Management of Fournier's gangrene--report of 7 cases and review of the literature.

Fournier's gangrene is a rare infection characterized with fast-progressing myonecrosis, that affect regions of perineum, genitalia and perianal area. This retrospective study presents authors' experiences and their principles in early diagnosis and treatment of Fournier's gangrene. The goal of this paper is to point out numerous diagnostically and therapeutic difficulties that lead to a high mortality if not recognized in time. We here describe seven male patients with myonecrosis and necrotising fasciitis in scrotal, perianal and perineal regions. Average age was 61 years (form 57 to 66 years of age), and average length of treatment was 25.8 days (from 14 to 36 days), with lethality of 14% (one case). We have recognised diabetes mellitus as risk factor, together with urethrostenosis, and other diseases of the perianal region (hemorrhoids, anal fissure, abscesses). Our hypothesis is that the key of the successful treatment is to treat as soon as symptoms onset, early and aggressive necrectomy under broad antibiotic protection. We also emphasize the possibility of recurrence of this disease even several years after treatment.

Bone mineral density changes and bone turnover in thyroid carcinoma patients treated with supraphysiologic doses of thyroxine.

The aim of this one-year prospective study was to determine whether longterm thyroxine treatment is a risk factor for elevated bone turnover, loss of bone mass and subsequent development of osteoporosis. Premenopausal women (N = 19), and men (N = 9) suffering from differentiated thyroid gland carcinoma in the mean age of 39.0 +/- 8.0 years and 41.8 +/- 10.0 years were investigated. All of them had undergone a total thyroidectomy and subsequent thyroxine therapy. The duration of the TSH-suppressive therapy prior to the the beginning of our study was 9.4 +/- 6.4 years in the female and 8.1 +/- 6.0 years in the male group. The prospective observation was performed by dual X-ray absorptiometry (DXA) at the spine and the femoral neck and by single-photon absorptiometry (SPA) at the distal radius. Laboratory testings included thyroid hormones T3, T4 and TSH, serum calcium, phosphate and PTH, and urinary calcium and phosphate from spontaneous and 24-hour urine samples. Markers of bone formation (osteocalcin, alkaline phosphatase and PICP) and resorption (Ca/Cr and ICTP) were determined. Statistically significant loss of bone mass was observed only on the distal radius in males (p<0.05). At the lumbar spine and femoral neck, only a minor bone loss was registered in a small number of patients. Almost 50 % of the females showed values above the reference range. In more than 30 % of the females, and smaller number of male patients, ICTP values ranged above the reference range, corresponding to elevated bone turnover. These two variables exhibited a slight correlation with bone density at the measured skeletal areas, mostly considering the male group. The results are a proof that accelerated bone turnover and subsequent bone loss occurs during TSH-suppressive thyroxine therapy. In future prospective studies a prolonged time of observation will be necessary, as well as to increase the number of studied patients, in order to better assess the relative risk of osteoporosis in patients undergoing TSH-suppressive treatment more precisely.

[Differential diagnosis of urinary retention: aneurysm of the iliac artery]. / Aneurysma der A. iliaca als Differenzialdiagnose des Harnverhalts.

A 69-year old male presented with anuric acute renal failure. Abdominal ultrasound at admission revealed a mass in the pelvis thought to be the urinary bladder and the diagnosis of urinary retention was made. When placement of an urinary catheter did not induce urine flow, digital rectal examination was done. Palpation of a pulsating mass finally led to the diagnosis of aneurysm of the iliac artery. Based on this case, the general problem of diagnosing an iliac artery aneurysm is discussed.

Prevalence and intraoral distribution of dentin hypersensitivity among students.

The exposed dentin which is the result of the consequence of the enamel loss (by erosion, abrasion, attrition), gingival recession or periodontal therapy, as well as anatomic defects often as its result has dentinal hypersensitivity. The purpose of this work is to examine the frequency of dentinal hypersensitivity in relation to the subjective estimation of the examined persons and objectively, by intraoral examination. Forty persons, students from the School of dentistry of average age of 22.35 years were tested and analysed. Subjective data are achieved by the method of questionnaire while the objective ones by pulling the probe in the area of the tooth neck for the purpose of mechanical testing and by air syringe for the cold stimulus. The results show that the clinical hypersensitivity amounts 52.5% in relation to the subjective data 32.5%. The duration of hypersensitivity amounts in average 18 months and the strongest way of its demonstration is the cold and mechanical stimulus. The half of the examined brush their teeth twice a day out of which 72.5% do that by the half hard nylon brush, and the percentage of teeth with cuneiform defects amounts to 4.45. The often phenomenon of dentin hypersensitivity already among the young underline the need of preventive action and removing the damaging factors which contribute to the start of hypersensitivity of the nude dentin.

Review on prostaglandin and oxytocin activity in preterm labor.

The principal difference between term and preterm labor is how they are activated. It has been proposed that term labor results from physiological activation of the common terminal pathway, whereas preterm labor is a pathological condition caused by multiple etiologies that activate one or more of the components of this pathway. Increased uterine contractility at preterm labor results from activation and stimulation of the myometrium. Myometrium is stimulated by increased concentrations ofprostaglandins and oxytocin. Increased production of stimulatory prostaglandins by intrauterine tissues is generally considered a central component of the cascade of events leading to preterm parturition. Prostaglandins act to mediate cervical ripening and to stimulate uterine contractions and indirectly to increase fundally dominant myometrial contractility by up regulation of gap junctions, oxytocin and arginine vasopressin receptors and synchronizations of contractions. The authors tried to explain the role and influence of oxytocin in human parturition, as well as the novel therapy in inhibiting the contractions in preterm labor. The selective oxytocin inhibitor was tested in vitro on human myometrium and decidua by the author of this article among the first in the world.

Comparative review of gnathometric characteristics in total dentures and eugnathic subjects.

The problem of determining the position and lining of the teeth in total dentures is presented by a comparative examination of gnathometric variables in eugnathic subjects and in those wearing total dentures. The material consisted of 51 plaster casts of eugnathic subjects and 49 subjects wearing total dentures. The following were examined: upper total number of incisors (T1), anterior width (AW), posterior width (PW), anterior length (AL) and posterior length (PL) of models. Analysis of the investigated variables was carried out by means of sliding calipers MECANIC Type 6901 (IVOCLAR, Lichtenstein) with a scale of 0-130 mm, and reading accuracy 97.5%. A three-dimensional pair of compasses according to Korhaus (Dentaurum, Germany) was used to measure the anterior and posterior lengths of models, with a scale 10-60 mm and reading accuracy 95%. No significant difference was observed between the eugnathic subjects and subjects wearing total dentures (p > 0.05). The results of this comparative gnathometric analysis of examined variables (Tl, AW, PW, AL and PL) are a contribution to the rules when lining anterior and posterior teeth in total dentures.

Ponderal index and disproportionate fetal growth in IDDM pregnancies.

Disproportionate macrosomia refers to excessive weight characterized by a high weight/length ratio. Disproportionate macrosomia is associated with an increased likelihood of neonatal complications. The aim of the study was to investigate incidence of ponderal indexes and disproportionate fetal growth rate in newborns originating from IDDM and healthy pregnancies. 144 IDDM pregnancies and 432 uneventful pregnancies with normal findings of oral glucose tolerance test were studied, and matched 1:3 for gestational age, sex of newborn, mothers's parity and year of delivery. The pregnancies selected terminated between 30-40th gestational week and resulted with live birth. Mean birth weight (+/- SD) in IDDM group was 3558 +/- 817.6 compared to 3132.4 +/- 534.4 grams of control group (F = 51.49; p < 0.001), mean birth length was 49.8 +/- 3.5 vrs 49.1 +/- 2.5 (F = 8.55; p < 0.005), mean gestation age by examination for both study groups 37.9 +/- 1.9, mean ponderal index of IDDM group was 2.82 +/- 0.28 vrs. 2.63 +/- 0.24 (F = 64.52; p < 0.001) of control group, rate of Apgar score < 7 was 21.14% vrs. 5.08% (chi 2 = 30.30; p < 0.001). 53.4% of IDDMs had macrosomia compared with 8.33% of control infants (chi 2 = 140.25; p < 0.001), and 35.24% of IDDMs had disproportionate macrosomia compared with 5.79% of control infants. Significantly higher rate of both proportionally and disproportionally grown infants with macrosomia was found among IDDMs than among control infants. The rate of disproportionate macrosomic infants significantly differ among study group.

Serum IgA, IgG, IgM and salivary IgA in recurrent aphthous ulceration.

Radial immunodiffusion technique was used to estimate salivary immunoglobulin A, and enzyme-linked immunosorbent assay for estimation of serum IgA, IgG and IgM in 30 patients with acute recurrent aphthous ulceration (RAU) and during remission period compared to 30 healthy controls. Significantly elevated level of salivary IgA (p < 0.05) was found in patients with minor RAU when compared to the control group. Serum IgA level was elevated in patients with minor acute RAU when compared to the controls (p < 0.05). Serum immunoglobulin level of IgG and IgM showed no differences between patients with either minor or major recurrent aphthous ulceration and controls.

Ovarian cancer and ovulation induction drugs--is there a link?

Screening for ovarian cancer in a group of women with induced ovulations was encouraged by recently reported controversies about a possible association between the use of ovulation induction drugs and the increased risk of ovarian carcinoma. Transvaginal color Doppler ultrasonography was applied in screening for early stage ovarian malignoma in 110 asymptomatic women who received an ovulation induction therapy for infertility. Already reported standard parameters for discriminating malignant from benign flows, such as resistance index RI < 0.40, pulsatility index PI < 1 and morphological score (borders, cyst quality, septate areas, papilla and ovarian tissue echogenicity) were used. Screening included 110 women and was carried out from April 1, 1198 to March 31, 1999. Seven examinees had abnormal ovarian findings. The finding spontaneously regressed in five of them, one underwent surgery for a persistent cyst with a benign pathohistologic diagnosis, and one was diagnosed with early stage ovarian malignoma. RI < 0.40 was reported in one patient (0.9%) with a morphologically suspect finding and a pathohistologically confirmed malignoma, PI < 1 was found in 40 subjects or 36.4%, while malignoma was demonstrated in one case alone. The results showed the advantage of RI over PI in discriminating malignant from benign structures. The association between the use of ovulation stimulation drugs and the increased risk of ovarian carcinoma remains unproved and also challenges new dilemmas. The paper cautions against undesirable, potentially serious long-term effects of the use of ovulation induction agents. Additional trials should therefore be performed including a long-term prospective follow-up of women with induced ovulations.

Qualitative dermatoglyphic traits in ovarian cancer patients: a case-control study.

The authors investigated the correlation between the occurrence of certain qualitative dermatoglyphic traits and the susceptibility to ovarian cancer, using the case-control design. A sample of 168 diseased cases, treated at the University Department of Gynecologic Oncology in Zagreb, Croatia between 1996-1997 was compared to 200 healthy females, investigated at the Institute for Anthropological Research in Zagreb. The results showed significant differences between ovarian cancer cases and healthy controls regarding the frequency of arches on the fingers of both hands (10-11% vs. 4-5%, respectively, p < 0.05), and of characteristic patterns on the palms of right hand (33% vs. 54% in 3rd interdigital space (IS), p < 0.001; 39% vs. 47% in 4th IS, p < 0.05) and of the left hand (42% vs. 58% in 4th IS, p < 0.001; 24% vs. 34% in hypothenar, p < 0.01). Although probably neither very sensitive nor specific, these findings could still be used in addition to other diagnostic procedures, as a rough screening method in early detecting of ovarian cancer.

Plasma cholinesterase activity in patients with uterine cervical cancer during radiotherapy.

The objectives of this study were to investigate: 1) the activity of pseudocholinesterase (PChE) in patients with uterine cervical cancer in different stages (uterine cervical carcinoma in stages II b and III and recurrent cervical carcinoma in stages III and IV a,b) and to compare it to the enzyme activity in patients with benign tumour of the uterus, and 2) the effects of radiotherapy on enzyme activity in those patients with uterine cervical carcinoma for which the chosen treatment was radical radiotherapy. Thirty patients with uterine cervical carcinoma in stages II b and III (Group A), sixteen patients with recurrent cervical carcinoma in stages III and IV a,b (Group B) and thirty-eight patients with benign tumours of the uterus (control, Group C) were evaluated and their PChE activity was determined prior to any treatment (pre-therapy enzyme activity). All eighty-four patients were free of any liver disease. The results have shown that the patients of Group A had the pre-therapy PChE activity practically identical to those in group C, but patients of Group B had significantly lower values of PChE with respect to enzyme activities of Groups A and C (p < 0.001). That is to say, PChE activity was influenced by the extent to which the malignancy had spread. Radical radiotherapy (up to 8 weeks in doses higher than 50 Gy into point A; average 80 Gy) which was the chosen treatment only for patients from group A did not cause a significant inhibition of PChE activity in any patients in comparison with their control values. With regard to the role of PChE in hydrolysis of succinylcholine, our results about the influence of the malignant disease and the radiotherapy on PChE activity are clinically significant.

Radiographic cephalometry of the facial profile.

Radiographic cephalometry is a biomorphological measuring method used in the prosthodontics as well, and for the facial profile analysis of persons with complete dentures. The purpose of this examination was to objectivize the facial esthetics in patients with complete dentures. The measurements were taken from LL X-ray radiographs obtained by the apparatus "Ortoceph 10" (Siemens, Bensheim, Germany). On the sample of 80 subjects a convexity angle of facial bone structures (N-A: A-Pg) and profile angle of soft facial tissue (ft-unt: lnt-ct) have been examined. The subjects were divided into a group with upper and lower complete dentures (20 males and 20 females) and a group with natural teeth of eugnatic characteristics (20 male and 20 female). The measurements were taken by standard protractor at 0.5% precision. The statistical analysis within and among groups has been made by F-test and t-test respectively. The results showed that the bone structure convexity angle span a range between 0 degree and 5.5 degrees (X = 2.5 degrees), and the facial profile angle between 139.5 degrees and 155 degrees (X = 149 degrees) in persons with complete dentures. In persons with natural teeth the values of bone structure convexity angles span a range between -0.5 degree and 4.8 degrees (X = 2 degrees), and the facial profile angle between 136 degrees and 155.5 degrees (X = 151 degrees). The results of tests proved that there were no statistically significant differences in examined variables between persons with natural teeth and those with complete dentures (p > 0.05). The conclusion is that clinical methods of determining the vertical and horizontal intermaxilliary relations used in the designing procedures of complete dentures were reliable enough in reconstruction of examined angles of soft and hard facial profile structures.

The effect of coagulation parameters on the placental respiratory and nutritive function in women having chronic hypertension with superimposed preeclampsia.

The aim of this study was to explore the relationship between coagulation and fibrinolytic system parameters with nutritive and respiratory placental function. We have analysed 79 pregnant women, of which 39 with severe preeclampsia (index group) and 41 healthy pregnant women. When comparing the study groups in third trimester, significantly lower platelet counts, fibrinogen values and antithrombin III values have been found in the index group compared to the control group. Factor VII levels were not found to be significantly different. The control group revealed significantly higher levels of coagulation factors II, V and VIII, compared to the index group. The increase of FDP, reduction of fibrinogen and increase of fibrinolysis in index group, when compared to the control group of healthy pregnant women, are the reflection of the intravascular fibrin deposition that leads to the described coagulation changes and consecutively to the foetal growth retardation. Indirect evidence are the correlation between newborns' weight and fibrinogen levels/fibrinolytic activity.

Holistic approach to analysis of medical data: vulvar cancer.

This paper continues the series of studies introducing holistic approach to analysis of clinical data. Namely, besides the information regarding his/her disease, each hospitalized cancer patient also provides the variety of data regarding his/her psychological, cultural, social, economical, genetic, constitutional and medical background. The aim of this study was to introduce a holistic approach to analysis of medical data, in this case clinical data regarding cancer of the vulva. Such approach requires the collection of data regarding different aspects of the cancer patients, and after the satisfactory sample size is obtained (which should be at least five times greater than the number of examined patient characteristics), the performance of factor analysis. In this study, the authors have processed the data regarding 25 characteristics of all 755 vulvar cancer patients treated between 1938 and 1990 at the Department for Gynecological Oncology of the University Hospital for Gynecology and Obstetrics, Zagreb, Croatia. In factor analysis, the principal components were rotated after the initial extraction (the authors recommended the use of oblimin rotation) in order to obtain better ground for interpretation of the obtained results. The next step in this approach was the stepwise exclusion of characteristics with smallest commonality according to Kaiser-Meyer-Olkin criteria, and retaining the characteristics and components with the most significant impact on the explained system variance. When the number of principal components and initial analyzed characteristics was reduced to 3-4 and 7-10, respectively, the ultimate interpretations and conclusions were made. This approach outlined some clusters of correlations between medical data which are difficult to identify using other statistical procedures, primarily the impacts of various socioeconomic and hereditary-constitutional variables on overall survival.

Transvaginal color flow imaging of the uterine artery during fertile period and postmenopause.

Transvaginal sonography with color flow mapping has been used in order to study various parts of uterine circulation during fertile period and postmenopause. The Doppler wave forms were analysed by pulsatility index and maximum systolic velocity of uterine artery and its ascending branches. A significantly lower vascular resistance was established in distal parts of the uterine artery. This finding could very likely represent a consequence of the effect of ovarian hormones on the vessel wall during the cycle. That might be a physiological basis for capability of fertilisation and carrying the normal pregnancy and child birth. Furthermore, it has been shown that during postmenopause, when ovaries normally cease steroid hormone production, it is difficult to detect wave forms in common uterine artery. However, postmenopausal extraovarian production of estrogen increases uterine flow and may precede hyperplastic or malignant changes of the endometrium. In women with proven pelvic masses, abnormal waveforms were recorded showing decreased uterine impedance and increased flow velocities.

Factor analysis of medical data of patients with primary and metastatic vaginal cancer.

This study adds up to the series of studies on application of factorial designs to analysis of cancer patients medical data. Namely, besides the information regarding his/her disease, each hospitalized cancer patient also provides the variety of data regarding his/her psychological, cultural, social, economical, genetic, constitutional and medical background. The aim of this particular study was to analyze clinical data in patients with primary and metastatic vaginal cancer and to compare them with the results of factor analytic approach in some other gynecological cancers, namely vulvar and cervical cancer. In this particular study the authors have processed the data regarding 25 characteristics of 200 consecutive patients with primary vaginal cancer and 300 consecutive patients with metastatic vaginal cancer treated between 1980 and 1994 at the Department for Gynecological Oncology of the University Hospital for Gynecology and Obstetrics, Zagreb, Croatia. The results revealed numerous repeating clusters of variable correlations across all four factor analyses in patients with cervical, vulvar, primary and metastatic vaginal cancers.

The effect of delivery on regression of abnormal cervical cytologic findings.

The purpose of this study was to determine whether abnormal antepartum cervical cytologic findings result in differing postpartum regression rates. Between 1993 and 2000, 107 pregnant women with antepartum abnormal cervical cytologic findings were identified. Papanicolaou smear data were separated into three groups by use of the CIN classification system. Postpartum regression rates of antepartum Papanicolaou smears were analyzed six months after delivery. Normalization of Papanicolaou smears in the postpartum period were observed in 50 of 107 women (46.7%). Regression of cervical cytologic findings was noted in 61 of 107 women (57%). Respectively, persistence of Papanicolaou smear was noted in 43 of 107 patients (40%). Only 3 of 107 (3%) antepartum findings progressed after delivery. Desquamation of the cervical epithelium or enhancement of a localized reparative immunologic response after vaginal delivery could play an important role in the spontaneous regression of cervical dysplasia in the postpartum period.

Circulating platelet aggregates and progression of visual field loss in glaucoma.

The aim of the study was to assess a relationship between circulating platelet aggregates (CPA) and progression of visual field loss in primary open-angle glaucoma patients. CPA was determined in 27 patients with open-angle glaucoma with nonprogressive visual field loss and 15 patients with open-angle glaucoma and progression of visual field loss. Intraocular pressure (IOP) under topical therapy was < 18 mmHg in all patients. CPA in glaucoma patients with progression of visual field loss was not significantly higher than those without visual field progression (p = 0.59). In conclusion, our study shows that increased platelet aggregability is not solely responsible for progression of visual field loss in glaucoma patients, and indicates the role of IOP in the pathogenesis of visual field loss.

Nicotinamide adenine dinucleotide phosphate-diaphorase (NADPH-d) histochemistry detecting NOS in healthy and chronically inflamed pulp.

The aim of this study was to examine the expression of nicotinamide adenine dinucleotide phosphate-diaphorase (NADPH-d) activity in human dental pulps and determine whether there are changes of the activity in chronically inflamed pulp tissue. Nineteen pulps with clinical diagnosis of chronic pulpitis were collected during endodontic treatment. The healthy controls were obtained from teeth extracted for orthodontic therapy. The clinical diagnosis was confirmed by histological analysis. Healthy pulps showed stratified odontoblasts in peripheral parts, while in central area there was normal connective tissue. Chronically inflamed pulps showed less expressed stratification of odontoblasts and infiltration of lymphocytes, polymorphonuclear leukocytes, plasma cells and mastocytes. NADPH-d granular reactivity was assessed semi quantitatively under the light microscope by a single observer and scored on an intensity scale from negative reaction to very strong reaction. In healthy human pulps, NADPH-d activity was strong to very strong in odontoblastic layer. Endothelial cells and Schwann cells showed strong NADPH-d reactivity, while the other parts of central area were weakly positive. Similar distribution of reactivity was expressed also in chronically inflamed pulp; moderate to strong reaction was observed in stromal area as result of positive reaction in inflammatory cells and endothelial cells of abundant newly formed capillaries.

Effects of preeclampsia and eclampsia on cord blood coagulation tests.

Blood coagulation tests were determined in fifty-three paired umbilical cord blood and maternal venous blood samples originating from term singleton vaginal cephalic deliveries. The index group comprised seventeen deliveries complicated by preeclampsia or eclampsia, and the control group comprised thirty-six healthy women with uneventful pregnancies and deliveries. Mean values obtained from the coagulation and fibrinolytic assays did not significantly differ between study groups, except for antithrombin III levels in index group of neonates, which were significantly lower. Comparison of coagulation and fibrinolytic characteristics between mothers and their neonates produced expected level of difference due to immaturity of their haemostatic mechanisms. We found alterations in maternal blood coagulation and fibrinolysis and evidence of increased intravascular coagulation with severe preeclampsia and IUGR.