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Introduction: Endometriosis is a benign condition affecting females of reproductive age. Although intestinal endometriosis is common, it is rarely manifested as an acute bowel obstruction secondary to ileal endometriosis. Enteric endometriosis should be considered as a differential diagnosis when assessing females of reproductive age with acute small bowel obstruction., Case Outline: A 41-year-old woman presented with symptoms and signs of an acute small bowel obstruction requiring emergency surgery. A small bowel resection was performed with end-to-end anastomosis. Histological examination demonstrated endometriosis with fibrosis and stricture of the ileal segment. This case is important to report as it highlights the diagnostic difficulty this particular condition pre sents to an emergency surgeon., Conclusion: In the differential diagnosis, endometriosis should be taken into consideration when assessing females of reproductive age who present with abdominal pain and small bowel obstruction.

Fatigue is a prominent symptom in a large number of medical conditions, malignant and infectious diseases. Fatigue is also a prominent symptom of sarcoidosis. The occurrence of fatigue in sarcoidosis is well known but exact incidence has not been established and varies from 30-70% of patients depending on age, sex and organ involvement by the granulomatous process. The exact definition of fatigue varies broadly. It can be both physical and mental. The patients describe their sensation of fatigue qualitatively different from that fatigue they experienced before they became sick. Fatigue has a major impact on the quality of life in sarcoidosis. Establishing the extent of fatigue in sarcoidosis provides relevant insight regarding the patient's quality of life. Unfortunately there is no objective parameter for assessing fatigue in sarcoidosis. Generally, fatigue is detected by means of questionnaires. Regarding the therapy, there is no effective treatment for fatigue in sarcoidosis.

Introduction: The pathogenesis of perinatal hypoxic-ischemic brain damage is highly complex., Objective: The aim of this study was to assess the role of oxidative stress in hypoxic-ischemic brain injury and subsequent abnormal neurological outcome in infants with perinatal hypoxic-ischemic encephalopathy (HIE). We estimated perinatal oxidative brain damage measuring activity of glutathione peroxidase (GPX) in cerebrospinal fluid (CSF) as an indirect biomarker of free radical production during cerebral hypoxia-ischemia in correlation with the level of intracellular enzyme neuron specific enolase (NSE) in CSF as a biomarker of extend of brain injury., Methods: Ninety neonates (>32 GA) with perinatal HIE were enrolled prospectively. HIE was categorized into three stages according Sarnat and Sarnat clinical scoring system and changes seen on amplitude integrated EEG. CSF for GPX analysis and NSE analysis was taken in the first 72 hours of life. Neurodevelopment outcome was assessed at 12 months of corrected gestational age., Results: GPX activity in CSF was in good relation with clinical stage of HIE (p < 0.0001) and GA (p < 0.0001) and significantly corresponded with subsequent neurodevelopment outcome (p < 0.001). GPX activity in CSF showed a strong correlation with NSE levels in CSF (p < 0.001) as the biomarker of extent of brain injury., Conclusion: Our results suggest that oxidative stress might be important contributing factor in perinatal hypoxic-ischemic brain damage, particularly in preterm neonates.

Introduction: Osteoporosis is a serious problem, since about 50% of women over the age of 50 suffer at least one osteoporotic fracture., Objective: The aim of this study was to evaluate compliance as well as the efficiency and safety of ibandronate treatment over a 6-month period in reducing the risk of subsequent fracture in women with postmenopausal osteoporosis., Methods: A multicenter, prospective, observational study was conducted during one year in thirteen medical centres in Serbia. In the first part of the study the participants received ibandronate tablets (150 mg) once a month for six months. In the second part, the patients were under clinical follow-up., Results: The mean age of the 184 menopausal women included in the study was 66.2 +/- 9.4 years. In 40.2% of the subjects the disease had been clinically manifest during the five preceding years. The mean T-score value at the onset of our investigation was -3.1 +/- 0.84 in 160 (87%) patients who were diagnosed osteoporosis. Compression vertebral fractures alone were noted in 24% of the women, spontaneous nonvertebral fractures in 49.4% and both in 4.9%. A history of osteoporotic fractures was much more common in patients with three or four risk factors (p = 0.001). Out of 39 adverse events during therapy with once monthly bisphosphonates only 2 (3.3%) were classified as severe. During the treatment, spontaneous fractures occurred in 13 (7.1%) patients., Conclusion: Ibadronate treatment once a month for 6 months was shown to be very safe, tolerated well and without more serious side effects.

Introduction: An altered perfusion of the optic nerve head has been proposed as a pathogenic factor in glaucoma., Objective: To evaluate changes of haemodynamic parameters in the retrobulbar arterial circulation after a decrease of elevated intraocular pressure (IOP) in patients with primary open angle glaucoma (POAG)., Methods: Twenty-six patients were examined, 14 men and 12 women, 21 up to 50 years old and 5 below, all with previously diagnosed and treated POAG, and all examined at the Eye Clinic, Clinical Centre of Serbia. IOP was measured both with a Goldmann aplanation tonometer and dynamic contour tonometer. Central corneal thickness was measured with ultrasound pachymeter. Imaging of the retrobulbar arterial circulation by colour Doppler was performed at the Neurology Clinic, Clinical Centre of Serbia. It involved measuring of haemodynamic parameters of the ophthalmic artery, central retinal artery, and posterior ciliary arteries. Peak systolic velocity (PSV) and end-diastolic velocity (EDV) were measured, and resistive index (RI) and pulsatility index (PI) were calculated., Results: Haemodynamic arterial parameters PSV and EDV in the ophthalmic and central retinal artery after decrease of IOP were lower, while RI and PI were higher. In the posterior ciliary arteries PSV, EDV and PI were lower, and RI was higher., Conclusion: Changes of the retrobulbar arterial circulation after elevated LOP in POAG patients are important for approach and treatment, while the role of vascular factors in the supplement of the optic disc neuroretinal rim could be a key for progression backlash of glaucoma and the radix of neuroprotection.

Introduction: The last decade of the usage of intrauterine contraception has been marked by the application of levonorgestrel-releasing hormonal devices. A hormonal intrauterine device (IUD) releases a certain amount of progestogen, whose effect on endometrium is such that, apart from preventing unwanted pregnancy, also regulates the menstrual bleeding by reducing the quantity and the duration of haemorrhage. This effect of hormonal IUDs has led to their additional indications and use, so that nowadays these IUDs are used not only as contraceptives but for therapeutic purposes as well., Case Outline: After examination and treatment in an out-patient department, a 38-year-old woman was referred to our hospital due to suspected spontaneous uterine perforation caused by hormonal IUD (Mirena) one month after its application. Clinical and sonographic examinations were unable to determine the uterine perforation or the exact IUD location. Radiographic examination confirmed the presence of the IUD in the abdomen, so it was decided to operate on the patient. Perforation in the isthmus of the uterus and to the right was identified intraoperatively. By exploration of the genital organs and the abdominal cavity, the IUD was finally located in the omentum., Conclusion: Even in cases of adequate indications for hormonal IUD application, the doctor's experience and complying with all the principles of appropriate insertion, we should always consider the possibility of the occurrence of serious complications, which sometimes may even require surgery. The extragenital position of IUD, as in this case, may create serious difficulties in the detection of location. A possible development of asymptomatic complications additionally emphasizes the necessity of regular check-ups of all IUD users.

Introduction: Several cardiovascular manifestations in patients with diabetes may be asymptomatic. Left ventricular diastolic dysfunction (LVDD) is considered to be the earliest metabolic myocardial lesion in these patients, and can be diagnosed with tissue Doppler echocardiography. Silent myocardial ischemia (SMI) is a characteristic and frequently described form of ischemic heart disease in patients with diabetes. Objective The aim of the study was to assess the prevalence of LVDD and SMI in patients with type 2 diabetes, as well as to compare demographic, clinical, and metabolic data among defined groups (patients with LVDD, patients with SMI and patients with type 2 diabetes, without LVDD and SMI)., Methods: We investigated 104 type 2 diabetic patients (mean age 55.4 +/- 9.1 years, 64.4% males) with normal blood pressure, prehypertension and arterial hypertension stage I. Study design included basic laboratory assessment and cardiological workup (transthoracic echocardiography and tissue Doppler, as well as the exercise stress echocardiography)., Results: LVDD was diagnosed in twelve patients (11.5%), while SMI was revealed in six patients (5.8%). Less patients with LVDD were using metformin, in comparison to other two groups (chi2 =12.152; p=0.002). Values of HDL cholesterol (F=4.515; p=0.013) and apolipoprotein A1 (F=5.128; p= 0.008) were significantly higher in patients with LVDD., Conclusion: The study confirmed asymptomatic cardiovascular complications in 17.3% patients with type 2 diabetes.

Introduction: Lung cancer is the leading cause of death from malignancy in Serbia., Objective: This is a retrospective analysis of lung cancer epidemiological changes regarding to its histological type and patients' age of both genders. Data were based on surgically treated lung cancer patients from 1985 to 2005., Methods: Data were collected from 972 pathohistological reports of operated patients of both genders divided into age groups. Histological types of lung cancer were distributed in four major groups: squamous cell cancer (SCC), adenocarcinoma (AC), small cell cancer (SCLC) and other rare histological types. Both genders together and separately were analysed. Chi-square with the level of significance p<0.05 and chi-square test for trends were used as statistical methods., Results: SCC predominated in both genders; in 44.7% females and 68.0% males. AC was less frequently diagnosed (21.8%) than SCC (64.0%) in both genders and all age groups. The most frequently operated patients were aged between 51 and 60 years (36.6%) with SCC and AC predominance. Three patients with SCLC were operated in 61-70 age-group. In age-group up to 30 years, three (0.5%) patients were operated on for SCC and other rare lung tumours, respectively. Predominance of other rare lung tumours was established in 51-60 age-group, 25% of patients of both genders., Conclusion: SCC is the most frequent histological type of lung cancer found in all age groups and in both genders of surgically treated patients.

Introduction: An altered perfusion of the optic nerve head has been proposed as a pathogenic factor in glaucoma., Objective: The aim of this study was to evaluate the correlation between ocular pulse amplitude (OPA), measured by Dynamic contour tonometer (DCT) and colour Doppler imaging (CDI) of the arteric retrobulbar vessels., Methods: Twenty patients older than 50 years were examined, and divided into two equal groups. The first group comprised of patients with normal tension glaucoma treated with topical antiglaucomatous therapy, and the second group included patients with ocular hypertension and glaucoma suspicious without any antiglaucomatous therapy. Ocular pulse amplitude (OPA) was measured with DCT. CDI was also performed. We measured haemodynamic parameters of the internal carotid artery (ICA), ophthalmic artery (OA), central retinal artery (CRA), and posterior ciliary arteries (PCA). Peak systolic (PSV), end-diastolic (EDV) velocities were measured, and resistance index (RI) and pulsatility index (PI) were calculated., Results: Correlation with OPA showed indirect servitude in the RI of the ICA, RI and PI of the CRA, in the first group; and in the PSV and EDV of the ICA, in the RI and PI of the OA, EDV and RI of the CRA, and RI of the PCA, in the second group, Conclusion: Increase of OPA was mostly followed by the increase of the parameters (PSV, EDV, RI, and PI) of the arteric retrobulbar vessels in the first group; in the second group, increase of OPA was in almost 50% of parameters followed by their decrease.

Unlabelled: INTRODUCTION; Sarcoidosis is a multisystem, granulomatous disease of unknown etiology. Sarcoid granulomas appear as immunological response to a particular but still unknown agent of the human body., Objective: The main purpose of this study was to point out the important fact that the exact diagnosis of sarcoidosis must be estimated by clinical and pathological correlation, and team cooperation between the clinician and the pathologist., Methods: Of 751 patients referred with the suspected diagnosis of sarcoidosis, from 1995 to 1999, 663 (431 female and 232 male) were analyzed and confirmed as having sarcoidosis stage I-III based on biopsy findings obtained by bronchoscopy, open lung biopsy, skin biopsy, liver biopsy or splenectomy., Results: Diagnosis of sarcoidosis was made in 663 patients, 431 females and 232 males (ratio 1.9:1). The average age of patients varied from 16 to 67 years, with those below age 50 years being predominant (78.4%). The highest number of patients was diagnosed in stage I of lung sarcoidosis (81.7%). Sarcoidosis was the most common cause of hilar and mediastinal lymphadenopathy (72.2%)., Conclusion: Biopsy is a necessary diagnostic procedure for pathological diagnosis of sarcoid granuloma before treatment even in patients where clinical, radiological, biochemical and immunological tests imply the diagnosis of sarcoidosis.

Introduction: New arrhythmias (NA) may appear late after accessory pathway (AP) ablation, but their relation to curative radiofrequency (RF) lesion is unknown., Objective: The aim of this study was to determine the prevalence and predictors for NA occurrence after AP ablation and to investigate pro-arrhythmic effect of RF., Methods: Total of 124 patients (88 males, mean age 43 +/- 14 years) with Wolff-Parkinson-White syndrome and single AP have been followed after successful RF ablation. Post-ablation finding of arrhythmia, not recorded before the procedure, was considered a NA. The origin of NA was assessed by analysis of P-wave and/or QRS-complex morphology, and, thereafter, it was compared with locations of previously ablated APs., Results: Over the follow-up of 4.3 +/- 3.9 years, NA was registered in 20 patients (16%). The prevalence of specific NAs was as follows: atrioventricular (AV) block 0.8%, atrial premature beats 1.6%, atrial fibrillation 5.4%, atrial flutter 0.8%, sinus tachycardia 4.8%, ventricular premature beats (VPBs) 7.3%. Multivariate Cox-regression analysis identified (1) pre-ablation history of pathway-mediated tachyarrhythmias >10 years (HR = 3.54, p = 0.016) and (2) septal AP location (HR = 4.25, p = 0.003), as the independent predictors for NA occurrence. In four NA cases (two cases of septal VPBs, one of typical AFL and one of AV-block) presumed NA origin was identified in the vicinity of previous ablation target., Conclusion: NAs were found in 16% of patients after AP elimination. In few of these cases, late on-site arrhythmic effect of initially curative RF lesion might be possible. While earlier intervention could prevent NA occurrence, closer follow-up is advised after ablation of septal AP.

Introduction: Deep infiltrating endometriosis is a form of endometriosis penetrating deeply under the peritoneal surface causing pain and infertility. Assessment of the pelvis by laparoscopy and histological confirmation of the disease is considered the golden standard of diagnosis., Case Outline: We are presenting a patient diagnosed with deep infiltrating endometriosis by transvaginal ultrasound and treated with minimally invasive radical surgery including segmental resection of the bowel., Conclusion: Transvaginal sonography has an important role in detecting deep endometriosis of the pelvis. Fertility sparing surgery is the treatment of choice in symptomatic women wishing to retain fertility, since drugs used for endometriosis interfere with ovulation.The success of the surgery depends on the accuracy of the preoperative diagnosis. A multidisciplinary approach in managing deep endometriosis is mandatory in order to offer patients the best possible treatment using the combined skills of the colorectal and gynaecologic surgical teams. The presented case exhibits the feasibility of laparoscopic approach to severe pelvic endometriosis with bowel involvement.

Introduction: Therapy related acute myeloid leukaemia (t-AML) is a distinct clinical entity recognized by the World Health Organization classification occurring after chemotherapy and/or radiation treatment administered for a previous disease. T-AML is characterised by pancytopenia, three-lineage myelodysplasia, high frequency of unfavourable cytogenetics and short survival., Objective: The aim of this study was to analyse clinical, cytogenetic, and cytological characteristics of t-AML and their impact on survival., Methods: Seventeen patients with t-AML (8 male and 9 female; median age 59 years) were identified among 730 consecutive patients with acute myeloid leukaemia. The degree of three-lineage dysplasia as well as haematological, cytological and cytogenetic analyses, were assessed by standard methods., Results: The patients survived a median of 62.5 days with the 10% probability of survival during two years. Prognostically favourable factors were a higher percentage of dysplastic granulocytic cells, age less than 60 years, and presence of prognostically favourable karyotype inv(16), t(15;17), t(8;21)., Conclusion: The stated prognostic factors that include age, cytogenetics findings and granulocytic dysplasia analysis could contribute to adequate risk stratification of t-AML, though fuller results would require additional analyses.

Introduction: Adnexal torsion is a rare cause of acute abdominal pain during pregnancy. The clinical and laboratory findings are non-specific. In this paper we present a case of adnexal torsion in the first trimester of pregnancy., Case Outline: On admission, the patient presented signs of acute abdomen.The pain started few hours prior to admission, and was predominantly localized, occasionally irradiating to the central parts of the lower abdomen, accompanied by nausea and vomiting. Ultrasound revealed viable intrauterine pregnancy and right adnexal mass with small amount of free fluid in the Douglas pouch. After short preoperative evaluation, laparotomy and adnexectomy were performed. Surgery and postoperative followup were uneventful, and histopathology reported torquated corpus luteum cysts., Conclusion: The diagnosis of adnexal torsion during pregnancy is difficult, and occasionally remains a diagnostic dilemma. Surgery is inevitable, must be prompt, and comprises adnexectomy.

Introduction: Over the last three decades the prevalence of respiratory diseases has been increasing worldwide thus increasing economic burden on the healthcare system. Recent studies have shown that the prevalence of asthma in West European countries ranges from 6-9%, while of chronic obstructive pulmonary diseases (COPD) is 8.0% worldwide., Objective: The aim of the study was to estimate the prevalence of respiratory symptoms and smoking habits, and to assess the prevalence of asthma and chronic bronchitis among adults in Belgrade, Serbia., Methods: To collect data we used a questionnaire based on the European Community Respiratory Health Survey (ECRHS) protocol, which was mailed to 10,208 randomly selected subjects., Results: There were 58.3% of responders to our questionnaire. We noted a higher prevalence of respiratory symptoms in subjects who responded promptly. The majority of the respondents were current or former smokers (37.5% and 17.5% respectively) and 79.9% of them reported respiratory symptoms. The most frequent symptoms were longstanding cough (32.2%), sputum production (30.4%) and wheezing (30.3%). Asthma attacks were reported in 4.4% of cases and 5.6% of subjects were using asthma medications. The prevalence of respiratory symptoms increased with age. Women reported coughing, attacks of breathlessness and coughing, chest tightness by night, allergic rhinitis and chronic coughing, more frequently than men. Productive cough was more frequent in men. The prevalence of almost all symptoms was higher in smokers compared to nonsmokers., Conclusion: In Serbia there is a high prevalence of respiratory symptoms, asthma and chronic bronchitis smoking addiction.

Antiphospholipid syndrome (APS) is an autoimmune disease with recurrent thromboses and pregnancy complications (90% are female patients) that can be primary and secondary (with concomitant autoimmune disease). Antiphospholipid antibodies are prothrombotic but also act directly with brain tissue. One clinical and one laboratory criterion is necessary for the diagnosis of APS. Positive serological tests have to be confirmed after at least 12 weeks. Clinical picture consists of thromboses in many organs and spontaneous miscarriages, sometimes thrombocytopaenia and haemolytic anaemia, but neurological cases are the most frequent: headaches, stroke, encephalopathy, seizures, visual disturbances, Sneddon syndrome, dementia, vertigo, chorea, balism, transitory global amnesia, psychosis, transversal myelopathy and Guillain-Barre syndrome. About 50% of strokes below 50 years of age are caused by APS. The first line of therapy in stroke is anticoagulation: intravenous heparin or low-weight heparins. In chronic treatment, oral anticoagulation and antiplatelet therapy are used, warfarin and aspirin, mostly for life. In resistant cases, corticosteroids, intravenous immunoglobulins and plasmapheresis are necessary. Prognosis is good in most patients but some are treatment-resistant with recurrent thrombotic events and eventually death.

Pelvic inflammatory disease (PID) is polymicrobial infection in women characterized by inflammation of the upper genital tract, including endometritis, salpingitis, pelvic peritonitis, occasionally leading to the formation of tubo-ovarian abscess (TOA). PID primarily affects young, sexually active women, and it is highly correlated with having several sexual partners, intrauterine contraceptive device and sexually transmitted diseases. The spectrum of disease is caused most commonly by Chlamydia trachomatis and Neisseria gonorrhoeae in 30-50% of cases. PID is responsible for severe acute morbidity and significant long-term sequelae, including tubal factor infertility, ectopic pregnancy, and chronic pelvic pain. The following clinical features are suggestive of a diagnosis of PID: bilateral lower abdominal tenderness, abnormal vaginal or cervical discharge, fever (higher than 38 degrees C), abnormal vaginal bleeding, dyspareunia, cervical motion tenderness and adnexal tenderness, with or without a palpable mass. In laboratory findings, there is presence of excess leucocytes, elevated erythrocyte sedimentation rate or C-reactive protein. Transvaginal ultrasound scanning may be helpful, and its sensitivity is up to 85%. It can identify inflamed and dilated tubes and tubo-ovarian masses. Magnetic resonance imaging can be helpful in a final diagnosis in 95% of cases. In 15-30% of suspected cases, there is no laparoscopic evidence of disease. Treatment regimens for PID include broad-spectrum antibiotics, including coverage for Neisseria gonorrhoeae and Chlamydia trachomatis. The usage of parenteral or oral therapy, inpatient or outpatient regimens, depends on the patient's clinical condition. Considering the potential complications of disease, there is a need for good health educational programmes in reproductive period.

Introduction: In anaesthesiology, economic aspects have been insufficiently studied., Objective: The aim of this paper was the assessment of rational choice of the anaesthesiological services based on the analysis of the scope, distribution, trend and cost., Methods: The costs of anaesthesiological services were counted based on "unit" prices from the Republic Health Insurance Fund. Data were analysed by methods of descriptive statistics and statistical significance was tested by Student's t-test and chi2-test., Results: The number of general anaesthesia was higher and average time of general anaesthesia was shorter, without statistical significance (t-test, p = 0.436) during 2006 compared to the previous year. Local anaesthesia was significantly higher (chi2-test, p = 0.001) in relation to planned operation in emergency surgery. The analysis of total anaesthesiological procedures revealed that a number of procedures significantly increased in ENT and MFH surgery, and ophthalmology, while some reduction was observed in general surgery, orthopaedics and trauma surgery and cardiovascular surgery (chi2-test, p = 0.000). The number of analgesia was higher than other procedures (chi2-test, p = 0.000). The structure of the cost was 24% in neurosurgery, 16% in digestive (general) surgery,14% in gynaecology and obstetrics, 13% in cardiovascular surgery and 9% in emergency room. Anaesthesiological services costs were the highest in neurosurgery, due to the length anaesthesia, and digestive surgery due to the total number of general anaesthesia performed., Conclusion: It is important to implement pharmacoeconomic studies in all departments, and to separate the anaesthesia services for emergency and planned operations. Disproportions between the number of anaesthesia, surgery interventions and the number of patients in surgical departments gives reason to design relation database.

Introduction: Aplastic anaemia is a rare but potentially fatal complication of treatment with ticlopidine., Case Outline: We present a 55-year-old male with aplastic anaemia which developed after 45 days of the therapy with 200 mg ticlopidine to prevent coronary thrombosis. The treatment with ticlopidine was withdrawn and broad spectrum antibiotics as well as transfusion of packed red cells, platelets and G-CSF were administered. Two weeks after the onset of the disease, the number of white blood cells dropped to 0.5 x 10(9)/l, along with drop of both haemoglobin concentration and the number of platelets. At that time, weakness of facial muscles due to bilateral facial nerve paralysis with Bell's phenomenon and after that weakness of muscles of both legs and signs of polyradiculoneuritis were developed. Western blot analysis of blood and liquor showed a high concentration of IgG and IgM antibodies against Borrelia burgdorferi. The treatment with cephtriaxone resulted in normalization of body temperature and gradual recovery of neurological findings. Blood picture became normal two months after the onset of the disease., Conclusion: The treatment with ticlopidine may result in different haematological complications such as agranulocytosis/ granulocytopaenia, thrombotic trombocytopenic purpura and rarely aplastic anaemia. Due to these complications blood pictures in patients on this therapy should be closely followed up and in case of complications, the treatment with ticlopidine has to be stopped and introduce the therapeutic procedures depending on the sort of the complications and clinical presentation.

Introduction: The causes leading to dislocation of the natural lenses are different involving injuries, hereditary diseases and spontaneous dislocation. Spontaneous dislocation of a transparent natural lens is extremely rare, especially dislocation of the anterior eye chamber. We report a case of spontaneous dislocation of the transparent natural lens to the anterior eye chamber in a patient who had no history of eye injuries., Case Outline: The patient was a 17-year-old boy. Lens dislocation was spontaneous, and the patient presented for ophthalmological consultation due to a sudden vision impairment of the left eye. Biomicroscopic examination verified that the transparent lens was in the anterior chamber, and it was spherophakia of lesser diameter; there were no signs of increased intraocular pressure, as typically expected in lens dislocation to the anterior chamber. The patient was operated on in general anaesthesia. Surgery involved intracapsular extraction of the dislocated lens through a corneoscleral incision., Conclusion: This case report shows that a spontaneous dislocation of the natural lens may occur in younger people. The dislocated spherophakic lens to the anterior eye chamber did not contribute to the rise of the intraocular pressure and development of acute glaucoma. The acute glaucoma resulted from the pilocarpine narrowing of the pupil due to pupillary block. The intracapsular instrumental extraction of the dislocated transparent lens from the anterior chamber was successfully completed through a corneoscleral incision.

Introduction: Incontinentia pigmenti (IP) is an X-linked genodermatosis in which skin changes are combined with dental, eye and central nervous system anomalies., Objective: The goal of the study was to analyze ocular findings, IP minor criteria in available literature concerning IP cases published until now., Methods: We have done meta-analysis of 1931 IP patients found in 302 references published until 2010. Comparison of data published for the 1906-1976 and 1976-2010 periods was made. The collected data were mainly frequencies of ocular anomalies. Chi-square test was used to compare observed frequencies with their expectations., Results: Of total number of IP patients, 1227 were ophthalmologically investigated. In 449 such patients 972 eye anomalies were registered, 2.16 anomalies per patient. Proportion of ophthalmologically investigated IP patients in the period 1906-1975 (70%) was higher than corresponding proportion (60%) for the period 1976-2010. For 1906-2010 period 36.5% IP patients with eye anomalies were diagnosed. The number of amaurotic eyes per patient did not significantly differ for the two periods (p = 0.50; > 0.05). The total number of eye anomalies per patient significantly differed for the same periods (p = 0.00005; < 0.05). Retinal anomalies were most frequent in both periods., Conclusion: This study suggests that IP is far more frequent than anyone could estimate. We believe that this study, covering 1906-2010 period, gives more reliable information about ophthalmological findings in IP; considering them as severe anomalies. Early detection and treatment of ophthalmological, neurological etc. findings may prevent severe consequences that IP may cause.

Introduction: The Pascal Dynamic Contour Tonometer (DCT) is an ophthalmic investigational device which directly calculates the dynamic pulsatile fluctuations in intraocular pressure (IOP) using a piezoelectric pressure sensor embedded in the devices tip., Objective: The aim of this study was to compare IOP results obtained with Goldmann applanation tonometer (GAT), and their correlation with central corneal thickness (CCT) in patients of various age groups., Methods: We studied 37 patients (17 male and 20 female), divided into three age groups: younger than 40 years; 40-60 years old, and older than 60 years. In the first and second group there were patients rarely and in the third mostly diagnosed and medicamentously compensated glaucoma. In topical anaesthesia, first we measured CCT, with ultrasound pachimeter, then IOP with DCT and GAT., Results: Statistically significant difference between measurements of IOP with the DCT and GAT appeared in all groups: I mean diff. -1.71 +/- 1.27 mm; p < 0.0001; II mean diff. -1.19 +/- 1.06 mm; p < 0.0001; III mean diff. -1.69 +/- 1.67 mm; p < 0.0001. CCT was in indirect correlation with the values of IOP measured both with the DCT and GAT in the first and third, while it was in the direct correlation with these values in the second group., Conclusion: CCT had no influence on IOP measurements both with the DCT and GAT in none of the groups. The DCT cannot replace GAT, but it is a reliable device for the measurement of IOP particularly in corneal deformations (keratoconus, after corneal refractive surgery, corneal scars, etc.).

Introduction: Incontinentia pigmenti (IP) is a rare complex X-linked genodermatosis in which skin changes are combined with anomalies of other organs. Mutations of the NEMO gene localized on chromosome Xq28 are responsible for IP. Clinical manifestations of IP according to evolution and prognosis can be considered as skin changes and dental, eye and central nervous system changes., Objective: The aim of our study was to investigate type and frequency of ocular features in Serbian population., Methods: We investigated the total of 9 families with 22 subjects, 20 females and 2 males, at the Institute of Dermatovenerology, Clinical Centre of Serbia, in the period from 1989 to 2009. Our subjects were diagnosed clinically by a dermatologist and the diagnosis confirmed by cutaneous histopathology and ultrastructural analysis. The pedigrees, karyotype analyses, routine laboratory findings, additional specialized clinical examinations were done for all subjects., Results: Among 22 IP patients from our study, different ophthalmological anomalies were observed in 16% of subjects. In female subjects, all of them with clinical characteristics of IP, we observed the following anomalies: retinal detachment, microphthalmia, cataract, strabismus and nystagmus., Conclusion: Compared to available literature data, our percentage of IP patients with anomalies was lower. It may be due to differences in examined populations or due to the fact that the patients in our study were firstly admitted to the Institute of Dermatology. Ophthalmological findings may be often considered as very severe anomalies in IP. It is very important to detect IP as early as possible, medically help and monitor these patients.

An immune-mediated, severe, acquired prothrombotic disorder, heparin-induced thrombocytopenia type II (HIT II) occurs in 0.5-5% of patients exposed to unfractionated heparin longer than 5-7 days. Arterial and venous thromboses are induced by HIT II in about 35-50% of patients. Typical death rate for HIT is about 29%, while 21% of HIT patients result in amputation of a limb. The trend towards the occurrence of HIT due to the administration of low molecular weight heparins (LMWH) taking ever conspicuous place in the standard venous thromboembolism (VTE) prophylaxis has been more frequently observed recently. It is considered that LMWH may cause HIT II in about 0.25-1%. The need for further modification of HIPA assays with LMWH has been imposed in the HIT laboratory diagnostics, heretofore overburdened with complexity. There are several constantly opposing problems arising in HIT laboratory diagnostics, one of which is that in a certain number of patients immunologic assays detect nonpathogenic antibodies (mainly IgM or IgA heparin-PF4 antibodies) while, on the other hand, the occurrence of HIT pathogenetically mediated by minor antigens (neutrophil-activating peptide 2 or interleukin 8) may be neglected in certain cases. The following factors play an important role in the interpretation of each laboratory HIT assays performed: 1. correlation with HIT clinical probability test, the best known of which is 4T'score, 2. the interpretation of the laboratory findings dependent on the time of the thrombocytopenia onset, as well as 3. the sensitivity and specificity of each test respectively. The HIT diagnostics in the presence of other comorbid states which may also induce thrombocytopenia, more precisely known as pseudo HIT (cancer, sepsis, disseminated intravascular coagulation, pulmonary embolism, antiphospholipid syndrome, etc), represents a specific clinical problem.

Introduction: The incidence rate of nasopharyngeal carcinoma in Serbia is less than one per 100,000 citizens, which classifies it as a region with low incidence for this disease., Objective: The aim of this study was to test some hypotheses of the risk factors for undifferentiated carcinoma of nasopharyngeal type (UCNT) in the low incidence population., Methods: A case-control study was used for the research. The study included 45 cases with histopathological diagnosis of UCNT and 90 controls. Cases and the controls were individually matched by sex, age (+/- 3 years), and place of residence (city-village). Data were gathered about sociodemographic characteristics, occupational exposure to harmful agents, habits, diet, personal history, and family history. In the analysis of the data, conditional univariate and multivariate logistic regression analyses were applied., Results: According to the results of multivariate logistic regression analysis UCNT was significantly positively associated with "passive smoking" of tobacco in the family during childhood, frequent consumption of industrially manufactured food additives for enhancing flavour and frequent consumption of white bread. UCNT was significantly negatively associated with frequent consumption of margarine, olive oil and cornbread., Conclusion: In our low incidence population, an independent risk factor for the occurrence of UCNT was "passive smoking" of tobacco in the family during childhood, use of industrially manufactured food with additives for enhancing flavour and consumption of white bread. Multicentric study enrolling a greater number of cases would be desirable.

Acquired inhibitors against coagulation factor VIII (FVIII), also termed acquired haemophilia A, neutralize its procoagulant function and result in severe or often life-threatening bleeding. The antibodies arise in individuals with no prior history of clinical bleeding. Acquired haemophilia occurs rarely with the incidence of approximately 1 to 4 per million/year, with severe bleeds in up to 90% of affected patients, and high mortality between 8-22%. About 50% of diagnosed patients were previously healthy, while the remaining cases may be associated with postpartum period, autoimmune diseases, malignancy, infections, or medications. Most patients have spontaneous haemorrhages into the skin, muscles or soft tissues, and mucous membranes, or after trauma and surgery, whereas haemarthroses are uncommon. The diagnosis of acquired haemophilia A based on the prolongation of activated partial thromboplastin time which does not normalize after the addition of normal plasma, reduced FVIII, with evidence of FVIII inhibitor measured by the Bethesda assay (Nijmegen modification). The treatment of acute bleeding episodes and the long-term eradication of the autoantibodies in acquired haemophilia are the main therapeutic strategy. Two options are currently available for acute bleeding control: the use rFVIIa or FEIBA in patients with higher inhibitor titer (> 5 BU), or to raise the level of FVIII by administration of DDAVP or concentrates of FVIII in patients with low level of inhibitors (< 5 BU). Treatment with FEIBA (50-100 IU/ kg every 8-12 hours) has shown good haemostatic response in 76-89% of the bleeding episodes. Patients treated with rFVIIa (90 microg/kg every 2-6 hours) have achieved good response in 95-100% as a first-line, and 75-80% as a salvage therapy. Patients with low inhibitor titer and lower response can be treated with concentrate of FVIII in the recommended dose of 40 IU/kg plus 20 IU/kg for each BU of inhibitor. The treatment of non-life-threatening haemorrhages with desmopressin (DDAVP 0.3 microg/kg) may increase both FVIII and vWF. Sometimes inhibitors disappear spontaneously, but long-term management is necessary for eradication of inhibitors by immunosuppression (prednisone 1 mg/kg 3 weeks alone or in combination cyclophosphamide 2 mg/kg), immunomodulation, intravenous immunoglobulin (HD IgG 2 g/kg 2 or 5 d), physical removal of antibodies (plasmapheresis or immunoadsorption), or various combinations. Recently, a therapy with rituximab, an anti-CD20 monoclonal antibody, has shown to be effective in acquired haemophilia.

Although the maintenance of precise balance between coagulation and fibrinolysis is of utmost importance for normal haemostasis, until recently these two systems were considered as completely separate mechanisms involved in the process of formation and dissolution of blood clot. Thrombin activatable fibrinolysis inhibitor (TAFI) is a recently described attenuator of the fibrinolytic rate and is considered to be the molecular link between coagulation and fibrinolysis. TAFI circulates in plasma as an inactive precursor and its conversion in active enzyme (TAFIa) occurs by the action of thrombin or plasmin, but most efficiently by thrombin in the presence of its cofactor thrombomodulin. Once generated, TAFI down-regulates fibrinolysis by removing C-terminal lysine residues from partially degraded fibrin; thereby preventing the upregulation of plasminogen binding and activation. Because TAFI is activated by thrombin on one side, and acts as the attenuator of fibrinolysis on another side, it enables fine synchronization between these two systems. The antifibrinolytic function of TAFI mostly depends on TAFI concentration, the rate of its activation and the half-life of TAFIa in plasma. Changes in thrombin generation can have a profound effect on the rate of TAFI activation, and consequently on the rate of fibrinolysis. Therefore, it has been hypothesized that increased thrombin generation seen in thrombophilia patients may enhance TAFI activation, leading to a hypofibrinolytic state, which may further contribute to the thrombotic tendency. However, the results of several studies, in which relation between TAFI level and the occurrence of thromboembolic complications in carriers of hereditary thrombophilia have been investigated, were not consistent.

Introduction: In the settings of trauma, liver transplantation and major surgery multifactorial coagulopathies are frequently encountered. The treatment of acutely bleeding patients is critically compromised by monitoring with standard available routine coagulation tests. In contrast to conventional tests, rotational thromboelastometry (ROTEM) provides an automated measurement of interactive dynamic haemostatic processes in whole blood starting with initial haemostasis up to and including fibrinolysis at a given time point. Especially fibrinogen, platelet dysfunction and hyperfibrinolysis pose diagnostic gaps. The aim of this report was to highlight the usefulness of ROTEM in making the correct diagnosis and adoption of therapeutic approaches in a timely manner in liver transplantation and trauma. We describe the value of ROTEM in two haemostatically compromised patients., Outline of Cases: In the first case, we present the ROTEM-based dynamic assessment and goal-directed treatment of acute haemorrhage in a liver transplant recipient. In the second case, after operation a multitraumatised patient developed uncontrolled massive bleeding unresponsive to conventional treatment and recombinant activated factor VII (rFVIIa) administration. The cessation of bleeding was achieved after guided therapy according to ROTEM results., Conclusion: In orthotopic liver transplantation and severely injured trauma patients ROTEM enables rapid and accurate detection and the differential diagnosis of multifactorial coagulopathies. Also, it provides the basis of rational approach to the use of blood component therapy and pharmacological interventions.

Introduction: The role of attribution in psychopathology has been investigated most systematically within the depression context. The presumption which makes people depressive consists, to an excessive degree, of internal, stable and global attributions to negative occurrences. Negative attributions for unpleasant events are associated with the loss of self-respect which follows. OBJECTIVE Establishing the characteristics of attribution style of depressive patients., Methods: The investigation included 62 subjects. The first group consisted of 32 patients with endogenous depression in remission. The second group included 30 healthy subjects. The characteristics of attribution style, in both groups, were tested by the Attribution Style Questionnaire (ASQ)., Results: The group of depressive patients, in comparison with healthy subjects, exhibited a significantly more marked internal attribution for negative events (t(60) = -3.700; p < 0.01) and global internal negative attributions (t(60)= -4.023; p < 0.01). There was no significant difference between the groups in the stability of these negative attributions (t(60)= -1.937; p > 0.05), and also the composite score which represents the measure of hopelessness did not make a significant difference between depressive and healthy subjects (t(60)= -1.810; p > 0.05)., Conclusion: Depressive patients exhibit an inclination towards internal and global attribution for negative events. These negative attributions do not have stable character, i.e. these attributions vary in time. Characteristics of attribution judgments of depressive people do not represent a permanent pattern within their cognitive style.

Introduction: Tuberculous otitis is a diagnostic problem due to the difficulty to obtain microbiological, histomorphological and cytological confirmation of the disease., Objective: Our objective was to compare clinical and radiological characteristic and development of otogenic complications in patients with tuberculous otitis and otitis with cholesteatoma as the most destructive form of chronic nonspecific otitis in the purpose of establishing the diagnostic criteria for tuberculous otitis., Methods: Medical records of 12 patients with tuberculous otitis and 163 patients with cholesteatoma treated at the Institute of Otorhinolaryngology and Maxillofacial Surgery in Belgrade during the eight-year period were analyzed. All of the patients underwent otomicroscopic, audiological and radiological examination of the thorax and temporal bone, microbiological examination of the secretion and histomorphological examination of the tissue taken during middle ear surgery. Statistical analysis was done using chi2 test with Yates correction., Results: Otogenic complication as facial palsy and sensorineural hearing loss were more frequent in tuberculous otitis patients, than in cholesteatoma. Also, fistulas of the labyrinth and facial canal bone destruction were also more frequent in tuberculous otitis than in cholesteatoma. A larger extent of temporal bone destruction was noticed on CT scans of the temporal bone in half of the patents with tuberculous otitis. Coexistence with miliary pulmonary tuberculosis was detected in one third of the patients. There were no microbiological or histomorphological confirmations of the disease, except in one case with positive ZiehI-Neelsen staining., Conclusion: Tuberculous otitis media should be considered in patients with serious otogenic complications and with shorter duration of ear discharge, and in association with diagnosed miliary pulmonary tuberculosis and extensive temporal bone destruction. Polymerase chain reaction still is not reliable for diagnosis.

Introduction: HELLP syndrome represents the form of preeclampsia characterized by moderate hypertension, often with absence of proteinuria and oedema. The frequency of HELLP syndrome in pregnant women with preeclampsia is 10-20%. The clinical course of the disease is characterized by the progressive worsening of mother and fetus condition, which can be stopped only by delivery. Disseminated intravascular coagulation is present in 8% of patients with HELLP syndrome and causes significant morbidity and mortality., Case Outline: We present a case of HELLP syndrome complicated by intrauterine fetal demise and disseminated intravascular coagulation in trigemelar pregnancy. After all surgical and medicamentous methods to establish haemostasis were exhausted, the patient was treated by recombinant activated factor VII (rFVIIa) in intravenous bolus dose of 90 microg/kg twice, which resulted in satisfactory haemostasis. Side effects of the drug were not registered., Conclusion: The application of rFVIIa reduced haemorrhage in our patient, both after the Caesarean section and after hysterectomy, contributing to the patient's full recovery, without neurological sequelae and with preserved renal function. RFVIIa is not an alternative to surgical haemostasis, but its administration should surely be considered before deciding to perform hysterectomy, especially in patients who want to preserve fertility. In cases of postpartum haemorrhage, when bleeding persists even after adequate surgical haemostasis, the administration of rFVIIa is to be considered not only as an alternative to hysterectomy, but also an effort to prevent significant maternal morbidity and mortality.

Introduction: Transsexual phenomenon is very complex, which is confirmed in everyday practice with these patients. There are many reasons why we have chosen to present this patient's case report., Case Outline: The aim of this case report was to indicate how our female-to-male (FtM) transsexual patient tried to change her own sexual drive with the purpose of showing high adaptation in social environment as her personal representation of mental health. At the same time, this was an attempt to escape from gender dysphoria by becoming heterosexual escaping from her basic sexual drive. Our patient could not put her erotic attributes in sexual relations, so she had numerous heterosexual, bisexual and homosexual relationships., Conclusion: By this case report, we want to present how conviction of belonging to the opposite sex can affect erotic contact with the same and different sex.

Autoimmune thyroid disease is a serious medical problem in which various operative procedures are performed. The objective of the study is to explore the type of applied surgical procedures in autoimmune thyroid disease, advantages and disadvantages of various procedures, and criteria they have to meet. This is retrospective clinical study on 1478 patients, operated for Graves' toxic goiter (117 males and 795 females mean age 37.7) and Hashimoto thyroiditis (27 males and 539 females mean age 50.6) from 1995 to April 2005. Cancer in Graves' disease was found in 61 patients (6.7%), papillary in 60 (occult in 53 or 6.6%) and metastatic in 1, Hashimoto thyroiditis and thyroid cancer was found in 141 patients (24.9%), papillary in 116 or 20.5% (occult in 55 or 9.7%), follicular in 2 (0.3%), Hurthle in 11 (1.9%), medullary in 8 (1.4%), anaplastic in 2 (0.3%) and lymphoma in 3 (0.5%). We performed subtotal bilateral lobectomy in 344 (312 in Graves and 32 in Hashimoto), total lobectomy on one side with subtotal on the oposite in 307 (228 in Graves and 79 in Hashimoto); out of them, in 59 patients, the remnant was left in the region of the upper pole which we called atypic lobectomy. The most common procedure, total or near by total thyroidectomy, performed in 719 (371 in Graves and 349 in Hashimoto). One side lobectomy was performed in 103 patients with Hashimoto thyroiditis. Lymph node dissection was performed in 21 (1 in Graves and 20 in Hashimoto), in all central, in 10 lateral functional and in 6 mediastinal, in 15 patients with cancer and in 6 patients with benign disease. There was no operative mortality. In Graves' disease, there was postoperative bleeding in 4 (0.4%), wound infection in 2 (0.2%) recurrent pulsy in 18 (2%) and permanent hypoparathyroidism in 13 (1.4%). In Hashimoto thyroiditis, there was postoperative bleeding in 2 (0.4%), recurrent nerve pulsy in 11 (1.9%) and permanent hypoparathyroidism in 6 (1.1%). The most common surgical procedure in autoimmune thyroid disease is total thyroidectomy which is followed by low complication rate in specialised centers. Cancer is more frequent in Hashimoto than in Graves' disease.

Autoimmune thyroid diseases are frequently associated with differentiated thyroid carcinomas. The role of autoimmune phenomena in the origin and clinical course of coexisting papillary and follicular carcinomas is still controversial. In Graves' patients, the prevalence of palpable thyroid nodules is 15.8%, and by using ultrasonography, the prevalence increases to 33.6%. Since the malignancy rate of palpable thyroid nodules in Graves' patients is 16.9%, approximately threefold higher than in general population, it seems that a thyroid nodule diagnosed in Graves' patients is at higher risk for malignancy. In addition, radioiodine therapy for Graves' disease was found to be associated with increased incidence of thyroid cancer in some studies. These studies however, were not able to confirm the carcinogenic effect of radioiodine therapy since the late growth of occult carcinomas could not be excluded. The frequency of the association of Hashimoto's thyroiditis and differentiated thyroid carcinomas is approximately 30%. The presence of coexistent Hashimoto's thyroiditis does not affect the diagnostic evaluation and management of papillary thyroid cancer. The frequent presentation of differentiated thyroid carcinomas in Graves' disease and Hashimoto's thyroiditis opens the possibility that some mutual pathogenethic mechanisms might be involved in the development of these diseases.

Changes of the affective and cognitive function are usually associated with thyroid gland dysfunction. In autoimmune thyroid disease, these changes can be caused by thyroid dysfunction (hypo- or hyperthyroidism) or associated with the presence of antithyroid antibodies. Even a small change in thyroid hormone concentration is associated with change of cognitive function. In euthyroid older males, variation of total and free thyroxin accounts for about 10% of Wechsler adult intelligence test variance. In euthyroid females, lower cognitive function, measured by Mini Mental test, also correlates with blood thyroxin. Short-term (4 weeks) hypothyroidism induces clinically significant cognitivedysfunction, which is reversible by thyroid hormone substitution. Mild hypothyroidism (TSH less than 10) also induces reversible cognitive dysfunction. In hypothyroidism, PET scanning shows global reduction of brain blood flow and glucose metabolism. Hashimoto's encephalopathy is characterized by corticosteroid reversible encephalopathy associated with the presence of antithyroid antibodies. Encephalopathy can be manifested as multiple stroke-like episodes (vasculitis like), or as diffuse, progressive type characterized by dementia and psychiatric symptoms. In euthyroid patients with Hashimoto's thyroiditis and no evidence of neurological disease, SPECT showed brain perfusion abnormalities. Post mortem and brain biopsy findings can be normal or show perivascular lymphocytic infiltration. Recently, presence of antineuronal antibodies has been found in patients with Hashimoto's thyroiditis. Specific high reactivity against human alpha-enolase was high in patients with Hashimoto's encephalopathy, but absent in patients with other neurological disorders and healthy subjects. Specific antineural antibodies were found in another group of Hashimoto's encephalopathy patients. Furthermore, Ferracci et al, found antithyroid antibodies in the CSF of patients with Hashimoto's encephalopathy.

Autoimmune thyroid disease (AITD) is the most common organ specific autoimmune disorder usually resulting in dysfunction (hyperfunction, hypofunction or both) of the thyroid gland. The syndromes comprising autoimmune thyroid disease are many intimately related illnesses: Graves' disease with goitre, hyperthyroidism and, in many patients, associated ophthalmopathy, Hashimoto's thyroiditis with goitre and euthyroidism or hypothyroidism but also thyroid dysfunction occurring independently of pregnancy and in 5-6% of postpartum women and thyroiditides induced by different drugs and other environmental influences. The immunological mechanisms involved in these diseases are closely related, while the phenotypes probably differ because of the specific type of immunological response that occurs. The syndromes are connected together by their similar thyroid pathology, similar immune mechanisms, co-occurrence in family groups, and transition from one clinical picture to another within the same individual over time. In some patients, other organ specific and nonorgan specific autoimmune syndromes are associated with autoimmune thyroid disease, including pernicious anemia, vitiligo, myasthenia gravis, primary adrenal autoimmune disease, celiac disease, rheumatoid arthritis or lupus. Thyroid peroxydase, TPO, the primary enzyme involved in thyroid hormonogenesis, was initially identified in 1959 as the 'thyroid microsomal antigenn. It is uncertain whether TPO autoantibodies or TPO-specific T cells are the primary cause of thyroid inflammation, which can lead, in some individuals, to thyroid failure and hypothyroidism. TPOAbs are the hallmark of AITB and are present in almost all patients with Hashimoto's thyroiditis, in two-thirds of patients with postpartum thyroiditis and also in 75% of patients with Graves' hyperthyroidism. The antibodies are mainly produced by lymphocytic infiltrate in the thyroid gland and only to a small extent by regional lymph nodes or the bone marrow. Unlike antibodies against thyroglobulin (Tg), TPO antibodies are capable of inducing antibody-dependent cell-mediated cytotoxicity. Antibodies to TSH-R mimic the function of TSH, and cause disease by binding to the TSH-R and stimulating (or inhibiting) thyroid cells. The TSHR, a member of the G protein-coupled receptor family with seven membrane-spanning segments. Patients with autoimmune thyroid disease may have both stimulating and blocking antibodies in their sera, the clinical picture being the result of the relative potency of each species; blocking antibodies seem more common in Graves' patients with ophthalmopathy compared to those without this complication. The major T cell epitopes are heterogeneous and T cell reactivity against certain TSH-R epitopes has been present in high proportion in normal subjects. More diversified response to TSH-R, with heterogeneity of epitope recognition by TSAb, is predictive of likely remission after antithyroid drug treatment for Graves' disease.

Thoracic electrical bioimpedance is a new non-invasive technique for obtaining haemodynamic parameters. The method involves the passing of low amperage, high frequency current through the thorax. The current induces a change of resistance within the thorax, which is registered by electrodes. The overall impedance of the thorax is a measure of the electrical resistance of the thorax to this high frequency, low amplitude current. In clinical practice, thoracic electrical bioimpedance has been applied in diagnostic, therapeutic, and prognostic use in patients with heart failure and hypertension, patients with pacemakers, within the scope of early diagnosis of implant rejection following heart transplantation, as well as in patients with kidney disorders, before and after dialysis. However, one of its most important applications is in the determination of antihypertensive therapy, because it provides the parameters that reflect the genesis of arterial blood pressure. In assessing these parameters, optimal therapy adjusted to the haemodynamic status of each patient can be prescribed.

Diffuse large-cell B lymphoma of the pancreas is a rare disease, representing less than 1% of all non-Hodgkin's lymphomas and less than 0.9% of all malignant tumours of the pancreas. About 150 cases of the disease have been observed so far. The tumours are more frequent in the head of the pancreas then in other parts of the organ. They are usually larger (average size of 8 cm) and are non-resectionable. As a rule, exact diagnosis is based on the histology and the immunohistology of the specimen taken during open surgery performed for general diagnosis of the pancreatic tumour. Very rarely can a very reliable and experienced cytopathologist establish a proper diagnosis based on material obtained from a fine needle biopsy. The disease usually responds positively to immunochemotherapy according to protocol R-CHOP. Occasionally, additional radiotherapy may be required. We present two women, 66 and 49 years old, in whom a diagnosis of large-cell B lymphoma of the pancreas was established, based on the histology and the immunohistochemistry of a specimen taken during open surgery performed in order to remove pancreatic tumours, which turned out to be non-resectionable. After immunochemotherapy, the symptoms disappeared and the tumours shrank, in one patient after additional radiotherapy. The authors would like to point out the importance of a proper histological diagnosis, which permitted the application of immunochemotherapy alone or together with additional radiotherapy with at least temporarily favourable results.

A bronchogenic cyst is a rare congenital anomaly that appears in the thorax, usually the lungs or the mediastinum, being much rarer in the retrosternal space, within the pericardium or the diaphragm, as well as in the neck, while localisation within the abdomen is extremely rare, with only about 30 reported cases. We present the case of a 68-year-old woman. During an investigation for an epigastric pain, a cystic lesion in the area of the body and tail of the pancreas was found. During open surgery, a cystic lesion, spanning 95 x 75 x 70 mm, above the body and tail of the pancreas was excised. The wall of the cyst was 8-12mm thick; it contained viscous fluid, the culture of which stayed sterile. Histology determined that it was a bronchogenic cyst. After an early uneventful recovery, the patient developed a left colonic fistula, which healed spontaneously within 3 weeks, probably because of the unnoticed operative damage to the splenic flexure of the colon during splenectomy, which was adherent to the cystic mass and impossible to save during excision. Six months after surgery, the patient continued to remain symptom free.

Introduction: Resynchronisation therapy with biventricular permanent pacing stimulation is one method of treating patients with systolic heart failure, with echocardiograph signs of ventricular asynchrony and a prolonged QRS of longer than 120 milliseconds. This method has been accepted in most medical centres around the world and was instigated in our Pacemaker Centre in December 2001, 3 months after FDA approval for human use., Objective: The aim of the study was to present this new procedure and the results obtained from our own group of patients., Method: A multi-site, biventricular pacemaker, with a special electrode for left-half heart stimulation was implanted in the coronary sinus of 17 patients who had suffered systolic heart failure (12 male and 5 female, average age 59.9 years). For all of them, the duration of the QRS interval was longer than 120 ms, with left bundle branch morphology, and an ejection fraction below 30%. All the patients were NYHA class II or III. Prior to and after the implantation, a 12-channel ECG and ECHO were carried out, a 6-minute hall walk test was performed, additionally, the total walked distance on a flat surface was measured, the general condition of the patient was evaluated, the number of medications being taken was noted, as was the number of days of hospitalisation., Results: The average time from diagnosis to implantation was 22 months, and the average post-operative follow-up was 14 months. Two of the patients died 10 and 7 months after the implantation, due to a new myocardial infarction and refractory heart failure. In addition, one patient did not show any improvement after the implantation of the multi-site pacemaker (there were three "non-responder" patients). All the other patients felt much better: decreased NYHA class for I - II class, increased left ventricle ejection fraction, reduced use of diuretics, increased 6-minute hall walk distance and general walk distance on a flat surface, and decreased number of days of hospitalisation., Conclusion: Resynchronisation heart failure therapy in the majority of patients with systolic left ventricular dysfunction and a prolonged QRS interval considerably improves cardiac function, in addition to reducing symptoms and hospital stays.

Investigations conducted in medical centers worldwide and ours indicate that patients with chronic allograft nephropathy (CAN) will have short kidney graft survival when proteinuria and/or azotemia develop early, during the first post transplantation year. The analysis of published results suggests that angiotensin-converting enzyme (ACE) DD genotype represents unfavorable marker of rapid progression of chronic renal allograft dysfunction (CRAD). Differences of response to ACEi therapy in patients with chronic nephropathy of one's one or transplanted kidney could be explained by ACE genotype variety, where ACE DD is unfavorable genotype. Related factors influencing the ACEi therapy success in patients with particular ACE genotype are highly salt diet, interactions of genotype variety of all renin-angiotensin-aldosterone system (RAS) molecules, i.e. diversity in the ACE, angiotensinogen, AT1 receptor or aldosterone genotype, as well as differences of ACEi responses in patients with glomerular and tubulointerstitial kidney diseases. Retardation of chronic renal failure in patients with ACE DD genotype who developed chronic allograft nephropathy has been obtained with long-term ACEi treatment and restricted salt intake to 50 mmol Na+ per day. We consider that genotype investigation of RAS molecule, primarily of ACE genotype in recipient and kidney donor should be done before high-risk kidney transplantation.

Introduction: Pathohistological (PH) analysis is recommended as basic diagnostic procedure during the investigation of myelodysplastic syndromes (MDS)., Aim: The aim of this paper was to investigate diagnostic and prognostic significance of bone marrow PH features in patients with MDS, and its relation to cytological characteristics of bone marrow aspirate., Methods: Cellularity, disorder of marrow histotopography, quantity of hematopoiesis lineages, cellular atypia, the amount of myeloblasts, and stromal changes were particularly analyzed in trephines of 236 patients with primary MDS., Results: In most cases (78.4%) hypercellular bone marrow was observed, although in 10.2% patients hypocellular subtype of MDS was diagnosed. Erythropoiesis dislocation was present in 64.7% patients, dislocation of MK-poiesis in 50.9% patients, while 61.3% had dislocation of granulopoesis (so-called ALIP phenomenon). In most cases three lineage hyperplasia was present, while relative hypoplasia of E- and MK-lineage was found in 1/4 cases, each, particularly in advanced MDS. Morphological features of dyseritropoiesis and dysmegakaryocytopoiesis were present in 42.5% and 75.7% cases, respectively. Different stages of reticulin and collagen fibrosis were observed in 55.5% patients, while 7.6% had hyperfibrotic subtype of MDS. Comparative analysis of cytological and histological features of MDS bone marrow showed positive correlation between two methods only in respect of estimation of eritropoiesis quantity, presence of dismegakaryocytopoiesis and "reactive" cells. The univariate analysis showed that MK- and G-lineage dislocation, quantity of E- and G-lineage, and presence of dysmegakaryocytopoiesis, were prognostic indicators for short survival and evolution of the disease in MDS patients. However, multivariate analysis showed that only G-lineage dislocation was independent prognostic variable for survival in MDS cases., Conclusion: PH analysis is irreplaceable diagnostic procedure during MDS investigation, since it provides reliable information of cellularity, architectural disorganization, number of megakaryocytes and alterations of marrow stroma. In addition, PH analysis provides numerous important prognostic information.

Peritonitis is a serious clinical complication in patients with terminal chronic renal failure (CRF) on peritoneal dialysis (PD). The incidence of peritonitis varies from center to center, and during the last decade it occurs approximately in one patient during 24-60 therapeutical months, which is the result of good education of patients, but also of employing the new systems for PD. Fungi as well as Mycobacterium tuberculosis are rare causes of peritonitis in patients on PD therapy. The incidence of peritonitis with these two causes varies: 1-15% and 0.7-3%, respectively. The most frequent causes of fungal peritonitis are yeasts (Candida species 70-100%, with most frequent C. parapsilosis), but rarely filamentous fungi such as: Aspergillus, Paecilomyces, Penicillium, Zygomycetes, etc. Gram stains are helpful for diagnosis, as well as the culture of peritoneal effluent. There are various kinds of treatment protocols: withdrawal of peritoneal catheters and application of antimicotic drugs such as amphotericin B (which has recently been abandoned), oral flucytosine, oral or intraperitoneal fluconazole (imidazol) or itraconazol in the case of resistance. Although clinical signs disappear, most of these patients cannot continue with peritoneal dialysis therapy because of peritoneal adhesions, abscesses, fibrosis or progressive sclerosing peritonitis. Percentage of death is 12-44%. The incidence of tuberculosis is higher in patients with CRF in comparison with the entire population, and tuberculous peritonitis can develop in patients who had infection with Mycobacterium tuberculosis which was not treated adequately. Diagnosis can be made by detecting mycobacterium in peritoneal effluent (cultivation for 6 weeks) and/or acidophilic bacillus or typical granuloma in peritoneal biopsy. Therapy consists of removing the peritoneal catheter and long lasting antituberculotic therapy: izoniazid, rifampicin, pyrazinamide, pyridoxin (6-12 months). Streptomycin and ethambutol are to be avoided because of side effects in these patients. In spite of therapy, possible consequences are: ultrafiltration loss, obstruction of intestines because of adhesions, abdominal abscesses, fistulae, ending PD therapy, and even death.

Acute appendicitis is the most common non-obstetric reason of abdominal pain in the pregnancy, causing significant increase of maternal and fetal morbidity and mortality. This is a case report of a patient in the third trimester of pregnancy in whom perforated appendicitis caused purulent peritonitis. She was operated as an emergency case and cesarean section was performed. After the surgery and antibiotic administration according to drug susceptibility test, her postoperative course was uneventful. Delayed diagnosis of the acute appendicitis leads to increased rate of appendicular perforation, with numerous maternal and fetal complications. In cases of suspected appendicitis during pregnancy, surgical exploration is indicated, either by laparoscopy or laparotomy. Laparotomy is the method of choice in cases after 20 weeks of pregnancy and whenever signs of diffuse peritonitis are present.

This review deals with bibliography on Munchausen syndrome by proxy (MSbP). The name of this disorder was introduced by English psychiatrist Roy Meadow who pointed to diagnostic difficulties as well as to serious medical and legal connotations of MSbP. MSbP was classified in DSM-IV among criteria sets provided for further study as "factitious disorder by proxy", while in ICD-10, though not explicitly cited, MSbP might be classified as "factitious disorders" F68.1. MSbP is a special form of abuse where the perpetrator induces somatic or mental symptoms of illness in the victim under his/her care and then persistently presents the victims for medical examinations and care. The victim is usually a preschool child and the perpetrator is the child's mother. Motivation for such pathological behavior of perpetrator is considered to be unconscious need to assume sick role by proxy while external incentives such as economic gain are absent. Conceptualization of MSbP development is still in the domain of psychodynamic speculation, its course is chronic and the prognosis is poor considering lack of consistent, efficient and specific treatment. The authors also present the case report of thirty-three year-old mother who had been abusing her nine year-old son both emotionally and physically over the last several years forcing him to, together with her, report to the police, medical and educational institutions that he had been the victim of rape, poisoning and beating by various individuals, especially teaching and medical staff. Mother manifested psychosis and her child presented with impaired cognitive development, emotional problems and conduct disorder.

Introduction: The diagnosis of radiological union of scaphoid bone after bone grafting requires clear evidence of bony trabeculae traversing the graft from the proximal to the distal pole on at least two of four standard scaphoid views. This sign is the only objective assessments of union. Radiographs of the scaphoid taken 18 weeks after operation, however, can be difficult to interpret. This fact led us to question whether radiographs of scaphoid at 18 weeks provide reliable and objective indication of union., Objective: Our study was, therefore, designed to determine the reliability of the radiographic diagnosis of scaphoid union after bone grafting by testing the degree of inter-observer agreement and reproducibility., Methods: Out of 30 sets of the scaphoid bone radiographs after bone grafting taken 18 weeks after operation, 15 of good quality were selected. Each set included four views: postero-anterior, lateral, semi- pronated and semi-supinated. Seven observers were tested: three orthopedic consultants, three residents and one consultant in radiology. Each was presented with 15 sets of radiographs designated from 1 to 15 and each was asked to answer the question: "Are there trabeculae crossing the fracture site?" Possible answers were 'yes' or 'no'. Eight weeks later, the same 15 sets of radiographs were marked in alphabetic order from A to K and presented to the same seven observers. Data was then analyzed and expressed in terms of interobserver agreement in pairs and intra-observer reproducibility. Calculation was done by kappa statistics so that the degree of disagreement was taken into account and allowance was made for chance agreement. Kappa values can vary from -1.0 (complete disagreement) through 1 (chance agreement) to +1 (complete agreement)., Results: For all 15 sets of radiographs, the degree of agreement between each pair of observers was illustrated in Table 2. It demonstrated the level of agreement between each pairs of seven observers. The overall median kappa coefficient for inter-observer agreement was 0,46. This value corresponded to "moderate" strength of agreement. Median kappa coefficient for consultant was 0.62, but median kappa coefficient for residents was 0.43. The degree of agreement between the opinions of each observer at his first and at his subsequent reviews of the same set of radiograph after 8 weeks was presented in Table 3. The overall median Kappa coefficient for the intraobserver agreement for all seven observers was 0.54. The ability of seven observers to reproduce their own opinion regarding trabeculae crossing the fracture line was poor to use it for assessment of bone union., Conclusion: Our conclusion is that radiographs taken 18 weeks after scaphoid grafting cannot be reliable and reproducible for assessment of bone union.

One of the established strategies for combating cancer is screening the asymptomatic population for premalignant conditions and early-stage disease. The prevalence of endometrial cancer in asymptomatic women is low and the overall prognosis is good because women present in early stage with abnormal bleeding. For all these reasons, screening for endometrial cancer is not recommended in general population. However, screening in high risk population will be very important in the future.

The objective of this study was to estimate the incidence of hip fractures in Belgrade for the period 1990-2000, and to determine distribution of fractures according to sex, age, and causes of injuries. Data based on medical records of the National Health Service in Belgrade were collected from all orthopedic hospitals and departments in Belgrade. A total number of 8904 hip fractures were included in the analysis, out of which 64.7% occurred in women. During the survey period, the estimated average annual incidence rate of hip fractures was 51.7/100 000 (95% CI= 48.1-55.4); 66.2/100 000 (95% CI= 60.8-72.1) in women and 35.3/100 000 (95% CI= 31.4-40.1) in men, respectively. In the age group > or =50 years, the incidence rates standardized by the 1985 US population were 228 and 96 per 100 000 female and male population, respectively. An exponential increase in the incidence of hip fractures with age was observed in both sexes, especially in women. The number of trochanteric fractures was 4718 (53.0%), compared with 4186 (47.0%) cervical fractures. Observation at three time points, in 1990, 1995, 2000, indicated the pronounced increase of trochanteric fractures in women and less distinctive in men. Fall on the flat ground resulted in 70.3% of hip fractures among persons aged 50 years or older, and traffic accidents were recorded as the major cause in 59.7% of patients under 50 years of age.

Splenic abscess is a rare disease but with increasing frequency. The authors present 9 patients with splenic abscess treated at the Institute of Digestive System Diseases, Clinical Centre of Serbia, in a period from January 1, 1986 to May 15, 2004. Splenic abscess was the complication of septic endocarditis in 4, trauma in 2, dental infection in 1, while in 2 cases it was the complication of chemotherapy in myeloproliferative disorders. All 9 patients had fever, 7 - abdominal pain, 4 - left shoulder pain, and 1 patient had nausea and vomiting. Higher white blood count was found in 6 patients, pleural effusion in 4, elevated left hemidiaphragm in 1 and basal pneumonia in 1 patient as well. Ultrasonography and CT were the most reliable diagnostic procedures. CT was superior in diagnosis of multiple small abscesses. Culture of the pus recovered the Enterococcus in 3 cases, Streptococcus a hemolyticus in 1, Staphylococcus epidermidis and Candida albicans in 1, Staphylococcus aureus, E. Coil and Candida albicans in 1, Staphylococcus aureus i Salmonella enteritidis in 1 case. Eight patients underwent splenectomy and 1 was cured by combined antibiotics in high doses. One patient died postoperatively due to septic endocarditis that had been present before surgery. The authors believe that splenectomy and antibiotics administered according to drug susceptibility test as well as management of underlying disease are the method of choice for splenic abscess treatment. Conservative antibiotic treatment is indicated in selected cases only.

Biliary mucinous cystadenoma of the liver is a rare tumor that develops almost exclusively in women. Its typical localization is near the hepatic hilus. It may become malignant, and therefore careful histological examination of the entire resected specimen is mandatory. Incomplete excision results in recurrence and occasionally in malignant alteration. The authors present a 66-year old woman who presented with the right upper abdominal pain and occasional vomiting, and who was diagnosed with cystic lesion of the right lobe of the liver. The lesion was totally excised by an open operation. It was filled with mucinous viscous fluid and there was proliferation in one part of the internal surface. The cystic lesion communicated with the common hepatic duct through a tiny duct (above the cystic duct), but in spite of that, it did not contain bile. Histological examination showed mucinous cystadenoma with focal malignant alteration. After the uneventful recovery, the pain and vomiting were eliminated and she has remained symptom free so far.