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7 UBT ANNUAL INTERNATIONALCONFERENCE

th

Proceedings of the 7th Annual International Conference

International Conference Medical, Chemical and

Pharmaceutical Sciences

Edited by

Edmond Hajrizi

October, 2018

Conference Book of Proceedings

International Conference

Pristina, 26-28 October 2018

© UBT – Higher Education Institution International Conference on Business, Technology and

Innovation

Pristina, Kosovo 26-28 October 2018

Editor: Edmond Hajrizi

Organizing Committee: Edmond Hajrizi, Murat Retkoceri, Hasan Metin, Bertan Karahoda, Eda Mehmeti, Xhemajl Mehmeti, Betim Gashi, Muhamet Sherifi, Muhamet Gërvalla, Bejtush Ademi, Artan Mustafa, Mimoza Sylejmani, Valon Dërguti, Visar Krelani, Krenare Pireva, Anisa Rada, Alisa Sadiku, Jorida Xhafaj, Vjollca Shahini, Rineta Jashari, Vjosa Hamiti, Mirlinda Reqica, Lirigzona Morina, Milot Reqica, Arbër Salihu, Eltis Sulejmani

Authors themselves are responsible for the integrity of what is being published. Copyright © 2018 UBT. All rights reserved.

Publisher, UBT

ISBN 978-9951-437-80-6

1

Editor Speech of IC - BTI 2018

International Conference is the 7th international interdisciplinary peer reviewed

conference which publishes works of the scientists as well as practitionersi n the area

where UBT is active in Education, Research and Development.

The UBT aims to implement an integrated strategy to establish itself as an

internationally competitive, research-intensive institution, committed to the transfer of

knowledge and the provision of a world-class education to the most talented students

from all backgrounds. It is delivering different courses in science, management and

technology.

This year we celebrate the 17th Years Anniversary.

The main perspective of the conference is to connect the scientists and practitioners

from different disciplines in the same place and make them be aware of the recent

advancements in different research fields, and provide them with a unique forum to

share their experiences. It is also the place to support the new academic staff for doing

research and publish their work in international standard level.

This conference consists of sub conferences in different fields:

- Management, Business and Economics

- Humanities and Social Sciences (Law, Political Sciences, Media and

Communications)

- Computer Science and Information Systems

- Mechatronics, Robotics, Energy and Systems Engineering

- Architecture, Integrated Design, Spatial Planning, Civil Engineering and

Infrastructure

- Life Sciences and Technologies (Health and Food)

This conference is the major scientific event of the UBT. It is organizing annually and

always in cooperation with the partner universities from the region and Europe.

In this case as partner universities are: University of Tirana – Faculty of Economics,

University of Korca. As professional partners in this conference are: Kosova

Association for Control, Automation and Systems Engineering (KA – CASE), Kosova

Association for Modeling and Simulation (KA – SIM), Quality Kosova, Kosova

Association for Management.

This conference is sponsored by EUROSIM - The European Association of

Simulation.

We have to thank all Authors, partners, sponsors and also the conference organizing

team making this event a real international scientific event. This year we have more

application, participants and publication than last year.

Congratulations!

Edmond Hajrizi,

Rector of UBT and Chair of IC - BTI 2018

2

CONTENTS Increased risk of falling of elderly men .............................................................................. 3 Altin Erindi .......................................................................................................................................... 3

Impact of Psychosocial Factors on Postpartum Depression of Mothers ........................... 16 Anita Sadikaj1, Artemisi Shehu2 ........................................................................................................ 16

Cranial Injuries with Screwdriver – UCCK ...................................................................... 22 Besnik Elshani¹, Salih Krasniqi¹ .......................................................................................................... 22

Nursing Care in Children with Type 1 Diabetes Mellitus ................................................ 27 Doruntina Ismaili1,Fëllënza Spahiu2,Lirije Beqiri2,Afërdita Berisha2 .................................................. 27

Side effects of metoclopramide (Reglan) oral overdose in pediatric patients ................... 36 Edmont Laho1,,Xhejni Borshi 2, Indrit Bimi3, Eti Muharremi4 ........................................................... 36

Topic: Evaluation of the appearance of dermatological bullous diseases in the oral cavity

.......................................................................................................................................... 43 Ilma Robo1, Vera Ostreni1, Eriola Meta1, Alert Xhaja2, Saimir Heta3.................................................. 43

RECIPROCAL GENETIC EFFECTS IN WEIGHT AND BLOOD GROUPS ............... 54 Naser Kamberi1 , Hyzer Rizani2 .......................................................................................................... 54

The impact end therapeutic efficacy of chlorhexidine-gel in gingival inflammation in

chronic Periodontopathy .................................................................................................. 60 Sahmedin Sali¹,.................................................................................................................................. 60

Topic: Gastro-oesophageal reflux,some data on diagnosis and clinical evaluation .......... 70 Saimir Heta, Kastriot Haxhirexha, Virtut Velmishi, Nevila Alliu, Ilma Robo ....................................... 70

Echocardiography in emergency room ............................................................................. 81 Sejran Abdushi1, Fadil Kryeziu1, Shpend Abdushi2............................................................................. 81

3

Increased risk of falling of elderly men

Altin Erindi

Introduction.

Obesity is recognized as a major health problem in many parts of the world and the incidence of

the condition is escalating at an alarming rate (1, 2). The global trend of increasing obesity

indicates that current measures in preventing, treating and managing the condition are ineffective

(3). Obesity significantly increases the risk of developing numerous medical conditions including

hypertension, stroke, respiratory disease, type 2 diabetes, gout, osteoarthritis, certain cancers and

various musculoskeletal disorders, particularly of the lower limbs and feet (4, 5). Despite

significant advances in our knowledge and understanding of the multi-factorial nature of the

condition, many questions regarding the specific consequences of the disease remain

unanswered.

Intense, short lasting muscle exertions are required frequently during everyday activities.

Obviously examples are when rising form a chair or ascending stairs. These exertions depend

upon the ability of the muscles to generate power, which involves the product of contractile force

and concentration velocity (i.e., speed of movement ;) (33). In younger people such movements

are normally trivial, but they may become challenging for the elderly person, since muscle power

deteriorates with aging (44)

The age-related decrease in muscle power is more pronounced than the decrease in muscle

strength (3.5% versus 1.5-2% per year from the age of 65 years ;) (44). Therefore, the decreased

muscle power may predispose a person to a higher risk of functional limitations in everyday

activities than is implied by the loss in muscle strength (16, 17, and 45).

Relative to the extensive literature now available on many aspects of the obese condition, there

is a dearth of information pertaining to the functional limitations imposed by overweight and

obesity. Subjective references have been made to the difficulties encountered by the overweight

and obese when executing simple activities of daily living (6). However, the implications of

persistent obesity on the musculoskeletal and locomotor’s systems, particularly

during weight bearing tasks such as walking and stair climbing, are poorly understood. To date,

the study of locomotor tasks has focused predominantly on normal weight individuals and

particularly those without physical disabilities associated with obesity. The limited number of

published studies focusing on the obese have encompassed the locomotor characteristics of obese

adults, plantar pressures under the feet of the obese, the influence of obesity on muscular strength

and power, and the potential relationships between obesity and postural control.

In spite of significant advances in the knowledge and understanding of the multifactorial nature

of obesity, many questions regarding the specific consequences of the disease remain

unanswered. In particular, there is a relative dearth of information pertaining to the functional

limitations imposed by overweight and obesity. The limited number of studies, to date, has been

mainly focused on the effect of obesity on the temporo-spatial characteristics of walking, plantar

foot pressures, muscular strength and, to a lesser extent, postural balance. Collectively, these

studies have implied that the functional limitations imposed by the additional loading of the

locomotor system in obesity result in aberrant mechanics and the potential for musculo-skeletal

injury. Despite the greater prevalence of musculoskeletal disorders in the obese, there has been

surprisingly little empirical investigation pertaining to the biomechanics of activities of daily

living or into the mechanical and neuromuscular factors that may predispose the obese to injury.

A better appreciation of the implications of increased levels of body adiposity on the movement

4

capabilities of the obese would afford a greater opportunity to provide meaningful support in

preventing, treating and managing the condition and its sequelae. Moreover, there is an urgent

need to establish the physical consequences of continued repetitive loading of major structures

of the body, particularly of the lower limbs in the obese, during the diverse range of activities of

daily living.

Effects of obesity on musculoskeletal function.

Research into the effect of adiposity on musculoskeletal function has largely focused on the

impact of obesity on the locomotor characteristics of adults and, to a lesser extent, focused on the

influence of increased fat mass on muscular strength and postural balance. Although in its

infancy, recent research has also investigated the movement strategies adopted by the overweight

and obese in performing activities of daily living, such as moving from a seated to standing

position.

Muscular strength and power Impaired muscle strength has been linked with complaints

involving the lower back and legs (7) and in the development of osteoarthritis of the knee (8, 9).

Although research has generally indicated that obese adults present with greater absolute strength

and power of muscles of the trunk and lower extremity (10, 11), the effect appears to be highly

site-specific. Studies evaluating both isometric and isokinetic knee extensor strength have

consistently reported superior absolute strength in obese individuals (10, 12, 13), whereas

absolute knee flexion strength has been reported to be either similar (10) or reduced (13) when

compared with normal-weight individuals. Likewise, the effects of obesity on absolute grip

strength appear equivocal, with studies reporting either increased (12), decreased (14) or no

difference in absolute grip strength (10) between obese and non-obese adults. However,

anthropometric factors, such as muscle morphology, appear to be the major determinants of age-

and gender-related differences in muscle strength (15–18). Consequently most clinical

investigations have adjusted for the increase in fat-free mass associated with obesity by

employing simple ratio standards in which strength is expressed relative to body weight or lean

body weight (9, 12, 14, and 19). In contrast to measures of absolute strength, obese subjects have

reduced isometric (~11–16%) and isokinetic knee extensor strength when adjusted for body

weight and compared with normal-weight subjects (12, 14, and 20). Although the rationale

underlying the normalization of strength measures based on simple ratio standards has been

recently questioned (21), more complex allometric approaches, in which knee strength was

expressed as an exponent of body weight, have reported similar reductions (~ 6%) in relative

knee extensor strength with obesity (10). Reductions in trunk extension (~10%), knee flexion (~

20%) and handgrip strength (~10%) have also been reported in the obese when the data were

corrected for differences in fat-free mass using allometric scaling (10).

It would appear, therefore, that even with the purported training effect and subsequent

hypertrophy incurred by lower extremity muscles in supporting and moving the additional mass

of adipose tissue (22, 23), obesity is characterized by reduced muscular strength. Hulens et al.

(10), in comparing the relative strength of the trunk, knee and hand in obese and non-obese

women, proposed that the relative reduction in strength observed in the obese was indicative of

impaired muscle function, rather than reduced physical activity, and was likely the consequence

of an altered metabolic state in obesity. In support of this concept, the hypertrophic muscle fibres

observed in obese adults have been shown to have a reduced oxidative capacity (24, 25), which

may, in part, reflect a decreased capillary density (26). Although suggestive of a lowered

muscular endurance in the obese, animal studies have indicated that the oxidative capacity of

muscle is positively influenced by physical activity (27) and, as such, the lower oxidative capacity

noted in muscle fibres of obese humans may reflect a lower level of physical activity within this

population. Moreover, Blimkie et al. (20) found no difference in the intrinsic strength or

5

contractile properties of the extensor muscles of the knee in obese and normal weight adolescents

when evoked via percutaneous stimulation. The authors subsequently attributed the lower knee

extension strength observed during maximum voluntary contraction in the obese to a reduced

neuromuscular activation of motor units. Motor unit activity, in turn, has been reported to be

dependent on several factors including motivation and physical activity level (22). The impaired

strength associated with obesity therefore appears to reflect a lower level of activity in association

with an increase in non-contributory mass. While it is recognized that inadequate muscular

strength, particularly of the lower limbs, can limit individuals from successfully performing

everyday tasks and predispose to a greater risk of fatigue and musculoskeletal injury (7), further

research into the long-term effect of reduced motor performance seems warranted.

Postural balance.

Research investigating the effect of adiposity on postural balance in adults is limited and, to date,

has primarily focused on measures of antero-posterior stability during bipedal stance (28–30).

Kejonen et al. (28) investigated the relationship between non-vestibular factors, such as body

anthropometry, on performance in tests of postural equilibrium in 100 healthy adults. Body mass

index (BMI) was the only characteristic that correlated with the antero-posterior movement of

the ankle during quiet bipedal stance. Similarly, Fregly et al. (31) identified abdominal

circumference, endomorphy and body weight as the most important factors influencing the

performance of military recruits on postural tests. The authors proposed that, in overweight

individuals, body size and shape influenced static postural stability by altering the location of the

centre of gravity. In support of this notion, Corbeil et al. (30), using a 15- segment model of the

body to investigate the effect of obesity on antero-posterior stability during bipedal stance,

indicated that with an anterior displacement of the centre of mass (2cm), a significantly greater

ankle torque was required to stabilize the body. Although a similar, but lesser, effect on ankle

torque was also noted with an increase in fat mass alone, the authors hypothesized that an anterior

displacement of the centre of mass would place obese individuals closer to their boundaries of

stability and, as such, at greater risk of falling when exposed to daily postural stress and

perturbations. However, Gravante et al. (29) found no difference in the location of the centre of

pressure during bipedal stance in 38 obese and 34 non-obese adults when measured via a force

platform. Thus, the authors suggested that, despite obese subjects presenting with an increased

waist-to-hip circumference ratio, the distribution of body fat did not appear to result in an anterior

displacement of the centre of mass during quiet stance.

Although largely untested, it seems logical that the increased antero-posterior sway observed

with obesity likely represents a limitation of controlling the inertial properties associated with

greater fat mass, rather than an impaired postural control system itself. By modifying muscle

activation patterns within the lower limb, both cutaneous and load receptor input are important

for the maintenance of bipedal stance and locomotion (32–34). In particular, the strength of leg

extensor muscle activation is dependent on load (35), with a reduced sensitivity to loading also

implicated in the development of certain movement disorders (36). There is also evidence that

the timing of neuromuscular responses has a profound influence on measures of postural sway

(37), by presumably altering the joint torque required to stabilize the body (30). In support of this

concept, Ledin and Odkvist (38) demonstrated a greater sway area, and slower sway velocity,

when normal-weight individuals were required to stand with added weight (20% body weight)

distributed evenly about the trunk. Similarly, Sartotio et al. (39) reported an improved time for

one-legged standing balance in 230 obese adults (BMI: 31.1– 65.8 kg m2 ) following a weight

loss programme consisting of a reduced caloric diet in conjunction with a low-intensity exercise

programme. In the absence of a control group, however, it is difficult to attribute the improved

performance on the balance task solely to a reduction in fat mass, especially because the improved

6

motor control may also represent a training effect (40, 41). While obesity has been shown to

induce a relative reduction in the strength of lower limb muscles once adjustments are made for

body weight (12, 14), the influence of adiposity on the state of the sensory-motor system has not

been established within the literature.

To date, most studies investigating postural control in the obese have employed cross-sectional

study designs and have not considered the potentially confounding effects of physical activity.

Physical activity status has been shown to have a profound influence on balance performance in

adults (42), and as such may obfuscate the effect of obesity on postural control. Given the

association between obesity and physical inactivity (43–46), it is unclear whether the additional

mass associated with obesity results in reduced postural stability, or alternately, whether the

greater adiposity of the obese is the consequence of postural instability and reduced activity.

There is also limited information regarding the regulation of medio-lateral balance in adult

obesity, despite its considerable importance to dynamic activities such as gait. Given that

epidemiological research has indicated a potential link between obesity and risk of falling (47),

further research employing a longitudinal study design in conjunction with measures of physical

activity may provide greater insight into the effects of obesity on postural balance in adults.

Reductions in step length and step frequency also noted (13, 56, and 57). In addition to a reduced

walking speed, a longer stance phase duration, shorter swing phase and a greater period of double

support have also been reported when compared with normal-weight individuals (56, 57).

Messier et al. (59) proposed that the greater prevalence of lower limb injuries in the obese was

the result of altered frontal plane mechanics of the foot and lower limb during gait. More recent

research involving the overweight and obese, however, has demonstrated that plantar pressures

are moderately dependent on body weight (29, 54).

Despite having larger footprint contact areas (~10%), Gravante et al. (29) observed that peak

pressures were 40–45% higher in obese subjects during stance, when compared with normal-

weight subjects, for men and women respectively).

Our aim.

The aim of this paper is to understand the effects of overweight or obesity on the lower limbs

during a simple Counter Movement Jump and Squat Jump. It is one of the key issues that may

challenge the overweight and obese when completing activities of daily living, including one the

most fundamental of voluntary movement patterns, jumping, reversing a movement during a

forward fall.

Because of the scale of the problem of obesity and the relative paucity of information available,

there is an urgent need to focus more attention on the physical consequences of repetitive loading

of major structures, particularly the lower extremity.

Material and Method

Subjects.

Community-dwelling elderly people 10 obese of average age of 58.6 years and 10 of normal

weight of average age of 60.9 years, with no statistically significant differences. A medical doctor

performed a medical evaluation, including an electrocardiogram and anamnesis, in order to

exclude any disease that could interfere with the tests. Subjects taking medication were only

included in the experiment if they were medically stable. At the time of the experiment the

7

subjects did not participate in any regular physical activity. All the subjects gave their informed

written consent to participate, and the local ethical committee approved the study.

Measurements

Anthropometry

Anthropometric data are reported in Table 1. The measures were done using calibrated measuring

appliances and standard methods of measuring. The height of subjects was measured in

centimeters (cm) by height gauge to the nearest 0, 5 cm and body mass and weight was assessed

in kilograms (kg) using the medical digital scales, with participants lightly dressed. Body mass

index (BMI) was calculated using the formula: BMI = weight in kilograms divided by square of

height in meters (kg/m2). We considered BMI as overweight when 25< BMI<30 kg/m2, and as

obesity when BMI>30 kg/m2. The Waist circumference was measured to the nearest 0, 5 cm with

a Gulick Handle in the level of the biiliac crestae.

Muscle power

Muscle power was assessed during a standardized both-legs counter-movement jump performed

on an Ergojump, a Bosco System licensed platform (Figure 1). Starting from a standing position.

The subjects (who were wearing comfortable shoes) were instructed to perform a fast downward

movement (to about 90o knee flexion) immediately followed by a fast upward movement, and to

jump as high as possible. Hands were kept on the hips to minimize any influence of the arms.

The jump was demonstrated to the subject, who subsequently performed two submaximal trials.

Following a short rest, three maximal jumps were performed at 1-min intervals, and the highest

jump was selected for further analysis.

Also the squat jump was performed after the subjects were instructed to perform the jump starting

from the position of half sitting (with the knee flexion of about 90o ) immediately followed by a

fast upward movement and to jump as high as possible. Hands were also kept on the hips to

minimize any influence of the arms. The jump was demonstrated to the subjects, who

subsequently performed two submaximal trials. Following a short rest, three maximal jumps were

performed at 1-min intervals, and the highest jump was selected for the analysis.

Figure 1. Methodology of

assessing the muscle power,

height, and contact time during

a standardized both-legs

counter-movement jump and

squat jump performed on an

Ergojump, a Bosco System

licensed platform.

Statistics: average, standard deviation, t-test, correlation. Descriptive measures were calculated for

all variables using a statistical package for social sciences (SPSS 15 for Windows XP). All the

data were tested for their normal distribution. Results are expressed as average ± SD and p<0.05

was considered statistically significant. For all parameters, a systematic bias between days was

assessed with a Student's t-test. Differences between jump types were investigated by using a

paired t-test.

8

Results

Table 1. Physical anthropometric characteristics of the subjects that participated in these

tests. The data are given as the average and standard deviation.

Table 2. Physical plyometric characteristics of the subjects that participated in these tests.

The data are given as the average and standard deviation.

Discussion.

The obese subjects have nearly the same muscle mass as those that have a norm weight, only that

they have to bear much more than the muscles, their adipose tissue, in their everyday life. This

predispose obese subjects to a greater and earlier risk of loss of independence than their peer

normal weight subjects during aging, and may present an important factor for the falls. Weight-

bearing tests, which appear more relevant for evaluating functional capacity, have rarely been

used to assess muscle power in healthy elderly people.

The power, produced by the muscle during the everyday life is closely related with the time

necessary for producing it. Only a 200 msec contact time interval discriminates the fallers from

the non fallers (65), normally it is necessary a 300 – 500 msec ground contact time to reach peak

force in human skeletal muscle (66, 62) and up to 1500 msec time to reach peak force during

multi-joint motor tasks in elderly subjects. This meaning that the elderly subjects are more prone

Characteristic Obese

(n=10)

SD Normal weight (n=10) SD

Age (years) 58.60 5.94 60.90 5.43

Height (cm) 167.80 6.91 168.60 5.85

Weight (kg) 92.60 10.72 64.40 5.61

BMI (kg*m-2) 32.88 3.09 22.65 1.40

Waist Circumference (cm)

111.80 8.84 89.85 3.89

Characteristic Obese

(n=10)

SD Normal weight

(n=10)

SD

SJ time (ms) 757.00 82.33 497.80 37.66

SJ high (cm) 21.51 0.95 23.30 3.01

CMJ Time (ms) 718.50 84.84 446.10 20.53

CMJ (cm) 26.65 4.87 28.65 3.78

∆ Jump-height (CMJ-SQJ) 5.15 4.49 5.35 3.84

Power out-put (W*kg-

1) 16.75 0.93 18.13 1.78

Total Power out-put (W)

1554.11 223.41 1172.34

194.12

9

to fall due to the fact that they cannot react in time to reverse a falling or a stair climbing or other

everyday situations.

Between the two groups there was no statistically significant difference for the age and the height,

and the power produced for kilogram.

The jump height is higher in lean subjects compared with obese, but it is statistically significantly

different (p<0.002), and the power produced is much higher from the obese subjects for the same

jump have to produce more energy.

To compare the two jump types, only their respective concentric phases were considered. In the

CMJ, the concentric phase was defined as the time period of upward movement of the Center of

Mass, while this phase constituted the entire push-off phase in the SJ. Peak power was determined

in the concentric phase of the Counter Movement Jump.

Maximal jump height was greater in countermovement jump (CMJ) compared with squat jump

(SQJ), yielding an augmentation in jump height from SQJ to CMJ ( jump-height CMJ-SQJ) of 5.15

cm for obese people and 5.35 cm for norm weight people. Maximal jump height for the obese

subjects was significantly greater for CMJ compared with SQJ [28.66 (SD 3.78) vs. 23.30 (SD

3.01) cm, P < 0.01], yielding a jump-height CMJ-SQJ of 5.35 cm with a SD of 3.84 cm (Table 2).

Maximal jump height for the lean subjects was significantly greater for CMJ compared with SQJ

[26.65 (SD 4.87) vs. 21.51 (SD 0.95) cm, P < 0.01], yielding a jump-height CMJ-SQJ of 5.15 cm

with a SD of 4.49 cm (Table 2).

Peak power output was different between obese and normal weight people. The obese men

produced a higher total power output than those of normal weight, but the reduced muscle power

per kg of weight of obese man as we see from the results obtained, during aging, make them more

prone than norm weight subjects to experience a reduced ability in managing simple everyday

activities. This may result in pronounced differences in the ability to cope with more demanding,

including various “emergency situations” where rapid executions and high muscle forces are

required (e.g. when regaining balance after tripping or a quick stop to avoid unexpected obstacles)

(63, 64).

Eccentric muscle actions often precede concentric contractions during everyday movements

based on a normal control strategy. The mechanical output of such coupled eccentric muscle

actions and concentric contractions is known to be superior to isolated concentric contractions

(50, 51). This fact is frequently utilized during everyday activities (e.g. when climbing a relatively

high step, as when alighting a bus). Eccentric muscle actions are also used frequently to control

or attenuate impact forces (e.g. when stepping down from a stair or sidewalk, when providing

stabilization during locomotion, or when trying to reverse the movement during a forward

fall)(52).

Although not tested, it seems logical that the increased antero-posterior sway observed with

obesity likely represents a limitation of controlling the inertial properties associated with greater

fat mass, rather than an impaired postural control system itself.

There is also evidence that the timing of neuromuscular responses has a profound influence on

measures of postural sway (37), by presumably altering the joint torque required to stabilize the

body (30).

Other factors, including an anterior tilt of the upper body, an altered step frequency, greater

vertical displacement of the centre of mass and extraneous movements resulting from greater

limb dimensions have also been hypothesized to reduce the mechanical efficiency of walking in

the obese, thereby increasing the metabolic cost of the task (55, 60, and 61). The excessive rear

foot movement associated with obesity might place additional strain on musculo-tendinous

structures of the lower limb, thus increasing the likelihood of injury. However, despite the

reduction in walking speed, BMI was still moderately correlated with the impact force and the

absolute force maxima (N) measured within the vertical and horizontal force components.

The greater adiposity tissue might contribute to the development of knee osteoarthritis by

impairing the ability of the obese to attenuate vertical load.

10

The finding that BMI and absolute vertical reaction force are positively correlated is not

surprising given the Newtonian association between body mass and ground reaction force.

Also in normal-weight subjects, the sit-to-stand tasks were characterized by a forward trunk

flexion, which resulted in a hip joint torque that was approximately twice that of the knee. Obese

subjects, however, adopted a different movement strategy to complete the sit-to-stand task that

was characterized by reduced trunk flexion and a posterior movement of the feet from their initial

position. The alternative strategy effectively limited the torque at the hip but at the expense of a

heightened knee joint moment, which was almost double that observed in normal-weight adults

(Figure 2). the limited trunk flexion and greater ankle dorsi-flexion that was characteristic of the

obese was evident only at the beginning of the movement task as previously reported in similar

tasks that involve the sitting in a chair etc. Galli et al (58) said that there is evidence that the

increased mass associated with obesity contributes to a relative reduction in muscle strength in

the obese (10), and presumably greater muscle fatigue.

Figure 2. Illustration of jumping strategies adopted by normal-weight and

obese individuals. (a) In normal-weight individuals, the sit-to-stand

movement is characterized by a forward flexion of the trunk, resulting in a

hip joint torque (solid arrow) approximately twice that of the knee (hollow

arrow). (b) In contrast, the obese strategy is characterized by reduced trunk

flexion and a posterior movement of the feet (D￠) resulting in relatively

low hip joint torque (solid arrow) but a knee joint moment (hollow arrow)

approximately double that observed in normal-weight adults. (From

Wearing et al 2006) (48).

It has previously been discussed whether the increase in jump height that

occurs when an eccentric contraction precedes the concentric push-off

phase (i.e., difference in jump height in SQJ vs. CMJ) is due to "elastic

energy recoil" by means of release of energy stored in the connective tissue

during the eccentric phase (50, 51), or whether jump height enhancement occurs due to a

potentiating effect on joint torque in the initial concentric phase resulting from the preceding

eccentric contraction (59). In the present study, this issue was addressed by correlating the

enhancement in jump height from SQJ to CMJ to the elastic properties of the tendinous structures

and the energy storage during the entire ramp contraction (0–90% MVC). (35). No relation was

observed between jump-height CMJ-SQJ and the elastic properties of the aponeurosis-tendon

structures, indicating that, at least for the knee extensor muscles, the increase in jump height with

CMJ is mainly associated with the increased force output in the initial push-off phase that is a

result of the preceding eccentric loading phase, which thus optimizes the kinetic impulse in the

push-off phase. This observation is in line with the observations of Zajac (53) Jump performance

is logically evaluated by jump height, but, because jumping is a highly complex movement task,

the ground reaction force signal was examined in detail to elucidate the mechanical characteristics

of the jump (49, 52). Maximal jump height is mainly determined by the power generated by the

knee extensor muscles during the concentric push-off phase (35). The jump height was associated

with connective tissue stiffness, and, combined with the observed relations between jump height,

contact time with the ground before the take-off, force and velocity, it seems that also in complex

movement tasks that include dynamic muscle actions such as jumping, the ability of the

connective tissue to transmit force effectively (i.e., stiffness) from the contracting elements to the

bone has importance for optimal jump performance (35).

Previous studies have emphasized the importance of correcting for scale when comparing

measures of physical performance to avoid influence of body size. The present data were

normalized to body mass.

11

The possibility exists, that obese man may be affected by their weight more than norm weight

subjects during explosive movements involving the small muscles groups.

The correlation coefficient between the waist circumference and the CMJ contact time is -0.701

but only in obese subjects, correlation that is not very high, but enough to understand the fact that

there is a connection between the two parameters. This maybe due to the changes of the position

in the Center of Mass (30) as found from Corbeil et al.

So, obesity significantly increases the risk of developing numerous medical conditions including

hypertension, stroke, respiratory disease, type 2 diabetes, gout, osteoarthritis, certain cancers and

various musculoskeletal disorders, particularly of the lower limbs and feet (4,5), but also make

this subjects to bear with them in their everyday life all this weight that makes them be at higher

risk of falling and suffer form fractures or other traumatologic problems. The test-retest reliability

for the reaction tests were lower (r ranging from 0.72 to 0.83). Hoffman & Kang found that the

results indicate that this testing device (Ergojump System) shows high test-retest reliability (r = 0.90), to assess CMJ height. In addition, anaerobic power assessment in a jump test provides

a specific measure of anaerobic power for many sports incorporating similar performance

patterns (67).

Conclusions.

The marked lower capacity for concentric contractions in obese man may result in an impaired

performance, especially in activities where intense and rapid movements are essential, for

example when reversing a forward fall. This may be one reason why obese elderly man are more

prone to falls than normal weight men, due to this they try to walk slower and doing so they use

less energy in their daily living with the result of more adipose tissue to carry during their life.

Perspectives.

A further understanding of the phases of the movement would be beneficial for the development

of specific training programs for preventive and rehabilitative strategies for the obese elderly

people. The necessity, to have at our lab, the equipment for EMG and Plate forces, for a better

testing of the SJ and CMJ.

Acknowledgements.

I would like to thank the volunteers that participated in the study. The chief of the department of

sport medicine of the Albanian University of Sport Sciences and Bashkim Delia and Perparim

Ferunaj for helping with the subjects and the testing procedures.

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16

Impact of Psychosocial Factors on Postpartum

Depression of Mothers

Anita Sadikaj1, Artemisi Shehu2

1 UBT-Higher Education Institution 2 DPP, Faculty of Social Sciences, University of Tirana

1anita.sadikaj@hotmail.com; 2artemisashehu@yahoo.com

Abstract. Postpartum depression (PPD) is an important depression episode which begins in

pregnancy or within 4 weeks after giving birth. Research is conducted in Gynecology and

Obstetrics Clinic, Pediatric Clinic and in private Hospital “Lindja”, in Prishtina, during period

May-June in 2018. Study is focused in relation of psychosocial factors such as: birthplace,

education, employment, economic level, mental health, number of children, breastfeeding,

anxiety, spousal relationship and social support. Subjects of this study were 136 mothers, from

the third day of giving birth till one year after this. The instruments were self-reporters, using

Edinburgh Postnatal Depression Scale (EPDS). Results showed that prevalence of

depression was 12,61%, in the sample of 136 subjects with an average age of 31.3 ± 6.4, years

of education 12±2,5, mostly living in rural area 44.9%. Related to social support, mothers report

high level of family and spousal support (respectively M=22.13±5.5; M=22.78±5.46) and lower

level of social support. Results notify that most of these factors have significant role.

Keywords: Mothers, PPD, Psychosocial factors, Family support

Introduction

The postnatal period is known as the time when women develop susceptibility to a variety of

emotional symptoms. However, postpartum depression is widely considered as a possible mood

disorder.

The American Psychological Association describes postpartum depression as, “a serious mental

health problem characterized by a prolonged period of emotional disturbance, occurring at a time

of major life change and increased responsibilities in the care of a newborn infant” (APA, 2015).

Postpartum Depression is the most emotional problem spread throughout women's lives

(Guardino & Schetter, 2014). PPD

is an easily recognizable, very widespread but very underdeveloped disease. Previous studies on

different communities show that mental disorders in women are mainly seen in reproductive age,

whereas after childbirth the risks of emerging of these problems have increased (Oslen et al,

2009). Therefore, pregnancy and motherhood are known as a possible period of women's mental

health vulnerability.

Epidemiological studies generally show that the prevalence of postpartum depresion is in the

range of 10-20% (Appleby et al., 1997; Warner et al., 1996; Swain, O'Hara, Starr and Gorman,

1997; Brugha et al, 1998; Lee et al, 2001; Chandran et al, 2002; Wisner et al,2014; Chen et al,

2018)

Postpartum depression typically begins before or any time after childbirth, but generally develops

between one week and one month after delivery. Mothers experiencing postpartum depression

17

describe feelings of extreme sadness, anxiety, and exhaustion (Thurgood, 2009; National Institute

of Medicine, 2015)

Previous research has identified risk factors that can increase a woman’s chance of developing

postpartum depression. If there is a history of mental health disorders during or after a previous

pregnancy, previous experience with mental health disorder, and a family history of depression

or other mental health illnesses increases the chances of a mother developing postpartum

depression (Vigot et al., 2010).

Also, Laggford, noted a lack of strong emotional support from a spouse, partner, family, or

friends has also been significant in determining the development of postpartum depression

(Laggford, 2009). In addition medical complications during the childbirth proces or mixed feeling

about the pregnancy have been found to increase the chances of a woman developing PPD.

Despite the efforts of researchers, the etiology of postpartum depresion is unstable and unknown

(Lusskin et al, 2007).

Beck (1967) postulated that depressed mood is the result of thought disturbances. Pessimism

toward oneself, the world, and the future contributes to a depressive mood. In addition, in the

absence of suitable role models, the woman feels loss of control and anxiety resulting in a lack

of a capability to cope with infant’s demands and care (Nemade et al, 2011). Some experts have

also noted that childbirth results in the loss of their identity and leads to the attraction of love and

loss of independence (Kaplan & Sadock, 2010). Moreover, the negative attitude of the family

affects the well-being of women and results in non-adaptation of the coping mechanisms.

If PPD is not treated, it may last for a period of time, often months or years, sometimes becoming

a chronic depressive disorder. Untreated postpartum depresion may have effects on child, infants,

fetuses and mothers (Abdollahi & Zarghami,2016).

Referring to the above studies can be said that PPD is a phenomenon that is present in many

women’s cases, but less studied. This phenomen varies from one culture to another. It is

influenced by many psychological, interpersonal, social and cultural factors. Among the factors

influencing the development of PP are genetic history of the case, previous experience with

mental health disorder and a family history of depresion or other mental health disorders, birth

problems, and many more.

Methods

The aim of this study was to assess impact of psychological factors during the postpartum

depression. Study is focused in relation of psychosocial factors such as: birthplace, education,

employment, economic level, mental health, number of children, breastfeeding, anxiety, spousal

relationship and social support.

The study has prospective design, with a single sampling phase. Parts of this study were women

who gave birth between May-June 2018, at Clinic of Gynecology and Obstetrics, Pediatric Clinic

at University Clinical Center of Kosova and in private Gynecological Hospital “Lindja”, in

Prishtina. In total they where 136 woman’s who were hospitalized from the third day of giving

birth till one year after this. These mothers were from different settlements in Kosovo and age

ranged from 16 to 55 years, all of them where interwiew by authors of this study and lasted

between 20 minutes and 50 minutes.

Ethics approval for the study was granted by the Ethics Committee of University Clinical Centre

of Kosova. Participants were informed about the objectives of the survey and ensured anonymity.

All participants provided written informed consent. Only women who were willing to participate

in the survey were interviewed and completed self-reporting questionnaires.

In the first part questionnaire was completed with questions on socio-demographic data for

research interests, such as the number of pregnancies, delivery and newborn, breastfeeding,

childcare and family support, relationship with partner, family status, social status, residence,

18

working and economic status, age, data on somatic diseases and mental illnesses in family

history, previous mental illnesses, especially in pregnancies and previous births, etc.

The second part was the Edinburgh Postnatal Depression Scale (EPDS) an internationally used

ten-item self-report questionnaire, designed as a screening tool to identify depressive symptoms

in the perinatal period. Items of the scale correspond to various clinical depression symptoms,

such as guilt feeling, sleep disturbance, low energy, anhedonia, and suicidal ideation.

EPDS questionnaire is used in a significant number of research works and reliability and validity

are well documented. The overall reliability (Cronbach’s alpha) of EPDS at our study was

α=.846.

Results and discussions

Results showed that prevalence of depression was an increasing indicator (M=12.61; SD=6.67)

in the sample of 136 subjects with an average age 31.3±6.4, years of education 12±2,5, mostly

living in urban area 55.1%, and underwent caesarean section delivery in 49.3% of cases.

Referring to the economic status 66.2% reported the middle level. In the respondents' households,

19.1% reported being suffering from depression and 17.6% of mothers suffered from a chronic

illness.be used to emphasize words in running text. Bold type and underlining should be avoided.

According to the questions about depression, filled out by all women in the sample 40.4%

responded positively to the question of loss of interest and satisfaction for life. None of them did

not attend any professional treatment, which requires a more serious approach to this problem.

Table 1. Correlation for postpartum depression

Factors Correlation

Earliest birth

experience

.180*

Delivery

complication

.243**

Delivery mode

Breastfeeding

.158

-.259*

Social support -.534**

Family support

Anxiety

-.504**

-.531**

Note: *. Correlation is significant at 0.05

**. Correlation is significant at 0.01

Correlational analysis between postpartum depression measured by EPDS and early birth

experience, delivery complications and difficulties, delivery mode, breastfeeding, anxiety and

social and family support, showed that there are important statistical links.

Previous delivery is significantly associated with PPD. Also, difficult maternal experiences

according to the correlational analysis, appear to have significant statistical correlation (r= -.243;

p<0.01) which means the harder the birth is, the higher postpartum depression rate reported by

the mothers. We did not find any correlation between delivery mode and PPD (r=.158).

Breastfeeding seems to be a very important on increasing PPD of mothers. Shows that there is a

negative significant correlation (r=-.259; p<0.01). Research has been showing that breastfeeding

promotes hormonal and psychological conditions and processes that are inversely associated with

postpartum depression. However, the simultaneous study of these dimensions and their potential

explanatory value in the connection between breastfeeding and pre- and postpartum depression

has not yet been accomplished.

19

Family and social support is significantly associated with PPD (r=-.504**; p<0.01: r= -.531;

p<0.01).

Attachment theory says that interpersonal struggles in an individual’s life have significant

influences on mental health. It is obvious that an individual requires affection which needs to be

fulfilled in the initial stage of a relationship. Uncertainties concerning a relationship may result

to disappointment and bring about depression and anxiety (Grupe & Nitschke, 2013). A number

of interpersonal factors play a role in women’s distress and sensitivity makes them prone to

develop postpartum disorders, these include insufficient social support and marital conflict.

Childbirth is a significant transitional event in life and support at this stage can potentially affect

women’s mental status after delivery (Hunker et al, 2009). Sudden psychosocial fluctuations

whithin motherhood and its challenges coupled with stresses could be other factor that may

trigger PPD. Previous studies in the field of medical social work have revealed that postpartum

depression is a global phenomenon that continues to be stigmatizing among new mothers often

because mothers suffer in silence (Kantrowitz-Gordon, 2013). A lack of strong emotional support

from a spouse, partner, family, or friends has also been significant in determining the

development of postpartum depresion.

Table 2: Child age and level of PPD

Edinburgh Scale

0-10 11-30

0-1 month 24.3% 32.4%

Child age 1-6 month 8.8% 19.1%

6-12month 6.6% 8.8%

Based on the data analysis performed, it is clear that the percentage of depressed subjects in the

mothers' group who have children a month age is higher than the percentage of other groups with

32.4%, then falls between 1-6 months with 19.1%, while 8.8% in the 6-12 months after birth,

showing that depressive symptoms are most common in mothers of children aged 0-1 months. as

the child age increases, depression decreases.

From the table analysis, it can be seen that with childbearing age the postpartum depression

decreases. This can also be supported by biological factors such as rapid changes in hormone

levels such as estrogen, progesterone, beta-endorphin, human chorionic gonadotropin, rapid

change in cortisol concentrations (increasing during pregnancy and significant decline after

delivery). Consequently, the mother becomes increasingly indifferent to her child and may show

more aggressive behavior and less time for parenting.

Table 3: Correlation between education and economic level on PPD

Level Correlation

Education -.449**

Economic -.219*

Note: *. Correlation is significant at 0.05

**. Correlation is significant at 0.01

In both cases we have a low negative correlation, where we see the lower level of education (r=-

.449; p<0.0) and economic status (r=-.219; p<0.05) have impact on increasing level of PPD.

Research has shown that PPD appears up to four times more often to women living in poverty,

compared to women with medium and high economic status. Often it is thought that socio-

economic status is the most frequent factor for PPD development.

20

Table 4: The impact of the profession on PPD

Household mothers have reported higher level of postpartum depresion, followed by nurses and

economists. This may be the result of long stay in home and indor environments. So even most

of the working women may not have been educated highly enough for their employment status

to have a positive effect on their mental health.

Results notify that most of these factors have significant role. Factors such as education,

employment, economic level, pregnancy progress and birth, children age, breastfeeding, anxiety,

spousal relationship seems to have high percentage of impact in postpartum depression.

Conclusions

Our study may be helpful in better understanding of female psychosocial problems and family

support after delivery and can help for the prospective planning of preventive intervention

strategies in improving women’s mental health.

Depression after giving birth is rising as a problem of mental health, and has negative impact on

personal, family and national level.

During the research was noted that psychosocial factors are really important to preserve

emotional, cognitive and behavior equilibrium.

Meanwhile family support is an important homeostatic component. Getting social help,

especially after giving birth, is important to lower the risk of PPD.

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13. Lusskin SI, Pundiak TM, Habib SM.: Perinatal depression: Hiding in plain sight. Can

J Psychiatry (2007) 52:479-88

14. Nemade, R., Reiss, S. N., & Dombeck, M.: Psychology of Depression-

Psychodynamic Theories (2011)

15. Oslen, M., Laursen, T. M., Mendelson, T., Pedersen, C. B., Mors, O., & Mortensen,

P. B.: Risk and predictors of readmission for a mental disorder during the postpartum

period. Arch Gen Psychiatry (2009) Vol. 66: 189-98

16. Thurgood, S. M., Avery, D., & Williamson, L.: Postpartum Depression. American

Journal of Clincal Medicine (2009) Six. 17-22

17. Vigot, S. N., Villegas, L., Dennis, C. L., & Ross, L. E.: Prevalence and risk factors

for postpartum depression among women with preterm and low-birth weight infants:

a systematic review. BJOG: An International Journal of Obstetrics and

Gynaecology, 117, 540–550. doi: 10.1111/j.1471-0528 (2010) 02493.x

22

Cranial Injuries with Screwdriver – UCCK

Besnik Elshani¹, Salih Krasniqi¹

UBT - Higher Education Institution, Lagjja Kalabria, 10000 p.n., Prishtina, Kosovo

Abstract In terms of anatomy, the human body is very complicated. Moreover it represents an

entire structure of a human being. What makes it very unique is the way of its composition;

different and diverse types of cells and everything is connected to everything else. A combination

of cells create tissues which then those tissues create the organ systems. Therefore, in this study

presentation I will present the importance of brain as an organ, with a focus on the cranial Injury

with a screwdriver. One of the most important and complicated parts of the body is the human

head.

Keywords: Skull, Cranial, Brain, Cells

Introduction

Those organs system make the human body to function properly and they grow (age) within

years. It is located in the upper portion and certainly is represented by a unique face, thus,

maintained by the (inside) skull and the brain is located within the skull. Skull plays an important

role, because it directly protects the human brain, which, results to be the most complicated and

fascinating organ in the human body. Without brain nothing would function properly, indeed.

Introduction of the brain & Cranial Injury

To start with, the human brain is consisted of the frontal lobe (front), the parietal lobe (middle)

and the occipital lobe (on the back – (end) of the brain) and each lobe has its own role forcing

the brain to maintain its health and manage other organs. Nevertheless, it is the central organ of

the nervous system and connecting with the spinal cord (back of the human body) it is known

otherwise as the central nervous system of the human body. Besides the cerebral lobes mentioned

earlier, the nervous system is made of the cerebrum, cerebellum and last but not least, the

brainstem. Being the most important organ is not an easy duty. Numerous of processes, maybe

billions of processes are controlled by the brain itself, followed with the body activities, precise

coordination of information, receiving and delivering that information properly and controlling

the senses of a human, followed with good decision making skills as well [1].

Secondly, brain protection is highly studied and experimented, due to the fact that being the most

important and diverse organ, the upper portion needs extra protection [2]. The skull bones of the

head serve as a good prevention from the brain being harmed accidentally – physically. However,

except physical injuries that might happen to the brain and the human body in general, there are

also certain types of traumas that might directly harm the brain. Such traumas are known as

Cranial Traumas (most commonly affects the adults for specific reasons). Patients who already

suffer from such traumas are more likely to have had brain injuries which could also affect other

(important) organs that serve to maintain the stability of the body itself [1].

Thirdly, re-stating the fact that brain can be damaged physically is probably one of the most

common cases in today’s world and / or society. Additionally, head injuries in general include

23

brain, scalp or skull injury. Despite the fact of what really may cause a head injury which may

cause skull fractures and other undesired wounds, the consequences can be seen either

immediately after the injury or later on in life, depending the fact of the severity of the injury

itself [3]. Head injuries are most commonly caused by everyday life situations, such as car

accidents (including motor vehicles as well – probably a more direct way to injure the head due

to less protection of the human body in general).It may also happen from a fall (still depends on

the height and the type of ground – soft (grass) or hard (asphalt type)) and often by physical

assaults (which can lead to the use of different weapons, even a screwdriver).

Cranial Injury with a screwdriver

As stated at the beginning of this study presentation, the main focus will be on the physical

assaults, resulting with a cranial injury of the head (skull and brain) with a screwdriver. A

screwdriver is a tool which often is used by construction companies, or even one can have it at

home for fixing something [4]. Nevertheless, this statement does not ignore the fact that a

screwdriver can and it is being used as a weapon for direct assaults and the most common injury

is the head (skull and brain) injury.

To make this more clear, there are a variety of head injuries which can be activated by an

undesirable physical contact and / or can further lead to the underdevelopment of the brain itself,

causing the malfunction of the human body or some parts of it (organ(s) malfunction) [4].

The (most common) major types of a head injury are (listed below):

• Hematoma

• Hemorrhage

• Concussion

• Edema

• Skull Fracture

1. CASE Report (Prishtina, Kosovo)

At the University Clinical Center in Prishtina Kosovo, in one of the neurological clinics, a rare

case has been operated. The patient was admitted to the Emergency Center in Pristina around

15:00 in the afternoon, from a regional part of Kosovo where the injury occurred. The patient in

admission was in a state of mind with partial communication and blend of words. Objectively the

metal tool penetrated into the endocardium in the left frontal region. It is realized the brain CT,

24

where is seen the metal tool known as a screwdriver, which had penetrated the shaft and was up

to the breccia area (a clear reason why the patient started to lose speech). The patient is urgently

prepared for operation, including general anesthetic surgery. An operator intervention is

performed by the caregiver's neurosurgeon by opening a small craniotomy around the traumatic

lesions and carefully penetrating the brain tissue up to the tip of the traumatic brain tract.

It is possible to successfully leave the metal tool. Correct hemostasis of the brain becomes

minimal invasive bleeding. The operation ends within one hour. After the operation, the patient

has only shown signs of neurological improvement, where he returns full speech / communication

abilities very fluently. After a few hours the patient can also control body movements such as

standing up, hands movements, headaches, walking right, and non-passive speech. Finally, after

about 24 hours, a control brain CT is performed, which presents without any bleeding in the head

of the patient in question. This is the first and rare case in UCCK, which has been treated

professionally and successfully by taking into account the rapid reaction of the moment of

hospital administration, where within an hour everything ends. It is worth mentioning that the

nodular deficit manifested by the sensomotoric defect has been eliminated after the operation and

the patient returns to normal neurological conditions.

Note: The case occurred in 2017 (27 April)

25

Similar Case Report from United Kingdom (UK)

Such cases are reportedly to happen also around the world, due to different type of attacks [5].

One of the countries that particularly shares such case reports is United Kingdom. Cranial Injuries

with a screwdriver tend to happen very often and not only between adults (+18 and beyond), but

also to children and teenagers as well, which can lead to a more difficult case (surgery) to be

solved [5]. An attack with the screwdriver can lead to major infections as well. A similar Case

report happened in United Kingdom (UK), where a 26 year old man was sent to emergency due

to an angry assault from someone else. After the surgery he was discharged home, however the

other day the man came back since he had a very strong headache and his confusion started to

increase. Apparently he had an intracranial hemorrhage in the parietal lobe. After that and the

needed care, he was sent back home after 17 days in the rehabilitation unit in the hospital.

It is of high importance that such cases are required to be notified earlier because the infection(s)

may lead to other difficulties and make the case even worse. It is stated that “such case is a

reminder of the need for a high index of suspicion in intoxicated head injured patients in whom

the diagnosis of intracranial injuries is often delayed” (Tutton, et al. 1).

Moreover, cranial injuries with a screwdriver or otherwise known and presented as penetrating

screwdriver, such wounds seem to be very unusual and less introduced in the literature and

neurosurgical practice [6]. Additionally, screwdriver is one of the least tools to be used as a

weapon and trying to penetrate with it into someone’s head. Although, the damage may be very

serious and cause severe injuries in the head and most importantly touch the brain.

Conclusion

The safety of the human body especially the upper portion of it should be a must in our everyday

life, due to the fact that the human head contains the most important organ, the brain, which in

fact, does control our movements, thinking, and processing information and so on. It is consisted

of three lobes: Frontal, Parietal and Occipital lobe.

The case report section is a great example of a cranial injury that happened in Prishtina, Kosovo,

which is considered a rare case due to the fact that the injury was done with a screwdriver. The

neurosurgeon tried to keep the health of the brain while removing the tool made out of metal and

after the successful operation a control CT endocranion was performed and resulted that the

patient was fine and able to communicate better than before the operation. It is very important to

re-state the fact that body movements of the patient were improved within a very short time, since

after the one-hour surgery and a little rest, he was able to walk and talk, controlling hand

movements, head movements and trying to keep a non-passive communication with the doctors.

References

1. Haas LF (December 2001). "Phineas Gage and the science of brain localisation".

Journal of Neurology, Neurosurgery, and Psychiatry. 71 (6): 761.

2. “Head Injury: Types, Causes, and Symptoms.” Healthline, Healthline Media,

3. Retrieved from: www.healthline.com/health/head-injury.

4. Kuppermann N, Holmes JF, Dayan PS, Hoyle JD, Atabaki SM, Holubkov R, et al.

(October 2009). "Identification of children at very low risk of clinically-important

brain injuries after head trauma: a prospective cohort study". Lancet. 374 (9696):

1160–70.

26

5. Powell T (2004). Head Injury: A Practical Guide (2nd ed.). United Kingdom: Speech

mark publishing Ltd. ISBN 978-0-86388-451-1.

6. "Traumatic Brain Injury (TBI)", SpringerReference, Springer-Verlag.

7. Tutton, Matthew G, et al. “Screwdriver Assaults and Intracranial Injuries.”

Emergency Medicine Journal, British Association for Accident and Emergency

Medicine, 1 May 2000.

27

Nursing Care in Children with Type 1 Diabetes Mellitus

Doruntina Ismaili1,Fëllënza Spahiu2,Lirije Beqiri2,Afërdita Berisha2

1,2 UBT-Higher Education Institution, Lagjia Kalabria, 10000 p.n., Prishtinë.

Kosovo

ismailidoruntina@gmail.com, fllazaspahiu@gmail.com, lirijebeqiri@yahoo.com, afro_leka@hotmail.com

Abstract. A life dependent from insulin certainly requires patience, support, care and a constant

education from our side as professionals of medicine toward our patients who are affected by

diabetes. The prevalence of this disease is increasing, whereas the incidence is approximately 4

cases per 100 000 inhabitants. Factors that affect this disease are many, ranging from the genetic

basis to stress and trauma. The complications of this are inevitable that touch almost the whole

system and bodies starting from the brain to the legs.

Based on the research conducted the total number of children with type 1 diabetes mellitus in the

endocrinology department at the Pediatric Clinic in Prishtina during the 5 year period from 2012

-2016, in totally there are 386 new cases, 183 are females and 185 are males, we have concluded

that urban areas are the most affected by rural areas, gender is affected by almost both sexes,

while age groups are: females are born between 2001 and 2015, while men range between 2004

and 2016.

Education - Periodic control of glucose reduces hyperglycemia complications. For the self-

treatment of insulin, the nurse should educate the child in light of his age. They are explained

where and how to inject insulin, injection angle, then education for bodily activities, diet and

maintaining personal hygiene (foot care).

Keywords: Type 1 Diabetes mellitus, insulin, research, education.

INTRODUCTION

According to the World Health Organization (WHO), diabetes is defined as a condition of chronic

hyperglycemia, determined by genetic and environmental factors. Type 1 diabetes belongs to the

most common chronic endocrine disorder of children. Type 1 diabetes is an autoimmune

syndrome that destroys pancreatic beta cells and is characterized by the almost complete absence

of insulin secretion from the endocrine pancreas. Autoimmune Disorder is a disorder in which

the immune system of the body, which normally protects the body against foreign invaders,

incorrectly identifies part of the body as a foreigner and attacks healthy tissue. The disease is due

to lack of insulin, which leads to carbohydrate, fat, and protein metabolism disorders with typical

clinical presentation. Insulin is the main anabolic hormone in the body. The main feature of

diabetes in children is insulin dependence. The main reason for this is the absolute lack of insulin.

The stages of the disease are: 1. Prediabetes- is the period from the beginning of the process to

the possible occurrence of the first abnormalities in carbohydrate metabolism in children, 2.

Subclinical Diabetes - Carbohydrate metabolism is only disrupted in the event of infections,

caries, trauma or surgery, 3. Diabetes patients who are ill at this stage of the disease are without

any symptoms, rarely have normal glucose levels in the blood, but hyperglycemia occurs after

food intake or after oral glucose loading, 4. Diabetes manifestations of children appear swiftly,

28

while switching from latent stage to manifest is provoked by infections, traumas, and surgical

interventions. Symptoms and clinical signs of the disease start due to the difficult use of glucose

in cells due to lack of insulin. Lack of insulin results in blood glucose collection (hyperglycemia).

When the blood glucose concentration exceeds the maximum kidney transplant (about 9.0 mmol

/ L), glucose begins to appear in the urine (glucose). Glucose in the urine draws water by

increasing the volume of urine and frequent urination (polyuria). Increasing the loss of fluid with

urine causes an increased and permanent thirst for the patient, which he tends to compensate for

by adding juices (polydipsia). The overall lack of energy consequently has subjective feeling of

hunger and increased food intake (polyphagia), but with no effect, which consequently has a

growing stagnation, weakening (loss of body mass) to cachexia in unidentified cases, not well-

cared for melitic type 1 diabetes. Diagnosis of type 1 diabetes mellitus is confirmed by the

presence of glucose and hyperglycemia above 6.6 mmol / L (120mg%) in soma or above 8.8

mmol / L (160 mg%) after food. In ketoacidosis, the acetone test in urine is positive and other

acidosis lab tests. Blood glucose hemoglobin (HbA1C) is over 8% (proportional to the amount

of glucose in the blood). The complications of type 1 diabetes mellitus can be: acute and

chronic. Acute complications - The most important acute diabetes mellitus type 1 complications

are: hypoglycemia and diabetic ketoacidosis. While chronic complications appear after several

years (10-20 years) from the onset of the disease. Chronic complications are: Angiopathy,

Diabetic Nephropathy, Neuropathy, Diabetic Retinopathy, Bleeding in the Eye Glass,

Macrovascular Diseases. The purpose of the medication is normalization of blood glucose and of

all metabolic processes in the body, which are mediated by insulin. Insulin delivery, rigorous

diet, physical activity, hygiene, preservation from infections and complications will be the whole

type 1 diabetes medication. Insulin is the basic treatment for diabetes. It is used through

subcutaneous injections or insulin pump, along with dietary management, including carbohydrate

monitoring and blood glucose control, using glucose meters. Administered via subcutaneous and

intravenous routes. Eliminated through the urine and the balance. There are some insulin forms;

insulin with short, medium and long acting. It is preferred to combine these forms. The injection

site changes after each injection line, it also affects the duration of the start of the action; abdomen

(fast), upper arm (slowly), upper leg (still slower).

Care and nursing education is based on: 1. Providing insulin, 2. Diet, 3. Corporal activity, 4.

Blood glucose monitoring, 5. Maintaining personal hygiene-care for the feet, 6. Monitoring vital

signs.

• Providing insulin: All insulin preparations, which are currently in use, should be

administered in the form of subcutaneous (subcutaneous) injections with the 45 "angle

on the outer (lateral) side of the thigh, both at the front and the front, on the abdominal

wall and in gluteus or intravenous infusion, there is no insulin for oral use (by mouth)

because if insulin is taken through the mouth to the stomach and the intestine is

decomposed like any other protein. Insulin preparations are distinguished from each

other by: time, moment of injection under the skin until the beginning of their action

and duration of the action.

• Diet: The diet of a child with melite diabetes should be such that it contains 50-60% of

carbon hydrate, 25-30% of fats and 15-20% of protein and the content of minerals,

vitamins and oligoelements. In addition to the three main food rations (morning, lunch,

dinner), the child should also take two or three small rations (at 10.17 and 21).

29

• Corporal activity: With activity it is possible that glucose under the action of insulin

is faster and easier to use by the cells. The diabetic diabetes child should deal with

common physical and sports activities like all his peers in a community (except for

swimming, motoring, parachuting).

• Blood glucose monitoring: Glycemia should be measured 6-7 times per 24 h for the

purpose of changing insulin doses to have a better control of the disease. The test for

the use of insulin, the use of gleukometers, where the finger is first disinfected with

alcohol and then needle-drilling, the first blood outlet is always removed and the second

blood test is performed on the glukometric bar. The most accurate moments for

measuring glycemia are bread, before the three meals, two hours after the meal and

before bedtime.

• Maintaining personal hygiene-care for the feet: Patients with DM to prevent the

appearance of the diabetic foot should undertake the following care. Handkerchiefs and

shoes should be 1-2 bigger midsoles, should be checked for the presence of foreign

trousers, socks should be cotton, should not be worn with synthetic socks at the knee

level because they hinder the circulation and should not wear the shoe. Care of the

nails, before the nails are cut out, should be washed with warm water for 15 minutes.

The nails are cut right, adjusted with side lime. General Information: Never walk

barefoot, do not use creams and solutions without a doctor's description, do not let your

feet burn in the sun and do not stand crossed.

• Monitoring vital signs: Hypotension and tachycardia are present in hypothetical

monitoring of hypovolemia, hypovolaemia estimates should be made, respiratory type

- acetone is due to acetic acid acid disruption and should be reduced as corrected

ketosis, dry mouth, augmentation but appetite associated with weight loss, fatigue more

than usual, stomach pain, blurred vision, lack of concentration, numbness of the hands

or feet, changing temperature, skin color and moisture-fever and chills are common

with the infectious process and dehydration occurs.

PURPOSE OF THE STUDY

• Accounting of the total number of patients with Diabetes Mellitus type1 placed in the

endocrinology ward, in the Pediatric Clinic in Prishtina, during the 5 year period from

2012 -2016,

• Study of cases of diabetes mellitus type 1 by age groups,

30

• Study of cases of diabetes mellitus type 1 by gender,

• Study of cases affected by type 1 diabetes mellitus and variations of results,

• Widespread knowledge of the disease, its etiology and its treatment,

• Nursing care and education in patients with type 1 diabetes mellitus.

HYPOTHESIS

• The general knowledge about diabetes mellitus type 1,

• Nursing education and care for children affected by type 1 diabetes mellitus, in

improving and relieving the disease.

RESEARCH QUESTIONS

• The research questions were focused on:

• Finding the total number of patients with Diabetes Type 1 Mellitus placed in the

Department of Endocrinology at the Pediatric Clinic in Prishtina during the 5 year

period from 2012 -2016,

• Number of type 1 diabetes cases by age groups,

• Number of type 1 diabetes cases by gender,

• Number of cases affected by type 1 diabetes based on residence and variations in results

MATERIALS AND METHODOLOGY

The study is retrospective for all patients treated in 2012-2016. The data for this research were

collected from the Patient Clinic Protocol in Prishtina. The data was processed and generated in

tabular and graphical form through the microsoft EXCEL application

31

RESULTS

Chart number 1. In the Department of Endocrinology at the Pediatric Clinic in Pristina,

children diagnosed with Type 1 diabetes were examined, out of a total of 368 patients, 183 were

female and 185 were males.

Table number 1. Cases presented on the basis of sex in years.

182

184

186

Year 2012-2016

Female 183

Male 185

Year

Male

%

Female

%

2012 27 43.55% 35 56.45%

2013 37 51.39% 35 48.61%

2014 42 52.50% 38 47.50%

2015 38 52.05% 35 47.95%

2016 41 50.62% 40 49.38%

Total 185 183

32

Table number 2. Number of cases diagnosed with type 1 diabetes mellitus in the Pediatric Clinic

based on settlements for 5 years analyzed.

Chart number 2. The table and graph shown above shows the number of cases of type 1 diabetes

mellitus for each year from 2012 to 2016. In 2012 we have a total of 62 cases with diabetes

mellitus type 1, then in 2013 there are 72 cases with this diagnosis, in 2014 there are a total of 80

cases, in there are 73 cases in 2015 and in 2016 there are currently 81 cases affected by this

disease. The results show that there is a fluctuation of the cases presented from year to year where

the highest cases are in 2016.

Year 2012 2013 2014 2015 2016

Female Nr % Nr % Nr % Nr % Nr %

Rural

areas

10 28.57%

13 37.14% 14 36.84% 7 20.00% 18 45.00%

Urban

areas

25 71%

22 62.86% 24 63.16% 28 80.00% 22 55.00%

Total 35 100.00% 35 100.00% 38 100.00% 35 100.00% 40 100.00%

Male Nr % Nr % Nr % Nr % Nr %

Rural

areas

6 22.22% 6 16.22% 13 30.95% 8 21.05% 21 51.22%

Urban

areas

21 77.77% 31 83.78 % 29 69.05% 30 78.95% 20 48.78%

Total 27 100.00% 37 100.00% 42 100.00% 38 100.00% 41 100.00%

0

10

20

30

40

50

60

70

80

90

2012

2013

2014

33

Chart number 3. If we were to make a comparison of this data, we would have the Prevalence

of Diabetes mellitus in the World by WHO, with a 2-6% incidence in Western countries and the

highest in other ethnicities. Hyperglycemia is rare in newborns (1% before 15 years) but its

frequency increases with age (7% after 65 years). The ratio between sexes is roughly the same,

affecting every age but with greater frequency ages over ages 45. In 1995 diabetics were 135

million, in 2006 were 264 million but alarming is that it is predicted that in 2025 we will have

380 million diabetics. Type 1 diabetes affects 11 to 22 million people worldwide.

DISCUSSION

As can be seen from the results of the study, the number of people with type 1 diabetes mellitus

in the Pediatric Clinic in Pristina is 368 patients, of whom 183 are female and 185 are males. So

diabetes mellitus type 1 affects almost the same gender, where their percentage is almost halved.

In women, the percentage is 49.97% and in men it is 50.03%. It belongs to the year of birth of

children with type 1 diabetes mellitus in females varies between 2001 and 2015. Where 2001 and

2005 are most affected with a higher rate of diabetes, while in men it differs in periods from 2005

until 2016. Where since 2005 we have an increase in the number of patients affected with type 1

diabetes mellitus. The table on male gender by dwelling place shows that the most affected cases

are urban areas, where the affected are almost three times more than rural areas, for 2012, 2013,

2014 and 2015, except in 2016 have similar numbers of cases in urban and rural areas. Where in

the city we have 131 cases for five years, while in rural areas we have 54 patients. The graph

shows us a figure fluctuation year-on-year, with the highest rates being in 2016. As seen from

the table, cases have always been increasing, while the female shows the incidence according to

settlements from 2012-2016 where even in this case the urban area is more affected than the rural

one. In urban areas we have 121 cases and in rural areas we have 62 cases. The peak of new cases

is in 2016 with 40 new cases. The prevalence of type 1 diabetes in Kosovo for the last 5 years.

The table and graphs shown above show the number of type 1 diabetes cases per year from 2012

to 2016. In 2012 we have a total of 62 cases of type 1 diabetes mellitus, then in 2013 there are 72

cases with this diagnosis, in 2014 there are a total of 80 cases, in 2015 are presented 73 cases and

0

100

200

300

400

Year 1995 Year 2006 Year 2025

Prevalence of Diabetes Mellitus in the World

34

in 2016 there are 81 cases affected by this disease. The results show that we have a fluctuation

of results from year to year, where the highest cases are in 2016.

CONCLUSION

Diabetes screening is the key to preventing complications, early diagnosis, helps preventative

complications. Periodic control of glucose reduces complications of hyperglycemia. In patients

with type 1 diabetes mellitus, intensive insulin therapy has beneficial effects on reducing the risk

of cardiovascular disease. Blood pressure control reduces the risk of cardiovascular, exkemias,

hemorrhagic diseases. Any reduction of 10 mmHg of TA reduces with 12% complications.

Patients with diabetes should have special care to protect themselves from infections because

they seriously affect diabetes. Protection is achieved simply through three precautionary

measures:

First: respecting the rules of body hygiene, protection from moisture and cold.

Second: Regular vaccination against all infectious diseases, including the flu.

Third: Regular and meticulous treatment of diabetes, maintaining its constant balance.

When the patient is affected by various infections, serious antibiotic treatment should be

performed. Those who are treated with insulin should increase their dose, while those who are

given oral or dietary medication may need to temporarily start insulin treatment. A person with

type 1 diabetes mellitus should be informed about the treatment of the disease and the importance

of his treatment. For insulin, there must be a medical staff to teach the patient the places where

injections of insulin are in the abdomen, thigh, and forearm skin. The injection angle is 45-90 °,

whereby the skin is initially withdrawn and then injected. It is advisable for patients not to rub

the injection site. Also in small children, or elderly, family members are instructed. Patients are

given insulin types, meals when used. Hyperglycemia and hypoglycaemia are known and the

measures to be taken. Insulin storage is done in a refrigerator, but injection of cold insulin is

painful, so it is recommended to keep it at room temperature, but not over 25-50 degrees. The

amount of storage is kept in the refrigerator at 2-8 ° C, avoiding freezing because it can damage

insulin.

References

1. Azemi M, Jaha V. Pediatria dhe Kujdesi Infermieror: për studentët e Infermierisë dhe

mamisë. Prishtinë: Olymp, 2016

2. Cakerri L, Nanushi M. Bazat e Fiziologjisë të njeriut .

3. Ceka Xh. Histologjia – Tirane 2005

4. Ekoe J, Zimmet P, Williams R, -The epidemiology of diabetes an international

perspective, ISBN:0-471-97448-X. ©2001

5. Kozdine D. Patologjia morfologjike –.Triptik 2006

6. Lebovitz H. Therapy for diabetes mellitus and related 1disordes. ISBN: 0-945-448-

94-5. ©1998

7. Llano Y. Dietologji. Triptik 2006

35

8. Mandro F, Zahaj M, Stefoni S. Bazat e farmakologjisë klinike. ISBN:99927-35-61-9.

©2011. Tiranë.

9. Ralton B. Exercise&disease management of diabetes. ISBN978-1- 4398-2579-

8.©2011

10. Remuzzi R. Nephropathy of tape 2 diabetes mellitus, J AM Soc Nephrol 1998

11. Saliaj A. Pediatria – ISBN: 978-99956-91-28-8

12. Saracini E, Saracini H. Anatomia dhe Fiziologjia e njeriut. Prishtinë; 2001

13. Ogden A. Practical Insuline. - ISBN: 978-1-580-40-447-1. ©2011

36

Side effects of metoclopramide (Reglan) oral overdose in

pediatric patients

Edmont Laho1,,Xhejni Borshi 2, Indrit Bimi3, Eti Muharremi4

1Department of pediatrics, Medical hospital center Elbasan,Albania

Albanian University, Tirana, Albania 2The head of the Deparatment of Physiotherapy and Nursing

Albanian University, Tirana, Albania 3The pedagogue of the Deparatment of Physiotherapy and Nursing

“Aleksander Mosiu”University, Durres,, Albania 4General physician Public Healthy Regional Directory, Elbasan

lahoe90@gmail.com

Abstract. Drugs like metoclopramide are used in pediatric patients for the treatment of frequent

vomiting or gastrointestinal disorders especially at the age of three. The most common use is

Reglan solution, but its dose should be strictly observed because of low therapeutic index

overdose is easily achieved, manifesting with extrapyramidal side effects.

The purpose of the study is to detect the frequent side-effects of the extrapyramidal nervous

system that are due to the oral overdose of Reglan in the pediatric population.

Materials and methods. This study analyzed all the cases of Metoclopramide toxicity who took

the Reglan solution in an outpatient setting and were then diagnosed and treated in the Pediatric

Service in the Hospital of Elbasan during January 2014 to December 2016 period. These cases

have been treated in the Pediatric Service in Elbasan. After having been diagnosed with signs of

the nervous system from the overdose of Reglan solution they were surveyed in terms of dose

taken, duration of use, age, etc.

Results. The17 cases diagnosed in our service varied in clinical presentation from nuchal rigidity

to whole body contractions and somnolence. Out of these, nine children were younger than 1 year

old, 5 children 1-4 years old, and 3 children were aged 4-8 years. All the children younger than

one received Reglan solution at high doses 3 times 1 coffee spoon (also fivefold-tenfold of the

dose) while the therapeutic dose for Reglan solution is 0.1mg / kg in 3-4 doses.

Conclusions. Considering this medication has a low therapeutic index, cautions to prescribe and

administer the right dose are of the upmost importance. As a result, the general practitioner and

the pharmacists should be instructed that children younger than 1 year old should not take this

medication and if need be and there are no other alternatives it should be administered with drops

and not with coffee spoon (2.5 ml) or jam spoon (5 ml).

Keywords: vomiting, dosage, reflux, reglan, drops

Introduction

Metoclopramide is a Dopamine receptor antagonist. Metoclopramide has antiemetic,

antinauseant and gastrokinetic activity. It stimulates motility of the upper gastrointestinal tract

without stimulating gastric, biliary or pancreatic secretions. The rate of gastric emptying is

increased due to increased peristalsis of the jejunum and duodenum. The tone and amplitude of

37

gastric contractions are increased, with relaxation of the pyloric sphincter and duodenal bulb.

These effects combine to result in decreased intestinal transit time, making a good anti emetic.

The effect of metoclopramide on motility is not dependent on intact vagal innervation, but it can

be abolished by anticholinergic drugs. Metoclopramide has little, if any, effect on the motility of

the colon or bladder. Metoclopramide also exhibits dopamine antagonist activity and

consequently produces sedation and, rarely, other extrapyramidal reactions.

It was firstly used by an American physician in 1964 and it has since been used all over the world.

Metoclopramide is one of the 100 most used drugs in the last ten years in USA. It has also made

the list of Essential drugs of World Health Organization (WHO) [1].

The structural formula is:

Metoclopramide is sold under the trade name Reglan or Primepran and it is widely used for

gastrointestinal disturbances, hiatal hernia, biliary stones, gastritis and gastric ulcers. This drug

is used to control nausea, stomach ache and upper abdominal pain [2].. In our clinical experience

we have witnessed a very high efficacy of this drug in controlling the vomiting of different causes

and makes a great choice in diabetics with vomiting due to gastroparesis. Metoclopramide is used

in surgery to control the post-operative vomiting.

Metoclopramide is also used in pediatric patients to control vomiting due to gastroenteritis or

enteroviral infections. It is essential to administer the correct dossage due to risky side effects

seen with its toxicity. This drug is also used to control vomiting associated with radiation therapy

or intolerance to cytotoxic drug or used preoperatively to stop the vomiting during surgery and

also assists in small bowel intubation [3]..

Dossage and administration

• Adults 20 years and over: Maximum of 10 mg three times a day.

• Children: Treatment of children should commence at the lower dosage of 0.1-0.15

mg/kg three times a day or as a solution 5mg/5ml a clear, colourless, sterile,

preservative-free solution containing metoclopramide hydrochloride anhydrous used

to come with a dropper (Primepran) [4].

Parenteral forms (I.V. or I.M.) are 10 mg/2 ml. This is recomended in patients with extensive

vomiting, after the patient is firstly hydrated with Ringer’s solution or Sodium Chloride

0.9% [5].

38

Side effect

Tardive dyskinesia may appear in some patients on long-term therapy or may appear after drug

therapy has been discontinued. The risk appears to be greater in pediatric patients on high dose

therapy. The symptoms are persistent and can often at times appear to be irreversible. The

syndrome is characterized by rhythmical involuntary movement of the tongue, face, mouth or

jaw (e.g. protrusion of tongue, puffing of cheeks, puckering of mouth, chewing movements).

Sometimes these may be accompanied by involuntary movement of extremities. The frequency

and severity of seizures or extrapyramidal reactions may be increased in epileptic patients given

metoclopramide. Dystonic reactions occur in approximately 1% of patients given

metoclopramide [6]. These occur more often in children and young adults and may occur after a

single dose. Neuroleptic malignant syndrome has been reported when metoclopramide has been

used alone or in combination with neuroleptics. Metoclopramide elevates prolactin levels. This

may be of importance in patients with previously detected breast cancer, in which the breast

cancer is prolactin dependent. Because of prolactin elevation it presents with disturbances such

as galactorrhea, amenorrhea, gynecomastia and impotence in men. Because of its cholinomimetic

properties and because it decreases intestinal transit time this drug may induce diarrhea.

The purpose of this study is to evident the extrapyramidal side effects and other side effects

related to Metoclopramide (Reglan) toxicity after oral or parenteral administration in pediatric

population.

Patients and methods

This study analyzed all the cases of Metoclopramide toxicity diagnosed and treated in the

Pediatric Hospital of Elbasan during January 2014 to December 2016 period. The cases were

then classified regarding the epidemiologic criteria, the dosage administered to the patient, the

time the patient was on the drug, the coexistence of other pathologies and socio-demographic

variables like: age, residency.

Results

There were 17 cases in total diagnosed in the Pediatric Hospital of Elbasan. Their clinical

symptoms varied from neck rigidity to whole body contractions and somnolence. Some of the

children had “facial mask” or facial spasms. Patients aged older than 3 years old could not talk

and they exhibit uncontrollable movements of the extremities and they fell whenever they tried

to walk.

9 of the 17 children were younger than 1 year of age, 5 children were 1-4 years of age and 3 were

4-8 years old.

39

Graph 1: Children classified by age group.

All the children younger than 1 year old were administered Reglan solution 5-10 times (3 times

1 coffee spoon) the allowed dose of 0.1mg/kg 3 times a day.

Regarding their place of residence: 11 children were located in rural areas while only 6 were

located in urban areas.

Graph 2: Place of residence of children who were intoxicated with Metoclopramide.

Regarding the pathology the children first came for in the clinic for which they took

Metoclopramide: 6 were diagnosed as Enteroviral infection, 7 cases of Gastroenteritis and 4 of

Gastroesophageal reflux (GERD).

0

1

2

3

4

5

6

7

8

9

10

<1 year old 1-4 years old 4-8 years old

Children

11 children

6 children

Rural areas

Urban areas

40

Graph 3: Divided by the pathology the children first came for in the clinic for which they

took Metoclopramide

In our study we analyzed the cases of Metoclopramide (Reglan) toxicity considering the timeline

of emerging side effects. In children younger than 1 year of age the first signs of intoxication

started during the second day (after the first 24h) of taking the medication. Six out of nine of

these cases had a severe clinical manifestation with extrapyramidal signs because of taking the

medication in doses of 4-5 ml.

Discussion

Side effects from metoclopramide (Reglan) toxicity are fairly often in the clinical practice

compared to other medications. The most cases are reported in pediatric population. This is

illustrated on Graphic 1 where more than 60 % of the cases included in this study are 0-1 years

of age. Infants are poisoned with this medication, receiving a dose greater than the maximal daily

dose of 0.3 mg/kg (0.1 – 0.15 mg/kg taken 2-3 times a day) [7]. A 7 kg child should not be

administered more than 10-15 drops per day (0.7 ml 2-3 times a day). In this study we found out

that many children have received the medication 2-3 times per day up to 4-5 ml, making it an

overdose. In this situation the children were presented to the Emergency Room with the

extrapyramidal symptoms described above [8]. This mistake occurs due to a miscommunication

between the physician and pharmacist, the latter one being responsible a lot of times for selling

medications without prescription or misreads the correct dosage of the medication.

The risk is increased because in our country Metoclopramide that is sold under the trade name

Reglan lacks a dropper. A few years ago Primeran solution was widely available in the drug

market in Albania. It had a dropper that helped avoiding mistakes in dossing administration.

In this study we found that most of the cases were from rural centers. This not only shows the

problems and the shortcoming of specialized doctors in these zones but also the lack of medical

knowledge in the population. In two cases after the children, respectively 4 and 7 years of age,

were still vomiting after taking Reglan, the medical personnel administered Primepran (I.M.) too.

Another added risk factor we came through was the non-administration of Ringer or Glucose

6 children

7 children

4 children

Enteroviral infection

Gastroenteritis

GERD

41

solution to treat the dehydration after taking Reglan. Certain authors emphasize the

contraindication of Metoclopramide in infants (<1 year old) because of the side effects [9] [10].

In recent years even though there is an increase in other anti-emetics like Domperidone or

Ranitidine to treat the acutely ill patients, Metoclopramide still remains the most preferred due

to best efficacy in clinical setting even though the literature suggests that there are no differences

in efficacy between Domperidone and Metoclopramide. Domperidone is suggested to be used

more due to its safer profile [11].

Ondansetron, a serotonin 5HT-3 antagonist, FDA approved for children older than 1 month of

age (earlier than any of the other medications discussed above). Scientific evidence support the

use of Ondansetron in children that present with vomiting [12]. It is the only antiemetic for which

there are randomized, controlled trials that support its use. A meta-analysis from DeCamp et al.,

all the children who were administered Ondansetron were less predisposed to have ongoing

vomiting, need for I.V. fluids or hospitalization. In Europe Ondansetron is available in 16

countries under the trade name Setofilm in 4 mg and 8 mg doses [13] [14].

Patient and parents experience these sudden and rapidly accelerated symptoms very dramatically

making it very hard to get an anamnesis.

One other study from LC Low and K M Goel observed 15 children with metoclopramide

(MaxoIon) poisoning. One of the 5 children accidentally poisoned developed slight

extrapyramidal signs. All 10 children who experienced extrapyramidal side effects while being

treated with metoclopramide had received a dose greater than that recommended by the

manufacturer of 0,5 mg/kg per day [15]. Dystonic reactions are likely to occur if the

recommended dose is exceeded, but individual susceptibility to metoclopramide and the

cumulative effect of repeated doses of the drug may also be important. Similar reasons were

identified in our study.

Conclusions

Side effects from Reglan solution (Metoclopramide) are common in pediatric population and

happen due to mistakes in dosing. Considering this medication has a low therapeutic index,

cautions to prescribe and administer the right dose are of the upmost importance. As a result, the

general practitioner and the pharmacists should be instructed that children younger than 1 year

old should not take this medication and if need be and there are no other alternatives it should be

administered with drops and not with coffee spoon (2.5 ml) or jam spoon (5 ml).

A healthy professional interaction between the physician, the pharmacist and the nursing staff is

very important in order to elude the mistakes in the future. Medical personnel should be advised

to not administer Metoclopramide P.O. or I.M. before starting fluids in order to hydrate the

patient when dehydration is present. After the electrolyte balances are controlled lowering the

risk of side effects, the patient can be administered Metoclopramide to control the vomiting.

References

1. European Medicines Agency recommends changes to the use of metoclopramide,

2013.

2. Sedat Işıkay, Kutluhan Yılmaz, Mehmet Almacıoğlu (2013) Evaluation of Patients

with Metoclopramide-Induced Acute Dystonic Reaction. JAEM 12: 80-84.

42

3. Selda Hizel Bulbul,Emine Dibek Misirlioglu,Erennur Tufan,Olcay Evliyaoglu (2010)

Side Effects of Metoclopramide: Does It Deserve to Prescribe For Nausea,Vomiting?

The New Journal of Medicine 27: 84- 86.

4. Witzel K. Extrapyramidal-motorische Störungen bei Kindern als Nebenwirkung der

Therapie mit Neuroleptica und dem neuen Antiemeticum Metoclopramid. Arch

Kinderheilkd. 1968 Sep;177(3):277–283. [PubMed]

5. Casteels-Van Daele M, Jaeken J, Van der Schueren P, Van den Bon P. Dystonic

reactions in children caused by metoclopramide. Arch Dis Child. 1970

Feb;45(239):130–133. [PMC free article][PubMed]

6. Fournier A, Pauli A, Ducoulombier H, Cousin J. Effets du surdosage en

méthoclopramide chez l'enfant. A propos de 9 observations cliniques. Pediatrie. 1969

Oct-Nov;24(7):799–805. [PubMed]

7. Cousin J, Katende C, Pauli A, Fournier A. L'intoxication par le Métoclopramide chez

l'enfant. Nouv Presse Med. 1972 Aug 26;1(30):1995–1995. [PubMed]

8. Sedat Işıkay, Mehmet Almacıoğlu, Kutluhan Yılmaz (2012) Metoclopramide Induced

Acute Dystonic Reaction in a Child: A Case Report. JAEMCR 3(2): 59-61.

9. Sills JA, Glass EJ. Metoclopramide in young children. Br Med J. 1978 Aug

5;2(6134):431–431.[PMC free article] [PubMed]

10. Bateman DN, Davies DS. Pharmacokinetics of metoclopramide. Lancet. 1979 Jan

20;1(8108):166–166. [PubMed]

11. LC K Low and K M Goel, Royal Hospital for Sick Children, Glasgow:

Metoclopramide poisoning in children 1980

12. Strange GR, Ahrens WR, Lelyveld S, Schafermeyer RW. Pediatric emergency

medicine: a comprehensive study guide. 2nd ed. Toronto, Ont: McGraw-Hill; 2002.

pp. 347–352.

13. 2. Canadian Paediatric Society, Nutrition Committee. Oral rehydration therapy and

early refeeding in the management of childhood gastroenteritis. Can J

Ped. 1994;1:160–164.

14. 3. Burkhart DM. Management of acute gastroenteritis in children. Am Fam

Physician. 1999;60(9):2555–2563. [PubMed]

15. 4. Kwon KT, Rudkin SE, Langdorf MI. Antiemetic use in pediatric gastroenteritis: a

national survey of emergency physicians, pediatricians, and pediatric emergency

physicians. Clin Pediatr (Phila) 2002;41(9):641–652. [PubMed]

43

Topic: Evaluation of the appearance of dermatological

bullous diseases in the oral cavity

Ilma Robo1, Vera Ostreni1, Eriola Meta1, Alert Xhaja2, Saimir Heta3

1Albanian University, Department of Stomatology, Tirana, Albania 2Department of Dermatology, QSUT, Tirana, Albania

3Department of Pediatric Surgery, QSUT, Tirana, Albania

ilmarobo@yahoo.com

Abstract

Introduction: Dermatological bullous diseases have visible signs in the oral cavity. The study is

aimed at early detection of oral lesions, to link them to the presence or not of apparent skin

disorders affecting the quality of the patient's lifestyle. Patient awareness of coexistence between

dermatological concerns and the presence of oral lesions should be the starting point of every

dentist during the intraoral examination, after drying of the mucous membranes and gingiva.

Materials and methods: The study includes patients randomly presented: patients at the

University Clinic AU and patients in the Dermatology Department, QSUT, during the period

between november 2017 and january 2018. Patients were evaluated according to the

Dermatological Life Quality Index (ICJD) and the presence of oral lesions in the oral cavity.

Results: Oral lesions reported in the patients appear to be more commonly occurring in female

patients than in male patients over 40 years of age. Oral buccal mucosa areas are more affected

than gingival area, palatum and tongue areas.

Conclusions: Detection of disorders during oral routine examination is the beginning to follow

the evolution of these dermatological bullous diseases, as the further prognosis also depends on

the moment of detection and awareness of the initial existence of the disease.

Keywords: ICJD, bullous diseases, oral mucous membranes, gingiva

Introduction

Patients affected by bullous diseases are divided into two categories, those who are pre-diagnosed

and well-informed of the presence of the disease, and those who do not know the presence of the

disease. In the last group, their first contact for more information is the dentist who checks,

examines and evaluates the presence of "wounds" in the mouth. The challenge in this process is

the duplication of primary lesions in secondary lesions, which are undiagnosed, and which still

make the clinical appearance of the patient more difficult.(1)

The other purpose of this study consisted in sensitizing the diagnosis of desquamative gingivitis,

about the connection of its existence with the presence of a non-expressed immunological disease

with a clinical appearance in the skin. Desquamative gingivitis is a symptom treated by dental

practitioners, but the agitation and all-inclusivity from the later disease of the organism causes

the patient to pass the dermatologist for further, hospitalized treatment. Sensitization about this

pathology makes dental practitioners more aware about the existence and the possibility of

treatment, or perhaps the referral of the patient to their peer specialists.(2)

Bullous diseases based on their clinical appearance in the oral cavity are implantable diseases for

the dentist, as it is emphasized the fact that intraoral examination may also be required for

44

extracorporeal surgery, and in addition to the strong stomach (teeth), the intracranial soft

structures, a well-behaved eye about the clinical appearance of soft tissue lesions. Bullous

diseases affect men and women more often than menopause, as the systemic flow of menopause

with its decreases and elevations promotes clinical expression of these diseases. Receiving data

in hospitalized patients and in outpatients helps in comparing the patient's views with these

diseases and at the dentist's view on patient access.(3) Each patient involved in the study is well-

informed, and then has been agreed upon in full consensus on the condition of the patient, became

part of the study, and then proceeded with the established protocol.

Materials and methods

The study includes patients randomly presented at the University Clinic AU and

patients in the Department of Dermatology, QSUT, time periods between November

2017 and January 2018. The patients of the first group included in the study, were

patients presented ad-hock at the University Clinic for periodontal treatment during the

period between November and January 2017-2018. All involved patients were informed

about the protocol and duration of the procedure, the obligation to answer some

questions, to examine and photograph in case of evidence of a lesson in oral cavity.

This protocol was also clarified with patients, carried out only for the effect of the study,

the patient would be kept anonymous, and in case of indication would be referred for

further examinations. Of the total of 400 patients, 89 of them refused to take part in the

study. 78% of respondents gave their consent to become a part of the study, some of

them (female gender) despite having been provided with the anonymity, were not ready

to present to others the sensation or symptoms they would questioned.

Every patient involved in the study is well informed, and then the consensus is fully

consensus to become part of the study, and then proceed with the established protocol.

The response to the questionnaire, Dermatological Life Quality Index (ICJD), was also

a part of taking the history.(6,20) The index consists of 10 questions that the patient can

answer in 5 different ways. The objective of this questionnaire is to see how the skin

problems last week affected the life of the patient. The answers are evaluated with the

following points: many 3 points, 2 points, 1 point and not at all, and 0 points.

The questionnaire is finally evaluated with a total score of 10 questions, as follows:

0-1 = no effect in the patient's life,

2-5 = minimal effect on patient's life,

6-10 = moderate effect on patient's life,

11-20 = significant effect on patient's life,

21-30 = very high effect on patient's life.

Results can also be translated into percentages eg, 3, 6.

Subsequently, patients underwent oral mucous membrane and gingival examination.

Every lesion or pathology was recorded. Patients were required to be photographed in

the lesson to be documented for further examinations.

Patients of the second group are patients who, with the help of the dermatologist and

with their consent, were only subjected to visual examination of skin lesions. Patients

of this group were patients in the Department of Dermatology QSUT Tirana, during the

same period above the first group patients (November-January 2017-2018).

Continuous data were presented in average and standard deviation, while discrete data

were presented in absolute value and in percentage. Graphs and tables of various types

(simple and complex) were used to present the data. P values smaller than 0.05 were

considered statically important. The statistical analysis was carried out mainly through

the SPSS version 15 program and partly through the MS Excel program.

45

Results

After collecting the data in the base table of excellence, they were processed for purpose of

displaying the results of the study according to the tables below.

Table 1. This table shows the availability of patients according to the male:female ratio, to be

included in the study where they could divide life-quality components based on the

dermatologically selected index.

Patiets Included % of inclusion Not included % of non-inclusion

Female 175 56% 62 70%

Male 136 44% 27 30%

Total 311 100% 89 100%

The average age of female patients was 43 years and the average age of male patients was 45

years (the patient involved in the study).

Graph 1. The graph shows the data on the inclusion of patients according to the female male

ratio, to the registration of the Dermatological Life Quality Index.

0%

20%

40%

60%

80%

Female male

Inclusion of patients according to male ratio: female

Included Not included

46

Table 2. Separation of patients by age and area of lesion - female, male patients.

Female

Patients

Lesions in

mucosa

% Lesions in

gingiva

% Lesions in

gingiva and

oral mucosa

%

≤ 39 vjeç 4 21% 0 0% 0 0%

≥40 vjeç 8 42% 4 21% 3 16%

Totali 12 63% 4 21% 3 16%

Figure 2. The graph shows the age-specific and lesion-specific patients - female patients / male

patients.

0%

20%

40%

60%

80%

≤ 39 vjeç ≥40 vjeç Totali

Female patients divided by age and appearance of lesions.

lesions at mucosa Lesions at gingiva Lesions at mucosa-gingiva

Male

patients

Lesions in

mucosa

% Lesions in

mucosa

% Lesions in

gingiva and

oral mucosa

%

≤ 39 vjeç 0 0% 2 29% 0 0%

≥40 vjeç 1 14% 4 57% 0 0%

Totali 1 14% 6 86% 0 0%

47

Table 4. The table presents the prevalence of dermatological disease by age in female and male

patients by age limit - 40 years.

Patients Female % Male %

≤ 39 vjeç 4 15% 2 8%

≥40 vjeç 15 58% 5 19%

Total 19 73% 7 27% Graph 4. The graph shows the prevalence of dermatological disease, by sex and age.

Table 5. The table presents the data collected from the Dermatological Quality Index,

according to the subsection below.

0-1 = no effect in the patient's life

2-5 = minimal effect on patient's life

6-10 = moderate effect on patient's life 11-20 = Significant effect on patient's life

21-30 = very high effect on patient's life.

0%

20%

40%

60%

80%

100%

≤ 39 vjeç ≥40 vjeç Totali

Male patients divided by age and appearance of lesions

Lesions atmucosa Lesions at gingiva Lezione nё mukozё-gingivё

0%

20%

40%

60%

80%

100%

120%

≤ 39 vjeç ≥40 vjeç Totali

Prevalence of dermatological disease, by sex and age

Female Male Total

48

Total at point of

reply Female % Male %

0-1 0 0% 0 0%

2-5 16 9% 4 2%

6-10 3 2% 3 1.7%

11-20 0 0% 0 0%

21-30 0 0% 0 0%

Total 19 11% 0 3.7%

The following figures give clinical cases presented to the Clinic.

Fig. 1. This figure shows oral lesions in a female patient under the age of 39.

Fig. 2. A female patient with site lesions in the ulcer, posterior region and hypersensitivity of

the other side is shown in this figure.

Fig. 3. Male patients with initial lesions of gingivitis defective in the area of the incisors and

maxillary mandibular molar-premolars.

49

Fig. 4. Patients with generalized dermatological lesions, posed in the Department of

Dermatology, QSUT.

Discussion

Patient availability data to be included in the study, from literature data can be said that there are

already many registered studies in well-informed and recorded dental students during the cycle

of studies, about patients involved in different studies. The difficulty lies in the fact that the

student is questioning the patient and this is what the latter puts, because the student pretends to

learn, instruct the patient about oral hygiene, or dental problems, or is the student who claims to

help patient with the goal of removing dental anxiety. This is the key to the inner conflict that

occurs in the patient, in answering if he/she wants to include in the questionnaire where the patient

will share personal information elements that are important to the patient.

Another element of the difficulty lies in the fact that the student should also explain how the

questionnaire meets. In some cases, even a member of a medical staff should be present, as

questioners may have difficulty in understanding how they should be fulfilled. This is the reason

why the questionnaires can be filled out by the patients themselves, or they must be filled in with

the presence of a dental student or a staff member. Sometimes, it is good for students to be offered

the personal experience of the medical staff member when he or she is a patient or student to

experience the patient's experience of understanding the patient's doubts in the decision whether

to include the questionnaire or not. Absolutely volunteer patient should be a patient willing to

50

help students in acquiring communication skills. There should be no limits and selection criteria

for volunteer involvement of patients in studies, widespread volunteer variety, enhanced student

experience, experience gained and assimilated, and more positive feedback.(25)

In support of published literature on clinical and pathological relationships of various oral lesions,

a non-compliance ranges from 17 to 42%. Still, in this literature, this discrepancy in the clinical

and pathological correlations of oral lesions depends on different factors, selected from

predetermined histopathological areas, total patient samples as percentages and patient types

varied between studies. This inconsistency also depends on the subjective variations of the

clinician and the histopathologist. There is a need for strict clinical and histological criteria for

establishing the diagnosis. In the case of our study, in view of the difficulties encountered in the

diagnosis and treatment of dermatological diseases of autoimmune origin in our country, the

imposition of these criteria was difficult.(15, 18) From the variety of dermatological diseases of

autoimmune origin, was only pemphigus is chosen with all its types, not the point of diagnosis

of various types of clinic of this disease, but only to identify, within the possibilities, endangered

individuals. In the results of our study were included exclusionary criteria, all patients who were

positive to Kobner's symptom. This is to exclude patients prone to dermatological diseases, not

the appearance of gingivitis in the oral cavity.

Based on the research in literature, pemphigus vulgaris reflects a total susceptibility of 12.5%,

for example with lichen planus in 37.5% or leukoplakin with 20% susceptibility.(23) Backed up

to this source of literature in patients with lichen planus male ratio: female was 43.3% with

56.6%, for leukoplakin was 60% with 40% and for pemphigus vulgaris was 60% at 40%. For

lupus erythematosus the patient's vulnerability to this disease was 12.5% divided by gender by

30% with 70%. In the case of our study, the susceptibility to male ratio: female was 27% at 73%.

Further, the purpose of the study was the age effect on the appearance of dermatological disorders

of patients.

The age limit set in our study is 40 years of age. Lessons and dermatological problems

encountered before the age of 40, or after the age of 40 years. This age limit was only based on

fact that this age serves as the limit of starting the initial menopause signs. It is known that

sensitive fluctuations in sex hormone levels have a significant effect on sensitive fluctuations in

the female body, immune response rates, and the susceptibility of the organism to dermatological

diseases of autoimmune origin. By comparing the age levels of oral lesions in the oral cavity for

autoimmune diseases, in relation to local risk factors, it can be said that the largest number of

patients with lichen planus, lupus erythematosus and pemphigus vulgaris ranged from 31 to 45

years and leukoplakis lesions, the age of patients varies from 46 to 60 years. If we talk about the

average age of patients affected by these diseases specifically for lupus is 38 years old with

standard deviation 14.62, for lichen planus is 39.6 years with a standard deviation of 14.62, for

pemphigus vulgaris the average age is 38 years with a standard deviation of 11.73.(22, 24) In our

study, the average age of female patients was 43 years and the average age of male patients was

45.(25) In our study, the average age of the patients was 45 years and the average age of the patients

was 45.(25)

Only gingivitis lesions can occur, but can also occur in mucosal lesions, or in both areas at the

same time. Moreover, when we talk about pemphigus, when it is necessary that the lesion's

laboratory analysis be confirmed with direct immunofosforism and reconfirmed with indirect

immunofosforce. Both analyzes should be positive to confirm the safe presence of the disease.

Analysis that is costly for the patient, but when performed in the right time prevents the disease,

when the treatment begins in the right time. Advice for dental professionals includes some of the

following:

A complete oral mucous examination should be performed, evaluating for any anomalies,

including complications in the oral cavity of pemphigus or pemphigoid treatment, such as

candidosis, so everyone needs to be careful about maintenance schedules and set more frequent

schedules to control the gravity and progression of the disease.(1,2)(5,7-11) Nisengard and Levine(10)

cited as standard in establishing clinical diagnosis of gingivitis, chronic rash, ulceration, and/or

51

bubble formation. Gingivitis deskuamtiv: (1) presence of gingival erythema that does not result

from the plaque, (2) gingivitis, (3) other intraoral lesions and sometimes extra, sore mouth

complaints, especially in case of application of aromatic foods. It is reported that most cases of

dysfunctional gingivitis are caused by some mucocutaneous diseases. (5, 7-9) In our study, the

initial signs of dysfunctional gingivitis are present in 7 patients, but all of these in lighter clinical

signs.

Pemphigoid mucosal membrane and lichen planus erosive are the most common causes of

dysfunctional gingivitis, respectively 48.9% and 23.6% of all cases of dysfunctional gingivitis.(8)

In our patients there were no pruritus signs in the skin of the back or on the dorsal surfaces of the

arms and legs, which removed the clinical diagnosis of pemphigus vulgaris from the lichen

planus. In the patients involved in the study, there were no sign of symblepharon, a clinical sign

that removed the clinical diagnosis from pemphigoid. Histopathological examination and direct

immunofluorescence testing are necessary to establish the ultimate diagnosis of diseases

responsible for the defective gingivitis. (5, 7, 9-11) Given that pemphigus vulgaris is potentially fatal,

the recognition of gingival lesions of gingivitis desquaming, though rare, is essential for ultimate

diagnosis, timely therapy, and patient follow-up. There are cases where it is needed for more than

1 year until the final diagnosis of pemphigus vulgaris(25), which is measured after the patient's

appearance in the dental unit, with primary signs of oral cavity. During this period, the patient

visited a dental clinic, an otolaryngology clinic and an internal medicine clinic, but no final

diagnosis was provided at any of these clinics. Reasons for delayed diagnosis may be explained

by the fact that the symptoms of pemphigus vulgaris of the patient are limited to the gingiva and

are clinically very light and by the fact that the symptoms occur in repeated cycles of healing and

deterioration.

For the final diagnosis of pemphigus vulgaris, the following criteria must be met: (1) the presence

of relevant clinical lesions, (2) confirmation of acantholysis in biopsy specimens, and (3)

autoantibody confirmation in tissue or serum, or both. In the present case, a final diagnosis of

pemphigus vulgaris was made based on a general assessment of the following findings: (1)

positive phenomenon of Nikolsk, (2) presence of acantholysis in biopsy specimens, and (3)

locating deposition of antibodies between epithelial cells with direct immunofluorescence test.

All patients involved in the study are recommended for further visits to dermatologists, as

establishing a diagnosis for pemphigus is a multidisciplinary decision in terms of treatment and

diagnosis for such diseases in our country.

Conclusions

The documented data showed the presence of initial signs of gingivitis desquamative, clinical

signs that should be checked and carefully examined by dental specialists as they are the first to

contact the patient suffering from these symptoms.

Dermatological diseases of autoimmune origin, classified as vesiculobulose diseases, are

encountered in the gingiva, in the mucous membranes, or in the gingiva and in the mucous

membranes. For female patients, tachycardia appears more frequently in the lining of the mucous

membrane, while for male patients, tachycardia appears more frequently with gingival lesions.

The fact that women are most affected by autoimmune bulous lesions and higher predisposition

have been confirmed by women over the age of 40. The impact of the skin on the patient's

difficulties during the day-to-day activity is more pronounced in female patients than in male

patients, which is based on the Dermatological Life Quality Index assessment, applied in our

study.

Acknowledgments: Our thanks belong to our family. Henri and Hera drive us forward, and

further in the field of scientific research.

52

Author Contributions: Literature research was conducted by Dr. Saimir Heta. It was his

insistent work that made it possible to reach the conclusions in this article.

Conflicts of Interest: We declare that there is no conflict of interest between the authors and the

material presented in this article.

References

1. Stanley, John R. (2003). "Chapter 59: Pemphigus". In Freedberg; et al.

Fitzpatrick's Dermatology in General Medicine (6th ed.). McGraw-Hill.

p. 559. ISBN 0-07-138067-1.

2. https://media.gettyimages.com/photos/pemphigus-vulgaris-an-autoimmune-

intraepithelial-blistering-disease-picture-id128575331).

3. http://www.ijdvl.com/articles/2015/81/6/images/ijdvl_2015_81_6_655_168342_f1.jp

g.

4. Irwin M. Freedberg; et al., eds. (2003). Fitzpatrick's dermatology in general

medicine (6th ed.). New York, NY [u.a.]: McGraw-Hill. p. 558. ISBN 0-07-

138076-0.

5. International Journal of Women's Dermatology; Volume 1, Issue 1, February

2015, Pages 4-12.

6. Cathy Y.ZhaoMBBS, MMedDédée F.MurrellMA, BMBCh, FACD, FAAD,

FRCP, MD; ”Autoimmune blistering diseases in females: a review”; Int J

Womens Dermatol. 2015 Feb; 1(1): 4–12.; Published online 2015 Feb 26.

doi: 10.1016/j.ijwd.2015.01.002.

7. Theofilopoulos AN. The basis of autoimmunity: Part I: Mechanisms of aberrant self-

recognition. Immunol Today. 1995;16:90–97. [PubMed]

8. Aoki V1, Rivitti EA, Diaz LA; “Update on fogo selvagem, an endemic form of

pemphigus foliaceus.; Cooperative Group on Fogo Selvagem Research”; J

Dermatol. 2015 Jan;42(1):18-26. doi: 10.1111/1346-8138.12675.

9. Carranza – Clinical periodontology; Mosby 2009; Kapitulli Gingiviti Deskuamativ.

10. Kim D. Edhegard, Russell P. Hall, in Clinical Immunology (Fourth Edition),

2013.

11. Hashimoto T, Teye K, Ishii N. Clinical and immunological studies of 49

cases of various types of intercellular IgA dermatosis and 13 cases of

classical subcorneal pustular dermatosis examined at Kurume University. Br

J Dermatol 2017; 176:168.

12. J Am Acad Dermatol. 1990 May;22(5 Pt 2):917-9. Intraepidermal neutrophilic IgA

dermatosis. Kuan YZ1, Chiou HT, Chang HC, Chan HL, Kuo TT. Dermatology

1992;185:311–313.

13. Gengoux P. · Tennstedt D. · Lachapelle J.M.; Intraepidermal Neutrophilic IgA

Dermatosis: Pemphigus-Like IgA Deposits; Unit of Occupational and Environmental

Dermatology, Louvain University, Brussels, Belgium; Dermatology 1992;185:311–

313; (DOI:10.1159/000247480).

53

14. Korman NJ1, Eyre RW, Zone J, Stanley JR. Drug-induced pemphigus:

autoantibodies directed against the pemphigus antigen complexes are present in

penicillamine and captopril-induced pemphigus. J Invest Dermatol. 1991

Feb;96(2):273-6.

15. Landau M1, Brenner S. Histopathologic findings in drug-induced pemphigus. Am J

Dermatopathol. 1997 Aug;19(4):411-4.

16. https://www.mayoclinic.org/-/media/kcms/gbs/patient-

consumer/images/2013/08/26/10/29/ds00749_im01954_r7_pemphigusfoliac

eusthu_jpg.jpg.

17. https://www.mayoclinic.org/-/media/kcms/gbs/patient-

consumer/images/2013/08/26/10/05/ds00749_im00813_ans7_pemphigusthu

_jpg.jpg.

18. Ferri FF. Pemphigus vulgaris. In: Ferri FF, ed. Ferri's Clinical Advisor 2016.

Philadelphia, PA: Elsevier; 2016:941-942.

19. Habif TP. Vesicular and bullous diseases. In: Habif TP, ed. Clinical Dermatology. 6th

ed. Philadelphia, PA: Elsevier; 2016:chap 16.

20. Finlay AY, Khan GK. "The Dermatology Life Quality Index: A simple

practical measure for routine clinical use". British Association of

Dermatologists Annual Meeting, Oxford, July 1993. British Journal of

Dermatology, 1993; 129 (Suppl 42): 27.

21. Finlay AY, Khan GK. "The Dermatology Life Quality Index: A simple

practical measure for routine clinical use". British Association of

Dermatologists Annual Meeting, Oxford, July 1993. British Journal of

Dermatology, 1993; 129 (Suppl 42): 27.

22. Finlay AY, Khan GK. Dermatology Life Quality Index (DLQI) - a simple

practical measure for routine clinical use. Clinical and Experimental

Dermatology, 1994; 19: 210-216.

23. Anstey A, Reynolds NJ. "What does the BJD now stand for? A position

statement". British Journal of Dermatology 2015; 172: 1463-1465.

24. World Health Organisation. Global report on psoriasis. ISBN 978 92 4

156518 9. WHO Press, Geneva, 2016, p16.

25. https://www.google.com/url;health.adelaide.edu.auFvolunteer-patient-program.

54

RECIPROCAL GENETIC EFFECTS IN WEIGHT AND

BLOOD GROUPS

Naser Kamberi1 , Hyzer Rizani2

UBT - Higher Education Institution, Lagjja Kalabria, 10000 p.n., Prishtina, Kosovo

Abstract. Based on the actions of the genes within the cell as a whole in this study we present

the correlation of body weight with blood groups. In this study are included individuals of both

genders. To accomplish this work without any selection are included 400 individuals of which

200 are men and 200 are women. In this sample of 200 individuals, both sexes for each blood

group were included in 50 females and 50 males (4 groups x 50 = 200). This paper is intended

to observe body weight comparisons between individuals with different blood groups of both

sexes and their similarities based on these two traits. It is worth mentioning that these two

qualities are genetically different because weight is a quantitative quality because here besides

the genetic influence factor there is also the environmental factor, while on the other hand the

blood groups are mainly attributed to the genetic factor. By doing the calculations of values we

can show which blood group has the highest body weight of both genders and whether there is a

similar ratio between the two genders.

Keywords: genetic effect, reciprocal, weight, blood groups.

Introduction

The correlative research of the influence of blood groups on body weight can be done by

comparing the values of the obtained results. For this reason, the results of this paper can be

considered as a modest contribution to the recognition of the blood's body's influence on body

weight in humans. This impact will appear based on the values gained in which group of blood

we have the highest body weight and how the ratio in the other groups stays. We can also observe

the results of both sexes by presenting variables to both sexes. Individuals included in this study

are 18 year old students of 3 generations. Measurement and determination of blood groups was

done in 2016-2108 in the same age students at the Presevo High School. The research and

preparation of such a genetic and anthropometric study in essence has to do with how the weight-

to-blood relation binds to blood groups.

Material and methods

As a research material in this study is included sample which totals 400 students. From this

sample included in this study 200 belong to the female gender and to as many as 200 male gender.

For each group of blood were taken into consideration by 50 individuals as follows: 50 female

students per blood group O, 50 men with blood group O, 50 female students per blood group A,

50 men with blood group A, 50 female students for blood group B, 50 men with blood group B,

50 women for AB blood group, and 50 men with blood group AB. Data collected by individuals

are recorded in the data evaluation software program. Mathematical-statistical methods were used

to obtain these results.

55

The material included in this study appears in Table 1.

Table1. The material involved in this study

Male-18

years

Fre

quen

cy (

M)

mal

e

Female-

18 years

Fre

qu

ency

(F

)

fem

ale

Group

A

Group B

Group

AB

Group O

Weight Weight M F M F M F M F

48 6 45 5 1 1 2 1 2 1 1 1

49 5 46 5 0 1 2 1 2 1 2 1

51 5 47 8 1 2 2 2 2 1 1 1

52 5 48 4 1 1 1 1 1 0 1 0

54 4 49 6 0 0 2 2 1 1 1 1

55 5 50 4 2 2 0 1 1 1 2 1

56 6 51 12 2 5 1 2 1 3 2 2

57 7 52 8 2 2 1 1 2 1 1 2

58 9 53 9 2 4 1 1 1 2 2 3

59 6 54 9 3 3 2 1 2 2 2 2

60 10 55 8 4 2 2 2 2 2 3 2

61 9 56 15 1 3 2 3 3 5 2 3

62 10 57 13 3 4 1 2 2 2 2 4

63 10 58 8 3 1 2 1 2 1 3 2

64 11 59 10 3 4 2 2 3 2 3 6

65 10 60 9 3 2 3 2 3 2 3 2

66 7 62 9 3 3 2 2 1 2 2 3

67 9 63 10 2 4 2 2 2 2 1 3

68 18 64 8 3 0 2 2 2 2 3 0

69 11 65 9 3 1 2 3 3 2 3 1

71 10 66 9 3 1 3 2 2 2 2 5

72 7 67 7 2 2 2 3 2 2 2 2

73 6 68 5 2 1 3 2 1 3 2 1

75 5 69 5 1 1 2 3 2 2 2 1

81 4 70 2 0 0 3 3 3 3 1 0

87 5 73 3 0 0 3 3 2 3 1 1

200 200 50 50 50 50 5

0

5

0

50 50

56

Results and discussion

Based on measurements of body weight in individuals with different blood groups according to

the results obtained we see a change in weight. Of the total male number is of higher weight for

1333 kg than that feminine. The total male average is 64.585kg while on the other hand the female

gender is 57.92kg average and based on these values the difference is 6.665kg. These results are

presented in Table 1 where we have 200 men and 200 women in discussion. Results presented in

Table 2. represent the average body weight of individuals for each blood group.

Table 2. The value of the average body weight

The average body weight in masculine (M) and feminine (F)

Total weight

=12917(M)

Total weight =11584 (F) Change M 1333 > F

12917/200= 64.585 11584/200=57.92 Change M 6.665> F

Apart from the arithmetic average, we also have the average of the position which is less accurate

than the arithmetic average. How is the word moda that includes the size of the weight that is

repeated most often. In our case the size which is repeated more often in males is 68 kg (it is

repeated 18 times). If we make these sizes with a graph, then we will have a curve.

The curve represents the mod.

Graph.1. Presentation of the mod masculine roof

In feminine mod females appearing with a peak of 15 times the weight of the parks is 56 kg.

Analyzing the value of the arithmetic average with the mod values of both sexes it is obvious that

in men the mod has the highest value for 3.415 kg, whereas in females these values are much

more approximate and here the arithmetic mean value is greater for 1.92 kg (roughly 2kg) than

the value of mod.

57

Graph.2. Presentation of the mod feminine roof

Likewise, we have the Median which represents a size of the central position starting from the

smallest to the largest. In this case men of 26 variances have two central values of 61kg and 62kg

and here we have a theoretical average that is the average of two sizes standing in the middle of

the rankings worth 61.5kg. Median females include 56 kg and 57 kg weight and in this case the

average of two sizes is 56.5 kg.

Table 3. Average weight by blood group male (M) and female gender (F)

Table 3 where the mean values for weight (P) for male and male sex (F) are presented by blood

groups, based on the obtained results it is clear that men with blood groups B and AB are of a

weight greater than individuals with group A and 0. While on the other hand, the females with

blood group B and AB have a higher body weight than women with group 0 and A. Individuals

with blood group 0 are more closely related to those with group B and AB than individuals with

blood group A. This phenomenon may be a cause of evolution as this antigen-free group does

not refuse antigen B compared to antigen A.

Based on these results it is clear that individuals with blood groups B and AB have a correlation

with body weight. This means that group B and AB are related to the quality of body weight.

This is confirmed by the fact that even individuals with AB blood group have antigen B which

seems to have effects on body weight. While the Beta antibody in the blood group A has no effect

on body weight. Therefore we can say that the effect of weight is related to antigen B. Since

alleles of blood groups are found in chromosome 9, we may think that genes for body weight

may also be located in the same chromosome and considered as related genes. As compared to

Blood

group

0 A B AB

Gender M F M F M F M F

Weight

average

63.56 58.4 56.44 57.02 65.34 59.96 64.24 60.02

Total

weight

3178

2920 2822 2851 3268 2998 3212 3001

58

AB it is seen a proximity associated with the presence of antigen B in the AB blood group. These

results are presented in Table 3 for both sexes, males and females. Body weight ratios by blood

groups are also shown in graph 3. Observing visually clearly men dominate in three blood groups

in weight such as 0, B and AB, while on the other side of blood group A, the phenylalanine has

greater weight.

Graph.3. Appearance of arithmetic mean of body weight of both sexes by blood groups

Table 3 shows weight values of 50 males and 50 females by blood group: 0, A, B and AB. These

values are as follows and based on the results we have graph

4.

Graph.4. Presentation of tidal weight values by blood groups of both sexes

0 A B AB

M F M F M F M F

63.56 58.4 56.44 57.02 65.34 59.96 64.24 60.02

3178

2920 2822 2851 3268 2998 3212 3001

59

Table 4 is called a matrix of distances between populations by blood groups, but also changes in

weight. This shows the changes in body weight between individuals with blood groups A, B, AB

and 0. Observing these results according to mathematical calculations it is clear that group B and

AB are of greater weight than the other two groups and are more roughly equal value. Smaller

values are individuals with blood group A.

Table4. Change of weight medians expressed in kilograms of males (M) and females (F) by blood

group

These weight-loss results clearly indicate that this feature is associated with blood group B and

since this antigen B is also found in group AB the values of both groups are greater than the other

two groups A and 0.

Conclusions:

On basis of these results get out these conclusions:

1. Based on the results of the fit we can say that the body weight is tied to the group B.

2. Blood group AB has proximity to group B values based on the presence of antigen B in group

AB.

3. The largest change is group A that is smaller than group B value for 8.9 kg weight.

4. I think that this is the cause of evolution since group B is the third in a row.

Acknowledgements: I thank the schools for the help of collecting the material.

References:

1. Arthur C. Guyton,; Medicinska fiziologija. Medicinsaka knjiga, Zagreb, 1986, 39-55.

2. D.Ninoslav; S. Zoran. 2004.Principi genetike.Beograd.201-220.

3. Kurelic N, Momirovic K, Stojanovic , Sturm J, Radojevic D, Viskic–Stelac N.;

Struktura i razvoj morfoloshkih i motorickih dimenzija omladine. Beograd, 1975.

4. Stojanovic M.; Biologija razvoja covjeka sa zdravstvenom kontrolom. skripta,

Beograd, 1961, 13-19

5. Radojevic Dj.; Fizicki razvitak, motorne i funkcionalne sposobnosti skolske omladine

SR B i H. Zavod za fizicku kulturu, Sarajevo, 1972, 1-6.

Group

s

>A >B >AB >0

M F M F M F M F

A< / /

<8.9k

g <2.94kg <7.8kg <3kg <7.12kg <1.38kg

/ / / / / / / /

B< / / / / 1.1kg> <0.06kg 1.78kg> 1.56kg>

/ / / / / / / /

AB< / / / / / / 0.68kg> 1.62kg>

/ / / / / / / /

60

The impact end therapeutic efficacy of chlorhexidine-gel

in gingival inflammation in chronic Periodontopathy

Sahmedin Sali¹,

¹ Sahmedin Sali, Univesity of Tetova, Faculty of Dentistry, Tetovo, Republic of

Macedonia,

semi.dent@live.com

Abstract. Objectivies: evaluation of the impact therapeutic effect of the gel which contain

Chlorhexidine Gluconate on the gingival inflammation through comparative analysis in patients

with the application of the conventional method (CM) and conventional therapy supported with

Chlorhexidine Gluconate Gel (KM-G) .

Materials and Methods: For the realization of our aim was included 30 patients from both

genders, aged 20-50 years, in which radiographic and clinically was diagnosed chronic

periodontal disease with a periodontal pocket depth of 3 mm but not exceeding 5 mm. The

subjects are divided in two groups: in the first was used only the conventional method and in the

second the subjects were treated with KM - G. In both groups included in this study we have

determined the index by Loo-Sillnes and the index of the gingival inflammation by Sillness –

Loo in four time points: the first during the initial treatment at the first examination. Then after

5th day, after 10th day and on the end after the 30th day from the first treatment. The Chlorhexidine

Gluconate Gel in patients was administered at the beginning during the first examination. The

numerical statistical was analyzed with descriptive statistics methods ( Mean ± Standard

deviation . , ± 95 % CI , Min . , Max . ), while the interactive effects between the two examined

methods after the first treatment during the first examination , at 5th, at 10th and at 30th day, were

analyzed with the Repeated measures Anova ( F ) / Post - hoc Bonferroni test ( p ) .

Results. The results show reduction of the dental plaque and of the gingival inflammation in both

groups after the 5 th, 10 th and after the 30th days from the initial treatment in comparison with the

first examination. The comparison of the dental plaque index and the index of gingival

Inflammation on the 5th, 10th and 30th day between the both groups, demonstrate significantly

better therapeutic efficiency in the group treated with KM which was supported with using of

the Chlorhexidine Gluconate Gel.

Conclusion: The subjects treated with the KM- G , as opposed to those treated with KM, had an

significantly improved clinical effects which were observed through decreased gingival

inflammation and trough dental plaque reduction in all stages of our research .

Keywords: chronic periodontal disease, gingival inflammation, conventional therapy,

chlorhexidine gluconate gel .

Introduction

Bio film as unavoidable etiologic factor in its content and structure contains bacterial

conglomerate which with toxins, enzymes and other associated factors cause gingival

inflammation i.e. progressive destruction of connective tissue attachment and alveolar bone ⁽¹⁾.

61

The control of dental plaque through daily maintenance of oral hygiene, removing the newly

emerging supra and sub gingival plaques are one of the ways to act preventive or curative when

the gingival inflammation appears or to preserve the achieved therapeutic success ⁽²⁾.

Irregular and unskilled mechanical instrumentation can damage the hard tissues where the sign

is the appearance of gingival recession ⁽ᶟ’⁴⁾.

In therapeutic treatment despite of removing plaque microorganisms mechanically, in clinical

practice is used chemotherapy antimicrobial local or systemic therapy.

On these objectives are used many methods which in this occasion would apostrophized CIST-

protocol.

CIST-protocol or otherwise named, modify the conventional (basement) periodontal method, as

a therapeutic procedure which includes antimicrobials assets or modern antiseptic assets in the

form of a gel, in which the leadership belongs to chlorhexidine.

Based on the latest scientific knowledge and proven results on the effectiveness of local

administration antiseptic assets in gel form, we set the goal of this research, we follow the

therapeutic effect of chlorhexidinegluconate gel on gingival inflammation through comparative

analysisof patients using conventional therapy (KM) and conventional therapy aided by

chlorhexidinegluconate gel (KM-G).

Material and working method

For realization of this goal, the research is implemented in the dental office “Fjolla medica” in

cooperation with the Clinic for mouth and periodontal Diseases in Dental Faculty, where were

followed 30 patients of both sexes aged 20-50 years where was diagnosed with X-ray and

Periodontopathy in second clinical stage.

From all examinees were taken anamnestic data and was carried out clinical examination by

analyzing the x-ray.

Examinees who were a part of this study were divided into 2 groups:

- Examinees from the first group were treated with conventional method (KM)-

standard method (removing local irritation, dental plaque, tartar and processing

periodontal pockets). In this group the toilet of periodontal pocket was consisted of

rinsing with 3% hydrogen and maintaining oral hygiene.

- Examinees from the second group were treated with combined method

conventional- method and application of chlorhexidine gluconate gel (KM-G),

following processing periodontal pockets.

Patients who formed the group treated by KM-G were given instructions after application of the

gel, maintaining good oral hygiene.

Chlorhexidine gluconate gel product on the market known as CHLO-SITE contains 1.5%

chlorhexidine in the form of xanthan whose producer is the Ghimas Company from Italy.

The research was made in several stages: with the first examination of the patient, after 5, 10 and

30 days of the conventional procedure and the same procedure aided by chlorhexidine gel

therapy.

To all examinees were made clinical examinations through the evaluation of dental plaque and

gingival inflammation index.

The Gingival inflammation index is determinate by the Loe-Silnes method.

The findings were compared between the two groups in different examined groups i.e. after

admission, 5, 10 and 30th day of the treatment. All obtained results were statistically processed.

In series with numerical marks are assessed: Descriptive statistics

(Mean±Std.Dev.,±95%CI,Min.,Max.), while the interactive effects of the two examined methods

62

after the treatment due to the first examination, after 5, 10 and 30 days were examined according

to the Repeated measures Anova (F)/Post-hoc-Bonferroni test (p).

Results

Table 1 presents gingival inflammation (during the first examination, after 5, 10 and 30 days), on

patients with KM and KM-G. The given results of this research are shown in table 1 and chart

1)

For F=88,23 and p<0,001 (p=0,000) in given distribution there was significant difference (table

1 and chart 1)

The patients treated with KM-G after 5th day of the control for p<0,001 (p=0,000) there was

significant lower gingival inflammation (0,27) , compared with the first examination (1,48). We

found identical results after the 10th controlling day, for p<0,001 (p=0,000) with gingival

inflammation (0,13) compared with the first examination (1,48). Significant gingival

inflammation p<0,001 (p=0,000) was noticed even after the 30th day of the treatment.

Table 1.Display of gingival inflammation to the examined groups in different time periods on

patients treated with both methods.

G.inf.*Group ; LS Means; Current effect: F(3, 84)=88,23, p=0,000 Effective hypothesis

decomposition

Group treated with: Gingival inflammation

DV_1

Mean

DV_1

Std.Err

.

DV_1

-

95.00%

DV_1

+95.00

%

N

1 KM-G First examination 1,48 0,06 1,35 1,61 1

5

2 KM-G After 5 days 0,27 0,04 0,19 0,35 1

5

3 KM-G After 10 days 0,13 0,05 0,02 0,24 1

5

4 KM-G After 30 days 0,02 0,03 -0,03 0,07 1

5

5 KM First examination 1,49 0,06 1,47 1,73 1

5

6 KM After 5 days 0,92 0,04 0,85 1,00 1

5

7 KM After 10 days 0,91 0,05 0,80 1,02 1

5

8 KM After 30 days 1,08 0,03 1,02 1,13 1

5

63

Chart 1.Therapeutic efficacy of the use of various therapeutic modalities in both groups in

different time periods

G.inf .*Grupa; LS Means

Current ef f ect: F(3, 84)=88,233, p=0,0000

Ef f ectiv e hy pothesis decomposition

Vertical bars denote 0,95 conf idence interv als

Grupa

!~\FT1,,,gel

Grupa

!~\FT1,,,standardG.Inf ./priem G.Inf ./kon5 G.Inf ./kon10 G.Inf ./kon30

G.inf .

-0,4

-0,2

0,0

0,2

0,4

0,6

0,8

1,0

1,2

1,4

1,6

1,8

2,0

DV

_1

The given results show reduction of gingival inflammation to all examinees that were treated

with KM and KM-G in all stages of research, after 5, 10 and 30 days, against results of the first

examination. Comparison between two groups showed improved clinical results in the group

treated with KM-G.

Table 2. Display of gingival inflammation – Post-hoc Test/Bonferroni test/ on both examined

groups compared with receipt day, 5, 10 and 30 day of treatment.

Group Gingival Inflammation

{1}

1,48

{2}

0,27

{3}

0,13

{4}

0,02

{5}

1,60

{6}

0,92

{7}

0,91

{8}

1,08

1. KT-G First treatment 0,000 0,000 0,000 0,000 0,000 0,000

2. KT-G after 5 days 0,000 0,03 0,000 0,000 0,000 0,000 0,000

3. KT-G after 10days 0,000 0,03 0,000 0,000 0,000 0,000

4. KT-G after 30 days 0,000 0,000 0,000 0,000 0,000 0,000

5. KT First treatment 0,000 0,000 0,000 0,000 0,000 0,000

6. KT after 5 days 0,000 0,000 0,000 0,000 0,000 0,01

7. KT after 10 days 0,000 0,000 0,000 0,000 0,000 0,003

8. KT after 30 days 0,000 0,000 0,000 0,000 0,000 0,01 0,003

From table 2. Evident is better therapeutic result in the group treated with KM-G against KM

after 5, 10 and 30 day of the treatment.

64

Table 3. Display of dental plaque on the examined groups in different time periods in patients

treated with both methods.

D.plaque*group; LS Means; Current effect: F(3, 84)=1,47, p=,23

Effective hypothesis decomposition

Group Dental plaque DV_1

Mean

DV_1

Std.Err.

DV_1

-95,00%

DV_1

+95,00% N

1 KM-G Treatment 1,41 0,18 1,03 1,78 15

2 KM-G after 5 days 0,01 0,01 -0,02 0,03 15

3 KM-G after 10 days 0,04 0,03 -0,01 0,09 15

4 KM-G after 30 days 0,05 0,18 -0,32 0,43 15

5 KM Treatment 1,42 0,18 1,50 2,23 15

6 KM after 5 days 0,05 0,01 0,03 0,08 15

7 KM after 10 days 0,11 0,03 0,05 0,16 15

8 KM after 30 days 0,43 0,18 0,06 0,81 15

On table 3. Display distribution of dental plaque (examination control after 5, 10 and 30 days)

to the patients treated with KM method and to the patients treated with KM-G).

For F=1,47 and p>0,05 (p=0,23) in the shown distribution do not exist significant difference

(table 3 and chart 2)

Chart 2. The presence of dental plaque among respondents after application of different treatment

modalities in both groups in different time periods

65

D.plak*Grupa; LS Means

Current ef f ect: F(3, 84)=1,4714, p=,22822

Ef f ectiv e hy pothesis decomposition

Vertical bars denote 0,95 conf idence interv als

Grupa

!~\FT1,,,gel

Grupa

!~\FT1,,,standardD.plak/priem D.plak/kon5 D.plak/kon10 D.plak/kon30

D.plak

-1,0

-0,5

0,0

0,5

1,0

1,5

2,0

2,5

3,0

DV

_1

Table 4: Are displayed values of dental plaque – Post-hoc Test/Bonferroni test/ on the both

groups compared with the day of receipt, 5, 10 and 30 day of the treatment.

Table 4. Display of dental plaque – Post-hoc Test/Bonferroni test/ on the both groups compared

with the day of receipt, 5, 10 and 30 day of the treatment.

Group Dental plaque {1} 1,41

{2} 0,01

{3} 0,04

{4} 0,05

{5} 1,87

{6} 0,05

{7} 0,11

{8} 0,43

1 KM-G receipt 0,000 0,000 0,000 0,000 0,000 0,000

2 KM-G after 5 days 0,000 0,000

3 KM-G after 10 days 0,000 0,000

4 KM-G after 30 days 0,000 0,000

5 KM Receipt 0,000 0,000 0,000 0,000 0,000 0,000

6 KM after 5 days 0,000 0,000

7 KM after 10 days 0,000 0,000

8 KM after 30 days 0,000 0,000

There isn’t any significant difference (p>0,05) for the dental plaque, between two groups from

the first treatment.

66

The patients who were treated with KM-G after the 5th day for p<0,001 (p=0,000) they have

significantly lower presence of the dental plaque (0,01) compared with the reception day (1,41).

Identical results were observed on the patients treated with KM-G after the 5th day of control, for

p<0,001 (p=0,000) they have significantly lower presence of dental plaque (0,01), compared with

the patients treated by KM, (0,04), as well as the control after the 10th day to the examinees who

were at KM-G for p<0,001 (p=0,000) they have much lower presence of dental plaque (0,04)

compared with those who were treated with KM (0,11).

The patients treated with KM-G after the 30th day for p<0,001 (p=0,000) they have significantly

lower presence of dental plaque (0,05), compared with the group treated on KM (0,43).

Discussion

Dental plaque as an important segment in the etiology of many dental and periodontaldiseases

we say it is organic layer of teeth, colorless, opalescent and slimy substance made up of many

micro-organisms that cause the initial vascular changes in gingival tissue and otherpathogenic

events that ended with the loss of collagen tissue and apical migration on epithelial connection⁽⁵⁾.

In fact, most of the authors confirm the connection between plaque and gingival inflammation

⁽⁵˒⁶˒⁷⁾ and definitely confirm the theory of periodontal pockets and periodontal disease.

This study, analyzed the difference in the presence of dental plaque using the both methods:

conventional and conventional plus chlorhexidine gel. The results showed that there was no

significant difference in the presence of dental plaque between those two groups after the first

examination of the patients, but there was significant difference in the presence of dental plaque

after the 5th day of the treatment. After the 10th and 30th day it was the same situation between

the both groups.

After the complete treatment regardless in what period was made and which method was used, it

was evident the reduction of index value of dental plaque.

Statistics showed that patients treated with classic method after the 5th (0,05), the 10th (0,11) and

the 30th day (0,43), were having much lower presence of dental plaque compared to the first

examination (1,42). The same results we found when we analyzed the patients treated with

conventional method adding the gel after the 5th (0,01), 10th (0,04) and 30th day (0,05). In this

case was recorded much lower presence of dental plaque compared with the first visit (1,41).

Especially evident fact of this research was the magnificent lower values of the dental plaque in

the group treated with KM-G in all stages of this research.

Our results were obtained in accordance to the results of many authors ⁽⁸˒⁹˒¹⁰⁾ and they confirmed

that the application of chlorhexidine gel in the treatment of periodontal disease effectively had

influence on the clinical symptomatology.

Actually, the CIST-protocol or otherwise named, modification on conventional periodontal

method, highlights the antimicrobial effect on this modern antiseptic asset in the form of the gel,

specially in cases where the periodontal pockets are from 3-5 mm deep, and in cases when we

lose periodontal bone to 2 mm ⁽¹¹⁾.

Its therapeutic effect is followed in the study of Eit⁽¹²⁾ who claims that the therapeutic effect on

the chlorhexidine gluconate as an adjuvant asset in the treatment of periodontal disease is having

a positive effect on gingival.

In this study after the treatment made on the both groups there was a difference in the application

of KM and KM-G in terms of gingival inflammation.

The presence of dental plaque nearby the gingiva causes inflammation of the gingiva.

67

Gingival inflammation in the same time means the introduction to the periodontopathy and the

reason more to emphasize the accumulation of dental plaque, who through the factors of

inflammation contributes to increase the level of osteoresorptive factor in inflamed gingival, with

progression of chronic periodontopathy ⁽¹ᶟ⁾.

The results of gingival inflammation after the use of both methods KM and KM-G showed that

there is significant difference in the index of gingival inflammation between the two groups after

the 5, 10 and 30 days from the treatment.

The patients that were treated with KM-G after the 5th (0,27), 10th day (0,13) and 30th day (0,02),

were registered much lower values of the gingival inflammation compared with the first

examination (1,48), but the patients that were treated with KM after the 5th day (0,92), after the

10th (0,91) and after the 30th day of control (1,08) were having significant lower values of the

gingival inflammation compared with the first examination (1,60).

Similar to those results the patients who were treated with KM-G after the 5th day of control

(0,27), 10th day (0,13) and after the 30th day (0,02) were registered significant lower values of the

gingival inflammation compared with the values on the patients who were treated with KM after

the 5th day of control (0,92), 10th day (0,91) and after the 30th day (1,08).

The results of this research showed positive therapeutic effect in patients treated with KM-G. We

think that the evident improvement in clinical symptoms first in gingival inflammation is because

of the chlorhexidine gel like a adjuvant asset in the treatment of periodontal disease.

The chlorhexidine gel is the local antiseptic that directly reduces the qualitative and quantitative

composition of the microorganisms in bio films, and thus have positive influence on the gingival

and periodontal status ⁽¹²⁾.

Actually, the gel chlorhexidine contains the range of local antimicrobial ingredients and the most

important is xanthan. The xanthan in contact with water is decomposing and is slowly forming

the resistant gel coating which acts favorably by 30 days max.

We, relying on this scientific results explain also our results that goes in addition to the group

treated with chlorhexidine gel.

In accordance to our obtained results and interpretations here are the results of ⁽¹²˒¹⁴˒¹⁵˒¹⁶˒¹⁷˒¹⁸˒¹⁹⁾.

In connection with this, Chetan ⁽²⁰⁾ following the effect of hlosit xanthan gel due to the clinical

and microbiological parameters she came to the conclusion that after the curettage of the

periodontal pockets and hlosit use the clinical improvements were significant as well as the

reduction in the number of bacterial colonies Fusobacterium nucleatum, Porphiromonas

gingivalis and Tanerella forsythesis.

Biodegradable xanthan gel composed of chlorhexidine digluconate and chlorhexidine

dihydrochloride (1:2) leads to a rapid decrease of the sub gingival concentration on periodontal

bacteria ⁽²¹⁾.

Actually, the reduction of microorganisms in dental plaque is the key role for the lower values of

the plaque and have satisfactory effects on gingival.

Conclusion

Based on the results we can conclude that the examinees treated by KM-G, against those treated

only with KM, were having significantly better clinical results in all phases of this research .

68

Because of the easy application, easy degradable power, nontoxic and we could definitely

recommend it like an adjuvant of the conventional treatment on periodontal disease.

References

1. Haffajee AD, Socransky SS, Patel MR, Song. Microbial complexes in supragingival

plaque.

Oral Microbiol Immunol 2008;23(3):196-205.

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periodontal Res 1977;12:120-127.

3. Ljushkovic B. Paradontologija i oralna Medicina Voeno izdavacki zavod,Beograd

2009:149-152

4. Gurinsky BS. Concepts in periodontology, Winter, Texas, 2009:2-3.

5. Sbordone L, Bortolaia C. Oral Microbial Biofilms and Plaque-Related Diseases.

Clin Oral Research 2003;7:.181-188.

6. Zhou T, Xie H, Yue Z. Relationships of five periodontal pathogens causing

subgingival plaque in patients with chronic periodontitis under different periodontal

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7. Wang J, Chen W, Jiang Y, Liang J. Imaging of extraradicular biofilm using

combined scanning electron microscopy and stereomicroscopy.Microsc Res Tech.

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8. Mancl KA, Kirsner RS, Ajdic D. Wound biofilms: lessons learned from oral

biofilms.

Wound Repair Regen. 2013;21(3):352-62.

9. Killoy GW. Assessing the effectiveness of locally delivered chlorhexidine in the

treatment of periodontitis. JADA, 1999;130:567 - 570.

10. Angst PD, Piccinin FB, Oppermann RV, Marcantonio RA, Gomes SC. Response of

molars and non-molars to a strict supragingival control in periodontal patients.Braz

Oral Res. 2013; 27(1):55-60.

11. Galgut P. Periodontal diseases. School of Dental Hygiene, University College Dental

Hospital, London, U.K. 2009;26-28.

12. Eit HAA,Usama M, Gouda MM. Al-Abdaly ,The evaluation of Topical Application

of CHLO-SITE (Chlorhexidine gel) in Management of Chronic Periodontitis, ED

Journal, 2010;56(2.3):120-129.

13. Yue Y, Liu Q, Xu C, Loo WT, Wang M, Wen G, Cheung MN, Bai LJ, Dou YD,

Chow LW, Hao L, Tian Y, Li JL, Yip AY, Ng EL.Comparative evaluation of

cytokines in gingival crevicular fluid and saliva of patients with aggressive

periodontitis. Int J Biol Markers. 2013;28(1):108-12.

14. Bollen CM, Quirynen M. Microbiological response to mechanical treatment in

combination with adjunctive therapy. A review of the literature, J. Periodontol.1996; 67:

1143±1158.

69

15. Benedettis M and Grassi R, Clinical and microbiologic effects of subgingival

controlled- release delivery of chlorhexidine chip in the treatment of periodontitis: a

multicenter study. J Periodontol. 2008;79(2):271-82.

16. Bromberg LE, Buxton DK, Friden PM. Novel periodontal drug delivery system for

treatment of periodontitis. J Control Release. 2001;71(3):251-9.

17. Greenstein G. Polson A. The role of local drug delivery in the management of

periodontal diseases: a comprehensive review. Department of Periodontology,

University of Medicine and Dentistry, Newark, NJ, USA. J Periodontol.

1998;69(5):507-20.

18. Abrishami M, Iramloo B, Ansari G, Eslami G, Akbarzadeh AB, Anaraki M. The

effect of locally delivered xanthan based CHLOSITE gel with scaling and root

planning in the treatment of chronic periodontitis : microbial findings J Dent

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70

Topic: Gastro-oesophageal reflux,some data on diagnosis

and clinical evaluation

Saimir Heta, Kastriot Haxhirexha, Virtut Velmishi, Nevila Alliu, Ilma Robo

Department of Pediatric Surgery, QSUT, Tirana, Albania

sa.heta@yahoo.com

Abstract

Introduction: Treatment of gastro-oesophageal reflux involves number of therapeutic measures

that eventually conclude with surgical treatment. It should be noted that surgical treatment should

be the last resort to be used to treat this pathology, due to the complications and recurrences that

this surgery may give.

Materials and methods: This study included 59 children operated for gastro-oesophageal reflux

with the laparoscopic method and for the same period 14 children operated with the open method.

By gender in these two groups the study involves 34 males and 25 females in the first group of

laparoscopic methods and 8 males and 6 females in the open method group. The average age of

the treated children was 13.21 and 12.56 years old in the laparoscopic method, 7.34-year-old

males and 8.15-year-olds in the open method.

Children after being diagnosed by radiology, pharmacology and after having received a proton

pump prolonged long-term treatment for indications, were planned for intervention. Prior to the

intervention, the child is evaluated in all respects and is subject to the full anesthetic protocol.

Including biochemical balance, complete blood, cholesterol, blood group. The child is treated

with general anesthesia with endotracheal intubation using as anesthetic inhaler and intravenous

subjects.

Conclusions: Gastro-oesophageal reflux at childhood is a disease that has long been given

particular attention, by both, pediatricians and pediatric surgeons. A pathology that in its benign

form, that is non-pathological reflux captures, a very large percentage of children in the first year

of life where, according to some studies, appears in 50% of cases with a maximum prevalence

rise in the 4th month of life, in our results this aspect is not vulnerable, because we have only

studied children who have been subjected to intervention. So are those children who have gone

through all the main links of diagnosis and conservative treatment.

Keywords: gastro-oesophageal reflux, open method, laparoscopy

Introduction

Treatment of gastro-oesophageal reflux involves number of therapeutic measures that eventually

conclude with surgical treatment. It should be noted that surgical treatment should be the last

resort to be used to treat this pathology, due to the complications and recurrences that this surgery

may give. The age of the patient's presentation the presence of complications or predisposing

factors is a clue that helps us in treating this pathology. The vomiting without strain that occurs

to the latitudes after the meal, is a symptom that cann’t be called a disease that calms if the latent

after food is kept in elevated position. With the maturation of the lower esophagus sphincter this

calms down and disappears almost over time. Seeing that the symptom was lifted from the raised

position, it was thought to be used chalasia chair (chalasia chair). It was soon noticed that this

71

resulted in the increase in reflux (1), compared to the placement of children in the 30th grade.

But it has been seen that the use of this overturning position is not without consequences and

should be carefully applied according to a study (2) that the use of this position should be

recognized as a treatment that has side effects associated with drug therapy. In a study (3) that

sees the SIDS connection with the position, it is not recommended to use lateral positioners and

that the child should be placed in the back position. This is the recap of AAP American Academy

of Pediatric. Another method of treating these children is the obesity of the products they receive.

This is not very applicable to the infact. As a thickener can use rice cereal flour. Now the

pharmaceutical industry is approaching number of solutions. The use of medications in the

treatment of gastro-oesophageal reflux is a tangible reality. Use of motilium or cisapride which

is a prokinetic agent that has very good clinical effects. The preparation has been shown to

increase peristalsis increases the pressure of the lower esophagus sphincter and accelerates the

gastric rupture. (4) In adults, the preparation is associated with causing cardiac arrhythmias that

have been fatal. But the discovery of cardiac problems that this product could give in America

led to the withdrawal from the market (5). However, it is in use with us, but it should be taken in

account that treatment with it, should be as limited and prudent due to these complications.

Materials and methods

This study included 59 children operated for gastro-oesophageal reflux with the laparoscopic

method and for the same period 14 children operated with the open method. By gender in these

two groups the study involves 34 males and 25 females in the first group of laparoscopic methods

and 8 males and 6 females in the open method group. The average age of the treated children was

13.21 and 12.56 years old in the laparoscopic method, 7.34-year-old males and 8.15-year-olds in

the open method.

Children after being diagnosed by radiology, pharmacology and after having received a proton

pump prolonged long-term treatment for indications, were planed for intervention. Prior to the

intervention, the child is evaluated in all respects and is subject to the full anesthetic protocol.

Including biochemical balance, complete blood, cholesterol, blood group. The child is treated

with general anesthesia with endotracheal intubation using as anesthetic inhaler and intravenous

subjects.

The data for these two groups were obtained through an elaborated type file with the help of

statists from the Burlo Garafolol Trieste Italy Institute. Data is collected prospectively based on

this type file. The data has been collected and described in such a way that it is statistically

analyzable. Type card data included: age, sex, anti-acid therapy, pathological morphology,

fibrogastroscopy data, biopsy, impendecometry, barium passage.

During the study was evaluated the degree of scoliosis, the neurological clinic, the cause of

neurological pathology, preoperative nutrition, the baseline pathology was examined according

to ASA classification. During the study, respiratory insurances, the use of barbiturates, the type

of anesthesia used, postoperative analgesia, the use of sedatives, the time of extubation,

reinturbation, and respiratory assistance were evaluated. The intervention was considered, the

laparoscopic approach to the open method.

72

Results

Demographic data

Table 1: Gender - Laparoscopic Group

Frequency Percentage Cumulative

Percentage

Male 34 57.63 57.63

Female 25 42.37 100.00

Total 59 100.00

This table shows male demographic data for the first group.

Table 2: Gender Group Open Method.

Frequency Percentage Cumulative

Percentage

Male 8 57.14 57.14

Female 6 42.86 100.00

Total 14 100.00

It is seen that the percentage and the second group is almost identical to the first group.

Table 3: Average age.

Average

laparoscopic age

Average age open

method

P

Male 13.21±2.2 7.34±3.4 0.00568

Female 12.56±2.7 8.15±2.4

Total average 12.7±2.5 7.8±3.1

This table shows an important statistical difference between the average age of both groups.

Preoperative data

Table 4: Refractive Therapy Group of Laparoscopic Methodes

Therapy antacid Frequency Percentage Cumulative

Percentage

Antiacid 2 3.39 3.39

Omeprazol 49 83.05 86.44

Omeprazol and

antiacid

8 13.56 100.00

Total 59 100.00

This table shows the use of preoperative therapy in all first group patients, divided by type of

medication.

73

Table 5: Antireflective Therapy Open Method Group

Therapy antacid Frequency Percentage Cumulative

Percentage

Omeprazol 9 64.28 64.28

Omeprazol and

antiacid

5 35.72 100.00

Totali 14 100.00

This table shows the use of preoperative therapy in all second group patients, divided by type of

medication.

As noted, anti-acid therapy is used in all patients involved in both groups.

Table 6: Pathological morphology Laparoscopic Method Group

Pathologic

morphology

Frequency Percentage Cumulative

Percentage

Cardiac

intrathoracic

6 10.17 10.17

Hernia

paraesophageal

7 11.86 22.03

Hernia hiatale 18 30.51 52.54

Reflux without

noticeable cause

28 47.46 100.00

Total 59 100.00

In this table it is evidenced radiological findings in the laparoscopic methotrexate group by which

we determined the anatomical cause of pathology. As noted in the data in 47% of cases it has not

been possible to detect an actual anatomical cause of reflux.

Table 7: Pathological Morphology Open Method Group

Pathologic

morphology

Frequency Percentage Cumulative

Percentage

Cardiac

intrathoracic

3 21.43 21.43

Hernia

paraesophageal

1 7.14 28.57

Hernia hiatale 4 28.57 57.14

Reflux without

noticeable cause

6 42.86 100.00

Total 14 100.00

In this table we have evidenced radiological findings in the open methotrexate group, where in

the case of the first group we have determined the anatomical cause of the pathology. It is noticed

an approximate frequency of the anatomical cause of pathology as in the case of the first group.

74

Graph 1 Pathological morphology

Table 8: Preoperative Fibrogastrosopopy Laparoscopic Method Group

Fibrogastroscopy Frequency Percentage

It's not done 15 25.42

Reflux sign 17 28.81

The presence of hiatary

hernies

13 22.03

Hernie hiatale +

esophagitis

14 23.73

Total 59 100.00

The table presents fibroscopic data in laparoscopic patients. As seen in fibroscopy is a widely

used examination, in almost 74% of patients. By this method we had the opportunity to determine

the esophagitis morphologically and at the same time to obtain the histological material.

Table 9: Preoperative Fibrogastrosopopy Open Method Group

Fibrogastroscopy Frequensy Percentage

It's not done 7 50.00

Reflux sign 2 14.29

The presence of hiatary

hernies

2 14.29

Hernie hiatale +

esophagitis

3 21.42

Total 14 100.00 The table represents fibroscopic data in open method group patients. As it is noticed,

fibroscroscopy is not performed in 50% of cases and this is more for objective reasons. In cases

that have been performed in all cases, we have found signs of gastro-oesophageal pathology.

05

101520253035404550

Laparascopy

Open Method

75

Graph 2: Preoperative Fibrogastrosopics

Table 10: Histology

Histology Frequensy Percentage

It's not done 36 61.02

Esofagit 22 37.29

Ezofag Barret 1 1.69

Total 59 100.00

The table presents the histological data in the patients of the first group. In all cases in which

biopsy was performed, the presence of esophagitis was noted. Histology is one of the finest points

of an accurate diagnosis.

Table 11: Impednometry

Impednometry Frequensy Percentage

Normal reflux 3 5.08

Pathological Reflux 14 23.73

It has not been

completed

42 71.19

Total 59 100.00

Impendencecometer a coherent examination presents a sensitivity of about 82% in this series.

Table 12: Binding Clinical Data - Impednometer

Klinik –impendcometri

Frequensy Percentage

Clinical compatibility 7 11.86

No clinical compatibility 3 5.08

Not done 49 83.05

Total 59 100.00

0 10 20 30 40 50 60

Nuk është bërë

Shenja refluksi

Prezence e hernies hiatale

Hernie hiatale +esofagit

Laparoskopi

Metode e hapur

76

In the table there is a consistency between clinical data and impendometry that goes to 70% of

cases. The data show a lower sensitivity of impendecometry, but this connection was realized in

only 10 patients concluding that sensitivity is approximate.

Table 13: Degree of Scoliosis

Scoliosis Frequensy Percentage

0 9 15.25

1 22 37.29

2 22 37.29

3 5 8.47

4 1 1.69

Total 59 100.00

O- no scoliosis

1- <10 grade without any symptoms

2-> 25 grade with light pulmonary symptom

3-> 40 grades with indications for intervention

4-> 70 grade with pulmonary volume reduction

Scoliosis as one of the predisposing factors in gastro-oesophageal reflux is analyzed in this chart.

10% of patients have a 3-4 level scoliosis that can cause anesthetic complications and operators.

Table 14: Neurological clinic

Neurological clinic Frequensy Percentage

Without neurological problems 16 27.12

Only dementia 1 1.69

Neuropathy flashed 3 5.08

Tetraparesis spastic 39 66.10

Total 59 100.00 Above is the neurological data of patients, where there is a high frequency of the presence of

neurological pathologies.

It is clear, only 27% of patients have no neurological problems.

Table 15: The cause of neurological pathology

The cause of neurological pathology Frequensy Percentage

Without pathology 12 20.34

Prematurity 2 3.39

Perinatal Asphyxiation 26 44.07

Malformation SNQ 10 16.95

Chromosome abnormalities 6 10.17

Brain Infection 2 3.39

Fealopathic syndrome 1 1.69

Total 59 100.00

77

Discussions

Gastro-oesophageal reflux at childhood is a disease that has long been given particular attention

by both pediatricians and pediatric surgeons. A pathology that in its benign form that is non-

pathological reflux captures a very large percentage of children in the first year of life (6) where,

according to some studies, appears in 50% of cases with a maximum prevalence rise in the 4th

month of life. In our results this aspect is not vulnerable because we have only studied children

who have been subjected to intervention. So are those children who have gone through all the

main links of diagnosis and conservative treatment. It is nearly identical number of males and

females in the laparoscopic group (Table 1) and in the open method group (Table 2). It is seen

that we have a percentage of about 57% of men. This ratio of male women is also found in

literature (7-9). When we look at the average age of childishly treated children, we notice a large

change in the average age of the two groups (Table 3). This has come for several reasons. The

first reason is that in the laparoscopic group are treated children up to 18 years of age, whereas

in our group we have treated children with a maximum age of 14 due to the different rules applied

by the pediatric surgery clinic in Albania and Italy. But the other factor is that in the laparoscopic

group there are many children who are neurological or scoliosis children so they have a diagnosed

gastro-oesophageal reflux disease at a later stage. When we look at the results we can see that

conservative treatment (Table 4) is used in all patients. Use of other proton pump inhibitors where

omeprazole is the typical proponent. is an innovation that embraced more enthusiasm. The first

reports have been very encouraging (10, 11) by seeing the Proton Pump Frenus (PPI) as a solution

to the problem that could and was an alternative to intervention. Even in some books, it was seen

as new era in the treatment of pathological reflux. But over time, this enthusiasm has fallen,

seeing that recent studies (12) the effect of PPI on infants is low although no comparative studies

with placebo have been conducted. Thus, the general impression is that the use of omeprazole is

safe (13) as a therapeutic treatment but its efficacy is not proven. Using omeprazole is a drug that

is highly effective for treating esophagitis. Thus, the use of omeprazole has a good effect on the

treatment of symptoms of gastro-oesophageal reflux for this reason its use is one of the most

effective conservative therapies in treating gastroesophageal reflux (13, 34). However, there are

studies (12) that accuse him of a rise in gastroenteritis and an increase in pneumonia. As we have

said above, it is also accused of hypomagnesis or of bone fractures. Omeprazole two study groups

were used in all patients before intervention (Table 4.5). Diagnosis of gastro-oesophageal reflux

besides clinical suspicion should pass into an examination protocol involving imaging study. This

examination is a key examination in diagnosing gastro-oesophageal reflux as well as establishing

a direct relationship between the clinic and pathology. What is important is that through this

examination we can realize a prediction of anatomy or rather of the pathological morphology that

caused this pathology before intervening. In our series, imaging is performed in all patients.

(Table 6, 7). Through it we find that in 52.54% of cases we have found an anatomical factor such

as intrathoracic kardia, parahexa phage hernia, hiatary hernia. But in the rest of the patients, only

pure esophageal reflux is observed. We say that we have not seen a tangible anatomical factor.

And in the series operated there is the same pathology determining pathology. What is worth

noting is that contrast imaging with the upper tract is a conventional image that has been protocols

for many years. One of the important phases of the imaging protocol is the trendelenbourg

position that is needed to determine especially cases with pure esophageal reflux where the

anatomical changes are not imaging-susceptible. The accuracy of imaging diagnosis is an open

debate where it is thought that using ph-metrix is the most reliable method. (16) In this study it

is seen that the barium study is lower than the ph-meter, 36% at 70 %. By comparing it with

clinical data which in our opinion is not very accurate. (17) The fact of the accuracy of the

imaging study cann’t be taken very basically by looking at our tables because we do not intervene

in children unless we had a positive image. So, for us imaging is the key study in the diagnosis

of gastro-oesophageal reflux and in determining surgical indications. So, determining the

78

sensibility of this method is beyond the possibilities of this study. Differential diagnosis that can

be accomplished through barium scopy is one of the strengths that this examination has. By

means of it, it is possible to diagnose or suspect the possibility of mesenteritis, duodenal

membrane, hypertrophic pylori stenosis. It seems that these pathologies are clearly separated

from the clinic and the diagnosis of gastro-oesophageal reflux but the daily experience shows

that this examination is often the case that has led us to an accurate diagnosis in diagnosing the

errors of diagnosis. This is very important especially in the case of laparoscopic surgery because

this surgery does not give us the possibility of intraoperative tactility that the diagnosis should be

as accurate as possible. In (Graph 1) we have visually presented Table 6.7 data. It is seen that

there is no significant difference in the percentage between imaging findings in both groups. Use

of fibrogastroscopy as a sourcing and sometimes defining method. It is performed in more than

75% of cases. As can be seen in (Table 8) it is a routine method that has given us quite valuable

data. Through it we have received information about reflux, esophagitis and presence of hiatary

hernias. Fibrogastoscopy may well diagnose esophageal which is one of the inflammatory

consequences of gastro-oesophageal reflux. But on the other hand, to determine the degree of

esophagitis and to have a precise indication of the morphological changes and at the cellular

level, biopsy may also be performed. With the histology sections can be determined the

esophagitis its degree and can also be diagnosed with the precancerous metaplasia like Barret's

esophagus (18-20). Fibrogastrocopy also diagnoses hiatal hernias especially when they are large,

allowing us to have a very accurate diagnosis and defined a more detailed operator plan. As seen

from (Tables 8, 9) and from (Graph 2) fibrogastroscopy was performed in the first group in more

than 75% of cases and in the second group in only 50% of cases. In (Table 10) it is clearly seen

that the use of histology so differently of biopsy is a datum that concedes us in a more and more

accurate diagnosis. The esophagus biopsy is not a routine exercise. The biopsy was performed in

37.29% of the cases. But taking in account that fibroscopy is performed in 75% of cases it is seen

that the biopsy was performed in 52.27% of the cases that have performed fibrogastricopy in

more than half of the patients. This has resulted in a clear morphological diagnosis. In children

treated with us the esophagus biopsy is not an action that is still being protocols and has not been

performed. It should be taken in account that the diagnosis of esophagitis does not interfere with

interventionism (21). On the other hand, fibrogatroscopy and more esophageal biopsy in young

children is an action that requires special susceptibility and a special technical skill (22). It is an

action that may have its own complications and so in the balance benefit the risk at the time of

the study it is seen that the benefit was scarce. One of the most important examinations we have

and a diagnosis with a very high accuracy is impendecometry. Impendencometry is an

examination that not only measures acid reflux but mats and refluxes are not acidic themselves.

As a compiled and contemporaneous examination, one of the basic studies is how to diagnose

how to carry out comparative studies because being digitized data is a measurable and

comparable study. It is widely used in the patients analyzed in the first group. In (Table 11) it is

seen that the use of impendencometry has been performed in 17 cases where the sensitivity in the

group that has performed this examination is 82%. This is a lump which is lower than what is

referred to in literature where the sensitivity of impendecometry is about 90%. According to

many authors (22-25) it is seen that the ph-meter is considered as (gold standard) for the diagnosis

of this pathology.

Acknowledgments: Our thanks belong to our family. Henri and Hera drive us forward, and

further in the field of scientific research.

Author Contributions: Literature research was conducted by Dr. Saimir Heta. It was his

insistent work that made it possible to reach the conclusions in this article.

Conflicts of Interest: We declare that there is no conflict of interest between the authors and the

material presented in this article.

79

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81

Echocardiography in emergency room

Sejran Abdushi1, Fadil Kryeziu1, Shpend Abdushi2

1UBT – Higher Education Institution, Lagjja Kalabria, 10000 p.n., Prishtinë,

Republic of Kosovo; 2Faculty of Medicine, University Hasan Prishtina of Prishtina.

Abstract. Patients with the worrying clinical condition are challenging in the emergency room.

Accurate and timely diagnosis is very important in life-threatening conditions. Echocardiography

can be very useful in the diagnosis, evaluation and triage of patients with severe cardiovascular

conditions in the emergency department. Echocardiography is very useful in patients presenting

with: chest pain syndrome, hypotension, unexplained dyspnoea, palpitation, recurrent syncope,

cardiac arrest and chest trauma. It will help in minimizing the unnecessary admission to the

hospital and facilitating in hospital evaluation of the admitted patients with echocardiographic

information. Transthoracic echocardiography is the main source of information in the emergency

setting. This article focuses on the clinical information that can be obtained from

echocardiography according to the most frequent presentations suggesting a cardiovascular

emergency.

Keywords: Echocardiography, Emergency room.

Introduction

The evaluation and management of symptomatic patients in the emergency room is a daily

challenge. Fast and accurate diagnosis is life-saving. Mobility and relatively low cost of

echocardiography machines, including hand-held devices, allow their use virtually everywhere

[1] [2] [3]. In addition, in expert hands, echocardiography may provide an instantaneous and

comprehensive assessment of cardiac structure and function as well as hemodynamics, with

minimal discomfort or risk for the patient, without using radiological contrast media or ionizing

radiations [4]. Mostly, physician which perform echocardiography assessment may be the same

who is managing the patient, this will speed decision-making and leading to better treatment of

the patient.

Almost, echocardiography is included in all management guidelines for patients with

cardiovascular emergencies. However, it is important to recognize its opportunities and

limitations with the aim of reducing the possibility of errors with serious consequences. It is

imperative that competent professional societies determine the necessary standards of knowledge

for applying echocardiography in emergency conditions.

The aim of this review was to present possibilities of transtoracic echocardiography for the

assessment of cardiovascular emergencies.

Medical emergencies which require emergent echocardiography

A Report of the American College of Cardiology Foundation Quality Strategic Directions

Committee Appropriateness Criteria Working Group [5] dated July 2007 have recommended

82

indications for echocardiography evaluation in an acute cardiovascular setting, which are listed

below:

1. Hypotension or Hemodynamic instability

2. Myocardial ischemia/Infarction

3. Respiratory Failure

4. Pulmonary Embolism

Neskovic AN et al. (2013) have recommended echocardiography use in cardiac and cardiac-like

emergencies, in several clinical settings: Acute chest pain, Acute dyspnoea, Hemodynamic

instability/Shock, New heart murmur, Chest trauma, Cardiac arrest/CPR [4].

Hypotension and/or hemodynamic instability

Shock is defined as acute circulatory failure with inadequate or inappropriately distributed tissue

perfusion resulting in generalized cellular hypoxia [6]. For patients without known etiology of

hypotension, echocardiography is primarily used for detecting or excluding cardiac causes of

shock. Whether the cause of shock is unknown, suspected, or established, echocardiography is

utilized in its diagnosis and management and to monitor progress [7]. It is recommended as the

modality of first choice in consensus guidelines [8]. A RACE assessment, using only two-

dimensional (2D) and M‐mode echocardiography demonstrates major underlying abnormalities

rapidly in the acute scenario [9].

Overall cardiac performance

Assessment of cardiac output by echocardiography is overall recognized. Although it can be

measured using the 2D Simpson’s multidisc method, the use of pulsed-wave Doppler across the

left ventricular output tract (LVOT) is more accurate [10]. So she could replace the invasive CO

measurement.

Left ventricular systolic function

Dilated left heart chambers are sign of chronic impairment of myocardial contractility, Left

ventricular ejection fraction (LVEF) is a well-established parameter which can be a helpful guide.

It is sufficiently robust to be used regularly in large studies in the chronic heart failure setting

where it serves as a prognostic marker [11]. When the endocardial border is difficult to visualize,

contrast echo may enhance accuracy [12]. In situations when segmental wall motion

abnormalities are present urgent revascularization should be taken in consideration.

Left ventricular diastolic dysfunction

Approximately half the patients presenting with acute heart failure have preserved ejection

fraction via a number of mechanisms, including diastolic dysfunction reduced coronary flow

reserve [13], [14]. High metabolic rates frequently present in critically ill patients can impair the

left ventricular diastolic function. Spectral Doppler of mitral inflow is widely used for diastolic

dysfunction assessment of left ventricle. Both an E/A ratio >2 and an E wave deceleration time

<120 ms predict a LAP >20 mmHg [15]. With TDI, the mitral annulus e′ offers a quick guide to

the presence of left ventricular diastolic dysfunction with a lateral e′ <10 and medial <7 cm/s

highly suggestive of diastolic dysfunction and elevated left atrial pressures [16]. When the sample

volume of the tissue Doppler imaging is placed at the mitral annulus, two distinctive velocities

during diastole in patients with sinus rhythm can be obtained. Early diastolic mitral annulus

velocity (E) implies rate of relaxation during early diastole as the cardiac apex is relatively fixed

during the cardiac cycle. Therefore, patients with relaxation abnormality characteristically show

low E’ velocity. A’: late diastolic mitral annulus velocity [17] (Figure 1).

83

Figure 1 - Diastolic function assessment using tissue Doppler of mitral annulus inflow.

Hypovolemic shock

Mostly, hypovolemia is readily evident but it is difficult to be determined only with a physical

exam. Basically, severe hypovolemia can be suggested by 2D views when they show the collapse

of left ventricular walls at end-systole so-called “kissing-walls”. Variations of inferior vena cava

(IVC) are widely used. Numerous studies have explored refining the technique using vessel

diameter variation in response to the respiratory cycle, maximum diameter, and percentage of

diameter alteration to assess right atrial pressure (RAP) [18]. The IVC is a highly compliant

vessel, consequently, its size and dynamics vary with changes in CVP and volume [19]. Table 1

shows values of RAP due to IVC parameters [20].

IVC size (cm) Inspiration effect Estimated mean RAP

(mmHg)

Small < 1.5 Collapse 0 – 5

Normal 1.5 – 2.5 ↓≥ 50% 5 – 10

Normal 1.5 – 2.5 ↓≤ 50% 10 – 15

Dilated > 2.5 ↓≤ 50% 15 – 20

Dilated + hepatic veins No collapse ➢ 20 Table 1 – Estimation of RA pressure on the basis of IVC diameter and collapse.

Cardiac Tamponade

The excessive increase of intrapericardial pressure associated with the impaired filling of heart

chambers during diastole results with cardiac tamponade. Cardiac tamponade is a life-threatening

condition which can be easily managed if it can be timely diagnosed. Symptoms of significant

pericardial effusion include tachycardia, orthopnea, pulsus paradoxus, and pericardial rub.

Presence of hypotension and bradycardia are suggestive for cardiac arrest. Echocardiography is

a key for diagnosis of cardiac tamponade. Echocardiography allows assessment of pericardial

effusion size, collapse of right heart chambers and pseudo hypertrophy of left ventricle [21].

84

Pulsed-wave Doppler is a key in the assessment of respiratory variations of the transvalvular

flows in patients with cardiac tamponade [22]. A physiological variation of the cardiac output of

around 5% exists with normal respiratory cycle, which is reflected in normal peak E-wave

variation of up to 10% [23]. During cardiac tamponade this variations are even higher, at least

more than 25% [22]. On Figure 2 are shown right heart chambers collapse and significant

variations of peak E-wave.

Figure 2 – A: Right chambers collapse; B: E-wave variation > 25% during respiration.

Myocardial ischemia/Infarction The response of left ventricular function to ischemia is monotonous and independent of the

employed stress [24]. The same echocardiographic signs can be found in transient ischemia and

acute infarction [25]. Transient ischemia is manifested with regional wall abnormalities in three

forms: decreased wall movement and systolic thickening (hypokinesia), absence of movement

and systolic thickening (akinesia), and paradoxical movement and possible systolic thickening

(dyskinesia). All this changes are clearly identified in transthoracic echocardiography.

Echocardiography is also very in detecting of location and size of myocardial infarction and its

complications. Myocardial infarction complications which can be detected by transthoracic

echocardiography are: myocardial wall rupture, acute mitral regurgitation (due to papillary

muscle rupture or myocardial dysfunction), pericardial effusion and tamponade, formation of true

left ventricular aneurysm, left ventricular thrombi. In figure 3 are shown echocardiographic

images of complications of myocardial infarction.

85

Figure 3 – A: Rupture of interventricular septum; B: True ventricular aneurism with thrombus

formation; C: Pseudo aneurysm; D: Pericardial effusion after myocardial infarction.

Respiratory failure

Acute respiratory failure (ARF) is a common medical emergency with increasing incidence [26].

Timely diagnosis and adequate treatment of patients with ARF improves their outcomes. Timely

antibiotic administration in community-acquired pneumonia reduces mortality, making early

diagnosis vital [27] [28]. Bedside use of Doppler echocardiography is being featured as a

promising, clinically useful tool in assessing the pulmonary circulation in patients with acute

respiratory distress syndrome (ARDS) [29]. A qualitative and repetitive echocardiographic

evaluation, by a simple visualization in real time of the kinetics and size of cardiac cavities, has

been shown to be essential in assessing right-sided heart after loading [30]. Echocardiographic

assessment of right ventricle function mast includes a long-axis view to assessing the size of right

chambers, and in short-axis view to assessing the septal kinetics.

Pulmonary embolism

Suspected high-risk acute pulmonary embolism (PE) presenting with shock or hypotension is a

life-threatening situation, and according to international guidelines it requires urgent diagnostic

workup and therapy [31]. Presence of right ventricular dysfunction on echocardiography

identifies patients with a poor prognosis and is consistent with the presence of larger pulmonary

perfusion defects [32]. Echocardiographic evaluation is useful for early risk stratification and has

a helpful impact on management strategies of patients with acute pulmonary embolism. Presence

of right ventricular dysfunction on echocardiography identifies patients with a poor prognosis

86

and is consistent with the presence of larger pulmonary perfusion defects [32]. Some

echocardiographic data are suggestive for poor outcome and may indicate more aggressive

treatment strategies. In these data are included: impaired right ventricular function,

interventricular septum bulging into the left ventricle (“D-shaped” septum), dilated proximal

pulmonary arteries, elevated right atrial pressure, elevated pulmonary artery pressure, free-

floating right ventricular thrombi. In figure 4 are shown some of these features.

Figure 4 – A: Enlarged right chambers of heart; B: “D” shaped left ventricle. RA – Right

atrium; RV – Right ventricle; LV – Left ventricle.

Conclusions

Echocardiography is a noninvasive diagnostic method, which can be easily used on the bedside

of critically ill patients. It can offer valuable data which can help physicians in the emergency

room to reduce unnecessary hospitalizations and safely discharge of patients. Also,

echocardiography can help to choose the best management strategies for life-threatening

conditions and can be used for monitoring of success rate of treatment. But, echocardiography

use in emergency room requires knowledge of the strengths and limitations of this imaging

modality. Especially, echocardiography is a portable rapid, noninvasive diagnostic tool, which

can be repeated when required makes it very helpful in the emergency room.

87

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MEDICAL DENTAL AND PHARACEUTICAL SCIENCES

FOOD SCIENCE AND TECHNOLOGY

ARCHITECTURE AND SPATIAL PLANNING

CIVIL ENGINEERING, INFRASTRUCTURE AND ENVIRONMENT

INTEGRATED DESIGN

EDUCATION AND DEVELOPMENT

LAW

POLITICAL SCIENCE

MEDIA & COMMUNICATION

PSYCHOLOGY

INTERNATIONAL CONFERENCE ON BUSINESS,TECHNOLOGY AND INNOVATION

CHAPTERS: