[Challenges and advances in the care of injuries in the Republic of Serbia].

There are many problems that trauma care system in Serbia is facing today. Few of them are: 1) Lack of categorization of trauma centers; 2) Diversity in managing of trauma patients among institutions; 3) There is no trauma management training, 4) Inappropriate cooperation between pre hospital trauma care and hospital trauma care; 5) There is no standard in managing of trauma patients as well as procedures. To improve trauma care quality throughout the country we must learn from the experiences of other countries. The aim of this paper was to report representative data about organization, management, stuff and equipment of ambulance and emergency services in Serbia. We analyzed 12 out of 138 parameters we obtained from the relevant institutions.

[Blood replacement in severely injured patients].

Haemorrhage remains a leading cause of early death in injured and application of concentrated RBC transfusion in the treatment of multiple injuries is the basis and potential component of saving lives. The aim of this study was to analyze the received amount reimbursed blood in patients with severe trauma, depending on the outcome, severity and mechanism of injury. Collected data on gender, age and age as the mechanism of injury, amount of blood recovered intraoperatively and during the first six days of hospitalization, which were analyzed according to outcome of treatment, ISS, AIS, and APACHE II score. Results showed that patients with lethal outcome received a larger amount of blood, there is a statistically significant correlation with ISS and AIS score for extremity injuries, and that larger amount of blood received patients injured in the traffic accidents, as pedestrians and motorcycle riders/bike, and there is no correlation with APACHE II score. Based on the importance of this topic for further research are necessary in this area in order to more accurately define indications and dosage and method of reimbursement of blood in patient with severe trauma.

[Topographic localisation of insertion of the anterior cruciate ligament].

INTRODUCTION: Determining the center of tibial insertion of the anterior cruciate ligament is important during reconstruction ligament. AIM: Determining the center of insertion of the anterior cruciate ligament on the anterior intercondylar area relate to anterior and medial edge of the upper end of tibia. MATERIAL AND METHODS: The messurement has been done on 102 tibia. We measured distance from the center of ACL to anterior and medial edge of the uper part of tibia, and the lenght and the width of the tibial insetion. Also, we showed the procentual ratio these distances with medio-lateral and anteroposterior diametar of upper tibial part. RESULTS: The distance between the centre of attachment and medial edge is at 39% from entire latero-medial diametar, while the distance from anterior edge is at 31% from entire anterio-posterior diametar. The possitive correlation between the distance of centar of the anterior cruciate ligament from anterior and inner edge (r = 0.366, p) was found. CONCLUSION: The center of the attachment of the ACL at anterior intercondylarl area is at 1/3 of antero-posterial diametar behind the anterior edge of the upper part of tibia and 2/5 of latero-medial diametar inside from the medial edge.

[The position of anterior cuciate ligament in frontal and sagittal plane].

INTRODUCTION: Position of the anterior cruciate ligament (ACL) represents one of the anatomical factors which can lead to the rupture of the ligament. AIM: The aim of this study was to overview and compare gender and age differences of the position of the ACL and its relation with the medial aspect of the lateral femoral condyle. METHOD: The measurements were performed on the fifty cadaver knees (32 male and 18 female) aged between 15 - 53 years with intact ACL. We were measuring the angle of the ACL in sagittal and frontal plane and the angle of the medial aspect of the lateral condyle in frontal and horizontal plane. RESULTS: Measurements of the ACL in sagittal plane and measurements of the angle of the medial aspect of the lateral femoral condyle in horizontal plane showed statistically significant variations with the age (p < 0.05 and p < 0.01, respectively). The angle of the medial aspect of the lateral femoral condyle in frontal plane was statistically significant higher than the same measured angle in the horizontal plane ( p < 0.01). CONCLUSION: ACL fomis narrower angle with medial aspect of the lateral femoral condyle in extension of lower leg than in flexion as a result of smaller angle of the medial aspect of the lateral femoral condyle in frontal compared to horizontal plane.

Evaluation of the Alvarado score in the diagnosis of acute appendicitis.

This study has been performed in the Emergency center, Clinical centre of Serbia, during the period 01.03.2007-01.09.2007. We performed this study on 57 patients with diagnosis suspected for acute appendicitis (ages 16-70). Parameters that make the Alvarado score are the following: migration of pain, anorexia, nausea or vomiting, right lower abdominal quadrant tenderness, rebound tenderness in right iliac fossa, elevated temperature, leukocytosis, shift to the left of neutrophils. The aim of the work is to evaluate the Alvarado scoring system in diagnosis of the acute appendicitis. With all the patients Alvarado score has been determinate preoperatively, and diagnosis was confirmed by intraoperative finding and histopatological examination of the removed appendix. All the patients with score 7 or more were surgically managed. Specificity (positive predictive value) was 92.59 % in males and 76.67 % in females. The negative appendectomy rate was 7.41 % with the males and 23.33 % with the females. The values of the Alvarado score are significantly higher in the patients with acute appendicitis, compared with the patients of the other diseases. With the application of the Alvarado scoring system we can decrease postoperative morbidity and mortality.

[Risk factors for bleeding from stress ulcer in severely injured and critically ill persons].

Bleeding stress ulcus is a mucosal stress induced lesion which appears as a result of mucosal damage in severely injured and critically ill persons. Prophylaxis treatment has dramatically reduced the incidence of bleeding in Intensive care units. We conducted a prospective study for the five years period. Of 954 patients (196 with acute necrotizing pancreatitis and 758 with severe injuries), 84 (8.5%) has clinically important bleeding. About 80% of these patients had more than one independent risk for acute bleeding from gastrointestinal tract. Prophylaxis treatment reduced bleeding in 90% risk patients (according Zinner score). Despite of prophylaxis, 13 patients required surgery. Overall mortality was 29 (34%) of 84 patients, including seven of 13 who required surgery. Sepsis and respiratory failure were identified as strong risk factors for bleeding in our group. The choice of the best prophylactic agens still remains the question.

[Surgical perspectives in treatment of bleeding peptic ulcers].

Peptic ulcer bleeding has overall incidence of 50 to 150 on 100.000 grown-ups per year and represents cause for over 1% of all urgent hospitalization today. Despite of the evolution of the endoscopic diagnostics and haemostasis, improved intensive care and surgical treatment, overall mortality is still over 10% (operative treatment over 20%), and it almost hasn't changed over past 40 years. For more than 100 years surgery had major role in treatment of peptic bleeding ulcers, whereas nowadays it is limited to treatment of its complications. Adequate surgical treatment demands properly timed operation, safest but appropriate operation and trained surgeon. Early surgery is much better compared to the last minute surgery. At high risk rebleeding ulcer, early delayed surgery appears to be adequate, since the complications and lethal outcome are more frequent in this group.

[Surgical treatment of gastroduodenal ulcer bleeding-our experience].

INTRODUCTION: Acute bleeding from the upper gastrointestinal tract remains the commonest emergency in gastroen-terology, and is most often caused by gastroduodenal ulcer disease. Despite introduction of novel endoscopic techniques and pharmacological treatment, 6-15% patients have to be operated. The aim of our investigation is analyze data of patients treated for gastrointestinal ulcer bleeding in our institution, their treatment options and outcome. PATIENTS AND METHODS: We included 2237 patients admitted in the Department for Emergency medicine of Clinical center of Serbia during the period from January 1999 until December 2003. because of gastroduodenal ulcer bleeding. We analyzed age, gender treatment option, hospital stay and mortality. RESULTS: The mean age of our patients was 61.58 years, 1346 male and 891 female. The majority of patients were conservatively treated (84.5%). Operated patients mostly undergo Billroth II resection (57.8%). The mean hospital stay was 7.3 days. Average mortality was 14.4%. CONCLUSIONS: Despite adequate endoscopic management of bleeding gastroduodenal ulcer, surgeons will continue to treat this patients for emergency surgery.

[Gastrointestinal gastric tumor (GIST) as a cause of massive hemorrhage from the upper digestive tract].

Gastrointestinal stromal tumors GIST are rare mesenchymal tumors of the gastrointestinal tract characterized by expression of a receptor that activates tyrosine kinase called C- kit. Since malignant GIST has an extremely poor prognosis even after surgical resection. The developement of a tyrosine kinase inhibitor, STI571/imatinib mesylate/Gleevec, Glivec which inhibits the BCR-ABL, PDGF-R alpha, and C-Kit receptors, has changed the management of unresectable malignant GIST and has improved the survival of patients with metastaic disease. We report a 32 year old male patient with subcardiale gastric GIST and massive gastrointestinale bleeding. The patient underwent total gastrectomy, D2 lymphadenestomy, distal pancreatectomy and splenectomy on 02.02. 2004. Histopathology examination of the primary tumor revealed a strong C-Kit expression and CD 34 +++, Ki67 20 and so called "Pure GIST" was approved Liver metastasis was detected on ultrasound and CT 12 months later and segmentectomy S7 was performed on 23.03.2005. Postoperative course was uneventfull. HP examination--malignant 35 x 30 mm sarcoma like tumor of mesenchymal origin. The patient received adjuvant imatinib-mesylate Gleevec Novartis Pharma Basel 400 mg a day. The initial complete response to treatment continued to 24 monts postoperatively Imatinib is a recent and very promising tretemenextirpation remains the only curative treatment of malignant GIST as evideneced by our patient.

[Total gastrectomy in the surgical treatment of acute massive hemorrhage caused by Dieulafoy lesion of the gastric fundus].

GI bleeding caused by Dieulafoy lesion in the gastric fundus: a case report Dieulafoy lesion is a rare cause of massive gastrointestinal (GI) hemorrhage that can be fatal. It arises from an abnormally large eroded submucosal artery and in more than 75% of cases the lesion is mostly found within 6 cm of the cardia. The severity of bleeding and the site of the lesion render the diagnosis sometimes difficult, more than one endoscopic exam is often required. Surgery was regarded as the treatment of choice in the past, but recently endoscopic management has become the standard approach. We report a case of an 42-year-old man presented with upper GI hemorrhage. Repeated upper GI endoscopies revealed a missed diagnosis of subcardial gastric ulcer and Mallory-Weis lesion. Following conservative treatment, the frequency and amount of haemorrhage decreased and totally stop. 48 hours after admission patient developed sudden massive upper GI bleeding and underwent emergency total gastrectomy. The diagnosis of Dieulafoy lesion was made histologically. The patient recovered uneventfully and discharged on the postoperative day 11th. Therefore, Dieulafoy disease represent a diagnostic and therapeutic challenge. Advances in endoscopic technique have greatly assisted in earlier diagnosis and added options to the treatment regimen for this lesion. The relationship of this anomaly to possible exsanguination makes it essential that both endosopical and surgical approach play an important role in the management of this pathology.

[Protective ventilation strategy in the acute respiratory distress syndrome]. / Protektivna strategija ventilacije u sindromu akutnog respiratornog distresa.

Acute lung injury (ALI) and acute respiratory distress syndrome (ARDS) contribute to progressive hypoxemia in critically ill patients. It has been proved that conventional mechanical ventilation with physiological respiratory volume contributes to further lung damage. In this respect, application of protective ventilatory strategy--pulmonary ventilation with limited volume and pressure can avoid mentioned consequences. The aim of this paper is to discuss mechanims by which elements contained in protective mechanical ventilation of patients with ALI/ARDS prevent further progrssive lung injury, to argue the effects of positive end--expiratory pressure and present insturctions for its application.

[Prevention and treatment of organ injury in acute pancreatitis]. / Prevencija i lecenje organskih ostecenja u toku akutnog pankreatitisa.

Acute pancreatitis is illness with unpredictable outcome. In some patients course of illness is progressive and leading to multiple organ dysfunction syndrome often resulting with lethal outcome. During last decade the treatment protocols have changed. Basic pathophysiologic mechanisms leading to progression of the illness, as well as, contemporary diagnostic and treatment possibilities that can prevent occurrence of severe consequences and improve outcome are presented.

[Splenic injuries and mortality in polytrauma]. / Povrede slezine i mortalitet u politraumi.

Severe trauma is the leading cause of death in the working population. Traffic accidents are the most frequent etiological factor, with substantially more male than female victims. In this paper we have analyzed 53 cases of dead patients, among 240 severe traumatized treated in Center of emergency surgery, Emergency Center, CCS from January, 2000-June 2002. Spleen is the most frequent injured abdominal organ. In 34% surviving period was less than 72 hours. One-third of patients required at least two surgeries, including laparotomy. The most preciously diagnosis were performed in the cases of spleen injuries. The most common cause of death was cariopulmonal insufficiency, according both clinical diagnosis and forensic findings.