275 - KCUS
Transcription
275 - KCUS
268 0HGLFDO-RXUQDO ZZZNFXVED PUBLISHER Editor-in-Chief Institute for Research and Development Clinical Center University of Sarajevo 6DUDMHYR%ROQLþND Bosnia and Herzegovina 0LU]D'LOLü For publisher 'DPLU$JDQRYLü0'3K' general manager CCUS AIMS AND SCOPE 0HGLFDO-RXUQDOLVWKHRI¿FDOTDUWHUO\LVVXHG-RXUQDORIWKH,QVWLWXWHIRU5HVHDUFKDQG'HYHORSPHQWRIWKH &OLQLFDO&HQWHU8QLYHUVLW\RI6DUDMHYRDQGKDVEHHQSXEOLVKHGUHJXODUO\VLQFH-RXUQDOLVSXEOLVKHGRQ the languages of the people of Bosnia and Herzegovina i.e. Bosnian, Croatian and Serbian language as well as in English. 7KH0HGLFDO-RXUQDODLPVWRSXEOLVKWKHKLJKHVWTXDOLW\PDWHULDOERWKFOLQLFDODQGVFLHQWL¿FRQDOODVSHFWVRI FOLQLFDOPHGLFLQH7KH-RXUQDORIIHUVWKHUHDGHUDFROOHFWLRQRIFRQWHPSRUDU\RUJLQDOSHHUUHYLHZHGSDSHUV professional articles, review articles, editorials, together with special articles and case reports. &RS\ULJKW7KHIXOOWH[WRIDUWLFOHVSXEOLVKHGLQ0HGLFDO-RXUQDOFDQEHXVHGIRUHGXFDWLRQDODQGSHUVRQDODLPVLH reference cited according to authors permission. If the basic aim is commercial no any part of published materials may be use or reproduced without permission of the publisher. Special permission are available for education DQGQRQSUR¿WHGXFDWLRQDOFODVVURRPXVH(OHFWURQLFVWRUDJHDQGXVDJH([FHSWDVRXWOLQHGDERYHQRSDUWRI this publication may be reproduced, stored in a retrieval system or transmitted in any form or by any means ZLWKRXWSULRUZULWWHQSHUPLVVLRQRIWKH3XEOLVKHU All rights reserved © Clinical Center University of Sarajevo. Notice: The authors, editor and publisher do not accept responsibility for any loss or damage arising from acitions or decisions based on information contained in this publication; ultimate responsibility for the treatment of patients and interpretation of published materials lies with the medical practitioner. The opinion expressed are those of the DXWKRUVDQGWKHLQFOXVLRQLQWKLVSXEOLFDWLRQRIPDWHULDOUHODWLQJWRVSHFL¿FSURGXFWPHWKRGRUWHFKQLTXHVGRHVQRW DPRXQWWRDQHQGRUVHPHQWRILWVYDOXHRUTXDOLW\RURIWKHFODLPVPDGHRILWE\LWVPDQXIDFWXUHU EDITORIAL OFFICE $GGUHVV0HGLFDO-RXUQDO,QVWLWXWHIRU5HVHDUFKDQG'HYHORSPHQW Clinical Center University of Sarajevo, 71000 Sarajevo, %ROQLþND Bosnia and Herzegovina, 7HO)D[ &RQWDFWSHUVRQ-HOHQD.RSULYLFD0$ (PDLOELEOLRWHNDQLU#NFXVED ZZZNFXVED (GLWRULQ&KLHIPGLOLF#ELKQHWED SUBSCRIPTION 7KHDQQXDOVXEVFULSWLRQUDWHV%RVQLDDQG+HU]HJRYLQD¼(XURSH¼DQGRWKHU¼ SUPPLEMENTS, REPRINTS AND CORPORATE SALES Editorial Board ,VPHW*DYUDQNDSHWDQRYLüSUHVLGHQW 'DPLU$JDQRYLü0DUNR%XNãD6HQND 'LQDUHYLü-DGUDQND'L]GDUHYLü.HPDO 'L]GDUHYLü$PLUD'XULü9MHNRVODY*HUF 0HKPHG*ULEDMþHYLü6DIHW*XVND =RUDQ+DGåLDKPHWRYLü0LGKDW+DUDþLü 0XVWDID+LURã%HüLU+HOMLü6HELMD ,]HWEHJRYLü'UDJDQ.RVRULü$EGXODK .XþXNDOLü0HQVXUD.XGXPRYLü/LGLMD /LQFHQGHU6ORERGDQ/RJD%DNLU0HKLü 1HUPLQD2EUDOLü/LOLMDQD2UXþ6YMHWODQD 5DGRYLü6HQLMD5DãLü6ORERGDQ7UQLQLü +DVDQäXWLüVHFUHWDU\ International Advisory Board .HQDQ$UQDXWRYLü86$5DIIDHOH %XJLDUGLQL,WDO\(UROûHWLQ7XUNH\ 0DULD'RUREDQWX5RPDQLD2NWD\ (UJHQH7XUNH\=ODWNR)UDV6ORYHQLD 'DQ*DLWD5RPDQLD0DULR,YDQXãD &URDWLD6WHHQ'DOE\.ULVWHQVHQ'HQ PDUN0LPR]D/H]KH$OEDQLD0DULR 0DU]HOOL,WDO\0LOLFD0HGLü6WRMDQRYVND 6HUELD'DYRU0LOLþLü&URDWLD)DXVWR 3LQWR3RUWXJDO0LKDLOR3RSRYLFL0RO GRYD0DUFHOOD5LHWVFKHO*HUPDQ\ 1DGDQ5XVWHPRYLü&URDWLD*HRUJHV 6DDGH/HEDQRQ3HWDU6HIHURYLü6HU ELD'UDJDQ6WDQLVDYOMHYLü6ORYHQLD %RMDQ7UãLQDU6ORYHQLD3DQRV9DUGDV *UHHFH*RUGDQ9XMDQLü8.-RVH =DPRUDQR6SDLQ English language revision 9HUD%LþDNþLü Medical Journal is Indexed in (%6&2SXEOLVKLQJ86$ www.ebscohost.com )RUUHTXHVWHVIURPLQGXVWU\DQGFRPSDQLHQVUHJDUGLQJVXSSOHPHQWVEXONDUWLFOHVUHSULQWVVSRQVRUHGVXEVFULSW tions, translations opportunities for previously published material, and corporate online opportunities, plase HPDLOWRELEOLRWHNDQLU#NFXVED PRINT 0LUEHUJUDIGRR6DUDMHYR 3ULQWHGRQDFLGIUHHSDSHU TECHNICAL EDITOR 0LUEHUJUDIGRR CIRCULATION FRSLHV 0HGLFLQVNLåXUQDO 0HPEHU RI WKH (6& 1DWLRQDO 6RFLHWLHV &DUGLRYDVFXODU-RXUQDOV Contents ORIGINAL ARTICLE ANATOMIC CHARACTERISTICS OF ARTERIAL SUPPLY OF THE CONDUCTING SYSTEM OF THE HEART ,13$7,(176:,7+&2521$5<',6($6($1'',$%(7(60(//,786 $LGD+DVDQRYLü,OLULMDQD+D[KLEHTLUL.DUDEGLü$LGD6DUDþ+DGåLKDOLORYLü0XKDPHG6SXåLü EVALUATION OF TREATMENT RESULTS IN CHILDHOOD LYMPHOMA............................................................................... 276 (GR+DVDQEHJRYLü6QLMHåDQD+DVDQEHJRYLü /$5<1*23+$5<1*($/5()/8;',6($6(2857+5((<($5(;3(5,(1&( 0LUMDQD*QMDWLü6ORERGDQ6SUHPR3UHGUDJâSLULü'PLWDU7UDYDU6DQMDâSLULü'DQLMHOD.HVLü0LMLü7DWMDQD%DUDü COMORBIDITY OF DEPRESSION IN NEUROLOGIC PATIENTS............................................................................................. 286 1DWDãD/RJD$QGULMLü$]UD$ODMEHJRYLü6YMHWODQD/RJD=HF PREVALENCE AND ANTIMICROBIAL RESISTANCE OF PSEUDOMONAS AERUGINOSA ,17+(:281'6:$%6 0DLGDâLãLUDN0LUVDGD+XNLü$PUD=YL]GLü'DULD%HNLü $1$/<7,&$/(9$/8$7,212)7+($87,21+<%5,'$8$8720$7('85,1($1$/<=(5 -R]RûRULü%HULQD+DVDQHIHQGLü%HOPDäROMLü/HMOD+DVDQEHJRYLü &203$5,6212)()),&,(1&<2)3/(852'(6,6:,7+',))(5(176&/(526$167+528*+3/(85$/&$7+(7(5 $OPD$OLKRGåLü3DãDOLü6DIHW*XVND$OHQ3LODY.HPDO*UELü 7+(35(9$/(1&(2)%$&7(5,$/9$*,126,6,135(*1$17:20(1:,7+7+5($7(1('35(7(50%,57+ 0RKDPPDG$ERX(O$UGDW=XOIR*RGLQMDN6DQMLQ'HNRYLü/DQD/DþHYLü(OGDU0HKPHGEDãLü$UPLQD5RYþDQLQ PREDICTORS OF PROGRESSION OF BONE METASTASES IN BREAST CANCER DIAGNOSED WITH SKELETAL 6&,17,*5$3+<%$6('217+(+25021(5(&(372567$786$1'+(53527(,16 âHMOD&HULü(OPD.XþXNDOLü6HOLPRYLü7LPXU&HULü1HUPLQD2EUDOLü6HPLU%HãOLMD6HOPD$JLü ,03$&72)($5/<'(7(&7,212)(/%2:29(586(6<1'520(2175($70(17 ,YDQND0DÿDU6LPLF$GQDQD7DOLü7DQRYLü0LUMDQD0DÿDU=HF ,03$&72)$&&203$1<,1*',6($6(6215(68/762)75($7,1*3$7,(176:,7+3/(85$/(03<(0$ ,OLMD]3LODY6DIHW*XVND6DIHW0XãDQRYLü $1$/<6,62)&2521$5<5,6.)$&7256,12%(6(3$7,(176:,7++<327+<52,',60 %HOPD$ãþLü%XWXURYLü$PLU5HGåHSRYLü$PLOD0HKPHGRYLü PROFESSIONAL ARTICLE (9$/8$7,212)',$672/,&'<6)81&7,21,1$&87(0<2&$5',$/,1)$5&7,21 'HQLV0DþNLü'DPLUâHþLü$JR2PHUEDãLü$PLUýHKDMLü(OYLUD'åDPEDVRYLü REVIEW ARTICLE 5811,1*,1-85,(6 (PLU%HQFD3HMPDQ=LDL*REHUWYRQ6NUEHQVN\$PLU$KPHWRLYü5HLQKDUG:LQGKDJHU6HOPD.USR CASE REPORT %(1,*1 ,175$&5$1,$/ +<3(57(16,21 ,1'8&(' %< $//75$16 5(7,12,& $&,' $75$ ,1 7+( 3$7,(17 :,7+ $&87(3520<(/2&<7,&/(8.(0,$ /HMOD%XUD]HURYLü(OGLQ%XUD]HURYLü ,19(56(326,7,212)63/((16720$&+$1'3$1&5($6 /LGLMD/LQFHQGHU&YLMHWLü6DQMDâHKRYLü,UPLQD6H¿ü3DãLü9HVQDĈXURYLü6DUDMOLü6DQGUD9HJDU=XERYLü UPUTSTVO AUTORIMA INSTRUCTIONS TO AUTHORS 0HGLFLQVNLåXUQDO $LGD+DVDQRYLü,OLULMDQD+D[KLEHTLUL.DUDEGLü$LGD6DUDþ+DGåLKDOLORYLü0XKDPHG6SXåLü$QDWRPLFFKDUDFWHULVWLFVRIDUWHULDOVXSSO\RIWKHFRQ GXFWLQJV\VWHPRIWKHKHDUWLQSDWLHQWVZLWKFRURQDU\GLVHDVHDQGGLDEHWHVPHOOLWXV Original article ANATOMIC CHARACTERISTICS OF ARTERIAL SUPPLY OF THE CONDUCTING SYSTEM OF THE HEART IN PATIENTS WITH CORONARY DISEASE AND DIABETES MELLITUS $1$7206.( .$5$.7(5,67,.( 9$6.8/$5,=$&,-( 635292'12* 6,67(0$ 65&$.2'3$&,-(1$7$6$.2521$5120%2/(âû8,',-$%(7(60(/,78SOM $LGD+DVDQRYLü,OLULMDQD+D[KLEHTLUL.DUDEGLü2$LGD6DUDþ+DGåLKDOLORYLü0XKDPHG6SXåLü2 'HSDUWPHQWRI$QDWRP\)DFXOW\RI0HGLFLQH8QLYHUVLW\RI6DUDMHYRýHNDOXãD6DUDMHYR%RVQLDDQG Herzegovina; +HDUW &HQWHU &OLQLFDO &HQWHU 8QLYHUVLW\ RI 6DUDMHYR %ROQLþND 6DUDMHYR %RVQLD DQG Herzegovina 1 * Corresponding author ABSTRACT The aim of the study was to establish angiographi cally anatomic characteristics of the sinoatrial QRGDODUWHU\UQRGLVLQXDWULDOLVDQGDWULRYHQWULFX ODU QRGDO DUWHU\ U QRGL DWULRYHQWULFXODULV DQG LWV correlation with the dominance of the coronary arteries in patients with coronary disease and diabetes mellitus. Coronary artery disease is the major cardiovascular abnormality in diabetes mel litus patients and the major cause of mortality in GLDEHWHVPHOOLWXVW\SH7KHUHWURVSHFWLYHVWXG\ LQFOXGHG SDWLHQWV IHPDOHV PDOHV DJHG EHWZHHQ DQG \HDUV ZKR XQGHUZHQW coronary angiography in Heart Centre of the Clini cal Center University of Sarajevo in period from -XO\WR-XO\HLWKHUIRUWKHV\PSWRPVRI FKHVW SDLQ DQJLQD SHFWRULV HWF /DERUDWRU\ ¿QG ings in all patients included in the study showed the presence of diabetes mellitus. Coronary an giography of coronary arteries were performed LQWKHULJKWDQGOHIWDQWHULRUREOLTXHSRVLWLRQ7KH origin of r. nodi sinuatrialis and r. nodi atrioven tricularis was observed and correlated with the ar WHULDOGRPLQDQFH,QWKHSUHVHQWVWXG\SDWLHQWV RI RXU SDWLHQWV KDG WKH ULJKW FRUR QDU\ GRPLQDQFH SDWLHQWV KDG WKH OHIW FRURQDU\GRPLQDQFHDQGLQSDWLHQWV were detected coronary codominance. R. nodi atrioventricularis was a branch of the dominant DUWHU\LQFDVHVLQFRPSDULVRQWRWKHU nodi sinuatrialis which was a branch of the domi QDQWDUWHU\RQO\LQFDVHV7KHVLQRDWULDO 6$ QRGDO DUWHU\ RULJLQDWHG IURP WKH ULJKW FRUR QDU\DUWHU\5&$LQRISDWLHQWV LQ SDWLHQWV IURP WKH FLUFXPÀH[ EUDQFK &; RI WKH OHIW FRURQDU\ DUWHU\ /&$ DQG LQ RIFDVHVIURPWKHERWKFRURQDU\DUWHULHV 5&$&; 7KH DWULRYHQWULFXODU $9 QRGDO DUWHU\ RULJLQDWHGIURPWKH5&$LQSDWLHQWV LQSDWLHQWVIURPWKH&;EUDQFKRIWKH /&$DQGLQQRQHRIWKHFDVHVZDVWKLVQRGHVXS 0HGLFLQVNLåXUQDO SOLHGE\ERWKFRURQDU\DUWHULHV5&$&;7KHUH ZHUH VWDWLVWLFDOO\ VLJQL¿FDQW GLIIHUHQFHV EHWZHHQ the origin of the nodal arteries in relationship to the type of dominance of coronary arteries, in fa vor r. nodi atrioventricularis The variations in origin of the nodal arteries may result with serious post operative complications due to their intraoperative damages. Increased prevalence of cardiac con duction abnormalities in diabetes mellitus patients is evident. The results of the present study may provide safe approach to interventional cardiolo gist and cardiac surgeon during percutaneous and surgical interventions. Key words: sinoatrial nodal artery, atrioventricu lar nodal artery, coronary angiography, coronary disease, diabetes mellitus 6$ä(7$. &LOMLVWUDåLYDQMDMHELRDQJLRJUDIVNLXWYUGLWLDQDWRP VNHNDUDNWHULVWLNHUQRGLVLQXDWULDOLVLUQRGLDWULR YHQWULFXODULVWHQMLKRYXNRUHODFLMXVDGRPLQDFLMRP NRURQDUQLKDUWHULMDNRGSDFLMHQDWDVDNRURQDUQRP EROHãüXLGLMDEHWHVPHOLWXVRP.RURQDUQDDUWHULM VNDEROHVWMHYRGHüDNDUGLRYDVNXODUQDNRPSOLNDFL MDLYRGHüLX]URNVPUWQRVWLXWLSGLDEHWHVPHOOL WXV5HWURVSHNWLYQRLVWUDåLYDQMHMHREXKYDWLOR SDFLMHQDWDåHQDPXãNDUDFDåLYRWQHGREL RGGRJRGLQDNRMLVXELOLSRGYUJQXWLNRURQDU QRMDQJLRJUD¿MLX&HQWUX]DVUFH.OLQLþNRJFHQWUD 8QLYHU]LWHWDX6DUDMHYXXSHULRGXRGMXODGR MXOD JRGLQH ]ERJ VLPSWRPD EROL X SUVLPD DQJLQHSHNWRULVLVO/DERUDWRULMVNLQDOD]LVYLKSDFL MHQDWDXNOMXþHQLKXVWXGLMXXND]DOLVXQDSRVWRMDQ MHGLMDEHWHVPHOLWXVD6QLPDQMHMHYUãHQRXGYLMH SURMHNFLMHGHVQRMLOLMHYRMSUHGQMRMNRVRMSURMHNFLML 3ROD]LãWHUQRGLVLQXDWULDOLVLUQRGLDWULRYHQWULFX ODULVMHRSVHUYLUDQRLNRUHOLUDQRVDWLSRPDUWHULMVNH GRPLQDFLMH 8 SUH]HQWLUDQRP UDGX RGXNXSQRSDFLMHQDWDLPDORMHGHVQLWLSNRUR QDUQHGRPLQDFLMHSDFLMHQDWDOLMHYLWLSNR $LGD+DVDQRYLü,OLULMDQD+D[KLEHTLUL.DUDEGLü$LGD6DUDþ+DGåLKDOLORYLü0XKDPHG6SXåLü$QDWRPLFFKDUDFWHULVWLFVRIDUWHULDOVXSSO\RIWKHFRQ GXFWLQJV\VWHPRIWKHKHDUWLQSDWLHQWVZLWKFRURQDU\GLVHDVHDQGGLDEHWHVPHOOLWXV URQDUQHGRPLQDFLMHLNRGSDFLMHQDWD XRþHQ MH VLPHWULþQL WLS NRURQDUQH GRPLQDFLMH 5 nodi atrioventricularis je bio grana dominantne ar WHULMHXVOXþDMHYDXSRUHÿHQMXVDUQRGL VLQXDWULDOLVNRMLMHELRJUDQDGRPLQDQWQHDUWHULMHX VDPRVOXþDMHYD5QRGLVLQXDWULDOLV6$ MHRGOD]LRRGGHVQHNRURQDUQHDUWHULMH5&$NRG RG XNXSQR SDFLMHQDWD NRG SDFLMHQDWDRGOD]LRMHRGUFLUFXPÀH[XV&; OLMHYHNRURQDUQHDUWHULMH/&$LNRGSDFLMHQDWD RGREMHNRURQDUQHDUWHULMH5&$&;5 QRGLDWULRYHQWULFXODULV$9MHRGOD]LRRGGHVQHNR URQDUQHDUWHULMHNRGSDFLMHQDWDNRG SDFLMHQDWD RG U FLUFXPÀH[XV OLMHYH NRURQDUQH DUWHULMH L QL X MHGQRP VOXþDMX QLMH ELR REVNUEOMHQ RG REMH NRURQDUQH DUWHULMH 5&$&; 6WDWLVWLþND DQDOL]D MH SRND]DOD GD SRVWRML VLJ QL¿NDQWQD UD]OLND X SROD]LãWX DUWHULMD VSURYRGQH PXVNXODWXUHVUFDXRGQRVXQDWLSDUWHULMVNHYDVNX ODUL]DFLMHXNRULVWUQRGLDWULRYHQWULFXODULV9DULMDE LOQRVWXSROD]LãWXQRGDOQLKDUWHULMDPRåHUH]XOWLUDWL R]ELOMQLP SRVWRSHUDWLYQLP NRPSOLNDFLMDPD ]ERJ QMLKRYRJ LQWUDRSHUDWLYQRJ RãWHüHQMD 3RYHüDQD XþHVWDORVW SRUHPHüDMD VSURYRGQRJ VLVWHPD VUFD NRGSDFLMHQDWDVDGLMDEHWHVPHOLWXVRPMHHYLGHQW QD 5H]XOWDWL SUH]HQWLUDQH VWXGLMH PRJX SRPRüL LQWHUYHQWQLPNDUGLROR]LPDLNDUGLRKLUXU]LPDWRNRP SHUNXWDQLKLKLUXUãNLKLQWHUYHQFLMD .OMXþQH ULMHþL r. nodi sinuatrialis, r. nodi atrio YHQWULFXODULV NRURQDUQD DQJLRJUD¿MD NRURQDUQD bolest, dijabetes melitus INTRODUCTION Anatomic descriptions of the blood supply of WKH FDUGLDF FRQGXFWLRQ V\VWHP VSHFL¿FDOO\ WKH VLQRDWULDO6$QRGHDQGWKHDWULRYHQWULFXODU$9 node, have been reported in several published articles in the literature. These descriptions have been based solely on detailed cadaveric dissec tions of the human heart and angiographic stud LHV 0DQ\ SRVWPRUWHP DQG D IHZ DQJLRJUDSKLF VWXGLHVKDYHGHPRQVWUDWHGWKDWWKHVLQRDWULDO6$ QRGH DUWHU\ ZDV PRVW IUHTXHQWO\ D ODUJH DWULDO branch of the right coronary artery in approximate O\ RI FDVHV DQG IURP WKH OHIW FLUFXPÀH[ LQ WKHUHPDLQLQJRIFDVHVZLWKDPHDQH[WHUQDO GLDPHWHURIPP7KHDUWHULDOVXSSO\ RIWKH$9QRGHDURVHLQDSSUR[LPDWHO\RIWKH hearts from the RCA in the posterior atrioven tricular sulcus at a point just beyond the origin of WKHSRVWHULRULQWHUYHQWULFXODUDUWHU\,QRIWKH KHDUWVWKH$9QRGHDURVHIURPWKHWHUPLQDOSDUWRI WKH&;DWWKHFUX[RIWKHKHDUWZLWKDPHDQH[WHU QDOGLDPHWHUPP The distributing artery of the conducting system of the heart is occasionally injured in cardiac sur JHU\,GHQWL¿FDWLRQRIWKHRULJLQFRXUVHDQG relationships to adjacent anatomical structures of WKH 6$ QRGDO DQG$9 QRGDO DUWHULHV PD\ KHOS LQ RYHUFRPLQJGLI¿FXOWLHVLQFOLQLFDOSUDFWLFHLQRYHU FRPLQJSRWHQWLDOGLI¿FXOWLHVLQWUHDWLQJDUUK\WKPLDV DQGLQPLWUDOYDOYHVXUJHU\ 'LDEHWHV PHOOLWXV LV D PDMRU ULVN IDFWRU IRU FDU diovascular disease and mortality with increasing prevalence in the ageing population. Coronary artery disease is the major cardiovascular abnor mality in diabetes mellitus patients. Cardiomyopa thy and left ventricular hypertrophy are two other NQRZQ DVVRFLDWHG FDUGLRYDVFXODU DEQRUPDOLWLHV The aim of the present study was to establish angiographically anatomic characteristics of the VLQRDWULDO QRGDO DUWHU\ U QRGL VLQXDWULDOLV DQG DWULRYHQWULFXODUQRGDODUWHU\UQRGLDWULRYHQWULFX ODULVDQGLWVFRUUHODWLRQZLWKWKHGRPLQDQFHRIWKH coronary arteries in patients with coronary disease and diabetes mellitus Coronary angiography was the preferred method of study as it is most commonly used in today’s clinical setting and such a study would be of more FOLQLFDOVLJQL¿FDQFHWKDQVWXGLHVGRQHRQFDGDYHU hearts. MATERIALS AND METHODS 6WXG\SRSXODWLRQ Retrospectively, the authors studied coronary an JLRJUDPVRISDWLHQWVIHPDOHVPDOHV DJHG EHWZHHQ DQG \HDUV ZKR XQGHUZHQW coronary angiography in Heart Centre of the Clini cal Center University of Sarajevo in period from -XO\WR-XO\HLWKHUIRUWKHV\PSWRPVRI FKHVW SDLQ DQJLQD SHFWRULV HWF /DERUDWRU\ ¿QG ings in all patients included in the study showed the existence of diabetes mellitus. 3URFHGXUH Coronary angiography was performed by the per FXWDQHRXV WUDQVIHPRUDO DSSURDFK XVLQJ WKH -XG NLQVWHFKQLTXH6HULDOUDGLRJUDSKVRIWKHULJKWDQG left coronary arteries were obtained in the right DQG OHIW DQWHULRU REOLTXH SURMHFWLRQV 2Q WKH angiograms we established anatomical variations RIFRURQDU\FLUFXODWLRQFODVVL¿HGDVULJKWOHIWDQG balance type. On the angiograms the origin of r. nodi sinuatrialis and r. nodi atrioventricularis from the coronary arteries was observed and correlated ZLWKWKHDUWHULDOGRPLQDQFH:HDQDO\]HGWKHRUL gin of the posterior interventricular artery to deter mine the coronary dominance. 6WDWLVWLFDODQDO\VLV The statistical analysis of the results was per 0HGLFLQVNLåXUQDO 272 $LGD+DVDQRYLü,OLULMDQD+D[KLEHTLUL.DUDEGLü$LGD6DUDþ+DGåLKDOLORYLü0XKDPHG6SXåLü$QDWRPLFFKDUDFWHULVWLFVRIDUWHULDOVXSSO\RIWKHFRQ GXFWLQJV\VWHPRIWKHKHDUWLQSDWLHQWVZLWKFRURQDU\GLVHDVHDQGGLDEHWHVPHOOLWXV IRUPHGXVLQJ.ROPRJRURZ6PLUQRZWHVWDQGWKH differences in the origin of arteries of conductive system in correlation with the dominance of the FRURQDU\ DUWHULHV ZHUH FRQVLGHUHG VLJQL¿FDQW RQ WKHOHYHOS )LJXUH5LJKWFRURQDU\DUWHU\LQOHIWDQWHULRUREOLTXHSURMHF WLRQ$DQGULJKWDQWHULRUREOLTXHSURMHFWLRQ%VKRZLQJWKH6$ nodal artery originating from the proximal part of right coronary artery it was termed as a right SA nodal artery. RESULTS ,QWKHSUHVHQWVWXG\SDWLHQWVRIRXU SDWLHQWVKDGWKHULJKWFRURQDU\GRPLQDQFH SDWLHQWV KDG WKH OHIW FRURQDU\ GRPLQDQFH DQGLQSDWLHQWVZHUHGHWHFWHGFRUR QDU\FRGRPLQDQFH7DEOH:HHVWDEOLVKHGWKH differences in the type of coronary dominance in favor of the right coronary dominance. 7DEOHCoronary dominance. A ,WZDVIRXQGWKDWLQRIRXUSDWLHQWV WKH6$QRGDODUWHU\RULJLQDWHGIURPWKH5&$LQ SDWLHQWV IURP WKH &; EUDQFK RI WKH /&$ DQGLQRIFDVHVIURPWKHERWKFRURQDU\ DUWHULHV5&$&; 7KH$9 QRGDO DUWHU\ RULJLQDWHG IURP WKH 5&$ LQ RI RXU SDWLHQWV LQ SDWLHQWV IURPWKH&;EUDQFKRIWKH/&$DQGLQ none of the cases was this node supplied by both FRURQDU\DUWHULHV5&$&;7DEOH)LJXUH Table 2. Origin of the sinoatrial and atrioventricular nodal arteries. B Figure 2./HIWFRURQDU\DUWHU\LQULJKWDQWHULRUREOLTXHSURMHFWLRQ VKRZLQJWKH6$QRGDODUWHU\RULJLQDWHGIURPWKH&;RIWKHOHIW FRURQDU\DUWHU\LWZDVGHVLJQDWHGDVDOHIW6$QRGDODUWHU\$ 5LJKWFRURQDU\DUWHU\LQOHIWDQWHULRUREOLTXHSURMHFWLRQVKRZLQJ WKH$9QRGDODUWHU\RULJLQDWHGIURPWKH5&$% 0HGLFLQVNLåXUQDO $LGD+DVDQRYLü,OLULMDQD+D[KLEHTLUL.DUDEGLü$LGD6DUDþ+DGåLKDOLORYLü0XKDPHG6SXåLü$QDWRPLFFKDUDFWHULVWLFVRIDUWHULDOVXSSO\RIWKHFRQ GXFWLQJV\VWHPRIWKHKHDUWLQSDWLHQWVZLWKFRURQDU\GLVHDVHDQGGLDEHWHVPHOOLWXV R. nodi atrioventricularis was a branch of the dom LQDQWDUWHU\LQFDVHVLQFRPSDULVRQWR the r. nodi sinuatrialis which was a branch of the GRPLQDQW DUWHU\ RQO\ LQ FDVHV 6WDWLVWL FDODQDO\VLVE\XVLQJ.ROPRJRURZ±6PLUQRZWHVW GHWHUPLQDWHG WKH VLJQL¿FDQW GLIIHUHQFHV EHWZHHQ the origin of the nodal arteries in relationship to the type of dominance of coronary arteries, in fa YRUUQRGLDWULRYHQWULFXODULVS)LJXUH )LJXUH Relationship between the origin of the nodal arteries and coronary dominance. A ,WZDVIRXQGWKDWLQRIWKHFDVHVERWK WKH6$DQG$9QRGDODUWHULHVRULJLQDWHGIURPWKH 5&$LQRIWKHFDVHVERWKWKH6$DQG $9 QRGDO DUWHULHV RULJLQDWHG IURP WKH &; EUDQFK RI/&$DQGLQRIWKHFDVHVERWKWKH 6$DQG$9QRGDODUWHULHVRULJLQDWHGIURPGLIIHUHQW FRURQDU\DUWHULHV5&$&; DISCUSSION B )LJXUH5LJKWFRURQDU\DUWHU\LQOHIWDQWHULRUREOLTXHSURMHF tion showing the SA nodal artery originated from the proximal SRUWLRQ RI WKH ULJKW FRURQDU\ DUWHU\ DQG WKH$9 QRGDO DUWHU\ from the posterolateral branch of the right coronary artery. This clear demonstration of the arterial blood supply to the atrioventricular and sinoatrial node KDVSUDFWLFDOFOLQLFDOVLJQL¿FDQFHWRERWKWKHFDU GLRORJLVW DQG VXUJHRQ,GHQWL¿FDWLRQ RI WKH RULJLQ course and relationships to adjacent anatomical VWUXFWXUHV RI WKH 6$ QRGDO DQG $9 QRGDO DUWHU LHV PD\ KHOS LQ RYHUFRPLQJ WKHVH GLI¿FXOWLHV LQ clinical practice. The incidence of cardiac rhythm GLVWXUEDQFHGXHWRLQWUDRSHUDWLYHGDPDJHWRWKH VLQRDWULDO 6$ QRGH DUWHU\ LV KLJK DQG LQ VRPH FDVHVSDFHPDNHULPSODQWDWLRQLVUHTXLUHG7KHUH LVDOVRDKLJKULVNRIHDUO\SRVWRSHUDWLYHDWULRYHQ WULFXODU$9QRGHEORFNGXHWRGDPDJHWRWKH$9 QRGHDUWHU\GXULQJPDQLSXODWLRQRIWKH¿EURXVULQJ RIWKHPLWUDOYDOYHDQQXOXV¿EURVXV,QDGGLWLRQ ablation procedures in treating arrhythmias can UHVXOWLQFRPSOHWH$9EORFNGXHWRGDPDJHWRWKH $9QRGDODUWHU\ On classic anatomical dissection of human hearts DXWKRUVVKRZHGWKDWWKHVLQRDWULDO6$QRGDO DUWHU\ZDVPRVWIUHTXHQWO\DODUJHDWULDOEUDQFKRI WKHULJKWFRURQDU\DUWHU\LQRIFDVHV 0HGLFLQVNLåXUQDO $LGD+DVDQRYLü,OLULMDQD+D[KLEHTLUL.DUDEGLü$LGD6DUDþ+DGåLKDOLORYLü0XKDPHG6SXåLü$QDWRPLFFKDUDFWHULVWLFVRIDUWHULDOVXSSO\RIWKHFRQ GXFWLQJV\VWHPRIWKHKHDUWLQSDWLHQWVZLWKFRURQDU\GLVHDVHDQGGLDEHWHVPHOOLWXV the SA nodal artery was a branch of the left coro nary artery or one of its branches. The atrioven WULFXODU$9QRGDODUWHU\ZDVWKH¿UVWDQGORQJHVW LQIHULRUVHSWDOSHUIRUDWLQJEUDQFKRIWKHULJKW RU OHIW FRURQDU\ DUWHU\7KLV VWXG\ VKRZHG that the origin of the SA nodal artery was not re lated to coronary arterial dominance, but the origin RIWKH$9QRGDODUWHU\ZDVGHSHQGHQWRQFRURQDU\ arterial dominance. The present study evaluated angiographically an atomic characteristics of the origins of sinoatrial QRGDODUWHU\UQRGLVLQXDWULDOLVDQGDWULRYHQWULFX ODU QRGDO DUWHU\ U QRGL DWULRYHQWULFXODULV DQG LWV correlation with the dominance of the coronary arteries in patients with coronary disease and dia betes mellitus. 'LDEHWHV PHOOLWXV LV D PDMRU ULVN IDFWRU IRU FDU diovascular disease and mortality with increasing prevalence in the ageing population. Coronary artery disease is the major cardiovascular abnor mality in diabetes mellitus patients. Cardiomyopa thy and left ventricular hypertrophy are two other NQRZQDVVRFLDWHGFDUGLRYDVFXODUDEQRUPDOLWLHV 7KHUH DUH D IHZ QRQUDQGRPL]HG VWXGLHV UHSRUW ing increased prevalence of cardiac conduction DEQRUPDOLWLHVVXFKDVULJKWEXQGOHEUDQFKEORFN 5%%% DQG KLJK GHJUHH DWULRYHQWULFXODU $9 EORFN EXW QRW OHIW EXQGOH EUDQFK EORFN /%%% LQ GLDEHWHV PHOOLWXV SDWLHQWV 0RVW FOLQLFLDQV DUH not aware of this association, and it is rarely men tioned in the published reviews about cardiovas cular abnormalities in this population. The cause of cardiac conduction abnormalities in diabetes PHOOLWXVSDWLHQWVLVQRWNQRZQ 5DPDQDWKDQHWDOLQWKHLUVWXG\IRXQGWKDWWKH origin of the SA node artery was mainly from the 5&$DQG/&$RQO\LQFDV es was the SA nodal artery supplied by both coro QDU\DUWHULHV7KH$9QRGDODUWHU\RULJLQDWHGHLWKHU IURPWKH5&$RUIURPWKH&[EUDQFKRI /&$ .\ULDNLGLVHWDOVWXGLHGWKHDUWHULDOEORRGVXSSO\ to the sinus node area in 309 consecutive patients undergoing coronary arteriography. The sinus node artery arose from the right coronary artery in SDWLHQWV7KHPDMRULW\DURVHSUR[LPDOO\ 1 to 3 cm from the aortic ostium. In 87 of the 119 patients in whom the SA node artery arose from WKH OHIW &; LW DURVH IURP WKH SUR[LPDO SRUWLRQ RI WKHOHIW&[9LHZHJ:9HWDOLQDQJLRJUDSKLF study established that the SA nodal artery arose IURPWKHULJKWFRURQDU\DUWHU\LQWKHOHIWFRUR QDU\DUWHU\LQDQGKDGDGXDORULJLQLQ 7KH$9QRGDODUWHU\DURVHIURPWKHULJKWFRURQDU\ DUWHU\LQWKHOHIWFRURQDU\DUWHU\LQDQG IURPERWKLQRIWKHSDWLHQWV In our study, the origin of the SA nodal artery was PDLQO\ IURP WKH 5&$ DQG /&$ RQO\LQFDVHVZDVWKH6$QRGDODUWHU\VXS 0HGLFLQVNLåXUQDO SOLHGE\ERWKFRURQDU\DUWHULHV7KH$9QRGDODU WHU\ RULJLQDWHG HLWKHU IURP WKH 5&$ RU IURPWKH&;EUDQFKRI/&$,QQRQHRI the cases was this node supplied by both coronary DUWHULHV5&$&; 2XU UHVXOWV FRQ¿UPHG WKDW LQ RI WKH FDVHVERWKWKH6$DQG$9QRGDODUWHULHVRULJLQDW HGIURPWKH5&$LQRIWKHFDVHVERWK WKH6$DQG$9QRGDODUWHULHVRULJLQDWHGIURPWKH &[EUDQFKRI/&$DQGLQRIWKHFDV HV ERWK WKH 6$ DQG$9 QRGDO DUWHULHV RULJLQDWHG IURPGLIIHUHQWFRURQDU\DUWHULHV5&$&[ 6DUHPLHWDOUHWURVSHFWLYHO\HYDOXDWHGDQDWRPLF characteristics of the arterial supply to the sinuatri DOQRGHDQGWKHDWULRYHQWULFXODUQRGHZLWKVHF WLRQFRPSXWHGWRPRJUDSK\&7$XWKRUVGH¿QHG that a single sinuatrial nodal artery originated from the proximal 40 mm of the right coronary artery 5&$LQDQGIURPWKHSUR[LPDOPPRIWKH OHIWFLUFXPÀH[/&;DUWHU\LQSDWLHQWV$GXDO blood supply to the SA node was seen in six pa WLHQWV7KH$9QRGHZDVVXSSOLHGE\WKH5&$LQ SDWLHQWVWKH/&;DUWHU\LQSDWLHQWVDQGE\ERWK arteries in two patients. 2XUUHVXOWVUHJDUGLQJWKHIUHTXHQF\RI5&$RULJLQ RIWKH$9QRGHDUWHU\DUHVLPLODUWRUH VXOWVRIWKHVWXG\E\)XWDPLHWDO)XIDPLHWDO determined that the atrioventricular node was sup SOLHGE\WKHULJKWFRURQDU\DUWHU\RIFDVHV PRUHWKDQE\WKHOHIWDQGLQRIWKHFDV es this node was supplied by both coronary arter LHV,WLVLPSRUWDQWWRUHPDUNWKDWWKHRULJLQRIWKH $9QRGDODUWHU\GRHVQRWGHSHQGXSRQOHIWRUULJKW FRURQDU\ GRPLQDQFH 0RUHRYHU WKHUH DUH VRPH FDVHVLQZKLFKWKH$9QRGHLVVXSSOLHGE\³$9 node arteries”—one from the right coronary artery DQG WKH RWKHU IURP WKH FLUFXPÀH[ 7KLV VWUDQJH SDWWHUQPDNHVWKH$9QRGHUHVLVWDQWWRLVFKHPLF HYHQWV <HVLO 0 HW DO DQDO\VHG ORFDWLRQV RI FRURQDU\ artery lesions in patients with severe conduction GLVWXUEDQFH 3DWLHQWV ZLWK VHYHUH FRQGXFWLRQ GLVWXUEDQFHV WHQG WR KDYH D VSHFL¿F FRURQDU\ lesion distribution that involves either proximal /$' EUDQFKHV RU D FRPELQDWLRQ RI WKLV ZLWK VLJ QL¿FDQW 5&$ GLVHDVH FRPSURPLVLQJ VXSSO\ WR VLQRDWULDORU$9QRGHV%HUGDMVHWDOGHVFULEHG the topographic relation between the sinus node artery and the superior posterior border of the in teratrial septum with regard to the sinus node dys function that follows the superior transseptal ap proach to the mitral valve. They established that the SA nodal artery crosses the superior poste ULRUERUGHURIWKHLQWHUDWULDOVHSWXPLQRIWKH FDVHVDQGFRQFOXGHGWKDWWKHULVNIRULQWUDRSHUD tive damage to the sinus node artery during the superior transseptal approach to the mitral valve LV KLJK 2NPHQ HW DO VWXGLHG FRURQDU\ DQJLRJUDSK\WRGHWHFWVSHFL¿FDOO\6$QRGDODUWHU\ $LGD+DVDQRYLü,OLULMDQD+D[KLEHTLUL.DUDEGLü$LGD6DUDþ+DGåLKDOLORYLü0XKDPHG6SXåLü$QDWRPLFFKDUDFWHULVWLFVRIDUWHULDOVXSSO\RIWKHFRQ GXFWLQJV\VWHPRIWKHKHDUWLQSDWLHQWVZLWKFRURQDU\GLVHDVHDQGGLDEHWHVPHOOLWXV originating from posterolateral branch of RCA. The origin of SA nodal artery was proximal RCA LQ FLUFXPÀH[ DUWHU\ LQ DQG 3/ EUDQFK RI 5&$ LQ SDWLHQWV ,Q WKH SUHVHQW VWXG\ RI RXU SDWLHQWV KDG WKH ULJKW FRURQDU\ GRPLQDQFH KDG WKH OHIWFRURQDU\GRPLQDQFHDQGZHUHGHWHFW ed coronary codominance. Our results regarding the correlation the origins of sinoatrial and atrio ventricular nodal artery with the dominance of the FRURQDU\DUWHULHVVKRZHGWKDWWKH$9QRGDODUWHU\ ZDV D EUDQFK RI WKH GRPLQDQW DUWHU\ LQ LQ comparison to the SA nodal artery which was a EUDQFK RI WKH GRPLQDQW DUWHU\ RQO\ LQ 6WD WLVWLFDODQDO\VLVE\XVLQJ.ROPRJRURZ±6PLUQRZ test determinated that the relationship between the blood supply to the conducting system and FRURQDU\ GRPLQDQFH ZDV VLJQL¿FDQW LQ IDYRU RI the right coronary dominance. Increased preva lence of cardiac conduction abnormalities, in dia betes mellitus patients are evident. The origin of the supply of blood to the conduction system is highly relevant to clinical and surgical procedures. Therefore, we encourage a thorough review of cardiac mapping, with an eye to revision. CONCLUSIONS ,QWKHSUHVHQWVWXG\DWULRYHQWULFXODUQRGDODUWHU\ ZDV D EUDQFK RI WKH GRPLQDQW DUWHU\ LQ in comparison to the sinoatrial nodal artery which ZDVDEUDQFKRIWKHGRPLQDQWDUWHU\RQO\LQ 7KHUHDUHVLJQL¿FDQWGLIIHUHQFHVEHWZHHQWKHRUL gin of the nodal arteries in relationship to the type of dominance of coronary arteries, in favor r. nodi atrioventricularis. 7KH$9QRGDODUWHU\RULJLQDWHGIURPWKH5&$LQ RIFDVHVLQIURPWKH&;EUDQFK RI WKH /&$ DQG LQ QRQH RI WKH FDVHV WKLV QRGH ZDVVXSSOLHGE\ERWKFRURQDU\DUWHULHV5&$&; The SA nodal artery originated from the RCA in RI FDVHV LQ IURP WKH &; EUDQFK RI WKH/&$DQGLQIURPWKHERWKFRURQDU\DU WHULHV5&$&; ,QFUHDVHGSUHYDOHQFHRIFDUGLDFFRQGXFWLRQDE QRUPDOLWLHV VXFK DV ULJKW EXQGOH EUDQFK EORFN 5%%% DQG KLJK GHJUHH DWULRYHQWULFXODU $9 EORFNEXWQRWOHIWEXQGOHEUDQFKEORFN/%%%LQ diabetes mellitus patients are evident. The cause of cardiac conduction abnormalities in diabetes PHOOLWXVSDWLHQWVLVQRWNQRZQ 7KHYDULDWLRQVLQRULJLQRIWKHQRGDODUWHULHVPD\ result with serious postoperative complications due to their intraoperative damages. The results of the present study may provide safe approach to interventional cardiologist and cardiac surgeon during percutaneous and surgical interventions. &RQÀLFWRILQWHUHVW none declared. REFERENCES 3HMNRYLü % .UDMQF , $QGHUKXEHU ) .RãXWLü ' Anatomical aspects of the arterial blood supply to the sinoatrial and atrioventricular nodes of the human heart. 7KH -RXUQDO RI ,QWHUQDWLRQDO 0HGLFDO 5HVHDUFK +DGåLVHOLPRYLü+.UYQLVXGRYLVUFD=DJUHE-XJR VODYHQVNDPHGLFLQVNDQDNODGD 5DPDQDWKDQ/6KHWW\31D\DN65.ULVKQDPXUWK\ $&KHWWLDU*.&KRFNDOLQJDP$2ULJLQRIWKHVLQRDWULDO and atrioventricular nodal arteries in South Indians: an DQJLRJUDSKLFVWXG\$UJ%UDV&DUGLRO .\ULDNLGLV09\VVRXOLV*%DUEHWVHDV-7RXWRX]DV 3$FOLQLFDODQJLRJUDSKLFVWXG\RIWKHDUWHULDOEORRGVXS SO\WRWKHVLQXVQRGH&KHVW 9LHZHJ :9 $OSHUW -6 +DJDQ $' 2ULJLQ RI WKH sinoatrial node and atrioventricular node arteries in right, mixed, and left inferior emphasis systems. Cathet &DUGLRYDV'LDJQ 6DUHPL)$EROKRGD$$VKLN\DQ20LOOLNHQ-&1DUX OD - *XUXGHYDQ 69 HW DO$UWHULDO VXSSO\ WR VLQXDWULDO DQG DWULRYHQWULFXODU QRGHV ,PDJLQJ ZLWK 0XOWLGHWHFWRU &75DGLRORJ\ )XWDPL&7DQXPD.7DQXPD<6DLWR77KHDUWHULDO blood supply of the conducting system in normal human KHDUWV6XUJ5DGLRO$QDW <HVLO0$ULNDQ(3RVWDFL1%D\DWD6<LOPD]5/R cations of coronary artery lesions in patients with severe FRQGXFWLRQGLVWXUEDQFH,QW+HDUW- %HUGDMV ' 3DWRQD\ /7XULQD 0,7KH FOLQLFDO DQDW RP\ RI WKH VLQXV QRGH DUWHU\$QQ7KRUDF 6XUJ 2NPHQ$6 2NPHQ ( 6LQRDWULDO QRGH DUWHU\ DULV ing from posterolateral branch of right coronary artery: GH¿QLWLRQE\VFUHHQLQJFRQVHFXWLYHFRURQDU\DQJL RJUDSKLHV$QDGROX.DUGL\RO'HUJ $EXLQ*1LHSRQLFH$%DUFHOy$5RMDV*UDQDGRV $ +HUUHUD6DLQW /HX 3 $UWHDJD0DUWtQH] 0$QD tomical reasons for the discrepancies in atrioventricular EORFNDIWHU,QIHULRUP\RFDUGLDOLQIDUFWLRQZLWKDQGZLWK RXWULJKWYHQWULFXODULQYROYHPHQW7H[+HDUW,QVW- ± +DVDQRYLü $ $ãþLü%XWXURYLü % 6SXåLü 0 &RUR nary angiography review of anatomic variations of the FRURQDU\DUWHULHV0HGäXUQDO 2YþLQD ) âXãNR , +DVDQRYLü$ ,QWUDPXUDO EORRG YHVVHOVRIWKH$9VHJPHQWRIWKHFRQGXFWLYHV\VWHPLQ WKHKXPDQKHDUW0HG$UK 0RYDKHG05'LDEHWHVDVDULVNIDFWRUIRUFDUGLDF FRQGXFWLRQ GHIHFWV D UHYLHZ 'LDEHWHV 2EHV 0HWDE 1LVKL\DPD$6KLNDWD&.LPXUD1,PDQLVKL$+L UDL12KWD0HWDO5LVNIDFWRUVIRUFRURQDU\DUWHU\VFOH URVLV LQ SDWLHQWV ZLWK GLDEHWHV ([S &OLQ &DUGLRO Address: 3URI$LGD+DVDQRYLü0'3K' Department of Anatomy, )DFXOW\RI0HGLFLQH8QLYHUVLW\RI6DUDMHYR ýHNDOXãD6DUDMHYR Bosnia and Herzegovina 3KRQH (PDLODLGDK#XWLFQHWED 0HGLFLQVNLåXUQDO 276 (GR+DVDQEHJRYLü6QLMHåDQD+DVDQEHJRYLü(YDOXDWLRQRIWUHDWPHQWUHVXOWVLQFKLOGKRRGO\PSKRPD Original article EVALUATION OF TREATMENT RESULTS IN CHILDHOOD LYMPHOMA (9$/8$&,-$5(=8/7$7$/,-(ý(1-$/,0)20$'-(ý,-('2%, (GR+DVDQEHJRYLü6QLMHåDQD+DVDQEHJRYLü 3HGLDWULF&OLQLF&OLQLFDO&HQWHU8QLYHUVLW\RI6DUDMHYR3DWULRWVNHOLJH6DUDMHYR%RVQLDDQG+HU]HJRYLQD &RUUHVSRQGLQJDXWKRU ABSTRACT The aim of this paper is to present the results of treatment of children suffering from lymphoma +RGJNLQDQG1RQ+RGJNLQDWWKH'HSDUWPHQWIRU 2QFRORJ\ DQG +HPDWRORJ\ RQ 3HGLDWULF &OLQLF LQ Sarajevo for ten year period. 3DWLHQWVDQG0HWKRGV7KHVWXG\LQFOXGHGFKLOGUHQ ZLWKO\PSKRPD+RGJNLQO\PSKRPD+/DQG1RQ +RGJNLQO\PSKRPD1+/GLDJQRVHGDQGWUHDWHG at the Department for Oncology and Hematology RQ 3HGLDWULF &OLQLF LQ 6DUDMHYR GXULQJ WKH SHULRG IURP-DQXDU\WR'HFHPEHU7KH study was conducted as a retrospective investiga WLRQIRUSDWLHQWVDJHG\HDUV7UHDWPHQWZDV performed by combination of cytostatic and radi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onclusion: The results of lymphoma treatment 0HGLFLQVNLåXUQDO WKH3HGLDWULF&OLQLFLQ6DUDMHYRDUHVLPLODUZLWKUH sults other European centers. Key words: O\PSKRPD+RGJNLQ¶V1RQ+RGJNLQ treatment results. 6$ä(7$. &LOM UDGD MH SULND]DWL UH]XOWDWH OLMHþHQMD GMHFH REROMHOH RG OLPIRPD +RGJNLQ L 1RQ +RGJNLQ QD +HPDWRRQNRORãNRPRGMHOX3HGLMDWULMVNHNOLQLNHX 6DUDMHYXXGHVHWRJRGLãQMHPSHULRGX ,VSWDQLFL L PHWRGH ,VWUDåLYDQMHP VX ELOD REXKYDüHQDGMHFDREROMHODRGOLPIRPD+RGJNLQL 1RQ+RGJNLQOLPIRPQD+HPDWRORãNRPRGMHOMH QMX3HGLMDWULMVNHNOLQLNHX6DUDMHYXXSHULRGXRG ,VWUDåLYDQMH MH SURYHGH QRNDRUHWURVSHNWLYQR]DSDFLMHQWHX]UDVWDRG JRGLQD7HUDSLMDMHVSURYHGHQDNRPELQDFLMRPFLWR VWDWVNH L UDGLRWHUDSLMH 3URWRNRORP 8.&&6* +' &KO933$%9']D+RGJNLQOLPIRP+/ =D7 üHOLMVNL 1RQ+RGJNLQ OLPIRP 1+/ NRULãWHQ MH$/%)03URWRNROXD]D%üHOLMVNL1+/WHUDSLMD MHVSURYHGHQD%1+/%)0SURWRNRORP 5H]XOWDWL8NXSQRMHOLMHþHQRGMHFH GMHþDNDLGMHYRMþLFD 1DMYLãH MH SDFLMHQDWD ELOR X GREQRM VNXSLQL JRGLQDLWR +RGJNLQRY OLPIRP MH QDMþHãüH GLMDJQRVWLFLUDQ X ,, VWDGLMX EROHVWL NRG X ,9 VWDGLMX D X ,,, VWDGLMX SDFLMHQDWD .RG 1+/ QDMYLãH SDFLMHQDWD MH GLMDJQRVWLFLUDQR X ,9 VWDGLMXLX,,VWDGLMXSDFLMHQDWD +HPRWHUDSLMRPOLMHþHQRMHLOLSDFL MHQDWDVD+/LLOLSDFLMHQDWDVD1+/ Hemoterapiju i radioterapiju primalo je 10 pacije QDWDLOL]D+/LLOL]D1+/ 8NXSQRSDFLMHQWDMHåLYRLOLVD+/ L LOL VD 1+/ MH LPDOR UHODSVH LOLSDFLMHQDWDVD+/LLOLVD1+/ S DNRGSDFLMHQDWDQDVWXSLRMHHJ]LWXV OHWDOLVLOLSDFLMHQDWDVD+/LLOL (GR+DVDQEHJRYLü6QLMHåDQD+DVDQEHJRYLü(YDOXDWLRQRIWUHDWPHQWUHVXOWVLQFKLOGKRRGO\PSKRPD VD 1+/ =DNOMXþDN 3ULND]DQL UH]XOWDWL OLMHþHQMD OLPIRPD QD 3HGLMDWULMVNRM NOLQLFL X 6DUDMHYX VOLþQL VX UH]XOWDLPD OLMHþHQMD X GUXJLP (YURSVNLP FHQ trima. .OMXþQH ULMHþL OLPIRPL +RGJNLQ 1RQ+RGJNLQ UH]XOWDWLOLMHþHQMD INTRODUCTION /\PSKRPDVDUHWKHSULPDU\QHRSODVLDRIWKHO\P SKDWLFV\VWHPZKLFKLVXVXDOO\PDQLIHVWHGE\ RI QHZ PDOLJQDQFLHV LQ FKLOGKRRG /\PSKR PDV DUH GLYLGHG LQWR +RGJNLQ¶V O\PSKRPD +/ DQG QRQ+RGJNLQ¶V O\PSKRPD 1+/ 7KH\ DUH various diseases according epidemiology, biology, diagnostic approach, treatment so that they are WUHDWHG TXLWH VHSDUDWHO\$ERXW RI FKLOGUHQ¶V O\PSKRPDZDVWHLQ1+/ +RGJNLQO\PSKRPD0RUEXV+RGJNLQLVWKHPRVW common malignant lymphoma, characterized by hyperplasia of lymphoid tissue areas which in FOXGHV5HHG6WHUQEHUJ56FHOOV,WXVXDOO\VWDUWV as a painless lymphadenopathy, usually on the QHFNDQGODWHUWKHGLVHDVHVSUHDGVWRRWKHUO\PSK QRGHVDQGPD\FDXVHLQ¿OWUDWLRQRIH[WUDO\PSKDWLF RUJDQVDQGWLVVXHV/\PSKQRGHVDUHPXFKELJ ger and harder than in benign lymphadenopathy, which is usually seen in children. Common symp WRPVVXFKDVIHYHU!&ZHLJKWORVVRI!LQ WKHODVWPRQWKVQLJKWVZHDWVLWFK\VNLQDUHÄ% V\PSWRPV³DUHQRWXQFRPPRQLQFKLOGUHQ(WLROR J\RIGLVHDVHLVQRWFOHDU3UREDEO\WKHUHLVDQLP SRUWDQWLQÀXHQFHRIJHQHWLFSUHGLVSRVLWLRQDQGHQ vironmental factors, among which socioeconomic DQGLQIHFWLRXVDUHLPSRUWDQW,QDOPRVWRIWKH VDPSOH +/ LQ FKLOGKRRG LQYROYHPHQW RI (SVWHLQ Barr virus can be proved. Based on the diagnos tic biopsy and anatomic distribution the stage of WKHGLVHDVHDQGWUHDWPHQWDUHGHWHUPLQHG,QWUD abdominal disease is commonly diagnosed radio ORJLFDOO\XOWUDVRXQG&705, +LVWRSDWKRORJLFDO\ IRXU W\SHV RI +/ DUH GLVWLQ guished: lymphocytic predominance, nodular scle rosis, mixed cellularity and lymphocyte depletion. The most favorable prognosis is in the patients with lymphocytic predominance, and the most disadvantaged in lymphocyte depletion patients. /\PSKRF\WLFGHSOHWLRQLQFKLOGUHQ+/LVUDUH 7KHWUHDWPHQWRI+/KDVGUDPDWLFDOO\LPSURYHGLQ WKHODVW\HDUV:LWKFRPELQDWLRQRIWKHWKHUDS\ including chemotherapy and radiotherapy, perma QHQWFXUHLVDFKLHYHGLQRISDWLHQWV0RVWIUH TXHQWO\XVHGSURWRFROVIRUWKHWUHDWPHQWRI+/LQ FKLOGUHQDUH$%9'$GU\DPLFLQ%OHRP\FLQ9LQ FULVWLQH '7,& &KO933 FKORUDPEXFLO 9LQEODV WLQH3URFDUEDVLG3URQLVRQDQG&233&LFORIRV IDPLG2QFRYLQ3URFDUED]LQ3URQLVRQ 1RQ+RGJNLQ O\PSKRPD 1+/ LV D KHWHURJHQH ous group of lymphoproliferative malignancies characterized with appearance of changed malig nant cells in the lymph node, and rarely primary LQ RWKHU RUJDQV 1+/ LV FKDUDFWHUL]HG E\ UDSLG growth, early dissemination and a high degree of PDOLJQDQF\([WUHPHO\UDUHO\1+/RFFXUVLQFKLO GUHQ \RXQJHU WKDQ \HDUV DIWHU ZKLFK WKH UDWH increases gradually during childhood reaches its SHDNEHWZHHQWKHWKWK\HDU1+/LVWLPHV more common in boys than in girls. There is the URXJK GLYLVLRQ RI QRQ+RGJNLQ O\PSKRPD GH pending on the cell line to which they belong, on WKH 1+/ DQG %1+/7 JURXS 7KH :RUOG +HDOWK 2UJDQL]DWLRQ :+2 1+/ LQ FKLOGUHQ LV GLYLGHG into four main types: %1+/ %FHOO QRQ+RGJNLQ O\PSKRPD %XUNLWW DQGQRQ%XUNLWWO\PSKRPD '/%&/GLIIXVHODUJH%FHOOO\PSKRPD //O\PSKREODVWLFO\PSKRPD $/&/DQDSODVWLFODUJHFHOOO\PSKRPD )LYH\HDUVXUYLYDOLQSDWLHQWVZKRZHUHGLDJQRVHG ZLWK 1+/ \RXQJHU WKDQ WZHQW\ \HDUV ZDV 7KHDLPRIWKHVWXG\ 7KHDLPRIWKHUHVHDUFKLVWRDVVHVVWKHHI¿FLHQF\ of chemotherapy and radiotherapy in the treat PHQW RI FKLOGUHQ VXIIHULQJ IURP O\PSKRPD +/ 1+/DWWKH&DQFHU:DUG3HGLDWULF&OLQLF&OLQLFDO Centre in Sarajevo. MATERIALS AND METHODS 7KHVWXG\LQFOXGHGFKLOGUHQDJHG\HDUVGLDJ QRVHGZLWK+/ZKLFKZHUHWUHDWHGDWWKH&DQFHU :DUG3HGLDWULF&OLQLFLQ6DUDMHYR Study would represent a retrospective analysis of SDWLHQWV LQ WKH WHQ \HDU SHULRG IURP -DQXDU\ WR 'HFHPEHU DQG GDWD ZHUH RE tained from patient histories. :HDQDO\]HG *HQGHUDQGDJHVWUXFWXUHRIWKHSDWLHQWV 7KHVWDJHRIWKHGLVHDVHDFFRUGLQJWR$QQ$UERU FODVVL¿FDWLRQIRU+RGJNLQO\PSKRPD 7KHVWDJHRIWKHGLVHDVHE\6W-XGHFODVVL¿FD WLRQ1+/ 0HWKRGRIWUHDWPHQWFKHPRWKHUDS\DQGRUUD GLRWKHUDS\DXWRORJRXVWUDQVSODQWDWLRQ 7KHRXWFRPHRIWUHDWPHQWRI+/DQG1+/ RESULTS 7DEOH Gender structure of children suffering from lymphoma 0HGLFLQVNLåXUQDO 277 278 (GR+DVDQEHJRYLü6QLMHåDQD+DVDQEHJRYLü(YDOXDWLRQRIWUHDWPHQWUHVXOWVLQFKLOGKRRGO\PSKRPD Table 1 shows all patients from ten years study by JHQGHU FODVVL¿HG E\ W\SH RI O\PSKRPD +/ DQG 1+/$WRWDORISDWLHQWVVXIIHULQJIURPPDOLJ QDQW O\PSKRPD ZHUH ER\V DQG ZHUHJLUOV7KHUHZDVDVWDWLVWLFDOO\VLJ QL¿FDQWGLIIHUHQFHEHWZHHQWKHJURXSVRIER\VDQG JLUOVZLWK1+/S ZLWKSUHGRPLQDQWER\V suffering from lymphoma. 7DEOH6W-XGHFODVVL¿FDWLRQ1+/DQGWKHFOLQLFDOVWDJHRI disease progression. Table 2. The age structure of children suffering from lympho ma. 7DEOHVKRZVWKHQXPEHURI1+/SDWLHQWVFODVVL ¿HGE\FOLQLFDOVWDJHRIGLVHDVHSURJUHVVLRQ0RVW RI WKH SDWLHQWV DUH GLDJQRVHG LQ VWDJH ,9 DQG DQG,,VWDJH 7DEOH Treatment of malignant lymphoma. 7DEOH VKRZV WKH DJH VWUXFWXUH RI SDWLHQWV ZLWK PDOLJQDQW O\PSKRPD 0RVW RI WKH SDWLHQWV ZHUHLQWKHDJHJURXS\HDUV7KHUH ZDV D VWDWLVWLFDOO\ VLJQL¿FDQW GLIIHUHQFH LQ WKH LQ cidence of malignant lymphomas between ages JURXS\HDUVDQGJURXS\HDUVS DQG LQ PRUELGLW\ RI +/ EHWZHHQ DJHV JURXS \HDUVDQG\HDUVS 7DEOH&ODVVL¿FDWLRQRI+RGJNLQO\PSKRPDDFFRUGLQJWRWKH FOLQLFDOVWDJHRIGLVHDVHSURJUHVVLRQ$QQ$UERUFODVVL¿FDWLRQ VWDJH+RGJNLQ¶VO\PSKRPD 7DEOHSUHVHQWVWKHWUHDWPHQWRIWKHSHGLDWULFSD WLHQWV ZLWK PDOLJQDQW O\PSKRPD 0RVW RI WKH SD WLHQWVZHUHWUHDWHGZLWKFKHPRWKHUDS\RU RISDWLHQWVZLWK+/DQGRURI SDWLHQWVZLWK1+/ Chemotherapy and radiotherapy treatment re FHLYHGSDWLHQWVRURI+/DQGRU RI1+/ Table 6. The outcome of treatment of malignant lymphoma at WKH3HGLDWULF&OLQLF&&86 7DEOHSUHVHQWVWKHQXPEHURISDWLHQWVFODVVL¿HG E\$QQ$UERUFODVVL¿FDWLRQVWDJH+RGJNLQO\PSKR PD0RVWSDWLHQWVDUHGLDJQRVHGLQVWDJH ,, DQG WKHQ LQ WKH IRXUWK VWDJH SDWLHQWV DQGLQVWDJH,,,SDWLHQWV 0HGLFLQVNLåXUQDO (GR+DVDQEHJRYLü6QLMHåDQD+DVDQEHJRYLü(YDOXDWLRQRIWUHDWPHQWUHVXOWVLQFKLOGKRRGO\PSKRPD 7DEOH VKRZV WKH RXWFRPH RI WKH WUHDWPHQW RI O\PSKRPD DW WKH 3HGLDWULF &OLQLF &&86 $ WRWDO RISDWLHQWVDUHVWLOODOLYHRUZLWK+/ DQGRUIURPWKH1+/RIWKHSDWLHQWV KDG D UHODSVH RU RI SDWLHQWV ZLWK +/ DQGRUZLWK1+/S DQGSDWLHQWV GLHG RU RI SDWLHQWV ZLWK +/ DQG RU ZLWK1+/ DISCUSSION :HDQDO\]HGSDWLHQWVVXIIHULQJIURPPDOLJQDQW O\PSKRPD ER\V DQG JLUOV 7KHUH ZDV D VWDWLVWLFDOO\ VLJQL¿FDQW GLIIHU ence between the groups of boys and girls suf IHULQJ IURP 1+/ S DQG WKHVH GDWD DUH consistent with the literature, which states that malignant lymphoma has up to 3 times greater SUHGRPLQDQFHLQER\VWKDQLQJLUOV 0RVW RI WKH SDWLHQWV ZHUH LQ WKH DJH JURXS \HDUVDQG 6WDWLVWLFDODQDO\VLVVKRZHGDVLJQL¿FDQWGLIIHUHQFH S EHWZHHQWKHDJHVRISDWLHQWVZLWK+/ and the difference between the age groups of the WRWDOQXPEHURISDWLHQWVS FRUUHVSRQG ing to the literature. Data from the literature and VWXGLHV VKRZ WKDW WKH +/ DQG 1+/ UDUHO\ RFFXU EHIRUHWKHDJHRIWZR\HDUVDQGPRUHIUHTXHQWO\ DIWHU \HDUV 7KHUH ZDV QR VWDWLVWLFDOO\ VLJQL¿FDQW GLIIHUHQFH EHWZHHQ WKH DJH JURXSV RI SDWLHQWVZLWK1+/S +/FODVVL¿FDWLRQDFFRUGLQJWRWKHFOLQLFDOVWDJHRI GLVHDVHSURJUHVVLRQLVGRQHE\$QQ$UERUFODVVL¿ FDWLRQV\VWHP7DEOH0RVWRIQHZO\GLDJQRVHG SDWLHQWV RU ZHUH LQ ,, VWDJH RI GLVHDVH DQG WKHQ LQ WKH IRXUWK VWDJH RU RI QHZO\ GLDJQRVHG SDWLHQWZKLOHRURIQHZO\GLDJ nosed patients were in stage III. It is important to emphasize that there was no detected cases in VWDJH , +RGJNLQ O\PSKRPD 7KH OLWHUDWXUH VWDWHV WKDW RI SDWLHQWV DW GLDJQRVLV KDYH +/ VWDJH , DQG LQ ,, VWDJH ZHUH ,,, DQG ZHUH LQ VWDJH,9 0RVW 1+/ SDWLHQWV RU ZHUH GLDJQRVHG LQVWDJH,9RIWKHGLVHDVH7KHUHZHUHSDWLHQWV GLDJQRVHGLQVWDJH,,DQGSDWLHQWVRU 7DEOH 7KHVH UHVXOWV DUH FRQVLVWHQW ZLWK GDWD IURPWKHOLWHUDWXUH ,Q WKH WUHDWPHQW RI +RGJNLQ O\PSKRPD FKHPR therapy is applied at lower doses and smaller ra GLDWLRQ¿HOGVLQWKHHDUO\VWDJHVGRHVQRWDSSO\WR UDGLDWLRQ 3RO\FKHPRWKHUDS\ LV H[FOXVLYHO\ XVHG with purpose to reduce the cumulative toxicity of certain cytostatics and avoiding the appearance of resistant tumors. Chemotherapy is the treatment RI FKRLFH IRU WKH 1+/ DQG WKH LQWHQVLW\ DQG GX UDWLRQGHSHQGRQWKHW\SHRI1+/DVZHOODVWKH stage of the disease. Radiation therapy is rarely used because it acts locally and the disease is XVXDOO\ JHQHUDOL]HG 0RVW RI RXU SDWLHQWV RIWKHPRUZHUHWUHDWHGRQO\ZLWKFKHPR WKHUDS\DQGRURISDWLHQWVZHUHWUHDWHG ZLWKFRPELQDWLRQWKHUDS\FKHPRWKHUDS\DQGLUUD GLDWLRQ 7UHDWLQJ SDWLHQWV DW WKH &DQFHU 'HSDUW PHQW RI 3HGLDWULF &OLQLF &&86 LV FRPSOHWHO\ LQ DFFRUGDQFHZLWKLQWHUQDWLRQDOVWDQGDUGV 2IWKHWRWDORISDWLHQWVLVDOLYH SDWLHQWVRUGLHGDQGSDWLHQWVZHUHLQWKH course of treatment experienced a relapse of the GLVHDVH2IWKHWRWDORISDWLHQWVRU GLDJQRVHG ZLWK +/ ZHUH DOLYH RU GLHG and 7 patients in the course of treatment experi enced a relapse of the disease. Out of 19 patients GLDJQRVHG ZLWK 1+/ DQG RI WKHP RU ZHUHDOLYHRUGLHGDQGRQHSDWLHQWH[SH ULHQFHGDUHODSVHGXULQJWUHDWPHQW:HREVHUYHG D VWDWLVWLFDOO\ VLJQL¿FDQW GLIIHUHQFH EHWZHHQ WKH RFFXUUHQFHRIUHODSVHLQ+/DQG1+/S The percentage of cure in this study is consistent ZLWKGDWDIURPWKHOLWHUDWXUHDQGVWXGLHV CONCLUSION 0DOLJQDQW O\PSKRPD +/ DQG 1+/ DUH LQ WKLUG SODFH EHKLQG RQ WKH LQFLGHQFH RI OHXNHPLD DQG &16WXPRUVLQWKHSHGLDWULFSRSXODWLRQ3UHVHQWHG UHVXOWVRIWUHDWPHQWRIO\PSKRPDDWWKH3HGLDWULF Clinic in Sarajevo are similar to results of treat ment in the other European centers. &RQÀLFWRILQWHUHVW none declared. REFERENCES %\NSDNPXNFX 0 1RQ+RGJNLQ¶V O\PSKRPDV ,Q Cancer in Children: Clinical management. Fourth Edi WLRQ92873$.DOLID&%DUUHWW$HGV2[IRUG2[IRUG 8QLYHUVLW\3UHVVSS 3L]]R$3RSODFN'*3ULQFLSOHVRI3HGLDWULF2QFRO RJ\ WK HG 3KLODGHOSKLD /LSSLQFRWW :LOOLDPV:LONLQV 6DXQGHUV & +VX 0RQLND / 0HW]JHU 0HOLVVD 0 Hudson et al. Comparison of Treatment Outcomes of &KLOGKRRG +RGJNLQ /\PSKRPD LQ 7ZR 86 &HQWHUV DQG D &HQWHU LQ 5HFLIH 3HGLDWULF %ORRG &DQFHU 'H9LWR97$VHOHFWLYHKLVWRU\RIWKHWKHUDS\RI+RGJ NLQ¶VGLVHDVH%U-+HPDWRO 7KRPVRQ $% :DOODFH :+% 7UHDWPHQW RI SHGLDW ULF+RGJNLQ¶VGLVHDVHDEDODQFHRIULVNV(X-&DQFHU 9DWV763HGLDWULF1RQ+RGJNLQ¶VO\PSKRPDVLQFKLO GUHQ'LDJQRVLVDQGFXUUHQWPDQDJHPHQW,QGLDQ3HGL DWULFV &DLUR06HWDO1RQ+RGJNLQO\PSKRPDLQFKLOGUHQ ,Q.XID':&DQFHUPHGLFLQH(G/RQGRQ%&'HFN HU,QFSS +RZDUG 6& 0HW]JHU 0/ +XGVRQ 00 3HGLDWULF 0HGLFLQVNLåXUQDO (GR+DVDQEHJRYLü6QLMHåDQD+DVDQEHJRYLü(YDOXDWLRQRIWUHDWPHQWUHVXOWVLQFKLOGKRRGO\PSKRPD +RGJNLQ O\PSKRPD ,Q$QWLOORQ )$ %HUQDROD ( 6LHU UDVHVXPDJD/HGV3HGLDWULF2QFRORJ\3HDUVRQ(GX FDWLRQ 'H9LWR97$VHOHFWLYHKLVWRU\RIWKHWKHUDS\RI+RG NLQ¶VGLVHDVH%U-+HPDWRO 5HLWHU $ 0 6FKUDSSH 3DUZDUHVFK 5 HW DO 1RQ +RGJNLQ¶VO\PSKRPDRIFKLOGKRRGDQGDGROHVFHQFHUH VXOWVRIDWUHDWPHQWVWUDWL¿HGIRUELRORJLFVXEW\SHVDQG VWDJH-&OLQ2QFRO 7KRPVRQ$% :DOODFH :+% 7UHDWPHQW RI SHGLDW ULF+RGJNLQ¶VGLVHDVHDEDODQFHRIULVNV(X-&DQFHU Address: (GR+DVDQEHJRYLü0'3K' 3HGLDWULF&OLQLF Clinical Center University of Sarajevo 3DWULRWVNHOLJH6DUDMHYR Bosnia and Herzegovina 3KRQH (PDLOHKDVDQEH#ELKQHWED Naš prilog redukciji kardiovaskularnih bolesti ! Our contribution in reduction of cardiovascular disease ! 0HGLFLQVNLåXUQDO 0LUMDQD*QMDWLü6ORERGDQ6SUHPR3UHGUDJâSLULü'PLWDU7UDYDU6DQMDâSLULü'DQLMHOD.HVLü0LMLü7DWMDQD%DUDü/DU\QJRSKDU\QJHDOUHÀX[GLV HDVH±RXUWKUHH\HDUH[SHULHQFH Original article LARYNGOPHARYNGEAL REFLUX DISEASE – OUR THREE YEAR EXPERIENCE LARINGEALNA REFLUKSNA BOLEST – NAŠE TROGODIŠNJE ISKUSTVO 0LUMDQD*QMDWLü, Slobodan Spremo3UHGUDJâSLULü, Dmitar Travar6DQMDâSLULü'DQLMHOD.HVLü0LMLü2, 7DWMDQD%DUDü (17&OLQLF8QLYHUVLW\&OLQLFDO&HQWUH%DQMDOXND%HEDEE%DQMD/XND56%RVQLDDQG+HU]HJRYLQD (PHUJHQF\VHUYLFHZLWKHGXFDWLRQDOFHQWUH+HDOWK&HQWHU%DQMD/XND=GUDYH.RUGH%DQMD/XND56 Bosnia and Herzegovina; 3 *DVWURHQWHURORJ\&OLQLF8QLYHUVLW\&OLQLFDO&HQWUH%DQMDOXND%HEDEE%DQMD /XND56%RVQLDDQG+HU]HJRYLQD 1 &RUUHVSRQGLQJDXWKRU ABSTRACT 6$ä(7$. /DU\QJRSKDU\QJHDOUHÀX[DQG*DVWURHVRSKDJHDO UHÀX[ GLVHDVH *(5' DUH GLIIHUHQW GLVRUGHUV Several millions of people suffer from conse TXHQFHV RI WKHVH GLVHDVHV UDQJLQJ IURP VXEWOH complaints to serious diseases, such as asthma, VOHHS DSQHD ODU\QJHDO FDQFHU /DU\QJRSKDU\Q JHDOUHÀX[LVDFKURQLFUHODSVLQJFRQGLWLRQWKDWUH sults from repeated extraesophageal exposure to gastric contents. The recent studies have shown WKDW *(5' DQG /35 DUH WZR XQLTXH EXW UHODWHG GLVHDVHHQWLWLHVZLWKGLIIHUHQWULVNIDFWRUVV\PS toms, pathophysiology and responses to therapy. $LPRIZRUNLVWRHVWLPDWHLPSURYHPHQWRIOLIHTXDO ity patients with laryngeal and gastric symptoms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sophageal symptoms again showed better results ZLWK V\PSWRP LPSURYHPHQW FRPSDUHG WR RIH[WUDHVRSKDJHDODQGRI(9/6 symptoms reduction. &RQFOXVLRQ2XUDQDO\VLVSURYHGWKDW,33WKHUDS\ PDGH LPSURYHPHQW LQ ERWK H[WUDHVRSKDJHDO DV ZHOODVJDVWURHVRSKDJHDOV\PSWRPV33,WKHUDS\ had no effect on Barret’s metaplasia and precan cerous conditions. *DVWURH]RIDJHDOQDUHÀXNVQDEROHVW*(5%LODU LQJRIDULQJHDOQDUHÀXNVQDEROHVW/5%VXUD]OLþLWL SRUHPHüDML1HNROLNRPLOLRQDOMXGLSDWLRGSRVOMHG ica ovih bolesti, od blagih smetnji do ozbiljnih WHJRED NDR ãWR VX DVWPD RSVWUXNWLYQD DSQHD X VQX ODULQJHDOQL NDUFLQRP /DULQJRIDULQJHDOQD UH ÀXNVQDEROHVWMHKURQLþQRUHFLGLYDQWQRVWDQMHNRMH VH NDUDNWHULãH SRQRYOMHQLP HSL]RGDPD L]ODJDQMD MHGQMDND L ODULQJVD GHMVWYX JDVWULþQRJ VDGUåDMD 3RVOHGQMHVWXGLMHVXSRND]DOHGDVX*(5%L/5% GYD PHÿXVREQR SRYH]DQD HQWLWHWD VD UD]OLþLWLP IDNWRULPD UL]LND VLPSWRPLPD SDWR¿]LRORãNLP X] rocima, te odgovorom na terapiju. &LOMUDGDMHSRND]DWLHIHNWHWUHWPDQDLQKLELWRUDSUR WRQVNHSXPSH,33±SDQWRSUD]ROQDJDVWURH]RI DJHDOQHLHNVWUDH]RIDJHDOQHVLPSWRPHNRG/35L *(5%SDFLMHQDWDQDNRQQHGHOMD 5DÿHQD MH WURJRGLãQMD SURVSHNWLYQD VWXGLMD X .OLQLþNRP &HQWUX %DQMDOXND SUL þHPX MH SUDüHQD JUXSDRGSDFLMHQDVDGRND]DQRP/5%NRMLVX OLMHþHQL VD LQKLELWRULPD SURWRQVNH SXPSH SDQWR SUD]ROWRNRPQHGHOMD2EDJDVWURVNRSLVNLLHQ GRYLGHRVWURERVNRSVNL(9/6SUHJOHGVXL]YRÿHQL GYDSXWDQDNRQLQHGHOMDRG]DSRþLQMDQMDWHUD SLMH1DNRQSHULRGDRGQHGHOMHQDMYHüLQDSUHGDN u simptomatologiji bolesti se odnosi uglavnom na JDVWURH]RIDJHDOQH VLPSWRPH SREROMãDQMH GRN (9/6 UH]XOWDWL SRND]XMX SREROMãDQMH RG 1DNRQQHGHOMDWHUDSLMHJDVWURH]RIDJH DOQLVLPSWRPLSRQRYRSRND]XMXEROMHUH]XOWDWHRG SREROMãDQMDQDVSUDPH[WUDH]RIDJH DOQLKL(9/6VPDQMHQMDVLPSWRPD =DNOMXþDN 6WXGLMD MH GRND]DOD GD WHUDSLMD ,33 SRND]DOD SREROMãDQMH VLPSWRPD YH]DQLK ]D RED HQWLWHWD NDNR JDVWULþQD WDNR L HNVWUDH]RIDJH DOQH SULURGH 7HUDSLMD ,33 QLMH LPDOD HIHNDW QD %DUUHW¶RYXPHWDSOD]LMXLSUHNDQFHUR]QHOH]LMH Keywords: ODU\QJRSKDU\QJHDO UHÀX[ JDVWURVFR S\33,WKHUDS\ .OMXþQH ULMHþL ODULQJRIDULQJHDOQL UHÀXNV JDV WURVNRSLMDLQKLELWRULSURWRQVNHSXPSH 0HGLFLQVNLåXUQDO 282 0LUMDQD *QMDWLü 6ORERGDQ 6SUHPR 3UHGUDJ âSLULü 'PLWDU 7UDYDU 6DQMD âSLULü 'DQLMHOD .HVLü0LMLü 7DWMDQD %DUDü /DU\QJRSKDU\QJHDO UHÀX[ GLVHDVH±RXUWKUHH\HDUH[SHULHQFH INTRODUCTION -DPHV .RXIPDQ ZDV DPRQJ WKH ¿UVW RQHV ZKR SRLQW RXW LPSRUWDQFH RI ODU\QJHDO UHÀX[ GLVHDVH DQGFDOOHGLWODU\QJRSKDU\QJHDOUHÀX[/35 /DU\QJRSKDU\QJHDOUHÀX[DQG*DVWURHVRSKDJHDO UHÀX[GLVHDVH*(5'DUHGLIIHUHQWGLVRUGHUV/DU \QJRSKDU\QJHDO UHÀX[ /35 UHIHUV WR WKH EDFN ÀRZRIVWRPDFKFRQWHQWVLQWRWKHWKURDW7KHUHLV QRGRXEWWKDWWKHRQHSDUWRILQÀDPPDWLRQGLVHDV HVOLNHFKURQLFODU\QJLWLVDQGSKDU\QJLWLVFKURQLF rhinosinusitis, secretory otitis and laryngomalatia LVLQGLUHFWFRQQHFWLRQZLWK/35&ODULI\LQJWKHUROH RI /35D LQ SDWKRJHQHVLV WKHVH GLVHDVHV PLJKW change present prevention and therapeutic proce GXUHV 7KLV UHÀX[ UHVXOWV LQ V\PSWRPV VXFK DV YRLFH changes, cough, repetitive throat clearing, and pharyngeal sensations of fullness. The most com PRQV\PSWRPRI/35LVKRDUVHQHVVZKLFK LV SUHVHQW LQ SDWLHQWV 1H[W IUHTXHQW symptom is chronic throat clearing which is pre VHQW LQ SDWLHQWV ZLWK /35 WKHQ JOREXV SKDU\QJHXV LQ DQG G\VSKDJLD LQ SD WLHQWV2WKHUPDQLIHVWDWLRQVRI/35DDUHODU\QJR VSDVPXV ¿[DWLRQ RI DULWHQRLGV VWHQRVLV ODU\QJLV DQG5HLQNHRHGHPDQRGXOHVRQWKHYRFDOFRUGV UHFXUUHQWUHVSLUDWRU\SDSLOORPDVUHFXUUHQWOHXNR SODNLDDQGFDUFLQRPDODU\QJLV UXSWWKHLQÀDPPDWRU\SURFHVVLQSKDU\QJHDODQG laryngeal mucosa by inhibiting gastric acid and re VWRUHQRUPDODQWLUHÀX[GHIHQVHVLILWLVSRVVLEOH 7KH GUXJ RI FKRLFH LQ WKH WUHDWPHQW RI /35 LV D SURWRQSXPSLQKLELWRU33, )LJXUH3VHXGRVXOFXVYRFDOLV Figure 2. 3RVWHULRUODU\QJLWLV /35LVFRQ¿UPHGLQRISDWLHQWVZLWKODU\QJHDO FDQFHUDQGRQO\RIWKHPZHUHDFWLYHVPRN HUV *LYHQ WKH VHYHULW\ RI V\PSWRPV /35 is divided into three groups: mild, severe and life WKUHDWHQLQJ /LIH WKUHDWHQLQJ /35 LV SUHVHQW ZLWK patients who have serious obstruction of airways, because of glottic and subglottic stenosis, laryn JRVSDVPDVWKPDFDQFHURUG\VSODVLD Aim Symptoms can show no changes in the mucosa of WKHODU\Q[SKDU\Q[DQGPD\EHQRQVSHFL¿F)LJ XUH 7KHPRVWVLJQL¿FDQWFKDQJHVDUHDOVRSDWKRJQR monic: edema and erythema of the posterior com PLVVXUH±VRFDOOHGSRVWHULRUODU\QJLWLV)LJXUH 7KHSUHGRPLQDQWV\PSWRPRI/35LVKRDUVHQHVV ZKLFK LV QRW SUHVHQW LQ SDWLHQWV ZLWK GERD. On the other hand, the burning sensation LQ WKH FKHVW RFFXUV LQ RQO\ RI SDWLHQWV ZLWK /35DQGZLWKWKRVHZKRKDYH*(5'7KXV V\PSWRPVRISDWLHQWVZLWK/35DUHWKURDWLOOQHVV laryngopharyngeal, and those with GERD mostly gastrointestinal. 7KHDLPRIDQWLUHÀX[WKHUDS\LVWZRIROGWRLQWHU 0HGLFLQVNLåXUQDO The aim of the article is to estimate improvement RITXDOLW\RIOLIHSDWLHQWVZLWKODU\QJHDOV\PSWRPV FDXVHGZLWK*(5'DQG/35GLVHDVHVGXULQJWKH SHULRGRIZHHNVE\33,WKHUDS\SDQWRSUD]RO The second aim was to assess the effectiveness of an empirical treatment with proton pump inhibi WRUV33,VLQSDWLHQWVZLWKERWK*(5'UHODWHGDQG QRQ*(5'UHODWHG/35 MATERIALS AND METODS :HSHUIRUPHGDWKUHH\HDUSURVSHFWLYHVWXG\EH WZHHQ 0D\ DQG 1RYHPEHU LQ &OLQLFDO &HQWUH%DQMD/XNDZKLFKLQFOXGHGSDWLHQWVZLWK SURYHQ /35 ZKR ZHUH WUHDWHG ZLWK 33, WKHUDS\ SDQWRSUD]ROGXULQJWKHSHULRGRIZHHNV 0LUMDQD *QMDWLü 6ORERGDQ 6SUHPR 3UHGUDJ âSLULü 'PLWDU 7UDYDU 6DQMD âSLULü 'DQLMHOD .HVLü0LMLü 7DWMDQD %DUDü /DU\QJRSKDU\QJHDO UHÀX[ GLVHDVH±RXUWKUHH\HDUH[SHULHQFH 7RDVVHVVWKHUROHRI33,HIIHFWRI33,RQUHÀX[ ¿QGLQJ VFRUH DQG UHÀX[ V\PSWRP LQGH[ DW HDFK and follow up were used. 7KHPRVWFRPPRQV\PSWRPVLQSDWLHQWVZLWK/35 were heartburn, epigastric pain, esophagitis, Ba rett metaplasia and precancerosis. RESULTS 7DEOH3RVLWLYHHQGRYLGHRODU\QJRVWURERVFRS\VLJQV(9/6 Our results are in accordance with the recommen GDWLRQV RI FRQVHQVXV FRQIHUHQFH UHSRUW and American Academy of Otolaryngology and +HDGDQG1HFNVXUJHU\ )LJXUHSex distribution. $IWHUZHHNVRIWKHUDS\(9/6WKHEHVWSURJUHVV KDV EHHQ PDGH LQ SRVWFULFRLG HGHPD UHPRYHG RIV\PSWRPVDQGWKHOHDVWSURJUHVVLQK\ SHUWURSK\ RI WKH SRVWHULRU FRPPLVVXUH UHPRYHG RIV\PSWRPV Table 2. Gastroesophageal symptoms. Figure 2. Age distribution. $IWHUZHHNVRIWKHUDS\WKHEHVWUHVXOWVUHIHUWR gastroesophageal symptoms where the total num EHURIUHPRYHGV\PSWRPVLQFUHDVHGWRIURP baseline. $JH RI WKH SDWLHQWV YDULHG IURP WR RYHU years. Age distribution showed that majority of pa WLHQWVZHUHDJHGWR\HDUVDQGPLQRULW\ZHUH EHORZ)LJXUHDQG ,QRXUVWXGLHVSDWLHQWVKDYHJDVWURHVRSKDJHDO V\PSWRPVZKLOHDOOVKRZHGSRVLWLYH(9/6DQG extraesophageal symptoms. 7DEOHExtraesophageal symptoms. )LJXUH. The most common symptoms. Extraesophageal symptoms; the best progress KDV EHHQ PDGH LQ KRDUVHQHVV ZKHUH symptoms were removed and worst results in bronchial asthma was found in patients who main WDLQHGUHPLVVLRQLQDVLQIRXUZHHNVWKHUDS\ 0HGLFLQVNLåXUQDO 0LUMDQD *QMDWLü 6ORERGDQ 6SUHPR 3UHGUDJ âSLULü 'PLWDU 7UDYDU 6DQMD âSLULü 'DQLMHOD .HVLü0LMLü 7DWMDQD %DUDü /DU\QJRSKDU\QJHDO UHÀX[ GLVHDVH±RXUWKUHH\HDUH[SHULHQFH )LJXUH Final results. $IWHU 33, WKHUDS\ SDQWRSUD]RO [PJ GXULQJ SHULRGRIDQGZHHNVIROORZLQJUHVXOWVZHUHRE tained: $IWHUZHHNVRIWKHUDS\WKHEHVWUHVXOWVZHUHUH ODWHGWRJDVWURHVRSKDJHDOV\PSWRPVV\PS WRPVKDYHEHHQUHPRYHGDQGZHDNHUUHVXOWVRQ (9/6 V\PSWRPV KDYH EHHQ UHPRYHG while extraesophageal symptoms had been re PRYHG DISCUSSION GERD is considered as an important cause of la U\QJHDO LQÀDPPDWLRQ 7KH PRVW FRPPRQ V\PS WRPVRIWKLVFRQGLWLRQWHUPHG/35E\(17SK\VL cians, include hoarseness, throat pain, sensation of a lump in the throat, cough and repetitive throat clearing. However, these symptoms are nonspe FL¿FDQGFDQDOVREHVHHQLQRWKHUGLVHDVHVVXFK DVSRVWQDVDOGULSV\QGURPHRUHQYLURQPHQWDOH[ SRVXUHWRDOOHUJHQVDQGRWKHULUULWDQWV The study evaluated 17 males and 14 females. 0DOHV RXWQXPEHUHG WKH IHPDOHV LQ the current study. This result is in accordance with the indexed literature where females outnumbered WKHPDOHVOLNHWKDWRI%HOIDVN\DQG3RVWPD,VV LQJ DQG .DUNRV %LOJHQ DQG 2JXW 0HVDOODP DQG 6WHPSOH7RURVDQG7RURV :H IRXQG VLJQL¿FDQW LPSURYHPHQW LQ ERWK V\PS WRPV DQG VLJQV DIWHU PRQWKV RI 33, WKHUDS\ Symptomatic improvement was obvious after PRQWKV RI WKHUDS\ EXW ODU\QJHDO VLJQV WRRN PRQWKV WR VKRZ LPSURYHPHQW /DU\QJHDO VLJQV PD\WDNHPRUHWLPHWRUHVROYHDVDOVRUHSRUWHGLQ OLWHUDWXUH 33, WKHUDS\ LV FRQVLGHUHG WR EH WKH VWDQGDUG RI FDUHLQSDWLHQWVZLWK/35ZKHQ*(5'LVWKHXQ derlying suspected etiology. In clinical practice, it 0HGLFLQVNLåXUQDO LVEHOLHYHGWKDWSDWLHQWVZLWKUHÀX[UHODWHGODU\Q JLWLVUHTXLUHPRUHDJJUHVVLYHDQGSURORQJHG33, treatments to achieve an improvement of larynge al symptoms than those with typical GERD symp WRPV &RQYHUVHO\ VHYHUDO SODFHERFRQWUROOHG WUL DOVDQGPHWDDQDO\VHVKDYHIDLOHGWRGHPRQVWUDWH DQ\WKHUDSHXWLFEHQH¿WRI33,V Some studies have shown that the proportion of SDWLHQWV ZLWK PDUNHG LPSURYHPHQW LQ ODU\QJHDO V\PSWRPVDIWHU33,WKHUDS\LVKLJKHULQ*(5'SD tients than in those without GERD. On the other KDQGWKHPRVWUHFHQWPXOWLFHQWHUVWXG\ZLWK SDWLHQWV VXVSHFWHG RI KDYLQJ /35 GLG QRW VKRZ DQ\EHQH¿WLQSDWLHQWVWUHDWHGZLWKHVRPHSUD]ROH 40 mg bid for 4 months vs. placebo. In particu ODUH[WUDHVRSKDJHDOUHÀX[FDQQRZEHGHWHFWHG E\ UHFRJQL]LQJ SKDU\QJHDO DFLGL¿FDWLRQ XVLQJ D PLQLDWXUL]HG S+ SUREH DQG E\ WKH QRQLQYDVLYH LGHQWL¿FDWLRQ RI SHSVLQ LQ VDOLYD DQG LQ H[KDOHG breath condensate using the pepsin immunoas VD\ 2XUSDWLHQWVRI/35UHVSRQGHGZLWKLQZHHNVRI WKHUDS\ZKLOHODU\QJHDOVLJQVWRRNPRUHWLPHWRUH VROYHDERXWPRQWKV,QPRVWSDWLHQWVZLWK/35 XVH RI 33, WZLFH D GD\ LV QHHGHG DQG LW VKRXOG EHSUHVFULEHGIRUQRWOHVVWKDQZHHNV,QPRVW SDWLHQWVZLWK/35WZLFHDGD\33,LVQHHGHGDQG LWVKRXOGEHSUHVFULEHGIRUQRWOHVVWKDQPRQWKV Our results are in accordance with the recommen GDWLRQV RI FRQVHQVXV FRQIHUHQFH UHSRUW and American Academy of Otolaryngology and +HDGDQG1HFN6XUJHU\(YHQWKRXJK ZHGLGQRW¿QGDQ\SDWLHQWZKRGLGQRWUHVSRQG but as reported in literature treatment failures are not uncommon. 7UHDWPHQWRI/35RIPRUHWKDQPRQWKVPD\EH LQGLFDWHG WR DWWDLQ IXOO UHVROXWLRQ RI SK\VLFDO ¿QG LQJVDQGWRUHGXFHWKHULVNRIUHWXUQRIV\PSWRPV $OWKRXJK /35 LV D FRPPRQ FRQGLWLRQ SUHVHQWLQJ in ENT settings, the symptoms and signs may be FRPSOH[0RVWFOLQLFLDQVUHO\RQWKHLUFOLQLFDO¿QG ings for diagnosing this condition. Our analysis SURYHG WKDW 33, WKHUDS\ PDGH WKH LPSURYHPHQW in both extraesophageal as well as gastroesopha JHDO V\PSWRPV $IWHU ZHHNV RI 33, WUHDWPHQW the best progress was made with heartburn and HSLJDVWULFSDLQ33,WKHUDS\KDGQRHIIHFWRQ%DU ret’s metaplasia and precancerous conditions. Af WHUZHHNVRIWUHDWPHQWRISRVWFULFRLGHGH PDZDVUHPRYHGDVZHOODVRILQWHUDU\WHQRLG pachyderm. &RQVLGHULQJ /35 ZH FRXOG FKDQJH WKH FXUUHQW understanding of etiopathogenesis of many dis 0LUMDQD *QMDWLü 6ORERGDQ 6SUHPR 3UHGUDJ âSLULü 'PLWDU 7UDYDU 6DQMD âSLULü 'DQLMHOD .HVLü0LMLü 7DWMDQD %DUDü /DU\QJRSKDU\QJHDO UHÀX[ GLVHDVH±RXUWKUHH\HDUH[SHULHQFH HDVHV D FRUUHFW DQG LQ WLPH GLDJQRVLV RI /35 could modify therapeutic approaches and their ef fectiveness in treating the disease such as chronic laryngitis and pharyngitis, chronic rhinosinusitis, asthma, sleep apnea, secretory otitis media in children, laryngomalatia, and even change the prevention and treatment for cancers of the larynx and pharynx. CONCLUSIONS &XUUHQW NQRZOHGJH RQ /35 GLDJQRVLV DQG PDQ agement need to be expanded with new diag QRVWLFWHFKQLTXHVZLWKWKHDLPWRDEHWWHUXQGHU standing and the underlying pathophysiological mechanisms. In this respect, the present study XQGHUVFRUHVWKHLPSRUWDQFHRI0,,S+PRQLWRULQJ to assess the presence of an established associa WLRQEHWZHHQ*(5'DQGVXVSHFWHG/35 &RQÀLFWRILQWHUHVW none declared. 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Evaluation and management of laryn JRSKDU\QJHDOUHÀX[-$0$± 6WHZDUG '/ :LOVRQ .0 .HOO\ '+ 3DWLO 06 6FKZDUW]EDXHU+5/RQJ-':HOJH-$3URWRQSXPS LQKLELWRUWKHUDS\IRUFKURQLFODU\QJRSKDU\QJLWLVDUDQ GRPL]HG SODFHERFRQWURO WULDO 2WRODU\QJRO +HDG 1HFN 6XUJ± 6KDKHHQ1-&URFNHWW6'%ULJKW6'0DGDQLFN5' %XFNPLUH5&RXFK0'HOORQ(6*DODQNR-$6KDUS OHVV * 0RUJDQ '5 HW DO 5DQGRPLVHG FOLQLFDO WULDO KLJKGRVH DFLG VXSSUHVVLRQ IRU FKURQLF FRXJK D GRX EOHEOLQG SODFHERFRQWUROOHG VWXG\$OLPHQW 3KDUPDFRO 7KHU± %HOIDVN\3&3RVWPD*17KHYDOLGLW\DQGUHOLDELOLW\ RIUHÀX[¿QGLQJVFRUH/DU\QJRVFRSH± 1317. 7RURV6=7RURV$%$VVRFLDWLRQRIODU\QJRSKDU\Q JHDO PDQLIHVWDWLRQ DQG JDVWURHVRSKDJHDO UHÀX[ (XU $UFK2WRUKLQRODU\QJRO± .RXIPDQ-6DWDORII577RRKLOO5/DU\QJRSKDU\Q JHDO UHÀX[ /35 &RQVHQVXV &RQIHUHQFH 5HSRUW - 9RLFH .RXIPDQ-$:HLQHU*-:DOODFH&:5HÀX[ODU\Q JLWLVDQGLWVVHTXHODHWKHGLDJQRVWLFUROHRIDPEXODWRU\ KRXUS+PRQLWRULQJ-9RLFH± Address: 0LUMDQD*QMDWLü0' (17&OLQLF8QLYHUVLW\&OLQLFDO&HQWUH%DQMD/XND %HEDEE%DQMD/XND RS, Bosnia and Herzegovina 3KRQH (PDLOPJQMDWLF#JPDLOFRP 0HGLFLQVNLåXUQDO 286 1DWDãD/RJD$QGULMLü$]UD$ODMEHJRYLü6YMHWODQD/RJD=HF&RPRUELGLW\RIGHSUHVVLRQLQQHXURORJLFSDWLHQWV Original article COMORBIDITY OF DEPRESSION IN NEUROLOGIC PATIENTS KOMORBIDITET DEPRESIJE KOD NEUROLOŠKIH PACIJENATA 1DWDãD/RJD$QGULMLü$]UD$ODMEHJRYLü6YMHWODQD/RJD=HF2 1HXURORJ\&OLQLF&OLQLFDO&HQWHU8QLYHUVLW\RI6DUDMHYR%ROQLþND6DUDMHYR%RVQLDDQG+HU]HJRYLQD ,QVWLWXWHRI3KDUPDFRORJ\DQG7R[LFRORJ\0HGLFDO)DFXOW\6DUDMHYR8QLYHUVLW\RI6DUDMHYRýHNDOXãD%RVQLD and Herzegovina 1 &RUUHVSRQGLQJDXWKRU ABSTRACT Depression is the most common comorbid disease LQ FKURQLF QHXURORJLFDO GLVRUGHUV 6XLFLGH ULVN LQ QHXURORJLFDO SDWLHQWV LV VLJQL¿FDQWO\ DVVRFLDWHG with depression, feelings of hopelessness and social isolation. The aim of this study was to in vestigate the presence of depression, assess se verity of depressive disorder and to determine the correlation between the degree of depression and WRWDO%HFN6FDOHIRU6XLFLGH,GHDWLRQ%66VFRUH LQGLIIHUHQWJURXSVRIQHXURORJLFDOGLVRUGHUVHSL OHSV\PXOWLSOHVFOHURVLVSDUNLQVRQLVP7KLVVXU YH\FRYHUHGDWRWDORIQHXURORJLFDOLQSDWLHQWV and outpatients of both genders, aged 18 years and older, treated at the Department of Neurology, Clinical Center University of Sarajevo in the peri RGIURP$SULOVWWR2FWREHUVW7KHVDPSOH ZDVFRQVLVWHGRIWKUHHJURXSVRISDWLHQWVZLWK 3DUNLQVRQLVP HSLOHSV\ DQG PXOWLSOH VFOHURVLV selected randomly. Applied research instruments ZHUHJHQHUDOTXHVWLRQQDLUH+$0'DQG%66 'HSUHVVLRQZDVSUHVHQWLQ3DUNLQVRQLVPSD WLHQWVDQGHTXDOO\LQJURXSVZLWKHSLOHSV\DQGPXO WLSOHVFOHURVLVE\ZLWKQRVWDWLVWLFDOO\VLJQL¿ cant differences between groups. The severity of depression in most neurological patients positively correlated with elevated BSS score. Because of WKHKLJKIUHTXHQF\RIGHSUHVVLYHV\PSWRPVWKHUH is a need for routine assessment of depression in the population of neurological patients. Key words: GHSUHVVLRQ 3DUNLQVRQLVP HSLOHSV\ multiple sclerosis 6$ä(7$. 'HSUHVLMD SUHGVWDYOMD QDMþHãüH NRPRUELGQR REROMHQMH NRG KURQLþQLK QHXURORãNLK EROHVWL6XL FLGDOQLUL]LNNRGQHXURORãNLKEROHVQLNDMH]QDþDMQR DVRFLUDQVDGHSUHVLMRPRVMHüDMHPEH]QDGQRVWLL socijalnom izolacijom. Cilj ovog rada bio je da se 0HGLFLQVNLåXUQDO ispita prisustvo depresije, utvrdi nivo depresivnosti LRGUHGLNRUHODFLMDL]PHÿXWHåLQHGHSUHVLMHLXNX SQRJVNRUD%HFNRYHVNDOH]DVXLFLGDOQHLGHDFLMH %66 NRG UD]OLþLWLK JUXSD QHXURORãNLK REROMHQMD HSLOHSVLMD PXOWLSODV NOHUR]D SDUNLQVRQL]DP 2YLP LVWUDåLYDQMHP REXKYDüHQR MH XNXSQR QHXURORãNLK EROHVQLND RED VSROD VWDURVQH GREL iznad 18 godina, hospitaliziranih ili ambulantno SUDüHQLKQD1HXURORãNRMNOLQLFL.&86XSHULRGXRG JRGLQH8]RUDNVXVDþLQMDYDOH WUL JUXSH RG SR EROHVQLND VD GLMDJQR]RP SDU NLQVRQL]PDHSLOHSVLMHRGQRVQRPXOWLSOHVNOHUR]H L]DEUDQLK PHWRGRP VOXþDMQRJ L]ERUD .RULãWHQL LQVWUXPHQWL LVWUDåLYDQMD VX DQNHWQL XSLWQLN +$0 ' L %66 'HSUHVLMD MH ELOD SULVXWQD NRG SDFLMHQDWD VD SDUNLQVRQL]PRP D SRGMHGQDNR X JUXSDPD HSLOHSVLMH L PXOWLSOH VNOHUR]H SR EH] VWDWLVWLþNL ]QDþDMQH UD]OLNH PHÿX JUXSDPD 7HåLQD GHSUHVLMH NRG YHüLQH QHXURORãNLK SDFLMH QDWDSR]LWLYQRNRUHOLUDVSRYLãHQLP%66VNRURP 6RE]LURPQDYLVRNXXþHVWDORVWGHSUHVLYQLKVLPS WRPDQDPHüHVHSRWUHED]DUXWLQVNRPSURFMHQRP GHSUHVLMHXSRSXODFLMLQHXURORãNLKEROHVQLND .OMXþQH ULMHþL GHSUHVLMD SDUNLQVRQL]DP HSLOHS VLMDPXOWLSODVNOHUR]D INTRODUCTION Depressive disorder is a major public health prob lem worldwide due to a high increase in the fre TXHQF\GXULQJWKHPRGHUQHUD%\GHSUHV sion will be the second leading cause of world GLVDELOLW\:+2DQGE\LWLVH[SHFWHG to be the largest contributor to disease burden :+2 Depression occurs in comorbidity with many so matic diseases and it is the most common comor bid psychiatric disorder in neurological patients. 7KHLQFLGHQFHRIGHSUHVVLRQLQSDWLHQWVZLWK3DU NLQVRQ¶VGLVHDVHUDQJHVIURPWRLQPXO WLSOHVFOHURVLVDURXQGDQGDIIHFWV 1DWDãD/RJD$QGULMLü$]UD$ODMEHJRYLü6YMHWODQD/RJD=HF&RPRUELGLW\RIGHSUHVVLRQLQQHXURORJLFSDWLHQWV SDWLHQWVZLWKHSLOHSV\7KLVFRPRUELGLW\LVWKH result of interplay between variety of endogenous DQG H[RJHQRXV IDFWRUV LQFOXGLQJ LDWURJHQLF IDF WRUV It is noteworthy that depressive disorder is associ DWHGZLWKLQFUHDVHGULVNRIVXLFLGHDQGDFFRUGLQJ WRWKHOLWHUDWXUHRIGHSUHVVHGSDWLHQWVFRP PLW VXLFLGH 6XLFLGH ULVN LQ QHXURORJLFDO SD WLHQWV LV VLJQL¿FDQWO\ DVVRFLDWHG ZLWK GHSUHVVLRQ feelings of hopelessness or helplessness, as well DVVRFLDOLVRODWLRQ The goal of this study was to analyze the pres ence of depression, assess severity of depressive disorder and to determine the correlation between the degree of depression and total score on BSS scale in different groups of neurological disorders HSLOHSV\PXOWLSOHVFOHURVLV3DUNLQVRQLVP MATERIALS AND METHODS The study of depression in neurological patients ZDVFOLQLFDOHSLGHPLRORJLFDOSURVSHFWLYHDQDO\WL cal, descriptive and controlled. The sample was consisted of three groups of neurological patients VHOHFWHGUDQGRPO\DQGLQFOXGHGDWRWDORIUH VSRQGHQWV 7KH ¿UVW JURXS RI UHVSRQGHQWV includes patients with epilepsy;the second group SDWLHQWVZLWKPXOWLSOHVFOHURVLV06DQGWKLUG VWXG\JURXSDUHSDWLHQWVZLWK3DUNLQVRQLVP Examined inpatients and outpatients have to meet the following criteria: have clinically established GLDJQRVLVRIHSLOHSV\PXOWLSOHVFOHURVLVRU3DUNLQ sonism, were treated at the Department of Neurol RJ\&&86LQWKHSHULRGIURP$SULOVWXQWLO 2FWREHUVWROGHUWKDQ\HDUVRIDJHRI both genders, with the signed voluntary consent to participate in the research. $SSOLHGUHVHDUFKLQVWUXPHQWVZHUHJHQHUDOTXHV tionnaire, constructed for the purposes of this study, Hamilton Rating Scale for Depression, LWHPV YHUVLRQ +$0' DQG WKH %HFN 6FDOH IRU 6XLFLGH ,GHDWLRQ %66 $OO SDWLHQWV DSSOLHG D TXHVWLRQQDLUH WR REWDLQ LQIRUPDWLRQ RQ demographic and clinical characteristics of pa WLHQWV'HPRJUDSKLFYDULDEOHVDJHJHQGHUPDUL WDOVWDWXVOHYHORIHGXFDWLRQHPSOR\PHQWVWDWXV and clinical characteristics of patients including type of disease, age of onsetand used medica tions were collected. Depression was evaluated DQGFRQ¿UPHGE\+$0')LQDOO\DOOUHVSRQG HQWV ZHUH WHVWHG XVLQJ WKH VHOIHYDOXDWLRQ %66 scale. 6WDWLVWLFDO DQDO\VLV ZDV FRQGXFWHG XVLQJ 6366 computer software for statistical analysis, version 5HVXOWVDUHSUHVHQWHGLQFKDUWVDVDSHUFHQW age, absolute value, odds ratio with corresponding FRQ¿GHQFHLQWHUYDOVDQGWKHPHDQYDOXH[ ZLWKVWDQGDUGGHYLDWLRQ6')RUWKHDQDO\VLVRI FDWHJRULFDO YDULDEOHV FKLVTXDUH WHVW ZDV XVHG &RUUHODWLRQ ZDV GHWHUPLQHG E\ 6SHDUPDQ UDQN WHVW3ZDVFRQVLGHUHGDVVWDWLVWLFDOO\VLJQL¿ cant. The protocol of this study was approved by the Ethics Committee of Clinical Center University of Sarajevo and was carried out in accordance with the ethical standards laid down in the Declaration RI +HOVLQNL$OO SDWLHQWV ZHUH YROXQWDULO\ DGPLWWHG and gave an informed consent. RESULTS 3DWLHQWVZLWK3DUNLQVRQLVPQ ZHUHSUHGRPL QDQWO\PDOHPDUULHGPHDQDJH \HDUV 7KH DYHUDJH DJH RI RQVHW ZDV \HDUV,QWKHJURXSRISDWLHQWVZLWKHSL OHSV\WKHUHZHUHPDOHDQGIH PDOHSDWLHQWVPRVWO\VLQJOHDWPHDQDJH RI \HDUV 7KH DYHUDJH DJH DW RQVHW RI HSLOHSV\ZDV\HDUV3DWLHQWVZLWKPXOWL SOHVFOHURVLVZHUHPRVWO\ZRPHQPDUULHG DWPHDQDJHRI\HDUV7KHPHDQ DJHRI06RQVHWZDV\HDUV 'HSUHVVLRQZDVSUHVHQWLQSDWLHQWVZLWK 3DUNLQVRQLVP&,DQGHTXDOO\ LQJURXSVZLWKHSLOHSV\DQGPXOWLSOHVFOHURVLVE\ UHVSRQGHQWV &, )LJXUH 7KHUH ZHUH QR VWDWLVWLFDOO\ VLJQL¿ FDQW GLIIHUHQFHV EHWZHHQ WKH JURXSV Ȥ S )LJXUH Depression in neurologic patients. 6XLFLGH LGHDWLRQV ZHUH SUHVHQW LQ SDWLHQWVZLWK3DUNLQVRQLVP&, LQ HSLOHSV\ SDWLHQWV &, DQGRQO\LQ06SDWLHQWV&, 3UHVHQFHDQGVHYHULW\RIGHSUHVVLRQLQQHXURORJLF SDWLHQWVZLWKVXLFLGHLGHDVEDVHGRQ+$0'WRWDO VFRUHVDUHVKRZQLQ)LJXUHVDQG 0HGLFLQVNLåXUQDO 287 1DWDãD/RJD$QGULMLü$]UD$ODMEHJRYLü6YMHWODQD/RJD=HF&RPRUELGLW\RIGHSUHVVLRQLQQHXURORJLFSDWLHQWV Figure 2. 'HSUHVVLRQ LQ SDWLHQWV ZLWK 3DUNLQVRQLVP DQG VXLFLGDOLGHDWLRQDFFRUGLQJWR+$0' )LJXUH Depression in patients with epilepsy and suicidal LGHDWLRQDFFRUGLQJWR+$0' )LJXUH'HSUHVVLRQLQSDWLHQWVZLWK06DQGVXLFLGDOLGHDWLRQ DFFRUGLQJWR+$0' Spearman correlation revealed a statistically VLJQL¿FDQW FRUUHODWLRQ EHWZHHQ WKH GHJUHH RI depression and BSS total score in patients with 3DUNLQVRQLVP DQG VXLFLGH LGHDWLRQV UKR S DV ZHOO DV LQ WKH JURXS RI SDWLHQWV ZLWK HSLOHSV\ DQG VXLFLGH LGHDV UKR S ,Q 06 SDWLHQWV ZLWK VXLFLGH LGHDV WKHUH ZDV QR correlation between the BSS total score and VHYHULW\RIGHSUHVVLRQUKR 16 0HGLFLQVNLåXUQDO DISCUSSION In this study we analyzed the presence of depression, estimated severity of depressive disorder and examined the correlation between the severity of depression and total BSS scores in different groups of neurological disorders HSLOHSV\ PXOWLSOH VFOHURVLV 3DUNLQVRQLVP The highest rate of depression was observed in SDWLHQWV ZLWK 3DUNLQVRQLVP DQG LGHQWLFDO appearance of depression was found in patients ZLWKHSLOHSV\DQGPXOWLSOHVFOHURVLVE\ZLWK QRVWDWLVWLFDOO\VLJQL¿FDQWGLIIHUHQFHVEHWZHHQWKH groups. According to the recent studies, the prevalence RIGHSUHVVLRQLQ3DUNLQVRQ¶VGLVHDVHKDVDUDQJH IURP ZLWK DQ DYHUDJH RI DERXW 6RPH DXWKRUV VXJJHVW WKDW DSSHDUDQFH of depression in these patients is biphasic, with D SHDN HDUO\ LQ WKH LOOQHVV DQG DQRWKHU JUDGXDO LQFUHDVH LQ LWV ODWWHU VWDJHV 8VH RI /GRSD preparations can lead to the development of VHYHUH GHSUHVVLRQ %\ /GRSD SUHSDUDWLRQV DQG RU DQWLFKROLQHUJLF GUXJV ZDV WUHDWHG VLJQL¿FDQWO\ PRUH SDWLHQWV LQ FRPSDULVRQ WR QHZ generation dopaminergic agentsseparately or LQ FRPELQDWLRQ ZLWK /GRSD SUHSDUDWLRQV $ WRWDO RI SDWLHQWV XVHG /GRSD SUHSDUDWLRQV ZKLFK FRXOG SRWHQWLDOO\ KDYH D VLJQL¿FDQW LPSDFW on the presence of depression in sample. Similar to our results, in a study conducted in /RQGRQ RI SDWLHQWV KDG PLOG GHSUHVVLRQ PRGHUDWHGHSUHVVLRQDQGDVHYHUHIRUPRI GHSUHVVLYHGLVRUGHULQRIUHVSRQGHQWV7RWDO RIPHWWKHFULWHULDIRUPRGHUDWHWRVHYHUH GHSUHVVLYHHSLVRGH In our research in case of epilepsy the depression ZDV REVHUYHG LQ RI SDWLHQWV ZKLFK LV similar to other studies. According to the earlier epidemiological studies, the prevalence of GHSUHVVLRQ LQ SDWLHQWV ZLWK HSLOHSV\ LV FRPSDUHGWRLQWKHJHQHUDOSRSXODWLRQ $OPRVW LGHQWLFDO WR RXU UHVXOWV .DQQHU UHSRUWV WKDW RI SDWLHQWV ZLWK HSLOHSV\ ZHUH GHSUHVVHGKDGH[SHULHQFHGUHFHQWVXLFLGDO LGHDWLRQ DQG RQO\ RI WKHVH SDWLHQWV ZHUH WUHDWHG ZLWK DQWLGHSUHVVDQWV &DUVRQ HW DO found that depressive disorder was diagnosed LQ RI HSLOHSV\ LQSDWLHQWV DQG RI ZKLFK KDG VLJQV RI VHYHUH GHSUHVVLRQ 7KH VWXG\ which tested the incidence of depression in chronic physical illnesses conducted by Filipcic LQ =DJUHE LQYROYHG SDWLHQWV VXIIHULQJ IURP HSLOHSV\'HSUHVVLRQZDVSUHVHQWLQ RISDWLHQWVPLOGGHSUHVVLYHHSLVRGHVLQ PRGHUDWHLQDQGVHYHUHLQRI SDWLHQWV There are controversial data whether some of the DQWLHSLOHSWLFV$('VLQFUHDVHWKHULVNRIVXLFLGDO 1DWDãD/RJD$QGULMLü$]UD$ODMEHJRYLü6YMHWODQD/RJD=HF&RPRUELGLW\RIGHSUHVVLRQLQQHXURORJLFSDWLHQWV EHKDYLRU &HUWDLQ $('V SDUWLFXODUO\*$%$HUJLF DJHQWV HJ YLJDEDWULQ WRSLUDPDWH DQG SKHQREDUELWDO PD\ DFFRUGLQJ WR VRPH UHSRUWV cause or exacerbate existing symptoms of GHSUHVVLRQ +RZHYHU WKLV VWXG\ KDV QRW LQYHVWLJDWHG LQGLYLGXDO $('V DQG FRQVHTXHQWO\ the potential adverse effects. In patients with multiple sclerosis, depression ZDV SUHVHQW LQ KDOI RI WKH WHVWHG VDPSOH According to recent study, lifetime prevalence of GHSUHVVLRQ LQ 06 LV RYHU DQG DERXW WKUHH times more common than in the general population, with the prevalence of major depressive disorder RI7KHREWDLQHGUHVXOWVRIWKLVVWXG\ are similar with epidemiological data from other studies, according to which the appearance of GHSUHVVLRQ LQ 06 SDWLHQWV LV EHWZHHQ DQG $OPRVWLGHQWLFDOUHVXOWZDVUHFRUGHGLQ RXUSUHYLRXVVWXG\RIGHSUHVVLRQLQ06SDWLHQWV conducted at the Department of Neurology CCUS. 'HSUHVVLRQZDVSUHVHQWLQRISDWLHQWVDOVR ZLWKRXWVLJQL¿FDQWGLIIHUHQFHLQUHODWLRQWRJHQGHU ,QDUHFHQWVWXG\XVLQJWKHVDPHLQVWUXPHQW DV LQ RXU VWXG\ +$0' VFDOH ZDV LGHQWL¿HG D WRWDORIRIGHSUHVVHGSDWLHQWV 7KH HSLGHPLRORJLFDO VWXG\ E\ &KZDVWLDN DQG DVVRFLDWHV ZKLFK LQFOXGHG 06 SDWLHQWV RI SDWLHQWV KDG GHSUHVVLRQ RI ZKLFK of patients had moderate or severe depression. Depression was associated with shorter duration of GLVHDVHGLVHDVHGXUDWLRQOHVVWKDQ\HDUVZDV DVVRFLDWHGZLWKDJUHDWHUULVNIRUGHSUHVVLRQ 7KH VWXG\ RI WKH SUHYDOHQFH RI GHSUHVVLYH symptoms that Gottberg and associates FRQGXFWHG DPRQJ 06 SDWLHQWV VKRZHG WKDW D¿IWKRIUHVSRQGHQWVZHUHGHSUHVVHG The emergence of suicidal thoughts in our study ZDVVLJQL¿FDQWO\KLJKHUFRPSDUHGWRWKHUHVXOWVRI *RWWEHUJHWDODFFRUGLQJWRZKLFKRISDWLHQWV FRQ¿UPHGVXLFLGDOWKRXJKWV 3RVVLEO\PRRGVZLQJVLQ06FDQRFFXUDVDGYHUVH effect of certain medications use. Steroids and spasmolytics may be associated with low mood. Also, an association may exist between the use RI ,)1ȕ WUHDWPHQW DQG V\PSWRPV RI GHSUHVVLRQ The presence of depressive symptoms in nearly WKUHHTXDUWHUV RI SDWLHQWV ZLWK 3DUNLQVRQLVP DQG half of surveyed patients with epilepsy and multiple sclerosis are noteworthy data. In this paper the presence of depression compared with different populations with neurological diseases was determined. Future research should determine the clinical impact of this phenomenon, the further course of the disease and fully LQYHVWLJDWHWKHULVNIDFWRUVIRUWKHLURFFXUUHQFH $FFRUGLQJ WR WKH VWXG\ UHVXOWV QHDUO\ WKUHH TXDUWHUV RI SDWLHQWV ZLWK 3DUNLQVRQLVP DQG every second patient with epilepsy and multiple sclerosis had depressive symptoms, so it has EHHQFRQ¿UPHGWKHKLJKSUHVHQFHRIGHSUHVVLRQ among neurological patients. $ VLJQL¿FDQW LPSOLFDWLRQ RI WKLV ZRUN IRU SXEOLF health is the importance of depression screening in neurological patients. Because of the high IUHTXHQF\ RI GHSUHVVLYH V\PSWRPV WKHUH LV D need for routine assessment of depression in this population. CONCLUSIONS 'HSUHVVLRQ LV UHJLVWHUHG LQ D WRWDO RI RI SDWLHQWV ZLWK 3DUNLQVRQLVP LQ RI SDWLHQWV ZLWK HSLOHSV\ DQG WKH VDPH QXPEHU of patients with multiple sclerosis. The study FRQ¿UPHGWKDWGHSUHVVLYHV\PSWRPVDUHFRPPRQ LQWKHSRSXODWLRQRIQHXURORJLFDOSDWLHQWVHSLOHSV\ PXOWLSOH VFOHURVLV 3DUNLQVRQLVP 7KH IUHTXHQF\ and severity of depressive symptoms correlates with BSS total score in the group of patients with 3DUNLQVRQLVP DQG HSLOHSV\ EXW QRW DPRQJ 06 patients. Depressive disorder is a very common psychiatric comorbidity of neurological disorders. Hence, this study underlines the importance of recognizing comorbid depressive disorder at the earliest VWDJH RI WKH GLVHDVH GXH WR DGHTXDWH DFFHVV WR treatment and the need for routine assessment of depression in the population of neurological patients with screening instruments. &RQÀLFWRILQWHUHVW none declared. 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Depression and multiple sclerosis: Review of a lethal FRPELQDWLRQ-5HKDELO5HV'HY± Address: 1DWDãD/RJD$QGULMLü0' Department of Neurology Clinical Centre University of Sarajevo %ROQLþND6DUDMHYR Bosnia and Herzegovina 3KRQHID[ (PDLOQDWDVDORJD#\DKRRFRP 0DLGDâLãLUDN0LUVDGD+XNLü$PUD=YL]GLü'DULD%HNLü3UHYDOHQFHDQGDQWLPLFURELDOUHVLVWDQFHRISVHXGRPRQDVDHUXJLQRVDLQWKHZRXQGVZDEV Original article PREVALENCE AND ANTIMICROBIAL RESISTANCE OF PSEUDOMONAS AERUGINOSA IN THE WOUND SWABS 35(9$/(1&$ , 5(=,67(1&,-$ 1$ $17,%,27,.( 36(8'2021$6 $(58*,126$ 8 BRISEVIMA RANA 0DLGDâLãLUDN0LUVDGD+XNLü$PUD=YL]GLü'DULD%HNLü &OLQLFDO0LFURELRORJ\&OLQLFDO&HQWHU8QLYHUVLW\RI6DUDMHYR%ROQLþND6DUDMHYR%RVQLDDQG+HU]HJRYLQD &RUUHVSRQGLQJDXWKRU ABSTRACT 6$ä(7$. 2YHUWKHSDVWIHZGHFDGHV3VHXGRPRQDVDHUXJL nosa has emerged as one of the leading nosoco mial pathogens throughout the world. This is partly due to its intrinsic aptitude to persist in the hospi WDOVHWWLQJDQGDFTXLUHPXOWLSOHUHVLVWDQFHPHFKD nisms. The aim of this study was to analyze the IUHTXHQF\ DQG DQWLPLFURELDO UHVLVWDQFH RI 3VHX domonas aeruginosa isolated from wound swabs. :RXQGVZDEVRIDOOFRQVHFXWLYHSDWLHQWVKRVSLWDO ized in the different departments in the University RI 6DUDMHYR &OLQLFDO &HQWUH IURP -DQXDU\ WR 'HFHPEHU ZHUH H[DPLQHG 7KH LVRODWHV ZHUH LGHQWL¿HG E\ FRQYHQWLRQDO PHWKRGV$QWLPL crobial susceptibility testing was performed by .LUE\%DXHU GLVFGLIIXVLRQ PHWKRG DV SHU &/6, guidelines. $ WRWDO RI ZRXQG VZDEV ZHUH H[DPLQHG VZDEV ZHUH SRVLWLYH DQG ZHUH VWHULOH 3VHXGRPRQDV DHUXJLQRVD ZDVLVRODWHGLQVZDEVDQGLWZDVWKH PRVWFRPPRQFDXVHDPRQJJUDPQHJDWLYHPLFUR organisms. Overall yearly resistance rates to anti ELRWLFVKDGDQLQFUHDVLQJWUHQGGXULQJVHYHQ\HDUV SHULRGFHIWULD[RQHIURPWRFHIWD]L GLPHIURPWRFHIRWD[LPHIURP WRFHIHSLPHIURPWRDPLNDFLQ IURPWRJHQWDP\FLQIURPWR FLSURÀR[DFLQIURPWRSLSHUD FLOOLQWD]REDFWDP IURP WR LPLSHQHP IURP WR DQG PHURSHQHP IURP WR Conclusion: Our study reveals increasing trend of UHVLVWDQFH3VHXGRPRQDVDHUXJLQRVDWRDOODQWLPL crobials. Rapid and accurate reporting of antibi otic resistance is essential in guiding therapeutic decisions. Establishing antimicrobial resistance surveillance systems and implementing measures to support the prudent use of antibiotics by set ting evidence based guidelines has been recom mended. Key words: wound infections, resistance, antibi otics 7LMHNRP SURWHNOLK GHVHWOMHüD 3VHXGRPRQDV DHU XJLQRVD MH SRVWDR MHGDQ RG YRGHüLK X]URþQLND EROQLþNLK LQIHNFLMD ãLURP VYLMHWD 7R MH SRVOMHGLFD njegove izuzetne sposobnosti da perzistira u EROQLþNRMVUHGLQLLEURMQLKPHKDQL]DPDUH]LVWHQFL MH&LOMRYHVWXGLMHELRMHDQDOL]LUDWLXþHVWDORVWLDQ WLPLNUREQXUH]LVWHQFLMX3VHXGRPRQDVDHUXJLQRVD izoliranog iz briseva rana. Brisevi rana pacijenata hospitaliziranih na UD]OLþLWLPRGMHOLPD.OLQLþNRJFHQWUD8QLYHU]LWHWDX 6DUDMHYX LVSLWDQL VX X SHULRGX RG MDQXDUD GR GHFHPEUD JRGLQH ,GHQWL¿NDFLMD L]RODWD L]YUãHQD MH UXWLQVNLP PHWRGDPD 2VMHWOMLYRVW QD DQWLELRWLNH LVSLWDQD MH GLVNGLIX]LRQRP PHWRGRP SUHPDLQWHUSUHWDFLMVNLPNULWHULMLPD&/6,D $QDOL]LUDQRMHEULVHYDUDQD EULVHYD ELOR MH SR]LWLYQR D VWHULO QR 3VHXGRPRQDV DHUXJLQRVD MH L]ROLUDQ X EULVHYD L ELR MH QDMþHãüL X]URþQLN PHÿX *UDPQHJDWLYQLP PLNURRUJDQL]PLPD 5H]LVWHQ FLMDQDDQWLELRWLNHSRND]DODMHUDVWXüLWUHQGWRNRP VHGDP JRGLQD FHIWULD[RQ RG QD FHIWD]LGLPRGQDFHIRWD[LPRG QD FHIHSLPH RG QD DPLND FLQRGQDJHQWDPLFLQRGQD FLSURÀR[DFLQRGQDSLSHUDFLO OLQWD]REDFWDP RG QD LPLSHQHP RG QDLPHURSHQHPRGQD =DNOMXþDN1DãDVWXGLMDMHSRND]DODSRUDVWUH]LVW HQFLMH3VHXGRPRQDVDHUXJLQRVDQDVYHDQWLPLN UREQHOLMHNRYH%U]RLWDþQRL]YMHãWDYDQMHRUH]LVW HQFLML QD DQWLELRWLNH MH ELWQR X L]UDGL WHUDSHXWVNLK YRGLþD 3UHSRUXND MH XVSRVWDYOMDQMH PUHåH SUDüHQMDDQWLPLNUREQHUH]LVWHQFLMHWHLPSOHPHQWL UDQMH PMHUD ]D GRSULQRV UD]XPQRM SRWURãQML DQWL ELRWLND NUR] UD]YLMDQMH QDFLRQDOQLK VPMHUQLFD R XSRWUHELDQWLELRWLND .OMXþQHULMHþLLQIHNFLMHUDQHUH]LVWHQFLMDDQWLEL otici 0HGLFLQVNLåXUQDO 0DLGDâLãLUDN0LUVDGD+XNLü$PUD=YL]GLü'DULD%HNLü3UHYDOHQFHDQGDQWLPLFURELDOUHVLVWDQFHRISVHXGRPRQDVDHUXJLQRVDLQWKHZRXQGVZDEV INTRODUCTION Nosocomial infections are serious problem in PRGHUQ FOLQLFDO PHGLFLQH 6XUJLFDO VLWH LQIHF WLRQV66,VDVWKH\DUHFDOOHGWRGD\DFFRXQWHG IRURIDOOKRVSLWDODFTXLUHGLQIHFWLRQVPDNLQJ WKHP WKH WKLUG PRVW IUHTXHQW W\SH RI QRVRFRPLDO infections in developed countries. The rates were KLJKHULQGHYHORSLQJFRXQWULHVDQGYDU\IURP WR7KLVLVDJUHDWSUREOHPHVSHFLDOO\LQUH VRXUFHSRRUFRXQWULHV 7KHUH DUH PXOWLSOH UHDVRQV IRU SRVWRSHUDWLYH wound infections, which have been validated and GRFXPHQWHG DV ULVN IDFWRU $ ULVN IDFWRU LV DQ\ UHFRJQL]HG FRQWULEXWLRQ WR DQ LQFUHDVH LQ SRVW RSHUDWLYHZRXQGLQIHFWLRQ7KHYLUXOHQFHDQG invasive capability of the organisms have been UHSRUWHGWRLQÀXHQFHWKHULVNRILQIHFWLRQEXWWKH physiological state of the tissue in the wound and immunological integrity of the host seem to be of HTXDOLPSRUWDQFHLQGHWHUPLQLQJZKHWKHULQIHFWLRQ RFFXUV Infection of surgical wound is considered as noso comial infection if it occurred within 30 days after surgery, or within one year in case of implant. In IHFWLRQZDVGH¿QHGDVGLVFKDUJHRISXVIURPWKH wound, or a clinical suspicion of wound infection, EDVHGRQLQÀDPPDWRU\VLJQVVXFKDVUDLVHGWHP perature, redness and tenderness of the wound. Surgical wound infections are prolonging the du UDWLRQRIKRVSLWDOL]DWLRQLQFUHDVHWKHULVNRISRRU cicatrisation and increase morbidity and mortality. The most critical factors in the prevention of post operative wound infections are sound judgment DQGSURSHUWHFKQLTXHRIWKHVXUJHRQDQGVXUJLFDO team, as well as the general health and disease VWDWHRIWKHSDWLHQW,QRUGHUWRPLQLPL]HWKH postoperative wound infections, it is important to create a safe environment by controlling four main VRXUFHVRILQIHFWLRQLHSHUVRQQHOHTXLSPHQWWKH HQYLURQPHQW DQG SDWLHQW¶V ULVN IDFWRUV 'LDJ nosis and treatment of these infections are very expensive and present an additional load to health insurance funds. It is very useful to explore the causes of these infections in order to timely detect DQGUHPRYHWKHFDXVDWLYHDJHQWV%DFWHULRORJL FDOVWXGLHVKDYHVKRZQWKDWSRVWRSHUDWLYHZRXQG infection is universal and that the bacteria types present vary with geographical location, bacteria UHVLGHQWRQWKHVNLQFORWKLQJDWWKHVLWHRIZRXQG WLPHEHWZHHQVXUJHU\DQGZRXQGH[DPLQDWLRQ :LWKLQ UHFHQW \HDUV WKHUH KDV EHHQ D JURZLQJ SUHYDOHQFHRI*UDPQHJDWLYHRUJDQLVPVDVFDXV es of serious infections. The growing incidence of 3VHXGRPRQDVDHUXJLQRVDKDVEHHQRISDUWLFXODU LQWHUHVW 3VHXGRPRQDV DHUXJLQRVD KDV EHHQ UHFRJQL]HG for a long time as one of the leading cause of hos pital infections all over the world. It is a common 0HGLFLQVNLåXUQDO cause of infection in hospitalized patients and so LVDPRQJWKHVLJQL¿FDQWHWLRORJLFDODJHQWVRIQR VRFRPLDOLQIHFWLRQV0RVWRILWVVWUDLQVFDQ colonize individuals, without symptoms, for either short or extended period of time, causing disease when the immune system becomes compromised. 3VHXGRPRQDVDHUXJLQRVDYLUXOHQFHGHWHUPLQDQWV LQFOXGHFHOODVVRFLDWHGOLSRSRO\VDFFKDULGHHQGR WR[LQÀDJHOOXPSLOLDQGH[WUDFHOOXODUDOJLQDWHH[ RWR[LQ$H[RHQ]\PH6S\RFLDQLQHODVWDVHHWF factors. It has been demonstrated that expression RI WKHVH YLUXOHQFH IDFWRUV LV UHJXODWHG E\ D FHOO GHQVLW\GHSHQGHQW VLJQDOLQJ PHFKDQLVP NQRZQ DV TXRUXPVHQVLQJ 7KH ÀDJHOOXP SLOL DQG exopolysaccharide are important in pathogenic ity because they enable the bacteria to form bio ¿OP %LR¿OPV DUH H[WUHPHO\ GLI¿FXOW WR HUDGLFDWH since they are shielded from host defenses such as phagocytes or antibodies, as well as antibiotics DQGFDQEHWKHVRXUFHRIFKURQLFLQIHFWLRQV 3VHXGRPRQDVDHUXJLQRVDZRXQGLQIHFWLRQLV DFRPSOLFDWHGSURFHVVWKDWLQYROYHVLQÀDPPDWLRQ LPPXQH UHVSRQVH DQG ZRXQG KHDOLQJ 7KH LQWHUDFWLRQ EHWZHHQ D *UDPQHJDWLYH EDFWHULXP and its host is mediated by molecular structures SURGXFHGE\WKHSDWKRJHQFDOOHGSDWKRJHQDVVR ciated molecular patterns; these are recognized by pattern recognition receptors, associated with PROHFXOHVFDOOHGWROOOLNHUHFHSWRUV7/5VRQLQ QDWH LPPXQH FHOOV )RU *UDPQHJDWLYH EDFWHULD a lipopolysaccharide receptor complex is asso FLDWHG ZLWK 7/5 ZKLFK UHJXODWHV WKH LQGXFLEOH expression of various effector molecules, includ LQJGLIIHUHQWF\WRNLQHVFKHPRNLQHVDQGRWKHUPRO HFXOHV WKDW DUH LQYROYHG LQ WKH LQÀDPPDWRU\ DQG VXEVHTXHQWLPPXQHUHVSRQVH ,QIHFWLRQV FDXVHG E\ 3VHXGRPRQDV DHUXJLQRVD DUH GLI¿FXOW IRU WUHDWPHQW 7KH PDMRULW\ RI LVR lates exhibit varying degrees of intrinsic resist ance against many antimicrobial agents due to ORZ SHUPHDELOLW\ RI LWV FHOO ZDOO 3VHXGRPRQDV aeruginosa has the genetic capacity to express a wide repertoire of resistance mechanisms. It can become resistant through mutation in chro mosomal genes which regulate resistance genes. $OVR LW FDQ DFTXLUH DGGLWLRQDO UHVLVWDQFH JHQHV from other organisms via plasmids, transposons DQGEDFWHULRSKDJHV,QDGGLWLRQH[SRVXUHWR antimicrobiales of different classes can result in the emergence of mutant strains that are highly UHVLVWDQW WR PDQ\ DQWLPLFURELDOV 6XFK PXO WLGUXJ UHVLVWDQW 3VHXGRPRQDV DHUXJLQRVD FDQ present a major therapeutic problem especially in immunocompromised patients. Resistance to antimicrobial agents and numerous virulence fac WRUVPHDQVWKDW3VHXGRPRQDVDHUXJLQRVDFDXVHV PDQ\FKURQLFLQIHFWLRQV Irrational use of antimicrobial drugs leads to the increase of resistance, causing certain treatment 0DLGDâLãLUDN0LUVDGD+XNLü$PUD=YL]GLü'DULD%HNLü3UHYDOHQFHDQGDQWLPLFURELDOUHVLVWDQFHRISVHXGRPRQDVDHUXJLQRVDLQWKHZRXQGVZDEV problems. The spread of microorganisms resistant to antibiotics represents a global problem in the world today, because it increases treatment costs and increases the mortality of patients. The dis tribution of resistant microorganisms, especially those causing intrahospital infections, differs de pending on the type of hospital institution and type RISDWLHQWVWUHDWHGLQWKRVHLQVWLWXWLRQV Numerous studies cite that bacterial resistance to antimicrobials varies in the different parts of the world, even in the different parts of the same country, even in the different wards of one hos pital. There is a need for constant monitoring of bacterial resistance for improvement guidelines for empirical antibiotic treatment. The aim of this study was to investigate the SUHYDOHQFHDQGDQWLPLFURELDOUHVLVWDQFHRI3VHX domonas aeruginosa isolated from postoperative wounds in our hospital. :RUOG0HGLFDO$VVRFLDWLRQ'HFODUDWLRQRI+HOVLQNL were applied in this study. RESULTS :RXQG VZDEV RI DOO FRQVHFXWLYH SDWLHQWV KRVSL talized in the different departments in the Clinical &HQWUH8QLYHUVLW\RI6DUDMHYRIURP-DQXDU\ WR'HFHPEHUZHUHH[DPLQHG*HQGHUVWUXF WXUH RI SDWLHQWV ZDV IHPDOHV DQG males. The average age of patients was 48 years RIOLIHUDQJHIURPWR $ WRWDO RI ZRXQG VZDEV ZHUH H[DPLQHG VZDEV ZHUH VWHULOH DQG ZHUHSRVLWLYH)LJXUH )LJXUH Review of examination wound swabs. MATERIALS AND METHODS $WRWDORIVZDEVWDNHQIURPVXUJLFDOZRXQGV ZHUHH[DPLQHGIURP-DQXDU\WR'HFHPEHU $OOODERUDWRU\WHVWLQJZHUHSHUIRUPHGDWWKH ,QVWLWXWH IRU &OLQLFDO 0LFURELRORJ\ &OLQLFDO &HQWHU University of Sarajevo. $OOZRXQGVZDEVZHUHWUHDWHGIROORZLQJ3URWRFRO RIZRUNIRU/DERUDWRU\RIEDFWHULRORJ\ 6DPSOHVZHUHSODWHGRQEORRGDJDUDQG0DF&R QNH\DJDU%HFWRQ'LFNLQVRQ1HZ-HUVH\8QLWHG 6WDWHV0DF&RQNH\DJDUZDVXVHGIRUVHOHFWLYH isolation of Enterobacteriacae. These media are specially designed to distinguish lactose ferment LQJ SLQN WR UHG IURP QRQODFWRVH±IHUPHQWLQJ FRORQLHVFRORXUOHVVRUVOLJKWO\EHLJH7KHSODWHV ZHUH LQFXEDWHG RYHUQLJKW DW ƕ& LQ EDFWHULR ORJLFDO LQFXEDWRUV$OO LVRODWHV ZHUH LGHQWL¿HG E\ FRQYHQWLRQDO ELRFKHPLFDO WHVWLQJ $QWLPLFUR ELDOVXVFHSWLELOLW\WHVWLQJZDVSHUIRUPHGE\.LUE\ %DXHU GLVFGLIIXVLRQ PHWKRG RQ 0XHOOHU+LQWRQ DJDUDFFRUGLQJWRWKH&OLQLFDO/DERUDWRU\6WDQG DUGV,QVWLWXWH&/6,JXLGHOLQHV%DFWHULDOLQ oculate was prepared by suspending the freshly grown bacteria in the sterile normal saline and DGMXVWHGWRD0F)DUODQGVWDQGDUG$QWLPLFUR bial susceptibility was determined for cefotaxime, ceftazidime, ceftriaxone, cefepime, gentamicin, DPLNDFLQ FLSURÀR[DFLQ SLSHUDFLOOLQWD]REDFWDP LPLSHQHP DQG PHURSHQHP 0XOWLGUXJUHVLVWDQW RUJDQLVPV 0'52V DUH GH¿QHG DV PLFURRUJDQ isms that are resistant to one or more classes of antimicrobial agents. For the evaluation of the results, standard statisti cal methods were used. Statistical analysis was SHUIRUPHGE\XVLQJD&KLVTXDUHWHVWRU)LVKHU¶V H[DFWWHVWV6WDWLVWLFDOVLJQL¿FDQFHZDVGH¿QHGIRU S 7HVW UHVXOWV ZHUH SUHVHQWHG JUDSKLFDOO\ or in tabular form. Ethical principles outlined in the positive sterile The most common isolated microorganisms from wound swabs were: Staphylococcus aureus in 3VHXGRPRQDVDHUXJLQRVDLQ (VFKHULFKLDFROLLQ6HUUDWLD PDUVFHVFHQV LQ DQG .OHEVLHOOD SQHXPRQLDHLQFDVHV7DEOH 7DEOH. The most common causes of wound infections. ,VRODWHGPLFURRUJDQLVPV Q 6WDSK\ORFRFFXVDXUHXV 3VHXGRPRQDVDHUXJLQRVD Escherichia coli 1110 8.7 6HUUDWLDPDUFHVFHQV .OHEVLHOODSQHXPRQLDH $FLQHWREDFWHUEDXPDQQLL 3URWHXVPLUUDELOLV (QWHUREDFWHUFORDFDH (QWHURFRFFXVIDHFDOLV Infections of surgical wound caused by 3VHXGRPRQDV DHUXJLQRVD GRPLQDWHG DW &OLQLF IRU 3ODVWLF 6XUJHU\ &OLQLF IRU 2UWKRSDHGLF 6XUJHU\ DQG DW &OLQLF IRU 1HXURVXUJHU\ )LJXUH 0HGLFLQVNLåXUQDO 0DLGDâLãLUDN0LUVDGD+XNLü$PUD=YL]GLü'DULD%HNLü3UHYDOHQFHDQGDQWLPLFURELDOUHVLVWDQFHRISVHXGRPRQDVDHUXJLQRVDLQWKHZRXQGVZDEV Figure 2. 5HYLHZ RI 3VHXGRPRQDV DHUXJLQRVD SRVLWLYH samples in the different surgical departments. Prevalence of Pseudomonas aeruginosa in the different departments 3ODVWLFVXUJHU\ Orthopaedic surgery Neurosurgery Other clinics 'XULQJ VHYHQ\HDUV SHULRG WKH UHVLVWDQFH WR antibiotics increased noticeably: ceftriaxone from WRFHIWD]LGLPHIURPWR FHIRWD[LPH IURP WR FHIHSLPH IURP WR DPLNDFLQ IURP WR JHQWDP\FLQ IURP WR FLSURÀR[DFLQ IURP WR SLSHUDFLOOLQWD]REDFWDP IURPWRLPLSHQHPIURPWR DQG PHURSHQHP IURP WR )LJXUH The resistance to all antibiotics demonstrated LPSUHVVLYHLQFUHDVHS --)LJXUH 7KH UHVLVWDQFH WR DQWLELRWLFV 3VHXGRPRQDV DHUXJLQRVDLQDQGLQ Resistance to antibiotics Pseudomonas aeruginosa ce ftri ax on e ce fo t ax im e ce fta z id im e ce fe p im e ge nta my cin DP LND FLQ im ipe ne m me ro pe ne m SLS WD ]R ED c ip rof ox ac resistance antibiotics DISCUSSION 3RVWRSHUDWLYH ZRXQG LQIHFWLRQV FRQWLQXHV WR be a major source of morbidity and mortality for patients undergoing operative procedures, despite UHFHQWDGYDQFHVLQWKHRSHUDWLYHWHFKQLTXHVDQG better understanding of the pathogenesis of the wound infections. Diagnosis and treatment of these infection are very expensive and present DGGLWLRQDO ORDG WR KHDOWK LQVXUDQFH IXQGV It is very useful to explore the causes of these infections due to timely detection and removal 0HGLFLQVNLåXUQDO of causative agents. Surveillance of surgical site infection is useful to demonstrate magnitude RI WKH SUREOHP 5HJXODU IHHGEDFN RI ZRXQG LQIHFWLRQ WR WKH VXUJHRQ LV YHU\ LPSRUWDQW 6WXGLHVVXSSRUWWKHFRQFHSWWKDWDUHGXFWLRQLQ postoperative wound infection is directly related to increased education and awareness of its causes 3UHYHQWLRQ LV JUHDWO\ DLGHG E\ FULWLFDOO\ HYDOXDWHGLQIHFWLRQFRQWUROSUDFWLFH 3VHXGRPRQDV DHUXJLQRVD KDV EHHQ UHFRJQL]HG for a long time as one of the leading causes of QRVRFRPLDO ZRXQG LQIHFWLRQV 3VHXGRPRQDV DHUXJLQRVD LQIHFWLRQ LV RIWHQ GLI¿FXOW WR HUDGLFDWH EHFDXVH RI UHVLVWDQFH WR PDQ\ DQWLELRWLFV DQG GLVLQIHFWDQWV &RQVHTXHQWO\ WKLV RUJDQLVP LV DQ HPHUJLQJ therapeutic problem. In our study we wanted to explore the most common causes of wound infections by examination of wound swabs. Especially, we wanted to analyze WKH IUHTXHQF\ DQG DQWLPLFURELDO UHVLVWDQFH RI 3VHXGRPRQDV DHUXJLQRVD LVRODWHG IURP ZRXQG swabs. :H H[DPLQHG VZDEV WDNHQ IURP VXUJLFDO ZRXQGV VZDEV ZHUH SRVLWLYH DQG ZHUH VWHULOH 3VHXGRPRQDV DHUXJLQRVDZDVLVRODWHGLQVZDEV The results obtained showed a high incidence of 3VHXGRPRQDV DHUXJLQRVD DQG LW ZDV WKH PRVW FRPPRQFDXVHRIZRXQGLQIHFWLRQVDPRQJJUDP negative microorganisms. :LWKLQ UHFHQW \HDUV WKHUH KDV EHHQ D JURZLQJ prevalence of this microorganism in many hospitals. Bertrand et al. recorded prevalent rate RI+DQL$HWDOUHFRUGHGLPSUHVVLYH LQFLGHQFHRI7KLVFRXOGEHDWWULEXWHGWR differences in geographical location and hygienic PHDVXUHV 7KH LQFLGHQFH RI 3VHXGRPRQDV aeruginosa in postoperative wound infection is becoming more serious in developing countries EHFDXVHRIODFNJHQHUDOK\JLHQLFPHDVXUHVPDVV SURGXFWLRQRIORZTXDOLW\DQWLVHSWLFDQGPHGLFLQDO VROXWLRQV IRU WUHDWPHQW DQG GLI¿FXOWLHV LQ SURSHU GH¿QLWLRQRIWKHUHVSRQVLELOLWLHVDPRQJWKHKRVSLWDO VWDII Evaluation of antimicrobial resistance 3VHXGRPRQDVDHUXJLQRVDUHYHDOVWKDWPXOWLGUXJ resistant phenotype dominated as the agent of nosocomial wound infections. The resistance to all antibiotics demonstrated impressive increase S 6HYHUDO VWXGLHV KDYH VKRZQ WKH VLPLODU UHVXOWV 7KHUH ZHUH FRQVLGHUDEOH LQWHUFRXQWU\ YDULDWLRQ LQ WKH SURSRUWLRQ RI PXOWLGUXJ UHVLVWDQW 3VHXGRPRQDV DHUXJLQRVDUDQJLQJIURPLQ7XUNH\WRLQ 6SDLQ*HUPDQ\WKH8.DQG0DOWD Carbapenems have been the agents of choice WR VHULRXV 3VHXGRPRQDV DHUXJLQRVD LQIHFWLRQV but unfortunately resistance to those agents 0DLGDâLãLUDN0LUVDGD+XNLü$PUD=YL]GLü'DULD%HNLü3UHYDOHQFHDQGDQWLPLFURELDOUHVLVWDQFHRISVHXGRPRQDVDHUXJLQRVDLQWKHZRXQGVZDEV LV LQFUHDVLQJ &DUEDSHQHP UHVLVWDQW 3VHXGRPRQDVDHUXJLQRVD&53$LQIHFWLRQVDQG KRVSLWDOZLGH RXWEUHDNV KDYH EHHQ UHSRUWHG IURP PDQ\ FRXQWULHV 3VHXGRPRQDV aeruginosa resistance proportions to carbapenems appear to be rather high all over Europe. The highest proportions of resistance were reported E\ WKH &]HFK 5HSXEOLF DQG *UHHFH All northern European countries still reported UHVLVWDQFHEHORZ'HQPDUN)LQODQG 6ZHGHQHWF Carbapenems susceptibility data in our study indicate that of the two carbapenems, meropenem exhibits robust activity against the resistant SKHQRW\SHVWKDQLPLSHQHP7KLVUHÀHFWVWKHIDFW that the interplay of resistance mechanisms in 3VHXGRPRQDVDHUXJLQRVDGLIIHUVEHWZHHQWKHWZR carbapenems. The resistance to meropenem is PRUHGLI¿FXOWWRDFKLHYHWKDQWRLPLSHQHPEHFDXVH WZR PXWDWLRQV ORVV RI 2SU' DQG XSUHJXODWLRQ RI 0H[$0H[% 2SU0 DUH QHHGHG UDWKHU WKDQ RQH This study provide information on the prevalence of emerging resistance in clinically important RUJDQLVP 3VHXGRPRQDV DHUXJLQRVD DQG KHOS to identify candidate antimicrobials for empiric RU ¿UVWOLQH WUHDWPHQW 'HWHFWLQJ UHVLVWDQFH LV D crucial step in infectious disease management. :HOOGHVLJQHG ORFDO VXUYHLOODQFH SURJUDP LV important tool for the development of rational therapy protocols. CONCLUSION 2XU VWXG\ UHYHDOV WKDW PXOWLGUXJUHVLVWDQW SKHQRW\SH RI 3VHXGRPRQDV DHUXJLQRVD dominated as the cause of nosocomial wound infections. Rapid and accurate reporting of antibiotic resistance is essential in guiding therapeutic decisions. Restriction of the usage DQWLELRWLFV HVSHFLDOO\ WKRVH ZLWK EURDGVSHFWUXP DFWLYLW\ DQG WKRVH LGHQWL¿HG DV DQWLELRWLFV RI ODVW resort is a necessary complement to any infection control strategy. Establishing antimicrobial resistance surveillance systems and implementing measures to support the prudent use of antibiotics by setting evidence based guidelines has been recommended. &RQÀLFWRILQWHUHVW none declared. REFERENCES *DUQHU -6 -DUYLV :5 *UDFH (PRUL 7 +RUDQ 7& +DXJKV -0 &'& GH¿QLWLRQ IRU QRVRFRPLDO LQIHFWLRQV $P-,QIHFW&RQWURO (PRUL 7* *D\QHV 53$Q RYHUYLHZ RI QRVRFRPLDO infections, including the role of the microbiology ODERUDWRU\&OLQ0LFURELRO5HY /HDSHU '- 9DQ *RRU + 5HLOO\ - 3HWURVLOOR 1 *HLVV+.7RUUHV$-%HUJHU$6XUJLFDOVLWHLQIHFWLRQ European perspective of incidence and economic EXUGHQ,QW:RXQG- +HLQ]HOPDQQ06FRWW0/DP7)DFWRUVSUHGLVSRVLQJ WREDFWHULDOLQYDVLRQDQGLQIHFWLRQ$P-6XUJHU\ 0DUWRQH :- 1LFKROV 5, 5HFRJQLWLRQ SUHYHQWLRQ surveillance and management of surgical site infection: introduction to the problem and symposium overview. &OLQ,QIHFW'LV6XSSO 7ULOOD $ (SLGHPLRORJ\ RI QRVRFRPLDO LQIHFWLRQV LQ DGXOWLQWHQVLYHFDUHXQLWV,QW&DUH0HG $QXSXUED 6 %KDWWDFKDUMHH $ *DUJ $ 6HQ 05 $QWLPLFURELDOVXVFHSWLELOLW\RI3VHXGRPRQDVDHUXJLQRVD LVRODWHGIURPZRXQGLQIHFWLRQV,QGLDQ-'HUPDWRO $QGUHDVVHQ -- .RUVDJHU %$OVWUXS 3 -HSVHQ 2% 3RVWRSHUDWLYH ZRXQG LQIHFWLRQ ,QGLFDWRU RI FOLQLFDO TXDOLW\"'DQ0HG%XOO *D\QHV 5 (GZDUGV -5 1DWLRQDO 1RVRFRPLDO Infections Surveillance System. 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An epidemiological study of the susceptibility DQG IUHTXHQF\ RI PXOWLSOHGUXJUHVLVWDQW VWUDLQV RI 3VHXGRPRQDVDHUXJLQRVDLVRODWHGDWPHGLFDOLQVWLWXWHV QDWLRQZLGHLQ-DSDQ-,QIHFW&KHPRWKHU *RRVVHQV + 6XVFHSWLELOLW\ RI PXOWLGUXJUHVLVWDQW 3VHXGRPRQDV DHUXJLQRVD LQ LQWHQVLYH FDUH XQLWV UHVXOWV IURP WKH (XURSHDQ 0<67,& VWXG\ JURXS &OLQ 0LFURELRO,QIHFW 0F*RZDQ -( 5HVLVWDQFH LQ QRQIHUPHQWLQJ JUDP negative bacteria: multidrug resistance to the maximum. $P-,QIHFW&RQWURO /X]]DUR)0DQWHQJROL(3HULOOL0HWDO'\QDPLFV RI D QRVRFRPLDO RXWEUHDN RI PXOWLGUXJUHVLVWDQW 3VHXGRPRQDV DHUXJLQRVD SURGXFLQJ WKH 3(5 H[WHQGHGVSHFWUXP ȕ±ODFWDPDVH - &OLQ 0LFURELRO &'&11,66\VWHP1DWLRQDO1RVRFRPLDO,QIHFWLRQV 6XUYHLOODQFH11,66\VWHPUHSRUWGDWDVXPPDU\IURP -DQXDU\ 0D\ LVVXHG LQ $P - ,QIHFW &RQWURO *RRVVHQV+)HUHFK09DQGHU6WLFKHOH5+%XWOHU && 9DQGHU 6WLFKHOH 5+ 9HUKHLM 7- HW DO 2XWSDWLHQW antibiotic use in Europe and association with resistance: DFURVVQDWLRQDOGDWDEDVHVWXG\/DQFHW ($566 $QQXDO 5HSRUW $QWLPLFURELDO UHVLVWDQFHLQ(XURSH7KH1HWKHUODQGV 6XDUH]&3HQD&$UFK2'RPLQJXH]0$7XEDX ) -XDQ & HW DO$ ODUJH VXVWDLQHG HQGHPLF RXWEUHDN RI PXOWLUHVLVWDQW3VHXGRPRQDV DHUXJLQRVD D QHZ HSLGHPLRORJLFDO VFHQDULR IRU QRVRFRPLDO DFTXLVLWLRQ %0&,QIHFW'LVGRL .RKOHU70LFKHD+DP]HKSRXU0(SS6)3HFKHUH -& &DUEDSHQHP DFWLYLWLHV DJDLQVW 3VHXGRPRQDV DHUXJLQRVD$QWLPLFURE$JHQWV&KHPRWKHU Address: 0DLGDâLãLUDN0'06F 'HSDUWPHQWRI&OLQLFDO0LFURELRORJ\ Clinical Centre University of Sarajevo %ROQLþND6DUDMHYR Bosnia and Herzegovina 3KRQH (PDLOPDLGDVLVLUDN#\DKRRFRP Naš prilog redukciji kardiovaskularnih bolesti ! Our contribution in reduction of cardiovascular diseases ! 0HGLFLQVNLåXUQDO -R]RûRULü%HULQD+DVDQHIHQGLü%HOPDäROMLü/HMOD+DVDQEHJRYLü$QDO\WLFDOHYDOXDWLRQRIWKHDXWLRQK\EULG$8DXWRPDWHGXULQHDQDO\]HU Original article $1$/<7,&$/ (9$/8$7,21 2) 7+( $87,21 +<%5,' $8 $8720$7(' 85,1($1$/<=(5 $1$/,7,ý.$352&-(1$85,16.2*$1$/,=$725$$87,21+<%5,'$8 -R]RûRULü%HULQD+DVDQHIHQGLü%HOPDäROMLü/HMOD+DVDQEHJRYLü 'HSDUWPHQWRI&OLQLFDO&KHPLVWU\&OLQLFDO&HQWHU8QLYHUVLW\RI6DUDMHYR%ROQLþND6DUDMHYR%RVQLDDQG Herzegovina &RUUHVSRQGLQJDXWKRU ABSTRACT Automation is necessary in laboratory system; LW HQDEOHV UHGXFWLRQ RI WLPH UHTXLUHG IRU VDPSOH analysis, as well as standardization of methods. Aim of this study is to compare the diagnostic per IRUPDQFHRI$XWLRQ+\EULG$8DQDO\]HUDQG determine the convenience of use in the labora tory. $ WRWDO RI FRQVHFXWLYH IUHVK XULQH VDPSOHV were analyzed by microscopy and automated analyzers. Certain elements of urine sediment separated by manual microscopy were compared WR WKRVH DQDO\]HG E\ WKH$XWLRQ +\EULG$8 V\VWHP HU\WKURF\WHV OHXNRF\WHV FU\VWDOV F\OLQ GHUV DQG EDFWHULD 3UHFLVLRQ RI WKH V\VWHP ZDV tested using two commercial control urine mate rials. All elements of chemical examination were compared, such as: glucose, proteins, bilirubin, XURELOLQRJHQ S+ NHWRQHV QLWULWHV DQG VSHFL¿F gravity. Conclusion: Automated urinalysis Aution Hybrid $8 V\VWHPV FDQ VDYH ODERU DQG WLPH DQG DUHYDOXDEOHLQKLJKYROXPHODERUDWRULHV7KHVHQ VLWLYLW\ DQG VSHFL¿FLW\ RI $XWLRQ +\EULG $8 would remove the need for manual microscopy for most specimens. The chemical urinalysis system showed excellent agreement. Keywords: automated urine analysis, urine sedi ment, chemical urine analysis 6$ä(7$. $XWRPDWL]DFLMDMHQHRSKRGQDXODERUDWRULMVNLPVLV WHPLPD1MRPHVHSRVWLåHVNUDüHQMHYUHPHQDQH RSKRGQRJ]DDQDOL]LUDQMHX]RUDNDNDRLVWDQGDU GD]DFLMDPHWRGD&LOMRYHVWXGLMHMHGDNRPSDULUDMX UH]XOWDWLRGUHÿLYDQMDQDDXWRPDWVNRPDQDOL]DWRUX $XWLRQ+\EULG$8VDPDQXDOQLPWHKQLNDPD ,]YUãHQR MH XSRUHGQR RGUHÿLYDQMH X]RUDND XULQD QD DXWRPDWVNRP VLVWHPX L PLNURVNRSVNLP metodama. Elementi sedimenta urina separirani VXPDQXHOQRPPLNURVNRSLMRPLNRPSDULUDQLVDDX WRPDWVNLP DQDOL]DWRULPD$XWLRQ +\EULG $8L WR HULWURFLWL OHXNRFLWL NULVWDOL FLOLQGUL L EDNWHULMH 3UHFL]QRVW MH WHVWLUDQD NRULãWHQMHP GYD NRPHUFL MDOQD NRQWUROQD XULQVND X]RUND .RPSDULUDQD VX HOHPHQWL NHPLMVNRJ LVSLWLYDQMD XULQD L WR JOXNR]D SURWHLQLELOLUXELQXURELOLQRJHQS+NHWRQLQLWULWLL VSHFL¿þQDWHåLQD =DNOMXþDN $XWRPDWVND DQDOL]D XULQD SRPRüX DQDOL]DWRUD $XWLRQ +\EULG $8 VNUDüXMH YUL MHPH SRWUHEQR ]D DQDOL]X QDURþLWR X ODERUDWRUL MDPDVDYHOLNLPEURMHPDQDOL]D'REUDRVMHWOMLYRVW L VSHFL¿þQRVW XULQVNRJ DQDOL]DWRUD $XWLRQ +\EULG $8 VPDQMXMH SRWUHEX ]D PDQXHOQRP PLN URVNRSLMRPNRGYHüLQHX]RUDND .OMXþQHULMHþL automatizirana analiza urina, sedi PHQWXULQDNHPLMVNLSUHJOHGXULQD INTRODUCTION 8ULQH DQDO\VLV LV RQH RI WKH PRVW IUHTXHQWO\ XWL lized analyses in the routine laboratory practice 5RXWLQHH[DPLQDWLRQRIXULQHE\YLVXDOFKHPL cal, and microscopic means has become an es sential part of many diagnostic evaluations, par ticularly when renal or urinary tract involvement LVVXVSHFWHG%HFDXVHXULQDO\VLVKDVEHFRPH DKLJKYROXPHSURFHGXUHPDQXDOUHDGLQJRIGLS VWLFNVDQGH[DPLQDWLRQRIXULQHVHGLPHQWUHTXLUH DODUJHH[SHQGLWXUHRIODERU Automation is necessary in laboratory systems. ,W HQDEOHV UHGXFWLRQ RI WLPH UHTXLUHG IRU VDPSOH analysis, as well as standardization of methods. Not long ago, the necessary automated system IRUXULQHDQDO\VHVKDYHDOVREHHQGHYHORSHG Urine analysis should be based on standardized procedures of sample gathering, transporting and DQDO\]LQJ:LWKLQWKHVFRSHRIVWDQGDUGL]DWLRQRI these procedures, there is a necessity of results interpretation correlation and referent ranges cor 0HGLFLQVNLåXUQDO -R]RûRULü%HULQD+DVDQHIHQGLü%HOPDäROMLü/HMOD+DVDQEHJRYLü$QDO\WLFDOHYDOXDWLRQRIWKHDXWLRQK\EULG$8DXWRPDWHGXULQHDQDO\]HU UHODWLRQ 7R LPSURYH VWDQGDUGL]DWLRQ WKH (X URSHDQ&RQIHGHUDWLRQRI/DERUDWRU\0HGLFLQHKDV SXEOLVKHG*XLGHOLQHVIRU0DQXDO&RXQWLQJRI3DU WLFOHVLQ1RQ&HQWULIXJHGDQG&RQFHQWUDWHG8ULQH 6DPSOHVLQ The objective of this paper is to perform the ana O\WLFDO HYDOXDWLRQ $XWLRQ +\EULG $8 V\VWHP in relation to the standardized microscopes urine VHGLPHQW DQG FKHPLFDO XULQH DQDO\VLV 4XDQWLWD tive results are reported directly for red blood cells 5%& ZKLWH EORRG FHOOV :%& EDFWHULD %$& HSLWKHOLDOFHOOV(&WRWDOFDVWV&$67DQGEDF WHULD%$&7 centration ranges. Statistical analysis, descriptive VWDWLVWLFVDQGFRHI¿FLHQWRIFRUUHODWLRQZHUHSHU IRUPHGXVLQJ0LFURVRIW2I¿FH([FHOSURJUDP5H VXOWVDUHH[SUHVVHGDVPHDQDQGWKHFRHI¿FLHQW RIYDULDWLRQ RESULTS Inaccuracy of the microscope module in series was determined in ten measurements in Aution &RQWURO6ROXWLRQ/DQG+ 7DEOH Inaccuracy of individual analyses according to de clared values control solution in normal and pathological range. MATERIALS AND METHODS 8ULQH6SHFLPHQV 8ULQH VSHFLPHQV IURP SDWLHQWV ZHUH FROOHFW ed. Fresh urine samples submitted to the labora tory were selected for the study and stored at 4 0C for a maximum of 4h until analyzed to avoid interference of preservative added to the samples. Analytical procedures $XWLRQ +\EULG$8 LV FRPSOHWHO\ DXWRPDWHG urine analyzing system. Chemical module for XULQHDQDO\VLVLQWKHVFRSH$XWLRQ+\EULG$8 is simple to use because, after positioning the VDPSOHLQWRWKHVWDQGLWLVRQO\UHTXLUHGWRLQVHUW WKHVWLFNLQWKHGUXPRIWKHLQVWUXPHQWDQGSUHVV the Start button. The pipette aspirates the sample, agitates it and automatically distributes the drops RQ WKH WHVW VWLFNV 0LQLPXP YROXPH RI XULQH UH TXLUHG IRU FKHPLFDO DQDO\VLV LV P/ DVSLUDWLQJ YROXPH LV P/ 7KH PHDVXUHPHQW PHWKRGV DUH WKH IROORZLQJ 7HVW 6WULS'XDO VLQJOH :DYH OHQJKW 5HÀHFWDQFH 0HWKRG 6SHFL¿F *UDYLW\5H IUDFWLYH ,QGH[ 0HWKRG &RORU)RXU :DYHOHQJKW 5HÀHFWDQFH 0HWKRG DQG 7XUELGLW\7UDQVSDUHQF\ ,QGH[0HWKRGV 7KH $XWLRQ +\EULG $8 LQFRUSRUDWHV ÀRZ cytometry and impedance to identify and count formed elements in urine sediment. Stained urine LV VFDQQHG DW D KLJK ÀRZ UDWH E\ DQ DUJRQ ODVHU EHDPZLWKOLJKWVFDWWHUÀXRUHVFHQFHDQGLPSHG ance measured simultaneously. Signal rations are then processed by mathematical cluser analysis to LGHQWLI\DQGTXDQWLWDWHIRUPHGVHGLPHQWHOHPHQWV %\ WKH $XWLRQ +\EULG $8 V\VWHP DQG WKH standard procedures of manual microscopy and FKHPLFDOXULQHDQDO\VLVE\0XOWLVWL[VWLFNIRUXULQH FKHPLFDODQDO\VLVVDPSOHVZHUHDQDO\]HGFRP paratively. The samples were analyzed not later than two hours after receipt. For an analytical evaluation of the Aution Hybrid $8 V\VWHP PLFURVFRSH PRGXOH WKH IROORZ ing test was performed: inaccuracy test in series, GD\DIWHUGD\ LQDFFXUDF\ UHSURGXFLELOLW\ E\ XV LQJ$XWLRQ&RQWURO6ROXWLRQ/DQG+LQYDULRXVFRQ 0HGLFLQVNLåXUQDO 3UHFLVLRQRIWKH$8:LWKLQUXQLPSUHFLVLRQ RI $8 ZDV HYDOXDWHG E\ DQDO\]LQJ XULQH control material a total of 10 times during the same GD\7KHUHVXOWVDUHVXPPDUL]HGLQWDEOHVDQG Table 2. :LWKLQ5XQ ,PSUHFLVLRQ RI WKH $8 $XWRPDWHG 8ULQH0LFURVFRS\$QDO\]HU/VROXWLRQ 7DEHOH :LWKLQ5XQ ,PSUHFLVLRQ RI WKH$8$XWRPDWHG 8ULQH0LFURVFRS\$QDO\]HU+VROXWLRQ -R]RûRULü%HULQD+DVDQHIHQGLü%HOPDäROMLü/HMOD+DVDQEHJRYLü$QDO\WLFDOHYDOXDWLRQRIWKHDXWLRQK\EULG$8DXWRPDWHGXULQHDQDO\]HU :LWKLQUXQ LPSUHFLVLRQ RI FHOO FRXQWV RI WKH $QDO\]HUH[SUHVVHGDV&9PHDQFHOOFRXQW+3) ZDV IRU HU\WKURF\WHV IRU ZKLWH EORRG FHOOV :%& IRU HSLWKHOLDO FHOO (& DQG FDVW $ GD\DIWHUGD\ LQDFFXUDF\ PHDVXUHPHQW ZDV carried out in the period of 10 days, also by using DQ$XWLRQ&RQWURO6ROXWLRQ/DQG+ Except for urobilinogen, by the automated system FKHPLFDO PRGXOH VRPH PRUH SRVLWLYH ¿QGLQJV ZHUHGHWHFWHGWKDQE\XVLQJ0XOWLVWL[VWLFNV Results obtained by comparative testing of urine VSHFL¿F JUDYLW\ DQG S+ YDOXH DUH SUHVHQWHG LQ Table 7. Table 7. &RPSDULVRQ EHWZHHQ S+ DQG VSHFL¿F JUDYLW\ XVLQJ 0XOWLVWL[VWLFNDQG$8FKHPLFDOPRGXOH 7DEOH%HWZHHQ5XQ,PSUHFLVLRQRIWKH$8$XWRPDWHG 8ULQH0LFURVFRS\$QDO\]HU/VROXWLRQ A comparison of pH value results, higher correlation rate was obtained than in the case of VSHFL¿FJUDYLW\ DISCUSSION 7DEOH%HWZHHQ5XQ,PSUHFLVLRQRIWKH$8$XWRPDWHG 8ULQH0LFURVFRS\$QDO\]HU+VROXWLRQ %HWZHHQUXQ LPSUHFLVLRQ RI WKH $8 $XWRPDWHG 8ULQH 0LFURVFRS\ $QDO\]HU ZDV H[FHOOHQW DW KLJK FHOO FRXQWV EDVHG RQ &9 OHVV WKDQIRU&$67FRXQWV$WORZHUFHOOFRXQWV EHWZHHQUXQ LPSUHFLVLRQ ZDV JRRG DSSURDFKLQJ IRU5%&FRXQWV The results obtained by comparative testing of XULQH FKHPLFDO DQDO\VHV SHUIRUPHG E\ 0XOWLVWL[ VWLFN DQG E\ DQ $XWLRQ +\EULG$8 DQDO\]HU DUHSUHVHQWHGLQ7DEOH Table 68ULQHFKHPLFDOH[DPLQDWLRQVZLWK0XOWLVWL[VWLFNVDQG $XWLRQ +\EULG $8FKHPLFDO PRGXOHUHYLHZ RI SRVLWLYH results. 7KH$XWLRQ+\EULG$8LVDQHZDXWRPDWHG V\VWHPIRUURXWLQHLGHQWL¿FDWLRQRIFHOODQGSDUWLFOHV in native urine. Our study was intended to evaluate automated urinalysis systems for comparability of results with discrepancies resolved by selected PDQXDOPLFURVFRSLFUHYLHZRIVHGLPHQWHI¿FLHQF\ of chemical urinalysis to minimize the need for sediment analysis, and relative ease and convenience of operability. The operation of LQVWUXPHQW ZDV VLPSOH PDLQWHQDQFH UHTXLUHG only a few minutes a day and no malfunctions were observed during the evaluation period which ODVWHGDERXWRQHPRQWK ,QKRVSLWDOLQVWLWXWLRQVWKHUHLVDIUHTXHQWSUREOHPRI SURPSWGHOLYHU\RIWKH¿UVWPRUQLQJXULQHVDPSOHV from certain clinics. Therefore, the recommended WLPH RI KRXUV GXULQJ ZKLFK WKH XULQH DQDO\VLV should be carried out, is exceeded in numerous cases. The samples in this study were analyzed ZLWKLQKRXUVIURPUHFHLSWRIPDWHULDO 6WDQGDUG GHYLDWLRQV DQG FRHI¿FLHQWV RI YDULDWLRQ cannot be calculated for test strip Analyzers operating in discrete mode, so in the tables the percentage of times the instrument repeats a FHUWDLQYDOXHLVLQGLFDWHG :LWKLQUXQ LPSUHFLVLRQ RI FHOO FRXQWV RI WKH $QDO\]HU H[SUHVVHG DV &9 PHDQ FHOO FRXQW +3)ZDVIRUHU\WKURF\WHVIRUZKLWHEORRG FHOOV :%& IRU HSLWKHOLDO FHOO (& DQGFDVW%HWZHHQUXQLPSUHFLVLRQRIFHOO FRXQWVRIWKH$QDO\]HUZDVIRUHU\WKURF\WHV IRU ZKLWH EORRG FHOOV :%& IRU HSLWKHOLDO FHOO (& DQG FDVW 7KHUH ZHUH discrepancies between sediment counts, with 11 for red blood cells, 8 for white blood cells. Arbitration of these discrepancies with manual PLFURVFRS\ IDYRUHG $XWLRQ +\EULG $8 Except for urobilinogen, by the automated system 0HGLFLQVNLåXUQDO -R]RûRULü%HULQD+DVDQHIHQGLü%HOPDäROMLü/HMOD+DVDQEHJRYLü$QDO\WLFDOHYDOXDWLRQRIWKHDXWLRQK\EULG$8DXWRPDWHGXULQHDQDO\]HU $8 VRPH PRUH SRVLWLYH ¿QGLQJV ZHUH GHWHFWHG DOWKRXJK LQVLJQL¿FDQWO\ WKDQ E\ XVLQJ 0XOWLVWL[VWLFN The results obtained by a comparative analysis RI0XOWLVWL[VWLFNDQG$8PRVWO\PDQLIHVWHG satisfactory compatibility. Testing pH value SURYLGHV UHPDUNDEOH FRUUHODWLRQ S DV ZHOO DV WHVWLQJ VSHFL¿F JUDYLW\ EXW WR D VRPHZKDWORZHUGHJUHHS Although automation has already been widely used in laboratory diagnostics, in urine analysis it still does not have such an important role. 0DQXDOPLFURVFRS\DQGXWLOL]DWLRQRIYDULRXVVWLFN for chemical analysis are still common in almost all laboratories. Utilization of urine samples WKDW GR QRW UHTXLUH DQ\ SUHSDUDWLRQ SURFHGXUH H[ FHQWULIXJLQJ FRPSOHWH VWDQGDUGL]DWLRQ RI WKH DQDO\VW DV ZHOO DV VKRUWHU WLPH UHTXLUHG IRU sample analysis provide great advantage for the automated system in comparison to manual WHFKQLTXHLQURXWLQHRSHUDWLRQ CONCLUSION Utilization of automated urine analyzing systems is recommendable, especially in institutions with a large number of daily analyses. Total average time needed for single urinalysis decreased from WRPLQXWHV7KHSRVVLELOLW\RIUHSRUWLQJ WKH ¿QGLQJV QXPEHU KLJK SRZHU ¿HOG KDV HDVHG the transition from manual to automated urinalysis for both the clinicians and patients. &RQÀLFWRILQWHUHVW none declared. :DK 7 :LVLV . %XWFK : $QDO\WLF 3HUIRUPDQFH RI WKH 4 $XWRPDWHG 8ULQH 0LFURVFRS\ $QDO\]HU DQG &RPDUDVLRQ :LWK 0DQXDO &RXQWV 8VLQJ )XFKV5RVHQWKDO &HOO &KDPEHUV $P - &OLQ 3DWKRO $NLQ 2. 6HUGDU 0$ &L]PHFL = &RPSDUDVLRQ RI /DE0DW ZLWK 8UL6HG DQG L4 IXOO\ DXWRPDWLF XULQH sediment Analyzers with manual urine analysis. %LRWHFKQRO$SSO%LRFKHP .RXUL77*DQW9$)DJR]]L*%7RZDUGV(XURSHDQ urinanalysis guidelines: introduction of a project under (XURSHDQ &RQIHGHUDWLRQ RI /DERUDWRU\ 0HGLFLQH &OLQ &KLP$FWD 7. Aslan D, Sandreberg S. Simple statistics in diagnostic WHVWV-RXUQDORI0HGLFDO%LRFKHPLVWU\ %ODQG -0 $OWPDQ '* 6WDWLVWLFDO PHWKRGV IRU assessing agreement between two methods of clinical PHDVXUHPHQW%LRFKLP&OLQ $NLQ 2. 6HUGDU 0$ &L]PHFL = *HQF 2$\GLQ 6 &RPSDULVRQ RI /DE0DW ZLWK 8UL6HG DQG L4 IXOO\ automatic urine sediment Analyzers with manual urine DQDO\VLV %LRWHFKQRO $SSO %LRFKHP 107. %RQLQL3/XFLOOD&*URVVL/&HULRWWL)0XURQH0 Automation in urinalysis: evaluation of three urine test VWULS$QDO\]HUV-$XWRPDW&KHP /LQNR6.DXUL777RLYRQHQ($QDO\WLFDOSHUIRUPDQFH RIWKH,ULVL4DXWRPDWHGXULQHPLFURVFRS\$QDO\]HU &OLQLFD&KLPLFD$FWD 7KRPVRQ 5 *DPPLH $ /HZLV ' 6PLWK 5 Automated urine screening systems. Bristol Urological ,QVWLWXWH%8,,VVXH +XJKHV&5RHEXFN0(YDOXDWLRQRIWKH,5,6 ÀRZPLFURVFRSHDVDVFUHHQLQJV\VWHPIRUXULQDU\WUDFW LQIHFWLRQ-&OLQ3DWK REFERENCES 7RIIDOHWWL - 'RWVRQ 0 6KDUPDQ 3 &RPDUDVLRQ RI $XWRPDWHG 6\VWHPV IRU 8ULQH 6HGLPHQW $QDO\VLV /DERUDWRU\+HPDWRORJ\ ýDUEDNDSD 9 ĈHULü 0 6WRãLü = 7HVWLQJ RI ,4 automated urine analyzer analytical performances LQ FRPSDUDVLRQ ZLWK PDQXDO WHFKQLTXHV -RXUQDO RI 0HGLFDO%LRFKHPLVWU\ +XJKHV&5RHEXFN0(YDOXDWLRQRIWKH,5,6 8G[ÀRZPLFURVNRSHDVDVFUHHQLQJV\VWHPIRUXULQDU\ WUDFWLQIHFWLRQ-&OLQ3DWKRO 0HGLFLQVNLåXUQDO Address: 3URI-R]RûRULü3K' Department of Clinical Chemistry Clinical Center University of Sarajevo %ROQLþND6DUDMHYR Bosnia and Herzegovina 3KRQH (PDLOFRULFMR]R#KRWPDLOFRP $OPD$OLKRGåLü3DãDOLü6DIHW*XVND$OHQ3LODY.HPDO*UELü&RPSDULVRQRIHI¿FLHQF\RISOHXURGHVLVZLWKGLIIHUHQWVFOHURVDQVWKURXJKSOHXUDOFDWKHWHU Original article COMPARISON OF EFFICIENCY OF PLEURODESIS WITH DIFFERENT SCLEROSANS THROUGH PLEURAL CATHETER .203$5$&,-$ (),.$61267, 3/(852'(=( 5$=/,ý,7,0 6./(52=$16,0$ .52=3/(85$/1,.$7(7(5 $OPD$OLKRGåLü3DãDOLü6DIHW*XVND$OHQ3LODY.HPDO*UELü &OLQLFRI7KRUDFLF6XUJHU\&OLQLFDO&HQWHU8QLYHUVLW\RI6DUDMHYR%ROQLþND6DUDMHYR%RVQLDDQG+HU zegovina &RUUHVSRQGLQJDXWKRU ABSTRACT 0DOLJQDQW SOHXUDO HIIXVLRQ 03, LV WKH PRVW IUH TXHQWLQWKHODWHSKDVHRIWKHPDOLJQDQWGLVHDVH LQXSWRRIFDVHVZKLOHWKHIUHTXHQF\LQWKH HDUO\SKDVHLVEHWZHHQWKH±'\VSQHDLV WKHPRVWIUHTXHQWV\PSWRPDQGDVDUXOHWKHHI¿ cient palliation of dyspnea should be the main ob jective of the therapy. The aim of the study is the comparative analyses for chemical pleurodesis by doxycycline and talc installed through the pleural FDWKHWHU 3OHXUDFDQ DQDO\VHV RI WKH OHQJWK RI the period of thoracic drainage and appearance of the complications and assessment of the sub jective parameters of patient prior and after the pleurodesis with the impact of the pleurodesis to WKHTXDOLW\RIOLIH5HWURVSHFWLYHDQDO\VHVLQFOXGHG SDWLHQWVWRZKRPWKHFKHPLFDOSOHXURGHVLVKDV been conducted by talc or doxycycline through the pleural catheters at the Clinic for Thoracic Surgery RI &&86 LQ WKH SHULRG IURP -DQXDU\ WR -DQXDU\,QFOXVLRQFULWHULDZHUHERWKJHQ ders, established pleural effusion with prior estab OLVKHG PDOLJQDQW FRQGLWLRQ .DUQRIVN\ LQGH[ OLIH H[SHFWDQF\ RYHU GD\V VXEMHFWLYH DQG objective better general conditions after the thora cocentesis. The thoracostomy was performed to all patients with pleural catheter and patients were divided into two groups depending on type of scle URVDQV*URXS3OHXURGHVLVE\WDOFDQG*URXS 3OHXURGHVLVE\GR[\F\FOLQH3RVWSOHXURGHVLVFRQ trols were conducted once a month until the third PRQWK ZKHQ WKH HI¿FLHQF\ ZDV DVVHVVHG 7KH VXFFHVV ZDV FDWHJRUL]HG DV FRPSOHWH WKHUH LV QRUHDFFXPXODWLRQZLWKLQPRQWKVDIWHUWKHLQWHU YHQWLRQSDUWLDOOHVVUHDFFXPXODWLRQLQFRPSDUL VRQ WR WKH SUHGUDLQDJH OHYHO DQG XQVXFFHVVIXO VDPHRUODUJHUUHDFFXPXODWLRQ6WDWLVWLFDODQDO \VLVZDVGRQHE\VWDWLVWLFDOIXQFWLRQVRI06([FHO software with application of appropriate statistical PHWKRGV'HWHUPLQHGOHYHORIVLJQL¿FDQFHZDVS &RPSOHWH VXFFHVV RI SOHXURGHVLV E\ WDOF ZDVLQE\GR[\F\FOLQHLQ SDWLHQWV UHVSHFWLYHO\ 7KH PRVW IUHTXHQW symptoms prior to pleurodesis were: dyspnea in FRXJK LQ IDWLJXH LQ DQG SDLQ LQ RI FDVHV/RVVRIERG\ZHLJKWKDVEHHQHVWDEOLVKHG LQ RI SDWLHQWV7KH IUHTXHQF\ RI same symptoms after the pleurodesis was as fol ORZVG\VSQHDFRXJKDQGSDLQHDFKLQ DQGIDWLJXHLQSDWLHQWVZKLOH the additional loss of body weight has been es WDEOLVKHGLQRIFDVHV7KHDYHUDJH OHQJWKRIGUDLQDJHIRUDOOSDWLHQWVZDV GD\V 7KH DYHUDJH OHQJWK RI GUDLQDJH IRU *URXSZDVDQGWKH*URXS GD\V7KHUHLVQRVWDWLVWLFDOO\VLJQL¿FDQWGLIIHUHQFH S!LQWKHOHQJWKRIGUDLQDJHEHWZHHQWKHWZR JURXSV7KHPRVWIUHTXHQWFRPSOLFDWLRQZDVIHYHU LQDQGSDLQLQSD tients. Conclusions: Applying pleural catheter with chemical pleurodesis can achieve identical results as when using standard thoracic drainage. In rela WLRQWRWKHDSSOLHGVFOHURVLQJDJHQWWDOFYVGR[\ F\FOLQH VXFFHVV RI SOHXURGHVLV ZDV EHWWHU ZKHQ using talc. Key words: malignant pleural effusion, pleural catheter, chemical pleurodesis 6$ä(7$. 0DOLJQL SOHXUDOQL L]OMHY 03, QDMþHãüH VH MDY OMD X NDVQRM ID]L HYROXFLMH PDOLJQH EROHVWL L GR X VOXþDMHYD GRN MH XþHVWDORVW X UDQRM ID]L L]PHÿX 'LVSQHD MH QDMþHãüL VLPSWRP L X SUDYLOX EL NRULVQD L H¿NDVQD SDOLMDFLMD GLVSQHH trebala biti glavni cilj terapije. Cilj rada je uraditi NRPSDUDWLYQX DQDOL]D KHPLMVNH SOHXURGH]H+3 GRNVLFLNOLQRP L WDONRP LQVWLOLUDQLK NUR] SOHXUDO QL NDWHWHU 3OHXUDFDQ $QDOL]D GXåLQH WUDMDQMD WRUDNDOQHGUHQDåHLSRMDYDNRPSOLNDFLMD3URFMHQD VXEMHNWLYQLK SDUDPHWDUD SDFLMHQDWD SULMH L SRVOLMH 0HGLFLQVNLåXUQDO $OPD$OLKRGåLü3DãDOLü6DIHW*XVND$OHQ3LODY.HPDO*UELü&RPSDULVRQRIHI¿FLHQF\RISOHXURGHVLVZLWKGLIIHUHQWVFOHURVDQVWKURXJKSOHXUDOFDWKHWHU SOHXURGH]HXVPLVOXXWLFDMDSOHXURGH]HQDNYDOLWHW åLYRWD5HWURVSHNWLYQDDQDOL]DXNOMXþXMHSDFLMH QDWDNRMLPDMHXUDÿHQD+3WDONRPLOLGRNVLFLNOLQRP SUHNR SOHXUDOQLK NDWHWHUD QD .OLQLFL ]D WRUDNDOQX KLUXUJLMX .&86 X SHULRGX RG GR JRGLQH .ULWHULML ]D XNOMXþHQMH X VWXG LMX RED SROD XWYUÿHQ SOHXUDOQL L]OLY NRG SUHWK RGQR XVWDQRYOMHQRJ PDOLJQLWHWD .DUQRIVNL LQGH[ RþHNLYDQR WUDMDQMH åLYRWD SUHNR GDQD VXEMHNWLYQR L REMHNWLYQR EROMH RSãWH VWDQMH QDNRQ WRUDNRFHQWH]H6YLPSDFLMHQWLPDMHXUDÿHQDWRUD NRVWRPLMDVDSOHXUDOQLPNDWHWHURPLSRGMHOMHQLVX X GYLMH JUXSH RYLVQR R YUVWL VNOHUR]DQVD *UXSD SOHXURGH]DWDONRPL*UXSDSOHXURGH]DGRN VLFLNOLQRP 3RVWSOHXURGH]QH NRQWUROH VX YUãHQH MHGQRP PMHVHþQR GR WUHüHJ PMHVHFD NDGD VH SURFMHQMLYDOD H¿NDVQRVW SURYHGHQH SOHXURGH]H 8VSMHK+3VHNDWHJRUL]LUDRNDRNRPSOHWDQQHPD UHDNXPXODFLMH XQXWDU PMHVHFD QDNRQ LQWHUYHQ FLMHSDUFLMDODQPDQMDUHDNXPXODFLMDXRGQRVXQD SUHGUHQDåQLQLYRLQHXVSMHãDQLVWDLOLYHüDUHDNX PXODFLMD6WDWLVWLþNDREUDGDSRGDWDNDMHXUDÿHQD VWDWLVWLþNLPIXQNFLMDPDVRIWYHUVNRJSURJUDPD06 ([FHO X] SULPMHQX RGJRYDUDMXüLK VWDWLVWLþNLK PH WRGD2GUHÿHQLQLYR]QDþDMQRVWLMHS.RP SOHWDQXVSMHKSOHXURGH]HWDONRPMHELRNRG DGRNVLFLNOLQRPNRGSDFL MHQDWD 1DMþHãüL VLPSWRPL SULMH SOHXURGH]H VX GLVSQHDXVWDQRYOMHQDNRGNDãDOM NRG]DPRUNRGLERONRG VOXþDMHYD*XELWDN77MHXVWDQRY OMHQNRGSDFLMHQDWD8þHVWDORVWLV WLKVLPSWRPDQDNRQSOHXURGH]HMHELODNDNRVOLMHGL GLVSQHDNDãDOMLEROVDSRL]DPRU NRG SDFLMHQDWD D GDOML JXELWDN 77 MH XVWDQRYOMHQNRGVOXþDMHYD3URVMHþQR WUDMDQMHGUHQDåH]DVYHSDFLMHQWHMHELOR GDQD3URVMHþQRWUDMDQMHGUHQDåHNRGJUXSH VD WDON SOHXURGH]RP D JUXSH VD GRN VLFLNOLQRP GDQD 1H SRVWRML VWDWLVWLþNL ]QDþDMQDUD]OLNDXGXåLQLWUDMDQMDGUHQDåHL]PHÿX GYLMH JUXSH S! 1DMþHãüD NRPSOLNDFLMD MH ELOD WHPSHUDWXUD NRG L ERO NRG SDFLMHQDWD =DNOMXþDN SULPMHQRP SOHXUDOQLKNDWHWHUDX]+3PRJXVHSRVWLüLLGHQWLþQL UH]XOWDWLNDRLNRGSULPMHQHVWDQGDUGQHWRUDNDOQH GUHQDåH8RGQRVXQDSULPMHQMHQRVNOHUR]LUDMXüH VUHGVWYR WDON YV GRNVLFLNOLQ XVSMHK SOHXURGH]H NRPSOHWQL L SDUFLMDOQL MH ELR EROML NRG XSRWUHEH WDOND .OMXþQHULMHþLPDOLJQLSOHXUDOQLL]OLYSOHXUDOQLND WHWHUKHPLMVNDSOHXURGH]D INTRODUCTION 0DOLJQDQWSOHXUDOHIIXVLRQ03(LVWKHPRVWIUH TXHQW LQ WKH ODWH SKDVH RI HYROXWLRQ RI WKH PD OLJQDQW GLVHDVH LQ XS WR RI FDVHV ZKLOH WKH IUHTXHQF\LQWKHHDUO\SKDVHLVEHWZHHQ 0HGLFLQVNLåXUQDO <HDUO\WKHUHDUHPRUHWKDQQHZ UHJLVWHUHG FDVHV RI 03( LQ 86$ RXW RI ZKLFK DUH FDXVHG E\ WKH EURQFKLDO RU EUHDVW FDQ FHU7KHSDWLHQWVZLWK03(DUHWUHDWHGPDLQO\ symptomatically since such an effusion indicates to the extended disease. Dyspnea is the most IUHTXHQW V\PSWRP WKDW PD\ EH DVVLJQHG WR WKH HIIXVLRQ LWVHOI$V D UXOH WKH XVHIXO DQG HI¿FLHQW palliation of dyspnea should be the main objec tive of the therapy, especially in patients with tu mors with poor reaction to the given systematic WKHUDS\ 3DOOLDWLYH WUHDWPHQW LV LQLWLDWHG by the thoracocentesis. Thoracocentesis provides fast and satisfactory relief of symptoms caused by WKHSOHXUDOHIIXVLRQEXWLWLVLQHI¿FLHQWLQSUHYHQWLQJ RIUHDFFXPXODWLRQRISOHXUDOOLTXLGHI¿FLHQF\ ,IWKHG\VSQHDHQGDQJHUVWKHTXDOLW\RIWKH patient’s life and if it is the intention to alleviate it for a longer term by the therapeutic intervention, it is necessary to conduct one of the following pro FHGXUHV 6WDQGDUG WKRUDFRVWRP\ ODUJH ERUH GUDLQ )) ZLWK LQVWLOODWLRQ RI VFOHURVDQVH 7KRUDFRVFRS\ ZLWK SOHXUDO DEUDVLRQ DQGRU E\ application of sclerosanse, 3. Thoracostomy with SOHXUDO FDWKHWHU )) DQG SOHXURGHVLV RU (PEHGGLQJ RI WKH SOHXURSHULWRQHDO VKXQW &KHPLFDOSOHXURGHVLVLVRIWHQVXI¿FLHQWRSWLRQIRU FRQWURORIUHDFFXPXODWLRQRISOHXUDOOLTXLGDOOHYLD tion of pain and dyspnea and improvement of the TXDOLW\RIOLIH7KHPDLQREMHFWLYHRIFKHPL cal pleurodesis is to cause the creation of adhe sion between the visceral and parietal pleura thus creating obliteration which eliminates the pres HQFHRISOHXUDOVSDFHSUHYHQWLQJUHDFFXPXODWLRQ RI ÀXLG 7KH PDLQ LQGLFDWLRQ IRU FKHPLFDO pleurodesis is the presence of dyspnea and chest pain, which is proved to be related with pleural ef IXVLRQ7KHUDGLRORJLFDOFRQ¿UPDWLRQLVQHFHVVDU\ VRWKDWWKHOXQJVPD\EHIXOO\UHH[SDQGHG&KHP ical pleurodesis is contraindicated in the patients ZLWK VKRUW OLIH H[SHFWDQF\ GD\V DQG LQ WKH SDWLHQWVZLWKLQFRPSOHWHOXQJUHH[SDQVLRQ$EVR lute contraindications for pleurodesis include the absence of relief of dyspnea after the therapeu WLFWKRUDFRFHQWHVLV³WUDSSHG´OXQJRURFFOXVLRQRI the main bronchus. Relative contraindications for pleurodesis include the terminal condition of pa tient, widespread of metastasis, poor performance VWDWXVDFWLYHDLU¿VWXODVORZS+SOHXUDOOLTXLGVH vere existing lung disease, and the condition after the extensive pleural abrasion or several biopsies. 7RGD\ WKH PRVW IUHTXHQWO\ XVHG DJHQWV ZLWK WKH aim to achieve pleurodesis are talc, doxycycline and bleomycin. Chemical pleurodesis should be FRQGXFWHGLQWKHPRVWHI¿FLHQWWKHPRVWFRPIRUW able and the most humane manner for the patient. Since the placing of the large bores thoracic drains is invasive procedure with potential morbidity and complications, there is a need for the use of small er diameter drains, so called pleural catheters that $OPD$OLKRGåLü3DãDOLü6DIHW*XVND$OHQ3LODY.HPDO*UELü&RPSDULVRQRIHI¿FLHQF\RISOHXURGHVLVZLWKGLIIHUHQWVFOHURVDQVWKURXJKSOHXUDOFDWKHWHU are well tolerated and with minimal complications. 8VHRISOHXUDOFDWKHWHUVLVUHÀHFWLRQRIWKHGHVLUH of the part of the health service providers, patients DQGWKRVH¿QDQFLQJWKHKHDOWKLQVXUDQFHWKDWWKH 03(WUHDWPHQWLIDQGZKHQSRVVLEOHLVFRQGXFWHG on an outpatient basis. Twelve studies with total of SDWLHQWV SXEOLVKHG WKH DSSOLFDWLRQ RI SOHXUDO FDWKHWHUV &K ZLWK WKH JRDO WR DFKLHYH WKH chemical pleurodesis where the average rate of HI¿FLHQF\ZDV Goals The comparative analyses of chemical pleu rodesis with doxycycline or talc instilled through WKH SOHXUDO FDWKHWHU 3OHXUDFDQ DQDO\VHV RI WKH length of the period of thoracic drainage and ap pearance of complications, assessment of the VXEMHFWLYHSDUDPHWHUVG\VSQHDFRXJKSDLQORVV RIERG\ZHLJKWIDWLJXHRISDWLHQWSULRUDQGDIWHU the pleurodesis with the impact of the pleurodesis WRWKHTXDOLW\RIOLIH MATERIALS AND METHODS 5HWURVSHFWLYH DQDO\VHV LQFOXGHG SDWLHQWV WR whom the chemical pleurodesis has been con ducted by talc or doxycycline through the pleural catheters at the Clinic for Thoracic Surgery Clini cal Center University of Sarajevo in period from -DQXDU\XQWLO-DQXDU\7KHFULWHULD for inclusion into study: both genders, pleural effu sion has been established with prior established PDOLJQDQW FRQGLWLRQ .DUQRIVN\ LQGH[ OLIH expectancy over 30 days, subjective and objective better general conditions after the thoracocente VLV7KHFULWHULDIRUH[FOXVLRQIURPVWXG\.DUQRI VN\ LQGH[ SRRU JHQHUDO FRQGLWLRQ ZLWK OLIH expectancy of < 30 days, atelectasis due to endo EURQFKLDO REVWUXFWLRQ YLVFHUDO SOHXUDO WKLFNHQLQJ pleural empyema, inability to achieve the full lung UHH[SDQVLRQ DQG FRQWDFW EHWZHHQ WKH YLVFHUDO DQGSDULHWDOSOHXUDH[LVWLQJOXQJVGLVHDVHODUJH DLU ¿VWXOD DQG VLPLODU SOHXUDO HIIXVLRQ RI RWKHU etiology. The thoracostomy was performed to all SDWLHQWV ZLWK SOHXUDO FDWKHWHU 3OHXUDFDQ %UDXQ and patients were divided into two groups depend LQJ RQ W\SH RI VFOHURVDQV *URXS 3OHXURGHVLV E\WDOFDQG*URXS3OHXURGHVLVE\GR[\F\FOLQH 2EWDLQHG SOHXUDO ÀXLG KDV EHHQ DQDO\]HG PLFUR biologically, biochemically and cytopathologically. 3RVWSOHXURGHVLVFRQWUROVZHUHFRQGXFWHGRQFHD PRQWKXQWLOWKHWKLUGPRQWKZKHQWKHHI¿FLHQF\RI conducted pleurodesis was assessed. 7KH WHFKQLTXH RI LQVHUWLQJ WKH SOHXUDO FDWKHWHU In the local anaesthesia the pleural catheter is in VHUWHGSHUFXWDQHRXVO\3OHXUDFDQ%UDXQDQGWKH SOHXUDOÀXLGLVHYDFXDWHG$IWHUWKHHYDFXDWLRQWKH UHH[SDQVLRQRIOXQJVLVFKHFNHGUDGLRJUDSKLFDOO\ :KHQWKHFRQGLWLRQVDUHPHWVHFUHWLRQLVUHGXFHG EHORZ PO K RU PONJ RI ERG\ ZHLJKW the pleurodesis by talc or by doxycycline was per formed. After the instillation of agent, the drain is FORVLQJWKHSDWLHQWIRUQH[WKRXUVFKDQJHVWKH SRVLWLRQ LQ WKH EHG HYHU\ PLQXWHV LQ RUGHU WR KDYH WKH DJHQW HTXDOO\ GLVWULEXWHG DOO RYHU WKH pleural surfaces, and then the drainage system is FRQQHFWHGWRWKHDFWLYHVXFWLRQIRUQH[WKRXUV After the reduction or elimination of secretion the drain should be removed. The success of pleu rodesis is controlled radiologically. The success of chemical pleurodesis was catego rized as: FRPSOHWH WKHUH LV QR UHDFFXPXODWLRQ ZLWKLQ PRQWKVDIWHUWKHLQWHUYHQWLRQ SDUWLDO OHVV UHDFFXPXODWLRQ LQ FRPSDULVRQ WR WKHSUHGUDLQDJHOHYHODQG XQVXFFHVVIXOVDPHRUODUJHUUHDFFXPXODWLRQ Statistical analysis of data has been performed E\VWDWLVWLFDOIXQFWLRQVRI06([FHOVRIWZDUHZLWK application of appropriate statistical methods. De WHUPLQHGOHYHORIVLJQL¿FDQFHLVS7KHUH sults were determined and comparison has been made between the results with the data of relevant research in modern referential literature with the presentation of discussion and comments of indi vidual results. RESULTS At the Clinic for Thoracic Surgery, in the period IURP-DQXDU\WR-DQXDU\SD WLHQWV ZLWK FRQ¿UPHG 03( ZHUH WUHDWHG ,Q UHOD WLRQWRJHQGHUZHUHZRPHQDQG ZHUHPDQZKHUHWKHSURSRUWLRQ ZDVLQIDYRURIZRPHQ7KHDYHUDJHDJHRI SDWLHQWVZDV\HDUV ,Q UHODWLRQ WR HWLRORJ\ RI 03( WKH PRVW IUHTXHQW causes are presented in the Figure 1. )LJXUHType of primary malignancy. lung cancer brest cancer lymphoma others 7KHPRVWIUHTXHQWFDXVHVRI03(ZHUHWKHOXQJ FDQFHU > @ DQG EUHDVW FDQFHU >@2EWDLQHGSOHXUDOÀXLGZDVDQD O\]HG F\WRSDWKRORJLFDOO\ PLFURELRORJLFDOO\ DQG ELRFKHPLFDOO\ 7KH F\WRORJLFDO DQDO\VHV )LJXUH 0HGLFLQVNLåXUQDO $OPD$OLKRGåLü3DãDOLü6DIHW*XVND$OHQ3LODY.HPDO*UELü&RPSDULVRQRIHI¿FLHQF\RISOHXURGHVLVZLWKGLIIHUHQWVFOHURVDQVWKURXJKSOHXUDOFDWKHWHU FRQ¿UPHG WKH SUHVHQFH RI PDOLJQDQW FHOOV LQ SDWLHQWV%LRFKHPLFDODQDO\VHVRI SOHXUDOÀXLGWKHSRVLWLYHK\DOXURQLFDFLGDONDOLQH S+ORZOHYHOVRIJOXFRVHKLJKOHYHOVRI/'+ZHUH IRXQG LQ SDWLHQWV 0LFURELRORJL cal analyses showed the presence of bacteria in RIFDVHV%.FXOWXUHLQDOOSDWLHQWV remained sterile. Figure 2. 3UHVHQFHRIPDOLJQDQWFHOOVLQSOHXUDOHIIXVLRQ Complete success of pleurodesis by talc was in ZKLOH E\ GR[\F\FOLQH LW ZDV LQ SDWLHQWV 7KHPDLQGLI¿FXOWLHVWKDWWKHSDWLHQWVFRPSODLQHG were dyspnea, cough, pain, fatigue and loss of ERG\ZHLJKW)LJXUH )LJXUH)UHTXHQF\RIV\PSWRPDWRORJ\SULRUWRDQGDIWHUWKH pleurodesis. 90,00% 80,00% 70,00% 60,00% 50,00% pre-pleurodesis post-pleurodesis 40,00% positive 30,00% negative 20,00% 10,00% 0DFURVFRSLF DSSHDUDQFH RI 03( ZDV VKRZQ DW Figure 3. )LJXUH0DFURVFRSLFDSSHDUDQFHRISOHXUDOHIIXVLRQ 50,00% 45,00% 40,00% 35,00% 30,00% 25,00% 20,00% 15,00% 10,00% 5,00% 0,00% hemorragic sero-hemorragic serous 0DOLJQDQWSOHXUDOHIIXVLRQLQWKHPDMRULW\RIFDVHV ZDVVHURKHPRUUKDJLF>@DQGVH URXV>@ 7KH VXFFHVV RI SOHXURGHVLV 7DEOH LV FDWHJR UL]HGDVDFRPSOHWHWKHUHLVQRUHDFFXPXODWLRQ ZLWKLQ PRQWKV DIWHU WKH LQWHUYHQWLRQ SDUWLDO OHVV UHDFFXPXODWLRQ LQ FRPSDULVRQ WR WKH SUH GUDLQDJHOHYHODQGXQVXFFHVVIXOVDPHRUODUJHU UHDFFXPXODWLRQ 0,00% cough dyspnea pain fatigue loss of body weight 7KHPRVWIUHTXHQWV\PSWRPVSULRUWRSOHXURGHVLV ZHUH G\VSQHD HVWDEOLVKHG LQ FRXJKLQIDWLJXHLQDQG SDLQ LQ RI FDVHV /RVV RI ERG\ ZHLJKWKDVEHHQHVWDEOLVKHGLQRI SDWLHQWV7KHIUHTXHQF\RIVDPHV\PSWRPVDIWHU the pleurodesis was as follows: dyspnea, cough DQG SDLQ HDFK LQ DQG IDWLJXH LQ SDWLHQWV ZKLOH WKH DGGLWLRQDO ORVV RI ERG\ZHLJKWKDVEHHQHVWDEOLVKHGLQ of cases. The average length of drainage for all patients ZDVGD\V7KHDYHUDJHOHQJWKRI drainage for group of patients with talc pleurode VLVZDVDQGWKHJURXSZLWKGR[\F\FOLQH GD\V7KHUHLVQRVWDWLVWLFDOO\VLJQL¿FDQW GLIIHUHQFH S! LQ WKH OHQJWK RI GUDLQDJH EH tween the two groups. 7KH PRVW IUHTXHQW FRPSOLFDWLRQV 7DEOH ZHUH fever, pain and separation of effusion. Table 2. Complications of pleurodesis. 7DEOH. Success of pleurodesis after three months in relation to type of sclerosans. 7KHPRVWIUHTXHQWFRPSOLFDWLRQZDVIHYHULQ DQGSDLQLQSDWLHQWV During the period of three months, pleurodesis PXVW KDYH EHHQ UHSHDWHG *URXS LQ FDVHVDQG*URXSLQRIFDVHV ,QSDWLHQWVIURP*URXSWKHSOHX 0HGLFLQVNLåXUQDO $OPD$OLKRGåLü3DãDOLü6DIHW*XVND$OHQ3LODY.HPDO*UELü&RPSDULVRQRIHI¿FLHQF\RISOHXURGHVLVZLWKGLIIHUHQWVFOHURVDQVWKURXJKSOHXUDOFDWKHWHU ral catheter had to be changed as it was clogged DQG REVWUXFWHG ,Q RI SDWLHQWV WKH catheter was dislocated outside of pleural space and new one had to be placed in. DISCUSION At the Clinic for Thoracic Surgery CCUS pleurode sis was performed through the pleural catheter LQSDWLHQWVLQWKHSHULRGIURP-DQXDU\ XQWLO -DQXDU\ ,Q UHODWLRQ WR WKH JHQGHU ZHUHZRPHQDQG PHQZKHUHWKHSURSRUWLRQZDVLQIDYRXURI ZRPHQ7KHDYHUDJHDJHRISDWLHQWVZDV \HDUV/RFDOL]DWLRQDQGW\SHRIWXPRUZDV NQRZQLQDOOSDWLHQWVSULRUWRWKHXQGHUJRLQJSURFH GXUHRIFKHPLFDOSOHXURGHVLV,QWKHPRVWIUHTXHQW QXPEHU RI FDVHV LW ZDV WKH OXQJ FDQFHU > @ DQG EUHDVW FDQFHU > @ 0DFURVFRSLF DSSHDUDQFH RI WKH HIIXVLRQ LQ WKH PDMRULW\RIFDVHVZDVVHURKHPRUUKDJLFLQ DQGVHURXVLQSDWLHQWV &\WRSDWKRORJLFDODQDO\VHVRISOHXUDOFRQWHQWFRQ ¿UPHGWKHSUHVHQFHRIPDOLJQDQWFHOOVLQ SDWLHQWV %LRFKHPLFDO DQDO\VHV RI SOHXUDO OLTXLG VKRZHG SRVLWLYH K\DOXURQLF DFLG DONDOLQH S+ ORZ YDOXHV RI JOXFRVH KLJK OHYHOV RI /'+ LQ SDWLHQWV0LFURELRORJLFDODQDO\VHV IRXQG WKH SUHVHQFH RI EDFWHULD LQ FDVHV%.FXOWXUHLQDOOSDWLHQWVUHPDLQHGVWHULOH 6XFFHVVRISOHXURGHVLV7DEOHZDVFDWHJRUL]HG as follows: &RPSOHWH WKHUH LV QR UHDFFXPXODWLRQ ZLWKLQ PRQWKVDIWHUWKHLQWHUYHQWLRQ ƕ7DOFLQSDWLHQWV ƕ'R[\F\FOLQHLQSDWLHQWV 3DUWLDOOHVVUHDFFXPXODWLRQLQFRPSDULVRQWRWKH SUHGUDLQDJHOHYHO ƕ7DOFLQSDWLHQWV ƕ'R[\F\FOLQHLQSDWLHQWV 8QVXFFHVVIXOVDPHRUODUJHUUHDFFXPXODWLRQ ƕ7DOFLQSDWLHQWV ƕ'R[\F\FOLQHLQSDWLHQWV 7KH PRVW IUHTXHQW VXEMHFWLYH V\PSWRPV SULRU WR SOHXURGHVLV ZHUH G\VSQHD LQ FRXJKLQDQGIDWLJXHLQ DQG WKH SDLQ LQ FDVHV /RVV RI ERG\ ZHLJKW SULRU WR SHUIRUPDQFH RI WKH SOHXURGHVLV ZDV HVWDEOLVKHG LQ SDWLHQWV7KHIUHTXHQF\RIWKHVDPHV\PSWRPVDI ter the pleurodesis was as follows: dyspnea, cough DQGSDLQLQDQGIDWLJXHLQ SDWLHQWV ZKLOH DGGLWLRQDO ORVV RI ERG\ ZHLJKW KDV EHHQ HVWDEOLVKHG LQ cases. The average length of the pleural drainage IRU DOO SDWLHQWV ZDV GD\V ,Q WKH JURXS ZLWK WDOF SOHXURGHVLV LW ZDV DQG WKHGR[\F\FOLQHJURXSGD\V7KHUHLVQR VWDWLVWLFDOO\ VLJQL¿FDQW GLIIHUHQFH S! LQ WKH length of drainage between the two groups. The PRVWIUHTXHQWFRPSOLFDWLRQZDVIHYHUUHJLVWHUHGLQ DQG SDLQ LQ SD WLHQWV ,Q SDWLHQWV IURP *URXS the pleural catheter had to be changed as it was FORJJHGDQGREVWUXFWHG,QSDWLHQWV the catheter was dislocated outside of the pleural space and new one had to be placed in. During the period of three months, the pleurodesis must have EHHQUHSHDWHG*URXSLQFDVHV DQG*URXSLQRIFDVHV,Q3DW] published a series of 19 patients who underwent successful outpatient pleurodesis by pleural cath HWHUDQG3DUXOHNDUHWDOZKRDUJXHWKDWWKHUHLVQR GLIIHUHQFH LQ HI¿FDF\ FRPSDUHG WR VWDQGDUG SOHX UDOGUDLQDJH)XUKDP/DZOHVVHWDOXVHG GUDLQVFDWKHWHUVRIVPDOOGLDPHWHUDQGIRXQGWKDW they are less traumatic and more comfortable for SDWLHQWVZLWKDQHI¿FLHQF\WKDWLVVLPLODUWRWKDWLQ the application of pleural drains of larger diameter WKH VXFFHVV UDWH WR *UR]GLQ DQG%DFNDUHDOVRXVHGVPDOOGLDPHWHUGUDLQVLQ cases and found that they are safe, effective and FRVWHI¿FLHQW&OHPHQWVHQHWDODUJXHWKDWWKH success of pleurodesis with drains of small diame WHUVLQDPEXODWRU\FRQGLWLRQVUDQJLQJIURP WR6XPPDU\RI(QJOLVKOLWHU ature described the treatment of malignant pleural HIIXVLRQZLWKFKHPLFDOVXEVWDQFHVLQSDWLHQWV ,QWKHDIRUHPHQWLRQHGUHSRUWVXFFHVV IXOSOHXURGHVLVKDVEHHQGH¿QHGDVFRPSOHWHUH sponse to the applied sclerosans, which means the DEVHQFHRIWKHUHDFFXPXODWLRQRIWKHSOHXUDOÀXLG DV GH¿QHG E\ WKH FOLQLFDO FRQGLWLRQ RI WKH SDWLHQW DQGFKHVWV;5D\%\XVLQJWKHPHQWLRQHGFULWHULD WKH FRPSOHWH VXFFHVV ZDV DFKLHYHG LQ SDWLHQWV 1HDUO\ RI patients treated with talc had a complete response. Doxycycline, Corynebacterium parvum and Bleo P\FLQDFKLHYHGWKHFRPSOHWHUHVSRQVHLQ DQG SDWLHQWV UHVSHFWLYHO\ 7KH most common side effects of chemical pleurodesis were chest pain and fever. Based on the reports, which are mostly retrospective, the incidence of SDLQYDULHVIURPWRDQGIHYHUIURP WRRIWKHFDVHV)HYHUXVXDOO\DS SHDUHGZLWKLQWKH¿UVWKRXUVDIWHUWKHLQVWLOODWLRQ of sclerosans and it generally stoped, without spe FLDOWUHDWPHQWHYHQWXDOO\DQWLS\UHWLFVGXULQJWKH QH[WKRXUV7ZHOYHDGGLWLRQDOVWXG LHVZLWKWRWDORISDWLHQWVSXEOLVKHGWKHDSSOL FDWLRQRISOHXUDOFDWKHWHUV&KZLWKREMHFWLYH WR DFKLHYH WKH FKHPLFDO SOHXURGHVLV ,Q SDWLHQWV WKH SOHXURGHVLV ZDV SHUIRUPHG E\ WDOFLQE\GR[\F\FOLQHLQE\EOHRP\FLQDQG 0HGLFLQVNLåXUQDO $OPD$OLKRGåLü3DãDOLü6DIHW*XVND$OHQ3LODY.HPDO*UELü&RPSDULVRQRIHI¿FLHQF\RISOHXURGHVLVZLWKGLIIHUHQWVFOHURVDQVWKURXJKSOHXUDOFDWKHWHU LQSDWLHQWVE\WHWUDF\FOLQH2YHUDOOVXF FHVVUDWHLQSDWLHQWVLQZKRPSOHXUDOFDWKHWHUV XVHGZDV CONCLUSION Applying pleural catheter with chemical pleurode sis can achieve identical results as when using standard thoracic drainage. In relation to the ap SOLHG VFOHURVLQJ DJHQW WDOF YV GR[\F\FOLQH VXF cess of pleurodesis was better when using talc. &RQÀLFWRILQWHUHVW none declared REFERENCES *XVND 6 7UHWPDQ SDFLMHQDWD VD PDOLJQLP SOHX UDOQLP L]OLYRP 8 *XVND 6 2SãWL SULQFLSL VDYUHPHQH WRUDNRKLUXUãNH SUDNVH 6DUDMHYR 0HGLFLQVNL IDNXOWHW 6DUDMHYRVWU 6DKQ6$0DOLJQDQWSOHXUDOHIIXVLRQV6HPLQ5HVS &ULW&DUH0HG 5REHUWV0(1HYLOOH(%HUULVIRUG5*$QWXQHV*$OL 1-0DQDJHPHQWRIDPDOLJQDQWSOHXUDOHIIXVLRQ%ULWLVK 7KRUDFLF6RFLHW\3OHXUDO'LVHDVH*XLGHOLQH7KR UD[6XSSOLL± %HQQHWW50DVNHO10DQDJHPHQWRIPDOLJQDQWSOHX UDOHIIXVLRQV&XUU2SLQ3XOP0HG 'UHVVOHU &' 2ODN - +HUQGRQ -( 5LFKDUGV :* 6FDO]HWWL ()OHLVKPDQ 6% HW DO 3KDVH ,,,LQWHUJURXS study of talc poudrage vs talc slurry sclerosis for malig QDQWSOHXUDOHIIXVLRQ&KHVW 6KDZ 3 $JDUZDO 5 3OHXURGHVLV IRU PDOLJQDQW pleural effusions. Cochrane Database Syst Rev. &' <LOGLULP+0HWLQWDV0$N*HWDO3UHGLFWRUVRIWDOF pleurodesis outcome in patients with malignant pleural HIIXVLRQV/XQJ&DQFHU 'HPP\7/*X/%XUNKDOWHU-(7ROR]D(0'¶$PLFR TA, Sutherland S, et al. Optimal management of malig QDQWSOHXUDOHIIXVLRQVUHVXOWVRI&$/*%-1DWO &RPSU&DQF1HWZ 4XUHVKL155DKPDQ10*OHHVRQ)97KRUDFLFXO trasound in the diagnosis of malignant pleural effusion. 7KRUD[± +XQW%0)DULYDU$69DOOLqUHV(/RXLH%($\H5: )ORUHV((*RUGHQ-$7KRUDFRVFRSLFWDOFYHUVXVWXQ neled pleural catheters for palliation of malignant pleural HIIXVLRQV$QQ7KRUDF6XUJ 6WHJHU 9 0LND 8 7RRPHV + :DONHU 7 (QJHO & .\ULVV7HWDO:KRJDLQVPRVW"$\HDUH[SHULHQFH ZLWK WKRUDFRVFRSLF WDOF SOHXURGHVHV $QQ 7KRUDF 6XUJ &DUGLOOR*)DFFLROR)&DUERQH/5HJDO0&RU]DQL )5LFFL$HWDO/RQJWHUPIROORZXSRIYLGHRDVVLVWHG talc pleurodesis in malignant recurrent pleural effusions. (XU-&DUGLRWKRUDF6XUJ 0DVNHOO 1$ *OHHVRQ )9 'DYLHV 5- 6WDQGDUG SOHXUDO ELRSV\ YHUVXV &7JXLGHG FXWWLQJQHHGOH ELRS sy for diagnosis of malignant disease in pleural effu VLRQV D UDQGRPLVHG FRQWUROOHG WULDO /DQFHW ± :DUUHQ :+ .DOLPL 5 .KRGDGDGLDQ /0 .LP$: 0DQDJHPHQW RI PDOLJQDQW SOHXUDO HIIXVLRQV XVLQJ WKH 3OHXU[ FDWKHWHU $QQ 7KRUDF 6XUJ Address: $OPD$OLKRGåLü3DãDOLü0' Clinic of Thoracic Surgery Clinical Center University of Sarajevo %ROQLþND6DUDMHYR Bosnia and Herzegovina (PDLODOPDBDS#\DKRRFRP Naš prilog redukciji kardiovaskularnih bolesti ! Our contribution in reduction of cardiovascular diseases ! 0HGLFLQVNLåXUQDO 0RKDPPDG$ERX(O$UGDW=XOIR*RGLQMDN6DQMLQ'HNRYLü/DQD/DþHYLü(OGDU0HKPHGEDãLü$UPLQD5RYþDQLQ7KHSUHYDOHQFHRIEDFWHULDOYDJL QRVLVLQSUHJQDQWZRPHQZLWKWKUHDWHQHGSUHWHUPELUWK Original article THE PREVALENCE OF BACTERIAL VAGINOSIS IN PREGNANT WOMEN WITH THREATENED PRETERM BIRTH 35(9$/(1&$ %$.7(5,-6.( 9$*,12=(8 758'1,&$ 6$ 35,-(7(û,0 35,-(95(0(1,03252Ĉ$-(0 0RKDPPDG $ERX (O$UGDW =XOIR *RGLQMDN 6DQMLQ 'HNRYLü /DQD /DþHYLü (OGDU 0HKPHGEDãLü $UPLQD 5RYþDQLQ &OLQLFIRU*\QHFRORJ\DQG2EVWHWULFV&OLQLFDO&HQWHU8QLYHUVLW\RI6DUDMHYR3DWULRWVNHOLJH6DUDMHYR Bosnia and Herzegovina &RUUHVSRQGLQJDXWKRU ABSTRACT In Europe and many developed countries the pre WHUPELUWKUDWHLVJHQHUDOO\±DQGLQWKH86$ LWKDVHYHQEHHQLQFUHDVHGWR±,QIHFWLRQV play a major role in the genesis of preterm birth DQGPD\DFFRXQWXSWR±HYHQWV Aims were to determine demographic and clinical characteristics of pregnant women with threat HQHG SUHWHUP ELUWK 737% DQG WR GHWHUPLQH DV VRFLDWLRQEHWZHHQEDFWHULDOYDJLQRVLVDQG737% 7KHFURVVVHFWLRQDOVWXG\LQFOXGHGSUHJQDQW ZRPHQZLWK737%KRVSLWDOL]HGDWWKH&OLQLFRI*\ necology and Obstetrics, Clinical Center Univer sity of Sarajevo in one year period. In the control JURXS Q SUHJQDQW ZRPHQ ZLWKRXW 737% were analyzed. Statistical analysis was performed ZLWK&KL6TXDUHWHVW$3YDOXHZDVFRQVLG HUHGDVVLJQL¿FDQW 7KHSUHYDOHQFHRIEDFWHULDOYDJLQRVLVZDV LQSUHJQDQWZRPHQZLWK737%DQGDV\PSWRPDWLF EDFWHULDOYDJLQRVLVZDVLQSUHJQDQWZRPHQ ZLWKRXW 737% 7KH KLJKHVW QXPEHU RI SUHJQDQW ZRPHQZLWK737%RUDQGSUHJ QDQW ZRPHQ ZLWKRXW 737% RU ZHUH EHWZHHQ \HDUV ROG 7KH KLJK VFKRRO OHYHO RI HGXFDWLRQ ZDV WKH PRVW IUHTXHQW RQH LQ SUHJQDQW ZRPHQ ZLWK 737% RU DQG SUHJQDQW ZRPHQ ZLWKRXW 737% RU 7KHUH LV QR VLJQL¿FDQW GLIIHUHQFH LQ IUH TXHQF\RISUHYLRXVVSRQWDQHRXVȤ 3 DQGDUWL¿FLDODERUWLRQȤ 3 EHWZHHQWKHVHWZRJURXSV7KHUHLVDVLJQL¿FDQW GLIIHUHQFH LQ IUHTXHQF\ RI GLIIHUHQW YDJLQDO GLV FKDUJH ZKLWH\HOORZLVK \HOORZJUHHQ ZKLWH\HO ORZLVKVRPHZKDWOLNHFRWWDJHFKHHVHZKLWHJUD\ LVK KRPRJHQHRXV OLNH PLON EHWZHHQ SUHJQDQW ZRPHQ ZLWK 737% YV YV YV UHVSHFWLYHO\ DQG SUHJQDQW ZRPHQ ZLWKRXW 737% YV YV YV UHVSHFWLYHO\Ȥ 33UHJ QDQWZRPHQZLWK737%KDGKLJKHUSUHYDOHQFHRI YDJLQDO S+!>25 &, Ȥ 3@ SRVLWLYH $PLQH 2GRU 7HVW >25 &, Ȥ 3 @ DQG QDWLYH SUHSDUDWLRQ RI YDJLQDO ÀXLG ZLWK SRVLWLYH7ULFKRPRQDVYDJLQDOLV>25 &, Ȥ 3@ Conclusion: the present study showed that preva lence of bacterial vaginosis in women with threat ened preterm birth was higher than in women without threatened preterm birth. Key words: bacterial vaginosis, threatened pre term birth 6$ä(7$. 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Gardnerela vaginalis is a part of QRUPDOYDJLQDOÀRUD,WSURGXFHVDPLQRDFLGVDQG the anaerobes produce enzymes that dissolve the DPLQRDFLGVWRDPLQHVSXWUHVFLQNDGDYHULQDQG trimetilamin. The amines increase the vaginal se FUHWLRQS+ZKLFKLQÀXHQFHVRQWKHLQFUHDVHGYDJ 0HGLFLQVNLåXUQDO LQDOHSLWKHOLXPGHVTXDPDWLRQZKLFKFRQVHTXHQW O\LQFUHDVHVWKHDPRXQWRIYDJLQDOVHFUHWLRQ %9LVRQHRIWKHPRVWFRPPRQORZHUJHQLWDOWUDFW FRQGLWLRQV RFFXUULQJ LQ RI SUHJQDQW ZRPHQ DWWHQGLQJ VH[XDOO\ WUDQVPLWWHG LQIHFWLRQ 67, LQ FOLQLFVWRRISUHJQDQWZRPHQDQG WRRISUHJQDQWZRPHQDWWHQGLQJJ\QHFRORJ\ FOLQLFV 7KH SUHYDOHQFH LQ WKH 8QLWHG 6WDWHV LV HVWLPDWHG WR EH PLOOLRQ DPRQJ SUHJQDQWZRPHQDJHG±EDVHGRQDQDWLRQ ally representative sample of pregnant women ZKR SDUWLFLSDWHG LQ 1+$1(6 ± 7KH IROORZLQJ ¿QGLQJV IURP WKLV VWXG\ DUH PRVW SUHJQDQWZRPHQIRXQGWRKDYH%9UHSRUW ed no symptoms; pregnant women who have not had vaginal, oral, or anal sex can still be affected E\ %9 DV FDQ SUHJQDQW ZRPHQ and pregnant women who have ever been preg QDQWSUHYDOHQFHRI%9LQFUHDVHVEDVHG on lifetime number of sexual partners. In clinical SUDFWLFH%9LVGLDJQRVHGXVLQJµ$PVHO¶VFULWHULD¶ 7KLV FOLQLFDO GLDJQRVLV UHTXLUHV WKDW WKUHH RI WKH IROORZLQJIRXUFULWHULDKDYHWREHPHW¿UVWDYDJL QDOS+RIJUHDWHUWKDQS+VHFRQGWKHSUHV HQFHRIFOXHFHOOVLQWKHYDJLQDOÀXLGWKLUGDPLON\ KRPRJHQHRXV YDJLQDO GLVFKDUJH DQG ¿QDOO\ WKH UHOHDVHRIDQDPLQH¿VK\RGRXUDIWHUDGGLWLRQRI SRWDVVLXPK\GUR[LGHWRWKHYDJLQDOÀXLG At least three of four criteria should be present for DGLDJQRVLVFRQ¿UPDWLRQ MATERIALS AND METHODS 7KHFURVVVHFWLRQDOVWXG\LQFOXGHGSUHJQDQW ZRPHQZLWKWKUHDWHQHGSUHWHUPELUWK737%KRV pitalized at the Clinic of Gynecology and Obstet rics and Clinical Center University of Sarajevo LQRQH\HDUSHULRG,QWKHFRQWUROJURXSQ SUHJQDQW ZRPHQ ZLWKRXW 737% ZHUH DQDO\]HG Inclusion criteria were: pregnant women from 6DUDMHYR &DQWRQ DJH EHWZHHQ \HDUV UH JDUGOHVVRISDULW\JHVWDWLRQDODJHEHWZHHQ ZHHNVVLJQHGLQIRUPHGFRQVHQW([FOXVLRQFULWH ULDZHUHWDNLQJDQDQWLELRWLFPXOWLSOHSUHJQDQF\ SDWKRORJ\RISUHJQDQF\SODFHQWDSUHYLDDEUXSWLR SODFHQWDH SODFHQWDO LQVXI¿FLHQF\ DQRPDOLHV RI WKHXWHUXVDQGFHUYL[IHWDODEQRUPDOLW\ROLJRDQG SRO\K\GUDPQLRVVHYHUIRUPVRIJHVWRVLVHFODPS V\DQGSUHHFODPSV\DFXWHDQGFKURQLFV\VWHPLF or local maternal infection, except for an infection of the lower genital tract, systemic autoimmune diseases, malignity, endocrinopathies, previously FDUULHGRXWVXUJLFDOSURFHGXUHVRQWKHFHUYL[+,9 +%9DQG+&9LQIHFWLRQV%9ZDVGLDJQRVHGDS plying following Amsel’s criteria: the presence of the increased homogeneous secretion was de termined by inspection, litmus paper was used in GHWHUPLQLQJ WKH VHFUHWLRQ ZLWK S+ RYHU DQG WKH SUHVHQFH RI WKH SRVLWLYH DPLQH RGRU ³VPHOO´ 0RKDPPDG$ERX(O$UGDW=XOIR*RGLQMDN6DQMLQ'HNRYLü/DQD/DþHYLü(OGDU0HKPHGEDãLü$UPLQD5RYþDQLQ7KHSUHYDOHQFHRIEDFWHULDOYDJL QRVLVLQSUHJQDQWZRPHQZLWKWKUHDWHQHGSUHWHUPELUWK test was determined by exposing the vaginal se FUHWLRQ WR .2+ WKDW OHDGV WR DPLQH UHOHDVH DQG¿VKRGRUDSSHDUDQFH5HVXOWVDUHH[SUHVVHG DV PHDQVWDQGDUG GHYLDWLRQ LQ FDVH RI FRQWLQX ous normal distributed variables. In case of cat egorical variables, counts and percentages were reported. Statistical analysis was performed with &KL6TXDUHWHVW$3YDOXHZDVFRQVLGHUHG DV VLJQL¿FDQW 6WDWLVWLFDO DQDO\VLV ZDV SHUIRUPHG E\XVLQJWKH6WDWLVWLFDO3DFNDJHIRUWKH6RFLDO6FL HQFHV63665HOHDVH6366,QF&KLFDJR ,OOLQRLV8QLWHG6WDWHVRI$PHULFDVRIWZDUH RESULTS 7KH SUHYDOHQFH RI EDFWHULDO YDJLQRVLV ZDV LQ SUHJQDQW ZRPHQ ZLWK 737% DQG DV\PSWR PDWLF EDFWHULDO YDJLQRVLV ZDV LQ SUHJQDQW ZRPHQ ZLWKRXW 737% 7KH KLJKHVW QXPEHU RI SUHJQDQW ZRPHQ ZLWK 737% RU DQG SUHJQDQW ZRPHQ ZLWKRXW 737% RU ZHUHEHWZHHQ\HDUVROG7KHUHLVD VLJQL¿FDQW GLIIHUHQFH LQ IUHTXHQF\ RI DJH JURXSV EHWZHHQ JURXSV Ȥ 3 VWDQG DUGL]HG UHVLGXDOV ZHUH QRW VLJQL¿FDQW IRU DOO DJH groups. The high school educational level was WKHPRVWIUHTXHQWLQSUHJQDQWZRPHQZLWK737% RUDQGLQSUHJQDQWZRPHQZLWK RXW737%RU 7DEOH Demographic and clinical characteristics of pregnant ZRPHQZLWK737%Q DQGSUHJQDQWZRPHQZLWKRXW737% Q 7KHUH LV QR VLJQL¿FDQW GLIIHUHQFH LQ OHYHO RI HGX FDWLRQEHWZHHQWKHVHWZRJURXSVȤ 3 7KHKLJKHVWQXPEHURISUHJQDQWZRPHQLQ 737% JURXS RU DQG QRQ 737% JURXSRUKDGRUELUWKV7KHUH LV D VLJQL¿FDQW GLIIHUHQFH LQ IUHTXHQF\ RI ELUWKV EHWZHHQJURXSVȤ 3 7KHUHLV QRVLJQL¿FDQWGLIIHUHQFHLQIUHTXHQF\RISUHYLRXV VSRQWDQHRXV Ȥ 3 DQG DUWL¿FLDO DERUWLRQȤ 3 EHWZHHQWKHVHWZR JURXSV 7KHUH LV D VLJQL¿FDQW GLIIHUHQFH LQ IUH TXHQF\ RI SUHYLRXV H[DPLQDWLRQ EHWZHHQ JURXSV Ȥ 3 RUSUHJQDQWZRPHQZLWK RXW737%DUHOHVVOLNHO\WRUHSRUWWRH[DPLQD WLRQ7KHUHLVDVLJQL¿FDQWGLIIHUHQFHLQIUHTXHQF\ RI GLIIHUHQW YDJLQDO GLVFKDUJH ZKLWH\HOORZLVK \HOORZJUHHQZKLWH\HOORZLVKVRPHZKDWOLNHFRW WDJH FKHHVH ZKLWHJUD\LVK KRPRJHQHRXV OLNH PLONEHWZHHQSUHJQDQWZRPHQZLWK737% YV YV YV DQG SUHJQDQW ZRPHQZLWKRXW737%YVYV YVȤ 37KHIUHTXHQF\ RI ZKLWH\HOORZLVK YDJLQDO GLVFKDUJH LV OHVV WKDQ H[SHFWHG] \HOORZJUHHQLVPRUHWKDQH[ SHFWHG] DQGZKLWHJUD\LVKKRPRJHQHRXV OLNH PLON LV PRUH WKDQ H[SHFWHG ] LQ JURXS ZLWK737%)LJXUH )LJXUH9DJLQDOGLVFKDUJHPDFURVFRSLFRISUHJQDQWZRP HQ ZLWK 737% Q DQG SUHJQDQW ZRPHQ ZLWKRXW 737% Q 3 3UHJQDQWZRPHQZLWK737%KDGKLJKHUSUHYDOHQFH RIYDJLQDOS+!RUFRPSDUHGWR SUHJQDQWZRPHQZLWKRXW737%RU >25 &, Ȥ 3 @ 7KLV VHHPV WR UHSUHVHQW WKH IDFW WKDW based on the odds ratio, the odds of vaginal pH ! ZHUH WLPHV KLJKHU LQ SUHJQDQW ZRPHQ ZLWK737%FRPSDUHGWRSUHJQDQWZRPHQZLWKRXW 737% 3UHJQDQW ZRPHQ ZLWK 737% KDG KLJKHU SUHYDOHQFHRISRVLWLYH$PLQH2GRU7HVW RU FRPSDUHG WR SUHJQDQW ZRPHQ ZLWKRXW 737%RU>25 &, Ȥ 3@ 0HGLFLQVNLåXUQDO 0RKDPPDG$ERX(O$UGDW=XOIR*RGLQMDN6DQMLQ'HNRYLü/DQD/DþHYLü(OGDU0HKPHGEDãLü$UPLQD5RYþDQLQ7KHSUHYDOHQFHRIEDFWHULDOYDJL QRVLVLQSUHJQDQWZRPHQZLWKWKUHDWHQHGSUHWHUPELUWK Table 2. Results of tests in pregnant women with threatened 37% Q DQG SUHJQDQW ZRPHQ ZLWKRXW WKUHDWHQHG 37% Q YVYVUHVSHFWLYHO\DQGVXJ JHVWLYH GLVFKDUJH ZDV YV YV UHVSHFWLYHO\ ,Q WKH SUHVHQW VWXG\ WKH RGGV RIYDJLQDOS+!ZHUHWLPHVKLJKHULQSUHJ QDQW ZRPHQ ZLWK 737% FRPSDUHG WR SUHJQDQW ZRPHQZLWKRXW737%37KHSHUFHQWDJH RI KRPRJHQHRXV D PLON\ YDJLQDO GLVFKDUJH ZDV VLJQL¿FDQWO\KLJKHULQSUHJQDQWZRPHQZLWK737% WKDQ LQ SUHJQDQW ZRPHQ ZLWKRXW 737% >25 &,Ȥ 3@7KHRGGVRISRVLWLYH7ULFKRPRQDVYDJL QDOLV LQ QDWLYH SUHSDUDWLRQ RI YDJLQDO ÀXLG ZHUH WLPHVKLJKHULQSUHJQDQWZRPHQZLWK737% FRPSDUHGWRSUHJQDQWZRPHQZLWKRXW737% CONCLUSION 7KHRGGVRISRVLWLYH$PLQH2GRU7HVWZHUH WLPHVKLJKHULQSUHJQDQWZRPHQZLWK737%FRP SDUHG WR SUHJQDQW ZRPHQ ZLWKRXW 737% 3UHJ QDQW ZRPHQ ZLWK 737% KDG KLJKHU SUHYDOHQFH RI QDWLYH SUHSDUDWLRQ RI YDJLQDO ÀXLG ZLWK SRVL WLYH 7ULFKRPRQDV YDJLQDOLV RU FRPSDUHG WR SUHJQDQW ZRPHQ ZLWKRXW 737% RU>25 &, Ȥ 3@7DEOH DISCUSSION Amsel’s clinical criterion is the most widely recog nized test and its disadvantage is the subjective visual and olfactory criteria. In the present study, bacterial vaginosis was more common among SUHJQDQWZRPHQZLWK737%WKDQDPRQJ SUHJQDQWZRPHQZLWKRXW737%/HLWLFKHW DOSHUIRUPHGDPHWDDQDO\VLVWRHYDOXDWHEDFWH ULDOYDJLQRVLVDVDULVNIDFWRUIRUSUHWHUPGHOLYHU\ (LJKWHHQ VWXGLHV ZLWK UHVXOWV IRU SDWLHQWV were included. Bacterial vaginosis increased the ULVN RI SUHWHUP GHOLYHU\ !IROG RGGV UDWLR &, ,Q VWXG\ RI 0F3KHHWHUV et al.bacterial vaginosis in early pregnancy was associated with hospitalization for preterm labor EHWZHHQDQGZHHNVRIJHVWDWLRQRGGVUD WLR &, DPRQJ SUHJQDQW ZRPHQ ,Q VWXG\ RI 3LSSD HW DO WKLUWHHQ SHU FHQW RI SUHJQDQW ZRPHQ KDG EDFWHULDO YDJLQRVLV7KHUHODWLYHULVN55RISUHWHUPELUWKLQ pregnant women with bacterial vaginosis was 0.9 FRQ¿GHQFHLQWHUYDO>&,@ WR+RZ ever, bacterial vaginosis was associated with late PLVFDUULDJHDW±ZHHNV55 &, WR,QWKHVWXG\RI&KDZDQSDLERRQ DQG 3LPRO WKHUH ZDV D VWDWLVWLFDO GLIIHUHQFH EH tween prevalence of bacterial vaginosis in threat HQHG SUHWHUP ODERXU DQG WHUP ODERXU 3 7KH SHUFHQWDJH RI S+! LQ threatened preterm, preterm, and term labor was 0HGLFLQVNLåXUQDO The present study showed that prevalence of bac terial vaginosis in women with threatened preterm birth was higher than in women without threatened preterm birth. The testing for bacterial vaginosis of WKUHDWHQHG SUHWHUP ODERU PD\ UHGXFH WKH ULVN RI preterm birth. &RQÀLFWRILQWHUHVW none declared. REFERENCES ,QWHUQDWLRQDO FODVVL¿FDWLRQ RI GLVHDVHV DQG UHODWHG KHDOWK SUREOHPV WK UHYLVLRQ *HQHYD :RUOG +HDOWK 2UJDQL]DWLRQ +XGG\&/-RKQVRQ$+RSH3/(GXFDWLRQDODQGEH KDYLRUDOSUREOHPVLQEDELHVRI±ZHHNVJHVWDWLRQ $UFK'LV&KLOG)HWDO1HRQDWDO(G) :DQJ 0/ 'RUHU '- )OHPLQJ 03 &DWOLQ ($ &OLQLFDO RXWFRPHV RI QHDUWHUP LQIDQWV 3HGLDWULFV *ROGHQEHUJ 5/ &XOKDQH -) ,DPV -' 5RPHUR 5 (SLGHPLRORJ\DQGFDXVHVRISUHWHUPELUWK/DQFHW *ROGHQEHUJ5/+DXWK-&$QGUHZV::,QWUDXWHU LQHLQIHFWLRQDQGSUHWHUPGHOLYHU\1(QJO-0HG +LOOLHU 6/ 1XJHQW 53 (VFKHQEDFK '$ .URKQ 0$ *LEEV560DUWLQ'+HWDO$VVRFLDWLRQEHWZHHQEDFWH ULDOYDJLQRVLVDQGSUHWHUPGHOLYHU\RIDORZELUWKZHLJKW infant. The vaginal infections and prematurity study JURXS1(QJO-0HG /LQJ=.RQJ-/LX)=KX+&KHQ;:DQJ<HWDO 0ROHFXODUDQDO\VLVRIWKHGLYHUVLW\RIYDJLQDOPLFURELRWD DVVRFLDWHG ZLWK EDFWHULDO YDJLQRVLV %0& *HQRPLFV GRL /DPRQW 5) 6REHO -' $NLQV 5$ +DVVDQ 66 &KDLZRUDSRQJVD 7 .XVDQRYLF -3 HW DO 7KH YDJL nal microbiome: new information about genital tract ÀRUD XVLQJ PROHFXODU EDVHG WHFKQLTXHV %-2* +LOO*%7KHPLFURELRORJ\RIEDFWHULDOYDJLQRVLV$P- 2EVWHW*\QHFRO$XJ 0RKDPPDG$ERX(O$UGDW=XOIR*RGLQMDN6DQMLQ'HNRYLü/DQD/DþHYLü(OGDU0HKPHGEDãLü$UPLQD5RYþDQLQ7KHSUHYDOHQFHRIEDFWHULDOYDJL QRVLVLQSUHJQDQWZRPHQZLWKWKUHDWHQHGSUHWHUPELUWK 7KRPDVRQ-/6KHOGRQ0*6FDJOLRQH1-%DFWHULDO vaginosis: Current review with indications for asympto PDWLFWKHUDS\$P-2EVWHW*\QHFRO 7. 11. Eschenbach DA. History and review of Bacterial YDJLQRVLV$P-2EVWHW*\QHFRO .RXPDQV(+6WHUQEHUJ0%UXFH&0F4XLOODQ* .HQGULFN - 6XWWRQ 0 0DUNRZLW] /( 7KH SUHYDOHQFH RIEDFWHULDOYDJLQRVLVLQWKH8QLWHG6WDWHV associations with symptoms, sexual behaviors, and re SURGXFWLYHKHDOWK6H[7UDQVP'LV $PVHO 5 7RWWHQ 3$ 6SLHJHO &$ &KHQ .&6 (V FKHQEDFK ' +ROPHV .. 1RQVSHFL¿F YDJLQLWLV GLDJ nostic criteria and microbial and epidemiologic associa WLRQV$P-0HG /HLWLFK+%RGQHU$GOHU%%UXQEDXHU0.DLGHU$ (JDUWHU&+XVVOHLQ3%DFWHULDOYDJLQRVLVDVDULVNIDF WRUIRUSUHWHUPGHOLYHU\DPHWDDQDO\VLV$P-2EVWHW *\QHFRO 0F3KHHWHUV 0/ 0LOOHU :& +DUWPDQQ .( 6DYLW] '$.DXIPDQ-6*DUUHWW-07KRUS-07KHHSLGHPLRO ogy of threatened preterm labor: a prospective cohort VWXG\$P-2EVWHW*\QHFRO 2DNHVKRWW3.HUU\6+D\6+D\3%DFWHULDOYDJL QRVLVDQGSUHWHUPELUWKDSURVSHFWLYHFRPPXQLW\EDVHG FRKRUWVWXG\%U-*HQ3UDFW &KDZDQSDLERRQ63LPRO.%DFWHULDOYDJLQRVLVLQ WKUHDWHQHGSUHWHUPSUHWHUPDQGWHUPODERXU-0HG$V VRF7KDL. Address: 0RKDPPDG$ERX(O$UGDW0' Clinic for Gynecology and Obstetrics Clinical Center University of Sarajevo 3DWULRWVNHOLJH6DUDMHYR Bosnia and Herzegovina 3KRQH (PDLODUGDWGUP#KRWPDLOFRP 1RYDFHQWUDOQD]JUDGD.OLQLþNRJ&HQWUD8QLYHU]LWHWDX6DUDMHYX New Central building of the Clinical Center University of Sarajevo 0HGLFLQVNLåXUQDO âHMOD&HULü(OPD.XFXNDOLü6HOLPRYLü7LPXU&HULü1HUPLQD2EUDOLü6HPLU%HãOLMD6HOPD$JLü3UHGLFWRUVRISURJUHVVLRQRIERQHPHWDVWDVHVLQ EUHDVWFDQFHUGLDJQRVHGZLWKVNHOHWDOVFLQWLJUDSK\EDVHGRQWKHKRUPRQHUHFHSWRUVWDWXVDQG+(5SURWHLQV Original article PREDICTORS OF PROGRESSION OF BONE METASTASES IN BREAST CANCER DIAGNOSED WITH SKELETAL SCINTIGRAPHY BASED ON THE HORMONE RECEPTOR STATUS AND HER2 PROTEINS 352&-(1$ 5,=,.$ 5$=92-$ .2â7$1,+ 0(7$67$=$ .2' 3$&,-(17,&$ 6$ KARCINOMOM DOJKE PREMA STATUSU HORMONALNIH RECEPTORA I HER2 PROTEINA âHMOD&HULü(OPD.XFXNDOLü6HOLPRYLü7LPXU&HULü21HUPLQD2EUDOLü2, Semir Bešlija26HOPD$JLü &OLQLFIRU1XFOHDU0HGLFLQH&OLQLFDO&HQWHU8QLYHUVLW\RI6DUDMHYR%ROQLþND6DUDMHYR%RVQLDDQG+HU zegovina; &OLQLFIRU2QFRORJ\&OLQLFDO&HQWHU8QLYHUVLW\RI6DUDMHYR%ROQLþND6DUDMHYR%RVQLDDQG Herzegovina 1 &RUUHVSRQGLQJDXWKRU ABSTRACT 6$ä(7$. Bone is one of the most common locations for the breast cancer metastasis. Numerous reports have VKRZQ WKDW (535 SRVLWLYH VWDWXV FRXSOHG ZLWK patient’s age, represent positive predictors to the bone metastasis development in breast cancer SDWLHQWV6HYHQ\HDUVDJRDQRYHUH[SUHVVLRQRI WKH+(5QHXRQFRJHQHSURGXFW+(5SURWHLQ ZDVLQFOXGHGWRWKHEUHDVWFDQFHUULVNFDWHJRULHV ,Q JHQHUDO WKH +(5 SURWHLQ RYHUH[SUHVVLRQ LV seen as consistent within both, the primary tumor tissue and the metastatic tissue. Certain reports of WKH+(5RYHUH[SUHVVLRQVXJJHVWWKDWLQFLGHQFH of metastasis spreading to the lungs, liver and brain is higher than the one to the bones. 7KLV VWXG\ LQYROYHG D WRWDO RI EUHDVW FDQFHU SDWLHQWV GLYLGHG LQWR IRXU JURXSV7KH ¿UVW JURXS included patients with the positive status of ER DQG 35 KRUPRQH UHFHSWRUV DQG QHJDWLYH +(5 status and the second group consisted of patients ZLWK WKH QHJDWLYH VWDWXV RI (5 DQG 35 KRUPRQH UHFHSWRUV DQG SRVLWLYH +(5 VWDWXV 7KHUHLQ the third group had patients with triple negative breast cancer and fourth group patients with posi WLYHVWDWXVRI(5DQG35KRUPRQHUHFHSWRUVDQG SRVLWLYH +(5 VWDWXV 7KH UHVHDUFK WRRN LQWR DFFRXQW VNHOHWDO VFLQWLJUDSK\ LPDJLQJ RI EUHDVW FDQFHU SDWLHQWV LQ WKH < DQG WKH <$OO breast cancer patients had their diagnosis patho KLVWRORJLFDOO\FRQ¿UPHG &RQFOXVLRQ6WDWLVWLFDOO\SDWLHQWVZLWK+(5QHJ ative, hormone positive and triple positive breast FDQFHUDUHSURQHWRKLJKHUULVNRIGHYHORSLQJVHF RQGDU\ERQHGHSRVLWV3DWLHQWVZLWKWULSOHQHJDWLYH DQG+(5(535QHJDWLYHEUHDVWFDQFHUKDYH ORZULVNRIVHFRQGDU\GHSRVLWVLQERQHV .DUFLQRP GRMNH MH QDMþHãüL ]ORüXGQL WXPRU NRG åHQD X VYLMHWX 0HWDVWD]H VX VHNXQGDUQR QDVW DOH SURPMHQH NRMH QLVX X GRGLUX V SULPDUQLP WXPRURP .RVWL SUHGVWDYOMDMX QDMþHãüH PMHVWR PHWDVWD]LUDQMD NRG NDUFLQRPD GRMNH 8þHVWDORVW SRMDYHSUYHPHWDVWD]HXNRãWDQRPVLVWHPXNDR ]QDN SURJUHVLMH RVQRYQRJ REROMHQMD MH UD]OLþLWD X ]DYLVQRVWLRGDXWRUDNRMLVXVHEDYLOLRYLPSUREOH PRPLNUHüHVHRGGR'RVDGDãQMDLVNXVW YDVXSRND]DODGDEROHVQLFDVDNDUFLQRPRP GRMNHNRMHLPDMXVDPRNRãWDQHPHWDVWD]HLPDMX SHULRGSUHåLYOMDYDQMDGRJRGLQD%URMQLL]YMHãWDML SRND]XMXGD(535SR]LWLYQRVW]DMHGQRVDGREL SDFLMHQWLFHSUHGVWDYOMDMXSR]LWLYQHSUHGLNDWRUHUD] YRMDNRãWDQLKPHWDVWD]DNRGSDFLMHQWLFDVDNDUFL QRP GRMNH 3ULMH JRGLQD RYHUHNVSUHVLMD +(5 QHX RQNRJHQVNRJ SURGXNWD +(5 SURWHLQ MH SULGRGDQD UL]LNR NDWHJRULMDPD NDUFLQRPD GRMNH 2YHUHNVSUHVLMD+(5SURWHLQDRSüHQLWRVHVPDWUD GDMHNRQ]LVWHQWQDXSULPDUQRPWXPRUVNRPWNLYX NDRLPHWDVWDWVNRPWNLYXLGDMHPHWDVWDWVNLSRWHQ FLMDOYHüLNRGRYHUHVNSUHVLMH+(51HNLL]YMHãWDML VXJHULUDMX GD MH YHüD LQFLGHQFD PHWDVWD]LUDQMD X SOXüDMHWUXLPR]DNQHJRXNRVWLNRG+(5RYHU HNVSUHVLMH 2YDVWXGLMDMHSURYHGHQDNDRSURVSHNWLYQRUHWURV SHNWLYQDVWXGLMD8NXSQRSDFLMHQWLFDVDNDUFL QRPRPGRMNHMHSRGLMHOMHQRXþHWLULJUXSH8SUYRM grupi su pacijentice sa pozitivnim statusom hor PRQDOQLKUHFHSWRUD(5L35DQHJDWLYQLK+(5 statusom, u drugoj grupi su pacijentice sa nega WLYQLP(5L35KRUPRQDOQLPUHFHSWRULPDDSR]L WLYQLP+(5VWDWXVRPXWUHüRMJUXSLVXSDFL MHQWLFHVDWULSOHQHJDWLYQLPNDUFLQRPRPGRMNHWHX þHWYUWRMSDFLMHQWLFHVDSR]LWLYQLPVWDWXVRPKRUPR QDOQLKUHFHSWRUD(5L35WH+(5SR]LWLYQLPVWD WXVRP8RYRPLVWUDåLYDQMXNRULãWHQLVXVQLPFL VFLQWLJUD¿MHVNHOHWDSDFLMHQWLFDREROMHOLKRGNDUFL QRPDGRMNHNRMLVXUDÿHQLXSHURGXGYLMHJRGLQH RGGRJRGLQH6FLQWLJUD¿MHVNHOHWDVX Key words: bone metastases, bone scintigraphy, EUHDVWFDQFHU(535UHFHSWRUV+(5SURWHLQ 0HGLFLQVNLåXUQDO âHMOD&HULü(OPD.XFXNDOLü6HOLPRYLü7LPXU&HULü1HUPLQD2EUDOLü6HPLU%HãOLMD6HOPD$JLü3UHGLFWRUVRISURJUHVVLRQRIERQHPHWDVWDVHVLQ EUHDVWFDQFHUGLDJQRVHGZLWKVNHOHWDOVFLQWLJUDSK\EDVHGRQWKHKRUPRQHUHFHSWRUVWDWXVDQG+(5SURWHLQV VHUDGLOHQD.OLQLFL]DQXNOHDUQXPHGLFLQX.&86 6YHSDFLMHQWLFHVXLPDOHSDWRKLVWRORãNLYHUL¿FLUDQX GLMDJQR]X NDUFLQRPD GRMNH =DNOMXþFL SDFLMHQWLFH VD+(5QHJKRUPRQDOQRSR]LWLYQLPLWULSOHSR]L WLYQLPNDUFLQRPRPGRMNHLPDMXVWDWLVWLþNLYHüLUL]LN ]DUD]YRMVHNXQGDUQLKNRãWDQLKGHSR]LWD3DFLMHQ WLFHVDWULSOHQHJDWLYQLPL+(5(535QHJD WLYQLPNDUFLQRPRPGRMNHLPDMXPDQMLUL]LNRGSR MDYHVHNXQGDUQLKNRãWDQLKGHSR]LWD .OMXþQH ULMHþL NDUFLQRP GRMNH NRãWDQH PHWDVWD]HVFLQWLJUD¿MDVNHOHWD(535UHFHSWRU +(5SURWHLQ INTRODUCTION %UHDVWFDQFHULVWKHPRVWIUHTXHQWIRUPRIWXPRULQ ZRPHQZRUOGZLGH$FFRUGLQJWR<HVWLPDWHV WKHUH ZHUH QHZ FDVHV RI EUHDVW FDQ FHULQWKHZRUOGDQGZRPHQGLHGRIWKLV disease. In developed countries, breast cancer is responsible for one fourth of new cases of car FLQRPD ZLWK ZRPHQ ,Q (XURSH DURXQG women fell to this illness every year, and 131,900 GLHVRILW<HVWLPDWHV %DVHGRQLQIRUPDWLRQIURPWKH5HJLVWU\RI0DOLJ nant Neoplasm Clinical Centre University of Sa UDMHYR &&86 WKHUH ZHUH SDWLHQWV WKDW underwent breast cancer treatments at CCUS in WKH SHULRG IURP WR 7KLV UHSUHVHQWV RI WKH RYHUDOO QXPEHU RI WKH PRVW IUHTXHQW tumor types treated at CCUS during this time VSDQ 7KLV PDNHV WKH EUHDVW FDQFHU WKH VHFRQG PRVW IUHTXHQW W\SH RI WXPRU ULJKW DIWHU WKH OXQJ FDQFHU%UHDVWFDQFHULVDOVRWKHPRVWIUH TXHQWFDQFHUZLWKZRPHQWDNLQJDVKDUHRI of all malignoma detected with women in the said time period. According to data from the Croatian 1DWLRQDO&DQFHU5HJLVWU\&URDWLDQ3XEOLF+HDOWK ,QVWLWXWHWKHUHDUHDSSZRPHQZLWKEUHDVW cancer every year. Unfortunately, B&H has not still established a cancer registry at the national level, so we have considered herein information from the Croatian National Cancer Registry for reasons of similar geomorphologic and hereditary charac teristics of the population and similar population ¿JXUH There is whole range of prognostic factors regard ing the breast cancer. Some of these factors are SURYHQDQGFRQ¿UPHGHJWXPRUVL]HKLVWRORJL FDOGLIIHUHQWLDWLRQDQG3+'ZKLOHRWKHUSURJQRV WLFIDFWRUVUHPDLQWREHFRQ¿UPHG $WXPRUVL]HLVRQHRINH\SURJQRVWLFIDFWRUVHV pecially in patients with negative values for armpit lymph nodes. There is a linear relationship be tween tumor size and affected regions of lymph nodes, on one side, and tumor size and survival UDWH RQ WKH RWKHU 3DWLHQWV ZLWK VPDOOHU WXPRU KDYH EHWWHU SURJQRVLV 6LJQL¿FDQFH RI GLVVHFWLRQ and analysis of lymph nodes rests primarily with REWDLQLQJ NH\ SURJQRVWLF LQIRUPDWLRQ DQG FRQ trolling of the illness. This is the most important prognostic factor for patients with breast cancer. $ULVNRIWXPRUUHFXUUHQFHDQGWKHRYHUDOOVXUYLYDO rate also depend on the number of affected lymph nodes. 0HWDVWDVHVDUHWKHVHFRQGDU\FKDQJHVQRWFRQ nected to the primary tumor. Their occurrence is one of the most important characteristics of ma lignity, although not all malignant tumors produce PHWDVWDVHV%RQHVDUHWKHPRVWIUHTXHQWPHWDV WDVLVORFDWLRQRIWKHEUHDVWFDQFHU:KHQHVWDE lishing the primary diagnosis of the breast cancer, WKHIUHTXHQF\RIERQHPHWDVWDVHVLV7KH IUHTXHQF\RIWKH¿UVWPHWDVWDVLVZLWKLQWKHVNHOHWDO system, determined as a sign of the primary illness progression, varies among different authors deal ing with this issue and is found to be somewhere EHWZHHQ&XUUHQWH[SHULHQFHKDVVKRZQ WKDWRIEUHDVWFDQFHUSDWLHQWVZLWKRQO\ERQH PHWDVWDVLVKDYHWKHVXUYLYDOUDWHRI\HDUV 5HSRUWVSUHVHQWHGDWWKH$6&2$PHULFDQ $VVRFLDWLRQ RI &OLQLFDO 2QFRORJ\ KDYH VKRZQ WKDW(535SRVLWLYHVWDWXVFRXSOHGZLWKSDWLHQWV¶ age represent positive predictive factors to de velopment of bone metastasis for breast cancer patients . Another possible predictive factor is the +(5 VWDWXV +XPDQ (SLGHUPDO *URZWK )DFWRU 5HFHSWRU$WWKHWK6W*DOOHQ([SHUW&RQVHQVXV 0HHWLQJDQRYHUH[SUHVVLRQRIWKH+(5 QHXRQFRJHQLFSURGXFW+(5SURWHLQZDVDGGHG WR WKH EUHDVW FDQFHU ULVN FDWHJRULHV 7KH +(5 protein over expression is generally considered consistent within the primary tumor tissue, as well as within the metastasis tissue. Also, metastasis SRWHQWLDOLVJUHDWHULQFDVHRIWKH+(5RYHUH[ pression. Certain reports suggest that the HER” over expression also entails higher incidence of metastasis of lungs, liver and brain, rather than the bone metastasis. So far, no comparative stud LHVZHUHGRQHLQRXUUHJLRQUHJDUGLQJ(535DQG +(5RYHUH[SUHVVLRQDQGWKHIUHTXHQF\RIERQH PHWDVWDVLV,QFDVHRIREWDLQLQJVLJQL¿FDQWVWDWLVWL cal results, this manner of monitoring bone me tastases would also help further determine models for screening of breast cancer patients. There are several diagnostic methods to detect ing bone metastasis, among which are radiology PHWKRGVVXFKDV&705,DQGVNHOHWDOVFLQWLJUD SK\,WLVSHUWLQHQWWRQRWHWKDWWKHVNHOHWDOVFLQWLJ raphy is a highly sensitive method in detection of WKHERQHPHWDVWDVLVDQGWKDWLWEHDUVORZVSHFL¿F QDWXUH 0HWDVWDWLF WXPRUV FDXVH DQ RVWHREODVWLF response even in cases when a lesion is osteo lytic. This is a precondition for metastases to at tract more radiopharmaceuticals during the scin WLJUDSK\DQGKHQFHKLJKOLJKWWKLVDVD³KRW´]RQH In most cases, this relates to multiple metastases 0HGLFLQVNLåXUQDO âHMOD&HULü(OPD.XFXNDOLü6HOLPRYLü7LPXU&HULü1HUPLQD2EUDOLü6HPLU%HãOLMD6HOPD$JLü3UHGLFWRUVRISURJUHVVLRQRIERQHPHWDVWDVHVLQ EUHDVWFDQFHUGLDJQRVHGZLWKVNHOHWDOVFLQWLJUDSK\EDVHGRQWKHKRUPRQHUHFHSWRUVWDWXVDQG+(5SURWHLQV VKRZQRQWKHVFLQWLJUDPDVPXOWLSOH³KRW´]RQHV 7KLV LV PRVWO\ IUHTXHQWO\ DVVRFLDWHG ZLWK WXPRUV W\SLFDOO\SURGXFLQJERQHPHWDVWDVHVEUHDVWFDQ cer, prostate cancer, bronchial cancer, gastric FDQFHU HWF 7KH VNHOHWDO VFLQWLJUDSK\ PD\ EH used to monitor the bone metastases’ response to treatment by means of examining deposits of radiopharmaceuticals in lesions before and after WDNLQJ DQ DSSURSULDWH WKHUDS\ ,Q FDVH RI GLIIXVH bone metastasis, the scintigraphy will provide a VRFDOOHG³VXSHUVFDQ´,WVFKDUDFWHULVWLFVDUHYHU\ high accumulation of radiopharmaceuticals in the VNHOHWDO V\VWHP LH PRUH WKDQ RI WKH GRV DJH QR DFWLYLW\ LQ NLGQH\V DQG XULQDU\ EODGGHU and very low circulatory activity and activity with regards to soft tissues. MATERIALS AND METHODS This study includes scintigraphy images of a total RIEUHDVWFDQFHUSDWLHQWVWDNHQZLWKLQWKHSH ULRG RI WZR \HDUV 7KH VNHOHWDO VFLQWLJUDSK\ ZDV FRQGXFWHGDWWKH&OLQLFIRU1XFOHDU0HGLFLQH&OLQ LF&OLQLFDO&HQWHU8QLYHUVLW\RI6DUDMHYR&&86 These are patients referred by oncologists from the Oncology Clinic, by surgeons from the Glan dular and Oncology Surgery Clinic of CCUS and by physicians of other relevant medical institutions within the Federation of Bosnia and Herzegovina. 7KHVHSDWLHQWVKDGDSDWRKLVWRORJLFDO\FRQ¿UPHG diagnosis of the breast cancer. 5HOHYDQW3+VDPSOHVZHUHSURFHVVHGDWWKH3D thology Clinic of CCU. 6NHOHWDO VFLQWLJUDSK\ LPDJHV ZHUH WDNHQ E\ 6LH PHQVGXDOKHDGJDPPDFDPHUDZLWK/(+5/RZ (QHUJ\+LJK5HVROXWLRQFROOLPDWRU8VLQJDZLGH range gamma camera and a high resolution col OLPDWRU WKH VNHOHWDO VFLQWLJUDSK\ ZDV FRQGXFWHG three hours after an intravenous application of osteotropic radiopharmaceutical. The most ap propriate time for the scintigraphy is three hours after administrating the radiopharmaceutical since this is the best time span for bone activity in their HQYLURQPHQW 3DWLHQWV DUH DGPLQLVWHUHG ZLWK 0%T P&L 7FP RI PDUNHG SRO\SKRVSKDWH or diphosphate compound. Gamma camera can FDSWXUHWKHVFLQWLJUDSK\LPDJHRIWKHHQWLUHVNHO HWRQ RU LQGLYLGXDO UHJLRQV IRU PRUH DFFXUDWH OR FDOL]DWLRQRIOHVLRQV /RFDOL]LQJDOHVLRQLVWKHPRVWDFFXUDWHZLWKVLQJOH SKRWRQHPLVVLRQFRPSXWHGWRPRJUDSK\63(&7 ,Q WHUPV RI TXDQWL¿FDWLRQ PHWKRGV WKH PRVW IUH TXHQWLVWKHPHWKRGRIUHJLRQVRILQWHUHVWPHDQLQJ that we compare an activity within the bone with pathological changes and an activity of a healthy bone in the same region. In this way, we arrive to the activity ratio between bones with pathological changes and healthy bones. 7KLV VWXG\ ZDV GHVLJQHG DV D SURVSHFWLYHUHWUR 0HGLFLQVNLåXUQDO spective study and was conducted within the pe ULRGRIWZR\HDUV-DQXDU\'HFHPEHU $OOEUHDVWFDQFHUSDWLHQWVZHUHGLYLGHG LQWRIRXUJURXSV7KH¿UVWJURXSLQFOXGHGSDWLHQWV with positive status of hormonal receptors ER and 35DQGQHJDWLYH+(5VWDWXVWKHVHFRQGJURXS ZHUHSDWLHQWVZLWKQHJDWLYH(5DQG35KRUPRQDO UHFHSWRUV DQG SRVLWLYH +(5 VWDWXV WKH WKLUG JURXSZHUHSDWLHQWVZLWKQHJDWLYH(5DQG35KRU PRQDO UHFHSWRUV DQG QHJDWLYH +(5 VWDWXV LH WULSOH QHJDWLYH EUHDVW FDUFLQRPD ZKLOH WKH IRUWK JURXSZHUHSDWLHQWVZLWKSRVLWLYH(5DQG35KRU PRQDOUHFHSWRUVDQGSRVLWLYH+(5VWDWXV 3ULPDU\ REMHFWLYH ZDV WR UXQ D FRPSDULVRQ EH tween the occurrence of bone metastasis and WHVWHGJURXSVRIEUHDVWFDQFHUSDWLHQWVDVSHUWKH VWDWXV RI 3URJHVWHURQH(VWURJHQ UHFHSWRUV DQG +(5 VWDWXV ZLWK DQ REMHFWLYH RI LGHQWLI\LQJ WKH group to possibly conduct a routine screening of bone metastasis. Secondary objective was to run DFRPSDULVRQRIWKHIUHTXHQF\RIERQHPHWDVWDVLV DPRQJWHVWHGJURXSVRIEUHDVWFDQFHUSDWLHQWVDV SHUWKHVWDWXVRI3URJHVWHURQH(VWURJHQUHFHSWRUV DQG+(5VWDWXVFRQVLGHULQJWKHUHLQWKHWXPRU VL]HDQGDIIHFWHGO\PSKQRGHVLH710FODVVL¿ cation of the breast cancer. Statistical processing and analysis of data was SHUIRUPHG XVLQJ WKH ,%0 6WDWLVWLFV 6366 VRIWZDUH 3URFHVVLQJ RI WKH ¿QGLQJV ZDV EDVHG RQ WKH FKLVTXDUH WHVW DQG WKH RQHZD\ DQDO\VLV RI YDULDQFH $129$ IRU SXUSRVH RI GHWHUPLQ LQJVLJQL¿FDQWGLIIHUHQFHVEHWZHHQWHVWHGSDWLHQW groups. The selected methods are standard meth RGVIRUFDOFXODWLQJDFWXDOSUREDELOLW\RIFRQ¿UPLQJ the primary hypothesis at the reliability level of S7HVWLQJPDWHULDOVZHUHVWDWLVWLFDOO\ SURFHVVHG DQG UHOHYDQW ¿QGLQJV DUH SURYLGHG LQ tables and charts based on an absolute number RIFDVHVUHODWLYHQXPEHURIFDVHVSHUFHQWDJHV arithmetical mean, standard deviation, standard error and value range depending on data type. RESULTS According to immunohistochemical characteris tics of a tumor, patients were divided into 4 tested JURXSVWRLQFOXGH+(5QHJDWLYHDQGKRUPRQH SRVLWLYH +(5 SRVLWLYH DQG KRUPRQHQHJDWLYH WULSOHQHJDWLYHDQGWULSOHSRVLWLYH:LWKLQWKHWRWDO VDPSOH1 PDMRULW\RISDWLHQWVSDWLHQWV RU ZDV ZLWKLQ WKH JURXS RI +( QHJDWLYH DQG (5 35 +(5 (5 35 QHJDWLYH JURXS LQFOXGHGSDWLHQWVZKLOHWULSOHSRVLWLYH ZHUH SDWLHQWV DQG WKH OHDVW QXPEHU of patients was within the group of triple negative FDUFLQRPDSDWLHQWVRU $ WXPRU VL]H FRPSDULVRQ 7 VWXG\ E\ SDWLHQW JURXSVVKRZVQRVWDWLVWLFDOO\VLJQL¿FDQWGLIIHUHQF HVS!DQGLQGLFDWHVWKDWPRVWRIFDUFLQRPD âHMOD&HULü(OPD.XFXNDOLü6HOLPRYLü7LPXU&HULü1HUPLQD2EUDOLü6HPLU%HãOLMD6HOPD$JLü3UHGLFWRUVRISURJUHVVLRQRIERQHPHWDVWDVHVLQ EUHDVWFDQFHUGLDJQRVHGZLWKVNHOHWDOVFLQWLJUDSK\EDVHGRQWKHKRUPRQHUHFHSWRUVWDWXVDQG+(5SURWHLQV LQDOOIRXUJURXSVLVLQWKH7VWDJH $ FRPSDULVRQ RI WXPRUDIIHFWHG UDWH RI O\PSK QRGHV1VWXG\E\SDWLHQWJURXSVVKRZVQRVWD WLVWLFDOO\VLJQL¿FDQWGLIIHUHQFHVS!DQGLQGL cates that the largest number of carcinoma in the tested sample is in the N1 stage, while the least QXPEHULVLQWKHVWDJH1[Ȥ S $QDQDO\VLVRIH[LVWHQFHRIGLVWDQWPHWDVWDVLV0 VWXG\VKRZVWKDWWKHKLJKHVWSHUFHQWDJHRIFDUFL QRPDLQWKH0VWDJHUHODWHVWRWKHJURXS+(5 (5 35 QHJDWLYH DQG WKH ORZHVW SHU FHQWDJH LV ZLWK WKH WULSOH QHJDWLYH JURXS 7KHUH ZHUH QR VWDWLVWLFDOO\ VLJQL¿FDQW GLIIHUHQFHV DPRQJJURXSVS!Ȥ S $QDQDO\VLVRIVFLQWLJUDSK\¿QGLQJVZLWKLQWKHWR tal sample showed that there were 119 patients RU RI SDWLHQWV ZLWK SRVLWLYH VFLQWLJUDSK\ UH sults. The largest number of positive scintigraphy UHVXOWVUHIHUVWRWKHWULSOHSRVLWLYHJURXS IROORZHG E\ WKH +(5 QHJDWLYH (5 35 SRVLWLYH JURXSWULSOHQHJDWLYHJURXSDQG +(5 (5 35 QHJDWLYH JURXS 7KLV ZDVDFFRPSDQLHGZLWKVWDWLVWLFDOO\VLJQL¿FDQWGLI IHUHQFHVDPRQJJURXSVSZKLFKFRQ¿UPV WKH SULPDU\ K\SRWKHVLV RI VLJQL¿FDQW GLIIHUHQFHV between tested groups of breast cancer patients DVSHUWKHVWDWXVRI3URJHVWHURQH(VWURJHQUHFHS WRUVDQG+(5VWDWXVLQWHUPVRIIUHTXHQF\RIWKH ERQHPHWDVWDVLVȤ S 7DEOH)LJXUH 7DEOH&RPSDULVRQRIVFLQWLJURSKLF¿QGLQJVWRJURXSVRISD WLHQWV; S An analysis among individual groups indicates WRVWDWLVWLFDOO\VLJQL¿FDQWGLIIHUHQFHVEHWZHHQWKH +(5(535QHJDWLYHJURXSDQGWULSOHSRVLWLYH group, as well as between the triple negative group DQG WULSOH SRVLWLYH JURXS S $FFRUGLQJ WR the analysis of these parameters, this means that patients with triple positive carcinoma have greater chances of developing bone metastasis, ZKLOH SDWLHQWV ZLWK WULSOH QHJDWLYH DQG +(5 (535QHJDWLYHFDUFLQRPDKDYHIHZHUFKDQFHVRI developing such metastasis. This may represent an important element in a clinical evaluation of WKHVHSDWLHQWV7DEOH Table 2.5HVXOWVRI&KLVTXDUHWHVWEHWZHHQLQGLYLGXDO groups of patients. $Q DQDO\VLV RI VNHOHWDO VFLQWLJUDK\ UHVXOWV DV SHU WKH WXPRU VL]H 7 VWDJH LQGLFDWHV WR VWDWLVWLFDOO\ VLJQL¿FDQW GLIIHUHQFHV ZLWKLQ WKH JURXS RI +(5 QHJDWLYH (5 35 SRVLWLYH EUHDVW FDQFHUV DV ZHOO DV ZLWKLQ WKH RYHUDOO VDPSOH S 7KLV PHDQVWKDWDQLQFUHDVHRIWKHWXPRUVL]H7VWDJH is accompanied with an increase in statistical probability of the bone metastasis occurrence 7DEOH 7DEOH &RPSDULVRQ RI ERQH VFLQWLJURSK\ ¿QGLQJV WR WXPRU VL]H7VWDJH )LJXUH &RPSDULVRQ RI VFLQWLJURSKLF ¿QGLQJV WR JURXSV RI patients. 0HGLFLQVNLåXUQDO âHMOD&HULü(OPD.XFXNDOLü6HOLPRYLü7LPXU&HULü1HUPLQD2EUDOLü6HPLU%HãOLMD6HOPD$JLü3UHGLFWRUVRISURJUHVVLRQRIERQHPHWDVWDVHVLQ EUHDVWFDQFHUGLDJQRVHGZLWKVNHOHWDOVFLQWLJUDSK\EDVHGRQWKHKRUPRQHUHFHSWRUVWDWXVDQG+(5SURWHLQV $QDQDO\VLVRIVNHOHWDOVFLQWLJUDSK\UHVXOWVDQGDI IHFWHGUDWHRIO\PSKQRGHV1VWDJHZLWKFDUFLQR PDLQGLFDWHVWRVWDWLVWLFDOO\VLJQL¿FDQWGLIIHUHQFHV ZLWKLQWKHJURXS+(5QHJDWLYH(535SRVLWLYH within the triple positive group and within the over DOOVDPSOHS7KLVPHDQVWKDWWKHLQFUHDVH RIWKH1VWDJHDIIHFWHGUDWHRIWKHO\PSKQRGHV brings along an increase of statistical probability of WKHERQHPHWDVWDVLVRFFXUUHQFH7DEOH 7DEOH&RPSDULVRQRIERQHVFLQWLJURSK\¿QGLQJVDQGO\PSK QRGHLQYROYHPHQW1VWDJH $QDQDO\VLVRIUHVXOWVDVSHUWKH710VWDJHDQG RFFXUUHQFH RI ERQH PHWDVWDVLV FRQ¿UPHG E\ WKH VNHOHWDOVFLQWLJUDSK\IROORZWKHH[SHFWHGSDWWHUQLQ sense that larger tumor with affected lymph nodes can be an independent predictive factor to devel opment of bone metastasis with breast cancer pa tients. DISCUSSION $QDQDO\VLVRIGLVWDQWPHWDVWDVLV0VWDJHIRUWKH group of patients with positive scintigraphy results KDV VKRZQ WKDW RI SDWLHQWV KDG DQ LQLWLDO LOO QHVV VWDJH 0 DQG 0[7KLV LQIRUPDWLRQ WHOOV XV WKDWERQHVZHUHWKH¿UVWORFDWLRQRIPHWDVWDWLFGLV SHUVLRQIRUWKHVHSDWLHQWV7DEOH 7DEOH&RPSDULVRQRIERQHVFLQWLJURSK\¿QGLQJVDQGSUHV HQFHRIGLVWDQWPHWDVWDVHV0VWDJH 0HGLFLQVNLåXUQDO Development of a breast cancer is a gradual pro cess based on genetic alterations leading to a pro gressive transformation of normal human cells to highly malignant products. In case of the breast FDQFHUPHWDVWDWLFGLVSHUVLRQPRVWIUHTXHQWO\RF FXUV ZLWKLQ WKH VNHOHWRQ 'HVSLWH LWV FOLQLFDO UHOH vance, the main cell and molecular mechanisms involved in the bone metastasis process are still GLI¿FXOWWRIXOO\XQGHUVWDQG$FFRUGLQJO\LWLVQHF essary to gain more comprehensive and clear understanding of these cell and molecular pro cesses. ,QGHYHORSHGFRXQWULHVDURXQGRIDOOEUHDVW FDQFHUV RFFXU ZLWK SRVWPHQRSDXVH ZRPHQ RI ZKLFK DSS KDG SRVLWLYH KRUPRQH ¿QGLQJV 7KHPHWDVWDVLVLVDUHDVRQIRUDSSRIGHDWK occurrences with breast cancer patients. Accord LQJWRWKHSRVWPRUWHPH[DPLQDWLRQDURXQG of all patients who died of the breast cancer had the metastatic bone dispersion. This was a chron ic condition with most of these patients. Since the occurrence of distant metastasis is âHMOD&HULü(OPD.XFXNDOLü6HOLPRYLü7LPXU&HULü1HUPLQD2EUDOLü6HPLU%HãOLMD6HOPD$JLü3UHGLFWRUVRISURJUHVVLRQRIERQHPHWDVWDVHVLQ EUHDVWFDQFHUGLDJQRVHGZLWKVNHOHWDOVFLQWLJUDSK\EDVHGRQWKHKRUPRQHUHFHSWRUVWDWXVDQGKHUSURWHLQV consistently related to the mortality rate of breast cancer patients, measurement of this distant met DVWDWLF GLVSHUVLRQ FDQ EH XVHG DV D VLJQL¿FDQW VXUURJDWH PDUNHU IRU WKH VXUYLYDO UDWH DQG KDV D potential of ensuring early results related to testing of new types of therapy models. 5HVHDUFK UHVXOWV E\ -DPHV DQG DVVRFLDWHV SXE OLVKHGLQWKH<%ULWLVK-RXUQDORI&DQFHUKDYH shown that bone metastases were the most fre TXHQWO\ GHVFULEHG PHWDVWDWLF LOOQHVV ZLWK UHVSHFW WR EUHDVW FDQFHU SDWLHQWV $OO SDWLHQWV KDG ERQHPHWDVWDVLVDVDORFDWLRQIRUWKH¿UVWRFFXU rence of the metastatic illness. Out of this number, 170 patients had no evidence RI WKH ERQH PHWDVWDVLV XSRQ WKHLU ¿UVW H[DPLQD tion. Also out of this total number, 91 patients had the bone metastasis as the only location of the met astatic illness. It is generally accepted fact that the hormonal receptors’ status correlates with the overall survival rate. However, actual effect of hor monal receptors to the dispersion manner of this LOOQHVVUHPDLQVXQNQRZQHYHQWRGD\ 7KHUHVHDUFKFRQGXFWHGE\0DNLDQGDVVRFLDWHV LQWKHSHULRGIURPWRHQFRPSDVVHG SDWLHQWVZLWKNQRZQLGHQWL¿HGVWDWXVRIKRUPRQDO receptors. These were patients with a potential for metastatic breast cancer, where all of them under ZHQWVNHOHWDOVFLQWLJUDSK\DQGFRQWUDVW05,RIWKH brain. Results obtained in this research indicated that SDWLHQWVZLWKVNHOHWDOPHWDVWDVHVEXWQREUDLQ PHWDVWDVHV KDG (535 RI WKHP$OVR WHQ SDWLHQWV ZLWK EUDLQ PHWDVWDVHV EXW QR VNHO HWDOPHWDVWDVHVKDG(535LHRIWKHP $VIRURISDWLHQWVWKH\KDGQHLWKHUEUDLQQRU VNHOHWDO PHWDVWDVHV EXW KDYH EHHQ GLDJQRVHG with a metastatic illness within the thorax and ab GRPHQ7KH\KDGWKH(535VWDWXV7KHIRXUWK group included patients with the metastatic illness ZLWKLQWKHEUDLQYLVFHUDORUJDQVDQGVNHOHWRQDQG QRQHRIWKHPKDG(535 According to this study, there are two forms of me WDVWDVLVZLWKUHJDUGVWRWKHEUHDVWFDQFHUH[FOXG LQJKHUHLQSDWLHQWVZLWKPDMRUGLIIXVHPHWDVWDVHV ± SDWLHQWV ZLWK (535 FDQFHU DQG ZLWK GHYHO RSHGERQHPHWDVWDVHVDQGSDWLHQWVZLWK(535 cancer and with a potential for brain metastases. Upon considering these distributions, a clinician can estimate a metastasis probability for different organ systems. This study corroborates our re search in sense that patients with triple negative cancer have fewer incidence of the bone metas tasis as opposed to those with positive hormonal status. 7KHVWXG\E\3DUNDQGDVVRFLDWHVLQ<GHDOW with types of relapses and metastatic dispersion ZLWK+(5SRVLWLYHEUHDVWWXPRUVDVSHUWKHHV WURJHQUHFHSWRUVWDWXVDQGLQFOXGHGSDWLHQWV WUHDWHGEHWZHHQDQG2XWRIWKHWR WDO QXPEHU WKH\ LGHQWL¿HG SDWLHQWV ZLWK WKH +(5 SRVLWLYH WXPRU 7KHUHRI SDWLHQWV KDG metastatic breast cancer. The research resulted LQWKHIROORZLQJ¿QGLQJVPHDQVXUYLYDOUDWHZLWK out any relapses was longer with patients within WKH+(5SRVLWLYH(5SRVLWLYHJURXSWKDQWKRVH LQ WKH +(5 SRVLWLYH (5 QHJDWLYH JURXS YV PRQWKV S ,Q UHODWLRQ WR WKH +(5(5 JURXS SHDN WLPH RI D UHFXUUHQW LOO QHVVZDVPRQWKVDIWHUDVXUJHU\LHWLPHEH IRUH7UDVWX]XPDE7KHUHODSVHSHDNWLPHIRUWKH +(5(5JURXSDSSHDUHGODWHUDQGZDVORZHU DQGPRQWKVDIWHUWKHVXUJHU\WKDQIRUWKH +(5(5SDWLHQWVDQGPRQWKVDIWHUWKH VXUJHU\ +HUHLQ WKH\ DOVR LGHQWL¿HG WKHVH LQGH SHQGHQW ULVN IDFWRUV IRU WKH UHODSVH \RXQJ DJH UDQJH >KD]DUG UDWLR +5 S @ 710 VWDJH +5 S DQG (5QHJDWLYH VWDWXV +5 S $Q LQWHUHVWLQJ IDFW UHJDUGLQJRXUUHVHDUFKLVWKDWWKH+(5SRVLWLYH (5 SRVLWLYH JURXS LQFOXGHV PDMRU ERQH PHWDV WDVHV +5 S DQG PDVVLYH KHSDWLF PHWDVWDVLV+5S ZLWKLQWKH+(5 SRVLWLYH (5 QHJDWLYH JURXS7KHVH ZHUH LGHQWL ¿HGDVORFDWLRQVRIWKHPRUHIUHTXHQWSURJUHVVLRQ within the patients of these groups. Our research DFWXDOO\FRQ¿UPHGWKDWSDWLHQWVZLWKWULSOHSRVLWLYH WXPRUVKDYHDVWDWLVWLFDOO\VLJQL¿FDQWSUREDELOLW\RI WKHERQHPHWDVWDVLVWKDQWKRVHZLWK+(5SRVL WLYH(5DQG35QHJDWLYHVWDWXV7KLVLVDQLQWHU HVWLQJ¿QGLQJFRQVLGHULQJWKDWWKHUHDUHQRPDQ\ available materials substantiating this thesis. CONCLUSIONS In our study we presented data that patients with +(5QHJDWLYHSRVLWLYHKRUPRQDOVWDWXVDQGWUL ple positive breast cancer have statistically great HUULVNRIGHYHORSLQJWKHERQHPHWDVWDVLV $OVRSDWLHQWVZLWKWULSOHQHJDWLYHDQG+(5(5 35EUHDVWFDQFHUDUHH[SRVHGWRIHZHUULVNRIWKH ERQH PHWDVWDVLV +HQFH VNHOHWDO VFLQWLJUDSK\ LQ their case is indicated only in special cases. &OLQLFLDQV DUH KHUHE\ JLYHQ D UHFRPPHQGDWLRQ guideline regarding a diagnostic protocol in sense that, in certain selected cases patients, it should LQFOXGH DQ LQGLFDWLRQ IRU D VNHOHWDO VFLQWLJUDSK\ during the cancer staging process for these pa WLHQWVSULRUWRRUDIWHUWKHUHOHYDQWVXUJHU\ &RQÀLFWRILQWHUHVWnone declared. 0HGLFLQVNLåXUQDO âHMOD&HULü(OPD.XFXNDOLü6HOLPRYLü7LPXU&HULü1HUPLQD2EUDOLü6HPLU%HãOLMD6HOPD$JLü3UHGLFWRUVRISURJUHVVLRQRIERQHPHWDVWDVHVLQ EUHDVWFDQFHUGLDJQRVHGZLWKVNHOHWDOVFLQWLJUDSK\EDVHGRQWKHKRUPRQHUHFHSWRUVWDWXVDQG+(5SURWHLQV REFERENCES 2EUDOLü 1 XUHG 5HJLVWDU PDOLJQLK QHRSOD]PL .OLQLþNRJ FHQWUD XQLYHU]LWHWD X 6DUDMHYX JRGLQHLQDOD]DSRGDWDND]DSHULRGJRGLQH 6DUDMHYR ,QVWLWXW ]D QDXþQR LVWUDåLYDþNL UDG L UD]YRM .&86VWU *ROGKLUVFK$*OLFN-+*HOEHU5'&RDWHV$66HQQ +-0HHWLQJKLJKOLJKWV,QWHUQDWLRQDO&RQVHQVXV3DQHO RQWKH7UHDWPHQWRI3ULPDU\%UHDVW&DQFHU6HYHQWK,Q WHUQDWLRQDO&RQIHUHQFHRQ$GMXYDQW7KHUDS\RI3ULPDU\ %UHDVW&DQFHU-&OLQ2QFRO 9DQ¶W 9HHU /- :HLJHOW % 5RDG PDS WR PHWDVWDVLV 1DWXUH0HG /HH<7 %UHDVW FDUFLQRPD SDWWHUQ RI PHWDVWDVLV DW DXWRSV\-6XUJ2QFRO .DPE\ & 9HMERUJ , 'DXJDUG ' *XOGKDPPHU % 'LUNVHQ + 5RVVLQJ 1 HW DO &OLQLFDO DQG UDGLRORJLFDO characteristic of bone metastases in breast cancer. &DQFHU $GDLU ) %HUJ - -RXEHUW / 5RELQVRQ * /RQJWHUP IROORZXSRIEUHDVWFDQFHUSDWLHQWV7KH\HDUUHSRUW &DQFHU $\DVV : (O 6HUHLND 6 9DQ /RQGHQ * %UXIVN\$ 3UHGLFWRUVRISURJUHVVLRQRIERQHPHWDVWDVHVLQEUHDVW FDQFHU SDWLHQWV - &OLQ 2QFRO VXSSO DEVWUDFW H *ROGKLUVFK$*OLFN-+*HOEHU5'&RDWHV$67KXUOL PDQQ%6HQQ+-0HHWLQJKLJKOLJKWV,QWHUQDWLRQDOH[ pert consensus on the primary therapy of early breast FDQFHU$QQ2QFROW± EUHDVW FDUFLQRPD IRXQG DW DXWRSV\ -SQ - &OLQ 2QFRO ,YDQþHYLü ' 'RGLJ ' .XVLü = .OLQLþND QXNOHDUQD PHGLFLQD 11. Coleman RE. Clinical features of metastatic bone GLVHDVHDQGULVNRIVNHOHWDOPRUELGLW\&OLQ&DQFHU5HV 3WVV -DPHV -- (YDQV $- 3LQGHU 6( *XWWHULGJH ( &KHXQJ ./ &KDQ 6 DW DO %RQH PHWDVWDVHV IURP EUHDVW FDUFLQRPD KLVWRSDWKRORJLFDO ± UDGLRORJLFDO FRU UHODWLRQV DQG SURJQRVWLF IHDWXUHV %U - &DQFHU ± 0DNL''*URVVPDQ5,3DWWHUQVRIGLVHDVHVSUHDG LQ 0HWDVWDWLF %UHDVW FDUFLQRPD ,QIXOHQFH RI (VWURJHQ DQG 3URJHVWHURQH 5HFHSWRU 6WDWXV $P - 1HXURGLRO 3DUN<+ /HH 6 &KR (< &KRL</ /HH -( 1DP 6-<DQJ-+DWDO3DWWHUQVRIUHODSVHDQGPHWDVWDWLF VSUHDGLQ+(5RYHUH[SUHVVLQJEUHDVWFDQFHUDFFRUG ing to estrogen receptor status. Cancer Chemother 3KDUPDFRO Address: âHMOD&HULü0' &OLQLFIRU1XFOHDU0HGLFLQH Clinical Center University of Sarajevo %ROQLþND6DUDMHYR Bosnia and Herzegovina 3KRQH (PDLOGHOMNRYLFVHMOD#\DKRRFRP 1RYDFHQWUDOQD]JUDGD.OLQLþNRJ&HQWUD8QLYHU]LWHWDX6DUDMHYX New Central building of the Clinical Center University of Sarajevo .\RGD6.LQRVKLWD67DNH\DPD+8FKLGD.0RUL NDZD 7 +(5 SURWHLQ RYHUH[SUHVVLRQ LQ PHWDVWDWLF 0HGLFLQVNLåXUQDO ,YDQND0DÿDU6LPLü$GQDQD7DOLü7DQRYLü0LUMDQD0DÿDU=HF,PSDFWRIHDUO\GHWHFWLRQRIHOERZRYHUXVHV\QGURPHRQWUHDWPHQW Original article IMPACT OF EARLY DETECTION OF ELBOW OVERUSE SYNDROME ON TREATMENT 87-(&$- 5$1( '(7(.&,-( 6,1'520$ 35(1$35(=$1-$ /$.7$ 1$ /,-(ý(1-( ,YDQND0DÿDU6LPLü$GQDQD7DOLü7DQRYLü20LUMDQD0DÿDU=HF 1 3ULPDU\+HDOWK&DUH&HQWHU5XÿHUD%RãNRYLüDEE1RYL7UDYQLN%RVQLDDQG+HU]HJRYLQDOrthopedics DQG7UDXPDWRORJ\&OLQLF&OLQLFDO&HQWHU8QLYHUVLW\RI6DUDMHYR%ROQLþND6DUDMHYR%RVQLDDQG+HU]HJR vina B&H; 3&URDWLDQ+RVSLWDOÄ'UIUD0DWR1LNROLF³1RYD%LOD7UDYQLN%RVQLDDQG+HU]HJRYLQD &RUUHVSRQGLQJDXWKRU ABSTRACT Overuse elbow syndrome is a set of chronic dam age incurred in sport and recreation, or in some RFFXSDWLRQV DV D UHVXOW RI ORQJWHUP RYHUXVH ,W RFFXUVRQWKHRXWVLGHRIWKHHOERZWHQQLVHOERZ DQGRQWKHLQQHUVLGHRIWKHHOERZJROIHU¶VHOERZ The main symptom is pain in the lateral or medial epicondyle. Often enough attention is not given to WKH¿UVWV\PSWRPVZKLFKOHDGVWRGHOD\LQGLDJQR sis and thus the approach to treatment. However, based on a thorough history and physical exami QDWLRQ DORQJ ZLWK VSHFL¿F FOLQLFDO WHVWV WKH GH WHFWLRQLVSRVVLEOH3URSHUDQGHDUO\GHWHFWLRQRI disease is important for treatment that is basically conservative. Surgical treatment is rarely used. The aim of this study was to demonstrate the im pact of early detection of overuse elbow injuries to treatment, duration of treatment and complete UHWXUQRISDWLHQWVWRGDLO\ZRUNDQGVSRUWDFWLYLWLHV 2XUVWXG\LQFOXGHGSDWLHQWVRIERWKVH[HVDJHG \HDUVZLWKDSDLQIXOV\QGURPHLQWKHHOERZ GLYLGHG LQWR WZR JURXSV 7KH ¿UVW JURXS ± LQMX ries related to professional or sports activity and were treated in the primary health care center af ter more than 48 hours after symptoms occurred, DQG VHFRQG JURXS DWKOHWHV WUHDWHG E\ D GRFWRU of sports medicine or club doctors within 48 hours of symptom onset, and covered the period of two years . The results showed that the analysis of the duration of physical treatment, complete treat PHQW GXUDWLRQ DQG WKH OHQJWK RI LQDELOLW\ WR ZRUN and perform sports activities shows that all three SDUDPHWHUVZHUHVWDWLVWLFDOO\VLJQL¿FDQWO\ORQJHULQ SDWLHQWVLQJURXS,FRPSDUHGWRJURXS,,S indicating shorter treatment and a better outcome in patients who earlier reported to the treatment ZLWKLQ KRXUV :H FRQFOXGH WKDW HDUO\ GHWHF tion of overuse elbow injuries shortens the dura tion of treatment, and enables faster and more complete return of patients to their professional, sports and everyday activities. Key words: overuse syndrome, detection, pain, elbow 6$ä(7$. 6LQGURP SUHQDSUH]DQMD ODNWD SUHGVWDYOMD VNXS NURQLþQLKRãWHüHQMDQDVWDOLKXVSRUWXLUHNUHDFLMLLOL XQHNLP]DQLPDQMLPDNDRSRVOMHGLFDGXJRWUDMQRJ SUHQDSUH]DQMD -DYOMD VH QD YDQMVNRM VWUDQL ODNWD WHQLVNLODNDWLQDXQXWDUQMRMVWUDQLODNWDJROIHUVNL ODNDW2VQRYQLVLPSWRPMHEROXSRGUXþMXODWHUDO QRJ LOL PHGLMDOQRJ HSLNRQGLOD 3UYLP VLPSWRPLPD þHVWR VH QH SRNODQMD GRYROMQD SR]RUQRVW L NDVQL VHXGLMDJQR]LDWLPHLVDPRPSULVWXSXOLMHþHQMX 0HÿXWLPQDRVQRYXGHWDOMQHDQDPQH]HLNOLQLþNRJ SUHJOHGDX]VSHFL¿þQHNOLQLþNHWHVWRYHGHWHNFLMD MH PRJXüD 3UDYLOQD L UDQD GHWHNFLMD REROMHQMD YDåQDMH]DOLMHþHQMHNRMHMHXSULQFLSXNRQ]HUYD WLYQR.LUXUãNROLMHþHQMHVHULMHWNRSULPMHQMXMH &LOMRYHVWXGLMHMHELRSRND]DWLXWMHFDMUDQHGHWHN FLMH VLQGURPD SUHQDSUH]DQMD X ODNWX QD OLMHþHQMH GXOMLQX OLMHþHQMD L SRWSXQLML SRYUDWDN SDFLMHQDWD VYDNRGQHYQLPUDGQLPLVSRUWVNLPDNWLYQRVWLPD 1DãH LVWUDåLYDQMH XNOMXþLOR MH SDFLMHQDWD RED VSRODGRELRGJRGLQDVWDURVWLVEROQLPVLQ GURPRP X ODNWX SRGLMHOMHQL X GYLMH JUXSH 3UYD JUXSDRVREHYH]DQH]DSURIHVLRQDOQXLOLVSRUWVNX DNWLYQRVWDOLMHþHQLVXX'=QDNRQVDWLRGSR MDYHVLPSWRPDLGUXJDJUXSDVSRUWLVWLOLMHþHQLNRG OLMHþQLNDVSRUWVNHPHGLFLQHLOLNOXSVNRJOLMHþQLNDGR 48 sati od pojave simptoma, a obuhvatilo je vre PHQVNLSHULRGRGGYLMHJRGLQH5H]XOWDWLVXSRND ]DOLGDDQDOL]DGXOMLQHWUDMDQMD¿]LNDOQRJWUHWPDQD GXOMLQH OLMHþHQMD L GXOMLQH VSULMHþHQRVWL ]D UDG L VSRUWVNHDNWLYQRVWLSRND]XMHGDVXVYDWULSDUDPH WUDELODVWDWLVWLþNLVLJQLINDQWQRGXåDNRGSDFLMHQDWD JUXSH , X RGQRVX QD SDFLMHQWH JUXSH ,, S XND]XMXüL QDNUDüLWUHWPDQLEROML LVKRGNRGSDFL MHQDWD NRML VX VH UDQLMH MDYLOL QD OLMHþHQMH XQXWDU K =DNOMXþXMHPR GD UDQRP GHWHNFLMRP VLQ GURPD SUHQDSUH]DQMD X ODNWX VNUDüXMH VH GXOMLQD OLMHþHQMD D EUåL MH L SRWSXQLML SRYUDWDN SDFLMHQDWD 0HGLFLQVNLåXUQDO ,YDQND0DÿDU6LPLü$GQDQD7DOLü7DQRYLü0LUMDQD0DÿDU=HF,PSDFWRIHDUO\GHWHFWLRQRIHOERZRYHUXVHV\QGURPHRQWUHDWPHQW VYRMLPSURIHVLRQDOQLPVSRUWVNLPLVYDNRGQHYQLP DNWLYQRVWLPD .OMXþQHULMHþLVLQGURPSUHQDSUH]DQMDGHWHNFLMD EROODNDW INTRODUCTION Overuse syndrome is a set of chronic elbow dam age incurred in sport and recreation, or in some RFFXSDWLRQVDVDUHVXOWRIORQJWHUPRYHUVWUDLQLQJ creating discomfort or pain in the muscles, joints, WHQGRQVQHUYHVDQGVRIWWLVVXH ,W RFFXUV LQ WZR GLIIHUHQW SODFHV RQ WKH RXWVLGH RI WKH HOERZ ODWHUDO HSLFRQG\OLWLV WHQQLV HOERZ DQG RQ WKH LQQHU VLGH RI WKH HOERZ PHGLDO HSL FRQG\OLWLV JROIHU¶V HOERZ 7KH ORZHU SDUW RI WKH KXPHUXVKDVDERQHVSXUHSLFRQG\OHRQWKHRXW side and the inside of the elbow, from which depart IRUHDUPPXVFOHWHQGRQVWKDWEHQGWKH¿QJHUVDQG ZULVW ÀH[RUV DQG WKH WHQGRQV DQG PXVFOHV H[ WHQG¿QJHUVDQGZULVWVH[WHQVLRQ(PHUJHQFHRI overuse injuries in the elbow joint can complicate these movements and occur not only by sports, but also by everyday life and professional activi ties. Cause of golfer’s and tennis elbow is repeated me FKDQLFDO RYHUORDG RI H[WHUQDO RU LQWHUQDO VNHOHWDO muscle origin. This result in more or less damage to tendons of affected muscle, their bone origin, and in untreated patients and patients with chronic illnesses also damage to the surrounding tissue. The most common symptoms are reduced hand function, sensitivity and tenderness over the bony origin of muscle tendons which increases with the use of arms. Symptoms develop gradually and ZRUVHQRYHUWLPHLIOHIWXQWUHDWHG6\QGURPH GHYHORSV LQ DERXW RI WKH DGXOW SRSXODWLRQ in both sexes, more in the dominant hand, and most affected are those in the middle age, which in the course of using the maximum way forearm PXVFOHV ZRUNHUV ZLWK SQHXPDWLF GULOOV WDLORUV barbers , builders, drivers, mechanics, ceramists, waiters, persons engaged in gardening, carpen WHUV ZDVKLQJ GLVKHV DV ZHOO DV KRXVHZLYHV DQGFHUWDLQO\ZHVKRXOGQRWIRUJHWDWKOHWHVWHQQLV players, hence the name tennis elbow, table ten QLV SOD\HUV ZHLJKW OLIWHUV VNLHUV ERG\ EXLOGHUV Tennis elbow occurs 10 times more often than JROIHU¶VHOERZ7KHPDLQV\PSWRPRIWHQQLV and golfer’s elbow is pain in the lateral or medial epicondyle of the elbow, which can be of varying intensity, from mild after the activity, to the constant pain that prevents any activity. The characteristic symptom is decreased strength of the hand, that patients complain about the appearance of strong pain when lifting even very light loads which are held in the hand, such as when lifting a cup of tea RU FRIIHH WXUQLQJ WKH NH\ LQ WKH ORFN DQG ZKLFK 0HGLFLQVNLåXUQDO XVXDOO\GRHVQRWFDXVHVSDLQLQWKHHOERZ 2IWHQWRWKH¿UVWV\PSWRPVLVQRWSDLGHQRXJKDW tention which leads to delay in diagnosis and thus the approach to treatment. +RZHYHU EDVHG RQ GHWDLOHG KLVWRU\ VXEMHFWLYH FRPSODLQWVRISDWLHQWVLQIRUPDWLRQDERXWKLVKHUV RFFXSDWLRQRUVSHFL¿FVSRUWVDFWLYLW\DQGFOLQLFDO H[DPLQDWLRQZLWKVSHFL¿FFOLQLFDOWHVWVRIWHQXVHG ÄFKDLUWHVW³DQG0LOOHVWHVWGHWHFWLRQRIWHQQLVHO ERZ LV SRVVLEOH &OLQLFDO H[DPLQDWLRQ FDQ determine the exact painful parts of the elbow joint and functional changes in their active and passive motion, sometimes the presence of effusion in the HOERZMRLQWORFDOVLJQVRILQÀDPPDWLRQRUWKHSUHV HQFHRIEORRGEUXLVHVKHPDWRPD Although the diagnosis of lateral epicondylitis is essentially set on the basis of clinical examination, however, also may be helpful radiological and ul WUDVRXQGGLDJQRVLV6WDQGDUG;UD\RIWKH elbow in most cases are normal and are made to identify any other damage or deformation of the HOERZ ZKLOH LQ D VPDOO QXPEHU RI FDVHV WKH ; UD\UHYHDOVDFDOFL¿FDWLRQLQWKHHSLFRQG\OHZKLFK VSHDNLQIDYRURIRYHUXVHLQMXU\RIWKHHOERZ8O trasound examination can detect focal hypoecho JHQLFDUHDVZLWKLQWKHWHQGRQVWKDWDUHWKLFNHQHG around which can be found traces of effusion, as ZHOO DV FDOFL¿FDWLRQ LQ PXVFOHWHQGRQ VWUXFWXUHV 0DJQHWLFUHVRQDQFHLPDJLQJLVXVHGZKHQRWKHU LQWUDDUWLFXODUGLVHDVHVDUHVXVSHFWHG 3URSHUDQGHDUO\GHWHFWLRQRIGLVHDVHLVLPSRUWDQW for the treatment which needs to start as early as possible. Treatment is essentially conservative. 7KH¿UVWVWHSLQWUHDWPHQWLVFHUWDLQO\DEVROXWHUHVW and refrain from activities that lead to unhealthy FRQGLWLRQDVORQJDVWKHV\PSWRPVPLQLPXPUH FRYHU\SHULRGLVGD\VZLWKWKHORFDODSSOLFD tion of cold compresses and ice, as well as elastic EDQGDJH5,&(PHWKRG5HVW,FH&RPSUHVVLRQ (OHYDWLRQ DQG SK\VLFDO WKHUDS\ VWUHWFKLQJ H[ ercises, isotonic and isometric exercises, cryo WKHUDS\ WKHUDSHXWLF XOWUDVRXQG HWF ,Q FDVHRIPRUHSURQRXQFHGSDLQFDQEHXVHGQRQ VWHURLGDO DQWLLQÀDPPDWRU\ GUXJV ORFDOO\ DSSOLHG :LWKFRQVHUYDWLYHWUHDWPHQWUHFRYHU\LVDFKLHYHG LQDSSUR[LPDWHO\RIFDVHV6XUJLFDOWUHDW ment is rarely used and is reserved for resistant and recurrent cases where are diagnosed degen HUDWLYH DQG FDOFLI\LQJ FKDQJHV LQ PXVFOHWHQGRQ structures with the aim of removing the damaged WLVVXHDQGVHFWLRQRIDIIHFWHGPXVFOH Aim The aim of this study was to show the effects of early detection of overuse elbow injuries on treat ment, achievement of better treatment results and IXOO UHWXUQ RI SDWLHQWV WR GDLO\ ZRUN DQG VSRUWLQJ activities. ,YDQND0DÿDU6LPLü$GQDQD7DOLü7DQRYLü0LUMDQD0DÿDU=HF,PSDFWRIHDUO\GHWHFWLRQRIHOERZRYHUXVHV\QGURPHRQWUHDWPHQW MATERIALS AND METHODS SDWLHQWV ZLWK RYHUXVH HOERZ LQMXULHV RI ERWK sexes, whose painful symptoms were related to RFFXSDWLRQDODQGVSRUWVDFWLYLWLHVDWDJHIURP \HDUVZHUHWDNHQLQFRQVLGHUDWLRQSDWLHQWV RI WKH WRWDO QXPEHU ZDV WUHDWHG DW WKH 3ULPDU\ +HDOWK&DQWHU1RYL7UDYQLNDQGDQRWKHUZHUH athletes and were treated by a doctor of sports medicine and club doctor at sports clubs. To col lect relevant data on each patient, manner of in jury, type of professional or sports activities, time to consult a doctor, diagnostic procedures, type DQGGXUDWLRQRIWUHDWPHQWDEVHQFHIURPZRUNWKH length of disability since sports activities and the ¿QDO HYDOXDWLRQ FOLQLFDO DQG IXQFWLRQDO ZDV DG PLQLVWHUHGPHGLFDOUHFRUGTXHVWLRQQDLUH The study covered a period from November 1, WR'HFHPEHU All patients were divided into two groups of 30 pa tients: ,JURXSSDWLHQWVLQFOXGHGDODUJHUQXPEHURI subjects with injuries related to professional activ ity and a smaller number of athletes who reported to an examination by a surgeon in a medical cent er because of pain in the elbow for a period of time longer than 48 h. ,,JURXSSDWLHQWVLQFOXGHGDWKOHWHVZKRFRQ tacted and were treated at a sport medicine spe cialist or club doctor because of pain in the elbow at a time up to 48 hours since the onset of pain. 7KHVWXG\ZDVRIUHWURVSHFWLYH±SURVSHFWLYHW\SH Data were collected and used from medical re cords of patients and the protocol of registry of medical records from the surgical clinic of the 3ULPDU\ +HDOWK &HQWHU 1RYL 7UDYQLN RI UHJLVWU\ of medical records from sports clubs, physiatrist protocols and surgical protocols of Hospital Nova %LOD )RU DOO SDWLHQWV LQ WKH ¿UVW JURXS ZDV SHU formed the same diagnostic procedures. In each SDWLHQWZDVWDNHQDGHWDLOHGPHGLFDOKLVWRU\FRQ ducted clinical examination to determine the exact location of pain, and in case of suspicion to ten nis and golfer’s elbow were applied some of the VSHFL¿F FOLQLFDO WHVWV ÄFKDLU WHVW³ 0LOOHV WHVW ,Q DOOSDWLHQWVDVWDQGDUG;UD\ZDVGRQHZKLFKZDV DLPHGWRGHWHUPLQHFDOFL¿FDWLRQRQODWHUDOHSLFRQ G\OH WKDW VSHDN LQ IDYRU RI HSLFRQG\OLWLV DV ZHOO as observations of other injury or deformity of the elbow. Ultrasound examination revealed focal hypoecho JHQLFDUHDVZLWKLQWKHWHQGRQVWKDWDUHWKLFNHQHG and around which can be found traces of the ef fusion. If necessary, magnetic resonance imaging was done, especially in another suspected joint disease of the elbow. 'LDJQRVWLFV FOLQLFDO DQG UDGLRORJLFDO IRU HDFK patient from the II group, which includes athletes, was performed by a doctor of sports medicine and club doctor with the availability of standard radi ography, ultrasound of the painful elbow area and 05,LIQHFHVVDU\ After diagnostic procedure was indicated individu al therapy by choice of sports medicine doctor or a FOXEGRFWRUZLWK¿OOLQJRXWD¿OLQJPHGLFDOUHFRUGV of the treatment procedures performed, which are used for evaluation. All patients examined in this study, to which was indicated physical therapy, the treatment was con ducted at the Department of physical medicine at Hospital Nova Bila. For statistical analysis was used statistical soft ZDUH 6366 3URFHVVLQJ LV GRQH E\ PHWK ods of descriptive statistics in order to calculate WKHPHDQDQGVWDQGDUGGHYLDWLRQZLWKWWHVWDQG FKLVTXDUHWHVW6WDWLVWLFDODQDO\VLVZDVSHUIRUPHG ZLWKLQDFRQ¿GHQFHLQWHUYDORIDQGDYDOXHRI SZDVFRQVLGHUHGDVVLJQL¿FDQW RESULTS The study involved two groups of 30 patients each. In both study group analysis by gender showed a higher prevalence of male patients, while accord ing to the side, the localization of the disease in most cases was on the right side. 7DEOH 3UHVHQWDWLRQ RI JHQGHU DQG V\QGURPH ORFDOL]DWLRQ side. 2IWKHWRWDORIDQDO\]HGSDWLHQWVWKHUHZHUHRU RIPHQDQGRURIZRPHQ7KHDQDO\ VLVVKRZVWKDWPHQZHUHVOLJKWO\RYHUUHSUHVHQW ed in both groups as well as in the total sample, EXW ZLWKRXW VWDWLVWLFDOO\ VLJQL¿FDQW GLIIHUHQFHV S! According to the localization of the disease in most FDVHV LW ZDV WKH ULJKW HOERZ RU FRP SDUHGWRWKHOHIWVLGHRU7KLVGLVWULEX tion is retained within the group and between the VH[HVZLWKRXWVWDWLVWLFDOO\VLJQL¿FDQWGLIIHUHQFHVS 7DEOH Table 2. 3UHVHQWDWLRQRIDFWLYLWLHVDQGW\SHVRIV\QGURPHVE\ localization. 0HGLFLQVNLåXUQDO ,YDQND0DÿDU6LPLü$GQDQD7DOLü7DQRYLü0LUMDQD0DÿDU=HF,PSDFWRIHDUO\GHWHFWLRQRIHOERZRYHUXVHV\QGURPHRQWUHDWPHQW Analyzing the occurrence of the syndrome by ac tivities it can be noticed that in the total sample, PRVWV\QGURPHVDUHUHODWHGWRVSRUWVDFWLYLW\ RUFRPSDUHGWRWKHV\QGURPHVUHVXOWLQJLQ SURIHVVLRQDO DFWLYLWLHV RU WKDW ZHUH UH corded only in group I. 6WDWLVWLFDODQDO\VLVLQGLFDWHVWKDWWKHUHDUHVLJQL¿ cant differences in the activities in which the injury RFFXUUHGE\JURXSVS Also type of overuse injuries localization shows WKDWPRVWZDVRIWHQQLVHOERZW\SHRU FRPSDUHG WR JROIHU¶V HOERZ RU ZLWKRXW VWDWLVWLFDOO\ VLJQL¿FDQW GLIIHUHQFHV EHWZHHQ WKH groups as well as the activities which leaded to WKHLQMXU\S!7DEOH If we compare the average age of patients in both groups we can notice that patients in group II, with DPHDQDJHRI\HDUVUDQJH\HDUV are slightly older than the patients in group I with DPHDQDJHRIUDQJH\HDUV$OVR ZHFDQQRWLFHWKDWWKHUHLVQRVWDWLVWLFDOO\VLJQL¿ FDQWGLIIHUHQFHS7DEOHD 7DEOH Type of treatment in groups I and II. 7DEOH Comparison of age groups. Figure 2. 3HUFHQWDJH RI SDWLHQWV DFFRUGLQJ WR WKH WUHDWPHQW type. )LJXUH3HUFHQWDJHRIUHVSRQGHQWVE\DJHJURXSV It is notable that all patients from group II 30 DQG SDWLHQWV RI *URXS , DUH WUHDWHGFRQVHUYDWLYHO\ZKLOHRQO\RISD tients from Group I were treated conservatively FRPELQHGZLWKVXUJHU\ZLWKRXWVWDWLVWLFDOO\VLJQL¿ FDQW GLIIHUHQFHV EHWZHHQ JURXSV S! 7DEOH DQG)LJXUH Review by age groups indicates that in the total sample as well as in the individual groups of larg HVW QXPEHU RI SDWLHQWV ZHUH DJHG \HDUV RU ZLWKRXW VWDWLVWLFDOO\ VLJQL¿FDQW GLI IHUHQFHV EHWZHHQ JURXSV S 7DEOH DQG )LJXUH 7DEOHComparison of the average duration since the symp tom onset until start of the treatment. 7DEOHD Comparison of mean age between the groups. Analysis of time from symptom onset to the start of treatment indicates that the patients in group I had the average time since onset of symptoms WR WUHDWPHQW RI GD\V UDQJH GD\V while the patients from group II had an average RIGD\VUDQJHGD\VZLWKVWDWLVWLFDOO\ 0HGLFLQVNLåXUQDO ,YDQND0DÿDU6LPLü$GQDQD7DOLü7DQRYLü0LUMDQD0DÿDU=HF,PSDFWRIHDUO\GHWHFWLRQRIHOERZRYHUXVHV\QGURPHRQWUHDWPHQW VLJQL¿FDQW GLIIHUHQFH EHWZHHQ JURXSV S 7DEOH Table 6. Comparison of the average time of treatment and dis ability. )LJXUH Comparison of the average time of treatment and disability. Analysis of the physical treatment duration, com plete treatment duration and the length of inability WR ZRUN DQG KDYH VSRUWV DFWLYLWLHV VKRZV WKDW DOO WKUHH SDUDPHWHUV ZHUH VWDWLVWLFDOO\ VLJQL¿FDQWO\ longer for patients in group I compared to group ,,SDWLHQWVSLQGLFDWLQJDVKRUWHUWUHDWPHQW and better outcome in patients who have started WKHWUHDWPHQWHDUOLHUZLWKLQKRXUV7DEOHDQG )LJXUH DISCUSSION Overuse elbow syndrome is a set of chronic dam age incurred in sport and recreation, or in some RFFXSDWLRQVDVDUHVXOWRIORQJWHUPRYHUVWUDLQLQJ ,W RFFXUV LQ WZR ORFDWLRQV ± DW WKH RXWVLGH RI WKH HOERZWHQQLVHOERZDQGWKHLQVLGHRIWKHHOERZ JROIHU¶VHOERZ Analyzing the results obtained in both groups, we VHHWKDWIURPDEDVHOLQHSDWLHQWVZHUHPDOHRU DQGRUIHPDOH7KHDQDO\VLVVKRZV WKDW PHQ ZHUH VOLJKWO\ RYHUUHSUHVHQWHG LQ ERWK groups as well as in the total sample but without VLJQL¿FDQWVWDWLVWLFDOGLIIHUHQFHS!2YHUXVH syndrome is usually localized at the dominant hand. In our study the localization of the disease LQPRVWFDVHVZDVWKHULJKWHOERZRU ZKLOHRQWKHOHIWVLGHLQRURIFDVHV7KLV distribution is retained within the groups and be WZHHQ WKH VH[HV ZLWKRXW VWDWLVWLFDOO\ VLJQL¿FDQW GLIIHUHQFHVS([DPLQDWLRQE\DJHJURXSV noted that in the total sample as well as individual JURXSVODUJHVWQXPEHURISDWLHQWVZHUHDJHG \HDUVRUZLWKRXWVWDWLVWLFDOO\VLJQL¿ FDQW GLIIHUHQFHV EHWZHHQ JURXSV S &RP paring the average age of patients in both groups is observed that patients in group II, with a mean DJH RI \HDUV UDQJH \HDUV DUH slightly older than the patients in group I with a PHDQ DJH RI UDQJH \HDUV EXW WKHUH ZDV QR VWDWLVWLFDOO\ VLJQL¿FDQW GLIIHUHQFH S 2YHUXVH HOERZ V\QGURPH GHYHORSV LQ DERXWRIWKHDGXOWSRSXODWLRQLQERWKVH[HV more in the dominant hand, while most affected DUHWKRVHLQPLGGOHDJHWKDWGXULQJZRUNDUHXVLQJ LQWKHPD[LPDOPDQQHUIRUHDUPPXVFOHV.UDSDF HWDO Comparing the data obtained in this study with data found in other studies, it can be said that the incidence of overuse elbow syndrome according to gender, age and according to the side are con sistent. 2IWHQDWWHQWLRQLVQRWSDLGWRWKH¿UVWV\PSWRPV with delay in the diagnosis and therefore the start of the treatment. However, based on detailed case KLVWRU\VXEMHFWLYHFRPSODLQWVRISDWLHQWVLQIRUPD WLRQ DERXW KLVKHUV RFFXSDWLRQ RU VSHFL¿F VSRUWV DFWLYLW\DQGFOLQLFDOH[DPLQDWLRQZLWKVSHFL¿FFOLQL FDOWHVWVRIWHQXVHGÄFKDLUWHVW³DQG0LOOHVWHVW ZLWKGLDJQRVWLFSURFHGXUHV;UD\DQGXOWUDVRXQG GHWHFWLRQRIRYHUXVHLQMXULHVLQWKHHOERZWHQQLV DQG JROIHU¶V HOERZ LV SRVVLEOH DW DQ HDUO\ VWDJH Basically there is a great similarity in damages re lated to the sports and professional activities with FOHDUO\ H[SUHVVHG FKDQJHV DW WKH SDWKRORJLFDO DQDWRPLFDO OHYHO DQ LQÀDPPDWLRQ ZKLFK LV D UH VSRQVHWRWLVVXHLQMXU\ Analyzing the development of the activities of the syndrome in our study, we see that the majority of syndromes in the baseline sample was related to VSRUWVDFWLYLWLHVRUFRPSDUHGWRWKHV\Q GURPHV FDXVHG E\ SURIHVVLRQDO DFWLYLWLHV RU WKDWZHUHUHFRUGHGRQO\LQWKHJURXS,6WD WLVWLFDODQDO\VLVLQGLFDWHVWKDWWKHUHDUHVLJQL¿FDQW differences in the activities in which the infringe PHQWRFFXUUHGDFFRUGLQJWRJURXSVS Similarly type of overuse syndrome localization in our study indicates that most of are of tennis HOERZ W\SH RU FRPSDUHG WR JROIHU¶V HOERZRUZLWKRXWVWDWLVWLFDOO\VLJQL¿FDQW differences between the groups as well as the ac WLYLWLHVWKDWFDXVHGLQMXU\S! 0HGLFLQVNLåXUQDO ,YDQND0DÿDU6LPLü$GQDQD7DOLü7DQRYLü0LUMDQD0DÿDU=HF,PSDFWRIHDUO\GHWHFWLRQRIHOERZRYHUXVHV\QGURPHRQWUHDWPHQW According to data from other studies, tennis elbow occurs 10 times more often than golfer’s elbow &DYHHWDO Analysis of time period from symptom onset to start of treatment indicates that patients in group I had a long period since symptom onset until VWDUWRIWUHDWPHQWZKLFKZDVRQDYHUDJH GD\VUDQJHGD\VDQGLWZDVDFDVHIRUODUJH number of subjects related to an occupation injury, while in group II subjects had a shorter period with DYHUDJHRIGD\VUDQJHGD\VLQGLFDW LQJ WKH VWDWLVWLFDO VLJQL¿FDQW GLIIHUHQFH EHWZHHQ JURXSVS Damage is usually chronic, resulting in a series of consecutive micro trauma, which are initially ig nored, patient continues its activities and it is dif ¿FXOWWRGLDJQRVH:HLQRXUVWXG\LQWKHJURXS,, had the time up to two days since onset of symp WRPV WR DQ WLPHO\ DFFHVV WR DGHTXDWH WUHDWPHQW in group II and all patients were treated conserva WLYHO\ RI WKHP ,Q WKH JURXS , EHVLGH conservative treatment it was also applied surgi FDOWUHDWPHQWLQSDWLHQWVDQGLWZDVRQH case of car mechanic and one person who was HQJDJHGLQJDUGHQLQJRUJDQLFIRRGSURGXFWLRQ Treatment is essentially conservative, nonsur JLFDO :LWK FRQVHUYDWLYH WUHDWPHQW UHFRYHU\ LV DFKLHYHGLQDSSUR[LPDWHO\RIFDVHVDQG access is at the individual level, because we can not treat in the same manner active sportsmen, those injuries related to a professional activity and NLGV 6XUJLFDO WUHDWPHQW LV UDUHO\ XVHG DQG LV UH served for resistant and recurrent cases when are diagnosed degenerative and calcifying changes in PXVFOHWHQGRQ VWUXFWXUHV ZLWK WKH DLP RI UHPRY ing the damaged tissue and section of affected PXVFOH From our study it can be seen that the patients IURPJURXS,,DQGSDWLHQWV from group I were treated conservatively and only RU RI SDWLHQWV IURP JURXS , ZHUH WUHDWHG ZLWKDFRPELQDWLRQFRQVHUYDWLYH±VXUJLFDOWUHDW PHQW ZLWKRXW VWDWLVWLFDOO\ VLJQL¿FDQW GLIIHUHQFHV EHWZHHQJURXSVS! In our study, analysis of the duration of physical treatment, duration of complete treatment and WKH GXUDWLRQ RI WKH LQDELOLW\ WR ZRUN DQG HQJDJH in sports activities shows that all three param HWHUV ZHUH VWDWLVWLFDOO\ VLJQL¿FDQWO\ ORQJHU LQ SD tients from group I than in case of group II pa WLHQWV S LQGLFDWLQJ D VKRUWHU DQG D EHWWHU treatment outcome in patients who have started WKH WUHDWPHQW HDUOLHU ZLWKLQ K 5HVXOWV RI WKH analysis are in favor of group II, which included patients with painful syndrome in the elbow, and the problems were related to sports activity. By such early detection, we have shown the im pact on the treatment, achievement of better re sults of treatment and full return of patients to daily 0HGLFLQVNLåXUQDO ZRUNDQGVSRUWVDFWLYLWLHVDQGFRQ¿UPWKHJRDOV of our study. CONCLUSION 2YHUXVHHOERZV\QGURPHWHQQLVDQGJROIHU¶VHO ERZ LV D VHW RI FKURQLF PLFUR WUDXPD GDPDJHV incurred in sport and recreation, or in some occu SDWLRQVDVDUHVXOWRIORQJWHUPVWHUHRW\SLFDOORDG In this paper we have shown that early detection of overuse injuries in the elbow, and the length of time from symptom onset to start of treatment af fects the course and results of treatment of this disease. Clinical diagnostics, along with a detailed KLVWRU\ DQG H[DPLQDWLRQ RI VSHFL¿F FOLQLFDO WHVW WHVWZLWKFKDLU0LOOHVWHVWDOORZVHDUO\GLDJQRVLV and hence early treatment. Treatment is usually conservative with a recommendation to start as early as possible, and access is always individual, because we cannot treat the same the persons with injuries related to a sporting, recreational or professional activity. &RQÀLFWRILQWHUHVW none declared. REFERENCES 7DOLü7DQRYLü $ +DGåLDKPHWRYLü = 6SRUWVND WUDX PDWRORJLMD6DUDMHYR)RWR$UW6DUDMHYR .UDSDF/&RPPRQRYHUXVHV\QGURPHVRIXSSHUH[ WUHPLWLHV DVVRFLDWHG ZLWK ZRUN$UK +LJ 5DGD7RNVLNRO 3HüLQD 0 6LQGURPL SUHQDSUH]DQMD VXVWDYD ]D NUH WDQMHRSüHQLWR$UK+LJ5DGD7RNVLNRO %XVKELQGHU5*UHHQ66WUXLMV37HQQLVHOERZ$P )DP3K\VLFLDQ 9DYUD+DGåLDKPHWRYLü12VQRYHNOLQLþNRJSUHJOHGD X¿]LMDWULML6DUDMHYR0HGLFLQVNLIDNXOWHW8QLYHU]LWHW6D UDMHYR +DZNLQV'$QGHUVVRQ+/2YHUXVHLQMXULHVLQ\RXWK VSRUWV ELRPHFKDQLFDO FRQVLGHUDWLRQV 0HG 6FL 6SRUWV ([HUF 'HVFDWKD $ /HFOHUF $ &KDVWDQJ -) HW DO0HGLDO epicondylitis in occupational settings: prevalence, in FLGHQFH DQG DVVRFLDWHG ULVN IDFWRUV - 2FFXS (QYLURQ 0HG $OOHQ*0:LOVRQ'-8OWUDVRXQGLQVSRUWVPHGLFLQHD FULWLFDOHYDOXDWLRQ(XU-5DGLRO &DLQ(/-U'XJDV-5:ROI56$QGUHZV-5(OERZ injuries in throwing athletes. Current concepts review. $P-6SRUWV0HG /HYLQ'1D]DULDQ/10LOOHU772¶.DQH3/)HOG5, 3DUNHU/0FKDQH-0/DWHUDOHSLFRQG\OLWLVRIWKHHOERZ 86¿QGLQJV5DGLRORJ\ 3HüLQD0LVXUDGQLFL2UWRSHGLMD=DJUHE1DNODGD /MHYDN +RJDQ.$*URVV5+0'2YHUXVHLQMXULHVLQSHGL DWULF DWKOHWHV 2UWKRS &OLQ 1RUWK $P -XO ,YDQND0DÿDU6LPLü$GQDQD7DOLü7DQRYLü0LUMDQD0DÿDU=HF,PSDFWRIHDUO\GHWHFWLRQRIHOERZRYHUXVHV\QGURPHRQWUHDWPHQW 6PLGWK1/HZLV09':'$+D\(0%RXWHU/0 &URIW3/DWHUDOHSLFRQG\OLWLVLQJHQHUDOSUDFWLFHFRXUVH DQG SURJQRVWLF LQGLFDWRUV RI RXWFRPH - 5KHXPDWRO -RKQVRQ*:&DGZDOODGHU.6FKHIIHO6%(SSHUO\ 7' 7UHDWPHQW RI ODWHUDO HSLFRQGLOLWLV $P )DP 3K\VL FLDQ 6PHGW7-RQJ$/HHPSXW:/LHYHQ'*ODEEHHN ) /DWHUDO HSLFRQG\OLWLV LQ WHQQLV XSGDWH RQ DHWLRORJ\ ELRPHFKDQLFV DQG WUHDWPHQW %U - 6SRUWV 0HG .LQYGVHQ5'DPERUJ)6XUJLFDOWUHDWPHQWRIWHQ QLVHOERZ8JHVNU/DHJHU Address: ,YDQND0DÿDUâLPLü0'06F 3ULPDU\+HDOWK&DUH&HQWHU1RYL7UDYQLN 5XÿHUD%RãNRYLüDEE1RYL7UDYQLN Bosnia and Herzegovina 3KRQH (PDLOLYDQNDPDGMDUVLPLF#JPDLOFRP Naš prilog redukciji kardiovaskularnih bolesti ! Our contribution in reduction of cardiovascular diseases ! 0HGLFLQVNLåXUQDO ,OLMD]3LODY6DIHW*XVND6DIHW0XãDQRYLü,PSDFWRIDFFRPSDQ\LQJGLVHDVHVRQUHVXOWVRIWUHDWLQJSDWLHQWVZLWKSOHXUDOHPS\HPD Original article IMPACT OF ACCOMPANYING DISEASES ON RESULTS OF TREATING PATIENTS WITH PLEURAL EMPYEMA 87,&$- 3235$71,+ %2/(67, 1$ 5(=8/7$7( 75(70$1$ 3$&,-(1$7$ 6$ PLEURALNIM EMPIJEMOM ,OLMD]3LODY6DIHW*XVND6DIHW0XãDQRYLü &OLQLFIRU7KRUDFLF6XUJHU\&OLQLFDO&HQWHU8QLYHUVLW\RI6DUDMHYR%ROQLþND6DUDMHYR%RVQLDDQG+HU zegovina &RUUHVSRQGLQJDXWKRU ABSTRACT 6$ä(7$. 3DUDSQHXPRQLF HIIXVLRQV RFFXU LQ RI patients who are hospitalized with pneumonia, DQG DERXW RI HIIXVLRQV SURJUHVVHV LQWR HP pyema. Treatment of acute empyema is focused on rapid and complete evacuation of empyema content and supporting measures enabling to achieve general resistance of the organism. One of the important factors that affect the outcome of treatment is presence of accompanying diseases. The study included 100 patients with test results corresponding to parapneumonic and metapneu monic pleural empyema, who were treated at the &OLQLF IRU 7KRUDFLF 6XUJHU\ 7KH ¿UVW JURXS FRQVLVWHGRISDWLHQWVZLWKRXWFOLQLFDOO\YHUL¿HGV\V WHPGLVHDVHV7KHVHFRQGJURXSFRQVLVWHGRI patients with accompanying diseases. Diabetes mellitus was leading disease among ac companying diseases in patients covered by this VWXG\ &RU GHFRPSHQVDWXP UHSUHVHQWHG $YHUDJHOHQJWKRIWUHDWPHQWRISDWLHQWVZLWK DFFRPSDQ\LQJ GLVHDVHV ZDV GD\V and average length of treatment of patients with RXW DFFRPSDQ\LQJ GLVHDVHV ZDV GD\V 7RWDO PRUWDOLW\ SHUFHQWDJH ZDV 0RU tality in group I was not recorded. All cases with fatal outcome were recorded in patients with ac FRPSDQ\LQJGLVHDVHV0RUWDOLW\LQJURXSZLWKDF FRPSDQ\LQJ GLVHDVHV ZDV &RQFOXVLRQV 3DUDSQHXPRQLF SOHXUDO HPS\HPD LV D WKHUDSHX tic problem in patients with severe accompanying GLVHDVHVDQGLVUHFRUGHGLQSDWLHQWVROGHUWKDQ years. There was an increased mortality rate com pared to patients without accompanying diseases, and treatment is prolonged. 3DUDSQHXPRQLþQL L]OMHYL VH MDYOMDMX NRG REROMHOLK RG SQHXPRQLMH D RNR L]OMHYD SURJUHGLUD X HPSLMHP /LMHþHQMH DNXWQRJ HPSL MHPD SRGUD]XPLMHYD EU]X L SRWSXQX HYDNXDFLMX HPSLMHPVNRJ VDGUåDMD L QD SRWSRUQH PMHUH NR MLPD VH SRVWLåH RSãWD RWSRUQRVW RUJDQL]PD -HGDQ RG ELWQLK IDNWRUD NRML XWMHþH QD LVKRG OLþHQMD MHVWH SULVXVWYR GUXJLK SUDWHüLK REROMHQMD ,VWUDåLYDQMHP MH REXKYDüHQR SDFLMHQDWD VD QDOD]LPD RGJRYDUDMXüLP ]D SDUDSQHXPRQLþQL L PHWDSQHXPRQLþQLHPSLMHPSOHXUHNRMLVXWUHWLUDQL QD .OLQLFL ]D WRUDNDOQX KLUXUJLMX 3UYX JUXSX VDþLQMDYDOL VX SDFLMHQWL EH] NOLQLþNL YHUL¿NRYDQLK VLVWHPVNLK EROHVWL 'UXJX JUXSX VDþLQMDYDOL VXSDFLMHQWLVDSULGUXåHQLPREROMHQMLPD 'LDEHWHVPHOOLWXVYRGHüLPHÿXSUDWHüLPEROHVWLPD NRGSDFLMHQDWDREXKYDüHQLKRYRPVWXGLMRP &RU GHFRPSHQVDWXP MH þLQLR 3URVMHþQD GXåLQD OLMHþHQMD SDFLMHQDWD VD SUDWHüLP REROMHQ MLPD L]QRVLOD MH GDQD D SURVMHþQD GXåLQDOLMHþHQMDSDFLMHQDWDEH]SULGUXåHQLKEROHVWL MH GDQD 8NXSQL PRUWDOLWHW VHULMH L]QRVLRMH0RUWDOLWHWXJUXSL,QLMH]DELOMHåHQ 6YL VOXþDMHYL VD VPUWQLP LVKRGRP ELOL VX SDFL MHQWL VD WHãNLP SUDWHüLP REROMHQMLPD 0RUWDOLWHW X JUXSL VD SUDWHüLP REROMHQMLPD L]QRVL =DNOMXþFL3DUDSQHXPRQLþQL HPSLMHP SOHXUH SUHGVWDYOMD WHUDSLMVNL SUREOHP NRG SDFLMHQDWD VD SUDWHüLP REROMHQMLPD L NRG SDFLMHQDWD L]QDG JRGLQD åLYRWD 8VWDQRYOMHQD MH SRYHüDQD VWRSD PRUWDOLWHWD X RGQRVX QD SDFLMHQWH EH] SUDWHüLK REROMHQMDDOLMHþHQMHMHSURORQJLUDQR Key words: parapneumonic pleural empyema, accompanying diseases. .OMXþQHULMHþLSDUDSQHXPRQLþQLHPSLMHPSOHXUH SUDWHüDREROMHQMD 0HGLFLQVNLåXUQDO ,OLMD]3LODY6DIHW*XVND6DIHW0XãDQRYLü,PSDFWRIDFFRPSDQ\LQJGLVHDVHVRQUHVXOWVRIWUHDWLQJSDWLHQWVZLWKSOHXUDOHPS\HPD INTRODUCTION 3DUDSQHXPRQLF HIIXVLRQV RFFXU LQ RI patients who are hospitalized with pneumonia, DQG DERXW RI HIIXVLRQV SURJUHVVHV LQWR HP S\HPD3OHXUDOHPS\HPDLVDUHODWLYHO\IUH TXHQWGLVHDVH)RUVXFFHVVIXOWUHDWPHQWRIDFXWH pleural empyema early correct diagnosis is of sub stantial importance. Treatment of acute empyema LV IRFXVHG RQ TXLFN DQG FRPSOHWH HYDFXDWLRQ RI empyema content and supporting measures that achieve general resistance of organism affected 0HGLFDPHQWWKHUDS\LHXVLQJRIDQWLELRW LFVLVFDUULHGRXWEDVHGRQDQWLELRJUDPWHVWZKHQ SDWKRJHQ LV LVRODWHG RU RQ WKH EDVLV RI FOLQLFDO evaluation in connection with probable cause of LQIHFWLRQLQVSHFL¿FVLWXDWLRQGDWDFRQFHUQLQJSUH viously isolated bacteria, presence of concurrent infection of other sites in organism, status of ex FUHWRU\RUJDQVOLYHUDQGNLGQH\VDQGRQWKHEDVLV RIJHQHUDOLPPXQHVWDWXVRIWKHSDWLHQW 0RUWDOLW\ LQ 3( DFFRUGLQJ WR :LQWHUEDXHU UDQJHV IURPWRGHSHQGLQJRQSDWLHQW¶VDJHDQG other factors accompanied with patient. One of im portant factor affecting the outcome of treatment is presence of other accompanying diseases in pa WLHQWV SDWLHQWV ZDV IURP WR \HDUV 5HJDUGLQJJHQGHURISDWLHQWVZHUH PHQ DQG ZHUH ZRPHQ ZLWK PDQ ZRPHQUDWLR SDWLHQWV ZLWKRXW DFFRPSDQ\LQJ GLVHDVHV JURXSDQGSDWLHQWVZLWKYHUL¿HGVHYHUHDF FRPSDQ\LQJGLVHDVHVZHUHWUHDWHG±JURXS 3UHVHQFH RI DFFRPSDQ\LQJ GLVHDVHV LQ SDWLHQWV covered by this study is shown in Tables 1 and 3 DQG)LJXUHDQG 7DEOH3UHVHQFHRIDFFRPSDQ\LQJGLVHDVH )LJXUH Review of accompanying diseases. 34% MATERIALS AND METHODS The study included 100 patients with clinical, laboratory and radiological tests corresponding to parapneumonic and metapneumonic pleural em pyema treated at the Clinic for Thoracic Surgery Clinical Center University of Sarajevo in period -DQXDU\-DQXDU\&ULWHULDIRULQ clusion in the study were clinical, radiological and biochemical tests corresponding to pleural empy ema, with test showing presence of pus in pleura during thoracentesis. The study included both presence of accompanying diseases in patients ZLWK SOHXUDO HPS\HPD DQG WKHLU LQÀXHQFH RQ WKH course and outcome of treatment. 3DWLHQWVZHUHGLYLGHGLQWRWZRJURXSV 7KH¿UVWJURXSFRQVLVWHGRISDWLHQWVZLWKRXW FOLQLFDOO\ YHUL¿HG VHYHUH V\VWHP GLVHDVHV 7KH VHFRQG JURXS FRQVLVWHG RI SDWLHQWV ZLWK DF companying disease: diabetes mellitus, chronic KHDUWIDLOXUH,,,DQG,9VWDJHDFFRUGLQJWR1<+$ FODVVL¿FDWLRQ VHYHUH FKURQLF REVWUXFWLYH SXOPR QDU\ GLVHDVH PHQWDO UHWDUGDWLRQ ,&9 HSLOHSV\ etc. 66% ,Q RI SDWLHQWV SUHVHQFH RI DFFRPSDQ\LQJGLVHDVHVZDVUHFRUGHGDQGLQ RISDWLHQWVWKHUHZHUHQRDFFRPSDQ\LQJ GLVHDVHV ; WHVW VKRZHG VWDWLVWLFDOO\ VLJQL¿FDQW difference in regard of accompanying diseases SUHVHQFH LQ WRWDO QXPEHU RI WHVWHG SDWLHQWV ; S Table 2. Accompanying diseases. RESULTS ,QSHULRG-DQXDU\-DQXDU\DWWKH Clinic for Thoracic Surgery, Clinical Centre Univer sity of Sarajevo 100 patients with parapneumonic pleural empyema were treated. Average age of 0HGLFLQVNLåXUQDO ,OLMD]3LODY6DIHW*XVND6DIHW0XãDQRYLü,PSDFWRIDFFRPSDQ\LQJGLVHDVHVRQUHVXOWVRIWUHDWLQJSDWLHQWVZLWKSOHXUDOHPS\HPD )LJXUHRecorded mortality per groups. Figure 2. Accompanying diseases. 16% 12 40% 10 8 6 26% 4 2 8% 10% 0 Cor decompensatum Diabetes mellitus ICV Epilepsy Other diseases 5HFRUGHGPRUWDOLW\SHUJURXSV *URXS, *URXS,, Average length of treating patients with DFFRPSDQ\LQJGLVHDVHVJURXS,ZDV days, and average length of treating patients ZLWKRXW DFFRPSDQ\LQJ GLVHDVHV JURXS ,, ZDV GD\V)LJXUH 2XWRIWRWDOQXPEHURISDWLHQWVZHUH cured, and percentage of patients who died was 7RWDO PRUWDOLW\ RI VHULHV ZDV 0RUWDOLW\ LQ JURXS , SDWLHQWV ZLWKRXW DF FRPSDQ\LQJ GLVHDVHV ZDV QRW UHFRUGHG $OO cases with fatal outcome were found in patients ZLWK VHYHUH DFFRPSDQ\LQJ GLVHDVHV JURXS ,, 0RUWDOLW\LQJURXSZLWKDFFRPSDQ\LQJGLVHDVHVLV ,QDOOFDVHVZLWKIDWDORXWFRPHVXU gical treatment was carried out at level of thoracic drainage. )LJXUH Average treatment length per groups. DISCUSSION Diabetes mellitus was leading disease among accompanying diseases covered by this VWXG\ &RU GHFRPSHQVDWXP ZDV SUHVHQWHGLQSHUFHQWDJHRIDPRQJDOO accompanying diseases. 25 20 15 10 5 0 $YHUDJHWUHDWPHQWOHQJWK *URXS, *URXS,, 6WDWLVWLFDOO\ VLJQL¿FDQW GLIIHUHQFH LQ WUHDWPHQW OHQJWK ZDV UHFRUGHG ; S where patients with accompanying diseases were treated longer. Outcome of treatment of patients in this study is shown in Table 3 and Figure 3. 7DEOH Outcome of treatment. 0HGLFLQVNLåXUQDO ,Q SHULRG IURP WR WRWDO 100 patients with pleural empyema, average age RI\HDUVZDVWUHDWHG7KHVWXG\IRXQGWKDW men suffered from pleural empyema more often WKDQ ZRPHQ DQG PHQZRPHQ UDWLR ZDV 3UHVHQFH RI DFFRPSDQ\LQJ GLVHDVHV DIIHFWLQJ the course and outcome of treatment of patients suffered from pleural empyema was analysed. In RISDWLHQWVSUHVHQFHRIDFFRPSDQ\ ing diseases was recorded. Statistically, there is a VLJQL¿FDQW GLIIHUHQFH LQ UHJDUG RI DFFRPSDQ\LQJ GLVHDVHVSUHVHQFH; S In our series of 100 cases, the ratio between pa tients with severe accompanying diseases and patients without these diseases is highly unfavour DEOH S FRPSDUHG WR GDWD RI RWKHU DXWKRUVZKLOHWKHDJHVWUXFWXUH of patients is similar. These patients have an ex tremely bad prognosis of pleural empyema and PRUWDOLW\ UDQJHV XS WR RSSRVHG WR PRUWDO LW\RILQSDWLHQWVZLWKDFFRPSDQ\LQJGLVHDVHV Diabetes mellitus was leading disease among patients with accompanying diseases covered by WKLVVWXG\&RUGHFRPSHQVDWXPZDV SUHVHQWHGLQSHUFHQWDJHRIRXWRIWRWDO accompanying diseases. Despite using modern therapy, mortality caused ,OLMD]3LODY6DIHW*XVND6DIHW0XãDQRYLü,PSDFWRIDFFRPSDQ\LQJGLVHDVHVRQUHVXOWVRIWUHDWLQJSDWLHQWVZLWKSOHXUDOHPS\HPD E\ SDUDSQHXPRQLF SOHXUDO HPS\HPD LV VWLOO TXLWH high and according to most literature data ex FHHGVDQGLWLVWREHQRWHGWKDWLQSRSXODWLRQ ROGHUWKDQ\HDUVWKLVUDWHLVXSWRZKLFKLV higher than mortality determined within this study 7RWDO PRUWDOLW\ LQ WKLV VWXG\ LV 7KHVH ZHUH mainly patients with severe accompanying diseas HV6LJQL¿FDQWLQGLFDWRULVWKDWDOOFDVHVRIGHDWK were recorded in the group of patients with ac FRPSDQ\LQJGLVHDVHV0RUWDOLW\UDWHLQWKLVJURXS LV (YHQ WKLV KLJK PRUWDOLW\ SHUFHQWDJH recorded in this study is one of more favourable outcomes in comparison with results published in reference literature. 0RUWDOLW\LVUHVXOWLQJSULPDULO\IURPKLJKYLUXOHQFH RI SDWKRJHQV *UDPQHJDWLYH HQWHUREDFWHULD and also from the fact that these were patients with severe accompanying diseases. Although the results in terms of mortality in this study is lower than the results provided in reference literature, there is a possibility for improving these results if SDWLHQWVDUHDGHTXDWHO\WUHDWHGIURPSULPDU\GLV HDVHVDQGDOVRLIWKHSHULRGIURPWKH¿UVWYLVLWWR doctor to visit to thoracic surgeon is shorter. CONCLUSIONS 3DUDSQHXPRQLF SOHXUDO HPS\HPD LV D WKHUDSHX tic problem in patients with severe accompanying GLVHDVHVDQGLQSDWLHQWVROGHUWKDQ\HDUV An increased mortality rate was found in regard of patients without accompanying diseases, and treatment was prolonged and faced with major challenges both in surgical and medicament seg ment. Regular radiological test made in all patients suf IHULQJIURPSQHXPRQLDDQGHVSHFLDOO\LQKLJKULVN groups and early diagnostic thoracentesis are ba sic measures to reduce morbidity and mortality in case of pleural empyema. &RQÀLFWRILQWHUHVW none declared. REFERENCES $PHULFDQ7KRUDFLF6RFLHW\0DQDJHPHQWRIQRQWXEHU FXORXVHPS\HPD$P5HY5HVSLU'LV± (PS\HPD&RPPLVVLRQ&DVHVRIHPS\HPDDW&DPS /HH9LUJLQLD-$0$± /LJKW 5 : 3DUDSQHXPRQLF (IIXVLRQV DQG (PS\HPD 3URF$P7KRUDF6RF± +XJKHV&(9DQ6FR\5($QWLELRWLFWKHUDS\RISOHXUDO HPS\HPD6HPLQ5HVSLU,QIHFW± &RRWH 1 6XUJLFDO YHUVXV QRQVXUJLFDO PDQDJHPHQW of pleural empyema. Cochrane Database Syst Rev &' 7KRPVRQ$++XOO-.XPDU05:DOOLV&%DOIRXU/\QQ ,05DQGRPLVHGWULDORILQWUDSOHXUDOXURNLQDVHLQWKHWUHDW PHQWRIFKLOGKRRGHPS\HPD7KRUD[± 5LV +% 3H]]HWWD ( .UXHJHU7 /DUGLQRLV ' 6XUJLFDO treatment of pleural infections: the surgeon’s point of view. (XU5HVSLU0RQ± .XUW%$:LQWHUKDOWHU.0&RQQRUV5+%HW]%::LQ WHUV-:7KHUDS\RISDUDSQHXPRQLFHIIXVLRQVLQFKLOGUHQ YLGHRDVVLVWHGWKRUDFRVFRSLFVXUJHU\YHUVXVFRQYHQWLRQDO WKRUDFRVWRP\GUDLQDJH3HGLDWULFVH± <LP$3& 6LKRH$'/ 9$76 DV D GLDJQRVWLF WRRO ,Q 6KLHOGV7:/RFLFHUR-3RQQ5%5XVFK9:HGV*HQ HUDOWKRUDFLFVXUJHU\WKHG3KLODGHOSKLD3$/LSSLQFRWW :LOOLDPV:LONLQVSS /DUGLQRLV'*RFN03H]]HWWD(%XFKOL&5RXVVRQ9 )XUUHU0HWDO'HOD\HGUHIHUUDODQG*UDPQHJDWLYHRUJDQ isms increase the conversion thoracotomy rate in patients XQGHUJRLQJYLGHRDVVLVWHGWKRUDFRVFRSLFVXUJHU\IRUHP S\HPD$QQ7KRUDF6XUJ :DOOHU'$5HQJDUDMDQ$7KRUDFRVFRSLFGHFRUWLFDWLRQ DUROHIRUYLGHRDVVLVWHGVXUJHU\LQFKURQLFSRVWSQHXPRQ LF SOHXUDO HPS\HPD$QQ7KRUDF 6XUJ 'DYLHV&:+*OHHVRQ)9'DYLHV5-2%76JXLGH OLQHVIRUWKHPDQDJHPHQWRISOHXUD 5]\PDQ : 6NRNRZVNL - 5RPDQRZLF] * /DVV 3 ']LDG]LXV]NR 5 'HFRUWLFDWLRQ LQ FKURQLF SOHXUDO HPS\ HPDHIIHFW RQ OXQJ IXQFWLRQ (XU - &DUGLRWKRUDF 6XUJ ± +LOOLDUG71+HQGHUVRQ$-/DQJWRQ+HZHU6&0DQ agement of parapneumonic effusion and empyema. Arch 'LV&KLOG± 6KDQNDU.5.HQQ\6(2NR\H%2&DUW\+0/OR\G '$ /RVW\ 3' (YROYLQJ H[SHULHQFH LQ WKH PDQDJHPHQW RIHPS\HPDWKRUDFLV$FWD3DHGLDWU± 6RQQDSSD 6 &RKHQ * 2ZHQV &0 YDQ 'RRUQ & &DLUQV - 6WDQRMHYLF 6 HW DO &RPSDULVRQ RI XURNLQDVH DQG YLGHRDVVLVWHG WKRUDFRVFRSLF VXUJHU\ IRU WUHDWPHQW RIFKLOGKRRGHPS\HPD$P-5HVSLU&ULW&DUH0HG ± &KHQJ<-:X++&KRX6+.DR(/9LGHRDVVLVWHG thoracoscopic surgery in the treatment of chronic empy HPDWKRUDFLV6XUJ7RGD\ (DVWKDP.0)UHHPDQ5.HDUQV$0(OWULQJKDP* &ODUN-/HHPLQJ-HWDO&OLQLFDOIHDWXUHVDHWLRORJ\DQG outcome of empyema in children in the north east of Eng ODQG7KRUD[± %DOIRXU/\QQ,0$EUDKDPVRQ(&RKHQ*+DUWOH\- .LQJ63DULNK'HWDO%76JXLGHOLQHVIRUWKHPDQDJH PHQWRISOHXUDOLQIHFWLRQLQFKLOGUHQ7KRUD[6XS SOL± $PSRIR.%\LQJWRQ&0DQDJHPHQWRISDUDSQHXPRQ LFHPS\HPD3HGLDWU,QIHFW'LV-± Address: ,OLMD]3LODY0'3K' Clinic for Thoracic Surgery Clinical Center University of Sarajevo %ROQLþND6DUDMHYR Bosnia and Herzegovina 3KRQH (PDLOLOLMD]#GUFRP 0HGLFLQVNLåXUQDO %HOPD$ãþLü±%XWXURYLü$PLU5HGåHSRYLü$PLOD0HKPHGRYLü$QDO\VLVRIFRURQDU\ULVNIDFWRUVLQREHVHSDWLHQWVZLWKK\SRWK\URLGLVP Original article ANALYSIS OF CORONARY RISK FACTORS IN OBESE PATIENTS WITH HYPOTHYROIDISM $1$/,=$ )$.725$ .2521$512* 5,=,.$ 8 *2-$=1,+ 3$&,-(1$7$ 6$ +,327,5(2=20 %HOPD$ãþLü±%XWXURYLü$PLU5HGåHSRYLü2$PLOD0HKPHGRYLü &OLQLFIRU(QGRFULQRORJ\'LDEHWHVDQG0HWDEROLF'LVHDVHV&OLQLFDO&HQWUH8QLYHUVLW\RI6DUDMHYR%ROQLþND 71000 Sarajevo, Bosnia and Herzegovina; (PHUJHQF\0HGLFDO6HUYLFH6DUDMHYR&DQWRQ6DUDMHYR%RVQLD and Herzegovina, 3&OLQLFIRUJDVWURHQWHURORJ\DQGKHSDWRORJ\&OLQLFDO&HQWUH8QLYHUVLW\RI6DUDMHYR%ROQLþND 71000 Sarajevo, Bosnia and Herzegovina. 1 &RUUHVSRQGLQJDXWKRU ABSTRACT Cardiovascular disease remains the leading cause of global mortality and morbidity. Strong ef IRUWVLQWKHUHGXFWLRQRIULVNIDFWRUVKDYHOHGWRD drop in mortality from coronary heart disease by 3UHVHQFH RI FRURQDU\ ULVN IDFWRUV LQ REHVH patients with hypothyroidism is more common than in patients with normal body weight. The aim: to compare the prevalence of coronary ULVNIDFWRUVLQDSRSXODWLRQRISDWLHQWVZLWKK\SR thyroidism; in overweight patients and in ones with normal weight. The study was conducted as an observational, open, retrospective clinical study, with data col OHFWHGLQSHULRGIURP-DQXDU\WR6HSWHPEHU 3DWLHQW¶VPHGLFDOKLVWRULHVZHUHWDNHQIURP Clinical Centre University of Sarajevo, Clinic of Endocrinology as well as from Sarajevo Canton +HDOWK&HQWHU7RWDORISDWLHQWVGLDJQRVHGZLWK hypothyroidism, were divided into groups, accord LQJWR%0,RU%0,!DQGWKHVXEJURXSZLWK %0,! The analysis included blood pressure monitoring and laboratory tests: blood glucose, cholesterol, WULJO\FHULGHV+'//'/DQGWK\URLGKRUPRQHVWD tus. Results: The average serum cholesterol level was higher in patients with hypothyroidism, with D %0, ! DYHUDJH YDOXHG PPRO O DQG FRPSDUHG ZLWK WKH JURXS ZLWK %0, GLIIHUHG RQWKHOHYHORIS 6HUXPWULJO\FHULGHOHYHOV GLIIHUHGE\JURXSVZLWKS ,QWKHVXEJURXS RISDWLHQWVZLWKD%0,!WKHDYHUDJHYDOXHRI VHUXPFKROHVWHUROOHYHOZDVPPROO +LJKHU DYHUDJH VHUXP /'/ FKROHVWHURO IUDFWLRQ ZDV LQ WKH JURXS ZLWK %0,! DQG ZDV PPROOLQJURXS%0,PPROO6WDWLVWL cal analysis with Student’s t test showed that the VLJQL¿FDQFHZDVS /'/FKROHVWHUROIUDF WLRQV LQ WKH VXEJURXS ZLWK D %0, ! ZDV PPRO O 7KH SRVLWLYH FRUUHODWLRQ EHWZHHQ %0, 0HGLFLQVNLåXUQDO DQGVHUXP/'/ZDVSURYHGE\3HDUVRQFRHI¿FLHQW U 8VLQJ PHWKRG RI OLQHDU UHJUHVVLRQ RI DOO SDWLHQWVGDWDHTXDWLRQZDVUHDFKHG/'/PPRO O [%0, Conclusion: These results suggest that obese pa tients with hypothyroidism have increased serum OHYHOV RI /'/ DQG K\SHUWHQVLRQ 7KHUHIRUH WKH\ KDYH PRUH FRURQDU\ ULVN IDFWRUV SUHVHQW FRP pared with patients having normal body weight. Evaluation of the hormonal status of the thyroid gland should be an integral part of the treatment of patients with coronary heart disease Keywords: FRURQDU\ KHDUW GLVHDVH ULVN IDFWRUV K\SRWK\URLGLVP%0,/'/ 6$ä(7$. .DUGLRYDVNXODUQHEROHVWLLGDOMHSUHGVWDYOMDMXYRGHüL X]URN JOREDOQRJ PRUWDOLWHWD L PRUELGLWHWD 6QDåQL QDSRULXUHGXNFLMLIDNWRUDUL]LNDGRYHOLVXGRSDGD PRUWDOLWHWD RG NRURQDUQH EROHVWL ]D =DVWX SOMHQRVW NRURQDUQLK UL]LNR IDNWRUD X JRMD]QLK SDFL MHQDWDVDKLSRWLUHR]RPMHPQRJRXþHVWDOLMDQHJRX SDFLMHQDWDVDXUHGQRPWMHOHVQRPWHåLQRP &LOMUDGDMHNRPSDULUDWLXþHVWDORVWIDNWRUDNRURQDU QRJ UL]LND X SRSXODFLML SDFLMHQDWD VD KLSRWLUHR]RP XUHGQHWMHOHVQHWHåLQHLJRMD]QLKSDFLMHQDWD ,VWUDåLYDQMH MH SURYHGHQR NDR RSVHUYDFLRQD RW YRUHQDUHWURVSHNWLYQDNOLQLþNDVWXGLMDXWRNXMDQXDU J ± VHPSWHPEDU J 8 LVSLWLYDQMX MH NRULãWHQ PDWHULMDO L PHGLFLQVNH KLVWRULMH .OLQLNH ]D HQGRNULQRORJLMX.OLQLþNRJFHQWUD8QLYHU]LWHWDX6D UDMHYXL'RPD=GUDYOMD.DQWRQD6DUDMHYR 8NXSQRLVSLWDQLNDVDGLMDJQRVWLFLUDQRPKLSRWLU HR]RP MH RYLVQR R YULMHGQRVWL %0, SRGLMHOMHQR X JUXSH%0,LOL%0,!LSRGVNXSLQX%0,! $QDOL]D MH REXKYDWLOD SUDüHQMH DUWHULMVNRJ WODND WH ODERUDWRULMVNX REUDGX JOLNHPLMH KROHVWHUROD WULJOLFHULGD+'//'/LKRUPRQDOQRJVWDWXVDãWLWQH åOLMH]GH 3URVMHþDQVHUXPVNLQLYRKROHVWHURODMHELRYHüLX %HOPD$ãþLü±%XWXURYLü$PLU5HGåHSRYLü$PLOD0HKPHGRYLü$QDO\VLVRIFRURQDU\ULVNIDFWRUVLQREHVHSDWLHQWVZLWKK\SRWK\URLGLVP JUXSL SDFLMHQDWD VD KLSRWLUHR]RP VD %0, ! L L]QRVLR MH PPROO L X SRUHÿHQMX VD JUXSRP VD%0,UD]OLNRYDRVHQDUD]LQLS 1LYR VHUXPVNLKWULJOLFHULGDUD]OLNRYDRVHVDS 8 SRGVNXSLQL LVSLWDQLND VD %0, ! SURVMHþQD YUL MHGQRVW QLYRD VHUXPVNRJ KROHVWHUROD L]QRVLOD MH PPROO 3URVMHþQRYHüDVHUXPVNDNRQFHQWUDFLMD/'/IUDN FLMHKROHVWHURODMHELODXJUXSL%0,!LL]QRVLOD MHPPROODXJUXSL%0,PPROO 6WDWLVWLþND DQDOL]D VD 6WXGHQWRYLP 7 WHVWRP MH SRND]DOD GD MH VLJQL¿NDQWQRVW ELOD S 1LYR/'/IUDNFLMDKROHVWHURODXSRGVNXSLQLVD%0, !MHELRPPROO =DNOMXþDN 8 SUHWLOL SDFLMHQDWL NRML EROXMX RG KL SRWLUHR]H GRND]DQR MH SRYHüDQMH ]DVWXSOMHQRVWL NRURQDUQLKUL]LNRIDNWRUDYHüDUD]LQD/'/KROHV WHURODWULJOLFHULGDLYHüDXþHVWDORVWKLSHUWHQ]LMHX SRUHÿHQMXVDSDFLMHQWLPDXUHGQHWMHOHVQHWHåLQH 3URFMHQDKRUPRQDOQRJVWDWXVDãWLWQHåOLMH]GHWUH EDELWLVDVWDYQLGLRREUDGHSDFLMHQDWDVDNRURQDU QRPEROHãüX .OMXþQHULMHþLNRURQDUQDEROHVWUL]LNRIDNWRULKL SRWLUHR]D%0,/'/ INTRODUCTION Cardiovascular disease remains the leading cause of global mortality and cause of the nearly 17 mil lion deaths per year and almost half of deaths in (XURSHPRUHWKDQPLOOLRQGHDWKVSHU\HDU Causes that lead to the development of coronary KHDUW GLVHDVH DUH VWLOO XQNQRZQ EXW RQ WKH RWK HUKDQGULVNIDFWRUVWKDWDUHDVVRFLDWHGZLWKWKH emergence and development of coronary artery GLVHDVHDUHZHOONQRZQ ,QPRVWSDWLHQWVWKHUHDUHPDQ\FRURQDU\ULVNIDF tors present, and their early detection and action WDNLQJ WRZDUGV WKHLU UHPRYDO LV HVVHQWLDO IRU WKH further course of the disease. In patients suffering from hypothyroidism, altera tion of metabolic processes is expected; in addi tion, increased body weight has an additional ef fect on the cardiovascular system and coronary KHDUW GLVHDVH VR LW UHPDLQV LPSRUWDQW WR GH¿QH ULVNIDFWRUVZKLFKDULVHLQWKHVHVLWXDWLRQV Development of atherosclerosis may be due to HQGRWKHOLDO GDPDJH LQÀDPPDWLRQ RU K\SHUFKR lesterolemia, after which the platelet adhesion comes in place, platelet aggregation, then pen etration of monocytes in the sub endothelial layer occurs together with the release of growth factors 3'*)DQGOHXNRWULHQHVDVZHOODVPLJUDWLRQDQG SUROLIHUDWLRQRIVPRRWKPXVFOHFHOOVH[WUDFHOOXODU DQGLQQHUFHOOXODUDFFXPXODWLRQRIOLSLGVXSJUDGH E\¿EURVLVRUDUWHULDOSODTXHWKURPERVLV It has been shown that the occurrence of athero sclerotic changes has a higher incidence in pa tients who had repeated viral or bacterial infec WLRQ &HQWUDO UROH LQ WKH LQÀDPPDWRU\ UHVSRQVH KDVLQWHUOHXNLQZKRVHVWHDGLO\LQFUHDVHGYDOXH has poorer hospital prognosis in coronary artery GLVHDVH ,QWHUOHXNLQ PHFKDQLVP RI DFWLRQ LV WR stimulate platelet aggregation, promote adhesion of molecules on the endothelium and to increase OHYHOV RI ¿EULQRJHQ ZKLOH UHGXFLQJ WKH OHYHO RI +'/FKROHVWHURO (OHYDWHG VHUXP OHYHOV RI 9/'/ DQG /'/ FKROHV terol plays an important role in the development of atherosclerosis. After endothelial damage, adher ence and platelet aggregation, adhesion of mono F\WHVDQGOHXNRF\WHVDQGQHZSODWHOHWVDWWUDFWLRQ fats accumulate and lead to the formation of foam cells. Endothelial cells are damaged and endothe lial windows that have electronegative charge are thus created. Therefore, there is suction and the DFFXPXODWLRQ RI PROHFXOHV RI /'/ FKROHVWHURO ZKLFKR[LGL]H2[LGDWLYHPRGL¿HG/'/FKROHVWHURO molecules exhibit hemotactic effect on circulating PRQRF\WHVDVZHOODV7/\OHDGLQJWRDQLQFUHDVH in their adhesiveness and increased aggregation. ,PSRUWDQWUROHLQDWKHURJHQHVLVKDV+'/FKROHV terol, which in recent literature, is referred to as a SURWHFWLYH OLSRSURWHLQ +'/ KDV DW VXI¿FLHQW IUHH FRQQHFWLRQIRUERQGLQJ,'/FKROHVWHUROLQWHUGHQ VLW\OLSRSURWHLQDWDQ\JLYHQWLPH$Q\XQFROOHFWHG SDUWLFOHRI,'/SDVVHVLQWR9/'/RU/'/ 7KHDLP The aim of the study is to analyze the prevalence RIFRURQDU\ULVNIDFWRUVLQREHVHSDWLHQWVZLWKK\ SRWK\URLGLVP%0,!DQGWRFRPSDUHWKHSUHY DOHQFHRIFRURQDU\ULVNIDFWRUVLQWKHSRSXODWLRQRI SDWLHQWVZLWKK\SRWK\URLGLVPZLWK%0,DQGD SRSXODWLRQRISDWLHQWVZLWK%0,! MATERIALS AND METHODS The study was a retrospective, observational, comparative study. Evaluation for inclusion in the study included: ZRUNLQJ IRUP FRPSOHWHG E\ LQWHUYLHZ PHWKRG available medical records as proof of primary di DJQRVHV K\SRWK\URLGLVP DYDLODEOH PHGLFDO UH cords of previous treatment, and available labora tory records with the values of needed laboratory parameters. Special forms have been designed for the study in order to collect the relevant data ZRUNVKHHWLQZKLFKIROORZLQJGDWDRQWKHEDVLV of medical interviews was collected and entered: name, gender, age, body weight and height, the FULWHULDIRULQFOXVLRQH[FOXVLRQGDWDRQGLDJQRVLV DQGWUHDWPHQWRIK\SHUWKLUHRVLVH[LVWHQFHRIULVN factors for developing coronary artery disease. :RUNLQJVKHHWLQFOXGHGODERUDWRU\GDWDDQG%0, The study used materials and medical histories of the Clinical Center University of Sarajevo, Clinic of Endocrinology as well as data from Sarajevo Canton Health Center. 6XEMHFWV 7KHVWXG\LQFOXGHGPDOHDQGIHPDOHVXEMHFWV 0HGLFLQVNLåXUQDO %HOPD$ãþLü±%XWXURYLü$PLU5HGåHSRYLü$PLOD0HKPHGRYLü$QDO\VLVRIFRURQDU\ULVNIDFWRUVLQREHVHSDWLHQWVZLWKK\SRWK\URLGLVP ZLWK D PHDQ DJH RI \HDUV ROG ZLWK K\SRWK\ roidism, divided into two groups according to %0,%RG\0DVV,QGH[6FUHHQLQJ LVGRQHRQD sample of 133 patients; 38 of them did not have complete information needed for carrying out the study. Data was collected from medical records of patients with hypothyroidism during the period -DQXDU\6HSWHPEHU Before inclusion in the study subjects had to meet WKH FULWHULD IRU LQFOXVLRQ 3DWLHQWV ZKR KDG WKH FULWHULD IRU QRQ LQFOXVLRQ DQG H[FOXVLRQ IURP WKH VWXG\ ZHUH QRW HYDOXDWHG 3DWLHQWV ZHUH GLYLGHG LQWRJURXSVXSRQFRPSOHWLRQRIWKHVXUYH\E\¿OO ing out the form. The survey was conducted for a SHULRGRIPRQWKVGXULQJWKH\HDU Subjects were divided into the following groups: *URXSSDWLHQWVZLWKK\SRWK\URLGLVP%0, group included 43 patients; *URXSSDWLHQWVZLWKK\SRWK\URLGLVP%0,! JURXSLQFOXGHGVXEMHFWVLQZKLFKZHLQFOXGHG SDWLHQWVZLWKD%0,!JURXSD 5HVHDUFKPHWKRGV 3DWLHQWVZHUHDQDO\]HGFOLQLFDOO\DQGLQODERUDWRU\ with special emphasis on the thyroid gland func tional status. &OLQLFDOSURFHVVLQJWRRNDGHWDLOHGKLVWRU\DQGVWD tus presence: D0HGLFDO+LVWRU\ The history of disease; data on the existence of FRPRUELGLWLHV GLDEHWHV K\SHUWHQVLRQ FRURQDU\ KHDUWGLVHDVHGDWDRQWKHXVHRIQLFRWLQHWKHH[ istence of a positive family history on cardiovascu lar disease, data on the use of medications. E7KHFOLQLFDOVWDWXVRISDWLHQWVERG\ZHLJKWDQG KHLJKWQXWULWLRQDOVWDWXVEORRGSUHVVXUHV\VWROLF GLDVWROLFJHQHUDOFOLQLFDOVWDWXVRISDWLHQWV F /DERUDWRU\ WHVWV WKH IXQFWLRQDO VWDWXV RI WKH WK\URLGJODQGVHUXPOHYHOVRI7776+ELR FKHPLFDOEORRGWHVWVEORRGJOXFRVHFKROHVWHURO WULJO\FHULGHV/'/+'/ 6WUDWL¿FDWLRQ OHYHO RI ULVN IRU FRURQDU\ KHDUW GLV ease was done according to the criteria of the (XURSHDQ $VVRFLDWLRQ IRU $WKHURVFOHURVLV ($6 where the table was determined on the basis of a WHQ\HDUDEVROXWHULVN 6WDWLVWLFDODQDO\VLV Statistical analysis of data was performed upon completion of the tests as well as preparation of comprehensive statistics thesis on the tests. The statistical evaluation and analysis included all sub MHFWV'DWDZDVVWDWLVWLFDOO\HYDOXDWHGXVLQJ6366 DQG0LFURVRIW2I¿FH([FHO 3UHVHQWDWLRQ RI EDVLF GHPRJUDSKLF GDWD DQG UH search results is given in tables and graphs. Statistical analysis was performed using descrip tive statistics, Student’s t test, test of multiple cor relation and linear regression analysis. 'HPRJUDSKLFVGDWD 0HGLFLQVNLåXUQDO Basic demographic data are presented in tables. 1RQSDUDPHWULF PHGLDQ FKL VTXDUH WHVW ;WHVW for two independent samples was applied. This test examined whether two samples belong to the same median population. The Yates correction was applied. Testing was done by calculating the multiple cor relations and using the Student t test. The level of VLJQL¿FDQFHZDVS RESULTS $WRWDORIVXEMHFWVZHUHLQFOXGHGGLYLGHGLQWR WZRJURXSVGHSHQGLQJRQWKHYDOXHRI%0,JURXS %0,LQFOXGHGSDWLHQWVJURXS%0,! LQFOXGHGSDWLHQWVZLWKLQZKLFKSDWLHQWV ZHUHLQFOXGHGZLWK%0,!JURXSD According to the demographic characteristics cri WHULD WKH JURXSV ZHUH QRW VLJQL¿FDQWO\ GLIIHUHQW and the differences observed in the examined pa rameters might have been due to the prevailing diseases that we have studied. The following tables show the results of a statisti cal analysis of descriptive statistics parameters by groups. The table 1 shows the basic demographic and an thropological parameters of subjects per group. )LJXUHDQGVKRZWKHGLVWULEXWLRQRI%0,YDOXHV LQJURXSVDQG Gender structure of subjects per group is shown in Figure 3 i 4. 7DEOH Demographic and anthropological parameters by JURXSV6'VWDQGDUGGHYLDWLRQ%0,%RG\0DVV,QGH[ *URXS$JH\HDUV6' %0,6' %0, %0,! D%0,! )LJXUH%0,GLVWULEXWLRQLQWKHJURXS %HOPD$ãþLü±%XWXURYLü$PLU5HGåHSRYLü$PLOD0HKPHGRYLü$QDO\VLVRIFRURQDU\ULVNIDFWRUVLQREHVHSDWLHQWVZLWKK\SRWK\URLGLVP Figure 2.RI%0,GLVWULEXWLRQLQWKHJURXS Table 2.%LRFKHPLFDOSDUDPHWHUVRIVXEMHFWVSHUJURXS$E EUHYLDWLRQVDUHGH¿QHGLQWKH0DWHULDOVDQG0HWKRGVVHFWLRQ 6'VWDQGDUGGHYLDWLRQ 7KH)LJXUHDQGVKRZWKHSUHYDOHQFHRIVPRN ing in groups; it is evident that there is a greater QXPEHU RI VPRNHUV LQ WKH JURXS ZLWK %0, 7KHUHZHUHQCWDQ\VPRNHUVLQWKHVXEJURXSRISD WLHQWVZLWKD%0,! )LJXUH*HQGHUVWUXFWXUHRIJURXSPDOHV )LJXUH3UHYDOHQFHRIVPRNLQJDVDULVNIDFWRULQWKHJURXS Figure 6.3UHYDOHQFHRIVPRNLQJDVDULVNIDFWRULQWKHJURXS )LJXUH*HQGHUVWUXFWXUHRIJURXS Figures 7, 8 and 9 show the positive family history DVDULVNIDFWRUIRUFDUGLRYDVFXODUGLVHDVHDFFRUG ing to the groups. Figure 7. 3UHVHQFHRISRVLWLYHIDPLO\KLVWRU\DVDULVNIDFWRU in the group 1. 7DEOHVKRZVWKHUHVXOWVRIWKHDYHUDJHYDOXHDF WLYLWLHVRIJO\FHPLDFKROHVWHUROWULJO\FHULGHV+'/ /'/DQGWK\URLGKRUPRQHVWDWXVLQJURXSV1RWH the elevated serum blood glucose, the cholesterol DQG/'/LQWKHJURXSZLWK%0,!FRPSDUHGWR WKHJURXSZLWK%0,HVSHFLDOO\LQSDWLHQWVZLWK D %0,! 7ULJO\FHULGH OHYHOV ZHUH VLJQL¿FDQWO\ KLJKHULQWKHJURXSZLWK%0,!+RUPRQDOVWDWXV of the thyroid gland was balanced in both groups. 0HGLFLQVNLåXUQDO %HOPD$ãþLü±%XWXURYLü$PLU5HGåHSRYLü$PLOD0HKPHGRYLü$QDO\VLVRIFRURQDU\ULVNIDFWRUVLQREHVHSDWLHQWVZLWKK\SRWK\URLGLVP Figure 8. 3UHVHQFHRISRVLWLYHIDPLO\KLVWRU\DVDULVNIDFWRU LQWKHJURXS )LJXUH3UHYDOHQFHRIK\SHUWHQVLRQDVDULVNIDFWRULQWKH JURXSZLWK%0,! )LJXUH3UHVHQFHRISRVLWLYHIDPLO\KLVWRU\DVDULVNIDFWRULQ WKHVXEJURXSRI%0,! )LJXUHV DQG VKRZ WKH EORRG SUHVVXUH score in patients. Distribution of systolic and dias tolic pressure is shown, measured in mmHg. )LJXUHThe blood pressure score in patients with hypothy URLGLVP%0, )LJXUHVDQGVKRZWKHSUHVHQFHRIK\ pertension in groups, greater number of hyperten sive patients was observed in group 1. )LJXUHThe blood pressure score in patients with hypothy URLGLVP%0,! )LJXUH 3UHYDOHQFH RI K\SHUWHQVLRQ DV D ULVN IDFWRU LQ WKH group 1. )LJXUH The blood pressure score in patients with K\SRWK\URLGLVP%0,! )LJXUH3UHYDOHQFHRIK\SHUWHQVLRQDVDULVNIDFWRULQWKH JURXS )LJXUH VKRZV D UHSUHVHQWDWLRQ RI GLDEHWHV PHOOLWXV LQ JURXSV DQG 7KHUH ZHUH WKUHH VXEMHFWVLQWKHVXEJURXSZLWKD%0,! )LJXUH3UHYDOHQFHRIGLDEHWHVE\JURXSV 0HGLFLQVNLåXUQDO %HOPD$ãþLü±%XWXURYLü$PLU5HGåHSRYLü$PLOD0HKPHGRYLü$QDO\VLVRIFRURQDU\ULVNIDFWRUVLQREHVHSDWLHQWVZLWKK\SRWK\URLGLVP *URXS±%0,*URXS%0,! Figure 17 displays the values of cholesterol, tri JO\FHULGHV +'/ DQG /'/ E\ JURXSV 2EHVH SD WLHQWVKDGKLJKHUOHYHOVRIVHUXPFKROHVWHURO+'/ DQG/'/WKDQSDWLHQWVZLWKQRUPDOZHLJKW)LJXUH 18 shows the average value of the measured T3 and TSH in groups. )LJXUH$QDO\VLVRIG\VOLSLGHPLDLQJURXSVDQG )LJXUH Analysis of hormonal status of thyroid glands in JURXSVDQG VWDWLVWLFDOGLIIHUHQFHWRWKHJURXSVZDVS $YHUDJH KLJKHU VHUXP /'/ FKROHVWHURO FRQFHQ WUDWLRQZDVIRXQGLQWKHJURXSZLWK%0,!DQG DPRXQWHGWRPPROODQGLQWKHJURXS%0, DPRXQWHGWRPPROO6WDWLVWLFDODQDO\VLV with Student t test, comparing the average valu HVRI/'/E\JURXSVVKRZHGWKDWWKHVLJQL¿FDQFH ZDVS $YHUDJH YDOXHV RI V\VWROLF EORRG SUHVVXUH PP +JE\JURXSVVKRZHGDGLIIHUHQFHZLWKDVLJQL¿ FDQFHRIS DQGIRUGLDVWROLFSUHVVXUHVLJQL ¿FDQFHRIS ,QWHUGHSHQGHQFHEHWZHHQ%0,DQGVHUXP/'/OH vels on the entire sample is shown in Figure 19. It FDQEHVHHQWKDWLQFUHDVLQJ%0,LVDFFRPSDQLHG E\LQFUHDVHGVHUXPFRQFHQWUDWLRQVRI/'/ ,W LV SURYHQ WKDW /'/ UDQJH PRYH GHSHQGLQJ RQ WKH %0, IRUPXOD /'/ PPRO O [ %0, ZKLFKLVSURYHQE\PHWKRGRIOLQHDUUHJUH ssion of the studied sample. )LJXUH6HUXPOHYHOVRI/'/PPROOLQWKHWRWDOVDPSOH RISDWLHQWVZHUHPRYLQJLQUHODWLRQWR%0,DFFRUGLQJWRWKHIRU PXODZLWKWKHVTXDUHRIWKHFRHI¿FLHQWRIGHWHUPLQDWLRQLV DISCUSSION 0RQLWRULQJYDOXHVZHUHQRWVLJQL¿FDQWO\GLIIHUHQW ZKLFKVKRZVTXLWHXQLIRUPSKDUPDFRORJLFDOFRQ trol of hypothyroidism, in all subjects. :H VWDWLVWLFDOO\ DQDO\]HG SDUDPHWHUV RI LQWHUHVW WRWKHVWXG\EORRGJOXFRVHFKROHVWHUROWULJO\FH ULGHV+'//'/V\VWROLFSUHVVXUHDQGFRPSDUHG WKHPWRWKHJURXSRIDQGXVLQJWKH6WXGHQWW test. Statistical analysis of glucose by groups differed ZLWKS FDOFXODWHGE\6WXGHQW¶VWWHVW The average serum cholesterol level was higher in the group of patients with hypothyroidism, with D %0,! DQG DPRXQWHG WR PPRO O DQG GLIIHUHGFRPSDUHGZLWKWKHJURXSZLWK%0,RQ WKHOHYHORIS 6HUXPWULJO\FHULGHVOHYHOVGLIIHUHGZLWKS LQ FRPSDULVRQWR%0,JURXSDQG 7KH DYHUDJH +'/ OHYHO ZDV KLJKHU LQ WKH JURXS ZLWK %0,! DQG DPRXQWHG WR PPRO O D 6WUDWL¿FDWLRQ OHYHO RI ULVN IRU FRURQDU\ KHDUW GLV ease was performed according to the criteria of WKH (XURSHDQ $VVRFLDWLRQ IRU $WKHURVFOHURVLV ($6ZKHUHE\WKHWHQ\HDUULVNLVHYDOXDWHGEDVHG RQWKH6&25(V\VWHP6\VWHPDWLF&RURQDU\5LVN (YDOXDWLRQ 5LVNIDFWRUVIRUFRURQDU\GLVHDVHDUHK\SHUFKROHV WHUROHPLDDQGK\SHUOLSLGHPLDVPRNLQJLQFUHDVHG blood pressure, diabetes, genetic predisposition, age and sex of patient, obesity and physical inac tivity, lipoprotein a, psychological and social fac tors. In cases of altered metabolic processes, as in imbalance in the hormonal status of the thyroid JODQGLWLVJHQHUDOO\NQRZQWKDWWKHFRQVHTXHQFHV occur in almost every process in the body, at the OHYHORIHDFKFHOODQGWKHPLWRFKRQGULD0HWDEROLF SURFHVVHVDUHGLUHFWHGWRSODFHV³GLFWDWHGE\WK\ roid hormones.” 0HGLFLQVNLåXUQDO %HOPD$ãþLü±%XWXURYLü$PLU5HGåHSRYLü$PLOD0HKPHGRYLü$QDO\VLVRIFRURQDU\ULVNIDFWRUVLQREHVHSDWLHQWVZLWKK\SRWK\URLGLVP Due to the great abundance of changeable and XQFKDQJHDEOHULVNIDFWRUVIRUFRURQDU\KHDUWGLV ease existence in the general population, it re mains important and interesting to compare how GR WKH LQGLFDWRUV IRU WKH H[LVWHQFH RI ULVN IRU GH veloping coronary heart disease in patients with hypothyroidism, with or without obesity, actually PRYH The patient sample was made on the popula tion with established hypothyroidism, which was treated by medications. The sample was divided LQWRWZRJURXSVGHSHQGLQJRQWKHYDOXHRI%0,! RUDQGLQWKHJURXSZLWK%0,!WKHUHZDVD SURFHVVHGVXEJURXSZLWK%0,!2EVHUYHGSD rameters were contrasted comparatively. Biochemical parameters analyzed were: blood JOXFRVH FKROHVWHURO WULJO\FHULGHV +'/ DQG /'/ and hormonal status of the thyroid gland. The study included clinical monitoring of the hyperten VLRQ SUHVHQFH V\VWROLF DQG GLDVWROLF SUHVVXUH 5LVNIDFWRUVIRUVPRNLQJGLDEHWHVSRVLWLYHIDPLO\ history were also observed. Emphasis was made on the metabolic role of thy URLGKRUPRQHVLQWHUPVRILPSDFWRQWKH.UHEVCV cycle and metabolism of fat, so it was of great in terest to observe the relationship between the de JUHHRIREHVLW\PHDVXUHGE\%0,DQG/'/WKH PDLQELRFKHPLFDODWKHURJHQLFIDFWRUV This paper presents the results of comparing the parameters in two groups of patients with hypo WK\URLGLVP IRUPHG E\ WKH SUHVHQFH RI RWKHU ULVN IDFWRUVREHVLW\ The aim of this study was to investigate whether patients with hypothyroidism, in the presence or DEVHQFHRIREHVLW\FDQEHFODVVL¿HGLQWRGLIIHUHQW JURXSVDFFRUGLQJWRWKHSUHVHQFHRIULVNIDFWRUVRI heart disease. 7KHVWXG\ZDVUHWURVSHFWLYHSHUIRUPHGIURP-DQ XDU\6HSWHPEHU Database search returned no results with similar studies, but it was found that in recent times there was an increasing interest in role of hormonal sta tus of the thyroid gland in the occurrence of coro QDU\DUWHU\GLVHDVH $ WRWDO RI SDWLHQWV ZLWK K\SRWK\URLGLVP ZHUH observed, and divided into two groups: normal ZHLJKW%0,ZKLFKLQFOXGHGSDWLHQWVDQG DJURXSRI%0,!ZLWKSDWLHQWVLQZKLFKWKH JURXS ZLWK D %0,! ZDV WUHDWHG LQFOXGLQJ patients. 7KHJURXSVGLGQRWGLIIHUVLJQL¿FDQWO\DFFRUGLQJWR characteristics by age, and in this regard, we de termined the homogenization of the respondents, which ensured the objectivity of comparing the re sults obtained, according to the criteria of weight. $QWKURSRORJLFDO SDUDPHWHUV ZHLJKW KHLJKW DQG %0, ZHUH WKH FULWHULD IRU GLIIHUHQWLDWLRQ LQ WKH 0HGLFLQVNLåXUQDO JURXSVRWKHJURXS%0,KDGDQDYHUDJHRI JURXS%0,KDGDQDYHUDJHRIVXEJURXSD %0,DPRXQWHGWR It was observed that most of the respondents were IHPDOH LQ WKH JURXS ZLWK QRUPDO ZHLJKW FRPSDUHGWRWKHJURXSZLWK%0,!,QWKH VXEJURXS ZLWK D %0,! DOO UHVSRQGHQWV ZHUH female. These results were considered to be as a result of involvement of hypothyroidism demo graphically in predominantly female population, and according to the latest research in our region WKLVUDWLRLVLQIDYRURIZRPHQ,QFUHDVHG QXPEHURIZRPHQLQWKHJURXSZLWK%0,!ZDV probably caused by changes in the metabolism and hormones in most subjects, considering that the average age was slightly higher in this group DQGZDV The average value of glucose was higher in the JURXSRISDWLHQWVZLWK%0,!PPROOWKDQ that of the group of patients having proper body ZHLJKW PPRO O VWDWLVWLFDOO\ FDOFXODWHG E\ WKH 6WXGHQW W WHVW ZKLFK VKRZHG D VLJQL¿FDQFH OHYHORIS 6HYHUDOVWXGLHVKDYHGHDOWZLWK SDWKRSK\VLRORJLFDO PXWXDO LQÀXHQFH RI K\SRWK\ roidism and diabetes, as well as undisputed in terconnection of these metabolic disorders. Given that disturbed hormonal status of the thyroid gland is found in a large number of diabetics, some au thors recommend screening for thyroid hormones GXULQJK\SHUJO\FHPLDWUHDWPHQW Analysis of biochemical parameters of dyslipid emia included analysis of serum cholesterol, tri JO\FHULGHV+'/DQG/'/ Average serum cholesterol levels were higher in WKH JURXS RI SDWLHQWV ZLWK %0,! FRPSDUHG WR those in patients with normal weight, with statisti FDOGLIIHUHQFHDWS 7ULJO\FHULGHOHYHOVZHUH KLJKHVWLQWKHJURXSZLWK%0,!PPROO Statistical difference measured by Student t test IRU WZR LQGHSHQGHQW VDPSOHV ZDV ZLWK D VLJQL¿ FDQFHRIS 7KHGLIIHUHQFHLQWKHPHDVXUHG +'/ZDVDWWKHOHYHORIS 7KHPRVWVLJQL¿FDQWUHVXOWVZHUHIRXQGZKHQFRP SDULQJVHUXP/'/LQERWKJURXSVRISDWLHQWV7KH DYHUDJHYDOXHRIVHUXP/'/FKROHVWHUROSDUWLFOHV ZDVKLJKHULQSDWLHQWVZLWK%0,!FRPSDUHGWR WKRVHSDWLHQWVZLWK%0,PPROO 6WDWLVWLFDO DQDO\VLV VKRZHG VLJQL¿FDQFH RI S $ SRVLWLYH FRUUHODWLRQ ZDV REVHUYHG EH WZHHQ %0, DQG VHUXP /'/ WKH 3HDUVRQ FRHI¿ FLHQWU 8VLQJOLQHDUUHJUHVVLRQDQDO\VLVZH SHUIRUPHGSUHGLFWLYHPRGHOWKDWSUHGLFWV/'/YDO XHVGHSHQGLQJRQ%0,LQFUHPHQW)LJXUH After searching the medical database, we found LQWHUHVWLQJVWXGLHVRQWKHLQÀXHQFHRI%0,RQWKH degree of dyslipidemia and increased cardiovas FXODU ULVN +RZHYHU ZH KDYHQ¶W IRXQG %HOPD$ãþLü±%XWXURYLü$PLU5HGåHSRYLü$PLOD0HKPHGRYLü$QDO\VLVRIFRURQDU\ULVNIDFWRUVLQREHVHSDWLHQWVZLWKK\SRWK\URLGLVP any studies that follow these parameters in pa tients with established hypothyroidism, so these results can be considered as preliminary in consid eration of the pathophysiology of hypothyroidism, DWKHURVFOHURVLVDQGFRURQDU\ULVNDVVHVVPHQW 0RQLWRULQJRIVHUXPOHYHOVRI7776+LQSD WLHQWVPRQLWRUHGE\JURXSVVKRZHGQRVLJQL¿FDQW differences, indicating good medical therapy in WKHVHSDWLHQWV0RQLWRULQJRIEORRGSUHVVXUHLQSD tients, showed that the values of systolic pressure ZHUHKLJKHULQWKHJURXSRISDWLHQWVZLWKD%0,! WKDQLQWKRVHRIQRUPDOZHLJKWDQGWKHVWDWLVWL FDOVLJQL¿FDQFHRIS 'LDVWROLFEORRGSUHV sure values were also higher in the group of pa WLHQWVZLWKD%0,!DQGWKHGLIIHUHQFHEHWZHHQ WKH WZR JURXSV ZDV S +\SHUWHQVLRQ ZDV DOVRLQGLFDWHGDVDULVNIDFWRULQWKLVVWXG\ZKLFK RFFXUVRULQWHQVL¿HVLQSDWLHQWVZLWKK\SRWK\URLG ism and obesity. 6WXG\E\-HUDQWRDQGDQDVVRFLDWHLQVKRZHG that being overweight is associated with diabetes and hypertension, causing an increase in mortal LW\ *UHDW(QJODQGVWXG\SXEOLVKHGLQRQDVDP ple of 1.4 million patients showed that overweight, REHVLW\ DQG SRVVLEOH PDOQXWULWLRQ LV DVVRFLDWHG ZLWKLQFUHDVHGWRWDOPRUWDOLW\0RUWDOLW\ZDVORZHVW DPRQJUHVSRQGHQWVZLWK%0,WR 7KH VWXG\ LQFOXGHG DQDO\VLV RI VPRNLQJ KDELWV positive history for family cardiovascular disease, and the presence of diabetes and hypertension. 7KHVHULVNIDFWRUVZHUHTXLWHHYHQO\UHSUHVHQWHG in groups, showing that it could be expected that the differences in the studied parameters of dys lipidemia have been dependent to a greater extent on obesity. CONCLUSION It has been proven that in obese patients suffering from hypothyroidism there is an increasing preva OHQFHRIFRURQDU\ULVNIDFWRUVKLJKHUOHYHOVRI/'/ cholesterol, triglycerides, and higher prevalence of hypertension compared with patients having proper body weight. Assessment of the thyroid gland hormonal status should be an integral part in the treatment of pa tients with coronary artery disease. &RQÀLFWRILQWHUHVWnone declared REFERENCES 6PLWK6&-U-DFNVRQ53HDUVRQ7$)XVWHU9<XVXI 6 )DHUJHPDQ 2HW DO 3ULQFLSOHV IRU QDWLRQDO DQG UH gional guidelines on cardiovascular disease prevention. &LUFXODWLRQ-XQ $OOHQGHU66FDUERURXJK33HWR95D\QHU0/HDO- /XHQJR)HUQDQGH] 5 *UD\$ (XURSHDQ FDUGLRYDVFX ODUGLVHDVHVWDWLVWLFVHG(XURSHDQ+HDUW1HWZRUN 3\|UlOl . 'H %DFNHU * *UDKDP , 3RROH:LOVRQ 3 :RRG ' 3UHYHQWLRQ RI &RURQDU\ +HDUW 'LVHDVH LQ &OLQLFDO 3UDFWLFH 5HFRPHQGDWLRQV RI WKH 7DVN )RUFH of the European Atherosclerosis Society and Euro SHDQ 6RFLHW\ RI +\SHUWHQVLRQ (XU +HDUW - 2FW (XURSHDQ$VVRFLDWLRQIRU&DUGLRYDVFXODU3UHYHQWLRQ 5HKDELOLWDWLRQ5HLQHU=&DWDSDQR$/'H%DFNHU* *UDKDP , 7DVNLQHQ 05 :LNOXQG 2 HW DO (6&($6 *XLGHOLQHVIRUWKHPDQDJHPHQWRIG\VOLSLGDHPLDV(6& EAS Guidelines for the management of dyslipidaemias: WKH7DVN)RUFHIRUWKHPDQDJHPHQWRIG\VOLSLGDHPLDV RI WKH (XURSHDQ 6RFLHW\ RI &DUGLRORJ\ (6& DQG WKH (XURSHDQ$WKHURVFOHURVLV 6RFLHW\ ($6 (XU +HDUW - /DGHQVRQ3:6LQJHU3$$LQ.%%DJFKL1%LJRV 67/HY\(*HWDO$PHULFDQ7K\URLG$VVRFLDWLRQJXLGH lines for detection of thyroid dysfunction. Arch Intern 0HG± %DUHWLü0\HDUVRI+DVKLPRWRWK\URLGLWLVVWLOODQ LQWULJXLQJGLVHDVH$FWD0HG&URDWLFD %RHODHUW.1HZE\356LPPRQGV0-HWDO3UHYD OHQFHDQGUHODWLYHULVNRIRWKHUDXWRLPPXQHGLVHDVHVLQ VXEMHFWV ZLWK DXWRLPPXQH WK\URLG GLVHDVH$P - 0HG H±H 2WW - 3URPEHUJHU 5 .REHU ) 1HXKROG 1 7HD 0 +XEHU-&HWDO+DVKLPRWR¶VWK\URLGLWLVDIIHFWVV\PS WRPORDGDQGTXDOLW\RIOLIHXQUHODWHGWRK\SRWK\URLGLVP D SURVSHFWLYH FDVH±FRQWURO VWXG\ LQ ZRPHQ XQGHU JRLQJ WK\URLGHFWRP\ IRU EHQLJQ JRLWHU 7K\URLG ± 5RGRQGL11HZPDQ$%9LWWLQJKRII(GH5HNHQHLUH 16DWWHU¿HOG6+DUULV7%HWDO6XEFOLQLFDOK\SRWK\ URLGLVP DQG WKH ULVN RI KHDUW IDLOXUH RWKHU FDUGLRYDV FXODU HYHQWV DQG GHDWK $UFK ,QWHUQ 0HG ± 5HLVPDQQ36RPRJ\L$'LDEHWHVDQGWK\URLGGLVRU GHUV2UY+HWLO %D\V+(&KDSPDQ5+*UDQG\66+,(/',QYHV WLJDWRUV¶ *URXS7KH 5HODWLRQVKLS RI %RG\ 0DVV ,QGH[ WR 'LDEHWHV 0HOOLWXV +\SHUWHQVLRQ DQG '\VOLSLGDHPLD &RPSDULVRQRI'DWD)URP7ZR1DWLRQDO6XUYH\V,QW- &OLQ3UDFW *UHJJ (: &KHQJ<- &DGZHOO %/ ,PSHUDWRUH * :LOOLDPV'()OHJDO.0HWDO6HFXODUWUHQGVLQFDUGLR YDVFXODU GLVHDVH ULVN IDFWRUV DFFRUGLQJ WR ERG\ PDVV LQGH[LQ86DGXOWV-$0$ -HUDQW $ )UDQNV 3 %RG\ 0DVV ,QGH[ 'LDEHWHV +\SHUWHQVLRQ DQG 6KRUW7HUP 0RUWDOLW\$ 3RSXODWLRQ %DVHG 2EVHUYDWLRQDO 6WXG\ ± - $P %RDUG )DP0HG %HUULQJWRQ GH *RQ]DOH] $ +DUWJH 3 &HUKDQ -5 )OLQW$-+DQQDQ/0DF,QQLV5-HWDO%RG\PDVVLQ 0HGLFLQVNLåXUQDO %HOPD$ãþLü±%XWXURYLü$PLU5HGåHSRYLü$PLOD0HKPHGRYLü$QDO\VLVRIFRURQDU\ULVNIDFWRUVLQREHVHSDWLHQWVZLWKK\SRWK\URLGLVP GH[ DQG PRUWDOLW\ DPRQJ PLOOLRQ ZKLWH DGXOWV 1 (QJO-0HG± 2USDQD+0%HUWKHORW-0.DSODQ06)HHQ\'+ 0F)DUODQG%5RVV1$%0,DQGPRUWDOLW\UHVXOWVIURP a national longitudinal study of Canadian adults. Obe VLW\± +XUOH\ '/ 0F0DKRQ 00 0HFKDQLFN -, 0HGLFDO QXWULWLRQIRUHQGRFULQRORJLVWV3URJUDPDQGDEVWUDFWVRI the American Association of Clinical Endocrinologists, VW$QQXDO6FLHQWL¿F&OLQLFDO&RQJUHVV0D\ 3KLODGHOSKLD3HQQV\OYDQLD Address: 3URI%HOPD$ãþLü%XWXURYLü0'3K' &OLQLF IRU (QGRFULQRORJ\ 'LDEHWHV DQG 0HWDEROLF Diseases Clinical Center University of Sarajevo 6DUDMHYR%ROQLþND Bosnia and Herzegovina 3KRQH (PDLODVFLFEXWXURYLF#KRWPDLOFRP 1RYDFHQWUDOQD]JUDGD.OLQLþNRJ&HQWUD8QLYHU]LWHWDX6DUDMHYX New Central building of the Clinical Center University of Sarajevo 0HGLFLQVNLåXUQDO 'HQLV0DþNLü'DPLUâHþLü$JR2PHUEDãLü$PLUýHKDMLü(OYLUD'åDPEDVRYLü(YDOXDWLRQRIGLDVWROLFG\VIXQFWLRQLQDFXWHP\RFDUGLDOLQIDUFWLRQ Professional article EVALUATION OF DIASTOLIC DYSFUNCTION IN ACUTE MYOCARDIAL INFARCTION PROCJENA DIJASTOLNE DISFUNKCIJE U AKUTNOM INFARKTU MIOKARDA 'HQLV0DþNLü'DPLUâHþLü2$JR2PHUEDãLü2$PLUýHKDMLü(OYLUD'åDPEDVRYLü 'HSDUWPHQWRI,QWHUQDO0HGLFLQH*HQHUDO+RVSLWDO³3ULPGU$EGXODK1DNDã´6DUDMHYR6DUDMHYR%RVQLD and Herzegovina; )DFXOW\RI0HGLFLQH8QLYHUVLW\RI6DUDMHYRýHNDOXãD6DUDMHYR%RVQLDDQG+HU]H govina 1* &RUUHVSRQGLQJDXWKRU ABSTRACT ,W LV NQRZQ WKDW FKDQJHV UHJDUGLQJ GLDVWROLF DQG systolic function within patients that suffer acute myocardial infarction can be observed. This study GHPRQVWUDWHVIUHTXHQF\RIGLDVWROLFG\VIXQFWLRQRI patients with previous acute myocardial infarction. 3DWLHQWV DQG PHWKRGV 2XW RI SDWLHQWV LQ FOXGHG LQ WKH VWXG\ WKHUH ZHUH PHQ DQG women. These patients were treated at Internal Department of General Hospital in Sarajevo due to myocardial infarction on the basis of clinical pic ture, ECG changes and biohumoral status. From SDWLHQWVDFFRUGLQJWRWKHDSSURSULDWHFULWHULD SDWLHQWVZHUHH[FOXGHG 7KHDYHUDJHSDWLHQWV¶DJHZDV7KH\RXQJHVW SDWLHQWZDVDQGWKHROGHVW2XWRISD WLHQWVKDGQRUPDOGLDVWROLFIXQFWLRQ RUKDGDGLVRUGHURIGLDVWROLFIXQFWLRQRI LPSDLUHGUHOD[DWLRQKDGPRGHUDWHGL astolic dysfunction of pseudonormalization, while SDWLHQWVKDGSURPLQHQWGLVRUGHURIGLDV tolic function of restrictive type. 7KHUHLVQRVWDWLVWLFDOO\VLJQL¿FDQWGLIIHUHQFHLQIUH TXHQF\RIGLDVWROLFG\VIXQFWLRQLQWKHWHUPVRIVH[ of the patients included in the study and localiza tion of myocardial infarction. On the other hand, DQLQFUHDVHGIUHTXHQF\RIGLDVWROLFG\VIXQFWLRQRI older age patients with acute myocardial infarction was observed. Conclusions: It can be concluded that coronary heart disease, especially acute coronary incidents DUHVLJQL¿FDQWIDFWRUVFRQWULEXWLQJWRWKHLPSDLUHG diastolic function. Key words: diastolic dysfunction, echocardiogra phy, myocardial infarction. 6$ä(7$. 3R]QDWR MH GD PRJX ELWL SULVXWQH SURPMHQH GL MDVWROQH L VLVWROQH IXQNFLMH SDFLMHQDWD VD DNXWQLP LQIDUNWRP PLRNDUGD 6WXGLMD SRND]XMH XþHVWDORVW GLMDVWROQH GLVIXQNFLMH NRG SDFLMHQDWD VD UDQLMLP LQIDUNWRP PLRNDUGD &LOM RYH VWXGLMH MH GD RFLMHQL VWHSHQGLMDVWROQHGLVIXQNFLMHSDFLMHQDWDVDDNXW QRP LQIDUNWRP PLRNDUGD 3DFLMHQWL L PHWRGH 2G SDFLMHQDWD XNOMXþHQLK X VWXGLMX ELOD VX PXãNDUFD L åHQH 2YL VX SDFLMHQWL WUHWLUDQL QD ,QWHUQRP RGMHOX 2SãWH EROQLFH X 6DUDMHYX ]ERJ LQIDUNWDPLRNDUGDQDRVQRYXNOLQLþNHVOLNHSURP MHQD(.*DLELRKXPRUDOQRJVWDWXVD2GXNXSQR SDFLMHQWDSUHPDRGJRYDUDMXüLPNULWHULMLPD SDFLMHQDWDMHELORLVNOMXþHQR 3URVMHþQD GRE SDFLMHQDWD MH ELOD JRGLQD 1DMPODÿLSDFLMHQWMHLPDRLQDMVWDULMLJRGLQD 2G SDFLMHQDWD MH LPDOR QRUPDOQX GLMDVWROQX IXQNFLMX LOL SRUHPHüDM GLMDV WROQH IXQNFLMH ]ERJ SRUHPHüHQH UHODNVDFLMH XPMHUHQXGLMDVWROQXGLVIXQNFLMXWLSDSVHX GRQRUPDOL]DFLMHGRNMHSDFLMHQDWDLP DOR L]UDåHQ SRUHPHüDM GLMDVWROQH IXQNFLMH UHVWULN WLYQRJWLSD1LVPRQDãOLVWDWLVWLþNL]QDþDMQXUD]OLNX X XþHVWDORVWL GLMDVWROQH GLVIXQNFLMH X RGQRVX QD VSRO L ORNDOL]DFLMX LQIDUNWD 3ULVXWQD MH SRYHüDQD XþHVWDORVWGLMDVWROQHGLVIXQNFLMHSDFLMHQDWDVWDULMH GRELVDLQIDUNWRPPLRNDUGD =DNOMXþFL.RURQDUQDVUþDQDEROHVWSRVHEQRDNXW QL LQIDUNW PLRNDUGD SUHGVWDYOMDMX ]QDþDMDQ IDNWRU ]DRãWHþHQMHGLMDVWROQHIXQNFLMH .OMXþQH ULMHþL GLMDVWROQD GLVIXQNFLMD HKRNDUGLR JUD¿MDLQIDUNWPLRNDUGD INTRODUCTION Diastolic ventricular dysfunction is an important factor in numerous heart diseases. According to the available literature, almost half of patients with symptoms of heart disease have preserved sys tolic function, or ejection fraction of left ventricle, therefore they have primary diastolic heart failure 0HGLFLQVNLåXUQDO 'HQLV0DþNLü'DPLUâHþLü$JR2PHUEDãLü$PLUýHKDMLü(OYLUD'åDPEDVRYLü(YDOXDWLRQRIGLDVWROLFG\VIXQFWLRQLQDFXWHP\RFDUGLDOLQIDUFWLRQ Diastole can be divided in 4 phases: D,VRYROXPLFUHOD[DWLRQ E3KDVHRIUDSLG¿OOLQJ F'LDVWDVLV G/DWHGLDVWROLF¿OOLQJFDXVHGE\DWULDOFRQWUDFWLRQ Among patients with signs of heart failure, Doppler XOWUDVRXQGFRPELQHGZLWKWZRGLPHQVLRQDOHFKR FDUGLRJUDSK\ZLOODQVZHUWKHTXHVWLRQZKHWKHUWKH FDXVH RI KHDUW GLVHDVH V\PSWRPV LV OLNHO\ WR EH diastolic dysfunction of left ventricle. 7KHPRVWIUHTXHQWFDXVHVRIGLDVWROLFG\VIXQFWLRQ of left ventricle are those conditions that may also cause systolic dysfunction of left ventricle, more precisely, coronary artery disease, arterial hyper tension and valvular heart disease. 0RVW SDWLHQWV DIWHU DFXWH P\RFDUGLDO LQIDUFWLRQ develop some level of diastolic dysfunction dur LQJWKH¿UVWGD\VDIWHULQIDUFWLRQ)XUWKHUPRUHDQ LQFUHDVHRIKHDUWELRPDUNHUVLVVLJQL¿FDQWO\ODUJHU in case of restrictive disorder of diastolic function. ,QÀDPPDWRU\ UHVSRQVH &53 DOVR SOD\V DQ LP portant role in development of diastolic dysfunc tion. Diastolic function is in close relationship with systolic as it is believed that ejection fraction at UHVWULFWLYH W\SH RI GLDVWROLF G\VIXQFWLRQ LV VLJQL¿ cantly lower than in case of impaired relaxation. /HYHOVRIGLDVWROLFG\VIXQFWLRQDUH VWOHYHOLPSDLUHGUHOD[DWLRQ QGOHYHO±SVHXGRQRUPDOL]DWLRQ UGOHYHOUHVWULFWLYH¿OOLQJ In the studies of some authors a correlation is found between impaired diastolic function deter mined by Doppler ultrasound regarding acute my ocardial infarction with not so rare lethal outcome especially at severe forms of disorder of diastolic IXQFWLRQ ,PSDLUHG UHOD[DWLRQ LV IHDWXUHG E\ UHGXFHG VSHHG RI ( ZDYHV H[WHQGHG ,957 LVR YROXPLFUHOD[DWLRQWLPHSURORQJHGHDUO\GLDVWROLF '7 DQG (¶ OHVV WKDQ FPV QG OHYHO RI GLDV tolic dysfunction is called pseudonormal because ($ UHODWLRQ LV PRUH WKDQ EXW DIWHU 9DOVDOYD¶V maneuver E speed decreases so it becomes less than 1. Other features are short deceleration WLPHUHGXFHG(¶ZLWK(¶(DOHVVWKDQDQG((¶ VKRUWHQ ,957 DQG GLDVWROLF FRPSRQHQW RI ÀRZ WKURXJK OXQJV YHLQV WKDW LV KLJKHU WKDQ V\V tolic component. Severe diastolic dysfunction of UHVWULFWLYHW\SHLVIHDWXUHGE\LQFUHDVHG($UDWLR VKRUWHQ '7 VPDOO VSHHG (¶ ZLWK ((¶ PRUH WKDQ VKRUW ,957 DQG DEQRUPDO ÀRZ WKURXJK OXQJV YHLQVGLDVWROLFFRPSRQHQWKLJKHUWKDQV\VWROLFLQ FUHDVHGVSHHGDQGGXUDWLRQRIDWULDOUHYHUVHÀRZ Recent studies lead to the conclusions that the presence of diastolic dysfunction is much more IUHTXHQW WKDQ LW ZDV FRQVLGHUHG HDUO\ DW SDWLHQWV ZLWKDFXWHP\RFDUGLDOLQIDUFWLRQ 0HGLFLQVNLåXUQDO MATERIALS AND METHODS 7KHVWXG\LQFOXGHGSDWLHQWVZLWKDFXWHP\R cardial infarction that were hospitalized in General +RVSLWDOLQ6DUDMHYRGXULQJWKHSHULRGIURP-DQX DU\XQWLO'HFHPEHURWKHUSDWLHQWVZLWK acute pain were transferred from the above hospi tal to Clinical Center Sarajevo due to possibility of percutaneous coronary intervention. The inclusion criteria were: patients of both sexes, DJH\HDUVDGPLVVLRQDW'HSDUWPHQWRI,Q ternal Diseases, General Hospital Sarajevo due to diagnosed myocardial infarction on the basis of clinical signs, changes on electrocardiography and positive biohumoral status. 1RQLQFOXVLRQ FULWHULD ZHUH VWDEOH DQG XQVWDEOH angina pectoris, chronic ischemic cardiomyopa thy. ([FOXVLRQ FULWHULD ZHUH LQWUDKRVSLWDO OHWKDO RXW FRPH DWULDO ¿EULOODWLRQ SDWLHQWV UHIHUUHG WR RWKHU hospitals and patients who were discharged from WKHKRVSLWDODWWKHLURZQUHTXHVW2QWKHEDVLVRI H[FOXVLRQFULWHULDWKHVWXG\H[FOXGHGRXWRI SODQQHGSDWLHQWVVRSDWLHQWVUHPDLQHGLQWKH study. Echocardiography was performed within seven days from acute myocardial infarction on the ma FKLQH 9LYLG *( XVLQJ VWDQGDUG FDUGLRORJLFDO SUREH'DQG0PRGHSXOVHFRQWLQXRXVFRORU and tissue Doppler. All patients were treated with conservative ther apy. RESULTS 7KH DYHUDJH DJH RI SDWLHQWV ZDV \HDUV ZLWK the oldest patient at age of 89 and youngest at 19. $PRQJDOOSDWLHQWVWKHUHZHUHPHQDQG ZRPHQ $PRQJ SDWLHQWV KDG QRUPDO GL DVWROLF IXQFWLRQ KDG PLOG GLDVWROLF G\VIXQFWLRQLPSDLUHGUHOD[DWLRQKDG PRGHUDWHGLDVWROLFG\VIXQFWLRQSVHXGRQRUPDOL]D WLRQVHYHQSDWLHQWVKDGVHYHUHGLDVWROLF G\VIXQFWLRQUHVWULFWLYH¿OOLQJ 7DEOH)UHTXHQF\RIGLDVWROLFG\VIXQFWLRQDWDFXWHP\RFDU dial infarction. 'HQLV0DþNLü'DPLUâHþLü$JR2PHUEDãLü$PLUýHKDMLü(OYLUD'åDPEDVRYLü(YDOXDWLRQRIGLDVWROLFG\VIXQFWLRQLQDFXWHP\RFDUGLDOLQIDUFWLRQ 7KHUH LV VWDWLVWLFDOO\ VLJQL¿FDQW GLIIHUHQFH EH tween separate degrees of diastolic dysfunction in patients with acute myocardial infarction with ; DQGS 0RVWO\ROGHUSDWLHQWVKDYHGLDVWROLFG\VIXQFWLRQDW DFXWHP\RFDUGLDOLQIDUFWLRQ7KHUHLVDVLJQL¿FDQW statistical difference among patients considering DJHZLWKW DQGS Table 2. Structure of sample considering sex and age. 7DEOH Degree of diastolic dysfunction in regards to localiza tion of myocardial infarction. 7DEOH )UHTXHQF\ RI GLDVWROLF G\VIXQFWLRQ LQ UHODWLRQ WR VH[ and age. 7KHUHLVQRVWDWLVWLFDOO\VLJQL¿FDQWGLIIHUHQFHFRQ VLGHULQJORFDOL]DWLRQZLWKYDOXH; LS DISCUSSION 7KHUH LV VLJQL¿FDQW VWDWLVWLFDO GLIIHUHQFH EHWZHHQ male and female patients with diastolic dysfuncti RQRIVWDQGQGGHJUHHRIP\RFDUGLDOLQIDUFWLRQ ZLWKYDOXH; DQGS 7DEOH)UHTXHQF\RIGLDVWROLFG\VIXQFWLRQLQUHODWLRQSDWLHQW¶V age. (OGHUO\SDWLHQWVDUHPRUHIUHTXHQWO\DIIHFWHGWKDQ younger patient, more precisely, younger patient DUHWLPHVOHVVUHSUHVHQWHGLQWKHVDPSOH6LP LODUO\LIZHWDNHLQWRFRQVLGHUDWLRQVWUXFWXUHRIWKH VDPSOH IHPDOH SDWLHQWV DUH UHSUHVHQWHG E\ XQOLNH PDOH SDWLHQWV ZLWK DOPRVW GRXEOH QXPEHU 0DMRULW\ RI SDWLHQWV ZLWK DFXWH LQIDUFWLRQ KDVGLVRUGHURIGLDVWROLFIXQFWLRQGXULQJ¿UVWVHYHQ days after an ultrasound is done. The major num ber of patients suffering from diastolic dysfunction RUDERXWRIWKHPKDVGLDVWROLFG\VIXQFWLRQRI 1st degree or impaired relaxation. On the other KDQGRQO\RISDWLHQWVKDYHGLDVWROLFG\VIXQF WLRQRIQGDQGUGGHJUHH$IWHUDQDO\VLVRIGLDV tolic dysfunction in relation to the patient’s gender LQ JHQHUDO VWDWLVWLFDOO\ VLJQL¿FDQW GLIIHUHQFH ZDV not found in the presence of diastolic dysfunction between male and female patients. However, there is a difference regarding level of diastolic dysfunc tion between male and female patients. There are more male patients with diastolic dysfunction of 1st degree, in fact; there is a major percentage of female patients with acute myocardial infarction WKDWKDYHGLDVWROLFG\VIXQFWLRQRIQGGHJUHHZLWK VWDWLVWLFDOO\VLJQL¿FDQWGLIIHUHQFH,QWKHIUHTXHQF\ of 3rd degree of diastolic dysfunction there is no VWDWLVWLFDOO\VLJQL¿FDQWGLIIHUHQFHUHJDUGLQJVH[ ,Q WRWDO SDWLHQWV ZKR ZHUH DOPRVW DOO ROGHU RQHV H[FHSW SDWLHQWV KDYH GLDVWROLF G\VIXQF tion. On the other hand, younger patients with myocardial infarction have preserved diastolic 0HGLFLQVNLåXUQDO 'HQLV0DþNLü'DPLUâHþLü$JR2PHUEDãLü$PLUýHKDMLü(OYLUD'åDPEDVRYLü(YDOXDWLRQRIGLDVWROLFG\VIXQFWLRQLQDFXWHP\RFDUGLDOLQIDUFWLRQ IXQFWLRQ LQ RI FDVHV ,W LV DOVR DUJXDEOH WKDW protracted observations of general disorder of di astolic function in relation to infarction localization UHYHDOHGWKDWWKHUHZDVQRVLJQL¿FDQWGLIIHUHQFHLQ diastolic function in relation to mentioned localiza tions. Doppler echocardiographic evaluation of hemody namics of patients with acute myocardial infarc tion is very important, in particular, as a noninva sive prognostic tool. It is also very important for SDWLHQWV ZLWK LQFUHDVHG ¿OOLQJ SUHVVXUH ZLWK UHOD WLYHO\SUHVHUYHGV\VWROLFIXQFWLRQ'HJUHHV DQGRIGLDVWROLFG\VIXQFWLRQKDYHOHVVPRUWDOLW\ comparing with 3rd degree of diastolic dysfunction 2XUSDWLHQWVWKDWKDGOHWKDORXWFRPHZHUH found to have predominantly diastolic dysfunction of 3rd degree. Additionally, a damage to diastolic function as well as systolic of left ventricle appears very early at as a heart disease, but often with subclinical forms and mild symptomatology being REVHUYDEOH7KLVSRVWXODWHPLJKWLQGLUHFWO\ H[SODLQKLJKIUHTXHQF\RIGLDVWROLFG\VIXQFWLRQH[ perienced by our patients. &OLQLFDO VWXGLHV KDYH VKRZQ WKDW DW DFXWH myocardial infarction, poor prognosis had from RI SDWLHQWV FRPSDULQJ ZLWK RI the patients with mild disorder of diastolic function. 2I FRXUVH LW VKRXOG EH WDNHQ LQWR FRQVLGHUDWLRQ that before acute myocardial infarction younger persons have usually normal diastolic function of the left ventricle, while older patients with coexist LQJK\SHUWURSK\RIOHIWYHQWULFOHLQFOXGLQJSRVVLEOH HDUOLHUP\RFDUGLDOLQIDUFWLRQXVXDOO\H[SHULHQFHD certain level of diastolic dysfunction. 0RUH WKDQ D KDOI RI SDWLHQWV ZLWK P\RFDUGLDO LQ farction and elevation of ST segment had diastolic G\VIXQFWLRQ¿UVWGD\DIWHUSHUFXWDQHRXVFRURQDU\ LQWHUYHQWLRQ (QGV\VWROLF DQG HQGGLDVWROLF YROXPHV ZHUH VLJQL¿FDQWO\ LQFUHDVHG LQ SDWLHQWV ZLWK SVHXGR QRUPDO DQG UHVWULFWLYH ¿OOLQJ GXULQJ ¿UVW WKUHH PRQWKV DIWHU DFXWH P\RFDUGLDO LQIDUF WLRQ6LPLODUO\WKHUHLVPRUHIUHTXHQWSURJUHVVLYH dilatation of left ventricle and possible death of pa tients with pseudo normal and restrictive diastolic GLVRUGHU1RWZLWKVWDQGLQJDVPDOOHUSHUFHQW age of our patients having pseudonormal and re strictive diastolic dysfunction, it is still necessary to proceed with further echocardiographic follow ups of patients after acute myocardial infarction. If patient suffers from acute myocardial infarction KH LV OLNHO\ WR GHYHORS PLOG GLDVWROLF G\VIXQFWLRQ RI¿UVWGHJUHHPDQLIHVWHGDVLPSDLUHGUHOD[DWLRQ +RZHYHU WKH DXWKRU LV DOVR RI WKH RSLQLRQ RU LW LV FRPPRQO\ EHOLHYHG WKDW VXFFHVVIXO WLPHO\ and appropriate therapy might cause the diastolic function of left ventricle to return to normal. If a patient experienced myocardial infarction but preserved systolic function, mild diastolic dysfunc 0HGLFLQVNLåXUQDO tion of impaired relaxation type would be the most IUHTXHQW7KHVWXGLHVSHUIRUPHGRQSDWLHQWVVXV WDLQLQJODUJHLQIDUFWLRQVDQGVLJQL¿FDQWO\UHGXFHG systolic function of left ventricle, moderate dias WROLF G\VIXQFWLRQ SVHXGRQRUPDOL]DWLRQ LV XVX DOO\SUHVHQW'XULQJWKHVXEVHTXHQW\HDUVVRPH patients would experience high level of diastolic function impairment of the left ventricle which is of irreversible restrictive type. CONCLUSIONS Coronary heart disease, in particular acute coro nary incidents represent very important factor contributing to the impairment of diastolic heart function, therefore heart function in whole, even WKRXJK DFXWH FRURQDU\ LQFLGHQWV SULPDULO\ LQÀLFW a damage to diastolic function of left ventricle and after that systolic function. /HYHO RI GLDVWROLF IXQFWLRQ GLVRUGHU DIWHU P\RFDU dial infarction has an important impact on disease prognosis. &RQÀLFWRILQWHUHVW none declared. REFERENCES $XULJHPPD*3*DDVFK:+'LDVWROLFKHDUWIDLOXUH 1(QJO-0HG 3RLULHU 3 %RJDW\ 3 *DUQHDX & 0DURLV / 'X PHVQLO -* 'LDVWROLF G\VIXQFWLRQ LQ QRUPRWHQVLYH PHQ ZLWK ZHOOFRQWUROOHG W\SH GLDEHWHV 'LDEHWHV &DUH $KPHG$ 1DQGD 1& :HDYHU 07$OOPDQ 50 'H /RQJ -) &OLQLFDO FRUUHODWHV RI LVRODWHG OHIW YHQWULFXODU diastolic dysfunction among hospitalized older heart IDLOXUHSDWLHQWV$P-*HULDWU&DUGLRO *DUFLD5XELUD-&0RODQR)(VSLQD$&DOYR5*RQ ]DOH]9DOGD\0*DUFLD0DUWLQH]-7HWDO$EQRUPDO¿OO ing pattern of the left ventricle and outcome in acute P\RFDUGLDOLQIDUFWLRQ,QW-&DUGLRO± 0ROOHU-((JVWUXS..REHU/3RXOVHQ6+1\YDG2 7RUS3HGHUVHQ&3URJQRVWLFLPSRUWDQFHRIV\VWROLFDQG diastolic function after acute myocardial infarction. Am +HDUW-± %RXQWLRXNRV 0 6FKLQNHO $) %D[ -- /DPSURSRX ORV 6 3ROGHUPDQV ' 7KH LPSDFW RI K\SHUWHQVLRQ RQ systolic and diastolic left ventricular function. A tis VXH 'RSSOHU HFKRFDUGLRJUDSKLF VWXG\ $P +HDUW - H 0ROOHU-(6RQGHUJDDUG(3RXOVHQ6+(JVWUXS. 3VHXGRQRUPDO DQG UHVWULFWLYH ¿OOLQJ SDWWHUQV SUHGLFW OHIW YHQWULFXODU GLODWLRQ DQG FDUGLDF GHDWK DIWHU D ¿UVW P\RFDUGLDO LQIDUFWLRQ D VHULDO FRORU 0PRGH 'RSSOHU HFKRFDUGLRJUDSKLFVWXG\-$P&ROO&DUGLRO ± 0ROOHU-(3HOOLNND3$+LOOLV*62K-.3URJQRVWLF LPSRUWDQFH RI GLDVWROLF IXQFWLRQ DQG ¿OOLQJ SUHVVXUH LQ patients with acute myocardial infarction. Circulation. 'HQLV0DþNLü'DPLUâHþLü$JR2PHUEDãLü$PLUýHKDMLü(OYLUD'åDPEDVRYLü(YDOXDWLRQRIGLDVWROLFG\VIXQFWLRQLQDFXWHP\RFDUGLDOLQIDUFWLRQ *DOGHULVL 0 %HQMDPLQ (6 (YDQV -& '¶$JRVWLQR 5% )XOOHU '/ /HKPDQ % HW DO ,QWUD DQG LQWHURE VHUYHU UHSURGXFLELOLW\ RI 'RSSOHUDVVHVVHG LQGH[HV RI OHIW YHQWULFXODU GLDVWROLF IXQFWLRQ LQ D SRSXODWLRQEDVHG VWXG\ WKH )UDPLQJKDP +HDUW 6WXG\ $P - &DUGLRO 6WHLQH.6WXJDDUG06PLVHWK2$0HFKDQLVPVRI UHWDUGHG DSLFDO ¿OOLQJ LQ DFXWH LVFKHPLF OHIW YHQWULFXODU IDLOXUH&LUFXODWLRQ± .X]QHWVRYD7+HUERWV/-LQ<6WRODU]6NU]\SHN. 6WDHVVHQ-$6\VWROLFDQGGLDVWROLFOHIWYHQWULFXODUG\V IXQFWLRQ IURP ULVN IDFWRUV WR RYHUW KHDUW IDLOXUH ([SHUW 5HY&DUGLRYDVF7KHU *LDQQX]]L3,PSDUDWR$7HPSRUHOOL3/GH9LWR) 6LOYD3/6FDSHOODWR)HWDO'RSSOHUGHULYHGPLWUDOGH FHOHUDWLRQ WLPH RI HDUO\ ¿OOLQJ DV D VWURQJ SUHGLFWRU RI pulmonary capillary wedge pressure in postinfarction SDWLHQWVZLWKOHIWYHQWULFXODUV\VWROLFG\VIXQFWLRQ-$P &ROO&DUGLRO± 0LV]WDO 2 6WRS\UD . *DFNRZVNL $ =PXGND . 3LZRZDUVND : $VVHVVPHQW RI OHIW YHQWULFOH GLDVWROLF function in myocardial infarction patients treated with SULPDU\DQJLRSODVW\&DUGLRO- Address: 'HQLV0DþNLü0' 'HSDUWPHQWRI,QWHUQDO0HGLFLQH *HQHUDO+RVSLWDO³3ULPGU$EGXODK1DNDã´ .UDQMþHYLþHYD6DUDMHYR Bosnia and Herzegovina 3KRQH (PDLOGHQLVPDFNLF#KRWPDLOFom 1RYDFHQWUDOQD]JUDGD.OLQLþNRJ&HQWUD8QLYHU]LWHWDX6DUDMHYX New Central building of the Clinical Center University of Sarajevo 0HGLFLQVNLåXUQDO (PLU%HQFD3HMPDQ=LDL*REHUWYRQ6NUEHQVN\$PLU$KPHWRYLü5HLQKDUG:LQGKDJHU6HOPD.USR5XQQLQJLQMXULHV Review article RUNNING INJURIES 3295('(35,75ý$1-8 Emir Benca3HMPDQ=LDL2, Gobert von Skrbensky$PLU$KPHWRYLü, Reinhard Windhager, Selma Krpo 'HSDUWPHQWRI2UWKRSDHGLF6XUJHU\0HGLFDO8QLYHUVLW\RI9LHQQD:DHKULQJHU*XHUWHO9LHQQD$XV tria; 6SRUWKRPHG9LHQQD .UHX]JDVVH 9LHQQD $XVWULD 3 Orthopaedic and Traumatology Clinic, Clinical &HQWHU8QLYHUVLW\RI6DUDMHYR%ROQLþND6DUDMHYR%RVQLDDQG+HU]HJRYLQD 1 &RUUHVSRQGLQJDXWKRU ABSTRACT This study was conducted with a purpose to pre sent common running injuries, their etiology and WUHDWPHQW $ 3XE0HG0HGOLQH GDWDEDVH VHDUFK was performed and additional literature was used E\ WKH DXWKRUV WR FRPSOHWH WKH VWXG\ 7KH NQHH ZDVLGHQWL¿HGDVWKHPRVWFRPPRQLQMXU\VLWHDQG the patellofemoral pain syndrome as the predomi nant diagnose in runners. A yearly incidence rate UDQJHGIURPWR7ZRWKLUGVRIWKHVHUXQ ners are forced to interrupt their normal training program due to injury. There is a strong evidence WKDWZRPHQKDYHDKLJKHUULVNIDFWRUIRULQMXU\WKHQ men, other intrinsic factors, which increase injuries in running, are age, higher body mass index, low SK\VLFDO¿WQHVVLQÀH[LELOLW\DQGWKHSDVWKLVWRU\RI injury, while training errors, shoes, running terrain present most common extrinsic factors leading to injury. Key words: running injuries, marathon 6$ä(7$. 2YDM SUHJOHGQR L]WUDåLYDþNL UDG MH VSURYHGHQ VD FLOMHPGDSUHGVWDYLþHVWHSRYUHGHSULWUþDQMXQML KRYXHWLRORJLMXLWUHWPDQ,]YUãHQRMHSUHWUDåLYDQMH 3XE0HG ED]H SRGDWDND L GRGDWQD OLWHUDWXUH MH NRULãWHQD RG VWUDQH DXWRUD X VYUKX GRYUãDYDQMD VWXGLMH .ROMHQR MH LGHQWL¿FLUDQR NDR QDMþHãüH PMHVWRR]OMHGHLSDWHORIHPRUDOQLEROQLVLQGURPNDR GRPLQDQWQDSUHGRPLQDQWQDGLDJQR]DNRGWUNDþD *RGLãQMDVWRSDLQFLGHQFLMHXUDVSRQXRGGR 'YLMHWUHüLQHWLKWUNDþDVXSULVLOMHQLSUHNLQXWL svoj normalan program treninga zbog ozljede. 3RVWRML MDN GRND] GD VX åHQH L]ORåHQH YHüHP UL]LNXRGR]OMHGHQHJRPXãNDUDFLGUXJLXQXWDUQML IDNWRULNRMLSRYHüDYDMXR]OMHGHSULWUþDQMXVXGRE 0HGLFLQVNLåXUQDO YLãLLQGHNVWMHOHVQHPDVHVODEDWMHOHVQDNRQGLFLMD QHÀHNVLELOQRVW L SRYLMHVW R]OMHGH GRN VX JUHãNH X WUHQLQJX RGDELUX REXüD NDR L YUVWD WHUHQD QDMþHãüLYDQMVNLIDNWRULNRMLGRYRGHGRR]OMHGH .OMXþQHULMHþLSRYUHGHSULWUþDQMXPDUDWRQ INTRODUCTION $FFRUGLQJ WR WKH DXWKRUV RI D DUWLFOH SXE lished in Nature the genus Homo evolved to travel ORQJ GLVWDQFHV E\ ERWK ZDONLQJ DQG UXQQLQJ Running was advantageous for early Homo in hunting or scavenging, but also to compete with other scavengers, including other hominids and DELOLW\HVVHQWLDOIRUVXUYLYDO Running represents not only a terrestrial locomo tion allowing rapid movement on foot, but a sport practiced by millions of athletes and amateurs worldwide with rising popularity. It is the most FRPPRQSHUIRUPHGVSRUWVDFWLYLW\ZRUOGZLGHGXH WRLWVHFRQRPLFFRQYHQLHQFHDQGKHDOWKEHQH¿WV such as reduction of obesity, cardiovascular dis HDVHDQGPDQ\RWKHUKHDOWKSUREOHPV,Q DQXPEHURIDOPRVWPLOOLRQUXQQHUVSHU FHQWRIWRWDOSRSXODWLRQZDVHVWLPDWHGRQO\LQWKH United States. ,QWKH¿UVWKDOIPDUDWKRQNPZDV held in Bosnia and Herzegovina’s capital Sarajevo DQGZDVUHSHDWHGHYHU\VXEVHTXHQW\HDU,WFDQ be expected that the city of Sarajevo will intro GXFHWKH¿UVWIXOOPDUDWKRQLQWKHFRXQWU\LQQHDU future. The number of the participants is presently UHODWLYHO\ ORZ SDUWLFLSDQWV LQ 7DEOH compared to similar modern competitions in the UHJLRQSDUWLFLSDQWVLQDWWKH9LHQQD &LW\0DUDWKRQ+RZHYHUWKHUHLVDVWHDG\JURZWK of amateur and professional runners in every age FDWHJRU\7DEOHWKURXJKRXWWKHZKROHFRXQWU\ (PLU%HQFD3HMPDQ=LDL*REHUWYRQ6NUEHQVN\$PLU$KPHWRYLü5HLQKDUG:LQGKDJHU6HOPD.USR5XQQLQJLQMXULHV 7DEOH1XPEHURISDUWLFLSDQWVLQ6DUDMHYRKDOIPDUDWKRQIRU WKH\HDUVWRLQFOXGLQJWKHQXPEHURIIHPDOHPDOH and Bosnian nationals as well as the annual growth of the total number in percent. Running can be performed on different surfaces VXFKDVFRQFUHWHFHPHQWWUDLOVRURIIURDGJUDVV VDQGWUDFNVRUWUHDGPLOOV7KHPDMRULW\RIUXQQHUV FKRVHWRUXQRQURDGVPRVWO\GXHWRODFNRIRWKHU options. +RZHYHU UXQQLQJ OLNH DQ\ RWKHU VSRUWV DFWLYLW\ might cause injury ranging from sore muscles and blisters to complex fractures. The aim of this paper is to present common run ning injuries from recent literature with attention WR WKHLU HWLRORJ\ ULVN IDFWRUV DQG ELRPHFKDQLFV DVZHOODVWKHXSWRGDWHFRQVHUYDWLYHDQGVXUJL cal treatment methods and educate medical pro fessionals in order to reestablish the anatomical structures and biomechanics and allow injured professional athletes and amateurs to continue their running career, but also to prevent or mini mize the injury rate. METHODS $ 0HGOLQH OLWHUDWXUH VHDUFK ZDV FRQGXFWHG IURP WR 0DUFK .H\ ZRUGV IRU WKH 0HGOLQH VHDUFKLQFOXGHGµUXQQLQJLQMXU\¶IRUWKH¿HOG7LWOH Abstract. 6WXG\,QFOXVLRQ([FOXVLRQ&ULWHULD 7KHVXEMHFWRIWKHVWXG\ZDVUXQQLQJLQMXULHVLQ running in general, long distance running or bio PHFKDQLFVRIUXQQLQJDQGRUUXQQLQJLQMXULHVDQG ULVNIDFWRUV 2QO\SDSHUVZKLFKLQFOXGHGDOOPXVFXORVNHOHWDO injuries of lower extremities or the entire body, were considered. 6WXGLHV SHUIRUPHG ZLWK HOLWH UXQQHUV ZHUH H[ cluded. 2QO\SDSHUVSXEOLVKHGLQ(QJOLVKRU*HUPDQLQ SHHUUHYLHZHG MRXUQDOV ZHUH LQFOXGHG 1RW SXE lished papers and conference abstracts were not included. 2QO\SDSHUVZKLFKFRXOGKDYHEHHQREWDLQHGDV a full text through the study group, were included. &DVHUHSRUWVZHUHH[FOXGHGIURPWKHUHVXOWV 3DSHUUHYLHZLQFOXGHGVFUHHQLQJRIWKHWLWOHVDE stract, and full texts by a single reviewer. A total of 113 articles were now found and where DVVL[W\RIWKHPZHUHLGHQWL¿HGDVSRWHQWLDOO\UHO HYDQW EDVHG RQ WKH 0HGOLQH VHDUFK$OO RI WKHVH were obtained in abstract form and most of them, depending on their availability in full length and H[DPLQHG 2WKHU DUWLFOHV GLVFRYHUHG E\ SHU sonal reviews of the study group members were also added. )LJXUH Number of studies published for each year since ZKLFKLQFOXGHWKHWHUPµ5XQQLQJ,QMXULHV¶LQWKHWLWOHDQG RUDEVWUDFW$OLQHDUWUHQGOLQHVKRZVWKHJURZWKRISXEOLVKHG ZRUNVDQGVFLHQWL¿FLQWHUHVWLQWKLVWRSLF Table 2. Sarajevo half marathon age statistic for the years WRGLYLGHGLQWRHLJKWDJHJURXSVLQDFFRUGDQFHZLWK commonly presented race results. 0HGLFLQVNLåXUQDO (PLU%HQFD3HMPDQ=LDL*REHUWYRQ6NUEHQVN\$PLU$KPHWRYLü5HLQKDUG:LQGKDJHU6HOPD.USR5XQQLQJLQMXULHV Review of injuries 0DFHUD HW DO GH¿QHG WKH WHUP µUXQQLQJ LQMXU\¶ DV µµ$Q LQMXU\ WR PXVFOHV MRLQWV WHQGRQV DQGRU ERQHV RI WKH ORZHU H[WUHPLWLHV KLS JURLQ WKLJK NQHH ORZHU OHJ DQNOH IRRW WRH WKDW WKH SDUWLFL SDQWDWWULEXWHGWRUXQQLQJ¶¶ A Swiss Study showed that running injuries are WLPHVOHVVIUHTXHQWWKHQIURPLQFRPSDUL VRQ WR DOO RWKHU VSRUWV DQG WLPHV OHVV IUHTXHQW WKDQVNLLQMXULHV$\HDUO\LQFLGHQFHUDWHRIDV KLJKDVZDVUHSRUWHGIRUWKRVHWUDLQLQJIRU DWKHNPDQGORZHUH[WUHPLW\LQMX ULHV LQ PDOH UXQQHUV RQO\ WR IRU WKRVH WUDLQLQJ IRU PDUDWKRQV IRU WKH ZKROH PDUDWKRQ distance. Two thirds of these runners are forced to interrupt their normal training program due to injury, however most injuries are not serious and VHOGRPOLIHWKUHDWHQLQJ9DQ0HFKHOHQFDO FXODWHGGHWHUPLQHGWKDWWKHLQFLGHQFHFDOFXODWHG according to the exposure of running is as high as WRLQMXULHVSHUKRXUVRIUXQQLQJ It can be distinguished between acute or traumatic and overuse injuries. Running is one of the most common sports activities in which overuse injuries LQORZHUH[WUHPLWLHVRFFXUXSWRLQD\HDU SHULRG )RUFHV EHORZ WKH WHQVLOH OLPLW RI WKH anatomical structures that are repeatedly applied WRWKHVDPHVWUXFWXUHVDQGRULQDGHTXDWHUHFRYHU\ time between force application can cause overuse LQMXU\$XWKRUVFODVVLI\RYHUXVHLQMXULHVDVFX PXODWLYHPLFURWUDXPDLQMXULHVDQGWKH\UHSUHVHQW WKHPDMRULW\RIDOOUXQQLQJUHODWHGLQMXULHV Overuse injuries in runners are typically runner’s NQHHVKLQVSOLQWVVWUHVVIUDFWXUHV$FKLOOHVWHQGLQ itis, runner’s heel bumps, heel spurs, arch fatigue, pain and cramps, neuromas, and boney deformity 7KHVHPRVWIUHTXHQWNLQGRIGLVRUGHUVVORZO\ develop over a long period of time and are exclu VLYHO\ FDXVHG E\ WUDLQLQJ HUURUV 2YHU training is a common cause for overuse injuries, EXWDOVRDQDWRPLFDOYDULDWLRQVÀDWRUKLJKDUFKHV e.g. length discrepancies, or an abnormally sized RU SRVLWLRQHG NQHHFDS EXW PD\EH DOVR ZURQJ footwear. The pain resulting from these injuries is mostly not severe; however in cases of persist LQJ SDLQ ORQJHU WKDQ RQH WR WZR ZHHNV PHGLFDO assistance should be sought. Traumatic injuries are caused by a violent and sudden incident and UHTXLUHRIWHQLPPHGLDWHPHGLFDOH[DPLQDWLRQHV SHFLDOO\ LI WKH DWKOHWH KHDUV RU IHHOV D FUDFNLQJ tearing or popping sound and the pain persists. Typical traumatic injuries include sprains, lac erations, torn ligaments, pulled muscles, or bone fractures. Traumatic injuries are hard to prevent as they happen sudden, whereas proper training, proper conditioning and proper biomechanical VWUXFWXUHPDNHRYHUXVHSUHYHQWLRQSRVVLEOH &OLQLFDO VWXGLHV VKRZ WKDW WKH NQHH MRLQW LV WKH 0HGLFLQVNLåXUQDO most prevalent site of running injury, account LQJEHWZHHQDQGRIDOOUXQQLQJLQMXULHV )HUEHUHWDOUHSRUWWKDWRI UXQQLQJUHODWHGLQMXULHVZKLFKRFFXUDWNQHHKHLJKW RUEHORZ0RVWLQMXULHVDUHJUDGHSDLQGXU ing running, but not restricting distance or speed JUDGH5XQQHU¶VNQHHLVDYHU\FRPPRQSUREOHP in joggers and professional runners and is often D FRPELQDWLRQ RI IDFWRUV OLNH DVVRFLDWHG ZLWK FKRQGURPDODFLDRIWKHNQHHSDWHOODUNQHHFDS FRPSUHVVLRQ SDWHOODU VXEOX[DWLRQ DQGRU SDWHOODU WHQGLQLWLVMXPSHU¶VNQHH 7DEOH%UHDNGRZQRILQMXU\ORFDWLRQIRUYDULRXVVWXGLHV . Patellofemoral Pain Syndrome 3DWHOORIHPRUDO SDLQ V\QGURPH 3)36 LV UHSRUW ed to be the most commonly occurring injury in WKHOLWHUDWXUH\HDUVDJRLQWKHSDVWDQG SUHVHQW 7KH V\QGURPH LV D UHVXOW from either abnormal forces or prolonged repeti tive compressive or shearing forces on the patel lofemoral joint during running. It leads primarily to chondromalacia of the cartilage in the patella and femoral condyles, synovial irritation and in ÀDPPDWLRQ VXEFKRQGUDO ERQH GHIRUPDWLRQV DQG secondarily to fractures, joint derangement and osteoarthritis. Hill running, especially downhill, causes excessive patella load and should be avoided by athletes ZLWKDQXQVWDEOHNQHH Generally there is a wide range of treatment meth RGV IRU 3)36 DQG PRVW DXWKRUV UHSRUW JRRG UH VXOWV E\ TXDGULFHSV VWUHQJWKHQLQJ LPSRVLQJ LW DV WKHJROGVWDQGDUGIRU3)36WUHDWPHQW Iliotibial Band Syndrome An overuse syndrome of tractus ilitibialis can be observed proximal as well as distal, whereas the GLVWDO SUHVHQFH LV PRUH FRPPRQ 3UHGLVSRVLQJ factors as a cause can be varus deformities with a higher internal rotation of the lower limb, a higher LQWHUQDOURWDWLRQRIWKHIRUHIRRWHJLQUXQQHUVZLWK VSOD\IRRWRUKLJKDUFKDSRVWHURODWHUDOURWDWLRQDO LQVWDELOLW\LQWKHNQHHMRLQW7KHHQKDQFHGFRQWDFW (PLU%HQFD3HMPDQ=LDL*REHUWYRQ6NUEHQVN\$PLU$KPHWRYLü5HLQKDUG:LQGKDJHU6HOPD.USR5XQQLQJLQMXULHV between the distal tractus with the lateral condylus XOWLPDWHO\UHVXOWVLQDWHQGLQLWLV3UR[LPDOO\KLJKHU LQWHUQDO URWDWLRQV RI WKH KLS EXW DOVR FR[DYDOJD OHDG WR D KLJK SHDN SUHVVXUH EHWZHHQ WKH WUDF tus and the trochanter mayor of the femur, which causes tendinitis. In this context diverse patholo gies of the pelvic girdle might constitute predispos ing factor. The recognition of a malalignment as an initiating factor and its elimination is essential for a permanent and successful therapy. Plantar Fasciitis Heel spurs are considered to be a condition of a ODWHVWDWHRISODQWDUIDVFLLWLV+HHOVSXUVDUH FRPPRQO\ FDOFL¿HG LQÀDPHG WLVVXH RI WKH IRRW where the arch meets the heel, easily noticeable RQ;UD\V7KHKHHOLVLQPRVWUXQQHUVWKH¿UVW contact point and is exposed to ground reaction forces as high as three times the body weight 6XUJHULHV DUH RQO\ LQGLFDWHG LQ FDVHV where conservative treatment with orthotics and cortisone injections failed. Meniscal Injury 7DXQWRQHWDOVKRZHGLQWKHLUVWXG\LQWKDW ROGHUDQGPDOHDWKOHWHVKDYHPRUHIUHTXHQWPH QLVFDOLQMXULHV$PDODOLJQPHQWRIWKHOHJD[HV can cause a higher degenerative reduction of WKH PHQLVFDO WLVVXH :KLOH D YDUXV PDODOLJQPHQW generates an increased load on the medial me niscus, a valgus malalignment results in a higher degeneration of the lateral meniscus. Instability RIWKHOLJDPHQWRXVDSSDUDWXVHJDFKURQLF$&/ instability, lateral or medial ligamentous instability UHVXOWLQJLQDQLQFUHDVHGYDUXVRUYDOJXVORDGLQ WKHNQHHMRLQWSRVWHURODWHUDOLQVWDELOLW\FRPELQHG ZHDNQHVV RI WKH 3&/ DQG PXVFXOXV SRSOLWHXV generates a higher degeneration in menisci, as well as in cartilage. Medial Tibial Stress Syndrome The medial tibial stress syndrome or commonly NQRZQ DV VKLQ VSOLQW 6KLQ VSOLQW LV D FROOHFWLYH WHUP XVHG WR GHVFULEH LQÀDPPDWLRQ RI WKH ERQH SHULRVWLWLV LQÀDPPDWLRQ RI WKH PXVFOH P\RVL WLV RU LQÀDPPDWLRQ RI WKH WHQGRQV WHQGLQLWLV 7KHUHDVRQVKHUHIRUHDUHDQH[FHVVLYHORDG generated by repetitive contraction of the poste ULRUWLELDOLVWHQGRQVROHXVPXVFOHDQGÀH[RUGLJL WRUXPWHQGRQUHVXOWLQJLQDQLQÀDPPDWLRQRIWKH periosteal tissue, and a high persistent stress on the tibia caused by muscular contracting forces DQGLQVXI¿FLHQWFDSDFLW\IRUERQHUHPRGHOLQJ :HDNQHVV LQ WKH H[WHQVRU PXVFOH JURXS LV FRP monly involved with running on hard surfaces or KLOOV 3UHYHQWLYH PHDVXUHV LQFOXGH H[HUFLVLQJ DQG strengthen of the extensor group, stretching of the Achilles tendon and utilization of ice following a UXQQLQJ VHVVLRQ RQ VRUH PXVFOHV IRU PLQ XWHV5XQQLQJRQVRIWHUWHUUDLQVLVDGYLVDEOH depending on its availability. Achilles Tendinitis Excessive and repetitive loading might lead to tendon degeneration. The loads generated in the gastrocnemius and soleus muscles while running might cause Achilles tendinitis in runners. A seg mental malalignment of the leg, the hind foot or the arch is seen as a predisposing factor. A 3° or more malalignment of the calcaneus in connec tion with hind foot varus or valgus can result in a VLJQL¿FDQW LQFUHDVH RI WKH PXVFXODU WHQVLRQ ZLWK DQLQÀDPPDWRU\UHDFWLRQRIWKHWHQGLQRXVSRUWLRQ of gastrocnemicus as the end result. Some au thors suggest changing the running pattern from WRHGDVK WR KHHOIRRWWRH RU IRRWWRH VWULGH LQ RU GHU WR UHGXFH WKH ULVN RI WKLV SUREOHP (LQH VWDWLVFKH .RUUHNWXU =% GXUFK YDULVLHUHQGH RGHU YDOJLVLHUHQGH (LQODJHQ NDQQ GHXWOLFKH 9RUWHLOH LQ GHU7KHUDSLHEHZLUNHQ Ankle Sprain Trauma %\GH¿QLWLRQDQNOHVSUDLQLVWKHVWUHWFKLQJRI¿EHUV RU WKH FROODJHQ RI WKH DQNOH OLJDPHQWV ZKHUHE\ WKH¿EHUVDUHSDUWLDOO\RUFRPSOHWHO\GLVUXSWHG 7KHV\PSWRPVLQFOXGHSDLQZHDNQHVVFUHSLWXV LQVWDELOLW\VZHOOLQJDQGVWLIIQHVV0RVWDWKOHWHVLQ sports involving running experience one or more DQNOHVSUDLQV$QNOHVSUDLQLVRIWHQUHJDUGHG as trivial, not only by athletes, but also by medical professionals. <HXQJHWDOVKRZHGWKDWLQUHFRUGHGVSUDLQHG DQNOHVLQSURIHVVLRQDODWKOHWHVWKHLQMXU\VROHO\WR WKHGRPLQDQWOHJ¶VDQNOHLVWLPHVKLJKHUWKDQ LQMXU\VROHO\WRWKHQRQGRPLQDQWVLGH+RZ HYHU WKLV VWDWHPHQW LV PRVW OLNHO\ EDVHG RQ GDWD from sports, which include jumping, where the dominant leg is more exposed to higher impact forces. In case of recurrent sprains stabilizing foot orthot ics are suggested, however most orthotics are not SURYLGLQJWKHGHVLUHGVWDELOLW\LQWKHDQNOHMRLQWDQG should be chosen carefully by orthopedic profes sionals. Stress Fractures 6WUHVVIUDFWXUHVDUHFRPPRQO\VHHQLQWKH¿EXOD or the metatarsal bone of the foot. They might not EHVHHQRQLQLWLDO;UD\VEXWSUHVHQWLQZHHNV DIWHUWKHLQMXU\RFFXUUHG,QFDVHRISHUVLVWLQJ SDLQXQGHUORDGDQ05,RU&$7VFDQLVQHFHVVDU\ IRUGLDJQRVLVFRQ¿UPDWLRQ Blisters Blisters result from mechanical friction between WKHVNLQOD\HUV$QDXWRJHQLFUHDFWLRQIRUPVDKRO ORZVSDFH¿OOHGZLWKVHUXPRUSODVPDFDXVLQJWHQ 0HGLFLQVNLåXUQDO (PLU%HQFD3HMPDQ=LDL*REHUWYRQ6NUEHQVN\$PLU$KPHWRYLü5HLQKDUG:LQGKDJHU6HOPD.USR5XQQLQJLQMXULHV sions and pain in the affected area. Runners often face this problem, which also might be caused by H[FHVVLYHFRUQHDIRUPDWLRQRUGU\VNLQ 0RVW DXWKRUV GRQ¶W FRQVLGHU EOLVWHUV DQ LQMXU\ however it is probably the most common problem a runner will face in his athletic career. To avoid blister formation, it is advisable to wear SURSHU IRRWZHDU DQG WKLQ DQG EUHDWKDEOH VRFNV ZLWK ORZ FRHI¿FLHQW RI IULFWLRQ 7KH DIIHFWHG VNLQ SRUWLRQFDQEHDSSOLHGZLWKDWKLQOD\HURIVNLQMHOO\ VXFKDV9DVHOLQH Treatment of blisters includes piercing the blister itself, sterilization and mechanical decompression. Increasing running injuries correlate with extrin sic factors such as training intensity, training er URUV VKRHV UXQQLQJ WHUUDLQ ZHDWKHU WLPH of the day, warm up and stretching, but also with LQWULQVLF IDFWRUV VXFK DV DJH KHLJKW JHQGHU KLJKHU LQMXU\ ULVN H[LVWV KHUH IRU ZRPHQ KLJKHU ERG\ LQGH[ %0, SV\ FKRORJLFDO IDFWRUV ORZ OHYHO RI SRRU SK\VLFDO ¿WQHVV OHYHO DW WKH FRPPHQFHPHQW RI D WUDLQLQJ SURJUDP LQÀH[LELOLW\ DQG LQMXU\ KLVWRU\ 2QO\ D SRRU number of studies exist demonstrating an associa tion between running injuries and factors such as ZDUPXS VWUHWFKLQJ UXQQLQJ IUHTXHQF\ OHYHO RI performance, shoes and stabilizing orthoses. Fur WKHUPRUHYDQ0HFKHOHQVKRZHGLQDUHYLHZRIWKH epidemiological literature that age, gender, body mass index, running hills, running on hard surfac es, participation in other sports, time of the year DQGWLPHRIWKHGD\DUHVLJQL¿FDQWO\QRWDVVRFLDWHG ZLWK UXQQLQJ LQMXULHV ,QMXULHV DUH RIWHQ PXOWL factorial and can also often be ascribed to training errors. The three most common factors described LQOLWHUDWXUHDUHLDQLQFUHDVHLQZHHNO\PLOHDJH WRRTXLFNO\LLSUHYLRXVLQMXU\DQGLLLDFRPSHWL WLYH WUDLQLQJ PRWLYH 2WKHU IDFWRUV LQFOXGH anatomical and physiological abnormalities such DV DW\SLFDO IRRW SURQDWLRQ DQG LQDGHTXDWH KLS muscle stabilization11, the latter one especially in ZRPHQ Other factors such as stretching were found insuf ¿FLHQWWRSURYHDQ\EHQH¿WLQGHFUHDVHRIUXQQLQJ LQMXULHVGHVSLWHWKHFRPPRQEHOLHI Running Distance 5XQQLQJGLVWDQFHDQGRUDQ\VXGGHQLQFUHDVHLQ UXQQLQJ ORDG RU WUDLQLQJ YROXPH DQGRU LQWHQVLW\ ZLOOLQFUHDVHWKHULVNIDFWRUDVVRFLDWHGZLWKLQMXU\ (VSHFLDOO\ LQ WKH EHJLQQLQJ RI WKH WUDFN VHDVRQ SUREOHPV OLNH VKLQ VSOLQWV PLJKW RFFXU GXH WR ZHDNHU DQWHULRU PXVFOHV 2QH VWXG\ VKRZHG D SDUWLFXODUO\ KLJK ULVN IRU LQMXU\ RQFH D WKUHVKROGRIPLOHVNPSHUZHHNLVFURVVHG Any changes in training programs should be done JUDGXDOO\ DQG SDLQIUHH ,QGLYLGXDO WUDLQLQJ SUR 0HGLFLQVNLåXUQDO grams are highly recommendable since body re sponse to physical stress differs. Footwear Running footwear is used to protect the foot from UXQQLQJ VXUIDFH DQG RWKHU REMHFWV DEVRUE VKRFN and provide grip. Additionally proper shoes should also allow biomechanical support of the foot. The IRRWFRQYHUWVDQ\URWDWLRQLQWKHKLSNQHHDQGDQ NOHMRLQWDQGFRQYHUWVWKHPLQWRDIRUZDUGPRWLRQ ZKLOHUXQQLQJ0DQ\LQMXULHVLQUXQQLQJDUHFDXVHG E\ D IRRW IDXOW .LQHPDWLF UHVHDUFK VKRZV that the foot is in the neutral position in two leg stand prior the moment when the heel leaves the ground. An abnormal pronation of the foot results LQÀDWWHULQJRIWKHDUFKDQGLQWHUQDOURWDWLRQRIWKH leg with upcoming unstable patella and runner’s NQHHV\QGURPH3URSHUIRRWZHDUVKRXOGHQD ble a neutral position and excessive pronation and avoid additional load and overtime muscle activity to prevent overload. 1R RSWLPDO RQH¿WVDOO UXQQLQJ VKRH H[LVWV EXW a certain construction, designed to support the VWULGH W\SH DQDWRPLFDO DQGRU SK\VLRORJLFDO LQGL vidual conditions. However there is often no suf ¿FLHQW SURYH LQ OLWHUDWXUH RI GHFUHDVHG LQMXU\ ULVN IRUUXQQHUVXVLQJVKRHVZKLFKDUH¿WWLQJWKHIRRW JDLWW\SH7KLVLVRQHRIWKHPRVWGHEDWHG topics in running sports nowadays and further re search is needed. Ideally running shoes should be purchased in spe cialized shops with treadmills and video analysis V\VWHPVXQGHUVXSHUYLVLRQVRITXDOL¿HGVWDII Taunton et al. showed that runners with shoes one to three months old had an injury rate above the PHDQ 7KLV ¿QGLQJ FDQ EH H[SODLQHG LQ WKH FKDQJH RI WKH NLQHPDWLFV DQG NLQHWLFV ZKHQ XV ing new shoe models, as well as in the fact that injured runners try to solve their problems by fre TXHQWO\ FKDQJLQJ VKRHV ,W LV DGYLVDEOH WR VORZO\ expose the body to the new footwear allowing the PXVFXORVNHOHWDOV\VWHPWRDGDSWWRWKHFKDQJHLQ biomechanics. However more research is neces sary to provide the effect of shoes, shoe inserts DQGRUWKRWLFVRQVSHFL¿FLQMXULHV Barefoot running or running with minimal footwear as prevention for future injuries has been a contro YHUVLDOO\GLVFXVVHGWRSLFLQUHFHQWOLWHUDWXUH:KLOH PRVWUXQQHUVWRODQGRQWKHLU KHHOUHDUIRRWVWULNHRU5)6DURXQGDTXDUWHURI WKHPODQGZLWKDÀDWIRRWPLGIRRWVWULNHRU0)6 and only a small percentage, mostly elite run QHUVODQGRQWKHEDOORIWKHLUIRRWIRUHIRRWVWULNH RU))6+RZHYHUZKHQUXQQLQJEDUHIRRWDWKOHWHV land more softly landing on the ball of the foot, DYRLGLQJXQFRPIRUWDEOHKHHOVWULNHV7KHEHQH¿WV DUHORZHULPSDFWSHDNORDGVLQWKHYHUWLFDOJURXQG UHDFWLRQ IRUFH GXULQJ FRQWDFW ERG\ ZHLJKWVLQEDUHIRRWUXQQHUVZKR))6 ERG\ZHLJKWVLQVKRHGUXQQHUVZKR5)6VKRUWHU (PLU%HQFD3HMPDQ=LDL*REHUWYRQ6NUEHQVN\$PLU$KPHWRYLü5HLQKDUG:LQGKDJHU6HOPD.USR5XQQLQJLQMXULHV stride length, where the foot lands closer to the body’s center of mass resulting in a smaller mo PHQWDUPRIWKHJURXQGUHDFWLRQIRUFHWRWKHNQHH and hip joint and the generated moments in these MRLQWV 2Q WKH RWKHU KDQG WKH ORDG LQ WKH calf musculature is increased in barefoot runners and presents a potential cause for calf strains and Achilles tendinitis, but also to cuts, bruises and abrasions. Altman et al. suggest a slow adaption from normal footwear to barefoot or running with PLQLPDOIRRWZHDU 7KHUHLVVWLOODODFNRIVFLHQWL¿FUHVHDUFKRQH[DFW biomechanics and injury patterns in barefoot run ners in order to give a clear recommendation for the ideal footwear. Age $JH LV WKH PRVW FRPPRQ UHSRUWHG LQWULQVLF ULVN factor for running injuries in the literature. Howev HUWKHUHLVYHU\OLWWOHVLJQL¿FDQWGDWDWRHQGRUVHWKLV assumption. Taunton et al. found that among rec UHDWLRQDOIHPDOHUXQQHUVWKHULVNRILQMXU\LVKLJKHU IRU WKRVH ROGHU WKDQ \HDUV $ VLJQL¿FDQW KLJKHULQMXU\ULVNFRXOGQRWEHIRXQGLQDQ\RWKHU group nor among male runners in the same study. Body Mass Index and Bodyweight :KLOHKLJKHU%0,DQGERG\ZHLJKWDUHUHVSRQVLEOH IRUDEURDGVSHFWUXPRIKHDOWKLVVXHVWKHLULQÀX HQFHRQWKHLQMXU\ULVNLQUXQQHUVLVFRQWUDGLFWLYHLQ OLWHUDWXUH,WLVVHOIH[SODQDWRU\WKDWLQGLYLGXDOVZLWK a higher percentage of body fat have excessive VWUHVVHVRQWKHLUPXVFXORVNHOHWDOV\VWHPVZKLOH LQGLYLGXDOVZLWKDORZ%0,PLJKWQRWKDYHHQRXJK lean body mass to support their bodies during physical activities and are also more predisposed to osteoporosis and reduced collagen elasticity HVSHFLDOO\IHPDOHUXQQHUVKDYLQJDKLJKHULQMXU\ ULVNDVDUHVXOW Gender As mentioned above, many authors associate KLJKHU ULVN IRU LQMXU\ ZLWK IHPDOH VH[ +RZHYHU RQO\IHZDXWKRUVUHSRUWHGDVLJQL¿FDQWKLJKHULQ MXU\UDWHLQIHPDOHWKHQPDOHUXQQHUV Taunton et al assume that this might be caused by LQFUHDVHG SDUWLFLSDWLRQ RI ZRPHQ DQGRU ZRPHQ EHLQJPRUHLQFOLQHGWRVHHNPHGLFDODGYLFHZKLFK might seem a plausible explanation, while on the RWKHUKDQGGXHWRWKHLUGLIIHUHQWSK\VLRORJ\ZLGHU pelvis, smaller heart volume, lower vital capac LW\VKRUWHU$FKLOOHVWHQGRQPHQVWUXDOF\FOHHWF women are more affected by e.g. osteoporosis, which might result in a higher rate of stress frac ture, which are however rarely reported in the lit HUDWXUHGXHWRWKHLULQIUHTXHQF\ Past History of Injury 0DQ\DXWKRUVKDYHIRXQGDVLJQL¿FDQWFRUUHODWLRQ EHWZHHQSDVWKLVWRU\RILQMXU\DQGDKLJKHUULVNIRU LQMXU\LQUXQQHUV0DFHUDHWDO found that recreational runners with a past history RILQMXU\ZHUHWLPHVPRUHOLNHO\WRVXIIHUDORZHU limb injury then runners without any previous injury 2XUFOLQLFDOH[SHULHQFHVKRZVDKLJKUHRFFXU UHQFHLQDQNOHVSUDLQV$QNOHVSUDLQVDUHRIWHQQRW GLDJQRVHGDGHTXDWHO\DQGRUQRWWUHDWHGFRUUHFWO\ so that the ligamentous structures are exposed to excessive loads prior to complete healing of the original injury. It is recommendable to commence with exercising only after full recovery of musculo VNHOHWDOLQMXU\DQGLQUHVSHFWWRVORZDGDSWLRQWR regular training intensity. Physical Fitness :KLOH UXQQHUV ZLWK KLJKHU SK\VLFDO ¿WQHVV OHYHO KDYHDGRSWHGWKHLUPXVFXORVNHOHWDOV\VWHPWRH[ cessive load in running as well as a proper tech QLTXHLQGLYLGXDOVZLWKRXWUXQQLQJKLVWRU\DUHPRUH OLNHO\ WR VXIIHU LQMXU\ GXH WR RYHUORDG RU D WUDLQ LQJHUURU(VSHFLDOO\EHJLQQHUVDUHDKLJKO\LQMXU\ effected group, experienced sportsmen are more NHHQWROLVWHQWRWKHLUERG\ODQJXDJH Terrain Biomechanically, the majority of overuse injuries LVOLQNHGWRNLQHWLFV'LIIHUHQWWHUUDLQFDQLQÀXHQFH the magnitude of impact forces and the magnitude joint forces and moments. Even though there is no prove of running terrain to be associated with WKHQXPEHURILQMXULHVPRVWO\GXHWRWKHGLI¿FXOW\ WR DGHTXDWHO\ TXDQWLI\ WKH WLPH DQG LQWHQVLW\ RI running on different surfaces, it seems plausible, WKDWVRIWHUVXUIDFHVVXFKDVJUDVVWUDFNVRUVDQG ZLOO RIIHU D JUHDW VKRFN DEVRUSWLRQ SUHVHUYLQJ WKH MRLQWV ZKLOH XQHYHQ WHUUDLQ VXFK DV RIIURDG ZLOO OHDG WR D KLJKHU QXPEHU RI IDOOV DQGRU DQ NOHVSUDLQV,QDUHFHQWVWXG\7HVVXWWLHWDOFRXOG VKRZWKDWUXQQLQJRQJUDVVSURGXFHVWR ORZHUSHDNSUHVVXUHWKHQUXQQLQJRQDVSKDOWFRQ FUHWHDQGUXEEHUDQGDVDFRQVHTXHQFHUHGXFHV WKHVWUHVVRQWRWKHPXVFXORVNHOHWDOV\VWHP Hard terrain or hills stress the anterior leg mus FOHVRIWHQFDXVLQJVKLQVSOLQWV7DSLQJDVZHOO as stabilizing foot orthotic could provide additional VXSSRUWRIWKHDQNOHMRLQWRQXQHYHQWHUUDLQV'H pending on the terrain, athletes should also use VKRHVWKDWSURYLGHSURSHUVKRFNDEVRUEDQFHDQG new terrains should be introduced gradually to al low the joints to adapt to different biomechanics. CONCLUSIONS :KLOH WKH PRGHUQL]DWLRQ DQG FRPSXWHUL]DWLRQ RI our society is steadily reducing the physical labor DQG FUHDWLQJ PRUH RI¿FH MREV SRSXODULW\ RI UHF reational outlets, such as running, are steadily JURZLQJ7KLVPRGHUQDQGKHDOWKEHQH¿FLDOWUHQG UHTXLUHVDZDUHQHVVDQGVSHFLDODWWHQWLRQE\PHGL cal professionals in order to recognize and also 0HGLFLQVNLåXUQDO (PLU%HQFD3HMPDQ=LDL*REHUWYRQ6NUEHQVN\$PLU$KPHWRYLü5HLQKDUG:LQGKDJHU6HOPD.USR5XQQLQJLQMXULHV WUHDW FRUUHFWO\ DFFRPSDQ\LQJ PXVFXORVNHOHWDO LQ juries in recreational but also competitive runners. 3UHYHQWLRQQRQHRIWKHUHYLHZHGSDSHUVGLGGH ¿QHDPHWKRGWKDWZLOOSUHYHQWDUXQQHUIURPEH ing injured. It is impossible to relate the statistical ¿QGLQJVRIFOLQLFDOVWXGLHVRQUXQQLQJLQMXULHVRQD single individual with exact factors on when and how will an injury occur. However it is advisable for every athlete to listen to the language of their body and respect the limitations set by factors such as DJH JHQGHU SK\VLFDO ¿WQHVV DQG SDVW KLVWRU\ RI injury and pay close attention to overall training load and moderate increase in training intensity DQGYROXPHLQRUGHUWRGHFUHDVHWKHULVNRIEHLQJ LQMXUHG 7KH WUDLQLQJ PRWWR VKRXOG EH µWUDLQ GRQ¶W strain’. Excessive training intensity doesn’t allow SK\VLRORJLFDODGDSWLRQDQGLVOLNHO\WRUHVXOWLQDQ injury. In order to reduce the injury probability a QRQZHLJKWEHDULQJDFWLYLW\VXFKDVVZLPPLQJRU F\FOLQJ FDQ UHSODFH VRPH RI WKH ZHHNO\ UXQQLQJ mileage and eliminate some impact loads that con WULEXWHWRLQMXU\$JHQHUDOUXOHIRUPXVFOH H[HUFLVHLVWRVWUHWFKWKHDQWLJUDYLW\PXVFOHVLQ WKHEDFNRIWKHWKLJKDQGOHJDQGVWUHQJWKHQWKH JUDYLW\PXVFOHVLQIURQWRIWKHWKLJKOHJDQGIRRW 6SHFLDODWWHQWLRQVKRXOGEHSDLGWRVWUHQJWK ening of the anterior muscles and stretching of the Achilles tendon in order to prevent medial tibial stress syndrome. Injury prevention should include health education, which includes early recognition of symptoms, especially in overuse injuries and WKHDGHTXDWHDQGFRPSOHWHUHKDELOLWDWLRQ0HGLFDO professionals should give greater attention to the past medical history due to higher incidence rate in runners with injury history in the past, especially LQWKHDQNOHDQGNQHHMRLQW'LDJQRVWLFVLQRUGHU to prevent reoccurring injuries primary diagnosis has to include all simultaneous injuries followed E\DGHTXDWHWKHUDSLHV;UD\VLQWKH¿UVWLQVWDQFH 05,RU&7VFDQSULPDU\RULQDVHFRQGLQVWDQFH G\QDPLF VRQRJUDSK\ LQ FDVH RI /LJDPHQW OHVLRQ HVSHFLDOO\ LQ WKH DQNOH MRLQW RU LQ FDVH RI WHQ don overload or dislocation, could be necessary. Treatment: treatment of running injuries consists of multioriented measures. Conservative therapy LQFOXGHVWUDLQLQJPRGL¿FDWLRQDQWLLQÀDPPDWRULHV and physiotherapy, stretching and strengthening RIVRIWWLVVXHVEXWDOVRXOWUDVRXQGFU\RDQGKHDW therapy. In case of overload, symptomatic treat ment is often successful. Recognition of muscu ORVNHOHWDOGH¿FLWVFRXOGEHHVVHQWLDOLQSUHYHQWLRQ RI FKURQL¿FDWLRQ %HVLGH VWDWLF WRROV IXQFWLRQDO physiotherapy in a middle term would be neces VDU\6SHFLDOLQMXULHVOLNHIUDFWXUHGERQHVRUFRP plicated soft tissue damages could need surgery. In most cases conservative treatment with immo bilization in especially designed apparatus with IROORZLQJSK\VLRWKHUDS\DUHVXI¿FLHQW $FNQRZOHGJPHQW7KHDXWKRUVZRXOGOLNHWRWKDQN 0HGLFLQVNLåXUQDO (URO0XMDQRYLFDQG)UDQMR6RODIURPWKH$VVRFLD WLRQ0DUDWKRQLQ6DUDMHYR &RQÀLFWVRILQWHUHVWNone declared. REFERENCES %UDPEOH'0/LHEHUPDQ'((QGXUDQFHUXQQLQJDQG WKHHYROXWLRQRI+RPR1DWXUH 9DQ 0LGGHONRRS 0 .RONPDQ - 9DQ 2FKWHQ - %L HUPD=HLQVWUD 60 .RHV % 3UHYDOHQFH DQG LQFLGHQFH of lower extremity injuries in male marathon runners. 6FDQG-0HG6FL6SRUWV YDQ *HQW 51 6LHP ' YDQ 0LGGHONRRS 0 YDQ 2V $*%LHUPD=HLQVWUD60.RHV%:,QFLGHQFHDQGGH terminants of lower extremity running injuries in long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reljac, A. Impact and overuse injuries in runners. 0HG6FL6SRUWV([HUF /RSHV$'+HVSDQKRO-XQLRU/&<HXQJ66&RVWD /2 :KDW DUH WKH PDLQ UXQQLQJUHODWHG PXVFXORVNHO HWDO LQMXULHV"$ 6\VWHPDWLF 5HYLHZ 6SRUWV 0HG )HUEHU5+UHOMDF$.HQGDOO.'6XVSHFWHG0HFKD nisms in the Cause of Overuse Running Injuries: A Clini FDO5HYLHZ6SRUWV+HDOWK 6XERWQLFN6,$ELRPHFKDQLFDODSSURDFKWRUXQQLQJ LQMXULHV$QQ1<$FDG6FL +UHOMDF $ 0DUVKDOO 51 +XPH 3$ (YDOXDWLRQ RI ORZHUH[WUHPLW\RYHUXVHLQMXU\SRWHQWLDOLQUXQQHUV0HG 6FL6SRUWV([HUF -DPHV 6/ %DWHV %7 2VWHUQLJ /5 ,QMXULHV WR UXQ QHUV$P-6SRUWV0HG &OHPHQW'%7DXQWRQ-(6PDUW*:0F1LFRO./ $6XUYH\RI2YHUXVH5XQQLQJ,QMXULHV0HGLFLQH6FL ence in Sports & Exercise 1981;3:83 . 7DXQWRQ-(5\DQ0%&OHPHQW'%0F.HQ]LH'& /OR\G6PLWK'5=XPER%'$SURVSHFWLYHVWXG\RIUXQ QLQJLQMXULHVWKH9DQFRXYHU6XQ5XQ³,Q7UDLQLQJ´FOLQ LFV%U-6SRUWV0HG 7DXQWRQ-(5\DQ0%&OHPHQW'%0F.HQ]LH'& (PLU%HQFD3HMPDQ=LDL*REHUWYRQ6NUEHQVN\$PLU$KPHWRYLü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tive management of patellofemoral pain syndrome: a V\VWHPDWLF UHYLHZ RI WKH OLWHUDWXUH IURP WR ,QW-6SRUWV3K\V7KHU %XFKKRUQ7=LDL36SRUWYHUOHW]XQJHQ6LFKHUHUN HQQHQULFKWLJKDQGHOQ%/9%XFKYHUODJ*PE+&RP SDQ\ /LHEHUPDQ'(9HQNDGHVDQ0:HUEHO:$'DRXG $,'¶$QGUHD6'DYLV,6HWDO)RRWVWULNHSDWWHUQVDQG collision forces in habitually barefoot versus shod run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ltman AR, Davis IS. Barefoot running: biomechan ics and implications for running injuries. Curr Sports 0HG5HS 7HVVXWWL95LEHLUR$37URPELQL6RX]D)6DFFR,& Attenuation of foot pressure during running on four dif ferent surfaces: asphalt, concrete, rubber, and natural JUDVV-6SRUWV6FL Address: (PLU%HQFD06F $GROI /RUHQ] /DERUDWRU\ IRU %LRPHFKDQLFV DQG Experimental Orthopaedic Surgery Department of Orthopaedic Surgery 0HGLFDO8QLYHUVLW\RI9LHQQD :DHKULQJHU*XHUWHO 9LHQQD Austria (PDLOHPLUEHQFD#PHGXQLZLHQDFDW 0HGLFLQVNLåXUQDO /HMOD%XUD]HURYLü(OGLQ%XUD]HURYLü%HQLJQLQWUDFUDQLDOK\SHUWHQVLRQLQGXFHGE\DOOWUDQVUHWLQRLFDFLG$75$LQWKHSDWLHQWZLWKDFXWHSURP\HOR F\WLFOHXNHPLD&DVH5HSRUW Case report %(1,*1,175$&5$1,$/+<3(57(16,21,1'8&('%<$//75$165(7,12,&$&,'$75$,1 THE PATIENT WITH ACUTE PROMYELOCYTIC LEUKEMIA: Case Report %(1,*1$ ,175$.5$1,-$/1$ +,3(57(1=,-$ ,1'8&,5$1$ $//75$165(7,12,ý120 .,(6/,1,0$75$83$&,-(17$6$$.871203520,-(/2&,7120/(8.(0,-20SULND]VOXþDMD /HMOD%XUD]HURYLü(OGLQ%XUD]HURYLü2 &OLQLF RI +HPDWRORJ\ &OLQLFDO &HQWUH 8QLYHUVLW\ RI 6DUDMHYR %ROQLþND 6DUDMHYR %RVQLD DQG +HU]H govina; 1HXURVXUJLFDO &OLQLF &OLQLFDO &HQWUH 8QLYHUVLW\ RI 6DUDMHYR %ROQLþND 6DUDMHYR %RVQLD DQG Herzegovina 1 &RUUHVSRQGLQJDXWKRU ABSTRACT %HQLJQLQWUDFUDQLDOK\SHUWHQVLRQ%,+RUSVHXGR WXPRUFHUHEUL37&LVDQHXURORJLFDOGLVRUGHUWKDW is characterized by increased intracranial pres VXUH RI ! PP +2 LQ WKH DEVHQFH RI LQWUDF UDQLDO DEQRUPDOLWLHV E\ &7 RU 05, RI KHDG 7KH main symptoms are headache, nausea and vomit ing, as well as pulsatile tinnitus, double vison and other visual symptoms. Intracranial hypertension VHFRQGDU\ WR DOOWUDQVUHWLQRLF DFLG $75$ ZDV LQLWLDOO\ GRFXPHQWHG LQ RI SHGLDWULF SDWLHQWV ZLWK DFXWH SURP\HORF\WLF OHXNHPLD $3/ WUHDWHG ZLWK$75$DWPJPSHUGD\7KHSDWKRSK\VL RORJ\ RI $75$LQGXFHG LQWUDFUDQLDO K\SHUWHQVLRQ LVXQNQRZQEXWLVOLNHO\UHODWHGWRLQWUDFUDQLDOK\ pertension due to vitamin A toxicity. Acute promye ORF\WLFOHXNHPLD$3/LVDUHODWLYHO\UDUHIRUPRI DFXWH P\HORJHQRXV OHXNHPLD $0/ DFFRXQWLQJ IRUXSWRRIFDVHVRI$0/ :H SUHVHQW WKH FDVH RI \RXQJ DGXOW$3/ SDWLHQW with benign intracranial hypertension caused by $75$ 7KLV LV WKH ¿UVW UHSRUWHG FDVH RI %,+ LQ GXFHG$75$DWWKLVUHJLRQDVZHOODVZHNQRZ Key words: DFXWH SURP\HORF\WLF OHXNHPLD EH QLJQ LQWUDFUDQLDO K\SHUWHQVLRQ DOOWUDQVUHWLQRLF DFLG$75$ 6$ä(7$. %HQLJQDLQWUDNUDQLMDOQDKLSHUWHQ]LMD%,+LOLSVHX GRWXPRU FHUHEUL 37& MH QHXURORãNR REROMHQ MH NDUDNWHUL]LUDQR SRYHüDQLP LQWUDNUDQLMDOQLP SULWLVNRP ! PP +2 X RGVXWQRVWL LQWUDNUDQL MDOQLK DEQRUPDOQRVWL QD &7 LOL 05, JODYH *ODYQL VLPSWRPL VX JODYREROMD PXþQLQD L SRYUDüDQMH NDRLSXOVLUDMXüLWLQLWXVGXSOHVOLNHLGUXJLYL]XHOQL VLPSWRPL 6HNXQGDUQR QDVWDOD LQWUDNUDQLMDOQD KL SHUWHQ]LMD ]ERJ DOOWUDVUHWLQRLþQH NLVHOLQH $75$ MHSULPDUQRGRNXPHQWLUDQDXRGSHGLMDWULMVNLK SDFLMHQDWD VD DNXWQRP SURPLMHORFLWQRP OHXNH 0HGLFLQVNLåXUQDO PLMRPNRMLVXWUHWLUDQLVD$75$XGR]LRGPJ P GQHYQR 3DWR¿]LRORJLMD $75$ LQGXFLUDQH LQ WUDNUDQLMDOQHKLSHUWHQ]LMHMHQHSR]QDWDDOLMHYMHUR YDWQRXYH]LVDLQWUDNUDQLMDOQRPKLSHUWHQ]LMRPXV OMHGWRNVLþQRJHIHNWDYLWDPLQD$ $NXWQDSURPLMHORFLWQDOHXNHPLMD$3/MHUHODWLYQR ULMHWND IRUPD DNXWQH PLMHORLþQH OHXNHPLMH $0/ XNOMXþXMHGRVOXþDMHYDDNXWQHPLMHORLþQHOHX NHPLMH 0LVPRSULND]DOLVOXþDMPODÿHJDGXOWDREROMHORJRG $3/ VD EHQLJQRP LQWUDNUDQLMDOQRP KLSHUWHQ]LMRP LQGXFLUDQRP $75$ WHUDSLMRP 2YR MH SUYL VOXþDM %,+ LQGXFLUDQH$75$ X RYRM UHJLML NROLNR QDP MH poznato. .OMXþQH ULMHþL DNXWQD SURPLMHORFLWQD OHXNH PLMD EHQLJQD LQWUDNUDQLMDOQD KLSHUWHQ]LMD DOO WUDQVUHWLQRLþQDNLHVOLQD$75$ INTRODUCTION %HQLJQLQWUDFUDQLDOK\SHUWHQVLRQ%,+RUSVHXGR WXPRUFHUHEUL37&LVDQHXURORJLFDOGLVRUGHUWKDW is characterized by increased intracranial pres VXUH RI ! PP +2 LQ WKH DEVHQFH RI LQWUDF UDQLDO DEQRUPDOLWLHV E\ &7 RU 05, RI KHDG 7KH main symptoms are headache, nausea and vomit ing, as well as pulsatile tinnitus, double vision and other visual symptoms. In some cases etiology is XQNQRZQ,QWUDFUDQLDOSUHVVXUHPD\EHLQFUHDVHG GXH WR PHGLFDWLRQV VXFK DV KLJKGRVH YLWDPLQ$ GHULYDWLYHV ORQJWHUP WHWUDF\FOLQH DQWLELRWLFV DQG hormonal contraceptives. Common causes of sec ondary intracranial hypertension include obstruc tive sleep apnea, systemic lupus erythematosis 6/(FKURQLFNLGQH\GLVHDVHDQG%HKFHW¶VGLV ease. Intracranial hypertension secondary to ATRA was LQLWLDOO\ GHRFLPHQWHG LQ RI SHGLDWULF SDWLHQWV ZLWK DFXWH SURP\HORF\WLF OHXNHPLD $3/ WUHDWHG ZLWK$75$DWPJPSHUGD\,WKDVEHHQ the subject of many case reports, predominantly in /HMOD%XUD]HURYLü(OGLQ%XUD]HURYLü%HQLJQLQWUDFUDQLDOK\SHUWHQVLRQLQGXFHGE\DOOWUDQVUHWLQRLFDFLG$75$LQWKHSDWLHQWZLWKDFXWHSURP\HOR F\WLFOHXNHPLD&DVH5HSRUW SHGLDWULFSDWLHQWVUHFHLYLQJ$75$GRVHRIPJ PSHUGD\RUPRUHEXWDOVRRFFDVLRQDOO\LQ\RXQJ DGXOWV$FXWHSURP\HORF\WLFOHXNHPLD$3/LV a relatively rare form of acute myelogenous leu NHPLD$0/DFFRXQWLQJIRUXSWRRIFDVHVRI $0/7KHDYHUDJHDJHRIRQVHWLV\HDUV 7KH PDMRU FRPSRQHQW RI WKHUDS\ IRU $3/ LV DOO WUDQVUHWLQRLF DFLG $75$ $75$ LV DQ DQWLFDQ FHUFKHPRWKHUDS\GUXJFODVVL¿HGDVDÄUHWLQRLG³ Retinoids are drugs that are relatives of vitamin A. 7KHGRVLQJIRU$75$LQWKHUDS\RI$3/ZDVWUDGL WLRQDOO\PJPSHUGD\GLYLGHGWZLFHDGD\EXW PD\EHHIIHFWLYHDWDORZHUGRVHRIPJPSHU GD\ LQ SHGLDWULF SDWLHQWV 2QH RI WKH VLGH HI IHFWVIRUSDWLHQWVWDNLQJ$75$RFFXUULQJLQJUHDWHU WKDQLVW\SLFDOUHWLQRLGWR[LFLW\KHDGDFKHIH YHUGU\VNLQGU\PXFRXVPHPEUDQHVERQHSDLQ nausea and vomiting, rash, mouth sores, itching, VZHDWLQJH\HVLJKWFKDQJHV 7KHSDWKRSK\VLRORJ\RI$75$LQGXFHGLQWUDFUDQLDO K\SHUWHQVLRQ LV XQNQRZQ EXW LV OLNHO\ UHODWHG WR intracranial hypertension due to vitamin A toxicity. ATRA may cause overstimulation of RAR alfa re ceptors in the central nervous system, resulting in increased intracranial pressure by impairing CSF absorption. If untreated, it may lead to swelling of the optic disc in the eye, which can progress to vi VLRQORVV,QWUDFUDQLDOK\SHUWHQVLRQDVVRFLDWHG with ATRA usually presents between 3 to 17 days after onset of ATRA therapy, but there have been FDVH UHSRUWV RI SDWLHQWV GHYHORSLQJ V\PSWRPV PRQWKVDIWHURQVHWRI$75$ Differential diagnosis include: intracranial hemor rhage, ATRA induced headache, optic nerve in ¿OWUDWLRQ E\ $3/ PHQLQJHDO OHXNHPLF LQ¿OWUDWLRQ VROLGWXPRUEDFWHULDOLQIHFWLRXVPHQLQJLWLV,QWKH SDWLHQWV WKDW GHYHORS $75$LQGXFHG LQWUDFUDQLDO hypertension, cessation of ATRA treatment or halving dosage usually leads to the resolution of LQWUDFUDQLDO K\SHUWHQVLRQ ZLWKLQ PRQWKV LQ cluding resolution of headache and disc edema /XPEDUSXQFWXUHPD\SURYLGHWHPSRUDU\DQG sometimes permanent relief from the symptoms. Some respond to Acetazolamide, but others re TXLUHVXUJHU\WRUHOLHYHWKHSUHVVXUH CASE REPORT 0.D\HDUROGPDOHZDVDGPLWWHGDW&OLQLFRI Hematology Clinical Center University of Saraje YRLQ-DQXDU\+LVFRPSODLQWVZHUHEOHHG LQJ KHPRSW\VLV DQG IHYHU & %ORRG WHVWV VKRZHG+HPRJORELQJ/3OHWHOHV[/ :KLWH EORRG FHOOV [/ GLIIHUHQWLDO FRXQW EODVW FHOOV SURP\HORF\WHV ZLWK $XHU URGV QHXWURSKLOV O\PSKRF\WHV /'+ 8/,15D377V)LEULQRJHQJ/ 'GLPHUPJ/%RQHPDUURZDQG),6+ZHUH FRPSDWLEOHZLWKDGLDJQRVLVRI$3/ZLWKW :H VWDUWHG ZLWK LQGXFWLRQ WKHUDS\ UHJLPHQ ,&( ,GDUXELFLQ(WRSRVLGH$UD&$75$PJP SRPJGD\WRWDOGRVHRQGD\VIROORZHG E\$75$ PJP 5HSHDWHG ERQH PDUURZ H[ amination showed remission and we continued ZLWK FRQVROLGDWLRQ WKHUDS\ DFFRUGLQJ WR 3(7+( 0$ UHJLPHQ ,GDUXELFLQ RQ GD\V $75$ PJPSRPJGD\WRWDOGRVHIRUGD\V After 39 days of ATRA therapy the patient started WR FRPSODLQ RQ KHDGDFKH 3K\VLFDO H[DPLQDWLRQ of the nervous system was normal. Ophthalmo ORJLFH[DPLQDWLRQVKRZHGQRDEQRUPDOLWHV/XP EDUSXQFWLRQZLWKDYLHZWRFRQ¿UPDWLRQH[FOXVLRQ RI &16 LQYROYHPHQW E\ OHXNHPLF FHOOV ZDV SHU IRUPHG 1R EODVWV LQ FHUHEURVSLQDO ÀXLG 05, RI head showed cystis arachnoidalis located in right IURQWRSDULHWDOLVUHJLRQ[FPQRWFRPSUHVVLYH EEG was normal. In the further course of his treat PHQW WKH SDWLHQW FRQWLQXHG ZLWK DGGLWLRQDO F\ cles of consolidation chemotherapy which include $75$IRUGD\VSHUF\FOHV:HUHGXFHGGRVHRI $75$WRPJPSHUGD\ZKDWLQGXFHGWHPSR rary relief from headache. One day after he com pleted his third cycle of consolidation chemothera py, 3 months of onset of ATRA therapy the patient started to complain on severe headache, diplopia DQGWLQQQLWXV%RQHPDUURZELRSV\DQGNDU\RW\SH FRQ¿UPHG DFKLHYHPHQW RI FRPSOHWH UHPLVVLRQ Ophthalmological examination documented bilat eral papilledema with ophtalmoplegia of the right DEGXFHQV QHUYH VL[WK QHUYH 05, RI KHDG ZDV WKH VDPH DV SUHYLRXVO\ :H FRQVXOWHG QHXURVXU geon who done lumbar punction and documented HOHYDWLRQ RI FHUHEURVSLQDO ÀXLG SUHVVXUH PRUH WKDQPPRIZDWHU&\WRFKHPLFDODQGPLFUR ELRORJLFDO HYDOXDWLRQ RI &16 ÀXLG ZDV QHJDWLYH 'LDJQRVLV RI 37& ZDV WKHUHIRUH PDGH /XPEDU punction was followed by prompt clinical improve ment of the patient status. The patient started to WDNH$FHWD]RODPLGHLQGRVHRIPJWZLFHDGD\ what induced further improvement of the patient’s status. Ophthalmologic follow up documented no papilledema and ophthalmoplegia of right abdu cens nerve 10 days after. )URP 0D\ WKH SDWLHQW XQGHUJRQH PDLQWH nance therapy with administration of ATRA again $75$PJPGD\IRUGHYHU\PRQWKVSOXV 0HUFDSWRSXULQ PJPGD\ 32 SOXV 0HWKR WKUH[DWH PJP 32 ZHHNO\ 7KLV SURWRFRO QHHGVWREHDGPLQLVWHULQJIRU\HDUV7KHSDWLHQW KDV WDNHQ$75$ LQ IXOO GRVH ZLWK$]HWD]RODPLGH concurrently. After one year the patient is still do ing great. DISCUSSION Benign intracranial hypertension is a diagnosis of H[FOXVLRQZKLFKUHTXLUHVQH[WFULWHULDIRUFRQ¿UPD tion: 0HGLFLQVNLåXUQDO /HMOD%XUD]HURYLü(OGLQ%XUD]HURYLü%HQLJQLQWUDFUDQLDOK\SHUWHQVLRQLQGXFHGE\DOOWUDQVUHWLQRLFDFLG$75$LQWKHSDWLHQWZLWKDFXWHSURP\HOR F\WLFOHXNHPLD&DVH5HSRUW 1. signs and symptoms of intracranial hyperten VLRQKHDGDFKHQDXVHDYRPLWLQJSXOVDWLOHWLQQL WXVGRXEOHYLVLRQDQGRWKHUYLVXDOV\PSWRPV DEVHQFH RI WXPRU RU RWKHU GLVHDVHV E\ &7 RU 05,RIKHDG 3. increased intracranial pressure of more than PP+ QRUPDOFRPSRVLWLRQRIFHUHEURVSLQDOÀXLG QR RWKHU LGHQWL¿DEOH FDXVHV RI LQWUDFUDQLDO K\ pertension. CONCLUSIONS The case described in this article is a typical ex DPSOH RI 37& DULVLQJ LQ D \RXQJ DGXOW ZLWK$3/ ZKRKDVEHHQWUHDWHGZLWK$75$7KLVLVWKH¿UVW reported case of BIH induced ATRA at region as ZHOO DV ZH NQRZ :H KDYH WR NHHS LQ PLQG WKH possibility of BIH during ATRA therapy even in adults. 3. Ribeiro R. Update on the management of pediatric DFXWHSURP\HORF\WLFOHXNDHPLD&OLQ$GY+HPDWRO2Q FRO GH%RWWRQ6&RLWHX[9&KHYUHW65D\RQ&9LOPHU( 6DQ]0HWDO2XWFRPHRIFKLOGKRRGDFXWHSURP\HORF\W LFOHXNDHPLDZLWKDOOWUDQVUHWLQRLFDQGFKHPRWKHUDS\- &OLQ2QFRO %LQGHU'.+RUWRQ-&/DZWRQ070F'HUPRWW0: Idiopathic intracranial hypertension. Neurosurgery <HK <& 7DQJ +) )DQJ ,0 3VHXGRWXPRU FHUHEUL FDXVHG E\ DOOWUDQVUHWLQRLF DFLG WUHDWPHQW IRU DFXWH SURP\HORF\WLF OHXNDHPLD -SQ - 2SKWDOPRO 0DFKQHU % 1HSSHUW % 3DXOVHQ 0 +RIPDQQ & 6DQGHU 7 +HOPFKHQ & 3VHXGRWXPRU FHUHEUL DV UH YHUVLEOH VLGH HIIHFW RI DOOWUDQVUHWLQRLF DFLG WUHDWPHQW LQDFXWHSURP\HORF\WLFOHXNDHPLD(XU-1HXURO H &RQÀLFWRILQWHUHVW none declared. REFERENCES 0DKPRXG ++ +XUZLW] &$ 5REHUWV :0 6DQ WDQD 90 5LEHLUR 5& .UDQFH 5$ 7UHWLQRLQ WR[LFLW\ LQ FKLOGUHQ ZLWK DFXWH SURP\HORF\WLF OHXNDHPLD /DQFHW &ROXFFLHOOR 0 3VHXGRWXPRU FHUHEUL LQGXFHG E\ DOO trans retinoic acid treatment of acute promyelocytic leu NDHPLD$UFK2SKWDOPRO 0HGLFLQVNLåXUQDO Address: /HMOD%XUD]HURYLü0'06F Clinic of Hematology Clinical Centre University of Sarajevo %ROQLþND6DUDMHYR Bosnia and Herzegovina 3KRQH (PDLOOHMODNODQFHYLF#\DKRRFRP /LGLMD/LQFHQGHU&YLMHWLü6DQMDâHKRYLü,UPLQD6H¿ü3DãLü9HVQDĈXURYLü6DUDMOLü6DQGUD9HJDU=XERYLü,QYHUVHSRVLWLRQRIVSOHHQVWRPDFK DQGSDQFUHDV Case report INVERSE POSITION OF SPLEEN, STOMACH AND PANCREAS ,19(5=1$32=,&,-$6/(=(1(ä(/8&$,3$1.5($6$ /LGLMD /LQFHQGHU&YLMHWLü 6DQMD âHKRYLü2 ,UPLQD 6H¿ü3DãLü 9HVQD ĈXURYLü 6DUDMOLü , Sandra Vegar=XERYLü $FDGHP\ RI 6FLHQFH DQG$UW RI %RVQLD DQG +HU]HJRYLQD %LVWULN 6DUDMHYR %RVQLD DQG +HU]HJRYLQD 3ROLNOLQLND6XQFH$JUDPLQ6DUDMHYR6DUDMHYR%RVQLDDQG+HU]HJRYLQD3 Radiology Clinic, Clinical Center 8QLYHUVLW\RI6DUDMHYR%ROQLþND6DUDMHYR%RVQLDDQG+HU]HJRYLQD 1 &RUUHVSRQGLQJDXWKRU ABSTRACT The authors present a case of a rare congenital condition with inversed position of spleen, stom ach and pancreas. Situs inversus totalis is a rare congenital anomaly with mirror image of viscera combined with dextrocardia. The concept of situs or laterality of the viscerovascular anatomy is im portant for understanding, imaging, and interpre tation of congenital visceral and vascular malfor mations. 3DWLHQWFDPHWRWKHURXWLQHH[DP8OWUDVRXQGZDV WKH¿UVWPHWKRGRIH[DPLQDWLRQZHUHVROLGPDVV XQGHU XSSHU SROH RI WKH ULJKW NLGQH\ ZDV IRXQG &7 DQG 05, RI WKH DEGRPHQ IROORZHG WKH 86 exam. Both of these methods revealed right sided spleen, prevertebral position of the pancreas and VWRPDFKERWKRQWKHULJKWVLGH3DWLHQWZDVZLWK out any clinical symptoms and laboratory abnor PDOLWLHVDQGWKLVZDVDQDFFLGHQWDO¿QGLQJ Conclusion: variation in spleen position can be congenital as a part of Situs viscerum inversus, RU FDQ EH DFTXLUHG &7 DQG 05, DUH PRGDOLWLHV of choice for correct diagnosis. Our patient was FRPSOHWHO\ DV\PSWRPDWLF DQG WKH ¿QGLQJV ZHUH accidental. Key words: inverse position, spleen, stomach, pancreas. 6$ä(7$. &LOM UDGD MH SUHGVWDYOMDQMH VOXþDMD ULMHWNRJ NRQ genitalnog stanja sa inverznom pozicijom slezene, åHOXFDLSDQNUHDVD6LWXVLQYHUVXVWRWDOLVMHULMHWND NRQJHQLWDOQD DQRPDOLMD VD REUQXWLP SRORåDMHP YLVFHUDOQLK RUJDQD NDR ³VOLND X RJOHGDOX´ NRPEL QRYDQDVDGHNVWURNDUGLMRP.RQFHSWVLWXVDLOLODW HUDOL]DFLMH YLVFHURYDVNXODUQH DQDWRPLMH MH YDåDQ ]D UD]XPLMHYDQMH LPLGåLQJ L LQWHUSUHWDFLMX NRQ JHQLWDOQLK YLVFHUDOQLK L YDVNXODUQLK PDOIRUPDFLMD 0L SULND]XMHPR VOXþDM LQYHU]QH SR]LFLMH VOH]HQH åHOXFDLSDQNUHDVD3DFLMHQWMHGRãDRQDUXWLQVNL SUHJOHG8OWUD]YXNMHELRSUYDPHWRGDSUHJOHGD NRMRPVPRQDãOLVROLGQXPDVXLVSRGJRUQMHJSROD GHVQRJ EXEUHJD 1DNRQ XOWUD]YXþQRJ SUHJOHGD XUDGLOL VPR &7 L 05, DEGRPHQD 2EMH PHWRGH SRND]DOHVXGHVQLSRORåDMVOH]HQHSUHYHUWHEUDOQL SRORåDMSDQNUHDVDLåHOXFDNRMLVXVHQDOD]LOLQD GHVQRMVWUDQL3DFLMHQWMHELREH]LNDNYLKNOLQLþNLK VLPSWRPD L ODERUDWRULMVNLK DQRPDOLMD RYR MH ELR VOXþDMDQQDOD] =DNOMXþDN YDULMDFLMH SRORåDMD VOH]HQH PRJX ELWL NRQJHQLWDOQH NDR GLR ³VLWXV YLVFHUXP LQYHUVXV´ VLQGURPDLOLVWHþHQH&7L05,VXUDGLRORãNLPR GDOLWHWL L]ERUD ]D SRVWDYOMDQMH WDþQH GLMDJQR]H 1Dã SDFLMHQW MH ELR X SRWSXQRVWL EH] VLPSWRPD L UDGLORVHRVOXþDMQRPQDOD]X .OMXþQHULMHþLLQYHU]QLSRORåDMVOH]HQDåHOXGDF SDQNUHDV INTRODUCTION 6LWXVLQYHUVXVDOVRFDOOHGVLWXVWUDQVYHUVXVRURS SRVLWXVLVDFRQJHQLWDOFRQGLWLRQLQZKLFKWKHPD jor visceral organs are reversed or mirrored from their normal position. The normal arrangement is NQRZQ DV VLWXV VROLWXV ,Q RWKHU UDUH FDVHV LQ D FRQGLWLRQNQRZQDVVLWXVDPELJXXVRUKHWHURWD[\ situs cannot be determined. The term situs inver VXVLVDVKRUWIRUPRIWKH/DWLQSKUDVHÄVLWXVLQYHU VXV YLVFHUXP³ PHDQLQJ ÄLQYHUWHG SRVLWLRQ RI WKH LQWHUQDORUJDQV³'H[WURFDUGLDWKHKHDUWEHLQJOR FDWHGRQWKHULJKWVLGHRIWKHWKRUD[ZDV¿UVWVHHQ DQG GUDZQ E\ /HRQDUGR GD 9LQFL LQ DQGWKHQUHFRJQL]HGE\0DUFR$XUHOLR6HYHULQRLQ +RZHYHUVLWXVLQYHUVXVZDV¿UVWGHVFULEHG PRUHWKDQDFHQWXU\ODWHUE\0DWWKHZ%DLOOLH7KH prevalence of situs inversus varies among differ ent populations, but less than 1 in 10.000 people 6SOHHQ¶V XVXDO SRVLWLRQ LV LQ WKH OHIW XSSHU TXDGUDQW'HYHORSPHQWRIVSOHHQVWDUWVLQZHHN with accumulation of mesenchymal cells in dor 0HGLFLQVNLåXUQDO /LGLMD/LQFHQGHU&YLMHWLü6DQMDâHKRYLü,UPLQD6H¿ü3DãLü9HVQDĈXURYLü6DUDMOLü6DQGUD9HJDU=XERYLü,QYHUVHSRVLWLRQRIVSOHHQVWRPDFK DQGSDQFUHDV sal mesogastrium. Then a dorsal mesogastrium divides in two parts, one which connects spleen ZLWK GRUVDO DEGRPLQDO ZDOO SDUV SKUHQLFROLHQDOLV PHVRJDVWULLGRUVDOLVDQGVHFRQGSDUWZKLFKFRQ QHFWVVSOHHQZLWKVWRPDFKSDUVJDVWURGXHRGHQD OLVPHVRJDVWULLGRUVDOLV 9LVFHUDOSRUWLRQRIVSOHHQLVFRPPRQO\VXUURXQG HG E\ VWRPDFK OHIW NLGQH\ FRORQLF OLHQDO ÀH[XUH and pancreatic tail. Usually spleen is completely FRYHUHG ZLWK SHULWRQHXP /LHQRUHQDO OLJDPHQW PDNHVVSOHHQ¶VKLOXVZKLFKFRQWDLQVOLHQDODUWHU\ and vein and its position is in front of pancreatic WDLODQGOHIWNLGQH\*DVWUROLHQDOOLJDPHQWLVIRUPHG RISHULWRQHXPRPHQWXPPDLXVDQGPLQXV,Q DGXOWVVSOHHQGLPHQVLRQDUH[[FPDQGDYHU DJH ZHLJKW DURXQG JU 0D[LPXP OHQJWK RI VSOHHQ LV WR FP 6SOHHQ LV QHWZRUN RI ZKLWHDQGUHGEORRGFHOOV1RUPDOYDULDWLRQRI VSOHHQSRVLWLRQLVUHWURUHQDOVSOHHQ±ZKHQVSOHHQ OLHVGRUVDOWREDFNHGJHRIOHIWNLGQH\ZKLFKLV FRPPRQO\VHHQLQHOGHUO\SRSXODWLRQÄ:DQGHULQJ spleen”, or ectopic spleen, is seen when spleen PLJUDWH IURP QRUPDO SRVLWLRQ LQ OHIW XSSHU TXDG rant, accessory spleen is more common condition. It is usually located in spleen’s hilum, but it can be DQ\ZKHUHLQWKHSHULWRQHDOFDYLW\ Accessory spleen length can be up to 4 cm. Ac cessory spleen has also been described near SDQFUHDWLF DUHD DQG DURXQG RI DFFHVVRU\ VSOHHQV FDQ EH VHHQ LQ SDQFUHDWLF WDLO DUHD and can be misinterpreted as an endocrine pan FUHDWLFWXPRU These variations of spleen position can be asymp WRPDWLF 9DULDWLRQ RI VWRPDFK SRVLWLRQ EHVLGHV SWRVLV ZKHQ S\ORULF FDQDO LV ORFDWHG LQ WKH OHYHO RI/YHUWHEUDFDQEHUHODWHGWRVWRPDFKHFWDVLD and than it is located in lower hemiabdomen more WR WKH OHIW 3DQFUHDV LQ VLWXV LQYHUVXV YLVFHUXV FDQ EH ORFDWHG LQ WKH ULJKW KHPLDEGRPHQ WDLO DQGERG\DQGSDQFUHDWLFKHDGVWD\VLQGXRGHQDO frame, i.e. prevertebraly. The aim of this report was to present rare case of anomalous position of spleen, stomach and pan creas. Study case $\HDUROGSDWLHQWFDPHWRWKHURXWLQHSK\VLFDO examination. She was not complaining to any ab dominal pain and her lab test were in the normal UDQJH 8OWUDVRXQG 86 RI XSSHU DEGRPHQ ZDV performed and revealed soft tissue, oval tumor PDVVDERYHWKHULJKWNLGQH\VXUURXQGHGZLWKOLYHU on the right and lateral side, right adrenal gland ZDVQRWYLVLEOH0XOWL6OLFH&RPSXWHUL]HG7RPRJ UDSK\06&7ZDVSHUIRUPHGLQWKHQDWLYHVHULHV )LJ)LJ)LJ 0HGLFLQVNLåXUQDO )LJXUHDQG Coronal CT scan normal position of gallblad GHUZKLWHFKHYURQ&RURQDO&7VFDQVWRPDFKRQWKHULJKWVLGH EODFNDUURZKHDG $IWHU QDWLYH 06&7 0DJQHWLF 5HVRQDQFH 05, was performed in the native and post contrast VHULHV RQ 7 05, XQLW ([DPLQDWLRQ LQFOXGHG IROORZLQJ VHTXHQFHV 7ZL 7ZL LQ D[LDO FRURQDO DQG VDJLWWDO SODQHV 2Q WKH 05, LPDJHV D ODUJH liver that occupies almost the whole subdiaphrag mal space of the upper abdomen was found. Gall bladder was located in right hypochondrium at its XVXDOORFDWLRQ)LJ )LJXUHDQG$[LDO&7VFDQVSOHHQRQWKHULJKWVLGHZKLWH DUURZKHDGDQGWKUHHDFFHVVRU\VSOHHQVFXUYHGOHIWDUURZ &RURQDO05VFDQQRUPDOSRVLWLRQRIWKHJDOOEODGGHUEODFNDU URZDQGHQODUJHGOHIWOLYHUOREH /LGLMD/LQFHQGHU&YLMHWLü6DQMDâHKRYLü,UPLQD6H¿ü3DãLü9HVQDĈXURYLü6DUDMOLü6DQGUD9HJDU=XERYLü,QYHUVHSRVLWLRQRIVSOHHQVWRPDFK DQGSDQFUHDV Stomach was located on the right ventral side; FDUGLDZDVLQWKHQRUPDOSRVLWLRQ)LJ(VRSKD gus was in front of the aorta and vena cava. In the XSSHU OHIW TXDGUDQW VSOHHQ ZDV QRW IRXQGHG DV well as pancreas and stomach. Subdiaphragmal space was occupied with enlarged left liver lobe )LJ DISCUSSION In projection above and lateral of upper pole of ULJKWNLGQH\DQGPHGLDOIURPOLYHUÄVSOHHQOLNHIRU PDWLRQ³KDVEHHQVHHQRQPHGLDOFRQWRXURIWKLV formation notch that is typical for spleen hilus has EHHQYLVXDOL]HGZLWKOLHQDOYHLQ)LJ )LJXUH$[LDO05VFDQVSOHHQDQGVWRPDFKRQWKHULJKWVLGH OLQHDOYHLQLQWKHOLHQDOKLOXVOHIWFXUYHGDUURZ Below the spleen hilus four accessory spleens were seen. In front and caudally, glandular pa renchyma structure was observed, which was GLUHFWHG REOLTXH WR PHGLDO VLGH DQG YHQWUDO SUH vertebraly. In its parenchyma pancreatic duct was GLIIHUHQWLDWHG)LJ Figure 6. $[LDO 05 VFDQ SDQFUHDV RQ WKH ULJKW SUHYHUWHEUDO VSDFHEODFNDUURZ 9DULDWLRQLQVSOHHQSRVLWLRQFDQEHFRQJHQLWDODVD SDUWRI6LWXVLQYHUVXVYLVFHUXVRUFDQEHDFTXLUHG The concept of situs or laterality of the viscera vascular anatomy is important to understanding, imaging and interpretation of congenital visceral and vascular malformations. Assignment of lat HUDOLW\ FDQ EH LQKHUHQWO\ GLI¿FXOW DQG DIIHFWHG E\ VSHFL¿F FOLQLFDO ELDVHV 7KH JDVWURHQWHUROR gist may focus on the presence or absence of the VSOHHQ,QWKHFDVHRIDEGRPLQDOWUDXPDH[ act diagnosis of spleen position is very important. Change in spleen position can be of importance in PDNLQJGHFLVLRQRIXUJHQWVXUJHU\ $FTXLUHG FKDQJHV LQ VSOHHQ ORFDWLRQ DUH PRELOH DQG ÄZDQGHULQJ³VSOHHQ 0RELOH VSOHHQ UHIHUV WR condition where spleen has increased movements compared to normal movements of spleen and di aphragm during respiration. One of the congenital causes of mobile spleen is anomaly in develop ment of posterior mesogastrium, when the con nection between lateral part of mesogastrium and ODWHUDOSHULWRQHXPLVGH¿FLHQWRQWKHSRVWHULRUDE dominal wall. Another cause of mobile spleen can be decreased tension of the abdominal wall, which is followed by general enteroptosis. This condition is usually a result of sudden decreased in body weight. Trauma with stretch of the suspension mechanisms can cause change in spleen position. Also in same infective diseases, position of spleen FDQEHFKDQJHGGXHWRVSOHQRPHJDOLD9DULDWLRQV of spleen position are usually asymptomatic, but in cases of spenomegalia, spleen can cause pres sure to surrounding organs. In the case of mobile spleen there is always possibility of torsion that can appear suddenly or gradually with repeated colic pain. $OLHQLDDFRPSOHWHODFNRIVSOHHQLVUDUHDQGXVX ally associated with incomplete development of RWKHURUJDQV3HRSOHZLWKDOLHQLDDUHXVXDOO\DV \PSWRPDWLF 3DWLHQW ZLWK 6LWXV DPELJXXV WHQG WR EHJURXSHGZLWKWKRVHLQZKRPULJKWRUOHIWVLGHG structures predominate. Generalization may be PDGH LQ WKHVH JURXSV 3DWLHQWV ZLWK ULJKWVLGHG V\PPHWU\W\SLFDOO\ODFNVSOHHQZKHUHDVSDWLHQWV ZLWK OHIWVLGHG V\PPHWU\ W\SLFDOO\ KDYH D VHJ PHQWHGVSOHHQRUPXOWLSOHVSOHQXOHV6SOHHQ can be composed of multiple fragments which can EH VHSDUDWHG IURP HDFK RWKHU VSOHQXQFXOXVDF FHVVRU\$FFHVVRU\ VSOHHQV DUH XVXDOO\ ORFDWHG 0HGLFLQVNLåXUQDO /LGLMD/LQFHQGHU&YLMHWLü6DQMDâHKRYLü,UPLQD6H¿ü3DãLü9HVQDĈXURYLü6DUDMOLü6DQGUD9HJDU=XERYLü,QYHUVHSRVLWLRQRIVSOHHQVWRPDFK DQGSDQFUHDV around a spleen, but can be founded in other loca WLRQV In our case, patient has variation in spleen posi WLRQ ULJKWVLGHG VWRPDFK DQG SDQFUHDV DQG WKLV GLDJQRVLV ZDV PDGH DIWHU SHUIRUPHG 06&7 DQG 05, H[DPLQDWLRQV 2XU SDWLHQW ZDV FRPSOHWHO\ DV\PSWRPDWLF DQG ¿QGLQJV ZHUH DFFLGHQWDO ,Q literature, Situs inversus viscerum, dextrocardia and complete inversion of abdominal organs and digestive system is commonly described. In our case only partial inversion of the spleen, stomach and pancreas was detected. Situs ambiguus associated with other conditions of major clinical relevance, such as intestinal mal rotation, biliary atresia, splenic abnormalities and FRQVHTXHQW LPPXQRORJLF GHUDQJHPHQWV IDXOW\ gastric suspension mechanisms, displacement of abdominal viscera and aberrant vascular struc tures and vascular connections. Each of these abnormalities is derived from embryologic inability to determine laterality and establish the complex solitus asymmetry, where as symmetrical struc WXUHVUHPDLQXQDIIHFWHG CONCLUSION ,Q RXU FDVH \HDU ROG SDWLHQW ZLWK GH[WURSRVL tion of the spleen, pancreas and stomach was SUHVHQWHG¿QGLQJZDVDFFLGHQWDODQGSDWLHQWZDV DV\PSWRPDWLF3DWLHQWFDPHWRWKHURXWLQHSK\VL FDOH[DPLQDWLRQZKHQXOWUDVRXQG¿QGLQJUHYHDOHG DVROLGPDVVXQGHUWKHXSSHUSROHRIWKHULJKWNLG ney. Than as a second imaging method, abdomi QDO 06&7 DQG 05, ZHUH SHUIRUPHG RQ ZKLFK ULJKWVLGHG VSOHHQ SDQFUHDV ERG\ DQG WDLO DQG the stomach were revealed. Funding: there is no DQ\IXQGLQJRUFRQÀLFWRILQWHUHVW /HH 6( .LP +< -XQJ 6( /HH 6& 3DUN .: .LP :.6LWXVDQRPDOLHVDQGJDVWURLQWHVWLQDODEQRUPDOLWLHV -3HGLDWU6XUJ 0DOGLMDQ 3' 6DULF 0 $SSURDFK WR GH[WURFDU GLD LQ DGXOWV UHYLHZ $P - 5RHQWJHQRO VXSSO6 +RSSHU .' &KDQWHORLV $( 7KH UHWURSHULWRQHDO spleen: Impact for percutaneous left renal procedures. ,QYHVW5DGLRO 1DNRPDWR '$ 6SOHHQ ,Q +DDJD -5 'RJUD 96 )RUVWLQJ0*LONHVRQ56+D+.6XQGDUDP0&7DQG 05,RIWKH:KROH%RG\WKHG6W/RXLV0RVE\(OVH YLHUSS9RO %RUDVFKL 3 )UDQFHVFDPDULD ' 9ROSL $ &DPSDUL G. Intrapancreatic accessory spleen. Diagnosis with 5(6 VSHFL¿F FRQWUDVWHQKDQFHG 05,$P 5RHQWJHQRO *LQGHV/+HJHVK-%DUNDL*-DFREVRQ-0$FKLURQ R. Isolated levocardia: prenatal diagnosis, clinical im SRUWDQFHDQGOLWHUDWXUHUHYLHZ-8OWUDVRXQG0HG )XQJ 7< &KDQ '/ /HXQJ 71 /HXQJ 7< /DX 7. 'H[WURFDUGLDLQSUHJQDQF\\HDUVH[SHULHQFH-5H SURG0HG ;X6%36KHQ.8/+X-+)HQJ;//L+0/DQJ =2&OLQLFDOFKDUDFWHULVWLFVRISULPDU\FLOLDU\G\VNLQHVLD LQFKLOGUHQ&-3 .D\KDQ$/DNDGDP\DOL+2RPPHQ-2WR$3RO\ splenia syndrome accompanied with situs inversus to talis and annular pancreas in an elderly patient. Clinical ,PDJLQJ &RQÀLFWRILQWHUHVWnone declared. REFERENCES 0FPDQXV & 5LJKW KDQG OHIW KDQG WKH RULJLQV RI asymmetry in brains, bodies, atoms and cultures. 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Key wordsLQ%6&DQGLQ(QJOLVKODQJXDJHXSWR¿YHZRUGVVKRXOGEHOLVWHGEHORZ6XPPDU\RU Abstract. 0HGLFLQVNLåXUQDO ARTICLE BODY The main body of the article should be systematically ordered under the following headings: - INTRODUCTION - MATERIALS AND METHODS - RESULTS - DISCUSSION - CONCLUSION - REFERENCES INTRODUCTION Introduction is a concise, short part of the article, and it contains purpose of the article relating to other SXEOLVKHGDUWLFOHVZLWKWKHVDPHWRSLF,WLVQHFHVVDU\WRTXRWHWKHPDLQSUREOHPDLPRILQYHVWLJDWLRQ DQGRUPDLQK\SRWKHVLVZKLFKLVLQYHVWLJDWHG MATERIALS AND METHODS 7KLVSDUWVKRXOGFRQWDLQGHVFULSWLRQRIRULJLQDORUPRGL¿FDWLRQRINQRZQPHWKRGV,IWKHUHLVDPHWKRG WKDWKDVSUHYLRXVO\EHHQGHVFULEHGLWZRXOGEHVXI¿FLHQWWRLQFOXGHLWLQWKHUHIHUHQFHOLVW,QFOLQLFDO and epidemiological studies the following should be described: sample, protocol and type of clinical LQYHVWJDWLRQSODFHDQGSHULRGRILQYHVWLJDWLRQ0DLQFKDUDFWHULVWLFVRILQYHVWLJDWLRQVKRXOGEHGHVFULEHG UDQGRPL]DWLRQGRXEOHEOLQGWHVWFURVVWHVWSODFHERWHVWVWDQGDUGYDOXHVIRUWHVWVWLPHIUDPHZRUN SURVSHFWLYHUHWURVSHFWLYHVWXG\VHOHFWLRQDQGQXPEHURISDWLHQWV±FULWHULDIRULQFOXVLRQDQGH[FOXVLRQ from the study. RESULTS 0DLQUHVXOWVRILQYHVWLJDWLRQDQGOHYHORILWVVWDWLVWLFDOVLJQL¿FDQFHVKRXOGEHTXRWHG5HVXOWVVKRXOGEH SUHVHQWHGLQWDEOHVJUDSKV¿JXUHVDQGGLUHFWO\LQFRUSRUDWHGLQWKHWH[WDWWKHH[DFWSODFHZLWKRUGLQDO QXPEHUDQGFRQFLVHKHDGLQJ7DEOHVKRXOGKDYHDWOHDVWWZRFROXPQVDQGH[SODQDWLRQ¿JXUHVFOHDQ and contrasted, graphs clear, with visible text and explanation. DISCUSSION Discussion is concise and refers to own results, in comparison with the other authors’ results. Citation RIUHIHUHQFHVVKRXOGIROORZ9DQFRXYHUUXOHV'LVFXVVLRQVKRXOGEHFRQFOXGHGE\WKHFRQ¿UPDWLRQRIWKH stated aim or hypothesis, or by its negation. CONCLUSION Conclusion should be concise and should contain most important facts, which were obtained during investigation and its eventual clinical application, as well as the additional studies for the completed ap SOLFDWLRQ$I¿UPDWLYHDQGQHJDWLYHFRQFOXVLRQVVKRXOGEHVWDWHG REFERENCES 5HIHUHQFHVVKRXOGIROORZWKHIRUPDWRIWKHUHTXLUHPHQWVRIVancouver rules. 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