Repetitive suicide attempts by poisoning in Vojvodina, Serbia - Psychotropic drugs as main causes

OBJECTIVE

Repetitive acute self-poisoning takes great part of all admissions at the Emergency Department including self-harm as one of the main reasons. The aim of this study is to analyze the characteristics of the patients treated for repetitive self-poisoning with suicidal intent (RSP-SI) in Vojvodina (Serbia), in order to propose preventative strategy and better management of the issue.

PATIENTS AND METHODS

The retrospective study included data regarding patients treated for RSP-SI during a 5-year period in Vojvodina, Serbia.

RESULTS

Repetitive self-poisoning was determined in 485 patients, of whom 35.05% reported suicidal intention. Mean number of RSP-SI per patient was 3.61±3.08. The mean period between two RSP-SI in group of females and males was 9.69±13.60 and 6.95±11.02 months, respectively. Almost two thirds (65.29%) of them were unemployed. Most of the patients had mental and behavioral disorders due to psychoactive substance use (ICD F10-19; 51.18%) and anxiety, dissociative, stress-related, somatoform and other nonpsychotic mental disorders (ICD F40-48; 33.53%). The sole etiological agent was identified in 39.15% attempts. In 58.08% of the attempts more than one substance was detected (2.50±0.73 per attempt). The co-ingestion of alcohol and benzodiazepines was the most common combination (19.41%). Psychiatry intervention was needed in 70.31% of the patients. Five of all patients with RSP-SI (2.94%) committed suicide.

CONCLUSIONS

The recognition and the treatment of mental disorders as well as the control of psychiatric medications prescribing could represent one of the most important preventive strategies for repetitive suicidal behavior.

Glycogen synthase downregulation rescues the amylopectinosis of murine RBCK1 deficiency

Longer glucan chains tend to precipitate. Glycogen, by far the largest mammalian glucan and the largest molecule in the cytosol with up to 55 000 glucoses, does not, due to a highly regularly branched spherical structure that allows it to be perfused with cytosol. Aberrant construction of glycogen leads it to precipitate, accumulate into polyglucosan bodies that resemble plant starch amylopectin and cause disease. This pathology, amylopectinosis, is caused by mutations in a series of single genes whose functions are under active study toward understanding the mechanisms of proper glycogen construction. Concurrently, we are characterizing the physicochemical particularities of glycogen and polyglucosans associated with each gene. These genes include GBE1, EPM2A and EPM2B, which respectively encode the glycogen branching enzyme, the glycogen phosphatase laforin and the laforin-interacting E3 ubiquitin ligase malin, for which an unequivocal function is not yet known. Mutations in GBE1 cause a motor neuron disease (adult polyglucosan body disease), and mutations in EPM2A or EPM2B a fatal progressive myoclonus epilepsy (Lafora disease). RBCK1 deficiency causes an amylopectinosis with fatal skeletal and cardiac myopathy (polyglucosan body myopathy 1, OMIM# 615895). RBCK1 is a component of the linear ubiquitin chain assembly complex, with unique functions including generating linear ubiquitin chains and ubiquitinating hydroxyl (versus canonical amine) residues, including of glycogen. In a mouse model we now show (i) that the amylopectinosis of RBCK1 deficiency, like in adult polyglucosan body disease and Lafora disease, affects the brain; (ii) that RBCK1 deficiency glycogen, like in adult polyglucosan body disease and Lafora disease, has overlong branches; (iii) that unlike adult polyglucosan body disease but like Lafora disease, RBCK1 deficiency glycogen is hyperphosphorylated; and finally (iv) that unlike laforin-deficient Lafora disease but like malin-deficient Lafora disease, RBCK1 deficiency's glycogen hyperphosphorylation is limited to precipitated polyglucosans. In summary, the fundamental glycogen pathology of RBCK1 deficiency recapitulates that of malin-deficient Lafora disease. Additionally, we uncover sex and genetic background effects in RBCK1 deficiency on organ- and brain-region specific amylopectinoses, and in the brain on consequent neuroinflammation and behavioural deficits. Finally, we exploit the portion of the basic glycogen pathology that is common to adult polyglucosan body disease, both forms of Lafora disease and RBCK1 deficiency, namely overlong branches, to show that a unified approach based on downregulating glycogen synthase, the enzyme that elongates glycogen branches, can rescue all four diseases.

An inducible glycogen synthase-1 knockout halts but does not reverse Lafora disease progression in mice

Malstructured glycogen accumulates over time in Lafora disease (LD) and precipitates into Lafora bodies (LBs), leading to neurodegeneration and intractable fatal epilepsy. Constitutive reduction of glycogen synthase-1 (GYS1) activity prevents murine LD, but the effect of GYS1 reduction later in disease course is unknown. Our goal was to knock out Gys1 in laforin (Epm2a)-deficient LD mice after disease onset to determine whether LD can be halted in midcourse, or even reversed. We generated Epm2a-deficient LD mice with tamoxifen-inducible Cre-mediated Gys1 knockout. Tamoxifen was administered at 4 months and disease progression assessed at 12 months. We verified successful knockout at mRNA and protein levels using droplet digital PCR and Western blots. Glycogen determination and periodic acid-Schiff-diastase staining were used to analyze glycogen and LB accumulation. Immunohistochemistry using astrocytic (glial fibrillary acidic protein) and microglial (ionized calcium-binding adapter molecule 1) markers was performed to investigate neuroinflammation. In the disease-relevant organ, the brain, Gys1 mRNA levels were reduced by 85% and GYS1 protein depleted. Glycogen accumulation was halted at the 4-month level, while LB formation and neuroinflammation were significantly, though incompletely, prevented. Skeletal muscle analysis confirmed that Gys1 knockout inhibits glycogen and LB accumulation. However, tamoxifen-independent Cre recombination precluded determination of disease halting or reversal in this tissue. Our study shows that Gys1 knockdown is a powerful means to prevent LD progression, but this approach did not reduce brain glycogen or LBs to levels below those at the time of intervention. These data suggest that endogenous mechanisms to clear brain LBs are absent or, possibly, compromised in laforin-deficient murine LD.

Sensitive quantification of α-glucans in mouse tissues, cell cultures, and human cerebrospinal fluid

The soluble α-polyglucan glycogen is a central metabolite enabling transient glucose storage to suit cellular energy needs. Glycogen storage diseases (GSDs) comprise over 15 entities caused by generalized or tissue-specific defects in enzymes of glycogen metabolism. In several, e.g. in Lafora disease caused by the absence of the glycogen phosphatase laforin or its interacting partner malin, degradation-resistant abnormally structured insoluble glycogen accumulates. Sensitive quantification methods for soluble and insoluble glycogen are critical to research, including therapeutic studies, in such diseases. This paper establishes methodological advancements relevant to glycogen metabolism investigations generally, and GSDs. Introducing a pre-extraction incubation method, we measure degradation-resistant glycogen in as little as 30 mg of skeletal muscle or a single hippocampus from Lafora disease mouse models. The digestion-resistant glycogen correlates with the disease-pathogenic insoluble glycogen and can readily be detected in very young mice where glycogen accumulation has just begun. Second, we establish a high-sensitivity glucose assay with detection of ATP depletion, enabling 1) quantification of α-glucans in cell culture using a medium-throughput assay suitable for assessment of candidate glycogen synthesis inhibitors, and 2) discovery of α-glucan material in healthy human cerebrospinal fluid, establishing a novel methodological platform for biomarker analyses in Lafora disease and other GSDs.

Intestinal surgery in treatment of advanced ovarian cancer--review of our experience

INTRODUCTION

In cases of advanced ovarian cancer bowel surgery is necessary during the primary surgical procedure, in the course of the disease for recurrence or palliation of the symptoms. Treatment with maximal cytoreductive surgery followed by chemotherapy in women with advanced ovarian cancer is well established.

MATERIAL AND METHODS

We retrospectivly evaluated 56 women who were surgically treated for ovarian cancer over five years (from 2004 to 2008) at the Institute of Obstetrics and Gynecology, Clinical Center of Serbia. In 56 patients, 82 intestine operations were performed, which means that in some patients more than one intestine operation was performed. We analyzed patient characteristics, tumor features, intraoperative findings, pelvic node involvement, surgical procedure performed, indications for bowel surgery, and early postoperative complications.

RESULTS

In our study the majority of patients had Stage III (82%) or IV (10%) carcinoma with poor differentiation. Epithelial ovarian cancer was the most common histopathological finding (78%) in our group of patients. There were 30 cases (53%) with serous, nine (16%) with mucinous and five (9%) with endometriod tumors. Bowel surgery was indicated in 12.2% of our patients with ovarian cancer which was mostly performed to reduce the volume of the tumor (68%), while it was indicated in recurrence of the disease in 18% of women. In addition to the standard surgery procedure, which includes removal of internal genital organs, omentum minus/majus, peritoneal tumor masses, large and small bowel resection were performed. Of 56 patients most underwent small bowel surgery--43 of a total of 82 intestinal operations (52.4%). Of these we performed small bowel resection in 34 (41.5% of all intestinal operations), while ileostomy and jejunostomy were performed in nine cases (11%). There were 39 colon operations (47.6%) and most of the cases underwent rectosygmoid resection with the Hartman procedure (33 or 40.2% of all intestinal operations). Other colon operations included hemicolectomy (3 cases--3.7%), transverse colon resection (2 cases--2.4%) and pancolectomy (1 case--1.2%). According to our experience, wound infection and febrile morbidity were the most common early postoperative complications. Mortality rates in the literature vary between 0% and 8%, and anastomotic complications between 0 and 4%, which is in agreement with our results.

CONCLUSION

Radical surgical procedures in treatment of ovarian cancer including multi-organ resection are necesery to achieve a minimal residual disease state prior to initiating adjuvant chemotherapy. Bowel preparation and CT/MR imaging should be performed in patients with possible malignant ovarian masses.

Surgical treatment of ovarian cancer and early detection of venous thromboembolism

INTRODUCTION

Deep vein thrombosis (DVT) is present in 10.6% patients after operative treatment for ovarian malignancy. We undertook the present study to find the risk factors for venous thromboembolism (VTE) after surgical treatment for ovarian cancer and to clarify the prognostic value of D-dimer and a positive PTP test (Wells score) in these patients.

MATERIAL AND METHODS

A total of 31 consecutive patients with histologically confirmed ovarian cancer after surgery, clinically suspicious for DVT were followed from January 2006 to December 2008. All patients were operatively treated at the Clinical Center of Serbia. Study variables included age, cardiovascular disease, FIGO stage, histology, BMI, presence of massive ascites and tumor size, D-dimer level and Wells score. All patients were postoperatively administered anticoagulant therapy.

RESULTS

DVT was found in nine of 31 patients (29.0%). High BMI and presence of massive ascites were significantly associated with DVT. D-dimer (DD) levels were high in 27 of out 31 patients (87.1%). Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were 100, 18.2, 33.3 and 100%. Results of the PTP test (according to Wells score) was positive in 20 out of 31 patients (64.5%). PTP score was not significantly different in patients with or without VTE (p = 0.606). Sensitivity, specificity, PPV and NPV were 66.7, 36.4, 30.0 and 72.7%, respectively.

CONCLUSION

Incidence of VTE after gynecological operations for ovarian cancer in our study was similar to other investigators. Obesity and the massive ascites are statistically significant risk factors. Measurement of DD level and ultrasonography could become the standard in predicting VTE in ovarian cancer surgery. The use of Wells score is not satisfying in these patients. Prediction of VTE after gynecological surgery needs further confirmation in randomized controlled trials.

[Radical treachelectomy in treatment of early stages of cervical cancer]

The aim of the study was to determine if radical trachelectomy with pelvic lymphonodectomy could be a method for treatment of early cervical cancer to preserve fertility. We examined 12 patients who were operatively treated from 1996. to 2006. year. Diagnostic method for cervical cancer was histologic examination, cone or biopsy. Histologic condition was planocelular carcinoma well differented. Two of the patients had Ia1 stage, seven had Ia2, and three of them had Ib1. We performed abdominal radical trachelectomy with pelvic lymphonodectomy. Resectional edges were patohistologically analyzed ex tempore, as well as lymphonodi, selectively. According to ex tempore analysis we determined if the radical trachelectomy should be done. In one patient resectional edges were positive, so she underwent radical hysterectomy. Postoperatively we found a positive lymphonodus in one patient, so we continued radiation therapy. In two-year follow-up period we did not find any sign of residual cancer. We concluded that radical trachelectomy with pelvic lymphonodectomy could be appropriate method for treatment of early stage cervical cancer.

Renal cell carcinoma in pregnancy: a case report

Renal cell carcinoma is seen most frequently after childbearing years, but occasionally is diagnosed in pregnancy. The pregnancy demands special considerations in terms of the diagnostic evaluation and management. A case of a patient with renal cell carcinoma diagnosed in the first trimester of pregnancy, which suddenly enlarged at the end of the second trimester, is presented. She underwent radical nephrectomy after delivery. Since the mother's welfare is the primary concern, surgical management should not be delayed.

Radicality of surgical treatment for cervical cancer

Analyses were carried out on 545 Wertheim-Meigs radical hysterectomies performed at the Institute of Gynecology and Obstetrics of the Clinical Center of Serbia during a four-year period from 2002 to 2006. More than ten lymphatic glands in 84.4% of patients were removed. The apical part of the vagina was removed in 77.8% of cases, and 77.6% of patients had the right part of the vagina removed. Distribution of surgical radicality according to FIGO stage of disease has been demonstrated. Comparison of research results in the period from 1996 to 2000 shows a significantly more radical approach concerning the number of lymphatic glands removed during this period.

Vulvar neoplasm and reconstruction of a lesion with a vertical rectus abdominis myocutaneous flap: case report

A 41-year-old nulliparous woman was admitted to the Institute of Gynecology and Obstetrics in 2007 with a painless tumor mass invading the whole vulvoperineal and gluteal region. Pathohistological biopsy revealed FIGO Stage II squamocellular invasive carcinoma, but clinically it was Stage IVa verucal vulvar carcinoma because of malignant infiltration to the distal part of the vagina and bilateral gluteal region. The patient underwent radical vulvectomy with bilateral inguinofemoral lymphadenectomy and partial vaginectomy. Reconstruction was performed after three weeks using a distally based vertical rectus abdominis myocutaneous flap (VRAM). A new entrance of the vagina was created. The patient was further treated with radiation therapy.

Radical abdominal trachelectomy in managing early cervical invasion

The purpose of the study was to determine if radical abdominal trachelectomy with pelvic lymphadenectomy could be a method for treatment of early cervical cancer to preserve fertility. We examined 12 patients who were surgically treated from 2002 to 2006. The diagnostic method to determine cervical cancer was histologic examination by cone or biopsy. The histologic condition was well differented planocellular carcinoma. Two of the patients had Stage Ia1, seven had Ia2, and three had Ib1. We performed radical abdominal trachelectomy with pelvic lymphadenectomy. Resection edges were pathohistologically analyzed extemporaneously, as well as selective lymph nodes. According to the extempore analysis we determined if radical trachelectomy should be done. In one patient resection edges were positive, so she underwent radical hysterectomy. Postoperatively we found a positive lymph node in one patient, so radiation therapy was continued. In the two-year follow-up period we did not find any signs of residual cancer. We concluded that radical trachelectomy with pelvic lymphadenectomy could be an appropriate method for treatment of early-stage cervical cancer.

Treatment for infertility and risk of invasive epithelial ovarian cancer--a case report

A 30-year-old women was admitted to the Institute of Gynecology and Obstetrics, Clinical Center of Serbia in April 2004 with the following diagnosis: adnexal mass soon after in vitro fertilization. Her history revealed salpingo-oophorectomy for mucinous cystadenofibroma of the left ovary eight years before and cystectomy of the right ovary three years before. At admission, the most remarkable findings were high temperature and elevated white blood cells with erythrocyte sedimentation rate. After the antibiotic treatment, laparatomy was performed and a multilocular right adnexal tumor was found. The right salpingo-oophorectomy was performed and pathological diagnosis was mucinous ovarian adenocarcinoma. Two weeks later, radical surgery was carried out and chemotherapy was applied. There is an urgent need for clear interpretation of the link between ovarian stimulation and ovarian cancer. An association between ovarian stimulation treatment and ovarian cancer has still not been completely proven.

Paget's disease of the vulva--a review of our experience

OBJECTIVE

The aim of our study was to review our experience with Paget's disease of the vulvar relative to initial examination, treatment and oncological outcome.

METHODS

Ten women with extramammary Paget's diseases of the vulva were treated during the 10-year period. The charts of these patients were reviewed and data were collected regarding patient demographics, symptoms, previous Paget's disease, surgical treatments and time to recurrence.

RESULTS

Eight women (80%) were treated with wide local excision or partial vulvectomy, and two patients (20%) required radical resection for invasive adenocarcinoma. The group of women who had invasive diseases also underwent inquinofemoral lymphadenectomy and no lymphatic metastases were noted. Three women (30%) experienced recurrence. The mean time to relapse was 30 months (range 3-88 months).

CONCLUSION

Recurrence is very common and long-term monitoring is recommended with careful examination of any abnormal vulvar lesion.

[Intrapartum uterine rupture, causes and treatment]

During 3 year period there were over 20000 deliveries at the Institute for Gynecology and Obstetrics. Considering the fact that our clinic's maternity hospital is the largest in the Balkans and that we are at the top of medical practice, the largest number of deliveries in Serbia and Monte Negro is performed in our institution. For the number of uterus ruptures dramatically increased, we analyzed the way of their repair and possible measures for preventing postpartum hysterectomies. We compared patients with performed hysterectomies or uterus sutures. We analyzed the possibility to approach more conservatively to such complications. 30 patients were subjected to interventions. In the group A there were 25 women subjected to more conservative therapy. In the group B there were 5 patients with total hysterectomy with conservation of one or both adnexes.

[Clinical characteristics of chronic post-traumatic spinal neurogenic pain syndrome]

In order to define clinical features of chronic posttraumatic spinal neurogenic pain syndrome we have analyzed a group of 23 patients with posttraumatic neurogenic pain. Patients (21 males and 2 females) were aged from 22 to 59 years, averagely 35.8 years. Painful sensations had the character of mechanical-incisive pain in 7 (30%) patients, and thermal pain equivalents in 3 (13%) patients. In 13 (57%) patients, sensor structure of this painful state had the character of associated thermal and mechanical painful sensations. Typical posttraumatic chronic spinal syndrome in our group of patients had persistent thermal qualities, of fluctuating intensity, with periodical, intensive pain onsets of mechanical character. Level of conus and cauda equina is predilectional level of the lesion for the development of intensive pain syndrome. Posttraumatic pain syndrome can be classified as intermittent and steady pain in relation to the rhythm of its manifestation, and as diffuse and dermatomal pain in relation to extension, in which painful state of occasional rhythm and dermatomal topography is the optimal indication for operative neurosurgical treatment.

DREZ surgery on conus medullaris (after failed implantation of vascular omental graft) for treating chronic pain due to spine (gunshot) injuries

The results of DREZlesioning procedure used for the treatment of chronic intractable pain due to deafferentation caused by gunshot injuries at the thoracolumbar (T10-L1) spine level are reported in six patients. The specificity of these cases arises from the fact that all the patients underwent, after decompressive laminectomy, an implantation of vascularized omental graft on the injured cord segments, 4-17 months after injury. Because of the failure of this method, which did not improve spinal function nor hinder the development of pain, surgery in the DREZ was performed 2-5 years after implantation. The results of the microsurgical DREZotomy procedure in those patients, 7-12 months after the surgery were: 4 patients with complete pain relief and 2 patients with pain relieved of 80%. All the patients with well-confined segmental pain were completely cured.

New technique for artificial lung maturation. Direct intramuscular fetal corticosteroid therapy

The aim of this study was to present a new technique of administration of antenatal corticosteroid therapy in order to cause fetal lung maturation. A single dexamethasone dose of 4 mg was applied directly to the fetal gluteal musculature by ultrasound-guided intramuscular injection 48 h before delivery. This technique of fetal corticosteroid therapy was applied in six cases. Our patients had high risk pregnancies (preeclampsia diabetes mellitus, intracranial hemorrhage, epilepsy, hyperthyreosis). The pregnancies were terminated in the mother's vital interest. The lecithin/sphyngomyelin (US) ratio was < 1.5:1. There were no procedure-related complications. The fetuses were delivered by cesarean, 48 hours later except for the vaginal delivery in the patient in which fetal death occurred in utero. In five cases an uneventful outcome of fetuses indicated that direct fetal corticosteroid treatment improved postnatal lung function in preterm fetuses. A new technique of corticosteroid application successfully prevents respiratory distress in preterm infants decreasing the risk of maternal complications. To our knowledge, this is the first report of fetal intramuscular corticosteroid therapy in the human population.

[Radical hysterectomy with pelvic lymphadenectomy in patients with carcinoma of the uterine cervix--3 years' experience]

INTRODUCTION

Almost all patients with invasive cervical carcinoma can be treated with either primary irradiation therapy or primary surgery. Some patients are appropriately treated with the combination of irradiation and surgery. Chemotherapy is not effective as primary treatment of invasive cervical cancer but may be used as additional therapy and when the disease is recurrent or persistent. There are some important advantages of primary extensive surgery over irradiation. The findings at operation and that from the careful pathologic examination of surgical specimens can be very helpful in selection of patients for supplementary postoperation irradiation therapy or chemotherapy, or both [1-6].

AIM OF THE STUDY

The aim of the study was to compare pretreatment clinical evaluations with surgical and postsurgical pathohistological findings.

METHODS

Extensive hysterectomy and bilateral pelvic lymphadenectomy were used in the treatment of 251 patients with early invasive cervical cancer. The patients were treated at the Department of Obstetrics and Gynaecology of the Clinical Centre of Serbia in Belgrade, between 1993 and 1995. Cervical cancer was detected by clinical examination, colposcopic and cytologic (Pap smear) findings, colposcopically directed biopsy or conisation and pathological findings, sonography, chest radiography, blood and urine analyses. In some cases we had to make other examinations (cystography, cystoscopy, intravenous pyelography, sygmoidoscopy, rectoscopy, CT scanning and magnetic resonance). The surgical treatment of invasive carcinoma of the cervix was limited to those patients in whom the disease was confined to the cervix or vaginal fornix (stage Ia, stage Ib or stage IIa), and who were in high surgical risk.

RESULTS

Over a three year period (1993-1995) there were 251 patients with invasive cervical cancer, treated by primary surgery (radical hysterectomy and bilateral pelvic lymphadenectomy sec. Werthein-Meigs), average age 42 years. Most of the patients demonstrated invasive cervical cancer, clinically classified in Ib st. (81.67%). Some characteristics of pathologic findings, such as parametric width, number of removed lymph nodes, percentage of lymph nodes metastases and correlation with clinical stage of invasive cervical cancer, histologic grade of cervical cancer with lymph node metastasis, pathologic findings after surgical treatment, correlation between clinical and surgical staging, were already presented in tables.

DISCUSSION

In the last decades the incidence of invasive cervical cancer and death rate have been decreased. Progress in reducing mortality is primarily attributed to the introduction of cervical cancer screening as part of regular gynaecologic examinations. Regular testing with Papanicolaou (Pap) smear and colposcopy have an important role in this problem [1]. Extensive hysterectomy and bilateral pelvic lymphadenectomy were used in the treatment of 251 patients with early invasive cervical cancer. We found that the clinical diagnosis of disease extent was correct in 67.7% of patients who underwent extensive surgery for early invasive cervical cancer. Sensitivity of clinical findings was 75.8% and positive predictive value was 86.2%. Lymph node metastasis was detected in 17% patients. Brodman at al. [14] found that clinical examinations, including CT scanning and magnetic resonance, were correct in only 62.5% of cases. It is very difficult to detect parametric involvement and lymph node metastasis by clinical examinations. Irradiation therapy was used in the postoperative period as additional treatment of extensive hysterectomy and bilateral pelvic lymphadenectomy in 89.7% of patients.

CONCLUSION

The findings at operation and that from the careful pathologic examination of surgical specimens are absolutely irreplaceable and important in grading invasive cervical cancer and selection of patients for supplementary postoperate irradiation therapy.

[Primary tumors of the fallopian tubes: retrospective analysis of results in 7 patients]

Primary malignant tumours of the Fallopian tube are among the rarest of gynaecological malignancies. Seven patients with primary malignant tumour of the Fallopian tube, treated between 1991 and 1996, were studied. The average age was 60 years, with nulliparity rate of 29 percent and a mean parity of 2.2. The most common symptoms were atypical vaginal bleeding (29 percent), abdominal pain and distention (29 percent), whereas 43 percent of patients had no symptoms. No patient had a correct preoperative diagnosis. Primary surgical treatment was in all patients hysterectomy and bilateral salpingo-oophorotomy with or without omentectomy. Staging was done according to the FIGO classification for Fallopian tube carcinomas. In Stage I 29 percent of patients were classified, 43 percent in Stage II and 29 percent in Stage III. Six patients (86 percent) had adenocarcinoma (1 in G1, 2 in G2, 3 in G3) and 1 had MMMT (malignant mixed tumour-heterology type). All patients received additional postoperative therapy including: chemotherapy (58 percent), radiotherapy (14 percent), hormonotherapy (14 percent) or combination of chemotherapy and hormone therapy (14 percent). Our results are comparable to those of other authors. The time is too short to predict a 5-year survival, but this will be reported in our next paper.

[The polycystic ovary syndrome associated with ovarian tumor]

Case report of a girl with PCOD (polycystic ovarian disease) and Sertoli-Leydig ovarian tumour. A sixteen-year old girl was clinically, endocrinologically, echosonographically and laparoscopically examined, and polycystic ovarian disease was diagnosed. After a two-year period she was reexamined: normal adrenal function was confirmed and left ovarian tumour was discovered echosonographically. Therefore, she was operated on and adnexectomy of the left ovarian tumour and biopsy of the right ovary were done. The histopathologic analysis revealed the Sertoli-Leydig tumour of the left ovary and polycystic degeneration of the right ovary. In conclusion, because of the greater frequency of ovarian tumours in women with PCOD, the permanent follow-up of women with PCOD is necessary.

[Effect of opioids and gamma-aminobutyric acid on ovulation]

Neurons secreting gonadotropin-releasing hormone (GnRH) contain receptors of gamma-aminobutyric acid (GABA), glutamate, fibroblast-growth factor, prolactin, beta-adrenergic receptor and dopamine receptor. Oestrogens and opioid peptides have a very important influence on gonadotropin secretion, but have no their own receptors in GnRH neurons. The role and interaction between gamma-aminobutyric acid and opioids in the inhibition of ovulation were studied, using valproate (GABA agonist) and naloxone (opioid antagonist)

SUBJECT AND METHOD

Groups: postmenopausal women (50), postmenopausal women on oestrogen replacement therapy, consisting of 200 mcg/day transdermally oestrogen for one month (50), and women in luteal phase of their regular menstrual cycle (50). Thirty women from each group were studied after placebo (1st day) administration, and after 300, 600 or 1200 mg of valproate (2nd day). Gonadotropins and prolactin were measured in the same way, at intervals of 24 h, on the placebo day, and on the 2nd day. The interaction between naloxone and valproate was tested in 20 women from each group; day 1-placebo; day 2-naloxon (infusion-1.6 mg/h for 6 h); day 3-naloxon infusion, preceded by 1200 mg of valproate.

RESULTS

Valproate. The concentration of luteinizing hormone (LH) was significantly decreased after the administration of valproate in postmenopausal women (up to 20%) and to women in luteal phase of the cycle (up to 80%). In substituted postmenopausal women there was no change in LH concentration after valproate administration. Naloxon. Naloxon infusion had no effect on LH concentration in postmenopausal women, and was significantly increased in mean serum LH in substituted postmenopausal women (52%) and in women in luteal phase of the cycle (27%). Valproate and naloxon. In women with a high oestrogen concentrations (substituted postmenopausal women) opioid blockade with naloxon (situation analogous to preovulatory phase of the cycle) contributed to the appearance of inhibitory influence of valproate on LH secretion (29.2 IU/L-after naloxone infusion; 13.2 IU/L-after administration of valproate and naloxone). In this group of patients there was no effect of valproate on LH previous secretion.

CONCLUSION

GABA may have a significant role in the inhibition of ovulation because of its inhibitory role in LH secretion in the situations when oestrogen secretion is high, and opioid concentration is low.

[Results of repair of severed nerves in war injuries]

The results of surgical treatment of 397 wounded with 482 neurotmeses (64 median, 97 ulnar, 100 radial, 7 musculocutaneal, 120 peroneal and 94 tibial nerves) were analyzed. The treatment outcome was determined 12-36 months postoperatively by analyzing the sensorimotor recovery, EMNG status and operated person's attitude to the repair outcome. The change of all the four mentioned parameters was graded from 0 to 5 points, and the outcome was qualified as poor, moderate, good or excellent according to the point sum total. The majority of good and excellent results was obtained after radial (85%) and musculocutaneal (100%) nerve repairs and the less after peroneal nerve repair (13.3%). Based on the obtained results, it was concluded that radial and musculocutaneal neurotmeses should always be repaired, disregarding the height of lesion. Repair of high ulnar and peroneal lesions was unsuccessful. High lesions of tibial and median nerves should be repaired because of the possible recovery of protective sensibility in autonomous nerve zone.

[Changes in F-response parameters in supraspinal lesions of the central nervous system]

Since the F response is the result of antidromic activation of limited number of alpha motor neurons, the motor neurons excitability level can be investigated and established by analyzing parameter values of F response. The excitability of alpha motor neurons is the result of balance between excitatory and inhibitory influences of mainly supraspinal origin. The aim of this study was to perform the analysis of basic parameters of the F response in the lesions of pyramidal, extrapyramidal and cerebellar system, and to determine the eventual predictive value of the F response in lesion outcome. The investigations were carried out in 65 patients and 30 neurologically healthy subjects in control group. The patient group consisted of 38 patients with pyramidal lesions due to ischemic stroke, 15 patients with Parkinson's disease and 12 patients with vascular cerebellar lesions. The F response investigations were repeated monthly during 12 months in 12 patients with ischemic stroke. The results showed significant increase in F amplitude and frequency. These changes were in positive correlation with the increase of spastic muscular tone. In patients with cerebellar lesions decreased amplitude and frequency of F response were in positive correlation with the reduction of muscle tone. It was concluded that the measurement of the F response parameters might be reliable marker of the alpha motor neurons excitability and might have predictive value in the early phase of ischemic stroke.

[Lesions of the peripheral nerves associated with pseudoaneurysms of the major arteries caused by gunshot wounds]

Ten wounded persons, operated on for gunshot-induced peripheral nerve lesion in which pseudoaneurysm of the main artery was found intraoperatively, were presented. Preoperative clinical course, intraoperative neurovascular topography and pathoanatomy, operative procedures and postoperative results were analyzed. The correlation was established between preoperative neurologic deficit and intraoperative findings on arteries and nerves. It was concluded that such patients have to be operated on as soon as possible, but not later than five days from the beginning of neurologic aggravation, to prevent the development of irreversible neural damage.

[Repair of a severed nerve with denatured muscle graft--preliminary results of a new surgical technic]

In Neurosurgical Clinic of Military Medical Academy prospective study about the use of denatured muscle graft in nerve repair is in progress, based on numerous experimental and sporadic clinical literature data. The first, experimental part of the investigation is directed to operative technique details and also to find out the manner and duration of muscle denaturation which provide ideal conditions for regenerating axons sprouting. It is concluded that greater pectoral muscle have to be muscle graft donor for nerve defects shorter than 6 cm, and sartorius muscle for those longer than 6 cm. Denaturation for 30 seconds in liquid nitrogen and after that in distilled water for 3 minutes results in micromorphological status in muscle graft which is optimal for axonal regeneration. In the second, clinical part of the work reparations of missile neurotmesis of radial nerve with denatured muscle grafts are performed. Preliminary results 9 months after operation are quite comparable with results after sural nerve graft reparation.

[Post-gunshot wound lesions of the peripheral nerves which may be prevented with adequate primary surgical wound care]

The retrospective study includes 24 wounded persons with iatrogenic peripheral nerve lesion and 94 wounded whose neural damage occurred due to peripheral nerve engagement in scar tissue after main artery reconstruction, missile bone fracture or after soft tissues defects covering by Tiersch transplants. The authors analyzed frequency and localization of these lesions, intraoperative findings, applied operative procedures and clinical findings during preoperative follow-up. It is recommended to create the new bad for exposed peripheral nerve from adjacent muscles as part of primary surgical wound treatment. This procedure eliminates the risk of subsequent epineural scar formation in all situations that have been described (soft tissue defects, artery reconstruction and bone fracture) and makes the later operations on peripheral nerves unnecessary.

[Diagnostic and prognostic significance of long latency reflexes, somatosensory evoked potentials and the blink reflex in cerebral ischemia]

In order to determine diagnostic and prognostic value of long latency reflexes, blink reflex and somatosensory evoked potentials in patients with ischemic brain disease (IBD), examinations were done in 32 patients of both sexes with IBD, average age 44-76 years. First examinations were performed within first week of the onset of IBD and in majority of patients repeated after 3 and 6 months. Changes of electrophysiological characteristics compared with the degree of IBD, clinical presentation, localization, extent of infarction zone (measured by CT) and functional recovery where analyzed. Electrophysiological changes were predominantly associated with amplitude of physiological response and were in correlation with the degree of IBD, localization and the extent of infarction zone. Latencies were prolonged only in case of subcortical ischemic lesions. Correlation between functional recovery and electrophysiological changes was present only within the structures responsible for certain components of electrophysiological responses and localization of ischemic lesion. In conclusion, electrophysiological examinations are of high diagnostic and predictive value in IBD.

[Sensitivity of electrophysiologic tests in the diagnosis of carpal tunnel syndrome]

According to anatomic characteristics of median nerve branches and pathophysiological basis of the carpal tunnel syndrome (CTS), significant difference in sensitivity of some electrophysiological parameters in the diagnosis of this syndrome was presumed. The aim of this study was to analyze characteristics of some abnormalities of electrophysiological parameters and to determine their frequency in the carpal tunnel syndrome. Investigation was performed on 34 patients with the carpal tunnel syndrome and 30 neurologically healthy subjects. EMGs of the tenar muscles, terminal latency parameters for the median nerve and sensory conductivity of the median nerve branches including cutaneous palmar branch and ulnar nerve branches of the ring finger were examined and analyzed. Results have shown that abnormalities were most frequently found in sensory conductivity parameters for median nerve branch of the ring finger. Significant difference between sensory conductivity parameters for cutaneous palmar branch and median nerve branch of the thumb was also found. These results were discussed in terms of current knowledge about anatomic characteristics of the hand innervation and pathophysiology of the carpal tunnel syndrome. It was concluded that the most frequent physiological findings could be used as a highly sensitive test for reliable and early diagnosis of CTS.

[Correlation of sonographic and patho-anatomic findings in myomatous changes in the uterus]

In spite of the fact that ultrasound is an accessory diagnostic measure in gynaecology, added to clinical examination, it can help in a more accurate diagnosis and better preparation for surgery. The comparison of data obtained by ultrasonic and macroscopic measurements of uterine leiomyoma in 130 patients did not reveal a statistically significant difference between the two methods. The mean size of all measured leiomyomas was 61.47 mm in longitudinal diameter, 53.00 mm in anteroposterior and 53.95 mm in transversal. Measured by ultrasound the mean dimensions of the same diameters were 62.29 mm, 56.91 mm and 55.11 mm respectively. Differences in the mean values of all measured diameters obtained in some cases can be explained by subjective elements in the use of ultrasound, the examiners experience and postoperative reduction of the removed organ volume, as well as by technical factors which may influence the ultrasonic image. Thus, the accuracy of ultrasonic measurement completes the knowledge about the size of the pelvic mass; it is helpful in preparation for surgery, and decreases the possibility of unexpected situations during the surgery.

[Smoking and nonmalignant changes in the uterine cervix]

The evidence of the association between smoking and cervical dysplasias has been established by several reports. It has been suggested that smoking might depress the immune mechanism and allow a sexually transmitted infective agent to result in an abnormal cellular development, leading to the onset of dysplasia. It, was also established that some chemical products of smoking could be selectively deposited in gynaecological tissues. The aim of this study was to examine the frequency of smoking habits in patients with non-malignant cervical changes and to compare it to the one in patients without cytological or colposcopical cervical abnormalities. The study group consisted of 63 patients with historically confirmed non-malignant cervical changes: 6 patients with cervicitis, 12 with leukokeratosis of the cervical epithelium, 13 with mild dysplasia, 21 with moderate dysplasia and 11 patients with sever dysplasia. 68 patients were without cervical changes and made the control group. The percentage of smokers among the patients with cervical changes (53.97%) statistically significantly differs from the results of the control group (32.35%). This percentage is increasing with the severity of cervical change. Testing for a dose-response relationship reveals no difference between the light and heavy smokers. An increased risk for development of cervical changes with increasing duration of smoking could not be established. The results are in agreement with the opinions that smoking is associated with an increased risk for development of cervical dysplasia which is considered to be a precursor lesion of cancer of the cervix. Although it could not be established by our analysis, it is thought that this risk increases with the increased frequency and longer duration of smoking.

[Primary ovarian cancer]

Out of 108 patients treated for primary ovarian cancer from 1984 to 1986, 76% suggested adnexal changes, while malignancy was suspected only in 35% of them. The first symptoms appeared in 51.8% of patients up to three months before the establishment of the diagnosis. In the two thirds of them the disease was in the III or IV stage. Histologically, epithelial tumours were most frequent (86.1%), mostly (51.6%) moderately differentiated. Surgery ranged from hysterectomy with adnexectomy and omentectomy (58.3%) to explorative laparotomy with biopsy. Later intervention included chemotherapy in 62%, chemotherapy and radiotherapy in 15.7%, and radiotherapy alone in 14.8% of patients. Too short a time has elapsed since the treatment started to predict a 5-year survival, but the 2-year survival for all patients amounts to 38.9%.

[Advantages and disadvantages of transabdominal taking of chorionic villi in prenatal diagnosis]

The analyses concerns 186 aspirated chorionic villi. In 168 cases (group A) the aspiration was transcervical and in 18 cases (group B) transabdominal. At that time the average gestation period was 9.7 (+/- 1.2) weeks in group A and 11.9 (+/- 1.3) weeks in group B. The quality of the sample of chorionic villi in group A increased with the experience of the medical team, so that after the first 60 aspirations the unfavourable findings were registered in 11.6 of cases and in the last 48 patients it was 4.2%. Failure of cytogenetic analyses was found in 9 of 154 cases with sufficient chorionic tissue. On the other hand there were no unsuccessful aspirations and cytogenetic analyses in group B. Immediate and early complications of the cervical transabdominal taking of chorionic villi were noted after the first 60 aspirations in 25% of patients.

The changing pattern of renal tuberculosis

The authors present a series of 2,173 patients with renal tuberculosis seen between 1950 and 1979. This is group 1, serving only to show the incidence of renal tuberculosis during the antibiotic era. The fact is that the incidence of renal tuberculosis is going down slightly but constantly in the last years because the resistance of patients is increasing and the virulence of the TB bacillus is decreasing. The second group consists of 128 patients completely examined and the conclusion is that certain forms of very active TB have disappeared; high fever, very active forms of renal TB with deep and limited ulcerations in the kidney do not occur anymore. The third group is formed of 208 patients reviewed in order to demonstrate the residues after long antituberculotic treatment. It has been found that certain residual changes in the parenchyma are minimal but present as the remnants of antibiotic treatment indicating that probably the bilateral forms of renal TB are more common than we supposed before, in full agreement with Cibert's claim.

[Prenatal diagnosis in the 1st trimester of pregnancy of the male fetus at risk for hemophilia B]

It is for the first time that chorionic villi biopsy was performed for diagnostic purposes; the indication for prenatal testing was haemophilia B-X-linked disease. The chorionic tissue was obtained by transcervical aspiration in the 9th week of gestation under ultrasound guidance. The techniques used for cytogenetic investigation were the Y body technique and direct fetal karyotyping. The presence of Y body was determined by slide examination. The analysis of the fetal karyotype confirmed the diagnosis of a male fetus. As this fetus had a great risk (50%) of being born with haemophilia B, the parents decided to terminate the pregnancy. It was done 9 days following the test. During this period no complications were observed. The chorionic villi biopsy has proved easy, quick, and successful in the diagnosis of X-linked disorders.