Correlation between Bauman's and carrying angle in children with supracondylar fracture of humerus.

UNLABELLED: Supracondylar fractures are the result of a fall on outstretched hand in more than 70% of cases, and more common in the non-dominant arm. Bauman's angle is used to determine the degree of displacement and angulation, and the quality of fracture reduction. Carrying angle is the clinical parameter ofvarus-valgus angulation with elbow fully extended and forearm completely supinated. PATIENTS AND METHODS: The study was a retrospective-prospective and there were analyzed children under 14 years of age with supracondylar humerus fracture. They were analyzed by X-ray anteroposterior view of injured elbow, made before and after the surgery, with measuring Bauman's angle. Clinical examination was performed after completing physical therapy, when was measured carrying angle of the injured and healthy elbow using a goniometer. RESULTS AND DISCUSSION: The results showed that there is a negative correlation Bauman and carrying angle of injured elbow (r = -0.543, p < 0.0001). Analyzing Bauman's angle deviation from value of 75 degrees and the loss of carrying angle there is noticed significant positive correlation between the Bauman angle deviation and loss of carrying angle. Bauman's angle correlates well with the carrying angle and can be used as an indicator of the potential cosmetic complications. CONCLUSION: Carrying angle of uninjured elbow measured when reviewing a child who has suffered supracondylar fracture, can serve as a useful parameter in the assessment of real Bauman's angle, thereby the adequacy of fracture reduction on the injured arm. KEYWORDS: supracondylar fracture,

The Visualization and Frequency of Cerebral Cavernous Angioma on Magnetic Resonance.

Background: Cavernous angiomas (CAs) are abnormal, congenital, vascular malformations, which often grow in size over the course of life. Conservative treatment, microsurgical resection, and stereotactic radiosurgery are the three main options for treatment of CA. Radiological studies play a key role in diagnosis, with magnetic resonance (MR) being the method of choice. Objective: The aim of this study was to establish the prevalence of cavernous angiomas, the size, appearance, that is, the type of CAs and to determine visualization of cavernous angiomas by magnetic resonance. Methods: The study included all patients who underwent an MR of the brain in the period from January 2011 to the end of December 2017 at the Radiology Clinic of Tuzla University Clinical Centre, and in whom MR examination verified one or more CAs. Results: The prevalence of cavernous angioma in the study was 0.57%, and men and women were equally represented. The number of cavernous angiomas per patient was between 1 and 79 ; the average diameter was 11mm, and the most common type at ≥ 3mm was equivalent to Type II, whilst the largest number of cavernous angiomas, regardless of the size and visualization on individual sequences, were equivalent to Type IV. No significant difference was found in sensitivity between spin echo sequence and T2W gradient echo sequence in the group comprised of cavernous angiomas ≥ 3mm, whilst in the group comprised of punctiform cavernomas < 3mm, T2W* was a significantly more sensitive sequence than spin echo, that is, spin echo sequence had significantly lower sensitivity in the detection of punctiform CAs. Conclusion: The prevalence of CAs was in line with the results of other studies. T2W* sequence is significantly more sensitive in comparison with spin echo only in the detection of punctiform CAs, and is important in the detection of multiple familiar CAs.

Spastic Paraparesis After SARS-CoV-2 Infection Without Radiological Changes.

Coronavirus disease 2019 (COVID-19) is primarily a disease of the respiratory system but severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) may cause several immune-related complications including different neurological disorders, such as myelopathy with paraparesis.In this atypical case a female patient with progressive spastic paraparesis after COVID-19 infection, brisk reflexes and positive Babinski sign, reduced vibratory sensation to the thoracic level, elevated immunoglobulin levels (IgG) in cerebrospinal fluid, but negative magnetic resonance imaging (MRI) of the brain and spine, is presented.  A 57-year-old woman with spastic paraparesis and inability to walk was admitted to our neurological department. About four months before hospitalization, she started feeling numbness and tingling in the feet and lumbar spine area. Gradually, numbness and tingling ascended to the thoracic spine level Th7/8, and she developed weakness mostly in her legs. In the neurological exam she had spastic paraparesis. MRI of the brain, cervical and thoracic spine did not reveal any signal abnormality. Serological testing for SARS-CoV-2 was performed and results were highly positive IgG and IgM+IgA levels. The lumbar puncture finding confirmed the suspicion of immune-related complications after SARS-CoV-2 infection (intrathecal IgG synthesis).  This case draws attention to spastic paraparesis or progressive MRI-negative myelitis after SARS-CoV-2 infection, which obviously has immune-mediated pathogenesis that happen in response to the virus or its antibodies. Similarities in spastic paraparesis after human T-lymphotropic virus (HTLV-1) or human immunodeficiency virus (HIV-1) and SARS-CoV-2 infections were observed. The patient had a good response to corticosteroid therapy and had good recovery.

Sleep Disorders in Acute Stroke.

Background: Stroke patients have sleep-wake disorders, mostly in form of insomnia, excessive daytime sleepiness/fatigue, or hypersomnia (increased sleep needs). Objective: The aim of this study was to analyze types of sleep disorder (SD) and their frequency in patients with sleep apnea and acute stroke in relation to the type of stroke and side of lesion. Methods: The study analyzed 110 patients with sleep apnea and acute stroke hospitalized in the Clinic of Neurology, University Clinical Centre Tuzla. Acute stroke has been verified either by computerized tomography or magnetic resonance imaging of the brain. SD was verified according to the Berlin Questionnaire Test, The Epworth Sleepiness Scale, The Stanford Sleepiness Scale and the General sleep questionnaire. Strokes were divided by: a) type, into hemorrhagic and ischemic, and b) the localization of the stroke, to right and left cerebral hemispheres. Results: Of the total number of respondents, all had some sleep disorder. 20% of respondents had severe level of SD, 35.4% moderate, 37.3% moderate- severe and 7.3% mild problems. There were no statistically significant differences in the frequency of SD among patients with ischemic and hemorrhagic stroke (p = 0.58). In relation to the side of lesion, there was more patient with SD and stroke in the both sides, but there were no statistically significant differences (X2=1.98, p=0.161). According Epworth Sleepiness Scale, Stanford Sleepiness Scale and Berlin Questionnaire test snoring was present in 81% and daytime sleepiness in all patients. Conclusion: SD as a neuropsychological disorder has a significant incidence in the acute phase of stroke in patients with sleep apnea. Sleep disorder is more common in ischemic stroke and stroke in the both hemisphere, but it is not statistically significant difference. Daytime sleepiness, fatigue and snoring are the most common sleep problems in patients with acute stroke and apnea, but it is not statistically significant.

Coexistence of myasthenia gravis and amyotrophic lateral sclerosis in a Bosnian male: an unusual clinical presentation.

PURPOSE: Myasthenia gravis (MG) and amyotrophic lateral sclerosis (ALS) are two different diseases. The coexistence of both of them is extremely rare and represents a diagnostic challenge which requires thoughtful interpretation of clinical characteristics. CASE REPORT: We present the case of a 46-year-old Bosnian male who developed ALS five months after MG. Diagnosis of MG was based on elevated titers of anti-AchR antibodies, positive edrophonium test, and decremental responses on a repetitive nerve stimulation test while the diagnosis of ALS was based on clinical and neurophysiological findings: upper motor neuron signs in the lumbar region, lower motor neuron signs in the bulbar and cervical regions, generalized fasciculations and muscle atrophy and progressive asymetric muscle weakness together with active and chronic denervation in the cervical and lumbosacral region determined by electromyoneurography. CONCLUSIONS: The coexistence of MG and ALS is rare and request an adequate interpretation of clinical symptoms. The relationship between these two diseases in as interesting phenomen to present.

Risk Factors in Acute Stroke Patients With and Without Sleep Apnea.

BACKGROUND: More than 50% of stroke patients have sleep-disordered breathing (SDB), mostly in the form of obstructive sleep apnea (OSA). SDB represents both a risk factor and a consequence of stroke. The presence of SDB has been linked with the poorer long-term outcome and increased long-term stroke mortality. About 20 to 40% of stroke patients have sleep-wake disorders (SWD), mostly in form of insomnia, excessive daytime sleepiness/fatigue, or hypersomnia (increased sleep needs). OBJECTIVE: The aim of this study was to analyze the frequency of risk factors in patients with acute stroke and sleep apnea. METHODS: The study included patients without cognitive impairment or with mild cognitive impairment. The diagnosis of apnea syndrome was made on the basis of the Snoring and Apnea Syndrome Questionnaire, the Epworth Sleep Scale, the Berlin Questionnaire, the Stanford Sleepiness Scale, and the General Sleep Questionnaire. The severity of stroke was assessed by the National Institutes of Health Stroke Scale and the Rankin Disability Scale. Patients with a Glasgow score <8 on the day of neuropsychiatric examination were excluded from the study, as well as patients with epileptic seizures at the onset of stroke, with aphasia, with Mini - mental test <23, with verified previous dementia / cognitive impairment. RESULTS: There is no statistically significant difference in the age of men and women, both with apnea and without apnea. In patients with apnea, heart disease was in the first place 91.8%, followed by hypertension 86.4%, Body mass index 79.1%, hyperlipidemia 50%, smoking 38.2 % and diabetes mellitus 20.9%. Hypertension was the most common risk factor in patients without apnea 83.6%, followed by heart disease 81.0%, Body mass index 60.9%, hyperlipidemia 48.21%, smoking 28.2 % and diabetes mellitus 20%. CONCLUSION: Heart diseases, hypertension and body mass index are significantly more frequent in patients with than in patients without sleep apnea.

Psychosocial assistance to students with posttraumatic stress disorder in primary and secondary schools in post-war Bosnia Herzegovina.

BACKGROUND: The 1992-1995 war in Bosnia and Herzegovina (BH) has had a tremendous impact on civilians; thousands of inhabitants were left with numerous traumatic experiences. Many children suffered or witnessed horrifying acts of violence and aggression. Although young trauma victims are often resilient, many experience mental health difficulties, including PTSD. The aim of the study was to estimate whether psychosocial support given by the School Project of Humanitarian Association of " Prijateljice" reduced posttraumatic consequences in students in primary and secondary schools in Bosnia and Herzegovina after 1992-1995 war. SUBJECTS AND METHODS: A stratified sample of 336 students in primary and secondary schools located in two entities of North-East Bosnia and Herzegovina, involved in psychosocial support, was compared with 72 voluntarily selected same-age students from the same schools who were not involved in this project. Data were collected on two occasions, beginning of December 2005 and end of May 2006, by using a self-evaluation survey method for measuring symptoms of posttraumatic stress disorder (PTSD) according to DSM IV. The Index of Children Post-traumatic reactions were used. RESULTS: The severity of PTSD symptoms among students involved in the School Project decreased from (mean+/-standard deviation=35.3+/-10.2 to 26.7+/-8.7) (t=13.1, P<0.001, Paired sample test), whereas in the group with no psychosocial assistance this reduction was from (29.7+/-10.9 to 28.1+/-11.8) (t=0.9, P=0.396, Paired sample test). CONCLUSION: This study suggests that work with students by giving them psychosocial support within the School Project resulted in significant reduction of PTSD symptoms' severity.

Clinicopathologic features in a case of intermuscular myopericitoma of thigh.

Myopericytoma is a benign tumor with the most common presentation as a well-circumscribed, slow-growing mass. It is frequently misdiagnosed as a sarcoma. We presented a 23-year-old patient with a history of a sciatic pain of the right leg. A careful physical examination discovered tumor-like mass in the posterior part of the thigh. Neurological finding showed a reduction of myotatic reflexes on the right leg with a weaker muscle strength on the right leg. The right leg musculature was slightly hypotrophic in the range of 2-3 cm comparing to left leg. Initially electrophysiological and radiological diagnostic with magnetic resonance imaging (MRI) of the lumbar spine, pelvis and thighs were normal. Magnetic resonance imaging of the right thigh discovered a slow growing 2.1 × 3.8 cm sized mass that was initially described by radiologist as a neurinoma. Patient was admitted to department of neurosurgery and operated on for a tumor removal. Tumor was located intimately to femur and sciatic nerve and after careful dissection completely removed. Patient was doing well after surgery and discharge after three days from the hospital. In the postoperative period the symptoms disappeared. Histopathology showed a myopericitoma. Postoperative MRI after three months of follow up showed no tumor residues, and after 6 and 12 months there was no tumor recurrence. Myopericytoma behave in a benign fashion, but, because local recurrences and rarely metastases may occur in atypical and malignant neoplasms, a careful follow-up after radical resection is recommended.

Effects of Treating an Overactive Urinary Bladder in Patients with Multiple Sclerosis.

OBJECTIVE: The purpose of this study was to evaluate the efficiency of the anticholinergic therapy with oxybutynin and the effects of daily transcutaneous tibial nerve stimulation (TTNS) on the quality of life of patients with an overactive bladder (OAB) and multiple sclerosis (MS). PATIENTS AND METHODS: The study was designed as a randomized controlled trial. The patients who suffer from MS underwent urodynamic tests which showed that they had an OAB. The tests used to assess symptoms and quality of life were Overactive Bladder Questionnaires (OAB-q) SF. Patients were divided into 2 groups of 30 patients each. The first group received a 5 mg oxybutynin tablet twice a day for 3 months and the second group had TTNS every day for 3 months. RESULTS: The anticholinergic therapy showed a statistically significant improvement in all symptoms and quality of life (P<0.001). Side effects such as dry mouth were observed in about 35% of patients. The results of the study TTNS daily therapy showed good performance in the reduction all clin ical symptoms of the bladder and improved quality of life, with statistical significance (P<0.05) and with no side effects. It was found that the improved quality of life parameters and the reduced symptoms were more statistically significant in the treatment with oxybutynin tablets than TTNS therapy (P<0.001). CONLCUSION: Our recommendation for the treatment of OAB is oxybutynin in doses of 2x5 mg. If a patient can not tolerate anticholinergic drugs, daily TTNS is recommended to reduce OAB symptoms and improve quality of life, without side effects.

Plasmapheresis in neurological disorders: six years experience from University Clinical center Tuzla.

BACKGROUND: Therapeutic plasma exchange (TPE) is an extracorporeal blood purification technique that is designed to remove substances with a large molecular weight. The TPE procedure includes removal of antibodies, alloantibodies, immune complexes, monoclonal protein, toxins or cytokines, and involves the replenishment of a specific plasma factor. The aim of the study was to describe the clinical response to TPE in various neurological patients, and to assess the clinical response to this therapy. METHODS: The study was retrospective. We analyzed the medical records of 77 patients who were treated at the Department of Neurology, University Clinical Center (UCC) Tuzla from 2011 to 2016.   Results: 83 therapeutic plasma exchanges were performed in the 77 patients. There was a slight predominance of male patients (54.5%), with an average age of 51±15.9 years. The most common underlying neurological diseases were Guillain-Barré syndrome (GBS) (37.7%), then chronic inflammatory demyelinating polyneuropathy (CIDP) (23.4%), multiple sclerosis (MS) (11.7%) and myasthenia gravis (10.4%). Less frequent neurological diseases that were encountered were paraneoplastic polyneuropathies (5.2%), neuromyelitis optica (also known as Devic's disease) (3.9%), motor neuron disease (3.9%), polymyositis (2.6%) and multifocal motor neuropathy (1.2%). CONCLUSIONS: Six years experience of therapeutic plasma exchange in neurological patients in our department have shown that, following evidence-based guidelines for plasmapheresis, the procedure was most effective in patients with GBS, CIDP and myasthenia gravis.

Anton's Syndrome due to Bilateral Ischemic Occipital Lobe Strokes.

We present a case of a patient with Anton's syndrome (i.e., visual anosognosia with confabulations), who developed bilateral occipital lobe infarct. Bilateral occipital brain damage results in blindness, and patients start to confabulate to fill in the missing sensory input. In addition, the patient occasionally becomes agitated and talks to himself, which indicates that, besides Anton's syndrome, he might have had Charles Bonnet syndrome, characterized by both visual loss and hallucinations. Anton syndrome, is not so frequent condition and is most commonly caused by ischemic stroke. In this particular case, the patient had successive bilateral occipital ischemia as a result of massive stenoses of head and neck arteries.

Risk factors impact on the long-term survival after hemorrhagic stroke.

AIM: To analyze the impact of risk factors on the survival rate within a period of five years after hemorrhagic stroke (HS). PATIENTS AND METHODS: In this study 303 patients were analyzed with a first ever hemorrhagic stroke admitted at the Department of Neurology Tuzla, from January 1st 1997 to December 31st 1998. Data were collected from patient's medical records, whereas the final examination of all patients, who survived HS, took place five years after stroke. Medical history was obtained and presence of risk factors was evaluated on the day of admission. Computed tomography (CT) of the brain was performed in all patients during hospitalization. The average age of patients was 62 +/- 11 (from 31 to 90) years, 180 (59%) were women. The most frequent risk factor was hypertension, registered in 252 (83%) patients, followed by history of heart diseases in 182 patients (60%), smoking in 72 (23.8%), diabetes mellitus in 26 (8.5%), history of transient ischemic attack in 24 (8%) and alcohol intake in 13 (4.3%) patients. The risk factors were not registered in 22 (7.3%) patients. RESULTS: Five years after HS 82 (26.7%) patients survived. No statistical significance was found in survival between men and women (p = 0.2). The lowest number of patient that survived were over 70 years old (9%), while the highest number of survived was between 41-50 years (60.5%). The average number of risk factors was 2.5 +/- 1.0 and significantly higher in men compared to women (2.7 +/- 1 : 2.3 +/- 1) (p < 0.001). Significant difference was found in patients with hypertension (n = 252) (p < 0.0001), alcohol intake (n = 13) (p = 0.0170), as well as in patients with diabetes mellitus (n = 26) (p = 0.005). Regarding other risk factors such as heart diseases, cigarette smoking and transient ischemic attack there were no significant difference in survival in patients with hemorrhagic stroke (p = 0.2; p = 0.7; p = 0.8; retrospectively). CONCLUSION: We found that hemorrhagic stroke is associated with a very high risk for death in the acute and subacute phase. The survival rate after hemorrhagic stroke was 26.7% within a period of five years. Long-term survival rate prognosis is significantly better among the younger patients, without hypertension, alcohol intake and diabetes mellitus.

[Obstetric lesions of brachial plexus]. / Porodajne lezije pleksusa brahijalisa.

BACKGROUND: Obstetrical brachial plexus lesion (OBPL) (also known in its various forms as Erb's palsy, Klumpke's paralysis, Erb-Duchenne palsy) complicates a very small proportion of births. Furthermore, it seems that more likely many cases recover with little in the way of remaining deficit, but it is equally certain that some cases will not recover. Electro diagnostic examinations are used as following the physical examination and can provide data on both the severity and timing of the injury. The initial study usually is performed 2-3 weeks after injury, when signs of enervation are seen in children with moderate or serious injuries. The incidence of obstetric brachial plexus palsy varies from 0.4 to 1 case per 1000 new born children. This incidence has remained unchanged since the beginning of this century despite current technologic advances. The aim of this paper is to review the literature and authors experience with OBPL. PATIENTS AND METHODS: The study included 30 children examined in last 10 years at Electro myoneurography laboratory, Department of Neurology, University Clinical Center Tuzla, Bosnia and Herzegovina. RESULTS AND DISCUSSION: Total out of 20 children (66.67%) were male, and 10 (33.3%) female; in 11 (36.67%) palsy was on left, and in 19 (63.33%) on right side. Erb's palsy was seen in 27 (90%) and total palsy in the remaining 3 (10%) limbs. Electromyography was very useful test not only for diagnosis, but also for evaluation of recovery. Good recovery was observed in majority of these children, but some children has difficulty with active shoulder abduction, forward flexion, symmetric elbow flexion and forearm supination at age of one year and more, and mild shortening and atrophy of the limb are also observed.