Rectal prolapse as the initial presentation of rectal cancer-A case report.

Herein we report the case of a 63-year-old female tourist who presented to our Emergency Department with complete rectal prolapse. She had complained of diarrhea with traces of blood and mucus and had experienced fatigue after hiking. After the initial evaluation, it became clear that prolapse bares a large rectal tumor as a leading point. The prolapse was reduced under general anesthesia, along with a tumor biopsy. Further workup confirmed locally advanced adenocarcinoma of the rectum, which was treated with neoadjuvant chemoradiation followed by curative surgery in another hospital after repatriation. Rectal prolapse affects people of all ages, but it is more common in older adults, particularly women. Treatment options vary depending on the severity of the prolapse and can range from conservative measures to surgical interventions. This case report highlights the importance of early recognition and appropriate management of rectal prolapse in the emergency setting and the possibility of an underlying malignancy.

Extensive clostridial myonecrosis after gluteal intramuscular injection in immunocompromised patient treated with surgical debridement and negative-pressure wound therapy.

Gas gangrene is infectious disease caused by Clostridium perfringens infection. We are presenting extremely rare case of gluteal clostridial myonecrosis after intramuscular injection of diclofenac in immunocompromised young patient on a long-standing corticosteroid therapy presented with sepsis and initially absent clinical signs of severe anaerobic infection. After delayed diagnosis, she was treated with aggressive surgical removal of necrosed tissue and targeted antibiotic therapy which led to a rapid improvement allowing application of a negative-pressure wound therapy device with favorable outcome. This report shows the importance of timely diagnosis with pitfalls of imaging. It confirms that surgical debridement along with specific antibiotic therapy is the mainstay of treatment, but also promotes negative-pressure wound therapy which has proved convenient for accelerated closure of large incisions with tissue loss without any adverse effects or the need for complex reconstructive procedures.

Comparison of new versus reused Harmonic scalpel performance in laparoscopic appendectomy in patients with acute appendicitis-a randomized clinical trial.

BACKGROUND: The aim of this study was to compare lateral thermal damage of the appendix and clinical outcomes after laparoscopic appendectomy using new versus reused Harmonic scalpels. METHODS: A total of 100 consecutive patients with acute appendicitis who underwent laparoscopic appendectomy were enrolled in the two-center, randomized clinical trial. Using a computer random number generator, patients were allocated to new or reused group. Histopathological measurement of lateral thermal damage of the appendiceal base and mesoappendix, speed of transection of the appendiceal base, duration of surgery, subjective rating of device functionality, length of hospital stay, and complications were compared within groups. RESULTS: The median lateral thermal damage on the appendiceal base in the new group (N = 49) was 0.2 mm (IQR 0.1-0.2) and 0.1 mm (IQR 0.1-0.3) in the reused group (N = 51) (P = 0.644), while on the mesoappendix for both groups, thermal damage was 0.1 mm (IQR 0.1-0.2) (P = 0.418). The median time required for base transection in both groups was 8 s (IQR 7-9) (P = 0.776). The median duration of surgery was also comparable between the groups (22 min, IQR 20-30 vs 25 min, IQR 21-35; P = 0.233). Two postoperative complications in the new group and one in the reused group were recorded (4% vs 2%; P = 0.536). Surgeons' subjective assessment of the instrument did not reveal significant difference between the groups in all of the investigated categories. CONCLUSIONS: The results of our study support the reuse of Harmonic scalpels especially in the settings where economic constraints might hamper access to minimally invasive surgery to a larger number of patients. The results obtained on laparoscopic appendectomy might not be reproducible to other more demanding surgical procedures. TRIAL REGISTRATION: ClinicalTrials.gov registry under identifier NCT04226482.

Tumor angiogenesis as an important prognostic factor in advanced non-small cell lung cancer (Stage IIIA).

The aim of the present study was to evaluate angiogenesis by determining the micro vascular density (MVD) and the expression of vascular endothelial growth factor (VEGF-A) in advanced non-small cell lung cancer (NSCLC) tumor samples, and to analyze their associations with clinical parameters and survival. Tumor tissue specimens of fifty patients (41 males and 9 females), who underwent radical surgical treatment for NSCLC in stage IIIA (T1-3N2) were collected for immunohistochemical analysis. MVD evaluation was performed using an anti-CD31 monoclonal antibody and VEGF-A expression using a polyclonal anti-VEGF-A antibody. The results were associated with two-year survival. Statistical analysis revealed significant associations in the level of angiogenesis (high MVD) and shorter survival of patients with NSCLC (P=0.0007). VEGF-A expression showed no association with micro vascular density (P=0.51) or survival (P=0.68). There was no significant association between MVD and VEGF-A. The measurable, clinical MVD parameters could be used as a reliable prognostic factor for the survival of patients with advanced NSCLC.

RESULTS OF CLAVICLE FRACTURE TREATMENT IN CHILDREN.

Treatment of clavicle fracture is principally outpatient. Operative treatment is accompanied by the need for more x-rays and possible complications. Fractures with absolute indications for operative treatment occur only sporadically and these indications are relatively clear, but children often undergo surgery because of relative indications (shortening, fragment displacement, multifragmentary fractures), which are open to debate. In a retrospective study on 256 children, of 44 (17%) patients that received operative treatment only one 17-year-old boy had an absolute indication for surgical intervention. Other indications were fragment distraction (22 mm on average), age, associated injuries, and multifragmentary fracture. The placement of K-wire of appropriate thickness is often difficult, since the wire tends to bend and break, and patients have to undergo two additional operations of plate and screw fixation and later removal. In this retrospective study, we considered the advantages of using titanium or an elastic steel pin. All patients had favorable outcome, although some experienced numbness around the operation scar (4.5%), skin infections around the wire (15%), and/or the implanted K-wire damage (7%).

Complications of ESIN osteosynthesis--Experience in 270 patients.

BACKGROUND: Elastic stable intramedullary nailing (ESIN) osteosynthesis has been used in our department for the treatment of long-bone fractures in children and adolescents for more than 17 years. During this period we have shown that ESIN has several advantages compared with other methods of treatment. However, as with every other method, ESIN has its drawbacks and complications. These occur primarily if indication criteria are not respected or ESIN technique is inadequate. This paper presents the rate of complications that occurred with this method in our patients, and the means of prevention and treatment of these complications. PATIENTS AND METHODS: A total of 270 patients treated with ESIN osteosynthesis for fractures of long bones of the extremities completed treatment. The study was conducted at the Department of Child Surgery and Orthopaedics of the Clinical Hospital Centre in Rijeka. All the Nancy Nails used in the study were of the same quality, from one manufacturer and were applied using the standard ESIN technique. In 228 patients (84%), ESIN was the primary treatment, whereas in the remaining 42 patients (16%), ESIN was applied after an attempt at manual reposition and immobilisation of bone fragments. All patients had control radiography at least three times and postoperative monitoring was conducted for at least two years. RESULTS: A total of 35 of the 270 observed patients developed complications; some patients had several complications. There were 53 early intraoperational complications and 29 late postoperative complications. All complications resolved with appropriate therapy. The treatment was satisfactory in all patients except those with an elongation of the extremity (leg) of more than 1cm. CONCLUSION: Postoperative complications related to the ESIN method of osteosynthesis in the patients in this study were detected by radiological control examinations and long-term clinical monitoring. All the complications of ESIN were relatively easy to treat with current medical methods. The frequency of particular complications is significantly reduced if indication criteria for ESIN are respected and correct ESIN technique is used.

[SUBUNGUAL EXOSTOSIS OF THE THUMB - CASE REPORT IN AN EIGHT YEAR OLD GIRL]. / SUBUNGVALNA EGZOSTOZA PALCA STOPALA - PRIKAZ OSMOGODISNJE DJEVOJCICE.

Subungual exostosis (SE) is a benign osteocartilaginous tumor of the distal phalanx of the finger, particularly of the toes. It affects both sexes, the most frequently occurring in the second and third decades of life, and very rarely in children younger than eight years. We present subungual exostosis (SE) in a eith year old female child affecting the terminal phalanx of the right thumb. She presented to us with gradually enlarging, painless, subungual hard nodule on the right thumb, spherical appearance size of 12 mm in diameter. Roentogram of the foot showed bony outgrowth arising from the terminal phalanx of right thumb. Lesion was excised with prior ablation of the nail, and sent for histopathological examination. Histology showed evidence of SE. No recurrence at postoperated site was seen till ten months of follow-up.

[CLAVICLE FRACTURES IN CHILDREN--CIRCUMSTANCES AND CAUSES OF INJURY]. / PRIJELOM KLAVIKULE U DJECE--OKOLNOSTI I UZROCI NASTANKA.

Clavicle fractures in children occur twice as often as in adults. During a child's growth period they account for 10-15% of all fractures sustained. The questions which should be asked are how these fractures are sustained and under which circumstances are the children injured. In the study 256 children with clavicle fractures treated during the period 2008-2013 were analyzed. The underlying cause and place of injuries were classified using the ICD-10 classification system, using environmental causes of injury. The circumstances were in each case accidental injury. Environmental causes were traffic accidents (V01-V99) or mishaps/accidents (W00-X59). Fracture injuries were caused in traffic accidents in 24 (9.4%), and in mishaps/accidents in 232 (90.6%) children. Of the injuries caused by mishaps/accidents, in 204 children these were caused by falls (W00-W19). In 123 of them the injuries were caused by falls from a ground level, and in 81 were from a greater height. Direct blow injuries, caused by another person or a blunt instrument, weere the causes of fractures seen in 28 children. Place of fracture sustainment was dominantly at home. This was followed by injuries sustained outside in recreational areas, while least were suffered at school or kindergarden facilities. Bicycle riding was the cause of clavicle fractures in 48 children, which was 18.7% of all fractures seen. Sports related injuries and fractures were seen in 47 (18.4%) out of 256 children: 30 in football, 10 in defensive sports (wrestling, judo, karate), three in hockey, while basketball and gymnastics accounted for two each. Preschool children were injured more often while in the care of their parents while school aged children were adaquately protected, but in after-school activities they were often injured. The most common injuries after school were those suffered in traffic accidents and recreational sports activities. In the adolescent period, the most common injuries seen were again those in traffic accidents, bicycle riding, recreational sports activities and injuries sustained at home.

Treatment outcomes of both-bone diaphyseal paediatric forearm fractures.

BACKGROUND: Elastic-stable intramedullary nailing (ESIN), is an accepted method for stabilization of unstable forearm shaft fractures in children. This study analyzed the radiographic and functional outcomes of intramedullary nailing of forearm diaphyseal fractures in children. MATERIALS AND METHODS: A retrospective analysis was performed of children with forearm shaft fractures and open epiphyseal plates, treated with ESIN between 2000 and 2012 in our institution. Evaluation of cases was conducted minimum 14 months after osteosynthesis. Clinical results were evaluated according to the criteria developed by Price et al. and Flynn et al. RESULTS: The study included 88 (42 boys) children. The average age of children at day injury was 10.5 ± 2.59 years (range 4-16), and at the review clinic was 13.4 ± 1.85 years (range 7-18). Forty six (52.3 %) had right forearm and 42 (47.7%) had left fracture respectively. Open reduction was required in 20 (22.7%) children. Primarily surgically were treated 62 (70.5%) children and 26 (29.5%) were operated as a second procedure after failed conservative management. There was one delayed union. Rotational forearm restriction with values between 11 and 20 degrees was present in nine children. Six children developed radial nerve hypoesthesia which eventually resolved with time. After removal of the implant one child sustained a re-fracture. The overall complication rate was 25%. Complete recovery to the original condition was noted in 76 (86.4%) children, eleven children (12.5%) had good and only one (1.1%) had poor outcome. CONCLUSION: Our study suggests that ESIN osteosynthesis for diaphyseal forearm fractures remains a valid technique with very good functional results.

The problem of post-traumatic varization of the distal end of the humerus remaining after the recovery of a supracondylar fracture.

We aimed to determine whether the distal end of the humerus had the capacity of spontaneous realignment of the remaining deformity following an inadequate reposition of the supracondylar fracture. The results in 56 children with a supracondylar humerus fracture were analysed. In 45 patients (80%), manual repositioning was performed along with transcutaneous fixation, whereas in 11 patients (20%), only manual repositioning and immobilization in plaster cast was applied. Immobilization was removed and physical therapy was started in all patients on the 21st day following the intervention. Anteroposterior and left-lateral radiography was performed and Baumann's angle was determined. Follow-up radiograph of the elbow of the traumatized and healthy extremity was performed at an interval of 5-15 years (median 9.4). There was no statistically significant difference between the relationship of Baumann's angle of the injured arm measured on the 21st day after the reduction of fragments on the one hand and the carrying angle of the injured and healthy arm measured at the long-term follow-up on the other (t=0.48, P=0.63). Similarly, there was no statistically significant difference between the relationship of Baumann's angle of the injured arm measured at the long-term follow-up and the findings of the carrying angle of both the injured and the healthy arm obtained on the same examination (t=0.78, P=0.44). On the basis of our experience, we conclude that there is no biological capacity to rectify a possible remaining postreduction varus deformity by spontaneous remodelling.

The role of videomediastinoscopy in staging of non-small cell lung cancer.

Lung cancer is the most frequent malignant disease and the leading cause of death from malignant diseases in the world and its incidence is increasing. At the time when diagnosis is established most patients have advanced disease and are not candidates for radical surgical treatment. Patients without distant metastases are subjected to various diagnostic methods to detect metastases in mediastinal lymph nodes that make up the path of lymph drainage from the lungs. The most reliable invasive diagnostic procedures for detecting metastases in mediastinal lymph nodes are videomediastinoscopy and endobronchial ultrasound with transtracheal puncture. In the absence of mediastinal lymph node metastases surgery is the treatment of choice. If mediastinal lymph nodes are positive for metastases multimodal treatment is implemented. At the Department of Thoracic Surgery, Zadar General Hospital, videomediastinoscopy for the staging of primary non-small cell lung cancer has been performed routinely since September 2009.

Venomous snakebites in the Croatian North Dalmatia region.

AIM: The aim of this research project is to analyze the epidemiological, clinical and laboratory attributes of venomous snakebites and to ascertain the timely and efficient treatment at the location where the incident took place or in varying clinical conditions. METHODS: Epidemiological, clinical and laboratory data were collected from people who were bitten by venomous snakes as well as treatments at Zadar General Hospital during a span of eleven years (1999-2009) which were analyzed retrospectively. RESULTS: During that period, 93 people were bitten by venomous snakes of which 57 patients (62%) were male and 36 (38%) were female. In 82 cases (90%), the bite area was localized on the limbs while in the remaining 11 cases the bite area was located elsewhere. At the time of the venomous snakebite, 31 (33%) patients were performing leisure activities and 44 (47.31%) of them were at work. The most common local snakebite signs are swelling and pain at the bite site (93 patients; 100%), hematomas and ecchymoses (87 patients; 89%). Of the affected patients, 8 suffered from compartment syndrome and one person (0.97%) expired. CONCLUSION: Antivenom treatment for preventing possible allergic reactions should take place at the medical institution where the victim was transported. However, when transport is not immediately available or in cases where the victim shows clear signs of envenomation, antivenom treatment should be used immediately because its effect is weaker if the venom is allowed to run its course.

Efficacy of IP6 + inositol in the treatment of breast cancer patients receiving chemotherapy: prospective, randomized, pilot clinical study.

BACKGROUND: Prospective, randomized, pilot clinical study was conducted to evaluate the beneficial effects of inositol hexaphosphate (IP6) + Inositol in breast cancer patients treated with adjuvant therapy. PATIENTS AND METHODS: Patients with invasive ductal breast cancer where polychemotherapy was indicated were monitored in the period from 2005-2007. Fourteen patients in the same stage of ductal invasive breast cancer were involved in the study, divided in two randomized groups. One group was subjected to take IP6 + Inositol while the other group was taking placebo. In both groups of patients the same laboratory parameters were monitored. When the treatment was finished, all patients have filled questionnaires QLQ C30 and QLQ-BR23 to determine the quality of life. RESULTS: Patients receiving chemotherapy, along with IP6 + Inositol did not have cytopenia, drop in leukocyte and platelet counts. Red blood cell counts and tumor markers were unaltered in both groups. However, patients who took IP6 + Inositol had significantly better quality of life (p = 0.05) and functional status (p = 0.0003) and were able to perform their daily activities. CONCLUSION: IP6 + Inositol as an adjunctive therapy is valuable help in ameliorating the side effects and preserving quality of life among the patients treated with chemotherapy.

Fist fractures at child's age.

The aim of this work is to confirm or deny the hypothesis that the fist fracture medical treatment at child's age in the General Hospital in Zadar does not differ much from the medical treatment method in other centers which have already published their results. The work is based on the retrospective study. The examinees are children with fist fractures in the General Hospital in Zadar from 1999 to 2003. The control group is formed by the examinees of the published studies about children fist fractures, which have been collected and statistically elaborated. The examinees of our group and the control group are classified by the same criterion: age, sex, place, sort and type of fracture as well as the method of medical treatment. The used statistical methods are the testing of frequency differences and chi2 test. Statistically essential differences between our group and the control group have been noticed. There are also differences among the control group subgroups. The difference in the method of medical treatment is statistically essential and shows that the methods are not the same as in our group and the control group. The surgical way of treatment is less represented by our results than in those of the control group. The different attitude in medical treatment is conditioned by the attitude that surgical intervention of finger bones does not always give us the expected functional result.