Vojnosanitetski pregled

The Host immuno-inflammatory response and intravascular volume replacement therapy in critically ill septic patients – are fluids a double-edged sword?

Tue, 26 May 2026 13:07:12 +0200

Intravascular volume replacement fluid therapy plays a pivotal role in the treatment of patients in circulatory shock. The interaction between various lines of therapy and immune response in critically ill septic patients remains a significant clinical challenge with no simple solution. Plasma expanders, crystalloids (such as physiological saline, balanced Ringer’s lactate, and Plasma-Lyte solution), and human albumin solution–the only acceptable colloid for critically ill patients–should be considered as necessary potent drugs with significant adverse effects. Sepsis is a very heterogeneous syndrome, with various magnitudes and persistence of inflammatory responses. Bearing in mind that the natural course of sepsis is highly complex, with phases of hyperinflammation and immunosuppression often occurring simultaneously in different locations, it is almost impossible to avoid the adverse effects of crystalloids, which are first-line intravascular volume-replacement solutions. Large-volume replacement therapy or rapid intravenous fluid infusion may induce shedding or partial denudation of the endothelial glycocalyx, thereby propagating tissue injury, leukocyte and platelet adhesion and activation. A compromised glycocalyx leads to detrimental capillary leak syndrome in sepsis. In clinical practice, serum albumin levels may indicate the timing and need to administer intravenous human albumin solution during fluid resuscitation when substantial volumes of crystalloids are required. This is an example of a “glycoprotective” fluid approach, with lower volumes and slower crystalloid infusion rates. The complex interaction among fluid therapy, the endothelium, the glycocalyx, and immune mediators is pathophysiologically relevant and very important for clinicians in therapeutic approaches.

Cone-beam computed tomography–guided precise chemoembolization for hypovascular hepatocellular carcinoma

Chengzi Jun Sun, Jiahui Zhou — Tue, 26 May 2026 13:08:25 +0200

Background/Aim. Hypovascular hepatocellular carcinoma (HCC) remains a therapeutic challenge owing to its inadequate arterial supply and limited responsiveness to standard transarterial chemoembolization (TACE). The aim of this study was to assess the clinical efficacy and safety of cone-beam computed tomography (CBCT) three-dimensional (3D) imaging-guided precise TACE vs. conventional digital subtraction angiography (DSA)-guided TACE in the treatment of hypovascular HCC. Methods. A retrospective study was performed on patients with hypovascular HCC who underwent TACE at our institution from January 2020 to December 2023. Using propensity score matching (PSM) with a 1 : 1 ratio, 58 patients were allocated to each of the two groups: the CBCT-guided precise TACE group (CBCT group) and the conventional DSA-guided TACE group (DSA group). Matching covariates included age, gender, Child-Pugh grade, tumor size, and tumor number. Short-term efficacy, long-term survival, and safety profiles were compared between the two groups. Results. Three months after the procedure, the CBCT group exhibited a markedly higher objective response rate (63.79% vs. 36.21%) and disease control rate (86.21% vs. 68.97%) compared to the DSA group (p < 0.05). Regarding long-term survival, the CBCT group exhibited significantly prolonged median progression-free survival (10.80 months vs. 7.10 months) and a higher 1-year progression-free survival rate (65.52% vs. 41.38%) compared to the DSA group (p < 0.05). However, no statistically significant differences were observed between the CBCT and DSA groups for median overall survival (22.50 months vs. 19.10 months) or the 1-year overall survival rate (81.03% vs. 72.41%) (p > 0.05). The incidence of post-embolization syndrome and severe complications (e.g., liver abscess, hepatic failure) did not differ significantly across the groups (p > 0.05). Notably, the elevation in alanine aminotransferase levels on the third postoperative day was considerably lower in the CBCT group than in the DSA group (p = 0.016). Conclusion. CBCT 3D imaging-guided precise TACE significantly enhances short-term therapeutic efficacy, prolongs progression-free survival, and provides superior hepatoprotection without increasing procedural risks, establishing it as a safe and effective interventional treatment option for hypovascular HCC.

Association of anticoagulant therapy dosing with laboratory biomarkers and clinical outcomes in critically ill COVID-19 patients in the ICU

Igor Vasković, Vojislava Nešković — Tue, 26 May 2026 00:00:00 +0200

Background/Aim. In immunothrombotic disorders such as coronavirus disease 2019 (COVID-19), D-dimer levels are frequently elevated, reflecting increased fibrin formation and turnover. Additional biomarkers, such as the neutrophil-to-lymphocyte ratio (NLR) and levels of C-reactive protein (CRP), and lactate dehydrogenase (LDH), are associated with disease severity and outcomes. The aim of the study was to evaluate the impact of two different anticoagulation protocols on serum levels of biomarkers D-dimer, NLR, CRP, and LDH, as well as their prognostic value regarding clinical outcomes in critically ill patients with COVID-19. Methods. The retrospective study included critically ill COVID-19 patients, admitted to the Intensive Care Unit (ICU) between April 2020 and December 2021, and compared D-dimer–guided and anti-Xa–guided anticoagulation protocols. Patients were divided into two groups according to the anticoagulant therapy regimen: a group with a protocol guided by anti-Xa values (AXa group – A-XaG) and a group with a protocol dosing according to D-dimer values (D-d group – D-dG). Results. A total of 395 patients were analyzed: 137 in A-XaG and 258 in D-dG. The levels of CRP, LDH, and D-dimer were significantly lower in A-XaG compared to D-dG (p < 0.001, p < 0.001, and p = 0.001, respectively). The univariate analysis identified age [odds ratio (OR): 1.064; p < 0.001], LDH (OR: 1.002; p < 0.001), CRP (OR: 1.005; p < 0.001), and D-dimer (OR: 1.054; p = 0.020) as prognostic factors for mortality. The multivariate model analysis revealed that only age > 64 years (OR: 10.215; p < 0.001) and LDH > 395 U/L (OR: 5.491; p = 0.005) remained independently associated with mortality. Conclusion. Anti-Xa–guided anticoagulation was associated with lower inflammatory biomarker levels in ICU COVID-19 patients. While univariate analysis identified age, LDH, CRP, and D-dimer as potential prognostic factors for mortality, only age and LDH remained significant in multivariate modelling, suggesting independent prognostic value in this patient population.

Diagnostic performance of the McIsaac score for group A streptococcal pharyngitis in children under three years of age

Momčilo Pavlović, Karolina Berenji, Željko Rokvić, Tatjana Ilić — Tue, 26 May 2026 13:10:54 +0200

Background/Aim. Group A β-hemolytic streptococcus (GAS) pharyngitis most commonly affects school-aged children. The aim of this study was to assess the effectiveness and clinical applicability of the McIsaac score for diagnosing GAS pharyngitis in children under 3 years of age. Methods. The retrospective study included a total of 282 children under 3 years of age diagnosed with acute pharyngitis in a pediatric outpatient setting in Subotica, Serbia, between September 2023 and August 2024. Data on demographic and clinical characteristics were collected, including McIsaac score values. The obtained results were analyzed in relation to rapid antigen detection test (RADT) findings, which were performed on all children. Results. Of the total 282 children, 143 (50.7%) were RADT-positive. The McIsaac score demonstrated limited diagnostic accuracy, with sensitivity and specificity values for scores 0–2 of 69.9% and 38.1%, respectively, and for scores 3–4 of 30.7% and 61.9%, respectively. Receiver operating characteristic (ROC) curve analysis yielded an area under the curve (AUC) of 0.561. The absence of cough was the only individual McIsaac criterion significantly associated with a positive RADT result. Conclusion. The McIsaac score alone has limited effectiveness in identifying GAS pharyngitis in children under 3 years of age. Given the substantial symptom overlap between bacterial and viral infections in this age group, additional diagnostic methods are necessary to improve diagnostic accuracy.

Clinical and radiographic outcomes of autologous pulp transplantation enhanced with concentrated growth factor in mature necrotic teeth: a clinical study

Aliye Kamalak, Esra Balkanlıoğlu, Elife Ülkü Tatar — Tue, 26 May 2026 13:15:38 +0200

Background/Aim. Regenerative endodontic therapy in mature teeth remains challenging due to limited stem cell recruitment and apical vascularization. The aim of the prospective pilot clinical study was to evaluate the feasibility and preliminary clinical, radiographic, and functional outcomes of autologous pulp transplantation enhanced with concentrated growth factor (CGF) in mature necrotic permanent teeth. Methods. The study included six systemically healthy patients (five females and one male, aged 18–27 years) presenting with single-rooted mature permanent teeth, diagnosed with pulp necrosis and associated periapical lesions. Autologous pulp tissue was harvested from extracted third molars and transplanted into disinfected recipient root canals in combination with CGF prepared from venous blood. Clinical and radiographic evaluations were performed at 3, 6, and 12 months. Periapical healing was assessed using cone-beam computed tomography (CBCT), while pulp sensibility was evaluated using electric pulp testing (EPT). Treatment outcome measures included postoperative symptoms, tooth function, radiographic healing, and recovery of pulp sensibility. Results. All treated teeth (6/6) remained asymptomatic and functional throughout the 12-month follow-up period, with no postoperative complications, such as pain, swelling, sinus tract formation, or abnormal mobility. Progressive recovery of pulp sensibility was observed during follow-up, and positive EPT responses (reflecting neural responsiveness) were detected in two cases at 4 months, one case at 6 months, and in all cases by the 12-month evaluation. CBCT analysis at 12 months demonstrated complete resolution of periapical radiolucency and restoration of apical bone architecture in all treated teeth (6/6). Conclusion. Within the limitations of this pilot clinical study, CGF-enhanced autologous pulp transplantation was associated with favorable short-term clinical and radiographic outcomes, as well as recovery of pulp sensibility in mature necrotic teeth. These preliminary findings suggest the potential of this biologically based regenerative approach. However, comparative effectiveness remains to be established.

Sudden pulmonary edema induced by phenylephrine misuse: a case report

Qing Xie, Dong-Dong Tian, Jia Lu — Tue, 26 May 2026 13:29:49 +0200

Introduction. Phenylephrine, a widely used vasoactive drug in clinical practice, may lead to severe cardiovascular complications when misused. Among these complications, sudden pulmonary edema, though rare, warrants the attention of clinicians. The given case report presents a sudden pulmonary edema caused by the misuse of phenylephrine. Case report. A female patient aged 68-years undergoing radical mastectomy for left breast cancer developed severe hypertension and hypoxemia 40 min into the procedure. The patient’s medical history included meningioma but no other significant comorbidities. A diagnosis of sudden (acute) pulmonary edema was made. The patient received prompt treatment, including strict perioperative blood pressure control, lung protective ventilation, glucocorticoids, diuretics, coronary-dilation and cardiotonic drugs, postoperative oxygen therapy, and continuous vital sign monitoring. Investigation revealed that phenylephrine had been mistakenly administered intravenously instead of dexamethasone. She recovered and was discharged one week postoperatively. Conclusion. This case highlights the risks associated with the inadvertent administration of a high dose of phenylephrine, leading to sudden pulmonary edema. It underscores the importance of vigilance among anesthesiologists, prompt management of complications, and strategies to prevent errors, including enhanced education for resident anesthesiologists, measures to address practitioner fatigue, and improved drug packaging to minimize look-alike errors.

From the ‘Jumpers in Maine’ to the ‘Boy from Paris’: the life of Georges Gilles de la Tourette and the first description of tic disease

Radomir Damjanović, Nikola Jovanović, Dejan Aleksić , Jelena Stamenović — Tue, 26 May 2026 13:49:22 +0200

In 1885, French neuropsychiatrist Dr. Georges Gilles de la Tourette was the first to describe a disease of tics. His success was not unexpected, as he was a student of the renowned neurologist Dr. Jean-Martin Charcot. Georges Gilles de la Tourette was born on October 30, 1857, in Saint-Gervais-les-Trois-Clochers, France, as the eldest of four children. Immediately after graduating in 1881, he went to Paris for further training. His special interests included hysteria, psychotherapy, and hypnotism. By revising an article titled “Experiments with the ‘Jumpers of Maine’ ”, he concluded that a somewhat similar disorder exists in different cultures across the world. He soon described additional signs of the syndrome, including inarticulate sounds, echolalia, and coprolalia, and accentuated the hereditary nature of the disease. Insightful and dedicated yet short-tempered and arrogant, Georges Gilles de la Tourette was an inspiring physician and teacher. He left behind a significant legacy in the study of involuntary movements, particularly through his description of the syndrome that would come to be known as Tourette syndrome. This description of the syndrome is just a portion of his contributions to neurology and psychiatry. His work, often met with both admiration and criticism, reflects the complexities of his personality and the challenges he faced in his professional life.