Metastatic Malignant Melanoma Causing Small Bowel Intussusception: A Case Report with 4-year Follow-up.

Primary mucosal malignant melanoma of the small bowel is extremely rare. The small bowel is mostly affected by metastases of the primary malignant melanoma of the skin. Bowel obstruction is a rare complication of metastatic melanoma. We present a case of small bowel obstruction in a 49-year-old man with history of skin malignant melanoma. A segmental resection of the ileum with termino-terminal anastomosis was performed. Pathohistological examination showed metastatic melanoma. After 4 years of follow-up, the patient is still free of the disease.

Workplace Stress in the University Clinical Settings: Comparison between the Cardiac Unit snd Emergency Center Medical Staff.

BACKGROUND: Stress at work is a specific type of stress arising from the work environment. Stress of the medical staff has been investigated in recent years by the medical institutions of different countries. The aim of this study was to examine the stress levels in medical staff of Department of Cardiac Surgery and Center of emergency medicine (CEM) in the Clinical settings, and to compare them. SUBJECTS AND METHODS: We conducted a cross-sectional study which included 55 patients between 21 and 50 years of age. The study group consisted of 30 employees from the Department of Cardiac Surgery of Mostar University Clinical Hospital, while the control group comprised 25 employees from the CEM. Research instruments were the Occupational Stress Questionnaire for Hospital Health Care Workers (OSQ-HHCW), General Health Questionnaire (GHQ 28) and a Stress MGMT-TEST A. RESULTS: The subjects from the control group had significantly higher stress experience in "bombing" with new information (p=0.028), unavailability of literature (p=0.039), poor communication with superiors (p<0.001), conflicts with patients (p=0.042) and inappropriate public criticism (p=0.007). The highest stress level showed F1 group of stressors, concerning the organization of work and funding. CEM employees had statistically significantly higher level of stress on public criticism and lawsuits compared to the study group (p=0.013), as well as higher score on the anxiety/insomnia subscale (p<0.001), social dysfunction scale (p=0.002) and on the depression subscale (p<0.001). CONCLUSIONS: Stressors from the group of organizational factors have proven to be the most common stressors in both groups. However, in some areas within the impact of workplace stress, CEM employees had significantly greater vulnerability compared to employees of the Department of cardiac surgery. Further studies are needed to establish the frequency and intensity of stress among health professionals, and to clearly determine the risk factors for its development.

Pain Intensity Scales Comparison in Patient with Abdominal Pain.

BACKGROUND: The aim of study was to explore efficiency of the pain rating scales on patients experiencing abdominal pain, determine correlation between the scales and their applicability to general population and determine the minimal clinical important difference in mm on the VAS as discriminatory for difference in pain intensity. SUBJECTS AND METHODS: The study was performed at the Emergency Department of the University Clinical Hospital of Mostar on patients with abdominal pain which started less than 24 hours before, excluding patients under 16 years old, uncooperative patients and those with altered state of consciousness. The sample data were collected from February to May 2010. Hundred patients completed the questionnaire. Two patients, admitted to the Abdominal Surgery Department, were excluded. The patients were asked to sign the informed consent form and assess the level of pain on three scales (VAS, NRS, VRS). RESULTS: The NRS showed a significant difference in assessing the pain intensity in the observed time. By lapse of time, the patients were reporting lower pain intensity (P=0.017). VAS and NRS had high correlation coefficient values, indicating strong correlation and credibility. The NRS showed strong results correlation (r=0.784; P<0.001). Inter-scale correlation was growing over time. Correlation between VAS and NRS was very strong, the strongest in the last measurement (r=0.950; P<0.001). The NRS correlation with VRS (r=0.430; P<0.001) was slightly better than with VAS (r=0.402; P<0.001). The NRS proved to be the most sensitive to changes in pain intensity (SRM=0.305), whereas the VRS showed extremely low responsiveness (SRM=0.185). CONCLUSION: Having proved as the most useful, reliable and efficient pain assessment instrument, the NRS is hereby recommended as method of pain objectification and determining changes in pain intensity.

Attitudes of Students of Medicine, University of Mostar According to Induced Abortion.

BACKGROUND: Aim of this study was to establish attitudes of medical students on induced abortion and connection of those attitudes with religiousness, length of their studies, sex and various circumstances of pregnancy. SUBJECTS AND METHODS: In total, 148 students of the first, second, fifth and sixth year of medical faculty participated in the research. The study was conducted at the Medical Faculty of the University in Mostar. While collecting the data, we used a survey taken over from literature. The data were tested with adequate statistical methods afterwards. RESULTS: 81.1% of students would perform an abortion under certain circumstances (χ2=57.189; P<0.001). Most students answered that they would perform an abortion in case that a fetus had malformations (χ2=3.892; P=0.49) or if the mother's life were endangered (χ2=47.676; P<0.001). By comparison of students' readiness to perform an abortion under various circumstances of pregnancy depending on length of medical education, statistically significant difference was proved in the following circumstances: rape (χ2=6.097; P=0.014) and if the pregnancy would endanger mother's mental health (χ2=4.488; P=0.034). Students with shorter medical education expressed more liberal attitudes in the above stated circumstances. By comparison of students' readiness to perform an abortion under various circumstances of pregnancy depending on religiousness statistically significant difference was proved in the following circumstances: in case of 'abortion on demand', no matter the reason (χ2=11.908; P=0.012), teenage pregnancy (χ2=33.308; P<0.001) and if the pregnancy would interfere with mother's career χ2=35.897; P<0.001). Unreligious students expressed more liberal attitudes. CONCLUSION: Influence of length of medical education and sex on attitudes on abortion was not proved statistically. Impact of religiousness on that attitude cannot be commented due to very small share of unreligious students in the sample.

The influence of different types of brackets and efficacy of two chlorhexidine mouthwashes on oral hygiene and the incidence of white spot lesions in adolescents during the orthodontic therapy.

BACKGROUND: To detect the effect of two different types of brackets (ceramic and stainless steel) and investigate the effectiveness of two chlorhexidine mouthwashes 0.2% (CHX) on oral hygiene status and incidence of white spot lesions (WSLs) in adolescents wearing fixed orthodontic appliance. SUBJECTS AND METHODS: One hundred and twenty subjects (aged 11 to 18 years, mean age 14.5 years) were divided into six equal groups according to brackets type and to different mouthwashes: Group 1: metal brackets and conventional CHX, Group 2: metal brackets and CHX with anti-discoloration system (CHX-ADS), Group 3: ceramic brackets and conventional CHX, Group 4: ceramic brackets and CHX-ADS, Group 5: metal brackets and water correction flavors mouthwash (placebo), Group 6: ceramic brackets and placebo. Four weeks after the placement of fixed orthodontic appliance the subjects were provided with three different mouthwashes for use during the next two weeks. Assessment was carried out according to oral hygiene index-simplified (OHI-S) and WSL index performed: prior to placement of the appliance (baseline), four weeks, six weeks, eighteen weeks, and thirty weeks after the placement. The data were then subjected to statistical analysis. RESULTS: Group 4 showed reduction in the OHI-S scores when compared to the Group 5 (in the 6th week), and Group 6 (in the 6th and 18th week), which was statistically significant, P<0.05. Group 4 showed decrease in the WSLs scores when compared to the Group 1 (in the 4th, 6th, 18th and 30th week), Group 5 (in the 18th and 30th week) and Group 6 (in the 6th, 18th and 30th week), which was statistically significant, P<0.05. CONCLUSION: The ceramic brackets and the usage of CHX-ADS resulted in better oral hygiene status and lower incidence of WSLs.

A randomised two-way comparison of mastectomy performed using harmonic scalpel or monopolar diathermy.

The purpose of this study was to perform an overall evaluation and comparison of the success rate of modified radical mastectomy by harmonic scalpel and monopolar electrocauter The prospective study included all of the patients that were planned for and mastectiomized because of breast carcinoma during July 1st 2008 until December 21st 2008 at the Department of Surgery and Urology, University Hospital Mostar. Duration of the surgical procedure, intraoperative blood loss and operational drain secretion was measured and registered. Leukocyte number (Le), interleukin 6 (IL-6), C-reactive protein (CRP) and erythrocyte sedimentation rate was tested and registered out of peripheral venous blood before the operation, 4 hrs after it, as well as on the first, second and third day after the operation. Every patient was tested for postoperative pain intensity, amount of administered analgesics during hospital stay, number and types of postoperative complications; also the time needed for return to everyday activities was registered. 61 patients were included in the study. 31 patients were operated with the harmonic scalpel, and 30 of them with the monopolar electrocauter. There is no statistically significant difference between the operation time in the two groups: 78.50 +/- 17.50 minutes by harmonic scalpel and 82.50 +/- 18.50 minutes by electrocauter (p = 0.796). The smaller amount of intraoperative blood loss is statistically significant in the group of patients mastectomized by harmonic scalpel 78 +/- 31 ml compared to 256 +/- 112 ml in the group mastectomized by electrocauter (p < 0.001); as is the total operational drain secretion: patients mastectomized by harmonic scalpel 540 +/- 390 mL compared to 960 +/- 710 mL in patients mastectomized by electrocauter (p < 0.001). There is no statistical difference in the number of leukocytes in blood after modified radical mastectomy using the harmonic scalpel or electrocauter (p = 0.957), or in erythrocyte sedimentation rate (p = 0.114), CRP (p = 0.071) and IL-6 (p = 0.082). The duration of postoperative hospital stay does not differ statistically between the two groups, nor does the postoperative pain intensity, amount of administered analgesics, number or types of postoperative complications, as well as the time needed for return to everyday activities. Therefore using the ultrasound harmonic scalpel in comparison to monopolar electrocauter brings certain advantages, which however do not contribute significantly to the total success rate of the operation.

The relationships between self-esteem, emotional reactions and quality of life in pediatric locomotory trauma patients.

The main aim of this study was to establish the relationships between several psychosocial characteristics in children and adolescents differently treated for isolated long tubular bones' fractures. Examined variables were: self-esteem, basic emotional reactions toward illness or injury including depression and anxiety, as well as perception of quality of life and social support during the treatment. Whole sample comprehends 135 patients, both gender, 10-18 years of age, treated for mentioned fractures in period 2003-2005 at the Departments of Pediatric Surgery of 3 hospitals: University Hospital Centre in Rijeka and Clinical Children's Hospital in Zagreb, both in Croatia and University Hospital in Mostar, BiH. 73 patients were treated conservatively (CT), 40 of them underwent Elastic Stable Intramedullary Nailing (ESIN) and 22 of them underwent other surgical techniques (OST). Basic methods of work were: interview to collect data for half-structured socio-demographical questionnaire, evaluation of medical records and self-reported questionnaires including: Rosenberg Self-esteem Scale (RSS), Children Depression Inventory (CDI), Spielberg State Trait Anxiety Inventory (STAI), Short Form 36 Health Survey (SF-36) and Test of Perception of Social Support (TPSS). RSS, CDI and STAI were administered to the patients at baseline and after 6 months of the trauma, while SF-36 and TPSS after 1 month of the trauma. Results of this study point to close and strong relationships between examined variables, mostly statistically significant at level p < 0.01 in all patients with fractures, regardless of the type of the treatment. There were also statistically significant differences in all variables between first and second measure; self-esteem increased and depression and anxiety decreased during the time in all patients (with different dynamics regarding the type of treatment); higher perception of social support enhanced that effect. Perception of quality of life in whole sample in summary measures was statistically significant at level p < 0.01 correlated positively with self-esteem and negatively with depression and anxiety, thus connection with perception of social support was statistically significant only in sibdomain of physical pain. There was also statistically significant difference in self-perception of quality of life related to psychosocial variables according to the type of treatment (F = 3.27; p = 0.01). Results of this study suggest that there are strong connections between physical trauma and different psychosocial variables in patients which point at need of understanding locomotory trauma in children in wider context including physical state and social functioning of the patient as well as the choice of type of treatment of fractures which influences complete process of healing.

Abdominal pain patient referrals to emergency surgical service: appropriateness of diagnosis and attitudes of general practitioners.

This study evaluate the need for general practitioners referrals and self referrals of acute abdominal pain patients to emergency surgical service, the appropriateness of GP referral diagnosis and their attitudes dealing with abdominal pain. In three months period all acute abdominal pain patient referrals to our hospital emergency surgical service were audited. Data on final diagnosis, surgical treatment, admission to hospital and surgery performance were recorded. Self referral or GP referral, referring GP diagnosis, referral letters indicating presenting complaint or history, axillar and rectal temperature measurement, laboratory checking and abdominal radiography checking by GP were recorded as well. Also, GPs examination details as palpation, auscultation and digit-rectal checking were recorded. We calculated sensitivity, specificity, positive and negative predictive value (PV) for referring diagnosis. Self referrals and GP referrals differences were evaluated. During the study 318 patients were admitted. A total of 163 (51.25%) referrals were deemed inappropriate; 102 (52.6% of GP referrals) and 61 (49.2% of self referred) (p < 0.05). There were no differences in general treatment, hospital admission and operative treatment in self referred and GP referred groups (p < 0.05 for all three categories). Sensitivity, specificity, positive and negative predictive values for most frequent GP referral diagnoses were: abdominal colic/abdomen in observation 0.78; 0.66; 0.74; 0.70; acute appendicitis 0.37; 0.92; 0.44; 0.90; acute abdomen/peritonitis 0.30; 0.97; 0.54; 0.92; constipation 0.95; 0.98; 0.85; 0.99; and ileus 0.83; 0.97; 0.50; 0.99. Data on GP including clinical examination, patient history and running basic diagnostics were poor. Our results suggest that a general agreement within the profession about what constitutes a necessary hospital referral is necessary. GP consultation quality must be improved by booking more time per patient and by giving more medical/technical attention to patients.

[Familial adenomatous polyposis with extracolonic manifestations--case report]. / Familijarna adenomatozna polipoza sa ekstrakolonicnim manifestacijama.

The familial adenomatous polyposis syndrome is an autosomal dominant inherited disease characterized by progressive development of multiple adenomatous polyps throughout the colon and rectum. Due to the malignant potential of adenomatous polyps, colorectal cancer develops in 100% of cases, approximately 10-15 years after the onset of symptoms. Extracolonic manifestations of the disease including adenomatous polyps of the stomach, duodenum, small intestine and periampullatory region are rare. The etiology of the disease is germline mutation at the site of tumor suppressor gene located on chromosomes 5q21-22. A case is described of a 48-year-old man hospitalized at the Department of Abdominal Surgery, Sveti Duh General Hospital in Zagreb for the treatment of familial adenomatous polyposis syndrome. For some time the patient reported occasional abdominal pain, frequent stools and diarrhea with blood, anemia and body weight loss. Laboratory, radiology and endoscopy examinations verified multiple adenomatous polyps of the colon and rectum, also with polyps of the stomach, duodenum and jejunum. Histopathology confirmed the polyps to show moderately poorly differentiated cylindric epithelium and moderate to severe dysplasia. Radical surgery was required, so proctocolectomy with Brook ileostomy was performed. The postoperative recovery and wound healing were normal. The patient was discharged twelve days of the surgery for home care. Oncologic treatment was suggested. Verified extracolonic manifestations of the disease require periodical endoscopic follow up and possible treatment.