Eculizumab for paroxysmal nocturnal hemoglobinuria: Two cases of successful pregnancy outcomes.

Paroxysmal nocturnal hemoglobinuria is a rare disease with the incidence ranging from 0.08 to 0.57 per 100,000 person-years. Up to 25% of cases in women are detected during pregnancy. We report two cases of successful pregnancy outcomes in patients treated with eculizumab, pointing out the importance of interdisciplinary approach in these high-risk pregnancies.

Chronic Polyhydramnios: A Medical Entity Which Could Be a Model of Muscle Development in Decreased Mechanical Loading Condition.

Polyhydramnios is a condition related to an excessive accumulation of amniotic fluid in the third trimester of pregnancy and it can be acute and chronic depending on the duration. Published data suggest that during muscle development, in the stage of late histochemical differentiation decreased mechanical loading cause decreased expression of myosin heavy chain (MHC) type 1 leading to slow-to-fast transition. In the case of chronic polyhydramnios, histochemical muscle differentiation could be affected as a consequence of permanent decreased physical loading. Most affected would be muscles which are the most active i.e., spine extensor muscles and muscles of legs. Long-lasting decreased mechanical loading on muscle should cause decreased expression of MHC type 1 leading to slow-to-fast transition, decreased number of muscle fiber type I especially in extensor muscles of spine and legs. Additionally, because MHC type 1 is present in all skeletal muscles it could lead to various degrees of hypotrophy depending on constituting a percentage of MHC type 1 in affected muscles. These changes in the case of preexisting muscle disorders have the potential to deteriorate the muscle condition additionally. Given these facts, idiopathic chronic polyhydramnios is a rare opportunity to study the influence of reduced physical loading on muscle development in the human fetus. Also, it could be a medical entity to examine the influence of micro- and hypogravity conditions on the development of the fetal muscular system during the last trimester of gestation.

Lymph Node Metastases Papillary Thyroid Carcinoma and their Importance in Recurrence of Disease.

BACKGROUND: The purpose of this study is to establish whether the lymph node metastases of the papillary thyroid carcinoma are a significant factor in recurrence of the disease by analyzing the time until recurrence of the disease and frequency of recurrence of the disease. METHODS: From 1 January 1995 until 30 June 2017, 102 patients were treated at the Public Health Institute Hospital "Sveti Vracevi" in Bijeljina for PTC. In all patients, surgery of the thyroid gland and/or lymph nodes of the neck was performed. Total thyroidectomy (TT) was performed in 20 patients and near-total thyroidectomy leaving <1 g thyroid tissue adjacent to the recurrent laryngeal nerve in 7 patients. TT and lymph nodes dissection were performed in 71 patients. Palliative surgery and biopsy due to locally advanced disease were performed in 3 patients. RESULTS: In our study, 102 patients with PTC were analyzed. 82 patients experienced pure PTC (80.4%), the other 20 patients (19.6%) experienced other variants of PTC. 24 patients (23.5%) experienced multi centric or bilateral tumors. 71 patients (69.6%) experienced histologically verified metastases in the lymph nodes of the neck. 7 patients (6.8%) experienced distant metastases. 20 patients underwent total thyroidectomy (TT), and 7 near-total thyroidectomy. Total thyroidectomy + dissection of central and lower jugular lymph nodes with frozen section histopathology verification was performed in 71 patients (69.6%). Out of these 71 patients, in 50 patients (70.4%) metastases were verified in the lower jugular lymph nodes. A modified lymph node dissection (MRND) was also performed in these patients. CONCLUSION: Lymph node metastases of the papillary thyroid carcinoma are a plausible prognostic factor. They are important for recurrence of the disease, but not for survival.

Duplex System with Ectopic Ureter Opens into the Posterior Urethra: Case Report.

INTRODUCTION: Duplicated ureter or Duplex Collecting System is a congenital condition in which the ureteric bud, the embryological origin of the ureter, arises twice, resulting in two ureters draining a single kidney. This congenital anomaly is rare, and even rarer when the duplex system with ectopic ureter is present. This type of congenital anomaly is even more rarely diagnosed and surgically treated in adulthood. CASE REPORT: This case report presents a case of a 32-year-old male, who had a duplex collecting system with two ureters on the left side. Ectopic ureter, draining the upper pole of the left kidney, opened into the posterior urethra. In our patient, taking into account the clinical perspective, the renal tissue damaging of the upper pole which was not functional, partial nephrectomy and ureterectomy was successfully performed.

Encrustation of the Ureteral Double J Stent in Patients with a Solitary Functional Kidney - a Case Report.

INTRODUCTION: The efficacy of ureteric stents in the management of various urological conditions causing the upper urinary tract obstruction has been extensively proven, and their contribution to urology remains enormous. The clinical use of ureteric stents is associated with several complications. "Stent syndrome," encrustation, migration and urothelial hyperplasia are the most common problems related to long-term ureteral stenting. CASE REPORT: This work presents an interesting case from our practice: a complete encrustation of a classical polyurethane double J stent two and a half months after its initial instillation, in a 70 year old man, with a solitary functioning kidney, as well as successful removal of it by using a simultaneous treatment of extracorporeal lithotripsy and ureteroscopy with a contact disintegration of encrustations and with percutaneous nephrostomy, as an auxiliary procedure for providing of additional urine derivation. CONCLUSION: These problems can be overcome by the introduction of new advanced ureteral stent designs and biomaterials.

Correlation of Parathormone and the Serum Values of Acidum Uricum with Calcium Nephrolithiasis Examined by Three Different Methods of Diagnostics.

INTRODUCTION: Urolithiasis is a multifactorial disease. Changes in social and economic living conditions have generated changes in chemical composition of urolith too. Although calcium is a predominant crystalline constituent of kidney stones in 80% of cases, metabolic disorders are not the main reason for their formation. Hyperparathyroidism may be a cause of occurrence of calcium lithiasis, however, the biggest number of its occurrence is not a consequence of elevated values of parathormone. Acid uric has a pervasive presence in all body fluids. The serum level of acid uric is determined by its rate of synthesis, rate of excretion by kidney and gastrointestinal tract, and metabolism. GOAL: The goal of our study is to determine a correlation of calcium lithiasis of the upper part of the urinary tract with the parathormone values and the concomitant values of acidum uricum. MATERIAL AND METHODS: The study was prospective and included 120 patients with calcium lithiasis of the upper part of urinary tract, divided in three age categories, 20-40 years, 40-60 years and older than 60 years. The diagnosis of calcium lithiasis of the upper part of the urinary tract was made on the basis of urinary tract ultrasonography, and kidney-ureter-bladder radiography (KUB) /intravenous urography (IVU), urine culture and chemical analysis of stone with patients who had a spontaneous emission of stone or following some of the methods for active removal of stone; with some patients non-contrast (NCCT) was carried out too. All patients were subjected to the laboratory analysis of the serum level of acidum uricum and parathormone. RESULTS: With observed 120 patients suffering from calcium urolithiasis, who belonged to adult population, no patient had an elevated value of parathormone, while three patients (2.5%) had the values of acidum uricum higher than the reference values. The average value (for both parameters) was the lowest with the youngest patients and vice versa, and only in the group of 40 to 60 years of age there were patients whose values of the acidum uricum parameter was outside the interval of reference values; the other age groups did not have such values. Based on the analysis of the variance, as a statistical method, it was determined that the average values of acidum uricum in different age groups were statistically significantly different, which is not the case for the parameter parathormone. (p>0,05). CONCLUSION: The biggest number of nephrolithiasis is not a consequence of elevated values of parathormone. Hyperuricosemia may be present with calcium urolithiasis, without participation in forming kidney stones, most probably as an indirect sign of the existence of the initial insulin resistance and metabolic disease.

Correlation of serum and ionized calcium in patients with calcium nephrolithiasis.

INTRODUCTION: Pathogenesis of kidney stones includes many factors, whereas uroliths, as a generic term for kidney stones, are of a different composition. In pathogenesis of calcium urolithiasis hypercalcemia/hypercalciuria takes a significant place. Hypercalcemia exists when the serum calcium is of increased values, along with measurement and calculation of physiologically active calcium, when there are differences in the Ph of the blood or albumin. GOAL: the goal of this research is to determine the correlation of values of the serum (CaS) and ionized calcium (Ca++) in patients with the calcium nephrolithiasis, whom have been established not to have hyperparathyroidism and malign diseases. MATERIAL AND METHODS: the research was prospective and implemented at the Clinical Center in Banja Luka, at the Urology Clinic, in the period between 1(st) April 2012 - 1(st) January 2013 and it included 120 patients with the calcium lithiasis of the upper part of the urinary tract, divided into three age categories. Diagnosis of the calcium lithiasis of the upper part of the urinary tract was established on the basis of the ultrasonography of the urinary tract as well as native urinary tract/intravenous urography and chemical analysis of the stone in patients with spontaneous stone emission or after some of the methods for active removal of the stone. Chemical laboratory analysis of the serum and ionized calcium was done for all the patients, with 3ml of blood being taken for establishing the aforementioned parameters (1-2 ml of the serum) in vacuumed test tubes or glass tubes of capillary blood. Increased parathormone values (PHT) and history of malignity were excluding factors. RESULTS: out of the 120 patients observed, Cs(S) had the value in the reference interval with most of them, that is, in 110 patients (91.7%). Those, whose value was out of the interval, are of an older age (all above 40). Average value of this parameter amounted to 2.3017, with an average difference (the standard deviation) of 0.11391. Observing the value of Ca++, the value within the reference interval was found in 106 patients (88.3%). Out of the remaining 14 patients, only two simultaneously had the value of Ca(S) out of the permitted interval. The majority of this group consisted of older patients (a half of those whose values were outside the interval was over 60). Average value of Ca++ amounted to 1.22 mmol/L with an average difference of 0.06454. In the 2 aforementioned patients, who simultaneously had increased values of CaS and Ca++, the blood Ph was within the referential value limits, which suggests that, in line with the hyporcalcemia definition, only 2 patients with nephrolithiasis, in the total sample of 120 patients of our research sample, could have had a true hypercalcemia. CONCLUSION: the biggest number of patients with the calcium urolithiasis, who do not have hyperparathyroidism and history of malign diseases, do not have a real hypercalcemia.

Treatment of vesicovaginal fistulas: an experience of 30 cases.

BACKGROUND: Vesicovaginal fistulas (VVF) are rare. In developed countries, the majority of vesicovaginal fistulas occur after gynecological procedures such as total hysterectomies. OBJECTIVE: The evaluation of successfulness of VVF surgical repairs with transvesical, transvaginal and transabdominal approach with omental flap in 30 patients. METHODS: This is a retrospective study of patients suffering from VVF who were treated with transvesical, transvaginal and transabdominal approach with omental flap from July 2004 until December 2012. During that period, 30 patients with VVF underwent a surgical treatment at the Clinic of Urology, University Clinical Center of Banjaluka. Ten patients had previously taken radiotherapy due to cervical cancer and as a consequence of that VVF developed. In 19 patients, fistula occurred after total hysterectomy, and in one patient it occurred after the cesarean section. In six patients, primary surgical repair was performed by supravesical urinary diversion. The average size of fistula was 14 mm. RESULTS: The primary repair of VVF was successful in 75.00% of patients (18/24). In six patients (25.00%), it was not successful, and they remained incontinent. The successfulness of primary repairs with transvaginal and transabdominal approach with the use of omental flap was 100%, and with transvesical approach, it was 68.42%. The secondary surgical repair was performed in the remaining five patients, and it was successful in two patients (40.00%), but cumulatively speaking, the successfulness was 83.33% (20/24). In the secondary repair, the successfulness of transvaginal approach was 50.00%, and of transvesical one, it was 33.33%. Three patients underwent the tertiary surgical repair and its successfulness was 0%, and the approaches were transvaginal in one patient, transvesical in another one, and combination of transvesical with additional stitches with transvaginal approach in the third patient. When the surgical repair was undertaken for the fourth time, the successfulness was 100%. In two patients, the approach was transabdominal with interposition of omental flap, and in one patient, the approach was transvaginal. When everything is taken into consideration, 23 out of 24 patients had a successful closure of fistula, and we lost track of one patient whose primary repair was unsuccessful. CONCLUSION: The selective approach to the repair of VVF mostly depends on the surgeons skill and experience. The successfulness of the repair depends on the excision of the pathological tissue, the closure of fistula in a well vascularized tissue and on urine drainage.

Lipid peroxidation in the first trimester of pregnancy.

AIM: To determine the existence and level of oxidative stress caused by lipid peroxidation in pregnancy. METHODS: The research was conducted as prospective examination that included 60 healthy women (age 18-45). The women included in the examination were divided into two groups. The group I (N-31) included women in the first trimester of normal, healthy pregnancy. The group II included healthy nongravid women (N-29). Concentrations of markers of lipid peroxidation malondialdehyde (MDA) and thiobarbituric acid (TBARS) were determined using commercial ELISA tests OxiSelect(™) TBARS Assay Kit and OxiSelect(™) MDA ELISA Kit. RESULTS: The results of this research indicate that the concentrations of the markers of lipid peroxidation TBARS and MDA are detectable in both groups. Higher mean values of MDA (>20 pmol/mg) were measured in the group of pregnant women, than in the group of nongravid women. The results indicate that mean values of TBARS markers are lower in pregnant women (≤50 µM) than in nongravid women (>100 µM). CONCLUSION: The marker of lipid peroxidation MDA proved to be a sensitive marker for following lipid peroxidation during pregnancy, therefore it can be considered as a good predictor of possible complications during pregnancy.

[Medico-legal aspects of hysterectomy].

INTRODUCTION: Understanding the lawful implementations of surgical procedures, such as hysterectomy, raises practical questions concerning legal relations between a doctor and his patient, and consequences of this relationship, which may be legally relevant. The modern legal theory and practice consider doctors and patients to be partners. CONSENT AND INFORMATION: Medical practitioners performing surgical procedures are obliged to obtain informed consent. They are also required to inform their patients about indications, course of the operative procedure, postoperative treatment, possible complications during and after the procedure, and quality of life after the operation. Informed conversation should take into account the age, mental status and patient's intellectual abilities. Legal consequences ofsurgical procedures Malpractice litigation mostly concers medical error and negligence. Medical errors should not be confused with ineffective outcome, or complicated postoperative course. Even if the surgical procedure was followed correctly and uneventful outcome took place, there might be some problems. CONCLUSION: A patient has a right to receive complete information from a physician about the specific nature of a proposed treatment. A physician has an obligation to elucidate and justify, treatment he proposes. Certain codification of all operative procedures may facilitate this task. Codification instructions about procedures, in this case hysterectomy, must include indications for a certain type of hysterectomy (subtotal, total, radical), as well as for the operative technique (abdominal, vaginal, laparoscopic). Patient information brochures should be available in print, and include information about indications and potential risks associated with the proposed surgical procedure. In this way, it is possible to prevent the inconveniences which may arise from insufficient knowledge and information about surgical procedures.

[The concept and importance of medical law].

INTRODUCTION: Medical law is a scientific discipline which has not been affirmed in our country, but at law schools in many developed countries it has gained the status of a separate scientific discipline and today it is studied with multidisciplinary cooperation of Schools of Medicine, Schools of Dentistry and Schools of Pharmacy. Generally speaking, medical law concerns the rights and duties of the medical profession. ETHICS AND LEGAL QUESTIONS OF MEDICAL LAW: The progress of scientific research and of new technology used in diagnostics and treatment, opens new fields in terms of responsibility. Most European countries have legal institutions in the field of health care. These include laws and legal acts, as well as codification of professional norms. LAW CONCERNING PHYSISIANS: Apart from the national law, there is also an international law concerning physisians. The World Health Organization and the World Association of Medical Doctors brought the following declarations: Declaration on Promotion of Patients' Rights, the Revised Lisbon Declaration on Patients' Rights, the Revised Helsinki Declaration on Biomedical Research Involving Human Subjects and the Council of Europe's Convention on Human Rights and Biomedicine. CONCLUSION: There is no national order of physicians in Serbia and Montenegro, because chambers of physicians with legal authority and mandatory membership have not been formed. The foundation of Chambers of Physicians of Vojvodina and Montenegro is the first step to goal achieving.

[Current issues in contraception].

INTRODUCTION: The authors analyze contemporary methods of contraception. Regarding oral contraception, they point to agents which decrease the efficacy of oral contraception. They also deal with agents which increase the level of estrogen, thus increasing side effects (paracetamol, vitamin C). ORAL CONTRACEPTIVES: Oral contraceptives may also have an impact on the efficacy of some medications (anticonvulsants, antidepresants). Health risks of oral contraceptives are also mentioned, as well as WHO's, guidelines for women using contraceptives based on risks and benefits. OTHER METHODS OF CONTRACEPTION The authors also offer criteria for use of bioactive intrauterine devices (IUD), with recommendations of WHO. Besides men's, there are women's condoms, which are very reliable protection against infections, but their negative side is that they are rather expensive. Bad sides of vaginal wash are also emphasized, although this method is rather widespread in the world. CONCLUSION: At the end, the authors quote the Internationa Family Planning Fund (IFPF) which considers IUD to be the most reliable method of contraception nowadays.

Abdominal sling surgery--artificial sacro-uterine ligament.

Abdominal sling surgery is defined as attachment of either the connective tissue graft (fascia lata) or some synthetic material (Mersilene) to the anterior wall of the exposed vaginal vault following total hysterectomy or to the posterior wall of the uterine cervix in total and subtotal uterine prolapse, whereas the other end is attached to the anterior longitudinal ligament extending along the anterior surface of the vertebrae. Our analysis comprised 45 operations: 20 cases of vaginal vault prolapse following vaginal hysterectomy; 7 cases of vaginal vault prolapse following HTA: 2 cases of prolapse following subtotal hysterectomy; 3 cases of nondefined TH; 2 cases following Burch operation; 1 following Kocher; 1 following Manchester, 1 following Neugebauer-Le Fort operation in which HTA was performed 2 times. Abdominal sling operation was associated with the following surgical procedures: sling in 13 cases, sling + douglasorrhaphy in 16 cases, sling + douglasorrhaphy + colpoperineoplastics in 6 cases, sling + colpoperineoplastics in 9 cases and sling + marshall marcetti in 1 case. Recurrence of enterocele was recorded in 5 patients in whom closure of the douglas pouch had not been performed. This procedure was therefore later included into our approach to the operation. The abdominal sling operation has been a logical and physiologic approach to surgical therapy of genital prolapse, particularly of the vaginal vault prolapse following total hysterectomy. This operation ensures subsequent normal sexual relations.