medicinski glasnik 13.indd
Transcription
medicinski glasnik 13.indd
MEDICINSKI GLASNIK Official publication of the Medical Association of Zenica-Doboj Canton, Bosnia and Herzegovina Volume 7 Number 2, August 2010. ISSN 1840-0132 Published and copyright by: Medical Assotiation of Zenica-Doboj Canton; Address: Zenica, 72000, Bulevar kralja Tvrtka I 4, Bosnia and Herzegovina; tel./fax: +387 32 444 270; Email: ljkozedo@bih.net.ba, web site: http//www.ljkzedo.com.ba For ordering information please contact: Tatjana Žilo, ljkozedo@bih.net.ba; Access to this journal is available free online trough: www.ljkzedo.com.ba The Journal is indexed by MEDLINE, Science Citation Index Expanded (SciSearch®), and Journal Citation Reports/Science Edition, EMBASE (Exerpta Medica), Scopus, EBSCO; ISSN 1840-0132 Printed by: EG - ING & Graphic and web design studio “B Panel” Zenica, Armije BiH 2, E-mail: info@bpanel.ba, tel. +387 32 441 290, 441 291 Printing supported by the Federal Ministry of Education and Science (Federalno ministarstvo obrazovanja i nauke, BiH) Medicinski Glasnik Official Publication of the Medical Association of Zenica-Doboj Canton Bosnia and Herzegovina Editorial Board Editor-in-chief Selma Uzunović-Kamberović Zenica, Bosnia and Herzegovina MANAGING Harun Drljević Zenica, Bosnia and Herzegovina Editors Adem Balić, Tuzla, Bosnia and Herzegovina Dubravka Bartolek, Zagreb, Croatia Branka Bedenić, Zagreb, Croatia Asja Čelebić, Zagreb, Croatia Josip Čulig, Zagreb, Croatia Filip Čulo, Mostar, Bosnia and Herzegovina Jordan Dimanovski, Zagreb, Croatia Branko Dmitrović, Osijek, Croatia Davorin Đanić, Slavonski Brod, Croatia Lejla Ibrahimagić-Šeper, Zenica, Bosnia and Herzegovina Tatjana Ille, Belgrade, Serbia Vjekoslav Jerolimov, Zagreb, Croatia Mirko Šamija, Zagreb, Croatia Ines Drenjančević-Perić, Osijek, Croatia Sven Kurbel, Osijek, Croatia Snježana Pejičić, Banja Luka, Bosnia and Herzegovina Belma Pojskić, Zenica, Bosnia and Herzegovina Asja Prohić, Sarajevo, Bosnia and Herzegovina Velimir Profozić, Zagreb, Croatia Zlatko Puvačić, Sarajevo, Bosnia and Herzegovina Radivoje Radić, Osijek, Croatia Amira Redžić, Sarajevo, Bosnia and Herzegovina Suad Sivić, Zenica, Bosnia and Herzegovina Sonja Smole-Možina, Ljubljana, Slovenia Vladimir Šimunović, Mostar, Bosnia and Herzegovina Adrijana Vince, Zagreb, Croatia Jasmina Vraneš, Zagreb, Croatia Živojin Žagar, Zagreb, Croatia Secretary: Tatjana Žilo; Proofreaders: Aras Borić (Bosnian, Croatian, Serbian), Glorija Alić (English), Cover: Miroslav Šetka - The Flower MEDICINSKI GLASNIK Official Publication of the Medical Association of Zenica-Doboj Canton, Bosnia and Herzegovina Volume 7, Number 2, August 2010 Free full-text online at: www.ljkzedo.com.ba, and www.doaj.org (DOAJ, Directory of Open Access Journals) EDITORIAL Review Original article 89 Posebnosti genitalnih infekcija humanim papiloma virusom u muškaraca Mihael Skerlev, Suzana Ljubojević 96 Surveillance of wildlife zoonotic diseases in the Balkans Region Mirsada Hukić, Fatima Numanović, Maida Šiširak, Almedina Moro, Edina Dervović, Sanja Jakovac, Irma Salimović Bešić 106 Beginnings and successes in preventing anophelism by means of gambusia fish on the island of Krk in Croatia from 1922 to 1927 Ante Škrobonja, Neven Materljan, Ivana Škrobonja 111 Emanuel Edward Klein, a diligent and industrious plodder or the father of British microbiology Bruno Atalić, Ines Drenjančević-Perić, Stella Fatovic-Ferenčić 116 Efficiency of hypertonic and isotonic seawater solutions in chronic rhinosinusitis Josip Čulig, Marcel Leppée, Andrijana Včeva, Davorin Djanic 124 Promjene u strukturi i kliničkom značenju pozitivnih rezultata pretransfuzijskog testiranja kod prijelaza s klasične metode aglutinacije u epruveti na metodu u gel mikrostupcu Changes in the structure and clinical significance of the positive results of pretransfusion testing during the switching from tube test agglutination to gel microcolumn technique Alma Petrušić-Kafedžić, Zdravko Ivanković, Sabahudin Ekinović, Lejla Ibrahimagić-Šeper 132 Etiologija limfadenopatija dječije dobi Etiology of lymphadenopathy in childhood Edo Hasanbegović, Senada Mehadžić 137 Lunarni ciklus i cerebralni napadi u djece The lunar cycle and seizures in children Devleta Hadžić, Nada Mladina, Belkisa Čolić-Hadžić, Amela Numanović 143 Increased P wave dispersion in patients with liver steatosis Mustafa Aparci, Zafer Isilak, Omer Uz, Ejder Kardesoglu, Omer Yiginer, Onur Sildiroglu, Murat Yalcin, Namık Ozmen, Bekir Yilmaz Cingozbay, Bekir Sitki Cebeci 148 Impact of reversionary and other etiological factors on prognosis and course of schizophrenia Ifeta Ličanin, Amira Redžić 153 Standardi fetalnog rasta za Tuzlansku regiju Intrauterine growth standards for Tuzla region Adem Balić, Devleta Balić 160 Notes Case reports Erratum 166 Stereološka analiza sinciciotrofoblasta resorpcijske resice posteljice trudnica mlađe i starije životne dobi Stereological analysis of syncytiotrophoblast in resorption villi of placentas of young and older pregnant women Sergije Marković, Zlata Žigić, Suada Ramić, Jasminka Hadžihalilović Operativni tretman endometrioze u u Kliničkom centru Kragujevac u periodu 2004 -2008.godine Operative treatment of endometriosis in the Clinical Centre of Kragujevac during the period 2004-2008 Momčilo Đorđević, Božidar Jovanović, Gordana Đorđević 169 Emerging risk for viral hepatitis A in Croatian adults Vladimir Mićović, Albert Cattunar, Danijela Štimac, Krunoslav Capak, Dražen Stojanović, Davor Jurišić 172 Intaktna blizanačka tubarna trudnoća Intact twin tubal pregnancy Jasmin Hodžić, Abdulah Granić, Nina Hodžić, Aida Idrizbegović 174 Obstruction of left ventricular outflow tract by a calcified mass at mitral valve Miro Bakula, Željka Gavranović , Maja Bakula , Roman Urek , Nikola Jankovic , Goran Milicevic 177 Laparoscopic treatment of achalasia Ferid Latić, Vlatka Pitlović, Josip Samardžić, Azra Latić, Hrvoje Pitlović, Đuro Miškić 180 Medicinski Glasnik is indexed by MEDLINE, Science Citation Index Expanded (SciSearch®), and Journal Citation Reports/Science Edition, EMBASE (Exerpta Medica), Scopus, EBSCO. EDITORIAL Medicinski Glasnik is reaching MEDLINE after five years of publishing I am very pleased to be in a position to introduce a new era of the Medicinski Glasnik (MG), reaching MEDLINE after five years of publishing. It was a great personal honour to be asked to take up the challenge of leading our publication to the indexing in MEDLINE, for mutual benefit of our authors and scientific community, so I did it! As you already know, our publication has been selected for coverage by Elsevier Bibliographic Databases from 2006 (Vol 3 No 1) onwards. These include EMBASE (Excerpta Medica), EMNursing, Compendex, GEOBASE, several specialized niche databases and other derivative products such as Mosby Yearbooks as well as Scopus. Launched commercially a few years ago, Scopus, the world’s largest abstract and indexing database of scientific and social sciences literature, is already firmly established as the all-science database of choice, with close to 8 million users at more than 500 institutions worldwide. For an overview and details of Elsevier Bibliographic Databases, please visit www.elsevier.com (click on Bibliographic databases) and www.info. scopus.com. Since 2007 (Vol 4 No 1) the MG has been selected for coverage by Thomson Reuters, which includes Science Citation Index Expanded (SciSearch®) and Journal Citation Reports (JCR)/ Science Edition (http://scientific.thomson.com ) and covers more than 8,000 of the world’s most highly cited, peer-reviewed journals from 3,300 publishers in approx. 227 disciplines, from 66 countries (less than 2% journals from developing countries). Journal Citation Reports (JCR)/Science Edition offers a systematic, objective means to critically evaluate the world’s leading journals, with quantifiable, statistical information based on citation data and helps to measure research influence and impact at the journal and category levels, and shows the relationship between citing and cited journals. Science Citation Index Expanded (SciSearch®), accssed via Web of Science® provides researches, administrators, faculty, and students with quick, powerful access to the bibliographic and citation information they need to find research data, analyze trends, journals and researches, and share their findings. In order to increase dissemination of authors’ papers published in the MG we have decided to include the MG and all its contents free of charge in the Directory of Open Access Journals (DOAJ, www.doaj.org) from 2005 onwards. This service covers free, full text, quality controlled scientific and scholarly journals. There are now 5021 journals in the directory, and 2063 journals are searchable at the article level. In the 2008 we also accepted an offer by EBSCO Publishing, Academic Search Complete (www. ebscohost.com) for inclusion of the MG in this database. It is the world’s most valuable comprehensive scholary, mulstidisciplinary full-text database, with more than 5500 full-text periodicals, including more than 4600 peer-reviewed journals. Finally, I am very pleased to inform all of you that as of 2010, Vol 7 No 1 the Medicinski Glasnik has been selected for coverage by MEDLINE, US National Library of Medicine® (NLM®) (the National Institutes of Health, NIH), which is a premier bibliographic database, covering biomedicine and life sciences topics vital to biomedical practitioners, educators, and researches, such as bioengineering, public health, clinical care, and plant and animal science, nursing, dentistry, veterinary medicine, marine biology, and preclinical sciences. MEDLINE provides global coverage, indexing content from over 4,900 journals in 30 languages (http://www.ncbi.nlm.nih. gov/pubmed/) VII Official abbreviation of our journal is: Med Glas Ljek komore Zenicko-doboj kantona Harun Drljević, remains the Managing Editor mainly in charge of dealing with our publisher. As you know, inclusion in the abstract and indexing databases increases dissemination of authors’ papers because sophisticated linking technologies drive additional traffic to individual articles. This in turn promotes journal brand awareness and subscription sales. The immediate ambition of the Editorial Team was to make the MG the foremost regional journal for all medical and related professionals. However, to achieve this goal, we need continuous support of our readers, including authors and reviewers of submissions that we receive. I hope that we can rely on your support and that you will consider the MG to be a suitable journal for publishing some of your best articles in the future. We look forward to receiving your submissions and feedback and thank you in anticipation of your collaboration. Our readers have already noticed a number of stylistic changes to the journal. Considerable changes in format and style of its content have also been made. Further details can be found in our updated ‘Guidelines for Authors’ posted on our reconstructed new-old web site: www.ljkzedo.com.ba The editorial process has also undergone significant modifications. I am very grateful to have the support of an enthusiastic team of Editors and numerous reviewers who assist with the evaluation of manuscripts. The final stages of the scientific editorial process are my responsibility, while It will be of great importance for the development and improvement of the MG in the future, because it is our main goal. All submissions are very welcome. We especially encourage you to write your papers in English, and I can promise, on behalf of the Editorial Board and myself, that we will extend any help and support you may need. Editor-in-Chief Selma Uzunovic-Kamberovic REVIEW Posebnosti genitalnih infekcija humanim papiloma virusom u muškaraca Mihael Skerlev, Suzana Ljubojević Klinika za kožne i spolne bolesti Kliničkog bolničkog centra Zagreb i Medicinskog fakulteta Sveučilišta u Zagrebu, Zagreb, Hrvatska SAŽETAK Fax.: +385 1 4920 017 Genitalne infekcije uzrokovane humanim papiloma virusom (HPV) sve su više predmetom istraživanja, s obzirom na njihovu najvišu učestalost unutar skupine virusnih spolno prenosivih infekcija, sklonost recidivima, dugotrajno liječenje i povezanost s pojavom zloćudnih bolesti. Zahvaljujući razvoju suvremenih metoda molekulske medicine, prije svega rekombinantne tehnologije DNA, do danas je utvrđeno oko 150 tipova HPV-a. Genitalne infekcije uzrokovane HPV-om, klinički se najčešće manifestiraju kao širok spektar dermatoveneroloških bolesti, od kojih se posebno ističu condylomata acuminata (šiljasti kondilomi), condylomata plana (ravni kondilomi), gigantski kondilom Buschke-Löwenstein, papulosis Bowenoides, kao i razne druge kliničke manifestacije intraepitelnih neoplazija (IN) vanjskog genitalnog sustava (dakle, ne samo cervikalne intraepitelne neoplazije, CIN), poput npr. penilne (PIN), analne (AIN), vulvarne (VIN), skrotalne (SIN) ili vaginalne (VAIN) intraepitelne neoplazije. Izbor liječenja ovisi o općem stanju i dobi bolesnika, o obliku, veličini i lokalizaciji promjena, kao i o iskustvu terapeuta. No, svakako treba istaći da još uvijek ne postoji specifično protuvirusno liječenje HPV genitalnih infekcija; recidivi su česti (30-70%), a raznovrsni terapijski pristupi ponekad vrlo neugodni za bolesnika i zahtjevni za liječnika. S obzirom na sve navedeno, kao i na dostupnost cjepiva protiv HPV infekcija, danas je HPV cijepljenje oba spola ozbiljan pomak koji značajno unapređuje pristup ovom problemu. E-mail: mskerlev@kbc-zagreb.hr Ključne riječi: HPV, muškarci, HPV vakcina Corresponding author: Mihael Skerlev, Klinika za kožne i spolne bolesti Kliničkog bolničkog centra Zagreb i Medicinskog fakulteta Sveučilišta u Zagrebu, Šalata 4, 10000 Zagreb, Hrvatska Phone: +385 1 2368 981; Originalna prijava: 20. januar 2010.; Prihvaćeno: 14. februar 2010. Med Glas Ljek komore Zenicko-doboj kantona 2010; 7(2):89-95 89 Medicinski Glasnik, Volumen 7, Number 2, August 2010 UVOD Genitalne infekcije uzrokovane humanim papiloma virusom (HPV) sve su više predmetom istraživanja, s obzirom na njihovu relativno visoku učestalost unutar skupine spolno prenosivih infekcija (engl. sexually transmitted infections STIs), sklonost recidivima, dugotrajno liječenje i mogućnost povezanosti s pojavom zloćudnih bolesti. Osim toga, važno je napomenuti da se HPV genitalne infekcije najčešće pojavljuju u mladoj, generativno sposobnoj populaciji, te je stoga njihovo uspješno praćenje i liječenje obveza svakog društva koje teži napretku. ETIOLOGIJA Danas je poznato oko 150 tipova HPV-a. Na temelju povezanosti prisustva pojedinog genotipa HPV-a na vratu maternice i pojave raka vrata maternice, standardno se određuje onkogeni rizik tipova HPV-a. Tako postoje HPV DNA tipovi niskog rizika (6, 11, 30, 42, 43, 44 itd. ) i HPV DNA tipovi visokog rizika (16, 18, 31, 33, 35, 45, 52, 56 itd.), a neki autori navode i HPV DNA tipove srednjeg rizika (31, 33, 35, 39, 51, 52, 58, 61 itd.). Treba svakako pripomenuti da navedena podjela nije, naravno, konačna, s obzirom da se sustavno otkrivaju i klasificiraju novi tipovi HPV-a, međutim, potrebno je, ipak, određeno vrijeme da se potvrdi onkogeno značenje svakog pojedinog tipa HPV-a (1, 2). EPIDEMIOLOGIJA U epidemiološkom smislu HPV genitalne infekcije su ubikvitarne i njihov je broj, čini se, u stalnom porastu (3). Prema rezultatima nekih opsežnih studija u Sjedinjenim Američkim Državama, broj se posjeta liječničkim ordinacijama zbog HPV genitalnih infekcija ušesterostručio u posljednja tri desetljeća (4, 5). Stoga je incidencija HPV genitalnih infekcija (13/100.000 u 1960. godini u odnosu na 106/100.000 u 1990. i 200/100.000 u 2000. godini) danas tri puta veća u usporedbi s genitalnim herpesom (6, 7), koji, uz HPV genitalne infekcije, predstavlja jedan od najvećih problema u venerološkoj praksi. U Hrvatskoj, također, HPV genitalne infekcije pripadaju među najčešće STD bolesti (8-10). Prema rezultatima nekih epidemioloških studija, kod 60% seksualno aktivnih žena pronađen je HPV u obrisku vrata maternice (9). Znaci HPV bolesti pronađeni su kod 40-60% muških partnera žena s virusološki dokazanom HPV genitalnom infekcijom (6-7). Incidencija HPV 90 genitalnih infekcija najviša je u dobi od 20 do 24 godine (11) i bitno opada nakon 40. godine života, međutim, sve se više pojavljuju (ili prepoznavaju!?) slučajevi HPV genitalne infekcije u dječjoj dobi, kao i u menopuazi, odnosno andropauzi (12). Epidemiološki podaci o HPV genitalnim infekcijama najviše su ispitivani u vezi s pojavom raka vrata maternice. Smatra se da se u svijetu godišnje dijagnosticira 500.000 novih slučajeva raka vrata maternice, te da je taj karcinom drugi po redu učestalosti zloćudnih tumora u ženskoj populaciji (6, 7, 13). Uzevši u obzir činjenicu da je inkubacija HPV genitalnih infekcija relativno duga i da traje od 2 do 9 mjeseci (i dulje) (11, 12), zaražene osobe mogu predstavljati neprepoznati supklinički izvor zaraze i vjerojatno su razlogom relativno teškog načina otkrivanja izvora i praćenja putova širenja HPV genitalne infekcije (12-13). Što se tiče onkogenog aspekta HPV-a, zur Hausen (13) je prvi dokazao uzročno-posljedičnu vezu između HPV infekcije, tipom 16 i 18, i karcinoma vrata maternice, zbog čega mu je i dodijeljena Nobelova nagrada za fiziologiju i medicinu 2008. godine. Rizični čimbenici i način prenošenja Čimbenici rizika za prijenos HPV infekcije prvenstveno ovise o imunološkom stanju organizma pojedinca. Prvi spolni odnos u ranoj životnoj dobi, udaja i rađanje u ranoj životnoj dobi, višebrojni spolni partneri, porodi većeg broja djece, spolni odnosi s rizičnim muškim/ženskim partnerom, niski socioekonomski status jesu najčešći čimbenici (14, 15). Drugi potencijalni čimbenici su korištenje oralnih kontraceptiva, pušenje, konzumacija alkohola, nedostatak vitamina, spolno prenosive bolesti izazvane herpes simplex virusom (HSV), te druge spolno prenosive bolesti (Chlamydia trachomatis, Neisseria gonorrrhoeae, Gardnerella vaginalis, Mycoplasma hominis, Trichomonas vaginalis, citomegalo virus infekcije) (14-26). Spolno prenosivi put jeste najčešći put prenošenja. S obzirom da se HPV opisuje i kod djevica, novorođenčadi, djece (kao juvenilna laringealna papilomatoza), zaključilo se da se HPV može prenositi i drugim putevima (27-32). Stoga su opisani i drugi načini prenošenja, kao autoinokulacija, perinatalni prijenos, te prenošenje putem kirurških instrumenata (27-32). Načini prenošenja uključuju vertikalni, ‘’nevini’’ (autoinokulacija i heteroinokulacija s bradavica na ruci) i spolni odnos (28). Skerlev et al Genitalne HPV infekcije u muškaraca PATOGENEZA Jedan od ključnih patogenetskih koraka u razvitku tumorske bolesti jeste nekontrolirana proliferacija stanica (3). Temeljni molekularni mehanizmi, koji pokreću i održavaju nekontroliranu diobu tumorske stanice, jesu aktivacija onkogena i inaktivacija tumor supresorskih gena (33-35). Onkogeni su geni oni čija je aktivnost povezana sa zloćudnom preobrazbom stanice, dok su tumor supresorski geni oni čija aktivnost koči zloćudnu preobrazbu (33-35). Integracija virusa u genom domaćina smatra se bitnim mehanizmom u karcinogenezi (36, 37). Međutim, u posljednje se vrijeme sve veća pozornost pridaje, uz već relativno dobro istraženu povezanost HPV-a i cervikalne intraepitelijske neoplazije, intraepitelijskim neoplazijama vanjskog genitala u oba spola povezanim s HPV-om (38). Stoga se sve više govori o, primjerice, penilnoj (PIN), analnoj (AIN), vaginalnoj (VAIN) (38), vulvarnoj (VIN) (38-41) i skrotalnoj (SIN) intraepitelijskoj neoplaziji. Studije koje istražuju povezanost HPV-a i karcinoma muškog genitalnog sustava (najčešće glans, prepucij ili skrotum), ukazuju na povezanost HPV-a 16 i 18 sa spinocelularnim karcinomom penisa u 44% slučajeva (40). U nekim je slučajevima bio izoliran HPV 16 u sjemenoj tekućini i obrisku uretre kod bolesnika sa spinocelularnim karcinomom glansa (41). Značenje HPV-a kod karcinoma prostate nije do kraja razjašnjeno, iako postoje studije koje ukazuju na prisustvo HPV-a 16 i 18 u hipertrofiji i karcinomu prostate (40, 41). KLINIČKA SLIKA Genitalne infekcije HPV-a mogu se podijeliti u tri skupine: klinička, supklinička i latentna infekcija. Kliničke infekcije jesu one koje se vide pri pregledu, dok su supkliničke one koje su vidljive nakon premazivanja 3-5% octene kiseline, uz primjenu kolposkopske tehnike. Latentna infekcija karakterizirana je prisutnošću HPV DNA u tkivu, dok je virus odsutan u kolposkopskim i histološkim nalazima, a otkriva se HPV DNA genotipizacijskim metodama (42, 43). Što se kliničkog aspekta HPV genitalnih infekcija tiče, najčešće govorimo o slijedećim entitetima: condylomata acuminata (šiljasti kondilomi), condylomata plana (ravni kondilomi), gigantski kondilom Buschke-Löwenstein i papulosis Bowenoides i Mb. Bowen u genitalnoj regiji (Tablica 1). Ni u kom slučaju ne treba zanemariti ni planocelularni karcinom penisa, karakterističan za stariju životnu dob, no, u posljednje se vrijeme Tablica 1. Kliničke manifestacije i odgovarajući HPV tipovi (Skerlev M., Ljubojević S.) ANOGENITALNE BOLESTI HPV TIP Šiljasti kondilomi (condylomata acuminata) Bowenoidna papuloza 6, 11, 30, 42, 43, 44, 45, 51, 52, 54; rjeđe 16,18, 33 16, 18, 34, 39, 42, 45 Bowenova bolest 16, 18, 31, 34 Gigantski kondilom (BuschkeLöwenstein) 6, 11; rijetko 16, 18 Nespecificirana intraepitelna neoplazija 30, 34, 39, 40, 53, 57, 59, 61, 62, 64, 66, 67, 68, 69 Intraepitelna neoplazija niskog stupnja 6, 11, 43 Intraepitelna neoplazija srednjeg stupnja 31, 33, 35, 42, 44, 45, 51, 52 Intraepitelna neoplazija visokog stupnja 16, 18, 56, 58 Karcinom vulve 6, 11, 16, 18 Karcinom vagine 16 Karcinom cerviksa 16, 18, 31 Karcinom anusa 16, 31, 32, 33 Karcinom in situ penisa (erythroplasia Queyrat) 16 Karcinom penisa 16, 18 opisuju sve češći slučajevi pojave ove bolesti i kod mlađih muškaraca (38). Od svih navedenih entiteta najčešći su šiljasti kondilomi - condylomata acuminata. To su papulozne ili nodozne tvorbe, papilomatoznog, odnosno verukoidnog izgleda, najčešće lokalizirane na vanjskom genitalu (Slika 1), često na distalnom dijelu korpusa penisa ili na prepuciju kod muškaraca (39), odnosno na vulvi kod žena ili pak na analnoj regiji kod oba spola. U posljednje se vrijeme sve više navodi značenje intrauretralnih (meatalnih) kondiloma zbog mogućnosti prijenosa HPV-a u unutrašnje dijelove mokraćnog sustava zbog moguće povezanosti intrauretralnih kondiloma s pojavom karcinoma mokraćnog mjehura i prostate (40, 41, 44), kao i zbog rezistentnosti na uobičajenu terapiju. No, značenje šiljastih kondiloma ne treba ‘’banalizirati“ s obzirom da se u 1020% slučajeva šiljastih kondiloma mogu detektirati Slika 1. HPV-genitalna infekcija (šiljasti kondilomi); lokalizacija na distalnom dijelu korpusa genitala (solitarne promjene) i na pubičnoj regiji (konfluentne promjene) (Skerlev M, Ljubojević S, iz zbirke slika 2009.) 91 Medicinski Glasnik, Volumen 7, Number 2, August 2010 HPV visokog rizika (10, 41). U novijoj literaturi (41) posebno se opisuju ravni kondilomi - condylomata plana, koji su prije bili opisivani kao varijanta kliničke slike šiljastih kondiloma. Condylomata plana su papilomatozne tvorbe ravnog oblika, najčešće uzrokovane HPV tipovima 16, 18, 31 ili 33. Većina autora ravne kondilome izdvojila je u poseban entitet, ne samo zbog njihovog drugačijeg oblika od šiljastih kondiloma, već i zbog njihove teže kliničke uočljivosti i zbog njihovog znatno većeg onkogenog potencijala u usporedbi s ‘’klasičnim’’ šiljastim kondilomima. Najveći broj HPV genitalnih infekcija vrata maternice, kao i određeni broj asimptomatskih promjena kod muškaraca, pripadaju baš ovom kliničkom obrascu (11, 13). Gigantski kondilom Buschke-Löwenstein (BL) je masivna tumorska lezija anogenitalne regije. No, osim kliničke impresivnosti, treba, ipak, navesti i rezultate najnovijih studija koji ukazuju na kliničke i histološke znakove malignosti (u smislu verukoznog karcinoma) i detekciju HPV tipova visokog rizika kod ovog entiteta (44-47). Kod bovenoidne se papuloze, tvorbe sastavljene od multiplih papula najčešće lokaliziranih na vanjskom spolovilu, histološki nalaze znaci stanične atipije koji podsjećaju na Morbus Bowen ili spinocelularni karcinom in situ (48). Iz bovenoidne papuloze izoliran je najčešće HPV 16 (48). Na temelju svega navedenog vidljivo je da danas govorimo o širokom spektru kliničkih promjena izazvanih HPV-om. Međutim, u posljednje se vrijeme sve veća pozornost pridaje, uz već relativno dobro istraženu povezanost HPV-a i cervikalne intraepitelijske neoplazije, intraepitelijskim neoplazijama vanjskog genitala u oba spola povezanim s HPV-om (49). Stoga se sve više govori o, primjerice, penilnoj (PIN), analnoj (AIN), vaginalnoj (VAIN) (49), vulvarnoj (VIN) (41, 49-51) i skrotalnoj (SIN) intraepitelijskoj neoplaziji. Studije koje istražuju povezanost HPV-a i karcinoma muškog genitalnog sustava (najčešće glans, prepucij ili skrotum) ukazuju na povezanost HPV-a 16 i 18 sa spinocelularnim karcinomom penisa u 44% slučajeva (51). U nekim je slučajevima bio izoliran HPV 16 u sjemenoj tekućini i obrisku uretre kod bolesnika s planocelularnim karcinomom glansa (38). Značenje HPV-a kod karcinoma prostate nije do kraja razjašnjeno, iako postoje studije koje ukazuju na prisustvo HPV-a 16 i 18 u hipertrofiji i karcinomu prostate (38, 51). Na temelju svega navedenog vidljivo je da danas govorimo o širokom spektru kliničkih promjena izazvanih HPV-om. 92 DIJAGNOZA Klinički pregled je osnova za postavljanje dijagnoze vidljivih HPV lezija vanjskog spolovila. Pregledati treba cijelu anogenitalnu regiju, uz pomoć jakog svjetla i povećala. Supklinički oblik bolesti može se vidjeti tek nakon premazivanja tkiva 3-5%tnom octenom kiselinom i primjenom kolposkopa. Supkliničke lezije, vidljive peniskopom, mogu se klasificirati kao ravne, papularne, PIN promjene (u acidobijelom epitelu punktacije), klasični kondilom i nespecifične lezije (52). Nespecifični i/ili lažno pozitivni peniskopski nalaz najčešće nalazimo kod mikrotrauma, upalnih procesa, najčešćih gljivičnih infekcija (kandidijaza ili trihomonijaza), zatim folikulitisa, kontaktnog alergijskog ili iritativnog dermatitisa, te nekih bolesti poput vulgarne psorijaze i lichnen planusa (53). Karakteristične histološke promjene HPV genitalnih infekcija su koilociti. Koilociti su morfološki promijenjene stanice, koje su inficirane HPV-om (54). Te stanice karakterizira perinuklearna citoplazmatska vakuolizacija, veći broj nepravilnih jezgra, grube nakupine kromatina i polikromazija. Javljaju se u slučaju produktivne infekcije (’’vegetativne’’) viralne replikacije. Osim svjetlosnim mikroskopom, prisutnost HPV-a može se dokazati elektronskim mikroskopom i imunohistokemijskim metodama (55, 56). Međutim, sve ove metode imaju relativno nisku osjetljivost i specifičnost, a osim toga, ne omogućavaju genotipizaciju HPV-a. Danas se za preciznu dijagnostiku zaraze HPV-om isključivo upotrebljavaju metode molekularne dijagnostike. Molekularne metode za detekciju DNA temelje se na lančanoj reakciji polimeraze (engl. polymerase chain reaction, PCR) ili na hibridizaciji nukleinskih kiselina (57-59). LIJEČENJE Još uvijek ne postoji idealno sredstvo za etiološko liječenje HPV infekcija urogenitalnog trakta. Liječenje se, u načelu, svodi na mehaničko odstranjenje manifestacija HPV genitalne infekcije. Iako jedan dio neliječenih genitalnih infekcija (osobito onih koje nisu jasno klinički manifestne, dakle, latentne i/ili supkliničke infekcije) može spontano regredirati, moguća je i perzistencija HPV-a, koja može dovesti do progresije bolesti. U svakom slučaju, iznimno je važna što ranija dijagnoza HPV genitalnih infekcija u oba partnera, kako bi se spriječio nastanak prekanceroza, kao i karcinoma urogenitalnog trakta. Skerlev et al Genitalne HPV infekcije u muškaraca Infekcije izazvane HPV-om mogu se liječiti podofilinom, podofilatoksinom, krioterapijom, lokalnom primjenom 5-fluorouracila, triklor octenom kiselinom, imiquimodom, intralezijski ili peroralno primijenjenim interferonom, intralezijski primijenjenim bleomicinom, ekskohleacijom, elektrokoagulacijom, klasičnom i laserskom kirurškom terapijom (60-64) (Tablica 2). Treba svakako napomenuti da izbor terapijskog sredstva ovisi i o izraženosti i lokalizaciji kliničkih promjena, iskustvu terapeuta, stavu bolesnika, kao i o ekonomskim okolnostima. Terapijske su opcije ponekad vrlo neugodne za bolesnika, frustrirajuće za liječnika i, unatoč svemu, recidivi mogu biti česti i terapijski uspjeh skroman. PREVENCIJA PRIMJENOM HPV VAKCINE Svakako treba napomenuti da su u svijetu, pa tako i u Hrvatskoj, registrirane dvije vakcine protiv HPV-a: četverovalentno cjepivo protiv četiri najčešća HPV DNA tipa (HPV DNA 6, 11, 16 i 18) i dvovalentno protiv dva najčešća tipa visokog rizika (HPV DNA 16 i 18). HPV vakcina definitivno predstavlja značajan pomak u pristupu HPV genitalnim infekcijama, pri čemu, jasno, ne smiju biti zanemareni ni ostali aspekti prevencije poput edukacije, odgovornog spolnog ponašanja i primjene kondoma. Navedene su vakcine, kao i Tablica 2. Liječenje anogenitalnih bradavica (Skerlev M., Ljubojević S.) PRIMJENJUJE LIJEČNIK Krioterapija tekućim dušikom Elektrokoagulacija MOŽE PRIMIJENITI I SÂM BOLESNIK Podofilotoksin 0.5% tekućina ili 0.15% krema Imiquimod 5% krema Ekskohleacija Ekscizija Laser Trikloroctena kiselina 70-90% Podofilin 20% tekućina (Pazi!!! Obvezatno ispiranje tretiranih promjena nakon 5h!) većina drugih vakcina, prije svega, profilaktičke, te se očekuje uvođenje HPV vakcine u rutinski program cijepljenja. Četverovalentno cjepivo usmjereno je na prevenciju cervikalne intraepitelne neoplazije (CIN), intraepitelne neoplazije drugih dijelova vanjskog genitalnog sustava žena i muškaraca, kao npr. vulve (VIN), vagine (VAIN), penisa (PIN) ili anusa (AIN), te na prevenciju anogenitalnih bradavica oba spola. Prevencijom pojave navedenih invazivnih lezija, spriječila bi se progresija bolesti prema karcinomu vrata maternice (65). Dvovalentno cjepivo usmjereno je na prevenciju cervikalne intraepitelne neoplazije (CIN) i prevenciju karcinoma vrata maternice. Stoga je cilj cijepljenja zaštititi djecu i adolescente, oba spola, prije prvog mogućeg kontakta s HPV-om (66). U tu svrhu važno je procijepiti mladu populaciju u dobi već od devet, odnosno 12 godina. Najnoviji rezultati multicentričnih studija učinkovitosti četverovalentne HPV vakcine na velikom broju muških ispitanika, nedvosmisleno ukazuju na visoku učinkovitost protiv sva četiri ispitivana HPV DNA tipa, obuhvaćena ovim cjepivom (65). Svakako treba uzeti u obzir i činjenicu da, u užem smislu riječi, etiološka terapija HPV-a još uvijek ne postoji i da je liječenje najčešće višekratno, ponekad neugodno za bolesnika i zahtjevno za liječnika, a recidivi se mogu, unatoč liječenju, pojaviti u 30-70% slučajeva. Na temelju svega navedenog jasno je da su HPV genitalne infekcije vrlo veliki zdravstveni problem i muškarcima, kako zbog epidemioloških, tako i zbog onkoloških i psiholoških reperkusija, te tu činjenicu treba uzeti u obzir pri razvoju suvremene strategije za prevenciju spolno prenosivih bolesti. ZAHVALE/IZJAVA Komercijalni ili potencijalni dvostruki interes ne postoji. LITERATURA 1. 2. 3. 4. Nicolau SM, Martins NV, Ferraz PE, Stavale JN, Goncalves WJ, Baracat EC, de Lima GR. 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Strauss MJ, Khanna V, Koenig JD, Downs SM, Goldberg SH, Manyak MJ, Patsner B. The cost of treating genital warts. Int J Dermatol 1996; 35:340-8. 64. Mahony CO, Law C, Gollnick HPM, Marini M. New patient-applied therapy for anogenital warts is rated favorably by patients. Int J STD 2001; 12:565-70. 65. Palefsky J, Giuliano A on behalf of the male quadrivalent HPV vaccine efficacy trial study group. Efficacy of the quadrivalent HPV vaccine against HPV 6/11/16/18-related genital infection in young men. EUROGIN 2008. http://www.eurogin.com/2008/. (18. ožujka 2010.) 66. Stretch R. Implementing a school-based HPV vaccination programme. Nurs Times 2008; 104:30-3. The specifities of the HPV-genital infections in males Mihael Skerlev, Suzana Ljubojević University Department of Dermatology and Venereology, Zagreb University Hospital Centre and Zagreb University School of Medicine, Zagreb, Croatia. ABSTRACT Anogenital infections caused by Human papillomavirus (HPV) are the most frequently diagnosed sexually transmitted infections of viral origin and up to 150 HPV DNA types have been recognized so far. Anogenital warts (condylomata acuminata) are the most common lesions presented in men, however, during the last decade the other HPV-associated exaggerated lesions such as condylomata plana, penile, scrotal, and anal intraepithelial neoplasias, as well as the penile, urine bladder and prostate cancer have been studied somewhat more extensively. The clinical variations might range from clinically invisible, asymptomatic lesions to the bizarre forms of giant condyloma of Buschke-Löwenstein type, including Bowenoid papulosis, Mb. Bowen, different kinds of eryhtroplasia both in men and women and a large spectrum of HPV-induced dermatovenereological entities in genital region including high-grade intraepithelial genital neoplasias, such as penile, anal, scrotal, vulvar, vaginal etc. (thus not only cervical), and, last but not least - the anogenital warts. A prophylactic vaccine that targets these types should thus substantially reduce the burden of HPV-associated clinical diseases. Ultimately, within the spectrum of therapeutic options for condylomata, no method is really superior to others; recurrences occurred in 30-70% of cases. We definitely need the HPV vaccination programme to eliminate one of the oldest and up to now unsolved problems of the mankind. Since HPV is transmitted by sexual intercourse, treatment of both partners is necessary in order to eliminate the virus from the population. Approaches to this include prophylactic vaccines such as quadrivalent HPV vaccine for both men and women. Key words: HPV, men, HPV vaccine Original submission: 20 January 2010; Accepted: 14 February 2010. 95 REVIEW Surveillance of wildlife zoonotic diseases in the Balkans Region Mirsada Hukić1, Fatima Numanović2, Maida Šiširak1, Almedina Moro1, Edina Dervović1, Sanja Jakovac3, Irma Salimović Bešić1 Institute of Clinical Microbiology, Clinical Center of the University of Sarajevo, 2Institute of Microbiology, Clinical Center of the University of Tuzla, 3Institute of Microbiology, Clinical Center of the University of Mostar; Bosnia and Herzegovina 1 ABSTRACT Corresponding author: Mirsada Hukić Institute of Clinical Microbiology, Clinical Center University of Sarajevo, Bonička 25, 71000 Sarajevo, Bosnia and Herzegovina Phone/fax: +387 33 440 447; E-mail: mirsadahukic@yahoo.com Original submission: 14 December 2009; Revised submission: 30 December 2009; The countries of the Balkan Peninsula have become the region with frequent outbreaks of the emerging and re-emerging diseases during the last decade of the 20th and the first decade of the 21st century. The majority of outbreaks were wildlife zoonotic, and vector-borne diseases, such as brucellosis, leptospirosis, listeriosis, tularemia, Q-fever, Lyme disease, anthrax, rabies, viral hemorrhagic fevers, sandfly fever, tick-borne encephalitis and leishmainiasis. Epidemiological factors determined by ecology of causative agents are often the most useful diagnostic clues. The recognition of evolving problems of emerging and re-emerging diseases emphasizes the need for the development of better laboratory diagnostic methods for the surveillance and tracking of the diseases, and for continued research of factors contributing to the transmission of the organisms. The continuous occurrence of previously unidentified infections requires prospective national strategies for timely recognition of the syndromes, causative agent identification, establishment of criteria and methods for the diagnosis, optimization of the treatment regime, and determination of successful approaches to prevention and control. Wildlife diseases surveillance in the most of the Balkan countries has been coordinated by the WHO since 1992. Although new technology and communication have extremely improved in the last decade, there is a need for optimal communication lines among the Balkan countries, better exploitation of communication technologies like the Internet and other media in the field of emerging diseases. Key words: surveillance, wildlife zoonotic diseases, Balkan Penninsula Accepted: 05 January 2010 Med Glas Ljek komore Zenicko-doboj kantona 2010; 7(2):96-105 96 Hukić et al Wildlife zoonoses in the Balkans Region INTRODUCTION A zoonosis is an animal disease that may be transmitted to humans in natural conditions. Almost a half out of 1700 known pathogens affecting humans are estimated to be zoonotic (1). It has been reported that there are up to 335 pathogens which were associated with emerging infectious diseases (EID) in the global human population between 1940 and 2004, and majority of them were caused by the wildlife zoonotic diseases, while vector-borne diseases were responsible for up to 22.8% (1). Many wildlife zoonotic disease (WZD) outbreaks were reported in the area of the Balkan Peninsula during the last twenty years (2). The wartime period (1992-1995) was associated with socio-economic, human demographics, behavioral, ecological and environmental (climate, ecosystems, microbial adaptation) changes that had significant impact on public health and global economy, as well as to wildlife zoonotic diseases (3). The additional variables which mostly influence zoonoses and vector borne diseases are human population density, human population growth, and wildlife and non-wildlife host species richness (1, 3-5). Breaking of communications channels between the former Yugoslav countries during the wartime and some years in post-war periods, and lack of political will to control the diseases have also greatly contributed to the appearance of WZD outbreaks in the Balkans area. There is a need for different actions to be undertaken in order to recognize and control EIDs and WZDs. First of all, it is important to improve the reporting system of infectious diseases at the state, regional and World Health Organization level. It is also important to improve several tools for controlling EIDs and WZDs such as epidemiologic field investigation, control, elimination and eradication, training, diagnostic development, and basic and applied research activities including technology transfer. Surveillance of infectious diseases and continuous systematic collection, collation, analysis and interpretation of data and the dissemination of information to the authorities have to be established in order to take any actions (4-7). The purpose of the disease surveillance is to identify the changes of infection and/or health status of animal and human populations, and it is essential to provide rigorous evidence of the disease absence or to determine pathogen prevalence. To be successful in the understanding WZDs a basic lack of integration between disciplines needs to be eliminated, the most noticeably between human and veterinary medicine and also among different branches within these fields. Although new technology and communications have extremely advanced in the last decade, there is still a need for better exploitation of communication technologies such as the Internet and other media in the field of EIDs (5-7). WILDLIFE ZOONOSIS IN THE BALKANS REGION The epidemiological situation related to zoonoses in the Balkan countries is not well characterized due to the difficult circumstances prevailing during the previous decade. There is a lack of reporting and publishing system of the infection and/or health status of animal and human populations. Although there were no readily accessible data concerning epidemiology and epizootology of WZDs, limited official and published data were analyzed. Anthrax Anthrax is endemic in some regions of the Balkan Peninsula, but it is not a significant public health problem (2). However, in the past century cutaneous anthrax cases with several clinical signs of septicemia were recorded in Bulgaria, Bosnia and Herzegovina (B&H) and Croatia, with a low mortality rate (1.64%) (7-9). Brucellosis Brucellosis is a significant health problem among animals and humans in the Balkan Peninsula. Brucellosis is spread in Greece, the former Yugoslav Republic of Macedonia, Kosovo, Serbia and Croatia (10, 11). It is an endemic disease among animals and humans in the southern part of the Balkan Peninsula, Greece, the Former Yugoslav Republic of Macedonia and Kosovo at the end of 20th century, which was a consequence of the changes in political situation in this area followed by the wartime. Appearance of brucellosis represents a classical example of spreading zoonosis as a result of the population and animal migration (9, 12, 13). Brucellosis is an EID in B&H and it is still an increasing public health problem. Only one case 97 Medicinski Glasnik, Volumen 7, Number 2, August 2010 of human brucellosis was reported in 1999, while in 2008 there were 988 cases reported (14). The current animal health situation in B&H shows an increase in the number of reported outbreaks in ruminants. The number of seropositive cases as compared with the number of processed serums in last four years has ranged from 0.047% to 1.09% (11). In Greece, cattle are also affected either by B. melitensis or B. abortus. Wild boars (Sus scrofa) were found to be carriers and reservoirs of Brucella suis biovar 2 in Croatia (15), whereas Brucella suis biovar 3 was isolated from horses in Croatia (16). Due to the dimension of the disease-related problems, there is a need to establish cooperation in the elimination and prevention of brucellosis among all countries in the region, supported by World Health Organization. Leptospirosis Leptospirosis is an endemic zoonosis existing Croatia and B&H (17-20). This is a widely spread disease with frequent epidemic occurrence, especially among miners in B&H and foresters in Croatia (18, 21, 22). Serological testing conducted in 1983 revealed antibodies to Leptospira serovares pomona, grippotyphosa, sejroe, australis and bataviae (21) in 10.08% of the B&H miners population. Leptospiroisis outbreak among miners in B&H occurred 25 years later (2005) but caused by new serovars: L. ballum, L. ictrohaemorrhagiae, L. sejroe and L. tarassovi (22). Serological tests in patients from Croatia have shown 18 different serovars of Leptospira, with the highest prevalence of L. sejroe, L.pomona, L. australis and L. icterohaemorrhagiae (23). Leptospira seroprevalence among small rodents captured in shafts of the lignite mines in B&H of 37.5% was noted in 1983 (21). An analysis of Leptospira sp. among small rodents in Croatia revealed three different species: L. borgpetersenii, L. kirschneri and L. interrogans. Mus musculus exhibited the highest infection level which was confirmed as a major reservoir of the serogroup Sejroë (23). Leptospira infection was also found among European brown bears (Ursus arctos) in Croatia (24), and based on the antibody titers, several serovars found were implicated: australis, sejroe, canicola 98 and icterohaemorrhagiae. A strong correlation between serovars in bears and serovars previously isolated from small mammals in Croatia was noted (25). Listeriosis Listeriosis is present in the area of the Balkan Peninsula, but it is not a considerable public health problem. However, occasional cases of different clinical forms of leptospirosis have been recorded recently (26, 27). The analysis of the contamination level of different kinds of raw meat (raw beef, pork and chicken) in B&H showed overall presence of Listeria spp. in 49.4% samples; L. monocytogenes detected in 23.3%, L. innocua in 22.2% and L. welshimeri in 3.9% analyzed row meat samples (28). Both beef and pork were mostly contaminated by L. monocytogenes, in 34.3% and 25.7%, respectively. Chicken had the lowest level of contamination amounting to 10.0% (28). In a study conducted in Serbia, 45% of all pigs examined harboured L. monocytogenes in their tonsils, and 3% were intestinal carriers. L. monocytogenes was detected in 29% of swabs from retropharyngeal nodes and in 19% of fecal samples of cattle. L. monocytogenes was found in 69% of minced meat (mixed pork and beef) samples, in 19% of raw dry sausages, and in 21% of vacuum-packaged hot smoked sausages. However, L. monocytogenes was not detected in the hot smoked sausages heated to internal temperature of 70-75 °C after the fumigation process (29). Tularemia Francisella tularensis has been recognized as a human pathogen for almost 100 years and it is the etiological agent of the zoonotic disease, tularemia. The organism has been isolated from over 250 different species, including fish, birds, amphibians, rabbits, squirrels, hares, voles, ticks and flies. An important aspect of F. tularensis pathogenesis is the transmission via arthropod vectors into mammalian host. Chrysops spp. and Tabanus spp. also designated as deer fly and horsefly, respectively, are common arthropod vectors of Francisella transmission to humans, resulting in initial clinical presentation with ulceroglandular form of the disease (30, 31) Due to its easy dissemination, multiple routes and low dose infection, morbidity and mortali- Hukić et al Wildlife zoonoses in the Balkans Region ty rates, F. tularensis subsp. tularensis has been classified as a category A bioterrorism agent by the CDC (32). Tularemia is an emergent infectious disease in several countries at the Balkan Peninsula. The first outbreak of tularemia occurred in B&H in 1995, during the wartime (33). A large tularemia outbreak occurred in Kosovo in the early postwar period, 1999-2000 (34). Only sporadic cases of tularemia have been recognized and reported since the first epidemic in Kosovo (32, 34). There are no data about tularemia seroprevalence in general population or in the high risk groups, e.g. foresters, hunters, veterinarians, or soldiers. Epidemiological and environmental investigations were conducted to identify sources of infection, modes of transmission, and household risk factors in Kosovo. The results suggested that the infection was transmitted through contaminated food or water and that the source of the infection were rodents (34). Environmental circumstances in the war-torn Kosovo led to epizootic rodent tularemia and its spread to displaced rural populations living under circumstances of substandard housing, hygiene, and sanitation (34). Tularemia outbreak areas in 1962 and 1997-2006 periods in Bulgaria were different. The first case of tularemia was reported in 1997. Starting from 1998 to 2008, 296 cases were registered. Amplified fragment length polymorphism (AFLP) and multiple-locus variable number of tandem-repeats analysis (MLVA) typing, confirmed epidemic spread and evolution, and comparison of strains isolated from different regions in Bulgaria and Turkey resulted in the finding of the common “Balkan” genovar of Francisella. In addition, several novel genotypes of endosymbionts of Francisella-like organisms have been found in Hyalomma and Dermacentor ticks (9). Lyme disease Lyme boreliosis is an emergent disease in many Balkan countries: Bosnia and Herzegovina, Croatia, Slovenia, Serbia and Bulgaria (35-39). It is a zoonosis transmitted from animals to humans by ticks of Ixodes ricinus complex. Lyme borreliosis is caused by Borelia burgdorferi sensu lato, which has four different species (36). In order to evaluate prevalence rate of tick-borne bacterial pathogens, unfed adult Ixodes ricinus ticks were collected from vegetation at 18 localities throughout Serbia in 2001, 2003, and 2004, a total of 287 ticks were examined by PCR technique for the presence of Borrelia burgdorferi sensu lato; prevalence rate for B. burgdorferi sensu lato was 42.5% (36, 39). The presence of five B. burgdorferi sensu lato genospecies, namely B. burgdorferi sensu stricto, B. afzelii, B. garinii, B. lusitaniae, and B. valaisiana was identified by restriction fragment length polymorphism (RFLP) analysis (39). The most frequent B. burgdorferi sensu lato genospecies was B. lusitaniae, followed by B. burgdorferi sensu stricto. These findings indicate a public health threat in Serbia related to tickborne diseases caused by B. burgdorferi sensu lato (39). Q-fever Q-fever has been present in the region of the Balkan Peninsula since it was first recorded as ‘’the Balkans flu’’ (1941–1942), and it occurs in the form of small-scale epidemics and epizooties (8, 40). Across the ex-Yugoslavia territories Q fever was discovered rather early – in Zagreb (1948), Banat (1950), Bosnia (1951, 1953), Sandzak (1953), Serbia (1953, 1956 – the Pirot strain), Dalmatia (1957), Vojvodina (1957), Gacko (1959), Croatia (1962), B&H (1964), Pula (1972), Vojvodina (1983), Croatia (1984), Vojvodina (1984), Bosnia (1985), Kosovo and Metohija, Cacak (1985), Vojvodina (1991, 1992, 1993, 1994, 1995), Macva (in sheep from Kosovo 1998), Montenegro (1999), Serbia (2003), B&H (1998., 2000., 2002., 2004) (41,42). Analyzing the available epizootiological and epidemiological data on the incidence of Q fever in the region, it could be concluded that beside classical locally focused character of the disease, incidence of new epidemics was also influenced by uncontrolled dislocation of animals, mostly sheep and goats (41- 44). Although some experts deny the significance of Q fever from the viewpoint of veterinary medicine, the latent forms of this disease in domestic animals and abortions in sheep and goats result in huge economic losses, thus confirming the importance of Q fever as a problem of the veterinary practice (39. 41). Moreover, having also in mind the fact that veterinarians together with other professionals are 99 Medicinski Glasnik, Volumen 7, Number 2, August 2010 very exposed to this infection, it is obvious that Q fever must not remain marginalized in the veterinary science. The frequent incidence of this disease in humans should be followed by systematic investigations of the infections in animals and natural reservoirs (42, 43). Hantavirus infections The Balkan Peninsula has been known as a highly endemic region for hantavirus infections. So far our research has shown that at least two different Hantaviruses (HTV) (the murine Dobrava (DOBV) and the avricoline Puumala (PUUV) viruses), each carried by a different rodent species, have been circulating in the area (44,45). So far two viruses, Puumala and Dobrava have been identified as causative agents of hemorrhagic fever with renal syndrome in Albania, B&H, Greece, Croatia, Kosovo, Montenegro, Slovenia and Serbia (45-50). Additionally, Tula virus, which is considered a non-pathogenic hantavirus was detected in small mammals (51). However, Clethrionomys glareolus, Apodemus agrarius and Apodemus flavicollis are the main reservoirs of hantaviruses in the region (46). The incidence of haemorrhagic fever with renal syndrome (HFRS) varies in a cyclic fashion, with peaks occurring every three to four years, coinciding with peaks in rodents population (45). Several HFRS outbreaks were registered in the area of the Balkan Peninsula in: 1967, 1986, 1987, 1989, 1995 (45, 51), and 2002 with more than 1000 HFRS cases. Dual infections with hantaviruses and leptospira were also detected in humans as well as in rodents (52). In the Balkan states where PUU and DOB viruses co-circulate, seroprevalence in general population is between 1.6% (Slovenia) up to 5.18% in B&H, which has been recognized as a highly endemic region for hantavirus infections for over 56 years (45,51,53). As early as in 1952 the first ‘’probable’’ HFRS case was described in the region - the victim was a soldier and infection occurred near Fojnica city, B&H. The first documented HFRS outbreak was reported in 1967, followed by five outbreaks in the region and the majority of the affected population was located in B&H. The total number of HFRS reported cases was 1242, but the real number of HFRS cases is probably higher because the surveillance of infectious disease had not been regular until 1992 (53). 100 Rabies Rabies remains endemic within a number of countries in Southeast Europe including Romania, Bulgaria, B&H and Turkey (7, 44, 55, 56). With the exception of Turkey, the red fox (Vulpes vulpes) is the principal disease reservoir in Southeast Europe. However, cases of rabies in dog (Canis familiaris) are regularly reported. In contrast to Northern Europe, the raccoon dog (Nyctereutes procyonoides) does not appear to be a vector in the south. In Bulgaria, dogs are the main vectors bringing rabies into contact with humans and livestock. Foxes are the principal reservoir species for rabies in Romania although cases in dogs are regularly reported. Despite a gradual decline in dog rabies, urban pockets of the disease remain in many regions of Turkey. Furthermore, there is some evidence that the foxes have been a significant vector for rabies and might be responsible for increased rabies in cattle. Rabies in Croatia has been registered in wild animals (mostly foxes) and sporadically in domestic animals (dogs, cats). The last human case was described in 1964. The fox and dogs are the principal reservoir species for rabies in B&H. Throughout the region there is evidence of cross-border movement of rabies by both wildlife and canine vectors (55,56). The lyssaviruses currently consist of 7 established genotypes or lineaages of rabies(-like) viruses (56) of which classical rabies virus is found throughout the world and associated with terrestrial mammalian hosts and American bats forms genotype 1. Phylogenetic relationships among sequences of five viruses isolated in B&H have shown the presence of two phylogenetic lines, one which is present in the Northwestern part and the other, which is present in the Northeastern part of the country. Viruses are closely related to Western European isolates of rabies virus (56). Tick-borne encephalitis Tick-borne encephalitis virus is the causative agent of the most prevalent arboviral human infections in Europe. Three subtypes have been identified: European (TBEV-Eu), Far Eastern (TBV-FE) and Siberian (TBEV-Sib). The vector of TBEV-Eu transmission is the tick Ixodes ricinus, whereas I. persulcatus is the vector of other two subtypes. The virus is maintained in nature through cycles involving tick and wild vertebra- Hukić et al Wildlife zoonoses in the Balkans Region te hosts and also by transovarial and transstadial transmission in its vector. Many different vertebrates have been implicated in the maintenances and circulation of the TBE virus. The major causative role in Central Europe seems to belong to Apodemus flavicollis and Myodes glareolus, not only because they are abundant in the regions where TBE incidence is high and they are excellent hosts for both nymphal and larval stages of the tick, but also because they promote transmission by co-feeding (44,57,58). The distribution of TBEV is well coordinated with its vector distribution. There is a lack of data related to TBEV seroprevalence among the wild animals in the Balkan region. Data from Slovenia have shown that the infection prevalence in rodents sampled in Slovenia in the period between 1990 and 2008 entirely varied based on the rodent species, from 14% in Myodes glareolus to 2-4% in Apodemus species (57-59). Tick-borne encephalitis (TBE) in Slovenia represents a serious public health problem with hundred official reported cases (58). In Croatia TBE was first discovered in 1953. The only really documented natural focus of tick-borne encephalitis was the northern part of the country, between the Sava and Drava rivers. Alleged cases from other parts of Croatia still have to be confirmed and analyzed, and additional research and collaboration between different professionals is required (44, 57, 59). Official data show no occurrence of TBE in Albania, Bosnia and Herzegovina, Bulgaria, the Former Yugoslav Republic of Macedonia and Turkey (57). Sandfly fever Sandfly fever viruses (SFV) are moderately endemic along the Adriatic coast of Albania, Croatia, B&H, Slovenia and landlocked Serbia, and focally distributed throughout Greece and the former Yugoslav Republic Macedonia (44, 60-65). Historical data of the sandfly fever (Pappataci fever) indicate its origin in B&H at the end of the 19th century (62, 63). Before the World War II, the pappataci fever in the former Yugoslavia was mainly detected in Herzegovina, Dalmatia, Montenegro and especially in Macedonia, where its prevalence coincided with that of Phlebotomus papatasi (64, 66). Most of the clinical and epidemiologic studies had been conducted in B&H between 1886 and 1962 (66-68), but there was no published data about the SFV infection between 1971 and 2006. The recent infection was found in 9.38% to 12.50% of patients during the period of three years (2006-2008) (68). The first extensive serological investigations of the prevalence of the arbovirus infection were reported in 1975-1982 (64, 68-70). The results indicated a high prevalence of the antibodies to Naples and Sicilian sandfly fever viruses in Dalmatian population, North Croatia and Kosovo. On the island of Brač, 57.6% of the population had antibodies for the Naples virus and 15.6% for the Sicilian virus, in Kosovo- 27.9% and 9.6%, respectively. The prevalence of the Naples virus infection reached 62.1% in the inhabitants of B&H in 1962 (69). These results indicated the continuous circulation of Naples virus in nature. Finding the TOSV positive results in clinical samples after more than forty years (66), means that the virus has been circulating in this region, but has not been the point of interest of local researchers. It is very important to direct the attention of clinicians to sandfly fever (papatasi fever) because the disease was unrecognized in the region until recently. Leishmainiasis Leishmainiasis is widespread on the Balkan Peninsula. It is a protozoan parasitic infection caused by Leishmania infantum that is transmitted to human beings through the bite of an infected female sadfly (71). The disease occurs in urban centers and rural highland villages in Albania, B&H, Croatia, Greece, Montenegro, Serbia, Romania and Slovenia (71-76). Zoonotic visceral leishmaniasis (VL) is a re-emerging disease in the Balkan area (1, 3-5, 73, 74). The re-emerging is probably due to a combination of factors including increased monitoring, intensified research, demographic change, land-use/land cover changes that create new habitants and/or changes in microclimate, and changes in seasonal climate (2). Some human cases are usually detected in the area every year (74-76). Visceral leishmaniasis in 50 children was reported from Albania in 2009 (72). Leishmaniasis is mostly a problem in veterinary medicine. The investigation of 272 dogs sera originating from different regions in Albania 101 Medicinski Glasnik, Volumen 7, Number 2, August 2010 and Kosovo have shown specific antibodies for Leishmania in 3.3% of animals. All leishmaniapositive animals were stray dogs (74, 75). Those animals contribute to the maintenance of Leishmania transmission in endemic areas, and a control of the canine stray population should be considered (74-78). A historical review on human and canine leishmaniasis in Croatia documents the presence of stable disease foci in coastal and insular territories of central and southern Dalmatia since the beginning of the 20th century (71,74). Among the species which may act as Leishmania infantum vectors in Croatia, Phlebotomus tobbi and P. neglectus were the most abundant (74). Echinococcosis Echinococcosis remains a very serious public health problem in Southeast Europe, although a decrease in incidence has been observed in some endemic areas during the last decades (77-80). However, in some non-endemic areas an increase in infected cases and new foci of animal echinococcosis were registered during the same time (77). The disease is very common in the Balkan Peninsula, with the former republics of Yugoslavia having one of the highest prevalence rates (77-80). Echinococcosis is zoonosis transmitted by dogs in livestock-raising areas and accidentally affects men. The most frequent site of hydatid cysts is in the liver (78%), followed by lungs (17%), and less frequently, spleen, kidneys, heart, bones, central nervous system, and elsewhere (80). Trichinelosis In the majority of Southeast European countries cases of trichinellosis among the human and animal populations were described in the late 19th or early 20th century (80-81). Trichinella infections among wildlife were also described in the aforementioned countries (5, 80). Today, the prevalence of trichinellosis between the Balkans and bordering countries is different (81-83). A high prevalence of trichinellosis in domestic animals and humans has been reported in Bulgaria, Serbia and Montenegro, Romania and Croatia (80-84), and a moderate prevalence was found in B&H. Trichinellosis has not been found among domestic animals and humans in Greece and Macedonia in recent years, while in Turkey and Slovenia 102 human trichinellosis is sporadic (83). A re-emergence of trichinellosis is connected with the changes in the social and political systems in Bulgaria and Romania (81, 84). In B&H, Kosovo, Serbia as well in Croatia, however, the re-emergence of trichinellosis did not only happen due to political and social changes, but also due to the war that took place in these countries during the last years of the 20th century (84). There are some other zoonoses and vector-borne diseases with more or less documented evidence on epidemiological, clinical or etiological features (1, 8, 44, 85, 86). The special attention deserves tuberculosis and rickettiosis, because the outbreaks affected the history of the Balkan Peninsula. THE SURVEILLANCE OF WILDLIFE ZOONOSIS DISEASES The last outbreaks of avian A (H5N1) and swine influenza A (H1N1) showed the importance of greater collaboration between physicians and veterinarians as well as for the disease surveillance in humans, domestic animals and wild animals (5). The surveillance of diseases in wild animals is a relatively new activity compared to the surveillance of diseases in humans or domestic animals (5, 7). At the moment, there is no Balkanwide network of health surveillance. Since 1992, the disease surveillance in most Balkan countries is irregular and coordinated by the WHO. A number of new zoonotic infections emerged or re-emerged during the past 17 years, caused by social, political, climate and environmental changes in the area. The communication channels among Balkan countries were broken, so preventive action has not been done. There is an urgent need for building of a European health surveillance network. It should include the following elements: national surveillance programs that cover the whole country; human diseases, domestic animal diseases, all wildlife species, and all diseases; comparable methodology among surveillance programs, so that it is valid to compare results; strong interaction among surveillance programs, so that new information and knowledge is rapidly and efficiently shared. Recent initiative called One Health, which supports the unique approach to zoonoses, is a concept of the worldwide strategy for expanding Hukić et al Wildlife zoonoses in the Balkans Region interdisciplinary collaborations and communications in all aspects of health care for humans and animals (86). ACKNOWLEDGEMENTS/DISCLOSURES Competing interests: none declared. REFERENCES 1. Jones KE, Patel NG, Levy MA, Storeygard A, Balk D, Gittleman JL, Daszak P. Global trends in emerging infectious diseases. Nature 2008; 451:990-3. 2. Semenza JC, Menne B. Climate change and infectious diseases in Europe. 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Mission Statement. http:// www.onehealthinitiative.com/ (14 December 2009) 105 REVIEW Beginnings and success in preventing anophelism by means of gambusia fish on the island of Krk in Croatia from 1922 to 1927 Ante Škrobonja1, Neven Materljan2, Ivana Škrobonja3 Departement for the History of Medicine, Rijeka University School of Medicine, 2Associate Department for the History of Medicine, Rijeka University School of Medicine, 3Clinic Hospital Centre Rijeka, Department for Clinical Microbiology; Rijeka, Croatia 1 ABSTRACT Corresponding author: Ante Škrobonja, Rijeka University School of Medicine, Braće Branchetta 20, 51000 Rijeka, Croatia Phone: ++385 51 651 165; Fax: +385 51 651 180; The introductory part has summarized the role of malaria in the course of history and various attempts of its eradication in Croatia before the World War I. Furthemore, there is a list of activities and results accomplished between 1922 and 1927 on the island of Krk by Dr. Otmar Trausmiller. After a systematic sanitation of all anopheles habitats, primarily natural and artificial bodies of still water, and introduction of imported gambusia to those bodies of water, anopheles was virtually eradicated on the island. What followed was an evident decrease of new malaria incidents, and in the campaign against malaria there was still major concern in the form of chronic patients and intensive quinine therapy. Today, about eighty years after it was introduced to Krk, gambusia still abides in ponds across the island and it represents one of the main factors in the protection against potential revival of indigenous malaria. Key words: history of medicine, malaria, gambusia fish, eradication, Otmar Trausmiller, the island of Krk, Croatia E-mail: anteskrobonja@yahoo.com Original submission: 31 July 2009; Revised submission: 16 September 2009; Accepted: 30 October 2009 Med Glas Ljek komore Zenicko-doboj kantona 2010; 7(2):106-110 106 Škrobonja et al Preventing anophelism on the island of Krk MALARIA IN CROATIA BEFORE WORLD WAR I Although malaria has been present in Croatia for as long as anyone can remember, particularly in the vicinity of larger rivers and especially in the Croatian Littoral, Istria and Dalmatia, the first written documents on malaria in Croatia date from the 16th century and concern Istria . Before the end of the 16th century, malaria was spread across almost the entire territory of Croatia. The first studies of the disease, as described in “De morbo Naroniano tractatus” (On the “Neretva disease”), written by the Paduan professor Giusepe Antonio Pujati, were performed as early as the 18th century (1). In the western part of Croatia, especially in the Kvarner region, as the public health problem of malaria was present mainly on the islands of Krk, Rab and Pag (2), where an outbreak of epidemic known as Škrljevo disease (at the turn of the 8th and early 19th century), and after its settling (3) remain the leading health problem. However, the mainland, with a few exceptions, was not affected by malaria. On these islands the main malaria mosquito habitats were mostly artificial ponds for cattle watering and lakes in the vicinity of Omišalj on the island of Krk and Velo Blato on Pag. The prevailing type of mosquito was again Anopheles maculipennis, which, apart from the zoophylous type, was also represented by the antropophylous type Labranchiae. Earlier authors claim that this type of malaria was usually a benign tertiary infection (4). Malaria, which was present endemically near rivers, swamps (particularly near swamps along karst rivers) and ponds, was sometimes a decisive factor in some of the historical events in Istria from the ancient times until the 20th century. The best example is the city of Dvigrad (Ital., Due Castelli) that had coped with several epidemics of the plague or similar diseases from the antiquity, but life ceased there in the 18th century, after the adjacent river had changed its course and gave way to fatal swamps (5). On the other hand, many swampy areas were brought to life by the effective land-reclamation and eradication of mosquitoes, as was achieved on the Brijuni Islands thanks to Robert Koch (6). Although the problem of malaria was more systematically dealt with by the authorities in Dalmatia as early as during providur Dandol’s rule (who was a pharmacist by profession) and Napoleon’s Illyrian provinces (1808 – 1813) (7), and the first results were achieved, more detailed data on the spread and the character of malaria in Dalmatia date only from 1905, when it was estimated that approximately 80,000 persons infected with malaria lived in the area, and that the prevalence of malaria in certain districts varied between 29% in Knin and 63% in Zadar. After the invitation of the Royal Regency, the Italian malariologist Giovanni Battista Grassi and the German epidemiologist Fritz Richard Schaudin soon came to Dalmatia and prepared and applied “quinisation”. In 1902., Rudolf Battara eradicated malaria in Nin, Croatian Royal Town. In 1908, under dr. Jakov Gljivanović, 25 doctors and 423 pill distributors were included in the quinisation. They went around villages on a regular basis, distributed pills and monitored their use. Comprehensive assanations of the terrain were also conducted. This soon yielded positive results (8). Following World War I malaria spread again. Tropical malaria was more widely spread and the number of malaria patients was estimated to reach 150,000. The specific index was also significantly higher and in some areas reached 70 to 90% (9). DR. OTMAR TRAUSMILER AND GAMBUSIA FISH IN FIGHTING MALARIA ON THE ISLAND OF KRK A new organised anti-malaria campaign in the Croatian littoral area began after World War I and was lead from two centres: the Institute for the Research and Fighting of Malaria in Trogir and the Public Health Institute in Sušak (10,11). Extensive malariometric surveys and anophelism surveys were conducted. Moreover, many new malaria centres were set up. Systematic assanation in Dalmatia was focused on the melioration of swampy areas and on making wells out of ponds. Anophelism was also successfully combated by applying paraffin and Paris Green. In the Croatian Littoral, particularly on the island of Krk, apart from what was just said about 1924, ponds were stocked with gambusia fish (Gambusia holbrochi Grd.) (12). Gambusia fish live in warm still waters of the central part of the New World. There are two types of these larvivorous small fish, Gambusia affinis i Gambusia holbrochi. 107 Medicinski Glasnik, Volumen 7, Number 2, August 2010 Gambusia are viviparous, which is a great evolutionaty advantage. A large number of gambusia survive their youth and reach sexual maturity. The females in the aquarium reach sexual maturity at four months of age, and have a brood of 200 young at a time. They multiply during the warm season in temperate climate and have one brood of young every three to six months. In tropical climate, gambusia fish multiply throughout the year. They are not too choosy about their food; however, after it had been noticed that they had a strong affinity for Anopheles larvae that feed on the water surface, there was an attempt of transmitting them to other parts of the world as a means of eradicating Anopheles. This biological method of fighting Anopheles was very successful and appropriate since the living and breeding conditions for this fish were very favourable and the ecological risks minimal (13). On the largest Croatian island of Krk (406 km2), known for its endemic malaria from the times of antiquity, the main sources of the disease were many artificial ponds for cattle watering that were virtually infested with Anopheles larvae (4). In 1923 an extensive and the Sušak Public Health Institute co-ordinated anti-malaria action on the Island of Krk was to be carried by Dr. Otmar Trausmiler. As for the basic hydrotechnical works, Dr. Trausmiler could rely solely on the local labourers, hand tools, and scanty resources. Under such circumstance, Dr. Trausmiler decided to apply a new method of ‘’bio-weaponry’’ by introducing a new, alochtonic species to the island – the tropical Gambusia fish. He would widely report on this idea, its realization as well as the results in his 1927 monography entitled ‘’Malaria on the Island of Krk’’ (Figure 1-3). This work was accompanied by exquisite photographs and drawings, while the results were displayed in tables and graphs and supported by the recent references from the international publications (12). After he had made a detailed and soundly grounded presentation of the historical and actual circumstance related to malaria on the island, the author elaborated on the project of assanation of all the Anopheles habitats, mainly the natural and artificial still waters and their stocking with the imported Gambusia fish. Dr. Trausmiler’s presentation of the results opens with the statement that despite the minimum fi- 108 nancial support and scanty technical equipment the initial hydrotechnical works had been finished and the conditions set for experimental stocking so that by the end of August 1924 400 Gambusia holbrochi Grd. fish from Italy were imported. The fish were dropped into several ponds as soon as they had been brought. Due to the stress they had undergone in transport almost half of the Gambusia fish instantly died. Luckily enough, the remaining Gambusia accommodated fast and well and a large number of them survived the winter 1924/1925 in a new habitat. In May 1925 the first young Gambusia fish were noticed in the fish-stocked ponds and then they were systematically transmitted into other ponds. By the fall 1925 there were 25 newly stocked ponds on the Island of Krk, and fish-stocking was continued with the same intensity. There were at least 1000 to 2000 Gambusia in every fish-stocked pond. The winter 1925/1926 was exceedingly cold so that every pond on the island was covered with Figure 1. Črna Lokva (Black pond) the first breeding pond for Gambusia fish on the island of Krk (Photo by Dr. O. Trausmiler, 1927) (accepted from: Trausmiler O. Malarija na otoku Krku epidemiologija i pobijanje 1923.-1926. Sušak: Dom narodnog zdravlja, 1927., p. 76) Figure 2. Pond with a wall constructed of stone (Photo by Dr. O. Trausmiler, 1927). (accepted from: Trausmiler O. Malarija na otoku Krku epidemiologija i pobijanje 1923.-1926. Sušak: Dom narodnog zdravlja, 1927., p. 77) Škrobonja et al Preventing anophelism on the island of Krk ice. The Gambusia fish survived and in the spring 1926 they again started to multiply fast so that Dr. Trausmiler’s field-workers proceeded with even more intense fish-stocking of the remaining ponds on the island. Dr Trausmiler pinpoints the first positive effects: the Anopheles larvae vanished from the ponds whose edges were walled, cleaned of water plants, and stocked with Gambusia fish. The fish that were dropped into ponds in springtime would multiply until summer and eat all the Anopheles and Culex larvae. A considerable decrease in the incidence of the new cases of malaria was soon registered. The chronic malaria patients anf the intensive quinine therapy thus became a priority of the anti-malaria campaign. DISCUSSION Thanks to the introduction of Gambusia fish to the Island of Krk, the two traditional methods of the Anopheles larvae eradication have been abandoned – relatively expensive paraffin, and Paris Green, effective in certain conditions alone. Spilt onto the pool surface, paraffin would mechani- Figure 3. Coverpage of Trausmiler’s book “Malaria on the Island of Krk: Epidemiology and melioration, 1923.-1926.” from 1927. (accepted from: Trausmiler O. Malarija na otoku Krku -epidemiologija i pobijanje 1923.-1926. Sušak: Dom narodnog zdravlja, 1927.) cally smother the Anopheles larvae, and would evaporate in a couple of days, which would make ponds usable for cattle watering again. The less expensive Paris Green was a powder insecticide blend of arsenic and copper. Prior to application, Paris Green was to be mixed with gravel dust. Since the latter was scarce on the Island of Krk, it was replaced by sifted ash. In order to apply Paris Green, there should have been no wind to ripple the water surface; as it was often windy on the island of Krk, Paris Green could be rarely applied. In contrast to these methods, Gambusia fish served as an effective non-toxic and inexpensive biological means against Anopheles larvae. It was enough to catch Gambusia fish with an improvised fishing net, transport them in a bucket or any other vessel and drop them into an Anopheles larvae infected pond; moreover, Gambusia fish made a permanent larvicidial means that did not endanger natural balance. The ponds were mainly artificial cattle watering places without traditional aquatic life; therefore, the use of Gambusia fish as a larvicidal means in this case meant no threat to the local aquatic life.This is even more important because the imprudent introduction of Gambusia fish and its residence in larger water bodies have brought about dramatic changes of eco-systems, especially those of running waters in various parts of the world. It has brought on the decrease in number and a permanent threat to the survival of local invertebrates, fishes, and amphibians. It has been established lately that the dropping of Gambusia fish into some natural ponds and small lakes in California has brought on a considerable decrease in number of the endemic fairy shrimp (Linderiella occidentalis) (13), while in New Zealand Gambusia fish represents a threat to the endemic fish of dwarf inganga (Galaxias gracilis) (14). Although Gambusia fish were not used in the continental but solely Mediterrannean part of Croatia, they vastly contributed to the eradication of malaria in Croatia. The most successful of the methods used after World War II was the action started in 1950 using the concept of prof. Branko Richter from the School of Public Health “Andrija Štampar” in Zagreb, based on the application of the new chemical DDT, followed by other new insecticides in all endemic areas. This, along 109 Medicinski Glasnik, Volumen 7, Number 2, August 2010 with the systematic assanation of the terrain and the improved social and economic conditions of the people, finally resulted in uprooting malaria in Croatia. The last indigenous cases of malaria infections were registered in 1958 and WHO in 1964 officially declared that malaria in Croatia was eradicated. Despite the setbacks, up until 1969, when the global eradication policy was finally abandoned, the following European countries had managed to completely eradicate endemic malaria by interrupting transmission: Hungary, Bulgaria, Romania, Spain, Poland, Italy, Netherlands, Portugal and former Yugoslavia (15,16). In conclusion, today, eighty years after the introduction of Gambusia fish to the Island of Krk, they still live in the ponds across the island. They probably make their 200th generation. Gambusia fish still tirelessly devour mosquito larvae and thus reduce the number of Anopheles and Culex on the island. Entirely acclimatized and domesticated, these tropical fish represent a contingent and precious larvicidal means in the hands of experts. ACKNOWLEDGEMENTS/DISCLOSURES Competing interests: none declared. REFERENCES 1. 2. 3. 4. 5. 6. 7. 8. 9. 110 Gregurić Gračner G, Vučevac Bajt V. History of Eradication of malaria in Croatia. Orvostort Kozl 2002;47:145-55. Azman J, Muzur A, Frković V, Pavletic H, Prunk A, Skrobonja A. Public health problems in the medieval statutes of Vinodol, Vrbnik and Senj (West Croatia). J Public Health (Oxf) 2006; 28:166-7. Muzur A, Škrobonja A. Škrljevo disease: Between myth an reality. Croat Med J 2004; 45:428-31. Cubich GB. Notizie naturali e storiche sull’isola di Veglia. Trieste: Stabilimento tipografico Appolonio & Caprin, 1874-75. Čehić M, Karabajić M. Dvigrad – simbol medicinske nemoći. U: Rašajski R. urednik. Zbornik 2. naučnog kongresa. Vršac: Naučno društvo za historiju zdravstvene kulture Jugoslavije, 1970., pp. 181-5. Fatović-Ferenčić S. Brijuni Archipelago: story of Kupelwieser, Koch and the Cultivation of 14 islands. Croat Med J 2006; 47:369-71. Fisković C. Zdravstvene prilike u Splitu krajem XVIII. i prvih godina XIX. stoljeća. U: Grmek M.D., Dujmušić S, urednici. Iz hrvatske medicinske prošlosti. Zagreb: Zbor liječnika Hrvatske, 1954, pp. 238-54. Nežić E. Historija endemske malarije u Dalmaciji do 1923. godine. U: Zbornik. Prvi simpozij o historiji mikrobiologije i imunologije u Hrvatskoj do 1926. godine. Zagreb: JAZU, 1973., pp. 71-80. Simić C. Malarija. Beograd-Zagreb: Medicinska knjiga, 1948., pp. 237-42. 10. Emili H. Razvoj preventivne zdravstvene službe na sjevernojadranskoj obali od otvaranja Doma narodnog zdravlja u Sušaku do početka II svjetskog rata – 1926. do 1941. Liječ Vjesn 1988; 110:118-24. 11. Bakašun V, Alebić-Juretić A. Sto godina preventivne medicine na Riječkom području. Liječ Vjesn 2002; 124:380-9. 12. Trausmiler O. Malarija na otoku Krku epidemiologija i pobijanje 1923.-1926. Sušak: Dom narodnog zdravlja, 1927. 13. Duryea R, Donnelly J, Guthrie D, Claudia O’malley C, Romanowski M, Schmidt R. Gambusia Affinis effectiveness in New Jersey Mosquito Control. Proceedings of the Eighty-Third Annual Meeting of the New Jersey Mosquito Control Association, Inc. 1996, pp 95-102. [Online] http://www.rci.rutgers. edu/~insects/gamb2.htm (23 September 2009). 14. Rowe D. Manegement trials to restore dwarf inganga show mosquitofish a threat to native fish. Water and Atmosphere 1998; 6:10-12 15. Richter B. Osvrt na dosadašnji rad antimalarične službe i njezine zadatke u 1950. godini. Higijena 1950; 4:299-311. 16. Richter B. Doprinos Jugoslavije u konceptu eradikacije malarije U: Angelovski A, urednik. Eradikacija na malarijata vo Jugoslavija. Skopje: Makedonsko lekarsko društvo, 1973., pp. 43-9. ORIGINAL ARTICLE Emanuel Edward Klein, a diligent and industrious plodder or the father of British microbiology Bruno Atalić1,2, Ines Drenjančević-Perić1, Stella Fatovic-Ferenčić2 Department for the Physiology and Immunology, 2Department for the Family Medicine, History of Medicine and Medical Ethics; School of Medicine, Josip Juraj Strossmayer University, Osijek, Croatia 1 ABSTRACT Corresponding author: Bruno Atalić Department for the Physiology and Immunology and Department for the Family Medicine, History of Medicine and Medical Ethics School of Medicine, Josip Juraj Strossmayer University Josip Huttler 4, 31000 Osijek, Croatia Emanuel Edward Klein (Osijek, 1844 - Hove, 1925) was a British microbiologist of Croatian origin. He completed his medical studies in Vienna in 1869. In 1869 he was sent to England to determine terms for the translation of Samuel Stricker’s manual Handbuch von den Geweben des Menchen und der Tiere. During his visit he made a good impression on John Burdon Sanderson and John Simon, which was the main reason why he was invited to London in 1871 to conduct investigations under their guidance. In 1873 Klein began his collaboration with the Saint Bartholomew‘s Hospital, where he was appointed as a Joint Professor of General Anatomy and Physiology. His researches were in the fields of anatomy, histology, pathology, embryology, physiology, and especially microbiology. He did a great deal to its development in Britain. He has written about 260 scientific papers on a broad range of different topics. Despite all the aforementioned facts, his work was never properly studied, and he is almost unknown outside academic circles. For that reason, attitudes towards him still range between the extremes of calling him the father of British microbiology on one side, and attributing him as a diligent and industrious plodder on the other. In this paper we will try to prove the first attitude. We will put his researches in a general context. Finally we will highlight his original achievements in the isolation of new microbes. Key words: Klein, Emanuel Edward; United Kingdom; Microbiology; 19th Century; 20th Century Phone: ++385 31 512 500; Fax: ++385 31 512 566; E-mail: batalic@mefos.hr Original submission: 29 May 2009.; Revised submission: 03 August 2009.; Accepted: 11 August 2009. Med Glas Ljek komore Zenicko-doboj kantona 2010; 7(2):111-115 111 Medicinski Glasnik, Volumen 7, Number 2, August 2010 INTRODUCTION The germ theory gave public health functions a plausible new rationale mainly in setting up bacteriological laboratories for infective diseases starting from the half of the 19th century on. Important research centres for investigations into typhoid fever, typhus, scarlet fever, small pox, cholera, and tuberculosis, laboratories sprang up and their researches were not just fuelled by the professional curiosity, but also by the political competition. This was particularly true for France and Germany, which, according to Latour, after the defeat of the French Empire and the proclamation of the German Empire in 1871, switched from military campaigns to scientific pursuits (1). The major proponents of medical microbiology in Britain were the Scottish surgeon Joseph Lister (1827-1912), who introduced antisepsis with the carbolic acid spray in Glasgow in 1871, and Emanuel Edward Klein, who was the first general bacteriologist (2). Lister has made a major contribution to medical practice with his invention of antisepsis, because of which he is widely known, but Klein has made only minor contributions to medical science, which is the reason why he is generally unknown. His work was never studied in depth, although he was occasionally mentioned as an example of medical contacts between the two nations (3). In this paper we shall concentrate only on Klein’s microbiological researches as the main field of his professional career focusing primarily on his isolation of ‘’Streptococcus pneumoniae’’, ‘’Streptococcus scarlatinae’’, ‘’Bacillus enteritidis sporogenes’’, ‘’Bacillus cadaveris’’, and ‘’Bacillus carnis’’ today known as Streptococcus pneumoniae, Streptococcus pyogenes, Salmonella enteritidis, Clostridium cadaveris, and Clostridium carnis, as his original contributions in the isolation of new microbes. Our research is based on primary and secondary sources mostly kept in the Oxford Bodleian Library - Radcliffe Science Library, the Cambridge University Library - Rare Books Department, and Saint Bartholomew’s Hospital Archive in London, United Kingdom. LIFE AND LEGACY Emanuel Edward Klein was born on 31 October 1844 in Osijek, in the Virovitica County, in the Kingdom of Slavonia, which was then part of the 112 Austrian-Hungarian Empire, to a German speaking, non-observant Jewish family. He finished the grammar school in his hometown and graduated in 1863. With the help of a scholarship he studied medicine in Vienna, and obtained the M.D. in 1869, but actually never practiced medicine. At first he worked with physiologist Ernst von Brücke, and later with pathologist Salomon Stricker (1834-1898). Klein soon achieved the title of Privat Dozent (4). In 1869 Klein was sent to England to determine terms for the translation of Samuel Stricker’s manual Handbuch von den Geweben des Menchen und der Tiere (Leipzig 1869-1872, London 18701873) (5). During his visit he was introduced to John Burdon Sanderson, superintendent at the Brown Sanitary Institution, John Simon, medical officer to the Local Government Board, and Thomas Henry Huxley, founder of the Natural History Museum in London, on whom he made an excellent impression. This was the main reason why in 1871 he was invited by Sanderson to work at his private laboratory in Howland Street. In 1873 he was appointed as an Assistant Professor of Comparative Pathology at the Brown Sanitary Institution in order to conduct pathological, clinical and epidemiological researches, under the supervision of Simon. Klein was in charge of the bacteriological research laboratory (5). His research was at first conducted in a histological manner, by looking for the infecting agent with a microscope, and then after a couple of years he adopted the cultivation approach. He zealously implemented the Continental improvements into his work. In this respect he did a great deal to develop English bacteriology. In recognition of his investigations he was elected a Fellow of the Royal Society of London on 3 June 1875 after his nomination from the general knowledge by John Tyndall, and from the personal one by Charles Darwin (6) (Figure 1). Later on he was recommended by the President and Council of the Royal Society of London for election into the Council for the year 1889 (7). In 1873 Klein began his collaboration with the Saint Bartholomew‘s Hospital, the oldest hospital in London, founded in 1123 by the monk Rahere, which was to last until his retirement in 1911. During his 38 working years at the Saint Bartholomew‘s Hospital, Klein was Joint Lecturer in General Anatomy and Physiology (1873- Atalić et al Edward Emanuel Klein RESEARCH IN MICROBIOLOGY Emanuel Edward Klein was employed as an Assistant Professor of Comparative Pathology at the Brown Sanitary Institution between 1873 and 1897. He conducted scientific researches on the commission from the Local Government Board, and they can be analyzed primarily from his numerous annual papers sent for publication in the Reports of the Local Government Board. In 1884 Klein identified a new micrococcus from the lymph of ill sheep, and claimed it to be the cause of foot-and-mouth disease. Due to its shape, Klein first named it Diplococcus, then Micrococcus, and finally Streptococcus (12), but in 1901 it was renamed Streptococcus pneumoniae by the American pathologist William Chester, who proved that it was not the cause of foot-and-mouth disease, but of pneumonia (13). Figure 1. “Certificate of a Candidate for Election into the Royal Society of London” (Public Domain of the Wellcome Institute Library in London; http://images.wellcome.ac.uk) 1902), Lecturer in Histology (1873-82), Lecturer in Microscopic Anatomy (1874-92), Lecturer in General Anatomy and Physiology (1882-1903), Lecturer in Bacteriology (1903-12), Lecturer in Advanced Bacteriology (1910-11), and he retired with the title of Emeritus Professor (8). His teaching was always in the forefront of the newest scientific discoveries. In 1889 he was elected as a Professor of Bacteriology in the College of State Medicine (Jenner Institution), founded by the retired surgeons-general of the Navy, Army and Indian Services, where he held lectures and tutorials until 1891 (9). In 1890 he opened a private school in Great Russell Street and gave practical and technical bacteriological classes to pupils like Sir Ronald Ross (1857-1932) (10). In 1891 he was invited by the Medical School authorities of the Saint Bartholomew‘s Hospital to conduct full-time researches for them and was allotted a laboratory composed of three rooms at the top of the school building. His laboratory was always open to students, who were encouraged in bacteriological researches (11). At the end of 1885 and the beginning of 1886 an extensive outbreak of an unknown disease occurred among the cows at a farm in Hendon (14). It was described as scarlet fever and called the Hendon Disease by Klein and as cowpox by Crookshank. Although in the end Crookshank was victorious and became an unofficial leader of the so called British bacteriological school, Klein also made a significant discovery (15). He managed to isolate four different species of micrococci: ‘Micrococcus citreus’, ‘Micrococcus aurantiacus’, ‘Staphylococcus pyogenes’, and ‘Micrococcus scarlatinae’, from the tissues obtained from the Hendon cows and from scarlet fever patients. Together with the local MOH, William Power, Klein proved that ‘Micrococcus scarlatinae’ came into milk not indirectly from the milkers’ hands, but directly from the cows’ udders, which in the end developed into one of the most important preventive measures against scarlet fever epidemics (16, 17). Although it was later renamed Streptococcus pyogenes, due to the suggestion of the German physician Anton Rosenbach, who described its properties already in 1884, the explanation of the streptococcal origin of scarlet fever was Klein’s contribution (13). Emanuel Edward Klein had been engaged as a lecturer at the Medical School of the SBH since 1873. In 1891 he completely transferred his laboratory work to the newly built laboratory allotted to him, and stayed there until his retirement in 1911. In this period he was free to pursue micro- 113 Medicinski Glasnik, Volumen 7, Number 2, August 2010 biological investigations according to his own interests. Their results were published overwhelmingly in The Lancet, but also in Public Health and Saint Bartholomew’s Hospital Reports. On 2 March 1889 Klein announced the isolation of a microorganism responsible for the summer diarrhoea epidemic at the SBH, which he named ‘Bacillus enteritidis sporogenes’, and which was later renamed Salmonella enteritidis. It was isolated from the stool specimens, and described as an aerobic bacillus, which formed large oval spores. When inoculated into guinea pigs, it caused haemorrhagic oedema, necrosis, and death (18). In 1889 Klein isolated a microorganism from the peritoneum of a rabbit, and named it ‘Bacillus cadaveris’. He proved that it was not pathogenic for guinea-pigs and rabbits. Due to its occurrence in human cadavers, today it is know as Clostridium cadaveris. Again in 1904 Klein isolated another one from soil, and named it ‘Bacillus carnis’. When inoculated into a rabbit it produced oedema, necrosis, and death. Nowadays it is know as Clostridium carnis. The mentioned bacilli are still named after Klein, who was the first one to isolate them (13). DISCUSSION Due to the fact that attitudes of various historiographers towards Klein’s investigations were exceedingly diverse, his legacy needs a profound revaluation. According to Bulloch, for example, Klein was ‘a tremendously diligent plodder with an untiring industry’ who failed to make any discovery of permanent value, due to his individual, dogmatic and polemical character (9). Waddington is also on this track, by stating that Klein was more interested in his own research, than in the shaping of medical education, and characterizing him as undiplomatic, blunt, and unpopular (10). His obituaries compromised by admitting that he himself did not make any significant discovery, because he was self-taught, influenced by the Jennerian tradition of connecting diseases of humans and animals, and conducted experiments not in accordance with his intuition, but on the requests of the Local Government Board, and by giving him credit for the comprehensive education of future microbiologists (6, 9, 19). On the other side, Lambert in his influential book on the development of public health in England 114 called Klein ‘the father of English bacteriology‘, gave him the credit for the significant discoveries, and portrayed him as the most prominent member of the Brown Sanitary Institution (20). Foster was also on this track by placing the emphasis on his discovery of the streptococcal origin of scarlet fever (17). Moreover, Waller described him as the first person in microbiological history to undertake an auto-experiment, by drinking water infected with the Vibrio cholerae in July 1884 (21). Morrant put Klein in the same context as Edgar Crookshank, Henry Gradle, and George Sternberg, by emphasizing the importance of his handbook Micro-organisms and Diseases (22) published in 1884 as the first British microbiological handbook, which made Pasteur’s and Koch’s bacteriological discoveries published in French and German journals available to English and American scientists (23). Rupke tried to put his vivisections into the European context, by showing that the physiologists conducted the same experiments in Britain and on the Continent, despite different public attitudes (24). Finally, Worboys balanced the afore mentioned extremes by showing the influence of Klein’s experimental work on popularization of bacteriology in the public health, surgery and medicine (25). Our analysis has proved that Klein’s microbiological achievements can be recognized on the three levels: microbiology in general, British microbiology, and that of his original contributions to the identification of new microorganisms. Regarding the microbiology in general, Klein certainly can be compared neither with Pasteur, who formulated the germ theory, nor with Koch, who developed microbiological techniques, or Lister, who invented antisepsis with carbolic acid. We should bear in mind that Klein’s importance was not in the original contributions, but in the work of critical evaluation by his experiments and the scientific propagation through his writings of the original contributions of other microbiologists, which is represented by his 264 scientific papers, published in the most prestigious journals. Moreover, with his insistence on the necessary connection between microscopical identification, cultural isolation, and animal inoculation as the three phases in the connection between specific germ and specific disease, he established the standards of microbiological research. While his Atalić et al Edward Emanuel Klein contemporaries were followers of either Pasteur or Koch, Klein was self-confident or stubborn enough to pursue his own way, thus making British microbiology at least autonomous, if not original, in its development. Furthermore, due to the breadth of his researches, rigorous implementation of the Continental improvements, and the continuous education of future microbiologists, he laid the foundations of the mentioned discipline in this country. It is true that Klein claimed the discoveries of new microbes, or opposed the other microbiologists in claiming the same, which were both later refuted, but the work of every serious scientist in a developing discipline is composed of a series of attempts and mistakes, which in the end leads to the right conclusion. In this respect, the identifications of ‘Streptococcus pneumoniae’, ‘Streptococcus scarlatinae’, ‘Bacillus enteritidis sporogenes’, ‘Bacillus cadaveris’, and ‘Bacillus carnis’, although later mainly renamed according to the contemporary approaches, are still regarded as his original contributions to the development of microbiology (13). If we take into account that he conducted his researches at the request of the Local Government Board in order to improve public health policies, and not to seek his own fame, that he was equally ready to acknowledge his own mistakes as to criticize the mistakes of others, and finally, that despite the fact that he himself was self-taught, he unselfishly passed his knowledge to his pupils, it would be more objective to remember him as the father of British microbiology, than as a diligent and industrious plodder, as well as the first general British microbiologist. ACKNOWLEDGEMENTS/DISCLOSURES This paper is a result of the research financed by the National Foundation for Science, Higher Education and Technological Development of the Republic of Croatia, and Ministry of Science, Education and Sports projects No. 219-21601332034 and No. 101-1012555-2553. Competing interests: none declared. REFERENCES 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. Latour B. The Pasteurization of France. Cambridge and London: Harvard University Press, 1988. Belicza B. Klein Emanuel. In: Padovan I. (Ed.). Medicinski leksikon. Zagreb: Leksikografski Zavod Miroslav Krleža, 1992. Loewenthal Z. Anglo-Yugoslav medical relations in peace and war. BMJ 1961; 2-5267:1634-7. Loewenthal Z. Klein Emanuel. In: Grmek MD. (Ed.). Medicinska enciklopedija. Zagreb: Hrvatska medicinska bibliografija, 1970. Bulloch W. The history of bacteriology. Oxford: Oxford University Press, 1938. Andrewes FW. In Memoriam – Edward Emanuel Klein, MD, FRS. Saint Bartholomew‘s Hospital Reports 1925; 58:1-6. Anonymous. The Council of the Royal Society. BMJ 1888; 2:1454. Saint Bartholomew’s Hospital: Handbooks to bacteriology; MS 20; London: Medical College Handbooks. Bulloch W. In Memoriam: Emanuel Klein: 18441925. The Journal of Pathology and Bacteriology 1925; 28:684-97. Waddington K. Medical education at Saint Bartholomew’s Hospital, 1123-1995. Woodbridge: The Boydell Press, 2003. Medvei VC, Thornton JL. The Royal Hospital of Saint Bartholomew, 1123-1973. London: The Royal Hospital of Saint Bartholomew, 1974. Klein, EE. The etiology of foot-and-mouth disease. The Lancet 1886; 127-3253: 15. Euzeby JP. List of bacterial names with standing in nomenclature. http://www.bacterio.net (18 April 2009). 14. Klein EE. Some of the infectious diseases common to men and lower animals. The Lancet 1887; 1303355:124-6. 15. Klein EE. Report of the medical officer for 1885. 15th Annual Report of the Local Government Board 1886; 15:90-110. 16. Russell JB, Chalmers AK, Klein EE. Report on an outbreak of scarlet fever in Glasgow. Glasgow, 1893. 17. Foster WD. A history of medical bacteriology and immunology. London: Cox and Wyman Ltd., 1970. 18. Klein EE. On the causation of the summer diarrhoea. Saint Bartholomew’s Hospital Journal 1889; 6-9:133. 19. DA P. Obituary. Saint Bartholomew’s Hospital Journal 1925; 32: 89-90. 20. Lambert R. Sir John Simone 1816-1904: and English Social Administration. London: MacGibbon and Kee, 1963. 21. Waller, J. The Discovery of the Germ. Duxford: Icon Books, 2002. 22. Klein EE. Micro-organisms and disease: an introduction into the study of specific micro-organisms. London: Macmillan, 1884. 23. Mortimer PP. The Bacteria Craze of 1880s. The Lancet 1999; 353 (1999): 581-84. 24. Rupke NA. Vivisection in Historical Perspective. London: Routledge, 1987. 25. Worboys M. Spreading germs: disease theories and medical practice in Britain, 1865-1900. Cambridge: Cambridge University Press, 2000. 115 Medicinski Glasnik, Volumen 7, Number 2, August 2010 ORIGINAL ARTICLE Efficiency of hypertonic and isotonic seawater solutions in chronic rhinosinusitis Josip Čulig1,2, Marcel Leppée1, Andrijana Včeva3, Davorin Djanic4 Department of Pharmacoepidemiology, Andrija Štampar Institute of Public Health, Zagreb, Croatia, 2Department of Pharmacology, School of Medicine, Josip Juraj Strossmayer University Osijek, Osijek, Croatia, 3Department of Otorhinolaryngology, School of Medicine, Josip Juraj Strossmayer University of Osijek, Osijek, Croatia, 4Department of Otorhinolaryngology and Cervicofacial Surgery, General Hospital Dr. Josip Benčević, Slavonski Brod, Croatia 1,2 ABSTRACT Aim To compare the efficiency of isotonic and hypertonic seawater solutions used for nasal lavage and quality of life of the patients with chronic rhinosinusitis. Methods A random and controlled clinical study was performed. The study included 60 patients with history of chronic rhinosinusitis. At the beginning of the study, each subject was given a Patient Logbook, which needed to be filled out daily during the 15-day study period. There were three visits per each patient during the study. Corresponding author: Josip Čulig Andrija Štampar Institute of Public Health Mirogojska 16, 10000 Zagreb, Croatia Phone.: +385 1 469 6150; fax: +385 1 4678012 E-mail: josip.culig@stampar.hr Results Patient Logbook notes showed significant statistical differences in all symptoms in the group of patients using hypertonic seawater solution. However, while the notes showed significant statistical differences in congestion and rhinorrhea, in the group of patients using isotonic seawater solution, other symptoms showed no major changes during the study period. Conclusion Hypertonic seawater solution has been proven to be better than isotonic seawater solution in eliminating the symptoms of nasal congestion, rhinorrhea, cough, headache and waking up during the night. Key words: seawater solution, chronic rhinosinusitis, hypertonic, isotonic, QoL Original submission: 18 April 2010; Revised submission: 04 May 2010; Accepted: 23 May 2010. Med Glas Ljek komore Zenicko-doboj kantona 2010; 7(1):116-123 116 Čulig et al Seawater solutions in chronic rhinosinusitis introduction Some discrepancies among definitions of chronic rhinosinusitis occur mainly because of the usage of different criteria, such as symptom type, duration, intensity, as well as the need for other exploration methods, such as radiologic imaging or bacterial culture test. In the definition proposed by the International Conference on Sinus Disease, the criteria for chronic rhinosinusitis in adults are symptoms and signs persisting for eight weeks, or four episodes of recurrent acute rhinosinusitis per year, each lasting for at least 10 days, in association with persistent changes on computerized tomography scans, at four weeks of medical treatment, without intervening acute infection (1). The new and more specific Task Force definition is as follows: “Chronic rhinosinusitis is a group of multifactorial diseases characterized by inflammation of the mucosa of the nose and paranasal sinuses, with a history of at least 12 weeks of persistent symptoms and signs, despite maximum medical therapy” (2). Chronic rhinosinusitis has been reported to affect a varying percentage of the population. According to the National Health Interview Survey in the United States, the rate of chronic rhinosinusitis ranges from 14% to 16%. However, current prevalence may often be exaggerated (3). The clinical picture of chronic rhinosinusitis is predominated by nasal obstruction and increased nasal discharge. Irrespective of the etiology of chronic inflammation, topical therapy by lavage and administration of vasoconstrictive agents is the main mode of treatment aimed at the restitution of the nasal physiologic functions (4). Stimulators of alpha-adrenergic receptors are most frequently used for nasal decongestion (2). The decongestion of nasal mucosa is crucial in the management of nasal obstruction of any etiology. When sympathomimetics are used, the possible undesired effects should be taken in consideration. Therefore, the use sympathomimetics should be limited to a few days only (5). Discontinuation of prolonged sympathomimetic therapy may also result in side effects characterized by vasodilation, congestion and rhinorrhea. These events are attributed to the so-called rebound phenomenon (5). The nasal mucosa lavage with isotonic saline is definitely useful. Nasal mucosa produces about half a liter of mucus per 24 hours, which contains 2% mucin and 1%-2% salt, pH 6.5-7.2 (4). The use of hypertonic solution may reduce the need of nasal decongestives, thus avoiding the risk of side effects due to the overstimulation of adrenergic receptors in the nasal mucosa (6). Patients with rhinosinusitis experience symptoms of nasal disease, along with associated symptoms, such as headaches (7). Each of the symptoms may influence the individual’s physical, occupational or social functioning to a certain extent (7). The great impact of these diseases on the quality of life (QoL) may occasionally be inadequately recognized by the patient’s environment (7). In rhinosinusitis patients, the aim of treatment is to alleviate the disease signs and symptoms. Therefore, this clinical study also included an assessment of the impact that health conditions have on the QoL as the primary disease outcome. QoL assessment frequently implies different terms for different people, thus making its definition more difficult (7). The QoL is influenced by health, material conditions and the general state of mind of each individual (7). The health-dependent QoL is part of the overall QoL that is primarily determined by the overall state of health, and it can be influenced by clinical intervention (7). It should be assessed as a functional impact of the disease. The patient is preoccupied by discomforts associated with the disease. It is especially emphasized in clinical conditions, where the primary therapeutic goal is the patient’s wellbeing, and the majority of patients suffering from rhinosinusitis expect some improvement as the ultimate result (8). In chronic rhinosinusitis, clinicians evaluate the clinical status of the nasal region on the basis of nasal symptoms, objective examination, rhinomanometry, and radiologic examination. These usual parameters of nasal mucosa inflammation indicate the condition of the nose itself, but do not refer to the issue of the reduced QoL in patients with rhinosinusitis (8). Rhinosinusitis can cause sleep disorders and consequently chronic fatigue (9). Patients suffer from frequent headaches, which, in some cases, may lead to transient inability to work. In addition, patients encounter various other problems of varying intensity, depending on their ability to cope with the problems (9). 117 Medicinski Glasnik, Volumen 7, Number 2, August 2010 The primary aim of the study was to compare the efficiency of isotonic and hypertonic seawater solutions used for nasal lavage and maintaining patency in chronic rhinosinusitis. The secondary aim was to evaluate the improvement in the QoL of patients suffering from chronic rhinosinusitis with the use of seawater solutions. MATERIALS AND METHODS Data were collected at ENT Outpatient Clinic, University Hospital in Osijek and ENT Outpatient Clinic, Josip Benčević General Hospital in Slavonski Brod, Croatia. The treatment lasted for two weeks. The study started on November 15, 2008, with the anticipated inclusion period of three months, i.e. till February 14, 2009, and was completed on February 28, 2009. Subjects The study included 60 patients with the history of chronic rhinosinusitis who wanted to participate in the study were required to sign an informed consent form. Patients needed to be at least 18 years of age, of whichever sex, and needed to have clinically established signs of the disease. These signs were determined by a physical examination and included nasal discharge, nasal obstruction, headaches, pain in the facial region, and high body temperature. Sinus endoscopy or x-ray finding was not necessary for including criteria; they were already performed and recorded in patient’s file (5). If all of these criteria were met, patients were thoroughly informed on the aims, preparations and methodology which were to be used in the study, after which they were administered the informed consent form to sign. Exclusion criteria were the subject’s decision not to take part in the study, his/her physician’s request, intolerance to seawater solution, and any circumstance incompatible with the study protocol. Excluded patients could have been replaced unless the inclusion period had not yet expired. The study included 60 patients with chronic rhinosinusitis, 30 per study location, who met the inclusion criteria and signed the informed consent form. Along with therapy prescribed by their physicians, study patients applied either nasal spray at least three times daily or six times if necessary, keeping notes on the exact daily dose in the Patient Logbook. 118 Study preparations The efficiency of the two seawater solutions: isotonic solution (Sterimar) and hypertonic solution (Sterimar Hypertonic) was investigated. Sterimar is an isotonic seawater solution available in the form of a microspray with an anatomic applicator. The active substance is natural seawater, mean salinity 2.80%-2.85%. The solution contains 31.82 mL of seawater in 100 mL solution, with physiologic NaCl concentration of 0.9%. Apart from NaCl, the solution contains natural minerals and oligoelements in traces, i.e. in lower than physiologic concentrations. The solution is intended for daily nose hygiene and nasal mucosa lavage in infants, children and adults. The solution is applied 3-6 times daily by pressing the applicator for at least 3 seconds, spraying the solution into both nares. Sterimar Hypertonic is a solution in a microspray with anatomic applicator. The active substance is natural seawater, mean salinity 2.80%-2.85%. The preparation contains 75.00 mL seawater in 100 mL solution, with NaCl concentration of 2.12%. Besides NaCl, the solution contains natural minerals and oligoelements in traces, i.e. in lower concentrations than physiologic ones. The solution is additionally enriched with monohydrated manganese (Mn) salts and pentahydrated copper (Cu) salts to the concentrations identical to those found in body cells. The preparation is intended for nasal lavage and maintaining nasal mucosa patency, which is achieved by osmotic effect induced by the higher solution NaCl concentration and natural decongestive action. The use is identical to that described for isotonic solution. The study was designed as an open and random controlled trial. Study subjects continued taking their previous medication (e.g., antibiotics, steroids, vasoconstrictors, etc.), as advised by the physician, which was recorded in the Test List. The use of vasoconstrictive drops (each administration) was additionally noted in the Logbook. Randomization Randomization was performed using a table of random numbers for cohorts of 30 subjects each. Group 1 included numbers 1 to 30, and group 2 included numbers 31 to 60. Each group had randomly distributed 15 even numbers and 15 odd Čulig et al Seawater solutions in chronic rhinosinusitis numbers. Study subjects were allocated numbers according to randomization, whereby those allocated even numbers received the isotonic solution, and those allocated odd numbers received the hypertonic solution. For example, group 1-30 included the number sequence 12, 15, 22, 11, 28, 10, 13, 9, etc., and the respective subjects were administered study solutions as follows: 12 Sterimar, 15 Sterimar Hypertonic, 22 Sterimar, 11 Sterimar Hypertonic, 28 Sterimar, 10 Sterimar, etc. (source: Random Sequence Generator, Sequence 1 and 2). Test List History data and data obtained by clinical physical examination were entered into the Test List. The history included demographic data (age and sex), socioeconomic status (employed, unemployed or retired), educational level (elementary school, high school or university), current disease (onset and frequency) and other diseases, medication used and side effects (if present). On physical examination, the presence of rhinorrhea, congestion, cough, headache and sinus region sensitivity on palpation were assessed in grades 0 (symptom-free) to 3 (severe); breath sounds were assessed by auscultation. Current medication was recorded in the Test List. Patient Logbook At study entry, each subject was administered a Patient Logbook to be filled out daily during the 15-day study period; day 0 in the Logbook corresponded to the day of the first follow up visit noted in the Test List. Study subjects entered data on total dosage, i.e. number of Sterimar applications, and on total doses of other drugs taken along with Sterimar, e.g., nasal decongestives, antihistamines, corticosteroid drops and possibly other topical therapies. In addition, data on particular symptoms such as nasal obstruction, rhinorrhea, cough, headache, and related waking episodes were entered in grades ranging from symptomfree condition to fully pronounced symptoms. Accordingly, the patient followed up nearly the same symptoms as the physician, with the exception of facial sensitivity on palpation evaluated by the physician after physical examination, whereas the patient recorded possible episodes of symptom-induced waking during the night. The physician assessed the symptoms during the follow up examination, whereas patients did it by self-assessment. QoL questionnaire Study subjects filled out the QoL questionnaire (self-assessment) on day 0, at the first follow up visit and at the end of the study, i.e. at the end of week 2. They entered data on the following six groups of symptoms: nasal disease symptoms, other symptoms, sleep, activities, daily problems, and emotions, grading them on the visual analog scale 0-10, marking the grade corresponding best to the difficulties caused by rhinosinusitis and experienced during the study period. Statistical analysis Apart from the descriptive analysis of the data collected, statistical significance of between-group differences was determined. Student’s t-test, Whitney Rank Sum test and Chi-square test with a significance level of p<0.05 were used when appropriate for the evaluation of the results. The analysis had enough statistical power to detect the significant difference that would have been evident if the statistical power had been greater. Odds ratios were calculated by cross-tabulation with a 95% confidence interval. All analyses were performed with SigmaStat 3.0 for Windows (SPSS Science software products, Chicago, IL, US). Follow up of adverse events The randomized controlled clinical study protocol included the recording of any possible untoward event (e.g., side effect, associated disease, etc.) in the Test List. According to the protocol, data on the type, date, duration, therapy and outcome of the adverse event were recorded. Any serious adverse event should have been readily reported to the Agency for Drugs and Medicinal Products of the Republic of Croatia, while the investigator was obliged to fill out the severe adverse event reporting form. RESULTS The study included more female than male subjects (n=47; 78.3% vs. n=13; 21.7%), therefore women predominated in the use of both study preparations (Table 1). 119 Medicinski Glasnik, Volumen 7, Number 2, August 2010 According to age, the 20-29 age group prevailed (n=14; 23.3%). Generally, two thirds of the study subjects (n=37; 61.7%) were aged 20-49. The hypertonic solution was mostly administered in the 20-29 age group (n=11; 36.7%) and isotonic solution in the 30-39 and 40-49 age groups (n=7; 23.3%). In the majority of study patients, the disease duration was 7 or more years, or 85 or more months (n=26; 43.3%). The mean number of daily doses declined in both patients taking hypertonic solution and those using isotonic solution, i.e. from 4.17 to 3.40 (18.5%) and from 3.60 to 2.97 (17.5%), respectively. From previous therapy for chronic rhinosinusitis, most patients were taking medications in the following order: antibiotics (n=43/60; 71.7%), nasal decongestives (40; 66.7%), intranasal corticosteroids (27; 45.0) and antihistamines (23; 38.3%). There were no significant statistical differences between the two study groups. During 2nd visit the number of patients who were still taking other medications beside the saline solutions were significantly reduced. Antibiotics were Table 1. Demographic and clinical characteristics of study sample and patients No. of patients n (% on total) Hypertonic n (%) Isotonic n (%) 60 (100.0) 30 (50.0) 30 (50.0) Age groups 10-19 5 (8.3) 3 (10.0) 2 (6.7) 20-29 14 (23.3) 11 (36.7) 3 (10.0) 30-39 11 (18.3) 4 (13.3) 7 (23.3) 40-49 12 (20.0) 5 (16.7) 7 (23.3) 50-59 9 (15.0) 5 (16.7) 4 (13.3) 60-69 8 (13.3) 2 (6.7) 6 (20.0) 70-79 1 (1.7) 0 (0.0) 1 (3.3) = >80 0 (0.0) 0 (0.0) 0 (0.0) prescribed to three patients in hypertonic solution group and one in isotonic solution group. Corticosteroids were used by five patients in hypertonic group and four in isotonic group, but nasal decongestants were taken only by two patients in isotonic group. There was no statistical significant difference between the two patient groups, but there was a significant difference between the number of prescribed medications before the beginning of the study and 2nd and 3rd visit during the trial with everyday administration of saline solutions (p<0,05). During the two-week study period, five symptoms closely associated with chronic rhinosinusitis, i.e. rhinorrhea, congestion, cough, headache and facial sensitivity on palpation, were followed up and recorded in the Test List. On the initial examination (1st follow up visit), there was no difference in the symptoms between the subjects using hypertonic solution and those using isotonic solution. At the 2nd follow up visit, a statistically significant between-group difference was found for congestion, and on the 3rd follow up visit, at two weeks of seawater solution application, such a difference was recorded for congestion and cough (Table 2). On day 0 in the Logbook notes, there was no difference in the symptoms between the groups of subjects using hypertonic and isotonic seawater solutions. The earliest statistically significant difference was recorded for congestion (day 4), followed by waking (day 6, just for a while, then Table 2. Symptom variations between hypertonic and isotonic solution groups at 1st, 2nd and 3rd follow up visit Symptom Rhinorrhea Gender Males 13 (21.7) 5 (16.7) 8 (26.7) Females 47 (78.3) 25 (83.3) 22 (73.3) Congestion Duration of illness (months) ≤12 6 (10.0) 2 (6.7) 4 (13.3) 13-24 4 (6.7) 3 (10.0) 1 (3.3) 25-36 7 (11.7) 6 (20.0) 1 (3.3) 37-48 6 (10.0) 4 (13.3) 2 (6.7) 49-60 5 (8.3) 4 (13.3) 1 (3.3) 61-72 4 (6.7) 3 (10.0) 1 (3.3) 73-84 1 (1.7) 1 (3.3) 0 (0.0) 26 (43.3) 7 (23.3) 19 (63.3) 1 (6.7) 0 (0.0) 1 (3.3) 85+ Missing 120 Cough Headache Facial sensitivity on palpation Follow up visit P value* Statistical significance of difference 1st visit 0.295 No 2nd visit 0.711 No 3rd visit 0.145 No 1st visit 0.994 No 2nd visit 0.038 Yes 3rd visit 0.009 Yes 1st visit 0.728 No 2nd visit 0.318 No 3rd visit 0.040 Yes 1st visit 0.506 No 2nd visit 0.549 No 3rd visit 0.300 No 1st visit 0.061 No 2nd visit 0.813 No 3rd visit 0.652 No Source: Test List; *Mann-Whitney Rank Sum Test Čulig et al Seawater solutions in chronic rhinosinusitis again on day 9), headache (day 11), cough (day 14), and no such difference for rhinorrhea (Table 3). Testing for significance of difference in particular symptoms between day 0 and day 15 of the Patient Logbook notes yielded statistically significant differences in all symptoms in the group of patients using hypertonic seawater solution. Testing for significance of difference in particular symptoms between day 0 and day 15 of the Patient Logbook notes yielded statistically significant differences in congestion and rhinorrhea, whereas other symptoms showed no major changes during the study period in the group of patients using isotonic seawater solution. A comparison was made between the symptoms recorded by the physician on the 1st, 2nd and 3rd physical examination (taken at 7-day intervals and noted in the Test List) and the same symptoms recorded by the study patients in the Logbook on day 1, day 8 and day 15, separately for the groups of patients receiving isotonic and hypertonic seawater solutions. Symptom patterns in patient groups administered hypertonic and isotonic seawater solutions as recorded in the QoL questionnaire filled in by study patients at study entry, then at week 1 and week 2, are shown below. Mean values were presented; patients graded their symptoms on a 0-10 scale, where 10 indicated severe and very frequent symptoms, and 0 indicated a symptomfree condition. Table 3. Symptom differences between subjects using hypertonic and isotonic seawater solution Day Rhinorrhea Congestion Cough Headache Waking 1 0.684 0.106 0.169 0.367 0.965 2 0.363 0.141 0.231 0.420 0.290 3 0.344 0.056 0.332 0.610 0.085 4 0.965 0.027* 0.237 0.918 0.063 5 0.862 0.030* 0.180 0.762 0.183 6 0.574 0.027* 0.251 0.424 0.034* 7 0.679 0.014* 0.631 0.277 0.158 8 0.476 0.017* 0.665 0.143 0.082 9 0.848 0.019* 0.807 0.157 0.030* 10 0.178 0.027* 0.524 0.110 0.034* 0.001* 11 0.099 0.070* 0.303 0.006* 12 0.252 0.018* 0.141 0.025* 0.011* 13 0.147 0.005* 0.102 0.023* 0.031* 14 0.112 0.013* 0.028* 0.007* 0.022* 15 0.154 0.001* 0.023* 0.001* 0.015* Source: Patient Logbook The severity of almost all of the symptoms present in the patient group using Hypertonic seawater solution, as evaluated at three time points (initial, at week 1 and week 2), was reduced by over 50%. The greatest reduction was recorded in the following symptoms: morning weariness and sleep deprivation (75.6%), anxiety (70.8%), unease for nasal disease symptoms (70.4%), sleeping difficulties (68.8%), headaches (67.9%), frustration (67.5%). The grade of reduction in the symptom patterns in the patient group using isotonic seawater solution, evaluated at three time points (initial, at week 1 and week 2), greatly varied. The greatest reduction was recorded in the following symptoms: sleeping difficulties (46.4%), waking during the night (38.7%), cough (38.1% ). No side effects were recorded during the clinical trial period (15 days). DISCUSSION The role of mucus in the inflammatory process has been widely discussed. Some studies demonstrated the potential disease association with mucociliary functional changes, with special reference to the role of mucus within the nasal cavity (10). The mucus transport ratio decreases significantly in patients with chronic rhinosinusitis, as compared with healthy subjects, and modified mucus properties rather than ciliary abnormalities are considered to underlie pathologic changes (11). In another study, seawater solution applied in the form of spray considerably improved the rate of nasal mucociliary clearance in cystic fibrosis patients, free from sinus disease symptoms (11). A study in healthy subjects free from nasal or sinus disease symptoms revealed that the clearance rate only improves upon lavage with a hypertonic saline, but not with a physiological (isotonic) saline (8). The destruction of the ciliary epithelium, due to long-lasting nasal mucosa colonization with pathogenic microorganisms, is another cause of reduced nasal mucociliary clearance in chronic rhinosinusitis patients (12). It is manifested as a decreased frequency of ciliary movements, which increases with long-term antibiotic therapy (13). A continuous reduction of disease symptoms is one of the indicators of the seawater solution efficiency recorded in the present study, 18,5% 121 Medicinski Glasnik, Volumen 7, Number 2, August 2010 and 17,5% with hypertonic and isotonic seawater solution, respectively. Results of this clinical trial showed that the use of seawater solution is beneficial in patients with chronic rhinosinusitis. In addition, hypertonic seawater solution proved to be better than isotonic seawater solution in removing the symptoms of nasal congestion, rhinorrhea, cough, headache and waking due to discomforts caused by the disease. The evaluation of the effectiveness and safety of topical saline in the management of chronic rhinosinusitis were done by searching the Cochrane Central Register of Controlled Trials (4). There is evidence that saline is beneficial in the treatment of the symptoms of chronic rhinosinusitis when used as the sole therapy. Two studies compared different hypertonic solutions against isotonic saline. Some evidence suggests that hypertonic solutions improve objective measures but the impact on symptoms is less clear. In our study hypertonic solution showed superiority on the symptoms of congestion (2nd visit , p= 0,038 ; 3rd visit .p= 0,009 ) and cough ( 3rd visit, p=0,04). The size of the study sample was based on the prevalence of chronic rhinosinusitis in Croatia of 1.5‰ according to the health statistics data, or 1.5 per 1000 inhabitants older than 18. As Osijek has 88767 citizens older than 18, the calculated prevalence is 133, and for Slavonski Brod with 47613 citizens older than 18 it is 71, or 204 in total. According to the total sample size (N=204), the study sample should have consisted of 134 patients. However, the present study included 60 patients. This sample size was considered adequate because of the low phenomenon variability (strictly defined symptoms of chronic rhinosinusitis) and for financial restrictions (1,10). A number of randomized controlled trials have tested nasal and antral irrigation with isotonic or hypertonic saline in the treatment of acute/intermittent and chronic/persistent rhinosinusitis (4). Although saline is considered a control treatment itself, patients in these randomized trials were assigned different modalities of saline application, hypertonic saline, or hypertonic compared to isotonic saline. Group results were compared. Most of them offer evidence that nasal washouts, or irrigations with isotonic or hypertonic saline, are beneficial in terms of symptom alleviation, 122 endoscopic findings and Health-Related QoL improvement in patients with chronic persistent rhinosinusitis (14). Hypertonic saline is preferred to isotonic treatment for rhinosinusitis by some authors in the USA, mostly based on a paper indicating it significantly improves nasal mucociliary clearance, measured by saccharine test, in healthy volunteers (5, 6). The present study showed that the QoL in patients with chronic rhinosinusitis improves sooner with the use of hypertonic seawater solution. During the two-week study period, a follow up of the five symptoms closely associated with chronic rhinosinusitis yielded a statistically significant difference in improvement of the symptoms of nasal congestion and cough. Apart from these medical findings, study patients made notes on favorable changes themselves, with the earliest statistically significant difference recorded for nasal congestion (day 4), waking up for a while (day 6, then again on day 9), headache (day 11) and cough (day 14), but not for rhinorrhea. The spray was well tolerated and was not associated with any significant adverse event. The superiority of hypertonic seawater solution was manifested by the statistically significant reduction in all of the symptoms observed, unlike with the isotonic seawater solution, where some symptom reduction was only recorded in nasal congestion and rhinorrhea. Most questionnaires concentrate on the duration of the symptoms and not on the severity of the symptoms. A QoL questionnaire, developed by Damm et al, includes the severity of the symptom scale (15). The domains in the questionnaire are the overall QoL, nasal breathing obstruction, post-nasal drip or discharge, dry mucosa, smell, headache and asthmatic complaints. In a generic SF-36 survey, the scores of chronic rhinosinusitis patients were compared to those of a healthy population. The results showed statistically significant differences in seven of eight domains (7). Gliklich and Metson (9) have reported that patients with chronic rhinosinusitis have more bodily pain and worse social functioning than for example, patients with chronic obstructive pulmonary disease, congestive heart failure, or back pain. The questionnaire used in the present study was validated in the previous research (16). Čulig et al Seawater solutions in chronic rhinosinusitis It has a similar structure to the one used in the study with allergic rhinitis patients. The day to day analysis showed the high sensitivity, noticing even short, intermittent changes, which is characteristic of chronic diseases. The results of this clinical trial have shown that the use of seawater solution is beneficial to patients with chronic rhinosinusitis. Hypertonic seawater solution has been found to be better than isotonic seawater solution in eliminating the symptoms of nasal congestion, rhinorrhea, cough, headache and waking up during the night. The study demonstrated that the QoL in patients with chronic rhinosinusitis improves sooner with the use of hypertonic seawater solution. Additional topical therapy with nasal decongestants was required in only four study patients (two in the group receiving hypertonic and isotonic seawater solution each, during the study period only in the patients using isotonic solutions), which was statistically non-significant. ACKNOWLEDGEMENTS/DISCLOSURES The authors are grateful to the companies Pharmatheka Consult and Sofibel-Laboratoires Fumouze for providing the products and financial support. REFERENCES 1. 2. 3. 4. 5. 6. 7. 8. 9. Van Cauwenberge P, Watelet JB. Epidemiology of chronic rhinosinusitis. Thorax 2000; 55 (Suppl 2): 20-1;doi:10.1136/thorax.55.suppl_2.20. Eloy P, Watelet JB, Rombaux P, Dale J, Bertrand B. Management of chronic rhinosinusitis without polyps in adults. B-ENT 2005; 1(Suppl): 65-74; quiz 75-6. Ron G, Shashy MD, Eric J, Moore MD, Amy Weaver MS. Prevalence of the chronic sinusitis diagnosis in Olmsted County, Minnesota. Arch Otolaryngol Head Neck Surg 2004; 130: 320-3. Harvey R, Hannan SA, Badia L, Scadding G. Nasal saline irrigations for the symptoms of chronic rhinosinusitis. Cochrane Database Syst Rev 2007; 18: CD006394. Fokkens WJ, Lund VJ, Mullol J; European Position Paper on Rhinosinusitis and Nasal Polyps group. European position paper on rhinosinusitis and nasal polyps 2007. Rhinology 2007; 45(Suppl 20): 1-139. Talbot AR, Herr TM, Parsons DS. Mucociliary clearance and buffered hypertonic saline solution. Laryngoscope 1997; 107: 500-3. Durr DG, Desrosiers MY, Dassa C. Quality of life in patients with rhinosinusitis. J Otolaryngol 1999; 28: 108-11. Lund VJ, Kennedy DW. Quantification for staging sinusitis. The staging and therapy group. Ann Otol Rhinol Laryngol 1995; 167 (Suppl): 17-21. Gliklich RE, Metson R. The health impact of chronic sinusitis in patients seeking otolaryngologic care. Otolaryngol Head Neck Surg 1995; 113: 104-9. 10. Croatian Health Service Yearbook 2007. Zagreb: Croatian National Institute of Public Health, 2008. 11. Majima Y, Sakakura Y, Matsubara T, Murai S, Miyoshi Y. Mucociliary clearence in chronic sinusitis: related human nasal clearence and in vitro bullfrog clearence. Biorheology 1983; 20: 251-62. 12. Middleton PG, Geddes DM, Alton EW. Effect of amiloride and saline on nasal mucociliary clearance and potential difference in cystic fibrosis and normal subjects. Thorax 1993; 48: 812-6. 13. Wilson R, Cole PJ. The effect of bacterial products on ciliary function. Am Rev Respir Dis 1988; 138: 49-53. 14. Scadding GK, Lund VJ, Darby YC. The effect of long-term antibiotic therapy upon ciliary beat frequency in chronic rhinosinusitis. J Laryngol Otol 1995; 109: 24-6. 15. Damm M, Quante G, Jungehuelsing M, Stennert E. Impact of functional endoscopic sinus surgery on symptoms and quality of life in chronic rhinosinusitis. Laryngoscope 2002; 112: 310-5. 16. Včeva A, Djanić D, Kotromanović Z, Pajić-Penavić I. Comparison of isotonic and hypertonic seawater solution in the treatment of chronic rhinosinusitis. In: Abstract of the 6th Congress of Croatian Society for Otorhynolaryngology and Head and Neck Surgery with International Participation, Dubrovnik, Croatia, 2009. Abstract 104, str. 119. Croatian Society for Otorhynolaryngology and Head and Neck Surgery, Zagreb, Croatia. 123 ORIGINAL ARTICLE Promjene u strukturi i kliničkom značenju pozitivnih rezultata pretransfuzijskog testiranja kod prijelaza s klasične metode aglutinacije u epruveti na metodu u gel mikrostupcu Alma Petrušić-Kafedžić1, Zdravko Ivanković2, Sabahudin Ekinović³, Lejla Ibrahimagić-Šeper4 Služba za transfuziju krvi, Kantonalna bolnica Zenica, Zenica, Bosna i Hercegovina, 2DiaHem, Buelach, Švicarska, ³Rektorat Univerziteta u Zenici, Univerzitet u Zenici, Zenica, Bosna i Hercegovina, 4JU Dom zdravlja, Zenica, Bosna i Hercegovina. 1 SAŽETAK Cilj Istražiti promjene pretransfuzijskog testiranja iregularnih antitijela kod prijelaza s aglutinacijskog testa u epruveti na test u gelu. Metode Klinički značaj pozitivnih rezultata analiziran je u 7667 pretransfuzijskih testiranja (s 16610 interakcija) učinjenih testom u epruveti u 2005.-2006. godini, te u 7372 pretransfuzijskih ispitivanja (s 17294 interakcija) učinjenih u 2007.-2008. godini testom u gelu. Corresponding author: Alma Petrušić-Kafedžić, Služba za transfuziju krvi, Kantonalna bolnica Zenica, Crkvice 67, 72000 Zenica, Bosna i Hercegovina Phone: ++387 32 406 279; Fax: ++387 32 202 502; E-mail: alma_petrusic@yahoo.co.uk Originalna prijava: 09. april 2009.; Korigirana verzija: 28. oktobar 2009.; Prihvaćeno: Rezultati Detekcija iregularnih antitijela, u oba ispitivana perioda, bila je pozitivna u 1,3%, a interakcija u 0,3% slučajeva. Barem jedan od tih testova nađen je pozitivan u 1,4% pretransfuzijskih testiranja testom u epruveti, odnosno u 1,3% testom u gelu, uz >75% pozitivnih rezultata u žena. Gledajući slučajeve s pozitivnom interakcijom, a negativnom detekcijom iregularnih antitijela, osam od deset slučajeva, nađenih testom u epruveti, bilo je uzrokovano ‘’hladnim’’, a sva tri slučaja testom u gelu ‘’toplim nespecifičnim’’ antitijelima. Testom u gelu nađen je veći udio imunih antitijela nego testom u epruveti (69,8%, odnosno 41,3%, p<0,001), uz dvostruki porast udjela anti-K i Rh-antitijela. Testom u epruveti nađena su 24, a testom u gelu nijedan slučaj klinički beznačajnih antitijela (p<0,001). ‘’Nespecifična antitijela’’ češće su uzrokovala pozitivnu interakciju nego detekciju iregularnih antitijela (42,6%, odnosno 29,9% testom u epruveti, 28,9%, odnosno 18,3% testom u gelu). Iako blizu u pogledu detekcije iregularnih antitijela (p=0,062), razlika testa u epruveti i u gelu nije dosegla značaj. ‘’Nespecifična antitijela’’ nađena su ovim testovima češće u žena, dok se faktor odjela pokazao bez značaja. Zaključak Gel test se pokazao kao optimalnija tehnika pretransfuzijskog ispitivanja. Detekcija iregularnih antitijela preporuča se kao obavezni dio pretransfuzijskog testiranja. Ključne riječi: pretransfuzijsko testiranje, gel test, specifičnost 05. februar 2010. Med Glas Ljek komore Zenicko-doboj kantona 2010; 7(1):124-131 124 Petrušić-Kafedžić et al Pretransfuzijsko testiranje: gel stubac UVOD Pretransfuzijsko testiranje (PT) (1-5), koje se danas provodi tehnikom aglutinacije eritrocita, a posebno indirektnim antiglobulinskim testom (IAT) (4-7), ima za cilj izbjegavanje hemolitičke transfuzijske reakcije (HTR) kod transfundiranog bolesnika. Uz aglutinacijski test u epruveti (TE) uvedena je aglutinacija u mikrostupcu, posebno test u gelu (GT), koji je omogućio značajnu standardizaciju, objektivizaciju i reproducibilnost testiranja, uz niz drugih prednosti (8-9). Najveći doprinos GT-a, s obzirom na sigurnost transfundiranog pacijenta, jeste povećanje specifičnosti i reproducibilnosti testa (izbjegavanje klinički beznačajnih antitijela reaktivnih pretežno na temperaturama ispod tjelesne i izbjegavanje varijabilnosti u izvođenju i očitanju testova) (8-13). Uz GT detektiraju se najčešće samo ‘’imuna’’ antitijela (nastala pravom eritrocitnom imunizacijom i sposobna izazvati kliničku HTR), čime se i značajno smanjuje broj nepotrebno odgođenih transfuzija, zbog pozitivnih, a klinički beznačajnih rezultata testiranja (8-24). Prije svakog transfuzijskog liječenja produktima koji sadrže eritrocite, provodi se obavezno PT, koje uključuje provjeru ABO i RhD antigena bolesnika i doze krvi, detekciju iregularnih antitijela (IRA) i interakciju (IRR) između bolesnikovog seruma i eritrocita davaoca (4-6). Detekcija IRA i IRR, posebno se često provode putem GT-a, i to tehnikom IAT-a, koja je osnovna tehnika PT-a u svim internacionalnim i nacionalnim vodičima, te praksi (6, 25-28). Iako je prevalencija HTR-a uz GT smanjena na oko 0,04% (5), još uvijek nisu dovoljno istražene karakteristike ovog modela PT-a. Optimizacija PT-a, u općem i lokalnom smislu, ostaje trajni zadatak svake transfuzijske službe, kako one koja se bavi formiranjem nacionalnih preporuka, tako i one čiji je zadatak na terenu i praktično brinuti o određenoj populaciji. Stoga je, osim ispitivanja promjena u općoj učestalosti pozitivnih pretransfuzijskih testiranja i strukturi nađenih antitijela nakon uvođenja GT-a, cilj ovoga istraživanja bio ispitati potrebu uvođenja eventualnih akcija u saniranju mogućih propusta napravljenih tokom desetljeća upotrebe TE-a. Osim toga, cilj ispitivanja bio je odrediti učestalost i strukturu tzv. nespecifičnih rezultata, koji najviše doprinose nepotrebnom odgađanju transfuzija krvi, te utjecaj nekih lokalnih faktora na uspješnost GT-a, a time i na kontrolne postupke pri njenom uvođenju. Ti bi podaci mogli, u nacionalnim okvirima, ukazati na optimalnu konfiguraciju PT-a putem GT-a i u ostalim ustanovama naše zemlje. ISPITANICI I METODE U Službi za transfuziju krvi Kantonalne bolnice Zenica provedeno je retrospektivno-prospektivno istraživanje rezultata pretransfuzijskog testiranja (PT) u svih bolesnika koji su liječeni transfuzijama eritrocitnih produkata krvi, u razdoblju od 2005. do 2008. godine u Kantonalnoj bolnici Zenica. Obavezno PT, u ispitivanom razdoblju, provedeno je u sukladu s internacionalnim preporukama (6, 25, 26) koje u svakom PT-u propisuju obaveznu detekciju iregularnih antitijela (IRA) u bolesnika, kao i interakciju (IRR) seruma bolesnika s eritrocitima doze krvi predviđene za transfuziju tehnikom indirektnog antiglobulinskog testa (IAT), a u sukladu s uputama iz literature (6, 7), te proizvođača reagensa. U 2005. i 2006. godini, PT je provedeno klasičnim testom u epruveti (TE) na uzorku krvi bez antikoagulansa, tehnikom IAT-a, koristeći za detekciju IRA test eritrocite Panoscreen I-II (GAMMA Immucor, Norcross, SAD) i polispecifični antihumani serum (BioGnost, Zagreb, Hrvatska), koji se koristio i u IRR-u. Tokom 2007. i 2008. godine cjelokupno PT provedeno je tehnikom IAT-a, no upotrebom testa u gelu (GT) na uzorku krvi s EDTA antikoagulansom, koristeći za detekciju IRA test eritrocite ID-DiaCell I-II i gel kartice s dodanim antihumanoglobulinskim serumom ID-LISS Coombs, koje su korištene i za IRR (DiaMed, Cressier sur Morat, Švicarska). Svaka pozitivna detekcija IRA i/ili IRR ponovljena je u duplikatu istim reagensima korištenim i u osnovnom testu. Svaki uzorak s barem jednim ponovljeno pozitivnim rezultatom upućen je na identifikaciju prisutnih antitijela. Identifikacija antitijela također je učinjena metodom kao u osnovnom PT-u, u 2005. i 2006. godini putem TE, koristeći test eritrocite PanoCell-10 (GAMMA Immucor, Norcross, SAD) i 125 Medicinski Glasnik, Volumen 7, Number 2, August 2010 antihumani serum (BioGnost, Zagreb, Hrvatska), a u godinama 2007. i 2008. putem GT-a, koristeći test eritrocite ID-DiaCell I-II i gel karticu ID-LISS Coombs (DiaMed, Cressier sur Morat, Švicarska). U prvom razdoblju identifikacija antitijela provedena je, prema pravilima za TE, na sobnoj temperaturi, na 37°C i nakon dodatka antihumanoglobulinskog reagensa. U drugom razdoblju, prema pravilima GT-a, identifikacija je provedena nakon inkubacije, samo na 37 °C. Identificirana specifična antitijela označena su kao ‘’imuna’’ (klinički značajna), ‘’potencijalno klinički značajna’’ ili ‘’klinički beznačajna’’, prema uobičajenim kriterijima za mogućnost izazivanja hemolitičke transfuzijske reakcije (HTR) (1-7). Antitijela, u oba perioda, koja su u identifikaciji pokazala reaktivnost s određenim eritrocitima panela, no nisu pokazala obrazac specifičnih antitijela, označavana su kao ‘’nespecifična’’, i to ‘’nespecifična hladna’’ (ako je reaktivnost bila na temperaturama ispod tjelesne) ili ‘’nespecifična topla’’ (ako je reaktivnost bila samo na 37 oC). Učestalost nespecifičnih rezultata stavljena je u korelaciju sa spolom, dobi i matičnim odjelom bolesnika. U testiranju korelacija posebna pažnja posvećena je kliničkom značaju pozitivnih i negativnih rezultata, uključujući i one koji utječu na nepotrebno odgađanje transfuzijskog liječenja. Statistička značajnost izračunata je χ2 testom, uz prihvaćenu razinu značaja od p<0.05. REZULTATI U periodu 2005.-2006. godine, kada je pretransfuzijsko testiranje (PT) provedeno putem testa u epruveti (TE), učinjeno je ukupno 7667 (3787 i 3880) testova, s 16610 interakcija (IRR). U periodu 2007.-2008. godine, kada je PT provedeno koristeći gel test (GT), učinjeno je ukupno 7372 (3765 i 3607) testova, s 17294 IRR. U TE periodu detekcija IRA je nađena pozitivna u 97 (1,3%), a IRR u 54 (0,3%) PT, a kod ukupno 109 (1,4%) pretransfuzijskih ispitivanja barem je jedan od ovih testova nađen pozitivan, i to najvećim dijelom kod žena (82, 75.2%). Oba su testa bila pozitivna u 42 slučaja. U GT periodu detekcija IRA je nađena pozitivna u 93 (1,3%), a IRR u 45 (0,3%) PT. Oba testa također su nađena pozitivna u 42 slučaja. Ukupno je barem jedan pozitivan test nađen u 96 (1,3%) 126 PT-a, a 76 bolesnika s barem jednim pozitivnim testom (79.2%) bilo je ženskog spola. Učestalosti pozitivne detekcije IRA ili IRR u TE i GT periodima, kao i spolna distribucija bila je podjednaka (p>0,05). Statističku značajnost u oba perioda (p<0.05) dosegla je samo veća učestalost žena među bolesnicima s pozitivnim testovima. Prosječna dob bolesnika s pozitivnom detekcijom IRA ili IRR u TE periodu iznosila je 50,0 (10-75), a u GT 49,6 (19-77) godina (p>0,05). U oba razdoblja nađena je veća učestalost pozitivne detekcije IRA-e nego pozitivne IRR (1,3% prema 0,3%, p<0,05). No, u TE periodu opažen je veći broj slučajeva s pozitivnom IRR, a negativnom detekcijom IRA-e (N=10), u usporedbi s GT periodom (N=3) (p<0,05). I uzroci takvih nalaza razlikovali su se između dva perioda: u TE periodu u osam od 10 slučajeva nađena su antitijela s optimumom reakcije na temperaturi <370C (‘’nespecifična hladna’’ u tri, anti-Lea u dva, te anti-M, anti-P1 i anti-Leb u po jednom slučaju), a samo u dva slučaja radilo se o ‘’nespecifičnim toplim’’ antitijelima; nasuprot tome, sva tri slučaja u GT periodu bila su uzrokovana ‘’nespecifičnim toplim’’ antitijelima. Učestalost pojedinih antitijela nađenih u uzorcima s pozitivnim PT prikazana je u Tablici 1. U GT periodu među detektiranim antitijelima nađen je značajno veći udio imunih antitijela (67 od 96, 69,8%) u odnosu na TE period (45 od 109, 41,3%) (p<0.001), s najvećim porastom udjela anti-K, a zatim anti-D i ostalih Rh-antitijela u Tablica 1. Broj i udio pojedinih antitijela identificiranih u uzorcima s pozitivnim pretransfuzijskim testiranjem (detekcija iregularnih antitijela i interakcije, sumarno) Antitijela Test u epruveti (TE) Test u gelu (GT) (2005/06.) (2007/08.) N (%) N (%) Anti-D (+/- C) 14 (12,8%) 18 (18,8%)* Ostala Rh (uključujući c+E) 12 (11,0%) 18 (18,8%)* Anti-K 11(10,1%) 21 (21,9%)* Ostala imuna 5 (4,6%) 6 (6,3%) Više imunih 3 (2,8%) 4 (4,2%) Potencijalno klin. značajna (M, Lea, P1, Lu) 14 (12,8%) 9 (9,4%) Klinički beznačajna (Leb, nesp. hladna) 24 (22,0%) 0† “Nespecifična topla” † 26 (23,9%) 20 (20,8%) 109 96 Ukupno *p<0,05; †nalaz identifikacije na 37 oC: reakcija na određene eritrocite panela, no bez obrasca specifičnog antitijela Petrušić-Kafedžić et al Pretransfuzijsko testiranje: gel stubac Tablica 2. Raspodjela pozitivnih testova detekcije iregularnih antitijela kod kojih nije nađeno specifično antitijelo prema spolu Tehnika/period Pozitivan test detekcije gdje nije nađeno specifično antitijelo Ukupno Tehnika/ period Žene N (%) Muškarci N (%) Test u epruveti (TE) (2005/06) 21 (72,4%) 8 (27,6%) 29 Test u gelu (GT) (2007/08) 11 (64,7%) 6 (35,3%) 17 32 14 36 Ukupno GT. U GT periodu niti u jednom slučaju nisu detektirana klinički beznačajna antitijela, nasuprot 24 slučaja u TE periodu (p<0,001). Gledajući sumarno prevalenciju pojedinih kategorija antitijela u ukupnom broju učinjenih detekcija IRA i IRR, onda su u TE periodu imuna antitijela nađena s učestalošću 45 u 24277 svih testiranja (0,19%), dok je u GT periodu incidencija povećana na 66 u 24666 testova (0,27%) (p<0,05). Slučajevi u kojima se specifičnost antitijela nije mogla odrediti (nespecifična hladna i nespecifična topla antitijela), u TE periodu činili su 29 od 97 (29,9%) pozitivnih detekcija IRA i 23 od 54 (42,6%) pozitivnih IRR, nasuprot 17 od 93 (18,3%) pozitivnih detekcija IRA i 13 od 45 (28,9%) pozitivnih IRR u GT periodu. U pogledu IRR razlika TE i GT perioda nije se pokazala signifikantnom (p=0,2), no u pogledu detekcije IRA, iako je nije dosegla, razlika se približila statističkoj značajnosti (p=0,062). Statistički značajna razlika (p<0,05) zamijećena je u učestalosti nespecifičnih nalaza između detekcije IRA i IRR: u oba perioda antitijela bez nađene specifičnosti češće su uzrokovala pozitivnu IRR, no pozitivnu detekciju IRA (42,6% prema 29,9% u TE, odnosno 28,9% prema 18,3% u GT periodu). Pozitivno PT, a bez identificiranih specifičnih antitijela, nađeno je češće u žena nego u muškaraca (p<0,05) i blaga tendencija većeg udjela žena u nespecifično pozitivnim testovima u TE nego u GT periodu: 72,4% prema 64,7% kod detekciTablica 3. Raspodjela pozitivne interakcije kod kojih nije nađeno specifično antitijelo prema spolu Tehnika/period Pozitivna interakcija gdje nije nađeno specifično antitijelo Tablica 4. Pozitivni testovi detekcije iregularnih antitijela kod kojih nije nađeno specifično antitijelo: raspodjela prema matičnim odjelima pacijenata Ukupno Test u epruveti (TE) (2005/06) Test u gelu (GT) (2007/08) Ukupno Pozitivan test detekcije gdje nije nađeno specifično antitijelo kirurške grane N (%) Ukupno internističke ginekologija i grane porodiljstvo N (%) N (%) 9 (31,0%) 9 (31,0%) 11 (37,9%) 29 5 (29,4%) 6 (35,3%) 6 (35,3%) 17 14 15 17 36 je IRA, odnosno 73,9% prema 61,5% kod IRR (p=0,11) (Tablice 2 i 3). Distribucija matičnih odjela pacijenata s pozitivnim PT-om, a bez identificiranih specifičnih antitijela, prikazana je u Tablicama 4 i 5. Značajnih razlika između TE i GT perioda nije zamijećeno ni u jednoj ispitivanoj kategoriji, iako je u pacijentica Odjela za ginekologiju i porodiljstvo zamijećena tendencija veće učestalosti nespecifično pozitivnih IRR u TE nego u GT periodu (p=0,2). DISKUSIJA Uvođenje testa aglutinacije u gel mikrostupcu nesumnjivo je dovelo do velikih promjena u pretransfuzijskom ispitivanju, posebno u detekciji klinički značajnih antitijela (8-24), što su pokazali i rezultati ovoga istraživanja, uz održanu opću razinu učestalosti pozitivnih testova. Najveći porast broja detektiranih antitijela bio je zamijećen kod anti-K i Rh-antitijela, za koja je poznato da se i inače najčešće pojavljuju u imuniziranih bolesnika (1-6, 29, 30). U isto vrijeme, u GT periodu nije zamijećen nijedan slučaj klinički beznačajnih, ‘’hladnih’’ antitijela, što je za direktnu posljedicu imalo smanjen broj nepotrebno odgođenih transfuzija. Naša ispitivana populacija, s gotovo 50000 pretransfuzijskih testiranja, na način kako propisuju međunarodni standardi i uz raspodjelu prema spolu i dobi navedenoj i u druTablica 5. Pozitivne interakcije kod kojih nije nađeno specifično antitijelo: raspodjela prema matičnim odjelima pacijenata Tehnika/ period Pozitivne interakcije kod kojih nije nađeno specifično antitijelo Žene N (%) Muškarci N (%) Test u epruveti (TE) (2005/06) 17 (73,9%) 6 (26,1%) 23 Test u epruveti (TE) (2005/06) 8 (34,8%) 7 (30,4%) 8 (34,8%) 23 Test u gelu (GT) (2007/08) 8 (61,5%) 5 (38,5%) 13 Test u gelu (GT) (2007/08) 6 (46,2%) 5 (38,5%) 2 (15,4%) 13 25 11 36 Ukupno 14 12 10 36 Ukupno kirurške grane Ukupno internističke ginekologija i grane porodiljstvo 127 Medicinski Glasnik, Volumen 7, Number 2, August 2010 gim radovima (29-32), zasigurno je adekvatna za donošenje zaključaka o poboljšanoj detekciji klinički značajnih imunih antitijela. Ipak, cilj u našem ispitivanju bio je odrediti i druge aspekte ‘’novog’’ pretransfuzijskog testiranja. Ako ispitivanja pokažu da su testiranjem u epruveti godinama propuštana pojedina imuna antitijela, onda je zadatak transfuzijske službe, u najmanju ruku, analizirati potrebu za retrogradnim ispitivanjem. Detekcija iregularnih antitijela u toku sadašnjih PT-a može biti nedovoljna, jer titar pojedinih antitijela, tokom godina, u čak do 3040% slučajeva pada ispod razine detekcije, a ipak nakon nove ekspozicije antigenu brzo poraste i dovodi do odgođene HTR (6, 29). Takvi bi se bolesnici mogli potencijalno detektirati samo retrogradnom detekcijom IRA u arhiviranom uzorku, i to gel testom, što je zahtjevan proces i mora imati uporište u konkretnim dokazima o njenoj potrebi. U tom pogledu, poznato je da antitijela iz Kidd sistema, zbog brzog pada i rasta titra antitijela, uzrokuju najteže slučajeve odgođenih reakcija, a nakon toga po učestalosti slijede sistemi Duffy, Kell i MNSs (1-6, 27, 29). U našem radu Kidd i Duffy antitijela nađena su s ponešto većom učestalosti u GT periodu, no razlika, najvjerojatnije zbog malog broja antitijela, nije dosegla razinu značaja, dok je, pak, porast učestalosti detekcije Kell i MNSs antitijela dosegao tu razinu. Posebno je bio značajan porast anti-K antitijela zbog njegovog kliničkog značaja, učestalosti i činjenice da se K-antigen u BiH rutinski ne određuje u davaoca, niti u primaoca transfuzije. Ipak, nekoliko činjenica ne govore u prilog neophodne potrebe za opsežnom detekcijom IRA u arhiviranim uzorcima u službama koje su desetljećima koristile klasičan test u epruveti. Prije svega, ako i pretpostavimo da je GT u detekciji anti-K i drugih antitijela višestruko osjetljiviji od TE-a (odnosno da je to uzrok učestalije detekcije u 2007.-2008. godini), ostaje nepoznanica koliko bi se antitijela zaista detektiralo u arhiviranom uzorku, putem GT-a, u koliko bi od tih slučajeva titar pao ispod detektibilnog kod GT-a, koliko takvih slučajeva pripada bolesnicima koji učestalo primaju transfuzije, s većom šansom da prime npr. K-pozitivnu transfuziju, gdje je učestalost antigena <10% (1-6)? Osim toga, takva akcija trebala bi preživjeti analizu ekonomske opravdanosti i konačno, u našim uvjetima, upitna je i tehnička 128 izvodivost ovog ispitivanja, budući da zahtijeva odlično održavanu arhivu uzoraka i podataka. Zbog svega toga, dojam je da je u pitanju detekcije mogućih propuštenih, djelotvornije sistemski riješiti pitanje unificiranog provođenja potpunog PT-a putem GT-a i pitanje određivanja pojedinih, posebno K-antigena u svih davalaca krvi. U našem radu jasno je pokazana prednost detekcije IRA pred IRR. Detekcija IRA, gdje se koriste test eritrociti definirane konfiguracije i jače ekspresije klinički značajnih antigena, pruža znatno veću mogućnost otkrivanja iregularnih antitijela nego pojedinačna IRR, gdje se serum pacijenta inkubira s eritrocitima samo jedne osobe, slučajne konfiguracije i ponekad slabo izraženih antigena. Uz to, u našem radu, detekcija IRA putem GT-a bila je ‘’otpornija’’ na nespecifične rezultate od IRR. Zbog svega toga, detekcija IRA i u BiH mora biti nezaobilazan dio PT-a, kako je to predviđeno u praktično svim međunarodnim i nacionalnim preporukama (5, 6, 18, 24, 25). Uz to, u većini je europskih zemalja, no još ne i u BiH, određivanje K-antigena u davaoca krvi prihvaćeno kao rutinski postupak nakon ABO i Rh određivanja (6, 26, 27). U našoj ustanovi uvedene su i obavezna detekcija IRA i određivanje Kell-antigena kod svih davaoca krvi i pacijenata s iregularnim antitijelima. Mada isplativost ovih akcija zahtijeva opsežniju analizu, zasigurno je ona više na strani opravdanosti od retrogradne detekcije u arhiviranim uzorcima. Najčešći nespecifični rezultati u ovom istraživanju bili su slučajevi s pozitivnim samo jednim pretransfuzijskim testom. U TE periodu opažen je značajno veći broj slučajeva s pozitivnom samo IRR, a uzrok tome, kao i u većini drugih radova (10-19), mahom su bila ‘’hladna’’, klinički beznačajna antitijela. Ako se dodaju i rezultati našeg prethodnog ispitivanja (33), koji su pokazali veću učestalost nespecifičnih nalaza u jutarnjoj smjeni i među mlađim tehničarima, jasno je kako GT itekako može utjecati na sigurnost transfundiranih pacijenata. Sva tri nespecifična rezultata u GT periodu bila su povezana s ‘’toplim nespecifičnim’’ antitijelima, dok je iz dostupne literature poznato da su u GT metodi najznačajniji uzrok ovih nalaza antitijela HLA specifičnosti (34-37). Kako HLA antitijela, prema dostupnim podacima, izuzetno rijetko ili nikada ne uzrokuju klinički izražene hemolitičke reakcije, to u eri GT-a Petrušić-Kafedžić et al Pretransfuzijsko testiranje: gel stubac može dovesti do praktičnog razmišljanja: kako je velika većina nespecifičnih nalaza u GT-u uzrokovana ovim putem, onda pacijenti s negativnom detekcijom IRA, a pozitivnom IRR, mogu u hitnoći s relativno velikom dozom sigurnosti primiti drugu, IRR negativnu dozu, čak i prije opsežne identifikacije uzroka pozitivnog testa. Ako se takav pristup pokaže prihvaćen, GT metoda donijela bi dodatnu prednost pred klasičnom TE metodom, koje je bila karakterizirana često nepotrebnim odgađanjima transfuzijskog liječenja. Pozitivno PT općenito se češće nalazi u žena, poglavito zbog učestalih imunizacija tokom trudnoće (1). Zbog toga ne čudi ni viša stopa nespecifično pozitivnih rezultata u žena, u našem, kao i u drugim ispitivanjima (30, 32, 34). Iznenađujuće, u TE periodu, opaženo je nešto veće (no, ne i statistički značajno) učešće žena u nespecifičnim rezultatima, uz neočekivano učestala nespecifična ‘’topla’’ antitijela. Uzroci takvog nalaza najvjerojatnije su visok titar HLA-antitijela u žena naše regije, detektibilan i putem TE-a, ili pak nemogućnost tačne identifikacije antitijela samo jednim dostupnim panelom test eritrocita, kao što je slučaj u našoj ustanovi. Uzevši u obzir dob bolesnica (u prosjeku oko 50 godina) i veći broj trudnoća kojima su tradicionalno izložene u našoj regiji, te činjenicu da se jednim panelom ne može identificirati samo relativno mali broj pojedinačnih antitijela ili rijetkih kombinacija, visok titar HLA-antitijela čini se potencijalno značajnim uzrokom. U vezi utjecaja matičnih odjela, odnosno osnovnih bolesti bolesnika, na nespecifične rezultate PT-a, očito je potreban veći broj bolesnika s točno raščlanjenim bolestima, jer je teško zamisliti da bolesti poput hematoloških nemaju značajnog utjecaja na učestalost nespecifičnih rezultata PT-a. U zaključku, promjene, zabilježene u prve dvije godine upotrebe GT-a u našoj ustanovi, bez sumnje ohrabruju njegovu najširu upotrebu. S druge strane, ispitivanje nekih manje istraženih i lokalnih faktora kliničkog značaja detektiranih antitijela pokazalo je da prijelaz na GT može imati još značajniji utjecaj na neke kategorije bolesnika, poput žena s većim brojem prethodnih trudnoća. I konačno, rezultati ovog ispitivanja upućuju i na neophodne promjene uobičajenog pretransfuzijskog ispitivanja u BiH, u sferi dovršenja i praktičnog provođenja propisa o pretransfuzijskom testiranju. S gledišta rezultata ovoga rada, najpotrebnijim se čine akcije uvođenja obavezne detekcije iregularnih antitijela u svako pretransfuzijsko ispitivanje i rutinsko odredjivanje Kantigena u svih davalaca krvi. ZAHVALE/IZJAVE Posebnu zahvalu autori žele uputiti prim. dr. Aliji Striki, direktoru Kantonalne bolnice Zenica, koji je, svih ovih godina, pokazao izuzetno razumijevanje i bezrezervnu podršku uvođenju najsuvremenije dijagnostike, te općem podizanju stručnog nivoa cijele transfuzijske službe Kantonalne bolnice Zenica, kao i zahvalu osoblju Službe za transfuziju krvi koje je to provelo u praksu. Komercijalni ili potencijalni dvostruki interes ne postoji. LITERATURA 1. 2. 3. 4. 5. 6. 7. Anderson KC, Ness PM. Scientific basis of transfusion medicine. 2. ed. Philadelphia: WB Saunders, 1999. Urbaniak SJ. Alloimmunity to human red blood cell antigens. Vox Sang 2002; 83 (Suppl. 1): 293-7. British Committee for Standards in Haematology. Guidelines for compatibility procedures in blood transfusion laboratories. Transf Med 2004;14: 5973. Klein HG, Anstee DJ. Blood transfusion in clinical medicine. 11. ed. Oxford: Blackwell Publishing, 2005. Grgičević D. Transfuzijska medicina u kliničkoj praksi. Zagreb: Medicinska naklada, 2006. Roback JD, Combs MR, Grossman BJ, Hillyer CD. Technical manual. 16. ed. Bethesda: American Association of Blood Banks, 2008. Judd WJ. Methods in immunohematology. 2. ed. Durham: Montgomery Scientific Publications, 1994. 8. 9. 10. 11. 12. 13. Schoenitzer D. Pretransfusion testing before and after discovery of gel agglutination method. U: Proceedings of the Ten Years Using the Gel Test in Slovenia. Maribor: DiaMed Switzerland, 2006; 3-6. Bromilow IM, Adams KE, Hope J, Eggington J, Duguid JKM. Evaluation of the ID-gel test antibody screening and identification. Trans Med 1991; 1:159-61 Jovanović-Srzentić S, Đokić M. Upotreba metoda različite osjetljivosti u dokazivanju antieritrocitnih antitela. Bilt transfuziol 2002, 47: 57-60. Daniels G, Poole J, de Silva M, Callaghan S, Smith N. The clinical significance of blood group antibodies. Transf Med 2002;12: 287-95. Jovanović-Srzentić S, Veljković KD. Imunobiološki i klinički značaj krvnih grupa. Intra.Net Communication, Beograd, 2009. Knight RC, Poole GD. Detection of red cell antibodies: curent and future techniques. Br J Biomed Sci 1995;52: 297-305. 129 Medicinski Glasnik, Volumen 7, Number 2, August 2010 14. Poole J, Daniels G. Blood group antibodies and their significance in transfusion medicine. Transfus Med Rev 2007; 21:58. 15. Garratty G. Evaluating the clinical significance of blood group alloantibodies that are causing problems in pretransfusion testing. Vox Sang 1998; 74: 285-90. 16. Bunker ML, Thomas CL, Geyer SJ. Optimizing pretransfusion antibody detection and identification: a parallel, blinded comparison of tube PEG, solidphase, and automated methods. Transfusion 2001; 41: 621-628. 17. Blackburn, Vincent JL, Indrikovs AJ. Antibody detection and identification: gel technology versus tube method. Transfusion 2002; 42 (Suppl): S109. 18. Combs MR, Bredehoeft SJ. Selecting an acceptable and safe antibody detection test can present a dilemma. Immunohematology 2001; 17:86-9. 19. Eichler H, Boehler A, Hastka J, Richter E, Kerowgan M, Goldmann SF. Micro-column affinity test and gel test: comparative study of two techniques for red cell antibody screening. Vox Sang 1999; 77:154-8. 20. Duran J, Figueiredo M. Antibody screening in 37 degrees C saline. Is it safe to omit it using the indirect antiglobulin (gel) test? Immunohematology. 2002; 18:13-5. 21. Weisbach V, Ziener A, Zimmermann R, Glaser A, Zingsem J, Eckstein R. Comparison of the performance of four microtube column systems in the detection of red cell alloantibodies. Transfusion 1999; 39:1045-50. 22. Knight RC, de Silva M. New technologies for red cell serology. Blood Rev 1996; 10:101-10. 23. Moulds JM, Diekman L, Wells TD. Evaluation of column technology for direct antiglobulin testing. Immunohematology 1998; 14:146-8. 24. Voak D. The status of new methods for the detection of red cell agglutination. Transfusion 1999; 39:1037-40. 25. European Committee (Partial Agreement) on Blood Transfusion. Guide to the preparation, use and quality assurance of blood components. 14. ed. Strasbourg: Council of Europe, 2008. 26. Virge J. Guidelines for the Blood Transfusion Services in the UK. 7. izd. London: TSO, 2005. http://www.transfusionguidelines.org/index. aspx?Publication=RB&Section=25 130 27. McClelland DBL. Handbook of Transfusion Medicine. 4. izd. London: TSO, 2007. http://www.transfusionguidelines.org/docs/pdfs/htm_edition-4_allpages.pdf 28. Shulman IA, Maffei LM, Downes KA. North American pretransfusion testing practices, 2001-2004: results from the College of American Pathologists. Interlaboratory Comparison Program survey data, 2001-2004. Arch Pathol Lab Med. 2005; 129:984-9. 29. Schonewille H, Haak HL, van Zijl AM. RBC antibody persistence. Transfusion 2000; 40:1127-31. 30. O’Hagan J, White J, Milkins CE, Benkhaled D, Rowley MR. Frequency of alloantibodies in an UK hospital patient population. Trans Med 2002; 12 (Suppl 1): 34. 31. Verenini M, Verani MA, Talarico G, Strada P, Solda AM, Govoni M, Matteuci G, Mazzei C, Bonfa A, Girlli G, Vaglio S, Luciani M, Massaro AL, Rossi T, Ciaffoni S, Unis L, Malaguti J, Tomasini I, Cinollo G, Sindaco F, Reverberi R. Positive reactions in red cell antibody screening tests; a multicenter study. Vox Sang 2000; 78 (Suppl 1): 23. 32. Gooch A, Poole G, Knight R, Howkins K, Malde R, Maley M. The incidence of specific red cell antibodies reactive only in newer IAT technologies. Trans Med 2002; 12 (Suppl 1): 34. 33. Petrušić-Kafedžić A, Ljubunčić G, Samardžić M, Nikić S, Ivankovic Z. Changes observed after switch from tube test to gel microcolumn technique in pretransfusion testing, with factors possibly influencing the benefits. Vox Sang 2009; 96 (Suppl 1): 170. 34. Scharber EA, Roth S, Senne J, Ernst A, Huck K, Seyboth S, Richter E. HLA class I antibodies are the most common reason for unclear positive reactions in red cell antibody screen test in the gel technique. Transfusion 2002; 42 (Suppl): S104. 35. Rodey GE, Revels K, Fuller TC. Epitope specificity of HLA class I alloantibodies: II. Stability of crossreactive group antibody patterns over extended time periods. Transplantation 1997; 63: 885-93. 36. Lubenko A, Rodi KM. The detection by enzymelinked immunosorbent assay of non-complementfixing HLA antibodies in transfusion medicine. Transfusion 1998; 38:41-4. 37. Lubenko A, Rodi K, Wiliams M. HLA on RBC: more A plus B than just Bg. Trans Med 1997; 7 (Suppl 1):32. Petrušić-Kafedžić et al Pretransfuzijsko testiranje: gel stubac Changes in the structure and clinical significance of the positive results of pretransfusion testing during the switching from tube test agglutination to gel microcolumn technique Petrušić-Kafedžić Alma1, Ivanković Zdravko2, Ekinović Sabahudin³, Ibrahimagić-Šeper Lejla4 Department for Transfusiology, Cantonal Hospital Zenica, Zenica, Bosnia and Herzegovina, 2DiaHem, Buelach, Switzerland, ³ Faculty of mechanical engineering, University of Zenica, Zenica, 4Health Care Center Zenica; Zenica, Bosnia and Herzegovina 1 ABSTRACT Aim To investigate the changes in pretransfusion testing during the switch from the agglutination tube test to the gel test. Methods Clinical significance of positive results has been analyzed in 7667 pretransfusion tests (with 16610 cross-matches) performed by the tube test in 2005-2006, and in 7372 pretransfusion tests (with 17294 cross-matches) performed in 2007-2008 by the gel test. Results In both analyzed periods antibody detection was positive in 1.3% and cross-matching in 0.3% cases. At least one test was positive in 1.4% pretransfusions tested by the tube test and in 1.3% by the gel test, with >75% positive results in women. Analyzing cases with positive cross-matching but negative antibody detection, eight of ten such cases found by the tube test were caused by ‘cold antibodies’ whereas ‘warm non-specific antibodies’ caused all three cases found by the gel test. The gel test detected higher proportion of immune antibodies than the tube test (69.8% vs 41.3%, p<0.001), with a double increase in anti-K and Rh antibodies. The tube test detected 24 cases of clinically non-significant antibodies, as compared with no cases found by the gel test (p<0,001). ‘Non-specific antibodies’ more often caused positive cross-matches than antibody detection (42.6% vs. 29.9% by the tube test, 28.9% vs. 18.3% by the gel test). Despite of being close in the detection of irregular antibodies (p=0.062), the difference between the tube and gel test was not significant. ‘Non-specific antibodies’ were found by both tests more often in women, while clinical departments were of no significance. Conclusion The gel test has proved to be a more optimal technique of pretransfusion testing. The detection of irregular antibodies is recommended as an obligatory part of pretransfusion testing. Key words: pretransfusion testing, gel test, specificity Original submission: 09 April 2009; Revised submission: 28 October 2009; Accepted: 05 February 2010 131 ORIGINAL ARTICLE Etiologija limfadenopatije dječije dobi Edo Hasanbegović, Senada Mehadžić, Pedijatrijska klinika Kliničkog centra Univerziteta u Sarajevu SAŽETAK Cilj rada Utvrditi etiologiju i stepen rasprostranjenosti limfadenopatije kod djece. Metode Uzorak je obuhvatao 150 djece, uzrasta od 0-15 godina, kojima je na Pedijatrijskoj klinici u Sarajevu, tokom 2008. godine, dijagnosticirana limfadenopatija. Analizirani su dob, spol, etiologija i distribucija rasprostranjenosti limfadenopatije. Corresponding author: Edo Hasanbegović, Pedijatrijska klinika Kliničkog centra Univerziteta u Sarajevu, Patriotske lige 81, 71000 Sarajevo, Bosna i Hercegovina Phone: ++ 387 33 566 428; 566 400; Fax: ++ 387 71 566 525; E-mail: ehasanbe@bih.net.ba Rezultati Nije bilo statistički signifikantne razlike (p>0,05) u spolnoj i dobnoj strukturi ispitanika. U etiologiji limfadenopatije prednjačile su infekcije, kod 94 (62,7%), te malignomi, kod 20 (13,3%) pacijenata. Najčešće izolovani uzročnici infektivnih limfadenopatija bili su virusi kod 65 (69%) i bakterije kod 26 (28%) pacijenata. U etiologiji malignih limfadenopatija najčešće su bile zastupljene leukemije, i to akutne limfoblastne leukemije kod 11 (55%) i akutne mijeloične leukemije kod dvoje (10%) djece. Regionalna limfadenopatija bila je zastupljena kod 103 (68,7%), a generalizirana kod 47 (31,3%) pacijenata. Kod regionalne limfadenopatije najčešće su bile zahvaćene regije vrata, kod 83 (80,5%), aksile, kod 8 (7,8%) i prepone, 5 (4,8%) pacijenata. Zaključak Regionalne i generalizirane limfadenopatije uslovljene su etiologijom bolesti i značajno su utjecale na prognozu bolesti. Ključne riječi: limfadenopatija, etiologija, djeca Originalna prijava: 13. maj 2009.; Korigirana verzija: 11. august 2009.; Prihvaćeno: 16. septembar 2009. Med Glas Ljek komore Zenicko-doboj kantona 2010; 7(2):132-136 132 Hasanbegović et al Etiologija limfadenopatije kod djece UVOD Limfadenopatija je termin koji se upotrebljava za uvećane limfne čvorove i predstavlja jedan od čestih dijagnostičkih problema u pedijatrijskoj praksi. Smatra se da limfni čvor veći od 1 cm, u jednoj ili više regija, predstavlja limfadenopatiju, mada se njihova veličina razlikuje od regije do regije. Limfadenopatija može biti regionalna ili generalizirana. Regionalna limfadenopatija podrazumijeva povećanje jednog ili više čvorova u jednoj regiji, a generalizirana podrazumijeva povećanje limfnih čvorova u dvije ili više regija (2). Limfadenopatija može biti uzrokovana infektivnim i neinfektivnim uzročnicima. Infektivne limfadenopatije ili limfadenitisi mogu biti uzrokovani bakterijama, virusima, gljivama, protozoama ili parazitima. Neinfektivne limfadenopatije uzrokovane su imunološkom reakcijom u limfnim čvorovima ili malignom infiltracijom limfnih čvorova (1, 2). U diferencijalnoj dijagnozi limfadenopatije najvažnije je etiološki razjasniti uzrok nastanka limfadenopatije, odnosno prepoznati na vrijeme maligne bolesti limfnog i nelimfnog tkiva, koje se prezentiraju povećanim limfnim čvorovima (3). Cilj ovoga rada je utvrditi etiologiju i učestalost regionalne i generalizirane limfadenopatije kod djece, liječene na Pedijatrijskoj klinici u Sarajevu, u jednogodišnjem periodu. Budući da je dječija limfadenopatija čest diferencijalno- dijagnostički problem u pedijatrijskoj praksi, rezultati ovoga istraživanja poslužit će ljekarima primarne, sekundarne i tercijarne zdravstvene zaštite, koji se bave liječenjem djece za brzu i tačnu trijažu, dijagnostiku i terapiju ovog stanja. Naime, u našoj zemlji nije bilo sličnih istraživanja, a slične studije rađene su u Turskoj i Austriji (4-6). ISPITANICI I METODE U ovome retrospektivno-prospektivnom istraživanju obuhvaćena su sva djeca, uzrasta od 0-15 godina, kojima je na Pedijatrijskoj klinici Kliničkog centra u Sarajevu dijagnosticirana limfadenopatija, u periodu 01. 01. do 31. 12. 2008. godine. U studiju su uključena djeca kojima je prvi put postavljena dijagnoza limfadenopatije. Izvor podataka bile su istorije bolesti i anketni upitnik koji je posebno pripremljen za ovu studiju. Anketni upitnik sadržavao je slijedeće elemente: opšte podatke o pacijentu (ime i prezime, datum rođenja); ličnu i porodičnu anamnezu; nalaz kliničkog pregleda; laboratorijske pretrage (sedimentacija, kompletna krvna slika, transaminaze, bakar, beta-2-globulin); mikrobiološke pretrage (bris guše i nosa) i serološka analiza na Ebstein-Barrov virus (EBV) i citomegalovirus (CMV); radiološku pretragu grudnog koša (Rtg); ultrazvučni pregled (UZ) vrata i abdomena; te citološke i patohistološke pretrage. Virusna etiologija bolesti dokazivana je serološkim pretragama na EBV-u i CMV-u, te na temelju hematoloških pretraga (u perifernoj krvnoj slici leukopenija s limfocitozom, monocitozom i atipičnim limfocitima, uz isključenje druge etiologije). Prema dobnim skupinama formirane su tri grupe ispitanika: 0-5, 6-10 i 11-15 godina. Prema etiologiji limfadenopatije ispitanici su podijeljeni u dvije grupe, infektivnu i neinfektivnu, a prema stepenu rasprostranjenosti, na regionalnu i generaliziranu limfadenopatiju. Pod infektivnim limfadenopatijama podrazumijevane su one kod kojih je, na osnovu laboratorijskih i mikrobioloških pretraga, potvrđen infektivni uzrok bolesti. Neinfektivne limfadenopatije podrazumijevale su maligne, autoimune i atopijske bolesti. U akutne limfadenopatije uključili smo one koje su trajale 1-2 mjeseca, a kod kojih je, nakon tog vremena, došlo do smanjenja promjera limfnih čvorova do ispod 1-1,5 cm; a u kronične limfadenopatije one koje su trajale duže od 2 mjeseca, te su limfni čvorovi ostali povećani više od 1,5 cm poslije završene terapije. U statističkoj obradi podataka korištene su standardne metode deskriptivne statistike (mjere centralne tendencije, mjere disperzije). Za testiranje značajnosti razlika među uzorcima korišteni su parametarski i neparametarski testovi signifikantnosti (medijan hi kvadrat test- X²-test, Studentov t-test). Statističke hipoteze testirane su na nivou značajnosti od 95% (p< 0,05). Ovo istraživanje odobrili su etički komiteti Kliničkog centra Univerziteta u Sarajevu i Medicinskog fakulteta u Sarajevu. REZULTATI Ukupno je ispitano 150 djece, od kojih je 97 (64,66%) bilo dječaka, a 53 (35,34%) djevojčice (1,8:1) (p = 0,826). Interval starosne dobi pojave bolesti iznosio je 0,3-15 godina za dječake i 0,615 godina za djevojčice. 133 Medicinski Glasnik, Volumen 7, Number 2, August 2010 Tabela 1. Etiologija limfadenopatije s obzirom na spol djece Infektivna Maligna Ostala* Nepoznata Dječaci (n=97) 59 13 6 20 97 Djevojčice (n=53) 35 7 6 4 53 Ukupno (n= 150) 94 (62.7%) 20 (13.3%) 12 (8%) 24 (16%) 150 Tabela 3. Etiologija regionalne i generalizirane limfadenopatije Ukupno Infektivna Maligna Ostala* Nepoznata Regionalna Dječaci (n=63) 37 8 3 15 Djevojčice (n=40) 27 6 3 4 Ukupno (n=103) 64 (62,1%) 14 (13,6%) 6 (5,8%) 19 (18,5%) Dječaci (n=34) 22 5 2 5 8 1 4 0 *autoimune bolesti (n=6) , atopijske bolesti (n=4) i ciste glandule parotis (n=1) i glandule tireoidee (n=1). Iako je u svim dobnim skupinama (0-5, 6-10 i 1115 godina) broj dječaka s limfadenopatijom bio veći od broja djevojčica, 45, 38 i 14, odnosno 28, 20 i 5, razlika nije bila statistički značajna (p > 0 ,05). Najčešće zabilježena bila je infektivna etiologija limfadenopatije, kod 94 (62,7%) pacijenta, a maligna limfadenopatija kod 20 (13,3 %) pacijenata (Tabela 1). Virusi su bili najčešći uzročnici infektivnih limfadenopatija, kod 65 (69%) djece, i to EbsteinBarrov virus (EBV) kod 15 i citomeglovirus kod 12, te drugi virusi kod 38 pacijenata. Bakterije su bile uzročnici kod 26 (28%) djece, i to Staphylococcus aureus kod 7, Streptococcus beta haemoliticus kod 6, Streptococcus pneumoniae i Bartonella henselae svaki kod 3, te Mycobacterium tuberculosis kod 7 djece. Analiza etiologije malignih limfadenopatija pokazala je da su najčešće bile zastupljene leukemije, i to najčešće akutne limfoblastne leukemije (ALL), kod 11 (55%) djece (Tabela 2). Od limfadenopatija druge etiologije, koje su bile zastupljene kod 12 (8%) pacijenata, autoimune bolesti su nađene kod šest i atopijske bolesti kod četvoro djece (u istom broju kod dječaka i djevojčica), dok je kod jednog dječaka i jedne djevojčice ustanovljena cista glandule parotis, odnosno cista glandule tireoidee. Tabela 2. Distribucija maligne limfadenopatije prema etiologiji* ALL AML CML HL NHL RMS PNET Ukupno Dječaci 9 1 1 0 2 2 0 15 Djevojčice 2 1 0 1 0 0 1 5 Uku11 2 1 1 2 2 1 20 pno (55 %) (10%) (5 %) (5 %) (10%) (10%) (5 %) (100 %) *ALL, akutna limfoblastna leukemija; AML, akutna mijeloična leukemija; CML, kronična mijeloična leukemija; HL, Hodgkin limfom; NHL, Non-Hodgkin limfom; RMS, rabdomiosarcoma; PNET, primitivni neuroektodermalni tumor 134 Genera- Djevojčice lizirana (n=13) Ukupno (n=47) 30 (63,8%) 6 6 (12,8%) (12,8%) 5 (10,6%) *autoimune bolesti (n=6), atopijske bolesti (n=4), ciste glandule parotis (n=1), ciste glandulae tireoidee (n=1). Regionalna limfadenopatija bila je češće zastupljena, kod 103 (63 dječaka i 40 djevojčica) djece (68,7%), a generalizirana kod 47 (34 dječaka i 13 djevojčica) (31,3%) djece, bez statistički značajne razlike (p= 0,253). I regionalne i generalizirane limfadenopatije, u oba spola, bile su najčešće infektivne prirode, u 64 (62,1%), odnosno u 30 (63,8%) slučajeva (Tabela 3). Kod regionalnih limfadenopatija najčešće je bila zahvaćena regija vrata, kod 83 (55 dječaka i 28 djevojčica) (80,5%) djece, zatim regije aksile kod osam (podjednako kod dječaka i djevojčica) (7,8%), prepone kod pet (četiri dječaka i jedne djevojčice) (4,8%), te u regijama medijastinuma i abdomena kod četvoro (tri dječaka i jedne djevojčice), odnosno troje (dva dječaka i jedne djevojčice) djece (3,9%, odnosno 2,9%). Akutna limfadenopatija bila je češće zastupljena od kronične, u 103, odnosno 47 (68,7%, odnosno 31,3%) djece (Tabela 4). DISKUSIJA Od ukupno 150 pacijenata s limfadenopatijom, u našoj studiji, bilo je više dječaka od djevojčica u odnosu (1,8:1), što odgovara opisanim podacima iz literature (4, 5). Schaffer i saradnici, dva puta Tabela 4. Način javljanja i stepen rasprostranjenosti limfadenopatije* Regionalna (n=103) Generalizirana (n=47) Akutna (n=103) 68 35 Kronična (n=47) 35 12 * p = 0.398 Hasanbegović et al Etiologija limfadenopatije kod djece veći broj dječaka s limfadenopatijom u odnosu na djevojčice, objasnili su činjenicom da su novorođenčad, dojenčad i djeca do tri godine muškog spola, osjetljivija na bakterijske i virusne infekcije zbog razlike na nivou spolnih kromosoma i zbog više koncentracije IgM antitijela kod muške djece, a djevojčice tek u dobi od oko tri godine starosti dosežu nivo IgM antitijela muške djece (7). U etiologiji limfadenopatije u ovom istraživanju prednjačila je infektivna i maligna, (62,7%, odnosno 13,3%). Visoka prevalencija malignih limfadenopatija u našoj studiji (13,3%) rezultat je velikog broja djece upućene iz primarne zdravstvene zaštite, gdje je i postavljena sumnja na malignitet. Infektivna limfadenopatija, koja je inače puno češća, ne zahtijeva pregled i liječenje hematologa na klinici. Infektivna etiologija, u nekim istraživanjima, zastupljena je i do 81% slučajeva, a maligna 1624% (4, 5, 8). U studiji Granado RMJ i saradnika, iz 1992. godine, pronađeno je 16% limfadenopatija maligne etiologije, što je slično našim rezultatima (8). Virusna etiologija limfadenopatije, u našoj studiji, imala je značajno učešće, kako u regionalnoj, tako i u generaliziranoj limfadenopatiji (69%), te zatim bakterije (28%). Najčešće izoliran bio je EBV (21,7%), što je u skladu s rezultatima drugih studija (6). Relativno mali broj mikrobiološki potvrđenih bakterijskih izolata može se tumačiti činjenicom da je 50% naših pacijenata već bilo pod antibiotskom terapijom, kada su došli na našu kliniku. U nekim istraživanjima procenat bakterijskih infekcija bio je i do 35% (9, 10). Prema podacima iz literature, prevalencija tuberkulozne etiologije od 15-32% bila je znatno veća nego u našoj studiji (4,7%) (11). Regionalna limfadenopatija, u našem istraživanju, bila je češće zastupljena i kod akutnih i kod kroničnih limfadenopatija, što je u skladu s objavljenim podacima (4, 5). Prema podacima u literaturi, najčešće zahvaćena regija kod infektivne etiologije bila je cervikalna, a zatim aksilarna i ingvinalna, što je u potpunosti u skladu s našim rezultatima (3). Osim toga, cervikalna limfadenopatija javlja se i u više od 70 djece oboljele od limfoma (Hodgkin i Non Hodgkin) (12). Osim u regijama dostupnim fizikalnom pregledu, limfadenopatija može biti hilarna, medijastinalna i abdominalna (13, 14). Druga po učestalosti je aksilarna limfadenopatija, što je također u skladu s našim rezultatima. Prisustvo supraklavikularne limfadenopatije postavlja temeljnu sumnju na malignu etiologiju (12, 15). U dvije trećine slučajeva cervikalna limfadenopatija udružena je s medijastinalnom masom (16). Ove različite lokalizacije maligne limfadenopatije, već pri prvom kontaktu s pacijentom, mogu usmjeriti dijagnostiku prema malignom oboljenju. Limfadenopatija predstavlja veliki diferencijalno-dijagnostički problem za ljekara, te treba imati na umu da je zastupljenost regionalne i generalizirane limfadenopatije uslovljena etiologijom bolesti. Najčešći uzrok nastanka i regionalne, i generalizirane limfadenopatije, jesu infekcije izazvane virusima i bakterijama, ali je značajan broj limfadenopatija maligne etiologije (leukemije), na što uvijek treba misliti ukoliko povećani limfni čvorovi dugo traju i nema pozitivnog odgovora na antibiotsku terapiju. ZAHVALE/IZJAVE Komercijalni ili potencijalni dvostruki interes ne postoji. LITERATURA 1. 2. 3. Camitta B. The lymphatic system. U: Kliegeman BM, Behrman RE, Jenson HB. Stanton BF, urednici. Nelson textbook of pediatrics. 18. izd. Philadelphia: Saunders Elsevier, 2007:1677- 9. Stunzner D, Mangge H, Schenkeli R, Deutsch J. Peripheral lymphadenopathy in childhood-recommandations for diagnostic evaluation. Klin Pediatric 2000; 212: 277-82. Bazemore AW, Smucker DR. Lymphadenopathy and malignancy. Am Fam Physicians 2002; 66:210310. 4. 5. 6. Oguz A, Karadeniz C, Temel E, Citak E, Okur F. Evaluation of peripheral lymphadenopathy in children. Pediatr Hematol Oncol 2006; 23: 549-61. Ceyda K, Aynur O, Ustun E, Gulyuz O, Ayse D. The etiology of peripheral lymphadenopathy in children. Pediatr Hematol Oncol 1999;16:525-31. Benesch M, Kerbl R, Winsberger A, Stunzner D, Mangge H, Schenkeli R, Deutsch J. Peripheral lymphadenopathy in childhood-recommandations for diagnostic evaluation. Klin Pediatric 2000; 212:277-82. 135 Medicinski Glasnik, Volumen 7, Number 2, August 2010 7. Schaffer A J, Avery ME. Infections. U: Schaffer AJ,Avery ME, urednici. Disease of the newborn. 3. izd. Philadelphia: W.B. Saunders Company, 1997: 632-5. 8. Granado RMJ, A Guisasola FJ, Gomez MI, Bobillo del AH, Quirus B, Mateos Otero JJ. Diagnostic evaluation of cervical adenopathies in childhood. An Esp Pediatr 1992; 37:233-7. 9. Schleiss MR. Streptococcal infection. Pediatr Infect Dis J 2002; 21:796-7. 10. Trobs RB, Grafe G, Muller P, Handrick W. Bacterial cervical lymphadenitis- surgical aspect. Klin Pediatr 2003; 215:208-12. 11. Batra V, Ang JY, Asmar BI. Tuberculosis. South Med J 2003; 96:206-8. 12. Howard SC, Metzger MI, Hudson MM. Pediatric Hodgkin lymphoma. U:Antillon FA, Bernoala E, Sierrasesumaga I, urednici. Pediatric oncology. Pearson Education, 2006. 13. Hasanbegović E. Kliničke i hematološke karakteristike dječijih leukemija. ed Arh 2006; 60 (Suppl. 2):84-86. 14. Dahl GV, Weinstein HJ. Acute myeloid leukemia in children. U: Hoffman R, Benz EJ, Shatil SJ, Fuzie B, Colie HJ, urednici. Hematology: Basic principles and practice. Philadelphia: Churchil Lyvingstone, 2004:1121-33. 15. Rue D, Thomas RK, Behringer K, Diehl V. From Hodgkin disease to Hodgkin lymphoma: biologic insights and therapeutic potential. Blood 2005; 105: 4553-60. 16. Predojević-Samardžić J, Roganović J. Limfomi u djece. Pedijatrija danas 2009; 5:51-61. Etiology of lymphadenopathy in childhood Edo Hasanbegović, Senada Mehadžić Pediatric Clinic, Clinical Centre University of Sarajevo ABSTRACT Aim To establish etiology and level of prevalence of lymphadenopathy in children. Methods: One hundred and fifteen children aged 0-15 years with diagnosed lymphadenopathy at the Pediatric Clinic in Sarajevo during 2008 were included in the study. It analyzed age, sex, etiology and distribution and prevalence of lymphadenopathy. Results There was no statistically significant difference (p > 0,05) according to gender and age of children with lymphadenopathy. Leading etiological causes of lymphadenopathy were infections in 95% (62,7 %) and malignancies in 20 (13,3 %) cases. The most frequent isolated microorganisms were viruses in 65 children (65 %) and bacteria in 26 (28%) of children. Most frequent causes of malignant lymphadenopathy were acute lymphoblastic leukemia in 11 children (55 %) and acute myeloid leukemia in two (10%) children. Regional lymphadenopathy was more frequent than generalized lymphadenopathy, in 103 children (68,7%) and 47 (31,3 %) children, respectively. Most frequent localizations of regional lymphadenopathy were neck, axillae and groin, in 83, 8, and 5 (80,5 %, 7,8%, 4,8%) children. Conclusion The regional and generalized lymphadenopathies in children depend on their etiology and have significant prognostic value for the disease. Key words lymphadenopathy, etiology, children Original submission: 13 May 2009.; Revised submission: 11 August 2009.; Accepted: 16 September 2009 136 ORIGINAL ARTICLE Lunarni ciklus i cerebralni napadi u djece Devleta Hadžić, Nada Mladina, Belkisa Čolić-Hadžić, Amela Numanović Univerzitetski klinički centar Tuzla, Klinika za dječije bolesti SAŽETAK Cilj Analizirati jednogodišnji trend hospitalizacije djece liječene zbog cerebralnih napada i mogući uticaj lunarnog ciklusa. Metode Retrospektivno su analizirani podaci koji se odnose na sezonsku distribuciju prijema u bolnicu (mjesec, sedmica, datum i čas prijema, dan u sedmici, doba dana, te odnos prema lunarnim ciklusima) svih pacijenata liječenih zbog cerebralnih napada (konvulzije, epi napad, kriza svijesti i epi napad u djece s neurorazvojnim poremećajima), tokom 2008. godine, u Klinici za dječije bolesti Univerzitetskog kliničkog centra. Corresponding author: Devleta Hadžić, Univerzitetski klinički centar Tuzla, Klinika za dječije bolesti Trnovac bb, 75000 Tuzla Bosna i Hercegovina Phone.: ++387 35 303 713; Fax.: ++387 35 250-474; E-mail: devletahadzic@yahoo.com Originalna prijava: 14. april 2009.; Rezultati Od ukupno 234 liječene djece, dojenčadi je bilo 55 (23,5%), djece do šest godina 101 (43,1%), a djece školskog uzrasta 78 (33,3%). Najčešći oblik cerebralnih napada bile su konvulzije, 123 (52,6 %). Sredinom sedmice zabilježen je veći broj napada nego vikendom. Najveći broj djece liječen je u januaru, februaru, julu i augustu, odnosno, u 4., 7., 27. i 31. sedmici u godini. U 149 pacijenata (63,7%) cerebralni napad dogodio se tokom dana, a kod 84 pacijenta (35,9%) tokom noći (p < 0,0034). Broj liječenih pacijenata bio je značajno veći u trećoj i četvrtoj lunarnoj fazi (p < 0,018). Zaključak Budući da su rezultati istraživanja pokazali sezonski i sedmični trend hospitalizacije pacijenata zbog cerebralnih napada, te povezanost s cirkadijanim i lunarnim ciklusom, oni bi mogli poslužiti kao osnova za daljnje i detaljnije istraživanje na većem uzorku s ciljem provjere rezultata i eventualnih novih saznanja. To bi moglo doprinijeti boljem razumijevanju i jedinstvenijem tumačenju teorija o uticaju mjeseca i njegovih pojedinih faza na zdravlje ljudi. Ključne riječi: lunarni ciklus, cerebralni napadi, djeca; Korigirana verzija: 31. juli 2009.; Prihvaćeno: 19. august 2009. Med Glas Ljek komore Zenicko-doboj kantona 2010; 7(2):137-142 137 Medicinski Glasnik, Volumen 7, Number 2, August 2010 UVOD ISPITANICI I METODE Po definiciji cerebralni napadi obilježeni su naglom, ali prolaznom pojavom psihičkih, motoričkih, senzornih ili vegetativnih simptoma, koji su posljedica prolazne disfunkcije mozga (1). Prema patogenezi dijele se na epileptičke, hipoksične, metaboličke, toksične, psihogene i neepileptičke; s tim da se mogu kombinirati i izazivati jedan drugi (2). Najčešći pojavni oblik cerebralnih napada u djece jesu različiti oblici konvulzija, s prevalencijom u ukupnoj populaciji djece do 5 godina starosti od 5-7% (1, 2). Na svu sreću, konvulzije ili cerebralni napadi većinom ne predstavljaju epilepsiju, već su prolazne epizode koje prestaju kada se ukloni uzrok (3). Epilepsije su hronične bolesti mozga različitog uzroka, obilježene ponavljanjem epileptičkih napada i u pravilu praćene elektroencefalografskim abnormalnostima. Hroničnost, odnosno recidivi napada, jedno su od bitnih obilježja epilepsije. Kada govorimo o epilepsiji, želimo istaknuti da postoji više različitih oblika ove bolesti koji se međusobno razlikuju po uzrocima, dobi javljanja, kliničkoj slici, liječenju i prognozi (4). Svaka deseta osoba u svom životu doživi epileptički napad ili je njime u stanovitoj mjeri ugrožena (3). Retrospektivno, koristeći protokole prijema, kao i historije bolesti, analizirani su svi pacijenti liječeni zbog cerebralnih napada u Klinici za dječije bolesti Univerzitetskog kliničkog centra (UKC) Tuzla, u periodu od 01. 01. do 31. 12. 2008. godine. Istraživanje je provedeno u skladu s etičkim normama i standardima, te odobreno od strane Etičkog komiteta ove ustanove. Uzroci pojave cerebralnih napada su različiti. Osim osnovnih uzroka, postoji veliki broj poznatih i nepoznatih svakodnevnih provocirajućih i dispozicijskih faktora koji mogu provocirati napad, kao naprimjer: spavanje, neprospavana noć, fotostimulusi, duboko disanje, povišena temperatura, vrsta prehrane, opstipacija, napetost ili opuštenost, emocionalne promjene, napori, poremećaji metabolizma, izlaganje suncu, vremenske promjene i dr. (3, 4). U nekim istraživanjima ustanovljena je povezanost povećanog broja pacijenata s konvulzijama, epilepsijom i drugim bolestima s precipitirajućim okolinskim faktorima, kao što su dnevne, sedmične, mjesečne, sezonske oscilacije (5, 6), dok je u drugim predmet istraživanja bio lunarni ciklus i njegov mogući uticaj na čovjeka i zdravlje (7, 8). Cilj ovog istraživanja bio je da se analizom jednogodišnjeg kretanja broja pacijenata, primljenih zbog cerebralnih napada u Kliniku za dječije bolesti Tuzla, istraži mogući uticaj lunarnog ciklusa na trend hospitalizacije. 138 Cerebralni napadi, u našem istraživanju, svrstani su u četiri grupe: konvulzije, epi napad, kriza svijesti i epi napad u djece s neurorazvojnim poremećajima (NRP). Analizirani su dob, spol, mjesto stanovanja i sezonska distribucija prijema u bolnicu (mjesec, sedmica, datum i čas prijema, dan u sedmici, doba dana, te odnos prema lunarnim ciklusima). U istraživanju je korištena i druga baza podataka dobijena iz aktuelnog lunarnog kalendara (9) za period koji je bio obuhvaćen istraživanjem. Lunarni kalendar sadrži 12 lunarnih mjeseci koji traju 29,5 dana. Svaki lunarni mjesec sadrži četiri lunarne faze od po sedam dana. Prva i druga faza jesu faze rastućeg mjeseca, a treća i četvrta faze mjeseca u opadanju. Između druge i treće faze su dani punog mjeseca (9). Podaci iz ovog kalendara pridruženi su odgovarajućim podacima iz važećeg solarnog gregorijanskog kalendara za period koji je obuhvaćen istraživanjem. Svakom pacijentu izračunata je pripadajuća lunarna faza u vrijeme prijema u bolnicu, odnosno u vrijeme doživljenog cerebralnog napada. U statističkoj obradi podataka korištene su standardne metode deskriptivne statistike (mjere centralne tendencije, mjere disperzije). Za testiranje značajnosti razlika među uzorcima korišteni su parametarski i neparametarski testovi signifikantnosti (X²-test, Studentov t-test), kao i metoda linearne korelacije. Statističke hipoteze testirane su na nivou signifikantnosti od 95% (p < 0,05). REZULTATI U promatranom jednogodišnjem periodu u Klinici za dječije bolesti UKC Tuzla, liječeno je 3470 pacijenata. Od toga su 234 (6,74%) pacijenta, u dobi od jednog mjeseca do 15 godina, bili hitno primljeni zbog cerebralnih napada: konvulzije, epilepsije, krize svijesti i epilepsije u sklopu neurorazvojnih bolesti. Prosječna starosna dob uzor- Hadžić et al Lunarni ciklus i cerebralni napadi u djece Grafikon 1. Dobna i spolna distribucija djece liječene zbog cerebralnih napada Grafikon 2. Distribucija uzorka prema spolu i vrsti napada ka iznosila je 4,9 ± 4,6 godina. Distribucija po spolu pokazala je da su 116 (49,6%) pacijenata bili dječaci, a 118 (50,4%) djevojčice. Dojenčadi je bilo 55 (23,5%), pacijenata od jedne do šest godina 101 (43,1%), a školskog uzrasta 78 (33,3%) pacijenata (Grafikon 1). Raspodjela uzorka prema zabilježenom satu napada pokazala je najčešću pojavu napada u periodu između 12 i 15 sati, kod 44 pacijenta (18,8%), a najmanji broj napada zabilježen je u periodu između 3 i 6 sati ujutro, kod 10 pacijenata (4,3%) (Grafikon 4). Od ukupnog broja liječenih pacijenata najveći broj bio je liječen zbog konvulzija, ukupno 123 pacijenta (52,6%) (Grafikon 2). Od ukupno 234 pacijenta, kod 149 (63,7%) cerebralni napad dogodio se tokom dana, dok se kod 84 pacijenta (35,9%) cerebralni napad dogodio tokom noći (Grafikon 4). Geografska distribucija uzorka djece liječene zbog cerebralnih napada, u toku jednogodišnjeg perioda, gotovo je u potpunosti odgovarala geografskoj distribuciji ukupne populacije djece do 15 godina za područje Tuzlanskog kantona. Najveći broj djece liječen je u januaru, februaru, julu i augustu (Slika 1). Najveći broj pacijenata liječen je u 4., 7., 27. i 31. sedmici u godini (Slika 2). Najveći broj napada dogodio se četvrtkom, kod 49 pacijenata (20,9%), a najmanji broj napada subotom, kod 21 (9%) pacijenta (p < 0,041) (Grafikon 3). Slika 1. Distribucija pacijenata s cerebralnim napadom po mjesecima Broj liječenih pacijenata bio je značajno veći u periodu mjeseca u opadanju (treća i četvrta faza), 124, u odnosu na period mjeseca u porastu (prva i druga faza), 110 (p < 0,018) (Grafikon 5). Konvulzije nisu imale značajne razlike u učestalosti tokom pojedinih lunarnih faza, dok su epi napadi bili značajno češći u trećoj i četvrtoj lunarnoj fazi. Krize svijesti i epi napadi u djece s neurorazvojnim poremećajima bili su najčešći u trećoj lunarnoj fazi (Grafikon 6). Slika 1. Distribucija pacijenata s cerebralnim napadom po sedmicama 139 Medicinski Glasnik, Volumen 7, Number 2, August 2010 Grafikon 3. Distribucija pojava napada prema danima u sedmici Grafikon 5. Broj liječenih pacijenata u pojedinim mjesečevim fazama Konvulzije kod dječaka bile su češće u prvoj i trećoj lunarnoj fazi, 21 (34,4%), 17 pacijenata (27,9%), za razliku od djevojčica kod kojih su konvulzije bile češće u drugoj i četvrtoj lunarnoj fazi, 18 (29,0%), odnosno 16 pacijenata (25,8%). Epi napad u dječaka bio je najčešći u trećoj, a u djevojčica u četvrtoj lunarnoj fazi, 8 pacijenata u obje grupe (38,1%, odnosno 44,4%). Krize svijesti, i u dječaka i u djevojčica, bile su najčešće u trećoj lunarnoj fazi, 9 (32,1%), odnosno 10 (27,8%). U djece s neurorazvojnim poremećajima učestalost epi napada u dječaka nije se značajno mijenjala tokom lunarnih faza, dok je u djevojčica s neurorazvojnim poremećajima epi napad zabilježen u trećoj lunarnoj fazi kod obje (Slika 3). lokalizacije epi fokusa. Ravnoteža ovog cirkadijanog ritma i neuroendokrinog cirkadijanog ciklusa, ritma spavanje/budnost, te niza okolinskih faktora, jesu pretpostavljeni ambijent koji rezultira pojavom cerebralnih napada (5, 10, 11). Najveći broj pacijenata liječenih zbog cerebralnih napada u Klinici za dječije bolesti UKC Tuzla, tokom 2008. godine, bili su u uzrastu do šest godina. Ova dobna raspodjela odgovara vrsti zabilježenih napada jer su konvulzije bile najčešći oblik cerebralnih napada. Na trend hospitalizacije nisu bitnije utjecali spol i mjesto stanovanja, ali je statistički značajno ustanovljen sezonski i sedmični karakter, te povezanost s cirkadijanim i lunarnim ciklusom. Do sada objavljeni podaci sugeriraju o cirkadijanom karakteru cerebralnih napada, koji zavisi od vrste napada i eventualne Vjerovanje da puni mjesec ima uticaja na zdravlje ljudi perzistira uprkos 50-godišnjim studijama koje pokazuju da ova veza ne postoji (12). Ove studije trasirale su historijsku putanju vjerovanju moći mjeseca da izazove mentalne poremećaje, prije svega nesanicu i epilepsiju. Vul je 1976. godine, na bazi matematičke analize 84000 slučajeva konvulzije tokom 101 promatrane mjesečeve faze, ustanovio porast konvulzija u pacijenata s epilepsijom u odnosu na pacijenate s ostalim oblicima konvulzija tokom promatranih perioda punog i mladog mjeseca, što je objasnio utjecajem fizičkih faktora, kao što je magnetna teorija nastanka epileptičkog procesa (13). Prioritet u napretku novim spoznajama o uticaju mjeseca bio je kroz spoznaju da mjesec, preko fenomena osvjetljenja, narušava ciklus san/buđenje s tendencijom da izazove deprivaciju od sna u vrijeme faze punog mjeseca (8, 12). Ova parcijalna deprivacija od sna dovoljna je da inducira maniju, hipomaniju ili mogući bipolarni poremećaj, ili konvulzivni napad u pacijenata s epilepsijom. Moderna saznanja umanjuju značaj ovom lunarnom efektu, pogotovo u modernim urbanim područjima gdje je provedena većina studija o Grafikon 4. Distribucija uzorka prema satu pojave napada u toku dana Grafikon 6. Distribucija pojedinih oblika cerebralnih napada po lunarnim fazama DISKUSIJA 140 Hadžić et al Lunarni ciklus i cerebralni napadi u djece Slika 3. Distribucija pacijenata prema vrsti napada, spolu i lunarnoj fazi lunarnom efektu u 20. stoljeću (13). Analiza lunarnog ciklusa i broja hospitaliziranih pacijenata zbog cerebralnih napada, u našem je istraživanju pokazala da je broj liječenih pacijenata bio značajno veći u trećoj i četvrtoj lunarnoj fazi (period mjeseca u opadanju), u odnosu na prvu i drugu lunarnu fazu (mjesec u porastu), te da se učestalost konvulzija nije mijenjala tokom pojedinih lunarnih faza, dok su epi napadi bili značajno češći u trećoj i četvrtoj lunarnoj fazi, i to u dječaka u trećoj, a u djevojčica u četvrtoj lunarnoj fazi. Rezultati objavljenih studija u kojima je analiziran uticaj lunarnih faza na trend hospitalizacije zbog konvulzija i epilepsije nisu jedinstveni. Benbadis i saradnici 2004. godine, analizirajući trend prijema u bolnicu zbog epileptičkih i neepileptičkih konvulzija, u ukupnom uzorku nisu ustanovili statistički značajnu povezanost s pojedinim fazama lunarnog ciklusa, dok je pojedinačna analiza pokazala porast neepileptičkih konvulzija u danima punog mjeseca, a epileptičkih konvulzija u četvrtoj fazi lunarnog ciklusa (14). Za razliku od ove studije, Polychro- nopolulos i saradnici 2006. godine registrovali su signifikantno grupisanje broja napada u periodu punog mjeseca (15). U prilog ovom su i rezultati studije Terra-Bustamante i saradnika, objavljeni 2008. godine, koji sugeriraju moguću korelaciju punog mjeseca i iznenadne smrti u epilepsiji (16). Rezultate slične našima objavili su Ruegg i saradnici 2008. godine, te ustanovili signifikantno češću hospitalizaciju pacijenata u epilepsijskom statusu tokom dana, najčešće između 16 i 17 sati, a najmanji broj prijema u ranim jutarnjim satima. Prijem je statistički značajno varirao tokom pojedinih faza lunarnog ciklusa, a incidenca prijema bila je signifikantno niža tokom vikenda (7). U studiji Baxendalea i Fisfera iz 2008. godine, nađena je značajna negativna korelacija između prosjeka broja napada i stepena mjesečeve osvijetljenosti, što je sugeriralo važniju ulogu mjesečeve osvijetljenosti nego same mjesečeve faze (17). U zaključku možemo reći da najnovije studije potvrđuju uticaj mjeseca i njegovih pojedinih faza na trend hospitalizacije pacijenata zbog cerebralnih napada, prije svega epilepsije, ali da mehanizam uticaja i povezanosti ipak još uvijek nije do kraja razjašnjen. U našem istraživanju trend hospitalizacije pacijenata zbog cerebralnih napada bio je statistički značajno povezan s okolinskim faktorima, kao što su sezonski, sedmični i cirkadijani ciklus. Uticaj lunarnog ciklusa također se pokazao značajnim jer je broj liječenih pacijenata bio značajno veći u trećoj i četvrtoj lunarnoj fazi u odnosu na prvu i drugu fazu. Ovi rezultati mogli bi biti osnova za daljnju, detaljniju analizu i istraživanje na većem uzorku, s ciljem provjere rezultata i eventualnih novih saznanja. To bi moglo doprinijeti boljem razumijevanju i jedinstvenijem tumačenju teorija o uticaju mjeseca i njegovih pojedinih faza na zdravlje ljudi. ZAHVALE/IZJAVE Komercijalni ili potencijalni dvostruki interes ne postoji. LITERATURA 1. Anić O, Durrigl V, Judaš M, Jušić A, KostovićKnežević Lj, Kostović I, Pospiš M, Sofijanov N, Zergollern Lj. Bolesti živčanog sustava i mišića. U: Zergollern Lj, urednik. Pedijatrija. Zagreb: Naprijed, 1994:1510-629. 2. 3. Škarpa D. Bolesti živčanog sustava i mišića. U: Mardešić D, urednik. Pedijatrija. Zgreb: Školska knjiga, 2003:959-1050. Fenichel G. Clinical Pediatr Neurol: A signs and symptoms approach. 5. izdanje. Philapelphhia: Saunders, 2005:256-63. 141 Medicinski Glasnik, Volumen 7, Number 2, August 2010 4. Fountain NB. Status epilepticus: risk factors and complications. Epilepsia 2000; 41: 23-30. 5. Quiqq M. Circadian rhythms: interactions with seizures and epilepsy. Epilepsy Res 2000; 42: 43-55. 6. Kotsopoulos IA, van Merode T, Kessels FG, de Krom MC, Knottnerus JA. Systematic review and meta-analysis of incidence studies of epilepsy and unprovoked seizures. Epilepsia 2002; 43:1402-9. 7. Ruegg S, Hunziker P, Marsch S, Schindler C. Association of environmental factors with the onset of status epilepticus. Epilepsy Behav 2008; 12:66-73. 8. Eadie MJ. The understanding of epilepsy across three millennia. Clin Exp Neurol 1994; 31:1-12. 9. Kafadar H. Izrada I obračun kalendara I vaktija. Takvim za 2008. Sarajevo: Rijaset IZ u BiH, 2007: 278-300. 10. Pavlova MK, Shea SA, Bromfield EB. Day/night patterns of focal seizures. Epilepsy Behav 2004; 5:44-9. 11. Manfredini R, Verqine G, Boari B, Faqqioli R, Borqna-Piqnatti C. Circadian and seasonal variation of first febrile seizures. J Pediatr 2004; 145:838-9. 12. Raison CL, Klein HM, Steckler M. The moon and madness reconsidered. Affect Disord 1999; 53:99106. 13. Vul FR. “Lunar rhythms” in the course of the epileptic process. Zh Nevropatol Psikhiatr Im S S Korsakova 1976; 76:1875-9. 14. Benbadis SR, Chang S, Hunter J, Wang W. The infuence of the full moon on seizure frequency: myth or reality? Epilepsy Behav 2004; 5:596-7. 15. Polychronopoulos P, Argyriou AA, Sirrou V, Huliara V, Aplada M, Gourzis P, Economou A, Terzis E, Chroni E. Lunar phases and seizure occurrence: just an ancient legend? Neurology 2006; 66:1442-3. 16. Terra-Bustamante VC, Scorza CA, de Albuquerque M, Sakamoto AC, Machado HR, Arida RM, Cavalheiro EA, Scorza FA. Does the lunar phase have an effect on sudden unexpected death in epilepsy? Epilepsy Behav 2008; 14: 624-31. 17. Baxendale S, Fisher J. Moonstruck? The effect of the lunar cycle on seizures. Epilepsy Behav 2008; 13:549-50. The lunar cycle and seizures in children Devleta Hadžić, Nada Mladina, Belkisa Čolić-Hadžić, Amela Numanović Pediatrics Clinic, University Clinical Center of Tuzla ABSTRACT Aim To analyze the annual trend of hospitalization and potential influence of the lunar cycle of children treated for seizures. Methods The data of the patients treated for seizures (convulsions, epileptic seizures, disturbance of consciousness and epileptic seizures in children with neurodevelopmental disability) in the Pediatrics Clinic of the University Clinical Center of Tuzla were retrospectively analyzed during 2008 in relation to seasonal distribution, admission time (month, week, admission moment, day in a week, time of the day) and the lunar cycle. Results Out f the total of 234 treated children, 55 (23,5%) were infants, 101 (43,1%) were under six years of age and 78 (33,3%) were of school age. The most common type of seizures were convulsions, 123 (42,6%). The seizures were numerous in the midst of the week, as opposed to weekends. The highest number of children was treated in January, February, July and August, that it, in the fourth, seventh, twenty-seventh and thirty-first week of the year. Seizures occured during the day in 149 patients (63,7%) and during the night in 84 (35,9%) patients (p < 0,0034). The number of treated patients was significantly larger in the third and fourth lunar phases (p < 0,018). Conclusion The results suggested seasonal and weekly trends of hospitalization of patients with seizures and their relation with circadian and lunar cycles. There is a need for further prospective studies in order to get better understanding of the influence of the lunar cycle on health. Key words: the lunar cycle, seizures, children. Original submission: 14 April 2009.; Revised submission: 31 July 2009.; Accepted: 19 August 2009 142 ORIGINAL ARTICLE Increased P wave dispersion in patients with liver steatosis Mustafa Aparci1, Zafer Isilak2, Omer Uz2, Ejder Kardesoglu2, Omer Yiginer2, Onur Sildiroglu3, Murat Yalcin4, Namık Ozmen2, Bekir Yilmaz Cingozbay2, Bekir Sitki Cebeci2 1 3 Air Force Academy Hospital, Cardiology Service, Istanbul, 2GATA Haydarpaşa Teaching Hospital, Department of Cardiology, Istanbul, GATA Haydarpaşa Teaching Hospital, Department of Radiology, İstanbul, 4Izmir Military Hospital, Cardiology Service, Izmir, Turkey ABSTRACT Aim Hepatic steatosis is associated with metabolic and hemodynamic abnormalities induced by insulin resistance and inflammatory state. Since abnormalities of P wave dispersion may be accompanied with latter issues we evaluated this subject in patients with hepatic steatosis. Methods Total of 106 patients and 56 healthy subjects were enrolled and performed hepatic ultrasonography, echocardiography, electrocardiogram, and biochemistry tests. Clinical features, laboratory and echocardiographic parameters, P wave dispersion were compared between groups and analyzed for any correlation among parameters. Corresponding author: Mustafa Aparci Air Force Academy Hospital, Cardiology Service Yesilyurt/ Istanbul/ Turkey Phone: ++90 505 3947131; Fax: ++90 212 233 44 56; Email: maparci@gmail.com Original submission: 06 July 2009.; Revised submission: 25 August 2009.; Accepted: 04 November 2009. Results Body mass index (BMI), waist circumference, systolic and diastolic blood pressure, levels of total and LDL cholesterol, and fasting blood glucose (FBG), and left atrial diameter were significantly higher in patients with hepatic steatosis. Peak velocities of mitral E and A waves and their ratio were abnormally changed in patients compared to normals. In multiple linear regression analysis, approximately all of the variables previously correlated within Pearsons’ correlation test were found to be significantly correlated with P wave dispersion [ waist circumference (ß=0.151, p=0.048), LDL cholesterol (ß=0.234, p=0.000), FBG (ß=0.402, p= 0.000), alanine aminotransferase (ALT) (ß=0.205, p= 0.006), alkaline phosphatase (ALP) (ß=0.277, p=0.000), γ-glutamyl transferase (γ-GT) (ß=0.240, p=0.000), left atrial diameter (ß=0.204, p=0.003), heart rate (ß=0.123, p=0.037)]. Conclusion Increased P wave dispersion may indicate a risk of atrial arrhythmia which may be complicated with disabling symptoms and thromboembolism in patients with hepatic steatosis. Consequently, hepatic steatosis is associated with increased risk for cardiovascular disease due to metabolic and hemodynamic abnormalities probably induced by insulin resistance and inflammatory state. Key words: fatty liver, arrhythmia, echocardiography, insulin, inflammation Med Glas Ljek komore Zenicko-doboj kantona 2010; 7(2):143-147 143 Medicinski Glasnik, Volumen 7, Number 2, August 2010 INTRODUCTION Prevalence of hepatic steatosis is growing in developed countries probably due to lifestyle and dietary habits which potentially promote atherosclerosis. Consequently an increase in prevalence of cardiovascular diseases among either diabetic or non-diabetic patients with hepatic steatosis is being observed (1). Thus this clinical issue is suggested to be a novel component of metabolic syndrome (2). It was documented that hepatic steatosis was closely associated with insulin resistance and increased levels of oxidative stress and endothelial dysfunction (3). Since liver steatosis is a low-grade inflammatory disease of the liver atherosclerosis in which inflammatory mediators might have had an important role could easily be initiated and progress (4). Also insulin resistance and subclinical inflammation have a reciprocal and an additive relationship which may induce a predisposition to atherosclerosis. Moreover, those abnormalities may induce sympathetic over-activity which could induce inhomogeneous electrical activity of myocardium and also atrium (5,6). Sympathetic over-activity and sub-inflammation may coexist and are probably the essential features of hemodynamic abnormalities clustered in metabolic syndrome (7). P wave is the reflection of atrial electrical activity on the surface electrocardiogram (8). It may potentially be influenced by the hemodynamic and metabolic abnormalities which are frequent in patients with liver steatosis (9). Thus, we aimed to evaluate the P wave dispersion in patients with hepatic steatosis in this study. PATIENTS AND METHODS The total of 106 patients with hepatic steatosis and 56 healthy subjects underwent clinical examination, echocardiography, hepatic ultrasonography, and 12 lead electrocardiograhy. All participants were informed about the study and signed informed consent forms. Electrocardiograms (ECG) were recorded at 50 mm/sec rate and 10 mm/mV and analyzed digitally. P wave dispersion was determined as the difference between minimum and maximum P wave durations by a cardiologist blinded to the study project and clinical information of patients. (P wave dispersion=PMaximum-PMi). Participants with ECG abnormalities (<60 nimum 144 or >100 beats per minute, ST segment and T wave abnormalities, short PR interval, left ventricular hypertrophy criteria, etc.) were excluded. Hepatic ultrasonography was performed by a single experienced radiologist who was bound to study project. Ultrasonography has a sensitivity of 90% and a specificity of 95% in diagnosing and grading of hepatic steatosis (10). Serum levels of plasma liver tests including alanine aminotransferase (ALT), aspartate aminotransferase (AST), alkaline phosphatase (ALP) and GGT, and total cholesterol, LDL cholesterol, HDL cholesterol, and triglyceride, fasting blood glucose (FBG) were determined from venous blood samples obtained at 12 hour fasting state. Patients with cirrhotic liver disease, positive serology for viral hepatitis B and C, history of hepatotoxic medication, heavy smoking and alcohol consumption, overt diabetes and hypertension, familial hyperlipidemia were excluded from the study. We used Independent-Samples-t test for comparison of continuous variables. Associations of P wave with clinical, echocardiographic and laboratory parameters assessed by Pearson’s correlation test and independent relationships were assessed by multiple linear regression analysis and reported as standardized regression coefficients and their significance. A 2-tailed p value <0.05 was considered as statistically significant. Statistical analyses were performed using SPSS 11.0 for Windows. RESULTS In comparison of patients with liver steatosis and healthy subjects, body mass index (BMI), waist circumference, systolic and diastolic blood pressures were significantly higher in patients with liver steatosis (p<0.01) (Table 1). Also laboratory parameters such as levels of total cholesterol , LDL and HDL cholesterol, triglyceride, fasting blood glucose were abnormally increased in patients’ group (p<0.05). Serum levels of liver enzymes such as ALT, ALP, and γ-glutamyl transferase (γ-GT) except AST were significantly higher in patients with liver steatosis as expected (p<0.01). In comparison of echocardiographic parameters ejection fraction was slightly higher in healthy subjects and left atrial diameter was significantly increased in patients with liver steatosis (p<0.01). Peak velocities of both mitral E Aparci et al P wave dispersion in hepatic steatosis and A waves were significantly increased in patients with liver steatosis as compared to healthy subjects (p<0.05). Additionally, ratio of peak velocities of mitral E wave to A wave was significantly decreased in the patients’ group (p<0.05). Deceleration time of mitral E wave and isovolumic relaxation time were not statistically significant between groups (p>0.05). Heart rate was Table 1. Comparison of clinical features, laboratory parameters and parameters of aortic elasticity among patients with liver steatosis and healthy individuals Patients with liver steatosis (n=102) Healthy Subjects (n=56) 34,5±7,0 33,1±6,3 0.064 66/36 38/18 0.23** p Clinical features* Age (years) Gender (M/F) BMI (kg/m2) 27.32±3.2 24.8±2.4 0.000 Waist circumference M F 104.2±10.7 90.4±8.2 96.7±9.2 84.6±9.2 0.001 Systolic blood pressure (mm Hg) 120.8±7.0 115.0±10.9 0.000 Diastolic blood pressure (mm Hg) 72.2±7.5 64,6±9.6 0.000 Laboratory parameters Total cholesterol (mg/dl) 214.06±42.6 194.8±32.2 0.007 LDL cholesterol (mg/dl) 120.4±24.8 0.007 HDL cholesterol (mg/dl) 136.0±30.8 42.8±8.2 39.8±6.0 0.013 Triglyceride (mg/dl) 158.8±64.6 150.4±60.6 0.377 FBG (mg/dl) 97.4±10.8 94.6±6.0 0.043 BUN (mg/dl) 13.2±3.1 13.8±1.8 0.327 AST (IU/L) 26.8±10.5 24.4±8.1 0.46 ALT (IU/L) 52.8±23.6 34.6±7.4 0.000 ALP (IU/L) 74.2±18.6 54.4±20.8 0.000 γ-GT (IU/L) 48.8±11.8 40.2±8.4 0.003 Echocardiography LVIDd (mm) 45.9±3.2 45.4±2.7 0.276 LVIDs (mm) 28.6±3.7 28.2±2.4 0.348 EF (%) 65.8±4.7 67.3±3.0 0.067 LAD (mm) 33.6±2.6 32.0±2.5 0.000 Mitral E wave velocity (m/s) 0.72±0.14 0.63±0.16 0.000 Mitral A wave velocity (m/s) 0.58±0.10 0.46±0.16 0.022 E/A ratio 1.37±0.22 1.47±0.39 0.016 E wave DT (msec) 167.40±45.35 160.31±34.01 0.289 IVRT (msec) 100.4±21.66 101.9±30.3 significantly higher in patients with liver steatosis (p<0.01). Also P wave dispersion was significantly increased in patients with liver steatosis as compared to healthy subjects (41.6±6.5 msec vs 36.2±4.8 msec, p<0.01) (Table 1). P wave dispersion was significantly correlated with waist circumference, LDL cholesterol, fasting blood glucose, levels of ALT, ALP, and γ-GT, left atrial diameter, and also heart rate in bivariate correlation analysis (p<0.05) (Table 2). In multiple linear regression analysis, approximately all of the variables previously correlated within Pearsons’ correlation test were found to be significantly correlated with P wave dispersion [ waist circumference (ß=0.151, p=0.048), LDL cholesterol (ß=0.234, p=0.000), FBG (ß=0.402, p= 0.000), ALT (ß=0.205, p= 0.006), ALP (ß=0.277, p=0.000), γ-GT (ß=0.240, p=0.000), left atrial diameter (ß=0.204, p=0.003), heart rate (ß=0.123, p=0.037)] (Table 2). DISCUSSION The main result of our study is that P wave dispersion was significantly increased and also correlated with laboratory, metabolic and echocardiographic abnormalities in patients with liver steatosis (Table 1, 2). Liver steatosis, a candidate to be a novel component of metabolic syndrome, is closely associated with insulin resistance (2, 11, 12). Insulin resistance causes metabolic derangements, increased central blood volume and abnormal sympathetic activity (13). Increased SBP, DBP, heart rate and FBG might have been consequences of those abnormalities induced by insulin resistance. P wave duration and P wave dispersion were reported to be influenced by abTable 2. Bivariate and multivariate correlations of P wave dispersion with clinical and echocardiographic variables in patients with liver steatosis* P wave dispersion (msec) 0.680 Pearson correlation coefficient p Standardized ß regression coefficients p Waist circumference 0.160 0.014 0.151 0.048 LDL cholesterol 0.213 0.001 0.234 0.000 FBG 0.140 0.032 0.402 0.000 ALT 0.148 0.023 0.205 0.006 γ-GT 0.174 0.004 0.240 0.000 ALP 0.161 0.013 0.277 0.000 LAD 0.381 0.000 0.204 0.003 Heart Rate 0.148 0.032 0.123 0.037 Electrocardiographic features Variables Heart rate (bpm) 84.6±12.2 79.8±8.2 0.001 Pdisp (msec) 41.6±6.5 36.2±4.8 0.000 *M/F, Male/Female; BMI, Body mass index; LDL, low density lipoprotein; HDL, high density lipoprotein; FBG, fasting blood glucose; BUN, blood urea nitrogen; AST, aspartate aminotransferase; ALT, alanine aminotransferase; ALP, alkaline phosphatase; γ-GT, γ-glutamyl transferase; LVIDd/s, diastolic and systolic internal diameters of left ventricle; EF, left ventricular ejection fraction; LAD, left atrial diameter; DT, deceleration time; IVRT, isovolumic relaxation time; bpm, beat per minute; Pdisp, dispersion of P wave duration; **Chi-Square test; p<0.05, statistically significant *abbreviations as in Table 1 145 Medicinski Glasnik, Volumen 7, Number 2, August 2010 normal autonomic tone (14). Increased heart rate and FBG but not the blood pressure values were significantly correlated with P wave dispersion in our study (Table 2). Left atrial diameter was significantly enlarged and correlated with P wave dispersion in patients with liver steatosis. Left atrial volume and diameters are the strong indicators of inhomogeneous propagation of the sinus impulse through the atriums in congestive heart failure (15). This association may be present in hepatic steatosis as well as in congestive heart failure. Atrial enlargement is probably a consequence of atrial remodeling as a response to the increased filling pressures and chronic pressure overload induced by insulin resistance in hepatic steatosis (13, 16). Nicolaou et al reported that metabolic syndrome favor the occurrence of paroxysmal atrial fibrillation by increasing atrial size (17). Peak velocities of mitral E and A waves but not their ratio were significantly higher and may also reflect the atrial pressure overload and the dependence of left ventricular filling to atrial contractions in patients with liver steatosis (Table 1). Mureddu et al reported that impairment of myocardial relaxation in obese patients was predominantly induced by insulin resistance (18). Roes et al reported that both the insulin resistance and low grade inflammation may contribute to the abnormal diastolic function in patients with metabolic syndrome (19). Low grade inflammatory state is accompanied with increased levels of soluble intercellular and vascular adhesion molecules, oxidative stress, and endothelial dysfunction (20). It is associated with increased P wave dispersion and also risk of atrial fibrillation in patients with chronic non-cardiac diseases (21, 22). Pleiotropic anti-inflammatory effect of statins may be one of the rationales on reducing the risk of post-operatively new-onset atrial fibrillation (23, 24). In fact, hepatic steatosis is a chronic inflammatory disease of liver (25). Also, P wave dispersion was found to be significantly correlated with those liver enzymes in our study. Watanabe et al reported that metabolic syndrome was associated with increased risk of atrial fibrillation probably due to metabolic derangements (9). P wave dispersion longer than ≥ 40 msec is clinically important (26). Thus, a mean P wave dispersion about 41.6±6.5 msec in our patients with liver steatosis may indicate an increased risk of atrial fibrillation as well as in other clinical conditions; hypertension, pre-hypertension, diabetes, obesity, metabolic syndrome, etc (27-29). It is probably a consequence of both the metabolic derangements due to insulin resistance and the inflammatory state due to liver steatosis. In this study we did not measure the insulin levels to determine the insulin resistance. Although this seems to be a limitation of our study, the role of insulin levels in diagnosis of insulin resistance is still a disputable issue (30). Additionally, we did not evaluate the level of inflammation and inflammatory markers since the latter issue was reported to be higher in liver steatosis by numerous studies (20, 25). P wave dispersion, which is clinically important for atrial arrhythmia, is increased in patients with liver steatosis. Atrial arrhythmia may increase the burden of cardiovascular diseases by either disabling symptoms or thromboembolic events in patients with liver steatosis. Consequently, liver steatosis, potentially a novel component of metabolic syndrome, is associated with increased risk for cardiovascular disease due to metabolic and hemodynamic abnormalities probably induced by insulin resistance and inflammatory state. ACKNOWLWEDGEMENTS/DISCLOSURES This study was partly presented by Zafer Isilak, Mustafa Aparcı, Omer Yiginer, Ejder Kardesoglu, Namik Ozmen, Omer Uz, Murat Yalcın, Bekir Yilmaz Cingozbay, Bekir Sitki Cebeci. Increased QTc and P wave dispersion in patients with hepatosteaosis. Proceedings of the 6th International Mediterranean Meeting of Hypertension and Atherosclerosis, Antalya, Turkey, March 24-28, 2009. Competing interests: none declared REFERENCES 1. 146 Saely CH, Aczel S, Marte T, Langer P, Hoefle G, Drexel H. The metabolic syndrome, insulin resistance, and cardiovascular risk in diabetic and nondiabetic patients. J Clin Endocrinol Metab 2005; 90:698703. 2. Musso G, Gambino R, Bo S, Uberti B, Biroli G, Pagano G, Cassader M. Should nonalcoholic fatty liver disease be included in the definition of metabolic syndrome? Diabetes Care 2008; 31:562-8. Aparci et al P wave dispersion in hepatic steatosis 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 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JAMA. 2004; 292:2471-77 Movahed MR, Hashemzadeh M, Jamal MM. Diabetes mellitus is a strong, independent risk for atrial fibrillation and flutter in addition to other cardiovascular disease. Int J Cardiol 2005; 105:315-8. Samaras K, McElduff A, Twigg SM, Proietto J, Prins JB, WelbornTA, Zimmet P, Chisholm DJ, Campbell LV. Insulin levels in insulin resistance: phantom of the metabolic opera? MJA 2006; 185:159-61. 147 ORIGINAL ARTICLE Impact of reversionary and other etiological factors on prognosis and course of schizophrenia Ifeta Ličanin¹, Amira Redžić² ¹Psychiatric Clinics, Clinical Center, University of Sarajevo, ²Department of Biology and Human Genetics, School of Medicine, University of Sarajevo; Sarajevo, Bosnia and Herzegovina ABSTRACT Aim To identify the presence of schizophrenia among patients and their relatives, factors affecting duration and prognosis of the disease and other etiological factors related to schizophrenia. Corresponding Author: Ifeta Ličanin Psychiatric Clinics, Clinical Center, University of Sarajevo, Bolnička 25, 71000, Sarajevo, Bosnia and Herzegovina Phone; ++387 33 297 228; fax.: ++387 33 265 710 email: licaninifeta@hotmail.com Original submission: 9 February 2009; Revised submission: 13 June 2009; Methods This retrospective, descriptive, analytical and epidemiological research, which was conducted at the Psychiatric hospital of the Clinical Center of the University of Sarajevo during 2007, covered randomly selected 100 hospitalized patients with schizophrenia according to diagnostic criteria of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). Diagnosis of schizophrenia among relatives was based on anamnesis- Structural Clinical Interview (SCID) and it was applied to confirm DSM-IV diagnosis of schizophrenia. Results The presence of schizophrenia among patient relatives was the most important in etiology of schizophrenia (62%), and etiological factors were represented in 38 % of examinees (p=0,0001). Among relatives of examinees aged 20 – 30 years, schizophrenia was present in 37 (59.7%) cases. Schizophrenia among relatives caused earlier appearance of the disease. Duration of hospitalization of over 60 days was in the group of examinees which have the relatives with schizophrenia, 18 (29.0%); multiple hospitalizations were noted in the group of relatives in 40 (64.5%) cases; in one case (8.3%) traumatic experience was noted, in three (42.8%) acute stress, and in four 4 cases (28.6%) non-adequate living conditions. Conclusions The results of this study show that reversionary factors are responsible for inducing schizophrenia, which leads towards chronic course of the disease and worsened prognosis. Key words: schizophrenia, relatives, reversion, stress, etiology, epidemiology. Accepted: 02 November 2009 Med Glas Ljek komore Zenicko-doboj kantona 2010; 7(2):148-152 148 Ličanin et al Etiological factors and schizophrenia INTRODUCTION Schizophrenia is the most serious and most common mental disorder that is mostly characterized with disruptions in opinion making and observation process, while emotions are non-adequate or blunt (1). Disease has a chronic course with deteriorations and remissions and it is a significant medical – sociological issue (2-5). Etiological factors of schizophrenia could be separated into predisposing (genetic factors, environmental factors), precipitating (acute stress) and perpetuating (chronic stress, emotional “atmosphere” that patient is living at) (6- 8). Reduction of epidemiological researches from the social community to the family level has enabled a more precise research of the role and importance of reversionary factors (a person is likely to have schizophrenia if other members of the family also have schizophrenia and that the likelihood of the person’s having schizophrenia is correlated with the closeness of the relationships: e.g. first-degree or second-degree relative) as well as environmental factors relevant for mental health, on-set and course of psychiatric disorders (9-11). Genealogical studies represent the oldest and most relevant form of researches about the presence of schizophrenia among relatives (5,12-15). The risk of developing schizophrenia is higher if one or both parents have the schizophrenia, but it does not mean that every child with schizophrenic parents would develop the disease itself (2). Even though it is clear that there is a heredity basis of schizophrenia, frequency of diseases with monozygotic twins could be different, which indicates that disease with certain gene-type is not reversionary, but reversionary is predisposition or tendency to develop the disorder (5, 6, 9, 10). This statement is supported by many studies on progenies of monozygotic twins with different diseases (one twin develops a disease, and other does not) that indicate comparable risk for developing diseases with progenies of affected and non-affected twin (7,8,16). This shows that specific presence of schizophrenia among relatives that confirm and transfer a predisposition to disease are transferred, and they do not have to be expressed (17). Environmental factors are among the etiological factors involved in the appearance of schizophre- nia. Diagnose of schizophrenia among relatives could cause inheritance of neurotransmiter abnormalities among relatives (17,18). Relevant world researches are mostly related to studies on multiple genes, genomes, and environmental factors. There is a lack of studies in our region related to comparison of reversionary and other etiological factors of schizophrenia. That is one of the reasons why we decided to conduct our study. The aim of this study was to determine the agespecific prevalence of schizophrenia, the presence of schizophrenia among patient relatives, etiological factors responsible for the development of schizophrenia, other etiological factors affecting course and prognosis of the disease (by observing a number of cases and duration of hospitalization). PATIENTS AND METHODS After an approval of Ethic Committee Clinical Centre Sarajevo University had been obtained one hundred patients who were hospitalized because of the diagnosed schizophrenia during 2007 were assessed retrospectively. Subjects were evaluated by experienced clinicians using the SCID-I interview for DSM-IV at the Psychiatric Clinic of the Clinical Center of the University in Sarajevo. Inclusion criteria for the study were one hundred patients randomly selected whose diagnosis of schizophrenia was confirmed according to the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV F20X, irrespective of subtype) (19). Patients’ medical records were used for the examination of variables: demographic data (gender, age, education level, employment, income and socio-economic status, marital status, occurrence of schizophrenia within the family, number and duration of hospitalizations), the presence of schizophrenia among patients’ relatives, or presence of schizophrenia in parents, siblings or cousins), other etiological factors involved in the appearance of schizophrenia (traumatic event, acute stress, non adequate living conditions). Family relations were determined according to the Structured Clinical Interview for DSM disorders RESULTS The prevalence of schizophrenia was significantly higher in females, 65 (65%), than in males, 149 Medicinski Glasnik, Volumen 7, Number 2, August 2010 Table 1. Etiological factors of schizophrenia in relation to patients age of disease occurrence* Age (years) when disease was diagnosed Presence among relatives (%) Traumatic events (%) Acute stress Chronic stress Inadequate (%) (%) living conditions (%) Total (%) 20-30 37 (59.7) 2 (16.7) 0 0 8 (57.1) 47 (47.0) 30-40 10 (16.1) 7 (58.3) 6 (85.7) 0 (,0) 2 (14.3) 25 (25.0) 40-50 15 (24.1) 0 0 4 (80.0) 0 19 (19.0) 50-60 0 3 (25.0) 1 (14.3) 1 (20.0) 4 (28.6) 9 (9.0) Total 62 (62.0) 12 (12.0) 7 (7.0) 5 (5.0) 14 (14.0) 100 *X2=61,921p=0,0001 35 (35%). The prevalence of schizophrenia was decreasing with the decrease of patients’ age: the highest prevalence was noted in patients 20-30 years of age, 47 (47%), and lowest one in patients 50-60 years of age, nine of them (9%). In the age groups 30-40 and 40-50 years the prevalence was 25 (25%) and 19 (19%), respectively. examinees with acquired etiological factors, e. g. traumatic events in twelve (12%), acute stress in seven (7%), chronic stress in five (5%), and bad living conditions in four (4%) cases. Table 3 represents the number of hospitalizations in relation to etiological factors: multiple hospitalizations were the most frequent among patients with the disease among relatives (4, 5%), and none among patients with chronic stress as an etiological factor. The reversionary factors were mostly presented in etiology of schizophrenia, in 62 patients (62%). Acquired etiological factors were presented in 38 (38%) patients: traumatic events were responsible for the disease occurrence in 12%, acute stress in 7%, chronic stress in 5%, and nonadequate living conditions in 14% of cases. DISCUSSION The results of this research have shown female/ male ratio of 35:65, and the highest prevalence of schizophrenia in patients in the age group 20-30 (47%), which is in accordance with the results of other researches (2-5). The presence of schizophrenia among relatives was the most important factor in etiology of schizophrenia in this research (62%), whereas among other etiological factors (38%) traumatic events were responsible for disease appearance in 12%, acute stress in 7%, chronic stress in 5%, and non-adequate living conditions in 14% cases. Table 1 shows etiological factors of schizophrenia in relation to the age when the disease occurred. The most common presence of schizophrenia among relatives was noted within the age group of 20-30, in 37 (59.7%) of cases. Table 2 shows duration of hospitalization in relation to etiological factors, with different tendencies. Multiple and extended (more than 60 days) hospitalizations were noted among examinees with positive history of schizophrenia among their relatives, in 62 (62%) cases. Shorter and less often hospitalizations were noted among Dominant genetic etiological factors, as well as some risk factors for disease development in he- Table 2. Duration of hospitalization of patients with schizophrenia in relation to etiological factors* Duration of hospitalization (days) Presence among relatives (%) Traumatic events (%) Acute stress (%) Chronic stress (%) Inadequate living conditions (%) Total < 15 8 (12.9) 2 (16.7) 2 (28.6) 2 (40.0) 3 (21.4) 17 (17.0) 15 – 30 12 (19.4) 3 (25.0) 3 (42.9) 1 (20.0) 4 (28.6) 23 (23.0) 30 -45 14 (22.6) 3 (25.0) 1 (14.3) 2 (40.0) 3 (21.4) 23 (23.0) 45 -60 10 (16.1) 2 (16.7) 1 (14.3) 0 4 (28.6) 17 (17.0) > 60 18 (29.0) 2 (16.7) 0 0 0 20 (20.0) Total 62 (62.0) 12 (12.0) 7 (7.0) 5 (5.0) 14 (14.0) 100 (100.0) *X2=14,631, p=0,0001 Table 3. Number of hospitalization in relation to etiological factors* Number of hospitalizations Second hospitalization Presence among relatives (%) 10 (16.1) Traumatic events (%) 7 (58.7) Acute stress (%) 2 (28.6) Chronic stress (%) 3 (60.0) Inadequate living conditions (%) 4 (28.6) Total (%) 26 (26.0) 26 (26.0) Third hospitalization 12 (19.4) 4 (33.3) 2 (28.6) 2 (40.0) 6 (42.8) Multiple hospitalizations 40 (64.5) 1 (8.3) 3 (42.8) 0 4 (28.6) 48 (48.0) Total 62 (62.0) 12 (12.0) 7 (7.0) 5 (5.0) 14 (14.0) 100 (100.0) X2=23.648, p=0.0001 150 Ličanin et al Etiological factors and schizophrenia althy individuals were also shown in other researches (3, 19). According to this, some authors recommend screening of vulnerable patients in prevention of schizophrenia on-set (3, 19-21). The most common presence of schizophrenia among relatives was noted within the age group of 20-30, in 37 (59.7%) cases. These results were similar to other results (5,14, 20). Current data indicate the appearance of the disease in early twenties in the examinees with positive heredity, as well as much more malignant course of the disease, or the worse prognosis (22-24). The group of authors from Spain has stated that the appearance of schizophrenia in an earlier age of life has a better prognostic sign, which is opposite to our results. The same authors indicated irrelevance of other socio-demographic factors to the development of schizophrenia (25). Multiple and extended (more than 60 days) hospitalizations were noted among examinees with positive history of schizophrenia among their relatives (62%). Shorter and less frequent hospitalizations occured among examinees with acquired etiological factors (38%). These results match the results of researches, where authors indicated the appearance of the disease with a bad prognostic sign, especially according to the number and dura- tion of hospitalizations. The same authors also discuss living conditions, education level and age as bad for prognostic factors for the disease (26-30). This research has shown that most of the presented factors responsible for the appearance of schizophrenia occured in patients with positive family history for schizophrenia, which leads towards a chronic course of the disease and worsened prognosis. Prevention of schizophrenia is an important issue related to the treatment. There are two steps in the prevention: identification of persons at risk, and their successful treatment. Investigation of the factors involved in the appearance of schizophrenia from a specific geographic region (Bosnia and Herzegovina) could serve as a basis for its comparison with other regions in order to bring better understanding and develop prevention of this disorder. 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Riecher-Rössler A, Häfner H, Häfner-Ranabauer W, Löffler W, Reinhard I. Late-onset schizophrenia versus paranoid psychoses: a valid diagnostic distinction? Am J Geriatr Psychiatry 2003; 11:595-604. 28. Schürhoff F, Golmard JL, Szöke A, Bellivier F, Berthier A, Méary A, Rouillon F, Leboyer M. Admixture analysis of age at onset in schizophrenia. Schizophr Res 2004; 71:35-41. 29. Lin CH, Chen CC, Wang SY, Lin SC, Chen MC, Lin CH. Factors affecting time to re-hospitalization in Han Chinese patients with schizophrenic disorder in Taiwan. Kaohsiung J Med Sci 2008; 24:408-14. 30. Cooper SA, Smiley E, Finlayson J, Jackson A, Allan L, Williamson A, Mantry D, Morrison J. The prevalence, incidence, and factors predictive of mental illhealth in adults with profound intellectual disabilities. J Appl Res Intellect Disabil 2007; 20: 493-501. 31. Dagnan D. Psychosocial interventions for people with intellectual disabilities and mental ill-health. Curr Opin Psychiatry 2007; 20:456-60. 32. Hemmings CP. Community services for people with intellectual disabilities and mental health problems. Curr Opin Psychiatry 2008; 21:459-62. 33. Hurley AD. Depression in adults with intellectual disability: symptoms and challenging behaviour. J Appl Res Intellect Disabil 2008; 52:905-16. ORIGINAL ARTICLE Standardi fetalnog rasta za tuzlansku regiju Adem Balić1, Devleta Balić2 1 Služba za ginekologiju i perinatologiju, Dom zdravlja u Tuzli; 2 Ginekološka ordinacija „Dr. Balić” Tuzla; Tuzla, Bosna i Hercegovina SAŽETAK Cilj ovoga rada je izrađivanje standarda normalnog intrauterinog rasta za područje Tuzlanskog kantona. Metode U periodu 2002-2005. godine provedeno je prospektivno praćenje fetalnog rasta (biparijetalni i abdominalni dijametar, obim glave i abdomena, te dužina femura), prema kriterijima FIGO-a (Federation International Gynaecologist and Obstetrician) (FIGO, 1986), kod stotinu zdravih trudnica s normalnom jednoplodnom trudnoćom koje su se spontano vaginalno porodile između 38. i 41. nedjelje trudnoće. Mjerenja su vršena najmanje jednom u četiri nedjelje, počev od 12. pa do kraja 41. nedjelje. Corresponding author: Adem Balić, Služba za ginekologiju i perinatologiju, Dom zdravlja u Tuzli, Kojšino 25, 75000 Tuzla Phone: +387 35 286 724; fax.: +387 35 286-724 E-mail: badem@bih.net.ba Originalna prijava: Rezultati Prosječna težina novorođenčadi u 38. nedjelji iznosila je 3280 ± 345 g, u 39. nedjelji 3360 ± 280 g, u 40. nedjelji 3596 ± 320 g i u 41. nedjelji 3732 ± 380 g. Dobijeni standardi pokazali su nešto manje vrijednosti svih ispitivanih parametara i u svim nedjeljama trudnoće, s tim da su razlike bilo vrlo male kod standarda za BPD i FL, dok su bile znatno veće kod standarda za obim glave i obim abdomena, koja su bila najizraženija u zadnje četiri nedjelje. Zaključak Imajući u vidu uočene razlike između vrijednosti dobivenih standarda i onih koje smo najviše koristili (Hadlock, 1983 i Latin, 2000), a koje su najveće u zadnje četiri nedjelje trudnoće kada su varijacije fetalnog rasta i najveće, izrada standarda fetalnog rasta za našu populaciju bila je opravdana, te će njegova primjena sigurno doprinijeti daljnjem sniženju perinatalnog mortaliteta u Bosni i Hercegovini. Ključne riječi: fetalni rast, standard, BPD, FL 18. novembar 2009.; Korigirana verzija: 15. januar 2010.; Prihvaćeno: 19. januar 2010. Med Glas Ljek komore Zenicko-doboj kantona 2010; 7(2):153-159 153 Medicinski Glasnik, Volumen 7, Number 2, August 2010 UVOD Rast i razvoj ljudskog ploda od davnina je pobuđivao veliku radoznalost s obzirom na njegovu tijesnu povezanost s perinatalnim ishodom, odnosno s neonatalnim morbiditetom i mortalitetom. Do uvođenja ultrazvuka u akušerstvo početkom sedamdesetih godina, intrauterini rast je procjenjivan indirektno prema veličini uterusa, obimu trbuha i udaljenosti fundus-simfiza, u čemu su odstupanja ponekad bila vrlo velika. Ultrazvučna dijagnostika omogućila je brzo, neinvazivno i tačno mjerenje različitih fetalnih struktura, a time i pouzdanu procjenu njegove težine (1). Mjereni su različiti dijelovi tijela fetusa, a najviše su korišteni: biparijetalni dijametar (BPD), frontookcipitalni dijametar (FOD), obim glave (HC, head circumpherence), poprečni abdominalni dijametar (ABD), obim abdomena (AC, abdominal circumpherence) i dužina femura (FL, femur lenght), s obzirom da su se pokazali najpogodnijim za procjenu fetalnog rasta tokom cijele trudnoće (2). Naime, otkad postoji akušerstvo, poznata je činjenica da je novorođenče veće i teže što trudnoća duže traje, ali dileme vezane za odstupanja od ovoga rasvijetljene su tek zahvaljujući ultrazvučnim mjerenjima (3). Među prvima je Gruenwald (4) jasno diferencirao dva pojma - nasljedni i stečeni potencijal za rast. Nasljedni ili genetski potencijal za rast koga je nazvao ‘’intrinsic factor’’, a to je, prije svega, rasno i etničko porijeklo, može biti razlogom rođenja većih ili manjih novorođenčadi. S druge strane, stečeni faktor rasta vezan je za transplacentarni dotok hranjivih tvari na što mogu uticati različiti poremećaji zdravstvenog stanja majke, ishrane, uslova življenja i slično (5). To je i bio povod da je veći broj autora, za svoje područje, izradio krivulje fetalnog rasta (6-10). U našoj sredini do 1990. godine, odnosno do početka rata, korišteni su standardi intrauterinog rasta beogradske populacije iz 1974. (9), a u toku i nakon rata, koriste se različiti standardi instalirani u ultrazvučnim aparatima. To je nerijetko razlog pogrešne procjene devijacije fetalnog rasta i svih dijagnostičkih procedura koje nakon toga slijede. Iako je potreba za fetalnim standardima prilično stara, objektivni razlozi za kašnjenje njihove izrade jesu ratna i poratna zbivanja u Bosni i Hercegovini koja su imala uticaj na mnoge sfere života, a samim tim i na fetalni rast, te standardi 154 rađeni u tom periodu ne bi bili pravi odraz fetalnog rasta u našoj sredini. Istraživanje Skokićeve pokazalo je da je težina novorođenčadi u toku rata bila značajno manja (235 g !) nego u prijeratnom i poslijeratnom periodu (11). Cilj ove prospektivne studije bio je utvrditi normalan fetalni rast kod trudnica s jednoplodnom, nekomplikovanom trudnoćom, koje gravitiraju području Tuzlanskog kantona, te kreirati njihov normogram. MATERIJAL I METODE U četverogodišnjem periodu, počev od 01. 01. 2003. godine, praćen je fetalni rast kod stotinu trudnica s normalnom, jednoplodnom trudnoćom, prema kriterijima FIGO-a (Federation International Gynacologist and Obstetrician) (FIGO) (12), u Službi za zdravstvenu zaštitu žena i trudnica Doma zdravlja u Tuzli i Ginekološkoj ordinaciji ‘’Dr. Balić’’ u Tuzli (Tabela 1). Mjerenja su vršena kod svih trudnica koje su se javljale na preglede u navedenim ustanovama tokom ispitivanog perioda, a koje su ispunjavale navedene kriterije. Istraživanje je sprovedeno u skladu s odlukom Etičkog komiteta JZU Dom zdravlja Tuzla. Tačnost gestacijske dobi utvrđena je na osnovu slaganja procjene veličine trudnoće prema datumu zadnje menstruacije i ultrazvučne biometrije u prvom trimestru. Studijom su bile obuhvaćene samo one trudnice koje su ispunjavale sve kriterije FIGO-a, odnosno koje su spontano dobile porođajne bolove i koje su rodile djecu bez anomalija. Trudnice kod kojih je u toku trudnoće došlo do komplikacija (krvarenje, hipertenzija, zastoj u rastu), koje su se porodile prije 39. nedjelje ili carskim rezom, te zbog nekih drugih elemenata predviđenih kriterijima FIGO-a, nisu uključene u studiju. Tabela 1. Kriteriji za ispitivanu grupu trudnica i njihovih fetusa (FIGO - 1986) Zdrava žena Nepušač i neuživalac droga i drugih opojnih sredstava Nije imala prekidâ trudnoće, perinatalne smrti čeda ili dijete s usporenim rastom Pouzdan datum zadnje menstruacije (po mogućnosti potvrđen ultrazvučnim pregledom u prvom trimestru) Jednostruka trudnoća Trudnoća bez komplikacija Bez krvarenja u trudnoći Spontani trudovi između 38. i 41. nedjelje trudnoće Živahno dijete pri porođaju Odsutnost kongenitalnih anomalija ploda Balić et al Standardi fetalnog rasta Fetalni rast je procjenjivan na osnovu slijedećih ultrazvučnih parametara: biparijetalni dijametar (BPD), frontookcipitalni dijametar (FOD), obim glave (head circumpherency – HC), poprečni dijametar abdomena (ABD), obim abdomena (abdominal circumpherency - AC) i dužina bedrene kosti (femur lenght - FL). BPD i FOD su mjereni po modifikaciji Campbella (13), tj. najveći uzdužni i poprečni promjeri fetalne glavice na nivou središnje linije, talamusa, corpus callosuma i cavuma septi pelucidi. Vrijednosti obima glave računate su na osnovu veličine BPD-a i FOD-a korištenjem formule za elipsu: y = (D1+D2) x 1,62 (Slika 1). Dužina femura mjerena je metodom O’Briena i saradnika (14); nakon određivanja uzdužne osovine ploda, sonda se na nju postavi pod pravim uglom, a zatim se pomjeri ka fetalnoj karlici i rotira za 35-45° prema abdomenu da bi se dobila cijela dužina femura (Slika 2). Obim abdomena izračunat je na osnovu mjerenja transverzalnog i anteroposteriornog dijametra prema formuli za elipsu. Mjerenja su vršena na presjeku ispod srčane sjene gdje se prikazuju strukture jetre, bifurkacija portalne vene, želudac, abdominalna aorta i kičma (15) (Slika 3). Sva mjerenja, prema navedenim kriterijima, u intervalima od 2 do 4 nedjelje, obavljalo je pet iskusnih ultrasoničara. Za ultrazvučne preglede korišteni su General Electric Logic 200 (Beč, Austrija) i Aloka 1700 SSD (Tokio, Japan), General Electric Voluson 730 Expert (Beč, Austrija) s transabdominalnim sondama 3-5 MHz. Osim navedenih biometrijskih parametara, analizirani su i paritet, zanimanje, visina, težina, mjesto boravka i starosna dob trudnica. Statistička obrada rezultata izvršena je računanjem srednje vrijednosti i standardne devijacije za svaki ispitivani biometrijski parametar i za svaku nedjelju trudnoće, a dobivene vrijednosti uvrštavane su kao vrijednosti za tekuće nedjelje (npr. 40. nedjelja = 39+1 do 40+0). REZULTATI U četverogodišnjem periodu prospektivno je praćen fetalni rast kod trudnica kontrolisanih u Savjetovalištu za trudnice Službe za zdravstvenu zaštitu žena i trudnica Doma zdravlja u Tuzli i Tabela 2. Težina novorođenčadi na rođenju prema gestacijskoj dobi Gestaciona dob 37/1 - 38/0 38/1 -39/0 NG 39/1-40/0 NG 40/1-41/0 NG (nedjelje) Tjelesna masa na 3280 ± 345 rođenju ug 3360 ± 280 3596 ± 320 3732 ± 380 Ginekološkoj ordinaciji ‘’Dr. Balić“. Prema kriterijima FIGO-a ultrazvučna mjerenja izvršena su kod stotinu trudnica s normalnom, jednoplodnom trudnoćom. Mjerenja su vršena svake dvije do četiri nedjelje, tako da je svaka trudnica imala najmanje na pet mjerenja. Najveći je broj trudnica bio iz Tuzle [79, (79%)], dok su ostale bile sa šireg područja Tuzlanskog kantona (Kladanj, Kalesija, Dokanj, Seljublje, Živinice, Sapna, Gradačac, Teočak i Lukavac). Prema zanimanju 51 (51%) trudnica bila je nezaposlena, a 49 (49%) zaposlene. Prema stepenu obrazovanja četiri (4%) ispitanice bile su bez obrazovanja, 28 (28%) s osnovnim, 56 (56%) sa srednjim i 12 (12%) s visokim obrazovanjem. Prema paritetnoj strukturi bilo je 54 (54%) prvorotki, 30 (30%) drugorotki, 14 (14%) trećerotki i dvije (2%) višerotke. Prosječna životna dob ispiTabela 3. Biparijetalni dijametar (BPD) i obim glave (HC) kod fetusa u normalnoj trudnoći* NG 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 BPD (mm) 18,9 22,7 25,8 27,7 32,6 38,7 40,6 44,5 46,3 49,2 50,3 54,5 59,1 61,0 65,5 67,8 69,1 74,3 76,5 78,7 81,3 85,6 86,3 86,6 88,6 90,6 91,7 93,5 94,5 SD 2,64 2,18 1,83 0,58 0,89 1,52 1,39 1,29 2,85 2,64 2,50 2,56 2,89 2,22 2,41 2,5 2,96 3,21 3,01 2,33 2,97 1,17 2,64 2,87 1,60 2,60 2,46 1,77 3,53 HC (mm) 72,1 77,2 105,3 109,4 125,1 134,2 146,4 155,3 166,1 179,5 181,5 192,2 207,1 222,4 229,8 238,4 247,7 259,8 272,4 280,5 287,8 294,4 300,2 308,1 315,4 318,8 323,4 328,1 333,2 SD 2,1 2,8 3,1 3,4 3,8 3,99 4,11 3,91 4,89 4,42 5,46 4,83 5,12 5,7 4,9 5,1 4,92 7,8 8,9 11,25 11,47 12,85 12,11 10,24 10,9 11,8 12,84 13,22 12,5 * NG, nedjelje gestacije; BPD, biparijetalni dijametar; HC, head circumpherency; SD, standardna devijacija; 155 Medicinski Glasnik, Volumen 7, Number 2, August 2010 tanica bila je 26,55 ± 4,2 godine (najmlađa 18, a najstarija 38 godina), prosječna visina 167,65 ± 4,83 cm, a prosječna težina 65,35 ± 8,58 kg. Prema spolu novorođenčadi 54 (54%) su bili muškog, a 46 (46%) ženskog spola. Najveća prosječna težina novorođenčadi na rođenju iznosila je 380 g u 40. nedjelji (porast za oko 200 g sa standardnom devijacijom) (Tabela 2). Prosječne vrijednosti biparijetalnog dijametra iznosile su od 18,9 u 12. nedjelji do 94,5 u 40. nedjelji (standardna devijacija od 0,58 do 3,53). Porast BPD-a u zadnjim nedjeljama trudnoće iznosio je oko 1 mm (Tabela 3). Prosječne vrijednosti za obim glave iznosile su od 72,1 mm u 12. nedjelji do 333,2 u 40. nedjelji. Porast u zadnjim nedjeljama iznosio je 5-7 mm (SD između 10,9 i 13,22) (Tabela 3). Srednje vrijednosti i standardna devijacija (SD) za poprečni dijametar abdomena (ABD) i obim abdomena (AC) po nedjeljama trudnoće prikazane su u Tabeli 4. Rast po nedjeljama kretao se od 1,4 do 2,9 mm za ABD i 3-10 mm za AC, dok se SD za ABD kretala od 1,2 mm (12. nedjelja) do 7,9 mm (40. nedjelja), a SD za AC kretala se od Tabela 4. Poprečni dijametar (ABD) i obim abdomena (AC) kod fetusa u normalnoj trudnoći* NG ABD (mm) SD AC (mm) SD 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 18,7 21,8 24,2 28,2 31,4 36,8 41,3 45,2 47,8 51,2 54,1 55,6 58,1 61,4 65,1 68,9 71,2 74,8 78,2 83,1 84,8 90,4 93,2 95,1 97,4 98,1 99,5 102,9 105 1,2 1,41 2,12 1,71 2,4 2,5 2,7 29 3,12 3,4 3,9 4,4 5,2 5,5 38 2,15 4,2 3,8 3,91 4,4 4,5 4,76 4,91 5,1 5,9 6,2 6,7 7,08 7,9 61 64 80 88 97 115 128 140 148 155 162 169 178 194 205 216 223 235 245 260 273 282 292 298 304 310 315 323 329,5 2,4 2,8 3,9 4,2 3,91 5,2 4,8 6,1 7,3 8,2 8,9 9,1 9,2 9,9 10,1 11,3 11,9 13,1 13,9 14,2 14,8 14,7 13,8 12,9 14,5 15,1 13,2 15,8 16,0 * NG, nedjelje gestacije; ABD, abdominalni dijametar; AC, abdominal circumpherency; SD, standardna devijacija; 156 2,4 mm (12. nedjelja) do 16 mm (40. nedjelja). Prosječne vrijednosti rasta femura u normalnoj trudnoći po nedjeljama bile su ujednačene, za 2 mm u prosjeku (minimalno 1,9 mm u 13. nedjelji i maksimalno 3 mm u 21. nedjelji) (SD je iznosila od 0,74 do 2,96) (Tabela 5). DISKUSIJA Prema preporukama FIGO-a (12) prospektivno je praćen fetalni rast na osnovu odabranih ultrazvučnih biometrijskih parametara, kod zdravih trudnica s jednoplodnom normalnom trudnoćom, s urednom reproduktivnom anamnezom, a koje su se porodile spontano vaginalno, u periodu između navršene 38. i 41. nedjelje, te da su sva djeca bila živahna na porodu i bez anomalija. Statistički su obrađeni podaci za stotinu trudnica koje su ispunile navedene kriterije, mada je broj uključenih u studiju bio znatno veći, ali su one zbog krvarenja, hipertenzije, gestacijskog dijabetesa, prijevremenog ili porođaja carskim rezom, isključene iz studije. To je glavni razlog zašto je broj trudnica u ovoj studiji značajno manji nego u drugim (6-10, 13-16) jer je, na ovaj način, izračunat vrlo važan i značajan idealan fetalni rast budući da su korišteni aparati koji imaju mogućnost Tabela 5. Dužina femura (FL) kod fetusa u normalnoj trudnoći* NG FL (mm) SD 12 8,05 0,74 13 10,9 1,06 14 12,7 1,55 15 17,1 1,51 16 19,5 1,6 17 23,8 1,83 18 26,2 2,19 19 29,6 2,26 20 31,8 2,1 21 34,5 2,3 22 37,5 2,9 23 40,2 1,48 24 41,7 2,05 25 44,1 2,59 26 48,3 2,29 27 51,1 2,65 28 53,5 2,18 29 55,7 1,87 30 57,3 2,61 31 59,1 2,96 32 61,8 2,7 33 63,3 2,72 34 65,3 2,89 35 66,8 2,8 36 68,8 2,75 37 71,1 2,11 38 72,5 2,27 39 73,6 1,7 40 74,5 2,08 * NG, nedjelje gestacije; FL, femur lenght; SD, standardna devijacija; Balić et al Standardi fetalnog rasta Tabela 6. Uporedne vrijednosti biparijetalnog dijametra, obima glave, obima abdomena i dužine femura u određenim periodima trudnoće* BPD NG 13 20 30 34 37 38 39 40 HC Balić Hadlock (16) Latin (10) 22,7 46,3 76,5 86,3 90,6 91,2 93,5 94,5 23 48 76 85 91 92 94 96 23,8 47 76,8 85,5 90,8 92,4 94 94,8 AC Balić Hadlock (16) Latin (10) 77 166 272 300 319 323 328 333 80 175 277 309 330 337 344 350 83 175 283 317 339 346 352 358 FL Balić Hadlock (16) Latin (10) 74 148 245 292 310 315 323 329,5 75 150 259 299 329 339 348 355 75,3 158,5 256 302 331 336 350 366 Balić Hadlock (16) Latin (10) 10,9 31,8 57,3 65,3 71,1 72,5 73,6 74,5 11 33 58 66 73 74 76 78 11,9 33,6 56 64,2 71,5 70,4 72,9 75,3 * NG, nedjelje gestacije; BPD, biparijetalni dijametar; HC, head circumpherency; AC, abdominal circumpherency; FL, femur lenght; ‘’cine loop“ (tzv. vraćanja izvjesnog broja sličica), što je omogućavalo lakše i brže pronalaženje idealnih presjeka za mjerenje, te mogućnost mjerenja i desetog dijela milimetra. u mjerenjima, budući da je na mjerenju radilo samo pet iskusnih ultrasoničara, kao i kvaliteta ultrazvučnih aparata koja je omogućila visoku preciznost mjerenja. Sve su trudnice ispunjavale kriterije FIGO-a, te je uzorak bio reprezentativan za populaciju tuzlanske regije s očekivano normalnim prirastom težine tokom trudnoće. Standardi intrauterinog rasta važni su za određeno populaciono područje ne samo zbog validnog uvida u fetalni rast, nego i radi blagovremene dijagnostike različitih poremećaja koji u trudnoći mogu nastupiti. S obzirom da je još Gruenwald (4) ukazao na urođeni potencijal za fetalni rast, u mnogim su sredinama izrađeni odgovarajući standardi kako bi se izbjegle ili bar svele na najmanju moguću mjeru, greške u procjeni gestacijske dobi zbog razlika po etničkoj i rasnoj osnovi. Poredeći prosječnu težinu djece s rezultatima drugih, uočava se da je novorođenčad naših ispitanica teža (u 38. do 41. nedjelji iznosila je 3280 g do 3732 g), što su pokazali i rezultati iz Tuzle za 2002. godinu, kada je prosječna težina svih živorođenih iznosila 3520 g, odnosno bila je veća nego u drugim gradovima i regijama (11). Tako je prosječna tjelesna težina na rođenju u 39. nedjelji, u Zagrebu 3231 g (17), u Beogradu 3378 g (9), Novom Sadu 3344 g (8) i Nikšiću 3400 g (18). Ovdje takođe treba istaći da su drugi autori obrađivali i podatke fetalnog rasta kod trudnica koje se nisu spontano porodile ili koje su imale neke poremećaje u trudnoći kao što su krvarenje, hipertenzija i gestacijski dijabetes, čime se još može objasniti nešto veća porođajna težina. U poređenju sa standardima po Hadlocku (16) i Latinu (10) (Tabela 6) uočava se da su vrijednosti svih naših ispitivanih parametara intrauterinog rasta nešto manje, što je u suprotnosti od očekivanih prema podacima o porođajnoj težini. Kada su u pitanju BPD i dužina femura, razlike su minimalne, dok su razlike kod obima abdomena i obima glave očite. Ove razlike mogu se objasniti činjenicom da su korištene različite formule za računanje obima elipse, te izvjesnim odstupanjima kod mjerenja drugog prečnika, kao i već pomenutim, mada minimalnim, razlikama u mjerenju samog BPD-a i ABD-a. Osim toga, jedan od mogućih razloga jesu i minimalne varijacije S obzirom da je do sada procjena intrauterinog rasta u tuzlanskoj regiji, ali i šire, vršena na osnovu različitih standarda koji su nam se empirijski činili najprihvatljivijim, dešavalo se da ona bude pogrešna, pa tako i svi postupci koji su proistekli iz takve procjene. Isključivši ostale moguće uzroke devijacije fetalnog rasta, ostala je i mogućnost da standardi po Hadlocku i sar. iz 1983. godine (16), koji su instalirani u ultrazvučnim aparatima, a po kojima većina ultrasoničara radi, nisu odgovarajući za našu populaciju. Mogućnost greške u procjeni fetalnog rasta najizraženija je u grupi trudnica s nepouzdanim terminom, čija se učestalost kreće između 10% i 20% (3, 20). Tako, naprimjer, Dražančić predlaže da porodilišta s preko 1000 poroda odrede posebno kvalificiranog liječnika za konačnu prosudbu dobi trudnoće (3). Imajući u vidu sve ove činjenice, više puta je pokušano da se naprave standardi fetalnog rasta za bosanskohercegovačku populaciju, ali bez uspjeha, jer je devedesetih godina, kada su se stekli realni uslovi za realizaciju ovoga projekta, izbio rat koji je doveo do prave perinatalne katastro- 157 Medicinski Glasnik, Volumen 7, Number 2, August 2010 fe: smrtnost majki iznosila je 80/100.000 (19), a perinatalni mortalitet preko 25‰ (20). Međutim, i poslije rata, niz faktora (obnova zemlje, nezaposlenost, siromaštvo, promjena demografske strukture) imali su negativan uticaj na perinatalna zbivanja, te se moralo sačekati da se perinatalni mortalitet vrati na prijeratne vrijednosti, što se desilo tek u zadnjih nekoliko godina (11, 21). unatoč svemu bila opravdana, te da će njihova primjena smanjiti broj pogrešnih procjena fetalnog rasta, posebno kod trudnica s nepouzdanim terminom, što bi trebalo uticati na daljnje smanjenje perinatalnog mortaliteta u Bosni i Hercegovini. Prezentirani standardi intrauterinog rasta za tuzlansku regiju pokazuju veliku sličnost sa standardima Hadlocka i saradnika, kao i aktuelnim standardima koji se koriste u Hrvatskoj kada su u pitanju BPD i FL, s tim što su standardi dobiveni u ovom istraživanju, ipak, u svim nedjeljama nešto niži. Razlike u obimu glave i abdomena su značajnije, što znači da je izrada ovih standarda Autori zahvaljuju specijalistima ginekologije i akušerstva Doma zdravlja u Tuzli prim. dr. Jasmini Dragović, prim. dr. Ameli Adžajlić i prim. dr. Amri Habibović, na pomoći kod praćenja intrauterinog rasta na osnovu ultrazvučnih parametara kod ispitivane grupe trudnica. ZAHVALE/IZJAVE Komercijalni ili potencijalni dvostruki interes ne postoji. LITERATURA 1. Balić A. Ultrazvuk u trudnoći. U: Balić A i sar., ur. Perinatologija. Tuzla: PrintCom 2007: 43-66. 2. Siemer J, Wolf T, Hart N, Schrauder M, Meurer B, Goecke T, Beckmann MW, Schild RL. Increased accuracy of fetl weight estimation with a gender – specific weight formula. Fetal Diagn Ther 2008; 24:321-6. 3. Dražančić A. Krivulje fetalnog rasta, usporeni fetalni rast, dismaturnost. Ginekol Perinatol 2009; 18:1-18. 4. Gruenwald P. Growth of the human fetus I. Normal growth and its variation. AM J Obstet Gynaecol 1966; 94:1112-9. 5. Gruenwald P. Growth of the human fetus II. Abnormal growth in twins and in infants of mothers with diabetes, hypertension or isoimunisation. AM J Obstet Gynaecol 1966; 94:1120-32. 6. Lubchenco LO, Hamsamn Ch, Dressler M, Boyd E. Intrauterine growth as estimated from live-born birth weight at 24 to 42 weeks of gestation. Pediatrics 1963; 32:793-800. 7. Sterky G. Swedish standard curves for intrauterine growth. Pediatrics 1970; 46: 7-9. 8. Nikolić Lj. Intrauterini rast živorođene djece. Jugoslav ginekol opstet 1973; 16:131-7. 9. Radojković Z, Ivanović Lj, Avramović K. Standardi intrauterinog rasta živorođene djece. Jugoslav Ginekol Opstet 1974; 15:99-106. 10. Latin V, Klobučar A, Kos M. Fetalna biometrija i procjena gestacijske dobi. U: Kurjak A i sar., ur. Ultrazvuk u ginekologiji i porodništvu. Zegreb: Art Studio Azinović 2000: 250-64. 11. Skokić F, Radoja G, Fatušić Z, Muratović S, Šabić N, Babović A. Postnatal estimation of intrauterine growth in three different socioeconomic period. Acta Med Sal 2003; 32:93-6. 158 12. Report of the FIGo subcomitee on Perinatal Epidemiology and Health statistics following a Workshop in Cairo 1984 on the Metodology of Measurement and Recording of Infant Growth in the Perinatal Period. Int J Gynaecol Obstet 1986; 26: 483. 13. Campbell S. An important metohod of fetal cephalometry by ultrasound. J Obstet Gynaecol Br Cwth 1968; 12: 23-30. 14. Jeanty P, Romero R. Obstetrical ultrasound. New York: McGrow Hill, 1984:55-56. 15. O’Brien GD, Queenan JT, Campbell S. Assement of gestational age in the second trimester by real time ultrasound of the femur lenght. Am J Obstet Gynaecol 1981; 138:875-80. 16. Hadlock FP, Harrist RB, Deter RL. A prospective evaluation of fetal femoral lenght and biparietal diameter in predicting gestational age. J Ultrasound Med 1983; 2:111-7. 17. Dražančić A. Rast fetusa u Zagrebu. Jugoslav Ginekol Perinatol; 1988; 28: 13-20. 18. Kaluđerović M. Krivulja percentilne težine i duljine donesene djece općine Nikšić. Magistarski rad. Zagreb 1982. 19. Balić A, Balić D, Balić B. Protocol for determining the gestational age an due date of patients with uncertain term. Prenat Neonat Med 2000; 2:72. 20. Balić B. Impact of the war on maternal mortality. In: Voto SL. Margulies M, Cosmi EV ed. IV World Congress of Perinatal Medicine, Buenos Aires, Argentina, April 18-22, 1999. Bologna: Monduzzi Editore 1999; 907-910. 21. Balić A, Balić D. Perinatalna zbivanja u Tuzlanskoj regiji kroz naučni rad i djelo prof. dr. sci. Branislave Balić. Tuzla: PrintCom 2006; 1-110. Balić et al Standardi fetalnog rasta Intrauterine growth standards for Tuzla region Adem Balić1, Devleta Balić2 Department of Obstetric and Gynaecology, Health Centre Tuzla, Gynaecological Office “Dr Balić” Tuzla ABSTRACT Aim To evaluate normal fetal growth and create a normogram for the population of the Tuzla Canton. Methods In the period 2002-2005 we evaluated fetal growth by ultrasound measurements (biparietal diameter -BPD, head circumpherency -HC, abdominal diameter -ABD, abdominal circumpherency -AC, femur length - FL) according to the criteria of FIGO (1986) in 100 healthy pregnant women with normal singleton pregnancy. All of them had spontaneous vaginal delivery between the 38th and 41st week. These measurements were done once per month starting from 12 to 41 weeks. Results Mean birth weight value in 38th week was 3280 ± 345g, in 39th week 3360 ± 280g, in 40th week 3596 ± 320g and in 41st week 3732 ± 38 g. These standards have shown lower values of all examined parameters in all the gestation weeks. Values of BPD and FL were very similar but differences between our values of HC and AC in the last four weeks were very high. Conclusion We found significant differences between our standards and others (Hadlock, 1983 i Latin, 2000) especially in the last four weeks of gestation. Now, when we have standards of fetal growth for our population we expect better evaluation of gestational age and lower perinatal mortality in Bosnia and Herzegovina. Key words fetal growth, standards, BPD, FL Original submission: 18 November 2009; Revised submission: 15 January 2010; Accepted: 19 January 2010. 159 ORIGINAL ARTICLE Stereološka analiza sinciciotrofoblasta resorpcijske resice posteljice trudnica mlađe i starije životne dobi Sergije Marković1, Zlata Žigić1, Suada Ramić1, Jasminka Hadžihalilović2 1 Zavod za histologiju i embriologiju, Medicinski fakultet, Univerzitet u Tuzli; 2Prirodno-matematički fakultet, Univerzitet u Tuzli; Tuzla, Bosna i Hercegovina SAŽETAK Cilj Odrediti kvantitativne parametre volumenske gustoće i apsolutnog volumena sinciciotrofoblasta resorpcijske resice kontrolne i eksperimentalne skupine, te dobijene rezultate uporediti i ustanoviti postoje li statistički značajne razlike analiziranih strukturnih parametara resorpcijskih resica u zavisnosti od životne dobi trudnice. Corresponding author: Sergije Marković, Univerzitet u Tuzli, Medicinski fakultet, Univerzitetska 1, 75000 Tuzla, Bosna i Hercegovina Phone: +387 35 320 640; fax: +387 35 320 601 E-mail: sergije.markovic@untz.ba Originalna prijava: 22. januar 2009.; Korigirana verzija: 08. mart 2010..; Prihvaćeno: 01. april 2010. Metode Istraživanje je izvršeno na 60 humanih posteljica terminske trudnoće, podijeljenih u dvije skupine: 30 posteljica trudnica od 20. - 34. godine životne dobi (kontrolna skupina) i 30 posteljica trudnica od 35. godine životne dobi i više (eksperimentalna skupina). Stereološka analiza izvršena je mnogonamjenskim testnim sistemom M-42, uz povećanje objektiva 40x. Rezultati Prosječna volumenska gustoća sinciciotrofoblasta resorpcijskih resica eksperimentalne skupine iznosila je Vvss = (0,489 ± 0,032) mm0, a kontrolne grupe Vvsm = (0,389 ± 0,078) mm0. Statistička analiza rezultata Studentovim t-testom pokazala je kako je volumenska gustoća sinciciotrofoblasta resorpcijskih resica eksperimentalne skupine bila značajno veća u odnosu na kontrolnu skupinu (p<0,001). Apsolutni volumen sinciciotrofoblasta resorpcijskih resica eksperimentalne skupine iznosio je Vss = (205,250 ± 40,894) cm3, a kontrolne skupine Vsm = (178,386 ± 44,413) cm3. Utvrđeno je da je apsolutni volumen sinciciotrofoblasta resorpcijskih resica eksperimentalne skupine značajno veći u odnosu na kontrolnu skupinu (p<0,005). Zaključak Statistički značajno veće vrijednosti volumenske gustoće i apsolutnog volumena sinciciotrofoblasta resorpcijskih resica posteljica trudnica starije životne dobi, predstavljaju kompenzatorni mehanizam kao odgovor na smanjenu metaboličku izmjenu tvari između majke i ploda. Ključne riječi: posteljica, resorpcijska resica, sinciciotrofoblast, trudnice mlađe i starije životne dobi, stereološka analiza. Med Glas Ljek komore Zenicko-doboj kantona 2010; 7(2):160-165 160 Marković et al Stereološka analiza sinciciotrofoblasta UVOD Optimalna životna dob žene za trudnoću i rađanje je između 20. i 29. godine života, a trudnoće žena starijih od 35. godine smatraju se rizičnim (1, 2). Promjene unutar placentne membrane kroz koju se vrši razmjena materija između krvi majke i krvi ploda, u zavisnosti od intenziteta i dužine trajanja promjene, mogu dovesti do intrauterine patnje i poremećenog razvoja ploda (3). Ove promjene mogu imati za posljedicu rađanje hipotrofične i nedonešene djece, pojavu respiratornog distresa, akutnu ili hroničnu hipoksiju, povišen perinatalni morbiditet i mortalitet (4, 5). Do sada provedena kvantitativna istraživanja trofoblasta posteljice terminske trudnoće i poroda odnosila su se na cjelokupni trofoblast resorpcijskih resica (6-9). Analize strukturnih komponenti (sinusoidni kapilari, stroma, sinciciotrofoblast) resorpcijskih resica posteljice, pokazale su kako su one mjesto najvećih morfoloških promjena u posteljici za vrijeme desetog lunarnog mjeseca (8). Kako rizik za djecu raste kod trudnica starije životne dobi, poznavanje veličine površina dostupnih za transport tvari važno je za ocjenjivanje količine hranidbenih tvari koje mogu biti prenesene fetusu za njegov normalan rast i razvoj. Zbog velikog značenja koje se u cijelom svijetu pridaje utjecaju starije životne dobi na tok i ishod trudnoće, a zbog nedostatka ispitivanja kompenzatorne uloge strukturnih dijelova trofoblasta, sprovedeno je istraživanje u cilju kvantitativnog određivanja vrijednosti fetomaternalne izmjene tvari, volumenske gustoće i apsolutnog volumena sinciciotrofoblasta resorpcijske resice, posteljice trudnica mlađe i trudnica starije žđivotne dobi. MATERIJAL I METODE Istraživanje je izvršeno na 60 humanih posteljica terminske trudnoće na Ginekološko-akušerskoj klinici UKC-a Tuzla, u periodu od decembra 2005. do decembra 2006. godine. Ispitanice su bile podijeljene u dvije skupine: trudnice od 20. - 34. godine životne dobi (kontrolna skupina) i trudnice od 35. godine životne dobi i više (eksperimentalna skupina). U svakoj skupini istraživalo se po 30 posteljica. Dob trudnoće određivana je prema prvom danu zadnje menstruacije kod trudnica s redovnim menstruacionim ciklusom, a potvrđena je UZ pregledom u prvom trimestru trudnoće. Sa svake istraživane posteljice najprije su odstranjeni ovoji i pupkovina. Masa posteljice određivana je vaganjem (u gramima), a njen je volumen određivan indirektno, mjerenjem istisnute tekućine (mm3). Za histološku obradu uzimani su uzorci tkiva debljinom čitavog organa, od horionske do bazalne ploče (parenhimski dio). Tkivo je fiksirano u 10% vodenoj otopini neutralnog formalina, uklopljeno u parafin i rezano na rezove debljine 8 µm. Deparafinizirani rezovi su obojeni hemalaunom i eozinom. Za stereološku analizu referentni prostor bila je resorpcijska resica posteljice, a stereološka analiza izvršena je na histološkim preparatima. Veličina uzorka, odnosno potreban broj stereoloških mjerenja za svaku istraživanu varijablu, u obje skupine trudnica, određen je postupkom po de Hoffu (Slika 1) (10). Dobijeni broj ''n'' predstavlja broj testnih polja koje je trebalo stereološki analizirati pri 95% intervalu povjerenja, kako rezultat ne bi odstupao od stvarne vrijednosti prosjeka populacije za više od 10%. Slika 1. Formula 1. Postupak po de Hoffu (10) Stereološka analiza izvršena je mnogonamjenskim testnim sistemom M-42, uz povećanje objektiva 40x, te je obuhvatila relativne i apsolutne varijable. Od relativnih stereoloških varijabli određena je volumenska gustoća sinciciotrofoblasta (Vvs). Volumenska gustoća je relativna stereološka varijabla koja predstavlja udio ispitivane strukture u jedinici volumena (Slika 2): Slika 2. Formula za izračunavanje volumenske gustoće (10) 161 Medicinski Glasnik, Volumen 7, Number 2, August 2010 Od apsolutnih varijabli određen je apsolutni volumen (V), kojim je označen ukupni volumen istraživanih strukturnih komponenti unutar volumena čitavog organa (mm3) (Slika 3): Vf =Vvf ·Vo Slika 3. Formula za izračunavanje apsolutnog volumena (10) Dobijeni rezultati obrađeni su slijedećim statističkim metodama: izračunate su aritmetička sredina (x), standardna devijacija (s) i standardna greška (SE). Značaj razlike rezultata između posteljica u odnosu na starost trudnice, određena je Studentovim t-testom. Koeficijent varijabilnosti (KV) izračunat je za relativne i apsolutne vrijednosti istraživanih varijabli u navedenim posteljicama. 162 Grafikon 2. Prosječna vrijednost i standardna devijacija volumenske gustoće sinciciotrofoblasta (Vvs) resorpcijskih resica istraživanih posteljica trudnica mlađe i starije životne dobi (mm0) REZULTATI prikazana je na Grafikonu 2. Volumenska gustoća sinciciotrofoblasta resorpcijskih resica posteljica trudnica starije životne dobi imala je značajno veću vrijednost u odnosu na trudnice mlađe životne dobi (p<0,001). Relativne stereološke varijable Apsolutne stereološke varijable Volumenska gustoća sinciciotrofoblasta (Vvs) resorpcijskih resica posteljica trudnica mlađe životne dobi (Vvsm), za istraživane posteljice, kretala se u rasponu 0,25 - 0,58 mm0, a kod trudnica starije životne dobi (Vvss) u rasponu 0,43 - 0,56 mm3. Učestalost volumenske gustoće sinciciotrofoblasta (Vvs) resorpcijskih resica istraživanih posteljica trudnica mlađe i starije životne dobi prikazana je na Grafikonu 1. Prosječna volumenska gustoća sinciciotrofoblasta resorpcijskih resica posteljica trudnica mlađe životne dobi iznosila je Vvsm = (0,389 ± 0,078 mm0), dok je kod trudnica starije životne dobi iznosila Vvss = (0,489 ± 0,032 mm0). Prosječna vrijednost i standardna devijacija volumenske gustoće sinciciotrofoblasta (Vvs) resorpcijskih resica istraživanih posteljica trudnica mlađe i starije životne dobi (mm0) Apsolutni volumen sinciciotrofoblasta (Vs) resorpcijskih resica posteljica trudnica mlađe životne dobi (Vsm), za istraživane posteljice, kretao se u rasponu od 112,98 - 296,20 cm3, a kod trudnica starije životne dobi (Vss) u rasponu od 139,93 - 332,73 cm3. Frekvencija rezultata apsolutnog volumena sinciciotrofoblasta (Vs) resorpcijskih resica posteljica trudnica mlađe i starije životne dobi prikazana je na Grafikonu 3. Grafikon 1. Frekvencija rezultata volumenske gustoće sinciciotrofoblasta (Vvs) resorpcijskih resica istraživanih posteljica trudnica mlađe i starije životne dobi Grafikon 3. Frekvencija rezultata apsolutnog volumena sinciciotrofoblasta (Vs) resorpcijskih resica posteljica trudnica mlađe i starije životne dobi Prosječna vrijednost apsolutnog volumena sinciciotrofoblasta resorpcijskih resica posteljica trudnica mlađe životne dobi iznosila je Vsm = (178,386 ± 44,413 cm3), a kod trudnica starije životne dobi Vss = (205,250 ± 40,894 cm3). Prosječna vrijednost i standardna devijacija apsolutnog volumena sinciciotrofoblasta (Vs) resorpcijskih resica posteljica trudnica mlađe i starije Marković et al Stereološka analiza sinciciotrofoblasta ljica trudnica koje pripadaju grupi EPH gestoza (edemi-proteinuria-hipertenzija). To ukazuje na jače odbacivanje istrošenih dijelova trofoblasta koje prevladava nad proliferacijom i diferencijacijom. Drugi su autori (15) ustanovili kako je prosječna vrijednost površinske gustoće resorpcijskih resica iznosila 22,190 mm-1 kod mlađih, a 22,098 mm-1 kod starijih (razlika između obje grupe nije bila statistički značajna). Grafikon 4. Prosječna vrijednost i standardna devijacija apsolutnog volumena sinciciotrofoblasta (Vs) resorpcijskih resica posteljica trudnica mlađe i starije životne dobi (cm3) životne dobi (cm3) prikazana je na Grafikonu 4. Apsolutni volumen sinciciotrofoblasta resorpcijskih resica posteljica trudnica starije životne dobi bio je značajno veći u odnosu na trudnice mlađe životne dobi (p<0,005). DISKUSIJA Rezultati našeg istraživanja pokazali su kako je prosječna vrijednost volumenske gustoće sinciciotrofoblasta iznosila 38,85% resorpcijske resice kod posteljica trudnica mlađe životne dobi, a kod trudnica starije životne dobi 48,85%. Posteljice trudnica starije životne dobi imale su 25,74% veći udio trofoblasta resorpcijske resice nego posteljice trudnica mlađe životne dobi, uz statistički značajnu razliku, što upućuje na zaključak da je došlo do aktivacije kompenzacijskih mehanizama i rezervnih kapaciteta posteljice kako bi se održala zadovoljavajuća fetomaternalna izmjena tvari potrebna za normalan rast i razvoj ploda (11). Do sada provedena kvantitativna istraživanja sinciciotrofoblasta posteljice normalne trudnoće i poroda odnosila su se na cjelokupni trofoblast resorpcijskih resica, te je ustanovljeno da iznosi 35% volumena posteljice (6) i 28,7% terminalne resice (8). Pojedini autori izvještavaju o smanjenju sinciciotrofoblastne membrane kod intrauterinog zaostajanja u rastu i razvoju ploda i hipoksije ploda, a što se pripisuje kompenzatornom mehanizmu (12, 13). Imunocitohemijskim metodama (14) dokazano je da je apoptoza trofoblasta u porastu kod poste- Pored relativnih vrijednosti, manji broj istraživača opisuje apsolutnu vrijednost volumena trofoblasta (16), ali ne i sinciciotrofoblasta resorpcijske resice posteljica. U našem istraživanju prosječni apsolutni volumen sinciciotrofoblasta resorpcijskih resica posteljica trudnica starije životne dobi iznosio je 205,250 cm3, a kod onih mlađe životne dobi 178,386 cm3 (p<0,005). Naši su rezultati potvrdili da se i u posteljicama starijih trudnica pokreću kompenzacijski mehanizmi koji osiguravaju dostatnu fetomaternalnu izmjenu tvari, pa i posteljice trudnica starije životne dobi funkcijski udovoljavaju potrebama normalnog rasta i razvoja fetusa (11), kao i da nema značajnog gubitka trofoblasta, te da se ne očekuju promjene na nivou fetomaternalne izmjene tvari (17). Rezultati ovog istraživanja navode i na zaključak da bit patološkog mehanizma posteljice nije u ukupnom volumenu resice, nego u strukturalnom i funkcionalnom kvalitetu same resice, što utiče na fetomaternalnu i metaboličku izmjenu tvari (15). Dobijeni rezultati dodatno objašnjavaju fiziologiju posteljice trudnica starije životne dobi i njenu sposobnost da pokrene kompenzatorne mehanizme čiji je glavni cilj dostatna fetomaternalna izmjena tvari. Dobijene vrijednosti jedan su od parametara za prosuđivanje funkcionalnih kapaciteta posteljice u pogledu izmjene tvari između majke i ploda. Određivanjem kvantitativnih parametara o građi posteljica trudnica različite životne dobi, postavljeni su kriteriji za ocjenjivanje njenih funkcionalnih kapaciteta, kao i patoloških strukturnih promjena (4, 18). ZAHVALE/IZJAVE Komercijalni ili potencijalni dvostruki interes ne postoji. 163 Medicinski Glasnik, Volumen 7, Number 2, August 2010 LITERATURA 1. 2. 3. 4. 5. 6. 7. 8. 9. 164 Miletić T, Aberle N, Mikulandra F. Perinatal outcome of pregnancies in women aged 40 and over. Coll Antropol 2002; 26:251-8. Abu-Heija AT, Jallad MF, Abukteish F Maternal and perinatal outcome of pregnancies after the age of 45. J Obstet Gynaecol Res 2000; 26: 27-30. Lawlor D, Shaw M, Johns S. Interpregnancy interval and risk of preterm birth and neonatal death:retrospective cohort study. BMJ 2007; 327:313-27. Jauniaux E, Watson AL, Hempstock J, Bao Y-P, Skepper JN, Burton GJ. Onset of maternal arterial blood flow and placental oxidative stress. A possible factor in human early pregnancy failure. Am J Pathol 2000; 157:2111-22. Hellström M, Gerhardt H, Kalén M, Li X, Eriksson U, Wolburg H, Betsholtz C. Lack of pericytes leads to endothelial hyperplasia and abnormal vascular morphogenesis. J Cell Biol 2001; 153:543-53. Van der Velde WJ. Structural changes in the placenta of smoking mothers: A quantitative study. Placenta 1983; 4:231-40. Boyd PA Quantitative structure of the normal human placenta from 10 weeks of gestation to term. Early Hum Dev 1984; 9: 297-307. Grbeša Đ, Živković BD. Does the human placenta differentiate structurally during the 10th lunar month. Acta Med Croatica 1994; 48:117-21. Bogdanović G. Uticaj pušenja u trudnoći na morfometrijska svojstva posteljice i stanje novorođenčeta. Doktorska disertacija. Tuzla: Medicinski fakultet Univerziteta u Tuzli, 2005;14-24. 10. Kališnik M. Temelji stereologije. Ljubljana: Društvo za stereologijo in kvantitativno analizo slike: DSKAS, 2002:14-47. 11. Mayhew TM. Stereological studies on fetal vascular development in human placental villi. Placenta 2004; 25: 226-33. 12. Burton GJ, Reshetnikova OS, Milovanov AP, Teleshova OV. Stereological evaluation of vascular adaptations in human placental villi to differing forms of hypoxic stress. Placenta 1996; 17: 49-55. 13. Battistelli M, Burattini S, Pomimi F. Ultrastructural study on human placenta from intrauterine growth retardation cases. Microsc Res Tech 2004; 65:150-8. 14. Vogt Isaksen C. Maternal smoking, intrauterine growth restriction, and placental apoptosis. Pediatr Dev Pathol 2004; 7:433-42. 15. Ramić S, Žigić Z, Alečković M. Stereological analysis of mature human placenta of pregnant women of different age. BJBMS 2006; 6:7-10. 16. Teasdale F, Jean - Jacques G. Morphometric evaluation of the microvillous surface enlargment factor in the human placenta from midgestation to term. Placenta 1985; 6:375-81. 17. Yamada Z, Kitagawa M, Takemura T, Hirokawa K. Effect of maternal age on incidences of apoptotic and proliferative cells in trophoblasts of full-term human placenta. Mol Hum Reprod 2001; 7:1779-85. 18. Sheiner E, Shoham-Vardi I, Hallak M (2003) Placental abruption in term pregnancies: Clinical significance and obstetric risk factors. J Matern Fetal Neonatal Med 2003; 13: 45-9. Marković et al Stereološka analiza sinciciotrofoblasta Stereological analysis of syncytiotrophoblast in resorption villi of placentas of young and older pregnant women Sergije Marković1, Zlata Žigić1, Suada Ramić1, Jasminka Hadžihalilović2 Department of Histology and Embryology, School of Medicine, 2 School of Natural Sciences; University of Tuzla, Tuzla, Bosnia and Herzegovina 1 ABSTRACT Aim To determine quantitative parameters of volume density and absolute volume of syncytiotrophoblast in resorption villi of control and experimental group, compare the results and search for correlation between structural parameters of resorption villi and pregnancy age. Metods The research was performed on 60 human placentas of term pregnancy: 30 placentas of pregnant women of age 20 - 34 (control group), and 30 placentas of pregnant women of age 35 and older (experimental group). Stereological analysis was performed on multipurpose testing system M42 with 40 times objective magnification. Results Average volume density of syncytiotrophoblast in resorption villi of experimental and control group was Vvss = (0,489 ± 0,032) mm0 and Vvsm = (0,389 ± 0,078) mm0 , respectively. Statistical analysis of results using Student t-test indicated a significantly higher volume density of syncytiotrophoblast of resorption villi in the experimental than in the control group (p<0,001). Absolute volume of syncytiotrophoblast in resorption villi of the experimental and control groups was Vss = (205,250±40,894) cm3 and Vsm = (178,386 ± 44,413) cm3, respectively. We have found a significantly higher absolute volume of syncytiotrophoblast in resorption villi in the experimental than in the control group (p<0,005). Conclusion Statistically significant higher values of volume density and absolute volume of syncytiotrophoblast in resorption villi of placentas in older pregnant women represent a compensatory mechanism as a response to decreased metabolic exchange between a mother and a fetus. Key words: placenta, resorption villi, syncytiotrophoblast, young and older pregnant women, stereological analysis. Original submission: 22 January 2009; Revised submission: 08 March 2010; Accepted: 01. April 2010 165 Medicinski Glasnik, Volumen 7, Number 2, August 2010 NOTES Operativni tretman endometrioze u Kliničkom centru Kragujevac u periodu 2004.-2008. godine Momčilo \orđević1, Božidar Jovanović1, Gordana \orđević2 Ginekološko-akušerska klinika, Klinički centar Kragujevac, 2 Medicinski fakultet u Kragujevcu; Kragujevac, Srbija 1 Corresponding author: Momčilo \orđević, Ginekološkoakušerska klinika, Klinički centar Kragujevac, Zmaj Jovina 25/8, 34000 Kragujevac, Srbija, Tel: ++ 381 34 345-230; E mail: mogidj@ptt.rs Originalna prijava: 17. mart 2009.; Korigirana verzija: 11. maj 2009.; Prihvaćeno: 28. august 2009. Med Glas Ljek komore Zenicko-doboj kantona 2010; 7(2):166-169 SAŽETAK U ovom retrospektivnom istraživanju analizirani su parametri vezani za nastanak i lečenje pelvične endometrioze (operativni zahvat, godine starosti, operativni pristup i konzervativnost operacije, rasprostranjenost endometrioze na okolne organe male karlice) na Ginekološko-akušerskoj klinici Kliničkog centra Kragujevac, tokom petogodišnjeg perioda. Od ukupno 88 pacijentkinja koje su imale cistu na jajniku i povišenu vrednost tumorskog markera Ca 125, te patohistološku verifikaciju endometrioze, najviše ih je bilo starosne dobi od 26 do 35 godina (56,8%). Najčešće je primenjivan radikalni hirurški zahvat, adneksektomija kod 53 (60,2%) i hosterektomija kod 24 (45,83%) pacijentkinje (p<0,01), a s gotovo podjednakom verovatnoćom primenjivane su laparotomija i laparoskopija (p>0,01). Endometrioza jajnika često je bila udružena i s endometriozom na drugim organima male karlice. Ključne riječi: pelvična endometrioza, endometrioza, laparoskopija UVOD Endometrioza je treći uzrok hospitalizacije u SAD-u među ginekološkim obolenjima (1, 2). Uprkos visokom morbiditetu i troškovima koja ova bolest iziskuje, malo se zna o njenoj etiologiji i patogenezi za koju postoji mnogo teorija (2). Šira definicija endometrioze podrazumeva prisustvo endometrijalnog tkiva van šupljine materice, što je udruženo sa simptomima dismenoreje, dispareunije, hroničnog pelvičnog bola i subfertil- 166 nosti (3). Prava dijagnoza postavlja se patohistološkom analizom (3). Bolest se klasifikuje strogo koristeći tradicionalni revidirani sistem Američke asocijacije za fertilitet (The American Fertility Association) na četiri stadijuma, od minimalne do ozbiljne, bazirajući se na veličini implantata, prisustvu cista i adhezija (3). Dijagnoza endometrioze može se postaviti samo vizuelizacijom i histološkom verifikacijom, što je jedino moguće laparoskopijom ili laparotomijom (3). Jedini neinvazivni test koji može sugerisati endometriozu jeste tumorski marker CA-125 (4). Zato prevalenca u opštoj populaciji nije poznata. Endometrioza se javlja u najvećem procentu u fertilnom periodu (1-3). Glavna etiološka hipoteza za nastanak endometrioze je retrogradno menstruiranje (3). Međutim, retrogradna se menstruacija viđa kod čak 90% žena, što pretpostavlja i ulogu drugih faktora u nastanku endometrioze (1, 5-7). Cilj ovoga istraživanja bio je ispitati parametre vezane za nastanak i lečenje pelvične endometrioze (operativni zahvat, godine starosti, operativni pristup i konzervativnost operacije, rasprostranjenost endometrioze na okolne organe male karlice) na Ginekološko-akušerskoj klinici Kliničkog centra Kragujevac. U našem okruženju nisu rađena slična istraživanja, te je svrha ovog istraživanja evaluacija dosadašnjeg stava o operativnom pristupu i radikalnosti. ISPITANICI I METODE Tokom 2009. godine provedena je retrospektivna studija na Ginekološko-akušerskoj klinici Kliničkog centra Kragujevac u Kragujevcu. U istraživanje su bile uključene pacijentkinje u kojih je verificirana cista na jajniku, veća od 5 cm, koja je perzistirala najmanje 3 meseca, povišene vrednosti tumorskog markera Ca-125 (> 35 IU/L), te patohistološka verifikacija endometrioze. Kod pacijentkinja koje nisu ispunjavale ove kriterije bila je rezervisana samo medikamentozna terapija s gonadotropin-releasing hormonom (GNRH), i to u trajanju od 4 meseca kod pacijentkinja koje su rađale, te u trajanju od 6 meseci kod onih koje nisu rađale. Kod ispitanica su određivani sledeći parametri: godine starosti, operativni pristup i konzervativnost operacije, te rasprostranjenost endometrioze na okolne organe male karlice. Notes Zaključivanje o validnosti razlika između pojedinih parametara i njihovih verovatnoća utvrđena je primenom χ2 testa. Za nivo pouzdanosti uzeto je do 5% (p < 0,05). REZULTATI U periodu 2004.-2008. godine, na Ginekološkoakušerskoj klinici Kliničkog centra Kragujevac, zabeleženo je 88 pacijentkinja kod koji je dijagnostikovana pelvična endometrioza. Najveći broj pacijentkinja zabeležen je 2007. godine (20), a najmanji 2004. godine (16). Najviše su obolevale žene u dobi od 26 do 35 godina (56,8%), zatim žene od 36 do 45 godina (30,7%), mlađih od 25 godina bilo je 7 (8,0%), a starijih od 45 godina 4 (4,5%). Prisustvo endometrioze je statistički značajno češće ustanovljeno samo na jajniku (kod 65 (73,9%) žena), dok je kod 23 (26,1%) žene endometrioza ustanovljena i na jajniku i na okolnim organima male karlice (p < 0,01). Najčešće su bili zahvaćeni peritoneum (kod 15 (65,2%) slučajeva), zatim na materici (kod 5 (21,7%) slučajeva), te na crijevima i bešiki kod dva, odnosno jednom slučaju. Značajno češće primenjivana je radikalna operacija (kod 53 (60,2%) pacijentkinje), i to adneksektomija kod 29 (54,17%), te histerektomija kod 24 (45,83%) pacijentkinje, dok je resekcija jajnika primenjena kod 35 (39,8%) pacijentkinja (p < 0,01). Laparoskopija je rađena kod pacijentkinja koje nisu rađale i kod kojih je bilo potrebno da se izvrši konzervacija jajnika, što nije uspelo u samo jednom slučaju kada je urađena adneksektomija. Recidiv je zabeležen kod 3, a trudnoća kod 9 pacijentkinja. Niti kod jedne pacijentkinje nije zabeležena teža komplikacija vezana za operativni zahvat ili anesteziju, osim kod jedne pacijentkinje gde je izvršena konverzija laparoskopije u laparotomiju zbog opsežnosti endometrijalnih promena. Značajno češće primenjivana je laparotomija, kod 52 (59,1%), dok je laparoskopija primenjena kod 36 (40,9%) slučajeva (p > 0,01). DISKUSIJA U našoj studiji za razmatranje su uzete samo ozbiljnije forme endometrioze koje podrazumevaju prisustvo endometrijalnih cista na jajniku i endometriozu na okolnim organima male karlice, s povišenim vrednostima tumorskog markera Ca125. Treba naglasiti da vrednosti Ca 125 mogu biti povišene i u perimenstruacijskom razdoblju, kod upale i u neoangiogenezi (4). Endometrioza se u najvećem procentu javlja u fertilnom periodu. Najviše obolelih, u našem istraživanju, bilo je u dobi 26-35 godina (56,8%), što je u skladu s rezultatima drugih (1, 8), a prosečna starost kod naših pacijentkinja (32,3 godine) bila je nešto viša u odnosu na rezultate drugih istraživanja (29,4 godine) (8, 9). Razlog tome je verovatno činjenica da su u našem ispitivanju učestvovale pacijentkinje s dijagnostikovanom cistom na jajniku, većom od 5 cm. Endometrioza nije retka bolest ni kod adolesceneta. Aproksimativno polovina žena ispod 20 godina, koje imaju hronični pelvični bol ili dispareuniju, imaju ovu bolest (7). Oko 5% endometrioznih slučajeva viđaju se kod žena u postmenopauzi, budući da egzogeno davanje estrogena ima ulogu u nastanku endometrioze (9), te su i u ovome istraživanju zabeleženi slični rezultati kod žena starijih od 45 godina. Najčešći operativni zahvat koji je primenjivan u zbrinjavanju pelvične endometrioze u našem istraživanju bio je radikalni (60,2%), što je za posledicu imalo adneksektomiju kod 32,9% i histerektomiju kod 27,3% pacijentkinje, a značajno manje konzervacija jajnika, kod 39,8% pacijentkinja. Histerektomija kod belkinja u SAD-u primenjuje se kod 11%, što je značajno manje u odnosu na naše istraživanje (2, 10). Resekcija jajnika, kao konzervativni operativni tretman, povoljnija je za pacijentkinju jer kasnije, u kombinaciji s GNRH, manje remeti daljnju fertilnu sposobnost i rezervisana je pretežno za mlađe pacijentkinje (11). I u našem istraživanju najbrojnije su bile mlađe pacijentkinje, te je posle kombinovane terapije (hirurške i medikamentozne) zabeleženo 9 trudnoća. Rezultati našeg istraživanja pokazali su visoku prevalencu adneksektomija (samostalno ili u kombinaciji s histerektomijom), što se delimično može opravdati činjenicom da kod velikih endometriotičnih cista nije moguće uraditi konzervaciju ovarijuma, zatim u raširenosti endometrioze na druge organe, završenoj reproduktivnoj funkciji žene, starosti. Radikalnost operativnih zahvata kod pacijentkinja gde su postojali uslovi za resekciju ovarijuma nema neko veliko uporište (8). 167 Medicinski Glasnik, Volumen 7, Number 2, August 2010 Kod naših pacijentkinja, s gotovo podjednakom verovatnoćom, primenjivane su laparotomija (59,1%) i laparoskopija (40,9%). Iako su poznate prednosti laparoskopije, ipak nešto veća primena laparotomije, premda bez statističke značajnosti, posledica je verovatno više faktora. Pored neopravdanih razloga (primena kod pacijentkinja koje su rađale, nedovoljno poznavanje tehnike laparoskopije), razlog za ovako visoku prevalencu primene laparotomije kod naših pacijentkinja jeste i nemogućnost postavljanja adekvatne preoperativne dijagnoze (sumnja na benignu bolest). Stoga je kod naših pacijentkinja laparotomija i primenjivana kod onih starije dobi, kao i kod onih kod kojih je završena reproduktivna funkcija. Laparoskopija je samo novi način pristupa operativnom polju, a nije posebna vrsta operativnog zahvata, te bi indikacije za laparoskopiju trebale biti identične onima u klasičnoj hirurgiji, odnosno ovisne o dijagnozi bolesti (10). Endometrioza ne može da se razmatra separatno od adhezija koje zahvataju razne organe. Najčešća je na ovarijumu, zatim na peritoneumu i kao duboka infiltrišuća endometrioza, a ređe na ostalim organima, što je u saglasju s našim rezultatima (11, 12). Tretman podrazumeva operativni zahvat i hormonalnu supresiju, ali, na žalost, kod mnogih bez očekivanog uspeha (10, 13-15). Postavljanje dijagnoze pelvične endometrioze, kao i odabir terapije, kompleksan je problem. S obzirom da se endometrioza najčešće javlja u fertilnom dobu i da ozbiljnije forme uvek zahtevaju, pored medikamentozne, i hiruršku terapiju, tome treba prilagoditi vrstu operativnog pristupa i radikalnost operacija. ZAHVALE/IZJAVE Komercijalni ili potencijalni dvostruki interes ne postoji. LITERATURA 1. 2. 3. 4. 168 Missmer SA, Hankinson SE, Spiegelman D, Barbieri RL, Malspeis S, Willett WC, Hunter DJ. Reproductive history and endometriosis among premenopausal women. ACOG. Obstet Gynecol 2004; 104:965-74. Kyama CM, Mwenda JM, Machoki J, Mihalul A, Simsa P, Chai DC, D’Hooghe TM. Endometriosis in African women. J Women’s Health 2007; 3:629-35. Zondervan KT, Cardon LR, Kennedy SH. What makes a good case-control study? Design issuesfor complex traits such asendometriosis. Hum Reprod 2002; 17:1415-23. Hornstein MD, Harlow BL, Thomas PP, Check 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. JH. Endometriosis: Use of a new CA 125 assay in the diagnosis of endometriosis. Hum Reprod 1995; 10:932-34. Jašović-Siveska E, Jašović V. Povezanost kontrolisane hiperstimulacije ovarijuma kod bolesnica sablagim oblikom endometrioze. Vojnosanit Pregl 2008; 65:147-52. Seleem MI, Hashemy AM, Obeid MA. Umbilical endometriosis: a diagnostic dilemma - case report. J Kuwait Med 2002; 34:303-05. Attia GR, Zeitoun K, Edwards D, Johns A, Carr BR and Bulun SE. Progesterone receptor isoform A but not B is expressed in endometriosis. J Clin Endocrinol 2000; 85:2897-02. Blanco G, Parithivel VS, Shah AK, Gumbs MA, Schein M, Gerst PH. Abdominal wall endometriomas. Am J Surg 2003; 185:596-98. Shawky Badawy ZA, Liberatore C, Farhat MA, Valente AL, Landas S. Cervical endometriosis stimulated by estrogen therapy following supracervical hysterectomy. J Gynecol Surg 2003; 19:141-44. Ozkan S, Murk W, Arici A. Endometriosis and Infertility. Epidemiology and Evidence-based Treatments. Ann N Y Acad Sci 2008; 1127:92-100.?? C. Chapron, H. Barakat, X. Fritel, J.-B. Dubuisson, G. Breart, Fauconnier A. Presurgical diagnosis of posterior deep infiltrating endometriosis based on a standardized questionnaire. Hum Reprod 2005; 20:507-13. Erel CT, Senturk LM. Is laparoscopy necessary before assisted reproductive technology?. Curr Opin Obstet Gynecol. 2005; 17:243-48. Story L, Kennedy S. Animal studies in endometriosis: A Review. ILAR J 2004; 45:132-39. Bazot M, Detchev R, Cortez A, Amouyal P, Uzan S and Dara E. Transvaginal sonography and rectal endoscopic sonography for the assessment of pelvic endometriosis: a preliminary comparison. Hum Reprod 2003; 18:1686-92. Bazot M, Darai E, Hourani R, Thomassin I, Cortez A, Uzan S. Deep pelvic endometriosis. Radiology 2004; 232:379-89. Operative treatment of endometriosis in the Clinical Centre of Kragujevac during the period 2004-2008 ABSTRACT In this retrospective research parameters connected to the pathogenesis and treatment of pelvic endometriosis have been analyzed (surgical operation, age, surgical approach and conservativeness of the operation, spreading of the endometrioses to the surrounding pelvic organs) at Gynecology and Obstetric Clinic of Clinical Centre in Kragujevac during a five year period. The total number of observed patients was 88. They all had ovary cysts and a high value of the Ca 125 tumor marker and pathological verification of endometrioses. The greatest number of Notes patients were in the age group 26-35 (56,8%). The most common procedure was radical surgical operation adnexectomy in 53 (60,2%) and hysterectomy in 24 (45,83%) patients (p<0,01). With almost equal probability both laparotomy and laparoscopy were performed (p>0,01). Ovary endometriosis was often joined with other pelvic organs endometriosis. Key words: pelvic endometriosis, endometriosis, laparoscopy Original submission: 17 March 2009; Revised submission: 11 May 2009; Accepted: 28 August 2009; NOTES Emerging risk for viral hepatitis A in Croatian adults Vladimir Mićović 1, Albert Cattunar1, Danijela Štimac 2, Krunoslav Capak3, Dražen Stojanović 4, Davor Jurišić5 Department of Environmental Health, School of Medicine, University of Rijeka, 2Zagreb Institute of Public Health, Zagreb, 3 Croatian National Institute of Public Health, Zagreb, 4Department of Social Medicine and Epidemiology, School of Medicine, University of Rijeka, 5University Hospital Center Rijeka; Croatia 1 Corresponding author: Danijela Štimac, Zagreb Institute of Public Health, Mirogojska 16, 10000 Zagreb, Croatia, Phone +385 1 4696172; fax +385 1 4678019, Email: danijela.stimac@ stampar.hr Original submission: 10 April 2009; Revised submission: 27 October 2009; Accepted: 04 January 2010 Med Glas Ljek komore Zenicko-doboj kantona 2010; 7(2):169-172 ABSTRACT An objective of the study was to determine the changes in the risk of developing hepatitis A in the 30-years period and discuss the need for vaccination against HAV infection in Croatia and the city of Rijeka comparing incidence of hepatitis A between 1970-1974 and 2000-2004 periods. Hepatitis A declined in both populations and affected more prominently older population groups. Improvement of hygiene and sanitary conditions appears to have decreased hepatitis A incidence among children and adults, but only a seroepidemiological study can give more accurate data as a basis for discussion on the necessity of vaccination as a further measure in reducing hepatitis A incidence. Key words: adults, children, hepatitis A, incidence INTRODUCTION In recent years in Croatia the incidence of diseases associated with low hygienic and living standards, i.e. typhoid fever, bacillary dysentery, and hepatitis A, has clearly regressed to the levels typical of developed countries (1). An 8-year monitoring of infectious disease cases and deaths revealed a low and relatively stabilized trend of hepatitis A virus (HAV) infections in Croatia, in spite of a certain rise after the lowest incidence rate of 34/100 000 in 1998. However, these levels are far below those of the 1960s when up to 14 000/100 000 cases had been registered annually (2). During the past decades more adult than child/ adolescent patients with HAV infection were hospitalized, and clear decline in incidence was observed through the national system of the reporting infectious diseases (3). A similar phenomenon of declining HAV morbidity and shift of age distribution was observed in several European countries (4,5). The objective of the study was to determine the risk of developing HAV infection and discuss the feasibility of vaccination against HAV infection. METHODS The study of HAV infection incidence was carried out in the database of the Croatian Registry of Infectious Diseases of the Croatian National Institute of Public Health. The clinical diagnosis of HAV infection was supported by epidemiological data and confirmed with a serological test by the local hospital or public health institute laboratory. Following confirmation, the case has been reported to the local epidemiological service and then notified at the national level. The notification system is compulsory in Croatia according to the Act on Population Protection against Communicable Diseases. For the purpose of this study the population of the City of Rijeka and Republic of Croatia have been selected. Crude annual cumulative incidence (CI) for Rijeka and Croatia was calculated per 100 000 inhabitants. Five-year CI per 100 000 inhabitants of the disease was age-adjusted to the standard world population by direct method for each age group. 169 Medicinski Glasnik, Volumen 7, Number 2, August 2010 The age distribution of cumulative reported cases was compared between children (ages 0-14) and adults (older than 15) in the two 5-year periods 30 years apart (1970-74 and 2000-04). The 5-year periods were considered suitable for the analysis in order to avoid potential bias of annual variation in disease incidence caused by outbreaks. Frequencies of the reported cases between study periods (1970-74 and 2000-04) were compared by chi square test at alpha level of 0.05. Table 1. Cummulative incidence of the hepatitis A in Rijeka and Croatia in 1970-74 and 2000-04 periods compared between children and adults (15 and above) RESULTS ference in incidence between children and adults was statistically significant for the city of Rijeka. More than 20-fold decline of the annual crude CI per 100 000 inhabitants of the acute HAV infection was observed during the study period (Figure 1). During the first 5 study years, 42 900 cases of hepatitis A were reported in the whole of Croatia (1731 in Rijeka, 41 187 in the rest of Croatia). After 30 years the values decreased: 1946 reported cases in Croatia, out of which 29 were in Rijeka and 1917 in the rest of Croatia. Ageadjusted 5-year CI in Croatia was 5220/100 000 (7828/100 000 in Rijeka) during 1970-74. Between 2000 and 2004 the incidence in Croatia declined to 273/100 000 (57/100 000 in Rijeka). Differences between affected children and adults in the 1970-74 period and the 2000-04 period were statistically significant in Rijeka (χ2=11,19; p=0,0008), but not in the rest of Croatia (χ2=0,14; p=0,7067) (Table 1). DISCUSSION Between periods 1970-74 and 2000-04 the incidence of hepatitis A declined from 42 900/100 000 to 1946/100 000 in Croatia, and from 1731/100 000 to 29/100 000 in the city of Rijeka. The dif- Region Period 5-years CI* 1970 - 74 7828 1776 733 1197 2000 - 04 57 0 12 20 8† 17† 1970 - 74 5220 450 1912 1485 512 861 2000 - 04 273 58 91 55 30 39 Age groups 0 - 4 5 - 9 10 - 14 15 - 19 > 20 Rijeka Croatia‡ 1499 2623 * CI=cummulative incidence/ 100 000 † statistically significant (χ2 = 11,19; p=0,0008) ‡ cases from Rijeka were excluded form Croatian total Results of this study have shown that HAV infection in the second period of examination affected more frequently (with statistical significance) adults (up to one half of all patients), in comparison to the 1970-1974 period, for both the city of Rijeka and Croatia as a whole. The agedistribution morbidity has changed, e.g. shifted toward adults. This is a phenomenon observed in developed countries (6-8). However, the CI in the city of Rijeka was higher than the national one, which could be ascribed to higher population density which is known to stimulate transmission of infectious diseases (9). During the 20th century Croatia underwent improvements in the general prophylactic measures against infectious diseases. In 2001, the death rate for infectious diseases was 1.03/100 000 (10). Better individual hygiene, improved food, water supply and sewage disposal, especially in day-care centers, kindergartens and schools, were of particular importance in reducing transmission of infectious diseases related to sanitary conditions and HAV infection (11). Figure 1. Crude annual cumulative incidence of reported hepatitis A cases per 100 000 inhabitants during 1970-2004 170 Notes Experience in administration of HAV vaccine for immunization of children in low endemic countries has shown that significant results could be achieved in further morbidity reduction, even in minor coverage, due to the effects of herd immunity. The above was noted in the USA after 1999, when the recommendation on routine infant vaccination was adopted (12), and in Israel and Spain where the same routine vaccination of children led to significant further morbidity reduction (13,14). However, Hepatitis A is a cyclic disease and any valid conclusions regarding the benefits of vaccination in low endemicity conditions will require more time. Vaccination against HAV infection is available in Croatia, but only for international travelers to high risk areas, and on request. Results of this study have shown that HAV infection in Croatia continuously declines followed by peaks in epidemic years. Due to improved sanitary conditions less children contract hepatitis A during childhood, and more older children, adolescents and adults are susceptible, so in the near future further changes in age distribution of HAV infection could be expected. Decreasing the incidence of HAV infection will make the population more susceptible to the disease, as a consequence of a larger number of non-immune persons (15). A constant trend of decline in morbidity will gradually decrease the number of naturally immune persons in upcoming decades. Loss of natural immunization during childhood will cause a remarkable shift of morbidity toward adults. This process was noticed in the countries of Western Europe and Scandinavia during the past decades (16). Adults are more susceptible than children to the clinical form of disease, as well as complications such as fulminant hepatitis (17). While considering the applicability and feasibility of introducing vaccination against hepatitis A in Croatia, one should be extremely cautious and bear numerous factors in mind. Morbidity reduction in infants, when inapparent infection predominates, leads to an increase in sensitivity in older age groups with predominant symptomatic diseases and more common complications. This study reflects reported cases – clinically evidenced HAV infection. Underreporting of HAV infection is a well known problem due to unapparent cases (18). The problem has persisted over the years and caused absolute figures to be less accurate. It is reasonable to believe, though, that this error is always similar, thus portraying accurate trends. This may be of particular practical importance, because more accurate seroprevalence studies, which are very expensive, have to be conducted for the purpose of a survey of HAV infection. However, this study emphasizes that HAV infection burden cannot be estimated without a seroepidemiological study of HAV seroprevalence. Furthermore, too short a time has elapsed between vaccine registration and now, while applicability studies were conducted in only few low endemicity countries, which, unlike Croatia, are immigrant countries. The disease can be controlled by improving hygienic and sanitary living conditions, as well as wise application of vaccines for high risk individuals. ACKNOWLEDGEMENTS/DISCLOSURES Thanks to Bernard Kaić, MD, MSc, epidemiologist of the Croatian National Institute of Public Health, Department of Epidemiology, for providing the data records at the national level. REFERENCES 1. 2. 3. 4. 5. 6. 7. 8. Jacobsen KH, Koopman JS. Declining hepatitis A seroprevalence: a global rewiew and analisys. Epidemiol Infect 2004; 132:1005-22. Strnad Pešikan M, Kuzman M, urednici. Croatian Health Service Yearbook 2000. Zagreb: Croatian National Institute of Public Health, 2001:19. Milinović D, Baklaić Ž, uredici. Croatian Health Indicators. Zagreb: Ministry of Health and Social Welfare and Croatian National Institute of Public Health, 2007: 78-85. Frösner GG, Papaevangelous G, Butter R, Iwarson S, Lindholm A, Courouc-Pauty A, Haas H, Deinhardt F. Antibody against hepatitis A in seven European countries. I. Comparison of prevalence in different age groups. Am J Epidemiol 1979; 110:63-9. Kremastinou T, Kalapothaki V, Trichopoulos D. The changing epidemiologic pattern of hepatitis A infection in urban Greece. Am J Epidemiol 1986; 120:703-6. Chiaramonte M, Moschen M, Stroffolini T, Rapicetta M, Bertin T, Renzulli G. Changing epidemiology of hepatitis A virus (HAV) infection: A comparative seroepidemiological study (1979 vs. 1989) in north east Italy. Ital J Gastroenterol 1991; 23:344-6. Frosner G, Willers H, Muller R, Schenzle D, Deinhardt F, Hopken W. Decrease in incidence of hepatitis A infections in Germany. Infection 1978; 6:25960. Marino RT, Valente AR, Ramatho FJ, de Moura MC. The changing epidemiological pattern of hepatitis A in Lisbon, Portugal. Eur J Gastroenterol Hepatol 1997; 9:795-7. 171 Medicinski Glasnik, Volumen 7, Number 1, 2, August January2010 2010 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. Shapiro CN, Coleman PJ, McQuillan GM, Alter MJ, Margolis HS. Epidemiology of hepatitis A: seroepidemiology and risk groups in the USA. Vaccine 1992; 10 (Suppl 1): S59-S62. Strnad Pešikan M, Kuzman M, urednici. Croatian Health Service Yearbook 2001. Zagreb: Croatian National Institute of Public Health, 2002:248 Bell BP. Global epidemiology of hepatitis A: implications for control strategies. U: Margolis HS, Alter MJ, Liang JT, Dienstag JL, ur. Viral Hepatitis and Liver Disease. London: International Medical Press, 2002:9-14. Wasley A, Samandari T, Bell BP. Incidence of hepatitis A in the United States in the era of vaccination. JAMA 2005; 294:194-201. Dagan R, Leventhal A, AnisE, Slater P,Ashur Y, Shouval D. Incidence of hepatitis A in Israel following universal immunisation of toddlers. JAMA 2005; 294:202-10. Lopalco PL, Salleras L, Barbuti S, Germinario C, Bruguera M, Buti M, Dominiguez A. Hepatitis A and B in children and adolescents-what can be learn from Puglia (Italy) and Catalonia (Spain)? Vaccine 2001; 19:470-4. Gdalevich M, Grotto I, Mandel Y, et al. Hepatitis A antibody prevalence among young adults in Israel-the decline continues. Epidemiol Infect 1998; 121:477-9. Melnick J. History and epidemiology of hepatitis A virus. J Infect Dis 1995; 171 (Suppl 1): S2-8. Lednar W, Lemon S, Kirkpatrik J, Redfield R, Fields M, Kelley P. Frequency of illness associated with epidemic hepatitis A virus infections in adults. Am J Epidemiol 1985; 122:226-33. Hadler S. Global impact of hepatitis A virus infection; changing patterns. U: Lemon S, Margolis H, ur. Viral hepatitis and liver disease. Baltimore: Williams and Wilkins, 1991:4-20. CASE REPORT Intaktna blizanačka tubarna trudnoća Jasmin Hodžić, Abdulah Granić, Nina Hodžić, Aida Idrizbegović Služba za ženske bolesti, neonatologiju i perinatologiju, Kantonalna bolnica Zenica, Zenica, Bosna i Hercegovina Corresponding author: Jasmin Hodžić, Služba za ženske bolesti, neonatologiju i perinatologiju, Kantonalna bolnica Zenica, Crkvice 67, 72000 Zenica, Bosna i Hercegovina, Phone: +387 32 446 670; fax.: +387 32 448 102, E-mail: drjassmin@ hotmail.com Originalna prijava: 06. novembar 2009.; Korigirana verzija: 03. decembar 2009.; Prihvaćeno: 22. decembar 2009. Med Glas Ljek komore Zenicko-doboj kantona 2010; 7(2):172-174 SAŽETAK U radu je prezentiran slučaj intaktne blizanačke ektopične trudnoće u osmoj sedmici, koja je otkrivena transvaginalnim ultrazvučnim pregledom u desnom jajovodu kod 35-godišnje multipare. Nakon operativnog zahvata učinjenog putem transverzalne laparotomije, odstranjen je desni jajovod u kome su se nalazila dva intaktna gestacijska 172 mješka. Do sada je u svijetu opisano tek nešto više od 100 slučajeva ektopične blizanačke trudnoće. Ključne riječi: blizanačka ektopična trudnoća, transvaginalni ultrazvučni pregled, transverzalna laparatomija UVOD Blizanačka ektopična trudnoća izuzetno je rijetka pojava. Od prvog opisa bolesnice s unilateralnom blizanačkom trudnoćom u jajovodu, koju je objavio De Ott još 1891. godine, ove su se trudnoće javljale pojedinačno jednom godišnje, te je od tada do danas u literaturi opisano tek nešto više od 100 slučajeva (1, 2). Incidenca blizanačke ektopične trudnoće kreće se oko 1:125.000 trudnoćâ, a samo u osam objavljenih slučajeva bila je evidentirana srčana akcija embriona (3). U ovom radu prikazat ćemo slučaj tubarne ektopične trudnoće multipare s anamnestičkim podacima koji govore u prilog čestih upalnih promjena reproduktivnih organa. PRIKAZ SLUČAJA Tridesetpetogodišnja multipara (četiri vaginalna poroda i jedan porod dovršen operativnim putem) upućena je na ginekološki odjel Kantonalne bolnice Zenica radi oskudnog vaginalnog krvarenja i bolova u dnu stomaka koji su trajali unazad dva dana. Zadnju menstruaciju pacijentica je imala osam sedmica ranije i nije koristila nijedan oblik kontacepcije. Iz anamneze pacijentica je navela operaciju appendixa prije deset godina, carski rez prije četiri godine i učestale vaginalne infekcije. Grav-index, koji je bio učinjen u 5. sedmici amenoreje od strane nadležnog ginekologa radi sumnje na trudnoću, bio je pozitivan. Na prijemu pacijentica je bila hemodinamski stabilna, krvni pritisak je iznosio 110/70 mmHg, a srčana frekvenca 80 otkucaja/min. Palpatornim nalazom abdomena ustanovljena je bolna osjetljivost u predjelu desne ilijačne regije gdje se istovremeno palpirala cistično-tjestasta konzistencija proširenog desnog jajovoda. Nije bilo znakova akutnog abdomena. Pregledom, uz pomoć spekuluma, uočeno je oskudno krvarenje iz uterusa. Bimanuelnim vaginalnim pregledom ustanovljeno je razmekšanje, te bolna osjetljivost grlića maternice na palpaciju. Laboratorijske analize pokazale su sljedeće vrijednosti: Le 10,5 x 109/L, Er 4,17 x 10¹²/L, Hgb 12,7 g/L, Htc 0,37 L/L, trombociti 333 109/L. Grav-index je bio pozitivan. Case report Pregledom transvaginalnim kolor-doplerom (TVCD), sondom jačine 6,5 MHz, ustanovljeno je sljedeće: maternica normalne veličine s praznim materništem i decidualno promijenjenim endometrijem; nepromijenjeni lijevi adneksi; u predjelu desnih adneksa jasno su uočena dva odvojena gestacijska mješka sa zamecima. Udaljenost tjeme-trtica jednog zametka iznosila je 15,9 mm s evidentnom srčanom akcijom. U drugom, manjem, gestacijskom mješku zametak nije ultrazvučno izmjeren, te u njemu nije bilo evidentne srčane akcije (Slika 1). Dan nakon prijema učinjena je transverzalna laparotomija. Pri zahvatu je ustanovljen proširen ampularni dio desnog jajovoda, tankog i napetog zida koji je plavičasto prosijavao (promjera 5-6 cm) s nešto malo krvi u Douglasovom prostoru, što je upućivalo na intaktnu tubarnu trudnoću. Ostali organi male zdjelice bili su bez vidljivih promjena. U toku operacije učinjena je salpingektomija s desne strane, a na lični zahtjev pacijentice, urađena je sterilizacija lijeve tube po metodi Pomeroya. Nakon operativnog zahvata odstranjena desna tuba s intaktnim gestacijskim mješcima je presječena i na taj način su se prikazala dva zametka koji su se razvijali u odvojenim gestacijskim mješcima (Slika 2). stavlja jedan od najvećih zdravstvenih rizika kod žena (4). Prevalencija ektopične trudnoće povećala se u zadnjih nekoliko godina, te sada iznosi 1-2% svih trudnoća, odnosno 2,1-9,4% u potpomognutim trudnoćama (5). Blizanačka ektopična trudnoća javlja se s incidencom od 1 na 200 svih ektopičnih trudnoća i ne prati trend porasta incidence ektopičnih trudnoća (6). Rizik pojave ektopičnih trudnoća povećan je u uvjetima koji mijenjaju normalnu funkciju jajovoda kao što su upalne promjene u zdjelici, prijašnje ektopične trudnoće, hirurški zahvati na jajovodima, operacije u zdjelici, trudnoće nakon asistirane humane reprodukcije, unutarmaternični uložak, žene starije od 35 i mlađe od 25 godina (7). U našem slučaju predisponirajući faktori za nastanak ektopične trudnoće bili su česte upalne promjene u zdjelici i prethodni porod dovršen operativnim putem. Dijagnoza ektopične trudnoće postavlja se anamnestički, općim i ginekološkim pregledom, biohemijskim biljezima (βHCG, estriol, progesteron), te ultrazvučnim pregledom (8). U normalnoj trudnoći, razina βHCG-a u plazmi udvostručuje se svakih 1,4-2,1 dan, dok kod ektopične trudnoće razina ovog hormona u plazmi pokazuje znatno niže vrijednosti (9). Uprkos tehnološkom napretku rane dijagnostike i tretmana, ektopična trudnoća još uvijek pred- Pojavom transvaginalnog ultrazvuka dijagnosticiranje ektopične trudnoće znatno je olakšano. Transvaginalni ultrazvuk pokazao se vrlo pouzdanim u dijagnostici jer je u 90,9% slučajeva prije operativnog zahvata potvrdio ektopičnu trudnoću (10). Transabdominalnim ultrazvukom moguće je dijagnosticirati ektopičnu trudnoću kod vrijednosti βHCG od 5000-6000 mIU/mL, a transvaginalnim ultrazvukom kod vrijednosti βHCG od 1000-1500 mIU/mL (11). Posljednjih godina tehnološkim usavršavanjem transvaginal- Slika 1. Ultrazvučni prikaz blizanačke tubarne trudnoće u osmoj nedjelji (I, prvi gestacijski mešak; II, drugi gestacijski mešak; III, uterus) (Hodžić J, 2009.) Slika 2. Prikaz otvorenog desnog jajovoda i dva zametka sa horionskim tkivom (Hodžić J, 2009.) Postoperativni tok je protekao bez komplikacija, te je pacijentica nakon 4. dana otpuštena s ginekološkog odjela Kantonalne bolnice Zenica. Patohistološki nalaz proširene desne tube uterine potvrdio je prisustvo ugrušaka krvi s mladim horijalnim resicama. Stroma proširenog dijela tube bila je decidualno transformirana, a u zidu, u svim slojevima, bilo je umnoženo vezivo infiltrirano limfocitima. 173 Medicinski Glasnik, Volumen 7, Number 2, August 2010 nog doplera u boji i 3D ultrazvuka omogućeno je jasno prikazivanje ranih stadija blizanačkih trudnoća u jajovodima (12). Liječenje ektopične trudnoće može biti hirurško i konzervativno. Konzervativno liječenje metotreksatom i prostaglandinima primjenjuje se u slučajevima male nerupturirane ektopične trudnoće (manje od 4 cm) s isključenom heterotopičnom trudnoćom, kod koje su vrijednosti βHCG-a ≤ 3000 mIU/ml, vrijednosti progesterona manje od 40 nmol/L i kod hemodinamski stabilne pacijentice (7). Međutim, još uvijek ne postoje usaglašeni stavovi o adekvatnoj dozi metotreksata u liječenju unilateralne ektopične blizanačke trudnoće. Hirurško liječenje provodi se radikalno salpingektomijom (kao što je to bio slučaj kod naše pacijentice) i konzervativno kod mlađih žena koje nisu rađale (fimbrijalna ekspresija, linearna salpingotomija, sedimentalna resekcija i laparoskopska aspiracija). Brojna su istraživanja pokazala da su za uspjeh liječenja manje važni metoda i vrsta hirurškog zahvata u odnosu na razloge koji su doveli do ektopične trudnoće. Ipak, pravovremena dijagnoza i liječenje ektopične trudnoće spašavaju život pacijentice, pa pristup dijagnosticiranju mora biti krajnje ozbiljan. Kombinacija kliničke slike, transvaginalnog ultrazvuka, serijskog βHCG-a i laparoskopije, predstavljaju ‘’zlatnu kombinaciju’’ ranog dijagnosticiranja ektopične trudnoće. Zahvaljujući boljoj dijagnostici i razvoju endoskopije, ektopična trudnoća, od 1993. godine, uglavnom se tretira laparoskopski (13) što predstavlja ‘’zlatni standard’’ hirurškog liječenja ektopične trudnoće. LITERATURA 1. De Ott. A case of unilateral twin gestation. Ann Gynaecol Obstet 1891; 36:304–5. 2. Aty E, Lam SL. Clinics in diagnostics imaging (106). Viable left tubal twin ectopic pregnancy. Singapore Med J 2005; 46:651–5. 3. Parker J, Hewson AD, Calder-Mason T, Lai J. Transvaginal ultrasound diagnosis of a live twin tubal ectopic pregnancy. Australas Radiol 1999; 43:95-7. 4. Murray H, Baakdah H, Bardell T, Tulandi T. Diagnosis and treatment of ectopic pregnancy. CMAJ 2005; 173:905-12. 5. Pyrgiotis E, Sultan KM, Neal GS. Ectopic pregnancies after in-vitro fertilization and embryo transfer. J Assist Reprod Gen 1994; 5:185–8. 6. Hanchate V, Garg A, Sheth R, Rao J, Jadhav PJ, Karayil D. Transvaginal sonographic diagnosis of live monochorionic twin ectopic pregnancy. J Clin Ultrasound 2002; 30:52-56. 7. Šimunić V. Izvanmaterična trudnoća. U: Šimunić V i sur. (ur.) Ginekologija. Zagreb: Naklada Ljevak, 2001:183-94. 174 8. Lurie S. The history of the diagnosis and treatment of ectopic pregnancy. A medical adventure. Eur J Obstet Gynecol Reprod Biol 1992; 43:1–7. 9. Greer IA, Cameron IT, Kitchener HC, Prentice A. Mosby’s color atlas and text of Obstetrics and Gynecology. London: Mosby International Limited 2001; 4:88-93. 10. Ash KM, Lyons EA, Levi CS, Lindsay DJ. Endovaginal sonographic diagnosis of ectopic twin gestation. J Ultrasound Med 1991; 10:497–500. 11. Farquhar MC. Ectopic pregnancy. Lancet 2005; 366:583-91. 12. Gabrielli s, Marconi R, Ceccarini M , Valeri B, de Iaco P, Pilu G. Transvaginal and three ultrasound diagnosis of twin tubal pregnancy. Prenatal Diagn 2006; 26:85-93. 13. Gualandi M, Steemers N, Keyser JL. First reported case of preoperative diagnosis and laparoscopic treatment of unilateral twin tubal pregnancy. Rev Fr Gynecol Obstet 1994; 89:134–6. Intact twin tubal pregnancy Jasmin Hodžić, Abdulah Granić, Nina Hodžić, Aida Idrizbegović Department of Women’s Health, Neonatology and Perinatology, Cantonal Hospital Zenica ABSTRACT A case of a unilateral eight-week twin ectopic pregnancy diagnosed with transvaginal sonography is presented here. This ectopic pregnancy was found in the right Fallopian tube of a 35-year old woman. After the surgical procedure conducted by the method of transversal laparotomy, we removed the right Fallopian tube with two gestational sacs. So far only a hundred of such cases of ectopic twin pregnancy have been described worldwide. Key words: twin Fallopian tube pregnancy, transvaginal sonography diagnostics, surgical treatment. Original submission: 06 November 2009.; Revised submission: 03 December 2009.; Accepted: 22 December 2009 Case report Obstruction of left ventricular outflow tract by a calcified mass at mitral valve Miro Bakula1, Zeljka Gavranovic2, Maja Bakula3, Roman Urek1, Nikola Jankovic4, Goran Milicevic1 Department of Cardiology, Clinical Hospital Sveti Duh, Medical School Zagreb and Medical School Osijek, 2 Department of Anesthesiology and Intensive Care, University Hospital Sestre Milosrdnice, 3 Vuk Vrhovac University Clinic for Diabetes and Metabolic Diseases, 4Department of Nephrology, Clinical Hospital Sveti Duh; Zagreb, Croatia 1 Case report Corresponding author: Goran Miličević, Division of Cardiology, University Department of Medicine, Medical School Osijek, Clinical Hospital Sveti Duh, Sveti Duh 64, 10000 Zagreb, Croatia, Phone: +385 1 371 2248; fax. +385 1 371 2112, E-mail address: gmilicevic@mefos.hr Original submission: 28 October 2009; Revised submission: 08 March 2010; Accepted: 11 March 2010. Med Glas Ljek komore Zenicko-doboj kantona 2010; 7(2):174-177 ABSTRACT A case of an unusual left ventricular outflow tract obstruction by mitral valve pathology in a 35-year old female with diabetes and end-stage renal disease is presented in the study. The patient suffered from fever of an unknown origin after lower-leg amputation. Although the wound healed well, fever persisted for three weeks despite a triple antibiotic treatment until the infection was resolved with vancomycin. Three months later echocardiography displayed a floating mass attached to mitral valve, producing a newly developed systolic murmur and a mild haemodynamic obstruction of the left ventricular outflow tract. The calcified vegetation was probably formed during an unrecognized subacute infective endocarditis. Key words: left ventricular outflow tract obstruction, mitral valve, infective endocarditis, echocardiography, haemodialysis INTRODUCTION Left ventricular outflow tract (LVOT) obstruction caused by mitral valve pathology is very rare. It has been described in patients with accessory mitral cusp (1) or retained native anterior leaflet following mitral valve replacement (2), in those with anterior leaflet diverticula (3) or anomalous papillary muscle insertion (4), in patients with myxomas (5) or giant blood cysts of the anterior mitral leaflet (6), and in massive posterior mitral annular calcification with mitral valve protrusion into the LVOT (7). The case of mitral valve endocarditis presented by Chandraratna et al. has indicated a possible LVOT obstruction, but haemodynamic measurements were not done (8). This paper presents a rare case of LVOT obstruction caused by calcified vegetation of the mitral valve in an end-stage renal disease patient CASE REPORT A 35-year old female patient was admitted to the hospital for diagnostic evaluation prior to elective parathyroidectomy due to secondary hyperparathyroidism. She has had diabetes for 23 years, developing all chronic complications, including renal failure. Diabetes was treated with basal-bolus regimen, combination of two doses of basal insulin analogue and three prandial doses of rapid-acting insulin analogue (lyspro). Physical examination revealed a previously unrecorded grade 3/6 systolic murmur above the precordium with the punctum maximum just above the aortal ostium. Three months before the current hospitalization, the patient had been hospitalized for a left foot phlegmon. Gangrene developed and a below-knee amputation was performed. Despite the prolonged and adequately dosed antibiotic treatment (a combination of cefuroxime, metronidazole and gentamicin) and a well-healing leg stump, elevated body temperature (up to 38.2 ºC) persisted for three weeks. Leukocyte count and C-reactive protein were increased (13.5 x109/L and 83 mg/L, respectively), and haemoglobin was found to be decreased (77 g/L). Repeated haemoculture, urine culture and peritoneal catheter smear analysed for aerobic and anaerobic bacteria and fungi were sterile. After a six-week empirical vancomycin treatment the patient became afebrile, without clinical and laboratory signs of infection. In addition, medical history revealed chronic peritoneal dialysis during the last five years, with an occasional intermittent hemodialysis via arteriovenous fistula, and sometimes via subclavian catheter as well. Secondary hyperparathyroidism was diagnosed a month prior to the current hospitalization and peripheral vascular disease five months earlier. Echocardiographic examination performed du- Figure 1. Apical four chamber echocardiographic view revealed a floating calcified mass at the anterior mitral cusp and adjoining tendinous cords, measuring 3.0x1.2 cm, protruding towards LVOT in systole. The arrow indicates calcified vegetation. (Roman Urek, MD, PhD, 2006.) (LV, left ventricle; RV, right ventricle; LA, left atrium; RA, right atrium). 175 Medicinski Glasnik, Volumen 7, Number 2, August 2010 ring the current hospitalization revealed a hyperechogenic, floating mass of 3.0x1.2 cm in size, attached at anterior mitral cusp and adjoining tendinous cords. The mass protruded towards the LVOT in systole (Figure 1). Colour Doppler imaging showed a turbulent flow at LVOT (Figure 2). A mild haemodynamic obstruction produced a 23 mmHg pressure gradient. Besides anaemia of a chronic disease type (haemoglobin 100 g/L), laboratory results revealed an increased parathyroid hormone value (71 pmol/L) with serum calcium being 2.59 mmol/L. Diabetes was poorly regulated. Glycated haemoglobin value was 7.9%. Blood glucose levels were 16, 9.6, 10.8 and 10.1 mmol/L at 8, 12, 18 and 21 hours, respectively. Infection parameters were within the normal range (L 9.2 x 109/L, CRP 15.4 mg/L). Repeated haemoculture and urine culture were sterile. The patient refused further diagnostic evaluation and a possible surgical intervention. DISCUSSION The rare case of LVOT obstruction caused by a calcified vegetation of the mitral valve is presented. The calcified vegetation was assumed to be a consequence of an unrecognized subacute infective endocarditis with a rapidly progressing calcification in a milieu of end-stage renal disease and hyperparathyroidism. LVOT obstruction caused by a mitral valve pathology in the absence of systolic anterior motion is very rare. To our knowledge, a possible LVOT obstruction has previously been described in only one case of mitral valve endocarditis (8). That case, described in 1977, was based on M-mode Figure 2. Colour Doppler showed turbulent flow at LVOT, above and below the point of obstruction. (Roman Urek, MD, PhD, 2006.) (LV, left ventricle; RV, right ventricle; LA, left atrium; RA, right atrium). 176 echocardiography finding. Although convincing with illustrative M-mode echocardiography imaging and pathological specimens, it did not contain haemodynamic measurements, either Doppler or invasive ones. Our report, however, undoubtedly confirmed the influence of mitral valve calcified vegetation on LVOT haemodynamics. Intracavitary obstruction of LVOT, most often found in idiopathic hypertrophic subaortic stenosis, may lead to serious complications, because it rises left ventricular intracavitary pressure, first systolic and then end-diastolic, as well as left atrial pressure, which may results in pulmonary congestion. In our patient intracavitary pressure gradient was too low to produce such haemodynamic consequences, but the progression of the disease could lead to other complications, such as to mitral valve chordal rupture and onset of acute mitral valve regurgitation (9), as well as to peripheral embolisation (10). Although the embolic potential of a fibronised, partially calcified structure was low, that point has to be emphasized considering surgical approach, which was, as well as additional examinations, rejected by the patient. The lack of microbiological or histo-pathological confirmation of the calcified mass etiology is a limitation of our case report. The mass on the mitral apparatus might have resembled a marked calcification of endocardial structures that are common in dialysed patients (11), but other cardiac structures were not as calcified as the mass. The diagnosis of infective endocarditis matched one main and two minor Duke’s criteria: a newly developed heart murmur with positive echocardiographic finding, fever and intravenous access via a subclavian catheter (12). Repeated negative haemocultures could be explained by the previous antibiotic treatment of the foot phlegmon. In a retrospective study by Aguada et al. causative microorganism could not be identified for the same reason in 20% of cases of infective endocarditis (13). Other clinical circumstances and laboratory findings strongly suggested an unrecognised subacute infective endocarditis as a cause of the development of the mass. Although infective endocarditis probably originated from bacteraemia that developed during the left foot phlegmon, any dialysis procedure might also have resulted in this problem (14). The most frequently isolated microorganisms Case report causing infective endocarditis in hemodialysis patients (Staphylococcus aureus, Staphylococcus epidermidis and Enterococcus species) are susceptible to vankomycine therapy, which was used to treat our patient (15) . In conclusion, we have found this case to be interesting, as LVOT obstruction caused by mitral valve vegetation occurs extremely rarely. Although there were no serious haemodynamic consequences, surgical intervention might be needed in the close future to prevent further mitral valve damage and embolic incident with a potentially fatal outcome. ACKNOWLEDGMENT/DISCLOSURES Competing interests: none declared. REFERENCES McGlinchey P, Fitzpatrick S, Purvis J. Accessory mitral valve leaflet causing left ventricular outflow tract obstruction in an adult. Heart 2009; 95:1219. 2. Okamoto K, Kiso I, Inoue Y, Matayoshi H, Takahashi R, Umezu Y. Left ventricular outflow obstruction after mitral valve replacement preserving native anterior leaflet. Ann Thorac Surg 2006; 82:735-7. 3. Agathos EA, Moran M, Mangion J, Lovell A, Engelman RM, Rousou JA. “Diverticula” of anterior mitral valve leaflet as a cause of subvalvular aortic stenosis. J Heart Valve Dis 1996; 5:309-11. 4. Yang HS, Lee KS, Chaliki HP, Tazelaar HD, Lusk JL, Chandrasekaran K, Tajik AJ. Anomalous insertion of the papillary muscle causing left ventricular outflow obstruction: visualization by real-time threedimensional echocardiography. Eur J Echocardiogr 2008; 9:855-60. 5. Ozcan AV, Evrengul H, Bir F, Tanriverdi H, Goksin I, Kaftan A. Multiple myxomas originating from anterior and posterior mitral leaflets in the left ventricle leading to LV outflow tract obstruction. Circ J 2008; 72:1709-11. 6. Minneci C, Casolo G, Popoff G, Sulla A, Comin CE, Pedemonti E. A rare case of left ventricular outflow obstruction. Eur J Echocardiogr 2004; 5:72-5. 7. Puri P, Sarma R, Ostrzega EL, Varadarajan P, Pai RG. Massive posterior mitral annular calcification causing dynamic left ventricular outflow tract obstruction: mechanism and management implications. J Am Soc Echocardiogr 2005; 18:1106. 8. Chandraratna PAN, Robinson MJ, Byrd C, Pitha JV. Significance of abnormal echoes in left ventricular outflow tract. Br Heart J 1977; 39:381-9. 9. Kaymaz C, Nihal Özdemir N, Özkan M. Differentiating clinical and echocardiographic characteristics of chordal rupture detected in patients with rheumatic mitral valve disease and floppy mitral valve: impact of the infective endocarditis on chordal rupture. Eur J Echocardiogr 2005; 6:117-26. 10. Snygg-Martin U, Gustafsson L, Rosengren L, Alsiö Å, Ackerholm P, Andersson R, Olaison L. Cerebrovascular Complications in Patients with Left -Sided 11. 12. 13. 14. 15. Infective Endocarditis Are Common: A Prospective Study Using Magnetic Resonance Imaging and Neurochemical Brain Damage Markers. Clinical Infectious Diseases 2008; 47:23-30. Madu EC, D’Cruz IA, Wall B, Mansour N, Shearin S. Transesophageal echocardiographic spectrum of calcific mitral abnormalities in patients with end-stage renal disease. Echocardiography 2000; 17:29-35. Durack, DT, Lukes, AS, Bright, DK. New criteria for diagnosis of infective endocarditis: utilization of specific echocardiographic findings. Duke Endocarditis Service. Am J Med 1994; 96:200. Aguado JM, Gonzalez-Vilchez F, Martin-Duran R, Arjona R, Vazquez de Prada J. Perivalvular abscess associated with endocarditis: clinical features and diagnostic accuracy of two-dimensional echocardiography. Chest 1993; 104:88-93 Abbot KC, Agodoa LY. Hospitalizations for bacterial endocarditis after initiation of chronic dialysis in the United States. Nephron 2002; 91:203-9. Robinson DL, Flower VG, Sexton DJ, Corey RG, Conlon PJ. Bacterial endocarditis in hemodialysis patients. Am Jour Kidney Dis 1997; 30:521-4. 1. CASE REPORT Laparoscopic treatment of achalasia first case in Croatia Ferid Latić, Vlatka Pitlović , Josip Samardžić, Azra Latić, Hrvoje Pitlović,\uro Miškić, Department of Surgery, General Hospital “Dr. Josip Benčević”, Slavonski Brod, Croatia Corresponding author: Vlatka Pitlović, Department of Surgery General Hospital “Dr. Josip Benčević”, Andrije Štampara 42, 35 000 Slavonski Brod, Croatia, Phone : +385 35 201 653 E-mail: vpit@net.hr Original submission: 24 December 2009; Revised submission: 21 March 2010; Accepted: 21 March 2010. Med Glas Ljek komore Zenicko-doboj kantona 2010; 7(2):177-179 ABSTRACT Esophageal achalasia is a primary esophageal motility disorder. Commonly used treatments are botulinum toxin injections, endoscopic balloon dilation and surgical myotomy with or without fundoplication. We are hereby presenting the first case of laproscopic myotomy with fundoplication performed in Croatia. A 32-year old female was admitted to the hospital due to the symptoms of dysphagia, regurgitation, chest pain and weight loss. Upper gastrointestinal tract radiography with contrast and flexible endoscopy confirmed the clinical diagnosis of achalasia. She was treated by the Heller laparoscopic procedure and Dor anterior fundoplication. The patient 177 Medicinski Glasnik, Volumen 7, Number 2, August 2010 had a successful recovery and was discharged on the fifth postoperative day. This case shows that laparoscopic treatment of achalasia is a feasibile and safe procedure which can be performed even in a small country hospital, but it requires great technical care and experience of the surgeon. Key words: esophageal achalasia, laparoscopic myotomy, anterior fundoplication. INTRODUCTION Esophageal achalasia is primary esophageal motility disorder (1), characterized by the absence of esophageal peristalsis and increased pressure at the lower esophageal sphincter due to the inability of the sphincter to relax (2). Clinical symptoms of advanced achalasia are dysphagia, regurgitation, chest pain and weight loss. The exact diagnosis is achieved by upper gastrointestinal tract radiography with barium and oesophageal gastric duodenoscopy (3).Commonly used treatments are botulinum toxin injections, endoscopic balloon dilation and surgical myotomy with or without fundoplication (1). Laparoscopic myotomy of distal oesophagus and gastric cardia with antireflux anterior partial fundoplication has gained popularity in recent years and is now considered to be a treatment of choice for oesophageal achalasia in most centres (4). In this paper we have presented the case of the first laparoscopic treatment of a 32-year old female with achalasia in Croatia. CASE REPORT A thirty-two year old female was admitted to hospital because of dysphagia, regurgitation, chest pain and weight loss symptoms. Chest radiography, upper gastrointestinal radiography with barium (Figure 1) and oesophageal gastric duodenoscopy confirmed our clinical diagnosis of achalasia. After the standard preoperative assessment we have performed the laparoscopic Heller myotomy with anterior partial fundoplication (Dor). During this procedure, the patient is placed in a supine position with reverse Trendelenburg maneuver and separated legs. The first surgeon stands between the patient’s legs with a camera on the right side of the patient and the second surgeon on the left. Trocars are placed as follows: 1 on the left flank on the hemiclavicular line, 1 transumbilicaly for the camera, 1 left subcostally, and 1 left and 1 right periumbilically. A pneumoperitoneum is created by CO2 insufflation with a 12 mmHg pressure. After retracting the stomach and liver and detecting the gastroesophageal junction, the phrenoesophageal ligaments are cut and isolation of oesophagus is achieved. Anteriorly, a myotomy is then carried out (Figure 2), leading to mucosal herniation, with muscle dissection approximately 7 cm. Air insufflation through a nasogastric tube aims at excluding perforation of the herniated esophageal mucosa, and the presence Figure 1. Upper gastrointestinal radiography with barium (Department of Radiology, General Hospital “Dr. Josip Benčević “, Slavonski Brod, 2003) 178 Figure 2. Laparoscopic myotomy and cutting of phrenoesophageal ligaments (F. Latić, 2003) Case report of air bubbles at the myotomy site must be ruled out as well. The procedure is completed with a 180° anterior funduplication to protect the herniated mucosa and prevent gastroesophageal reflux. The nasogastric tube inserted at the moment of surgery was removed after 24 to 48 hours, and patient resumed oral feeding on the 3rd day postoperatively and was discharged on the 5th day. The aim of the therapy is to relieve dysphagia. Commonly used treatments are botulinum toxin injections, endoscopic balloon dilatation and surgical myotomy with or without fundoplication(1). Pharmacological therapy is the only non-invasive treatment for achalasia, but provides a short-term clinical response and it is considered as an option for patients who are too frail for endoscopic or surgical treatment (5). Endoscopic botulinum toxin injections should be reserved for elderly patients with severe comorbidity (1) and balloon dilatation has many side effects. Surgical therapy seems to accomplish the aim of therapy with reproducible results and low morbidity. Surgical approach includes open thoracic and transabdominal, thoracoscopic and laparoscopic techniques. With the adaptation of laparoscopy to many conventional surgical procedures, this minimally invasive procedure has become a good alternative for the treatment of achalasia. However, whether it is performed abdominally or thoracically, the length of myotomy at the esophagus, the length of myotomy at the stomach, and the choice of additive antireflux procedure are the aspects of the procedure that still need to be evaluated (6). The main reason for controversy about the choice of surgical method in achalasia is the possibility of postoperative dysphagia and reflux. The length of esophageal myotomy has been reported to be between 5 and 12 cm (7, 8). We performed the myotomy with the length of 7 cm. It is reported that esophageal myotomy with a length of <5 cm results in a high incidence of dysphagia (8). We performed the laparoscopic esophagomyotomy with Dor anterior fundoplication without any postoperative complications. The majority of studies reported no case of esophageal mucosal perforation and excellent or good results in 78100% of cases (relief from symptoms or occasional dysphagia not requiring medication or dietary restriction) (9,11). This case has shown that laparoscopic esophagomyotomy has the advantages of minimal invasive surgery, including less mobilization of the esophagus, less dysphagia and reflux with appropriate esophagogastric myotomy, short hospitalization, and minimal post-operative pain. It is feasible and safe procedure which can be performed even in a small country hospital, but it requires great technical care and experience of the surgeon. ACKNOWLEDGMENT/DISCLOCURE Competing interests: none declared REFERENCES 1. Campos GM, Vittinghoff E, Rabl C, Takata M, Gadenstätter M, Lin F, Ciovica R. Endoscopic and surgical treatments for achalasia: a systematic review and meta-analysis. Ann Surg 2009; 249:45-57. 2. Swanstrom LL, Pennings J. Laparoscopic esophagomyotomy for achalasia. Surg Endosc1995; 9:286-92. 3. Levine MS, Rubesin SE. Diseases of the esophagus: diagnosis with esophagography.Radiology 2005; 237:414-27. 4. Patient Care Committee; Society for Surgery of the Alimentary Tract: Esophageal Achalasia. SSAT patient care guidelines. J Gastrointest Surg 2004, 8:367-8. 5. Leyden JE, Moss AC, MacMathuna P. Endoscopic pneumatic dilatation versus botulinum toxin injection in the management of primary achalasia. Cohrane Database Rev 2006; CD005046. 6. Ígcí A, Müslümanoglu M, Dolay K, Yamaner S, Asoglu O, Avci C. Laparoscopic esophagomyotomy without an antireflux. Procedure for the treatment of achalasia. J Laparoendosc Adv Surg Tech A 1998; 6:409-16. 7. Bonavina L, Nosadini A, Bardini R. Primary treatment of esophageal achalasia. Long-term results of myotomy and Dor fundoplication. Arch Surg 1992; 127:222-7. 8. Piciocchi A, Cardillo G, D’ugo D, Castrucci G. Surgical treatment of achalasia: a retrospective comparative study. Jpn J Surg 1993; 23:855-9. 9. Robertson GSM, Lloyd DM, Wicks ACB, DeCaestecker J, Veitch PS. Laparoscopic Heller’s cardiomyotomy without an antireflux procedure. Br J Surg 1995; 82:957-9. 10. Delgado F, Bolufer JM, Martinez-Abad M. Laparoscopic treatment of esophageal achalasia. Surg Laparosc Endosc 1996; 6:83-90. 11. Hunter JG, Trus TL, Branum GD, Waring JP. Laparoscopic Heller myotomy and fundoplication for achalasia. Ann Surg 1997; 225:655-65. 179 ERRATUM Volume 7, No. 1, February 2010 EDITORIAL This thematic issue of the Medicinski Glasnik deals with the diagnosis and treatment of genitourinary tract infections. Out of 13 papers, six were presented during the 1 Croatian Congress on Urogenital and Sexually Transmitted Infections held in Opatija, Croatia, in June 2009. st The main goal of the thematic issue is to discuss the management of genitourinary tract infections, with the particular emphasis on bacterial resistance. The increasing bacterial resistance, especially among older antimicrobial drugs, presents new clinical and therapeutic dilemmas, which necessitate a deeper understanding of current and new potential strategies. Since urinary tract infections (UTIs) in women are a common problem in primary care settings, treatment of uncomplicated UTIs is the main topic of the most authors (Uzunović-Kamberović at al., Tićac at al, Marijan at al.). Community-acquired UTIs are caused by Escherichia coli in approximately 90% of cases, and less commonly, by other Enterobacteriaceae, such as Klebsiella spp. and Proteus spp. The current management of acute uncomplicated cysti- tis is usually empirical, without the use of urine culture or susceptibilities testing to guide therapy (Škerk and Markotić). However, as with many other community-acquired infections, antimicrobial resistance to different groups of antibiotics is increasing due to the spread and high-level usage of antibiotics (Culig at al). Knowledge about such specific antimicrobial resistance patterns in particular geographic areas is of the utmost importance when recommending the most suitable antibiotic treatment (Bedenić at al.), The second, though not less important goal of this issue, is to present new opportunities in diagnostics of the most prevalent infections of genital tract, chlamydial and human papilloma virus (HPV) infections (Ljubin Sternak and Škerk, Židovec Lepej and Vince, Žele Starčević at al). Prof. Jasmina Vraneš, MD, PhD Guest Editor Ass. Prof. Selma Uzunović-Kamberović, MD, MA, PhD Editor-in-Chief Medicinski Glasnik 180