sanamed 10(1) 2015

UREDNI[TVO

Glavni i odgovorni urednikPrim. dr Avdo ]erani}

Gostuju}i urednici u ovom brojuProf. dr Fahrija Skoki}Prof. dr Svetoslav Kalevski

Pomo}nici glavnog i odgovornog urednikadr Dènana Detanacdr Dèmail Detanac

Tehni~ki urednikdr Dèmail Detanac

Nau~ni savet Me|unarodni nau~ni savetProf. dr Aleksandar Karamarkovi} (Srbija) Prof. dr Ivan Damjanov (SAD)Prof. dr Branka Nikoli} (Srbija) Prof. dr Milan R. Kneèvi} ([panija)Prof. dr Radivoj Koci} (Srbija) Prof. dr Ino Husedìnovi} (Hrvatska)Prof. dr Ivan Dimitrijevi} (Srbija) Prof. dr Anastasika Poposka (Makedonija)Prof. dr Stojan Sekuli} (Srbija) Prof. dr Sergio Zylbersztejn (Brazil)Prof. dr Marina Savin (Srbija) Prof. dr Beniamino Palmieri (Italija)Prof. dr Milica Berisavac (Srbija) Prof. dr Sahib H. Muminagi} (Bosna i Hercegovina)Prof. dr Milan Kneèvi} (Srbija) Prof. dr Osman Sinanovi} (Bosna i Hercegovina)Prof. dr Milo{ Jovanovi} (Srbija) Prof. dr Selma Uzunovi}-Kamberovi} (Bosna i Hercegovina)Prof. dr Sneàna Jan~i} (Srbija) Prof. dr Agima Ljaljevi} (Crna Gora)Prof. dr êdomir S. Vu~eti} (Srbija) Prof. dr Suada Helji} (Bosna i Hercegovina)Prof. dr Slobodan Obradovi} (Srbija) Prof. dr Milica Martinovi} (Crna Gora)Prof. dr Slobodan Grebeldinger (Srbija) Prof. dr Nermina Hadìgrahi} (Bosna i Hercegovina)Prof. dr Slobodan M. Jankovi} (Srbija) Prof. dr Miralem Musi} (Bosna i Hercegovina)Prof. dr @ivan Maksimovi} (Srbija) Prof. dr Spase Jovkovski (Makedonija)Prof. dr Zlata Janji} (Srbija) Prof. dr Evangelos J. Giamarellos-Bourboulis (Gr~ka)Prof. dr Svetislav Milenkovi} (Srbija) Prof. dr Paolo Pelosi (Italija)Prof. dr Radmilo Jankovi} (Srbija) Prof. dr Zsolt Molnar (Ma|arska)

Lektor za engleski jezikSelma Mehovi}

DizajnPrim. dr Avdo ]erani}

Izdava~Udruènje lekara Sanamed, Novi Pazar

ÂSOPIS IZLAZI TRI PUTA GODI[NJE

Adresa uredni{tva„SANAMED“, Ul. Palih boraca 52, 36300 Novi Pazar, Srbijaemail: sanamednp2006ªgmail.com, www.sanamed.rs

[tampa„ProGraphico“, Novi Pazar

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ISSN-1452-662X

EDITORIAL BOARD

Editor-in-chiefPrim. dr Avdo ]erani}

Guest Editors in this issueProf. dr Fahrija Skoki}Prof. dr Svetoslav Kalevski

Associate Editorsdr Dènana Detanacdr Dèmail Detanac

Technical Editordr Dèmail Detanac

Scientific council International scientific councilProf. dr Aleksandar Karamarkovi} (Serbia) Prof. dr Ivan Damjanov (USA)Prof. dr Branka Nikoli} (Serbia) Prof. dr Milan R. Kneèvi} (Spain)Prof. dr Radivoj Koci} (Serbia) Prof. dr Ino Husedìnovi} (Croatia)Prof. dr Ivan Dimitrijevi} (Serbia) Prof. dr Anastasika Poposka (R. Macedonia)Prof. dr Stojan Sekuli} (Serbia) Prof. dr Sergio Zylbersztejn (Brazil)Prof. dr Marina Savin (Serbia) Prof. dr Beniamino Palmieri (Italy)Prof. dr Milica Berisavac (Serbia) Prof. dr Sahib H. Muminagi} (Bosnia and Herzegovina)Prof. dr Milan Kneèvi} (Serbia) Prof. dr Osman Sinanovi} (Bosnia and Herzegovina)Prof. dr Milo{ Jovanovi} (Serbia) Prof. dr Selma Uzunovi}-Kamberovi} (Bosnia and Herzegovina)Prof. dr Sneàna Jan~i} (Serbia) Prof. dr Agima Ljaljevi} (Montenegro)Prof. dr êdomir S. Vu~eti} (Serbia) Prof. dr Suada Helji} (Bosnia and Herzegovina)Prof. dr Slobodan Obradovi} (Serbia) Prof. dr Milica Martinovi} (Montenegro)Prof. dr Slobodan Grebeldinger (Serbia) Prof. dr Nermina Hadìgrahi} (Bosnia and Herzegovina)Prof. dr Slobodan M. Jankovi} (Serbia) Prof. dr Miralem Musi} (Bosnia and Herzegovina)Prof. dr @ivan Maksimovi} (Serbia) Prof. dr Spase Jovkovski (R. Macedonia)Prof. dr Zlata Janji} (Serbia) Prof. dr Evangelos J. Giamarellos-Bourboulis (Greece)Prof. dr Svetislav Milenkovi} (Serbia) Prof. dr Paolo Pelosi (Italy)Prof. dr Radmilo Jankovi} (Serbia) Prof. dr Zsolt Molnar (Hungary)

English language editorSelma Mehovi}

DesignPrim. dr Avdo ]erani}

PublisherAssociation of medical doctors “Sanamed”, Novi Pazar

ISSUED THREE TIMES A YEAR

Editorial address“SANAMED”, St. Palih boraca 52, 36300 Novi Pazar, Serbiaemail: sanamednpªgmail.com, www.sanamed.rs

Print“ProGraphico”, Novi Pazar

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SubscriptionAnnual subscriptions: 4000 RSD for domestic institutions and 1500 RSD for individuals. For readers abroad, an-nual subscription is 75 Euro (in Dinar equivalent at the exchange rate on the day of payment). For further instruc-tions and informations, contact Editorial Board.

ISSN-1452-662X

CONTENTS

• AWORD FROM THE GUEST EDITOR.................................................................................................... 9

• AWORD FROM THE GUEST EDITOR.................................................................................................... 10

• AWORD FROM THE EDITOR ................................................................................................................. 11

• ORIGINAL ARTICLE

• PERINATAL OUTCOME OF PRETERM INFANTS IN FEDERATIONOF BOSNIAAND HERZEGOVINA.......................................................................................................... 15Skokic Fahrija,

1Hotic Nesad,

1Muratovic Selma,

2Skokic Maida,

1Hadzic Devleta,

1Cosickic Almira,

1

Selimovic Amela,1

Zulic Evlijana,1

Meric Alma,1

Halilbasic Amir1

1Paediatric Clinic, University Clinical Centre Tuzla, Faculty of Medicine Tuzla, Bosnia and Herzegovina

2Gynaecology and Obstetrics Clinic, University Clinical Centre Tuzla, Faculty of Medicine Tuzla, Bosnia and Herzegovina

• ARYTENOIDCORDECTOMY FOR BILATERAL VOCAL CORD PARALYSIS:PRIMARY AND REVISION PROCEDURE.............................................................................................. 23Zenev Ivan,

1Sapundzhiev Nikolay

2

1Hospital “Queen Jioanna”, Department of Oto-rhino-laryngology, Medical University Sofia, Bulgaria

2Department of Oto-rhino-laryngology, Medical University Varna, Bulgaria

• HIV / AIDS EDUCATION OF HEALTH CARE PROVIDERS .................................................................. 31Ljaljevic Agima, Scepanovic Lidija, Mugosa Boban, Catic Sabina

Institute of Public Health Montenegro, Podgorica, Montenegro

• PROFESSIONAL ARTICLE

• SYNDROME OF HYDROCEPHALUS IN YOUNG AND MIDDLE-AGED ADULTS.REVIEW OF THE LITERATURE AND ILUSTRATIVE CASES ............................................................. 37Kalevski Svetoslav, Peev Nikolay

Department Of Neurosurgery, Medical University Of Varna, Bulgaria, St. Anna Multiprofile Hospital, Varna, Bulgaria

• ACUTE RENAL FAILURE IN THE NEWBORNS HOSPITALIZEDAT THE INTENSIVE CARE UNIT, UNIVERSITY CLINICAL CENTRE TUZLA .................................. 47Zulic Evlijana, Hadzic Devleta

University Clinical Center Tuzla, Pediatric Clinic, Tuzla, Bosnia and Herzegovina

• OUR EXPERIENCE WITH MAGERL`S MODIFIED TECHNIQUEFOR STABILIZATION OF SUBAXIAL CERVICAL SPINE .................................................................... 51Haritonov Dimitar,

1Kalevski Svetoslav,

1, 2Peev Nikolay

1

1University Hospital “St. Anna”, Department of Neurosurgery, Varna, Bulgaria

2University of Varna, School of Medicine Varna, Bulgaria

• CARACTERISTICS OF PNEUMONIAHOSPITALIZATIONS AT PEDIATRIC CLINIC TUZLA ......... 57Hadzic Devleta, Zulic Evlijana

University Clinical Center of Tuzla, Pediatrics clinic, Tuzla, Bosnia and Herzegovina

Broj 10(1)/2015

• CASE REPORT

• TANDEM COMPRESSION OF MEDULLASPINALIS AND CAUDAEQUINA.................................... 65Zhelyazkov Christo,

1Davarski Atanas,

1Kitova Tanya,

2Kehayov Ivo,

1Kitov Borislav

1

1Department of Neurosurgery, Medical University, Plovdiv, Bulgaria

2Department of Anatomy, Histology and Embriology, Medical University, Plovdiv, Bulgaria

• REVIEW ARTICLE

• INTRA-ABDOMINAL INFECTION AND ACUTE ABDOMEN-EPIDEMIOLOGY,DIAGNOSIS AND GENERAL PRINCIPLES OF SURGICAL MANAGEMENT.................................... 69Jovanovic Dusan,

1Loncar Zlatibor,

1, 2Doklestic Krstina,

1, 2Karamarkovic Aleksandar

1, 2

1Clinic for Emergency Surgery, Clinical Center of Serbia, Belgrade, Serbia

2Faculty of Medicine, University of Belgrade, Serbia

• INSTRUCTIONS FOR AUTHORS............................................................................................................ 83

SADR@AJ

• RE^ GOSTUJU]EG UREDNIKA............................................................................................................. 9

• RE^ GOSTUJU]EG UREDNIKA............................................................................................................. 10

• RE^ UREDNIKA ....................................................................................................................................... 11

• ORIGINALNI NAU^NI RAD

• PERINATALNI ISHOD NEDONO[ÂDI U FEDERACIJI BOSNE I HERCEGOVINI .......................... 15Skoki} Fahrija,

1Hoti} Nesad,

1Muratovi} Selma,

2Skoki} Maida,

1Hadì} Devleta,

1]osi}ki} Almira,

1

Selimovi} Amela,1

Zuli} Evlijana,1

Meri} Alma,1

Halilba{i} Amir1

1Klinika za dje~ije bolesti, Univerzitetski klini~ki centar Tuzla, Medicinski fakultet u Tuzli, Bosna i Hercegovina

2Klinika za ginekologiju i aku{erstvo, Univerzitetski klini~ki centar Tuzla, Medicinski fakultet u Tuzli, Bosna i Hercegovina

• ARITENOIDKORDEKTOMIJA KOD BILATERALNE PARALIZE GLASNIH @ICA:PRIMARNAI REVIZIONAPROCEDURA............................................................................................... 23Zenev Ivan,

1Sapundzhiev Nikolay

2

1Bolnica “Carica Ioanna”, Odeljenje za otorinolaringologiju, Medicinski fakultet Univerziteta u Sofiji, Bugarska

2Odeljenje za Otorinolaringologiju, Medicinski fakultet Univerziteta u Varni, Bugarska

• HIV/AIDS EDUKACIJAZDRAVSTVENIH RADNIKA .......................................................................... 31Ljaljevi} Agima, [}epanovi} Lidija, Mugo{a Boban, ]ati} Sabina

Institut za javno zdravlje Crna Gora, Podgorica, Crna Gora

• STRU^NI RAD

• SINDROM HIDROCEFALUSA KOD MLADIH I OSOBA SREDNJE @IVOTNE DOBI— PREGLED LITERATURE I PRIKAZI SLUÂJEVA............................................................................ 37Kalevski Svetoslav,

1, 2Peev Nikolay

2

1Multiprofile Hospital “St. Anna”, Department Of Neurosurgery, Varna, Bulgaria

2University Of Varna, School of medicine, Varna, Bulgaria

• AKUTNA RENALNA INSUFICIJENCIJA KOD NOVORO\ENÂDI HOSPITALIZOVANIHNAODELJENJU INTENZIVNE NEGE UNIVERZITETSKOG KLINI^KOG CENTRATUZLA .......... 47Zuli} Evlijana, Hadì} Devleta

Klinika za dje~ije bolesti, Univerzitetski klini~ki centar Tuzla, Bosna i Hercegovina

• NA[E ISKUSTVO SA MAGERL-OVOM MODIFIKOVANOM TEHNIKOMZASTABILIZACIJU SUBAKSIJALNE CERVIKALNE KI^ME............................................................. 51Haritonov Dimitar,

1Kalevski Svetoslav,

1, 2Peev Nikolay

1

1University Hospital “St. Anna“, Department of Neurosurgery, Varna, Bulgaria


• KARAKTERISTIKE PNEUMONIJA KOD HOSPITALIZOVANIHNAPEDIJATRIJSKOJ KLINICI TUZLA................................................................................................... 57Hadì} Devleta, Zuli} Evlijana

Klinika za dje~ije bolesti, Univerzitetski klini~ki centar Tuzla, Tuzla, Bosna i Hercegovina

Broj 10(1)/2015

• PRIKAZ SLU^AJA

• TANDEM KOMPRESIJAKI^MENE MO@DINE I KAUDE EKVINE..................................................... 65Zhelyazkov Christo,

1Davarski Atanas,

1Kitova Tanya,

2Kehayov Ivo,

1Kitov Borislav

1



• REVIJALNI RAD

• INTRA-ABDOMINALNA INFEKCIJA I AKUTNI ABDOMEN-EPIDEMIOLOGIJA,DIJAGNOZAI OP[TI PRINCIPI HIRUR[KOG RE[AVANJA ................................................................ 69Jovanovi} Du{an,

1Lon~ar Zlatibor,

1, 2Doklesti} Krstina,

1, 2Karamarkovi} Aleksandar

1, 2

1Klinika za urgentnu hirurgiju, Klini~ki centar Srbije, Beograd, Srbija

2Medicinski fakultet Univerziteta u Beogradu, Beograd, Srbija

• UPUTSTVO AUTORIMA.......................................................................................................................... 79

Re~ gostuju}eg urednika

/ A word from the guest editorPo{tovani ~itaoci, drage kolege i saradnici,âst mi je i neizmjerno zadovoljstvo obratiti Vam se u ulozi

jednog od gostuju}ih urednika ~asopisa Sanamed. Publikova-njem radova iz razli~itih oblasti klini~ke i preventivne medicine,~asopis Sanamed èli i uspijeva da pribliì najnovije tekovine sa-vremene medicine ljekarima i svim prijateljima medicine. Ujed-no, ~asopis daje podstrek ljekarima, za publikovanje stru~nih inau~nih radova i podsti~e istraìva~ki duh mladih ljekara {to seod jednog znanstvenog ~asopisa i o~ekuje, a {to ujedno njegovomuredni{tvu ~ini veliko zadovoljstvo i daje motiva za dalji rad.

Posebno treba naglasiti da se ~asopis distribuira u zemlji iu inostranstvu, pa smo tako i mi u Bosni i Hercegovini uz sve lju-de dobre volje koji pomaù opstanak ovog ~asopisima u ovim ne-sigurnim vremenima.

Dio materijala koji smo ovdje iznijeli iz kazuistike je dje~i-je i perinatalne patologije Univerzitetsko klini~kog centra u Tu-zli. Rije~ je o svakodnevnim stru~nim problemima vezanim zadje~ju dob i probleme organizacije zdravstvene za{tite s kojim sesusre}emo svakodnevno. Svakom radu autori su pristupilistru~no i znanstveno, s ciljem da obra|eni materijal bude dosto-jan ~asopisa.

Po{tovani ~itaoci, drage kolege i saradnici pred nama jenovi broj Sanameda u kojem vam pored nau~nih i stru~nih ~lana-ka donosimo i novitete iz medicine. Svakako da nas raduje {tam-panje ovog, ali i svih narednih brojeva.

Do narednog broja,Va{a

Prof. dr Fahrija Skoki}Pedijatar neonatolog

Pomo~nik direktora za medicinska pitanja UKC Tuzla[ef Katedre za Pedijatriju Medicinskog fakulteta

Univerziteta u TuzliBosna i Hercegovina

* * *

Dear readers, colleagues and associates,It is my honour and immense pleasure to address You in a

role of one of the guest editors of the journal Sanamed. By publis-hing of papers from different areas of clinical and preventive me-dicine, journal Sanamed wants and manages to bring the newestachievements of modern medicine to doctors and all friends ofmedicine. At the same time, the journal gives doctors an incentive

for publishing of scientific papers and encourages exploratoryspirit of young doctors, which is expected from one scientific jo-urnal, and what also gives its editorship a great pleasure and mo-tivation for further work.

It is especially necessary to stress out that the journal is di-stributed in country and abroad, so we in Bosnia and Herzegovi-na are with all the good people who help the survival of this jour-nal in these unsecured times.

Part of the material presented here is taken from casuistryof child and perinatal pathology at the University clinical centrein Tuzla. The matter is about everyday professional issues relatedto the children’s age and issues of health care organization,which we encounter every day. Each paper, the authors have ap-proached professionally and scientifically, for the sake of valueof the processed material.

Dear readers, dear colleagues and co-workers, in front ofus is the new issue of Sanamed where next to the scientific artic-les we bring also innovations from the world of medicine. Certa-inly we are glad about printing of this, and all next issues.

Until the next issue,Your,

Prof. dr Fahrija SkokicPaediatrician neonatologist

Assistant to the director for medicine mattersUniversity Clinical Centre Tuzla

Head of the Department for Paediatricsat the Faculty of Medicine, University of Tuzla

Bosnia and Herzegovina

A word from the guest editor

/ Re~ gostuju}eg urednikaDear Colleagues,

This is a great honor for me to be one of the gu-

est editors of such an authoritative medical journal

as “Sanamed”. I think this journal has a very high

scientific level and I congratulate the publishers,

and wish them many more years of successful devel-

opment. Given the high scientific quality of the jour-

nal and its authors, I always recommend with confi-

dence my colleagues to publish their scientific con-

tributions mainly in “Sanamed”, and more likely to

include it in their references. In support of these

words in this issue we present several scientific arti-

cles of Bulgarian authors, and we hope that this

trend will become permanent. The idea of The Edi-

torial Board in each issue to have different guest ed-

itors is very useful and will help a lot for the promo-

tion of the medical journal to a wider circle of read-

ers. In this sense, I would like to thank especially Dr.

Dzemail Detanac for this great initiative, and to

wish him very good health and success.

Prof. Dr Svetoslav Kalevski, MD, PhD, DScNeurosurgeon

Head of Dept. of NeurosurgeryMedical University of Varna

Varna, Bulgaria

* * *

Po{tovane kolege,

Izuzetna ~ast je to {to mi je ukazana prilika da

budem jedan od gostuju}ih urednika u autoritativ-

nom medicinskom ~asopisu kao {to je „Sanamed“.

Mi{ljenja sam da je ovo ~asopis sa vrlo visokim na-

u~nim nivoom, i ovom prilikom ~estitam izdava~i-

ma, i èlim im jo{ mnogo godina uspe{nog razvoja.

S obzirom na visok nau~ni kvalitet ~asopisa i njego-

vih autora, uvek s poverenjem preporu~ujem kole-

gama da publikuju svoja nau~na dostignu}a uglav-

nom un „Sanamed-u“, kao i da ga uklju~e u svoje

reference. U ovom broju predstavljamo nekoliko

nau~nih radova bugarskih autora, sa èljom da ovaj

trend postane trajan. Ideja Uredni{tva da u svakom

broju imaju razli~ite gostuju}e urednike je vrlo ko-

risna i pomo}i }e promociji ovog medicinskog ~aso-

pisa {irem krugu ~itatelja. U tom smislu, èleo bih

se zahvaliti, posebno dr Dèmailu Detancu, za ovu

veliku inicijativu, kao i da mu poèlim dobro zdra-

vlje i uspeh.

Prof. Dr Svetoslav Kalevski, MD, PhD, DScNeurohirurg

[ef katedre za neurohirurgijuMedicinski fakultet u Varni

Bugarska

Rije~ urednika

/ A word from the editorPo{tovani,

Uvijek mi je pravo zadovoljstvo to {to imam

privilegiju da se obratim Vama, stvaraocima, i po-

{tovaocima nau~ne i stru~ne medicinske misli. „SA-

NAMED“ je odavno postao na{ most povezivanja.

Ustanova u kojoj radim je tako|e odavno ve} posta-

la prepoznatljiva po na{em „SANAMED“-u. Lako

je primijetiti da mi vi{e nijesmo sami, posebno od

kako je na inicijativu zamjenika glavnog urednika,

dr Dèmaila Detanca, hirurga, uvedena institucija

„Gost urednik“, {to se pokazalo kao veoma zna~aj-

no, jer smo se na neki na~in ra{irili po svijetu, po-

tom zbliìli i okupili oko stru~ne misli. Iz tako geo-

grafski udaljenih destinacija govorimo istim jezi-

kom medicine, a oni koji su sada na{i kourednici se

sa ni{ta manje àra stru~no tro{e da bi svaki novi

broj ~asopisa bio bolji od prethodnog. Svi oni, na{i

prijatelji, visoki znanstvenici koji nas podràvaju i

neposredno daju li~ni doprinos za bolji kvalitet, di-

jele}i sa nama utro{eni trud i vrijeme, poklanjaju is-

kustvo i znanje onima koji to cijene i koriste za raz-

voj nauke, u korist ~ovjeka, za zdravu populaciju.

Ako je Hipokrat u tekstu ljekarske zakletve za-

vjetovao da ljekari budu na usluzi ~ovjeku, to mogu

samo ako neprestano u~e, istraùju, prenose i raz-

mijenjuju iskustva. Ljekari su bra}a i sestre po stru-

ci i humanosti, a pacijent kao najve}a svijetinja ko-

joj se posvje}uju. Tako se zbliàvamo, a da se sa

mnogima nikada i ne sretnemo, uz istu èlju da

udahnemo neki novi ìvot, bez motivacije za materi-

jalnom dobiti.

[ta treba jo{ re}i?

Pravom humanisti, kolegi, prijatelju, srce je

uvijek ispunjeno saosje}anjem i u te{kom trenutku.

To smo osjetili ovih dana, kada nas je ovdje, i u cije-

loj zemlji zadesio tuàn tragi~ni doga|aj, u kojem je

{est odabranih sinova ove zemlje nesre}no izgubilo

ìvot, spa{avaju}i jedno malo, tek ro|eno ljudsko

bi}e. @rtvovali su sebe da bi pruìli {ansu drugome

da ìvi. Zla kob i sudbina od Boga bili su nemilosrd-

ni. Svo sedmoro su nas zauvek napustili. Me|u nji-

ma i dvojica mladih ljudi zdravstvene struke, na{

kolega i saradnik, a mi, koji jo{ privremeno stojimo

u redu i ~ekamo na ovom svijetu, ostali smo da ih à-

limo i da im se divimo. Postavljam pitanje: kakvi su

to kontrasti, i koje je to kosmi~ko zra~enje poremeti-

lo um pojedincima, da iz nekog skrovi{ta diriguju

uni{tavanje desetine, stotine i hiljade ljudskih ìvo-

ta koji nisu na zemlji njegovom voljom, a da mu se

puls i krvni pritisak ne promijeni?

Ovim putem èlim da se iskreno zahvalim svim

prijateljima {irom svijeta (iz Indije, Turske, Brazila,

Kanade, Bugarske i drugih zemalja), na{im sarad-

nicima, koji su nam izrazili svoje duboko sau~e{}e.

Po{tovane kolege i prijatelji, molim Boga da se

nikom ne desi ovakva `rtva ne bi li se spasio tu| ì-

vot. Poku{ajmo da kroz stalne znanstvene aktivnosti

podignemo nivo znanja i uslova u lije~enju, kako ne

bi dolazili u situaciju da se izlaèmo ovakvim rizici-

ma. Ovo i jeste na{ moto, da se znanjem bogatimo

{to vi{e i u svakom delu Zemljine kugle da se stvore

uslovi za brze stru~ne i profesionalne pristupe u re-

{avanju rizi~nih zdravstvenih stanja kod ljudi. Ako

12

je Bog stvorio sve ljude na isti na~in, ne dijele}i ih

po boji, rasi, vjeri i drugoj pripadnosti, onda zaslu-

`uju i da svi imaju iste uslove za lije~enje.

Dvadeset prvi vijek mora da elimini{e sve ne-

dostatke, dru{tvo mora da podr`i nauku, da kroz

razmjenu znanja stvori dostojnu medicinu i kao ta-

kvu dostupnu svakom mjestu Zemljine kugle.

Dragi gostuju}i urednici, Va{ doprinos za kva-

litet na{eg ~asopisa je ogroman, ali je mnogo vi{e to

{to kroz takvo djelovanje podsti~ete i druge da se

okupljamo, pi{emo, objavljujemo i unapre|ujemo ni-

vo znanja. U svakom novom izdanju nas je sve vi{e.

Hvala Vam na nesebi~nosti, sve smo bolji, i vje-

rujem u uspjeh.

Prim. dr Avdo ]erani}glavni i odgovorni urednik

* * *

Respected,

It is always a true pleasure to be privileged to

address You, creators and admirers of science and

professional medical thought. “SANAMED” is our

bridge of connection for a long time. The institution

for which I work is also now recognizable by our

“SANAMED”. It is easy to notice that we are no

longer alone, especially since the initiative “guest

editor” is implemented, by the deputy editor in chi-

ef, dr. Dzemail Detanac — surgeon, which has

shown as quite significant, because in some way we

have spread all over the world, and afterwards we

have come together around the scientific thought.

From such distant geographic destinations, we spe-

ak the same language of medicine, and our co-edi-

tors are passionately working so that every new edi-

tion would be better than the previous one. All of

them, our friends, senior scientists which support us

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ment. We have this feeling these days, here, in the

whole country, when sad, tragic event occurred,

event where six chosen sons of this country tragi-

cally lost their lives, saving one small, newborn hu-

man being. They have sacrificed themselves to give

a fighting chance for someone else. Doom and des-

tiny of God were ruthless. All seven of them have left

us. Among them are also two young people from me-

dical science, our colleagues and co-workers, and

we, who still temporarily wait in the line in this

world, are here to mourn and admire them. I ask a

question: what are these contrasts, and what is this

cosmic radiation which disturbed the mind of indi-

viduals, to direct the destruction of docents, hun-

dreds and thousands of human lives from their shel-

ters, without even changing their blood pressure?

I hereby wish to sincerely thank all friends

from all over the world (India, Turkey, Brasil, Can-

ada, Bulgaria and other countries), our colleagues

who expressed their deep condolences.

Respected colleagues and friends, I pray to

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order to save someone elses life. Let us try, thorugh

constant scientific activities, to rise the level of

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get more wealthy in knowledge and to create condi-

tions for quick professional accesses in solving

risky health conditions in people, in every part of

the Earth. If God created all people in the same way,

not dividing them by colour, rase, religion or any ot-

her affiliation, then they deserve to have the same

treatment conditions.

The twenty first centiry must eliminate all

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You support others as well — to gather, write, pub-

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new issue, we are larger in number.

Thank you for your selflessness, we are doing

better and better, and I believe in success.

Prim. dr Avdo CeranicEditor in Chief

PERINATAL OUTCOME OF PRETERM INFANTS

IN FEDERATION OF BOSNIA AND HERZEGOVINA

Skokic Fahrija,1

Hoti} Nesad,1

Muratovic Selma,2

Skokic Maida,1

Hadzic Devleta,1

Cosickic Almira,1

Selimovic Amela,1

Zulic Evlijana,1

Meric Alma,1

Halilbasic Amir1

1Paediatric Clinic, University Clinical Centre Tuzla, Faculty of Medicine Tuzla, Bosnia and Herzegovina

2Gynaecology and Obstetrics Clinic, University Clinical Centre Tuzla, Faculty of Medicine Tuzla,

Bosnia and Herzegovina

Primljen/Received 30. 01. 2015. god. Prihva}en/Accepted 28. 02. 2015. god.

Abstract: Introduction: Despite growing progressof perinatal medicine and perinatal care, between 9–19%of preterm infants are born each year. Improvement insurvival of infants and the reduction in infant mortalityrates is a key role of perinatal quality healthcare.

The Aim: To evaluate the perinatal outcome ofpreterm infants in maternity wards of the Federation ofBosnia and Herzegovina for a period of one year.

Material and methods: Of 22 897 live newborns,the research criteria matched 669 (2.9%) preterm in-fants with complete medical records in ten cantons ofthe Federation Bosnia and Herzegovina. We analyzeddata from maternity wards documentation and dischar-ge letters from tertiary health care centers.

Results: Most deliveries were in the Tuzla and Sa-rajevo Canton with 42.5% of preterm infants. The meangestational age of preterm infants was 31.4 weeks, withSD ± 5.34, and the mean birth weight 1295 grams, SD ±234.2. The mean Apgar score was 4.6 ± 2.1, and in thefifth minute 6.6 ± 1.9. Of 669 examinees, there were 345(51.56%) males and 324 (48.44%) females (51.56 vs48.44; �

2 = 1.19; P = 0.27). By analyzing the frequencyof preterm infant birth rate according to weight categori-es, we found a significant difference in some levels ofperinatal health institution, between the 1

stand 2

ndinsti-

tutions levels (1.76% vs 3.01%; P < 0.0001), also betwe-en 2

ndand 3

rdinstitutions levels (3.01% vs 3.03%; P <

0.0002), and between 1st and 3rd institutions levels(1.76% vs 3.03%; P < 0.0001). A significant statisticaldifference in survival of tested newborns was found ininstitutions of 3rd level �

2 = 49.25; P < 0.0001 with alow risk for unfavorable outcome ŠOR = 0.436; 95%CI(0.346–0.550)¹.

Conclusion: Perinatal outcome of preterm infantsin the Federation Bosnia and Herzegovina significantly

depends on the level of perinatal health care. Survivalrate of infants born in the institutions of the 3rd levelwas statistically much higher than the survival rate ofinfants who were born in the 1

stand the 2

ndlevel institu-

tions.Key words: preterm infants, perinatal outcome,

preterm birth, regionalization, neonatal mortality.

INTRODUCTION

Preterm birth is the most common complication ofthe second half of pregnancy and preterm labour itselfis associated with a higher risk of medical complica-tion for mother and child. Due to high perinatal ratemortality (60–80%), preterm labour is one of the mostimportant problems of modern medicine (1). The chan-ces for preterm infants’ survival probability is severaltimes less compared to chances for survival of a fullterm infants. Either they do not survive, or if they sur-vive, they have significant chances to suffer from disa-bilities. In addition to a various fetal complications thatmay occur during pregnancy and labour, premature in-fant with its immature organs and organ systems is be-ing exposed to a greater risk for early and late neonatalcomplications that occur while adjusting the life outsi-de the uterus. Regionalization of perinatal care, impro-ving technology, and better understanding of the pat-hopsychology of preterm infants and their specific ne-eds made a significant increase in the preterm infantssurvival rate (2). Preterm born infant has a real chanceof survival if born at a gestational age 26–28 weeks orweighing 800–1000 grams, although the application ofsurfactants and new mechanical ventilation options in-crease the cances of survival. Preterm is defined as in-fant born at a gestational age before 37 weeks, and its

UDK: 616-053.31(497.6)

2015; 10(1): 15–22 ID: 214199820

ISSN-1452-662X Original article

weight is important at any time of pregnancy (3). Parti-culary vulnerable are infants, 15% of them, with pri-mary immaturity and signs of intrauterine growth re-striction (4). Total mortality for this group of infants is12.1%, and there is increase in the incidence of respira-tory distress syndrome, intracranial hemorrhage, pre-mature retinopaty and necrotizing enerocolitis. The in-fluence of certain factors such are male, twin preg-nancy, hypothermia and sepsis increase the risk. Mor-tality and morbidity of preterm infants is significantlyhigher in smaller perinatal centers (5). Improvement insurvival rate of newborn infants and the reduction ininfant mortality rate is a key role of perinatal qualityhealthcare. It is common that the total mortality rate ofa newborns in the region or country is being expressedby groups of birth weight and gestational age. Howe-ver, by comparing the possibility of survival, it is clearthat the infant with the same birth weight will have agreater chance of survival if not seriously ill ( if e.g. donot develop respiratory distress or if there is no li-fe-threatening anomaly) (6).

Among other criteria, the success of neonatal in-stitution is often measured by mortality rate and survi-val rate of patients. In these comparisons, newborns areusually stratified by outcome predictors, most com-monly by a birth weight, and later there are comparablegroups of patients from different neonatal institutions.Some studies have been adjusted to the differences bet-ween birth weight and other prognostic characteristicin treated infants. They showed great differences inmortality rates in the third level health institutions anda lower- level neonatal institutions (7).

The existence of differences in medical practiceand outcome of patients badly effects the credibility ofmedicine. That is why reducing these differences isone of priorities in the system of organized health care.The outcome of patients is in a function of health carequality, but it is subjected to other influences, even ac-cidental, but it is also a function of the clinical charac-teristic of patiens, including the severity of disease.

Diseases severity is defined and measured by qu-antifying the deviation from the physiological and/orthe presence of a pathological condition and/or the pre-sence and intensity of the disease. To compare the out-comes of patients between individual neonatal institu-tions, it is necessary to stratify cases by severity of dis-ease in these institutions. The comparison of neonatalinstitutions is only possible by the outcome of strati-fied patients. To this end, a research project of risk- ad-justed outcomes is carried out. This is the processs ofclassifying subjects of compared groups into variousclasses of risk to compare outcomes separately for eachclass. This approach allows better comparation of gro-ups, and it is inevasible while analysing the patients

outcome when it is difficult or impossible to do the ran-domization of group of patients, such as in the cases ofexploring hospitals possibilities, differences in clinicalpractice, health care organization in the region, outco-me trends through time period, resources using, healthcare services financing etc. Survival rate on infantswith birth weight less than 1500 grams until the mo-ment of discharge from hospital (N = 514) in a period1996–2001 in one of neonatal institution of the third le-vel in the Czech Republic was 90.7%, and for the gro-up of infants of birth weight 1000–15000 grams (N =321) was 98.8% (8). In a group of patients of other neo-natal institutions in the Czech Republic, survival rateof infants of birth weight less than 1000 grams by thetime of discharge from hospital in a period 1996–2001was 77%, while in Norway, in a similar period, was89% (9).

Despite growing progress of perinatal medicineand perinatal care, between 9–19% of premature in-fants are born each year. It is estimated that more than95% of preterm infants are being born in developingcountries, with birth incidence of 16.5%, among still-borns even 20%, without a tendency of decrease (10).Also, there is no a tendency of decrease in neonatalmorbidity, mortality neuromotor impairments, cere-bral palsy with incidence between 1 and 2/1000 livebirths in general population (10). A lower birth weight,shorter gestational age and low frequency of antenatalsteroid administration, as well as “air leak syndrome“are associated with a higher risk of death. Survival rateis higher and morbitity rate is lower if the place of birthis maternity ward of the third level rather than elsewhe-re. Recent years have seen marked changes in the gene-ral approach to the management of preterm infantsbringing a significant contribution to a higher survivalrate, lower morbidity and lower prevalence of disabil-ity. There is a higher rate of labours of such infants inthe marternity wards of third level, prenatal corticoste-roids administration, wider use of high- quality venti-lators and incubators, surfactants and early pharmaco-logical closure of ductus arteriousus in preterm infants.

The progress of regionalization of perinatal careincreased the ratio of infants’ birth less than 1500grams born in maternity hospitals of the third level, andreduced the number of births in maternity hospitals ofthe first and second level. The research from the begin-ning of the process of regionalization of perinatal carein the USAhas shown that during the two four- year pe-riods brought an increase in the proportion of infantsborn with birth weight of 454–1820 grams in the ma-ternity wards of the third level and the decrease in theproportion among infants born in the maternity ward ofthe first level, while the proportion of infants born inthe maternity wards of the second level remained un-

16 Skokic Fahrija, Hoti} N., Muratovic S., Skokic M., Hadzic D., Cosickic A., Selimovic A., Zulic E., Meric A., Halilbasic A.

changed (10). Caring for a preterm infant takes a lot ofspecific care, and today the treatment and care are di-rected to specialized tertiary care centers, favouring in-utero transport. Perinatal and neonatal health care inthe F B&H is not regionalized. Antenatal transporttransport of patients is left to the personal initiative of adoctor on the field. Postnatal transport is carried out“from itself” instead of “to itself”. Based on global ex-perience and situation assesment in the F&H, there areonly a few working groups for perinatal medicine andthe implementation of the regional perinatal care orga-nization (11). The aim of this paper is to evaluate theperinatal outcome of preterm infants in maternitywards of the Federation of Bosnia and Herzegovina fora period of one year.

PATIENTS AND METHODS

This paper presents and analyzes the results of ret-rospective study which evaluated preterm birth inci-dence in the cantons of the Federation of Bosnia andHerzegovina, according to the levels of the maternitywards in which they were born. Also, this paper ana-lyzes overall survival rate of infants and compares thesubgroups of birth weight and the levels of maternitywards. The research place is the Federation of Bosniaand Herzegovina, which is administratively divided in-to ten cantons (Figure 1).

As an infant we took every child born up to 36+6weeks of pregnancy and birth weight of 2500 grams andless. All the pregnancies of whom are preterm infantborn were single, and the infants were divided into thesoubgroups according to birth weight (500–999 grams,1000–1449 grams, 1500–1999 grams, 2000–2499 grams),

adding that there were no livebirth preterm infants withbirth weight less than 500 grams. Of total 22 897 in-fants, these terms met 669 (2,9%) of them. We ana-lyzed data from the maternity wards and discharge let-ters from the tertiary health care centers. For the purpo-ses of this study, the levels of neonatal units are definedaccording to diagnostic and therapeutic capabilities,and all according to the definition of the Association ofNeonatologists of the FB&H from 2000 (11).

The regional distribution of maternity wards andneonatal units followed the current situation of the orga-nization and the common practice of postnatal transport:

• first level — capacity to care for eutrophic termnewborns,

• second level — capacity to care for term new-borns with hyperbilirubinemia, hypoglicemia and aci-dosis,

• third level — capacity to care for newborns withvarious health problems of any gestational age andbirth weight, including mechanical ventilation, exan-guinotransfusion, and all surgical procedures exceptcardio surgical.

In some cantons there are only maternity wardswithout neonatal institution, so that the place of birthand health care for newborns are being marked as peri-natal health institutions (PHI) according to the leves.

The data were analyzed by the �2 test in the con-

tingency 2 by 2 tables. The data were shown accordingto the level of perinatal care. The results of the logisticmodels were expressed as odds ratios (OR) with 95%confidence intervals (CI). Those infants who were bornat the lower level of care were identified and their out-come was presented as number of transported infantswith early neonatal mortality rate. Statistical analysiswas performed with SAS software, version 9.1 (SASInstitute, Cary, NC). P < 0.05 was considered statisti-cally significant.

RESULTS

The examined infants are born in a period 1st

Janu-ary 2014 to 31

stDecember 2014, in the FB&H. The

highest birth rate was in the biggest two cantons, theTuzla and Sarajevo Canton, where 42.5% of total pre-term infants in the FB&H were born. The remaining18.3% of infants were born in the Zenica- Doboj Can-ton, 12.5% of infants in the Una- Sana Canton, 10.8%in the Central Bosnia Canton, and 15.9% in other can-tons of the FB&H. The total sample included 669 pre-term infants who had a birth weight less than 2500grams. The range of birth weight was 500 to 2499grams, with an average birth weight of 1295 grams, SD± 234.2, while an average gestational age was 31.4 ges-tational weeks with SD ± 5.34.

PERINATAL OUTCOME OF PRETERM INFANTS IN FEDERATION OF BOSNIA AND HERZEGOVINA 17

Figure 1. Cantons in the Federation of Bosnia

and Herzegovina

The average age of mothers of 661 preterm infantswas 27.7 years (SD ± 1.2), and ranged 16 to 38 years.Out of 669 mothers of an infants examined, the data onmother’s age were not available for 8 (1.2%), and thedata on Apgar score were not available for 154 (23%)infants.

The mean Apgar score in the first minute was 4.6± 2.1, and in the fifth minute 6.6 ± 1.9. Of 669 tested in-fants, 345 (51.56%) were male, and the remaining 324(48.44%) were female, with a male: female ratio of1.06:1. Male newborns were not statistically more pre-valent (51.56 vs 48.44; �

2 = 1.19; P = 0.27). The dataon gender distribution are shown in Figure 2.

411 (61.4%) of the tested preterm infants wereborn by a normal childbirth, and 141 (21.1%) preterminfants were operatively born with statisticaly signifi-cant difference (� 2 = 344.32; P < 0.0001). There wereno available data on the methods of childbirth for 63(9.4%) preterm infants.

The analysis of the tested newborns by 500grams- birth weight subgroups has shown that the big-gest number of the tested newborns was in the subgro-up of the biggest birth weight of 2000 — 2499 grams,307 of them (45.9%), while the smallest number wasfound in 500–999 grams subgroup, 49 of them (7.3%).

By analyzing the frequency of births of tested in-fants according to weight groups, we have found a sig-nificant difference in certain levels of PHI, as shown inFigure 1. In the total sample of tested newborns, statis-tically significant difference was found in the distribu-tion of birth of tested between 1

stand 2

ndlevel of PHI

(1.76% vs 3.01%; P < 0.0001), thereafter between 2nd

and 3rd

level of PHI (3.01% vs 3.03%; P < 0.0002), andbetween 1

stand 2

ndlevel of PHI (1.76% vs 3.03%; P <

0.0001).

10% of the tested infants in weight group 500-999grams was in the 1st level of PHI, 4.2% of the tested in-fants from this subgroup was in the 2

ndlevel of PHI,

and 9.6% infants in the 3rd

level of PHI. Statisticallysignificant difference was found between the 2

ndand 3

rd

level of PHI (4.2% vs 9.65; P = 0.01). The differencewas found in a weight group of 1000–1499 grams(12.9% vs 20.3%; P = 0.01). Statistically significantdifference in the frequency of births between the 2

nd

and 3rd

level of perinatal health institution (PHI) wasfound in the biggest weight group of newborns 2000––2499 grams (� 2 = 24.21; P < 0.0001).

In the 1st level of PHI, 48% of infants were in thebiggest weight group of 2000–2499 grams. This we-ight group of infants was the most represented in the 2

nd

level of PHI 60.1%, while in the 3rd

level of PHI thisgroup was slightly less represented 40.9% (Figure 3).

Extremely premature infants of 22 to 32 gestationweeks accounted for one-third of the tested infants(219; 32.7%), while moderately premature infants we-re the least represented – 25.7%.

By analyzing the frequency of tested newborns ac-cording to a gestational age, we have found a significantdifference in certain leves of PHI, as shown in Figure 2.


Birth weightPHI

+

1st

levelN/%

PHI2

ndlevel

N/%

PHI3

rdlevel

N/%

�2 P

PHI1

st/2

nd

�2 P

PHI2

nd/3

rd

�2 P

PHI1

st/3

rd

500–999 3 (10.4%) 12 (4.2%) 34 (9.6%)�

2 1.04

P 0.30

�2 6.26

P 0.01

�2 0 .01

P 0.89

1000–1449 3 (10.4%) 37 (12.9%) 72 (20.3%)�

2 0.01

P 0.91

�2 5.62

P 0.01

�2 1.12

P 0.28

1500–1999 9 (31%) 63 (22%) 103 (29.1%)�

2 0.75

P 0.38

�2 3.75

P 0.52

�2 0.00

P 0.99

2000–2499 14 (48.3%) 174 (60.1%) 145 (40.9%)�

2 1.24

P 0.26

�2 24.21

P 0.0001

�2 0.32

P 0.56

TOTAL 29 (1.76%) 286 (3.01%) 354 (3.03%)�

2 = 272.1;

P < 0.0001

�2 = 13.4;

P < 0.0002

�2 = 548.1

P < 0.0001+

PHI – perinatal healthcare institution

Table 1. Distribution of preterm infants birth according to weight groups and the level of perinatal institutions

Figure 2. Gender distribution of tested newborns

The frequency of preterm infant births was signifi-cally different also according to a gestational age incomparison of the first level of PHI with the second andthird level of PHI, but there were no statistically signifi-cant diference between the second and third level of pe-rinatal health institution when about a gestational age30–32 weeks (� 2 = 2.42; P = 0.11), also when about agestational age 33–35 weeks (� 2 = 1.34; P = 0.24).

The options of primary and definite health care inPHI of cantons in the Federation of Bosnia and Herze-govina are limited. More than 47% of a lowbirth we-ight infants was born in the first and second level ofPHI, while 53% was born in the third level of PHI inthe corresponding neonatal intensive care unit in theFB&H. The outcome of the tested infants was followedthrough the survival rate, early neonatal and total neo-natal mortality rate, because these are clear indicatorsof perinatal care.

The early neonatal mortality rate of the tested in-fants in the first level of PHI was the lowest (1.8‰), inthe second level of PHI was the biggest (5.6‰), and in

the third level of PHI was 4.5‰. Although the percent-age of deaths within the first seven days among the te-sted infants from the second level of PHI (5.6‰) washigher compared to the first level, the difference wasnot statistically significant, with an equal relative riskfor fatal outcome (� 2 = 0.71; P = 0.398); ŠRR = 0.507(95% CI 0.148–1.738)¹. Analogous to this, we compa-red the rate of early nenonatal deaths of the second andthird level (5.6‰ vs 4.5‰; P < 0.0001) and found stati-stically significant difference (� 2 = 71.8; P < 0.0001);ŠRR = 6.349 (95% CI 4.030–10.003)¹ with a high rela-tive risk for fatal outcome in the second level of PHI.

108/669 (16.1%) of the tested infants died during theearly neonatal period, so the total rate of early neonatalmortality in all three PHI was 4.7 per 1000 live births.


Gestationalage

PHI1

stlevel

N/%

PHI2

ndlevel

N/%

PHI3

rdlevel

N/%

�2 P

PHI I /II

�2 P

PHI II/III

�2 P

PHI I/III

22–26 0 (%) 5 (1.7%) 17 (4.8%)�

2 = 6.4

P < 0.01

�2 = 11

P < 0.0009

�2 = 30.11;

P < 0.0001

27–29 2 (6.9%) 23 (8.5%) 49 (13.8%)�

2 = 32

P < 0.0001

�2 = 17.36;

P < 0.0001

�2 = 82.98;

P < 0.0001

30–32 5 (17.24%) 53 (18.5%) 66 (18.6%)�

2 = 76.17;

P < 0.0001

�2 =2.42;

P = 0.11

�2 = 101.4;

P < 0.0001

33–36 7 (24.1%) 84 (29.3%) 96 (27.1%)�

2 = 126.94;

P < 0.0001

�2 = 1.34;

P = 0.24

�2 = 150.3;

P < 0.0001

Less 37 15 (51%) 121 (42.3%) 126 (35.6%)�

2 = 162.13;

P < 0.0001

�2 = 0.12;

P = 0.71

�2 = 171.6;

P < 0.0001

TOTAL 29 (1.76%) 286 (3.01%) 354 (3.03%)�

2 = 272.1;

P < 0.0001

�2 = 13.4;

P < 0.0002

�2 = 548.1;

P < 0.0001

Table 2. Distribution of the births of a lowbirth weight infants according to a gestational age

and the level of perinatal institution in the F B&H

Figure 3. Distribution of preterm infants births

according to a weight groups and perinatal health

care institution level

Table 3. The rate of early neonatal mortality

of the tested infants according to the levels

of perinatal health institutions in the Federation

of Bosnia and Herzegovina in 2009

Levelof PHI

Died preterminfants in the first

seven days

The early neonatalmortality rate

I 3/1651 1.8‰

II 53/9490 5.6‰

III 52/11666 4.5‰

TOTAL 108/22807 (4.7‰)

(�2 = 0,71; P = 0,398); ŠRR = 0,507 (95% CI 0.148–1.738)¹

PZU of the first and second level.(�2 = 71,8; P P < 0,0001); ŠRR = 6,349 (95% CI 4.030–10.003)¹PZU of the second and third level.

In the study period, 42.4% of the tested infantshad died, while 57.5% survived. When compared tothe ratios died: survived, it was found statistically sig-nificant difference (� 2 = 29.89; P < 0.0001).

As can be seen from the table, there were no survi-ved infants in the first level of PHI during the first sevendays of life. In the second level of PHI there were 10.5%of survived infants during the first seven days of life. Inthe study, we compared the survival rate between the firstand second levels of PHI. Although the percentage of sur-vived infants in the second level of PHI was 10.5%, thedifference was not statistically significant (� 2 = 0.71; P =0.398). Analogous to this, we compared the survival rateof the tested infants in the third level of PHI, where 89.5%infants survived during the first seven days of life, withthe survival rate in the second level of PHI (89.5% vs10.5%; �

2 = 71.8; P < 0.0001), and it was found statisti-cally significant difference.

By the end of the first month of life (up to 28 daysof life) another 176 (26.3%) infants had died. There wasa total of 284/669 (42.4% ) deaths of the tested infants.

During the study period, 42.4% of the tested in-fants had died, and 57.5% survived in total. Compared

to died: survived, we found statistically significant dif-ference (� 2 = 29.89; P < 0.0001).

Out of 669 newborns, 112 (16.7%) of them died inthe second level of PHI, while 93 (13.9%) survived.The difference was not statistically significant (� 2 =1.86; P = 0.171) ŠOR = 1.125; 95%CI (0.923–1.678)¹and the risk for a favorable and unfavorable outcome isequal.


Levelof PHI

The numberof infants born

N/%

The numberof treated infants

N/%

The numberof survived infants

N/%

The number of diedinfants in the first

7 days of lifeN/%

I 29 (4.3%) 3 (0.5%) 0 3 (2.8%)

II 286 (42.8%) 127 (19.7%) 54 (10.5%) 53 (49%)

III 354 (52.9%) 513 (79.8%) 461 (89.5%) 52 (49.2%)

TOTAL 669 (100%) 643 (100%) 515 (100%) 108 (100%)

(�2 = 0,71; P = 0,398) PHI of the first and second level(�2 = 71,8; P < 0,0001) PHI of the second and third level

Table 4. The outcome of the tested infants according to the level of perinatal health institutions

and the treatment in the Federation of Bosnia and Herzegovina

Table 5. The outcome of the tested infants by the end of 28 days of life

in the Federation of Bosnia and Herzegovina

Died infantsto 28 days of life

Survived infantsto 28 days of life

�2 P

OR 95%CI

I 3/669 (0.4%) 0

II 112/669 (16.7%) 93/669 (13.9%)�

2 = 1.86; P = 0.171

OR = 1.125; 95%CI(0.923–1.678)

III 169/669 (25.3%) 292/669 (43.6%)�

2 = 49.25; P < 0.0001

OR = 0.436; 95%CI(0.346–0.550)

TOTAL 284/669 (42.4%) 385/669 (57.5%) �2 = 29.89; P < 0.0001

Figure 4. The outcome of the tested infants

by the end of 28th day of life in the Federation

of Bosnia and Herzegovina

Statistically significant difference in survival rateof the tested infants was found in the third level of PHI�

2 = 49.25; P < 0.0001 with a low risk for unfavorableoutcome ŠOR = 0.436; 95%CI (0.346–0.550)¹.

DISCUSSION

In 10 cantons of the FB&H in the period from 01.01. to 31. 12. 2014 22897 infants were born of whom 11liveborn infants had birth weight below 500 grams,which was the exclusion criterion. The total population of22897 infants was left of whom 669 (2.9%) were preterminfants. Rate in the FB&H is relatively low in the compar-ison with other countries where it ranges from 3.3 to 38%.Prematurity and LBW (low birth weight) rates are partic-ularly high in Asia and sub-Saharan countries. In BurkinaFaso, it is estimated that 19% of all live births in1999–2005 were LBW. An estimated 20% of infants areborn prematurely in Bangladesh, 30% of whom are LBW.Perinatal outcome is the indicator of the quality of perina-tal care. Prematurity and LBW is a public health problem,and complicates around 17% of all births. It is among themajor mortality risk factors in early infancy (12).

Majority of preterm infants were born in Sarajevo,Middle Bosnia, Una — Sana, and Herzegovina — Ne-retva Cantons. In neonatal institutions of the 1st level,29/1651 preterm infants were born, while in the neona-tal institutions of the 2

ndlevel 286/9490 infants were

born. Preterm infant rate between the institutions of the1st and the 2

ndlevel is significantly different between

these institutions and the institutions of the 3rd

level.At the beginning of the regionalization of perina-

tal care (1970–1985) in the USA, relatively small num-ber of preterm infants was born in the 3

rdlevel instituti-

ons. Comparing our results with currently available re-ports from the countries with existing regionalized pe-

rinatal care, the preterm LBW infant rates in FB&H arelow (8). Regionalization is a regulatory approach to ra-tionalization of resource allocation, especially forhighly specialized medical services or technologies.Proposals to encourage regionalization have waxedand waned in popularity over the years. A major argu-ment in favour of regionalization is the possibility ofachieving better patient outcomes. Experiences in regi-onalizing perinatal and neonatal care have resulted inimproved outcomes for mothers and infants (13).

The limitation of our study is that it was not takinginto account the differences between the regionalizedand non regionalized institutions which are treatingsick newborns like paediatric trauma centres and neo-natal intensive care units.

CONCLUSION

It would be ideal that every high risk pregnant wo-man is transferred to the institution of appropriate or-ganisational level before delivery. Unfortunately, it isnot always possible to predict the delivery of high riskinfants, which makes transport “in utero” not alwayspossible. In these circumstances post-natal transport ofseverely sick newborn is mandatory. The existing regi-onalization of perinatal care in the FB&H significantlyaffects the mortality of preterm infants. Survival rate ofinfants born in the institutions of the 3

rdlevel was stati-

stically much higher than the survival rate of infantswho were born in the 1

stand the 2

ndlevel institutions.

Abbreviations

PHI — Perinatal Healthcare InstitutionsLBW — Low Birth WeightFB&H — Federation of Bosnia and Herzegovina


Saètak

PERINATALNI ISHOD NEDONO[ÂDI

U FEDERACIJI BOSNE I HERCEGOVINE

Skoki} Fahrija,1

Hoti} Nesad,1

Muratovi} Selma,2

Skoki} Maida,1

Hadì} Devleta,1

]osi}ki} Almira,1

Selimovi} Amela,1

Zuli} Evlijana,1

Meri} Alma,1

Halilba{i} Amir1

1Klinika za dje~ije bolesti, Univerzitetski klini~ki centar Tuzla, Medicinski fakultet u Tuzli, Bosna i Hercegovina

2Klinika za ginekologiju i aku{erstvo, Univerzitetski klini~ki centar Tuzla, Medicinski fakultet u Tuzli, Bosna i Hercegovina

Uvod: Uprkos napretku perinatalne medicine inege, svake godine se rodi 9–19% nedono{~adi. Po-bolj{anje preìvljavanja takve novoro|en~adi i sma-njenje neonatalnog mortaliteta je klju~no u kvalitetuperinatalne zdravstvene nege.

Cilj studije: Evaluirati perinatalni ishod nedono-{~adi u porodili{tima u Federaciji Bosne i Hercegovineu jednogodi{njem periodu.

Ispitanici i metodi: Od ukupno 22 897 novoro-|en~adi, ulazne kriterijume je zadovoljilo 669 (2,9%)nedono{~adi sa kompletnom zdravstvenom dokumen-tacijom u 10 kantona Federacije Bosne i Hercegovine.Analizirali smo podatke iz porodili{ta i otpusne liste iztercijarnih zdravstvenih centara.

Rezultati: Najvi{e poro|aja je bilo u Tuzlanskomi Sarajevskom kantonu sa 42,5% nedono{~adi. Srednja

REFERENCES

1. Fiscella K. Race, genes and preterm delivery. J NatalMed Assoc 2005; 97(11): 1516–26.

2. Thorsen P, Schendel DE, Deshpande AD, Vogel I, Du-dley DJ, Olsen J. Identification of biological/biochemical mar-ker(s) for preterm delivery. Paediatr Perinat Epidemiol 2001; 15(Suppl 2): 90–103.

3. Horbar JD, Badger GJ, Carpenter JH, et al. Trends inmortality and morbidity for very low birth weight infants,1991–1999. Pediatrics. 2002; 110 (1 Pt 1): 143–51.

4. Mathews TJ, MacDorman MF. Infant mortality statis-tics from the 2005 period linked birth/infant death data set. NatlVital Stat Rep. 2008; 57(2): 1–32.

5. Regev RH, Lusky A, Dolfin T et al. Excess mortalityand morbidity among small-for-gestational-age premature in-fants: a population-based study. J Pediatr 2003; 143(2): 186–91.

6. Bartels DB, Kreienbrock L, Dammann O, WenzalffP,Poets CF. Population based study of small for gestational agenewborns. Arch Dis Child Fetal Neonatal Ed 2005; 90(1): 53–9.

7. Warner B, Musial MJ, Chenier T, Donovan E. The effectofbirth hospital type on the outcome of very low birth weight in-fants. Pediatrics. 2004; 113 (1 Pt 1): 35–41.

8. Lee HC, Green C, Hintz SR, et al. Predicition of deathfor extremely premature infants in a population-based cohort.Pediatrics. 2010; 126(3): 644–50.

9. Kollée LA, den Ouden AL, Drewes JG, Brouwers HA,Verwey RA, Verloove-Vanhorick SP. Increase in perinatal referralto regional centers of premature birth in The Netherlands: compari-son 1983 and 1993. Ned Tijdschr Geneeskd. 1998; 142(3): 131–4.

10. Rosenblatt RA, Macfarlane A, Dawson AJ, Cartlidge PH,Larson EH, Hart LG. The regionalization of perinatal care in Walesand Washington State. Am J Public Health. 1996; 86(7): 1011–5.

11. Association of Neonatologists and NICU experts of theFederation of Bosnia and Herzegovina. Šhomepage on the Inter-net¹. Available from: http://www.unif.ba.

12. Department of Reproductive Health and Research,World Health Organization Šhomepage on the Internet¹. GlobalMonitoring and evaluation. c2004 — Šcited 2010 December 20¹.Available from: http://www.who.int/reproductivehealth/glo-bal_monitoring/ skilled_attendant.html/.

13. American Academy of Pediatrics. Committee on Pedi-atric Emergency Medicine. American College of Critical CareMedicine. Society of Critical Care Medicine. Consensus reportfor regionalization of services for critically ill or injured chil-dren. Pediatrics.2000; 105 (1 Pt 1): 152–5. PMid:10617722.


gestaciona dob nedono{~adi je iznosila 31,4 sedmica,sa SD ± 5.34 i srednjom poro|ajnom masom od 1295grama, SD ± 234.2. Srednja vrednost Apgar skora je iz-nosila 4.6 ± 2.1 u prvoj minuti, a 6.6 ± 1.9 u petoj minu-ti. Od ukupno 669 ispitanika, bilo je 345 (51.56%) mu-{kog pola i 324 (48.44%) ènskog pola (51.56 vs48.44; ÷2 = 1.19; P = 0.27). Analiziraju}i frekvencu ra-|anja nedono{~adi prema poro|ajnoj masi, prona{lismo zna~ajnu razliku u razli~itim nivoima perinatalnihzdravstvenih ustanova, izme|u prvog i drugog institu-cionalnog nivoa (1.76% vs 3.01%; P < 0.0001), kao i

izme|u drugog i tre}eg institucionalnog nivoa (3.01%vs 3.03%; P < 0.0002), te izme|u prvog i tre}eg institu-cionalnog nivoa (1.76% vs 3.03%; P < 0.0001).

Zaklju~ak: Perinatalni ishod nedono{~adi u Fede-raciji Bosne i Hercegovine zna~ajno zavisi od nivoa pe-rinatalne zdravstvene ustanove. Stopa preìvljavanjanedono{~adi ro|enih u instituciji tre}eg nivoa je bilazna~ajno ve}a od stope preìvljavanja nedono{~adi ro-|enih u perinatalnim institucijama prvog i drugog nivoa.

Klju~ne re~i: nedono{~ad, perinatalni ishod, pre-vremeno ro|enje, regionalizacija, neonatalni mortalitet.

Correspondence to/Autor za korespondencijuFahrija Skoki}Paediatric Clinic University Clinical Centre TuzlaTrnovac bb. 75000 TuzlaBosnia and HerzegovinaTel.: +38761152351e-mail: fskokicªhotmail.com

ARYTENOIDCORDECTOMY FOR BILATERAL VOCAL CORD

PARALYSIS: PRIMARY AND REVISION PROCEDURE

Zenev Ivan,1

Sapundzhiev Nikolay2

1Hospital “Queen Jioanna”, Department of Oto-rhino-laryngology,

Medical University — Sofia, Bulgaria2

Department of Oto-rhino-laryngology, Medical University — Varna, Bulgaria


Abstract: Background: Definitive enlargementof the glottis with preservation of adequate voicing inpatients with bilateral recurrent nerve paralysis rema-ins a surgical challenge especially in patients with pre-vious unsuccessful surgery.

Study design: Report of a novel surgical techni-que for glottis enlargement and presentation of mid-term results.

Methods: Four adult patients with bilateral recur-rent nerve paralysis were subjected to submucosalarytenoidcordectomy through a thyreofissure appro-ach with ventricular folds transposition and long-termtranslaryngeal stenting. Two of them had had previoussurgeries at the glottic level. Preoperative data as wellas postoperative functional results are reviewed. Fol-low-up ranged from 8 to 28 months.

Results: In all patients tracheostomy closure wasachieved. Midterm follow-up revealed stable airway,adequate for the patients’ routine physical activities.Postoperatively patients phonated with the ventricularfolds and the resulting voice quality was good.

Conclusions: We describe a novel approach for ma-nagement of impaired airway because of bilateral recur-rent nerve paralysis and/or stenosis. It comprises intra-laryngeal soft tissue resection, enlargement of the cartila-ginous framework of the larynx and long-term tran-slaryngeal stenting. The surgical approach described hereproved to be successful both in patients with simple bilat-eral vocal fold motion impairment and in those, who havebeen already unsuccessfully treated with other surgery.Nevertheless the technique should be regarded as an op-tion only in complicated revision cases, rather than a pri-mary intervention in bilateral vocal fold paralysis.

Key words: vocal fold paralysis failure, laryngealstenosis, arytenoidectomy, cordectomy, translaryngealstenting.

INTRODUCTION

Bilateral vocal fold immobility due to recurrentnerve paralysis is characterized by paramedian posi-tion of the vocal folds, narrow glottic chink and impair-ment of the normal respiration. Such patients are in aprecarious position with respect to the airway, whilethe voice may be minimally impaired and they oftenend having some kind of surgery for enlargement of theglottis (1, 2). In cases when the continuity of at leastone of the recurrent nerves is preserved partial restitu-tion of the normal laryngeal function could be expectedto occur within 3 to 6 months, so no radical surgery forlaryngeal enlargement should be undertaken, but onlytemporary securing of the airway with a tracheostomyor laterofixation (3). However if the paralysis persistsat the end of this period or initially both recurrent ner-ves were irreversibly damaged, decision should be ma-de for further definitive treatment, as few patients aresatisfied with the tracheostomy, the majority wishingto dispense with the tube (4). Numerous different sur-gical techniques for definitive airway enlargement,aiming the restoration of normal breathing through thenose (mouth) with maximal preservation of voice func-tion, have been described (5, 6, 7). None of them hadshown to be definitely superior to the others, whichagain comes to underline the complexity of the prob-lem (2). The major causes of surgery failure include in-adequate airway with tracheostomy dependency, badvoice results or recurrent stenosis at the glottic level.The incidence of re-stenosis after first operation, tho-ugh variable with the different surgical techniques andsurgeons, could be as high as 40% and is much higherin already operated patients. This condition should bealready considered as fibrous stenosis (8, 9). In attemptto solve this problem we used a modified surgical tech-

UDK: 616.225-009.1-089

2015; 10(1): 23–29 ID: 214198796


nique for submucosal arytenoidcordectomy and enlar-gement of the laryngeal skeleton. This operation wasimplemented so far successfully in 4 patients. We re-port on our experience and midterm results with thisnew surgical intervention.

MATERIAL AND METHODS

Four patients with stenosis of the larynx at theglottic level were treated using modified submucosalarytenoidcordectomy through a thyreofissure appro-ach with long-term translaryngeal stenting (Table 1).Of them 1 was male and the rest 3 — female, aged37–59 years. All of them had compromised airway atthe glottic level. In 3 of them the initial bilateral vocalfold motion impairment was due to recurrent nerve in-jury during thyroid surgery and in 1 — after gunshotwound in the upper chest and surgery. Two of the pati-ents had had previous surgery for airway improvementin other clinics: Patient N 2 had had one cordectomywith thyreofissure approach. The postoperative coursewas complicated by formation of granulations. Follo-wing two endoscopic cold steel microsurgical operati-ons with only temporary effect, and later fibrous steno-sis developed. After carbon dioxide laser surgery withonly temporary improvement of the airway again nodecannulation was achieved. Patient N 3 had had car-bon dioxide laser cordotomy 3 times at different inter-vals, so in between temporary decannulation and trac-heotomy closure had been achieved. The patient pre-sented to us with slowly progressing dyspnea over5 months. Of the other two patients one presented withprogressing dyspnea over 9 months 8 years after thy-roid surgery and one was already with tracheostomyperformed 18 months after thyroid surgery.

Surgical technique

The operation was carried out under general anes-thesia. A tracheotomy was performed low in the neckin 2 patients. In the other 2 patients the existing trache-ostomy was used for intubation. A vertical skin inci-sion was made along the midline, extending from the

hyoid bone to the tracheostomal opening. Theplatysma was incised as well. The strap muscles wereseparated vertically in the midline and retracted. In allpatients the thyroid isthmus had been previously divi-ded during other surgery or the whole thyroid glandhad been extirpated. Further a vertical incision wasmade through the perichondrium of the thyroid cartila-ge in the exact midline with a blade. The perichondri-um was dissected off the midline some 5 mm on eitherside. The cartilage was cut vertically with a rotatingsaw. The cut was placed just short of the inner peric-hondrium. After that the perichondrial and mucosal in-cisions were carefully completed with a blade. Thethyroid laminae were lateralized with small dull retrac-tors so good exposure of the intralaryngeal structureswas achieved. Now a longitudinal incision of the mu-cosa from the arytenoid to the anterior commissure wasmade just under the vocal ligament. Inferiorly the mu-cosa was dissected from the underlying thyroarytenoidmuscle, forming a caudally based flap. The soft tissuesor local scars from the anterior commissure to thearytenoid were excised with fine long scissors. Thearytenoid cartilage was separated from the periaryte-noid tissues by sharp dissection, disarticulated and re-moved. Occasional bleeding was controlled with bipo-lar electrocautery. From the incision line a small super-iorly based mucosal flap was created by dissecting in asubmucosal plane. The caudal (subglottic) mucosalflap was carefully advanced superiorly. Both superiorand inferior mucosal flaps were approximated and clo-sed over the incision with interrupted sutures with 4-0PDS. The anterior commissure together with the baseof the epiglottis was tacked to the anterior edge of thethyroid cartilage at the level of the thyrotomy to pre-vent from foreshortening. The anterior ends of the ven-tricular folds were sutured to the external perichondri-um on both sides. A PVC T-tube laryngeal stent (SDGarant-PP, Burgas, Bulgaria, Ref.: ON-0286113-92)of a corresponding size was placed in the larynx so it’ssuperior end passed through the glottis and laid justabove the ventricular folds, and the inferior end —2–3 cm in the trachea. The extraluminal limb was pas-

24 Zenev Ivan, Sapundzhiev Nikolay

N Sex/agePrimary condition, that led

to paralysis or stenosisBreathing

Previous interventions Operations/yearOpen Endoscopic

1. f/59 Thyroidectomy before 2 years Tracheostomy 0 0 0

2. f/37 Subtotal thyroidectomy Tracheostomy 1 3 2

3. m/54 Thoracic gunshot wound and surgeryDyspnea since

5 months0 3 0.3

4. f/52 Thyroidectomy before 8 yearDyspnea since

9 months0 0 0

Table 1. Patient characteristics

sed between the thyroid alae (Figure 1). An iodoformgauze pack was placed around the stent, its end wasbrought out through the skin incision. The midlinethyrotomy was then approximated tightly with 4-0chromic catgut suture material. The strap muscles wereclosed in similar fashion. A penrose drain was placedimmediately overlying the thyrotomy and brought outthrough the inferior end of the skin incision. Theplatysma was closed with 4-0 chromic catgut and theskin was closed using monofilament suture material.

Postoperative care

Peri- and postoperatively patients received antibi-otic for 3 to 5 days. Upon awakening after the extubati-on all patients resumed breathing through the stent.During the first postoperative days only occasionallycleaning of the stent through the horizontal limb with asoft suction catheter was needed. The iodoform gauzewas removed over the next two days. All patients wereallowed normal oral feeding on the same evening afterthe surgery. In one patient there was severe postopera-tive dysphagia with inability to swallow and aspirationwith choking occurred. After indirect laryngoscopy weassumed, that this was due to high supraglottic positionof the superior end of the stent, which interfered withthe tilting of the epiglottis backwards and downwardsin the act of swallowing. Under local anesthesia thefirst suture under the horizontal limb of the stent wasremoved and the stent was carefully pushed few milli-

meters downwards. This led to significant improve-ment of the dysfagia so the patient was able to drinkwith minimal aspiration. The gradual removing of theiodoform gauze over the second and third postoperati-ve day led to further improvement. On dischargingfrom the hospital on the fifth day this patient could eatand drink without difficulty and aspiration (Figure 2).

The tracheostomies were left to close spontaneo-usly by shrinking and secondary wound healing. In allbut one patients total occlusion occurred within 7 dayspostoperatively. One month after discharging patientN 1 presented to us at the regular follow up with minorresidual opening at the place of the stoma with minimalair and secret leakage. The edges of the opening werefreshened and compressive dressing was placed. Underthis treatment the channel closed shortly after.

Stent removal

Between the first and the second operations thepatients were followed on monthly basis. In three pati-ents the stent was left in place for 3 months (patientsN 1, N 2, N 4). In patient N 3 (with multiple operationsin the neck and thorax and 3 endoscopic CO2 laser cor-dotomies) the stent was left in place for 6 months. Stentremoval was done under local anesthesia. The old ver-tical scar was incised and the stent simply pulled out.The intervention lasted only few minutes. Minor blee-ding was observed. No suturing of the wound was do-ne. All patients tolerated well the second operation.They were further observed for 2 days before beingdischarged from the hospital. In three patients (all wo-men) this second incision closed spontaneously withina week. In the last patient a part of the thyreofissure,

ARYTENOIDCORDECTOMY FOR BILATERAL VOCAL CORD PARALYSIS: PRIMARY AND REVISION PROCEDURE 25

Figure 1. Translaryngeal stenting with a rigid

T-Tube. The upper end lies just above the ventricular

folds. The horizontal limb passes between

the thyroid laminae

Figure 2. Patient N 1: CT-scan showing

the stent in the larynx

where the horisontal limb of the stent passed, remainedopen. This necessitated a plastic closure — the skin lat-erally to the incisions was mobilized, brought to themiddle line and sutured.

RESULTS

After the first operation all four patients couldbreathe easily through the stent. As the stent was pla-ced quite high in the larynx with its superior end lyingslightly above the ventricular folds the patients couldonly whisper between the two operations. Thus theircommunication possibilities were limited. Neverthe-less two of them could have conversation over the pho-ne. Early postoperative dysphagia developed in onepatient and disappeared after adjustment of the stentposition. At discharge all patients could eat and drinkwithout aspiration to occur.

After stent removal all four patients could breathewithout any difficulties. They resumed normal diet onthe same day. Three of the patients reported transientmild dysphagia, but no one had signs of aspiration. Infact the risk of aspiration after arytenoidectomy is min-imal and is often overemphasized.

In all four patients the resulting airway was suffici-ent for normal breathing so they all dispensed with thetracheostomy. FEV1 was between 80 and 110% of thepredicted normal value for the sex and age. The physicalactivity of the patients was partially limited by concomi-tant diseases, but not by the airway. In patient N 2 afterstent removal small granulations were observed in theregion of the former anterior commissure. With the timethey showed a tendency to decrease. As after a monththey still persisted, they were removed by micro-laryngoscopic surgery with cold steel instruments.

After the removal of the stent two of the patientsstarted speaking with ease. They phonated with theventricular folds. In the other 2 patients this ability de-veloped slowly over days to weeks. In all patients thenew voice was characterized by marked roughness to adifferent extent, but allowed fluent conversation in the-ir daily social and professional life. Three can havenormal conversation on the phone and only one (pati-

ent N 1) reports difficulties when having a conversa-tion on the phone. Though in all patients reduced pho-nation time and limited frequency range were obser-ved, they were satisfied with the phonatory outcome.The voice quality was satisfying as judged by the pati-ents themselves (Table 2).

In two patients late postoperative fibrotracheo-scopy revealed residual changes at the place of the oldtracheostomy: in patient N 3 — stenosis (lumen reduc-tion by 20%); in patient N 2 - malacic segment of theanterior tracheal wall, corresponding to 1 or 2 trachealrings, that collapsed only in forced inspiration (lumenreduction by 10%). Both findings were asymptomaticand did not require any surgical treatment.

DISCUSSION

Many different surgical techniques for enlargementof the glottis have been proposed and tried over almost acentury, starting in 1922 with C. Jackson’s “ventriculo-cordectomy”. The majority of them are based on resec-tion of laryngeal structures: partial or total arytenoidec-tomy, ventriculo-/cordectomy, arytenoidcoredctomy (2).Other interventions only retailor the structures withoutresecting tissue: omohyoid muscle transposition, verti-cal transposition of the arytenoid, cricoid split, cordo-tomy. A third group of surgical techniques cause minorto no tissue modifications (2, 5, 6, 7). Generally surgeryfor glottis enlargement has a significant failure rate ofapproximately 1/4 of the cases and the degree of loss ofthe vocal capability is unpredictable (1).

Recurrences after surgery for airway enlargementin bilateral recurrent nerve paralysis develop in about25% of the cases (8). Most often this is due to fibrosisthat develops at the site of operation. All surgical tech-niques inevitably cause some kind of scaring. Control-led fibrosis at defined areas, which keeps the tissues inthe new position and so secures the airway, is the goalof some techniques (5, 8). On the other hand excessiveimproper scaring leads to stenosis, deterioration of thefunctional results and makes further surgery more dif-ficult. The newly developed scar could stretch from theanterior commissure to the arytenoid region forming


Table 2. Duration of stenting and midterm results

N Sex/ageDuration of stenting

(months)Spontaneous closure of the

Airway Voice Follow uptracheostomy thyreofissure

1. f/59 3 No* Yes adequate adequate 28 months

2. f/37 3 Yes Yes adequate good 20 months

3. m/54 6 Yes No* adequate good 8 months

4. f/52 3 Yes Yes adequate good 10 months

* These patients required minor interventions under local anesthesia for closure of the remaining airway opening.

an adventitious cord, web or a longitudinal concentricstenosis (4, 8). The fibrocytes have a directional mem-ory — if incompletely excised the fibrous tissue at-tempts to replace itself in the original state. This phe-nomenon explains the difference between patients whoundergo first glottis enlargement surgery and thosewith repetitive surgery, the second group requiring mo-re radical surgery, stenting and nevertheless still hav-ing a doubtful prognosis (9). Another type of woundhealing — the formation of granulations — could alsolead to recurrent laryngeal stenosis. This type of tissuereaction is often associated with intralaryngeal sten-ting, CO2-laser surgery (8) or electrocautery (10). Theparticles of carbonized tissues that remain in the wo-und bed are the promoters of this process.

With the surgical technique described here, ourgoal was to control the process of postoperative scar-ing. We found the thyreofissure approach especiallysuitable for recurrent intralaryngeal stenosis, when en-doscopic techniques fail to improve the airway. Usu-ally the larynx is exposed through a horizontal inci-sion (9). We initially selected the vertical skin incisionin order to facilitate the implantation of the stent and itsremoval in the second stage.

The majority of surgical interventions for airwayenlargement aim at the posterior “respiratory” part ofthe glottis, leaving the anterior ligamental two thirds ofthe vocal cords — the “phonatory” part — as intact aspossible (7). Nevertheless enlargement of the anteriorglottis has already been reported with good phonatoryresults (11, 12). Thyroid cartilage enlargement (expansi-

on laryngoplasty, or type II lateralization thyroplasty)was described as voice improving operation in spa-smodyc dysphonia, but not as an airway enlargingone (13). In the technique described here we used a sim-ilar approach for enlargement of the whole glottic plane— arytenoid cartilage and vocal fold are removed andthe thyroid plates are separated and retracted laterallytill the scar tissue in between gets stable, so they couldremain in this position after the removal of the stent. Inour patients the gap between the two anterior thyroid ed-ges remained clearly palpable under the skin.

The submucousal approach for the soft tissue re-section, followed by meticulous closure of the mucosalflaps over the wound allows minimizing the risk of for-mation of granulations. The intraluminal stenting is of-ten used for protecting the lumen in the early postoper-ative period. In the majority of surgical techniques de-scribed in the literature, only short-term intraluminalstenting is used — from 24 hours (7) to about 2 weeks(5). We deliberately chose to stent our patients in atranslaryngeal way over a long period of time till weobtain a solid, mature fibrous plaque between the boththyroid allae, which would be able to keep them retrac-ted (respectively the lumen of the airway broad) afterthe removal of the stent (Figure 3). Three months pro-ved to be a reasonable period of time (14). Longer peri-ods of stenting could be recommended in patients, whohad had unsuccessful surgery and severe stenosis. Wehave observed our patients for 8 to 28 months after theremoval of the stent. In no one the airway showed ten-dency to restenose to a clinically manifest degree.

Special cannulas with third upper part projectinginto the larynx were used already at the end of the firstquarter of 20-th century. The main respiratory flowpassed through the stoma like in a usual cannula andthey were to be changed daily (15). In the sixties Mont-gomery introduced the silicon (dimethylpolysiloxan)T-stents (16). The outer limb of the stent is to be plug-ged all the time. The patient breathes along the normalairway and so coughs more effectively, which is themajor mechanism for natural cleaning of the stent.Such a stent does not require daily change. Being flexi-ble the Montgomery silicon T-stents are well adaptedfor stenting the trachea. We used a T-stent made ofPVC. It is more rigid than the silicon one, while beingstill elastic. To completely compress it a force 6 timesgreater is needed than for the original silastic Montgo-mery stent (Fig. 4). In this way the stent used by us al-lowed adequate retraction of the thyroid alae, where anormal silastic Montgomery T-stent would collapse.Here again the horizontal limb should be occluded, toallow respiration along the normal airway. If this sim-ple rule is obeyed the stent could be safely left in placefor months.


Figure 3. Patient N 2: CT-scan 4 months after

the stent removal. The glottic level is widely opened

and stable. The plates of the thyroid cartilage lay

separated by a plaque of fibrous tissue (arrow)

In bilateral recurrent nerve paralysis (paramedianposition of the vocal folds) the phonatory function ofthe larynx is relatively little influenced in comparisonwith the respiratory. The weak collateral innervation ofthe intralaryngeal musculature by minor fibers of then. laryngeus superior allows a general and badly coor-dinated spasm so the glottis takes a voicing positionclose to normal. When reviewing articles, describingsurgery for glottic enlargement we found little to no in-formation on the mechanism of postoperative voicingand the structures that actually produce the sound.Most of the authors comment only on the quality of thevoice. In our group of patients we clearly could iden-tify, that after the removal of the stent the patients star-ted to phonate with the ventricular folds (dysphoniaplicae ventricularis). This ability developed graduallyfor several days to weeks and was supported by speechtherapy. Leading role for the movement of this neo-glottis play the stylopharyngeus and palatopharyngeusmuscles, innervated by the pharyngeal plexus. Whencontracting they push the arytenoid towards the midli-ne and so approximate the ventricular folds (15, 17,18). In the surgical technique we use, we consider thesuturing of the anterior parts of the ventricular folds to

the external perichondrium of the thyroid alae an im-portant point of the operation. In this way they arestretched and brought closely together at the anteriorpart of the larynx, so even after the total enlargement ofthe cartilaginous framework, they remain quite close toeach other and so form a new phonatory substrate.

The complications we observed in these four pati-ents were related to the stent. In one patient severedysphagia and aspiration occurred immediately afterthe operation. After correction of the stent position andremoval of the iodoform gauze these symptoms disap-peared. In another patient after stent removal we obser-ved minimal granulations at the anterior commissure.Though they remained clinically irrelevant and evenslow regression was observed, we decided to removethem by endoscopic microsurgery.

CONCLUSION

The surgical technique we use for restoration ofthe airway in patients stenosis at the glottic level com-prises thyreofissure, submucosal arytenoidcordectomyand stretching of the ventricular folds. Long term tran-slaryngeal stenting provides enlargement of the wholecartilaginous framework of the larynx. The resultingairway was stable in all patients with maximal followup of 28 months. The intervention allowed all patientsto dispense with the tracheostomy tube. Postoperati-vely patients phonated with the ventricular folds. Voicequality was good and allowed conversation with ease.Aspiration was limited to a minimum. The surgical tec-hnique described is not to be recommended as a pri-mary treatment for bilateral vocal fold paralysis, beca-use of the massive trauma to the larynx and the poorphonatory outcome. It should rather be regarded as anoption for cases with failure of primary and/or revisionsurgery for glottic enlargement, where laryngeal steno-is had developed and the patients remain tracheo-stomy-dependent. In our hands this technique provedto be effective in patients with previous unsuccessfulsurgery for bilateral vocal fold paralysis and partial fi-brous stenosis.


Figure 4. The T-tube used by us (below) is more

rigid than the silicon one (above), is hardly

to be compressed, but is still flexible

Sa`etak

ARITENOIDKORDEKTOMIJA KOD BILATERALNE PARALIZE

GLASNIH @ICA: PRIMARNA I REVIZIONA PROCEDURA

Zenev Ivan,1

Sapundzhiev Nikolay2

1Bolnica “Carica Ioanna”, Odeljenje za otorinolaringologiju, Medicinski fakultet Univerziteta u Sofiji, Bugarska

2Odeljenje za Otorinolaringologiju, Medicinski fakultet Univerziteta u Varni, Bugarska

Uvod: Definitivno pro{irenje glotisa uz o~uvanjegovora, kod pacijenata s bilateralnom paralizom reku-

rentnog `ivca, ostaje hirur{ki izazov, posebno kod pa-cijenata sa prethodno neuspelom operacijom.

REFERENCES

1. Tucker HM. Rehabilitation of the immobile vocal fold.In: Fried MP, editor. The larynx. A multidisciplinary approach.2nd ed. St. Louis: Mosby; 1996. p. 215–7.

2. Sapundzhiev N, Lichtenberger G, Eckel HE, et al. Surgeryof adult bilateral vocal fold paralysis in adduction: history andtrends. Eur Arch Oto Rhino Laryngol. 2008; 265(12): 1501–14.

3. Werner JA, Lippert BM. Laterofixation der Stimmlippestat Tracheotomie bei akuter beidseitiger Stimmlippenparese.Dtsch Med Wochenschr. 2002; 127(17): 917–22.

4. Downey WL, Kennon WG Jr. Laryngofissure approach forbilateral abductor paralysis. Arch Otolaryngol. 1968; 88(5): 513–7.

5. De Campora E, Camaioni A, Corradini C, D’Agnone N,Calabrese V, Croce A. Thornell’s approach for arytenoidectomyin the surgical treatment of bilateral abductor paralysis; personalexperience and results. J Laryngol Otol. 1985; 99: 379–82.

6. Danino J, Goldenberg D, Joachims HZ. Submucosalarytenoidectomy: new surgical technique and review of the lite-rature. J Otolaryngol. 2000; 29(1): 13–6.

7. Remacle M, Lawson G, Mayné A, Jamart J. Subtotalcarbon dioxide laser arytenoidectomy by endoscopic approachfor treatment of bilateral cord immobility in adduction. AnnOtol Rhinol Laryngol. 1996; 105(6): 438–45.

8. Ossoff RH, Sisson GA, Duncavage JA, Moselle HI, An-drews PE, McMillan WG. Endoscopic laser arytenoidectomyfor the treatment of bilateral vocal cord paralysis. The Laryngo-scope. 1984; 94(10): 1293–7.

9. Sessions DG, Ogura JH, Heeneman H. Surgical mana-gement of bilateral vocal cord paralysis. The Laryngoscope.1976; 86(4): 559–66.

10. Gray S, Miller R, Myer CM, Cotton RT. Adjunctivemeasures for successful laryngotracheal reconstruction. AnnOtol Rhinol Laryngol. 1987; 96(5): 509–13.

11. Eckel HE, Thumfart M, Wassermann K, Vössing M,Thumfart WF. Cordectomy versus arytenoidectomy in the man-agement of bilateral vocal cord paralysis. Ann Otol RhinolLaryngol. 1994; 103(11): 852–7.

12. Kleinsasser O. Endolaryngeale Arytenoidektomie undsubmuköse Hemichordektomie zur Erweiterung der Glottis beibilateraler Abduktorenparese. Mschr Ohr Laryngorhinol. 1968;102: 443–6.

13. Friedrich G, de Jong FI, Mahieu HF, Benninger MS,Isshiki N. Laryngeal framework surgery: a proposal for classifi-cation and nomenclature by the Phonosurgery Committee of theEuropean Laryngological Society. Eur Arch Oto RhinoLaryngol. 2001; 258(8): 389–96.

14. Zenev I, Sapundzhiev N. Dilating stents used inlaryngotracheal stenosis with a report of one case. Annual pro-ceedings IMAB. 2000; 6: 296–7.

15. Rethi A. Eine neue operative Behandlung der beidsei-tigen Paramedianstimmbandfixation mit einem Hinweis auf dieOperation der narbiger Kehlkopfstenose. Z Für Laryngol RhinolOtol Ihre Grenzgeb. 1955; 34(7): 464–72.

16. Montgomery WW. Silicone tracheal T-tube. Ann OtolRhinol Laryngol. 1974; 83(1): 71–5.

17. Langnickel R. An endolaryngeal method of vertico-la-teral transposition of the vocal cord for bilateral abductor paral-ysis. The Laryngoscope. 1976; 86(7): 1020–8.

18. Thomé R, Thomé DC, Behlau M. The use of buccalmucosa graft at posterior cricoid splitting for subglottic stenosisrepair. The Laryngoscope. 2001; 111(12): 2191–4.


Cilj: Prikaz nove hirur{ke tehnike kod pro{irenjaglotisa i prikaz rezultata.

Metod: êtiri odrasla pacijenta sa bilateralnom para-lizom rekurentnog ìvca podvrgnuti su submukoznoj arite-noidkordektomiji, kroz tireofisuru, sa transpozicijom ven-trikularnih nabora i dugoro~nim translaringealnim sten-tom. Dva pacijenta, od njih ~etvoro, su imala prethodneoperacije na nivou glotisa. Preoperativna medicinska do-kumentacija, kao i postoperativni funkcionalni rezultati supregledani. Pra}enje je trajalo od 8 do 28 meseci.

Rezultati: Kod svih pacijenata je postignuto zatvara-nje traheostome. Tokom pra}enja uspostavljen je stabilanvazdu{ni put, adekvatan za rutinske fizi~ke aktivnosti paci-jenata. Postoperativno, pacijenti su fonirali sa vestibular-nim naborima i rezultiraju}i kvalitet glasa je bio dobar.

Zaklju~ak: Opisali smo nov pristup za tretmano{te}enih disajnih puteva zbog bilateralne paralize re-kurentnog ìvca i / ili stenoze. On obuhvata resekcijuintralaringealnog mekog tkiva, pro{irenje hrskavi~a-vog zida grkljana i dugoro~ni translaringealni stent.Opisani hirur{ki pristup pokazao se uspe{nim kod pa-cijenata sa jednostavnim, bilateralnim oslabljenim po-kretima glasnih ìca i kod onih koji su ve} neuspe{nole~eni drugom hirur{kom tehnikom. Ipak, ovu tehnikutreba razmatrati kao opciju samo u komplikovanim re-vizionim slu~ajevima, a ne kao primarnnu intervencijukod bilateralne paralizom glasnih ìca.

Klju~ne re~i: paraliza glasnih ìca, stenoza gr-kljana, aritenoidektomija, kordektomija, translaringe-alni stent.

Correspondence to/Autor za korespondencijuNikolay SapundzhievDepartment of Oto-rhino-laryngologyMedical University — Varna, BulgariaMarin Drinov str. 55, Varna 9002, BulgariaTelephone: 00359 (0) 52 978 571E-mail: n.sapundzhievªgmail.com

HIV/AIDS EDUCATION OF HEALTH CARE PROVIDERS

Ljaljevic Agima, Scepanovic Lidija, Mugosa Boban, Catic Sabina

Institute of Public Health Montenegro, Podgorica, Montenegro


Abstract: Introduction: The aim of this studywas to determine perceptions of service providers inthe healthcare on their awareness and knowledge aboutHIV/AIDS, as well as the relationship of the above pa-rameters and the existence of stigma and discrimina-tion against people with HIV/AIDS.

Method: The type of the study was a behavioralcross sectional study. The survey was conducted in2012, on a representative sample of health workers inMontenegro. The main survey instrument was specifi-cally designed questionnaire that consisted of six parts,out of which one was related to knowledge about HIVand AIDS. Data were analyzed by methods of inferen-tial statistics.

Results: More than four out of ten respondents havenever attended educational workshops on HIV/AIDS.Research has shown that there is a highly significantstatistical correlation between estimates of their ownknowledge about HIV / AIDS and previous educations.Almost two-thirds of respondents, who attended sometype of education in the field of HIV/AIDS, believe tohave a satisfactory level of knowledge in the area.

Conclusion: Health care service providers evalu-ate their knowledge of HIV/AIDS as insufficient.

Key words: HIV/AIDS, service providers in he-alth, knowledge.

INTRODUCTION

Health workers should protect themselves andtheir patients in their daily work by using standardnon-specific protection measures in order to preventinfections that are transmitted by blood (1). At the sa-me time, it is of particular importance that health work-ers meet users of health care without stigma and discri-mination, as well as without various forms of prejudi-ce. Open approach is of particular importance whenspeaking of health services for people living withHIV/AIDS. Several qualitative studies, conducted inother countries in the last few years, demonstrated a

significant degree of stigma and discrimination againstpeople living with HIV among health professionals (2).Studies analyzing causes of stigma and discriminationagainst people living with HIV/AIDS have not beenconducted in Montenegro.

Discrimination against people living withHIV/AIDS is caused primarily by lack of informationand knowledge of service providers in the health sec-tor. People living in societies that are facing HIV epide-mic often do not have sufficient and accurate informa-tion, and perceive HIV as a deadly disease with unk-nown modes of transmission and unsafe methods ofprotection, resulting in great fear and sense of personalvulnerability (3). As a result of stigma and discrimina-tion, people living with HIV/AIDS develop uncerta-inty and distrust in health workers, avoiding availablehealth services that consequently leads to disruption oftheir health status. The conclusion is that isolation andexclusion of infected people appears to be a natural re-sponse to fear. In addition, people living withHIV/AIDS are considered to be members of the popu-lation groups that were previously marginalized andstigmatized in society — sex workers, drug addicts andhomosexuals, and consequently seen as culprits fortheir infection. Such perception of people living withHIV leads to external stigma and discrimination, butalso to internal, the perceived stigma.

When defining measures for reduction or comple-te elimination of health workers stigmatization and dis-crimination against people living with HIV/AIDS, it isnecessary to identify essential elements causing thisphenomenon. In some cases, the root of stigma is, infact, the lack of specific knowledge, but very often, re-gardless of awareness of HIV ways of transmission,most people have irrational fears that come from othersources, Causes of stigma are often deeply rooted in at-titudes and moral convictions.

General prerequisites for proper treatment whenmeeting health needs of users are: adequate education,

UDK: 616.98:578.828¹:614.253(497.16)2015; 10(1): 31–35 ID: 214200076


researches focusing on identification of causes of stig-ma and discrimination, as well as adequate workingconditions (4).

The aim of the research was to determine percep-tions of service providers in the healthcare, their awa-reness and knowledge about HIV/AIDS, as well as re-lationship of the above parameters and the existence ofstigma and discrimination against people living withHIV/AIDS.

METHOD

The survey was conducted as behavioral crosssection study.

The survey was conducted in 2012 on a represen-tative sample of health workers in Montenegro. A fra-mework for defining the sample represented officialhealth workers data collected at the Institute of PublicHealth (8). Each participant has previously had to giveconsent on voluntary participation in the study.

In planning the sample all health institutions at alllevels of health care and all health care workers wereincluded. The sample was stratified so as to give thepossibility to representativeness related to the type ofinstitution, level of care, number and gender of em-ployees, as well as their territorial distribution. Afterstratification, with respect to the foregoing parametersof each identified stratum, were randomly proportionto the size of the strata, identified 10% of all health careworkers involved in the sample. In order to ensure theplanned number of patients, due to refusal to participa-te in the research of a number of respondents, 12% ofall health care workers entered the sample.

The main survey instrument was specifically de-signed questionnaire that consisted of six parts, out ofwhich one was related to knowledge about HIV/AIDS.

The questionnaire consisted of closed questionsthat were related to a wide range of knowledge of healthworkers, from general knowledge of the population thatreceives information through the media, to very specificknowledge for persons engaged in the diagnosis and tre-atment of infected by HIV, or suffering from AIDS.

The research was conducted by a research teamfrom the Institute of Public Health and the interviewerswere trained prior to conducting research.

Each questionnaire data were entered into previo-usly created database, after which they were treated bythe methods of inferential statistics.

For statistical analysis of the data, the statisticalsoftware package SPSS has been used. Also, methodsof descriptive and inferential statistics, or method ofunivariate and multivariate statistics for testing the sig-nificance of differences and testing connectivity bet-ween different variables have been applied.

RESULTS

Representation of respondents aligned with thestructure of donors Facilities in the health system ofMontenegro (Figure 1).

Figure 1. The structure of respondees

health services providers

The study included 813 health care providers inMontenegro (which accounts for about 12% of the to-tal number of employees in this sector) from all institu-tions at all three levels of health care. Most respondents(41.5%) were from Podgorica. More than a quarter ofthe examined (25.8%) were men, while among respon-dents forefront of women, which corresponds to thegender breakdown in health. The age of respondentsranged from 20 to 70 years (retired doctors who workon service contracts), where the average age was 42years. Length of service examined ranged from one to43 years, and the average length of service was about19 years old. The structure of employees, with the par-ticipation of more than half (55.9%) were dominatedby nurses / technicians. As in relation to other categori-es in the sample represented structure is aligned withthe structure of employees.

More than four out of ten respondents (42.6%) hadnever attended educational workshops on HIV/AIDS,while 13.5% attended these workshops in the last year,and 43.9% in the last five years. Educational workshopswere attended by 57.4% of respondents (Figure 2).

Figure 2. Participation of healthcare workers

to educational workshops on HIV/AIDS

In relation to the field of health care they wereengaged in, service providers were mostly physiothe-rapists, midwives and nurses/technicians who have nothad any training in the previous period (Figure 3). It isobvious that there is statistically significant differencein attendance of education in the field of HIV/AIDS

32 Ljaljevic Agima, Scepanovic Lidija, Mugosa Boban, Catic Sabina

by the field of healthcare of respondents (÷ 2 = 34.094;p < 0.001).

Health workers mostly recognize the need for trai-ning in the field of HIV/AIDS, while there are differen-ces in the levels of needs for new knowledge in the re-spective field (Figure 4).

Figure 4. Use of gained knowledge in practice by

healthcare service providers

Research has shown that there is a highly significantcorrelation between estimates of their own knowled-ge about HIV/AIDS and past education (÷ 2 = 105 080;p > 0.001). Among the respondents who indicated thatthey have not had education on HIV/AIDS, 42.7% esti-

mated to have no knowledge in this field. Among therespondents who indicated that they had some form ofeducation on HIV/AIDS, the highest percentage, attheir own opinion, have good knowledge in this area(Table 1).

If we reduce categories of knowledge on HIV/AIDSon two categories: a little and much, we can see thatthere are statistically significant differences in respon-dents responses who did and did not attended trainingsin the previous period (÷ 2 = 44.001, p < 0.001). Nearlytwo-thirds of those who attended some types of educa-tion in the field of HIV/AIDS are considered to have asatisfactory level of knowledge in the field (Table 2).

DISCUSSION

Availability of information and increase of knowl-edge in the field of HIV/AIDS are particularly impor-tant for service providers in healthcare, which is whyexperts say that certain quantum of knowledge is nec-essary for adequate provision of health services (5).Research has shown that there is a highly significantdifference in knowledge of providers of healthcare ser-vices in relation to whether they had the opportunity toattend some kind of training in the field of HIV/AIDSor not.

Healthcare service providers estimate that there isan increased risk of HIV transmission from patient toperson in their working environment. Such answers in-directly show that health workers do not have enoughknowledge about types of exposure that are consideredrisky. Assessment of the risk of infection that is trans-

HIV/AIDS EDUCATION OF HEALTH CARE PROVIDERS 33

Figure 3. Attitudes of health workers in relation

to needs for education in the field of HIV/AIDS

Table 2. Correlation estimates of their own knowledge and past education on HIV/AIDS

Assessment of respondentsknowledge on HIV/AIDS

Passed education in the field of HIV/AIDS

Yes % No % Total %

Little 273 50,7 265 49,3 538 100,0

Much 72 26,4 201 73,6 273 100,0

Total 347 42,5 466 57,5 813 100,0

Table 1. Correlation between education on HIV / AIDS and knowledge in this field

Assessmentof respondents

knowledgeon HIV / AIDS

NoYes in the last five

yearsYes in the last year Total

Number % Number % Number % Number %

Almost nothing 17 68,0 6 24,0 2 8,0 25 100,0

Very little 105 66,9 42 26,8 10 6,4 157 100,0

A little 153 42,7 166 46,4 39 10,9 358 100,0

Much 61 26,5 129 56,1 40 17,4 230 100,0

Very much 11 25,6 13 30,2 19 44,2 43 100,0

Total 347 42,7 356 43,8 110 13,5 813 100,0

mitted by blood and opportunities of HIV transmissionin the health care setting are directly related to theknowledge of the definition of high-risk proceduresand bodily fluids that are considered potentially infec-tious. Therefore, knowledge of health professionals isextremely important in relation to these aspects of HIVinfection (6).

Respondents lined up biological material for tran-smission of HIV according to the risk assessment fortheir health, as follows: blood, semen, vaginal secreti-ons, cerebrospinal fluid, saliva, urine, stool and sweat.Similar results were obtained in a research conductedamong health workers in primary health care of the Re-public of Serbia, in the period from November to De-cember 2008 (7).

In this study, nearly the same number of respon-dents stated that HIV infection and AIDS are two termsfor the same phenomenon, while about 11% said theydid not know the answer to this question. Though thiswas significantly better than in previous studies (9),there is still plenty of room for further education ofproviders in healthcare. Wu and associates found thatabout one-third of respondents, 27.5%, did not knowwhat abbreviation HIV was and 21.4% what acronymAIDS meant (8). The data showed that ignorance waspresent in a significant higher number of respondents,but the research was conducted ten years ago.

The results show that among service providers inhealth care there was some confusion regarding themode of HIV transmission, as well as the concepts rela-ted to HIV infection. Thus, 22.2% of respondents beli-eve that HIV can be transmitted by mosquitoes, and17.1% do not know whether this statement is true. It isshown that the education of health workers is neces-sary component in the process of preserving their he-alth, the health of users and overcoming stigma and di-scrimination. However, it is evident that the prevalenceof HIV/AIDS significantly conditions knowledge abo-ut this infection, because if the service providers in thehealth care are more often exposed to work with peopleliving with HIV/AIDS, it provides them more opportu-nities to learn, to have more experience and to overco-me their stigmatizing attitudes. It is quite expected thatservice providers who provide health care services to

persons living with HIV/AIDS have comprehensiveand complete information related to this disease thanothers. Research on knowledge, attitudes and behaviorof health workers towards people living withHIV/AIDS in Tanzania (10) showed that no healthworker marked mosquito transmits of HIV as a true an-swer. The same survey in Rwanda (11) showed thatonly 4.5% of respondents gave the wrong answer to thequestion of whether a mosquito can transmit HIV. Al-so, research on stigma of health workers towards peo-ple living with HIV/AIDS in Ukraine showed no mis-understanding with transfer modes (12). Accordingly,it can be noted that in countries with a high prevalenceof the disease, knowledge of healthcare providers isfuller and more comprehensive in relation to the speci-fic disease.

Our respondents mostly evaluated their knowledgeabout HIV/AIDS as insufficient, whereby it should betaken into account that a significant number of them ha-ve not had the opportunity to attend training courses inthe field (13). Respondents who had attended some kindof training on HIV/AIDS believe that they significantlyused gained knowledge in practice. At the same time re-spondents expressed the need for additional training invarious aspects related to HIV/AIDS, which, in accor-dance with the above, is needed for their daily activities.

CONCLUSIONS

Healthcare service providers asses their knowled-ge in the field of HIV/AIDS as insufficient. Less than20% of surveyed could specify all necessary means ofprotection at work when providing services, when the-re is a possible contact with the blood of the user. Therewere even fewer correct answers to questions related topossible routes of transmission of HIV, while there wasa difference in relation to the field of healthcare theywere engaged in service. More often than every fourthprovider of health care did not had the opportunity toattend some type of education on HIV/AIDS, but onethird of those who have undergone such training belie-ve to use their knowledge in the respective field inpractice. It is shown that knowledge in the field ofHIV/AIDS is not complete, and should be improved.

34 Ljaljevic Agima, Scepanovic Lidija, Mugosa Boban, Catic Sabina

Sa`etak

HIV/AIDS EDUKACIJA ZDRAVSTVENIH RADNIKA

Ljaljevi} Agima, [}epanovi} Lidija, Mugo{a Boban, ]ati} Sabina

Institut za javno zdravlje Crna Gora, Podgorica, Crna Gora

Uvod: Cilj ovog istra`ivanja bio je utvrditi percep-cije zdravstvenih radnika o njihovoj svesti i znanju o

HIV/AIDS-u, kao i odnos navedenih parametara i po-stojanje stigme i diskriminacije osoba s HIV/AIDS-a.

REFERENCES

1. Picerno I, Spataro P, Cannavb G, et al. Evaluation of theAIDS risk perception among healthcare workers in the HospitalUniversity Unit of Messina (Italy). J Prev Med Hyg. 2008;49(3): 97–100.

2. Centers for Disease Control. Update: human immuno-deficiency virus infections in health-care workers exposed toblood of infected patients. Morb Mortal Wkly Rep. 1987;36(19): 285–9.

3. UNAIDS/WHO. Guidelines for using HIV testing tech-nologies in surveillance. Geneva: WHO/CDS/CSR/EDC/2001.16.UNAIDS/01.22E. 2001; 1–38.

4. Umeh C, Essien J, Ezedinachi E, Ross MW. Knowled-ge, beliefs and attitudes about HIV/AIDS related issues, and thesources of knowledge among health care profesionals in south-ern Nigeria. J R Soc Promot Health. 2008; 128(5): 233–9.

5. Koci} B, Petrovi} B, Bogdanovi} D, Jovanovi} J, Niki}D, Nikoli} M. Professional risk, knowledge, attitudes and prac-tice of health care personnel in Serbia with regard to HIV andAIDS. Cent Eur J Public Health. 2008; 16(3): 134–7.

6. U.S. Public Health Service. Updated U.S. Public HealthService Guidelines for the Management of Occupational Expo-sures to HBV, HCV, and HIV and Recommendations for Postex-posure Prophy-laxis. MMWR Recomm Rep. 2001; 50(RR-11):1–52.

7. Mihajlovi} I, Koci} B, Cagulovi} T. Procena znanjazdravstvenih radnika primarne zdravstvene za{tite u op{tini Ra-ànj u vezi sa HIV infekcijom. Acta Medica Medianae. 2009;48(4): 32–9.

8. Wu Z, Detels R, Ji G, et al. Diffusion of HIV/AIDSknowledge, positive attitudes, and behaviors through training ofhealth professionals in China. AIDS Educ Prev. 2002; 14 (5):379–90.

9. US Agency for International Development (USAID)Health Policy Initiative, Task Order 1. Stigmatization and Dis-crimination of HIVpositive People by Providers of General Me-dical Services in Ukraine. Washington DC: Futures Group, He-alth Policy Initiative, Task Order 1; 2007.

10. Kitaura H, Adachi N, Kobayashi K, Yamada T. Knowl-edge and attitudes of Japanese dental health care workers to-wards HIV-related disease. J Dent.1997; 25(3-4): 279–83.

11. Uebel KE, Nash J, Avalos A. Caring for the caregivers:models of HIV/AIDS care and treatment provision for health ca-re workers in Southern Africa. J Infect Dis. 2007; 196(Suppl 3):500–4.

12. Sadob AE, Fawole AO, Sadoh WE, Oladimeji AO, So-tiloye OS. Attitude of health-care workers to HIV/AIDS. Afr JReprod Health. 2006; 10(1): 39–46.

13. Wilson WO. Infection control issue: understandingand addressing the prevalence of unsafe injection practices inhealthcare. AANA J. 2008; 76(4): 251–3.

HIV/AIDS EDUCATION OF HEALTH CARE PROVIDERS 35

Metod: radi se o bihejvioralnoj studiji preseka. Is-traìvanje je sprovedeno tokom 2012. godine, na repre-zentativnom uzorku zdravstvenih radnika u Crnoj Go-ri. Glavni instrument istraìvanja je posebno dizajniranupitnik koji se sastojao od {est delova, od kojih je jedanbio u vezi sa znanjem o HIV-u i AIDS-u. Podaci su ana-lizirani pomo}u metode inferencijalne statistike.

Rezultati: Vi{e od ~etiri od deset ispitanika nikadanisu poha|ali edukativne radionice o HIV/AIDS-u. Istra-

ìvanja su pokazala da postoji vrlo zna~ajna statisti~kapovezanost izme|u procena vlastitog znanja oHIV/AIDS-u i prethodnih edukacija. Gotovo dve tre}ineispitanika, koji su imali neki tip edukacija o HIV/AIDS-u,veruju da imaju zadovoljavaju}i nivo znanja o toj oblasti.

Zaklju~ak: Zdravstveni radnici ocenjuju njihovoznaje o HIV/AIDS-u kao nedovoljno.

Klju~ne re~i: HIV/AIDS, zdravstveni radnici, edu-kacija.

Correspondence to/Autor za korespondencijuProf. dr Agima LjaljevicInstitute of Public HealthLjubljanska bb81000 PodgoricaMontenegroE-mail: agima.ljaljevicªijzcg.meTel. +382 67 2666 795

SYNDROME OF HYDROCEPHALUS IN YOUNG

AND MIDDLE-AGED ADULTS. REVIEW OF THE LITERATURE

AND ILLUSTRATIVE CASES

Kalevski Svetoslav,1, 2

Peev Nikolay2




Abstract: Introduction: A multitude of underly-ing reasons result in hydrocephalus (HC), and its clas-sification remains controversial. The current study lo-oks at patients with the Syndrome of Hydrocephalus inYoung and Middle-Aged adults (SHYMA) through acase series.

Patients and methods: We report 35 patients withHC referred to St. Anna Multiprofile Hospital duringthe period 2008–2012. Inclusion criteria were decom-pensated congenital hydrocephalus, (DCH), acquiredhydrocephalus (AHC), or idiopathic hydrocephalus(IHC) in the age range of 16–55 years, treated with aventriculo-peritoneal shunt (VPS) — 17 patients weretreated with Strata Adjustable Delta Valve (“Strata”group) and 18 patients had Medtronic Orbis Sigma val-ves inserted (“Orbis Sigma” group).

Results: Eight patients (22.86%) had DCH, 14(40%) had AHC, and 13 (37.14%) had IHC.

Regardless the underlying cause for HC, all the pati-ents had similar symptoms, mainly related to gait in 26(74.3%), cognition in 30 (85.7%), bladder control in 20(57.14%) and chronic headaches in 24 patients (68.57%).

Symptomatic improvement was achieved in 34 ofthe shunted 35 patients (97.14%), but the postoperativecomplications rate was found to be significantly lowerin the “Strata” group.

Conclusion: The clinical presentation of hydro-cephalus in the age 16–55 years has common featurespresenting with syndrome of hydrocephalus in youngand middle-aged adults as separate clinical entity.

VPS is a feasible treatment option in SHYMA.Due to the excessive, long standing ventriculomegaly,thus sensitive compliance of brain parenchyma andhigh tendency to develop subdural hematomas, adjust-able VPS are advisable option.

Key words: adult onset hydrocephalus, shunt, LO-VA, SHYMA, subdural effusion.

INTRODUCTION

A multitude of underlying etiological reasons canresult in hydrocephalus (HC), and the classificationand terminology used in adult hydrocephalus remainscontroversial (1-4) åven a century after the first ever at-tempt at classification by Dandy (5, 6). Hydrocephalusis typically divided into age groups: Infants, Childrenand the Elderly being the main groups with well char-acterised presenting features in each group, such as ex-cessive head enlargement and developmental delay ininfants; headache, nausea, vomiting, altered mental sta-tus and drowsiness among children; and cognitive decli-ne, gait apraxia and urinary incontinence in the elderly.

One group which has tended to be neglected is theage group which includes young to middle aged adults,and it has been proposed that patients in this age groupwho present with hydrocephalus represent a separateclinical category. The first systematic review in thisage group was first described by S. Oi in mid-ninetiesas Longstanding Overt Ventriculomegaly in Adults(LOVA) (7). LOVA is a relatively new concept — aspecific form of non-communicating hydrocephalusthat often causes hydrocephalic dementia. Before thisnew clinical entity was proposed, patients with LOVAhad been considered as normal pressure hydrocephalus(NPH) variants (8). Since then descriptions of LOVApresenting in young and middle-aged adults have beenlargely restricted to obstructive hydrocephalus second-ary to aqueductal stenosis. However in the age group16–55 years LOVA-like symptoms are not exclusive topatients with aqueductal stenosis. The presentation ofhydrocephalus in young and middle-aged adults is of-

UDK: 616.831

2015; 10(1): 37–45 ID: 214200844

ISSN-1452-662X Professional article

ten atypical or subtle enough to be unrecognized as aclinical manifestation of hydrocephalus.

Cowan et al. in 2005 first described the syndromeof hydrocephalus in young and middle-aged adults(SHYMA) (9). They proposed the recognition of a sin-gle, clinically distinct syndrome of hydrocephalus inyoung and middle-aged adults, associated with ventri-culomegaly with signs and symptoms that are age rela-ted and with a common feature set, unrelated to the pri-mary aetiology of hydrocephalus.

The aim of the current study is to look at the com-mon presenting features and treatment options in pati-ents with hydrocephalus in this age group through a ca-se series review, in order to shed light on the diagnosisand treatment of Longstanding Overt Ventriculome-galy in Adults (LOVA) and Syndrome of Hydrocepha-lus in Young and Middle-Aged adults (SHYMA).

PATIENTS AND METHODS

35 patients with HC were referred to “St. Anna”Multiprofile Hospital during the period 2008–2012.Inclusion criteria were decompensated congenital hy-drocephalus, (DCH), acquired hydrocephalus (AHC),or idiopathic hydrocephalus (IHC) within the age ran-ge of 16–55 years. Exclusion criteria in the ACH groupwere: patients who developed acute HC secondary todiseases such as subarachnoid haemorrhage, tumours,meningitis and intraventricular haemorrhage. The di-agnosis of symptomatic hydrocephalus was made onthe basis of history, signs and symptoms, computed to-mography (CT) or magnetic resonance imaging (MRI)documented hydrocephalus with evidence of elevatedintracranial pressure (ICP).

Patients were classified as having DCH, AHC, orIHC on the basis of history and clinical examination. Pa-tients were included in the DCH group if their head cir-cumference was at the 97

thpercentile or more for sex and

height. Usually a thoroughly taken history for the patientswith DHC revealed problems in early childhood consis-tent with the present symptoms. Those in the AH grouphad medical histories including head trauma, meningitis,encephalitis, or brain tumour. Head trauma was conside-red significant if it resulted in loss of consciousness andhospitalization. Patients not meeting the criteria for thetwo previous groups were considered to have IH.

The age of symptom onset was determined by ask-ing patients and family, when they first noticed symp-toms, or if possible, through previous medical records.The age of diagnosis was defined as the point at whichthe patient’s ventriculomegaly, seen on CT or MRI scan,was associated with their symptoms. The time-to-diag-nosis (TTD) was determined by calculating the differen-ce between the age of diagnosis and the age of symptom

onset. All patients underwent surgery with placement ofeither a flow regulated Medtronic Orbis Sigma valve orwith adjustable pressure Strata valve (Medtronic, US).Patients who underwent shunt surgery were followed upby a neurosurgeon weekly in the first month, then on the2, 3 and 6 months, and yearly thereafter.

The outcomes were assessed by determining the ex-tent of symptom resolution. Complete improvement wasdeWned as complete resolution of all presenting symp-toms. Partial improvement was deWned as complete res-olution of at least one of the presenting symptoms. Pati-ents were classiWed as having no improvement if all oftheir pre-treatment symptoms persisted at follow-up.

The patient were divided in 2 groups: Group 1 —patients shunted with flow regulated valve MedtronicOrbis Sigma; Group 2 — patients shunted with StrataAdjustable Delta Valve. The Strata valve had been ini-tially set to maximal pressure — 2.5 and reduced with0.5 afterwards on the weekly follow ups until the reso-lution of the symptoms continues. Complications ratein the two groups in terms of subdural hematoma for-mation was evaluated and compared.

Statistical analysis to compare the rate of compli-cation in the two groups of patients was performed viatwo-sided t test or one-way analysis of variance (ANO-VA). Data was presented as the mean ± SEM. Differen-ces were considered significant when P < 0.05.

RESULTS

We evaluated 35 patients (18 men; 17 women) bet-ween 2008 and 2012. Eight patients (22.86%) had DCH,14(40%) had AHC, and 13 (37.14%) had IHC. The cau-ses of AHC included head trauma (n = 7), subarachnoidhaemorrhage (n = 5), meningitis (n = 2). The reason for theHC in the DHC was aqueductal stenosis. All the patientswith no apparent reason for the HC were classified as IHC.

The mean age at of the patients was 47.2 years(range 16–65). The mean TTD for all patients was 7.7years (range 0.7–29.6 years).

Symptoms at the time of diagnosis were related togait in 26 (74.3%), cognition in 30 (85.7%), bladdercontrol in 20 (57.14%) and chronic headaches in 24 pa-tients (68.57%). The other symptoms were visualchanges in three (8.57%), nausea/vomiting in three(8.57%), alteration in consciousness in 2 (5.71%) andseizure in 1 patient (2.86%).

Disturbances in gait were most frequently descri-bed as clumsiness, difficulty on uneven surfaces, anddifficulty with stairs. Physical Wndings of subtle gaitabnormalities (widened base or stance, shortened stri-de length, impaired tandem stance or walk) were seenin 26 (74.3%) of the patients, but overt gait apraxia wasabsent in the examined group.

38 Kalevski Svetoslav, Peev Nikolay

Cognitive disturbance, varying from mild cogniti-ve impairment, resulting mainly in poor organizationalskills, or dependence on lists, to frank dementia wasfound in 30 of the patients (85.71%). The main urinarysymptoms found in 20 (57.14%) patients were frequ-ency and urgency and 4 only (11.43%) patients hadtrue urinary incontinence.

All the patients were treated with ventriculo-peri-toneal shunt placement (VPS) — 17 patients were trea-ted with Strata Adjustable Valve (“Strata” group) andthe rest 18 patients had Medtronic Orbis Sigma (“OrbisSigma” group).

Symptomatic improvement was achieved in 34out of 35 patients shunted (97.14%). Follow up of the100% of the patients was achieved up to the 6

thmonth.

All of the 34 patients preserved the symptomatic impro-vement at 6

thmonths follow-up. The VPS (Medtronic

Orbis Sigma) in one of the patients was removed due tosignificant over drainage and formation of significantbilateral effusions, and the patient was discharged withno improvement, but no deterioration. In the “Strata”group only one patient(5.88%) developed subdural he-matoma postoperatively due to the wrong protocol be-ing followed — the valve had been set directly to 0.5,but not to 2.5 with slow decrease afterwards. Shunt revi-sion was required in 3 of the patients (17.64%).

In the “Orbis Sigma” group, subdural haematomaswere found in 6 (33.33%) patients and 10(55.55%) pati-ents needed shunt revision. All the hematomas were trea-ted within the same admission. The revisions of the VPSwere performed within the initial admission (10/13) orwithin the first month after the discharge (3/13).

The following table (Table 1) presents the numberof the patients from the different groups that had revi-sion surgery and SDH.

Illustrative cases

Case 1 (DHC, obstructive,

aqueductal stenosis)

A 42-year old man presented with progressive he-adache, gait difficulty, memory loss, and urinary frequ-ency. The head circumference was found to be above

the 97th

percentile. A thorough history taking revealedthat the patient had had meningitis in early childhoodafter which he became deaf and mute. MRI scan revea-led isolated ventriculomegaly of the lateral and thirdventricles with normal fourth ventricle (Figure 1). con-firming aqueductal stenosis (Figure 2). The patient wasoperated and the hydrocephalus was shunted withMedtronic Orbis Sigma valve. The postoperative scanperformed 7 days after the shunt surgery revealed mas-sive bilateral subdural collections (Figure 3). After cli-nical discussion the VPS it was decided that the shuntbe removed and the subdural collections to be monito-

SYNDROME OF HYDROCEPHALUS IN YOUNG AND MIDDLE-AGED ADULTS. REVIEW OF THE LITERATURE... 39

DHC (n = 8) AHC (n = 14) IHC (n = 13)

Orbis Sigma (n = 18) 4 7 7

Strata (n = 17) 4 7 6

SDH (Orbis Sigma) (n = 6) 1 3 2

SDH (Strata) (n = 1) 1 0 0

REVISION (Orbis Sigma) (n = 10) 2 4 4

REVISION (Strata) (n = 3) 1 1 1

Table 1. The number of the patients from different groups that had revision surgery

Figure 1. Isolated ventriculomegaly

of the lateral ventricles

Figure 2. Aqueductal stenosis

red with serial CT scans. Three months after the shuntremoval, the subdural collections had resolved (Figure4) and the patient reported no headaches, with impro-ved gait and urinary control. Patient remained clini-cally stable with no complains on the sixth month fol-low up visit.

Case 2 (IHC)

A28-year old man presented with one year historyof headache, dizziness, difficulties finding words, lo-wer limbs weakness and urinary incontinence. Theconversation with his relatives revealed learning diffi-culties and mental retardation during the childhood.MRI investigation revealed excessive dilatation of theall four ventricles (Figure 5A and 5B). Intracranialpressure measured in recumbent position pre-operati-vely revealed an ICP of 6 mm Hg. After clinical discus-sion it was decided the hydrocephalus to be treatedwith Strata Adjustable Valve. The valve was intra-ope-ratively set at 1.0. CT scan on the sixth post-operativeday showed an acute epidural hematoma (Figure 6)

that had to be evacuated urgently. The valve was set in-tra-operatively to 2.0. The postoperative period wentuneventfully. Patient was discharged with significantimprovement — no headaches and dizziness, impro-ved word finding, improved gait and urinary control,which remained unchanged on the sixth month followup visit.


Figure 3. Massive bilateral subdural collections

Figure 4. Three months after the shunt removal,

the subdural collections had resolved

Figure 5A. Excessive dilatation of the

all four ventricles

Figure 5B. Excessive dilatation of the lateral

ventricles

Figure 6. Acute epidural hematoma

Case 3 (ACH)

38 year-old female presented in Emergency De-partment after generalized tonic-clonic seizure. CTscan demonstrated a moderate-sized acute on chronicsubdural hematoma, excessively enlarged lateral andthird ventricle and VP shunt system (Figure 7A and7B). The conversation with the relatives, together withthe medical documentation revealed that the patienthad an implanted Strata Adjustable Valve back in2009, set at 1.5. The reason for shunt surgery had beencomplaints of headaches, memory problems and uri-nary urgency. Detailed questioning of the relatives alsorevealed multiple head injuries during early childhoodwith loss of consciousness. A burr hole evacuation ofthe subdural hematoma was initially attempted. Howe-ver due to a 4mm thick parietal haematoma capsule fo-und intra-operatively, the burr hole was converted to amini-craniotomy (Figure 8). The Valve was set to 2.0postoperatively, which resulted in transient postopera-tive urinary urgency and night bed wetting, which sub-sided gradually over a 2 week period. The patient was

discharged on anticonvulsant treatment. The postoper-ative follow up CT scans (Figure 9) on the 1

stand 2

nd

and 6th

month revealed that the size of the subdural he-matoma was unchanged, but the patient remained freeof symptoms.

DISCUSSION

A multitude of underlying etiological reasons cancause hydrocephalus (HC). Its classification and termi-nology is still controversial and a widely accepted con-sensus is still due to be achieved.

The pathophysiology of hydrocephalus (HC) firststarted in the beginning of the previous century withthe work of Dandy and Blackfan (5). In 1913 they hadfirst introduced the term “Internal Hydrocephalus” andalso described the main features of the so called Com-municating and Non-communicating Hydrocephalus.By 1919 Dandy (6) had developed an experimental an-imal model in order to study and develop treatment forHC. Since that first classification, there are numerousattempts at HC classifications, reflecting different as-pects of the problem, but 100 years after the Dandy’s


Figure 7B. Moderate-sized acute on chronic subdural

hematoma, excessively enlarged lateral ventricles

Figure 7A. Excessively enlarged lateral ventricles

and VP shunt system

Figure 8. Mini-craniotomy for evacuation

of the hematoma

Figure 9. Postoperative follow up CT scan

and Blackfan’s work, despite the many major achieve-ments led to many classifications covering different as-pects of HC, the ideal comprehensive classification co-vering all the aspects remains elusive. Hence the termhydrocephalus generally represents a complex pat-hophysiological entity with one main characteristic —disturbed cerebrospinal fluid (CSF) turnover, withcomplex, not well understood and on many occasionsintuitive treatment.

Despite the first Dandy and Blackfan classifica-tion is already a century old, it remains popular andstill in use. The authors defined two main subgroups ofHC — communicating and non-communicating, sim-plistically based on the ability of a dye injected to thelateral ventricles to be isolated in the lumbar subarac-hnoid space by a lumbar puncture, respectively to eval-uate the communication of the lateral ventricles withthe lumbar subarachnoid space. Later on Russell (10)further developed the idea with the introduction of theterms obstructive and non-obstructive hydrocephalus.The obstruction is defined as a condition of disturbedCSF circulation due to a blockage at any point in themajor CSF pathway including the ventricular systemand cistern/subarachnoid apace, hence the causes fornon-obstructive hydrocephalus are limited to eitherCSF overproduction by choroid plexus papilloma orCSF malabsorption due to sinus thrombosis. So after athorough reading of these two authors it would appearthat the terms communicating/non-communicatingand obstructive/non-obstructive hydrocephalus are notidentical. While communicating/non communicatingstate is based simply on the ability of a dye to movefreely from the lateral ventricles to the lumbar subarac-hnoid space, the obstruction defined by Russell is atany region in the major CSF pathway including theventricular system, and entire cistern/subarachnoidspace. Hence the term non-obstructive hydrocephalusshould be assigned only for pathology causing CSFoverproduction like choroid plexus papilloma or CSFmalabsorption due to sinus thrombosis.

In 1960 Ransohoff (11) revised the Dandy’s com-municating/non communicating HC classification ba-sed on his experiments. The author believed that all ofthe HC forms involve obstruction of the CSF pathwaysomewhere between its point of production in the chor-oids plexus and its point of absorption in the arachnoidvilli. Hence he termed the Dandy’s noncommunicatingHC as “intraventricular obstructive HC” while thecommunicating HC had been renamed to “extraventri-cular obstructive HC”.

Later Raimondi (2) defined hydrocephalus as apathologic increase in intracranial CSF volume — in-tra- or extraparenchymal, independent of hydrostaticor barometric pressure. He literally interpreted HC as

“water head” and considered all the pathological con-ditions leading to accumulation of water in the intrac-ranial compartments. Thus he classified hydrocephalusinto intraparenchymal (cerebral oedema) and extrapa-renchymal, with the extraparenchymal types sub- clas-sified into subarachnoid, cisternal, and intraventricularforms.

All these and many other classifications focus onthe site of obstruction or the compartment of CSF accu-mulation, which was a reason why Satoshi Takahashi,in a comment in Journal of Hydrocephalus (12), at-tempted to unite all these and many other classificati-ons into a classification in which any type of hydrocep-halus could fit. In his comment he differentiated anot-her two major groups of HC classifications, namelyclassifications that focus on specific developmentalstages (ex. neonates, infants, or adults) and also classi-fications that described some specific forms of hydro-cephalus like NPH, LOVA, etc.

The developmental and chronological trends inclassifying hydrocephalus are reflected in the work ofShizuo Oi.

The developmental trend is reflected in the so cal-led “Evolution theory in cerebrospinal fluid dynamics”proposed by Oi in 2006 (13). The author proposed theterm “minor pathway” — the pattern of ventriculo-ci-sternography in neonatal/infantile cases revealed a pre-dominantly intra-parenchymal pattern of CSF circula-tion, unlike the adult type of CSF circulation which istermed “Major pathway”. This was the primary reasonproposed by the author for the high incidence of “failu-re to arrest hydrocephalus” by neuroendoscopic ventri-culostomy in fetal, neonatal and infantile periods —while the major CSF pathway is not developed, the mi-nor pathway plays a significant role in the neonates.Based on these findings the author postulated “minorpathway hydrocephalus”. The development of the“major pathway” Oi juxtaposed with the evolutionalfindings in the development of the CSF pathways, as inthe animals, ex. rats where the minor CSF pathway pre-dominates, towards the matured adult human brainswhere the major CSF pathway is predominant. This gi-ves the ground the theory to be termed “Evolution the-ory in cerebrospinal fluid dynamics”.

The chronological trend classifying HC is reflec-ted by the Perspective Classification of Congenital Hy-drocephalus (PCCH) (14). This classification is an at-tempt to determine the factors for the postnatal progno-sis of fetal hydrocephalus — in this paper the authorbelieved that the prognosis in fetal hydrocephalus sho-uld be determined not only with morphological analy-sis of prenatal diagnostic imaging, but also in combina-tion with the degree of brain parenchymal damage andHC progression. Based on that Oi described five clini-


co-embryological stages ŠPCCH Stage I-V¹ with diffe-rent prognoses in HC.

As classification dealing with specific forms ofHC could be: Normal pressure hydrocephalus (NPH),Longstanding overt ventriculomegaly in adult (LO-VA), Hydrocephalus-parkinsonism complex, etc. (15),The syndrome of hydrocephalus in young and mid-dle-aged adults (SHYMA), etc.

CSF circulation and turnover is a complex processand is described by many variables and is dependent ona multitude of factors which complicates attempts at aunifying classification system. Based on the systema-tic review of almost 10000 publications from the pe-riod of 1950–2008 in the HC area, and also based onhis own experimental and clinical work, in 2010 Oiproposed “Multi-categorical Hydrocephalus classifi-cation, attempting to cover all the aspects of the HC“(16). Each HC case according to this classification isconfronted to ten categories with multiple subcategori-es, with a final count of 54 HC subtypes listed. If onewould wish to cover all the possible combinations inthis classification, there would be theoretically72,576,000 patterns of hydrocephalus classified.

As classification dealing with specific forms ofHC could be pointed Normal pressure hydrocephalus(NPH) (17), Longstanding overt ventriculomegaly inadult (LOVA), Hydrocephalus-parkinsonism complex(15), The syndrome of hydrocephalus in young andmiddle-aged adults (SHYMA), etc.

Longstanding overt ventriculomegaly in adult(LOVA) is a specific form of non-communicating hy-drocephalus that often causes hydrocephalic dementia.It is a unique category of hydrocephalus first presentedby Oi in the mid-1990’s. Before this new category wasproposed, patients with LOVA might have been consi-dered within the spectrum of normal pressure hydro-cephalus (NPH) (17–20).

But descriptions of LOVA presentation in youngand middle-aged adults have largely been restricted toobstructive hydrocephalus due to aqueductal stenosis.Because adults in this age range have been included incohorts of predominately elderly patients with NPH(18,21,22) the clinical presentation of young adults hasnot been differentiated until Cowan et al. (9) describedin 2005 a new subgroup of HC patients — hydrocepha-lus in young and middle-aged adults. They proposedthe recognition of a single, clinically distinct syndromeof hydrocephalus in young and middle-aged adults(SHYMA), which is associated with ventriculomegalyand signs and symptoms that are age related andmostly similar, regardless of the aetiology of the hy-drocephalus. So according to the authors, LOVA pati-ent group — those with obstructive hydrocephalus dueto aqueductal stenosis, appear to be a subset of

SHYMA patient group, which comprise chronic HCpatients not only with decompensated HC due to aque-ductal stenosis, but HC due to obstruction elsewherebut aqueduct, also non obstructive HC forms and alsoidiopathic HC.

The results from the followed in our investigationgroup of 35 patients is concordant with the findings ofCowan et al. The majority of the patients present withthe following 4 symptoms regardless of the etiology.Namely mild gait disturbance (74.3%), but not overtgait apraxia; different extent of cognitive decline(85.7%); bladder control problems (57.14%), but onlyrarely overt incontinence; chronic headache (68.57%).The other symptoms that were additionally supportingthe diagnosis were visual changes (8.57%), nausea/vo-miting (8.57%), alteration in consciousness (5.71%)and seizure in 1 patient (2.86%). The common symp-toms in the three subgroups, regardless of the causingthe HC pathology, suggests that the age is significantdeterminant of the development and the clinical pre-sentation of the disease.

The good results on the follow ups showed thatthe VPS is a feasible option for this subgroup of HC pa-tients, but the rate of the post-shunting hematoma for-mation suggests that adjustable shunts should be usedin order to reduce the rate of complications, especiallywith the patients with excessive ventriculomegaly dueto chronic HC, due to the sensitive compliance of theirbrain parenchyma (23) — these patients have high ten-dency to develop bilateral subdural hematoma whentreated with improperly chosen shunt systems.

There are investigations clearly stating the role ofthe resistance to outflow and brain compliance as im-portant parameters in the hydrocephalus patho-physio-logy, thus important parameters for appropriate shuntselection. Some milestone studies based on modernflow-sensitive MRI protocols establish the brain com-pliance as very important parameter for the chronic hy-drocephalus patients (24, 25, 26).

CONCLUSION

Based on the available literature and also our in-vestigation, we accept the age as a major determinantof the clinical expression of the CH. The clinical pre-sentation of hydrocephalus in young and middle-agedadults has common features that allow differentiating asubgroup of HC patients presenting with syndrome ofhydrocephalus in young and middle-aged adults(SHYMA) as separate clinical entity.

VPS is a feasible treatment option in SHYMA.Due to the excessive and long standing ventriculome-galy that these patients have, which suggests sensitivecompliance of brain parenchyma, respectively high


tendency to develop subdural hematomas when treatedwith improperly chosen shunt systems, adjustable VPSare advisable to be used for their treatment.

Abbreviations

AHC — acquired hydrocephalusANOVA — analysis of varianceCSF — cerebrospinal fluidCT — computed tomographyDCH — decompensated congenital hydrocephalusHC — hydrocephalus

IHC — idiopathic hydrocephalusICP — elevated intracranial pressureLOVA — Longstanding Overt Ventriculomegaly

in AdultsMRI — magnetic resonance imagingNPH — normal pressure hydrocephalusPCCH — Perspective Classification of Congeni-

tal HydrocephalusSHYMA — Syndrome of Hydrocephalus in Young

and Middle-Aged adultsTTD — time-to-diagnosisVPS — ventriculo-peritoneal shunt


Saètak

SINDROM HIDROCEFALUSA KOD MLADIH I OSOBA SREDNJE

@IVOTNE DOBI — PREGLED LITERATURE I PRIKAZI SLUÂJEVA


Peev Nikolay2



Uvod: Veliki broj stanja za posledicu ima hidroce-falus (HC), a njegova klasifikacija i dalje ostaje kon-troverzna. Ova studija obuhvata mlade i sredove~nepacijente sa sindromom hidrocefalusa (SHYMA), iprikaze reprezentativnih slu~ajeva.

Pacijenti i metode: Prikazujemo 35 pacijenata saHC, le~enih u bolnici „St. Anna“, u periodu od 2008.do 2012. godine. Kriterijumi za uklju~ivanje u studijusu dekompenzovani uro|eni hidrocefalus (DCH), ste-~eni hidrocefalus (AHO), ili idiopatski hidrocefalus(IHH), u starosnoj dobi od 16–55 godina, tretirani ven-triculo-peritonealnim {antom (VPS) — 17 bolesnika jele~eno Strata podesivim Delta valvulama („Strata“grupa) i 18 pacijenata Medtronic Orbis Sigma valvula-ma („Orbis Sigma“ grupa).

Rezultati: Osam pacijenata (22.86%) je imaloDCH, 14 (40%) je imalo AHO i 13 (37.14% ) IHC. Bezobzira na osnovni uzrok hidrocefalusa, svi pacijenti su

imali sli~ne simptome, koji su se uglavnom odnosili nahod kod 26 (74,3%), kognitivne funkcije kod 30(85,7%), kontrolu mokrenja kod 20 (57,14%) i hro-ni~ne glavobolje kod 24 pacijenta (68,57%). Simpto-matsko pobolj{anje ostvareno je kod 34 od 35 {antova-nih pacijenata (97,14%), ali je utvr|eno da je stopa po-stoperativnih komplikacije zna~ajno nià u „Strata“grupi.

Zaklju~ak: Klini~ka prezentacija hidrocefalusa udobi od 16–55 godina, ima zajedni~ka obele`ja prezen-tovana sindromom hidrocefalusa kod mladih i sredo-ve~nih odraslih kao zasebnim klini~kim entitetima. VPSje mogu}a opcija le~enja kod SHYMA. Zbog prekomer-ne dugogodi{nje ventrikulomegalije, osetljivosti mo-`danog parenhima i visoke sklonosti za razvoj subdural-nog hematoma, podesivi VPS su poèljna opcija.

Klju~ne re~i: hidrocefalus odraslih, {ant, LOVA,SHYMA, subduralni izliv.

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Correspondence to /Autor za korespondencijuProf. Dr. Svetoslav Kalevski, MD, PhD, DScDep. NeurosurgeryMedical University of Varna55 “Marin Drinov” Str.BG-9002 Varna,BulgariaMobile:+359 888 212 387E-mail: dr_kalevskiªabv.bgFax:+359 52 355 553

Nikolay Angelov Peev, MD, PhD (Neurosurgery),FRCS (England)Consultant NeurosurgeonBelfast HSC TrustMobile: +44 (0) 77096 74083E-mail: nikolay.a.peevªgmail.com


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22. Vanneste J, Augustijn P, Tan WF, Dirven C. Shuntingnormal pressure hydrocephalus: the predictive value of combi-ned clinical and CT data. J Neurol Neurosurg Psychiat. 1993;56(3): 251–6.

23. Levine DN. Intracranial pressure and ventricular ex-pansion in hydrocephalus: Have we been asking the wrong que-stion? J Neurol Sci. 2008; 269(1–2): 1–11.

24. Kiefer M, Eymann R. Clinical proof of the importanceof compliance for hydrocephalus pathophysiology. Acta Neu-rochir Suppl. 2010; 106: 69–73.

25. Greitz D. Radiological assessment of hydrocephalus:New theories and implications for therapy Neurosurg. Rev.2004; 27 (3): 145–65.

26. Bateman GA, Lev CR, Schofield P, Wang Y, LovettEC. The venous manifestations of pulse wave encephalopathy:Windkessel dysfunction in normal aging and senile dementia.Neuroradiology. 2008; 50(6): 491–7.

ACUTE RENAL FAILURE IN THE NEWBORNS

HOSPITALIZED AT THE INTENSIVE CARE UNIT,

UNIVERSITY CLINICAL CENTRE TUZLA

Zulic Evlijana, Hadzic Devleta

Pediatrics clinic, University Clinical Center of Tuzla, Bosnia and Herzegovina


Abstract: Introduction: Reasons for acute renalfailure in hospitalized infants were sepsis, hypovole-mia, asphyxia, respiratory distress syndrome, surgicalinterventions and congenital heart defects.

The aim of this study was to determine the frequ-ency and and main etiologies, and early outcome ofneonatal acute renal failure.

Materials and Methods: At Intensive Care Unit,Clinical Center Tuzla, from 15. 01. 2013 to 15. 01.2015 in 21 newborn was diagnosed renal failure, basedon the amount of excreted urine and serum creatinine.

Results: The prevalence of renal failure was6.84%, with a higher incidence of female. 33.3% of in-fants were term neonates. Oliguria was diagnosed in71.4% of newborns. Sepsis was the most common pre-disposing factor for the development of renal failure,associated with high mortality. Other causes of renalfailure were perinatal hypoxia, RDS, surgical interven-tions and congenital heart defects. There was a positivecorrelation between the gestational age of the newbornand serum creatinine.

Discussion: Early prevention of risk factors withrapid diagnosis and effective treatment, can affect furt-her outcome of acute renal failure in infants.

Key words: acute kidney injury, newborns, inten-sive care unit.

INTRODUCTION

Acute renal failure (ARF) is a common problem inthe hospitalised newborn at Intensive care unit (ICU).It is the rapid decline in the kidney ability of maintain-ing homeostasis of water and electrolytes, associatedwith a reduction of the glomerular filtration rate (1).Currently, there is not a uniform definition of ARF inadult and pediatric patients, and ARF is defined inmultiple ways, but the majority of definitions of ARF

currently in use involve a change in the serum creatini-ne level. ARF in term newborns within the first fewdays of life refers to progressive increment in plasmacreatinine by higher than 1,5 mg/dl for at least 24–48 h,if a mother has normal kidney function. Serum creati-nine concentration in preterm infants in the first fewdays of life may not be a reflection of the glomerularfiltration rate because creatinine rises during the first36-96 h and then decreases gradually during the first 2weeks (1, 2, 3). The plasma creatinine concentrationimmediately after term delivery declines graduallyfrom 1,1 mg/dl (preterm neonate from 1,3 mg/dl) to 0,4mg/dl during the first 2 weeks of life (2, 3). In the new-born, renal failure may have a prenatal onset in conge-nital diseases such as renal dysplasia with or withoutobstructive uropathy and in genetic diseases such asautosomal recessive polycystic kidney disease. Acuterenal failure in the newborn is also commonly acquiredin the postnatal period because of hypoxic ischemic in-jury and toxic insults. Nephrotoxic acute renal failurein newborns is usually associated with aminoglycosideantibiotics and nonsteroidal anti-inflammatory medi-cations used to close a patent ductus arteriosis. Renalartery thrombosis and renal vein thrombosis will resultin renal failure if bilateral or if either occurs in a soli-tary kidney. Cortical necrosis is associated with hypo-xic/ischemic insults due to perinatal anoxia, placentaabruption and twin-twin or twin-maternal transfusionswith resultant activation of the coagulation cascade (2,3). Pre-renal injury results from renal hypoperfusiondue to true volume contraction from hemorrhage, de-hydration due to gastrointestinal losses, salt-wastingrenal or adrenal diseases, central or nephrogenic diabe-tes insipidus, increased insensible losses, as occurs inburns, and in disease states associated with third spacelosses, such as sepsis, nephrotic syndrome, traumati-zed tissue, and capillary leak syndrome. Decreased ef-

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fective blood volume occurs when the true blood volu-me is normal or increased but renal perfusion is decrea-sed due to diseases such as congestive heart failure,cardiac tamponade, and hepatorenal syndrome. Whet-her pre-renal injury is caused by true volume depletionor decreased effective blood volume, correction of theunderlying disturbance will return renal function tonormal (3, 4, 5).Considering the high incidence rate ofARF (10–26%) in hospitalized newborns and the highmortality rate of this disease (20–50%), it is one of themost important diseases among ICU patients (2, 3, 4,5). Oliguria was defined as urine output < 1 ml/Kg/hr,so that patient with ARF were subdivided into oliguricand nonoliguric (4, 5). Reduction of urine cannot bethe only criterion for ARF (2, 5). Measurement of pla-sma creatinine level is the simplest and most practicalmean for assessment of renal function (5, 6, 7). Treat-ment of ARF includes conservative therapy, dialysis,and rarely surgery of urinary tract obstruction.Someearly outcomes observed in ARF of neonates includedeath and long-term hospitalization due to variousconditions such as convulsion, uremic encephalopathy,and sepsis. The aim of this study wasto determine thefrequency and main etiologies of ARF, and early out-come of neonatal ARF.


The analysis included hospitalised 307 newbornsat Intensive Care Unit, in the Clinical for children dise-ase of the University Clinical Centre Tuzla in the pe-riod between 15. 01. 2013 and 15. 01. 2015. All data of

our patients were acquired based on available medicaldocumentation (illnes history and medical charts),physical examination and laboratory findings. ARFwas diagnosed in 21 hospitalized newborns, if serumcreatinine level was > 1.5 mg/dl. The urine output cri-teria were incorporated to pRIFLE and named neonatalRIFLE, or nRIFLE (8). Statistical analysis were per-formed with biomedical application software called“MedCalc for Windows, version 114.4”. P < 0.05 wereconsidered as statistically significant.

RESULTS

In total, 21 out of hospitalised 307 neonates(6,84%) were diagnosed as ARF. Of 21 ARF new-borns, 15 (87,8%) were female and 6 (28,6%) weremale, with significant diference (p = 0,01). The avera-ge age of patients was 8,4 ± 1,4 days and the averageweight of ARF neonates was 2285 ± 890 g. 14 patients(66,7%) were pre-term neonates. The mean duration ofhospitalization for each newborn was 10,2 ± 3,2days.Oliguria was detected in 15 patients (71,4%) and6 newborns (28,6%), were nonoliguric.The most com-mon causes of ARFin our patients were, in order ofprevalence, included sepsis (71,5%), followed byhypoxia secondary to perinatal asphyxia (42,8%), RDS(38%), same such as surgical procedure (38%), andcongenital heart disease (23,8%). Death occurred in 18patients (36.7%), while 63.3% were discharged withnormal renal function (Table 1). There was a signifi-cant relationship between gestation age, and plasmacreatinine level (Table 2).

48 Zulic Evlijana, Hadzic Devleta

Table 1. Demographic and clinical data of newborns with acute renal failure

VariableKidney failure n = 21 (6,8%)

P valueOliguric n = 15(71,4%)

Nonoliguric n = 6(28,6%)

Gestational agePretermTerm

10 (47,6%)2 (9,5%)

4 (19%)5 (23,8)

0,12

GenderFemaleMale

13 (86,6)4 (26,6)

2 (33,3)2 (33,3)

0,01

Weight (g)< 2500> 2500

14 (93,3)1 (6,67)

4 (66,7)2 (33,3)

0,57

EtiologySepsisPerinatal asphyxiaRDSSurgical procedureCongenital heart disease

9 (60)8 (53,3)8 (53,3)6 (90)3 (20)

5 (83,3)3 (50)3 (50)

2 (33,3)1 (16,7)

0,570,120,540,370,33

OutcomeDeathDischarge

14 (93,4)2 (73,4)

2 (33,3)3 (50)

0,88

DISCUSSION

In our study 21 of hospitalised 307 neonates (6,84%)were diagnosed as ARF. The incidence of AKI in chil-dren appears to be increasing and the etiology of ARFover the past decades has shifted from primary renal di-sease to multifactorial causes, particularly in hospitali-zed children (6, 7).Critically ill neonates are at greaterrisk of having AKI as they are commonly exposed tonephrotoxic medications and have frequent infections,which leads to multiorgan failure (1, 3, 4).

Of our 21 newborns with ARF, 15 (87,8%) werefemale and 6 (28,6%) were male. In other studies, theboys had a higher prevalence of ARF (9, 10). 66,7%patients were pre-term neonates. Newborn’s kidneysare more susceptible to hypoperfusion and have lowglomerular filtration rate, high renal vascular resistan-ce, high plasma renin activity, decreased intercorticalperfusion, and decreased reabsorption of sodium in theproximal tubules. All these features make newbornsmore susceptible to injury in the first days of life (11).

The average age of our patients was 8,4 ± 1,4 daysand the average weight of ARF neonates was 2285 ±890 g. In Nouri et al., study the average age of the pati-ents was similar like us 8,0 ± 2,5 days, while the birthweight was more then 2500 g in ARF group (12).

The mean duration of hospitalization for eachnewborn was 10,2 ± 3,2 days. In other study the meanduration of hospitalisation was shorter according withother comorbidity (12, 13).

The most common causes of ARF in our patientswere, in order of prevalence, included sepsis (71,5%),followed by hypoxia secondary to perinatal asphyxia(42,8%), RDS (38%), same such as surgical procedure(38%), and congenital heart disease (23,8%). Sepsisand incidence of ARF were significantly related (P =0.03). Recent studies included only special neonatalpopulations have shown that postneonatal asphyxia,low birth weight, and after cardiac surgery have signif-ficant more ARF in compare with other (6, 7, 11, 12).

In study of Csaicsich at all., the most common ca-uses of renal failure was sepsis andall infants were ma-naged conservatively with corrections of fluids, elec-trolytes and acidosis, including medication with diure-

tics and dopamine.In the same study infants with lowurine output, higher scores for failed organs or lowbirth weight were significantly more likely to die (6).

Most of neonates with oliguric ARF (65%) had se-vere perinatal asphyxia while in those with nonoliguricARF moderate perinatal asphyxia predominated (73%)(13). Serum creatinine values were significantly higherin asphyxiated babies (12, 14). Five minute Apgar < or= 6 had the best sensitivity to predict renal failurein as-phyxiated babies (9, 10).

Aggarwal et al. (17) indicated that ARF was deve-loped in 26.0% of newborns from which 15% hadRDS.The mortality occurred in 20% of the newborns, whichwas higher in patients with sepsis, RDS and ones whoneeded mechanical ventilation(10, 15). ARF after pe-diatric cardiac and other operations is associated withpoor outcomes and is difficult to predict (16).

Children who have ARF as a component of mul-tisystem failure have a much higher mortality rate thanchildren with intrinsic renal disease (7, 14). Recoveryfrom intrinsic renal disease is also highly dependent onthe underlying etiology of the ARF. Children who haveexperienced ARF from any cause are at risk for latedevelopment of renal failure long after the initial in-sult. Such children need life-long monitoring of theirrenal function, blood pressure, and urinalysis.

CONCLUSION

The most common causes of neonatal ARF arehypovolemia, hypotension and hypoxia. The preven-tion of ARF is likely to have a larger impact on mortal-ity rates than other measures. Newborns with acute re-nal failure need life-long monitoring of their renal fun-ction, blood pressure, and urinalysis.

Abbreviations

ARF — Acute renal failureICU — Intensive care unitRDS — respiratory distres syndrompRIFLE — pediatric Risk, Injury, Failure, Loss,

End-Stage Renal DiseasenRIFLE — neonatal Risk, Injury, Failure, Loss,

End-Stage Renal Disease

ACUTE RENAL FAILURE IN THE NEWBORNS HOSPITALIZED AT THE INTENSIVE CARE UNIT, UNIVERSITY... 49

Table 2. Demographic and laboratory data of newborns with acute renal failure

Demographicand laboratory date

OR- odds ratio Beta P value

Age 0,17 –6,262 0,617

Gestational age 0,673 –0,513 0,032

Weight 10,365 0,231 0,223

Creatinine 5,471 2,245 0,016

REFERENCES

1. Andreoli SP. Acute renal failure in the newborn. SeminPerinatol. 2004; 28(2): 112–23.

2. Momtaz HE, Sabzehei MK, Rasuli B, Torabian S. Themain etiologies of acute kidney injury in the newborns hospitali-zed in the neonatal intensive care unit. J Clin Neonatol. 2014;3(2): 99–102.

3. Gouyon JB, Guignard JP. Management of acute renal fa-ilure in newborns. Pediatr Nephrol. 2000; 14(10–11): 1037–44.

4. Youssef D, Abd-Elrahman H, Shehab MM, Abd-Elrhe-em M. Incidence of acute kidney injury in the neonatal intensivecare unit. Saudi J Kidney Dis Transpl. 2015; 26(1): 67–72.

5. Kleinman LI, Stewart CL, Kaskel FJ. Renal disease inthe newborn. In: Edelman CM Jr, editor. Pediatric Kidney Dise-ase. 2nd ed. Boston: Little, Brown and Co; 1992. p. 1043.

6. Csaicsich D, Russo-Schlaff N, Messerschmidt A, WeningerM, Pollak A, Aufricht C. Renal failure, comorbidity and mortality inpreterm infants. Wien Klin Wochenschr. 2008; 120(5–6): 153–7.

7. Andreoli SP. Management of acute kidney injury in chil-dren: a guide for pediatricians.Paediatr Drugs. 2008; 10(6): 379–90.

8. Ricci Z, Ronco C. Neonatal RIFLE. Nephrology Dialy-sis Transplantation. 2013; 28(9): 2211–4.

9. Mortazavi F, Hosseinpour Sakha S, Nejati N. Acute kidneyfailure in neonatal period. Iran J Kidney Dis. 2009; 3(3): 136–40.

10. Subramanian S, Agarwal R, Deorari AK, Paul VK,Bagga A. Acute renal failure in neonates. Indian J Pediatr. 2008;75(4): 385–91.

11. Libório AB, Branco KM, Torres de Melo Bezerra C.Acute Kidney Injury in Neonates: From Urine Output to NewBiomarkers. Biomed Res Int. 2014; 2014: 601568.

12. Nouri S, Mahdhaoui N, Beizig S, et al. Acute renal fail-ure in full term neonates with perinatal asphyxia. Prospectivestudy of 87 cases. Arch Pediatr. 2008; 15(3): 229–35.

13. Pejovi} B, Peco-Anti} A, Dunji} R. Acute oliguric re-nal failure in hypoxic neonates born at full term. Srp Arh CelokLek. 2002; 130(11–12): 367–70.

14. Askenazi DJ, Ambalavanan N,Goldstein SL. Acutekidney injury in critically ill newborns: What do we know?What do we need to learn? Pediatr Nephrol. 2009; 24(2):265–74.

15. Durkan AM, Alexander RT. Acute kidney injury postneonatal asphyxia. J Pediatr. 2011; 158(2 Suppl): e29–e33.

16. Hornik CP, Krawczeski CD, Zappitelli M, et al. Serumbrain natriuretic peptide and risk of acute kidney injury aftercardiac operations in children.Ann Thorac Surg. 2014; 97(6):2142–7.

17. Aggarwal A, Kumar P, Chowdhary G, Majumdar S,Narang A. Evaluation of renal functions in asphyxiated new-borns. J Trop Pediatr. 2005; 51(5): 295–9.

50 Zulic Evlijana, Hadzic Devleta

Saètak

AKUTNA RENALNA INSUFICIJENCIJA KOD NOVORO\ENÂDI

HOSPITALIZOVANIH NA ODELJENJU INTENZIVNE NEGE

UNIVERZITETSKOG KLINI^KOG CENTRA TUZLA

Zuli} Evlijana, Hadì} Devleta

Klinika za dje~ije bolesti, Univerzitetski klini~ki centar Tuzla, Bosna i Hercegovina

Uvod: Razlozi akutne bubre`ne insuficijencijekod hospitalizovanih novoro|en~adi su sepsa, hipovo-lemija, asfiksija, respiratorni distres sindrom, hiru{keinterevencije i uro|ene sr~ane mane.

Cilj: ove studije je bio utvrditi u~estalost i razlogeakutne bubre`ne insuficijencije novoro|en~adi, uzfaktore koji su uticali na rani ishod bolesti.

Materijal i metode: U Odjeljenju intenzivne te-rapije i nege, Klini~kog Centra Tuzla, od 15. 01. 2013.do 15. 01. 2015. godine kod 21 novoro|en~eta je dijag-nostikovana bubre`na insuficijencija, na osnovu koli-~ine izlu~enog urina i serumskog kreatinina.

Rezultati: Prevalenca bubre`ne insuficijencije je bi-la 6,84%, sa ve}om u~estalo{}u ènskog pola. 33,3% no-

voro|en~adi su bila terminska deca. Oligurija je dijagno-stikovana u 71,4% novoro|en~adi. Sepsa je bila naj~e{}ipredisponiraju}i faktor za nastanak bubre`ne insuficijen-cije, udruèna sa visokim mortalitetom. Drugi razlozi bu-bre`ne insuficijencije su bili perinatalna hipoksija, respi-ratorni distres sindrom, hiru{ke intervencije i uro|ene sr-~ane mane. Na|ena je pozitivna korelacija izme|u gesta-cijske dobi novoro|en~eta i nivoa serumskog kreatinina.

Diskusija: Rana prevencija rizi~nih faktora uz br-zo dijagnostikovanje i efektivni tretman, moè uticatina dalji ishod akutne bubre`ne insuficijencije kod no-voro|en~adi.

Klju~ne re~i: akutna bubre`na insuficijencija, no-voro|en~ad, Odeljenje intenzivne terapije i nege.

Correspondence to/Autor za korespondencijuEvlijana ZulicUniversity Clinical Center, Pediatric Clinic Tuzlaevlijanahªyahoo.commobile: 38761887721

OUR EXPERIENCE WITH MAGERL’S MODIFIED TECHNIQUE

FOR STABILIZATION OF SUBAXIAL CERVICAL SPINE

Haritonov Dimitar,1


Peev Nikolay1




Abstract: Aim: There are different surgical tech-niques for massa lateralis screw instrumentation of su-baxial cervical spine — those of Roy-Camille, Magerl,Anderson, and An. Each has different starting pointand trajectorys of screw implantation.For each techni-que there is a potential risk to affect vascular and neu-ral structures.In this paper we share our experience inusing a modified Magerl’s technique for stabilizationof subaxial cervical spine.

Method: We present a retrospective study and cli-nical follow-up of 27 patients operated on the occasionof cervical injury that we have used the modified tech-nique of Magerl. In 8 patients was carried and an ante-rior decompression and stabilization.

Results: In these patients was carried posterior orcombined — posterior and anterior stabilization. Theposterior fixation was massa lateralis with this modi-fied technique of Magerl with multiaxial screws. Withthis technique were inserted 160 multiaxial screws andthe most common length of the implants were 108 mm(108 from 160 or 67.5%).

Conclusion: Based on world literature, experien-ce and analysis of clinical cases, we believe that thismodified technique for subaxial cervical fixation is ef-fective (the pull-out strength approach to the strengthof pedicle screw instrumentation) and is much safer.

Key words: Posterior subaxial instrumentation,Magerl’s technique, suaxial instability.

INTRODUCTION

Various techniques and instrumentations are avai-lable for the posterior stabilization of subaxial cervicalspines after extensive decompressive surgery or trau-ma-related instability. These include wiring, place-ment of Halifax clamps, and use of various kinds of

screws with plates or rods (1–5) and the combination ofhooks and plates (6). Each of these techniques, howe-ver, presents its own limitations (7). Wiring is used lessand less because it can only be carried out where cer-tain key parts of the posterior element of the subaxialspine are present; therefore, it is impossible in mostscenarios where laminectomies have been required fordecompression or exposure of target lesions. Moreo-ver, wiring provides less fixation strength in compari-son with other rigid instrumentations. Halifax clampsmay provide better fixation strength than wiring but arestill not optimal. Lateral mass screws with plate fixati-on require precise contour tailoring for each patientand are thus extremely difficult for practical applica-tion. Recently, the use of lateral mass screws fixation inconjunction with rod systems has greatly increased be-cause this technique can avoid the above-mentionedshortcomings. For examples, lateral mass screw fixati-on can be performed after laminectomies, and it is alsoapplicable in extension to the occiput or the thoracicspines, and in multilevel placement with biomechani-cal superiority (8, 9). Various authors such as Magerl(6), Roy-Camille (10, 11), Anderson (3), Louis (12),and An (13) have developed different methods of plac-ing screws into the lateral mass. However, each of the-se methods has carried the risk of potential injury to theneural or vascular structures due to the anatomical va-riations among different levels of the cervical spineand different patients. To overcome these ongoing pro-blems, we have developed a modified technique to mi-nimize iatrogenic neurovascular injuries while achievemaximal purchase of the screw on the bone. The patho-logic features, surgical indications, surgical results,and complications of the 27 patients, treated with themodified techniques, were presented. More than halfof the patients treated with skipped level fixation werealso presented and discussed.

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We present a retrospective study and clinical fol-low-up of 27 patients operated on the occasion of cer-vical injury that we have used the modified techniqueof Magerl. In 8 patients was carried and an anterior de-compression and stabilization. In all cases is used preo-perative CT and MRI of the subaxial cervical spine(C3-C7) for assessment of anatomical peculiarities andmeasurements, postoperative CT to assess the positionof the implants, pre- and postoperative NDI score wereused as instruments for assessment. In these patientswas carried posterior or combined — posterior and ante-rior stabilization. The posterior fixation was massa late-ralis with this modified technique of Magerl with multi-axial screws. With this technique were inserted 160multiaxial screws and the most common length of theimplants were 16 mm Š108 from 160 or 67,5%¹. Thescrews with length of 14 mm — 30 or 18,75% and 18 mmscrews were implanted 22 or 13,75 % (figure 1 and 2).

Results:

The mean follow up period was 15 months (4–35months). A total of 160 screws were used in 27 patientsplacing into the lateral masses of the subaxial cervicalspine from C3 including C6. Of which 24 screws wereplaced on C3 level, 58 were placed on C4 and C5 levelsand 20 were placed on C6 level (Figure 2). The mostfrequently used screw were 16 mm in length (Figure1). The levels C4 and C5 received a greater percentageof longer screws. No newly developed neurologic defi-cits occurred after surgery. Neither spinal cord injuriesnor spinal nerve root injuries were observed postopera-tively. We seldom encountered excessive haemorrhag-ing during screw placement. None of these 27 patientsexperienced any postoperative ischemic neurologicsymptoms, especially those involving posterior circu-lation such as vertigo, dizziness or vomiting. No verte-

bral artery injury was encountered. Radiography taken at8–12 weeks after operative procedure, when hard cervi-cal collar was taken away, revealed that most patients hadsubstantial bone fusion. The stability was further confir-med by dynamic lateral radiography (flexion/extension).Although it is difficult to ensure complete bone fusion.No instrumentation failure has been observed with thelongest follow-up time 35 months, except one patientwho did develop secondary kyphotic deformity andscrews self-pulled out, which was demonstrated on late-ral radiography 3 months after operation.

DISCUSSION

Lateral mass plating has been the procedure ofchoice in the past decade in posterior cervical fixation(14, 15). Butthere are at least 4 drawbacks of such in-strumentation (4). First, plates are difficult to contour,especially in cases of severe deformity associated withspondylosis or trauma. Second, the fixed hole spacingof the plate significantly limits screw positioning. Itmay make the entry point of lateral mass screws beco-me less ideal. Some levels of the cervical spine cannotbut omit from plating because the plate’s fixed hole do-es not fit for screw placement at that particular level.This limitation is especially obvious when longer con-structs are required. Third, it is difficult to adapt theplate system for fusion up to the occiput or down to thethoracic spine. Fourth, postoperative radiculopathy islikely to occur because of the lag screw effect (16), inwhich there is a risk of iatrogenic foraminal stenosiswhere the plating system has been used. Precise conto-uring can be easily achieved with rod systems than thatof using plate system. Therefore, the use of rod systemwith lateral mass screws has become more popular. So-me encouraging results using rod system have been re-ported (5, 17). Our experience with lateral mass screwsand rod systems is compatible with these recent find-ings. And the usage of polyaxial screw with rods is be-coming the principal device of choice for posterior sta-bilization of cervical spine, especially when upward ordownward extension is required (18).

52 Haritonov Dimitar, Kalevski Svetoslav, Peev Nikolay

Figure 1. Distribution of the cervical levels

and length of implants

Figure 2. Distribution of the cervical levels

and length of implants

MODIFIED SURGICALTECHNIGUES

There are many techniques for placing lateralmass screws, as described by several authors such asMagerl (6), Anderson (3, 18), An (12), and Roy-Camil-le (10). The principal complications caused by malpo-sitioned screws are violation of vertebral arteries andcervical nerve root injury (19). Many authors (19–23)have conducted anatomical studies to clarify the prosand cons of each method of screw placement. In 1995,Pait and al (24) divided the lateral cervical mass (artic-ular pillars of the cervical spine) into quadrants andconcluded that the superior lateral quadrant was the“safe quadrant” for placing screws. In 2002, Merolaand colleagues (22) came to a similar conclusion: thataiming at the superior-lateral corner of the lateral massitself offers the maximum amount of bone for screwpurchase. Xu and his colleagues (19) found in 1999that the potential risk for nerve root violation is lowerfor theAn technique than the Magerl and Anderson tec-hnique. In 2005, Barrey and colleagues (20) found the

Roy-Camille technique is the best option for C3 andC4, whereas the Magerl technique is a safer, althoughmore demanding, procedure for C5 and C6. We try todevelop a simple and uniform method for placing late-ral mass screws from C3 to C7, by proposing a modifi-cation technique that shifted the screw entry point to1.5 mm medial and inferior to the geometry center ofthe lateral mass surface (Figure 3 and 4). The screw tra-jectory, which aims at its superior lateral quadrant, ismodified from theAn, Anderson, and Magerl techniqu-es. Our entry point selection combined with the trajec-tory allows to aim at the “safe quadrant”. This usuallyrequires longer screws because of the longer path in thelateral mass. Thus, the screw length most often used inour series was 16 mm long, compared with the 14-mmscrews used by Sekhon (25) in 2005. One potentialdrawback of this modified technique isthat if the entrypoint is not low enough or if the sagittal trajectory ismade too steep, the overlying surface of the lateralmass could possibly break, thus making it impossibleto place the screws (26–30). Nevertheless, the main-stay of this modification is that the surgeon is able toaccurately estimate the depth and height of the unexpo-sed superior lateral corner in conjunction with a properentry point.

Comparison with other techniquesof lateral mass screw insertion:

This modification techniques of screw placementtechniques consisted of a more angulated trajectory, witha modified entry point. The entrance point we chose wasmore caudally and medially located, thus allowing a lon-ger tract inside lateral mass to maximize the screw pur-chase. The Roy-Camille technique may represent anotherend of the spectrum for the ideal tip position, given that itcomprises a completely different screw trajectory that isnearly perpendicular to the horizon, with a centered entrypoint (Figure 5 and 6). One of the main reasons that weare able to follow such a greatly angulated trajectory isthe development of polyaxial screws. It made possible toplace the screw toward the superior-lateral-ventral cornerof the lateral mass, with ease of construction with rods.

OUR EXPERIENCE WITH MAGERL’S MODIFIED TECHNIQUE FOR STABILIZATION OF SUBAXIAL CERVICAL SPINE 53

Figure 4. Occipitospinodesis

(C3-C4 massa lateralis/occiput)

Figure 3. A 360° cervical fixation

Figure 5. Proper position of implants

— CT axial image

The longer screw purchase with more angulated trajec-tory might account for the low rate of screw pullout in ourseries. The risks of vascular and neuralinjury with thelonger screws could be reduced by placing their tips in the

ideal position, the superior-lateral-ventral corner of thelateral mass (31–36).

CONCLUSION

The results of our study indicate that lateral massscrew fixation is safe and cost-effective for stabilizationof the subaxial cervical spine, including those with skip-ped level fixation. Our modified entrance point andscrew trajectory are believed to be a good alternativecomparable to other reported methods of screw place-ment. More biomechanical studies of such techniqueand longer follow-up time are required to confirm thevalue and satisfactory results of our modified technique.

54 Haritonov Dimitar, Kalevski Svetoslav, Peev Nikolay

Figure 6. Intraoperative image — occiput/massa

lateralis instrumentation

Saètak

NA[E ISKUSTVO SA MAGERL-OVOM MODIFIKOVANOM TEHNIKOM

ZA STABILIZACIJU SUBAKSIJALNE CERVIKALNE KI^ME

Haritonov Dimitar,1


Peev Nikolay1



Cilj: Postoje razli~ite hirur{ke tehnike za plasiranjespolja{njih {rafova kod povreda subaksijalne vratne ki~me— Roy-Camille, Magerl, Anderson i An tehnike. Svaka odnjih ima druga~iju po~etnu ta~ku i putanju impalntacija{rafa. Za svaku tehniku postoji potencijalni rizik za po-vredu vaskularnih i nervnih struktura. U ovom radu izla-èmo na{e iskustvo sa upotrebom modifikovane Ma-grel-ove tehnike za stabilizaciju subaksijalne vratne ki~me.

Metod: Ovom retrospektivnom studijom prikaza-no je klini~ko pra}enje 27 pacijenata operisanih zbogpovrede vratne ki~me kod kojih smo koristili modifi-kovanu Megerl-ovu tehniku. Kod 8 pacijenata prime-njena je i prednja dekompresija i stabilizacija.

Rezultati: Kod ovih pacijenata primenjena je zad-nja ili kombinovana — zadnja i prednja stabilizacija.Zadnja fiksacija je bila massa lateralis sa modifikova-nom Megerl-ovom tehnikom sa multiaksijalnim {rafo-vima. Ovo tehnikom plasirano je 160 multiaksijalnih{rafova i naj~e{}a duìna implanta bila je 108 mm (108od 160 ili 67.5% ).

Zaklju~ak: Na osnovu svetske literature, iskustvai analize klini~kih slu~ajeva, verujemo da je ova modi-fikovana tehnika subaksijalne cervikalne fiksacijeefektivna i mnogo sigurnija.

Klju~ne re~i: Zadnja aksijalna instrumentacija,Magerl-ova tehnika, subasijalna nestabilnost.

REFERENCES

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2. Abumi K, Kaneda K, Shono Y, Fujiya M. One-stage po-sterior decompression and reconstruction of the cervical spineby using pedicle screw fixation systems. J Neurosurg. 1999; 90(1 Suppl): 19–26.

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Correspondence to/Autor za korespondencijuDimitar HaritonovBul. Tzar Osvoboditel N1009000 Varna, BulgariaDepartment of NeurosurgeryUniversity Hospital St. Anna Varnadharitonovªharitonov.eu+359 888313357

OUR EXPERIENCE WITH MAGERL’S MODIFIED TECHNIQUE FOR STABILIZATION OF SUBAXIAL CERVICAL SPINE 55

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CARACTERISTICS OF PNEUMONIA HOSPITALIZATIONS

AT PEDIATRIC CLINIC TUZLA

Hadzic Devleta, Zulic Evlijana

Pediatrics clinic, University Clinical Center of Tuzla, Bosnia and Herzegovina


Abstract: Introduction: Pneumonia is the mostserious inflammatory disease of the lower respiratorysystem caused by various microorganisms. It occurs inall age groups, more often in children aged 5 years andbelow, in children with chronic diseases and impair-ments of the immune status. The aim of this study wasto present the epidemiological, etiological and clinicalcharacteristics of pneumonia in hospitalized children.Patients and methods: We analyzed the epidemiolog-ical, etiological and clinical characteristics of pneumo-nia in 224 children hospitalized at the Pediatric hospi-tal Tuzla during one year period with radiologicallyproven pneumonia. Results: Almost half of childrenwith pneumonia (46.4%) were infants, and 82.1% ofpatients were under five years of age. The boys wereleading in all age groups. A significant number of chil-dren had one or more predisposing risk factors. Clini-cal signs, gas analyses and pulse oximetry well correla-ted with hypoxemic type of respiratory failure. Themost frequently isolated pathogens were Staphylococ-

cus aureus, Klebsiella sp. and Pseudomonas aerugino-

sa. The average length of intensive treatment was 2.8days and the average total length of treatment was 9.5days. Conclusion: Pneumonia hospitalizations of chil-dren at the Pediatric Clinic Tuzla, showed the usual ageand gender distribution. A significant number of chil-dren had underlying chronic diseases. Etiological char-acteristics emphasizing severity of disease and immu-ne status of children. The management of pneumoniain children has to follow general pediatric principles,and special attention should be given to risk categories.

Key words: characteristics, pneumonia hospitali-zation, children, etiology, prevalence.

INTRODUCTION

Pneumonia is one of the most common causes ofchildhood mortality worldwide, especially among tho-se under 5 years of age. Although, mortality is lower in

developed countries, pneumonia in children is still as-sociated with substantial morbidity and remains themost common indication for hospitalization outsidethe newborn period. Also, it is one of the most costlypediatric diseases (1).

Classification of pneumonia in children is not uni-que. Today generally accepted classification is com-munity-acquired pneumonia, nosocomial pneumoniaand pneumonia in patients with impaired immunity (2).The spectrum of clinical presentations is wide: frommild to life-threatening cases. Risk of severe infectionsis particularly big in infants and preschool children.The severe pneumonia is defined with the presence offever, respiratory distress and/or dehydration (3). Sim-ple pneumonia may evolve into complicated pneumo-nia, characterized by the development of parapneumo-nic effusions, empyema, pyopneumothorax, or necroti-zing pneumonia. There are differences between re-cently published guidelines in terms of the clinical cri-teria of severity of pneumonia, although all of the ex-perts agreed that hypoxemia is the most important pa-rameter for decision making process (4). On the basisof clinical signs, laboratory and radiographic examina-tions, it is very difficult to distinguish between bacte-rial and viral pneumonia. On the basis of epidemiologi-cal, clinical, radiological, and laboratory findings weare able to identify pathogens and implement optimaltreatment.

The incidence of pneumonia in general populationis determined by the climate, epidemic trends, age, im-munisation status, and immune competence (5). In de-veloped countries, approximately 10–15 children per1000 are diagnosed with community-acquired pneu-monia and one-to-four per 1000 are admitted to hospi-tal yearly (6). Hospital admissions in resource-rich co-untries for pneumonia in children increased during the1990’s and early 2000’s (6). As a result, pediatric pne-umonia is often the focus of epidemiological studies

UDK: 616.24-002-053.2(497.6)

2015; 10(1): 57–63 ID: 214202892


and research outcomes and serves as an ideal target forquality benchmarking and improvement efforts (3).

The aim of this study was to show epidemiolo-gic, etiologic and clinical characteristics of pneumoniain hospitalized children at the Pediatric hospital Tuzla.

METHODS

Medical records of 224 children, treated for pneu-monia at the Paediatric hospital in Tuzla during theone-year period (from January 2014 to the end of De-cember 2014), were retrospectively analysed. We ana-lyzed the medical history, clinical and laboratory find-ings, therapeutic procedures, length of intensive care,length of total treatments and their outcomes. From themedical history data age, gender, and general pediatricfindings were analyzed. Also, leading clinical signsand symptoms were analyzed which included: localauscultatory findings, vital parameters such as pulserate, respiratory rate, body temperature, and blood ox-ygen saturation. Blood oxygen saturation was measu-red by pulse oximetry. Laboratory parameters whichwere analyzed included: erythrocytes sedimentationrate full blood count, hematocrit, C-reactive protein,and gas analysis. Radiographic lung findings and mic-robiological analyzes of the blood, throat and nasalswabs were done. Further, therapeutic procedures suchas the application and the length of oxygen therapy,drug ain inhalation therapy (bronchodilators), antibio-tic therapy, administration of systemic corticosteroids,the need for other supportive care, bronchoscopy, andsurgical drainage,.The length of treatment and outco-me of each treatment were monitored and included inthe analyses. For statistical analysis results appliedstandard methods of descriptive statistics, used statisti-cal program Arcus QuicStat and Systat software.

RESULTS

In 2014, about 332 children (208 boys (62.7%) and124 girls (37.3%) respectively, were hospitalized andtreated for the lower respiratory tract infections at thePediatric hospital Tuzla. About 224 (67.5%) childrenhad radiologicaly proven pneumonia, and about 31(9.3%) of children had pulmonary atelectasis as a com-plication of pneumonia. The boys were numerically do-minated in all age groups. Almost half of children withpneumonia (46.4%) were infants, and 82.1% of childrenwere under 5 years of age. Pneumonia was bilateral in102 children (45.5%), right-sided in 100 (44.6%) andleft- sided in 22 children (9.8%) (Figure 1).

A large number of patients had one or more predi-sposing factors (Table 1).

Pneumonia in hospitalized children was clinicallymanifested with signs of dyspnea, tachypnea, tachycar-

dia and hypoxemia leading to imminent respiratory fail-ure. The vital parameters of children with pneumonia inthis study are presented in the following table (Table 2).

Table 2. Vital signs in patients with pneumonia

The vital parameters (heart rate and respiratory ra-te) in children with pneumonia were higher in relationto the normal values for their age. Table 3 shows theparameters of acid-base status and gas analysis in chil-dren with pneumonia.

Clinical signs, gas analyses and oxygen satura-tion, correlated well with hypoxemic type of respira-tory failure.

Basic laboratory tests results such as full bloodcount, erythrocyte sedimentation rate, and C-reactiveprotein (CRP) values are presented in Table 4.

58 Hadzic Devleta, Zulic Evlijana

Figure 1. Age and gender distribution of children

treated for pneumonia

Table 1. The presence of risk factors for pneumonia

in treated children

Risk factors n (%)

Immunodeficiency 16 (7.1)

Anemia 100 (44.6)

Congenital heart defects 24 (10.7)

Neuromuscular Disease 5 (2.2)

Neurodevelopmental disorders 28 (12.5)

Tracheostomy 3 (1.3)

Cystic fibrosis 2 (0.9)

Age (years) 0–1 1–3 3–7 7–14

Heart rate

(per minute)

minimum 126 120 120 100

maximum 160 150 136 144

mean 146.7 136 124.3 120.6

normal 110–160 100–140 95–120 60–110

Respiratory

rate

(per minute)

minimum 26 42 24 10

maximum 65 60 52 48

mean 49.3 47.6 36 29.4

normal 30–40 25–30 20–25 15–20

Table 4. Biochemical parameters

in patients with pneumonia

Out of 224 children with radiologically confirmedpneumonia, about 100 children had CRP value above 10mg/l on admission. Leukocytosis above 15 x 109 / l wasfound in 76children. About 67 children were febrile atthe hospital. Admission analysis of microbiological fin-dings showed positive throat swab cultures in 47 chil-dren, in 41 children positive nasal swabs cultures, andeight children ain had positive blood cultures (Figure 2).

The most frequently isolated pathogens were Staph-

ylococcus aureus, Klebsiella sp. and Pseudomonas aeru-

ginosa.Among other therapeutic procedures intensive su-

pervision, monitoring of vital parameters and oxygentherapy were required. Parenteral antibiotics were ad-ministered to 207 children (92.5%). Bronchodilatorsand intensive respiratory physiotherapy were appliedin almost all children. Cardiotonics were required andadministered to 61 children (27.4%). The largest ofchildren (44) who had signs of congestive heart failureand required cardiotonics and diuretics were infants.The medical treatment of pneumonia in hospitalizedchildren is given in Table 5 and it shows the various de-grees of severity of the disease in the treated children.

Table 5. Therapeutical treatment in patients

hospitalized for pneumonia

The average length of intensive treatment was 2.8days, and the average total length of hospital treatmentwas 9.5 days. All children treated for pneumonia had asuccessful outcome.

DISCUSSION

Pneumonia is the largest single cause of death inchildren aged < 5-years (1). Global estimates of the an-nual incidence of pneumonia in children under 5 yearsof age, range from 120 to 160 million episodes peryear, with more than 99% occurring in resource-limi-ted countries (1, 2, 3). In high-income countries it isone of the most common reasons for clinic attendanceand hospitalization in this age group (5). Furthermore,pneumonia in children increases the risk of developing

CARACTERISTICS OF PNEUMONIA HOSPITALIZATIONS AT PEDIATRIC CLINIC TUZLA 59

Table 3. Gases analysis in patients with pneumonia

ParametarMean

± SD*Minimun Maksimum Median

pH 7.35 ± 0,07 7.08 7.47 7.35

pCO2 (kPa) 4.99 ± 0.96 2.64 7.49 4.9

pO2 (kPa) 6.62 ± 1.27 3.59 8.6 6.85

Base excess –2.4 ± 4 –14 2.5 –1.4

Bicarbonates

(mmol/l)21 ± 3.6 10 28 21.25

Oxygen

saturation (%)78 ± 12 45.2 90 80

* mean ± standard deviation

ParametarMean

± SD*Minimun Maksimum Median

Erythrocyte

sedimentat.33 ± 27 5 110 30

C-reactive

prot. (mg/L)37 ± 56 0.1 249 17.5

Hemoglobin

(g/L)116 ± 16 75 148 119

Erythrocytes

(x1012/L)4.23 ± 0.52 3.2 5.4 4.2

Leukocytes

(x109/L)14.4 ± 5.4 5.2 27 13.7

Hematocrit

(L/L)0.34 ± 0.04 0.27 0.40.34

* mean ± standard deviation

Figure 2. Pathogens isolated in patients with pneumonia

Treatment N (%)

Monitoring 104 (46.4)

Oxygen Therapy 128 (57.1)

Rehydration 185 (82.6)

Bronchodilators 210 (93.7)

Respiratory physiotherapy 198 (88.4)

Antibiotics 207 (92.5)

Intravenous immunoglobulin 4 (1.8)

Parenteral nutrition 6 (2.7)

Blood products 12 (5.3)

Cardiotonics 61 (27.4)

Vasopressors 8 (3.5)

Mechanical ventilation 3 (1.3)

Bronchoscopy 5 (2.2)

Surgical drainage of the pleural space 6 (2.7)

Surgical lung decortication 2 (0.9)

chronic pulmonary disorders in later adult life (6). Inour study, during one-year period about 224 childrenwere hospitalized for pneumonia. Almost half of themwere infants, and more than 80% of children were un-der five years of age. This age distribution correspondto the usual distribution of lower respiratory tract in-fections in children and distribution of pneumonia inthe general (5). Although this study analyzed only pne-umonia in children who required hospitalization, ourlocal results are consistent with the epidemiologicalstudies from different geographic areas (4, 5, 6). In ad-dition to age, gender is also reported as a risk factor fordistribution of respiratory infections and pneumonia.According to current published data boys aged under 5years more often have pneumonia than girls, whereas atschool age no gender differences in the occurrence ofpneumonia. Unexpected, our study showed a high inci-dence of pneumonia in boys at all ages (2–6). Possiblethat this declared distribution primarily refers to previo-usly healthy children, whereas in our study, were domi-nated children with one or more underlying chronic dis-eases. Few of them had recurrent pneumonia.

Recurrent pneumonia as a diagnostic and therapeu-tic problem, conventionally is associated with structuraldamage of the lower respiratory tract, or to immunodefi-ciency, that is linked with a number of chronic diseases(7, 8). Treatment of children with chronic diseases pos-ing new challenges for health services. The need for he-alth care services for these children is up to 20 times hig-her than for healthy children, depending on the underly-ing disease (9). Children with underlying chronic disea-ses require more frequently hospital admissions andlonger treatments for their lower tract respiratory infec-tions, and are more inclined to respiratory failure (10).Studies showed that 40–70% of children treated in in-tensive care units come from the group of children withunderlying chronic diseases (9, 10). A number of chro-nic diseases favor the occurrence of recurrent or persis-tent pneumonia such as: congenital heart defects, cysticfibrosis, neuromuscular diseases, immunodeficiency,anatomic variations lungs, etc. Among children withpneumonia and underlying cause of disease, childrenwith neurodevelopmental disorders are the most domi-nant ones (10). Chronic diseases have been identified asrisk factors in our patients too. Besides neurodevelop-mental disorders, the most common was anemia. Al-most half of children with pneumonia were anemic.Anemia is a significant etiological factor which can cau-se difficulties in breathing, acute respiratory failure, andrecurrent respiratory illnesses in children. Anemia has aproved influence on children’s immune system and in-creases a predisposition to infection (11).

Pneumonia, especially when recurrent, is linkedto future chronic lung disease, which highlights impor-

tance of timely and correct diagnosis. (6). Thus, inter-ventions that reduce pneumonia and acute lower respi-ratory infections have both short and long-term bene-fits. Clinicians have traditionally used radiography asthe gold standard in the diagnosis of pneumonia. Thereis disagreement over whether a chest X-ray should bean index test. Current guidelines on childhood pneu-monia do not advocate mandatory a chest X-ray outsi-de of hospital settings. Furthermore, their interpreta-tion is subjective often resulting in additional diagnos-tic variability. However our local current algorithmsstill respect radiography as the gold standard of diag-nosis and monitoring treatment of pneumonia. For acorrect diagnosis sometimes there is a needfor thechest computed tomography scans (4). For our patientsradiographically confirmed pneumonia was the selec-tion criteria, but the course of treatment in some com-plicated cases required a CT scan in addition.

Early recognition and appropriate treatment ofimminent respiratory failure is crucial for the reduc-tion of risk for long-term complications (12). Monito-ring of vital parameters of endangered patient is inte-gral part of intensive supervision and treatment. De-pending on the equipment modern monitoring mayinclude monitoring a range of vital parameters. Themost important are: pulse rate, respiratory rate, bloodpressure, body temperature. Pulse oximetry is simpleand non-invasive assessment methods therefore in thecurrent literature means as the fifth vital sign, practi-cally unavoidable in rapid assessment of respiratoryfunction. Pulse oximetry observed isolated, can beunreliable. The basic test that can determine level ofpatients respiratory inadequacy are gas analyses andthey are a mandatory part of the monitoring for pati-ents with threatening respiratory failure (13). Generalcondition and recognized signs of dyspnea and hypo-xia are determinants of selection children who requirehospitalization. The highest morbidity and mortalityrates of pneumonia economic and health underdevel-oped areas where diagnostic capabilities are limited.The predictive value of specific clinical symptomsand signs, has already been investigated, especially inorder to identify hypoxemia in children. In all thesestudies, tachypnea and signs of dyspnea significantlycorrelated with hypoxemia in children (14, 15). The-refore, thelain current World Health Organization(WHO) recommendations for the diagnosis and treat-ment of pneumonia in children is generally based onclinical parameters (16).

Community healthcare workers often diagnosepneumonia based on medical history and physical exa-mination (respiratory rate, signs of dyspnea, ausculta-tory findings). According to the WHO, pneumonia canbe recognized by cough or breathing difficulties, and


age-adjusted tachypnea are sufficient for diagnosingmild-to-moderate pneumonia (16). In our study clinicalfindings at admission were characterized by tachycar-dia, tachypnea and low oxygen saturation. These are un-ambiguous clinical signs of dyspnea, which correlatewell with hypoxemia assessed by pulse oximetry. Gasanalysis have confirmed moderate hypoxemia so thatclinical parameters, pulse oximetry and gas analysis we-re matched according to the type of hypoxemic respira-tory failure. Previously studies suggest that gas analysis,especially confirmed hypoxemia, correlates well withradiologically verified pneumonia in children (14).

Current studies determining the etiology of pneu-monia vary substantially with respect to factors that in-fluence the diagnosis and ascribed microbial etiology.These include case definitions, use of and interpreta-tion of chest x-rays, peripheral blood white cell counts,and inflammatory markers, depth of investigations, fa-cility type, and patient characteristics. Consequently,studies describe different frequency and types of pat-hogens associated with pneumonia. Recent studies ba-sed on modern microbiological diagnostics stated thatin more than 25% of children with pneumonia causati-ve agent does not identify; in 25% proved by the viraletiology in 25% of bacterial and 25% of patients have amixed infection (17). Major viral causes of pneumoniain infants and children include respiratory syncytial vi-rus, influenza, adenoviruses, parainfluenza and humanmetapneumovirus. While viruses are the predominantcause of pneumonia, especially in the young children,respiratory bacterial pathogens are most often implica-ted in childhood deaths from pneumonia (18). The pre-dominant bacterial pathogen is Streptococcus pneumo-

niae, which dominates across all age groups, but otherimportant pathogens include Haemophilus influenzae,

Staphylococcus aureus and, in older children, Myco-

plasma pneumoniae (4). For children with impairedimmune systems pneumonia is usually caused by viru-ses, bacteria and fungi (19).

Non-specific markers of inflammation (erythro-cyte sedimentation rate, C-reactive protein and leuko-cytes) are not very important in distinguishing childrenwith viral and bacterial pneumonia. However, the veryhigh value of individual inflammatory markers are ra-rely seen in viral infections. C-reactive protein greaterthan 10 mg/l is significant for bacterial pneumonia (20,21, 22). Etiological studies of pneumonia vary depend-ing on the age, season, climate, epidemic trends, andstatus of immune system in children. Our results aredifferent than most of published studies, which gener-ally report a typical pathogens, separately for individ-ual categories: community-acquired pneumonia; hos-pital or pneumonia in immunodeficient patients. In ourstudy microbiological findings indirectly talking about

immune status of patients with regard to agents more ap-propriate for the progressive complicated pneumoniaand pneumonia in immunodeficient patients. The focusis on the antimicrobial therapy when appropriate, cor-recting hypoxemia, fluid and nutritional management,treatment of co-morbidities, and close observation fordeveloping complications. National treatment guideli-nes exist, but there is wide variability in managing pneu-monia, even in resource-rich countries. Preventing pne-umonia in children is an essential component of a strat-egy to reduce child mortality. Important factors identi-fied for increasing the risk of pneumonia include over-crowding, access to clean water, malnutrition, anemia,young maternal age, low birth weight, and exposure totobacco smoke and other environmental pollutants. Pro-tect children from pneumonia includes promoting ex-clusive breastfeeding and adequate complementary fee-ding. Vaccines, such as pertussis, measles, and more re-cently haemophilus influenzae and pneumococcal, havereduced the worldwide incidence of pneumonia. Howe-ver, the benefit from population vaccination programs isnot always uniform, which although having signifi-cantly reduced pneumonia rates in target and some olderage groups. There seems to be a viral etiological compo-nent in at least half of all pneumonia that require hospi-talization. Respiratory sincytial virus is a dominant viralcause, but the role of other viruses should not be neglec-ted. Significant role could have started program of pre-vention respiratory syncytial virus infection for the mostvulnerable child categories.

CONCLUSION

The aim of this study was to show epidemiologic,etiologic and clinical characteristics of pneumonia inhospitalized children at the Pediatric hospital Tuzla.

The incidence of pneumonia was significant, es-pecially in infants. Almost half of children with pneu-monia were infants, and three quarters of treated chil-dren were under five years of age. The boys were lead-ing in all age groups. A significant number of childrenhad one or more predisposing risk factors. Childrenwith underlying chronic diseases required more frequ-ently hospital admissions and longer treatments forpneumonia, and are more inclined to respiratory failu-re. Among them, children with neurodevelopmentaldisorders were the most dominant. Besides neurodeve-lopmental disorders, almost half of children with pneu-monia were anemic. Clinical signs, gas analyses and oxy-gen saturation correlated well with the radiological find-ings, also well correlated with hypoxemic type of respira-tory failure. The most frequently isolated pathogens wereStaphylococcus aureus, Klebsiella sp. and Pseudomonas

aeruginosa, which are different than most of published


studies with generally reported a typical pathogens. Thatemphasizing the severity of disease and immune status ofchildren. The management of pneumonia in children hasto follow general pediatric principles. Special attentionshould be given to risk categories.

Abbreviations

pCO2 — partial pressure of carbon dioxidepO2 — partial pressure of oxygenWHO — World Health Organization


Saètak

KARAKTERISTIKE PNEUMONIJA KOD HOSPITALIZOVANIH

NA PEDIJATRIJSKOJ KLINICI TUZLA

Hadì} Devleta, Zuli} Evlijana

Klinika za dje~ije bolesti, Univerzitetski klini~ki centar Tuzla, Tuzla, Bosna i Hercegovina

Uvod: Pneumonija je najteà zapaljenska bolestdonjih disajnih puteva, uzrokovana brojnim i razli~i-tim mikroorganizmima. Pojavljuje se u svim starosnimgrupama, ~e{}e kod dece uzrasta do 5 godina, te kodosoba sa hroni~nim bolestima i o{te}enjima imunolo-{kog statusa.

Cilj rada: je bio da se prikaù epidemiolo{ke, eti-olo{ke i klini~ke karakteristike pneumonije kod hospi-talizovane dece.

Pacijenti i metode: Studijom je obuhva}eno 224dece hospitalizovanih na Klinici za de~ije bolesti Tu-zla, u jednogodi{njem periodu, sa radiolo{ki dokaza-nom pneumonijom.

Rezultati: Skoro polovina dece sa pneumonijom(46,4%) bila su odoj~ad, a 82,1 % pacijenata bili sumla|i od 5 godina. De~aci su prednja~ili u svim staro-snim grupama. Zna~ajan broj pacijenata imao je jedanili vi{e predisponiraju}ih faktora. Klini~ki znaci, nalaz

gasnih analiza i pulsna oksimetrija, bili su u korelaciji ipo tipu hipoksemijske respiratorne insuficijencije.Naj~e{}e izolovani uzro~nici bili su Staphylococcus

aureus, Klebsiella sp. i Pseudomonas aeruginosa. Pro-se~na duìna intenzivnog tretmana bila je 2,8 dana, aprose~na duìna ukupnog tretmana 9,5 dana.

Zaklju~ak: Karakteristike pneumonije kod ho-spitalizovane dece na Klinici za de~ije bolesti Tuzlapotvrdile su uobi~ajenu dobnu i delimi~no polnu ras-podelu. Zna~ajan broj dece imao jednu ili vi{e hro-ni~nih oboljenja u podlozi. Etiolo{ke karakteristike iizolovani uzro~nici vi{e su nagla{avali ozbiljnost bole-sti i imunolo{kog statusa le~ene dece. Tretman pneu-monije kod dece mora slediti op{ta pedijatrijska na~e-la, a posebnu pa`nju treba posvetiti rizi~nim kategori-jama.

Klju~ne re~i: karakteristike pneumonija, hospita-lizacija, deca, etiologija, u~estalost.

REFERENCES

1. Chang AB, Ooi MH, Perera D, Grimwood K. Improvingthe Diagnosis, Management, and Outcomes of Children withPneumonia: Where are the Gaps? Front Pediatr. 2013; 1:29.

2. Walker CL, Rudan I, Liu L, et al. Global burden ofchildhood pneumonia and diarrhoea. Lancet. 2013; 381(9875):1405–16.

3. Graham SM. Child pneumonia: current status, futureprospects. Int J Tuberc Lung Dis. 2010; 14(11): 1357–61.

4. Lynch T, Bialy L, Kellner JD, et al. A Systematic Revi-ew on the Diagnosis of Pediatric Bacterial Pneumonia: WhenGold Is Bronze. PLoS One. 2010; 5(8): e11989.

5. Dennehy PH. Community-acquired pneumonia in chil-dren. Med Health R I. 2010; 93(7): 211–5.

6. Lee GE, Lorch SA, Sheffler-Collins S, Kronman MP,Shah SS. National hospitalization trends for pediatric pneumo-nia and associated complications. Pediatrics.2010; 126(2): 204–13.

7. Sara~evi} E. Rekurentne pneumonije u detinjstvu, dife-rencijalna dijagnoza. U: Aberle N , urednik.1. izd. Sekundarnaprevencija u pedijatriji. Slavonski Brod: Hrvatsko pedijatrijskodr{tvo; 2007. str. 70–3.

8. Don M, Valent F, Canciani M, Korppi M. Prediction ofdelayed recovery from pediatric community-acquired pneumo-nia. Ital J Pediatr. 2010; 36(1): 51–57.

9. Me{trovi} J, Kardum G, Poli} B, et al. The influence ofchronic health conditions on susceptibility to severe acute illnesof children treated in PICU. Eur J Pediatr. 2006; 165(8): 526–9.

10. Hadì} D, Mladina N, Pra{o M, Brki} S, ôli} B, Ko-nji} E. Te{ko}e u disanju u djece sa hroni~nim oboljenjima. De-fektologija. 2008; 14(1): 78–83.

11. Mladina N, Hadì} D, Latifagi} A, Konji} E, Bazar-dànovi} M, Mladina @. Anemije i infekcije donjih di{nih pute-va u djece. Defektologija. 2008; 14(1): 84–93.

12. Carrillo AA, Martinez GA, Salvat GF. Recognition ofthe child at risk of cardiopulmonary arrest. An Pediatr (Barc).2006; 65(2): 147–53.

13. Dobyns E. Assesment and monitoring of respiratoryfunction. In: Fuhrman BP, Zimmerman J, editors. Pediatric criti-cal care. Philadelphia: Mosby Elsevier; 2006. p. 530–5.

14. Lodha R, Bhadauria PS, Kuttikat AV, et al. Can Clini-cal Symptoms or Signs Accurately Predict Hypoxemia in Chil-dran with Acute Lower Respiratory Tract Infections? Indian Pe-diatr. 2004; 41(2): 129–35.

Correspondence to /Autor za korespondencijuDevleta Had`i}Univerzitetski klini~ki centar Tuzla,Klinika za dje~ije bolestiTrnovac bb, 75000 TuzlaBosna i Hercegovina00 387 35 303 733e-mail: devletahadzicªyahoo.com


15. Rahnamai MS, Geilen RP, Singhi S, Van den Akker M,Chavannes NH. Which clinical signs and symptoms predict hypoxe-mia in acute childhood asthma. Indian J Pediatr. 2006; 73(9): 771–5.

16. Rudan I, Boschi-Pinto C, Biloglav Z, Mulholland K,Campbell H. Epidemiology and etiology of childhood pneumo-nia. Bull World Health Organ. 2008; 86(5): 408–16.

17. Gilani Z, Kwong YD, Levine OS, et al. A literature re-view and survey of childhood pneumonia etiology studies:2000-2010. Clin Infect Dis. 2012; 54 (suppl 2): S102–8.

18. Chang AB, Clark R, Acworth JP, Petsky HL, Sloots TP.The impact of viral respiratory infection on the severity and re-covery from an asthma exacerbation. Pediatr Infect Dis J. 2009;28(4): 290–4.

19. Esposito S, Marchese A, Tozzi AE, et al. Bacteremic pne-umococcal community-acquired pneumonia in children less than 5years of age in Italy. Pediatr Infect Dis J. 2012; 31(7): 705–10.

20. Tumgor G, Celik U, Alabaz D, et al. Aetiologicalagenst, interleukin-6, interleukin-8 and CRP concentrations inchildren with communitiy-acquired pneumonia. Ann Trop Pedi-atr 2006; 26(4): 285–91.

21. Almirall J, Bolibar I, Toran P, et al. Contribution of C-re-active protein to the diagnosis and assesment of severity of com-munitiy-acquired pneumonia. Chest. 2004; 125(4): 1335–42.

22. Lagerstrom F, Engfeldt P, Holmberg H. C-reactive pro-tein in diagnosis of comunity-acquired pneumonia in patient inprimary care. Scand J Infect Dis. 2006; 38(11–12): 964–9.

TANDEM COMPRESSION OF MEDULLA SPINALIS

AND CAUDA EQUINA

Zhelyazkov Christo,1

Davarski Atanas,1

Kitova Tanya,2

Kehayov Ivo,1

Kitov Borislav1




Abstract: Objective: To analyze and present ca-ses of tandem compression of medulla spinalis and ca-uda equina.

Material and Methods: The subjects of observa-tion were four patients with simultaneous compressionof medulla spinalis and cauda equina, admitted to theNeurosurgery Clinic of the St George University Hos-pital, Plovdiv, Bulgaria during the period March 2012— March 2014. The average age of the patients was60.5 years (47–72).

In one case, left-sided paramedian herniated discswere found at levels L1–2 and L4–5 combined with a con-comitant stenosis, in another case — right-sided para-median herniated discs on the level of Th12 — L1 and adegenerative stenosis at level of L3–4, in the third case— pronounced degenerative compression at level Th7–8

and a central stenosis at level of L4–5, and in the last ca-se — degenerative stenosis at level L3–5 and spinal me-ningioma at level Th9–10.

Results: The clinical signs of the simultaneouscompression of the spinal cord and cauda equina havebeen examined. These signs may mislead the physicianin the diagnosis of the spinal lesion, thus, resulting ininappropriate surgical strategy.

Conclusion: The involvement of the spinal cordmust be clinically confirmed to rule out lesions in thethoracic region. When the lumbar imaging examinati-ons are inconclusive or cannot explain the clinicalsymptoms of a certain patient, it is advisable to per-form a magnetic resonance imaging of the entire spine.

Key words: tandem compression, spinal tumor,thoracic stenosis, lumbar stenosis.

INTRODUCTION

The term ‘tandemspinal stenosis’ was first intro-duced by P. Teng and C. Papatheodorou in 1964 in anattempt to describe the simultaneous compression in

the cervical and lumbar regions (1). Subsequently, sev-eral publications have been published in the speciali-zed literature that discuss the simultaneous compres-sion in the thoracic, thoraco-lumbar and lumbar regi-ons (2, 3), resulting from degenerative stenosis (4),disc herniation (3), arachnoid cysts (5) or spinal tumors(6). In some cases, surgeons first operate on the lumbarlesion due to its apparent clinical and imaging manifes-tation. Nevertheless, neurological complications aresometimes possible resulting from the superiorly loca-ted lesion (3).

Objective

Analyzing and presenting cases of tandem com-pression of medulla spinalis and cauda equina.


We present 4 cases (3 male and 1 female) that we-re treated in the Clinic of Neurosurgery at St GeorgeUniversity Hospital, Plovdiv, Bulgaria between March2012 and March 2014. The mean age of the patientswas 60.5 years (47–72). All cases have long-lastingmedical history of back pain irradiating unilaterally orbilaterally to the legs which was subsequently overlap-ped by stiffness and weakness in the lower extremities(Table 1).

In one of our cases, the clinical presentation wasdominated solely by lower back pain accompanied byradicular sensory and motor deficit. All other three ca-ses presented with combined symptoms of central andperipheral system damage (Table 2).

CASE DESCRIPTIONS

All four cases are systematically presented on Ta-bles 1, 2 and 3.

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66 Zhelyazkov Christo, Davarski Atanas, Kitova Tanya, Kehayov Ivo, Kitov Borislav

Table 1. Affected spinal segments and initial symptoms

Patient/Gender/Age Reported initial symptomsLevel of compromise

of caudaequinaLevel of compromise

of medullaspinalis

1. Female, 72 Back pain, left leg pain andnumbness

Stenosis L4–L5

(HIJ + HYL + DH)StenosisL1–L2

(HIJ + HVL + DH)

2. Male, 58 Pain in the thoraco-lumbar regionand leg stiffness

Stenosis L3–L4

(HIJ + HVL + DH)Disc herniationat Th12–L1 level

3. Female, 65 Pain in the back and legs.Numbness across L5 and S1

dermatomes bilaterally

Stenosis L4–L5(HIJ + HYL + DH)

Stenosis Th7–Th8(HIJ + HYL + DH)

4. Female, 47 Pain in the back and legs.Progressive weakness in the legs

Stenosis L3–L4 and L4–L5

(HIJ + DH)Meningiomaat Th9–10 level

HIJ — hypertrophy of the intervertebral joint; HYL — hypertrophy of the yellow ligament; HVL — hypertrophy of the vertebrallamina; DH — disc herniation;

Table 2. Neurological status of the patients at hospital admission

Patient/Gender/Age Neurological status

1. Female, 72 Lumbar vertebral syndrome: Possitive Lassegue sign at 30°on the left. Pain and hypest-hesiaacross L2–S1 drematomes on the left. Loss of knee-jerk and ankle-jerk reflexes onthe left. Fibular nerve plegiaand tibialnerve paresis on the right side (Grade Con theFrankel Scale). Hypotrophy of the muscles of the left thigh and calf.

2. Male, 58 Thoraco-lumbar vertebral syndrome. Pain and hypesthesia across L5 and S1 dermato-mes bilaterally. Increased knee-jerk and ankle-jerk reflexes. Positive Babinski sign bi-laterally, latent inferior paraparesis (Grade Don the Frankel Scale).

3. Female, 65 Thoraco-lumbar vertebral syndrome. Pain and hypesthesia across L5 and S1 dermato-mes bilaterally. Inferior paraplegia (Grade Aon the Frankel Scale). Positive Babinskisign bilaterally. Conductive hypesthesia distally from Th9 dermatome. Bowel andbladder retention.

4. Female, 47 Lumbar vertebral syndrome: Pain and hypesthesia across L5 and S1dermatomes on theleft. Inferior spastic paraparesis, more severe on the left (Grade Con the Frankel Scale).Increased knee-jerk but diminished ankle-jerk reflexes. Positive Babinski sign bilater-ally Conductive hypesthesia distally from Th12 dermatome.

Table 3. Patients’ neurological outcome

Patient/Gender/Age Neurological outcome

1. Female, 72 Substantial relieffrom the pain and vertebral syndromes. Mild reduction of the sensorydeficit. Reduction of the right-sided fibular palsy and tibial paresis.

2. Male, 58 Substantial relief from the pain and vertebral syndromes. No motor and sensory deficitof the lower extremities (Grade Don the Frankel) Persistent hypesthesia across L5 andS1 dermatomes.

3. Female, 65 Postoperative recovery was satisfactory with alleviation of the vertebral and radicularsyndromes together with reduction of the inferior paraplegia to Grade Caccording toFrankel Scale. Bowel and bladder disturbances were persistent.

4. Female, 47 The neurological examination at 24th

postoperative month revealed substantially im-proved neurological function to Grade D on the Frankel Scale; substantial relief of thepain syndrome; persistent hypesthesia across the left S1 dermatome, absent left an-kle-jerk reflex and mild difficulty in the plantar flexion of the toe resulting from the pe-ripheral damage due to the lumbar pathology. The patient is able to perform her previo-us duties. The postoperative MRI of the thoraco-lumbar spine showed no tumor reoc-currence and adequate decompression of the lumbar spinal stenosis.

Case 3: Sixty-five year old female who sufferedfrom long-lasting back pain that, occasionally, irradia-ted to the gluteal region and the antero-lateral surfaceofboth thighs accompanied by numbness.One day prior tohospitalization, upon physical exertion she felt acute in-tensive pain in the thoraco-lumbar region, followed bynumbness, stiffness and weakness of the legs that gotcompletely paralyzed within hours. The lumbo-dorsalCT-assisted myelography demonstrated degenerativecompression at Th7–8 level with laminar, facet and yel-low ligament hypertrophy accompanied by severe cen-tral degenerative stenosis at L4–5 causing complete lowerstop of the contrast agent (Figure 1 and 2).

One-stage surgical decompression was performedat Th7–8 followed by L4–5 level. Degenerative stenosiswith laminar, facet and yellow ligament hypertrophywas found at both levels.

DISCUSSION AND CONCLUSIONS

According to the published data, the variety of clini-cal symptoms typical of the tandem compression of thespinal cord and cauda equin can lead to incomplete diag-nosis (2, 3, 7). In these cases, the detection of the thoraciccompression can be omitted due to different factors:

1. The hypereflexia and leg spasticity caused by themyelopathy can be overlapped by the symptoms result-ing from the compression of the cauda equina and thenerve roots (3, 7). All patients in our series demonstrateexcitatory and depressed sensory redicular symptoms.Two of the patients showed motor deficits and absent ten-don reflexes of the lower extremities, and three of thempresented with more or less obvious signs of myelopathy.

2. Patients with compression of the epiconus and co-nus medullaris (from Th10 to L2) resemble the clinical pre-sentation of lumbar radiculopathy (8, 9). Toribatake et al.published a series of 15 patients with similar lesion locali-zations. All patients presented with unilateral or bilateralmuscle atrophy and sensory deficit, in 87% — absence oftendon reflexes, in 67% — bowel and bladder disturban-ces and in only 20% — pathological reflexes (9). Thecompression at L1–L2 level typically presents with pain inthe gluteal region and the antero-lateral surface of thethighs as well as positive femoral nerve stretch test, espe-cially, when LasPgue sign is negative (9). Similar clinicalpresentation was observed in our patient N°1.

3. Primary degenerative stenosis of the thoracicspine is relatively rare. Older patients often harborasymptomatic cervical and/or thoracic degenerativestenosis that are not amenable to surgical intervention(1, 9). This is why physicians are focused on the clini-cally manifested lumbar pathology and, occasionally,omit the more superior compression (10).

All cases with clinically manifested lumbar spinalstenosis must undergo thorough neurological examinati-on. If any minor myelopathic signs are present, it is man-datory to perform MRI of the entire spine to rule out com-pression of the spinal cord that can eventually compromi-se the treatment strategy and result in poor outcomes.

The timing and the surgical strategy in cases withtandem compression of the spinal cord and cauda equi-na that lead to neurological deficits in the lower extre-mities is a matter of debate. Some authors advocate ini-tial surgery of the spinal cord compression, especiallyin urgent cases that are not suitable for one-staged pro-cedure. In our series, we performed one-staged proce-dures in all cases with tandem thoracic and lumbar de-generative compression. We first addressed the thora-cic lesion. We operated on the patient with combinedthoracic meningioma and degenerative lumbar spinalstenosis at two separate stages as we first removed thethoracic compression.

Abbreviations:

HIJ — hypertrophy of the intervertebral joint;HYL — hypertrophy of the yellow ligament;HVL — hypertrophy of the vertebral lamina;DH — disc herniation

TANDEM COMPRESSION OF MEDULLA SPINALIS AND CAUDA EQUINA 67

Figure 1. CT-assisted myelography: (A) axial view

at L4–5 level; (B) sagittal reconstruction

— degenerative stenosis at L4–5 level

Figure 2. CT-assisted myelography: (A) axial view

at Th7–8 level; (B) sagittal reconstruction

— degenerative stenosis at Th7–8 level

REFERENCES

1. Teng P, Papatheodorou C. Combined cervical andlum-bar spondylosis. Arch Neurol.1964; 10: 298–307.

2. Hioki A, Miyamoto K, Hosoe H, Fukuta S, Shimizu K.Two-stage decompression for combined epiconus and caudaequina syndrome due to multilevel spinal canal stenosis of thethoracolumbar spine: a case report. Arch Orthop Trauma Surg.2008; 128(9): 955–8.

3. Takeuchi A, Miyamoto K, Hosoe H, Shimizu K. Thora-cic paraplegia due to missed thoracic compressive lesions afterlumbar spinal decompression surgery: report of three cases. JNeurosurg. 2004; 100 (1 Suppl Spine): 71–4.

4. Kim BS, Kim J, Koh HS, et al. Asymptomatic cervicalor thoracic lesions in elderly patients who have undergone de-compressive lumbar surgery for stenosis. Asian Spine J.2010;4(2): 65–70.

5. Valls PL, Naul LG, Kanter SL. Paraplegia after a routinelumbar laminectomy: report of a rare complication and success-ful management. Neurosurgery.1990; 27(4): 638–40.

6. Ko SB, Lee SW, Shim JH. Paraplegia due to missedthoracic meningioma after laminotomy for lumbar spinal steno-sis: report of two cases. Asian Spine J. 2011; 5(4): 253–7.

7. Fushimi K, Miyamoto K, Hioki A, Hosoe H, TakeuchiA, Shimizu K. Neurological deterioration due to missedthoracicspinal stenosis after decompressivelumbal surgery:A report ofsix cases of tandem thoracic and lumbar spinal stenosis. BoneJoint J.2013; 95–B(10): 1388–91.

8. Toribatake Y, Baba H, Kawahara N, Mizuno K, Tomi-ta K.The epiconus syndrome presenting with radicular-type ne-urological features. Spinal Cord. 1997; 35(3): 163–70.

9. Lee S-Ho, Seokmin Choi S. L1-2 Disc Herniations:Clinical Characteristics and Surgical Results. J Korean Neuro-surg Soc. 2005 (38): 196–201.

10. Wood KB, Garvey TA, Gundry C, Heithoff KB. Magne-tic resonance imaging of thethoracic spine: evaluation of asymp-tomatic individuals. J Bone Joint Surg.1995; 77(11): 1631–8.

11. Barnett GH, Hardy RW Jr, Little JR, Bay JW, SypertGW. Thoracic spinal canal stenosis. J Neurosurg.1987; 66(3):338–44.

68 Zhelyazkov Christo, Davarski Atanas, Kitova Tanya, Kehayov Ivo, Kitov Borislav

Sa`etak

TANDEM KOMPRESIJA KI^MENE MO@DINE I KAUDE EKVINE

Zhelyazkov Christo,1

Davarski Atanas,1

Kitova Tanya,2

Kehayov Ivo,1

Kitov Borislav1



Cilj: Analiza i prikaz slu~ajeva tandem kompresi-je ki~mene mo`dine i kaude ekvine.

Materijal i metode: Predmet posmatranja su ~eti-ri pacijenta sa istovremenom kompresijom ki~menemo`dine i kaude ekvine, koji su primljeni na Kliniku zaneurohirurgiju Univerzitetske bolnice Sveti George,Plovdiv, u Bugarskoj, tokom perioda Mart 2012 —Mart 2014. Prose~na starost pacijenata je 60,5 godina(47–72).

U prvom slu~aju levostrana paramedijalna diskushernija, prona|ena je na nivou L1-2 i L4-5 u kombinacijisa prate}om stenozom, u drugom slu~aju, desnostranaparamedijalna diskus hernija na nivou Th12–L1 kao idegenerativna stenoza na nivou od L3–4. U tre}em slu-~aju, na|ena je nagla{ena degenerativna kompresija na

nivou Th7–8 i centralna stenoza na nivou L4–5, a u po-slednjem slu~aju degenerativna stenoza na nivou L3–5 iki~meni meningeom na nivou Th9–10.

Rezultati: Klini~ki znaci istovremene kompresijeki~mene mo`dine i kaude ekvine su bili ispitani. Oviznaci mogu obmanuti lekara u dijagnostici ki~mene le-zije i tako rezultirati neodgovaraju}im hirur{kim stra-tegijama.

Zaklju~ak: Uklju~ivanje ki~mene mo`dine morabiti klini~ki potvr|eno da bi isklju~ilo lezije u grudnomregionu. Kada su lumbalni pregledi nepotpuni ili neuspevaju da objasne klini~ke simptome odre|enog pa-cijenta, savetuje se magnetna rezonanca cele ki~me.

Klju~ne re~i: tandem kompresija, spinalni tumor,torakalna stenoza, lumbalna stenoza.

Correspondence to/Autor za korespondencijuIvo KehayovDepartment of Neurosurgery15A Vassil Aprilov Blvd, Plovdiv 4000, BulgariaEmail dr.kehayovªgmail.com

INTRA-ABDOMINAL INFECTION AND ACUTE

ABDOMEN-EPIDEMIOLOGY, DIAGNOSIS AND GENERAL

PRINCIPLES OF SURGICAL MANAGEMENT

Jovanovic Dusan,1

Loncar Zlatibor,1, 2

Doklestic Krstina,1, 2

Karamarkovic Aleksandar1, 2

1Clinic for Emergency Surgery, Clinical Center of Serbia, Belgrade, Serbia

2Faculty of Medicine, University of Belgrade, Serbia


Abstract: Intra-abdominal infections are multi-factorial and present an complex inflammatory respon-se of the peritoneum to microorganisms followed byexudation in the abdominal cavity and systemic re-sponse Despite advances in management and criticalcare of patients with acute generalized peritonitis dueto hollow viscus perforation, prognosis is still very po-or, with high mortality rate. Early detection and adequ-ate treatment is essential to minimize complications inthe patient with acute abdomen. Prognostic evaluationof complicated IAI by modern scoring systems is im-portant to assess the severity and the prognosis of thedisease. Control of the septic source can be achievedeither by nonoperative or operative means. Nonopera-tive interventional procedures include percutaneousdrainages of abscesses. The management of primaryperitonitis is non-surgical and antibiotic- treatment.The management of secondary peritonitis include sur-gery to control the source of infection, removal of tox-ins, bacteria, and necrotic tissue, antibiotic therapy,supportive therapy and nutrition. “Source control” issine qua non of success and adequate surgical procedu-re involves closure or resection of any openings intothe gastrointestinal tract, resection of inflamed tissueand drainage of all abdominal and pelivic collections.

Key words: Intra-abdominal infection, secondaryperitonitis, source control, surgery.

INTRODUCTION

Intra-abdominal infection (IAI) present an complexinflammatory response of the peritoneum to microorgan-isms followed by exudation in the abdominal cavity andsystemic response (1). Intra-abdominal infection presenta primary, secondary and tertiary peritonitis; in uncompli-cated and complicated forms (1). Acute generalized sec-

ondary peritonitis from gastrointestinal hollow viscusperforation is a potentially life threatening condition. De-spite major advances in diagnosis, management and criti-cal care of patients with secondary peritonitis, prognosisis still very poor, with high mortality rate (1, 2, 3). Sourcecontrol, resuscitation and early antibiotic administrationare crucial (1–4). Intra-abdominal infections are also clas-sified into community-acquired intra-abdominal infecti-ons (CAIAIs) acquired in community and healthcare-ac-quired intra-abdominal infections (HA-IAIs), develop inhospitalized patients (1–4). They are characterized by in-creased mortality because of both underlying patient he-alth status and infection is caused by multi drugs resistantorganisms (4). Uncomplicated IAI involves a one singleorgan and does not proceed to the whole peritoneum,such infections can be successfully treated by surgical re-section alone, or with antibiotics alone (5). In complica-ted IAI the infection spreads from localized peritonitis tothe diffuse peritonitis (1, 2). The treatment of patientswith complicated intra-abdominal infections necessarilyinvolves both: source control and antibiotic therapy (1, 2,6). Both, the anatomic source of infection, and to a greaterdegree the physiological compromise, affect the outco-me. The outcome of IAI depends on the severity of thepatient’s systemic response and his premorbid physiolog-ical reserves, estimated best using the (7).

This review comments on epidemiology, diagno-sis and general principles of surgical management inpatients with acute abdomen.

DEFINITION, CLASSIFICATION,

SCORING

The accepted classification of intra-abdominal in-fection is a division into primary, secondary and terti-ary peritonitis (Table 1) (6).

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Primary peritonitis present the result of the hemato-genous bacterial spread to the peritoneum without lossof integrity of the gastrointestinal tract, secondary peri-tonitis follows a perforation of a hollow organs or cysticstructure and tertiary peritonitis is a recurrent infectionof the peritoneal cavity that follows either primary or se-condary peritonitis (2). Primary peritonitis is rare, and itmainly occurs in early childhood and in cirrhotic adultpatients (2). Secondary peritonitis is an acute peritonealinfection resulting from loss of integrity of the gastroin-testinal tract due to spontaneous or traumatic organ rup-ture (Figure 1) (6). It is the most common form of perito-nitis. Most frequently encountered in clinical practice asa result of perforation of the duodenal ulcer, or by directinvasion from infected gangrenous appendicitis. Ana-stomotic dehiscences are common causes of peritonitisin the postoperative period. Secondary peritonitis withsevere sepsis or septic shock have mortality rates of ap-proximately 30% (4, 6, 8).

Early prognostic evaluation of complicated IAI isimportant to assess the severity and the prognosis of

the disease. Scoring systems can be divided into: disea-se-independent scores for evaluation of serious pati-ents requiring care in the intensive care unit (ICU) suchas Acute Physiology and Chronic Health Evaluation II(APACHE II) scoring system and Simplified AcutePhysiology Score (SAPS II) and peritonitis-specificscores such as Mannheim Peritonitis Index (MPI) (7,9). APCHE-II is applied within 24 hours of admissionof a patient to an ICU: an integer score from 0 to 71 isbased on several measurements; higher scores corre-spond to more severe disease and a higher risk of death(7). The APACHE-II score has been validated prospec-tively in a large number of patients and has been adop-ted by the Surgical Infection Society as the best availa-ble method of risk stratification in IAI (7). AlthoughAPACHE II is considered as a golden standard, valueof this scoring system in peritonitis has been questio-ned because of the APACHE II impossibility to evalua-te interventions, despite the fact that interventionsmight significantly alter many of the physiological va-riables (10, 11, 12).

70 Jovanovic Dusan, Loncar Zlatibor, Doklestic Krstina, Karamarkovic Aleksandar

Figure 1. Secondary peritonitis. a. Perforated liver abscess. b. Fibrin on small bowel loops.

c. Colon perforation. d. Infected pancreatic necrosis.

(Image source: Clinic for Emergency Surgery, Clinical Center of Serbia, Belgrade, Serbia)

The Mannheim Peritonitis Index (MPI) is a speci-fic score, which provides an easy way to handle with cli-nical parameters, allowing the outcome prediction.Long-term survivors have an MPI score of about 20;non-survivors have a score of 33. The MPI is specificfor peritonitis and easy to calculate, even during surgery(11, 12, 13). Billing et al. demonstrated the reliability ofMPI in 2003 patients from 7 centres in Europe (14). Forpatients with a score less than 21 the mean mortality ratewas 2.3%, for score 21–29 mortality was 22.5% and forscore greater than 29 mortality was 59.1%; the sensitiv-ity was 86%, specificity 74% and accuracy 83% in pre-dicting mortality (14). Panhofer et al. proposed the useof both MPI and APACHE II in patients who developedtertiary peritonitis, concluding that combination ofprognostic scores was very useful to detect tertiary peri-tonitis (15). Inui at al. investigated the utility of Char-lson Comorbidity Index and multiple organ dysfunction(MOD) (16). Among patients who failed initial therapy,a non-appendiceal source of infection and a Charlsonscore > or = 2 were determined to be independent riskfactors. Nonappendiceal source of infection and MODscore > or = 4 on postoperative day 7 were independentpredictors for re-intervention (16).

PATHOPHYSIOLOGY

AND HOST RESPONSE

The total area of the peritoneum is approximately1.8 m

2, which is covered by the mesothelial cells mic-

rovilli that measure to 3.0 m in length (2). Peritonealfluid has the properties of lymph, and is secreted by theperitoneal serosa. Diaphragmatic lymphatic channelsact like valves and suck synchronous with respirationperitoneal fluid and any bacteria and pro inflammatorymediators through the thoracic ducts into the venouscirculation. Inspiration decreases intra-thoracic pres-sure relative to intra-abdominal pressure, creating apressure gradient favoring fluid movement out of theabdomen. Entry of pro-inflammatory substances intothe vascular space produces hemodynamic and respira-tory findings of sepsis. Positive-pressure ventilation li-kely attenuates this process. Perforation of the gastro-intestinal tract is the most common cause of acute in-tra-abdominal infection and their highly infectiouscontent flows into the free peritoneal cavity triggers astrong host response (2). The most common causes ofacute abdomen are perforation due to peptic ulcer dise-ase, diverticulitis, appendicitis, malignant lesion, bo-

INTRA-ABDOMINAL INFECTION AND ACUTE ABDOMEN-EPIDEMIOLOGY, DIAGNOSIS AND GENERAL... 71

Table 1. Classification of intraabdominal infections

PRIMARY PERITONITIS Diffuse bacterial peritonitis in theabsence of disruption of intraab-dominal hollow viscera

A. Spontaneous peritonitis in chil-dren

B. Spontaneous peritonitis in adults

C. Peritonitis in patients with CAPD

D. Tuberculous and other granulo-matous peritonitis

SECONDARY PERITONITIS Localized (abscess) or diffuse pe-ritonitis originating from a defectin abdominal viscus

A. Acute perforation peritonitis

1. Gastrointestinal perforation

2. Intestinal ischemia

3. Pelviperitonitis and other forms

B. Postoperative peritonitis

1. Anastomotic leak

2. Accidental perforation and de-vascularization

C. Post-traumatic peritonitis

1. After blunt abdominal trauma

2. After penetrating abdominal tra-uma

TERTIARY PERITONITIS Peritonitislike syndrome occurringlate due to disturbance in the host’simmune response

A. Peritonitis without evidence forpathogens

B. Peritonitis with fungi

C. Peritonitis with low-grade pat-hogenic bacteria

wel wall necrosis after strangulation or incarceratedhernia. The three major intra-peritoneal defense mech-anisms are: mechanical clearance of bacteria vialymphatics, phagocytic killing of bacteria by immunecells, and mechanical sequestration (2). The arm of theperitoneal defense system is to localize bacterial conta-mination. Hyperemia and exudation of fluid follow ac-tivation of immune cells. Several events favor the de-position of fibrin, including activation of mesothelialand macro-phage-mediated procoagulant activity act-ing on fibrinogen in reactive peritoneal fluid, coupledwith loss of plasminogen activator from mesothelialcells. The combined effect is the deposition of fibrino-us exudates. Ileus and fibrin formation accentuate theprocess. Formation of an abscess is one of the benefi-cial functions of fibrin formation encapsulating the in-fection and preventing systemic spread.

DIAGNOSIS

Early detection and adequate treatment is essen-tial to minimize complications in the patient with acuteabdomen (17–21). A physical examination combinedwith abdominal ultrasonography (US) represents theinitial investigation in patients with acute abdominalpain. The abdomen is distended, it is quiet to ausculta-tion, and tender to palpation. Abdominal pain is almostalways the predominant symptom, unless its percep-tion is masked by the administration of analgesics orthe presence of a fresh surgical wound. Rupture of a vi-scus is associated with sudden on-set pain. When fullydeveloped, pain is steady, unrelenting, burning, andaggravated by any motion. Pain is usually most intensein the region of most advanced peritoneal inflamma-tion. Patients can usually localize pain arising from ir-ritation of the parietal peritoneum -peritoneal signs. Itmay be associated with tenderness and involuntarymuscle spasm -guarding. Rebound tenderness can beelicited by gently depressing an area distant from thearea of pathology and letting it bounce back. Direct,percussion tenderness and referred rebound tendernessconfirms the presence of peritoneal irritation. Rigidityof the abdominal muscles is produced after involve-ment of the parietal peritoneum by inflammation butalso by reflex muscle spasm and abdominal hyperten-sion. Reflex spasm may become so severe that it pro-duces board like abdominal rigidity. Rectal and vaginalexaminations are essential to locate the extent of ten-derness and the possible presence of a pelvic mass. An-orexia is always present, nausea is frequent and rarelyaccompanied by vomiting.

Systemic manifestations in complicated IAI areSIRS manifestations: body temperature > 38 °C or < 36 °C,heart rate > 90 beats per minute, respiratory rate > 20

breaths per minute (not ventilated) or PaCO2 < 32mm Hg (ventilated), WBC > 12,000, < 4,000 or >10% immature forms (bands) (18). Bone RC Temper-ature usually ranges between 38 °C and 40 °C; the fe-ver is more spiking in character in younger and healt-hier patients, whereas older or debilitated patientsmay exhibit only a modest febrile response. Tachy-cardia and a diminished palpable peripheral pulse vo-lume are indicative of hypovolemia, hypovolemicshock and sepsis. Respirations are typically rapid andshallow. Hypotension and hypoperfusion signs suchas lactic acidosis, oliguria, and acute alteration ofmental status are indicative of evolution to severesepsis (21). A leukocyte count of more than 25,000 orleukopenia of fewer than 4000/mL3 are both associa-ted with higher mortality. The differential count sho-wing relative lymphopenia and moderate to markedleftward shift, even if the leukocyte count is normal orsubnormal. Procalcitonin (PCT) appeared to be a pa-rameter for early detection of progressing sepsis andvaluable aid in deciding if further relaparotomies we-re necessary after initial operative treatment of an in-tra-abdominal septic focus (19, 22).

Computerized tomography (CT) is the imaging ofchoice for most intra-abdominal processes in he-modynamically stable patient (17, 20, 21). Diagnosticlaparoscopy should be considered in patients without aspecific diagnosis after appropriate imaging and as analternative to active clinical observation which is thecurrent practice in patients with non-specific abdomi-nal pain (17). Plain radiographs of the abdomen mayreveal free air on an upright abdominal or lateral decu-bitus film, a uniform indicator of visceral perforationin the absence of prior intervention (17, 21). The radio-logical picture of intra-abdominal infection otherwisemimics that of paralytic ileus. Radiographs of the chestmay show air beneath the diaphragm if the patient re-mains in an upright position for 5 min or more beforethe film (21).

GENERAL MANAGEMENT

Early treatment of generalized secondary perito-nitis may result in a better outcome and any delay maycorrelate with exponentially increasing mortality (21).Control of the septic source can be achieved either bynonoperative or operative means (21, 23, 24). Nonope-rative interventional procedures include percutaneousdrainages of abscesses. The management of primaryperitonitis, an essentially “non-surgical”, is antibiotic-treatment. The management of secondary peritonitisinclude surgery to control the source of infection, anti-biotic therapy, supportive therapy and nutrition (21,23, 24).


SOURCE CONTROL

“Source control” is sine qua non of success andadequate surgical procedure involves closure or resec-tion of any openings into the gastrointestinal tract, re-section of inflamed tissue and drainage of all fluid col-lections (25). Laparotomy is usually performed thro-ugh a midline incision. Timing and adequacy of sourcecontrol are the most important issues in the manage-ment of intra-abdominal infections, because inadequa-te and late operation may have a negative effect on theoutcome (26, 27, 28). The latter aspect of surgical man-agement is controversial, with recent recommendati-ons focused only on the source of infection as opposedto complete peritoneal debridement. Intensive caremeasures to support tissue oxygenation and maintainorgan function remain important, while awaiting reco-very brought upon trough surgical and antibiotic ther-apy. Antibiotic therapy should be started as early aspossible after diagnosis (26, 27, 28). The trend to conti-nue administration of antibiotics for fixed periods is nolonger justified (28). An important rule towards limit-ing the currently prevailing practices of excessive anti-biotic prescription is the recommendation of the Surgi-cal Infection Society that ’simple’ intra-abdominal in-fection do not require therapeutic postoperative antibi-otics. Antimicrobial regimens effective against com-mon gram-negative and anaerobic enteric pathogensare the mainstay of therapy (26, 27, 28). For patientswith community-acquired intra-abdominal infections,narrower-spectrum antimicrobial agents with a low po-tential for iatrogenic complications are appropriate.Patients with nosocomially-acquired, intra-abdominalinfections are more likely to harbor resistant patho-gens. Inadequate empiric antimicrobial therapy is as-sociated with treatment failure and death. Therefore,broader spectrum antimicrobial regimens are recom-mended for these patients, and to coverage of more re-sistant gram-negative bacilli and anaerobes, use ofagents effective against enterococci, resistant staphy-lococci and Candida should be considered (26, 27, 28).Conditions without such peritoneal inflammatory re-sponse, in which contamination has occurred but infec-tion is not established, or in which the infectious pro-cess remains contained within a diseased, but resecta-ble organ, represent ’simple’ forms of peritonitis like inappedicitis or cholecystitis, not requiring additionalantibiotic therapy for more than 3 to 5 postoperativedays (25–28).

OPERATIVE STRATEGIES

Reduction in mortality is not possible without ef-fective source control (21). The mortality of intraabdo-minal infection was about 90% at the end of the 19th

century, when management was mainly non-operative.Source control done in a single operation reduced mor-tality by more than 50% (21).

The classical, single operation for IAI accomplis-hes the main goal: surgical source control and a one-ti-me removal of toxins, bacteria, and necrotic tissue(21). The single operation is sufficient in the majorityof cases. Only 15% of patients present with advanceddisease that require multiple abdominal re-entries (21,28). The choice of the procedure, and whether the endsof resected bowel are anastomosed, exteriorized, orsimply closed, depends on the anatomical source of in-fection, the degree of peritoneal inflammation and gen-eralized septic response, patient’s comorbidit conditi-ons and physiological reserve. All infectious fluidsshould be aspirated and particulate matter removed byswabbing. Although, cosmetically appealing and pop-ular with surgeons, there is more evidence other thanwashing out bacteria that intraoperative peritoneal la-vage reduces mortality or the incidence of septic com-plications in patients receiving adequate systemic anti-biotics. Drains are still commonly used and misused. Inaddition to the false sense of security and reassurancethey provide, drains can erode into intestine or bloodvessels and promote infective complications. Their useshould be limited to the evacuation of an establishedabscess, to allow escape of potential visceral secretionsas biliary, or pancreatic and to establish a controlled in-testinal fistula when the latter cannot be exteriorized.

Decompression of the abdominal compartmentand intra-abdominal hypertension (IAH) is addressedby the decompression methods, mainly the “leavingthe abdomen open” techniques (28). Adkins Tempo-rary closure of the abdomen may be achieved usingself-adhesive membrane dressings, absorbable mes-hes, nonabsorbable meshes, zippers and vacuum-assi-sted closure (VAC) devices (29, 30). Today Vacu-um-assisted fascial closure (VAC) has become an op-tion for the treatment of open abdomen (29–32). Thesurgical treatment strategies following an initial emer-gency laparotomy may include either a relaparotomy,only when the patient’s condition demands it (“relapa-rotomy on-demand”), or a planned relaparotomy after36–48 hours with temporarily abdomen closure oropen abdomen (33). Wild STAR (Stage AbdominalRepair) permits continuous control of anastomoses andintra-abdominal healing and effective bacterial elimi-nation (34). This is the only method were post-operati-ve complications are diagnosed early before progress-ing to major damages. Additionally, peritoneal fluidlosses can be measured and protein losses replaced byFFP exactly to match the losses. If a patient developsrecurrent peritonitis, a re-intervention is required. Thissituation has been named “relaparotomy on demand.”


It is associated with high mortality rates because the di-agnosis of post-operative peritonitis delayed and pati-ents are operated too late. They often presented withorgan failure and advanced disease that is responsiblefor bad outcome. Ruler et al. published a randomized,clinical trial comparing on-Demand vs Planned Rela-parotomy strategy in patients with severe peritonitis(35). The patients in the on-demand relaparotomy gro-up did not have a significantly lower rate of death ormajor peritonitis-related morbidity compared with theplanned relaparotomy group but did have a substantialreduction in relaparotomies, health care utilization,and medical costs (35).

Source control of appendix perforation

Acute appendicitis is the most common intra-ab-dominal condition requiring emergency surgery. De-layed diagnosis and treatment of appendicitis also maylead to perforation with diffuse peritonitis. Dissemina-ted intra-abdominal infection from appendicitis, howe-ver, is not seen as often today as in the first decades ofthe 20th century, when appendicitis was the major cau-se of severe peritonitis and peritonitis-related mortality(36, 37, 38). Although antibiotics may be used as pri-mary treatment for selected patients with suspected un-complicated appendicitis, appendectomy is still thegold standard therapy for acute appendicitis (36, 37,38). Treatment includes source control by appendec-tomy, rarely in the most severe cases staged abdominalrepair in cases when peritoneal edema has led to abdo-minal compartment syndrome. Studies have demon-strated that antibiotics alone may be useful to treat pati-ents with early, non perforated appendicitis, even ifthere is a risk of recurrence (36, 37, 38). Randomizedclinical trial by Hanson et al. compared antibiotic ther-apy versus appendectomy as primary treatment of acu-te appendicitis (39). Treatment efficacy was 90.8% forantibiotic therapy and 89.2% for surgery. Recurrent ap-pendicitis occurred in 13.9% of patients treated conser-vatively after a median of 1 year (39). The course of ap-pendicitis leading to massive necrosis and life threate-ning infection, often surpassing the omentum’s capabi-lity to contain the infection and form a perityphlic ab-scess and diffuse suppurative peritonitis then results(40, 41). Appendix abscess occurs in 10% of patientswith acute appendicitis (40). There is much contro-versy whether interval appendicectomy is appropriatefor adults with an appendiceal abscess. The traditionalmanagement of appendiceal mass has been initial con-servative treatment followed by interval appendicec-tomy (40). Deakin et al. demonstrated that conservati-ve management approach was successful in the major-ity of patients presenting with an appendix mass (42).

The authors concluded that after initial successful conser-vative management, routine use of interval appendicec-tomy was not justified in asymptomatic patients (42).

Source control

of gastro-duodenal perforation

Gastroduodenal perforations have decreased sig-nificantly in the last years thanks to the widespreadadoption of medical therapies for peptic ulcer diseaseand stress ulcer prophylaxis among critically ill pati-ents. Successful laparoscopic repair of perforated gas-tric and duodenal ulcers has been reported but the tech-nique has yet to be universally accepted (43, 44, 45).This form of peritonitis is initially chemical but in ashort time becomes infected. The proper managementis simple closure. Antibiotic therapy may be given overa very short period in the range of 1 to 3 days becausebacterial numbers are generally small and the sourcecan be closed safely. The high mortality rate of anasto-motic leakage or suture line breakdown after gas-tro-duodenal operations Billroth I and Billroth II resec-tions are explained by the fact that the duodenum is re-troperitoneally fixed and cannot be exteriorized, andthe source of infection often cannot be adequately con-trolled or closed.

Source Control of Colon Perforation

Antibiotics are the standard of care for uncompli-cated diverticulitis (46). Percutaneous drainage is theintervention of choice for simple uniloculated absces-ses (46). It has a success rate of more than 80%, but itmay have a high failure rate in cases of complex multi-loculated or inaccessible abscesses (46). Colon perfo-ration due to diverticulitis or cancer is a common causeof diffuse, fecal peritonitis (Figure 1). Urgent surgeryfor colonic diverticula perforations is indicated in pati-ents with large or/and multiloculated diverticular ab-scesses inaccessible to percutaneous drainage or inwhom clinical symptoms persist after CT guided per-cutaneous drainage, diverticulitis associated with freeperforation and purulent or fecal diffuse peritonitis.This factor, together with the many associated diseasesin the population of elderly patients with colon disease,contributes to the high mortality rate of 37% (46). The-re is still controversy about the optimal surgical mana-gement of peritonitis caused by colonic diverticular di-sease (46, 47). Hartmann’s resection has been the pro-cedure of choice in patients with generalized peritoni-tis and remains a safe technique for emergency colec-tomy in perforated diverticulitis, especially in elderlypatients with multiple co-morbidities. This group ofpatients particularly benefits from staged abdominal


repair for which the overall mortality rate is less than20% (46). Antibiotic therapy needs to cover both facul-tative and obligate anaerobic bacteria and can be dis-continued after five days duration (46). More recently,some reports have suggested that primary resectionand anastomosis is the preferred approach to diverticu-litis, even in the presence of diffuse peritonitis (46, 47).

Peritonitis of Biliary Origin

Because of the delay of diagnosis, biliary peritoni-tis is associated with mortality rates exceeding 30%.Early suspicion is key. Removal of the gallbladder andcommon duct stones represents effective source con-trol (48–54). Early laparoscopic cholecystectomy foracute cholecystitis is safer and shows lower rates ofconversions than delay laparoscopic cholecystectomy(50). Half of the mortality of biliary peritonitis is cau-sed by E. coli and one fourth by clostridium perfrin-

gens, which may cause a fulminate necrotizing infec-tion leading to death within hours (50–54). The lattermay requires immediate re-operation, high doses ofpenicillin (10 million units every 6 hours) IntensiveCare and hyperbaric oxygen. Most cases of acute cho-lecystitis as a complication of Intensive Care are acal-culous and likely represent complications of microva-scular and mucosal dysfunction. This condition, oftenpresents during sepsis originating in the necrotic gall-bladder that becomes infected and must be removed foreffective source control. Despite the evidence, early la-paroscopic cholecystectomy is not the most commontreatment for acute cholecystitis in practise andwrongly it remains common practice to treat acute cho-lecystitis with intravenous antibiotic therapy and inter-val laparoscopic cholecystectomy preferentially (55).

Source Controlof Infected Pancreatic Necrosis

In the acute phase of pancreatitis, antibiotic ther-apy, supporativ therapy and intravenous hydrationaimed at maintaining the patient’s intravascular volu-me and perfusion pressures is the mainstay of treat-ment. Usually during the third week after onset of acu-te pancreatitis, the disease has progressed from initialchemical inflammation to intraabdominal infectionwith high mortality because source control is difficult(Figure 1) (56). Endoscopic retrograde cholangiopan-creatography (ERCP) and sphincterotomy are indica-ted in patients with biliary pancreatitis and impactedgall stones, biliary sepsis, or obstructive jaundice (56).In septic patients with necrotizing pancreatitis, a Fi-ne-needle aspiration (FNA) should be performed fordifferentiation of sterile and infected pancreatic necro-

sis (56). Adequate volume resuscitation and analgesictreatment are the most important treatment of acutepancreatitis. Antibiotic prophylaxis reduces septiccomplications in severe necrotizing pancreatitis andshould be started early, best with 1 gram of imipe-nem/cilastatin every 6 to 8 hours at the onset of acutepancreatitis before infection can be proven. Antibioticsmust be administered for longer periods (56). Surgicaltherapy is indicated in patients with infected pancreaticnecrosis (56, 57). The optimal time point for the surgi-cal intervention is the 3rd to 4th week after onset of thedisease, in that time necrotic tissue will be well demar-cated. The surgical technique of choice is necrosec-tomy with postoperative closed lavage (56, 57, 58).Before closure, large abdominal drains must be placedinto the pancreatic bed to further drain necrotic areasand to collect pancreatic juice preventing further intra-abdominal spread of digestive enzymes. When mostnecroses are removed or overgrown by granulation tis-sue, usually after 8–12 abdominal entries if STAR isdone, and peritoneal edema disappears, the abdomencan be closed fascia-to fascia without meshes. Cho-lecystectomy should be performed to avoid recurrenceof gallstone-associated acute pancreatitis.

Source Control of Small

Bowel Perforation

Most non-traumatic small intestinal perforationsare due to unrecognized bowel strangulation and intes-tinal ischemia (59, 60, 61). Source control includes re-section of the diseased segment and anastomosis (59,60, 61). The high mortality rate of more than 50% canbe reduced by treating advanced cases with the STARoperation that permits inspection of the anastomosis atsubsequent abdominal entries, and diagnose and treatnew necrosis early. In addition, anastomoses can be de-ferred and the bowel simply stapled off at the firstSTAR in deteriorating patients who will not tolerateextensive procedures during sepsis. If small bowel per-forations operated before peritonitis develops it can ha-ve an excellent prognosis. Source control is usually ac-hieved by simple suture closure, rarely by resection ofthe perforated segment and anastomosis.

Source Control

in Postoperative Peritonitis

Postoperative peritonitis is usually due to a leakfrom a suture line (4, 62). Diagnosis is often delay, andpatients, as a rule, are re-explored between the fifth andseventh postoperative day, which contributed to thehigh mortality rate. A suture line leak is easier to repairif it is observed in the colon, small bowel or stomach


compared with leaks of the duodenum or esophagus.Upper gastrointestinal tract disease after an operationallows only a limited therapeutic correction to controlthe source, because these organs are fixed or closely at-tached to the retroperitoneum and the infectious sourcecannot be totally excluded under most circumstances.Resection of the anastomosis or bowel segment is bet-ter than repair. Staged abdominal repair using a tempo-rary abdominal closure device may be of particular be-nefit to this subset of patients with intraabdominal in-fections; we were able to reduce mortality to 24% (62).

Source Control

in Posttraumatic Peritonitis

Peritonitis coused by intestine perforation may de-velop in patients after blunt abdominal trauma (63). Thistype of intraabdominal infection is usually severe becau-se it is masked by other injuries and often recognized late,even when an initial CT was done. This causes delay indiagnosis and most cases present with a diffuse peritonitis(63). General principles of treatment do not differ fromthat of intraabdominal infection (63). Contamination ofthe abdominal cavity seen after penetrating abdominaltrauma is not considered an intraabdominal infection.

In a conclusion, intra-abdominal infections pres-ent an complex inflammatory response of the peritone-um to microorganisms. Despite all advances in mana-gement of patients with secondary peritonitis, progno-sis is still very poor, with high mortality rate. Acute ge-neralized secondary peritonitis is still very interestingfor surgeons and adequate source control is sine quanon of treatment.

Abbreviations

IAI — Intra-abdominal infectionCAIAIs — community-acquired intra-abdominal

infectionsHA-IAIs — healthcare-acquired intra-abdominal

infectionsICU — intensive care unitAPACHE II — Acute Physiology and Chronic

Health Evaluation IISAPS II — Simplified Acute Physiology ScoreMPI — Mannheim Peritonitis IndexMOD — multiple organ dysfunctionVAC — vacuum-assisted closureSTAR — Stage Abdominal Repair


Saètak

INTRA-ABDOMINALNA INFEKCIJA I AKUTNI

ABDOMEN-EPIDEMIOLOGIJA, DIJAGNOZA I OP[TI PRINCIPI

HIRUR[KOG RE[AVANJA

Jovanovi} Du{an,1

Lon~ar Zlatibor,1, 2

Doklesti} Krstina,1, 2

Karamarkovi} Aleksandar1, 2

1Klinika za urgentnu hirurgiju, Klini~ki centar Srbije, Beograd, Srbija

2Medicinski fakultet Univerziteta u Beogradu, Beograd, Srbija

Intra-abdominalne infekcije (IAI) su multifaktorijal-ne i predstavljaju sloèni inflamatorni odgovor peritone-uma na prisustvo patogenih mikroorganizama, sa eksuda-cijom u trbu{nu duplju i sistemskim odgovorom. Uprkosnapretku u zbrinjavanju pacijenata sa akutnim difuznimperitonitisom koji je posledica perforacije {upljeg trbu-{nog organa, prognoza je i dalje veoma lo{a, sa visokomstopom smrtnosti. Rano postavljanje dijagnoze i adekvat-no le~enje su od su{tinskog zna~aja za minimiziranjekomplikacija kod pacijenta sa akutnim abdomenom.Prognosti~ka evaluacija komplikovanih IAI savremenimbodovnim sistemima je va`na zbog procene teìne bolestii prognoze. Kontrola izvora infekcije moè biti ne-hirur-{ka i hirur{ka. Ne-hirur{ke interventne procedure uklju-

~uju drenaù gnojne kolekcije/apscesa. Le~enje sekun-darnog peritonitisa je kompleksno i uklju~uje: hirur{kukontrolu izvora infekcije, uklanjanje nekroti~nog tkiva idetritusa iz trbuha, antibiotsku terapiju, supstitucionu isimptomatsku terapiju, i ishranu. „Kontrola izvora infek-cije“ je sine qua non adekvatnog le~enja, a obuhvata: su-turu mesta perforacije {upljeg organa gastrointestinalnogtrakta, resekciju ishemi~no-nektoti~nog tkiva, uklanjanjeorgana u celini (appendectomia, cholecystectomia), lava-ù trbuha u slu~aju difuznog peritonitisa, kao i drenaùsva ~etri kvadranta, uz plasiranje kontaktnog drena namestu hirur{kog rada.

Klju~ne re~i: Intraabdominalna ifekcija, sekun-darni peritonitis, kontrola izvora, hirurgija.

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23. Solomkin JS, Mazuski JE, Baron EJ, et al. Guidelinesfor the selection of anti-infective agents for complicated in-tra-abdominal infections. Clin Infect Dis. 2003; 37(8):997–1005.

24. Suding PN, Orrico RP, Johnson SB, Wilson SE. Con-cordance of inter-rater assessments of surgical methods to achie-ve source control of intra-abdominal infections. Am J Surg.2008; 196(1): 70–3.

25. Blot S, De Waele JJ. Critical issues in the clinical man-agement of complicated intra-abdominal infections. Drugs.2005; 65(12): 1611–20.

26. Mazuski JE, Sawyer RG, Nathens AB, et al. Therapeu-tic Agents Committee of the Surgical Infections Society. TheSurgical Infection Society guidelines on antimicrobial therapyfor intra-abdominal infections: evidence for the recommendati-ons. Surg Infect (Larchmt). 2002; 3(3): 175–233.

27. Mazuski JE. Antimicrobial treatment for intra-abdom-inal infections. Expert Opin Pharmacother. 2007; 8(17):2933–45.

28. Adkins AL, Robbins J, Villalba M, Bendick P, ShanleyCJ. Open abdomen management of intra-abdominal sepsis. AmSurg. 2004; 70(2): 137–40.

29. Barker DE, Kaufman HJ, Smith LA, Ciraulo DL, Ric-hart CL, Burns RP. Vacuum pack technique of temporary abdo-minal closure: A 7-year experience with 112 patients. J trauma.2000; 48(2): 201–6.

30. Miller Pr, Meredith JW, Johnson JC, Chang MC. Pro-spective evaluation of vacuum-assisted fascial closure afteropen abdomen: Planned ventral hernia rate is substantially redu-ced. Ann Surg. 2004; 239(5): 608–14.

31. Perez D, Wildi S, Demartines N, Bramkamp M, Koe-hler C, Clavien PA. Prospective evaluation of vacuum-assistedclosure in abdominal compartment syndrome and severe abdo-minal sepsis. J Am Coll Surg. 2007; 205(4): 586–92.

32. Jansen JO, Loudon MA. Damage control surgery in anon-trauma setting. Br J Surg. 2007; 94(7): 789–90.

33. Wild T, Stortecky S, Stremitzer S, et al. Abdominaldressing — a new standard in therapy of the open abdomen fol-lowing secondary peritonitis?. Zentralbl Chir. 2006; 131 (Suppl1): S111–4.

34. Ozgüç H, Yilmazlar T, Gürlüler E, Ozen Y, Korun N,Zorluo—lu A. Staged abdominal repair in the treatment of in-tra-abdominal infection: analysis of 102 patients. J GastrointestSurg. 2003; 7(5): 646–51.

35. Van Ruler O, Mahler CW, Boer KR, et al. Comparisonof on-demand vs planned relaparotomy strategy in patients with


severe peritonitis: A randomized trial. JAMA. 2007; 298(8):865–72.

36. Mason RJ. Surgery for appendicitis: is it necessary?Surg Infect (Larchmt). 2008; 9(4): 481–8.

37. Eriksson S, Granström L. Randomized controlled trialof appendicectomy versus antibiotic therapy for acute appendi-citis. Br J Surg. 1995; 82(2): 166–9.

38. Styrud J, Eriksson S, Nilsson I,et al. Appendectomyversus antibiotic treatment in acute appendicitis. a prospectivemulticentre randomized controlled trial. World J Surg. 2006;30(6): 1033–7.

39. Hansson J, Körner U, Khorram-Manesh A, Solberg A,Lundholm K. Randomized clinical trial of antibiotic therapyversus appendicectomy as primary treatment of acute appendi-citis in unselected patients. Br J Surg. 2009; 96(5): 473–81.

40. Corfield L.Interval appendicectomy after appendicealmass or abscess in adults: What is “best practice”? Surg Today.2007; 37(1): 1–4.

41. Andersson RE, Petzold MG. Nonsurgical treatment ofappendiceal abscess or phlegmon: A systematic review and me-ta-analysis. Ann Surg. 2007; 246(5): 741–8.

42. Deakin DE, Ahmed I. Interval appendicectomy afterresolution of adult inflammatory appendix mass — is it neces-sary? Surgeon. 2007; 5(1): 45–50.

43. Sauerlenad S, Agresta F, Bergamaschi R, et al. Laparo-scopic for abdominal emergencies: Evidence based guidelinesof the European Association for Endoscopic Surgery. Surg En-dosc. 2006; 20(1): 14–29.

44. Sanabria AE, Morales CH, Villegas MI. Laparoscopicrepair for perforated peptic ulcer disease. Cochrane DatabaseSyst Rev. 2005; 19(4): CD004778.

45. Ergul E, Gozetlik EO. Emergency spontaneous gastricperforations: ulcus versus cancer. Langenbecks Arch Surg.2009; 394(4): 643–6.

46. McCafferty MH, Roth L, Jorden J. Current manage-ment of diverticulitis. Am Surg. 2008; 74(11): 1041–9.

47. Salem L, Flum DR. Primary anastomosis or Hart-mann’s procedure for patients with diverticular peritonitis? Asystematic review. Dis Colon Rectum. 2004; 47(11): 1953–64.

48. Chandra V, Nelson H, Larson DR, Harrington JR. Im-pact of primary resection on the outcome of patients with perfo-rated diverticulitis. Arch Surg. 2004; 139(11): 1221–4.

49. Martín-Pérez J, Delgado-Plasencia L, Bravo-GutiérrezA, et al. Gallstone ileus as a cause of acute abdomen. Importanceof early diagnosis for surgical treatment. Cir Esp. 2013; 91(8):485–9.

50. Lau H, Lo CY, Patil NG, Yuen WK. Early versus de-layed-interval laparoscopic cholecystectomy for acute cho-lecystitis. A meta-analysis. Surg Endosc. 2006; 20(1): 82–7.

51. Papi C, Catarci M, D’Ambrosio L, et al. Timing ofcholecystectomy for acute cholecystitis: A meta-analysis. Am JGastroenterol. 2004; 99(1): 147–55.

52. Gurusamy KS, Samraj K. Early versus delayed laparo-scopic cholecystectomy for acute cholecystitis. Cochrane Data-base Syst Rev. 2006; 18(4): CD005440.

53. Shikata S, Noguchi Y, Fukui T. Early versus delayedcholecystectomy for acute cholecystitis: A meta-analysis of ran-domized controlled trials. Surg Today. 2005; 35(7): 553–60.

54. González-Rodríguez FJ, Paredes-Cotoré JP, Pontón C,et al. Early or delayed laparoscopic cholecystectomy in acutecholecystitis? Conclusions of a controlled trial. Hepatogastroen-terology. 2009; 56(89): 11–6.

55. Casillas RA, Yegiyants S, Collins JC. Early laparosco-pic cholecystectomy is the preferred management of acute cho-lecystitis. Arch Surg. 2008; 143(6): 533–7.

56. Werner J, Büchler MW. Infectious complications innecrotizing pancreatitis. Zentralbl Chir. 2007; 132(5): 433–7.

57. Amano H, Takada T, Isaji S, et al. Therapeutic inter-vention and surgery of acute pancreatitis. J Hepatobiliary Pan-creat Sci. 2010; 17(1): 53–9.

58. Milian J W, Portugal S J, Laynez Ch R, Rodríguez A C,Targarona J, Barreda C L. Necrotic acute pancreatitis in the in-tensive care unit: a comparison between conservative and surgi-cal medical treatment. Rev Gastroenterol Peru. 2010; 30(3):195–200.

59. Ara C, Sogutlu G, Yildiz R, et al. Spontaneous smallbowel perforations due to intestinal tuberculosis should not berepaired by simple closure. J Gastrointest Surg. 2005; 9(4):514–7.

60. Doklesti} K., Karamarkovic A. Ileum perforation dueto accidental chicken bone ingestion — a rare couse of the acuteabdomen. Sanamed. 2012; 7(1): 31–4.

61. Ghosheh B, Salameh JR. Laparoscopic approach toacute small bowel obstruction: review of 1061 cases. Surg En-dosc. 2007; 21(11): 1945–9.

62. Babadzhanov BD, Teshaev OR, Beketov GI. New ap-proaches to the treatment of postoperative peritonitis. VestnKhir Im I I Grek. 2002; 161(4): 25–8.

63. Chichom Mefire A, Weledji PE, Verla VS, Lidwine NM.Diagnostic and therapeutic challenges of isolated small bowel per-forations after blunt abdominal injury in low income settings: anal-ysis of twenty three new cases. Injury. 2014; 45(1): 141–5.


Correspondence to/Autor za korespondencijuDu{an Jovanovi}Clinic for Emergency Surgery,Pasterova 2Clinical Center of Serbia, Belgrade, Serbiae-mail: dr.dusan26ªmail.com

UPUTSTVO AUTORIMA

SANAMED je medicinski ~asopis osnovan 2006.godine. âsopis objavljuje: originalne nau~ne i stru~ne~lanke, prikaze bolesnika, revijske radove, pisma ured-niku, ~lanke iz istorije medicine, prikaz objavljenihknjiga i druge medicinske informacije.

Rukopise slati na adresu:Prim. dr Avdo ]erani},(za Sanamed)Ul. Palih boraca 52, 36300 Novi PazarEmail: sanamednp2006ªgmail.comwww.sanamed.rs

Prispeli rukopis Ure|iva~ki odbor {alje recenzen-tima radi stru~ne procene. Ukoliko recenzenti predloèizmene ili dopune, kopija recenzije se dostavlja autorus molbom da unese traène izmene u tekst rada ili daargumentovano obrazloì svoje neslaganje s primed-bama recenzenta. Kona~nu odluku o prihvatanju radaza {tampu donosi glavni i odgovorni urednik.

Za objavljene radove se ne ispla}uje honorar, aautorska prava se prenose na izdava~a. Rukopisi i pri-lozi se ne vra}aju. Za reprodukciju ili ponovno obja-vljivanje nekog segmenta rada publikovanog u Sana-medu neophodna je saglasnost izdava~a.

âsopis se {tampa na srpskom jeziku, sa kratkimsadràjem prevedenim na engleski jezik. Radovi stra-nih autora se {tampaju na engleskom jeziku sa kratkimsadràjem na srpskom i engleskom jeziku.

OP[TA UPUTSTVA

Rukopis treba poslati u tri primerka, otkucan jedno-strano na beloj hartiji formata A4. Tekst rada kucati u pro-gramu za obradu teksta Word, latinicom, sa dvostrukimproredom, isklju~ivo fontom Times New Roman i veli~i-nom slova 12 ta~aka (12 pt). Sve margine podesiti na 25mm, a tekst kucati sa levim poravnanjem i uvla~enjemsvakog pasusa za 10 mm, bez deljenja re~i (hifenacije).

Rukopis mora biti organizovan na slede}i na~in:naslovna strana, saètak na srpskom jeziku, saètak naengleskom jeziku, klju~ne re~i, uvod, cilj rada, bole-snici i metodi/materijal i metodi, rezultati, diskusija,zaklju~ak, literatura, tabele, legende za slike i slike.

Svaki deo rukopisa (naslovna strana, itd.) morapo~eti na posebnoj strani. Sve strane moraju biti nume-risane po redosledu, po~ev od naslovne strane. Prezimeprvog autora se mora otkucati u gornjem desnom uglusvake stranice. Podaci o kori{}enoj literaturi u tekstuozna~avaju se arapskim brojevima u zagradama, i toonim redosledom kojim se pojavljuju u tekstu.

Obim rukopisa. Celokupni rukopis rada, koji ~i-ne naslovna strana, kratak sadràj, tekst rada, spisak li-terature, svi prilozi, odnosno potpisi za njih i legenda(tabele, slike, grafikoni, sheme, crteì), naslovna stra-na i saètak na engleskom jeziku, mora iznositi za ori-ginalni rad, saop{tenje, rad iz istorije medicine i pre-gled literature do 5.000 re~i, a za prikaz bolesnika, radza praksu, edukativni ~lanak do 3.000 re~i; radovi zaostale rubrike moraju imati do 1.500 re~i.

Provera broja re~i u dokumentu moè se izvr{iti uprogramu Word kroz podmeni Tools-Word Count ili Fi-

le-Properties-Statistics.

Sva merenja, izuzev krvnog pritiska, moraju bitiizraèna u internacionalnim SI jedinicama, a ako jeneophodno, i u konvencionalnim jedinicama (u zagra-di). Za lekove se moraju koristiti generi~ka imena. Za-{ti}ena imena se mogu dodati u zagradi.

Savetujemo autore da sa~uvaju bar jednu kopijurukopisa za sebe. SANAMED nije odgovoran ako serukopis izgubi u po{ti.

Naslovna strana. Naslovna strana sadrì naslov ra-da, kratak naslov rada (do 50 slovnih mesta), puna prezi-mena i imena svih autora, naziv i mesto institucije u ko-joj je rad izvr{en, zahvalnost za pomo} u izvr{enju rada(ako je ima), obja{njenje skra}enica koje su kori{}ene utekstu (ako ih je bilo) i u donjem desnom uglu ime iadresu autora sa kojim }e se obavljati korespondencija.

Naslov rada treba da bude saèt, ali informativan.

Ako je potrebno, moè se dodati i podnaslov.

Kratak naslov treba da sadrì najbitnije informaci-je iz punog naslova rada, ali ne sme biti duì od 50slovnih mesta.

Ako je bilo materijalne ili neke druge pomo}i u iz-radi rada, onda se moè saèto izre}i zahvalnost osoba-ma ili institucijama koje su tu pomo} pruìle.

Treba otkucati listu svih skra}enica upotrebljenihu tekstu. Lista mora biti ure|ena po abecednom redupri ~emu svaku skra}enicu sledi obja{njenje. Uop{te,skra}enice treba izbegavati, ako nisu neophodne.

U donjem desnom uglu naslovne strane treba ot-kucati ime i prezime, telefonski broj, broj faksa i ta~nuadresu autora sa kojim ce se obavljati korespodencija.

Stranica sa saètkom. Saètak mora imati do 350re~i. Treba koncizno da iskaè cilj, rezultate i zaklju-~ak rada koji je opisan u rukopisu. Saètak ne moè sa-dràti skra}enice, fusnote i reference.

Klju~ne re~i. Ispod saètka treba navesti 3 do 8klju~nih re~i koje su potrebne za indeksiranje rada. Uizboru klju~nih re~i koristiti Medical Subject Headings— MeSH.

Stranica sa saètkom na engleskom jeziku. Tre-ba da sadrì pun naslov rada na engleskom jeziku, kra-tak naslov rada na engleskom jeziku, naziv institucijegde je rad ura|en na engleskom jeziku, tekst saètka naengleskom jeziku i klju~ne re~i na engleskom jeziku.

Struktura rada. Svi podnaslovi se pi{u velikimslovima i boldovano.

Originalni rad treba da ima slede}e podnaslove:uvod, cilj rada, metod rada, rezultati, diskusija, zaklju-~ak, literatura.

Prikaz bolesnika ~ine: uvod, prikaz bolesnika, di-skusija, literatura.

Pregled iz literature ~ine: uvod, odgovaraju}i pod-naslovi, zaklju~ak, literatura.

Bolesnici i metode/materijal i metode. Trebaopisati izbor bolesnika ili eksperimentalnih ìvotinja,uklju~uju}i kontrolu. Imena bolesnika i brojeve istorijane treba koristiti.

Metode rada treba opisati sa dovoljno detalja kakobi drugi istraìva~i mogli proceniti i ponoviti rad.

Kada se pi{e o eksperimentima na ljudima, trebapriloìti pismenu izjavu u kojoj se tvrdi da su eksperi-menti obavljeni u skladu sa moralnim standardima Ko-miteta za eksperimente na ljudima institucije u kojoj suautori radili, kao i prema uslovima Helsin{ke deklara-cije. Rizi~ne procedure ili hemikalije koje su upotre-bljene se moraju opisati do detalja, uklju~uju}i sve me-re predostro`nosti. Tako|e, ako je ra|eno na ìvotinja-ma, treba priloìti izjavu da se sa njima postupalo uskladu sa prihva}enim standardima.

Treba navesti statisti~ke metode koje su kori{}eneu obradi rezultata.

Rezultati. Rezultati treba da budu jasni i saèti, saminimalnim brojem tabela i slika neophodnih za dobruprezentaciju.

Diskusija. Ne treba ~initi obiman pregled literatu-re. Treba diskutovati glavne rezultate u vezi sa rezulta-tima objavljenim u drugim radovima. Poku{ati da seobjasne razlike izme|u dobijenih rezultata i rezultata

drugih autora. Hipoteze i spekulativne zaklju~ke trebajasno izdvojiti. Diskusija ne treba da bude ponovo iz-no{enje zaklju~aka.

Literatura. Reference numerisati rednim arapskimbrojevima prema redosledu navo|enja u tekstu. Broj re-ferenci ne bi trebalo da bude ve}i od 30, osim u pregleduliterature, u kojem je dozvoljeno da ih bude do 50.

Izbegavati kori{}enje apstrakta kao reference, aapstrakte starije od dve godine ne citirati.

Reference se citiraju prema tzv. Vankuverskimpravilima, koja su zasnovana na formatima koja kori-ste National Library of Medicine i Index Medicus.

Primeri:1. ^lanak: (svi autori se navode ako ih je {est i

manje, ako ih je vi{e navode se samo prva tri i dodajese ”et al.”)

Spates ST, Mellette JR, Fitzpatrick J. Metastaticbasal cell carcinoma. J Dermatol Surg 2003; 29:650–652.

2. Knjiga:

Sherlock S. Disease of the liver and biliary sys-tem. 8th ed. Oxford: Blackwell Sc Publ, 1989.

3. Poglavlje ili ~lanak u knjizi:

Latkovi} Z. Tumori o~nih kapaka. U: Litri~in O isar. Tumori oka. 1. izd. Beograd: Zavod za ud`be-nike i nastavna sredstva, 1998: 18–23.

Tabele. Tabele se ozna~avaju arapskim brojevimapo redosledu navo|enja u tekstu, sa nazivom tabele iz-nad. Svaku tabelu od{tampati na posebnom listu papirai dostaviti po jedan primerak uz svaku kopiju rada.

Slike. Sve ilustracije (fotografije, grafici, crteì) sesmatraju slikama i ozna~avaju se arapskim brojevima utekstu i na legendama, prema redosledu pojavljivanja.Treba koristiti minimalni broj slika koje su zaista neop-hodne za razumevanje rada. Slike nemaju nazive. Slova,brojevi i simboli moraju biti jasni, proporcionalni, i do-voljno veliki da se mogu reprodukovati. Pri izboru veli-~ine grafika treba voditi ra~una da prilikom njihovogsmanjivanja na {irinu jednog stupca teksta ne}e do}i dogubitka ~itljivosti. Legende za slike se moraju dati naposebnim listovima, nikako na samoj slici.

Ako je uveli~anje zna~ajno (fotomikrografije) onotreba da bude nazna~eno kalibracionom linijom na samojslici. Duìna kalibracione linije se unosi u legendu slike.

Treba poslati dva kompleta slika, u dva odvojenakoverta, za{ti}ene tvrdim kartonom. Na pozadini slikatreba napisati obi~nom olovkom prezime prvog autora,broj slike i strelicu koja pokazuje vrh slike.

Uz fotografije na kojima se bolesnici mogu prepo-znati treba poslati pismenu saglasnost bolesnika da seone objave.

Za slike koje su ranije ve} objavljivane treba na-vesti ta~an izvor, treba se zahvaliti autoru, i treba prilo-

80

ìti pismeni pristanak nosioca izdava~kog prava da seslike ponovo objave.

Pisma uredniku. Mogu se publikovali pisma ured-niku koja se odnose na radove koji su objavljeni u SA-NAMEDU, ali i druga pisma. Ona mogu sadràti i jed-nu tabelu ili sliku, i do pet referenci.

Propratno pismo. Uz rukopis obavezno priloìtipismo koje su potpisali svi autori, a koje treba da sadr-ì: izjavu da rad prethodno nije publikovan i da nijeistovremeno podnet za objavljivanje u nekom drugom~asopisu, te izjavu da su rukopis pro~itali i odobrili sviautori koji ispunjavaju merila autorstva. Tako|e je po-trebno dostaviti kopije svih dozvola za: reprodukova-nje prethodno objavljenog materijala, upotrebu ilustra-cija i objavljivanje informacija o poznatim ljudima iliimenovanje ljudi koji su doprineli izradi rada.

Tro{kovi pripreme rada

Svi autori radova, imaju obavezu da pre nego {todobiju potvrdu da }e rad biti objavljen u Sanamedu, iz-

vr{e uplatu za pokri}e dela tro{kova {tampe koja zaautora rada iznosi 1200 dinara, a za koautore po 700 di-nara, za svaki prihva}eni rad. Za autora rada iz ino-stranstva naknada za {tampanje iznosi 30 eura (u dinar-skoj protivrednosti po kursu na dan uplate), a za koau-tore 15 eura. Dodatno }e biti napla}ena svaka stranicana kojoj se nalaze slike u boji, po ceni od 30 eura; crnobele slike se ne napla}uju.

âsopis Sanamed zadràva pravo dalje distribuci-je i {tampanja radova. Naknade za {tampanje su oslo-bo|eni autori koji objave rad, na poziv Uredni{tva.

Za sva dalja uputstva i informacije kontaktirajteUredni{tvo.

Napomena. Rad koji ne ispunjava uslove ovoguputstva ne moè biti upu}en na recenziju i bi}e vra}enautorima da ga dopune i isprave. Pridràvanjem uput-stva za pisanje rada za SANAMED znatno }e se skratitivreme celokupnog procesa do objavljivanja rada u ~a-sopisu, {to }e pozitivno uticati na kvalitet i redovnostizlaènja svezaka.

81

INSTRUCTIONS TO AUTHORS

SANAMED is a medical journal, published since2006. The journal publishes: original papers, case re-ports, review articles, letters to the Editor, other articlesand information concerned with practice and researchin medicine.

Address manuscripts to:Prim. dr Avdo ]erani},(for Sanamed)Ul. Palih boraca 52, 36300 Novi PazarEmail sanamednp2006ªgmail.comwww.sanamed.rs

Arrived manuscript is sent to reviewers for expertassessment by the Editorial Board. If reviewers propo-se changes or amendments, copies of reviews are sub-mitted to authors with a request to enter the requiredchanges to the text or explain its disagreement with theremarks of the reviewer. The final decision of accep-tance for publishing is given by Editor in chief.

There are no paid royalties for published works,and copyrights are transferred to publisher. Manu-scripts are not returned. To reproduce or republish anypart of paper in SANAMED approval of publishers isrequired.

The journal is published in Serbian, with the sum-mary translated into English. Works of foreign authorsare published in English with a summary in Englishand Serbian.

GENERAL GUIDELINES

The manuscript should be submitted in triplicate,typed on one side of A4 white paper. Text of the papershould be typed in a word processing program Word,written in Latin, double-spaced, only in Times New Ro-

man font size 12 points. All margins should be set at 25mm, and the text should be typed with the left align-ment and paragraph indentations of 10 mm, without di-viding the words.

The manuscript should be arranged as following:title page, abstract, key words, introduction, patients andmethods/material and methods, results, discussion, con-clusion, references, tables, figure legends and figures.

Each manuscript component (title page, etc.) be-gins on a separate page. All pages are numbered consec-utively beginning with the title page. The first author’slast name is typed at the top right corner of each page.

References in the text are designated with Arabicnumerals in parentheses, and the order in which theyappear in the text.

Manuscript volume. The complete manuscript,which includes title page, short abstract, text of the ar-ticle, literature, all figures and permisions for them andlegends (tables, images, graphs, diagrams, drawings),title page and abstract in English, can have the lengthup to 5000 words for original paper, report, paper onthe history of medicine and literature overview, whilefor patient presentation, practice paper, educative arti-cle it can be up to 3000 words, and other papers can beup to 1500 words.

The word count check in a document can be donein Word processor program in submenu Tools Word Co-

unt or File Properties Statistics.

All measurements, except blood pressure, are re-ported in the System International (SI) and, if neces-sary, in conventional units (in parentheses). Genericnames are used for drugs. Brand names may be inser-ted in parentheses.

Authors are advised to retain extra copies of themanuscript. SANAMED is not responsible for the lossof manuscripts in the mail.

Title page. The title page contains the title, shorttitle, full names of all the authors, names and full loca-tion of the department and institution where work wasperformed, acknowledgments, abbreviations used,and name of the corresponding author. The title of thearticle is concise but informative, and it includes ani-mal species if appropriate. A subtitle can be added ifnecessary.

Ashort title of less than 50 spaces, for use as a run-ning head, is included.

A brief acknowledgment of grants and other assis-tance, if any, is included.

A list of abbreviations used in the paper, if any, isincluded. List abbreviations alphabetically followed

by an explanation of what they stand for. In general, theuse of abbreviations is discouraged unless they are es-sential for improving the readabillity of the text.

The name, telephone number, fax number, and ex-act postal address of the author to whom communicati-ons and reprints should be sent, are typed at the lowerright corner of the title page.

Abstract page. An abstract of less than 180 wordsconcisely states the objective, findings, and conclusionof the studies described in the manuscript. The abstractdoes not contain abbreviations, footnotes or references.

Below the abstract, 3 to 8 keywords or short phra-ses are provided for indexing purposes.

The structure of work. All headings are writtenin capital letters and bold.

Original work should have the following head-ings: introduction, aim, methods, results, discussion,conclusion, references.

A case report include: introduction, case report,discussion, references.

Review of the literature include: an introduction,subheadings, conclusion, references.

Patients and methods/Material and methods.

The selection of patients or experimental animals, in-cluding controls is described. Patients’ names and hos-pital numbers are not used.

Methods are described in sufficient detail to per-mit evaluation and duplication of the work by other in-vestigators.

When reporting experiments on human subjects,it should be indicated whether the procedures followedwere in accordance with ethical standards of the Com-mittee on human experimentation of the institution inwhich they were done and in accordance with the Dec-laration of Helsinki. Hazardous procedures or chemi-cals, if used, are described in detail, including the sa-fety precautions observed. When appropriate, a state-ment is included verifying that the care of laboratoryanimals followed the accepted standards.

Statistical methods used, are outlined.Results. Results are clear and concise, and inclu-

de a minimum number of tables and figures necessaryfor proper presentation.

Discussion. An exhaustive review of literature isnot necessary. The major findings should be discussedin relation to other published works. Attempts shouldbe made to explain differences between results of thepresent study and those of the others. The hypothesisand speculative statements should be clearly identi-fied. The discussion section should not be a restate-ment of results, and new results should not be introdu-ced in the discussion.

References. References are identified in the textby Arabic numerals in parentheses. They are numbe-

red consecutively in the order in which they appear inthe text. Number of references should not exceed 30,except in the literature review, which is allowed to beto 50.

Avoid using abstracts as references and abstractolder than two years are not cited.

References are cited by the so-called Vancouverrules, which are based on formats that use the NationalLibrary of Medicine and Index Medicus. The follow-ing are examples:

1. Article: (all authors are listed if there are six orfewer, otherwise only the first three are listed followedby “et al.“)

Spates ST, Mellette JR, Fitzpatrick J. Metastaticbasal cell carcinoma. J Dermatol Surg 2003; 29:650–652.

2. Book:

Sherlock S. Disease of the liver and biliary sys-tem. 8th ed. Oxford: Blackwell Sc Publ, 1989.

3. Chapter or article in a book:

Trier JJ. Celiac sprue. In: Sleisenger MH, For-dtran J5, eds. Gastro-intestinal disease. 4 th ed.Philadelphia: WB Saunders Co, 1989: 1134–52.

Tables. Tables are typed on separate sheets withfigure numbers (Arabic) and title above the table andexplanatory notes, if any, below the table.

Figures and figure legends. All illustrations(photographs, graphs, diagrams) are to be consideredfigures, and are numbered consecutively in the text andfigure legend in Arabic numerals. The number of figu-res included is the least required to convey the messageof the paper, and no figure duplicates the data presen-ted in the tables or text. Figures do not have titles. Let-ters, numerals and symbols must be clear, in proportionto each other, and large enough to be readable when re-duced for publication. Figures are submitted as near totheir printed size as possible. Legends for figures sho-uld be given on separate pages.

If magnification is significant (photomicrographs),it is indicated by a calibration bar on the print, not by amagnification factor in the figure legend. The length ofthe bar is indicated on the figure or in the figure legend.

Two complete sets of high quality unmountedglossy prints are submitted in two separate envelopes,and shielded by an appropriate cardboard. The backs ofsingle or grouped illustrations (plates) bear the first au-thor’s last name, figure number, and an arrow indicat-ing the top. This information is penciled in lightly orplaced on a typed self-adhesive label in order to pre-vent marking the front surface of the illustration.

Photographs of identifiable patients are accompa-nied by written permission from the patient.

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For figures published previously, the original sou-rce is acknowledged, and written permission from thecopyright holder to reproduce it is submitted.

Letters to the Editor. Both letters concerning andthose not concerning the articles that have been publishedin SANAMED will be considered for publication. Theymay contain one table or figure and up to five references.

Cover letter. The letter signed by all authors mustbe attached with the manuscript. The letter should con-sist of: the statement that the paper has not been publis-hed previously and that it is not submitted for publica-tion to some other journal, the statement that the manu-script has been read and approved by all the authorswho fulfill the authorship criteria. Furthermore, aut-hors should attach copies of all permits: for reproduc-tion of previously published materials, for use of illus-trations and for publication of information about pub-licly known persons or naming the people who contrib-uted to the creation of the work.

Costs of paper preparation

All authors of papers, have obligation, before theyreceive confirmation that the paper will be published in

Sanamed, to pay part of expenses of printing, which is1200 RSD for author, 700 RSD for co-authors, for eachpaper.

For paper author from abroad printing fees are 30Euro (in Dinar equivalent at the exchange rate on theday of payment), and 15 Euro for co-authors. Addition-ally will be charged each page with pictures in color,costing 30 Euro; black and white pictures will not becharged.

Sanamed journal keeps the right of further distri-bution and paper printing.

Authors, invited by the Editorial Board for publis-hing in Sanamed journal are free of payment.

For any further instructions and information, con-tact Editorial Board.

Note. The paper which does not fulfill the conditi-ons set in this instruction cannot be set to reviewers andwill be returned to the authors for amendments and cor-rections. By following the instructions for writing thepapers for Medical Journal, the time needed for theprocess of publication of papers in the journal will beshortened, which will have positive impact on the qual-ity and regularity of publication of volumes.

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SANAMED / glavni i odgovorni urednik Avdo ]erani}. —God. 1, br. 1 (2006)– . — Novi Pazar : Udru`enje lekara Sana-med, 2006– (Novi Pazar : ProGraphico). — 30 cm

Tri puta godišnje. — Drugo izdanje na drugom medijumu: Sana-med (Online) = ISSN 2217-8171

ISSN 1452-662X = Sanamed

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sanamed 10(1) 2015

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