Effectiveness of a structured intervention to make routine clinical meetings therapeutically effective (DIALOG+) for patients with depressive and anxiety disorders in Bosnia and Herzegovina: A cluster randomised controlled trial

Background

DIALOG+ is a patient-centred, solution-focused intervention, which aims to make routine patient-clinician meetings therapeutically effective. Existing evidence suggests that it is effective for patients with psychotic disorders in high-income countries. We tested the effectiveness of DIALOG ​+ ​for patients with depressive and anxiety disorders in Bosnia and Herzegovina, a middle-income country.

Methods

We conducted a parallel-group, cluster randomised controlled trial of DIALOG+ in an outpatient clinic in Sarajevo. Patients inclusion criteria were: 18 years and older, a diagnosis of depressive or anxiety disorders, and low quality of life. Clinicians and their patients were randomly allocated to either the DIALOG ​+ ​intervention or routine care in a 1:1 ratio. The primary outcome, quality of life, and secondary outcomes, psychiatric symptoms and objective social outcomes, were measured at 6- and 12-months by blinded assessors.

Results

Fifteen clinicians and 72 patients were randomised. Loss to follow-up was 12% at 6-months and 19% at 12-months. Quality of life did not significantly differ between intervention and control group after six months, but patients receiving DIALOG ​+ ​had significantly better quality of life after 12 months, with a medium effect size (Cohen's d ​= ​0.632, p ​= ​0.007). General symptoms as well as specifically anxiety and depression symptoms were significantly lower after six and 12 months, and the objective social situation showed a statistical trend after 12 months, all in favour of the intervention group. No adverse events were reported.

Limitations

Delivery of the intervention was variable and COVID-19 affected 12-month follow-up assessments in both groups.

Conclusion

The findings suggest DIALOG ​+ ​could be an effective treatment option for improving quality of life and reducing psychiatric symptoms in patients with depressive and anxiety disorders in a low-resource setting.

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As DIALOG+ is used within routine clinical meeting, no additional staff or resources are required for implementation.

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DIALOG+ utilises existing patient resources, is not difficult to implement and is inexpensive.

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Eighty patients met our inclusion criteria and 72 agreed to participate and completed a baseline assessment.

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At 12 months, the intervention group showed a significantly better quality of life.

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Patients in the intervention group had significantly lower levels of symptoms time with medium to large effect sizes.

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The objective social situation did not differ significantly between the two groups after six months.

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The objective social situation showed a statistical trend towards a more positive outcome in the intervention group.

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Findings suggest DIALOG + could be an effective treatment for improving quality of life and reducing psychiatric symptoms.

Stress, locus of control, hope and depression as determinants of quality of life of pregnant women: Croatian Islands' Birth Cohort Study (CRIBS)

The aims were to investigate determinants of the quality of life (QoL) of pregnant women. Total of 302 healthy women 18 to 28 weeks of gestation participated in prospective study. WHOQOL-bref, Multidimensional Health Locus of Control scales, Edinburgh Postnatal Depression Scale, and the perceived stress appraisals were administered. Various patterns of predictors for four domains of QoL were identified, for psychological (42% variance explained), social relationship (29%), environmental (29%) and physical health (25%). Depression and hope, together with the extent to which one's health is influenced by powerful other or chance should be targeted in health promotion strategies during pregnancy.

Operative treatment of acute acromioclavicular dislocations Rockwood III and V-Comparative study between K-wires combined with FiberTape(®) vs. TightRope System(®)

INTRODUCTION

Acromioclavicular (AC) joint dislocations usually occur in a young active population as a result of a fall on the shoulder. Rockwood divided these dislocations into six types. Optimal treatment is still a matter of discussion. Many operative techniques have been developed, but the main choice is between open and minimally-invasive arthroscopic procedures. The aim of this study was to compare two different surgical methods on two groups of patients to find out which method is superior in terms of benefit to the patient. The methods were evaluated through objective and subjective scores, with a focus on complications and material costs.

MATERIAL AND METHODS

A retrospective two-centre study was conducted in patients with acute AC joint dislocation Rockwood types III and V. The two methods conducted were an open procedure using K-wires combined with FiberTape(®) (Arthrex, Naples, USA) (Group 1) and an arthroscopic procedure using the TightRope System(®) (Arthrex, Naples, USA) (Group 2). Groups underwent procedures during a two-year period. Diagnosis was based on the clinical and radiographic examination of both AC joints. Surgical treatment and rehabilitation were performed.

RESULTS

Sixteen patients were included in this study: Group 1 comprised 10 patients, all male, average age 41.6 years (range 17-64 years), Rockwood type III (eight patients) and Rockwood type V (two patients); Group 2 had six patients, one female and five male, average age 37.8 years (range 18-58 years), Rockwood type III (two patients) and Rockwood type V (four patients). Time from injury to surgery was shorter and patients needed less time to return to daily activities in Group 1. Duration of the surgical procedure was shorter in Group 2 compared with Group 1. Complications of each method were noted. According to the measured scores and operative outcome between dislocation Rockwood type III and V, no significant difference was found. Implant material used in Group 2 was 4.7 times more expensive than that used in Group 1.

CONCLUSION

Both methods offer many advantages with satisfying evaluated scores. K-wires with FiberTape(®) offer a shorter period for complete recovery and a significantly more cost-effective outcome, whereas the TightRope System(®) offers shorter operative procedure, better cosmetic result and avoidance of intraoperative fluoroscopy.

Doctoral degree in health professions: professional needs and legal requirement

To respond to ever increasing complexity of health care professions, education of nurses, midwives, physiotherapists, radiology engineers, and medical laboratory workers, has been upgraded to pregraduate, graduate and postgraduate university levels. In Croatia, nursing was defined as a branch of clinical medical science in 1997. Croatia and Bosnia and Herzegovina have introduced first two levels, but there is a strong need for the third one (doctoral degree). It should last three years and contain 180 ECTS points. It includes acquisition of evidence-based advanced health care, and the ability for independent research and critical analysis. Doctoral degrees in health professions are instrumental for academic careers of faculty of health professions. Yet this will not separate them from their patients or make them administrators, as the majority of their work will still be spent alongside patients.

Glucocorticoid-resistant Evans' syndrome successfully controlled with low-dose cyclosporine

OBJECTIVE

To present a patient suffering from Evans' syndrome (ES), whose bouts of severe cytopenia were prevented by low-dose cyclosporine maintenance therapy.

CASE SUMMARY

A boy suffering from frequent mild respiratory infections, first time evaluated in a tertiary care pediatric center at age 4, was found to have lymphadenopathy and mild splenomegaly. The thrombocytopenia was first noted at age 6. He was diagnosed to have ES at the age of 8, during another bout of thrombocytopenia, this time associated with Coombs-positive hemolytic anemia. Immunoglobulin concentration in the plasma was measured repeatedly, and was in the normal range, or even increased. Lymphocyte subpopulation numbers were in the normal range, with decreased CD4+/ CD8+ ratio (0.6). Autoimmune lymphoproliferative syndrome was excluded by the absence of CD4-CD8- T lymphocytes. Since the patient failed to respond to standard therapy with prednisolon 2 mg/kg, high dose intravenous methylprednisolone (10 mg/ kg/d for 3 days) and high dose intravenous immunoglobulin (1 g/kg/d for 2 days), cyclosporine treatment was initiated (6 mg/ kg/d) and resulted in normalization of platelet count and resolution of hemolysis. Two attempts to withdraw cyclosporine therapy resulted in life-threatening hemolytic crisis with severe thrombocytopenia, requiring the re-institution of cyclosporine. The dose of cyclosporine was eventually tapered to the present 0.5 mg/kg, corresponding to drug serum levels of 5 - 8 mg/ml. The patient is now free of manifestations of Evans' syndrome but, after 20 years of cyclosporine treatment, has slightly impaired kidney function.

CONCLUSION

Low-dose cyclosporine therapy given to our patient appears to have subdued the autoimmune process thought to underlie the manifestations of ES, albeit at the cost of some toxicity to the kidneys.

The Croatian model of university education for health professionals

In all European countries healthcare professions are regulated by law. In Croatia, the legally--regulated professions are: medicine, dentistry, pharmacy, nursing, physiotherapy and midwifery, as well as radiographers, occupational therapists and medical laboratory technicians. Current education of health professionals in Croatia is traditional, inadequate and poorly harmonized with current educational trends, as well as with requirements and directives of European Commission. This Croatian model for education of health professionals at university level follows the recommendations specified in Croatian Qualification Framework: (i) learning outcomes are competency-based; (ii) mobility of students and faculty is encouraged; (iii) the means of quality assurance are anticipated. The Croatian model of university education for health professionals will make sure that all procedures, specified in the European and Croatian Qualification Framework addressing recognizability of study programs, mobility, learning outcomes, quality assurance and reliability of required qualifications are successfully completed.

CT perfusion and noncontrast CT in acute ischemic stroke diagnosing--is there influence on early thrombolytic therapy outcome?

The objective of this study was to compare noncontrast computed tomography (NCCT) and computed tomography perfusion (CTP) in early diagnosis of acute ischemic stroke and to define influence of these diagnostic procedures on early outcome of thrombolytic therapy (TLTH). The study included 45 patients, 35 patients submitted to NCCT and CTP and 10 patients who underwent only NCCT, before CTP was introduced. Based on the National Institute of Health Stroke Scale (NIHSS) score we compared early outcome of patients who received TLTH after NCCT only (group 1) with the early outcome of patients who received TLTH following NCCT and CTP (group 2). Statistically significant difference was found in acute stroke diagnosing between CTP and NCCT (p = 0.002). There were no statistically significant differences in TLTH early outcome between group 1 and group 2. In conclusion, CTP should be done regulary in patients presenting with acute ischemic stroke symptoms. More research needs to be done in defining exact influence of CTP implementation on the TLTH outcome.

Breast reconstruction after mastectomy

Results of our analysis show as that breast reconstruction become a standard part of the care of female patients with breast cancer We will analyse the factors that are important for the primary or secondary breast reconstruction after mastectomy, and also take a closer look on the most recent scientific advances on breast reconstruction and on the protocols regarding them. The breast is the most common site of cancer in Croatia women. Breast cancer is the first leading cause of cancer death among women today. The incidence of female breast cancer in Croatia estimates that approximately 2.200 news cases of female breast will be diagnosed every year. We retrospectively analysed data of 101 female patients undergoing reconstructive surgery for breast reconstruction after mastectomy at Division of Plastic Surgery and Burns, University Hospital Center Split and University Clinic of Plastic and Reconstructive Surgery, Innsbruck, Austria, between 1998 and 2008. For the purpose of outcome assessment, we performed the tree different type of questionnaire: (1) Personal/medical profile (Table 1), (2) Aesthetic assessment (Table 2), and (3) Psychosocial assessment (Table 3). The occurrence of main complications during breast reconstruction (partial necrosis of flap, hernia of donor site, pulmonary embolism, deep venous thrombosis, infection rate, hemathoma and seroma formation, and extrusion of expander/implant) during hospitalisation and follow up period until 6 post operatively were analysed with respect to use different type of reconstructive methods for breast reconstruction. The difference in complication between patients groups was evaluated by chi2-test. The level of significance was set up at p = 0.05. Mann-Whitney test was used to compare the time from mastectomy to breast reconstruction, due to asymmetrical data distribution. The three main variables of this study were to identify significant risk factors, asses the aesthetic outcome, and patient satisfaction with performed different methods for breast reconstruction (LD flap with or without tissue expander and implant, pedicle and free TRAM flaps, and expander /implants only. These variables determined the current guidelines for early and late breast reconstruction after mastectomy such as patient data, age and own decision, relation ship between reconstruction and radiotherapy, and chemotherapy, and finally about breast preserving operation. The result should confirm that breast reconstruction after mastectomy is justified, especially in young women, as well as how essential is team work involved in breast cancer operation and breast reconstruction after mastectomy.

Beta2-microglobuline plasma level and painful shoulder in haemodialysed patients

Painful shoulder in patients on chronic haemodialyis is most often associated with dialysis arthropathy or accumulation of deposits containing modified fibrils of beta2- microglobuline especially in bones and joints due to insufficient elimination during the therapy. The aim of this study is to investigate whether there is connection between painful shoulder and plasma level of beta2-microglobuline and to corroborate that with morphologic parameters found in proved amyloidosis. It has to be emphasized that even other causes may contribute the development of painful shoulder. Real time sonography and conventional plain radiographs of the 108 shoulders were performed in 54 patients receiving chronic haemodialysis as a treatment of terminal renal failure (without previous history of rheumatoid arthritis), 27 symptomatic with persistent pain and stiffness in both shoulders and lasting for more than 6 weeks and restriction of movements in various degree and 27 asymptomatic. Plasma level of beta2-microglobuline, CRP and uric acid were taken periodically as routine procedure during a one year prospective trial, as well as plasma level of calcium, phosphor and alkaline phosphatase. Plasmatic level of beta2-microglobuline is strongly connected with painful shoulder in dialyzed patients, as well as CRP as sign of acute inflammation. That is proved by morphologic parameters associated with histological proved amyloidosis in patients on long term dialysis, more then 10 years.

Genome-wide association study of anthropometric traits in Korcula Island, Croatia

AIM

To identify genetic variants underlying six anthropometric traits: body height, body weight, body mass index, brachial circumference, waist circumference, and hip circumference, using a genome-wide association study.

METHODS

The study was carried out in the isolated population of the island of Korcula, Croatia, with 898 adult examinees who participated in the larger DNA-based genetic epidemiological study in 2007. Anthropometric measurements followed standard internationally accepted procedures. Examinees were genotyped using HumanHap 370CNV chip by Illumina, with a genome-wide scan containing 316730 single nucleotide polymorphisms (SNP).

RESULTS

A total of 11 SNPs were associated with the investigated traits at the level of P<10(-5), with one SNP (rs7792939 in gene zinc finger protein 498, ZNF498) associated with body weight, hip circumference, and brachial circumference (P=3.59-5.73 x 10(-6)), and another one (rs157350 in gene delta-sarcoglycan, SGCD) with both brachial and hip circumference (P=3.70-6.08 x 10(-6). Variants in CRIM1, a gene regulating delivery of bone morphogenetic proteins to the cell surface, and ITGA1, involved in the regulation of mesenchymal stem cell proliferation and cartilage production, were also associated with brachial circumference (P=7.82 and 9.68 x 10(-6), respectively) and represent interesting functional candidates. Other associations involved those between genes SEZ6L2 and MAX and waist circumference, XTP6 and brachial circumference, and AMPA1/GRIA1 and height.

CONCLUSION

Although the study was underpowered for the reported associations to reach formal threshold of genome-wide significance under the assumption of independent multiple testing, the consistency of association between the 2 variants and a set of anthropometric traits makes CRIM1 and ITGA1 highly interesting for further replication and functional follow-up. Increased linkage disequilibrium between the used markers in an isolated population makes the formal significance threshold overly stringent, and changed allele frequencies in isolate population may contribute to identifying variants that would not be easily identified in large outbred populations.

Genome-wide association study of biochemical traits in Korcula Island, Croatia

AIM

To identify genetic variants underlying biochemical traits--total cholesterol, low-density lipoprotein (LDL) cholesterol, high-density lipoprotein (HDL) cholesterol, triglycerides, uric acid, albumin, and fibrinogen, in a genome-wide association study in an isolated population where rare variants of larger effect may be more easily identified.

METHODS

The study included 944 adult inhabitants of the island of Korcula, as a part of larger DNA-based genetic epidemiological study in 2007. Biochemical measurements were performed in a single laboratory with stringent internal and external quality control procedures. Examinees were genotyped using Human Hap370CNV chip by Illumina, with a genome-wide scan containing 346027 single nucleotide polymorphisms (SNP).

RESULTS

A total of 31 SNPs were associated with 7 investigated traits at the level of P<1.00 x 10(-5). Nine of SNPs implicated the role of SLC2A9 in uric acid regulation (P=4.10 x 10(-6)-2.58 x 10(-12)), as previously found in other populations. All 22 remaining associations fell into the P=1.00 x 10(-5)-1.00 x 10(-6) significance range. One of them replicated the association between cholesteryl ester transfer protein (CETP) and HDL, and 7 associations were more than 100 kilobases away from the closest known gene. Nearby SNPs, rs4767631 and rs10444502, in gene kinase suppressor of ras 2 (KSR2) on chromosome 12 were associated with LDL cholesterol levels, and rs10444502 in the same gene with total cholesterol levels. Similarly, rs2839619 in gene PBX/knotted 1 homeobox 1 (PKNOX1) on chromosome 21 was associated with total and LDL cholesterol levels. The remaining 9 findings implied possible associations between phosphatidylethanolamine N-methyltransferase (PEMT) gene and total cholesterol; USP46, RAP1GDS1, and ZCCHC16 genes and triglycerides; BCAT1 and SLC14A2 genes and albumin; and NR3C2, GRIK2, and PCSK2 genes and fibrinogen.

CONCLUSION

Although this study was underpowered for most of the reported associations to reach formal threshold of genome-wide significance under the assumption of independent multiple testing, replications of previous findings and consistency of association between the identified variants and more than one studied trait make such findings interesting for further functional follow-up studies. Changed allele frequencies in isolate population may contribute to identifying variants that would not be easily identified in much larger samples in outbred populations.

[Sensitivity and specificity of clinical assessment in the diagnosis of acute brain diseases]

Acute brain diseases require timely and correct diagnosis. The basic guideline in treating these patients is clinical-neurological assessment. We tested the sensitivity and specificity of clinical assessment of acute brain disease according to definitive diagnosis determined by neuroradiology and computerized tomography (CT). We found a statistically significant correlation between the disease assessment and brain CT in patients with ischemic stroke. In patients with hemorrhagic stroke and brain tumors, the clinical-neurological assessment was found to be of statistically significantly lower sensitivity and specificity. Clinical assessment may produce false-positive and false-negative findings concerning hemorrhagic stroke and brain tumors. Study results indicated brain CT to be an unavoidable diagnostic method, along with clinical assessment of acute brain disorders.

Laboratory and sonographic findings in dialyzed patients with bilateral chronic knee pain versus dialyzed asymptomatic patients

The aim of this study is to evaluate connection of plasma level of beta2-microglobulin, C-reactive protein and uric acid as well as sonographic parameters like thickness of synovial membrane, thickness of femoral condylar cartilage and presence of joint effusion and Baker's cysts with bilateral knee pain in dialyzed patients, comparing them with parameters in asymptomatic dialyzed patients. Plasma levels of beta2-microglobulin and C-reactive protein were significantly higher in symptomatic patients while uric acid level showed no difference among the groups. In symptomatic patients synovial membrane was thicker and in those patients there were more knee effusions and Baker's cysts. Thickness of femoral condylar cartilage showed no difference between groups. That suggests that inflammatory mechanisms developing from beta2-microglobulin accumulation could be important factor in bilateral knee pain in dialyzed patients even in shorter duration dialysis.

Neurotoxicity that may mimic progressive multifocal leukoencephalopathy in patient with transplanted kidney

We present the 55-year-old woman who has had kidney transplantation three times. She has been treated with immunosuppressive therapy and lamivudine for hepatitis B and C. Nine years after the last transplantation she showed neurological symptoms that presented in the form of confusion and epileptic seizures of the grand mal type. A brain MRI showed large oval zones of hyperintense MR signal in T2-weighted image and hypointense in T1-weighted image around the frontal horns of the lateral ventricles, bilaterally and in both cerebellar hemispheres. After reduction in immunosuppression and the exclusion of lamivudine from therapy, the patient was stable with normal neurological status during the course of next five years. We start from the assumption that the concomitant use of cyclosporin with mycophenolate mofetil and lamivudine, despite normal concentrations of cyclosporin, might cause the accumulation of toxic metabolites and lead to neurotoxicity that mimics PML in a chronic viral environment.

Primary extranodal lymphomas of gastrointestinal localizations: a single institution 5-yr experience

This study is aimed at comparison of patients with extranodal lymphomas based on pathohistological findings differences (MALT vs non-MALT) as well as regarding gastric and non-gastric localization, and determining the significance of clinical-laboratory parameters with respect to therapeutic response and length of survival. A total of 56 patients with extranodal non-Hodgkin's lymphomas of the gastrointestinal tract were evaluated over a 5-yr period. Regarding the localization of the disease, the stomach was most frequently affected, 39 patients (70%); followed by small and large intestines, 17 patients. As for the pathohistological findings, MALT lymphoma accounted for 70%, DLBCL 25%, while other subtypes accounted for 5%. Patients' distribution was analyzed according to CS based on both Ann Arbor and Lugano systems; however, the difference obtained between the groups was not statistically significant in both staging types of patients. Statistically significant difference in patients' distribution was not found with respect to IPI index, bone marrow infiltration, anemia, hypoalbuminemia, or histological subtype and localization. Difference in survival between patients according to the pathohistological type was not statistically significant also according to the type of the affected gastrointestinal tract organ. Statistical significance of difference according to survival probability was obtained based on age (survival is longer in patients over 55 yr of age); according to CS and according to Ann Arbor and Lugano classifications (the patients with lower CS live significantly longer); according to IPI index (the survival is significantly longer in patients with lower probability: IPI-0,1, and 2), as well as patients free of bone marrow infiltration whose survival is also significantly longer.

Pulmonary function in persons who are professionally exposed to formaldehyde fumes

The present study examines long-term effects of occupational exposure to formaldehyde fumes on lung function. Forced spirometry and diffusing lung capacity were measured in 16 health-service professionals (8 medical doctors and 8 laboratory technicians) working at the pathoanatomic laboratory for at least 4 years with daily exposure 8 +/- 1 hours. Control group employed 16 males, which were matched by age and stature to members of the exposed group. Only non-smokers were included in the study. Spirometric parameters in study participants exposed to formaldehyde fumes compared to control group were not significantly different indicating absence of restrictive and/or obstructive deterioration of lung function in exposed group. The only parameter differing in two groups was blood volume of pulmonary capillaries (Vc') which was significantly larger in a group exposed to formaldehyde fumes. The possibility that the hyperemic lung reaction is the consequence of the exposure to formaldehyde fumes should be further explored.

Relevant sonographic parameters of a painful shoulder in symptomatic dialyzed patients versus asymptomatic dialyzed and healthy volunteers

The aim of this study is to find dialysis relevant sonographic parameters of painful shoulder of the symptomatic dialyzed patients comparing them with parameters in asymptomatic dialyzed patients and healthy volunteers. Significant difference in all metric parameters (thickness of supraspinatus tendon, diameter of biceps tendon sheet and capsula-bone distance) were noticed between all groups and the symptomatic had the highest values. Asymptomatic had the higher values then volunteers. Inhomogenicity of the tendon and biceps tendon sheet effusion in the symptomatic patients were the most often occurred. Subdeltoid effusion, deposits and tendon rupture were found only in symptomatic patients. No difference in presence of calcifications between symptomatic and asymptomatic was found. Metric parameters are relevant and associated with dialysis, as well as biceps tendon effusion tendon inhomogenicity, deposits and subdeltoid effusion. Tendon ruptures are relatively rare and nonspecific.

Extranodal marginal zone B-cell lymphoma most probably of MALT type appearing in CNS as parasagittal extracerebral tumor

A 63 years old male patient with systemic extranodal marginal zone lymphoma, most probably originating from mucosa associated lymphoid tissue (MALT) involving central nervous system (CNS) is presented. The usual site of origin of this type of lymphoma was not identified. The diagnosis was stated after neurosurgery according to histopathology, immunohistochemistry and additional haematologic examination. Postoperative therapy included local irradiation (30Gy) of rest tumor, combined by Rituximab-CHOP (R-CHOP) protocol, which resulted in complete remission lasting three years up to now.

Diet and Bladder Cancer: A Case–Control Study

To investigate possible relationships between diet and risk for bladder cancer in Serbia, the hospital-based case-control study was carried out. This study included 130 newly diagnosed bladder cancer patients and the same number of controls matched by sex, age (%+/-%2 years) and type of residence (rural or urban). Dietary information was obtained by using a food frequency questionnaire. Initial case-control comparisons were based on tertiles of average daily intake of control group. The odds ratios (ORs) were computed for each tertile, with the lowest tertile defined as the referent category. All variables (food items) significantly related to bladder cancer were included in multivariable logistic regression analysis. According to this analysis, risk factors for bladder cancer appeared to be consumption of liver (OR=6.60, 95%CI=1.89-23.03), eggs (OR=3.12, 95%CI=1.10-8.80), pork (OR=2.99, 95%CI=1.16-7.72), and pickled vegetable (OR=3.25, 95%CI=1.36-7.71). A protective effect was found for dietary intake of kale (OR=0.21, 95%CI=0.06-0.73), cereals (OR=0.19, 95%CI=0.06-0.62), tangerines (OR=0.21, 95%CI=0.07-0.68), cabbage (OR=0.27, 95% CI=0.11-0.68), and carrots (OR=0.15, 95%CI=0.05-0.41). The study indicated a potentially important role for dietary fat and pickled vegetables in bladder carcinogenesis. An inverse association was recorded between consumption of fruits, vegetables and cereals, and the development of bladder cancer.

Diet in bladder cancer ethiopathogenesis

The aim of this paper is to show influence of different foods on bladder cancer appearance, as well as possible consequent ways of prevention. Consumption of food rich in animal fat and cholesterol, fried foods, especially several times used cookin oil for frying, processed meat with additives (nitrates, nitrites, azo-colourrs) can influence bladder cancer occurrence. Regularly, continuous consumption of fermented milk products, which contains come types of milky - acids bacterias, is considered as protective factor in developing bladder cancer. Reports that fruit and vegetable are protective food items are pretty consistent. Data about mineral intake and bladder cancer are obscure.

Lung function changes in pleural asbestosis

The aim of this study was to examine the relationship between radiographically detectable pleural changes and lung function in pleural asbestosis. One hundred and twenty chrysotile asbestos-exposed workers were enrolled in this retrospective study. For each examinee the length of asbestos exposure and the degree of dust cover at the workplace were assessed as well as the radiological and functional tests has been performed. The examinees were divided into two groups based on radiologically detectable changes: a) group with pleural changes (29%) and b) group without perceived pleural changes (71%). The obtained results indicate association between the length of asbestos exposure, pleural changes and the impairment of lung function.

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.

Anti-CD20 monoclonal antibody (Rituximab) for therapy of mediastinal CD20-positive large B-cell non-Hodgkin lymphoma with a local tumor extension into the lung of a 10-year-old girl

Intravenous therapy with the anti-CD20 antibody Rituximab has been recently approved for the treatment of CD20 positive non-Hodgkin's lymphoma (NHL) in adults but not in children. The authors present the benefits of its application for mediastinal NHL CD 20+ with a local extension into the lung of a 10-year-old-girl. Receiving the chemotherapy according to study NHL-BFM-95 for high-risk lymphoma the girl did not reach complete remission. Before the last chemotherapy block was started, a computed tomography scan of the thorax showed residue in the right lung. Twenty-five days after the last chemotherapy she received Rituximab at a dose of 375 mg/m(2) by intravenous infusion once a week for a total of four doses without the adverse reactions. Complete remission was achieved. The patient was high risk with lung involvement of lymphoma suggesting a pure prognosis. The results suggest that Rituximab may improve the outcome in high-risk patients and appeared to be safe and effective in children also.

[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.