[Scoring system for evaluation of clinical outcome of severe injuries in patients].

A trauma-scoring system converts the severity of injury into a number, so helping clinicians to define patient's condition. Aim of our investigation was assessment of scoring systems in clinical outcome of patients with severe traumatic injury, as well as ISS, AIS, APACHE II and SOFA score were counted. Mean age of traumatized patients was 35 yrs, predominantly males. Based on results of our investigation we concluded that ISS, APACHE II and SOFA score adequately can be used for predicting clinical outcome of severe traumatized patients.

[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.

An experimental, non-uremic rabbit model of peritoneal dialysis.

Peritoneal dialysis (PD) is a well established method of depuration in uremic patients. Standard dialysis solutions currently in use are not biocompatible with the peritoneal membrane. Studying effects of dialysate on peritoneal membrane in humans is still a challenge. There is no consensus on the ideal experimental model so far. We, therefore, wanted to develop a new experimental non-uremic rabbit model of peritoneal dialysis, which would be practical, easy to conduct, not too costly, and convenient to investigate the long-term effect of dialysis fluids. The study was done on 17 healthy Chinchilla male and female rabbits, anesthetized with Thiopental in a dose of 0.5 mg/kg body mass. A catheter, specially made from Tro-soluset (Troge Medical GMBH, Hamburg, Germany) infusion system, was then surgically inserted and tunneled from animals' abdomen to their neck. The planned experimental procedure was 4 weeks of peritoneal dialysate instillation. The presented non-uremic rabbit model of peritoneal dialysis is relatively inexpensive, does not require sophisticated technology and was well tolerated by the animals. Complications such as peritonitis, dialysis fluid leakage, constipation and catheter obstruction were negligible. This model is reproducible and can be used to analyze the effects of different dialysis solutions on the rabbit peritoneal membrane.

[The role of wireless capsule endoscopy in the evaluation of patients with suspected small bowel bleeding: a single center experience].

BACKGROUND: Capsule endoscopy (CE) is a new diagnostic tool for the study of patients with suspected small bowel pathology. The aim of the study was to clarify the usefulness of CE in the group of patients with obscure (overt / occult) gastrointestinal (GI) bleeding. PATIENTS AND METHODS: Thirty patients (14 men, 16 women, mean age 50 years, range 9 -79 years) were enrolled in the study. All of them undergone non-diagnostic esophagogastroduodenoscopy, colonoscopy and barium follow-through of the small bowel. All patients underwent capsule endoscopy. Fourteen patients had overt and sixteen occult bleeding. The single senior endoscopist interpreted CE findings in an unblinded manner. RESULTS: CE identified a source of bleeding in 14/30 patients (46.6%). Lesions identified were: tumors in five pts, vascular lesions, Crohnzs disease and Meckelzs diverticulum in two pts and fresh bleeding, segmental celiac disease and colonic diverticulosis in one patient each. CE identified a source of bleeding in 9/14 (64.3%) of patients with ongoing overt bleeding and in only 5/16 (31.3%) of patients with occult bleeding. The positive suspicious findings were seen in 6/30 (20%) of patients (2/14 with overt bleeding and 4/16 with occult bleeding. In 3/14 (21.4%) with overt and 7/16 (43.7%) with occult bleeding findings on CE were negative. All patients with negative findings on follow-up remained asymptomatic for one year. Capsule retention because of unsuspected stenosis occurred in a single patient and required surgery, which resolved the problem. CONCLUSION: CE is an effective diagnostic tool for patients with obscure GI bleeding. It is safe and painless technique which can diagnose the bleeding site beyond the reach of conventional endoscopy. The best candidates for the procedure are those with ongoing and overt bleeding.

[The influence of risk factors in recurrent peptic ulcer haemorrhage].

Gastrointestinal hemorrhage is one of the most frequent complications that occurs in 15 20% patients with peptic ulcer disease. Recurrent ulcer haemorrhage presents in the first 72 hours after initial bleeding: they are the most im portant cause of death. The aim of our study was to show the possibility of ulcer recurrent haemorrhage combined with risk factors: age 60, high risk lesion (active arterial bleeding, visible blood vessel, adherent coagulum), the size, ulcer base and localization (posterior duodenal wall. lesser curvature or high gastric ulcer), commorbidities ( cardiovascular and liver diseases) and haemodynamic instabilities. The combination of these risk-factor, unproportionally increases the risk: presence of two risk factors gives the possibility of recurrent bleeding of 16.67%, three risk factors 58.82%, four 93.33%, while the presence of five risk factors shows 100% posibility. Probability of death is 8.27 times greater if ulcer haemorrhage occurs.

[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.

[Bleeding oesophageal varices--therapeutic options].

INTRODUCTION: Emergency endoscopy plays the most important role in diagnosis and treatment of patients with esophageal variceal bleeding. Endoscopic sclerotherapy (EST), placement of esophageal band ligatures (EVL), medicamentous treatment using somatostatin and its derivatives and balloon tamponade are the methods most frequently applied in treatment of the bleeding esophageal varices. PATIENTS AND METHODS: Endoscopic reports on the patients with bleeding esophageal and gastric varices were retrospectively analyzed in the emergency unit of the Clinic of Gastroenterology and Hepatology, Clinical Center of Serbia over the five-year period--since January 2001 till December 2005. RESULTS: The total of approximately 3, 954 emergency upper endoscopies were performed due to the upper gastrointestinal tract bleeding. Out of the total number of patients, bleeding was diagnosed in 324 (8.2%) patients due to the esophageal varices. In the group of patients with bleeding esophageal varices, the total of 252 (77.8%) males and 72 (22.2%) females averagely aged 56.8 + 7.5 years (range 24 - 80 years) were examined. The primary sclerosant therapy with absolute alcohol was applied in 118 (36.4%) patients, while Blakemore probe tamponade was performed in 145 (44.8%) patients with bleeding esophageal varices. The total of 240 (74.1%) patientswere treated with vasoactive substances (somatostatin and its analogues), as additional therapy and control of the primary hemostasis. It was evidenced that out of 118 patients intra and paravariceally treated with the sclerosant agent (absolute alcohol) hemostasis was achieved in 47 (39.8%). Out of 145 patients subjected to Blakemore probe placement, bleeding was successfully arrested in 117 (80.7%) patients. Somatostatin and its analogues as primary and only treatment of the bleeding esophageal varices were applied in 71 (29.6%) patients, while in the remaining 169 (70.4%) patients, they were applied as additional therapy to the endoscopic sclerotherapy and mechanical treatment of bleeding. Out of 71 patients treated with somatostatin preparations as the only therapeutic option, 45 (63.4%) responded positively by arrest of bleeding for 72 hours. CONCLUSION: Treatment of the acute bleeding esophageal varices is focused on the arrest of bleeding, prevention of early recurrent bleeding and reduction of mortality. Based on the most recent studies, efficacy of the modern endoscopic therapy in the form of sclerotherapy and band ligature placement, as well as application of vasoactive substances reaches up to 90%. Our results evidence minimal efficacy of the sclerotherapy (approximately 40%), which indicates the need of better preparation of patients for the intervention itself and additional education of the personnel.

[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.

[Endoscopic ultrasonography in choledocholithiasis].

Diagnosis of choledocholithiasis is still difficult to establish and presents a great challenge in gastroenterology and surgery of biliary tract, since it requires expensive and sophisticated examining techniques. 10 to 15% of patients with symptomatic cholelithiasis were presented with choledocholithiasis as well. By EUS is possible to establish a diagnosis of choledocholithiasis with accuracy of 90 to 100% and precisely estimate dimensions of revealed stones. The main purpose of this survey is to present a great importance and many advantages of EUS as a contemporary diagnostic method. All patients were examined by Olympus equipment for endoscopic ultrasound with radial probe working with the frequency of 7,5 and 12 MHz at the Department for Endoscopic Ultrasound of the Clinic for Gastroenterology and Hepatology, Clinical Center of Serbia. They were previously diagnosed with choledocholithiasis by ERCP method. We examined 16 patients, which were selected by estimated risk for cholelithiasis. We have tried to evaluate the importance of diameter of choledochus, defined by common ultrasonography, as well as values of alkaline phosphatase and serum ?GT. We defined 3 groups of patients: group no.1, with 2 patients presented with a low risk for choledocholithiasis; group no.2, with 6 patients with a moderate risk for choledocholithiasis, and group no.3, with 8 patients presented with significant risk for cholelithiasis. According to obtained results, EUS presents the most effective method for detecting of choledocholithiasis, which is sometimes even more efficient than ERCP. After choledocholithiasis is previously revealed by EUS, it is much easier to decide if some invasive method such as EPT or precut papillotomy has to be used. EUS is always recommended as a diagnostic method when it is necessary to avoid some expected complications, such as pancreatitis.

[The role of endoscopic ultrasonography in diagnostic and estimation of common bile duct carcinoma invasion].

The main purpose of this survey is to present the importance of EUS in establishing a diagnosis of tumor of the choledochus. It is also important to emphasize that EUS is the most suitable diagnostic method for determination of tumor invasion to choledochus, i.e. to determine TN patient status and to predict if tumor could be successfully resected. The author would like to present his own experience in using of EUS as a contemporary method for establishing a diagnosis and effective treatment of patients with tumor of choledochus. All patients were examined by Olympus equipment for endoscopic ultrasound with radial probe working with the frequency of 7,5 and 12 MHz at the Department for Endoscopic Ultrasound of the Clinic for Gastroenterology and Hepatology, Clinical Center of Serbia. All examined patients were subjected to surgical exploration after that. Therefore it was possible to compare preoperative estimation of tumor invasion with a final result obtained by surgical exploration. Five patients were diagnosed with tumor of choledochus localized at the distal part of choledochus. TN status of examined patients was specified by standard criteria. Estimated TN status for two patients was defined as T2N1a and T2N0, which indicate the possibility of excessive surgical treatment, what was confirmed by surgical exploration as well. A small number of patients was not possible to use for statistical evaluation. Our conclusion is that EUS presents the most effective method to estimate a degree of tumor invasion to choledochus, since it provides an accurate definition of TN patient status and predicts if tumor could be successfully resected.

[Endoscopic ultrasonography in pancreatic carcinoma].

Even though pancreatic cancer is not such a common diagnosis, its treatment is very expensive and it has a great economic impact to the health system. 5-year survival rates after excessive surgical treatment is only 5%, which imposes more careful selection of patients that have to be surgically treated. According to experience from some medical centers all over the world, EUS is considered as a high sensitive diagnostic method for establishing a diagnosis of pancreatic cancer and evaluation of TNM staging. The main purpose of this survey is to present our experience in using of EUS as a diagnostic method in establishing a diagnosis of pancreatic cancer, as well as to evaluate how reliable this method is in preoperative evaluation if tumor could be successfully resected. We examined the group of 63 patients with pancreatic cancer, which were surgically explored after EUS examination. We wanted to compare TNM status before and after the surgical treatment. All patients were examined by Olympus equipment for endoscopic ultrasound with radial probe working with the frequency of 7,5 and 12 MHz at the Department for Endoscopic Ultrasound of the Clinic for Gastroenterology and Hepatology, Clinical Center of Serbia. Evaluation of pancreatic tumor extension to local organs (pancreas, duodenum, choledochus, stomach, colon and large veins) was performed for all patients. All regional lymph nodes were also explored. Due to low penetration ability of the probe working with the frequency of 7.5 MHz, EUS is not a suitable method for evaluation of M stage (figure 8,9). Patients were divided in different groups, specified by TNM status. For 10 patients resection was estimated as a probably successful solution, but only 8 of them was surgically treated. According to this, our estimation was 79.7% accurate, which is in accordance to results obtained from other medical centers all over the world.

[The role of endosonography (EUS) in preoperative staging of patients with stomach cancer].

BACKGROUND: To evaluate the diagnostic accuracy of endosonography (EUS) in preoperative staging of stomach cancer. METHODS: Sixty-two patients with gastric carcinoma were investigated by endosonography. 49 underwent surgery. EUS reports were compared with operative and histology findings. Tumours were staged according to the 2000. TNM classification. RESULTS: EUS had a diagnostic accuracy of 89.8% for the T category, 83.7% for the N category. CONCLUSION: EUS is an excellent clinical procedure for the staging of local-regional spread of gastric cancer and useful complement to the other gastrointestinal examinations for evaluation of these tumours.

[The role of endoscopic ultrasound(EUS) in differential diagnosis of subepithelial oesophago-gastric lesions].

BACKGROUND: Endoscopic ultrasonography(EUS) allows high-resolution demonstration of the entire gut wall. The aim of the study was to clarify the usefulness of the EUS in differential diagnosis of upper gastro-intestinal subepithelail lesions(SEL). METHODS: From September 1998- March 2005, EUS was performed in 1600 patients. Among them, in 206pts (13%), this examination was carried out due to previous upper endoscopy, which revealed the suspicion to SEL or extraluminal compression. We studied the location, the size, echo pattern and originating layer of SEL. The results were compared with CT, angiography and operation with histology when possible. All EUS examinations were performed using Olympus GIF-130 videoecho-endoscope with 7,5/12MHz switchable radial probe. RESULTS: EUS accuracy in separating intramural masses from extraluminal compression was 96%(44/46). Among 160 pts with true SEL, in 95(59.3%), EUS revealed the existence of a stromal tumor arising from muscularis propria (92) or muscularis mucosae (3). The size of the tumor varied from 5-75mm; depth: 8-40mm. 33 patients were operated on. In 14/16(87%), the EUS diagnosis of benign stromal tumor was confirmed on operation. In 18/19(95%), EUS correctly disclosed the malignant tumor. EUS accuracy in predicting malignancy was 91.5%(32/35). Findings suggestive for malignancy were: size 40mm; inhomogenicity with microcysts and irregular outer margin. In 12 pts, EUS revealed lypoma. Abberant pancreas was correctly diagnosed in all 22pts. In 16 persons, EUS disclosed submucosal cysts: 6 of them were operated on and EUS diagnosis was confirmed in all. In 10 patients EUS visualized varices. The finding was confirmed on angiography. CONCLUSION: The EUS appears to be very effective in differential diagnosis of SEL in upper gastro-intestinal tract. Tumour size greater than 40mm, inhomomogenous echo pattern and irregular outer margin are very suggestive for malignancy.

[Peritoneal hepatobiliary cystadenoma--case report].

Hepatobiliary cystadenoma with mesenchymal stroma are infrequent form of cystic neoplasm that may be found in females only. It is difficult to reach correct diagnosis prior to surgery. We are presenting a case of 32 years-old female referred to our institution for revealing a cause of discomfort and pain in right subcostal region whereas peritoneal hepatobiliary cystadenoma has been determined. Abdominal ultrasonography and computerized tomography revealed cystic lesion adjacent to gall bladder, which was initially thought to be of echynococcal origin. At surgery, a mesenterial cystic neoplasm has been revealed, having a close contact with gall bladder, without signs of its infiltration. Pathophysiology discovered hepatobiliary cystadenoma with mesenchymal stroma. Pre-surgical differential diagnosis in hepatobiliary cystadenoma may be very difficult, especially if, like in the presented case, neoplasm has extra hepatic localization. Radical surgical excision is treatment of choice, concerning malignant potential of these neoplasms.

[Reiter's syndrome--analysis of 187 patients]. / Reiterov sindrom--analiza 187 bolesnika.

The study included 187 patients with positive diagnosis of Reiter's syndrome (RS) examined and treated in the Clinic of Rheumatology of Military Medical Academy in the period of 26 years (1970-1995). There were 176 males and 11 females (16:1) aged from 12 to 65 (average age 28.5) years. The disease diagnosis was made upon the clinical finding of at least two of four RS main features: acute urogenital or enteral infection, arthritis, ophthalmic and mucocutaneous changes. Family disease occurrence was noticed in 5, and juvenile type in 6 patients. HLA-B27 antigen was present in 81.5% patients. In 74.3% patients the urogenital disease type was determined, in 18.2% enterocolitic and in 7.5% initial causative agent was not discovered. Three or two RS main signs were present in approximately same number of patients (42.2% and 42.6%) while all the four disease signs were found in 15% patients. Acute or subacute course was found in 43.8%, recurrent in 34.2% and chronic in 22% patients. Clinically, the disease was revealed in locomotor system, most frequently as the asymmetric oligoartritis localized in lower extremities. Sacroiliac arthritis, partial or more frequently asymmetric mutual, radiologically confirmed, was present in 18.2% patients. Only one patient was with sacroiliitis without peripheral arthritis, pain in heel was present in 31.5%, and dactilitis, more frequently in the feet, in 13.9% patients. Radiological changes were found in 51.8% patients, most frequently in sacroiliac joints and heel bone. Chlamydia trachomatis or genital mycoplasma were isolated in synovial fluid of 33.3% (6/18) patients. The most frequent urogenital change was urethritis (56.7), ophthalmic--conjunctivitis (46.5), and mucocutaneous--balanitis (12.3). Positive damage of heart and kidneys by primary disease was found in 2, i.e. 4 patients, and possible in 7, i.e. 14 patients. No differences in RS clinical demonstration among sexes were observed. Besides conventional therapy, in only 26 (13.9%) patients were applied drugs out of the basic group, so as the radiation synovectomy and surgical methods of treatment.

The features of rheumatoid arthritis in the patients above the age of 60.

Fifty-seven patients with rheumatoid arthritis (RA), who were divided into 2 groups: below 50 and above the age of 60 with the disease onset at the age of 24 to 81 were analyzed. They were treated in the Clinic for Rheumatology between 1985 and 1995. All the patients fulfilled the American Rheumatism Association (ARA) criteria for RA from 1988. The aim of the study was to reveal any specific qualities of RA with the onset at the age above 60 and to compare them with the specific qualities in younger patients in order to come to certain conclusions useful for diagnosis and the treatment. The investigations revealed significant differences in articular and systemic manifestations in the patients with the late onset of RA. The disease onset was often acute, with monoarthritis of the large joints, high erythrocyte sedimentation rate (ESR), increased level of alkaline phosphatase (ALP), and with slow and incomplete remissions. The effect of nonsteroid anti-inflammatory drugs (NSAID-s) was poorer, followed by more frequent adverse effects in the group of patients above 60 than in the younger patients. The administration of gold and D-penicillamine showed no effect in the elderly, and the cytostatic treatment was not also indicated. The complications and relapses occurred more frequently, and remissions were shorter compared to those in the younger patient group.

Endothelium-independent contractile and relaxant responses to histamine in the rabbit aorta and common carotid, mesenteric, renal, and femoral arteries.

1. The role of the vascular endothelium in the relaxant and contractile responses to histamine of the isolated rabbit aorta; common carotid, mesenteric, renal, and femoral arteries; as well as receptor types mediating these responses were analyzed. 2. Histamine (10(-8) to 10(-4) mol/l) contracted resting rings and caused a further concentration-dependent contraction of rings of the arteries precontracted by phenylephrine. 3. Pyrilamine abolished the contractile response to histamine in resting rings of the arteries, whereas it reversed that response into a concentration-dependent relaxant response in precontracted rings of the arteries. The relaxant effect of histamine was abolished by metiamide, but it was not affected by sotalol and atropine. Moreover, in control experiments, the phenylephrine-induced contractions and acetylcholine-induced relaxations were not changed by pyrilamine and metiamide, respectively. 4. Endothelial removal did not influence the contractile and relaxant responses of the arteries to histamine. 5. These findings indicate that, in the isolated rabbit aorta and common carotid, mesenteric, renal, and femoral arteries, the contractile effect of histamine resulting from the activation of H1 receptors overcomes its relaxant effect resulting from the activation of H2 receptors. The effects of histamine are neither mediated nor modulated by the endothelial cells.

Treatment of rheumatoid arthritis with radionuclide combination.

Radiation synovectomy (RSIN) with radionuclide combination (N) was performed in 135 patients with rheumatoid arthritis or 417 joints: 155 knee joints (90Y), 230 MCF or PIF joints (169Er), 17 ankle, 7 wrist, 6 elbow and 2 shoulder joints (186Re). Therapeutic effect was followed up during 8 year period. After 3 years positive effect of the treatment was achieved in 70-80% of cases and complete treatment in 50-60% of cases, while 8 years later the same effects were maintained in 55-60%, i.e. 35-40% of the treated joints. The best effect was achieved in the treatment of the knee and the worst in the treatment of the wrist joint. At simultaneous application of one or several different RN, the total dose for one patient did not exceed 259 MBq while the maximum dose was 695 MBq during the long-term treatment.