Bleeding hepatico-cutaneous fistula: Unusual complication of the percutaneous liver biopsy

Introduction. Arteriovenous fistula is one of the complications that can occur during percutaneous liver biopsy. Hepatic arterio-venous fistula with chronic bleeding from the puncture site on the skin is extremly rare complication following percutaneous liver biopsy. Case report. The case represents a 35-year-old woman with secondary anemia caused by chronic bleeding at the site of a granuloma caused by a previous liver biopsy done 7 years ago. The patient was examined and treated for several years due to anemic syndrome. The pathological communication between the right hepatic vein, the anterior sectional branch of the portal vein and the posterior arterial sectional branch was detected on a CT scan, and proven by fistulography. Due to the failed embolization, a laparotomy was performed, where a tumor mass was found in the VI and VII segment of the liver, which communicates with the skin. Tumor mass was removed by atypical resection of VI and VII liver segments. Due to hemorrhage, re-exploration was performed, where bleeding was found from the surface of the resected liver parenchyma. Two weeks after the last operation, the patient was released for home treatment. Conclusion. Although percutaneous liver biopsy is a safe procedure, the complication in the form of bleeding occurs in less than 25% of cases and with spontaneous cessation. In our presentation, there was a complicated intrahepatic arteriovenous-portal fistula with the formation of communication with the puncture site on the skin. This is the first case of complications of this type after percutaneous liver biopsy.

Trabeculectomy with mitomycin C for glaucoma secondary to emulsified silicone oil after pars plana vitrectomy: three-years follow up

Background/Aim: To evaluate the efficacy of trabeculectomy with mitomycin C (MMC) for lowering intraocular pressure (IOP) in patients with open angle glaucoma (OAG) secondary to emulsified silicone oil (SO) after pars plana vitrectomy. Methods: A single-center, prospective study was conducted, from December 2014 to December 2019, on 56 consecutive patients with an uncontrolled elevation of IOP after SO removal. The primary end-point was the IOP at the three-years follow-up visit. Complete surgical success was defined as an IOP ranging from 7 mmHg to 18 mmHg without glaucoma medication. Qualified success was defined as IOP ? 21 mmHg with one or two topical medications. Results: Fifty-six patients with mean (standard deviation) age of 56.6 (13.1) years had a mean baseline IOP of 42.3 (39.3 to 45.3) mmHg, which reduced to 18.6 (17.9 to 19.3) mmHg at 3 years after surgery (P < 0.0001). 17 (30.4%) eyes were classified as complete success, 21 (37,5%) as qualified success, and 18 (32.1%) as failure. In all treated patients, the number of antiglaucoma medications was significantly reduced from 2.85 (0.77) to 1.63 (0.62), p<0.0001. Conclusion: Trabeculectomy with MMC may be an option for lowering IOP in patients with OAG secondary to emulsified SO which was not controlled with maximum antiglaucomatous medical treatment.

Macular morphologic changes following successful retinal detachment repair by scleral buckling surgery

Background/Aim: Spectral domain optical coherence tomography (SD-OCT) is very useful for accurate examination of macular microstructure. The aim of this study was to evaluate macular morphologic changes after successful retinal detachment (RD) surgery by scleral buckling using SD-OCT and assess their impact on vision repair. Methods: SD-OCT examination was performed 1, 6 and 12 months in 27 eyes following scleral buckling (SB) surgery with successful anatomical repair of rhegmatogenous retinal detachment (RRD) which also affected the macular region. The examination was performed in a 6mm diameter central macular region and included measurements of the central foveal thickness (CFT), average overall retinal thickness and thickness of the outer and inner retinal layers separately. The numerical values of operated eyes were compared with those of the fellow (control) eyes. The condition of the outer limiting membrane (ELM) and inner segment/outer segment of the photoreceptors (IS/OS) was also examined. Results: The mean total and outer retinal thickness (TRT and ORT) in the reattached regions in the operated eyes were significantly thinner than the corresponding regions of the fellow (control) eye, and throughout the follow-up period the difference was statistically significant. There was a statistically significant difference in TRT (after 1 month p=0.021, after 6 months p=0.026, after 12 months p=0.027) and ORT (after 1 month p=0.018, after 6 months p=0.019, after 12 months p=0.021) between the eyes with a longer pre-operative duration of macular detachment of 2 weeks and eyes with shorter detachment period. Disruptions of the photoreceptors IS/OS and ELM on OCT examination after one month were observed in 37.04% eyes, after 6 months in 29.6% eyes, and at the end of the follow-up period in 14.8% eyes. A statistically significant difference was found in the frequency of disruptions of the IS/OS and ELM depending on the preoperative duration of RD (p= 0.007). Conclusion: Overall decrease in the mean retinal thickness after successful anatomical repair of RD is result of decreases in the thicknesses of outer retinal layers. The alterations of the external limiting membrane and inner and outer photoreceptors segments observed on the early SD-OCT scans are mostly associated with limited visual recovery. The prolonged macular detachment leads to damage to the neurosensory tissue of the retina and especially the photoreceptors, which may explain the limited visual recovery after successful scleral buckling RD repair.

Expression of Kv4.2 and Kv4.3 potassium channels in human umbilical veins from normal, diabetic and hypertensive pregnancies

Objective: A substantial line of evidence indicates that Kv4.2 and Kv4.3 channels are the major components of rapid transient-outward potassium currents (A-type currents). It is speculated that those currents may be involved in the maintenance of the membrane potential, as well as in the regulation of propagation and frequency of action potentials. However, very little is known about the presence and function of A-type currents in human vascular smooth muscles such as human umbilical vein (HUV). Having in mind its crucial role in the proper fetal oxygenation the aim of the study was to determine whether Kv4.2 and Kv4.3 potassium channels are present in HUV smooth muscle and to investigate potential alterations of their expression during maternal pathological conditions - gestational diabetes mellitus (GDM) and pregnancy-induced hypertension (PIH). Materials and methods: Healthy, diabetic and hypertensive pregnancies were subjects of this investigation. Each group was consisted of 6 HUV samples obtained from 6 normal pregnancies, 6 pregnancies with GDM, and 6 pregnancies with PIH. After pharmacology analysis, immunohistochemistry and Western blot were performed. Results: Immunohistochemistry revealed similar expression pattern of both, Kv4.2 and Kv4.3 subunits, in HUV smooth muscle in all groups of patients. Results obtained by Western blot were in agreement with immunohistochemical staining. The expression of Kv4.2 and Kv4.3 subunits was not significantly different between the groups. Conclusion: Collectively, this is the first study that demonstrated presence of Kv4.2 and Kv4.3 potassium channels in the HUV smooth muscle and their preservation during the course of GDM and PIH. These channels are most likely major components of rapid A-type currents that may be relevant for maternal-fetus blood flow and hence fetal development. Also, they may represent sensors for detecting hemodynamic and/or metabolic changes in the local environment.

Antithrombin activity is a significant predictor of early mortality in pulmonary embolism patients

Introduction and aim. The role of antithrombin (AT) activity in the prediction of early mortality in patients with pulmonary embolism (PE), measured at an early stage of the disease, has not yet been investigated. Therefore the aim is to examine the predictive value of AT activity for all-cause 30-day mortality, measured in consecutive PE patients on admission to the hospital. Methodology. This is a single-center, clinical retrospective cross-sectional study, which followed consecutive patients with acute PE in the period from 2014-2021. On admission to the hospital, venous blood was taken from patients for laboratory analyzes, from which, in addition to basic analyzes, the activity of AT was also measured. The basic parameters of the patients were recorded on admission and through univariate analysis, their connection with 30-day mortality was tested. The predictive significance of AT values for 30-day mortality was tested through quartile values by comparing the first quartile with all others together. Cox regression model analysis was used in the multivariate analysis where one parameter marked as significant in the univariate analysis was added to the basic model (AT, age and risk affiliation in two groups). Results. A total of 378 PE patients were included in the study. The total all-cause 30-day mortality was 30 patients (7.8%). Patients with AT activity in the first quartile had significantly higher early mortality compared with the other quartiles combined (log rank p = 0.001). AT retained a significant predictive value for early mortality in the multivariate analysis despite the comorbidity present, which also significantly affected mortality. Conclusion. Low AT activity measured at admission in PE patients is a significant and independent predictor of 30-day mortality.

The impact of complete atrioventricular block on in-hospital and long-term mortality in patients treated with primary percutaneous coronary intervention

Objective: To analyze the incidence and the prognostic impact of complete AV block on in-hospital and 6-year mortality in STEMI patients treated with pPCI. Method: Study included 3044 consecutive STEMI patients. Results: Complete AV block was registered only at admission in 144 (4.73%) patients; 125 (86.8%) patients with complete AV block had inferior infarction. Temporary pacemaker was implanted in 72 (50%) patients with complete AV block. No patient underwent permanent pacemaker implantation. In-hospital mortality was significantly higher in patients with complete AV block than in patients without complete AV block: 17.9%vs3.6%, respectively, p<0.001. In patients with heart block and inferior infarction inhospital mortality was 13%, whereas in patients with heart block and anterior infarction inhospital mortality was 53%. When we analyzed patients who were discharged alive from the hospital, we also found significantly higher long-term (6-year) mortality rate in those with complete AV block vs patients without AV block: 7.8%v 3.4% respectively, p<0.001. Complete AV block was an independent predictor for in-hospital and 6-year mortality: inhospital mortality OR 2.94 95%CI 1.23-5.22; six year mortality HR 1.61, 95%CI 1.10- 2.37. When subanalysis was performed, in patients with inferior STEMI, complete AV block was an independent predictor of in-hospital and 6-year mortality, while in patients with anterior STEMI, complete AV block was an independent predictor of in-hospital mortality. Conclusion: In analyzed STEMI patients complete AV block was transitory and was registered only at hospital admission. Although transitory, complete AV block remained a strong independent predictor of in-hospital and long-term mortality.

Costs and consumption of analgesics, with special reference to opiates in Serbia and Montenegro from 2015 to 2019

Background/Aim: Patients in developing countries do not always receive adequate painrelieving treatment. Monitoring of analgesic consumption is of great importance, since this can help assessing the quality of painful condition management. The aim of this paper is to present a five-year consumption and costs of drugs with analgesic effects in developing countries, exemplified by Serbia and Montenegro, and indicate the main reasons for their (in)adequate prescribing. Methods: The observational, retrospective, cross-sectional study was conducted in order to analyse consumption of all analgesics, both opioid and non-opioid, in Serbia and Montenegro, as developing countries. The data concerning analgesic consumption and drug prices were obtained from annual editions of the publications of the Medicines and Medical Devices Agency of Serbia and Montenegro. The WHO methodology with defined daily dose (DDD) as a unit of measure (it is defined by the number of DDD per 1000 inhabitants per day) was used in these publications. Results: In the course of the fiveyear period (from 2015 to 2019) in Serbia, the total allocations for analgesic therapy had a rising trend; from about 43.6 million to 63.3 million of Euros, while in Montenegro expenditures showed annual variations with highest value in 2018. Most of the money in both countries was invested in M01A group of drugs, for which the highest consumption was also recorded. Significantly higher consumption of opioid analgesics in Montenegro comparing with Serbia was observed in the same period, and it predominatly reflected the difference in fentanyl (N02AB03, transdermal patch) prescribing. In Montenegro, consumption of M01group of drugs was prominently higher in comparison to M01AE group during the whole five-year period, similarly like in Serbia in which this was not the case only in 2018. Conclusions: Taking into account the importance of analgesics for everyday medical practice, more rational prescribing of these drugs is necessary both in Serbia and Montenegro in the future.

Tacrolimus-induced bilateral optic neuropathy: A case report

Intrduction. Tacrolimus (fujimycin or FK506) is a potent immunosuppressive drug with growing usage. It is usually used in prevention of transplanted organ rejection. Its use is highly valuable, but like other immunosupressants, it has adverse effects. One of them is optic neuropathy. Case report. A 47-year-old white male patients who had received tacrolimus therapy for nine years, after kidney transplantation, developed a subacute, painless vision loss on both eyes. He was thoroughly examined on different possible optic neuropathies and other causes of vision loss. After exclusion of other possible causes, the diagnosis of toxic optic neuropathy was established. His therapy was converted to cyclosporine, by his nephrologist, but his vision had improved only slightly. Conclusion. Toxic optic neuropathies are presented in everyday ophthalmological practice, but they are underestimated. Diagnosis can be demanding, especially when it comes to drugs and substances whose possible toxic effect on the optic nerve is not widely known. Unlike other adverse effects of tacrolimus therapy on nervous system, optic neuropathy can causes great and permanent functional impairment.

A simple calculation of the maximum dose of the local anesthetic in pediatric dentistry with nomogram in Serbian

Clinicians should identify the risks associated with the use of anesthetics and understand the maximum recommended doses of local anesthetics. Errors in calculating the dose of local anesthetics are common due to the widespread use of these agents. Different methods of calculating the dose of the drug have different advantages and disadvantages, and no method can guarantee a calculation without errors. Nomogram is a simple graphical tool on which one can read the result of arithmetic operations with given numbers. The nomogram for calculating the maximum dose of local anesthetic enables quick cross-checking of the calculation, based on the patient's age or body weight. They are of special importance in the application of local anesthesia in children.

Clinical outcome and side effects of concomitant chemoradiotherapy in the treatment of locally advanced inoperable non-small cell lung cancer: Our experiences

Background/Aim. About 1.8 million new lung cancer cases are diagnosed in the world every year, and about 1.6 million cases are with fatal outcome. Despite improvements in treatment in previous decades, the survival of patients with lung cancer is still poor. The five-year survival rate is about 50% for patients with localized disease, 20% for patients with regionally advanced disease, 2% for patients with metastatic disease, and about 14% for all stages. The median survival of patients with untreated NSCLC in the advanced stage is four to five months and the annual survival rate is only 10%. The main goal of the research is to obtain and analyze the results of treatment with concomitant chemotherapy in terms of its efficacy and toxicity in selected patients with locally advanced inoperable non-small cell lung cancer. Methods. The study included data analysis of 31 patients of both sexes who were diagnosed and pathohistologically verified with NSCLC in inoperable stage III and were referred by the Council for Malignant Lung Diseases to the Radiotherapy Department of the Military Medical Academy for concomitant chemoradiotherapy treatment. Upon expiry of the three-month period from the performed radiation treatment, the tumor resonance was assessed on the basis of MSCT examination of the chest and upper abdomen according to RECIST 1.1 criteria (Response Evaluation Criteria in Solid Tumors). According to the same criteria, progression-free survival (PFS) was also assessed every three months during the first two years, then every 6 months or until the onset of disease symptoms, as well as overall survival (OS). Result. The median progression-free survival is 13 months, and the median overall survival is 20 months. During and immediately after RT, 9 (29%) patients had a grade 2 or higher adverse event. Conclusion. The use of concomitant chemoradiotherapy in patients in the third stage of locally advanced inoperable non-small cell lung cancer provides a good opportunity for a favorable therapeutic outcome, with an acceptable degree of acute and late toxicity, and represents the standard therapeutic approach for selected patients in this stage of the disease.