[Obstacles in wound healing]. / Prepreke u cijeljenju rane.

Wound healing is a complex process that involves a significant number of chemical and physiological events acting on the cellular and molecular level. Wound healing passes through four stages, which are not distinctly separated one from another. There are many factors that can affect the wound healing process and their activities slow down, or completely interrupt the healing process. Wound around tissue ischemia, which is due to spasm of the arteries or atherosclerotic changes in them, can easily lead to slowing down or even stops the wound healing process. Wound infections and use of corticosteroids are significant barriers to healing. Other factors that can influence the course of wound healing are inadequate nutrition with consequent lack of energy or protein and some vitamins, wound abidance, wound bed status, localization of wound, etc. Only with the knowledge of the wound healing pathophysiology and understanding all the factors that may affect delayed wound healing, we can adequately prevent and treat chronic wounds.

[Debridement- crucial procedure in the treatment of chronic wounds]. / Debridement- krucijalni postupak u lijecenju kronicnih rana.

Debridement is the process of removing dead tissue from the wound bed. Devitalized tissue can obstruct or completely stop healing of the wound. The aim of debridement is to transform a chronic wound into an acute wound and to initiate the process of healing. Debridement is the basis of each wound treatment and it has to be repeated, depending on the necrotic tissue formation. There are several types of debridement, as follows: mechanical, autolytic, chemical, enzymatic, biological, and new debridement techniques. With advances in technology, new types of debridement have been introduced. Besides standard methods, methods of pulsed lavage debridement (hydro-surgery, water-jet) and ultrasound-assisted wound treatment are ever more frequently introduced. The method of debridement the clinician will choose depends on the amount of necrotic (devitalized) tissue in the wound bed, size and depth of the wound, underlying disease, possible comorbidity, and the patient general condition. Frequently, the methods of debridement are combined in order to achieve better removal of devitalized tissue. In addition, debridement significantly reduces bacterial burden.

[Negative pressure therapy- supportive method in chronic wound treatment]. / Terapija negativnim tlakom - potporna metoda lijecenja kronicne rane.

Negative pressure sound therapy is one of the supportive options for chronic wound treatment. Good results have been reported in increasing angiogenesis, improving blood flow in the wounds, decreasing edema, regulating moist environment, granulation tissue stimulation and wound retraction. In addition, there is significant reduction in bacterial burden and in the amount of harmful products (exotoxins, endotoxins, cytokines and matrix metalloproteinases) in the wound. The healing time for chronic wounds is reduced in comparison with other conservative treatments.

[Toilet of chronic wound]. / Previjanje kronicne rane.

Chronic wound toilet, with appropriate care of the surrounding skin, is one of the basic steps that must be performed in the treatment of patients with chronic wound. On wound cleaning and bandaging, it is of utmost importance to choose an appropriate technique of cleansing, select an appropriate solution for leaching and choose an appropriate wound dressing. In this way, the wound is protected from dirt from the environment and microorganisms, while protecting the surrounding tissue from the wound exudate, providing optimal conditions for better and faster wound healing and contributing to improved patient quality of life. The frequency of dressing change is individual and must be tailored to each patient in correlation with the psychosocial status of the patient, the type of the wound, the amount and type of wound exudate, as well as what is to be put on the wound. One of the most important elements in wound toilet is appropriate care for the surrounding skin. Basic guidelines for skin care must meet three basic criteria: adequate washing and cleansing of the skin, maintain the physiological balance of the skin and protect the skin from external damage.

[Prevention of pressure ulcer (bedsore)]. / Prevencija tlacnog vrijeda (dekubitusa).

Although progress in many fields of science, medicine and technology is evident, we are still witnessing the appearance of bedsores and its consequences. However, in the last fifty years there has been considerable progress in the understanding of its causes, prevention and treatment. Prevention and treatment of pressure ulcers are complicated by the many misconceptions. However, with due knowledge of the process of healing of acute and chronic wounds and of the pathophysiological processes, in many cases chronic wounds, like pressure ulcers, can now be prevented and cured, and thus reduce the cost of treatment, as well as the mortality rate.

[Setting of compression therapy]. / Postavljanje kompresijske terapije.

Compression therapy is the basic therapy in phlebology and lymphology. The pressure under the bandages has to exceed the intravenous pressure especially in standing position. Different compression materials such as short stretch systems, long stretch bandages and compression garments work differently on ambulatory venous hypertension, speed of reducing edema and arterial flow. Compression with high stiffness, inelastic materials is more effective than compression with low stiffness, elastic materials. These materials have to be placed correctly. Inelastic systems should be applied with high initial pressure because the pressure will loose at some time after walking. Even after one week of wearing, inelastic bandages keep higher resting and working pressure during walking than elastic bandages. However, more important is that they have lower resting pressure than elastic materials. Long stretch bandages and compression garments with great extensibility ensure low working pressure and higher resting pressure than short stretch systems.

[Modern wound dressings]. / Suvremena pokrivala za rane.

Chronic wounds are, due to the slow healing, a major clinical problem. In addition to classic materials, a great number of supportive wound dressings for chronic wound treatment, developed on the basis of new knowledge about the pathophysiological events in non-healing wounds, are available on the market. Today we know that modern wound dressings provide the best local environment for optimal healing (moisture, warmth, appropriate pH). Wound dressings control the amount of exudate from the wound and bacterial load, thus protecting local skin from the wound exudate and the wound from secondary infections from the environment. Using supportive wound dressings makes sense only when the wound has been properly assessed, the etiologic factors have been clarified and the obstacles making the wound chronic identified. The choice of dressing is correlated with the characteristics of the wound, the knowledge and experience of the medical staff, and the patient's needs. We believe that the main advantage of modern wound dressing versus conventional dressing is more effective wound cleaning, simple dressing application, painless bandaging owing to reduced adhesion to the wound, and increased absorption of the wound exudate. Faster wound granulation shortens the length of patient hospitalization, and eventually facilitates the work of medical staff. The overall cost of treatment is a minor issue due to faster wound healing despite the fact that modern supportive wound dressings are more expensive than conventional bandaging. The article describes different types of modern supportive wound dressings, as well as their characteristics and indications for use.

[Effect of compression therapy in the management of venous ulcer - practical experience]. / Ucinak kompresivne terapije u lijecenju venskog vrijeda - primjer iz prakse.

Venous insufficiency is one of the most common causes of chronic wounds. Venous ulcers account for about 75% of all leg ulcers, and 50% of venous leg ulcers require long-term treatment lasting for more than 1 year. The most common location of venous ulcers is the lower third of the leg, as it is the site of strongest venous pressure; less often there are multiple venous ulcers that tend to be localized on both lower legs. In addition to the negative impact on the quality of life, such as immobility, pain and social isolation, which significantly affect the course and length of treatment, we cannot ignore the high costs of long-term and often uncertain treatment, which poses a major health, social and economic problem in the world and in our country.

[Contemporary management of leg ulcer]. / Suvremeni pristup lijecenju kronicnog venskog ulkusa.

Chronic wounds are becoming an increasing health, economic and social problem worldwide, including Croatia. Most common chronic wounds are the results of venous insufficiency of lower legs, and their incidence is about 75% of all chronic wounds. Costs of treating patients with leg ulcer are not trivial. According to available data from different countries, they range from 1% to 3% of total fund allocated for health care. Expensive, time-consuming, difficult, and often uncertain treatment is still great health, social and economic problem. The paper describes current approach to the treatment of venous leg ulcers, with emphasis on the cost-benefit of this approach. Before hospitalization, the patient was treated without compression therapy, just with local application of various types of coatings for 4 years. There are no precise data on the types of dressings that were used, and no data on the microbiological status of the wound during this period. After admission to the hospital, the first step was approach to preparation and conditioning the bed of leg ulcer. After achieving satisfactory local status, the ulcer was covered by free skin graft. Upon discharge from the hospital, minor residual skin defects were treated with alginate dressings and fully healed within 3 weeks. Total cost of 3-month treatment (one-month preoperative period, hospitalization and time elapsed from discharge from the hospital to complete recovery) was 17,085.95 HRK. An approximate cost estimate of 4-year unsuccessful treatment is more than 100,000.00 HRK. Contemporary and active approach that is consistent with current state-of-the-art can achieve significant cost saving in the treatment of patients with chronic leg ulcer.

[The role of short-stretch bandage in therapy of lymphedema]. / Uloga kratkoelasticnih zavoja u terapiji limfedema.

Compression therapy is the main therapeutic modality in the treatment oflymphedema and its complications. Compression therapy is performed with various elastic and non-elastic materials which, based on their properties, induce active or passive compression when the patient is walking as well as in rest. The choice of bandage depends on the stage of lymphedema. The pressures under the bandage depend not only on the material, but also on the force employed for compression, number of layers and coverage of particular bandages, as well on bandage method.

[Treatment of the wound surrounding skin]. / Lijecenje koze u okolini rane.

Skin barrier function around the ulcer is usually impaired. Additionally, the skin can be atrophic, thinned, without skin adnexa and elastic fibers, dry and prone to callus formation. Skin barrier function can be improved with regular use of emollients. It is important to differentiate erythema around the ulcer induced by hypostatic eczema from cellulitis or erysipelas and from allergic or toxic contact dermatitis or eczema vulgaris because therapy is completely different.

[Application of modern wound dressings in the treatment of chronic wounds]. / Primjena suvremenih obloga u lijecenju kronicnih rana.

Chronic and acute infected wounds can pose a major clinical problem because of associated complications and slow healing. In addition to classic preparations for wound treatment, an array of modern dressings for chronic wound care are currently available on the market. These dressings are intended for the wounds due to intralesional physiological, pathophysiological and pathological causes and which failed to heal as expected upon the use of standard procedures. Classic materials such as gauze and bandage are now considered obsolete and of just historical relevance because modern materials employed in wound treatment, such as moisture, warmth and appropriate pH are known to ensure optimal conditions for wound healing. Modern wound dressings absorb wound discharge, reduce bacterial contamination, while protecting wound surrounding from secondary infection and preventing transfer of infection from the surrounding area onto the wound surface. The use of modern wound dressings is only justified when the cause of wound development has been established or chronic wound due to the underlying disease has been diagnosed. Wound dressing is chosen according to wound characteristics and by experience. We believe that the main advantages of modern wound dressings versus classic materials include more efficient wound cleaning, simpler placement of the dressing, reduced pain to touch, decreased sticking to the wound surface, and increased capacity of absorbing wound exudate. Modern wound dressings accelerate the formation of granulation tissue, reduce the length of possible hospital stay and facilitate personnel work. Thus, the overall cost of treatment is reduced, although the price of modern wound dressings is higher than that of classic materials. All types of modern wound dressings, their characteristics and indications for use are described.

[Role of debridement in treatment of chronic wounds]. / Uloga debridmana u lijecenju kronicnih rana.

Debridement is the process of removing dead tissue from the wound bed. Since devitalized tissue can obstruct or completely stop healing of the wound, it is indicated to debride wound bed as part of the treatment process. The aim of debridement is to transform a chronic wound into an acute wound and to initiate the process of healing. Debridement is the foundation of each wound treatment and it has to be repeated, depending on the necrotic tissue formation. There are several types of debridement: surgical, autolytic, chemical, enzymatic, mechanical, and biological. Using previous knowledge and advances in technology, new types of debridement have been introduced. Besides standard methods, methods of pulsed lavage debridement (hydro-surgery, water-jet) and ultrasound-assisted wound treatment (UAW) are ever more widely introduced. The method of debridement the clinician will choose depends on the amount of necrotic (devitalized) tissue in the wound bed, the size and depth of the wound, the underlying disease, the possible comorbidity, as well as on the general condition of the patient. Frequently, the methods of debridement are combined in order to achieve better removal of devitalized tissue. Debridement in addition significantly reduces bacterial burden. Regardless of the method of debridement, it is essential to take pain to the lowest point.

[Wounds in vascular and metabolic diseases]. / Rane kod vaskularnih i metabolickih bolesti.

There are many causes of leg ulcer development; however, vascular etiology is most commonly involved. Venous or lymphatic causes underlay 80% and arterial or arteriovenous causes 20%-25% of cases. Over years, the prevalence of arteriovenous ulcers has increased due to the increased prevalence of peripheral arterial disease. Concerning metabolic reasons, diabetes is the most common underlying disease leading to ulcer formation, whereas calciphylaxis is a very rare one. In addition to the general principles of local ulcer therapy, additional therapy treating the cause of ulcer is necessary. Therapy of leg ulcers is manly interdisciplinary and should include a dermatologist, surgeon, internal medicine specialist, radiologist, general practitioner.

[Squamous cell carcinoma--case report]. / Planocelularni karcinom--prikaz bolesnika.

Carcinoma that develops in chronic ulcers, wounds, burn scars and fistulas is known as Marjolin's ulcer. It occurs primarily as a squamous cell carcinoma and rarely as basal cell carcinoma. Marjolin's ulcer represents 2% to 5% of all squamous cell carcinomas of the skin. We present a 60-year-old male patient with chronic ulceration on the right leg. The ulceration appeared 15 years before at the localization of the burn scar following an injury and was treated for years as a chronic venous ulcer. After sudden enlargement of the ulcer, biopsy confirmed it to be invasive squamous cell carcinoma. Ultrasound and computed tomography revealed a metastatic squamous cell carcinoma in the inguinal lymph node. After complete excision of the tumor and inguinal lymph node dissection, the patient was under supervision of the surgeon and oncologist because of tumor relapse on the skin and lymph node. This case should serve as a reminder to practitioners to perform biopsy of every ulcer that fails to heal or when other risk factors for venous ulcers are missing, in order to avoid delay in diagnosis and complications.

[Calciphylaxis]. / Kalcifilaksija.

Calciphylaxis is a form of extra-skeletal calcification characterized by calcium deposits in arterial tunica media and vascular thrombosis, which leads to tissue ischemia including skin ischemia with consequential skin necrosis. Necroses may also develop in the subcutaneous adipose tissue and skeletal muscle. The cause of this disorder remains unknown. It was first described by Bryant and White as early as 1989 in association with uremia, and the syndrome remained clinically inadequately recognizable until 1976. Then, Gipstein and coworkers described the disorder in more detail, followed by a great number of calciphylaxis case reports since then, including data on morbidity and therapeutic dilemmas. Calciphylaxis has been reported in association with hepatic insufficiency, obesity, and diabetes mellitus. The authors present the clinical procedure of identifying and treating major ulcerations on both lower legs in a patient with polymorbidity and recognized calciphylaxis, which caused skin necroses with consequential chronic leg ulcers.

[Role of negative pressure therapy in the treatment of chronic wounds]. / Uloga terapije negativnim tlakom u tretmanu kronicnih rana.

Negative Pressure Wound Therapy (NPWT) is one of the supportive options for chronic wound treatment. The level of negative pressure is between 40 and 125 mm Hg below ambient. Good results in increasing angiogenesis, improvement of blood flow in wounds, edema reduction, regulation of moist environment, granulation tissue stimulation and wound retraction have been proved. In addition, bacterial burden in the wound and the amount of harmful products (exotoxins, endotoxins, cytokines and matrix metalloproteinases) are also significantly reduced. Chronic wound healing time is accelerated in comparison with other conservative treatments. The NPWT can be applied in either inpatient or outpatient settings.

[Self-mutilation--artifacts--case report]. / Samoozljedivanje--artefakti--prikaz bolesnika.

Despite the knowledge and the development of sophisticated procedures in the treatment of wounds, many clinicians are faced with the wounds that heal very slowly or they do not heal at all. In spite of repeated reconsideration of the treatment strategies and focusing on the biological factors, we still pay little attention to the psychosocial factors that are listed as one of the causes of atypical wounds. One factor is self-mutilation caused by psychological disorder called hospital addiction syndrome or Munchausen syndrome, which belongs to a group of the states called imaginary disorder where someone with great need for attention turns to disease or injury. In people with "hospital addiction syndrome", we are confronted with evidence for the symptoms to be imaginary or consequential to self-inflicted injuries; they usually deny these clams and often leave the hospital despite advice but in search for other physicians and hospitals.

[Video-assisted extirpation of breast fibroadenoma with immediate bilateral breast augmentation--a case report]. / Videoasistirana ekstirpacija fibroadenoma dojke s neposrednim obostranim povecanjem dojki--prikaz bolesnice.

BACKGROUND: Since mid 1990s video-assisted breast surgery (VABS) has been developed in the treatment of benign and malignant breast diseases. According to studies that are conducted mainly in Japan, this tehnique is safe, easy to learn and his main advantage is excellent cosmetic results on postoperative appearance of breasts that cannot be achived with standard surgical procedures. OBJECTIVE: To present a first case of video assisted breast surgery in Croatia applied to treatment of breast fibroadenoma and immediate bilateral breast augmentation. CASE REPORT: A 39 year old female patient was admitted to our hospital for elective procedure of breast augmentation. On this occasion video assisted extirpation of fibroadenoma was performed through inframammary incision and followed by immediate bilateral breast augmentation. CONCLUSION: VABS is feasible, cosmetic effects are evident and the VABS deserves attention as a possible surgical option in breast surgery. However further experience on this field must be gained and it remains to evaluate this tehnique on the additional studies.

[Surgical and radiotherapy in treatment of postauricular keloids--case report]. / Kirurska i iradijacijska terapija u lijecenju postaurikularnih keloida.

Treatment of keloid remains a great challenge for clinicians, in spite of numerous therapeutic regimens reported in the literature to date. Earlobe or postauricular regions are predominant locations for postoperative keloids due to the treatment of lop ears. There are several treatments that include intralesional steroid injections, surgical excision, cryotherapy, laser therapy, radiotherapy and pharmacotherapy. A case is presented with fourth recurrence of keloids after surgical treatment of lop ears with final satisfactory outcome after combined therapy that included surgical excision, skin flap transposition and radiotherapy. It is concluded that interdisciplinary approach that includes a combination of surgery and radiotherapy results in a satisfactory outcome of keloid treatment.