AKTET ISSN 2073-2244 Journal of Institute Alb-Shkenca www.alb-shkenca.org Reviste Shkencore e Institutit Alb-Shkenca Copyright © Institute Alb-Shkenca
TREATING KERATOKONUS DISEASE WITH CROSS-LINKING METHOD TRAJTIMI I KERATOKONUSIT ME METODEN E CROSS-LINKING
TEUTA рAVE‘I ″i u ge oftal ologe, “pitali A e ika , Ti a e e- ail:tha e i@spitalia e ika . o
ABSTRACT Keratokonus is a degenerative disease, starting generally at 14- 25 years old and causing progressive thinning of the cornea. Because of these thinning, corneal shape is reduced into a conical one, causing also distortion of vision. Clinically, keratokonus presents progressive changes of the refraction, principally of astigmatisms, the patient f e ue tl ha ge the glasses ut do t feel o fo ta le ith the . E t e e ad a e e t of the keratokonus can cause corneal perforation, destroying the vision. To avoid this, corneal transplant is required to save the eye. Considering the young age of the patients, high cost of the of the corneal transplantation, and the risk of transplant reject, high priority is given to the early diagnose and halting treatment. Nowadays, cross-linking is the only procedure used to halt the natural progression of keratokonus, Studied and applied for the first time at Dresden University, a great number of clinical studies supported its efficacy in halting the progression of keratokonus.
PERMBLEDHJE Keratokonusi është sëmundje degjenerative e kornesë, e cila fillon të evidentohet në moshën 14- jeҫ dhe shkakton hollim progresiv të saj.Për shkak të këtij hollimi, kornea merr formë konike duke shkaktuar deformim dhe dëmtim të shikimit.Klinikisht paraqitet me rritje progressive të korrigjimit optik,kryesisht të astigmatizmit,pacienti ndërron shpesh syzet por nuk ndihet komod me to.Ndërkaq mprehtësia e pamjes ulet progresivisht. Në stadet e deformimit te avancuar dhe të hollimit ekstrem, kur kornea tenton perforimin, transplanti I kornesë është e vetmja metodë që mund të shpëtojë syrin.Duke pasur parasysh faktin se prek kryesisht moshat e reja,koston e lartë të transplantit të kornesë si dhe pasojat invalidizuese për shikimin në rastin e flakjes së këtij të fundit, rëndësi të eҫa të e diag ostiki i I he shë dhe t ajti i e etodë e oss-linking. Cross-linking është për momentin e vetmja metodë e njohur që vitet e fundit po përdoret gjerësisht në frenimin e ecurisë progressive te keratokonusit. E eksperimentuar dhe aplikuar për herë të parë në Universitetin e Dresdenit, studime të shumta kanë mbështetur efikasitetin e saj në trajtimin e keratokonusit.
Key words: ke atoko us,ke ato et i,paki et i, oss-li ki g,ko ea
INTRODUCTION hi h o d the pa allel o es to ea h-othe , gi i g to The o ea is a t a spa e t i te fa e o e i g the f o t the o ea its atu al st e gth. This phe o e o is of the e e. It has the fu tio of p ote ti g the e e all k o as atu al oss-li ki g a d it is espo si le fo a d also is a po e ful ef a ti g su fa e, p o idi g / the o ea s esista e agai st of the e e's fo usi g po e . The adult o ea has a defo atio .″e ato o us is a ilate al o - thi k ess of µ a d is o p ised of la e s: i fla ato disease hi h auses p og essi e o eal epitheliu , Bo a 's e a e, st o a, Des e et's thi i g, leadi g to p ot usio , disto tio , a d s a i g e a e a d the e dotheliu . The st o a is the of the o ea It is a atu all o u i g o ula thi kest la e o posed of ollage fi ils o ie ted o ditio hi h leads to steepe i g of the e t al pa allel to ea h-othe . It has also t a s e sal fi ils o ea, i easi g opia, i egula astig atis , a d Haveri loss of est spe ta le- o e ted isual a uit . Co eal o eal epitheliu la e , follo ed i utes of thi i g o all o u s i the i fe o-te po al o i i ofla i ad i ist atio , su se ue tl , UVA light is the e t al o ea . E eptio al ase of supe io applied fo i utes. The o eal epithelial la e is lo alizatio s ha e also ee des i ed , .″e atoko us ge e all e o ed to i ease pe et atio of the e o es e ide t o all du i g pu e t , although i ofla i i to the st o a.[ ] Du i g the UV light the disease has also ee fou d to de elop ea lie illu i atio , i ofla i a ts fu the as a shield du i g a d latte i life .It pote tiall p og esses u til the i adiatio to the o ea, p ote ti g deepe o ula fou th de ade of life, he it usuall sta ilizes . A st u tu es su h as the e dotheliu , le s, a d eti a stud has dete i ed that % of o -affe ted e es of f o UV-A i adia es that a e too high A othe su je ts ith u ilate al ke ato o us ill de elop the i po ta t ole of i ofla i is to p e e t o eal disease i ea s . If left u t eated, ke atoko us deh d atio du i g e posu e The o i atio of f e ue tl p og esses to fo atio of des e e t s i ofla i a d UV-A light eates – % a so ptio tea s k o as Vogt s st ies a d o eal pe fo atio , i to the o ea du i g oss-li ki g depe di g o the se iousl th eate i g the isio . At this poi t, o eal o e t atio a d the o eal thi k ess Gi e t a spla tatio is e ui ed to esto e useful isio a d the si pli it a d i i al osts of the t eat e t, sa i g the e e. Co eal Collage C oss-li ki g is a oss-li ki g t eat e t is also ell-suited fo t eat e t fo ke ato o us a d othe o eal e tasia de elopi g ou t ies Late a d latest stud , as hi h as de eloped fi st at the U i e sit of D esde the “ie a E e “tud , i estigates lo g-te effe ts of i . I this p o edu e ult a iolet UV light a d sta da d oss-li ki g. Th ee hu d ed a d si t -th ee i ofla i ita i B d ops a e used to st e gthe the e es e e t eated a d o ito ed o e ea s, o ea's st u tu e, to slo o halt the p og essio of p odu i g elia le lo g-te esults p o i g the ke ato o us, p e e ti g dete io atio of isio a d the effi a of the p o edu e i te s of lo g-te sta ilit eed fo o eal t a spla tatio . нi stl e pe i e ted of the o ea halti g the p og essio of i po i e a d a its o eas, the esults sho ed that ke atoko us, a d p o i g the safet of the i ofla i soaked a d UVA i adiated o eas e e p o edu e stiffe a d o e esista t to e z ati digestio . I estigatio s also p o ed that the t eated o eas I ou hospital, oss-li ki g te h i ue is applied f o o tai ed high ole ula eight pol e s of ollage . The patie t p ese ted ith o plai s su h as: due to fi il oss-li ki g .Othe s, i it o p og essi e ha ge e ts i ef a tio , ha gi g i estigatio s, o hu a a d po i e o eas f e ue tl the glasses a d ot feeli g o fo ta le ith e a i ed the est t eat e t pa a ete s fo sta da d the , high astig atis a d opia, a e suspe ted fo oss-liki g, su h as i ofla i o e t atio , i te sit , ke atoko us. These patie ts a e ad ised to u de go a ele gth of UV-A light, a d du atio of t eat e t. topog aphi e a i atio ith Pe ta a i st u e t Also it has ee p o ed that UVA i adiatio is ot hi h is ased o the “ hei pflug o ki g p i iple, ha ful fo the e dotheliu , if the o eal thi k ess is taki g – i ages of the o ea at diffe e t a gles a o e µ Afte the la o ato , li i al esults usi g a otati g a e a. A te io a d poste io o eal e e also e ou agi g. The pilot stud i luded ele atio s a e the easu ed usi g topog aphi patie ts ith p og essi e ke atoko us that e e a al sis, p o idi g useful i fo atio i ke atoko us t eated ith oss-li ki g. All of the sho ed stopped diag osti a d g adi g the se e it of ke atoko us p og essi g afte t eat e t. % had flatte i g of the IV-th g ade of ke atoko us ith pa h et lo e tha steepest ke ato et , de ease i a e age a d µ , Vogt s st iae o o eal h d ops a e a i u ke ato et i alues a d % had isual i ediatel ad ised to u de go o eal t a spla t a uit i p o e e t. No o pli atio epo ted p o edu e. The patie ts, diag osed i stage - of ke atoko us, ith o o eal ha ge e ts a e Afte that, oss-li ki g e a e a o ld ide used follo ed fo o th to he k the e ide e of te h i ue. Ge e all is applied usi g D esde ke atoko us p og essio a d i this ase, a e ad ised p oto ol e ui i g the e o al of e t al of to u de go oss-li ki g p o edu e. Othe s, al ead
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Haveri p ese ti g lea e ide e of p og essio i o pa iso Table 2 Values of steepest keratometry of ea lie topog aphi e a i atio a e i ediatel Time Value Testi Wilcoxon p ad ised to the oss-li ki g p o edu e. The esults of Before cross- linking 50.6 follo -up a e olle ted a d dis ussed i ‘esults a d 1 Month after 51.1 Z=2.6 P = 0.0117 Dis ussio sho i g e ide e of flatte i g the o ea treatment a d stoppi g the p og ess of ke atoko us. 3 Months 50.5 Z= 0.04 P = 0.969 6 Months 49.9 Z= 2.399 P = 0.0164
PATIENTS AND METHODS 12 Months 49.2 Z= 3.85 P < 0.001 e es ith p og essi e ke ato o us e e i luded i the stud . A e age age as . ea s the ou gest Table 3 Values of average keratometry ea s old a d the oldest ea s old . A otati g Time Value Test Wilcoxon “ hei pflug a e a Pe ta a р‘, O ulus is used to Before cross-linking diag ose a d follo -up the ke atoko us efo e a d 48.3 post oss-li ki g t eat e t. Co eal ele atio , 1 Month after treatment 50.0 Z=3.8 P = pa h et a d ke ato et e e the pa a ete s 0.0001 easu ed. The i lusio ite ias e e: p og essio of 3 Month after treatment 48.3 Z= 0.54 P = ke ato o us ese ted as a i esi g i a i u 0.585 ke ato et steepest ke ato et at least , D i o ths, p eope ati e o eal thi k ess a o e µ , 6 Month after treatment 47.6 Z= 2.83 P = o o eal s a , o p e isious o eal 0.004 su ge ies.Patie ts u de e t oss-li ki g p o edu e 12 Month after treatment 47.1 Z= 2.8 P < a o di g to D esde p oto ol.Afte oss-li ki g 0.001 p o edu e the patie ts e e follo ed ith th ee di e sio al o eal topog aph Pe ta a р‘ Table 4 Values of UCVA (uncorrected visual acuity) O ulus a d the pa a ete s follo ed e e: Time Value Test Wilcoxon ke ato et steepest, flattest, a e age, o eal Before cross-linking paki et a e age a d thi est, u o e ted a d 0.68 est- o e ted isual a uit . The follo -up ti e as 1 Month after treatment 0.21 Z=1.15 P = o ths. 0.24 3 Month after treatment 0.29 Z= 0.63 P = RESULTS AND DISCUSSION 0.524 The values for each parameters are recorded after 1 6 Month after treatment 0.31 Z= 1.88 P = month, 3 month, 6 months and 12 months after cross- 0.05 linking. The average value is recorded for each variable 12 Month after treatment 0.65 Z= 2.1 P for each period of time and compared using the =0.74 Willcoxon test to obtain the values of z and p.The results are recorder in the tables below: Table 5 Values of BCVA ( best corrected visual acuity) Time Value Testi Wilcoxon Table 1 Values of flattest keratometry Before cross-linking Tiime Value Test Wilcoxon 0.54 Before cross- 1 Month after treatment 0.46 Z = 017 P = linking 46.6 0.2455 1 Month after 46.9 Z=2.29 P = 0.0254 3 Month after treatment 0.55 Z= 0.9 P = treatment 0.3547 3 Months 46.2 Z= 0.59 P = 0.5799 6 Month after treatment 0.61 Z= 2.8 P < 6 Months 45.6 Z= 3.88 P = 0.0023 0.001 12 Months 44.8 Z= 3.71 P = 0.0005 12 Month after treatment 0.64 Z= 2.8 P < 0.001
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As we see in table 1,2 and 3 , keratometry value of the Legeais, Renard G. Superior keratoconus. Cornea first month after cross-linking, have the tendency to 1997;16:693–4. be higher than before . The remodeling of the 3. Weed KH, McGhee CN, Mac Ewen CJ. Atypical keratokonus area is not yet started. The real reduction unilateral superior keratoconus in young males. in keratometry results become evident after 6 months Contact Lens Anterior Eye 2005;28:177–9. and progressively continuing after 12 months. From 4. Rahmen W, Anwar S. An unusual case of table 1 and 2 is noted that after 1 year : keratoconus. J Pediatr Ophthalmol Strabismus 2006;43 - flattest keratometry reduced of 1.8 D 5. Rabinowitz YS, Yang H, Rasheed K, Li X. - steepest keratometry reduced of 1,4 D Longitudinal analysis of the fellow eyes in unilateral ( statistically significant Z= 3,85 p< 0,001) keratoconus. Invest Ophthalmol Vis Sci 2003;44 - average keratometry reduced of 1,2 D 6. Wollensak G, Spoerl E, Seiler T. ( statistically significant Z=2.8 p< 0,001) Riboflavin/ultraviolet-a-induced collagen crosslinking Tables 3 and 4 presents the values of UCVA and BCVA, for the treatment of keratoconus. Am J Ophthalmol. measured with Snellen chart, and their changements 2003;135:620–7. after 1,3,6, 12 months are recoreded. This values are 7. Complication and failure rates after corneal lower 3 months after cross-linking mostly due to crosslinking Koller T, Mrochen M, Seiler T J Cataract corneal haze after it. The visual acuity recovers 6 Refract Surg. 2009 Aug; 35(8):1358-62. months after cross-linking and later changes as follow: 8. P T Ashwin, P J McDonnell. Collagen cross-linkage: - UCVA remains the same 12 months after a comprehensive review and directions for future cross-linking research. Br J Ophthalmol 2010;94:965-970. - BCVA improves 1 line 12 months after cross- 9. Induction of cross-links in corneal tissue. Spoerl E, linking ( z=2.8 p<0,001) Huhle M, Seiler T ;Exp Eye Res. 1998 Jan; 66(1):97-103 10. Spoerl E1, Mrochen M, Sliney D, Trokel S, Seiler The alues of o eal thi k ess e ai s al ost the T.Safety of UVA-riboflavin cross-linking of the cornea. sa e a d e e goi g do µ . The edu e of Cornea. 2007 May;26(4):385-9. µ o e o ths is due to o eal sh i ki g i du ed 11. Aurich H, Wirbelauer C, Jaroszewski J, Hartmann C, f o i te sified ollage oss-li ki g p o ess. Pham DT. Continuous measurement of corneal dehydration with online optical coherence CONCLUSIONS pachymetry. Cornea. 2006;25:182–4. Afte ollage oss-li ki g, the odifi atio i 12. Long-term results of riboflavin ultraviolet a corneal collagen cross-linking for keratoconus in Italy: the o eal shape a d thi k ess a d BCVA e e Siena eye cross study Caporossi A, Mazzotta C, Baiocchi fou d to e: S, Caporossi T Am J Ophthalmol. 2010 Apr; 149(4):585- - ‘edu tio i ke ato et flattest , D, 93. steepest , D 13. Ishii R, Kamiya K, Igarashi A, Shimizu K, Utsumi Y, - “ta ilizatio i o eal thi k ess Kumanomido T Correlation of corneal elevation with - I p o i g of BCVA li e severity of keratoconus by means of anterior and The efo e flatte i g a d sta ilizi g the o ea, posterior topographic analysis. Cornea. 2012 ollage oss-li ki g sho ed to e a effi ie t Mar;31(3):253-8. ethod i stoppi g ke atoko us p og essio 14. Wittig-Silva C, Whiting M, Lamoureux E, Lindsay RG, Sullivan LJ, Snibson GR. A randomized controlled BIBLIOGRAPHY trial of corneal collagen cross-linking in progressive 1. Krachmer JH, Feder RS, Belin MW. Keratoconus keratoconus: preliminary results. J Refract Surg. and related noninflammatory corneal thinning 2008;24:S720-S725. disorders. Surv Ophthalmol. 1984; 28:293–322. 15. Biomechanical evidence of the distribution of 2. Auffarth GU, Wang L, Völcker HE. Keratoconus cross-links in corneas treated with riboflavin and evaluation using the Orbscan topography system. J ultraviolet A light. Kohlhaas M, Spoerl E, Schilde T, Unger G, Wittig C, Pillunat LE; J Cataract Refract Surg. Cataract Refract Surg 2000;26:222–8.3- Prisant O, 2006 Feb; 32(2):279-83.
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AKTET ISSN 2073-2244 Journal of Institute Alb-Shkenca www.alb-shkenca.org Revistë Shkencore e Institutit Alb-Shkenca Copyright © Institute Alb-Shkenca
NEONATES IN INDUCTION OF LABOR COMPARED WITH EXPECTANT MANAGEMENT
ALMA NURÇE a, * VJOLLCA SHPATA a, XHENSILA PRENDUSHI a, GENTA KOROVESHI b, IRENA KOLA a, ENKELEIDA KAMBERI c a Medi al “ ie e Te h i al нa ult , Ti a a, Al a ia. рospital of O stet i G e ologi Ge aldi e Quee , Ti a a, Al a ia. c Obstetric-G e ologi рospital ″oço Gliozhe i , Ti a a, Al a ia. * Corresponding author: [email protected]
SUMMARY The aim: To study the relationship between neonatal problems, induction of labor and determine whether there is an optimal delivery gestational age. Materials and methods: It is a study in Hospital of Obstetric Gynecologic Ge aldi e Quee i Ti a a fo eo ates ith histo of p e atu e uptu e of e a e hou s fo out o e of neonate in induction of labor compared with expectant management. Results: Were included 617 newborn. 213(37.4%) infants were premature. The labor was induction in 263(42.6%) cases. The incidence of neonatal infection was 11.53%, sepsis 9.27%. Mortality was seen in 8(1.3%) neonates. Conclusions: Induction of labor is protective factor in premature rupture of membranes. Key words: neonate, rupture of membranes, induction, expectant management
PERMBLEDHJE Qёlli i: Tё studiojё lidhje dё jet p o le e e tё eo atit ё li dje e i duktua dhe pё akti i ku ёshtё koha ё e pё shtatsh e pё li dje.Mate ialet dhe etoda: Ёshtё jё studi ё “pitali O stet ik Gji ekologjik M etё esha Ge aldi ё Ti a ё pё eo atёt e histo i tё uptu ёs sё pa akohёsh e tё e a a e o ё pё ezultatet e eo atit ё li djet e i duktua k ahasua e ё d i i p itёs. ‘ezultatet: u pё fshi ё ё studi . . % eo atё ishi p e atu ё. Li dja u i duktua ё . % aste. I ide a e i feksio it eo atal ishte . %, sepsis ё . %. Mortaliteti rezultoi 1.3%. Konkluzion: Induksioni i lindjes ёshtё faktor mbrojtёs ё uptu ё e pa akohёsh e tё e a a e. нjalё k çe: eo at, uptu ё e e a a e, i duksio , ё d i p itёs.
Background: Premature rupture of membranes is a planned. The use of prophylactic antibiotics, or spontaneous rupture of fetal membranes and leakage corticosteroids, fetal lung maturity testing, and of fluid from the vagina before the onset of true labor. immediate delivery compared with expectant Premature rupture of membranes happens to full term management are undefined aspects of management. infants (PROM) and to preterm infants (PPROM). (16, (7, 19) 18, 12) It has a risk for neonatal morbidity such as: When PROM occurs at term, early delivery is infection, sepsis, birth asphyxia, respiratory distress associated with a lower incidence of maternal syndrome, apnea, neurologic disorder ( 10, 12,16 18) infection compared with expectant management.(2) At There are two options for managing of premature extreme preterm gestations, in the absence of rupture of membranes, expectant management (a wait maternal or fetal compromise, there is unanimity in and see approach) or early planned birth. The that expectant management to allow further fetal infection is the main risk in management is maturation is desirable (13) expectant. This risk need to be balanced against the risk of iatrogenic prematurity if early delivery is Nurce et al.
The aim: To evaluate the effectiveness of early history of PROM >18 hours and included in the study. In planned birth compared with expectant management 263(42.6%) cases the born were inducted. 231(37.4%) for neonates of women with PROM. infants were born premature. 328(53.2%) infants delivered within 24 hours of PROM and 289(46.8%) Materials and methods: It is a prospective descriptive infants delivered after 24 hours of PROM. study in University Hospital of Obstetric Gynecologic Ge aldi e Quee i Ti a a Al a ia du i g a pe iod Table 1: Neonatal characteristics January 2009 to 31December 2012. We study the outcome of neonate with history of PROM in induction Deviation Variable Median Range of labor compared with expectant management. standard Entered into this study all neonates of mother with Apgar score 8.16 ±1.19 1÷10 histo of P‘OM hou s. Age of p eg a is (min 1) years. Exclusion criteria were as follows: infants with Apgar score 9.43 ±0.91 3÷19 congenital anomalies, multi fetal gestation, infantile (min 5) was not born at our hospital. According to the Birth weight 1588.561 2938.9141 300÷3900 gestational age neonates were classified into five groups: (grams) 7 28-30 weeks, 31-32weeks, 33-34 weeks, 35-36 weeks, Duration of 7.84 ±5.77 1÷27 up to 37 weeks. hospital stay Time of rupture of membranes from delivery was classified into the early birth group (will be delivered within 24 hours and the later birth group (will be delivered after 24 hours). Options for managing was No. % classified into two groups: expectant management (a 386 wait and see approach) and induction of labor (early planned birth) with intravenous oxytocin. The infant outcome was neonatal infection, sepsis, neonatal major and minor morbidity, perinatal mortality, duration of stay in hospital, birth weight, 102 79 63 Apgar. Maternal outcomes included: treated 40 10 2 6 13 16 (antibiotics and glucocorticoids), induction of labor. Neonatal infection defined as the presence of clinical signs of infection and a positive culture of a known 28-30 31-32 33-34 35-36 >37 pathogen from blood or cerebrospinal fluid. Clinical week week week week week signs of infection include respiratory distress syndrome (RDS), apnea, lethargy, hypotension, poor Figure 1: The classification of infants by gestational perfusion, need for inotropic support or volume age expansion, poor feeding and/or temperature instability. The incidence of infection resulted 11.54% (n=71). Neonatal major morbidity was defined as presence of Infants in the induction group were less likely to have any of the following: RDS, intraventricular hemorrhage, infection, than those in the expectant management need of artificial ventilation, bronchopulmonary group OR=0.26, 95%CI: 0.14-0.49, P<0.0001. The dysplasia, sepsis, seizure, necrotizing enter colitis, preterm infants had more likely to infection OR=9.56, pneumonia, meningitis, patent ducts arteriosis. 95%CI: 5.10-17.9, P<0.0001. Premature had greater Neonatal minor morbidity was defined as presence risk for infection and the risk increases with decrease any of the following: jaundice, transient hypo or of the pediatric age P<0.0001. hyperglycemia. A statistical calculation was performed by SPSS16. Was used chi square test, student t test, logistic regression analysis.
RESULTS: 27196 newborn infants were born alive during study period. 617(23.9%) infants had a maternal
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Table 2: Correlates of infection with age of the pregnancy
8 95% Age Relative 6.85 Infection Confidential p value 6 (week) risk 5.6 interval 4 28-30 7 20.67 10.57-40.44 P<0.0001 2 Relativ 1.2 risk 31-32 18 13.29 7.04-25.07 P<0.0001 0 0 33-34 22 8.22 4.33-15.6 P<0.0001 35-36 11 3.18 1.47-6.89 0.003 >37 13 reference
Figure 3: Relative risk of infection according to the period of latency Relativ risk In induction of labor the newborn had less likely to occur sepsis. OR=0.19, 95%CI: 0.09-0.41, P<0.0001. 87(14.1%) neonates were born with asphyxia. 20.67 Induction increased the chances of asphyxia, but 13.29 without statistical significance. OR = 1.17, 95%CI: 0.74- 8.22 1.84, P = 0.4. In prolonged latency period and 3.18 0 premature infants were more likely to asphyxia respective: OR = 1:55, 95% CI: 0.98-2.46, P = 0.05; OR = 28-30 31-32 33-34 35-36 >37 2.75, 95% CI: 1.73-4.37, P<0.0001. week week week week week Mortality was seen in 8(1.3%) neonates. Induction of
labor reduced the chances of mortality, but not Figure 2: Relative risk of infection according to age of statisti all sig ifi a t. O‘ = : , % CI: : - 2:21, the pregnancy P = 0.2. The major composite morbidities were detected in After 24 hours of PROM, infantile were more likely to 139(22.5%) infants. RDS was the most common major make infection OR = 3:32, 95%CI: 1.93-5.73, P<0.0001. morbidity and resulted in 120(19:45%) infants. Preterm There is high risk of infection after 48 hours and the infant was more likely for major morbidity OR = 11.82, risk increases with the latency period P<0.0001. 95% CI: 7.44-18.7, P <0.0001. The major neonatal morbidity was significantly higher risk at 28-30 weeks Table 3: Correlates of infection with the period of of gestation p<0.0001 latency: With increasing time of PROM infant had more likely major morbidity. Infants at greater risk were when Time 95% latency period were >48 hours Relative of Infection Confidential p value 162(26.26%) infants resulted with minor morbidity. risk PROM interval Babies in the induction group were less likely to stay in intensive care units than in the expectant management 18-24 20 reference hour g oup ut ot statisti all sig ifi a t. O‘ = : , %CI: 0.07-1.72, P = 0:16. 24-48 14 1.2 0.62-2.32 0.5 Both maternal and infant length of hospital stay were hour significantly longer for cases of preterm PROM > 48 23 6.85 4.04-11.6 <0.0001 delivered at 34 weeks of gestation or less as compared hour with those who delivered after 36 weeks of gestation. >7 14 5.6 3.07-10.2 <0.0001 hour
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DISCUSSION evaluated major neonatal outcomes between the 2 Overall incidence of PROM >18 hours was 23.9 % in our study groups. study. There is correlation to neonate problems with Cox et al(5) randomly assigned 129 women with gestational age, delivery interval and whether labor PPROM between 30 and 34 weeks of gestation to was induced with oxytocin (42.6% N=263). either immediate delivery or expectant management. In our study resulted that neonatal outcome largely No fetal lung maturity testing, tocolytic, or depends on fetal gestational age than PPROM itself. corticosteroids were used in the study participants. No This finding is consistent with other studies. (15,17,20) significant differences, however, were noted between Most preterm birth occurs after PPROM.(16) the 2 groups with regard to any of the evaluated Preterm labor before 34 weeks of gestation needs a neonatal outcomes. course of antenatal corticosteroid. Naef et al (14) evaluated aggressive compared with In our study, infections, sepsis, mortality, respiratory conservative management of women with preterm distress syndrome, were high in study groups. PROM at 34 to 37 weeks of gestation. In this PROM results in loss of natural protection of fetus and prospective investigation, 120 women with preterm intrauterine content. Both fetus and mother are at risk PROM were randomly assigned to receive oxytocin of infection. The incidence of neonatal infection of induction or observation. No significant differences 11.54% in infants with maternal PROM >18 hours in were noted in the incidence of major neonatal our study was higher than previous studies (2.4-10%) morbidities between the 2 groups. (1, 4, 6) probably due to the difference in diagnostic Although these studies suggest that neonatal and problems of our country conditions. outcomes are similar between women who were In our study the sepsis neonatal with history of managed expectantly compared with immediate preterm premature rupture of membranes (PROM) induction, these investigations lacked sufficient >18 hours resulted 9.27%. Although the risk of statistical power to fully evaluate neonatal outcomes. neonatal sepsis is reduced after intrapartum Despite the pivotal importance of accurate data prophylaxis of mother with antibiotic therapy. regarding major and minor neonatal morbidities in In our study the neonatal mortality resulted 1.3%. pregnancies complicated by preterm PROM, few Approximately 5.3-20% of perinatal deaths are directly studies have attempted fully to characterize these or indirectly attributable to PPROM. (1, 8) morbidities in an attempt to identify an optimal The decision to abandon expectant management of gestational age for delivery of pregnancies complicated women with preterm PROM in favor of delivery by preterm PROM. requires a close assessment of the potential risks Our findings are similar to those reported by related to development of intrauterine infection in Jothivijayarani et al.(9) These investigators those pregnancies expectantly managed compared characterized maternal and neonatal outcomes of 79 with the gestational age–related risks for neonatal women with PPROM between 32 and 36 weeks of morbidity and mortality related to intentional delivery. gestation In our study resulted that infants in the induction The basis of our results we recommend: group were less likely to have infection, sepsis, At gestations remote from term, expectant mortality than those in the expectant management management is appropriate to allow fetal maturation. group. Therefore induction of labor is protective When PPROM complicates pregnancies closer to term factor for neonatal infection, sepsis, mortality. Same, the risks of prematurity are lower and the risk to the randomized clinical trials have compared the maternal infant of sepsis becomes of greater significance. and neonatal outcomes related to immediate delivery This trial will provide evidence on the optimal care for compared with expectant management in women with women with PPROM close to term (34-37 weeks preterm PROM between 30 and 36 weeks of gestation. gestation). If it can be demonstrated that early planned (3,5,11,14) birth in this clinical situation is associated with less Mercer et al (13) randomly assigned 93 women with maternal and neonatal morbidity PPROM between 32 and 36 weeks of gestation that Induction of labor is protective factor for neonatal had confirmed fetal lung maturity either to immediate infection in premature rupture of membranes. delivery or to expectant management. These Expectant management in labor at 34 weeks investigators demonstrated a trend toward decreased gestational age and beyond is of limited benefit incidence of sepsis workups and confirmed sepsis, there were no significant differences in any of the
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REFERENCE 11. Mercer BM, Crocker LG, Boe.NM. Induction versus 1. Aa o B Caughe , Julia N ‘o i so , MD, a d E ol expectant management in premature rupture of the ‘ No itz, MD, PhD Co te po a Diag osis a d membranes with mature amniotic fluid at 32 to 36 Management of Preterm Premature Rupture of weeks:a randomized trial. Am J Obstet Gynecol Membranes Obstet Gynecol. 2008 Winter; 1(1): 11–22. 1993;169:775–82. 2. ACOG Committee on Practice Bulletins-Obstetrics, 12. Mercer BM. Preterm premature rupture of the authors. Clinical management guidelines for membranes. Obstet Gynecol. 2003;101(1):178–193. obstetrician-gynecologists. (ACOG Practice Bulletin 13. Mercer BM. Preterm premature rupture of the No.80: premature rupture of membranes). Obstet membranes:current approaches to evaluation and Gynecol. 2007;109:1007–1019. management. Obstet Gynecol Clin North Am. 3. Buchanan SL, Crowther CA, Levett KM, Middleton P, 2005;32:411–428. Morris J Planned early birth versus expectant 14. Naef RW, Allbert JR, Ross EL, Weber M. Premature management for women with preterm prelabour rupture of membranes at 34 to 37 weeks' uptu e of e a es p io to eeks gestatio fo gestation:aggressive versus conservative management. improving pregnancy outcome 2010 The Cochrane Am J Obstet Gynecol 1998;178:126–30. Collaboration. 15. Pasquier JC, Picaud JC, Rabilloud M et al. Neonatal 4. Caughey AB, Robinson JN, Norwitz ER. Contemporary outcomes after elective delivery management of Diagnosis and Management of Preterm Premature preterm premature rupture of the membranes before Rupture of Membranes. Rev Obstet Gynaecol. 2008 34 weeks' gestation Eur J Obst Gynecol Reprod Biol winter; 1(1):11-22. 2009;143: 18-23. 5. Cox SM, Leveno KJ. Intentional delivery versus 16. Payam DA, Xavier BA, Francesc FI, David MA, et al. expectant management with preterm ruptured Air Pollution and Preterm Premature Rupture of membranes at 30–34 weeks' gestation. ObstetGynecol Membranes: A Spatiotemporal Am. J. Epidemiol. 1995;86:875–9. 2014;179(2): 200-207. 6. Eleje GU, Ezebialu IU, Umeobika JC, Eke AC, Ezeama 17. Pristauz G, Bader AA, Schwantzer G et al. CO, Okechukwu ZC Pre-Labour Rupture of Membranes Assessment of risk factors for survival of neonates at Term: A Review of Management in a Health Care born after second-trimester PPROM. Early Hum Dev Institution AFRIMEDIC Journal Volume 1, No. 2 July - 2009; 85:177-80. 1 December, 2010. 18. Simhan HN, Canavan TP. Preterm premature 7. Garite TJ. Management of premature rupture of rupture of membranes: diagnosis, evaluation and membranes. Clin Perinatol 2001;28:837–4 management strategies. BJOG. 2005;112(suppl 1):32– 8. Husseiny AE. Prelabor rupture of the membrane 37. (PROM); tailored Guideline. Ain Shams J Obst Gynecol 19. Singh K, Mercer B. Antibiotics After Preterm 2005; 2:275-6. Premature Rupture of the Membranes. Clinical 9. Jothivijayarani A, Hansen W. Preterm premature Obstetrics and Gynecology. 2011;54(2):344-50... rupture of membranes at 32 to 36 weeks of gestation: 20. Yang LC, Donald RT, Howard HK et al. Maternal and neonatal and maternal outcomes. J Soc Gynecol Fetal Outcomes of Spontaneous preterm Premature Investig 2002;9:98A. Rupture of membranes. J Amer Osteopath Assoc 2004; 10. Medina TM, Hill DA. Preterm Premature Rupture of 104:537-42 Membranes: Diagnosis and Management. Amer Fam Physician 2006; 73:659-64.
AKTET, Vol VIII, Nr 1, 2015 9 AKTET ISSN 2073-2244 Journal of Institute Alb-Shkenca www.alb-shkenca.org Revistë Shkencore e Institutit Alb-Shkenca Copyright © Institute Alb-Shkenca
THE DETERMINATION OF TREND INDICATOR IN A CESAREAN DELIVERY. A RETROSPECTIVE STUDY.
PËRCAKTIMI I TRENDIT TË INDIKACIONEVE NË NJË LINDJE CEZARIANE. NJË STUDIM RETROSPEKTIV.
RISIDA GJONEJ, ALBANA POLOSKA , MIMOZA KETA , FLORA ZYBERAJ , VALBONA BEZHANI , ETLEVA SMAKAJ , AURORA BAJRAKTARI
1,2,4,5,6 Faculty of Medical Sciences Technical, Tiranë 3 Maternity Hospital " Koço Gliozheni ", Tiranë 7 Maternity Hospital " Mbretëresha Geraldinë ", Tiranë Autori korespondent R.GJONEJ: [email protected]
SUMMARY Cesarean section is a major surgical procedure most commonly performed in women. In the last three decades it is increased all over the world and it is a major concern for many countries. Increasing number of cesarean delivery is occurring in countries with middle and higher income. Cesarean section might be an emergency procedure to save the mother/fetal life. Determination the incidence of cesarean deliveries, identifying contributing factors is the aim of this study. The study included all records from clinical charts, from January 2008 till December 2010. For statistical date is used SPSS 11.5 package and Chi-Square test. Accepted error is less than 5% (p <0.05). The incidence of cesarean delivery is 35.4 %. Repeated cesarean delivery is the main factor in the rising incidence of Cesarean section from year to year.
Key words: Cesarean delivery, fetal complication, maternal indication, repeated cesarean delivery.
Introduction. Cesarean delivery is a surgical procedure which applied in pregnant women who can not give vaginal birth. This procedure realized by an incision in uterine wall.
Fig.2 Types of cesarean section.
Cesarean section is a major surgical procedure Fig.1 Cesarean delivery most commonly performed in pregnant women1. GJONEJ et al.
In the last three decades it is increased all over Aim the world9 and this surgical porcedure is a major Determination the incidence of cesarean concern for many countries7. This technique, was deliveries for the years 2008-2010. Identification born and developed time by time for the sole of contributing factors that affect the births by purpose of preventing the fetal and maternal surgical procedure, but also determining the complications. Increasing number of cesarean trend of these factors. delivery is occurring in countries with middle and higher income14. But in the other side there are Methods no scientific sources which show significant This is a qualitative, descriptive and retrospective benefits for the mother and the baby. so this study. In this study are included all records of increasing of cesarean delivery is unjustified clinical charts from obstetric department at 4,5,12,15 Maternity Hospital " Koço Gliozheni " Tiranë, . Cesarean delivery can be accomplished from January 2008 till December 2010. The data because the mother chooses it with her own collection procedure consisted of surveying 8 decision , but it can also be performed as a result information available in clinical records. 3,11 of unpredictable events . This surgical delivery For statistical date is used SPSS 11.5 package and may be an emergency procedure to save the Chi-Square test. Accepted error is less than 5% (p mother and / or baby. Such emergencies may <0.05). In this study are included only pregnant include: fetal distress, abruption of the placenta, women which gave birth by surgical procedure. Have been calculated also demographic and umbilical cord prolaps, placenta previa, active obstetrical data from clinical charts. herpes etc. But this delivery has potential risks for the mother as well as the fetus if we compare Results 2 it with vaginal delivery . Because when applying By analyzing the clinical charts for three years, this surgical procedure is necessary the incision results that were born 18 589 babies of which, of uterine wall, which is associated with blood 6585 were born by surgical procedure. So the loss, increased risk of damage to internal organs, rate or the incidence of cesarean section is 35.4 especially the bladder and uterine vessels. It may %. This mean that approximately 1 in 3 births is performed with cesarean section. In fact this also be necessary re hospitalization because of incidence of cesarean births is very high, these women wound infection. Potential risk for considering what WHO recommends for cesarean maternal mortality as a result of complications births. In 1985, the World Health Organization from anesthesia, puerperal infection, (WHO) determined that there is no justification thrombosis. Such complications have an for any region in the world to have cesarean incidence of about 3.6 times more than the childbirth rates over 10-15%, supporting the hypothesis that when this rate increases to more vaginal delivery. While children born by cesarean than 15%, the health risks overcome the benefits. section represent a potential risk for respiratory Two decades later, however, the cesarean complications. These complications are the most childbirth rates continue to contradict the WHO common reason for transfer the babies in the recommendation, in developed as well as in neonatal intensive care unit. developing countries12. But despite the complications that may be In 2008 have born 5710 and 2030 of them are associated with cesarean delivery we see that the born by cesarean section. In 2009, 6188 babies have born, and 2211 of them have born by number of cesarean section is increasing10. cesarean section. In 2010 we see that the number of live births is increased and the same
AKTET Vol. VIII, Nr 1, 2015 11 GJONEJ et al. thing we can say for the cesarean section with a membranes ratio 6691/2344. Previous 34% 35.9% 38% cesarean 2008 2009 2010 section N. Total 5710 6188 6691 Others 7.2% 14.6% 14% live birth Table 2. expresses the % of the contributing N. C/S 2030(35.55%) 2211(35 2344(3 factors of cesarean delivery in the years we .73%) 5.03%) studied. Table 1. Describe the percentage of cesarean * Others = diabetes, serotine pregnancy, section. premature, fetal abnormalities, cervical cancer, active infection by herpes etc. * N- number of cesarean delivery. Ratio total live birth/ C/S In general the table shows the factors that 2344 contributed in the rising trend of cesarean 2010 6691 delivery for each year. As we see, we realize that approximately a little decrease for each 2211 2009 6188 contributing factors in 2010, exept previous cesarean section that is increasing year after 2030 year. 2008 5710 Interpreting the table we realize that repeat cesarean delivery occupies a main place in the Graph.1 Show the ratio of total live births and rising incidence of Cesarean section from year to cesarean section for years 2008-2010. year. So in 2008 the number of previous cesarean
section was 665 (34%) of total cesarean section The table which is shown below explains some contributing factors that affect the cesarean performance. In 2009 and 2010 the number of delivery rate. previous cesarean section increased from 815 (35.9%) to 897 (38%) in 2010. 2008- N 2009- N 2010-N But in the same time, premature rupture of 2030 C/S 2211 2344 membranes and fetal distress also have C/S C/S contributed in the rising trend of cesarean P. Previa 3.1% 1% 2% delivery from 2008 to 2010. The mean of fetal Multiple 2.1% 1.9% 3% distress for this three years we studied is 378 or Gestation 17.3%, while for premature rupture of Preeclampsia 9.3% 6.8% 8% membranes as a factor contributing in rising Abnormal 5.2% 3.9% 4% trend of cesarean section is 277 or 12.3 %. presentation of fetus Fetal distress 18.5% 18.4% 15% Dystocia 6.2% 4.9% 6% Premature 14.4% 12.6% 10% rupture of
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non-medicinal reasons(women who choose Expressed in graphical way would be: private medical service, the grate age of woman, educated women ect). While in our country the 201 Previous increasing number of cesarean delivery is due to cesarean medical reasons but followed very closely also by 0 section non-medicinal reasons. So, it is important to 200 select carefully the patients if they really need a 9 Premature caesarean section or not. rupture of 200 membranes References 8 1. Cluver C, Novikova N, Hofmeyr GJ, Hall Fetal distress DR(2010). Maternal position during caesarean 0.00% 20.00% 40.00% section for preventing maternal and neonatal complications (Review).The Cochrane
Graph.2 Most important factors of C/S. Collaboration. Published by JohnWiley & Sons, Ltd. 1-35. So, previous cesarean section changes with an 2. Dadhwal V, Mittal S, Kumar S, Anandlakshmi average of approximately 36 % in the three years PN, Vimala N (2003). Vaginal Birth after Cesarean that we studied. While the mean of fetal distress Delivery: Variables affecting Outcome. JK is 17.3%, and premature rupture of membranes SCIENCE 5(1) 11-14. varies 12.3%. 3. De Sousa L, Rodarti PAC, Gomes FA, Spanó NAM, Jorge FCH (2009). Measurement and In same studies which describe the reasons of characteristics of post-cesarean section pain and rising trend of cesarean births in worlwide we the relationship to limitation of physical realize that most contributing factors are: activities. Acta Paul Enferm 22(6):741-747. previous cesarean section, dystocia, transverse 4. Gliozheni Orion (2008). Cesarean Section – presentation of fetus and of course fetal distress Where are we goning?. Bulletin of Medicine 6 . As well as in our study we find some similar Science. Supplement 39(3). 16-19. factors contributing in cesarean section rate as 5. Jani RS, Munshi DS (2013). NHL Journal of are: previous cesarean section, fetal distress and Medical Sciences 2(2).59-63. premature rupture of membranes. 6. Kaur J, Singh S, Kaur K(2013). Current trend of caesarean sections and vaginal births. Pelagia Conclusions Research Library. Advances in Applied Science In our study (for years 2008-2010), we found that Research 4(4):196-202 the incidence of cesarean delivery is 7. Khawaja M , Jurdi R , and Kabakian-Khasholian approximately 35.4%. The factors that T (2009). Cesarean Section.US National Library of contributed more in the rising trend of cesarean Medicine Natioanl Institutes of Health. section are: previous cesarean section, fetal 8. Kuguoglu S, Yildiz H, Tanir Meltem K, distress, premature rupture of membranes. In Demirbag BC (2012). Breastfeeding After a some cases we found the voluntary of woman Cesarean Delivery. www.intechopen.com 122- making decision in favor of cesarean section. So it 151 is important to provide detailed information 9. Liu NH, Mazzoni A, Zamberlin N, Colomar M, about cesarean delivery before decision of the woman. Discussing for the complications that can Chang OH, Arnaud L, Althabe Fand Belizán JM accompany it, and high cost it has for maternity. (2013). Preferences for mode of delivery in Based on some several studies conducted US, the nulliparous.Argentinean women: a qualitative increasing number of cesarean delivery is due to study" Reproductive Health Journal.
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10. Parthasarathy S, Rajah C (2011). Feasibility of experienced cesarean section and obstetric care early breast feeding after caesarean section. Sri at a public maternity hospital in ribeirao preto. Lanka Journal of Child Health 40, 11-12 Text Context Nursing, Florianópolis, 21(2): 418- 11. Perez ER, Maulen RI, Dewey KG(1996). The 426. Association between Cesarean Delivery and 14. Torloni MR, Daher S, Betrán AP, Widmer M, Breast-Feeding Outcomes among Mexican Montilla P, Souza JP, Merialdi M(2011). Portrayal Women. American Journal of Public Health June, of caesarean section in B azilia o e s 86(6) 832-836. magazines: 20 year review. BMJ 25 January. 12. RTI International-University of North Carolina. 15. TREFFERS PE (1993). The rising trend for Cesarean Delivery on Maternal Request. For caesarean birth. BMJ. 307, 1017-1018. Agency for Healthcare Research and Quality U.S. Department of Health and Human Services 540 Gaither Road Rockville, MD 20850. 13. Sanches NC, Mamede FV, Vivancos RB Z (2012). The profile of women who have
14 AKTET Vol. VIII, Nr 1, 2015 AKTET ISSN 2073-2244 Journal of Institute Alb-Shkenca www.alb-shkenca.org Revistë Shkencore e Institutit Alb-Shkenca Copyright © Institute Alb-Shkenca
NUTRITIONAL SUPPORT OF ADULT PATIENTS IN INTENSIVE CARE UNIT
VJOLLCA SHPATA1, ALMA NURÇE1, MANIKA KREKA1, XHENSILA PRENDUSHI1, ALKETA HOXHA1, ERGERTA KTONA1
1 Faculty of Medical Technical Sciences, University of Medicine of Medicine in Tirana, Albania *Corresponding author: Vjollca Shpata MD, PhD, Lecturer at Faculty of Medical Technical Sciences, University of Medicine in Tirana, Albania, Tel: 003552465298, e-mail: [email protected]
SUMMARY Background: In the patients of the ICU (intensive care unit), there is a delayed or inadequate nutrition support. The purpose of this study was to examine the relationship between energy balance and clinical outcome in critically ill patients. Methods: Prospective obse atio al stud o du ted i o se uti e patie ts sta i g da s i the i ed ICU of the Q“UT Mothe Te esa . E e g ala e as al ulated as e e g deli e i us ut itio al requirements. Results: Multiple regression analysis identified cumulated energy deficits as being independently associated with infectious complications, overall complications, the ventilator stay, ICU stay and with mortality. Conclusions: Negative energy balance cumulated during inadequate nutrition support was associated with a higher rate of infectious complications, mortality, longer ventilator stay and ICU stay. Our findings suggest the need for implementation of quality improvement measures by the healthcare team to enhance the provision of nutrition support to the patients of the intensive care unit.
Keywords: critically ill, nutritional support, enteral nutrition, parenteral nutrition, energy balance, morbidity and mortality.
INTRODUCTION protein balance observed in these patients Over 2 millennia ago Hippocrates, Father of [2,3]. Prevention of nutrient depletion during Medicine (460- BC , o e said If e ould nutritional support can eliminate the excess give every individual the right amount of morbidity and mortality associated with nourishment and exercise, not too little and not malnutrition. too much, we would have found the safest way to health . Vincent has emphasized the importance of Traditionally, nutrition support in the critically feeding the ICU patient in a simple but ill population was regarded as adjunctive care appeali g p eu o i : нA“T рUG нeedi g, designed to provide exogenous fuels to support Analgesia, Sedation, Thromboembolic the patient during the stress response. prophylaxis, Head end elevation, Ulcer Nutrition care is considered to be a basic and prophylaxis, and Glucose control) [4]. mandatory (essential) element of modern Prolonged hypocaloric feeding is associated intensive care treatment. Nutritional support with clinical complications; energy balance influences morbidity and mortality rates in should be calculated in the most ill patients. critically ill patients [1]. Administration of Underfeeding ICU patients for periods longer nutritional support is required in critically ill than a few days can cause unnecessary protein patients to limit the negative energy and losses, may lead to further nutritional Shpata et al. deterioration, and consequent complications infusions used for drug dilution and fluid (increased nosocomial infections, poor wound support). healing and respiratory muscle dysfunction) [5]. Energy balance was calculated as energy Particularly in the patients of the ICU, there is a delivery minus energy target, on daily basis. delayed or inadequate nutrition support [6,7,8]. Data were collected on energy delivery, and The purpose of the present study was: 1. To cumulated energy balance on discharge from evaluate the cumulated energy balance during ICU. Cumulated energy balance was calculated ICU stay. 2. To examine the relationship on discharge. Five levels of energy balance were between energy balance and clinical outcome considered for analysis: 1: 0 to – 5000 kcal, 2: - in critically ill patients. 5001 to -10000 kcal, 3: -10001 to -15000 kcal, 4: -15001-20000 kcal, 4: larger then -20000 kcal Material and methods [8]. The study was designed as a prospective Clinical follow-up: Duration of ICU stay and observational study, conducted in consecutive length of ventilator stay, total complications, patients stayi g da s i the i ed ICU of the infectious complications and ICU mortality were U i e sit рospital Ce t e Mothe Te esa of recorded. Infectious complications were Tirana, Albania, collecting data during 2010 and defined as sepsis or systemic inflammatory 2012. As nutrition support may only be relevant response syndrome [15], pneumonia, urinary to critically ill patients who remain in the ICU tract infection, central venous catheter sepsis, for a prolonged period of time, we examined and wound infection. Other complications the use of nutrition support in patients above were: post-operative (open abdominal wound, 18 years old, who remained in the ICU longer post-operative bleeding, anastomotic leak), than 4 days. neurological, respiratory, gastro-intestinal, Data were made anonymous for analysis. cardiovascular, hepatic failure (by SOFA), renal Patient data: Age, sex, weight, height, and BMI, failure (by SOFA) [16], and coagulation disorder. diagnosis and Acute Physiology and Chronic The duration of time in the ICU was defined as Health Evaluation (APACHE II) prognosis score the time from admission of patients until they [9] were recorded upon admission to the ICU. were ready for discharge. All patients were Nutritional status on admission was assessed followed clinically until leaving the ICU or death according to Nutritional Risk Screening 2002 and their outcome recorded. [ ]. The patie t ith a total s o e as considered at nutritional risk. Statistical analysis: Data are presented as the Determination of energy requirements: Indirect mean (SD: standard deviation) and ranges for calorimetry, despite being the gold standard for numerical variables, as number (n) or determination of energy requirements, remains percentage (%) for categorical variables. unavailable in the vast majority of ICUs [11]. Categorical data were analyzed using the Ch2 Predictive equations however over- or test. underestimate requirements [12]. Indirect Multiple linear and logistic regression analysis calorimetry studies have shown that, in most was used to analyze the effect of cumulated situations, a value of 25 kcal/kg/day can be energy balance on length of ICU stay, length of used to estimate energy requirements. This is ventilator stay, total complications, infectious also recommended by ESPEN [13,14]. As in our complications and mortality. clinic is not available indirect calorimetry, Statistical significance was considered at the energy target was set at 25 kcal/kg/day. le el of p . . Energy delivery: total delivery includes energy All tests were two tailed. SPSS statistical from enteral and parenteral feeds, from non- package version 15.0 was used to analyze the nutritional sources (glucose and gluco-saline data.
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Results 60000 Were studied a total of 432 patients that stayed in the ICU for more than 4 days. The mean age 50000 was 60.96 years old (16.20), with 56.48% (n = 40000 244) being male. According to NRS 2002 the prevalence of malnutrition risk at the time of 30000 ICU admission was 63.6% (65.81% in the 20000 surgical patients and 57.98% in the medical patients, p = 0.16). The mean APACHE II score 10000 was 18.07 (5.54). ICU length of stay was 9.34 0 days (8.23); mechanical ventilation lasted 2.17 1 2 3 4 days (4.34). Cancer was present in 98 patients, ICU stay:1-1st week,2-2nd week,3-3d week,4-4th week 22.7% of the cases. 313 patients (72.45%) were Figure 1. Cumulated energy deficit (in – kcal) post operative. according to the length of ICU stay in weeks During ICU stay 143 patients (33.1%) have had It did not find any association of negative ICU-acquired infections, 233 patients (53.9%) energy balance with the total number of have had complications. ICU mortality was complications (OR: 1.17; 95% CI: 0.965 - 1.41; p 28.7%. = 0.10). For the values of cumulated energy The days without feeding were characterized by deficit higher than -15000 kcal relative risk for the unintentional delivery of 150-200 kcal from complications was increased progressively. glucose infusions. All the stud s patie ts e e The regression analysis identified cumulated in negative balance at the end of their ICU stay. energy deficits during the ICU stay as being Energy deficit was lower during combined independently associated with mortality: OR = enteral and parenteral feeding. 1.29; 95% CI: 1.05 - 1.58; p = 0.014. Energy delivery was lowest during the first Energy deficit during the ICU stay correlated week and therefore the largest negative with ICU length of stay: F = 580.09, P < 0.001; balances were observed during the first week and the length of stay on mechanical (figure 1). ventilation: F = 116.95, P < 0.001 (table 1). Negative energy deficit was accompanied in all the patients by negative protein balance [- 68.9 Table 1. Relationship between clinical outcome ± 20.0 (71.5)] g protein/day. During their ICU and cumulated energy deficit during ICU stay by stay patients received [16.5 ± 17.14 (19)] g regression analysis protein/day, or 19.8% ± 20.9% (15%) of their protein daily requirements (the values are given Variable of outcome p F as mean ± standard deviation and median). ICU length of stay < 0.001 580.09 The regression analysis identified cumulated energy deficits during the ICU stay as being Complications 0.197 1.66 independently associated with ICU-acquired ICU-acquired infections < 0.001 85.59 infections: OR = 2.54; 95% CI: 1.98-3.26; p = Mechanical ventilation < 0.001 116.95 0.0000. length of stay A cumulated energy deficit above -10000 kcal is Mortality 0.014 6.14 associated with an increased risk for infections compared to the patients with cumulated energy deficit under -10000 kcal, RR = 1.87, 95% CI: 0.99-3.54, P = 0.05.
AKTET, Vol VIII, Nr 1, 2015 17 Shpata et al.
Discussions This study investigated the nutritional support Conclusions in 432 patients and showed that all patients This study confirms that negative energy were in negative balance at the end of their ICU balance cumulated during inadequate nutrition stay. Our study showed that negative energy support was associated with a higher rate of balance correlated with the infectious infectious complications, mortality, longer complications, longer stay on mechanical ventilator stay and longer ICU stay. ventilation, longer stay on ICU, and mortality, Our findings suggest the need for but not with the total number of complications. implementation of Guidelines for nutrition Some recent studies had shown that infectious support in critically ill patients, in order to are a classical complication of malnutrition and improve the clinical outcome of them. As the underfeeding [8,17]. The multiple regression budget for the ICU is limited, a major problem analysis showed that the cumulated energy remains underestimation of nutritional support balance of the ICU stay was the strongest and consequently an inappropriate nutrition predictor of prolonged ICU stay. The present support. Evidence of the impact of malnutrition study as other studies [8], confirms that and energy deficit in clinical outcome can negative energy balance cumulated during encourage policymakers about the importance inadequate nutrition support was associated of investing on nutritional support. with a higher rate of infections, complications, mortality, and longer ICU stay. References A recent study including 38 patients intubated 1. Giner M, Laviano A, Meguid MM, & Gleason at least 7 days suggested that large negative JR. In 1995 a correlation between malnutrition energy balance seems to be an independent and poor outcome in critically ill patients still determinant of ICU mortality in a very sick exists. Nutrition. 1996;12:23-29. medical population requiring prolonged acute 2. Faisy C, Guerot E, Diehl JL, Labrousse J, mechanical ventilation [18]. Also the present Fagon JY. Assessment of resting energy study showed that cumulated energy deficit is expenditure in mechanically ventilated patients. an independent risk factor on ICU mortality. Am J Clin Nutr 2003; 78:241-9 In our study we did not examine the 3. Weissman C, Kemper M, Hyman AI. relationship between the amount of protein Variation in the resting metabolic rate of administered and clinical outcomes, but all the mechanically ventilated critically ill patients. patients had protein deficit and energy deficit Anesth Analg 1992; 68: 457-61. was always associated with protein deficit. We 4. Vincent JL. Give your patient a fast hug (at have not studied the relation between caloric least) once a day. Crit Care Med. 2005;33:1225– intakes and outcome, but from the results of 9. the present study we can suggest that 5. Heidegger CP, Romand JA, Treggiari MM, attempting to meet caloric targets may be Pichard C. Is it now time to promote mixed associated with improved clinical outcomes in enteral and parenteral nutrition for the critically critically ill patients, as it was confirmed by ill patient? Intensive Care Med 2007;33(6):963– some studies [19]. Another study including 200 969 medical ICU patients, observed a reduction in 6. Heyland D, Cook DJ, Winder B, Brylowski L, length of mechanical ventilation associated Van deMark H, Guyatt G. Enteral nutrition in with improved nutritional support [20]. Based the critically ill patient: A prospective survey. on these findings we can suggest that Crit Care Med 1995; 23:1055-1060 attempting to meet caloric targets may be 7. Heyland DK, Schroter-Noppe D, Drover JW, associated with improved clinical outcomes in Jain M, Keefe L, Dhaliwal R, Day A. Nutrition critically ill patients [19]. support in the critical care setting: current
18 AKTET, Vol VIII, Nr 1, 2015 Shpata et al. practice in canadian ICUs-opportunities for 16. Vincent JL, de Mendonca A, Cantraine F, improvement? JPEN J Parenter Enteral Nutr Moreno R, Takala J, Suter PM, et al. Use of the 2003;27:74-83. SOFA score to assess the incidence of organ 8. Villet, S, Chiolero R, Bollmann M, Revelly J, dysfunction/failure in intensive care units: Cayeux M, Delarue J, et al. Negative impact of results of a multicenter, prospective study. hypocaloric feeding and energy balance on Working group on sepsis-related problems of clinical outcome in ICU patients. Clin Nutr the European Society of Intensive Care 2005;24(4):502-9 Medicine. Crit Care Med 1998;26:1793-800. 9. Knaus WA, Draper EA, Wagner DP, 17. Rubinson, L., Diette, G.B., Song, X., Brower, Zimmerman JE. APACHE II: a severity of disease R.G., Krishnan, J.A. Low caloric intake is classification system. Crit Care Med associated with nosocomial bloodstream 1985;13(10):818-29. infections in patients in the medical intensive 10. Kondrup J, Allison SP, Elia M, Vellas B, care unit. Crit Care Med. 2004;32:350–357. Plauth M. ESPEN Guidelines for Nutrition 18. Faisy C, Lerolle N, Dachraoui F, Savard JF, Screening 2002. Clin Nutr 2003; 22:415-421 Abboud I, Tadie JM, Fagon JY. Impact of energy 11. Stapleton RD, Jones N, Heyland DK. Feeding deficit calculated by a predictive method on critically ill patients: what is the optimal outcome in medical patients requiring amount of energy? Crit Care Med prolonged acute mechanical ventilation. Br J 2007;35:S535-S540. Nutr 2009; 101(7):1079-87. 12. Zauner A, Schneeweiss B, Kneidinger N, 19. Heyland DK, Naomi C, Andrew G. Optimal Lindner G, Zauner C. Weight-adjusted resting amount of calories for critically ill patients: energy expenditure is not constant in critically depends on how you slice the cake! Critical ill patients. Intensive Care Med 2006;32:428- Care Med 2011; 39(12):2619-2626. 434. 20. Barr J, Hecht M, Flavin KE, Khorana A, Gould 13. Kreymann KG, Berger MM, Deutz NEP, MK. Outcomes in critically ill patients before Hiesmayr M, Jolliet P, Kazandjiev G, et al. ESPEN and after the implementation of an evidence- guidelines on enteral nutrition: intensive care. based nutritional management protocol. Chest. Clin Nutr 2006; 25:210-223 2004;125(4):1446–57. 14. Singer P, Berger MM, Van den Berghe G , Biolo G, Calder Ph, Forbes A, et al. ESPEN Guidelines on Parenteral Nutrition: Intensive Conflict of interest statement care. Clin Nutr 2009;28:387-400 On behalf of all authors, it is hereby stated that 15. Bone RC, Balk RA, Cerra FB. Definitions for there is no conflict of interest regarding this sepsis and organ failure and guidelines for the paper use of innovative therapies in sepsis. The ACCP/SCCM Consensus Conference Committee. American College of Chest Physicians/Society of Critical Care Medicine. Chest 1992;101:1644- 1655.
AKTET, Vol VIII, Nr 1, 2015 19 AKTET ISSN 2073-2244 Journal of Institute Alb-Shkenca www.alb-shkenca.org Revistë Shkencore e Institutit Alb-Shkenca Copyright © Institute Alb-Shkenca
ISOLATION AND IDENTIFICATION OF SALMONELLA SPP., IN POULTRY FOR EGG PRODUCTION IN THE REGION OF SHTIME, LIPJAN AND FERIZAJ – KOSOVO
HYZER RIZANI , BESART JASHARI , PRANVERA CABELI , TANA SHTYLLA , SONILA COCOLI . Agricultural University of Tirana, Faculty of Veterinary Medicine, Tirana, Albania Food and Veterinary Agency, the Food and Veterinary Laboratory, Pristina, Kosovo Email: [email protected]
PËRMBLEDHJE Në këtë studim është hulumtuar prania bakterieve të gjinisë Salmonella spp. në shpendë për prodhimin e vezëve. Studimi është kryer në fermat dhe pularitë private në rajonin e Shtimës, Lipjanit dhe Ferizajit në Kosovë. Mostrat e prelevuar nga fecet, vezët dhe organet i janë nënshtruar metodës ISO 6579:2002, metodë standarde për zbulimin e Salmonella spp., ku me këtë rast janë hulumtuar gjithsej 312 mostra, ku 28 prej tyre ose 8.97% janë konfirmuar të jenë Salmonella spp. Përqindja më e madhe nga totali i shtameve të izoluara është paraqitur në rajonin e Lipjanit me 39.28%, në atë Shtimes 32.14% dhe Ferizajit 28.57%. Nga totali i shtameve të izoluara në këtë studim është konstatuar se numri më i madh është gjetur në mostrat e feceve, 18 shtame ose shprehur në përqindje 64.2%, ndërsa në vezë janë izoluar 7 shtame (25%) dhe në organe 3 shtame apo 10.7% ndaj totalit të izoluar. Fjalët çelës: ekspozimi mjekësor, doza e hyrjes sipërfaqësore, TLD
SUMMARY The study investigated the presence of bacteria Salmonella spp. gender in poultry for eggs production. The study was conducted in poultry and private farms in the region of Shtime, Lipjan and Ferizaj, Kosovo. Taken samples of feces, eggs and organs samples underwent in ISO 6579:2002 method, which is standard method for detection of the Salmonella spp., where 312 samples were investigated, 28 of them or 8.97% were confirmed to be Salmonella spp. The largest percentage of the total isolated strains is presented in Lipjan region with 39.28%, 32.14% in Shtime and 28.57% in Ferizaj. From the total number of isolated strains in this study, is illustrated that the largest number was found in feces samples 18 strains or 64.2% expressed in percentages, while in the eggs are isolated 7 strains (25%) and in organs 3 strains or 10.7 % of total isolation.
Key words: Salmonella spp, pathogens, poultry, serovars, strains
INTRODUCTION the main reservoir of infections caused by species Poultry in region of Shtime, Lipjan, Ferizaj and of Salmonella gender (Luiz et al., 2004). The wider in Kosovo, is the line that is developing infection enters through oral routes, causing in quickly, especially in the production of eggs and the most cases difficulty of inflammatory meat poultry. Modernization of poultry breeding processes of the digestive tract. The Salmonella industry has played a crucial role in not spreading typically recognized as zoonotic species, induced and transmitting sal o ella s i fe tio s in pathogens and are intracellular parasites. The poultry (VELGA et al., 2005). Poultry and their bacteria of Salmonella gender is belong to the products are often connected with the outbreak Enterobacteriaceae family with 2400 serovars. In of sal o ella s epide i s in animals and in poultry the most known types of Salmonella spp humans around the world. Poultry and farms are serovars are: Salmonella enteritidis, S.typhi, Rizani et al.
S.gallinarum, S.typhimurium, who also are the Salmonella A-67 omnivalent, Anti-Salmonella I (A- most significant agents of salmonellas food E) and Anti-Salmonella F-67. transited in humans (Popoff et al., 2004). Serotype is an important tool to understand the Results and Discussion epidemiology of infections caused by species of From this study, after analyzing 312 samples from Salmonella gender, which develops according to organs, eggs and feces of poultry for egg White Kaufmanns scheme(1920), and based on production, based on ISO 6579:2002 method, the discovery of H flagella antigen, somatic were isolated 28 strains of Salmonella gender or antigen O and the surface antigen Vi (Cabeli P., 8.97% of the total analyzed. The same results are 2006). also found in other researches that have been done in other countries of the world. While the Material and Methods same studies were conducted in Montreal The samples for isolation and identification of Canadas, where about 264 samples were species of the Salmonella gender were taken investigated, 8.7% of them were infected by from organs, eggs, feces from poultry and private Salmonella spp, whereas in the Mekong Delta farms, during January-April 2014 in the region of Vietnam, from 302 samples inspected, 7.9% were Shtime, Lipjan and Ferizaj. Totally were taken: 63 infected with salmonella spp. feces samples, 189 samples from internal organs (liver, spleen, intestine and cloaca ) and 60 egg Chart.1. Percentage of Salmonella spp., from samples. The isolation and identification is based the total of investigated samples on ISO 6579:2002 method, and was conducted at the Microbiological Laboratory of Food in the Percetentage Salmonella Food and Veterinary Agency of Kosovo. For Region Total of the total spp. diagnosis was used this material: BPW, RVS, BG- sample number agar, XLD-agar, TSI-agar, Salmonella LATEX TEST - Shtime 104 9 8.65% Oxoid England, Salmonella antiserum Siffin Berlin Lipjan 104 11 10.58% (Anti-Salmonella A-67 omnivalent, Anti- Ferizaj 104 8 7.69% Salmonella I (A-E ) and Anti-Salmonella F-67. 25 Total 312 28 8.97% gr. of feces were taken for each sample and transferred into 225 ml of BPW. 25 gr. of each egg (white, vitelus and eggshell) were transferred into 225 ml BPW richen field. 25 g. of organs (liver, spleen, intestines and cloaca) were planted in 225 ml BPW. All cultures were cultivated in thermostat at 370C for 18-24 hours. After incubation, 0.1 ml of the cultures were transferred into tubes with 10 ml RVS (selective richen field) and incubated for 24 hours at 41.5- 42 0C. Further crops were planted in the selected solid field BGA-agar and XLD-agar, than those were cultivated in the incubator for 24 hours at 37C. Five suspicious colonies were re-planted in Nutrien-agar and underwent biochemical Graphic 1: Percentage of Salmonella spp,, from confirmation tests using sugars, in TSI - agar 37C the total of investigated samples. for 24 hours. Biochemical evidences were followed by serological tests such as Salmonella LATEX TEST-OXOID and use of antiserum as Anti-
AKTET, Vol VIII, Nr 1, 2015 21 Rizani et al.
Strai Feces Egg (the Organs ( Graphic 2: Percentages of Salmonella spp, from Regi ns white,vit liver, isolated strains on Total elus and spleen, in bark) intestine Regi and cloaca) As might be seen from the chart and graphic on St % St % Str % above, higher presence of cases is presented in rai rai ain Lipjan region with 39.28%, further Shtime region ns ns s with 32.14% and 28.57% in Ferizaj. Shti 9 6 66.6 2 22. 1 11.1 In chart.3 are given the results of Salmonella spp me % 2% % expressed in percentages, in analyzed samples: feces, eggs and organs. Lipja 11 7 63.6 3 27. 1 9.1% n % 2% Chart.3. Percentages of Salmonella spp, in Feriz 8 5 62.5 2 25 1 12.5 feces, eggs and organs aj % % % The above results indicate that from 28 isolated Total 28 18 64.2 7 25 3 10.7 Region Strains Salmonella Percentage % % % Total spp. %
Shtime 28 9 32.14% Chart.2. Percentages of Salmonella spp. from the total of isolated strains Lipjan 28 11 39.28% The above results show that from 312 feces Ferizaj 28 8 28.57% samples, eggs and organs analyzed, 8.97 % of strains the highest percentage of samples are them belong to the species of Salmonella gender, observed into feces, where 18 strains of indicating the presence of the infection in the three regions: Shtimje, Lipjan and Ferizaj. In the chart and graphic below in percentages are given species of isolated Salmonella gender comparing with total number, analyzed in the studied regions.
Photo.1. Salmonella spp.of in TSI-agar
PERCENT OF SALMONELLA Spp, FROM TOTAL OF THE STRAINS ISOLATED Salmonella spp. are isolated or 64.2% of the total , in eggs are isolated 7 strains of Salmonella spp. or 25% of the total ,and in the organs are isolated only 3 strains of Salmonella spp. or 10.7%. This study will continue further by conducting of biochemical tests, which will be followed by serological tests such: Salmonella LATEX TEST- OXOID, and use of antiserums as Anti-Salmonella A-67 omnivalent, Anti-Salmonella I (A-E) and anti-
22 AKTET, Vol VIII, Nr 1, 2015 Rizani et al.
Salmonella F-67, which will facilitate further 5. Luiz Ade F, M. F. (2004, August). identification of the Salmonella gender species http://www.ncbi.nlm.nih.gov. Retrieved present in eggs, feces and organs samples in the from.http://www.ncbi.nlm.nih.gov/pubmed/155 poultry of Shtime, Lipjan and Ferizaj regions. 43409. 6. Messier, S. Q. (1992). PREVALENCE OF Conclusion SALMONELLA SPP., CAMPYLOBACTER SPP. AND From 312 analyzed samples by ISO 6759:2002 LISTERIA SPP. IN RING-BILLED GULLS (LARUS method, in three studied regions was found a DELAWARENSIS). October 1992, Vol. 28, No. 4, prevalence of Salmonella spp, about 28 strains or pp. . Journal of Wildlife Diseases , No. 4, pages 8.97% of the total analyzed samples. 526-531. The highest prevalence of Salmonella spp, has 7. Programme, J. F. (2010). CODEX the region of Lipjan with 39.28%, than Shtime ALIMENTARIUS COMMISSION. Rome,Italy: 32.14% and 28.57% in Ferizaj to the overall total. FAO/WHO. The highest percentage is found in feces, 8. Popoff YM: Institut Pastuer France: Antigenic where18 strains were isolated or 64.2%, in eggs formula Salmonella serovar, 9 edition WHO. were isolated 7 strains or 25% and in organs were Collaborating Centre for Reference and Research isolated 3 strains with 10.7% on Salmonella. 2007. Comparing the presence of Salmonella spp, 9. Report of the Task Force om zooneses Data with the total number of isolated strains, results Collection on the Analysis of the baseline study that obtained feces from Shtime region has a on the prevalence of Salmonella in holdings of o higher percentage with 66.6%, followed by Lipjan laying henflocks of Gallus gallus 1 Question N 63.6%, and finally Ferizaj with 62.5 %. EFSA Q-2006-039 The EFSA Journal 2007.97. Comparing the presence of Salmonella spp, 10. Salm-Surv, G. (2003). Laboratory Protocols. In with the total number of isolated strains, comes R. S. Hendriksen, Laboratory Protocols Level 1 out that in eggs, the percentage of salmonella Training Course Identification of Salmonella. infection in Lipjan region is the highest with Global Salm-Surv. 27.2%, than in Ferizaj with 25%, and Shtime 11. Tran TP(1), L. T. (2004 Aug). Prevalence of 22.2%. Salmonella spp. in pigs, chickens and ducks in the The comparison of the Salmonella spp, Mekong Delta,. J Vet Med Sci , 66(8):1011-4. presence with the total number of isolated 12. Waltman WD, Mallison ET: Isolation of strains in organs show that samples taken from Salmonella from poultry tissue and Ferizaj have the highest percentage with 12.5%, environmental samples national wide survey. followed by Shtime with 11.1% and Lipjan 9.1%. Avian Diseases, 1995.39,45-54. 13. Vegle H, C. A. (2005). Emergence of Literature Salmonella epidemics: The problem realted to 1. Dr. Jose C. Jimenez (Edited by), (2012) Salmonella Enterica serotype Enteriditis and Biochemical Testing, 4. multiple antibiotic resistance in other major 2. Çabeli, P. a. (2006). Bakteriologjia-Mykologji serotypes. Veterinary Research 36,267-288. Veterinare. Tiranë: Universiteti Bujqësor i Tiranës. . 3. F. Polo a, M. F., & *, I. I. (2006, January 17). http://onlinelibrary.wiley.com. Retrieved from http://onlinelibrary.wiley.com/doi/10.1111/j.157 4-6968.1998.tb12919.x/references. 4. García C, S. J.-G. (2011, Jul). http://www.ncbi.nlm.nih.gov. Retrieved from.http://www.ncbi.nlm.nih.gov/pubmed/216 73175.
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.AKTET ISSN 2073-2244 Journal of Institute Alb-Shkenca www.alb-shkenca.org Revistë Shkencore e Institutit Alb-Shkenca Copyright © Institute Alb-Shkenca
EVALUATION OF LUSHNJA AQUIFER GROUNDWATER THROUGH THE USE OF ENVIRONMENTAL ISOTOPES VLERËSIMI I UJËRAVE NËNTOKËSORE TË AKUIFERIT TË LUSHNJËS NËPËRMJET PËRDORIMIT TË IZOTOPEVE MJEDISORE
1IRIS BAKIRI, 2ARBEN PAMBUKU, 3EDUARD ANDONI, 1Institute of Applied Nuclear Physics, University of Tirana 2Department of Hydrogeology, Albanian Geological Survey 3Departament of Chemistry, Faculty of Natural Sciences, University of Tirana E-mail: [email protected]
PËRMBLEDHJE Akuiferi i ultësirës së Lushnjës midis lumenjve Shkumbin e Seman është studiuar për shfrytëzimin e ujërave nëntokësore për furnizimin e popullsisë me ujë të pijshëm. Zhvillimi i zonës dhe ndryshimet klimaterike që kanë ndodhur gjatë viteve të fundit e kanë bërë të domosdoshëm rivlerësimin e këtij akuiferi. Në këtë artikull bëhet një vlerësim mbi prejardhjen e ujërave nëntokësore të akuiferit te Lushnjës nëpërmjet matjes së izotopeve stabël mjedisore. Përveç përcaktimeve hidrokimike të përdorura deri më sot për studimin e zonës, u kryen edhe përcaktime të raporteve izotopike të oksigjenit-18 dhe deuteriumit. Për këtë qëllim u morën mostra uji nga pus 2 shpi e, puse të dë tua a ga i di idë p i atë dhe ost a eshjesh. I te ali i pë ë jes izotopike pë δ H varion 18 nga - . ‰ de i - . ‰ dhe pë δ O intervali i përbërjes izotopike të mostrave varion nga - . ‰ de i - . ‰. Fjalët çelës: Hidrogjeologji, hidrologji izotopike, oksigjen-18, deuterium, ujëra nëntokësore.
SUMMARY The aquifer of the Lushnja lowland which lies between the river Shkumbin and the river Seman has been studied in order to evaluate the use of groundwater in supplying the population with drinking water. Due to the changes that this region has been through, it is necessary to expand the study of this aquifer. In this paper it is discussed about the origin of the Lushnja aquifer groundwater by environmental isotopes measurements. In addition to the hydrochemical analyses, were determined the isotopic composition of the stable isotopes of hydrogen and oxygen. This study was conducted on water samples collected from boreholes, private wells and precipitations. The isotopic 2 18 o positio i te al of the easu e e ts of δ H ranges from - . ‰ to - . ‰ a d fo δ O the isotopic composition interval of the measurements ranges from - . ‰ to - . ‰. Key words: Hydrogeology, isotopic hydrology, oxygen-18, deuterium, groundwater
INTRODUCTION of oxygen and hydrogen isotopes that constitutes Environmental isotopes are very important for water. the investigation of the hydrological cycle. They The stable isotopes ratios 2H and 18O in water offer information concerning the origin and sa ples a e e p essed i te s of so alled δ- movement of groundwater. alues a d epo ted i pe il ‰ elati e to The isotopic ratios of oxygen and hydrogen in VSMOW2 (Vienna Standard Mean Ocean Water) water are unique and often considered as ate sta da d ‰ [ ; ]: fi ge p i ts , thus due to diffe e t p opo tio s