In sickness and in health: pivotal role of vitamin D.

Within the last several years, frequency of vitamin D testing has multiplied substantially all over the world, since it has been shown to have an important role in many diseases and conditions. Even though liquid chromatography - tandem mass spectrometry (LC-MS/MS) has been identified as "gold standard" method for vitamin D measurement, most laboratories still use immunochemistry methods. Besides analytical problems (hydrophobicity, low circulating concentrations, ability to bind to lipids, albumins and vitamin D binding protein, presence of multiple vitamin D metabolites and variable ratios of 25(OH)D2 and 25(OH)D3 in the blood), vitamin D shows great preanalytical variability, since its concentration is drastically influenced by seasonal changes, exposure to sun, type of clothes or sun block creams. Vitamin D is mostly measured in serum or plasma, but new studies are showing importance of measuring vitamin D in pleural effusions, breast milk, urine, synovial fluid and saliva. Besides the main role in calcium homeostasis and bone metabolism, many studies linked vitamin D deficiency with cancer, cardiovascular diseases, diabetes, fertility and many other conditions. However, even though initial observational studies indicated that supplementation with vitamin D might be beneficial in disease development and progression; first results of well-designed randomized controlled prospective studies did not find differences in frequency of cardiovascular events or invasive cancer between patients taking vitamin D supplementation compared to placebo. In the light of these recent findings, validity of excessive vitamin D testing remains an open question.

Third and Fourth Degree Perineal Tear in Four-Year Period at Sestre Milosrdnice University Hospital Center, Zagreb, Croatia.

OBJECTIVES: Obstetric anal sphincter injury (OASIS) includes the third and fourth degree of perineal injury. The risk for OASIS is about 1% of all vaginal deliveries. If not recognised and treated properly, obstetric anal sphincter injury can have serious consequences for reproductive age woman. MATERIAL AND METHODS: We have retrospectively gathered and analysed data on obstetric anal sphincter injury in a four-year period at our department. The control group in this study included vaginal deliveries in 2012. RESULTS: We recorded 0.34% third and fourth degree of perineal injury in all vaginal deliveries, and 87.9% of those patients were primiparae. Episiotomy was performed in 57.6% of all women with obstetric anal sphincter injury. In 30.3% of cases, newborns were large for gestational age. Gestational diabetes was found in 9.1% of OASIS cases, occipitoposterior position was found in 9.1% of cases. Induced labour took place in 39.4%, and oxytocin infusion was applied in 60.6% of OASIS cases. Vacuum extraction was performed in 12.1% of deliveries with OASIS. The average BMI in 3a and 3b injuries was 29.9. In 3c degree it was 28.0, and in the fourth degree, it was 32.1. In 27.0% of OASIS cases due to the extent of the injury surgeon engagement was necessary. When compared with vaginal deliveries in 2012 we found a significant increase in OASIS in primiparas, large for gestational age, occipitoposterior position, induced labour, vacuum extraction and hypertension (P < 0.01). There is also increased incidence of OASIS in episiotomy and oxytocin use group (P < 0.05). CONCLUSION: Low incidence of OASIS in our department is a result of active management of delivery, manual perineal protection and timely episiotomy.

Abdominal Wall Endometriosis Eleven Years After Cesarean Section: Case Report

Endometriosis is a common chronic disease characterized by growth of the endometrial gland and stroma outside the uterus. Symptoms affect physical, mental and social well-being. Extrapelvic location of endometriosis is very rare. Abdominal wall endometriosis occurs in 0.03%-2% of women with a previous cesarean section or other abdominopelvic operation. The leading symptoms are abdominal nodular mass, pain and cyclic symptomatology. The number of cesarean sections is increasing and so is the incidence of abdominal wall endometriosis as a potential complication of the procedure. There are cases of malignant transformation of abdominal wall endometriosis. Therefore, it is important to recognize this condition and treat it surgically. We report a case of a 37-year-old woman with abdominal wall endometriosis 11 years after cesarean section. She had low abdominal pain related to menstrual cycle, which intensified at the end of menstrual bleeding. A nodule painful to palpation was found in the medial part of previous Pfannenstiel incision. Ultrasound guided biopsy was performed and the diagnosis of endometriosis confirmed. Surgery is the treatment of choice for abdominal wall endometriosis. Excision with histologically proven free surgical margins of 1 cm is mandatory to prevent recurrence. A wide spectrum of mimicking conditions is the main reason for late diagnosis and treatment of abdominal wall endometriosis. In our case, the symptoms lasted for eight years and had intensified in the last six months prior to surgery.

Synergetic Effects of K, Ca, Cu and Zn in Human Semen in Relation to Parameters Indicative of Spontaneous Hyperactivation of Spermatozoa.

We have observed that sperm quality parameters indicative of spermatozoa hyperactivation such are lower "linearity" and "straightness", and as showed by this research "elongation", were more pronounced in patients with normal spermiogram compared to the group of men with reduced sperm motility who were undergoing routine in vitro fertilisation. The research encompassed 97 men diagnosed with normozoospermia (n = 20), asthenozoospermia (n = 54) and oligoasthenozoospermia (n = 23). The findings indicate that sperm quality of patients with normal spermiogram diagnosed according to WHO criteria, may be compromised by showing premature spontaneous hyperactivation which can decrease the chances of natural conception. We assessed synergistic effects of multiple chemical elements in ejaculated semen to find if premature spontaneous hyperactivation of spermatozoa can be a sign of imbalanced semen composition especially of elements K, Ca, Cu and Zn. Human semen samples showing low or high baseline status of chemical elements concentrations were found in samples from all three diagnostic groups. However, correlation of K/Ca and Cu/Zn ratios, taking into account samples from all three groups of men, were negative at statistical significance level p = 0.01. We tested if the negative correlation between K/Ca and Cu/Zn ratio works for greater number of semen samples. We found the negative correlation to be valid for 175 semen samples at statistical significance of p = 0.00002. The ratio of K/Ca and Cu/Zn, i.e. increased concentrations of K and Zn in comparison to concentrations of Ca and Cu, were associated with a decrease of "straightness" in the group of men with normal spermiogram and pronounced spontaneous hyperactivation of spermatozoa, implying that these elements act in synergy and that the balance of elements and not their absolute concentrations plays the major role in premature spermatozoa hyperactivation in ejaculated semen.

THE RISK OF HYPERCOAGULABILITY IN OVARIAN HYPERSTIMULATION SYNDROME.

Ovarian hyperstimulation syndrome (OHSS) is a rare and potentially life-threatening complication of infertility treatment occurring during either the luteal phase or early pregnancy. An increasing number of thromboembolic complications associated with the increased use of assisted reproductive techniques have been reported in the literature. Identification of the risk factors is crucial for prevention of thromboembolic events in OHSS patients. Alterations in the hemostatic system cause hypercoagulability in women affected by severe OHSS. Coexistence of inherited hypercoagulable conditions increases the risk of thromboembolism. The role of clinical parameters that can help predict development of thrombosis is controversial. Patients with a personal or family history of thrombosis undergoing infertility treatment should be considered for thrombophilia screening, while routine examination of inherited thrombophilic mutations is not indicated in infertile patients. Antithrombotic primary prevention is not indicated in healthy women undergoing assisted reproductive procedures or in women with thrombophilia. Anticoagulant therapy is indicted if there is clinical evidence of thrombosis or laboratory evidence of hypercoagulability. In this review, the risks of hypercoagulability in the OHSS are discussed.

Abdominal wall endometriosis: case report.

Abdominal wall endometriosis, also known as scar endometrioma, is a rare condition, in most cases occurring after previous cesarean section or pelvic surgery. The incidence of scar endometrioma is estimated to 0.03%-1.5% of all women with previous cesarean delivery. The predominant clinical picture is cyclic pain. Due to a wide range of mimicking conditions and a relative rarity, a significant delay is often observed from the onset of symptoms to proper treatment. We report on a case of a 36-year-old patient with scar endometrioma after two previous cesarean deliveries. The possible diagnostic pitfalls and treatment options are discussed.

The possibility of respiratory distress syndrome prevention of premature born children.

Pregnant women and premature born children were classified into four groups. In each group there were thirty of them. The first group included the pregnant women with premature rupture of membranes and amniotic fluid effluxed for 72 hours before the delivery. The second group included the pregnant women with amniotic fluid effluxing less then 72 hours before the delivery. The third group included the pregnant women who were given corticosteroids. The forth group was a control group formed by those pregnant women (and their premature born children) whose amniotic fluid did not efflux long and those who weren't given corticosteroids during pregnancy. In all groups of pregnant women we observed: median age of pregnant women, the duration of pregnancy and mode of delivery (vaginal or cesarean section). In groups of premature born children we also observed: newborn birth weight, Apgar score in the first minute after delivery, Apgar score in the fifth minute after delivery, pH of the blood of umbilical cord, L/S ratio of amniotic fluid (lecithin-sphingomyelin ratio), RDS (neonatologist valuation in any degree of RDS developed et newborn child). Symptoms of RDS include tachypnoea, chest wall retraction and cyanosis and a zground glass' appearance of the chest on X-ray. Histopatological examinations of placentas compared the frequency of inflammatory or noninflammatory changes, also in all groups. No significant difference was found among groups of pregnant women for the following factors: the age of pregnant women, the duration of pregnancy and mode of delivery. No significant difference was found among the groups of children for the following factors: newborn birth weight, Apgar score in the fifth minute after delivery, blood pH of umbilical cord, L/S ratio of amniotic fluid. Significant difference was found among groups for the following factors: Apgar score in the first minute after delivery, the frequency of RDS and hystology of placentas. The prevention of premature delivery is the most important. All the pregnant women with symptoms of the premature delivery must be transported to the centers with the well developed unites of intensive neonatal care ("transport in utero").

Biochemical screening of fetal aneuploidies and neural tube defects by "double-test" in Croatia: a 10 years' experience.

The aim of the study is to investigate the efficiency of the second-trimester biochemical screening, with maternal serum alpha-fetoprotein (MS-AFP) and free beta-subunit of human chorionic gonadotropin (free beta-hCG), during the ten-year period. The study included 11,292 of pregnant women between the 15th and 18th gestational week, who underwent screening from November 1996 to December 2006. The risk for trisomy 21 and trisomy 18 were calculated by computer software, based on a model which generated the final risk for fetal aneuploidies from the pregnant woman's a priori age risk and the likelihood ratio of the distribution of the biochemical markers, according to the second-trimester gestation. With the cut-off value of the final risk > or = 1:250, the detection rate for trisomy 21 was 75% (21/28). In women less than or equal to 35, the detection was 57.1% (8/14) and 92.9% (13/14) in those over 35 years, respectively. The detection rate of trisomy 18 was 50% (2/4). The results confirmed that the implementation of double-test, as non-invasive screening for fetal aneuploidies, should be accepted as a complementary method of antenatal care.

Cytologic follow-up in patients with CIN treated by LLETZ, Cold knife Conization and Semm's cold coagulation.

Management of cervical premalignant lesions starts with abnormal Pap smear. Regular screening of asymptomatic women (the Pap smear) allows us to diagnose and treat preinvasive lesions before they progress to cervical cancer. There is a wide variety of ablative and destructive methods used in treatment of cervical premalignant lesions. In this study we have compared follow-up cytology results in patient groups treated by LLETZ (Large Loop Excision of the Transformation Zone), Cold Knife Conization (CKC) and Semm's cold coagulation (Electrocoagulation, ECG) according to CIN on target biopsy specimen, and definite therapeutic approach according to patient age, parity and lesion grading. The aim was to evaluate therapeutic success in all three patient groups on the basis of control cytology findings. Normal cytology findings after treatment were recorded in 43 women in LLETZ group (88%), 22 women in CKC group (73%) and in 22 women from the Semm's cold coagulation group (73%). The importance of the use of diagnostic and therapeutic guidelines and regular follow up is emphasized, bearing in mind primarily the young female population with severe preinvasive lesions of uterine cervix. Treating cervical preinvasive lesions offers an excellent opportunity to prevent the occurrence of cervical cancer in the large majority of women with abnormal cervical smears.

Diagnostic approach for precancerous and early invasive cancerous lesions of the uterine cervix.

Invasive cervical cancer is second most common female cancer worldwide with about 493,000 new cases per year. About 273,000 women die from cervical cancer each year, 85% of which take place in developing countries. Cervical cancer has a slow progress, from pre-invasive cervical intraepithelial neoplasia (CIN) to invasive phases, meaning that the disease can be diagnosed while in the phase of pre-invasive lesion, and treated successfully thanks to the regular screening of asymptomatic women (the Pap smear). The authors review new possibilities of early detection of cervical cancer with emphasis on colposcopy. The role of colposcopy is discussed among possibilities of early diagnosis. The authors discuss additional diagnostic procedures for preinvasive lesions of the uterine cervix like DNA cytometry, (flow cytometry). This method can point to dysplasia which can progress to severe stages, such as HSIL (High grade Squamous Intraepithelial Lesion). If the level of chromosomal disturbance is higher (aneuploidy), it is more probable that HSIL will develop. Laser screening of cells extracted with modern cytologic screening LBC (Liquid Base Cytology) enables us to automatically measure ploidy (chromosome regularity, or irregularity) and PCR provides analysis of HPV types. These methods are recommended for a routine check-up of borderline cervical lesions in order to anticipate ones likely to regress or progress.

Trends, habits and attitudes towards suntanning.

Epidemiological studies suggest a relationship between suntanning habits and high risk of malignant melanoma (MM). The incidence of MM is increased during the last 40 years. Sun exposure is highly prevalent in all age groups, especially among young and it is influenced by certain believes and attitudes towards suntanning and stimulated by peer pressure and aesthetic references. What is the cause of higher incidence of MM? Is it only trend and attitudes towards suntanning? A prototype of a young female of 21st century is attractive, slim, with bronze complexion, dresses in the bathing suit, whereas the lady of the 19th is pale, dressed in white dress and with hat or sunshade that protects face and hair from the sun. When did social mores and medical knowledge about sun exposure change? A critical interplay occurred between the end of 19th century and the start of the 20th century with significant success of phototherapy and the growing popularity of sunbathing which reflected number of social changes. During the same time of invigoration of sun exposure, appeared the first reports about correlation between sunlight and skin cancer, but without significant repercussion on medical profession and therefore without knowledge of the public. The 1920s and 1930s were highlighted with the great discovery that ultraviolet wavelengths less than 313 nm played the role in vitamin D synthesis which prevents rickets. Numerous other medical benefits were soon attributed to the sunlight. Finally, the cancerogenity of UV light came to attention when scientist succeeded in induction of skin cancer in rodents after UV light exposure. The etiology of sunlight in development of skin cancer was mentioned in scientific articles and public magazines in 1940s and 1950s. Over the decades the message that sunlight exposure leads to increased risk of skin cancer, reach the public. But despite the knowledge, even at present people believe that tan person looks healthier. Additional and continuous educational campaigns are needed for changing people's behavior.

Chloasma--the mask of pregnancy.

Chloasma is a required hypermelanosis of sun-exposed areas occurred during pregnancy and it can affect 50-70% of pregnant women. It presents as symmetric hyperpigmented macules, which can confluent or punctuate. The most common locations are the cheeks, the upper lip, the chin and the forehead. The exact mechanism by which pregnancy affects the process of melanogenesis is unknown. Estrogen, progesterone, and melanocyte-stimulating hormone (MSH) levels are normally increased during the third trimester of pregnancy. However, nulliparous patients with chloasma have no increased levels of estrogen or MSH. In addition, the occurrence of melasma with estrogen- and progesterone-containing oral contraceptive pills has been reported. The observation that postmenopausal woman who are given progesterone develop melasma, while those who are given only estrogen do not, implicates progesterone as playing a critical role in the development of melasma. UV-B, UV-A, and visible light are all capable of stimulating melanogenesis. The condition is self-limited; however spontaneous resolution is time-consuming and may take months to resolve normal pigmentation. Therefore, it is worthwhile to prevent the onset of chloasma, by strict photoprotection. Prudent measures to avoid sun exposure include hats and other forms of shade combined with the application of a broad-spectrum sunscreen at least daily. Sunscreens containing physical blockers, such as titanium dioxide and zinc oxide, are preferred over chemical blockers because of their broader protection. Chloasma can be difficult to treat. Quick fixes with destructive modalities (eg, cryotherapy, medium-depth chemical peels, lasers) yield unpredictable results and are associated with a number of potential adverse effects. The mainstay of treatment remains topical depigmenting agents. Hydroquinone (HQ) is most commonly used.

Ultrasonographic estimation of fetal weight--residents accuracy.

The aim of this retrospective study was to evaluate the accuracy of gynecology and obstetrics residents when performing ultrasonographic estimation of fetal weight. The total of 400 ultrasonographic estimations of fetal weight and corresponding neonatal weight were collected and divided into 3 groups according to physicians' experience (junior and senior residents, staff physicians). The accuracy of fetal weight estimation correlated positively with the level of physicians'experience. The proportional difference between ultrasound estimation and actual birth weight varied from 8.45% to 6.88% (junior residents 8.45%, senior residents 6.95%, staff physicians 6.88%). The proportion of ultrasonograhic estimates that fell within 10% of birth weight varied from 59.09% to 79.21% (junior residents 59.09%, senior residents 78.44%, staff physicians 79.21%). Senior residents reach a highly acceptable accuracy in ultrasonographic estimation of fetal weight which is comparable to staff physicians.