Phenomenology and psychiatric origin of psychogenic nonepileptic seizures

INTRODUCTION Psychogenic nonepileptic seizure (PNES) is a sudden change in a person's behavior, perception, thinking, or feeling that is usually time limited and resembles, or is mistaken for, epilepsy but does not have the characteristic electroencephalographic (EEG) changes that accompanies a true epileptic seizure [1]. It is considered that PNES is a somatic manifestation of mental distress, in response to a psychological conflict or other Stressors [2]. A wide spectrum of clinical presentation includes syncope, generalized tonic-clonic seizure, simple and complex partial seizure, myoclonic seizure, frontal lobe seizures and status epilepticus [3]. Coexistence of epilepsy and PNES is seen in approximately 9% of cases [5]. Between 25-30% of patients referred to tertiary centers and initially diagnosed as refractory epilepsy were on further examination diagnosed as PNES [6,7]. In DSM-IV [12] PNES are usually categorized under conversion disorder with seizures or convulsions. However, psychiatric basis of PNES may be anxiousness (panic attack), somatization or factitious disorder, simulation, dissociative disorders and psychosis [1]. AIM The aim of the study was to establish clinical phenomenology and EEG characteristics as well as basic psychiatric disorder in patients with PNES. METHOD In a retrospective study covering the period from January 1st 1999 till April 31 st 2003, 24 patients (22 female, 2 male) treated at the Institute of Neurology in Belgrade were analyzed. PNES were defined as sudden change in behavior incoherent with epileptiform activity registered on EEG. Possible PNES were determined on the basis of history data and clinical examination during the attack but definitive confirmation was established only by the finding of no ictal EEG changes during typical seizure of each patient. Patients with coexisting epilepsy were included in the study, too. At least two standard EEG (range 2-6, median 4) were performed at the beginning of diagnostic evaluation. Demographic data, clinical presentation (apparent loss of consciousness, type of convulsion and associated clinical signs) and placebo-induced seizures (administration of saline near the cubital vein) with EEG or video-EEG monitoring were analyzed. Basic psychiatric disorder was classified according to DSM IV classification criteria. RESULTS Duration of PNES was 4.7 years (range from 2 months to 30 years). The time from onset to the diagnosis of PNES was 4.5 years. Epilepsy comorbidity was diagnosed in 9 patients (37.5%). The average time of use of antiepileptic drugs (AED) in the group of isolated PNES was 2.4 years and 20% of patients were treated with two or more AED. The vast majority of patients presented with bilateral convulsions (54.16%) with apparent loss of consciousness found in 91.6% of cases. Ictal iwury (16.7%), tongue bite (4.2%) and premonition of the seizure (17.4%) were uncommon. Variability in clinical presentation of seizures was found in over half of patients (57%). Psychological trigger could be determined in over 60% of patients. EEG findings in a group with isolated PNES suggesting the existence of epileptiform activity was found in one case. EEG monitoring of placebo-induced seizure was performed in 20 patients, of whom 19 (95%) showed typical habitual attack with no electroclinical correlate. In 70% of cases conversion disorder DSM-IV criteria were fulfilled. Somatization disorder and undifferentiated somatoform disorder were found in 3 patients. The diagnosis of factitious disorder was made in one case and only two patients were undiagnosed according to DSM-IV. DISCUSSION Average delay from onset to diagnosis of PNES in larger studies was estimated to be approximately 7 years [8]. Even though diagnostic delay in our study was shorter, organizational reasons for this could not be found. Longer duration of a typical attack (compared to the epileptic seizure), apparent loss of consciousness, bilateral convulsion behavior and significant clinical variability in absence of typical epileptic elements such as tongue bite and ictal iwury could be the main clinical manifestation of PNES. We found rare interictal abnormalities (6.7%) in the group with isolated PNES and significant percentage (77.7%) in patients with coexisting epilepsy which is coherent with other reports [8]. The latest could lead to prolonged delay in appropriate diagnosis and suitable treatment. Clear psychological trigger wasn't noted in whole group of patients (61 %). This, however, is not unusual since PNES represents a chronic disorder with repeated triggering that could lead to less significant role of the same psychological trigger in developed PNES. Even insufficiently resolved in ethical terms, placebo-induced procedure was of huge sensitivity. In clinical practice conversion disorder is hard to differ from malingering or implementation of secondary gain. One could make the conclusion only on the basis of detailed and careful estimation of the symptoms developing context Conversion disorder is more prevalent among women (from 2:1 to 10:1) [4, 13] but modest percentage of affected men could be explained only by limited sample in this study. CONCLUSION PNES is often replaced with epilepsy and in number of cases clinical differentiation is not easy. One should be acquainted with clinical presentation of PNES as well as its psychiatric origin in order to adequately recognize and treat the disorder.

Fluid intake and bladder cancer. A case control study

To examine the relation of the total intake of fluids and the types of beverages to the risk of bladder cancer, we conducted a hospital based case-control study with 130 newly diagnosed bladder cancer patients and the same number of matched controls. Information of total fluid intake was derived from the reported frequency of consumption of the different types of beverages on the food frequency questionnaire. Univariate and multivariate logistic regression analyses were performed in statistical analysis. There was no statistically significant difference between the cases and the controls in total daily fluid intake. Multivariate logistic regression model showed consumption of: soda (OR=8.32; 95%CI=3.18-21.76), coffee (OR=1.46; 95%CI=1.05-2.01) and spirits (OR=1.15; 95%CI=1.04-1.28) as statistically significant risk factors, while mineral water (OR=0.52; 95%CI=0.34-0.79), skim milk (OR=0.38; 95%CI=0.16-0.91), yogurt (OR=0.34; 95%CI=0.12-0.97) and frequency of daily urination (OR=0.27; 95%CI=0.18-0.41) were statistically significant protective variables. In our study no statistically significant association was observed for total fluid intake. The findings suggest consumption of soda, coffee and spirits were indicated as a risk factors for bladder cancer, while mineral water, skim milk, yogurt and frequency of urination as protective factors for bladder cancer.

Diet and breast cancer

Nutritional factors have been prominent among the environmental determinants of breast cancer hypothesized to account for the large increases in rates among offspring of migrants from countries with low incidence to countries with high incidence. The dominant hypothesis has been that high fat intake increases risk, but in addition to this possibility, several alternative hypotheses have been suggested, too.

[Concussive convulsions in the differential diagnosis of post-traumatic epilepsy]

INTRODUCTION

Concussive convulsions are motor manifestations in acute head injury. This clinical phenomenon should be distinguished from epileptic seizures. We present two young men with motor and convulsive manifestations in acute head injury. Patient 1. A 18-year old basketball player fell on the parquet during a game. Initially he was struck on the right shoulder which caused brief and vigorous twitch of the head towards the ground and additional temporal impact. At the moment of impact he lost consciousness and developed tonic leg and arm posturing with both clenched fists. His legs were extended during next 20 seconds. Thereafter he was still and his loss of consciousness lasted 3 minutes. Patient 2. A 26-year old man fell on the wooden ground from a 4 m high ferry. He got head impact and lost consciousness. In a few seconds he had tonic/clonic convulsions for the next 10-15 seconds. Ten minutes later he awaked. Results of subsequent neurological examination, electroencephalography and cerebral magnetic resonance imaging studies were normal in both patients. They returned to their occupations after four weeks without problems for a further one year.

CONCLUSION

Described motor manifestations present concussive convulsions. These clinical features are due to transient functional decerebration and corticomedullary dissociation during cerebral concussion. Concussive convulsions are a non-epileptic phenomenon, they are not associated with structural brain injury and have good prognosis. Antiepileptic treatment is not indicated.

[The groin pain syndrome]

Groin pain is defined as tendon enthesitis of adductor longus muscle and/or abdominal muscles that may lead to degenerative arthropathy of pubic symphises in an advanced stage. Pubic region is a point where kinematic forces cross. The balance between the adductor and abdominal muscles is of great importance, as well as the elasticity of pubic symphises which enables movement of up to 2 mm and rotation of up to 3 degrees. The weakness of the abdominal muscle wall, known as the sportsman's hernia, is the most common cause of painful groin. Groin pain is the most common in soccer players (6.24% in Croatia). Most authors believe that the main cause of groin pain is the adductor muscle overload. When active, sportsmen start to feel a dull pain in the groin region. The adductor test is of great importance for physical examination; the patient should be lying supine with his hips abducted and flexed at 80 degrees. The test is positive if the patient, while attempting to pull his/her legs against pressing in the opposite direction, feels a sharp pain in the groins. The treatment of groin pain is complex and individual, as its causes may vary from patient to patient. Gradual physical therapy combined with pharmacotherapy should be effective in most cases. The latter includes nonsteroid anti-inflammatory drugs and muscle relaxants. A physical therapy programme usually involves stretching and strengthening of adductor muscles, abdominal wall muscles, iliopsoas muscle, quadriceps, and hamstrings. In case that physical therapy and pharmacotherapy fail, surgery is needed, depending on the cause.

Body composition and functional abilities in terms of the quality of professional ballerinas

The objective of this research was to determine the variability of the sample of professional ballerinas in the space of characteristics of their body composition and some functional characteristics according to the requirements of their roles in ballet. The sample of examinees was comprised of 30 professional ballerinas, members of the Croatian National Theatre Ballet (15 soloists and 15 members of the corps de ballet). The data showed that the soloists were characterized by a significantly larger knee diameter, significantly lower thickness of skin folds on the trunk and the lower fat body mass percentage, as well as by greater grip strength. Aerobic capacity was only moderately more developed than in fit people who participated in physical exercising because of recreational reasons, and there were no differences between soloists and the members of the corps.

Traumatic false aneurysm of the subclavian artery treated by insertion of Memotherm stent

Traumatic aneurysms of the left subclavian artery and transverse cervical artery, subsequent to penetrating gunshot wound were diagnosed by angiography in 35-year-old patient. Subclavian artery aneurysm was treated by insertion of the Memotherm bare stent, whereas the false aneurysm of the transverse cervical artery was embolized with Gianturco's coils. The follow up examinations at 6 and 12 months showed good patency of subclavian artery.

Frequency of portal and systemic bacteremia in acute appendicitis

BACKGROUND

Acute appendicitis is the most common condition requiring an emergency abdominal operation in childhood. In the present study, we analyzed the frequency of portal and systemic bacteremia in 42 patients with acute appendicitis and determined the microbial agents responsible for an acute appendicitis and for portal and systemic bacteremia.

METHODS

Appendectomies were performed on 50 young patients (5-18 years of age), as well as clinical and bacteriological tests. Six independent samples from each patient isolated from the peripheral vein, superior mesenteric vein, appendix and peritoneum were obtained prior to surgery, during surgery and after surgery for biochemical, immunologic and bacteriologic examination.

RESULTS

Pathohistology confirmed the diagnosis of appendicitis in 42 patients, while in the other eight patients there were no obvious pathologic findings, so they served as a control group. Of 50 patients with a clinical appearance of acute appendicitis, in 19 patients (38%) we detected portal bacteremia in the mesenteric vein, while in only three cases (6%) did we find systemic bacteremia detected from the peripheral vein. Furthermore, bacteriologic analysis revealed that Bacteroides spp. and Escherichia coli were the predominant species isolated.

CONCLUSIONS

The results presented in this paper suggests that portal bacteremia did not influence peripheral blood reactions. Furthermore, in the present study we have found a positive correlation between the smear and bacteremia of the superior mesenteric vein, but not with the bacteremia of systemic blood.

Survival of Balkan endemic nephropathy patients

The retrospective cohort study comprised 97 Balkan endemic nephropathy (BEN) and BEN-suspected patients discovered in 1971 in the field examination in the village of Sopić, one of the regions most frequently affected by the disease. Our aim was to determine the outcome of the disease in patients and to compare the survival of BEN-suspected and BEN-manifested patients and the survival of their kidneys. The mean survival time was 16.4 years for all patients (95% CI 14.51-18.21) and 23.1 years for suspected and 13.3 years for manifested patients (log-rank = 19.46; d.f. = 1; p < 0.001). According to our results, it can be concluded that BEN is characterized by slow course and prolonged evolution and that the prognosis was consistently better for BEN-suspected than for BEN-manifested patients.

Disseminated Burkitt's-like lymphoma during pregnancy

The occurrence of Burkitt's-like lymphoma (BL) during pregnancy is rarely diagnosed and its outcome is poor. A case of BL localized in the uterus, ovaries and breast during the course of pregnancy is presented. The patient was treated with a combination of surgery and chemotherapy and was disease-free for 6 months after the diagnosis.

Craniocerebral war missile injuries: clinical and radiological study

In this study we reviewed the initial clinical and radiological management and early outcomes of 176 consecutive patients from the war in Croatia.

[Angioblastic lymphadenopathy--its course and prognosis]

INTRODUCTION

In recent years important advances have been made in the understanding of angioimmunoblastic lymphadenopathy since substantial controversy has been related to the name, course, prognosis and therapy of the disease. It was first recognized in the Kil Classification as a low risk T-cell lymphoma [5], and omitted from the most widely used Working Formulation for clinical purposes. According to the criteria of REAL (Revised European American Lymphoma), classification angioimmunoblastic lymphadenopathy (AILD) is one of peripheral postthymic T cell lymphomas that are an immunologically defined category of non-Hodgkin's lymphomas originating from the peripheral lymphatic tissues. Morphologically, AILD is characterized by partially or completely obliterated sinuses and frequent infiltration of the pericapsular tissue and substantial proliferation of epithelioid, postcapillary venules. Cytologically, polymorphous cellular infiltration with immunoblasts, transformed lymphoid cells, polyclonal plasma cells, eosinophils and epithelioid cells are found. Clinically, rapid occurrence of systemic symptoms in elderly individuals (sixth and seventh decades of life) with generalized lymphadenopathy, hepatosplenomegaly and cutaneous maculo-papulous or erythematous rash is noted. The patients are characterized with hyperimmune condition in the form of Coombs' positive haemolytic anaemia, polyclonal hypergamma-globulinaemia and liability to infections [8, 9]. In spite of numerous suggestions, therapeutic consensus has not been achieved, and the reported survival ranges from 1 to 30 months [10, 11]. Therefore, this information suggests an aggressive form of the disease with the 60% mortality rate.

METHODS

At the Institute of Haematology of the Clinical Centre of Serbia in Belgrade in the last five years, from 1993 through August 1998, nine patients were diagnosed with AILD according to the results of pathohistological examination of the extirpated peripheral lymph nodes and the correlation with clinical picture and relevant laboratory findings.

RESULTS

Clinical characteristics of nine patients in whom AILD was diagnosed after lymph node biopsy are given in Table 1. The group consisted of 6 men and 3 women, mean age 53. Eight patients were in advanced stage of the disease at the time of the diagnosis (III and IC CS), while the patient in II CS stage had a large tumorous mass (M+). All patients had initial systemic symptoms. Five of them developed fever with chills. Three patients had evidence of extranodal infiltration of the bone marrow. Infiltration of the liver was suspected in two patients according to aberrant hepatogram values, although pathohistological verification was not obtained. In one patient lung infiltration was histologically verified in addition to bone marrow and liver infiltration. All patients had peripheral lymphadenopathy, and most of them hepatosplenomegaly, as well. Three patients had the so called bulky form of the disease since the diameter of the largest tumour exceeded 10 cm. On admission, most were in poor overall condition, and only two were apparently healthy. Knowing that AILD is basically an immunoregulatory disease and that the described cases of association with systemic diseases of the connective tissue and some drugs were implied in the triggering of AILD, Table 2 shows important information obtained form histories of these patients. Namely, 7 of 9 patients had cutaneous changes suggestive of erythematous or maculopapular rash, while three had received corticosteroid therapy for months before AILD was diagnosed since toxoallergic exanthema had been incorrectly suspected. Three patients received gold sodium thiosulfate therapy for rheumatoid arthritis, while four had history of allergy to drugs and pollen. Table 3 shows laboratory results: anaemia was present in 8 of 9 patients, it was severe in three with haemoglobin values of 67 g/L, 72 g/L and 50 g/L, respectively. Five patients had haemolysis. A

[Descriptive and epidemiologic characteristics of patients with malignant upper urothelial tumors in the endemic area of Lazarevac]

Although there is permanent increase in incidence of malignant upper urothelial tumours [1, 2], these malignancies are rare neoplasms in relation to both all malignant tumours and urotract tumours. Upper urothelial tumours, i.e. tumours of the renal pelvis and ureter are more frequent in the regions affected by endemic nephropathy [3-5]. The aim of this paper was to describe the main epidemiological characteristics in patients with upper urothelial tumours (UUT) in endemic nephropathic (EN) foci in Lazarevac. We analyzed 73 patients treated at the Institute of Endemic Nephropathy, Lazarevac and the Institute of Urology and Nephrology, Belgrade, from January 1, 1992 to December 31, 1994. The descriptive-epidemiological methods was used. The characteristics in patients with histopathologically confirmed upper urothelial tumours were examined. The diagnosis was made on the basis of the clinical picture, echo-sonographic and radioscopic examinations, intravenous and infusion urography and retrograde pielography. With genealogic analysis, a genealogical tree as far as the fourth degree of kinship for each patient, was made both for urothelial tumours and endemic nephropathy. The average age of the patients at the time of diagnosis was 64.2 years, and the majority of the patients (59%) was in the seventh decade of life (Figure 1). Our results are in accordance with the results of other authors who examined the patients with upper urothelial tumours in the regions with endemic nephropathy and out of them [7, 8, 12, 14]. Females were more affected than males (1.4:1). These results are in accordance with the results of other authors who studied the endemic regions [7, 11, 13]. Foreign authors found that males were more affected by upper urothelial tumours [9, 10]. In view of anatomic localization of tumours (Table 2) our results are in accordance with results of the studies carried out in endemic [11, 12, 15, 19] and non-endemic regions [8]. The majority of patients were rural population and lived in villages known as endemic foci (89%) (Table 1). Agriculture was their main or additional occupation. A large number of UUT patients (67%) had endemic nephropathy as well. The other authors from our country found that farmers were most affected [17, 18]. In foreign studies, there are no data on the fact that farming is risk for the appearance of upper urothelial tumours. The family agglomeration of UUT and EN in UUT patients has been observed in all degrees of relation, especially in the second and third generations (Table 3). The obtained results are comparable with hypotheses on a possible mutual or the same aetiological factor for both diseases, which is in accordance with the results of other authors who studied the endemic regions [6, 7, 12, 13].

[Viral hepatitis C]

INTRODUCTION

Viral hepatitis type C became one of the most dangerous hepatic diseases, bearing high risk of eventually fatal complications. Now a great deal of public health funds has to be used for prevention and treatment of this serious disease. Only very detailed knowledge of the disease could help to a medical practitioner in his everyday confrontation with this serious problem.

MATERIALS AND METHODS

Data, diagnostic, therapeutic and preventive suggestions given in this paper are result of a comprehensive review of relevant literature.

RESULTS

The causative agent of hepatitis type C is an RNA virus with six different genotypes. It is easily transmitted from one host to the other only by transferring large amounts of body fluids (blood or plasma transfusion, or prolonged, repeated inoculations of small quantities of infected fluids intravenous drug abusers, recipients of clotting factors, accidental needle sticks). The quantification of the disease activity could be done by a numerical scoring system, originally issued by Knodell, which takes into account four categories: periportal necrosis, intralobular necrosis, portal inflammation and fibrosis. The incubation period of hepatitis C varies from 5 to 7 weeks. It starts like a relatively mild acute disease, but eventually it progresses to chronicity. About 10-20% of patients develops cirrhosis, and yet unknown percentage of patients develops hepatocellular carcinoma. On average, it takes about 30 years for chronic hepatitis C to progress to cirrhosis or cancer.

DISCUSSION

Serologic testing for anti-HCV proves the existence of specific antibodies against hepatitis C virus. It becomes positive only after 5-6 weeks from clinical onset. Much more sensitive test is PCR, which proves the viral RNA in body fluids. PCR is positive as early as 2 weeks from the onset of hepatitis. Up to now, the only 100% certain way to prove existence of chronic hepatitis is liver biopsy. Interferon alpha is nowadays used for management of this serious disease. The accepted dose is 3,000,000 U three times weekly for 24 weeks. About 46% of treated patients will have both serological and histological improvement. Total liver collagen and iron staining in portal areas are significantly decreased after the treatment course, giving hope for postponing the onset of cirrhosis. However, half of the responders will experience relapse of the disease within 8 months from the end of treatment, and sustained biochemical and virological response could be seen in only 5% of patients. The sustained response rate was increased in some studies to 29% when iron reduction was undertaken along with interferon.

CONCLUSION

Since there is no effective treatment for hepatitis C, much of the efforts should be directed to prevention. Since hepatitis C virus is transmitted only by parenteral route or close personal contact (sexual contact mostly), in the family environment general hygienic measures are considered sufficient. Hands should be washed properly, food, clothing, utensils, linen and excreta of the patient should be handled separately. During sexual intercourse, prophylactics should be used. The most important measure for prevention of posttransfusion hepatitis C is regular testing of all blood donors for anti-HCV antibodies.

Plasma and cerebrospinal fluid endogenous digoxin-like immunoreactivity in patients with aneurysmal subarachnoid haemorrhage

Recent evidence indicates the presence of naturally occurring digitalis-like compounds in mammals, collectively known as either digitalis-like (DLF) or ouabain-like (OLF) factors, presumed to be endogenous hormones regulating the biological activity of the NA+/ K(+)-ATPase and its isoforms. This substance has been postulated to enhance renal tubular sodium excretion and to increase peripheral vascular resistance. Digoxin-like immunoreactive substance (DLIS) was observed in plasma of some patients with spontaneous subarachnoid haemorrhage (SSAH). Accumulating evidence suggests the central nervous system as a site of synthesis, but also as a site of hypertensinogenic action of endogenous cardioglycosides. The present study intends to establish the ratio of the DLIS in plasma to that in cerebrospinal fluid (CSF) in patients with SSAH and to investigate possible connection of this substance with development of arterial vasospasm. A prospective analysis of DLIS levels was performed on plasma and CSF samples obtained in 40 patients who had suffered a recent SSAH. DLIS levels were determined by the fluorescence polarisation immuno-assay method immediately after the admission to the Ward, and again seven days later. The comparison of CSF and plasma DLIS levels did not show statistically significant differences between the results--neither for the first (Z = 0.530; P = 0.591) nor for the seventh day after the disease onset (Z = 0.448; P = 0.654). Three possible hypothetical explanations of these results are offered: a) substance determined by digoxin immuno-assay has no essential likeness to digoxin; b) loss of the haemato-encephalic barrier integrity enabling free substance exchange between plasma and central nervous system; c) digoxin-like substance production within the central nervous system. Further, comparison of DLIS plasma levels (7th day from onset of SSAH) with angiography results showed that patients with multiple vasospasm had essentially higher plasma DLIS levels compared to patients with no vasospasms (Z = 2.59; P = 0.0097). The amount of extravasated blood, assessed on the basis of cranial CT scanning, was also connected with higher plasma DLIS levels (X2 = 3.29; P = 0.0305). The enhanced arterial narrowing which occurs in SSAH may be in part mediated by increased digitalis-like factor activity.

Subclavian artery stenosis caused by non-specific arteritis (Takayasu disease): treatment with Palmaz stent

A 32-year old woman was admitted to the hospital with a sudden onset of right-sided hemiplegia and aphasia. Immediate angiographic examination revealed a severe form of type I Takayasu arteritis with occlusion of all supra-aortic vessels, with the exception of the left subclavian artery which was, however, almost completely occluded 1 cm proximal to the origin of the left vertebral artery. Since the latter provided the entire blood supply to the brain tissues, an immediate attempt was undertaken to dilate the left subclavian artery; when this was unrewarding, stenting of the lesion was successfully accomplished with excellent primary and 6-month follow-up results.

Spine and spinal cord war injuries during the war in Croatia

OBJECTIVE

The present report summarizes the experience of an evacuation hospital in southern Croatia in treating 96 patients with spine and spinal cord war injuries.

METHODS

A retrospective review was done for 96 wounded persons (86 soldiers, 10 civilians) with spinal cord injuries from August 1991 through December 1995. The ages ranged from 15 to 59 years (mean, 28.3 years for soldiers, 38.5 years for civilians). Diagnostic procedures were plain radiography, computed tomography, and computed tomographic myelography. However, in most cases a more conservative surgical approach was used.

RESULTS

The highest rates of admittance were recorded in 1992 (N = 38) and 1993 (N = 47). The lumbar spine was injured in 55% of the patients, the cervical and thoracic spines in 17.7%. All injuries were caused by projectiles from automatic rifles and sniper fire (51%) and from fragments of explosive devices (49%). Blast injury of the spinal cord was found in 10 patients. The most frequent complications caused by the fragments were wound infection, urinary tract infection, decubitus, and pneumonia. Four patients (4.2%) died in the hospital, and 43.0% of patients survived but were severely handicapped.

CONCLUSION

Careful clinical examination combined with modern diagnostic imaging and use of broad-spectrum antibiotics reduced the need for surgical intervention in patients with spinal cord injuries.

A case of syphilitic interstitial pulmonary fibrosis

Diagnosis of late pulmonary syphilis was made in a 72-year old woman on the basis of her medical history of untreated genital syphilis, serological and radiological findings, and the response to therapy. The diagnosis was confirmed two years later by autopsy findings. There was a good correlation between chest x-ray radiography, computed tomography scans, and autopsy findings. In the diagnosis of sarcoidosis and other diseases with similar radiological interstitial lung pattern, syphilitic interstitial pulmonary fibrosis should be carefully excluded.

[Treatment of aggressive non-Hodgkin's lymphoma with the ProMACE- CytaBOM protocol]

INTRODUCTION

The Working Formulation Classification (for clinical use) divides non-Hodgkin's lymphoma (NHL), according to the nature of the disease and response to therapy into the low, medium and high risk lymphomas. Although these subgroups include different pathohistological types of NHL, they are considered sufficiently homogenous for joint therapy planning [1]. The first generation protocol (CHOP) managed to achieve complete remission (CR) in 50-55% of patients with 30-35% of survival rate [2]. A large four-branch comparative study of SWOG group compared CHOP as the first generation protocol with the third generation protocols ProMACE CytaBOM, m-BACOD and MCOD-D. The results have shown a similar CR and survival rates, so that CHOP is considered a gold standard for the treatment of aggressive NHL [6]. In the light of individual reports stating a high CR rate in the treatment of aggressive NHL by ProMACE CytaBOM [3-5] we present our experience and observations related to the use of this protocol.

METHOD

Over the period from 1991 through May 1996 at the Department of Lymphoproliferative Diseases, Institute of Haematology, Clinical Centre of Serbia in Belgrade, we treated 25 patients with pathohistologic evidence of medium to high risk lymphomas, where cases of lymphoblast lymphoma and Burkit's lymphoma were excluded. The median follow-up was 27 months (maximum 63 months).

RESULTS

Four of 25 patients were > 60 years. Three of these died. Pathohistological analysis revealed that of 20 cases of medium risk aggressive lymphoma five had diffuse, small cleaved cells, 7 had diffuse mixed and 8 diffuse centroblast cells. Although diffuse NHL with small cleaved cells is classified into clinically indolent lymphomas, two of five patients were in the fourth clinical stage, and three of five patients had a large tumorous mass. In the high risk group five patients had immunoblast lymphoma. Karnofsky index was high in 20/25. According to Ann Arbor criteria 19/25 patients were in IVCS and 7/25 had a large tumour mass. Most patients had clinical symptoms (21/25). Extranodal localization was confirmed in 19 patients. Bone marrow and hepatic infiltrations were most common: 9 and 6 patients, respectively. Eleven patients had a single extranodal localization, while 8 had 2 or more. The median follow-up was 27 months (maximum 63 months), and 21/25 (84%) patients responded to therapy (CR + PR). Complete remission was achieved in 14 patients (56%), and PR in 7 (28%) patients. In the CR group two died, and relapse developed in one after 28 months. In 11 cases CR is maintained. The average duration of CR was 16 months (3-38 months), and PR was maintained for 6 months (20 months in one case). The average survival was 24.5 months (range 3-53).

DISCUSSION

The fact that a half of adult patients with disseminated aggressive NHL can be cured with combined chemotherapy is the major oncological achievement in the last 20 years. The protocol combines 4-8 drugs, and the joint report of the SFOG group for lymphoma in over 1200 patients with lymphoma has shown that the second and third generation protocols are not more effective than the standard CHOP or CHOPBleom protocols [6]. The optimum therapeutic protocol in the treatment of aggressive lymphoma is still unpredictable due to the fact that it is inadequate to compare the results of individual institutions with the results of collaborative groups; there is also a significant difference in the prognostic factors in different research groups; there is no sufficient complete and published results that suggest the lower CR than the original reports (which may be related to the evaluation of tumour and remission). There are not sufficient data on the incidence of secondary carcinoma and leukaemia [1]. The decision on the therapy should be based on two lines of information: those related to each particular patient (age, associated diseases) and those related to the tumour (large mass, immunophenotyping, cytoge

Orbitocranial war injuries: report of 14 cases

OBJECTIVE

In this study, we review the initial clinical and radiological management and early outcomes of 14 patients with orbitocranial war injuries treated at the University Hospital Split between 1991 and 1995.

METHODS

This investigation involves 14 patients (13 soldiers and 1 civilian) with orbitocranial war injuries. The mean patient age was 31 years (range, 23-54 years). The penetrating object was a metal shrapnel fragment in 8 patients and a bullet in 6 patients. The results of clinical and radiological management were retrospectively analyzed.

RESULTS

The mean time from the moment of wounding to hospital admission was 6 hours (range, 1-30 hours). The mean Glasgow Coma Scale score was 8 (range, 3-14). Craniotomy was the basic neurosurgical procedure, and three patients were treated with simple scalp wound debridement and closure. Osteoplastic operations of the orbital bones were performed in 13 patients. Enucleation/evisceration was performed in 6 patients (42.8%). At discharge, the mean Glasgow Outcome Scale score was 13, and 1 patient died in the hospital. Blindness (including amaurosis and anophthalmus) was present in nine eyes (8 patients), light-perception positivity and projection positivity were present in four eyes, and visual acuity was at 0.1 in 1 patient.

CONCLUSION

An early multidisciplinary therapeutic approach and computed tomography as a diagnostic procedure are necessary for a good result in the treatment of orbitocranial war injuries.

[T lymphocytes in allergic inflammation]

T lymphocytes are the crucial cells in immunopathogenesis of allergic diseases since they regulate the occurrence of allergic sensitisation, synthesis of immunoglobulin E and allergic inflammation. The importance of lymphocyte T is reflected on the fact that after activation by a specific antigen they are able to produce different cytokines responsible for activation and aggregation of specific inflammatory cells in target tissues, promoting the occurrence and maintenance of allergic inflammation. Discovery of functional dichotomy of activated lymphocytes T CD4+ capable of suppressing synthesis of immunoglobulin E (Th1) or stimulate immunoglobulin E and allergic inflammation (Th2) is an important element in elucidation of pathogenesis of allergic inflammation and inadequate synthesis of immunoglobulin E. The immunoglobulin synthesis is regulated by a complex combination of factors and signals where lymphocytes CD4+ play the central regulatory role.

Clinical and radiological management of wartime eye and orbit injuries

OBJECTIVE

The purpose of this study is to present our experience in treating 191 patients with eye and orbit injuries that occurred during the war in Croatia and Bosnia and Herzegovina.

METHODS

The authors retrospectively reviewed the clinical and radiological management of wartime eye and orbit injuries in patients hospitalized at Clinical Hospital Split.

RESULTS

Seventy-nine percent of the war eye and orbit injuries were caused by fragments of explosive devices, 9.9% by high-velocity missiles, and 8.4% by other objects. Most of the patients were admitted to the hospital within 24 hours of injury. The total number of injured globes was 222; 48.2% of globes had intrabulbar (mostly magnetic) foreign bodies, and 13% had extrabulbar intraorbital foreign bodies. Extensive wounds (perforation, double perforation, rupture, and evisceration/ enucleation) were encountered in 74% of patients, and 26% of patients had slight trauma. There was a statistically significant correlation between admission within the first 12 hours and postoperative visual acuity (Chi 2 = 3.93; p = 0.0474).

CONCLUSION

Along with clinical examination, computed tomography is the most important diagnostic procedure in preoperative evaluation of various forms of globe and orbit injuries. The admission time is the most important factor in determining postoperative visual acuity.

Psychological characteristics of wounded and disabled Croatian war veterans

OBJECTIVE

Evaluation of the psychological state of a group of 119 Croatian disabled war veterans who suffered grave traumatic war experiences during the war in Croatia (1991-1992).

METHODS

Semistructured Clinical Interview, Profile Index Emotions test, and Zung's Self-Rating Depression Scale were used to assess disabled war veterans accommodated in special institutions for rehabilitation.

RESULTS

Changes in psychological functioning were established in 63.8% of disabled war veterans, the most frequent among them being indisposition, irritability, anxiety, and fear. In nearly half of the veterans there were changes in their relationships with close persons, difficulties in accepting the reality of their situations, and increased aggressiveness. Higher average values on the depression index (0.52) were also established.

CONCLUSION

The established change in the psychological profile of disabled Croatian war veterans was lower than expected. However, because of their great vulnerability, it is necessary to increase efforts to secure their complete psychosocial recovery.

Early intracranial infections after brain missile injuries--the role of computer tomography in diagnosis and treatment

During the war in Croatia, from August 1991 until December 1994, 138 soldiers were treated at the Split University Hospital for different brain injuries inflicted by missiles. Nine of these 138 patients developed intracranial infection. This retrospective study reports on the outcome of these 9 intracranial infections caused by penetrating missile head injuries. In case of clinically suspected infection, computerized tomography scan was obtained at two time points during the course of infection in the same patient. Scans were obtained with and without contrast media, 7 to 14 days after the injury and the 4 weeks later. The role of computerized tomography in the detection and follow-up of various intracranial infections and long-term consequences were evaluated.

Analysis of medical aid to Croatian Army soldiers wounded at the front line

OBJECTIVE

Analysis of medical aid to Croatian Army soldiers at the front lines.

METHODS

This investigation concerned 115 severely wounded Croatian soldiers (males, median age 29 years, range 17-57 years) at three rehabilitation institutions. All had been wounded at the front line by various explosive devices or bullets. In the investigation, semi-structured clinical interviews were used.

RESULTS

First aid was provided to 47 soldiers (40.9%) within 15 minutes and to 44 soldiers (38.3%) within 1 hour. First aid was either self-administered or given by fellow combatants in 55 cases (47.8%), by physicians in 37 cases (23.2%), and by medical technicians and orderlies in 21 cases (18.2%). The basic procedures of medical aid were hemostasis, hemodynamic substitution, immobilization, and analgesia. First surgical operations were performed at health stations on 4 soldiers (3.5%), at war hospitals on 43 soldiers (37.4%), and at evacuation hospitals on 68 soldiers (59.1%).

CONCLUSION

First aid either self-administered or provided by fellow combatants is the most important procedure at the front lines before medical aid is administered.