Showing papers in "Acta medica Croatica : c̆asopis Hravatske akademije medicinskih znanosti in 2001"

Helicobacter pylori infection in patients with Brunner's gland adenoma.

Abstract: Histopathologic and clinical data strongly suggest a causal relation between Helicobacter pylori infection and gastritis, peptic ulcer disease, or both. However, little has been written about the potential association between H. pylori infection and Brunner's gland adenoma. Therefore, we carried out a prospective study to determine the presence of H. pylori infection among patients with Brunner's gland adenoma. From November 1996 till October 1999, 19100 patients who had undergone upper gastrointestinal endoscopy at two clinical centers in Zagreb, Croatia, were candidates for participation in the study. Brunner's gland adenoma was diagnosed on the basis of histologic samples taken from the polyp (four patients) or after the entire polyp was made available upon endoscopic removal (three patients). When all endoscopic examinations had been performed, biopsy samples were taken from the antrum and body of the stomach, so that gastritis could be classified and H. pylori determined by histology. Biopsy samples were also taken from the duodenal bulb to verify duodenitis. Two other samples were taken from the antrum for rapid urease test. The patients were considered positive for H. pylori when both histology and rapid urease test were positive. Brunner's gland adenoma was diagnosed in seven patients (five women and two men; median age, 49 yrs). Five (71%) patients with diagnosed Brunner's gland adenoma had concurrent H. pylori infection. Duodenitis associated with gastric metaplasia was observed in six patients. Complete eradication of H. pylori was achieved in only two patients. Symptoms disappeared or markedly diminished in all patients with significant improvement during therapy or immediately upon endoscopic removal of the polyp. Although limited by a very small number of patients, our results suggest that concurrent H. pylori infection is very common in patients with Brunner's gland adenoma. However, the role of H. pylori infection in the pathogenesis and development of Brunner's gland hyperplasia remains unclear.

Angiotensin-converting enzyme gene polymorphism in patients with systemic lupus.

Abstract: The renin-angiotensin-aldosterone system (RAAS) has been considered one of the probable pathophysiologic mechanisms involved in disease progression. Genetic polymorphism of the RAAS has been associated with the clinical course of renal disease. One of the genetic polymorphisms is a deletion or insertion of a 287 base pair fragment in intron 16 of the angiotensin-converting enzyme (ACE) gene. It is known that ACE gene polymorphism is present in humans and that it is associated with an increased risk of cardiovascular diseases, renal disease progression and sarcoidosis. In this study, the potential significance of ACE gene polymorphism in patients with systemic lupus erythematosus (SLE) was investigated. ACE gene polymorphism was determined in 18 patients with SLE and in 21 healthy volunteers as a control group. The mean age of patients was 38.5 years. All patients had a mean follow-up of 30.7 +/- 20.2 months (range 5-95 months). ACE genotypes were determined by the method of polymerase chain reaction. Proteinuria and creatinine were also followed. The frequency of DD, ID and II genotypes was 50%, 28% and 22% in SLE patients and 25%, 50% and 25% in healthy controls, respectively. DD genotype was more common in SLE patients than in the control group. The patients with II genotype had lower proteinuria and creatinine level than those with DD genotype (p < 0.05). The time to disease remission was shorter in patients with II genotype (p < 0.05). Study results indicated an increased frequency of D allele in SLE patients. The increased ACE activity in these patients pointed to the need of further studies of ACE gene polymorphism in SLE.

The prevalence of anaerobic infection in pilonidal sinus of the sacrococcygeal region and its effect on the complications.

Abstract: Bacteriologic characteristics of pilonidal disease of the sacrococcygeal region were assessed in two groups of patients: patients with disease recurrence (group A), and patients who first ever presented for surgical treatment (group B). The frequency of anaerobic colonization was studied. Bacterial colonization is frequently present in patients with pilonidal disease of the sacrococcygeal region. Samples of the skin over the sacrococcygeal sinus showed the presence of bacterial colonization in 78% and 70% of group A and group B patients, respectively. Analysis of sinus fluid samples revealed the presence of bacteria in 88% of group A patients and 78% of group B patients. Anaerobic colonization in the content of pilonidal sinus was found in approximately 2/3 (64%) group A patients and about a half (52%) group B patients. Considerable bacterial colonization was also recorded in skin swab samples, i.e. in 48% of group A patients and 38% of group B patients. Anaerobic bacteria were rarely detected in pure cultures (in group A 6% skin swab, and 20% of sinus fluid samples, and in group B, 4% of skin swab and 12% of sinus fluid samples). Anaerobes were mostly detected in combined cultures (42% of skin swab and 44% of sinus fluid samples from group A, 32% of skin swab and 40% of sinus fluid samples from group B). Surgical methods to considerably reduce the conditions for anaerobic bacterial colonization of the wound should be the methods of choice in the management of pilonidal disease of the sacrococcygeal region.

Experimental and clinical study in the treatment of sigmoid volvulus.

Abstract: The aim of the study was to introduce an alternative surgical procedure for the treatment of primary volvuius of the sigmoid colon. Sigmoid colon plication was performed in 42 dogs, and afterwards in six patients. The procedure consists of systematic plaiting the sigmoid colon wall with interrupted serosubmucosal 3/0 Vicryl sutures along the whole circumference, except on the mesenteric border. Five parallel circular folds were done in dogs, and 20-30 folds in patients, with appropriate bowel length reduction. In the experimental study, dogs were randomly divided into three experimental and one control group of 14 animals each. The group 1 dogs were sacrificed on day 8, group 2 dogs on day 15, and group 3 and control group dogs on day 30 postoperatively. On exploration, sigmold colon adhesions were found in 6 (14.3%) animals. Intestinal wall and lumen were normal. In the clinical study, six patients with sigmoid volvulus were operated on within 6-8 hours of admission. A viable colon was a prerequisite for the sigmoid plication procedure. The operating time was 60-90 minutes. Recovery was uneventful, with average hospitalization 11 (range 8-15) days. No volvulus recurrence was recorded during the three-year follow-up. Based on our experimental and clinical data, we believe that the plication procedure could be appropriate treatment in some selected patients with volvulus of the sigmold colon.

Diagnostic accuracy of transesophageal echocardiography for detection of atrial masses.

Abstract: The aim of this study was to assess the diagnostic accuracy of transthoracic (TTE) and transesophageal echocardiography (TEE) for the detection of atrial masses. The authors' own experiences with the use of TTE and TEE images in the assessment of atrial masses are reported. These masses included tumors, thrombi, and valvular vegetations. The study groups consisted of 14 consecutive patients (7 women an 7 men), age range 24-72 (mean age 56.6 < +13.4) years. Eleven patients had left atrial tumor, two patients had atrial thrombi, and one patient had vegetation in left atrium detected with TEE. Eight patients had left atrial myoma, two patients had right atrial myxoma, and one patient had right atrial leiomyosarcoma. There was no false negative and no false positive TEE diagnosis, yielding a 100% sensitivity and specificity of TEE in detecting atrial masses. TEE detected atrial masses in six (43%) patients, provided poor images in five (36%) patients, and failed to reveal atrial masses in three (21%) patients. The TEE diagnosis was confirmed by surgery and pathohistology in all patients. The ability of TEE to visualize both atria with great diagnostic accuracy makes it a very valuable procedure in the assessment of atrial masses.

Immunohistochemical and ultrastructural features of Gaucher's cells--five case reports.

Abstract: Gaucher's disease is an autosomal recessive lysosomal storage disease resulting from glucocerebrosidase deficiency. In this report, five patients with adult Gaucher's disease are described. The clinical course of these patients was characterized by progressive diffuse aseptic necrosis in the large bones, so-called Erlenmeyer's flask deformity, and hepatosplenomegaly. Splenomegaly was accompanied by hypersplenism with anemia and thrombocytopenia, therefore splenectomy was performed. The diagnosis of Gaucher's disease was based on the finding of Gaucher's cells on bone marrow biopsy. Tissue blocks were cut and routinely processed. Slides staining for iron (Peris' blue) and PAS (periodic acid--Schiff) including immunohistochemical staining for CD68 and HLA-DR was performed in all five cases. Gaucher's cells were seen as large cells with granular or fibrillar distended cytoplasm, with the characteristic 'wrinkled tissue paper' appearance, and eccentric nuclei. PAS staining showed strongly positive granular or fibrillar material in the cytoplasm. Immunohistochemical stain for CD68 and HLA-DR helped identify isolated Gaucher's cells, which are hystiocytic in nature. This stain accentuates their fine linear striations. Small pieces were ultrastructurally analyzed.

Clinical, epidemiological and epizootic features of Q fever in the northern coastal part of Croatia from 1989 to 1998.

Abstract: Although Q fever is endemic in the northern coastal part of Croatia, it usually occurs sporadically. Analysis of 58 patients hospitalized for Q fever during the last 10-year period (1989-1998) revealed some differences in the clinical manifestation compared to a previous study (1954-1977). Most cases of Q fever (N = 55; 91%), presented with pneumonia, but no rash was noticed, compared to 46% of patients with Q fever developing exanthema in the previous study. The previously observed high seropositivity to Coxiella burnetii among domestic animals was confirmed in this study. A two-peak seasonal distribution of Q fever observed in 1991 was connected with the imported Russian sort of sheep with special biology of delivery. The clinical outcome was favorable for all patients, since no complications or chronic forms of the disease were recorded. Disproportion between the number of registered and hospitalized patients, including a number of asymptomatic and several undiagnosed or misdiagnosed infections, leads to a conclusion that the real number of persons infected with Coxiella burnetii in the area is several times higher.

Myeloma kidney: pathogenesis and treatment.

Abstract: Renal failure frequently complicates the course of multiple myeloma. Factors that determine the development of myeloma kidney include a high rate of light chain excretion, biochemical characteristics of light chain, and concurrent volume depletion. There are two main pathogenetic mechanisms; i.e. direct tubular toxicity and intratubular cast formation. Therapeutic measures include chemotherapy, bone marrow or peripheral blood stem cell transplantation, hyperhydration, plasmapheresis, dialysis, solving of hypercalcemia, treatment of anemia with erythropoietin, and avoidance of nephrotoxic drugs and radiocontrast agents. Experimental approach includes administration of colchicines and alkalinization of the urine.

Flail chest stabilization with palacos prosthesis.

Abstract: The approach and management of patients with post-traumatic flail chest continue to be a controversial issue. A method of surgical stabilization of flail chest using palacos, a cement-like material is described. A ready-made prosthesis is placed on the external side of the ribs vertically bridging the flailed chest segment, and fixed to the first upper and first lower intact rib as well as to the mobile segments of the affected ribs. Surgical fixation was carried out in 56 patients. The results proved the method to be a simple and effective procedure.

Dual infection: tularemia and Lyme borreliosis acquired by single tick bite in northwest Croatia.

Abstract: A case of dual infection, tularemia and Lyme borreliosis acquired by a single tick bite in northwest Croatia is presented. The patient came from a highly endemic region for Lyme borreliosis, where 45% of the ticks are infected with Borrelia burgdorferi. Clinically, tularemia manifested as the ulceroglandular form, and Lyme borreliosis manifested with arthritis (knee). Both diseases responded well to combined antibiotic therapy.

Osteoma of the internal auditory canal.

Abstract: Osteomas of the internal auditory canal, inaccesible to clinical examination, are rare lesions. There are only 14 cases of osteomas and exostoses of the internal auditory canal reported in the international medical literature. A patient with an osteoma of the internal auditory canal is presented, along with differential diagnosis and possible etiologic factors for the lesion. The auditory brainsteam evoked response testing showed increased absolute latencies of 1 wave and discrepancy of the wave morphology due to bony compression of the eight nerve in the internal auditory canal. Computed tomography showed a bony growth in the internal auditory canal. Magnetic response showed no abnormalities. No surgery was performed since the symptoms improved by conservative therapy.

Angiogenesis in malignant tumors.

Abstract: Angiogenesis is the formation of new blood vessels from the existing vascular network. It is a complex, multi-step process involving extracellular matrix remodeling, endothelial cell migration and proliferation, capillary differentiation, and anastomoses. Angiogenesis is crucial for tumor progression and metastasizing. Intratumor microvessel density is believed to reflect the degree of angiogenesis in carcinomas. Angiogenesis is also very important in many preneoplastic lesions.

Lipid abnormalities in chronic renal failure, nephrotic syndrome and dialysis.

Abstract: Cardiovascular, cerebrovascular and peripheral vascular development are the largest cause-specific reason for morbidity and mortality in end-stage renal disease (ESRD) patients. The high prevalence of cardio- and cerebrovascular death may be explained by multiple factors present in patients with progressive renal disease, including hypertension, hyperlipidemia, hyperhomocysteinemia, diabetes mellitus, and hyperparathyroidism. Experimental studies have provided in vivo and in vitro data to support the notion that lipid abnormalities contribute to glomerular and interstitial injury of the renal parenchyma. Hyperchlolesterolemia and increased low-density lipoprotein (LDL) cholesterol are prevalent in patients with the nephrotic syndrome. Plasma high-density lipoprotein (HDL) cholesterol is decreased, and reverse cholesterol transport is impaired in hemodialysis (HD) and pre-ESRD patients. Chronic renal failure patients treated with HD have an increased prevalence of intermediate-density lipoprotein (IDL), and lipoprotein(a). The findings in diabetic patients corresponded with those in nondiabetic patients with renal failure, but diabetic patients have higher apoliprotein C-III and apoliprotein E concentrations. Impaired lipid metabolism is common in patients receiving peritoneal dialysis (PD). In most ESRD patients treated with peritoneal dialysis hypercholesterolemia and hyperglyceridemia are found. Wide panels of therapeutic interventions aimed at correcting the lipid abnormalities that may develop in chronic renal patients as well as in ESRD patients are currently available. Although some novel pharmacological agents are remarkably effective in returning the lipid abnormalities to normal, there is still no convincing evidence based on long-term prospective studies, that would clearly demonstrate a significant reduction of cardiovascular morbidity and mortality of ESRD patients. The therapeutic approaches, which may be considered, include mainly dietary and life-style modifications, selective use of some technical components of dialysis systems, and the judicious prescriptions of lipid-lowering drugs.

Acute pancreatitis in the Zabok General Hospital.

Abstract: Acute pancreatitis is an acute disease of the pancreas due to the organ autodigestion. The disease is still burdened with numerous complications and quite frequently with lethal outcome, in spite of the sophisticated diagnostic and therapeutic methods currently available. The disease has a benign course in a majority of patients (80%), however, in the remaining 20% it assumes a malignant course with the development of massive necroses of the pancreatic and peripancreatic tissues, infection, hemorrhage, and endogenous intoxication with lesions of the lungs, kidneys, heart and liver. The biliary tract disease plays the major role in the etiology of acute pancreatitis (80%), followed by alcoholism (10% to 15%). This differs from the experience acquired at the Zabok General Hospital, where an almost identical incidence of biliary and ethylic etiology was recorded. Other, less common causes include post-traumatic, postoperative, infective and hormonal (hyperparathyroidism) etiology. In some cases, the cause of acute pancreatitis remains unknown. The disease shows a female predominance, which results from the higher prevalence of cholelithiasis in women than in men. Anatomically, there are two main forms of acute pancreatitis, interstitial or edematous form, and hemorrhagic necrotizing form. The interstitial or edematous form of acute pancreatitis is characterized by edema (exudation) of the pancreatic interstitium. The hemorrhagic necrotizing form of acute pancreatitis is characterized by autodigestion of a minor or major portion of the pancreas and peripancreatic tissues. The diagnosis of acute pancreatitis may initially pose a considerable problem. Decision on the mode of treatment should primarily be based on the clinical picture and supported by relevant laboratory parameters and other diagnostic procedures (ultrasonography, computed tomography). Conservative therapy is indicated for the edematous form of acute pancreatitis, whereas operative treatment is as a rule used for the necrotizing form of acute pancreatitis. Secondary bacterial contamination of the necrotic foci with the development of septic complications occurs in more than 50% of patients with the necrotizing form of acute pancreatitis, and is an absolute indication for surgical intervention. The modes of treatment used in 57 patients admitted for acute pancreatitis during the 1996-1999 period are described. Cholelithiasis was the cause of acute pancreatitis in 28 (49.1%), and alcoholism in 29 (50.9%) patients. Conservative treatment was used in 41 (72%) patients. Sixteen (28%) patients underwent operative treatment. Explorative laparotomy and drainage were performed in four patients, and explorative laparotomy, necrectomy, sequestrectomy and drainage with two or more drains in 11 patients. Cholecystectomy and T drainage along with necrectomy and drainage were performed in one patient. There were 12 (21%) patients with the most severe form of acute pancreatitis. Nine of these patients were operated on (necrectomy drainage) between day 6 and 10 of the disease. Two of these patients had to be reoperated on within a month, due to necrosis and abscess recurrence. Three of the 12 patients with the severe form of acute pancreatitis received conservative therapy. Fifteen patients were operated on 8-10 weeks after acute pancreatitis had subsided. Pseudocysts developed in three patients. These patients were operated on 6-8 weeks from the onset of disease, with internal drainage via isolated small intestine flexure performed in all of these patients. The mean duration of intensive care unit stay for all patients with acute pancreatitis was 20.6 days. Four of 57 patients hospitalized for acute pancreatitis died. The mortality rate in the group of patients with the severe form of acute pancreatitis (n = 12) was 33%. Complications developed in 50% of operatively treated patients.

Angiotensin-converting enzyme gene polymorphism, lipids, and apolipoproteins in menopausal women on hormone replacement therapy.

Abstract: This study investigated the frequency of angiotensin-converting enzyme (ACE) genotypes, concentrations of total cholesterol (T-C), triglycerides (TG), high-density lipoprotein cholesterol (HDL-C), low-density lipoprotein cholesterol (LDL-C), lipoprotein Lp (a), Established Risk Factor (ERF) ratio (total cholesterol/HDL-C), apolipoproteins A-I, A-II, apoBand apoE in 134 menopausal women aged 49.62 +/- 4.83 on oral hormone replacement therapy (HRT) (2 mg 17 beta estradiol plus 1 mg norethisterone acetate/day), during (mean +/- SD) 15.77 +/- 9.94 months. ACE genotypes of 134 menopausal women showed DD genotype in 48 (36%), ID genotype in 59 (44%), and II genotype in 27 (20%) women, with the mean body mass index (BMI) (kg/m2) of 26.34 +/- 4.02, systolic blood pressure (mm Hg) of 145.71 +/- 23.32, diastolic blood pressure of 95.28 +/- 12.88, pulse rate of 77.76 +/- 13.81, positive family history of myocardial infarction (MI) (23%) and stroke (22%); 26% were smokers and 6% consumed alcohol regularly. The mean levels of TC (mmol/l) were 5.72 +/- 1.25, TG (mmol/L) 1.63 +/- 0.82, HDL-C (mmol/L) 1.15 +/- 0.29, LDL-C (mmol/L) 3.98 +/- 1.31, lipoprotein Lp(a) (g/L) 0.16 +/- 0.24, ERF ratio 5.35 +/- 1.90, apolipoproteins (g/L): A-I 1.83 +/- 0.39, A-II 0.57 +/- 0.12, apoB 0.92 +/- 0.31, and apoE 0.08 +/- 0.04. The highest mean levels of T-C 5.89 +/- 1.40, TG 1.67 +/- 0.96, LDL-C 4.15 +/- 1.60, lipoprotein Lp(a) 0.19 +/- 0.25) apoB 0.95 +/- 0.32 and ERF ratio 5.46 +/- 2.24 were found in ID genotype, while in DD genotype HDL-C 1.11 +/- 0.28 and apo A-I 1.78 +/- 0.34 were lowest. In II genotype, the levels of apo A-II 0.56 +/- 0.11 were lowest and of apoE 0.09 +/- 0.05 highest. According to DD, ID and II genotypes and lipid, lipoprotein Lp(a), ERF ratio and apolipoprotein concentrations, there were no statistically significant differences between groups. ERF ratio in DD genotype showed a positive correlation with TG (r = 0.59) and LDL-C (r = 0.57), a slight positive correlation with apoB (r = 0.40), and a strong negative correlation with HDL-C (r = -0.73). ERF in ID genotype showed a strong negative correlation with HDL-C (r = -0.73), strong positive correlation with TG (r = 0.70), and T-C (r = 0.58), and slight positive correlation with LDL-C (r = 0.36) and alcohol abuse (r = 0.34). In II genotype, ERF ratio showed a strong positive correlation with LDL-C (r = 0.73), T-C (r = 0.70) and apoE (r = 0.58), slight positive correlation with apoB (r = 0.46) and TG (r = 0.36), and negative correlation with HDL-C (r = -0.54). Matrix correlation of DD genotypes showed the highest positive correlation between T-C and LDL-C (r = 0.91) and apoE (r = 0.45), and negative correlation between HDL-C and ERF ratio (r = 77), and LDL-C and ERF ratio (r = 0.55). In ID genotype, T-C showed a strong positive correlation between LDL-C (r = 0.75) and ERF ratio (r = 0.63), TG and ERF ratio (r = 0.73), and negative with HDL-C (r = 0.53). In genotype II, T-C showed a strong positive correlation between LDL-C (r = 0.96), ERF ratio (r = 0.71), apoB (r = 0.66) and apoE (r = 0.46). LDL-C correlated positively with ERF ratio (r = 0.72), apoB (r = 0.61) and apoE (r = 0.48). These findings indicated the frequency of ACE genotypes to differ within the group of menopausal women. Analysis of ACE genotypes showed ID genotype to be most common among menopausal women. This result indicated their intermediate risk of coronary heart disease (CHD) and myocardial infarction (MI). It has been well established that an increased risk of MI is associated with high frequency of DD genotype, and a low risk with high frequencies of II genotype. In addition to ACE polymorphism analysis, assessment of lipid, apolipoprotein, and lipoprotein Lp(a) concentrations, and of ERF ratio provides further important parameters for better understanding of the risk factors for CDH in women. In the present study, assessment of the genetic, metabolic and environmental markers pointed to an intermediate risk of CHD in menopausal women on HRT, although the mechanism underlying the disease is not clear and well understood yet.

Clinically significant red cell alloantibodies in patients with warm autoimmune hemolytic anemia.

Abstract: It has been generally accepted that the prevalence of clinically significant red cell alloantibodies is higher in patients with warm autoimmune hemolytic anemia (AIHA) than in other patients. In the present study, immunohematologic testing was performed in 328 polytransfusion patients with internal diseases. The patients were divided into two groups, i.e., without and with clinical signs of warm AIHA. Identification of red cell antibodies was performed in nonadsorbed sera of all patients, and in autoadsorbed and auto- and alloabsorbed sera of patients with warm AIHA. In the AIHA group, antibodies indicating red cell specificity were detected in 38.5% and 24.3% of patients in nonadsorbed and autoadsorbed sera, respectively. Clinically significant red cell alloantibodies were demonstrated in 10.3% nonadsorbed sera of patients free from signs of warm AIHA and in 10.4% auto- and alloadsorbed sera of patients with signs of warm AIHA. Study results showed the prevalence of clinically significant red cell alloantibodies in patients with signs of warm AIHA depend on the method of identification used rather than on the enhanced immune response induced by the autoimmune process.

Gastrointestinal malignant lymphomas in Macedonia.

Abstract: The gastrointestinal tract including oral cavity is the most common location of extranodal lymphomas. In this retrospective study, the histomorphological, immunohistochemical and clinical features of 21 Macedonian cases with diagnosed malignant lymphomas were investigated. The series included 15 males and 6 females, mean age 44 (4-78) years. The most common locations were hard palate (n = 7), gastric site (n = 5), small intestinal wall (n = 2), large intestinal wall (n = 5), and lingual root (n = 2). All cases were B cell lymphomas, 23.8% of them low grade B cell lymphoma of mucosa associated lymphoid tissue, 4.7% mantle cell lymphoma, 47.6% diffuse large cell lymphoma, and 23.8% Burkitt type lymphoma. There was no T cell lymphoma. Most of the cases were positive for CD20 and CD79a. Monoclonality was confirmed by light chain restriction, except for nine cases where it failed due to poor tissue preservation. The fact that eight cases were in the clinically advanced third and fourth stage implied a conclusion that not only primary non-Hodgkin's lymphomas but also secondary lesions could invade the gastrointestinal tract. Immunohistochemical staining was helpful in differentiation between benign and malignant infiltration in low grade lymphomas, and in distinguishing diffuse large cell lymphomas from undifferentiated epithelial neoplasms.

Reconstruction of total lower lip, labial commissure and palatomaxillary defect with composite island cheek flap.

Abstract: Functional and cosmetic restoration of total lower lip, labial commissure, and palatomaxillary defects can be achieved by using multiform flaps. The possibility of reconstruction of these areas with composite island cheek flap is presented. The flap was used in three patients who were surgically treated between 1993 and 1998. In one female patient, total lower lip and chin defect was restored with a small contralateral platysma muscle cutaneous flap. The functional and cosmetic result was achieved with composite island cheek flap. In the other two cases, reconstruction was performed without another flap. Composite island cheek flap is supplied with bloody by the facial artery and vein, and contains mucous membrane, muscle and skin of the cheek. In two cases, the flap was formed by the anterior part of the buccal muscle, and in the case with the reconstruction of labial commissure, the greater and lesser zygomatic muscles with levator muscle of the angle of mouth were used. By freeing the blood vessels from the surrounding structures, isolation and transsection of minor vessel branches allowed straightening of the tortuous main vessels. With this technique, excellent functional and satisfactory cosmetic results were achieved in a single act, with minimal morbidity for labial commissure, and total lower lip or palatomaxillary defect reconstruction.

Antiphospholipid antibody syndrome and fetal outcome.

Abstract: The presence of antiphospholipid antibodies, lupus anticoagulant and anticardiolipin antibody in patients with systemic lupus erythematosus has been associated with the clinical features of thrombosis, fetal loss and thrombocytopenia, and the syndrome is designated as antiphospholipid antibody syndrome (APS). APS has been increasingly diagnosed in patients without underlying autoimmune disease and is most frequently seen in obstetric patients suffering spontaneous abortion, preeclampsia and intrauterine growth restriction. The hypothesis underlying most research into the pathophysiology of APS is that autoantibodies are not only the markers of the disease, but also directly contribute to the development of clinical features. This review summarizes recent information on the pathophysiology and potential roles of autoantibodies in the obstetric patients suffering, particularly in the subgroup of repeated spontaneous abortions.

Congenital gastrointestinal system malformations in a 5-year post mortem series.

Abstract: The aim of this study was to determine the types and frequencies of congenital gastroinstestinal (G-I) tract malformations on post mortem in the period from 1996 to 2000. Autopsy protocols of aborted fetuses, stillborn infants and infants that died within 7 days after delivery were retrieved from the archive and studied. Cases of cleft lip and/or palate, biliary tract, pancreatic and diaphragmal malformations were not included in the study. During the mentioned period, 1251 autopsy was performed with 127 showing some malformation. G-I tract malformation was diagnosed in 37 cases (2.9% and 29.1%, respectively). Most frequent malformations were atresias at the different level of the G-I tract (56.75%), followed by omphalocoele (35.13%) and gastroschisis (8.1%). Of atresias, the most frequent were oesophageal and anorectal (38.1% of atresias, each). A striking male preponderance (2.36:1) in the frequency of G-I malformations was noticed. Isolated G-I malformations were found in 32.4%, different but simultaneous G-I malformations in 5.4% and association with other organ system(s) malformations in 62.2%. Omphalocoele and anorectal atresia were associated with other organ system malformation(s) in 34.8%, each. Other organ systems affected by malformation besides the G-I tract were cardiovascular system (65.21%), urogenital system (also 65.2%), gastrointestinal system with the malformation of another kind or atresia at the different level (17.4%), CNS (17.4%), skeletal system (26.1%) and other organs or systems (30.7%).

Treatment evaluation of hindfoot injuries caused by pressure activated explosive devices in the war and peace time.

Abstract: Injuries caused by pressure activated explosive devices are very complex medical and social problem in Bosnia and Herzegovina. Hindfoot injuries are also a big challenge for orthopedic surgeons concerning all forthcoming physical assessment of the patients and the fact that the forefoot and midfoot remain preserved. The study included 60 patients with amputation that followed such an injury, and 60 patients treated with reconstructive procedures. The gait of the patients was assessed in the period of 4 years. In 20 patients, destroyed tissues were sent referred for pathohistologic examination, which revealed typical signs of a damage caused by high kinetic energy devices. The gait was analyzed objectively by the examiner and subjectively by the patients, which was the main indicator of successful treatment. Infection analysis and plantogram were also taken into account. The study showed that in a number of cases primary reconstruction of the hindfoot injuries caused by pressure activated explosive devices was possible with satisfactory results, thus foot amputation having strict indication. Indications for amputation have been limited and foot preservation has become more real in the majority of patients.

Laparoscopic management of infantile hypertrophic pyloric stenosis.

Abstract: Infantile hypertrophic pyloric stenosis is a common problem in pediatric surgery. Conventional management by the upper laparotomy was the method of choice over the last few decades. Advanced minimally invasive surgery allows successful endoscopic management of this entity too. We report on our initial experience with endoscopic surgery in the treatment of infantile hypertrophic pyloric stenosis with respect to some technical details. The operative procedure was well tolerated by the infant. After a short and uneventful postoperative course, the infant regained eating habits and was discharged from the hospital on the fifth postoperative day. Our favourable initial experience suggests that laparoscopic pyloromyotomy could be a safe and efficient alternative to the open surgery.

Radiologic changes of ischial tuberosity in ankylosing spondylitis.

Abstract: The objective of the paper was to emphasize the meaning of involvement of ischial tuberosity in ankylosing spondylitis, enriching the clinical picture of the disease and pointing to ankylosing spondylitis, especially when sacroiliitis is absent or less developed. Radiologic examination of ischial tuberosity was performed in 68 patients with different developmental stages of ankylosing spondylitis. There were 66 (97%) men and two (3%) women, aged 30 to 56 years. Anteroposterior radiographs of the pelvis were performed in all patients and independently assessed by two radiologists. The radiologic changes of ischial tuberosity were classified into four stages: 1) stage of minimal changes, 2) stage of destructive changes, 3) stage of reconstructive changes, and 4) stage of ossification of tendon fibers in the form of rumpled tufts. Radiologic changes of enthesitis were found on ischial tuberosity in 31 patients (45.5%, p < 0.01). Stage 1 or minimal changes were found in two (6.5%); stage 2 or destructive changes in 13 (42.0%); stage 3 or reconstructive changes in 11 (35.5%) and stage 4 or "tufts phenomenon" in five (16.0%) patients. The classification of changes is useful for the assessment of disease range and progression as well as for the diagnosis when sacroiliitis is obscurely developed and other radiologic signs are not present.

Hypokalemic metabolic alkalosis--three case reports.

Abstract: The two most common forms of inherited normotensive hypokalemic metabolic alkalosis are Bartter's and Gitelman's syndromes. Bartter's syndrome typically present with normal or increased calcium excretion. Hypomagnesemia occurs in only one third of affected individuals. In contrast, hypomagnesemia and hypocalciuria are considered hallmarks of Gitelman's syndrome. In most patients, the symptom of muscle weakness and polyuria occur early in life, which may be attributed to potassium depletion. Despite hyperaldosteronism, the patients tend to be normotensive, which is at least explained by vascular hyperresponsiveness to prostaglandins. Therapeutic approaches to Bartter's and Gitelman's syndromes include potassium supplementation, prostaglandin synthesis inhibitors (nonsteroid anti-inflammatory agents), aldosterone antagonists and converting enzyme inhibitors. Three patients with hypokalemia, normal blood pressure, metabolic alkalosis, hyperreninemia and hyperaldosteronism are described. Two patients had Bartter's syndrome and one patients had Gitelman's syndrome.

Clinical varieties of mastocytoses.

Abstract: Varieties of the clinical features of mastocytoses, also called mastocytosis syndrome, are presented. The disease is characterized by excessive accumulation of mast cells, their proliferation and action in the skin and other organs, even in the central nervous system. The mastocytosis syndrome was known as early as the second half of the 19th century under the term urticaria pigmentosa, and was histologically confirmed by the presence in the dermis of metachromatic cells, i.e. Ehrlich mast cells with red-purple cytoplasmic granules visible with Giemsa or toluidine blue stains. The mastocytosis syndrome was then supposed to be a benign chronic dermatosis of childhood with spontaneous regression by adolescence. The clinically pathognomonic symptoms of Darier's sign (urtication of primary skin lesion upon rubbing) and flushing help in the diagnosis of mastocytosis syndrome. In the 1950s, there was a progression in the diagnosis of systemic mastocytosis achieved by scientists and clinicians of various specialties. Upon the discovery of many mast cell released mediators (heparin, histamine, leukotrienes, prostaglandins, proteases, cytokines), receptor functions, relationship to IgE, anaphylatoxin, etc., they were recognized as triggers of various clinical features of the mastocytosis syndrome. In this paper, different forms of cutaneous and systemic mastocytosis are described, with special reference to 'mastocytosis mucocutanea haemorrhagica' observed by one of the authors in a female infant and followed from 6 months till 2.5 years of age. The patient showed practically all the diverse forms of cutaneous mastocytosis: urticaria pigmentosa, papular, nodular, tumorous-like melanoma, vesiculobullous, erythrodermic, telangiectasia eruptiva maculosa perstans. She also suffered from nasal and rectal hemorrhage, conjunctival suggillations, plaque-like infiltrations of the glossal, oropharyngeal and laryngotracheal mucosa, episodes of flushing, and transitory apnea. It is emphasized that the diagnosis of mastocytosis syndrome may be difficult for its mimicking various other diseases. The occurence of mastocytosis syndrome from the neonatal period through adult and old age, and possibilities of symptomatic treatment and prevention of sudden death or fatalities are discussed. Familial occurrence of mastocytosis syndrome and new genetic studies that may prove highly useful for understanding the etiopathogenesis of mastocytosis syndrome are described.

Epidemiologic characteristics of sexually transmitted infection/coinfection with Chlamydia trachomatis and Neisseria gonorrhoeae.

Abstract: Sexually transmitted infection/coinfection with Chlamydia trachomatis and Neisseria gonorrhoeae is responsible for pelvic inflammatory disease, ectopic pregnancy, infertility, neonatal conjunctivitis, and adhesive perihepatitis. The increase in the rate of chlamydial and gonococcal infection/coinfection has been related to promiscuity, inadequate use of mechanical contraception (condom), early sexual activity, and lack of proper sexual education. Therefore, the need of primary prevention and education of the young population, and introduction of amplification screening tests in the diagnosis of chlamydial infection at least before each intrauterine procedure, in women with mucopurulent discharge and in women below age 25 is emphasized.

Duplex ultrasonography in diagnosis of spigelian hernia with incarcerated jejunal loop.

Abstract: Spigelian hernia is a very rare anterior abdominal wall hernia with uncharacteristic symptoms and challenging diagnosis. The case of a 76-year-old male patient with colicky pain and vomiting lasting for 24 hours before admission to the hospital is presented. Physical examination of the patient revealed abdominal tenderness and a round-shaped tumefaction of 3 cm in size, located in the left lower abdominal quadrant. X-ray examination of the abdomen, obtained in left lateral position of the patient, showed small bowel ileus with distended jejunal loops. The abdominal ultrasound examination, followed by duplex ultrasonography, revealed a spigelian hernia with ischemic changes of strangulated bowel segment indicating incarceration of the herniated jejunal loop. Preoperative findings were confirmed by intraoperative diagnosis of spigelian hernia and incarcerated jejunal loop with ischemic changes and deserosation, followed by resection of the bowel segment involved and plastic surgical reconstruction of anterior abdominal wall. This case report highlights the role of duplex ultrasonography in the evaluation of circulatory status of potentially incarcerated bowel segment within hernial sac.