Evaluation activities of daily living in patient`s rehabili
Transcription
Evaluation activities of daily living in patient`s rehabili
1 New ORs - Central Medical Building - Clinical Center University of Sarajevo Novi operacioni blok - Klinički Centar Univerziteta u Sarajevu 2 New ICU - Central Medical Building - Clinical Center University of Sarajevo Nova Intenzivna njega - Klinički Centar Univerziteta u Sarajevu 3 New Central Medical Building - Clinical Center University of Sarajevo Novi Centralni Medicinski Blok - Klinički Centar Univerziteta u Sarajevu www.kcus.ba Medical Journal PUBLISHER Institute for Research and Development Clinical Center University of Sarajevo 71000 Sarajevo, Bolnička 25 Bosnia and Herzegovina For publisher: Damir Aganović, MD, PhD general manager CCUS AIMS AND SCOPE Medical Journal is the official quarterly issued journal of the Institute for Research and Development of the Clinical Center University of Sarajevo and has been published regularly since 1994. 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TECHNICAL EDITOR Blicdruk studio CIRCULATION 500 copies Member of National Journals Networks of the European Society of Cardiology Contents Medical Journal (2014) Vol. 20, No. 1 Original article Incidence of anticardiolipin antibodies evaluated by elisa method on hytec 288 ................................................................................ 7 Marina Delić-Šarac, Jasenko Karamehić, Đemo Subašić, Nejra Džananović, Suvada Švrakić, Aida Šaban, Ognjen Riđić Appearance of N-metastases in presence of peritumoral lymphovascular infiltration at lung cancer ................................... 13 Kemal Grbić, Safet Guska, Alma Alihodžić-Pašalić, Alen Pilav, Ferid Krupić The usefulness of penile compression-release index for diagnosing bladder outlet obstruction ............................................... 18 in patients with benign prostatic enlargement Damir Aganović, Alden Prcić, Munira Hasanbegović, Osman Hadžiosmanović, Hajrudin Spahović Evaluation activities of daily living in patient’s rehabilitation with osteoporosis ............................................................................... 24 Edina Tanović, Aldijana Kadić, Haris Tanović, Dževad Vrabac Testicular volume in healthy prepubertal boys ................................................................................................................................................... 27 Zlatan Zvizdić, Denisa Zvizdić, Sandra Vegar Zubović, Amra Džananović, Faris Fočo Correlation of gastroesophageal reflux disease and Helicobacter pylori infection ........................................................................... 30 Nenad Vanis, Amila Mehmedović, Rusmir Mesihović, Amir Redžepović, Aida Saray A prospective comparison of preperitoneal with prefascial herniorrhaphy for the treatment of inguinal hernias .................... 33 Ismar Rašić, Goran Akšamija, Adi Mulabdić, Adis Kandić Assessment of initial diagnostic procedures in isolated thoracic injuries .............................................................................................. 38 Alma Alihodžić-Pašalić, Safet Guska, Ademir Hadžismailović, Alen Pilav, Kemal Grbić Medicamentous abortion induction in the second trimester in pathological pregnancies ........................................................... 42 Naima Imširija, Zulfo Godinjak, Lejla Imširija, Edin Idrizbegović, Fatima Gavrankapetanović, Admir Rama, Muhamed Ardat Professional article Endoscopic retrograde cholangiopancreatography: our experience .............................................................................................................. 46 Kenan Nahodović, Rusmir Mesihović, Nenad Vanis, Amra Puhalović, Srdjan Gornjaković, Amila Mehmedović, Alma Nahodović People with disabilities and their free access to hospital facilities in the compound of Clinical Center University of Sarajevo: special focus on Central Medical Building ............................................................................................................ 50 Mirza Dilić, Mustafa Hiroš, Mirela Imširija, Naima Imširija-Galijašević Case report Intraluminal lipoma as a cause of intestinal obstruction ............................................................................................................................... 60 Amir Hadžibeganović, Adnan Kulo, Lana Sarajlić, Dijela Kulo, Abdulah Efendić Entrapment syndrome of the left renal vein ........................................................................................................................................................ 63 Zoran Roljić, Božina Radević, Dušan Janičić, Slavko Grbić, Milan Žigić, Jevrosima Roljić, Vladimir Keča, Severin Dunović, Novak Milović Instructions to authors ................................................................................................................................................................................................... 66 Uputstva autorima .......................................................................................................................................................................................................... 68 Original article Medical Journal (2014) Vol. 20, No. 1, 7-12 Incidence of anticardiolipin antibodies evaluated by elisa method on hytec 288 Incidenca antikardiolipin antitijela evaluiranih elisa hytec 288 metodom Marina Delić-Šarac1*, Jasenko Karamehić1, Đemo Subašić1, Nejra Džananović1, Suvada Švrakić2, Aida Šaban3, Ognjen Riđić4 Department for Clinical Immunology, Clinical Center University of Sarajevo, Bolnička 25, 71000 Sarajevo, Bosnia and Herzegovina; 2 Department for Quality Improvement and Safety of Health Services, Clinical Center University of Sarajevo Bolnička 25, 71000 Sarajevo, Bosnia and Herzegovina; 3 Stomatology Department, Primary Health Care Center Travnik, 72270 Travnik, Bosnia and Herzegovina; 4 Health Faculty, University of Zenica, Crkvice 57, 72000 Zenica, Bosnia and Herzegovina. 1 *Corresponding author ABSTRACT SAŽETAK Antiphospholipid antibody syndrome (commonly called antiphospholipid syndrome or APS) is an autoimmune disease present mostly in young women. Antibodies that are found in the blood of these patients are called anti-phospholipid autoantibodies (commonly called aPL). Phospholipid antibodies and lupus anticoagulants are found with increased frequency in patients with systemic rheumatic diseases, especially lupus erythematosus. The term antiphospholipid syndrome (APS) is used to describe the triad of thrombosis, recurrent fetal loss and thrombocytopenia accompanied by phospholipid antibodies or a lupus anticoagulant. The aCL (anticardiolipin antibodies) assay is only one of the methods used to detect aPL, and the test should be administered with the LA and anti-B2GPI assays.The aCL assay is reasonably sensitive, but not at all specific; therefore, clinicians should treat the clinical state and not an incidentally found antibody. There is an association between antibody titer and risk of thrombosis and this is not a ground for ignoring or not reporting weakly positive results. False-positive results that are difficult to interpret are particularly likely to occur when there are other causes of thrombosis, such as atherosclerosis in the elderly; therefore, screening widely should not be encouraged. Antifosfolipidni sindrom je autoimuno oboljenje koje se javlja uglavnom kod mlađih žena. U serumu pacijenata se nalaze specifična antitijela koja se nazivaju antifosfolipidna antitijela (često se nazivaju aPL). Antifosfolipidna antitijela i lupus antikoagulans se nalaze kod pacijenata sa autoimunim oboljenjima i posebno lupus eritematodesom. Kao najčešći simptomi antifosfolipidnog sindroma javljaju se učestale tromboze, ponavljani pobačaji i trombocitopenija koji su udruženi sa pojavom antifosfolipidnih antitijela i lupus antikoagulansa u serumu pacijenata. Najčešće se za detekciju ovih antitijela koristi aCL (antikardiolipinska antitijela) esej, a to je esej za detekciju antikardiolipinskih antitijela, kojeg treba uvijek raditi uporedo sa detekcijom lupus antikoagulansa i beta 2 glikoproteina. Test kojim se radi detekcija antikardiolipinskih antitijela ima značajnu senzitivnost, ali ne i specifičnost, pa je značajno da kliničari tretiraju simptome kod pacijenta, a ne slučajno detektovana antitijela. Postoji povezanost između titra antitijela i rizika od razvoja tromboze, što ne isključuje praćenje slabo pozitivnih rezultata. Lažno pozitivne rezultate je iz tog razloga jako teško pratiti i interpretirati, posebno ukoliko postoji i tromboza kod starijih pacijenata sa aterosklerozom; zato i nije preporučnjiv široki screening pacijenata. Key words: antiphospholipid antibody syndrome, thrombosis, miscarriages, phospholipid antibodies, lupus anticoagulants Ključne riječi: antifosfolipidni sindrom, tromboza, ponavljani pobačaji, antifosfolipidna antitijela, lupus antikoagulans. INTRODUCTION Antiphospholipid antibody syndrome (commonly called antiphospholipid syndrome or APS) is an autoimmune disease present mostly in young women. Antibodies that are found in the blood of these patients are called anti-phospholipid autoantibodies (commonly called aPL). These autoantibodies interfere with coagulation, leading to thrombosis. Patients can also experience the following symptoms: • neurological symptoms, • chronic headaches, migraines, dementia and seizures, • livedo reticularis on their wrists and knees, • cardiovascular disease and • thrombocytopenia There are also some infrequent signs and symptoms, which may include: • Movement disorder, chorea, • Cognitive problems, 8 M. Delić Šarac et al. • Sudden hearing loss, • Mental health problems, depression or psychosis The damage caused by this clotting can vary depending on the site of the clot. Repeated small clots in the heart can cause heart valve thickening or damage, with the risk of releasing clots into the blood, which can ultimately lead to an arterial embolism. aPL may also be associated with heart attacks in young people without any known cardiac risk factors. Blood clots in the arteries can lead to heart attacks and strokes or pulmonary embolism. Blood clots from aPL can occur anywhere in the circulation and can affect any organ in the body. Clots forming in the veins most frequently occur in the lower legs (1,2,3,4). Patients with the antiphospholipid syndrome can have a specific of antibodies. These antibodies include: VDRL/RPR (a syphilis test that can be falsely positive in these patients), lupus anticoagulant, prolonged PTT and cardiolipin antibody. As mentioned above, the anticardiolipin antibody has also been found in patients with the immune disease called systemic lupus erythematosus (5,6,7). The cause of antiphospholipid syndrome is not completely known. Antiphospholipid antibodies reduce the levels of annexin V, a protein that binds phospholipids and has potent clot-blocking (anticoagulant) activity.The reduction of annexin V levels is thought to be a possible mechanism underlying the increased tendency of blood to clot and the propensity to pregnancy loss, characteristic of the antiphospholipid syndrome. Antiphospholipid antibodies, such as anticardiolipin, have also been associated with decreased levels of prostacyclin that prevents the clumping of platelets. The treatment of patients with anticardiolipin syndrome has substantially evolved, since they were discovered to be clinically important in the mid-1980s. Each manifestation of the antiphospholipid syndrome, and each individual patient with the condition, is treated uniquely. Because many of the features of illness with anticardiolipin syndrome are associated with an abnormal grouping of normal platelets, the treatment is often directed toward preventing clotting. Patients with this disorder have an abnormal tendency to thrombosis. Aanticoagulation treatment such as heparin and warfarin are used. Aspirin has an effect on platelets by inhibiting their aggregation and has also been used in low doses. Cortisone-related medications, such as prednisone, have been used to suppress the immune activity and inflammation in patients with certain features of the condition. For patients with systemic lupus erythematosus who also have antiphospholipid syndrome, hydroxychloroquine was shown to be effective in thrombosis (8,9,10). Other reported treatments include; the use of intravenous gamma globulin for selected patients with histories of premature miscarriage and those with thrombocytopenia during pregnancy. However, recent research studies, suggest that intravenous gamma globulin may be no more effective than combination of aspirin and heparin treatment. The plasma membranes of mammalian cells are formed from phospholipids. Phosphatidylserine is found on the cytoplasmic surface and phosphatidylcholine on the external surface. They both participate in several important cellular functions including: exchanging metabolites across membranes, transferring molecular signals and serving as a platform for the assembly of protein-lipid complexes. During platelet-mediated blood coagulation, phosphatidylserine is translocated from the inner platelet membrane and provides a surface for the assembly of the prothrombinase enzyme complex that catalyzes the formation of thrombin. Complexes of negatively charged phospholipids and endogenous plasma proteins provide epitopes recognized by natural autoantibodies. Plasma from normal individuals contains low concentrations of natural IgG autoantibodies of moderate affinity. Pathologic levels of autoantibodies reflect loss of tolerance and increased production of antibodies. These autoantibodies are called phospholipid or cardiolipin antibodies, when they are detected by immunoassays that employ anionic phospholipids, as substrates (11,12,13). The most commonly used phospholipid substrate is cardiolipin. The autoantibodies react with epitopes of protein’s molecules that associate noncovalently with reagent phospholipids. The best characterized phospholipid-binding protein is beta 2 glycoprotein 1 and most immunoassays for phospholipid antibodies employ a composite substrate consisting of cardiolipin plus beta 2 glycoprotein 1(beta 2 GP1). Beta 2 GP1 is a 326 amino acid polypeptide that contains 5 homologous domains, each of them consisting of approximately 60 amino acids. Most phospholipid antibodies bind to an epitope associated with domain 1 near the N-terminus. Autoantibodies can also be detected by the use of functional, phospholipid-dependent coagulation assays. Phospholipid antibodies detected by functional assays are often called lupus anticoagulants, because they produce prolongation of phospholipid-dependent clotting in vitro. Not all phospholipid antibodies possess lupus anticoagulant activity. Only those phospholipid antibodies that are capable of cross-linking beta 2 GP1 molecules can interact efficiently with phospholipid surfaces in functional coagulation assays. It is hypothesized that complexes formed in vivo between bivalent, natural autoantibodies and beta 2 GP1 bind to translocated, anionic phospholipid on activated platelets at sites of endothelial injury.This binding is believed to promote further platelet activation that may lead to thrombosis. Phospholipid antibodies occur in patients with a variety of clinical signs and symptoms such as: thrombosis (arterial or venous), pregnancy morbidity (i.e. unexplained fetal death, premature birth, severe preeclampsia, or placental insufficiency), unexplained cutaneous circulation disturbances (e.g. livido reticularis or pyoderma gangrenosum) thrombocytopenia or hemolytic anemia and nonbacterial thrombotic endocarditis. Phospholipid antibodies and lupus anticoagulants are found with increased frequency in patients with systemic rheumatic diseases, especially lupus erythematosus. The term antiphospholipid syndrome (APS) is used to describe the triad of thrombosis, recurrent fetal loss and thrombocytopenia accompanied by phospholipid antibodies or a lupus anticoagulant (14,15). APS is diagnosed when, at least one requirement, from both clinical and laboratory criteria is met. Clinical criteria include the following: • Vascular thrombotic episodes in any tissue or organ and • Pregnancy loss (≥1 unexplained loss of a normal fetus beyond the 10th gestational week, ≥1 premature birth before the 34th gestational week due to eclampsia or placental insufficiency or ≥3 spontaneous abortions before the 10th gestational week) Incidence of anticardiolipin antibodies evaluated by elisa method on hytec 288 Laboratory criteria include the following: • Lupus anticoagulant (LA) present in serum, • Anticardiolipin (aCL) antibody of immunoglobulin G (IgG) and/or immunoglobulin M (IgM) isotype present in serum (>40 GPL or MPL units or above the 99th percentile) and • Anti–beta2 glycoprotein-I (b2-GPI) antibody of IgG and/or IgM isotype (i.e. in titer above the 99th percentile) in serum 9 Picture 1 HYTEC 288 instrument for ELISA assays Although not included in the diagnostic criteria, other clinical symptoms, such as: livedo reticularis, nephropathy, thrombocytopenia, cardiac valvular disease and neurological symptoms are commonly associated comorbidities (16). MATERIALS AND METHODS We analyzed serums of patients that were sent to department of Immunology at Clinical Center University of Sarajevo (CCUS), in period from 17.05.2013. to 30.11. 2013. These patients sera were analyzed on Hytec 288. Hytec 288 is an automated immunoassay instrument for the performance of Allergy and Autoimmune antibody testing, and for ELISA commercial or developed assays. It is specifically designed for increased productivity and enhanced efficiency. The HYTEC 288 is compatible with many interface protocols and provides quality control management. It also complies with FDA’s Quality System Regulation, current International ISO Standards, NCCLS guidelines and CE-mark guidelines (17,18,19). For each patient, we analyzed separately anticardiolipin antibodies (i.e. IgG and IgM and beta 2 glycoprotein IgG and IgM). The results of anti cardiolipin assay can be used as aid in diagnosis of autoimmune diseases associated with elevated levels of anti-cardiolipin antibodies, including anti-phospholipid syndrome. Levels of these auto antibodies represent one indicator in a multi-facorial diagnostic regime. Anti cardiolipin and anti phosphatidyl serine antibodies, along with others, such as Lupus Anticoagulant, belong to the family of anti-phospholipid antibodies. Anticardiolipin antibodies are circulating serum antibodies often associated with recurrent arterial and venous thromboembolism, recurrent fetal loss and thrombocytopenia. These symptoms are often present in cases of Systemic Lupus Erithematodes (SLE) and in many other conditions, both of an autoimmune and non-autoimmune nature. Some studies show that over 50% of SLE patients have one or more classes of anti cardiolipin antibodies. The presence of these antibodies serves as a marker for the risk of a thromboembolic event. Those SLE patients exhibiting high levels of these auto antibodies are four times more likely to experience such an event than those not expressing the auto antibodies. Anti cardiolipin auto antibodies can be of any combination of the IgM, IgA and IgG classes. IgG antibodies are the most prevalent class of auto antibody and the class with the greatest clinical correlation. Samples found to have IgG levels in the “high “ anti-cardiolipin band are the most likely to display overt clinical symptoms. However, IgA and IgM auto antibodies are often found, either alone or in association with the IgG class. Measurement of all three classes is therefore recommended. Anti-cardiolipin are the most commonly measured anti-phospholipid antibodies. It is known that some patients with infectious diseases and other autoimmune disorders show some antibody activity against cardiolipin (20). Patients samples were collected in tubes with gel, and centrifuged on 3000 x15 minutes. After that process we collected sera of the patients and prepared them for automatized ELISA assay. The Autostat II assay for detection of auto antibodies is a solid phase immunosorbent assay (ELISA), in which the analyte is indicated by a color reaction of an enzyme and substrate. The Autostat II wells are coated with purified antigen. On adding diluted serum to the wells the antibodies present bind to the antigen. After incubating at room temperature and washing away unbound material, horseradish peroxidase conjugated anti-IgG antibody is added, which binds to the immobilized antibodies. Following further incubation and washing, tetra methyl benzidine substrate (TMB) is added te each well.The presence of the antigen antibody conjugate complex turns the substrate to a dark blue color. Addition of the stop solution turns the color to yellow. The color intensity is proportional to the amount of autoantibodies present in the original serum sample. Reference values of antiphospholipid antibodies were: • <10.0 GPL (negative), • 10.0-14.9 GPL (borderline), • 15.0-39.9 GPL (weakly positive), • 40.0-79.9 GPL (positive), • or =80.0 GPL (strongly positive). GPL refers to IgG Phospholipid Units. One GPL unit is 1 microgram of IgG antibody. Reference values apply to all ages. RESULTS We examined 158 serum samples of patients in the period from 30.01.2012. to 03.05.2012 at the Institute for Clinical Immunology - Clinical Center University of Sarajevo. We analyzed 124 serum samples of female and 34 male patients. The serum sample distribution was 78 percent of female and 22 percent of male patients. Table1 Number of analyzed female and male samples 10 M. Delić Šarac et al. we analyzed the patients in this way, we have seen that the total positive were 24 and 134 negative samples. Table 3 Review of positive and negative samples Figure 1 Percentage share of female and male patients Of the total number of samples analyzed we had following proportion of positive samples proportioned between female and male patients: 71% (18 patients) of female patients and 29% of positive samples of male patients (6 patients). Figure 4 The percentage share of positive antiphospholipid antibodies specific to the inclusion criteria for antiphospholipid syndrome Figure 2 The percentage share of positive samples of female and male patients When we analyzed separatel ACA IgG, ACA IgM, B2G IgG and B2G IgM antibodies we noticed the following: Table 2 Positive samples Next, we analyzed which of the antibodies were most frequently positive in these samples, so we received the following results. Among all the specific positive samples in female patients ACAM was usually present, followed by B2GG and B2GM. Table 4 Positive separate antibodies in female patients samples We had the most positive samples in class ACA IgM, followed by ACA IgG, B2G IgG and IgM B2G. The high proportion of positive ACA IgM can be attributed to the fact that the ACA IgM was elevated in non-specific inflammatory changes of different etiology. Figure 5 Percentage of positive separate antibodies in female patients samples We also measured ACAM and B2GM in male patients’ samples. Figure 3 Percentage share of single positive antiphospholipid antibodies According to the criteria for the diagnosis of antiphospholipid syndrome, it is necessary that one of the ACA and one of B2G is positive in analyzed parallel series in interval of 12 weeks. When Table 5 Positive separate antibodies in male patients samples Incidence of anticardiolipin antibodies evaluated by elisa method on hytec 288 Figure 6 Percentage of positive separate antibodies in male patients samples DISCUSSION We analyzed a total of 158 samples, of which 124 samples were of female patients and 34 male patients. This proportion of female patients fits in so far known data that is the higher proportion of female patients in all autoimmune diseases such as antiphospholipid syndrome. Additionally, the proportion of positive samples is also on the female side. Positive and strongly-positive results for IgG and IgM phospholipid (cardiolipin) antibodies (>40 GPL and/or >40 MPL) are diagnostic criteria for antiphospholipid syndrome (APS). Lower levels of IgG and IgM phospholipid (cardiolipin) antibodies and antibodies of the IgA isotype may occur in patients with clinical signs of APS but the results are not considered diagnostic. Phospholipid (cardiolipin) antibodies must be detected on two or more occasions at least 12 weeks apart to fulfill the laboratory diagnostic criteria for APS. Detection of phospholipid (cardiolipin) antibodies is not affected by anticoagulant treatment. The immunoassay for phospholipid (cardiolipin) antibodies does not distinguish between autoantibodies and antibodies produced in response to infectious agents or as epiphenomena following thrombosis. For this reason, a single positive test result is not sufficient to meet accepted serologic criteria for the diagnosis of antiphospholipid syndrome (APS). In 158 analyzed samples we had two cases of strongly positive results in female patients’ and the results were ACAG: 100, ACAM: 60, B2GG: 3,79 and B2GM: 34,38, and for other female patient we had ACAG: 100, ACAM 60, B2GG 12,88 and for B2GM 12,39. Except of these laboratory results clinician should consider clinical signs and symptoms in inclusion criteria for APS. The presence of serum anticardiolipin (aCL) antibody without clinical symptoms does not support a diagnosis of antiphospholipid syndrome (APS). A positive result supports the diagnosis only in the presence of thrombosis or fetal loss.A higher aCL titer indicates more frequent clinical manifestations among individuals with APS. Patients with primary or secondary APS may have a negative aCL result but may be positive for LA or occasionally anti-B2GPI. In APS the antibody titers correlate with the severity of the disease in a patient group, it is established that in the low range of antibody titers some patients have significant clinical disease: as the patients’ antibody level may fluctuate over time into the normal range and 11 may also fall at the time of thrombosis (23, 24,25), patient may not be diagnosed with the syndrome. Recurrent thrombosis may even occur at the time of a normalized aCL level (27,28,29). The combined aCL and LA tests, although assumed to be highly sensitive, are not specific. aCL are also found in infections (26) such as hepatitis C (30,31,32), malaria, lyme disease, syphilis, and HIV; leukemias and solid-organ malignancies; and frequently in alcoholic cirrhosis. LA is also found in children with infections, such as varicella, in elderly patients, and in cases of drug reactions. Repeating the test in 6 weeks may help in acute infections, as in this instance the aPL are temporary. Elevated aCL levels are commonly found in the elderly, and 51% of a well, medication-free nursing home population with a mean age of 81 years was positive. Positive test result (for aCL, LA, or both) for a person without clinical features need not to be a false-positive result. APS does not appear to be a uniform predilection to thrombosis but, rather, a spectrum of severity that may depend not only on antibody isotype and titer but also on antibody avidity and other “hits”, such as: activated protein C resistance, smoking, oral contraceptive use, serum homocysteine level (the other prothrombotic state that can produce arterial, venous, and cerebral sinus thrombosis), and acute factors such as trauma or immobilization (33,34,35). One of the most difficult clinical issues in APS is the lack of specificity of the aCL for the diagnosis, leading to the possibility of false-positive diagnoses, both obscuring the true diagnosis and possibly leading to unnecessary anticoagulation. A clinically useful increase in specificity can be achieved with a phospholipid-free anti-B2GPI ELISA. We had 46 serum samples positive for ACAG and 68 serum samples positive for ACAM, but most of these were not specific enough because we had negative B2G values and we could not determine their role in diagnosing APS. The aCL assay is only one of the methods used to detect aPL, and the test should be administered with the LA and anti-B2GPI assays. The aCL assay is reasonably sensitive but not at all specific; therefore, clinicians should treat the clinical state and not an incidentally found antibody. Although, there is an association between antibody titer and risk of thrombosis, this is not a ground for ignoring or not reporting weakly positive results. False-positive results that are difficult to interpret are particularly likely to occur when there are other causes of thrombosis such as atherosclerosis in the elderly; therefore, screening widely should not be encouraged (36,37,38). CONCLUSION Antiphospholipid syndrome is an autoimmune disease that is recognized as very serious and not so rare condition. Diagnostics of anticardiolipin antibodies is available and should be considered in cases of recurrent thrombosis or recurrent fetal loss and miscarriages. It is also important to note that these antibodies are not specific and they have large sensitivity so clinician must recognize the syndrome and treat the patients with not accidentally higher antibody levels. Conflict of interest: none declared. 12 REFERENCES 1. Bevers EM, Comfurius P, Dekkers DW, Zwaal RF. Lipid translocation across the plasma membrane of mammalian cells. Biochim Biophys Acta 1999;1439(3):317330. 2. Arnout J,Vermylen J. Current status and implications of autoimmune antiphospholipid antibodies in relation to thrombotc disease. J Thromb Haemost 2003;1(5):931942. 3. Proven A, Bartlett RP, Moder KG, Chang-Miller A, Cardel LK, Heit JA, et al. 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Reprint requests and correspondence: Marina Delić-Šarac, MD Department for Clinical Immunology Clinical Center University of Sarajevo Bolnička 25, 71000 Sarajevo Bosnia and Herzegovina Phone: +387 33 297 000 Email: [email protected] Original article Medical Journal (2014) Vol. 20, No. 1, 13-16 Appearance of N-metastases in presence of peritumoral lymphovascular infiltration at lung cancer Pojava N-metastaza u prisustvu peritumoralne limfovaskularne infiltracije kod karcinoma pluća Kemal Grbić1*, Safet Guska1, Alma Alihodžić-Pašalić1, Alen Pilav1, Ferid Krupić2 Clinic of Thoracic Surgery, Clinical Center University of Sarajevo, Bolnička 25, 71000 Sarajevo, Bosnia and Herzegovina; 2Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Sweden. 1 *Corresponding author ABSTRACT SAŽETAK Basic charesteristic of epithelical lung cancer is possibility of early lymphatic spreading or in other words intaking of regional lymphic nodes, which statistically proved represents the most significant individual prognostic factor of therapeutic result and survival of those who are suffering from it, and in pre operational stage it is a possibility or limitation of resectional treatment. Aim of work is analysis of frequences of peritumoral lymphovascular infiltration and its possible influence on more frequent appearence of N- metastases at lung cancer. Retrospective research has included 239 surgicaly treated patients at Clinic for Thoracic Surgery CCU Sarajevo in period from 01.01.2010. to 01.01.2013. with pre diagnosed lung cancer. Datas were collected from the existing medical documentation, including definite pathohistological tests which contein presence/absence of peritumoral lymphovascular infiltration and status of lymphic nodes, and according to present TNM classification. Average age of hospitalized patients is 62.72± 7.68 years, where is proportion in relation to gender 3.8:1 on behalf of men. Statistically there is significant difference of age in relation to gender at those who suffer, where patients of male gender in relation to female gender are in average older ( t-student test=2.12 and p<0.03517). Presence of PLV infiltration was evidented in 68.2% cases. Malignant negative nodes (N0) were 56,1%, N1-positive were 38,9%, while N2 nodes were caught in 5,0% cases. At pathohistologically proved N0 cases peritumoral lymphovascular infiltration is present at 46,3% patients (χ2=3.25; p>0.07). At patohistologically proved lymphic nodes (N1,N2) , peritumoral lymphovascular infiltration is present at 96.2% patients (χ2=0.29; p<0.0000019481). Conclusion: Significantly greater representation of peritumoral lymphovascular infiltration, and significant connection of existing of the same and intaking of regional lymphic nodes. Bazna osobina epitelnog plućnog karcinoma je mogućnost ranog limfogenog širenja, odnosno zahvaćenost regionalnih limfnih čvorova, koji statistički dokazanao, predstavljaju najbitniji pojedinačni prognostički faktor terapijskog ishoda i preživljavanja oboljelih, a u preoperativnom stejdžingu mogućnost, odnosno limitiranost resekcionog tretmana. Analiza učestalosti peritumoralne limfovaskularne infiltracije i njenog mogućeg uticaja na češću pojavu N-metastaza kod plućnog karcinoma. Pacijenti i metode: Retrospektivno istraživanje je obuhvatilo 239 hiruški tretiranih pacijenata na Klinici za torakalnu hirurgiju KCU Sarajevo u periodu od 01.01.2010 do 01.01.2013 godine sa prethodno dijagnostikovanim plućnim karcinomom. Podaci su prikupljeni iz postojeće medicinske dokumentacije, uključujući definitivne patohistološke nalaze koji sadrže prisustvo/odsustvo peritumoralne limfovaskularne infiltracije i status limfnih čvorova, a prema važećoj TNM-klasifikaciji. Prosječna starost hospitaliziranih pacijenata je bila 62.72±7.68 godina, gdje je omjer u odnosu na spol 3.8:1 u korist muškaraca. Statistički postoji značajna razlika starosne dobi u odnosu na spol kod oboljelih, pri čemu su osobe muškog u odnosu na osobe ženskog spola, prosječno starije životne dobi (t – Student test = 2.12 i p < 0.03517). Prisustvo PLV infiltracije je evidentirano u 68.2% slučajeva. Maligno negativnih nodusa (N0) je bilo 56.1%, N1-pozitivnih 38.9% , dok su N2 nodusi zahvaćeni u 5.0% slučajeva. Kod patohistološki potvrđenih N0 slučajeva peritumoralna limfovaskularna infiltracija je prisutna kod 46.3% pacijenata (χ22=3.25; p>0.07). Od ukupnog broja metastatskih promjenjenih limfnih nodusa (N1,N2), peritumoralna limfovaskularna infiltracija je prisutna kod 96.2% slučajeva (χ22=0.99; p<0.0000019481). Zaključak: Znatno veća zastupljenost peritumoralne limfovaskularne infiltracije, te bitna veza postojanja iste i zahvaćenosti regionalnih limfnih čvorova. Key words: lung cancer, peritumoral lymphovascular infiltration, N metastases Ključne riječi: karcinom pluća, peritumoralna limfovaskularna infiltracija, N metastaze INTRODUCTION cially in undeveloped countries, and with move of border of age to younger life age and those of female gender. According to the newest data of American Cancer Society, there is more than 170.000 of new diagnosed cases anually in the USA (1,2,3). Lung cancer presents significant health problem nowadays , with permanent increase of incidence of morbidity and mortality espe- 14 Anaplastically changed station of lung cancer leads to loss of morphofunctional organisation of neoplastical tissue, with great authonomy of malignant station, which are not linked as in a normal tissue, and it gives them possibility to perfore basal membrane and to get access to blood and lymph vessels , and what is a good predisposition to further spreading of cancer and building of secondary deposits (4). Intaking of dreinagal regional lymph nodes with metastases is manifesting with their increase which is preoperationally discovered most frequently by CT scaning of thorax, or by postoperationally with definite pathohistological tests (4,5). Analysis of international base of data from The International Association for the Study of Lung Cancer- IASLC shows that so far existing descriptors represent the most significant individual factor in relation to survival of those who suffer from lung cancer (Table 1) (3,6,7,8). K. Grbić et al. datas of relevant researches which are presented in today referent literature with presentation of discussion and comments. RESULTS Table 1 Rate of survival at NSCLC on the base of pathologic analysis of lymph nodes (comparison between 6th and 7th TNM classification) In period from 01.01.2010. to 01.01.2013. at Clinic for Thoracic Surgery CCUS in total of 239 patients under diagnosis of lung cancer were treated with some of resectional operations. Average age of all hospitalized patients was 62.72± 7.68 years. From the total number of patients 79.08 % (189/239) were men, and 20.92% (50/239) were women while proportion was 3.8 : 1 (189/50) for men. Average age for male patients was 63.46± 7.67 (from 42 to 84) and for female 59.94± 7.86 (from 21 to 80) years. Statistically there is significant difference of age in relation to gender of patients who suffer from lung cancer (t- Student = 2.12; p< 0.035) while patients of male gender in relation to female gender are in average older. State of regional lymphic nodes (of N- disease) at anylized patients is shown on Figure 1. The aim of work is to make evidence of frequency of appearence of peritumoral lymphovascular infiltration, intaking of regional lymphic nodes and to anylise possible connection of the mentioned variables, and their statistical significance. Figure 1 Representation of N- disease at patients who suffer from lung cancer. MATERIALS AND METHODS This work has analised all surgically treated patients who were hospitalised at Clinic for Thoracic Surgery CCUS (Clinical Center University of Sarajevo) with diagnossis of lung cancer in period from 01.01.2010. to 01.01.2013. Research has included 239 patients of all ages both genders. The patients who were undergone explorative thoracotomy were excluded. Research is retrospective, clinically-manipulative and descriptivlly-analitical. For each patient there is a record of workup of definite datas from existing history of diseases. Pahtohistilogical workup of unloaded operational preparations was done at Department for Pathology CCUS. Definitive pathohistological diagnosis in minimum consisted from: sort, size and degree of differentation of cancer, presence/absence of peritumoral lymphovascular (PLV) infiltration and status of lymph nodes (N0, N1 and N2). Results are demonstrated in texts, in numerals , in charts and in graphics. Statistical workup was done on PC in functions of MS Excel programme by applying coresponding statistical methods. Parametric datas were done by demonstration of absolute and procentual values, arithmetic mean was done by counting standard deviation and t- Student test in relation to set variables, while nonparametrical datas were done by chi-square test. Define level of significance is p< 0.05. There are also defined own results and there was done comparison of these results with The most representative patients were those without presence of malignant cells in lymphic nodes (N0), with share of 56.06% (134/239), while presence of N metastases is found at 43.94% (105/239) of those who suffer, where N1 level is intaken with 38.91% (93/105), and N2 with 5.03% (12/105) of secondary deposit of primary disease. Frequency of peritumoral lymphovascular infiltration of patients in total is shown on Figure 2. Figure 2 Representation of peritumoral lymphovascular infiltration. Peritumoral lymphovascular infiltration at patients who suffer from lung cancer is represented at 68.20%(163/239) cases, while at 31.80% (76/239) it did not exist. Appearance of N metastases in presence of peritumoral lymphovascular infiltration at lung cancer Figure 3. shows cumulative relation of states of lymphic nodes and existance of lymphovascular peritumoral infiltration of lung cancer. 15 Table 3. shows data on whose base thr relative risk of appearence of N metastasis in relation to PLV infiltration was worked out. Table 3 Diagram of frequency of appearence of N metastases in relation to lymphovascular peritumoral infiltration Figure 3 Relation of state of lymphic nodes and existance of PLV infiltration At case with negative lymphic nodes (N0) (134/239), lymphovascular peritumoral infiltration was present at 46.27% (62/134) while at 53.73% (72/134) cases it was absent while the mentioned difference is not statistically significant (chi-square test=3.25; p>0.07). From the total number of N1 metastases 95.70% (89/93) case had presence of lymphovascular infiltration, while only 4.30% (4/93) case did not have it. At intaking of N2 level of secondary deposit, lymphovascular infiltration was present at 100% of cases. Statistically there is a significant difference in intaking of lymphic nodes in relation to existance of PLV infiltration (chi-square test=0.99; p< 0.00000000000000019). Sensitivity, specifity, positive and negative predictive value of peritumoral lymphovascular infiltration in relation to frequency of appearance of N metastases are counted on the base of data given in the Table 2.ž Table 2 Diagram of frequency of appearance of N metastases in relation to lymphovascular peritumoral infiltraton. Sensitivity is defined as proportion or procentage of intaken lymphic nodes at existance of peritumoral lymphovascular infiltration and equals 96.1%. Specifity is defined as proportion or procentage of lymphic nodes which are not intaken in relation to existing peritumoral lymphovascular infiltration and equals 53.7%. PPV (positive predictable value) is defined as proportion of intaken lymphic nodes at existance of peritumoral lymphovascular infiltration and equals 61.9%. NPV (negative predictable value) is proportion pf patients who do not have intaking of lymphic nodes and where there is no existance of peritumoral lymphovascular infiltration and it equals 94.7%. Risk among positives : 101/4=25.2 (risk of coming into being of metastasis in lymph nodes at patient with presence of PLV infiltration). Risk among negatives:62/72=0.86 (risk of coming into being of metastasis in lymph nodes at patients where there is no presence of PLV infiltration). Total relative risk 101/4 : 62/72 =29.3 (risk of coming into being of metastasis in lymph nodes at patients with presence of PLV infiltration). DISCUSSION Lung cancer is definitely becomming the most frequent diagnosed malignic disease all over the world and is leading cause of cancers linked to mortality at women the same as men. It represents fatal disease with in the USA so far the highest noted rate of 5-years period survival of 14%, while in Europe similar as in the rest of the developed world the rate is about 8% (1,3,9). The most important surgical prognistic factor in curing lung cancer is state of lymphic nodes of mediastinumwhish significantly influence survival of five years period for patients with this disease (Table 1) (3,6,7,8,9). It was shown that presence of N1 disease significantly influence on survival of 5-years period while it was noted that the same depends of the number of N1 lymphic nodes which were intaken. Presence of N2 disease is still subject of many discussions whose results is that majority of surgens and oncoligists decide to choose combined access to disease (6,7,8,10). Within period from 01.01.2010. to 01.01 2013. at Clinic for Thoracic Surgery CCUS, total of 239 patients with diagnosis of lung cancer were undergone some of resectional operations. From total number of patients , lung cuncer was diagnosed at 79.08% (189/239) patients of male gender and 20.92% (50/239) at patients of female gender, while the proportion was 3.8:1 for men. Given data are corresponding to reports collected from relevant and accessable literature where there is mentioned similar proportion (3-5 : 1) of appearance of lung cancer among male and female gender (1,9,11). Average age of all hospitalised patients was 62.72± 7.68 (from 21 to 84) years. This detail shows a little bit lower age of patients analised in this work in relation to date from available literature where there is mentioned that frequency of appearence of lung cancer in the USA has its peak among patients older than 70 years. The mentioned difference in frequency of appearence of lung cancer in relation to age, among the data worked out in this 16 work and in available literature is most possibly partly result of the fact that in this work we only analised patients who were surgically treated, while in literature the data are related to the total number of patients who suffer from lung cancer. We should also bear in mind the fact that the average length of life in developed countries is longer (1,9,11). Average age for men was 63.46± 7.67 (from 42 to 84), and for women 59.94± 7.86 (from 21 to 80) years. It was calculated that statistically there is a significant difference (p<0.035) in average age in relation to gender while male gender is statistically older in relation to female gender what is relevant to majority of literal reports (1,3,11). Analysis od definite pathohistological tests showed that the intaking og regional lymphic nodes in metastases of primary disease (Ndisease) was 43.94% (105/239), from which in level N1 there was 38.92% (93/105), and in N2 5.03% (12/105)of secondary deposit. The most representative patients were those without presence of malignic cells in lymphic nodes (N0) with participation of 56.06% (134/239). These data are comparativly identical to data available in medical literature (6,7,12,13,14). From the total number of analized patients peritumoral lymphovascular infiltration is present at 68.20% (163/239) what leads to the conclusion that infiltration of basal membrane is present in about 2/3 of cases and it proves the fact of high potential of metastasing of epithel lung malignom. The mentioned fact is proved also on the base of the fact that from total number of metastatically changed lymph nodes (N1,N2), peritumoral lymphovascular infiltration was present at 96.19% (101/105) of cases (5,6,7,13,14). At pathologicaly proved N1 cases (93/239), PLV infiltration was present at 95.70% (89/93), while at N2 cases (12/239) PLV infiltration is present at all patients 100% (12/12). On the base of earlier shown results it was worked out that there is statistically significant relation (chi- square test = 0.99; p< 0.00000000000000019) of intaking of lymph nodes in relation to existance of PLV infiltration. At pathohistologically proved N0 cases (134/239), PLV infiltration was present at 46.27% (62/134). From the above mentioned we come to the conclusion that at non-existing of N disease there is significantly less part of existance of PLV infiltration, and that also at existance of the same it is not rule that there must be the appearence of N1 and N2 metastasis. (5,12,13,14) Relation between non-existing of N disease and existance of PLV infiltration is not statistically significant (chi–square test =3.25; p>0.07). The calculated sensitivity (96.1%), specificity (53.7%), positive (61.9%) and negative predictive value (94.7%) the same as total relative risk which shows that there is a chance of intaking of lymph nodes nearly 30 times higher at presence of PLV infiltration and they can also be indirect indicators of dependency of mentioned variables and predictors of limitation of theraupetic treatment and postresectional survival. CONCLUSION Presence of peritumoral lymphovascular infiltration in more than 2/3 of postresectional definite pathohistological tests, leads to the fact that there is statistically significant connection between the mentioned charateristic of lung cancer and frequency of regional lymphonodular metastatic invasion. Conflict of interest: none declared. K. Grbić et al. REFERENCES 1. American Cancer Society. 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Tumor characteristics influencing non – sentinel lymph node involvement in clinically node negative patients with breast cancer. J Breast Cancer. 2011;14(2):124-128. 14. Marra A, Hillejan L, Zaboura G, Fujimoto T, Greschuchna D, Stamatis G.Pathologic N1 non – small cell lung cancer: Correlation between pattern of lymphatic spread and prognosis. J Thorac Cardiovasc Surg 2003;125:543-553. Reprint requests and correspondence: Kemal Grbić, MD Clinic of Thoracic Surgery Clinical Center University of Sarajevo Bolnička 25, 71000 Sarajevo Bosnia and Herzegovina Phone: + 387 33 297 000 Email: [email protected] Appearance of N metastases in presence of peritumoral lymphovascular infiltration at lung cancer Our contribution to the reduction of cardiovascular disease in Bosnia and Herzegovina! Naš prilog redukciji kardiovaskularnih bolesti u Bosni i Hercegovini! 17 Original article Medical Journal (2014) Vol. 20, No. 1, 18-23 The usefulness of penile compression-release index for diagnosing bladder outlet obstruction in patients with benign prostatic enlargement Korisnost indeksa penilne kompresije-otpuštanja u dijagnozi opstrukcije bešičnog izlaza kod pacijenata sa benignim prostatičnim uvećanjem Damir Aganović*1, Alden Prcić1, Munira Hasanbegović1, Osman Hadžiosmanović1, Hajrudin Spahović2 1 Clinic of Urology, University Clinical Centre Sarajevo, Bolnička 25, 71000 Sarajevo, Bosnia and Herzegovina, 2General Hospital Sarajevo “Prim.dr. Abdulah Nakaš”, 71000 Sarajevo, Bosnia and Herzegovina *Corresponding author ABSTRACT SAŽETAK Objective: to determine the discriminatory power of penile urethral compression-release (PCR) index for the detection of bladder outlet obstruction and the associated bladder abnormality in patients with benign prostatic enlargement (BPE). Material and methods: 135 patients with proven BPE from daily urological practice underwent urodynamic measurement (UDM) and PCR maneuver. PCR Index was calculated following the formula: PCRI = (Qs-Qss/Qss) x 100 (%).UDM results were plotted on Schafer and URA nomograms. Results: High sensitivity and specificity have been shown (74% and 94%, respectively), as well as positive predictive value (93%) of PCR index (PCRI) in diagnosing infravesical obstruction with cut-off point of 96%. PCRI clearly distinguishes obstructed patients with normocontractile detrusor and the presence of detrusor overactivity (161% and 187%, respectively) versus those unobstructed (PCRI=63%) or obstructed patients with detrusor underactivity (DUA; PCRI=83%). Further on, there is a statistically significant difference between obstructed patients with DUA and those unobstructed (ANOVA test; F=3.8; p=0.03). Conclusion: PCRI is a very good noninvasive urodynamic test for group-wise detection of bladder outlet obstruction in patients with BPE. The understanding and application of this index can serve as a good transition toward introducing penile cuff test in daily urological practice. Cilj: odrediti diskriminantnu moć Indexa penilne kompresijeotpuštanja (PCRI) u detekciji opstrukcije bešičnog izlaza kod pacijenata sa benignim prostatičnim uvećanjem (BPU). Materijali i metode: 135 pacijenata sa dokazanim BPU iz svakodnevne urološke prakse podvrgnuto je urodinamskom mjerenju (UDM) i PCR manevru. PCR Indeks je izračunat prema formuli: PCRI= (Qs-Qss/ Qss) x 100 (izraženo u procentima). Rezultati UDM su plotirani na Schafferov i URA nomogram. Rezultati: Pokazana je visoka senzitivnost i specifičnost (74% i 94%, odnosno), te pozitivna prediktivna vrijednost (93%) PCR indeksa u dijagnozi infravezikalne opstrukcije, sa graničnom vrijednošću od 96%. PCRI jasno razdvaja pacijente u opstrukciji sa normokontraktilnim detruzorom i postojanjem detruzorske hiperaktivnosti (161% i 187%, odnosno) u odnosu na pacijente van opstrukcije (PCRI=63%) ili u opstrukciji sa detruzorskom hipokontraktilnošću (DUA; PCRI=83%). Nadalje, postoji statistički signifikantna razlika između pacijenata sa DUA u opstrukciji u odnosu na pacijente van opstrukcije (ANOVA test; F=3, 8; p=0,03). Zaključak: PCR indeks predstavlja veoma dobar neinvazivni urodinamski test u grupnoj detekciji opstrukcije bešičnog izlaza kod pacijenata sa BPU. Shvatanje i aplikacija ovoga indeksa služe kao dobar prelaz prema uvođenju testa sa penilnom manžetnom u svakodnevnu urološku praksu. Key words: benign prostatic enlargement, bladder outlet obstruction, non invasive urodynamics Ključne riječi: benigno uvećanje prostate, opstrukcija bešičnog izlaza, neinvazivna urodinamika INTRODUCTION in the diagnosis of this disease, but from the therapy optimization perspective it is very important to prove bladder outlet obstruction (infravesical obstruction). In patients with LUTS and suspected bladder outlet obstruction, the obstruction is urodynamically proven only in 50% to 66% of cases (1). Benign prostatic enlargement (BPE) is an aging disease, causing considerable deterioration in quality of life, expressed by lower urinary tract symptoms (LUTS). There are a number of algorithms The usefulness of penile compression-release index for diagnosing bladder outlet obstruction in patients with benign prostatic enlargement Uroflowmetry is an additional test for diagnosing the disease, but it is not sufficiently sensitive or specific since a low flow is not necessarily caused by the obstruction, it can also be caused by detrusor underactivity (DUA) (2). For the time being, pressureflow studies (PFS) are the only method for an accurate diagnosis of infravesical obstruction. This urodynamic test is reliable, reproducible, but also time-consuming and invasive, causing discomfort and pain to patients. This is why numerous noninvasive techniques have been developed and validated, including penile compression-release index, condom catheter method, and penile cuff technique (3), to replace invasive testing. The penile urethral compression-release (PCR) maneuver is a test which determines a possible infravesical obstruction by a simple gradual squeezing of penile urethra during urination (4). The theory is based on isobaric conduit (bladder and urethra) and the generation of isovolumetric detrusor pressure, when flow rate reduction amounts to zero, i.e. when the flow stops completely. The flow generated after the release maneuver represents surge flow (Qs), and once the flow has stabilized, quasi steady-state flow appears (Qss) (Figure 1). PCR index is determined from these reference points. In such a way, it is possible to distinguish, with a high discrimination value, between obstructed patients and those unobstructed; however, there are difficulties in diagnosing unobstructed patients with DUA or another bladder abnormality. This is why this prospective study was conducted – to examine the sensitivity of this parameter in patients with BPE accompanied by the above-mentioned abnormalities. The difference in PCR index in obstructed patients was specifically focused on, depending on the presence of detrusor overactivity (DO). Figure 1 Uroflow examination. After PCR maneuver, high Qsurge was reached. After the stabilization of the flow, steadystate flow emerged (Qss=7,8 ml/sec.). Patient is in the region of clear defined obstruction (URA= 39 cmH2O), with normal contractility of detrusor. PCRI= 117%. Qsurge (Qs)=17 ml/sec, steady-state flow (Qss)=7.8 ml/sec. MATERIALS AND METHODS During the period 2011-2013, the prospective study was carried out on 140 patients with lower urinary tract symptoms (LUTS) due to BPE at the Urology Clinic of the Sarajevo University Hospital. Finally, 135 patients were covered by the analysis. The exclusion criteria were all conditions, illnesses, neurological abnormalities 19 and medication that could interfere with the act of micturition.The transabdominal ultrasound (TAUS) determined the patients’ prostate volume, as well as intravesical protrusion of the prostate (IPP) at the bladder volume of 150-200 ml.The intravesical prostatic protrusion (IPP) and bladder wall thickness (BWT) were measured applying standard methodology described elsewhere (5, 6). The patients completed International Prostatic Symptom Score (IPSS) and signed the Informed Consent Form. After that, it was explained to the patients how the penile compression-release (PCR) maneuver is performed. During the examination of flow, once the urinary stream started, the patient should gradually squeeze the penis to abort the flow with complete relaxation of the pelvic floor. After 2-3 seconds, the patient released the compressed urethra and voiding was continued till the end. Two main points were taken; surge flow after releasing the urethra (marked as the reference point Qs), and the second point was taken when the flow was stabilized (marked as the reference point of the steady-state flow - Qss). PCR Index was calculated for each patient, following the formula: PCRI = (Qs-Qss/Qss) x 100. The index was expressed as a percentage (4). Patients with the voided volume of less than 150 ml during PCR testing were excluded because of proven poor reliability (7). The next day, the patients underwent conventional urodynamic studies (UDS) using the Andromeda Ellipse 4 apparatus. Urodynamic studies were done according to the “good urodynamic practices” by the International Continence Society (ICS) (8). Then, the findings of pressure/flow studies (PFS) were plotted on the Schafer obstruction class nomogram (9) and URA-group specific urethral resistance factor (10). Each patient had their bladder outlet obstruction index (BOOI= PdetQmax -2Qmax) determined, as well as bladder contractility index (BCI= PdetQmax +5Qmax) and bladder voiding efficiency (BVE=voided volume/total bladder capacity x100) calculated (11). Statistical analysis was performed applying ANOVA test, Pearson correlation coefficient, calculation of area under the receiver operating characteristic (ROC) curve for predicting obstruction, while AUCs were compared via the method of DeLong (12). The Bland-Altman plot, or difference plot (13) was used as a graphical method to compare the two measurement techniques; in this study to determine the possible differences between the values of Qmax and Qss. Statistic analysis was made using Medcalc program for Windows version 12. The level of significance (two-tailed) was set at p <0.05. RESULTS Out of the 140 patients that underwent the PCR maneuver, 135 of them were finally covered by the analysis.The drop-out 4% were the patients unable to initiate the stream (restore the flow) following the PCR maneuver, probably due to reflex inhibition of the resulting pelvic floor contraction. Only eleven patients (8%) experienced pain and discomfort in the perineum, within the pubic space, and in the urethra, following the PCR maneuver (they all belonged to the unobstructed group). 70 patients (52%) had urodynamically proven obstruction, according to URA nomogram. The mean age of subjects was 66 years, the average IPSS (17.1) fell within the 2nd category (moderate symptoms).The mean pros- 20 tate volume amounted to 47.1 ccm, while postvoid residual urine amounted to 66 ml (0-286 range). The average bladder contractility index (BCI) amounted to 103.5, therefore, on the borderline towards the region of detrusor underactivity (DUA), and the average PCR Index amounted to 100.3% (26-266 range). The data are shown in Table 1. D. Aganović et al. rate (Qmax), detrusor contraction duration (DCD), detrusor pressure at maximum flow (PdetQmax) and maximum detrusor pressure (Pdetmax). The correlation with bladder contractility index (BCI) is not shown (p=0.36), although there is a very strong correlation with the grade of detrusor contraction (GDC), according to Schafer nomogram. Also, PCRI correlates very well with the degree of urodynamic obstruction, expressed as BOOI (Figure 2). Table 1 Summary statistics IPSS- International prostatic symptom score, PV-prostate volume, PVR-post void residual urine, IPP –intravesical protrusion of prostate, PCR Index- penile compressionrelease index, BCI- bladder contractility index. In order to determine the correlation of the observed variable (PCRI) according to physiological, radiologic and urodynamic parameters, a correlation matrix was done for the observed variables. The most important results are shown in Table 2. Figure 2 Linear regression for BOOI and PCR Index Table 2 Correlation coefficient for PCRI and observed variables Since a good statistical correlation of PCR index with age was shown, patients were subgrouped into three age categories. The category under 60 years of age included 21 patients (15.5%), the category under 70 years of age included 63 patients (47%), while the category of oldest patients – those over 70 years of age, included 51 patients (37.5%). ANOVA test (F=5.9; p 0.003) showed age dependence of PCRI value, including the dependence on a higher degree of infravesical obstruction. The average PCRI for the youngest age group amounts to 67% (most patients unobstructed), followed by the medium-age and the oldest groups with PCRI amounting to an average of 98.4% and of 116.2%, respectively (Figure 3). PV-prostate volume, Qmax –maximum urinary flow, BWT-bladder wall thickness, IPP –intravesical protrusion of prostate, PVR-post void residual urine, IPSS- International prostatic symptom score, DCD-detrusor contraction duration, GDC- grade of detrusor contraction, BCI- bladder contractility index, BVE –bladder voiding efficiency*Spearman’s coefficient of rank correlation (rho) There is a statistically significant correlation of PCRI with patient’s age and the size of intravesical protrusion as a factor of infravesical obstruction. Observed from urodynamic point of view, there is a strong correlation of this parameter with maximum flow Figure 3 Age depending PCR index The usefulness of penile compression-release index for diagnosing bladder outlet obstruction in patients with benign prostatic enlargement Then, the predicted probability of this noninvasive urodynamic factor was determined according to urodynamic bladder outlet obstruction, defined based on URA nomogram. Cut-off point for PCRI of 96.4% gives the sensitivity and specificity of 74.3% and 93.8%, respectively, according to the obstruction, with a high positive predictive value (PPV) of 93%, and negative predictive value (NPV) of 77.2% (95% CI 0.777 to 0.904). Figure 4 Interactive dot diagram for PCR Index and URA nomogram NO-no obstruction, OB-obstruction Since the high predictive power of this factor according to the obstruction was proven, it was compared with other obstruction factors, i.e. maximum flow rate (Qmax) and intravesical prostatic protrusion (IPP). A comparative analysis was made using ROC curves, and again the best discriminatory power of PCR Index according to the obstruction was shown. The area under the curve (AUC) for PCRI is 0.85, while AUC for Qmax is 0.8 (sensitivity and specificity 67.1% and 80%, respectively; 95% CI 0.72-0.78), while for IPP 0.71 (sensitivity and specificity 69% and 74%, respectively; 95% CI 0.621-0.701), Figure 5. Pair-wise comparison of ROC curves by DeLong method showed a statistically significant difference between areas for PCR Index and IPP (a=0.143; p=0.007), Table 3. 21 Table 3 Pair wise comparison of ROC curves The patients were then divided into five groups, depending on detrusor contractility and obstruction: the first group of 27 patients with normal detrusor contractility and no obstruction (20%), the second group of 38 patients with impaired detrusor contractility and no obstruction (28%), the third group of 34 patients in the region of clear obstruction with normal contractility (25%), the fourth group of 19 patients with obstruction and with normal contractility and detrusor overactivity (14%), and the fifth group of 26 patients with obstruction and with impaired detrusor contractility (19%) (Figure 6.). A clear difference was shown in obstructed patients with preserved contractility with or without detrusor overactivity (PCRI=161% and 187%, respectively; ANOVA test; F=9.2, p=0.005), and in relation to the non-obstructed group and the group of patients with obstruction and impaired detrusor contractility (PCRI= 63% and PCRI=83%, respectively; ANOVA test; F=43, p<.00001).The obstructed patients with impaired detrusor contractility based on PCR Index (PCRI=83%) as a group could be statistically different from the group of unobstructed patients with or without impaired detrusor contractility, using ANOVA test (F=3.8, p=0.03). Figure 6 Average values of PCR Index depending on detrusor contractility, obstruction and the presence of DO. IC-NO impaired contractility-no obstruction, NC-NO normal contractility -no obstruction, NC-OB normal contractility with obstruction, IC-OB impaired contractility with obstruction, NC-OB +DOA normal contractility with obstruction and detrusor overactivity Figure 5 Comparison of ROC curves in the prediction of obstruction Qmax-maximum flow rate, PCR Index- penile compression- release index, IPP –intravesical protrusion of prostate In order to analyze PRC index only with obstruction, patients from this category (No=70), were divided according to detrusor contractility and the presence of DO. Of 44 patients with preserved detrusor contractility (63%), 19 patients (43,1%) had detrusor overcontractility (DO). Of 26 patients with impaired detrusor contractility, 10 patients (38%) had DO (Figure 7). There is a clear distinction in PCR index in patients with the presence of DO and preserved detrusor contractility (PCRI= 187% and 141%, respectively) compared with those with impaired detrusor contractility and the presence of DO, where there is no clear statistical difference (PCRI=80% and 86%, respectively; ANOVA test; F=2, p=0.16). 22 Figure 6 Average values of PCR Index depending on detrusor contractility and the presence of DO in the region of obstruction. NC;DOA normal contractility without detrusor overactivity, NC;DOA + normal contractility with detrusor overactivity, IC;DOA impaired contractility without detrusor overactivity, IC- DOA + impaired contractility with detrusor overactivity The patients were also analyzed for maximum flow rate and PCRI reference points, i.e. Qs and Qss (Table 4). What clearly distinguishes the patients without obstruction and with normal detrusor contractility is a clearly higher Qmax, compared with the other two categories, while the patients with impaired detrusor contractility, regardless of the condition regarding obstruction, have both Qs and Qss far lower, compared with the other categories. The patients with obstruction and with preserved detrusor contractility and the presence of DO have the highest Qs. Table 4 Group wise values of maximum urinary flow (Qmax), surge flow (Qs), and steady-state flow (Qss). IC-NO impaired contractility-no obstruction, NC-NO normal contractility no obstruction, IC-OB impaired contractility with obstruction, NC-OB normal contractility with obstruction, NC-OB +DOA normal contractility with obstruction and detrusor overactivity Since there was a strong similarity between the values of maximum urinary flow (Qmax) and Qss during the PCR index, these two variables were comparatively analyzed, using Bland-Altman plot (Figure 8.). The mean value of Qmax is 8.8 ml/sec, while the mean value of Qss is 7.7 ml/sec, giving the average difference of -1.1 ml/ sec (SD 1.8; 95%CI -1.318 to -0.0773). The agreement was further confirmed by defining the correlation coefficient for these two variables with a strong r=0.88 (95% CI 0.8314 to 0.9111; p<.0001). D. Aganović et al. Figure 8 Bland-Altman plot of difference between Qss and Qmax as a function of mean DISCUSSION In the pioneer research of Sullivan and Yalla (4), it was shown that PCR Index clearly distinguished patients with obstruction (PCRI= 183%) from those without obstruction, but with the presence of DO (PCRI=157%), as well as from those with impaired detrusor contractility (PCRI=70%) or those with normal detrusor contractility without obstruction (PCRI=67%). Also, younger volunteers without obstruction did not have a high PCR index. Sullivan, using PCR index cut-off of 100%, shows the sensitivity and specificity according to the obstruction of 91% and 70%, respectively. However, this study does not emphasize the obstructive status of patients with DUA or DO. Harding et al. (14), while comparing standard pressure/flow studies with penile cuff test, also determined PCR Index. They found the optimal threshold for the detection of obstruction with PCR Index of 160%, with PPV of 69% according to bladder outlet obstruction. Such an increase in the cut-off value can be explained by the use of automated penile cuff, since it was proven that external control of compression produces higher values of isovolumetric pressure than the voluntary mechanical compression, perhaps due to the inhibition of detrusor contraction in patients performing the manual compression. PCR index, as confirmed by this study as well, provides twice as high values in obstructed patients than in those not obstructed or those obstructed, having impaired detrusor contractility. Formerly, it was viewed that there is no difference in patients with obstruction or another bladder abnormality just because patients with DO were clearly distinguished, without being classified into obstructed or nonobstructed group. The originality of this study lies in the fact that obstructed patients were dichotomized into those with the presence or absence of DO. A statistically more significant increase in PCR index was shown in patients having normocontractile detrusor with DO than in those having normocontractile muscle but without DO (average value 187.2% vs. 161 %, p= 0.005). Further on, our study has shown a strong discriminatory power of PCRI according to the obstruction with sensitivity and specificity of 75% and 94%, respectively, and excellent PPV (93%), with the most optimal PCR Index cut-off of 96%. The usefulness of penile compression-release index for diagnosing bladder outlet obstruction in patients with benign prostatic enlargement 23 There are weak statistically significant differences in patients without obstruction and those with impaired detrusor contractility. That is why it is very important to follow both Qmax and uroflow curve in the conditions of low flow, for the detection of DUA. It is also very important to follow reference points during the determination of PCRI, i.e. Qs and Qss, since they provide very important information. Patients with detrusor overactivity (DO) without obstruction have a typical curve during PCR maneuver. High Qs is also characteristic, accompanied with a high Qss, which is similar to that in patients without obstruction and normal contractility. Qs has an increasing tendency in patients with DO, compared with those having normal flow, which correlates with enhanced contractility in the presence of DO. Patients without clearly obstructive pathology have a higher Qss, which corresponds to a higher maximum flow rate. Patients with detrusor underactivity neither have high Qs nor do they have high Qmax (Qss). (15). As emphasized in earlier studies, the increase of PCRI points to increased contractility and velocity of the detrusor. PCRI correlates very well with urodynamic determinants of obstruction (Qmax, PdetQmax, Pdetmax). Since the dependence of PCRI on detrusor contractility has been proven, it is logical that this variable strongly correlates with the grade of detrusor contraction (GDC), derived from Schafer nomogram (rho=0. 44, p<0.0001), however, correlation with bladder contractility index (BCI) is not shown (p=0.16). Again, there is very strong correlation between BCI and GDC (rho=0.6; p<0.0001), suggesting that in similar research studies GDC should be used as a measure for detrusor contractility. Further on, better sensitivity and specificity of PCR Index have been shown compared with the maximum flow rate (Qmax) or the volume of intravesical prostatic protrusion (IPP), being good predictors of obstruction (16, 17). Again, PCRI correlates well with age, since the group-wise increase of PCR Index has been shown with age; thus, the mean PCR Index in the youngest age group of patients with BPE is only 67%, compared with patients over seventy years of age, having almost twice as high mean PCR Index of 116%. Harding et al. (14) did not find differences between Qmax measured during conventional PF studies and Qss, determined during PCR maneuver. The mean difference between these two parameters was 0.4 ml/sec (SD 4.5). This study also showed significant agreement between Qmax and Qss (mean difference 1.1 ml/sec; SD 1.8), along with excellent correlation coefficient (r=0.88); thus, these two parameters can be used interchangeably in daily practice, particularly in diagnosing the state of obstruction with low detrusor contractility, along with additional uroflow curve monitoring. The results of the study suggest that PCR index combines the measure of detrusor contractility (Qs) with the actual maximum flow rate (Qss). Qs, therefore, is an important measure of detrusor contractility (isovolumetric strenght). physiology, detrusor contractility and isovolumetric pressure generation in patients with BPE. The test is easy to perform; drop-out rate is very low, while side effects are rare and tolerable. CONCLUSION Reprint requests and correspondence: Damir Aganović, MD, PhD Clinic of Urology, CCUS, Bolnička 25, 71000 Sarajevo, Bosnia and Herzegovina, Phone: +387 33 297 754 Email: [email protected] PCR Index is shown to be a very good diagnostic instrument for the detection of infravesical obstruction. It represents a very good introduction to noninvasive urodynamic diagnostics since it shows significant specificity and PPV in the condition of infravesical obstruction caused by BPE, and is useful in the study of urethra Conflict of interest: none declared. 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Med Arh 2012;66(4): 296-300 Original article Medical Journal (2014) Vol. 20, No. 1, 24-26 Evaluation activities of daily living in patient’s rehabilitation with osteoporosis Procjena aktivnosti svakodnevnog života u rehabilitaciji pacijenata sa osteoporozom Edina Tanović1*, Aldijana Kadić1, Haris Tanović2, Dževad Vrabac1 Clinic for Physical Medicine and Rehabilitation, Clinical Center University of Sarajevo, Bolnička 25, 71000 Sarajevo, Bosnia and Herzegovina; Clinic for Abdominal Surgery, Clinical Center University of Sarajevo, Bolnička 25, 71000 Sarajevo, Bosnia and Herzegovina 1 2 *Corresponding author ABSTRACT SAŽETAK The objectives are to evaluated the length of stay in hospital (LOH), and Barthel index (BI) at admission and discharge from rehabilitation, in patients with osteoporosis as comorbidity.We were conducted a retrospective study in the period from January, 1st to the December, 31th 2012 and as a source of data we used medical records. The study included 39 patients with osteoporosis and who were hospitalized at the Clinic for Physical Medicine and Rehabilitation, Clinical Center University of Sarajevo. We have evaluated activities of daily living by Barthel index. Descriptive statistical methods were used: frequency and relative frequency, median and interquartile range (iqr). Results: Out of a total number of patients (n=39), 31 (79.5%) were females and 8 (20.5%) were males. The median age for females was 70.0 years (IQR=61.0 to 74.0), and for males 72.5 years (IQR=48.3 to 79.5). The median of LOH was 29.0 days (IQR=22.5 to 36.0). The median of BI at admission was 16.0 (IQR=11.0 to 19.5) and the median of BI at discharge was 17.0 (IQR=13.0 to 20.0). Conclusion: Osteoporosis as comorbidity didn’ t influence on longer length of stay in hospital and there was not a clinicaly significant improvement in activities of daily living in these patients. Cilj rada je procijeniti koliko osteoporoza utiče na dužinu hospitalizacije, te vrijednosti Barthel indeksa-a na prijemu i na otpustu kod pacijenata sa osteoporozom kao komorbiditetom. Provedena je retrospektivna studija koja uključuje 39 pacijenata sa osteoporozom kao komorbiditetom, hospitaliziranih na Klinici za fizijatriju i rehabilitaciju, Klinički centar Univerziteta u Sarajevu u periodu janaur-decembar 2012. godine. Kao izvor podataka su analizirane istorije bolesti pacijenata. Aktivnosti svakodnevnog života su procjenjene prema Barthel indeksu. Korištene su deskriptivne statističke metode: apsolutna i relativna frekvencija, mjere centralne tendencije (medijana i interkvartilni raspon - IQR).Rezultati: Od ukupanog broja pacijenata (n=39), 31 (79,5%) su bili ženskog spola i 8 (20,5%) su bili muškog spola. Medijana starosne dobi za žene iznosi 70,0 godina (IQR=61,0 do 74,0 godine) i za muškarce 72,5 godine (IQR=48,3 do 79,5 godina). Medijana dužine hospitalizacije iznosi 29,0 dana (IQR=22,5 do 36,0 dana). Medijana vrijednosti Barthel indexa-a na prijemu iznosi 16,0 dana (IQR=11,0 do 19,5 dana), a na otpustu 17,0 dana (IQR=13,0 do 20,0). Zaključak: Osteoporosa kao komorbiditena bolest nije značajno uticala na dužu hospitalizaciju, a u aktivnostima svakodnevnog života nije evidentirano klinički signifikantno poboljšanje kod pacijenata na rehabilitaciji. Key words: osteoporosis, Length of Stay in Hospital (LOH), Activities of Daily Living (ADL), Barthel index (BI) Ključne riječi: osteoporoza, dužina hospitalizacije, aktivnosti svakodnevnog života, Barthel indeks INTRODUCTION tion. Throughout youth, the body uses these minerals to produce bones. If calcium intake is not sufficient, or if the body does not absorb enough calcium from the diet, bone production and bone tissues may suffer (3). As people age, calcium and phospate may be reabsorbed back into the body from the bones, which makes the bone tissue weaker. Both situations can result in brittle, fragile bones that are subject to fractures, even in the absence of trauma. Researchers estimate that about 20% of American women over the age of 50 have osteoporosis. In addition, another 30% of them have osteopenia, which is abnormally low bone density that may eventually deteriorate into osteoporosis, if not treated. About half of all women over the age of 50 will suffer a fracture of the hip, wrist, or vertebra (3,4). Now we know that 1 in 5 people with a hip fracture do not walk again. The results show the importance of the rehabilitation of these patients, as well as the significant ef- Osteoporosis is characterized by low bone mass and structural deterioration of bone tissue, which leads to bone fragility and an increased propensity to fractures (1). In the U.S. 44 million people over 55 years of age are diagnosed with osteoporosis. In BiH currently affects 162 000 women. The World Health Organization estimates that by 2025. the number of hip fractures will grow up to 3 million a year. Epidemiological studies which confirm that subjects who are born light and whose growth falters in the first year of postnatal life, have significantly lower bone size and mineral content, at age 60 to 75 years (1,2). Osteoporosis occurs when the body fails to form enough new bone, or when too much old bone is reabsorbed by the body, or both. Calcium and phosphate are two minerals that are essential for normal bone forma- 25 Evaluation activities of daily living in patient’s rehabilitation with osteoporosis fects on the patient, the family and their economic status (3,5). Preventive strategies against osteoporotic fracture can be targeted throughout the life course. Although there is evidence to suggest that peak bone mass is inherited, current genetic markers are able to explain only a small proprostion of the variation in individual bone mass or fracture risk. Evidence has begun to accrue that fracture risk might be modified by environmental influences during intrauterine or early postnatal life (1). The rapid development and availability of effective therapies for osteoporosis over the last 20 years has been one of the grest success stories- many might therefore belive that the problem of osteoporosis is largely solved. But the full impact of therapeutic strategies, both pharmacological and non- pharmacological (e.g. exercise, falls prevention) can only be achieved by widespread, systemic application of best clinical practice targeting to best therapies to those most at risk (2). One of the best indicators that a skeleton will fail in the future in the fact that is has failed in the past. Those patients thet suffer a fragility fracture today are much more likely to suffer fractures in the future (2,3). The objectives are to evaluated the length of stay in hospital (LOH), and Barthel index (BI) at admission and discharge from hospital, in patients with osteoporosis as comorbidity. Figure 2 Distribution of patients according to age The median age for females was 70.0 years (IQR=61.0 to 74.0), and for males 72.5 years (IQR=48.3 to 79.5) for males (Figure 2). The median of length of stay in hospital (LOH) was 29.0 days (IQR=22.5 to 36.0). MATERIALS AND METHODS We were conducted a retrospective study in the period from January, 1st to the December, 31th 2012 and as a source of data we used medical records. The study included 39 patients with osteoporosis who were hospitalized at the Clinic for Physical Medicine and Rehabilitation, Clinical Center University of Sarajevo. We analyzed socio-demographic variables such as gender and age and also the length of stay in hospital on rehabilitation.We have evaluated activities of daily living by Barthel index at admission and at discharge. Stastical analysis Descriptive statistical methods were used: frequency and relative frequency, median and interquartile range (IQR). RESULTS Figure 3 Box plot of Barthel index at admission and discharge The median of BI at admission was 16.0 (IQR=11.0 to 19.5) and the median of BI at discharge was 17.0 (IQR=13.0 to 20.0) (Fig.3). DISCUSSION Figure 1 Distribution of patients according to gender Out of a total number of patients (n=39), 31/39 (79.5%) were females and 8/39 (20.5%) were males (Figure 1). In our stady we analyzed a 39 patients. The frequency of males was 79.5% and 20.5% were males.These results are consistent with others similar studies ( 3,5,6 ). The median age for females was 70.0 years (IQR=61.0 to 74.0), and for males 72.5 years (IQR=48.3 to 79.5) for males. Garcia et al. published that the median age for women was 72.1 years, which coincides with the data in our study (5). Boskovic and al. mentioned that the quality of life of patients with the osteoporosis observes the role of physical functioning, which leads to the need for adequate assessment of the quality of life through specific surveys (6). Spica and colleagues in their study published in 2008 stress that patients who were treated with only physical procedures didn’t experience an increase in bone 26 density, but there was no increase in the number of fractures, which is considered a positive effect of physical therapy (7). The median of length of stay in hospital was 29.0 days (IQR=22.5 to 36.0).The rehabilitation of these patients are usualy longer because they need more help and rehabilitation would continue at home (3). The median of BI at admission was 16.0 and the median of BI at discharge was 17.0.In our work, after assessing activities of daily living, we determined that was no significant recovery by Barhel index. Patients with osteoporosis can not be rehabilitated in the period as they treated our patients. This period was used to assist and guide patients in the rehabilitation process that they will continue at home (3,7). Rauter in a paper published in 2008 highlights the shortcomings of measuring activities of daily living. Bojnec and associates in the work of 2011 emphasis that there is no general consensus on the evaluation activities of daily living of patients with ostoporosis (8,9). Physical activities continue to stimulate increases in bone diameter throughout the lifespan.(10) These exercise-stimulated increases in bone diameter diminish the risk of fractures by mechanically counteracting the thinning of bones and increases in bone porosity.(11) Exercise should be dynamic, exceed a threshold intensity and strain frequency, be relatively brief but intermittent, and also be supported by unlimited nutrient energy and adequate calcium and vitamin D3 supplements (12,13). Prevention of osteoporosis is necessary and when it is identified as a co-morbidity. Further analysis in this regard, especially the application of appropriate questionnaires to verify the effects on activities of daily living, would be useful. E. Tanović et al. 4. Avdić D. Pad u trećoj životnoj dobi. Sarajevo: OKO; 2004. 5. Garcia-Martin A, Reyes-Garcia R, Garcia-Catsro JM, Munoz-Tormes M. Diabetes and osteoporosis: action of gastrointestinal hormones on the bone. Rev Clin Esp 2013;213(6):294-7. 6. Bošković K, Protić-Glava B, Grajić M, Madić D, Obradović B. Adapted physical activity in the prevention of therapy of osteoprosis. Med pregl 2013;66(56):221-224. 7. Romano-Spica V, Partalo A, Partalo D, Lorenzo E, et all. Health promotion through physicals activity: teritories models and experiens. Ann Ig 2008;20(3):291-11. 8. Rauter T, Pugartnik T. Outcome Measuerment of Hip Fracture. Rehabilitacija: Inštitut Republike Slovenije za rehabilitacijo. 2008;7(2):35-39. 9. Bojnec V, Celan D, Palfy M, Turk Z. Efects of exercise on quality of life in patients with osteopenia or osteoporosis-implementation of the qualeffo-41 quastionare in Slovenia. Rehabilitacija: Inštitut Republike Slovenije za rehabilitacijo. 2011;10(12):37-44. 10. Tanović E. Opća kineziterapija. Sarajevo: V-Graf; 2012. 11. Shava H, Favela E, Diaz J. Knowledge of osteoporosis among men in the primary care setting. South Med J 2011;104(8):584-588. 12. Park J, Linde K, Maucimer E, Malsberger A, Sherman K, Smith C, et al. The Status and Future of Acunptucture Clinical Research. J Altern Complement Med 2008;14(7):871-881. 13. Maliberger A, Straeilberger K, Kraemer J, Brittinger C, Witte S, Boewing G, et al. Desinging and Acupuncture study II.The Nationwide, Randomized, Controled German Acupuncture Trials of Low Back Pain and Goanrthrosis. J Altern Complement Med 2006;12(8):733-742. CONCLUSION Osteoporosis as comorbidity did not influence on longer length of stay in hospital and there was not a clinicaly significant improvement in activities of daily living in these patients. REFERENCES 1. Cooper C. Epigenetics and developmental originis of osteoporosis. Osteoporosis Int 2013;24 (Suppl 1):27-31. 2. McCloskey E. Secondary prevention: a call to action. Osteoporosis Int 2013;24 (Supp 1):27-31. 3. Tanović E, Čelik D, Kadić A, Vrabac Dž. One Year Prevalence Rate for Osteoporosis as a Comorbidity in Patients on Rehabilitation. Osteoporosis Int 2013;24 (Supp 1):310. Reprint requests and correspondence: Edina Tanović, MD, PhD Clinic for Physical Medicine and Rehabilitation Clinical Centar University of Sarajevo Bolnička 25, 71000 Sarajevo Bosnia and Herzegovina Phone: +387 33 298 465 Email: [email protected] Original article Medical Journal (2014) Vol. 20, No. 1, 27-29 Testicular volume in healthy prepubertal boys Zlatan Zvizdić1*, Denisa Zvizdić2, Sandra Vegar Zubović3, Amra Džananović3, Faris Fočo4 1 Clinic of Pediatric Surgery, Clinical Centre University of Sarajevo, Bolnička 25, 71000 Sarajevo, Bosnia and Herzegovina; 2Clinic of Ophthalmology, Clinical Centre University of Sarajevo, Bolnička 25, 71000 Sarajevo, Bosnia and Herzegovina; 3Clinic of Radiology, Clinical Center University of Sarajevo, Bolnička 25, 71000 Sarajevo, Bosnia and Herzegovina; 4Clinic for Maxillofacial Surgery, Clinical Center University of Sarajevo, 71000 Sarajevo, Bosnia and Herzegovina * Corresponding author ABSTRACT SAŽETAK Estimation of prepubertal testicular volume is important to define the onset of puberty as well as in the evaluation of boys with a variety of disorders affecting testicular growth and development, such as varicocele and undescended testis, and after testicular torsion. In this study, we determined the baseline testicular volume measured by ultrasonography (USG) and using the Prader orchidometer. In addition, we assessed the validity of the Prader orchidometer per age group by correlating it with volume measurement by ultrasonography. Our study included 60 healthy boys, aged 0.5 to 12 years, divided into fourth groups according the age: 0.5-3, 4-6, 7-10 and 11-12 years. The ultrasonography measurements of testicular volume were calculated using Lambert formula (length x width x height x 0.71.). Mean testicular volume was compared between the different age categories. The results showed that the mean testicular volume in boys aged 0.53 years was 1.032ml ± 0.12, in boys aged 4-6 years was 1.163ml ± 0.12, in boys aged 7-10 years was 1.257ml ± 0.09 while testicular volume in boys aged 11-12 years was significantly higher than in all younger age groups. Određivanje volumena prepubertalnog testisa je važno u definisanju javljanja puberteta kao i u evaluaciji dječaka s različitim poremećajima koji uzrokuju poremećaj rasta i razvoja zahvaćenog testisa, kao što su varikokela i nespušteni testis, kao i poslije torzije testisa. U ovom istraživanju smo utvrđivali referentne vrijednosti testikularnog volumena dobijene ultrasonografski i korištenjem Praderovog orhidometra. Osim toga, procjenjivali smo validnost rezultata dobijenih Praderovim orhidometrom za dobne grupe, koreliranjem sa volumenima izmjerenim ultrasonografski. Naše istraživanje je uljučilo 60 zdravih dječaka, u dobi od 5 mjeseci do 12 godina, podijeljeni u četiri grupe po dobu: 0,5-3, 4-6, 7-10 i 11-12 godina. Ultrazvučno određivanje volumena testisa je izračunavano korištenjem Lamberove formule (dužiba x širina x debljina x 0,71). Srednji testikularni volumen je kompariran između različitih dobnih grupa. Rezultati su pokazali da je srednji testikularni volumen kod dječaka starosti 0,5-3 godine bio 1.032ml ± 0.12, kod dječaka starosti 4-6 godina 1.163ml ± 0.12, kod dječaka starosti 7-10 godina 1.257ml ± 0.09, dok je volumen testisa kod dječaka u dobi 11-12 godina signifikantno veći nego u svim mlađim dobnim grupama. Key Words: testicular volume, measurement, prepubertal boys Ključne riječi: testikularni volumen, mjerenje, prepubertalni dječaci INTRODUCTION composed of a series of 12 consecutive testicular samples with a size ranging from 1 to 25 ml which are made of different materials including plastic or wood (4) (Figure1). Testicular volume is related to various reproductive endocrine parameters (1). Furthermore, testicular volume significantly correlated with the testicular function, since seminiferous tubules and germinal elements comprise approximately 98% of testicular mass (2). Estimation of prepubertal testicular volume is important to define the onset of puberty as well as in the evaluation of boys with a variety of disorders affecting testicular growth and development, such as varicocele and undescended testis, hypogonadism with respect to tubular function and after testicular torsion (3).Therefore, the measurement of testicular volume represents important indirect indicator of functional status of the measured prepubertal testicle. A number of clinical methods have been used for the measurement of testicular volumes, including a centimeter ruler, orchidometers (4,5), sliding caliper or ultrasonography. Probably the most common orchidometer among the ones used currently is the orchidometer developed by Prader, described in 1966, which is Figure 1 Prader orchidometer 28 MATERIALS AND METHODS In accordance with the Helsinki declaration, the Institutional Review Board (IRB), and the Independent Ethics Committee of Clinical Center University of Sarajevo approved all aspects of this study. 60 healthy boys whose families gave consent were included in the study. The participans were divided into four groups according to age: 0.5 to 3, 4 to 6, 7 to 10 and over 10 years. The ages of the children were calculated using decimal age table. All children were examined by the same physicians. The volume of 120 testes in 60 prepubertal boys with a mean age of 6,1 years (range 0.5 to 12 years) was measured by ultrasonography and using the Prader orchidometer. Testicular volumes (ml) were calculated using the empiric formula of Lambert (length x width x height x 0.71) (6). Ultrasound studies were performed by experienced sonog¬raphers using linear array probe 7.5 - 10 MHz. Data analyses Statistical analyses was done using the Statistical Package for Social Sciences (SPSS) version 17.0. Simple frequencies were determined for the age, while descriptive statistics were used for the testicular volume measurements.The paired sample t-test was used for evaluating the significance of testicular volumes, while the correlation was determined using the Pearson correlation coefficient. RESULTS We found no statistically significant differences in the results of measurements by different techniques (ultrasonography vs Prader orchidometer). Actually, statistical correlation of measured results between the two methods showed statistically significant correlation correlation (P < 0.01). Figure 2 Mean testicular volume between the different age categories. There are presented average (X+SEM) of the testicular volumes of examinees aged 0,5-3 years (N =32); 4-6 years (N =24); 7-10 years (N =40); and > 10 years (N =24), p< - probability The mean testicular volume ( ± SD) per age category is shown in Figure 2. The results showed no significant differences in the testicular volume between groups of the healthy boys aged 0.53 years (1.032 ± 0.12), 4-6 years (1.163 ± 0.12) and 7-10 years (1.257 ± 0.09). Inversely, there was statistically significant difference Z. Zvizdić et al. between testicular volume of the each of aforementioned groups respectively to the group of the healthy children older than 10 years in whom the maen testicular volume ( ± SD) was 1.82 ± 0.15. Thus the boys aged 0.5-3 years had the maen testiculare volume decreased by 43% (P < 0.0002), the boys aged 4-6 years decreased by 36% (P < 0.001) and the boys aged 7-10 years by 31% (P < 0.002) compared to the mean testicular volume in boys older than 10 years. DISCUSSION Different methods have been used for the clinical measurement of testicular volumes: measurements of the testis in the scrotum by a ruler, by a caliper, by orchidometers or by ultrasonography. A number of orchidometers have been described such as the Prader orchidometer (4) and the Takihara (also known as the Rochester orchidometer) (5), and they are still the most commonly used. Currently, ultrasonographic determination of testicular volume is emerging as the most accurate method because of the ability to enable one to distinguish the testis from the adjacent soft tissues (7). Althouth numerous studies have shown that ultrasonography provides more accurate volumes than those obtained by orchidometer especially in small testicles (7,8,9), we found no statistically significant differences in the results of measurements by different techniques (ultrasonography vs Prader orchidometer). Our results are in accordance with those studies that have found a significant correlation between the values of testicular volume obtained by Prader orchidometer and by ultrasound (10,11). Various formulas have been used in the ultrasonography assessment of testicular volume: the formula for an ellipsoid (L × W × H × 0.52), the formula for a prolate spheroid (L × W2 × 0.52), and the empirical formula of Lambert (6) (L × W × H × 0.71). However, few studies have made direct comparisons of their accuracy and precision. Paltiel et al. (9) as well as Sakamoto et al. (12) found that the formula in which testicular volume is calculated by L × W × H × 0.71 has the smallest mean bias relative to actual volume over the entire volume range and concluded that this formula is the most accurate for calculating the testicular volume. Therefore, in our study we used the empiric formula of Lambert (6) to calculate testicular volumes. The results of our research in terms of getting normal testicular volume values in the different age groups in prepubertal boys could serve as reference values. We found that there is a slight increase in testicular volume to ten years of age but without a statistically significant values. These our results are in accordance with the results of previous studies that have also found that there is no significant increase in testicular volume in the first 10 years of life (13,14). Previous studies have found that testicular growth occurs during the fetal period and in infants and then remains static from about 1 year until early puberty (14). Reasons for the growth of the testes in the early postnatal period lie in the existence of so- called ‘mini-puberty’ which describes a peak in gonadotropic hormones (LH, FSH, inhibin B and testosteron) around 3 to 4 months of age (15,16). Such an increase in levels of gonadotropins after delivery is caused by suppresion of placental negative feedback and activation of the hypothalamic–pituitary–testicular axis (17). Testosterone and LH return to a 29 Testicular volume in healthy prepubertal boys minimum again at 6–9 months. It takes slightly longer for FSH and inhibin B to reach the low pre-pubertal levels (17). For all these reasons, it is very difficult to assess the functional status of prepubertal testes. In contrast to adults in whom testicular size correlates with hormonal and function status as well as spermatogenesis (12), the only objective indicator of testicular function in childhood represents testicular biopsy with histopathologic analysis. Since seminiferous tubules and germinal elements comprise approximately 98% of testicular mass, estimation of testicular volume has become an important method of indirect assessment of the functional status of the testes (18). Most children have similar left-and right-hand side testicular volumes; however, it is common for the left-hand side testicle to have a slightly lower volume than the right-hand side one. Our results indicate that maesurement of testicles is able to detect such a small biologically relevant change in testicular volume, which indicates that this is a highly valuable and accurate method to measure the size of pre-pubertal testicles. CONCLUSIONS Our research has provided normal values for testicular volume measured by ultrasonography and Prader orchidometer in boys aged 0.5 - 12 years. Ultrasonography method and method of measurements with Prader orchidometer have similar diagnostic value in comparing the size of both testes. Intensive growth of testes starts in the 11th year of life. The formula L x W x H x 0.71 provides a superior estimate of testicular volume and should be used in clinical practice. REFERENCES 1. Bahk JY, Jung JH, Jin LM, Min SK. Cut-off value of testes volume in young adults and correlation among testes volume, body mass index, hormonal level, and seminal profiles. Urology 2010;75(6):1318-1323. 2. Kollin C, Hesser U, Ritzen EM, Karpe B. Testicular growth from birth to two years of age, and the effect of orchidopexy at age nine months: a randomized, controlled study. Acta Paediatr 2006;95:318-324. 3. Goede J, Hack WW, Sijstermans K, van der Voort-Doedens LM, Van der Ploeg T, Meij-de Vries A et al. Normative values for testicular volume measured by ultrasonography in a normal population from infancy to adolescence. Horm Res Paediatr 2011;76(1):56-64. 4. Prader A. Testicular size: assessment and clinical importance. Triangle 1966;7:240243. 5. Takihara H, Cosentino MJ, Sakatoku J, Cockett ATK. The significance of testicular size measurement in andrology correlation of testicular size with testicular function. J Urol 1987;137:416-419. 6. Lambert B. The frequency of mumps and mumps orchitis and the consequences for sexuallity and fertility. Acta Genet Stat Med 1951;2:1-166. 7. Hsieh ML, Huang ST, Huang HC, Chen Y, Hsu YC.The reliability of ultrasonographic measurements for testicular volume assessment: comparison of three common formulas with true testicular volume. Asian J Androl 2009;11(2):261-265. 8. Shiraishi K, Takihara H, Kamiryo Y, Naito K. Usefulness and limitation of punchedout orchidometer in testicular volume measurement. Asian J Androl 2005;7:77-80. 9. Paltiel HJ, Diamond DA, Di Canzio J, Zurakowski D, Borer JG, Atala A. Testicular volume: comparison of orchidometer and US measurements in dogs. Radiology 2002; 222(1):114-119. 10. Taskinen S, Taavitsainen M, Wikström S. Measurement of testicular volume: comparison of 3 different methods. J Urol 1996;155(3):930-933. 11. Schiff JD, Li PS, Goldstein M. Correlation of ultrasonographic and orchidometer measurements of testis volume in adults. BJU Int 2004;93(7):1015-1017. 12. Sakamoto H, Yajima T, Nagata M, Okumura T, Suzuki K, Ogawa Y. Relationship between testicular size by ultrasonography and testicular function: measurement of testicular length, width, and depth in patients with infertility. Int J Urol 2008;15(6):529-533. 13. Cendron M, Huff DS, Keating MA, Snyder HMcC, Duckett JW. Anatomical, morphological and volumetric analysis: a review of 759 cases of testicular maldescent. J Urol 1993;149:570-573. 14. Main KM, Toppari J, Skakkebeak NE. Gonadal development and reproductive hormones in infant boys. Eur J Endocrinol 2006;155:S51-S57. 15. Hadžiselimović F, Živković D, Bica DT, Emmons LR. The importance of minipuberty for fertility in cryptorchidism. J Urol 2005;174:1536-1539. 16. Grumbach MM. A window of opportunity: the diagnosis of gonadotropin deficiency in the male infant. J Clin Endocrinol Metab 2005;90:3122-3127. 17. Chada M, Prusa R, Bronsky J, Kotaska K, Sidlova K, Pechova M, Lisa L. Inhibin B, follicle stimulating hormone, luteinizing hormone and testosterone during childhood and puberty in males: changes in serum concentrations in relation to age and stage of puberty. Physiol Res 2003;52:45-51. 18. Kollin C, Hesser U, Ritzen EM, Karpe B. Testicular growth from birth to two years of age, and the effect of orchidopexy at age nine months: a randomized, controlled study. Acta Paediatr 2006;95:318-324. Reprint requests and correspondence: Zlatan Zvizdić, MD, PhD Clinic of Pediatric Surgery Clinical Center University of Sarajevo, Bolnička 25, 71000 Sarajevo Bosnia and Herzegovina Phone: +387 33 297 144 Email: [email protected] Original article Medical Journal (2014) Vol. 20, No. 1, 30-32 Correlation of gastroesophageal reflux disease and Helicobacter pylori infection Korelacija gastroezofagealnog refluksa i Helicobacter pylori infekcije Nenad Vanis1*, Amila Mehmedović1, Rusmir Mesihović1, Amir Redžepović2, Aida Saray1 Clinic for Gastroenterohepatology, Clinical Centre University of Sarajevo, Bolnička 25, 71000 Sarajevo, Bosnia and Herzegovina, Emergency Medical Services, Sarajevo, Bosnia and Herzegovina. 1 2 *Corresponding author ABSTRACT The nature of the relationship between Helicobacter pylori (HP) and reflux oesophagitis is still not clear. Aim of the study is to investigate the correlation between Helicobacter pylori infection and gastroesophageal reflux disease (GERD) taking into account endoscopic data. Materials and methods: the study was perfomed from Jan. 2013 to Jan. 2014. as a prospective study in total of 146 patients with GERD in order to determine the prevalence of Helicobacter pylori infection in GERD patients. Further the value endoscopic parameters of the patients with and without Helicobacter pylori infection were studied and statistically compared. Finally, univariate analysis of the above mentioned data were performed in order to evaluate the statistical correlation with reflux esophagitis. Results: there were no statistically significant differences between the two groups, HP infected and HP negative patients, regarding age and gender. There was statistical difference between the two groups regarding severity of symptoms of regurgitation, dysphagia and epigastric pain, which were more registred in Helicobacter pylori positive group. We observed that hiatal hernia (p=0,01), LES size (p=0,05) and pathological reflux number (p=0,05) were significantly related to the presence of reflux oesophagitis. Conclusion: based on these findings, we found statistical difference regarding presence and severity of reflux esophagitis between patients with and without Helicobacter pylori infection. Key words: Helicobacter pylori, GERD, symptoms. INTRODUCTION Helicobacter pylori (HP) has been demonstrated the causative factor of various gastrointestinal diseases; nevertheless, the relationship between HP infection and gastroesophageal reflux disease (GERD) is still debated (1).To date, different studies have examined the relationship between atrophic gastritis due to HP infection and reflux oesophagitis with conflicting results. HP infection has been associated to inflammation of gastric mucosa that increases cellular apoptosis and epithelium proliferation. The excessive apoptosis, leads to the atrophy of epithelial cells and glands and could contribute to carcinogenesis (2). Some authors have found an in- crease of reflux oesophagitis after HP eradication. On the contrary, other authors suggested a correlation between HP infection and presence and severity of reflux esophagitis (3). It was suggested that HP could contribute to GERD through different mechanisms: cardias inflammation causing sphincter weakness; increased acid secretion due to antral gastritis; delayed gastric emptying and citotoxin production causing esophageal epithelium injury. Conversely, other authors believe that HP infection may even protect against GERD and HP eradication may lead to an accelerated development of GERD in ulcer disease patients (4-6). Further, previous studies have shown an increased effect of proton pump inhibitors on intragastric pH in HP-infected patients suffering from GERD with rapid heartburn relief and lack of relapse (7). HP could play a protective role through different mechanisms: decrease of acid secretion resulting from chronic gastritis of the gastric body; improvement of gastro-oesophageal junction due to proximal gastritis and finally production of ammonium by the gastric colonization of HP that could be a potential stopgap system (7-10). The present prospective study was performed in 146 patients with GERD in order to determine the prevalence of Helicobacter pylori (HP) infection at gastric mucosa; furthermore the correlation between HP infection and endoscopic and histological findings was studied through the statistical comparison of endoscopic and histological data between subjects with and without HP infection. Finally, we analysed the statistical correlation between reflux esophagitis and HP infection and endoscopic data. MATERIALS AND METHODS Between January 2013 and January 2014, 146 consecutive patients with daily reflux symptoms were evaluated at the Clinic for gastroenterology and hepatology, Clinical Centre University of Sarajevo. Exclusion criteria were the following; 1. Previous therapy to eradicate HP, 2. Concomitant assumption of aspirin and non-steroidal anti-inflammatory drugs, 3. Previous surgical procedures on digestive tract. All patients were underwent to the protocol, which included anamnesis, clinical examination, esophagogastroduodenoscopy and HP determination. Symptoms (heartburn, pain, and regurgitation) were assessed by patients visits. At endoscopy lower oesophageal 31 Correaltion of gastroesophageal reflux disease and Helicobacter pylori infection sphingter (LES) opening, presence of hiatus hernia, evident refluxes and esophagitis were evaluated. Esophagitis was graded by endoscopy according to the SavaryMiller classification: Grade 0; no lesions; Grade 1; erythema of the mucosa with multiple erythematous and exudative lesions; Grade 2; multiple erosions affecting multiple folds, not confluent; Grade 3; multiple linear or circumferential erosions that may be confluent; Grade 4; ulcer, stricture, or esophageal shortening, Barrett’s epithelium. Barrett’s esophagus has been defined as the presence of squamo-columnar metaplasia localized at least 3 cm above the oesophagus-gastric junction; 2–3 samples of the lower oesophagus (last 3 cm) were obtained. Endoscopic biopsy both of the gastric body and of the antrum was performed in order to diagnose HP infection and to obtain histological evaluation of the mucosa. Statistical analyses All statistical elaborations were obtained by using SPSS 17.0 Results are expressed as mean values and standard deviation (SD). Quantitative variables between the two groups (HP positive and HP negative patients) were compared using the Student’s t-test; qualitative parameters were compared between the two groups using chi-squared test. Results were considered statistically significant at P < 0.05. RESULTS The study included 146 patients, 58 males and 88 females with a mean age of 51,5 ± 15,2 years (range 23–89). HP infection was diagnosed in 35 patients (24%), 13 males and in 22 females, while 111 patients (76%), 45 males and 66 females, were HP negative. Patients with and without HP infection were statistically compared. There were no significant differences between the two groups regarding age and gender. Hiatal hernia was found in 97 cases out of 146 patients (66.4%); 25 patients were HP positive (25.7%) and 72 were HP negative (74.3%); p< 0,05. Reflux esophagitis was evidenced by endoscopy in 41 patients (28%); according the Savary-Miller classification, out of 146 patients, 105 were graded 0; Table 1 Clinical parameters of 146 GERD patients 14 patients were graded 1–3 (3 HP positive patients and 11 HP negative) and finally 27 patients were graded 4 (9 HP positive patients and 18 HP negative) p< 0,05 (Table 1). We observed that hiatal hernia (p = 0,01), LES opening (p< 0,05) and pathological reflux number (p = 0,05) were significantly related to the presence of oesophagitis. Regarding the severity of symptoms statistical difference complained by the patients between the two groups, was found as follows: DISCUSSION The incidence of HP infection in the patients with GERD, varies widely in literature from 30% to 90% and is approximately of 35% in most series (11). It was suggested that HP could contribute to GERD through different mechanisms: development of antral gastritis that increases acid production, decrease of LES pressure and impairment of gastric filling (12). Nevertheless, the decreasing prevalence of HP infection and related diseases (ulcer disease, gastric cancer) in western countries has been paralleled by an increased incidence of gastro-esophageal reflux and related complications. These epidemiological data do not support a causative role of HP for reflux disease, but suggest a negative association (13). Further, most trials on correlation between HP infection and GERD have indicated no causal relationship (14,15) Some other authors have even found a lower prevalence of HP infection in patients with reflux symptoms and have suggested a ‘protective’ role of HP infection against the development of esophageal diseases (16,17). Patients with HP-related corpus-predominant gastritis may have reduced gastric acid probably mediated by cytokines such as interleukin 1 (13). In our trial, out of 146 GERD patients, only 24% were HP infected while 76% were HP negative; in addition we found statistical difference regarding presence and severity of reflux esophagitis between patients with and without HP infection ( p< 0,05). Most trials on correlation between HP infection and GERD are based only on endoscopic observations (18-20). We found significant correlation between HP infection and hiatal hernia, considered by some authors as a supporting element of GERD and significantly associated with the development of oesophagitis (21,22). Finally, the relationship between HP infection and Barrett’s oesophagus and oesophageal adenocarcinom is still contraversary (22). CONCLUSION Based on these findings, we found statistical difference regarding presence and severity of reflux esophagitis between patients with and without Helicobacter pylori infection. However, this is an evolving area with ongoing research and further assessments in prospective large studies are warranted. Conflict of interest: none declared. REFERENCES 1. Harry HX, Yi Yang, Benjamin Chun-Yu Wong: Relationship between Helicobacter pylori infection and gastroesophageal reflux disease. Chinese J Digestive Disease 2012;5:1-6. 32 2. Kohli Y, Tanaka Y, Ito S. Endoscopic diagnosis of Helicobacter pylori distribution in human gastric mucosa by phenol red dye spraying method. Nippon Rinsh 2013;51:182-186. 3. Nordenstedt H, Nilsson M, Johnsen R, Lagergren J, Hveem K. Helicobacter pylori infection and gastroesophageal reflux in a population-based study. Helicobacter 2010;12:16-22. 4. Labenz J, Blum AL, Bayerdörffer E, Meining A, Stolte M, Börsch G. Curing helicobacter pylori infection in patients with duodenal ulcer may provoke reflux esophagitis. Gastroenterology 1997;112:1442-1447. 5. DeVault KR, Castell DO. American College of Gastroenterology: Updated guidelines for the diagnosis and treatment of gastroesophageal reflux disease. Am J Gastroenterology 2005; 100:190-200. 6. Tee W, Lambert JR, Dwyer B. Cytotoxin production by helicobacter pylori from patients with upper gastrointestinal tract disease. J Clin Microbiol 1995;33:12031205. 7. Calleja JL, Suarez M, De Tejada AH, Navarro A. Pantogerd Group. Helicobacter pylori infection in patients with erosive esophagitis is associated with rapid heartburn relief and lack of relapse after treatment with pantoprazole. Dig Dis Sci 2005; 50:432-439. 8. Cammarota G, Gasbarrini GB. Helicobacter pylori and gastro-oesophageal reflux disease: information underlying pathology is not given. BMJ 2004; 14:402. 9. Thor PT, Blaut U:. Helicobacter pylori infection in pathogenesis of gastroesophageal reflux disease. J Physiology and Pharmacology 2006; 57(S3):81-90. 10. Dore MP, Fastame L, Tocco A, Negrini R, Delitala G, Realdi G. Immunity markers in patients with Helicobacter pylori infection: effect of eradication. Helicobacter 2005; 10:391-397. 11. Smout AJPM:. Endoscopy-negative acid reflux disease. Aliment Pharmacol Ther 1997; 11(S2):81-85. 12. Gisbert JP, Pajares JM, Losa C. Helicobacter pylori and gastroesophageal reflux disease: friends or foes? Hepatogastroenterology 1999; 46:1023-1029. 13. Sharma P, Vakil N. Helicobacter pylori and reflux disease. Aliment Pharmacol Ther 2003; 17:297-305. 14. Lord RV, Frommer DJ, Inder S, Tran D, Ward RL. Prevalence of Helicobacter pylori infection in 160 patients with Barrett’s oesophagus or Barrett’s adenocarcinoma. Aust NZJ Surg 2000; 70:26-33. N. Vanis et al . 15. Wu JC, Sung JJ, Ng EK, Chan FK, Ching JY, Ng AC, Go MY, Wong SK, Ng EK, Chung SC. Helicobacter pylori infection is associated with milder gastro-oesophageal reflux disease. Aliment Pharmacol Ther 2000;14:427-432. 16. Ohara S, Sekine H, Iijima K, Moriyama S, Nakayama Y, Kinpara T, Kato K, Asaki S, Katakura T, Ikeda T, Toyota T. Gastric mucosal atrophy and prevalence of Helicobacter pylori in reflux esophagitis of the elderly. Nippon Shokakibyo Gakkai Zasshi 1996;93:235-9. 17. Moayyedi P, Talley NJ. Gastro-oesophageal reflux disease. Lancet 2006; 367:20862100. 18. Fennerty MB, Sampliner RE, Grewal HS. Barrett’s oesophagus-cancer risk, biology and therapeutic management. Aliment Pharmacol Ther 1993; 7:339-345. 19. Güliter S, Kandilci U. The effect of Helicobacter pylori eradication on gastroesophageal reflux disease. J Clin Gastroenterol 2004;38:750-755. 20. Oberg S, Peters JH, Nigro JJ, Theisen J, Hagen JA, DeMeester SR, Bremner CG, DeMeester TR. Helicobacter pylori is not associated with the manifestations of gastroesophageal reflux disease. Arch Surg 1999;134:722-726. 21. Schwizer W, Thumshirn M, Dent J, Guldenschuh I, Menne D, Cathomas G, Fried M. Helicobacter pylori and symptomatic relapse of gastro-esophageal reflux disease: a randomized controlled trial. Lancet 2001;357:1738-1742 22. Sharma VK, Howden CW. Decreased prevalence of H. pylori and cagA+ H. pylori in GERD and Barrett’s esophagus (BE) with or without dysplasia or adenocarcinoma (D/AC): a meta-analysis. Gastroenterology 2002;122:A291. Reprint requests and correspondence: Nenad Vanis, MD, PhD Clinic for Gastroenterohepatology, Clinical Center University of Sarajevo Bolnička 25, 71000 Sarajevo, Bosnia and Herzegovina Phone: +387 33 297 911 Email: [email protected] Original article Medical Journal (2014) Vol. 20, No. 1, 33-37 A prospective comparison of preperitoneal with prefascial herniorrhaphy for the treatment of inguinal hernias Prospektivna komparacija preperitonealne i prefascijalne hernioplastike u tretmanu ingvinalnih hernija Ismar Rašić*, Goran Akšamija, Adi Mulabdić, Adis Kandić Clinic for General and Abdominal Surgery, Clinical Center University of Sarajevo, Bolnička 25, 71000 Sarajevo, Bosnia and Herzegovina *Corresponding author ABSTRACT SAŽETAK Inguinal hernia repair is the most common operation in general surgery. The fact is that in the field of inguinal repairs are several different surgical methods, but it is still a current issue of choice in the operative treatment of inguinal hernias and places the best position for the prostetic mesh. The aim of this study was to evaluate and compare the outcome and postoperative complications of open inguinal hernia repair by using Rives and the Lichtenstein tension-free technique, and to determine their association with the technique and placing prostetic meshes. A prospective clinical study was carried during 2012 at the Clinic for General and Abdominal Surgery, Clinical Center University of Sarajevo. From 60 patients with inguinal hernia, 30 patients were surgically treated by Rives technique, while other 30 patients were undergoing hernia repair by Lichtenstein technique. For all patients it were collected planned clinical data from the medical and surgical protocols, the length of follow-up surgery, length of hospitalization, surgical outcomes and appearing of postoperative complications untill one year after surgery.The results showed that the duration of surgery significantly shorter in patients operated using Lichtenstein technique (p<0.001), while the length of hospitalisation is significantly less in patients operated by Rives technique (p<0.001). The significantly lower rate of pain (p<0.01), infection (p=0.019), fever (p= 0.006) was found in the early postoperative period, as well as the occurrence of seroma (p=0.038) at patients treated by Rives technique with preperitoneal mesh position. None of the patients in both groups did not develop recurrence of inguinal hernia during the study period (up to twelve months after surgery), while the varicocele occurred in one patient one year after Lichtenstein herniorrhaphy. In patients who were underwent surgery using Lichtenstein technique, four (13.3%) patients were developed hydrocele for a period of one year follow-up, while two patients (6.6%) developed ischemic orchitis with accompanying atrophy of the testes.The results of this study indicate that there are significant differences in the incidence of postoperative complications between the observed tension-free techniques of inguinal hernia repair with prosthetic mesh on different locations, emphasizing hernioplastics Rives with preperitoneal mesh setting as a safer and more efficient method of operative solving of inguinal hernia. Ingvinalna hernioplastika je najčešća operacija u opštoj hirurgiji. Činjenica je da na polju ingvinalne hernioplastike postoji više različitih operativnih metoda, ali je i dalje aktualno pitanje izbora tehnike u operativnom tretmanu preponske kile i mjesta najbolje pozicije za mrežicu. Cilj ovog rada je bio komparirati ishod i postoperativne komplikacije otvorene netenzione ingvinalne hernioplastike tehnikom po Rivesu i tehnikom po Lichtensteinu, te utvrditi njihovu povezanost sa operativnom tehnikom mjestom postavljanja mrežice. Ova klinička studija prospektivnog karaktera provedena je na Klinici za opštu i abdominalnu hirurgiju Kliničkog centra Univerziteta u Sarajevu tokom 2012. godine. Ispitivanjem je bilo obuhvaćeno 60 pacijenata sa ingvinalnom hernijom, od kojih je 30 pacijenata operisano tehnikom po Rivesu, a ostalih 30 tehnikom po Lichtensteinu. Svim pacijentima sakupljani su planirani klinički podaci iz istorija bolesti i operativnog protokola, uz praćenje dužine operacije, dužine hospitalizacije, operativnog ishoda i pojave postoperativnih komplikacija do godine dana nakon operacije. Rezultati ispitivanja ukazuju da je trajanje operacije značajno kraće kod pacijenata operisanih Lichtenstein tehnikom (p<0.001), a da je dužina hospitalizacije značajno manja kod pacijenata operisanih Rives tehnikom (p<0.001). U ranom postoperativnom periodu je nađena signifikantno manja učestalost boli (p<0.01), infekcije (p=0.019) i febrilnosti (p=0.006), kao i pojave seroma (p=0.038) kod pacijenata tretiranih Rives tehnikom sa preperitonealnom pozicijom mrežice. Ni jedan pacijent iz obje grupe nije razvio rekurenciju ingvinalne hernie tokom praćenog perioda, dok se varikokela javila u jednog pacijenta godinu dana nakon urađene Lichtenstein hernioplastike. U pacijenata operisanih Lichtenstein metodom hidrokela se razvila kod četiri pacijenta (13.3%) nakon perioda praćenja od godinu dana. U istoj grupi pacijenata u navedenom vremenskom periodu kod dva pacijenta (6.6%) se razvio ishemični orhitis sa pratećom atrofijom testisa. Rezultati ovog ispitivanja ukazuju na postojanje značajnih razlika u učestalosti postoperativnih komplikacija između posmatranih netenzionih tehnika ingvinalne hernioplastike sa različitom lokacijom mrežice, ističući hernioplastiku po Rivesu sa preperitonealnim postavljanjem mrežice kao sigurniju i efikasnu metoda u operativnom rješavanju ingvinalne hernije. Key wods: inguinal hernia, hernia repair, Rives, Lichtenstein Ključne riječi: ingvinalne hernije, hernioplastika, Rives, Lichtenstein 34 INTRODUCTION A hernia of the abdominal wall is the protrusion of parietal peritoneum through congenital or acquired opening of the abdominal wall, in which, as in a bag, enter organs of abdominal cavity. Inguinal hernias are the most common pathology in the field of surgery and make up around two thirds of all hernias of the abdominal wall. All inguinal hernias are the result of the weakness of the inguinal region as the lowest part of the abdominal wall, or weakened transverse fascia in the region of myopectineal orifice of the inguinal canal, which is the passage from the abdomen into the scrotum. As a result of the testis passage through the inguinal region of the anterior abdominal wall, in this wall remains the inguinal canal as his weak point (1). Repair of inguinal hernia is one of the most performed surgical procedures. These surgical techniques can be devided into tension and tension free procedures. Tension free techniques can be classic open procedures like Lichtenstein and Rives or endoscopic like transabdominal preperitoneal herniorrhaphy (TAPP) and total extraperitoneal herniorrhaphy (TEP) (2). First tension free techniques are starting to develop in the mid sixties, while the first successful and widely used Lichtenstein method with prefascial setting the mesh used since 1986 (3). Amid with his associates found that the Lichtenstein method is safe, easy and efficient way of hernia repair with the recurrence rate of only 0.12 at 3.250 were done hernioplastics (4). Various prosthetic materials can be used for tension free procedures like dacron and polypropylene mesh.The meta-analysis, done by the EU Hernia Trialists, has been shown that hernia repair with the use of mesh reduces the relapse rate by 50% (2% of the mesh versus 4.9% without mesh) (5). Position meshes with nontension methods can be at different levels. Some believe that the front subaponeurotic approach is superior because it is technically feasible, and when done correctly, is associated with a lower incidence of recurrence. By placing nonresorptive mesh between mioaponeurotic ports up and inguinal canal down reinforces the posterior wall of the inguinal canal without tension. Others argue that the mesh should be placed in the preperitoneal position (Rives technique), where the intra-abdominal pressure will hold it in place (6,7). Aim of this study was to compare outcome of two tension free technique in the treatment of primary inguinal hernia: Rives with preperitoneal setting the mesh and Lichtenstein with prefascial setting the mesh. I. Rašić et al . the same education. Lichtenstein technique is based on prefascial mesh position, with its fixation to the pubic tubercle, along ligamentum Pouparty and the internal oblique muscle, while Rives technique is based on the preperitoneal mesh position with its fixation to Cooper’s ligament, along iliopubic tract laterally and medially for transversal muscular arch. In all patients polypropylene mesh 6 x 11 cm was applied using 2-0 Prolene suture. Antibiotic prophylaxis with cefotaxim 2 g i.v. was performed in all patients of both groups prior to surgery, while prophylactic anticoagulant therapy was given to all patients during hospitalization. Patients were monitored on occurrence of early postoperative complications (hematoma of wound, hematoma of scrotum, infection of wound, urinary retention, urinary tract infection, postoperative wound pain) during the first 7 and after 30 postoperative days, and late postoperative complications six and 12 months after surgery (persistent postoperative pain, testicular atrophy, hydrocele, varicocele, relapse). The protocol of study was approved by the local Ethics Committee. Informed consents was also obteined from all patients. Statisical analyses All statistical analyses were conducted using statistical program SPSS Version 15. Data are expressed as numbers, percentage (%), means with standard deviation (SD). Student’s t-test was used for comparison of mean values of the variables with normal, while MannWhitney U test was used for comparison of variables without normal distribution. Chi-square test was used to determine the existence of differences in categorical variables between groups. Pearson correlation test was used to determine the correlation between monitored variables in the selected surgical techniques. Statistical significance was considered with p<0.05. RESULTS All the patients in both groups were males. The average age of the patients surgically treated with Lichtenstein procedure (group 1) was 58.0±11.7 years, and patients undergoing Rives hernia repair (group 2) 55.7±11.8 years (Figure 1). Most of the respondents in both groups of patients were over 60 years of age. No significant differences in the number of patients by age groups in both patient groups (X2=0.725, p=0.948). MATERIALS AND METHODS This prospective clinical study was conducted during 2012 years in the Clinic for General and Abdominal Surgery of Clinical Center University of Sarajevo. After excluding cases of severe comorbidity, previous lower abdominal or retropubic surgery that might interfere with placement of the mesh, previous contralateral hernia repair with preperitoneal prosthetic material, reccurent hernia, incarcerate inquinal hernia, proven abdominal neoplasms with a short term survival and refusal of surgical treatment, 60 patients with primary inguinal hernia were included in the study. All patients were devided randomly into two groups: 30 patients for surgical treatement by Rives technique and 30 patients for surgical treatement by Lichtenstein technique. Both surgical procedures were performed under general anasthesia and done by a team of surgeons who have undergone Figure 1 The age of the respondents in relation to surgical technique 1 - Lichtenstein group, 2 - Rives group Data are presented as median and interquartile range. A prospective comparison of preperitoneal with prefascial herniorrhaphy for the treatment of inguinal hernias In relation to the type of hernia, 30% of patients treated with Lichtenstein technique were had indirect hernia, 63.3% direct hernia, while the combined inguinal hernia was present in 6.7% of patients of this group (Table 1). In the group of patients treated by Rives surgical technique the most patients (43.3%) were had a direct hernia. Indirect inguinal hernia was present in 33.3% of patients, while 23.3% of patients were had a combined hernia. There were no statistically significant differences in the frequency of different types of hernia between the two groups of patients followed (X2=3.955, p=0.138). Table 1 Type of inguinal hernias X2=3.955; p=0.138 According to the Nyhus classification, the highest number of hernias of both groups were Nyhus III a grade (63.33% vs. 43.33%), followed by Nyhus II (20% vs. 30%), while the least was Nyhus III b grade (16.66% vs. 26.7%). No patients had a hernia classified as Nyhus I or Nyhus IV. There were no statistically significant differences in the incidence of hernia by Nyhus classification between these groups of patients (p=0.298). Mean surgery duration was significantly shorter in the Lichtenstein group (36.37±5.49 minutes) compared to subjects of Rives group (46.03±6.29 minutes), p<0.001 (Figure 2). The average of hospitalization length in the Lichtenstein group was 3.05±1.27 days, while in Rives group was 2.87±0.82, a statistically significant difference (p<0.001). Figure 2 The time of surgery duration in relation to the applied surgical technique patients monitored groups in the early postoperative period. Namely, 30% of patients in the Lichtenstein group were febrile compared to 3.33% in the Rives group (X2=7.68, p=0.006). Infections of surgical wound were significantly higher in the first seven days in the Lichtenstein group patients (p=0.019) compared to a comparative group of patients. It was diagnosed in 16.7% of patients from the Lichtenstein group, while patients surgically treated Rives technique did not have detected infection of wound in any of case. In patients who underwent hernia repair by using Lichtenstein technique seroma was found in 13.3% of patients, whereas in patients with initial Rives hernioplastics has been free of seroma as postoperative complications (p=0.038). In the first seven days postoperatively there was no significant differences in the frequency of occurrence of hematoma of wounds between the two groups of patients (X2=0.162, p=0.687), but swelling of scrotum was found in 20% of patients in the Lichtenstein group compared to 3.3% in Rives group (X2=4.043, p=0.044). The occurrence of urinary tract infections and urinary retention has not been recorded in these groups of patients. Significant intergroup differences in the intensity of pain in the groin area was confirmed after the first, sixth and twelfth postoperative month (p <0.001). One year after surgery varicocele is registered in one (3.33%) patients in the Lichtenstein group, while patients from Rives group did not develop this kind of complications. One year after surgery hydrocele is registered in 4 (13.3%) patients in the Lichtenstein group, without the appearance in Rives group. Ischemic orchitis with subsequent testicular atrophy was found in two (6.66%) patients in the Lichtenstein group, without the appearance of Rives group. Relapse hernia has not been verified in any of the operated patients after a follow-up period of twelve months. There was a statistically significant positive correlation between the presence of pain of the first and sixth (r=0.549, p=0.002), and the sixth and twelfth months (r=0.771, p<0.001) after Lichtenstein hernioplastics done. In this group of patients demonstrated a statistically significant association between early infection and fever (r=0.683, p<0.01), infection of wound and length of hospitalization (r=0.703, p<0.01), and the association between surgical intervention and duration of hospitalization (r=0.613, p<0.01). Length of hospitalization was also in direct significant correlation with the occurrence of postoperative hematoma (r=0.381, p<0.05), table 2. A significant positive correlation in the early postoperative period was confirmed between the occurrence of hematoma of wound and length of hospitalization (r=0.469, p<0.01) in patients with Rives herniorrhaphy, as well as between the appearance of the swelling of scrotum and length of hospitalization (r=0.492, p<0.01), Table 3. Table 2 Correlation of early postoperative complications in patients with Lichtenstein herniorrhaphy 1 - Lichtenstein group, 2 - Rives group Data are presented as median and interquartile range. Using a pain scale (Visual Analogue Pain Scale) significant intergroup difference in the intensity of pain in the area of the surgical incision was observed on the second day (5.53±1.1 vs. 3.2±1.24, p<0.01), and the third day (4.87±1.36 vs. 2.74±0.99, p<0.01) in the Lichtenstein patient group compared to the Rives group. There was significant difference in the frequency of occurrence of fever among 35 ** Correlation is significant at p<0.01. * Correlation is significant at p<0.05. 36 Table 3 Correlation of early postoperative complications in patients with Rives herniorrhaphy ** Correlation is significant at p<0.01. * Correlation is significant at p<0.05. Analysis of monitored variables one year after surgery indicates a statistically significant negative correlation between Lichtenstein herniorrhaphy and the presence of chronic postherniorrhaphy pain (r=-0302, p<0.05). It was observed a statistically significant positive correlation between chronic postherniorrhaphy pain in this group of patients and the occurrence of varicocele (r=0.432, p<0.01) as well as a significant positive correlation between chronic postherniorrhaphy pain and the occurrence of hydrocele (r=0.280, p<0.05) and ischemic orchitis / testicular atrophy (r=0.280, p<0.05). DISCUSSION Numerous studies have compared the Lichtenstein technique with other surgical treatment of inguinal hernia. The European collaborative study on hernia (The European Union Hernia Trialists Collaboration), which analyzed all randomized studies that compared the open inguinal hernia repair with mesh-type Lichtenstein with methods without mesh, included 4.005 treated patients (8).The study indicated that the results of surgical treatment were far better with methods that are used mesh, including faster return work activity and lower incidence of hernia recurrence.All hernioplastics in our study were performed as elective surgery.There were no statistically significant differences in the incidence of hernia by Nyhus classification between these groups of patients (p=0.298). The average age of patients surgically treated with Lichtenstein or Rives procedure was not significantly different, with the largest number of patients in both groups older than 60 years (60% vs. 56.7%), which is consistent with published data on the average age of patients with initial inguinal hernia repair in the world (9,10). The operating procedure was significantly shorter in the Lichtenstein group of patients in comparison to Rives hernia repair, but the duration of hospitalization was significantly shorter in patients after Rives hernioplastics. The length of hospitalization after Lichtenstein hernioplastics was significantly associated with the occurrence of infection of wound, fever and hematoma of wound, while the length of hospitalization after Rives hernioplastics was significantly associated with hematoma of wound and swelling of the scrotum. Muldoon and colleagues have compared the results Lichtenstein inguinal hernia repair with mesh subaponeurotic position in 126 surgically treated patients with the results of Read-Rives technique with preperitoneal mesh position in 121 patients (11). The average time operation in Read-Rives reparation was 9 minutes longer than in Lichtenstein reparation. In study by Zejbek and associates the average duration of the operation by Lichtenstein procedure was 56 minutes and the av- I. Rasić et al . erage time restore routine activities of 20 days, with post-operative complications registered in 11.7% of patients and hernia recurrence in 0.6% of treated patients (10). In study from Güner and associates the average length of preperitoneal inguinal hernia repair was significantly longer with significantly shorter length of hospitalization compared to patients with initial hernia repair by Lichtenstein method (12). In contrast to these results, Fricano and associates in a sample of 406 patients mean age of 52±12.7 years, found that the average time for Lichtenstein procedure with minor modifications was 65±13.8 minutes, which is almost twice as long compared to duration of the same procedures in our sample (13). In our research, we found significant differences in the intensity of early postoperative pain between groups, with significantly lower pain intensity after Rives hernioplastics (p<0.01), which can be explained by preperitoneal mesh position and its separation from funicular elements in the inguinal canal with repaired transversal fascia and absence of fibrous tissue reactions to the mesh. No patient in Rives group had infection of wound, whereas in the first seven days infection of wound had 16.7% of patients in the Lichtenstein group. Infection is one of the most common complications after hernioplastics done. It can be recognized only as a minimal occurrence of pus around a cutaneous suture, or as a process that can be extensive and require prolongation of hospitalization, intravenous antibiotics or surgical re-intervention with debridement, drainage and eventual extraction of mesh. The ratio of infection of wound after hernioplasty of inguinal hernia was ranging from 0.9 to 9%, depending on the clinical variables of the population, as well as whether to use mesh or antibiotic prophylaxis. Several studies in the United Kingdom have announced a relatively high incidence of infections of surgical wound after inguinal groin repairs. Holmes and Readman reported the occurrence of infection of wound in 4% patients after the first postoperative month (14). Despite the opinion of some authors that the mesh increases the risk of infection, Gilbert and Felton found no difference in the proportion of infections in hernia repair with and without the use of mesh (15). According to the results of this study, the two most important variables in reducing local complications in the surgical wound were antibiotic prophylaxis and techniques of closing. The introduction of antibiotic prophylaxis resulted in reducing the ratio of infection from 1.2% (in patients who did not receive antibiotic prophylaxis) to 0.2% (in those who received antibiotic prophylaxis). In contrast to these findings, the results of Perez and authors have shown that preoperative administration of singledose antibiotic does not reduce significantly the risk of infection of wound (16). However, most authors agree that the prophylactic use of antibiotics is justified (17).Antibiotic prophylaxis as a single variant are applied in all our patients. However, the incidence of infections of wound in the early postoperative period was higher after the Lichtenstein hernia repair compared to Rives. In doing so, none of the patients after Rives hernioplastics had no drainage. All patients after Lichtenstein hernioplastics had subaponeurotic drainage, which can be coupled with the onset of fever and a higher incidence of infection of wound in this group of patients. We found that the incidence of seroma and scrotal swelling in the early postoperative period was significantly greater after Lichtenstein hernioplastics compared to Rives technique. Also, prefascial position of the mesh in Lichtenstein procedure was statistically significantly A prospective comparison of preperitoneal with prefascial herniorrhaphy for the treatment of inguinal hernias associated with the development of varicocele and hydrocele with ischemic orchitis one year after surgery. There were no reported recurrence of inguinal hernia in any groups of patients during the studied period. In a large prospective clinical study which was conducted from 1989 to 2007 Just and his colleagues were included 2.002 inguinal hernia repair by Lichtenstein technique and found that 7.7% cases were accompanied by complications, of which 3.7% were hematomas, 2.2% infections, 1.3% seroma and 0.5% complications of other causes (18). Muldoon and colleagues, comparing the results of Lichtenstein inguinal hernia repair in 126 patients with results of Read-Rives technique in 121 patients, did not register infections of wound, and frequency of other early and late complications was low and similar in both groups of patients (11). Hematoma of scrotum was found in 3.5% of patients in the Lichtenstein versus 3.7% in the Read-Rives group, hematoma of wound in 2.6% vs. 4.6%, testicular atrophy in 2.6% vs. 0.9%, inguinal discomfort and pain in 9.3% vs. 6.1% of patients, confirming that both the operational procedures provide a low ratio of postoperative complications and good longterm outcome. CONCLUSION Results of the study indicate the justification preperitoneal setting mesh, considering the significantly lower incidence of postoperative complications, especially infection of wound and seroma formation in the early postoperative period as well as absence of varicocele and hydrocele formation during one year follow-up. Preperitoneal mesh setting close to all the weak spots of myopectineal orifice.This surgical technique can be especially recommended for addressing inguinal hernia in patients with increased intra-abdominal pressure when other techniques may be insufficient due to the protrusion of the mesh. 5. The EU Hernia Trialists Collaboration. Repair of groin hernia with synthetic mesh: meta-analysis of randomized controlled trials. Ann Surg 2002;235(3):322-332. 6. Bringman S, Ramel S, Heikkkinen TJ, England T, Westman B, Anderberg B. Tensionfree inguinal hernia repair: TEP versus mesh plug versus Lichtenstein: a prospective randomized controlled trial. Ann Surg 2003;237(1):142-147. 7. Bhat MG, Somasundaram SK. Preperitoneal mesh repair of incisional hernias: A seven year retrospective study. Indian J Surg 2007;69:95-98. 8. EU Hernia Triallists Collaboration. Mesh compared with non-mesh methods of open groin hernia repair: Systematic Review of randomized controlled trials. Br J Surg 2000; 87(7):854-859. 9. Kingsnorth A, LeBlanc K. Hernias: inguinal and incisional. Lancet 2003; 362(9395):1561-1571. 10. Zejbek N, Tas H, Peker Y, Yildiz F, Akdeniz A, Tufan T. Comparison of Modified Darn Repair and Lichtenstein Repair of Primary Inguinal Hernias. J Surg Res 2008;146(2):225-229. 11. Muldoon RL, Marchant K, Johnson DD, Yoder GG, Read RC, Hauer-Jensen M. Lichtenstein vs anterior preperitoneal prosthetic mesh placement in open inguinal hernia repair: A prospective, randomized trial. Hernia 2004;8(2):98-103. 12. Güner A, Güler K, Bozkurt S, Kaya MA, Leblebici IM. Anterior Lichtenstein Repair versus Posterior Preperitoneal Repair Techniques for Recurrent Inguinal Hernia. Erciyes Medical Journal 2009;31(1):37-43. 13. Fricano S, Fiorentino E, Cipolla C, Matranga D, Bottino A, Mastrosimone A, Bonanno E, Latteri MA. A minor modification of Lichtenstein repair of primary inguinal hernia: postoperative discomfort evaluation. Am Surg 2010;76(7):764-769. 14. Holmes J, Readman R. A study of wound infection following inquired hernia repair. J Hosp Infect 1994;28(2):153-156. 15. Gilbert AJ, Felton LL. Infection in inguinal hernia repair considering bacterial and antibiotics. Surg Gynecol Obstet 1993;177(2):126-130. 16. Perez AR, Roxas MF, Hilvano SS. A randomized, double-blind, placebo-controlled trial to determine the effectiveness of antibiotic profilaxis for tension-free mesh herniorraphy. J Am Coll Surg 2005;200(3):392-398. 17. Sanabria A, Dominguez LC, Valdivieso E, Gomez G. Prophylactic antibiotics for mesh inguinal hernioplasty. A meta-analysis. Ann Surg 2007;245(3):392-394. 18. Just E, Botet X, Martinez S, Escola D, Moreno I, Duque E. Reduction of the complication rate in Lichtenstein hernia repair. International Journal of Surger 2010;8(6):462-465. Conflict of interest: none declared. REFERENCES 1. Gluhović A, Parčević Z, Popović M. Hirurgija preponskih kila. Novi Sad-Sombor: Visio Mundi Academic Press; 2005. 2. Kurzer M, Kark A, Hussain T. Inguinal hernia repair. J Perioper Pract 2001;17(7):318330. 3. Lichtenstein IG, Shulman AG. Ambulatory (outpatient) hernia surgery including a new concept: introducing tension-free repair. Int Surg 1986;71(1):1-4. 4. Amid PK, Shulman AG, Lichtenstein H. A clinical evaluation of the Lichtenstein tension-free hernioplasty. Int Surg 1994;79(1):76-79. 37 Reprint requests and correspondence: Ismar Rašić, MD Clinic for General and Abdominal Surgery Clinical Center University of Sarajevo Bolnička 25, 71000 Sarajevo Bosnia and Herzegovina Phone: +387 33 297 326 Email: [email protected] Original article Medical Journal (2014) Vol. 20, No. 1, 38-42 Assessment of initial diagnostic procedures in isolated thoracic injuries Procjena inicijalnih dijagnostičkih procedura kod izolovanih povreda grudnog koša Alma Alihodžić-Pašalić*, Safet Guska, Ademir Hadžismailović, Alen Pilav, Kemal Grbić Clinic of Thoracic Surgery, Clinical Center University of Sarajevo, Bolnička 25, 71000 Sarajevo, Bosnia and Herzegovina *Corresponding author ABSTRACT SAŽETAK Thoracic injuries are the cause of 20 - 25% of all deaths caused by trauma and the second most common cause of mortality and the main contributing factor in the 50% of all deaths. A large number of patients with chest injuries are not hospitalized but are treated on an outpatient basis. Chest injuries must be treated properly to avoid potential complications that may be life threatening. The most serious thoracic injuries often occur in the absence of damage to the chest wall. Therefore it is very important to fully understand the different events that occur as a result of thoracic injury in respect of which it is possible to define the severity of injury. Two factors are very important: time and a type of surgical help. We retrospectively analyzed the conducted initial diagnostic procedures of injured persons with isolated injuries of the chest. At the Clinic for Thoracic Surgery, Clinical Center University of Sarajevo were analyzed 320 patients between January 2007 and January 2012 years. The initial diagnostic procedures were performed at 67.81% (217/320) injured. After secondary examination or shorter monitoring, additional diagnostic procedures were indicated and performed in only 5% (16/320) of injured. Initial diagnostic sensitivity was 98.1%, specificity 98.6%, positive predictive value 97.1% and negative predictive value of 99.0%. Conclusion: the defined initial diagnostic procedures in the majority of patients with isolated thoracic injuries were sufficient to assess the type and severity of injury. Torakalne povrede su uzrok kod 20 25% svih smrtnih slučajeva uzrokovanih traumom, a na drugom su mjestu uzroka smrtnosti i glavni doprinoseći faktor u ostalih 50% smrtnih slučajeva. Veliki broj pacijenata sa povredama grudnog koša se ne hospitalizira već se tretira ambulantno. Povrede grudnog koša moraju biti ispravno tretirane da bi se izbjegle potencijalne komplikacije koje mogu ugroziti život povrijeđenog. Najteže torakalne povrede se često pojavljuju u odsustvu oštećenja zida grudnog koša. Zbog toga je jako važno detaljno poznavanje različitih manifestacija koje mogu nastati kao posljedica torakalne povrede, a na osnovu kojih se mogu ustanoviti pojedine lezije. Treba voditi računa o dva faktora: faktor vrijeme i faktor hirurška pomoć. Istraživanjem je obuhvaćeno 320 pacijenata hospitaliziranih na Klinici za torakalnu hirurgiju Kliničkog centra Univerziteta Sarajevo sa isključivo izolovanim torakalnim povredama što je ujedno i osnovni kriterij uključivanja pacijenata u provedeno istraživanje.Inicijalna dijagnostička obrada je provedena kod 67,81%(217/320) povrijeđenih. Nakon sekundarnog pregleda ili kraćeg praćenja stanja povrijeđenog dodatna dijagnostika je bila indicirana i urađena kod samo 5% (16/320) povrijeđenih. Senzitivitet inicijalne dijagnostike je 98,1%, specificitet 98,6%, pozitivna prediktivna vrijednost 97,1% i negativna prediktivna vrijednost 99,0%. Zaključak: definisana inicijalna dijagnostička obrada je kod većine pacijenata sa izolovanim torakalnim povredama bila dovoljna za procjenu vrste i težine povrede. Key words: isolated thoracic injuries, the initial diagnostic procedures Ključne riječi: izolovana torakalna povreda, inicijalne dijagnostičke procedure INTRODUCTION Primary aim of the first examination of the patients with isolated thoracic injuries is to identify life-threatening conditions which are necessary to be disposed of immediately (1,4,5,6,7,8). The first review should start trying to obtain appropriate medical history or hetero-history data associated with the violation. Getting the data should be accompanied by physical examination (inspection, palpation, percussion and auscultation) and the concomitant use of basic laboratory tests (including blood sample to determine the blood Group and cross-reaction) and if the patient’s condition permits continues with diagnostic procedures (standard chest radiography, FAST) (1,6,9,10,11,12). Many health centers, in addition to the above procedures, as the initial diagnostic proce- Thoracic trauma is a major diagnostic and therapeutic challenge for surgeons (1,2,3). In diagnostic evaluation there are precisely defined sequence of procedures for patients with isolated thoracic trauma. Committee on Trauma American College of Surgeons in 1997. adopted ATLS (Advanced Trauma Life Support) (1.2) which includes: 1. First examination 2. Resuscitation 3. Secondary examination and 4. Treatment 39 Assessment of initial diagnostic procedures in isolated thoracic injuries dure use CT of the thorax (7,13,14,15). At the Clinic for Thoracic Surgery UCC Sarajevo initial diagnostic procedures include: history and heteroamnesis,physical examination (inspection, palpation, percussion and auscultation) standard chest radiography,setting a standard laboratory, blood group and cross reacting, abdominal ultrasound and lung bases. The aim 1. Analysis ofthe conducted initial diagnostic procedures and their valuation in the diagnosis of the type and severity of isolated thoracic injuries. 2. Calculat specificity, sensitivity, positive and negative predictive value of total initial diagnostic evaluation of patients with isolated thoracic injuries. MATERIALS AND METHODS Retrospective analysis included 320 patients hospitalized at the Clinic for Thoracic Surgery, Clinical Center University of Sarajevo in the period between January 2007 and January 2012 with only isolated thoracic injuries. Defined criteria for inclusion of patients in the survey include: RESULTS Total of 320 patients with isolated chest trauma was hospitalized and treated for at the Clinic for Thoracic Surgery UCC Sarajevo. Male [78.44% (251/320)] to female [21.56% (69/320)] ratio was 3.64:1. The average age of hospitalized patients was 43.17 ± 17.9 (2-98 years). Average age of men was 46.83 ± 17.80 (range 14 to 90 years), and women 54.91 ± 18, 54 (2 to 98 years) and there is a statistically significant difference (p<0.001634) in relation to the age by gender. The initial diagnostic procedures; history, clinical examination, PA chest radiography, standard laboratory and ultrasonic examination of the thorax and abdomen, was performed in 67.81% (217/320) injured (Table 1). In patients with fractures of the sternum was mandatory made cardiological examination with ECG and determination of biohumoral enzyme status and was perfomed in 15,31% (49/320). The initial diagnostics procedures complemented with CT scan of the thorax was performed in 14,06% (45/320) injured. Table 1 Performed the initial diagnostic procedures 1. General information (name, age, sex, date of admission and discharge, injury mechanism, type and severity of injury). 2. Diagnostic procedures were performed in all patients were divided into two groups: Initial (standardized) diagnostic procedures (medical history, physical examination, standard PA or AP chest radiography, depending on the condition of the patient, and the lateral radiogram if the patient’s condition permits, standard laboratory tests, ultrasound examination of the abdomen and thorax bases. Additional diagnostic procedures according to the type of injury and the patient’s condition are: - in patients with fractures of the sternum was mandatory made cardiological examination with ECG and determination of biohumoral enzyme status. Initial treatment that could be performed after the initial diagnostic procedures confirmed their sufficiency in assessment of the type and severity of injury. Initial treatment (Figure 1) was conservative in 63.75% (204/320) of cases while surgical treatment was carried out in 36.25% (116/320) injured. - CT with contrast in order to resolve diagnostic problems unexplained by the previous standard treatment, -endoscopic examinations (bronchoscopy in suspected rupture of a major airway, esophagography and esophagoscopy for suspected possible esophageal injury) The results are presented numerically, graphically and in tables. Statistical analysis was performed by statistical software MS Excel by using the appropriate statistical methods (parametric data were analyzed by calculating the absolute and the percentage value, the arithmetic mean with standard deviations, and t - Student test; nonparametric data are processed in absolute and percentages values and with corresponding chi square test). A defined level of significance was p <0.05. Our results were identified and compared with the results of relevant research data presented in contemporary literature. Figure 1 Types of initial treatment Secondary examination is much more detailed and complete review, and aims to identify all violations on the basis of which it will be planned further diagnostic procedures and appropriate treatment. Additional diagnostic procedures (Figure 2) were indicated in only 5% (16/320) of cases. 40 Figure 2 Additional diagnostic procedures. The average period of the hospitalization for all injured with isolated thoracic trauma was 5,9±4,0 days (from 6 hours to 16 days). In relation to the type of injury (Table 2), penetrating vs. blunt, the average length of hospitalization was 5.4 ± 3.36 and 6.07 ± 4.26 days respectively. Statistically, there is no significant difference in relation to the duration of hospitalization between penetrating vs. blunt trauma (0,2766 > 0,05). Table 2 Length of hospitalization in relation to the type of injury Pneumothorax was the most common [51.72% (75/145)] endopleural disorder established in blunt injuries and hemato - pneumothorax [37.72% (46/145)] in penetrating injuries (Table 3). Table 3 Types endopleural disorders in relation to the violation Sensitivity, specificity, positive and negative predictive value of total initial diagnosis of isolated thoracic injuries of all patients treated in the study period at the Clinic of Thoracic Surgery CCU are: SENZITIVITY = 98,1%; SPECIFICITY = 98,6%; PPV = 97,1% and NPV = 99,0%. DISCUSSION At the Clinic for Thoracic Surgery CCU Sarajevo initial diagnostic procedures include: history and heteroanamnaesis, physical examination (inspection, palpation, percussion and auscultation) standard chest radiography, a standard laboratory, blood group and A. Alihodžić-Pašalić et al. cross reacting, abdominal ultrasound and lung bases. In the fiveyear study, previously described initial diagnostic procedure was performed at 67.81% (217/320) injured. With the existence of an infringement sternal region initial diagnostic evaluation is mandatory supplemented with lateral radiogram sternum, ECG with analysis of biohumoral status and cardiologist consultation , and carried out at 15.31% (49/320) of injured. Initial diagnostic work was complemented by CT of the chest in 14.06% (45/320) patients. In 2.50% (8/320) patients with superficial chest injuries were only done standard radiography and basic laboratories, and one patient [0.32% (1/320)] initially underwent standard radiography and CT of the spine, because he had an extremely strong pain in the area of the thoracic spine, caused by a fall on the back.Today is not a small number of health care institutions, especially those with organized trauma centers, which in the initial diagnostic procedure inevitably and routinely indicate chest CT (10,11,16). As demonstrated, CT in patients with isolated thoracic injury is done only in the strictly indicated cases [14.06% (45/320)], based on the clinical assessment of the severity of the patient and the possible existence of severe injuries that could not be excluded on the basis of previously conducted initial diagnostic procedures.The reason for this selective use of CT of the chest can be explained with: First of all it is a time-consuming diagnostic procedure that may delay the necessary initial treatment for at least 20 - 30 minutes which in severe cases of thoracic injuries may represent unnecessary loss of valuable time. If we keep in mind that the radiation dose during CT of the chest is equivalent to radiation dose of 50-450 pairs of radiography one should consider the benefits versus the justification of the additional radiation exposure. The effective radiation dose for standard and lateral radiography ranges from 0.06 to 0.25 milli sievert (mSv). Corresponding dose of conventional CT of the thorax is 3 - 27mSv, and from 0.3 to 0.55 mSv if someone uses a CT scan with low-dose radiation. International Commission of Radiological Protection (ICRP) in a publication of 1990. suggests that low doses of radiation may be carcinogenic, especially in children. The situation is further complicated by the fact that radiation has a cumulative effect. Today we can speak about the invasion of lawsuits and litigation aimed in respect of justification of medical protocols and procedures, including diagnostic procedures. The above-mentioned trends have resulted in almost regular and mandatory professional liability insurance of health workers. However it must be emphasized that it is necessary to define precisely the legal protection from judicial prosecution of health workers to provide health care services. In countries with developed legal and judicial systems (UK, USA), jurisprudence and law follow the development of medical science and practice in order to quickly and accurately define acceptable procedures and protocols that are mandatory for health care workers in specific cases. In the initial treatment of injuried with isolated thoracic injuries at the Clinic of Thoracic Surgery, in the five-year study, the conservative treatment was more frequently applied and was sufficient in 63.75% (204/320) of the patients. Such treatment consisted of: continuous observation of the condition, pharmacological treatment, physical therapy and thoracentesis. Initial surgical treatment was necessary in 36.25% (116/320) injured. Based on the results of the study for the majority of patients 41 Assessment of initial diagnostic procedure in isolated thoracic injuries the initial diagnostic procedures (history, physical examination, standard PA or AP chest radiography, standard laboratory tests and ultrasound examination) are usually sufficient for an initial assessment of the injured and the application of appropriate treatment and there is rarely a need for more complicated, time-consuming and expensive diagnostic procedures. Bearing in mind the results of this study, chest CT should be selectively indicate as the part of the initial diagnostic procedures of injuried with isolated thoracic trauma. Secondary examination is much more detailed and aims to identify all injuries. On this basis should be planned further diagnostic procedures and appropriate treatment (1,15,16,17). Further testing may include: CT scan of the chest, CT angiography, esophagoscopy, esophagography, bronchoscopy as well as all other available diagnostic procedures depending on the type of injury (1,14,17,18,19). After secondary examination or shorter monitoring of injured an additional diagnostic procedures were indicated and performed in only 5% (16/320) injured. The analysis showed that necessary additional diagnostic procedures were as follows : bronchoscopy in 1,25%(4/320), chest CT in 2,18(7/320), ultrasound of the heart in 0,93%(3/320), CT aortography in 0,31%(1/320) and esophagoscopy in 0,31(1/320) injuried. Bronchoscopy as an additional diagnostic procedure is indicated in 1.25% (4/320) injuried because of suspected rupture of a major airway (large air fistula, absence of lung reexpansion after pleural drainage, radiologically proven subcutaneous and mediastinal emphysema and etc.) In two patients was confirmed the existence of a large airway rupture (rupture of trachea, rupture of the intermediate bronchus). It is relatively rare indicated additional CT of the chest [2.18% (7/320)], the most common indication was assessment of the state of lung parenchyma. Ultrasound of the heart was indicated at 0.93% (3/320) injured with verified sternal fracture accompanied by changes in the ECG and changes in the biohumoral status. After ultrasound of the heart we could excluded the existence of severe injuries of the heart and the possible existence of pericardial tamponade. Due to the expansion of the upper mediastinal shadow CT aortography was indicated in one patient [0.31% (1/320)] which excluded the possible existence of aortic rupture. Esophagoscopy was indicated in [0.31% (1/320)] because of the low down paravertebral stab wound of left hemithorax, which excluded esophagus lesion. The results obtained in this study correspond to the most data of the other centers in which a secondary examination or shorter observation with further diagnostic tests are used to confirm or rule out specific violations (1,4,5,7,11,20,21,22,23). Overall value of performed initial diagnostic procedures was assessed after: initially perfomed therapeutic procedures, secondary examination, additional diagnostic procedures and continuous monitoring of the injured. The average period of the hospitalization for all injured with isolated thoracic trauma was 5,9±4,0 days (from 6 hours to 16 days). In relation to the type of injury, penetrating vs. blunt, the average length of hospitalization was 5.4 ± 3.36 and 6.07 ± 4.26 days respectively. Statistically, there is no significant difference in relation to the duration of hospitalization between penetrating vs. blunt trauma (0,2766>0,05). Initial diagnostic sensitivity in comparison to the indication for active treatment, which is the percentage or proportion of correctly identified injuries was 98.1%. Initial diagnostic specificity represents a percentage or proportion of correctly identified patients in whom there was no indication for active treatment and was 98.6%.The positive predictive value as the proportion of patients who had an indication for active treatment and whom the initial treatment confirmed indication was 97.1%. The negative predictive value as the proportion of patients for whom there was no indication for active treatment was 99.0%. Sensitivity, specificity, positive and negative predictive values of the total initial diagnostic procedures of all injured with isolated thoracic trauma showed that the initial diagnostic procedures (history, clinical examination, standard and lateral chest radiography, ultrasound abdomen and basic laboratory findings) were sufficient to assess the severity of most isolated chest injuries. CONCLUSION Initial diagnostic evaluation (medical history, clinical and physical examination, standard chest radiography, ultrasound examination of the abdomen and the base of the thorax and standard laboratory tests) in the majority of patients with isolated thoracic injuries were sufficient (sensitivity, 98.1%; specificity 98.6%; positive predictive value of 97.1% and a negative predictive value of 99.0%) for an initial assesment of the type and severity of injury. Based on the above results of initial diagnostic work of most injuried with isolated thoracic injuries it is possible to carry out the necessary and appropriate initial therapeutic procedures. Conflict of interest: none declared. REFERENCES 1. Guska S. Torakalna trauma. U: Guska S. Opšti principi savremene torakohirurške prakse. Sarajevo: Medicinski fakultet Univerziteta u Sarajevu; 2012; 629-680. 2. Guska S, Hadžismailović A, Čerimagić Z. Vodič za torakalnu traumu. Sarajevo: Ministarstvo zdravstva Kantona Sarajevo: Institut za naučno-istraživački rad i razvoj KCU Sarajevo; 2007. 3. Schelzig H, Kick J, Orend KH, Sunder-Plassmann L. Thorax injuries. Chirurg 2006;77(3):281-96. 4. Miller LA. Chest wall, lung, and pleural space trauma. Radiol Clin North Am 2006;44(2):213-24. 5. Guska S, Pilav A, Banjanović B, Mušanović S. Primary surgical repair of traumatic rupture of the bronchus intermedius in closed chest trauma. Scripta Medica 2008;39(1,1 Suppl):227–233. 6. 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Reprint requests and correspondence: Alma Alihodžić-Pašalić, MD Clinic of Thoracic Surgery Clinical Center University of Sarajevo Bolnička 25, 71000 Sarajevo, Bosnia and Herzegovina Email: [email protected] Our contribution to the reduction of cardiovascular disease in Bosnia and Herzegovina! Naš prilog redukciji kardiovaskularnih bolesti u Bosni i Hercegovini! Original article Medical Journal (2014) Vol. 20, No. 1, 43-45 Medicamentous abortion induction in the second trimester in pathological pregnancies Medikamentozna indukcija pobačaja u drugom trimestru kod patoloških trudnoća Naima Imširija1*, Zulfo Godinjak2, Lejla Imširija1, Edin Idrizbegović2, Fatima Gavrankapetanović1, Admir Rama1, Muhamed Ardat2 Clinic for Obstetrics, Clinical Center University of Sarajevo, Patriotske lige 81, 71000 Sarajevo, Bosnia and Herzegovina; Clinic for Gynecology, Clinical Center University of Sarajevo, Patriotske lige 81, 71000 Sarajevo, Bosnia and Herzegovina 1 2 *Corresponding author ABSTRACT Optimal modern methods of abortion include instrumental methods and methods of abortion by the means of medications, according to certain schemes and protocols depending on the age of the pregnancy. In the late sixties of the past century, there were natural prostaglandins available for abortions, such as carboprost (PGF2alpha) and dinoprostone (PGE2). Misoprostol is a synthetic analogue of prostaglandin E 1 and it is in use since the early nineties of the past century. Mifepristone is a synthetic derivative of the norethindrone progestin, it is progesterone receptor antagonist, it causes contractions, softens the cervix and makes endometrium sensitive to the effects of prostaglandins that stimulate uterine contractions and expulsion of the fetus. A clinical study aims to show the efficiency of prepidil gel as well as mifepristone, misoprostol and prostin M-15 in the induction of abortion in pathological pregnancies in the second trimester. The study included 90 subjects in whom the medicationinduced abortion was performed in the second trimester of patological pregnancy at the Department of Obstetrics, Clinical Center University of Sarajevo. In relation to the combination of medications by which the abortion was induced all patients have been divided into three groups of 30 subjects. Group I was induced with prepidil gel and prostin M-15, Group II with prepidil gel and misoprostol, group III with mifepristone and misoprostol. Results:The highest number of pregnancies was terminated because of the foetus mortus in utero diagnosis, a total of 79 ( 87.8 % ) in comparison to the entire specimen. The percentage in group I (patients treated with prepidil gel and prostin M-15) amounted to 83.33 %, and in group II (patients induced with prepidil gel and misoprostol) together with group III (patients treated with mifepristone and misoprostol) amounted to 90 % each. Down syndrome was present in five pregnancies, while multiple anomalies and malformations were represented at 3.33 %. The longest induction of abortion have had the subjects in group and was at 52.93 ± 10.87h , followed with the subjects in group II with 52.06 ± 10.56h and shortest induction was present in group III with 47.7 ± 12.27h . Of the total number of subjects and groups, complete abortion was present in 86.7 %, in group II there was a total of 90 % of complete abortions, while the percentage in group III was 96.7 % . By analyzing the frequency of side effects (bleeding, nausea, diarrhea), it was shown that the patients in group III had the lowest number of treatment complications and side effects. Conclusion: Medicamentous non-surgical interruption of pathological pregnancies in the second trimester has significant advantages in relation to the surgical method.The combination of mifepristone and misoprostol is a more efficient way to end pathological pregnancies in the second trimester compared to induced abortions by combination of misoprostol with prepidil gel or prepidil gel with prostin M-15. Key words: medicamentous abortion, pathological pregnancy, prostaglandins, mifepristone SAŽETAK Optimalne savremene metode prekida trudnoće podrazumijevaju instrumentalne metode i metode prekida trudnoće lijekovima, po određenim šemama i protokolima u zavisnosti od starosti trudnoće. Za prekide trudnoće, prirodni prostaglandini, kasnih šezdesetih godina prošlog vijeka bili su dostupni kao karboprost (PGF2alfa) i dinoproston (PGE2). Mizoprostol (misoprostol) je, sintetski analog prostaglandina E 1 i u upotrebi je od početka devedesetih prošlog vijeka. Mifepriston je sintetički derivat progestina noretindrona; antagonista je progesteronskih receptora; izaziva kontrakcije materice, omekšava grlić materice i senzibiliše endometrijum na dejstvo prostaglandina koji stimulišu kontrakcije materice i ekspulziju ploda. Klinička studija ima za cilj da prikaže efikasnost prepidil gela, mifepristona, mizoprostola i prostina M-15 u indukciji pobačaja kod patoloških trudnoća u drugom trimestru. Istraživanje je obuhvatilo 90 ispitanica kod kojih je na Klinici za ginekologiju Kliničkog centra Univerziteta u Sarajevu urađen medikamentozni pobačaj, u drugom trimestru patološke trudnoće. U odnosu na kombinaciju lijekova kojima je indukovan abortus sve pacijentice smo podjelili u tri skupine po 30 ispitanica. Skupina I je inducirana prepidil gelom i prostinom M-15, skupina II prepidil gelom i misoprostolom, skupina III mifepristonom i misoprostolom. Rezultati: Najveći broj trudnoća je prekinuto zbog postavljene dijagnoze foetus mortus in utero i to ukupno 79 (87.8%) u odnosu na čitav uzorak.Taj procenat u skupini I (pacijentice tretirane prepidil gelom i prostinom M-15) je iznosio 83.33%, u skupini II (pacijentice inducirane prepidil gelom i misoprostolom) i III (pacijentice tretirane mifepristonom i misoprostolom) po 90%. Down sindrom 44 N. Imširija et al. je bio prisutan u 5 trudnoća, dok su multiple anomalije i malformacije bile zastupljene po 3.33%. Najdužu indukciju pobačaja imale su ispitanice skupine I iznosila je 52.93±10.87h, zatim ispitanice skupine II 52.06±10.56h, a najkraću ispitanice skupine III 47.7±12.27h. Od ukupnog broja ispitanica skupine I, kompletan pobačaj je imalo 86.7%, u skupini II bilo je ukupno 90% kompletnih pobačaja, dok je taj procenat u skupini III iznosio 96.7%. Analizom učestalosti nus pojava (krvarenje, mučnina, proljev) ustanovljeno je da su ispitanice skupine III imale najmanji broj komplikacija i neželjenih efekata primjenjene terapije. Zaključak: Medikamentozni nehirurški prekid patoloških trudnoća u drugom trimestru ima znatne prednosti u odonosu na hirurški način. Kombinacija mifepristona i mizoprostala je efikasniji način prekida patoloških trudnoća u II trimestru u odnosu na indukciju pobačaja kombinacijom misoprostola i prepidil gela i prepidil gela i prostina M-15. INTRODUCTION used was used for qualitative variables, and the Anova test for quantitaive ones.The level of significance was p <0.05.The largest number of pathological pregnancies (total of 79 87.8 % ) refers to the fetus in utero mortus diagnosis, Down syndrome was present in 5 pregnancies ( 5:56 % ), and multiple anomalies were diagnosed in 3 pregnancies (33.3 % ). In relation to the combination of medications which induced abortion, all patients have been divided into three groups of 30 subjects.The first group was given prepidil intracervical gel and after “cervical ripening“ we proceeded with induction of prostin M-15 intramuscularly, up to 5 doses every 3 hours. In the second group we used prepidil intracervical gel and misoprostol 200μg, up to five doses every 4 hours, and in the third group we used mifepristone 600 mg per os, and misoprostol 200μg, up to five doses every four hours. There are about 46 million abortions carried out (1) annually in the world, although recent data from the 2011 point to the fact that their number is decreasing and that it is closer to number of 41 million (2). Of this number, about 48 % falls under unsafe abortions, performed by non professionals by inadequate techniques in inadequate conditions (3). Uunsafe abortions are mainly present in countries where abortion is prohibited or restrictively permitted because of certain medical indications and such abortions are the cause of high morbidity and mortality in women (4). Optimal modern methods of abortion include instrumental methods and medication-induced abortion methods, according to certain schemes and protocols depending on the age of the pregnancy, the available methods and other conditions affecting the general health condition of women and local conditions. Medicamentous way of abortion occurred in response to attempts to reduce the risks associated with abortion performed by surgical intervention, mainly those related to accidents related to anesthesia (mortality up to 1 %), infection (and possible sterility) as well as genital and other organs injuries during the intervention (5). Natural prostaglandins PGF2 alpha and PGE2 play an important role in the regulation of uterine activity. PGE2 has a stronger effect on the cervix and causes its softening and dilatation, and PGF2 alpha has greater effect on inducing uterine contractions. Misoprostol, a synthetic analogue of prostaglandin E1, is used in over 80 countries worldwide. Because of its effects on the cervix, it can be applied in preparing the cervix - for softening and dilatation of the cervix prior to the instrumental abortion or before hysteroscopy. For abortions in the first and second trimester, it is applied in various schemes (6). Mifepristone is a synthetic derivative of the norethindrone progestin, it is progesterone receptor antagonist, and it causes contractions, it softens the cervix and makes endometrium sensitive to the effects of prostaglandins that stimulate uterine contractions and expulsion of the concept. In the absence of progesterone, mifepristone acts as a partial agonist of progestine. At doses higher than those used for abortion, it has antiglucocorticoid and weak antiandrogenic effect (7). MATERIALS AND METHODS The clinical study was aimed to show the efficiency of prepidil gel, mifepristone, misoprostol and prostin M-15 in the induction of abortion in pathological pregnancies in the second trimester.The study included 90 subjects in whom the medicamentous abortion was performed by the application of prostaglandins in the second trimester of patological pregnancy at the Department of Obstetrics, Clinical Center University of Sarajevo. After the research, data were analyzed by statistical software SPSS, version 20.0. Chi square test Ključne riječi: medikamentozni abortus, patološka trudnoća, prostaglandini, mifepriston RESULTS The oldest gestational age had the patients in group III (patients induced with mifepristone and misoprostol) and it amounted to 18.56 ± 2.89 weeks, followed by group I (patients induced with prepidil gel and prostin M-15) 18.06 ± 3.21 weeks, and the lowest had the patients in group II (patients induced with Prepidil gel and misoprostol), 17.83 ± 2.40 weeks. Anova test showed that there was no statistically significant difference in the length of gestational age during pregnancy termination between the examined groups, F = 0.384, p = 0.682. Table 1 Average gestational age during pregnancy termination There was a statistically significant difference in the length of the abortion induction in relation to test group F=1.034, p=0.039. The longest abortion induction was present in group I patients (patients induced with prepidil gel and prostin M-15) and it amounted to 52.93 ± 10.87h, followed with group II patients (patients induced with prepidil gel and misoprostol) 52.06 ± 10.56h and shortest induction was in group III patients (patients induced with mifepristone and misoprostol) 47.7 ± 12.27h. Table 2 The average length of the abortion induction Medicamentous abortion induction in the second trimester in pathological pregnancies From the total number of respondents in group I (patients induced with prepidil gel and prostin M-15), complete abortion occured in 86.7%, in group II (patients induced with prepidil gel and misoprostol) there were a total of 90% of complete abortions, while the same percentage in group III (patients induced with mifepristone and misoprostol) amounted to 96.7%. In other women abortion also occured, but because of incomplete abortions, in a total of 8.9% of the patients, we underwent revision of the uterine cavity. Table 3 Success of induction as compared to the experimental group 45 tion was shorter. Honkanen et al. states that oral administration of 600 mg dose of mifepristone causes more frequent diarrhea, nausea and vomiting, than when it is used in lower doses of 200 mg and pelvic pain after oral administration of misoprostol occurs on average one hour earlier (9). Guengant et al. states that a dose of 600 mg mifepristone administered orally is successful in 95.4%, with the likelihood of side effects in the form of bleeding and vomiting in 8.2% (10). Spitz et al. specify nausea in 30%, vomiting in 16-21% and pelvic pain in 80, the incidence of hemostatic curettage at 1:45 %, as well as the need for transfusion at 0.15% and analgesics in 16% of pregnant women in the event of termination of pregnancy up to 49 days of amenorrhea (10). In this study, patients in group III (patients treated with mifepristone and misoprostol) had the lowest number of treatment complications and side effects. CONCLUSION By analyzing the frequency of side effects (bleeding, nausea, diarrhea) a statistically significant difference was shown in the incidence of therapy side effects and complications, where the patients in group III (patients induced with mifepristone and misoprostol) had the lowest number of complications (infections, residues and post abortum perforations) and treatment side effects. Group I patients (patients induced with prepidil gel and prostin M-15) had significantly higher incidence of side effects (nausea and diarrhea), and complications (infections and post abortum residues) as compared to the other two groups. Table 4 The frequency of side effects caused by medications and the treatment complications Medicamentous non-surgical interruption of pathological pregnancies in the second trimester has considerable advantages over the surgical method. It reduces the number of complications (infection, bleeding, residue post abortum) and subsequent cervical incompetence in subsequent pregnancies, as well as adverse effects (bleeding, nausea, vomiting). The psychological aspects of fear were significantly lower in the medicamentous abortion. The combination of mifepristone and mizoprostal is a more efficient way to break pathological pregnancies in the second trimester compared to induced abortion combination of mifepristone with prepidil gel or prepidil gel with prostin M-15. Conflict of interest: none declared. REFERENCES DISCUSSION Modern methods of abortion by medications are nowadays available to women in many countries by the range of different protocols. The discovery of synergistic action of the antiprogestin (mifepristone) and its synthetic analogue, prostaglandin E1 (misoprostol) on abortions in the second trimester, has developed a new, highly effective and safe method of abortion with medicaments. Existing today, there are established schemes of administering these medications, provided by the World Health Organization, at various gestational age on the basis of many studies done in this area. If an unwanted pregnancy or pathological pregnancy occur, it is necessary to enable women to have a choice as well as these modern methods of medicamentous abortion on which about half of women actually decides on in countries where it is available (8). In the first group treated with prepidil gel and prostin M–15, abortion occured in 86.7 % of the patients, in the second group treated with prepidil gel and misoprostol that percentage was higher, and amounted to 90 %. The analysis of the success in the third group treated with mifepristone in combination with misoprostol in the second trimester, showed that the success was much higher ( 96.7 % ), and duration of induc- 1. Alan Guttmacher Institute. Sharing responsibility: women, society and abortion worldwide. New York: The Alan Guttmacher Institute; 2009. 2. Sedgh G, Henshaw S, Singh S, Lhman E, Shah IH. Induced abortion: rates and trends worldwide. Lancet 2007;370(9595): 1338-45. 3. Safe abortion: technical and policy guidance for health systems. Geneva: WHO; 2003. 4. WHO Scientific Group. Medical methods for termination of pregnancy: report. Geneva: WHO; 2007. 5. Misoprostol AHFS drug information 2001:2837-42. 6. Schcepcrs HC, van Erp EJ, van den Bergh AS. Use of misoprostol in first and second trimester abortion: a review. Obstet Gynecol Surv 1999;54(9): 592-600. 7. Song J. Use of misoprostol in obstetrics and gynecology. Obstet Gynecol Surv 2000;55(8):1-12. 8. Kapamadzija A, Vukelic J, Bjelica A, Kopitovic V. Abortus lekovima - savremena metoda prekida trudnoće. Med Pregl 2010;53(1-2): 63-67. 9. Honkanen H, Piaggio G, Hertzen H, Bartfai G, Erdenetungalag R, Gemzell-Danielsson K, et al. WHO multinational study of three misoprostol regimens after mifepristone for early medical abortion. BJOG 2004;111(7):715–25. 10. Spitz IM, Bardin CW, Benton L, Robbins A. Early pregnancy termination with mifepristone and misoprostol in the United States. N Engl J Med 2008;338(18):1241–7. Reprint requests and correspondence: Naima Imširija, MD Clinic for Gynecology and Obstetrics Clinical Center University of Sarajevo Patriotske brigade 81, 71000 Sarajevo Bosnia and Herzegovina Phone: +387 33 250 250 Email: [email protected] Professional article Medical Journal (2014) Vol. 20, No. 1, 46-49 Endoscopic retrograde cholangiopancreatography: our experience Endoskopska retrogradna holangiopankreatografija: naša iskustva Kenan Nahodović*, Rusmir Mesihović, Nenad Vanis, Amra Puhalović, Srdjan Gornjaković, Amila Mehmedović, Alma Nahodović Clinic for Gastroenterohepatology, Clinical Center University of Sarajevo, Bolnička 25, 71000 Sarajevo, Bosnia and Herzegovina *Corresponding author ABSTRACT SAŽETAK Introduction: ERCP is a technique that combines endoscopic and radiological procedures in diagnosis and treatment of biliopancreatic diseases. ERCP is used in the diagnosis and treatment of choledocholithiasis, various stenosis of biliopancreatic system, carcinoma treatment. Today ERCP is mainly used for therapeutic purposes, and as such carries the risk of a large number of complications. Objective: To evaluate the number of patients who underwent ERCP, ERCP success, the most common diagnosis, and the rate of complications. Methods: we retrospectively analyzed 570 patients who were admitted during 2011. at the Clinic of Gastroenterohepatology CCUS. The patients were on admission underwent the basic lab findings and diagnostic procedures followed by indicated ERCP. Statistically analyzed demographic structure of patients diagnosed during ERCP, the performance of the procedure and the emergence of post ERCP complications. Results: during year 2011., 570 patient were admitted at our Clinic of Gastroenterohepatology for endoscopic retrograde cholangiopancreatography. The largest number of patients was more than 50 yrs of age (82.1%), and at least between 20 and 29 years of age (2.1%). ERCP was successful in 556 or 97.54% of the cases and unsuccessful in 14 or 2.5% of cases. The most common diagnosis verified during ERCP was choledocholithiasis, 303 patients (53.2%), followed by tumors of the head of the pancreas, 112 patients (19.6%).The most common complication was the occurrence of mild pancreatitis in 35 patients, or 6.1% of cases, and severe in only 1 case or 0.2%. Conclusion: ERCP is a safe method that is used in the treatment of diseases of biliopancreatic system, especially choledocholithiasis and malignant obstruction. The percentage of post ERCP complications is very small and is in accordance to global standards. The mortality rate is extremely low. Uvod: ERCP je tehnika koja kombinira endoskopske i radiološke procedure u dijagnostici i tretmanu bolesti biliopankreatičnog sistema.ERCP se koristi u dijagnostici I tretmanu holedoholitijaze, raznih stenoza biliopankreatičnog sistema, tretmana carcinoma. Danas se ERCP uglavnom koristi u terapeutske svrhe, I kao takva nosi rizik od velikog broja komplikacija. Cilj: evaluirati broj pacijenata kod kojih je radjen ercp, uspješnost ercp, najčešća dijagnoza, i procenat komplikacija. Metod rada: retrospektivno smo analizirali 570 pacijenata koji su primljeni tokom 2011. godine na Kliniku za Gastroenterohepatologiju KCUS. Pacijentima su pri prijemu urađeni osnovni laboratorijski nalazi i dijagnostičke procedure nakon čega je indiciran ERCP. Statistički smo analizirali demografsku strukturu pacijenata, dijagnozu prilikom ERCP, uspješnost izvođenja procedure i nastanak post ERCP komplikacija. Rezultati: tokom 2011. godine na Kliniku za Gastroenterohepatologiju je primljeno 570 pacijenata kojima je urađena endoskopska retrogradna holangiopankreatografija. Najveći broj pacijenata je bio preko 50 godina starosti (82,1%), a najmanje između 20 i 29 godina starosti (2,1%). ERCP je bio upješan u 556 ili 97,54% slučajeva a neuspješan u 14 ili 2,5% slučajeva. Najčešća dijagnoza koja je verificirana tokom ERCP je bila holedoholitijaza, 303 pacijenta (53,2%), potom neoplazma glave pankreasa, 112 pacijenata (19,6%). Najčešća komplikacija je bila pojava pankreatitisa blagog pankreatisita, 35 pacijenata ili 6,1% slučajeva, te teški pankraetitis u samo jednom slučaju ili 0,2%. Stopa mortaliteta je iznosila 0,3%. Zaključak: ERCP je sigurna metoda koja se koristi u tretmanu oboljenja biliopankreatičnog sistema, posebno holedoholitijaze i malignih opstrukcija. Procenat post ERCP komplikacija je vrlo mali i u skladu je svjetskim standarima. Stopa mortaliteta je izrazito niska. Key words: ERCP, complication, pancreatitis, bleeding. Ključne riječi: ERCP, komplikacije, pankreatitis, krvarenje. INTRODUCTION have improved, endoscopic retrograde cholangiopancreatography (ERCP) has evolved from primarily a diagnostic procedure into primarily a therapeutic procedure (4-7). ERCP is helpful in diagnosing and treating choledocholithiasis, benign and malignant biliary strictures, operative and traumatic ductal injuries, and sphincter of Oddi dysfunction. However, this diagnostic technique may lead to potential complications, even post-ERCP mortality, which should be reduced by avoidance of its unnecessary use (8,9). The first endoscopic pancreatogram was obtained in 1968, and in 1974, biliary sphincterotomy was first described (1-2). This was followed by the first report of papillotomy for the management of choledocholithiasis (3) and in subsequent years, numerous endoscopic techniques evolved to address pancreaticobiliary disease. As computerized axial tomography and magnetic resonance imaging 47 Endoscopic retrograde cholangiopancreatography: our experience MATERIALS AND METHODS We retrospectively analyzed 570 patients who were admitted during 2011. at the Clinic of Gastroenterohepatology Clinical Center University of Sarajevo (CCUS).The patients were on admission underwent the basic laboratory findings and diagnostic procedures followed by indicated ERCP. We statistically analyzed demographic structure of patients diagnosed during ERCP, the performance of the procedure and the emergence of post ERCP complications. Basic demographic parameters are given in Figure 1. The most common diagnosis during ERCP was choledoholithiasis, 303 patients (53,2%), and pancreatic cancer 112 patients (19,6%). Nine patients (1,65%) had normal findings, and only 2 patients (0,4%) had billiar leakage (Figure 2). Figure 3 Post ERCP pancreatitis Figure 1 Demographic parameters As for the demographics of patients most patients had more than 50 years of age (82.1%), and at least between 20 and 29 years of age (2.1%). Pancreatitis has appeared as of mild in 35 (6.1%) of cases and severe in only 1 case (0.2%). Patients who had verified mild pancreatitis were successfully treated with conservative therapy, while in patient who developed severe pancreatitis surgical treatment was indicated (Figure 3). Table 2 ERCP age distribution RESULTS Table 1 ERCP efficacy ERCP was succesfully performed in 556 patients (97,4%), unsuccesfully in 14 patients (2,5%). Majority of patients in whom ERCP could not be perfomed had altered digestive anatomy of previous operations (hepatico jejuno anastomosis (0,7%) and Billroth II anastomosis ( 0,4%). The least patients, 1 or 0,2%, had diffuse malignancy caused by pancreatic cancer who could not had been treated endoscopicaly and they were reffered to surgery (Table 1). hi=2,928; p=1,000 Relationship to the occurrence of pancreatitis vintage and endoscopic diagnosis, which indicates that there is no significant difference between the incidence of pancreatitis in relation to age and endoscopic diagnosis (p=1.000) (Table 2.) Figure 4 Post ERCP bleeding Figure 2 ERCP diagnosis during procedure Bleeding was reported in 4 cases or 0.5% of the total sample. 48 Figure 5 Post ERCP perforation Duodenal perforation was recorded in the 4 cases or 0.5% of the total sample (N=870). According to the diagnosis, duodenal perforation was observed more frequently in diagnosis of neo pancreatic head (3 or 75%) compared to 1, or 25% of diagnosis choledocholithiasis slots within the total number of slots (Figure 5). Mortality rate of the total 870 patients was observed in 3 cases or 0.3%. DISCUSSION ERCP is an established diagnostic and therapeutic tool for pancreatobiliary diseases including choledocholithiasis, malignant opstruction, biliar leakage. The rate of technical success, complete duct clearance, early/late complications, and mortality are reportedly 80.5%-100%, 86.0%-98.0%, 5.0%-6.3%, 0-5.0%, and 0-3.2%, respectively (10,11,12,13). The largest number of patients that was hospitalized, had over 50 years of age, the most common indication for ERCP was choledocholithiasis and obstructive jaundice caused by malignancy of the pancreatic head.The success of the ERCP was 97.54%, which is consistent with studies in the world where it describes the performance of up to 97% (10,11). The largest number of patients in whom we could not perform ERCP had deteriorated anatomy after previous surgery (Billroth II anastomosis and hepaticojejunoanastomosis), and are referred to the PTC or surgical treatment. Since its introduction in 1968., ERCP has become a commonly performed endoscopic procedure (14). The diagnostic and therapeutic utility of ERCP has been well demonstrated for a variety of disorders, including the management of choledocholithiasis, diagnosis and management of biliary and pancreatic neoplasms, and the postoperative management of biliary perioperative complications (15,16,17). Performing ERCP is associated with numerous complications (perforation, bleeding, pancreatitis). Numerous studies have helped determine the expected rates of complications, potential contributing factors for these adverse events, and possible methods for improving the safety of ERCP. Recognition and understanding of potential complications of ERCP are vital in the acquisition of appropriate informed consent (18). Pancreatitis is the most common serious ERCP complication (19,20,21). Although transient increase in serum pancreatic enzymes may occur in as many as 75% of patients,16 such an increase does not necessarily constitute pancreatitis. A widely used consensus definition for K. Nahodović et al. post ERCP pancreatitis is (1) new or worsened abdominal pain, (2) new or prolongation of hospitalization for at least 2 days, and (3) serum amylase 3 times or more the upper limit of normal, measured more than 24 hours after the procedure (22). By using this or similar definitions, the incidence of PEP in a meta-analysis of 21 prospective studies was approximately 3.5%, but ranges widely (1.6%-15.7%) depending on patient selection (23,24). Our study showed that post ERCP pancreatitis had 36 patients (6,3%), majority of them had mild form (6,1%) and only one patient had severe pancreatitis (0,2%). Patients with mild pancreatitis were treated conservative, while patient with severe form of pancreatitis needed further surgical treatment. Most ERCP-associated bleeding is intraluminal, although intraductal bleeding can occur and hematomas (hepatic, splenic, and intra-abdominal) have been reported (26,27). Hemorrhage is primarily a complication related to sphincterotomy rather than diagnostic ERCP. In a meta-analysis of 21 prospective trials, the rate of hemorrhage as a complication of ERCP was 1.3% (95% CI, 1.2%-1.5%) with 70% of the bleeding episodes classified as mild (23). Hemorrhagic complications may be immediate or delayed, with recognition occurring up to 2 weeks after the procedure. In our case bleeding rate was 0,5%. Bleeding was immediate after sphincterotomy and was treated with injection of adrenalin solution or heater probe. Perforation rates with ERCP range from 0.1% to 0.6% (19, 20, 28, 29,30). Three distinct types of perforation have been described: guidewire-induced perforation, periampullary perforation during sphincterotomy, and luminal perforation at a site remote from the papilla (30). Risk factors for perforation determined in a large retrospective study included the performance of a sphincterotomy, Billroth II anatomy, the intramural injection of contrast, prolonged duration of procedure, biliary stricture dilation, and SOD (28,31). In our study 3 patients had perforation as a major complication. Two of them had luminal perforation at site remote from the papila and one had perforation that occured during sphincterotomy. All three of them were treated surgicaly with good outcome. CONCLUSION Endoscopic retrograde cholangiopankreatography is safe and very succesfull method for treatment of bilio pancreatic disorders. It is very invasive procedure that is used only in therapeutic purpose. For endoscopists to accurately assess the clinical appropriateness of ERCP, it is important to have a thorough understanding of the potential complications of this procedure. Rate of complications is very low as well as mortality rate. 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Reprint requests and correspondence: Kenan Nahodović, MD Clinic for Gastroenterohepatology, Clinical Center University of Sarajevo Bolnička 25, 71000 Sarajevo, Bosnia and Herzegovina Phone: +387 33 297 911 Email: [email protected] Professional article Medical Journal (2014) Vol. 20, No. 1, 50-58 People with disabilities and their free access to hospital facilities in the compound of Clinical Center University of Sarajevo: special focus on Central Medical Building Analiza kretanja osoba umanjenih tjelesnih mogućnosti kroz objekte nove gradnje u Kliničkom Centru Univerziteta u Sarajevu; poseban osvrt na Centralni medicinski blok Mirza Dilić1, Mustafa Hiroš2, Mirela Imširija3*, Naima Imširija-Galijašević3 1 Internal Clinics and Departments, Clinical Center University of Sarajevo, Bolnička 25, 71000 Sarajevo, Bosnia and Herzegovina, 2Surgical Clinics and Departments, Clinical Center University of Sarajevo, Bolnička 25, 71000 Sarajevo, Bosnia and Herzegovina, 1Technical Department, Clinical Center University of Sarajevo, Bolnička 25, 71000 Sarajevo, Bosnia and Herzegovina, Clinic of Ginecology and optetrition, Clinical Center University of Sarajevo, Jezero *Corresponding author ABSTRACT SAŽETAK The reasons for this article lies in the fact that modern society is not sufficiently sensitive to the population of persons with currently or permanently reduced physical abilities. The involvement of the whole community is required, to provide independent lifestyle for these people.The public institutions carry a special responsibility in overcoming architectural, as well as every other barriers. Individual contribution of each and one of us should be present in our local communities. Clinical Center University of Sarajevo (CCUS) is a tertiary health care institution, and as such it should and it must be an example for all other public institutions in implementation of the principle of handicapped friendly construction. The analyses of the post-war construction reveals that the movement of handicapped persons had been taken into an account.This particularly applies to the new Central Medical Building (CMB), which is building of a 50,000 m2 gross area and whose full construction is in progress. In current implementation of CMB’s construction, this issue has been taken into an account, particularly bearing in mind that the potential moves reduction may be of temporary (broken limbs, etc) and permanent character. The approach to this issue in the analyses of future activities and creation of “free train line” was multidisciplinary, and included the joint work of doctors and engineers, which resulted in the establishment of the best and shortest safe and dry lines (covered corridors, tunnels, etc.) connections within the building. The backbone of the future construction of demanding object, as a starting point and an important basis for the planning of movement within other health institutions. The paper contains additional drawings and graphics of handicapped people’s movement plan, which can be of a great help to the physically disabled persons, as a movement lines within CCUS objects of the “Koševo“ location. Razlozi za istraživanje ove teme leže u činjenici da savremeno društvo nije dovoljno osjetljivo na populaciju osoba trenutno ili trajno umanjenih tjelesnih sposobnosti. U omogućavanju samostalnog života ovih ljudi potreban je angažman cijele zajednice, ali u javnim ustanovama leži posebna odgovornost u prevazilaženju arhitektonskih kao i svakih drugih barijera. Pojedinačan doprinos svakoga od nas treba da bude u našim lokalnim radnim sredinama. Klinički Centar Univerziteta u Sarajevu (KCUS) je zdravstvena ustanova tercijarnog nivoa i kao takva treba i mora da bude za primjer svim drugim javnim ustanovama u provedbi humanističkih principa gradnje. Analizom postratne izgradnje vidljivo je da se vodilo računa o kretanju osoba umanjenih tjelesnih sposobnosti.To se posebno odnosi na novi Centralni medicinski blok (CMB), koji je objekat od 50.000 m2 brutto površine i čija puna izgradnja je u toku. U dosadašnjoj realizaciji gradnje CMB-a, o ovoj problematici se vodilo posebno računa imajući u vidu da umanjenje mogućnosti kretanja može biti privremenog (lomovi ekstremiteta i sl.) i trajnog karaktera. Pristup ovoj problematici kod analize budućih aktivnosti i kreiranja „hodnih linija“ je bio multidisciplinaran i podrazumijevao je zajednički rad doktora i inžinjera, što je rezultiralo uspostavljanjem najboljih i najkraćih toplih (pokrivenih, tunelskih, itd) veza unutar objekta. Okosnica je to buduće izgradnje ovog zahtjevnog objekta, kao polazna i važna osnova planiranja kretanja unutar drugih zdravstvenih institucija. U radu su dati i grafički prilozi plana kretanja, što može biti od velike pomoći ljudima umanjenih tjelesnih sposobnosti kao vodič za kretanje unutar dijela objekata KCUS-a na lokalitetu „Koševo“. Keywords: people of reduced physical abilities, newly built hospital facilities, Central Medical Building, Clinical Center University of Sarajevo Ključne riječi: osobe umanjenih tjelesnih sposobnosti, novija gradnja bolničkih kapaciteta, Centralni medicinski blok, Klinički Centar Univerziteta u Sarajevu People with disabilities and their free access to hospital facilities in the compound of Clinical Center University of Sarajevo: special focus on Central Medical Building UVOD Tretman osoba umanjenih tjelesnih sposobnosti u javnim objektima s aspekta arhitektonskih barijera Činjenica je da Bosna i Hercegovina nema zvaničan podatak o broju osoba sa trajno umanjenim tjelesnim sposobnostima. Ulazni podatak može jedino da se pretpostavi na temelju istraživanja Svjetske zdravstvene organizacije (SZO) i drugih međunarodnih organizacija. Smatra se, na osnovu istraživanja SZO kao i procjene specijalizovanih agencija i međunarodnih organizacija, da je krajem sedamdesetih godina u svijetu bilo oko 450 miliona ljudi sa trajno umanjenim sposobnostima. U tom momentu, to je iznosilo oko 10% ukupnog broja svjetskog stanovništva. Statistčki pokazatelji morbiditeta jasno ukazuju na očekivano povećanje broja osoba sa trajno umanjenim tjelesnim sposobnostima. Ovaj trend prvenstveno ima tendenciju rasta zahvaljujući napretku savremene medicine, čiji su izvanredni rezultati omogućili da veliki broj ljudi doživi duboku starost, i da takođe veliki broj preživi teška, do prije koju deceniju najčešće smrtonosna tjelesna oštećenja, ali sa smanjenom tjelesnom sposobnošću kao posljedicom (1,2,3,4).Također je važno napomenuti da su iz ovih numeričkih podataka izuzete sve druge osobe čije su umanjene sposobnosti kretanja privremenog karaktera. To se odnosi na povrede čije izlječenje podrazumijeva privremenu korištenje različitih vrsta ortopedskih pomagala; štake, štap, kolica i dr. Bosna i Hercegovina trenutno se nalazi u postratnom periodu koji je sasvim sigurno značajno uvećao broj ljudi iz ove kategorije kao direktnu ili indirektnu posljedicu ranjavanja. Postavlja se realno pitanje koliko mi zaista brinemo o njima, odnosno koliko svojim nemarom i/ili nebrigom dodatno otežavamo život? Ova problematika svakako bi morala biti jače podržana od strane cijele zajednice, međutim u konkretnim arhitektonskim barijerama s kojima se ova populacija susreće svakodnevno, ne možemo i ne trebamo abolirati arhitekte, urbaniste i sve ostale koji imaju mogućnost direktno intervenirati u određenim lošim arhitektonskim rješenjima. Kretanje unutar već izgrađenih javnih, stambenih i drugih objekata najčešće biva nemoguće bez pomoći trećih lica, što za posljedicu ima „zatvaranje u svoja četiri zida“ velikog broja ljudi iz ove kategorije što je neprihvatljivo (2,3). Iako je na nivou države donesen veliki broj uredbi, pravilnika, odluka itd, provođenje njima predviđenih mjera još uvijek je jako slabo. Sve javne ustanove morale bi imati u potpunosti realiziranu mogućnost kretanja ove populacije, što sada nije slučaj. U velikom broju primjera, vanjske rampe su neprimjerenih nagiba i onemogućavaju samostalno kretanje, vanjske platforme (koje su postavljene poštujući najčešće uvjete tehničkih prijema objekata), ostanu prekrivene i van funkcije su. To znači da se ovakvo stanje mora mijenjati (2,3,4). Klinički centar Univerziteta u Sarajevu je ustanova tercijarne zdravstvene zaštite i kao takva jedna od krovnih zdravstvenih institucija u Bosni i Hercegovini. To znači da veliki broj ljudi sa privremeno ili trajno umanjenim tjelesnim mogućnostima dolazi svakodnevno na ove lokalitete. To nameće dodatnu obavezu u promišljanju i projektiranju objekata koje će ova populacija moći samostalno koristiti. Kroz KCUS ponuđene su najkvalitetnije i konsultativno-specijalističke i hospitalne usluge najšireg spektra. Klinički centar raspolaže sa 2030 bolesničkih postelja, raspoređenih u 33 zgrade, te suvremenom medicinskom opremom (3,5,6,8,9,10). 51 Slika 1 Situacioni plan kompleksa Kliničkog centra Univerziteta u Sarajevu sa naznačenim nukleusom prostornog razvoja novih objekata. KONCEPT NOVE GRADNJE Nova gradnja predstavlja tipični blokovski koncept po uzoru na na velike bolničke sisteme u SAD-u, Evropi, Japanu, Australiji i širem Azijskom regionu, a koji u svom sadržaju ima: - Centralni medicinski blok sa stacionarom i funkcionalnim dijelom (CMB) - Objekat dijagnostike i poliklinike (DIP) - Objekat za nauku i nastavu (NIN) - Tehno-ekonomski blok (TEB) Svi ovi objekti međusobno su povezani podzemnim i nadzemnim komunikaciono-instalacionim koridorima. Sa postojećim objektima novijeg datuma gradnje na kojima su izvedeni odgovarajući rekonstruktivni radovi čine okosnicu novog Kliničkog centra na lokalitetu Koševo. Zadržavanjem dijela postojećih objekata i izgradnjom novih mijenja se u prostornom smislu koncept bolnice u blok-paviljonski. Skoro polovina posteljnih kapaciteta KCUS-a biće smještena u Centralnom medicinskom bloku, a druga polovina u postojećim objektima novijeg datuma gradnje. Stari nefunkcionalni objekti biće porušeni. Neki od njih biće zadržani i restaurirani za nemedicinske namjene (biblioteke, muzeji, klubovi i sl.).To znači da će nukleus buduće izgradnje biti Centralni medicinski blok (CMB), koji je prema svojoj i situacionoj i funkcionalnoj poziciji centralni. Zbog toga će u daljnjoj analizi kretanja osoba sa umanjenim tjelesnim sposobnostima biti dat poseban osvrt na mogućnosti kretanja unutar ovog objekta. U ovom trenutku on ima “tople veze” sa objektom DIP-a, TEB-a, Ortopedije, Magnetne rezonanse i Klinike za Urgentnu medicinu (4,5,6,7). Slika 2 Fotografija makete kompleksa Koševo sa označenim novim objektima (Maketa: „Arhitekt“ d.o.o. Sarajevo; Imširija M.) 52 Osnovni podaci o funkcijama novih objekata M. Dilić. et al. Slika 3 Maketa kompleksa sa naznačenom pozicijom objekta CMB - KCUS (Tehnički sektor; Imširija M.) Tehnoekonomski blok (TEB) je objekat u kome su smješteni energetski i pogonski uređaji i servisi neophodni za funkcionisanje KCUS-a. Unutrašnjim saobraćajnicama povezan je sa svim objektima na lokalitetu kao i sa gradskim saobraćajnicama. Na ovaj način omogućeno je efikasno snabdijevanje robama, gorivom i materijalima. Sa većinom medicinskih sadržaja povezan je toplim vezama.U okviru tehno-ekonomskih sadržaja izgrađeni su: Centralna kuhinja, Centralna praonica rublja, servisi, radionice, Dispečerski centar, procesno skladište i telefonska centrala. Dijagnostika i poliklinika (DIP) je dio Centralnog medicinskog objekta (CMO). Objekat se sastoji iz međusobno povezanih funkcionalnih cjelina: poliklinike, nuklearne medicine i Centralnog laboratorija. Poliklinički sadržaji u okviru jedne djelatnosti osigurava im optimum interdisciplinarnog rada. Pored konsultativne dijagnostičko-terapeutske djelatnosti, u ovim jedinicama se organizuje i praktična nastava za studente i liječnike kao i određena naučno istraživačka istraživanja. Nauka i nastava (NIN) je takođe dio Centralnog medicinskog objekta (CMO) i izgrađen je uz CMB i sa kojim ima neposrednu toplu vezu. U objektu NIN-a nalaze se dva savremena amfiteatra namjenjena za održavanje nastave studentima Medicinskog fakulteta kao i za druge manifestacije.Tu je i glavni ulaz za sve studente koji dolaze na ovu lokaciju. OPIS CENTRALNOG MEDICINSKOG BLOKA (CMB-a) Centralni medicinski blok (CMB) je najveći objekat na lokalitetu Koševo (Slika 3). Njegova ukupna brutto površina je oko 50.000 m2 i sastoji se iz šest samostalnih lamela, projektantski označenih kao: A, B, C, D, E i F. Većim svojim dijelom objekat prati konfiguraciju terena na kome je izgrađen (Slika 4). Slika 4 Osnova CMB-a sa rasporedom lamela CENTRALNI MEDICINSKI OBJEKAT (CMO) Centralni medicinski objekat (CMO) je najveći objekat na lokalitetu Koševo. U njegov sastav ulazi (ranije opisani) objekat DIP-a i Centralni medicinski blok (CMB), čija intenzivna gradnja je u toku. Do ovog trenutka je izvedeno cca. 35% od ukupne površine objekta, koja iznosi cca. 50.000m2. Iz funkcionalne šeme vidljivo je da sve discipline i djelatnosti smještene u centralne objekte, moraju biti jasno diferencirane, a istovremeno međusobno povezane u jedinstvenu tehnološku cjelinu. Centralni medicinski objekat ima šest ulaza primarnog značaja; 1. ulaz za osoblje i posjetioce, 2. ulaz za vanjske pacijente, koji koriste usluge dnevne bolnice, polikliničko – dijagnostičkih i laboratorijskih jedinica. Ulaz mora biti odvojen od ulaza za osoblje, studente i posjetioce, 3. ulaz za studente, 4. ulaz opskrbe u TEB, 5. urgentni ulaz, 6. ulaz u dijagnostiku pacijenata koji su stacionirani na lokalitetu Koševo van Centralnog objekta i objekata povezanih toplim vezama. Unutarnje komuniciranje vanjskih pacijenata i hospitaliziranih bolesnika treba vidno dodatnom vizuelnom signalizacijom usmjeriti. Ovo se naročito odnosi na prostore poliklinike, dijagnostike i centralne laboratorije koje koriste i vanjski pacijenti (poseban ulaz, ulazni hol, čekaonice) i hospitalizirani bolesnici (veza sa stacionarom). Hospitalni dio - stacionar je riješen u obliku slova H, koga čine lamele A i C (prostori u kojima su smještene bolesničke sobe) i spojna komunikaciona lamela B. U lameli B su projektovani vertikalni komunikacioni putevi (baterija od 9 liftova i dva stepeništa) i zajednički prostori . Dijagnostičko-terapijski dio objekta čine niski dijelovi lamela A, B i C, te interpolirane četverospratne lamele D i E. One popunjavaju prostor između lamela A, B i C na etažama 04, 05, 06 i 07. Na etaži 06 smješten je Operacioni blok sa 15 OP sala, hirurška intenzivna njega sa 26 kreveta, endoskopije i stacionar Kardiohirurgije. Na nižoj etaži (05) predviđeni su Centralna sterilizacija, Apoteka, Restoran i Glavni ulazni hol sa recepcijom. Etaža 04 planirana je za Patologiju i Centralne garderobe. Rtg dijagnostika i Radioterapija predviđeni su na etažama 03 i 02. Lamela F je niski dvoetažni objekat koji spaja CMB sa starijim objektom Ortopedsko-traumatološke klinike. Podaci o objektima sadržani su u prethodnim studijama, u kojima su oni sa tehničko-tehnološkog aspekta detaljno analizirani. (4) People with disabilities and their free access to hospital facilities in the compound of Clinical Center University of Sarajevo: special focus on Central Medical Building 53 Osvrt na način dosadašnje gradnje novih objekata STACIONAR CMB-a - tipska etaža Novi objekti Kliničkog centra Univerziteta u Sarajevu, prema postavljenim standardima kvaliteta moraju ispuniti maksimalne tehničkotehnološke uvjete savremene gradnje medicinskih objekata. Njihova gradnja je izuzetno skupa, imajući u vidu veliki broj zahtjevnih instalacija. Osnovno opredjeljenje je da ono što se izgradi mora biti na putu maksimalno humaniziranog, odnosno „friendly“ pristupa kada su pacijenti, posjetioci i uposlenici u pitanju. Samo takav prostor čini bolesnim ljudima, ali i njihovim obiteljima situaciju lakšom i s humanog aspekta prihvatljivom. U tom smislu promišlja se i kada su u pitanju osobe sa umanjenim tjelesnim mogućnostima. Uvažavajući činjenicu da su tjelesna oštećenja dosta širok pojam, referentna skupina čije kretanje se mora posebno analizirati su ljudi u invalidskim kolicima. Kada se obezbijedi njihovo samostalno kretanje, određeni prostor će biti bez arhitektonskih barijera i za ostale skupine ove populacije. Da je to opredjeljenje primarno dokazuje i činjenica da je unutar Centralnog medicinskog bloka, uz prve dijagnostičko-polikliničke prostore izgrađen najveći dio vertikalnih komunikacija, kao i kupatila za ove osobe. Ulazna vrata u sve stacionare i bolesničke sobe su širine 120cm, što omogućava nesmetan ulaz/izlaz pacijenata sa otežanim kretanjem, ali istovremeno omogućava obilazak pacijenata od strane posjeta (koje mogu imati isti problem). S obzirom da je izgrađen manji stepen ovog zahtjevnog objekta, vidljiva je razvijena svijest o potrebama svih ljudi u obezbjeđivanju njihovog samostalnog kretanja kroz njega. Međutim, dosta korisnika usluga Kliničkog centra još uvijek ne poznaje sve prostorne mogućnosti u njihovom samostalnom kretanju do njihovih odredišta unutar lokaliteta Koševo. Postavljanje posebnih obilježja o mogućim pravcima kretanja i drugih usluga, ne odnosi se samo na ljude u kolicima. Potrebno je voditi računa i o drugim osobama sa poteškoćama (npr. slabovidni). To je dovoljan razlog da se uradi poseban projekat vizuelne signalizacije koja treba da im pomogne u tome. U tome svakako mogu biti od pomoći piktogrami prikazani na Slici 5 (1,2). Stacionar služi za smještaj, liječenje i njegu onih bolesnika čiji medicinski tretman nije moguće u cjelosti sprovesti u polikliničkodijagnostičkim jedinicama, a organizovan je na principu progresivne njege. Slika 5 Vizuelna signalizacija za različite potrebe ljudi sa umanjenim tjelesnim mogućnostima (Uvećana slika na strani 59) Slika 6 Šematski prikaz stacionara CMB-a sa naznačenom lamelom ”B” koja je glavna komunikaciona lamela za cijeli objekat CMB-a Stacionar je riješen u obliku slova „H“ sa četiri grupe njege od po 26- 30 ležajeva, što zavisi od specifičnih potreba pojedinih OJ. Grupa njege se sastoji od 6 kreveta postintenzivne (2 dvokrevetne i 2 jednokrevetne) i 20-24 kreveta standardne njege. Blok sa stacionarnim jedinicama biće povezan sa svim ostalim dijelovima Kliničkog centra, a posebno sa prijemom i upućivanjem bolesnika, polikliničko-dijagnostičkim jedinicama i laboratorijem, kao i intenzivnom njegom i Centralnim OP blokom. Osnovni tip jedinice je bolesnička jedinica sa 26-30 kreveta koja se sastoji od: - šest kreveta poluintenzivne njege - 24 kreveta za standardnu njegu - dvije sobe sa po dva radna mjesta za liječnike - pult za centralni nadzor i prostor za odmor sestara - prostor za intervencije sa priručnom apotekom - prostor za pripremu terapije - odgovarajući servisni i sanitarni prostori Standardna njega se odvija u sedam trokrevetnih soba, jednoj dvokrevetnoj i jednoj jednokrevetnoj sobi. Svaka soba opremljena je jednim umivaonikom koji služi za pranje ruku liječnika ili sestre nakon određenih radnji koje se obavljaju na krevetu. Svaka soba ima zaseban sanitarni čvor (tuš, WC, umivaonik), koji se nalazi neposredno kraj ulaza u sobu. Dvije grupe njege po 26-30 kreveta čine jednu jedinicu njege sa 52-60 kreveta. Ona pored nabrojanih sadržaja ima i slijedeće zajedničke prostore: prijemni pult, soba šefa jedinice, soba glavne sestre, soba dežurnog liječnika, soba za sastanke i rad sa studen- 54 M. Dilić. et al. tima, dnevni boravak za pacijente, katni terminal i odgovarajuće sanitarne prostorije. Ovakav tipski raspored biće prilagođen specifičnim potrebama odgovarajućih disciplina koje su uvjetovane medicinskom tehnologijom rada. Na slikama 7-20 prikazani su već izgrađeni prostori CMB-a po etažama i analizom mogućeg kretanja osoba sa umanjenim tjelesnim mogućnostima. Na slikama su prikazane potpuno ili djelomično izgrađene etaže CMB-a. Iz njih se vidi da je moguće samostalno kretanje ljudi umanjenih tjelesnih sposobnosti unutar objekta. Naime, do sada je stepen izgrađenosti ovog objekta 15%, ali su i unutar tog dijela novih prostora stvoreni uslovi za nesmetano kretanje. U grafičkom prilogu će se detaljnije prikazati pravci kretanja osoba umanjenih tjelesnih mogućnosti unutar objekta CMB-a. To su: ETAŽA 02 ETAŽA 03 ETAŽA 05 ETAŽA 06 ETAŽA 13 - Hemoterapija i radioterapija. - Onkologija, CT aparati i druga dijagnostika. - Centralna sterilizacija i koridori, tople veze CMB-a prema objektu TEB-a i Ortopedije. - Tek izgrađeni dio etaže 06-Kardiohirurgija. - Dio izgrađene prve stacionarne etaže 13 (na kojoj se nalazi 12 kreveta poluintenzivne njege i 48 kreveta standardne njege) Na tlocrtima izgrađenih etaža ili dijelova etaža CMB-a, označene su komunikacije; vertikalne (liftovi), horizontalne (tople veze i koridori), i kupatila za osobe sa umanjenim tjelesnim sposobnostima (kroz kompletno izgrađeni dio objekta). CENTRALNI MEDICINSKI BLOK - ETAŽA 02 Slika 7 Šematski prikaz etaže 02 CMB-a - Hemoterapija i radioterapija Slike 8, 9, 10. Kupatilo za osobe sa umanjenim tjelesnim mogućnostima People with disabilities and their free access to hospital facilities in the compound of Clinical Center University of Sarajevo: special focus on Central Medical Building CENTRALNI MEDICINSKI BLOK - ETAŽA 02 Slika 11 Liftovi - baterija od tri bolesnička lifta Slika 12 Šematski prikaz etaže 03 CMB-a - Onkologija, CT aparati i druga dijagnostika Slike 13,14 Izgled i pozicija vanjske rampe za ulaz na Onkologiju u CMB-a 55 56 M. Dilić. et al. CENTRALNI MEDICINSKI BLOK - ETAŽA 05 Slika 15 Šematski prikaz etaže 05 CMB-a - Glavni ulaz u CMB, Recepcija, i prateći sadržaji CENTRALNI MEDICINSKI BLOK - ETAŽA 06 Slika 16 Šematski prikaz etaže 06 CMB-a - Novi Operacioni blok, Kardiohirurgija Dio etaže 06, koji je još uvijek u izgradnji koristiće Klinika za Kardiohirurgiju. Ona u svom sastavu ima 12 kreveta intenzivne njege i 24 kreveta standardne njege. U okviru prostora standardne njege, planirano je i izgrađeno moderno kupatilo za nepokretne i osobe umanjenih tjelesnih mogućnosti. People with disabilities and their free access to hospital facilities in the compound of Clinical Center University of Sarajevo: special focus on Central Medical Building CENTRALNI MEDICINSKI BLOK - Etaža13 - izgrađeni obuhvat stacionara Slika 17 Šematski prikaz etaže 13 CMB-a. Slika 18, 19, 20 Kupatila za nepokretne i osobe umanjenih tjelesnih mogućnosti Slika 21 Tipična stacionarna etaža s šematskim prikazom osnovnih jedinica 57 58 Stacionarni dio Centralnog medicinskog bloka (CMB) je izgrađen samo jednom polovinom etaže 13 (lamele A i dio lamele B). Ostale stacionarne etaže imaju oblik slova H sa ukupno 104-120 kreveta po etaži. Za svaku jedinicu standardne i poluintenzivne njege (ukupno 26-30 kreveta) ide jedno kupatilo za nepokretne, odnosno osobe umanjenih tjelesnih mogućnosti. To znači da će na jednoj etaži biti 4 takva kupatila, što potvrđuje opredjeljenost Kliničkog Centra Univerziteta u Sarajevu da poklanja dužnu pažnju ovom dijelu populacije. ZAKLJUČAK Zdravstveni objekti izgrađeni na lokalitetu Koševo u vrijeme austrougarskog perioda bili su paviljonskog tipa, međusobno odvojeni i po pravilu sa ulazom denivelisanim stepenicima od nivoa ulice. Takva gradnja bila je skupa s aspekta održavanja, uvezivanja različitih medicinskih disciplina i otežavala je kretanje ljudi sa umanjenim tjelesnim sposobnostima (koji su najčešći korisnici bolničkih usluga). Novi princip gradnje bolničkih objekata je blokovski, što podrazumijeva koncentraciju dijagnostičko-polikliničkih i stacionarnih prostora unutar jednog objekta. Takav pristup ima za cilj obezbijediti što veću koncentraciju zdravstvenih usluga onima kojima su one potrebne. Istovremeno održavanje tako koncipiranih objekata je jeftinije i lakše. Primjer ovakve gradnje je Centralni medicinski objekat (CMB), koji i lokacijski i funkcionalno će biti centralna prostorna okosnica razvoja. Ovakav koncept omogućava osobama umanjenih tjelesnih mogućnosti sigurno kretanje i obezbjeđivanje korištenja svih prostora i uređaja bolnice (WC, telefon, šalteri i sl,). Strategija adekvatnog planiranja je naročito važna obzirom na važnost tercijarnog nivoa zdravstvene zaštite koji se provodi u Kliničkom centru Univerziteta u Sarajevu. Uvažavajući potrebe ove populacije (čiji dio možemo biti svi mi već sutra), a sa prirodnim procesom starenja svakako izgledno u budućnosti, moramo biti posebno osjetljivi i obezbijediti im potpuno samostalno kretanje. Referentna grupa za osobe umanjenih tjelesnih sposobnosti su ljudi u invalidskim kolicima i sva dobra arhitektonska rješenja podrazumijevaju njihovo kretanje bez ikakvih poteškoća. To se ne smije doživljavati samo kao uvjet dobijanja upotrebnih dozvola novoizgrađenih dijelova objekta, već kao odraz lične savjesti i inžinjerskih vještina da to izgradimo na pravi način. Samo oni objekti koji obezbijede nesmetano kretanje svih ljudi u određenom prostoru su dobri objekti, sve drugo su loša tehnička i arhitektonska rješenja. Nemamo pravo i dalje se komotno ponašati i na taj način ugrožavati nečije pravo na dostojanstven i samostalan život. CONCLUSION Health facilities which were built at the Koševo area during the Austro-Hungarian period, were pavilions in the compound of hospital, divided from each other, and with entrance with stairs sloping from the street level. Such a construction was expensive in terms of maintenance, binding various medical disciplines and with serious difficulties regarding the movement of people with reduced physical abilities (which are the most frequent users of hospital services).The new principle of hospital facilities construction is single building i.e. „all in one“, which means the concentration of diagnostic, polyclinic and stationary departments within a single building. This approach aims to ensure a most effective concentration of health services to those who need it. At the same time, maintaining of facilities so conceived is cheaper and easier. An example of such a construction is our Central Medical Building (CMB), which will be a central spatial M. Dilić. et al. development framework by its function and location. This concept allows safe movement to persons with disabilities, and it also provides them easy use of space and hospitals’ equipment (toilettes, telephone, counters, etc.). That is an important strategy, especially when taking into account the importance of the tertiary level of health care that is provide at the Clinical Center University of Sarajevo.We must take into account the needs of this population, and we must be particularly sensitive and provide them with a completely independent movement. Within the broader group of handicapped people, the reference group is the one of people in wheelchairs, and all the functional architectural solutions should be (must be) adjusted for their movement without any difficulties. It should not be perceived only as a condition of obtaining constructions’ licences for new components of the object, but also as a reflection of our personal conscience as well as engineering skills to build those objects in a right and functional way. Only those objects that provide easy and smooth movement of all people in a certain area are good facilities, everything else is a non-functional i.e. bad technical and architectural solutions. We have no right to continue with comfortably manner and without having in mind disabled persons and theis basic right to a dignified and independent life. Conflict of interest: none declared. REFERENCES 1. UN Convention on the rights of persons with disabilities (2006). http:/www. un. org/ disabilities /convention/conventionfull.(access Dec. 2013) 2. Uredba o prostornim standardima, urbanističko-tehničkim uvjetima i normativima za sprječavanje stvaranja arhitektonsko-urbanističkih prepreka za osobe sa umanjenim tjelesnim mogućnostima. Vlada Federacije Bosne i Hercegovine na 109. sjednici, 16.07.2009. 3. Fejzić E. Osobe umanjenih tjelesnih sposobnosti i arhitektonske barijere. Izdavač; Expedito. Centar za održivi prostorni razvoj. Kotor. 2007. 4. Prijedlog za dogradnju, rekonstrukciju i povezivanje sa centralnim novim objektom. Institut za socijalnu medicinu, organizaciju i ekonomiku zdravstva. Sarajevo;1987. 5. Građevinsko-arhitektonski i medicinski program za rekonstrukciju i adaptaciju postojećih objekata Kliničkog centra na lokalitetu Koševo. Medicinski fakultet i Institut za socijalnu medicinu. Sarajevo; 1987. 6. Građevinsko-arhitektonski i medicinski program za projektiranje Kliničkog centra - Centralni objekat Koševo. Arhitekt d.d. Sarajevo; 1986. 7. Analiza postojećeg građevinskog i medicinsko-tehnološkog stanja bolničkih objekata na lokalitetu “Koševo“. Institut za socijalnu medicinu, organizaciju i ekonomiku zdravstva. -Sarajevo;1986. 8. http//www.kcus.ba/izlaz/08.06.2010./ 9. Hospitals and People with Disabilities. http://www.nidirect.gov.uk/index/information-and-services/people-with-isabilities/health-and-support/hospitals-and-peoplewith-disabilities /in-hospital.htm (access Jan. 2014) 10. Access To Medical Care For Individuals With Mobility Disabilities. http.// www. ada. gov /medcare_mobility_ta/medcare_ta.htm. (access Dec. 2013) Reprint requests and correspondence: Mirza Dilić, MD, PhD Internal Clinics and Departments, Clinical Center University of Sarajevo Bolnička 25, 71000 Sarajevo Bosnia and Herzegovina Phone: +387 33 298 077 Email: [email protected] People with disabilities and their free access to hospital facilities in the compound of Clinical Center University of Sarajevo: special focus on Central Medical Building Vizuelna signalizacija za različite potrebe ljudi sa umanjenim tjelesnim mogućnostima 59 Case report Medical Journal (2014) Vol. 20, No. 1, 60-62 Intraluminal lipoma as a cause of intestinal obstruction Intraluminalni lipom kao uzrok intestinalne opstrukcije Amir Hadžibeganović1, Adnan Kulo1, Lana Sarajlić1*, Dijela Kulo2, Abdulah Efendić3 1 Clinic of General and Abdominal surgery, Clinical Center University of Sarajevo, Bolnička 25, 71000 Sarajevo, Bosnia and Herzegovina; 2Medical Faculty University of Sarajevo, Čekaluša 90, 71000 Sarajevo, Bosnia and Herzegovina; 3General Hospital „Prim. dr Abdulah Nakaš“ Kranjčevićeva 12, 71000 Sarajevo, Bosnia and Herzegovina *Corresponding author ABSTRACT SAŽETAK Intestinal lipomas are rare benign tumors and intussusceptions due to a gastrointestinal lipoma constitutes an infrequent clinical entity. Lipoma may develop as a benign tumor in all organs and rarely in large or small intestine.The occurrence of intussusception in adults is rare, accounting for less than 5% of all cases of intussusceptions and almost 1%-5% of bowel obstruction. The condition is found in less than 1 in 1300 abdominal operations and 1 in 100 patients operated for intestinal obstruction. The child to adult ratio is more than 20:1. Gastrointestinal lipomas are rare benign tumors that can occur anywhere along the gut, and the small bowel is the second most common site for gastrointestinal lipomas after the colon. We report a rare case of jejunojejunal intussusception in an 32 year-old adult secondary to an jejunal lipoma. The present report describes a case of jejunojejunal intussusceptions in an adult with a colicky upper abdominal pain. Invagination was diagnosed by computed tomography scan. Exploratory laparotomy revealed jejunojejunal intussusception secondary to a lipoma which was successfully treated with tumor resection. Surgical resection remains the recommended treatment for nearly all cases, but there is controversy about whether or not the intussusception should be initially reduced before resection. Intestinalni lipomi su rijetki benigni tumori te intususcepcije zbog gastrointestinalnog lipoma predstavlja rijedak klinički entitet. Lipom se može razviti kao benigni tumor u svim organima, a rijetko u tankim i debelim crijevima. Pojava intususcepcije kod odraslih je rijetka te čini manje od 5% svih slučajeva intususcepcije i 1% -5% crijevne opstrukcije. Stanje se nalazi u manje od 1 na 1300 abdominalnih operacija te 1 od 100 bolesnika operisanih zbog intestinalne opstrukcije. Odnos djece i odraslih je više od 20:01. Gastrointestinalni lipomi su rijetki benignih tumora koji se mogu pojaviti bilo gdje duž crijeva, a tanko crevo je druga najčešća lokalizacija gastrointestinalnih lipoma nakon kolona. Izvještavamo o rijetkom slučaju jejunojejunalne intususcepcije kod 32 godine starog pacijenta sekundarno jejunalnoom lipomu. Ovaj rad opisuje slučaj jejunojejunalne intususcepcije u odraslih sa količnom boli u trbuhu. Invaginacija je dijagnosticirana CT skeniranjem. Explorativna laparotomija otkrila je jejunojejunalnu intususcepciju sekundarno zbog lipoma koji je uspješno tretiran resekcijom tumora. Kirurška resekcija ostaje preporučeni tretman u gotovo svim slučajevima, ali postoji kontroverza oko toga da li treba ili ne inicijalno smanjiti intususcepciju prije resekcije. Key words: intussusception, colon, lipoma. Ključne riječi: intususcepcija, kolon, lipom. INTRODUCTION reported as a cause of adult intussusceptions (4). Gastrointestinal lipomas are uncommon, slow growing, fatty tumors that can occur anywhere along the gut, and the small bowel is the second most common site for gastrointestinal lipomas after the colon with about 20~25% of the cases of lipoma occurring in the small bowel. Approximately 90% to 95% of all lipomas are located in the submucosa and because of its usual position immediately superficial to the muscularis propria, the underlying muscular contractions tend to draw the tumor into the bowel lumen and form an intraluminal polyp (5). This produces the intussusception as the leading point or this creates intestinal obstruction by occlusion of the lumen (6, 7). We report a rare case of jejunojejunal intussusception in an 32 years old adult secondary to an jejunal lipoma. The present report describes a case of jejunojejunal intussusceptions in an adult with a colicky upper abdominal pain. Invagination was diagnosed by computed tomography scan. Exploratory laparotomy revealed jejunojejunal intussusception secondary to a lipoma which was successfully treated with tumor resection. Intestinal lipomas are rare benign tumors and intussusceptions due to a gastrointestinal lipoma constitutes an infrequent clinical entity (1). Lipoma may develop as a benign tumor in all organs and rarely in large or small intestine (2).The occurrence of intussusception in adults is rare, accounting for less than 5% of all cases of intussusceptions and almost 1%-5% of bowel obstruction.The condition is found in less than 1 in 1300 abdominal operations and 1 in 100 patients operated for intestinal obstruction. The child to adult ratio is more than 20:1. In contrast to childhood intussusception, adult intussusception has an underlying lesion within the intussusception in 83% to 95% of the cases that require surgical resection (3). This disease usually has a subacute or chronic onset so that the diagnosis can be delayed and it is frequently established only when performing emergency laparotomy for treating the obstructive symptoms. Neoplasms are the most frequent causes of adult intussusception, and gastrointestinal lipoma has been infrequently 61 Intraluminal lipoma as a cause of intestinal obstruction CASE REPORT A 32 year-old patient was admitted to the clinic in the emergency room because of severe abdominal pain, persistent vomiting under clinical, laboratory, X-ray and CT-image of ileus. The patient had no past history of peptic ulcer disease, alteration in bowel habits, melena or weight loss. On examination, he was apyrexial and hemodynamically stable. His abdomen was distended and no palpable abdominal masses; bowel sounds were hyper audible. Initial rectal examination revealed no masses or blood.Abdominal radiography revealed prominent dilatation of the small bowel with air fluid levels (Figure 1). Abdominal CT showed a target sign- or sausage-shaped lesion typical of an intussusceptions that varied in appearance relative to the slice axis (Figure 2). The inner central area represented the invigilated intussuscepted, surrounded by its mesenteric fat and associated vasculature, and all surrounded by the thick-walled intussuscipiens. More head-side scans showed a low-density homogenous mass measuring 4 cm that was considered to be the leading point for the invagination (Figure 3). Figure 3 Computed tomography scan of the abdomen without oral contrast Figure 1 Abdominal X-Ray, in favor of bowel obstruction These findings led to a diagnosis of intussusceptions induced by a tumor most likely begin. Nasogastric probe is placed and after a short resuscitation lines up an indication for prompt surgical treatment. The patient underwent an urgent exploratory laparotomy. At laparotomy 20 cm below the Treitz’s ligament clear jejunal invagination was identified ,approximately 15 cm in length, and distally in the lumen of intestine is palpable soft tumorous formation. Enterotomy was done directly under intussusception and we found intraluminal tumor size of tangerine on long stem that lead to intussusception. Intestinal trophic was completely neat. Ligature of tumor stem was made and tumor was fully removed and the intestine was sewn in two layers. Removed tumor was sent to histopathology analysis. The histopathology report confirmed a submucosal lipoma in the jejunum as a cause for a 15-cm jejuno-jejunal intussusception. There was no evidence of dysplasia or malignancy. The postoperative period was uneventful, intestinal passage was established spontaneously and the patient was discharged on the sixth postoperative day with a good general condition and adequate local findings. DISCUSSION Figure 2 Abdominal computed tomography, showing a fatty oval mass in the small intestine. Intussusception occurs when a proximal segment of the bowel telescopes into an adjacent distal segment (8). The typical symptoms found in adult patients with intussusceptions are often chronic; such as abdominal pain, fever, nausea, vomiting, melaena, weight loss, and constipation (9). Physical examination may demonstrate diffuse or localized abdominal tenderness, while an abdominal mass is detected in a minority of cases. In our case, these symptoms and signs did not occur, with a first presentation of acute large-bowel obstruction (10). The use of computed tomography in the evaluation of patients with uncharacteristic abdominal pain may allow the condition to be more reliably diagnosed (11, 12). However, in our 62 case a colonic malignancy could not be ruled out and therefore the patient had an emergency laparotomy. Resection or reduction of the colon involved is still controversial. However, many speculate against reduction before resection, especially when taking into account cases where the bowel is nonviable or when malignancy is suspected. Lipoma of the colon is an uncommon tumor of the gastrointestinal tract. In general, colonic lipomas do not cause symptoms and, therefore, are usually detected incidentally during colonoscopy, surgery and autopsy. However, a minority of lipomas can cause symptoms when the lesion is large, especially for those with a diameter greater than 2cm. With the widespread application of colonoscopy, small lesions are found incidentally, and their diagnosis and treatment are mainly dependent on endoscopy. Large colonic lipomas are often mistaken for more serious pathology, as a result of their rarity and variable presentation. Therefore, more attention should be paid to how to increase the rate of preoperative diagnosis. Clinical features are still important, especially for those large lesions.Many therapeutic interventions have been tried for the treatment of colonic lipoma, which have varied from hemicolectomy to segmental resection and local excision, according to the correct preoperative diagnosis and intraoperative findings. With the advancement of colonoscopy, endoscopic cautery snare resection of colonic lipomas has become popular and has been proven to be a safe therapeutic method, especially for small lesions. This is unlikely to be of value in large lipomas as in our case, and resection would be recommended in large colonic lipomas. The removal of colonic lipoma with the assistance of laparoscopy has also been reported, but this would be contraindicated in a patient with acute bowel obstruction (13). CONCLUSION Surgical resection remains the recommended treatment for nearly all cases, but there is controversy about whether or not the intussusception should be initially reduced before resection. Conflict of interest: none declared A. Hadžibeganović et al. REFERENCES 1. Kim CY, Bandres D, Tio TL, Benjamin SB, Al-Kawas FH. Endoscopic removal of largecolonic lipomas. Gastrointest Endosc 200;55(7):929-931. 2. Liessi G, Pavanello M, Cesari S, Dell’Antonio C, Avventi P. Large lipomas of the colon: CT and MR findings in three symptomatic cases. Abdom Imaging 2006;21(2):150-152. 3. Pfeil SA,Weaver MG, Abdul-Karim FW, Yang P. Colonic lipomas: outcome of endoscopic removal. Gastrointest Endosc 1990;36(5):435-438. 4. Ryan J, Martin JE, Pollock DJ. Fatty tumours of the large intestine: a clinicopathological review of 13 cases. Br J Surg 1989;76(8):793-796. 5. Radhi JM. Lipoma of the colon: self amputation. Am J Gastroenterol 1993; 88 (11): 1981-1982. 6. Jiang L, Jiang LS, Li FY, Ye H, Li N, Cheng NS, Zhou Y. Giant submucosal lipoma located in the descending colon: a case report and review of the literature. World J Gastroenterol 2007; 13(42):5664-7. 7. Azar T, Berger DL. Adult intussusception. Ann Surg 1997;226(2):134-138. 8. Reijnen HA, Joosten HJ, de Boer HH. Diagnosis and treatment of adult intussusception. Am J Surg 1989;158(1):25-28. 9. Begos DG, Sandor A, Modlin IM. The diagnosis and management of adult intussusception. Am J Surg 1997;173(2):88-94. 10. Creasy TS, Baker AR, Talbot IC, Veitch PS. Symptomatic submucosal lipoma of the large bowel. Br J Surg 1987;74(11):984-986. 11. Bar-Meir S, Halla A, Baratz M. Endoscopic removal of colonic lipoma. Endoscopy 1981; 13(3):135-136. 12. Michowitz M, Lazebnik N, Noy S, Lazebnik R. Lipoma of the colon. A report of 22 cases. Am J Surg 1985;51(8):449-454. 13. Scoggin SD, Frazee RC. Laparoscopically assisted resection of a colonic lipoma. J Laparoendosc Surg 1992;2:185-189. Reprint requests and correspondence: Lana Sarajlić, MD Clinic of General and Abdominal Surgery Clinical Center University of Sarajevo Bolnička 25, 71000 Sarajevo Bosnia and Herzegovina Email: [email protected] Case report Medical Journal (2014) Vol. 20, No. 1, 63-65 Entrapment syndrome of the left renal vein Entrapment sindrom lijeve renalne vene Zoran Roljić1*, Božina Radević1, Dušan Janičić1, Slavko Grbić1, Milan Žigić1, Jevrosima Roljić1,Vladimir Keča1, Severin Dunović1, Novak Milović2 Clinic for Vascular Surgery, Clinical Center Banja Luka, Dvanaest beba 1, 78000 Banja Luka, Bosnia and Herzegovina; Military Medical Academy, Crnotravska 17, 11000 Belgrade, Republic of Serbia 1 2 * Corresponding author ABSTRACT SAŽETAK Symptomatic stenosis of the left renal vein in preaortic position is consequence of compression of a. mesenterica superior to the aorta, and in retroaortic position, by compresion of aorta to the spine. Symptoms arise from hypertension in left renal vein. Our patient had pains in pelvis and in the left lumbal region for two years, and recidivant hematuria. Hematuria in left urether was diagnosed with cystoscopy. Color Doppler and CT angiography showed diametar of left renal vein retroaortic of 2 mm, and in proximal part of 14 mm.We decided for surgery and underwnt preaortic transposition of left renal vein preaortic with interposition of autovenous panel vein graft of v.saphena magna. Our patient is without any simptoms after operation. Simptomatska stenoza lijeve renalne vene u preaortičnoj poziciji nastaje kompresijom gornje mezenterične arterije prema aorti, a retroaortične, kompresijom aorte prema kičmi. Simptomi nastaju zbog hipertenzije u sistemu lijeve renalne vene. Naša bolesnica je godinama imala bolove u maloj karlici i lijevoj slabinskoj loži, a nekoliko puta je imala hematuriju u posljednje dvije godine. Cistoskopijom je nađena hematurija iz lijevog uretera. Color Dopplerom i CT angiografijom je prikazana lijeva renalna vena promjera 2 mm u retroaortičnom i 14 mm u proksimalnom dijelu. Urađena je preaortična transpozija lijeve renalne vene interpozicijom autovenskog grafta vene safene magne duplog lumena. Poslije operacije bolesnica je bez tegoba. Key words: compression, left renal vein, operative treatment Ključne riječi: kompresija, lijeva renalna vena, operativni tretman INTRODUCTION METHODS The left renal vain is circumaortic in the beginning of the embrional development, and like that staies in 5,7 to 15 % of the population. With involution of preaortic part of the vein remains retroaortic vein in 1.8 to 4% of the population, and with involution of the retroaortic part remains preaortic left renal vein in 92 % of the population. Preaortic left renal vein is compressed by a.mesenterica sup. and aorta in 75%, and it makes stenosis in 50% cases. his is not hemodynamicaly significant stenosis. Percentage of stenosis of preaortic left renal vein depends of aortomesenteric angle and kidney position due to left renal vein. If aortomesenteric angle is smaller then 21 degree, then compression on the vein is significant and can narrow the vein lumina. The same effect is compression of aorta and spina on the retroaortic left renal vein. This stenosis of left renal vein is hemodynamicaly significant if diametar of left renal vein in the stenotic part is 5 to 7 times smaller then the diametar of proximal part, and if gradient of pressure in left renal vein and in the v.cava inf. is 3 mmHg and higher. This pressure makes dilatation in the system of left renal vein and symptoms like pain in left lumbal region, in pelvis, hematuria, left varicocela, and pelvical varices. Some of this symptoms are the part of the another clinical entities, and early observation on this syndrome is important for diagnosis (1,2,3,4). We had a female patient, 44 years old, with chronic pain in left lumbal region and pelvis. She had recidivant hematuria for last two years. Cystoscopy showed bleading from left kidney and color doppler ultrasound showed high position of left kidney and retroaortic left renal vein. MR and MSCT angiography showed retroaortic left renal vein, which was compressed by aorta and first lumbal vertebra (Figure 1 and 2). That part of the vein was shown like stenosis with diametar of 2 mm and lenght of 1,5 cm. Proximal part of left renal vein had diametar of 14 mm. The branches of left renal vein was dilated, especially v.ovarica with varices in pelvis.This findings was enough for diagnosis of symptomatic compression of left renal vein, with indication for operation (5,6). The operation was underwent in general anestesia. We made transversal laparathomy. V.cava inferior, aorta, both renal arteries and left renal vein were preparated. Retroaortic part of left renal vein was 2 mm in diameter and fixed with surrounding tissue up to v.cava. Proximal part of vein was dilated like its branches with varices in pelvis.Transposition of left renal vein and direct anastomosis with v.cava inf. was not able because of fixed vein and lenght of stenotic part of vein. The stenotic part of left renal vein was resected and clossed with sutturing, and preaortic transposition was made with interposition of panel autograft v.saph.magnae with double lumen. Autovein graft 64 of v.saphena magna was anastomosed with v. renalis sin. and v.cava inf. 2 cm lower then its natural position. Postoperative and control findings were good and our patient is without symptoms (7). Z. Roljić et al. before and after stenosis. Stenosis of left renal vein is hemodynamicaly significant if diametar of left renal vein in the stenotic part is 5 times smaller then the diametar of proximal part, and if gradient of pressure in left renal vein proximal part and in the v. cava inf. is 3 mmHg and higher, while the pressure in the v.cava inf. is smaller then 1 mmHg. Our patient had pain in the pelvis left lumbal region, hematuria and dismenorrhea. Hematuria was showen by the cystoscopy, and stenosis with ultrasound. MR and MSCT angiography showed stenotic part of vein in the lenght of 1,5 cm. and diametar of 2 mm, and proximal part with diametar of 14 mm, and dilated v.ovarica and pelvic varices, as well (8,9,10,11). Compression syndrome of the left renal vein described by El Sadr et al.(1950), but De Schepper (1972) named this entitet. Medical treatmant and embolisation is selected for isolated pelvic vein hypertension.Operative anmd interventional procedures are indicate for treatment in patient with renal and pelvic symptoms. Transposition of vein is the method, from retroaortic position to preaortic or preaortic with new influence in v.cava inf. 3 or 5 cm lower. Both procedures are now feasible with open or laparascopic technique. Patients with congestive pelvical syndrome should underwent transection of v.ovarica or v.testicularis. Autotransplatation is method for operation but it has high risk and should be avoided. Endovascular procedure is dilatation and stenting of the vein but with risk or restenosis and dislocation of stent (12). CONCLUSION Our patient has retroaortic left renal vein with symptoms of vein hypertension in left kidney and with syndrome or pelvic congestion. We did resection of stenotic part of the left renal vein and make preaortic transposition with autovein graft. Conflict of interest: none declared. Figure I and 2 MRI scan and CT scan: Compression on left renal vein REFERENCES DISCUSSION 1. Hollinshead WH.Textbook of Anatomy. 3rd ed. New York: Harper & Row; 1974. 521- The left renal vein is lenght 8 to 10 cm. The left renal vein goes in 92% cases between aorta and a. mesenterica sup, and in 1,8 to 4% between aorta and spina to the influence in v.cava inf. It has many branches and good connection with another veins. Left renal vein influents are: v. ovarica (v. spermatica), v.uretralis, vv.capsulares, vv.lumbales, v.suprarenalis medialis, v.diafragmalis inf. There is connection with v.azygos sin. and with internal and external vertebral plexus. Compression on renal vein, with significant reduction of flow, increases pressure in proximal part of the vein, and in the kidney. Hypertension in the left renal vein makes varices in kidney and varicocela in males. In females there is varices of kidney, varices of the v.ovarica and pelvic congestion syndrome, with chronic pain in pelvis, urinary problems and dismenorrhea.The problems arise when patient is in sitting or standing position. Gluteal, perineal and femoral varices can be part of this syndrome. Ultrasound, MR and MSCT angiography can show position and stenosis of the left renal vein. Hemodynamic degree of stenosis can be measured with ultrasound and with measuring of the pressure in the vein 2. Hilgard P, Oberholzer K, Meyer KH, Hohenfellner R, Gerken G. Das “Nuýknacker- 523. Syndrom” der Vena renalis (Arteria-mesenterica-superior-Syndrom) als Ursache gastrointestinaler Beschwerden. Dtsch Med Wochenschr 1998;123(31-32):936940. 3. Hohenfellner M, Steinbach F, Schultz-Lampel D, Schantzen W, Walter K, Cramer BM, et al. The nutcracker syndrome: new aspects of pathophysiology, diagnosis and treatment. J Urol 1991;146(3):685-688. 4. Andrianne R, Limet R, Waltregny D, de Leval J. Hematuria caused by nutcracker syndrome: preoperative confirmation of its presence. Prog Urol 2002;12(6):13231326. 5. Rudloff U, Holmes RJ, Prem JT, Faust GR, Moldwin R, Siegel D. Mesoaortic compression of the left renal vein (nutcracker syndrome): case reports and review of the literature. Ann Vasc Surg 2006;20(1):120-129. 6. Basile A, Tsetis D, Calcara G, Figuera D, Patti MT, Coppolino F, et al. Nutcracker Syndrome Due to Left Renal Vein Compression by an Aberrant Right Renal Artery. Am J Kid Dis 2007;50(2):326-329. 7. Thompson PN, Darling RC, Chang BB, Shah DM, Leather RP. A case of nutcracker syndrome: treatment by mesoaortic transposition. J Vasc Surg 1992;16(4):663-665. 65 Entrapment syndrome of the left renal vein 8. Ming-Feng L,Tsung-Lung Y. Nutcracker syndrome. Nephrology 2011;16(1):118 9. Takebayashi S, Ueki T, Ikeda N, Fujikawa A. Diagnosis of the nutcracker syndrome with color Doppler sonography: correlation with flow patterns on retrograde left renal venography. Am J Roentgenol 1999;172(1):39-43. 10. Altugan FS, Ekim M, Fitöz S, Özçakar ZB, Burgu B,Yalçınkaya F, Soygür T. Nutcracker syndrome with urolithiasis. J Ped Urology 2010;6(5):519-521. 11. De Schepper A. Nutcracker phenomenon of the renal vein causing left renal vein pathology. J Belge Radiol 1972;55(5):507-511. 12. Shokeir AA, El-Diasty TA, Ghoniem MA.The nutcracker syndrome: new methods of diagnosis and treatment. Br J Urol 1994;74(2):139-143. Reprint requests and correspondence: Zoran Roljić, MD Department of Vascular Surgery Clinical Center of Banja Luka Dvanaest beba 1 78000 Banja Luka, RS Bosnia and Herzegovina Phone: + 387 65 673 135 Email: [email protected] 66 INSTRUCTIONS TO AUTHORS Journal “Medical Journal” publishes original research articles, professional, review and educative articles, case reports, criticism, reports, professional news, in the fields of all medical disciplines. 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