PROCEEDINGS
INTERNATIONAL CONFERENCE ON MEDICAL, CHEMICAL AND PHARMACEUTICAL SCIENCES
OCTOBER26 - 28
UBT InnovationCampus
Leadership and InnovationEducation | Research | Training | Consulting | Certification
7 UBT ANNUAL INTERNATIONALCONFERENCE
th
Proceedings of the 7th Annual International Conference
International Conference Medical, Chemical and
Pharmaceutical Sciences
Edited by
Edmond Hajrizi
October, 2018
Conference Book of Proceedings
International Conference
Pristina, 26-28 October 2018
© UBT – Higher Education Institution International Conference on Business, Technology and
Innovation
Pristina, Kosovo 26-28 October 2018
Editor: Edmond Hajrizi
Organizing Committee: Edmond Hajrizi, Murat Retkoceri, Hasan Metin, Bertan Karahoda, Eda Mehmeti, Xhemajl Mehmeti, Betim Gashi, Muhamet Sherifi, Muhamet Gërvalla, Bejtush Ademi, Artan Mustafa, Mimoza Sylejmani, Valon Dërguti, Visar Krelani, Krenare Pireva, Anisa Rada, Alisa Sadiku, Jorida Xhafaj, Vjollca Shahini, Rineta Jashari, Vjosa Hamiti, Mirlinda Reqica, Lirigzona Morina, Milot Reqica, Arbër Salihu, Eltis Sulejmani
Authors themselves are responsible for the integrity of what is being published. Copyright © 2018 UBT. All rights reserved.
Publisher, UBT
ISBN 978-9951-437-80-6
1
Editor Speech of IC - BTI 2018
International Conference is the 7th international interdisciplinary peer reviewed
conference which publishes works of the scientists as well as practitionersi n the area
where UBT is active in Education, Research and Development.
The UBT aims to implement an integrated strategy to establish itself as an
internationally competitive, research-intensive institution, committed to the transfer of
knowledge and the provision of a world-class education to the most talented students
from all backgrounds. It is delivering different courses in science, management and
technology.
This year we celebrate the 17th Years Anniversary.
The main perspective of the conference is to connect the scientists and practitioners
from different disciplines in the same place and make them be aware of the recent
advancements in different research fields, and provide them with a unique forum to
share their experiences. It is also the place to support the new academic staff for doing
research and publish their work in international standard level.
This conference consists of sub conferences in different fields:
- Management, Business and Economics
- Humanities and Social Sciences (Law, Political Sciences, Media and
Communications)
- Computer Science and Information Systems
- Mechatronics, Robotics, Energy and Systems Engineering
- Architecture, Integrated Design, Spatial Planning, Civil Engineering and
Infrastructure
- Life Sciences and Technologies (Health and Food)
This conference is the major scientific event of the UBT. It is organizing annually and
always in cooperation with the partner universities from the region and Europe.
In this case as partner universities are: University of Tirana – Faculty of Economics,
University of Korca. As professional partners in this conference are: Kosova
Association for Control, Automation and Systems Engineering (KA – CASE), Kosova
Association for Modeling and Simulation (KA – SIM), Quality Kosova, Kosova
Association for Management.
This conference is sponsored by EUROSIM - The European Association of
Simulation.
We have to thank all Authors, partners, sponsors and also the conference organizing
team making this event a real international scientific event. This year we have more
application, participants and publication than last year.
Congratulations!
Edmond Hajrizi,
Rector of UBT and Chair of IC - BTI 2018
2
CONTENTS Increased risk of falling of elderly men .............................................................................. 3 Altin Erindi .......................................................................................................................................... 3
Impact of Psychosocial Factors on Postpartum Depression of Mothers ........................... 16 Anita Sadikaj1, Artemisi Shehu2 ........................................................................................................ 16
Cranial Injuries with Screwdriver – UCCK ...................................................................... 22 Besnik Elshani¹, Salih Krasniqi¹ .......................................................................................................... 22
Nursing Care in Children with Type 1 Diabetes Mellitus ................................................ 27 Doruntina Ismaili1,Fëllënza Spahiu2,Lirije Beqiri2,Afërdita Berisha2 .................................................. 27
Side effects of metoclopramide (Reglan) oral overdose in pediatric patients ................... 36 Edmont Laho1,,Xhejni Borshi 2, Indrit Bimi3, Eti Muharremi4 ........................................................... 36
Topic: Evaluation of the appearance of dermatological bullous diseases in the oral cavity
.......................................................................................................................................... 43 Ilma Robo1, Vera Ostreni1, Eriola Meta1, Alert Xhaja2, Saimir Heta3.................................................. 43
RECIPROCAL GENETIC EFFECTS IN WEIGHT AND BLOOD GROUPS ............... 54 Naser Kamberi1 , Hyzer Rizani2 .......................................................................................................... 54
The impact end therapeutic efficacy of chlorhexidine-gel in gingival inflammation in
chronic Periodontopathy .................................................................................................. 60 Sahmedin Sali¹,.................................................................................................................................. 60
Topic: Gastro-oesophageal reflux,some data on diagnosis and clinical evaluation .......... 70 Saimir Heta, Kastriot Haxhirexha, Virtut Velmishi, Nevila Alliu, Ilma Robo ....................................... 70
Echocardiography in emergency room ............................................................................. 81 Sejran Abdushi1, Fadil Kryeziu1, Shpend Abdushi2............................................................................. 81
3
Increased risk of falling of elderly men
Altin Erindi
Introduction.
Obesity is recognized as a major health problem in many parts of the world and the incidence of
the condition is escalating at an alarming rate (1, 2). The global trend of increasing obesity
indicates that current measures in preventing, treating and managing the condition are ineffective
(3). Obesity significantly increases the risk of developing numerous medical conditions including
hypertension, stroke, respiratory disease, type 2 diabetes, gout, osteoarthritis, certain cancers and
various musculoskeletal disorders, particularly of the lower limbs and feet (4, 5). Despite
significant advances in our knowledge and understanding of the multi-factorial nature of the
condition, many questions regarding the specific consequences of the disease remain
unanswered.
Intense, short lasting muscle exertions are required frequently during everyday activities.
Obviously examples are when rising form a chair or ascending stairs. These exertions depend
upon the ability of the muscles to generate power, which involves the product of contractile force
and concentration velocity (i.e., speed of movement ;) (33). In younger people such movements
are normally trivial, but they may become challenging for the elderly person, since muscle power
deteriorates with aging (44)
The age-related decrease in muscle power is more pronounced than the decrease in muscle
strength (3.5% versus 1.5-2% per year from the age of 65 years ;) (44). Therefore, the decreased
muscle power may predispose a person to a higher risk of functional limitations in everyday
activities than is implied by the loss in muscle strength (16, 17, and 45).
Relative to the extensive literature now available on many aspects of the obese condition, there
is a dearth of information pertaining to the functional limitations imposed by overweight and
obesity. Subjective references have been made to the difficulties encountered by the overweight
and obese when executing simple activities of daily living (6). However, the implications of
persistent obesity on the musculoskeletal and locomotor’s systems, particularly
during weight bearing tasks such as walking and stair climbing, are poorly understood. To date,
the study of locomotor tasks has focused predominantly on normal weight individuals and
particularly those without physical disabilities associated with obesity. The limited number of
published studies focusing on the obese have encompassed the locomotor characteristics of obese
adults, plantar pressures under the feet of the obese, the influence of obesity on muscular strength
and power, and the potential relationships between obesity and postural control.
In spite of significant advances in the knowledge and understanding of the multifactorial nature
of obesity, many questions regarding the specific consequences of the disease remain
unanswered. In particular, there is a relative dearth of information pertaining to the functional
limitations imposed by overweight and obesity. The limited number of studies, to date, has been
mainly focused on the effect of obesity on the temporo-spatial characteristics of walking, plantar
foot pressures, muscular strength and, to a lesser extent, postural balance. Collectively, these
studies have implied that the functional limitations imposed by the additional loading of the
locomotor system in obesity result in aberrant mechanics and the potential for musculo-skeletal
injury. Despite the greater prevalence of musculoskeletal disorders in the obese, there has been
surprisingly little empirical investigation pertaining to the biomechanics of activities of daily
living or into the mechanical and neuromuscular factors that may predispose the obese to injury.
A better appreciation of the implications of increased levels of body adiposity on the movement
4
capabilities of the obese would afford a greater opportunity to provide meaningful support in
preventing, treating and managing the condition and its sequelae. Moreover, there is an urgent
need to establish the physical consequences of continued repetitive loading of major structures
of the body, particularly of the lower limbs in the obese, during the diverse range of activities of
daily living.
Effects of obesity on musculoskeletal function.
Research into the effect of adiposity on musculoskeletal function has largely focused on the
impact of obesity on the locomotor characteristics of adults and, to a lesser extent, focused on the
influence of increased fat mass on muscular strength and postural balance. Although in its
infancy, recent research has also investigated the movement strategies adopted by the overweight
and obese in performing activities of daily living, such as moving from a seated to standing
position.
Muscular strength and power Impaired muscle strength has been linked with complaints
involving the lower back and legs (7) and in the development of osteoarthritis of the knee (8, 9).
Although research has generally indicated that obese adults present with greater absolute strength
and power of muscles of the trunk and lower extremity (10, 11), the effect appears to be highly
site-specific. Studies evaluating both isometric and isokinetic knee extensor strength have
consistently reported superior absolute strength in obese individuals (10, 12, 13), whereas
absolute knee flexion strength has been reported to be either similar (10) or reduced (13) when
compared with normal-weight individuals. Likewise, the effects of obesity on absolute grip
strength appear equivocal, with studies reporting either increased (12), decreased (14) or no
difference in absolute grip strength (10) between obese and non-obese adults. However,
anthropometric factors, such as muscle morphology, appear to be the major determinants of age-
and gender-related differences in muscle strength (15–18). Consequently most clinical
investigations have adjusted for the increase in fat-free mass associated with obesity by
employing simple ratio standards in which strength is expressed relative to body weight or lean
body weight (9, 12, 14, and 19). In contrast to measures of absolute strength, obese subjects have
reduced isometric (~11–16%) and isokinetic knee extensor strength when adjusted for body
weight and compared with normal-weight subjects (12, 14, and 20). Although the rationale
underlying the normalization of strength measures based on simple ratio standards has been
recently questioned (21), more complex allometric approaches, in which knee strength was
expressed as an exponent of body weight, have reported similar reductions (~ 6%) in relative
knee extensor strength with obesity (10). Reductions in trunk extension (~10%), knee flexion (~
20%) and handgrip strength (~10%) have also been reported in the obese when the data were
corrected for differences in fat-free mass using allometric scaling (10).
It would appear, therefore, that even with the purported training effect and subsequent
hypertrophy incurred by lower extremity muscles in supporting and moving the additional mass
of adipose tissue (22, 23), obesity is characterized by reduced muscular strength. Hulens et al.
(10), in comparing the relative strength of the trunk, knee and hand in obese and non-obese
women, proposed that the relative reduction in strength observed in the obese was indicative of
impaired muscle function, rather than reduced physical activity, and was likely the consequence
of an altered metabolic state in obesity. In support of this concept, the hypertrophic muscle fibres
observed in obese adults have been shown to have a reduced oxidative capacity (24, 25), which
may, in part, reflect a decreased capillary density (26). Although suggestive of a lowered
muscular endurance in the obese, animal studies have indicated that the oxidative capacity of
muscle is positively influenced by physical activity (27) and, as such, the lower oxidative capacity
noted in muscle fibres of obese humans may reflect a lower level of physical activity within this
population. Moreover, Blimkie et al. (20) found no difference in the intrinsic strength or
5
contractile properties of the extensor muscles of the knee in obese and normal weight adolescents
when evoked via percutaneous stimulation. The authors subsequently attributed the lower knee
extension strength observed during maximum voluntary contraction in the obese to a reduced
neuromuscular activation of motor units. Motor unit activity, in turn, has been reported to be
dependent on several factors including motivation and physical activity level (22). The impaired
strength associated with obesity therefore appears to reflect a lower level of activity in association
with an increase in non-contributory mass. While it is recognized that inadequate muscular
strength, particularly of the lower limbs, can limit individuals from successfully performing
everyday tasks and predispose to a greater risk of fatigue and musculoskeletal injury (7), further
research into the long-term effect of reduced motor performance seems warranted.
Postural balance.
Research investigating the effect of adiposity on postural balance in adults is limited and, to date,
has primarily focused on measures of antero-posterior stability during bipedal stance (28–30).
Kejonen et al. (28) investigated the relationship between non-vestibular factors, such as body
anthropometry, on performance in tests of postural equilibrium in 100 healthy adults. Body mass
index (BMI) was the only characteristic that correlated with the antero-posterior movement of
the ankle during quiet bipedal stance. Similarly, Fregly et al. (31) identified abdominal
circumference, endomorphy and body weight as the most important factors influencing the
performance of military recruits on postural tests. The authors proposed that, in overweight
individuals, body size and shape influenced static postural stability by altering the location of the
centre of gravity. In support of this notion, Corbeil et al. (30), using a 15- segment model of the
body to investigate the effect of obesity on antero-posterior stability during bipedal stance,
indicated that with an anterior displacement of the centre of mass (2cm), a significantly greater
ankle torque was required to stabilize the body. Although a similar, but lesser, effect on ankle
torque was also noted with an increase in fat mass alone, the authors hypothesized that an anterior
displacement of the centre of mass would place obese individuals closer to their boundaries of
stability and, as such, at greater risk of falling when exposed to daily postural stress and
perturbations. However, Gravante et al. (29) found no difference in the location of the centre of
pressure during bipedal stance in 38 obese and 34 non-obese adults when measured via a force
platform. Thus, the authors suggested that, despite obese subjects presenting with an increased
waist-to-hip circumference ratio, the distribution of body fat did not appear to result in an anterior
displacement of the centre of mass during quiet stance.
Although largely untested, it seems logical that the increased antero-posterior sway observed
with obesity likely represents a limitation of controlling the inertial properties associated with
greater fat mass, rather than an impaired postural control system itself. By modifying muscle
activation patterns within the lower limb, both cutaneous and load receptor input are important
for the maintenance of bipedal stance and locomotion (32–34). In particular, the strength of leg
extensor muscle activation is dependent on load (35), with a reduced sensitivity to loading also
implicated in the development of certain movement disorders (36). There is also evidence that
the timing of neuromuscular responses has a profound influence on measures of postural sway
(37), by presumably altering the joint torque required to stabilize the body (30). In support of this
concept, Ledin and Odkvist (38) demonstrated a greater sway area, and slower sway velocity,
when normal-weight individuals were required to stand with added weight (20% body weight)
distributed evenly about the trunk. Similarly, Sartotio et al. (39) reported an improved time for
one-legged standing balance in 230 obese adults (BMI: 31.1– 65.8 kg m2 ) following a weight
loss programme consisting of a reduced caloric diet in conjunction with a low-intensity exercise
programme. In the absence of a control group, however, it is difficult to attribute the improved
performance on the balance task solely to a reduction in fat mass, especially because the improved
6
motor control may also represent a training effect (40, 41). While obesity has been shown to
induce a relative reduction in the strength of lower limb muscles once adjustments are made for
body weight (12, 14), the influence of adiposity on the state of the sensory-motor system has not
been established within the literature.
To date, most studies investigating postural control in the obese have employed cross-sectional
study designs and have not considered the potentially confounding effects of physical activity.
Physical activity status has been shown to have a profound influence on balance performance in
adults (42), and as such may obfuscate the effect of obesity on postural control. Given the
association between obesity and physical inactivity (43–46), it is unclear whether the additional
mass associated with obesity results in reduced postural stability, or alternately, whether the
greater adiposity of the obese is the consequence of postural instability and reduced activity.
There is also limited information regarding the regulation of medio-lateral balance in adult
obesity, despite its considerable importance to dynamic activities such as gait. Given that
epidemiological research has indicated a potential link between obesity and risk of falling (47),
further research employing a longitudinal study design in conjunction with measures of physical
activity may provide greater insight into the effects of obesity on postural balance in adults.
Reductions in step length and step frequency also noted (13, 56, and 57). In addition to a reduced
walking speed, a longer stance phase duration, shorter swing phase and a greater period of double
support have also been reported when compared with normal-weight individuals (56, 57).
Messier et al. (59) proposed that the greater prevalence of lower limb injuries in the obese was
the result of altered frontal plane mechanics of the foot and lower limb during gait. More recent
research involving the overweight and obese, however, has demonstrated that plantar pressures
are moderately dependent on body weight (29, 54).
Despite having larger footprint contact areas (~10%), Gravante et al. (29) observed that peak
pressures were 40–45% higher in obese subjects during stance, when compared with normal-
weight subjects, for men and women respectively).
Our aim.
The aim of this paper is to understand the effects of overweight or obesity on the lower limbs
during a simple Counter Movement Jump and Squat Jump. It is one of the key issues that may
challenge the overweight and obese when completing activities of daily living, including one the
most fundamental of voluntary movement patterns, jumping, reversing a movement during a
forward fall.
Because of the scale of the problem of obesity and the relative paucity of information available,
there is an urgent need to focus more attention on the physical consequences of repetitive loading
of major structures, particularly the lower extremity.
Material and Method
Subjects.
Community-dwelling elderly people 10 obese of average age of 58.6 years and 10 of normal
weight of average age of 60.9 years, with no statistically significant differences. A medical doctor
performed a medical evaluation, including an electrocardiogram and anamnesis, in order to
exclude any disease that could interfere with the tests. Subjects taking medication were only
included in the experiment if they were medically stable. At the time of the experiment the
7
subjects did not participate in any regular physical activity. All the subjects gave their informed
written consent to participate, and the local ethical committee approved the study.
Measurements
Anthropometry
Anthropometric data are reported in Table 1. The measures were done using calibrated measuring
appliances and standard methods of measuring. The height of subjects was measured in
centimeters (cm) by height gauge to the nearest 0, 5 cm and body mass and weight was assessed
in kilograms (kg) using the medical digital scales, with participants lightly dressed. Body mass
index (BMI) was calculated using the formula: BMI = weight in kilograms divided by square of
height in meters (kg/m2). We considered BMI as overweight when 25< BMI<30 kg/m2, and as
obesity when BMI>30 kg/m2. The Waist circumference was measured to the nearest 0, 5 cm with
a Gulick Handle in the level of the biiliac crestae.
Muscle power
Muscle power was assessed during a standardized both-legs counter-movement jump performed
on an Ergojump, a Bosco System licensed platform (Figure 1). Starting from a standing position.
The subjects (who were wearing comfortable shoes) were instructed to perform a fast downward
movement (to about 90o knee flexion) immediately followed by a fast upward movement, and to
jump as high as possible. Hands were kept on the hips to minimize any influence of the arms.
The jump was demonstrated to the subject, who subsequently performed two submaximal trials.
Following a short rest, three maximal jumps were performed at 1-min intervals, and the highest
jump was selected for further analysis.
Also the squat jump was performed after the subjects were instructed to perform the jump starting
from the position of half sitting (with the knee flexion of about 90o ) immediately followed by a
fast upward movement and to jump as high as possible. Hands were also kept on the hips to
minimize any influence of the arms. The jump was demonstrated to the subjects, who
subsequently performed two submaximal trials. Following a short rest, three maximal jumps were
performed at 1-min intervals, and the highest jump was selected for the analysis.
Figure 1. Methodology of
assessing the muscle power,
height, and contact time during
a standardized both-legs
counter-movement jump and
squat jump performed on an
Ergojump, a Bosco System
licensed platform.
Statistics: average, standard deviation, t-test, correlation. Descriptive measures were calculated for
all variables using a statistical package for social sciences (SPSS 15 for Windows XP). All the
data were tested for their normal distribution. Results are expressed as average ± SD and p<0.05
was considered statistically significant. For all parameters, a systematic bias between days was
assessed with a Student's t-test. Differences between jump types were investigated by using a
paired t-test.
8
Results
Table 1. Physical anthropometric characteristics of the subjects that participated in these
tests. The data are given as the average and standard deviation.
Table 2. Physical plyometric characteristics of the subjects that participated in these tests.
The data are given as the average and standard deviation.
Discussion.
The obese subjects have nearly the same muscle mass as those that have a norm weight, only that
they have to bear much more than the muscles, their adipose tissue, in their everyday life. This
predispose obese subjects to a greater and earlier risk of loss of independence than their peer
normal weight subjects during aging, and may present an important factor for the falls. Weight-
bearing tests, which appear more relevant for evaluating functional capacity, have rarely been
used to assess muscle power in healthy elderly people.
The power, produced by the muscle during the everyday life is closely related with the time
necessary for producing it. Only a 200 msec contact time interval discriminates the fallers from
the non fallers (65), normally it is necessary a 300 – 500 msec ground contact time to reach peak
force in human skeletal muscle (66, 62) and up to 1500 msec time to reach peak force during
multi-joint motor tasks in elderly subjects. This meaning that the elderly subjects are more prone
Characteristic Obese
(n=10)
SD Normal weight (n=10) SD
Age (years) 58.60 5.94 60.90 5.43
Height (cm) 167.80 6.91 168.60 5.85
Weight (kg) 92.60 10.72 64.40 5.61
BMI (kg*m-2) 32.88 3.09 22.65 1.40
Waist Circumference (cm)
111.80 8.84 89.85 3.89
Characteristic Obese
(n=10)
SD Normal weight
(n=10)
SD
SJ time (ms) 757.00 82.33 497.80 37.66
SJ high (cm) 21.51 0.95 23.30 3.01
CMJ Time (ms) 718.50 84.84 446.10 20.53
CMJ (cm) 26.65 4.87 28.65 3.78
∆ Jump-height (CMJ-SQJ) 5.15 4.49 5.35 3.84
Power out-put (W*kg-
1) 16.75 0.93 18.13 1.78
Total Power out-put (W)
1554.11 223.41 1172.34
194.12
9
to fall due to the fact that they cannot react in time to reverse a falling or a stair climbing or other
everyday situations.
Between the two groups there was no statistically significant difference for the age and the height,
and the power produced for kilogram.
The jump height is higher in lean subjects compared with obese, but it is statistically significantly
different (p<0.002), and the power produced is much higher from the obese subjects for the same
jump have to produce more energy.
To compare the two jump types, only their respective concentric phases were considered. In the
CMJ, the concentric phase was defined as the time period of upward movement of the Center of
Mass, while this phase constituted the entire push-off phase in the SJ. Peak power was determined
in the concentric phase of the Counter Movement Jump.
Maximal jump height was greater in countermovement jump (CMJ) compared with squat jump
(SQJ), yielding an augmentation in jump height from SQJ to CMJ ( jump-height CMJ-SQJ) of 5.15
cm for obese people and 5.35 cm for norm weight people. Maximal jump height for the obese
subjects was significantly greater for CMJ compared with SQJ [28.66 (SD 3.78) vs. 23.30 (SD
3.01) cm, P < 0.01], yielding a jump-height CMJ-SQJ of 5.35 cm with a SD of 3.84 cm (Table 2).
Maximal jump height for the lean subjects was significantly greater for CMJ compared with SQJ
[26.65 (SD 4.87) vs. 21.51 (SD 0.95) cm, P < 0.01], yielding a jump-height CMJ-SQJ of 5.15 cm
with a SD of 4.49 cm (Table 2).
Peak power output was different between obese and normal weight people. The obese men
produced a higher total power output than those of normal weight, but the reduced muscle power
per kg of weight of obese man as we see from the results obtained, during aging, make them more
prone than norm weight subjects to experience a reduced ability in managing simple everyday
activities. This may result in pronounced differences in the ability to cope with more demanding,
including various “emergency situations” where rapid executions and high muscle forces are
required (e.g. when regaining balance after tripping or a quick stop to avoid unexpected obstacles)
(63, 64).
Eccentric muscle actions often precede concentric contractions during everyday movements
based on a normal control strategy. The mechanical output of such coupled eccentric muscle
actions and concentric contractions is known to be superior to isolated concentric contractions
(50, 51). This fact is frequently utilized during everyday activities (e.g. when climbing a relatively
high step, as when alighting a bus). Eccentric muscle actions are also used frequently to control
or attenuate impact forces (e.g. when stepping down from a stair or sidewalk, when providing
stabilization during locomotion, or when trying to reverse the movement during a forward
fall)(52).
Although not tested, it seems logical that the increased antero-posterior sway observed with
obesity likely represents a limitation of controlling the inertial properties associated with greater
fat mass, rather than an impaired postural control system itself.
There is also evidence that the timing of neuromuscular responses has a profound influence on
measures of postural sway (37), by presumably altering the joint torque required to stabilize the
body (30).
Other factors, including an anterior tilt of the upper body, an altered step frequency, greater
vertical displacement of the centre of mass and extraneous movements resulting from greater
limb dimensions have also been hypothesized to reduce the mechanical efficiency of walking in
the obese, thereby increasing the metabolic cost of the task (55, 60, and 61). The excessive rear
foot movement associated with obesity might place additional strain on musculo-tendinous
structures of the lower limb, thus increasing the likelihood of injury. However, despite the
reduction in walking speed, BMI was still moderately correlated with the impact force and the
absolute force maxima (N) measured within the vertical and horizontal force components.
The greater adiposity tissue might contribute to the development of knee osteoarthritis by
impairing the ability of the obese to attenuate vertical load.
10
The finding that BMI and absolute vertical reaction force are positively correlated is not
surprising given the Newtonian association between body mass and ground reaction force.
Also in normal-weight subjects, the sit-to-stand tasks were characterized by a forward trunk
flexion, which resulted in a hip joint torque that was approximately twice that of the knee. Obese
subjects, however, adopted a different movement strategy to complete the sit-to-stand task that
was characterized by reduced trunk flexion and a posterior movement of the feet from their initial
position. The alternative strategy effectively limited the torque at the hip but at the expense of a
heightened knee joint moment, which was almost double that observed in normal-weight adults
(Figure 2). the limited trunk flexion and greater ankle dorsi-flexion that was characteristic of the
obese was evident only at the beginning of the movement task as previously reported in similar
tasks that involve the sitting in a chair etc. Galli et al (58) said that there is evidence that the
increased mass associated with obesity contributes to a relative reduction in muscle strength in
the obese (10), and presumably greater muscle fatigue.
Figure 2. Illustration of jumping strategies adopted by normal-weight and
obese individuals. (a) In normal-weight individuals, the sit-to-stand
movement is characterized by a forward flexion of the trunk, resulting in a
hip joint torque (solid arrow) approximately twice that of the knee (hollow
arrow). (b) In contrast, the obese strategy is characterized by reduced trunk
flexion and a posterior movement of the feet (D¢) resulting in relatively
low hip joint torque (solid arrow) but a knee joint moment (hollow arrow)
approximately double that observed in normal-weight adults. (From
Wearing et al 2006) (48).
It has previously been discussed whether the increase in jump height that
occurs when an eccentric contraction precedes the concentric push-off
phase (i.e., difference in jump height in SQJ vs. CMJ) is due to "elastic
energy recoil" by means of release of energy stored in the connective tissue
during the eccentric phase (50, 51), or whether jump height enhancement occurs due to a
potentiating effect on joint torque in the initial concentric phase resulting from the preceding
eccentric contraction (59). In the present study, this issue was addressed by correlating the
enhancement in jump height from SQJ to CMJ to the elastic properties of the tendinous structures
and the energy storage during the entire ramp contraction (0–90% MVC). (35). No relation was
observed between jump-height CMJ-SQJ and the elastic properties of the aponeurosis-tendon
structures, indicating that, at least for the knee extensor muscles, the increase in jump height with
CMJ is mainly associated with the increased force output in the initial push-off phase that is a
result of the preceding eccentric loading phase, which thus optimizes the kinetic impulse in the
push-off phase. This observation is in line with the observations of Zajac (53) Jump performance
is logically evaluated by jump height, but, because jumping is a highly complex movement task,
the ground reaction force signal was examined in detail to elucidate the mechanical characteristics
of the jump (49, 52). Maximal jump height is mainly determined by the power generated by the
knee extensor muscles during the concentric push-off phase (35). The jump height was associated
with connective tissue stiffness, and, combined with the observed relations between jump height,
contact time with the ground before the take-off, force and velocity, it seems that also in complex
movement tasks that include dynamic muscle actions such as jumping, the ability of the
connective tissue to transmit force effectively (i.e., stiffness) from the contracting elements to the
bone has importance for optimal jump performance (35).
Previous studies have emphasized the importance of correcting for scale when comparing
measures of physical performance to avoid influence of body size. The present data were
normalized to body mass.
11
The possibility exists, that obese man may be affected by their weight more than norm weight
subjects during explosive movements involving the small muscles groups.
The correlation coefficient between the waist circumference and the CMJ contact time is -0.701
but only in obese subjects, correlation that is not very high, but enough to understand the fact that
there is a connection between the two parameters. This maybe due to the changes of the position
in the Center of Mass (30) as found from Corbeil et al.
So, obesity significantly increases the risk of developing numerous medical conditions including
hypertension, stroke, respiratory disease, type 2 diabetes, gout, osteoarthritis, certain cancers and
various musculoskeletal disorders, particularly of the lower limbs and feet (4,5), but also make
this subjects to bear with them in their everyday life all this weight that makes them be at higher
risk of falling and suffer form fractures or other traumatologic problems. The test-retest reliability
for the reaction tests were lower (r ranging from 0.72 to 0.83). Hoffman & Kang found that the
results indicate that this testing device (Ergojump System) shows high test-retest reliability (r = 0.90), to assess CMJ height. In addition, anaerobic power assessment in a jump test provides
a specific measure of anaerobic power for many sports incorporating similar performance
patterns (67).
Conclusions.
The marked lower capacity for concentric contractions in obese man may result in an impaired
performance, especially in activities where intense and rapid movements are essential, for
example when reversing a forward fall. This may be one reason why obese elderly man are more
prone to falls than normal weight men, due to this they try to walk slower and doing so they use
less energy in their daily living with the result of more adipose tissue to carry during their life.
Perspectives.
A further understanding of the phases of the movement would be beneficial for the development
of specific training programs for preventive and rehabilitative strategies for the obese elderly
people. The necessity, to have at our lab, the equipment for EMG and Plate forces, for a better
testing of the SJ and CMJ.
Acknowledgements.
I would like to thank the volunteers that participated in the study. The chief of the department of
sport medicine of the Albanian University of Sport Sciences and Bashkim Delia and Perparim
Ferunaj for helping with the subjects and the testing procedures.
References
1. National Health and Medical Research Council. Acting on Australia’s Weight: A
Strategy for the Prevention of Overweight and Obesity. Australian Government
Publishing Service: Canberra, 1997.
12
2. World Health Organization. Obesity: Preventing and Managing the Global Epidemic.
Report of a WHO Consultation on Obesity. WHO: Geneva, 1998.
3. British Nutrition Foundation. Obesity. Blackwell Science: London, 2000.
4. James WP. A public health approach to the problem of obesity. Int J Obes Relat
Metab Disord 1995; 19: S37–S45.
5. Must A, Strauss RS. Risks and consequences of childhood and adolescent obesity.
Int J Obes Relat Metab Disord 1999; 23: S2– S11.
6. Hills AP, Wahlqvist ML. Exercise and Obesity. Smith-Gordon: London, 1994.
7. Karvonen MJ, Viitasalo JT, Komi PV, Nummi J, Jarvinen T. Back and leg
complaints in relation to muscle strength in young men. Scand J Rehabil Med 1980;
12: 53–59.
8. Slemenda C, Heilman DK, Brandt KD, Katz BP, Mazzuca SA, Braunstein EM, Byrd
D. Reduced quadriceps strength relative to body weight: a risk factor for knee
osteoarthritis in women? Arthritis Rheum 1998; 41: 1951–1959.
9. Brandt KD, Heilman DK, Slemenda C, Katz BP, Mazzuca S, Braunstein EM, Byrd
D. A comparison of lower extremity muscle strength, obesity, and depression scores
in elderly subjects with knee pain with and without radiographic evidence of knee
osteoarthritis. J Rheumatol 2000; 27: 1937–1946.
10. Hulens M, Vansant G, Lysens R, Claessens AL, Muls E, Brumagne S. Study of
differences in peripheral muscle strength of lean versus obese women: an allometric
approach. Int J Obes Relat Metab Disord 2001; 25: 676–681.
11. Sartorio A, Proietti M, Marinone PG, Agosti F, Adorni F, Lafortuna CL. Influence of
gender, age and BMI on lower limb muscular power output in a large population of
obese men and women. Int J Obes Relat Metab Disord 2004; 28: 91–98.
12. Miyatake N, Fujii M, Nishikawa H, Wada J, Shikata K, Makino H, Kimura I.
Clinical evaluation of muscle strength in 20–79-years-old obese Japanese. Diabetes
Res Clin Pract 2000; 48: 15–21.
13. Hulens M, Vansant G, Claessens AL, Lysens R, Muls E. Predictors of 6-minute walk
test results in lean, obese and morbidly obese women. Scand J Med Sci Sports 2003;
13: 98–105.
14. Kitagawa K, Miyashita M. Muscle strengths in relation to fat storage rate in young
men. Eur J Appl Physiol Occup Physiol 1978; 38: 189–196.
15. Hulens M, Vansant G, Lysens R, Claessens AL, Muls E. Assessment of isokinetic
muscle strength in women who are obese. J Orthop Sports Phys Ther 2002; 32: 347–
356.
16. Bassey EJ (1997) Measurement of muscle strength and power. Muscle nerve suppl
5; S44-S46.
17. Bassey EJ, Fiatarone MA, O’Neill EF, Kelly M, Evans W, Lipsitz LA (1992) Leg
extension power and functional performance in very old men and women. Clin Sci
82; 321-327.
18. Neder JA, Nery LE, Shinzato GT, Andrade MS, Peres C, Silva AC. Reference values
for concentric knee isokinetic strength and power in nonathletic men and women
from 20 to 80 years old. J Orthop Sports Phys Ther 1999; 29: 116–126.
19. Miyatake N, Nishikawa H, Fujii M. Clinical evaluation of physical fitness in male
obese Japanese. Chin Med J 2001; 114: 707–710.
13
20. Blimkie CJ, Sale DG, Bar-Or O. Voluntary strength, evoked twitch contractile
properties and motor unit activation of knee extensors in obese and non-obese
adolescent males. Eur J Appl Physiol Occup Physiol 1990; 61: 313–318.
21. Davies MJ, Dalsky GP. Normalizing strength for body size differences in older
adults. Med Sci Sports Exerc 1997; 29: 713– 717.
22. Wadström C, Larsson L, Knutsson E, Edström L. The effect of excessive weight loss
on skeletal muscle in man: a study of obese patients following gastroplasty. Eur J
Surg 1991; 157: 347–354.
23. Kelley DE, Slasky BS, Janosky J. Skeletal muscle density: effects of obesity and
non-insulin-dependent diabetes mellitus. Am J Clin Nutr 1991; 54: 509–515.
24. Newcomer BR, Larson-Meyer DE, Hunter GR, Weinsier RL. Skeletal muscle
metabolism in overweight and post-overweight women: an isometric exercise study
using (31)P magnetic resonance spectroscopy. Int J Obes Relat Metab Disord 2001;
25: 1309–1315.
25. Kirkwood SP, Zurlo F, Larson K, Ravussin E. Muscle mitochondrial morphology,
body composition, and energy expenditure in sedentary individuals. Am J Physiol
Endocrinol Metab 1991; 260: E89–E94.
26. Mandroukas K, Krotkiewski M, Hedberg M, Wroblewski Z, Björntorp P, Grimby G.
Physical training in obese women: effects of muscle morphology, biochemistry and
function. Eur J Appl Physiol Occup Physiol 1984; 52: 355–361.
27. Zoll J, Koulmann N, Bahi L, Ventura-Clapier R, Bigard AX. Quantitative and
qualitative adaptation of skeletal muscle mitochondria to increased physical activity. J
Cell Physiol 2003; 194: 186–193.
28. Kejonen P, Kauranen K, Vanharanta H. The relationship between anthropometric
factors and body-balancing movements in postural balance. Arch Phys Med Rehabil
2003; 84: 17–22.
29. Gravante G, Russo G, Pomara F, Ridola C. Comparison of ground reaction forces
between obese and control young adults during quiet standing on a baropodometric
platform. Clin Biomech 2003; 18: 780–782.
30. Corbeil P, Simoneau M, Rancourt D, Tremblay A, Teasdale N. Increased risk for
falling associated with obesity: mathematical modelling of postural control. IEEE
Trans Neural Syst Rehabil Eng 2001; 9: 126–136.
31. Fregly AR, Oberman A, Graybiel A, Mitchell RE. Thousand aviator study:
nonvestibular contributions to postural equilibrium functions. Aero Med 1968; 39:
33–37.
32. Era P, Schroll M, Ytting H, Gause-Nilsson I, Heikkinen E, Steen B. Postural balance
and its sensory-motor correlates in 75- year-old men and women: a cross-national
comparative study. J Gerontol A Biol Sci Med Sci 1996; 51: M53–M63.
33. Kostka Tomasz, Bonnefoy MA, Laurent M, Berthouze SE, Belli AL, Jean-Rene
(1997) Habitual physical activity and peak anaerobic power in elderly women. Eur J
Appl Physiol 76: 81-87.
34. Nurse MA, Nigg BM. The effect of changes in foot sensation on plantar pressure and
muscle activity. Clin Biomech 2001; 16: 719–727.
35. Bojsen-Møller J., Magnusson S. P., L R. Rasmussen, Kjaer M., Aagaard P.
Muscle performance during maximal isometric and dynamic contractions is
14
influenced by the stiffness of the tendinous structures. J Appl Physiol 99:986-994,
2005.
36. Dietz V, Colombo G. Influence of body load on the gait pattern in Parkinson’s
disease. Mov Disord 1998; 13: 255–261.
37. Simmons RW, Richardson C. The effects of muscle activation on postural stability in
diabetes mellitus patients with cutaneous sensory deficit in the foot. Diabetes Res
Clin Pract 2001; 53: 25–32.
38. Ledin T, Odkvist LM. Effects of increased inertial load in dynamic and randomized
perturbed posturography. Acta Otolaryngol 1993; 113: 249–252.
39. Sartorio A, Lafortuna CL, Conte G, Faglia G, Narici MV. Changes in motor control
and muscle performance after a shortterm body mass reduction program in obese
subjects. J Endocrinol Invest 2001; 24: 393–398.
40. Tarantola J, Nardone A, Tacchini E, Schieppati M. Human stance stability improves
with the repetition of the task: effect of foot position and visual condition. Neurosci
Lett 1997; 228: 75– 78.
41. Pintsaar A, Brynhildsen J, Tropp H. Postural corrections after standardised
perturbations of single limb stance: effect of training and orthotic devices in patients
with ankle instability. Br J Sports Med 1996; 30: 151–155.
42. Bulbulian R, Hargan ML. The effect of activity history and current activity on static
and dynamic postural balance in older adults. Physiol Behav 2000; 70: 319–325.
43. Jebb SA, Moore MS. Contribution of a sedentary lifestyle and inactivity to the
etiology of overweight and obesity: current evidence and research issues. Med Sci
Sports Exerc 1999; 31: S534– S541.
44. Skelton DA, Greig CA. Davies JM, Young A (1994) Strength, power and related
functional ability of healthy people aged 65 – 89 years. Age Ageing 23; 371-377.
45. Rantanen T. Avela J. (1997) Leg extension power and walking speed in very old
people living independently. J. Gerontol 52 A; M225-M231.
46. Kvaavik E, Tell GS, Klepp KI. Predictors and tracking of body mass index from
adolescence into adulthood: follow-up of 18–20 years in the Oslo Youth Study. Arch
Pediatr Adolesc Med 2003; 157: 1212–1218.
47. Wallace C, Reiber GE, LeMaster J, Smith DG, Sullivan K, Hayes S, Vath C.
Incidence of falls, risk factors for falls, and fallrelated fractures in individuals with
diabetes and a prior foot ulcer. Diab Care 2002; 25: 1983–1986.
48. Wearing S. C., Hennig E. M. Byrne N. M. Steele J. R. Hills A. P. (2006) The
biomechanics of restricted movement in adult obesity The International Association
for the Study of Obesity. Obesity reviews 7 , 13–24
49. Caserotti P, Aagaard P, Simonsen EB, and Puggaard L. Contraction-specific
differences in maximal muscle power during stretch-shortening cycle movements in
elderly males and females. Eur J Appl Physiol 84: 206–212, 2001.
50. Komi PV and Bosco C. Utilization of stored elastic energy in leg extensor muscles
by men and women. Med Sci Sports Exerc 10: 261–265, 1978.
51. . Cavagna GA. Storage and utilization of elastic energy in skeletal muscle. Exerc
Sport Sci Rev 5: 89–129, 1977.
52. Rittweger J, Schiessl H, Felsenberg D, and Runge M. Reproducibility of the jumping
mechanography as a test of mechanical power output in physically competent adult
and elderly subjects. J Am Geriatr Soc 52: 128–131, 2004.
15
53. Zajac FE. Muscle coordination of movement: a perspective. J Biomech 26, Suppl 1:
109–124, 1993
54. Hills AP, Hennig EM, McDonald M, Bar-Or O. Plantar pressure differences between
obese and non-obese adults: a biomechanical analysis. Int J Obes Relat Metab Disord
2001; 25: 1674–1679.
55. Foster GD, Wadden TA, Kendrick ZV, Letizia KA, Lander DP, Conill AM. The
energy cost of walking before and after significant weight loss. Med Sci Sports Exerc
1995; 27: 888–894.
56. Spyropoulos P, Pisciotta JC, Pavlou KN, Cairns MA, Simon SR. Biomechanical gait
analysis in obese men. Arch Phys Med Rehabil 1991; 72: 1065–1070.
57. DeVita P, Hortobágyi T. Obesity is not associated with increased knee joint torque
and power during level walking. J Biomech 2003; 36: 1355–1362.
58. Galli M, Crivellini M, Sibella F, Montesano A, Bertocco P, Parisio C. Sit-to-stand
movement analysis in obese subjects. Int J Obes Relat Metab Disord 2000; 24: 1488–
1492.
59. Messier SP, Davies AB, Moore DT, Davis SE, Pack RJ, Kazmar SC. Severe obesity:
effects on foot mechanics during walking. Foot Ankle Int 1994; 15: 29–34.
60. Katch V, Becque MD, Marks C, Moorehead C, Rocchini A Oxygen uptake and
energy output during walking of obese male and female adolescents. Am J Clin Nutr
1988; 47: 26–32.
61. Volpe Ayub B, Bar-Or O. Energy cost of walking in boys who differ in adiposity but
are matched for body mass. Med Sci Sports Exerc 2003; 35: 669–674.
62. Thorstensson A. Grimby G. and Karlsson J. Force-velocity relations and fiber
composition in human knee extensor muscles. J. Appl Physiol 40: 12-16, 1976.
63. Dutta C. Significance of sarcopenia in the elderly . J. Nutr 127: 992S-993S, 1997.
64. Schultz AB, Ashton-Miller JA, Alexander NB, What leads to age and gender
differences in balance and recovery? Muscle Nerve Suppl 5: S60-S64.
65. Pijnappels M, Bobbert MF, and van Dieën JH. How early reactions in the support
limb contribute to balance recovery after tripping. J Biomech 38: 627–634, 2005.
66. Sukop, J, and Nelson RC. Effects of isometrical training on the force-time
characteristics of muscle contractions. In: Biomechanics IV. Champaign, IL: Human
Kinetics, 1974, p. 440-447.
67. Hoffman J. R., Kang J. Evaluation of a New Anaerobic Power Testing System. The
J. of Streng. and Condit. Res.: (2002) Vol. 16, No. 1, pp. 142–148.
16
Impact of Psychosocial Factors on Postpartum
Depression of Mothers
Anita Sadikaj1, Artemisi Shehu2
1 UBT-Higher Education Institution 2 DPP, Faculty of Social Sciences, University of Tirana
[email protected]; [email protected]
Abstract. Postpartum depression (PPD) is an important depression episode which begins in
pregnancy or within 4 weeks after giving birth. Research is conducted in Gynecology and
Obstetrics Clinic, Pediatric Clinic and in private Hospital “Lindja”, in Prishtina, during period
May-June in 2018. Study is focused in relation of psychosocial factors such as: birthplace,
education, employment, economic level, mental health, number of children, breastfeeding,
anxiety, spousal relationship and social support. Subjects of this study were 136 mothers, from
the third day of giving birth till one year after this. The instruments were self-reporters, using
Edinburgh Postnatal Depression Scale (EPDS). Results showed that prevalence of
depression was 12,61%, in the sample of 136 subjects with an average age of 31.3 ± 6.4, years
of education 12±2,5, mostly living in rural area 44.9%. Related to social support, mothers report
high level of family and spousal support (respectively M=22.13±5.5; M=22.78±5.46) and lower
level of social support. Results notify that most of these factors have significant role.
Keywords: Mothers, PPD, Psychosocial factors, Family support
Introduction
The postnatal period is known as the time when women develop susceptibility to a variety of
emotional symptoms. However, postpartum depression is widely considered as a possible mood
disorder.
The American Psychological Association describes postpartum depression as, “a serious mental
health problem characterized by a prolonged period of emotional disturbance, occurring at a time
of major life change and increased responsibilities in the care of a newborn infant” (APA, 2015).
Postpartum Depression is the most emotional problem spread throughout women's lives
(Guardino & Schetter, 2014). PPD
is an easily recognizable, very widespread but very underdeveloped disease. Previous studies on
different communities show that mental disorders in women are mainly seen in reproductive age,
whereas after childbirth the risks of emerging of these problems have increased (Oslen et al,
2009). Therefore, pregnancy and motherhood are known as a possible period of women's mental
health vulnerability.
Epidemiological studies generally show that the prevalence of postpartum depresion is in the
range of 10-20% (Appleby et al., 1997; Warner et al., 1996; Swain, O'Hara, Starr and Gorman,
1997; Brugha et al, 1998; Lee et al, 2001; Chandran et al, 2002; Wisner et al,2014; Chen et al,
2018)
Postpartum depression typically begins before or any time after childbirth, but generally develops
between one week and one month after delivery. Mothers experiencing postpartum depression
17
describe feelings of extreme sadness, anxiety, and exhaustion (Thurgood, 2009; National Institute
of Medicine, 2015)
Previous research has identified risk factors that can increase a woman’s chance of developing
postpartum depression. If there is a history of mental health disorders during or after a previous
pregnancy, previous experience with mental health disorder, and a family history of depression
or other mental health illnesses increases the chances of a mother developing postpartum
depression (Vigot et al., 2010).
Also, Laggford, noted a lack of strong emotional support from a spouse, partner, family, or
friends has also been significant in determining the development of postpartum depression
(Laggford, 2009). In addition medical complications during the childbirth proces or mixed feeling
about the pregnancy have been found to increase the chances of a woman developing PPD.
Despite the efforts of researchers, the etiology of postpartum depresion is unstable and unknown
(Lusskin et al, 2007).
Beck (1967) postulated that depressed mood is the result of thought disturbances. Pessimism
toward oneself, the world, and the future contributes to a depressive mood. In addition, in the
absence of suitable role models, the woman feels loss of control and anxiety resulting in a lack
of a capability to cope with infant’s demands and care (Nemade et al, 2011). Some experts have
also noted that childbirth results in the loss of their identity and leads to the attraction of love and
loss of independence (Kaplan & Sadock, 2010). Moreover, the negative attitude of the family
affects the well-being of women and results in non-adaptation of the coping mechanisms.
If PPD is not treated, it may last for a period of time, often months or years, sometimes becoming
a chronic depressive disorder. Untreated postpartum depresion may have effects on child, infants,
fetuses and mothers (Abdollahi & Zarghami,2016).
Referring to the above studies can be said that PPD is a phenomenon that is present in many
women’s cases, but less studied. This phenomen varies from one culture to another. It is
influenced by many psychological, interpersonal, social and cultural factors. Among the factors
influencing the development of PP are genetic history of the case, previous experience with
mental health disorder and a family history of depresion or other mental health disorders, birth
problems, and many more.
Methods
The aim of this study was to assess impact of psychological factors during the postpartum
depression. Study is focused in relation of psychosocial factors such as: birthplace, education,
employment, economic level, mental health, number of children, breastfeeding, anxiety, spousal
relationship and social support.
The study has prospective design, with a single sampling phase. Parts of this study were women
who gave birth between May-June 2018, at Clinic of Gynecology and Obstetrics, Pediatric Clinic
at University Clinical Center of Kosova and in private Gynecological Hospital “Lindja”, in
Prishtina. In total they where 136 woman’s who were hospitalized from the third day of giving
birth till one year after this. These mothers were from different settlements in Kosovo and age
ranged from 16 to 55 years, all of them where interwiew by authors of this study and lasted
between 20 minutes and 50 minutes.
Ethics approval for the study was granted by the Ethics Committee of University Clinical Centre
of Kosova. Participants were informed about the objectives of the survey and ensured anonymity.
All participants provided written informed consent. Only women who were willing to participate
in the survey were interviewed and completed self-reporting questionnaires.
In the first part questionnaire was completed with questions on socio-demographic data for
research interests, such as the number of pregnancies, delivery and newborn, breastfeeding,
childcare and family support, relationship with partner, family status, social status, residence,
18
working and economic status, age, data on somatic diseases and mental illnesses in family
history, previous mental illnesses, especially in pregnancies and previous births, etc.
The second part was the Edinburgh Postnatal Depression Scale (EPDS) an internationally used
ten-item self-report questionnaire, designed as a screening tool to identify depressive symptoms
in the perinatal period. Items of the scale correspond to various clinical depression symptoms,
such as guilt feeling, sleep disturbance, low energy, anhedonia, and suicidal ideation.
EPDS questionnaire is used in a significant number of research works and reliability and validity
are well documented. The overall reliability (Cronbach’s alpha) of EPDS at our study was
α=.846.
Results and discussions
Results showed that prevalence of depression was an increasing indicator (M=12.61; SD=6.67)
in the sample of 136 subjects with an average age 31.3±6.4, years of education 12±2,5, mostly
living in urban area 55.1%, and underwent caesarean section delivery in 49.3% of cases.
Referring to the economic status 66.2% reported the middle level. In the respondents' households,
19.1% reported being suffering from depression and 17.6% of mothers suffered from a chronic
illness.be used to emphasize words in running text. Bold type and underlining should be avoided.
According to the questions about depression, filled out by all women in the sample 40.4%
responded positively to the question of loss of interest and satisfaction for life. None of them did
not attend any professional treatment, which requires a more serious approach to this problem.
Table 1. Correlation for postpartum depression
Factors Correlation
Earliest birth
experience
.180*
Delivery
complication
.243**
Delivery mode
Breastfeeding
.158
-.259*
Social support -.534**
Family support
Anxiety
-.504**
-.531**
Note: *. Correlation is significant at 0.05
**. Correlation is significant at 0.01
Correlational analysis between postpartum depression measured by EPDS and early birth
experience, delivery complications and difficulties, delivery mode, breastfeeding, anxiety and
social and family support, showed that there are important statistical links.
Previous delivery is significantly associated with PPD. Also, difficult maternal experiences
according to the correlational analysis, appear to have significant statistical correlation (r= -.243;
p<0.01) which means the harder the birth is, the higher postpartum depression rate reported by
the mothers. We did not find any correlation between delivery mode and PPD (r=.158).
Breastfeeding seems to be a very important on increasing PPD of mothers. Shows that there is a
negative significant correlation (r=-.259; p<0.01). Research has been showing that breastfeeding
promotes hormonal and psychological conditions and processes that are inversely associated with
postpartum depression. However, the simultaneous study of these dimensions and their potential
explanatory value in the connection between breastfeeding and pre- and postpartum depression
has not yet been accomplished.
19
Family and social support is significantly associated with PPD (r=-.504**; p<0.01: r= -.531;
p<0.01).
Attachment theory says that interpersonal struggles in an individual’s life have significant
influences on mental health. It is obvious that an individual requires affection which needs to be
fulfilled in the initial stage of a relationship. Uncertainties concerning a relationship may result
to disappointment and bring about depression and anxiety (Grupe & Nitschke, 2013). A number
of interpersonal factors play a role in women’s distress and sensitivity makes them prone to
develop postpartum disorders, these include insufficient social support and marital conflict.
Childbirth is a significant transitional event in life and support at this stage can potentially affect
women’s mental status after delivery (Hunker et al, 2009). Sudden psychosocial fluctuations
whithin motherhood and its challenges coupled with stresses could be other factor that may
trigger PPD. Previous studies in the field of medical social work have revealed that postpartum
depression is a global phenomenon that continues to be stigmatizing among new mothers often
because mothers suffer in silence (Kantrowitz-Gordon, 2013). A lack of strong emotional support
from a spouse, partner, family, or friends has also been significant in determining the
development of postpartum depresion.
Table 2: Child age and level of PPD
Edinburgh Scale
0-10 11-30
0-1 month 24.3% 32.4%
Child age 1-6 month 8.8% 19.1%
6-12month 6.6% 8.8%
Based on the data analysis performed, it is clear that the percentage of depressed subjects in the
mothers' group who have children a month age is higher than the percentage of other groups with
32.4%, then falls between 1-6 months with 19.1%, while 8.8% in the 6-12 months after birth,
showing that depressive symptoms are most common in mothers of children aged 0-1 months. as
the child age increases, depression decreases.
From the table analysis, it can be seen that with childbearing age the postpartum depression
decreases. This can also be supported by biological factors such as rapid changes in hormone
levels such as estrogen, progesterone, beta-endorphin, human chorionic gonadotropin, rapid
change in cortisol concentrations (increasing during pregnancy and significant decline after
delivery). Consequently, the mother becomes increasingly indifferent to her child and may show
more aggressive behavior and less time for parenting.
Table 3: Correlation between education and economic level on PPD
Level Correlation
Education -.449**
Economic -.219*
Note: *. Correlation is significant at 0.05
**. Correlation is significant at 0.01
In both cases we have a low negative correlation, where we see the lower level of education (r=-
.449; p<0.0) and economic status (r=-.219; p<0.05) have impact on increasing level of PPD.
Research has shown that PPD appears up to four times more often to women living in poverty,
compared to women with medium and high economic status. Often it is thought that socio-
economic status is the most frequent factor for PPD development.
20
Table 4: The impact of the profession on PPD
Household mothers have reported higher level of postpartum depresion, followed by nurses and
economists. This may be the result of long stay in home and indor environments. So even most
of the working women may not have been educated highly enough for their employment status
to have a positive effect on their mental health.
Results notify that most of these factors have significant role. Factors such as education,
employment, economic level, pregnancy progress and birth, children age, breastfeeding, anxiety,
spousal relationship seems to have high percentage of impact in postpartum depression.
Conclusions
Our study may be helpful in better understanding of female psychosocial problems and family
support after delivery and can help for the prospective planning of preventive intervention
strategies in improving women’s mental health.
Depression after giving birth is rising as a problem of mental health, and has negative impact on
personal, family and national level.
During the research was noted that psychosocial factors are really important to preserve
emotional, cognitive and behavior equilibrium.
Meanwhile family support is an important homeostatic component. Getting social help,
especially after giving birth, is important to lower the risk of PPD.
References
1. Abdollahi., F., Lye., M.S., & Zarghami., M.: Perspective of postpartum depression
theories: A narrative literature review (2016) Medknow Publications and Media Pvt.
Ltd
21
2. American Psychological Association, A. (2015) Postpartum Depression. Retrieved
from http://www.apa.org/pi/women/programs/depression/postpartum.aspx.
3. Appleby, L., Warner, R., Whitton, A., & Faragher, B.: A controlled study of
fluoxetine and cognitive-behavioural counselling in the treatment of postnatal
depression. BMJ, (1997) 314(7085):932936
4. Beck AT. Depression: Clinical, experimental, and theoretical aspects. New York:
Harper and Row; (1967)
5. Beck CT.: Theoretical perspectives of postpartum depression and their treatment
implications. Am J Maternal Child Nurs (2002) 27:282-7
6. Chen, L., Ding, L., Qi, M., Jiang, Ch., X.-M.M., Cai, W-Z.: Incidence of and social-
demographic and obstetric factors associated with postpartum depression: differences
among ethnic Han and Kazak women of Northwestern Chin (2018) PeerJ6:e4335;
DOI 10.7717/peerj.4335
7. Evans, J., Heron, J., Francomb , H., Oke, S., & Golding, J.: Cohort study of depressed
mood during pregnancy and after childbirth. BMJ (2001) 257-60
8. Grupe, D. W., & Nitschke, J. B.: Uncertainty and anticipation in anxiety: An
integrated neurobiological and psychological perspective. Nat Rev Neurosci
(2013)14:488-501
9. Guardino CM, Dunkel Schetter C. Coping during pregnancy: A systematic review
and recommendations. Health Psychol Rev (2014) 8:70-94
10. Kantrowitz-Gordon, I.: Internet confessions of Postpartum Depression. Issues in
Mental Health Nursing, (2013) 874-882.
11. Kaplan , B., & Sadock, A.: Synopsis of Psychiatry, Behavioral Sciences/Clinical
Psychiatry. 10th ed. Philadelphia: Lippincott Williams and Wilkins (2010)
12. Laggford, J.: The Role of Family Support in an Integrated Early Childhood System.
Helping Families Get What They Need to Support They Need to Support Support
Their Children’s Development. (2009) Center for the Study of Social Policy. US
13. Lusskin SI, Pundiak TM, Habib SM.: Perinatal depression: Hiding in plain sight. Can
J Psychiatry (2007) 52:479-88
14. Nemade, R., Reiss, S. N., & Dombeck, M.: Psychology of Depression-
Psychodynamic Theories (2011)
15. Oslen, M., Laursen, T. M., Mendelson, T., Pedersen, C. B., Mors, O., & Mortensen,
P. B.: Risk and predictors of readmission for a mental disorder during the postpartum
period. Arch Gen Psychiatry (2009) Vol. 66: 189-98
16. Thurgood, S. M., Avery, D., & Williamson, L.: Postpartum Depression. American
Journal of Clincal Medicine (2009) Six. 17-22
17. Vigot, S. N., Villegas, L., Dennis, C. L., & Ross, L. E.: Prevalence and risk factors
for postpartum depression among women with preterm and low-birth weight infants:
a systematic review. BJOG: An International Journal of Obstetrics and
Gynaecology, 117, 540–550. doi: 10.1111/j.1471-0528 (2010) 02493.x
22
Cranial Injuries with Screwdriver – UCCK
Besnik Elshani¹, Salih Krasniqi¹
UBT - Higher Education Institution, Lagjja Kalabria, 10000 p.n., Prishtina, Kosovo
Abstract In terms of anatomy, the human body is very complicated. Moreover it represents an
entire structure of a human being. What makes it very unique is the way of its composition;
different and diverse types of cells and everything is connected to everything else. A combination
of cells create tissues which then those tissues create the organ systems. Therefore, in this study
presentation I will present the importance of brain as an organ, with a focus on the cranial Injury
with a screwdriver. One of the most important and complicated parts of the body is the human
head.
Keywords: Skull, Cranial, Brain, Cells
Introduction
Those organs system make the human body to function properly and they grow (age) within
years. It is located in the upper portion and certainly is represented by a unique face, thus,
maintained by the (inside) skull and the brain is located within the skull. Skull plays an important
role, because it directly protects the human brain, which, results to be the most complicated and
fascinating organ in the human body. Without brain nothing would function properly, indeed.
Introduction of the brain & Cranial Injury
To start with, the human brain is consisted of the frontal lobe (front), the parietal lobe (middle)
and the occipital lobe (on the back – (end) of the brain) and each lobe has its own role forcing
the brain to maintain its health and manage other organs. Nevertheless, it is the central organ of
the nervous system and connecting with the spinal cord (back of the human body) it is known
otherwise as the central nervous system of the human body. Besides the cerebral lobes mentioned
earlier, the nervous system is made of the cerebrum, cerebellum and last but not least, the
brainstem. Being the most important organ is not an easy duty. Numerous of processes, maybe
billions of processes are controlled by the brain itself, followed with the body activities, precise
coordination of information, receiving and delivering that information properly and controlling
the senses of a human, followed with good decision making skills as well [1].
Secondly, brain protection is highly studied and experimented, due to the fact that being the most
important and diverse organ, the upper portion needs extra protection [2]. The skull bones of the
head serve as a good prevention from the brain being harmed accidentally – physically. However,
except physical injuries that might happen to the brain and the human body in general, there are
also certain types of traumas that might directly harm the brain. Such traumas are known as
Cranial Traumas (most commonly affects the adults for specific reasons). Patients who already
suffer from such traumas are more likely to have had brain injuries which could also affect other
(important) organs that serve to maintain the stability of the body itself [1].
Thirdly, re-stating the fact that brain can be damaged physically is probably one of the most
common cases in today’s world and / or society. Additionally, head injuries in general include
23
brain, scalp or skull injury. Despite the fact of what really may cause a head injury which may
cause skull fractures and other undesired wounds, the consequences can be seen either
immediately after the injury or later on in life, depending the fact of the severity of the injury
itself [3]. Head injuries are most commonly caused by everyday life situations, such as car
accidents (including motor vehicles as well – probably a more direct way to injure the head due
to less protection of the human body in general).It may also happen from a fall (still depends on
the height and the type of ground – soft (grass) or hard (asphalt type)) and often by physical
assaults (which can lead to the use of different weapons, even a screwdriver).
Cranial Injury with a screwdriver
As stated at the beginning of this study presentation, the main focus will be on the physical
assaults, resulting with a cranial injury of the head (skull and brain) with a screwdriver. A
screwdriver is a tool which often is used by construction companies, or even one can have it at
home for fixing something [4]. Nevertheless, this statement does not ignore the fact that a
screwdriver can and it is being used as a weapon for direct assaults and the most common injury
is the head (skull and brain) injury.
To make this more clear, there are a variety of head injuries which can be activated by an
undesirable physical contact and / or can further lead to the underdevelopment of the brain itself,
causing the malfunction of the human body or some parts of it (organ(s) malfunction) [4].
The (most common) major types of a head injury are (listed below):
• Hematoma
• Hemorrhage
• Concussion
• Edema
• Skull Fracture
1. CASE Report (Prishtina, Kosovo)
At the University Clinical Center in Prishtina Kosovo, in one of the neurological clinics, a rare
case has been operated. The patient was admitted to the Emergency Center in Pristina around
15:00 in the afternoon, from a regional part of Kosovo where the injury occurred. The patient in
admission was in a state of mind with partial communication and blend of words. Objectively the
metal tool penetrated into the endocardium in the left frontal region. It is realized the brain CT,
24
where is seen the metal tool known as a screwdriver, which had penetrated the shaft and was up
to the breccia area (a clear reason why the patient started to lose speech). The patient is urgently
prepared for operation, including general anesthetic surgery. An operator intervention is
performed by the caregiver's neurosurgeon by opening a small craniotomy around the traumatic
lesions and carefully penetrating the brain tissue up to the tip of the traumatic brain tract.
It is possible to successfully leave the metal tool. Correct hemostasis of the brain becomes
minimal invasive bleeding. The operation ends within one hour. After the operation, the patient
has only shown signs of neurological improvement, where he returns full speech / communication
abilities very fluently. After a few hours the patient can also control body movements such as
standing up, hands movements, headaches, walking right, and non-passive speech. Finally, after
about 24 hours, a control brain CT is performed, which presents without any bleeding in the head
of the patient in question. This is the first and rare case in UCCK, which has been treated
professionally and successfully by taking into account the rapid reaction of the moment of
hospital administration, where within an hour everything ends. It is worth mentioning that the
nodular deficit manifested by the sensomotoric defect has been eliminated after the operation and
the patient returns to normal neurological conditions.
Note: The case occurred in 2017 (27 April)
25
Similar Case Report from United Kingdom (UK)
Such cases are reportedly to happen also around the world, due to different type of attacks [5].
One of the countries that particularly shares such case reports is United Kingdom. Cranial Injuries
with a screwdriver tend to happen very often and not only between adults (+18 and beyond), but
also to children and teenagers as well, which can lead to a more difficult case (surgery) to be
solved [5]. An attack with the screwdriver can lead to major infections as well. A similar Case
report happened in United Kingdom (UK), where a 26 year old man was sent to emergency due
to an angry assault from someone else. After the surgery he was discharged home, however the
other day the man came back since he had a very strong headache and his confusion started to
increase. Apparently he had an intracranial hemorrhage in the parietal lobe. After that and the
needed care, he was sent back home after 17 days in the rehabilitation unit in the hospital.
It is of high importance that such cases are required to be notified earlier because the infection(s)
may lead to other difficulties and make the case even worse. It is stated that “such case is a
reminder of the need for a high index of suspicion in intoxicated head injured patients in whom
the diagnosis of intracranial injuries is often delayed” (Tutton, et al. 1).
Moreover, cranial injuries with a screwdriver or otherwise known and presented as penetrating
screwdriver, such wounds seem to be very unusual and less introduced in the literature and
neurosurgical practice [6]. Additionally, screwdriver is one of the least tools to be used as a
weapon and trying to penetrate with it into someone’s head. Although, the damage may be very
serious and cause severe injuries in the head and most importantly touch the brain.
Conclusion
The safety of the human body especially the upper portion of it should be a must in our everyday
life, due to the fact that the human head contains the most important organ, the brain, which in
fact, does control our movements, thinking, and processing information and so on. It is consisted
of three lobes: Frontal, Parietal and Occipital lobe.
The case report section is a great example of a cranial injury that happened in Prishtina, Kosovo,
which is considered a rare case due to the fact that the injury was done with a screwdriver. The
neurosurgeon tried to keep the health of the brain while removing the tool made out of metal and
after the successful operation a control CT endocranion was performed and resulted that the
patient was fine and able to communicate better than before the operation. It is very important to
re-state the fact that body movements of the patient were improved within a very short time, since
after the one-hour surgery and a little rest, he was able to walk and talk, controlling hand
movements, head movements and trying to keep a non-passive communication with the doctors.
References
1. Haas LF (December 2001). "Phineas Gage and the science of brain localisation".
Journal of Neurology, Neurosurgery, and Psychiatry. 71 (6): 761.
2. “Head Injury: Types, Causes, and Symptoms.” Healthline, Healthline Media,
3. Retrieved from: www.healthline.com/health/head-injury.
4. Kuppermann N, Holmes JF, Dayan PS, Hoyle JD, Atabaki SM, Holubkov R, et al.
(October 2009). "Identification of children at very low risk of clinically-important
brain injuries after head trauma: a prospective cohort study". Lancet. 374 (9696):
1160–70.
26
5. Powell T (2004). Head Injury: A Practical Guide (2nd ed.). United Kingdom: Speech
mark publishing Ltd. ISBN 978-0-86388-451-1.
6. "Traumatic Brain Injury (TBI)", SpringerReference, Springer-Verlag.
7. Tutton, Matthew G, et al. “Screwdriver Assaults and Intracranial Injuries.”
Emergency Medicine Journal, British Association for Accident and Emergency
Medicine, 1 May 2000.
27
Nursing Care in Children with Type 1 Diabetes Mellitus
Doruntina Ismaili1,Fëllënza Spahiu2,Lirije Beqiri2,Afërdita Berisha2
1,2 UBT-Higher Education Institution, Lagjia Kalabria, 10000 p.n., Prishtinë.
Kosovo
[email protected], [email protected], [email protected], [email protected]
Abstract. A life dependent from insulin certainly requires patience, support, care and a constant
education from our side as professionals of medicine toward our patients who are affected by
diabetes. The prevalence of this disease is increasing, whereas the incidence is approximately 4
cases per 100 000 inhabitants. Factors that affect this disease are many, ranging from the genetic
basis to stress and trauma. The complications of this are inevitable that touch almost the whole
system and bodies starting from the brain to the legs.
Based on the research conducted the total number of children with type 1 diabetes mellitus in the
endocrinology department at the Pediatric Clinic in Prishtina during the 5 year period from 2012
-2016, in totally there are 386 new cases, 183 are females and 185 are males, we have concluded
that urban areas are the most affected by rural areas, gender is affected by almost both sexes,
while age groups are: females are born between 2001 and 2015, while men range between 2004
and 2016.
Education - Periodic control of glucose reduces hyperglycemia complications. For the self-
treatment of insulin, the nurse should educate the child in light of his age. They are explained
where and how to inject insulin, injection angle, then education for bodily activities, diet and
maintaining personal hygiene (foot care).
Keywords: Type 1 Diabetes mellitus, insulin, research, education.
INTRODUCTION
According to the World Health Organization (WHO), diabetes is defined as a condition of chronic
hyperglycemia, determined by genetic and environmental factors. Type 1 diabetes belongs to the
most common chronic endocrine disorder of children. Type 1 diabetes is an autoimmune
syndrome that destroys pancreatic beta cells and is characterized by the almost complete absence
of insulin secretion from the endocrine pancreas. Autoimmune Disorder is a disorder in which
the immune system of the body, which normally protects the body against foreign invaders,
incorrectly identifies part of the body as a foreigner and attacks healthy tissue. The disease is due
to lack of insulin, which leads to carbohydrate, fat, and protein metabolism disorders with typical
clinical presentation. Insulin is the main anabolic hormone in the body. The main feature of
diabetes in children is insulin dependence. The main reason for this is the absolute lack of insulin.
The stages of the disease are: 1. Prediabetes- is the period from the beginning of the process to
the possible occurrence of the first abnormalities in carbohydrate metabolism in children, 2.
Subclinical Diabetes - Carbohydrate metabolism is only disrupted in the event of infections,
caries, trauma or surgery, 3. Diabetes patients who are ill at this stage of the disease are without
any symptoms, rarely have normal glucose levels in the blood, but hyperglycemia occurs after
food intake or after oral glucose loading, 4. Diabetes manifestations of children appear swiftly,
28
while switching from latent stage to manifest is provoked by infections, traumas, and surgical
interventions. Symptoms and clinical signs of the disease start due to the difficult use of glucose
in cells due to lack of insulin. Lack of insulin results in blood glucose collection (hyperglycemia).
When the blood glucose concentration exceeds the maximum kidney transplant (about 9.0 mmol
/ L), glucose begins to appear in the urine (glucose). Glucose in the urine draws water by
increasing the volume of urine and frequent urination (polyuria). Increasing the loss of fluid with
urine causes an increased and permanent thirst for the patient, which he tends to compensate for
by adding juices (polydipsia). The overall lack of energy consequently has subjective feeling of
hunger and increased food intake (polyphagia), but with no effect, which consequently has a
growing stagnation, weakening (loss of body mass) to cachexia in unidentified cases, not well-
cared for melitic type 1 diabetes. Diagnosis of type 1 diabetes mellitus is confirmed by the
presence of glucose and hyperglycemia above 6.6 mmol / L (120mg%) in soma or above 8.8
mmol / L (160 mg%) after food. In ketoacidosis, the acetone test in urine is positive and other
acidosis lab tests. Blood glucose hemoglobin (HbA1C) is over 8% (proportional to the amount
of glucose in the blood). The complications of type 1 diabetes mellitus can be: acute and
chronic. Acute complications - The most important acute diabetes mellitus type 1 complications
are: hypoglycemia and diabetic ketoacidosis. While chronic complications appear after several
years (10-20 years) from the onset of the disease. Chronic complications are: Angiopathy,
Diabetic Nephropathy, Neuropathy, Diabetic Retinopathy, Bleeding in the Eye Glass,
Macrovascular Diseases. The purpose of the medication is normalization of blood glucose and of
all metabolic processes in the body, which are mediated by insulin. Insulin delivery, rigorous
diet, physical activity, hygiene, preservation from infections and complications will be the whole
type 1 diabetes medication. Insulin is the basic treatment for diabetes. It is used through
subcutaneous injections or insulin pump, along with dietary management, including carbohydrate
monitoring and blood glucose control, using glucose meters. Administered via subcutaneous and
intravenous routes. Eliminated through the urine and the balance. There are some insulin forms;
insulin with short, medium and long acting. It is preferred to combine these forms. The injection
site changes after each injection line, it also affects the duration of the start of the action; abdomen
(fast), upper arm (slowly), upper leg (still slower).
Care and nursing education is based on: 1. Providing insulin, 2. Diet, 3. Corporal activity, 4.
Blood glucose monitoring, 5. Maintaining personal hygiene-care for the feet, 6. Monitoring vital
signs.
• Providing insulin: All insulin preparations, which are currently in use, should be
administered in the form of subcutaneous (subcutaneous) injections with the 45 "angle
on the outer (lateral) side of the thigh, both at the front and the front, on the abdominal
wall and in gluteus or intravenous infusion, there is no insulin for oral use (by mouth)
because if insulin is taken through the mouth to the stomach and the intestine is
decomposed like any other protein. Insulin preparations are distinguished from each
other by: time, moment of injection under the skin until the beginning of their action
and duration of the action.
• Diet: The diet of a child with melite diabetes should be such that it contains 50-60% of
carbon hydrate, 25-30% of fats and 15-20% of protein and the content of minerals,
vitamins and oligoelements. In addition to the three main food rations (morning, lunch,
dinner), the child should also take two or three small rations (at 10.17 and 21).
29
• Corporal activity: With activity it is possible that glucose under the action of insulin
is faster and easier to use by the cells. The diabetic diabetes child should deal with
common physical and sports activities like all his peers in a community (except for
swimming, motoring, parachuting).
• Blood glucose monitoring: Glycemia should be measured 6-7 times per 24 h for the
purpose of changing insulin doses to have a better control of the disease. The test for
the use of insulin, the use of gleukometers, where the finger is first disinfected with
alcohol and then needle-drilling, the first blood outlet is always removed and the second
blood test is performed on the glukometric bar. The most accurate moments for
measuring glycemia are bread, before the three meals, two hours after the meal and
before bedtime.
• Maintaining personal hygiene-care for the feet: Patients with DM to prevent the
appearance of the diabetic foot should undertake the following care. Handkerchiefs and
shoes should be 1-2 bigger midsoles, should be checked for the presence of foreign
trousers, socks should be cotton, should not be worn with synthetic socks at the knee
level because they hinder the circulation and should not wear the shoe. Care of the
nails, before the nails are cut out, should be washed with warm water for 15 minutes.
The nails are cut right, adjusted with side lime. General Information: Never walk
barefoot, do not use creams and solutions without a doctor's description, do not let your
feet burn in the sun and do not stand crossed.
• Monitoring vital signs: Hypotension and tachycardia are present in hypothetical
monitoring of hypovolemia, hypovolaemia estimates should be made, respiratory type
- acetone is due to acetic acid acid disruption and should be reduced as corrected
ketosis, dry mouth, augmentation but appetite associated with weight loss, fatigue more
than usual, stomach pain, blurred vision, lack of concentration, numbness of the hands
or feet, changing temperature, skin color and moisture-fever and chills are common
with the infectious process and dehydration occurs.
PURPOSE OF THE STUDY
• Accounting of the total number of patients with Diabetes Mellitus type1 placed in the
endocrinology ward, in the Pediatric Clinic in Prishtina, during the 5 year period from
2012 -2016,
• Study of cases of diabetes mellitus type 1 by age groups,
30
• Study of cases of diabetes mellitus type 1 by gender,
• Study of cases affected by type 1 diabetes mellitus and variations of results,
• Widespread knowledge of the disease, its etiology and its treatment,
• Nursing care and education in patients with type 1 diabetes mellitus.
HYPOTHESIS
• The general knowledge about diabetes mellitus type 1,
• Nursing education and care for children affected by type 1 diabetes mellitus, in
improving and relieving the disease.
RESEARCH QUESTIONS
• The research questions were focused on:
• Finding the total number of patients with Diabetes Type 1 Mellitus placed in the
Department of Endocrinology at the Pediatric Clinic in Prishtina during the 5 year
period from 2012 -2016,
• Number of type 1 diabetes cases by age groups,
• Number of type 1 diabetes cases by gender,
• Number of cases affected by type 1 diabetes based on residence and variations in results
MATERIALS AND METHODOLOGY
The study is retrospective for all patients treated in 2012-2016. The data for this research were
collected from the Patient Clinic Protocol in Prishtina. The data was processed and generated in
tabular and graphical form through the microsoft EXCEL application
31
RESULTS
Chart number 1. In the Department of Endocrinology at the Pediatric Clinic in Pristina,
children diagnosed with Type 1 diabetes were examined, out of a total of 368 patients, 183 were
female and 185 were males.
Table number 1. Cases presented on the basis of sex in years.
182
184
186
Year 2012-2016
Female 183
Male 185
Year
Male
%
Female
%
2012 27 43.55% 35 56.45%
2013 37 51.39% 35 48.61%
2014 42 52.50% 38 47.50%
2015 38 52.05% 35 47.95%
2016 41 50.62% 40 49.38%
Total 185 183
32
Table number 2. Number of cases diagnosed with type 1 diabetes mellitus in the Pediatric Clinic
based on settlements for 5 years analyzed.
Chart number 2. The table and graph shown above shows the number of cases of type 1 diabetes
mellitus for each year from 2012 to 2016. In 2012 we have a total of 62 cases with diabetes
mellitus type 1, then in 2013 there are 72 cases with this diagnosis, in 2014 there are a total of 80
cases, in there are 73 cases in 2015 and in 2016 there are currently 81 cases affected by this
disease. The results show that there is a fluctuation of the cases presented from year to year where
the highest cases are in 2016.
Year 2012 2013 2014 2015 2016
Female Nr % Nr % Nr % Nr % Nr %
Rural
areas
10 28.57%
13 37.14% 14 36.84% 7 20.00% 18 45.00%
Urban
areas
25 71%
22 62.86% 24 63.16% 28 80.00% 22 55.00%
Total 35 100.00% 35 100.00% 38 100.00% 35 100.00% 40 100.00%
Male Nr % Nr % Nr % Nr % Nr %
Rural
areas
6 22.22% 6 16.22% 13 30.95% 8 21.05% 21 51.22%
Urban
areas
21 77.77% 31 83.78 % 29 69.05% 30 78.95% 20 48.78%
Total 27 100.00% 37 100.00% 42 100.00% 38 100.00% 41 100.00%
0
10
20
30
40
50
60
70
80
90
2012
2013
2014
33
Chart number 3. If we were to make a comparison of this data, we would have the Prevalence
of Diabetes mellitus in the World by WHO, with a 2-6% incidence in Western countries and the
highest in other ethnicities. Hyperglycemia is rare in newborns (1% before 15 years) but its
frequency increases with age (7% after 65 years). The ratio between sexes is roughly the same,
affecting every age but with greater frequency ages over ages 45. In 1995 diabetics were 135
million, in 2006 were 264 million but alarming is that it is predicted that in 2025 we will have
380 million diabetics. Type 1 diabetes affects 11 to 22 million people worldwide.
DISCUSSION
As can be seen from the results of the study, the number of people with type 1 diabetes mellitus
in the Pediatric Clinic in Pristina is 368 patients, of whom 183 are female and 185 are males. So
diabetes mellitus type 1 affects almost the same gender, where their percentage is almost halved.
In women, the percentage is 49.97% and in men it is 50.03%. It belongs to the year of birth of
children with type 1 diabetes mellitus in females varies between 2001 and 2015. Where 2001 and
2005 are most affected with a higher rate of diabetes, while in men it differs in periods from 2005
until 2016. Where since 2005 we have an increase in the number of patients affected with type 1
diabetes mellitus. The table on male gender by dwelling place shows that the most affected cases
are urban areas, where the affected are almost three times more than rural areas, for 2012, 2013,
2014 and 2015, except in 2016 have similar numbers of cases in urban and rural areas. Where in
the city we have 131 cases for five years, while in rural areas we have 54 patients. The graph
shows us a figure fluctuation year-on-year, with the highest rates being in 2016. As seen from
the table, cases have always been increasing, while the female shows the incidence according to
settlements from 2012-2016 where even in this case the urban area is more affected than the rural
one. In urban areas we have 121 cases and in rural areas we have 62 cases. The peak of new cases
is in 2016 with 40 new cases. The prevalence of type 1 diabetes in Kosovo for the last 5 years.
The table and graphs shown above show the number of type 1 diabetes cases per year from 2012
to 2016. In 2012 we have a total of 62 cases of type 1 diabetes mellitus, then in 2013 there are 72
cases with this diagnosis, in 2014 there are a total of 80 cases, in 2015 are presented 73 cases and
0
100
200
300
400
Year 1995 Year 2006 Year 2025
Prevalence of Diabetes Mellitus in the World
34
in 2016 there are 81 cases affected by this disease. The results show that we have a fluctuation
of results from year to year, where the highest cases are in 2016.
CONCLUSION
Diabetes screening is the key to preventing complications, early diagnosis, helps preventative
complications. Periodic control of glucose reduces complications of hyperglycemia. In patients
with type 1 diabetes mellitus, intensive insulin therapy has beneficial effects on reducing the risk
of cardiovascular disease. Blood pressure control reduces the risk of cardiovascular, exkemias,
hemorrhagic diseases. Any reduction of 10 mmHg of TA reduces with 12% complications.
Patients with diabetes should have special care to protect themselves from infections because
they seriously affect diabetes. Protection is achieved simply through three precautionary
measures:
First: respecting the rules of body hygiene, protection from moisture and cold.
Second: Regular vaccination against all infectious diseases, including the flu.
Third: Regular and meticulous treatment of diabetes, maintaining its constant balance.
When the patient is affected by various infections, serious antibiotic treatment should be
performed. Those who are treated with insulin should increase their dose, while those who are
given oral or dietary medication may need to temporarily start insulin treatment. A person with
type 1 diabetes mellitus should be informed about the treatment of the disease and the importance
of his treatment. For insulin, there must be a medical staff to teach the patient the places where
injections of insulin are in the abdomen, thigh, and forearm skin. The injection angle is 45-90 °,
whereby the skin is initially withdrawn and then injected. It is advisable for patients not to rub
the injection site. Also in small children, or elderly, family members are instructed. Patients are
given insulin types, meals when used. Hyperglycemia and hypoglycaemia are known and the
measures to be taken. Insulin storage is done in a refrigerator, but injection of cold insulin is
painful, so it is recommended to keep it at room temperature, but not over 25-50 degrees. The
amount of storage is kept in the refrigerator at 2-8 ° C, avoiding freezing because it can damage
insulin.
References
1. Azemi M, Jaha V. Pediatria dhe Kujdesi Infermieror: për studentët e Infermierisë dhe
mamisë. Prishtinë: Olymp, 2016
2. Cakerri L, Nanushi M. Bazat e Fiziologjisë të njeriut .
3. Ceka Xh. Histologjia – Tirane 2005
4. Ekoe J, Zimmet P, Williams R, -The epidemiology of diabetes an international
perspective, ISBN:0-471-97448-X. ©2001
5. Kozdine D. Patologjia morfologjike –.Triptik 2006
6. Lebovitz H. Therapy for diabetes mellitus and related 1disordes. ISBN: 0-945-448-
94-5. ©1998
7. Llano Y. Dietologji. Triptik 2006
35
8. Mandro F, Zahaj M, Stefoni S. Bazat e farmakologjisë klinike. ISBN:99927-35-61-9.
©2011. Tiranë.
9. Ralton B. Exercise&disease management of diabetes. ISBN978-1- 4398-2579-
8.©2011
10. Remuzzi R. Nephropathy of tape 2 diabetes mellitus, J AM Soc Nephrol 1998
11. Saliaj A. Pediatria – ISBN: 978-99956-91-28-8
12. Saracini E, Saracini H. Anatomia dhe Fiziologjia e njeriut. Prishtinë; 2001
13. Ogden A. Practical Insuline. - ISBN: 978-1-580-40-447-1. ©2011
36
Side effects of metoclopramide (Reglan) oral overdose in
pediatric patients
Edmont Laho1,,Xhejni Borshi 2, Indrit Bimi3, Eti Muharremi4
1Department of pediatrics, Medical hospital center Elbasan,Albania
Albanian University, Tirana, Albania 2The head of the Deparatment of Physiotherapy and Nursing
Albanian University, Tirana, Albania 3The pedagogue of the Deparatment of Physiotherapy and Nursing
“Aleksander Mosiu”University, Durres,, Albania 4General physician Public Healthy Regional Directory, Elbasan
Abstract. Drugs like metoclopramide are used in pediatric patients for the treatment of frequent
vomiting or gastrointestinal disorders especially at the age of three. The most common use is
Reglan solution, but its dose should be strictly observed because of low therapeutic index
overdose is easily achieved, manifesting with extrapyramidal side effects.
The purpose of the study is to detect the frequent side-effects of the extrapyramidal nervous
system that are due to the oral overdose of Reglan in the pediatric population.
Materials and methods. This study analyzed all the cases of Metoclopramide toxicity who took
the Reglan solution in an outpatient setting and were then diagnosed and treated in the Pediatric
Service in the Hospital of Elbasan during January 2014 to December 2016 period. These cases
have been treated in the Pediatric Service in Elbasan. After having been diagnosed with signs of
the nervous system from the overdose of Reglan solution they were surveyed in terms of dose
taken, duration of use, age, etc.
Results. The17 cases diagnosed in our service varied in clinical presentation from nuchal rigidity
to whole body contractions and somnolence. Out of these, nine children were younger than 1 year
old, 5 children 1-4 years old, and 3 children were aged 4-8 years. All the children younger than
one received Reglan solution at high doses 3 times 1 coffee spoon (also fivefold-tenfold of the
dose) while the therapeutic dose for Reglan solution is 0.1mg / kg in 3-4 doses.
Conclusions. Considering this medication has a low therapeutic index, cautions to prescribe and
administer the right dose are of the upmost importance. As a result, the general practitioner and
the pharmacists should be instructed that children younger than 1 year old should not take this
medication and if need be and there are no other alternatives it should be administered with drops
and not with coffee spoon (2.5 ml) or jam spoon (5 ml).
Keywords: vomiting, dosage, reflux, reglan, drops
Introduction
Metoclopramide is a Dopamine receptor antagonist. Metoclopramide has antiemetic,
antinauseant and gastrokinetic activity. It stimulates motility of the upper gastrointestinal tract
without stimulating gastric, biliary or pancreatic secretions. The rate of gastric emptying is
increased due to increased peristalsis of the jejunum and duodenum. The tone and amplitude of
37
gastric contractions are increased, with relaxation of the pyloric sphincter and duodenal bulb.
These effects combine to result in decreased intestinal transit time, making a good anti emetic.
The effect of metoclopramide on motility is not dependent on intact vagal innervation, but it can
be abolished by anticholinergic drugs. Metoclopramide has little, if any, effect on the motility of
the colon or bladder. Metoclopramide also exhibits dopamine antagonist activity and
consequently produces sedation and, rarely, other extrapyramidal reactions.
It was firstly used by an American physician in 1964 and it has since been used all over the world.
Metoclopramide is one of the 100 most used drugs in the last ten years in USA. It has also made
the list of Essential drugs of World Health Organization (WHO) [1].
The structural formula is:
Metoclopramide is sold under the trade name Reglan or Primepran and it is widely used for
gastrointestinal disturbances, hiatal hernia, biliary stones, gastritis and gastric ulcers. This drug
is used to control nausea, stomach ache and upper abdominal pain [2].. In our clinical experience
we have witnessed a very high efficacy of this drug in controlling the vomiting of different causes
and makes a great choice in diabetics with vomiting due to gastroparesis. Metoclopramide is used
in surgery to control the post-operative vomiting.
Metoclopramide is also used in pediatric patients to control vomiting due to gastroenteritis or
enteroviral infections. It is essential to administer the correct dossage due to risky side effects
seen with its toxicity. This drug is also used to control vomiting associated with radiation therapy
or intolerance to cytotoxic drug or used preoperatively to stop the vomiting during surgery and
also assists in small bowel intubation [3]..
Dossage and administration
• Adults 20 years and over: Maximum of 10 mg three times a day.
• Children: Treatment of children should commence at the lower dosage of 0.1-0.15
mg/kg three times a day or as a solution 5mg/5ml a clear, colourless, sterile,
preservative-free solution containing metoclopramide hydrochloride anhydrous used
to come with a dropper (Primepran) [4].
Parenteral forms (I.V. or I.M.) are 10 mg/2 ml. This is recomended in patients with extensive
vomiting, after the patient is firstly hydrated with Ringer’s solution or Sodium Chloride
0.9% [5].
38
Side effect
Tardive dyskinesia may appear in some patients on long-term therapy or may appear after drug
therapy has been discontinued. The risk appears to be greater in pediatric patients on high dose
therapy. The symptoms are persistent and can often at times appear to be irreversible. The
syndrome is characterized by rhythmical involuntary movement of the tongue, face, mouth or
jaw (e.g. protrusion of tongue, puffing of cheeks, puckering of mouth, chewing movements).
Sometimes these may be accompanied by involuntary movement of extremities. The frequency
and severity of seizures or extrapyramidal reactions may be increased in epileptic patients given
metoclopramide. Dystonic reactions occur in approximately 1% of patients given
metoclopramide [6]. These occur more often in children and young adults and may occur after a
single dose. Neuroleptic malignant syndrome has been reported when metoclopramide has been
used alone or in combination with neuroleptics. Metoclopramide elevates prolactin levels. This
may be of importance in patients with previously detected breast cancer, in which the breast
cancer is prolactin dependent. Because of prolactin elevation it presents with disturbances such
as galactorrhea, amenorrhea, gynecomastia and impotence in men. Because of its cholinomimetic
properties and because it decreases intestinal transit time this drug may induce diarrhea.
The purpose of this study is to evident the extrapyramidal side effects and other side effects
related to Metoclopramide (Reglan) toxicity after oral or parenteral administration in pediatric
population.
Patients and methods
This study analyzed all the cases of Metoclopramide toxicity diagnosed and treated in the
Pediatric Hospital of Elbasan during January 2014 to December 2016 period. The cases were
then classified regarding the epidemiologic criteria, the dosage administered to the patient, the
time the patient was on the drug, the coexistence of other pathologies and socio-demographic
variables like: age, residency.
Results
There were 17 cases in total diagnosed in the Pediatric Hospital of Elbasan. Their clinical
symptoms varied from neck rigidity to whole body contractions and somnolence. Some of the
children had “facial mask” or facial spasms. Patients aged older than 3 years old could not talk
and they exhibit uncontrollable movements of the extremities and they fell whenever they tried
to walk.
9 of the 17 children were younger than 1 year of age, 5 children were 1-4 years of age and 3 were
4-8 years old.
39
Graph 1: Children classified by age group.
All the children younger than 1 year old were administered Reglan solution 5-10 times (3 times
1 coffee spoon) the allowed dose of 0.1mg/kg 3 times a day.
Regarding their place of residence: 11 children were located in rural areas while only 6 were
located in urban areas.
Graph 2: Place of residence of children who were intoxicated with Metoclopramide.
Regarding the pathology the children first came for in the clinic for which they took
Metoclopramide: 6 were diagnosed as Enteroviral infection, 7 cases of Gastroenteritis and 4 of
Gastroesophageal reflux (GERD).
0
1
2
3
4
5
6
7
8
9
10
<1 year old 1-4 years old 4-8 years old
Children
11 children
6 children
Rural areas
Urban areas
40
Graph 3: Divided by the pathology the children first came for in the clinic for which they
took Metoclopramide
In our study we analyzed the cases of Metoclopramide (Reglan) toxicity considering the timeline
of emerging side effects. In children younger than 1 year of age the first signs of intoxication
started during the second day (after the first 24h) of taking the medication. Six out of nine of
these cases had a severe clinical manifestation with extrapyramidal signs because of taking the
medication in doses of 4-5 ml.
Discussion
Side effects from metoclopramide (Reglan) toxicity are fairly often in the clinical practice
compared to other medications. The most cases are reported in pediatric population. This is
illustrated on Graphic 1 where more than 60 % of the cases included in this study are 0-1 years
of age. Infants are poisoned with this medication, receiving a dose greater than the maximal daily
dose of 0.3 mg/kg (0.1 – 0.15 mg/kg taken 2-3 times a day) [7]. A 7 kg child should not be
administered more than 10-15 drops per day (0.7 ml 2-3 times a day). In this study we found out
that many children have received the medication 2-3 times per day up to 4-5 ml, making it an
overdose. In this situation the children were presented to the Emergency Room with the
extrapyramidal symptoms described above [8]. This mistake occurs due to a miscommunication
between the physician and pharmacist, the latter one being responsible a lot of times for selling
medications without prescription or misreads the correct dosage of the medication.
The risk is increased because in our country Metoclopramide that is sold under the trade name
Reglan lacks a dropper. A few years ago Primeran solution was widely available in the drug
market in Albania. It had a dropper that helped avoiding mistakes in dossing administration.
In this study we found that most of the cases were from rural centers. This not only shows the
problems and the shortcoming of specialized doctors in these zones but also the lack of medical
knowledge in the population. In two cases after the children, respectively 4 and 7 years of age,
were still vomiting after taking Reglan, the medical personnel administered Primepran (I.M.) too.
Another added risk factor we came through was the non-administration of Ringer or Glucose
6 children
7 children
4 children
Enteroviral infection
Gastroenteritis
GERD
41
solution to treat the dehydration after taking Reglan. Certain authors emphasize the
contraindication of Metoclopramide in infants (<1 year old) because of the side effects [9] [10].
In recent years even though there is an increase in other anti-emetics like Domperidone or
Ranitidine to treat the acutely ill patients, Metoclopramide still remains the most preferred due
to best efficacy in clinical setting even though the literature suggests that there are no differences
in efficacy between Domperidone and Metoclopramide. Domperidone is suggested to be used
more due to its safer profile [11].
Ondansetron, a serotonin 5HT-3 antagonist, FDA approved for children older than 1 month of
age (earlier than any of the other medications discussed above). Scientific evidence support the
use of Ondansetron in children that present with vomiting [12]. It is the only antiemetic for which
there are randomized, controlled trials that support its use. A meta-analysis from DeCamp et al.,
all the children who were administered Ondansetron were less predisposed to have ongoing
vomiting, need for I.V. fluids or hospitalization. In Europe Ondansetron is available in 16
countries under the trade name Setofilm in 4 mg and 8 mg doses [13] [14].
Patient and parents experience these sudden and rapidly accelerated symptoms very dramatically
making it very hard to get an anamnesis.
One other study from LC Low and K M Goel observed 15 children with metoclopramide
(MaxoIon) poisoning. One of the 5 children accidentally poisoned developed slight
extrapyramidal signs. All 10 children who experienced extrapyramidal side effects while being
treated with metoclopramide had received a dose greater than that recommended by the
manufacturer of 0,5 mg/kg per day [15]. Dystonic reactions are likely to occur if the
recommended dose is exceeded, but individual susceptibility to metoclopramide and the
cumulative effect of repeated doses of the drug may also be important. Similar reasons were
identified in our study.
Conclusions
Side effects from Reglan solution (Metoclopramide) are common in pediatric population and
happen due to mistakes in dosing. Considering this medication has a low therapeutic index,
cautions to prescribe and administer the right dose are of the upmost importance. As a result, the
general practitioner and the pharmacists should be instructed that children younger than 1 year
old should not take this medication and if need be and there are no other alternatives it should be
administered with drops and not with coffee spoon (2.5 ml) or jam spoon (5 ml).
A healthy professional interaction between the physician, the pharmacist and the nursing staff is
very important in order to elude the mistakes in the future. Medical personnel should be advised
to not administer Metoclopramide P.O. or I.M. before starting fluids in order to hydrate the
patient when dehydration is present. After the electrolyte balances are controlled lowering the
risk of side effects, the patient can be administered Metoclopramide to control the vomiting.
References
1. European Medicines Agency recommends changes to the use of metoclopramide,
2013.
2. Sedat Işıkay, Kutluhan Yılmaz, Mehmet Almacıoğlu (2013) Evaluation of Patients
with Metoclopramide-Induced Acute Dystonic Reaction. JAEM 12: 80-84.
42
3. Selda Hizel Bulbul,Emine Dibek Misirlioglu,Erennur Tufan,Olcay Evliyaoglu (2010)
Side Effects of Metoclopramide: Does It Deserve to Prescribe For Nausea,Vomiting?
The New Journal of Medicine 27: 84- 86.
4. Witzel K. Extrapyramidal-motorische Störungen bei Kindern als Nebenwirkung der
Therapie mit Neuroleptica und dem neuen Antiemeticum Metoclopramid. Arch
Kinderheilkd. 1968 Sep;177(3):277–283. [PubMed]
5. Casteels-Van Daele M, Jaeken J, Van der Schueren P, Van den Bon P. Dystonic
reactions in children caused by metoclopramide. Arch Dis Child. 1970
Feb;45(239):130–133. [PMC free article][PubMed]
6. Fournier A, Pauli A, Ducoulombier H, Cousin J. Effets du surdosage en
méthoclopramide chez l'enfant. A propos de 9 observations cliniques. Pediatrie. 1969
Oct-Nov;24(7):799–805. [PubMed]
7. Cousin J, Katende C, Pauli A, Fournier A. L'intoxication par le Métoclopramide chez
l'enfant. Nouv Presse Med. 1972 Aug 26;1(30):1995–1995. [PubMed]
8. Sedat Işıkay, Mehmet Almacıoğlu, Kutluhan Yılmaz (2012) Metoclopramide Induced
Acute Dystonic Reaction in a Child: A Case Report. JAEMCR 3(2): 59-61.
9. Sills JA, Glass EJ. Metoclopramide in young children. Br Med J. 1978 Aug
5;2(6134):431–431.[PMC free article] [PubMed]
10. Bateman DN, Davies DS. Pharmacokinetics of metoclopramide. Lancet. 1979 Jan
20;1(8108):166–166. [PubMed]
11. LC K Low and K M Goel, Royal Hospital for Sick Children, Glasgow:
Metoclopramide poisoning in children 1980
12. Strange GR, Ahrens WR, Lelyveld S, Schafermeyer RW. Pediatric emergency
medicine: a comprehensive study guide. 2nd ed. Toronto, Ont: McGraw-Hill; 2002.
pp. 347–352.
13. 2. Canadian Paediatric Society, Nutrition Committee. Oral rehydration therapy and
early refeeding in the management of childhood gastroenteritis. Can J
Ped. 1994;1:160–164.
14. 3. Burkhart DM. Management of acute gastroenteritis in children. Am Fam
Physician. 1999;60(9):2555–2563. [PubMed]
15. 4. Kwon KT, Rudkin SE, Langdorf MI. Antiemetic use in pediatric gastroenteritis: a
national survey of emergency physicians, pediatricians, and pediatric emergency
physicians. Clin Pediatr (Phila) 2002;41(9):641–652. [PubMed]
43
Topic: Evaluation of the appearance of dermatological
bullous diseases in the oral cavity
Ilma Robo1, Vera Ostreni1, Eriola Meta1, Alert Xhaja2, Saimir Heta3
1Albanian University, Department of Stomatology, Tirana, Albania 2Department of Dermatology, QSUT, Tirana, Albania
3Department of Pediatric Surgery, QSUT, Tirana, Albania
Abstract
Introduction: Dermatological bullous diseases have visible signs in the oral cavity. The study is
aimed at early detection of oral lesions, to link them to the presence or not of apparent skin
disorders affecting the quality of the patient's lifestyle. Patient awareness of coexistence between
dermatological concerns and the presence of oral lesions should be the starting point of every
dentist during the intraoral examination, after drying of the mucous membranes and gingiva.
Materials and methods: The study includes patients randomly presented: patients at the
University Clinic AU and patients in the Dermatology Department, QSUT, during the period
between november 2017 and january 2018. Patients were evaluated according to the
Dermatological Life Quality Index (ICJD) and the presence of oral lesions in the oral cavity.
Results: Oral lesions reported in the patients appear to be more commonly occurring in female
patients than in male patients over 40 years of age. Oral buccal mucosa areas are more affected
than gingival area, palatum and tongue areas.
Conclusions: Detection of disorders during oral routine examination is the beginning to follow
the evolution of these dermatological bullous diseases, as the further prognosis also depends on
the moment of detection and awareness of the initial existence of the disease.
Keywords: ICJD, bullous diseases, oral mucous membranes, gingiva
Introduction
Patients affected by bullous diseases are divided into two categories, those who are pre-diagnosed
and well-informed of the presence of the disease, and those who do not know the presence of the
disease. In the last group, their first contact for more information is the dentist who checks,
examines and evaluates the presence of "wounds" in the mouth. The challenge in this process is
the duplication of primary lesions in secondary lesions, which are undiagnosed, and which still
make the clinical appearance of the patient more difficult.(1)
The other purpose of this study consisted in sensitizing the diagnosis of desquamative gingivitis,
about the connection of its existence with the presence of a non-expressed immunological disease
with a clinical appearance in the skin. Desquamative gingivitis is a symptom treated by dental
practitioners, but the agitation and all-inclusivity from the later disease of the organism causes
the patient to pass the dermatologist for further, hospitalized treatment. Sensitization about this
pathology makes dental practitioners more aware about the existence and the possibility of
treatment, or perhaps the referral of the patient to their peer specialists.(2)
Bullous diseases based on their clinical appearance in the oral cavity are implantable diseases for
the dentist, as it is emphasized the fact that intraoral examination may also be required for
44
extracorporeal surgery, and in addition to the strong stomach (teeth), the intracranial soft
structures, a well-behaved eye about the clinical appearance of soft tissue lesions. Bullous
diseases affect men and women more often than menopause, as the systemic flow of menopause
with its decreases and elevations promotes clinical expression of these diseases. Receiving data
in hospitalized patients and in outpatients helps in comparing the patient's views with these
diseases and at the dentist's view on patient access.(3) Each patient involved in the study is well-
informed, and then has been agreed upon in full consensus on the condition of the patient, became
part of the study, and then proceeded with the established protocol.
Materials and methods
The study includes patients randomly presented at the University Clinic AU and
patients in the Department of Dermatology, QSUT, time periods between November
2017 and January 2018. The patients of the first group included in the study, were
patients presented ad-hock at the University Clinic for periodontal treatment during the
period between November and January 2017-2018. All involved patients were informed
about the protocol and duration of the procedure, the obligation to answer some
questions, to examine and photograph in case of evidence of a lesson in oral cavity.
This protocol was also clarified with patients, carried out only for the effect of the study,
the patient would be kept anonymous, and in case of indication would be referred for
further examinations. Of the total of 400 patients, 89 of them refused to take part in the
study. 78% of respondents gave their consent to become a part of the study, some of
them (female gender) despite having been provided with the anonymity, were not ready
to present to others the sensation or symptoms they would questioned.
Every patient involved in the study is well informed, and then the consensus is fully
consensus to become part of the study, and then proceed with the established protocol.
The response to the questionnaire, Dermatological Life Quality Index (ICJD), was also
a part of taking the history.(6,20) The index consists of 10 questions that the patient can
answer in 5 different ways. The objective of this questionnaire is to see how the skin
problems last week affected the life of the patient. The answers are evaluated with the
following points: many 3 points, 2 points, 1 point and not at all, and 0 points.
The questionnaire is finally evaluated with a total score of 10 questions, as follows:
0-1 = no effect in the patient's life,
2-5 = minimal effect on patient's life,
6-10 = moderate effect on patient's life,
11-20 = significant effect on patient's life,
21-30 = very high effect on patient's life.
Results can also be translated into percentages eg, 3, 6.
Subsequently, patients underwent oral mucous membrane and gingival examination.
Every lesion or pathology was recorded. Patients were required to be photographed in
the lesson to be documented for further examinations.
Patients of the second group are patients who, with the help of the dermatologist and
with their consent, were only subjected to visual examination of skin lesions. Patients
of this group were patients in the Department of Dermatology QSUT Tirana, during the
same period above the first group patients (November-January 2017-2018).
Continuous data were presented in average and standard deviation, while discrete data
were presented in absolute value and in percentage. Graphs and tables of various types
(simple and complex) were used to present the data. P values smaller than 0.05 were
considered statically important. The statistical analysis was carried out mainly through
the SPSS version 15 program and partly through the MS Excel program.
45
Results
After collecting the data in the base table of excellence, they were processed for purpose of
displaying the results of the study according to the tables below.
Table 1. This table shows the availability of patients according to the male:female ratio, to be
included in the study where they could divide life-quality components based on the
dermatologically selected index.
Patiets Included % of inclusion Not included % of non-inclusion
Female 175 56% 62 70%
Male 136 44% 27 30%
Total 311 100% 89 100%
The average age of female patients was 43 years and the average age of male patients was 45
years (the patient involved in the study).
Graph 1. The graph shows the data on the inclusion of patients according to the female male
ratio, to the registration of the Dermatological Life Quality Index.
0%
20%
40%
60%
80%
Female male
Inclusion of patients according to male ratio: female
Included Not included
46
Table 2. Separation of patients by age and area of lesion - female, male patients.
Female
Patients
Lesions in
mucosa
% Lesions in
gingiva
% Lesions in
gingiva and
oral mucosa
%
≤ 39 vjeç 4 21% 0 0% 0 0%
≥40 vjeç 8 42% 4 21% 3 16%
Totali 12 63% 4 21% 3 16%
Figure 2. The graph shows the age-specific and lesion-specific patients - female patients / male
patients.
0%
20%
40%
60%
80%
≤ 39 vjeç ≥40 vjeç Totali
Female patients divided by age and appearance of lesions.
lesions at mucosa Lesions at gingiva Lesions at mucosa-gingiva
Male
patients
Lesions in
mucosa
% Lesions in
mucosa
% Lesions in
gingiva and
oral mucosa
%
≤ 39 vjeç 0 0% 2 29% 0 0%
≥40 vjeç 1 14% 4 57% 0 0%
Totali 1 14% 6 86% 0 0%
47
Table 4. The table presents the prevalence of dermatological disease by age in female and male
patients by age limit - 40 years.
Patients Female % Male %
≤ 39 vjeç 4 15% 2 8%
≥40 vjeç 15 58% 5 19%
Total 19 73% 7 27% Graph 4. The graph shows the prevalence of dermatological disease, by sex and age.
Table 5. The table presents the data collected from the Dermatological Quality Index,
according to the subsection below.
0-1 = no effect in the patient's life
2-5 = minimal effect on patient's life
6-10 = moderate effect on patient's life 11-20 = Significant effect on patient's life
21-30 = very high effect on patient's life.
0%
20%
40%
60%
80%
100%
≤ 39 vjeç ≥40 vjeç Totali
Male patients divided by age and appearance of lesions
Lesions atmucosa Lesions at gingiva Lezione nё mukozё-gingivё
0%
20%
40%
60%
80%
100%
120%
≤ 39 vjeç ≥40 vjeç Totali
Prevalence of dermatological disease, by sex and age
Female Male Total
48
Total at point of
reply Female % Male %
0-1 0 0% 0 0%
2-5 16 9% 4 2%
6-10 3 2% 3 1.7%
11-20 0 0% 0 0%
21-30 0 0% 0 0%
Total 19 11% 0 3.7%
The following figures give clinical cases presented to the Clinic.
Fig. 1. This figure shows oral lesions in a female patient under the age of 39.
Fig. 2. A female patient with site lesions in the ulcer, posterior region and hypersensitivity of
the other side is shown in this figure.
Fig. 3. Male patients with initial lesions of gingivitis defective in the area of the incisors and
maxillary mandibular molar-premolars.
49
Fig. 4. Patients with generalized dermatological lesions, posed in the Department of
Dermatology, QSUT.
Discussion
Patient availability data to be included in the study, from literature data can be said that there are
already many registered studies in well-informed and recorded dental students during the cycle
of studies, about patients involved in different studies. The difficulty lies in the fact that the
student is questioning the patient and this is what the latter puts, because the student pretends to
learn, instruct the patient about oral hygiene, or dental problems, or is the student who claims to
help patient with the goal of removing dental anxiety. This is the key to the inner conflict that
occurs in the patient, in answering if he/she wants to include in the questionnaire where the patient
will share personal information elements that are important to the patient.
Another element of the difficulty lies in the fact that the student should also explain how the
questionnaire meets. In some cases, even a member of a medical staff should be present, as
questioners may have difficulty in understanding how they should be fulfilled. This is the reason
why the questionnaires can be filled out by the patients themselves, or they must be filled in with
the presence of a dental student or a staff member. Sometimes, it is good for students to be offered
the personal experience of the medical staff member when he or she is a patient or student to
experience the patient's experience of understanding the patient's doubts in the decision whether
to include the questionnaire or not. Absolutely volunteer patient should be a patient willing to
50
help students in acquiring communication skills. There should be no limits and selection criteria
for volunteer involvement of patients in studies, widespread volunteer variety, enhanced student
experience, experience gained and assimilated, and more positive feedback.(25)
In support of published literature on clinical and pathological relationships of various oral lesions,
a non-compliance ranges from 17 to 42%. Still, in this literature, this discrepancy in the clinical
and pathological correlations of oral lesions depends on different factors, selected from
predetermined histopathological areas, total patient samples as percentages and patient types
varied between studies. This inconsistency also depends on the subjective variations of the
clinician and the histopathologist. There is a need for strict clinical and histological criteria for
establishing the diagnosis. In the case of our study, in view of the difficulties encountered in the
diagnosis and treatment of dermatological diseases of autoimmune origin in our country, the
imposition of these criteria was difficult.(15, 18) From the variety of dermatological diseases of
autoimmune origin, was only pemphigus is chosen with all its types, not the point of diagnosis
of various types of clinic of this disease, but only to identify, within the possibilities, endangered
individuals. In the results of our study were included exclusionary criteria, all patients who were
positive to Kobner's symptom. This is to exclude patients prone to dermatological diseases, not
the appearance of gingivitis in the oral cavity.
Based on the research in literature, pemphigus vulgaris reflects a total susceptibility of 12.5%,
for example with lichen planus in 37.5% or leukoplakin with 20% susceptibility.(23) Backed up
to this source of literature in patients with lichen planus male ratio: female was 43.3% with
56.6%, for leukoplakin was 60% with 40% and for pemphigus vulgaris was 60% at 40%. For
lupus erythematosus the patient's vulnerability to this disease was 12.5% divided by gender by
30% with 70%. In the case of our study, the susceptibility to male ratio: female was 27% at 73%.
Further, the purpose of the study was the age effect on the appearance of dermatological disorders
of patients.
The age limit set in our study is 40 years of age. Lessons and dermatological problems
encountered before the age of 40, or after the age of 40 years. This age limit was only based on
fact that this age serves as the limit of starting the initial menopause signs. It is known that
sensitive fluctuations in sex hormone levels have a significant effect on sensitive fluctuations in
the female body, immune response rates, and the susceptibility of the organism to dermatological
diseases of autoimmune origin. By comparing the age levels of oral lesions in the oral cavity for
autoimmune diseases, in relation to local risk factors, it can be said that the largest number of
patients with lichen planus, lupus erythematosus and pemphigus vulgaris ranged from 31 to 45
years and leukoplakis lesions, the age of patients varies from 46 to 60 years. If we talk about the
average age of patients affected by these diseases specifically for lupus is 38 years old with
standard deviation 14.62, for lichen planus is 39.6 years with a standard deviation of 14.62, for
pemphigus vulgaris the average age is 38 years with a standard deviation of 11.73.(22, 24) In our
study, the average age of female patients was 43 years and the average age of male patients was
45.(25) In our study, the average age of the patients was 45 years and the average age of the patients
was 45.(25)
Only gingivitis lesions can occur, but can also occur in mucosal lesions, or in both areas at the
same time. Moreover, when we talk about pemphigus, when it is necessary that the lesion's
laboratory analysis be confirmed with direct immunofosforism and reconfirmed with indirect
immunofosforce. Both analyzes should be positive to confirm the safe presence of the disease.
Analysis that is costly for the patient, but when performed in the right time prevents the disease,
when the treatment begins in the right time. Advice for dental professionals includes some of the
following:
A complete oral mucous examination should be performed, evaluating for any anomalies,
including complications in the oral cavity of pemphigus or pemphigoid treatment, such as
candidosis, so everyone needs to be careful about maintenance schedules and set more frequent
schedules to control the gravity and progression of the disease.(1,2)(5,7-11) Nisengard and Levine(10)
cited as standard in establishing clinical diagnosis of gingivitis, chronic rash, ulceration, and/or
51
bubble formation. Gingivitis deskuamtiv: (1) presence of gingival erythema that does not result
from the plaque, (2) gingivitis, (3) other intraoral lesions and sometimes extra, sore mouth
complaints, especially in case of application of aromatic foods. It is reported that most cases of
dysfunctional gingivitis are caused by some mucocutaneous diseases. (5, 7-9) In our study, the
initial signs of dysfunctional gingivitis are present in 7 patients, but all of these in lighter clinical
signs.
Pemphigoid mucosal membrane and lichen planus erosive are the most common causes of
dysfunctional gingivitis, respectively 48.9% and 23.6% of all cases of dysfunctional gingivitis.(8)
In our patients there were no pruritus signs in the skin of the back or on the dorsal surfaces of the
arms and legs, which removed the clinical diagnosis of pemphigus vulgaris from the lichen
planus. In the patients involved in the study, there were no sign of symblepharon, a clinical sign
that removed the clinical diagnosis from pemphigoid. Histopathological examination and direct
immunofluorescence testing are necessary to establish the ultimate diagnosis of diseases
responsible for the defective gingivitis. (5, 7, 9-11) Given that pemphigus vulgaris is potentially fatal,
the recognition of gingival lesions of gingivitis desquaming, though rare, is essential for ultimate
diagnosis, timely therapy, and patient follow-up. There are cases where it is needed for more than
1 year until the final diagnosis of pemphigus vulgaris(25), which is measured after the patient's
appearance in the dental unit, with primary signs of oral cavity. During this period, the patient
visited a dental clinic, an otolaryngology clinic and an internal medicine clinic, but no final
diagnosis was provided at any of these clinics. Reasons for delayed diagnosis may be explained
by the fact that the symptoms of pemphigus vulgaris of the patient are limited to the gingiva and
are clinically very light and by the fact that the symptoms occur in repeated cycles of healing and
deterioration.
For the final diagnosis of pemphigus vulgaris, the following criteria must be met: (1) the presence
of relevant clinical lesions, (2) confirmation of acantholysis in biopsy specimens, and (3)
autoantibody confirmation in tissue or serum, or both. In the present case, a final diagnosis of
pemphigus vulgaris was made based on a general assessment of the following findings: (1)
positive phenomenon of Nikolsk, (2) presence of acantholysis in biopsy specimens, and (3)
locating deposition of antibodies between epithelial cells with direct immunofluorescence test.
All patients involved in the study are recommended for further visits to dermatologists, as
establishing a diagnosis for pemphigus is a multidisciplinary decision in terms of treatment and
diagnosis for such diseases in our country.
Conclusions
The documented data showed the presence of initial signs of gingivitis desquamative, clinical
signs that should be checked and carefully examined by dental specialists as they are the first to
contact the patient suffering from these symptoms.
Dermatological diseases of autoimmune origin, classified as vesiculobulose diseases, are
encountered in the gingiva, in the mucous membranes, or in the gingiva and in the mucous
membranes. For female patients, tachycardia appears more frequently in the lining of the mucous
membrane, while for male patients, tachycardia appears more frequently with gingival lesions.
The fact that women are most affected by autoimmune bulous lesions and higher predisposition
have been confirmed by women over the age of 40. The impact of the skin on the patient's
difficulties during the day-to-day activity is more pronounced in female patients than in male
patients, which is based on the Dermatological Life Quality Index assessment, applied in our
study.
Acknowledgments: Our thanks belong to our family. Henri and Hera drive us forward, and
further in the field of scientific research.
52
Author Contributions: Literature research was conducted by Dr. Saimir Heta. It was his
insistent work that made it possible to reach the conclusions in this article.
Conflicts of Interest: We declare that there is no conflict of interest between the authors and the
material presented in this article.
References
1. Stanley, John R. (2003). "Chapter 59: Pemphigus". In Freedberg; et al.
Fitzpatrick's Dermatology in General Medicine (6th ed.). McGraw-Hill.
p. 559. ISBN 0-07-138067-1.
2. https://media.gettyimages.com/photos/pemphigus-vulgaris-an-autoimmune-
intraepithelial-blistering-disease-picture-id128575331).
3. http://www.ijdvl.com/articles/2015/81/6/images/ijdvl_2015_81_6_655_168342_f1.jp
g.
4. Irwin M. Freedberg; et al., eds. (2003). Fitzpatrick's dermatology in general
medicine (6th ed.). New York, NY [u.a.]: McGraw-Hill. p. 558. ISBN 0-07-
138076-0.
5. International Journal of Women's Dermatology; Volume 1, Issue 1, February
2015, Pages 4-12.
6. Cathy Y.ZhaoMBBS, MMedDédée F.MurrellMA, BMBCh, FACD, FAAD,
FRCP, MD; ”Autoimmune blistering diseases in females: a review”; Int J
Womens Dermatol. 2015 Feb; 1(1): 4–12.; Published online 2015 Feb 26.
doi: 10.1016/j.ijwd.2015.01.002.
7. Theofilopoulos AN. The basis of autoimmunity: Part I: Mechanisms of aberrant self-
recognition. Immunol Today. 1995;16:90–97. [PubMed]
8. Aoki V1, Rivitti EA, Diaz LA; “Update on fogo selvagem, an endemic form of
pemphigus foliaceus.; Cooperative Group on Fogo Selvagem Research”; J
Dermatol. 2015 Jan;42(1):18-26. doi: 10.1111/1346-8138.12675.
9. Carranza – Clinical periodontology; Mosby 2009; Kapitulli Gingiviti Deskuamativ.
10. Kim D. Edhegard, Russell P. Hall, in Clinical Immunology (Fourth Edition),
2013.
11. Hashimoto T, Teye K, Ishii N. Clinical and immunological studies of 49
cases of various types of intercellular IgA dermatosis and 13 cases of
classical subcorneal pustular dermatosis examined at Kurume University. Br
J Dermatol 2017; 176:168.
12. J Am Acad Dermatol. 1990 May;22(5 Pt 2):917-9. Intraepidermal neutrophilic IgA
dermatosis. Kuan YZ1, Chiou HT, Chang HC, Chan HL, Kuo TT. Dermatology
1992;185:311–313.
13. Gengoux P. · Tennstedt D. · Lachapelle J.M.; Intraepidermal Neutrophilic IgA
Dermatosis: Pemphigus-Like IgA Deposits; Unit of Occupational and Environmental
Dermatology, Louvain University, Brussels, Belgium; Dermatology 1992;185:311–
313; (DOI:10.1159/000247480).
53
14. Korman NJ1, Eyre RW, Zone J, Stanley JR. Drug-induced pemphigus:
autoantibodies directed against the pemphigus antigen complexes are present in
penicillamine and captopril-induced pemphigus. J Invest Dermatol. 1991
Feb;96(2):273-6.
15. Landau M1, Brenner S. Histopathologic findings in drug-induced pemphigus. Am J
Dermatopathol. 1997 Aug;19(4):411-4.
16. https://www.mayoclinic.org/-/media/kcms/gbs/patient-
consumer/images/2013/08/26/10/29/ds00749_im01954_r7_pemphigusfoliac
eusthu_jpg.jpg.
17. https://www.mayoclinic.org/-/media/kcms/gbs/patient-
consumer/images/2013/08/26/10/05/ds00749_im00813_ans7_pemphigusthu
_jpg.jpg.
18. Ferri FF. Pemphigus vulgaris. In: Ferri FF, ed. Ferri's Clinical Advisor 2016.
Philadelphia, PA: Elsevier; 2016:941-942.
19. Habif TP. Vesicular and bullous diseases. In: Habif TP, ed. Clinical Dermatology. 6th
ed. Philadelphia, PA: Elsevier; 2016:chap 16.
20. Finlay AY, Khan GK. "The Dermatology Life Quality Index: A simple
practical measure for routine clinical use". British Association of
Dermatologists Annual Meeting, Oxford, July 1993. British Journal of
Dermatology, 1993; 129 (Suppl 42): 27.
21. Finlay AY, Khan GK. "The Dermatology Life Quality Index: A simple
practical measure for routine clinical use". British Association of
Dermatologists Annual Meeting, Oxford, July 1993. British Journal of
Dermatology, 1993; 129 (Suppl 42): 27.
22. Finlay AY, Khan GK. Dermatology Life Quality Index (DLQI) - a simple
practical measure for routine clinical use. Clinical and Experimental
Dermatology, 1994; 19: 210-216.
23. Anstey A, Reynolds NJ. "What does the BJD now stand for? A position
statement". British Journal of Dermatology 2015; 172: 1463-1465.
24. World Health Organisation. Global report on psoriasis. ISBN 978 92 4
156518 9. WHO Press, Geneva, 2016, p16.
25. https://www.google.com/url;health.adelaide.edu.auFvolunteer-patient-program.
54
RECIPROCAL GENETIC EFFECTS IN WEIGHT AND
BLOOD GROUPS
Naser Kamberi1 , Hyzer Rizani2
UBT - Higher Education Institution, Lagjja Kalabria, 10000 p.n., Prishtina, Kosovo
Abstract. Based on the actions of the genes within the cell as a whole in this study we present
the correlation of body weight with blood groups. In this study are included individuals of both
genders. To accomplish this work without any selection are included 400 individuals of which
200 are men and 200 are women. In this sample of 200 individuals, both sexes for each blood
group were included in 50 females and 50 males (4 groups x 50 = 200). This paper is intended
to observe body weight comparisons between individuals with different blood groups of both
sexes and their similarities based on these two traits. It is worth mentioning that these two
qualities are genetically different because weight is a quantitative quality because here besides
the genetic influence factor there is also the environmental factor, while on the other hand the
blood groups are mainly attributed to the genetic factor. By doing the calculations of values we
can show which blood group has the highest body weight of both genders and whether there is a
similar ratio between the two genders.
Keywords: genetic effect, reciprocal, weight, blood groups.
Introduction
The correlative research of the influence of blood groups on body weight can be done by
comparing the values of the obtained results. For this reason, the results of this paper can be
considered as a modest contribution to the recognition of the blood's body's influence on body
weight in humans. This impact will appear based on the values gained in which group of blood
we have the highest body weight and how the ratio in the other groups stays. We can also observe
the results of both sexes by presenting variables to both sexes. Individuals included in this study
are 18 year old students of 3 generations. Measurement and determination of blood groups was
done in 2016-2108 in the same age students at the Presevo High School. The research and
preparation of such a genetic and anthropometric study in essence has to do with how the weight-
to-blood relation binds to blood groups.
Material and methods
As a research material in this study is included sample which totals 400 students. From this
sample included in this study 200 belong to the female gender and to as many as 200 male gender.
For each group of blood were taken into consideration by 50 individuals as follows: 50 female
students per blood group O, 50 men with blood group O, 50 female students per blood group A,
50 men with blood group A, 50 female students for blood group B, 50 men with blood group B,
50 women for AB blood group, and 50 men with blood group AB. Data collected by individuals
are recorded in the data evaluation software program. Mathematical-statistical methods were used
to obtain these results.
55
The material included in this study appears in Table 1.
Table1. The material involved in this study
Male-18
years
Fre
quen
cy (
M)
mal
e
Female-
18 years
Fre
qu
ency
(F
)
fem
ale
Group
A
Group B
Group
AB
Group O
Weight Weight M F M F M F M F
48 6 45 5 1 1 2 1 2 1 1 1
49 5 46 5 0 1 2 1 2 1 2 1
51 5 47 8 1 2 2 2 2 1 1 1
52 5 48 4 1 1 1 1 1 0 1 0
54 4 49 6 0 0 2 2 1 1 1 1
55 5 50 4 2 2 0 1 1 1 2 1
56 6 51 12 2 5 1 2 1 3 2 2
57 7 52 8 2 2 1 1 2 1 1 2
58 9 53 9 2 4 1 1 1 2 2 3
59 6 54 9 3 3 2 1 2 2 2 2
60 10 55 8 4 2 2 2 2 2 3 2
61 9 56 15 1 3 2 3 3 5 2 3
62 10 57 13 3 4 1 2 2 2 2 4
63 10 58 8 3 1 2 1 2 1 3 2
64 11 59 10 3 4 2 2 3 2 3 6
65 10 60 9 3 2 3 2 3 2 3 2
66 7 62 9 3 3 2 2 1 2 2 3
67 9 63 10 2 4 2 2 2 2 1 3
68 18 64 8 3 0 2 2 2 2 3 0
69 11 65 9 3 1 2 3 3 2 3 1
71 10 66 9 3 1 3 2 2 2 2 5
72 7 67 7 2 2 2 3 2 2 2 2
73 6 68 5 2 1 3 2 1 3 2 1
75 5 69 5 1 1 2 3 2 2 2 1
81 4 70 2 0 0 3 3 3 3 1 0
87 5 73 3 0 0 3 3 2 3 1 1
200 200 50 50 50 50 5
0
5
0
50 50
56
Results and discussion
Based on measurements of body weight in individuals with different blood groups according to
the results obtained we see a change in weight. Of the total male number is of higher weight for
1333 kg than that feminine. The total male average is 64.585kg while on the other hand the female
gender is 57.92kg average and based on these values the difference is 6.665kg. These results are
presented in Table 1 where we have 200 men and 200 women in discussion. Results presented in
Table 2. represent the average body weight of individuals for each blood group.
Table 2. The value of the average body weight
The average body weight in masculine (M) and feminine (F)
Total weight
=12917(M)
Total weight =11584 (F) Change M 1333 > F
12917/200= 64.585 11584/200=57.92 Change M 6.665> F
Apart from the arithmetic average, we also have the average of the position which is less accurate
than the arithmetic average. How is the word moda that includes the size of the weight that is
repeated most often. In our case the size which is repeated more often in males is 68 kg (it is
repeated 18 times). If we make these sizes with a graph, then we will have a curve.
The curve represents the mod.
Graph.1. Presentation of the mod masculine roof
In feminine mod females appearing with a peak of 15 times the weight of the parks is 56 kg.
Analyzing the value of the arithmetic average with the mod values of both sexes it is obvious that
in men the mod has the highest value for 3.415 kg, whereas in females these values are much
more approximate and here the arithmetic mean value is greater for 1.92 kg (roughly 2kg) than
the value of mod.
57
Graph.2. Presentation of the mod feminine roof
Likewise, we have the Median which represents a size of the central position starting from the
smallest to the largest. In this case men of 26 variances have two central values of 61kg and 62kg
and here we have a theoretical average that is the average of two sizes standing in the middle of
the rankings worth 61.5kg. Median females include 56 kg and 57 kg weight and in this case the
average of two sizes is 56.5 kg.
Table 3. Average weight by blood group male (M) and female gender (F)
Table 3 where the mean values for weight (P) for male and male sex (F) are presented by blood
groups, based on the obtained results it is clear that men with blood groups B and AB are of a
weight greater than individuals with group A and 0. While on the other hand, the females with
blood group B and AB have a higher body weight than women with group 0 and A. Individuals
with blood group 0 are more closely related to those with group B and AB than individuals with
blood group A. This phenomenon may be a cause of evolution as this antigen-free group does
not refuse antigen B compared to antigen A.
Based on these results it is clear that individuals with blood groups B and AB have a correlation
with body weight. This means that group B and AB are related to the quality of body weight.
This is confirmed by the fact that even individuals with AB blood group have antigen B which
seems to have effects on body weight. While the Beta antibody in the blood group A has no effect
on body weight. Therefore we can say that the effect of weight is related to antigen B. Since
alleles of blood groups are found in chromosome 9, we may think that genes for body weight
may also be located in the same chromosome and considered as related genes. As compared to
Blood
group
0 A B AB
Gender M F M F M F M F
Weight
average
63.56 58.4 56.44 57.02 65.34 59.96 64.24 60.02
Total
weight
3178
2920 2822 2851 3268 2998 3212 3001
58
AB it is seen a proximity associated with the presence of antigen B in the AB blood group. These
results are presented in Table 3 for both sexes, males and females. Body weight ratios by blood
groups are also shown in graph 3. Observing visually clearly men dominate in three blood groups
in weight such as 0, B and AB, while on the other side of blood group A, the phenylalanine has
greater weight.
Graph.3. Appearance of arithmetic mean of body weight of both sexes by blood groups
Table 3 shows weight values of 50 males and 50 females by blood group: 0, A, B and AB. These
values are as follows and based on the results we have graph
4.
Graph.4. Presentation of tidal weight values by blood groups of both sexes
0 A B AB
M F M F M F M F
63.56 58.4 56.44 57.02 65.34 59.96 64.24 60.02
3178
2920 2822 2851 3268 2998 3212 3001
59
Table 4 is called a matrix of distances between populations by blood groups, but also changes in
weight. This shows the changes in body weight between individuals with blood groups A, B, AB
and 0. Observing these results according to mathematical calculations it is clear that group B and
AB are of greater weight than the other two groups and are more roughly equal value. Smaller
values are individuals with blood group A.
Table4. Change of weight medians expressed in kilograms of males (M) and females (F) by blood
group
These weight-loss results clearly indicate that this feature is associated with blood group B and
since this antigen B is also found in group AB the values of both groups are greater than the other
two groups A and 0.
Conclusions:
On basis of these results get out these conclusions:
1. Based on the results of the fit we can say that the body weight is tied to the group B.
2. Blood group AB has proximity to group B values based on the presence of antigen B in group
AB.
3. The largest change is group A that is smaller than group B value for 8.9 kg weight.
4. I think that this is the cause of evolution since group B is the third in a row.
Acknowledgements: I thank the schools for the help of collecting the material.
References:
1. Arthur C. Guyton,; Medicinska fiziologija. Medicinsaka knjiga, Zagreb, 1986, 39-55.
2. D.Ninoslav; S. Zoran. 2004.Principi genetike.Beograd.201-220.
3. Kurelic N, Momirovic K, Stojanovic , Sturm J, Radojevic D, Viskic–Stelac N.;
Struktura i razvoj morfoloshkih i motorickih dimenzija omladine. Beograd, 1975.
4. Stojanovic M.; Biologija razvoja covjeka sa zdravstvenom kontrolom. skripta,
Beograd, 1961, 13-19
5. Radojevic Dj.; Fizicki razvitak, motorne i funkcionalne sposobnosti skolske omladine
SR B i H. Zavod za fizicku kulturu, Sarajevo, 1972, 1-6.
Group
s
>A >B >AB >0
M F M F M F M F
A< / /
<8.9k
g <2.94kg <7.8kg <3kg <7.12kg <1.38kg
/ / / / / / / /
B< / / / / 1.1kg> <0.06kg 1.78kg> 1.56kg>
/ / / / / / / /
AB< / / / / / / 0.68kg> 1.62kg>
/ / / / / / / /
60
The impact end therapeutic efficacy of chlorhexidine-gel
in gingival inflammation in chronic Periodontopathy
Sahmedin Sali¹,
¹ Sahmedin Sali, Univesity of Tetova, Faculty of Dentistry, Tetovo, Republic of
Macedonia,
Abstract. Objectivies: evaluation of the impact therapeutic effect of the gel which contain
Chlorhexidine Gluconate on the gingival inflammation through comparative analysis in patients
with the application of the conventional method (CM) and conventional therapy supported with
Chlorhexidine Gluconate Gel (KM-G) .
Materials and Methods: For the realization of our aim was included 30 patients from both
genders, aged 20-50 years, in which radiographic and clinically was diagnosed chronic
periodontal disease with a periodontal pocket depth of 3 mm but not exceeding 5 mm. The
subjects are divided in two groups: in the first was used only the conventional method and in the
second the subjects were treated with KM - G. In both groups included in this study we have
determined the index by Loo-Sillnes and the index of the gingival inflammation by Sillness –
Loo in four time points: the first during the initial treatment at the first examination. Then after
5th day, after 10th day and on the end after the 30th day from the first treatment. The Chlorhexidine
Gluconate Gel in patients was administered at the beginning during the first examination. The
numerical statistical was analyzed with descriptive statistics methods ( Mean ± Standard
deviation . , ± 95 % CI , Min . , Max . ), while the interactive effects between the two examined
methods after the first treatment during the first examination , at 5th, at 10th and at 30th day, were
analyzed with the Repeated measures Anova ( F ) / Post - hoc Bonferroni test ( p ) .
Results. The results show reduction of the dental plaque and of the gingival inflammation in both
groups after the 5 th, 10 th and after the 30th days from the initial treatment in comparison with the
first examination. The comparison of the dental plaque index and the index of gingival
Inflammation on the 5th, 10th and 30th day between the both groups, demonstrate significantly
better therapeutic efficiency in the group treated with KM which was supported with using of
the Chlorhexidine Gluconate Gel.
Conclusion: The subjects treated with the KM- G , as opposed to those treated with KM, had an
significantly improved clinical effects which were observed through decreased gingival
inflammation and trough dental plaque reduction in all stages of our research .
Keywords: chronic periodontal disease, gingival inflammation, conventional therapy,
chlorhexidine gluconate gel .
Introduction
Bio film as unavoidable etiologic factor in its content and structure contains bacterial
conglomerate which with toxins, enzymes and other associated factors cause gingival
inflammation i.e. progressive destruction of connective tissue attachment and alveolar bone ⁽¹⁾.
61
The control of dental plaque through daily maintenance of oral hygiene, removing the newly
emerging supra and sub gingival plaques are one of the ways to act preventive or curative when
the gingival inflammation appears or to preserve the achieved therapeutic success ⁽²⁾.
Irregular and unskilled mechanical instrumentation can damage the hard tissues where the sign
is the appearance of gingival recession ⁽ᶟ’⁴⁾.
In therapeutic treatment despite of removing plaque microorganisms mechanically, in clinical
practice is used chemotherapy antimicrobial local or systemic therapy.
On these objectives are used many methods which in this occasion would apostrophized CIST-
protocol.
CIST-protocol or otherwise named, modify the conventional (basement) periodontal method, as
a therapeutic procedure which includes antimicrobials assets or modern antiseptic assets in the
form of a gel, in which the leadership belongs to chlorhexidine.
Based on the latest scientific knowledge and proven results on the effectiveness of local
administration antiseptic assets in gel form, we set the goal of this research, we follow the
therapeutic effect of chlorhexidinegluconate gel on gingival inflammation through comparative
analysisof patients using conventional therapy (KM) and conventional therapy aided by
chlorhexidinegluconate gel (KM-G).
Material and working method
For realization of this goal, the research is implemented in the dental office “Fjolla medica” in
cooperation with the Clinic for mouth and periodontal Diseases in Dental Faculty, where were
followed 30 patients of both sexes aged 20-50 years where was diagnosed with X-ray and
Periodontopathy in second clinical stage.
From all examinees were taken anamnestic data and was carried out clinical examination by
analyzing the x-ray.
Examinees who were a part of this study were divided into 2 groups:
- Examinees from the first group were treated with conventional method (KM)-
standard method (removing local irritation, dental plaque, tartar and processing
periodontal pockets). In this group the toilet of periodontal pocket was consisted of
rinsing with 3% hydrogen and maintaining oral hygiene.
- Examinees from the second group were treated with combined method
conventional- method and application of chlorhexidine gluconate gel (KM-G),
following processing periodontal pockets.
Patients who formed the group treated by KM-G were given instructions after application of the
gel, maintaining good oral hygiene.
Chlorhexidine gluconate gel product on the market known as CHLO-SITE contains 1.5%
chlorhexidine in the form of xanthan whose producer is the Ghimas Company from Italy.
The research was made in several stages: with the first examination of the patient, after 5, 10 and
30 days of the conventional procedure and the same procedure aided by chlorhexidine gel
therapy.
To all examinees were made clinical examinations through the evaluation of dental plaque and
gingival inflammation index.
The Gingival inflammation index is determinate by the Loe-Silnes method.
The findings were compared between the two groups in different examined groups i.e. after
admission, 5, 10 and 30th day of the treatment. All obtained results were statistically processed.
In series with numerical marks are assessed: Descriptive statistics
(Mean±Std.Dev.,±95%CI,Min.,Max.), while the interactive effects of the two examined methods
62
after the treatment due to the first examination, after 5, 10 and 30 days were examined according
to the Repeated measures Anova (F)/Post-hoc-Bonferroni test (p).
Results
Table 1 presents gingival inflammation (during the first examination, after 5, 10 and 30 days), on
patients with KM and KM-G. The given results of this research are shown in table 1 and chart
1)
For F=88,23 and p<0,001 (p=0,000) in given distribution there was significant difference (table
1 and chart 1)
The patients treated with KM-G after 5th day of the control for p<0,001 (p=0,000) there was
significant lower gingival inflammation (0,27) , compared with the first examination (1,48). We
found identical results after the 10th controlling day, for p<0,001 (p=0,000) with gingival
inflammation (0,13) compared with the first examination (1,48). Significant gingival
inflammation p<0,001 (p=0,000) was noticed even after the 30th day of the treatment.
Table 1.Display of gingival inflammation to the examined groups in different time periods on
patients treated with both methods.
G.inf.*Group ; LS Means; Current effect: F(3, 84)=88,23, p=0,000 Effective hypothesis
decomposition
Group treated with: Gingival inflammation
DV_1
Mean
DV_1
Std.Err
.
DV_1
-
95.00%
DV_1
+95.00
%
N
1 KM-G First examination 1,48 0,06 1,35 1,61 1
5
2 KM-G After 5 days 0,27 0,04 0,19 0,35 1
5
3 KM-G After 10 days 0,13 0,05 0,02 0,24 1
5
4 KM-G After 30 days 0,02 0,03 -0,03 0,07 1
5
5 KM First examination 1,49 0,06 1,47 1,73 1
5
6 KM After 5 days 0,92 0,04 0,85 1,00 1
5
7 KM After 10 days 0,91 0,05 0,80 1,02 1
5
8 KM After 30 days 1,08 0,03 1,02 1,13 1
5
63
Chart 1.Therapeutic efficacy of the use of various therapeutic modalities in both groups in
different time periods
G.inf .*Grupa; LS Means
Current ef f ect: F(3, 84)=88,233, p=0,0000
Ef f ectiv e hy pothesis decomposition
Vertical bars denote 0,95 conf idence interv als
Grupa
!~\FT1,,,gel
Grupa
!~\FT1,,,standardG.Inf ./priem G.Inf ./kon5 G.Inf ./kon10 G.Inf ./kon30
G.inf .
-0,4
-0,2
0,0
0,2
0,4
0,6
0,8
1,0
1,2
1,4
1,6
1,8
2,0
DV
_1
The given results show reduction of gingival inflammation to all examinees that were treated
with KM and KM-G in all stages of research, after 5, 10 and 30 days, against results of the first
examination. Comparison between two groups showed improved clinical results in the group
treated with KM-G.
Table 2. Display of gingival inflammation – Post-hoc Test/Bonferroni test/ on both examined
groups compared with receipt day, 5, 10 and 30 day of treatment.
Group Gingival Inflammation
{1}
1,48
{2}
0,27
{3}
0,13
{4}
0,02
{5}
1,60
{6}
0,92
{7}
0,91
{8}
1,08
1. KT-G First treatment 0,000 0,000 0,000 0,000 0,000 0,000
2. KT-G after 5 days 0,000 0,03 0,000 0,000 0,000 0,000 0,000
3. KT-G after 10days 0,000 0,03 0,000 0,000 0,000 0,000
4. KT-G after 30 days 0,000 0,000 0,000 0,000 0,000 0,000
5. KT First treatment 0,000 0,000 0,000 0,000 0,000 0,000
6. KT after 5 days 0,000 0,000 0,000 0,000 0,000 0,01
7. KT after 10 days 0,000 0,000 0,000 0,000 0,000 0,003
8. KT after 30 days 0,000 0,000 0,000 0,000 0,000 0,01 0,003
From table 2. Evident is better therapeutic result in the group treated with KM-G against KM
after 5, 10 and 30 day of the treatment.
64
Table 3. Display of dental plaque on the examined groups in different time periods in patients
treated with both methods.
D.plaque*group; LS Means; Current effect: F(3, 84)=1,47, p=,23
Effective hypothesis decomposition
Group Dental plaque DV_1
Mean
DV_1
Std.Err.
DV_1
-95,00%
DV_1
+95,00% N
1 KM-G Treatment 1,41 0,18 1,03 1,78 15
2 KM-G after 5 days 0,01 0,01 -0,02 0,03 15
3 KM-G after 10 days 0,04 0,03 -0,01 0,09 15
4 KM-G after 30 days 0,05 0,18 -0,32 0,43 15
5 KM Treatment 1,42 0,18 1,50 2,23 15
6 KM after 5 days 0,05 0,01 0,03 0,08 15
7 KM after 10 days 0,11 0,03 0,05 0,16 15
8 KM after 30 days 0,43 0,18 0,06 0,81 15
On table 3. Display distribution of dental plaque (examination control after 5, 10 and 30 days)
to the patients treated with KM method and to the patients treated with KM-G).
For F=1,47 and p>0,05 (p=0,23) in the shown distribution do not exist significant difference
(table 3 and chart 2)
Chart 2. The presence of dental plaque among respondents after application of different treatment
modalities in both groups in different time periods
65
D.plak*Grupa; LS Means
Current ef f ect: F(3, 84)=1,4714, p=,22822
Ef f ectiv e hy pothesis decomposition
Vertical bars denote 0,95 conf idence interv als
Grupa
!~\FT1,,,gel
Grupa
!~\FT1,,,standardD.plak/priem D.plak/kon5 D.plak/kon10 D.plak/kon30
D.plak
-1,0
-0,5
0,0
0,5
1,0
1,5
2,0
2,5
3,0
DV
_1
Table 4: Are displayed values of dental plaque – Post-hoc Test/Bonferroni test/ on the both
groups compared with the day of receipt, 5, 10 and 30 day of the treatment.
Table 4. Display of dental plaque – Post-hoc Test/Bonferroni test/ on the both groups compared
with the day of receipt, 5, 10 and 30 day of the treatment.
Group Dental plaque {1} 1,41
{2} 0,01
{3} 0,04
{4} 0,05
{5} 1,87
{6} 0,05
{7} 0,11
{8} 0,43
1 KM-G receipt 0,000 0,000 0,000 0,000 0,000 0,000
2 KM-G after 5 days 0,000 0,000
3 KM-G after 10 days 0,000 0,000
4 KM-G after 30 days 0,000 0,000
5 KM Receipt 0,000 0,000 0,000 0,000 0,000 0,000
6 KM after 5 days 0,000 0,000
7 KM after 10 days 0,000 0,000
8 KM after 30 days 0,000 0,000
There isn’t any significant difference (p>0,05) for the dental plaque, between two groups from
the first treatment.
66
The patients who were treated with KM-G after the 5th day for p<0,001 (p=0,000) they have
significantly lower presence of the dental plaque (0,01) compared with the reception day (1,41).
Identical results were observed on the patients treated with KM-G after the 5th day of control, for
p<0,001 (p=0,000) they have significantly lower presence of dental plaque (0,01), compared with
the patients treated by KM, (0,04), as well as the control after the 10th day to the examinees who
were at KM-G for p<0,001 (p=0,000) they have much lower presence of dental plaque (0,04)
compared with those who were treated with KM (0,11).
The patients treated with KM-G after the 30th day for p<0,001 (p=0,000) they have significantly
lower presence of dental plaque (0,05), compared with the group treated on KM (0,43).
Discussion
Dental plaque as an important segment in the etiology of many dental and periodontaldiseases
we say it is organic layer of teeth, colorless, opalescent and slimy substance made up of many
micro-organisms that cause the initial vascular changes in gingival tissue and otherpathogenic
events that ended with the loss of collagen tissue and apical migration on epithelial connection⁽⁵⁾.
In fact, most of the authors confirm the connection between plaque and gingival inflammation
⁽⁵˒⁶˒⁷⁾ and definitely confirm the theory of periodontal pockets and periodontal disease.
This study, analyzed the difference in the presence of dental plaque using the both methods:
conventional and conventional plus chlorhexidine gel. The results showed that there was no
significant difference in the presence of dental plaque between those two groups after the first
examination of the patients, but there was significant difference in the presence of dental plaque
after the 5th day of the treatment. After the 10th and 30th day it was the same situation between
the both groups.
After the complete treatment regardless in what period was made and which method was used, it
was evident the reduction of index value of dental plaque.
Statistics showed that patients treated with classic method after the 5th (0,05), the 10th (0,11) and
the 30th day (0,43), were having much lower presence of dental plaque compared to the first
examination (1,42). The same results we found when we analyzed the patients treated with
conventional method adding the gel after the 5th (0,01), 10th (0,04) and 30th day (0,05). In this
case was recorded much lower presence of dental plaque compared with the first visit (1,41).
Especially evident fact of this research was the magnificent lower values of the dental plaque in
the group treated with KM-G in all stages of this research.
Our results were obtained in accordance to the results of many authors ⁽⁸˒⁹˒¹⁰⁾ and they confirmed
that the application of chlorhexidine gel in the treatment of periodontal disease effectively had
influence on the clinical symptomatology.
Actually, the CIST-protocol or otherwise named, modification on conventional periodontal
method, highlights the antimicrobial effect on this modern antiseptic asset in the form of the gel,
specially in cases where the periodontal pockets are from 3-5 mm deep, and in cases when we
lose periodontal bone to 2 mm ⁽¹¹⁾.
Its therapeutic effect is followed in the study of Eit⁽¹²⁾ who claims that the therapeutic effect on
the chlorhexidine gluconate as an adjuvant asset in the treatment of periodontal disease is having
a positive effect on gingival.
In this study after the treatment made on the both groups there was a difference in the application
of KM and KM-G in terms of gingival inflammation.
The presence of dental plaque nearby the gingiva causes inflammation of the gingiva.
67
Gingival inflammation in the same time means the introduction to the periodontopathy and the
reason more to emphasize the accumulation of dental plaque, who through the factors of
inflammation contributes to increase the level of osteoresorptive factor in inflamed gingival, with
progression of chronic periodontopathy ⁽¹ᶟ⁾.
The results of gingival inflammation after the use of both methods KM and KM-G showed that
there is significant difference in the index of gingival inflammation between the two groups after
the 5, 10 and 30 days from the treatment.
The patients that were treated with KM-G after the 5th (0,27), 10th day (0,13) and 30th day (0,02),
were registered much lower values of the gingival inflammation compared with the first
examination (1,48), but the patients that were treated with KM after the 5th day (0,92), after the
10th (0,91) and after the 30th day of control (1,08) were having significant lower values of the
gingival inflammation compared with the first examination (1,60).
Similar to those results the patients who were treated with KM-G after the 5th day of control
(0,27), 10th day (0,13) and after the 30th day (0,02) were registered significant lower values of the
gingival inflammation compared with the values on the patients who were treated with KM after
the 5th day of control (0,92), 10th day (0,91) and after the 30th day (1,08).
The results of this research showed positive therapeutic effect in patients treated with KM-G. We
think that the evident improvement in clinical symptoms first in gingival inflammation is because
of the chlorhexidine gel like a adjuvant asset in the treatment of periodontal disease.
The chlorhexidine gel is the local antiseptic that directly reduces the qualitative and quantitative
composition of the microorganisms in bio films, and thus have positive influence on the gingival
and periodontal status ⁽¹²⁾.
Actually, the gel chlorhexidine contains the range of local antimicrobial ingredients and the most
important is xanthan. The xanthan in contact with water is decomposing and is slowly forming
the resistant gel coating which acts favorably by 30 days max.
We, relying on this scientific results explain also our results that goes in addition to the group
treated with chlorhexidine gel.
In accordance to our obtained results and interpretations here are the results of ⁽¹²˒¹⁴˒¹⁵˒¹⁶˒¹⁷˒¹⁸˒¹⁹⁾.
In connection with this, Chetan ⁽²⁰⁾ following the effect of hlosit xanthan gel due to the clinical
and microbiological parameters she came to the conclusion that after the curettage of the
periodontal pockets and hlosit use the clinical improvements were significant as well as the
reduction in the number of bacterial colonies Fusobacterium nucleatum, Porphiromonas
gingivalis and Tanerella forsythesis.
Biodegradable xanthan gel composed of chlorhexidine digluconate and chlorhexidine
dihydrochloride (1:2) leads to a rapid decrease of the sub gingival concentration on periodontal
bacteria ⁽²¹⁾.
Actually, the reduction of microorganisms in dental plaque is the key role for the lower values of
the plaque and have satisfactory effects on gingival.
Conclusion
Based on the results we can conclude that the examinees treated by KM-G, against those treated
only with KM, were having significantly better clinical results in all phases of this research .
68
Because of the easy application, easy degradable power, nontoxic and we could definitely
recommend it like an adjuvant of the conventional treatment on periodontal disease.
References
1. Haffajee AD, Socransky SS, Patel MR, Song. Microbial complexes in supragingival
plaque.
Oral Microbiol Immunol 2008;23(3):196-205.
2. Newman MG. Socransky SS. Predominant Cultivable Microbiota in Periodontitis. J
periodontal Res 1977;12:120-127.
3. Ljushkovic B. Paradontologija i oralna Medicina Voeno izdavacki zavod,Beograd
2009:149-152
4. Gurinsky BS. Concepts in periodontology, Winter, Texas, 2009:2-3.
5. Sbordone L, Bortolaia C. Oral Microbial Biofilms and Plaque-Related Diseases.
Clin Oral Research 2003;7:.181-188.
6. Zhou T, Xie H, Yue Z. Relationships of five periodontal pathogens causing
subgingival plaque in patients with chronic periodontitis under different periodontal
conditions].
Hua Xi Kou Qiang Yi Xue Za Zhi. 2013;31(5):518-21.
7. Wang J, Chen W, Jiang Y, Liang J. Imaging of extraradicular biofilm using
combined scanning electron microscopy and stereomicroscopy.Microsc Res Tech.
2013;76(9):979-83.
8. Mancl KA, Kirsner RS, Ajdic D. Wound biofilms: lessons learned from oral
biofilms.
Wound Repair Regen. 2013;21(3):352-62.
9. Killoy GW. Assessing the effectiveness of locally delivered chlorhexidine in the
treatment of periodontitis. JADA, 1999;130:567 - 570.
10. Angst PD, Piccinin FB, Oppermann RV, Marcantonio RA, Gomes SC. Response of
molars and non-molars to a strict supragingival control in periodontal patients.Braz
Oral Res. 2013; 27(1):55-60.
11. Galgut P. Periodontal diseases. School of Dental Hygiene, University College Dental
Hospital, London, U.K. 2009;26-28.
12. Eit HAA,Usama M, Gouda MM. Al-Abdaly ,The evaluation of Topical Application
of CHLO-SITE (Chlorhexidine gel) in Management of Chronic Periodontitis, ED
Journal, 2010;56(2.3):120-129.
13. Yue Y, Liu Q, Xu C, Loo WT, Wang M, Wen G, Cheung MN, Bai LJ, Dou YD,
Chow LW, Hao L, Tian Y, Li JL, Yip AY, Ng EL.Comparative evaluation of
cytokines in gingival crevicular fluid and saliva of patients with aggressive
periodontitis. Int J Biol Markers. 2013;28(1):108-12.
14. Bollen CM, Quirynen M. Microbiological response to mechanical treatment in
combination with adjunctive therapy. A review of the literature, J. Periodontol.1996; 67:
1143±1158.
69
15. Benedettis M and Grassi R, Clinical and microbiologic effects of subgingival
controlled- release delivery of chlorhexidine chip in the treatment of periodontitis: a
multicenter study. J Periodontol. 2008;79(2):271-82.
16. Bromberg LE, Buxton DK, Friden PM. Novel periodontal drug delivery system for
treatment of periodontitis. J Control Release. 2001;71(3):251-9.
17. Greenstein G. Polson A. The role of local drug delivery in the management of
periodontal diseases: a comprehensive review. Department of Periodontology,
University of Medicine and Dentistry, Newark, NJ, USA. J Periodontol.
1998;69(5):507-20.
18. Abrishami M, Iramloo B, Ansari G, Eslami G, Akbarzadeh AB, Anaraki M. The
effect of locally delivered xanthan based CHLOSITE gel with scaling and root
planning in the treatment of chronic periodontitis : microbial findings J Dent
Research 2008;5(2): 47-52.
19. Soskolne WA. Citation Information Modified-Release Drug Delivery Technology
Edited by Michael J . Rathbone , Jonathan Hadgraft , and Michael S . Roberts Informa
ealthcare 2002: 99–400.
20. Chetan C, Effect of chlosite (xanthan gel with chlorhexidine) on clinical &
microbiological
parameters in smokers - A case series Year. 2010; 4(2):165-98.
21. Senel SI, Kas GG, Yousefi-Rad A, Sargon MF, Hıncal AA. Chitosan films and
hydrogels of chlorhexidine gluconate for oral mucosal Delivery.
70
Topic: Gastro-oesophageal reflux,some data on diagnosis
and clinical evaluation
Saimir Heta, Kastriot Haxhirexha, Virtut Velmishi, Nevila Alliu, Ilma Robo
Department of Pediatric Surgery, QSUT, Tirana, Albania
Abstract
Introduction: Treatment of gastro-oesophageal reflux involves number of therapeutic measures
that eventually conclude with surgical treatment. It should be noted that surgical treatment should
be the last resort to be used to treat this pathology, due to the complications and recurrences that
this surgery may give.
Materials and methods: This study included 59 children operated for gastro-oesophageal reflux
with the laparoscopic method and for the same period 14 children operated with the open method.
By gender in these two groups the study involves 34 males and 25 females in the first group of
laparoscopic methods and 8 males and 6 females in the open method group. The average age of
the treated children was 13.21 and 12.56 years old in the laparoscopic method, 7.34-year-old
males and 8.15-year-olds in the open method.
Children after being diagnosed by radiology, pharmacology and after having received a proton
pump prolonged long-term treatment for indications, were planned for intervention. Prior to the
intervention, the child is evaluated in all respects and is subject to the full anesthetic protocol.
Including biochemical balance, complete blood, cholesterol, blood group. The child is treated
with general anesthesia with endotracheal intubation using as anesthetic inhaler and intravenous
subjects.
Conclusions: Gastro-oesophageal reflux at childhood is a disease that has long been given
particular attention, by both, pediatricians and pediatric surgeons. A pathology that in its benign
form, that is non-pathological reflux captures, a very large percentage of children in the first year
of life where, according to some studies, appears in 50% of cases with a maximum prevalence
rise in the 4th month of life, in our results this aspect is not vulnerable, because we have only
studied children who have been subjected to intervention. So are those children who have gone
through all the main links of diagnosis and conservative treatment.
Keywords: gastro-oesophageal reflux, open method, laparoscopy
Introduction
Treatment of gastro-oesophageal reflux involves number of therapeutic measures that eventually
conclude with surgical treatment. It should be noted that surgical treatment should be the last
resort to be used to treat this pathology, due to the complications and recurrences that this surgery
may give. The age of the patient's presentation the presence of complications or predisposing
factors is a clue that helps us in treating this pathology. The vomiting without strain that occurs
to the latitudes after the meal, is a symptom that cann’t be called a disease that calms if the latent
after food is kept in elevated position. With the maturation of the lower esophagus sphincter this
calms down and disappears almost over time. Seeing that the symptom was lifted from the raised
position, it was thought to be used chalasia chair (chalasia chair). It was soon noticed that this
71
resulted in the increase in reflux (1), compared to the placement of children in the 30th grade.
But it has been seen that the use of this overturning position is not without consequences and
should be carefully applied according to a study (2) that the use of this position should be
recognized as a treatment that has side effects associated with drug therapy. In a study (3) that
sees the SIDS connection with the position, it is not recommended to use lateral positioners and
that the child should be placed in the back position. This is the recap of AAP American Academy
of Pediatric. Another method of treating these children is the obesity of the products they receive.
This is not very applicable to the infact. As a thickener can use rice cereal flour. Now the
pharmaceutical industry is approaching number of solutions. The use of medications in the
treatment of gastro-oesophageal reflux is a tangible reality. Use of motilium or cisapride which
is a prokinetic agent that has very good clinical effects. The preparation has been shown to
increase peristalsis increases the pressure of the lower esophagus sphincter and accelerates the
gastric rupture. (4) In adults, the preparation is associated with causing cardiac arrhythmias that
have been fatal. But the discovery of cardiac problems that this product could give in America
led to the withdrawal from the market (5). However, it is in use with us, but it should be taken in
account that treatment with it, should be as limited and prudent due to these complications.
Materials and methods
This study included 59 children operated for gastro-oesophageal reflux with the laparoscopic
method and for the same period 14 children operated with the open method. By gender in these
two groups the study involves 34 males and 25 females in the first group of laparoscopic methods
and 8 males and 6 females in the open method group. The average age of the treated children was
13.21 and 12.56 years old in the laparoscopic method, 7.34-year-old males and 8.15-year-olds in
the open method.
Children after being diagnosed by radiology, pharmacology and after having received a proton
pump prolonged long-term treatment for indications, were planed for intervention. Prior to the
intervention, the child is evaluated in all respects and is subject to the full anesthetic protocol.
Including biochemical balance, complete blood, cholesterol, blood group. The child is treated
with general anesthesia with endotracheal intubation using as anesthetic inhaler and intravenous
subjects.
The data for these two groups were obtained through an elaborated type file with the help of
statists from the Burlo Garafolol Trieste Italy Institute. Data is collected prospectively based on
this type file. The data has been collected and described in such a way that it is statistically
analyzable. Type card data included: age, sex, anti-acid therapy, pathological morphology,
fibrogastroscopy data, biopsy, impendecometry, barium passage.
During the study was evaluated the degree of scoliosis, the neurological clinic, the cause of
neurological pathology, preoperative nutrition, the baseline pathology was examined according
to ASA classification. During the study, respiratory insurances, the use of barbiturates, the type
of anesthesia used, postoperative analgesia, the use of sedatives, the time of extubation,
reinturbation, and respiratory assistance were evaluated. The intervention was considered, the
laparoscopic approach to the open method.
72
Results
Demographic data
Table 1: Gender - Laparoscopic Group
Frequency Percentage Cumulative
Percentage
Male 34 57.63 57.63
Female 25 42.37 100.00
Total 59 100.00
This table shows male demographic data for the first group.
Table 2: Gender Group Open Method.
Frequency Percentage Cumulative
Percentage
Male 8 57.14 57.14
Female 6 42.86 100.00
Total 14 100.00
It is seen that the percentage and the second group is almost identical to the first group.
Table 3: Average age.
Average
laparoscopic age
Average age open
method
P
Male 13.21±2.2 7.34±3.4 0.00568
Female 12.56±2.7 8.15±2.4
Total average 12.7±2.5 7.8±3.1
This table shows an important statistical difference between the average age of both groups.
Preoperative data
Table 4: Refractive Therapy Group of Laparoscopic Methodes
Therapy antacid Frequency Percentage Cumulative
Percentage
Antiacid 2 3.39 3.39
Omeprazol 49 83.05 86.44
Omeprazol and
antiacid
8 13.56 100.00
Total 59 100.00
This table shows the use of preoperative therapy in all first group patients, divided by type of
medication.
73
Table 5: Antireflective Therapy Open Method Group
Therapy antacid Frequency Percentage Cumulative
Percentage
Omeprazol 9 64.28 64.28
Omeprazol and
antiacid
5 35.72 100.00
Totali 14 100.00
This table shows the use of preoperative therapy in all second group patients, divided by type of
medication.
As noted, anti-acid therapy is used in all patients involved in both groups.
Table 6: Pathological morphology Laparoscopic Method Group
Pathologic
morphology
Frequency Percentage Cumulative
Percentage
Cardiac
intrathoracic
6 10.17 10.17
Hernia
paraesophageal
7 11.86 22.03
Hernia hiatale 18 30.51 52.54
Reflux without
noticeable cause
28 47.46 100.00
Total 59 100.00
In this table it is evidenced radiological findings in the laparoscopic methotrexate group by which
we determined the anatomical cause of pathology. As noted in the data in 47% of cases it has not
been possible to detect an actual anatomical cause of reflux.
Table 7: Pathological Morphology Open Method Group
Pathologic
morphology
Frequency Percentage Cumulative
Percentage
Cardiac
intrathoracic
3 21.43 21.43
Hernia
paraesophageal
1 7.14 28.57
Hernia hiatale 4 28.57 57.14
Reflux without
noticeable cause
6 42.86 100.00
Total 14 100.00
In this table we have evidenced radiological findings in the open methotrexate group, where in
the case of the first group we have determined the anatomical cause of the pathology. It is noticed
an approximate frequency of the anatomical cause of pathology as in the case of the first group.
74
Graph 1 Pathological morphology
Table 8: Preoperative Fibrogastrosopopy Laparoscopic Method Group
Fibrogastroscopy Frequency Percentage
It's not done 15 25.42
Reflux sign 17 28.81
The presence of hiatary
hernies
13 22.03
Hernie hiatale +
esophagitis
14 23.73
Total 59 100.00
The table presents fibroscopic data in laparoscopic patients. As seen in fibroscopy is a widely
used examination, in almost 74% of patients. By this method we had the opportunity to determine
the esophagitis morphologically and at the same time to obtain the histological material.
Table 9: Preoperative Fibrogastrosopopy Open Method Group
Fibrogastroscopy Frequensy Percentage
It's not done 7 50.00
Reflux sign 2 14.29
The presence of hiatary
hernies
2 14.29
Hernie hiatale +
esophagitis
3 21.42
Total 14 100.00 The table represents fibroscopic data in open method group patients. As it is noticed,
fibroscroscopy is not performed in 50% of cases and this is more for objective reasons. In cases
that have been performed in all cases, we have found signs of gastro-oesophageal pathology.
05
101520253035404550
Laparascopy
Open Method
75
Graph 2: Preoperative Fibrogastrosopics
Table 10: Histology
Histology Frequensy Percentage
It's not done 36 61.02
Esofagit 22 37.29
Ezofag Barret 1 1.69
Total 59 100.00
The table presents the histological data in the patients of the first group. In all cases in which
biopsy was performed, the presence of esophagitis was noted. Histology is one of the finest points
of an accurate diagnosis.
Table 11: Impednometry
Impednometry Frequensy Percentage
Normal reflux 3 5.08
Pathological Reflux 14 23.73
It has not been
completed
42 71.19
Total 59 100.00
Impendencecometer a coherent examination presents a sensitivity of about 82% in this series.
Table 12: Binding Clinical Data - Impednometer
Klinik –impendcometri
Frequensy Percentage
Clinical compatibility 7 11.86
No clinical compatibility 3 5.08
Not done 49 83.05
Total 59 100.00
0 10 20 30 40 50 60
Nuk është bërë
Shenja refluksi
Prezence e hernies hiatale
Hernie hiatale +esofagit
Laparoskopi
Metode e hapur
76
In the table there is a consistency between clinical data and impendometry that goes to 70% of
cases. The data show a lower sensitivity of impendecometry, but this connection was realized in
only 10 patients concluding that sensitivity is approximate.
Table 13: Degree of Scoliosis
Scoliosis Frequensy Percentage
0 9 15.25
1 22 37.29
2 22 37.29
3 5 8.47
4 1 1.69
Total 59 100.00
O- no scoliosis
1- <10 grade without any symptoms
2-> 25 grade with light pulmonary symptom
3-> 40 grades with indications for intervention
4-> 70 grade with pulmonary volume reduction
Scoliosis as one of the predisposing factors in gastro-oesophageal reflux is analyzed in this chart.
10% of patients have a 3-4 level scoliosis that can cause anesthetic complications and operators.
Table 14: Neurological clinic
Neurological clinic Frequensy Percentage
Without neurological problems 16 27.12
Only dementia 1 1.69
Neuropathy flashed 3 5.08
Tetraparesis spastic 39 66.10
Total 59 100.00 Above is the neurological data of patients, where there is a high frequency of the presence of
neurological pathologies.
It is clear, only 27% of patients have no neurological problems.
Table 15: The cause of neurological pathology
The cause of neurological pathology Frequensy Percentage
Without pathology 12 20.34
Prematurity 2 3.39
Perinatal Asphyxiation 26 44.07
Malformation SNQ 10 16.95
Chromosome abnormalities 6 10.17
Brain Infection 2 3.39
Fealopathic syndrome 1 1.69
Total 59 100.00
77
Discussions
Gastro-oesophageal reflux at childhood is a disease that has long been given particular attention
by both pediatricians and pediatric surgeons. A pathology that in its benign form that is non-
pathological reflux captures a very large percentage of children in the first year of life (6) where,
according to some studies, appears in 50% of cases with a maximum prevalence rise in the 4th
month of life. In our results this aspect is not vulnerable because we have only studied children
who have been subjected to intervention. So are those children who have gone through all the
main links of diagnosis and conservative treatment. It is nearly identical number of males and
females in the laparoscopic group (Table 1) and in the open method group (Table 2). It is seen
that we have a percentage of about 57% of men. This ratio of male women is also found in
literature (7-9). When we look at the average age of childishly treated children, we notice a large
change in the average age of the two groups (Table 3). This has come for several reasons. The
first reason is that in the laparoscopic group are treated children up to 18 years of age, whereas
in our group we have treated children with a maximum age of 14 due to the different rules applied
by the pediatric surgery clinic in Albania and Italy. But the other factor is that in the laparoscopic
group there are many children who are neurological or scoliosis children so they have a diagnosed
gastro-oesophageal reflux disease at a later stage. When we look at the results we can see that
conservative treatment (Table 4) is used in all patients. Use of other proton pump inhibitors where
omeprazole is the typical proponent. is an innovation that embraced more enthusiasm. The first
reports have been very encouraging (10, 11) by seeing the Proton Pump Frenus (PPI) as a solution
to the problem that could and was an alternative to intervention. Even in some books, it was seen
as new era in the treatment of pathological reflux. But over time, this enthusiasm has fallen,
seeing that recent studies (12) the effect of PPI on infants is low although no comparative studies
with placebo have been conducted. Thus, the general impression is that the use of omeprazole is
safe (13) as a therapeutic treatment but its efficacy is not proven. Using omeprazole is a drug that
is highly effective for treating esophagitis. Thus, the use of omeprazole has a good effect on the
treatment of symptoms of gastro-oesophageal reflux for this reason its use is one of the most
effective conservative therapies in treating gastroesophageal reflux (13, 34). However, there are
studies (12) that accuse him of a rise in gastroenteritis and an increase in pneumonia. As we have
said above, it is also accused of hypomagnesis or of bone fractures. Omeprazole two study groups
were used in all patients before intervention (Table 4.5). Diagnosis of gastro-oesophageal reflux
besides clinical suspicion should pass into an examination protocol involving imaging study. This
examination is a key examination in diagnosing gastro-oesophageal reflux as well as establishing
a direct relationship between the clinic and pathology. What is important is that through this
examination we can realize a prediction of anatomy or rather of the pathological morphology that
caused this pathology before intervening. In our series, imaging is performed in all patients.
(Table 6, 7). Through it we find that in 52.54% of cases we have found an anatomical factor such
as intrathoracic kardia, parahexa phage hernia, hiatary hernia. But in the rest of the patients, only
pure esophageal reflux is observed. We say that we have not seen a tangible anatomical factor.
And in the series operated there is the same pathology determining pathology. What is worth
noting is that contrast imaging with the upper tract is a conventional image that has been protocols
for many years. One of the important phases of the imaging protocol is the trendelenbourg
position that is needed to determine especially cases with pure esophageal reflux where the
anatomical changes are not imaging-susceptible. The accuracy of imaging diagnosis is an open
debate where it is thought that using ph-metrix is the most reliable method. (16) In this study it
is seen that the barium study is lower than the ph-meter, 36% at 70 %. By comparing it with
clinical data which in our opinion is not very accurate. (17) The fact of the accuracy of the
imaging study cann’t be taken very basically by looking at our tables because we do not intervene
in children unless we had a positive image. So, for us imaging is the key study in the diagnosis
of gastro-oesophageal reflux and in determining surgical indications. So, determining the
78
sensibility of this method is beyond the possibilities of this study. Differential diagnosis that can
be accomplished through barium scopy is one of the strengths that this examination has. By
means of it, it is possible to diagnose or suspect the possibility of mesenteritis, duodenal
membrane, hypertrophic pylori stenosis. It seems that these pathologies are clearly separated
from the clinic and the diagnosis of gastro-oesophageal reflux but the daily experience shows
that this examination is often the case that has led us to an accurate diagnosis in diagnosing the
errors of diagnosis. This is very important especially in the case of laparoscopic surgery because
this surgery does not give us the possibility of intraoperative tactility that the diagnosis should be
as accurate as possible. In (Graph 1) we have visually presented Table 6.7 data. It is seen that
there is no significant difference in the percentage between imaging findings in both groups. Use
of fibrogastroscopy as a sourcing and sometimes defining method. It is performed in more than
75% of cases. As can be seen in (Table 8) it is a routine method that has given us quite valuable
data. Through it we have received information about reflux, esophagitis and presence of hiatary
hernias. Fibrogastoscopy may well diagnose esophageal which is one of the inflammatory
consequences of gastro-oesophageal reflux. But on the other hand, to determine the degree of
esophagitis and to have a precise indication of the morphological changes and at the cellular
level, biopsy may also be performed. With the histology sections can be determined the
esophagitis its degree and can also be diagnosed with the precancerous metaplasia like Barret's
esophagus (18-20). Fibrogastrocopy also diagnoses hiatal hernias especially when they are large,
allowing us to have a very accurate diagnosis and defined a more detailed operator plan. As seen
from (Tables 8, 9) and from (Graph 2) fibrogastroscopy was performed in the first group in more
than 75% of cases and in the second group in only 50% of cases. In (Table 10) it is clearly seen
that the use of histology so differently of biopsy is a datum that concedes us in a more and more
accurate diagnosis. The esophagus biopsy is not a routine exercise. The biopsy was performed in
37.29% of the cases. But taking in account that fibroscopy is performed in 75% of cases it is seen
that the biopsy was performed in 52.27% of the cases that have performed fibrogastricopy in
more than half of the patients. This has resulted in a clear morphological diagnosis. In children
treated with us the esophagus biopsy is not an action that is still being protocols and has not been
performed. It should be taken in account that the diagnosis of esophagitis does not interfere with
interventionism (21). On the other hand, fibrogatroscopy and more esophageal biopsy in young
children is an action that requires special susceptibility and a special technical skill (22). It is an
action that may have its own complications and so in the balance benefit the risk at the time of
the study it is seen that the benefit was scarce. One of the most important examinations we have
and a diagnosis with a very high accuracy is impendecometry. Impendencometry is an
examination that not only measures acid reflux but mats and refluxes are not acidic themselves.
As a compiled and contemporaneous examination, one of the basic studies is how to diagnose
how to carry out comparative studies because being digitized data is a measurable and
comparable study. It is widely used in the patients analyzed in the first group. In (Table 11) it is
seen that the use of impendencometry has been performed in 17 cases where the sensitivity in the
group that has performed this examination is 82%. This is a lump which is lower than what is
referred to in literature where the sensitivity of impendecometry is about 90%. According to
many authors (22-25) it is seen that the ph-meter is considered as (gold standard) for the diagnosis
of this pathology.
Acknowledgments: Our thanks belong to our family. Henri and Hera drive us forward, and
further in the field of scientific research.
Author Contributions: Literature research was conducted by Dr. Saimir Heta. It was his
insistent work that made it possible to reach the conclusions in this article.
Conflicts of Interest: We declare that there is no conflict of interest between the authors and the
material presented in this article.
79
Reference
1. Suffocation deaths associated with use of infant sleep positioners--United States,
1997-2011. MMWR Morbidity and mortality weekly report. 2012 Nov
23;61(46):933-7. PubMed PMID: 23169313. Epub 2012/11/22. eng.
2. Vandenplas Y, Benatar A, Cools F, Arana A, Hegar B, Hauser B. Efficacy and
tolerability of cisapride in children. Paediatric drugs. 2001;3(8):559-73. PubMed
PMID: 11577921.
3. Quigley EM. Cisapride: what can we learn from the rise and fall of a prokinetic?
Journal of digestive diseases. 2011 Jun;12(3):147-56. PubMed PMID: 21615867.
Epub 2011/05/28. eng.
4. Tjon JA, Pe M, Soscia J, Mahant S. Efficacy and Safety of Proton Pump Inhibitors in
the Management of Pediatric Gastroesophageal Reflux Disease. Pharmacotherapy.
2013 May 26. PubMed PMID: 23712734.
5. Canani RB, Cirillo P, Roggero P, Romano C, Malamisura B, Terrin G, et al. Therapy
with gastric acidity inhibitors increases the risk of acute gastroenteritis and
community-acquired pneumonia in children. Pediatrics. 2006 May;117(5):e817-20.
PubMed PMID: 16651285.
6. Nazer D, Thomas R, Tolia V. Ethnicity and gender related differences in extended
intraesophageal pH monitoring parameters in infants: a retrospective study. BMC
pediatrics. 2005;5:24. PubMed PMID: 16026617. Pubmed Central PMCID: 1188060.
7. Gunasekaran TS, Hassall EG. Efficacy and safety of omeprazole for severe
gastroesophageal reflux in children. The Journal of pediatrics. 1993 Jul;123(1):148-
54. PubMed PMID: 8320610.
8. Hassall E. Wrap session: is the Nissen slipping? Can medical treatment replace
surgery for severe gastroesophageal reflux disease in children? The American journal
of gastroenterology. 1995 Aug;90(8):1212-20. PubMed PMID: 7639217.
9. van der Pol RJ, Smits MJ, van Ëijk MP, Omari TI, Tabbers MM, Benninga MA.
Efficacy of proton-pump inhibitors in children with gastroesophageal reflux disease:
a systematic revieë. Pediatrics. 2011 May;127(5):925-35. PubMed PMID: 21464183.
10. Hassall E, Kerr W, El-Serag HB. Characteristics of children receiving proton pump
inhibitors continuously for up to 11 years duration. The Journal of pediatrics. 2007
Mar;150(3):262-7, 7 e1. PubMed PMID: 17307542.
11. El Mouzan MI, Abdullah AM. The diagnosis of gastroesophageal reflux disease in
children. Saudi medical journal. 2002 Feb;23(2):164-7. PubMed PMID: 11938391.
12. Stephen TC, Younoszai MK, Massey MP, Fellows RA. Diagnosis of
gastroesophageal reflux in pediatrics. The Journal of the Kentucky Medical
Association. 1994 May;92(5):188-91. PubMed PMID: 8027639.
13. Pascu O, Lencu M. Barrett's Esophagus. Romanian journal of gastroenterology. 2004
Sep;13(3):219-22. PubMed PMID: 15470535.
14. Simonka Z, Paszt A, Abraham S, Pieler J, Tajti J, Tiszlavicz L, et al. The effects of
laparoscopic Nissen fundoplication on Barrett's esophagus: long-term results.
Scandinavian journal of gastroenterology. 2012 Jan;47(1):13-21. PubMed PMID:
22150083.
80
15. Heikenen JB, Werlin SL. Esophageal biopsy does not predict clinical outcome after
percutaneous endoscopic gastrostomy in children. Dysphagia. 2000
Summer;15(3):167-9. PubMed PMID: 10839831.
16. Cinquetti M, Zoppi G. [Intraesophageal pH measurement in childhood: the technic
and indications]. La Pediatria medica e chirurgica : Medical and surgical pediatrics.
1994 Sep-Oct;16(5):433-9. PubMed PMID: 7885951. La pH-metria intraesofagea in
eta pediatrica: tecnica ed indicazioni.
17. Assadamongkol K, Phuapradit P, Petsrikun K, Viravithya W. Gastroesophageal
reflux in children: correlation of symptoms with 24-hour esophageal pH monitoring.
Journal of the Medical Association of Thailand = Chotmaihet thangphaet. 1993
Oct;76 Suppl 2:49-54. PubMed PMID: 7823006.
18. Semeniuk J, Kaczmarski M. 24-hour esophageal pH monitoring in children with
pathological acid gastroesophageal reflux: primary and secondary to food allergy.
Part I. Intraesophageal pH values in distal channel; preliminary study and control
studies--after 1, 2, 4 and 9 years of clinical observation as ëell as dietary and
pharmacological treatment. Advances in medical sciences. 2007;52:199-205. PubMed
PMID: 18217419.
19. Armas Ramos H, Molina Arias M, Pena Quintana L, Eizaguirre Sexmilo I, Juste
Ruiz M, Sanchez Ruiz F, et al. [Current indications of esophageal pH-monitoring].
Anales espanoles de pediatria. 2002 Jan;56(1):49-56. PubMed PMID: 11792245.
Indicaciones actuales de la monitorizacion de la pHmetria esofagica.
20. Hoeffel JC, Lascombes P, Schmitt M, Galloy MA. [Peptic esophagitis and scoliosis
in children]. Annales de pediatrie. 1992 Nov;39(9):561-5. PubMed PMID: 1463303.
Oesophagite peptique et scoliose chez l'enfant.
21. Chidambaran V, Gentry C, Ajuba-Iwuji C, Sponsellar PD, Ain M, Lin E, et al. A
Retrospective Identification of Gastroesophageal Reflux Disease as a Neë Risk Factor
for Surgical Site Infection in Cerebral Palsy Patients After Spine Surgery. Anesthesia
and analgesia. 2013 May 17. PubMed PMID: 23687234.
22. van der Zee DC, Bax NM. Laparoscopic Thal fundoplication in severely scoliotic
children. Surgical endoscopy. 1995 Nov;9(11):1197-8. PubMed PMID: 8553233.
23. Goessler A, Huber-Zeyringer A, Hoellwarth ME. Does epilepsy influence the
outcome of antireflux procedures in neurologically impaired children? Pediatric
surgery international. 2006 Jun;22(6):485-90. PubMed PMID: 16736214.
24. Goessler A, Huber-Zeyringer A, Hoellëarth ME. Recurrent gastroesophageal reflux
in neurologically impaired patients after fundoplication. Acta paediatrica. 2007
Jan;96(1):87-93. PubMed PMID: 17187611.
25. Bergmeijer JH, Bouquet J, Hazebroek FË. Normal ranges of 24-hour pH-metry
established in corrected esophageal atresia. Journal of pediatric gastroenterology and
nutrition. 1999 Feb;28(2):162-3. PubMed PMID: 9932848.
81
Echocardiography in emergency room
Sejran Abdushi1, Fadil Kryeziu1, Shpend Abdushi2
1UBT – Higher Education Institution, Lagjja Kalabria, 10000 p.n., Prishtinë,
Republic of Kosovo; 2Faculty of Medicine, University Hasan Prishtina of Prishtina.
Abstract. Patients with the worrying clinical condition are challenging in the emergency room.
Accurate and timely diagnosis is very important in life-threatening conditions. Echocardiography
can be very useful in the diagnosis, evaluation and triage of patients with severe cardiovascular
conditions in the emergency department. Echocardiography is very useful in patients presenting
with: chest pain syndrome, hypotension, unexplained dyspnoea, palpitation, recurrent syncope,
cardiac arrest and chest trauma. It will help in minimizing the unnecessary admission to the
hospital and facilitating in hospital evaluation of the admitted patients with echocardiographic
information. Transthoracic echocardiography is the main source of information in the emergency
setting. This article focuses on the clinical information that can be obtained from
echocardiography according to the most frequent presentations suggesting a cardiovascular
emergency.
Keywords: Echocardiography, Emergency room.
Introduction
The evaluation and management of symptomatic patients in the emergency room is a daily
challenge. Fast and accurate diagnosis is life-saving. Mobility and relatively low cost of
echocardiography machines, including hand-held devices, allow their use virtually everywhere
[1] [2] [3]. In addition, in expert hands, echocardiography may provide an instantaneous and
comprehensive assessment of cardiac structure and function as well as hemodynamics, with
minimal discomfort or risk for the patient, without using radiological contrast media or ionizing
radiations [4]. Mostly, physician which perform echocardiography assessment may be the same
who is managing the patient, this will speed decision-making and leading to better treatment of
the patient.
Almost, echocardiography is included in all management guidelines for patients with
cardiovascular emergencies. However, it is important to recognize its opportunities and
limitations with the aim of reducing the possibility of errors with serious consequences. It is
imperative that competent professional societies determine the necessary standards of knowledge
for applying echocardiography in emergency conditions.
The aim of this review was to present possibilities of transtoracic echocardiography for the
assessment of cardiovascular emergencies.
Medical emergencies which require emergent echocardiography
A Report of the American College of Cardiology Foundation Quality Strategic Directions
Committee Appropriateness Criteria Working Group [5] dated July 2007 have recommended
82
indications for echocardiography evaluation in an acute cardiovascular setting, which are listed
below:
1. Hypotension or Hemodynamic instability
2. Myocardial ischemia/Infarction
3. Respiratory Failure
4. Pulmonary Embolism
Neskovic AN et al. (2013) have recommended echocardiography use in cardiac and cardiac-like
emergencies, in several clinical settings: Acute chest pain, Acute dyspnoea, Hemodynamic
instability/Shock, New heart murmur, Chest trauma, Cardiac arrest/CPR [4].
Hypotension and/or hemodynamic instability
Shock is defined as acute circulatory failure with inadequate or inappropriately distributed tissue
perfusion resulting in generalized cellular hypoxia [6]. For patients without known etiology of
hypotension, echocardiography is primarily used for detecting or excluding cardiac causes of
shock. Whether the cause of shock is unknown, suspected, or established, echocardiography is
utilized in its diagnosis and management and to monitor progress [7]. It is recommended as the
modality of first choice in consensus guidelines [8]. A RACE assessment, using only two-
dimensional (2D) and M‐mode echocardiography demonstrates major underlying abnormalities
rapidly in the acute scenario [9].
Overall cardiac performance
Assessment of cardiac output by echocardiography is overall recognized. Although it can be
measured using the 2D Simpson’s multidisc method, the use of pulsed-wave Doppler across the
left ventricular output tract (LVOT) is more accurate [10]. So she could replace the invasive CO
measurement.
Left ventricular systolic function
Dilated left heart chambers are sign of chronic impairment of myocardial contractility, Left
ventricular ejection fraction (LVEF) is a well-established parameter which can be a helpful guide.
It is sufficiently robust to be used regularly in large studies in the chronic heart failure setting
where it serves as a prognostic marker [11]. When the endocardial border is difficult to visualize,
contrast echo may enhance accuracy [12]. In situations when segmental wall motion
abnormalities are present urgent revascularization should be taken in consideration.
Left ventricular diastolic dysfunction
Approximately half the patients presenting with acute heart failure have preserved ejection
fraction via a number of mechanisms, including diastolic dysfunction reduced coronary flow
reserve [13], [14]. High metabolic rates frequently present in critically ill patients can impair the
left ventricular diastolic function. Spectral Doppler of mitral inflow is widely used for diastolic
dysfunction assessment of left ventricle. Both an E/A ratio >2 and an E wave deceleration time
<120 ms predict a LAP >20 mmHg [15]. With TDI, the mitral annulus e′ offers a quick guide to
the presence of left ventricular diastolic dysfunction with a lateral e′ <10 and medial <7 cm/s
highly suggestive of diastolic dysfunction and elevated left atrial pressures [16]. When the sample
volume of the tissue Doppler imaging is placed at the mitral annulus, two distinctive velocities
during diastole in patients with sinus rhythm can be obtained. Early diastolic mitral annulus
velocity (E) implies rate of relaxation during early diastole as the cardiac apex is relatively fixed
during the cardiac cycle. Therefore, patients with relaxation abnormality characteristically show
low E’ velocity. A’: late diastolic mitral annulus velocity [17] (Figure 1).
83
Figure 1 - Diastolic function assessment using tissue Doppler of mitral annulus inflow.
Hypovolemic shock
Mostly, hypovolemia is readily evident but it is difficult to be determined only with a physical
exam. Basically, severe hypovolemia can be suggested by 2D views when they show the collapse
of left ventricular walls at end-systole so-called “kissing-walls”. Variations of inferior vena cava
(IVC) are widely used. Numerous studies have explored refining the technique using vessel
diameter variation in response to the respiratory cycle, maximum diameter, and percentage of
diameter alteration to assess right atrial pressure (RAP) [18]. The IVC is a highly compliant
vessel, consequently, its size and dynamics vary with changes in CVP and volume [19]. Table 1
shows values of RAP due to IVC parameters [20].
IVC size (cm) Inspiration effect Estimated mean RAP
(mmHg)
Small < 1.5 Collapse 0 – 5
Normal 1.5 – 2.5 ↓≥ 50% 5 – 10
Normal 1.5 – 2.5 ↓≤ 50% 10 – 15
Dilated > 2.5 ↓≤ 50% 15 – 20
Dilated + hepatic veins No collapse ➢ 20 Table 1 – Estimation of RA pressure on the basis of IVC diameter and collapse.
Cardiac Tamponade
The excessive increase of intrapericardial pressure associated with the impaired filling of heart
chambers during diastole results with cardiac tamponade. Cardiac tamponade is a life-threatening
condition which can be easily managed if it can be timely diagnosed. Symptoms of significant
pericardial effusion include tachycardia, orthopnea, pulsus paradoxus, and pericardial rub.
Presence of hypotension and bradycardia are suggestive for cardiac arrest. Echocardiography is
a key for diagnosis of cardiac tamponade. Echocardiography allows assessment of pericardial
effusion size, collapse of right heart chambers and pseudo hypertrophy of left ventricle [21].
84
Pulsed-wave Doppler is a key in the assessment of respiratory variations of the transvalvular
flows in patients with cardiac tamponade [22]. A physiological variation of the cardiac output of
around 5% exists with normal respiratory cycle, which is reflected in normal peak E-wave
variation of up to 10% [23]. During cardiac tamponade this variations are even higher, at least
more than 25% [22]. On Figure 2 are shown right heart chambers collapse and significant
variations of peak E-wave.
Figure 2 – A: Right chambers collapse; B: E-wave variation > 25% during respiration.
Myocardial ischemia/Infarction The response of left ventricular function to ischemia is monotonous and independent of the
employed stress [24]. The same echocardiographic signs can be found in transient ischemia and
acute infarction [25]. Transient ischemia is manifested with regional wall abnormalities in three
forms: decreased wall movement and systolic thickening (hypokinesia), absence of movement
and systolic thickening (akinesia), and paradoxical movement and possible systolic thickening
(dyskinesia). All this changes are clearly identified in transthoracic echocardiography.
Echocardiography is also very in detecting of location and size of myocardial infarction and its
complications. Myocardial infarction complications which can be detected by transthoracic
echocardiography are: myocardial wall rupture, acute mitral regurgitation (due to papillary
muscle rupture or myocardial dysfunction), pericardial effusion and tamponade, formation of true
left ventricular aneurysm, left ventricular thrombi. In figure 3 are shown echocardiographic
images of complications of myocardial infarction.
85
Figure 3 – A: Rupture of interventricular septum; B: True ventricular aneurism with thrombus
formation; C: Pseudo aneurysm; D: Pericardial effusion after myocardial infarction.
Respiratory failure
Acute respiratory failure (ARF) is a common medical emergency with increasing incidence [26].
Timely diagnosis and adequate treatment of patients with ARF improves their outcomes. Timely
antibiotic administration in community-acquired pneumonia reduces mortality, making early
diagnosis vital [27] [28]. Bedside use of Doppler echocardiography is being featured as a
promising, clinically useful tool in assessing the pulmonary circulation in patients with acute
respiratory distress syndrome (ARDS) [29]. A qualitative and repetitive echocardiographic
evaluation, by a simple visualization in real time of the kinetics and size of cardiac cavities, has
been shown to be essential in assessing right-sided heart after loading [30]. Echocardiographic
assessment of right ventricle function mast includes a long-axis view to assessing the size of right
chambers, and in short-axis view to assessing the septal kinetics.
Pulmonary embolism
Suspected high-risk acute pulmonary embolism (PE) presenting with shock or hypotension is a
life-threatening situation, and according to international guidelines it requires urgent diagnostic
workup and therapy [31]. Presence of right ventricular dysfunction on echocardiography
identifies patients with a poor prognosis and is consistent with the presence of larger pulmonary
perfusion defects [32]. Echocardiographic evaluation is useful for early risk stratification and has
a helpful impact on management strategies of patients with acute pulmonary embolism. Presence
of right ventricular dysfunction on echocardiography identifies patients with a poor prognosis
86
and is consistent with the presence of larger pulmonary perfusion defects [32]. Some
echocardiographic data are suggestive for poor outcome and may indicate more aggressive
treatment strategies. In these data are included: impaired right ventricular function,
interventricular septum bulging into the left ventricle (“D-shaped” septum), dilated proximal
pulmonary arteries, elevated right atrial pressure, elevated pulmonary artery pressure, free-
floating right ventricular thrombi. In figure 4 are shown some of these features.
Figure 4 – A: Enlarged right chambers of heart; B: “D” shaped left ventricle. RA – Right
atrium; RV – Right ventricle; LV – Left ventricle.
Conclusions
Echocardiography is a noninvasive diagnostic method, which can be easily used on the bedside
of critically ill patients. It can offer valuable data which can help physicians in the emergency
room to reduce unnecessary hospitalizations and safely discharge of patients. Also,
echocardiography can help to choose the best management strategies for life-threatening
conditions and can be used for monitoring of success rate of treatment. But, echocardiography
use in emergency room requires knowledge of the strengths and limitations of this imaging
modality. Especially, echocardiography is a portable rapid, noninvasive diagnostic tool, which
can be repeated when required makes it very helpful in the emergency room.
87
References:
1. Popescu BA, Andrade MJ, Badano LP, Fox KF, Flachskampf FA, Lancellotti P et al,
on behalf of the European Association of Echocardiography. European Association of
Echocardiography recommendations for training, competence, and quality
improvement in echocardiography. European Journal of Echocardiography (2009)
10, 893–905.
2. Flachskampf FA, Voigt JU, Daniel WG. Cardiac ultrasound. In: Camm JA, Lüscher
TF, Serruys PW, eds. The ESC Textbook of Cardiovascular Medicine. 2nd ed. Oxford
University Press; 2009.
3. Galiuto L, Badano L, Fox K, Sicari R, Zamorano JL, eds. The EAE Textbook of
Echocardiography. 1st ed. New York: Oxford University Press; 2011.
4. Neskovic AN, Hagendorff A, Lancellotti P, Guarracino F, Varga A, Cosyns B,
Flachskampf FA et al, on behalf of the European Association of Cardiovascular
Imaging. Emergency echocardiography: the European Association of Cardiovascular
Imaging recommendations. European Heart Journal – Cardiovascular Imaging
(2013) 14, 1–11.
5. Douglas SP, Stainback FR, Khandheria Bet al. Appropriateness Criteria for
Echocardiography. JACC Vol. 50, No. 2, 2007.
6. Graham CA & Parke TRJ 2005 Critical care in the emergency department: shock and
circulatory support. Emergency Medicine Journal 22 17–21.
(doi:10.1136/emj.2003.012450).
7. McLean SA. Echocardiography in shock management. Critical Care (2016) 20:275.
DOI 10.1186/s13054-016-1401-7.
8. Cecconi M, De Backer A, Antonelli M, et al. Consensus on circulatory shock and
hemodynamic monitoring. Task force of the European society of Intensive Care
Medicine. Intensive Care Med. 2014;40:1795–815.
9. McMurray JJV, Adampoulos S, Anker SD, et al. ESC guidelines for the diagnosis
and treatment of acute and chronic heart failure. Eur Heart J. 2012;33:1787–847.
10. Williams GA, Labovitz AJ. Doppler estimation of cardiac output: principles and
pitfalls. Echocardiography. 1987; 4:355–74.
11. Solomon SD, Anavekar N, Skali H, et al. Influence of ejection fraction on
cardiovascular outcomes in a broad spectrum of heart failure patients. Circulation.
2005;112:3738.
12. Pickett CA, Cheezum MK, Kassop D, et al. Accuracy of cardiac CT, radionucleotide
and invasive ventriculography, two‐and three‐dimensional echocardiography, and
SPECT for left and right ventricular ejection fraction compared with cardiac MRI: a
meta‐analysis. Eur Heart J Cardiovasc Imaging. 2015;16:848–52.
13. Paulus WJ, Tschope C. A novel paradigm for heart failure with preserved ejection
fraction: comorbidities drive myocardial dysfunction and remodeling through
microvascular endothelial inflammation. J Am Coll Cardiol. 2013;62:263–71.
14. Ikonomidis I, Tzortzis S, Triantafyllidi H, et al. Association of impaired left
ventricular twisting‐untwisting with vascular dysfunction, neuro‐humoral activation,
88
and impaired exercise capacity in hypertensive heart disease. Eur J Heart Fail.
2015;17:1249–60.
15. Gianuzzi P, Imparato A, Temporelli PL, et al. Doppler‐derived deceleration time of
early filling as a strong predictor of pulmonary capillary wedge pressure in post‐
infarction patients with left ventricular systolic dysfunction. J Am Coll Cardiol.
1994;23(7):1630–7.
16. Flachskampf FA, Biering-Sorensen T, Solomon SD et al . Cardiac Imaging to
Evaluate Left VentricularDiastolic Function. JACC: Cardiovascular Imaging. 2015;
8(9):1071-1093.
17. Dae-Won Sohn. Heart failure due to abnormal filling function of the heart. Journal of
Cardiology (2011) 57, 148—159.
18. Kicher BJ, Himelman RB, Schiller NB. Noninvasive estimation of right atrial
pressure with 2‐dimensional and Doppler echocardiography: a simultaneous
catherization and echocardiographic study. Am J Cardiol. 1990;66(4):493–6.
19. Beigel R, CerceB, Luo H, and Siegel R. Noninvasive Evaluation of Right Atrial
Pressure. J Am Soc Echocardiogr 2013;26:1033-42.
20. Lawrence G et al. Guidelines for the Echocardiographic Assessment of the Right
Heart in Adults. J Am Soc Echocardiogr 2010;23:685-713.
21. Argulian E, Messerli F. Misconceptions and Facts about Pericardial Effusion and
Tamponade. The American Journal of Medicine, Vol 126, No 10, October 2013.
22. Leeman DE, Levine MJ, Come PC. Doppler echocardiography in cardiac tamponade:
exaggerated respiratory variation in transvalvular blood flow velocity integrals. J Am
Coll Cardiol (1988) 11:572–8. doi:10.1016/0735-1097(88)91533-1.
23. Klein AL, Abbara S, Agler DA, Appleton CP, Asher CR, Hoit B, et al. American
Society of echocardiography clinical recommendations for multimodality
cardiovascular imaging of patients with pericardial disease. J Am Soc Echocardiogr
(2013) 26:965–1012.
24. Picano E (1992) Stress echocardiography. From pathophysiological toy to diagnostic
tool. Circulation 85:1604–12.
25. Picano E. Stress Echocardiography. Fifth, Completely Revised and Updated Edition.
2009 Springer-Verlag Berlin Heidelberg. Pages 75-89.
26. Stefan S. M., et al., Epidemiology and outcomes of acute respiratory failure in the
United States, 2001 to 2009: a national survey, J. Hosp. Med. 8 (2) (2013) 76–82.
27. Mandell A. L., et al., Infectious Diseases Society of America/American Thoracic
Society consensus guidelines on the management of community-acquired pneumonia
in adults, Clin. Infect. Dis. 44 (Suppl 2) (2007) S27–S72.
28. Kumar A., et al., The duration of hypotension before the initiation of antibiotic
treatment is a critical determinant of survival in a murine model of Escherichia coli
septic shock: association with serum lactate and inflammatory cytokine levels, J.
Infect. Dis. 193 (2) (2006) 251–258.
29. Lazzeri C., et al. The potential role and limitations of echocardiography in acute
respiratory distress syndrome. Ther Adv Respir Dis. 2016, Vol. 10(2) 136–148.
30. Vieillard-Baron A, et al. EchoDoppler demonstration of acute cor pulmonale at the
bedside in the medical intensive care unit. Am J Respir Crit Care Med 2002; 166:
1310-9.
89
31. Authors/Task Force Members Konstantinides S, Torbicki A, Agnelli G, Danchin N,
Fitzmaurice D, Galie N, et al. 2014 ESC guidelines on the diagnosis and management
of acute pulmonary embolism: the Task Force for the Diagnosis and Management of
Acute Pulmonary Embolism of the European Society of Cardiology (ESC) endorsed
by the European Respiratory Society (ERS). Eur Heart J 2014;35:3033-80.
32. Kucher N, et al. Prognostic role of echocardiography among patients with acute
pulmonary embolism and a systolic arterial pressure of 90mm Hg or higher. Arch
Intern Med 2005;165:1777–81.
Katalogimi në botim – (CIP)
Biblioteka Kombëtare e Kosovës “Pjetër Bogdani”
61(496.51)”2018”(062)
615(496.51)”2018”(062)
International Conference Medical, Chemical and
Pharmaceutical Sciences : proceedings of the 7th Annual International
Conference Pristina, 26-28 october 2018 / organizing committee
Edmond Hajrizi…[et al.]. - Prishtinë : UBT, 2019. – 94 f. : ilustr. ; 30
cm.
1.Hajrizi, Edmond
ISBN 978-9951-437-80-6
Lagjja Kalabria p.n KS - 10000, Prishtinë
+381 38 541 400
+377 44 541 400
www.ubt-uni.net
MANAGEMENT, BUSINESS AND ECONOMICS
INFORMATION SYSTEMS AND SECURITY
ENERGY EFFICIENCY ENGINEERING
MECHATRONICS, SYSTEM ENGINEERING AND ROBOTICS
COMPUTER SCIENCE AND COMMUNICATION ENGINEERING
MEDICAL DENTAL AND PHARACEUTICAL SCIENCES
FOOD SCIENCE AND TECHNOLOGY
ARCHITECTURE AND SPATIAL PLANNING
CIVIL ENGINEERING, INFRASTRUCTURE AND ENVIRONMENT
INTEGRATED DESIGN
EDUCATION AND DEVELOPMENT
LAW
POLITICAL SCIENCE
MEDIA & COMMUNICATION
PSYCHOLOGY
INTERNATIONAL CONFERENCE ON BUSINESS,TECHNOLOGY AND INNOVATION
CHAPTERS: