Diagnosis and treatment of adult asthma patients in Serbia: a 2022 experts group position statement

INTRODUCTION

Asthma is the most common non-communicable chronic lung condition across all ages. Epidemiological data indicate that many asthma patients in Serbia remain undiagnosed and untreated. The implementation of recent global advances in asthma management is limited due to the lack of a systematic approach, drug availability and regulatory affairs. In addition, the global coronavirus disease pandemic has posed a significant challenge, particularly in resource-limited settings.

AREAS COVERED

In this paper, we propose an algorithm for treating adult asthma patients in Serbia. We performed PubMed database search on published asthma clinical trials and guidelines from 1 January 2015 to 10 March 2020. The consensus process incorporated a modified Delphi method that included two rounds of e-mail questionnaires and three rounds of national asthma expert meetings. We focus on 1) objective diagnosis of asthma, 2) the implementation of up-to-date therapeutic options, and 3) the identification and referral of severe asthma patients to newly established severe asthma centers.

EXPERT OPINION

Regional specificities and variations in healthcare systems require the adaptation of evidence-based knowledge. Practical, clinically oriented algorithms designed to overcome local barriers in healthcare delivery may facilitate timely and adequate asthma diagnosis and the local implementation of current advances in asthma management.

Recommendations for COPD management in Central and Eastern Europe

INTRODUCTION

The Global Initiative for Chronic Obstructive Lung Disease (GOLD) strategy report provides guidance on effective management of chronic obstructive pulmonary disease (COPD) according to local healthcare systems. However, COPD is a heterogenous disease and certain aspects, including prevalence, disease-time course and phenotype distribution, can differ between countries. Moreover, features of clinical practice and healthcare systems for COPD patients can vary widely, even in geographically close and economically similar countries.

AREAS COVERED

Based on an initial workshop of respiratory physicians from eleven countries across Central and Eastern Europe (CEE) in December 2018 and subsequent discussions, this article offers region-specific insights from clinical practice and healthcare systems in CEE. Taking GOLD 2020 recommendations into account, we suggest approaches to adapt these into national clinical guidelines for COPD management in CEE.

EXPERT OPINION

Several factors should be considered when optimizing management of COPD in CEE compared with other regions, including differences in smoking status, vaccination uptake, prevalence of tuberculosis and nontuberculous mycobacteria, and variations in healthcare systems. We provide guidance and algorithms for pharmacologic and non-pharmacologic management of COPD for the following scenarios: initial and follow-up treatment, treatment of patients with frequent exacerbations, and withdrawal of inhaled corticosteroids where appropriate.

Frequency and effects of seasonal flu vaccines on exacerbations of chronic obstructive pulmonary disease in Serbia

Background/Aim. The influenza virus is often the cause of exacerbations among chronic obstructive pulmonary disease (COPD) patients, especially during the winter season. However, vaccination rates are still below recommended even in developed countries. The aim of the study was to determine the rates and examine the effectiveness of immunization against seasonal influenza in preventing exacerbations among COPD patients in Serbia. Methods. The prospective cohort study of stable COPD outpatients was conducted over three years (between October 1, 2014, and September 30, 2017) at the Polyclinic Department of Institute for Pulmonary Diseases of Vojvodina, Sremska Kamenica, Serbia. The rates and effects of seasonal flu vaccination on COPD exacerbation rates were evaluated using univariate and multivariate logistic regression analysis, taking into account comorbidity, age, and body mass index (BMI). Results. The study included 840 patients. The flu vaccination rate was 37.1%. Exacerbations occurred more frequently in unvaccinated patients [176 (31.9%) vs. 375 (68.1%), p = 0.043]. In elderly vaccinated patients (? 65 years) there were fewer exacerbations compared to unvaccinated patients [89 (56.0%) vs. 188 (69.4%), p = 0.005]. Lower frequency of exacerbations was also observed in vaccinated patients with comorbidities [165 (61.1%) vs. 327 (69.4%), p = 0.021] and low BMI [27 (64.3%) vs. 78 (83.9%), p = 0.011]. Multivariate logistic regression analysis identified BMI < 21 kg/m2 [relative risk (RR): 0.490; 95% confidence interval (CI): 0.318?0.758; p = 0.001] and heart failure (RR: 2.734; 95% CI: 1.121?6.669; p = 0.027) as independent predictors of COPD exacerbations. Conclusion. Immunization for seasonal influenza in Serbia is below recommended rates. Flu vaccination was associated with a significant reduction in COPD exacerbation rates, particularly in elderly patients and patients with heart failure and low BMI.

Diagnosis and management of chronic obstructive pulmonary disease in Serbia: an expert group position statement

In recent years, several national chronic obstructive pulmonary disease (COPD) guidelines have been issued. In Serbia, the burden of COPD is high and most of the patients are diagnosed at late stages. Global Initiative for Chronic Obstructive Lung Disease (GOLD) strategy is poorly implemented in real-life practice, as many patients are still prescribed inhaled corticosteroids (ICS)-containing regimens and slow-release theophylline. In this document, we propose an algorithm for treating COPD patients in Serbia based on national experts’ opinion, taking into account global recommendations and recent findings from clinical trials that are tailored according to local needs. We identified four major components of COPD treatment based on country specifics: active case finding and early diagnosis in high-risk population, therapeutic algorithm for initiation and escalation of therapy that is simple and easy to use in real-life practice, de-escalation of ICS in low-risk non-exacerbators, and individual choice of inhaler device based on patients' ability and preferences. With this approach we aim to facilitate implementation of the recommendation, initiate the treatment in early stages, improve cost-effectiveness, reduce possible side effects, and ensure efficient treatment.

Frequency of COPD in health care workers who smoke

Objective:

COPD is one of the major causes of morbidity and mortality worldwide. Health care providers should counsel their smoking patients with COPD to quit smoking as the first treatment step. However, in countries with high prevalences of smoking, health care workers may also be smokers. The aim of this study was to determine the frequency and severity of COPD in health care workers who smoke.

Methods:

This was a cross-sectional study. All health care workers who smoke, from nine health care centers in Serbia, were invited to participate in the study and perform spirometry. The diagnosis of COPD was based on a post-bronchodilator FEV₁/FVC ratio of < 0.70. All patients completed the COPD Assessment Test and the Fagerström Test for Nicotine Dependence.

Results:

The study involved 305 subjects, and 47 (15.4%) were male. The mean age of the participants was 49.0 ± 6.5 years. Spirometry revealed obstructive ventilatory defect in 33 subjects (10.8%); restrictive ventilatory defect, in 5 (1.6%); and small airway disease, in 96 (31.5%). A diagnosis of COPD was made in 29 patients (9.5%), 25 (86.2%) of whom were newly diagnosed. On the basis of the Global Initiative for COPD guidelines, most COPD patients belonged to groups A or B (n = 14; 48.2%, for both); 1 belonged to group D (3.6%); and none, to group C. Very high nicotine dependence was more common in those with COPD than in those without it (20.7% vs. 5.4%, p = 0.01).

Conclusions:

In this sample of health care workers, the frequency of COPD was comparable with that in the general population. The presence of COPD in health care workers who smoke was associated with higher nicotine dependence.

The Differences in Spirometry Predictive Equations in Classifying Presence and Degree of Lung Function Impairment: Which Suit Fits the Best?

PURPOSE

The aim of this study was to compare the differences between three most commonly used predictive equations (PE): ECCS (European Community of Coal and Steel), the third National Health and Nutrition Examination Survey (NHANES III), and GLI (Global Lung Initiative) in healthy individuals and when grading severity of lung function impairment in patients with obstructive lung diseases.

METHODS

The study included 200 healthy volunteers and 200 patients with obstructive lung diseases at the Institute for Pulmonary Diseases of Vojvodina. In all subjects, we calculated the absolute and relative (percent) predicted values using ECCS, NHANES III, and GLI reference equations.

RESULTS

The mean differences between ECCS and NHANES III predicted values were 5.63% (95% CI  5.29-5.98%, p < 0.001) for FEV1 and 10% (95% CI 9.52-10.79%, p < 0.001) for FVC. Similar differences were observed between ECCS and GLI predicted values. There were minimal differences between NHANES III and GLI predictive values. In healthy subjects, the mean absolute difference between measured FEV1 and FEV1 ECCS predicted was 0.36l (95% CI 0.32l, 0.40l, p < 0.001), FEV1 NHANES predicted was 0.30 l (95% CI 0.27-0.35l, p < 0.001), and FEV1 GLI predicted was 0.31l (95% CI 0.27- 0.35l, p < 0.001). The use of three different PE leads to significant differences in classification of obstruction severity in both asthma and COPD patients.

CONCLUSIONS

There were significant differences between FEV1 and FVC predicted when using different PE. The absolute difference between actual and predicted FEV1 in healthy individuals was highest when using ECCS. The use of different PE may change the interpretation of severity of airway obstruction.

Pneumonia: Features registered in autopsy material

BACKGROUND

Despite improvements in clinical practice, pneumonia remains one of the leading causes of death worldwide. Pathologic findings from autopsy reports could provide more precise and valid data on characteristics of pneumonia patients.

METHODS

We retrospectively reviewed autopsy reports of deceased patients admitted to the Institute for Pulmonary Diseases of Vojvodina in Sremska Kamenica, Serbia, between 1994 and 2003. The patients were classified into two groups: group 1 (n = 161) comprised patients in whom pneumonia was the main cause of death, while group 2 (n = 165) consisted of patients in whom pneumonia was confirmed at autopsy but had various different causes of death.

RESULTS

From 1776 patients who underwent autopsy 326 (18.3%) were diagnosed with pneumonia. The most common underlying diseases were atherosclerosis (29.4%), chronic obstructive pulmonary disease (COPD) (26.7%), and malignancies (20.2%). Pneumonia was the main cause of death in 161 cases (group 1) while in group 2 major causes of death were heart failure (HF) (26.7%), acute myocardial infarction (AMI) (16.4%), and pulmonary embolism (PE) (10.9%). Multilobar involvement (91% vs.27%), pulmonary effusion (29% vs.14%), and lung abscess (23.6% vs.8.5%) were more frequently found in group 1, compared to group 2.

CONCLUSION

In patients with pneumonia who underwent autopsy most common underlying diseases were atherosclerosis, COPD, and malignancies, while major causes of death were: progression of pneumonia, HF, AMI, and PE.

Association Between the Inflammatory Biomarkers and Left Ventricular Systolic Dysfunction in Patients with Exacerbations of Chronic Obstructive Pulmonary Disease

Background:

Cardiovascular diseases are an important cause of morbidity and mortality in chronic obstructive pulmonary disease patients. The increased inflammatory biomarker levels predict exacerbations and are associated with cardiovascular diseases in stable chronic obstructive pulmonary disease patients but their role in the settings of acute chronic obstructive pulmonary disease exacerbations has not been determined.

Aims:

To analyse the association between inflammatory biomarkers and heart failure and also to determine the predictors of mortality in patients with exacerbations of chronic obstructive pulmonary disease.

Study Design:

Prospective observational study.

Methods:

We analysed 194 patients admitted for acute exacerbation of chronic obstructive pulmonary disease at The Institute for Pulmonary Diseases of Vojvodina, Sremska Kamenica, Serbia. In all patients, C-reactive protein, fibrinogen, N-terminal of the pro-hormone brain natriuretic peptide and white blood count were measured and transthoracic echocardiography was performed.

Results:

There were 119 men (61.3%) and the median age was 69 years (interquartile range 62-74). Left ventricular systolic dysfunction (ejection fraction <50%) was present in 47 (24.2%) subjects. Patients with left ventricular systolic dysfunction had higher C-reactive protein levels (median 100 vs. 31 mg/L, p=0.001) and fibrinogen (median 5 vs. 4 g/L, p=<0.001) compared to those with preserved ejection fraction. The overall hospital mortality was 8.2% (16/178). The levels of C-reactive protein, fibrinogen, N-terminal pro-brain natriuretic peptide and ejection fraction predicted hospital mortality in univariate analysis. After adjusting for age, hypoxemia and C-reactive protein, ejection fraction remained significant predictors of hospital mortality (OR 3.89, 95% CI 1.05-15.8).

Conclusion:

Nearly a quarter of patients with the exacerbation of chronic obstructive pulmonary disease present with left ventricular systolic dysfunction which may be associated with mortality.

Etiology and resistance patterns of bacteria causing ventilator-associated pneumonia in a respiratory intensive care unit

Background/Aim. Ventilator-associated pneumonia (VAP) incidence, causative pathogens, and resistance patterns are different among countries and intensive care units (ICUs). In Europe, resistant organisms have progressively increased in the last decade. However, there is a lack of data from Serbian ICUs. The aims of this study were to evaluate etiology and antimicrobial resistance for pathogens causing VAP in ICU patients, to examine whether there were differences among pathogens in early-onset and late-onset VAP and to identify mortality in patients with VAP after 30 and 60 days of hospitalization. Methods. A retrospective cohort study was conducted in the respiratory ICU and all adult patients diagnosed with VAP from 2009 to 2014 were included. Results. Gram negative organisms were the major pathogens (80.3%). The most commonly isolated was Acinetobacter spp (59.8%). There was a statistically significant increase in the incidence of infection with Klebsiella pneumoniae (8.9% vs 25.6%; p = 0.019). Extensively drugresistant strains (XDR) were the most common (78.7%). Lateonset VAP was developed in 81.1% of patients without differences among pathogens in comparison with early-onset VAP. Acinetobacter spp was susceptible to tigecycline and colistin with a significant increase in resistance to ampicillin/sulbactam (30.2% vs 58.6%; p = 0.01). Resistance rate of Pseudomonas aeruginosa and Klebsiella pneumoniae to carbapenems was 38% and 11%, respectively. In methicillin-resistant Staphylococcus aureus no resistance was observed against vancomycin and linezolid. There was no difference in mortality rate between patients with earlyonset and late-onset VAP after 30 and 60 days of hospitalization. Conclusion. Gram negative organisms were the primary cause of bacterial VAP of which the most common was the XDR strain of Acinetobacter spp. Patients with early- and late-onset VAP had the same pathogens. There was no difference in mortality between this two group of patients during 60 days of hospitalization.

Checklist for Early Recognition and Treatment of Acute Illness (CERTAIN): evolution of a content management system for point-of-care clinical decision support

Background

The Checklist for Early Recognition and Treatment of Acute Illness (CERTAIN) is an international collaborative project with the overall objective of standardizing the approach to the evaluation and treatment of critically ill patients world-wide, in accordance with best-practice principles. One of CERTAIN’s key features is clinical decision support providing point-of-care information about common acute illness syndromes, procedures, and medications in an index card format.

Methods

This paper describes 1) the process of developing and validating the content for point-of-care decision support, and 2) the content management system that facilitates frequent peer-review and allows rapid updates of content across different platforms (CERTAIN software, mobile apps, pdf-booklet) and different languages.

Results

Content was created based on survey results of acute care providers and validated using an open peer-review process. Over a 3 year period, CERTAIN content expanded to include 67 syndrome cards, 30 procedure cards, and 117 medication cards. 127 (59 %) cards have been peer-reviewed so far. Initially MS Word® and Dropbox® were used to create, store, and share content for peer-review. Recently Google Docs® was used to make the peer-review process more efficient. However, neither of these approaches met our security requirements nor has the capacity to instantly update the different CERTAIN platforms.

Conclusion

Although we were able to successfully develop and validate a large inventory of clinical decision support cards in a short period of time, commercially available software solutions for content management are suboptimal. Novel custom solutions are necessary for efficient global point of care content system management.

Electronic supplementary material

The online version of this article (doi:10.1186/s12911-016-0367-3) contains supplementary material, which is available to authorized users.

Sleep quality and daytime sleepiness in patients with COPD and asthma

INTRODUCTION

Nocturnal symptoms are common and important in both asthma and COPD but the relationship between sleep quality and diseases' characteristics has not been fully studied.

OBJECTIVE

To compare sleep quality and daytime sleepiness in asthma and COPD patients and to explore its relation to diseases' characteristics.

METHODS

In this cross-sectional study, we examined 217 consecutive asthma and COPD patients who underwent pulmonary function tests at The Center for Pathophysiology of Breathing and Sleep Medicine of The Institute for Pulmonary Diseases of Vojvodina, Sremska Kamenica, Serbia between July 2014 and January 2015. All patients completed Pittsburgh Sleep Quality Index (PSQI) and Epworth Sleepiness Scale (ESS).

RESULTS

Study included 117 patients with asthma, 100 patients with COPD, and 102 healthy controls. There was no difference in PSQI and ESS between patients with asthma and COPD (4.9 ± 3.9 vs 5.8 ± 4.3, P = .09 and 4.8 ± 3.4 vs 4.7 ± 3.6, P = .69, respectively). PSQI and ESS did not correlate with lung function parameters. Patients with uncontrolled asthma had higher PSQI scores (uncontrolled 7.0 ± 3.7 vs partially controlled 4.6 ± 3.1 vs controlled 3.2 ± 3.7, P < .001). PSQI scores were higher in COPD group D and B compared to A and C (group D 6.9 ±4.6 vs B 6.8 ± 4.1 vs A 2.9 ± 1.3 vs C 3.1 ± 3.9, P < .001). Compared to asthma, COPD patients had longer sleep latency and used sleep regulating medications more often.

CONCLUSIONS

There is no difference in sleep quality and level of daytime sleepiness between patients with asthma and COPD. Poor sleep quality is related to level of asthma control and is associated with COPD groups B and D.

General ward and pneumonia size as predictors of noninvasive ventilation failure

INTRODUCTION

Shortage of intensive care beds has led to more frequent use of noninvasive ventilation (NIV) outside respiratory units, and data on NIV efficacy and safety on general wards is lacking.

OBJECTIVE

The aim was to identify potential predictors for NIV failure.

METHODS

This was a retrospective analysis of patients treated with NIV at the Institute for Pulmonary Diseases of Vojvodina from 2009 to 2013. Demographics, blood gases, chest radiographs, setting, and outcomes were analyzed to identify predictors of NIV failure.

RESULTS

A total of 138 patients (65% men, mean age 66 ± 11 years) were treated with NIV. Indications for NIV were acute exacerbation of chronic obstructive pulmonary disease (85%) and cardiogenic pulmonary edema (7%), as well as respiratory insufficiency related to obesity and central hypoventilation (5%) and neuromuscular disease (3%). Rate of NIV failure was 34.8%. In 86 patients NIV was applied in the High Dependency Unit (HDU), while 52 received NIV on the general ward. Baseline characteristics in terms of gender, arterial blood gases, and the extent of consolidation on chest radiographs were similar. Patients treated in HDU were younger (64.4 ± 1.2 vs. 69.4 ± 1.5 years, p < 0.001). NIV on the general ward compared to HDU had higher rates of NIV failure (28/52 vs. 20/86, p < 0.001). Presence of consolidation involving two or more quadrants on chest radiograph (55% vs. 29%, p < 0.001) was associated with NIV failure. When adjusted for age and the extent of consolidation on chest radiograph, NIV failure was still less likely in patients treated in HDU (OR 0.23, 95% Cl 0.10-0.50).

CONCLUSION

Patients with consolidation on chest X-ray and patients treated with NIV outside of dedicated respiratory units are at a higher risk for NIV failure.

Correlation between the Wells score and the Quanadli index in patients with pulmonary embolism

BACKGROUND AND AIMS

Determining clinical probability of pulmonary embolism (PE) with Wells scoring system is the first step towards diagnosis of PE. Definitive diagnosis of PE is confirmed by computed tomography pulmonary angiography (CTPA).

METHODS

This was a prospective study on 80 patients referred to the Institute for Pulmonary Diseases of Vojvodina with suspected PE between April 2010 and August 2012. Clinical probability of PE was determined according to the Wells and modified Wells scoring system. CTPA was performed in 60 patients. The degree of pulmonary vascular obstruction was quantified by the Qanadli index.

RESULTS

Low clinical probability of PE was present in one patient (1.6%), moderate in 43 (71.6%) and high in 16 (26.6%) patients. PE was confirmed in 50 (83.3%) patients. There were 21 patients (42%) whose Quanadli index was <25%, 18 (36%) between 25%-50%, while Quanadli index was ≥50 in 11 patients (22%). When compared to CTPA findings, modified Wells scoring system showed 90% sensitivity [95% confidence interval (CI) 78.2%-96.6%], and 20% specificity (95% CI 3.11%-55.6%), positive predictive value (PPV) 84.9% (95% CI 72.4%-93.2%) and negative predictive value (NPV) 28.6% (95% CI 4.5%-70.7%). There was weak positive correlation between Wells score and Quanadli index (r = 0.14; P = 0.29), without statistical significance. Wells score was significantly higher in haemodynamically unstable than in haemodynamically stable patients (6.8 vs 5.6, P = 0.014). There was no statistically significant difference between the values of Quanadli index in these two groups (31.33% vs 26.64%, P = 0.062).

CONCLUSION

Modified Wells criteria have high sensitivity but low specificity in PE diagnostics. The Wells score does not correlate well with the Quanadli index.

Checklist for early recognition and treatment of acute illness: International collaboration to improve critical care practice

Processes to ensure world-wide best-practice for critical care delivery are likely to minimize preventable death, disability and costly complications for any healthcare system’s sickest patients, but no large-scale efforts have so far been undertaken towards these goals. The advances in medical informatics and human factors engineering have provided possibility for novel and user-friendly clinical decision support tools that can be applied in a complex and busy hospital setting. To facilitate timely and accurate best-practice delivery in critically ill patients international group of intensive care unit (ICU) physicians and researchers developed a simple decision support tool: Checklist for Early Recognition and Treatment of Acute Illness (CERTAIN). The tool has been refined and tested in high fidelity simulated clinical environment and has been shown to improve performance of clinical providers faced with simulated emergencies. The aim of this international educational intervention is to implement CERTAIN into clinical practice in hospital settings with variable resources (included those in low income countries) and evaluate the impact of the tool on the care processes and patient outcomes. To accomplish our aims, CERTAIN will be uniformly available on either mobile or fixed computing devices (as well as a backup paper version) and applied in a standardized manner in the ICUs of diverse hospitals. To ensure the effectiveness of the proposed intervention, access to CERTAIN is coupled with structured training of bedside ICU providers.

A survey on critical care resources and practices in low- and middle-income countries

BACKGROUND

Timely and appropriate care is the key to achieving good outcomes in acutely ill patients, but the effectiveness of critical care may be limited in resource-limited settings.

OBJECTIVES

This study sought to understand how to implement best practices in intensive care units (ICU) in low- and middle-income countries (LMIC) and to develop a point-of-care training and decision-support tool.

METHODS

An internationally representative group of clinicians performed a 22-item capacity-and-needs assessment survey in a convenience sample of 13 ICU in Eastern Europe (4), Asia (4), Latin America (3), and Africa (2), between April and July 2012. Two ICU were from low-income, 2 from low-middle-income, and 9 from upper-middle-income countries. Clinician respondents were asked about bed capacity, patient characteristics, human resources, available medications and equipment, access to education, and processes of care.

RESULTS

Thirteen clinicians from each of 13 hospitals (1 per ICU) responded. Surveyed hospitals had median of 560 (interquartile range [IQR]: 232, 1,200) beds. ICU had a median of 9 (IQR: 7, 12) beds and treated 40 (IQR: 20, 67) patients per month. Many ICU had ≥ 1 staff member with some formal critical care training (n = 9, 69%) or who completed Fundamental Critical Care Support (n = 7, 54%) or Advanced Cardiac Life Support (n = 9, 69%) courses. Only 2 ICU (15%) used any kind of checklists for acute resuscitation. Ten (77%) ICU listed lack of trained staff as the most important barrier to improving the care and outcomes of critically ill patients.

CONCLUSIONS

In a convenience sample of 13 ICU from LMIC, specialty-trained staff and standardized processes of care such as checklists are frequently lacking. ICU needs-assessment evaluations should be expanded in LMIC as a global priority, with the goal of creating and evaluating context-appropriate checklists for ICU best practices.

Changes in spirometry over time in uremic patients receiving long-term hemodialysis therapy

Complications of respiratory system in patients suffering from chronic renal failure who are treated with regular haemodialysis are well known. However, the influence of the duration of haemodialysis on pulmonary function is less understood. The aim of this study was to determine spirometry changes in patients on chronic haemodialysis over a five-year period. We tested 21 patients, out of which 11 female and 10 male, mean age of 50 (+/- 11) years. The mean duration of haemodialysis was 52.2 (+/- 44.7) months at the time of the inclusion. We performed spirometry testings in all patients, one hour before start and one hour after completion of haemodialysis. All parameters of spirometry recorded one hour after completion of haemodialysis (FVC, FEV1, FEF75, 50, 25, % of predicted), improved significantly (p < 0.01). After five years, only FVC demonstrated significant decline and none of the recorded spirometry parameters improved significantly one hour post haemodialysis compared to pre-haemodialysis period. Analysis of post-dialysis parameters of spirometry at the study onset and following five years of haemodialysis showed that all parameters, except FEF50 (p > 0.05), significantly deteriorated (p < 0.01). Patients who are on long-term haemodialysis show a significant decline in FVC following five years of treatment. Although the spirometry changes in observed population treated with chronic haemodialysis have reversible character during the first years of renal replacement therapy, five years after these changes become irreversible.

War-related transformation and work of surgery service of the Pozega Medical Center, East-Croatian Hospital unaffected by direct war activities

The work of the Pozega Medical Center Surgical Unit during the two war years (from July 16, 1991, to October 1, 1993) in Croatia is described. Since the war operations did not affect the town directly, the work was mostly characterized by treatment of wounds inflicted by explosive devices (51.2%) and localized mostly on the extremities (62.9%). Apart from these wounds, there were 0.7% burns, 26.6% gunshot wounds, and 19.6% injuries caused by blunt and hard objects. Of the total of 959 treated wounded persons, only 18 (1.9%) died, illustrating the success of the therapy administered according to the war surgery doctrine criteria.

[Morphometric evaluation of connective tissue reaction to cartilage implants]

In this paper, besides already investigated cartilage implants, we studied morphologically and histometrically possibilities to use human thyroid cartilage in reconstructive surgery, especially in nasal septum and pyramid reconstructions. Preserved human thyroid and rib cartilage as well as rabbit preserved rib cartilage were implanted under the back skin of 12 New Zealand rabbits. Animals were divided into two groups with 6 specimens in each group followed 6 and 12 weeks after implantation. Beside morphological investigation we measured histometrically the thickness of connective capsule around implants. Results obtained by our morphological and histometric studies indicate that preserved human thyroid cartilage could be used in reconstructive surgery with the same success as other cartilage implants already used.