Evaluation of Risk Factors for the Occurrence of Limb Fractures in Children Due to Unintentional Injury in Podgorica, Montenegro, Mediterranean.

Background and Objectives: Limb injuries in childhood are very common, with most of them being unintentional and often accompanied by soft tissue injuries. The aim of our study was to determine the risk factors that contribute to the occurrence of limb fractures as the most common type of accidental injury to children in our conditions. Materials and Methods: This study was designed as a prospective clinical analysis of predictive factors with a "nested" case-control study. It included all patients under the age of 18 who were diagnosed with unintentional limb injury and limb fracture due to accidental injury, at the Clinical Center of Montenegro, Podgorica, in the period of 7 January 2020-30 June 2021. Results: The gender of the child and the occurrence of the fracture are not related, and a statistically significant relationship was found between the occurrence of the fracture and the place of residence, the child's age, body mass index (BMI), the affected limb, the method of injury, and the mental state of the parents of the injured child, as well as their economic status. It was proved that the older the child was, the lower the chance of injury, while multivariate analysis proved that BMI could be a predictor of accidental fracture. The most common method of accidental limb fractures in children was a fall from a height. Conclusions: The analysis of factors that influence the occurrence of children's injuries is of great importance for public health. Such and similar research can enable a better understanding of the factors that influence accidental injuries, and therefore influence the prevention of these injuries by organizing various educational materials at the primary healthcare level or at the school level, for both children and parents.

Case 310: Posterior Epidural Migration of a Lumbar Disk Herniation.

HISTORY: A 49-year-old man presented with right foot drop, bilateral cruralgia mainly on the left side, and genital and perianal hypoesthesia, which started suddenly 12 days before. After onset of symptoms, the patient also experienced an accidental fall at home, resulting in a left fibular fracture, which was treated with reduction and with seven-hole plate Synthes Locking Compression Plate at the orthopedic clinic. The neurologic examination showed paresthesias on the posterior aspect of both thighs and crural regions that was worse on the left side, hypoesthesia in the L5 root region on the right side, and right foot drop. There was no urinary retention or fecal incontinence. The patient denied past surgery, back trauma, heavy manual labor, hypermobility, or any other remarkable medical history. The patient was afebrile. Laboratory results on the 1st day of hospitalization showed increased C-reactive protein level (0.62 mg/dL; reference range, 0.0-0.5 mg/dL), elevated erythrocyte sedimentation rate (60 mm/h; reference range, 0-20 mm/h), and increased aspartate transaminase (38 U/L [0.63 µkat/L]; reference range, 0-31 U/L [0-0.52 µkat/L]), alanine transaminase (70 U/L [1.17 µkat/L]; reference range, 0-31 U/L [0-0.52 µkat/L]), and high lymphocyte (4.55 × 103/mL; reference range, [1.0-3.0] ×103/mL), and neutrophil (8.79 × 103/mL; reference range, [2.0-7.0] × 103/mL) levels. Absence of coagulopathy was demonstrated by normal coagulation values (international normalized ratio, 1.19; reference value, 0.80-1.25; activated partial thromboplastin time ratio, 0.88 second; reference range, 0.79-1.27 seconds). Electroneurography showed marked hypoevocable F response in the right tibia. Electromyography indicated severe reduction of muscle recruitment pertaining to right L4, L5, and S1 nerve territory and, to a lesser extent, of muscles pertaining to L3 territory bilaterally in the absence of spontaneous denervation. Unenhanced CT and contrast-enhanced MRI of the lumbosacral spine were performed.

Fibrocartilaginous embolism: a rare cause leading to spinal cord infarction?

PURPOSE: Fibrocartilaginous nucleus pulposus components herniation and embolism rarely causes acute ischaemic events involving the spinal cord. Few reports have suggested this as a mechanism leading to anterior spinal artery syndrome. The purpose of this study was to evaluate the topography and pattern of this rare myelopathy by MRI. METHODS: A retrospective observational case series of patients, admitted to our Institute between 2008 and 2021, with a diagnosis of fibrocartilaginous embolism based on typical clinical and radiological features. RESULTS: Five patients were identified (2 men and 3 women; range 13-38 years). No one had pre-existing vascular risk factors. All referred potential precipitating event in the 24 h prior to symptom onset. MRI findings showed increased signal intensity of the spinal cord on T2-weighted images in all cases and degenerative disc changes opposite to it in four of them. The outcome was poor: three showed only partial sensitivity and motor improvement (mRs 4, 3, and 2, respectively); one completely recovered except for isolated hand paresis (mRs 1); and one remained severely neurologically affected (mRs 5). CONCLUSIONS: Fibrocartilaginous embolism must be a differential diagnosis in case of otherwise unexplained spinal cord infarction in adult and paediatric low risk population. Neuroradiological findings such as abnormal spinal cord signal intensity and degenerative disc changes can aid in early diagnosis of this rare myelopathy. The prevalent myelopathy location was thoracic. All signal alterations were detected in the anterior region of the spinal cord in the territories of the anterior spinal artery.

Magnetic resonance imaging characteristics of pediatric pilocytic astrocytoma.

PURPOSE: MRI has an important role in diagnosing pilocytic astrocytoma and post-surgical follow-up since the surgical approach has a leading role in its treatment. The purpose of our study is to provide an overview of the typical and atypical MRI findings in a series of pediatric patients with isolated-not NF1-related-pilocytic astrocytomas and to correlate specific MRI patterns with clinical variables. METHODS: This is a cross-sectional retrospective study providing the analysis of several clinical and neuroradiological findings from a cohort of pediatric pilocytic astrocytoma, starting from the data collected in the Fondazione IRCCS Istituto Neurologico Carlo Besta (FINCB) internal Cancer Registry during an 11-year time period (January 2008-January 2019). RESULTS: Fifty-six patients were included in the study. Median age at diagnosis was 9.4 years; a slight female prevalence was noticed (m/f ratio 44.6%/55.4%). The majority of pPAs had well-defined contours: 51 (91.1%), 47 (88.7%) were hypointense on T1-wi, all of them were hyperintense on T2-wi, 46 (90.2%) were hyperintense on FLAIR, and 48 (85.7%) were heterogeneous on T1-wi and T2-wi sequences. We found positive correlation between pPAs location and age (r = 0.017), and small degree of connection between pPAs location and gender (Cramer's V = 0.268). CONCLUSIONS: We presented typical and atypical pPAs MRI findings. Age and tumor location were positevely correlated, while degree of connection between gender and pPAs location was small. All of this may aid clinicians, most of all neuroradiologists, neurosurgeons, and neurologists in proper diagnoses and follow-up of these specific patient population.

Neuroimaging Modalities Used for Ischemic Stroke Diagnosis and Monitoring.

Strokes are one of the global leading causes of physical or mental impairment and fatality, classified into hemorrhagic and ischemic strokes. Ischemic strokes happen when a thrombus blocks or plugs an artery and interrupts or reduces blood supply to the brain tissue. Deciding on the imaging modality which will be used for stroke detection depends on the expertise and availability of staff and the infrastructure of hospitals. Magnetic resonance imaging provides valuable information, and its sensitivity for smaller infarcts is greater, while computed tomography is more extensively used, since it can promptly exclude acute cerebral hemorrhages and is more favorable speed-wise. The aim of this article was to give information about the neuroimaging modalities used for the diagnosis and monitoring of ischemic strokes. We reviewed the available literature and presented the use of computed tomography, CT angiography, CT perfusion, magnetic resonance imaging, MR angiography and MR perfusion for the detection of ischemic strokes and their monitoring in different phases of stroke development.

Case 310.

HISTORY: A 49-year-old man presented with right foot drop, bilateral cruralgia mainly on the left side, and genital and perianal hypoesthesia, which started suddenly 12 days before. After onset of symptoms, the patient also experienced an accidental fall at home, resulting in a left fibular fracture, which was treated with reduction and with seven-hole plate Synthes Locking Compression Plate at the orthopedic clinic. The neurologic examination showed paresthesias on the posterior aspect of both thighs and crural regions that was worse on the left side, hypoesthesia in the L5 root region on the right side, and right foot drop. There was no urinary retention or fecal incontinence. The patient denied past surgery, back trauma, heavy manual labor, hypermobility, or any other remarkable medical history. The patient was afebrile. Laboratory results on the 1st day of hospitalization showed increased C-reactive protein level (0.62 mg/dL; reference range, 0.0-0.5 mg/dL), elevated erythrocyte sedimentation rate (60 mm/h; reference range, 0-20 mm/h), and increased aspartate transaminase (38 U/L [0.63 µkat/L]; reference range, 0-31 U/L [0-0.52 µkat/L]), alanine transaminase (70 U/L [1.17 µkat/L]; reference range, 0-31 U/L [0-0.52 µkat/L]), and high lymphocyte (4.55 × 103/µL; reference range, [1.0-3.0] × 103/µL), and neutrophil (8.79 × 103/µL; reference range, [2.0-7.0] × 103/µL) levels. Absence of coagulopathy was demonstrated by normal coagulation values (international normalized ratio, 1.19; reference value, 0.80-1.25; activated partial thromboplastin time ratio, 0.88 second; reference range, 0.79-1.27 seconds). Electroneurography showed marked hypoevocable F response in the right tibia. Electromyography indicated severe reduction of muscle recruitment pertaining to right L4, L5, and S1 nerve territory and, to a lesser extent, of muscles pertaining to L3 territory bilaterally in the absence of spontaneous denervation. Unenhanced CT (Fig 1) and contrast-enhanced MRI of the lumbosacral spine were performed (Figs 2, 3).

Superficial siderosis in long-standing pilocytic astrocytoma.

BACKGROUND: Pilocytic astrocytoma (PA) rarely spreads along neuraxis, and association with superficial siderosis (SS) and chronic signs of intracranial hypertension is exceptional. CASE REPORT: A 48-year-old woman presented with slow onset hearing loss in the past year. Clinical examination revealed dysarthria, positive Romberg test, and severe optic neuropathy. Cerebrospinal fluid (CSF) analysis showed numerous red blood cells, increased proteins and LDH, and high opening pressure. Brain and spine MRI demonstrated extensive superficial siderosis, bone remodeling of the skull base and spine, and diffuse nodular leptomeningeal enhancement. Histological examination of a nodule in the dorsal spine evidenced PA. CONCLUSION: We report a case of PA associated with dural remodeling and SS. The mechanism of SS is unclear but might be related to meningeal tumor infiltration and altered CSF composition and resorption.

New instrument for measuring quality of life in patients with cervical cancer.

Our study aimed to develop and validate a reliable instrument that can measure the quality of life (QOL) of patients with cervical cancer living in a developing country, such as the Central Balkan country, Serbia. Our study was cross-sectional for assessing the reliability and validity of a questionnaire. Balkan questionnaire for QOL of patients with cervical cancer showed satisfactory reliability and temporal stability. When the investigators rated the questionnaire, Cronbach's alpha was 0.971 at the beginning, and one month later it was 0.967. When the questionnaire was rated by patients themselves, Cronbach's alpha was 0.972. The questionnaire should be considered as an addition to the existing armamentarium for measuring the quality of life in patients with cervical cancer.

A rating instrument for fear of hospitalisation.

AIMS AND OBJECTIVES: To develop and validate a reliable instrument that can measure fear of hospitalisation experienced by outpatients. BACKGROUND: After having a diagnosis established, some patients experience sense of fear, unpleasantness and embarrassment due to the possibility to be admitted to a hospital. Currently, there is no available instrument for measuring fear of hospitalisation. DESIGN: Cross-sectional study for assessing reliability and validity of a questionnaire. METHOD: The questionnaire with 17 items and answers according to the Likert scale was developed during two brainstorming sessions of the research team. Its reliability, validity and temporal stability were tested on the sample of 330 outpatients. The study was multicentric, involving patients from seven cities and three countries. RESULTS: Fear of hospitalisation scale showed satisfactory reliability, when rated both by the investigators (Cronbach's alpha .799) and by the patients themselves (Cronbach's alpha .760). It is temporally stable, and both divergent and convergent validity tests had good results. Factorial analysis revealed three domains: fear of being injured, trust to medical staff and fear of losing privacy or autonomy. CONCLUSIONS: This study developed new reliable and valid instrument for measuring fear of hospitalisation. RELEVANCE TO CLINICAL PRACTICE: Identification of patients with high level of fear of hospitalisation by this instrument should help clinicians to administer measures which may decrease fear and prevent avoidance of healthcare utilisation.

Treatment of Spinal Aneurysmal Bone Cyst with Percutaneous Injection of Hydroxyapatite Osteoconductive Cement.

PURPOSE: The aim of this study was to evaluate treatment efficacy of percutaneous injection of hydroxyapatite-osteoconductive-cement in patients with spinal aneurysmal bone cysts. MATERIALS AND METHODS: The study was designed as a retrospective observational clinical study. We included patients who were diagnosed with of spinal aneurysmal bone cyst, at our institution between 2013 and 2020, and treated with percutaneous injection of osteoconductive cement: "Cerament"® (BONESUPPORT AB, Lund, Sweden). Typical clinical and radiological features of the ABCs treatment and follow-up were investigated. RESULTS: Our study included nine patients, two children and seven adults. Three different types of approaches were applied: (single pedicle approach in 3 patients; double pedicle approach in 2 patients; while in the remaining cases, a multiple access approach was used. VAS score decreased from 8.5 ± 0.5 before treatment to 4.1 ± 0.9 at 6-months-follow up. All of the patients reacted well to treatment, with none neurological complications, complete loss of pain and achieved osteosclerosis as radiological marker of treatment success. CONCLUSION: Treatment of symptomatic spinal ABC's with hydroxyapatite cement is effective to achieve complete pain reduction and sclerosis.

Brixia Chest X-ray Score, Laboratory Parameters and Vaccination Status for Prediction of Mortality in COVID-19 Hospitalized Patients.

Chest X-ray has verified its role as a crucial tool in COVID-19 assessment due to its practicability, especially in emergency units, and Brixia score has proven as a useful tool for COVID-19 pneumonia grading. The aim of our study was to investigate correlations between main laboratory parameters, vaccination status, and Brixia score, as well as to confirm if Brixia score is a significant independent predictor of unfavorable outcome (death) in COVID-19 patients. The study was designed as a cross-sectional multicentric study. It included patients with a diagnosed COVID-19 infection who were hospitalized. This study included a total of 279 patients with a median age of 62 years. The only significant predictor of unfavorable outcome (death) was Brixia score (adjusted odds ratio 1.148, p = 0.022). In addition, the results of the multiple linear regression analysis (R2 = 0.334, F = 19.424, p < 0.001) have shown that male gender (B = 0.903, p = 0.046), severe COVID-19 (B = 1.970, p < 0.001), and lactate dehydrogenase (B = 0.002, p < 0.001) were significant positive predictors, while albumin level (B = -0.211, p < 0.001) was a significant negative predictor of Brixia score. Our results provide important information about factors influencing Brixia score and its usefulness in predicting the unfavorable outcome (death) of COVID-19 patients. These findings have clinical relevance, especially in epidemic circumstances.

Risk factors for cerebral vasospasm in patients with aneurysmal subarachnoid hemorrhage.

INTRODUCTION: Aneurysmal subarachnoid hemorrhage is a type of spontaneous hemorrhagic stroke, which is caused by a ruptured cerebral aneurysm. Cerebral vasospasm (CVS) is the most grievous complication of subarachnoid hemorrhage (SAH). The aim of this study was to examine the risk factors that influence the onset of CVS that develops after endovascular coil embolization of a ruptured aneurysm. MATERIALS AND METHODS: The study was designed as a cross-sectional study. The patients included in the study were 18 or more years of age, admitted within a period of 24 h of symptom onset, diagnosed and treated at a university medical center in Serbia during a 5-year period. RESULTS: Our study showed that the maximum recorded international normalized ratio (INR) values in patients who were not receiving anticoagulant therapy and the maximum recorded white blood cells (WBCs) were strongly associated with cerebrovascular spasm, increasing its chances 4.4 and 8.4 times with an increase of each integer of the INR value and 1,000 WBCs, respectively. CONCLUSIONS: SAH after the rupture of cerebral aneurysms creates an endocranial inflammatory state whose intensity is probably directly related to the occurrence of vasospasm and its adverse consequences.

Drug-drug interactions in patients receiving hematopoietic stem cell transplantation.

INTRODUCTION: Recipients of hematopoietic stem cell transplantation (HSCT) are exposed to numerous drugs in both pre- and post-transplantation period, which creates an opportunity for drug-drug interactions (DDIs); if clinically relevant DDIs happen, the risk of adverse treatment outcomes is increased. Areas covered: This review is focused on DDIs in recipients of HSCT that were observed and published as clinical trials, case series or case reports. Relevant publications were found by the systematic search of the following online databases: MEDLINE, SCOPUS, EBSCO, and SCINDEX. Expert opinion: The most important DDIs involve cytostatic or immunosuppressant drug on one side, and antimicrobial drugs on the other. The majority of clinically relevant interactions have pharmacokinetic character, involving drug metabolizing enzymes in the liver. Antifungal azoles inhibit metabolism of many cytostatic and immunosuppressant drugs at cytochromes and increase their plasma concentrations. Macrolide antibiotics and fluoroqunolones should be avoided in HSCT recipients, as they have much larger potential for DDIs than other antibiotic groups. HSCT recipients increasingly receive new immunomodulating drugs, and further observational studies are needed to reveal unsuspected DDIs with clinical relevance.

Antimicrobial treatment of Kocuria kristinae invasive infections: Systematic review.

Objective of this systematic review was to establish whether and what invasive infections in humans were caused by Kocuria kristinae, and to evaluate outcomes of administered antibiotic treatment. MEDLINE, EBSCO, SCOPUS, SCINDEKS and GOOGLE SCHOLAR were systematically searched for primary case reports or case series describing invasive infections with K. kristinae. K. kristinae is a pathogen microorganism that could cause invasive infections of various tissues in patients of any age. Majority of the patients had K. kristinae isolated from blood. It was also found in peritoneal fluid, pus, sputum, synovial fluid, bile, fluid from abdominal abscess, throat swab, urine catheter tip and mid-stream urine. Antibiotic treatment was almost universally effective, with only one death reported. Susceptibility was highest to vancomycin, linezolid, rifampicin, teicoplanin, tigecycline, cefotaxime, ampicillin/sulbactam, minocycline and meropenem. Initial treatment of Kocuria kristinae infections should involve parenteral vancomycin in combination with some other antibiotic to which it is susceptible.

Antimicrobial treatment of Stenotrophomonas maltophilia invasive infections: Systematic review.

Stenotrophomonas maltophilia can cause serious infections in immunocompromised patients. The aim of this systematic review was to establish what invasive infections in humans are caused by S. maltophilia and to evaluate the optimal choice of antibiotics for their treatment. MEDLINE, EBSCO, SCOPUS, SCINDEKS and GOOGLE SCHOLAR were systematically searched for clinical trials, observational studies, case reports or case series describing invasive infections with S. maltophilia in patients of any age. S. maltophilia may cause invasive infections of various tissues in hospitalized patients. In the great majority of cases it was susceptible to co-trimoxazole, levofloxacin and ceftazidime. In about three fourths of the cases, the treatment was successful, while less than 20% of the patients died. S. maltophilia is increasingly associated with serious invasive infections in hospitalized patients and due to growing trend of resistance to almost all antibiotics requires a careful approach to patients who is harboring this bacterium.

Risk factors for potential drug-drug interactions in intensive care unit patients.

PURPOSE: To determine risk factors for each severity-based category of potential drug-drug interactions (DDIs) encountered at intensive care unit (ICU) patients. METHODS: This was a retrospective cohort analysis of patients treated at the ICU of the Clinical Center Kragujevac, a public tertiary care hospital in Kragujevac, Serbia. Three interaction checkers were used to reveal drug-drug interactions: Medscape, Epocrates and Micromedex. RESULTS: The study included 201 patients, 66.19±16.11 years of age. Average number of DDIs per patient ranged from 10.49±8.80 (Micromedex) to 29.43±21.51 (Medscape). Antiarrhythmic or anticonvulsant drug prescription, Charlson Comorbidity Index, male sex, length of hospitalization, number of drugs or therapeutic groups prescribed and surgery increased the risk of DDIs in ICU patients, while presence of delirium or dementia and transfer from emergency department to ICU protected against. CONCLUSIONS: The rate of the DDIs in ICU patients at a tertiary care hospital is high, and adversely influenced by number of drugs or drug groups prescribed per patient, antiarrhythmic or anticonvulsant drug prescription, comorbidities, length of hospitalization and surgery. On the other hand, presence of cognitive deficit and transfer from emergency department to ICU protect ICU patients from the DDIs.

Evaluation of brivaracetam: a new drug to treat epilepsy.

INTRODUCTION: High prevalence of therapy-resistant epilepsy demands development of anticonvulsants with new mechanisms of action. Brivaracetam is an analogue of levetiracetam which binds to the synaptic vesicle protein 2A (SV2A) and decreases release of excitatory neurotransmitters. Areas covered: Relevant published studies were searched for by predefined strategy in MEDLINE, EBSCO and SCINDEKS electronic databases. Brivaracetam is effective as adjunctive therapy for uncontrolled partial-onset seizures with or without secondary generalization in patients 16 years and older with epilepsy. It reduces baseline-adjusted focal seizure frequency per week from 7.3 to 12.8% over placebo. Adverse events rate in patients with brivaracetam is not higher than in patients with placebo. Expert opinion: Brivaracetam is an important step forward in the treatment of therapy-resistant partial-onset seizures with or without secondary generalization. Its development was systematic and targeted. Due to its efficacy and excellent safety profile, it is likely that brivaracetam will be often prescribed. In future, efficacy and safety of brivaracetam should be tested in monotherapy settings and also in the first-line therapy of partial-onset seizures.