Risk of ocular manifestations in patients with giant cell arteritis: a nationwide study in Sweden.

OBJECTIVE: No large-scale nationwide study has determined the risk of ocular manifestations in patients with giant cell arteritis (GCA). The aim was to study the incidence and risk factors of ocular manifestations in patients with GCA in Sweden. METHOD: A national cohort was created by linking Swedish nationwide registers. GCA patients were identified from the Swedish Hospital Inpatient and Outpatient Registers between 2002 and 2010, and were followed until the development of ocular manifestations. Standardized incidence ratios (SIRs) and 95% confidence intervals (CIs) were calculated for ocular manifestations in patients with GCA compared to those without GCA. RESULTS: We identified 3737 males and 8311 females with GCA. A total of 1618 individuals had subsequent ocular manifestations, representing 13.4% of the GCA patients. The overall SIR of ocular manifestations was 6.96 (95% CI 6.63-7.31). The risk for disorders of the optic nerve or visual tract was particularly high (SIR = 51.68, 95% CI 46.12-57.73). Men with GCA had a higher risk than women, and GCA patients without polymyalgia rheumatica (PMR) symptoms had a higher risk than those with PMR symptoms. Living outside big cities was negatively associated with ocular manifestations in GCA patients, whereas hypertension and diabetes were associated with an increased risk of ocular manifestations. CONCLUSION: The overall risk of ocular manifestations was higher in GCA patients than in the general population, especially for men and for those without PMR symptoms.

Correlation of thermal deficit with clinical parameters and functional status in patients with unilateral lumbosacral radiculopathy.

INTRODUCTION: Lumbosacral radiculopathy is a pathological process that refers to the dysfunction of one or more spinal nerve roots in the lumbosacral region of the spine. Some studies have shown that infrared thermography can estimate the severity of the clinical manifestation of unilateral lumbosacral radiculopathy. This study aimed to examine the correlation of the regional thermal deficit of the affected lower extremity with pain intensity, mobility of the lumbar spine, and functional status in patients with unilateral lumbosacral radiculopathy. METHODS: This cross-sectional study was conducted at the Clinic for Physical Medicine and Rehabilitation of the Clinical Center Nis, Serbia. A total of 69 patients with unilateral lumbosacral radiculopathy of discogenic origin were recruited, with the following clinical parameters evaluated: (1) pain intensity by using a visual analogue scale, separately at rest and during active movement; (2) mobility of the lumbar spine by Schober test and the fingertip-to-floor test; and (3) functional status by the Oswestry Disability Index. Temperature differences between the symmetrical regions of the lower extremities were detected by infrared thermography. A quantitative analysis of thermograms determined the regions of interest with maximum thermal deficit. Correlation of maximum thermal deficit with each tested parameter was then determined. RESULTS: A significant and strong positive correlation was found between the regional thermal deficit and pain intensity at rest, as well as pain during active movements (rVAS - rest=0.887, rVAS - activity=0.890; P<0.001). The regional thermal deficit significantly and strongly correlated with the Oswestry Disability Index score and limited mobility of the lumbar spine (P<0.001). CONCLUSIONS: In patients with unilateral lumbosacral radiculopathy, the values of regional thermal deficit of the affected lower extremity are correlated with pain intensity, mobility of the lumbar spine, and functional status of the patient.

Reduced expression of angiotensin II and angiotensin receptor type 1 and type 2 in resistance arteries from nasal lesions in granulomatosis with polyangiitis (Wegener's granulomatosis).

OBJECTIVES: Angiotensin II (ANGII) is involved in vessel inflammation and is important in the development of cardiovascular disorders such as atherosclerosis. During active disease, patients with granulomatosis with polyangiitis (GPA; Wegener's granulomatosis) have accelerated atherosclerosis and ANGII inhibitors are recommended to these patients to reduce atherosclerosis. We assessed the hypothesis that the expression of ANGII and its receptors in arteries in granulomatous lesions change in GPA. METHODS: ANGII and angiotensin receptors were quantified in vessels from granulomatous lesions from patients with GPA using immunohistochemistry. Anti- ANGI type 1 (AT1) and type 2 (AT2) antibodies were applied on formalin-fixed and paraffin-embedded biopsies from nasal mucous membranes from eight patients with GPA and eight controls. RESULTS: ANGII expression was localized to the endothelial cells (ECs) in arteries and sparsely to vascular smooth muscle cells (VSMCs) in nasal biopsies. AT1 receptor (AT1R) staining was intense and located in the VSMCs in the medial layer of the control arteries. AT2 receptor (AT2R) immunostaining was faint and was located only in the ECs. Patients with GPA showed marked down-regulation of positively immunostained ECs for ANGII or AT2R, and a reduced number of AT1R in VSMCs. ANGII, AT1R, and AT2R staining was persistent on infiltrating leucocytes. CONCLUSIONS: These results suggest down-regulation of the angiotensin system in arteries in granulomatous nasal lesions in GPA. Inhibition of the angiotensin system may prove less efficient in inhibiting the vascular inflammation process in GPA.

Function after intersphincteric resection for low rectal cancer and its influence on quality of life.

AIM: The aim of the study was to investigate function and quality of life after different types of intersphincteric resection (ISR). METHOD: Between January 2006 and February 2008, 45 patients (34 men and 11 women) with distal third rectal cancer underwent curative ISR. Function was evaluated using the Memorial Sloan Kettering Cancer Center bowel function questionnaire and Wexner score, anal manometry and measurements of rectal capacity were also performed. Quality of life was assessed using the Serbian version of the European Organisation for Research and Treatment of Cancer, quality of life questionnaire (EORTC QLQ-C30) and the translated version of the fecal incontinence quality of life scale (FIQL). RESULTS: There were no postoperative deaths. Partial ISR was performed in 22 (48.9%) patients, subtotal ISR was performed in 19 (42.2%) patients and total ISR was performed in four (8.9%) patients. Anastomotic leakage occurred in nine (20%) patients. Five (11.1%) of 45 patients had major (complete) incontinence and a further six (13.3%) patients had continuing frequent faecal leakage 12 months after ileostomy reversal. There was no significant difference in quality of life between the groups in the EORTC QLQ-C30 scale, but this was significantly altered by internal anal sphincter resection in two of the FIQL scales (coping/behaviour and depression/self-perception). CONCLUSION: Although ISR does not affect quality of life in general, the extent of internal anal sphincter resection has a negative impact on symptom-specific quality of life owing to faecal incontinence.

Influence of long-term radiotherapy on symptoms and signs of locally advanced primary rectal cancer of distant localisation.

This study is a part of a clinical trial in preoperative radiotherapy of low rectal cancer, conducted as a prospective and partly retrospective clinical study. It was designed to estimate the influence of long-term radiotherapy on symptoms of locally advanced rectal cancer. We included 49 patients with T3/4 stage adenocarcinoma (diagnosis confirmed by clinical, pathological and CT examinations) of the lower two thirds of the rectum, who were treated with long-term radiotherapy (45 Gy in 20-25 fractions) and questioned for the presentation of symptoms before and after the treatment. The chief complaints of these patients were the presence of blood in stool, abdominal and pelvic pain, straining (tenesmus) and the alteration in bowel movement. We found a significant decrease in symptoms and signs of the illness after the radiotherapy as well as the improvement of the quality of life.

Ischaemic colitis--review.

Colonic ischaemia, commonly referred to as ischaemic colitis, is the most common type of intestinal ischaemia. The term "ischaemic colitis" was used by Marston (1966) with three typical patterns of injury described: transient reversible ischaemia, ischaemic ulcers with stricturing, and gangrenous ischaemic colitis. Dominant presenting symptoms were colicky abdominal pain, vomiting, bloody diarrhea, and hematochezia. Patients often have minimal signs on clinical examination. Most patients were diagnosed at colonoscopy. Two regions that are believed to be anatomically vulnerable to ischemic disease are "Griffith's point", at the splenic flexure and "Sudeck's critical point", of the Drummond marginal artery. Clinically, ischaemic colitis is classified as non-gangrenous or gangrenous. Non-gangrenous ischaemic colitis involves the mucosa and submucosa and accounts for 80-85 percent of all cases of ischaemic colitis. Non-gangrenous ischaemic colitis is further subclassified into transient, reversible ischaemic colitis with a less severe form of injury and chronic, non-reversible ischaemic colitis, which includes chronic colitis and stricture and has a more severe form of injury. Gangrenous ischaemic colitis accounts for the remaining 15-20 percent of cases and manifests as the most seve-re form of injury. It includes acute fulminant ischaemia with transmural infarction that may progress to necrosis and death. Specific indications for operation include peritonitis, perforation, recurrent fever or sepsis, clinical deterioration in patients refractory to me-ical management. Relative indications include fulminant colitis, massive hemorrhage, chronic protein losing colopathy, and symptomatic ischemic stricture.

Digestive system damage caused by substance abuse.

Substance abuse and addiction represent a worldwide problem and cause a number of family, social and health problems. Digestive system damage caused by substance intake is an increasing problem amoung drug addicts. Many studies show that substances can cause cancer of all parts of the digestive system. Alcohol consumption was significantly associated with colon and rectal cancer. For rectal cancer, the risk was increased in association with drinking of alcoholic beverages, specialy for beer consumption. Sinthetic drugs such as ecstasy may lead also to digestive and hepatic damage, as well as vascular complications of the stomach. Many studies show the existance of supstance associated enterocolitis as well as ishemic colitis. Diagnosis of ishemic colitis is based on the presence of rectal bleeding, abdominal pain, a history of substance use, supportive endoscopic and histopathologic findings, and the absence of other etiologic mechanisms of ischemic colitis. Great damage to the digestive system is also produced by smuggling narcotics packed into small pages that are afterwards been swallowed or implemented on other sorts of ways inside the smugglers natural body spaces as the rectum or vagina. In the paper authors reviewed literature conserning digestive system damage caused by substance abuse and drug smuggling.

Diagnostic and therapeutic approaches to bleeding from lower parts of the digestive system.

Bleeding from the gastrointestinal tract represents relatively common diagnostic and therapeutic challenge in clinical work of gastroenterologists and surgeons. Bleeding from the lower GI (LGIB) is mostly caused by pathologic conditions of the colon, although the source of bleeding cannot always be exactly localized, thus rendering optimal and prompt therapy difficult. During two year period, at IlI department of the First Surgical Clinic in Belgrade, we performed 424 colonoscopies for LGIB. According to our results the exact diagnosis was established in about 76% (324 patients) showing a great similarity with the results of other published studies (varying between 74% and 89%). The most common causes of bleeding were diverticulosis (37.11%), polyposis (10.3%) and colorectal cancer (46.14%). Besides that we have mentioned some specific facts involving the diagnosis and treatment of LGIB with an accent on some rare conditions, like angiodysplasia. Review of the diagnostic procedures and treatment modalities of the LGIB is useful for everyone who meets with this type of pathology in clinical practice. The diagnostic approach and the surgical treatment of these patients may represent a great problem, since the planning of the operative procedure can be very difficult and with uncertain result. Based on the literary data and our experience we have tried to set the algorithm of the diagnostics and treatment of the LGIB.

[Complications on skin and subcutaneous tissue among drug addicts caused by non sterile intra venous injections and burns].

The use of psychoactive substances causes various consequences and is harmful for all organs. Some of the health consequences among intravenous drug users are HIV infections, hepatitis C, local tissue infections after drug injection, family, professional and social consequences. Throught the world various harm reduction programs are established in order to educate drug users about safer drug injecting techniques, with the use of sterile needles and materials for disinfection of the drug injecting area. Authors presented epidemiological data, consequences on extremities after non sterile drug injecting and accidental burns, harm reduction programs as well as other guidelines in this field. In three case reports of intravenous drug addicts with surgical complications on the extremities and burns, surgical and anaesthesiological approaches were described. Special emphasis was given to preoperative preparations and the postoperative treatment as well as social-psychiatric aspect.

["I am sorry, I have bad news... "- principles in informing patients on the gravity of a disease and the treatment].

The discovery of the appearance of a serious disease, and the necessity for diagnostics, treatment and rehabilitation, particularly when malignity is involved, represents exceptionally stressful news for the patient and his family. Most often this is a task for the physician. In this paper the authors consider the meaning of bad news in unexpected life events which significantly disturb the individual psycho-social ballance of the patient, as well as the familly dynamics and structure. It presents a review of available literature on the subject of the definition of so-called "bad news", the development of approaches in announcement, and current practical approaches and models which assist physicians in helping suffering patients in professional and humane ways. It points out inadequacies in the education of phisicians for this kind of task, and the variety of approaches. With the aim of improving the education of phisicians, and especially clinicians in surgical fields, the authors recommend a number of educational programs: education in the area od psychological and psychiatric aspects of learning of a serious disease, including acute reactions such as depressive states, reactive psychotic states, consumption of alcohol, etc.; education in the area of the family life cycle, and the effect of the disease as an unexpected life crisis on the family dinamic; education in the area of fundamental principles of psycho-and pharmaco-therapy, as well as the provision of support to the patient and his familly; training in the skills of announcing bad news to the patient and his familly through the explanatory presentation of the case and supervised simulation of sessions.

Allantoic remnants presenting as a giant retroperitoneal cyst.

Urachal anomalies are usually found in early childhood or just after birth. These usually involve patent ductus urachus, urachal cyst, umbilical-urachal sinus or vesicourachal diverticulum. Very rarely are urachal anomalies found in adults, usully as an infected urachal cyst. We are presenting a case of surgically removed giant urachal retroperitoneal cyst that was found by chance during the abdominal ultrasound examination of a 22 year old man who was initially treated for idiopathic hypertension.

[Digital video technology in orthopedics].

Digital video technologies are new and powerful tools with wide applications in orthopaedics. Already integral to several common medical devices, digital images can be used for case documentation and presentation as well for diagnostic and surgical patient care information. Digital technologies allow easy manipulation of photographic, video and graphic materials in ways that were impossible with conventional techniques. Educational presentation has been transformed by use of computers and digital projectors. Understanding the basic foundations of digital imaging technology is important for effectively creating digital images, videos and presentations. In this review, we are going to discuss some of the issues that are raised by digital imaging in orthopaedics, digital image processing, as well as, we are giving some recommendations for good quality of pre-, post- and intra-operative photographs in clinical use.

[Specifics of preoperative care, intraoperative monitoring and postoperative evaluation of patients with thyroid carcinoma]. / Specificnosti preoperativne pripreme, intraoperativnog monitoringa i postoperativne evaluacije bolesnika sa karcinomom stitaste zlezde.

The aim of the study was to show the standards of preoperative management, intraoperative monitoring and postoperative evaluation of patients with thyroid gland carcinoma. It was point out the importance of the preoperative diagnosis of the tumor, and the concurrent diseases. The special attention was paid to difficult airway recognition and resolving this situation. Both, anesthetist's and surgeon's point of view of perioperative and postoperative complications were discussed with special interest on early surgical complications and the need for urgent anesthetic treatment. Criteria for minimal and desirable monitoring of vital functions were suggested in order to prevent, recognize and cure complications. Our conclusions were based on recent references from the world literature and on our own experience in Center for endocrine surgery KCS, Belgrade.

Chemotactic peptide-induced activation of Ras in human neutrophils is associated with inhibition of p120-GAP activity.

The monomeric G-protein Ras is now considered to function as an initial regulator of multiple signaling pathways in both normal and transformed cell types. Adhesion and chemoattractant receptors are known to trigger activation of Ras in human neutrophils, but the signaling mechanism that activates Ras has only been partially elucidated. The present results show that in neutrophils, a time- and dose-dependent f-Met-Leu-Phe (FMLP)-induced activation of Ras is mediated by Gi2-proteins, because such activation is inhibited by pertussis toxin and because direct stimulation of heterotrimeric G-proteins with AlF4- is sufficient to activate Ras. Pretreatment of neutrophils with tyrosine kinase inhibitors, i.e. genistein or erbstatin that completely block FMLP-stimulated protein tyrosine phosphorylations, did not affect the FMLP-induced activation of Ras. Moreover, FMLP did not induce any detectable translocation of Grb2 and Sos to the plasma membrane of neutrophils. Other signaling molecules, such as protein kinase C, phosphatidylinositol 3-kinase and Ca2+, do not appear to be involved in the FMLP-induced Ras activation. Instead, stimulation of neutrophils with FMLP or C5a, the latter of which also activates Gi2-proteins, resulted in transient inhibition of the activity of Ras GTPase-activating proteins (GAP) with kinetics that correlated well with the kinetics of Ras activation. Moreover, decreased Ras-GAP activity was found in p120-GAP but not in neurofibromin immunoprecipitates of FMLP-stimulated cells. These results suggest that tyrosine kinase-dependent Ras exchange factors do not contribute to the FMLP-induced activation of Ras but that such activation is mediated via inhibition of p120-GAP in neutrophils.