Case presentation of the smallest non-functional parathyroid carcinoma and review of the literature

INTRODUCTION

Non functional parathyroid carcinoma (PC) is one of the rarest malignant neoplasms. Due to the lack of symptoms and laboratory findings, it is mostly diagnosed in late AQ2 stages, when local invasion and dissemination are already present. However, our case is an exception, because it was detected in early stage, with no local invasion present. We present a case of the smallest non-functional PC yet reported and review of the literature.

CASE PRESENTATION

A 47-year-old woman was admitted to outpatient Clinic where fine-needle aspiration biopsy (FNAB) of bilateral thyroid nodules (slide 1) and central neck mass (slide 2), which was suspected to be an enlarged lymphatic nodule or parathyroid gland was performed. Results came back as Bethesda I-colloid (slide 1), and Bethesda IV (slide 2), stating that it is hard to distinguish thyroid gland oxyphil lesions from parathyroid cells. Total thyroidectomy was performed as well as excision of the left central neck mass, without any involvement of surrounding structures. Pathological examination revealed bilateral thyroid follicular nodular disease, papillary microcarcinoma, and parathyroid carcinoma with vascular and capsular invasion, measuring 10 × 8 × 7 mm. The immunohistochemical profile included positive PTH, Chromogranin A, and negative TTF1.

CONCLUSION

Non-functional PC is usually diagnosed in advanced stages, already involving adjacent structures; however, this case presents a rare example. It is important not to exclude PC as a differential diagnosis in the absence of elevated Ca and PTH serum levels. Follow-up will be difficult, since there are no prognostic parameters to rely on.

The influence of the tooth preparation finish line position on the expression of matrix metalloproteinase-9 and the presence of periodontopathogens in the gingival crevicular fluid

OBJECTIVE

The objective of the study was to determine the concentration of matrix metalloproteinase 9 (MMP-9) and changes in the presence of periodontopathogens in the gingival crevicular fluid before and after tooth preparation with the subgingival and equigingival finish line position.

PATIENTS AND METHODS

The clinical prospective study included 20 subjects with an indication for upper canine preparation, with the subgingival (group 1) and equigingival finish line (group 2). Samples were taken in four observation intervals: 5 minutes before (control samples), as well as 15 minutes, 24 and 72 hours after tooth preparation (experimental samples). Measurement of MMP-9 was done using Enzyme-linked Immunosorbent Assay (ELISA). The presence of bacteria in the gingival fluid was proven by the Polymerase chain reaction (PCR) analysis.

RESULTS

The MMP-9 values did not differ statistically significantly between the groups (p=0.524). The MMP-9 values showed a statistically significant difference in the given observation period (p<0.001) with a significant linear increase in values (p<0.001). A significant quadratic trend recorded a decrease in the MMP-9 values 15 minutes after preparation, and an increase 24 hours after preparation, without a significant difference in the interaction between groups (p=0.392). After preparation, a significant difference in the presence of periodontopathogens was confirmed, i.e., a decrease in the presence of Prevotella intermedia (p=0.025) and Tannerella forsythia (p=0.016) in group 1, and an increase in the presence of Aggregatibacter actinomycetemcomitans in both groups (p=0.029, p=0.026).

CONCLUSIONS

The study is a good basis for determining the influence of tooth preparation on gingival inflammation, with therapeutic (choice of preparation technique) and preventive significance regarding the protection of the periodontal tissue from possible iatrogenic damage.

The Impact of the COVID-19 Pandemic on Self-Inflicted Burn Injuries in Patients With Previously Diagnosed Bipolar Disorder

Here we present a case of a 52-year-old female patient who was admitted to the Clinic in December 2021 due to the presence of right side facial burns which were caused by a cigarette lighter under suspicious conditions. Her past medical history revealed she was diagnosed with bipolar disorder at the age of 20 and was hospitalized multiple times for the treatment of manic episodes. The last psychiatric hospitalization took place in October 2021. She had deep second-degree burns on the right side of the face, head and neck, with a total body surface area involvement of approximately 3%. On hospital day 18, she was found unresponsive, dyspnoic, with no palpable pulse and measurable tension. Electrocardiogram (ECG) monitoring revealed sinus bradycardia followed by cardiac asystole. After the first few minutes of cardiopulmonary resuscitation, heart and lung action was re-established. Due to the presence of ECG changes in the form of ST depression and negative T waves in V2-V6, D1 and aVL, also higher blood level of high sensitivity troponin T, she was urgently transported to the Coronary Unit where she was diagnosed with non-ST-elevation myocardial infarction. On hospital day 27, due to the presence of sub-febrile temperature and non-productive cough, she was tested for COVID-19 infection and transported to the COVID Hospital Batajnica. She was discharged with stable laboratory parameters and normal chest radiography 37 days following initial admission. Considering the great psychological impact related to the COVID-19 pandemic, extensive mental health support and regular monitoring of critical groups is indicated.

Challenges in Treating COVID-19 Patients With Severe Burn Injuries

Here we present a case report of a young female patient with severe burn injury inflicting 27% of total body surface area (TBSA) associated with COVID-19 infection. Upon admission, Acinetobacter spp. (sensitive only to Colistin) was isolated from the wound swabs of the right arm, hand and thorax. On the fifth day after admission, a surgical excision was performed and 12% of TBSA was covered with homotransplants. The following day the patient had a sudden drop in oxygen saturation with hypotension (85/45 mmHg). Additionally, agitation, visual and auditory hallucinations were noticed. We found a massive pleural effusion on the left side and pneumonic foci on the right side. On the thirteenth day after admission the final surgical excision and homotransplantation of the skin were performed. In the following days, debridement of all necrotic tissue and covering of all the burned areas with homotransplants were done. Hemodynamic instability of the patient progressed along with the finding on the chest radiography, despite the local finding including adherent homotransplants with no signs of lysis or local infection at the wound beds. Due to low oxygen saturation, the patient was intubated on the fourteenth day after admission. Despite the measures taken, the lethal outcome occurred on the twenty-fifth day after admission to our Clinic. A decision on the right timing for surgical treatment in severely burned COVID-19 patients needs to be investigated in order to enable surgeons to make evidence-based decisions during the pandemic.

An outbreak of fumonisin toxicosis in horses in Serbia

This paper reports on an outbreak of fumonisin toxicosis in a stable with 100 horses. Twenty-one horses were affected and fifteen died within a month. The animals were not febrile and exhibited poor appetite, somnolence, head pressing, blindness, ataxia, lethargy, and seizures, ending with death. The post mortem examination of the head of one 18-month-old colt revealed large, bilateral, slightly asymmetrical large areas of necrosis of the cerebral white matter. The lesions involved the frontal, parietal and occipital lobes only. Histological findings revealed leukomalacia with necrosis, infiltration of macrophages, neutrophils and eosinophils, haemorrhage and oedema of the surrounding grey matter. In response to the pathological findings, which indicated equine leukoencephalomalacia (ELEM), feed samples from the premises were tested for fumonisin B1 and B2 (FB1 and FB2). The milled maize samples contained 6.0 mg/kg FB1 and 2.4 mg/kg FB2, while the maize bran contained 6.05 mg/kg FB1 and 1.68 mg/kg FB2. These findings confirmed the diagnosis of fumonisin toxicosis. Hence, this report indicates that Serbia is one of the few regions in Europe with proven cases of ELEM.

Usage of GreenLight HPS 180-W laser vaporisation for treatment of benign prostatic hyperplasia

INTRODUCTION

Laser therapy has gained increasing acceptance as a relatively less invasive treatment for lower urinary tract symptoms (LUTS) due to benign prostatic hyperplasia (BPH). From the early procedure of interstitial laser coagulation through to the use of holmium laser enucleation of the prostate, there has been an expanding body of evidence on the efficacy of such procedures. One of the newer lasers is the Green Light HPS 180 W laser. Studies with this GreenLight laser (GLL) (American Medical Systems, Inc, Minnetonka, MN, USA) showing results as good as those of transurethral resection of the prostate (TURP). In this paper, the efficacy of the new GLL 180-W versus the gold standard TURP in patients with LUTS due to BPH was tested in a prospective clinical trial.

OBJECTIVE

To compare results of Green light laser (GLL) evaporisation of the prostatae and transurethral resection of the prostate (TURP) for treatment of BPH. MATERIJALS AND METHODS: A total of 62 patients with BPH were randomly assigned to two equal groups: TURP or GLL.

RESULTS

Both groups were compared regarding all relevant preoperative, operative, and postoperative parameters. Functional results in terms of improvement of International Prostate Symptom Score (IPSS), maximum flow rate (Qmax), and postvoid residual (PVR) urine were assessed at 1, 3, 6 and 12 mo. A total of 62 patients completed 12 mo of follow-up in the TURP and GLL groups, respectively. Baseline characteristics were comparable. Mean operative time was significantly shorter for TURP. Compared to preoperative values, there was significant reduction in hemoglobin levels at the end of TURP only. A significant difference in favor of GLL was achieved regarding the duration of catheterization and hospital stay. In the GLL, no major intraoperative complications were recorded and none of the patients required blood transfusion. Among TURP patients, 6 required transfusion, 1 developed TUR syndrome, and capsule perforation was observed in 5 patients. There was dramatic improvement in Qmax, IPSS, and GLL compared with preoperative values and the degree of improvement was comparable in both groups at all time points of follow-up. Four TURP patients and one GLL patients developed bladder neck contracture treated by bladder neck incision; none in either group experienced urethral stricture or urinary incontinence.

CONCLUSIONS

Compared to transurethral resection of the prostate, GreenLight HPS 180-W laser photoselective vaporization of the prostate is safe and effective in the treatment of patients suffering from lower urinary tract symptoms due to benign prostatic hyperplasia.

Trans-Obturator-Tape (T.O.T.) "outside-in" approach in surgical treatment of female stress urinary incontinence

OBJECTIVE

The aim of the study was to analyzed the efficacy and safety of a minimally invasive surgical procedure using the Trans- Obturator-Tape with "outside-in" approach for treatment female stress urinary incontinence.

PATIENTS AND METHODS

171 women with stress urinary incontinence (SUI) associated with urethral hypermobility, underwent the T.O.T. procedure (March 2010 to January 2014). 27 patients were previously operated for incontinence. Mean age was 59 years (37-80). 6 patients were having mixed incontinence, and 51 had SUI with urgencies. A non-elastic, polypropylene tape was placed under the mid-urethra. The surgical placement technique utilises a trans-obturator percutaneous approach. All patients underwent post-operative clinical examination, cough-stress test (full bladder), uroflowmetry, and post-voiding residual assessment.

RESULTS

Mean follow-up was 22 months (4-45). At 12 months follow-up 91,2% of the patients were completely cured. The overall peri-operative complication rate was 6.4% with no vascular, nerve or bowel injury. 5 patients (2.9%) had post-operative urinary retention.

CONCLUSION

The present study confirms the results obtained by the instigator of the technique, E. Delorme, and allows us to consider T.O.T. as an effective and safe technique for the treatment of female stress urinary incontinence.

Retrobulbar chondrosarcoma in a dog

This paper presents a review of a dog, with a retrobulbar chondrosarcoma, which was admitted for surgery for visible changes in his eye during inspection. Orbital neoplasia in dogs may be primary and secondary. Sixty percent of orbital neoplasia in dogs are primary, ninety percent of which are malignant. Retrobulbar neoplasms are rare and in their early stage represent a diagnostic challenge. Chondrosarcoma of the skull is a slow-progressing malignant disease which occurs locally, aggressive with invasion into the surrounding tissues. Dogs with chondrosarcoma of the skull have life expectancy between 210 and 580 days - in our case it was 180 days - after the first alterations on the eye of the dog occurred.

Age dependent influence of external temperature on the pathogenesis of idiopathic lower extremity deep vein thrombosis

AIM

The aim of the present study was to investigate the relationship between the incidence of idiopathic lower extremity deep vein thrombosis (DVT), age, location of the thrombus, and changes of temperature.

MATERIAL AND METHOD

During the two year period between May 2009 and April 2011, inclusive, 124 consecutive patients were diagnosed as having idiopathic lower extremity DVT at the Vascular Surgery Clinic, Clinical Center of Nis, Serbia.

RESULTS

In patients younger than 45 years, the increase in average daily temperature with 1 degree C 7 days before the event took place was associated (p 0.05) with a decrease of the risk of occurrence of idiopathic DVT of the lower limbs of 3.6% (0.4 6.7%) as well as DVT above the knees (p 0.01) of 4.7 % (1.3 8.0%). In patients of the age of 45 years and over the age of 45 years the increase of average daily temperature with 1 degree C 7 days before the event took place was associated (p 0.01) with the increase of the risk of occurrence of DVT below the knees of 9.4% (3.3 15.9%).

CONCLUSION

According to the results of this study, one can conclude that the influence of external temperature change on DVT incidence and location is based on age.

Correlation between the climatic factors and the pathogenesis of deep vein thrombosis

There are numerous researches dealing with the correlation between the seasons and climatic factors and the pathogenesis of deep vein thrombosis (DVT). The presented researches show an undoubted correlation between the climatic factors and the pathogenesis of DVT. In the majority of researches, retrospection is noted as a disadvantage. Further prospective researches could aim on testing the correlation between both climatic and thrombotics factors and the pathogenesis of DVT. This may additionally clarify the pathophysiological mechanism of the DVT incidence and contribute to the prevention and treatment of risk groups of patients in certain periods of the year.

Relationship between the incidence of idiopathic lower extremity deep vein thrombosis and the location of the thrombus depending on the changes in atmospheric pressure

AIM

The study analysed the relationship between the incidence of idiopathic lower extremity deep vein thrombosis (DVT) and the location of the thrombus with changes in atmospheric pressure.

MATERIAL AND METHOD

During the two year period between May 2009 and April 2011, inclusively, 124 consecutive patients were diagnosed as having idiopathic lower extremity DVT at the Vascular Surgical clinic "Clinical Center of Nis", Serbia.

RESULTS

The increased average daily values of atmospheric pressure for 1 millibar on the day when the event took place and 7 days before, were associated (p < 0,05) with the increase of the total risk of the occurrence of lower extremity idiopathic DVT for 5,1% (0,7-9,8%), as well as with the occurrence of idiopathic DVT above the knees (p < 0,05) for 5,9% (0,9-11,0%). The increase in the average atmospheric pressure by 1 millibar on the day when the event took place and 7 days before this in the subgroup of patients under the age of 45 years, and on the day when the event took place and 3 days before it in the subgroup of patients of the age of 45 and above, was related with the increased risk of the occurrence of lower extremity idiopathic DVT.

CONCLUSION

The increase of daily values of atmospheric pressure shows a significant relationship with the incidences of idiopathic lower extremity DVT and the location of the thrombus above the knee.

Influence of dissolution media composition on drug release and in-vitro/in-vivo correlation for paracetamol matrix tablets prepared with novel carbomer polymers

The influence of dissolution media composition on drug release kinetics and in-vitro/in-vivo correlation (IVIVC) for hydrophilic matrix tablets based on Carbopol 971P and Carbopol 71G was investigated. A number of buffered and unbuffered media differing with respect to their pH value, ionic strength and ionic species was evaluated. The observed in-vitro drug release profiles were compared with the hypothetical drug release profiles in-vivo calculated by numerical deconvolution from the results of an in-vivo study. The obtained IVIVC plots were examined using linear and non-linear (proportional odds, proportional hazards and proportional reversed hazards) mathematical models. Although the studied sustained release agents were chemically identical, they exhibited pronounced differences in drug product behaviour both in-vitro and in-vivo. The use of non-linear modelling resulted in an improved level of correlation, especially in the case of Carbopol 71G matrices. The obtained results indicated the susceptibility of drug release kinetics and hence IVIVC in the case of anionic polymer matrices to media composition, and emphasized the need for thorough evaluation of applied media during the development of biorelevant dissolution methodology. Although the use of non-linear modelling could be advantageous, the need for a simple and meaningful nonlinear relationship is pointed out.

[Current trends in surgical treatment of radial nerve injuries associated with injuries of the humerus]

Radial nerve is the most common injured peripheral nerve after bone and wrist injuries in human body. Radial nerve can be injured by force causing fracture of the humeral shaft, due to compound fracture of the bone or by direct injury with small fragments of the bone. This happen in of cases and in remaining caseswas caused by manipulation during the treatment of the fracture of the humeral shaft. Because of the possibility of spontaneous recovery, indication and timing of surgical treatment of the radial nerve still remain controversial. There is contradictory approach in the treatment of the injured radial nerve. In a period betwen 1979 and 2005 year we have operated 193 patients with injury of radial nerve. Among them, 97 (50.2%) have had combined injury of the humeral shaft or proximal part of radius. Rest of injuries of the radial nerve were associated with manipulation during treatment. Surgical treatment has been performed in a period between three and four months after neurological deficit. Analysing our result regarding recovery of the motor function we have used combination of gradation including British Medical Council Score and modified Highet Scale to obtain satisfactory analysis of useful functional recovery of motor function after surgical procedure. We have classified results as bad M O-2 for all muscles innervated by the radial nerve; satisfactory M3, for extensors of the wrist and fingers and M O-2 for abductor of the thumb, good M 4-5 extensors of the wrist and fingers and M3 for abductor of the thumb, and excellent M 4-5 for all muscles.

[Carpal tunnel syndrome--surgical and anesthesiology considerations]

Carpal tunnel syndrome presents the most common peripheral nerve entrapment, and section of carpal transverse ligament is the most common procedure in peripheral nerve surgery. Favourable outcomes depend on several factors including correct diagnosis, careful patient selection, precise operative technique and appropriate postoperative care. The goal of this paper is to establish the most common causes of failed surgery analysing primary and secondary outcomes, and to give the possibility for better results in the future. Analysis was based on 250 operated patients. Primary outcome and secondary outcome 3 months after surgery was estimated. Total rate of complications was 8% with persistent complaints in 7 (35%) patients and recurrent symptoms in 13 (65%) patients.

Occurrence of ochratoxin A and heavy metals in tissues associated with porcine nephropathy in Serbia

In order to find information on the occurrence of mycotoxic porcine nephropathy in Serbia, during a six month period (2006/2007) samples of blood, kidney and liver from individual animals were collected from healthy slaughtered pigs (n=90) and analysed by HPLC for ochratoxin A (OTA). In addition, the presence of nephrotoxic heavy metals such as cadmium, lead, mercury and arsenic were measured and the kidneys pathohistologically examined. Of the 90 liver samples, 26.6% contained OTA in the range of 0.22-14.5 ng/g. The incidence of OTA in serum and kidney were very similar (30 and 31.1%), but varied between 0.24-220.8 ng/ml and 0.17-52.5 ng/g, respectively. The presence of mercury was confirmed in 33.3% of kidney samples and concentrations ranged between 0.005-0.055 mg/kg, while cadmium was found less frequently (27.7% positive samples) but at higher levels (0.05-1.23 mg/kg). The presence of arsenic was found in only one sample, while lead was not detected in any sample. Histopathological examination of kidneys confirmed tubulopathies with oedema and cell vacuolisation. In addition, haemorrhages and necrosis of proximal kidney tubules' cells were found. These findings indicate that it is likely that most of the kidney injury is related to OTA and other nephrotoxic compounds which enhance the toxicity of OTA.

Streptococcus equi subsp. zooepidemicus meningitis

A 72-year-old woman was hospitalized for Streptococcus equi subsp. zooepidemicus meningitis. The same organism was cultured from her two horses. She denied contact with horses, but had a practice of consuming unpasteurized milk from a cow. The cow was in the same stable as the horses, and the ill woman's son milked the cow.

[The excision width in surgical treatment of basal cell carcinoma]

Basal cell carcinoma originates from pluripotent cells of basal layer of epiderm, external covering of hair follicles, sebaceous glands or other skin adnexa. It is characterized by local infiltrating and sometimes destructive growth. There are several types of basal cell carcinomas that may be manifested in over 12 clinical forms. Surgical treatment depends to a large extent on the histological type, localization and its clinical manifestation. The analysis included 250 patients of both gender and different age, operated for basal cell carcinoma. Clinical characteristics of basal cell carcinoma and the width of the excision were described. It was concluded that the width of the excision of basal cell cancer was in relation to histological type.

[Anal canal melanoma-- case report]

Anal canal melanoma is a rare disease comprising 1% of all colorectal ie. anal malignant tumours with very poor long term prognosis. Its significant biologic aggressivity is the consequence of the tendency towards lymphatic, local and hematogenous spread. At the moment of diagnosis even 30% of the patients have distant metastases. Surgical intervention represents the only possibility for cure. Modern approach to the anal canal melanoma treatment implies two types of intervention: wide local excision preserving the sphincter mechanism and abdominoperineal resection of the rectum. There are numerous dillemas about the choice of surgery in particular disease stages. The authors report on a 61 years old women in which anal canal melanoma with left inguinal lymphatic metastases was detected during the inspection of "haemorrhoids". After the diagnosis was established, abdominoperineal resection of the rectum was performed with dissection of both inguinal regions.

Bioequivalence testing of a new tablet formulation of generic fluoxetine

The pharmacokinetics and relative bioavailability of fluoxetine capsules (reference) and tablets (test) were compared in 24 healthy subjects of both sexes after a single 20 mg oral dose of fluoxetine (as a hydrochloride salt). A randomized, crossover design with a 2-week wash-out period between each dose was applied. Serum samples, obtained before dosing and at various appropriate time points up to 192 hours, were analyzed for fluoxetine and norfluoxetine content by a simple, accurate and precise HPLC method. ANOVA, power analysis, 90% confidence intervals (CI), and two one-sided tests were used for the statistical analysis of pharmacokinetic parameters. The tolerability of the preparations was good. The respective point estimates of the ratios of the geometric means of log-Cmax and log-AUC(0-infinity) of fluoxetine were 0.912 and 0.935 with 90% of 0.838-0.992 and 0.857-1.020. The corresponding point estimates of norfluoxetine were 0.952 (90% CI = 0.843-1.075) and 0.904 (90% CI = 0.807-1.013), respectively. Since both 90% CI for the AUC(0-infinity). and Cmax geometric mean ratios of fluoxetine and norfluoxetine were included in the 80% to 125% interval proposed by the FDA the test drug (fluoxetine tablets) was considered bioequivalent to the reference one (Prozac capsules) according both to the rate and extent of absorption.

The impact of diabetes mellitus on postoperative morbidity in laryngeal surgery

The main aim of this study was to analyze risk factors of postoperative morbidity after extended laryngeal surgery comparing patients with diabetes mellitus and non-diabetic patients. In retrospective study 69 patients (63 male and 6 female), who underwent partial laryngo-pharyngectomy and total laryngectomy between 2003 and 2004, were evaluated. 13 % of the total group of examined patients had concurrent diabetes, while 87% were nondiabetic patients. We performed partial laryngopharyngectomy in 39 out of 69 patients (56.5%) and total laryngectomy in 30 patients (43.5%). Secondary wound infections (88.9%) and pharyngocutaneus fistula (44.5%) had a significantly higher rate in diabetic patients (p<0.001). Among diabetics the cases with intraoperative or postoperative blood transfusions were more frequent - 44.4%(p<0.001). Diabetic patients with laryngectomy procedures had more frequently prolonged postoperative anemia (55.5%, p<0.001) and electrolitic disbalance (66.6%, p<0.001). Our results have confirmed that diabetes mellitus is an important independent general clinical factor, which increases postoperative morbidity and hospitalization time in laryngeal surgery. Our data indicate the need to make a very serious plan and clinical assessment for laryngeal surgical therapy in diabetic patients.

[An acute pancreatitis in a child caused by Na-valproate]

Na-valproat (Apilepsin, Eftil), is is a commonly prescribed medication approved for treatment of epilepsy, trigeminal neuralgy, migraine, and bipolar disorder. Although the common adverse effects associated with Na-valproat are usually benign, more serious and fatal complication like liver failure and acute pancreatitis (AP) can occur. Acute pancreatitis may take place in all ages, regardless of dose and serum levels of the medicine. An acute pancreatitis is relatively common after intravenous administration. The authors presented a case of acute opancreatitis in 13-years girl caused by Na-valproat.

Occupational accidents in Serbian industries in transition

Occupational accidents and injuries present a serious social, medical and economical problem in Serbian industries in transition. The purpose of this study is to estimate the number and average annual rate of occupational accidents and traumatic injuries in Serbian industries in transition, between 1992 and 2003, and to estimate the effects of a preventive safety program in the rubber manufacturing industry and in the production of electrical goods and equipment. This paper presents a descriptive analysis of occupational accidents and injuries which occurred in all industries over a twelve years period. In the rubber manufacturing industry and in the production of electrical goods and equipment a surveillance and prevention program has been implemented since 1997. A significant drop after 1997 in average annual accidents rate and severity ratio of injuries in these two industries has been observed, which was not the case in the other industries, and can be explained by the positive effects of the safety training program. The study documents that the safety training program showed significant effects, especially in case of workers with less than ten years of working experience.

Sesquiterpene lactone mix patch testing supplemented with dandelion extract in patients with allergic contact dermatitis, atopic dermatitis and non-allergic chronic inflammatory skin diseases

We investigated the value of patch testing with dandelion (Compositae) extract in addition to sesquiterpene lactone (SL) mix in selected patients. After we detected a case of contact erythema multiforme after patch testing with dandelion and common chickweed (Caryophyllaceae), additional testing with common chickweed extract was performed. A total of 235 adults with a mean age of 52.3 years were tested. There were 66 men and 169 women: 53 consecutive patients with allergic contact dermatitis (ACD); 43 with atopic dermatitis (AD); 90 non-atopics suffering from non-allergic chronic inflammatory skin diseases; 49 healthy volunteers. All were tested with SL mix 0.1% petrolatum (pet.) and diethyl ether extracts from Taraxacum officinale (dandelion) 0.1 and 3.0% pet. and from Stellaria media (common chickweed) 0.1 and 3% pet. A total of 14 individuals (5.9%) showed allergic reaction (AR) to at least 1 of the plant allergens, 4 (28.6%) to common chickweed extract, and 11 (78.6%) to Compositae allergens. These 11 persons made the overall prevalence of 4.7%: 8 (3.4%) were SL-positive and 3 (1.3%) reacted to dandelion extract. 5 persons (45.5%) had AD, 2 had ACD, 2 had psoriasis and 2 were healthy controls. The Compositae allergy was relevant in 8 cases (72.7%). The highest frequency of SL mix sensitivity (9.3%) was among those with AD. Half the SL mix-sensitive individuals had AD. ARs to dandelion extract were obtained only among patients with eczema. A total of 9 irritant reactions (IRs) in 9 individuals (3.8%) were recorded, 8 to SL mix and 1 to common chickweed extract 3.0% pet. No IR was recorded to dandelion extract (P = 0.007). Among those with relevant Compositae allergy, 50.0% had AR to fragrance mix and balsam of Peru (Myroxylon pereirae resin) and colophonium. SLs were detected in dandelion but not in common chickweed. Our study confirmed the importance of 1 positive reaction for emerging, not fully established, Compositae allergy. In conclusion, the overall prevalence of 4.7% in our study represents a basal SL mix detection rate of 3.4% reinforced and safely supplemented by testing with the dandelion extract.

Transmandibular approach to polycentric recurrent pleomorphic adenoma of the parapharyngeal space

Surgery for tumors of the parapharyngeal space PPS) requires adequate exposure to identify and protect vital structures. Thus transcervical and transcervical-transparotid approaches to the PPS may be enhanced by mandibulotomy for better visualisation. We have chosen this approach with single mandibulotomy just in front of foramen mentale and without lip incision. We present a 39 years old male who was undergone surgery for policentric recurrency of a pleomorphic adenoma of the parapharyngeal space.

Enterococcus durans endocarditis in a patient with transposition of the great vessels

A case of native valve endocarditis caused by Enterococcus durans in a patient with transposition of the great vessels is reported. The patient was treated initially with gentamicin and ceftriaxone; after isolation of enterococci, ceftriaxone was switched to ampicillin. The only virulence factors established in the strain were haemolytic activity and biofilm formation.

[Treatment of facial nerve paralysis using static suspension methods]

After the injury of facial nerve, facial muscles are subjected to complex series of biochemical and histological changes, which lead to muscular atrophy if reinnervation is not restored. Facial palsy is very difficult to manage completely. Regardless this fact, the plan of correction has to be directed towards the following: restoration of normal function, normal facial appearance at rest, symmetry in voluntary movements as well as symmetry in involuntary and emotional movements. Static suspension methods were used in our study. All patients had unilateral complete facial nerve palsy but one female patient who experienced the palsy of frontal branch of n.facialis. This method was successfully used to lift the eyebrow, the lid and to improve lagophthalmus on the paralytic side, then the angle and paralytic part of the lip, to reinforce buccal wall of oral cavity as well as to reconstruct new nasolabial fold. The results were satisfactory and permanent.

[Experimental and clinical possibilities of transplantation of the injured and totally devascularized spleen]

The most severe spleen lesions with conquasation and devascularisation of entire organ, when it is practically impossible to do any preservating surgical procedure, are the true indications for the transplantation of this extremely important immunological organ. We have performed the evaluation of the surgical procedure of heterotopic auto transplantation in the 30 dogs with severe spleen lesions. Simulation of totally devascularized spleen with the lesions of V degree was performed by disrupting all segmental blood vessels with deep and long longitudinal transhilar incision. During the 3 months follow-up period, animals were subjected to numerous explorations in order to macroscopically and histologically valuate the implant. In most cases (80-85%) implants had complete vitality with the preservation of normal tissue architecture, while 15-20% of implants had partial or total fibrosis. There were no mortality and no complications after this preservation procedure. The presence of fibrosis in some implants suggests that the implant preparation should be better performed and that transplantation of larger tissue volume is needed. Enriched with this experimental experience we have performed heterotopic auto transplantation in 2 patients with spleen lesion of V degree (car accident and injury at work) with very satisfactory results.

[Evaluation of the value of local protective methods using latex prosthesis and fibrin glue in colonic anastomoses]

In this experimental study on small animals (Wister rats) performed evaluation of local protective methods--latex prosthesis and fibrine adhesives--on colon anastomosis healing--prevention of dehiscency. Ninety experimental animals in whom segmental left colon resection was done, were divided into three groups of 30 animals. In the control group after segmental resection termino-terminal anastomosis with single-layer continuous suture was performed. In the second and third group with the same animals, anastomosis protection was performed with endoluminal latex prosthesis and extraluminal application of fibrine adhesives. In the postoperative course where the animals were monitored for 21 days in the control group, 3 (10%) died of acute diffuse peritonitis the cause of which was anastomosis dehiscency, in the latex prosthesis 2 animals (6.6%) died, while in the extraluminally applied fibrine glue group all animals survived. The results of this experiment demonstrate that local protective measures for colon anastomoses may produce better results, with fibrine adhesive administration as the best modality.

[Treatment of defects of soft tissue and sternum, as postoperative complications of A-C bypass, case report]

Medial sternotomy is optimal approach for great number of heart surgery. Deep infection of sternum and mediastinis are very rear, but very dangerous complications followed by high rate of morbidity and mortality. Factors which can be responsible for these complications are numerous: post operation bleedings, surgery reinterventions, extended mechanical ventilation, liver chronic diseases, older age, diabetes, previous irradiation therapy, respiratory obstructions and use of steroids. Clinical signs for these complications are: red skin around the surgical wound, leaking, dehiscence, increased body temperature and instability of sternum. Early diagnosis, adequate antimicrobial therapy, and aggressive surgical and multidisciplinary approach in initial phase, are base for successful treatment. Surgical treatment most often assumes use of flaps. Our main objective in this work was to present treatment of defect of sternum and soft tissues, after triple aorto-coronary bypass. After the surgery patients got slack of sternum's ficsation and reficsation. With satisfactory respiratory function, corrections of defect was achieved by omentum and bipedicular myocutan flaps. (m. pectoralis major flap). There was no complications.

Erythema multiforme due to contact with weeds: a recurrence after patch testing

Erythema multiforme (EM) as a complication of patch testing (PT) is rare. A 52-year-old woman with a 13-year history of episodes of EM, after contact with weeds during home gardening, had had no recent history of herpes simplex, other infection, drug ingestion or vaccination. On examination, EM lesions were distributed on the exposed skin. 5 weeks after complete resolution, PT and photopatch testing (PPT) were done with fresh plants she brought in. She was PT with a standard series and the Hermal-Trolab plants, woods, tars, balsams and flavors series. Intradermal testing, with a 3 + reaction to mixed weed pollens, was done 3 weeks later. Specific IgE to weed pollens class 1 (CAP-Pharmacia) was detected. Eczematous PT reactions were obtained with fresh leaves: common chickweed (Stellaria media Caryophyllaceae), dandelion (Taraxacum officinale Compositae), field-milk thistle (Sonchus arvensis Compositae) and white clover (Trifolium repens Leguminosae). Photoaggravation was seen to common chickweed and dandelion. Positive PT was also seen with alantolactone. By the 4-day reading, a typical EM had commenced, coming up to quite the same extent as seen on admission. There was no photosensitivity (UV skin tester, K. Waldmann). In the essential oil obtained from common chickweed, thin layer chromatography (TLC) revealed the well-known contact allergens borneol, menthol, linalool, 1,8-cineole, and other terpenes such as epoxy-dehydro-caryophyllene, monoterpene alcohol-ester and caryophyllene. Up to now, no data on essential oil in Stellaria media (common chickweed) have been reported. It can be concluded that EM developed due to contact with weeds, and recurred after patch testing. Neither blistering nor eczematous lesions have been seen on her skin, making this case very unusual. As far as the world literature is concerned, this is only the 4th report of EM developing in association with patch testing.

[Cholecystitis associated with milk of calcium] ]

Milk of calcium cholecystitis is a rare disease predominantely of adults. The term designates a pathologic accumulation of calcium carbonate in the gallbladder, much rarer in the common bile duct as well. The patient may be symptom-free. If present the symptoms may be very mild or as an acute biliary pain, transient jaundice and mild attack of pancreatitis. Calcium in the bile may be liquid or it may form a paste-like mass. Both may be seen on a plain X-ray of the abdomen. The stone or stones of calcium carbonate may be formed so that they may cause an obstruction of the gallbladder outflow tract or cystic duct or pass into the common bile duct or into the duodenum. [figure: see text] We present a 71 year old male who was admitted for inguinal hernia repair but in whom a mild hiperbilirubinaemia was found and then on ultrasonography a gallbladder stone was diagnosed. We performed a hernia repair as well as cholecystectomy and operative cholangiography which turn to be normal. Within an almost normal gallbladder a gray-whitesh paste-like mass was found composed of calcium carbonate. The postoperative recovery was uneventful and serum bilirubin become normal. Histology of gallbladder showed chronic nonspecific cholecystitis.

[Atrophic pilar keratosis of the face: case report]

INTRODUCTION

Keratosis pilaris atrophicans faciei (KPAF), previously called ulerythema ophryogenes, belongs to a group of follicular syndromes with inflammation and atrophy. The disease often starts at birth or during the first months of life with autosomal dominant inheritance.

CASE REPORT

We report a case of a 24-year-old woman, who noticed the first lesion two years ago. Skin lesion spread symmetrically on the cheeks, forehead and chin. Keratotic follicular papules were surrounded by erythema. After disappearance of follicular papules, atrophy occurred. Histopathological analysis from skin biopsy specimens confirmed the diagnosis of KPAF.

DISCUSSION

Follicular syndrome with inflammation and atrophy starts in early childhood, but first lesions can also appear among teenagers or in adults. The course of the disease is progressive with permanent follicular destruction. The histopathologic changes are dynamic and follow the clinical course of the disease. A topical retinoid: tretinoin therapy was introduced. After one month of treatment good effects were visible, including decrease of erythema and follicular hyperkeratosis.

[Darier's disease--a familial case report]

INTRODUCTION

Darier's disease is a slowly progressive autosomal dominant disorder characterized by a gene with variable penetrance. However, many cases of this disease are considered to be a new mutation in the genealogic tree. The prevalence of the disease was estimated as 1/55,000 to 1/100,000.

CASE REPORT

The authors report a case of a female patient, 66 years of age, with Darier's disease, hospitalized at the Clinic of Dermatovenereology of the Clinical Center Novi Sad. The first changes of the skin occurred at the age of 16 originally on the shins and face, as miniature hard papules confluent in larger areas. Skin changes always exacerbated in the summer. At hospital admission the patient's head and hair were whole covered with white, thick, keratotics layer, resembling a helmet. The skin of the trunk was covered with white-gray, hyperkeratotic, fused papules like verrucous plaques, more expressed on the back. The skin of forearms presented with hyperkeratotic papules, and dorsum of the hands presented with plaques. Lower legs were covered with fused papilokeratotic, rough cauliflower-like layers with macerates and foetor. Buccal mucous was covered with whitish papules on erythematous lesions of cobblestone-like appearance. The nails were thickened with longitudinal furrowing, whereas the left third finger presented with V-shaped onychorrhexis. 4 generations were investigated, and the disease occurred only in the patient's younger daughter.

DISCUSSION

Beside the classic "seborrheic" forms of Darier's disease there are a few clinical types: hypertrophied (intertriginous), vesiculo-bullous and linear (zosteriform) type.

CONCLUSION

This case is a very severe classic form of Darier's disease, with variable penetrance and severity in the family.

[Lichen sclerosus et atrophicus--a diagnostic problem]

INTRODUCTION

Lichen sclerosus et atrophicus (LSA) is a rare disease with etiology that has not been clearly defined up to now. This disease appears up to 10 times more frequently among women, than among men. It occurs at the age of 40-60. Anogenital site is the most common, but in 20% of cases it is extragenital.

CASE REPORT

We report a case of a 78-year-old woman with skin lesions on the hand and face, that appeared 7-8 years ago after intensive sun exposure. When admitted to hospital, she had a butterfly-shaped livid erythema on cheeks and nose hypopigmentation on its edges. Atrophic plaques were formed in some areas of lesions. On the dorsal side of hand clear atrophic plaques were noticed. Pathohistological analysis of skin lesions revealed epidermal hyperkeratosis and atrophy with follicular hyperkeratosis, dermal edema, with subepidermal blistering and edematous hyalinized connective tissue. Direct immunofluorescence of the face lesion has shown presence of IgA, IgG and IgM deposits along the epidermo-dermal interface. Based on all findings the following diagnosis was made: Lichen sclerosus et atrophicus bullosus.

DISCUSSION

Differentiation between chronic discoid lupus erythematosus and LSA presents a diagnostic challenge. Both diseases have some common pathohistological changes, but a single mixed inflammatory dermal infiltrate as well as edema and hyalinized connective tissue were the most important facts in making diagnosis.

CONCLUSION

Lack of knowledge in regard to etiology of this disease has caused some problems in differential diagnosis. This disease hasn't always been a separate entity, but we expect that many things regarding the etiology and pathogenesis to be explained in the future.

[Chronic venous insufficiency and compression therapy]

INTRODUCTION

Disorders of venous circulation are among most frequent diseases in the human population. During recent years there has been increased interest in physiopathology of chronic venous insufficiency (CVI), due to development of more accurate diagnostic methods and new therapeutic techniques. Considering patophysiology of CVI and its consequences the crucial points are stasis and reflux of blood flow, with increase of intravascular pressure.

CLASSIFICATION AND THERAPY OF CVI

Empirical experience and theoretical models suggest that progression of the disease can be stopped or reverted by correction of stasis. Today, this is the main direction in all therapeutic approaches. Compression therapy represents the most successful conservative technique. In this article we are presenting basic principles of the compression therapy of CVI. Evidence for the physiologic effect of compression therapy are decrease of edema, softening of lipodermatosclerosis, acceleration of venous flow, decrease in venous volume, blood shift into central compartments, reduction of venous refluxes, influence on arterial flow and improvement of microcirculation and lymph drainage. There are several types of compression devices: elastic stockings, elastic bandages, inelastic bandages, intermittent pneumatic compression devices. Other advantages of compression therapy are decrease of hospital treatment and better quality of life for patients with CVI.

[Angiographic analysis of the tensor fascia lata vascularized flap]

Vascularisation of the flap of tensor fasciae latae originates from the ascending branch of the lateral circumflex femoral artery which enters through the medial side of fascia lata tensor as a dominant branch. Knowing the vascular and characteristics of a vascular peduncle is of great importance while taking the flap, so knowing the site of the source of lateral circumflex femoral artery diameter at the source, the number of the terminal branches and the number of ascending branch anastomoses of lateral circumflex femoral artery are the basic significance for successful taking of the flap and its clinical application. Our investigations were done on clinical material, and the study was based on investigations of angiographies of the femoral artery. Measuring the diameter in the source of ascending branch we found that it was 33 mm while the diameter in the bifurcation of the terminal branches of ascending branch was 2.41 mm in average. The length of vascular peduncle of ascending branch was 68.88 mm in average. Vascular peduncle of the flap of tensor fasciae latae has appropriate length and diameter for microvascular anastomosis.

Professional exposure of drivers to carbon monoxide as a possible risk factor for the occurrence of traffic accidents in the road traffic

The aim of this study was to examine the effects of increased carbon monoxide concentrations in the air of car cabin on the health status of exposed drivers and the occurrence of traffic accidents. Exposed group was comprised of 250 drivers professionally exposed to increased carbon monoxide concentrations in the car cabins. Control group was comprised of 120 professional drivers who were not exposed to increased concentrations of carbon monoxide in the air of the car cabins. Average carbon monoxide concentration in the air of the car cabins of the drivers from exposed group was 71.2 +/- 8.1 ppm, which was significantly higher compared to the controls (5.4 +/- 1.2 ppm). The drivers from the exposed group more frequently suffered from headaches, irritability, vertigo and palpitation than the drivers from the control group. The prevalence of diabetes mellitus, arrhythmia, atherosclerotic peripheral artery diseases and coronary heart diseases was more frequent in the exposed than in the control group. Drivers from the exposed had longer reaction time on acoustic and visual stimulation compared to the control group. The examined drivers statistically caused more traffic accidents than the drivers from the control group.

[Arterial hypertension in an industrial population]

The aim of this study was to examine the prevalence and characteristics of arterial hypertension in a group of 1519 industrial workers from the region of Nis. The prevalence of arterial hypertension was 21.3%, and was higher in the group of workers professionally exposed to noise, to lead vapour, in shift and nightly workers than in the workers in workplaces without contact to professional noxiousness. Hypercholesterolaemia and hypertrigliceridaemia were more frequently found in the hypertensive workers than in workers without hypertension. It was observed that just a low number of hypertensive workers behaved in keeping with the prescribed therapy and advices.

[Persistent dyschromic erythema]

INTRODUCTION

Erythema dyschromicum perstans (ashy dermatosis) is a very rare skin disease included in the group of acquired, idiopathic hypermelanosis, with development of blue-gray macules. This disease appears more frequently in dark coloured persons, especially women in the first and second life decade.

CASE REPORT

A male patient, 42 years of age, was admitted to Clinic of Dermatovenereology in Novi Sad due to appearance of slightly pruriginous, brown-reddish macules on the trunk, upper and lower extremities, without affecting the skin of the face, scalp, palm soles and visible mucous membranes. Later, the color of the macules changed into blue-gray and new lesions appeared in axilla and flexor side of the big joints, with active, erythematous and thin raised borders. Laboratory findings showed no abnormalities; antinuclear antibodies were negative. Histopathological examination of the skin specimens (which were taken from two different places) showed vacuolar degeneration of the basal cell layer, numerous pigmentophages in papillary dermis and presence of lymphohistiocytic infiltrate in dermis. No history of drug intake or exposure to UV light was established.

DISCUSSION

Ashy dermatosis is included in the group of hypermelanosis of unknown origin. As possible etiological factors we can mention ingestion of ammonium nitrate, environmental pollution, hypersensitivity to cobalt chloride and postinflammatory pigmentation. Clinical characteristics: occurrence of blue-gray and gray macules on the trunk, face, neck and extremities (absence on the palms, soles, visible mucous membranes, scalp and nails). In the active phase of the disease, these macules are surrounded by erythematous and thin, raised borders. The lesions are mostly permanent. Due to clinical, histopathological, immunofluorescent and electron microscopy established similarities with lichen planus, it is considered that ashy dermatosis is a variant of lichen planus. Absence of previous drug intake, exposure to UV light, absence of the antinuclear antibodies, clinical picture and histological findings confirm the diagnosis of erythema dyschromicum perstans.

CONCLUSION

This case of ashy dermatosis shows that there is a need for differential diagnosis of acquired skin pigmentations, because this dermatosis must also be taken into consideration.