Srpski medicinski časopis Lekarske komore

PREVALENCE AND SOCIODEMOGRAPHIC INEQUALITIES IN DEVELOPING TYPE 2 DIABETES MULTIMORBIDITIES IN SERBIA

2024-07-09T07:17:54+02:00

Introduction: The number of people living with diabetes is increasing worldwide, with the majority of those affected residing in low- and middle-income countries. Type 2 diabetes mellitus (T2DM) is often associated with the co-occurrence of one or more long-term conditions (LTCs), which might be affected by patients’ socioeconomic characteristics, however, to what extent, it is as yet unknown in Serbia. Therefore, we have aimed to examine the prevalence and impact of sociodemographic factors on T2DM multimorbidity in Serbia.

Method: Secondary data analysis of the Serbian National Health Surveys 2013 and 2019 was conducted in a population older than 45 years. Multinomial logistic regression models were used to investigate relative risk ratios with 95% confidence intervals and corresponding predicted probabilities between the sociodemographic profiles of participants in different disease groups (with/without T2DM and one or more LTCs).

Results: The prevalence of T2DM comorbidity and multimorbidity was 8.8% and 29.5%, respectively. Most often, T2DM co-occurred with stroke, myocardial infarction, and liver cirrhosis. Multimorbidity was associated with older age, the female gender, lower level of education, and lower income. The biggest gender gap was identified in the predicted probabilities for having T2DM and two or more LTCs among the subjects with the lowest level of education (women: p = 0.333 vs. men: p = 0.208) and in the lowest income quintile (women: p = 0.366 vs. men: p = 0.236), while the gender gap was not identified among those with at least a bachelor's degree (women: p = 0.258 vs. men: p = 0.260).

Conclusion: A comprehensive approach to identifying and subgrouping populations based on their risk of LTCs yields valuable insights that can facilitate early detection and disease management.

EXAMINING THE PREVALENCE OF THROMBOPHILIA IN WOMEN WITH FETAL LOSS

2024-07-09T07:17:54+02:00

Introduction: In addition to antiphospholipid syndrome (APS), inherited thrombophilia is one of the most important hematologic disorders that can lead to pregnancy complications such as fetal loss, intrauterine growth restriction (IUGR), preeclampsia, and fetal death. The frequency of spontaneous abortions is up to 20% of all clinically recognized pregnancies.

Objective: The aim of this study was to determine the frequency of inherited thrombophilia in women with fetal loss, analyze the gestational period and age at which fetal loss occurred, and assess the frequency of successful pregnancies after prophylactic use of low molecular weight heparin (LMWH).

Material and methods: The study was designed as a 30-month retrospective observational study at the Clinic for Gynecology and Obstetrics of the University Clinical Center of the Republic of Srpska, involving 69 patients with one or more fetal losses in the second and third trimesters of pregnancy, or two or more repeated fetal losses in the first trimester of pregnancy. All patients underwent tests to detect the presence of thrombophilia.

Results: The average age of the patients was 30.7 years, and they had a total of 167 unsuccessful pregnancies. Thrombophilia was proven in a total of 40 patients (58%). The results showed that combined thrombophilia, including polymorphisms, occurred most frequently – 47.5% (n=19). In the group of patients with inherited thrombophilia, low molecular weight heparin (LMWH) was administered to 22 patients and it resulted in a successful pregnancy outcome in 19 patients.

Conclusion: Based on the conducted research, it can be concluded that combined thrombophilia, including combined polymorphisms MTHFR and PAI-1, carry a significantly higher risk of pregnancy loss in patients of all age groups. Age over 35 years is a risk factor for higher frequency of spontaneous abortions irrespective of the type of inherited thrombophilia. The use of LMWH significantly improves pregnancy outcomes in patients with inherited thrombophilia and previous pregnancy losses.

POSTOPERATIVE COMPLICATIONS AND THEIR CORRELATION WITH THE SURGICAL TECHNIQUE IN THE TREATMENT OF GASTROSCHISIS

2024-07-09T07:17:55+02:00

Introduction: Gastroschisis is a congenital paraumbilical defect of the anterior abdominal wall with evisceration of the abdominal organs. A modern approach to treating gastroschisis has contributed to better results, as evidenced by the 5% – 10% mortality rate.

Aim: The study aims to evaluate the frequency of complications and death in the population due to gastroschisis, as well as the connection between the surgical techniques used in the treatment and the outcome of the treatment.

Material and methods: The retrospective cohort study included 75 patients diagnosed with gastroschisis, treated from 2000 to 2020 at the Mother and Child Health Institute of Serbia Dr Vukan Čupić. By applying the exclusion criteria, a sample of 61 patients was obtained. Two cohorts of subjects were formed based on the applied surgical method, namely: primary repositioning and fascial closure of the defect (gastroschisis surgical cohort – GSC), i.e. delayed primary repositioning of the defect using a silastic bag (silastic gastroschisis cohort – SGC).

Results: The gastroschisis surgical cohort comprised 38 patients, while the silastic gastroschisis cohort comprised 23 subjects. It was found that necrotizing enterocolitis (NEC) was a statistically significantly more frequent complication in subjects from the silastic gastroschisis cohort (5/23, i.e. 21.7% in SGC and 0/38 in GSC; RR 0.32, 95% CI: 0.22 – 0.47; p = 0.003). The statistical significance of the difference in relation to the frequency of other complications was not proven: ileus (0/23 in SGC and 5/38, i.e. 13.2% in GSC; RR 0.59, 95% CI: 0.47 - 0.73, p = 0.069), compartment syndrome (0/23 in SGC and 2/38, i.e. 5.3% in GSC; RR 0.61, 95% CI: 0.50 – 0.75, p = 0.263) and death ( 2/23, i.e. 8.7% in SGC and 2/38, i.e. 5.3% in GSC; RR 1.26, 95% CI: 0.46 – 3.43, p = 0.600).

Conclusion: There is no distinctive proof of the superiority of one method over another. The risks of ileus and compartment syndrome are higher when applying primary fascial closure of the defect, while the risks of NEC and fatal outcome are higher when the silo method (use of a silastic bag, i.e., silo bag) is applied. The choice of method in treating gastroschisis depends on the abdominovisceral disproportion and the physical appearance of the eviscerated intestines, assessed with the Gastroschisis Prognostic Score (GPS).

THE OUTCOME EVALUATION OF AN ACUTE ISCHAEMIC STROKE IN THE POSTERIOR REGION IN RELATION TO ROUTINE BLOOD COUNT PARAMETERS – NEUTROPHIL/LYMPHOCYTE RATIO, PLATELETCRIT AND MEAN PLATELET VOLUME

2024-07-09T07:17:55+02:00

Introduction: Acute stroke is defined as a focal or global disorder of brain function that occurs suddenly and is the third leading cause of death in the world. Depending on the mechanism of occurrence, it can be classified as acute ischemic stroke and acute hemorrhagic stroke.

The work aims to examine the hypothesis that the ratio of neurtophils to lymphocytes (NLR), thrombocrit (Pct) and mean platelet volume (MVP) are significantly increased in patients with a worse outcome of a stroke in the posterior basin.

Material and methods: The basis of the methodology is the analysis of laboratory data of 205 patients with ischemic stroke of the posterior basin with data on the modified Rankin score at discharge, which were adjusted into ranks for three possible treatment outcomes: good, moderately bad, and bad disease outcomes.

Results: The strongest predictor of the outcome was the increase in the ratio of neutrophils and lymphocytes (NLR), which correlates with a poor outcome of the disease (p < 0,001). Thrombocrit also shows a moderate degree of association with the outcome of posterior basin ischemic stroke graded by ranks of the modified Rankin score (p = 0,002). The mean volume of platelets, in this sample of subjects, did not show either a statistical significance of the difference between the groups of patients according to the outcome of the disease graded by the ranks of the modified Rankin score, or a correlation with the outcome of the disease according to the same criterion.

Conclusion: Neutrophil to lymphocyte ratio (NLR), as well as thrombocrit (Pct), are variables that, based on this study and the results from the available literature, are significantly more often elevated in patients with a worse outcome of a stroke in the posterior basin where they represent a predictor of a worse outcome of the disease.

THE ROLE OF OXIDATIVE STRESS IN OVARIAN CANCER PATHOGENESIS

2024-07-09T07:17:55+02:00

Ovarian cancer is the deadliest form of gynecological malignancy. The presence of non-specific symptoms, together with the identification of the disease in an advanced stage, are the primary determinants of an unfavorable prognosis, resulting in an overall five-year survival rate of 45%. Currently, the treatment of choice for ovarian cancer is surgery aimed at completely removing the illness macroscopically, along with adjuvant chemotherapy. The significance of early diagnosis is evident in the several conducted prospective studies, which have not identified a successful method for early identification of this disease. Oxidative stress (OS) is a well-established contributor to carcinogenesis in several types of malignancies. It occurs when there is an imbalance between the production and clearance of reactive oxygen species. These molecules affect both pathological and physiological processes. Literature findings indicate that oxidative stress has a role in the development and pathophysiology of ovarian cancer by affecting the following four areas of cellular functioning: (i) genetic alterations, (ii) signaling pathways, (iii) transcription factors, and (iv) tumor microenvironment. Reactive oxygen species can induce mutations, which initiate the formation, proliferation, and maturation of tumor tissue. Also, prolonged elevation of the concentration of free radicals harmfully affects cells, causing the initiation of apoptotic pathways. Specifically, the presence of free radicals leads to the impairment of biomolecules and the creation of byproducts from this interaction. Consequently, these compounds may be found in various body structures and products such as tissue, plasma, urine, and other, where they can be detected. The study aims to enhance the readers' understanding of the pathogenesis of ovarian cancer, which is characterized by its undetermined cause and diverse nature. Previous research has primarily focused on surgical or medicamentous treatment, therefore the present study aims to shed light on the role of oxidative stress in this process.

UNDERSTANDING PUBLIC HEALTH PROFESSIONALS: THEIR ROLES, SIGNIFICANCE, AND CHALLENGES

2024-07-09T07:17:55+02:00

The dramatic progress in public health throughout the 20th century, including the extension of life expectancy, enhancement of quality of life, and significant reductions in infant and child mortality rates, as well as the successful reduction and eradication of some infectious diseases, could not have been achieved without public health professionals responsible for the management, coordination, and provision of essential public health services. Public health systems in countries around the world, including the Republic of Serbia, are "chronically" underinvested, and face difficulties in ensuring an adequate number and appropriate distribution of qualified public health workers. Numerous challenges related to the public health workforce can be classified into several groups: social (aging workers, the profession’s lack of appeal, diminished morale and motivation, retention challenges); technological (the diverse array of education and training options, scarce opportunities for professional development); economic (insufficient financing and low salaries); environmental (antibiotic resistance, pollution, food safety, climate change, urbanization); political (lack of prominence on the agendas of political leaders, lack of legal frameworks for workforce development); and legal and ethical (absence of a well-defined ethical framework in public health). To deliver high-quality public health services, mitigate health disparities, and effectively tackle emerging health crises, enhancing the capabilities of a skilled and competent workforce is imperative. This involves gaining a comprehensive understanding of the interests and needs of public health professionals, implementing strategic succession planning, optimizing recruitment and retention of workers, and ensuring more efficient use of resources. A thorough examination of public health personnel management, together with the development of strategic and operational personnel policies within the healthcare system of the Republic of Serbia, is necessary for effectively addressing the demands posed by crises such as the outbreak of a novel infectious disease pandemic.

RED BLOOD CELL ADAPTATIONS INDUCED BY EXERCISE

2024-07-09T07:17:56+02:00

Exercise significantly increases blood flow and perfusion in active muscles to enhance oxygen and nutrient delivery. These enhanced demands affect blood rheology and red blood cell (RBC) characteristics, leading to specific adaptations. These adaptations are influenced by exercise type, intensity, frequency, duration, and individual characteristics of subject population (gender, age, nutritional status etc.).

This review aims to comprehensively summarize the different adaptations of erythrocytes to short-term and long-term exercise, as well as the mechanisms of their occurrence, considering the influence of various factors.

The results from the previous research indicate that regular exercise enhances the metabolic, structural, and functional capabilities of RBCs. These adaptations include improved energy balance, increased cell turnover rate, improved membrane stability, as well as better antioxidative defense. Despite potential risks such as "sports anemia", exercise also affects the dynamics of hemoglobin and iron concentrations, as well as the appearance of extracellular hemoglobin. Overall, the literature highlights the critical role of exercise in maintaining optimal erythrocyte function, improving circulation, and overall health, offering potential therapeutic benefits.

Through a critical review of literature data on the influence of exercise on the characteristics and functions of erythrocytes, this paper can be a useful guideline for the interpretation of clinically significant results in physically active individuals.

WORKPLACE VIOLENCE AGAINST HEALTHCARE WORKERS – CALL TO ACTION

2024-07-09T07:17:56+02:00

Workplace violence against health workers is common within the healthcare system and yet there seems to be significant underreporting of workplace violence in healthcare. The most common type of workplace violence is verbal abuse. However, there seems to be a significant proportion of physical violence. Perpetrators vary, from patients and their families to co-workers, although less frequently. This article aims to present what workplace violence is, its prevalence, types, consequences, and possible interventions to reduce workplace violence.

LESSONS LEARNT FROM INAPPROPRIATE D-DIMER TESTING – CASE REPORT

2024-07-09T07:17:56+02:00

Introduction: Since the beginning of the COVID-19 pandemic, D-dimer testing has been widely used in not-yet-approved indications. This has led to misdiagnosis, overuse of diagnostic procedures, and unnecessary costs.

Case report: Herein, we report the case of a 50-year-old female patient who came to the emergency department with chest pain, shortness of breath, fatigue, and pain in her right leg. Because of an elevated level of D-dimer (4.73 mg/l (N:<0.5)), deep vein thrombosis and pulmonary embolism, as well as COVID-19 were excluded. Therapy with rivaroxaban, 10 mg/day, was initiated. Seven days later, the D-dimer level continued to rise (17.52 mg/l), which was why rivaroxaban was replaced with low molecular weight heparin (LMWH). After another five days, the level of D-dimer continued to rise (27.26 mg/l). A complete blood count revealed significant thrombocytopenia (54 x 109/l). As the 4Ts score for heparin-induced thrombocytopenia was 5, the anti-heparin/PF4 antibody test was performed, and it came back strongly positive (4+). LMWH was replaced with fondaparinux sodium, and the patient was referred to a hematologist. On examination, cutaneous bleeding and gingivorrhagia were present. Laboratory analyses registered pancytopenia (hemoglobin = 101 g/l; white blood cell count = 1.7 x 109/l; platelet count = 29 x 109/l) and consumption coagulopathy (INR = 1.7; aPTT = 27.1 s; fibrinogen = 0.8 g/l; D-dimer = 30.9 mg/l). Bone marrow aspirate was analyzed and the diagnosis of acute monoblastic leukemia, 47, XX, +12 [4] / 46, XX [16], FLT3-ITD, wild-type NPM1, was established.

Conclusion: D-dimer is a powerful diagnostic tool when used properly. It should never be treated as a single, isolated result and the decision to introduce anticoagulant therapy should never be made based on its value alone.

USE OF INTRANASAL ESKETAMINE IN THE TREATMENT OF TREATMENT-RESISTANT DEPRESSION: A CASE REPORT

2024-07-09T07:17:56+02:00

Introduction: Treatment-resistant depression (TRD) refers to a depressive episode that has not responded to treatment with two antidepressants. Pharmacological strategies for treating TRD involve a complex process, which includes several options for the use of different psychopharmaceuticals, fundamentally consisting of: (1) substituting/optimizing the dose of antidepressants, or (2) augmenting antidepressant therapy. Within the augmentation strategy, NMDA antagonists, including intranasal esketamine, play a significant role. Current research suggests that the application of intranasal esketamine as an augmentation agent is an effective pharmacological strategy in the treatment of TRD.

Case report: In this paper, we present the successful application of intranasal esketamine in co-administration with a serotonin/norepinephrine reuptake inhibitor (SNRI antidepressant) in a patient with TRD.

Conclusion: Further research is necessary to better understand the mechanisms of action, dosing modalities, as well as the long-term outcomes and safety profile of this approach.

CLINICAL AND SEROLOGICAL FEATURES IN AN 11-MONTH-OLD INFANT WITH PAROXYSMAL COLD HEMOGLOBINURIA

2024-07-09T07:17:57+02:00

Introduction: Paroxysmal cold hemoglobinuria (PCH) is an uncommon form of autoimmune hemolytic anemia (AIHA). A specific etiological factor has not been determined yet. The pathogenesis of the disease is explained by the presence of “biphasic hemolysin” or low-affinity IgG autoantibody, which in most cases binds to the erythrocyte P antigen, binding components of complement until the complete activation of the cascade and hemolysis of erythrocytes. The disease typically presents in children following an acute infection, usually involving the upper respiratory tract or gastroenteritis.

Case report: We present an 11-month-old female infant who was admitted to the Intensive Care Unit of the Institute due to vomiting, anemia, yellow discoloration of the skin and mucous membranes, dark-red-colored urine, and general weakness. Two days prior to admission, she had a nasal discharge. Initial blood tests revealed a hemoglobin level of 63 g/L, hematocrit at 17.3%, reticulocyte count of 1.76%, leukocytosis, thrombocytosis, elevated C-reactive protein at 75.7 mg/L, lactate dehydrogenase at 5365 IU/L, total/indirect bilirubin at 67.9/64.5 µmol/L, and decreased haptoglobin. No schizocytosis was evident in peripheral blood. Polyspecific direct antiglobulin test (DAT) was positive 3+ and monospecific DAT was C3d 1+. The infant was treated with intravenous immunoglobulins, a single unit of red blood cells transfusion, parenteral dual antimicrobial therapy, and a single dose of corticosteroids accompanied by intravenous hydration and correction of electrolyte disturbances. On the tenth day upon admission, blood samples were taken for the Donath-Landsteiner (DL) test, which showed the presence of “biphasic hemolysin” and confirmed the diagnosis of PCH.

Conclusion: Clinical recognition of PCH, the transient nature of “biphasic hemolysin” and the possibility of performing the DL test depend on the timely confirmation diagnosis of this rare form of AIHA.

PRIMARY LYMPH NODE PLASMACYTOMA – A RARE CLINICAL ENTITY

2024-07-09T07:17:57+02:00

Introduction: Extramedullary plasmacytoma localized in the region of the head and neck represents less than 1% of tumors found in that region. Primary solitary localization of plasmacytoma in the lymph node, as the only manifestation of plasmacytoma, is rare, with less than 50 cases reported so far.

Case report: A 58-year-old man came to the physician because of a painless swollen lymph node in the neck, afebrile, reporting no night sweats or weight loss. He was treated with broad-spectrum antibiotics for 10 days, but his health status did not change. A complete blood count (CBC) was performed, and normal test results were obtained. The patient tested negative for biohumoral inflammatory syndrome. The ultrasound examination of the neck showed a lymph gland, 30 mm x 15 mm in size. The patient was referred to a maxillofacial surgeon; total lymph node extirpation was performed, and the excised node was sent for histopathological analysis. The following pathohistological finding was obtained: diffuse infiltration by plasmacytoid tumor cells stronlgly positive for: OCT2, BOB1, CD38, MUM1, lambda, CD31, VIM, and CD79 alpha; negative for kappa; positive for Ki67 in 30%. The conclusion of the pathohistological examination was lambda positive plasmacytoma. Bone biopsy showed the following: plasmocytes 4%. The findings of multi-slice computed tomography (MSCT) of the thorax, abdomen, and lesser pelvis were normal. Radiographic imaging of the skeleton also showed normal findings. The M protein, in both serum and urine, was negative. Virology tests showed that the patient was HBsAg positive, while he was HCV and HIV negative. Local radiation therapy was indicated along with active antiviral therapy.

Conclusion: Each case of lymphadenopathy demands a serious and thorough approach to be established by the clinician. The question is whether an infection caused by the Hepatitis B virus may have served as a trigger for the development of plasmacytoma.