Altered cytokine expression in Helicobacter pylori infected patients with bleeding duodenal ulcer.

OBJECTIVE: Peptic ulcer disease is a condition in which an important role has infection with H. pylori. The most common complication of peptic ulcer is bleeding. The presence of H. pylori triggers local and systemic cytokine signaling which may affect processes such as healing, gastric or duodenal rupture, and carcinogenesis. In this study, we examined the concentrations of IL-1ß, IL-6, IL-10, TNF, TGF-ß and IL-17A in serum by enzyme immunoassay and their mRNA expressions in periulcer biopsies obtained from patients with bleeding peptic ulcer by means of real-time-PCR. RESULTS: We have shown that pro-inflammatory IL-6 and TNF concentrations in serum were significantly higher in patients who were infected with H. pylori, while the concentrations of TGF-ß and IL-17A were significantly lower compared to non-infected subjects. IL-17A expression in periulcer mucosa was significantly higher in patients who were infected with H. pylori, while the expression of other cytokines, there was no significant difference compared to non-infected controls. Considering higher serum concentrations in non-infected subjects and higher IL-17A expression in mucosal tissue of infected patients, our data support the studies that found IL-17A has protective role in eradication of H. pylori infection in infected patients.

Strengthening Emergency Care Systems to Mitigate Public Health Challenges Arising from Influxes of Individuals with Different Socio-Cultural Backgrounds to a Level One Emergency Center in South East Europe.

Emergency center visits are mostly unscheduled, undifferentiated, and unpredictable. A standardized triage process is an opportunity to obtain real-time data that paints a picture of the variation in acuity found in emergency centers. This is particularly pertinent as the influx of people seeking asylum or in transit mostly present with emergency care needs or first seek help at an emergency center. Triage not only reduces the risk of missing or losing a patient that may be deteriorating in the waiting room but also enables a time-critical response in the emergency care service provision. As part of a joint emergency care system strengthening and patient safety initiative, the Serbian Ministry of Health in collaboration with the Centre of Excellence in Emergency Medicine (CEEM) introduced a standardized triage process at the Clinical Centre of Serbia (CCS). This paper describes four crucial stages that were considered for the integration of a standardized triage process into acute care pathways.

Erythropoietin in the Evaluation of Treatment Outcomes in Patients with Polytrauma.

Polytrauma is a term describing patients with injuries involving multiple body regions that compromises function of the body and/or organ involved. The aim of the study was to evaluate the potential role of erythropoietin in predicting poorer outcome in trauma patients. This prospective study included 86 patients admitted to the Emergency Center of Serbia due to polytrauma assigned according to Injury Severity Score (ISS). The patients were further evaluated using the Acute Physiology and Chronic Health Evaluation II and Sequential Organ Failure Assessment scores and erythropoietin levels. There was a significant difference among erythropoietin levels at admission, after 48 and 72 hours, and on day 7 of hospital stay, with significantly higher levels in patients with ISS values 49-75. Based on the results, ROC curves were used to identify cut-off levels to predict ISS score with critical clinical course. It was concluded that erythropoietin could be a good marker of injury severity. Further research has to be performed to determine the cut-off values of erythropoietin that are significant for injury severity.

Hartmann's procedure vs loop colostomy in the treatment of obstructive rectosigmoid cancer.

INTRODUCTION: Colorectal carcinoma is the most common malignant gastrointestinal tumour. There is still a considerable controversy when it comes to urgent surgical treatment of obstructive carcinoma of the left colon and rectum. METHODS: Seventy-five patients from the randomized trial were followed up. This study was designed as a stratified randomized trial with four stratums according to age and ASA score (older/younger than 60 years and ASA score <>3). Each of the four groups is then divided into two sub-groups according to the operating technique: loop colostomy or Hartmann's procedure. RESULTS: There were no difference found in hospitalization among the groups (loop colostomy vs. Hartmann's procedure) in the same stratus (P = 0.3192, P = 0.5760, P = 0.9023 respectively), except in the case of doing reconstructive procedure after loop colostomy (P = 0.0049) in the fourth stratum (patients younger than 60 years with ASA score lower than 3). Type of operation had no influence over the blood test values observed on admittance and during hospitalization (P = 0.319, P = 0.871, P = 0.7, P = 0.843, P = 0.52 respectively for the blood values). In terms of surgical and non-surgical complications it has been shown that there is no statistically significant difference between patients treated by two methods. Age, gender, ASA score, type of operation and surgical complications were not singled out as a risk factor for fatal outcome (P = 0.199, P = 0.155, P = 0.764, P = 0.452 and P = 0.724 respectively). The only factors that are singled out as a risk factor for death are the emergence of non-surgical complications and angina pectoris (P = 0.006, P = 0.001). CONCLUSIONS: There is no difference in surgical treatment of large bowel obstruction caused by rectosigmoid carcinoma. Neither of those two methods showed significant advantage in treatment of large bowel obstruction caused by rectosigmoid cancer.

Interleukin-12 as a predictor of outcome in patients with severe acute pancreatitis.

BACKGROUND/AIMS: The aim of this study was to determine the role of serum Interleukin-12 level as early marker of severity of the SAP and correlation between IL12, SIRS score, APACHE II and Ranson score in prediction of illness severity as well as of outcome of SAP. METHODOLOGY: We evaluated a total of 234 patients with first onset of SAP, appears in last 24 hours, admitted in surgical Intensive care unit (ICU). Severe Acute Pancreatitis was diagnosed with an APACHE II score of 8 or higher, and/or a Ranson score of 3 or higher, and/or Balthazar scores of 5 or higher. Serum IL-12 concentrations were measured with a commercially aviable IL-12 kit, on admission and days 3, 7, and 14. RESULTS: IL-12 concentration was significantly higher at 24h compared with IL-12 levels at admission (P = 0.010) and after 72h (P = 0.005). IL-12 concentrations significantly correlated with IL-6 concentrations (r = 0.209, P < 0.001), IL-8 concentrations (r = 0.527, P < 0.001), IL-10 concentrations (r = 0.552, P < 0.001), interpheron-gamma (r = 0.740, P < 0.001), TNF-alpha (r = 0.088, P < 0.05), C-reactive protein (r = -0.097, P < 0.001), in-hospital death (r = -0.171, P < 0.001), APACHE II score (r = 0.140, P < 0.001), and Ranson score (r = -0.319, P < 0.001). CONCLUSIONS: The serum values of the IL-12 can be used as an early marker of severity and course of SAP.

Clinical relevance of IL-6 gene polymorphism in severely injured patients.

In polytrauma, injuries that may be surgically treated under regular circumstances due to a systemic inflammatory response become life-threatening. The inflammatory response involves a complex pattern of humoral and cellular responses and the expression of related factors is thought to be governed by genetic variations. This aim of this paper is to examine the influence of interleukin (IL) 6 single nucleotide polymorphism (SNP) -174C/G and -596G/A on the treatment outcome in severely injured patients. Forty-seven severely injured patients were included in this study. Patients were assigned an Injury Severity Score. Blood samples were drawn within 24 h after admission (designated day 1) and on subsequent days (24, 48, 72 hours and 7 days) of hospitalization. The IL-6 levels were determined through ELISA technique. Polymorphisms were analyzed by a method of Polymerase Chain Reaction-Restriction Fragment Length Polymorphism (PCR). Among subjects with different outcomes, no statistically relevant difference was found with regards to the gene IL-6 SNP-174G/C polymorphism. More than a half of subjects who died had the SNP-174G/C polymorphism, while this polymorphism was represented in a slightly lower number in survivors. The incidence of subjects without polymorphism and those with heterozygous and homozygous gene IL-6 SNP-596G/A polymorphism did not present statistically significant variations between survivors and those who died. The levels of IL-6 over the observation period did not present any statistically relevant difference among subjects without the IL-6 SNP-174 or IL- 6 SNP -596 gene polymorphism and those who had either a heterozygous or a homozygous polymorphism.

Distal ileal endometriosis as a cause of ileus: a case report.

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.

Glissonean pedicle approach in major liver resections.

BACKGROUND/AIMS: Liver resections are still one of the most challenging operations. The aim of this study was to analyze the efficiency and safety of the intrahepatic Glissonean pedicle approach vs. classical Hilar dissection in major hepatectomies. METHODOLOGY: Thirty-four patients were assigned to the Glissonean approach (GA, n=34), while the Hilar dissection were assessed as historical control, matched for the age, gender, comorbidities and Child-Pugh score (HD, n=34). RESULTS: The GA was associated with significantly shorter surgery duration (191.18±41.10 vs. 246.62± 56.55), transection time (38.94±14.56 vs. 56.32±19.40) and ischemic duration (26.03±11.27 vs. 41.18±12.80) than HD (p<0.001 for all). The amount of blood loss was significantly lower in GA (245.59±169.39 vs. 344.71±166.25; p=0.018). The amount of blood transfusion was significantly lower in GA during surgery (322.86±102.07 vs. 414.76±135.48) as well as postoperatively than HD (246.67±5.77 vs. 336.67±120.55) (p=0.038 and p=0.026. respectively). CONCLUSIONS: Major hepatectomy can be performed more easily using the Glissonean pedicle approach than by hilar dissection. En-masse transection of pedicles, as well as hepatic veins, using endo-GIA vascular stapler could be performed safely. Liver surgeons should know the Glissonean pedicle approach.

Research of injuries of passengers in city buses as a consequence of non-collision effects.

In this study, a research of injuries of passengers in city buses is presented, which are not a consequence of collision of buses with other objects. The number of injured passengers in the territory of Belgrade was registered, during three consecutive years. Most frequently injured body part was the head, while women over the age of 60 are the most vulnerable population of passengers. The most often reason for the appearance of injuries was the effect of acceleration. Also, it is pointed out to the importance of consideration of the problem of multiple injuries. These injuries are more complex than the individual ones, and they may indicate to the existence of greater omissions in the design of the interior of the bus. Proposals for certain system solutions, as well as some recommendations for designing are given, which can improve the safety of passengers who use the city bus as a means of transportation.

[Biometeorological influence on motorcyclists and bicyclists trauma].

INTRODUCTION: Biometeorological circumstances have great influence on all traffic participants, especially on reflexes, movement coordination and perception ability, increasing the number of accidents. Motocyclists and bicyclists are specific participants in traffic, so their traumatism has its own special characteristics. OBJECTIVE: The aim of this study was to establish biometeorological influence on motorcyclists and bicyclists accidents. METHODS: Comparative analysis of everyday biometeorological phases for the city of Kragujevac determinated by the Republic Hydrometeorological Service of Serbia and motorcyclists and bicyclists accident evidence received from Kragujevac traffic police for the period 2004-2008. RESULTS: There were 5,180 traffic accidents in this period, with 180 accidents in which 77 motorcyclists and 116 bicyclists were knocked down. Most of the accidents were in 2008 (53) and the least in 2005 (28). Most accidents occurred during August (28) and between 19.00 and 20.00 hours (18). There were no accidents during January, between 04.00 and 06.00 hours. There were 85% accidents in the urban area. Most of 169 males were aged 16-20 and 21-25 years (20 and 21). Most of 24 females (6) were aged 11-15 years. Those who caused the accident mostly sustained injuries due to improper speed limit (31), while the victims due to the disrespect of street-crossing priorities (32). Forty-one motorcyclists and 85 bicyclists suffered mild body injuries. Thirty-one motorcyclists and 27 bicyclist suffered severe injuries. Five motorcyclists and four bicyclists ended lethally. Most accidents happened in biometeorological phases 9 (63), 4 (32) and 1 (31). CONCLUSION: Statistical analysis showed a significant correlation between accidents and biometeorological phases, with most accidents occurring during stabile warm weather and rapid penetrations of cold fronts, and with a sudden switch of weather conditions.

[Biometeorological phases influence pedestrian trauma].

INTRODUCTION: Biometeorological circumstances have a big influence on all traffic participants, especially reflexes, moving coordination and perception ability. With a lower attention and drivers' and pedestrians' concentration, there was a larger amount of pedestrian trauma in certain biometeorological phases. OBJECTIVE: The aim of this study was to establish the correlation between pedestrian trauma and biometeorological phases. METHODS: The comparative analysis of everyday biometeorological phases for the city of Kragujevac determined by RHMI and the evidence of knocked-down pedestrians from the Kragujevac traffic police for the period 2003-2008. RESULTS: There were 6,127 accidents, with 696 knocked pedestrians in 666 (10.87%) accidents. Most of them happened in 2003 (135), and the fewest in 2005 (90). Most accidents were during December (74), the fewest were in June (46). The fewest accidents were during 04-05-06 hour interval (by 2), most during 13-14 hours (61). There were 374 males and 349 females. Most of the males (by 60) were 0-10 and 11-20 years old, most of the females (74) were 11-20 years old. There were 443 pedestrians who suffered slight body injuries (112 were 11-20), 225 suffered heavy and 28 had lethal injuries (most over 70). As provokers, the pedestrians suffered because of improper crossing roads (185), while as a casualties, they suffered due to speeding of vehicles (285). Most accidents happened in biometeorological phases 4 (168) and 9 (151), the fewest in phase 10 (4). CONCLUSION: Statistical analysis shows a significant correlation between pedestrians' accidents and biometeorological phases, when the most accidents occurred during penetrations of cold fronts, while there was a sudden switch of weather conditions from warm-dry to cold-wet weather.

SIRS score on admission and initial concentration of IL-6 as severe acute pancreatitis outcome predictors.

BACKGROUND/AIMS: Early recognition of severe form of acute pancreatitis is important because these patients need more agressive diagnostic and therapeutical approach an can develope systemic complications such as: sepsis, coagulopathy, Acute Lung Injury (ALI), Acute Respiratory Distress Syndrome (ARDS), Multiple Organ Dysfunction Syndrome (MODS), Multiple Organ Failure (MOF). To determine role of the combination of Systemic Inflammatory Response Syndrome (SIRS) score and serum Interleukin-6 (IL-6) level on admission as predictor of illness severity and outcome of Severe Acute Pancreatitis (SAP). METHODOLOGY: We evaluated 234 patients with first onset of SAP appears in last twenty four hours. A total of 77 (33%) patients died. SIRS score and serum IL-6 concentration were measured in first hour after admission. RESULTS: In 105 patients with SIRS score 3 and higher, initial measured IL-6 levels were significantly higher than in the group of remaining 129 patients (72 +/- 67 pg/mL, vs 18 +/- 15 pg/mL). All nonsurvivals were in the first group, with SIRS score 3 and 4 and initial IL-6 concentration 113 +/- 27 pg/mL. The values of C-reactive Protein (CRP) measured after 48h, Acute Physiology and Chronic Health Evaluation (APACHE II) score on admission and Ranson score showed the similar correlation, but serum amylase level did not correlate significantly with Ranson score, IL-6 concentration and APACHE II score. CONCLUSION: The combination of SIRS score on admission and IL-6 serum concentration can be early, predictor of illness severity and outcome in SAP.

Prospective evaluation of the prevalence of Helicobacter pylori in abdominal surgery patients.

BACKGROUND/AIMS: Helicobacter pylori infection is accepted to be associated with two mutually exclusive diseases duodenal ulcer and gastric cancer. The aim of this study was to explore the relationship and prevalence of Helicobacter pylori infection in different surgical diseases. METHODOLOGY: With use of simple serologic assays for detecting IgA and IgG antibodies to HP antigen, we studied the association of infection with HP and 15 surgical diseases. RESULTS: The prevalence of HP was 68.60% (results of assays were positive for 142 patients out of 207). This study confirmed statistically significant correlation between HP seropositivity and pancreatic cancer (p = 0.02), hepatocellular cancer (p = 0.000), gastric cancer (p = 0.01), colon cancer (p = 0.002), rectal cancer (p = 0.001), intestinal cancer (p = 0.026), stenosis pylori (p = 0.01), ulcer diseases (p = 0.004), jaundice (p = 0.002); statistically significant inverse association between HP seropositivity and the acute appendicitis (p = 0.013) and no correlation with HP infection and cholecystitis (p = 0.716), cholelithiasis (p = 0.06), and ulcer hemorrhage (p = 0.064). CONCLUSION: The use of simple serological tests to identify patients with HP infection could help to calculate the risk of development of severe gastrointestinal diseases.

[Surgical treatment of liver injury--5-year experience].

Due to improved methods of treatment and management of hemorrhage, the mortality from liver injuries has decreased significantly over the past few decades. In spite of that, liver injuries still represent diagnostic and therapeutic challenge. This retrospective study included 197 patients surgically treated because of trauma of the liver at The Clinic for Emergency Surgery, during the period 2004-2009. The results showed significant difference in mortality rates in cases of penetrating wounds compared to blunt trauma and gunshot wounds. The severity of injury evaluated by Organ Injury Scale was significantly higher in gunshot wounds compared to blunt and penetrating trauma. The correlation of severity of injuries and mortality rates showed that the mortality is significantly lower in patients with grade 1, 2, and 3 injuries compared to grades 4 and 5 (p = 0.016). Specific complication rate was 28.4%, while mortality rate was 21.8%. The results reflect diagnostic and treatment problems, as well as the importance of multidisciplinary approach to the patients with liver trauma.

[Surgical treatment of pancreatic injuries in severe abdominal trauma].

In spite of its low incidence, pancreatic injuries hold important place in abdominal trauma because of diagnostic difficulties, severe potential complications, therapeutic challenges, and high mortality rates. These injuries are related with specific morbidity and are very often accompanied with injuries of other organs. This retrospective study included 31 patients treated at The Clinic for Emergency Surgery of Clinical Center of Serbia during the period of 2004-2009 with intraoperativelly confirmed diagnosis of pancreatic trauma. The most common mechanism of injury was blunt trauma (83.9%). Among available diagnostic methods, abdominal ultrasound was characterized with high incidence of false-negative findings (33.3%) while for CT it was at 16.6%. The type of surgical procedure was related to degree and severity of injury. Specific complications occurred in 22.6% of patients, while mortality rate was 25.8%. The creation of unambiguous algorithms for optimal treatment of patients with pancreatic trauma require multi-centric prospective studies.

[Laparoscopy in the evaluation of blunt abdominal trauma].

Laparoscopic diagnostics provides fast, reliable, clear, and obvious information on extent and depth of abdominal organs injury with minimizing additional trauma to the patient. It is performed without any specific preparations and, if needed, it may be promptly converted into conventional laparotomy. Through use of optical equipment with various refraction angles and through variable patient positioning, laparoscopic technique enables visualization of whole abdominal cavity. In approximately 20% of cases of unclear findings, and after other performed diagnostic procedures, laparoscopy provides definitive diagnosis. Abdominal surgeons are familiar with this method, making interpretaion of the results very fast and reliable and, what is the most important, this method avoids additional trauma caused by conventional laparotomy.

[Surgical treatment of injuries of the stomach and duodenum in abdominal trauma].

Injuries of the stomach and duodenum have an important place in abdominal trauma, even though that the isolated injuries are rare. This kind of injury is most commonly associated with injuries of other abdominal organs. This retrospective study has been done at the Department of Emergency Surgery, Clinical Centre of Serbia, during the period from January 2004. until January 2009. The study included 36 patients diagnosed intraoperatively with the injury of the stomach and duodenum. The most common mechanism of harming were injuries due to blunt trauma (41.7%), the ones followed by gunshot wounds (30.5%), and the least were stab injuries (27.8%). With the majority of patients has been conducted sutures (46.3%) and serosation (30.6%) of the stomach and duodenum. In 24 (66.7%) patients on admission have been done ultrasound of the abdomen, in 6 (16.7%) abdominal CT was done, in 4 (11.1%) peritoneal lavage have been done and the x-ray of the abdomen was performed in 3 (8.3%) patients. Specific complications had 1 (2.8%) patient, while 14 (29.9%) patients have had non-specific complications. Total mortality has been 33.3%

[Oversights in the care of severe injuries].

Question of missed injuries is more often a question of human errors: task execution errors, procedural errors, communication errors, decision errors and noncompliance. Missed injuries are those which are not idetified in the first three days of hospitalisaation. This theme is not popular among physicians. Literature data mention percent from 3-29% missed injuries overall. The underlying causes errors are: false attributin, false negative prediction and false lebeling. False attribution involves a tendency to incorrectly link a clinical observation with an arroneous cause. This tendency also ignores one of the fundamental principles of the management of traumatic injury: that the index of suspicion should proceed on the basis of assumed wors resonable case scenario. Weaknesses of trauma systems: high patients volume, high-risk patients, long hours, changing set of resources, and problems sush bad admission planing, defficite anamnesis, defficite diagnostic procedures, bad communication, improvisation etc.

Use of recombinant factor VIIa in the treatment of massive retroperitoneal bleeding due to severe necrotizing pancreatitis.

BACKGROUND: Recently, a growing number of case reports and case series have suggested that the use of recombinant activated factor VII (rFVIIa) may be effective in treatment of patients with non-hemophilic acquired coagulopathy not responding to conventional treatment such as major surgery, major trauma, sepsis, necrotizing pancreatitis and bleeding due to cerebral arteriovenous malformations. CASE REPORT: We presented a septic patient with massive, life-threatening bleeding caused by retroperitoneal necrosis, due to severe acute necrotizing pancreatitis. As conservative treatment (blood, plasma, cryoprecipitates and platelet transfusions) failed to induce cessation of bleeding, the patient was urgently operated on. In spite of usual procedures of surgical hemostasis (ligation, suture, thermocauterisation, fibrin glue, temporary tamponade), hemorrhage could not be stopped. The patient manifested the signs of hypothermia and metabolic acidosis and, therefore, the decision was made to use recombinant activated factor VII (Novo Seven). The application of rFVIIa resulted in significant discontinuation of hemorrhage, restoration to normal blood count as well as other relevant coagulation parameters. CONCLUSION: Although application of rFVIIa is still in the initial clinical phase, and the experience is based mainly on uncontrolled series as well as on individual observations, it seems that this drug can be promising, potent and attractive adjunctive prohemostatic agent. This drug may play a beneficial role in the treatment of serious and unresponsive, "nonsurgical", life-threatening bleeding due to severe acute necrotizing pancreatitis.

Laser-induced damages of different types of human gallbladder stones.

BACKGROUND/AIMS: Today, treatment of human calculi, and particularly those of gallbladder, is, to a large extent, less invasive procedure due to numerous non-invasive methods that have been developed. METHODOLOGY: CO2 laser of pulse (output 5W)(W-watt, SI unit system) and continual mode (output 15W) and diode laser (808 nm-nanometer, SI) were used for tests of fragmentation of gallbladder calculi in vitro. RESULTS: A total of 15 human gallbladder calculi of known size were examined, which had been collected during surgical interventions. Damages caused by laser were examined visually and by stereomicroscope (10 to 25 times magnification). During testing, the dependence of fragmentation on the type of laser effect, as well as the degree of fragmentation on the type of tested calculus was noted. Different types and dimensions of damage caused by various laser beams, as well as coloration changes of superficial layers in relation to the type of tested calculi was noticed. CONCLUSION: Accordingly, in this specific case, the priority for removal of gallbladder calculi by ablation will be given to diode laser.