Contemporary review on spontaneous coronary artery dissection: insights into the angiographic finding and differential diagnosis.

Spontaneous coronary artery dissection (SCAD), although in the majority of cases presents as an acute coronary syndrome (ACS), has different pathophysiology from atherosclerosis that influences specific angiography findings and enables most patients to be solved by optimal medical therapy rather than percutaneous coronary intervention (PCI). Therefore, accurate diagnosis is essential for adequate treatment of each patient as management of SCAD differs from that of ACS of atherosclerotic aetiology. So far, invasive coronary angiography remains the most important diagnostic tool in suspected SCAD. However, there are ambiguous cases that can mimic SCAD. In this review, the authors summarize current knowledge about the diagnostic algorithms, particularly angiographic features of SCAD, pitfalls of angiography, and the role of intracoronary imaging in the context of SCAD diagnosis. Finally, apart from the pathognomonic angiographic features of SCAD that are thoroughly discussed in this review, the authors focus on obscure angiography findings and findings that can mimic SCAD as well. Differential diagnosis and the timely recognition of SCAD are crucial as there are differences in the acute and long-term management of SCAD and other causes of ACS.

The influence of the morphometric parameters of the intercondylar notch on occurrence of meniscofemoral ligaments.

BACKGROUND: The purpose of this study was to examine the existence of correlation between the morphometric parameters of the intercondylar notch of the femur and the occurrence of meniscofemoral ligaments (MFLs) and if there is any relationship in the running angle (RA) value between narrowed and normal sized intercondylar notch. MATERIALS AND METHODS: Coronal, sagittal and horizontal magnetic resonance (MR) images of 90 patients with specified exclusion criteria were included in this study. The c2 test was used for statistical analysis. In our research either one or both MFLs were identified in 70 (77.8%) of the 90 coronal MR images. In normal sized intercondylar notch, MFLs was seen in 39 (43.3%) cases and on 31 (34.4%) MR images with narrowed intercondylar notch. RESULTS: A significant correlation was established between the occurrence of the MFL and morphometric parameters of the intercondylar notch (p < 0.05). In normal sized intercondylar notch, 12 posterior meniscofemoral ligaments (pMFLs) of type I were detected (RA value 42°), 8 of type II (RA value 33°), 5 of type III (RA value 23°) and two were of indeterminate type, whilst 10 anterior meniscofemoral ligaments (aMFLs) were of type I (RA value 39°), 7 of type II (RA value 31°), 2 of type III (RA value 25°) and the remaining 6 were indeterminate. In narrowed intercondylar notch, 10 ligaments of pMFLs were of type I (RA value 30°), 8 of type II (RA value 25°), 5 of type III (RA value 20°), 10 ligaments of aMFLs were of type I (RA value 35°) and 9 were indeterminate. Statistically significant differences in the value of the running angle of pMFL type I and of type II were evaluated between two groups with different shaped intercondylar notch (p < 0.05). CONCLUSIONS: The results shown in our study may be useful in medical clinical practice, reconstructive surgery, interpretation of knee MR images as well as genetic research.

[Comparison of piezoelectric and conventional osteotomy in rhinoplasty : A systematic review]. / Vergleich von piezoelektrisch assistierter und konventioneller Osteotomie bei der Rhinoplastik : Ein systematisches Review.

BACKGROUND: Postoperative periorbital edema and ecchymosis after rhinoplasty are mainly caused by the osteotomy with hammer and chisel. The introduction of piezoelectric surgery could lead to a better early postoperative outcome due to improved preservation of soft tissues. The aim of this systematic review was to evaluate the methods and results of studies comparing conventional osteotomy to piezoelectric osteotomy. METHODS: A systematic literature search was conducted in the PubMed/MEDLINE and Google Scholar databases. In the primary selection, all studies on the comparison of conventional and piezoelectric osteotomies with regard to postoperative periorbital edema and/or ecchymosis were identified. Secondary selection included only study designs with a control group. RESULTS: Primary selection resulted in 15 thematically relevant publications with a notable increase in annual publications between 2007 and 2017. Six studies with control groups were selected secondarily. Qualitatively and methodologically, the studies were very heterogeneous. The results of five of the six studies indicated a significant advantage of piezo technology compared to conventional osteotomy. Only in one study was no significant difference found in the investigated postoperative outcome. CONCLUSION: Piezoelectric osteotomy resulted in a reduced propensity for postoperative edema and ecchymosis compared to the conventional osteotomy technique with a chisel. At this time, the results should be regarded as a trend. A definite recommendation favoring piezoelectric osteotomy cannot be made until more studies with higher patient numbers become available.

Low-dose daily aspirin reduces topical minoxidil efficacy in androgenetic alopecia patients.

Topical minoxidil is the only US FDA approved OTC drug for the treatment of androgenetic alopecia (AGA). Minoxidil is a pro-drug converted into its active form, minoxidil sulfate, by the sulfotransferase enzymes in the outer root sheath of hair follicles. Previously, we demonstrated that sulfotransferase activity in hair follicles predicts response to topical minoxidil in the treatment of AGA. In the human liver, sulfotransferase activity is significantly inhibited by salicylic acid. Low-dose OTC aspirin (75-81 mg), a derivative of salicylic acid, is used by millions of people daily for the prevention of coronary heart disease and cancer. It is not known whether oral aspirin inhibits sulfotransferase activity in hair follicles, potentially affecting minoxidil response in AGA patients. In the present study, we determined the follicular sulfotransferase enzymatic activity following 14 days of oral aspirin administration. In our cohort of 24 subjects, 50% were initially predicted to be responders to minoxidil. However, following 14 days of aspirin administration, only 27% of the subjects were predicted to respond to topical minoxidil. To the best of our knowledge, this is the first study to report the effect of low-dose daily aspirin use on the efficacy of topical minoxidil.

Mechanism of action of minoxidil in the treatment of androgenetic alopecia is likely mediated by mitochondrial adenosine triphosphate synthase-induced stem cell differentiation.

Topical minoxidil is the only topical drug approved by the US Food and Drug Administration (FDA) for the treatment of androgenetic alopecia. However, the exact mechanism by which minoxidil stimulates anagen phase and promotes hair growth is not fully understood. In the late telegen phase of the hair follicle growth cycle, stem cells located in the bulge region differentiate and re-enter anagen phase, a period of growth lasting 2-6 years. In androgenetic alopecia, the anagen phase is shortened and a progressive miniaturization of hair follicles occurs, eventually leading to hair loss. Several studies have demonstrated that minoxidil increases the amount of intracellular Ca2+, which has been shown to up-regulate the enzyme adenosine triphosphate (ATP) synthase. A recent study demonstrated that ATP synthase, independent of its role in ATP synthesis, promotes stem cell differentiation. As such, we propose that minoxidil induced Ca2+ influx can increase stem cell differentiation and may be a key factor in the mechanism by which minoxidil facilitates hair growth. Based on our theory, we provide a roadmap for the development of a new class of drugs for the treatment of androgenetic alopecia.

Crosstalk Between Enzyme Matrix Metalloproteinases 2 and 9 and Regulatory T Cell Immunity in the Global Burden of Atherosclerosis.

Changes in immune and inflammatory responses may play a crucial role in the development and progression of atherosclerosis, as an autoimmune, chronic and progressive inflammatory disease. Immunological activity and vascular inflammation during atherosclerosis can be modulated by autoimmune responses against self-antigens, according to changeable risk factors (cholesterol, oxidized low-density lipoprotein (ox-LDL) in the vascular wall, fatty acids, etc.), and accompanied by accumulation of leucocytes and proinflammatory cytokines, which stimulate the transcription of matrix metalloproteinases (MMPs), whose concentration are increased in foam cell-rich regions. Regulatory T cells (Tregs) represent a unique subpopulation of T cells specialized in the regulation of immune response and in the suppression of proatherogenic T cells. The aim of our study was to examine the interactions between the concentration of enzyme matrix metalloproteinases 2 and 9 (MMP-2 and 9) in urine and the percentage of Tregs in peripheral blood of two groups of patients: with carotid artery stenosis (CAS), undergoing surgery and with mild atherosclerosis (A) from general practice. The method of enzyme immunoassay (ELISA) was used to determine enzyme MMP expression, and Tregs was examined by flow cytometric analysis. Our data have showed a large increase in the enzyme MMP-2 and 9 in the urine of CAS and A patients in comparison with healthy controls and indicated this method as an easy marker for the monitoring of the development of atherosclerosis. Simultaneously, the diminished number of Tregs in the same patients pointed the importance of these regulatory mechanisms in the etiopathogenesis of atherosclerosis and possible Tregs-mediated therapy.

[New aspects in surgery of the nasal tip]. / Neue Aspekte in der Nasenspitzenchirurgie.

The creation of both a functionally and aesthetically pleasing nasal tip contour is demanding and depends on a variety of parameters. Typically, procedures are performed with emphasis on narrowing the nasal tip structure. Excisional techniques alone inevitably lead to reduction in skeletal support and are often prone to unpredictable deformities. But long-term results of classical suture techniques have also shown unfavorable outcomes. Particularly pinching of the alae and displacement of the caudal margin of the lateral crus below the cephalic margin belong in this category. A characteristic loss of structural continuity between the domes and the alar lobule and an undesirable shadowing occur. These effects lead to an unnatural appearance of the nasal tip and frequently to impaired nasal breathing. Stability and configuration of the alar cartilages alone do not allow for an adequate evaluation of the nasal tip contour. Rather a three-dimensional approach is required in order to describe all nasal tip structures. Especially the rotational angle of the alar surface as well as the position of the lateral crus in relation to the cranial septum should be considered in the three-dimensional analysis. Taking the various parameters into account the authors present new aspects in nasal tip surgery which contribute to the creation of a functionally and aesthetically pleasing as well as durable nasal tip contour.

[Flaring spreader flaps and upper lateral advancement. Modified techniques in the reconstruction of the internal nasal valve]. / "Flaring spreader flaps" und "upper lateral advancement". Modifizierte Techniken zur Rekonstruktion der inneren Nasenklappe.

BACKGROUND: A collapse of the internal nasal valve and the formation of an inverted-V deformity represent common findings following dorsal hump removal in rhinoplasty procedures. Spreader grafts are considered as standard both in the prevention and treatment of such undesirable outcomes. The authors introduce modified surgical concepts using flaring spreader flaps and the upper lateral advancement technique to reconstruct the internal nasal valve. METHODS: After mobilization of the mucosa and separation of the upper lateral cartilages from the septum also their attachments to the nasal bones are released. The cartilages then are rotated as spreader flaps into the area of the internal nasal valve and can be used as a replacement for conventional spreader grafts. By crucial modifications of commonly applied suture techniques both the contour and airway are improved. The upper lateral advancement technique is used in cases of already present inverted-V deformities. The upper lateral cartilages are mobilized in a similar fashion and serve as attachments to usual spreader grafts. RESULTS: Flaring spreader flaps have been used in 164 patients undergoing primary rhinoplasty procedures for dorsal hump removals, the treatment of tension noses as well as deviated noses. Postoperatively all cases showed an adequate width of the middle nasal vault and pleasant dorsal aesthetic lines. No signs of an inverted-V deformity or a collapse of the internal nasal valve were present. Nasal breathing was considered significantly improved. The upper lateral advancement technique was applied in 9 patients with a present inverted-V deformity after previous rhinoplasties. During the following revision procedures an adequate reconstruction of the middle nasal vault as well as a subjectively improved airway was achieved in all cases. CONCLUSION: Both flaring spreader flaps and the upper lateral advancement technique represent reliable methods in the reconstruction of the internal nasal valve and treatment of inverted-V deformities. Moreover, flaring spreader flaps can be considered as an appropriate alternative to conventional spreader grafts in patients with only small amounts of cartilage available.

Expression of ERCC1 protein in biopsy specimen predicts survival in advanced ovarian cancer patients treated with platinum-based chemotherapy.

PURPOSE: The purpose of this study was to investigate whether the expression of excision repair cross complementing 1 (ERCC1) protein I in tumor tissue was associated with resistance to standard carboplatin and paclitaxel (PC) combination chemotherapy in patients newly diagnosed with advanced epithelial ovarian carcinoma (EOC). METHODS: Fresh frozen tumor tissue was obtained from EOC patients. The protein expression levels of ERCC1 in tumor tissue were determined by Western blot analysis in 55 samples with advanced and metastatic EOC with different histologic subtypes; then these patients were treated with PC. RESULTS: The results showed that the clinical objective responses were significantly different in different categories of ERCC1 protein expression levels in patients with EOC. Time to progression (TTP) and overall survival (OS) in EOC patients previously treated with platinum-based chemotherapy were significantly longer in those with low expression compared with patients showing high expression of ERCC1 protein. CONCLUSION: Our results revealed that ERCC1 protein expression could potentially be used to customize chemotherapy by defining subsets of patients who would benefit the least from platinum-based chemotherapy.

p53 gene mutations and codon 72 polymorphism in ovarian carcinoma patients from Serbia.

PURPOSE: Ovarian cancer is the leading cause of death from gynecological malignancies. The early stages of this disease are asymptomatic and more than 75% of the cases are diagnosed with regional or distant metastases. p53 gene is frequently mutated in some histological subtypes of ovarian carcinomas. The role of p53 mutations and polymorphic variant of codon 72 in the prognosis of disease is still unclear. The aim of this study was to determine the frequency of p53 mutations and polymorphic variants of codon 72 among ovarian carcinoma patients and to correlate them with clinicopathological characteristics of disease. METHODS: 54 ovarian carcinoma patients were included in the study. DNA was isolated from tumor tissue by the salting- out method. p53 mutations in exons 4-8 were detected by PCR-SSCP (polymerase chain reaction - single-stranded conformational polymorphism) electrophoresis. Codon 72 polymorphism was assessed by RFLP (restriction fragment-length polymorphism) method. RESULTS: p53 mutations were present in 11 out of 54 patients (20.4%). Twenty-four patients (44.4%) exhibited Arg/ Arg, 24 patients (44.4%) Arg/Pro and 6 patients (11.2%) Pro/ Pro genotype of 72 codon polymorphism. Correlations between p53 mutations and various clinicopathological characteristics were not found. However, we observed that the frequency of Pro/Pro genotype was increasing with higher histological grade as well as in advanced compared to localized disease, but without statistical significance. Distribution of p53 gene mutations between Pro/Pro genotype and Arg/Pro plus Arg/Arg genotypes was not statistically significant. CONCLUSION: Our study suggests that Pro/Pro genotype of 72 codon polymorphism could be an independent prognostic marker in ovarian carcinomas.

[Radiation burden of patients in conventional diagnostic radiology: analysis of radiologic practice in Serbia].

X-rays are by far most significant contributor to total population dose from man-made sources of radiation. Diagnostic reference levels provide frameworks to reduce variability. The aim of this study is to establish, for the first time, a baseline for national diagnostic reference levels in Serbia for the most common X-ray examination types. Dose estimates are based on measurements of kerma-area product and Entrance surface air kerma for at least ten patients for each examination type, in each of 16 randomly selected hospitals in Serbia. Mean, median and third quartile values of patient doses are reported. Results have shown wide variation of mean hospital doses. Entrance surface doses were compared with previously published diagnostic reference levels. Doses for all studied examination types except chest radiography were within European DRL. The reasons for dose variation are discussed. The findings emphasize the importance of regular patient dose measurement to ensure that patient doses are kept as low as reasonable achievable.

Proximal humeral internal locking system (PHILOS) for the treatment of proximal humeral fractures.

INTRODUCTION: The aim of this study was to describe early results of a new internal locking system, PHILOS, used for the treatment of proximal humeral fractures. MATERIALS AND METHODS: A chart and radiographic review of 25 cases that had proximal humeral internal locking system (PHILOS) plate for the treatment of proximal humeral fractures was performed. RESULTS: Of the 25 cases, 20 went to union with a mean neck/shaft angle of 127.2 degrees . Five cases required or were considered for revision surgery for non-union or implant failure. Of the 25 implants, 4 had screw protrusion into the gleno-humeral joint, 4 had screw loosening and backing out, and 1 plate broke without further trauma. CONCLUSIONS: Our results suggest that PHILOS is an effective system for providing fracture stabilisation to bony union but awareness of potential hardware complications is essential.

Erythroid progenitor cells from pig bone marrow and peripheral blood.

With the intention of using the pig as a large animal model in haematopoietic research, a clonal assay in methylcellulose was developed and the optimal conditions for raising erythroid progenitors from adult pig bone marrow (BM) and peripheral blood (PB) have been established. Progenitor cells were stimulated to proliferate and differentiate in vitro by growth factors containing leucocyte condition medium (LCM), and with recombinant human erythropoietin (rhEpo). The number of PB BFU-E (burst forming units - erythroid) directly depended on the concentration of LCM, but BM BFU-E were not dependent on LCM. Both CFU-E (colony forming units - erythroid) and BFU-E were rhEpo dependent. Despite relatively high but expected individual variations, the mean number of colonies, as well as the functional characteristics of progenitor cells investigated, were similar to those of miniature pigs and some other mammals.

Radiosensitivity of human lymphocytes in vitro correlates more with proliferative ability of cells than with the incidence of radiation-induced damages of the genome.

The purpose of this study was the estimate the extent of individual variability in radioresponse of human lymphocytes in vitro and to establish the reasons of variability. Individual variability in radiation-response was evaluated using the cytochalasin B micronucleus test among 82 healthy individuals (36 men and 46 women), of mean age 38 (range 30-48). Blood samples were irradiated with gamma (60Co) rays at a dose of 2 Gy in vitro. The yield of radiation-induced micronuclei (MN), cytochalasin blocked proliferation index (CBPI), fraction of micronucleated binucleate (BN) cells and mean incidence of MN per micronucleated BN cells at a sampling time of 72 hours were scored. Our results brought out a significant effect of gender on the level of spontaneously occurring micronuclei, the lack of statistical differences between gender in the yield of radiation-induced micronuclei and marked variability in radiation response among individuals. Likelihood of expressing hypersensitivity was correlated with ability of cells to proliferate in vitro (beta = 0.41, p < 0.000) more than with the incidence of radiation-induced micronuclei per micronucleated cell (beta = 0.20, p < 0.000).

[Stomatology yesterday, today and tomorrow]. / Stomatologija juce, danas i sutra.

Authors have given a short historical review of the development of stomatology in our country. The authors present contemporary comprehension of preventive and curative activities in certain stomoatological disciplines (children's stomatology, orthopedics of jaws, paradontology, prosthodontics, maxillofacial surgery) in the light of scientific achievements and their application in our conditions. The future of stomatology is in the development of new scientific subdisciplines and permanent searching in the sphere of the biocompatibility of the matter, for the rehabilitation of ruined health condition of oral cavity combined with a wide application of preventive measures and health care education of each individual.

[Neuroleukemia in adults]. / Neuroleukemija kod odraslih osoba.

Involvement of CNS with leukemic cells is well recognized complication of acute lymphatic leukemia (ALL) in childhood, but with recent improvements in systemic treatment and longer survival the incidence of this complication has increased in adults. Neurological symptomatology in patients with CNS leukemia is due to meningeal infiltration, but sometimes also to diffuse and nodular cerebral infiltration. Between January 1991 and December 1994, 36 patients suffering of acute leukemia, 28 with ALL, and 8 with acute myeloid leukemia (AML) were demonstrated to have neuroleukemia by the following criteria: (1) the presence at lumbar puncture (LP) pleocytosis and blast cells on CSF sediment (without positive bacteriologic and fungal cultures), and (2) the presence of neurological symptoms and signs. All 36 patients had 46 episodes of CNS involvement. All patients had neurological examinations during every episode, and according to the neurological abnormalities were classified into four categories. LP was performed in all, and CSF sediments obtained by sedimentation in Sayk's chambers, were routinely stained by MGG and cytochemical stains to detection of leukemic cells (Fig. 1). EEG was done during 21 episodes, CT scan during 15. We divided patients into four groups according to the most prominent neurological symptoms and signs. First was the group included 23 episodes (50%), (18 ALL, 5 AML), where symptoms and signs of meningeal irritation predominated, mimicking the clinical picture of meningitis. This meningeal syndrome can sometimes produce differential diagnostic problems with CNS infections, when CSF examination is of primary importance. Second was the group of 9 patients (6 ALL and 3 AML) with 10 episodes (21.74%) where cranial nerve symptoms and signs-predominated, or were exclusively present. Most frequently affected were bulbomotors, facials and opticus. Third group consisted of 8 ALL patients (8 episodes, 17.39%) with dominant spinal root symptomatology, caused by pathological infiltration of either spinal roots or meninges surrounding them. This group includes also one patient with mononeuritis multiplex and the other with painful polyneuropathy. All patients in this group had pain on straight leg raising, but we stress here that all patients from other groups had positive Lazarevitsh's sign, too. So, it can be a good differential diagnostic parameter for distinguishing toxic medicamentous polyneuropathy from leukemic poliradiculoneuropathy. Fourth group included 5 patients (5 episodes, 10.87%). 4 ALL and 1 AML, where cerebral symptoms, such as seizures, hemiparesis and psychoorganic syndromes were prominent. CSF was obtained during all episodes by lumbar puncture. The protein concentration ranged from 21-3180 mg/dl, and was above normal (45 mg/dl) during 28 episodes. Mild hypoglycoracchia was present during 16 episodes. Cell count ranged from 11-4816 cells/cm3, malignant cells were identified during all episodes with same morphological and cytochemical characteristics of identified type of leukaemia. It has been established that the most valuable diagnostic procedure in CNS leukemia is CSF examination, and detection of blasts is sufficient for diagnosis. All other procedures like EEG, myelography and CT have only supplemental diagnostic significance. Finally, in this study we showed that neurological symptomatology in patients with acute leukemia is not dependent of the type of leukemia, moreover different types of AL can have same neurological manifestations. As others, we sometimes used the term CNS leukemia in this paper, although it is clear that meninges and peripheral nervous system are most often involved. This is the reason why we suggest that neuroleukemia, or NS leukemia should be used as more appropriate expressions.

[Transient global amnesia--possible aetiopathogenetic mechanisms]. / Tranzitorna globalna amnezija--moguci etipatogenetski mehanizmi.

Transient global amnesia is a clinically well defined syndrome, characterized by transient isolated epizodes of confusion with inability to acquire new data, repetitive quieries, retrograde amnesia and absence of other neurologic symptoms or signs. Eighteen patients who presented at admission the clinical picture of transient global amnesia were, after the examination, classified in three groups: patients with symptoms or signs of transitory focal ischemia, migraine group, and miscellaneous group. The transitory global amnesia in patients suffering from atherosclerotic changes of the vascular system is usually the first manifestation of transitory ischaemic attack pointing to the vascular insufficiency of the posterior cerebral regions as the cause of attack. The typical transient global amnesia is not a rare phenomenon, but it supposes the existence of the precipitating factors. Although its "pure" form is usually benign, the appearance of other factors such as cerebral neoplasms, involved in the aetiology of transient global amnesia, requires the complete clinical examination of each individual with these symptoms.

[Free forearm flap in the reconstruction of mucosal defects of the oral cavity and oropharynx after radical removal of a tumor]. / Slobodni podlakticni rezanj u rekonstrukciji defekata sluznice usne supljine i zdrijela nakon radikalnih odstranjenja tumora.

In the Department of Surgery, Clinical Hospital Center Rijeka in cooperation with ENT Department and the Department of Maxillofacial Surgery, fifty patients with the mouth and the throat tumor were operated since 1985. The defects were covered with free radial forearm flaps. In seven cases flap did not survived due to thrombosis of the anastomosis. The arterial anastomosis were usually made on the external carotid artery branches. Seven anastomosis were made on the opposite side of the neck because homolateral carotid artery was ligated. In three cases terminolateral anastomosis with common carotid artery was made. In eight patients the bone defect of the lower jaw was reconstructed with vascularized radial bone graft. Irradiation and/or cytostatic therapy was mostly applied two weeks after surgery. The donor site defect has no functional nor aesthetic implications.