Predicting no-reflow phenomenon prior to primary percutaneous coronary intervention using a novel probability risk score derived from clinical and angiographic parameters.

OBJECTIVE: We aimed to create a clinically usable probability risk score for prediction of no-reflow (NRF) phenomenon prior to primary percutaneous coronary intervention (PPCI). PATIENTS AND METHODS: This single-center and retrospective study included 1254 patients with acute ST-segment elevation myocardial infarction (STEMI) who underwent PPCI. Patients were randomly assigned into two groups in the ratio 2:1, the derivation dataset (n=840) and validation dataset (n=414). Independent predictors of NRF were identified and combined to create a prediction model using univariate and multivariate regression analysis in the derivation dataset. The risk score was tested and validated by calculating area under the receiver operating characteristic (ROC) curves in the derivation and validation datasets, respectively. RESULTS: Five significant, independent predictors of NRF were identified: age ≥ 65 years (odds ratio [OR]: 2.473, 95% confidence interval [CI]: 0.389-1.484, p < 0.01), heart rate ≥ 89 bpm (odds ratio [OR]: 1.622, 95% confidence interval [CI]: 0.024-0.945, p < 0.05), Killip class ≥ II (odds ratio [OR]: 1.914, 95% confidence interval [CI]: 0.024-1.306, p < 0.01), total ischemic time ≥ 268 min (odds ratio [OR]: 2.652, 95% confidence interval [CI]: 0.493-1.565, p < 0.01), and thrombus burden G≥4 (odds ratio [OR]: 8.351, 95% confidence interval [CI]: 0.344-15.901, p < 0.01). The risk score was created combining these predictors with assigned points. The overall score ranged from 0 to 17 points. The optimal cutoff value of the risk score was 11 points (area under curve [AUC]: 0.772, 95% confidence interval [CI]: 0.729-0.815, sensitivity 71.21%, specificity 70.34%, positive predictive value 30.92%, negative predictive value 92.91%, p < 0.001). The ROC curve for the validation group showed good discriminant power. CONCLUSIONS: We developed a novel risk score based on five clinical and angiographic parameters, which might be a useful clinical tool for prediction of NRF in STEMI patients prior to PPCI with an acceptable accuracy.

On aging and aged care in Serbia.

Serbia is a demographically old nation, with 17.4 % of its residents being aged 65 years and older in 2011. The previous two decades of turbulent history have significantly affected the demographic picture of this country, and their ramifications remain visible in Serbia's economic, political, cultural, and health spheres. Major demographic forces behind population aging in Serbia can be attributed to lower fertility rates, migrations, and declining mortality (reflecting improvements in overall health leading to a longer life expectancy). In Serbia, low fertility and migrations appear to play major roles, although the relative contribution of recent migrations cannot be measured with accuracy. Patterns of demographic aging vary considerably across different geographic, socioeconomic, and cultural settings. The common denominator throughout present day Serbia is extensive political and economic transition. One would expect that, given sufficient time, this process will result in improved population health, and yet, at this stage outcomes of major health care reform in Serbia are somewhat perplexing. For the second consecutive year, Serbia's health care system has been ranked at the very bottom of the scale among 34 European countries. It is then no surprise that the elderly represent particularly vulnerable population segment. This paper discusses some of the issues relevant to these demographic patterns of aging and aged care in contemporary Serbia, focusing on the period after 2000.

Monitoring of trace element atmospheric deposition using dry and wet moss bags: accumulation capacity versus exposure time.

To clarify the peculiarities of trace element accumulation in moss bags technique (active biomonitoring), samples of the moss Sphagnum girgensohnii Rusow were exposed in bags with and without irrigation for 15 days up to 5 months consequently in the semi-urban area of Belgrade (Serbia) starting from July 2007. The accumulation capacity for 49 elements determined by ICP-MS in wet and dry moss bags was compared. The concentration of some elements, i.e. Al, V, Cr, Fe, Zn, As, Se, Sr, Pb, and Sm increased continuously with exposure time in both dry and wet moss bags, whereas concentration of Na, Cl, K, Mn, Rb, Cs, and Ta decreased. Irrigation of moss resulted in a higher accumulation capacity for most of the elements, especially for Cr, Zn, As, Se, Br, and Sr. Principal component analysis was performed on the datasets of element concentrations in wet and dry moss bags for source identification. Results of the factor analysis were similar but not identical in the two cases due to possible differences in element accumulation mechanisms.

Active moss biomonitoring of trace elements with Sphagnum girgensohnii moss bags in relation to atmospheric bulk deposition in Belgrade, Serbia.

Active biomonitoring with wet and dry moss bags was used to examine trace element atmospheric deposition in the urban area of Belgrade. The element accumulation capability of Sphagnum girgensohnii Russow was tested in relation to atmospheric bulk deposition. Moss bags were mounted for five 3-month periods (July 2005-October 2006) at three representative urban sites. For the same period monthly bulk atmospheric deposition samples were collected. The concentrations of Al, V, Cr, Mn, Fe, Ni, Cu, Zn, As, Cd, and Pb were determined by instrumental neutron activation analyses and atomic absorption spectrometry. Significant accumulation of most elements occurred in the exposed moss bags compared with the initial moss content. High correlations between the elements in moss and bulk deposits were found for V, Cu, As, and Ni. The enrichment factors of the elements for both types of monitor followed the same pattern at the corresponding sites.

Modern treatment of invasive carcinoma of the uterine cervix.

Treatment of invasive cervical carcinoma is determined by the clinical disease stage. Microinvasive carcinoma of the uterine cervix, due to its limited metastatic potential, is usually curable with non-radical treatment. There are no standard approaches to the treatment of stage Ib-IIa carcinoma of the uterine cervix. Both radical surgery and radical radiotherapy are utilized with similar efficacy but with different associated morbidity and complications. Stage Ib1 was commonly treated with radical hysterectomy plus pelvic lymphadenectomy. Laparoscopically-assisted radical vaginal hysterectomy demonstrated similar efficacy and recurrence rates for this disease stage. In cases where fertility is to be preserved, radical vaginal trachelectomy is a valid option for small cervical cancers. Among the papers dealing with bulky cervical disease (stages Ib-IIa) a great deal of disagreement is evident. Some oncologic centres prefer primary surgery with postoperative radiotherapy, with or without chemotherapy, while others prefer primary chemoradiotherapy. Moreover, as a possible alternative, neoadjuvant chemotherapy followed by radical surgery is recommended for stage Ib2 disease. Simultaneous chemoradiation is being introduced as a new standard for advanced cancer, since it has been clearly demonstrated that it can prolong disease-free and overall survival. The treatment of recurrent carcinoma depends on the type of previous treatment, site and extent of recurrent disease, and on the disease-free period and general health of the patient. In conclusion, the decision on the treatment approach for invasive carcinoma of the uterine cervix should be individualized, based on numerous factors, such as disease stage, general health of the patient, cancer-related factors, in order to choose the best approach with minimal complications.

Contribution to biomonitoring of some trace metals by deciduous tree leaves in urban areas.

Leaves of the deciduous tree species, horse chestnut (Aesculus hippocastanum L.) and Turkish hazel (Corylus colurna L.) were used as accumulative biomonitors of trace metal pollution in the urban area of Belgrade. Using differential pulse anodic stripping voltametry, trace metal concentrations (Pb, Cu, Zn, Cd) were determined at the single leaf level (ten leaves per species, per month), during two successive years with markedly different atmospheric level of trace metals. Increased trace metal concentrations in the leaves of A. hippocastanum reflected elevated atmospheric trace metal pollution, whereas C. colurna L. did not respond accordingly. The contents of Pb and Zn in soil over the same period also followed this trend. Anatomical analyses, in young as well as in old leaves of both species, indicated typical foliar injuries of plants exposed to stressful air conditions. Water relations that correspond to leaf age may have contributed to the considerable trace metal accumulation in leaves.

The relationship between alcohol elimination rate and increasing blood alcohol concentration--calculated from two consecutive blood specimens.

In the period 1991-2005, a blood-alcohol concentration (BAC) analysis was carried out at the Institute of forensic medicine in Novi Sad including 2023 two consecutive blood specimens using the Headspace Gas Chromatography method. Cases with no alcohol concentration values, as well as cases where blood samples were taken within 1 h after the criminal act, were not taken into consideration. Following this rule, 1198 cases were considered in this study and all samples were grouped in 29 ranges of BAC1 of delta(BAC) = 0.1 g/kg, starting from 0.1-0.19 g/kg to 2.9-2.99 g/kg of absolute alcohol. Gathered results and elimination curve differ from the zero-order model of elimination proposed by Widmark and point to an elimination process similar to a well-known Michaelis-Menten elimination kinetics model and its variants. Results reported in this study show dependence of alcohol elimination rate (beta-slope) and BAC value. The analysis of beta60-slope versus BAC shows that a correlation between beta60 (y) and BAC (x) has a logarithmic trend line. The value of alcohol elimination rate shows a slight increment with increase of BAC alcohol, with the mean value of beta60 = 0.221 +/- 0.075 g/kg. Differences in values of beta60 among consecutive intervals of delta(BAC) = 0.1 g/kg are not significant (p>0.05). When obtained samples were grouped into ranges of 0.5 g/kg each in these intervals beta60 had the following values by range: 0.1-0.49 g/kg = 0.139 g/kg +/- 0.035; 0.5-0.99 g/kg = 0.184 g/kg +/- 0.043; 1-1.49 g/kg = 0.213 g/kg +/- 0.052; 1.5-1.99 g/kg = 0.239 g/kg +/- 0.058; 2-2.49 g/kg = 0.265 g/kg +/- 0.073; 2.5-2.99 g/kg = 0.306 g/kg +/- 0.096. Differences in values of beta slope among consecutive intervals of delta(BAC) = 0.5 g/kg are significant (p<0.01). The elimination curve in the BAC interval 0.5-2.5 g/kg has a linear trend, while beta-slope (y)/BAC (x) correlation is given as beta60 = 0.15 g/kg + (0.05 g/kg x BAC). Retrograde calculation of the blood alcohol concentration in tempore criminis (BAC(tc)) based on the determined alcohol concentration in the blood specimen (BAC(t)) shows a statistically significant difference between BAC(tc) calculated using a standard zero-order model versus corrected methodology. The higher the BAC(t) and the longer the calculation time, the greater and statistically more significant (p<0.01) is the difference between the calculated values of BAC(tc).

Characterization of trace metal particles deposited on some deciduous tree leaves in an urban area.

In 1996 and 1997 horse chestnut (Aesculus hippocastanum L.) and Turkish hazel (Corulys colurna L.) leaves were sampled at 2 m height in the Belgrade Botanic Garden, located in an urban area with heavy traffic. Using a scanning electron microscope with an energy dispersive X-ray spectroscopy (SEM-EDAX), the size, size distribution, morphology and chemical composition of individual particles were examined on the adaxial and abaxial surfaces of leaf discs of both species. The majority of particles observed on leaves belonged to a class of fine particles (D < 2 microm). Morphological and chemical composition indicated that the most abundant particles were soot and dust with minor constituents such as Pb, Zn, Ni, V, Cd, Ti, As and Cu. Using an electrochemical technique (DPASV), it was possible to measure trace metal concentrations (Pb, Cu, Zn) in a water-soluble fraction of deposits on each single leaf. Trace metal contents in the leaf deposits, increased during the vegetation period for both species and were considerably higher in A. hippocastanum due to different epidermal characteristics. The higher trace metal concentrations in deposits in 1997 reflected greater atmospheric pollution in the Belgrade urban area.

HELLP syndrome as a cause of unexpected rapid maternal death--a case report and review of the literature.

Unexpected rapid death after delivery due to HELLP syndrome (HS) may become the subject of a forensic expertise. Since this syndrome is rarely encountered in forensic pathology, our objective was to point to some specific findings which might present forensic aspects of HS. These include unexpectedness, suddenness and fulminant course of this syndrome, which may confuse physicians, and on the other hand these characteristics cast doubt on violent injury, diagnostic oversights or iatrogenic injuries. Absence of classical signs of preeclampsia and non-specific clinical symptoms cause considerable differential diagnostic problems leading to a diagnostic delay or initial wrong non-obstetric diagnosis. A definitive postmortem diagnosis of HS in questionable cases of maternal death and consecutive forensic expertise of suspected medical malpractice should be based on accepted laboratory criteria and characteristic histopathological alterations.

"Cognac alibi" as a drunk-driving defense and medico-legal challenge.

Some drivers with positive forensic ethanol analyses, offer an explanation that they consumed alcohol a short time before a traffic accident or after driving. In medico legal practice this is commonly known as hip-flask defense, but to us as "cognac alibi" defense. In these cases, the lawyers require the medico legal experts to offer as much information as possible so that the court may come to the most reliable conclusions about the driver's blood alcohol concentration at the moment of the traffic accident (BAC(Acc)). At the Institute of Forensic Medicine our own analytical approach was established to study this medico legal problem. It consists of three inter-related phases in which it combines the obtained BAC values, with testimonies of the drunk driving suspect andalso witnesses. A specific algorithm was designed for calculating absorption and elimination of consumed alcohol. All the above-mentioned elements and blood-ethanol values calculated according to Widmark's method were inserted into appropriate cells of MS Excel software in order to calculate BAC in the function of time. The result is a relevant analysis of the drunk driving suspect's BAC in 5-minute intervals, as well as a graphic representation in chart form.

Allele frequencies of the 15 AmpF lSTR Identifiler loci in the population of Vojvodina Province, Serbia and Montenegro.

The 15 AmpF lSTR Identifiler loci (D8S1179, D21S11, D7S820, CSF1PO, D3S1358, TH01, D13S317, D16S539, D2S1338, D19S433, VWA, TPOX, D18S51, D5S818 and FGA) were analyzed in the sample of 100 unrelated, autochthonous healthy adult Serbians from Novi Sad (Vojvodina Province, Serbia and Montenegro). The agreement with HWE was confirmed for all loci with the exception of D7S820 (based on the chi2-test only). The combined power of discrimination (PD) and the combined power of exclusion (PE) for the 15 tested STR loci were 0.99999999999999995 and 0.9999990, respectively. According to the presented data, D2S1338 and D18S51 are the most informative markers. Based on allelic frequencies and statistical parameters for forensic testing, it may be suggested that the AmpF lSTR Identifiler detection system represents a powerful strategy for individual identification and parentage analysis in the Serbian population.

Fractal analysis of STM images of photochemical polymer of coniferyl alcohol.

Fractal analysis was applied to images of photochemical lignin polymer obtained using scanning tunneling microscope. We studied the polymer obtained in vitro by ionic mechanism through UV radiation--induced polymerization. The analysis showed the regularity of the lignin-like polymer at different levels of organization. At the 95% confidence level, there was no significant difference in the fractal dimension between images representing different organizational levels of photochemical lignin. That means that lignin produced in in vitro conditions by photochemical mechanism of synthesis, has a fractal structural organization. The obtained values of the fractal dimension are in good agreement with the theoretically predicted value for the polyaddition and polycondensation mechanism of polymerization, known as the bulk model.

Unusual cases of suicide among health care workers.

We describe three unusual cases of suicide committed by health care workers. The aim of this paper was to analyze and evaluate the evidence of general diagnostic elements of poisoning in these cases.

Fractal analysis of STM images of lignin polymer obtained by in vitro synthesis.

Lignin, the structural polymer of the plant cell walls, is produced by free radical polymerization of phenolic alcohols, catalyzed by different peroxidases. The mechanism and the structural organization of lignin in the cell have not been completely understood. In this study we applied fractal analysis to images of lignin polymer obtained using scanning tunneling microscope. The analysis showed the regularity of the polymer at different levels of organization. According to the results obtained, at the 95% confidence level, there is no significant difference in the fractal dimension between images representing different organizational levels of lignin. In other words, lignin produced in in vitro conditions has fractal structural organization and, consequently the polymer can be expected to be regular in in vivo conditions. The value of the fractal dimension 1.929 +/- 0.021 is in good agreement with the theoretically predicted value for polyaddition and polycondensation mechanism of polymerization. The mechanism of in vivo lignin synthesis is discussed in terms of various experimental and theoretical evidences. In this paper, we could show that fractal analysis of the lignin polymer is a useful complementary approach to the experimental data collection in structural and phenomenological studies.

Brain trauma: cause-consequence connection problems.

Despite sophisticated equipment like computerized tomography, in some cases doctors have a problem with the diagnostic procedure in relation to patients with serious injuries of the central nervous system (CNS). There may be no clinical signs of disorders of the CNS, or other evidence of difficulties, but diffuse axonal lesions and demyelinisation processes often exist. This type of lesion is a special pathomorphological entity, known as the syndrome of patient who talks and dies. Macroscopical and microscopical findings are poor and rare, especially in the hours immediately following the injury. The main findings are not evidential and the problem is the explanation of sudden death from unknown causes. The following studies are based on human tissue analyses. They are based on the analyses of the CNS of patients who suffered from brain trauma. The specimens from the brain stem were taken in order to perform histological, microscopic analysis. Percentage value of surface of myelin for the control group was X1 38.62% for HE technique and X1 33.46% for Gomory's method. The value for the test group was X2 16.12% for HE technique and X2 13% for Gomory's technique. Statistical probability for both groups was 95% (P < 0.05; T = 14.9). Application of these procedures helps legal authorities to make trials more objective.

[Analysis of ischemic lesions of the liver after various periods of warm and cold ischemia]. / Analiza ishemijskih lezija jetre u razlicitim intervalima tople i hladne ishemije.

Liver and sinusoidal wall cells become swollen very fast due to ischemia in liver allograft, with Eurocollins preservation solution. This process consequently narrows the sinusoidal lumen and significantly disturbs the "functional structure" of Rapaport microcirculation units. Advanced changes on "functional structure" microcirculation liver units can cause outflow block phenomenon of the liver and a consequential primary graft dysfunction. In order to avoid this unfavorable consequence of transplantation, it is necessary to assess the potential allograft vitality in advance. The assessment can be based on measuring values of sinusoidal volume, increase of the serum glutaminpyruvic transaminaze (SGPT) level per mass unit of liver tissue in the preservation solution and increase of necrotizing hepatocytes' number in liver lobules. During the first 8 hours of cold ischemia these values do not change significantly, so we can conclude that in this interval of cold ischemia liver is suitable for transplantation, which is not the case with warm ischemia where changes occur much earlier. Practically, the intensity of lesions with 4 hour period of warm ischemia equals the intensity of lesions with 16 hour period of cold ischemia.

[Digitalization of histological images as a method of quantifying the demyelinating process]. / Digitalizacija histoloske slike kao metoda za kvantifikaciju procesa demijelinizacije.

The basic aim of this paper was to check the hypothesis whether after head trauma the brain tissue looses myelinic membrane which surrounds the axon, and if this possibly established loss can be quantified, that is if it is possible to determine the degree of disintegration. One of the aims was to examine this method itself. The gathered results show that both the hypothesis and the aims were justified. It has been established that the diffuse axonal lesion in the examined samples reflects in a loss of axon's myelinic membrane. The loss was 50% greater in the test group in regard to the control group. To digitalize histologic pictures we have used Laser Scanner Densitometry Station and software by Biomed. In regard to medical jurisprudence, the laser scanner densitometry offers more relevant data in cases apparently unclear and in sudden deaths after head injuries. Application of this method and further investigations will be directed to further attempts to clear up connections between the mechanism of injury and degree of biologic response of the brain tissue.

[Morphologic characteristics of the liver allograft in experimental warm ischemia]. / Morfoloske karakteristike alografta jetre u eksperimentalnoj toploj ishemiji.

Thirty-minute normothermic liver ischemia causes swelling of the hepatocytes and sinusoid wall cells, their individual necrosis and discharge of the glycogen supply in the hepatocytes. The swelling of the hepatocytes and of the sinusoid wall cells causes a significant reduction of the liver lobe sinusoid volume which decreases from 27.6% to 5.4%, representing, actually, one fifth of the normal value. Such finding was recorded as a critical vascular liver volume, because any further decrease of the sinusoid volume would inevitably lead toward manifest and persisting portal hypertension which evidently interferes with Bernoulli trial of the hepatitic perfusion. The obtained data determine morphofunctional relevancy of the liver allograft for transplantation and are useful for all other surgical interventions requiring partial resection of this organ or time limited regional and total ischemia.

[Personal experience with segmental corporo-caudal allotransplantation of the pancreas in an experiment on dogs]. / Nasa iskustva segmentalne korporokaudalne alotransplantacije pankreasa u eksperimentu na psima.

In the Institute for Surgery, its Experimental Centre, has already several years an experimental transplantations of pancreas been carried out with the aim of learning surgery technique and performing a clinical transplantation of that organ. In our work we have used a technique of corporacaudal allotransplatation of pancreas with vascular anastomosis. As the blood vessels of the graft we have used the arteria and vena lienalis with parts of aorta and portal vein, which have been anastomosed with a. and v. iliaca communis of the pancretotomized recipient. We have used techniques of the open pancreatic duct, ligated pancreatic duct, our own technique of permanent bleeding of the pancreatic graft during the transplantation pancreaticojejunostomy and pancreatico-vesicular anastomosis. As the parameters of function of allograft we are using: glycaemia, i.v. GT test, K constant, insulinaemia, amylasaemia, length of survival of animals and pathohistological finding. The average term of survival of experimental animals was 28 days. During the function of alograft the experimental animals shown some signs of laboratory subclinical diabetes. Refusal of transplant was followed by sudden increase of glycaemia, without any clinical or laboratory sign of anticipation of the refusal.

[Experimental study of liver allograft damage during cold ischemia]. / Eksperimentalna istrazivanja ostecenja alografta jetre u toku hladne ishemije.

Changes on the majority of structural complexes were observed in livers that underwent the influence of the preservant and cold ischemia. Cellular architecture of a such liver is disturbed. Hepatocites are with granular and vacuolar degeneration: focal cariolyzes and piasmolyzes are present, partial destruction of cellular membrane is noticeable. The dilatation of sinusoidal spaces is very emphasized and followed by the severe loss of endothelium. These changes along with the disturbed cellular architecture represent the findings of Pelosis hepatis. It is important to emphasize the significance of changes observed on liver sinusoids and endothelium especially since their intensity is much greater than of those changes observed on parenchim. We assume that these angioarchitectural damages play an important role in the onset and development of cardiopulmonal and coagulopatic components of the postreperfusional syndrome. The fact that the postreperfusional syndrome was also observed in cases with heterotopic transplantation could support this assumption.