Spinal Dexamethasone Effect on Cognitive Disorders After Hip Surgery

Background

Proximal femoral fractures (PrFF) are one of the most common causes of emergency admission in the elderly population. The majority of patients have pre-existing conditions that get worsened by unplanned surgery.

Objective

Purpose of this article was to evaluate if a is single shot of dexamethasone with levobupivacaine administered intrathecally reduces postoperative pain and cognitive complications in patients with proximal femoral fractures.

Methods

The study was performed at a level II trauma center which is a part of a teaching hospital with a catchment population of around 300,000 patients, the first author's affiliation. Around 500 PrFF are performed yearly in the center. All participants gave oral and written informed consent before randomization.

Results

In total, 60 patients with a PrFF, ASA status 2 or 3 were randomized into two groups for spinal anaesthesia as DLSA study group (received 8 mg of dexamethasone and 12.5 mg of 0.5 % levobupivacaine) or LSA control group (received 12.5 mg of 0,5 % levobupivacaine). Postoperative cognitive disturbance was evaluated using simplified Confusion Assessment Method (CAM) scale, pain intensity was measured using Visual Analogue Scale (VAS) and blood samples for defining cortisol concentrations were taken before and after the surgical procedure. The primary outcomes were effects of intrathecal dexamethasone on plasma cortisol affecting cognitive disturbances. Secondary outcomes included pain scores and length of hospital stay. The DLSA group demonstrated a reduced incidence of postoperative cognitive dysfunction (POCD), p=0.043, longer analgesia duration, p<0.001, decreased cortisol levels and shorter hospitalization p=0.045. Intrathecal dexamethasone was the only significant predictor of postoperative delirium, OR 7.76, p=0.019.

Conclusion

Single shot intrathecal administration of dexamethasone with levobupivacaine used in anaesthesia for proximal femoral fractures reduces the stress response by decreasing plasma cortisol concentrations prolonging analgesia. Complications such as delirium and POCD occurred with significantly lower frequency allowing better postoperative rehabilitation and shortening the hospitalization.

Obstetrics Anamnesis of the Empress Maria Theresia

Background:

The peculiar reigning and private life of Maria Theresa in the tumultuous time of continuous wars in the then Europe was interwoven with her predominant maternal/obstetric history, as presented below.

Objective:

All the sixteen pregnancies of Empress Maria Theresa ended in spontaneous vaginal deliveries at term, with no information on pregnancies ended in spontaneous abortion or preterm delivery.

Methods:

Medicohystorical review of the obstetrical anamnesis of Empress Maria Theresia.

Results:

There were fifteen live births, whereas one female baby was born without signs of life. Cephalic presentation was recorded in fourteen and breech presentation in two deliveries, one of the latter with lethal fetal outcome. Thirteen deliveries were free from complications, whereas three deliveries, i.e. second, tenth and sixteenth, were very difficult, associated with obstetric complications including one manual lysis of the placenta with postpartum bleeding and two difficult deliveries with breech presentation. Maria Theresa had all her deliveries accomplished with assistance of the Court midwife (Hofhebamme), whereas the Court physician performed manual lysis of the placenta. Following delivery, the Habsburg-Lorraine archduke or archduchess was baptized by papal nuncio, but two children were baptized by the midwife in life-threatening conditions

Conclusion:

Considering her policy of renewing her multiethnic empire and its population that suffered great losses at various battlefields, Maria Theresa was a true representative and record-holder in perinatal contribution among the then courts worldwide.

Pregnancy After Simultaneous Pancreas-Kidney Transplantation in Treatment of End-Stage Diabetes Mellitus: a Review

The majority of patients with simultaneous pancreas and kidney transplant (SPKT) required transplantation owing to a long-standing history of insulin-dependent diabetes mellitus (IDDM). The disease causes multiple organ damage, impairs fertility, and affects quality of life. A successful kidney and pancreas transplant can improve health, ameliorate the consequences of pre-existent diabetes, and restore fertility. Good graft function, without any sign of rejection, and stable doses of immunosuppressant drugs are of utmost importance prior to the planned pregnancy. SPKT recipients who become pregnant may be at an increased risk for an adverse outcome and require meticulous multidisciplinary surveillance. We present experiences with SPKT pregnancies, traditional approaches, and recent considerations. In light of complex interactions between new anatomic relations and the impact of developing pregnancy and immunosuppressive medications, special stress is put on the risk of graft rejection, development of pregnancy complications, and potential harmful effects on fetal development. Recent recommendations in management of SPKT recipients who wish to commence pregnancy are presented as well. Key words: transplantation, pregnancy, pancreas, kidney, simultaneous pancreas and kidney transplantation (SPKT).

Breastfeeding Promotion and the Results of the Maternity Ward - a Friend of Children Initiative Implementation in Bjelovar-Bilogora County in 2018

Background:

Objective:

Methods:

Results:

Conclusion:

Implementation of the Program for Early Detection of Cervical Cancer in the Federal Republic of Germany

Introduction

There are many cervical cancer screening programs in the world. Germany, as well as a number of other countries in the world, carry out its national cervical cancer screening program.

Aim

In order to improve screening results, new guidelines for cervical cancer screening are in force in Germany.

Methods

Auhors used descriptive-analytical method to described advantages and disadvantages of new adopted Guidelines for screnning program according eperiences of used previous program in Germany.

Discussion

These guidelines have been adopted and approved by the competent Federal Committee for the implementation of cervical cancer screening in Germany. The committee is under the independent management of doctors and health insurance companies. The Committee is also under the legal control of the German Federal Ministry of Health.

Conclusion

New Guidelines for Cervical Cancer Screening in Germany has an unchanged part relating to cervical cytodiagnostics. In addition, HPV typizatiion has been integrated in the new screening guidelines to further improve the quality of cervical cancer screening in Germany.

Spontaneous Heterotopic Pregnancy as an Uncommon Clinical Problem

BACKGROUND

Heterotopic pregnancy refers to the simultaneous coexistence of an intrauterine and extrauterine pregnancy. In natural conception it is very rare, with a rising incidence in patients undergoing assisted reproduction technologies. It presents a serious diagnostic problem which is often misdiagnosed. Currently, there are no standard protocols for the treatment and diagnosis of heterotopic pregnancy.

METHODS

Two rare cases of spontaneous heterotopic pregnancy are presented.

RESULT

The first patient had a complete abortion upon which an extrauterine pregnancy was detected. The second patient, after an extrauterine pregnancy removal, progressed with an intrauterine pregnancy until full term and it ended with the delivery of a healthy infant.

CONCLUSION

Two demonstrated cases underscore that whenever abnormal adnexal findings are presented and the beta-hCG blood test is positive, the possibility of a heterotopic pregnancy should be suspected.

Balkan Clinical Research Registry: Established by Academy of Medical Sciences of Bosnia and Herzegovina

Background:

From 2013 the World Medical Association’s Declaration of Helsinki explicitly requires pre-registration of a study involving human subjects. The registration gives a chance for improvement of design and avoidance of bias.

Objective:

The aim of this article was to describe process of bearing decision to create regional registry of clinical studies for Balkan countries.

Methods:

After finding relevant studies about research registries and designing the concept and structure of future regional registry an article was published in IJBH journal. The article was than used as basis for discussion at 2020 meeting of Academy of Medical Sciences of Bosnia and Herzegovina (AMSBH), and final decision was made by the Academy to create the research registry.

Results:

Regional registry of clinical studies will be under the auspices of AMSBH and web-based, with the option of online registration of new studies. The data required to be entered in the moment of registration relate to key elements of research plan: topic, variables, sample, type of the study and the study population. After applying for registration of a clinical study, the authors will soon receive the review made by the AMSBH expert committee. The application could be accepted, rejected or returned for major or minor revision. After an application is accepted, it will be deposited in the searchable database and given the registration number.

Conclusion:

The AMSBH’s decision to create the regional registry of clinical studies will satisfy needs of researchers from Balkan countries in the first place, who share cultural and lingual similarities. It will also help with increasing standards of clinical research in the region.

Guidelines for Editing Biomedical Journals: Recommended by Academy of Medical Sciences of Bosnia and Herzegovina

Background:

Enormous number of medical journals published around the globe requires standardization of editing practice.

Objective:

The aim of this article was to enlist main principles of editing biomedical scientific journals adopted at annual meeting of Academy of Medical Sciences of Bosnia & Herzegovina (AMSB&H).

Methods:

The evidence for writing this Guideline was systematically searched for during September 2020 in the PUBMED and GOOGLE SCHOLAR databases. The inclusion criteria were: original studies, systematic reviews, invited expert opinions, guidelines and editorials. The exclusion criteria were narrative reviews and uninvited opinion articles. The retrieved evidence was analyzed by members of the AMSB&H, then discussed at 2020 annual meeting of the AMSB&H and adopted by nominal group technique.

Results:

In total 14 recommendations were made, based on A to C class of evidence. The editors should educate potential authors and instruct them how to structure their manuscript, how to write every segment of the manuscript, and take care about correct use of statistical tests. Plagiarism detection softwares should be used regularly, and statistical and technical editing should be rigorous and thorough. International standards of reporting specific types of studies should be followed, and principles of ethical and responsible behavior of editors, reviewers and authors should be published on the journal’s web site. The editors should insist on registration of clinical studies before submission, and check whether non-essential personal information is removed from the articles; when essential personal information has to be included, an article should not be published without signed informed consent by the patient to whom these information relate.

Conclusions:

Principles of editing biomedical scientific journals recommended in this guideline should serve as one of the means of improving medical journals’ quality.

Coexistence of Condylomata Acuminata with Warty Squamous Cell Carcinoma and Squamous Cell Carcinoma

Introduction:

Condyloma acuminatum has previously been considered to be a benign growth with no malignant potential, but a review of the literature supports the concept that condylomata acuminata may precede or be associated with invasive squamous cell carcinoma (ISCC) or warty squamous cell carcinoma (WSCC).

Case report:

We present a clinical case of a 58-year old woman with large, slow-growing, exophytic tumor of external genitalia shaped like a cauliflower with the propagation to both legs and behind. We performed multiple biopsies to detect potential malignancy but malignancy was not confirmed histologically. The presence of HPV (human papilloma virus) low and high risk was discovered. Inguinal lymph nodes were enlarged both sides, but cytologic examination identified no malignant cells. The patient was initially treated by the loop electro surgical excision procedure (LEEP) and podophilin solution on the rest of the condylomas. Condyloma acuminatum was confirmed histologically. Later, we performed a wide surgical excision of the rest of the condylomas. The new changes on the previously treated region were removed using LEEP. WSCC and ISCC were confirmed histologically so were radical vulvectomy and inguinal lymphadenectomy performed. The patient was advised to remain under close follow-up.

The Infraorbital Artery in Fetuses: Clinical Relevance in Perforator Flap Surgery

Introduction:

The reconstruction of soft tissue detects in mid facial region are highly demanding. Most challenging region are nasal alla. For full thickness nasal alla defects most authors use nasolabial flap based on facial/angular arcade, but for recidivans tumors the infraorbital perforator flap is a good solution.

Aim:

The aim of our research was to analyze the number and the course of the infraorbital artery terminal branches.

Material and methods:

Material was 60 fetal hemifacial specimens of different gestational ages. Fetuses were fixed in 10% formalin and arterial blood vessels were injected with Micropaque solution (barium sulfate). Samples were further processed by Spalteholz technique, their images captured with digital camera and analyzed. Infraorbital artery was constant artery and had 2 to 4 terminal branches supplying infraorbital region. The majority of its terminal branches were characterized with descending course. Reach anatomical network of infraorbital artery made anastomoses with facial artery.

Conclusion:

Perforator flap based on infraorbital artery had well defined vascular supply with numerous soft tissue branches, which qualify this flap as safe solution for nasal reconstruction.

Ultrasonic investigation of parametric values of portal vein diameter in healthy subjects and patients with chronic diffuse liver disease

INTRODUCTION

Portal vein in healthy subjects and in patient with chronic diffuse liver disease was investigated by the combination of real-time technique and Doppler impulsive system.

PATIENTS AND METHODS

Control group consisted of 99 healthy subjects of median age of 36,8, and with life raging span from 14 to 77 yrs. Experimental group consisted of 55 patients with histologically proved liver disease approximately aged 48,1 yrs. And with life span from 11 to 77 yrs. In 15 patients, portal hypertension was proved, by the measurement of Wedged hepatic venous pressure (WXVP).

RESULTS

VP diameter was normally distributed in healthy subjects, variable with E(X) = 11,202 mm and SD = 1, 2534. The mentioned variable was also normally distributed in experimental group with E(X) = 10, 8 mm and SD = 1, 4832. VP diameter in healthy subjects did not statistically significantly differ from that one of the patient with chronic diffuse liver disease, which in contradictory to the generally accepted concepts. According to our results, portal vein diameter should not be taken as a parameter of portal hypertension.

Repeated administration of inhibitors for ion pumps reduce markedly tumor growth in vivo

Introduction:

Measurements of extracellular pH show that the micro environment of malignant tumors is more acidic than that of normal cells, whereas pH does not differ appreciable in normal and malignant cells. The acid micro environment of tumors is created by the secretion of tumor factors and ATP hydrolysis in hypoxic tumor tissue. In order to survive in a low pH-environment tumor cells develop regulatory mechanisms which keep their intracellular pH stable. Two of the most important systems are the Na+/H+ ion pump and the Na-dependent HCO3-/Cl- pump of stilbenian derivatives.

Material and methods:

Experiments were carried out on DBA mice of both sexes at the age of 4 month. Laboratory animals were grown in our institute and supplied with food and aqua ad libitum.

Results:

After termination of the experiments the mean tumor diameter in the control group was 12.4±0.8mm, in group A it was 6.9±0.6mm, and in group B we measured 6.6±3.1mm. At the final day the tumor size in treated animals was twice as small as in the control group. In addition we observed the rate of survival. In the control group only 18% of the animals were still alive at day 18. Considering the rate of survival a statistically significant difference between treated and untreated animals was observed. The survival of tumor cells is dependent on the function of these ion pumps which keep their intracellular pH values constant in the setting of an acid extracellular environment.

Conclusion:

The activity of the ion pump is especially important at the beginning of cell division and in cell proliferation. Our in vivo experiments demonstrate that prolonged administration of intratumoral ion pump inhibitors suppresses tumor growth as well as enhances survival of tumor-bearing animals. Research of inhibitors of ion pumps and their action in tumor growth opens new perspectives into pathophysiology of malignant tumors and may create new therapeutic options.

An Unusual Prenatal Ultrasound Image of Placental Lake in High Risk Pregnancy

No abstract available.Nepal Journal of Obstetrics and Gynaecology / Vol 8 / No. 2 / Issue 16 / July-Dec, 2013 / 75-76 DOI: http://dx.doi.org/10.3126/njog.v8i2.9779  

Single stage turn in perforator infraorbital artery island flap for nasal ala reconstruction

Background:

The reconstruction of fullthickness nasal alla defects is challenging procedure. Use of local flaps is acceptable approach. Flap based on infraorbital artery could be used for primary reconstruction of nasal ala defects.

Methods:

The prospective study include consecutive series of 15 patients with advanced skin carcinoma of the nasal ala and medial cheek staged T4 by TNM, in whom the turn in infraorbital flap was used. The patient characteristics, type of carcinoma and complications were analyzed.

Results:

The turn in infraorbital flap was used mostly in male patients (80%), mean age 64 years. The basal cell skin carcinoma was found in 60%. Skin layer was skin grafted. All flaps survived, but in one case a partial wound dehiscence in one partial skin graft loss was found, and in two patients partial nasal obstruction occurred. These three complications were solved as secondary procedures under local anesthesia.

Conclusion:

Full-thickness defect of the nasal ala can be properly reconstructed using flap based on infraorbital artery providing exceptional esthetic and functional results, as single stage procedure.

New Views on Cesarean Section, its Possible Complications and Long-Term Consequences for Children's Health

Historical developments and advancements in cesarean section techniques and logistics have reduced the maternal and neonatal risks associated with the procedure, while increasing the number of operatively completed pregnancies for medically unjustifiable reasons. The uncritical attitude towards cesarean section and the fast emergence of ‘modern’ diseases such as obesity at a young age, asthma, type 1 diabetes mellitus and various forms of dermatitis have stimulated researches associating cesarean section with these diseases. Intestinal flora of the children born by cesarean section contains less bifidobacteria, i.e. their intestinal flora is similar to the intestinal flora in diabetic individuals. In children born by cesarean section, the ‘good’ maternal bacterial that are normally found in the maternal birth canal and rectum are lacking, while the ‘bad’ bacteria that may endanger the child’s immune system are frequently present. In children born by vaginal delivery, the ‘good’ maternal bacteria stimulate the newborn’s white blood cells and other components of the immune system, which has been taken as a basis for the hypotheses explaining the evident association of the above morbidities and delivery by cesarean section.

Criteria and procedures for breast conserving surgery

AIM

Emphasizing circumstances that determine increasingly popular surgical approach of breast conserving surgery (BCS), used in lower grade breast tumors, while maintaining survival that is found when more radical procedures are used.

PATIENTS AND METHODS

Several leading oncological protocols in the world are compared, using PubMed database, and our own experience. Data gathered are compared to conclusions of Consensus Conference on Breast Conservation (Milan, 2005). Furthermore, surgical contraindications found in our everyday work are considered, having in mind satisfactory cosmetic outcome, as well as keeping the 1 cm border of "clear" edges. Such more practical problems of edge detection can compromise BCS results.

RESULTS

After observing several relevant protocols, we found very high frequency of mastectomy vs. BCS, despite the fact that stage of disease was low. We also found only 20% of absolute contraindications for BCS. Most frequent contraindication for BCS was multicentricity of the tumor (with micro calcifications), especially in ductal in situ carcinoma.

CONCLUSION

BCS followed by radiation therapy with tumor-free edges is standard procedure in treatment of T1 and small T2 breast cancers. This approach implies higher risk of local recurrence (LR), although local recurrence is low (1% per year), with rates of survival similar to radical procedures.

Comparing two techniques of panretinal photocoagulation on visual acuity on patients with proliferative diabetic retinopathy

We wanted to examine which of two panretinal photocoagulation (PRP) techniques, classical panretinal photocoagulation (CPRP) and modifield peripheral panretinal photocoagulation PPRP), causes less decline of visual acuity (VA) due to macular edema (ME) in patients with proliferative diabetic retinopathy (PRD). This clinical study includes 180 eyes with PDR with initial papillar neovascularization. The patients were divided into two groups according the RP. PPRP and CPRP showed the decline of VA in all patients, more pronounced in the CPRP group after one week. After three and six months, with CPRP and PPRP the values of VA was stabilized. The result suggests that eyes with PDR and starting epipapillar neovascularisation should be treated with PPRP with priority given to CPRP because it caused better VA.

A surgical approach to giant condyloma (Buschke-Löwenstein tumour) with underlying superficial vulvar carcinoma: A case report

Anogenital warts (condyloma acuminatum or venereal warts) are a common sexually transmitted disease in males and females. Common clinical treatment of anogenital warts is conservative, however, in extreme cases conservative therapy is insufficient and surgical excision is required. Giant condyloma acuminata (Buschke-Löwenstein tumour) is an extremely rare clinical type of genital wart, characterised by aggressive down growth into underlying dermal structures. A 55-year-old female presented with cauliflower-like growth over the anogenital and sacral region, earlier diagnosed as condyloma acuminatum which was resistant to conservative therapy. During the period between 2005 and 2008 the patient underwent five surgical procedures. Due to the size and location of the tumour, gynaecological and plastic surgeons were involved in the procedures. In addition, definitive histology examination identified a superficial vulvar carcinoma.

painDETECT questionnaire and lumbar epidural steroid injection for chronic radiculopathy

BACKGROUND

The painDETECT questionnaire (PD-Q) is a fast and uncomplicated way to ascertain the percentage of neuropathic pain in 'total pain' and is designed to detect neuropathic pain components in back pain. The purpose of this randomized, prospective study is to compare, with the assessment of the PD-Q, the efficacy of interlaminar (IL) and transforaminal (TF) steroid injections in patients with unilateral chronic lumbar radicular pain.

METHODS

Patients were treated fluoroscopically with epidural steroids, using the IL or TF method and with confirmation of the epidural space by contrast, using random computerized classification. The patients received a series of three IL or TF epidural steroid injections (ESI) at 2-week intervals. The patients were monitored for 6 months from the first steroid injection.

RESULTS

By analyzing the average values of the total sum of points in the PD-Q a dropping trend is confirmed for both groups. The trend equation (y = -1.1393x + 25.269) for the TF ESI shows a faster recovery than the IL ESI (y = -0.8089x + 26.654). The statistically significant difference in the two groups is proved between the first and the sixth visit (IL ESI, p = 0.014; TF ESI, p = 0.001). There is no statistically significant difference in the efficiency of the two dosages and the volumes of steroids between the IL and TF distribution of steroids.

CONCLUSIONS

Steroids are efficient; besides alleviating the overall pain, they also reduce the neuropathic component in chronic lumbar radicular pain, whether it is distributed epidurally by the IL or TF approach.

Perioperative PAI-1 values in surgically treated colorectal carcinoma patients under low molecular weight heparin thromboprophylaxis

AIM

We have monitored the perioperative changes of plasmatic values of plasminogen activator inhibitor -1 (PAI-1) in colorectal carcinoma patients depending on the stage of disease and the use of prophylactic low molecular weight heparin (LMWH).

METHODS

One hundred 100 colorectal carcinoma patients (64 men and 36 women) with average age of 60, in two randomized groups. All patients were surgically treated using the same technique and in all cases adenocarcinoma was confirmed. Two hours before the surgery, the first group (48 patients) received LMWH-nadroparin calcium in doses of 0.3 or 0.4 mL sc, while the second group (52 patients) received it eight hours after the surgery. Following the surgery, Nadroparin calcium was administered daily using the same dose as before. Blood samples were collected: before the surgery, 10 minutes after the first surgical incision, 8 hours after the surgery, and on the 3rd, 5th and 10 th postoperative days. The staging of the disease (according to the Dukes classification) was compared with the patients' blood plasma concentration of PAI-1. Statistical analysis using the c2 test, the LSD test, Wilcoxon and Mann-Whitney test was performed.

RESULTS

Adenocarcinoma was patohistologicaly confirmed in all 100 subjects. According to the Dukes classification, 6 patients had stage A, 51 had stage B, and 43 had stage C. PAI-1 measurements showed that baseline measurements were within normal boundaries for both groups. Ten minutes after the first incision a sharp decline of PAI-1 values in the plasma of both patient groups was observed, which could be explained by the use due to the effect on t-PA secreted from the damaged endothelium. PAI-1 values in both groups of subjects have returned to starting (baseline) values, and remained within these values through the third, fourth and fifth measurement in both groups of patients. There was no difference between the two randomized groups which leads to the conclusion that the application of LMWH does not affect PAI-1 values. A statistically significant difference of the tested parameters according to the Dukes classification was obtained only for parameter PAI-1 for pairs Dukes A:B as well as Dukes A:C. A statistically significant correlation was found for plasma values of fibrinolysis inhibitor PAI-1 according to the Dukes classification, but it does not correlate to the tumor invasion through intestinal wall structures. The reason for the statistically significant increase of PAI-1 values in the Dukes A stage remains unclear.

CONCLUSION

By activating t-PA and blocking PAI-1, Nadroparin calcium perioperatively makes the haemostasis system stable and balanced.

Fournier gangrene: our approach and patients

AIM

This retrospective analysis presents our experience in treating Fournier gangrene (FG) and aims to bring in focus diagnostic and therapeutic problems as well as early and aggressive treatment.

PATIENTS AND METHODS

A total of 16 male patients were included in the study. The gastrointestinal form was seen in 5 and the urogenital form in 11 patients. The subjects ranged in age from 39 to 74 years (average 61) for the urogenital, and from 48 to 72 (average 58) for the gastrointestinal form. Other conditions were seen in 9 patients (diabetes mellitus was most common). Most patients were infected with several bacteria. We performed colostomy in 1 patient, orchidectomy in 2 patients, cystostomy in 2 patients and penis amputation in 1 patient. Ultrasound-guided biopsy or aspiration, and CT was also used. Aggressive surgical necrectomy and aggressive antimicrobial therapy was used.

RESULTS

Treatment was successful in 14 of 16 patients (87.5%). The length of hospitalization was 19-58 days (average 48) for the urogenital form and 24-56 days (average 41) for the gastrointestinal form. Mortality was 12.5%. A lethal outcome was recorded in two patients infected with methicillin-resistant Staphylococcus aureus. The average time between onset and hospitalization was 3-11 days (5 on average) for urogenital FG and 4-10 days (average 6) for gastrointestinal FG. Treatment was significantly longer in patients with a comorbidity, such as diabetes or liver cirrhosis due to alcohol abuse.

CONCLUSION

Early diagnosis as well as intensive and aggressive treatment are key to successful treatment of FG. Comorbidity increases length of therapy and lowers the chance for recovery. Disease can be seen again several years after the initial outburst.

Chorangioma placentae

Chorangioma of the placenta is a rare tumor with a frequency of about 1%, which usually presents as a solitary nodule or, less frequently, as multiple nodules. It is found on the fetal surface of the placenta or in placental parenchyma. Most chorangiomas are small and possess no clinical significance. On the contrary, clinically significant chorangiomas, greater then 5 cm or multiple, may be associated with pregnancy complications. The case presented is one of the uncommon presentations of chorangioma, in which its presence and size were not related to a pregnancy disorders or developmental anomalies of the fetus.

Use of complementary and alternative medicine in departments of obstetrics in croatia and a comparison to Germany

BACKGROUND

This nationwide study assessed the use of complementary and alternative medicine (CAM) methods in departments of obstetrics in Croatia and compared it with an identical assessment carried out in Germany.

METHODS

All Croatian obstetrics departments were sent a questionnaire already tested in Germany which assessed the use of CAM methods: whether any were used during childbirth and if so how frequently, and the reasons behind their application.

RESULTS

Questionnaires were returned by 100% (36/36) of departments identified. The only used CAM therapy was acupuncture, which was available in 5.6% (2/36) of the departments. All other methods (homeopathy, aromatherapy, massage etc.) were not used at all. Furthermore, acupuncture was only administered by physicians. These findings were found to strongly contrast with the findings from Germany.

CONCLUSIONS

Among the main CAM methods only acupuncture is used to a small extent in the field of obstetrics in Croatia. Thus, the impression from the literature that shows a considerable use of CAM in this area definitely does not apply for all parts of the world. Future studies should seek to identify the reasons behind the intensive use of CAM in Germany and its virtual non-use in Croatia. This also means that analyses of CAM use are required with respect to perinatal outcome, the results of which could finally help decide about the reasonability of CAM.

Metastatic prostate cancer in an asymptomatic patient with an initial prostate-specific antigen (PSA) serum concentration of 21,380 ng/ml

BACKGROUND

Prostate cancer is the second most common cause of cancer death in men, being responsible for approximately 13% of all cancer deaths. Due to the high specificity for prostate tissue, prostate-specific antigen (PSA) is the primary serum tumor marker for prostate cancer. To our knowledge, in published data, the highest reported PSA level on initial presentation was 5,666 ng/ml.

CASE REPORT

We present a 64-year-old Caucasian man with no specific urologic or pain symptoms and with an initial PSA serum value of 21,380 ng/ml. Initial laboratory studies showed chronic anemia and elevated alkaline phosphatase, most likely from bone marrow infiltration due to metastatic disease. Prostate biopsies diagnosed an adenocarcinoma of the prostate (Gleason score 9). Computed tomography (CT) showed multiple liver metastases with retroperitoneal lymph nodes of up to 1 cm. The prostate was moderately enlarged (estimated weight 35 g). Both kidneys were normal (no hydronephrosis present). A bone scintigraphy demonstrated diffuse osseous metastasis. Treatment was initiated with bilateral subcapsular orchiectomy and bicalutamide therapy in an effort to create total androgen blockade. After 3 months of follow-up, the serum concentration of PSA was 29 ng/ml.

CONCLUSION

This case presents an asymptomatic prostate cancer patient with bone and liver metastasis, enlarged retroperitoneal lymph nodes and the highest PSA level published to date.

Hemolysis and survival of autologous red blood cells salvaged after cemented and uncemented total hip arthroplasty

Autotransfusion is widely used after total hip arthroplasty (THA), but there are concerns about damage of red blood cells (RBCs) collected after surgery. In this study, we wanted to determine the damage and survival of RBCs salvaged after cemented THA and after uncemented THA and to compare the results. In this prospective study of 60 patients-30 who underwent cemented THA and 30 who underwent uncemented THA-postoperative autotransfusion systems (BIODREN; B.E.R.C.O., Modena, Italy) were used. Levels of potassium and free hemoglobin in the postoperative blood samples were analyzed. Before transfusion, salvaged RBCs were labeled with radioactive chromium-51, and their survival was measured. In blood salvaged after cemented THA, medium potassium level was 4.1 mmol/L (range, 3.2-5.6 mmol/L), and mean free hemoglobin level was 327 mg% (range, 120-410 mg%). In blood salvaged after uncemented THA, mean potassium level was 4.2 mmol/L (range, 3.1-5.5 mmol/L), and mean free hemoglobin level was 296 mg% (range, 130-402 mg%). In the cemented group, RBC survival was 73% at 48 hours after transfusion (range, 61%-79%), and mean time from 100% activity to 50% activity was 21 days (range, 14.2-28.2 days). In the uncemented group, RBC survival was 75% at 48 hours after transfusion (range, 68%-82%), and mean time from 100% to 50% activity of radio-labeled RBCs was 22 days (range, 16.2-29.4 days). There were no statistically significant differences in potassium levels, free hemoglobin levels, or RBC survival between the cemented and uncemented groups. Blood salvaged after surgery was not significantly damaged. Our study results confirmed that washing blood collected after surgery is not necessary. Not washing this blood is safe and decreases allogeneic transfusion in orthopedic procedures.

Case report of congenital cystic adenomatoid malformation type III with lethal outcome

We present a rare case of congenital cystic adenomatoid malformation (CCAM) type III (mycrocystic) in young, 19 years old primigravida. Diagnosis has been accomplished by ultrasound examination in 26th week of gestation. Hyperechogenic, mycrocystic mass was found in left pulmonary lobe with contra lateral displacement of mediastinum, hypoplasia of the right lung and extensive polyhydramnios. Prenatal therapy was based upon a serial of amniodrainage procedures and pharmacological inhibition of amniotic fluid production and uterine activity. Spontaneous preterm labor occurred at 34 weeks of gestation, Diagnosis was confirmed postnatal. Infant was ventilated due to respiratory insufficiency and was operated at the age of 24 hours. Lethal outcome occurred during the second day due to heavy respiratory insufficiency provoked by pulmonary hypoplasia. We discuss about types of a disease, prenatal diagnostic and therapeutic possibilities and pregnancy outcome.

Xanthogranulomatous epididymitis: clinical report and immunohistochemical analysis

Xanthogranulomatous epididymitis is an uncommon non-neoplastic process with destruction of tissue and replacement by striking cellular infiltration of foamy macrophages, dense lymphocytes and plasma cells. We report on a 72-year-old man with a clinical history of inadequately treated arterial hypertension, who presented with a right scrotal mass associated with right scrotal pain for 10 days. Physical examination revealed pyogenic discharge from the hyperemic and edematous scrotum, with normal body temperature. Testicular tumor markers were normal. Ultrasonography (US) of the right testis showed edematous scrotal layers and a heterogeneous area of poorly defined margins within the testis and epididymis. There was minimal hydrocele, and the right funiculus was of normal diameter with no edema or pathologic formation. The progression of clinical findings, inflammatory parameters, US and color Doppler US findings with negative testicular tumor markers indicated surgical treatment. After preoperative treatment, right orchiepididymectomy was performed. Histology confirmed the diagnosis of xanthogranulomatous epididymitis.

Prenatal ultrasound assessment and fetal heart monitoring: analysis of dizygotic twins discordant for body stalk anomaly in the third trimester of pregnancy

We describe a case of dizygotic twin pregnancy which was referred to our centre because of a discordant anomaly of one of the twins. The ultrasound examination revealed a large extra-abdominal mass (liver and bowel) with micromelia, severe kyphoscoliosis and a short umbilical cord of the second dizygotic discordant twin. These ultrasound findings were diagnosed as body stalk anomaly. Body stalk anomaly in twins is extremely rare. This is, to our knowledge, one of the few documented cases reported on dizygotic twins discordant for this anomaly. This finding, in association with a decrease of amniotic fluid volume, may be attributed to early amniotic membrane rupture as the primary event in the pathogenesis of body stalk anomaly.

Management of Fournier's gangrene--report of 7 cases and review of the literature

Fournier's gangrene is a rare infection characterized with fast-progressing myonecrosis, that affect regions of perineum, genitalia and perianal area. This retrospective study presents authors' experiences and their principles in early diagnosis and treatment of Fournier's gangrene. The goal of this paper is to point out numerous diagnostically and therapeutic difficulties that lead to a high mortality if not recognized in time. We here describe seven male patients with myonecrosis and necrotising fasciitis in scrotal, perianal and perineal regions. Average age was 61 years (form 57 to 66 years of age), and average length of treatment was 25.8 days (from 14 to 36 days), with lethality of 14% (one case). We have recognised diabetes mellitus as risk factor, together with urethrostenosis, and other diseases of the perianal region (hemorrhoids, anal fissure, abscesses). Our hypothesis is that the key of the successful treatment is to treat as soon as symptoms onset, early and aggressive necrectomy under broad antibiotic protection. We also emphasize the possibility of recurrence of this disease even several years after treatment.

Diffuse eosinophilic gastroenteropathy with pleural effusion and ascites

We are reporting a case of a 39-year-old woman with a picture of constipation, who came to our department. Anamnesticly she claimed on constipation and flatulence for 6 days, and on slight cough for last two days, but no other symptoms. After complete diagnostic treatment we found a pleural effusion in right lung and ascites in a bowel. Cytologicly, we didn't find malignant cells in pleural effusion nor in ascites, but there was an amount of eosinophilic granulocytes in a gastric wall and a solid tumour mass near mesentery of a gut. We also found a lot of eosinophilic cells in a solid tumour mass. Other organs had no pathology. This finding indicated for eosinophilic gastroenteritis.

The congruity between urine and cervical swab cultures in pregnant women with versus without amniotic fluid infection

INTRODUCTION

We observed the congruity of bacteria found in urine and cervix of pregnant women with amniotic fluid infection (AFI) compared to healthy controls.

PATIENTS AND METHODS

Over three years, we prospectively analysed urine and cervical swabs cultures in 120 pregnant women in gestational week 16-20. The patient population was divided in two groups: group I patients had clinical symptoms of AFI. The rest of the patients were designated as healthy controls (group II). Congruity between findings in both groups was observed. In patients with bacterial growth, antibiotic treatment was initiated as recommended and once ended - culture probes were repeated.

RESULTS

The rates of nonsignificant and significant bacteriuria were doubled in group I. Fifty-five percent (n = 33) of patients in group I had identical bacteria cultured both from the urine sample and cervical swab, in contrast to only 13.3 % in group II. Congruity was most pronounced for Klebsiella species and E. coli, the later being single most dominant isolate in regards to both cultures. After antimicrobial treatment, microbial eradication occurred in 15 patients (45.5 %). The observed incidences of abortions and preterm deliveries were significantly lower in patients with microbial eradication versus patients with microbial persistence.

CONCLUSION

Patients with clinical symptoms of AFI have high risk for bacteriuria identical to bacterial culture from cervical swab. Antimicrobial treatment was effective only partially where indicated. Screening for eradication is recommended and consensus on the most appropriate therapy is needed.

[A new approach to the transvaginal needle suspension technique after Raz. Technique and long-term results]

AIM

Our aim is to describe the surgical technique and to present a long-term evaluation of the results.

MATERIALS AND METHODS

A total of 53 patients with stress incontinence underwent a Raz transvaginal needle suspension operation with the introduction of a polypropylene mesh strip (15x1.5-2 cm) pulled under the suspension threads. The suspension threads occur on the endopelvic fascia in order to support the bladder neck and to permit the function of the polypropylene mesh strip, which, however, does not take part in supporting the bladder neck. The same urologist carried out 53 consecutive operations with clinical evaluation at 6 months, 1 and 5 years after surgery.

RESULTS

After 6 months, 51 of the patients (96.2%) reported remaining dry after increasing intra-abdominal pressure. Two (3.7%) still had stress incontinence symptoms. After 1 and 5 years, 47 (88.6%) were dry and urinated normally, with spontaneous disappearance of nightly enuresis in two and surgery for subvesicular obstruction in one.

CONCLUSIONS

The introduction of a polypropylene mesh strip in the suspension threads in cases using the trasvaginal suspension technique has good, long-term results for the treatment of patients with stress incontinence.

New transobturator sling for less invasive treatment of urinary incontinence in women--SERASIS TO

Urinary incontinence, defined as a leakage of small amounts of urine during physical movement (coughing, sneezing, exercising) is rather a common problem. The treatment of this disorder is even more non-uniformed: there have been roundly 100 operations proposed for it. The Burch procedure has become probably the most popular. As traumatic and invasive as it is, this procedure is performed under general anaesthetic, the abdomen is opened, the bladder neck suspended and fixed with clips or sutures to the back of the pubic bone. Some of the advantages with this procedure include safety and reproducibility, direct access to internal organs and possibility of performing this procedure in laparoscopic settings. A recent study by the same group, employing 150 patients treated with this type of procedure showed that the SERASIS TO transobturator sling seems to be very effective, less traumatic, less dangerous and does not require cystoscopy or urethral deviation devices. Although long-term follow-up data are not available for the transobturator approach, short-term results are encouraging. Large comparative studies with other anti-incontinent procedures are needed.

Significance of CA 125 serum level in discrimination between benign and malignant masses in the pelvis

AIM

Our aim was to confirm that preoperative CA 125 serum level can be useful for discrimination between benign and malignant masses in the pelvis.

METHODS

Preoperative CA 125 serum level was analyzed retrospectively in 121 patients who had surgery because of a malignant ovarian tumor and in 91 patients with benign masses in the pelvis. The cutoff serum level CA 125 between benign and malignant masses in the pelvis was 35 and 65 IU/ml.

RESULTS

Of those patients with a malignant ovarian tumor, 65.3% had menopause whereas only 31.5% of those with a benign tumor did so. The average age of the patients with a malignant tumor was 54.2 years and of those with a benign tumor 46.8 years. The preoperative CA 125 serum level was higher than 35 IU/ml in 80.2% and higher than 65 IU/ml in 72.7% of all analyzed patients with a malignant tumor, whereas it was 23.9% and 9.8% respectively in patients with a benign mass. In early stage ovarian cancer disease (borderline stage, I/II) the preoperative CA 125 serum level was higher than 35 IU/ml in 67.8% and in 52.5% higher than 65 IU/ml. In advanced stages (III/IV), it was higher than 35 and 65 IU/ml in 96.1%. After therapy the CA 125 serum level dropped below 35 IU/ml in 70.8% and after three chemotherapy courses in 78.1%. A CA 125 level less than 35 IU/ml was achieved by therapy in 84.2% patients with an early stage disease (I/II) and in 62.1% in advanced stages (III/IV). The calculated sensitivity was 80.2% and negative 74.5% (CA 125 higher than 35 IU/ml) and 72.7%, 90.2%, 90.7%, 71.6% respectively (CA 125 higher than 65 IU/ml).

CONCLUSION

. Preoperative determination of CA 125 is a very useful method to discriminate between benign and malignant masses in the pelvis.

[Differential diagnosis of urinary retention: aneurysm of the iliac artery]

A 69-year old male presented with anuric acute renal failure. Abdominal ultrasound at admission revealed a mass in the pelvis thought to be the urinary bladder and the diagnosis of urinary retention was made. When placement of an urinary catheter did not induce urine flow, digital rectal examination was done. Palpation of a pulsating mass finally led to the diagnosis of aneurysm of the iliac artery. Based on this case, the general problem of diagnosing an iliac artery aneurysm is discussed.

The treatment of cervical dysplasia with laser

In 14 patients with different stages of cervical dysplasia laser vapourization was performed. Patients were between 25 and 44 year old (mean 35). Gynaecological history included 0-2 deliveries (mean 1.5). The procedure is minimally invasive after which complete cervical restitution is achieved. Control PAPA smear taken after 2 months, 6 months and one year respectively showed maximal therapeutic success. No complications were observed. The procedure is recommended for young women planning childbirth.

How to evaluate the risks of illnesses when there is a disorder of embroidery and supporting tissues

For the gynecologist it is not the priority activity of investigation the skin, bones and tissues, but we have the great relation and connection across the endocrinological ways. The main point is estrogen, gestagen and androgen, but also the condition of embroidery and supporting tissues have influence through the anabolic effects. If sexual steroids in anabolic activity are missing, the skin will dehydrate based on weither of corium, the risk of fracture of bones is bigger, the yielding of hardness of embroidery apparatus can cause deep pains in small of the back and we have a great number of cardiovascular illness. The function of skin, bones and blood vessels is mostly based on special characteristics of extracellular matrix. This can be defined again through the collagen. In spite of the coristant building and demolishing rise through the control of sexual steroids. At the same time, the mineralization of osteoids in the skeleton has influence of estradiol. A deficit of sexual steroids, unhealthy living and other factors can influence the degenerative changes of skin bones and blood vessels. To evaluate, obliged risk of illness and risks of accidents there are different procedures: the contents of collagen in skin and the fatness of blood vessels can be measured only by a high frequent ultrasound. Nevertheless we can confirm the condition of bones with radiological and ultrasound methods. In truth, the controversies about the prognostic values in consideration of risks of fractures exist which measured in the different cases trend in diagnosis of osteopenia/osteoporosis.

Ruptured interstitial pregnancy Two case reports

The authors described two cases of the ruptured unrecognized interstitial pregnancy. 32-year-old woman, was admitted for abdominal colics in 17th week of uncontrolled pregnancy. Obstetric finding on admission was normal, while ultrasonography pointed to 17th week of gestation. During the first night of hospitalization, severe abdominal pain, with collapse, tachycardia and hypotension developed. Laparotomy was performed in general endotracheal anesthesia with resuscitation measures, and revealed hematoperitoneum and ruptured right-sided interstitial pregnancy with a dead fetus among the bowels. Abdominal hysterectomy without adnexa was performed. S. J., a 35-year-old tertigravida, six years before, left-sided adnexectomy was performed for perforated tubal pregnancy. 5 weeks before artificial abortion now, ultrasonography revealed a vital fetus biometrically corresponding to the 11th week of gestation. The condition was recognized as an unsuccessful artificial abortion and intact pregnancy. During preoperative preparation the patient lost consciousness and required immediate resuscitation. The abdominal cavity was opened by Pfannenstiel's relaparotomy, and revealed hematoperitoneum with numerous adhesions between the small intestine, sigma, uterus and urinary bladder, and ruptured left-sided interstitial pregnancy. Adhesiolysis was completed, a lesion in the sigma was sutured, and hysterectomy was performed. Exploration of the abdominal cavity revealed a dead fetus among small intestine loops, and an indurated, sharply delineated neoplasia of the head of the pancreas.

Assessment of reliability endometrial brush cytology in detection etiology of late postmenopausal bleedings

We evaluated the possibility of discovering bleeding causes in late postmenopausal period with cytological examination of material received by endometrial brush in comparison with Pap test and fractionated curettage. Sixty-two women in late postmenopausal period with cervical canal bleeding, treated in gynecological department of clinical hospital in Osijek, were cytological and histological processed. Final diagnosis in 29 from 62 (46.8%) women with late postmenopausal bleeding was cancer. 25 (40.3%) women had endometrial adenocarcinoma and 4 (6.5%) of them had squamous endocervical carcinoma. Two women had endometrial precancerous (3.2%). With Pap test accurate diagnosis was set up in 13 from 25 (52.0%) women with endometrial adenocarcinoma and in all of them with squamous endocervical carcinoma. With endometrial brush accurate diagnosis was set up in 14 from 25 (56.0%) women with endometrial adenocarcinoma and in 3 from 4 (75.0%) women with squamous endocervical carcinoma. With fractional curettage the diagnosis of endometrial adenocarcinoma was accurately correct in 21 from 25 (84.0%) women and in all of them with squamous endocervical carcinoma. Cytological examination of material derived with endometrial brush, alike vaginal cytology, is not enough reliable method in our conditions for discovering bleeding causes in late postmenopausal period. Diagnostic exactness of procedure could be increased by histopathological examination of material from endometrial brush procedure and with ultrasound evaluation of endometrium thickness.

[Methemoglobinemia in a newborn infant following pudendal anesthesia in labor with prilocaine. A case report]

A genetically intact newborn suffered from methaemoglobinaemia after delivery under pudendum anaesthesia with prilocaine. Complete restitution was promoted by i.v. applied ascorbic acid and thionine. This is of special importance because in this case methaemoglobinaemia was not produced by medication of the patient herself but must be attributed to the local anaesthesia of the mother with prilocaine. The special sensitivity of newborn and infants, as well as the use of possible treatment methods as described in literature, are discussed.