30 patients,
to women’s general health and local conditions. Medical abortion if they did not miscarriage within 48 hours, the 200 µg vaginal doze
appeared as an answer to the efforts to reduce the surgical abor- of misoprostol was administered in four hour intervals, to a maxi-
tion risks, mainly those related to anesthesia (mortality up to 0.1%), mum of five doses in total. We monitored and recorded the amount
Contemporary treatment of pathological pregnancies in the first trimester 35
of bleeding, side effects (vomiting, diarrhea, temperature increase), proximately 48,53h, and in subgroup IB (patients treated with both
and the time elapsed from the administration of medical therapy to mifepriston and mizoprostol) the effects of mifepriston occurred
abortion. The third group of 30 patients ended with vacuum aspi- within approximately 45,07 hours, and the effects of mizoprostol
ration and curettage, and they were subjected to ultrasound mon- within 3.96 hours (Table 3).
itoring for possible complications (amount of bleeding, infections,
Table 3 Mean length of drug effects in the induction pro-
remaining fetal parts, etc.). That is a standard and the only method
cedure.
currently applicable at our Clinic, and will serve as a control group.
SUBGROUP MIFEPRISTON (H) MIZOPROSTOL (H) PREPIDIL GEL (H)
The main demographic data is presented in tables. We analyzed the
arithmetic mean (x), standard deviation (s), standard error (Sx), and IA 48.53 0 0
the median applying the nonparametric median Chi-square test (x²- IB 45.07 3.96 0
test) with two independent samples. The test was used to prove if
these two samples belonged to the population with the same me- Due to mifepriston effects in subgroup IA (patients treated only
dian. We applied the Yates correction. The aim of the study was to with mifepriston) 2 patients miscarried in less than 48 hours, 14 pa-
demonstrate the success of new medical termination of pathologi- tients miscarried within 48 hours, whereas 14 patients miscarried in
cal pregnancies in the first trimester. over 48 hours. In subgroup IB (patients treated with both mifepris-
ton and mizoprostol) due to the effects of mifepriston alone only 1
patient miscarried, while 29 patients miscarried due to joint effects
RESULTS of mifepriston and mizoprostol (Table 4).
Table 4 Advanced effects of certain drugs in the induction
Based on the analysis of indications for termination of pregnan-
procedure in relation to a number of the examined sub-
cy in the first trimester it was established that in 86.7% of Group group patients.
I patients pregnancy was terminated due to missed abortio, and in
13.3% due to blighted ovum. The chi-square test did not establish sta-
tistically significant difference in the frequency of indications within
the Group I subgroups, and in each of them pregnancy was termi-
nated due to missed abortion, χ2=1.284; p=0.257 (Table 1). Table 8 shows the manner in which pregnancy was terminated,
and the outcome thereof. In the subgroup IA (patients treated only
Table 1 Indications for pregnancy termination.
with mifepriston) successful medical abortion was performed in 21
INDICATIONS SUBGROUP TOTAL
(70%) patients, and 9 (30%) patients were subjected to curettage
IA IB IC after unsuccessful medical induction. In the subgroup IB (patients
Missed No. 25 25 28 78 treated with both mifepriston and mizoprostol) successful medical
% 83.3% 83.3% 93.3% 86.7% abortion was performed in 27 (90%) patients, and 3 (10%) patients
Blighted No. 5 5 2 12
were subjected to curettage after unsuccessful medical induction.
In the IC group (patients in which abortion ended surgically) 30 cu-
% 16.7% 16.7% 6.7% 13.3%
rettages were performed, of which 6 patients were subjected to
Total No. 30 30 30 90
repeated curettage. The Chi-square test showed that there was a
% 100.0% 100.0% 100.0% 100.0% statistically significant difference in the method and success of abor-
tion, and in that regard the IB group (patients treated with both
Based on the analysis of the time elapsed from the application mifepriston and mizoprostol) had the best outcome, χ2=31.43;
of the medicine to miscarriage it was established that for the IA sub- p<0.05.
group patients (patients treated only with mifepriston) that period
was 48.53±3.56 hours, and for the IB subgroup patients (patients Table 5 Method and success of miscarriage.
treated with both mifepriston and mizoprostol) 50,12±4,95 hours.
The ANOVA test showed that there was no statistically significant
difference between the IA (patients treated only with mifepriston)
and IB subgroup (patients treated with both mifepriston and mizo-
prostol) patients regarding the time needed for abortion, F=2.034;
p=0.159 (Table 2).
Table 2 Mean length of induced miscarriage. Table 6 Correlation between the analyzed variables.
LOWER UPPER
In patients from subgroup IA (patients treated only with mife- By application of the Pearson correlation the following has been
priston), due to mifepriston effects, miscarriage occurred within ap- established:
36 N. Imširija et al.
• Time necessary for the successful induction in the subgroup IA abortions in the second trimester there are several schemes in de-
(patient treated only with mifepriston) is in a statistically negative velopment. If unwanted pregnancy occurs, it is necessary to pro-
correlation with the cervix length (p=0.05), and with the ges- vide women with the opportunity to choose this new method of
tation time (p=0.002), but in a positive correlation with parity medical abortion which has been the choice of approximately half
(p=0.001) of the women in the countries in which it is available (4). The rate
• Time necessary for the successful induction in the subgroup IB of induced abortions (9/1000 women aged 15-49 in 2011) is low in
(patients treated with both mifepriston and mizoprostol) is in a Finland. 92% of them are performed on grounds of social reasons.
negative correlation with the cervix length (p=0.031), gestation Use of medical abortion (combination of mifepristone and miso-
time (p=0.026) and parity (p=0.036). prostol) has increased to nearly 90% of abortions, also in abortions
There was a better correlation between the induction and in- of 9-12 weeks of pregnancy. Intrauterine contraception, started at
dependent variables of the cervix length, gestation and parity in the time of abortion, lowers the risk of future unplanned pregnan-
the examined subgroup IB (patients treated with both mifepriston cies (5). Surgical abortion by vacuum aspiration or dilatation and
and mizoprostol) in relation to the subgroup IA (patients treated curettage has been the method of choice for early pregnancy ter-
only with mifepriston). mination since the 1960s. Medical abortion became an alternative
The analysis of the side effects frequency within the Group I method of first trimester pregnancy termination with the availability
subgroups showed that patients from the subgroup IC (patients in of prostaglandins in the early 1970s and anti-progesterones in the
which abortion ended surgically) had a statistically significant num- 1980s. In the Cochrane Controlled Trials Register the investigation
ber of side effects (p=0.042). They mainly had frequent bleedings was conducted in pregnant women with pathological pregnancy in
and febrility (p<0,05), whereas nausea was equally presented in all the first trimester. Patients were divided in groups depending on the
three subgroups (p=0.213). The lowest rate of side effects were drug used and the manner of administration, and it was concluded
registered in the IB subgroup (patients treated with both mifepriston that the most successful method of medical abortion was the com-
and mizoprostol) (n=4) (Table 7). bination of mifepriston and mizoprostol. In the combined regimen,
the dose of mifepristone can be lowered to 200 mg without signifi-
Table 7 Frequency of side effects.
cantly decreasing the method effectiveness and vaginal mizoprostol
is more effective than oral or sublingual administration (6). Abortion
services are legally available in Ukraine although there are issues in
quality and access. Two studies conducted at six clinics in Ukraine
tried to explain the advantages, effectiveness and possibilities of
The analysis of the complication frequency in the Group I sub- medical abortion by administration of mifepriston and misoprostol.
groups showed that patients from subgroup IC (patients in which These two studies have shown a high level of success and accept-
abortion ended surgically) had a statistically significant higher num- ability in the application of medical abortion in the first trimester in
ber of complications (p=0.047). Those patients frequently experi- respect to the classical approach in Ukraine (7).
enced rezidua post abortum and infections (p<0.05), with the low-
est number of complications registered in IB group (patients treated
with both mifepriston and mizoprostol) (Table 8). CONCLUSION
2. Sedgh G, Henshaw S, Singh S, Lhman E, Shah IH. Induced abortion: rates and trends
worldwide. Lancet. 2007;370:1338-45.
3. Safe abortion: technical and policy guidance for health systems. Geneva: WHO;
2003.
4. Hamoda H, Ashok PW, Flett GM, Templeton A. A randomized trial of mifepristone
in combination with misoprostol administered sublingually or vaginally for medical
abortion at 13–20 weeks gestation. Hum Reprod. 2005;20:2348–54. Reprint requests and correspondence:
5. Update in current care guidelines: induced abortion. Duodecim. 2013;129(7):776-7. Naima Imširija, MD, PhD
6. Kulier R, Kapp N, Gülmezoglu AM, Hofmeyr GJ, Cheng L, Campana A. Medical Clinic of Gynecology and Obstetrics
methods for first trimester abortion. Cochrane Database Syst Rev. 2011 Nov Clinical Center University of Sarajevo
9;(11):CD002855. Patriotske lige 81
7. Raghavan S, Maistruk G, Shochet T, Bannikov V, Posohova S, Zhuk S, et al. Effi- 71000 Sarajevo
cacy and acceptability of early mifepristone-misoprostol medical abortion in Bosnia and Herzegovina
Ukraine: results of two clinical trials. Eur J Contracept Reprod Health Care. 2013 Phone: + 387 33 250 250
Apr;18(2):112-9. Email: naimaimsirija@hotmail.com
*Corresponding author
ABSTRACT SAŽETAK
The aim of this study was to present surgical modifications of Cilj ove studije je da prikaže modifikaciju suprakrikoidne
supracricoid partial laryngectomy (SCPL) together with all advantag- parcijalne laringektomije(SCPL) zajedno sa svim prednostima
es that we brought with it. Background: SCPL is a valuable surgical koje ta modifikacija donosi. Uvod: SCPL je značajna poštedna
technique with the organ preservation aim. First time described by hirurška tehnika. Prvi put su je opisali Austrijski hirurzi Majer i
Austrian surgeons Majer and Rieder in 1959 remained more or less Rieder 1959 i od tada nije imala značajnih izmjena. Glavni nedo-
the same. Major drawbacks of this technique are long-term decannu- staci ove tehnike su dugotrajan postupak dekanilmana i prob-
lation with swallowing problem. Oncologic outcomes were proven lemi sa gutanjem. Onkološki rezultati ove tehnike su dokazani
by different independent studies. Material and methods: we analyzed mnogobrojnim nezavisnim studijama. Materijal i metode: ovim
a total of 16 patients in 6 year period with a diagnosis of advanced ispitivanjem je obuhvaćeno 16 pacijenata u periodu od 6 godi-
T3, T4 laryngeal cancer or recurrence treated with a suggested tech- na, sa dijagnozom uznapredovalog T3 i T4 ili recidiva carcinoma
nique of SCPL. Another inclusion criteria were ECOG lower than 1 larinksa koje smo liječili predloženom tehnikom. Ostali inkluzi-
(Karnofsky 80 and higher), one healthy crico-arythenoid joint. Re- oni kriterijumi su bili ECOG 1(Karnofsky skor 80 i više) jedan
sults: during the 6 year period we treated 16 patients with advanced funkcionalan krikoaritenoidni zglob. Rezultati: u šestogodišnjem
laryngeal cancer. Mean age was 59,5. In all patients we performed periodu liječili smo 16 pacijenata sa dijagnozom uznapredova-
modified SCPL without preliminary trachostomy and reconstructed log karcinoma larinksa. Prosječna starost pacijenata je bila 59,5
with cricohyoidopexy (CHP) or cricohyoidoepiglottopexy (CHEP). godina. Svi su liječeni modifikovanom tehnikom SCPL bez pre-
One of the patients was successfully operated as cricoglossopexy liminarne traheotomije sa krikoidopeksijom (CHP) ili krikohioi-
(CGP). No active suction was applied. Nasogastric tube feeding was doepiglotopeksijom (CHEP). Kod jednog pacijenta je urađena
maintained six day average. Patients stayed 9,18/7,4* day average in rekonstrukcija po tipu krikoglosopeksije (CGP). Nismo primjen-
hospital. Conclusion: SCPL can be performed without preliminary jivali sukcionu drenažu. Nazogastrična sonda je korištena pros-
tracheostomy. Patient’s breathing is established immediately after the ječno 6 dana. Prosječna hospitalizacija je bila 9,18/7,4 dana. Zak-
operation and swallowing in a few days. This makes modified SCPL ljučci: SCPL se može izvesti bez preliminarne traheotomije. Kod
highly desirable for surgeons as well as for the patients. Surgical tech- pacijenata se spontano disanje uspostavlja neposredno nakon
nique is simplified if compared with traditional one, can be easily re- ekstubacije a akt gutanja kroz nekoliko dana. To ovu tehniku čini
produced what makes it teachable and consequently acceptable in krajnje poželjnom kako za hirurga tako i za pacijente. Predložena
a surgical routine in laryngeal surgery. Patients with infection were tehnika je pojednostavljena, lako se uči i samim tim je prihvatljiva
excluded kao dio hirurške rutine u hirurgiji larinksa.
Key words: laryngeal cancer, surgery, supracricoid partial laryngec- Ključne riječi: karcinom larinksa, hirurgija, suprakrikoidna parcijal-
tomy, modification na laringektomija, modifikacija
RESULTS
1 Supraglottic R R
2 S upraglottic R R
3 Supraglottic IVa T3N2aMx
4 Supraglottic IVa T4aN2aMx
5 Supraglottic IVa T4N0Mx
1 CGP 0
2 CHP 0
3 CHP Selective
4 CHP Radical modified
5 CHEP 0
6 CHEP 0
7 CHP 0
8 CHP Radical modified
9 CHEP 0
10 CHP 0
Figure 5 Cricohyoidopexy.
11 CHP Selective
The second layer was soft tissue of pharyngeal muscles and 12 CHEP Selective
parts of subdermal structures sutured with 2-0 resorbable suture.
13 CHP Radical modified
After that we put deep stitches of skin with 2-0 silk suture. At the
end we put two silk stitches 1-0 through the skin and the periose- 14 CHP 0
um of mandibular and sternal bone in order to minimize voluntary 15 CHP 0
movement of the head backwards. Then the patient was extubated
16 CHEP 0
and sent to the ward with standard care.
Alternative approach to supracricoid partial laryngectomy 41
From this table is obvious that all patients had advanced laryngeal kind of controversial. It was always in competition with total laryn-
cancer of stage III to IVa mostly in supraglottic region. We operated gectomy to prove safety as well as functionality (4). This procedure
them by modifying the technique of SCPL without a tracheostomy. was invented in an attempt to sacrifice part of swallowing function
Author performed cricohyoidopexy (CHP) in ten cases, cricohyo- in order to spare two other functions, natural breathing and voice.
epiglottopexy (CHEP) in five cases and after the removal of hyoid After 1990 it is established as oncologically safe procedure, although
bone in one case we performed cricogottopexy (CGP). This kind hard to teach and reproduce (5). One of our reasons for making
of reconstruction is not yet established as standard reconstruction modification of this technique was to facilitate it’s reproducibility.
procedure, although article was presented at a German ENT annual At the same moment we wanted to ease patient’s postoperative
meeting in 2014 by Ahmed El Batawi et all as successful procedure. course. Decannulation is frustrating and long lasting process, some-
In six patient, selective or radical modified dissection was performed time impossible, and this is disappointing for patient and surgeon
as additional procedure. In all operated patients we did not use ac- (6,7). We operated cases with stage III and IV as a substitute for
tive suction drains. Results of surgical intervention were displayed in total laryngectomy. Patients with early stages of disease, we oper-
Table 2. ated with other surgical techniques. By our opinion and experience
In all our patients SCPL was performed without preliminary SCPL should be used for advanced stages of laryngeal cancer exclu-
tracheostomy. All patients were breathing sufficiently after extuba- sively while other techniques have advantages in comparison with
tion while nasogastric tube remained in position for enteral feeding. SCPL when used in early stages of disease. Some authors express
One patient underwent tracheostomy due insufficient breathing six the same opinion (8), of course, other authors have different expe-
hours after the operation. He was decannulated 7 days after the rience and used SCPL for a wide range of laryngeal cancer stages.
operation. A nasogastric feeding tube was in place for six day in Also, it is a very convenient technique for recurrences, no matter
average. It means that all patients established oral feeding during after surgical or chemoradiation therapy. We prefer CHP in recon-
the hospital stay. Two wound infections had conservative treatment struction because we found out that epiglottis is often a liability for
for 17/26 days. The average hospital stay was 9,18 days or 7,4 if breathing afterwards because it goes in reconstruction to low and
we count patients without complications. Postoperative outcomes cover part of air space. From the other side, it is not essential for
were presented in Table 3. airway protection during swallowing as arythenoid fold with active
cricoarythenoid joint seems to play key role in this process. When
Table 3 Postoperative outcome.
our technique is used, neck dissection is performed through a new
Cases Decannulation Nasogastric Complications Hospital stay skin incision as procedure by itself which makes two completely
in days tube in days in days
divided space compartments. We found it superior than the usual
1 0 5 0 6
apron neck incision, which unite this two procedures because there
2 0 5 0 6 is less possibility for infection spread from one surgical site to anoth-
3 0 4 0 8 er. With a modified technique of SCPL process of decannulation is
completely avoided which lowered morbidity with absolute patient
4 0 5 0 7
satisfaction. Most of the authors stressed long-term decannulation
5 0 5 0 8 as a major problem of SCPL(7).
6 0 15 0 8 We start oral feeding very early at day three or four and remove na-
sogastric tube at day six on average. Other authors frequently stress
7 0 7 Inflammation 17
swallowing problem (9). Of course, there is slight discomfort and
8 7 7 Inflammation 26 coughing due to minor aspiration of liquids during the swallowing
9 0 5 0 7 process but no pulmonary complications were observed. This is the
reason we start solid or semisolid food first and pure liquids later
10 0 7 0 7
with different neck positions to ease swallowing. We had two com-
11 0 6 0 8 plications of local wound infection without the need for additional
12 0 5 0 8 surgery intervention. Our hospital stay was 7,4 days at average for
patient without complications which is comparable with other in-
13 0 5 0 8
stitutions (10). Patients could be rejected from the hospital earlier
14 0 5 0 8 regarding health condition, but our policy was to stay in hospital until
15 0 6 0 8 stitches are removed.
16 0 5 0 7
6 (average) 12,5% 9,18 (7,4*) CONCLUSION
(average)
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Medical Journal (2015) Vol. 21, No. 1, 43 - 46 Professional article
Sarcopenia
Sarkopenija
Ksenija Miladinović*
Clinic of Physical and Rehabilitation Medicine, Clinical Center University of Sarajevo, Bolnička 25, 71000 Sarajevo, Bosnia and Herzegovina
*Corresponding author
ABSTRACT SAŽETAK
Introduction: there has not been a generally accepted definition Uvod: sarkopenija još nije dobila općeprihvaćenu definiciju,
for sarcopenia, nor determining parameters, which inhibits investi- niti determinirajuće parametre, što inhibira istraživanja i proiz-
gation and production of means for the treatment. A review of the vodnju lijekova. Pretraživanje literature imalo je za cilj da ukaže
literature was undertaken to point to its definition, etiology and na definiciju, etiologiju i tretman sarkopenije. Etiologija se dovodi
treatment. Etiology is associated with an imbalance of positive and u vezu sa disbalansom pozitivnih i negativnih regulatora mišića.
negative regulators of muscle. Possible determination parameters Mogući parametri determinacije su: mišićna masa, mišićna snaga,
are: muscle mass, muscle strength, muscle power, speed walk. Treat- mišićna moć, brzina hoda.Tretman se za sada zasniva na odgo-
ment is currently based on adequate non-acid diet with sufficient varajućoj neacidnoj dijeti sa dovoljnim unosom proteina, dovol-
protein intake, adequate intake of vitamin D, B12 and folic acid, as well jnom unosu D, B12 vitamina i folne kiseline, kao i individualno
as on individually adjusted exercise program, preferably resistance prilagodjenom programu vježbi, po mogućnosti sa otporom. Far-
training. Pharmacological agents are under investigation. Conclusion: makološka sredstva su u fazi ispitivanja. Zaključak: treba što pri-
the views around a single definition and the determining parameters je usaglasiti stavove oko jedinstvene definicije i determinirajućih
of sarcopenia should be harmonized as soon as possible, and until parametara sarkopenije, a do tada primjenjivati tretman koji je na
then apply a treatment that is available. raspolaganju.
Key words: sarcopenia, definition, treatment Ključne riječi: sarkopenija, definicija, tretman
tions of sarcopenia remains unresolved. Moreover, there are no gen- POSSIBLE PARAMETERS FOR DETERMINING SAR-
erally accepted guidelines that determine the favorable or unfavorable COPENIA
characteristics of its clinical significance in human studies. This presents
a problem for the development of pharmacological interventions that Muscle mass
alter natural course of the disease. Even numerous potential drugs
were identified as a result of a good understanding of the functional and Muscle mass is well characterized parameter that can be ob-
structural changes that are seen on the molecular level in sarcopenia, jectified by radiological methods. Decrease in muscle mass more
there is still no legal permission for their production. Why? There are no than 2 SD according to T score, considered to be the domain of
commonly accepted parameters that could define the disease, charac- sarcopenia. Loss of muscle mass is associated with high risk for de-
terize its progress, and provide measurement results in the application velopment of chronic metabolic diseases, such as Diabetes mellitus
of some interventions that would satisfy regulatory requirements. type 2. However, increase in muscle mass does not always mean the
Since 2005, in parallel with the new attempts to define sarcope- improvement of physical function, which is similar to osteoporosis,
nia there are some suggestions for the use of simple tests to screen i.e. an increase in bone mass does not necessarily mean that the risk
and identify patients with sarcopenia. Moreover, some of these mea- of fractures is reduced.
surements are recommended for diagnostic criteria of arcopenia and Various unsuitable methods were used to measure muscle mass,
weakness syndrome. The latest is that 2011. International Working which are no longer in use. Thus, due to imprecision anthropometric
Group for sarcopenia (5) presented four recommendations for the measurements are less used. To obtain a complete picture of body
identification of sarcopenia in clinical practice, and these are: 1) assess- composition requires a four-component model that includes water,
ment of the reduced physical abilities (or weakness), 2) consideration proteins, minerals and fatty tissue. Currently used radiological meth-
of sarcopenia in immobile patients or those who cannot get up from the ods are: DEXA densitometry (Figure 2), computerized tomography
wheelchair without assistance, 3) evaluation of the usual habitual walk (CT) (Figure 3) and magnetic resonance imaging (MRI) (Figure 4).
on four meters distance 4) patients with habitual gait with a speed of
less than 1m/s should be considered for quantitatively measuring body
composition (DEXA, CT, MRI).
ETIOLOGY OF SARCOPENIA
Muscle strength
Figure 4 MRI display of younger and older man thigh. Down- Figure 5 Martin vigorime- Figure 6 Jamar dynamom-
loaded at www.eatmore2weighless.com. ter eter
use of expensive equipment, and its use is limited. sarcopenia in clinical practice. Therefore, in clinical practice has been
The maximum power that can be generated in one maximum introduced a simple test sit-stand up for 30 seconds to determine
contraction is designated as one repetition maximum (1-RM). Early the average and peak muscle power. The objection to this proposal
research related to 1-RM date back to 1955, and from 1990 this is that this is not precisely measure for studies that deal with ther-
“unit” is used in research as a measure of muscle strength (Hoeger, apeutic agents. As for the other parameters, patients with arthritis
Hopkins and Hale, 1990). 1-RM is obtained using specific equipment are not eligible for the determination of muscle power.
for older people, designed for exercises with the generic type of
resistance, and it represents a reliable alternative that correlates Muscle fatigue
well with the assessment of muscle strength obtained by using the
Muscle fatigue is defined as the inability of muscles to produce
dynamometer. The lack of use of 1-RM is that the absolute value of
or maintain a level of power required for a given operating speed.
1-RM are not comparable between different sets of equipment.
Muscle fatigue itself has its own central and peripheral component.
As a measure of muscle strength is increasingly in use hand grip. For
However, there is little published research that associate muscle fa-
the measurement of grip there are two smaller dynamometer in use:
tigue and sarcopenia.
Jamar dynamometer (Figure 5) and Martin vigorimeter (Figure 6),
which has the advantage of being suitable for patients with arthritis,
Walking speed
since it has three sizes of rubber balls. It is recommended to take the
best of three test repetitions and for the left and right hand. Howev- Most commonly used distance for testing the walking speed
er, variations in the clinical practice are large, so that a comparison is 4m, and the current reference speed is 0.8 m/s by the recom-
with the results obtained in studies very difficult. It is an interesting mendation of EWGSOP and ESPEN-SIG, or 1 m/s by the recom-
study of Cooper and associates in 2010, because it was first made mendation of IWGS. In clinical practice walking speed, sit-stand up
transparent meta-analysis of the relationship between objectively test and standing balance are often measured in the context of the
measured physical ability (hand grip, speed walking, sit-stand up test Short Physical Performance Battery (BKFI/PPBS) (11). It is generally
and standing balance) and mortality in the elderly. Conclusion of 13 accepted that the total BKFI score less than 10/48 (there are 12
examined studies (44 638 participants) is that mortality is reduced sections, each scored 0-4) indicates a functional impairment in the
with each kilogram of increasing grip strength (8). It was also con- elderly population and that strictly predicts the loss of ability to walk
cluded that the walking speed, ability to rise from a chair and stand- 400 m distance.
ing balance are associated with mortality in the elderly population All above mentioned parameters are not generally accepted by
(over 70 years old), while the hand grip is associated with mortality all scientific, professional and regulatory bodies, and also proposals
in younger population as well (under 60 years). for their reference values are different. The best reviews of the cur-
rent situation in the field of sarcopenia are given by Cooper with
Muscular power
associates and Rizolli with associates in 2013 (3,4).
Muscular power defined as the maximum rate of muscle work
per time unite, seems more sensitive parameter for determination TREATMENT OF SARCOPENIA
of the physiological changes associated with aging, compared to
the muscle strength. This was confirmed by studies that have raised The current treatment for sarcopenia includes:
the muscle power as a strong predictor of physical ability in old- 1) The correct and adequate nutrition (especially adequate intake
er people (9). Other studies have attempted to explain the causes of proteins)
of reduced muscle power and led in connection with the biological 2) Sufficient intake of vitamin D
processes of aging, especially with neuromuscular impairments ac- 3) Individually adjusted physical activity, if possible, exercise with
tivation, rigidity of tendons, speed of contraction and changes in resistance
muscle architecture (10). Measurement of peak muscle power in 4) Pharmacological treatment is under investigation (angiotensin II
the elderly is objectively gained by feet pressure or knee extension converting enzyme, inhibitors of chronic inflammation and myostatin
at high speed training with resistance. Since this requires expensive produced positive results to the current phase of testing). Hormones
equipment this measurement is too expensive as a benchmark for have not shown good effects (4).
46 K. Miladinović
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creases in vitamin B12 and folic acid intake may also impair muscle 16. Campbell WW, Evans WJ. Protein requirements of elderly people. Eur J Clin Nutr.
function through their action on homocysteine (17). 1996;50 Suppl 1S180-3.
17. Mithal A, Bonjour J-P, Boonen S, Burckhardt P, Degens H, El Hajj Fuleihan G, et al.
Impact of nutrition on muscle strength and performance in older adults. Osteopo-
CONCLUSION ros Int. 2013;24(5):1555-66.
Although there has been some progress, remains the need for
unique consensus for defining and diagnosing of sarcopenia, as well
as for specifying the parameters for the assessment of the results in
the application of new potential means for its prevention and treat-
ment. The question is whether the means potentially affect the mus-
cle mass and muscle strength, considering that both parameters are
in most current definitions of sarcopenia, and besides, both are es-
sential in prevention of disability, occurrence of weakness, and even
mortality. To obtain legal permission for their production primarily
there is need for clear, generally accepted definition of anatomical
and physiological assessment of muscle mass and muscle strength. In
the meantime we must recognize sarcopenia in clinical practice, and
Reprint requests and correspondence:
treat it with current interventions that are available, i.e. individualy Ksenija Miladinović, MD, PhD
adjusted exercise programme, preferably resistance training, opti- Clinic of Physical and Rehabilitation Medicine
mal dietary acid-base balance and adequate supplementation with University Clinical Centre
vitamin D, B12 and folic acid. Bolnička 25, 71000 Sarajevo
Bosnia and Herzegovina
Conflict of interest: none declared. Email: k.miladinovic@yahoo.com
Medical Journal (2015) Vol. 21, No. 1, 47 - 50 Professional article
*Corresponding author
ABSTRACT SAŽETAK
Major trauma covers all serious, life-threatening injuries that usually Major trauma obuhvata sve teške, po život opasne, povrede koje
occur in traffic accidents, due to falls from a height, and as a result of najčešće nastaju u saobraćajnim udesima, kod padova sa visine, te kod
cold weapon or firearm activities. With the goal of reducing mortality djelovanja hladnog ili vatrenog oružja. Da bi se smanjio mortalitet i in-
and disability in these injuries, it is necessary to establish a harmonized validitet kod ovih povreda, potrebno je uspostaviti usaglašen trauma
system in prehospital trauma and in hospitalization of traumatized sistem u prehospitalnom i hospitalnom zbrinjavanju traumatiziranih
patients. For the purpose of survival, the most important thing is the pacijenata. Za preživljavanje najvažnije je uspostavljanje i održavanje
establishment and maintenance of vital functions and surgical manage- vitalnih funkcija te hirurško zbrinjavanje povrede.Prvi operacijski pe-
ment of injuries aimed towards preventing the occurrence of irrevers- riod je akutni ili intencioni period koji obuhvata prva tri sata od do-
ible shock. The first operating period is the acute or intention period laska povrijeđenog u bolničku ustanovu gdje se može pružiti potrebni
covering the first three hours from the arrival of the injured person to operativni tretman. Podrazumjeva zbrinjavanje vitalno ugroženih, kod
the hospital facility where he/she can receive a surgical treatment. It kojih sprovedene mjere reanimacije ne mogu spriječiti nepovoljan tok,
implies treatment of critically injured patients, where the implemented bez hirurške intervencije. Glavni cilj ovog istraživanja je utvrditi da li
reanimation measures cannot prevent an unfavourable course, without je preživljavanje životno ugroženih traumatiziranih pacijenata ovisio od
surgical intervention. The main goal of this research was to determine kvaliteta i brzine pružanja urgentne medicinske i neophodne hirurške
if the survival of critically traumatized patients depended on the quality intervencije. Predpostavka je da povrijeđeni pacijenti sa obilnim krva-
and promptness of urgent medical and necessary surgical intervention. renjem u nekom od organskih sistema imaju najviše šanse za preživl-
It is assumed that the injured patients with heavy bleeding in certain javanjem ako se operativni tretman učini unutar tri sata od nastanka
organs have the highest survival rate if surgically treated within three povrede. Istraživanje obuhvata povrijeđene pacijente koji su primljeni
hours from the moment of injury. The survey covers injured patients Na Kliniku urgentne medicine (KUM) Kliničkog centra Univerziteta u
admitted to the Clinic of Emergency Medicine of the Clinical Centre Sarajevu (KCUS) u toku 2009. i 2010. godine sa znacima poremećaja
University of Sarajevo (CCUS) during 2009 and 2010 with signs of vital vitalnih funkcija. U studiju su uključeni svi povrijeđeni životno ugroženi
function disorders. The study included all patients with life threatening pacijenti bez obzira na mehanizam povrede, na organski sistem koji
injuries regardless of the injury mechanism, the injured organ or gender, je povrijeđen, spol, koji su stariji od 15.g. (zbog korištenja specifičnog
patients over 15 years of age (due to use of a specific scoring system??), sistema skorovanja), kod kojih je povreda nastala unutar sarajevskog
who sustained injuries within the Sarajevo Canton (with transportation Kantona (sa vremenom transporta do 30 minuta), a na prijemu su bili
time of up to 30 minutes), and who at admission had signs of hemody- prisutni znaci hemodinamske nestabilnosti ili sa kliničkom i radiološ-
namic instability or clinical and radiological verification of life threaten- kom verifikacijom traumatskog supstrata koji ugrožava život. Iz studije
ing traumatic substrate. The study excluded patients with lethal exitus su isključeni pacijenti kod kojih je nastupio letalni egzitus neposredno
occurring immediately after the reception and patients in which the nakon prijema i kod kojih na prijemu nije bila postavljena vitalna indik-
vital surgery recommendation was not determined upon the reception. acija za operaciju. Ispitivanu skupinu sačinjava 60 povrijeđenih, životno
The study group consisted of 60 critically injured patients recommend- ugroženih pacijenata kod kojih je postavljena indikacija za hitnu operaci-
ed for urgent surgery. The primary or the intention group (GI) con- ju. Primarnu ili intencionu grupu (IG) čini 30 pacijenata koji su opera-
sisted of 30 patients who were surgically treated in the first operating tivno zbrinuti u prvom operacionom periodu. U drugoj, sekundarnoj
period. The secondary group (GII) consisted of 30 patients who were grupi (IIG) se nalazi 30 pacijenata koji su operativno tretirani nakon 3
surgically treated 3 hours later. This research has proven the assump- sata. Ovim ispitivanjem je dokazano da pretpostavka stoji jer opera-
tion that surgical treatment in the first three hours following the injury tivnim zbrinjavanjem u prva tri sata od povrede postiže se veći stepen
provides higher survival rate with faster general condition stabilization preživljavanja uz bržu stabilizaciju opšteg stanja sa minimalnim post-
and minimum post-traumatic sequelae. traumatskim sekvelama
Key words: major trauma, trauma system, the first operating period Ključne riječi: major trauma, trauma sistem, prvi operacijski period
48 G. Dedović Halilbegović et al.
INTRODUCTION the respective CCUS clinics can also be engaged. All the injured treat-
ed at the Clinic of Emergency Medicine are referred in accordance
Major trauma is a severe, life-threatening injury, which can affect with the ABCD Protocol. Diagnosis and initial reanimation is carried
multiple organ systems or regions, but only one body. It usually occurs out simultaneously with constant monitoring of vital parameters.
in traffic accidents, falls from a heights, or as a result of cold weap- The role of the ER surgeon is to recognize and recommend sur-
on or firearm activities. According to the World Health Organization gical treatment based on the level of urgency. In cases of massive
data, an estimated 5 million people worldwide died from injuries in bleeding the surgeon should recommend a life saving surgery without
2000 - a mortality rate of 83.7 per 100 000 population (1). Mortality prior diagnosis, and necessary consultation with other surgical profiles
caused by physical injuries is in third place, immediately after cardio- is made in the operating theatre “ad tabula”. The consilium decides
vascular and malignant diseases, but in first place in terms of impor- about the further referral of the patient which can be either to the
tance, given that the most vital age is at risk. In the major trauma care operating theatre or to the intensive care unit.
the first operating period is extremely important. This is the acute or The main goal of this research was to determine if the survival of
intention period which covers the first three hours from the arrival of critically traumatized patients depended on the quality and prompt-
the injured person to the hospital facility where he/she can receive ness of urgent medical and necessary surgical intervention. It is as-
surgical treatment. It implies taking care of critically injured patients, sumed that the injured patients with heavy bleeding in certain organs
from whom implemented reanimation measures cannot prevent an have the highest survival rate if surgically treated within three hours
unfavorable course without surgical intervention. from the moment of injury.
In order to prevent the permanent growth of this condition it is nec-
essary to take a number of preventive measures in all spheres of life;
from the construction of modern roads and control of weapon pos- MATERIALS AND METHODS
session, to combat against all forms of addictions, which will reduce
criminal activities, often resulting in severe, penetrating injuries. The study was conducted as a retrospective-prospective, compar-
On the other hand, in order to reduce mortality and disability, it is ative analytical study which included injured patients admitted to Clinic
imperative to establish a unique trauma system in prehospital and of Urgent Medicine of the CCUS during 2009 and 2010 with signs of
hospital care of traumatized patients. vital function disorders. The data was obtained from patient records,
The trauma system is the organized, coordinated provision of full original memorandums stored in the database, history of illnesses and
medical care to all of those injured in specific geographical areas inte- surgical lists. All the injured patients treated at the Clinic of Emergency
grated with local public health care (5). Medicine have been referred in accordance with the ABCD Protocol. In
For the purpose of survival the most important thing is the es- order to achieve objectivity in assessing the injury severity and the ex-
tablishment and maintenance of vital functions. Priority is given to pected survival, the following scoring systems were used: Physiological
the control of cardiac and respiratory functions, as well as shock pre- / GCS, RTS /, Anatomical / AIS, ISS / and Combined / TRISS /.
vention. This period can not exceed one hour. This “golden hour of The study included all patients with life threatening injuries regardless of
shock” should not be exceeded. The extension of this period leads to the injury mechanism, the injured organ or gender, and patients over 15
shock prolongation and development of irreversible ischemic changes years of age (due to the use of a specific scoring system), who sustained
(8,9). injuries within the Sarajevo Canton (with transportation time up to 30
minutes), and who at the reception had signs of hemodynamic instabil-
Treatment of injuries categorized as major trauma at the Clinic of Emer- ity or clinical and radiological verification of life threatening traumatic
gency Medicine of the Clinical Center University of Sarajevo substrate.
The study excluded patients with lethal exitus occurring immedi-
Clinic of Emergency Medicine of the CCUS covers the space of ately after the admission and in which vital surgery recommendation
2200 square meters. The dispensary diagnostic unit is comprised of was not determined upon the admission. The study group consists of
the CPR cabinet and the operating and stationary block so that pa- 60 critically injured patients randomly selected for urgent surgery. The
tients can promptly be provided with essential diagnostics and surgical primary or intention group (GI) consisted of 30 patients who were sur-
treatments at one place. The circular intersection is also provided. gically treated in the first operating period. The secondary group (GII)
Through inside halls, the Clinic is connected to the DIP building, The consisted of 30 patients surgically treated after 3 hours.
Central Medical Block, The Institute of Radiology, The Department
of Orthopaedics and The Traumatology and Techno-economic block.
RESULTS
There is a heliport at a distance of about 200 meters from the Clinic
of Emergency Medicine. Connection with other clinics is maintained Table 1 Age structure of critically traumatized patients.
by phones, pagers, and via radio networks with ER. Age Primary group(GI) Secondary groups(GII)
Injured patients are received and triaged in the surgical dispensary No % No %
by the emergency medicine specialists. Life threatening traumatized 15- 24 10 33 9 30
25- 34 11 37 7 23
patients are transported to the KPR cabinet. If need be, and upon
35- 44 4 12 5 17
request of the emergency physician, it is necessary to immediately 45- 54 2 7 4 13
include the anaesthesiologist with the anaesthetists, general surgeon 55- 64 3 10 2 7
and traumatologist present at the Clinic (working days from 2 am and 65 + 1 3 3 10
Total 30 100 30 100
24 hours on weekends). If required, surgeons of other profiles from
Major trauma care at Clinic of Emergency Medicine of the Clinical Center University of Sarajevo 49
Table 3 Leading trauma based on the organ systems (location Figure 2 The outcome of treatment in relation to operat-
of injury). ing period.
The organic systems Primary group(GI) Secondary groups(GII)
No % No % DISCUSSION
Head 18 60 17 57
Thorax 14 47 15 50 Life-threatening injuries are usually attributed to men (82%) up to
Abdomen 16 53 16 53 35 years of age. A high percentage of injuries relates to traffic acci-
dents (46%) with the prevalence of multiple trauma (55%) but also in-
juries inflicted by cold weapons and firearms (41%) with isolated (30%)
Table 4 Time spent at Clinic of Emergency Medicine.
or multiple trauma (15%).
Time spent in CUM Primary group(GI) Secondary groups(GII) The data corresponds to epidemiological studies in the world lit-
No % No % erature (3,10,11). According to the Trauma Committee of the Amer-
less than 60 min 11 37 7 23 ican Association of Surgeons (ACS) 34.7% of severe, life-threatening
60-120 min 5 17 13 44 injuries result from road traffic accidents (12).
120 > min 14 46 10 33 In a majority of patients, head and abdomen were leading traumas
Total 30 100 30 100 with blunt injury symptoms requiring several diagnostic procedures
and involvement of different profile surgeons. In the outpatient di-
agnostic block of the Clinic of Emergency Medicine, the majority of
Table 5 The expected survival according to the TRISS.
patients were kept up to 120 minutes. In the 2010 study conducted at
TRISS Ps Primary group(GI) Secondary groups(GII) Athens General Hospital, it was established that each additional diag-
No % No % nostic procedure subtracts 30 minutes (13) and the length of stay in
Less than 50% 18 61 19 63
50-60% 2 7 2 7 the Emergency suit was 121 + 100 (21-221) minutes (14).
61-70% 4 13 1 3 In the vast majority of patients the Injury Severity Score (ISS) was
71-80% 1 3 0 0 > 25, and in over 60% of respondents the estimated survival was un-
81-90% 1 3 3 10 der 50% according to the TRISS method. In his doctoral thesis Akšami-
More than 90% 4 13 5 17
Total 30 100 30 100 ja G, found that 66,2% of polytrauma patients had ISS> 25, while life
expectancy with an estimated TRISS <50% was attributed to 22.8% of
polytrauma patients (15).
Table 6 Distribution based on surgical blocks where emergen- Out of the total number of injuries, 57% were treated at the Cen-
cy surgery took place.
tral Operating Block (COB), but a majority of patients who were sur-
Surgical block (SB) Primary group(GI) Secondary groups(GII) gically treated in the first period, underwent surgical treatment at the
No % No % Operating Block (OB) of the Clinic of Emergency Medicine (58%). Af-
SB at Clinic of 22 58 7 21 ter endopleural drainage performed at the Clinic of Emergency Med-
Emergency Medicine
SB at COB 15 39 19 56 icine, 30% of patients from the GI group continued their operative
treatment at COB, and 13% of patients underwent abdomen surgery
SB at Clinic of
Neurosurgery 1 3 8 23 at the Clinic of Emergency Medicine.
In 50% of injured patients the intention operating period began in
the first 60 minutes following their arrival to the Clinic of Emergency
Medicine. Those were patients with ISS> 25, and with TRISS <50 in
61% of them. 37% of injured patients were retained at the Clinic of
Emergency Medicine for up to 60 minutes, and within that period 47%
of them were subjected to endopleuralna drainage.
Emergency operations in the second group of patients started
150-180 minutes following their arrival at the Clinic of Emergency
Medicine (+ 30 minutes for transportation from the place of accident),
Figure 1 Beginning of operating period (in minutes)
from the arrival at Clinic of Emergency Medicine. and in 47% of them in the interval of 3 hours and 30 minutes after the
injury. It can be explained that the aforementioned interval “was used”
50 G. Dedović Halilbegović et al.
for additional specialist examinations and subsequently recommended ing injuries to be treated within three hours of the injury, it is necessary
diagnostic procedure for 21% of patients surgically treated at Oper- to establish a consolidated trauma system in prehospital and hospital
ation Block of the Clinic of Emergency Medicine. Furthermore it can care of traumatized patients. Surgical treatment and further recovery
be explained that the interval was used for the admission and triage at should be centralized at the Clinic of Emergency Medicine with a mul-
PIT of the Clinic of Emergency Medicine due to required reanimation tidisciplinary approach developed through the trauma system, which
during the agreement of the Admission Advisory Board, or for the ensures that decisions about the life-threatened, traumatized patient
transportation of injured patients to COB and their reception by other are made by Trauma headed by the Trauma leader involved in the
teams (anesthesiologist and surgeon), given that 56% of patients from medical care from the very beginning.
the GII were surgically treated at COB. 23% of the injured patients
were surgically treated in the period from 3 to 48 hours after the inju- Conflict of interest: none declared.
ry, which can be explained by their serious condition requiring a longer
stabilization period, or the presence of a small amount of free fluid or
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12. American College of Surgeons. National Trauma Data Bank. Annual Report 2007.
It can be concluded that the time of surgery influenced the out- ACS 2007.
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ference recorded in the treatment outcome, with the largest number body multislice computed tomography as the primary and solid diagnostic tool in
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15. Akšamija G. Korelativnost postojećeg organizacijskog modela zbrinjavanja na
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CONCLUSION
Reprint requests and correspondence:
Survival of patients with signs of major trauma depends on the Gjulera Dedović Halilbegović, MD, MSc
general condition before the injury, age, but also to a large extent on Clinic of Emergency Medicine
Clinical Center University of Sarajevo
the quality of the offered emergency medical assistance, promptness
Bolnička 25
of the patient’s stabilization and necessary diagnostic procedures and 71000 Sarajevo
the time passed between the injury and urgent surgical treatment. In Bosnia and Herzegovina
order to enable the majority of traumatized patients with life threaten- Email: gjudedovic@yahoo.co.uk
Medical Journal (2015) Vol. 21, No. 1, 51 - 53 Professional article
*Corresponding author
for the repair of high-type ARMs was described by Georgeson et The most common malformations were those without fistula in
al. (11). It is a less invasive procedure when compared with those 17 patients (39.53%). Rectourethral fistula was found in 14 patients
operations that would have previously required a laparotomy such (32.56%). Out of that number 10 patients had rectourethral prostatic
as a rectobladder neck fistula and rectoprostatic fistula (12). fistula and 4 other patients had rectourethral bulbar fistula. Vestibu-
Despite all advances in operative techniques and improvements lar fistula was classified as intermediate lesion in 6 patients (13.95%).
of survival rate of these patients, there is a high incidence of postop- Rectal atresia as a rare malformation was diagnosed in 1 male patient
erative fecal incontinence and constipation that occur even after an (2.33%) while in females there was 1 case of cloacal malformation
excellent surgical repair. These complications are manageable by ad- (2.33%). All types of high ARMs according to Krickenbeck classifica-
ditional procedures such as the bowel management protocol, conti- tion are shown in Table 1.
nent appendicostomy and sometimes redo operations (13,14,15).
Table 1 Types of high and intermediate ARMs according to
Krickenbeck classification.
MATERIALS AND METHODS MALE FEMALE
TOTAL
high interm. high interm.
This study focused on 43 patients with high and intermediate
N N N N N %
anorectal malformations diagnosed and treated at the University
Recto-urethral fist. prostatic 10 - - - 10 23.26
Clinical Centre of Kosovo in the period from 2005 to 2014 in the
Recto-urethral fistula bulbar - 4 - - 4 9.30
framework of a combined retrospective and prospective analysis of
a total of 76 patients with anorectal malformations. Patient records Recto-vesical fistula 4 - - - 4 9.30
and databases of the Clinic of Pediatric Surgery and Clinic of Neona- Vestibular fistula - - - 6 6 13.95
tology were used to obtain necessary data. Operated patients were Cloaca - - 1 - 1 2.33
invited for evaluation of their postoperative functional outcome. No fistula 8 5 4 - 17 39.53
According to X-ray images and intraoperative findings we classified Rectal atresia 1 - - - 1 2.33
ARMs into high, intermediate and low according to Wingspread
Total 23 9 7 4 43 100
classification. All patients with low ARMs were excluded from this
study. We have also used Krickenbeck classification of ARM for de- Surgical treatment was performed in 33 patients. Out of that num-
fining the type of malformations and for evaluation of postoperative ber, 3 patients (9.09%) with intermediate lesions were treated primar-
functional outcome. Voluntary bowel movements (VBM) and soiling ily at first stage without colostomy whereas in 30 patients (90.91%)
were evaluated in a group of 29 patients at toilet training age (over surgical treatment consisted of three stages including the colostomy
3 years of age). Postoperative constipation was analyzed in a group creation after birth, definitive repair and colostomy closure. LAARP
of 32 patients starting as early as possible in life, from the moment was used in the treatment of 1 patient (3.03%) whereas 32 other pa-
the parents reported the occurrence of constipation. tients (96.97%) were treated using PSARP as the procedure of choice
(Figure 2).
RESULTS
soiling were evaluated in 29 patients over 3 years of age. VBM were patients, wound dehiscence at the sight of colostomy in 1 patient,
present in 15 patients (51.72%), whereas 11 patients (36.36%) still postoperative anal and urethral stenosis in 1 patient, and partial
had soiling. Therefore only 4 patients (13.79%) were considered con- wound dehiscence in 1 patient. Laparotomy was performed in case
tinent. In total, soiling was present in 25 patients (86.21%). with adhesive ileums, colostomy revision was performed in 3 pa-
Due to poor outcome after final treatment, five patients (15.63%) tients, and redo anoplasty in 1 patient. Patient with anal and urethral
underwent redo operations. Overall mortality rate of patients with stenosis was treated successfully with dilations of urethra and anus.
high ARMs was 13.95% (N=6). One patient with partial wound dehiscence after PSARP was treated
conservatively and wound was healed by secondary intention.
Out of 33 patients with finalized surgical treatment 1 patient
DISCUSSION who was operated in first stage with PSARP died 10 days after the
operation due to sepsis and complications thereof. Consequently,
As shown in Figure 1, high and intermediate type lesions were functional outcome was evaluated in 32 patients. Postoperative con-
more frequent in male than in female patients which seem to be stipation was present in 28.13% of analyzed patients (N-9). Con-
similar to the literature (6). The most common type in this study stipation of grade 2 (needs for laxatives) was present in 5 patients,
was ARM without fistula which was found in 17 patients (39.53%). whereas constipation of grade 3 (resistant to diet and laxatives) was
12 of them were classified as high type defects and 5 others as inter- present in 4 patients who were treated with enemas.
mediate. In female patients there were 4 cases without fistula and all 29 patients at toilette training age (over 3 years of age) were
of them were classified as high type. In the reports of M. Levitt and evaluated for VBM and soiling using Krickenbeck criteria for as-
A. Pena the incidence of ARM without fistula was 5% (16), which sessment of postoperative outcome (4). VBM were present in 15
was less than in our study. The second most common malforma- patients (51.72%) whereas 11 patients (36.36%) still had soiling.
tion in our study was recto-urethral fistula registered in 14 patients Therefore only 4 patients (13.79%) were considered continent. In
(32.56%). It was the most common malformation in male patients total, soiling was present in 25 patients (86.21%) including 14 pa-
presented in 10 patients with rectoprostatic fistula and 4 patients tients (48.28%) without VBM and 11 above mentioned patients with
with rectobulbar fistula. At this point, our study matches Alberto VBM but also soiling. Occasional soiling (grade 1) was registered in
Pena’s reports from 1995. In his series recto-urethral fistula was the 2 patients (6.90%), everyday soling with no social problems (grade
most common lesion in male patients (17). This study involved only 2) was registered in 6 patients (20.69%), and finally constant soiling
one case of rectal atresia (1.32%) and one cloaca (1.32%) with 5 cm (grade 3) was present in 17 patients (58.62%).
long common channel, so we considered it as high type lesion. 14 patients included in this study underwent bowel management
As mentioned before, a very important decision to be made in procedures with daily enemas which produced successful outcome
a neonate with ARM is whether the patient needs a colostomy and in 9 patients, whereas 5 patients needed two enemas daily to remain
staged treatment or primary treatment without colostomy at first completely clean.
stage. Out of 43 patients with high ARMs we opted for one stage Posterior sagittal approach including posterior plication of mus-
treatment without colostomy in 3 patients. This group consisted of cle complex and re-establishing of anorectal angle was also the
two female patients with vestibular fistula and one male patient with- procedure of choice in redo operations in 5 patients with poor
out fistula. In this regard there are reports in the literature related to functional outcome. The group of patients to whom redo PSARP
the treatment of high ARMs at first stage without colostomy (8,9). was performed consists of 3 patients with vestibular fistula, 1 pa-
93.02% of patients (N=40) underwent staged surgical treatment in- tient with rectourethral prostatic fistula and the patient treated with
cluding the formation of a divided colostomy, definitive repair of LAARP because of rectovesical fistula. Decision for redo operation
ARM and the colostomy closure. In all cases we performed divided in 3 patients (9.38%) was made due to fecal incontinence which oc-
colostomy at the level of sigmoid colon. We avoided loop colosto- curred as a result of incorrect anorectal angle and misplaced anus
mies because they were found to be associated with a higher total and rectum, and in 2 patients (6.25%) due to chronic and severe
incidence of complications than divided colostomies (18,19,20). In constipation, megarectum and overflow incontinence. In one patient
total, surgical treatment was completed in 33 patients. A group of with severe constipation and megarectum developed after vestibular
10 other patients to whom the surgical treatment was not complet- fistula repair, posterior sagittal anorectoplasty was a part of abdomi-
ed consists of 5 patients who died after colostomy, 3 patients with no-perineal approach, combined with laparotomy and resection of
colostomy waiting for definitive repair and 2 patients with colosto- megarectum, which provided excellent results. In four patients with
my who did not return to our clinic for further treatment. redo PSARP we recorded the improvement of functional outcome
PSARP is widely accepted as the standard procedure in patients but in the fifth patient, with poor developed muscle complex, results
with high and intermediate type of ARMs (10,21). It was also the were not satisfying. Usage of PSARP in redo operations was report-
standard operative technique for us, and therefore we used it in ed by many authors (22,23).
the treatment of 96.97% of patients in this study (N=32), including 6 neonatal patients died during this study (13.95%). 1 patient
3 patients treated at first stage without colostomy and 29 patients died prior to any surgical treatment. Another patient died after
with colostomy. Only one patient with colostomy, with rectovesical PSARP without colostomy, 3 patients after colostomy and the last
fistula, was surgically treated with LAARP (1.54%) (Figure 2). one (with associated long gap esophageal atresia) died after colos-
Postoperative complications occurred in 7 patients (16.67%) as tomy and gastrostomy. Pneumonia, cardio respiratory failure, acute
follows: postoperative adhesive ileus after colostomy in 1 patient, renal failure, sepsis and complications thereof were the causes of
prolapse of rectal mucosa in 1 patient, prolapse of colostomy in 2 deaths.
54 S. Statovci et al.
CONCLUSION 13. Bischoff A, Levitt M. A, Peña A. Bowel management for the treatment of pediatric
fecal incontinence. Pediatr Surg Int. 2009;25(12):1027–1042.
14. Har AF, Rescorla FJ, Croffie JM. Quality of life in pediatric patients with unremitting
Treatment of high ARMs is a challenging problem. It is associated constipation pre and post Malone Antegrade Continence Enema (MACE) proce-
with high percentage of children suffering from fecal incontinence dure. J Pediatr Surg. 2013;48(8):1733-7.
even after an excellent surgical treatment. Bowel management pro- 15. Brain AJ, Kiely EM. Psterior saggital anorectoplasty for reoperation in children with
tocol, when applied accurately, is very important in improving the anorectal malformations. Brit J Surg. 2001;76(1):57-59.
quality of life of operated patients with ARM because it offers better 16. Levitt MA, Peña A. Anorectal malformations. Orphanet Journal of Rare Diseases.
2007; 2:33.
opportunities for integration of the children in daily activities. Redo
17. Peña A. Anorectal Malformations. Semin Pediatr Surg. 1995;4:35-47.
operations must be considered in patients with constant soiling and
18. Peña, A., Levitt, M.A. Imperforate Anus. Pediatric Gastrointestinal and Liver Dis-
cases with megarectum. Correction of incorrect anorectal angle in ease, 3rd edition. 2006;749-755.
patients with well-developed muscle complex can give good results 19. Oda O, Davies D, Colapinto K, Gerstle JT. Loop versus divided colostomy for the
and significantly improve the patients’ quality of life. management of anorectal malformations. J Pediatr Surg. 2014;49(1):87-90;
20. Van den Hondel D, Sloots C, Meeussen C, Wijnen R. To split or not to split: co-
Conflict of interest: none declared. lostomy complications for anorectal malformations or hirschsprung disease: a sin-
gle center experience and a systematic review of the literature. Eur J Pediatr Surg.
2014;24(1):61-9.
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& neonatal. 1996;1(3,):219–230.
1. Upadhyaya VD, Gangopadhyay AN, Srivastava P, Hasan Z, Sharma SP. Evolution 22. Pena A. Posterior saggital anorectoplasty as a secondary operation for the treat-
of management of anorectal malformation through the ages. Internet J Surg. ment of faecal incontinence. J Pediatr Surg. 2001;18(6):762-773.
2008;17:1. 23. Dewan PA, Hrabovszky Z, Mathew M. Redo anorectoplasty in the management
2. Levitt MA, Peña A. Imperforate anus and cloacal malformations. In: Holcomb III of anorectal anomaly patients. Australian and New Zealand Journal of Surgery.
GW, Murphy JP, editors. Ashcraft’s Pediatric Surgery. 5th ed. Philadelphia, PA: Saun- 2000;70 (supple l), A109.
ders Elsevier. 2010:468-90.
3. Gangopadhyay AN, Pandey V. Anorectal malformations. J Indian Assoc Pediatr Surg.
2015;20(1):10-5.
4. Holschneider A, Hutson J, Pena A, et al. Preliminary report on the International
Conference for the Development of Standards for the Treatment of Anorectal
Malformations. Journal of Pediatric Surgery. 2005;40:1521-1526.
5. Peña A, Hong A (2000) Advances in the management of anorectal malformations.
Am J Surg. 180:370–376.
6. Endo MHayashi AIshihara M, et al. Analysis of 1992 patients with anorectal malfor-
mations over the past two decades in Japan. J Pediatr Surg. 1999;34435- 441
7. Mittal A, et al. Associated anomalies with anorectal malformation. Indian J Pediatr.
2004;71:509–514.
8. Albanese CT, Jennings RW, Lopoo JB: One-stage correction of high imperforate
anus in the male neonate. J Pediatr Surg. 1999;34(5):834-836
9. Liu G, Yuan J, Geng J, Wang C, Li T. The treatment of high and intermediate anorec-
tal malformations: one stage or three procedures? J Pediatr Surg. 2004;39(10):1466-
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10. De vries, Pena A. Posterior sagittal anorectoplasty. Journal of paediatric surgery. Reprint requests and correspondence:
2001: 17(5):638-643. Sejdi Statovci, MD
11. Georgeson KE, Inge TH, Albanese CT. Laparoscopically assisted anorectal pull- Clinic of Pediatric Surgery
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Medical Journal (2015) Vol. 21, No. 1, 55 - 57 Professional article
*Corresponding author
ABSTRACT SAŽETAK
Tonsillectomy is one of the most common surgeries and accounts Tonzilektomija spada među najčešće operativne zahvate i čini
for about half of all surgical procedures in children. Each year around oko polovinu svih hirurških procedura kod djece. U SAD-u se go-
200,000 of these operations are performed in the United States, and dišnje uradi oko 200 000 ovih operacija te tonzilektomije čine 1/3
tonsillectomy in general anesthesia makes one third of them. The mor- trećinu operacija od onih koje se izvedu u opštoj anesteziji. Sto-
tality rate is 1 to 10000-35000, and the morbidity rate varies from 1.5 pa mortaliteta je 1 na 10 000-35000, a stopa morbiditeta varira
% to 14 %. The aim of the study was to examine the effect of postoper- od 1.5% do 14%. Cilj studije je bio ispitati utjecaj postoperativnog
ative use of lysozyme and pyridoxine oritablets on pain reduction, fast- korištenja lizozim i piridoksin oritableta na smanjenje bola, brže
er wound healing and postoperative complications after tonsillectomy. zarastenje rane i postoperativne komplikacije nakon tonzilektomi-
The study included 100 patients. Patients were monitored for 14 days je. Studija je uključila 100 pacijenata. Pacijenti su praćeni 14 dana
after surgery. The research was done as a clinical, prospective study. nakon operacije. Istraživanje je provedeno kao klinička, prospek-
There was statistically significant difference in the degree of pain that tivna studija. Postojala je statistički značajna razlika u stepenu boli
respondents felt 7 and 14 days after surgery, and less pain was felt by koji su ispitanici osjećali 7 i 14 dana nakon operacije, te da su man-
subjects of the experimental group. There was statistically significant ju bol osjećali ispitanici ispitivane skupine. Postojala je statistički
difference in the consumption of analgesics, and the subjects of the značajna razlika u potrošnji analgetika, te su ispitanici ispitivane
experimental group used significantly less analgesics in the postopera- skupine trošili znatno manje analgetika u postoperativnom perio-
tive period. By analyzing the frequency of increased fibrin deposition du. Analizom učestalosti povećanih fibrinskih naslaga ustanovljeno
it was found that 6% of controlled and 8% of the experimental group je da je 6% ispitanika kontrolne i 8% ispitivane skupine imalo pov-
had increased fibrin deposits, and there was no statistically significant ećane fibrinske naslage, te nije postojala statistički značajna razlika
difference in the incidence of increased fibrin deposits in relation to the u učestalosti povećanih fibrinskih naslaga u odnosu na ispitivanu
experimental group. There was no statistically significant difference in skupinu. Nije bilo statistički značajne razlike u učestalosti komplik-
the incidence of complications among the two groups. acija u ispitivanim skupinama.
Key words: tonsillectomy, complications, lysozyme/pyridoxine or- Ključne riječi: tonzilektomija, komplikacije, lizozim i piridoksin orita-
itablets. blete
INTRODUCTION tomy is one of the most common surgeries and accounts for about
half of all surgical procedures in children. Each year around 200,000
Tonsillectomy was first described in 1000 BC, but it gained pop- of these operations are performed in the United States, and ton-
ularity in the 1800s when first partial removal of tonsils was per- sillectomy in general anesthesia makes one third of them. Tonsil-
formed. Given that a part of tonsil remained, they eventually hyper- lectomy is at twenty-fourth place when it comes to indications for
trophied and caused airway obstruction. At the beginning of 20th hospital admission. Earlier tonsillectomy was usually indicated be-
century the importance of tonsilar disease has been recognized and cause of infections, and now mostly due to airway obstruction. The
importance has been given to total tonsillectomy (1, 2). Tonsillec- mortality rate is 1 to 10000 -35000, and the morbidity rate varies
56 L. Sarajlić et al.
from 1.5 % to 14 %. Mortality and morbidity after tonsillectomy are Chi square test showed that there was no statistically significant
usually a result of post-operative bleeding. In addition to the bleed- difference in the age structure of the respondents between the two
ing, the most common complications include infection, pain, nausea groups, χ2 = 2.28; p = 0.131.
and vomiting (3,4). Lysozyme is a mucopolisaharidosis that catalyses Figure 1 shows analysis of the pain scale 7 and 14 days after sur-
hydrolytic degradation of large number of Gram positive and some gery in the control and test groups. The average pain scale value of
Gram negative bacteria. It exhibits its activity in cooperation with the control group subjects 7 days after the surgery was 5.55 ± 1.11
complementary immunoglobulin class A present in oropharingeal and 4.38 ± 1.06 in the test group subjects. 14th postoperative day
mucosis. In this way lysozyme exhibits its local antiinflammatory and was also analyzed and it was found that the average pain scale value
anesthetic effect. Pyridoxine (vitamin B6) in this medicine has a pro- in the control group was 2.40 ± 0.78 and 1.60 ± 0.75 in the test
tective and regenerative function to mucosis of oral cavity as well group subjects. ANOVA test showed that there was a statistically
as pronouncedly antiaphtous effect. Indication for its application is significant difference in the degree of pain that respondents felt 7
gingivitis, aphtes, herpetis lesions and erosions of oral cavity. Those and 14 days after surgery, and less pain was felt by subjects of the
lesions are always present after tonsillectomy. test group.
Aim
To examine the effect of postoperative use of lysozyme and
pyridoxine oritablets on pain reduction, faster wound healing and
postoperative complications after tonsillectomy.
The study included 100 patients of both sex, age between 7 and 30
years. Patients were divided into two groups; experimental and control:
1. Experimental group: patients who used lysozyme and pyridoxim
oritablets 24 hours after tonsillectomy for eight postoperative days.
Figure 1 Analysis of the pain scale 7 and 14 days after sur-
2. Control group: patients who did not use oritablets. They were gery in the control and test group.
monitored for 14 days after surgery. Control examinations were done
on the first, second, seventh and 14th postoperative day. Analysis of the average postoperative analgesic consumption
Impact of lysozyme and piridoxim oritablets to cessation of pain was established that the subjects in the control group used 3.36 ± 1.41
monitored in two ways: pieces of analgetics, while the test group respondents used 1.30 ±
- by pain scale from 1-10 1.52 pieces of analgetics. ANOVA test showed statistically signifi-
- through the need for analgetics cant difference in the consumption of analgesics, with the subjects
Effect of the medicine on wound healing was followed through of the test group using less analgesics in the postoperative period, F
the appearance of postoperative scar and on basis of possible com- = 63.27; p = 0.001 (Figure 2).
plications such as bleeding from the scar tissue and the appearance of
significant fibrin deposits. The amount of fibrin deposits was followed
by scale 1-3 (1-decreased, 2-common, 3-increased amount of fibrin de-
posits). The research was done as a clinical, prospective study.
RESULTS
*Corresponding author
ABSTRACT SAŽETAK
Sterilization is the process related to elimination or destruction of Sterilizacija je proces pri kome se vrši eliminacija ili destruk-
all microorganisms including their spores. Central sterilization is a unit cija svih mikroorganizama uključujući i sporogene oblike. Cen-
functioning within surgical disciplines of the Clinical Center University tralna sterilizacija je organizaciona jedinica u sastavu hirurških
of Sarajevo. It has become operational in 2001 in a newly built area disciplina Kliničkog centara Univerziteta u Sarajevu. Sa radom
of the Central Medical Block, covering the space of 940 m2. The or- je počela 2001. godine u novosagrađenom prostoru Centralnog
ganization of Central sterilization in one place has been an economic medicinskog bloka. Površina je 940 m2. Organizovanje Centralne
solution. The quality of sterile material is reliable, there is a better sterilizacije na jednom mjestu je ekonomično rješenje. Kvalitet
control, and less staff is engaged. Sterilization involves reprocessing of sterilnog materijala je pouzdan, bolja je kontrola, a angažovano je
surgical instruments and equipment for all operating theatres and de- manje osoblja. Djelatnost je reprocesiranje hirurških instrume-
partments of the Clinical Center, preparation of sterile surgical laun- nata i pribora za sve operacione sale i odjeljenja Kliničkog centra,
dry, transport of sterile materials and their distribution to operating priprema sterilnog operacijskog veša, transport sterilnog materi-
theatres at several locations. The aim of this article is to present the jala i distribucija prema operacijskim salama koje se nalaze na više
function and importance of Central Sterilization of the Clinical Cen- lokacija. Cilj rada je prikazivanje rada i zanačaja Centralne steril-
tre University of Sarajevo. Proper reprocessing of medical equipment izacije Kliničkog centra Univerziteta u Sarajevu. Pravilno repoce-
for repeated use, specifically mechanical cleaning, disinfection and siranje medicinske opreme za višekratnu upotrebu tj. mehaničko
sterilization, presents an important measure for preventing hospital čiščenje dezinfekcija i sterilizacija predstavlja značajnu mjeru za
infections. The sterilization technique using saturated stream under prevenciju bolničkih infekcija. Najpouzdaniji način sterilizacije je
pressure is the most reliable and as such is used in the CCUS. Each zasićenom parom pod pritiskom što koristimo u KCU Sarajevo.
sterilization step is controlled and recorded. Svaki korak sterilizacije je kontrolisan i dokumentovan.
Key words: central sterilization, surgical instruments, medical ma- Ključne riječi: centralna sterilizacija, hirurški instrumenti,
terials medicinski materijal
INTRODUCTION rary planning principles and comprises three separate parts. In ac-
cordance with the existing standards the Central sterilization of the
Sterilization is a health care unit not receiving adequate atten- CCUS is organized in three completely separated sectors depending
tion. It primarily has a preventive role in combating infections and is on purity of the processed materials. The first sector (impure) is
therefore important in treatment of hospitalized patients but also in used for processing of contaminated materials which following the
treatment of other users of health care protection. Bruch and Bruch disinfection enter the second sector (clean sector) through washing
(1971) suggest the use of definition according to which sterilization and disinfection machines. The third sector is sterile and sterile ma-
is the process by which living organisms are removed or killed to the terials are kept therein. There must be a physical barrier between
extent that they are no longer detectable in standard culture media the sectors preventing the staff ’s entry. Staff in the Central steriliza-
in which they previously have been found to proliferate, namely the tion wears surgical gowns (1,2).
microorganisms no longer grow thereon. Often forgotten and neglected, the central sterilization is an in-
Central sterilization is an organizational unit functioning with- dependent and unavoidable part of the hospital’s every day func-
in surgical disciplines of the CCUS. It has become operational in tioning. Although it is (unjustly) linked with the surgical work, its role
2001 in a newly built area of the Central Medical Block, covering the is much wider. The central sterilization is certainly the central part of
space of 940 m2. The space is organized in line with all contempo- the basic hospital functioning. Except for cleaning, disinfection, ster-
European sterilization standards in the Clinical Center University of Sarajevo 59
ilization and sterile packing of instruments, materials and equipment of microorganisms from the living tissue in order to prevent their
for the operating theatre needs, the central sterilization is also used development or for limitation and treatment of already existing in-
for preparation of materials, equipment and instruments necessary fection. From the aforementioned definitions it can be concluded
for every day functioning of literally all hospital departments and that asepsis is a working requirement in certain medical disciplines
dispensaries. achieved by sterilization of inanimate objects and materials getting in
Organization of the central sterilization in one space has been touch with the living tissues. Disinfection can be defined as the proce-
an economic solution. Quality of sterile material is reliable, there is dure for destruction, inhibition or removal of vegetative forms of mi-
a better control, and less staff is engaged. croorganisms, not necessarily the bacterial spores. Not all the existing
microorganisms should be destroyed by disinfection. It is sufficient to
reduce them to the level not harmful to human health or the quality
of groceries (2,4,5).
Function
Figure 2 Interior of Central Sterilization Unit.
Reprocessing of surgical instruments and equipment for all op-
erating theatres and departments of the CCUS, preparation and Preparing of instruments
sterilization of the surgical laundry for operating theatres, processing
and sterilization of the spongious bone for the need of the Clinic of There is a strictly established procedure in the medical materi-
Orthopedics and Traumatology, transport of the materials for ster- als-instruments sterilization cycle. Each step is of crucial importance,
ilization, specifically transport and distribution of sterile materials to and any mistake can lead to contamination and make the procedure
the operating theatres at several locations. useless. On the other hand, life and health of patients and staff are
Sterilization for medical and pharmaceutical purposes can be de- jeopardized and increase of financial expense can occur. Therefore,
fined as the procedure which in a bottom line guarantees that no each step in the sterilization cycle must be controlled in many ways,
more than one microorganism to one million will survive in the over- recorded and monitored; and the final goal is to get a safely sterilized
all number of sterilized units of the final product. Sterilization is the product, specifically a guarantee of assured quality (4,5)
procedure or process for elimination of all types and forms of micro-
organisms, including bacterial spores to the extent that they are no Transportation
longer detectable in standard culture media in which they previously
have been found to proliferate, namely the microorganisms no longer After use, the instruments and other reprocessed materials are
grow thereon. Thus, sterile means deprived of each and every life transported to the central sterilization service in closed systems (trol-
category. This is the definition we always use to emphasize the differ- leys and containers) where further treatments for safe and repeated
ence between sterilization and disinfection (1,3,4). use are performed.
The processing of reusable instruments and devices is conduct-
ed in automatic washing and disinfection facilities. For the purpose Cleaning/disinfection
of sterilization water purification is necessary for removing chemi-
cal hardness. Water demineralization is the procedure for complete The used instruments are placed in a special department of the
removal of minerals dissolved in the water. Depending on the puri- central sterilization service where a series of cleaning and disinfection
fication phase requirements for water, quality is different. Ideally, de- procedures take place (manual and automatic depending on the ma-
mineralized water should be used in all purification phases, specifically terial the instrument is made of, but also of its characteristics). The
high quality water with minimum amount of particles and dissolved majority of impurity and microorganisms are removed by adequate
minerals. Drinking water can be used for the initial washing, but the cleaning procedures. Cleaning is a precondition for successful ster-
water for final washing should be of high quality. Sensitive instruments ilization, or in other words, sterilization does not stand for replace-
and equipment should always be washed, sterilized and transported ment of cleaning (1,4,5).
in the appropriate transporting baskets with holders in order to pre- Each instrument treated in the central sterilization service, after
vent their damage during processing and handling. completed cleaning and disinfection, is a subject of thorough inspec-
Asepsis is the state of being free from live microorganisms (with- tion. The aim of the inspection is not the washing quality control
out germs). Antisepsis is the procedure for destruction and removal (which is the case if it relates to manual washing. There are series of
60 A. Talić-Tanović et al.
tests for manual and automatic washing with a view of controlling im- Standardization (EN and ISO). They are a relevant category, which
purity invisible to the naked eye) but the control of instrument func- means that in time and with development of new technologies they
tionality instead. Articular parts and scissor sharpness are subject to can be expanded and updated. Our goal is continuous monitoring of
control, meaning that each instrument must be functional in order to the mentioned standards and their evaluation.
be reused. It is wrong to check instruments in the operating theatre Societal development results in the expansion of numerous dis-
or during surgical interventions. A disfunctional instrument makes ease pathogen agents, of which new are discovered every day, but
the work more difficult, it can cause complications, and adequate re- measures for their repression have also been taken. Sterilization is a
placement can not be provided on time. Therefore, the inspection method of choice in the control of currently known disease agents. It
conducted in the central sterilization service provides for timely re- is not self-sufficient, but, i.e. when we talk about instruments, it large-
placement of the disfunctional instrument, namely it prevents possi- ly depends on previously conducted cleaning and disinfection proce-
ble complications in the operating theatre (1,6) dures. The goal is to direct all available resources to the same aim, and
that is to get a safely sterilized product. The nurse in charge of sterile
Packaging materials must keep records on all procedures in sterilization and in
distribution of sterile materials (date, department).
Packaging implies providing adequate types of package for ap- Biological survaillance of sterilization is the most important con-
propriate materials. The aim of the packaging is primarily to provide trol of the sterilization function, the only method of controling the
adequate protection to the packed materials; sterile barrier system; success of sterilization. Biological indicators (Bacillus Stearothermo-
aseptic opening; in other words to ensure that the packaging tech- philus spores – for sterilization in the autoclave and Bacillus Subtilis
nique and choice of materials provide high protection quality for the spores – dry heat and ethylene oxide sterilization) are to be placed
sterile product. in the sterilization chamber not reachable by steam. After completed
sterilization a package with biological material is sent to a microbio-
Sterilization logical laboratory to establish if microorganisms were destroyed or
not.
There are numerous sterilization techniques. In health care insti- More contemporary biological indicators, besides the indicator
tutions the most frequent sterilization method is by using saturated band with spores also have the growth medium, and the analysis can
steam under pressure (steam sterilizer). Regardless of the type of be made in the sterilization unit with a portable incubator which en-
sterilization it should provide safety for staff and patients. ables result reading within 24-48 hours, which is much faster than to
wait for results from the microbiological laboratory (three or more
Sterile storage days). The new generation of biological indicators can be read in 1-3
hours. Destroyed spores confirm the success of sterilization. Systems
Secure a place for storage of sterilized materials (adequate microcli- for speedy reading of biological indicators have removed the only
mate conditions; humidity, temperature). flaw of biological control – waiting for the results. After three hours
we can issue the material with absolute certainty in its sterility. Euro-
Transportation to users pean rules recommend biological survaillance of each autoclave filling
(1,2,7)
In closed systems (trolley, containers) – transport packing. Possible mistakes occur as a consequence of the sterilization
theory ignorance, ignorance about specific sterilizer functioning, ster-
Use ilizer overburdening, improper set preparations, lack of equipment
maintenance, short sterilization process, and efforts to speed up the
Accurate use of sterilized materials (aseptic opening and handling sterilization process. In case of more significant defects on certain
of materials). Only a wrong step in opening can result in material vital parts of the central sterilization equipment, there is an alternative
contamination before the use. sterilization at certain locations such as Clinic for Urgent Medicine,
Clinic of Orthopedics and Traumatology, Vascular Clinic, which in
Problems which determined our plans and our vision such cases should take responsibility for sterilization (1,7).
technology, which has been the biggest change in medical practice 4. Rutala WA, Weber DJ. New disinfection and sterilization methods. Emerg Inf Dis.
in the past few years. The sterilization process carries enormous 2001;7:348-53.
5. Švrakić S, Šemić E, Pindžo M. Vodič za sestre i tehničare instrumentare. Ministarstvo
responsibility of the entire institution, especially its employees. The
zdravstva Kantona Sarajevo, Sarajevo, 2010.
entire documentation must be kept neatly and be officially verified
6. Buchrieser V, Miorini T. Osnovna skripta za reprocesiranje medicinskih instrumena-
by the institution. One must bear in mind that, in case of accidents, ta i pribora, 2009.
this documentation can be used in the court proceedings. There 7. Kalenić S, et al. Medicinska mikrobiologija, 1. izd., Zagreb: Medicinska naklada,
are no exemptions for the sterility issues. Sterilization is the letter 2013.
A in the medical alphabet! Each patient has the right to get a prod-
uct which is safely treated to its final goal – to be used as sterile!
Sterilization is the heart of hospital, which can beat properly only
if all working criteria have been respected; if employees in the cen-
tral sterilization service work as a team, if they are familiarized with
norms and standards, if they are continuously educated, and have
high degree of self-conscience. Modern sterilization should be the
extended hand of the operating theatre.
Amela Dedeić-Ljubović*
Department of Clinical Microbiology, Clinical Centre University of Sarajevo, Bolnička 25, 71 000 Sarajevo, Bosnia and Herzegovina
*Corresponding author
ABSTRACT SAŽETAK
The emergence and global spread of carbapenemase-producing Pojava i globalno širenje enterobakterija koje produkuju karbap-
Enterobacteriaceae is of great concern to health services worldwide. enemaze je od velikog značaja za zdravstvene ustanove širom svijeta.
These β-lactamases hydrolyses almost all β-lactams, are plasmid-en- Ove β-laktamaze hidroliziraju gotovo sve β-laktame, plazmidskog su
coded and easily transferable among bacterial species. They are porijekla i lako se prenose među bakterijskim vrstama. Uglavnom
mostly of the KPC, VIM, IMP, NDM and OXA-48 types. Infections su KPC, VIM, IMP, NDM i OXA-48 tipa. Infekcije uzrokovane ovim
caused by these bacteria have limited treatment options and have bakterijama su praćene ograničenim terapijskim mogućnostima i pov-
been associated with high mortality rates. Carbapenemase produc- ezane su sa visokom stopom smrtnosti. Karbapenemaza producira-
ers are mainly identified among Klebsiella pneumoniae, Escherichia coli, jući sojevi su uglavnom dokazani među izolatima Klebsiella pneumoniae
and still mostly in hospital settings and rarely in the community. The i Escherichia coli, uglavnom u bolničkoj, rjeđe u vanbolničkoj sredini.
types of carbapenemase vary among countries, partially depending Tipovi karbapenemaza variraju od zemlje do zemlje, što djelomično
on the migration of population between the regions and the possible zavisi od migracije stanovništva između regija i mogućeg rezervoara
reservoirs of each carbapenemase. This review described the epide- istih. Ovaj pregled opisuje epidemiologiju karbapenemaza produci-
miology of carbapenemases produced by enterobacteria highlighting rajućih enterobakterija naglašavajući zabrinjavajuće stanje i potrebu
the troublesome situation and the need to detect and screen these detekcije i praćenja istih kako bi se preveniralo i kontrolisalo njihovo
enzymes to prevent and control their dissemination. širenje.
Key words: carbapenemases, Enterobacteriaceae, KPC, NDM, Ključne riječi: karbapenemaze, enterobak terije, KPC, NDM,
OXA-48 OXA-48
INTRODUCTION others are plasmid encoded (KPC, IMI-2, GES, derivatives), but all
effectively hydrolyze carbapenems and are partially inhibited by
Carbapenemases are an increasing concern for global health- clavulanic acid (4).
care due to their association with resistance to β-lactam antibiotics, KPCs (acronym for K. pneumoniae carbapenemase) are the
and to other classes of antibiotics such as aminoglycosides, fluoro- most frequently encountered enzymes in this group (5). Since the
quinolones and cotrimoxazole (1). Thus they reduce the possibility first report of this enzyme in 1996 isolated from a clinical Klebsiella
of treating infections due to multidrug-resistant strains (2). The first pneumonia strain in North Carolina, USA (8), the KPC producers
description of carbapenemase-producing enterobacteria (NmcA) have spread around the world and are becoming a major clinical and
was in 1993 (3). Since then, large varieties of carbapenemases have public health concern (9). Several KPC clones are disseminating har-
been identified belonging to three molecular classes: the Ambler boring different multilocus sequence type, β-lactamase content and
class A, B and D β-lactamases (4). They have become epidemiolog- plasmids. However the blaKPC genes are flanked by a same trans-
ically important in different parts of the world including Mediterra- poson Tn4401 located on conjugative plasmids and are horizontally
nean countries, in recent years (2, 5, 6). Their enzymes are carried transferred (10).
either on chromosome or acquired via plasmids (7). This gives to this enzyme an extraordinary spreading capacity
(11). They have been detected more often in Klebsiella spp. (5), but
Class A carbapenemases have also been reported in other Enterobacteriaceae (12). Thirteen
variants of KPC are known so far; KPC2 and KPC3 are the most
A variety of class A carbapenemases have been described: frequent worldwide variants (13). The mortality rate due to infec-
some are chromosome encoded (NmcA, Sme, IMI-1, SFC-1) and tion with a KPC producer ranged from 25% to 69% (14). Single or
Carbapenem resistant Enterobacteriaceae - increasing issue for global healthcare 63
sporadic hospital outbreaks caused by KPCs isolated from various to temocillin is interesting to detect this enzyme (33). OXA-48 was
species were reported (15, 16, 17). KPC-2 is clearly the most prev- initially identified in K. pneumoniae isolate from Turkey in 2001 (34).
alent variant in Europe (9). Since then, OXA-48 producing strains have been extensively
reported as sources of nosocomial outbreaks in many part of the
Class B carbapenemases world notably in Mediterranean countries (35-38).
Moreover this enzyme has been found in different Enterobac-
Class B metallo-β-lactamases (MBLs) are mostly of the Verona teriaceae, such as Citrobacter freundii (39). Providencia rettgeri, and
integron-encoded metallo- β- lactamase (VIM) and IMP types and, Enterobacter cloacae (35) and even in E. coli (40,41). The death rates
more recently, of the New Delhi metallo-β-lactamases-1 (NDM-1) associated with MBL producers are unknown.
type. MBLs can hydrolyze all β-lactams except monobactam (e.g.
aztreonam). Their activity is inhibited by EDTA but not by clavu- Occurrence of carbapenemase-producing Enterobacteriaceae according
lanic acid (18). The death rates associated with MBL producers are to ECDS
high (18% to 67%) (19). Italy was the first Mediterranean country
to report acquired metallo-β-lactamases, with sporadic isolates of 39 national experts (NEs) from Europe rated the occurrence
VIM-4-producing K. pneumoniae and Enterobacter cloacae (20). Since and spread of CPE for their respective country in 2013. 37 of the
then, single or sporadic hospital outbreaks caused by VIM-1 like NEs declared that they were fully aware of the current epidemiolo-
enzymes have been described from various regions in this country gy of CPE in their country. Three NEs (representing Iceland, Mon-
(21, 22). However, such VIM-producing Enterobacteriaceae have not tenegro and the Former Yugoslav Republic of Macedonia) reported
undergone wide dissemination, unlike the one observed in Greece no case of CPE in their country. Sporadic cases, single or sporadic
during the same period (23). Endemicity of VIM- and IMP-producing hospital outbreaks were reported by NEs from 21 countries. For 11
Klebsiella pneumoniae strains has now been noted in Greece (18). countries, regional or national spread was reported, whereas NEs
Most recently reported NDM-1 enzyme is spreading rapidly of three countries (Greece, Italy and Malta) reported that CPE are
worldwide notably in Central and South America which represented regularly isolated from patients in most hospitals, corresponding to
the last zone without description of this enzyme (24, 25). NDM-1 an endemic situation (figure 1). Thirty-three of the NEs indicated
was initially identified in E. coli and K. pneumoniae in a patient re- that Klebsiella pneumoniae was the most frequent Enterobacteriace-
turning to Sweden from India in 2008 (26). Most of the outbreaks ae species harbouring carbapenemases in their country. IMP, KPC,
indicated a link with the Indian subcontinent, and in some cases with NDM, OXA-48 and VIM are the five most common carbapenemas-
the Balkan countries (27) and the Middle East (28). es in Enterobacteriaceae and thirty three of the NEs reported that
Contrary to other carbapenemase genes, blaNDM-1 is not as- one or more of these most common carbapenemases could be
sociated with a single clone. Thus NDM-1 has been identified mostly isolated in their country. In five countries (Bosnia and Herzegovina,
in non-clonally related E. coli and K. pneumoniae and to a lesser ex- Estonia, Montenegro, Serbia and the Former Yugoslav Republic of
tent in other enterobacterial species. These enzymes are encoded Macedonia), these data were not available (42).
on highly transmissible plasmids that spread rapidly between bacte-
ria, rather than relying on clonal proliferation. The strains harboring
NDM are broadly resistant to many other drug classes in addition
to β-lactams, and carry a diversity of other resistance mechanisms,
which leaves few treatment options (tigecycline or colistin). NDM-1
producers have been reported in the environment and in the com-
munity (29). They have been identified in Enterobacteriaceae species
around the world highlighting the ability of this gene to disseminate
in bacteria (30). Moreover NDM-1 has been identified in E. coli
ST131, a well-known source of community infections (31).
Class D carbapenemases
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Medical Journal (2015) Vol. 21, No. 1, 66 - 69 Case report
Amira Dedić1*, Mersiha Avdić-Saračević2, Ljiljana Kesić3, Mia Hodžić1, Alma Kantardžić
1
Department of Paradontology and Oral Medicine, Faculty of Dentistry University of Sarajevo, Bolnička 4a, 71000 Sarajevo, Bosnia and Herzegovina,
2
Departmant of Periodontology, New Mowasat Hospital, Kuwait,
3
Dental Clinic, Department of Oral Medicine and Paradontology, Faculty of Medicine University of Niš, Republic of Serbia
*Corresponding author
ABSTRACT SAŽETAK
We present a case of a six-year old patient with recurrent aph- U radu smo prikazali slučaj šestogodišnjeg pacijenta sa
thous ulcerations (RAU) that has persisted since the birth. RAU man- rekurentnim aftoznim ulceracijama koje perzistiraju od rođen-
ifests itself through a combined presence of small round aphthous ja. RAU se očituje kombiniranim prisustvom malih aftoznih ul-
ulcers with a diameter varying from several mm to 2x5 cm located ceracija okruglog oblika od nekoliko mm u promjeru do velikih
on the mucosa of the cheeks and tongue. The diagnostic procedure veličine 2 x 5 cm, na sluznici obraza i jezika. Dijagnostička pro-
focused on determining the systematic etiological logical factor for the cedura je išla u pravcu određivanja sistemskog etiološkog fak-
purpose of excluding systematic and autoimmune diseases. The biopsy tora u cilju isključenja sistemskih i autoimunih bolesti. Biopsija
or patohistological analysis confirmed the clinical diagnosis of Crohn’s tj. patohistološki nalaz potvrdio je kliničku dijagnozu Crohnove
disease. The interdisciplinary diagnostics of the RAU and Crohn’s dis- bolesti. Interdisciplinarna dijagnostika RAU i Crohnove boles-
ease points to the correlation of the exact clinical diagnosis confirmed ti ukazuje na korelaciju egzaktne kliničke dijagnoze potvrđene
by the patohistological analysis of the oral mucosa and mucosa of the patohistološkim nalazom oralne sluznice i sluznice kolona. Stoga
colon. A multidisciplinary cooperation is thus recommended in case of se kod svih pacijenata sa RAU preporučuje multidisciplinarna
all patients suffering from RAU. saradnja.
Key words: recurrent aphthous ulceration, Crohn’s disease, helio- Ključne riječi: rekurentna aftozna ulceracija, Crohnova bolest, he-
bacter pylori, biopsy, patohistological analysis liobacter pylori, biopsija, patohistološki nalaz
tion of numerous cytokines in the mucosa tissue (14, 15). Patients The lesions in the oral cavity, both symptomatic and asymptom-
suffering from HIV, especially those with a number of CD4 cells re- atic, occur in case of 6 to 20% of patients suffering from Crohn’s
duced to under 100/mm3 are more prone to occurrence of revers- disease (9). According to Ljušković, frequent oral changes in the case
ible aphthae (9). of Crohn’s disease constitute its first stage. This is followed by the in-
Hematological disturbances, sideropenic anemia, lack of folic acid testinal disease. Characteristic oral changes in case of Crohn’s disease
and, vitamin B12 are well known causes of RAU, with a prevalence of occur on the buccal mucosa and lips. Curves and ulcerations are also
20%, although the results vary from study to study (16, 17). visible. Granular changes on the gingiva and angular heilitis may also
In their study Brailo et al. have shown a strong link between RAU occur (26).
and dyspeptic disturbances. The authors point out that after the ex-
clusion of hematological deficiencies (Fe, folic acid and vitamin B12) a Clinical and patohistological correlations
patient suffering from RAU needs to be sent to a gastroenterological
examination, and an infection caused by H. pylori needs to be exclud- The patohistological RAU analysis result points to a localized in-
ed. The reasons given by the authors are contained in the findings of flammation and necrosis of the oral mucosa. The perivascular mono-
the study that point to a high frequency of infections caused by H. nuclear infiltration is increased, including vascular abnormalities and
pylori in case of 11.7% of respondents and remission of RAU after edema. The infiltrate may reach deep into the corium where numer-
the eradication therapy in case of 62.5% of respondents (2). ous blood vessels are visible with pathological changes indicating vas-
The research by Gallo et al. shows to which extent psychological culitis (27). According to Radović, vasculitis is an inflammatory change
stress can influence the occurrence of RAU as a trigger or modifying of blood vessels diagnosed by means of a biopsy in order to deter-
factor, but not as a cause, since no direct correlation has been estab- mine the level of activity of the disease and possibly the existence of
lished (18). Albanidou-Farmaki et al. concluded that stress may be changes that might precede a malignant disease (28).
one of the etiological factors in the occurrence of RAU, since levels
of salivary and serum cortisol and level of anxiety were considerably The dynamics of diagnostic procedures in patients suffering from
higher than in the control group (19). RAU
Crohn’s disease
from the literature and research conducted so far, the clinical and
patohistological diagnosis has confirmed that RAU can be the initial
symptom of ulcerous colitis and Crohn’s disease.
DISCUSSION
CrohnThe literature confirms that RAU is more frequent in women 9. Greenberg MS. Burketova Oralna medicina: Dijagnoza i liječenje, 10th edition. Zagreb:
(2, 6, 34). Given that our case involved only one patient, we cannot Medicinska naklada; 2006.
10. Thomas DW, Bagg J, Walker DM. Characterization of the effector cells responsible for
coment this. However, the age and persistence of RAU in the case of
the in vitro cytotoxicity of blood leucocytes from aphthous ulcer patients for oral epithelial
the six-year old boy present a new data for the literature related to
cells. Gut. 1990;31:294.
diagnostic, clinical and patohistological procedures. 11. Hoover CI, Olson JA, Greenspan JA. Humoral responses and cross-reactivity to viridians
The important piece of information that around 10–15% of streptococci in recurrent aphthous ulceration. J Dent Res. 1986;65:1101.
patients have atypical symptoms of extraintestinal disease in the form 12. Greenspan JS, Gadol N, Olson JA, Hoover CI, Jacobsen PL, Shillitoe EJ, et al. Lymphocyte
of recurring aphthous ulcerations and extraoral complications (35) is function in recurrent aphthous ulceration. J Oral Pathol. 1985;14:592.
in compliance with the findings related to our patient. Nobody from 13. Burnetti PR, Wray D. Tyler effects of serum and mononuclear leukocytes on oral epithelial
cells in recurrent aphthous stomatitis. Clin Immunol Immunopathol. 1985;34:197.
the family suffered from Crohn’s disease, so the data on hereditary
14. Pedersen A. Psychologic stress and recurrent aphthous ulceration. J Oral Pathol Med.
defect of permeability is not important in this case. A colonoscopy
1989;18(2):119-22.
was performed on the mucosa of the rectum, sigmoid colon in the 15. Buño IJ1, Huff JC, Weston WL, Cook DT, Brice SL. Elevated levels of interferon gamma,
area of colon descendens, on a length of 55 cm shallow ulceration tumor necrosis factor alpha, interleukins 2,4,5, but not interleukin 10, are present in recur-
with fibrin bottom, from where a biopsy was taken, including a rent aphthous stomatitis. Arch Dermatol. 1998;134:827-31.
clinical finding of aphthous ulceration from the buccal mucosa and 16. Barnadas MA, Remacha A, Condomines J, de Moragas JM. Hematologic deficiencies in
mucosa of the tongue, which were compatible. However, the biopsy patients with recurrent oral aphthae. Med Clin (Barc). 1997;109(3):85–7.
17. Thongprasom K, Youngnak P, Aneksuk V. Hematologic abnormalities in recurrent oral ul-
of patohistological verification of the buccal mucosa and mucosa of
ceration. Southeast Asian J Trop Med Pub Health. 2002;33(4):872–7.
the tongue corresponded to inflammatory changes, which pointed
18. Gallo Cde B, Mimura MA, Sugaya NN. Psychological stress and recurrent aphthous stoma-
to a chronic inflammation, corresponding to the pH finding of oral titis. Clinics (Sao Paulo). 2009;64(7):645–8.
mucosae. These procedures confirmed the diagnosis of Crohn’s 19. Albanidou-Farmaki E, Poulopoulos AK, Epivatianos A, Farmakis K, Karamouzis M, Anto-
disease. Oral aphthous ulcerations of RAU are the initial findings for niades D. Increased anxiety level and high salivary and serum cortisol concentrations in
the detection of inflammatory intestinal diseases and Crohn’s disease. patients with recurrent aphthous stomatitis. The Tohoku journal of experimental medicine.
2008;214(4):291–6.
20. Vrhovac B, Jakšić B, Reiner Ž, Vucelić B. Interna medicina 2. Zagreb: Naprijed; 1991.
21. Topić B. Stomatološka praksa i bolesti pojedinih organskih sustava. Sarajevo-Zagreb:
CONCLUSION
Stomatološki fakultet Univerziteta u Sarajevu i Medicinska naklada; 2008.
22. Šimić D. Bolesti sluznica: multidisciplinarni pristup. Zagreb: Medicinska naklada; 2012.
Based on the presented clinical case of RAU, there are certain 23. Bishop RP, Brewster AC, Antonioloi DA. Crohn’s disease of the mouth. J Gastroenterol.
clinical dilemmas such as: (i) are oral ulcerations the initial symptom 1972;62:302-6.
of Crohn’s disease?, (ii) are repeated aphthous ulcerations an ex- 24. Achkar E, Farmer RG, Flesher B, editors. Clinical gastroenterology. 2nd ed. Philadelphia:
pression of Crohn’s disease?, (iii) do repeated aphthous ulcerations Lea and Febiger; 1992.
co-indicate finding of Crohn’s disease? 25. Curran FT, Youngs DJ, Allan RN. Candidacidal activity of Crohn’s disease neutrophils. Gut.
1991;32:55-60.
The clinical and patohistological diagnostics confirm that recur-
26. Ljušković B. Parodontologija i oralna medicina. Beograd: Vojna knjiga; 2009.
rent aphthous ulcerations of RAU are the initial symptom of Crohn’s
27. Dedić A. Autoimune bolesti: Praktikum. Sarajevo: Stomatološki fakultet Univerziteta u Sa-
disease. Dental medicine and gastroenterology are related because rajevu; 2010.
they focus on digestive tract, and interdisciplinary cooperation is a 28. Radović S, Dorić M, Tomić-Ćuk I, Babić M, Kuskunović S. Dijagnostičke procedure u pa-
clinical imperative. Therefore, it is necessary to follow clinical and tologiji. Sarajevo: Medicinski fakultet Univerziteta u Sarajevu; 2012.
patohistological diagnostic procedures. 29. Weusten BLAM, van de Wiel A. Aphthous ulcers and vitamin B12 deficiency. The Nether-
lands Journal of Medicine. 1998;53(4):172–175.
Conflict of interest: none declared. 30. Birek C, Grandhi R, McNeill K, Singer D, Ficarra G, Bowden G. Detection of Helicobacter
pylori in oral aphthous ulcers. J Oral Pathol Med. 1999;28(5):197–203.
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thous stomatitis tissue by PCR. J Oral Pathol Med. 2000;29(10):507–13.
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i salivarni parametri kod oboljelih od rekurentnih aftoznih ulceracija. Acta Stomatol Croat. Oralna medicina. Zagreb: Školska knjiga; 2005.
2012;46(1):43–49. 33. Siegel MA, Jacobson JJ. Inflammatory bowel diseases and the oral cavity. Oral Surg Oral
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disponirajućih čimbenika u 68 bolesnika. Liječ Vjesn. 2007;129:4–7. 34. Rodu B. Oral mucosal ulcers: Diagnosis and management. J Am Dent Assoc.
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Stomatološki fakultet; 2004. 35. Halme L, Meurman JH, Laine P, von Smitten K, Syrjänen S, Lindqvist C, et al. Oral find-
4. Đukanović D, Đajić D, Stanić S, Kovačević K. Bolesti usta: Oboljenja mekih tkiva usne duplje ings in patients with active or inactive Crohn’s disease. Oral Surg Oral Med Oral Pathol.
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Reccurent aphthous ulcers today: a review of the growing knowledge. Int J Oral Maxillofac
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Medical Journal (2015) Vol. 21, No. 1, 70 - 72 Case report
*Corresponding author
ABSTRACT SAŽETAK
The occurence of rhabdomyolysis with consequent renal fail- Pojava rabdomiolize sa posljedičnom renalnom insuficijencijom i
ure and diffuse hepatopathy should rise a high index of suspicion znacima difuzne hepatopatije treba probuditi visok indeks sumnje na
of drug overdose, even in the absence of obvoius intravenous drug predoziranje drogom, čak i u odsustvu očiglednih znakova intravenskog
abuse. Admission to the intensive care unit is associated with a korištenja droge. Prijem u Jedinicu intenzivne njege je povezan s mor-
mortality of 22% in the absence of acute kidney injury, and 59% if talitetom od 22% u nedostatku akutne renalne insuficijencije, a 59% ako
renal impairment occurs. It is very rare for overdose to occur after dođe do akutne renalne insuficijencije. Vrlo rijetko dolazi do predoz-
intranasal administration of heroin. We present a case of a 31- year iranja nakon intranzalnog uzimanja (šmrkanja) heroina. Predstavit ćemo
old male, admitted to our Intensive Care Unit with clinical pre- slučaj 31-godišnjeg muškarca koji je primljen u Jedinicu internističke in-
sentation of coma, rhabdomyolysis, acute kidney failure and diffuse tenzivne terapije pod kliničkom slikom kome, rabdomiolize, akutne re-
hepatopathy after heroin overdose caused by intranasal adminis- nalne insuficijencije i difuzne hepatopatije nakon predoziranja heroinom
tration (snifing). intranazalnim putem (ušmrkavanjem).
Key words: heroin overdose, coma, rhabdomyolysis, acute kidney Ključne riječi: predoziranje heroinom, koma, rabdomioliza, akutna
failure renalna insuficijencija
INTRODUCTION ants, the strength of the drug reduces, with the effect that if steps
are missed, the purity of the drug reaching the end user is higher
Even though overdose is a known complication of intravenous than they are used to, and because they are unable to tolerate the
heroin abuse, it is very rare in case of heroin sniffing. Worldwide, increase an overdose ensues (4).
the UN estimates that there are more than 50 million regular users Bosnia and Herzegovina has a strategic location on the Balkan
of heroin, cocaine and synthetic drugs (1). In 2009, it was estimated route which connects drug production centres in Asia and the mar-
that the number of intravenous drug users in Bosnia and Herzegovi- kets in western Europe. As such it become a regional traffic centre
na could be as many as 15000 (2). The European Monitoring Centre for international trafficking of narcotics in Europe. At least 60 tonnes
for Drugs and Drug Addiction reports that the retail price of heroin of heroin are smuggled annually via the Balkan route. At least 10
in most European countries varies between €35-40 per gram (3). tonnes of heroin pass through BiH and its police seize barely 10
The patient in our study revealed that he usually pays 10-20 KM kilograms per year. The purity of seized drugs is not investigated at
(5-10 €) for one dose of heroin of unknown purity. The average the moment in Bosnia and Herzegovina. Furthermore, there is an
purity of street heroin varies between 30% and 50%. The variation increasing number of synthetic new drugs, so-called „magic dragon“,
of purity has led to people suffering from overdoses as a result of „crocodile“ — homemade synthetic opiates stronger than heroin,
the heroin missing a stage on its journey from port to end user, as made from petrol, red phosphorus and codeine. These synthetic
each set of hands that the drug passes through adds further adulter- opiates have a structure nearly identical to heroin, and are reported
Heroin overdose caused by intranasal administration (sniffing) causes coma, rhabdomyolysis, acute kidney failure and diffuse hepatopathy 71
to cause liver and muscle damage. Further studies are needed to A diagnosis of heroin overdose, rhabdomyolysis and conse-
investigate the full effect of these new drugs. Currently there are no quent acute renal failure and diffuse hepatopathy was established.
available screening tests for these new drugs in the Clinical Center The day after the admission, the patient was afebrile and started
University of Sarajevo. improving. On the third day he regained conciousness and after
completing criteria for extubation, he was extubated. His labora-
tory parameters improved, with steady fall in Le to 6,85 x109/L,
CASE REPORT K 3,9 mmol/L, CK 4727 U/L, LDH 1065 U/L, AST 246 U/L, ALT
297 U/L, and CRP 96,9 mg/L, INR 1,02 and APTT 36,1 s. At this
A 31-year-old man was found in coma at his house and brought stage (fifth day of hospitalization), he was transferred to the Clinic
by emergency ambulance to the Emergency Medical Center and of Nephrology due to continued elevated levels of creatinine 272
hospitalized at the Medical Intensive Care Unit ( JIIT). He had a his- mmol/L and urea 17,5 mmol/L. After conservative treatment, he
tory drug abuse, including prescription drugs (Lexillium, Tramadol) fully recovered and was released from hospital.
and ultimately he confessed „recreational“ sniffing of heroin. A day
prior to the admission, he was at a party where he had taken an
undetermined amount of heroin of unknown quality which resulted DISCUSSION
in unconsciousnes upon returning home. He was in coma for at least
12 hours before his mother called an ambulance. The patient did The onset of heroin’s effects depends on the route of
not regain consciousness after receiving intravenous Naloxone (2 administration. Intravenous injection is the fastest route of drug
ampules) in the Emergency Medical Center. administration, causing blood concentrations to rise the most
He has lived with his mother since the age of 6, without father. quickly, followed by smoking, suppository (anal or vaginal insertion),
He had no significant medical or surgical history. He was of strong insufflation (snorting), and ingestion (swallowing). To insufflate (snif)
muscular built, given that weight-lifting and boxing were his hoobby heroin, a user crushes the heroin into a fine powder and then gently
for the past five years. inhales it (sometimes with a straw or a rolled up banknote, as with
Physical examination showed deep coma (GCS 3/15) with cocaine) into the nose, where heroin is absorbed through the soft
contracted pupils. He had no signs of venepuncture on his body. tissue in the mucous membrane of the sinus cavity and straight into
Apart from swelling and edema of his feet and two necrotic cu- the bloodstream. This method is sometimes preferred by users
taneous lesions on lateral sides of his ankles, physical examination who do not want to prepare and administer heroin for injection or
was not significant. His body temperature was 39,4oC upon admis- smoking, but still experience a fast onset.
sion, rising to the maximum of 40,0oC six hours after admission. The mother of our patient found a home-made set for sniffing
Blood pressure was 109/76 (87) mmHg, heart rate 135/min and including a mirror and a rolled piece of paper. Only one study so far
respiratory rate 35/min on admission. Acid-base status revealed described cases of fatal heroin overdose associated with non-parental
slight hyperchloremic metabolic acidosis (pH 7,30; pCO2 4,7; pO2 administration including sniffing (5). It is very rare for overdose to
9.7; HCO3 16,7; Base excess -8,5; anion gap 5,5 and sO2 93.0%). occur after intranasal administration of heroin. Rhabdomyolysis after
Laboratory data revealed an elevated leucocyte (Le) count of 14,5 intravenous administration has been reported but the occurrence of
x109/L, elevated potassium (K) level of 5,5 mmol/L, decreased cal- rhabdomyolisis after heroin insufflation (sniffing) is very uncommon.
cium (Ca) level of 2,04 mmol/L, increased levels of: creatinine 275 Rhabdomyolysis may often be present with or without muscle
mmol/L, urea 14,6 mmol/L, creatine kinase (CK) 32860 U/L, lactic swelling or limb compression or no symptoms at all, even in conscious
dehydrogenase (LDH) 2388 U/L, aspartate aminotransferase (AST) patients. Toxic or allergic reactions to heroin are probably more
1067 U/L, alanine aminotransferase (ALT) 779 U/L, and C-reactive important causes of rhabdomyolysis than limb compression.
protein (CRP) 53,0 mg/L. There was an increase in INR 1,62 and Release of the muscle tissue components into the bloodstream
activated partial thromboplastin time (APTT) 43,1 s. His toxicology causes disturbances in electrolytes, which can lead to nausea, vomiting,
results were positive for benziodiazepines, morphine and heroin. confusion, coma or abnormal heart rate and rhythm. Damage to the
Immediately after admission, the patient was intubated, and placed kidneys may give rise to decreased or absent urine production, usually
on mechanical ventilation. He was treated with IV hydration, antibi- 12 to 24 hours after the initial muscle damage. Our patient had 975
otics, and anticoagulant with dose adjustment with regard to creat- ml of diuresis in the first 12 hours after admission and over 2000 ml in
inine clearance. the next 24 hours. Swelling of the damaged muscle occasionally leads
A second laboratory test 12 hours after admission showed de- to the compartment syndrome—compression of surrounding tissues,
creased Ca level 1,74 mmol/L, and even more increased levels of: such as nerves and blood vessels, in the same fascial compartment—
creatinine 330 mmol/L, urea 18,6 mmol/L, CK 39600 U/L, LDH leading to the loss of blood supply and damage or loss of function in
3072 U/L, AST 1248 U/L, ALT 865 U/L, CRP 153,7 mg/L, INR the part(s) of the body supplied by these structures. Symptoms of this
1,53 and APTT 60,6 s. Troponin level increased to maximum of complication include pain or reduced sensation in the affected limb (6).
11,3 ng/mL 24 hours after admission. An electrocardiogram (ECG) The most reliable test in the diagnosis of rhabdomyolysis is the
showed sinus tachycardia with a ventricular rate of 143/min, with- level of creatine kinase (CK) in the blood. This enzyme is released
out signs of acute ischemia or myocardial lesion. Results of a com- by damaged muscle, and levels above 5 times the upper limit of
puted tomographic (CT) scan of the patient’s head were normal normal indicate rhabdomyolysis. Depending on the extent of the
upon admission and 24 hours after admission. Lumbar puncture rhabdomyolysis, concentrations up to 100,000 U/l are not unusual.
results were normal and cerebrospinal liquor was sterile. (7).
72 A. Godinjak et al.
CONCLUSION
*Corresponding author
ABSTRACT SAŽETAK
This paper presents a 82 year old female patient with the left ven- Prikazana je 82-godišnja bolesnica s pseudoaneurizmom
tricular pseudoaneurysm (PA), which most likely occurred as compli- lijevog ventrikula srca (PA), koja je nastala najvjerojatnije kao
cation of an acute myocardial infarction (MI) 15 years ago. She was rana komplikacija akutnog infarkta srca (MI) preležanog prije 15
treated with medications. Methods: we performed transthoracic godine. Liječena je medikamentozno. Metode: urađena je trans-
echocardiography (TTE) and computerized tomography (CT) of the torakalna ehokardiografija (TTE) i kompjuterizirana tomografi-
abdomen. Random PA was found. The survival of our patients was ja (CT) abdomena. Slučajno je nađena PA. Preživljavanje naše
compared to other non-surgically treated patients with PA, and the at- bolesnice je uspoređeno s drugim neoperiranim bolesnicima s
tention was drawn to differences in echocardiographic presentation of PA, te je ukazano na razlike u ehokardiografskom prikazu prave
the actual heart aneurysm and PA. Results: based on the available data aneurizme srca i PA. Rezultati: prema dostupnim podacima pri-
the above mentioned patient could be considered as the LV pseudo- kazana gospođa bi bila bolesnica s najdužim preživljavanjem s
aneurysm patient with the longest survival, receiving medicamentous PA, liječena medikamentozno.
treatment.
Ključne riječi: pseudoaneurizma, preživljavanje, ehokardiografija,
Key words: pseudoaneurysm, survival, echocardiography, CT CT
A heart rupture (HR) is a heavy complication of myocardial A 82 year old female patient was treated at Department of In-
infarction (MI). According to majority of studies, the incidence is ternal Medicine of the Clinical Hospital Mostar 15 years ago as acute
around 1%, mortality due to rupture of the free wall is 80%, and rup-
ture of interventricular septum is 41% (1). The incidence of HR was
higher before the era of thrombolytic therapy, PCI, and increased use
of beta-blockers, ACE inhibitors, antiplatelets, statins, and it is now
around 6% (1).
LV pseudoaneurysm is a severe complication that occurs after the
rupture of the free wall of adherent pericardium. The incidence is
uncertain due to high mortality, short survival, and small number of
patients. Most often it occurs after MI, in 55 % of patients, and after
cardiac intervention, 33 % of patients, after blunt trauma of the heart,
7%, and endocarditis, 5 % (2).
Due to cardiac tamponade and high mortality, cardio surgical
treatment was indicated. Survival of the majority of non-surgically
treated patients with PA is short, burdened by heart failure, arrhyth-
mias, thromboembolism and sudden death. Fewer patients live longer
and patients who lived 10 and 12 years afterwards have been present- Figure 1 ECG: atrial fibrillation, scar inferior, persistent ST
ed (3,4,5,6). segment elevation in V5 and V6, with negative T wave.
74 Z. Šantić et al.
inferolateral MI. In addition she had diabetes mellitus and arterial hy- Subsequently, in February 2011, the echocardiography was per-
pertension. During the hospitalization the echocardiogram was not formed. The procedure was rather difficult due to the reduced and
performed, and ECG recording at discharge showed sinus rhythm, deformed thorax (kyphoscoliosis). It was performed with a sector
80/min, q in II, III, aVF, V5, and V6 leads, with persistent ST segment probe of 2.0 MHz. Findings showed dilatation of the left ventricle,
elevation of 1mm in leads V5 and V6, with a negative T wave in I, LVIDd 59mm, with a large akinetic inferior wall of the cavity (Figures
aVL, V5 and V6. ECG of the patient is shown in Figure 1. 5 and 6), size 50 mm, with calcified rim (Figure 7), in communica-
In 2005 she was surgically treated for the ascending colon can- tion with the LV through the hole, width of 20,6 mm. Doppler flow
cer. The follow-up CT of January 2011 showed wide pericardial measurement through the hole in the extension of the LV obtained
outflow and calcification, enlargement of the left ventricle, diame- spectrum corresponding to low blood flow velocities in systole and
ter of 57.8 x 48.4 mm (Figure 2). Figure 3 shows larger thrombus diastole, due to wide PA hole (Figure 8).
(35.1x18mm) in the present expansion of the left ventricule (LV),
and Figure 4 shows that the described changes were associated with
posterior LV wall.
DISCUSSION
was performed, and given the state of the patients in the first days PA is very prone to rupture and cardiac tamponade, a rare aneurysm.
of infarction and the persistent ST segment elevation in leads V5 Patients with PA should receive anticoagulant therapy, given the high
and V6 (Figure 2), and PA findings, an early myocardial rupture was risk of thromboembolism.
suspected. It was only 12 years after MI that she was diagnosed with In a series of 290 patients with PA, Frances et al. showed that
heart PA. they all had electrocardiographical abnormalities, usually non-specific
LV free wall rupture in MI is a heavy complication, and it makes changes in the ST segment, and only 20 % of patients had ST segment
85% of all ruptures occurring in the first week, of which 40-50% in elevation (8).
the first 48 hours (2). Due to cardiac tamponade and high mortality
cardiac surgery is indicated, with mortality rate from 13 to 35.7%
CONCLUSION
(3). The risk of PA rupture is about 30-45%, and it is an indication
for urgent cardiac surgery. The mortality rate of patients with non-
Pseudoaneurysm of the left ventricle is a rare but very severe
surgically treated PA is 48-55% as compared to 19-35% of those
heart complication. Due to high risk of rupture, majority of pa-
underwent surgical treatment (7).
tients are subjected to emergency cardiac intervention. Given that
Jose Lopez - Sendone et al. (1) thoroughly analyzed the incidence
postoperative mortality is relatively high, they often have significant
and factors associated with rupture of the heart, through the Global
comorbidity, and that in some cases non-surgically treated patients
Registry of Acute Coronary Events (GRACE) in the period from
live for years, it is necessary to individually assess whether a patient
January 2000 to December 2007 in 60198 of patients with acute
should be treated surgically or conservatively.
coronary syndrome. The incidence of HR was 0.9% for STEMI, 0.17%
This paper presents a 82 year old female patient with unoperat-
for non-STEMI and 0.25 % for unstable angina. Hospital mortality
ed PA, who lived 15 years after acute inferolateral MI, probably oc-
was 58% compared to 4.5% of patients with no HR. Mortality in free
curred after an early myocardial rupture. According to the available
wall rupture was 80%, and 41% in septal rupture. Of the total of 273
data she is the PA diagnosed patient with the longest survival.
patients with HR, 0.2% had a rupture of the free wall and septum
rupture of 0.26% (1). Conflict of interest: none declared.
Patients who do not undergo cardiac surgery, can live for
several years (3,4,5,6). Some are almost asymptomatic, others with
signs of hypotension, heart failure, arrhythmias, thromboembolism. REFERENCES
According to a metaanalyses out of 107 patients who were operated,
25 died (23 %) within three days after surgery. The average survival 1. López-Sendón J, Gurfinkel EP, Lopez de Sa E, Agnelli G, Gore JM, Steg PG, et al.
of the other 82 patients who were operated was 46 weeks. The Factors related to heart rupture in acute coronary syndromes in the Global Registry
of Acute Coronary Events. Eur Heart J. 2010;31(12):1449-56.
total of 31 patients was treated conservatively and 15 of them (48
2. Kostić MB, Tomić M, Boričić N, Nedeljković O, Tasić M, Tomašević M et al. Pseu-
%) died in less than seven days. The remaining 16 patients lived for
doanurizma leve komore. Srce i krvni sudovi. 2012;31(1):34-37.
approximately 156 weeks. Among the patients who were surgically 3. Kocatürk H, Karaman A, Bayram E, Çolak M. Left Ventricular Pseudoaneurysm: A
treated, 12 lived for at least one year, five lived for at least 5 years and Four Year Folow-Up With Medical Therapy. N Engl J Med. 2011;28:59-61.
2 patients for at least 10 years (8). 4. Takx RAP, Fink C, Henzler T. Incidental left ventricular pseudoaneurysm discovered
Morreno et al. showed that the risk of PA rupture in their patients 5 years after myocardial infarction. OMICS J Radiology. 2013;2(5).
was not too high. For four years they followed 10 patients with PA. 5. Moreno R, Gardillo E, Zamorano J, Almeria C, Garcia-Rubira JC, Fernandez-Ortiz
A, et al. Long term outcame of patients with postinafarction left ventricular pseu-
One woman was surgically treated, nine received medicamentous
doanurism. Heart. 2003;89(10):1144-6.
treatment, and there was no lethal outcome. They specified a relatively 6. Mao CT, Li MF, Kao YC, Cherng WJ, Hung MJ. Long-term survival of a patient with
high risk of ischemic stroke, 32.5%, in the follow-up period (5). asymptomatic left ventricular pseudoaneurysm after acute myocardial infarction. J
Prolonged survival of unoperated patients may be due to a very Inter Med Taiwan. 2012;23:442-48.
narrow PA hole, small PA, reduced LV systolic function, and creation 7. Letonja M, Letonja MS. With computed tomography confirmed anterolateral left
of a large thrombus within PA. ventricular pseudoaneurysm in patient with dilatative alcoholic cardiomyopathi. Ra-
Our patient lived 15 years after MI which probably caused the PA in diol Oncol. 2011;45(3):180-3.
8. Frances C, Romero A, Grady D . Left ventricular pseudoaneurysm. J Am Coll Car-
the first attack. Based on these facts she could be considered the PA
diol. 1998;32(3):557-61.
registered patient with the longest survival rate (3).
9. Patra S, Dhadake SD, Agrawal N, Manjunath CN. Giant left ventricular pseudoan-
The diagnosis of PA was established on the basis of the eurysm folowing acute inferior wall myocardial infarction presenting with acute left
echocardiographic examination, contrast CT angiography of the ventricular failure: a rare complication. BMJ Case Rep. 2013.
left ventricle. Sometimes it is difficult to distinguish between heart
aneurysm and pseudoaneurysm. And for PA it is important to look
for cavities connected to a narrow hole cavity, LV 0.25 to 0.50 the
diameter of the cavity, and the ratio of actual aneurysm 0.9-1.0. PA Reprint requests and correspondence:
is three times more localized in the inferior or posterolateral wall, Zlatko Šantić, MD, PhD
while the right aneurysm in 80-90% of patients is localized in apical Polyclinic "Sunce"
Obilazna cesta 6
or anterolateral wall (9). Thrombus is often located in PA cavity. If
88220 Široki Brijeg
the hole is very narrow high flow spectra, can be found. Unlike the Bosnia and Herzegovina
heart aneurysm, PA has no endocardium and myocardium. There are Phone and Fax: + 387 39 705 767
only adherent pericardium, hemopericardium and often thrombus. Email: zlatko.santic@tel.net.ba
76
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Instructions to authors 77
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INTRODUCTION
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RESULTS
and directly incorporated in the text, at the exact place, with ordinal number and concise heading. Table should have at least two columns
DISCUSSION
Discussion is concise and refers to own results, in comparison with the other authors’ results. Citation of references should follow Vancou-
CONCLUSION
Conclusion should be concise and should contain most important facts, which were obtained during investigation and its eventual clinical
number in parenthesis at the end of the sentence according to the order of entering. Every further referring to the same reference, number
numbers in the order of entering in the text (entering reference number). Journal’s title is abbreviated using Index Medicus abbreviations.
It is very important to properly design references according to instructions that may be downloaded from addresses National Library of
Medicine Citing Medicine http://www.ncbi.nlm.nih.gov/books/bv.fcg?rid=citmed.TOC&depth=2,
or International Committee of Medical Journal Editors Uniform Requirements for Manuscripts Submitted to Biomedical Journals:
Sample References http://www.nlm.nih.gov/bsd/uniform_requirements.html.
78
UPUTSTVA AUTORIMA
Časopis “Medicinski žurnal” objavljuje originalne naučne radove, stručne, pregledne i edukativne, prikaze slučajeva, recenzije, saopćenja,
stručne obavijesti i drugo iz područja svih medicinskih disciplina. Rad in-extenso (cjelokupan) piše se na engleskom jeziku, uz sažetak i naslov
rada koji uz engleski trebaju biti napisani i na našim jezicima (bosanski, hrvatski i srpski). Autori su odgovorni za sve navode i stavove u nji-
hovim radovima. Ukoliko je rad pisalo više autora, potrebno je navesti tačnu adresu (uz telefonski broj i e-mail adresu) onog autora s kojim
će uredništvo sarađivati pri uređenju teksta za objavljivanje.
Ukoliko su u radu prikazana istraživanja na ljudima, mora se navesti da su provedena u skladu s načelima medicinske deontologije i Deklaracije
iz Helsinkija.
Ukoliko su u radu prikazana istraživanja na životinjama, mora se navesti da su provedena u skladu s etičkim načelima. Prilikom navođenja
mjernih jedinica, treba poštovati pravila navedena u SI sistemu.
Radovi se šalju Redakciji na adresu:
“MEDICINSKI ŽURNAL”
Institut za naučnoistraživački rad i razvoj Kliničkog centra Univerziteta u Sarajevu
Bolnička 25
71000 Sarajevo
Bosna i Hercegovina
e-mail: institutnir@bih.net.ba; bibliotekanir@kcus.ba
POPRATNO PISMO
Uz svoj rad, autori su dužni Redakciji “Medicinskog žurnala” dostaviti popratno pismo, koje sadržava vlastoručno potpisanu izjavu svih autora:
1. da navedeni rad nije objavljen ili primljen za objavljivanje u nekom drugom časopisu,
2. da je istraživanje odobrila Etička komisija,
3. da prihvaćeni rad postaje vlasništvo “Medicinskog žurnala”.
RAD SADRŽI:
Naziv i puna adresa institucije u kojoj je autor-koautor/i zaposlen/i (jednako za sve autore), na engleskom jeziku, te na kraju rada navedena
adresa kontakt-autora.
Sažetak na našem jeziku, kao i na engleskom - max. 200–250 riječi, s najznačajnijim činjenicama i podatcima iz kojih se može dobiti uvid u
kompletan rad.
Ključne riječi - Key words, na našem jeziku i na engleskom, ukupno do pet riječi, navode se ispod Sažetka, odnosno Abstracta.
SADRŽAJ
Sadržaj rada mora biti sistematično i strukturno pripremljen i podijeljen u poglavlja i to:
- UVOD
- MATERIJAL I METODE
- REZULTATI
- DISKUSIJA
- ZAKLJUČAK
- LITERATURA
Instructions to authors 79
UVOD
Uvod je kratak, koncizan dio rada i u njemu se navodi svrha rada u odnosu na druge objavljene radove sa istom tematikom. Potrebno je
navesti glavni problem, cilj istraživanja i/ili glavnu hipotezu koja se provjerava.
MATERIJAL I METODE
literaturi. U kliničko-epidemiološkim studijama opisuju se: uzorak, protokol i tip kliničkog istraživanja, mjesto i vrijeme istraživanja. Potreb-
no je opisati glavne karakteristike istraživanja (npr. randomizacija, dvostruko slijepi pokus, unakrsno testiranje, testiranje s placebom itd.),
standardne vrijednosti za testove, vremenski odnos (prospektivna, retrospektivna studija), izbor i broj ispitanika – kriterije za uključivanje i
isključivanje u istraživanje.
REZULTATI
-
ose u tekst gdje im je mjesto, s rednim brojem i konciznim naslovom.Tabela treba imati najmanje dva stupca s obrazloženjem što prikazuje;
DISKUSIJA
Piše se koncizno i odnosi se prvenstveno na vlastite rezultate, a potom se nastavlja upoređivanje vlastitih rezultata s rezultatima drugih
autora, pri čemu se citiranje literature navodi po važećim Vankuverskim pravilima. Diskusija se završava potvrdom zadatog cilja ili hipoteze,
odnosno njihovim negiranjem.
ZAKLJUČAK
Treba da bude kratak, da sadrži najbitnije činjenice do kojih se došlo u radu tokom istraživanja i njihovu eventualnu kliničku primjenu, kao i
Vascular disease
AF = atrial fibrilation; EF = ejection fraction (as documented by echocardiography, radio nuclide ventriculography, cardiac catheterization,
cardiac magnetic resonance imaging, etc.); LV = left venticular; TIA = trasient ischaemic attack.