Extraperitoneal Cesarean Section after two Medial Laparotomies, Anus Prater, and Surgical Treatment of the Rectovaginal Fistula in a Patient with Crohn's Disease: A Case Report.

The aim of this case report is to show the advantages of the extraperitoneal cesarean section (ECS) approach in a pregnant patient with multiple previous abdominal transperitoneal colon surgeries and Crohn's disease. A pregnant nulliparous woman with Crohn's disease was admitted for delivery. After delivery, a large rupture and lesion of the rectum was observed. Suturing of the vagina, rectum and sphincter was performed by an abdominal surgeon. Because of a very large and irregularly shaped rectum rupture, the patient underwent infraumbilical medial laparotomy and sigmoidostomy. After 18 months, the patient started to experience vaginal discharge and Y-shaped rectovaginal fistula was confirmed. Surgical reconstruction was performed. The patient's second pregnancy began one year later. At 38 weeks of pregnancy, elective extraperitoneal cesarean section was performed. A healthy newborn was delivered. Follow-up showed full and fast recovery after the ECS. In cases of pregnant women who have had multiple colon surgeries, gynecology surgeons can choose to perform an ECS to avoid transperitoneal entrance into the abdomen. ECS avoids lysis of postoperative adhesions after repetitive gastrointestinal surgeries, the formation of new adhesions by lysis of the old adhesions, and most importantly, the possibility of colon or small intestine lesions during lysis of dense or firm adhesions.

PARENTAL BREASTFEEDING BEHAVIOR AND ATTITUDE QUESTIONNAIRE.

A validated questionnaire is required to evaluate scientifically community-based breastfeeding support and promotion. The aim of this study was to create a valid and reliable questionnaire to measure parents' behavior and attitudes about breastfeeding. The items in the questionnaire were selected by the authors according to regular data from the professional literature, and in consultation with three pediatric lecturers at higher and secondary health education, fellow pediatricians, and parents. A working version of the questionnaire was available on the website of the For a Healthy and Happy Childhood association from February 1, 2019 to May 31, 2019. The study was approved by the Ethics Committee of the Bjelovar General Hospital. After item analysis, 15 behavioral questions that showed good internal consistency were retained. Concerning the attitudes, principal component analysis showed a four-factor structure with 17 items explaining 46.11% of total variance. Cronbach's alpha (0.88) indicated acceptable internal consistency. To analyze the ability of the questionnaire to differentiate parents according to the desired outcome, the χ2-test, correlation and logistic regression were used. In the study, the desired outcome was defined as exclusive breastfeeding for 5 or 6 months, as well as breastfeeding for 12 months or more. In conclusion, the final instrument is reliable and valid for collecting breastfeeding data and evaluating changes in parents' behaviors and attitudes achieved through participation in breastfeeding promotion and support programs. The questionnaire may, in addition to the BIAKQ questionnaire, support professionals and activists involved in breastfeeding to create methodologically well-conceived programs.

Ethical Aspects of Prenatal DNA Testing.

Cell-free DNA (cfDNA) first-trimester screening for fetal aneuploidies, as a non-invasive, safe, and rather accurate method, has changed prenatal screening policies all over the world. Owing to aggressive marketing, cfDNA screening tests exhibit global popularity and a rapid spread in routine prenatal care. However, wide availability of the tests, together with observed difficulties in the test's interpretation, bring to light several serious ethical concerns. To date it is vital to identify and address the most important ethical, legal, and social issues regarding prenatal screening tests. Furthermore, guidelines and restrictions in certain cfDNA screening advancements that may provide information regarding fetal genetic traits of unknown clinical significance, conditions with variable penetrance, or late-onset conditions, should be considered.

Pregnancy After Simultaneous Pancreas-Kidney Transplantation in Treatment of End-Stage Diabetes Mellitus: a Review.

The majority of patients with simultaneous pancreas and kidney transplant (SPKT) required transplantation owing to a long-standing history of insulin-dependent diabetes mellitus (IDDM). The disease causes multiple organ damage, impairs fertility, and affects quality of life. A successful kidney and pancreas transplant can improve health, ameliorate the consequences of pre-existent diabetes, and restore fertility. Good graft function, without any sign of rejection, and stable doses of immunosuppressant drugs are of utmost importance prior to the planned pregnancy. SPKT recipients who become pregnant may be at an increased risk for an adverse outcome and require meticulous multidisciplinary surveillance. We present experiences with SPKT pregnancies, traditional approaches, and recent considerations. In light of complex interactions between new anatomic relations and the impact of developing pregnancy and immunosuppressive medications, special stress is put on the risk of graft rejection, development of pregnancy complications, and potential harmful effects on fetal development. Recent recommendations in management of SPKT recipients who wish to commence pregnancy are presented as well. Key words: transplantation, pregnancy, pancreas, kidney, simultaneous pancreas and kidney transplantation (SPKT).

Fetomaternal Hemorrhage: Can We Use Hemoglobin Electrophoresis as a Diagnostic Tool?

Fetomaternal hemorrhage (FMH) is usually detected by either the Kleihauer-Betke (KB) test or by 2 cytometry, the latter of which represents the gold standard of FMH diagnosis today. But what do we do when neither method is available? We present two cases of suspected FMH due to their characteristic signs and symptoms that were ultimately confirmed by hemoglobin electrophoresis (HE).

Spontaneous Heterotopic Pregnancy as an Uncommon Clinical Problem.

BACKGROUND: Heterotopic pregnancy refers to the simultaneous coexistence of an intrauterine and extrauterine pregnancy. In natural conception it is very rare, with a rising incidence in patients undergoing assisted reproduction technologies. It presents a serious diagnostic problem which is often misdiagnosed. Currently, there are no standard protocols for the treatment and diagnosis of heterotopic pregnancy. METHODS: Two rare cases of spontaneous heterotopic pregnancy are presented. RESULT: The first patient had a complete abortion upon which an extrauterine pregnancy was detected. The second patient, after an extrauterine pregnancy removal, progressed with an intrauterine pregnancy until full term and it ended with the delivery of a healthy infant. CONCLUSION: Two demonstrated cases underscore that whenever abnormal adnexal findings are presented and the beta-hCG blood test is positive, the possibility of a heterotopic pregnancy should be suspected.

PRIMARY HODGKIN'S LYMPHOMA OF THE BREAST INITIALLY TREATED BY SURGICAL EXCISION AND AXILLARY DISSECTION.

Primary breast lymphoma accounts for 0.04%-0.5% of all breast malignancies. Primary non-Hodgkin's lymphomas of the breast are extremely rare and represent approximately 0.38%-0.7% of all cases. Epstein-Barr virus (EBV) has been postulated to play an important role in the pathogenesis of Hodgkin's lymphoma. We present a case of EBV-positive primary Hodgkin's lymphoma of the breast. Although there is no sufficient data on this challenging diagnosis, it is known that it could be misdiagnosed with inflammatory breast carcinoma. A crucial part of the proper histopathologic diagnosis is immunohistochemistry. Different modalities of treatment include operative procedure, chemotherapy and radiotherapy. Recent studies suggest chemotherapy and radiotherapy to be initial treatment for patients with primary breast lymphomas.

THE ROLE OF JOHN THE BAPTIST LALANGUE IN THE DEVELOPMENT OF CROATIAN PUBLIC HEALTH AND MIDWIFERY IN THE CONTEXT OF IMPLEMENTATION OF THE IMPERIAL PUBLIC HEALTH LAW FROM 1770.

To understand the development of public health in Croatia, there are newer insights into the life and work of John the Baptist Lalangue. John the Baptist Lalangue is most valued for implementation of the imperial law on public health and promotion of midwifery in Croatia during the second half of the 18th century. Lalangue is the author of the first printed medical textbook in Croatian, published in 1776, entitled Medicina ruralis iliti Vrachtva ladanyszka, za potrebochu musev, y sziromakov Horvatczkoga orszaga y okolu nyega, blisnesseh mest, Trattnern, Varazdin. In the same period, Lalangue published the first Croatian midwifery textbook entitled Brevis institute de reobstetritia iliti kratek navuk od mestrie pupkorezne za potrebochu muskeh y sziromaskeh ladanovskaya horvatskoga orszaga y okolo nyega blisnesseh sztrankih, Trattnern, Zagreb. In 1779, Lalangue published his balneological debut in Croatian, the book Tractatus de aquis medicati Regnorum Croatiae et Slavoniae Iliti Izpiszavanye vrachtvenih vod Horvatzkoga y Slavonskoga orszaga y od nachina nye vsivati za potrebochu lyudih, Trattnern, Zagreb. Lalangue's works were used in systematic training and education of midwives and they, as well as Lalangue, have an inevitable place in the history of Croatian midwifery. During his life and work, John the Baptist Lalangue made immeasurable contribution to the development of Croatian public health.

Coexistence of Condylomata Acuminata with Warty Squamous Cell Carcinoma and Squamous Cell Carcinoma.

INTRODUCTION: Condyloma acuminatum has previously been considered to be a benign growth with no malignant potential, but a review of the literature supports the concept that condylomata acuminata may precede or be associated with invasive squamous cell carcinoma (ISCC) or warty squamous cell carcinoma (WSCC). CASE REPORT: We present a clinical case of a 58-year old woman with large, slow-growing, exophytic tumor of external genitalia shaped like a cauliflower with the propagation to both legs and behind. We performed multiple biopsies to detect potential malignancy but malignancy was not confirmed histologically. The presence of HPV (human papilloma virus) low and high risk was discovered. Inguinal lymph nodes were enlarged both sides, but cytologic examination identified no malignant cells. The patient was initially treated by the loop electro surgical excision procedure (LEEP) and podophilin solution on the rest of the condylomas. Condyloma acuminatum was confirmed histologically. Later, we performed a wide surgical excision of the rest of the condylomas. The new changes on the previously treated region were removed using LEEP. WSCC and ISCC were confirmed histologically so were radical vulvectomy and inguinal lymphadenectomy performed. The patient was advised to remain under close follow-up.

The Infraorbital Artery in Fetuses: Clinical Relevance in Perforator Flap Surgery.

INTRODUCTION: The reconstruction of soft tissue detects in mid facial region are highly demanding. Most challenging region are nasal alla. For full thickness nasal alla defects most authors use nasolabial flap based on facial/angular arcade, but for recidivans tumors the infraorbital perforator flap is a good solution. AIM: The aim of our research was to analyze the number and the course of the infraorbital artery terminal branches. MATERIAL AND METHODS: Material was 60 fetal hemifacial specimens of different gestational ages. Fetuses were fixed in 10% formalin and arterial blood vessels were injected with Micropaque solution (barium sulfate). Samples were further processed by Spalteholz technique, their images captured with digital camera and analyzed. Infraorbital artery was constant artery and had 2 to 4 terminal branches supplying infraorbital region. The majority of its terminal branches were characterized with descending course. Reach anatomical network of infraorbital artery made anastomoses with facial artery. CONCLUSION: Perforator flap based on infraorbital artery had well defined vascular supply with numerous soft tissue branches, which qualify this flap as safe solution for nasal reconstruction.

Repeated administration of inhibitors for ion pumps reduce markedly tumor growth in vivo.

INTRODUCTION: Measurements of extracellular pH show that the micro environment of malignant tumors is more acidic than that of normal cells, whereas pH does not differ appreciable in normal and malignant cells. The acid micro environment of tumors is created by the secretion of tumor factors and ATP hydrolysis in hypoxic tumor tissue. In order to survive in a low pH-environment tumor cells develop regulatory mechanisms which keep their intracellular pH stable. Two of the most important systems are the Na+/H+ ion pump and the Na-dependent HCO3-/Cl- pump of stilbenian derivatives. MATERIAL AND METHODS: Experiments were carried out on DBA mice of both sexes at the age of 4 month. Laboratory animals were grown in our institute and supplied with food and aqua ad libitum. RESULTS: After termination of the experiments the mean tumor diameter in the control group was 12.4 +/- 0.8mm, in group A it was 6.9 +/- 0.6mm, and in group B we measured 6.6 +/- 3.1mm. At the final day the tumor size in treated animals was twice as small as in the control group. In addition we observed the rate of survival. In the control group only 18% of the animals were still alive at day 18. Considering the rate of survival a statistically significant difference between treated and untreated animals was observed. The survival of tumor cells is dependent on the function of these ion pumps which keep their intracellular pH values constant in the setting of an acid extracellular environment. CONCLUSION: The activity of the ion pump is especially important at the beginning of cell division and in cell proliferation. Our in vivo experiments demonstrate that prolonged administration of intratumoral ion pump inhibitors suppresses tumor growth as well as enhances survival of tumor-bearing animals. Research of inhibitors of ion pumps and their action in tumor growth opens new perspectives into pathophysiology of malignant tumors and may create new therapeutic options.

painDETECT questionnaire and lumbar epidural steroid injection for chronic radiculopathy.

BACKGROUND: The painDETECT questionnaire (PD-Q) is a fast and uncomplicated way to ascertain the percentage of neuropathic pain in 'total pain' and is designed to detect neuropathic pain components in back pain. The purpose of this randomized, prospective study is to compare, with the assessment of the PD-Q, the efficacy of interlaminar (IL) and transforaminal (TF) steroid injections in patients with unilateral chronic lumbar radicular pain. METHODS: Patients were treated fluoroscopically with epidural steroids, using the IL or TF method and with confirmation of the epidural space by contrast, using random computerized classification. The patients received a series of three IL or TF epidural steroid injections (ESI) at 2-week intervals. The patients were monitored for 6 months from the first steroid injection. RESULTS: By analyzing the average values of the total sum of points in the PD-Q a dropping trend is confirmed for both groups. The trend equation (y = -1.1393x + 25.269) for the TF ESI shows a faster recovery than the IL ESI (y = -0.8089x + 26.654). The statistically significant difference in the two groups is proved between the first and the sixth visit (IL ESI, p = 0.014; TF ESI, p = 0.001). There is no statistically significant difference in the efficiency of the two dosages and the volumes of steroids between the IL and TF distribution of steroids. CONCLUSIONS: Steroids are efficient; besides alleviating the overall pain, they also reduce the neuropathic component in chronic lumbar radicular pain, whether it is distributed epidurally by the IL or TF approach.

Pregnancy and vaginal delivery in epidural analgesia in woman with cerebrospinal fluid shunt.

Hydrocephalus is a medical condition characterized by enlargement of cerebral ventricles due to abnormal cerebrospinal fluid accumulation. Hydrocephalic women with cerebrospinal fluid (CSF) shunts are now surviving to reproductive age, but still there are doubts regarding the mode of delivery, analgesia and anesthesia. Postpartal complications are more frequently described in deliveries ended by cesarean section than in spontaneous vaginal deliveries. We present a case of labor in the 32-year old woman, with congenital hydrocephalus and a preexisting ventriculoperitoneal (VP) shunt. After thorough review of current literature, we came to conclusion that without absolute neurosurgical indication or acute development of listed symptoms (headaches, irritability, light sensitivity, hyperesthesia nausea, vomiting, vertigo, migraines, seizures, weakness in the arms or legs, strabismus and double vision) the best way to finish the pregnancy of woman with VP shunt is spontaneous vaginal delivery with the use of epidural analgesia, mediolateral episiotomy and vacuum extraction.

Single stage turn in perforator infraorbital artery island flap for nasal ala reconstruction.

BACKGROUND: The reconstruction of fullthickness nasal alla defects is challenging procedure. Use of local flaps is acceptable approach. Flap based on infraorbital artery could be used for primary reconstruction of nasal ala defects. METHODS: The prospective study include consecutive series of 15 patients with advanced skin carcinoma of the nasal ala and medial cheek staged T4 by TNM, in whom the turn in infraorbital flap was used. The patient characteristics, type of carcinoma and complications were analyzed. RESULTS: The turn in infraorbital flap was used mostly in male patients (80%), mean age 64 years. The basal cell skin carcinoma was found in 60%. Skin layer was skin grafted. All flaps survived, but in one case a partial wound dehiscence in one partial skin graft loss was found, and in two patients partial nasal obstruction occurred. These three complications were solved as secondary procedures under local anesthesia. CONCLUSION: Full-thickness defect of the nasal ala can be properly reconstructed using flap based on infraorbital artery providing exceptional esthetic and functional results, as single stage procedure.

New Views on Cesarean Section, its Possible Complications and Long-Term Consequences for Children's Health.

Historical developments and advancements in cesarean section techniques and logistics have reduced the maternal and neonatal risks associated with the procedure, while increasing the number of operatively completed pregnancies for medically unjustifiable reasons. The uncritical attitude towards cesarean section and the fast emergence of 'modern' diseases such as obesity at a young age, asthma, type 1 diabetes mellitus and various forms of dermatitis have stimulated researches associating cesarean section with these diseases. Intestinal flora of the children born by cesarean section contains less bifidobacteria, i.e. their intestinal flora is similar to the intestinal flora in diabetic individuals. In children born by cesarean section, the 'good' maternal bacterial that are normally found in the maternal birth canal and rectum are lacking, while the 'bad' bacteria that may endanger the child's immune system are frequently present. In children born by vaginal delivery, the 'good' maternal bacteria stimulate the newborn's white blood cells and other components of the immune system, which has been taken as a basis for the hypotheses explaining the evident association of the above morbidities and delivery by cesarean section.

Spinal Dexamethasone Effect on Cognitive Disorders After Hip Surgery.

Background: Proximal femoral fractures (PrFF) are one of the most common causes of emergency admission in the elderly population. The majority of patients have pre-existing conditions that get worsened by unplanned surgery. Objective: Purpose of this article was to evaluate if a is single shot of dexamethasone with levobupivacaine administered intrathecally reduces postoperative pain and cognitive complications in patients with proximal femoral fractures. Methods: The study was performed at a level II trauma center which is a part of a teaching hospital with a catchment population of around 300,000 patients, the first author's affiliation. Around 500 PrFF are performed yearly in the center. All participants gave oral and written informed consent before randomization. Results: In total, 60 patients with a PrFF, ASA status 2 or 3 were randomized into two groups for spinal anaesthesia as DLSA study group (received 8 mg of dexamethasone and 12.5 mg of 0.5 % levobupivacaine) or LSA control group (received 12.5 mg of 0,5 % levobupivacaine). Postoperative cognitive disturbance was evaluated using simplified Confusion Assessment Method (CAM) scale, pain intensity was measured using Visual Analogue Scale (VAS) and blood samples for defining cortisol concentrations were taken before and after the surgical procedure. The primary outcomes were effects of intrathecal dexamethasone on plasma cortisol affecting cognitive disturbances. Secondary outcomes included pain scores and length of hospital stay. The DLSA group demonstrated a reduced incidence of postoperative cognitive dysfunction (POCD), p=0.043, longer analgesia duration, p<0.001, decreased cortisol levels and shorter hospitalization p=0.045. Intrathecal dexamethasone was the only significant predictor of postoperative delirium, OR 7.76, p=0.019. Conclusion: Single shot intrathecal administration of dexamethasone with levobupivacaine used in anaesthesia for proximal femoral fractures reduces the stress response by decreasing plasma cortisol concentrations prolonging analgesia. Complications such as delirium and POCD occurred with significantly lower frequency allowing better postoperative rehabilitation and shortening the hospitalization.

Comparing two techniques of panretinal photocoagulation on visual acuity on patients with proliferative diabetic retinopathy.

We wanted to examine which of two panretinal photocoagulation (PRP) techniques, classical panretinal photocoagulation (CPRP) and modifield peripheral panretinal photocoagulation PPRP), causes less decline of visual acuity (VA) due to macular edema (ME) in patients with proliferative diabetic retinopathy (PRD). This clinical study includes 180 eyes with PDR with initial papillar neovascularization. The patients were divided into two groups according the RP. PPRP and CPRP showed the decline of VA in all patients, more pronounced in the CPRP group after one week. After three and six months, with CPRP and PPRP the values of VA was stabilized. The result suggests that eyes with PDR and starting epipapillar neovascularisation should be treated with PPRP with priority given to CPRP because it caused better VA.

Fournier gangrene: our approach and patients.

AIM: This retrospective analysis presents our experience in treating Fournier gangrene (FG) and aims to bring in focus diagnostic and therapeutic problems as well as early and aggressive treatment. PATIENTS AND METHODS: A total of 16 male patients were included in the study. The gastrointestinal form was seen in 5 and the urogenital form in 11 patients. The subjects ranged in age from 39 to 74 years (average 61) for the urogenital, and from 48 to 72 (average 58) for the gastrointestinal form. Other conditions were seen in 9 patients (diabetes mellitus was most common). Most patients were infected with several bacteria. We performed colostomy in 1 patient, orchidectomy in 2 patients, cystostomy in 2 patients and penis amputation in 1 patient. Ultrasound-guided biopsy or aspiration, and CT was also used. Aggressive surgical necrectomy and aggressive antimicrobial therapy was used. RESULTS: Treatment was successful in 14 of 16 patients (87.5%). The length of hospitalization was 19-58 days (average 48) for the urogenital form and 24-56 days (average 41) for the gastrointestinal form. Mortality was 12.5%. A lethal outcome was recorded in two patients infected with methicillin-resistant Staphylococcus aureus. The average time between onset and hospitalization was 3-11 days (5 on average) for urogenital FG and 4-10 days (average 6) for gastrointestinal FG. Treatment was significantly longer in patients with a comorbidity, such as diabetes or liver cirrhosis due to alcohol abuse. CONCLUSION: Early diagnosis as well as intensive and aggressive treatment are key to successful treatment of FG. Comorbidity increases length of therapy and lowers the chance for recovery. Disease can be seen again several years after the initial outburst.

Microdochectomy in the management of pathologic nipple discharge.

BACKGROUND: There is a debate in the literature whether a pathologic nipple discharge is a distinct sign of breast carcinoma. Our own results obtained by the use of microdochectomy as a minimally invasive operative procedure in 184 patients with pathologic nipple discharge were analysed. The aim of this retrospective 20-year study was to assess the efficacy of microdochectomy in detecting early stages of intraductal breast carcinoma. PATIENTS AND METHODS: The study included data on 184 patients aged 24-77 years (median 46.6) divided into two groups of premenopausal (n = 123) and postmenopausal (n = 61) women. There were 139 patients with unilateral single-duct sanguinolent discharge and 45 patients with other types of nipple discharge. The operative procedure consisted of the discharging duct excision by use of a guide probe, preceded by cytology and ductography studies. RESULTS: Histopathology of the excised ducts revealed only three carcinomas in premenopausal women and ten carcinomas in postmenopausal women. In a total of 13 carcinomas, there were 4 ductal carcinomas in situ, detected in patients aged 41-72 (median 66) years. Twelve carcinomas were associated with sanguinolent nipple discharge. Papilloma was the most common histology finding (56.5%). CONCLUSION: Results of the study suggested mainly the association of sanguinolent single-duct nipple discharge and papilloma, whereas the rate of malignancies detected (7.0%) was consistent with literature reports. Microdochectomy proved to be a highly efficient operative method free from any impairment of the breast integrity. Conservative treatment with close clinical monitoring of the patient with cytology and ultrasonographic assessment might be possible in selected cases.