Medical Assotiation of Zenica-Doboj Canton; Address

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Printing supported by the Federal Ministry of Education and Science (Federalno ministarstvo obrazo- vanja i nauke, BiH) Medicinski Glasnik Official Publication of the Medical Association of Zenica-Doboj Canton Bosnia and Herzegovina

EDITOR-IN-CHIEF Selma Uzunović Zenica, Bosnia and Herzegovina

MANAGING EDITOR Tarik Kapidžić Zenica, Bosnia and Herzegovina

EDITORS

Adem Balić, Tuzla, Bosnia and Herzegovina Dubravka Bartolek, Zagreb, Croatia Branka Bedenić, Zagreb, Croatia Asja Čelebić, Zagreb, Croatia Josip Čulig, Zagreb, Croatia Filip Čulo, Mostar, Bosnia and Herzegovina Jordan Dimanovski, Zagreb, Croatia Branko Dmitrović, Osijek, Croatia Ines Drenjančević, Osijek, Croatia Harun Drljević, Zenica, Bosnia and Herzegovina Davorin Đanić, Slavonski Brod, Croatia Lejla Ibrahimagić-Šeper, Zenica, Bosnia and Herzegovina Tatjana Ille, Belgrade, Serbia Vjekoslav Jerolimov, Zagreb, Croatia Mirko Šamija, Zagreb, Croatia Sven Kurbel, Osijek, Croatia Snježana Pejičić, Banja Luka, Bosnia and Herzegovina Belma Pojskić, Zenica, Bosnia and Herzegovina Besim Prnjavorac, Tešanj, Bosnia and Herzegovina Asja Prohić, Sarajevo, Bosnia and Herzegovina Velimir Profozić, Zagreb, Croatia Radivoje Radić, Osijek, Croatia Amira Redžić, Sarajevo, Bosnia and Herzegovina Suad Sivić, Zenica, Bosnia and Herzegovina Sonja Smole-Možina, Ljubljana, Slovenia Vladimir Šimunović, Mostar, Bosnia and Herzegovina Adrijana Vince, Zagreb, Croatia Jasmina Vraneš, Zagreb, Croatia Živojin Žagar, Zagreb, Croatia

Secretary: Tatjana Žilo; Proofreaders: Aras Borić (Bosnian, Croatian, Serbian), Glorija Alić (English) MEDICINSKI GLASNIK

Official Publication of the Medical Association of Zenica-Doboj Canton, Bosnia and Herzegovina Volume 11, Number 2, August 2014 Free full-text online at: www.ljkzedo.com.ba, and www.doaj.org (DOAJ, Directory of Open Access Journals)

Editorial 248 Academic community in a developing country: Bosnian realities Enver Zerem Original 252 Vascular geometry of vertebrobasilar tree with and without aneurysm Alma Efendić, Eldar Isaković, Jasmin Delić, Anel Mehinović, Asmir Hrustić article 258 Values of D-dimer test in the diagnostics of pulmonary embolism Vildana Arnautović-Torlak, Belma Pojskić, Hasan Žutic, Admir Rama 264 Talc pleurodesis in pleuropulmonary diseases treatment Nusret Ramić, Goran Krdžalić, Nermin Mušanović, Ferid Konjić, Šefika Umihanić, Suada Ramić, Jasminka Mustedanagić-Mujanović, Farid Ljuca, Enver Zerem 270 Cutaneous silent period in the assessment of small nerve fibers in patients on hemodialysis Merita Tirić-Čampara, Miro Denišlič, Emir Tupković, Salih Tandir, Jasminka Djelilović Vranić, Azra Alajbegović, Refet Gojak, Jasem Y. Al-Hashel, Halima Resić 276 Increased counts and degranulation of duodenal mast cells and eosinophils in functional dyspepsia- a clinical study Shijun Song, Yan Song, Haishan Zhang, Gaiqin Li, Xiaopei Li, Xiaohong Wang, Zhen Liu 283 Clinical case series of nine patients with tuberculousmeningitis in the Clinical Centre of Vojvodina, Novi Sad, AP Vojvodina, Serbia 2001-2010 Radoslava Doder, Grozdana Čanak, Sandra Stefan Mikić, Siniša Sević, Aleksandar Potkonjak, Dragan Doder, Vuk Vračar 289 The role of induced pluripotent stem cell (IPs) in the transplantation of glaucoma Mingshui Fu, Bijun Zhu, Xiaodong Sun, Dawei Luo 295 Occurrence and morphological characteristics of cataracts in patients treated with general steroid therapy at Cantonal Hospital Zenica Alma Čerim, Admira Dizdarević, Belma Pojskić 300 Importance of accurate diagnosis in benign paroxysmal positional vertigo (BPPV) therapy Siniša Maslovara, Tihana Vešligaj, Silva Butković Soldo, Ivana Pajić-Penavić, Karmela Maslovara, Tea Mirošević Zubonja, Anamarija Soldo 307 Evaluation of the surgical treatment of diabetic foot Amir Denjalić, Hakija Bečulić, Aldin Jusić, Lejla Bečulić 313 Serum Levels of ICAM-1, VCAM-1 and E-selectin in early postoperative period and three months after eversion carotid endarterectomy Hrvoje Palenkić, Tatjana Bačun, Anita Ćosić, Ivo Lovričević , Drago DeSyo, Ines Drenjančević

320 Surgical treatment of female stress urinary incontinence: retropubictransvaginal tape vs. transvaginal tape obturator Aleksandar Argirović, Cane Tulić, Rajka Argirović, Uroš Babić, Biljana Lazović, Ðorđe Argirović 326 Clinical relevance of IL-10 gene polymorphism in patients with major trauma Vasilije Jeremić, Tamara Alempijević, Srđan Mijatović, Vladimir Arsenijević, Nebojša Ladjevic, Slobodan Krstić 333 Relationship between ultrasound criteria and voiding ultrasonography (VUS) in the evaluation of vesicoureteral reflux (VUR) Sandra Vegar-Zubović, Spomenka Kristić, Aladin Čarovac, Irmina Sefić-Pašić, Amra Džananović, Danka Miličić-Pokrajac, Lincender Lidija 339 Clinical importance of independent prognostic factors for renal parenchymal carcinoma and a possibility of predicting the treatment outcome Harun Hodžić, Mustafa Bazardžanović, Samed Jagodić, Mustafa Hiroš, Benjamin Kulovac, Mirza Oruč, Mersiha Mahmić-Kaknjo 345 Ovarian cancer in the Federation of Bosnia and Herzegovina during the 1996 – 2010 period Feđa Omeragić, Azur Tulumović, Hasan Karahasan, Larisa Mešić Ðogić, Ermina Iljazović, Alija Šuko, Adnan Brčić 350 The incidence of dyslipidemia (hypertriglyceridemia and hypercholesterolemia) in patients treated with the new generation of antipsychotic drugs compared to conventional therapy Belma Sadibašić, Amra Macić-Džanković, Azra Šabić, Bajro Torlak, Gordana Lastrić, Amir Ćustović 356 Influences of socio-demographics on depression and anxiety in patients with complex partial and tonic-clonic seizures Duru Saygın Gülbahar, Hasan Huseyin Karadeli, Ömer Esenkaya, Muhammed Emin Ozcan, Gulistan Halac, Talip Asil 361 Auditory risk behaviours and hearing problems among college students in Serbia Milenko Budimčić, Kristina Seke, Slavica Krsmanović, Ljubica Živić 367 Association between high levels of stress and risky health behavior Amira Kurspahić-Mujčić, Feriha Hadžagić-Ćatibušić, Suad Sivić, Emina Hadžović 373 Association between somatic diseases and symptoms of depression and anxiety among Belgrade University students Mirjana Stojanović-Tasić, Anita Grgurević, Jovana Cvetković, Uglješa Grgurević, Goran Trajković

379 Is denture stomatitis always related with candida infection? A case control study Jovan Marinoski, Marija Bokor-Bratić, Miloš Čanković 385 Prevalence of periodontal diseases in North Herzegovina Ružica Zovko, Domagoj Glavina, Mirela Mabić, Stipo Cvitanović, Zdenko Šarac, Ante Ivanković Author’s 391 Evaluation of quality of life after radical prostatectomy-experience in Serbia Svetomir M. Dragićević, Snežana P. Krejović-Marić, Bajram H. Hasani correction Author’s 392 Hydronephrosis during pregnancy: how to make a decision for the time of intervention? Mehmet Nuri Bodakci, Namık Kemal Hatipoglu, Ali Ozler, Abdulkadir Turgut, Cihad Hamidi, Nebahat affiliation Hatipoglu, Bircan Alan5 correction

Medicinski Glasnik is indexed by MEDLINE, EMBASE (Exerpta Medica), EBSCO, Scopus, and Di- rectory of Research Journals Indexing (DRJI)

247 EDITORIAL

Academic community in a developing country: Bosnian realities

Enver Zerem

Department of Medical Sciences, Academy of Sciences and Arts, Bosnia and Herzegovina

ABSTRACT

This paper deals with problems of the academic community in Bo- snia and Herzegovina. This is a country in transition where a complex interrelation between politics and the academic community negatively impacts functioning of the academic community. Inabi- lity to implement internationally recognized criteria in the process of acquisition of scientific and academic titles has been a crucial problem. This paper seeks to identify causes of the community’s perplexed state; its failure to carry out the quintessential reforms in higher education based on the implementation of internationally recognised criteria and the lack of responsibility among those who make political decisions, which are important for the development and advancement of the academic community. Corresponding author: Keywords: internationally recognized criteria, academic commu- Enver Zerem nity, autonomy of university Academy of Sciences and Arts of Bosnia and Herzegovina Bistrik 7, 71000 Sarajevo, Bosnia and Herzegovina Phone: +387 33 560 700; Fax: +387 33 560 703; E-mail: [email protected]

Original submission: 04 February 2013; Revised submission: 31 March 2014; Accepted: 18 April 2014.

Med Glas (Zenica) 2014; 11(2):248-251

248 Zerem et al. Academic community in a developing country

Bosnia and Herzegovina is a country in transition of our ćevapčići which we offer on those occasi- currently facing a serious economic crisis who- ons, yet we do not have competitive presentati- se origin is multifactorial and it certainly is not ons at the same meetings nor do we have papers solely related to the war (1992-95). Quite some that could qualify for a peer-reviewed journal. time has passed since the war ended, yet no signi- Our academic community keeps pointing at the ficant progress has been made so far. Moreover, lack of investment in science and accentuates this the prospects of things changing for the better are as the main cause of its poor status. The authoriti- rather poor. We, the common people, do not make es in our academic community gladly discuss the vital decisions in the Parliament, which are sup- so-called “Bologna process” reform, the successes posed to pave our future. However, this does not that have been achieved in this regard and the im- prevent us from writing about the phenomena that portance of our university autonomy (1,2). Howe- afflict us and depend on us Bosnians and Herze- ver, the problems faced with on this path are almost govinians, and not on global or local politics. always classified as those of a lack of financial -re Tracing back the history of human progress and sources, a lack of space and equipment, understaf- achievements, the inevitable question arises how fing etc. The root causes are almost never traced come the ancient civilizations such as Egypt, back to the lack of internationally recognized cri- India and Greece are on a rather low economic teria in the acquisition of academic titles and choi- level nowadays, unlike the developed West. The ces in scientific and educational titles (1,3). At the USA has a history of no more than 200 years and same time, the number of master’s degrees, PhDs yet it rules the world. Switzerland produces some and academic titles does not reflect the reality of of the best chocolates and yet does not have a us being on the scientific periphery – on the con- single cocoa tree! Perhaps some would say they trary – according to these, we seem to be one of the are better organized, but the question is - why!? world’s superpowers! Also, wider public opinion, They are humans just like the rest of us! as well as that of the academic community, is that People in B&H have had enough of being proud we have quality professors and scholars, but lack of the ability to laugh at their own expense with funds for them to produce scientific achievements. a ‘stupid Bosnian’ usually ending up as a butt of Thus, we find ourselves in an absurd situation whe- every joke. We have had enough of being bran- re we are a country with an enormous number of ded by our national delicacy ‘ćevapčići’ (a type scientists, in comparison with our miserable and of grilled kebab) as our prime identifying feature. almost non-existent scientific production. It is even We have the capacity to offer much more sop- more absurd that a large number of these “scienti- histicated product to the world market than that. sts” have somehow confirmed their scientific cre- Our ‘’product’’ is Mr. Danis Tanovic, the Oscar- dibility. In order to reach the ‘title throne’ as quic- winning director, who claimed the prestigious kly as possible we have abandoned the pursuit of award back in 2002 with the movie ‘No Man’s the more demanding international scientific value Land’, and the world acclaimed writer and No- standards and have applied our own ‘well known’ bel Laureate Ivo Andric. It is obvious that we local measures (meters and kilograms) in order to have the capacity to be competitive on today’s evaluate our quasi-scientific accomplishments. All world market - those winners did not come from this has brought us to the paradoxical state of com- nowhere. They were able to learn how to read plete non-compatibility with the internationally re- and write in Bosnia and Herzegovina, they atten- cognized scientific value scale. When we say that ded Bosnian schools, receiving knowledge from our “scientists” have produced a hundred million their teachers, parents - Bosnian people, eventu- kilograms of “science” no one in the world knows ally reaching the stars. So, what is preventing us what it means according to the world’s scientific from having many more successful Bosnians and parameters: if it is a weight which requires sophi- Herzegovinians? We are confident that it is not sticated logistics and massive storage space or just only nationalism and politics; there must be so- small change that can fit into one’s pocket. mething within ourselves! So, going back to the important issue of the auto- We are proud when we host our colleagues from nomy of universities, which is supposed to be the abroad at various international scientific meetin- highest accomplishment of modern civilization, gs taking place in our country, and they are fond sadly, the Bosnian example favours mediocre beha-

249 Medicinski Glasnik, Volume 11, Number 2, July 2014

viour, since the vast majority of opinion givers and margin to the level they consider appropriate, decision makers have mediocre capacity. It is not in without having to adhere to any internationally their interest to change anything - they simply rule! recognized criteria (1). The Dayton Agreement of 1995 stipulates that hi- Therefore, graduate and post-graduate studies gher education is the responsibility of the cantons must improve in terms of teaching young people and entities. This has led to very diverse regula- in B&H about the methodology of scientific rese- tions in higher education, with practically 13 di- arch, which should be followed by a reform in the fferent higher education systems. Some cantons academic community. There should be someone have no legislation on higher education, despite appointed, such as a High Representative from the having several universities. Most politicians are international community (similar to the situation in favour of maintaining such a system in order to in politics), in order to impose and implement the keep the power within their administrative units, application of internationally recognized criteria and so remain almost completely independent of for pursuing teaching careers. This approach wo- the other parts of the country. At the same time uld have a direct impact on the quality of Masters they forget that the bad situation in education in of Science and PhD degrees, making them in- one part of the country has a direct and negative ternationally compatible according to European impact on the entire country, as diplomas obta- standards. This would eventually produce a hi- ined in one part the country do not have to be gher level of general knowledge and build a good officially valorised in another. foundation for economic development. The sine In Bosnia and Herzegovina the academic com- qua non in achieving this is to promote a change munity seems to interpret the term ‘autonomy of in people’s minds. However, such a change sho- universities’ as the right to self-govern and lay uld be encouraged as we do not have much more down their own rules according to which they time to waste. Sometimes the change needs to be want to operate. This includes determining their imposed via administrative decisions and that is own work quality standards, as well as the crite- what is badly needed nowadays in B&H. Witho- ria defining teaching staff competency. Formally, ut the introduction of internationally recognized no one on ‘the outside’ has the right to decide scientific criteria in the evaluation of scientific what level of quality needs to be achieved. In research, and the coordination of academic pro- practice this means that a deal is made between gress in accordance with these criteria, even the politics and the university where politics infor- current, pitiful investments in science are essen- mally influences the decisions of the latter by tially useless spending of the poor taxpayer’s mo- appointing ‘its own people’ as university staff, ney. Statements claiming that even international thus making the selection according to their pure criteria are not perfect and that they also have political suitability rather than scientific criteria. their flaws are just lame (4-6) excuses to retain Those appointed members of the university soon the status quo. Indeed, no rule is ideal and may become people of power within the academic co- be subject to change. However, from where we mmunity, who then, by linking themselves to the now stand, we first need to draw closer to be able more powerful people within the academic com- to enter the competition and clearly see the target munity, use their influence to impact political de- board. Only then can we start to discuss the desi- cisions. Therefore, university autonomy interpre- gn of the ‘bow and arrow’. ted in this way becomes its own goal, completely This paper talks about the problems of the aca- neglecting the internationally recognized criteria demic community in B&H and yet when I talk to in determining the quality of its performance. my colleagues from the neighbouring countries, It seems that the international community, in they seem to be complaining about similar pro- charge of implementing the reforms in higher blems (7,8). Perhaps all those countries in tran- education, has not understood the Bosnian si- sition share the same problem: the interrelation tuation entirely. Forcing the issue of university between politics and the academic community autonomy in the way it is being done in our case having a negative impact on the latter? does not exclude the influence of politics. In fact, Perhaps we all share similar ingredients yet differ it creates space for those decision makers within in the way we use them and choose them for our the academic community to lower the criteria local delicacies?

250 Zerem et al. Academic community in a developing country

REFERENCES 1. Zerem E. Right criteria for academia in Bosnia and 4. Marušić A, Marušić M. Authorship criteria and aca- Herzegovina. Lancet 2013; 382:128. demic reward. Lancet 1999; 353:1713-14. 2. Tanović L. Towards the European higher education 5. Hall T. The haunted forest: a ghost story. Lancet area Bologna process. http://www.ehea.info/Uplo- 1998; 352:1230. ads/Documents/National_Report_Bosnia-Herzego- 6. Horton R. Publication and promotion. A fair reward. vina_05.pdf (17 October 2013) Lancet 1998; 352:892. 3. Brennan KZ. The Bologna Process in Bosnia-Her- 7. AcademLink. http://www.academlink.com (20 Mar- zegovina: Strengthening, Re-Branding, or Undermi- ch 2014) ning Higher Education? In: 1st International Confe- 8. Klaic B. Analysis of scientific prodictivity in Croatia rence on Foreign Language Teaching and Applied according to the Science Citation Index, Social Sci- Linguistics (FLTAL), Sarajevo/Bosnia and Herzego- ence Citation Index, and Arts & Humanities Citation vina, 5-7 May 2011. http://eprints.ibu.edu.ba/682/1/ Index for the 1980-1995 period. Croat Med J 1997; FLTAL%202011%20Proceed%C4%B1ngs%20 38:88-98. Book_1_p1315-p1320.pdf (7 May 2011)

Problemi akademske zajednice zemalja u razvoju – bosanski primjer Enver Zerem Odjeljenje medicinskih nauka, Akademija nauka i umjetnosti Bosne i Hercegovine, Sarajevo, Bosna i Hercegovina SAŽETAK

U članku se razmatraju problemi s kojima se suočava akademska zajednica u Bosni i Hercegovini. Riječ je o zemlji u periodu tranzicije, s kompleksnim vezama između politike i akademske zajednice, koje imaju snažan negativni utjecaj na njen rad. Nemogućnost implementacije međunarodno priznatih kriterija u procesu stjecanja akademskih i naučnih titula krucijalni su problem akademske zajednice. U članku se nastoje identificirati uzroci konfuznog stanja u akademskoj zajednici, zastoja u implementaciji suštinskih reformi u visokom obrazovanju zasnovanih na implementaciji međunarodno priznatih kriterija i nedostatku odgovornosti među onima koji donose političke odluke bitne za napredak i razvoj akademske zajednice.

Ključne riječi: međunarodno priznati kriteriji, akademska zajednica, autonomija univerziteta

251 ORIGINAL ARTICLE

Vascular geometry of vertebrobasilar tree with and without aneurysm

Alma Efendić1, Eldar Isaković2, Jasmin Delić2, Anel Mehinović3, Asmir Hrustić3

1Department of Radiology, Cantonal Hospital Zenica, 2Department of Anatomy, Medical School, University of Tuzla, 3Clinic of Orthope- dics and Traumatology, Clinical Centre, University of Tuzla; Bosnia and Herzegovina

ABSTRACT

Aim To examine a possible relationship between the variable vascular geometry of vertebrobasilar joint angle and basilar bifurcation angle as well as the diameters of these blood vessels.

Methods The study included 60 adult patients, of both sexes, who were divided into two groups. One group (30) consisted of patients without aneurysm of vertebrobasilar tree, and another group (30) of patients with aneurysm. The patients were examined using Magnetic Resonance Imaging (MRI) and Computed Tomography Angiography (CTA) of head and neck.

Results In the group without aneurysm of vertebrobasilar tree, in 14 (46.6%) patients diameters of the right and the left vertebral artery were approximately the same. The average value of the an- Corresponding author: gle of junctions of vertebral arteries was 65.43°, and the average Alma Efendić angle of basilar bifurcation was around 94.53°. In the group with Department of Radiology, aneurysm of vertebrobasilar tree, in 12 (40%) patients diameters Cantonal-Hospital Zenica of the right and the left vertebral artery were also approximately Crkvice 67, 72000 Zenica, the same. The average angle of junction of vertebral arteries was Bosnia and Herzegovina 68.46º, and the average angle of basilar bifurcation was 121.93º. Phone:+387 32 209 422; Conclusion Anatomic variations of the vertebrobasilar joint angle Fax: +387 32 226 575; and basilar bifurcation angle, as well as the diameters of these blo- E-mail: [email protected] od vessels, are some of the factors in the increase of the incidence of aneurysm in this anatomic area.

Key words: vertebral artery, basilar artery, anatomy

Original submission: 13 March 2014; Revised submission: 19 May 2014; Accepted: 05 July 2014.

Med Glas (Zenica) 2014; 11(2):252-257

252 Efendić et al. Vascular geometry of vertebrobasilar tree

INTRODUCTION known as Virchow’s Triad (11,12). Many studies have shown a high incidence of atherosclerotic Vertebral artery, a branch of subclavia artery, pa- lesions in the arterial bifurcation region (13,14). sses among threads of brachial plexus in the neck Variations of the vertebrobasilar joint angle and region, and passing through the openings in the basilar bifurcation angle, as well as the diameters transverse processes of cervical vertebrae comes of these blood vessels most likely affect the con- to the vertebral artery sulcus at the posterior arch dition of the blood vessel walls. Surgical appro- of the atlas (1). It enters the cranial cavity thro- aches to this area are considered risky due to the ugh the foramen magnum of the occipital bone, presence of various important blood vessels and connects at a sharp angle with the opposite one, neural structures (4). The CT and MR angiograp- usually under the post-pontine groove (67%), hies allow a precise and detailed evaluation of and forms a basilar artery (2). After a short co- vertebrobasilar circulation (15). urse (25-35 mm), at the anterior part of the pons, the artery splits into its two terminal posterior The aim of this paper is to examine a possible cerebral arteries (3,4). Basilar artery may take a relationship between the variable vascular geo- straight course (9.6%), be wrapped into the shape metry of vertebrobasilar junctions and the angle of the letter “S” (34.6%) or can take the arched of basilar bifurcation and subsequent aneurysm course (55.8%) (5). formation. Suggestions about the potential possibility of an aneurysm in the vascular area of Basilar artery bifurcation angle ranges from 35°- vertebrobasilar joint angle as a result of specific 175º (6). The mean diameter of the vertebral ar- vascular geometry, may help neurologists and ne- tery was 3.4 mm on the left and 2.9 mm on the urosurgeons. right. The diameter of the basilar artery varied from 3-7 mm (mean of 4.3 mm) (3,7). PATIENTS AND METHODS Cerebral aneurysm is an abnormal widening of The retrospective study included 60 consecutive the blood vessels in the brain. At the base of the adult patients, both sexes, treated at the Clinical brain there is a tangle of arteries that make up University Centre of Tuzla during the period of the so-called Circle of Willis, which is, in all its four years, from 2008 to 2012. Data were gat- segments, subject to the anatomical variations hered from institutional IMPAX Archive. Permi- (8) and which the arteries that supply the brain ssion was obtained from the Ethics Committee branch from. Bifurcations of these arteries are the of the Clinical Centre, University of Tuzla (02- most common places where aneurysms (9) arise. 09/2-112/12). Cerebral aneurysm may occur due to a number of different factors (inheritance, polycystic kidney Patients were divided into two groups. One group disease, infection, trauma, neoplasm, etc.). The consisted of 30 patients without aneurysm of the most common type of brain aneurysm is saccular vertebrobasilar tree, which is formed of intracrani- (berry) aneurysm in, in 85 to 95% of cases. The al parts of the vertebral arteries (VAs), the basilar most frequent localization is the circulus arterio- artery (BA) and their branches, and another group sus of Willis, more precisely, its anterior segment of 30 patients with aneurysm. Patients were obser- (85%). In their research in 2008, Bor et al. pre- ved using Magnetic Resonance Imaging (MRI) sented the hypothesis that the predilective place or Computed Tomography Angiography (CTA) for the formation of aneurysm are bifurcation re- of head and neck. In all patients the presence of gions of large arteries with a sharp angle of bifur- joint angle of vertebral arteries (arteriavertebrali- cation, and the reason is, they assumed, complex ssinistra and arteriavertebralisdextra) was found hemodynamic relationship in the blood vessels and the basilar artery bifurcation angle, and the with subsequent development of atherosclerosis diameters of vertebral artery, basilar artery and po- and weakening of the artery wall (10). sterior cerebral artery (0.5 cm below and above the vertebrobasilar joint, and 0.5 cm below and above Atherosclerosis is a result of mutual and very the basilar bifurcation). We used CT and MRI sof- complex interactions of blood, hemodynamic tware to rotate the angles and recorded the highest characteristics of the blood flow and geometric value we have measured in order to get the value characteristics of the blood vessels, three entities of three-dimensional angles.

253 Medicinski Glasnik, Volume 11, Number 2, July 2014

The statistical analysis of the collected data used In the patients with aneurysm of the vertebro- descriptive statistics (determination of average basilar tree, in the joint area of both vertebral values, standard deviations and standard errors), arteries with the basilar artery, the average di- the correlation matrix, i.e. the test of the correla- ameter of the right vertebral artery was 3.61 tion between the measured values in which the mm and the left vertebral artery 3.94 mm. Di- correlation coefficient with statistical significan- ameters of the right and left vertebral arteri- ce of p<0.05 was used, and the Student’s T-test to es were approximately the same, in12 (40%) determine the significance of differences between patients (r = 0.563). Caudal part of the basilar the arithmetic average values. artery, in the vertebral artery joint area, had an average diameter of 5.08 mm, and the rostral RESULTS part, in the area of bifurcation 4.57 mm. The In this study, in the group of patients without initial part of the right posterior cerebral artery aneurysm, basilar arteries took the following co- had an average diameter of 2.62 mm, while the urses: arched course in 14 (46.6%), “S”- shaped initial part of the left posterior cerebral artery course in 7 (23.3%) and straight in 9 (30%) pa- had an average diameter of 2.52 mm. The bi- tients. In the group of patients with aneurysm, furcation angle of vertebral arteries averaged artery basilaris took these courses: arched course at 68.46º, and the average angle of the basilar in 13 (43.33%), “S” - shaped in 6 (20%) and stra- artery bifurcation was 121.93º (maximal angle ight in 11 (36.66%) patients. 166º, minimal angle 84º) . In patients without aneurysm of the vertebrobasi- In patients without aneurysm of the vertebroba- lar tree in the joint area of right and left vertebral silar tree, the measured diameter values for right arteries with the basilar artery, the average diame- vertebral arteries showed statistically significant ter of the right vertebral artery was 2.43 mm and positive correlation with measured diameter va- the average diameter of the left vertebral artery lues of the posterior cerebral arteries on the same was 2.83 mm. Diameters of the right and left ver- side (r=0.37). tebral arteries were approximately the same in 14 Statistically significant positive correlation was (46.6%) patients. Caudal part of the basilar artery also shown by diameter values of vertebral ar- in the vertebral artery joint area had an average di- tery and posterior cerebral artery on the left side ameter of 3.8 mm, and the rostral part, in the area (r=0.44). In the same group of patients, the basi- of bifurcation, 3.43 mm. The initial part of the ri- lar artery rostral part diameter values (in the bi- ght posterior cerebral artery had an average dia- furcation area) showed a statistically significant meter of 2.5 mm, while the initial part of the left positive correlation with the values of diameters posterior cerebral artery had an average diameter of 2.46 mm. The bifurcation angle of vertebral arteries average was 65.43º, and the average angle of the basilar artery bifurcation was 94.53º (minimal angle 46º and 174º, respectively) (Figure 1 ).

Figure 2. Maximal angle of the basilar artery bifurcation with Figure 1. Angles and the diameters of vertebral–basilar tree (MR aneurysm (CT angiography) (IMPAX archive, University Clinical angiography) (IMPAX Archive University Clinical Center Tuzla, 2012) Center Tuzla, 2008)

254 Efendić et al. Vascular geometry of vertebrobasilar tree

of the left posterior cerebral arteries (r=0.38). DISCUSSION Also, in this group of subjects, the basilar artery Anatomic variations of the vertebrobasilar joint rostral part diameter values (in the bifurcation angle and basilar bifurcation angle, as well as the area) showed a statistically significant positive diameters of these blood vessels, can be a factor correlation with the values of diameters of the in the increase of the incidence of aneurysm in right posterior cerebral arteries (r=0.48). The bi- this anatomic area (16). The intracranial vascular ggest correlation factor in this group of patients anatomical variations, although rare, represent an was between the diameter values of the basilar interesting field of research, since many anoma- artery at the caudal and rostral end and it was lous variants are possible and in most cases they (r=0.69).In the group of patients with the aneury- remain asymptomatic (17). In the population, in sm in vertebrobasilar tree, values of the measured general, basilar arteries can have three different diameters of all blood vessels that build the tree anatomic courses: arched course, the “S”- shaped were interacting in a positive statistical correlati- course and straight course (1). on (r=0.56) between the diameters of the left and right vertebral artery, and the highest correlation The results of our research did not demonstrate factor (r=0.93) between the diameters of the cau- a significant difference between the percentages dal and rostral parts of the basilar arteries. of the courses taken by the basilar arteries in patients with (43.33%, 20% and 36.66%, respec- The angle values of the vertebral into basilar artery tively) and without aneurysm (46.66%, 23.33% junction, as well as the bifurcation angles of the and 30%, respectively). Our results do not qu- basilar arteries were not in the statistically positive ite match the results found in a Japanese study correlation either in the group of patients witho- (5), where the percentages of the courses were ut an aneurysm or in the group of patients with 55.8%, 34.6% and 9.6%, respectively. aneurysm in the vertebrobasilar tree area. Avera- ge diameter values of the vertebral artery at the The angle of bifurcation of the basilar artery, in junction into the basilar artery, were significantly this study, ranged from 84° – 166° with an avera- higher in patients with aneurysm in the vertebro- ge of 121.93° in patients with basilar artery ane- basilar tree area than in the group without aneury- urysm, or 46°– 174° with an average of 94.53° in sm (p=0.000008 on the right side and p=0.000351 patients without aneurysm. Zurada et al. showed on the left side). Average values of joint angles similar values, where the average angle of bifur- of vertebral arteries in the group of patients with cation of the basilar artery was 117.7°, with the aneurysm were not statistically significantly diffe- angles ranging from 30.93°-172.2° (18). In other rent from the average values of the joint angles of study (6) average angle of bifurcation of the basi- vertebral arteries in the group of patients without lar artery was 107°, ranging from 35°-175°. aneurysm of the vertebrobasilar tree area. The results of our study have shown that the Average diameter values of the basilar arteries at average value of the basilar artery bifurcation the caudal and rostral part were statistically si- angles was significantly higher (121.93°) in pa- gnificantly higher in patients with aneurysm than tients with aneurysm, which was generally plain the group of patients without aneurysm in the ced on the bifurcation, than in patients without vertebrobasilar tree area (p=0.000105 at the cau- aneurysm (94.53°) of the vertebrobasilar tree. dal part, p=0.000300 at the rostral part). Average This result was opposite to the result of another diameter values of posterior cerebral arteries in study suggesting arterial bifurcation region with the group of patients with aneurysm in the verte- a sharp angle of bifurcation as predilective place brobasilar tree area, were not statistically signi- for aneurysm (12). The angle of the basilar artery ficantly different from the average values of the bifurcation is thought to influence the risk of the diameters of posterior cerebral arteries in the gro- development and rupture of aneurysms in this up of patients without aneurysm. Basilar artery anatomic place (19). bifurcation angles are on average statistically si- In our study, the diameter of the right vertebral gnificantly higher in the group of patients with artery varied from 2–4 mm and left from 1–4 mm aneurysm than in the group without aneurysm in in patients without aneurysm, whereas in patients the vertebrobasilar tree area (p=0.000215). with aneurysm it was 2-7.6 mm, and 2-8.1 mm,

255 Medicinski Glasnik, Volume 11, Number 2, July 2014

respectively. The diameter of the basilar artery at rysm compared to those without aneurysm, in all the caudal part varied from 3 – 5mm, and at the of the measured values, except for the diameters rostral part 2 – 4 mm in patients without aneury- of posterior cerebral arteries and vertebral arteri- sm, and in patients with aneurysm it varied from es joint angles. This means that the diameters of 2.8 - 9.9 mm and from 2.3 - 8.7 mm respectively. vertebral arteries at joining the basilar artery, as According to the results of other studies (20), the well as the basilar artery diameters at both ends, right and left vertebral arteries had different dia- and the basilar artery bifurcation angles, are on meters in almost 60% of the patients. average statistically significantly higher in pa- Nishijima et al. have reported the average maxi- tients with aneurysm. These results confirm the mum and minimum exterior diameter of the basi- hypothesis of the potential role of vascular geo- lar artery of 3.93+/- 0.76 mm and 3.14 /- .58 mm, metry and its variations as one of the factors of which is slightly different from the values in our the aneurysm of the vertebrobasilar tree. study, especially for diameters in patients with FUNDING aneurysm of the vertebrobasilar tree (5). The average values of the measured parameters No specific funding was received for this study of the vertebrobasilar tree vascular geometry TRANSPARENCY DECLARATIONS showed statistically significant differences and higher values in the group of patients with aneu- Competing interests: none to declare.

REFERENCES 1. Krmpotić–NemanićJ. Anatomijačovjeka. 5th ed. Za- 9. Bor AS, Velthuis BK, Majoie CB, Rinkel GJ. Con- greb: Medicinska naklada, 1993. figuration of intracranial arteries and development 2. Songur A, Gonul Y, Ozen OA, Kucuker H, Uzun I, of aneurysm: a follow –up study. Neurology 2008; Bas O, Toktas M. Variations in the intracranial ver- 70:700-5. tebrobasilar system. Surg Radiol Anat 2004; 30:257- 10. Nerem NR. Vascular fluid mechanics, the arteri- 64. al wall, and atherosclerosis. J Biomech Eng 1992; 3. Schulte-Altedorneburg G, Droste DW, Popa V, Wo- 114:274-82. hlgemuth WA, Kellermann M, Nabavi DG, Csiba 11. Ravensbergen J, Ravensbergen JW, Krijger JKB, L, Ringelstein EB. Visualization of the basilar ar- Hillen B, Hoogstraten HW. Localizing role of he- tery by transcranial color-coded duplex sonography modynamics in atherosclerosis in several human :comparison with postmortem results. Stroke 2000; vertebrobasilar junction geometries. Atheroscl 31:1123-Pai BS, Varma RG, Kulkarni RN, Nirmala Throm Vasc Biol 1998; 18:716-8. S, Manjunath LC, Rakshith S. Microsurgical anato- 12. Asacura T, Karino T. Flow patterns and spatial distri- my of the posterior circulation. Neurol India 2007; bution of atherosclerotic lesions in human coronary 55:31-41. arteries. Circ Res 1990; 66:1045-66. 4. Nishijima Y.Anatomical analysis of the basilar ar- 13. Frangos SG. Localization of atherosclerosis. Arch tery and its branches with special reference to the Surg1999; 134:1142-49. arterial anastomosis, and its course and distribution 14. Akgun V, Battal B, Bozkurt Y, Oz O, Hamcan S, Sari on the pontine ventral surface. Nippon Ika Daigaku S, Akgun H. Normal anatomical features and varia- Zasshi 1994; 61:529-47. tions of the vertebrobasilar circulation and its bran- 5. Vasović LJ, Jovanović I, Ugrenović S, Stojanov D, ches: an analysis with 64-detector row CT and 3T Radovanović Z. Basilar bifurcation: a comparison of MR angiographies. Scientific World Journal 2013; prenatal ant postnatal cases. Neuroanatomy 2008; 620162. 7:66-71. 15. Matsubara S, Hadeishi H, Suzuki A, Yasui N, Nis- 6. Yang H, Liu J, Wang JC, Liu CX, Sun YZ, Han GQ, himura H. Incidence and risk factors for the growth Gao FY, Kang CS, Wang HZ, Zhang JH.Anatomical of unruptured cerebral aneurysms: observation using study and three dimensional image characteristic serial computerized tomography angiography. J Ne- analysis of basicranial artery and its clinical signi- urosurg 2004; 101:908-14. ficance. Zhonghua Yi Xue Za Zhi 2003; 83:13-17. 16. Consoli A,Cuccuini M, Lorenzini F, Bianchi A, 7. Brkic F, Isakovic E, Delic J. Varjabilna anatomija Grazzini G, Scarpini G, Vitali I, Lacono A, Man- prednjeg segmenta circulus arteriosus cerebri (Willi- giafico , V Pellicanò G, Capaccioli L. Anatomical si) Acta Med Sal 2005; 34:85-9. variations of the posterior circulation: case reports 8. Ingebrigsten T, Morgan MK, Faulder K, Ingebrig- and a review of literature. Ital J Anat Embryol 2012; sten L, Sparr T, Schirmer H. Bifurcatio geometry 117:13-22. and the presence of cerebral artery aneurysm. J Neu- rosurg 2004; 101:108-13.

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17. Zurada A, St Gielecki J, Baron J, Zawiliński J, Ko- silar artery bifurcation angle among patients who złowska H. Interactive 3D stereoscopic digital-ima- present with a ruptured aneurysm at the top of the ge analysis of the basilar artery bifurcation. Clin basilar artery and patients with perimesencephalic Anat 2008; 21:127-37. subarachnoid hemorrhage: a retrospective cross-sec- 18. Jagadeesan BD,Kadkhodayan Y, Delgado Almandoz tional study. Neurosurgery 2013; 73:2-7. JE, Wallace A, Cross DT 3rd, Derdeyn CP, Zipfel 19. Shoja MM, Tubbs RS, Khaki AA, Shokouhi G, Fa- GJ, Dacey RG Jr, Moran CJ. Differences in the ba- rahani RM, Moein AA rare variation of the vertebral artery. Folia Morphol 2006; 65:167-70.

Vaskularna geometrija vertebro-bazilarnog stabla sa i bez aneurizme Alma Efendic1, Eldar Isaković2, Jasmin Delić2, Anel Mehinović3, Asmir Hrustić3 1Služba za radiologiju, Kantonalna bolnica Zenica; 2Katedra za anatomiju, Medicinski fakultet, Univerzitet u Tuzli; 3Klinika za ortopediju i traumatologiju, Klinički centar, Univerzitet u Tuzli; Bosna i Hercegovina

SAŽETAK

Cilj Ispitati moguće varijacije vertebro-bazilarnog dijela vaskularnog stabla, te utvrditi eventualnu povezanost varijabilne vaskularne geometrije ugla vertebro-bazilarnog spoja i ugla bazilarne bifurkacije, kao i dijametre ovih krvnih sudova.

Metode Istraživanje je obuhvatilo 60 konsekutivnih pacijenata, odraslih osoba, oba pola, koji su bili podijeljeni u dvije grupe. Jednu grupu (30) sačinjavali su pacijenti bez aneurizme bazilarne arterije, a drugu grupu (30) pacijenti s aneurizmom. Pacijenti su obrađeni metodom magnetne rezonance i kompjuterizovane tomografske angiografije u sklopu pregleda vrata.

Rezultati U grupi ispitanika bez aneurizme vertebro-bazilarnog stabla kod 14 (46,6%) ispitanika dijametri desne i lijeve arterije vertebralis bili su približno isti. Ugao spoja vertebralnih arterija bio je u prosjeku 65,43o, a prosječan ugao bifurkacije arterije basilaris bio je 94,53o. U grupi ispitanika s aneurizmom vertebro-bazilarnog stabla kod 12 (40%) ispitanika dijametri desne i lijeve arterije vertebralis također su bili približno isti. Ugao spoja vertebralnih arterija iznosio je u prosjeku 68,46o, a prosječan ugao bifurkacije arterije basilaris 121,93o.

Zaključak Varijacije ugla vertebro-bazilarnog spoja i ugla bazilarne bifurkacije, kao i dijametri ovih krvnih sudova, jedan su od faktora u nastanku aneurizme ovog područja.

Ključne riječi: arterija vertebralis, arterija basilaris, anatomija

257 ORIGINAL ARTICLE

Values of D-dimer test in the diagnostics of pulmonary embolism

Vildana Arnautović-Torlak1, Belma Pojskić1, Hasan Žutic2, Admir Rama3

1Department of Internal Diseases, Cantonal Hospital Zenica, 2Clinic for Pulmonary Diseases, Podhrastovi, Sarajevo, 3Clinic of Gynecol- ogy and Obstetrics Sarajevo; Bosnia and Herzegovina

ABSTRACT

Aim To establish a value of D-dimer and compare findings of elevated and normal values with the golden standard, computed tomography (CT) of lungs in patients who had symptoms indicating pulmonary thromboembolism (PTE) at admission.

Methods This retrospective/prospective study was conducted at the Department of Internal Diseases of the Cantonal Hospital Ze- nica, Bosnia and Herzegovina. A sample included 80 patients with symptoms indicating PTE at the time of admission, D-dimers and CT scan of thoracic organs were performed. The patients were divided into two groups: 40 examinees with PTE confirmed by CT scan and 40 patients (control group) whose PTE was not confirmed by the CT scan. Corresponding author: Results Sensitivity of D-dimer according to statistical calculation Vildana Torlak-Arnautović was 87.5%. Specificity of D-dimer was 57.5%. The chance of a Department of Internal Diseases, patient to have PTE in case of elevated values of D-dimer was Cantonal Hospital Zenica 3.58 higher than in patients with normal D-dimer values. The po- Crkvice, 72000 Zenica, sitive predicative value of D-dimer was 0.54, the negative predica- Bosnia and Herzegovina tive value was 0.75. Test accuracy was 57.5%. Values of D-dimer >0.83 using a ROC curve and present clinical symptoms of the Phone: +387 32 405 133; disease have indicated further diagnostic examination according Fax: +387 32 226 576; algorithm and a need for CT scan (of thoracic organs ) E-mail: [email protected] Conclusion D-dimer is important in the diagnostics of PTE, high sensitivity and low specificity have been proven. A positive D-dimer test indicates the presence of PTE. However, the test is not reliable. In order to set a diagnosis it is necessary to visualize a blood clot by computed tomography of lungs. Original submission: Key words: product fibrin, CT, Wels score 06 January 2014; Revised submission: 01 March 2014; Accepted: 07 April 2014.

Med Glas (Zenica) 2014; 11(2):258-263

258 Arnautović-Torlak et al. D-dimer and pulmonary embolism

INTRODUCTION Hospital Zenica, Bosnia and Herzegovina. The research was approved by the Ethics Committee Pulmonary thromboembolism (PTE) is a clinical of the School of Medicine in Sarajevo and the and pathophysiological condition occurring when Director of the Cantonal Hospital Zenica. The a blood clot originating from veins of systemic patients in the prospective study were informed circulation taken by bloodstream occludes one of about the vital importance of conducting the dia- the branches of the pulmonary artery and prevents gnostic algorithm and timely treatment, for whi- blood to reach a part of lungs (1). Pulmonary ch they gave their consents. The sample included thromboembolism is a leading cause of illness 80 patients with symptoms indicating probable and mortality, and it can occur in relation to many presence of PTE, and consequently D-dimers and clinical conditions (1,2). Pulmonary thromboem- computed tomography (CT) of thoracic organs bolism is on the third place according to prevalen- were performed. All the patients were divided ce after the ischemic heart disease and cerebro- into two groups: control group (n=40) included vascular disease with the incidence of 1-2% in the patients with symptoms indicating the presence general population and 12-20% in the population of PE, who underwent complete diagnostic pro- of hospitalized patients (2-4). Around 60% of all cedure, and the CT scan excluded pulmonary cases of vein thromboembolism are hospitalized thromboembolism. The study group (n=40) inpatients, with 5-10% of patients suffering from volved patients with symptoms indicating PTE, pulmonary thromboembolism (2,5,6). Epidemio- who underwent compete diagnostic procedure logical studies indicate that it is responsible for and the CT scan confirmed PTE diagnosis. over 50,000 death cases in the USA (3,7). Howe- ver, the available data show that less than 10% The research examined the following parameters of all cases of pulmonary embolism end up with taken at the onset of the disease (risk factors): tra- death (1,2,8,9). Therefore, the prevalence of fatal uma, fractures (especially large bone of lower lim- embolism cases together with non-fatal embolism bs), orthopedic surgery (especially hip and knee), is probably higher than 500,000 annually (2,3,5). major abdominal, gynecological, and vein surgery, Researchers from the Duke University have fo- cardiovascular diseases accompanied by cardiac und that the use of automatic, immunoturbidime- decompensation and arrhythmias, septic conditi- tric D-dimer assay, in combination with clinical ons, malignant diseases, miscarriage, childbirth. algorithm of risk, favors the the assay as the first D-dimers were determined by a new method of line in the treatment of patients with a high risk immunoturbidimetry (BCSX System, hemostasis of pulmonary embolism due to a small number of testing, Siemens Healthcare Diagnostic, Erlan- samples available for the analysis from that po- gen, Germany) and interpreted as elevated above pulation (1,3,5). In clinical practice, the biggest the reference values (<500 ng/L) in the Biochemi- problem arises from the question which is the va- cal Laboratory of the Cantonal Hospital Zenica. lue of D-dimer assay as a marker for further dia- Computed tomography was performed (Si- gnostic algorithm with clinical suspicion of PTE emens Somatom definition 44 slice device, (10,12). The aim of the research was to compare Erlangen,Germany) immediately after the admi- the elevated and normal D dimer test in patients ssion to hospital. The Ultravist 300 mg/ml pack who had clinical suspicion of PTE at admission to iopromide (Bayer Pharma AG, Berlin,Germany) hospital and compare the value of D- dimer with radiological contrast agent was used. Interpre- the golden standard, CT scan of thoracic organs. tation of the scan was done by an experienced Obtained data will help clinicians use the diagno- radiologist of the Cantonal Hospital Zenica. stic algorithm and ensure timely treatment of pul- Nominal and ordinal variables were analyzed monary embolism and prevention of death (8,13). using the χ2 test, and in case of a lack of expected PATIENTS AND METHODS frequency, Fisher exact test was applied. For continuous variables symmetry of their distribution The clinical retrospective/prospective study was was first analyzed with the Kolmogorov-Smirnov conducted in the periods February-August 2012, test. When the distribution of continuous varia- and September 2012 -March 2013, respectively, bles was symmetric, arithmetic mean and stan- at the Department of Internal Diseases, Cantonal dard deviation were used to show mean values

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and dispersion measure. To compare variables Table 2. Prevalence of physiological and pathological values parametric tests were applied (Student’s t test and of D-dimer within the examined groups No of patients ANOVA). Significance level was at p<0.05. Parameter Study group Control group Increased D-dimer values 37 (92.5%) 31 (77.5%) RESULTS Within normal physiological values 3 (7.5%) 9 (22.5%) D-dimer The average age of the control group and the study group was 61.07±14.44 (22-84) and 58.60±16.40 years (21-80), respectively. Average The analysis of average values of coagulation age of the patients involved in the research was factors in the study and control group has shown 59.83±15.40 years (21-84) (p=0.476) (Figure 1). significantly elevated levels of D-dimer in the study group (p=0.002). In the analysis of the average values of D-dimer test, we found that the value of D dimer was statistically higher in the study group patients (p = 0.002). The values of D-dimer varied from physiological values and they were significantly higher in the study group (p=0.002). Average values of activated partial thromboplastin time (APTT) and international normalized ratio (INR) were not statistically different (Figure 2).

Figure 1. Age of patients as compared with the control group

The analysis of symptoms indicating pulmonary thromboembolism has shown that 25 (62.5%) patients from the control group and 23 (57.5%) from the examined group were coughing, equal percentage of the examinees in both groups, 29 (72.5%), had difficulties breathing and suffocation; however, when it comes to the presence of pain, 36 (90%) patients from the study group Figure 2. Average values of coagulation factors in the study experienced pain as compared with 29 (72.5%) and control groups; APTT, activated partial thromboplastin time; from the control group (p=0.045) (Table 1). INR, international normalised ratio;

Table 1. Prevalence of clinical symptoms in patients with clinical suspicion of pulmonary thromboembolism The patients had 76.2% higher chance of ge- Control Study tting PTE if the values of D-dimer were hi- Symptoms p group group gher than 0.83 (p<0.05; cut off >0.83; CI95% Cough 25 (62.5) 23 (57.5) 0.803 Pain 29 (72.5) 36 (90.0) 0.045 0.653 – 0.850). The sensitivity of D-dimer of Difficult breathing and suffocation 29 (72.5) 29 (72.5) 1 87.5% (CI95% 73.2 – 95.8), and increased values of D-dimer obtained by the immunoturbidi- Analyzing the values of coagulation factors in metry method occurred in 87.5% patients with the control and study group we found that the ele- the symptoms of PTE, whose diagnosis was con- vated D-dimer was more present in the patients firmed by the CT scan. D-dimer specificity was from the study group (n=37), as compared with 57.5% (CI 95% 40.9–73.0), e.g. 57.5% patients the examinees from the control group; there is a D-dimer obtained by immunoturbidimetry was statistically significant difference in the prevalen- increased with no presence of pulmonary throm- ce of pathological findings of D-dimer between boembolism (it was not proven by the CT scan) the groups (p=0.047) (Table 2). (Figure 3).

260 Arnautović-Torlak et al. D-dimer and pulmonary embolism

why CT of thoracic organs was performed thus proving PTE. The negative value of D dimer test in combination with low risk by Wells score can effectively eliminate the need for expensive diagnostic imaging methods, which is confirmed by the references (13,15). Researchers at Duke University have found that the use of automatic immunoturbidimetric D-dimer test is useful in combination with certain risk factors through Walls, as the first-line screening test for diagnosing pulmonary thromboembolism (19,20). This study suggests that a negative D-dimer test with a little pretest is likely exclude the presence of venous thromboembolism, which was shown by Bates and his associates (7).

Figure 3. Analysis of ROC curve –D-dimer values Based on the obtained values of D-dimer test in the present study, the negative predicative value DISSCUSSION of D-dimer was 0.75, which means that in case Determining D-dimer concentration is one of the patients had physiological values of D-dimer basic tests used for exclusion of the diagnosis of with unclear clinical presentation of PTE, the thromboembolic diseases, deep vein thrombosis probability that they had no PTE was 75%. and pulmonary embolism (11-13). Testing of pla- Carrier et al. discovered that among the patients smatic D-dimers in the patients in this research aged 60-80, a low to negative Wells score in com- admitted to the Department for Internal Diseases, bination with a negative D-dimer test occurred in the Cantonal Hospital Zenica, proved to be an 99% of the negative predictive value (NPV), in- excellent non-invasive triage test in patients with dicating the probability that patients have pulmo- suspected PTE (10,14,15). The age difference of nary thromboembolism is 99%. (7,10). However, both studied groups was not statistically signifi- in patients older than 80 with low negative Wells cant. Average age in this study was 59.83 years. score in combination with the negative D-dimer A number of studies showed that the incidence test, 21-31% resulted in a negative predicative of PTE is higher in the middle and old age, and value (15). A study by Wels, Carries et al, et al. significantly higher in patients over 45 (7,11). In indicated that the use of a manual D-dimer test our study we analyzed the symptoms that indi- of blood agglutination in combination with the cated pulmonary thromboembolism and it was grading system for clinical pretest probability found that 62.5% of the patients of the control known as the Wells score resulted in the signi- group and 57.5% of the test group had had cough, ficant decrease of number of patients who had equal percentage of respondents in both groups undergone the diagnostic method of compression (72.5%) had experienced wheezing and choking, ultrasound (7,20). and 90% and 72.5% of the patients from the D- dimer test is not a specific marker for PTE, studied and control group, respectively, had felt however, it serves as an accessory test in the di- pain. D -dimer has a significant place in the diagnostic protocol for the exclusion of pulmonary agnostic algorithm of the acute PTE (6,16,). Our thromboembolism. In our study a positive predi- results showed high sensitivity of D-dimer test. cative value of the D-dimer implied that the CT D-dimer test is sensitive, but it is not a speci- confirmed PTE in 54% of patients corresponding fic marker for pulmonary thromboembolism to the results in the reviewed literature (11,21). (13,17). It has a low level of false negative re- Many factors are associated with positive D di- sults (15,18). Our results showed that from the mer (16). D-dimer test can be elevated in a range study group only 3.75% of patients had a nega- of non-thrombolytic disorders including recent tive value of D-dimer and the risk of pulmonary surgeries, bleeding, injuries, pregnancy, postpar- thromboembolism was high, which is the reason tum period, age older than 80 years, malignity

261 Medicinski Glasnik, Volume 11, Number 2, July 2014

and septic condition (7,15). In clinical practice suspected PTE, and it may help physicians with the biggest problem arises from the question whi- further diagnostic algorithm and eliminate the ch value of D-dimer test is to serve as a marker need for radiological tests, but only in combinati- for further diagnostic algorithm in case of clini- on with clinical presentation, associated risk fac- cal suspicion of PTE (17). Application of cut-off tors and the possible presence of other diseases, values significantly increases specificity without which can give similar symptoms of pulmonary changing the sensitivity of the test thereby im- thromboembolism. proving clinical benefit of D-dimer in the diagnosis of PTE (10,22). In this study we found that in ACKNOWLEDGEMENT case of clinical suspicion of pulmonary thrombo- The authors would like to thank colleagues from embolism, and D-dimer values higher than 0.83, the Cantonal Hospital Zenica, the Department of further diagnostic algorithm needed to include Internal Medicine, experienced radiologists and CT thoracic organs (23). Based on AUC ROC Sadida Zecevic, MSc, for accurate laboratory di- curve, we can conclude that respondents have agnosis. 76.2% greater risk of developing PTE if they have D-dimer values higher than 0.83. Increased FUNDING limits on the values of D-dimer can reduce false No specific funding was received for this study. positivity, and increase the false-negative results in older patients (11,22,23). TRANSPARENCY DECLARATION In conclusion, we found that D-dimer test was a Competing interests: none to declare. valuable tool in the evaluation of patients with

REFERENCES

1. Goldhaber SZ. Venous thromboembolism: Epidemi- 9. Carrier M, Le Gal G, Bates SM, Anderson DR, Wels ology and magnitude of the problem. Best Pract Res PS. D-dimer testing is useful to exclude deep vein Clin Haematol 2012; 25:235-42. thrombosis in elderly out patients. J Thromb Hae- 2. Bronic A. Thromboembolic diseases as biological most 2008; 6:1072–6. and clinical syndrome roleof the mediterranean le- 10. Moores L. Diagnosis and managment of pulmonary agueagainst thromboembolic diseases. Biochemia embolism-are we moving toward an outcome stan- Medica 2010; 20:9-12. dard. Arch Intern Med 2006; 166:147-8. 3. Heit JA, Silverstein MD, Mohr DN, Petterson 11. Manganaro A, Ando G, Lembo D, Sardo LS, BudaD. TM, Lohse CM, O’Fallon WM, Melton LJ 3rd: A retrospective analysis of hospitalized patient with The epidemiology of venous thromboembolism in documented deep-venosus thrombosis and their risk of the community. Thromb Haemost 2001; 86:452–63. pulmonary embolism Angiology 2008; 59:599-604. 4. Gupta RT. D-dimers and efficacy of clinical risk esti- 12. Carrier M, Righini M, Wells PS, Perrier A, Ander- mation algorithms: Sensitivity in evaluation of acute son DR, Rodger MA, Pleasance S, Le Gal G. Subse- pulmonary embolism. AJR Am J Roentgenol 2009; gmental pulmonary embolism diagnosed by compu- 193:425-30. ted tomography: incidence and clinical implications. 5. Zhu T, Martinez I, Emmerich J.Venosus thrombo- A systematic review and meta-analysis of the mana- embolism: risk factors for recurrence. Arterioscler gement outcome studies. J Thromb Haemost 2010; Thromb Vasc Biol 2009; 29:298-310 8:1716-22. 6. Belohlavek J, Dytrich V , Linhart A.Pulmonary em- 13. Gupta RT, Kakarla RK, Kirshenbaum KJ, Tapson bolism, part I: Epydemiology, risk factors and risc VF. D-dimers and efficacy of cli-nical risk estima- stratification, patophysiology, clinical presentation, tion algorithms: sensitivity in evaluation of acute diagnosis and nonthrombotic pulmonary embolism. pulmonary embolism. AJR Am J Roentgenol 2009; Exp Clin Cardiol 2013; 18:129-38. 193:425-30. 7. Uresandi F, Otero R, Cayuela A, Cabezudo MA, 14. Weitz JI. Unanswered questions in venous thrombo- Jiménez D, Laserna E, Conget F, Oribe M, Nauffal embolism. Thrombosis research 2009; 123(Suppl. D. A clinical prediction rule for identifying short- l4):S2-10. term risk of adverse events in patients with pulmo- 15. Singh B, Parsaik AK, Agarwal D, Surana A, Masca- nary thromboembolism. Arch Bronconeumol 2007; renhas SS, Chandra S. Diagnostic accuracy of pul- 43:617–22. monary embolism rule-out criteria: A systematic 8. Kline JA, Courtney DM, Kabrhel C, Moore review and meta-analysis. Ann Emerg Med 2012; CL,Smithline HA ,Plewa MC ,Richman PB, O’Neil 59:517-20. BJ, Nordenholz K. Prospective multicenter evalua- 16. Righini M, Perrier A, De Moerloose P, Bounameaux tion of the pulmonary embolism rule-out criteria. J H. D-dimer for venous thrombo-embolism diagnosis: Thromb Haemost 2008; 6:772-80. 20 years later. J Thromb Haemost 2008; 6:1059-71.

262 Arnautović-Torlak et al. D-dimer and pulmonary embolism

17. Masotti L, Ray P, Righini M, Le Gal G, Antonelli F, 21. Gavrilovic D. The role and importance of multide- Landini G, Capeli R, Prisco D, Rottoli P. Pulmonary tector computed (MDCT’s) pulmoangiografic the embolism in the elderly: a review on clinical, instru- diagnostic protocol for patients with suspected acute mental and laboratory presentation. Vascular Health pulmonary embolism. PONS 2012; 9:8-12. Risk Manag 2008; 4:629-36. 22. Schouten HJ, Geersing GJ, Koeh HL,Zuithoff 18. Park JH, Spresser CR, Valdivia J, Khadavi MJ, Das NP,Janssen KJ,Douma RA,van Delden JJ,Mons S, Ellerbeck EF, Cox GG. The simplified Geneva KG,Reitsma JB. Diagnosic accuracy of conventional score and the utilization of the D-dimer and compu- or age adjusted D-dimer cut-off values inolder pa- terized tomography for assessing pulmonary embo- cients with suspected venosus thromboembolismus: lism. KJM 2011; 4:99-104. sistematic rewiew meta-analysis. BMJ 2013; 346:f 19. Wells PS, Anderson DR, Rodger M, Forgie MF, 2492. Kearon C, Dreyer J, Kovacs G, Mitchell M, Lewan- 23. Douma RA, Tan M , Schutgens REG, Bates SM, dowski B, Kovacs MJ. Evaluation of D-dimer in the Perrier A, Legnani C, Biesma DH, diagnosis of suspected deep-vein thrombosis. New 24. Ginsberg JA, Bounameaux H, Palareti G, Carrier Engl J Med 2003; 349:1227-35. M, Mol GC, Le Gal G, Kamphuisen PW, Righini 20. Ruíz-Giménez N, Suárez C, González R, Nieto JA, M. Using an age-dependent D-dimer cut-off value Todolí JA, Samperiz AL, Monreal M; RIETE inve- increases the number of older patients in whom deep stigators. Predictive variables for major bleeding vein thrombosis can be safely excluded. Haematolo- events in patients presenting with documented acute gica 2012; 97:1507-13. venous thromboembolism: findings from the RIETE registry. Thromb Haemost 2008; 100:26-31.

Vrijednost D-dimer testa u dijagnostici akutne plućne tromboembolije Vildana Torlak-Arnautović1, Belma Pojskić1, Hasan Žutić2, Admir Rama3 1Služba za unutrašnje bolesti, Kantonalna bolnica Zenica; 2Klinika za plućne bolesti i tbc „Podhrastovi“ Sarajevo; 3Klinika za ginekologiju i akušerstvo Sarajevo; Bosna i Hercegovina

SAŽETAK

Cilj istraživanja je utvrditi vrijednost D-dimera i uporediti nalaz povišenih i normalnih vrijednosti sa „zlatnim standardom“ kompjuterizovane tomografije pluća (CT) kod pacijenata koji su pri prijemu imali simptome koji ukazuju na plućnu tromboemboliju (PTE).

Metode U retrospektivno-prospektivnoj studiji, provedenoj na Internom odjelu Kantonalne bolnice Zenica, uzorak je sačinjavalo 80 bolesnika sa simptomima koji su, pri prijemu u bolnicu, ukazivali na moguću PTE. Određena je vrijednost D-dimera i urađen CT torakalnih organa. Pacijenti su podijeljeni u dvije grupe: 40 ispitanika kojima je prema CT-u dokazana PTE i 40 ispitanika kojima to nije dokazano (kontrolna grupa).

Rezultati Osjetljivost D-dimer testa iznosila je 87.5%, a specifičnost 57.5%. Izračunavanjem omjera izgleda ustanovljeno je da je šansa da pacijent ima PTE kod povišenih vrijednosti D-dimera 3,58 puta bila veća nego kod ispitanika koji su imali normalne vrijednosti D-dimera. Pozitivna prediktivna vrijednost D-dimera iznosila je 0.54, a negativna 0.75. Tačnost testa iznosila je 57,5%. Vrijednosti D-dimera >0,83 primjenom ROC krive i prisutni klinički simptomi bolesti, ukazuju da se u daljem dijagnostičkom algoritmu obavezno uradi CT torakalnih organa.

Zaključak Određivanje vrijednosti D-dimer testa u dijagnostici PTE-a je značajna. Pozitivan D-dimer ukazuje na plućnu emboliju, ali test nije pouzdan. Za postavljanje dijagnoze PTE-a potrebna je vizuali- zacija tromba putem kompjuterizovane tomografije pluća.

Ključne riječi: produkt fibrina, CT, Wels-scor

263 ORIGINAL ARTICLE

Talc pleurodesis in pleuropulmonary diseases treatment

Nusret Ramić1, Goran Krdžalić1, Nermin Mušanović1, Ferid Konjić2, Šefika Umihanić3, Suada Ramić4, Jasminka Mustedanagić-Mujanović5, Farid Ljuca6, Enver Zerem7

1Department of Thoracic Surgery,2Department of General Surgery,3Clinic for Lung Diseases and Tuberculosis; University Clini- cal Centre Tuzla, 4Department of Histology, School of Medicine, University of Tuzla,5Institute for Pathology, University Clinical CentreTuzla,6Department ofpPhysiology,School of Medicine, University of Tuzla,7Clinic of Internal Medicine, University Clinical Centre Tuzla; Tuzla, Bosnia and Herzegovina

ABSTRACT

Aim To determine the efficiency and safety of talc pleurodesis in treating the malignant pleural effusion and recurrent spontaneous pneumothorax.

Methods The study included 54 patients with malignant pleural effusion and recurrent spontaneous pneumothorax, who underwent talc pleurodesis using the “talc slurry” method of pleural talc obliteration.

ResultsPleurodesis was successful in 52 (96%) patients. The ave- Corresponding author: rage duration of thoracic drainage was 4.4 days. Procedure compli- Nusret Ramić cations included higher body temperature, pneumonia and pleural University Clinical Center Tuzla, effusion separation. All of the patients had satisfying radiological findings at the point of discharge and three months later. There was Trnovac bb, 75000 Tuzla, no death outcome related to the procedure of pleurodesis itself. Bosnia and Herzegovina Phone: +38735303300; Conclusion Our study has proved the efficiency and simplicity Fax: +38735264500; oftalc pleurodesis in treating symptomatic malignant pleural ef- Email: [email protected] fusions and cases with recurrent spontaneous pneumothorax.Ap- propriatepatient selection and compliance with surgical principles during the procedure make this method safe, efficient and successful in treatingpleuropulmonal diseases.Large particle talc should be used for pleurodesis because of the minimum risk of complications.

Key words: surgery, malignant pleural effusion, pneumothorax Original submission: 04 February 2014; Revised submission: 05 March 2014; Accepted: 12 May 2014.

Med Glas (Zenica) 2014; 11(2):264-269

264 Ramić et al. Pleuropulmonary diseases tretment

INTRODUCTION PATIENTS AND METHODS Malignant pleural effusions (MPE) mostly appear This retrospective study including 54 patients who as consequences of primary or metastatic cancer underwent talcpleurodesis due to malignant pleu- (1). Approximately half of those suffering from ral effusion and secondary spontaneous pneumo- metastatic cancer will develop pleural effusion; thorax had been performed in the Department of lung cancer or breast cancer is present in 75% of the Thoracic Surgery of University Clinical Centre cases (2-4). The development of malignant pleural of Tuzlabetween January 2005 and January 2013 effusion often leads to the symptoms like dyspnea (Table 1). The Ethics Committee of the Clinical or cough, which considerable lowers the quality Center of Tuzla approved this investigation�� Crite- of life. Unfortunately, most malignant effusions do ria for the treatment were Karnofsky Performance not react to systemic therapy and demand another Scale (KPS): score ≥ 60 (the patient capable to different treatment approach (5,6). Today, sympto- take care of himself/herself, however, needs help matic malignant pleural effusion is considered an occasionally) and lung re-expanding again after option in repeated thoracocentesis, the placement a thoracic drainage without any air or liquid col- of permanent pleural chest tube and chemical ple- lections left (13). Antibiotics, corticosteroids and urodesis (6). Repeated thoracocentesis and the non-steroidal anti-inflammatory drugs were not placement of pleural catheters are good solutions systematically given during the procedure (14). for the patients who are expected to die soon (2). The only contraindication was empyema pleurae. After a while, accumulated liquid causes repeated Patients were divided into two groups: the first symptoms and repeated thoracocentesis becomes group consisting of 50 patients with MPE and sec- unpleasant and painful with possible complicati- ond group comprising four patients with recurrent ons (5). Also, repeated thoracocentesis results in pneumothorax. Mean age of our patients with MPE the loss of proteins and electrolytes (5,6). was 55+12,58 ranging from 21-84 years; mean age Spontaneous pneumothorax of secondary type of our patients with pneumothorax was 70+7,07 occurs in patients with already existing lung ranging from 58-76 years. In the group with MPE, disease. Those are mostly patients with chronic there were 22 male and 28 female patients: 25 obstructive pulmonary disease and tuberculosis patients with lung cancer, 13 patients with breast (7). The associated heart weakness makes the cancer, six patients with ovaries cancer, two with surgical treatment of such patients a very risky sarcomas, and one patient with either colon cancer, one, so the obliteration of pleural cavity is per- kidney cancer or lymphoma, as well as one patient formed by using the “talc slurry” method (8,9). with cancer of unknown primary origin. Talk is a substance which is insoluble in water. Table 1. Characteristics of 54 patients with malignant pleural effusion (MPE) and recurrent spontaneous pneumothorax Chemically, it is a hydrated magnesium silicate (PNTX) treatedby talc pleurodesis used for the first time in 1935 as apleurodesis agent No (%) of patients (9,10). The size of the particles plays a big roleas Pathology MPE Group (N=50) PNTX Group (N=4) talk preparations with mid-size particles smaller lung emphysema Lung carcinoma 25 (50) than 15µ result in much stronger systemic infla- Breast carcinoma 13 (26) mmatory response and the reaction of lung paren- Ovary carcinoma 6 (12) chyma on the mid-size 25µ particles talc (4,11). In Sarcoma 2 (4) Other malignoma 4 (8) some cases, talc can be found in other organs (kidneys, spleen, liver) after the application in pleural Four patients were treated for recurrent pneumo- cavity (12,13). Hereby, we present our experience thorax. All of them had severe bullous changes with the malignant pleural fluid chest drainage or in lung parenchyma with a consequent chronic recurrent spontaneus pneumothorax and subsequ- obstructive pulmonary disease (COPD). The ent instilation of talc. This study will attempt to Forced expiratory volume in first second (FEV1) point out the need forthe right selection of patients values were between 0.7 and 0.9 L. Surgery perfor pleurodesis. Results of the study will be useful formed by VATS procedure or classic thoracot- for general practitioners, pulmologists as well as omy (8,9) requires total anaesthesia with a high surgeons in understanding the surgical aspects of risk of the occurrence of complications relatedto these diseases. the surgery itself, and the following diseases.

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These patients had bad-quality lung parenchy- empyema pleurae. The procedure was performed ma, weak parenchymal re-expansion and in this on both sides in four patients. The drainage tube case surgery is often doomed to failure. Drain- was systematically removed on the third day af- age pipe with smaller diameter, up to 20 F was ter pleurodesis, except in patients with complica- used. Larger drainage pipe could slow down the tions. The average duration of thoracic drainage process of ruptured bullae healing process. After was 4.4 days. the air loss on the thoracic drainage pipe stopped, The instillation of talc into the pleural cavity pro- the “talc slurry“ method (12-14) was performed duced the increase of temperature in seven (14%) in order to prevent the disease relapse. patients. Raised body temperature was not above The following parameters were measured in the 38.5 °C. The pain that required continuous analge- patients: occurrence of high temperature, pain in- sia was present in 12 patients (22.2%) and in one tensity, respiratory complications, length of drai- case it was severe. It was systematically treated nage, air loss on the drainage pipe longer than 5 with paracetamol analgesics and the analgesics days, and efficiency of the procedure. Pain was with central effect. Amongst the 54 patients who assessed on VAS (Visual Analogue Scale) and was underwent talc pleurodesis, 28 (52%) patients did rated with a grade 1 to 5. The patient marked his not have any chronic chest pain (VAS score 1), 14 pain severity ranging from mild pain (score1) to (25.9%) had score 2, four had score 3 (7.4%), se- the most severe pain (score 5). Pleurodesis was ne- ven had score 4 (12.9%), and one (1.8%) patient- ver simultaneously performed on both sides. The had score 5. pleurodesis was considered successful if there was One patient developed empyema, in which case, no recurrent effusion or pneumothorax. The thorax the drainage tube was removed after 21 days, and drainage tube had previously been placed and the the treatment was successfully ended with the help diagnosis had been cytologically confirmed in all of antibiotics. The patient with pneumonia was patients. Steritalc (Novatech, France) was used to also successfully treated with antibiotic therapy. make the suspension whilst being particularly cali- Four cases of effusion separation were recorded. brated with an average particle size of 25µ in order Effusion separation was treated with additional to avoid systemic dissemination. drainage or with the mobilization of the existing The pleurodesis procedure was performed after drainage tube. Only in one case the effusion sepa- radiological confirmation on effusion evacuation ration lead to the localization of talc emulsion in and recurrent lung expansion and in the presence of the pleural cavity, and the whole procedure was <150 mL of pleural drainage in 24 hours. After tho- unsuccessful. In the group of patients with pne- rax drainage and complete re-expansion of lung pa- umothorax, there was one patient with a longer renhime, 12 g of talc was dissolved in 50 mL 0.9% drainage time caused by a prolonged air loss on physiological solutionin order to get a mush emul- the chest tube. The case was routinely solved by sion which was installed through thorax drainage gradual removal of the drainage tube. with 5mL of 1% xylocaine. The drainage tube was The success of pleurodesis did not depend on then closed and the patient is advised to change po- age, sex or histological type of tumor. We did not sition more often in order to distribute the emulsion notice the difference in treatment efficiency, con- evenly inside the pleural cavity.After 12 hours, the cerning the type of primary disease. The recovery drainage tube was affiliated to negative underwater time depended more on the general status of the suction. On the third day of pleurodesis, the draina- patient and the earlier lung parenchyma status. ge tube was removed in accordance with radiologi- The patients with prompt lung reexpansion af- cal confirmation. The follow-up x- ray shots were ter the effusion had the most favurable outcome. made three months after the procedure in order to Such a prompt reaction to the procedure was re- evaluate the efficiency of pleurodesis. corded in 45 patients (83%). RESULTS The pleurodesis was performed on both sides in four patients. In two cases, there was a mehastatic Pleurodesis was successful in 52 (96%) patients osteo and hondrosarcoma from limbs; in one case, with malignant pleural effusion, while the effusi- the patient had soft neck tissues sarcoma and in one on loculated in one patient, and one patient had

266 Ramić et al. Pleuropulmonary diseases tretment

case the patient suffered from metastatic ovary can- of talc in pleural cavity happens spontaneously cer. In these patients, the pleurodesis was perfor- while others suggest the necessity of patient’s ro- med successively with the interval of one month. tation in order to achieve this (9). Our experience Talc slurry is usually well tolerated. There were goes in favor of rotation of the patient. no serious complications such as adult respira- Since the moment when talcs has been introduced tory distress syndrome (ARDS) or respiratory fa- into clinical practice, there have been many dis- ilure related to the procedure (Table 2). No deaths agreements regarding its use and efficiency in the were attributed to the procedure. treatment of MPE and pneumothorax because of Table 2. Complicationsin patients with malignant pleural effu- its toxicity (19,20). Light (��20) ��thinks that doxy- sion (MPE) and recurrent spontaneous pneumothorax (PNTX) cycline is an optimal agent, superior to talc, while during and after the procedure of pleurodesis Ghio (21) believes that it should not be used in No (%) of patients the case of nonmalignant effusion due to the risk MPE Group PNTX Group Complications of respiratory complications. Glazer, on the other (N=27) (N=3) Pain 11 (22) 1 (25) hand, reports on the success of talc treatment of High temperature 7 (14) 1 (25) nonmalignant diseases with an acceptable risk Pneumonia 1 (2) (14). In most studies, the recommended dosage Empyema 1(2) 1 (2) Separated effusion 4 (8) of talc is up to 10 grams, while the dosage of 6-10 Prolonged air leak (>5 days) 1 (25) grams is considered optimal. Namely, some authors consider a greater dosage of talc responsible DISCUSSION for difficult complications including ARDS, air According to our results, talc pleurodesis is a embolism and arrhythmia, while others consider quick and efficient method of obliteration of the size of particles responsible for complications pleural cavity. It can be performed in patient’s (15,21). In our study, we used 12 grams of talc bed as a minor surgical procedure (15). Pleural and we did not notice and resinous respiratory pain and high temperature were the most com- complications. mon problems that occurred after the talc instal- According to our study, size of particles plays a lation during our study. Pleurodesis is generally key role in the toxicity of the product, not the qu- painful procedure, and thus adequate analgesia antity. This conclusion is supported by most avai- during and immediately post-procedure is essen- lable studies (4,10,13,15,19). Talc pleurodesis has tial (16-18). The reported incidence of chest pain also been proven to be a safe and effective scle- varies from 7-43% and fever 10-59% (6,8,9,15). rosant agent in patients suffering from secondary In our research, amongst the 54 patients who un- spontaneous pneumothorax (7,16,17). However, derwent talc pleurodesis, chronic chest pain and in older persons, especially those who are classed the increase of temperature is in accordance with as high surgical risk and with additional diseases, the published studies (6,8-10,13). In the treattreat-- especiallyat an advanced COPD (chronic�� obstruc- ment of a pain induced by talcpleurodesis some tive pulmonary disease) the administration has authors suggest the use of 2-4 mg of morphine in- its full justification, whic his consistent with our travenously in combination with lidocaine (15). study. In our study, talc was not used in younger In our study, the pain was successfully managed patients in accordance with the recommendations by paracetamol analgesics and the analgesics of the British Thoracic Society guideline, as well with central effect. Good cooperation with the pa- as other studies where the cancerous effect of talc tients is needed during and after the procedure. It is not excluded (8). We do not recommend the use is necessary to explain to the patients the purpose of non-steroidal anti-inflammatory drugs and cor- of the procedure and the necessity of changing ticosteroids in the postoperative period to avoid the body position in order to improve dispersion the possibility of interfering with hemostasisor of talc suspension in the chest (9,15). Rotation the formation of adherences. Preprocedure antianti-- of the patient following intrapleural administra- biotics were not given routinely. The procedure is tion of a sclerosing agent is described in most performed in sterile conditions just like any other pleurodesis studies (4,6,9,12,13). Some authors, surgical procedure (6). In our study, one patient however, consider that the uniformed distribution developed empyema because of a prolonged time

267 Medicinski Glasnik, Volume 11, Number 2, July 2014

with the intercostal tube and contamination of the 88% to 100% with a mean of 90% (2,4,5,8,14). In pleural space. our research, pleurodesis was successful in 96% However, in most studies talc was confirmed as patients. In conclusion talc was confirmed as the the best sclerosing agent (4, 5-7,11,13). The�� cu- best sclerosing agent. Large-particle talc should rrent British Thoracic Society guideline advocated be used if talc pleurodesis is elected. talc pleurodesis as first-line therapy for MPE (8). FUNDING Respiratory complications are the most serious and seem to have no connection with the quantity No specific funding was received for this study. of installed talc (6,10). Success rates (complete and partial response) for talc slurry range from TRANSPARENCY DECLARATIONS Competing interests: none to declare.

REFERENCES 12. Stefani A, Natali P, Casali C, Morandi U. Talc poudrage versus talc slurry in the treatment of mali- 1. Muduly DK, Deo SVS, Subi TS, Kallianpur AA, gnant pleural effusion. A prospective comparative Shukla NK. An update in the management of ma- study. Eur J Cardiothorac Surg 2006; 30:827-32. lignant pleural effusion. Indian J Palliat Care 2011; 13. Kolschmann S, Ballin A, Juergens UR, Rohde G, 17:98-103. Gessner C, Hammerschmidt S, Wirtz A, Gillissen 2. Koledin M, Đurić D, Bijelović M, Baroš B. Pleuro- A. Talc pleurodesis in malignant pleural effusions. deza talkom kod pleuralnih izliva maligne etiologije. Pneumologie 2006; 60:89-95. Pneumon 2000; 38:37-43. 14. Glazer M, Berkman N, Lafair JS, Kramer MR. Su- 3. Nikolić I, Stančić-Rokotov D, Janevski Z, Hodoba ccessful talc slurry pleurodesis in patients with non- N, Kolarić N, Špiček-Macan J, Helga Sertić-Mirić. malignant pleural effusion. Chest 2000; 117:1404-9. Videotorakoskopska biopsija pluća i pleure u dija- 15. Neville E, Duffy J, Ali N. BTS guidelines for the gnostici kroničnih izljeva prsišta. Acta Clin Croat management of malignant pleural effusions. Tho- 2007; 46:167-70. rax 2003; 58:29-38. 4. Genofre EH, Vargas FS, Acencio MM, Antonangelo 16. Hunt I, Barber B, Southonb R, Treasure T. Is talc L, Teixeira LR, Marchi E. Talc pleurodesis: evidence pleurodesis safe for young patients primary sponta- of systemic inflammatory response to small size neous pneumothorax? Interact Cardiovasc Thorac talc particles. Respir Med 2009; 103:91-7. Surg 2007; 6:117-20. 5. Crnjac A. Maligni pleuralni izljevi-metode u palija- 17. Lee P, Yap SW, Pek YW, Ng Keong Wei A. An audit tivnom tretmanu. Med Meseč 2006; 2:338-44. of medical thoracoscopy and talc poudrage for pne- 6. Hsia D, Mousani A. Management of malignant ple- umothorax prevention in advanced COPD. Chest ural effusions. Curr Respir Care Rep 2012; 1:73-81. 2004; 125:1315-20. 7. Zaragoulidis K, Zaragoulidis P, Darwiche K, Tsa- 18. Lardinoisa D, Vogtb P, Yanga L, Hegyib I, Baslam kiridis K, Machairiotis N, Kougioumtzi I, Cour- M, Wedera W. Non-steroidal anti-inflammatory dru- coutsakis N, Terzi E, Zaric B, Huang H, Freitag L, gs decrease the quality of pleurodesis after mec- Spyratos D. Malignant pleural effusion and algorit- hanical pleural abrasion. Eur J Cardiothorac Surg hm management. J Thorac Dis 2013; 4:413-9. 2004; 25:865–71. 8. Henry M, Arnold T, Harvey J. BTS guidelines for 19. Rossi VF, Vargas FS, Marchi E, Acencio MM, Ge- the management of spontaneous pneumothorax. nofre EH, Capelozzi I, Antonangelo N. Acute infla- Thorax 2003; 58:39-52. mmatory response secondary to intrapleural admi- 9. Tschopp JM, Rami-Porta R, Noppen M, Astoul P. nistration of two ypes of talc. Europ Respir J 2010; Management of spontaneous pneumothorax: state of 35:396–401. the arth. Eur Respir J 2006; 28:637-50. 20. Light WR. Pleurodesis: what agent should be 10. Davoudi M, Colt HG. The ideal pleurodesis agent: used? J Bras Pneumol 2003; 29:53-4. still searching after all these years. Lancet Oncol 21. Noppen M. Who’s (still) afraid of talc? Eur Respir 2008; 9:912-3. J 2007; 29:619–21. 11. Xia H, Wang XJ, Zhou Q, Shi HZ, Tong ZH. Effica- cy and safety of talc pleurodesis for malignant pleural effusion: a meta-analysis. PLoS One 2014; 9:1.

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Pleurodeza talkom u tretmanu pleuropulmonalnih oboljenja

Nusret Ramić1, Goran Krdžalić1, Nermin Mušanović1, Ferid Konjić2, Šefika, Umihanić3, Suada Ramić4, Jasminka Mustedanagić-Mujanović5, Farid Ljuca6, Enver Zerem7 1Odjel torakalne hirurgije, 2Odjel opće hirurgije, 3Klinika za plućne bolesti i tuberkulozu; Univerzitetski klinički centar Tuzla; 4Zavod za histologiju, Medicinski fakultet, Tuzla; 5Institut za patologiju, Univerzitetski klinički centar Tuzla; 6Zavod za fiziologiju, Medicinski fakultet, Tuzla; 7Klinika za internu medicinu, Univerzitetski klinički centar Tuzla; Tuzla, Bosna i Hercegovina SAŽETAK

Cilj Utvrditi efikasnost i sigurnost pleurodeze talkom u tretmanu malignog pleuralnog izljeva i recidi- virajućeg spontanog pneumotoraksa.

Metode U studiju su bila uključena 54 pacijenta s malignim pleuralnim izljevom (MPE) i recidivi- rajućim spontanim pneumotoraksom, kod kojih je načinjena pleurodeza talkom metodom talc slurry obliteracije pleuralnog prostora.

Rezultati Pleurodeza je bila uspješna kod 52 (96%) pacijenta. Prosječno trajanje torakalne drenaže iznosilo je 4,4 dana. Kao komplikacije postupka zabilježili smo povišenu tjelesnu temperaturu, pne- umoniju te separaciju pleuralnog izljeva. Svi pacijenti na dan otpusta, te tri mjeseca kasnije, imali su zadovoljavajuće radiološke nalaze. Nije bilo smrtnog ishoda vezanog za sâm postupak pleurodeze.

Zaključak Pleurodeza talkom, prema rezultatima našeg istraživanja, potvrdila je svoju efikasnost i jednostavnost u tretmanu simptomatskih malignih pleuralnih izljeva, te kod pacijenata s recidivirajućim spontanim pneumotoraksom. Pravilan odabir pacijenata i poštivanje hirurških principa tokom procedure čine ovu metodu sigurnom, efikasnom i uspješnom u tretmanu pleuropulmonalnih oboljenja. Talk velikih čestica treba biti korišten za pleurodezu zbog minimalnog rizika od komplikacija.

Ključne riječi: hirurgija, maligni pleuralni izljev, pneumotoraks

269 ORIGINAL ARTICLE

Cutaneous silent period in the assessment of small nerve fibers in patients on hemodialysis

Merita Tirić-Čampara1, Miro Denišlič2, Emir Tupković3, Salih Tandir4, Jasminka Djelilović Vranić1, Azra Alajbegović1, Refet Gojak5, Jasem Y. Al-Hashel6, Halima Resić7

1Department of Neurology, Clinical Centre, University of Sarajevo, Sarajevo, Bosnia and Herzegovina, 2School of Medicine, University of Ljubljana, Ljubljana, Slovenia, 3Department of Neurophysiology, Primary Health Care Centre Tuzla, Tuzla, 4Faculty of Health, University of Zenica, 5Department of Infectology, Clinical Centre, University of Sarajevo, Sarajevo; Bosnia and Herzegovina, 6Neurology Department, Ibn Sina Hospital, Kuwait, 7Department of Hemodialysis, Clinical Centre, University of Sarajevo, Sarajevo, Bosnia and Herzegovina

ABSTRACT

Aim In hemodialysis patients renal disease may cause an impairment of central and peripheral nervous system. In most cases of the peripheral nervous system polyneuropathy is reported. The aim of this study was to evaluate the function of small A-delta nerve fibres, whose function is often overlooked.

Methods The function of large diameter nerve fibers was performed by standard routine neurophysiological examination. Cutane- ous silent period (CSP) was elicited by single electrical stimulati- ons at the tip of digit II by the bipolar electrodes. The superficial electrodes were placed on the muscle belly of m. abductor pollicis Corresponding author: brevis. The onset latency (L1) was recorded at the beginning of Merita Tirić Čampara voluntary muscle activity suppression, the late latency (L2) at the start of new muscle activity. The difference between two latencies Department of Neurology, indicates the duration of CSP. Clinical Centre of Sarajevo University Bolnička 25, Sarajevo, Results The study included 38 consecutive patients (male/fema- Bosnia and Herzegovina le – 21/17, median age 56.6±10.9 years) treated with hemodialysis (one month to 30 years) and 35 healthy subjects (male/female Phone:+ 387 33 610-988; 23/17, age 47.4±10.1 years). The results of the conduction study Fax: +387 33 610-988; demonstrated a significant prolongation of F-waves of the median E-mail: [email protected] and ulnar nerves, decreased motor and sensory velocities of both nervesin patients on hemodialysis (p<0.001). In patients with A-V fistulas a significant prolongation of the onset CSP latency L1 was obtained (p<0.001), whereas duration of CSP was not changed.

Conclusion In hemodialysis patients the significant impairment Original submission: of small nerve fibers was recorded. The evaluation of small nerve 05 May 2014; fibers contributes to the assessment of the whole peripheral nerve function. Revised submission: 20 June 2014; Key words: uremic polyneuropathy, arteriovenous fistula, EMNG Accepted: 22 June 2014.

Med Glas (Zenica) 2014; 11(2):270-275

270 Tirić-Čampara et al. Silent period in patients on hemodialysis

INTRODUCTION PATIENTS AND METHODS Renal diseases cause diverse central nervous sy- This study included 38 consecutive patients stem disturbances - uremic encephalopathy, seizu- treated with hemodialysis at the Hemodialysis res, stroke, movement disorders, sleep alterations Department, Clinical Cente rof Sarajevo Univer- and peripheral nervous system involvement (1). sity, Bosnia and Herzegovina (B&H) in the pe- Polyneuropathy is a frequent neurological com- riod 05.01.2012-30.12.2013. Neurophysiological plication in patientswith renal failure. It occurs as evaluation was performed at Neurology Depar- uremic polyneuropathy (UP), mononeuropathies tment of Sarajevo. The patients with diabetes, and monomelic neuropathy due to arteriovenous alcoholism, systemic inflammatory, malignant (A-V) fistulas. Prevalence rates of UP range from diseases and psychiatric disorders were exclu- 50–80% (1-3). Clinically sensory symptoms of- ded. The control group consisted of 35 healthy ten predominate while motor dysfunction usually subjects (our co-workers, friends and relatives). developslater (4,5). Sensory loss mainly involves Before starting the study the informed consent large-diameter nerve fibers resulting in paresthesia from testing patients and healthy subjects was and occasionally pain and burning feet. Autonomic obtained. The study has received an approval of symptoms are usually subclinical. Few patients the Ethics Committee of the Sarajevo University develop subacute or chronic motor – predominant Clinical Centree. neuropathy simulating polyradiculoneuritis Guilla- The neurophysiological examination included in-Barré or chronic inflammatory demyelinating the routine nerve conduction study (NCS) and polyneuropathy. In these cases more frequent dial- CSP. Using the superficial electrodes (Care Fu- ysis or renal transplantation are required (6,7). He- sion, Middletonn, WI, USA) the motor parame- modialysis and peritoneal dialysis tend to diminish ters of the peripheral nerves were recorded: distal the progression of UP. The pathophysiological me- motor latencies (DML) of the median and ulnar chanism of UP is still unknown. The role of chronic nerves, motor responses (M–waves), F–waves hyperkalemic depolarisation is discussed. The ma- and motor conduction velocities (MCV). The ac- + intenance of a strictly normal serum K level may tive electrode was placed on the muscle abductor be an effective strategy in the treatment of UP (8). pollicis brevis and the reference electrode over Neurophysiological nerve conduction study pro- the muscle tendon. Stimulation was applied at vides the function of large-diameter motor and the wrist 8 cm from the active electrode. Sensory sensory nerve fibers (9). To assess the function conduction study of the median and ulnar nerves of small nerve fibers the routine electromyograp- included sensory conduction velocities (SCV) hy is insufficient. Cutaneous silent period (CSP) and amplitudes of sensory nerve action potentials obtained by nociceptive cutaneous stimulus (SNAP). The SNAP were obtained by antidromic applied to sensory fibers on a fingertip induces nerve stimulation over the skin of the lateral (me- a transient and brief suppression of voluntary dian nerve) and medial part (ulnar nerve) of the muscle activity. The CSP is a result of the activa- ring finger using standard bipolar electrodes. The tion of small A-delta nerve fibers and is conside- distance between the stimulating and the recor- red as a spinal inhibitory reflex (10,11). The CSP ding electrode was 14 cm. Standard electrophysi- measurement is used in the functional evaluation ological machine settings were used (15). of different neurological diseases (12-14). The CSP was elicited by single electrical stimu- The primary endpoint of our study was to assess lations (0.5 ms duration and 80-100 mA intensity, the function of small-diameter A-delta nervesfi- sweeps 250 ms, filters 30 and 10 kH) at the tip of bers in uremic patients with A-V fistulas by using digit II by the bipolar electrodes. The superficial CSP. The secondary endpoint was to compare electrodes were placed on the muscle belly of m. the sensitivity of large-diameter motor and sen- abductor pollicis brevis. During near-maximum, sory parameters of the median and ulnar nerves an activated APB muscle electrical stimulus was with CSP with the intention toevaluatenerve delivered. At least 4 individual responses were su- impairments in hands with A-V fistulas. To our perimposed. The onset latency (L1) was recorded at knowledge a study of CSP on hands with A-V fi- the beginning of voluntary muscle activity suppre- stulas had not been performed previously. ssion and the second - late latency (L2) at the start

271 Medicinski Glasnik, Volume 11, Number 2, July 2014

of new muscle activity. The difference between Table 3. Sensory conduction of median and ulnar nerve in two latencies indicates the duration of CSP. hemodialysis patients and controls Median nerve (mean ± SD) Ulnar nerve (mean ± SD) Routine nerve conduction study and CSP were Amplitude (mV) SCV (ms) Amplitude (mV) SCV (ms) undertaken using a Medelec Synergy system Patients 11.9 ± 8.0 41.5 ± 6.7 12.8 ± 7.2 43.9 ± 6.2 Controls 17.3 ± 7.0 50.2 ± 3.6 16.9 ± 9.0 52.7 ± 3.5 (Oxford Instruments, High Wycombe, UK). p 0.004 <0.0005 0.031 <0.0005 Parameters are expressed as mean values with SCV, sensory conduction velocities standard deviation. Shapiro-Wilk tests of nor- In patients on hemodialysis and A-V fistulas a mality was used. Additionally, indenpendent significant prolongation of the onset CSP laten- Student’s t-test, Spermann’s correlation coeffici- cy L1 was obtained (p< 0.001). There was no ent and Mann-Whitney U test were performed. important difference in the CSP duration of su- The level of significance was set at p=0.05. ppression of voluntary muscle activity (Table 4). RESULTS Table 4. Cutaneous silent period of nervus medianus in hemodialysis patients and controls The study enrolled 39 patients on hemodialysis. CSP L1 CSP duration In only one patient CSP was not elicitable. This (mean ± SD) (ms) (mean ± SD) (ms) patient was excluded and in the further study pa- Patients 79.9 ± 29.1 58.9 ± 20.3 Controls 57.6 ± 18.7 62.3 ± 21.4 rameters of 38 patients were evaluated. Out of 38 p <0.0005 0.491 patients 21 were males and 17 were females. The CSP, cutaneous silent period; CSP L1, the onset latency; duration of hemodialysis differs from 1 month to 30 years. The control group included 35 volun- There was no correlation between either motor or teers, 23 males and 12 females. Median age for sensory nerve parameters and the onset CSP L1 patients was 56.6 ± 10.9 years and for controls latencies in the patients group. 47.4 ± 10.1 years (Table 1). The evident prolongation of the onset CSP L1 latency inpatients with A-V fistulas was found Table 1. Demographic data of hemodialysis patients and (Figure 1). controls Patients Controls Number of patients 38 35 Age (median) (years) 56.6 ± 10.9 47.4 ± 10.1 Gender (Males/Females) 21/17 23/12 Duration of hemodialysis 7.9 ± 8.0 (0.1–30.0) – (median) (years)

The results of motor conduction study demonstrated a significant prolongation of F-waves for the median and ulnar nerves as well as a decreased MCV in patients on hemodialysis (p<0.001) (Table 2). There was no statistical difference in DML of both groups. Figure 1. Cutaneous silent period. A) Patient on hemodialysis; B) Table 2. Motor conduction of median and ulnar nerve in Controls L1, onset latency; L2, late latency hemodialysis patients and controls DISCUSSION Median nerve Ulnar nerve (mean ± SD) (ms) (mean ± SD) (ms) Neurological complications in patients with renal DML F-wave MCV DML F-wave MCV Patients 3.9 ± 0.6 30.8 ± 4.3 51.4 ± 7.6 3.3 ± 0.5 29.8 ± 3.1 56.4 ± 7.2 disease are quite common (1-4). The progressive Controls 3.9 ± 0.2 27.5 ± 3.9 58.2 ± 5.3 3.2 ± 0.3 27.6 ± 1.7 60.0 ± 4.8 renal failure may lead to the development of neu- p 0.739 0.001 <0.0005 0.852 <0.0005 0.015 rological disorders. In a few cases ischemic mono- DML, distal motor latencies; MCV, motor conduction velocity; melic neuropathy was reported (16). In our patients A significant amplitude decrease and a slowed no acute neuropathies were observed due to A-V SCV of the median and the ulnar sensory SNAP- fistulas. To rule out the impairment of peripheral compared to healthy subjects were recorded nervous system the neurophysiological evaluation (p<0.001) (Table 3). plays a very important role. Most of electrophysi-

272 Tirić-Čampara et al. Silent period in patients on hemodialysis

ological studies are focused on the evaluation of sing focal entrapment neuropathy (11,22). An im- nerves of the lower limbs (4,5,17). The damage is portant step in the development of the prolongation more prominent on the peripheral nerves of lower of the onset CSP latency L1 may be the ischemic limbs than on the upper limbs due to the length- factor due to A-V fistula (22,23). Some authors dependent factor of the nerves (1,8,11). The eva- suggest the occurrence of severe carpal tunnel luation of large-diameter nerve fibers in different syndrome with accompanying polyneuropathy in neuropathies is well established in routine praxis hemodialysis patients (24). In only one of our pa- (8,9,11). The role of thin unmyelinated nerve fi- tients (duration of hemodialysis 19 years) a severe rers in most studies is underestimated (3,4,16). entrapment syndrome with absent motor and sen- The CSP is a simple method and provides a new sory parameters including CSP was observed. The- feasibility in detecting the function of small nerve re is a great likelihood that the small unmyelinated fibers. Small nerve fibers are very susceptible and nerve fibers are more sensitive to ischemia than often precede the damage of large fibers in patients the large myelinates fibers. Most of our patients with metabolic polyneuropathy (17). In this study were complaining of paresthesia and pain. These we intended to assess the impairment of small ner- symptoms correlate with the involvement of small ve fibers on the hands with A-V fistulas and their nerve fibers (23). The duration of voluntary musc- relationship to conventional electromyography. In le activity suppression (CSP) was not changed in the previous study the it was described the onset the patient group. We assume that the reason for latency L1 of CSP of 66 ms (range 49-73) in fema- a prolonged onset CSP latency L1 was most pro- les, 69 ms (range 42-79) in males, late latency L2 bably due to decreased number of small nerve fi- of 121 ms (range 109-131) in females and 124 ms bers. The reduced number of the small nerve fibers (range 116-136) in males, where as the duration of reduced the impulse volley on interneurons in the suppression was 55,0 ms (range 45-74) in females spinal cord. The deficient afferent impulse volley and 59,0 ms (range 52-67) in males (18). There through the pathway to spinal interneurons has the is a small number of electrophysiological methods consequence of a delayed onset CSP L1 latency. which enable the quantitative assessment of these Simultaneously, the decreased number of large- types of nerve fibers (quantitative sensory testing) diameter A-alpha and A-beta fibers diminish the (19), or analysis of heart rate variability and sud- activity of the interneurons (9,11,17). Our finding motor axon reflexes (20). For this purposes a nerve demonstrated an early dysfunction of small nerves biopsy is rarely performed. fibers in patients with A-V fistulas.It seems that In our study we recruited 38 patients on hemo- vascular ischemic component due to A-V fistulas dialysis and 35 healthy subjects. In only one pa- contributes to the involvement of the thin nerve fi- tient CSP was not obtained. In this case DML of bers resulting in abnormalities of CSP (5,8). the median nerve was very prolonged and sensory In hemodialysis patients the routine electromyo- parameters were not elicitable. Similar results in a graphy and CSP were recorded. Wite both neu- small group of patients with carpal tunnel syndro- rophysiological techniques large and small-di- me were described previously (21). In our patients ameter nerve fibers were evaluated. Motor and motor conduction study showed normal DMLs but sensory conduction revealed significant changes prolonged F-wave latencies and decreased MCV; of motor and sensory parameters of the median sensory conduction revealed significant abnorma- and ulnar nerves, except DML. The significantly lities of sensory parameters, amplitude and SCV. prolonged CSP latency L1 indicates the impair- Additionally, in the patients with A-F fistulas signi- ment of small nerve fibers. It seems that the me- ficantly prolonged onset CSP latencies L1 were re- asurement of small nerve fibers in hemodialisis corded. This finding definitely indicates the impa- patient is recommended. irment of small nerve fibers of the median nerves. The delay of the onset CSP latencies L1 cannot be FUNDING related to the beginning carpal tunnel syndrome No specific funding was received for this study. because concomitant abnormalities of ulnar sensory parameters were observed. This supports the TRANSPARENCY DECLARATON impairment of small nerve fibers rather than ari- Competing interest: none to declare.

273 Medicinski Glasnik, Volume 11, Number 2, July 2014

REFERENCES 1. Baumgaertel MW, Kraemer M, Berlit P. Neurolo- 14. Pullman SL, Ford B, Elibol B, Uncini A, Su PC, gic complications of acute and chronic renal disese. Fahn S. Cutaneous electromyographic silent peri- Handb Clin Neurol 2014; 119:383-93. od findings in brachial dystonia. Neurology 1996; 2. Said G. Uremic neuropathy. Handb Clin Neurol 46:503-8. 2013; 115:607-12. 15. Lee HJ, DeLisa JA. Manual of nerve conducti- 3. Lacerda G, Krummel T, Hirsch E. Neurologic pre- on study and surface anatomy for needle elec- sentations of renal diseases. Neurol Clin 2010; tromyography, 4 th ed. Philadelphia: Lippincott 28:45-59. Wiliams&Wilkins, 2005:25-55. 4. Al-Hayk K. Neuromuscular complications in uremi- 16. Rogers NM, Lawton PD. Ischaemic monomelic ne- cs: A review. Neurologist 2007; 13:188-96. uropathy in a non-diabetic patient following creation 5. Aggarwal HK, Sood S, Jain D, Kaverappa V, Yadav of an upper limb arteriovenous fistula. Nephrol Dial S. Evaluation of spectrum of peripheral neuropathy Transpant 2007; 22:933-5. in predialysis patients with chronic kidney disease. 17. Stevens MJ, Edmonds ME, Foster AV, Watkins PJ. Ren Fail 2013; 35:1323-9. Selective neuropathy and preserved vascular res- 6. Ropper AH. Accelerated neuropathy in renal failure. ponses in diabetic Charcot foot. Diabetologia 1992; Arch Neurol 1993; 50:536-9. 35:148-54. 7. Said G, Boudier L, Selva J, Zingraff J, Drueke T. 18. Tiric-Campara M, Denislic M, Djelilovic-Vranic J, Different patterns of uremic polyneuropathy: clini- Alajbegovic A, Tupkovic E, Gojak R, et al. Cuta- co-pathologic study. Neurology 1983; 33:567-74. neous silent period in the evaluation of small nerve 8. Krishnan AV, Kierman MC. Uremic neuropathy: cli- fibres. Med Arh 2014; 68:6-9. nical features and new pathophysiological insight. 19. Denišlič M, Meh D. Die quantitative Bestimmung Muscle Nerve 2007; 35:273-90. der Function der dünnen Nervenfasern. Nervenarzt 9. Serrao M, Parisi L, Pierelli F, Rossi P. Cutaneous af- 1997; 68:509-14. ferents mediating the cutaneous silent period in the 20. Low PA, Caskey PE, Tuck RR, Fealey RD, Dyck PJ. upper limbs: evidences for a role of low-threshold Quantitative sudomotor axon reflex test in normal sensory fibres. Clinical Neurophysiology 2001; 112: and neuropathic subjects. Ann Neurol 1983; 3:573- 2007-14. 80. 10. Inghilleri M, Cruccu G, Argenta M, Polidori L, 21. Aurora SK, Ahmad BK, Aurora TK. Silent period Manfredi M. Silent period in upper limb muscles abnormalities in carpal tunnel syndrome. Muscle after noxius cutaneous stimulation in man. Electro- Nerve 1998; 21:1213-5. enecephalography and Clin Neurophysiology 1997; 22. Leis AA, Kofler M, Ross MA. The silent period 105:109-15. in pure sensory neuropathy. Muscle Nerve 1992; 11. Leis AA, Kofler M, Ross M. The silent period in 15:1345-8. pure sensory neuronopathy. Muscle Nerve 1992; 23. Koo YS, Park HR, Joo BE, Choi JY, Jung KY, Park 15:1345-8. KW, Cho SC, Kim BJ. Utility of the cutaneous silent 12. Berardelli A, Rothwell JC, Day BL, Marsden CD. period in the evaluation of carpal tunnel syndrome. Pathophysiology of blephasospasm and oromandi- Clin Neurophysiol 2010; 121:1584-8. bular dystonia. Brain 1985; 108:593-608. 24. Gousheh J, Iranpour A. Association between carpal 13. Fuhr P, Zeffiro T, Hallet M. Cutanous reflexes in tunnel syndrome and arteriovenous fistula in hemodi- Parkinson’s disease. Muscle Nerve 1992; 15:733-9. alysis patients. Plast Reconstr Surg 2005; 116:508-13.

274 Tirić-Čampara et al. Silent period in patients on hemodialysis

Kožni period tišine u procjeni malih nervnih vlakana kod pacijenta na hemodijalizi Merita Tirić-Čampara1, Miro Denišlič2, Emir Tupković3, Salih Tandir4, Jasminka Djelilović Vranić1, Azra Alajbegović1, Refet Gojak5, Jasem Y. Al-Hashel6, Halima Resić7

1Neurološka klinika, Klinički centar Univerziteta u Sarajevu, Sarajevo, Bosna i Hercegovina; 2Medicinski fakultet, Univerzitet u Ljubljani, Ljubljana, Slovenija; 3Odjel neurofiziologije, Dom zdravlja Tuzla; 4Zdravstveni fakultet, Univerzitet u Zenici, Zenica; 5Infektivna klinika, Klinički centar Univerziteta u Sarajevu, Sarajevo; Bosna i Hercegovina; 6Neurology Department, Ibn Sina Hospital, Kuwait; 7Klinika za hemodijalizu, Klinički centar Univerziteta u Sarajevu, Sarajevo, Bosna i Hercegovina

SAŽETAK

Cilj Bubrežno oboljenje kod pacijenata na hemodijalizi može uzrokovati oštećenja perifernog nervnog sistema. U većini slučajeva oštećenja perifernog nervnog sistema radi se o polineuropatijama. Cilj našeg istraživanja bio je evaluacija funkcije malih A-delta nervnih vlakana koja se često previdi prilikom ispitivanja.

Metode Funkcija nervnih vlakana većeg promjera izvršena je korištenjem standardnog rutinskog neu- rofiziološkog pregleda. Kožni period tišine (KPT) izazvan je električnom stimulacijom vrha kažiprsta putem bipolarnih elektroda. Površinske elektrode postavljene su na centar m. abductor pollicis brevis. Početna latenca (L1) zabilježena je na početku supresije voljne mišićne aktivnosti, a kasna latenca (L2) na početku nove mišićne aktivnosti. Razlika između dvije latence predstavlja trajanje KPT-a.

Rezultati Studija je uključila 38 pacijenata (muškarci/žene 21/17; prosječna dob 56,6±10.9 godina) koji su bili na hemodijaliznom tretmanu (od 1 mjeseca do 30 godina) i 35 zdravih ispitanika (muškarci/žene 23/17; prosječna dob 47,4±10,1 godina). Rezultati istraživanja provodljivosti pokazali su značajno pro- duljenje F-valova n. medianus i n. ulnaris, te smanjene motoričke i senzorne brzine provođenja oba nerva kod pacijenata na hemodijalizi (p<0,001). Kod pacijenata s A-V fistulama pronađeno je značajno produženje početka KPT latence L1 (p<0,001), dok je samo trajanje KPT-a ostalo nepromijenjeno.

Zaključak Kod pacijenata na hemodijalizi zabilježeno je značajno oštećenje malih nervnih vlakana. Evaluacija malih nervnih vlakana doprinosi procjeni cijele funkcije perifernog živca.

Ključne riječi: uremična polineuropatija, arteriovenska fistula, EMNG

275 ORIGINAL ARTICLE

Increased counts and degranulation of duodenal mast cells and eosinophils in functional dyspepsia- a clinical study

Shijun Song1, Yan Song1, Haishan Zhang1, Gaiqin Li2, Xiaopei Li 2, Xiaohong Wang2, Zhen Liu2

1Department of General Surgery, China-Japan Union Hospital of Jilin University, Jilin Province, 2Department of Gastroenterology, Taian City Central Hospital, Taian City, Shandong Province; China

ABSTRACT

Aim Immune factors, especially mast cells and eosinophils, play an important role in the pathogenesis of functional dyspepsia. However, the role of these cells in the duodenum has not been fully understood in patients with functional dyspepsia. We aimed to investigate the infiltration and activation of mast cells and eosinophils in the duodena of subjects with functional dyspepsia.

Methods Duodenal biopsies obtained in 48 patients with functional dyspepsia and 21 healthy volunteers were collected for the study. Eosinophils in the bulb (D1) and the descending part (D2) of the duodenum were identified and counted by hematoxylin and eosin (H&E) staining. Major basic protein immunostaining was used to evaluate eosinophil degranulation, as well as mast cells Corresponding author: and mast cell degranulation was identified by toluidine blue staining. Yan Song Department of General Surgery, Results In the D2 area, compared to controls, functional dyspep- China-Japan Union Hospital of Jilin sia patients showed a marked increase in eosinophil cell numbers University (p=0.008) and eosinophil degranulation rate (p=0.005). Mast cell 126 # Xiantai Road, Changchun city, numbers were significantly increased in patients compared with controls in the D1 (p=0.002) and D2 areas (p<0.001), and the Jilin Province 130033, China degranulation rates of mast cells were significantly increased in Phone/fax.: +86 431 898 767 81; functional dyspepsia patients in the D1 (p=0.028) and D2 areas Email: [email protected] (p=0.044).

Conclusion Duodenal eosinophils and mast cells may be involved in the pathogenesis of functional dyspepsia.

Key words: pathogenesis, duodenum, immune factors, hematoxylin, eosin Original submission: 30 January 2014; Revised submission: 21 February 2014; Accepted: 15 March 2014.

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276 Song et al. Duodenal mast cells and functional dyspepsia

INTRODUCTION hypothesis speculated that increased duodenal eosinophil numbers in FD are relevant because of the Functional dyspepsia (FD) is a functional syn- eosinophil–mast cell–nerve-gut axis. In part, mast drome thought to originate in the gastroduodenal cells can promote eosinophil migration in the ga- region (1). As one of the most prevalent functio- stric mucosa (17). Mast cells incubated with eo- nal gastrointestinal disorders (FGIDs), the preva- sinophil mediators, major basic proteins (MBP), lence rate of FD has been noted to vary between eosinophil cationic proteins, and eosinophil peroxi- 11.0%-29.2% globally (2), thus, FD represents dase can release histamine, which may modulate a major impairment to health-related quality of sensory-motor dysfunction (18). The neural–mast life and a social and economic burden (3-5). Al- cell–eosinophil interaction may cause abdominal though visceral hypersensitivity, gastric motor pain or meal-related symptoms characteristic of dysfunction, Helicobacter pylori (H. pylori) in- functional disease. Pathogens, food, infections, or fection and psychosocial factors (6) have been other allergens in the gut mucosa evoke eosinop- proposed as mechanisms in several investigati- hils, mast cells, and other components in a cascade ons, the pathogenesis of FD remains unclear. to up-regulate serotonin and to modulate the ente- In FD, the duodenum has now been implicated as a ric nervous system (ENS), thus the central nervous key area for the origination of symptoms (7). Pati- system (CNS) directly (19). Thus, as the key parti- ents with functional dyspepsia have abnormalities cipants in gut hypersensitivity, mast cells and eosi- in antral/duodenal motility (8), increased spontane- nophils are often co-dependent (19). However, few ous duodenal acid exposure (9,10) and increased investigations have shown a correlation between sensitivity to intraduodenal lipids (11). More im- duodenal mast cells and FD (20). portantly, patients with FD have duodenal immune According to the Rome III Criteria (36), the activation. Functional dyspepsia may begin after a symptoms of FD are described as epigastric pain, bout of gastroenteritis in the form of post-infectio- epigastric burning, postprandial fullness and ear- us functional dyspepsia (PI-FD), or it may begin de ly satiation in the absence of any organic, system- novo in the form of nonspecific functional dyspep- ic, or metabolic disease that is likely to explain sia. Post-infectious functional dyspepsia is associ- the symptoms. Functional dyspepsia has been ated with persisting focal T-cell aggregates, decre- divided into two subgroups: postprandial distress ased CD4+ cells and increased macrophage counts syndrome (PDS) and epigastric pain syndrome surrounding the crypts of the duodenum, indicating (EPS). The definition and subgroups of FD have the impaired ability of the immune system to ter- undergone major changes from the Rome II to minate the inflammatory response after acute in- the Rome III definitions (20,21), reflecting the sult (12). Duodenal eosinophilia and degranulation changing understanding of the categorization and have been shown to correlate with the symptoms of the pathophysiological basis of this disorder. The FD, especially with early satiety (13). Furthermore, Rome III committee proposed that the distinction in one report including patients with FD and with between meal-induced symptoms and meal-un- irritable bowel syndrome (IBS), mast cells were related symptoms was pathophysiologically and significantly increased in the duodenum of IBS pa- clinically relevant; this distinction forms the ba- tients, while eosinophils were increased in FD pati- sis of the newly defined subcategories of FD (1). ents, indicating that duodenal mast cell hyperplasia is linked to IBS and eosinophilia to FD. Duodenal The alteration of duodenal eosinophils and mast ce- biopsy may identify subsets of these disorders (14). lls in patients with FD consistent with the Rome III In postprandial distress syndrome (PDS), both the Criteria and the differences between PDS and EPS mean eosinophil counts and the prevalence of du- are unknown. The aim of this study was to investi- odenal eosinophilia were significantly higher than gate the infiltration and activation of mast cells and in controls (15). These studies regarding duodenal eosinophils in the duodena of subjects with FD. eosinophils in FD patients provided an eosinophil PATIENTS AND METHODS hypothesis for functional dyspepsia, which proposed that changes in duodenal eosinophils (and not Patients and controls gastric eosinophils) might be an underlying feature Newly diagnosed FD patients fulfilling the Rome (and primary pathogenic process) of FD (16). The III criteria and healthy volunteers were prospec-

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tively recruited from the outpatient gastroenterol- MBP Immunostaining for eosinophil degranulation ogy clinic and by public advertising, respectively. Major basic protein (MBP) immunostaining for the All the patients and controls had no history of sur- evaluation of eosinophil degranulation was perfor- gery or anaphylactic disease. Blood, urine, stool, med. Sections from D1 and D2 were cut at 3 µm stool occult blood, liver and kidney function, and deparaffinized. They were washed with xylene blood glucose, blood lipids, abdominal B ultra- for 5 minutes twice, 100% alcohol for 5 minutes sound and upper gastrointestinal tract endoscopy twice, 95% alcohol for 5 minutes twice, 90% al- examinations were performed in all patients and cohol for 5 minutes twice, 85% alcohol for 5 mi- controls. A complete medical history and physi- nutes twice, 80% alcohol for 5 minutes twice and cal examination were carried out. This study was then with water followed by PBS twice, blocked approved by the Ethics Committee of Shandong with 3% H O for 10 minutes, and washed with Province Taian City Central Hospital, and an in- 2 2 distilled water and then PBS for 5 minutes. Furt- formed consent was signed by all participants. her, the samples were purified as follows: incuba- Definition of functional dyspepsia tion with normal goat serum fluid for 10 minutes, removal of fluid, incubation with anti-eosinophil Dyspepsia was defined in the present study by major basic protein monoclonal antibody (Clone epigastric pain, epigastric burning, postprandial BMK-13, Thermo Scientific Inc, USA) overnight fullness, and early satiation. These cases were at 4oC, washing with 0.1 M PBS for 5 minutes 3 required to have no evidence of peptic ulcer dis- times, incubation with biotinylated goat anti-rabbit ease, gastro esophageal reflux disease with or IgG (ZYMED, USA) for 20 minutes at room tem- without esophagitis, malignancy, pancreaticobili- perature, washing with PBS for 3 minutes thrice, ary disease, or medication use. The diagnoses of incubation with horseradish enzyme labeling strep- FD, PDS and EPS were consistent with the Rome to-antibiotin fluid for 20 minutes at room tempera- III definitions (20). ture, and, finally, washing with PBS for 3 minutes Hematoxylin and eosin (H&E) staining 3 times. Diaminobenzidine (DAB) was used as the developer, while counterstaining was performed During the upper gastrointestinal tract endosco- with hematoxylin, and the slides were mounted py, two standardized biopsies were taken from with neutral gum. The sections were autoanalyzed the duodenal bulb (D1) and the descending part by a multipurpose genuine color cell image anal- (D2) of the duodenum. Biopsies were then fixed ysis administration system (Image-Pro Plus, Media in formalin and routinely processed in paraffin Cybernetics Inc, USA). Eosinophil degranulation wax. Sections were cut at 3 µm with levels and was considered positive if immunostained MBP stained with hematoxylin and eosin (H&E). granules released from eosinophils collected in the For the determination of duodenal pathology, the lamina propria of the section. The number of FD, architecture of the villi and the presence and gra- PDS, EPS and control subjects with positive eosi- de of acute and chronic inflammation were recor- nophil degranulation staining was counted. ded. Eosinophil counts in 5 non-overlapping high Duodenal cell counts (eosinophils, mast cells) power fields (HPF) were performed in D1 and D2 and summed up to give the total count of 5 HPF. Quantification of the eosinophils and mast cells was performed using an Olympus microscope Toluidine blue staining (BX51T-PHD-J11, Japan) at 40× magnification. Toluidine blue staining for the identification of Toluidine blue staining showed mast cells with mast cells was performed on paraffin-embedded purple granules and blue nuclei. The eosinophils, duodenal biopsies. Sections were then cut at 3 mast cells and mast cells with stained degranu- µm, deparaffinized, stained with 0.5% toluidine lation were counted in 5 non-overlapping HPF, blue solution, washed with water, differentiated with the counts of each expressed as the total with 0.5% glacial acetic acid solution until clear number of cells in the selected fields. Statistics nuclear and cytoplasmic granules were revealed, The data on the number of subjects with duodenal washed and dried, made transparent with xylene, eosinophil degranulation and the cell counts were and fixed with neutral gum. examined for differences using χ2-test and the

278 Song et al. Duodenal mast cells and functional dyspepsia

student’s t-test, respectively. The results are expressed as the means±SD. A p value of less than 0.05 was considered to indicate statistical significance.

RESULTS

Cases and controls Of the 21 control subjects recruited, 12 (57%) were women, with a mean age of 46 years (SD 10.58). Of the 48 FD subjects, 35 (73%) were women, with a mean age of 44 years (SD 11.64). Of the 48 patients diagnosed with FD according to the Rome III criteria, 23 were identified as having Figure 1. Typical eosinophil morphology (black circle) with a bilobed PDS (18 women) with a mean age of 45 years (SD nucleus and eosinophilic cytoplasm around the duodenal gland in functional dyspepsia (Hematoxylin and Eosin staining, 40×) 7.30) and 25 were identified as having EPS (17 (Figure 2). Major basic protein degranulation rates women) with a mean age of 47 years (SD 15.72). were assessed for the estimation of eosinophil de- Blood, urine, stool, stool occult blood, liver and granulation. In D2, eosinophil degranulation was kidney function, blood glucose, blood lipids, ab- observed in 26 of 48 subjects with FD, 12 of 23 dominal B ultrasound and upper gastrointestinal subjects with PDS and 14 of 25 EPS subjects vs. tract endoscopy examinations showed no abnor- 3 of 21 controls (p=0.005, p=0.02, and p=0.009, malities in any of the patients or controls. respectively). In D1, eosinophil degranulation was Histopathology in controls and FD subjects observed in 8 of 48 subjects with FD, 3 of 23 with PDS and 5 of 25 with EPS vs. 2 of 21 controls In the duodenum, the histology by H&E staining p=1.00, p=1.00, and p=1.00, respectively). in all cases showed normal architecture and, in FD and control subjects, normal histology in D1 and D2. No active duodenitis, visible intestinal parasites or cancer was observed in any subject.

Duodenal eosinophil counts There were significantly increased eosinophil counts in D2 in FD, PDS and EPS subjects vs. controls (p=0.008, p=0.045, p=0.007, respectively) (Figure 1); however, there was no significant alteration of the eosinophil counts in D1 in FD, PDS and EPS subjects vs. controls ( =0.82, p=0.85, p=0.84, respectively) (Table 1). Figure 2. Immunostaining of major basic protein (MBP) particles Table 1. Duodenal eosinophil counts in functional dyspepsia, released from eosinophils collected in the duodenal lamina propria postprandial distress syndrome and epigastric pain syndrome in functional dyspepsia (MBP Immunostaining, 40×) vs control No of D1 eosinophil co- D2 eosinophil Patient p p Duodenal mast cell counts and degranulation patients unt (mean±SD) count (mean±SD) Control 21 22.62±6.26 19.48±5.06 Mast cells without degranulation were observed as PDS 23 22.26±5.78 0.85 22.65±5.81 0.045 EPS 25 22.24±6.38 0.84 23.76±4.58 0.007 intact with uniform cytoplasm and clear membra- FD 48 22.25±6.03 0.82 23.23±5.18 0.008 nes; in contrast, mast cells with degranulation de- FD, functional dyspepsia; PDS, postprandial distress syndrome; EPS, monstrated irregular morphologies with ruptured epigastric pain syndrome; D1, duodenal bulb; D2, descending part of the duodenum; membranes and particles released from the mast cells gathered around the membranes (Figure 3). Eosinophil degranulation Mast cells were significantly increased in FD, PDS Major basic protein (MBP) immunohistoche- and EPS subjects in D1 (p=0.002, p=0.001 and mistry showed that MBP particles were released p=0.001, respectively) and D2 (p<0.001, p<0.001 from eosinophils collected in the lamina propria and p<0.001, respectively); mast cell degranu-

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lation was significantly increased in FD, PDS with host immune and nervous super systems, as and EPS subjects in D1 (p<0.001, p<0.001 and well as with gut microflora, to provide tight micro- p<0.001, respectively) and D2 (p=0.016, p<0.001 environmental conditions (22). They can release and p<0.001, respectively) (Tables 2 and 3). a wide range of potent mediators with a number of physiological functions in the gastrointestinal tract, namely, regulatory functions such as control of blood flow and coagulation, smooth muscle contraction and peristalsis, and secretion of acid, electrolytes, and mucus by epithelial cells (23). En- hanced knowledge of the pathophysiological basis of functional gastrointestinal disorders indicates that low-grade mucosal inflammation and mast cell hyperplasia are common findings (22). Ter- minal ileal mucosal mast cell counts (MMCC) are significantly elevated in majority of patients with IBS (24). The mast cells may be responsible for the altered visceral perception found in the gastrointe- Figure 3. Mast cells without degranulation (green arrow) and with degranulation (red arrow) in the duodenal lamina propria in stinal tracts of patients with IBS. Similar situati- functional dyspepsia (Toluidine blue staining, 40×) ons have been observed in cases of FD. Mast cells Table2. Duodenal mast cell counts in functional dyspepsia, are significantly increased in functional dyspepsia postprandial distress syndrome and epigastric pain syndrome samples in the antrum (25-27). Mast cells are also vs control relevant to gastric dysfunction in FD, for exam- D1 mast D2 mast No. of ple, in gastric emptying and electrogastrography Patient cell count p cell count p patients (mean±SD) (mean±SD) (EGG). Elevated mast cell density is associated Control 21 104.29±20.81 108.62±7.64 with slower one hour gastric emptying, increased PDS 23 121.00±13.75 0.001 124.32±16.53 <0.001 pre-prandial dysrhythmia and the pre-prandial per- EPS 25 120.88±13.13 0.001 122.24±9.54 <0.001 FD 48 120.94±13.31 0.002 123.28±13.40 <0.001 centage of tachygastria (27). In gastric biopsies in PI-FD patients, the number of mast cells increases FD, functional dyspepsia; PDS, postprandial distress syndrome; EPS, epigastric pain syndrome; D1, duodenal bulb; D2, descending part of with the density of chronic inflammatory cells. the duodenum; MC, mast cell Electron microscopy can be used to identify secre- Table 3. Duodenal mast cell degranulation rates (%) in func- ting granules in the cytoplasm of mast cells, and tional dyspepsia, postprandial distress syndrome and epigas- the number of activated mast cells at a distance of tric pain syndrome vs. control < 5 μm from nerve fibers is significantly greater in D1 mast D2 mast No. of Patient cell count p cell count p PI-FD vs nonspecific FD or controls (28). patients (mean±SD) (mean±SD) Our study may extend the results of previous stu- Control 21 25.38±2.32 30.66±2.89 PDS 23 59.84±4.50 <0.001 66.63±5.37 <0.001 dies showing mast cell hyperplasia in the stomach. EPS 25 60.58±5.66 0.001 67.28±5.32 <0.001 These findings regarding mast cells suggest that FD 48 60.23±5.10 <0.001 66.97±5.30 0.016 duodenal mast cells might be involved in the pa- FD, functional dyspepsia; PDS, postprandial distress syndrome; EPS, epigastric pain syndrome; D1, duodenal bulb; D2, descending part of thogenesis of functional dyspepsia. So far, there the duodenum; MC, mast cell have been several studies concerned with the al- DISCUSSION teration of duodenal mast cells in FD patients, and the results remain inconclusive. Schurman et al. This study suggests that the counts and degranu- found that at the individual symptom level, having lation of mast cells in the bulb and descending pain that wakes the patient from sleep was associ- part of the duodenum are significantly increased ated with a higher duodenal mast cell density (29). in FD, PDS and EPS patients. However, the co- Walker et al. reported that mast cells were signifi- unts and degranulation of eosinophils are signi- cantly increased in the duodenum in patients with ficantly increased only in the descending part of IBS but not FD (14). Our study supported the for- the duodenum in FD, PDS and EPS patients. mer report, which, although unlike ours, was based Mast cells are multipotent, mucosa-dwelling re- on data from cases of pediatric, not adult, functio- sidents that are uniquely located to communicate nal dyspepsia. Some factors may contribute to the

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differences between our study and that of Walker This study can provide implications for drug et al. First, the Rome III Criteria were adopted in therapy in FD using mast cell or eosinophil sta- our study, whereas the Rome II criteria were used bilizers. The mast cell stabilizer ketotifen can in their study. The changes from the Rome II to the decrease visceral hypersensitivity and improve Rome III definition reflect the changing understan- intestinal symptoms in patients with IBS (34). ding of the categorization and pathophysiological Camostat mesilate (CM), a synthetic protease basis of this disorder. Second, the gender distributi- inhibitor, could efficiently inhibit the visceral on among subjects with FD was different between sensitivity and paracellular permeability induced the two studies. There were thirty-five females out by the acute restraint stress in rats (35). Further of forty-eight subjects with FD in our study but study is required to assess whether these drugs only seven females of twenty-eight subjects in the- are of value to FD. irs. Gender may then correlate with mucosal mast A major strength of the present study is that the cell counts. One report showed that compared to subjects with FD in our study were consistent male IBS patients, female IBS patients had grea- with the Rome III Criteria of FGIDs, and these ter numbers of mast cells in their colons (30). We patients were divided into two subtypes accor- speculate that gender may influence duodenal mast ding to the Rome III definitions. In the Rome III cell counts, but conclusive evidence is still lacking. Criteria, considering FD as a broad category is This study suggests that increased counts and de- no longer thought to be useful in terms of resear- granulation of eosinophils in the descending part ch; instead, FD is defined by two new symptom of the duodenum are linked to FD. The role of duo- entities, epigastric pain (EPS) and meal-related denal eosinophils in FD may concern the eosinop- symptoms (PDS) (36). The limitations of our hil–mast cell–nerve-gut axis. Some triggers, such study also need to be considered. One limitation as stress, allergens, and pathogens, can activate is that the H. pylori status of subjects with FD eosinophils; degranulation of eosinophils leads to and the controls was not recorded. Although the increased epithelial permeability and the activation role of H. pylori infection in FD has been contro- of mast cells, which can lead to neural stimulation versial (37, 38), H. pylori infection may induce and smooth muscle contraction, in turn resulting in the migration and activation of mast cells (39). gastrointestinal symptoms, such as abdominal pain Furthermore, a correlation analysis between FD and bloating (31). Major basic protein released symptoms and duodenal mast cells or eosinophils from eosinophil degranulation can induce vagal was not performed in our study. M2 receptor dysfunction, thus increasing smooth In conclusion, the present study demonstrates that muscle reactivity (32). Major basic protein is also duodenal mast cells and eosinophils may be invol- a trigger in the activation of mast cells (33). In our ved in the pathogenesis of FD. Although further study, MBP degranulation in D2 was significantly work is needed to verify the findings, our results increased in patients with FD. We speculate that might have implications for a drug therapy in FD. mast cells and eosinophils in the duodenum, especially in the descending part, may participate in the FUNDING pathogenesis of functional dyspepsia. However, Funding: no specific funding was received for in contrast to the study of Walker et al., increased this study. eosinophil counts were not obtained in the bulb of TRANSPARENCY DECLARATION duodenum. The reason for this is unknown. Competing interests: None to declare. REFERENCES 1. Geeraerts B, Tack J. Functional dyspepsia: past, pre- 4. Chang L. Review article: epidemiology and quality of sent, and future. J Gastroenterol 2008; 43:251–5. life in functional gastrointestinal disorders. Aliment 2. Mahadeva S, Goh KL. Epidemiology of functional Pharmacol Ther 2004; 20:31–9. dyspepsia: a global perspective. World J Gastroente- 5. Talley NJ. Functional gastrointestinal disorders as a pu- rol 2006; 12:2661-6. blic health problem. Neurogastroenterol Motil 2008; 3. Talley NJ, Weaver AL, Zinsmeister AR. Impact of fun- 20:121–9. ctional dyspepsia on quality of life. Dig Dis Sci 1995; 6. Keohane J, Quigley EM. Functional dyspepsia: The 40:584-9. role of visceral hypersensitivity in its pathogenesis. World J Gastroenterol 2006; 12:2672-6.

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7. Walker MM, Warwick A, Ung C, Talley NJ. The role 24. Weston AP, Biddle WL, Bhatia PS, Miner PB Jr. Ter- of eosinophils and mast cells in intestinal functional minal ileal mucosal mast cells in irritable bowel syn- disease. Curr Gastroenterol Rep 2011; 13:323-30. drome. Dig Dis Sci 1993; 38:1590-5. 8. Sha W, Pasricha PJ, Chen JD. Correlations among 25. Hall W, Buckley M, Crotty P, O’Morain CA. Gastric electrogastrogram gastric dysmotility and duodenal mucosal mast cells are increased in Helicobacter dysmotility in patients with functional dyspepsia. J pylori-negative functional dyspepsia. Clin Gastroen- Clin Gastroenterol 2009; 43:716-22. terol Hepatol 2003; 1:363-9. 9. Lee KJ, Demarchi B, Demedts I, Sifrim D, Raeyma- 26. Matter SE, Bhatia PS, Miner PB. Evaluation of antral ekers P, Tack J. A pilot study on duodenal acid ex- mast cells in nonulcer dyspepsia. Dig Dis Sci 1990; posure and its relationship to symptoms in functional 35:1358-63. dyspepsia with prominent nausea. 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282 ORIGINAL ARTICLE

Clinical case series of nine patients with tuberculousmeningitis in the Clinical Centre of Vojvodina, Novi Sad, AP Vojvodina, Serbia 2001-2010

Radoslava Doder1,2, Grozdana Čanak1,2, Sandra Stefan Mikić1,2, Siniša Sević1,2, Aleksandar Potkonjak3, Dragan Doder4, Vuk Vračar3

1School of Medicine, University of Novi Sad, 2Department of Infectious Diseases, Clinical Centre of Vojvodina,3Department of Veteri- nary Medicine, Faculty of Agriculture, University of Novi Sad, 4Provincial Institute of Sports Medicine and Sports; Novi Sad, Serbia

ABSTRACT

Aim To determine immediate risk factors of developing tuberculous meningitis, to assess the practical importance of clinical signs and findings in the cerebrospinal fluid (CSF) when opting for the specific therapy, and to predict the outcome of disease in relation to the beginning of treatment.

Methods A retrospective clinical case series of nine patients with tuberculous meningitis who were treated from April 2001 until November 2010 at the Department of Infectious Diseases in Novi Sad, Serbia was presented. Data of patients’ medical records and Corresponding author: presentation of clinical and laboratory features, neuroradiological- Radoslava Doder findings and outcome were used. School of Medicine, University of Novi Sad; Results The factors of immediate risk/predisposition for the deve- Department of Infectious Diseases, lopment of tuberculous meningitis were found in two (22.2%) pa- Clinical Centre ofVojvodina tients. The duration of symptoms prior to admission was 9 days on Hajduk Veljkova 1-9, average (from 3 to 20 days). The most frequent symptoms on ad- 21000 Novi Sad, Serbia. mission were headache and fever in eight (88.9%) patients, whereas two patients (22.2%) were presented with stiff neck and pho- Phone: +381 21 484 3859; tophobia. Consciousness was preserved in six patients (66.7%), Fax:+381 21 480 062; two patients were somnolent and one was in coma. Two(22.2%) E mail: [email protected] patients had concurrent pulmonary tuberculosis. Neuroradiologi- cal signs of the disease were present in two patients.

Conclusion The duration of symptoms before admission, clinical examination and CSF analysis can be helpful in identifying pati- Original submission: ents who are at high risk of developing tuberculous meningitis. 05 February 2014; Key words: meningitis, tuberculosis, clinical features, complica- Revised submission: tions, outcome 14 April 2014; Accepted: 21 May 2014.

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INTRODUCTION to early changes in TBM, but the diagnostic sensitivity and specificity of these signs are low. In Tuberculosis of the central nervous system fact, similar radiological findings are typical for (CNS) is expected in about 1% of all patients cryptococcal meningitis, cytomegalovirus encep- having active tuberculosis (1). It is caused by halitis, toxoplasmosis, sarcoidosis, metastases in hematogenous dissemination of Mycobacterium the meninges and lymphoma (8). tuberculosis (MBT) from the primary infection in the lungs and the formation of small andsubepen- Treatment of all forms of CNS tuberculosis sho- dimal foci in the brain or spinal cord (1). Rupture uld be initiated by taking four drugs (isoniazid, of the tubercula on the surface of the brain leads rifampicin, pyrazinamide, ethambutol or strepto- to the direct penetration of MBT into the subara- mycin) for two months, and then continue with chnoid space and development of meningitis (2). two drugs (isoniazid, rifampicin) for the next ei- The process of merging of multiple small foci lo- ght to ten months (3,5,6). Streptomycin was one cated deep in the parenchyma of the brain or spi- of the first major antituberculous drugs, which nal cord results in tuberculomas (rarely abscess), was replaced by isoniazid as the cornerstone of without meningitis (1). therapy with less harmful side-effects. Its use is limited by high rates of resistance, parenteral Early diagnosis and promptly indicated treatment administration, nephrotoxicity, and ototoxicity are essential for the favorable course and out- (1,3,5). Ethambutol induced optic neuropathy, es- come of tuberculous meningitis (TBM)(2). This pecially when treating comatose patients (1,3,5). disease begins gradually with uncharacteristic According to the latest guidelines, adjuvant corti- symptoms such as headache, fever, vomiting and costeroid therapy (dexamethasone/prednisolone) anorexia. The stiff neck and paralysis of cranial is recommended in all patients with TBM, regar- nerves occur in 40-80% and 30-50% of patients, dless of the severity of the disease (9). Hydro- respectively (2). The analysis of cerebrospinal cephalus is common in children with TBM (7). fluid (CSF) is necessary and it usually reveals Diuretics, repeatedlumbar puncture (LP) or CSF typical, moderately intensive pleocytosis (10- diversion through ventriculoperitoneal or atrial 1000x103, with the dominance of lymphocytes), shunting can be used in accordance with the in- elevated protein level (0.5-3.0 g/L) and decreased creased intracranial pressure (5). concentration of glucose (sugar ratio in the CSF: blood sugar <0.5) (3). However, CSF findings The objective of this study was to determine im- may be atypical in immunocompromised patients mediate risk factors for the development of TBM, (e.g. acellular or dominated by neutrophils) (4). to assess the practical importance of clinical si- Direct microscopic identification of acid resistant gns and cytological and biochemical changes in bacilli and isolation of MBT from the CSF culture the CSF when opting for a specific therapy, and are the fastest and safest ways to confirm the di- to predict the outcome of the disease in relation agnosis (2,3). Thelatest meta-analysis has shown to the beginning of treatment. that the commercial techniques using amplifica- PATIENTS AND METHODS tion of DNA fragments in the diagnosis of TBM are 56% sensitive and 96% specific, and that they A clinical case series of nine patients, presented in can be useful in assessing therapeutic response this study, were diagnosed with tuberculous me- (5). Conventional radiography of the lungs can ningitis and treated at the Department of Infecti- detect active TB or old specific changes in half of ous Diseases in Novi Sad from April 2001 until the patients with TBM, and a miliary form of the November 2010.Patients were divided into two su- disease in 10% of patients (2).Computed tomo- bgroups, one having the confirmatory diagnosis of graphy (CT) of the head can detect hydrocepha- tuberculous meningitis (patient No 1,6 and 9) and lus and accumulation of the contrast in the base the other group having the presumptive diagnosis of the brain (6). Both signs are more often present of tuberculous meningitis (patient No 2,3,4,5,7 in children (~ 80%) than in adults (~40%) and and 8). The data were obtained from the medical may be absent in older patients (7). Magnetic re- records of all patients. Risk factors, demograp- sonance imaging (MRI) of endocranial cast can- hic, clinical and diagnostic data on admission and help to diagnose infratentorial lesions in relation clinical outcome after TBM treatment are hereby

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presented.This study was approved by the Ethics Statistical analysis Committee of Clinical Centre of Vojvodina. The methods of descriptive statistics were used Risk factors for statistical analysis. Pearson’s Chi square test was applied to determine the statistically signifi- The risk factors included a close contact with the cant correlation between the two subgroups (with person having a similar disease, previous pulmo- the confirmatory diagnosis and with a presump- nary tuberculosis, the use of corticosteroid drugs, tive diagnosis). malignant disease, head trauma, HIV co-infection as well as the social status. RESULTS

Diagnostic criteria Risk factors The definite diagnosis of TBM was made in three Epidemiological data regarding the contact with a patients when MBT was isolated from the CSF,or person having a similar disease were negative.No other body fluids or tissues. In all other patients, common risk factors for TBM (previous pulmo- the diagnosis of “probable TBM” was based on nary tuberculosis, use of corticosteroid drugs, ma- the clinical features and analysis of changes in lignant disease, and head trauma) were found. Half the CSF obtained by lumbar puncture on admi- of the patients were testedfor HIV status, and all of ssion, and favorable response to the application them were seronegative. Two patients (one from of anti-tuberculosis drugs (ATD). each subgroup) had data on alcohol consumption. Eight of nine patients lived in the cityarea. Clinical data Clinical data included the duration of symptoms Demographic and clinical characteristics before admission, presenting symptoms and The average age of patients was 47.3 years, ran- findings, CSF analysis results, basic hematolo- ging from 19 to 65 years; females were more pre- gical analyses and microbiological cultures on valent (F:M=66.5%:33.4%). The length of symp- admission, additional diagnostic procedures and toms before admission for treatment was 9 days applied therapy. The following inclusion criteria on average, ranging from 3 to 20 days (8.6 days wereused:fever >38.0 ºC, headache, meningeal and 9.1 days in the subgroup with the confirma- irritation, and neurological finding (examination tory diagnosis and the subgroup with presumpti- of consciousness, cerebral nerves, presence of ve diagnosis, respectively (p=0.904). physiological and/or pathological reflexes and On admission, eight (88.9%) patients had headache abnormal movements), as well as CSF pleocyto- and fever, stiff neck and photophobia were obser- sis, protein and glucose level and the reduction ved in two (22.2%) patients. Consciousness was in CSF/blood glucose ratio. Cytological-bioche- preserved in six (66.7%) patients: two patients had mical analysis of CSF was performed at the La- preserved consciousness and one female patient boratory Diagnostics Center, Clinical Center of was drowsy with dysarthria in the subgroup with Vojvodina. Blood culture, CSF culture, urine cul- the confirmatory diagnosis,whereasin the subgroup ture for bacteria and fungi, and microbiological with the presumptive diagnosis, four patients were analysis of nasal and throat swabs were carried conscious, one patient was somnolent and one was out at the Department of Microbiology, Institu- in coma.Nystagmus and hemiparesis were found te for Public Health of Vojvodina in Novi Sad. in one, and tremor in two patients in the subgroup Directmicroscopy and MBT culture in the CSF, with the presumptive diagnosis (Table 1). sputum and urine samples were performedin the Centre for Microbiology, Virusology and Immu- The CSF analysis on admission showed whi- 6 nology at the Institute for Pulmonary Diseases te blood cell count of 331.8±193.5 x 10 with of Vojvodina in Sremska Kamenica.All patients 61.2% lymphocytes (in the subgroup with the 6 underwent lung radiography, CT scan or MRI of confirmatory diagnosis it was 255.6±166.6x 10 the head, electroencephalogram (EEG), and other with 74.6% lymphocytes; in the subgroup with diagnostic methods as needed (abdominal ultra- the presumptive diagnosis it was 370 ± 208.6 x 6 sonography, chest CT scan, fundus examination). 10 with 54.5% lymphocytes) (p=0.440). The le-

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Table 1. Clinical characteristics on admission of patients with tuberculous meningitis Patient Age (years) Gender Residence Symptoms* Duration (days)† Neurological signs* 1‡ 65 F urban headache, fever, photophobia 14 preserved consciousness, disorientation 2 30 F urban headache, fever, photophobia 3 preserved consciousness, stiff neck 3 19 F rural thoracic pain 20 preserved consciousness 4 63 F urban headache, fever 5 preserved consciousness, stiff neck 5 54 M / headache, fever 10 drowsiness, nystagmus, tremor 6‡ 52 F / headache, fever 7 drowsiness, dysarthria 7 63 M urban headache, fever 10 coma, tremors 8 60 F urban headache, fever 7 preserved consciousness, left hemiparesis 9‡ 20 M urban headache, fever 5 preserved consciousness, stiff neck *Clinical symptoms and neurological sings on admission; †Duration of symptoms before admission; ‡Patients with confirmed diagnosis of tuberculous meningitis s vel of proteins in CSF was 1.9±1.2 g/L (2.2±1.5 Treatment and1.8 ± 1.2 in the subgroup with the confirma- Initial antituberculosis therapy with three drugs tory and presumptive diagnosis, respectively) (isoniazid, rifampicin, pyrazinamide) was ad- (p=0.675); the glucose concentration in CSF was ministered in four patients; other patients were 1.9±0.7 mmol/L (1.5 ± 0.5 and 2.1 ± 0.8, in the given four drugs (isoniazid, rifampicin, pyrazi- subgroup with the confirmatory and presumptive namide and ethambutol or streptomycin) for two diagnosis, respectively)(p=0.291) (Table 2). months. The therapy was introduced during the Diagnostic data first week of hospitalization in one patient and at the beginning of the second week in another. All patients had intracranial meningitis except Intermittent phase was continued with two drugs one female patient who had spinal form of menin- (isoniazid and rifampicin) for 9 months in total. gitis. Only three patients had positive CSF cultu- Side effects during the treatment were reported in re. The active form of tuberculosis was identified two patients in the form of toxic hepatitis. Four in two patients with the confirmatory diagnosis of the patients received the adjuvant therapy of of TBM. In younger patients, the disease had mi- corticosteroids (dexamethasone) together with liary, bronchiolitic and nodular form. The pati- antituberculosis drugs (ATD). ents underwent lymph node biopsy due to severe lymphadenomegaly three months before admi- Outcome ssion for treatment.According to Ziehl-Neelsen Seven (77.7%) patients were discharged without stain results no acid alcohol resistant bacilli were any consequences of the disease. One patient with presented.Magnetic resonance imaging of the the presumptive diagnosis was discharged with se- brain revealed specific changes intwo cases. Co- vere neurological deficit, and another one with the mmunicant decompensated hydrocephalus was confirmatory diagnosis was transferred to another detected in one patient with the presumptive di- facility due to exacerbated pulmonary infection. agnosis. In another case, post-contrast enhanced DISCUSSION nodular lesions in leptomeninges were found in a female patient with the confirmatory diagnosis. The duration of symptoms in tuberculous meningitis ranges from a few days to a month. The shorter Table 2. Diagnostic data in patients with tuberculous meningitis

WBC in WBC in PMN Protein Glucose MT in MT in Patient PMN Glucose Blood CSF blood SR Fibrinogen CSF in CSF level in level in CSF CSF sputum No (%) (mmol/L) culture culture (x 106) (x 106) (%) CSF (g/L) (mmol/L) culture culture 1* 7.4 78 62/110 5.5 7.3 negative 156 95 3.36 2.1 negative positive negative 2 7.9 85 30/61 2.31 5.3 negative 121 99 1.55 3.3 negative negative negative 3 7.2 80 139/144 6.6 3.80 negative 624 30 1.37 2.21 negative negative negative 4 21.5 84 40/45 2.25 6.3 negative 576 95 1.62 1.62 negative negative not done 5 7.4 75 22/48 5.1 6.2 negative 347 15 0,55 2.8 negative negative not done 6* 9.83 92 43/64 4.8 5.7 negative 163 99 0.54 1.2 negative positive positive 7 4,14 93 40/40 4.38 6.2 negative 152 53 4.2 1.3 negative negative negative 8 5.47 75 66/105 4.7 3.6 negative 400 35 1.81 1.6 negative negative negative 9* 7.52 93 22/44 2.89 5.0 negative 448 30 2.87 1.4 negative positive positive *Patients with confirmed diagnosis of tuberculous meningitis; WBC, white blood cell count; PMN,polymorphonuclear cells; SR, erytrocyte sedimentation rate; CSF, cerebrospinal fluid; MT,Mycobacterium tuberculosis

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course of illness (<5 days) may lead to the dia- halus, basal arachnoiditis, infarcts and tuberkulo- gnosis of bacterial or viral meningitis (7). Fungal mas (7,8,10,11). Computed tomography of the bra- meningitis, similar to the tuberculous meningitis, in or MRI of the endocranium, along with clinical may have a protracted course (7).The duration of and laboratory parameters are generally believed symptoms before admission for the treatment was to be very important for the diagnosis of tubercu- 9 daysin our cases, that in accordance with the data lous meningitis (13). In one of our patients, hydro- of other authors (10). Difficulties in establishing cephalus was diagnosed by CT and in the case of a early and accurate diagnosis based on clinical para- female patient with post-contrast enhanced nodular meters, changes in the CSF and neuroradiological lesions in leptomeninges described in the MRI, the diagnostic of TBM have been discussed in many previous CT scan was normal. The outcome of the clinical studies (4-7).Regardless of etiology, me- disease was favorable, with no deaths. It is gene- ningeal syndrome presents with similar symptoms rally believed that coma and delayed initiation of such as fever, headache, irritability, stiff neck and therapy were predictors of poor outcome. Similar vomiting (2,4,5). Drowsiness, cough, weight loss experience in relation to outcome has been descri- and night sweats may suggest tuberculosis, but bed in many studies (7,8,10,11-15). they are not specific enough (7). Therefore, it often Tuberculous meningitis affected middle-aged pe- happens that on admission many patients are alre- ople, predominantly women in our cases. The du- ady at the advanced stage of the disease and have ration of nonspecific symptoms before admission developed neurological signs such as seizures, was longer than a week. Common characteristics different degrees of coma and paralysis of cranial on admission were headache, fever and stiff neck. nerves (11). Many studies,which have attempted Analysis of the CSF is essential, especially if the to correlate headache and neurological deficit with culture is negative. Magnetic resonance imaging tuberculous meningitis, have shown no diagnostic of the brain and head is a diagnostic modality in value (5-8,10,11). In our cases, however, the most TBM complications. The outcome of the disease common clinical symptoms were headache and was favorable after 11 months of antituberculous fever, followed by the stiff neck and photophobia. chemotherapy, without fatal outcomes. A delayed In addition,consciousness was preserved in more treatment of TBM because of missed diagnosis than a half of the patients. Neurological signs such may result in poor outcome and death. A compa- as nystagmus, dysarthria and tremor were found in rison of patients with the confirmatory diagnosis individual cases. The routine analysis of the CSF in and with presumptive diagnosis of tuberculous many patients with TBM revealed moderate pleo- meningitis has resulted in the conclusion that cytosis dominated by lymphocytes, elevated prote- simple, noninvasive and practical clinical data in and decreased glucose concentration (3,5-7,10). and cerebrospinal fluid assessment can be useful Normal or atypical CSF findings were described to the physicians in diagnosing tuberculous me- in HIV-positive patients, cryptococcal meningitis ningitis in adults at an early stage. and cytomegalovirus meningitis, as well as in the central nervous system lymphoma (4,7,12). The FUNDING examination of cerebrospinal fluid of our patients No specific funding was received for this study. showed the typical finding for tuberculosis meningitis. The diagnostic evaluation can be helped by TRANSPARENCY DECLARATIONS neuroradiological changes in CT scan: hydrocep- Competing interests: none to declare REFERENCES

1. Thwaiters G, Fisher M, Hemingway C, Scot G, So- 3. Patel VB, Burger I, Connolly C. Temporal evolution lomon T, Innes J. British Infection Society guideli- of cerebrospinal fluid following initiation of -trea nes for diagnosis and treatment of tuberculosis of tment for tuberculous meningitis. S Afr Med J 2008; the central nervous system in adults and children. J 98:610-3. Infect 2009;59:167-87. 4. Cecchini D,Ambrosioni J,Brezzo C,Corti M,Rybko 2. Marais S,Thwaites G,Schoeman JF,Török ME,Misra A, Perez M,PoggiS,Ambroggi M.Tuberculous me- UK, Prasad K, Donald PR, WilkinsonRJ, Marais ningitis in HIV-infected and non-infected patients: BJ.Tuberculous meningitis: a uniform case defi- comparison of cerebrospinal fluid findings. Int J -Tu nition for use in clinical research. Lancet Infect berc Lung Dis 2009; 13:269-71. Dis2010;10:803-12.

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5. Principi N, Esposito S. Diagnosis and therapy of tions of tuberculous meningitis and its treatment at tuberculous meningitis in children. Tuberculosis Auckland City Hospital, New Zealand. J ClinNeu- (Edinb) 2012;92:377-83. rosci 2010; 17:1114-8. 6. Mihailidou E,Goutaki M,Nanou A, Tsiatsiou 12. Moreira J, Alarcon F,Bisoffi Z, Rivera J, Salinas O,Kavaliatis J. Tuberculous meningitis in Greek R,Menten J,Dueñas G, Van den Ende. Tuberculous children. Scand J Infect Dis 2012; 44:337-43. meningitis: does lowering the treatment threshold 7. Hsu PC, Yang CC, Ye JJ, Huang PY, Chiang PC, Lee result in many more treated patients? Trop Med Int MH. Prognostic factors of tuberculous meningitis in Health 2008; 13:68-75. adults: a 6-year retrospective study at a tertiary hos- 13. Coulter JB,Baretto RL,Mallucci CL, Romano MI, pital in northern Taiwan. J MicrobiolImmunol Infect Abernethy LJ, Isherwood DM,Kumararatne DS, La- 2010; 43:111-16. mmas DA. Tuberculous meningitis: protracted cour- 8. Figaji AA,Fieggen AG. The neurosurgical and acu- se and clinical response to interferon-gamma. Lancet te care menagment of tuberculous meningitis: Evi- Infect Dis 2007; 7:225-32. dence and current practice. Tuberculosis (Edinb) 14. Thwaites GE,Macmullen-Price J, Tran TH, Pham 2010;90:393-400. PM, Nguyen TD, Simmons CP, White NJ, Tran TH, 9. Byrd TF, Davis LE. Multidrug-resistant tuberculous Summers D, Farrar JJ. Serial MRI to determine the meningitis. CurrNeurolNeurosci Rep 2007;7:470-5. effect of dexamethasone on the cerebral pathology 10. Anderson NE,Somaratne J, Mason DF, Holland D, of tuberculous meningitis: an observational study. Thomas MG. A review of tuberculous meningitis at Lancet Neurol 2007; 6:230-6. Auckland City Hospital, New Zealand. J ClinNeu- 15. Sinha MK,Garg RK,Anuradha HK,Agarwal rosci 2010; 17:1018-22. A,Parihar A,Mandhani PA. Paradoxical vision loss 11. Anderson NE,Somaratne J, Mason DF, Holland D, associated with optochiasmatictuberculoma in tu- Thomas MG. Neurological and systemic complica- berculous meningitis: a report of 8 patients. J Infect 2010; 60:458-66.

Klinička serija slučajeva kod devet bolesnika s tuberkuloznim meningitisom u Kliničkom centru Vojvodine (AP Vojvodina, Srbija) u periodu od 2001. do 2010. godine Radoslava Doder1,2, Grozdana Čanak1,2, Sandra Stefan Mikić1,2, Siniša Sević1,2, Aleksandar Potkonjak3, Dragan Doder4, Vuk Vračar3 1Medicinski fakultet, Univerzitet u Novom Sadu,2Klinika za infektivne bolesti, Klinički centar Vojvodine, 3Departman za veterinarsku medicinu, Poljoprivredni fakultet, Univerzitet u Novom Sadu,4Pokrajinski zavod za sport i medicinu sporta; Novi Sad, Srbija SAŽETAK

Cilj Utvrditi faktore neposrednog rizika za razvoj tuberkuloznog meningitisa, ispitati praktični značaj kliničkih znakova i nalaza u likvoru u donošenju odluke za otpočinjanje specifične terapije, kao i usta- noviti ishod bolesti u odnosu na početak lečenja.

Metode Prikazana je retrospektivna serija devet bolesnika koji su pod dijagnozom tuberkuloznog meningitsa lečeni u periodu od aprila 2001. do novembra 2010. godine u Klinici za infektivne bolesti u Novom Sadu, Srbija. Podaci dobijeni iz istorijâ bolesti odnosili su se na kliničke, laboratorijske i demo- grafske karakteristike pacijenata, rezultate neuroradioloških ispitivanja i ishod bolesti.

Rezultati Faktori neposrednog rizika/predispozicije za razvoj tuberkuloznog meningitsa nađeni su kod dva (22,2%) bolesnika. Trajanje simptoma bolesti pre prijema na lečenje, iznosilo je u proseku 9 dana (od 3 do 20). Najčešći simptomi i znaci pri prijemu na lečenje bili su glavobolja i povišena temperatura kod osam (88,9%), te ukočen vrat i fotofobija kod dva (22,2%) bolesnika. Svest je bila očuvana kod šest (66,7%), dok su dva bolesnika bila somnolentna, a jedan u komi. Nistagmus, dizartrija i tremor registro- vani su u pojedinačnim slučajevima. Istovremena plućna tuberkuloza registrovana je kod dva (22,2%) bolesnika. Neuroradiološke znake bolesti imala su dva bolesnika. Kultura likvora bila je pozitivna kod tri (33,3%) pacijenta.

Zaključak Dužina simptoma pre prijema na lečenje, klinička slika i analiza likvora, mogu biti od po- moći u identifikaciji bolesnika koji su u visokom riziku za tuberkulozni meningitis.

Ključne reči: meningitis, tuberkulozni, klinička slika, komplikacije, ishod

288 ORIGINAL ARTICLE

The role of induced pluripotent stem cell (IPs) in the transplantation of glaucoma

Mingshui Fu, Bijun Zhu, Xiaodong Sun, Dawei Luo

Department of Ophthalmology, Shanghai First People’s Hospital Affiliated to Shanghai Jiaotong University, Shanghai, China

ABSTRACT

Aim Glaucoma is a heterogeneous group of optic diseases that affect almost 1% to 2% of the population older than 40 years. There are many types of glaucoma but the most common type is primary open angle glaucoma. In this study we have investigated the role of muller cell lines in the transplantation of glaucoma model in rats.

Methods Intra ocular pressure was created with the help of laser treatment in rats. The induced pluripotent stem cells (IPs) were transplanted into the vitreous or sub-retinal space of glaucomatous or untreated eyes. Double therapy was used for the prevention of graft rejection. The rats were served with the mixture of two drugs in the drinking water. For this purpose cyclosporine (20mg/kg/ Corresponding author: day) and azathioprine (2mg/kg/day) were used. This drug therapy started three days before induction of glaucoma. Dawei Luo Department of Ophthalmology, Results The transplanted cells were survived in vivo for 2 to 3 Shanghai First People’s Hospital Affiliated weeks and reduction in graft survival was also seen at the 4th week. to Shanghai Jiaotong University Immunohistochemical analysis showed that a large number of oli- Haining Road, Shanghai, godendrocyte precursor cells (OPCs), positive for the nuclear marker Olig2, survived in the vitreous, proximal to the inner surface of 200080,China the retina, in glaucomatous eye for up to four weeks. Phone: +86 021 63240090; Fax : +86 021 63067385; Conclusion Differentiating IPs cells within the glaucomatous eye E-mail: [email protected] produced cells that expressed glial cell markers. Key words: diseases, muller cells, laser, eyes

Original submission: 22 January 2013; Accepted: 29 April 2014.

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INTRODUCTION greatly restricted due to some ethical issues and graft rejection. Muller cells have the characteri- Glaucoma is a heterogeneous group of optic stics of stem cells and it has been reported in a diseases that affect almost 1% to 2% of the po- wide range of mammalian species, including the pulation older than 40 years (1). It is estimated adult human retina (13). that 66 million people in the world are suffering from glaucoma, although fewer than half of those A recent study explains that potential retinal stem patients do not realize that they have the disease cells and different types of stimuli have been (2). There are many types of glaucoma but the shown in the muller cells of chicken and rats (14- most common type is primary open angle glau- 15). Based on these facts this study was designed coma (2-4). One of the major risk factors for the to investigate the role of induced pluripotent stem development of primary open-angle glaucoma cell (IPs) in the transplantation of glaucoma. (POAG) is elevated intraocular pressure (IOP) MATERIAL AND METHODS (3). Vision loss caused by glaucoma is irreversible, and glaucoma is the second leading cause of Ethical statement blindness in the world. This disease is the main cause of blindness in many countries. The use of all the animals, as well as all animal The overall risk of developing glaucoma increa- experiments in this study was approved by the Et- ses with the number and strength of risk factors. hical Committee of the Department of Ophthalmo- It increases substantially with the level of intrao- logy, Shanghai First People’s Hospital Affiliated to cular pressure elevation and with increasing age Shanghai Jiaotong. University. All the animals, al- (3). Oligodendrocyte precursor cells (OPCs) hold bino rats (n=50) used for the experiment were kept great responsibility for the generation of oligo- at safe place and nourished with food, which is dendrocytes in the developmental stage, where- approved by food and drug administration (FDA). as in adult individuals, they play a vital role in Experimental design demyelinating pathologies and remyelinating of axons (4-6). Oligodendrocyte precursor cells Pilot experiment was done for checking graft re- appear to contain the majority of the stem cell jection in cells but it showed that administration characteristics (6) and have been shown to be ne- of cyclosporine alone wae not enough for the pre- uroprotective in vitro (3). vention of total graft rejection. Double therapies were used for the prevention of graft rejection. The measurement of intraocular pressure is not The rats were served with the mixture of two dru- an effective method for screening populations for gs in the drinking water. For this purpose cyclos- glaucoma. Moreover, the most commonly used porine (20mg/kg/day) and azathioprine (2mg/kg/ method for measurement, underestimates the day) were used. This drug therapy started three true intraocular pressure (IOP) of patients with days before induction of glaucoma. The serum thin corneas and overestimates it in patients with levels of cyclosporine were measured in all sam- thick ones. Almost half of all patients with pri- ples at different intervals. The average concentra- mary open angle glaucoma have pressures below tion was 502.2 ± 79 ug/lit. 23 mmHg at a single screening (7). Recent findings prove the link between gluco- Preparation of animals corticoid and gluacoma. Actually, G1C1A is Animals in this study were anaesthetized with the first glaucoma gene which was mapped to ketamine and xylene; later few drops of anesthe- chromosmeIq (8-10), and mutation in this gene tic agent were dropped into the eyes. Intra ocular is responsible for autosomal dominant juvenile pressure was measured with the help of tonome- glaucoma (ADJG) (11). Autosomal dominant ju- ter. Unilateral introcular pressure was induced in venile glaucoma is a rare form of glaucoma. the eyes with the help of laser (546 nm). Initial Stem cells have been proposed as a new approa- treatment consists of 60 to 65 spots of 45 μm di- ch for the regeneration of ganglion cells (12-13). ameter for 40 seconds. This laser treatment was On the other hand, the use of other stem cells, repeated for 7 to 8 weeks after every one week. like embryonic stem cells and neural stem cells is Then tissues of the eye were collected for further

290 Fu et al. Role of IPs in glaucoma

A) B)

C) D)

E) F)

Figure 1. Glaucoma in the human eye: histological section of the optic disk in a glaucomatous eye (Luo D, 2013) G) H) processing and then washed with PBS and preserved at -80ºC.

I) Preparation of induced pluripotent stem cell (IPs) culture The cell lines were prepared from postmortem human neural retina and engineered to express Figure 2. Survival and migration of induced pluripotent stem purple fluorescent protein to facilitate tracking on cells after transplantation into the eye. A, B) The cells were trans- transplantation. The cell lines were purified for planted; C) The cells were engrafted; D) Magnified Figure C; E, purple fluorescent protein for cell culturing. Ce- F) The eyes were stained with death associated protein 1(DAP1) (purple); G) intravitreal delivered EGFP positive IPs stem cells did lls were used for transplantation at passages 46 not migrate into the retina; H) Magnified G; I) Engrafted EGFP to 48. The cells were maintained as an adherent positive IPs stem cells (Luo D, 2013) cell lines in 70 cm2 tissue culture flasks which contain D-MEM (containing 0.45 g/L glucose, sodium pyruvate and stabilized L-glutamine) A) B) and penicillin. Thnreafter, the cells were washed with phosphate buffer saline (PBS) then detached from the flask with the help of trypsin. Then, we washed the complete cell culture medium and C) D) then converted it into fresh clean flask.

Histochemical analysis The cells were washed with PBS and then blocked with PBS-triton whose concentrationiwas E) F) 0.5%. All the monoclonal antibodies were diluted with this blocked. Then this whole section was incubated at 4ºC overnight in an incubator. After incubation cells were again washed with PBS and then added the purple fluorescent protein with pri- G) H) mary antibodies. Then again slides were washed and cover slip was put on the slides. Mouse IgG1 antibodies were used as a primary antibody.

RESULTS Figure 3. Facilitated IPs cells in the glaucomatous eye after transplantation of every 2 weeks in-vivo. A-D) Intraocular (IO) injection Figure 2 (A to I) shows the induced pluripotent of EPO and then cells migrate to retina. D) Antibodies were used stem cells which were not found to migrate into the to detect DPA1 purple; E-F) Intraocular migration is done; G) En- uninjured adult retina after intra vitreal delivery. grafted cells; H) Tissues were counterstained with DAP1 purple. Chondroitinase ABC activity was confirmed (Luo D, 2013)

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After the grafting of all layers of retina no human cells posses the stem cell like properties and a nuclear cells were observed in the retinal layer (Fi- human muller cell lines which have the potential gure 2C, Figure 2D). The transplantation of the ce- and ability to divide and be regenerated. These lls after one week was shown in Figures 2A, and cells are well explained in the treatment of many 2B. Cells were engrafted after two weeks (Figures diseases in many experiments (19). We have con- 2C and 2D). All induced pluripotent stem cells did cluded that muller cells remain very easily in the not retained their EGFP expression. Most of human eye and also respond to the environment. nuclear antigens were negative as shown by histo- As previously reported (24), the throat also been chemical labeling (Figure 2A, 2B, 2C and 2D). shown to increase expression of MBP by oligoden- For the encouragement of chondroitinase acti- dritic precursor cells (OPCs) in vivo and optionally vity, it has combined with erythropoietin. This oligodendritic precursor cells (OPC) mediated attempt modified the inhibitory retinal - envi myelination of RGC axons normally unmyelinated ronment. It calculated 19 to 35 cells EGFP+-IPs retinal. This study has observed less oligodendri- cells/eye. These cells were not observed in the tic precursor cells (OPC) differentiation into MBP retina (Figure 2A-2I). It should be noted that this - expressing cells in the retina than previously re- count is likely to be greatly underestimated, gi- ported. It is not clear why this difference in myelin ven that less than a half of the induced pluripo- production was detected, but it may be due to the tent stem cells were injected into the eye marked use of different breeds of rats which strain diffe- by EGFP (Figure 2). rences in the inflammatory response and protective The retina is exposed to EPO, either they were autoimmunity has been documented. invitreous form or in subretinal space (Figure 3). Oligodendritic precursor cells (OPCs) were injec- EFGP-positive cells appeared in the left side of ted into the vitreous of both injured and glauco- the retina. The presence of EPO (Figure 3A) was matous eye was found to survive well in all expe- one of the surviving grafts of the retina. These ce- riments. In addition to these, the grafted OPCs lls appeared in the induced pluripotent stem cells observed to spread across the inner membrane of and extended from ganglion to the outer nuclear retinal surface, which puts them for mediating the layer (Figure 3B). Co injection of chondroitina- observed neuroprotection. The number of grafted se ABC with IPs cells into the glaucomatous eye cells was lower in chronic graft, which had been greatly enhanced the ability of the transplanted OPCs in vivo for 12 weeks, compared with acute cells to invade the retina (Figure 3E and 3G). graft in vivo for only four weeks. The differentiation of induced pluripotent stem In this study it was found that the retina of both cells after their incorporation into the glaucoma- normal and glaucomatous eyes did not permit the tous retina was also examined in this experiment. integration of induced pluripotent stem cells beca- Immunohistochemical analysis showed that a use they are without extra cellular matrix modifi- large number of OPCs, positive for the nuclear cation. Even in the direct contact of retina IPs cells marker Olig2, survived in the vitreous, proximal are unable to penetrate in the membrane (25-28). to the inner surface of the retina, in glaucomatous It was demonstrated that induced pluripotent stem eye for up to four weeks. cells and the two other similar cell lines could in- tegrate into the retina of neonatal and injured adult DISCUSSION rats and then they differentiated into different cells Muller glial cells are the radial glial cells of the type (19, 29, 30). The results of this study have retina and have been shown to share a common shown the ability of muller cells to differentiate in phelytic lineage with retinal neurons and to derive the glaucomatous eye when cells were delivered from a common multipotent progenitor cells (16- in both cases either intravitreally or subretinally. 18). Retinal ganglion cell replacement (RGCR) is The intra-vitreous route is more reliable as com- one of the best possible methods to restore the vi- pared to subretinal delivery because they fail in sion after glaucoma (19-21). Stem cell transplan- grafting. This experiment demonstrated that intra- tation has been shown to neuronal loss and also vitreal injection was not without tribulations, as it replaces outer neuronal membrane (22-23). was often complicated to place the cells precisely adjacent to the retina (31). In the present study we have found that the IPs

292 Fu et al. Role of IPs in glaucoma

In summary, we have demonstrated that the hu- FUNDING man-derived IPs progenitor cell line induced plu- This research was supported by the Key sub ripotent stem cells is capable of surviving within Project of Chinese National Programs for Fun- the glaucomatous eye and of acquiring neural damental Research and Development973 sub morphology upon intravitreal transplantation. project-2011CB707506, Project of Shanghai Additionally, it has been found that delivery of Natural Science Foundation (13ZR1433200) and EPO and chondroitinase have the ability to mi- Opening Project of Shanghai Key Laboratory of grate into the adult retina. With the particular en- Fundus Diseases (07Z22911). vironment retinal environment of chondroitinase facilitated the IPs cells into the mature retina. TRANSPARENCY DECLARATION The results explain that differentiating induced plu- Competing interests: None to declare. ripotent stem (IPs) cells within the glaucomatous eye produced cells that expressed glial cell markers.

REFERENCE 1. Tielsch JM, Sommer A, Katz J, Royall RM, Qui- 12. Morissette J, Cote G, Anctil J-L. A common gene for gley HA, Javitt J. Racial variations in the prevalen- juvenile and adult-onset primary open-angle glauco- ce of primary open angle glaucoma. JAMA 1991; mas confined on chromosome 1q. Am J Hum Genet 266:369–74. 1995; 56:1431–42. 2. Quigley HA. Number of people with glaucoma 13. Stone EM, Fingert JH, Alward WLM. Identification worldwide. Br J Ophthalmol 1996; 80:389–93. of a gene that causes primary open angle glaucoma. 3. Sommer A, Tielsch JM, Katz J. Relationship Science 1997; 275:668–70. between intra ocular pressure and primary open an- 14. Alward WLM, Fingert JH, Coote MA. Clinical fea- gle glaucoma among white and black Americans. tures associated with mutations s in the chromosome Arch Ophthalmol 1991; 109:1090–5. 1 open-angle glaucoma gene (GLC1A). N Engl J 4. Rahmani B, Tielsch JM, Katz J. The cause-specific Med 1997; 338:1022–7. prevalence of visual impairment in an urban popu- 15. Adam MF, Belmouden A, Binisti P. Recurrent mu- lation. The Baltimore Eye Survey. Ophthalmology tations in a single exon encoding the evolutionarily 1996; 103:1721–6. conserved olfactomedin homology domain of TIGR 5. Quigley HA, Vitale S. Models of open-angle glau- in familial open-angle glaucoma. Hum Mol Genetics coma prevalence and incidence in the United States. 1997; 6:2091–7. Invest Ophthalmol Vis Sci 1997; 38:83–91. 16. Alward WLM. The genetics of open-angle glauco- 6. Dawson MR, Polito A, Levine JM, Reynolds R. ma: the story of GLC1A and myocilin. Eye 2000; NG2-expressing glial progenitor cells: an abundant 14:429–36. and widespread population of cycling cells in the 17. Coles BL, Angenieux B, Inoue T, Del Rio-Tsonis adult rat CNS. Mol Cell Neurosci 2003; 24:476-88. K, Spence JR, McInnes RR, Arsenijevic Y, van der 7. Mitchell P, Smith W, Attebo K, Healey PR. Pre- Kooy D. Facile isolation and the characterization valence of open-angle glaucoma in Australia: the of human retinal stem cells. ProcNatlAcadSci USA Blue Mountains eye study. Ophthalmology 1996; 2004; 101:15772-7. 103:1661–9. 18. Karl MO, Hayes S, Nelson BR, Tan K, Buckingham 8. Sheffield VC, Stone EM, Alward WLM. Genetic lin- B, Reh TA: Stimulation ofneural regeneration in kage of familial open angle glaucoma to chromoso- the mouse retina. Proc Natl Acad Sci U S A 2008; me 1q21–q31. Nat Genetics 1993; 4:47–50. 105:19508–13. 9. Sunden SLF, Alward WLM, Nichols BE, Rokhlina 19. Lawrence JM, Singhal S, Bhatia B, Keegan DJ, Reh TR, Nystuen A, Stone EM, Sheffield VC. Fine map- TA, Luthert PJ, KhawPeng T, Limb GA. MIO-M1 ping of the autosomal dominant juvenile open angle cells and similar Müller glial cell lines derived from glaucoma (GLC1A) region and evaluation of candi- adult human retina exhibit neural stem cell characte- date genes. Genome Res 1996; 6:862–9. ristics. Stem Cells 2007; 25:2033-43. 10. Richards JE, Lichter PR, Boehnke M. Mapping of 20. Fischer AJ, McGuire CR, Dierks BD, Reh TA. Insu- a gene for autosomal dominant juvenile-onset open- lin and fibroblast growth factor 2 activate a neuro- angle glaucoma to chromosome 1q. Am J Hum Ge- genic program in Müller glia of the chicken retina. J net 1994; 54:62–70. Neurosci 2002; 22:9387–98. 11. Wiggs JL, Haines JL, Paglinauan C, Fine A, Sporn 21. Bull ND, Limb GA, Martin KR. Human Müller stem C, Lou D. Genetic linkage of autosomal dominant cell (MIO-M1) transplantation in a rat model of gla- juvenile glaucoma to 1q21–q31 in three affected pe- ucoma: survival, differentiation, and integration. In- digrees. Genomics 1994; 21:299–303. vest Ophthalmol Vis Sci 2008; 49:3449–56. 22. Siqueira RC. Stem cell therapy for retinal diseases: update. Stem Cell Res Ther 2011; 2:50.

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23. Medina RJ, Archer DB, Stitt AW. Eyes open to stem 27. MacLaren RE, Pearson RA, MacNeil A. Retinal re- cells: safety trial may pave the way for cell thera- pairs by transplantation of photoreceptor precursors. py to treat retinal disease in patients. Stem Cell Res Nature 2006; 444:203–7. Ther 2011; 2:47. 28. Meyer JS, Katz ML, Maruniak JA, Kirk MD. Em- 24. Qiu G, Seiler MJ, Mui C. Photoreceptor differen- bryonic stem cell derived neural progenitors incor- tiation andintegration of retinal progenitor cells porate into degenerating retina and enhance survival transplanted into transgenicrats. Exp Eye Res 2005; of host photoreceptors. Stem Cells 2006; 24:274–83. 80:515–25. 29. Banin E, Obolensky A, Idelson M. Retinal incorpo- 25. Gamm DM, Wang S, Lu B, Girman S, Holmes T, ration and differentiation of neural precursors deri- Bischoff N, Shearer RL, Sauvé Y, Capowski E, ved from human embryonic stem cells. Stem Cells Svendsen CN, Lund RD. Protection of visual func- 2006; 24:246–57. tions by human neural progenitors in a rat model of 30. Hara A, Niwa M, Kunisada. Embryonic stem cells retinal disease. PloS One 2007; 2:e338. are capable of generating a neuronal network in the 26. Schraermeyer U, Thumann G, Luther T. Subretinally adult mouse retina. Brain Res 2004; 999:216–21. transplanted embryonic stem cells rescue photore- 31. Mooney DJ, Vandenburgh H. Cell delivery mechani- ceptor cells from degeneration in the RCS rats. Cell sms for tissue repair. Cell Stem Cell 2008; 2:205–13. Transplant 2001; 10:673–80.

294 ORIGINAL ARTICLE

Occurrence and morphological characteristics of cataracts in patients treated with general steroid therapy at Cantonal Hospital Zenica Alma Čerim1, Admira Dizdarević1, Belma Pojskić2

1Eye Department, 2Department of Internal Medicine; Cantonal Hospital Zenica, Zenica, Bosnia and Herzegovina

ABSTRACT

Aim To determine the occurrence and morphological characteristics of cataracts and the impact of general steroid therapy on its occurrence.

Methods A retrospective/prospective study was conducted on 90 patients who had been treated at the Cantonal Hospital Zenica with general steroid therapy. There were 30 patients whose general steroid therapy lasted shorter than 4 years and 30 patients on steroid therapy for more than 4 years. The remaining 30 patients were the control group. An examination of lens transparency and morphological characteristics of cataract was made by slit lamp with previously achieved mydriasis.

Results A significant (p<0.05) occurrence of cataracts in patients taking general steroid therapy > 4 years and significantly more Corresponding author: frequent occurrence of cataract in patients aged 60 years and over Alma Čerim was found. Iatrogenic diabetes affects the occurrence of cataracts Eye Department, in addition to age and duration of therapy, especially in those who Cantonal Hospital Zenica were on steroid therapy for more than 4 years. Steroid cataract was Crkvice 67, 72 000 Zenica, of subcapsular type according to its morphological characteristics. Bosnia and Herzegovina Conclusion A possibility of cataract occurrence during or after the Phone/fax: +387 32 405 133; treatment with corticosteroids therapy should not be ignored. Su- E-mail: [email protected] bcapsular location of cataracts reduces work ability, normal daily activities and requires surgery. Ophthalmic examination should be an obligatory part of the preparation of patients for corticosteroids treatment. Control examinations should be repeated every six months during the therapy, and even more frequently if required.

Keywords: iatrogenic cataract, iatrogenic diabetes, subcapsular cataract. Original submission: 16 April 2014; Revised submission: 26 May 2014; Accepted: 25 June 2014.

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INTRODUCTION PATIENTS AND METHODS Cataract is any innate or acquired opacity of the This retrospective/prospective research was con- lens which represents a significant public health ducted at the Cantonal Hospital Zenica in the pe- and economic problem, and also the leading cau- riod 2010-2012 with the previous permission of se of blindness in the world (1,2). Of approxima- the Cantonal Hospital Zenica Ethics Committee. tely 37 million blind people in the world, 47.8% The study involved neurological, dermatological suffer from cataract. About 90% of the blind in and internal medicine patients who had been tre- this study come from developing countries (2). ated for various reasons and in various periods According to the WHO blindness due to cataract with peroral, intramuscular or intravenous stero- is visual acuity less than 3/60 in a better eye. It id therapy and, as a part of the mandatory review, occurs at all age groups and its incidence is in- had had consultative ophthalmologic examinati- creasing exponentially over 50 years of age (3). ons in the Cantonal Hospital Zenica before the In addition to age, diabetes, myopia and UV ra- treatment with steroids. diation exposure, a steroid therapy is one of the The study involved a total of 90 patients older risks for cataract development. Steroid induced than 18, who had had no cataracts according ear- cataract is an unwanted effect of the steroid the- lier medical records. Sixty patients were treated rapy used for systemic diseases, inflammatory with peroral, intramuscular or intravenous cor- and allergy-related conditions and conditions ticosteroid therapy because of various diseases after organ transplantations (2,4). The most (multiple sclerosis, sarcoidosis, lupus erythema- common complication is posterior subcapsular tosus systemicus, thrombocytopenia, hemolytic cataract (4,5). anemia, rheumatoid arthritis, pemphigus vulga- ris); the group of 30 patients were treated with Until now it has not been possible to develop a corticosteroid therapy for more than 4 years, and reliable system of models on animal or isolated 30 patients for less than 4 years. The remaining lenses suitable for the study of steroid-induced 30 patients were randomly selected while having posterior subcapsular cataract. It is very difficult presbyopic spectacles administered during ordi- to produce opacity, similar to that seen in human nary daily outpatient ophthalmic examinations. lens even when the lenses are directly exposed to high concentrations of steroids (4,5). The rese- The study excluded patients with previous eye arch relating to the mechanism of appearance of and head trauma, radiation therapy, simultaneous steroid cataract has intensified in recent years and steroid and cytostatic therapy, as well as the pati- has offered several explanations of the molecu- ents with secondary inflammation of the eye and lar origin of steroid cataract: metabolic disorder, the inner sheath, glaucoma and diabetes verified osmotic failure, oxidation/conformational chan- before the introduction of the steroid therapy. ge, protein adduct formation, receptor mediated All data obtained from medical history records effects, aberrant cell behavior (6-14). were included in the retrospective investigation. The examination included visual acuity by Sne- Corticosteroids therapy is used as topical, local llen visual acuity card (15), intraocular pressure or general therapy (1). Therapeutic approach measurement (Goldmann applanation tonometer, (dosage and mode of application) is varied accor- Haag Streit, USA), slit lamp examination (Haag ding to a kind and stage of a disease. Streit, USA) and ophthalmoscopy (Heine direct The aim of this study was to show the expediency ophthalmoscope, Ohio, USA). Slit lamp exami- of multidisciplinary approach to all patients tre- nation and ophthalmoscopy were performed with ated with general steroid therapy for various rea- previously achieved mydriasis. sons. It is already known that one of the compli- The patients were classified according to sex and cations of steroid therapy is cataracts occurrence age, the existence or non-existence of lens opaci- especially when treated with steroids for more fication and according to morphological cataract than 4 years (1). The purpose of the study was characteristics. The results of an eye with prono- to alert about the needs and obligations of regular unced opacity were analyzed. Decrease in visual ophthalmologic examinations of all patients trea- acuity of at least two rows on Snellen’s (15) card ted with general steroid therapy. were considered as cataracts.

296 Čerim et al. Cataract in patients treated with steroids

As a part of prospective examination, cataracts tients who received therapy for a period longer occurrence was examined in patients treated than 4 years and 5 (16.7%) who received the- with pulse intravenous corticosteroid therapy at rapy for less than 4 years. There was no patient least six months after the completion of the the- with subcapsular cataract in the control group. rapy. In addition, in the group of patients recei- Eight (20%) patients in the control group had ving general corticosteroid therapy for less than 4 corticonuclear cataract (p<0.05) (Table 2). years the occurrence of cataract was analyzed at least 6 months from the beginning of the therapy. Table 2. Morphological characteristics of cataracts according Retrospective examination of cataracts occurren- to corticosteroid therapy usage No (%) of patients ce was conducted in patients receiving cortico- Subcapsular Corticonuclear Patient groups steroid therapy for more than 4 years. cataract cataract The study used ANOVA Tukey’s F test for testing Therapy length > 4 years 21 (70) 3 (10) Therapy length < 4 years 7 (23.3) 5 (16.7) the variance between the groups, Pearson’s Chi- Control group 0 6 (20) Square χ2 test to determine statistical significance between the characteristics of the samples gi- DISCUSSION ven in nonparametric form (modification χ2 test), and Fisher’s exact test. According to the available literature incidence of multiple sclerosis is twice higher in females RESULTS than in males, 90% of patients with lupus erythe- The study involved 68 (75.6%) females and 22 matosus systemicus are women, sarcoidosis and (24.4%) males. In all three investigated groups mixed connective tissue disease are more com- (therapy >4 years, therapy <4 years and control mon in women, and rheumatoid arthritis is three group) women were more represented. The study times more common in women (1). It is known involved adult patients, 31 (34.4%) patients were that sarcoidosis, multiple sclerosis, SLE occur in up to 49 years of age, 30 (33.3%) were aged the third decade of life, rheumatoid arthritis of- between 50 and 59, and 29 (32.2%) were older ten in the fourth decade, systemic sclerosis usu- than 60 years of age. All the patients who were ally in women under the age of 50 (1). on steroid therapy for over 4 years had iatrogenic Eighty percent of patients on steroid therapy for diabetes. over 4 years in this study had cataracts. In ad- Cataracts occurred in 24 (80%) patients who had dition to steroids, the development of cataracts received corticosteroid therapy for a period lon- could be a consequence of the patient age and ger than 4 years, and in 12 (40%) patients who iatrogenic diabetes (1,2,4,5). Most patients in- had received corticosteroid therapy for less than volved in the study were elderly (over 60 years 4 years. Also, statistical significance of cataract of age). It is known that the incidence of cata- occurrence was found (p<0.05) in patients on ract grows exponentially after the age of 50 (5). corticosteroid therapy for more than 4 years and Most of our patients on steroid therapy for a the control group (Table 1). period over four years had iatrogenic diabetes. One of the risk factors for the development of Table 1. Prevalence of lens transparency according to corti- cataracts is diabetes, as it has been described costeroid therapy usage No (%) of patients previously (1,2,5,16). Patient groups Transparent lens Opaque lens According to the WHO cataract is defined as opa- Therapy length > 4 years 6 (20) 24 (80) cification of the lens with a significant decrease Therapy length < 4 years 8 (60) 12 (40) Control group 24 (80) 6 (20) in visual acuity (3). In this study, visual acuity was not analyzed because of the large number of According morphological characteristics of cata- patients, especially in the group of the patients ract there was subcapsular cataract in 21 (70%) on the steroid therapy >4 years with iatrogenic patients in the group of patients on therapy lon- diabetes. In addition to diabetes as a cause of ca- ger than 4 years, and in 7 (23.3%) patients in the taracts, daily fluctuation of blood sugar affects group on therapy for a period less than 4 years. the refractive index of the lens and the amplitude Corticonuclear cataracts occurred in 3 (10%) pa- of accommodation (1). Hyperglycemia is reflec-

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ted in high levels of glucose in humor aqueous, A possibility of cataracts occurrence should not which diffused into the lens. The lens glucose be ignored during or after the treatment with is metabolized by means of aldose reductase to corticosteroids therapy. Subcapsular location of sorbitol, which is then accumulated in the lens cataract reduces the work ability, normal daily thus resulting in secondary osmotic hyperhydra- activities and requires surgery. Ophthalmic exa- tion of lens substances. This affects the refractive mination is an obligatory part of the preparation index of the lens with the consequent fluctuation of patients for the treatment with corticosteroids. of refraction related to the level of glucose in the Control examinations should be repeated every blood. Thus, for example, myopia is a result of six months during the therapy. hyperglycemia (1). FUNDING According to the morphological characteristics No specific funding was received for this study. subcapsular cataract was most commonly found in this study as a complication of general steroid TRANSPARENCY DECLARATIONS therapy usage (1). Competing interest: none to declare.

REFERENCES 1. Kanski JJ. Klinička oftalmologija. Beograd: Data 10. Hass C, Kohlmann H, Cosmmatzsch PK. Morpho- Status, 2004: 162-191. logic changes in the lens epithelium in patients with 2. Abraham AG, Condon NG,Gower EW. The new age-induced cataract, radiation and steroid cata- epidemiology of cataract. Ophtalmol Clin North Am ract following eye contusion. Ophtalmologe 1995; 2006; 19:415-25. 92:741-4. 3. World Health Organization. The Right to Sight. 11. Dickerson JE, Dotzel E, Clark AF. Steroid-induced www.who.int/blindness/Vision2020_report.pdf (22 cataract: new perspectives from in vitro and lens cul- November 2012) ture studies. Exp Eye Res 1997; 65:507-16. 4. Jobling AI, Augusteyn RC. What causes steroid cata- 12. Gupta V, Galante A, Soteropoulos P, Guo S, Wagner racts? A review of steroid-induced posterior subcap- BJ. Global gene profiling reveals novel glucocorti- sular cataracts. Clin Exp Optom 2002; 85:61-75. coid induced changes in gene expression of human 5. Levin LA, Albert DM. Ocular Disease: Mechanisms lens epithelial cells. Mol Vis 2005; 11:1018-40. and Management. Philadelphia: Sounders Elsevier, 13. Cenedella RJ, Sexton PS, Zhw XL. Lens epithelia 2010. contain a high-affinity, membrane steroid hormone- 6. Urban RC, Cotlier E. Corticosteroids induced cata- binding protein. Invest Ophthalmol Vis Sci 1999; racts. Surv Ophtalmol 1986; 31:102-10. 40:1452-9. 7. Praveen MR, Shah GD,Vasavada, Shah AR, Johar 14. Jobling AI, Augusteyn RC. Steroid adduct formation K, Gami Y, Diwan RP, Shah SM. Posterior capsule with lens crystallins. Clin Exp Optom 1999; 82:130- opacification in eyes with steroid induced cataracts: 5. Comparison of early results. J Cataract Refract Surg 15. Šimunović J. Vladimir. Katalog kliničkih vještina. 2011; 37:88-96. Charlestone: Crate Space, 2013. 8. James ER. The etiology of steroid cataract. J Ocul 16. Brian G, Taylor H. Cataract blindness – challenges Pharmacol Ther 2007; 23:403-20. for the 21th century. Bull World Health Organ 2001; 9. Nishigori H. Steroid (glucocorticoid) - induced cata- 79:249-56. ract. Yakugaku Zasshi 2006; 126:869-84.

298 Čerim et al. Cataract in patients treated with steroids

Pojava katarakte i njene morfološke karakteristike kod pacijenata tretiranih općom steroidnom terapijom u Kantonalnoj bolnici Zenica Alma Čerim1, Admira Dizdarević1, Belma Pojskić2 1Služba za očne bolesti, 2Služba za unutrašnje bolesti; Kantonalna bolnica Zenica, Zenica Bosna i Hercegovina

SAŽETAK

Cilj Utvrditi učestalost steroidima indukovane katarakte, njene morfološke karakteristike i utvrditi utjecaj dužine terapije na njen nastanak.

Metode Retroprospektivno ispitivanje provedeno je na 90 pacijenata liječenih općom steroidnom terapijom u Kantonalnoj bolnici Zenica. Na općoj steroidnoj terapiji, u periodu dužem od 4 godine, bilo je 30 pacijenata, dok je 30 pacijenata primalo opću steroidnu terapiju kraće od 4 godine, a 30 ih je bilo u kontrolnoj grupi. Pregled prozirnosti leće i morfoloških karakteristika katarakte rađen je biomikroskop- ski uz prethodno postignutu midrijazu.

Rezultati Dokazana je značajno češća pojava katarakte kod pacijenata liječenih steroidima u periodu >4 godine, te značajno češća pojava katarakte kod pacijenata starosne dobi 60 i više godina. Pored starosne dobi i dužine steroidnog liječenja na pojavu katarakte utjecao je i jatrogeni dijabetes od kojeg su bili oboljeli pacijenti na steroidnom liječenju >4 godine. Steroidna katarakta je prema morfološkim karakteristikama bila subkapsularna.

Zaključak Mogućnost pojave katarakte tokom i nakon tretmana kortikosteroidnom terapijom ne treba biti zanemarena. Katarakta, locirana subkapsularno, umanjuje radnu sposobnost, obavljanje svakod- nevnih i uobičajenih aktivnosti, te zahtijeva hirurško liječenje. Oftalmološki pregled treba da bude obavezan dio pripreme pacijenta za kortikosteroidnu terapiju. Kontrolne preglede tokom terapije treba obavljati svakih šest mjeseci, a u slučaju potrebe i češće.

Ključne riječi: jatrogena katarakta, jatrogeni dijabetes, subkapsularna katarakta.

299 ORIGINAL ARTICLE

Importance of accurate diagnosis in benign paroxysmal positional vertigo (BPPV) therapy

Siniša Maslovara1, Tihana Vešligaj1, Silva Butković Soldo3, Ivana Pajić-Penavić2, Karmela Maslovara1, Tea Mirošević Zubonja3, Anamarija Soldo3

1Department of Otolaryngology, County General Hospital Vukovar, 2Department of Otolaryngology, General Hospital “Josip Benčević”, Slavonski Brod, 3Department of Neurology, Clinical Hospital Center, Osijek; Croatia

ABSTRACT

Aim To determine the importance of accurate topological diagnostics of the otolith and the differentiation of certain clinical forms of benign paroxysmal positional vertigo (BPPV).

Methods A prospective study was conducted at the County Ge- neral Hospital Vukovar in the period from January 2011 till Janu- ary 2012. A total of 81 patients with BPPV, 59 females (72.84%) and 22 (27.16%) males (p <0.001), mean age 60.1 (± 12.1) were examined. The diagnosis was confirmed and documented by videonystagmography (VNG). The disability due to disease and risk of falling were monitored by filling in the Dizziness Handicap In- ventory (DHI) and Activities-specific Balance Confidence Scale (ABC) questionnaires at the beginning and at the end of the repo- Corresponding author: sitioning treatment. Siniša Maslovara Department of Otolaryngology, Results In 79 (97.3%) patients posterior semicircular canal was affected, and in a small number of patients, two (2.47%) the late- County General Hospital Vukovar ral one. After the repositioning procedures were performed, there Županijska 35, 32 000 Vukovar, Croatia was a significant reduction or complete elimination of symptoms Phone: +385 32452040; in the majority of subjects, 76 (93.82%). The median total DHI Fax: +385 32 452 002; sum amounted to 50.5 (± 22.2) at the beginning and 20.4 (± 18.5) E-mail: [email protected] at the end of the study (p <0.00). Similarly, the results of ABC questionnaires at the beginning of the study demonstrated a result of 59.2% (± 22.4%), and at the end of the treatment the average result of examinees was significantly higher, 84.9% (± 15.2%) (p<0.00).

Conclusion Although a subjectively positive Dix-Hallpike or a “supine roll” test is sufficient for the diagnosis of BPPV, it is necessary perform the VNG as well in order to precisely determine the Original submission: exact localization of the otolith, so that an appropriate repositio- 05 June 2014; ning procedure can be applied. Revised submission: Key words: diagnosis, videonistagmography, canalolithiasis, cu- 30 June 2014; pulolithiasis, canalith repostioning procedures Accepted: 04 July 2014.

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300 Maslovara et al. Accurate diagnosis and BPPV therapy

INTRODUCTION PATIENTS AND METHODS Benign paroxysmal positional vertigo (BPPV) still Study organization frequently remains undetected, although it represents about 20-40% of the total number of perip- The study was devised as an original scientific heral vertigo cases in general population (in the research based on prospective clinical trials (15- elderly population even up to 50%) (1,2), and a su- 17). All data were collected during the clinical bjectively positive Dix-Hallpike or a “supine roll” examination and patient treatment. The sources test is sufficient for the diagnosis. The most com- of the data obtained were general otoneurologic mon form of BPPV is the one in which the posteri- history, an otoneurologic review, particularly the or semicircular canal is affected (in approximately Dix-Hallpike test and videonystagmography, as 70-90% of cases), while the remainder relate to the well as questionnaires Dizziness Handicap In- lateral semicircular canal. The anterior and mixed ventory (DHI) or the classification table of dizzi- type account for only a very small percentage of ness and Activities-specific Balance Confidence cases (3,4). Although extremely rare, the otolith lo- Scale (ABC), a scale of balance confidence with calization in the anterior semicircular canal is signi- respect to the activities. During the study, the ficant because the form of nystagmus can appear as data were systematically entered into a database lesions on the central nervous system (5,6). Accor- created particularly for this study and saved by ding to Lopez-Escámez et al. (7), a simultaneous regular backups. involvement of multiple semicircular canals is not a rare case, and the values in these authors range up Patients to 20%. Tomaz et al. (8) report that multiple canals Potential examinees were all the patients who re- are rarely affected, and if so, they are usually the ported to the Ear, Nose and Throat (ENT) Depar- canals on the same side. In such cases there is a tment of the County General Hospital Vukovar far more frequent involvement of the posterior and Croatia between January 2012 and January 2013 lateral canal combination, than the anterior and po- having balance problems of either central or pe- sterior canal or the anterior and lateral one. ripheral origin. Among them, 81 patients with In his research Yagi et al. (9) demonstrated by BPPV were selected by a positive Dix-Hallpike a 3D analysis of videonistagmography (VNG) test. The diagnosis was then confirmed and docu- records, that most (2/3) localizations of BPPV mented by VOG. The used device is a compute- obtained by the analysis of VNG do not coinci- rized VO425 system (Interacoustics, Denmark). de with the direction of nystagmus. In addition, All the patients who agreed to the study and si- the introduction of Video Head Impulse test (10) gned an informed patient’s consent, a document also shows that the plain observation of a possi- in which they are made fully familiar with the ble occurrence of saccadic nystagmus is not su- type and method of research, as well as poten- fficient and that it cannot notice all the precise tial risks. The study was approved by the Ethics eye movements. Beside the typical clinical ca- Committee of Vukovar County General Hospital. nalolithiasis picture of the posterior semicircular The overall tests conducted to confirm the diagnosis canal, the finding of cupulolithiasis is far more of BPPV in all the examinees were the following: common than initially thought (11,12). In some history, which includes some general demograp- patients, quite different pictures of BPPV may hic characteristics (gender, age, occupation, level appear, such as nonspecific dizziness, blurriness, of education, social status) otoscopic examination, unsteadiness in walking (13,14), etc. otoneurologic review, with a mandatory Dix-Hall- The objective of this prospective clinical study pike and “supine roll” test, VNG (analysis of spon- was to determine the importance of accurate to- taneous, visual and positional nystagmus, analysis pological diagnostics of the otolith and the dif- of Fitzgerald-Hallpike bithermal caloric test), fi- ferentiation of certain clinical BPPV forms in lling in the DHI and the ABC forms. order to postulate an appropriate repositioning In some cases, if there was a reasonable suspicion procedure. It should have provided a rapid and of some other cause of dizziness, additional dia- complete recovery and reduced risk of patients’ gnostic tests were made, such as the following: falling and suffering injuries.

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tone audiometry, tympanometry, radiological examination was administered a week subsequ- examinations (brain CT and MRI, cervical spine ent to the treatment initialization. It was perfor- X-ray), carotid and vertebral arteries color Do- med by the Dix-Hallpike with the repeated DHI ppler (CDFI), vascular vertebrobasilary-conflu- and ABC questionnaires in case of weakening ence transcranial Doppler (TCD). the clinical symptoms of BPPV and feature of The patients were subjected to appropriate re- nystagmus in the Dix-Hallpike. If symptoms had positioning procedures depending on whether it not disappeared completely, the Epley procedure was a BPPV in the posterior, lateral or anterior was repeated twice in one session and a new fo- semicircular canals, and whether it was a case of llow-up examination was administered in a week canalo or cupulolithiasis. after the cure or remission due to a repositioning treatment. Then, using the same instruments, the Methods patients’ health status and quality of life were determined and a statistical analysis of the results The overall duration of the study was eight weeks, was made in correlation with the initial status. with the first examination completed upon the patient’s reporting to our specialist clinic. It in- Statistics cluded the previously mentioned diagnostic tests and filling out two questionnaires individually in The figures following a normal distribution were a peaceful and quiet room. The first of these was a described by an arithmetic average value and stan- specific, non-commercial Dizziness Handicap In- dard deviation. With numerical data that do not fo- ventory (DHI) questionnaire designed to quantify llow the normal distribution for the average asse- the difficulty and disability in everyday activities ssment the non-parametric measures of central that patients experience due to vertigo (15). It con- value (median) were used as the 25th and the 75th sists of 25 questions, (15) seven of which are re- centile scattering assessment. The regularity of lated to physical, and nine on both emotional and observed numeric data distribution was tested by functional health. The responses were rated in the the Kolmogorov-Smirnov test. Categorical varia- following way: the answer “no” – zero (0) points, bles were described in absolute and relative frequ- the answer “sometimes” – two (2) points and the encies. To explore the differences between the two answer “always” – four (4) points. Accordingly, dependent samples, Friedman and Wilcoxon test the maximum sum was 100, and the minimum 0 were used for data not normally distributed; the T- points. Within the sum, the maximum number of test for paired samples, and ANOVA for repeated points for physical health was 28, and for the state measurements for the data following normal dis- of emotional and functional health 36 points. The tribution. To assess the materiality of results, the higher sum indicates a greater disability of pati- level of essentiality p=0.05 was chosen. ents, and the study assumed18 and higher sums as Ethical principles clinically significant (16-18). Awarded 60 points in DHI test indicates a high probability of falling During this clinical research, the ethical princi- within the next six months. ples were respected in accordance with the well- The second questionnaire was the ABC scale. known and established basic principles of ethics This questionnaire is compatible with the DHI and human rights applicable in the field of bio- scale, and they are often used together. It is a very medical science. useful test in assessing the difficulties that the pa- RESULTS tients feel due to their dizziness, risk of falling, the quality of their quotidian life, as well as their The study encompassed 81 patients whereof the- general health status (19). re were significantly more females, 59 (72.84%) A reposition of the posterior semicircular canal and 22 (27.16%) males (p <0.001). The average otolith was performed by the Epley Canalith Re- age was 60.1 (± 12.1): 59.4 (± 12.2) for women positioning Procedure, while lateral semicircular and 61.9 (± 11.7) for men (Table 1). canal otolith reposition was performed by Lem- In 46 (56.79%) patients, the problem was canalo- pert procedure. Repositioning procedure was lithiasis and in 35 (43.21%) cupulolithiasis, whe- performed twice in one session and a follow-up re the posterior semicircular canal or its ampule

302 Maslovara et al. Accurate diagnosis and BPPV therapy

Table 1. Median age of patients according to gender Gender No (%) of patients Average age (SD) (Min - Max) p Males 22 (27.2) 61.9 (11.7) (39 – 79) Females 59 (72.8) 59.4 (12.3) (24 – 81) 0.483 Total 81 60.1 (12.1) (24 – 81) SD, Standard deviation; was primarily affected, in 79 (97.53%), while the lateral semicircular canal was affected in two (2.47%) patients (Table 2, Figure 1).

Table 2. Affected labyrinth and orientation of nystagmus in the Dix-Hallpike test No (%) of patients Dix-Hallpike p Geo Apogeo Total Right 18 (39.1) 20 (57.1) 38 (46.9) 0.122 Left 28 (60.9) 15 (42.9) 43 (53.1) Figure 2. Average values and reliability interval scale of DHI Total 46 (100%) 35 (100%) 81 (100%) questionnaire and total DHI scale Geo, geotropic nystagmus (directed towards the ground, i.e., towards the lower lying ear); Apogeo, apogeotropic nystagmus (directed op- mination, the average value of ABC scale was posite of the ground, i.e., toward the upper ear) significantly lower: 59.2% (± 22.4%) than the score that indicates an increased risk of falling (total score ≤ 67%), in contrast to the average value for the final examination when it was 84.9% (± 15.2%) (p<0.001) (Figure 3).

Figure 1. Affection of ampoulous side/posterior semicircular canal and presence of canalolithiasis/cupulolithiasis among the patients

The number of repositioning procedures ranged from 2 to 6, the median being two treatments (interquartile range 2-3), after which there was a significant reduction or a complete elimination of symptoms in all patients. Figure 3. Average values and reliability interval of ABC scale In all patients, significantly higher values were DISCUSSION shown during initial examination in all groups of questions applying the DHI questionnaire (physi- The BPPV often remains unrecognized, although cal, mental, and emotional health) in relation to it is the most common cause of all cases of di- the check-up (p <0.001) (Figure 2). The mean va- zziness and even though a subjectively positive lue (standard deviation) for physical health at the Dix-Hallpike or “supine roll” test result should first examination was 20 (± 10.4), while the final be sufficient for the accurate diagnosis of this one was 8.2 (± 7.9), with p <0.001. The result for disease, according to the Guidelines of the Uni- mental health at the start was 18.5 (± 6.8), while ted States Academy of Otolaryngology and Head in the end it was 7.5 (± 6.8) (p<0.001). The value and Neck Surgery in 2008 (19). Our observations for emotional health at the first examination was showed that it is also very important to perform at 12.2 (± 9.2), and at the final check-up at 4.7 (± the VNG tests in order to confirm and set precise 5.7) (p<0.001). The mean value (standard devi- diagnosis with respect to the affected ear, the af- ation) of the total DHI sum was 50.5 (± 22.2) at fected canal, and its part, because it is sometimes baseline and 20.4 (± 18.5) at the end of the study very difficult to accurately exclusively determine (p <0.001) by Wilcox test. During the initial exa- all the parameters on the basis of conducted posi-

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tional tests. Once the diagnosis is set, it is impor- up. The results of DHI testing on individual issu- tant to assess and monitor the patients’ physical, es showed a statistically significant difference in emotional, and mental status and determine their answers to certain questions among respondents. risk of falling (20-22). The similar results were found for the results in The average age of patients in this study of 60.1 (± relation to each group of questions as well. The 12.1) corresponds to other studies. Our results also highest sum was observed upon both the first exa- show that a BPPV disease mainly affects elderly mination and the final check-up in the group of persons, largely due to various degenerative chan- questions related to physical health. Upon the final ges associated with the aging process (23, 24). check-up, it is evident that there was a statistically significant improvement in answers to all three When it comes to the patients’ gender, there was sets of questions, with still the largest average a significantly higher prevalence of females scoring total for the group of questions related to (72.8%) compared to males (27.2%), so that the physical health. Nevertheless, this result is within ratio was about 2/3 : 1/3. An equal representation normal physiological limits, while the results of of both sexes is described only in a BPPV that the other two groups of questions related to mental occurs after injury (25). There was no difference and emotional health are fully within the normal in age according to gender (26,27). framework, set out for local population. The mean In the majority of cases in this study (93.82%), values of total DHI score and all subscales, before two repositions in one session were enough for and after repositioning treatment, corresponding a significant recovery of the patient, which is al- to the results of other authors, as well as our previ- most equal to healing, allowing the patients to ously published results (38-41). A relatively high return to their daily life activities (28-30). initial scoring sum may be noted, which over time According to the sides affected by the disease, an improves and becomes smaller, so that most an- equal involvement of both ears was shown in this swers in the questionnaire were negative. study. In the medical literature available, most The second questionnaire filled was the ABC sca- authors found a significantly higher incidence le of balance confidence. This test is very reliable of involvement of the right labyrinth in relation in assessing the difficulties that a respondent faces to the left. Von Brevern et al. speculate that this due to dizziness, danger of falling, general health finding is a result of sleeping habits on the right and quality of daily life. It showed a good corre- for most people, and Damman et al. only confirm lation with the results of the DHI test (29). The their claims (31,32). results obtained by completing the questionnaire Considering the involvement of individual semi- at the beginning of treatment showed the score of circular canal, the prevalence of otolith settled in 59.2% (± 22.4%), and thus pointed to a significant the lateral canal (2.47%) corresponds to the data risk of falling and possible injury, before repositi- from other studies (33,34). In contrast, with regard oning procedures were applied. In contrast, at the to nystagmus direction, the prevalence of ageo- end of the treatment, which consisted of at least topic direction (43.21%) in this study was higher two and a maximum of six repeated repositioning than it was expected. This could be explained by procedures by Epley, the average score of respon- a relatively small sample and a precise VNG dia- dents was significantly higherat 84.9% (± 15.2, far gnosis. Over the last ten years, some authors also from the score which represents the risk of falling. report a significantly higher prevalence of canalo In all patients involved in the study, subsequent to and cupulolithiasis of lateral semicircular canal, the diagnosis of BPPV by the Dix-Hallpike and “su- explicable by their accurate diagnosis (35-37). pine roll” test and proven by the VNG findings, an The Croatian version of the simple DHI questio- appropriate procedure of otolith reposition was per- nnaire accepted world-wide, translated and adap- formed (Epley, Lempert). In the majority of cases it ted to local population was used as a tool to exa- was sufficient for a significant recovery of the pati- mine the impact of BPPV on patients’ disability. ent. The DHI and ABC questionnaires were used in The questionnaire is specific for testing the impact monitoring the status of patients’ disability and their of various forms of dizziness on patients’ handicap quality of life related to health, especially in monito- and their everyday life, seen from their perspec- ring their progress during the treatment. Subsequent tive. The study subjects filled this questionnaire to a result analysis, one may conclude the following: during the first examination and the final check- the average scoring sum of both administered qu-

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estionnaires at the beginning and the end of the search in setting the precise diagnosis of otolith treatment showed a statistically significant impro- localization and clinical forms of BPPV, which vement, indicating the improvement of life quality allowed us to conduct the most appropriate re- related to physical, emotional and mental health, as position process and thereby achieve satisfactory well as a reduction of disability in performing usu- results in treatment. al, everyday activities. The risk of falling in patients is also significantly reduced: while the initial risk FUNDING of falling and subsequent injury was very large, at No specific funding was received for this study. the end of the treatment there was no real danger of falling that would have been caused by vertigo. TRANSPARENCY DECLARATIONS We must point out the significant role of VNG Competing interests: none to declare.

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28. Blatt PJ, Georgakakis GA, Herdman SJ, Clendaniel (BPPV). CMAJ 2003; 169:681-93. RA, Tusa RJ. The effect of the canalith repositioning 36. Moon SY, Kim JS, Kim BK, Kim JI, Lee H, Son maneuver on resolving postural instability in pati- SI, Kim KS, Rhee CK, Han GC, Lee WS. Clinical ents with benign paroxysmal positional vertigo. Am characteristics of benign paroxysmal positional ver- J Otol 2000; 21:356-63. tigo in Korea: a multicenter study. J Korean Med Sci 29. Honrubia V, Baloh RW, Harris MR, Jacobson K. 2006; 21:539-43. Paroxysmal positional vertigo syndrome. Am J Otol 37. Nuti D, Mandala M, Salerni L. Lateral canal paroxy- 1999; 20:465-70. smal positional vertigo revisited. Ann N Y Acad Sci 30. Ruckenstein MJ. Therapeutic efficacy of the Epley 2009; 1164:316-23. canalith repositioning maneuver. Laryngoscope 38. Whitney SL, Marchetti GF, Morris LO. Usefulness 2001; 111:940-5. of the dizziness handicap inventory in the screening 31. von Brevern M, Seelig T, Neuhauser H, Lempert for benign paroxysmal positional vertigo. Otol. Neu- T. Benign paroxysmal positional vertigo predomi- rotol 2005; 26:1027-33. nantly affect the right labirynth. J Neurol Neurosurg 39. Pereira AB, Santos JN, Volpe FM. Effect of Epley’s Psychiatry 2004; 75:1487-8. maneuver on the quality of life of paroxismal positi- 32. Damman W, Kuhweide R, Dehaene I. Benign pa- onal benign vertigo patients. Braz J Otorhinolaryn- roxysmal positional vertigo (BPPV) predominantly gol 2010; 76:704-8. affects the right labyrinth. J Neurol Neurosurg Psyc- 40. Bruintjes TD, Companjen J, van der Zaag-Loonen hiatry 2004; 75:1487-8. HJ, van Benthem PP. A randomised sham-controlled 33. Fife TD. Recognition and management of horizon- trial to assess the long-term effect of the Epley ma- tal canal benign positional vertigo. Am J Otol 1998; noeuvre for treatment of posterior canal benign pa- 19:345-51. roxysmal positional vertigo. Clin Otolaryngol 2014; 34. Cakir BO, Ercan I, Cakir ZA, Civelek S, Turgut S. 39:39-44. Relationship between the affected ear in benign pa- 41. Maslovara S, Soldo SB, Puksec M, Balaban B, roxysmal positional vertigo and habitual head lying Penavic IP. Benign paroxysmal positional vertigo side during bedrest. J Laryngol Otol 2006; 120:534-6. (BPPV): influence of pharmacotherapy and rehabi- 35. Parnes LS, Agrawal SK, Atlas J. Diagnosis and ma- litation therapy on patients’ recovery rate and life nagement of benign paroxysmal positional vertigo quality. Neuro Rehabilitation 2012; 31:435-41.

Značaj precizne dijagnoze u liječenju benignog paroksizmalnog pozicijskog vertiga (BPPV) Siniša Maslovara1, Tihana Vešligaj1, Silva Butković Soldo3, Ivana Pajić-Penavić2, Karmela Maslovara1, Tea Mirošević Zubonja3, Anamarija Soldo3 1Opća županijska bolnica Vukovar, Vukovar; 2Opća bolnica “Josip Benčević”, Slavonski Brod; 3Klinika za neurologiju Kliničko-bolničkog centra Osijek; Hrvatska

SAŽETAK

Cilj Utvrditi važnost precizne topografske dijagnoze benigne paroksizmalne pozicijske vrtoglavice (BPPV) kako bi se mogao primijeniti najprimjereniji oblik njegova liječenja. Metode Prospektivna studija provedena je u Općoj bolnici Vukovar, od siječnja 2011. do siječnja 2012. godine. Ispitan je 81 pacijent obolio od BPPV-a, odnosno 59 žena (72,84%) i 22 muškarca (27,16%) (p <0,001), prosječne životne dobi 60,1 (± 12,1) godina. Dijagnoza je potvrđena i dokumentirana videoni- stagmografijom (VNG). Onesposobljenost bolešću i rizik od padanja praćeni su popunjavanjem dvaju upitnika, tablice klasifikacije vrtoglavica (DHI) i ljestvice sigurnosti ravnoteže s obzirom na aktivnosti (ABC), prije i nakon repozicijskog liječenja. Rezultati U 79 (97,3%) pacijenata bio je zahvaćen stražnji polukružni kanalić, dok je bočni bio zahva- ćen u 2 (2,47%) slučaja. Nakon primjenjenog repozicijskog liječenja, došlo je do značajnog poboljšanja, pa čak i potpunog povlačenja simptoma kod 76 (93,82%) bolesnika. Prosječan skor DHI-a iznosio je 50,5 (± 22,2) na početku i 20,4 (± 18,5) na koncu istraživanja (p<0.00). Slično ovome, rezultati upitnika ABC-a na početku istraživanja pokazivali su vrijednost od 59,2% (± 22,4%), dok je prosječan rezultat po okončanju studije bio značajno viši i iznosio 84,9% (± 15.2%). Zaključak Iako je za postavljanje dijagnoze BPPV-a dovoljna pozitivna Dix-Hallpikeova ili “supine roll” proba, poželjno je učiniti i VNG pretragu, poglavito kod sumnje na zahvaćenost bočnog kanalića, s ciljem precizne dijagnoze bolesti i najprimjerenijeg liječenja, ali i rasvjetljavanja čestih nedoumica da li se BPPV pojavljuje kao samostalna bolest ili u sklopu nekog drugog vertiginoznog entiteta. Ključne riječi: dijagnoza, videonistagmografija, kanalolitijaza, kupulolitijaza, postupak repozicije otolita

306 ORIGINAL ARTICLE

Evaluation of the surgical treatment of diabetic foot

Amir Denjalić1, Hakija Bečulić2, Aldin Jusić2, Lejla Bečulić3

1Department of Surgery, General Hospital Tešanj, Tešanj, 2Department of Neurosurgery, 3Department of Oncology, Hematology and Radiotherapy; Cantonal Hospital Zenica, Zenica; Bosnia and Herzegovina

ABSTRACT

Aim To examine two modalities of surgical treatment of diabetic foot based on two different approaches, classical and multidisciplinary.

Methods A retrospective-prospective study including 120 consecutive patients with diabetic foot treated in the Department of Surgery, General Hospital Tešanj in the period 1999-2006. Since 2003 a new multidisciplinary approach to the treatment of diabetic foot based on a more conservative approach has been introduced. Two groups of patients were analyzed according to two treatment approaches: the first group included patients treated with classical method (in the period 1999-2002), and the second group included patients treated with multidisciplinary approach (in period 2003- 2006). An age distribution, gender, local changes in the extremities, results of microbiological analysis of wound swabs, and moda- Corresponding author: lities of surgical treatment of diabetic foot were analyzed. Hakija Bečulić Department of Neurosurgery, Results Duration of the disease (p=0.24), the level of blood glu- Cantonal Hospital Zenica cose (p=0.52) and glycosylated hemoglobin (p=0.10) had no statistically significant effect to the outcome of the treatment of Crkvice 67, 72 000 Zenica, diabetic foot, while the level of hematocrit (p<0.006), fibrinogen Bosna i Hercegovina (p<0.003), cholesterol (p<0.000001), and the absence of a pulse in Phone: +387 32 405 133; the peripheral arteries (p<0.000002), and the outcome of surgical +387 32 405 534; treatment of diabetic foot had the influence to the outcome of the E-mail: [email protected] treatment of diabetic foot with statistical significance.

Conclusion Aggressive and appropriate medical and surgical treatment according to a grade of disease could improve the outcome and reduce the morbidity and mortality of diabetic foot. The results of this study showed the importance of proper diabetes treatment, prevention of complications and a multidisciplinary approach to Original submission: the treatment of diabetic foot. 15 April 2014; Revised submission: Key words: complications, diabetes mellitus, multidisciplinary 03 June 2014; approach, outcome. Accepted: 14 July 2014.

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INTRODUCTION not involving tendon, capsule, or bone, grade 2 - wound penetrating to tendon or capsule, and grade Diabetes mellitus (DM) is a group of metabolic 3 -wound penetrating a bone or joint. Within each diseases in which a person has high blood sugar wound grade there are four stages: clean wounds level. Incidence of DM is about 3.3% in human (stage A), nonischemic infected wounds (stage B), population with equal rates in females and males ischemic noninfected wounds (stage C), and is- (1,2). Diabetes mellitus is classified into four broad chemic infected wounds (stage D) (10-12). categories: type 1, type 2, gestational diabetes, and other specific types. All forms of diabetes increase This protocol involves adequate control of blood the risk of long-term complications, but most of glucose, glycolated hemoglobin, glycemic pro- them come from type 1 (1-4). Long-term compli- file, treatment of wound infection, debridement cations typically develop after many (10–20) ye- of necrotic tissue, administration of antibiotics ars, but they might also be the first symptom of according to the antibiogram, gradual removal diabetic disease (3). Diabetic angiopathy and neu- of necrotic tissue from the affected foot with a ropathy could result in diabetic foot complications possible use of partial amputation. This protocol (3,4). Diabetic foot is a foot with a constellation prohibits application of caustic antiseptics in the of pathologic changes affecting the lower extremi- treatment of wounds (11,12). ty in diabetics, often leading to amputation and/ The aim of this research was to examine two mo- or death due to complications; the common initial dalities of surgical treatment of diabetic foot, using lesion leading to amputation is a non-healing skin two different approaches, classical based on a radi- ulcer, induced by regional pressure, pathogeni- cal surgical approach and a new multidisciplinary cally linked to sensory neuropathy, ischemia and approach based on a more conservative approach. infection (4). Diabetic foot complications are the The application of this protocol resulted in a de- most common cause of non-traumatic lower extre- crease of major amputations (femoral and tibial), mity amputations in the industrialized world (5). and in an increase of the functionality and support The risk of lower extremity amputation is 15 to 46 of the leg. The results of this study should show times higher in diabetics than in persons who do the importance of proper diabetes treatment, pre- not have diabetes mellitus (3-6). vention of complications and a multidisciplinary There is a two-fold aim of surgery, to control the approach to the treatment of diabetic foot. infection, and to attempt to salvage the leg (3). PATIENTS AND METHODS The eventual goal is always to preserve a functional limb (3,4). The surgical treatment of the Clinical trial design infection largely consists of draining of pus and removal of all necrotic and infected tissue (4). The retrospective-prospective, non-randomized, The outcome of the surgery mainly depends on controlled study included 120 consecutive pati- the skills, care, and experience of the surgeon (3). ents with diabetic foot who were treated at the In the Federation of Bosnia and Herzegovina Department of Surgery, General Hospital Tešanj (FBIH) 120,000-190,000 people are estimated to in the period 1999-2006. have diabetes, with the prevalence of about 5.4% Objective (7). Until January 2003 patients with diabetic foot had been treated according to the basic principles The aim of this research was to examine two of surgery. The approach to the patient was more modalities of surgical treatment of diabetic foot, individual without any defined protocol. This pe- using two different approaches, classical based riod is characterized by a high frequency of high on the radical surgical approach and the new amputations (femoral and tibial) (8,9). Since 2003 multidisciplinary approach based on a more con- we have been applying a standardized treatment servative approach. protocol of diabetic foot (Armstrong, 2003). This The outcome was defined by reducing the num- protocol used diabetic wound classification system ber of amputations and preserved foot support. based on a grade on the horizontal axis and a stage The patients were divided in two groups. The on the vertical axis: grade 0 -pre/or post-ulcerative first group included 53 (retrospectively) patients site that has healed, grade 1 - superficial wound treated with radical surgical approach characteri-

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zed with higher incidence of major amputations, The prevention of diabetic foot is related to which was performed in 31 patients during the the adequate control of the disease: glycaemia period January 1999 to December 2002. The se- control, blood count, glycosylated hemoglobin, cond group included 67 (prospectively) patients lipidograms, body mass reduction, adequate treated with a doctrinal approach in the period therapy, physical activity, etc. The treatment January 2003 to December 2006. of local changes is conditioned by their size, The research was conducted with the approval type and depth (10-13). Local treatment of of the Ethics Committee of the General Hospital wound includes antiseptic (3% hydrogen pe- Tešanj. roxide) application and irrigation with sterile saline solution, partial necrectomy and wound Eligibility criteria debridement, and administration of antibiotics according to microbiological analysis and sus- Patients with diabetes treated with insulin or oral ceptibility testing. Amputation is maximally antidiabetics, of different age and gender, with delayed (11,12). proven unilateral or bilateral diabetic foot were eligible for this research. Patients with diabetes Diabetic foot is defined as a foot with patho- treated with insulin or oral antidiabetics, of di- logic changes affecting the lower extremity in fferent age and gender, without evidence of di- diabetics. Phlegmon represents a spreading abetic foot and who died during the study were diffuse inflammatory process with formation excluded. All patients were followed to the com- of suppurative/purulent exudate or pus. Ulcers plete wound healing. All subjects included in this are wounds or open sores that will not heal or study voluntarily agreed to participate and gave keep returning, and are often complicated with written signed informed consents. infections. Expanding ulcers and spreading infection on a bone occur as osteomyelitis. Gan- Study interventions grene is the most serious form of diabetic foot. Until 2002 the surgical procedures treatment of There is necrosis or decay of the affected foot diabetic foot had not been standardized. This (17,18). approach includes the treatment of a local change Microbiological analysis of swabs of wound in- without clearly defined antiseptics, which meet fections were performed at the Department of the minimum toxicity to tissues and rapid elimi- the Laboratory Diagnostics, General Hospital nation from the tissues (13,14). A characteristic Tešanj, by standard microbiological methods of this approach is more frequent application of (19). Antibiotic susceptibility testing of isolated small and large amputations. Small amputations Gram-positive and Gram-negative bacteria was are performed at the level of the toes and feet: performed according to the Clinical Laboratory interphalangeal, metatarzofalangeal, intertarsal Standard Institute (CLSI) (20). (Lisfranc, Schopart, Pirogov). Large amputations In cases with superficial infection topical antibi- are femoral and tibial (14-16). otics (garamycin) were used until signs of the in- The doctrinal approach which was established fection were resolved and the wound healed. For in 2003 by Armstrong (11,12) involves multi- mild to severe infections, cephalosporins of the disciplinary approach that includes prevention, third and fourth generation and imipenem were conservative treatment and application of less used: for mild infections throughout the period of extensive surgery. This protocol used diabetic 12 weeks, for moderate and severe infections in wound classification system based on a grade on the period of 24 weeks. the horizontal axis and stage on the vertical axis: The decision on a modality of the treatment was grade 0 -pre/or postulcerative site that has healed, based on the prevalence of infection and necrosis grade 1 - superficial wound not involving tendon, size, signs of vasculopathy and a lack of pulse in capsule or bone, grade 2 - wound penetrating to the arteries of the foot and neuropathic changes. tendon or capsule, and grade 3 -wound penetra- All patients had a very bad medicament control ting the bone or joint. Within each wound grade of diabetes with high blood glucose (mean value there are four stages: clean wounds (stage A), no- 18.2mmol/L), glycosylated hemoglobin (mean nischemic infected wounds (stage B), ischemic value 11.2%), sedimentation (mean value 60.7), noninfected wounds (stage C), and ischemic in- fibrinogen (mean value 5.6) and cholesterol fected wounds (stage D) (10-12). (mean value 8.4).

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Follow up 28%, Proteus spp. in 25%, Pseudomonas aeruginosa in 10.8%, Klebsiella spp. in 3.3%, and Clo- All patients were followed until the complete stridium perfringens in 13.33% of the patients wound healing. The study did not follow up the (data not shown). patients after the healing of local changes, which is a significant limitation of this study. In all patients an appropriate antibiotic treatment according to the antibiogram was prescribed. The Statistical methods most commonly used antibiotics in gram- positi- ve and gram-negative bacteria were cephalospo- The results are presented in tables and expressed rins and imipenem. by relative values and mean value. The level of statistical significance was p<0.05. Surgical treatment RESULTS The first group included 53 patients who were treated with classical approach (more individu- Patients’ characteristics alized approach and it was not clearly adopted protocol of the treatment of diabetic foot) in the This study included 120 patients with diabetic period 1999-2002 and only one patient was trea- foot treated at the Department of Surgery, Gene- ted by conservative approach. The major ampu- ral Hospital Tešanj, during the period 1999-2006. tation (femoral and crural) was performed in 31 The patients were divided in two groups. In the (25.83%) patients, while small amputation (limi- first group 53 patients were treated using radical ted to foot) was performed in 11 (9.16%) pati- surgical approach (January 1999 to December ents. The first group included patients with poor 2002) and in the second group 67 patients were control of the disease and higher incidence of treated with multidisciplinary approach (January complications (phlegmon, ulceration, osteomye- 2003 to December 2006). litis and gangrene) (Table 2). The gender ratio was 67 females (55%) and 53 males (45%). The youngest patient was 33 and Table 2. Modalities of treatment of diabetic foot the oldest aged 85 (mean value 64.2). No (%) of patients Patients with Patients with Local changes Modality of treatment radical surgical multidisciplinary approach approach All patients had inflammatory and necrotic chan- Femoral amputation 17 (32.1) 6 (8.9) ges in the foot. Crural amputation 24 (45.5) 12 (17,1) Minor amputation 11 (20.75) - In the first group 14 (28.30%) patients had phle- Finger amputation - 13 (19.4) gmon, 12 (22.64%) had ulcers, six (11.32) had Foot amputation - 15 (22.4) Conservative treatment 1 (2) 21 (31.3) both, 10 (18.86%) had ulcers with osteomyelitis Total 53 67 and 11 (20.75%) had gangrene. In the second group 22 (32.38%) patients had phlegmon, 15 The second group included 67 (prospectively) pa- (22.38%) had ulcers, 10 (14.92%) had both, ei- tients who were treated in the period 2003-2006. ght (11.94%) had ulcers with osteomyelitis and In these patients, we used the doctrinal approa- 12 (17.91%) had gangrene (Table 1). ch in the treatment of patients with diabetic foot

Table 1. Local changes in patients with diabetic foot according to Armstrong (Table 2). A significant decrease of the incidence of major amputations No (%) of patients Patients with Patients with and an increase in the number of patients with Local changes radical surgical multidisciplinary preserved function of foot has been found. approach approach Phlegmon 14 (28.30) 22 (32.83) Laboratory parameters Ulcer 12 (22.64) 15 (22.38) Phlegmon and ulcer 6 (11.32) 10 (14.92) In the second group relevant laboratory parameters Ulcer with osteomyelitis 10 (18.86) 8 (11.94) Gangrene 11 (20.75) 12 (17.91) were controlled in all patients. They all had a very Total 53 67 bad medicament control of diabetes with high blood glucose (mean value 18.2 mmol/L), glycosyla- Bacterial flora and antibiotics ted hemoglobin (mean value 11.2 %), sedimentati- The most common isolated bacteria were Esche- on (mean value 60.7), fibrinogen (mean value 5.6) richia coli, in 49%, Staphylococcus aureus in and cholesterol (mean value 8.4) (Table 3).

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Table 3. Laboratory parameters in 67 prospectively treated In this research, the results of the treatment of di- patients abetic foot were significantly different in relation Laboratory parameter Mean value to the approach. Prior to the adoption of a sin- Blood glucose 18.2 Glycosylated hemoglobin 11.2 gle multidisciplinary approach to the treatment Sedimentation 60.7 of diabetic foot, there had been a much higher Fibrinogen 5.6 frequency of amputations compared to the se- Cholesterol 8.4 cond period, which is in relation with results of Statistical analysis showed that there was no other authors (5-8). In the second group of pati- statistical significance between the duration of ents percentage of large amputations was signifi- the disease (p=0.24), level of blood glucose (p= cantly reduced, thereby increasing the number of 0.52), level of glycosylated hemoglobin (p=0.10) patients with conservative treatment and minor and the outcome of the surgical treatment with amputations. This is also in relation with results preserved function of the foot. There was statisti- of other authors (3,15-18). cal significance between the level of hematocrit According to our research, there was no statisti- (p<0.006), level of fibrinogen (p<0.003), level of cal significance between the duration of the dise- cholesterol (p<0.000001), absence of pulse in pe- ase, level of glucose, level of glycosylated hemo- ripheral arteries (p<0.000002) and the outcome globin and the outcome of the surgical treatment of the surgical treatment of diabetic foot. of diabetic foot in the second group of patients. These data did not correlate with other studies DISCUSSION (3, 16-18). These results could be explained by Diabetes mellitus (DM) is a group of metabolic dian introduction of the conservative approach and seases in which a person has high blood sugar. In- better control of the disease with medicaments cidence of DM is 3.3 % in human population with and insulin. These data are missing for the first equal rates in females and males (1,2). Diabetes group of patients. mellitus increases the risk of long-term complica- Diabetic foot is a significant complication of ditions (1). Diabetic foot complications are the most abetes. Aggressive and appropriate medical and common cause of nontraumatic lower extremity surgical treatment according to a grade of the di- amputations in the industrialized world. The risk sease can improve the outcome and reduce mor- of lower extremity amputation is 15 to 46 times hi- bidity and mortality due to diabetes. gher in diabetics than in persons who do not have In conclusion, this study was conducted with the diabetes mellitus. The vast majority of diabetic principal aim to evaluate results of the surgical tre- foot complications resulting in amputation begin atment of diabetic foot using two different approa- with the formation of skin ulcers (3-6). ches. The first group included patients treated with The aim of surgery is to control the infection, to classical approach which had higher incidence of attempt to save the leg, and if possible, to preser- major amputations. The second group included ve a functional limb. The surgical treatment of patients treated with doctrinal approach which the infection largely consists of draining of pus characterized more the conservative approach, and removal of all necrotic and infected tissue. with delayed large amputations. Aggressive and The best results are achieved with a multidisci- appropriate medical and surgical treatment accor- plinary approach (3). ding to the grade of the disease could improve the Since 2003 a unified doctrinal approach has been outcome and reduce morbidity and mortality of established by Armstrong who gives a unique diabetic foot. The results of this study have shown classification of diabetic foot according to the the importance of proper diabetes treatment, pre- depth of the lesion, the degree of infection and vention of complications and a multidisciplinary ischemia (10-12). Modern approach is based on a approach to the treatment of diabetic foot. more conservative approach (2,3,13). FUNDING Our research has shown that gram-negative bacteria were commonly isolated from the wound swa- No specific funding was received for this study. bs, which is not in correlation with other studies TRANSPARENCY DECLARATIONS in which gram-positive (most commonly Stap- hylococcus) bacteria are predominant (6¸13-16). Competing interest; none to declare.

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REFERENCES 1. American Diabetes Association. Diagnosis and cla- 11. Armstrong DG, Lavery LA, Kimbriel HR, Nixon ssification of diabetes mellitus. Diabetes Care 2013; BP, Boulton AJ. Activity patterns of patients with 36(Suppl. 1):S67-74. diabetic foot ulceration patients with active ulcerati- 2. Armstrong DG, Kanda VA, Lavery LA, Marston on may not adhere to a standard pressure off-loading W, Mills JL, Boulton A J. Mind the gap: disparity regimen. Diabetes Care 2003; 26:2595-7. between research funding and costs of care for dia- 12. Armstrong DG, Frykberg RG. Classifying diabetic betic foot ulcers. Diabetes Care 2013; 36:1815-17. foot surgery: toward a rational definition. Diabetic 3. van Baal JG. Surgical Treatment of the Infected Dia- Med 2003; 20:329-31. betic Foot. Clin Infect Dis 2004; 39:123-8. 13. Jeffcoate WJ, Price P, Harding KG. Wound healing 4. Lipsky BA, Peters EJG, Berendt AR, Senneville E, and treatments for people with diabetic foot ulcers. Bakker K, Embil JM, Joseph WS, Karchmer AW, Diabetes Metab Res Rev 2004; 20:78-8. Pinzur MS, Senneville E. Specific guidlines for the 14. Kruse I, Edelman S. Evaluation and treatment of di- treatment of diabetic foot infections 2011. Diabetes abetic foot ulcers. Clinical Diabetes 2006; 24:91-3. Metab Res Rev 2012; 28:234-5. 15. Peters EJ, Lipsky BA. Diagnosis and management 5. Alexiadou K, Doupis J. Management od diabetic of infection in the diabetic foot. Med Clin North Am foot ulcers. Diabetes Ther 2012; 3:1-15. 2013; 97:911-46. 6. Vuorisalo S, Venermo M, Lepantalo M. Treatment 16. Ziegler D. Painful diabetic neuropathy: treatment of diabetic foot ulcers. J Cardiovasc Surg (Torino) and future aspects. Diabetes Metab Res Rev 2008; 2009; 50:275-91. 24:52-7. 7. Zavod za javno zdravstvo Federacije Bosne i Herce- 17. Armstrong DG, Lavery LA, Kimbriel HR, Nixon BP, govine. Zdravstveno stanje stanovništva i zdravstve- Boulton AJ. Activity patterns of patients with diabe- na zaštita u Federaciji Bosne i Hercegovine 2009. tic foot ulceration. Diabetes Care 2003; 26:2595-7. Sarajevo: Zavod za javno zdravstvo Federacije Bo- 18. Armstrong DG, Lavery LA, Wu S, Boulton AJ. Eva- sne i Hercegovine, 2010. lution of removable and irremovable cast walkers in 8. Bridges RM, Deitch EA. Diabetic foot infections. the healing of diabetic foot wounds. Diabetes Care Pathophysiology and treatment. Surg Clin North Am 2005; 28:551-4. 1994; 74:537-55. 19. Murray PR, Baron EJ, Jorgensen JH, Pfaller MA, 9. Caputo GM, Cavanagh PR, Ulbrecht JS, Gibbons Yolken RH, editors. Manual of Clinical Microbio- GW, Karchmer AW. Assessment and management of logy, Washington, DC: ASM Pres; 2003: p. 384-404. foot disease in patients with diabetes. NEJM 1994; 20. Clinical and Laboratory Standards Institute. Perfor- 331:854-60. mance Standards for Antimicrobial Susceptibility 10. Armstrong DG, Lipsky BA. Diabetic foot infections: Testing. Tenth Informational Supplement M100- stepwise medical and surgical management. Int Wo- S18. Wayne PA, USA: CLSI; 2009. und J 2004; 1:123-32. Evaluacija hirurškog liječenja dijabetičnog stopala Amir Denjalić1, Hakija Bečulić2, Aldin Jusić2, Lejla Bečulić3 1Odjeljenje hirurgije, Opća bolnica Tešanj, Tešanj; 2Služba za neurohirurgiju, 3Služba za onkologiju, hematologiju i radioterapiju; Kanton- alna bolnica Zenica; Zenica; Bosna i Hercegovina

SAŽETAK Cilj Ispitati modalitete hirurškog liječenja dijabetičnog stopala zasnovane na dva različita pristupa – klasičnom i multidisciplinarnom. Metode U retrospektivno-prospektivnu studiju bilo je uključeno 120 pacijenata s dijabetičnim stopalom, liječenih na Odjeljenju hirurgije Opće bolnice Tešanj, u periodu od 1999. do 2006. godine. Od 2003. godine uveden je novi multidisciplinarni pristup liječenju dijabetičnog stopala, zasnovan na više konzervativnom pristupu. Pacijenti su bili podijeljeni u dvije grupe – u prvu su bili uključeni pacijenti liječeni klasičnim pristupom (u periodu od 1999. do 2002. godine), a u drugu pacijenti liječeni multidisciplinarnim pristupom (u periodu od 2003. do 2006. godine). Analizirana je dobna i spolna distribucija, lokalne promjene na ekstre- mitetima, rezultati mikrobiološke analize briseva rana i modaliteti hirurškog liječenja dijabetičnog stopala. Rezultati Dužina trajanja bolesti (p=0,24), nivo glukoze u krvi (p= 0,52) i glikoliziranog hemoglobina (p=0,10), nisu imali značajan utjecaj na ishod liječenja dijabetičnog stopala, dok su vrijednost hemato- krita (p<0,006), fibrinogenafi brinogena (p<0,003), holesterola (p<0, 000001) i odsutnost pulsa u perifernim arteriarteri-- jama (p<0,000002), te ishod hirurškog liječenja dijabetičnog stopala, sa statističkom značajnošću imali utjecaj na ishod liječenja dijabetičnog stopala. Zaključak Agresivni i odgovarajući medicinski i hirurški tretman prema stadiju bolesti može poboljšati ishod liječenja i smanjiti morbiditet i mortalitet dijabetesa. Rezultati ove studije pokazali su važnost odgovarajućeg liječenja dijabetesa, prevenciju komplikacija i multidisciplinarnog pristupa u liječenju dijabetičnog stopala. Ključne riječi: komplikacije, dijabetes, multidisciplinarni pristup, ishod

312 ORIGINAL ARTICLE

Serum Levels of ICAM-1, VCAM-1 and E-selectin in early postoperative period and three months after eversion carotid endarterectomy Hrvoje Palenkić1, Tatjana Bačun2,3, Anita Ćosić2, Ivo Lovričević4 , Drago DeSyo4, Ines Drenjančević2

1General Hospital „Dr. Josip Benčević“, Slavonski Brod, 2School of Medicine, University ‘’Josip Juraj Strossmayer’’ Osijek, 3Clinic for Internal Medicine, Clinical Hospital Center Osijek, 4School of Medicine, University of Zagreb; Croatia

ABSTRACT

Aim To determine the influence of eversion endarterectomy on circulating adhesion molecules (CAMs): E-selectin, intercellular circulating adhesion molecule-1 (ICAM-1) and vascular circulating adhesion molecule-1 (VCAM-1).

Methods Forty patients underwent carotid endarterectomy. Veno- us blood samples have been gathered before operation, one hour and six hours after the operation and three months after the procedure. Levels of CAMs have been determined by sandwich ELISA test.

Results Statistically significant decrease of the ICAM-1 levels one Corresponding author: hour and six hours after the endarterectomy compared to levels Hrvoje Palenkić before the operation have been found. There were no statistically Opća bolnica “Dr. Josip Benčević” significant changes in concentration of VCAM-1 and E-selectin. Andrije Štampara 42, Three months after the operation levels of CAMs where similar to those before the operation. There was a statistically significant Slavonski Brod, Croatia decrease of systolic arterial blood pressure levels within early po- Phone: +38591 515 5255; stoperative period. Fax: +385 35 201 130; E-mail:[email protected] Conclusion Results suggest that decrease of ICAM-1 could be a possible marker of endothelial de-activation after plaque removal. Endarterectomy has a positive influence on systolic arterial blood pressure in early postoperative period. Further investigations are necessary to better understand and prevent the development of atherosclerotic plaque.

Key words: atherosclerhosis, adhesion molecules, carotid artery Original submission: stenosis 09 December 2013; Revised submission: 17 December 2014; Accepted: 06 May 2014.

Med Glas (Zenica) 2014; 11(2):313-319

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INTRODUCTION patch plastic or dissection at the origin of internal carotid artery (ICA) and removing atherosclero- Geometry of carotid artery bifurcation may be tic plaque by eversion of ICA. In our research one of the factors which influence hemodyna- eversion endarterectomy with primary suture was mic of blood flow causing atherosclerotic plaque an operating technique. formation. Lateral wall of carotid artery bifurcation and lateral wall of the beginning of the in- The aim of this paper was to determine serum le- ternal carotid artery are predilection locations for vels of circulating adhesion molecules (CAMs): plaque formation (1-3). Inflammation in vascular E-selectin, Intercellular Adhesion Molecule-1 wall is an important factor of atherogenesis and (ICAM-1) and Vascular Adhesion Molecule-1 early stages of atherosclerosis (4). (VCAM-1) in patients that underwent eversion endarterectomy Cell adhesion molecules are glycoproteins situated in cytoplasm, cell membrane and there is an outer PATIENTS AND METHODS cell part. They are divided in four groups: cadherins, integrins, selectins and immunoglobulin su- In the present study 40 patients were included per family. Cadherins connects heart cells, neural and selected by Color Doppler flow imaging synapses and cells in myelin envelope. Integrins (CDFI) on LG Logiq E9 machine with 9 MHz are involved in processes like thrombosis, morpho- probe. Stenosis was determined according to the genesis, remodeling of tissues, leukocyte migration North American Symptomatic Carotid Endarte- etc. That group includes ICAM-1 and VCAM-1. rectomy Trial (NASCET) criteria. Selectins are divided to L, P and E selectin and they Inclusion criteria were asymptomatic ≥70% steno- are very similar to each other by structure. They sis of Internal Carotid Artery (ICA) CDFI deter- are named by cells where they were first discove- mined, or symptomatic ≥50% ICA stenosis, CDFI red (L-lymphocyte, P- platelets and E- endotheli- determined, age between 51 and 81 and body mass al), (5). Inflammatory conditions causing increase index (BMI) less than 35 kgm-2 (Table 1). of circulating E-selectin, ICAM-1 and VCAM-1 Table 1. General descriptive parameters of patients levels and therefore they can be used as markers of No Mean± SD Minimum Maximum endothelial activation and deactivation (6). Height (cm) 40 169±8 152 186 Weight (kg) 40 77±10 58 99 Levels of soluble endothelial adhesion molecules BMI (kgm-2) 40 27±2 22 31 and diabetes mellitus (DM) are positively correla- Cholesterol (mmol/L) 40 4.58±0.78 2.3 9.5 HDL (mmol/L) 40 1.12±0.07 0.23 1.75 ted and that has been established in a number of in LDL (mmol/L) 40 3.34±0.15 2.01 6.65 vitro and in vivo experiments as well as in obesity, Tryglicerides (mmol/L) 40 2.12±0.62 0.41 7.34 arterial hypertension and serum lipid disorder (7- Males 26 - - - 9). Haemodialysis patients have an increased level Females 14 - - - BMI, body mass index; HDL, high density lipoproteins; LDL, low of CAMs but that is either result of inadequate cle- density lipoproteins; arance or enhanced synthesis and release of CAMs Exclusion criteria were acute cerebral incidents which has not been determined yet (10). Elevated within 6 weeks prior to surgery, diabetes mellitus levels of ICAM-1 were found in atherosclerotic (DM) and alcohol uptake more than 20 g per day. plaques in the high-grade regions of symptomatic All patients underwent eversion endarterectomy versus asymptomatic plaques and in high-grade under local regional anesthesia with levobupiva- versus low-grade region of symptomatic plaques caine hydrochloride (Chirocaine, Abbot Labora- (11). In a study by Hwang at al. the relationship tories d.o.o., EU) 0. 25% up to 40 ccm-3 in total. of ICAM-1 and E-selectin with coronary heart The venous blood samples were taken before the disease (CHD) and carotid artery atherosclerosis procedure, one hour after procedure, six hours af- (CAA) was independent of other known CHD risk ter the procedure and three months after surgery. factors suggesting that plasma levels of ICAM-1 All samples were then centrifuged at 2500 rpm and E-selectin may serve as molecular markers for for 10 minutes at room temperature and stored in atherosclerosis and the development of CHD (12). refrigerator on -25°C. Two-step sandwich ELISA Endarterectomy is a procedure where a surgeon assay was used for determination of ICAM-1, removes atherosclerotic plaque from diseased ar- VCAM-1 and E-selectin, (Human sICAM Pla- tery. It can be done by longitudinal incision with tinum ELISA, Human sVCAM Platinum ELI-

314 Palenkić et al. Endarterectomy and CAMs

SA, Human E-selectin Platinum ELISA, Bender Table 3. General descriptive parameters of the soluble vascu- MedSystems GmbH, Vienna, Austria). lar cell adhesion molecule-1 (sVCAM-1) Mini- Maxi- Median Mean ± SD The normality of the distribution was tested by mum mum sVCAM-1 before Kolmogorov-Smirnov test and Lilliefors norma- 579.54 515.67±302.63 182.06 1433.30 operation (ng/mL) lity test and Skewness and Kurtosis were calcu- sVCAM-1 1h after 540.99 496.93±297.27 72.35 1450.00 lated. E-selectin variables were slightly off the operation (ng/mL) sVCAM-1 6h after 551.02 503.23±251.16 139.00 1147.80 normal distribution. The ANOVA for repeated operation (ng/mL) sVCAM-1 3mo after measures was used as it is not very sensitive to 1153.8 1000.0±629.72* 105.77 2471.20 operation (ng/mL) moderate deviations from normality. Studies, *p<0.001 for sVCAM levels 3 months after surgery using a variety of non-normal distributions, have mising statistical parameters, there was no sta- shown that the false positive rate is not affected tistically significant difference from the starting very much by this (Glass et al. 1972, Harwell et level for repeated measures (Current effect: F[2. al. 1992, Lix et al. 1996), but inspite of that E-se- 76]=0.8861; p<0.4165) (Table 4). lectin results were confirmed with non-parametric Friedman ANOVA (13-16). Table 4. General descriptive parameters of the soluble vascular cell adhesion molecule-1 (sVCAM-1) with excluded RESULTS extremely high levels in 12 patients Mini- Maxi- Median Mean ± SD Levels of sICAM before the procedure were mum mum sVCAM-1 before 579.54 515.67±302.63 182.06 1433.30 470.54±153.84 ng/mL. One hour after the pro- operation (ng/mL) sVCAM-1 1h after cedure concentrations dropped to 404.96±125.60 540.99 496.93±297.27 72.35 1450.00 operation (ng/mL) ng/mL, and six hours after to 395.39±117.87 ng/ sVCAM-1 6h after 551.02 503.23±251.16 139.00 1147.80 operation (ng/mL) mL. Significant differences were found between sVCAM-1 3mo after 642.31 609.74 ±288.70 67.31 990.38 the concentrations of sICAM-1 before the proce- operation (ng/mL) dure and one hour after the procedure (p<0.001) There were no significant changes in serum soluble and between the concentrations of sICAM-1 be- E-selectin levels observed over time. Preoperati- fore the procedure and six hours after the proce- ve levels were 49.39±31.11 ng/mL, one hour after dure (p<0.001). There was no further significant the procedure decreased to 48.25±26.98 ng/mL, decrease in period between one hour to six hours while after six hours the mean concentration was after the procedure (p=0.681). Three months af- 47.87±26.98 ng/mL. None of those changes were ter the surgery levels were similar to those before statistically significant (p=0.14327; coeff. of con- the surgery (Table 2). cordance = 0.04858; aver. rank r=0.02418) (Table 5) Table 2. General descriptive parameters of the soluble intercellular adhesion molecule-1 (sICAM-1) Table 5. General descriptive parameters of the soluble Maxi- Mini- E-selectin (sE-selectin) Median Mean ± SD mum mum Median Mean ± SD Maximum Minimum sICAM-1 before sE-selectin before 470.26 434.35±153.84 263.20 843.48 49.40 39.76±31.11 13.53 128.51 operation (ng/mL) operation (ng/mL) sICAM-1 1h after sE-selectin 1h after 404.96 396.20±125.61* 214.66 771.30 48.25 37.99±26.98 18.59 113.09 operation (ng/mL) operation (ng/mL) sICAM-1 6h after sE-selectin 6h after 395.40 371.53±117.86* 235.05 719.51 47.87 37.34±26.99 18.76 112.66 operation (ng/mL) operation (ng/mL) sICAM-1 3 mo after sE-selectin 3mo after 485.45 448.44±146.32 305.31 1080.5 49.80 43.8±25.77 14.27 107.1 operation (ng/mL) operation (ng/mL) *p<0.001 for values one hour and six hours after surgery Before the procedure the Mean sVCAM-1 le- DISCUSSION vel was 579.54±302.63 ng/mL. One hour after the procedure the concentrations lowered to The aim of this paper was to determine serum le- 540.98±297.26 ng/mL and then six hours af- vels of circulating adhesion molecules (CAMs): ter the surgery increased to 551.02±251.15 ng/ E-selectin, intercellular circulating adhesion mL. Three months after the procedure level of molecule-1 (ICAM-1) and vascular circulating sVCAM-1 was double to those before the surge- adhesion molecule-1 (VCAM-1) in patients that ry probably due to extremely high levels measu- underwent eversion endarterectomy. red in few patients, e.g.( Table 3), after excluding For sICAM-1 the mean concentrations before the those patients from statistics, without compro- procedure dropped one hour after and six hours

315 Medicinski Glasnik, Volume 11, Number 2, July 2014

after the operation. Three months after the surgery ssible therapeutic target because there has been a levels of sICAM-1 were slightly higher than be- large number of polymorphism identified in the fore the operation. The changes in sICAM con- genes encoding different CAMs (24). Fassbender centrations one and six hours after the surgery at al. indicates that endothelial-derived adhesion were statistically significant. ��Changes�� in concen- molecules levels have been elevated in patients trations of sVCAM-1 in early postoperative pe- with large brain-supplying vessels stenosis as riod were not statistically significant. However, well as in the patients with subcortical vascular three months after the surgery average sVCAM-1 encephalopathy and that they play similarly im- concentrations were significantly higher in com- portant role in cerebrovascular disease (25). parison to the concentrations before the operation. Carotid artery atherosclerotic plaque has been in- This was a consequence of 12 extremely high val- vestigated using immunohystochemical methods. ues measured and after excluding those values, Symptomatic ones had statistically significant more the change in concentration of sVCAM-1 was not ulcerations and plaque ruptures than asymptomatic statistically significant. The values of sE-selectin patients as well as higher levels of inflammatory one hour after the procedure actually slightly de- cells which implicated that infiltration of those ce- creased from those preoperatively, while after six lls promotes plaque rupture and subsequently em- hours and three months the mean concentration bolisation and carotid artery occlusion (26). Kockx was a bit higher of those before the operation, but investigated specimens after carotid endarterecto- the change was not statistically significant. my and concluded that focal intra-plaque micro- A correlation between ischemic heart disease, hemorrhages and neovascularization can promote peripheral arterial disease and plasma levels of plaque expansion and rupture after the micro ve- CAMs has been investigated by several authors, ssels thrombosis (27). The research showed no and they all agree that there is enough evidence evidence of association of VCAM-1 plasma levels that inflammation plays an important role in at- and myocardial infarction in 474 men who suffe- herogenesis but exact mechanism is not determi- red from MI and control group matched by age, ned (17-19). Results of ICAM levels in rats after smoking status and length of follow-up, which is balloon injury of the carotid artery implicated in contrast with previous data about the association that balloon injury induced or up regulated the of ICAM-1 and myocardial infarction (28). Serum ICAM-1 expression on vascular smooth muscle levels of ICAM-1 are reliable markers of carotid cells and on regenerating endothelial cells (20). disease progression and can be used as a prognostic In model on mice with apolipoprotein deficiency factor for asymptomatic patients, e.g. symptomatic and deficiency of the ICAM, P and E selectin re- patients have statistically significantly higher le- sults indicated that reduction of those CAMs pro- vels of ICAM-1 than asymptomatic ones (29). tects from atherosclerotic plaque forming (21). Nuotio at al. showed no difference between pla- In a study on 14916 middle aged men who su- sma levels of ICAM-1 and VCAM-1 of symp- bsequently developed symptomatic peripheral tomatic and asymptomatic patients in immuno- arterial disease elevated levels of ICAM-1 have staining results of fresh frozen atherosclerotic been found implicating that CAMs participated plaques specimens, which is opposite to majority in accelerated atherosclerosis in otherwise he- of investigations (30). althy man (22). Circulating cell adhesion mole- Levels of ICAM-1, VCAM-1 and E-selectin have cules had been shedding in circulation in acute been measured in investigation of arterial lumen phase response and among others that could be and neovasculature. Higher levels of CAMs on one of the predicting factors for cardiovascular intimal neovasculature than on arterial lumen disease (23). Researchers focused on the adhe- endothelium have been determined and authors sion molecules and their part in early atherosc- concluded that in pathogenesis of atherosclerosis lerosis underlines influence of the CAMs on the neovasculature may play an important role (31). inflammatory cells and their presence in circula- Measuring intima-media thickness and comparing tion although their origin is not fully understood. with levels of serum CAMs authors demonstrate Future investigation is necessary to establish the a positive association between those two values role of the CAMs in atherosclerosis and as a po- which further support the role of systemic inflam-

316 Palenkić et al. Endarterectomy and CAMs

mation in the development of atherosclerotic lesi- also explained by progression of atherosclerosis on on (32). Signorelli et al. tried to determine levels some other place or places in circulation. Therefore, of plasma ICAM-1, VCAM-1 and E-selectin by it is necessary to continue investigating this subject comparing those levels in control group without to be able to understand the mechanism of atherosc- peripheral arterial disease and peripheral arterial lerotic plaque forming and then maybe in the future disease group before and after the treadmill exer- to be able to slow if not stop that mechanism. cise. Results confirm that CAMs increase in con- The results of this study showed statistically signi- ditions of hemodynamic stress (33). In patients ficant decrease of ICAM-1 levels immediately and with peripheral occlusive arterial disease (PAOD) six hours after the operation. Results suggest that levels of VCAM-1 before the procedure and six the decrease of ICAM-1 could be a possible mar- months after percutaneous transluminal angiopla- ker of endothelial de-activation after plaque re- sty (PTA) pointed that those patients who develo- moval. However, lowering of the ICAMs in early ped restenosis have higher levels of VCAM-1 and postoperative period contributes with other positi- other markers of endothelial activation (34). ve effects of endarterectomy to the benefit of the The elevation of sVCAM-1 levels in 12 patients 3 patients’ health and it remains for further research months after surgery can be partly explained with to determine if it has short or long-term influence. probably some kind of allergic reaction on some allergens that were not present at the time of opera- FUNDING tion because neither of those operated patients had No specific funding was received for this study. CDFI determined stenosis over 30% and no local signs of inflammation, which is in accordance with TRANSPARENCY DECLARATIONS a study of Chen and Khismatulin (35). It can be Competing interests: none to declare.

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17. Haught WH, Mansour M, Rothlein R, Kishimoto TK, Phagocytosis and macrophage activation associated Mainolfi EA, Hendricks JB, Hendricks C, Mehta JL. with hemorrhagic microvessels in human atheroscle- Alterations in circulating intercellular adhesion mo- rosis. Arterioscler Thromb Vasc Biol 2003; 23:440-6. lecule-1 and L-selectin: Further evidence for chronic 28. de Lemos JA, Hennekens CH, Ridker PM. Plasma inflammation in ischemic heart disease. Am Heart J concentration of soluble vascular cell adhesion mole- 1996; 13:21–8. cule-1 and subsequent cardiovascular risk. J Am Coll 18. Hulthe J, Wiklund O, Hurt-Camejo E, Bondjers G. Cardiol 2000; 36:423-6. Antibodies to oxidized LDL in relation to carotid 29. Mocco J, Choudhri T F, Mack W J, Laufer I, Lee J, atherosclerosis, cell adhesion molecules, and phosp- Kiss S ,Poisik A, Quest, DO, Solomon RA, Connolly holipase A2. Arterioscler Thromb Vasc Biol 2001; ES. Elevation of soluble intercellular adhesion mole- 21:269-74. cule-1 levels in symptomatic and asymptomatic caro- 19. van der Meer I M, de Maat M PM, Bots M L, Breteler tid atherosclerosis. Neurosurgery 2001; 48:718-22. M MB, Meijer J, Kiliaan A J, Hofman A,Witteman 30. Nuotio K, Lindsberg P J, Carpén O, Soinne L, Leh- JCM. Inflammatory mediators and cell adhesion mo- tonen-Smeds E, Saimanen E, Lassila R, Sairanen T, lecules as indicators of severity of atherosclerosis. Sarna S, Salonen O, Kovanen P T, Kaste M. Adhesion Arterioscler Thromb Vasc Biol 2002; 22:838-42. molecule expression in symptomatic and asymptoma- 20. Yasukawa H, Imaizumi T, Matsuoka H, Nakashima tic carotid stenosis. Neurology 2003; 60:1890-9. A, Morimatsu M. Inhibition of intimal hyperplasia af- 31. O’Brien KD, McDonald TO, Chait A, Allen MD, ter balloon injury by antibodies to intercellular adhe- Alpers CE. Neovascular expression of e-Selectin, sion molecule-1 and lymphocyte function–associated intercellular adhesion molecule-1, and vascular cell antigen-1. Circulation 1997; 95:1515-22. adhesion molecule-1 in human atherosclerosis and 21. Collins RG, Veljia R, Guevarab NV, Hicksc their relation to intimal leukocyte content. Circulation MJ,Chanb L, Beaudeta AL. P-selectin or intercellular 1996; 93:672-82. adhesion molecule (Icam)-1 deficiency substantially 32. Rohde LE, Lee RT, Rivero J, Jamacochian M, Arroyo protects against atherosclerosis in apolipoprotein E– LH, Briggs W, Rifai N, Libby P, Creager MA, Ridker deficient mice. J Exp Med 1991; 191:189-94. PM. Circulating cell adhesion molecules are corre- 22. Pradhan A D, Rifai N, Ridker PM, Soluble interce- lated with ultrasound-based assessment of carotid llular adhesion molecule-1, soluble vascular adhesi- atherosclerosis. Arterioscler Thromb Vasc Biol 1998; on molecule-1 and the development of symptomatic 18:1765-70. peripheral arterial disease in men. Circulation 2002; 33. Signorelli SS, Mazzarino MC, Di Pino L, Find Mala- 106:820-5. ponte G, Porto C, Pennisi G, Marchese G, Costa MP, 23. Black PH, Garbutt LD. Stress, inflammation and car- Digrandi D, Celotta G, Virgilio V. High circulating diovascular disease. J Psychosom Res 2002: 521-3. levels of cytokines (IL-6 and TNFalpha), adhesion 24. Blankenberg S, Barbaux S, Tiret L. Adhesion mo- molecules (VCAM-1 and ICAM-1) and selectins in lecules and atherosclerosis. Atherosclerosis 2003; patients with peripheral arterial disease at rest and af- 170:191-203. ter a treadmill test.Vasc Med 2003; 8:15-9. 25. Fassbender K, Bertsch T, Mielke O, Mühlhauser F, 34. Tsakiris DA, Tschöpl M, Jäger K, Haefeli WE, Wolf Hennerici M. Adhesion molecules in cerebrovascular F, Marbet GA. Circulating cell adhesion molecules diseases. Evidence for an inflammatory endothelial and endothelial markers before and after transluminal activation in cerebral large- and small-vessel disease. angioplasty in peripheral arterial occlusive disease. Stroke 1999; 30:1647-50. Atherosclerosis 1999; 142:193–200. 26. Golledge J, Greenhalgh RM, Davies AH. The sympto- 35. Chen C, Khismatulin DB. Synergistic effect of hista- matic carotid plaque. Stroke 2000; 31:774-781. mine and TNF-α on monocyte adhesion to vascular 27. Kockx M M, Cromheeke K M, Knaapen M WM, endothelial cells. Inflammation 2013; 36:309-19. Bosmans J M, De Meyer G RY, Herman A G, Bult H.

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Serumska koncentracija ICAM-1, VCAM-1 i E-selektina u ranom poslijeoperacijskom periodu i tri mjeseca nakon everzijske endarterektomije karotidnih arterija Hrvoje Palenkić1, Tatjana Bačun2,3, Anita Ćosić2, Ivo Lovričević4 , Drago DeSyo4, Ines Drenjančević2

1Opća bolnica „Dr. Josip Benčević“, Slavonski Brod, 2Medicinski fakultet Sveučilišta „Josip Juraj Strossmayer” Osijek, 3Klinika za internu medicinu Kliničkog bolničkog centra Osijek, 4Medicinski fakultet Sveučilišta u Zagrebu; Hrvatska SAŽETAK

Cilj Utvrditi utjecaj endarterektomije na koncentraciju cirkulirajućih adhezijskih molekula, E-selektina, međustanične adhezijske molekule-1 (ICAM-1) i adhezijske molekule žilne stijenke-1 (VCAM-1).

Metode Istraživanje je provedeno na 40 bolesnika kojima je učinjena endarterektomija karotidnih arterija. Uzorci venske krvi uzimani su prije operacije, jedan sat nakon operacije, šest sati nakon operativnog zahvata, te tri mjeseca poslije endarterektomije. Koncentracija topivih adhezijskih molekula endotela određivana je sendvič ELISA testom.

Rezultati Uočeno je smanjenje vrijednosti ICAM-1 jedan sat i šest sati nakon operativnog zahvata. Promjene u vrijednostima ICAM-1 bile su statistički značajne, dok promjene koncentracije druge dvije adhezijske molekule nisu. Tri mjeseca nakon operacije vrijednosti mjerenih topivih adhezijskih molekula endotela bile su kao i prije operacije. Uočen je statistički značajan pad sistoličkog arterijskog tlaka tijekom ranog poslijeoperacijskog perioda. Nije uočena statistički značajna razlika ovisno o spolu i ITM-u.

Zaključak Pad razine ICAM-1 nakon operacije može biti pokazatelj deaktivacije endotela nakon od- stranjenja aterosklerotskog plaka. Endarterektomija statistički značajno utječe na visinu sistoličkog arterijskog tlaka u ranom poslijeoperacijskom periodu. Neophodno je nastaviti ovakva istraživanja u smi- slu razumijevanja nastanka aterosklerotskog plaka, te mogućeg usporavanja ili zaustavljanja procesa, te prevencije cerebrovaskularnog inzulta.

Ključne riječi: ateroskleroza, adhezijske molekule, stenoza karotidne arterije

319 ORIGINAL ARTICLE

Surgical treatment of female stress urinary incontinence: retropubictransvaginal tape vs. transvaginal tape obturator

Aleksandar Argirović1, Cane Tulić2, Rajka Argirović3, Uroš Babić4, Biljana Lazović5, Ðorđe Argirović6

1Department of Urology,Clinical Hospital CenterZemun, 2Clinic of Urology,Clinical Center of Serbia, 3Institute of Obstetrics and Gynecol- ogy, Clinical Center of Serbia4, Clinic of Urology,Clinical Hospital Center‘’Dr.DragišaMišović’’, 5Clinic of Internal Medicine, Clinical Hospital CenterZemun, 6Outpatient Clinic ‘’Argirović’’;Urology;Belgrade, Serbia

ABSTRACT

Aim To compare two different operative techniques for stress urinary incontinence in women, transvaginal tape obturator (TVT-O) and retropubic transvaginal tape (TVT).

Methods The study included 63 women, of which 32 received TVT-O and 31 were treated with TVT. Follow-up for all patients was done after 1, 3, 6 and 12 months, and yearly thereafter. Each visit included objective evaluations (post-voig residual and stress test).

Results The average operating time was 13.19±3.72 minutes in TVT-O group and 26.92±4.77 minutes for TVT. Average time of Corresponding author: catheter removal was 1.19±0.4 and 1.26±0.44 for TVT-O and TVT, respectively. Average hospital stay was 2.38±0.75 days in TVT-O AleksandarArgirović group and 2.03±0.91 for TVT. Appearance of complications such Department of Urology, as trauma of urethra, bladder perforation, injury of vessels, hema- Clinical Hospital Center Zemun toma and wound infection were not registered. Two (6.3%) of the Vukova 9, 11000 Belgrade, Serbia patientswho underwent TVT-O had urinary infection. One (3.1%) Phone: +381 11 2788498; of the patients who underwent TVT-O had pelvic pain. De novo Fax: +381 11 3290234; urgency appeared in five(15.6%)patients for TVT-O and in four (12.9%) patients for TVT. The success rate in TVT-O group was E-mail: [email protected] 90.6% and 90.3% for TVT.

Conclusion Both procedures had very high success rate, with a low rate of perioperative and late postoperative complications.

Key words: TVT, TVT-O, surgery, objective success

Original submission: 13 January 2013; Revised submission: 17 February 2014; Accepted: 24 February 2014.

Med Glas (Zenica) 2014; 11(2):320-325

320 Argirović et al. Female stress urinary incontinence: TVT vs. TVT

INTRODUCTION until capacity of at least 300 mL) and at least 25 years of age. Exclusion criteria were a higher than the Stress urinary incontinence (SUI) is a common first stage urogenital prolapse (POP-Q ICS), con- pathological condition affecting women, with comitant pelvic organ prolapse surgery, concomi- prevalence rates ranging from 12.8% to 46.0% tant hysterectomy, previous incontinence surgery (1). It is defined as unintentional loss of uri- and previous radiation therapy of the pelvis. ne from the urethra that occurs during physical activity such as coughing, sneezing, laughing, The transvaginalmid-urethral sling TVT (Gyne- or exercise. Many different surgical approaches care TVT, Ethicon, USA) was inserted into 31 for treatment of SUI have been suggested with patients and 32 patients received the inside-out varying degrees of success. Ulmsten described transobturatormid-urethral sling TVT-O (Gyne- the tension-free vaginal tape (TVT) in 1996 (2). care TVT Obturator System, Ethicon, USA). The Delorme described a new mid-urethral sling TVT and TVT-O procedures were performed as using an outside-in transobturator approach, previously described in detail by Ulmsten (2) and where the tape is inserted through the skin and de Leval (4), respectively. Cystoscopy was per- the obturator foramen into the vagina obturator- formed in the TVTgroup upon each retropubic transvaginal tape(TOT) (3). DeLeval developed a pass of TVT needle. All surgeons involved were similar approach in 2003, where the tape is inser- experienced in the field of the urogynecology and ted inside-out from vagina through the obturator well trained in TVT and TVT-O surgery. foramen and the skin transvaginal tape obturator The procedures were performed in local, regional (TVT-O) (4). Both techniques were designed to and general anesthesia. Prophylactic antibiotics avoid the retropubic passage and thus reduce the were given 1 hour before of the operation, a sin- risk of urethral and bladder injuries. gle dose of cefuroxime 1.5g. The aim of the present study was to compare effi- In both groups a bladder catheter was kept in pla- cacies and complication rates of TVT and TVT-O ce for 24 hours. After catheter removal, patients in the treatment of stress urinary incontinencein were instructed to urinate three times before a females.This study will give useful information bladder scan was performed to measure post voi- to urologists and gynecologists regarding surgi- gresidual (PVR). When the PVR was greater than cal treatment of stress urinary incontinence. 100mL or there was complete retentiuon, a Foley catheter was inserted for further 24 hours. Pati- PATEIENTS AND METHODS ents were discharged when residual urine volume In this retrospective study two clinic participa- was less than 100 mL. ted, namely, the Clinic of Urology and Institute Follow-up for all patients was done at 1, 3, 6 and of Obstetrics and Gynecology, Clinical Center of 12 months and yearly thereafter and each visit Serbia, Belgrade. Informed consents were obta- included objective evaluations. The objective ined from all the patients with simple SUI pri- surgical outcomes were evaluated by the cough or to operation, 31 of whom were treated with stress test as cured or failed. Those who were the TVT procedure in the Clinic of Urology and considered “cured” showed negative results and 32 with the TVT-O procedure in the Institute of no reports of urine leakage during stress; those Obstetrics and Gynecology from January 2010 to who were defined “improved” did not leak during February 2012. the cough stress test but presented occasional uri- The patients were assigned to two groups in a ne leakage during stress, which did not influence non-randomized manner, according to operative their daily activities or require further treatment; prevalence of each institution. those who failed to meet the criteria above were considered to have had a “failed” treatment (6). Inclusion criteria were isolated SIU (according to the International Continence Society classification) All results are presented as mean ± standard de- (5), indication for surgical treatment of SIU, posi- viation (SD), median (minimum-maximum) or tive cough stress test (cough stress test was perfor- frequency (%). Variables were compared usingf- med in sitting and upright position after filling of the Student`s T test and χ2test. All p values less the bladder through the catheter with sterile liquid than 0.05 wers considered significant.

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RESULTS there was no statistically significant difference. There were no other complications, such as wo- No patients were lost on the follow-up at the 1-, und infection, intravesical or intraurethral tape 6- and 12-monts follow-up intervals. Some de- protrusion (Table 3). mographics characteristics of both groups of patients were presented in Table 1. Table 3. Postoperative outcome and complications

Table 1.Sociodemographic characteristics of patients Parameter TVT-O TVT p Characteristics TVT-O TVT p Objective success of the operation 29(90.6%) 28(90.3%) 0.967 Age, years 54.44±12.7 57.29±10.11 0.329 Average time of catheter removal, days 1.19±0.40 1.26±0.44 0.508 Parity 2 (1-3) 2 (0-5) 0.192 Hospital stay 2.38±0.75 2.03±0.91 0.108 Menopause 23 (71.9%) 20 (64.5%) 0.530 Postoperative retention 2 (6,3%) 3 (9.7%) Comorbidity 19 (59.38%) 14 (45.16%) 0.259 Urinary tract Infection 2 (6,3%) 0 Pelvic pain 1(3.1%) 0 0.321 TVT, retropubictransvaginal tape; TVT-O, transvaginal tape obturator De novo urgency 5 (15.6%) 4 (12,9%) 0.759 Wound infection 0 0 - The mean operating time was 13.19±3.72 minu- Intravesical or intraurethral tape 0 0 - tes and 26.9±4.77 minutes for TVT-O and TVT, protrusion respectively (Table 2). There was also a signifi- TVT, retropubictransvaginal tape; TVT-O, transvaginal tape obturator cant difference in the type of anesthesia used. In the TVT group all patients had regional anesthe- All patients had a follow-up of at least one year. sia, but in the TVT-O group two (6.2%) had local In the TVT group the objective success rate of the anesthesia, eight (25%) had regional anesthesia operation was 90.3%, while in the TVT-O it was and 22 (68.8%) had general anesthesia. 90.6%, at one year follow-up. Objective response classified as “improved” was not reported in Table 2. Operative characteristics of patients any of our patients. Otherwise, 3 patients in each TVT-O TVT p group had objective failure following operation. Anesthesiatype spinal 8(25.0%) 31(100%) DISCUSSION local 2(6.3%) 0 <0.001 general 22(68.8%) 0 This study conducted by two institution compa- Duration of procedure (minutes) 13.18 ± 3.72 26.93 ± 4.77 0.001 red two relatively new procedures, which have TVT, retropubictransvaginal tape; TVT-O, transvaginal tape obturator been performed for the past eight years in Bel- There were no major perioperative complications grade, e.g., objective success of the procedure, such as bladder perforation, urethral injury, vagi- perioperative and postoperative complications up nal wall laceration during the scissor dissection, to one year. Both groups of patients had similar nerve injury, bowel injury, significant blood loss demographic characteristics. and symptomatic hematoma. Our study assessed objective success of the two After catheter removal, the PVR was greater procedures (TVT vs. TVT-0), which included ne- than 100mL in three (9.7%) patients after TVT gative stress test and residual urine less than 100 and in two (6.3%) after TVT-O. Average time of mL. In both our groups success rate was very high. catheter removal was 1.19 days in the TVT-O The, reason for this may be our inclusion criteria group and 1.26 days in the TVT group. Mean (isolated SUI, no previous surgery or radio thera- hospital stay in the TVT-O group was 2.38±0.75 py in pelvis and no concomitant pelvic disorders). days, while in the TVT group it was 2.03±0.91 Groutz et al. found t 5-year cure rate of 74% in the days. These differences were not statistically si- group of 61 women who had undergone TVT-O, gnificant. Only one (3.1%) of the patients from but the authors did not exclude women with mixed the TVT-O group reported pelvic pain, while this urinary incontinence (7). Latthe et al. presentedhin complication was not reported in the TVT gro- a prospective multicentric study that objective su- up. De novo urgency occurred in five (15.6%) ccess rate for TVT goes from 83.9% to 100% and and four (12.9%) patients in the TVT-O and for TVT-O from 85.7% to 97.6% (8). TVT group, respectively. Two (6.3%) patients Mean operating time was significantly longer in in the TVT-O group had urinary tract infection the TVT group. This difference could be attribu- (UTI) that required antibiotic treatment, while ted to the need for cystoscopy during the TVT there was no UTI in TVT group. In terms of UTI procedure. Liapis et al. used cystoscopy during

322 Argirović et al. Female stress urinary incontinence: TVT vs. TVT

the TVT-O procedure and the operating time was Vaginal erosion did not occurd in any of the pa- nearly similar to TVT (9). tients from the two groups. Deval et al. reported In both groups average time of catheter removal higher incidence of vaginal erosion in TVT-O and hospital stay was short. There was no statisti- patients compared to TVT patients (13.8% vs. cal difference. These data presented that hospital 0.7%, respectively) (20). stay after both procedures was short, so patients Our study did not show statistical difference re- could quickly go back to their normal activity. garding UTI. Rates of UTI after sling procedures Sola et al. established four times longer hospital vary widely and are reported in the literature to stay for TVT (10). range from 4% to 43% depending on the defini- There were no injuries of bladder or urethra in tion used to diagnose infection (21-23). Ingber et any of the groups of patients. Bladder perforation al. published that patients with a UTI after surge- is most common with the TVT procedure, with ry were more likely to have a higher preoperative an incidence of 0.7-24% reported in literature PVR than those without a UTI (24). (11), although there are reports of this compli- Pelvic pain is late complication for both of the cation after obturator slings (12,13). Tamussino procedures, our results are presented in table 3. et al. showed a low rate of suchcomplications in Laurikainen et al. presented that this complicati- their study, which included 2541 patients, finding on appears more often after TVT-O, 16%, while 10 bladder and 2 urethral injuries (14). There is it appears in 1.5% of cases after TVT (25). TVT- also a report from the FDA MAUDE database pu- O trocars pass through the groin muscles during blished by Deng et al that found 14 unrecognized insertion, which explains their significant risk of bladder perforations and 7 unrecognized urethral postoperative thigh and groin pain. injuries, this paper included 11,806 patients (15). De novo urgency is a common complication Morey et al. recommended intraoperative cystos- of both procedures that occurred in both of our copy when performing obturator slings in case of groups with no significant difference. Ballert et extensive pelvic surgery or when needle passage al. reported incidence of de novo urgency after is difficult and suggest that the smaller helical TVT from 0.2% to 15%, while after TVT-O it needle may provide a higher safety margin for was from 2.1% to 13.9% (26). Transobturator avoiding pelvic organs (16). tape provides a less circumferential compression We did not identify any serious intraoperative of the urethra, which may lead to fewer posto- bleeding or appearance of postoperative hema- perative bladder irritation symptoms (27). Altho- toma in both of groups. Previous studies have ugh, according to Deval et al., the frequency of shown, although the TVT procedure is partly a de novo urinary urgency was three times higher blind one, the risk of severe perioperative blee- with TVT then with obturator slings and is linked ding (>500ml) and hematoma formation in the to changes in paraurethral collagen metabolism Retzius space is rare (0.9-2.5%) (17). and sclerosis around the prolene tape (20). Midurethral slings can be complicated with po- The results reported in this paper can be consi- stoperative bladder outlet obstruction. The litera- dered as preliminary. Therefore, the limitations ture presented percentage of voiding difficulties of our study include a relatively small number of after TVT from 1.4% to 9% and for TVT-O it was patients with SUI submitted to two different mo- from 3% to 13% (18). In our study, postoperative des of operative treatment and a short period of retention was similar in both groups and without postoperative follow-up. statistically significant difference. All cases with Both procedures are very safe, with a low rate postoperative retention were treated conservati- of perioperative and late postoperative compli- vely and with intermittent catheterization, within cations. Objective success is very high for both 24h. Although, there are some data in literatu- procedures. It takes less time to perform TVT-O re that presented a higher risk of postoperative compared to TVT procedure. Both procedures retention 1 day after surgery in TVT-O patients are minimally invasive and hospital stay is short, compared to TVT patients (6.6% vs. 2.7%, res- so patients can go back to normal life shortly af- pectively) (19). ter the surgery.

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ACKNOWLEDGEMENT FUNDING We cordially than Natalija Šeparović and Ivan No specific funding was received for this study. Soldatović for their help in statistical analysis. TRANSPARENCY DECLARATION Competing interests: None to declare.

REFERENCES 1. Botlero R, Urquhart DM, Davis SR, Bell RJ. Pre��- 15. Tamussino K, Hanzal E, Kölle D, Tammaa A, Preyer valence and incidence of urinary incontinence in O, Umek W, Bjelic-Radisic V, Enzelsberger H, Lang women: review of the literature and investigation of PF, Ralph G, Riss P; Austrian Urogynecology Wor- methodological issues. Int J Urol 2008;15:230-4. king Group. Transobturatortapes for stress urinary 2. Ulmsten U, Henriksson L, Johnson P,Varhos G. An incontinence: Results of the Austrian registry. Am J ambulatory surgical procedure under local anesthe- ObstetGynecol 2007;197:634.e1-5. sia for treatment of female urinary incontinence. 16. Deng DY, Rutman M, Raz S, Rodriguez LV. Pre- IntUrogynecol J Pelvic Floor Dysfunct 1996;7:81-5. sentation and management of major complications 3. Delorme E. Transobturator urethral suspensi- of midurethral slings: are complications under- on: mini-invasive procedure in the treatment of reported?NeurourolUrodyn 2007; 26:46-52. stress urinary incontinence in women. ProgUrol 17. Morey A, Medendorp AR, Noller MW, Mora RV, 2001;11:1306-13. Shandera KC, Foley JP, Rivera LR, Reyna JA, 4. De Leval J. Novel surgical technique for the trea- Terry PJ. Transobturator versus trnasabdominal tment of female stress urinary incontinence: tran- mid urethral slings: a multinstitutionalcompara- sobturator vaginal tape inside-out. EurUrol 2003; sion of obstructive voiding complications. J Urol 44:724-30. 2006;175:1014-7. 5. Abrams P, Cardozo L, Fall M, Griffiths D, Rosier P, 18. Abouassaly R, Stenberg JR, Lemieux M, Marois Ulmsten U, Van Kerrebroeck C, Gilchrist LI, Bourque JL, TU le M, Corcos J. 6. P, Victor A, Wein A. The standardisation of terminolo- Complications of tension-free vaginal tape surgery: gy of lower urinary tract function: report from the Stan- a multi-institutionalreview. BJU Int2004; 94:110-3. dardisation Sub-committee in the International Conti- 19. Lee KS, Han DH, Choi YS, Yum SH, Song SH, Doo nence Society.NeurourolUrodyn 2002;21:167-78. CK, Choo MS. A prospective trial comparing tensi- 7. Lee KS prospective comparison of the insade-outand on-free vaginal tape and trans-obturator vaginal tape outside-in transobturator-tape procedures for the tre- inside-out for surgical treatment of female stress atment of female stress urinary incontinence. IntU- urinary incontinence: 1-yearfollow up. J Urol 2007; rogynecol J Pelvic Floor Dysfunct 2008;19:577-82. 177:214-8. 8. Groutz A, Rosen G, Gold R,Lessing JB, Gor- 20. Krofta L, Feyereisl J, Otcenásek M, Velebil P, Ka- don D. Long-term outcome results of the insi- siková E, Krcmár M. TVT and TVT-O for surgical de-out transobturator tension-free vaginal tape: treatment of primary stress urinary incontinence: efficacy and risk factors for surgical failure. J prospective randomized trial. IntUrogynecol J Pel- WomensHealth(Larchmt) 2011;20:1525-8. vic Floor Dysfunct 2010;21:141-8. 9. Latthe PM, Foon R, Toozs-Hobson P. Transobtu- 21. Deval B, Farchaux J, Berry R, Gambino S, Ciofu C, rator and retropubic tape procedures in stress uri- Rafii A, Haab F. Objective and subjective cure rates nary incontinence: a systematic review and meta- after trans-obturatore tape (OBTAPE) treatment of analysis of effectiveness and complications. BJOG female urinary incontinence. EurUrol 2006;49:373- 2007;114:522-31. 7. 10. Liapis A, Bakas P, Giner M, Creatsas G. Tension- 22. Stanford EJ, Paraiso MR. A comprehensive review free vaginal tape versus tension-free vaginal tape of suburethral sling procedure complications. J Min obturator in women with stress urinary incontinence. InvGyn 2007; 15:132-45. GynecolObstet Invest 2006; 62:160-64. 23. Anger JT, Litwin MS, Wang Q, Pashos CL, Rodri- 11. Sola V, Pardo J, Ricci P, Guiloff E, Chiang H. TVT guey LV. Complications of sling surgery among fe- versus TVT-O for Minimally Invasive Surgical male Medicare beneficiaries. ObstetGynecol 2007; Correction of Stress Urinary Incontinence. Interna- 109:707-14. tional Braz J Urol 2007; 33:246-53. 24. Kuuva N, Nilsson CG. A nationwide analysis of 12. Chawla A. Transobturator tapes are preferable over complications associated with the tension-free vagi- transvaginal tapes for the management of female nal tape (TVT) Procedure. ActaObstetGynecolScand stress urinary incontinence: Against. Indian J Urol 2002;81:72-7. 2009;25:554-7. 25. Ingber MS, Vasavada SP, Firoozi F, Goldman 13. Hermieu JF, Messas A, Delmas V, Ravery V, Du- HB.Incidence of perioperative urinary tract infection monceau O, Boccon-Gibod L. Bladder injury after after single-dose antibiotic therapy for midurethal- TVT transobturator. ProgUrol 2003; 13:115-7. slings.Urology 2010;76:830-4. 14. Minaglia S, Ozel B, Klutke C, Ballard C, Klutke J. 26. Laurikainen E, Valpas A, Kivelä A, Kalliola T, Rinne Bladder injury during transobturator sling. Urology K, Takala T, Nilsson CG. Retropubic compared with 2004; 64:376-7. transobturator tape placement in treatment of urinary incontinence: a randomized controlled trial. ObstetGynecol 2007;109:4-11.

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27. Ballert KN, Kanofsky JA, Nitti VW. Effect�� of ten- 28. Whiteside JL, Walters MD Anatomy of the obtura- sion-free vaginal tape and TVT-obturator on lower tor region: relations to a trans-obturator sling. IntU- urinary tract symptoms other than stress urinary in- rogynecol J Pelvic Floor Dysfunct 2004;15:223-6. continence. IntUrogynecol J Pelvic Floor Dysfunct 2008; 19:335-40.

Hirurško lečenje urinarne stres inkontinencije kod žena: retropubična transvaginalna traka vs. obturatorna transvaginalna traka Aleksandar Argirović1, Cane Tulić2, Rajka Argirović3, Uroš Babić4, Biljana Lazović5, Ðorđe Argirović6

1Odeljenje za urologiju, Klinički bolnički centar Zemun, 2Klinika za urologiju, Klinički centar Srbije, 3Institut za ginekologiju i akušerstvo, Klinički centar Srbije, 4Klinika za urologiju, Klinički bolnički centar “Dr. Dragiša Mišović”, 5Klinika za internu medicinu, Klinički bolnički centar Zemun, 6Urologija, Poliklinika „Argirović“; Beograd, Srbija

SAŽETAK

Cilj Uporediti dve različite hirurške metode u rešavanju stres urinarne inkontinencije kod žena: retropu- bična transvaginalna traka (TVT) vs. obturatorna transvaginalna traka (TVT-O).

Metode Studijom su obuhvaćene ukupno 63 žene; od toga je kod 32 urađen TVT-O, a kod 31 je rađen TVT. Pacijentkinje su kontrolisane nakon mesec dana, tri i šest meseci, a potom godišnje. Na kontrol- nim pregledima pacijentkinjama je rađena proba na stres i merenje rezidualnog urina kateterizacijom.

Rezultati Prosečno vreme trajanja intervencije iznosilo je 13.19 ± 3.72 minute, a za TVT 26.92 ± 4.77 minuta. Prosečno vreme nošenja katetera iznosilo je 1.19 ± 0.4 dana za TVT-O, a za TVT 1.26 ± 0.44 dana. Prosečno vreme trajanja hospitalizacije iznosilo je 2.38 ± 0.75 dana za TVT-O, a za TVT 2.03 ± 0.91 dana. Pojave komplikacija, kao što su povreda uretre, perforacija bešike, povreda krvnih sudova, intrahospitalne infekcije, kao i pojave hematoma, nisu ustanovljene ni kod jedne operisane pacijentkinje. Dve (6,3%) pacijentkinje, kojima je rađen TVT-O, imale su pojavu urinarne infekcije. Jedna (3,1%) pacijentkinja, kojoj je rađen TVT-O, imala je pojavu bola u predelu male karlice. De novo urgencija pojavila se kod 5 (15,6%) pacijentkinja kojima je rađen TVT-O i kod 4 (12,9%) pacijentkinje kojima je rađen TVT. Uspešnost operacije za TVT-O iznosila je 90,6%, a za TVT 90,3%.

Zaključak Obe metode pokazale su visoku stopu uspešnosti, s malom učestalošću perioperativnih i kasnih postoperativnih komplikacija.

Ključne reči: TVT-O, TVT, operativno lečenje, objektvna uspešnost

325 ORIGINAL ARTICLE

Clinical relevance of IL-10 gene polymorphism in patients with major trauma

Vasilije Jeremić1,2, Tamara Alempijević1,3, Srđan Mijatović2, Vladimir Arsenijević2, Nebojša Ladjevic4, Slobodan Krstić1,2

1School of Medicine, University of Belgrade, 2Clinic for Emergency Surgery, 3Clinic for Gastroenterology and Hepatology, 4Center for Anesthesiology and Reanimation; Clinical Center of Serbia; Belgrade, Serbia

ABSTRACT

Aim To assess IL-10 serum concentration according to outcome of severe trauma treatment and influence of short nuclear polymorphism (SNP) 1082G/A within IL-10 gene on treatment outcome of patients with severe trauma.

Methods Forty-seven patients with major trauma were prospectively recruited, and they were divided into two groups according to outcome (survivors and non-survivors). The IL-10 gene polymorphisms were genotyped using restriction fragment length polymorphism analysis. Serum IL-10 levels were determined with enzyme-linked immunosorbent assay. Association between IL-10 serum concentration, IL-10 SNP type and IL-10 serum concentration in groups of patients with different SNPs with outcome after Corresponding author: severe trauma was evaluated. Tamara Alempijević Results Mean age of patients was 35.53±14.53 years. The major Clinic for Gastroenterology and mechanism of injury was traffic, and the mean injury severity sco- Hepatology, Clinical Center of Serbia re was 35.47±11.23. Despite higher values of IL-10 serum con- Dr. Koste Todorovića St. 2, centrations in patients with lethal outcome, the difference was not statistically significant. In 40 (85%) patients no gene polymorphi- 11000 Belgrade, Serbia sm for IL-10 was recorded. No statistical significance in frequen- Phone: +381 11 362 8582; cy of IL-10-1082 gene polymorphism was observed between the Fax: +381 11 362 8582; patients with different outcomes of polytrauma. No statistically E mail: [email protected] significant difference in IL-10 values was evidenced between the subjects with and without polymorphisms in any of the observed times of measurement, although a trend toward the higher values may be observed in patients with polymorphism in heterozygous form.

Original submission: Conclusion The patients with IL-10 SNP gene polymorphism despite no proven statistical significance appeared to have higher 02 February 2014; values of IL-10 and consequently worse outcome. Revised submission: 02 March 2014; Key words: interleukin 10, genetic association, IL-10 SNP Accepted: -1082G/A, outcome 16 April 2014.

Med Glas (Zenica) 2014; 11(2):326-332

326 Jeremić et al. IL-10 and outcome in trauma

INTRODUCTION some of the variants include single nucleotide polymorphism (SNP), short tandem repeats (STR), Trauma causes a complex metabolic, hormonal, and variable non-tandem repeats (VNTR). and cytokine response. “Whole-body inflammatory syndrome” is guided by a complicated sy- Despite improvement in treatment of patients stem of cellular interactions and mediators aimed with severe trauma, the mortality rate is still high. at induction of recovery and control of foreign The aim of this study was to assess IL-10 serum organisms. In certain cases of severe trauma, the concentration according to outcome of severe process of inflammation becomes uncontrolled, trauma treatment and influence of SNP (polymor- leading to injuries of the initially intact vital ti- phism) -1082G/A within IL-10 gene on treatment ssue (1). Due to involvement of numerous com- outcome of patients with severe trauma. We in- plex mediators and cell systems, interpretation of tended to analyze the value of genetic screening these multiple interactions and their changes that in changing the process of clinical practice occur over time is highly complicated (2,3). PATIENTS AND METHODS Cytokines are peptide hormones released by leu- kocytes and macrophages and they are highly im- Forty-seven severely injured patients were in- portant mediators due to their occasionally toxic cluded in this prospective study conducted in the systemic effects. Precisely regulated homeostasis Clinic for Emergency Surgery, Clinical Center of the pro- and anti-inflammatory cytokines con- of Serbia. The data were collected in the period trols body response to a trauma. Each imbalance between January and August 2012. Only pati- causes either hyperinflammatory state, which is ents without pre-existing chronic diseases, not frequently observed in the early post-traumatic receiving medications, and without penetrating period, or severe immunosuppression, which is injuries were included. All the patients were ad- described in a later period after trauma or sepsis mitted to the Intensive Care Unit due to severi- (4). Significance of the inflammatory mediators ty of the trauma. The patients were assigned an has been documented in numerous retrospective Injury Severity Score (ISS) (14) by independent and prospective studies, although the published evaluators. Exclusion criteria were age of <18 studies were mostly focused on sepsis, while the years or >65 years, admission >8h after trauma presented results recording patients with polytra- or secondary admission, penetrating injuries, and uma remained controversial (5,6). Namely, clear any chronic illnesses. Injuries of various body difference was evidenced in response between regions (head and neck, face, thorax, abdomen, the patients with tissue injuries accompanied by extremities, and skin) were classified by using significant blood loss and those without bleeding the Abbreviated Injury Scale (AIS) (14). The cli- (7). Major pro-inflammatory cytokines, such as nical course was monitored prospectively in all IL-1, IL-6, IL-8 and TNF-α have been investi- patients. Patients requiring surgical intervention gated in numerous studies, while the role and received standard surgical care and postoperative significance of antiinflammatory cytokines, such intensive care. as IL-4, IL-10, IL-13 or TGF-β, which suppress Blood samples were drawn within 24 h after ad- production of pro-inflammatory cytokines are sti- mission (designated day 1) and on subsequent ll subject of interest of numerous researchers (8). days (24, 48, 72 hours and 7days) of hospitaliza- As for the third group of cytokines, endogenous tion. Blood (9 mL) was collected in plastic tubes receptor antagonists (IL-1ra) or soluble cytokine (NH4-heparin tube; Sarsted, Nümbrecht, Ger- receptors, such as sTNFr, it was evidenced that many) along with the routine baseline laboratory they underwent up-regulation after trauma and work-up and was immediately used for stimula- influenced regulation of the pro-inflammatory tion ex vivo. cytokines as well (9-11). In order to obtain cytokine levels from blood Genes coding inflammatory mediators contain a samples, plasma was separated by centrifugati- large number of gene variants, that is, polymorp- on, and the sample was frozen instantaneously hisms that may have either minor or major functi- and stored at -70°C. Sample processing took onal consequences on expression and/or function approximately 30 min. The cytokine levels were of the proteins (12,13). According to their type, determined through ELISA technique by using

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by polyacrylamide gel electrophoresis, which is presented in figure 1 (15). This study received an approval from the Ethical Committee of the School of Medicine, University of Belgrade. All patients included in this study gave their written informed consents. In case of unconsciousness of the patient, informed consent was obtained from patients relatives, who were instructed about the purpose of the study. Descriptive data for all groups and variables were expressed as mean ± standard deviation (SD), mediana, minimum and maximum for continuous measures, or percent of a group for discrete measures. Categorical data were analyzed using the Pearson chi-square test. A normal distribution Figure 1. G/A change in promoter region in position -1082. Al- was tested using the Kolmogorov-Smirnov test. lele-specific PCR was performed for detection of G/A changes in If the data were normally distributed, the t-test promoter region at position -1082. In patients without IL10-1082 polymorphism a fragment of 242 bp is obtained, while in patients was used. Non-parametric data were analyzed with the polymorphisms, fragments of 242 bp and 122 bp are using the Mann Whitney U test, and Fridman test. obtained. In the figure below, number 1 designates the sample Differences were considered significant when the with present polymorphism, while numbers 2, 3, and 4 designate samples without polymorphism. p value was less than 0.05 (p<0.05).

Quantikine commercially available kits (R&D RESULTS Systems Inc, Minneapolis, USA; QIAampD- Demographic features and clinical characteristics NA Mini Kit, Qiagen GmbH, Hilden, Germany) of patients are presented in Table 1. The patients were used for genetic analysis. For the described are stratified according to outcome. The main polymorphism analyses -1082 G/A primer was mechanism of injury was by vehicle, 25 (53.2%). used. Normal genetic variant was GG. Presence The mean ISS for all included patients was 35.47, of GA was marked as heterozygous polymorphi- and the score was statistically significantly hism, and AA as homozygous polymorhism. The gher in patients with lethal outcome (40.10 and genetic analyses were performed by Polymerase 31.73, respectively). Chain Reaction-Restriction Fragment Length Po- Values of IL-10 with statistical significance drop- lymorphism (PCR-RFLP). This method involves ped during the measurement time in patients with PCR amplification of DNA segments that have lethal outcome (p=0.000), as well as in the gro- such polymorphisms, digestion of the resulting up of patients who survived the inflicted injuries PCR products by means of restriction enzymes (p=0.000). and analysis of the obtained digestion products

Table 1. Demographic features and clinical characteristics of patients with severe trauma All Survivors Non-survivors Significance Age 35.53+14.53 (32; 18-65) 34.65+13.41 (31.0; 18-61) 36.62+16.08 (33.0; 18-65) 0.659 Sex (M/F) 32/15 17/9 15/6 0.659 Vehicle 25 (53.2%) 14 (53.8%) 11 (52.4%) Mechanism of Pedestrian 5 (10.6%) 2 (7.7%) 3 (14.3%) injury n (%) Motorcycle 7 (14.9%) 3 (11.5%) 4 (19.0%) 0.609 Fall 8 (17.0%) 5 (19.2%) 3 (14.3%) Assault 2 (4.3%) 2 (7.7%) 0 (0%) ISS (X+SD) (Med; min-max) 35.47+11.23 (34; 21-57) 31.73±9.89 (29; 21-50) 40.10±11.27 (38; 22-57) 0.012 Head and neck 2.94+1.21 (1-5) 2.33+1.05 (2; 1-4) 3.50+1.09 (4; 1-5) 0.004 Face 2.30+1.16 (1-4) 2.50+1.29 (2; 1-4) 2.17+1.17 (2; 1-4) 0.660 AIS Chest 3.31+0.92 (3; 1-5) 3.17+0.94 (3; 1-5) 3.47+0.91 (3; 2-5) 0.340 Abdomen 3.86+1.17 (4; 2-5) 3.70+1.13 (3; 2-5) 4.07+1.22 (5; 2-5) 0.391 Extremities 2.76+0.70 (3; 2-4) 2.64+0.73 (2.5; 2-4) 2.89+0.66 (3; 2-4) 0.199 M/F, male/female; ISS, injury severity score; AIS, Abbreviated Injury Scale;

328 Jeremić et al. IL-10 and outcome in trauma

Intergroup analysis revealed no statistically si- in promoter region at position -1082 allele speci- gnificant difference in IL-10 value between the fic PCR was performed and showed that in pati- subjects with different outcomes at any observed ents without IL10-1082 polymorphism fragment time of measurement (Table 2). IL-10 values in of 242 bp was obtained, while in patients with the all times of measurements were higher in patients polymorphisms, fragments of 242 bp and 122 bp with lethal outcome. were obtained. Table 2. Il-10 levels measurements according to outcome DISCUSSION Follow up IL-10 (X±SD; Med; min-max) Significance period Survivors Non-survivors The results of our study assessed the role of 263.9±173.1 336.05±173.01 0h p=0.242 (198; 22-500) (350; 62-500) IL-10 serum concentration in patients with se- 123.44±100.8 194.2±174.05 24h p=0.119 vere trauma treatment and influence of SNP (82.3; 39.8-388) (129.4; 31.9-500) (polymorphism) -1082G/A within IL-10 gene on 95.6±78.95 133.2±121.2 48h p=0.261 (59.3; 21.3-290) (86.02; 30.4-500) outcome of the treatment. Patients were strati- 71.96±101.9 98.3±118.2 fied according to outcome to survivors and non 72h p=0.063 (45; 19.1-500) (66.4; 17-500) survivors, with demographic features and clinical 48.87±45.08 63.42±47.1 Day 7 p=0.091 (31.9; 19-206) (43.3; 22-175) characteristics. The mean Injury Severity Score (ISS) for all included patients was 35.47, and was The incidence of subjects with IL-10 SNP statistically significantly higher in patients with -1082G/A was not statistically significantly diffe- lethal outcome. rent between the groups with different outcomes In our studied series, no statistically significant (Table 3). No gene polymorphism was recogni- difference in IL-10-1082 gene polymorphism zed in 22 (84.6%) survivors, and in 18 (85.7%) was observed between the patients with different patients with lethal outcome. Gene coding IL-10 outcomes of polytrauma. Polymorphism of the and IL-10 SNP -1082G/A gene polymorphism gene was found only in the heterozygous form. were expressed only in heterozygous form, in 4 Results of the studies with IL-10-1082 GA pol- (15.4%) and 3 (14.3%), respectively. ymorphism are controversial (16). In studies with Table 3. Gene polymorphism incidence according to outcome critically ill patients, 1082-GG genotype appe- Outcome ars less frequently in patients with organ failure IL-10 SNP -1082G/A p Survivors Non-survivors when compared to healthy population (17). Mo- No polymorphism-GG 22 (84.6%) 18 (85.7%) Heterozygous p=0.916 reover, it was also found that 1082GG genotype 4 (15.4%) 3 (14.3%) polymorphism-GA is associated with significantly less prominent organ dysfunction and mortality in critically ill No statistically significant difference in IL-10 patients (16). serum concentration was observed between su- In our study there was no statistically significant di- bjects with and without gene polymorphism du- fference in IL-10 values between the subjects with ring the studied 7-day follow-up period (Table 4). and without polymorphisms in any of the observed In the group of patients with heterozygous poly- times of measurement: on admission, 24h, 48h, 72h morphism a more pronounced decline of the va- and 7 days after admission, although a trend toward lues was observed. For detection of G/A changes the higher values may be observed in patients with Table 4. Cytokine IL-10 levels according to gene polymorphism polymorphism in heterozygous form. IL-10 SNP-1082G/A (IL-10 X±SD; IL-10 is a major anti-inflammatory cytokine mo- Follow up Med; min-max) p period Heterozygous poly- dulating pro-inflammatory cytokines, such as No polymorphism GG morphism GA TNF-α, as well as synthesis of nitrous oxides, 286.95±169.98 351.32±208.14 0h 0.455 inflammatory cells apoptosis and suppression (268.5; 22-500) (500; 67-500) 164.47±144.42 65.15±20.99 of macrophage activation (3). IL-10 ameliorates 24h 0.183 (129.4;31.9-500) (65.45; 39.8-89.9) pro-inflammatory response in presence of sepsis 116.08±103.98 71.96±12.15 48h 0.989 (77.7; 21.3-500) (71.8; 60.2-84.1) and reduces mortality, which was evidenced in 85.60±113.81 58.15±28.79 72h 0.998 some animal studies. In humans, increased IL-10 (49.2; 17-500) (53.25; 29.8-96.3) 53.70±42.44 61.10±75.97 value is associated with septic shock, major inju- Day 7 0.450 (40; 19-206) (24.7; 20-175) ries and more frequent lethal outcomes (4). It was

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evidenced that 50-75% of variation in IL-10 pro- the published studies that IL-10 high producing duction is genetically controlled. In IL-10 genes, 1082GG genotype had protective significance for single nucleotide promoter polymorphism (G/A) reduction of mortality and organ failure in ARDS in position 1082 is essential for IL-10 regulation patients, which is consistent with the role of IL- (15-17). G-allele homozygotes (-1082GG) have 10 in escalation of the process of inflammation higher values of circulating IL-10, higher expre- and reparation of the damaged lung tissue (35). ssion of IL-10 mRNK and higher production of Other studies reported significant or nonsignifi- IL-10 after in vitro stimulation (15). cant associations between IL-10 -1082G allele IL-10 is essential antiinflammatory cytokine that and reduction of organ failure, severity of the modulates pro-inflammatory cytokines, such as disease of mortality in critically ill patients (34, TNF-α, as well as synthesis of nitrous oxide, 36-38). In non-critically ill patients with pneu- apoptosis of the inflammatory cells and suppre- monia, -1082 genotype is associated with ten- ssion of macrophage activity (17). It also down- dency toward development of sepsis and increase regulates major histocompatibility complex II in mortality (39,40). Diversity of studied popu- and expression of costimulatory protein B7 on lations of patients may explain the discrepan- the cell membrane, which reduces bacterial clea- cy. Other studies evidenced protective effect of rance (18,19). IL-10 decreases pro-inflammatory -1082G allele in critically ill patients or in cases response in presence of sepsis and reduces mor- with meningococcemia associated with marked tality in some animal models (20,21), however, proinflammatory response (37,41). Association the former was not evidenced on other experi- between the combined Fcγ receptor genotype and mental models (22). In humans, increased values IL-10 SNP-1082 was also documented in severe of circulating IL-10 are associated with septic meningococcal sepsis (16). Increased incidence shock (23), severity of injury (24,25) and mor- of pneumococcal infections was nor observed in tality (26,27). Several common polymorphisms a cohort group analyzed by Shaaf et al. (40), i.e., were evidenced on IL-10 gene promoters, inclu- patients genetically predisposed for higher pro- ding -1082 G>A and -592 C>A, which produce duction of IL-10 have linear growth on the risk three haplotypes in Caucasoid population (GCC, of more severe form of pneumococcal diseases ACC and ATA). Earlier studies evidenced that in and the highest risk of onset of septic shock. vivo production of IL-10 was increased in homo- Having in mind the fact that high incidence of zygous GCC haplotypes (28). On the other hand, -1082G allele was found in the population, re- lower incidence of GCC haplotype was found asonable explanation would be that IL-10 high in modern Spanish population in comparison to producing 1082GG genotype is not universally Northern and Central Europeans (29). The level harmful (35). Namely, in Japanese population, of iRNK expression was significantly increased no difference was evidenced in mortality rates in individuals carrying GCC/GCC genotype in between GG and AA genotypes in septic pati- comparison to ATA/ATA. It was reported that ents, although ethic differences in incidence of 50-75% of variation in IL-10 production is ge- gene polymorphisms were evidenced as well ne-controlled (30). Individual analysis of -1082 (42). Namely, incidence of -1082G allele is signi- genotype, independently from -819/-592 ge- ficantly lower in Japanese (5.3%) population in notype, has proven it to be functionally essential comparison to white population, where it varies SNP (31). High values of serum concentrations between 46 and 51% (32,33). of IL-10 were found in 21.6% of the population FUNDING (>2pg/mL), although majority of them had low or immeasurable concentrations. There was a trend This work has been funded by the Serbian Mini- toward higher IL-10 values in individuals ho- stry for Education and Science (project No. III- mozygous for -1082 genotype (31). Individuals 41004 and 43007). homozygous for G allele (-1082GG) have higher values of circulating IL-10, higher expression of TRANSPARENCY DECLARATION IL-10 iRNK and higher production of IL-10 after Competing interests: none declared. in vitro stimulation (32-34). It was evidenced in

330 Jeremić et al. IL-10 and outcome in trauma

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Is interleukin-6 an early marker of ponse dominates after septic shock: association of injury severity following major trauma in hu mans. low monocyte HLA-DR expression and high interle- Arch Surg 2000; 135:291-5. ukin-10 concentration. Immunol Lett 2004; 95:193-8. 9. Desborough JP. The stress response to trauma and 27. Simmons EM, Himmelfarb J, Sezer MT, Chertow surgery. Br J Anaesth 2000; 85:109-17. GM, Mehta RL, Paganini EP, Soroko S, Freedman 10. Flohe S, Lendemans S, Schade FU, Kreuzfel der E, S, Becker K, Spratt D, Shyr Y, Ikizler TA; PICARD Waydhas C. Influence of surgical intervention in the Study Group. Plasma cytokine levels predict morta- immune response of severely injured patients. Inten- lity in patients with acute renal failure. Kidney Int sive Care Med 2004; 30:96-102 2004; 65:1357-65 11. Mukaida N. Pathophysiolic roles of interleukin- 8/ 28. Van der Poll T, Keogh CV, Buurman WA, Lowry CXCL8 in pulmonary diseases. Am J Physiol Lung SF. 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34. Galley HF, Lowe PR, Carmichael RL, Webster NR. 39. Gallagher PM, Lowe G, Fitzgerald T, Bella A, Gree- Genotype and interleukin-10 responses after cardi- ne CM, McElvaney NG, O’Neill SJ. Association of opulmonary bypass. Br J Anaesth 2003; 91:424-6. IL-10 polymorphism with severity of illness in com- 35. Gong MN, Thompson BT, Williams PL, et al. Inter- munity acquired pneumonia. Thorax 2003; 58:154-6. leukin-10 polymorphism in position -1082 and acute 40. Schaaf BM, Boehmke F, Esnaashari H, Seitzer respiratory distress syndrome. Eur Respir J 2006; U, Kothe H, Maass M, Zabel P, Dalhoff K. Pneu- 27:674-81. mococcal septic shock is associated with the inter- 36. Balding J, Healy CM, Livingstone WJ, White B, leukin-10-1082 gene promoter polymorphism. Am J Mynett-Johnson L, Cafferkey M, Smith OP. Genomic Respir Crit Care Med 2003; 168:476-80. polymorphic profiles in an Irish population with me- 41. Parsons PE, Moss M, Vannice JL, Moore EE, Moore ningococcaemia: is it possible to predict severity and FA, Repine JE. Circulating IL-1ra and IL-10 levels outcome of disease? Genes Immun 2003; 4:533-40. are increased but do not predict the development of 37. Jaber BL, Rao M, Guo D, Balakrishnan VS, Peri- acute respiratory distress syndrome in at-risk pati- anayagam MC, Freeman RB, Pereira BJ. Cytokine ents. Am J Respir Crit Care Med 1997; 155:1469-73. gene promoter polymorphisms and mortality in acu- 42. Nakada TA, Hirasawa H, Oda S, Shiga H, Matsu- te renal failure. Cytokine 2004; 25:212-9. da K, Nakamura M, Watanabe E, Abe R, Hatano M, 38. Schroder O, Laun RA, Held B, Ekkernkamp A, Tokuhisa T. Influence of toll-like receptor 4, CD14, Schulte KM. Association of interleukin-10 promoter tumor necrosis factor, and interleukine-10 gene po- polymorphism with the incidence of multiple organ lymorphisms on clinical outcome in Japanese criti- dysfunction following major trauma: results of a cally ill patients. J Surg Res 2005; 129:322-8. prospective pilot study. Shock 2004; 21:306-10.

Klinički značaj IL-10 genskog polimorfizma kod pacijenata s teškom traumom Vasilije Jeremić1,2, Tamara Alempijević1,3, Srđan Mijatović2, Vladimir Arsenijević2, Nebojša Ladjevic4, Slobodan Krstić1,2 1Medicinski fakultet Univerziteta u Beogradu, 2Klinika za urgentnu hirurgiju, 3Klinika za gastroenterologiju i hepatologiju, 4Centar za anesteziju i reanimaciju; Klinički centar Srbije; Beograd, Srbija SAŽETAK

Cilj Procena vrednosti serumske koncentracije IL-10 u zavisnosti od ishoda lečenja teške povrede i uticaj kratkih nuklearnih polimorfizama (short nuclear polymorphism,SNP) 1082G/A na genu koji kodira IL-10 na ishod lečenja pacijenata s teškom traumom.

Metode U ovo istraživanje bilo je uključeno 47 teško povređenih pacijenata koji su, prema ishodu lečenja, podeljeni u grupu preživelih i grupu s letalnim ishodom. Analizirana je razlika u vrednostima serumske koncentracije IL-10, učestalosti prisustva SNP-a, kao i serumske koncentracije IL-10 u grupama s prisutnim različitim SNP-ovima i njihov uticaj na tok i ishod lečenja pacijenata s teškom traumom.

Rezultati Prosečna starost uključenih pacijenata iznosila je 35.53±14.53 godina. Glavni mehanizam po- vređivanja bio je saobraćaj, a srednja vrednost skora za procenu težine povrede iznosila je 35.47±11.23. Iako je uočena veća serumska koncentracija kod pacijenata s letalnim ishodom, ova razlika nije bila statistički značajna. Kod 40 (80%) pacijenata nije uočeno postojanje genskog polimorfizma. Takođe nije uočena statistički značajna razlika vrednosti u učestalosti pojavljivanja genskog polimorfizma u zavisnosti od ishoda lečenja bolesnika s teškom traumom. Nije uočena razlika u serumskim koncen- tracijama IL-10 u grupama sa ili bez prisutnog polimorfizma, mada su uočene nešto više vrednosti kod pacijenata s prisutnim polimorfizmom u heterozigotnoj formi za gen koji kodira IL-10.

Zaključak Pacijenti s prisutnim SNP-om za gen koji kodira IL-10, iako bez statistički značajne po- tvrde, imali su više vrednosti serumskih koncentracija IL-10 što je povezano s letalnim ishodom kod pacijenata s teškom povredom.

Ključne reči: interleukin 10, teška povreda, genski polimorfizmi, genske udruženosti

332 ORIGINAL ARTICLE

Relationship between ultrasound criteria and voiding ultrasonography (VUS) in the evaluation of vesicoureteral reflux (VUR)

Sandra Vegar-Zubović1, Spomenka Kristić1, Aladin Čarovac1, Irmina Sefić-Pašić1, Amra Džananović1, Danka Miličić-Pokrajac2, Lincender Lidija3

1Clinic of Radiology, 2Pediatric Clinic; Clinical Center of the University of Sarajevo, 3Academy of Science and Arts of Bosnia and Herze- govina; Sarajevo, Bosnia and Herzegovina

ABSTRACT

Aim To analyze the usefulness of five ultrasound parameters (ureteral dilatation, renal pelvis dilatation, renal parenchyma width reduction, calyceal dilatation, and urothelial reaction) in detecting vesicoureteral reflux (VUR).

Methods The study included 101 patients with diagnosed and therapeutically treated urinary infection. The ultrasound examination and voiding urosonography (VUS) were carried out according to a standard protocol. In the group of patients with proven VUR the presence of the indirect ecomorphological signs of VUR was evaluated.

Results The referral diagnosis urinary tract infection was present Corresponding author: at the admission in 53 patients, while the remaining 48 patients were admitted with the diagnosis of infectio tractus urinarii reci- Sandra Vegar-Zubović divans. Pathological VUS was found in 53 patients. The ultraso- Clinic of Radiology, und parameter with the highest sensitivity, specificity, and nega- Clinical Center of the University of tive predictive value (77.4%, 79.2%, and 76.0%, respectively) in Sarajevo detection of VUR was urethral dilatation, while the parameter with Bolnička 25, 71000 Sarajevo, the highest positive predictive value (62.5%) in detection of VUR Bosnia and Herzegovina was urothelial reaction. Phone: + 387 61 202 880; Conclusion In case of ultrasound verification of ureteral dilatation Fax: + 387 33 297 811; or urothelial reaction, especially in if the urinary infection has pro- E-mail: [email protected] ved, it is necessary to exclude the existence of VUR. Key words: urinary tract ultrasound, ureteral dilatation, urothelial reaction

Original submission: 20 February 2014; Revised submission: 06 May 2014; Accepted: 27 May 2014.

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INTRODUCTION or repeated urinary tract infections were enrolled. The pediatrician, a subspecialist of pedi- Urinary tract infections are a common and signi- atric nephrology with twenty years of clinical ficant problem in the pediatric population and if experience, diagnosed the presence of urinary not recognized or inadequately treated they can tract infection in all enrolled patients based on lead to renal scarring with subsequent develo- clinical status, pathological findings of urinary pment of hypertension (1). Since the urinary in- sediment (microscopically detected bacteria in fections are more frequent in the population of urine sediment or >20 leucocytes in urinary se- children with congenital malformations, the task diment or positive urinary culture), and patholo- of imaging methods is to establish the existence gical findings of blood analysis (CRP>20 mg/L; of this type of malformations (2). One of the most leucocytes>109/L). common urinary tract anomalies are the abnormalities related to the distal part of the ureter with Also, one of the criteria for enrolling in the subsequent development of vesicoureteral reflux study was the acquisition of three consecutively (VUR). In 20-30% of children with the first acute sterile urine cultures immediately following the urinary infection VUR is also present (3). conclusion of antibiotic treatment which lasted from seven to ten days. The day after receiving According to the National Institute for Health the third consecutive sterile urine culture, the and Care Excellence (NICE) guidelines, ultra- patients were sent for ultrasound examinati- sound is the first diagnostic method used in the on and VUS. Nineteen (18.8%) patients who evaluation of children with diagnosed urinary received parenteral antibiotic treatment were infection, since it allows simultaneous detecti- hospitalized in the Pediatric Clinic, while the on of morphological changes that occur during remaining 82 (81.2%) patients were treated the urinary infection and possible urinary tract with per oral antibiotics without the need for abnormalities (4), while the voiding cystouret- hospitalization. hrography (VCUG) is still the gold standard in definitive diagnosis of VUR (5). However, due Given that all the patients were minors, their pa- to the fact that VCUG is a method which invol- rents gave written consents for the examination ves the use of ionizing radiation, voiding uro- and inclusion in the study. sonography (VUS) has been increasingly used The ultrasound examination and VUS were in evaluating VUR in recent years. The VUS conducted in a single act; immediately after the is primarily used in the evaluation of VUR and grey scale ultrasound examination, we procee- according to leading experts it is considered ded with the VUS. practical, safe, relatively inexpensive, highly Exclusion criteria were the patients with incom- sensitive method, which does not use ionizing plete laboratory evaluation, patients without radiation; or in other words, a method closest to three consecutive sterile urine cultures immedia- the ideal screening method for the VUR detecti- tely following antibiotic treatment, patients with on and grading (6,7). urinary tract operations (deflux - Endoscopic The aim of our study is to analyze a predictive injection of Deflux gel around ureteral opening value of each of the five ultrasound parameters to create a valve function and to treat vesicourete- (ureteral dilatation, renal pelvis dilatation, renal ral reflux or classical surgical VUR corrections), parenchyma width reduction, calyceal dilatation, with anomalies of number of kidneys (agenesia, and urothelial reaction) in detection of VUR di- cross-fused ectopia, ren arcuatus) with diagnosed agnosed with VUS. glomerulonephritis, and patients with VUS proven bilateral VUR of different grade. PATIENTS AND METHODS All ultrasound and VUS examinations were con- In this prospective study, conducted between ducted by one experienced radiologist at the Cli- March and November 2012, 101 children, aged nic of Radiology, Clinical Centre University of 2 months to 16 years, who were therapeutically Sarajevo. A prerequisite for performing routine treated at the Pediatric Clinic of the Clinical gray scale ultrasound of urinary tract and VUS Center of University of Sarajevo, for their first were sterile urine culture and signed consent for examination by at least one parent.

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Ultrasound examination was applied in the amount of 1mL per filling of the bladder. It is the ultrasound contrast agent of the Gray scale ultrasound examination of urinary second generation consisting of stabilized aqueo- tract was performed with routine protocol in su- us suspension of sulfur hexafluoride microbubble pine and prone position. The appearance, shape, (SF6) with the phospholipids shell. Its application and thickness of the bladder wall were analyzed has to be careful and slow to minimize the destruc- as well as the appearance and width of the urete- tion of microbubble contrast and to reduce the de- ral orifice, appearance of ureter, longitudinal dia- position of the suspension. The diagnosis of reflux meter of kidneys, appearance and width of renal is established based on visualization of microbu- parenchyma and appearance of calyceal system. bble in the ureter and pyelon or collecting system. The mandatory part of the examination was the The examination was continued during miction to estimation of urothelial appearance and thickness. assess active vesicoureteral reflux. Ureteral dilatation was present if the ureter was Proven VUR was graded into one of three gra- seen as a hypoechoic tube of any diameter, since des (11): grade 1 - contrast in the ureter; grade the ureter should not normally be visualized du- 2 - contrast in the ureter, pelvis and calyx, pel- ring ultrasound examination (8). vis dilatation up to 10 mm, without dilated calix; Renal pelvis measurements were obtained at the grade 3 - contrast in the dilated pyelon over 10 widest section of the renal pelvis on transverse mm, widened collecting system, compression on mid-kidney ultrasound images. Renal pelvis was renal parenchyma. considered dilated if its maximum width was over 5 mm (8). Statistical analysis When assessing the renal parenchyma width, all Statistical analysis was performed by using a pa- values below 95% confidence interval (CI) for tient as a unit (two kidneys and two ureters were the age, were considered as reduced width of re- considered as a unit). The detection of unilateral nal parenchyma (8). or bilateral VUR was considered a positive or Ultrasound visualization of calices was conside- pathological VUS finding regarding the presence red as a sign of caliceal dilatation since calices of VUR. The study did not include patients with are not normally visualized during ultrasound diagnosed bilateral VUR of different grade. Re- examination (9). search results are presented in tables by absolu- Urothelial thickness was mesured at the level te numbers and percentages. Statistical analysis of renal pyelon. The renal pyelon was imaged was performed by the Spearman rank correlation in transverse and longitudinal planes. A cut-off coefficient, bivariate logistic regression analysis, value of 2.0 mm was used to distinguish healthy and the calculation of sensitivity, specificity, po- urothelium from pathologicaly thickened urothe- sitive, and negative predictive value. lium (10). The expression urothelial reaction as RESULTS a sinonime for thickened urothelium was used. During the eight-month prospective study a total Voiding urosonography (VUS) of 101 children, of which 68 (67.3%) were girls All patients were subjected to three days of antibio- and 33 (32.7%) were boys, were examined by ul- tic prophylaxis (day before the examination on the trasound and VUS. day of examination and one day after the examina- The mean age of patients was 4.2±3.9 years: the tion). Examination was started by placing a cathe- youngest patient was 2 months old, while the ol- ter into the lumen of the bladder and its discharge, dest was 16 years old. In terms of age groups, after which the lumen of the bladder under ultra- the majority of children were 0-3 years (59, sound control was filled with saline. The expec- 58.4%), followed by patients aged 5-10 years ted capacity of the bladder was calculated using (21, 20.8%), children aged 3-5 years (12, 11.9%), the following formula: = (age+2) x 30). Once the while the lowest number of children was older bladder was filled with saline in the amount corres- than 10 years (nine, 8.9%). ponding to half of the expected bladder capacity, Referral diagnoses were evaluated only from the contrast agent (Sono Vue, Bracco, Milan, Italy) the perspective whether it was the first or se-

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cond infectio tractus urinarii (ITU), or the re- gative predictive value (40.0%) for the occurren- current urinary tract infection infectio tractus ce of VUR (Table 2). urinarii recidivans (ITU recidivans). The majo- Table 2. Sensitivity, specificity, positive predictive value, and rity of patients (53, 52.5%) were admitted with negative predictive value of the five ultrasound parameters in the ITU diagnosis, while the remaining patients the detection of vesicoureteral reflux (VUR) (48, 47.5%) were admitted with the ITU recidi- Ultrasound parametar Sensitivity Specificity PPV NPV Renal parenchyma width vans diagnosis. 38.1% 43.8% 15.1% 72.9%. reduction The VUS finding was normal in 48 (47.5%) pa- Ureteral dilatation 77.4% 79.2% 30.3% 76.0% tients, while pathological in 53 (52.5%) patients. Calyceal dilatation 9.4% 66.6% 23.8% 40.0% Renal pelvis dilatation 41.5% 37.5% 42.3% 36.7% Of the total number of pathological VUS findings Urothelial reaction 56.6% 62.5% 62.5% 66.6% the VUR was diagnosed in 38 (71.7%) girls, and PPV, Positive Predictive Value; NPV, Negative Predictive Value; 15 (28.3%) boys. Regarding the VUR grade, the largest number of patients with positive findings Thirty patients with normal VUS finding and 22 had grade 2.24 (41.5%), and the lowest number patients with diagnosed VUR had a positive ul- of patients had grade 1 to 2, which was present trasound finding of renal pelvis dilatation. Statis- only in one patient (1.9%) (Table 1). tical analysis did not show significant correlation between VUR and renal pelvis dilatation (rho=- Table 1. Classification of positive vesicoureteral reflux (VUR) findings in different grades 0.116; p=0.222). VUR grade Number (%) of patients Ultrasound finding of urothelial reaction was 1 18 (34.0) positive in 30 patients with the diagnosis of 1 - 2 1 (1.9) 2 22 (41.5) VUR. This ultrasound finding was present in 18 2 - 3 3 (5.7) patients with a normal VUS finding. Statistical 3 9 (17.0) analysis revealed the existence of a significant Total 53 (100.0) correlation between the presence of urothelial re- Positive family history regarding the presence action and VUR (rho=0.294; p=0.002) (Table 2). of VUR was present in 15 patients with normal By using regression analysis the odds ratio of VUS finding, and in 17 patients with diagno- each one of the five studied ultrasound parame- sed VUR. ters in the detection of VUR was evaluated (Ta- Ultrasound finding of renal parenchyma width ble 3). Regression analysis indicated that from all reduction was noted in 13 patients with normal observed ultrasound parameters (renal parenchy- VUS finding, while renal parenchyma width ma width reduction, ureteral dilatation, calyceal reduction confirmed with ultrasound was pre- dilatation, renal pelvis dilatatio and urothelial re- sent in eight patients with diagnosed VUR. The action) only ureteral dilatation can be considered correlation between the aforesaid ultrasound as an independent ultrasound indicator of VUR parameter and existence of VUR was not obser- (OR=11.456; p=0.0001). ved (p>0.05). Table 3. Odds ratio of individual parameters Ten patients with normal VUS finding and 41 Parameter Odds Ratio (OR) p patients with diagnosed VUR had an ultrasound Renal parenchyma width reduction 1.443 .511 finding of ureteral dilatation. Statistically signifi- Ureteral dilatation 11.456 .000 Calyceal dilatation .248 .111 cant correlation (rho=0.468; p=0.0001) between Renal pelvis dilatation .699 .514 ureteral dilatation and VUR was observed. Urothelial reaction 1.564 .377 Sixteen patients with normal VUS finding and Constant .383 .065 five patients with diagnosed VUR had an ultra- DISCUSSION sound finding of calyceal dilatation. Though statistically significant correlation between calyceal In our study, VUS was used as a method for detec- dilatation and VUR has been observed, this ultra- ting VUR. Although this method has been used in sound parameter showed low sensitivity (9.4%), developed countries in everyday clinical practice relatively high specificity (66.6%), with low po- for many years, in 2012 the Clinic of Radiology sitive predictive value (23.8%), and mediocre ne- (Clinical Center of the University of Sarajevo) in-

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troduced this method in routine clinical practice. ureterovesical or ureteropelvic junction (17). Since Previously, the diagnosis of VUR was made exc- the renal pelvis dilatation, calyceal dilatation, and lusively by VCUG, a method that involves the use renal parenchyma width reduction are the charac- of ionizing radiation. Due to the fact that ionizing teristics of only high grade VUR (11), and the fact radiation has accumulation effect and is used pre- that in our research high grade VUR was detected dominantly in the pediatric population, the intro- only in minority of participants, the poor statistical duction of VUS has even greater value. correlation between those three ultrasound para- Numerous recent studies have demonstrated high meters and VUR was expected. diagnostic accuracy of VUS which is in the range In the case of ureteric dilatation, we found a stati- of 78-96% in detection of VUR in comparison stically significant correlation between this ultra- with the conventional method, e.g., VCUG. As a sound parameter and the existence of VUR, with conclusion of these results, VUS is increasingly high sensitivity, specificity, and high positive, becoming the primary imaging modality in the and negative predictive value. This result corres- VUR evaluation. It is important to note that VUS ponds to the results found by Leroy et al. (8). is still not sufficiently accurate in the evaluation The ultrasound parameter that we consider to be a of urethra in boys (12). possible indicator of the presence of VUR in our Our data related to the predominance of VUR in study was the urothelial reaction. According to the girls is consistent with data from literature (13). literature, urothelial reaction is the response to an Given the existence of correlation between urinary acute or recurrent urinary tract infection. Urotheli- infection and VUR (14), and taking into account al reaction, or urothelium thickened, is the respon- that ultrasound imaging is the first diagnostic met- se to inflammation. It can be present in both acute hod used in diagnostic algorithm for urinary tract or recurrent urinary tract infection and cannot be infections in the pediatric population (4), we deci- used to distinguish acute from chronic inflammati- ded to analyze the usefulness of ultrasound criteria on of the urothelium (10). Through reviewing the obtained during routine gray scale ultrasound exa- available literature, we could not find any study minations of the urinary tract in detecting VUR. A that analyzed correlation between this ultrasound review of the available literature shows that a num- parameter and the existence of VUR. In our study, ber of authors have analyzed the common overall we observed the existence of significant correla- sensitivity, specificity, positive predictive value, tions between the presence of urothelial reaction and negative predictive value of ultrasound para- and the presence of VUR. However, statistical meters indicative of the presence of VUR. They analysis showed that the ultrasound parameter of concluded that these parameters cannot be used in urothelial reaction cannot be designated as a cha- daily practice in detecting VUR due to low sensiti- racteristic of VUR, given that the same is common vity and specificity, and low positive and negative finding in urinary tract infections that are not asso- predictive value (15,16). The results of our study ciated with the presence of VUR. indicate that ultrasound parameters such as reduc- Our results suggest that among all five studied tion of renal parenchyma width, calyceal dilatation, ultrasound parameters, ureteral dilatation is sta- and renal pelvis dilatation observed individually tistically the most significant predictor of VUR, are not sufficiently sensitive and specific in detec- followed by urothelial reaction, renal parenchy- ting VUR, which is consistent with the results of ma width reduction, and renal pelvis dilatation other authors (15,16). Pyelocaliceal dilatation is respectively. In case of ultrasound verification most commonly a consequence of subpelvic ste- of ureteral dilatation or urothelial reaction, es- nosis which is primarily caused by congenenital pecially in case of prooven urinary infection, it is abberant vessels or fibrous bands and congenital necessary exclude the existence of VUR. ureteropelvic junction stenosis (17). The most common cause of renal parenchyma width reduction FUNDING in pediatric patients is hydronephrosis. In this gro- No specific funding was received for this study. up of patients, the majority of cases of hydronephrosis is caused by anatomic abnormalities, inclu- TRANSPARENCY DECLARATION ding urethral valves or stricture, and stenosis at the Competing interests: None to declare.

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REFERENCES 9. Fernbach SK, Maizels M, Conway JJ. Ultrasound grading of hydronephrosis: Introduction to the sy- 1. Marild S, Jodal U. Incidence rate of first-time symp- stem used by the Society for Fetal Urology. Pediatr tomatic urinary tract infection in children under 6 Radiol 1993; 23:478-80. years of age. Acta Paediatr 1998; 87:549-52. 10. Mitterberger M, Pinggera GM, Feuchtner G, Ne- 2. Prasad MM, Cheng EY. Radiographic Evaluation of ururer R, Bartsch G, Gradl J, Pallwein L, Strasser Children with febrile urinary tract infection: bottom- H, Frauscher F. Sonographic measurement of renal up, top-down, or none of the above? Adv Urol 2012; pelvis wall thickness as diagnostic criterion for acu- 2012:716739. te pyelonephritis in adults. Ultraschall Med 2007; 3. Williams G, Fletcher JT, Alexsander SI, Craig JC. 28:593-7. Vesicoureteral reflux. J Am Soc Nephrol 2008; 11. Ključevšek D. Echo-enhanced voiding urosonograp- 19:847-62. hy in children: state of the art. Paediatr Croat 2012; 4. National Collaborating Centre for Women’s and 56:147-50. Children’s Health (UK). Urinary Tract Infection 12. Darge K. Voiding urosonography with US contrast in Children: Diagnosis, Treatment and Long-term agents for the diagnosis of vesicoureteric reflux in Management. London: RCOG Press, 2007. NICE children: an update. Pediatr Radiol 2010; 40:956-62. Clinical Guidelines, No. 54. 2, Summary of reco- 13. Zimbaro G, Ascenti G, Visalli C, Bottari A, Zim- mmendations, patient flow pathway and algorithm. baro F, Martino N, Mazziotti S. Contrast-enhanced http://www.ncbi.nlm.nih.gov/books/NBK50599/ ultrasonography (voiding urosonography) of vesico- (20 April 2014). ureteral reflux: State of the art. Radiol Med 2007; 5. Takazakura R, Johnin K, Furukawa A, Nitta N, Ta- 112:1211-24. kahashi M, Okada Y, Murata K. Magnetic resonance 14. Dave S, Khoury AE. Diagnostic approach to reflux voiding cystourethrography for vesicoureteral re- in 2007. Adv Urol 2008; 367320. flux. J Magn Reson Imaging 2007; 25:170-4. 15. Mahant S, Friedman J, MacArtthur C. Renal ultra- 6. Darge K. Voiding urosonography with US contrast sound findings and vesicoureteral reflux in children agents for the diagnosis of vesicoureteric reflux in hospitalized with urinary tract infection. Arch Dis children. II. Comparison with radiological examina- Child 2002; 86:419-20. tions. Pediatr Radiol 2008; 38:54-63. 16. Zamir G, Sakran W, Horowitz Y, Koren A, Miron 7. O’Hara SM. Vesicoureteric reflux: latest opinion for D. Urinary tract infection: is there a need for rou- evaluation in children. Radiology 2001; 221:283-4. tine renal ultrasonography? Arch Dis Child 2004; 8. Leroy S, Vantalon S, Larakeb A, Ducou-Le-Poin- 89:466-8. te H, Bensman A. Vesicoureteral reflux in children 17. Pain VM, Strandhoy JW, Assimis, DG. Pathop- with urinary tract infection: comparison of diagno- hysiology of urinary tract obstruction. In: Kavoussi stic accuracy of renal US criteria. Radiology 2010; LR, Novick AC, Partin AW, Peters CA, Wein AJ, 255:890-8. eds. Campbell-Walsh Urology. Vol 2. 9th ed. Phila- delphia: Saunders Elsevier; 2007: 1227-73.

Odnos između ultrazvučnih kriterija i ultrazvučne mikcione cistografije (UMCG) u evaluaciji vezikoureteralnog refluksa (VUR) Sandra Vegar-Zubović1, Spomenka Kristić1, Aladin Čarovac1, Irmina Sefić-Pašić1, Amra Džananović1, Danka Miličić-Pokrajac2, Lincender Lidija3 1Klinika za radiologiju, 2Pedijatrijska klinika; Klinički centar Univerziteta u Sarajevu; 3Akademija nauka i umjetnosti Bosne i Hercegovine; Sarajevo, Bosna i Hercegovina

SAŽETAK Cilj Analizirati korisnost pet ultrazvučnih parametara (dilatacija uretera, dilatacija šijelona, redukcija širine parenhima bubrega, kalicealna dilatacija i realcija urotela) u detekciji vezikoureteralnog refluksa (VUR). Metode U studiju je bio uključen 101 pacijent s dijagnosticiranom i terapeutski tretiranom urinarnom infekcijom. Ultrazvučni pregled i ultrazvučna mikciona cistografija (UMCG) urađeni su prema stan- dardnom protokolu. U skupini pacijenata s dokazanim VUR-om analizirano je prisustvo indirektnih ehomorfoloških znakova VUR-a. Rezultati Uputna dijagnoza urinarna infekcija bila je prisutna kod 53 pacijenta pri prijemu, dok je ostalih 48 pacijenata primljeno pod uputnom dijagnozom infectio tractus urinarii recidivans. Nalaz UMCG-a bio je patološki kod 53 pacijenta. Ultrazvučni parametar s najvećom senzitivnošću, specifičnošću i negativ- nom prediktivnom vrijednošću (77.4%, 79.2%, odnosno 76.0%) u detekciji VUR-a bila je dilatacija uretera, dok je parametar s najvećom pozitivnom vrijednošću (62.5%) u detekciji VUR-a bila reakcija urotela. Zaključak U slučaju ultrazvučno verificirane dilatacije uretera ili reakcije urotela, osobito ukoliko je dokazana urinarna infekcija, neophodno je isključiti postojanje VUR-a. Ključne riječi: ultrazvuk urotrakta, dilatacija uretera, reakcija urotela

338 ORIGINAL ARTICLE

Clinical importance of independent prognostic factors for renal parenchymal carcinoma and a possibility of predicting the treatment outcome

Harun Hodžić1, Mustafa Bazardžanović2, Samed Jagodić2, Mustafa Hiroš3, Benjamin Kulovac3, Mirza Oruč4, Mersiha Mahmić-Kaknjo5

1Department of Urology, Cantonal Hospital Zenica, 2Urology Clinic, University Clinical Centre Tuzla, 3Urology Clinic, University Clinical Centre Sarajevo, 4Faculty of Health, University in Zenica, 5Department of Clinical Pharmacology, Cantonal Hospital Zenica; Bosnia and Herzegovina

ABSTRACT

Aim To determine the influence of independent predictors (nuclear grade, patient’s general condition, tumor size) on survival of patients suffering from renal cancer.

Methods The study included 158 patients treated for renal parenchymal carcinoma in the period between 01. 01. 1998 and 31. 12. 2011. The patients’ general condition was evaluated using the ECOG staging system. Nuclear grade (NG) was assessed by the Fuhrman criteria. Prognostic factors were tested applying the Cox regression analysis and based on the significance independent predictors were determined. Corresponding author: Harun Hodžić Results The total survival rate of patients with renal parenchy- Department of Urology, mal carcinoma was 81.2% after one year, 77.6% after 5 years and Cantonal Hospital Zenica 70.4% after 10 years. In patients with NG 1 the survival rate after Crkvice 67, 72000 Zenica, 5 years was 100%, whereas the survival in patients with NG2, 3 and 4 was 98%, 48% and 0%, respectively. The survival rate in Bosnia and Herzegovina patients with ECOG 0 and 1 after 5 years was 100%, while in Phone: +387 32 405 133, patients with ECOG 2 and 3 stage of the disease the survival rate Fax: +387 32 226 576; was 68% and 25%, respectively. In patients with a tumor node less E-mail: [email protected] than 40 mm, ten-year survival rate was100%, whereas the ten-year survival rate in patients with the tumor node sized 40 to 70 mm was 87%, and in patients with the tumor node over 70 mm ten-year survival rate was 66%.

Conclusion Multivariate analysis has established that the size of Original submission: the tumor node, patient’s general condition and nuclear grade are independent predictors of disease outcome. 04 February 2013; Revised submission: Key words: renal cancer, survival, predictors. 31 March 2014; Accepted: 18 April 2014.

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INTRODUCTION The study was approved by the Director of the Zenica Cantonal Hospital. Renal cell carcinoma (RCC) is ranked the ninth in Europe according to its prevalence, with 66,000 All the patients included in the research were di- newly detected cases, and 39,000 fatal outcomes vided based on the cancer type and nuclear gra- annually (1). Determining prognostic factors of de. All histopathological tests were performed at survival for patients with RCC would be valua- the Pathology Department of Cantonal Hospital ble in directing therapy and interpreting results Zenica, using the standard methods applied in hi- of clinical trials. Clinical trials that include survi- stopathology, i.e. conventional processing using val as an end point must account for prognostic immunohistochemical methods and detection of factors to assure that treatment outcomes can be tumor markers on an assay of the removed kidney, ascertained (2). Also, an assessment of patients’ according to the protocols of the European Associ- survival benefits both patients and physicians in ation of Pathologists i.e. the percentage of positive clinical management (2). tumor cells as a criterion, in accordance with the According to a retrospective epidemiological ASCO/CAP (2). In case of ambigious chromopho- study of renal cancers conducted in Zenica-Do- betype of cancer, immunohistochemical analyzes boj region during the1998-2011 period (3), we were performed: cytokeratin, EMA, CD-10, E-Ca- investigated if manner of detection, clinical sta- therin (Roche Diagnostics, Deutschland). ge and histopathological type of the tumor met The Eastern Cooperative Oncology Group the criteria for independent predictors for the (ECOG) Performance Scale was used to assess prognosis of renal cancer outcome, and negati- the patients’ performance status, evaluating a ve result was found. In this paper we analyzed status of patients’ ability with grades 0-5, where a correlation of tumor node size, nuclear grade zero means a fully active patient able to carry on (NG), and ECOG stage of patients with survival all pre-disease performance without restriction, rate and determined the role of these parameters and grade five means death. as criteria for independent predictors. Classification of RCC into four categories according to nuclear size and the presence of nucleoli, PATIENTS AND METHODS as reported by Fuhrman (1982), is currently the most widely used grading protocol in North Ame- The research was conducted in Cantonal Hospital rica and Europe (4-6). Fuhrman grading schema Zenica, Bosnia and Herzegovina (B&H), a large is an assessment based on the microscopic morp- 913-bed secondary hospital that serves 400,000 hology of a neoplasm stained with haematoxylin inhabitants of Zenica-Doboj Canton, as well as and eosin. The system categorizes renal cell car- the patients from other cantons as required. cinoma with grades 1-4 based on nuclear charac- This retrospective study included 202 patients teristics: size and irregularity of appearance. with diagnosed renal cancer in the period between 01. 01. 1998 and 31. 12. 2011. The study inclu- From the disease history the following laboratory ded 158 patients with renal parenchymal carci- parameters were analyzed: values of hemoglobin noma confirmed by histopathological diagnosis, and erythrocyte sedimentation rate, patient’s ge- who regularly reported for control examinations. neral condition at admission and histopathological Forty-four patients whose death was not related findings. At the control examination the patient’s to the cancer, those who had been treated with general condition was determined, and control immunotherapy and chemotherapy, and patients chest x-ray, ultrasound examination of abdomen with inadequate documentation were excluded. and retroperitoneum and CT scan were performed to establish the presence or absence of the disease. The patients’ average age was 57.5±11.1 years. There were 90 (57%) male, and 68 (43%) fema- Controls were performed as per the European le patients. In 90 patients laparotomy was used Assotiation of Urologists (EAU) protocols. The as a surgical procedure, whereas 68 patients un- first control was carried out after 6 months, and derwent lumbotomy. Total survival of patients the following ones once a year. After the fifth with renal parenchymal carcinoma was 97.5% year, controls were scheduled according to the after one year, 89.5% after 5 years and 80.6% af- individual risk profile. ter 10 years. Median follow-up was 87 months. Prognostic factors were tested using the Cox regression analysis, and based on significance indepen-

340 Hodžić et al. Renal carcinoma independent predictors

dent predictors were determined. Multivariate Cox year survival was 100%. As expected, the length regression factors were used to develop prognostic of survival decreased with the size of the tumor nomograms. Internal validation was conducted on node (Table 2). 200 bootstrap resampling. Predictive accuracy Table 2. Survival rate of patients according to the size of was assessed with ROC curve, which is obtained tumor node from the area under the curve (AUC). Statistical No (%) of patients survived significance was tested at the level p≤0.05. Based Tumor size 1-year 5-year 10-year < 40 mm 38 (100.0) 38 (100.0) 38 (100.0) on analyzed data a nomogram was created for 40-70 mm 103 (98.6) 93 (89.4) 90 (87.0) prediction of outcome, and comparison was made > 70 mm 15 (94.0) 13 (82.4) 11 (65.9) with the model of logistic regression.

RESULTS Further analysis found that the survival length of patients was significantly different in relation to The total survival rate of patients with renal pa- the nuclear grade (NG) (Log rank p<0.0001) (Ta- renchymal carcinoma was 154 (97.5%) after one ble 3). It was not possible to perform an analysis year, 141 (89.5%) after 5 years and 127 (80.6%) for the group of patients with the confirmed NG4, after 10 years. In 68 (43.1%) patients the general as there were only two patients in this group. condition evaluated according to ECOG was 0, ECOG 1 was found in 74 (46.8%) patients, ECOG Table 3. Determined length of one-year, five-year and ten- 2 in 12 (7.6%) patients, and 4 (2.5%) patients had year survival rate of patients according to nuclear grade (NG) ECOG 3. There were no patients with ECOG 4. No (%) of patients survived 1-year 5-year 10-year The average size of the primary tumor node was NG 1 72 (98.6) 68 (91.3) 66 (88.0) 65.9 ± 29.9 mm. The tumor nodes of size up to NG 2 67 (98.6) 64 (92.1) 56 (80.7) 40mm were found in 38 (24.1%) patients, tumor NG 3 9 (81.8) 7 (65.5) 0 (0.0) size between 40 and 70 mm was found in 104 Multivariate analysis established that the nuclear (65.8%) and in 16 (10.1%) patients the node size grade, patient’s general condition and tumor size was larger than 70 mm. category (up to 40 mm, between 40 and 70 mm Having analyzed the nuclear grade according to and over 70 mm) wereindependent predictors of Fuhrman, grade 1 was found in 75 (47.5%), gra- disease outcome, where as other analyzed factors de 2 in 70 (44.3%), grade 3 in 11 (6.9%) and gra- did not meet the requirements for independent de 4 was found in two (1.3%) patients. predictors (Table 4). As far as the general condition is concerned (Log Table 4. Multivariate analysis of independent prognostic rank p<0.0001), we found that the patients’ sur- factors vival was significantly different. In the group of Variable B SE p patients with ECOG 0 and ECOG 1, the survival Nuclear grade 0.5501 0.2940 0.05 rate of over 90% after 5 years was determined. General condition 1.7377 0.3072 <0.0001 As expected, the survival rate was shorter for pa- Size category 0.8348 0.4410 0.05 tients with a higher ECOG score (Table 1). DISSCUSSION Table 1. Survival rate of patients in relation to the Eastern Co- Most recent studies mention laparoscopy as a operative Oncology Group (ECOG) performance status score surgical approach, especially in patients with T1 No (%) of patients survived and T2 stages of the disease (7). Unfortunately, in 1-year 5-year 10-year ECOG 0 68 (100.0) 67 (98.1) 65 (95.9) our conditions laparoscopy is not performed due ECOG 1 73 (98.6) 68 (91.7) 63 (84.7) to very limited resources. ECOG 2 10 (83.3) 7 (59.3) 0 (0.0) ECOG 3 3 (75.0) 0 (0.) 0 (0.0) According to ECOG analysis of the patients, our results are comparable with Bamias et al. study Dividing the patients into groups according to the (8), as the assessment of the condition was su- size of tumor node, we found that there was a si- bjective and the distinction between the two gnificant difference in the survival rate (Log rank categories was not exact. Regardless of the afo- p=0.0036).In the group of patients with the tu- rementioned, most patients (around 90%) were mor node less than 40 mm, we found that the 10- fully physically active.

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Tumor nodes size in our study was very different Further analyses found that the survival rate was to tumor nodes sizes found by Santana-Rios et al; significantly different as compared with nuclear <40 mm found in 24.1% vs 11%, 40 to 70 mm in grade, lower NG, longer survival. The analysis 65.8% vs 23% and >70 mm in 10.1 vs 66%, res- for NG4 was not possible because there were only pectively (9). The explanation for this discrepancy two patients in the group. Nuclear grade as a direct could be in the fact that in our setting ultrasound indicator of malignant potential is an important was very popular and inexpensive diagnostic tool, predictor. It is particularly important to monitor so the disease was diagnosed in an early phase. patients with sarcomatoid component or a high Compared to a study by Tastekin et al, we found nuclear grade. Although our research practically more patients with lower grades: 47.5% vs 18% did not include patients with NG4, when compa- for NG1, 44.3% vs 41% for NG2, 6.9% vs 26% ring patients with NG1 or NG2 with patients ha- for NG3, and 1.3% vs 15% for NG4 (10). The ving NG3, there was a significant difference. It is nuclear grade is a direct indicator of cancer’s mali- true that the everyday practice pays little attention gnant potential. For this fact, it may be concluded to this factor, and more attention is given to the that the malign disease of the examined sample is size of the tumor node, although it was proven that of a significantly weaker malignant potential. the tumor size itself is not a predictor. According to our study a higher ECOG score was Multivariate analysis has established that the connected with a shorter survival. Verhoesta et nuclear grade, patient’s general condition and al. research involving 1124 patients in 5 referral size are independent predictors of the disease centers in Europe proved that the performance outcome. As opposed to univariate model, whi- status was an independent predictor (11), and ch tests only one variable, multivariate model most patients had the performance status 0 or 1, includes multiple factors and tests them among which was also the case in our research. each other and a degree of their individual participation in the model. Multivariate model is more A size of the primary node in our study did not potent than the prediction model, as it includes correlate with the survival rate. The same results more factors and reflects the real situation better were obtained by Jorns et al. (12). Interestingly, than the univariate model. none of the studies have investigated the location of the tumor in relation to vascular structures, After the multivariate analysis, variables were which could have larger impact on the develo- tested in the model of logistic regression, and pment of the disease. That would explain why the the exact prediction of treatment outcome was tumor of the same characteristics generates me- determined in 91.8% of patients. In patients who tastases in some patients, while in others it does survived for 10 years from the time of surgery the not, even in case of very small tumors (13). prediction accuracy is 97.8%. In patients who did not survive this period the prediction is accurate The division of patients into the groups according to in 50%. Studies showing prognostic models are the size of tumor node has shown a significant dif- contradictory; some underline the importance of ference in the survival rate. Steiner et al. have found the manner of detection (17-19), whereas there is a difference in the survival rate among the patients an increasing number of nomograms which in- (the size of 40 mm was taken as a borderline), and clude tumor size, histopathological type, nuclear in the group of patients with the tumor node less grade and clinical stage (17,20,21). than 40 mm, ten-year survival was 100% (14). Si- milar data have been shown in recent studies, which In conclusion, we found that the patients’ gene- point out that distant metastases very rarely occur in ral condition, size of the tumor node and nuclear patients with the primary node less than 3 cm (15), grade are independent predictors of the renal cell while Igarashi et al. did not find them at all (16). In carcinoma outcome. our study we proved that the patients with smaller FUNDING tumor survived longer, for the tumor node smaller than 40 mm, survival rate after 10 years was 100%. No specific funding was received for this study. Also, Steiner et al. pointed out that the survival rate was significantly lower in patients if the borderline TRANSPARENCY DECLARATIONS value was 70 mm, 177 vs. 237 months (14). Competing interests: none to declare.

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Clinical mensional tumour volume and cancer-specific survi- importance of dependent prognostic factors for renal val for patients undergoing nephrectomy to treat pT1 parenchymal carcinoma and a possibility of predic- clear-cell renal cell carcinoma. BJU Int 2012. [Epub ting the treatment outcome. Med Glas (Zenica) 2014; ahead of print] 11:145-51. 13. Klatte T, Remzi M, Zigeuner RE, Mannweiler S, Said 4. Fuhrman S, Lasky LC, Limas L. Prognostic signifi- JW, Kabbinavar FF, Haitel A, Waldert M, de Martino cance of morphologic parameters in renal cell carci- M, Marberger M, Belldegrun AS, Pantuck AJ. Deve- noma.Am J Surg Pathol 1982; 6:655–63. lopment and external validation of a nomogram pre- 5. Medeiros LJ, Jones EC, Aizawa S, Aldape HC, Che- dicting disease specific survival after nephrectomy ville JC, Goldstein NS, Lubensky IA, Ro J, Shanks for papillary renal cell carcinoma. J Urol 2010; 184: J, Pacelli A, Jung SH. Grading of renal cell carcino- 53-8. ma: Workgroup No. 2. Union Internationale Contre le 14. Steiner T, Knels R, Schubert J. Prognostic significan- Cancer and the American Joint Committee on Cancer ce of tumour size in patients after tumour nephrecto- (AJCC). Cancer 1997; 80:990-1. my for localised renal cell carcinoma. Eur Urol 2004; 6. Bostwick DG, Murphy GP. Diagnosis and prognosis 46:327-30. of renal cell carcinoma: highlights from an internati- 15. Remzi M, Ozsoy M, Klingler HC, Susani M, Waldert onal consensus workshop. Semin Urol Oncol 1998; M, Seitz C, Schmidbauer J, Marberger M. Are small 16:46–52. renal tumors harmless? Analysis of histopathological 7. Kattan MW, Reuter V, Motzer RJ, Katz J, Russo P. features according to tumors 4 cm or less in diameter. A postoperative prognostic nomogram for renal cell J Urol 2006; 176:896-9. carcinoma. J Urol 2001; 166:63–7. 16. Igarashi T, Tobe T, Nakatsu HO, Suzuki N, Murakami 8. Bamias A, Karadimou A, Lampaki S, Lainakis G, S, Hamano M, Maruoka M, Nagayama T, Matsuzaki Malettou L, Timotheadou E, Papazisis K, Andreadis O, Ito H. The impact of a 4 cm. cutoff point for strati- C, Kontovinis L, Anastasiou I, Stravodimos K, Xan- fication of T1N0M0 renal cell carcinoma after radical thakis I, Skolarikos A, Christodoulou C, Syrigos K, nephrectomy. J Urol 2001; 165:1103-6. Papandreou C, Razi E, Dafni U, Fountzilas G, Dimo- 17. Kattan MW. Comparison of Cox regression with ot- poulos MA. Prognostic stratification of patients with her methods for determining prediction models and advanced renal cell carcinoma treated with sunitinib: nomograms. J Urol 2003; 170 (6 Pt 2): S6-9. comparison with the Memorial Sloan-Kettering pro- 18. Ficarra V, Prayer-Galetti T, Novella G, Bratti E, Maf- gnostic factors model. BMC Cancer 2010; 10:45. fei N, Dal Bianco M, Artibani W, Pagano F. Inciden��- 9. Santana-Ríos Z, Urdiales-Ortíz A, Camarena-Reyno- tal detection beyond pathological factors as progno- so H, Fulda-Graue S, Pérez-Becerra R, Merayo-Cha- stic predictor of renal cell carcinoma. Eur Urol 2003; lico C, Hernández-Castellanos V, Saavedra-Briones, 43:663-9. Gustavo Sánchez-Turati D, Fernández-Noyola G, 19. Cindolo L, de la Taille A, Messina G, Romis L, Abbou Ahumada-Tamayo S, Martínez A, Camacho-Castro CC, Altieri V, Rodriguez A, Patard JJ. A�� preoperative- A, Muñoz-Ibarra E, García-Salcido F, Cantellano- clinicalprognostic model for non-metastaticrenalcell Orozco M, Morales-Montor G, Parraguirre S, Pache- carcinoma. BJU Int 2003; 92:901-5. co-Gahbler C. Renal cell cancer: pathologic and pro- 20. Ficarra V, Martignoni G, Galfano A, Novara G, gnostic factors and new staging strategies. Rev Mex Gobbo S, Brunelli M, Pea M, Zattoni F, Artibani W. Urol 2011; 71: 218-24. Prognostic role of the histologic subtypes of renal 10. Taştekin E, Puyan FO, Kaplan M, Tokuc B, Yurut- cell carcinoma after slide revision. Eur Urol 2006; Caloğlu V, Ozyılmaz F, Usta U, Kutlu AK. The Re- 50:786-93. lationship of human nuclear grade, tumor stage and 21. Patard JJ. Prognostic and biological significance of sarcomatoid differentiation with survival in renal cell lymph node spreading in renal cell carcinoma. Eur carcinomas. Balkan Med J 2012; 29:14-20. Urol 2006; 49:220-3.

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Klinički značaj neovisnih prediktora kod bubrežnog karcinoma i mogućnost predikcije ishoda Harun Hodžić1, Mustafa Bazardžanović2, Samed Jagodić2, Mustafa Hiroš3, Benjamin Kulovac3, Mirza Oruč4, Mersiha Mahmić-Kaknjo5 1Služba za urološke bolesti, Kantonalna bolnica Zenica; 2Klinika za urologiju, Univerzitetski klinički centar Tuzla; 3Klinika za urologiju, Klinički centar Univerziteta u Sarajevu; 4Zdravstveni fakultet, Univerzitet u Zenici; 5Služba za kliničku farmakologiju, Kantonalna bolnica Zenica; Bosna i Hercegovina SAŽETAK

Cilj Odrediti utjecaj neovisnih prediktora (nuklearni gradus, opće stanje bolesnika, veličina tumora) na preživljavanje kod oboljelih od karcinoma bubrega.

Metode Istraživanjem je obuhvaćeno 158 bolesnika koji su liječeni zbog karcinoma bubrežnog parenhima, u periodu od 01. 1. 1998. godine do 31. 12. 2011. godine. Opće stanje bolesnika procjenjivano je po- moću ECOG ljestvice. Nuklearni gradus (NG) procjenjivan je Fuhrmanovim kriterijima. Prognostički faktori testirani su Coxovom regresionom analizom, te su na osnovu značajnosti određeni neovisni prediktori.

Rezultati Stopa preživljavanja bolesnika s karcinomom bubrežnog parenhima iznosila je 81,2% nakon jedne godine, 77,6% nakon 5 godina i 70,4% nakon 10 godina. Kod bolesnika koji su imali NG 1 stopa preživljavanja iznosila je 100% nakon 5 godina, dok je petogodišnja stopa preživljavanja pacijenata s NG-om 2, 3 i 4 iznosila 98%, 48%, odnosno 0%. Stopa preživljavanja bolesnika s ECOG-om 0 i 1, nakon 5 godina, iznosila je 100%, dok je u pacijenata s ECOG-om 2 i 3 stadijem petogodišnja stopa preživljavanja iznosila 68,2%, odnosno 25%. U bolesnika s tumorskim čvorom manjim od 40 mm, desetogodišnja stopa preživljavanja iznosila je 100%, dok je u bolesnika s tumorskim čvorom veličine 40 do 70 mm iznosila 87%. Međutim, u bolesnika s tumorskim čvorom većim od 70 mm, desetogodišnja stopa preživljavanja iznosila je 65,9%.

Zaključak Multivarijantnom analizom utvrđeno je da su veličina tumorskog čvora, opće stanje bolesnika i nuklearni gradus neovisni prediktori ishoda bolesti.

Ključne riječi: karcinom bubrega, preživljavanje, prediktori.

344 ORIGINAL ARTICLE

Ovarian cancer in the Federation of Bosnia and Herzegovina during the 1996 – 2010 period

Feđa Omeragić1,2, Azur Tulumović1,3, Hasan Karahasan4, Larisa Mešić Ðogić5, Ermina Iljazović1,6, Alija Šuko7, Adnan Brčić8

1School of Medicine, University of Tuzla, 2Obsterics and Gynecology Private Practice “Omeragić” Tuzla, 3Obsterics and Gynecology Clinic, University Clinical Centre Tuzla, 4Obsterics and Gynecology Department, Cantonal Hospital Zenica , 5Obsterics and Gynecology Department, General Hospital Tešanj, 6 Institute for Pathology, University Clinical CentreTuzla, 7Obsterics and Gynecology Department, Cantonal Hospital Mostar “Dr. Safet Mujić”, 8 Private practice “Dr Aida Brčić”, Zavidovići; Bosnia and Herzegovina

ABSTRACT

Aim To investigate the ovarian cancer incidence for the period 1996-2010 in the Federation Bosnia and Herzegovina (FB&H) emphasizing that there is no official cancer database for that period.

Methods This retrospective study analyzed ovarian cancer incidence in the period 1996-2000 and an estimation of incidence for the period 2000-2010 based on this data, as well as on 2007 -2010 incidence according to the Federal Public Health Institute.

Results The incidence of ovarian cancer in the period 1996-2000 was 3.68-6.38/100.000. The estimate of incidence for the period 2000-2010 resulted with the rate of 14.6 at the end of the analyzed Corresponding author: period. According to the Federal Public Health Institute, incidence for the period 2007-2010 was 11.4-12.4/100.000. Feđa Omeragić Obstetrics and Gynecology Conclusion According to different sources incidence of ovarian Private practice “Omeragić” cancer in the Federation B&H varies from 11.4–12.4/100.000, Seadbega Kulovića 2, 75000 Tuzla which is lower than the incidence for Southern Europe and neighboring countries. Incidence published by the International Phone/fax: +387 35 262 622; Agency for Research on Cancer (2008) for B&H (both entities) E- mail: [email protected] was 10.1/100.000. An increasing trend of incidence is evident too. However, in FB&H a cancer database does not exist, while the system of cancer registration does not function or operate without proper coordination. A further main task for health authorities is to establish a functional system of cancer registration and a database, which would enable a follow-up and work on prevention and early detection of ovarian cancer.

Original submission: Key words: female malignancies, genital tumors, cancer incidence 02 December 2013;

Revised submission: 20 December 2014; Accepted: 20 February 2014.

Med Glas (Zenica) 2014; 11(2):345-349

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INTRODUCTION Federation of B&H emphasizing that Bosnia and Herzegovina in that period did not have an offici- Malignant ovarian tumors are the one of the lea- al database on cancer. This article represents lo- ding causes of death in females. This type of tu- gical continuation of the previous studies, which mor is killer number 1 among malignant tumors of attempted to create a database for ovarian mali- reproductive tract even though it is not as frequent gnant tumors in the period 1996-2000. as breast cancer, cervical cancer or endometrial cancer. The 5-year prevalence of women globally MATERIALS AND METHODS living with ovarian cancer is 22.3 per 100.000 (1- 3). The reason lies in its nature, progressive de- This is the retrospective study that analyzed data velopment, late detection and, consequently, poor from different sources. The initial research, whi- results of treatment (3,4). The incidence of ovarian ch included 272 patients with ovarian cancer in cancer in the most developed countries is approxi- the period 1996-2000, analyzed records of pa- mately 20/100.000, while some regions have in- tients that had been hospitalized in the health cidence of 4-5/100.000 (India, Japan, China) (3). institutions in FB&H, in the cities of Sarajevo, In our neighborhood, the ovarian cancer inci- Tuzla, Zenica, Mostar, Bihać and Travnik. Exi- dence is high: Slovenia 17.6, Croatia 20.3, Serbia sting demographic data for that period were obta- 16.3/100.000 (4-8). According to the International ined from the Ministry of Displaced Persons and Agency for Research on Cancers (IARC), the inci- Refugees, cantonal and municipal Public Offices dence for B&H is 10.1/100.000 (4). A 5- year sur- and the Federal Institute of Statistics. According veillance rate is lower than the same rate for breast to the data from the Federal Institute of Statisti- or cervical cancer for both Bosnia and Herzegovi- cs, FB&H had 2,335.846 -2,287.624 inhabitants. na (B&H) and the rest of the world (3.6%). Due to Exact demographic data for the period 1996- the lack of development of advanced techniques 2000 do not exist. In that period, demographic for ovarian cancer screening, the participation of data were obtained based on the estimates due early stages of ovarian cancer has not changed in to frequent migrations of the population within the last decades (1-4). B&H. Due to the same reasons, there was a lack of disease registration. Usually, disease registra- Unfortunately, B&H does not have an official da- tion starts at primary health care level (from fa- tabase on cancer for the period 1996 - 2007, in- mily medicine physician), but ovarian cancer is cluding ovarian cancer, which decreases the rele- more often registered by secondary health care vance of scientific studies and published articles. level (hospitals). Data from all sources (primary All available data come from health providers or secondary health level) are collected by canto- who are faced with negative results of inappro- nal Public Health Institutes and forwarded to the priate health policies. Without their efforts, we Federal Public Health Institute. Based on collec- would not have had any information about this ted data, the Public Health Institute is supposed terrifying disease for the period 1996 -2007. to issue annual reports. However, hospital data alone are not reliable for However, the system of disease registration did the database creation because there is a certain not function in that period. Only hospital records, number of patients who were not registered in hos- which included 272 patients with diagnoses of pital records due to migrations or were not hos- ovarian cancer, were obtained for calculation of pitalized at all. The Public Health Institute of the incidence of ovarian cancer for the period 1996 Federation Bosnia and Herzegovina (PHIFB&H) -2000. Based on the same data, an estimate of in- published first data on ovarian cancer during 2007 cidence in 2000 - 2010 was created. The second but those data were only partial and were insuffi- source of the data used was the official Report cient until 2012, when the Strategy for Preventi- on Health Status of the Population issued by on, Treatment and Control of Malignant Diseases the Public Health Institute of the Federation of 2012 -2020 was adopted by the Federal Assembly Bosnia and Herzegovina in 2011 (9). Published and the Federal Ministry of Health (9-11). incidence for the period 2007-2010 was calcula- The aim of this article was to show the ovarian ted for the population of 2,849.000 – 2,865.000 cancer incidence for the period 1996 -2010 in the inhabitants.

346 Omeragić et al. Ovarian cancer in FB&H 1996 -2010

RESULTS Table 2. Ovarian cancer incidence in the Federation of B&H in the period 1996 -2000: comparison of data The initial study took place in the period 1996 Incidence Projection of incidence Incidence Year -2000 in the Federation of Bosnia and Herzego- 1996-2000* 2000 - 2010† 2007-2010‡ vina. In that period in medical centers of Bihać, 1996 3.68 1997 3.71 Mostar, Sarajevo, Travnik, Tuzla and Zenica, 272 1998 4.90 patients with newly detected ovarian malignant 1999 5.22 tumor were registered. According to the data from 2000 6.38 2001 7.2 the Federal Institute of Statistics in the period 2002 8.0 1996 -2000 there were 2,335.846 - 2,287.624 in- 2003 8.8 habitants in FB&H. The most populated regions 2004 9.6 2005 10.4 (cantons) were Tuzla, Sarajevo and Zenica. Wit- 2006 11.4 hin the period 1996-2000 demographic changes 2007 12.2 11.4 were frequently noticed (almost on a daily basis). 2008 13.0 11.5 2009 13.8 11.9 According to the Federal Institute of Statistics esti- 2010 14.6 12.4 mated population figure for the period 1996-2000, *The incidence of ovarian cancer for the period 1996 -2000 calcula- a decrease in population was noticed in 1997: po- ted according to demographic data from the Federal Institute of Stati- pulation was estimated to be 2,208.143, of whom stics for the population of 2,335.846-2,287.624; data of 272 patients with diagnosed ovarian cancer are from hospital records. 1,146.458 (51.92%) were females (51.57% were †Estimate of incidence in the period 2000 - 2010 made according to 15-64, while 57.53% were ≥65 years of age). A data from the period 1996-2000; ‡Incidence for the period 2007-2010 from the Report on Health slight increase of population was seen in 1999, Status of the Population issued by the Public Health Institute of the 2,297.774, of whom 1,207.059 (52.5%) were fe- Federation of Bosnia and Herzegovina, 2011 (population covered males (52.9% were 15-64, while 57.6% were ≥65 2,849.000 – 2,865.000) years of age). In the 2000 the estimated population figure slightly decreased to 2,287.624 (Table 1). Table 1. Numbers of newly diagnosed cases of ovarian cancer in the period 1996-2000 per regions in FB&H City Tuzla Zenica Sarajevo Bihać Travnik Mostar Total 505,053 380,013 361,054 260,645 21,535 186,568 1,908,691- Population figures* -611,481 -426,565 -390,534 -299,756 -274,303 -216,736 2,219,375 Number of cancer cases† 85 (31.25%) 36 (13.23%) 83 (30.51%) 44 (16.1%) 13 (4.7%) 11 (4.04%) 272 (100%) * Estimate of population according to the Federal Institute of Statistics for the period 1996-2000 per cantons † Number of treated ovarian cancer patients during the period 1996-2000 for FB&H according to hospital records The increasing trend of incidence was evi- DISCUSSION denced, starting from 3.68/100.000 in 1996 to In the period 1996-2007 the Federal Public He- 6.38/100.000 in 2000, while demographic data alth Institute did not publish any report that in- had oscillations of altitude (lowest-highest) in the cluded data for ovarian cancer. All reports from number of population for approximately 120.000. that period were based on collected data from Based on the data from the period 1996-2000, an hospitals’ archives. However, the disease is usu- estimation of incidence was from 7.2/100.000 in ally detected too late, and has rapid progression. 1996, and it had an increasing trend resulting in Because of that, some patients had never been 14.6/100.000 at the end of the observed period. hospitalized. Furthermore, some patients were The incidence of ovarian cancer for the peri- treated outside B&H using the privilege of me- od 1996-2000, projected incidence for the pe- dical treatments in neighboring countries. Accor- riod 2000-2010 and incidence for the period dingly, there is a possibility that data for certain 2007-2010 were compared. According to the number of patients are missing. In the same time PHIFB&H, the incidence of ovarian cancer for emigration/immigration from/to B&H, as well as the period 2007-2010 was 11.4-12.4/100.000, within the Federation of B&H, influenced accu- with the highest rate of 12.4/100.000 in 2010 racy of demographic data. Consequently, there is (Table 2). a possibility that the numbers presented here are not exact (10-12).

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Presented incidence for the period 1996-2000 study, the incidence of ovarian cancer in 2010 has increased starting from 3.68 and reaching was 14.6/100.000, while PHI B&H data reported 6.38/100.000 in 2000. It can still be considered as incidence of 12.4/100.000 (9-12). a low incidence. Some other European countries Worldwide data also show an increase in inciden- reported similar incidence (4,13), while incidence. While some European countries reported low ce in 2000 for Southern Europe was 13.8/100.000 incidence rate (Cyprus, Portugal 7.1-7.2/100.000) (13). Neighboring countries reported higher in- others reported high incidence (Latvia, Lithua- cidence for the period 1999-2000: Serbia 9.1- nia, Ireland 18.2-19.2/100.000). In the USA the 11, Slovenia 17-19, Croatia 17-20.3/100.000 incidence is up to 22/100.000 (16-20). (4,10,13-16). In light of the presented data, ovarian cancer in- The estimate of incidence for the period 2000- cidence in FB&H had an increasing trend and it 2010 obtained in this research had a linear trend, is lower than in the neighboring countries but sli- reaching 14.6/100.000 in 2010, while in 2007- ghtly lower than average incidence for the South 2008 it was 12.2-13/100.000. The PHIFB&H pu- Europe region. This is probably a consequence of blished 11.4 – 11.5/100.000 incidence for ovarian nonexistence of cancer database in FB&H (can- cancer in the period 2007-2008. cer registration) and accordingly, proper coordi- According to the data on cancer incidence for nation. The main task for health authorities sho- 2008 published by the International Agency for uld be to establish a functional system of cancer Research on Cancer (IARC) (4), the incidence registration and a database, which would enable a for B&H was 10.1/100.000, while the incidence follow-up of the disease and work on prevention rates were higher for other neighboring countries. and early detection of ovarian cancer. The incidence for the entire region (B&H, Slove- FUNDING nia, Croatia, Serbia) of 16.1/100.000 was noticed, while incidence for respective countries varied, No specific funding was received for this study Serbia 16.3, Croatia 20.3, Slovenia 17.6/100.000 (4, 6-9,16). Data presented by the IARC refer to TRANSPARENCY DECLARATION the entire territory of B&H, not just the Federa- Competing interests: None to declare tion of B&H. According to the estimates of this

REFERENCES

1. Bray F, Ren JS, Masuyer E, Ferlay J. Estimates of 4. Ferlay J, Shin HR, Bray F, Forman D, Mathers C and global cancer prevalence for 27 sites in the adult po- Parkin DM. (Eds.). Cancer Incidence and Mortality pulation in 2008. Int J Cancer. 2013; 132:1133-45. Worldwide: IARC CancerBase No.10. Lyon, France: 2. Bolton KL, Chenevix-Trench G, Goh C, Sadetzki S, International Agency for Research on Cancer, 2010. Ramus SJ, Karlan BY, Lambrechts D, Despierre E, http://globocan.iarc.fr (28 October 2013) Barrowdale D, McGuffog L, Healey S, Easton DF, 5. Ferlay J, Steliarova–Foucher E, Lortet – Tieulent J, Sinilnikova O, Benítez J, García MJ, Neuhausen S, Rosso S, Coebergh J.W.W., Comber H, Forman D, Gail MH, Hartge P, Peock S, Frost D, Evans DG, Ee- Bray F. Cancer incidence and mortality patterns in les R, Godwin AK, Daly MB, Kwong A, Ma ES, Lá- Europe: Estimates for 40 countries in 2012. Eur J zaro C, Blanco I, Montagna M, D’Andrea E, Nico- Cancer 2013; 49:1374-1403. letto MO, Johnatty SE, Kjær SK, Jensen A, Høgdall 6. Božić A, Zupančić T. Health and health care in Slo- E, Goode EL, Fridley BL, Loud JT, Greene MH, Mai venia. Statistical Office of the Republic of Slovenia, PL, Chetrit A, Lubin F, Hirsh-Yechezkel G, Glendon 2009. http://www.stat.si (10 December 2013) G, Andrulis IL, Toland AE, Senter L, Gore ME, Go- 7. Kelava I, Tomičić K, Kokić M, Ćorušić A, Planinić urley C, Michie CO, Song H, Tyrer J, Whittemore P, Kirac I, Murgić J, Kuliš T, Znaor A. Breast and AS, McGuire V, Sieh W, Kristoffersson U, Olsson H, gynecological cancers in Croatia 1988-2008. Croat Borg Å, Levine DA, Steele L, Beattie MS, Chan S, Med J 2012; 53:100–108. Vrdoljak E, Wojtukiewicz Nussbaum RL, Moysich KB, Gross J, Cass I, Walsh M, Pienkowski T, Bodoky G, Berzinec P, Finek J, C, Li AJ, Leuchter R, Gordon O, Garcia-Closas M, Todorović V, Borojević N, Croitoru A and South Ea- Gayther SA, Chanock SJ, Antoniou AC, Pharoah stern European Research Oncology Group. Cancer PD. Association between BRCA1 and BRCA2 mu- epidemiology in Central and South Eastern Europe- tations and survival in women with invasive epithe- an countries. Croat Med J 2011; 52:478–87. lial ovarian cancer. JAMA 2012; 307:382-390. 8. Kišić Tepavčević D, Matejić B, Gazibara T, Pe- 3. Berek JS, Crum C, Friedlander M. Cancer report. kmezović T. Trends and patterns of ovarian cancer Cancer of the ovary, falopian tube and peritoneum. mortality in Belgrade, Serbia: a joinpoint regression Int J Gynecol Obstet 2012; 119(Suppl 2):S118-29. analysis. Int J Gynecol Cancer 2011; 21:1018-23.

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9. Zavod za javno zdravstvo Federacije Bosne i Her- 14. Quirk JT, Natarajan N. Ovarian cancer incidence in cegovine. Zdravstveno stanje stanovništva i zdravst- the United States 1992-1999. Gynecol Oncol 2005; vena zaštita u Federaciji Bosne i Hercegovine. Sa��- 97:519-23. rajevo, 2011. http://www.zzjzfbih.ba/wp-content/ 15. National Comprehensive Cancer Network. Ovarian uploads/2012/07/Zdravstveno-stanje-stanovnistva- Cancer Including Fallopian Tube Cancer and Pri- u-FBiH-2011.pdf (10 December 2013) mary Peritoneal Cancer. NCCN Clinical Practice 10. Ministarstvo zdravstva Federacije BiH. Strategija za Guidelines in Oncology. Version 2, 2011. http:// prevenciju, tretman i kontrolu malignih neoplazmi www.nccn.org/professionals/physician_gls/pdf/ova- u Federaciji Bosne i Hercegovine 2012-2020. Sara- rian.pdf (8 May 2011) jevo, 2011. http://www.fmoh.gov.ba/images/fede- 16. American Cancer Society. Cancer Facts & Figures. ralno_ministarstvo_zdravstva/zakoni_i_strategije/ American Cancer Society, 2009. http://www.cancer. strategije_i_politike/dokumenti/Strategija_maligne_ org (25 January 2010) final_decembar_2011.pdf (10 December 2013) 17. Jemal A, Siegel R, Xu J and Ward E. Cancer Statisti- 11. Omeragic F. Epidemiološke i kliničke karakteristike cs 2010, CA Cancer J Clin 60:277–300. malignih tumora jajnika u Federaciji BiH. Universi- 18. Cancer Research UK. Cancer Statistics Report. Ova- ty Tuzla, Tuzla, B&H, 1996; Ph.D thesis. rian cancer. 2013. http://www.cancerresearchuk.org 12. Obralić N, Gavrankapetanović F, Dizdarević Z, Du- (12 December 2013) rić O, Šišić F, Selak I, Balta S, Nakaš B. Regio- 19. U.S. Cancer Statistics Working Group. United States nal comparation of cancer incidence. Radiol Oncol Cancer Statistics: 1999–2010. Incidence and Mor- 2004; 38:145-51. tality. Web-based Report. Atlanta: U.S. Department 13. Trétarre B, Remontet L, Ménégoz F, Mace-Lesec’h of Health and Human Services, Centers for Disease J, Grosclaude P, Buemi A, Guizard AV, Velten M, Control and Prevention and National Cancer Insti- Arveux P, Peng J, Jougla E, Laffargue F, Daurès JP. tute; 2013. www.cdc.gov/uscs (1 December 2013) Ovarian cancer: incidence and mortality in France. J Gynecol Obstet Biol Reprod (Paris) 2005; 34:154-61.

Karcinom jajnika u Federaciji BiH u periodu od 1996. do 2010. godine Feđa Omeragić1,2, Azur Tulumovic1,3, Hasan Karahasan4, Larisa Mešić Ðogić5, Ermina Iljazović1,6, Alija Šuko7, Adnan Brčić8 1Medicinski fakultet u Tuzli; 2 Ordinacija za ginekologiju i perinatologiju “Omeragić”; 3Klinika za ginekologiju i akušerstvo, Univerzitetski klinički centar Tuzla; 4 Odjeljenje za ginekologiju i akušerstvo, Kantonalna bolnica Zenica; 5 Odjel za ginekologiju i akušerstvo, Opća bolnicaTešanj; 6Zavod za patologiju, Univerzitetski klinički centar Tuzla; 7Odjeljenje za ginekologiju i akušerstvo, Kantonalna bolnica “Dr. Safet Mujić” Mostar; 8Odjeljenje za ginekologiju i akušerstvo, Privatna ordinacija “Dr. Aida Brčić”, Zavidovići; Bosna i Hercegovina

SAŽETAK

Cilj Istražiti incidenciju ovarijskog karcinoma u Federaciji Bosne i Hercegovine (FBiH) za period od 1996. do 2010. godine, s obzirom da ne postoji službena baza podataka o karcinomu ovarija u navede- nom periodu. Metode U retrospektivnoj studiji, analizirana je incidencija ovarijskog karcinoma u FBiH u periodu od 1996. do 2000. godine, projekcija incidencije za period od 2000. do 2010. godine kreirana na osnovu tih podataka, kao i incidencija za period od 2007. do 2010. godine koju je objavio Federalni zavod za javno zdravstvo (FZJZ). Rezultati Prema analiziranim podacima, incidencija ovarijskog karcinoma u FBiH, u periodu od 1996. do 2000. godine, iznosila je 3,68-6,38/100.000. Projekcija incidencije, za period od 2000. do 2010. godine, rezultirala je stopom od 14,6 na kraju perioda projekcije. Prema podacima FZJZ-a, u periodu od 2007. do 2010. godine, incidencija je iznosila 11,4- 12,4/100.000. Zaključak Prema podacima iz različitih izvora, incidencija ovarijskog karcinoma u FBiH varira od 11,4 do 12,6/100.000 i niža je od incidencije južnoevropskih zemalja, te incidencije u susjednim zemljama. Međunarodna agencija za istraživanje karcinoma objavila je incidenciju za BiH, odnosno za oba entiteta, u 2008. godini, od 10,1/100.000. Također je evidentan i porast incidencije. Međutim, u FBiH ne postoji funkcionalna baza podataka za karcinome, a sistem prijavljivanja oboljenja ne funkcionira ili funkcionira bez odgovarajuće koordinacije. Glavni zadatak nosilaca zdravstvene politike i odgovornih osoba trebao bi biti uspostavljanje funkcionalnog sistema prijavljivanja oboljenja i funkcionalne baze podataka za rak, čime bi se omogućilo praćenje oboljenja i preduzimanje odgovarajućih koraka na pre- venciji, odnosno ranoj detekciji ovarijskog karcinoma. Ključne riječi: malignomi kod žena, genitalni tumori, incidencija karcinoma

349 ORIGINAL ARTICLE

The incidence of dyslipidemia (hypertriglyceridemia and hypercholesterolemia) in patients treated with the new generation of antipsychotic drugs compared to conventional therapy

Belma Sadibašić1, Amra Macić-Džanković2, Azra Šabić2, Bajro Torlak1, Gordana Lastrić1, Amir Ćustović1

1Department of Psychiatry, Cantonal Hospital Zenica, 2Department of Internal Medicine, General Hospital Sarajevo, Sarajevo; Bosnia and Herzegovina

ABSTRACT

Aim To investigate the incidence of dyslipidemia (hypertriglyceridemia and hypercholesterolemia) in patients treated with antipsychotics of new generation compared to conventional therapy.

Methods This retrospective study included 116 chronic psychiatric patients divided into two groups: a test group who were on treatment with antipsychotics of the new generation and a control group who were treated with classical antipsychotics. Laboratory and vital parameters were monitored in a group of patients who were treated with new generation antipsychotics (clozapine, olanzapine, risperidone), as well as in the group of patients who were treated with classical antipsychotics (promazine, levopromazin,haloperidol, fluphenazine). Corresponding author: Belma Sadibašić Results Mean triglyceride level in the test group was 3.13 mmol/L, Department of Psychiatry, and for the control group, 2.28 mmol/L, while the mean value for Cantonal Hospital Zenica cholesterol test group was 6.12 mmol/L, and for the control group, 5.85 mmol/L. The average age of the test group was 49.6 years, Crkvice 67, 72 000 Zenica, while the control group was 51.47 years. There was a statistical Bosnia and Herzegovina significance in triglycerides (p = 0.004), while the cholesterol (p Phone 387 32 405 133; = 0.239) and age (p = 0.356) had no statistical significance in the Fax.: +387 32 405 534; test group compared to the patients who were treated by the new E-mail: [email protected] generation of antipsychotics, and the control group of patients who were treated with antipsychotics.

Conclusion Dyslipidemia in the form of hypertriglyceridemia occurs more frequently in patients on therapy with the new generation of antipsychotics compared to patients treated with conventional therapy. Hypercholesterolemia as a form of dyslipidemia had Original submission: not been proven as significantly frequent during the therapy with 01 April 2014; new antipsychotics in relation to classical antipsychotic treatment. Revised submission: 28 May 2014; Keywords: lipids, antipsychotics of new generation, disorder Accepted: 03 July 2014.

Med Glas (Zenica) 2014; 11(2):350-355

350 Sadibašić et al. Dyslipidemia in psychotic disorders patients

INTRODUCTION PATIENTS AND METHODS Dyslipidemia is an increasing problem in most The clinical retrospective study was conducted industrialized societies and is a risk factor for co- at the Department of Psychiatry of the Cantonal ronary heart disease (CHD) (1,2). Imbalances in Hospital Zenica. The study included 116 patients individual lipid components, including serum trigl- who were diagnosed and treated as chronic psyc- ycerides, total cholesterol, low-density lipoprotein hosis in General and Emergency Department of (LDL) cholesterol, high-density lipoprotein (HDL) Psychiatry of the Cantonal Hospital in Zenica cholesterol have each been shown to contribute from 01 January 2009 to 31 May 2011. to this increased risk (3,4,5). Certain psychiatric These patients were aged between 33 and 66 ye- patient populations, such as those afflicted with ars with first or repeated hospitalization due to schizophrenia, are of particular concern. Psychi- worsening of psychotic disorders. Aimed at ho- atric patients with schizophrenia are naturally at mogenization of the groups, males and females increased risk for dyslipidemia and obesity, in part in a similar ratio were selected in both groups. due to poor diet and sedentary lifestyle, but these Patients who were admitted to the Emergency or conditions can be exacerbated by some antipsyc- General Department of Psychiatry, or who are hotic medications (6-9). Clozapine and olanzapine, refractory to classical antipsychotics, were tre- for example, appear to be associated with hyper- ated with the new-generation of antipsychotics lipidemia, which may be associated with changes (clozapin,olanzapin,risperidon) and they were in- in body weight (5,10,11). Further, newer antip- cluded into the test group of patients. Patients who sychotic agents may exhibit less susceptibility for had previously responded to conventional antip- weight gain and the development of dyslipidemia sychotics were included into the control group of (12). This review is intended to briefly highlight patients. The test group had included 78 patients, the association between dyslipidemia and certa- of whom 39 men and 39 women who were admi- in type of antipsychotic therapies (Risk-benefit tted to the Department of General and Emergency assessment) (12-14). Despite the adverse effects Psychiatry because of repeated worsening of psyc- mentioned above, a number of factors should be hotic disorder, and were treated with some of the considered while making a decision on a thera- new generation antipsychotics as monotherapy or py (15). These include the nature of the patient’s in combination with other psychoactive drugs, de- psychiatric condition, specific target signs and pending on the clinical status. symptoms, past history of drug response (both therapeutic and adverse), patient preference, history The control group included 38 patients, of whom of treatment adherence, medication effectiveness, 19 men and 19 women, who were admitted un- psychiatric and medical comorbidities, availability der the same circumstances and who were treated of appropriate formulations (e.g., fast-dissolving with classical antipsychotics as monotherapy or oral, short- or long-acting intramuscular), need for in combination with other psychoactive drugs. special monitoring, and cost of and access to medi- Test group protocol cations (9,16). Nonetheless, the risks of obesity, diabetes, and dyslipidemia have considerable clinical The test group patients who received therapy upon implications in this patient population and should receipt of the new generation of antipsychotics also influence drug choice (8,14,17). (group or clozapin tablets in dose of 25-100 mg, risperidon tablets at a dose of 1-4 mg, and olanza- Even for those medications associated with an in- pine tablets at a dose of 5-10 mg). Some patients creased risk of metabolic side effects, the benefit were treated with paroxetin and benzodiazepines to specific patients could outweigh the potential too. All these patients were tested by laboratory risks (14). For example, clozapine has unique be- tests of serum triglycerides and cholesterol at the nefits for treatment-refractory patients and those start of treatment and two years follow up period. at significant risk for suicidal behavior (18). Since treatment response in many psychiatric conditions Control group protocol is heterogeneous and unpredictable, physicians and patients can benefit from the availability of a Patients of the control group were treated by cla- broad array of different therapeutic agents (19,20). ssical antipsychotics (promazin tablets in dose of

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25 to 150 mg , levopromazin tablets in dose of 25 mmol/L (p=0.004), while the mean value for cho- to 75 mg, flufenazin tablets at a dose of 1 mg to lesterol test group was 6.12 mmol/L, and for the 2.5 mg , haloperidol tablets at a dose of 2 to 10 control group, 5.85 mmol/L (p=0.239) (Table 2). mg, or as a depot preparation of these classical Table 2. Difference in mean values of triglycerides, choles- antipsychotics). The control group was followed terol and age 95% Confidence Inter- up according to the same parameters as the study Mean t val of the Difference p Difference group in same period of follow up. Lower Upper Age -.927 -1.512 -4.745 1.720 0.356 Statistical methods Cholesterol 1.184 .27578 -.18565 .73721 0.239 Triglycerides 2.947 .84669 .27763 1.41576 0.004 T – test was used to determine the significance of differences between individual characteristics The minimum age in the test group was 33 ye- of groups in the sample given in the parametric ars and the maximum age 65 years, while in the form. A p value of <0.05 was considered to be control group the down age was 34 years and the statistically significant. Graphical representation maximum age 79 years (Figure 1). is made using Boxplot applied in descriptive statistics. Within Boxplot of 25% - 75% of the data, and the boundary lines are extreme data. It shows the difference between the samples, without any assumptions basic statistical distribution. For this investigation, the approval of the Ethics Committee of the Cantonal Hospital in Zenica was obtained.

RESULTS The study included 58 male and 58 female patients. Minimum age in the test group was 33 Figure 1. Differences in age between the test and control groups years and the maximum age was 65 years, while in the control group minimum age was 34 years The lowest value of cholesterol in the test group and the maximum age was 79 years. The lowest was 2.80 mmol/L, and the highest value of choleste- value of triglycerides in the test group was 0.90 rol in the test group was 8.50 mmol/L, while in the mmol/L, and the highest value of triglycerides control group, the lowest value of cholesterol was was 8.60 mmol/L, while in the control group, the 3.70 mmol/L, and the highest value of cholesterol lowest value triglyceride 0.80 mmol/L, and the in the control group was 8.80 mmol/L (Figure 2). highest value of triglycerides was 7.70 mmol/L. The lowest value of cholesterol in the test group was 2.80 mmol/L, and the highest value 8.50 mmol/L, while in the control group, the lowest value of the cholesterol was 3.70 mmol/L, and the highest value 8.80 mmol/L (Table 1). Table 1. Values of triglycerides, cholesterol, and average age Group of patients Parameters Mean Min. Max. Age 49.96 33 65 Test Cholesterol 6.12 2.80 8.50 N=78 Triglycerides 3.13 0.90 8.60 Age 51.47 34 79 Control Cholesterol 5.85 3.70 8.80 N=38 Triglycerides 2.28 0.80 7.70 The average age of the test group was 49.96 years, and the control group was 51.47 years (p=0.356). Mean triglyceride levels in the test group were 3.13 mmol/L, and for the control group, 2.28 Figure 2. Difference in cholesterol values between the test and control groups

352 Sadibašić et al. Dyslipidemia in psychotic disorders patients

The lowest value of triglycerides in the test gro- to specific patients could outweigh the potential up was 0.90 mmol/L, and the highest value of risks (12-14). The population of schizophrenic triglycerides in the test group was 8.60 mmol/L, patients is at greater risk for developing obesi- while in the control group, the lowest value of ty, type-2 diabetes, dyslipidemia and hypertensi- triglycerides was 0.80 mmol/L, and the highest on in the general population (21). The treatment value triglycerides in the control group was 7.70 with new generation antipsychotics is also asso- mmol/L (Figure 3). ciated with weight gain and other metabolic side effects (21). The relationship between weight gain caused by antipsychotic drugs and the occurrence of dyslipidemia is not yet entirely clear. Some studies suggest that weight gain and metabolic syndrome are certainly associated with the treatment with antipsychotics, but the occurrence of dyslipidemia was significantly associated with antipsychotic treatment (22). Clozapine and olanzapine significantly increase the risk of diabetes and dyslipidemia, with risperidone and qu- etiapine, the risk is possible, and ziprasidone and aripirazol no risk for diabetes and dyslipidemia. The results of this study have shown the increase in the triglycerides value when using the new Figure 3. Difference in triglycerides between the test and control generation of antipsychotic therapy compared to groups patients with conventional therapy, while for cho- DISCUSSION lesterol there was no increase in the value when using the new generation of antipsychotic the- Our study has shown that dyslipidemia was re- rapy compared to the patients who were treated presented in the form of hypertriglyceridemia in with antipsychotics. A comprehensive study in a patients on therapy with the new generation of an- mental hospital in Italy investigating the compa- tipsychotic drugs compared with patients treated rison between the 76 patients treated with new- with antipsychotics. Despite the adverse effects generation antipsychotics and 36 control patients or the impact of new antipsychotics, primarily who were not psychiatric patients, has shown clozapine and olanzapine in the development of that patients who were treated with new-genera- hyperlipidemia and obesity, a number of factors tion antipsychotics had a significant prevalence should be considered when choosing among the (four times greater chance) of hypertriglyceride- antipsychotic medications (15). These include mia compared with controls (17). Similar values the nature of the patient’s psychiatric condition, for hypertriglyceridemia were found in our study specific target signs and symptoms, past history comparing the test and control groups. In several of drug response (both therapeutic and adverse), studies it was found that in patients who were not patient preference, history of treatment adheren- obese and were not treated with antipsychotics, ce, medication effectiveness, psychiatric and me- the concentration of triglycerides for two weeks dical comorbidities, availability of appropriate after the treatment with the new generation of an- formulations (e.g. fast-dissolving oral, short- or tipsychotics significantly increased (23,24). Most long-acting intramuscular), need for special mo- antipsychotics may cause dyslipidemia indirectly nitoring, and cost of and access to medications through an increase in body weight, leading to (9,16 ). Nonetheless, the risks of obesity, diabe- abdominal obesity and hyperlipidemia. Howe- tes, and dyslipidemia have considerable clinical ver, some antipsychotics (especially olanzapine implications in this patient population and should and clozapine) may cause hyperlipidemia direct also influence a drug choice (8,14,17). mechanisms that cause the lowering of HDL cho- Even for those medications associated with an in- lesterol and an increase in total cholesterol, trigl- creased risk of metabolic side effects, the benefit yceride and LDL-cholesterol (25).

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Dyslipidemia in the form of hypertrigliceridemia the previous view that the new generation of an- occurs more frequently in patients on therapy tipsychotics affects lipid disorder, primarily of with the new generation of antipsychotics com- triglycerides. pared to patients treated with conventional therapy. Hypercholesterolemia, on the other hand, FUNDING as a form of dyslipidemia, does not occur signi- No specific funding was received for this study. ficantly more frequently in the therapy with the new antipsychotics in relation to the application TRANSPARENCY DECLARATION of usual, classic treatment. Our study confirmed Competing interests: none to declare.

REFERENCES 1. Tonstand S, Hjermann I. A high risk score for coro- 13. Lieberman JA, Stroup TS, McEvoy JP, Swartz nary heart disease is associated with the metabolic MS, Rosenheck RA, Perkins DO, Keefe RS, Davis syndrome in 40-year-old men and women. J Cardio- SM, Davis CE, Lebowitz BD, Severe J, Hsiao JK. Ef- vasc Risk 2003; 10:129-35. fectiveness of antipsychotic drugs inatients with chro- 2. Graham KA , Cho H, Brownley KA, Harp JB. Early nic schizophrenia. N Engl J Med 2005; 353:1209-23. treatment-related changes in diabetes and cardiovas- 14. Barnett AH, Mackin P, Chaudhry I, Farooqi A, Gad- cular disease risk markers in first episode psychosis sby R, Heald A, Hill J, Millar H, Peveler R, Rees subjects. Schizophr Res 2008; 101:287-94. A, Singh V, Taylor D, Vora J, Jones PB. Minimising 3. Atmaca M. Kuloglu M, Tezcan E, Ustundag B. Serum metabolic and cardiovascular risk factors in schizop- leptin and triglyceride levels in patients on treatment hrenia: diabetes, obesity and dyslipidaemia. J Psyc- with atypical antipsychotics. J Clin Psychiatry 2003; hopharmacol 2007; 21:357-73. 64:598-604. 15. Wahlbeck K, Tuunainen A, Ahokas A, Leucht S. Dro- 4. Haupt DW. Differential metabolic effects of antipsyc- pout rates in randomized antipsychotic drug trials. hotic treatments. Eur Neuropsychopharmacol 2006; Psychopharmacology (Berl) 2001; 155:230-3. 16:149-55. 16. Ginsberg HN. Treatment for patients with metabolic 5. Perez-Iglesias R, Mata I, Pelayo-Teran JM, Amado syndrome. Am J Cardiol 2003; 91:29-39. JA, Garcia-Unzueta MT, Berja A, Martinez-Garcia O, 17. Tarricone I, Casoria M, Gozzi BF, Grieco D, Men- Vazquez-Barquero JL, Crespo-Facorro B. Glucose and chetti M, Serretti A, Ujkaj M, Pastorelli R, Berardi lipid disturbances after 1 year of antipsychotic trea- D. Metabolic risk factor profile associated with use tment in a drug-naïve population. Schizophr Res 2009; of second generation antipsychotics. A cross sectio- 107:115-21. nal study in a community mental health centre. BMC 6. Cormac I, Ferriter M, Bening R, Saul C. Physical Psychiatry 2006; 6:11-8. health and health risk factors in a population of long- 18. Lewis DA. Atypical antipsychotic medications and stay psychiatric patients. Psychiatr Bull 2005; 29:18- the treatment of schizophrenia. Am J Psychiatry 20. 2002; 159:177-9. 7. Meyer JM, Davis VG, Goff DC, McEvoy JP, Na- 19. De Hert MA, van Winkel R, van Eyck D, Hanssens srallah HA, Davis SM, Rosenheck RA, Daumit GL, L,Wampers M, Scheen A, Peuskens J. Prevalence of Hsiao J, Swartz MS, Stroup TS, Lieberman JA. Chan- the metabolic syndrome in patients with schizophre- ge in metabolic syndrome parameters with antipsyc- nia treated with antipsychotic medication. Shizophr hotic treatment in the CATIE schizophrenia trial Res 2006; 83:87-93. prospective data from phase 1. Schizophr Res 2008; 20. Lehman AF, Lieberman JA, Dixon LB, McGlashan 101:273-86. TH, Miller AL, Perkins DO, Kreyenbuhl J; American 8. Stahl SM, Mignon L, Meyer JM. Which comes first: Psychiatric Association; Steering Committee on Prac- atypical antipsychotic treatment or cardiometabolic tice Guidelines. Practice guideline for the treatment risk? Acta Psychiatr Scand 2009; 119:171-9. of patients with schizophrenia, second edition. Am J 9. Phelan M, Stradins L, Morrison S. Physical heal- Psychiatry 2004; 161(2 Suppl):1-56. th of people with severe mental illness. BMJ 2001; 21. Barnett AH, Mackin P, Chaudhry I, Farooqi A, Gadsbi 322:443-4. R, Heald A, Hill J, Millar H, Peveler R, Rees A, Singh 10. Reist C, Mintz J, Albers LJ, Jamas MM, Szabo S, V, Taylor D, Vora j, Jones PB. Minimising metabolic Ozdemir V. Second-generation antipsychotic expo- and cardiovascular risk in schizophrenia: diabetes, sure and metabolic-related disorders in patients with obesity and dyslipidemia. J Psychopharmacol 2007; schizophrenia. J Clin Psychopharmacol 2007; 27: 46- 21:4:357-73. 51. 22. Birkenaes AB, Birkeland KI, Engh JA, Faerden A, 11. Tandon R, Jibson MD. Efficasy of newer generati- Jonsdottir H, Ringen PA, Friis S, Opjordsmoen S, on antipsychotics in the treatment of schizophrenia. Andreassen OA. Dyslipidemia independent of body Psychoneuroendocrinology 2003; 28( Suppl 1):9-26. mass in antipsychotic-treated patients under real-life 12. Uzun S, Kozumplik O, Mimica N, Folnegovic Šmalc conditions. J Clin Psychopharmacol 2008; 28:132-7. V. Nuspojave psihofarmaka. Zagreb: Medicinska naklada, 2005.

354 Sadibašić et al. Dyslipidemia in psychotic disorders patients

23. Chui Chih-Chiang, Chun-Hsin Chen, Bo-Yu Chen, with schizophrenia treated with second generation Shu-Han Yu, Mong-Liang Lu. The time-dependent antipsychotics: a 3-month follow-up. J Psychophar- change of insulin secretion in schizophrenic patients macol 2008; 23:915–22. treated with olanzapine. Prog Neuropsychopharmacol 25. Meyer JM, Koro CE. The effects of antipsychotic the- Biol Psychiatry 2010; 34:866-70. rapy on serum lipids: a comprehensive review. Schi- 24. Medved V, Rojnic Kuzman M, Jovanovic N, Grubisin zophr Res 2004; 70:1-17. J, Kuzman T. Metabolic syndrome in female patients

Incidenca dislipidemije kod pacijenata liječenih novom generacijom antipsihotika u odnosu na pacijente koji su tretirani klasičnim antipsihoticima Belma Sadibašić1, Amra Macić-Džanković2, Azra Šabić2, Bajro Torlak1, Gordana Lastrić1, Amir Ćustović1 1Kantonalna bolnica Zenica, Zenica; 2Opšta bolnica, Sarajevo; Bosna i Hercegovina SAŽETAK

Cilj Utvrditi incidencu dislipidemije (hipertrigliceridemije i hiperholesterolemije) kod pacijenata koji su tretirani antipsihoticima nove generacije u poređenju s pacijentima koji su na terapiji klasičnim antipsihoticima.

Metode Ova retrospektivna studija obuhvatila je 116 hroničnih psihijatrijskih pacijenata podijeljenih u dvije grupe: ispitnu grupu pacijenata koji su na terapiji antipsihoticima nove generacije i kontrolnu grupu pacijenata koji su tretirani klasičnim antipsihoticima. Laboratorijski i vitalni parametri praćeni su i u grupi pacijenata koji su tretirani antipsihoticima nove generacije (clozapin, olanzapin, risperidon), kao i u grupi pacijenata koji su tretirani klasičnim antipsihoticima (promazin, levopromazin, haloperidol, flufenazin), te su dobiveni podaci statistički obrađeni.

Rezultati Srednja triglicerida za ispitnu grupu bila je 3,13 mmol/L, a za kontrolnu 2,28 mmol/L, dok je srednja vrijednost holesterola za ispitnu grupu bila 6,12 mmol/L, a za kontrolnu 5,85 mmol/L. Prosječna starost ispitne grupe bila je 49,6 godina, a kontrolne 51,47 godina. Ustanovljena je statistička signifikantnost za trigliceride (p=0,004), dok za holesterol (p=0,239) i starosnu dob (p=0,356) nije postojala statistička signifikantnost u usporedbi ispitne grupe pacijenata koji su bili na terapiji antipsihoticima nove generacije i kontrolne grupe pacijenata koji su bili tretirani klasičnim antipsihoticima.

Zaključak Dislipidemija, u obliku hipertrigliceridemije, češće se javlja kod pacijenata koji su liječeni novom generacijom antipsihotika u odnosu na pacijente koji su tretirani klasičnom terapijom antipsihotika. Hiperholesterolemija, kao oblik dislipidemije, nije pokazala statističku signifikantnost u poređenju terapije novim i klasičnim antipsihoticima.

Ključne riječi: lipidi, antipsihotici nove generacije, poremećaj

355 ORIGINAL ARTICLE

Influences of socio-demographics on depression and anxiety in patients with complex partial and tonic-clonic seizures

1 2 1 2 Duru Saygın Gülbahar , Hasan Huseyin Karadeli , Ömer Esenkaya , Muhammed Emin Ozcan , Gulistan Halac2, Talip Asil2

Department of Psychiatry, Bakırköy Mental Health and Neurological Diseases Training and Research Hospital, 2Department of Neurol- ogy, Bezmialem Vakif University, Faculty of Medicine; Istanbul, Turkey

ABSTRACT

Aim To compare the levels of anxiety and depression in patients with milder epilepsy characterized by complex partial seizures versus more severe epilepsy comprised of generalized tonic-clonic seizures.

Methods A total of 60 patients aged between 18 and 80 admitted with seizures were prospectively enrolled. Patients with history of any psychiatric disorders were excluded. Imaging studies were performed to rule out any organic brain lesions that might be responsible for seizures. Patients were divided into two groups according to the type of the seizures: group 1 (n=30) with complex partial seizures without focal and generalized tonic-clonic seizures, and group 2 (n=30) with generalized tonic-clonic seizures. Struc- tured Clinical Interviews for DSM-IV Axis I disorders (SCID-I/ NP) were performed in all patients. Additionally, Hamilton Depre- Corresponding author: ssion Rating Scale (HAM-D) and Hamilton Anxiety Rating Scale Hasan Huseyin Karadeli (HAM-A) were administered to the patients where appropriate. All Department of Neurology, Bezmialem the parameters were statistically compared. Vakif University, Faculty of Medicine Results Mean age of the patients was 29.66±10.33 years, 38 Iskenderpasa mahallesi. Adnan Menders (63.3%) were females. Both groups were comparable in terms of Bulvari, 34093 Istanbul, Turkey age, educational status, marital status, occupational status, age of Phone : +90 532 443 67 48; epilepsy onset, and Hamilton scores. Mean HAM-D score (2.11) Fax : +90 212 233 98 76; and mean HAM-A total score (2.31) of the patients employed du- E-mail: [email protected] ring the last 6 months were different than the mean HAM-D score (4.76) and mean HAM-A total score (5.66) of the patients unemployed during last 6 months. Patients with no reliable employment within the past 6 months demonstrated significantly higher depression and anxiety scores (p<0.05).

Conclusion This study clearly demonstrated a relationship among Original submission: the features of epileptics and levels of depression and anxiety. 26 November 2013; There was a relationship between employment and depressive and Revised submission: anxiety symptoms of epileptic patients. Also, unemployment may 20 January 2014; be indicative for treatment compliance. Accepted: Keywords: epilepsy, treatment, compliance 29 January 2014.

Med Glas (Zenica) 2014; 11(2):356-360

356 Gülbahar et al. Socio-demographics and depression and anxiety

INTRODUCTION PATIENTS AND METHODS It was once thought that those afflicted with epi- Study participants were selected from 60 conse- leptic seizures were cursed or witches. Although cutive admissions for seizures to the Bakırköy people with epilepsy no longer face such extreme Prof. Dr. Mazhar Osman Mental Health and Ne- stigmatization, it is evident that psychosocial pro- urological Diseases Training and Research Hos- blems are highly prevalent in these patients (1). It pital epilepsy clinic. These patients were 18 to 80 has been recognized for many years that patients years old and only had epilepsy as a previous me- with epilepsy have higher rates of cognitive and dical diagnosis. As such, the study subjects lac- behavioral disorders in comparison to the general ked a history of psychiatric disorders including population (2). In fact, epilepsy is one of the most mental retardation, psychoactive drug use, and popular medical conditions to study in the fields of any trauma resulting in loss of consciousness. Pa- neurology, psychiatry, neurosurgery and pediatrics. tients were divided into two groups based on the During 1957 Pond described the psychiatric dis- seizure type that they experienced over the last orders that are comorbid with epilepsy, and this year: complex partial seizures without other focal classification scheme is still in use today. Psychi- or generalized tonic-clonic seizures (n=30) and atric disorders are frequently observed in epilep- generalized tonic-clonic seizures (n=30). Brain tics, yet these conditions often go undiagnosed imaging techniques, including magnetic reso- and patients do not receive proper therapy to con- nance imaging (MRI) and computed tomography trol their psychiatric symptoms (3). Inadequate (CT), were utilized to rule out whether patients psychiatric treatment may contribute to the high had lesions that may have caused epilepsy. If an rates of suicidal ideation and suicide attempts in organic cerebral lesion was identified the patient epileptic patients9. Furthermore, anxiety and de- was subsequently excluded from the study. pression are the most common psychiatric disor- After each patient received a neurological evalua- ders in patients with epilepsy, and in comparison tion, their socio-demographic data and history of to the general population, rates of these disorders epilepsy were recorded. The Turkish translation are greater for epileptics (4-9). of the Structured Clinical Interview for DSM-IV Development of psychopathology in epileptics Axis I disorders (SCID-I/NP) was performed to may be related to seizure type, frequency, dura- determine whether subjects had comorbid psyc- tion, and age of onset; quality of seizure control; hiatric conditions. If the patients exhibited depre- number of medications; and presence of organic ssive symptoms, the severity of those symptoms central nervous system disease. Further variables was measured with the Hamilton Depression Ra- that might impact the psychological health of these ting Scale (HAM-D). Furthermore, the Hamilton patients are other psychosocial factors and socio- Anxiety Rating Scale (HAM-A) was performed demographic characteristics such as age, sex and to determine the range and magnitude of anxiety employment status (10). Even the type of epilepsy symptoms. This study was reviewed and appro- may affect how these patients function in and are ved by the Ethics Committee of Bakırköy Prof. perceived by the society, which is likely to have Dr. Mazhar Osman Mental Health and Neurolo- resounding psychological implications. gical Diseases Training and Research Hospital. This study investigated the relationship between First developed in 1997, the SCID-I was utili- the levels of anxiety and depressive symptoms in zed to diagnose patients with Axis I disorders. epileptic patients that demonstrated either com- In 1999 SCID-I was translated into Turkish by plex partial seizures or generalized tonic-clonic Çorapçıoğlu and colleagues. After the studies seizures, which are generally perceived as milder confirmed reliability of this translation, the ma- or more severe forms of epilepsy, respectively. nual was released and called the SCID-I/NP (11). The aim of this study was to describe the need for The Hamilton Depression Rating Scale (HAM- an assessment of the relationship between epilep- D) was developed by Hamilton in 1961 and sy and psychiatric disorders such as anxiety and then revised in 1967 to examine the severity of depressive disorders, thus treatment protocols of patient’s depressive symptoms. In 1996 Akdemir epilepsy may consider the psychosocial state of and colleagues confirmed validity and reliability the patients such as employment. of the HAM-D Turkish translation (12). Utili-

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zing a 17-question form, we rated the severity of Table 1. Scores according to seizure type patient’s depressive symptoms on a scale of 0 (no Complex Generalized Score type partial tonic-clonic p symptoms) to 4 (severe symptoms). A total score Mean±SD Mean±SD ranging from 0 to 7 indicated no depression, a HAM-D Score 3.27±4.36 3.73±4.18 0.627 score ranging from 8 to 15 indicated mild depre- HAM-A Total Score 3.93±4.5 4.73±4.93 0.514 HAM-A Psychic Subscale Score 2.13±2.41 2.77±3.29 0.399 ssion, and a score of 16 or higher was designated HAM-A Somatic Subscale Score 2.00±2.75 1.96±2.37 0.960 as major depression. HAM-D, Hamilton Depression Rating Scale; HAM-A, Hamilton This study also used the Hamilton Anxiety Rating Anxiety Rating Scale; Scale (HAM-A), which was developed by Hamil- latest age when a patient was diagnosed was at ton in 1959, and is utilized to measure the seve- 48 years of age. The mean age distribution that rity of depressive symptoms and psychological patients were first diagnosed with epilepsy was and somatic anxiety. The validity and reliability 18.37±10.08 years. Out of all patients in the of the HAM-A Turkish translation was confirmed study population, the shortest life with epilepsy by Yazıcı and colleagues in 1998 (13). Presence was 2 years whereas the longest was 37 years. and severity of symptoms were rated based on the The mean time distribution that patients lived interviewer’s discretion and each symptom was with epilepsy was 11.18±7.78 years. scored separately on a scale from 0 (no symptoms) Demographics were also obtained for the study to 4 (severe symptoms). The total score for HAM- population to get a sense of each patient’s family A ranged from 0 to 56, but a cutoff score was not life, level of education, and type of employment. It calculated for this Turkish study. was determined that 29 (48.3%) participants were The chi-squared test was applied to evaluate rela- married while 31 (51.7%) of them were unmarri- tionships between qualitative data, and Student’s ed. Out of all the participants only two (3.3%) t-test was utilized to determine the difference were literate (but did not attend school), 18 (30%) between means of continuous variables. The graduated from primary school, 14 (23,3%) gra- Kruskal-Wallis test was applied to compare more duated from junior high school, 17 (28.3%) gra- than two groups of continuous variables. To de- duated from high school, and 9 (15%) graduated termine whether the differences among groups from a higher education institution. Demograp- were statistically significant a post hoc analysis hics regarding occupation demonstrated that six was performed. A p-value less than 0.05 was con- (10%) participants were unemployed, 14 (23.3%) sidered statistically significant. were housewives, 19 (31.7%) were employed, three (5%) were civil servants, three (5%) were RESULTS craftsmen, three (5%) were tradesmen, two (3.3%) Having performed an analysis of the types of se- were retired, and 10 (16.7%) were students. izures that the study participants exhibited over To measure the range of severity of the patient’s the past year, it was found that 50% of them had anxiety and depression the HAM-A and HAM- complex partial seizures while the remaining D were performed. When comparing all the su- 50% had generalized tonic-clonic seizures. The bjects, the minimum HAM-D score was 0 and age was distributed as the minimum age of 18 the maximum was 16 with a mean distribution and the maximum age was 54, and the mean age of 3.5±4.24. The HAM-A scores ranged from 0 was 29.66±10.33 for all sixty participants. Furt- hermore, 22 (36.7%) patients were males with a Table 2. Scores according to employment stability Working during Number of mean age distribution of 28.68±18.7 years, and Score type MEAN±SD p 38 (63.3%) were females with a mean age distri- last 6 months patients HAM-D YES 29 2,31±2,60 0.02 bution of 30.24±11.24 years. There was no signi- HAM-A Total Score NO 31 4,76±5,15 HAM-A Psychic YES 29 3,11±3,98 ficant difference between the mean age distributi- 0.03 on between epileptic males and females. Subscale score NO 31 5,66±5,04 HAM-D YES 29 1,86±2,46 0.09 Basic clinical histories for epilepsy were co- HAM-A Total Score NO 31 3,10±3,16 HAM-A Psychic YES 29 1,24±1,93 llected to determine at what age and how long 0.02 Subscale score NO 31 2,76±2,87 patients had this condition. The earliest age that HAM-D, Hamilton Depression Rating Scale; HAM-A, Hamilton epilepsy was diagnosed was at 2 years, and the Anxiety Rating Scale;

358 Gülbahar et al. Socio-demographics and depression and anxiety

to 18 and demonstrated a mean distribution of most common psychological disorders in adult 4.3±4.69. HAM-A Psychic Subscale scores ran- and pediatric patients (4,5,16). Following Tor- ged from 0 to 11 and averaged 2.45±2.88, where- ta and Keller’s example, we aimed to determine as for the HAM-A whether the severity of epilepsy and certain socio- Somatic Subscale scores, the minimum was 0 and demographic traits affect the severity of anxiety the maximum was 10 with a mean distribution and depression for these patients. However, there of 1.98±2.54. Overall, there were no significant were no such correlations observed in our study. differences among HAM-D scores and HAM-A Interestingly, in this research there were no di- total, Psychic Subscale and Somatic Subscale fferences in anxiety and depressive symptoms scores between complex partial seizures and ge- between male and female epileptics. This is in neralized tonic-clonic seizures groups. contrasts with previous findings that suggest that There were no significant differences among females without epilepsy demonstrate depression HAM-D and HAM-A total, Psychic Subscale and and anxiety disorders more often than males (17). Somatic Subscale scores according to the sex. However, there have been other reports that male epileptics have greater rates of depression as There were no significant differences among HAM- compared to females (18). It still remains uncle- D and HAM-A total, Psychic Subscale and Somatic ar why other studies have found greater levels of Subscale scores according to educational level. depression in male epileptics. Perhaps this diffe- There were significant differences noted among rence may be attributed to the high expectations HAM-D scores, HAM-A total scores, and HAM- that Turkish society places on males in addition A Somatic Subscale scores when comparing whet- to the stigma attached to epilepsy, which all to- her participants were securely employed or not gether may be so stressful that males are more (p<0.05). However, no significant difference was frequently depressed. observed for HAM-A Psychic Subscale scores. Even though there were no correlations between There were no significant differences among HAM- the intensity of epileptic seizures, socio-demo- D and HAM-A total, Psychic Subscale and Somatic graphic traits and the severity of comorbid psyc- Subscale scores according to marital status. hiatric conditions, many subjects demonstrated DISCUSSION anxiety and depression despite lacking a history of prior psychiatric diagnoses. While it may be It is reported that comorbid psychiatric disorders challenging to detect cognitive and behavioral such as depression and anxiety are diagnosed changes in epilepsy patients, it is paramount to more often in sick individuals than in healthy indi- do so during routine follow-up examinations. viduals (5,8). Because psychiatric conditions often Care providers must keep in mind that patients have multifactorial etiologies, it is not unusual to might exhibit psychiatric symptoms that are observe comorbid psychiatric disorders in patients not severe enough to qualify for a formal psyc- with health problems such as epilepsy. Accordin- hiatric diagnosis. It is proposed that one of the gly, patients with epilepsy or other neurological most serious limitations of the DSM-IV is that diseases demonstrate more psychopathology when it does not address how to approach subclinical compared to the general population (2). There are symptoms that might represent psychopathology cases in which comorbid psychiatric disorders sur- (14). In such cases it is important to monitor the- face even before epilepsy is diagnosed, yet these se symptoms over time to detect exacerbations disorders are observed following or during the di- that may need therapeutic intervention. This is agnosis of epilepsy as well (15). especially important for epileptic patients, be- As Torta and Keller revealed in 1999, compre- cause they have high rates of suicidal ideation hending the clinical, psychosocial and biological and suicide attempts (9). As such, care providers factors that contribute to developing psychiatric must be vigilant in screening for and detecting disorders is helpful when trying to elucidate the comorbid psychiatric conditions to give patients relationship between disease and comorbid psyc- optimal, holistic health care. However, this may hiatric conditions (19). Furthermore, the literature not always be feasible if patients cannot access data suggest that anxiety and depression are the health care due to lack of steady employment.

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In developing countries such as Turkey there are research may reveal possible solutions that might shortcomings in social support systems as the reduce the influence of stigmatization on treatment unemployed have limited access to resources. outcomes and patient well-being. By elucidating If the paucity of assistance for the unemployed the relationship between epilepsy and psychiatric remains uncorrected, it may be difficult to quell disorders such as depression and anxiety, it may the loss of workers looking for better opportuni- be possible to improve long-term health outcomes ties elsewhere. This study identified a significant in patients with chronic diseases such as epilep- increase in anxiety and depression for epileptics sy. Our study clearly demonstrated that there is a without regular employment as compared to pati- relationship among the features of epileptics and ents with a secure job over a six-month period. In levels of depression and anxiety. Although vast order to further support these patients from a he- majority of the features and Hamilton scores of the alth care perspective, a comprehensive approach patients were comparable between patients with must be adopted to identify psychiatric disorders complex partial seizures and generalized seizu- when these patients seek care for epilepsy. res, the history of unemployment was a significant In conclusion, this study investigated the relation- parameter increasing the depression and anxiety ship among the features of epileptics and levels of scores. The history of unemployment may indica- depression and anxiety. One of the main limitati- te the well-being and the treatment compliance of ons in our study was the lack of statistical power in the epileptic patients. our analyses due to an insufficient sample size. In FUNDING the future, prospective investigations with larger study populations are needed to further investiga- Funding: no specific funding was received for te the relationship between comorbid psychiatric this study. disorders and epilepsy. Another interesting avenue of study would be to investigate how social stigma TRANSPARENCY DECLARATION towards epileptics affects their treatment. Such Competing interests: None to declare.

REFERENCES 1. Drane DL, Meador KJ. Epilepsy, anticonvulsant 11. Çorapçıoğlu A. ÖSYM. Structured Clinical Intervi- drugs and cognition. Baillieres Clin Neurol 1996; ew for DSM-4(SCID-4). Ankara: HYB, 1999. 5:877-85. 12. Akdemir A, Örsel SD, Dağ İ, Türkçapar, MH, İşcan 2. Kwan P, Brodie MJ. Neuropsychological effects N , Özbay H. Realibility and validity of the Tur- of epilepsy and antiepileptic drugs. Lancet 2001; kish version of the Hamilton depresion rating scale. 357:216-22. Compr Psychiatry 2001; 42:161-65. 3. Caplan R, Siddarth P, Gurbani S, Hanson R, Sankar 13. Yazıcı MK, Demir B, Tanrıverdi N. Hamilton de- R, Shields WD. Depression and anxiety disorders in presion rating scale, reability and validity among pediatric epilepsy. Epilepsia 2005; 46:720-30. the estimators. Journal of Turkish Psychiatry 1998; 4. Blumer D, Montouris G, Hermann B. Psychiatric 9:114–17. morbidity in seizure patients on a neurodiagnostic 14. Adams SJ, O’Brien TJ, Lloyd J, Kilpatrick CJ, Salz- monitoring unit. J Neuropsychiatry Clin Neurosci berg MR, Velakoulis D. Neuropsychiatric morbidity 1995; 7:445-56. in focal epilepsy. Br J Psychiatry 2008; 192:464-69. 5. Beyenburg S, Damsa C. Psychiatric comorbidity in 15. Gaitatzis A, Trimble MR, Sander JW. The psychi- epilepsy. Bull Soc Sci Med Grand Duche Luxemb atric comorbidity of epilepsy. Acta Neurol Scand 2005; 283-92. 2004; 110:207-20. 6. Dunn DW, Austin JK. Behavioral issues in pediatric 16. Dunn DW, Austin JK, Huster GA. Symptoms of epilepsy. Neurology 1999; 53(5 Suppl 2):S96-100. depression in adolescents with epilepsy. J Am Acad 7. Devinsky O, Vazquez B. Behavioral changes asso- Child Adolesc Psychiatry 1999; 38:1132-38. ciated with epilepsy. Neurol Clin 1993; 11:127-49. 17. Piccinelli M, Wilkinson G. Gender differences in de- 8. Oguz A, Kurul S, Dirik E. Relationship of epilepsy- pression. Br J Psychiatry 2000; 177:486-92. related factors to anxiety and depression scores in 18. Lambert MV, Robertson MM. Depression in epilep- epileptic children. J Child Neurol 2002; 17:37-40. sy: etiology, phenomenology, and treatment. Epilep- 9. Pompili M, Vanacore N, Macone S, Amore M, Pe- sia 1999; 40(Suppl 10):S21-S47. triconi G, Tonna M. Depression, hopelessness and 19. Torta R, Keller R. Behavioral, psychotic, and anxi- suicide risk among patients suffering from epilepsy. ety disorders in epilepsy: etiology, clinical features, Ann Ist Super Sanita 2007; 43:425-29. and therapeutic implications. Epilepsia 1999; 40(Su- 10. Mensah SA, Beavis JM, Thapar AK, Kerr M. The ppl 10):S2-20. presence and clinical implications of depression in a community population of adults with epilepsy. Epi- lepsy Behav 2006; 8:213-19.

360 ORIGINAL ARTICLE

Auditory risk behaviours and hearing problems among college students in Serbia

Milenko Budimčić1, Kristina Seke2, Slavica Krsmanović1, Ljubica Živić3

1Departement for Sanitary Ecology, High Medical School of Professional Studies, Belgrade, 2Department for Disease Control and Prevention, Institute of Public Health of Serbia “Dr Milan Jovanović Batut”, Belgrade, 3Department for Otorhinolaryngology, School of Medicine, University of Kragujevac, Kragujevac; Serbia

ABSTRACT

Aim To investigate an association of auditory lifestyle and risk behaviours with hearing loss and to identify the leading hearing problems among college students in Serbia exposed to loud music.

Methods The participants of the study comprised 780 college students of the High Medical School of Professional Studies of Bel- grade (653 females and 127 males), the majority of whom were between 19 to 24 years of age. A cross sectional study was conducted in order to investigate the association between exposure to noise in one’s leisure time and subsequent hearing problems using a self-reporting questionnaire. Corresponding author: Seke Kristina Results A total of 640 (82.1%) of students had a habit of listening to loud music, 421 (65.8%) experienced tinnitus and 79 (10.1%) Department for Disease Control and had a subjective feeling of hearing loss. The most significant asso- Prevention, Institute of Public Health of ciation between self-reported hearing loss was living in noisy en- Serbia “Dr Milan Jovanovic Batut” vironments (p=0.000), and the appearance of difficulties (vertigo, Dr. Subotića 5, 11000 Belgrade, Serbia anxiety) (p=0.000), as well as usage of personal music devices Phone: +381 69 889 3247; (p=0.087). Fax: +381 11 268 4140; Conclusion While students who were exposed to loud sound le- Email: [email protected] vels may still not have shown serious hearing problems or hearing loss, a great number did experience tinnitus or some other difficulties after listening to music at loud volumes.

Key words: young people, loud music, life style, hearing loss.

Original submission: 02 December 2013; Revised submission: 20 December 2014; Accepted: 20 February 2014.

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INTRODUCTION urs among college students in Serbia, which are frequently related to hearing problems. Noise has become a growing environmental problem in today’s western society and has an im- EXAMINEES AND METHODS portant role to play in the development of general hearing health problems (1). Noise-induced hea- A cross-sectional study was conducted on 780 ring loss represents the most frequently occurring students of the High Medical School of Profe- preventable disability and can be caused by occu- ssional Studies of Belgrade during the six-month pational or recreational sources (2). Furthermore, period, from October to December 2012. A self- hearing loss is the most frequently recorded com- reporting questionnaire was created to target co- munication handicap, restricting several aspects llege students who had auditory risk behaviour in one’s quality of life (3). associated with such health issues, in accordance with those used in similar studies (1,6). The Many leisure activities may prove risky or dan- survey was designed to address key demographic gerous to one’s hearing: visiting dance clubs, data (sex, age group, living environment), and to using personal listening devices (MP3 or other subsequently address lifestyle and auditory risk media players), and attending concerts, among behaviours (exposure to high level music, frequ- others (1). Young people are particularly likely ent use of personal devices, visiting disco clubs to expose themselves to potentially damaging and other high volume music environments), as loud sounds. A number of studies have been re- well as hearing problems (tinnitus after listening cently published on the auditory effects of music to music at high volumes, hearing loss and ot- exposure at dance clubs and rock concerts (4-7). her difficulties-vertigo, anxiety) among students. Moreover, with the massive and widespread rise Questions were related to the habit of smoking in the popularity of portable MP3 players, ex- and consuming alcoholic drinks, occasionally or posure to high sound levels has also increased on a daily basis (11,12) and practicing any kind dramatically (8). Several studies have reported of sports activities (13,14) referred to as “yes” increasing numbers of adolescents and young or “no”. The respondents group comprised both adults suffering from symptoms such as distorti- male, 127 (16.3%) and female college students, on, tinnitus, hyperacusis, or other threshold shifts 653 (83.7%), mean age 22.74±4.52 years. The di- (2,6,9,10). Some studies have considered expo- rector of the High Medical School of Professio- sure to harmfully loud sounds through personal nal Studies of Belgrade gave the written approval music systems or other leisure activities to be li- for this research. kely associated with a lack of knowledge about the potential harmful effects of the exposure to Descriptive statistics was used with a purpose of excessively loud sounds (6). prevalence determination. In addition, different parameters were compared by exploratory anal- Hearing loss among young people caused by ysis. The cross tabulation method and χ2-square recreational sources represents a significant pu- test were used to examine the relation between blic health issue. Many previous studies (1-10) qualitative variables. Fisher’s exact test was used have been published, but there was no research to examine the significance of the association about life styles and hearing issues among co- (contingency) between the two kinds of classi- llege students in Serbia. This study was made fication. The strength of presence or absence to investigate the auditory risk behaviours and of an event in a given population was quantifi- hearing issues among young people. The data ed by the Odds Ratio (OR) and Relative Risk of this research may be relevant for the resear- (RR) was used as the ratio of the probability of ches in the future and to public health experts an event occurring in an exposed group. Multi- and health policy creators as well, in order to variate binary logistic regression analysis (Met- keep up to date with current research and to hod Forward Stepwise Conditional) was used to create adequate health policy and programs re- predict a binary response from independent pre- lated to this issue. dictors. The level of statistical significance was In this regard, the objective of the study was to defined as p<0.05. label the non-healthy life style and risk behavio-

362 Budimčić et al. Auditory risk behaviours among students

RESULTS Table 2. Self-reported hearing issues Number (%) of Hearing issues The majority of respondents, 499 (64.0%) grew respondents up in a noisy environment and at the time of the Ear ringing after listening to music at a 421 (65.8) research lived in a noisy environment. Six hundred high volumes and ninety three (88.8%) lived in an urban area, Duration of ringing: 1-2 hours 106 (25.2) and conversely, only 87 (11.2%) of the partici- One day 11 (2.6) pants lived in a rural area. A total number of 297 Several days 1 (0.2) (38.1%) students, from both groups, were of the Ceases quickly 303 (72.0) Other difficulties (vertigo, anxiety, reducti- 33 (6.1) opinion that they lived in a noisy neighbourhood. on of attention span, bad memory) A total number of 640 (82.1%) students wilfully Hearing loss 79 (10.1) exposed themselves to potentially harmful, loud music, and 204 (26.2%) respondents reported ha- ces once a week, 337 (83.6%), while 64 (15.9%) bitual use of personal listening devices. Majori- students went to such places 2-3 times a week ty of students, 488 (80.4%) visited disco clubs and only two (0.5%) of them did so daily. This is and other places that offer loud music at least comparable with those students, 27 (93.1%), who once a week, where 284 (46.7%) of them usually reported other difficulties in addition to tinnitus spent 2-3 hours. In such noisy environments, 154 and visit to noisy places one per week. (25.3%) students spent over 3 hours (Table 1). However, 16 (48.5%) students who suffered from Table 1. Lifestyle and auditory risk factors of students some other hearing problems in addition to tinni- Number (%) of Life style and auditory risk factors tus habitually listened to music with personal li- respondents stening devices (p=0.087). Moreover, 29 (87.9%) Exposure to high level music 640 (82.1) Frequent use of personal media devices 204 (26.2) students who suffered from hearing problems in Visiting disco clubs and other high volume 609 (78.1) addition to tinnitus had visited disco clubs and music environments concerts, and 13 (44.8%) of whom spent over Time spent at places that offer loud music: 1-2 hours 170 (28.0) three hours there (p=0.000), when visiting such 2-3 hours 284 (46.7) noisy environments. More than 3 hours 154 (25.3) Frequency of visiting clubs and other places The most significant association between self- with high volume music: reported hearing loss among college students Once a week 488 (80.4) was found to be living in noisy environments 2-3 times a week 115 (18.9) (p=0.000) and the appearance of difficulties such Every day 4 (0.7) Smoking 261 (33.5) as vertigo, anxiety, reduction of one’s attention Alcohol consumption 312 (40.0) span and bad memory (p=0.000) and use of per- Sports activities 185 (23.7) sonal music devices (p=0.087) as well. Previous head injuries 60 (7.7) Previous ear disease 76 (9.7) The majority of students, 24 (75.0%), who experienced other difficulties in addition to tinnitus were For majority of cases who reported tinnitus, 303 19–24 years of age. Students older than 30 years (72.0%), it ceased quickly. In 106 (25.2%) cases of age, 59 (7.6%), were visiting disco clubs signi- tinnitus was reported to last for 1-2 hours, while ficantly less (p<0.001) than their colleagues in the in 11 (2.6%) respondents it was reported to last age up to 30 years. Furthermore, they listened to one day. In addition to tinnitus, 33 (6.1%) stu- loud music significantly less than their younger dents experienced some other difficulties, such as colleagues (p<0.001) and were using significantly vertigo, anxiety, reduced attention span and bad less some personal media devices (p=0.001). memory. From all students who were participants in this survey, 79 (10.1%) reported subjective The Mantel-Haenszel Common Odds Ratio Esti- feeling of hearing loss (Table 2). mation was determined as OR=6.0 (p=0.000) and the Relative Risk for hearing loss, if additional The prevalence of self-reported hearing loss hearing difficulties had already been experien- among students who lived in noisy environments ced, was RR=4.9 (95% CI 2.5 – 9.5). This sen- was 45 (57.0%) (p=0.000). Significantly more stu- sitivity is found to decrease with age (Figure 1) dents with self-reported tinnitus visited noisy pla- (p=0.018).

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of studies have indicated the increase in the number of young people who suffer from symptoms of hearing impairment (10-13, 18-20). For example, Chung and others have shown that 61% of young people who attend concerts or visit clubs or parties that feature loud music reported experi- encing tinnitus or temporary hearing impairment (6), which is comparable with our results, where 65.8% of students commonly report tinnitus. Si- milar results were obtained in the second MTV survey, involving 2500 young adults, mean age 21.7 years, where the most experienced (77%) ear problem was tinnitus (16). In another survey, approximately 89.5% of the students had experienced transient tinnitus after loud music exposure (17). However, according to our results, significantly more students with self-reported tinnitus visit noisy places once a week (83.6%) and this Figure 1. Other difficulties (vertigo, anxiety, reduction of atten- situation could be an indication that individuals tion span, bad memory) after exposing to high volume music in relationship with age groups who suffer from certain hearing problems try to avoid places that feature loud music. In 72.0% of According to the results of the Multivariate Bi- cases, tinnitus ceases quickly, in 25.2% of cases nary Logistic Regression Analysis the following it lasts 1-2 hours and in just 2.6% of cases it lasts variables for category of the subjective sensation one day. Slightly different results were presented of hearing loss were found to be most influen- by Holmes and others (19), where 13.5% of res- tial: exposure to high level music (OR=28.76; pondents reported prolonged tinnitus. p=0.000), visiting disco clubs and other high vo- With the massive growth in popularity of port- lume music environments (OR=3.364; p=0.026), able MP3 players, exposure to high noise levels previous ear disease (OR=5.94; p=0.000) and has increased dramatically, and millions of young living in noisy environments (OR=3.263; people are potentially putting themselves at risk p=0.000). Nagelkerke R square for presented for permanent hearing loss every time they listen analyses was 0.430. A confusion matrix (15), to their favourite music (21). It has been found by done by Multivariate Binary Logistic Regression Vogel et al that the greater general risk of some Analysis, which contains information about actu- hearing problems occur in young people who use al and predicted classification, was 721 (92.4%). personal listening devices (MP3/Media players), more than in young people who visit dance clubs DISCUSSION or attend rock concerts (8). Vogel also noted that Music-induced hearing loss is a preventable pu- the prevention of personal media player induced blic health issue that has gained more importan- hearing loss should be managed through health ce as a health concern in recent years, because protection measures, and making manufacturers of episodic acoustic trauma exposure at public of personal listening devices and governmental concerts and clubs and extended private exposu- authorities equally responsible for the preven- re from the widespread usage of personal MP3 tion of hearing loss among young people as they players (16). Adolescents and young adults are themselves and their parents are. Nevertheless, often exposed to potentially damaging loud mu- our results indicate that 26.2% of respondents use sic during leisure activities (17). The growing ex- some of personal listening devices and 48.5% of posure of young people to environmental noise them suffer from tinnitus, or some other hearing and loud music has generated interest in studies problems. Further, McNeill and others evaluated on the impact of such exposure, as well as the a potential risk to hearing associated with the measures taken in these situations (1). A majority use of portable digital audio players. Significant

364 Budimčić et al. Auditory risk behaviours among students

differences in MP3 user listening patterns were warning prompts or a modeling technique (23). found between respondents who had experienced Intention to wear earplugs increased when young tinnitus and those who had not (22). people were made aware of the potential for per- This study has shown that a majority of college manent hearing loss when encouraged by medi- students was exposed to high sound levels du- cal professionals (6,24), and when earplugs were ring their usual leisure activities and that more provided free at the door of disco clubs (9,25). than half of them have reported to suffer from Some other authors concluded that young people tinnitus. Furthermore, the presented results indi- considered hearing loss to be an important health cate that younger individuals who are exposed to concern when they had received education about high sound levels during their leisure activities, such loss (6). including the use of personal stereo systems or In conclusion, in order to prevent music-induced media devices and visiting disco clubs, do not hearing loss in youth, awareness into determi- suffer from serious hearing problems or hearing nants and further theory-based research on the loss, except tinnitus and some other difficulties. association of young people’s hearing protection Also, our results indicate that the most important behavior during their leisure activities is needed. risk factors associated with self-reported hearing As visits to disco clubs proved to be among the problems among college students were living in significant risk behaviours, the need for sound noisy environment, visiting disco clubs and other level limitations in disco clubs and similar envi- high volume music environments, frequent use of ronments is emphasized. In addition, in order to personal media devices and spending over three achieve long lasting behavioral changes in ado- hours at places that offer loud music. lescents’ listening habits, preventive strategies Moreover, it has to be noted, according to previ- must be considered at more levels than just at the ous research, that the analysis indicated a signifi- individual and modifiable risk factors need to be cant correlation between perceived hearing loss addressed. Certain screening activities associated and respondent’s overall attitudes towards noise to risk of hearing loss, which would be included exposure (19). According to all presented above, in systematic physical examination of college introducing adequate preventive programs relat- students, should be proposed. ed to hearing problems among college students FUNDING in Serbia is needed. Some of potential preventive measures and strategies have already been No specific funding was received for this study proposed by some other authors in previous research and could be applicable in this situation as TRANSPARENCY DECLARATION well. For example, the volume of portable music The authors declare no conflict of interest to be players could be reduced effectively with visual present in this study.

REFERENCES 5. Vogel I, Brug J, Van der Ploeg CPB, Raat H. Preven- tion of adolescent’s music-induced hearing loss due 1. Fontana Zocoli AM, Catalani Morata T, Mendes to discotheque attendance: a Delphi study. Health Marques J. Youth Attitude to Noise Scale (YANS) Educ Res 2009; 24:1043-50. questionnaire adaptation into Brazilian Portugese. 6. Chung JH, Des Roches CM, Meunier J, Eavey RD. Braz J Otorhinolaryngol 2009; 75:485-92. Evaluation of noise-induced hearing loss in young 2. Shab A, Gopal B, Reis J, Novak M. Hear today, gone people using a web-based survey technique. Pedia- tomorrow: An assessment of portable entertainment trics 2005; 115:861-7. player use and hearing acuity in a community sam- 7. Folmer RL. Noise-Induced Hearing Loss in Young ple. J Am Board Fam Med 2009; 22:17-23. People. Pediatrics 2006; 117: 248-9. 3. Tsakiropoulou E, Konstantinidis I, Vital I, Kon- 8. Vogel I, Brug J, Hosli EJ, Van der Ploeg CPB, Raat stantindou S, Kotsani A. Hearing aids: Quality of H. MP3 players and hearing loss: adolescents’ per- life and socio-economic aspects. Hippokratia 2007; ceptions of loud music and hearing conversation. J 11:183-6. Pediatr 2008; 152:400-4. 4. Rawool VW, Colligon-Wayne LA. Auditory life- 9. Crandell C, Mills TL, Gauthier R. Knowledge, be- styles and beliefs related to hearing loss among haviors, and attitudes about hearing loss and hearing college students in the USA. Noise Health 2008; protection among racial/ethnically diverse young 10:1-10. adults. J Natl Med Assoc 2004; 96:176-86.

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10. Vogel I, Brug J, Van der Ploeg CPB and Raat H. 17. Gilles A, De Ridder D, Van Hal G, Wouters K, Klei- Strategies for the Prevention of MP3-Induced He- ne Punte A, Van de Heyning P. Prevalence of leisure aring Loss Among Adolescents: Expert Opinions noise-induced tinnitus and the attitude toward noise from a Delphi Study. Pediatrics 2009; 123:1257-62. in university students. Otol Neurotol 2012; 33:899- 11. Paavola M, Vartiainen E, Puska P. Smoking cessa- 906. tion between teenage years and adulthood. Health 18. Landälv D, Malmstörm M, Widén SE. Adolescent’s Educ Res 2001; 16:49-57. reported hearing symptoms and attitudes toward 12. U.S. Preventive Services Task Force. Screening and loud music. Noise Health 2013; 15:347-54. Behavioral Counseling Interventions in Primary 19. Holmes AE, Widén SE, Erlandsson S, Carver CL, Care to Reduce Alcohol Misuse: Recommendation White LL. Perceived hearing status and attitudes Statement. AHRQ Publication No. 12-05171-EF-3. toward noise in young adults. Am J Audiol 2007; http://www.uspreventiveservicestaskforce.org/usp- 16:182-9. stf12/alcmisuse/alcmisuserfinalrs. (16. Novembar 20. Zhao F, Manchaiah VK, French D, Price SM. Music 2013). exposure and hearing disorders: an overview. Int J 13. Atanasković-Marković Z, Bjegović V, Jankovic S, Audiol 2010; 49:54-64. Kocev N, Laaser U, Marinković J, Marković-Denić 21. Kasper CA. The simple guide to optimum hearing Lj, Pejin-Stokić Lj, Penev G, Stanisavljević D, health for the mp3 generation. New York: Craig A. Šantrić-Milićević M, Šaulić A, Šipetić-Grujičić S, Kasper; 2006. Terzić-Šupić Z, Vlajinac H. The burden of disease 22. McNeill K, Keith SE, Feder K, Konkle AT, Michaud and injury in Serbia. Beograd: Ministry of health of DS. MP3 player listening habits of 17 to 23 year the Republic of Serbia, 2003. old university students. J Acoust Soc Am 2010; 14. Šipetić-Grujičić S, Terzić-Šupić Z, Nikolić Ž, Grdić 128:646-53. D, Bjekić M, Bjegović V, Ratkov I. Risk factors for 23. Ferrari JR, Chan LM. Interventions to reduce high- the development of arterial hypertension. Med Glas volume portable headsets: “turn down the sound!”. J (Zenica) 2014; 11:19-25. Appl Behav Anal 1991; 24:695–704. 15. Kohavi R, Provost F. On Applied Research in Mac- 24. Vogel I, Brug J, Van der Ploeg CP, Raat H. Young hine Learning. Mach Learn 1998; 30:271-4. people’s exposure to loud music: a summary of the 16. Quintanilla-Dieck M, Artunduaga MA, Eavey RD. literature. Am J Prev Med 2007; 33:124-33. Intentional exposure to loud music: the second 25. Bogoch II, House RA, Kudla I. Perceptions about MTV.com survey reveals an opportunity to educate. hearing protection and noise-induced hearing loss J Pediatr 2009; 155:550-55. of attendees of rock concerts. Can J Public Health 2005; 96:69–72.

Uticaj stila života na pojavu problema sa sluhom kod studenata u Srbiji Milenko Budimčić1, Kristina Seke2, Slavica Krsmanović1, Ljubica Živić3 1Odsek za sanitarnu ekologiju, Visoka medicinska škola strukovnih studija, Beograd; 2Centar za prevenciju i kontrolu bolesti, Institut za javno zdravlje Srbije ”Dr. Milan Jovanović Batut“, Beograd; 3Katedra za otorinolaringologiju, Medicinski fakultet, Univerzitet u Kragu- jevcu, Kragujevac; Srbija

SAŽETAK Cilj Ispitati vezu životnog stila i rizičnog ponašanja s gubitkom sluha, te odrediti vodeće probleme sa sluhom nakon slušanja glasne muzike, u populaciji studenata u Srbiji. Metode Istraživanjem je obuhvaćeno 780 studenata Visoke zdravstvene strukovne škole u Beogradu, 653 ženskog i 127 muškog pola, od kojih je većina pripadala starosnoj grupi od 19 do 24 godine. Studija preseka sprovedena je kako bi se istražila veza između neprofesionalnog izlaganja buci u svakodnevnim aktivnostima mladih i pojave problema sa sluhom, pomoću upitnika koji je dizajniran tako da bi se de- finisali studenti s rizičnim ponašanjem koji su imali problem sa sluhom. Rezultati Naviku slušanja glasne muzike imalo je 640 (82.1%) studenata. Prisutnost osećaja zujanja u ušima, nakon slušanja glasne muzike, zabilježena je kod 421 (65.8%) studenta, dok je 79 (10.1%) njih izjavilo da ima osećaj gubitka sluha. Za oštećenje sluha kao značajni su se pokazali sledeći parametri: življenje u bučnoj sredini (p=0.000), pojava subjektivnih tegoba kao što su nesvestica, napetost, smanjenje pažnje i slabije pamćenje (p=0.000), te korištenje personalnih muzičkih uređaja (p=0.087). Zaključak Iako se kod većine studenata koji slušaju glasnu muziku još uvek nisu mogli uočiti ozbiljni poremećaji ili gubitak sluha, većina njih, nakon izlaganja dejstvu glasne muzike, iskusila je zujanje u ušima ili neke druge subjektivne tegobe. Ključne reči: mladi, glasna muzika, životni stil, gubitak sluha

366 ORIGINAL ARTICLE

Association between high levels of stress and risky health behavior

Amira Kurspahić-Mujčić1, Feriha Hadžagić-Ćatibušić2, Suad Sivić3, Emina Hadžović4

1Department of Social Medicine, School of Medicine, 2Pediatric Clinic, Clinical Center, University of Sarajevo; Sarajevo; 3Public Health Institute of Zenica-Doboj Canton, Zenica, 4Primary Health Care Center Travnik, Travnik; Bosnia and Herzegovina

ABSTRACT

Aim To determine the amount of stress to which young and adult persons were exposed during the last twelve months and relationship between stress levels and risky health behavior.

Methods The study was conducted from November 2011 until January 2012 in the Sarajevo Canton. The study included 700 respondents divided into two groups: 350 young people aged 15- 27 years and 350 adults aged over 27 years. As an instrument for data collection a questionnaire was used to provide information on demographic characteristics of respondents and habits, as well as Holmes & Rahe stress scale to determine the level of stress.

Results The average value of the stress scale score was 302.56±149.75 for the total sample, 331.7±165.7 for youth and 273.5±125.6 for adults. Respondents from the group of young pe- Corresponding author: ople in the last twelve months had an average of 3.6 highly stre- Amira Kurspahić-Mujčić ssful events and 1.9 in the group of adults. In the group of young School of Medicine, people there were more respondents with inadequate nutrition University of Sarajevo (p=0.023) and more smokers (p=0.128). In the group of adults Čekaluša 90, 71000 Sarajevo, more people were overweight (p=0.001) and had reduced physi- Bosnia and Herzegovina cal activity (p=0.006). Both study groups had an equal number of respondents who consumed alcohol. People with high levels of Phone: +387 33 202 051; stress consumed alcohol significantly more (p=0.03) and smoked Fax: +387 33 202 051; (p=0.02) compared to those with low levels of stress. Email: [email protected] Conclusion The respondents of both groups were exposed to large amount of stress that was associated with smoking and alcohol consumption. There is a need to design appropriate strategies for coping with stress and their implementation in lifestyle.

Original submission: Key words: stressful life events, age, coping 20 March 2014; Accepted: 24 May 2014.

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INTRODUCTION persons were exposed during the last twelve months and relationship between stress levels Today, stress is defined as a physical or mental with risky health behavior. tension caused by factors which alter the existing balance of the body (1). Stress is conceptualized in EXAMINEES AND METHODS three ways (2). Firstly, stress is seen as an objective stimulus that triggers the response to stress. This prospective study was conducted between Stress occurs in those circumstances where there November 2011 and January 2012, in the local is a deviation from the optimal level of require- communities within the municipality of Novo Sa- ments (3). Secondly, stress is seen as a response of rajevo. The sample consisted of 700 respondents the body to a stimulus. Stress occurs in response to who were divided into two groups. The first group any stressful stimulus, regardless of its nature (2). consisted of 350 young people aged 15-27 years, Thirdly, stress is an interaction of a person and its and the second group consisted of 350 adults aged environment in a stressful situation. Stress occurs over 27 years. In order to conduct the study we in case of imbalance between knowledge about the obtained the approval of the Ethics Committee of existence of specific needs and knowledge about the School of Medicine, University of Sarajevo. the possibilities for satisfying those needs (4). Each respondent was provided with an informed consent for the participation in this study. Cardiologist Wolf in 1950 noticed that his patients, one year before the onset of the disease, had Respondents were selected randomly. Inclusion reported about more frequent stressful events (5). criteria for the study were habitual residence at Holmes and Rahe believed that every event that Novo Sarajevo municipality and the minimum caused a change and discontinuity in the life of age of fifteen years. The study did not include pe- people is stressful, because it leads towards the ople who live alone, have disabilities, recipients need to adapt. Trying to measure the intensity of of social welfare and people without completed experienced stress caused by major life events primary school. Holmes and Rahe have constructed a standardi- Respondents were asked to complete an zed list of stressful events called a Scale in order anonymous questionnaire containing questions to assess social adjustment (6). Even the initial related to age, gender, total number of years of applications of Holmes&Rahe stress scale esta- education, body weight, body height and habits blished association of major life events and the (smoking, alcohol consumption, physical activi- occurrence of physical disorders and diseases ty) and the Holmes & Rahe stress scale which (7-9). Holmes and Rahe considered that a period summarize the events in life that have occurred of two years after major stressful events is the in the last twelve months. period of greatest risk, or the period in which the The completed questionnaire of respondents was tendency for occurrence of stress-related illness collected through an opening in a special box de- is significantly increased influenced by adaptive signed for this study. efforts that are being made by an individual in Smokers are considered to be persons who daily order to adjust to life changes that occurred (6). smoke more than ten cigarettes a day (17). Exce- Conducted studies have found that exposure to ssive alcohol consumption was considered if a stressful events leads to changes in health behavi- person drank more than five glasses of beer/two or (10,11). As a way of coping with stress and ac- glasses of wine/ three small glasses of brandy) hieving relaxation some persons consume alcohol, per week (18). Decreased physical activity enta- smoke cigarettes, while others turn to excessive iled less than 150 minutes of moderate physical food intake, thereby increasing the risk of obesity, activity or 75 minutes of intense physical activi- cardiovascular diseases and diabetes (12-15). ty or an equivalent combination of both types of Measurement of exposure to stress helps its activity per week (19). Persons with Body Mass better management, so ultimately better health Index equal to or over than 25 kg/m2 were consi- and positive health behavior (16). dered as overweight (20). Therefore, the aim of the study was to determine The statistical analysis of data included descrip- the amount of stress to which young and adult tive methods (relative numbers, standard error,

368 Kurspahić-Mujčić et al. Stress and health-compromising behavior

standard deviation, mean) and inferential stati- higher number of low stressful events (5-25 po- stics (chi-square test). A p value below 0.05 was ints). Between the groups there was no statisti- considered statistically significant cally significant difference in the number of moderately stressful events (30-55 points) (Table 2). RESULTS The analysis of the number of respondents with In both study groups, of young and adult persons, risky health behavior shows that in the group of women were slightly more represented. In the young people there were significantly more res- group of young people there were 193 (55.1%) pondents with inadequate nutrition (p=0.023) females, 177 (50.6%) in the group of adults. and more smokers, but not with significant dif- (p=0.128). ference (p=0.128). In the group of adults there In the group of young people average age was were significantly more respondents who were 22.1 years (SD±2.3), the youngest respondent overweight (p=0.001) and with reduced physical was 15 and the oldest 27 years. In the group of activity (p=0.006). In both study groups there adults average age was 48.2 years (SD±11.3), the was an equal number and percentage of respon- youngest respondent was 28 years old and the ol- dents who consumed alcohol (Figure 1). dest 84 years. Analysis of results on scale of recent stress shows that the mean score was 302.56±149.75 for the total sample, 331.7±165.7 for the group of young people and 273.5±125.6 for adult respondents. Statistical analysis showed that between the two groups a statistically significant difference was observed in the average score on the stress scale (p=0.000). Respondents from the group of young people had significantly higher values at the scale of recent stress compared to those from the group Figure 1. Number of respondents with risky health behaviors in the group of young people and the group of adults of adults (Table 1). The analysis by Pearson’s coefficients of line- Table 1. Mean value of stress scale score in the group of young people and the group of adults ar correlation showed a significant correlation Number of Standard Standard Mini- Maxi- between the scale of recent stress with tobacco Group Mean respondents deviation error mum mum smoking (p=0.02) and alcohol consumption Young 350 331.65 165.66 8.85 40 1005 (p=0.03). Significant correlation between the Adults 350 273.47 125.60 6.71 60 930 Total 700 302.56 149.75 5.66 40 1005 value of the stress scale score and overweight (p=0.51), inadequate nutrition (p=12.24) and re- The analysis of the number of stressful events duced physical activity (p=0.52) was not found. in specific score categories per person, which occurred during the last year, shows that the res- DISCUSSION pondents from the group of young people had a statistically significantly higher number of highly The goal of the study was to determine the stressful events (60-100 points), while respon- amount of stress to which young persons and dents from the group of adults had a significantly adults were exposed during the last twelve

Table 2. Number of stressful events, certain score categories by respondents in the group of young people and the group of adults Number of events categories (points) Group No Mean Standard deviation Standard error Min. Max. F p Young 350 3.60 2.162 0.116 0 13 60-100 Adults 350 1.91 1.393 0.074 0 7 150.299 0.000 Total 700 2.76 2.004 0.076 0 13 Young 350 3.61 2.296 0.123 0 14 30-55 Adults 350 3.60 2.099 0.112 0 13 0.003 0.959 Total 700 3.61 2.198 0.083 0 14 Young 350 3.58 2.257 0.121 0 11 5-25 Adults 349 4.11 2.350 0.126 0 13 9.211 0.002 Total 699 3.84 2.317 0.088 0 13 No, Number of respondents; Min., Minimum range; Max, Maximum range

369 Medicinski Glasnik, Volume 11, Number 2, July 2014

months with a Holmes & Rahe stress scale and excessive food intake and reduce their physical relationship between stress levels and risky he- activity, besides the fact that it has been proven alth behavior. The results of the study showed that this way of coping with stress breaks the na- a very high average value of the score on the tural anti-stress mechanisms and does not lead to stress scale of respondents from the group of reduction of stress, but creates addiction (28). young people (331.7±165.7 points). According Significant association of high levels of stress to the results of other studies on young peo- and alcohol consumption was found in a study ple, students are particularly exposed to a large conducted in the Netherlands on a sample from amount of stress (12,21,22). A study conducted the general population that included 2714 su- among students of public and private schools bjects aged 15-74 years (29). A study conducted in India found the average value in the range in India has shown that an increase in the level 404.5-458.7 points (23). The average value of stress leads to greater alcohol consumption, of the recent stress scale score in the group of and that in the same manner, the reduction in the adults in our study was 273.5±125.6 points, or level of stress leads to the reduction of alcohol it was at medium high level. Adults were ex- consumption (26). posed to the same amount of stress as health The results of our study showed a significant professionals in a study carried out in India association of high levels of stress with smo- (24). Stress levels of adult respondents were at king and alcohol consumption. Smoking was the same level of stress as in persons in highly more frequent among respondents in the group stressful occupations (25). of young people, who also have higher average Given the score values obtained by Holmes & value of stress score compared to those from the Rahe stress scale it can be concluded that the risk group of adults. Exposure to stressful events in of stress-related diseases occurrence in the near their youth may be the reason for the beginning future for respondents in the group of young pe- of excessive alcohol drinking and smoking, whi- ople is high or very high, and for the respondents ch is shown in a study conducted among 1,074 in the group of adults medium to high (6). students in Los Angeles (30). In the past twelve months the respondents from Although a significant number of studies con- both groups had a number of events that did not ducted around the world found a connection happen every day and which were by nature ge- between risky health behaviors and stress le- nerally unchangeable. Thr number of such stre- vels, in Bosnia and Herzegovina similar study ssful events of different score categories by the has not been conducted, despite the additional respondent in the study ranged from 1.9 to 4.1, fact that in the Federation of Bosnia and Herze- which is considerably higher when compared to govina, prevalence of smoking among adults is the results of studies conducted in the United Sta- 37.6%, 14.3% among young people, while 29.5 tes where the number of stressful events per res- % of the adult population consume alcohol and pondent was 1.79±2.10 (26). In the structure of 21.5% are overweight (31). stressful events among respondents in the group In conclusion, the study found that the respon- of young persons it significantly more represen- dents of both groups were exposed to a large ted high score events that require great effort of amount of stress that was associated with smo- the individual to adapt to a new situation. Events king and alcohol consumption. The obtained re- which represent easier life changes were signifi- sults are appealing and suggest the need to design cantly more represented among the respondents intervention programs with alternative techniqu- from the group of adults. es to reduce stress such as muscle relaxation, me- Some longitudinal studies have shown that ex- ditation, physical activity and their incorporation posure to a large amount of stressful experiences into lifestyle in order to reduce the use of alcohol is a predictor of risky health behaviors (27). A and smoking as a way of coping with stress. study conducted among medical doctors, which Given that the respondents from the group of registered a high level of stress, has determined young people had an extremely high value of that physicians, as a way to reduce the negative stress scale score, there is a need to conduct effects of stress, used to smoke, use alcohol, have

370 Kurspahić-Mujčić et al. Stress and health-compromising behavior

similar research, which will be focused on stu- FUNDING dents as a risk group in which high levels of No funding was received for this study. stress can have negative implications on the emotional and health status and later on their TRANSPARENCY DECLARATION professional career. Competing interests: None to declare.

REFERENCES 1. Bishopric NH. The virtue of just enough stress: a 17. Delnevo CD, Lewis MJ, Kaufman I, Abatemar- molecular model. Trans Am Clin Climatol Assoc co DJ. Defining cigarette smoking status in young 2012; 123:175-91. adults: a comparison of adolescent vs adult measu- 2. Salleh MR. Life event, stress and illness. Malays J res. Am J Health Behav 2004; 28:374–80. Med Sci 2008; 15:9–18. 18. World Health Organisation. Global status report on 3. Ursin H, Eriksen HR. The cognitive activation the- alcohol and health. Geneva: WHO, 2011. ory of stress. Psychoneuroendocrinology 2004; 19. World Health Organisation. Global recommendation 29:567-92. on physical activity for health. Geneva: WHO, 2010. 4. Schneiderman N, Ironson G, Siegel SD. Stress and 20. World Health Organisation. Obesity: preventing and health: psychological, behavioral and biological de- managing the global epidemic. WHO Technical Re- terminants. Annu Rew Psychol 2005; 1:607-28. port Series 894. Geneva: WHO, 2000. 5. Harmon DK, Masuda M, Holmes TH. The social 21. Uraz A, Tocak YS, Yozgatigl C, Cetiner S, Bal B. readjustment rating scale: a cross-cultural study of Psychological well-being, health and stress sour- Western Europeans and Americans. J Psychosom ces in Turkish dental students. J Dent Educ 2013; Res 1970; 14:391-400. 77:1345-55. 6. Holmes TH, Rahe RH. The social readjustment ra- 22. Yusoff MS, Abdul Rahim AF, Yacob MJ. Preva- ting scale. J Psychosom Res 1967; 11:213–8. lence of sources of stress among University Sains 7. Rod NH, Kristensen TS, Lange P, Prescotti E, Di- Malaysia medical students. Malays J Med 2010; derichsen F. Perceived stress and risk of adult-onset 17:30-7. asthma and other atopic disorders: a longitudinal co- 23. Augustine LF, Vazir S, Rao SE, Rao MV, Lammah hort study. Alergy 2012; 671:1408-14. A, Nar KM. Perceived stress, life events& coping 8. Plytycz B, Seljelid R. Stress and immunity: mini re- among higher secondary students of Hyderabad, In- view. Folia Biol 2002; 50:180-9. dia: a pilot study. Indian J Med 2011; 134:61-8. 9. Chi JS, Kloner RA. Stress and myocardial infarcti- 24. Mishra B, Mehta S, Sinha ND, Shukla SK, Ahmed on. Heart 2003; 89:475-6. N, Kawatra A. Evaluation of work place stress in 10. Barros MV, Nahas MV. Health risk behaviors, health health university workers: a study from rural India. status and stress perception among industrial wor- Indian J Community Med 2011; 36:39-44. kers. Rew Saude Pubica 2001; 35:554-63. 25. McManus IC, Winder BC, Gordon D. The causal 11. Rod NH, Granbaeck M, Schnobe P, Prescotti E, links between stress and burnout in a longitudinal Kristensen TS. Perceived stress as a risk factor for study of UK doctors. Lancet 2002; 359:2089–90. changes in health behavior and cardiac risk profile: a 26. Dawson DA, Grant BF, Ruan WJ. The association longitudinal study. J Intern Med 2009; 266:467-75. between stress and drinking: modifying effects of 12. Tavolacci MP, Ladner J, Grigioni S, Richard L, Vi- gender and vulnerability. Alcohol 2005; 40:453-60. llet H, Dechelotte P. Prevalence and association of 27. Steptoe A, Warde J, Pollard TM, Canaan L, Davies perceived stress, substance use and behavioral ad- GJ. Stress, social support and health-related beha- dictions: a cross-sectional study among university viour: a study os smoking, alcohol consumption and students in France 2009-2011. BMC Public Health physical exercise. J Psychosom Res 1996; 41:171-80. 2013; 13:724-30. 28. Kouvonen A, Heponiemi T, Vänskä J, Halila H, Si- 13. Veenstra MY, Lemmens PH, Friesema IH, Garret- nervo T, Kivimäki M, Elovainio M. Effects of acti- seni HF, Knotiner J, Zwietering PJ. A literature ve on-call hours on physicians’ turnover intentions overview of the relationship between life-events and and well-being. Scand J Work Environ Health 2008; alcohol use in the general population. Alcohol 2006; 34:356–63. 41:455-63. 29. San José B, Van Oers HAM, Van de Mheen HD, 14. Goldstein BI, Abela JR, Buchanan GM, Seligman Garretsen HFL, Mackenbach JP. Stressors and alco- ME. Attributional style and life events: a diathesis- hol consumption. Alcohol Alcohol 2000; 35:307– stress theory of alcohol consumption. Psychol Rep 12. 2000; 87:949-55. 30. Booker CL, Gallaher P, Unger JB, Ritt-Olson A, 15. Nichter M, Nichter M, Carkoglu A. Reconsidering Johnson CA. Stressful life events, smoking behavi- stress and smoking: a qualitative study among colle- or, and intentions to smoke among and multiethnic ge students. Tab Control 2007; 16:211-4. sample of sixth graders. Ethn Health 2004; 9:369-97. 16. McEwen BS. Physiology and neurobiology of stress 31. Zdravstveno stanje stanovništva i zdravstvena zašti- and adaptation: central role of the brain. Physiol Rev ta u Federaciji Bosne i Hercegovine 2011. godine. 2007; 87:873–904. Sarajevo: Zavod za javno zdravstvo FBiH, 2012.

371 Medicinski Glasnik, Volume 11, Number 2, July 2014

Udruženost visokog nivoa stresa i rizičnog zdravstvenog ponašanja

Amira Kurspahić-Mujčić1, Feriha Hadžagić Ćatibušić2, Suad Sivić3, Emina Hadžović4

1Katedra za socijalnu medicinu, Medicinski fakultet, 2Pedijatrijska klinika, Klinički centar; Univerzitet u Sarajevu, Sarajevo; 3Kantonalni zavod za javno zdravstvo Zenica, Zenica; 4Dom zdravlja Travnik, Travnik; Bosna i Hercegovina SAŽETAK

Cilj Odrediti količinu stresa kojoj su bile izložene mlade i odrasle osobe u posljednjih dvanaest mjeseci, te povezanost nivoa stresa s rizičnim zdravstvenim ponašanjem.

Metode Studija je provedena u periodu od novembra 2011. do januara 2012. godine na području kantona Sarajevo. U studiju je bilo uključeno 700 ispitanika podijeljenih u dvije grupe – 350 mladih osoba, starosti od 15 do 27 godina, te 350 odraslih osoba starijih od 27 godina. Korišten je anketni upitnik kojim su dobiveni podaci o demografskim karakteristikama ispitanika i njihovim navikama, te Holmes- Raheova skala stresa za određivanje nivoa stresa.

Rezultati Prosječna vrijednost skora skale stresa iznosila je 302.56±149.75 za ukupni uzorak, 331.7±165.7 za mlade i 273.5±125.6 za odrasle ispitanike. Ispitanici iz grupe mladih osoba, u posljednjih dvanaest mjeseci, imali su u prosjeku 3.6, a iz grupe odraslih osoba 1.9 visokostresnih događaja. U grupi mladih osoba bilo je više onih s neadekvatnom ishranom (p=0.023) i više pušača (p=0.128). U grupi odraslih osoba bilo je više ispitanika s prekomjernom tjelesnom težinom (p=0.001) i smanjenom fizičkom aktivnošću (p=0.006). U obje ispitivane grupe bio je podjednak broj osoba koje su konzumirale alkohol. Osobe s visokim nivoom stresa su signifikantno više konzumirale alkohol (p=0.03) i pušile (p=0.02) u odnosu na osobe s niskim nivoom stresa.

Zaključak Ispitanici obje grupe bili su izloženi velikoj količini stresa što je bilo udruženo s pušenjem i konzumiranjem alkohola. Nameće se potreba osmišljavanja primjerenih strategija suočavanja sa stre- som i primjene tih strategija u životnom stilu.

Ključne riječi: stresni događaji, životna dob, suočavanje

372 ORIGINAL ARTICLE

Association between somatic diseases and symptoms of depression and anxiety among Belgrade University students

Mirjana Stojanović-Tasić1, Anita Grgurević2, Jovana Cvetković1, Uglješa Grgurević3, Goran Trajković4

1Clinic for Neuropsychiatry, School of Medicine, University of Priština/Kosovska Mitrovica, 2Institute of Epidemiology, School of Medi- cine, University of Belgrade, 3Clinic for Otorhinolaryngology, Military Medical Academy, Belgrade, 4Institute of Medical Statistics and Informatics, School of Medicine, University of Belgrade; Serbia

ABSTRACT

Aim To investigate the relationship between somatic health problems and comorbid condition of anxiety and depression.

Methods The cross-sectional study in a population of 2,000 students of the Belgrade University (four schools: Medicine, Geo- graphy, Economics, Electrical Engineering) during the period April - June 2010 was conducted. The students were randomly selected. The main instrument for data collection was a standardized epidemiological questionnaire, designed at the Institute of Epidemiology, School of Medicine in Belgrade.

Results According to the Hamilton Depression Scale (HAMD), correlation was found between the following somatic diseases and Corresponding author: depression: diabetes (p=0.003), hypertension (p=0.007), heart disease (p=0.001), chronic bronchitis (p=0.033), neurological disea- Mirjana Stojanović-Tasić ses (p=0.013), and gastric or duodenal ulcer (p=0.003). According Clinic for Neuropsychiatry, to the Hamilton Anxiety Scale (HAMA) a correlation was found School of Medicine, University of Priština/ between the following somatic diseases and anxiety: diabetes Kosovska Mitrovica Anri Dinana bb, (p=0.020), hypertension (p<0.001), heart disease (p=0.000), chro- Priština/Kosovska Mitrovica, Srbija nic bronchitis (p=0.037), bronchial asthma (p=0.049), gastric or Phone/Fax: +38128498298; duodenal ulcer (p=0.003). E-mail: [email protected] Conclusion Depression and anxiety are common in persons with somatic diseases and have a significant association with physical health. This has considerable implications for somatic diseases management and clinical guidelines.

Key words: mental condition, chronic illness, comorbidity

Original submission: 18 June 2014; Revised submission: 05 July 2014; Accepted: 09 July 2014.

Med Glas (Zenica) 2014; 11(2):373-378

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INTRODUCTION and comorbid condition of anxiety and depression in Belgrade University student’s population. Chronic illness can lead to anxiety and depression. Approximately one fourth of adults in the United EXAMINEES AND METHODS States have a mental illness, and nearly half will develop at least one mental illness during their li- The cross-sectional study was conducted in a popu- fetime (1-3). The most common mental illnesses in lation of 2,000 students of the Belgrade University. adults are anxiety and mood disorders (1). Anxiety Four schools (Medicine, Geography, Economics, and depression simultaneously are more frequent Electrical Engineering) from which the students associated with physical morbidity than anxiety or participating in this research were randomly se- depression alone (4). Findings indicate that age and lected (by computer listing), were included in the gender of the adolescent and duration of illness did study conducted in the period April - June 2010. not affect the depression score, but type of illness From each of the schools an equal number of stu- affected it significantly (5). Depression and gene- dents per academic year was examined, and they ralized anxiety disorder were the most globally received practical training on a test day. The main disabling psychiatric disorders (6). Results of pre- instrument for data collection was a standardized vious studies have shown that in clinical practice, epidemiological questionnaire, designed at the treatment of depression and anxiety is far from op- Institute of Epidemiology, School of Medicine in timal as these symptoms are frequently overlooked Belgrade and it has been used in similar studies. and undertreated (7). Mental disorders were consi- The questionnaire included questions related to de- stently reported to be more disabling than physical mographics (gender, age, faculty and year of study, disorders and the degree of disability increased as place of residence), social characteristics (educati- the number of comorbid disorders increased. De- on and occupation of parents, social status) and be- pression, in particular, was rated consistently hi- havioral characteristics (reasons for starting prac- gher across all domains than all physical disorders. tizing this habit, attitudes related to knowledge of Despite high rates of mental disorders and associa- its harmfulness). A special part of the questionnaire ted disability they are less likely to be treated than included questions about diagnosed somatic dise- physical disorders (6). Similarly, other studies have ases. For the evaluation of depression and anxiety found higher prevalence rates for many psychiatric the Hamilton Rating Scale for evaluation of depre- than physical disorders (8). In a Norwegian survey ssion (HAMD) and Hamilton Anxiety Rating Sca- involving general population, about one-third of le (HAMA) were used. Participation was voluntary individuals reporting somatic health problems also and anonymous. The Institutional Review Board have anxiety disorder and/or depression. Some au- approved the study. Informed consent forms were thors have pointed out that comorbid anxiety disor- signed by all students who agreed to participate. der and depression are found to be more strongly Statistical analysis was performed using descrip- associated with somatic health problems than pure tive statistics and Chi-square test and Student anxiety disorder and pure depression (9). t-test to test group differences. For testing associ- The relationship between somatic health problems ation between variables the Spearman rank corre- and comorbid condition of anxiety and depression lation coefficient was calculated. has been given little attention in the literature, espe- RESULTS cially among university students (9). Only a small number of studies have shown that prevalence ra- Data were collected from 2,000 students of Uni- tes of mental disorders are higher in patients with versity of Belgrade, 860 (43%) males and 1,140 chronic somatic diseases than in a physically heal- (57%) females. The average age of the partici- thy person (10). Having in mind the university stu- pants was 21.5 years. From each of the schools dents are exposed to stress, overwork and fatigue, an equal number of students (500) per academic and that students’ mental health is a growing con- year was examined. Response rate was 99.8%. cern, we wanted to examine the association of so- Most students with diabetes were among the stu- matic diseases and mental states in this population. dents of the School of Economics, five (1%), with Therefore, the aim of this study was to investigate hypertension at the School of Electrical Enginee- the relationship between somatic health problems ring19 (3.9%), heart disease was found among

374 Stojanović-Tasić et al. Somatic diseases with depression and anxiety

students of the School of Economics, 12 (2.4%), Table 3. Correlation between somatic diseases and anxiety chronic bronchitis among students of the School of according to the Hamilton Anxiety Scale (HAMA) Medicine, 19 (3.8%). Bronchial asthma was most Somatic diseases p Diabetes 0.020 frequent among students at the School of Electrical Hypertension 0.000 Engineering, 26 (5.3%). When it comes to diagno- Heart disease 0.000 sed neurological diseases, the majority of students Chronic bronchitis 0.037 Bronchial asthma 0.049 were at the School of Medicine, four (0.8%). Ga- Neurological diseases 0.113 stric or duodenal ulcer was most frequent among Gastric or duodenal ulcer 0.003 the students at School of Economics, five (1%), Skin diseases 0.380 since skin diseases prevailed at the School of Geo- Among females a correlation was found between graphy, 18 (3.7%), (Table 1). However, statistically diabetes and depression (p=0.020), and gastric or significant differences among students of four sur- duodenal ulcer and depression according to the veyed schools were not found for somatic diseases. Hamilton Depression Scale (p=0.022). Among Table 1. Distribution of students of four surveyed schools in males the correlation was found between hyper- relation to diagnosed somatic diseases tension and depression (p<0.001), and neurologi- No (%) of students cal diseases and depression (p<0.001) according Diagnosed School of School of Econo- Electrical to the Hamilton Depression Scale. In both sexes somatic Total Medicine Geography mics Engineering diseases the correlation was found between heart disease Diabetes 2 (0.4) 3 (0.6) 5 (1.0) 2 (0.4) 12 (0.6) (p=0.012 for males and p=0.038 for females) and Hypertension 16 (3.2) 17 (3.5) 12 (2.4) 19 (3.9) 64 (3.2) Heart disease 7 (1.4) 8 (1.6) 12 (2.4) 6 (1.2) 33 (1.7) depression (Table 4). Chronic 19 (3.8) 17 (3.5) 15 (3.0) 13 (2.6) 64 (3.2) Table 4. Correlation between somatic diseases and depres- bronchitis sion according to the Hamilton Depression Scale with respect Bronchial 11 (2.2) 23 (4.7) 24 (4.8) 26 (5.3) 84 (4.3) to gender asthma Neurological p 4 (0.8) 3 (0.6) 3 (0.6) 1 (0.2) 11 (0.6) Somatic diseases diseases Males Females Gastric or du- Diabetes 0.090 0.020 2 (0.4) 1 (0.2) 5 (1.0) 1 (0.2) 9 (0.5) odenal ulcer Hypertension 0.000 0.807 Skin diseases 15 (3.0) 18 (3.7) 14 (2.8) 9 (1.8) 56 (2.8) Heart disease 0.012 0.038 Chronic bronchitis 0.200 0.093 According to the Hamilton Depression Scale Bronchial asthma 0.430 0.441 (HAMD), correlation was found between the Neurological diseases 0.000 0.877 Gastric or duodenal ulcer 0.072 0.022 following somatic diseases and depression: di- Skin diseases 0.635 0.759 abetes (p=0.003), hypertension (p=0.007), heart disease (p=0.001), chronic bronchitis (p=0.033), Among females the correlation between gastric or neurological diseases (p=0.013), and gastric or duodenal ulcer and anxiety according to the Hamil- duodenal ulcer (p=0.003) (Table 2). ton Anxiety Scale was found (p=0.007) since among males correlation was found between neurological Table 2. Correlation between somatic diseases and depres- diseases and anxiety (p=0.000) and hypertension sion according to the Hamilton Depression Scale (HAMD) and anxiety (p=0.001) too. In both sexes correlation Somatic diseases p Diabetes 0.003 was found between heart diseases (p=0.000 for ma- Hypertension 0.007 les and p=0.001 for females) and anxiety according Heart disease 0.001 to the Hamilton Anxiety Scale (Table 5). Chronic bronchitis 0.033 Bronchial asthma 0.313 Table 5. Correlation between somatic diseases and anxiety Neurological diseases 0.013 according to the Hamilton Anxiety Scale (HAMA) with respect Gastric or duodenal ulcer 0.003 to gender Skin diseases 0.875 p Somatic diseases According to the Hamilton Anxiety Scale Males Females Diabetes 0.056 0.163 (HAMA) a correlation was found between the Hypertension 0.001 0.117 following somatic diseases and anxiety: diabetes Heart disease 0.000 0.001 (p=0.020), hypertension (p<0.001), heart disease Chronic bronchitis 0.235 0.085 Bronchial asthma 0.212 0.101 (p<0.001), chronic bronchitis (p=0.037), bron- Neurological diseases 0.000 0.320 chial asthma (p=0.049), and gastric or duodenal Gastric or duodenal ulcer 0.136 0.007 ulcer (p=0.003) (Table 3). Skin diseases 0.247 0.073

375 Medicinski Glasnik, Volume 11, Number 2, July 2014

DISCUSSION and anxiety, which is consistent with studies from Norway (9) and Italy (19). Depression and anxiety are common comorbid health problems in patients with diabetes. It is well- Regarding heart diseases, our results indicate that known that patients with depression and diabetes, they are connected with symptoms of depression, compared to patients with diabetes alone, have been as it has been noted by others (10,20,21). Contrary linked with poor self-care and adherence to medical to these results in the USA research no association treatment, poorer glycemic control and more diabe- between depressive symptoms and unrecognized tes complications. Moreover, depression in diabetes glucose intolerance was found. Moreover, as de- patients is associated with a higher risk of morbidi- pression confers a higher risk for coronary heart ty and all causes of mortality (11). In our research disease, the risk for coronary heart disease may be involving the population of university students, the additive when both diseases are present (18). results indicate that diabetes affects the occurren- Anxiety seemed to be an independent risk factor ce of depression and anxiety, as well. Key findings for incident coronary heart disease and cardiac from eighteen surveys across 17 countries in Eu- mortality (22). rope, the Americas, the Middle East, Africa, Asia, In the present study a correlation between chronic and the South Pacific indicated that the risk of both bronchitis and depression was found and with anxi- mood and anxiety disorders are moderately higher ety as well, which is consistent with a study in Iran among persons with diabetes, as compared to the (23). When it comes to bronchial asthma, in the persons without diabetes (12). In a research in the current study the correlation was not found with UK the relationship between diabetes and depressi- depression and with anxiety it is on the border of on was found (13), since in a research on the Dutch statistical significance, while according to results population depressive symptoms, but not anxiety in Iran the correlation was found for both anxiety are associated with glucose metabolism (11). and depression (23). Comorbid symptoms of anxi- When it comes to correlation between diabetes and ety and depression are common in patients with depression regarding gender, among females stati- chronic obstructive pulmonary disease. In a Ger- stically significant difference was found in the pre- man study, results revealed significantly increased sent study, and among male participants it was not prevalence rates for depressive disorders, anxiety found, which is consistent with studies in Vietnam disorders, in chronic obstructive pulmonary dise- (14), in the Netherlands (15), in the UK (16) and ase patients. Similarly, increased prevalence rates also in a research on the population of European for depressive and anxiety disorders were found in and South-Asian countries (17). Although evidence patients’ spouses (24). Anxiety is common in pa- of the relationship between depression and diabetes tients with chronic obstructive pulmonary disease. is strong, the mechanism of the association rema- It is often associated with clinical depression (25). ins unclear: depression may lead to diabetes or di- In the current study correlation between neuro- abetes may lead to depression (18). In a survey on logical diseases and depression was found, but the population with diagnosed diabetes prevalence there was no correlation between neurological di- estimates of major depression ranged from 1.5% in seases and anxiety. Results of a French nationwi- Shanghai to 19.5% in Ukraine. When it comes to de survey indicate that patients with neuropathic anxiety, elevated anxiety symptoms were associated pain had higher anxiety/depression scores than with diabetes. Recent studies suggest that anxiety those reporting pain without neuropathic charac- disorders may also be associated with less favorable teristics and those without pain (26). In the USA glycemic control among adults with diabetes (12). research conducted in a population of patients Regarding blood pressure, a correlation with de- with neurological disorders caused by diabetes, pression and anxiety was found according to the both anxiety and depression were present (27). Hamilton Depression Scale as well as according In our research gastric or duodenal ulcer is asso- to the Hamilton Anxiety Scale in this study. Mo- ciated with depression and anxiety. In a Spanish reover, depression was found among males with survey on the population of adolescents with dia- higher blood pressure as anxiety, too; among gnosed ulcer, anxiety and depression were found female students the correlation was not found in 92% of the cases (28). Contrary to our results, between higher blood pressure and depression in a survey from the USA, patients with non- ul-

376 Stojanović-Tasić et al. Somatic diseases with depression and anxiety

cer dyspepsia are more likely to have symptoms Depression and anxiety are common in persons of anxiety and depression than healthy persons or with somatic diseases and have a significant asso- patients with ulcers (29). ciation with physical health. This connection has In two Italian researches results revealed a considerable implications for somatic diseases connection between skin diseases and depression management and clinical guidelines. Clinicians (30,31). In the USA survey majority of patients responsible for patients with somatic diseases with psoriasis reported clinically significant psyc- should be aware that psychiatric disorders can co- hiatric symptoms and are likely to receive psychi- occur with somatic illnesses. A greater focus on atric diagnoses, with both depression and anxiety anxiety and depression seems justified as essen- (32). Also the correlation between skin diseases tial to somatic disease management. The results and depression and anxiety has been documented suggest that efforts to prevent anxiety and depre- in a number of reports (32-34). However, our re- ssion may be of particular value. Bearing in mind search does not corroborate this association. the small number of studies on this issue, further investigations are needed to confirm our results. The results of this investigation show that diabetes, hypertension, heart disease, chronic bron- FUNDING chitis, bronchial asthma and gastric or duodenal No specific funding was received for this study ulcer are associated with anxiety, and all of these diseases except bronchial asthma including neu- TRANSPARENCY DECLARATIONS rological disease are associated with depression. Competing interests: none to declare.

REFERENCES 10. Härter M, Baumeister H, Reuter K, Jacobi F, Höfler M, Bengel J, Wittchen HU. Increased 12-month pre- 1. Kessler RC, Berglund P, Demler O, Jin R, Merikangas valence rates of mental disorders in patients with KR, Walters EE. Lifetime prevalence and age-of-on- chronic somatic diseases. Psychother Psychosom set distributions of DSM-IV disorders in the National 2007; 76:354-60. Comorbidity Survey Replication. Arch Gen Psych 11. Bouwman V, Adriaanse MC, van ‘t Riet E, Snoek FJ, 2005; 62:593–602. Dekker JM, Nijpels G. Depression, anxiety and glu- 2. Kessler RC, Chiu WT, Demler O, Walter EE. Prevalen- cose metabolism in the general dutch population: the ce, severity, and comorbidity of 12-month DSM-IV new Hoorn study. PLoS One 2010; 5:e9971. disorders in the National Comorbidity Survey Repli- 12. Lin EH, Korff MV, Alonso J, Angermeyer MC, Ant- cation. Arch Gen Psych 2005; 62:617–709. hony J, Bromet E, Bruffaerts R, Gasquet I, de Girola- 3. Kessler RC, Chiu WT, Colpe L, Demler O, Merikangas mo G, Gureje O, Haro JM, Karam E, Lara C, Lee S, KR, Walters EE, Wang PS. The prevalence and corre- Levinson D, Ormel JH, Posada-Villa J, Scott K, Wata- lates of serious mental illness (SMI) in the National nabe M, Williams D. Mental disorders among persons Comorbidity Survey Replication (NCS-R). In: Man- with diabetes—Results from the World Mental Health derscheid RW, Berry JT, Eds. Mental health, United Surveys. J Psychosom Res 2008; 65:571-80. States. Rockville, MD: Substance Abuse and Mental 13. Holt RI, Phillips DI, Jameson KA, Cooper C, Denni- Health Services Administration; US Department of son EM, Peveler RC; Hertfordshire Cohort Study Health and Human Services, 2004: 34-148. Group. The relationship between depression, anxiety 4. Mykletun A, Bjerkeset O, Dewey M, Prince M, Over- and cardiovascular disease: findings from the Hertfor- land S, Stewart R. Anxiety, depression, and cause- dshire Cohort Study. J Affect Disord 2013; 150:84-90. specific mortality: the HUNT study. Psychosom Med 14. Gale CR, Kivimaki M, Lawlor DA, Carroll D, Phillips 2007; 69:323-31. AC, Batty GD. Fasting glucose, diagnosis of type 5. Rao C, Ramu SA, Maiya PP. Depression in adolescents 2 diabetes and depression: the Vietnam experience with chronic medical illness Int J Adolesc Med Health study. Biol Psychiatry 2010; 67:189-92. 2011; 23:205-8. 15. Adriaanse MC, Dekker JM, Heine RJ, Snoek FJ, Bee- 6. Suliman S, Stein DJ, Myer L, Williams DR, Seedat S. Di- kman AJ, Stehouwer CD, Bouter LM, Nijpels G, Po- sability and treatment of psychiatric and physical disor- uwer F. Symptoms of depression in people with impa- ders in South Africa. J Nerv Ment Dis 2010; 198:8-15. ired glucose metabolism or Type 2 diabetes mellitus: 7. Stoop CH, Spek VR, Pop VJ, Pouwer F. Disease ma- The Hoorn Study. Diabet Med 2008; 25:843-9. nagement for co-morbid depression and anxiety in 16. Ali S, Stone MA, Peters JL, Davies MJ, Khunti K. diabetes mellitus: design of a randomised controlled The prevalence of co-morbid depression in adults trial in primary care. BMC Fam Pract 2011; 12:139. with Type 2 diabetes: a systematic review and meta- 8. Merikangas KR, Ames M, Cul L, Stang PE, Ustun TB, analysis. Diabet Med 2006; 23:1165-73. Von Korff M, Kessler R. The impact of comorbidity 17. Aujla N, Abrams KR, Davies MJ, Taub N, Skinner of mental and physical conditions on role disability in TC, Khunti K. The prevalence of depression in white- the US adult household population. Arch Gen Psychi- European and South-Asian people with impaired glu- atry 2007; 64:1180–8. cose regulation and screen-detected type 2 diabetes 9. Stordal E, Bjelland I, Dahl AA, Mykletun A. Anxiety mellitus. PLoS One 2009; 9;4:e7755. and depression in individuals with somatic health pro- 18. Rhee MK, Musselman D, Ziemer DC, Vaccarino V, blems. The Nord-Trøndelag Health Study (HUNT). Kolm P, Weintraub WS, Caudle JM, Varughese R M, Scand J Prim Health Care 2003; 21:136-41. Irving JM, and Phillips LS. Unrecognized glucose in-

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tolerance is not associated with depression. Screening ral neuropathy is associated with patient functioning, for Impaired Glucose Tolerance study 3 (SIGT 3) Di- symptom levels of anxiety and depression, and sleep. abet Med 2008; 25:1361–5. J Pain Symptom Manage 2005; 30:374-85. 19. Rafanelli C, Offidani E, Gostoli S, Roncuzzi R. Psyc- 28. Criollos Torres O, Frati Munari AC, Flores Suárez hological correlates in patients with different levels of RE, Martínez Peláez E. Chronic peptic ulcer among hypertension. Psychiatry Res 2012; 198:154-60. students and adolescents Bol Med Hosp Infant Mex 20. Burg MM, Abrams D. Depression in chronic medi- 1978; 35:23-32. cal illness: the case of coronary heart disease. J Clin 29. Dickerson LM, King DE. Evaluation and manage- Psychol 2001; 57:1323-37. ment of nonulcer dyspepsia. Am Fam Physician 2004; 21. Baune BT, Adrian I, Arolt V, Berger K. Associati- 70:107-14. ons between major depression, bipolar disorders, 30. Altobelli E, Maccarone M, Petrocelli R, Marziliano dysthymia and cardiovascular diseases in the gene- C, Giannetti A, Peris K, Chimenti S. Analysis of heral adult population. Psychother Psychosom 2006; alth care and actual needs of patients with psoriasis: a 75:319-26. survey on the Italian population. BMC Public Health 22. Roest AM, Martens EJ, de Jonge P, Denollet J. Anxi- 2007; 7:59. ety and risk of incident coronary heart disease: a me- 31. Coaccioli S, Di Cato L, Bruni PL, Papini M, Puxeddu ta-analysis. J Am Coll Cardiol 2010; 56:38-46. A. A proposal of questionnaire for evaluation of the 23. Asnaashari AM, Talaei A, Haghigh B. Evaluation of quality of life in patients with psoriatic arthritis Re- psychological status in patients with asthma and COPD. centi Prog Med 2003; 94:380-6. Iran J Allergy Asthma Immunol 2012; 11:65-71. 32. Kimball AB, Wu EQ, Guérin A, Yu AP, Tsaneva M, 24. Kühl K, Schürmann W, Rief W. Mental disorders and Gupta SR, Bao Y, Mulani PM. Risks of developing quality of life in COPD patients and their spouses. Int psychiatric disorders in pediatric patients with psoria- J Chron Obstruct Pulmon Dis 2008; 3:727-36. sis. J Am Acad Dermatol 2012; 67:651-7.e1-2. 25. Yohannes AM, Baldwin RC, Connolly MJ. Depression 33. Fortune DG, Richards HL, Corrin A, Taylor RJ, Griffi- and anxiety in elderly patients with chronic obstruc- ths CE, Main CJ. Attentional bias for psoriasis-speci- tive pulmonary disease. Age Ageing 2006; 35:457-9. fic and psychosocial threat in patients with psoriasis. 26. Attal N, Lanteri-Minet M, Laurent B, Fermanian J, J Behav Med 2003; 26:211-24. Bouhassira D. The specific disease burden of neuro- 34. Chu SY, Chen YJ, Tseng WC, Lin MW, Chen TJ, pathic pain: results of a French nationwide survey. Hwang CY, Chen CC, Lee DD, Chang YT, Wang WJ, Pain 2011; 152:2836-43. Liu HN. Psychiatric comorbidities in patients with 27. Gore M, Brandenburg NA, Dukes E, Hoffman DL, alopecia areata in Taiwan: a case-control study. Br J Tai KS, Stacey B. Pain severity in diabetic periphe- Dermatol 2012; 166:525-31.

Povezanost između somatskih bolesti i simptoma depresije i anksioznosti u populaciji studenata Univerziteta u Beogradu Mirjana Stojanović-Tasić1, Anita Grgurević2, Jovana Cvetković1, Uglješa Grgurević3, Goran Trajković4

1Klinika za neuropsihijatriju, Medicinski fakultet, Univerzitet Priština/Kosovska Mitrovica; 2Institut za epidemiologiju, Medicinski fakultet, Univerzitet u Beogradu; 3Klinika za otorinolaringologiju, Vojnomedicinska akademija, Beograd; 4Institut za medicinsku statistiku i infor- matiku, Medicinski fakultet, Univerzitet u Beogradu; Srbija

SAŽETAK Cilj Istražiti povezanosti između somatskih bolesti i komorbidnih stanja anksioznosti i depresije. Metode Sprovedena je studija prevalencije u populaciji 2000 studenata Univerziteta u Beogradu (Me- dicinski, Geografski, Ekonomski i Elektrotehnički fakultet), odabranih metodom slučajnog izbora, u periodu od aprila do juna 2010. godine. Osnovni instrument za prikupljanje podataka bio je standardi- zovani epidemiološki upitnik koji je dizajniran na Institutu za epidemiologiju Medicinskog fakulteta u Beogradu. Rezultati Prema Hamiltonovoj skali depresivnosti (HAMD), korelacija je nađena između sledećih somatskih bolesti i depresije: dijabetesa (p=0,003), hipertenzije (p=0,007), oboljenja srca (p=0,001), hroničnog bronhitisa (p=0,033), neuroloških oboljenja (p=0,013) i čira na želucu ili dvanaestopalačnom crevu (p=0,003). Prema Hamiltonovoj skali anksioznosti (HAMA) korelacija je nađena između sledećih somatskih bolesti i anksioznosti: dijabetesa (p=0,020), hipertenzije (p=0,000), oboljenja srca (p=0,000), hroničnog bronhitisa (p=0,037), bronhijalne astme (p=0,049) i čira na želucu ili dvanaestopalačnom crevu (p=0,003). Zaključak Depresija i anksioznost su česta komorbidna stanja kod studenata sa dijagnostikovanim somatskim oboljenjima. Ovakav nalaz ima značajne implikacije za kliničku praksu i ukazuje na potrebu šireg sagledavanja somatskih oboljenja. Ključne reči: mentalni poremećaji, hronične bolesti, komorbiditet.

378 ORIGINAL ARTICLE

Is denture stomatitis always related with candida infection? A case control study

Jovan Marinoski, Marija Bokor-Bratić, Miloš Čanković

Dental Clinic, School of Medicine, University of Novi Sad, Novi Sad, Serbia

ABSTRACT

Aim To examine the oral mucosa under the denture base and to determine the influence of local factors that contribute to denture stomatitis.

Methods In this prospective, case control study 30 patients with palatal inflammatory lesions were evaluated. A degree of palatal inflammation was scored. Swab samples were taken from tongue and palatal mucosa for microbiological examination. Denture plaque index, data of night wearing dentures, pH values of tongue and palatal mucosa were determined for all subjects.

Results Significantly higher incidence of poor denture cleanliness index (p=0.01) and night wearing of dentures (p=0.009) were found in patients with denture stomatitis. There were significant differences between the groups in relation to the pH value of the tongue and palatal mucosa (p=0.016 and p=0.035, respectively). Corresponding author: No significant association was found between denture stomatitis Miloš Čanković and microbiological findings, dentures age, type of dentures, pre- Clinic for Dentistry, Faculty of Medicine, sence of previous prosthesis, frequency or manner of dentures hy- Hajduk Veljkova 12, Novi Sad, Serbia giene and smoking habits. Phone/fax: +381 21 526 120; Conclusion Poor denture hygiene, overnight wearing of dentures E-mail: [email protected] and oral mucosa pH less than 6.5 are predominant local etiologycal factors that contribute to denture stomatitis development.

Keywords: dental prostheses, hygiene, oral candidiasis, etiology, dental care for elderly

Original submission: 28 March 2014; Revised submission: 14 May 2014; Accepted: 19 May 2014.

Med Glas (Zenica) 2014; 11(2):379-384

379 Medicinski Glasnik, Volume 11, Number 2, July 2014

INTRODUCTION the prosthesis and to determine the presence and influence of local factors (purity of dentures, den- Denture stomatitis (DS) is a clinical diagnosis of the ture age, night wearing of dentures, palate and oral mucosa inflammatory lesion, which is located tongue mucosal pH and Candida infection on the under the base of removable denture (1). Accor- oral mucosa) in the development of denture sto- ding to the classification proposed by Newton (2), matitis in upper removable dentures wearers. there are three clinical types of the disease: pin- point hyperemia (type 1), diffuse mucosal erythe- PATIENTS AND METHODS ma, which is limited by denture base (type 2) and inflammatory papillary hyperplasia (type 3). The The study was conducted as a prospective, case distribution of these lesions in removable dentu- control clinical study at the Oral Medicine Section res wearers tends to increase with age (3). Several of the Dental Clinic, School of Medicine, Novi Sad, studies have revealed that DS is more prevalent in Serbia between January 2012 and August 2013. the female population (4,5). The etiology of DS is The study group involved 30 consecutive patients multifactorial, with predominance of local factors. with upper removable dentures that had inflamma- The colonization of Candida genus yeasts, poor tory lesions on the mucosa of the alveolar ridge and denture hygiene, continual and nighttime wearing the hard palate (21 female and 9 male subjects of of removable dentures, denture age, trauma caused average age of 66.30 years (ranged 60-87 years). by dentures and smoking are described in literatu- The control group consisted of 30 healthy subjects re as important factors that lead to DS (1, 4, 6-9). with upper dentures and no oral mucosa lesions (25 Some authors reported the significant impact of females and 5 males of average age of 65.30 years poor hygiene in the development of inflammatory (ranged 58-76 years). Subjects with upper remo- lesions on the oral mucosa (7,10), which is explai- vable dentures (complete dentures, acrylic partial ned by the pathogenic influence of microorganisms dentures, cast partial dentures) older than 2 years (Candida spp., Staphylococcus spp., Streptococcus were included in the study. Criteria for exclusion spp. and Enterobacteriaceae/Pseudomonadaceae from the study were: the presence of systemic dise- families) being part of the denture plaque (11,12). ase (immune, neoplastic, infectious, and endocrine The association of Candida albicans colonization diseases), antibiotic or corticosteroid therapy wit- and palatal mucosa lesions has been mostly des- hin the previous 6 months and the presence of a dry cribed in the previous studies (5,7,10,12). Accor- mouth sense (xerostomia). ding to Budtz-Jorgensen (9), invasion of yeast into All subjects were interviewed using a structured the tissues, production of virulence factors and questionnaire by one investigator in order to mi- induction of hypersensitivity reactions have been nimize possible variations in the data gathering. described as possible mechanisms in initiation of Visual examination of the mouth was carried out the disease. The impact of overnight denture we- by a specialist in oral medicine experienced in that aring is also cited as an important predictor in the field. Information explaining the content of the pathogenesis of denture stomatitis (1,13). In conti- study and purpose of the research results, was pro- nuous wearing, a decline in the pH value of palatal vided to patients in writing. Having learned about mucosa due to acid products of yeasts, lactobacilli the procedure, the patients gave their written con- and streptococci is noted. Reduced salivation at ni- sents. The study was approved by the Ethical Co- ght also contributes to acid environment between mmittee of School of Medicine in Novi Sad. the denture base and oral mucosa (9). However, A questionnaire that included questions with ana- Yilmaz et al. (14) found no significant association mnestic predetermined sequence: generalities, so- between night-wear and denture stomatitis. There cio-demographic information, gender, age, height is no control study that observed all previously re- and weight, data of harmful habits (smoking and ported etiology factors at the same time and there is alcohol consumption), the frequency of visiting the a lack of information about oral mucosa pH value dentist, information about prosthetic restoration and its relation with Candida infection under the (prosthesis type, length of time wearing dentures, base of removable denture. presence of previous prosthesis, information about The aim of this study was to examine the oral the night wearing dentures, frequency and manner mucosa which is in direct contact with the base of of dentures hygiene), frequency and method of ma-

380 Marinoski et al. Local etiological factors and denture stomatitis

intaining dental hygiene, was completed for each media with dextrose (Difco, Detroit, MI, USA) in subject. During the clinical examination, condition aerobic conditions at 37 °C for 24/48 h. Inoculated of oral mucosa and dental status were established. culture media was observed after 48 h in order to Based on hard palate and alveolar ridge mucosa detect the presence of clinically significant species clinical examination in the patients with inflam- of bacteria and yeast in the examined material. mation, the degree of palatal inflammation was For attributive characteristics data is shown in the scored: 0-no inflammation; 1-slight inflammation form of absolute and relative numbers, and for nu- (localized slight hyperemia); 2-moderate inflam- meric characteristics through mean value and me- mation (diffuse hyperemia); 3-severe inflammati- asures of variability. Student’s t-test was applied on (diffuse and papillary hyperplasia) (15). for the testing of the differences between the two Denture plaque index was measured for each groups, for continuous variables, i.e. χ² test or χ² prosthesis. Denture base that is in direct contact test (Yates correction) for attributive characteristi- with oral mucosa was coated with 1% solution cs. The value p<0.05 was statistically significant. of gentian violet and then dentures were washed RESULTS under running water. Denture plaque index was determined according to Budtz-Jorgensen: exce- Comparing the average age and gender of the pa- llent (absence or presence of plaque in the form tients wearing denture there was no significant di- of a few points), satisfactory (less than half of fference between the groups (p>0.05). According the surface of denture base covered with plaque) to degree of the hard palate mucosal inflammati- and bad (more than half of the surface of denture on, it was found that 10 (33.3%) patients with DS base covered with plaque) (16). had slight, while 20 (66.7%) had moderately or Palatal mucosa and tongue pH values were deter- severely inflamed palatal mucosa (p<0.05). mined by using standard pH paper indicator with Table 1. Denture cleanliness index data in the groups a sensitivity of 0.5 (Neutralit, Merck, Darmstadt, No (%) of patients p Denture stomatitis Control Denture plaque index Germany). The pH values from 6.5-7.0 were con- n=30 group n=30 sidered normal (17). The pH paper was placed Excellent 2 (6.7) 11 (36.7) p=0.01 and gently pressed on the hard palate and dorsal Bad 28 (93.3) 19 (63.3) surface of the tongue for 5 s, and immediately The bad denture cleanliness index was detected after that the mucosa pH values were determined in 28 (93.3%) patients in the DS group and 19 comparing the color change of the paper with the (63.3%) patients from the control group. There attached scale. According to the measured pH was significant difference in denture cleanliness value of palatal and tongue mucosa, participants index between the groups (p=0.01). Due to the were classified into two groups: group with acid small number of patients with satisfactory index pH value (pH<6.5) and group with normal and and for the purpose of an adequate statistical alkaline pH value (pH≥6.5). analysis, subjects with satisfactory and bad in- Swab samples from tongue and palate (each lasting dex were merged into one group (bad) (Table 1). 10-15 seconds) for mycological and bacteriologi- The statistical analysis revealed a significantly cal examination were taken from the both groups. higher prevalence of night wearing dentures in All samples were taken in the morning (from 9 to patients with DS, 73.3% (22) than in the control 11 am), and reached the laboratory within 2 hours. group, 36.7% (11) (p=0.009) (Table 2). All swab samples were taken by one investigator. Table 2. Prevalence of night wearing dentures in the groups Swab samples were plated on Sabouraud dextrose No (%) of patients p Denture stomatitis Control agar (Difco, Detroit, MI, USA) and incubated un- Night wearing dentures n=30 group n=30 der aerobic conditions at 37 °C for 48 h for yeasts. Yes 22 (73.3) 11 (36.7) p=0.009 These colonies were sub-cultured and their iden- No 8 (26.7) 19 (63.3) tification included germ tube formation in bovine Acid pH value of palatal mucosa under the base serum, chlamydospore formation in corn meal of removable denture (pH<6.5) were found in 20 agar, ability to growth at 45 °C and assimilation (66.6%) patients with DS, and 10 (33.3%) pati- test (API 20C Aux, bioMerieux, Marcy l` Etoile, ents from the control group (Table 3). There were France). The bacteria inoculation was performed significant differences between the groups in re- on blood agar, MacConkey’s agar, and tioglikol lation to the pH value of the palate (p=0.016).

381 Medicinski Glasnik, Volume 11, Number 2, July 2014

Table 3. pH value of palate and tongue mucosa in the groups compared to the control group. Significant correla- No (%) of patients tion that was found between poor index of denture Denture stomatitis Control group p Mucosa n=30 n=30 cleanliness and DS has been reported in several pre- pH values Palate Tongue Palate Tongue Palate Tongue vious studies (4,6-8, 14). The current findings shos pH<6.5 20 (66.6) 22 (73.4) 10 (33.3) 12 (40.0) high prevalence of subjects with bad denture clean- 5 1 (3.3) 2 (6.7) 0 (0) 0 (0) 5.5 0 (0) 1 (3.3) 0 (0) 0 (0) liness index and this result falls in the range repor- 6 19 (63.3) 19 (63.3) 10 (33.3) 12 (40.0) p=0.016 p=0.035 ted previously (7,10). Although Naik et al. (10) did pH≥6.5 10 (33.3) 8 (26.7) 20 (66.6) 18 (60.0) not find significant difference between DS and -he 7 9 (30.0) 5 (16.7) 19 (63.3) 15 (50.0) 8 1 (3.3) 3 (10.0) 1 (3.3) 3 (10.0) althy subjects in relation to denture cleanliness, their results shos that poor denture hygiene is directly The pH<6.5 on the dorsal surface of the tongue proportional with the intensity of palatal inflamma- was measured in 22 (73.4%) subjects with DS tion. Kossioni (18) also points out the association and 12 (40%) control subjects. Significant dif- between poor dentures hygiene and inflammatory ferences were also found between the groups in changes of palatal mucosa in the form of papillary relation to the pH value of tongue (p = 0.035). hyperplasia. Also, the possible cause of poor dentu- Of the total 20 patients with pH<6.5 on palatal res hygiene could be a lack or inadequate instructi- mucosa, Candida species were isolated in 9 (45%) ons from the dentist or dental hygienist with regard patients with DS. Positive microbiological finding to the method and technique of hygiene. from the palate and the tongue was confirmed in The overnight or continuously denture wearing was 13 (43.3%) and 19 (63.3%) subjects with denture present in 73.3% of subjects with palatal inflamma- stomatitis respectively, while in the control group tion. The impact of night wearing of dentures on the 11 (36.7%) subjects had positive microbiologi- occurrence of the disease was supported by Jagana- cal finding from the tongue or the palate muco- than et al. (19), in which study overnight wearing sa (p=0.120 and p=0.596, respectively). In DS was present in 61% of subjects with palatal diffuse group, Candida albicans, Candida spp. and bac- erythema. Similar results were reported by Kossi- teria were isolated from the hard palate mucosa in oni (18), who found that 56% of respondents wore eight (26.7%), five (16.7%) and two (6.7%) pa- dentures at night. However, some authors did not tients respectively, while in the control group both confirm the influence of this habit in DS patients Candida species were found in four (13.3%) and (14). It is important that production of saliva is redu- bacteria in two (6.7%) patients. Candida albicans ced at night (9). Therefore, the presence of denture from the dorsal surface of the tongue was isolated further hinders its antimicrobial role. The absence in 10 (33.3%) patients with DS and five (16.7%) of mechanical effects of saliva and its antimicrobial from the control group, while Candida spp. was compounds that are an integral part oe saliva (lyso- present i nine (30%) patients with DS and six zyme, lactoferrin, salivary peroxidase, immunoglo- (20%) control subjects. Bacteria (Pseudomonas bulin A) during the night as possible mechanisms aeruginosa and Escherichia coli) were isolated in which contribute to inflammation, shouldeindicate four (13.3%) patients with denture stomatitis and a need to be explored in further studies. one (3.3%) control patiens. The current study showed that the oral mucosa There were no significant differences between pH values <6.5 were over-represented in pati- the groups in relationfto denturs age (p=0.667), ents with palatal lesions (66.6%) compared to type of dentures (p=0.954), presence of previo- the control group (33.7%). Comparing the pH us prosthesis (p=1.000), frequency or manner of values of denture biofilms, Olsen et al. (20) havn denturs hygiene (p=0.362) and cigarette smoking reported the differences between the groups with habits (p=0.754). and without palatal inflammation. Same authors suggest that the difference in pH values between DISCUSSION the groups was not accompanied by differences In the present study the condition of palatal mucosa in positive microbiological findings (genus Can- and influence of several local etiologycal factors on dida yeasts and bacteria) of palate and tongue, the occurrence of the disease have bees analyzed. and they did not uind a significant increase in the Our results confirmed DS multifactorial etiology. number of yeasts in conditions of pH decrease Poor denture hygiene was significantly more pre- (21). It should be noted that the pH values in sent in patients with palatal inflammatory lesions those studiey were measured on denture biofilm

382 Marinoski et al. Local etiological factors and denture stomatitis

using microelectrodes, and yeasts were isolated established candidiasis (27). According to th Rre- from denture biofilm. While in the present study, view of the literature on the epidemiology and eti- which suggests similar results, pH values of the ology of denture stomatitis, Gendreau and Loewy oral mucosa from which swabs were taken for (28) suggest that etiological factors such as poor microbiological examination were measured. denture hygiene, continual and nighttime wearing TheAassociation between DS and yeast coloniza- of removable dentures, accumulation of denture tion has been reported frequently by most of au- plaque and poor-fitting dentures appear to increase thors (5,7,10,12,22). In DS group, we found more the ability of Candida albicans to colonize both the positive microbiological findings on the palate and denture and oral mucosal surfaces, where it acts as tongue with no significant differences compared an opportunistic pathogen.Moreover, except Can- with the control. Positive swab results of microbio- dida species in some dentured patients, aerobic logical analysis from the oral mucosa accompanied gram-negative bacteria (Pseudomonas aeruginosa by clinical signs and symptomssare used for diag- and Escherichia coli) have been isolated from the nosis of oral candidiasisorather than determieing tongue or palate. Co-aggregation between Candida the colonization of the oral cavity (23), which is species and several other microorganisms (Staphy- previously reported asathe most frequeny factor re- lococcus spp. and Enterobacteriaceae/Pseudo- lated with DS (5,7,10,12). The presence of Candida monadaceae families) may play important roles in on the tongue and palate in denture wearers with in- the establishment and persistence of DS in com- flammatory oral lesions may indicate the existence plete denture wearers (11,12). Similar�� opportunis- of previous oral carriage of Candida species. Symp- tic and multiresistant bacteria, that are considered tom-free oral carriage of Candida species with the to belong to the transient oral microflora, we found prevalence in clinically normal mouts of healthy in our previous work on healthy men smokers with adults from 3 to 48% has been reported (7,24), with poor oral hygiene (29). Colonization of these bac- significant increase in proportions in thoso wear- teria increases with age, poor oral hygiene, smoking dentures (25). In this study, 36.7% of control ing, nail-biting or close contact with animals (30). subjects had positive mycological finding Candida( Thus, elderly patients�� should be suggested that be- genus yeasts) on tongue or palate. Theis data sug- fore handling removable dentures they need to thor- gets the reason why we did not obtain the signifi- oughly wash their hands. cant differences between the groups in relation to According to the results obtained, this study sug- mycological findings of the oral mucosa. Similar gests that poor denture hygiene, overnight wearing conclusion that mucosa candidal infections are not of dentures and oral mucosal pH less than 6.5 are the predisposing factor in the occurrence of den- predominant local factors that contributs to denture ture-induced stomatitis, but they play a major role, stomatitis development. Patient education and mo- has been reported in two recent studies (15,26). Th tivation about denture hygiene and their removing Ddecline of the pH values may also contribues to at night are the most important steps in the preven- yeats reproduction and development of a clinically tion of the oral mucosa diseases in dentate patients. visible Candida infection on the palate. There are mand suggested factors except dentures and decline FUNDING in pH value that can influence Candida infection. No specific funding was received for this study. Depression in normal host defense is undoubtedly a major factor that can predispose an individual to TRANSPARENCY DECLARATION yeast coloiszation, promote yeast overgrowth and Competing interests: None to declare. REFERENCES an older adults. Gerodontology 2010; 27:134-40. 5. Figueiral MH, Azul A, Pinto E, Fonseca PA, Branco 1. Shulman JD, Rivera-Hidalgo F, Beach MM. Risk FM, Scully C. Denture-related stomatitis: identifica- factors associated with denture stomatitis in the Uni- tion of aetiological and predisposing factors – a large ted States. J Oral Pathol Med 2005; 34:340-6. cohort. J Oral Rehabil 2007; 34:448–55. 2. Newton AV. Denture sore mouth: a possible etiolo- 6. Baran I, Nalçaci R. Self-reported denture hygiene gy. Br Dent J 1962; 112:357–60. habits and oral tissue conditions of complete denture 3. Jainkittivong A, Aneksuk V, Langlais RP. Oral mu- wearers. Arch Gerontol Geriatr 2009; 49:237-41. cosal lesions in denture wearers. Gerodontology 7. Kulak-Ozkan Y, Kazazoglu E, Arikan A. Oral hy- 2010; 27:26-32. giene habits, denture cleanliness, presence of yeasts 4. Santos CM, Hilgert JB, Padilha DMP, Hugo FN. Den- and stomatitis in eldery people. J Oral Rehabil 2002; ture stomatitis and its risk indicators in south Brazili- 29:300-4.

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8. Sadig W. The denture hygiene, denture stomatitis Oral Rehabil 1997; 24:468-72. and role of dental hygienist. Int J Dent Hyg 2010; 20. Olsen I, Birkeland JM. Denture stomatitis; yeast 8:227-31. occurrence and the pH of saliva and denture plaque. 9. Budtz-Jörgensen E. Ecology of candida-associated Scand J Dent Res 1977; 85:130-4. denture stomatitis. Microb Ecol Health Dis 2000; 21. Olsen I, Birkeland JM. Assessment of denture plaque 12:170–85. pH in subjects with and without denture stomatitis. 10. Naik AV, Pai RC. A study of factors contributing to Scand J Dent Res 1975; 83: 370-4. denture stomatitis in a North Indian community. Int 22. Salerno C, Pascale M, Contaldo M, Esposito V, Bu- J Dent 2011; 2011: 589064. sciolano M, Milillo L, Guida A, Petruzzi M, Serpico 11. Pereira CA,Toledo BC, Santos CT, Pereira Costa R. Candida-associated denture stomatitis. Med Oral AC, Back-Brito GN, Kaminagakura E, Jorge AO. Patol Oral Cir Bucal 2011; 16:139-43. Opportunistic microorganisms in individuals with 23. Skoglund A, Sunzel B, Lerner U, Comparison of lesions of denture stomatitis. Diagn Microbiol Infect three test methods used for diagnosis of candidiasis. Dis 2013; 76:419-24. Scand J Dent Res. 1994; 102:295-8. 12. Ribeiro DG, Pavarina AC, Dovigo LN, Machado 24. Muzurovic S, Hukic M, Babajic E, Smajic R. The AL, Giampaolo ET, Vergani CE. Prevalence�� of Can- relationship between cigarette smoking and oral dida spp. associated with bacteria species on com- colonization with Candida species in healthy adult plete dentures. Gerodontology 2012; 29:203-8. subjects. Med Glas (Zenica) 2013; 10:397-9. 13. Compagnoni MA, Souza RF, Marra J, Pero AC, Bar- 25. Resende MA, Sousa LVNF, Oliveira RCBW, Koga- bosa DB. Relationship�� between Candida and noctur- Ito CY, Lyon JP. Prevalence and antifungal suscep- nal denture wear: quantitative study. J Oral Rehabil tibility of yeasts obtained from the oral cavity of el- 2007; 34:600-5. derly individuals. Mycopathologia 2006; 162:39-44. 14. Yilmaz HH, Aydin U, Ipek C. Is denture stomatitis 26. Altarawneh S, Bencharit S, Mendoza L, Curran A, related with denture hygiene? Gulhane Tip Dergisi Barrow D, Barros S, Preisser J, Loewy ZG, Gen- 2002; 44:412-4. dreau L, Offenbacher S. Clinical and histological 15. Dağistan S, Aktas AE, Caglayan F, Ayyildiz A, Bilge findings of denture stomatitis as related to intraoral M. Differential diagnosis of denture-induced stoma- colonization patterns of Candida albicans, salivary titis, Candida, and their variations in patients using flow, and dry mouth. J Prosthodont 2013; 22:13–22. complete denture: a clinical and mycological study. 27. Cankovic M, Bokor-Bratic M. Candida albicans in- Mycoses 2009; 52:266-71. fection in patients with oral squamous cell carcino- 16. Budtz-Jörgensen E, Bertram U. Denture stomatitis. ma. Vojnosanit Pregl 2010; 67:766–70. The etiology in relation to trauma and infection. 28. Gendreau L, Loewy ZG. Epidemiology and Etiology Acta Odontol Scand 1970; 28:71-92. of denture stomatitis. J Prosthodont 2011; 20:251-60. 17. Aframian DJ, Davidowitz T, Benoliel R. The distri- 29. Cankovic M, Bokor-Bratic M, Cankovic D. Oral bution of oral mucosal pH values in healthy saliva fungal and bacterial infection in smokers. Heal- secretors. Oral Dis 2006; 12:420-3. thMed 2011; 5:1695-700. 18. Kossioni AE. The prevalence of denture stomatitis 30. Mager DL, Haffajee AD, Socransky SS. Effects of and its predisposing conditions in an older Greek po- periodontitis and smoking on the microbiota of oral pulation. Gerodontology 2011; 28:85-90. mucous membranes and saliva in systemically he- 19. Jaganathan S, Payne JA, Thean HPY. Denture sto- althy subjects. J Clin Periodontol 2003; 30:1031-7. matitis in an eldery edentulous Asian population. J Da li je protetski stomatitis uvek povezan s infekcijom kandidom – studija “slučaj-kontrola” Jovan Marinoski, Marija Bokor-Bratić, Miloš Čanković Klinika za stomatologiju, Medicinski fakultet, Univerzitet u Novom Sadu, Novi Sad, Srbija SAŽETAK Cilj Ispitati stanje oralne sluzokože koja je u direktnom kontaktu s bazom proteze, te utvrditi prisustvo i uticaj lokalnih faktora u nastanku protetskog stomatitisa. Metode Istraživanje je sprovedeno kao prospektivna studija s kontrolnom grupom kod 30 pacijenata s gornjim mobilnim protezama, koji su imali inflamatorne promene na sluzokoži alveolarnog grebena i tvrdog nepca. Kod svih ispitanika određivani su stepen zapaljenja sluzokože tvrdog nepca, indeks čistoće proteze, podaci o noćnom nošenju proteze i pH vrednost sluzokože jezika i tvrdog nepca. Ispita- nicima obe grupe uzet je bris jezika i nepca za mikološko i bakteriološko ispitivanje. Rezultati Kod ispitanika s protetskim stomatitisom značajno je veća učestalost loše higijene proteze (p=0,01) i noćnog nošenja proteze (p=0,009). Utvrđena je značajna razlika u vrednostima pH sluzokože jezika i nepca između grupa (p=0,016 odnosno p=0,035). Značajna povezanost nije utvrđena između protetskog stomatitisa i mikrobiološkog nalaza, starosti proteze, vrste protetske nadoknade, prisustva ranijih proteza, učestalosti održavanja higijene proteze i pušenja cigareta. Zaključak Loša higijena proteza, noćno nošenje i pH vrednost oralne sluzokože, manji od 6,5 pred- stavljaju najznačajnije lokalne etiološke faktore u nastanku protetskog stomatitisa. Ključne reči: zubna proteza, higijena, oralna kandidijaza, etiologija, stomatološka nega starih

384 ORIGINAL ARTICLE

Prevalence of periodontal diseases in North Herzegovina

Ružica Zovko1, Domagoj Glavina2, Mirela Mabić3, Stipo Cvitanović4, Zdenko Šarac1, Ante Ivanković5

1Health Care Center Mostar,Bosnia and Herzegovina,2Faculty of DentistryUniversity of Zagreb, Croatia, 3Schoolof Economics, University of Mostar, Bosnia and Herzegovina,4Health Care Center Prozor-Rama, Bosnia and Herzegovina, 5Schoolof Medicine, University of Mostar Bosnia and Herzegovina

ABSTRACT

Aim To investigate effects of smoking on periodontal tissue and the occurrence of periodontal disease in the population of North Herzegovina.

Methods The study included 800 persons of 20-49 years of age (400 smokers and 400 non-smokers), inhabitants of Prozor-Ra- ma Municipality, Bosnia and Herzegovina. Periodontal condition assessment was made by theCommunity Periodontal Index of Tre- atment Needs index (CPITN) at representative teeth: 16, 17, 21, 26, 27, 36, 37, 31, 46, and 47.Statistically significant difference between non-smokers and smokers was tested by χ2 test with the level of significance set at p=0.05.

Results The prevalence of healthy periodontal tissues was lower Corresponding author: in smokers than in non-smokers, 25 (6.3%)and 36 (9%), respecti- Ružica Zovko vely. The prevalence of gingival bleeding, calculus, shallow and Health Care Center Mostar deep periodontal pockets was higher in smokers than in non-smokers, although it was not significant. There was a risk between Hrvatskihbranitelja bb, 88 000 Mostar, occurrence of deep periodontal pockets and smoking (RR=2). A Bosnia and Herzegovina total of 64 (8%)participants neededonly instructions on proper oral Phone: +387 36 321 890; hygiene, 654 (81.8%) prophylaxis and initial treatment,while 21 Fax: +387 36 335 532; (2.6%) needed complex periodontal treatment. E-mail: [email protected] Conclusion Obtained results indicate a high need of preventive measures and the improvement of oral health in the population of North Herzegovina.

Keyword: nicotine, nonsmokers, smokers, periodontium, Prozor- Rama

Original submission: 12 December 2013; Revised submission: 27 January 2014; Accepted: 05 May 2014.

Med Glas (Zenica) 2014; 11(2):385-390

385 Medicinski Glasnik, Volume 11, Number 2, July 2014

INTRODUCTION pends on a number of cigarettes smoked daily, as well as duration of thesmoking habit and age According to the World Health Organization esti- when a person started smoking (18-20). Perio- mations, about one million people a year die of- dontal diseases and loss of teeth are significantly smoking (1,2). There are many harmful effects of higher in smokers than in non-smokers, and tobacco and tobacco products on human health, plaque is ticker as well (21). Anumber of young and they depend on the way of smoking and a people becoming tobacco addicts is increasing. length of smoking period. The main health ef- According to the National Survey on Drug Use fects caused by smoking are diseases of cardio- in 2007, 68 million people use tobacco, and more vascular system, respiratory diseases,including than 3.5 million adolescents are tobacco addicts cancer, especially lung, throat and oral cancer at the age between 12 and 17. In Bosnia and Her- (3-6). Smoking is a risk factor for a number of zegovina 40% of adults are active smokers, and systemic diseases and it has a negative impact on 50% primary school pupils in the Federation of all organs and organic systems in human body BiHare about to start smoking (22). (7).Smokers may have various changes in mouth becausetobacco smoke contains about 4000 This study examined harmful effects of smoking different toxins (8). Higher prevalence and pro- on periodontal disease, stage of periodontal dise- gression of periodontal diseases are caused by ase and treatment necessityamong population of disturbed immune response (9,10). Development Prozor-Rama Municipality. of periodontal diseases is also influenced by toxic EXAMINEES AND METHODS effect of nicotine (11). Beside chemical components, tobacco smoke contains radioactive com- Thisprospective study was conducted at the He- ponents and tar in different concentrations (12). alth Care Center ofProzor-Rama in 2009 and in- Smoking causes reduced supply of oxygen into cluded 800 persons or 8.79% out of 9,100 inha- gum tissue, facilitating the development of pat- bitants in Prozor-Rama Municipality.The sample hogenic bacteria in mouth that influence the in- was chosen from the Census in Gornja Rama, cidence of periodontal diseases (13). Research Donja Rama and the town of Prozor. The first res- shows that there are about 19 known cancerous pondent was randomly selected, and then every substances in cigarettes (14). Cigarette smoke tenth name from the list was chosen. Each person contains significant concentration of bensopyren had to meet criteria related to age. which has cancerous and mutagenic components Respondents were divided into two groups, 400 that cause incomplete oxidation of organic su- smokers, and 400 non-smokers at the age of 20 to bstances (15). Harmful effect of smoking on he- 49. The study excluded all persons younger than alth is especially associated with nitrosamines in 20 and those older than 49, and persons with dise- tobacco smoke and chemical reactions between ases that could influence occurrence of periodon- nicotine and various oxides and nitrogen that tal diseases, such as osteoporosis, diabetes, cardi- occur during smoking (16). ovascular diseases and persons under therapy of More studies prove that periodontal infection cau- cyclosporine, phenytoin or calcium blockers. sed by bacteria that exist in dental plaque is more Periodontal condition assessment was made by common in smokers since more than 350 bacterial CPITN index (Community Periodontal Index of species live in the mouth, and it is well known that Treatment Needs) that is based on registration of 20 of them cause periodontal disease (17). When intensity of inflammatory changes, calculus and plaque is formed on teeth surface, in gingival and depth of periodontal pockets (23). Together with periodontal tissue, inflammatory and immune res- instruments for routine examination, a probe with ponse occurs, following destruction of complex graduations in millimeters was introduced into supportive tissue because of formation of perio- the gingival sulcus. The following grades were dontal pockets and loss of alveolar bone. determined:0 - healthy periodontal tissue,1 - blee- Epidemiological studies point out a significant ding after careful probing,2 - supra-or sub-gin- role of smoking for periodontal diseasesonset, gival calculus or iatrogenic damage of marginal but that prevalence of the disease in smokers de- gingival edge,3 - periodontal pocket up to 5 mm deep,4 - periodontal pocket more than 6 mm deep.

386 Zovko et al. Periodontal disease in North Herzegovina

According to CPITN index, representative teeth cant difference was not found between the groups were examined in each respondent: 16, 17, 21, regarding periodontal health (p=0.143), norperi- 26, 27, 36, 37, 31, 46, and 47. Based on the exa- odontal diseases, e.g., changes ofperiodontium mination and assessment of periodontal condi- (p=0.519) (Table 1). tions regarding mesial and distal side of each Table 1. Classification of smokers and non-smokers accord- tooth, the treatment needs are determined for ing to periodontal condition each respondent: stage 0 - there is no need for No (%) of participants treatment,stage 1- requires instructions on pro- Smoking status Non-smo- Total per oral hygiene, stage 2 and stage 3 - require Smokers instructions on proper oral hygiene, removal of kers Periodontal Healthy 25 (6.3) 36 (9.0) 61 (7.6) teeth plaque, correction of fillings and prosthetic health Ill 375 (93.7) 364 (91.0) 739 (92.4) devices, polishing of root canal (curettage), stage Gingival bleeding 33 (8.8) 31 (8.5) 64 (8.7) 4 - requires complex periodontal treatment, cu- Calculus 311 (82.9) 310 (85.2) 621 (84.0) Periodontal Shallow periodontal 17 (4.5) 16 (4.4) 33 (4.5) rettage and some methods of periodontal surgery. diseases pockets Deep periodontal 14 (3.7) 7 (1.9) 21 (2.8) A method of determining the average number pockets of sextants affected by bleeding of gingival sulcus, calculus, shallow and deep periodontal Out of 130 smokers in the age group of 20 to 29 pockets was used in estimation of stage of peri- years, 11 (8.5%) respondents had healthy and 119 odontal diseases. (91.5%)unhealthy periodontal tissue, and calcu- The data were statistically processed, and the lus was the most common finding, in98 (82.4%) results were expressed in absolute and relative smokers. In the same age group of non-smo- frequencies (%). Statistically significant differen- kers,15 (10.9%)had healthy periodontium, and ce between non-smokers and smokers was deter- 123 (89.1%)had some pathological changes ofpe- mined by χ2 test with the level of significance set riodontium. Calculuswas also the most common at p=0.05. Relative risk (RR) indicator was obtai- finding in periodontal tissue, and it is presentin ned by dividing the risk of periodontal diseases at 106 (86.2%)participants. Considering changes in smokers with the risk of diseases at non-smokers. periodontal tissue, no significant changes were The confidence interval (CI) of 95%, was used found between the smoking and the non-smoking in research of correlation between smoking and groups (p=0.581). periodontal diseases. Table 2. Classification of smokers and non-smokers accord- All respondents were familiar with the purpose ing to the age and periodontal condition of research and voluntarily agreed to partici- No (%) of participants pate.The Ethics Committee of the Health Care Health condition of Periodontal diseases Center of Prozor-Rama and the Ministry of He- Age periodontium alth, Labour and Social Welfare of the Herze- (years) Gin- Shallow Deep Heal- gival Calcu- perio- perio- govina-Neretva Canton gave their consents for Ill thy blee- lus dontal dontal the research. ding pockets pockets Smokers 11 119 14 98 4 3 RESULTS (n=130) (8.5) (91.5) (11.8) (82.4) (3.4) (2.5) Non-smokers 15 123 12 106 3 2 20 - 29 Out of 400 smokers, only 25 (6.3%)had healthy (n=138) (10.9) (89.1) (9.8) (86.2) (2.4) (1.6) periodontium, while 375 (93.7%)participants Total 26 242 26 204 7 5 (n=268) (9.7) (90.3) (10.7) (84.3) (2.9) (2.1) had various changes on periodontium, withcal- Smokers 8 128 10 108 5 5 culusbeing the most common (it is found in 311 (n=136) (5.9) (94.1) (7.8) (84.4) (3.9) (3.9) Non-smokers 11 113 8 97 6 2 (82.9% of smokers). In non-smokers, 36 (9%)had 30 - 39 (n=124) (8.9) (91.1) (7.1) (85.8) (5.3) (1.8) no pathological changes considering their perio- Total 19 241 18 205 11 7 dontal tissue, while 364 (91%)of them had pa- (n=260) (7.3) (92.7) (7.5) (85.1) (4.6) (2.9) Smokers 6 128 9 105 8 6 thological changes ofperiodontal tissue. Among (n=134) (4.5) (95.5) (7.0) (82.0) (6.3) (4.7) Non-smokers 10 128 11 107 7 3 periodontal diseases, calculuswas the most com- 40 - 49 (n=138) (7.2) (92.8) (8.6) (83.6) (5.5) (2.3) mon in the non-smoker group, and it was found Total 16 256 20 212 15 9 in 310 (85.2%)participants. Statistically signifi- (n=272) (5.9) (94.1) (7.8) (82.8) (5.9) (3.5)

387 Medicinski Glasnik, Volume 11, Number 2, July 2014

In the age group of 30 to 39 healthy periodontal DISCUSSION tissue was more frequently found in non-smokers The purpose of the research was to determine how (11; 8.9%) compared to smokers (8; 5.9%), and smoking of tobacco and tobacco products affects similar to the previous age group, calculuswas the human health.The results show that prevalence of most common finding in108 (84.4%)smokers and periodontal diseases in Prozor-Rama Municipa- 97 (85.8%)non-smokers. Statistically,significant lity is very high in both, smokers and non-smo- difference was not found considering periodontal kers. According to the results of the present study health dependent on smoking habits (p=0.471). the influence of tobacco smoke and smoking ha- In the age group of 40 to 49, more non-smokers bitsisnot as high as it was thought to be. These had healthy periodontium than smokers (10; results showed that smokers had moreperiodontal 7.2% vs. 6; 4.5%). Calculuswas the most co- disease symptoms (shallow and deep periodontal mmon finding in105 (82%)smokers and in 107 pockets, noticeable destruction of alveolar bone) (83.6%)non-smokers. In this age group there was than non-smokers. The obtained results are simi- also no statistically significant difference consi- lar to the results obtained by Računica et al. (24). dering periodontal health between smokers and Epidemiological and clinical studies show that non-smokers (p=0.332) (Table 2). tobacco and its use is a risk factor for occurrence Values of relative risk of gingival bleeding, cal- and development of periodontal disease (25-30). culus and shallow periodontal pockets are about Study of Kinanae and Chesnutt showed that per- 1, which shows that both, smokers and non-smo- sons who stopped smoking reduced the risk of kers have the same chances to suffer from those periodontal diseases, which was associated with diseases (Table 3). However, smokers are twice as negative impact of smoking on humoral and ce- likely to be affected by deep periodontal pockets. llular immune reaction(31). Our study showed that 3.1% of smokers and Table 3. Values of relative risk according to periodontal conditions 4.5% of non-smokers had healthy periodontal ti- Periodontal conditions Relative risk CI (95%) ssue, while alarge proportion of respondents had Gingival bleeding 1.065 0.67 – 1.70 some symptomsthat indicated the presence ofpe- Calculus 1.003 0.93 – 1.08 riodontal disease. It is important to point out that Shallow periodontal pockets 1.063 0.54 – 2.07 calculus was found only in few older respondents Deep periodontal pockets 2.000 0.82 – 4.90 (40-49 years old), significantly more represen- CI, confidence interval ted among youth, but not statistically significant. Analysis of the respondents according to the Explanation of this could be that older respon- need of periodontal disease treatment showed no dents are more motivated in preservation of their statistically significant difference between smo- oral health than members of younger groups.Pa- kers and non-smokers. In both groups the majo- tients’ motivation to preserve their oral health is rity of the respondents had calculus and shallow very important in periodontal disease prevention. periodontal pockets where the dentist had to Our study showed high prevalence of periodontal make prophylaxis, remove calculus and plaque, diseases - 8% participantsneeded instructions on and to do polishing of tooth root and curettage proper oral hygiene, 81.8% needed prophylaxis (PROPH) (Table 4). and initial treatment (PROPH), and 2.6% needed a complex periodontal treatment (SPEC). Table 4. Classification of smokers and non-smokers according to the needs of treating periodontal disease All studies in the last 20 years confirmed that, No. (%) of participants regardless any other additional factors, smoking Smoking status was a high risk of periodontal diseases (32-34). Total Smokers Non-smokers (n=800) (n=400) (n=400) The studyusing the CPITN in 10320 sextants of Healthy periodontium - no 25 (6.3) 36 (9) 61 (7.6) 1720 participants showed that healing ofperi- need for any treatment Oral hygiene instructions odontium in highest percentage can be done in 33 (8.3) 31 (7.8) 64 (8) (OHI) theprimary dental care (21). Polishing of tooth root and 328 (82) 326 (81.5) 654 (81.8) curettage (PROPH) There was no enough research on risks of occu- Specialist periodontal 14 (3.5) 7 (1.8) 21 (2.6) treatment (SPEC) rrence and prevalence of periodontal diseases in

388 Zovko et al. Periodontal disease in North Herzegovina

Bosnia and Herzegovina. One of the earliest in- oral hygiene obviousy masked pathological ef- vestigations in 1978 showed that the prevalence fects of smoking on periodontal tissues in the of oral diseases (caries, periodontitis and malo- present study. cclusion) was registered in 75% of participants. Obtained results indicate a high need for preven- Signs of periodontal disease were found to be tive measures and a need for the improvement of 51% in the group of 14 year olds, 63.5% in the oral health in both studied groups in this region. age group between 35 and 44. In the age group of 25 to 44 yearsperiodontal disease was found in FUNDING 86.4% of participants (35). No specific funding was received for this study. Oral hygiene improvement is the primary goal. Although in available international literature TRANSPARENCY DECLARATIONS smoking has been declaired as a significant risk Competing interests: none to declare. for periodontal disease development, very poor

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34. Dolan A, Gilbert H, Ringelberg L, Legler W. Beha- 35. Maglajlić N,Hatibović Š,Gojković R. Program vioural risk indicators of attachment loss in adults stomatološke preventive u SR BiH. In: Rajić Floridans. J Periodontol 1999; 24:223-32. Z.Preventivniprogrami u stomatologiji. Zagreb: JU- MENA, 1990.

Prevalencija parodontnih bolesti u sjevernoj Hercegovini Ružica Zovko1, Domagoj Glavina2, Mirela Mabić3, Stipo Cvitanović4, Zdenko Šarac1, Ante Ivanković5 1Dom zdravlja Mostar, Bosna i Hercegovina; 2Stomatološki fakultet, Sveučilište u Zagrebu, Hrvatska; 3Ekonomski fakultet, Sveučilište u Mostaru, Bosna i Hercegovina; 4Dom zdravlja Prozor-Rama, Bosna i Hercegovina; 5Medicinski fakultet, Sveučilište u Mostaru, Bosna i Hercegovina SAŽETAK

Cilj Istražiti štetnost pušenja kao lokalnog čimbenika na promjene parodonta (potporne strukture zuba) i nastanak parodontne bolesti među stanovnicima sjeverne Hercegovine.

Metode Istraživanje je obuhvatilo 800 osoba, u dobi od 20 do 49 godina (400 pušača i 400 nepušača), stanovnika općine Prozor-Rama u Bosni i Hercegovini. Parodontološka procjena stanja napravljena je primjenom zajedničkog indeksa potrebe tretmana (CPITN) na reprezentativnim zubima: 16, 17, 21, 26, 27, 36, 37, 31, 46 i 47. Statistički značajna razlika između nepušača i pušača utvrđena je χ2 testom uz razinu značajnosti p=0,05.

Rezultati Prevalencija zdravih parodontnih tkiva bila je niža u pušača nego u nepušača, 25 (6,3%), odnosno 36 (9%). Prevalencija krvarenja gingive, zubnog kamenca, plitkih i dubokih džepova bila je veća u pušača nego u nepušača, iako razlika nije bila statistički značajna. Utvrđen je veći rizik pojave dubokih parodontnih džepova kod pušača (RR=2). Ukupno 64 (8%) ispitanika trebalo je samo upute za pravilnu oralnu higijenu, 654 (81,8%) profilaksu i početno liječenje, dok je 21 (2,6%) ispitanik trebao složeni parodontni tretman.

Zaključak Dobiveni rezultati ukazuju na visoku potrebu prevencije i unapređenja oralnog zdravlja među stanovnicima sjeverne Hercegovine.

Ključne riječi: Bosna i Hercegovina, nikotin, nepušači, pušači, parodont, Prozor-Rama

390 AUTHOR’S CORRECTION

Evaluation of quality of life after radical prostatectomy- experience in Serbia

Svetomir M. Dragićević1, Snežana P. Krejović-Marić2, Bajram H. Hasani3

1Clinic for Urology and Nephrology, Clinical center of Serbia, Belgrade, 2Regional General Hospital Užice- Health Center Užice, Užice, 3Health Center Bujanovac, Bujanovac; Serbia

Volume 9, no. 2, p. 388–392, 2012. Page 388: The byline should appear as shown above.

391 AUTHOR’S AFFILIATION CORRECTION

Hydronephrosis during pregnancy: how to make a decision for the time of intervention?

Mehmet Nuri Bodakci1, Namık Kemal Hatipoglu1, Ali Ozler2, Abdulkadir Turgut2, Cihad Hamidi3, Nebahat Hatipoglu4, Bircan Alan5

1Department of Urology, University of Dicle, 2Department of Gynecology and Obstetrics, University of Dicle, 3Department of Radiology, University of Dicle, 4Department of Radiology, Diyarbakir Education and Research Hospital, Diyarbakır Hospital, 5Department of Radiol- ogy, Diyarbakir Obstetrics and Gynecology and Children Diseases Hospital; Diyarbakır, Turkey

Volume 11, no. 1, p. 165–169, 2014. Page 165: author’s affiliation should appear as shown above.

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