A case report of biclonal immunoglobulin D lambda/lambda multiple myeloma in patient with liver echinococcosis.

Less than 2% of all symptomatic multiple myeloma (MM) has immunoglobulin D (IgD) as monoclonal protein. Biclonal gammopathy is much rarer. At the time of diagnosis, disease is often in advanced stage, including renal failure, anemia, hypercalcemia and lytic bone lesions. Due to the rarity of myeloma itself, but also due to the fact that anti-IgD antisera is not used in routine practice, there are only a few reports of IgD MM described in the literature. This case report describes a patient with IgD lambda MM with anemia and renal failure. Anemia, renal failure, and > 80 percent plasma cells in bone biopsy in our patient with IgD lambda MM meets International Myeloma Working Group criteria for diagnosis of MM. The patient clinical course was similar to other patients with IgD MM. The final result of serum protein immunofixation (s-IFE) showed IgD lambda and free lambda monoclonal bands. To prevent misdiagnosis, it is necessary to use anti-IgD and anti-IgE antisera whenever the serum protein immunofixation with IgA, IgM, IgG, kappa and lambda antiserums shows a kappa or lambda monoclonal band without monoclonal band in heavy chain.

Colorectal adenocarcinoma presenting with a pathological fracture due to a solitary bone metastasis to the tibia: a case report and literature review.

Introduction: Solitary bone metastasis of colorectal carcinoma (CRC) without other metastasis sites is extremely rare and can be found in less than 1% of patients with CRC. Aim: In the present study, we report the first case of a solitary tibia metastasis and its pathologic fracture as the first presenting feature of a colorectal adenocarcinoma. Material and methods: A 78-year-old female patient presented to our emergency department due to atraumatic pretibial swelling. Plain radiography did not detect any pathology. The swelling was incised and serous-bloody collection was evacuated, and the patient was discharged. On the 17th postoperative day, during a regular walk, the patient fell down and broke her leg, which transpired to be a pathologic fracture of the proximal tibial diaphysis, confirmed by X-ray. A biopsy of the altered bone tissue from the fracture site revealed metastatic colorectal adenocarcinoma. On colonoscopy, a circular mass in the upper rectum was found. Conclusions: Solitary bone metastases are most commonly found in bones that are related to venous drainage via the paravertebral plexus of Batson - the pelvis, vertebrae, and sacrum. Long bones are extremely rare localizations of solitary CRC metastases, with only few cases published so far in medical literature. In our case, the patient`s first symptom was related to the osseous tibial metastasis - leg swelling. No tumour was suspected until the pathologic fracture occurred. It is important to consider osseous metastasis in every patient with unexplained swelling, haematoma, or pain of the extremities and make a bone scan to recognize the metastasis early.

Personality Traits and Health Related Quality of Life in Patients with Irritable Bowel Sindrome and Inflammatory Bowel Disease.

BACKGROUND: Personality traits as alexithymia and type D personality may impair health related quality of life (HRQoL) in patients with irritable bowel syndrome (IBS) and inflammatory bowel disease (IBD). Aim of this study was to evaluate personality traits in patients with IBS and IBD and their impact on HRQoL. MATERIALS AND METHODS: The subjects (40 patients with IBS, 40 with IBD and 40 health control subjects) completed SF-36 questionnaire, TAS-20 and DS14 scale. RESULTS: Patients with IBS and IBD had higher results on TAS-20 and DS14 scale when compared with healthy controls. Also IBS patients had higher scores than IBD patients. Higher scores on TAS-20 and DS14 scales in IBS and IBD patients correlate with lower HRQoL. HRQoL was poorer in IBS and IBD patients than in healthy control subjects. CONCLUSIONS: Alexithymia and type D personality in IBS and IBD patients are associated with lower HRQoL and psychological interventions should be considered.

Jejunal Lipoma Causing Intussusception in an Adult.

First described by Barbette in 1674, intestinal intussusception represents a telescoping of proximal bowel segment into the lumen of the adjacent aboral segment. Adult intussusception comprises only about 5% of all intussusceptions. We present a case of 28-year male patient who complained of colicky, intermittent epigastric pain for the last one month. Imaging detected specific signs of intussusception. Laparotomy revealed enteric intussusception of the jejunum caused by an intraluminal tumour, confirmed to be a benign lipoma on histology. Small bowel obstruction caused by jejunal lipoma in adults is a rare clinical entity and must be kept in mind when evaluating adult patients with abdominal pain. Key Words: Intussusception, Lipoma, Ileus, Jejunum.

Rare Complication of Necrotizing Pancreatitis: Extension of Retroperitoneal Abscess into Femoral Region.

Distant abscesses are uncommon during the episode of acute pancreatitis (AP). However, these are possible sequalae of necrotizing pancreatitis and should be treated appropriately to prevent serious septic complications. We demonstrate a case of a 56-year-old male patient who presented with severe necrotizing pancreatitis and distant retroperitoneal abscess that reached femoral region and was detected on diagnostic imaging scans. Combination of surgical and supportive therapy was employed, and the patient recovered well with no permanent consequences. Our article highlights the importance of quick and accurate diagnosis and timely intervention in this rare type of pancreatitis complication.

Anxiety, Depression and Personality Types in Patients with Inflammatory Bowel Disease: Comparisons with Peptic Ulcer and the General Population.

BACKGROUND: To explore corellation of anxiety, depression ant type of personality in inflammatory bowel disease (IBD) and compare with peptic ulcer (PU). SUBJECTS AND METHODS: In this study, prevalence of anxiety, depression and type of personality was investigated in 362 cases divided into three groups: 112 of IBD patients, 122 of peptic ulcer patients and 128 of control group who didn't have any gastrointestinal or psychic complaints. IBD and peptic ulcer diagnosis were established by standard diagnostic procedures (anamnesis, clinical manifestations, laboratory, endoscopy and biopsy in IBD and upper endoscopy in peptic ulcer). Anxiety and depression were established by Hamilton anxiety rating scale (HAM-A) and Hamilton rating test for depression (HAM-D). Type of A/B personality was established by Bortner scale and D type of personality by Denollet scale (DS14). RESULTS: Anxiety was found in 47 (41.9%) and depression in 44 (38.3%) of a total of 112 IBD cases. In group with peptic ulcer anxiety was found in 40 (32.8%) and depression aalso in 40 (32.8%) of total 122 cases. In control group anxiety was diagnosed in 21 (16.4%) and depression in 20 (15.6%) of total 128 cases. Anxiety and depresson were significantly higher in both groups than in control group but anxiety and depression were significantly higher in IBD group than peptic ulcer group. D type of personality was statistically significant in peptic ulcer group. CONCLUSION: Anxiety and depression in IBD and peptic ulcer cases have a greater prevalence compared to the normal population and surprisingly are higher in IBD than peptic ulcer group. D type of personality is associated with peptic ulcer.

Extensive Abdominal Skin Necrosis Following Anterior Component Separation for a Large Ventral Hernia: A Case Report.

Introduction: Hernia surgery is one of the most common operative procedures, performed in about 20 million cases per year all over the world, with ventral hernia accounting for about 30% of the cases. Although the introduction of the anterior component separation (ACS) method, popularized primarily by Oscar Ramirez, has greatly facilitated the closure of the largest abdominal wall defects, the 30-year experience in this technique has pointed to the risk of ischemic skin complications consequential to the major subcutaneous tissue dissection required. The aim of this case presentation of a patient who developed extensive necrosis of the abdominal wall skin following ACS procedure is to emphasize the importance of preserving rectus abdominis perforator blood vessels in order to preserve skin vitality. Case Presentation: We present a case of a 58-year-old female patient with a large recurrent ventral hernia. The hernial defect was closed by placing a large (30 × 25 cm) polypropylene mesh in the retro-rectus space using the Rives-Stoppa technique. To facilitate upper fascia closure ACS according to Ramirez was performed bilaterally. The rectus perforator vessels were not preserved. Recovery of the patient was complicated with the extensive abdominal skin necrosis which was successfully treated with negative pressure wound therapy. Discussion: Transection of the musculocutaneous perforators of the epigastric artery during ACS results with the compromised blood supply of the abdominal skin depending solely upon the intercostal arteries. Skin ischemia following ACS is a serious complication that can be presented with extensive necrosis associated with high morbidity and even mortality, while the treatment is long lasting, complex, and expensive. Considering the ever-increasing prevalence of large ventral hernias, ever greater popularity of the ACS technique, and the growing proportion of surgeons performing large ventral hernia operations independently, we think that the role of preserving perforated rectus vessels has not been emphasized enough. Therefore, the objective of this case study is to stimulate surgeons to preserve skin vascularity and promote it in their routine in order to avoid these severe postoperative complications.

Intramural Stomach Gas with Hepatic Portal Venous Gas Indicating Spontaneous Stomach Necrosis.

Intramural gas in the stomach associated with hepatic portal venous gas is a rare entity, which suggests ischemic or infectious pathology of the stomach. We report a case of a 73-year-old man who presented with epigastric pain and nausea of 6 hours duration followed by hematemesis. The patient had pale skin, anemia, and a diffusively tender and distended abdomen. Abdominal radiography and computed tomography (CT) revealed gas in thickened gastric wall and gas in intrahepatic portal vein branches. Surgery was indicated, which consisted of partial gastrectomy with Roux en esophago-jejunal anastomosis. Postoperative course was uneventful, and pathohistological analysis indicated stomach wall necrosis with emphysametous gastritis (EG). The patient was free of symptoms at 2 years follow-up. Intramural gas in the stomach should always be meticulously investigated to differentiate between emphysematous gastritis and gastric emphysema, as this would direct the therapeutic approach to be adopted.

Nutritional status and its effect on complications in patients with colorectal cancer.

BACKGROUND: Nutritional status is an important factor for predicting the risk of developing complications after a surgical procedure. Many nutritional assessments are used in clinical practice, but their role in predicting postoperative outcomes is unknown. Therefore, the aim of this study was to assess the utility of nutritional risk factors at the diagnosis of colorectal cancer (CRC) for predicting early postsurgical complications. METHODS: This was a prospective observational study including 127 patients with CRC at diagnosis. Their preoperative nutritional status was analyzed by body mass index (BMI), triceps and subscapular skinfolds and two nutritional scales: the Patient-Generated Subjective Global Assessment (PG-SGA) and the Malnutrition Universal Screening Tool (MUST). The outcome variables, including postoperative complications, length of hospital stay and mortality, were analyzed. RESULTS: Patients identified as malnourished by PG-SGA score had prolonged hospital stays (p = 0.01). The risk of infection was increased in older patients (hazard ratio, HR 1.12; 95% confidence interval, CI 1.04-1.21) but was not associated with nutritional status. Early wound dehiscence was increased in patients with higher BMI (HR 1.15; 95% CI 1.01-1.29), with higher subscapular skinfold thickness and increased age (HR 1.05; 95% CI 1.05-1.10). Postoperative mortality was not significantly associated with nutritional status. CONCLUSION: Malnourished patients, as identified by the PG-SGA score, stayed longer in hospital than patients who were not malnourished, while increased BMI was recognized as a risk factor for wound dehiscence.

Association of colorectal carcinoma and metabolic syndrome.

Aim Colorectal carcinoma is one of the most common neoplasms, especially in Western countries and those with westernisation. On the other hand, high rate of metabolic syndrome (MetSy) has also been noticed, as well as in Western countries. It seems like these two conditions are somehow connected. In this study, we wish to explore some characteristics of colorectal carcinoma and its correlation with MetSy. Methods In this retrospective study the data were taken from medical records of 67 patients with colorectal carcinoma, and for 30 healthy controls. Input parameters of patients were compared mutually, as well as with parameters of healthy, control examinees that had negative screening colonoscopy for neoplasm. Results Average age of patients was 68 years. The most frequent localisation of neoplasm was on rectum (53.7%) and most frequent level was Dukes C (38.8%). The patients had MetSy more frequently when compared with controls (p=0.048), and also they had more MetSy components (p=0.006). The link between MetSy and localisation of neoplasm was not found, neither with its pathohystological characteristics. Conclusion Patients with MetSy should be warned about the increased risk of colorectal carcinoma, and, in this way, motivated for earlier and more frequent screening colonoscopies, as well as of a change of unhealthy lifestyle.

Type of Cell Separator, Fenwal Amicus vs Fresenius Com Tec, May Influence the Corpuscular Elements Value of the Donor`s Blood.

INTRODUCTION: During the plateletpheresis procedure the number of thrombocytes in the donor's blood significantly decreases, and the levels of the hematocrit (HCT), hemoglobin (Hgb), and leukocyte (WBC) diminish as well. Influence of the cell separator is one of the factors that affects the levels of HCT, Hgb and WBC. In this study, the goal was to determine the value difference of HCT, Hgb, WBC, and platelets after the platelet pheresis process between performance on Fenwal AMICUS and on Fresenius Com Tec. DONORS AND METHODS: The criteria for participation: male in the age range of 25-45. We have formed two groups: for both groups - 180 separations were performed on 60 participants were the values of hematocrits, concentration of hemoglobin and number of leukocytes were established before and after separation using the double-needle continuous flow cell separation (DN-CFCS) on two different devices, Fenwal AMICUS device and the Fresenius Com Tec. device. To confirm the statistical differences we have used Student t-test for independent or dependent samples, as well as Mann-Whitney U test as non-parametric alternative. To compare differences between the values of four parameters (P1-P2) from two groups (using two devices - Fenwal AMICUS and Fresenius Com Tec) The possibility of errors were accepted for α<0.05, and the difference between groups as statistical relevant were accepted for p<0.05. RESULTS: Statistically significant lower values were noted for all researched parameters after separation on both devices. The statistically significant average values for Hct, Hgb and WBC obtained between two devices, were less than 0.05 (p=0.05). For the platelets (Plt) there was no statistical significant difference (p>0.05 - α=0.05), between average level obtained using either Fenwal AMICUS or Frazenius Com Tec. CONCLUSION: The type of cell separator had the influence on the decrease value of the observed parameters.

Allergic reactions and anesthesia.

The diagnosis of allergic reactions during anesthesia is difficult. For example, cardio-respiratory symptoms may be due to the accompanying pharmacological effects of anesthetics and poor interpretation of the reaction during anesthesia. It is important to distinguish whether a real allergic reaction has occurred. Accidents with anesthetics and muscle relaxants are observed more often than we expect. Proper anaphylaxis rarely occurs during anesthesia (1: 20000). Muscle relaxants are the most common causes, followed by latex, chlorhexidine, antibiotics and opioids. To confirm the diagnosis it is necessary to perform a larger number of blood and skin tests. Targeted diagnostic approach and therapy allow avoiding more difficult events. Anesthesia should be selected for those medications that have been tested. Additionally, patients should be premedicated with antihistaminics and systemic steroids, as the emergence of intolerance is not completely excluded by negative testing. There is no gold standard for testing, even if every method is precisely performed; there are always false positive and false negative results. When anaphylaxis appears, urgent approach is needed to provide the patient with appropriate treatment. It is necessary to act according to the established algorithms and treatment protocols. Many anesthesiologists will not ever see such a reaction, and very few will see more than one during their work life. Awareness of allergy in anesthesia is still insufficient.

Correlation of clinical and endoscopic indices in IBD patients in University Clinical Hospital Mostar.

BACKGROUND: To explore correlation between clinical and endoscopic indices in inflammatory bowel disease (IBD) patients. SUBJECTS AND METHODS: There were 112 patients with inflammatory bowel disease. All patients with diagnosed IBD was established a degree of clinical and endoscopic disease activity. CDAI (Crohn's disease activity index) was used as clinical and SES-CD (Simplified Endoscopic Crohn Disease Index) as endoscopic index for Crohn's disease. For ulcerative colitis Truelov & Witts index was used as clinical and Baron as endoscopic activity index. Correlation of clinical and endoscopic indices were compared in Crohn disease (CD) and ulcerative colitis (UC). Patients were analyzed by clinical entities - CD and UC, according to sex, age, parameters of anemia, duration of disease and education. RESULTS: In the total of 112 IBD patients there were 69 patients diagnosed as ulcerative colitis (61.6%) and 43 as Crohn's disease (38.4%). There were 58 (51.8%) women and 54 (48.2%) men. Comparison between endoscopic and clinical indices in CD and UC demonstrated no significant differences in ilnness activity. Endoscopic and clinical disease activity was associated with a higher inflammatory parameters (CRP and leucocytes, L) and lower parameters of hemoglobin (Hb) and MCV. CONCLUSION: Our research has established a good correlation between clinical and endoscopic index of disease activity in the CB and UC in inflammation. Clinical indices can be used for monitoring inflammation.

Prevalence of amebiasis in inflammatory bowel disease in University Clinical Hospital Mostar.

AIM: To explore the prevalence of amebiasis in inflammatory bowel disease (IBD), Crohn's disease and ulcerative colitis, in patients in Clinical hospital Mostar (Bosnia and Herzegovina, region of Herzegovina). METHODS: In this study, Entamoeba histolytica/dispar prevalence was investigated in fresh faeces by native microscopy and immunochromatographic rapid assay "RIDA(®)QUICK Entamoeba test", in 119 cases of new found IBD patients, 84 of ulcerative colitis and 35 of Crohn's disease and in control group who had also 119 patients who didn't have any gastrointestinal complaints. IBD diagnosis was established by standard diagnostic procedures (anamnesis, clinical manifestations, laboratory, endoscopy and biopsy). RESULTS: Entamoeba histolytica/dispar were found in 19 (16.0 %) of a total of 119 cases, 12 (14.3 %) of the 84 patients with ulcerative colitis and 7 (20.0 %) of the 35 patients with Crohn's disease. As for the 119 patients in the control group who had not any gastrointestinal complaints, 2 (1.7 %) patients were found to have E. histolytica/dispar in their faeces. Amoeba prevalence in the patient group was determined to be significantly higher in group with Crohn's disease, ulcerative colitis and IBD total than in the control group (p < 0.001). CONCLUSION: Ameba infections in patients with Crohn's disease and ulcerative colitis, have a greater prevalence compared to the normal population.

Association of Asymmetric Dimethylarginine With Acute Pancreatitis-Induced Hyperglycemia.

OBJECTIVE: The objective of this study was to investigate the relationship between asymmetric dimethylarginine (ADMA), an endogenous nitric oxide synthase inhibitor, oxidative-nitrosative damage, and glucoregulation in acute pancreatitis (AP). METHODS: The study evaluated serum levels of ADMA, nitrotyrosine, and urinary 8-hydroxydeoxyguanosine in 40 male patients hospitalized for AP at baseline and at 2 and 10 days of treatment, respectively. The patients were classified into a mild and a moderately severe AP group (MAP and MSAP, respectively) according to Atlanta classification criteria. Glycemic status was evaluated by a 75-g oral glucose tolerance test 1 month after AP onset. Forty age-matched healthy subjects served as control subjects. RESULTS: Significant decrease of ADMA and increased levels of nitrotyrosine and urinary 8-hydroxydeoxyguanosine were found in MSAP, but not in MAP at baseline, with ADMA correction toward control levels at the 10th day of treatment. Fructosamine was found to significantly influence ADMA levels (r = -0.362, P = 0.002). After AP recovery, either impaired glucose tolerance or diabetes was identified with the oral glucose tolerance test in 10.5% and 92.8% of patients with MAP and MSAP, respectively. CONCLUSIONS: Insufficient inhibition of nitric oxide synthesis, through reduced bioavailability of ADMA, might be a novel significant contributory factor to the severity of AP and subsequent development of hyperglycemia.

Distribution and age-related bioaccumulation of lead (Pb), mercury (Hg), cadmium (Cd), and arsenic (As) in tissues of common carp (Cyprinus carpio) and European catfish (Sylurus glanis) from the Busko Blato reservoir (Bosnia and Herzegovina).

The purpose of this study was to quantify the bioaccumulation of Pb, Hg, Cd, and As in tissues of carp (Cyprinus carpio) and catfish (Silurus glanis) from Busko Blato in Bosnia and Herzegovina. Arsenic concentrations were below the Maximal Admissible Concentration (MAC) for Croatia and other countries. Mercury concentrations were below 1 mg kg(-1), but in most muscle samples of both species and all catfish liver samples, the values were higher than 0.5 mg kg(-1) (higher than the MAC for many countries including Croatia). Lead concentrations were higher than 1 mg kg(-1) (the MAC for Croatia) in most muscle samples; all kidney and most catfish liver samples also exceeded 1 mg kg(-1). Cadmium concentrations in all tissues, other than the gonads, were higher than 0.1 mg kg(-1) (MAC for Croatia), with the highest concentrations found in the kidneys. The only gender difference was found in carp, where a 68.4% higher concentration of As was found in the fry compared to the milt (P<0.05). Concentrations of all of the elements were higher in catfish compared to carp for most tissues. Significant correlations were found between all of the elements in the muscles and the liver of carp. In catfish, the muscles were the only tissue in which multiple correlations were found. Linear positive correlations with age and body mass were demonstrated for the concentrations of all heavy metals for all tissues except the gonads in both fish species. We concluded that significant heavy metal accumulation in carp and a catfish tissues correlates with age and body mass; bioaccumulation is species- and tissue-specific and is different for each element.

Correlation between biochemical and histopathological parameters in patients with chronic hepatitis C treated with pegylated interferon and ribavirin.

AIM: The main goal of this study was to compare the biochemical and histopathological findings in patients with sustained virological response (SVR) before and two years after the therapy with pegylated interferon α-2a and ribavirin in chronic hepatitis C. SUBJECTS AND METHODS: The study was conducted at the Department of Internal Medicine and the Clinic for Infectious Diseases of the Clinical Hospital Mostar. The study included 48 patients whose treatment for chronic hepatitis C with pegylated interferon α-2a and ribavirin was finished two years prior to the achieved SVR at the end of the treatment. The main criterion for inclusion was a negative result of HCV RNA, determined by the RealTime HCV assay. After taking a history, physical examination, laboratory tests: AST, ALT, GGT, a liver biopsy were performed with the help of the ultrasound. The assessment of necroinflamatory score was determined by histologic activity index (HAI) score, and the stage of fibrosis according to Knodell's numerical score. RESULTS: The values of AST and ALT levels were statistically significantly decreased after the successful treatment (p<0.001), as well as the value of HAI score (p=0.001) and the stage of fibrosis (p=0.010), in contrast to GGT (p=0.054). For the components of HAI score like focal necrosis (0.001) and portal inflammation (0.042) the result showed that they were significantly higher before the therapy, which was not true for the piecemeal (p=0.054) and confluated necrosis (p=0.078). The improvement of HAI score after therapy was found in 36 patients (75.0%), and 27 patients (56.2%) showed an improvement in the degree of fibrosis with the most common improvement of 1 degree (85.7%). One third of patients (31.3%) had the same result in the degree of fibrosis before and after the therapy. Before the treatment, a positive correlation was observed between ALT (p=0.039) and AST (p=0.04) with HAI, AST and the stage of fibrosis (p=0.04). In contrast, after the treatment the only correlation was observed between AST and the stage of fibrosis (p=0.042). CONCLUSION: Virological and biochemical responses in patients with SVR may not reflect the histopathological effects of the treatment and therefore these patients should be monitored for the possible development of the liver cirrhosis and hepatocellular carcinoma.