Vojnosanitetski pregled

Early rehabilitation challenges of surgical patients with COVID-19 infection – a single-arm study

Dušica Simić-Panić — 2024-06-27

Background/Aim. A very limited amount of data regarding the rehabilitation outcome of surgical patients with COVID-19 is available in the current literature. The aim of this study was to point out the characteristics of early rehabilitation of these patients and determine the predictors of rehabilitation outcomes. Methods. The study was designed as a prospective clinical trial. It included patients who had surgical treatment from April 1, 2022, to March 31, 2023, at the University Clinical Center of Vojvodina, Serbia and either had positive results for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) preoperatively or developed coronavirus disease 2019 (COVID-19) within 72 hrs after surgery. The rehabilitation program was planned for each patient according to the type of surgical treatment, age, clinical presentation and severity of the COVID-19, length of immobilization, and comorbidities. Rehabilitation treatment (RT) started with a minimum of one 30-minute daily session, up to three 30-minute sessions daily. Patients were assessed at the beginning of RT and discharge. Outcomes were assessed with the Modified Borg Scale (MBS) for dyspnoea, Barthel index (BI) for activities of daily living, Six-Minute Walk Test (6MWT) for exercise tolerance, and Timed up and Go (TUG) test for balance and lower limb mobility. Results. A total of 81 patients were included in the study. RT was successful for 42 patients (24 female and 18 male) with an average age of 62.10 ± 20.07 years. These patients exhibited significant functional improvement, which was measured by all tests that assessed rehabilitation outcome at discharge: BI (p < 0.001), MBS (p < 0.001), 6MWT (p < 0.001), and TUG test (p < 0.001). The remaining 31 patients had unsuccessful RT. The binary logistic regression analysis has shown that age (p = 0.009), cardiovascular disease (p = 0.017), and malignancy (p = 0.022) were significant predictors of rehabilitation outcome. Conclusion. Results of the present study implicate that individually tailored RT during the acute phase of COVID-19 in surgical patients is very challenging. Advanced age, cardiovascular disease, and malignancy are predictors of unfavorable outcomes, and careful consideration is needed when planning the treatment for these patients.

Evaluation of clinical, biohumoral, and morphological findings of the thyroid gland as possible predictors of risk for cancer in patients with atoxic nodular and multinodular goiter

Dragana Malović — 2024-06-27

Background/Aim. Thyroid nodules are usually asymptomatic and may occur in 68% of the general population. In most cases, they are discovered incidentally. As malignancy is proven in 10–15% of cases, a rational diagnostic approach is necessary. The aim of this retrospective study was to examine and grade different characteristics of patients with nodular and multinodular atoxic goiter in order to identify the potential predictors for the assessment of thyroid cancer risk. Methods. The study included 275 patients with nodular and multinodular atoxic goiter hospitalized at the Clinic for Endocrinology of the Military Medical Academy, Belgrade, Serbia, from January 1, 2017, to October 1, 2022, for preoperative preparation. The most relevant clinical, biohumoral, and pathomorphological characteristics were analyzed. Results. Patients with multiple thyroid nodules were older (57.21 ± 13.16 vs. 49.36 ± 15.83 years, p < 0.001) and had higher body mass index (29.12 kg/m² vs. 26.50 kg/m², p = 0.004) compared to patients with one nodule. On the other hand, patients with one thyroid nodule had a higher level of the thyroid-stimulating hormone than patients with multiple nodules (1.73 mIU/L vs. 1.21 mIU/L, p < 0.0001). Comparison of patients with and without proven thyroid cancer has shown a highly significant association between the higher categories of Bethesda classification and the presence of cancer (Bethesda IV–VI vs. Bethesda II–III, 52.2% vs. 22.3%, respectively, p = 0.002). Conclusion. Considering all the observed parameters, the cytological finding of fine needle aspiration biopsy emerged as the only one with predictive relevance for assessing thyroid cancer risk.

Traheostomija kod odojčadi: indikacije i ishodi

Aleksandar Sovtić — 2024-06-27

Uvod/Cilj. Produžena ventilacija predstavlja najčešću indikaciju za pedijatrijsku traheostomiju. Cilj rada bio je da se utvrde indikacije, komplikacije i ishod traheostomije kod dece, kao i udruženost fenotipa i komplikacija koje prate traheostomiju. Metode. Retrospektivnom studijom procenjene su osnovne indikacije, komplikacije i stope dekanulacije kod dece sa traheostomom, lečene na Institutu za zdravstvenu zaštitu majke i deteta Srbije ,,Dr Vukan Čupić” u Beogradu, tokom trogodišnjeg perioda. Rezultati. Studijom je obuhvaćeno ukupno 38 novorođenčadi, od kojih je njih 31 (81%) bilo podvrgnuto elektivnoj traheostomiji, a 7 (19%) urgentnoj traheostomiji zbog akutnog respiratornog distresa i teške intubacije. Srednja životna starost novorođenčadi bila je 5,4 ± 3,5 meseci, a najmlađe je bilo staro 36 sati. Primarna indikacija za elektivnu traheostomiju bila je produžena mehanička ventilacija kod 13 (42%) bolesnika, neuromuskularni poremećaji kod 5 (16%) bolesnika, opstrukcija disajnih puteva kod 10 (32%), kraniofacijalne anomalije kod 2 (5%) i plućna bolest kod jednog (3%) bolesnika. Rane komplikacije (koje su se javljale tokom prvih sedam dana od traheostomije) bile su prisutne kod 4 (10,5%) bolesnika, od kojih je njih troje imalo curenje vazduha (zbog neodgovarajućeg izbora kanile), a dehiscenciju rane imao je jedan bolesnik. Kasne komplikacije (koje su se pojavile kasnije od sedam dana posle traheostomije) bile su prisutne kod 4 (10,5%) bolesnika i to peristomalna granulacija kod tri bolesnika i opstrukcija tubusa, kod jednog bolesnika. Nije bilo smrtnih ishoda kod bolesnika povezanih sa traheostomijom, mada je ukupan mortalitet bio 21% (8 bolesnika). Svi ovi bolesnici preminuli su usled primarnog oboljenja. Sedamnaest (44,7%) bolesnika je uspešno dekanilisano. Zaključak. Za većinu bolesnika je, zbog prirode njihovih osnovnih oboljenja, bilo potrebno dugotrajno lečenje i retencija traheostomije što se podudaralo sa niskom stopom dekanulacije. Zbog toga bi traheostomije trebalo izvoditi prvenstveno u specijalizovanim centrima sa obučenim medicinskim osobljem, čime se obezbeđuje odgovarajuća zdravstvena zaštita.

The pros and cons of suturing the ventral hernia defect using the intraperitoneal onlay mesh technique

Bojan Jovanović — 2024-06-27

Background/Aim. Laparoscopic ventral hernia surgery, including intraperitoneal onlay mesh (IPOM), is as effective and safe as open surgery, with a lower recurrence rate. Some surgeons advocate laparoscopic primary fascial closure (PFC) with intraperitoneal mesh placement to reduce recurrence rates. The aim of this study was to compare the treatment outcome between two laparoscopic techniques: the PFC technique and mesh placement without suture closure (IPOM technique) for defects under 4 cm in patients with ventral hernias. Methods. The study sample was comprised of 50 patients who underwent laparoscopic ventral hernia surgery from January 1, 2018, until December 31, 2020. Half of the patients underwent only the IPOM technique (group of patients without the suture), while in others, this was preceded by the closure of the hernial ring (group of patients with the suture). All hernias were midline and all defects were under 4 cm. The studied groups were homogeneous according to gender and age. Comorbidities, complications, and postoperative comfort were monitored. Results. The most common (76%) hernias were primary, and the most common comorbidity was arterial hypertension (28%). One (2%) patient had intraoperative bleeding, and the most common postoperative complication was pain in 7 (14%) patients. After a three-year follow-up, there were 10 (20%) patients with complications – one hernia recurred, while 9 (18%) patients died. There was no difference in the types of occurrence of hernias, comorbidities, and intraoperative complications. The distribution of postoperative complications differed significantly (p = 0.007) between the groups. Pain was statistically significantly more prevalent in patients with sutures. During the first three months postoperatively, significantly more patients with sutures had chronic pain (χ²= 8.140; p = 0.004). Conclusion. We recommend the application of the PFC technique in selected ventral hernia repair cases, although it can lead to more frequent postoperative pain (which, fortunately, is easily treated).

Portal vein thrombosis in patients with liver cirrhosis

Željka Savić — 2024-06-27

Background/Aim. Portal vein thrombosis (PVT) in patients with liver cirrhosis (LC) has a prevalence of 0.6–26%. It is most commonly discovered incidentally as part of the evaluation of LC or in the context of acute decompensation of LC due to portal hypertension. The aim of the study was to determine the prevalence of PVT in patients with LC in relation to the severity of the disease and individual elements of portal hypertension. Methods. A total of 326 patients treated for LC decompensation were included in a retrospective study. Standard laboratory analyses, abdominal ultrasonography and/or computed tomography, and esophagogastroduodenoscopy were performed. Results. The diameter of the portal vein (PV) differed between patients without esophageal varices (12.2 mm) and those with large varices (13.6 mm), p = 0.026. PVT was identified in 6.1% of patients with LC. The patients were classified according to the Child-Pugh scoring system, which has the A, B, and C categories used to assess the severity of liver disease. PVT was present in 3.0% of patients in class C and 12.0% in class B, while none of the patients in class A had PVT (p = 0.005). PVT was present in 4.4% of patients with small varices and 16.7% with large varices (p < 0.001). There was no difference in the presence of PVT between the groups of patients with and without variceal bleeding nor between groups with different degrees of ascites. A fatal outcome occurred in 29.4% of patients, but there was no difference between patients with and without PVT. Conclusion. PVT is present in more advanced stages of LC and predominantly in patients with large esophageal varices. There was no higher prevalence of PVT observed with the occurrence of variceal bleeding or with the death outcome in patients with LC.

Comparative evaluation of titanium-prepared platelet-rich fibrin with and without herbal extract: a histological study

Shiva Shankar Gummaluri — 2024-06-27

Background/Aim. Injecting herbal extract into platelet concentrates is one of the newer treatment protocols, which enables platelet concentrates to act as sustained drug delivery (DD) systems. Histological analysis of titanium-prepared platelet-rich fibrin (T-PRF) injected with herbal extract, could help assess the appearance (pattern) and structural changes of T-PRF. The aim of the study was to evaluate the appearance of the fibrin network, cellularity, and fibrin border area of T-PRF alone and T-PRF injected with herbal extract. Methods. A total of 40 histological slides were prepared from 10 mL of blood from each patient, 20 with T-PRF alone and 20 with T-PRF+herbal extract. The slides were divided into a group consisting of T-PRF injected with neem gel (test group) and a group consisting of T-PRF alone (control group). The preparation protocol was made according to Bankroft’s manual adapted for light microscopy. Results. Regarding the fibrin network features (dense vs. loose), no statistical significance was found among the studied groups (p = 0.172). A statistically significant difference was shown in the packeting (p = 0.018) and layered (p = 0.028) patterns of the fibrin network, and there was no statistically significant difference in the scattered (p = 0.749) pattern among the examined groups. Cellularity and cell pattern values were not statistically significantly different for both groups (p = 1.00, p = 0.3111, respectively). Moreover, the values determined for red blood cells, white blood cells, and platelets were not statistically significantly different (p = 0.147), as well as for the fibrin border area between cells and meshwork (p = 0.206). Conclusion. The obtained results could be useful for the development of a new treatment strategy in dentistry, by utilizing T-PRF with incorporated herbal extracts or antibiotics, as a local sustained DD system.

Acoustic evoked potentials characteristics in patients with vertebral artery hypoplasia and posterior circulation stroke

Biljana Živadinović — 2024-06-27

Background/Aim. Acoustic evoked potentials (AEPs) represent an electrophysiological method used in diagnosing pathological changes of the brain stem (BSt), the acoustic nerve (its peripheral and central part), in patients in coma, in the confirmation of cerebral death, etc. The response includes seven negative waves which are generated in the structures of the BSt vascularized by the arteries of the posterior circulation. However, in everyday practice, due to their constancy, the first five waves are followed. The vertebral artery hypoplasia (VAH) is assumed to affect the AEPs finding. The current definition of VAH includes the criterion that the diameter of the blood vessel is ≤ 2 mm and that the ratio of the diameter of the left and right vertebral artery is ≥ 1 : 1.7. VAH is found in 5.3% of cases of the total population and its presence increases the risk of posterior circulation stroke (PCS). The aim of this study was to show a higher frequency of pathological findings of AEPs in patients with VAH and PCS and demonstrate the characteristics of AEP in that group of patients. Methods. This prospective study included 163 patients diagnosed with PCS over a period of two years. Computed tomography (CT) and magnetic resonance (MR) imaging (MRI) established the diagnosis of PCS. Suspicion of VAH was found by Color Doppler ultrasonography and confirmed by CT and MR angiography. All patients underwent AEPs testing. Wave amplitudes and interwave latencies (IWL) were monitored. Results. There was no statistically significant difference between gender (χ² = 1.823; p = 0.176) and age in relation to VAH (p = 0.815). A statistically significant greater number of patients with multiple PCS had a positive VAH finding (VAH group, 42.3%) compared to those without VAH (noVAH group, 26.6%) (χ²=4.278; p=0.038). A statistically significant greater number of pathological AEPs was found in the group of patients with PCS and VAH (χ²= 4.899; p = 0.026). A statistically significant IWL change accompanied by low amplitude waves in the VAH group has been determined (χ² = 4.465; p = 0.034). Conclusion. The distribution of VAH is not gender- or age-related. The frequency of pathological AEPs findings (presence of associated changes in wave amplitudes and prolonged IWL) is statistically significantly higher in patients with VAH and PCS.

Atraumatic rupture of the spleen caused by Plasmodium falciparum, challenge in UN peacekeeping operations – a case report

Saša Micković — 2024-06-27

Introduction. Unlike traumatic rupture of the spleen, which is the most common consequence of blunt abdominal trauma and is well documented in the literature, and unlike the atraumatic rupture of the spleen, which is less common but also well described, spontaneous rupture of the spleen in a patient with malaria is a rare complication, with a potentially fatal outcome. Case report. A soldier aged 46 years, was hospitalized, with the clinical picture of abdominal colic and diarrhea, previously treated for a primary attack of acute malaria. During hospitalization, deterioration of health condition occurred, with the development of a clinical picture of an acute abdomen due to spontaneous rupture of the spleen which was successfully resolved by splenectomy. Conclusion. Splenectomy is the method of choice for patients with unstable clinical presentation due to atraumatic rupture of the spleen.