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Risk factors impact on the long-term survival after hemorrhagic
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2009
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Medicinski arhivčasopis ljekara/liječnika bih
• Godina 2009 • volumen 63 • broj 4 •
Medical Archivesjournal of physicians of BiH
• Year 2009 • Volume 63 • No 4 •
Časopis je indeksiran u bazama medline (www.pubmed.gov), ebsco
(www.ebscohost.com)
and index copernicus (www.indexcopernicus.com)
ISSN 0350-199 X
Tije
šić P
etar
, Bro
d u
oluj
i, 19
69.
-
182 MED ARH 2009; 63(4) •
BOSNIAN JOURNAL OF BASIC MEDICAL SCIENCES 2009; 9 (1):
99-100
- Cre
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atas
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The only once-daily peakless insulin
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EDITORIAL BOARDEditor-In-Chief
Izet MasicSecretary
Alma ZejnilovicTechnical editor
Mirza HamzicLectors: Lejla Masic,Dubravko Vanicek
MEMBERS OF THE BOARD
Sebija Izetbegovic (Sarajevo, BiH)), Izet Hozo (Split, Croatia),
Zlatko
Hrgovic (Franfurt, Germany), Zdenka Krivokuca (Banja Luka,BiH)),
Dragica Milinkic (Sydney, Australia),
Sahib Muminagic (Zenica, BiH), Ljerka Ostojic (Mostar, BiH),
Haris Pandza (Sarajevo,BiH), Enra Suljic-Mehmedika
(Sarajevo,BiH), Selim Toromanovic (Bihac,BiH), Narcisa
Vavra-Hadziahmetovic
(Sarajevo,BiH), Muharem Zildzic (Tuzla,BiH), Adnan Zubovic
(Oxford,
UK)
ADDRESS OF THE BOARD
Sarajevo, Cekalusa 90,Tel: +387 33 444 714,e-mail:
[email protected]
www.avicenapublisher.org
PUBLISHED BYAvicena d.o.o., Sarajevo,
Zaima Sarca 43,Bank account:
UNION banka Sarajevo, br.:1020500000020077
SWIFT Code UBKSBA22, Deutsche Bank AG, Franfurt am Main
(DEUTDEFF), Account No. 9365073 10 (EUR).
Medical Archive journal is published five to six times per year
(Feb,
Apr, Jun, Oct, Dec). Subscription for individuals is 50 euros,
for
institutions 100 euros, and includes VAT and postal
services.
Journal is indexed in MEDLINE, EBSCO and
INDEX COPERNICUS–IC (ICV for 2008 is 5,55)
EDITORIAL184 The Role of European National Journals in
Education
ORIGINAL PAPERS187 Imunosupresivni tretman idiopatskog
membranoznog glomerulonefritisa sa nefrotskim
sindromom Immunosuppressive Treatment of Idiopathic Membranous
Glomerulonephritis with Nephrotic Syndrome
Alma Muslimović, Senija Rašić, Damir Rebić, Snežana Unčanin
191 Korelacija koronarne bolesti kod bolesnika sa Diabetes
mellitusom tip 2 Correlation of Coronary Disease in Patients with
Diabetes Mellitus Type 2
Mirsada Terzić-Avdagić
194 Stroke in Diabetic Patients in Cantonal Hospital ZenicaAzra
Alajbegovic, Salem Alajbegovic
197 Učestalost i klinička fenomenologija afazičkih poremećaja
nakon moždanog udara Incidence and Clinical Phenomenology of
Aphasic Disorders After Stroke
Ensala Brkić, Osman Sinanović, Mirjana Vidović, Dževdet
Smajlović
200 Antenatalni kortikosteroidi u prevenciji respiratornog
distres sindroma: učinkovitost u odnosu na tretman-porod
interval
Antenatal Corticosteroids in Respiratory Distress Syndrome
Prevention: Efficacy in Relation to Treatment-Delivery
IntervalSuada Heljić, Hajrija Maksić, Verica Mišanović, Jadranka
Dizdarević
203 Risk Factors Impact on the Long-term Survival After
Hemorrhagic StrokeBiljana Kojic, Adnan Burina, Renata Hodzic,
Zejneba Pasic, Osman Sinanovic
207 Intrahospitalne infekcije i antimikrobna rezistencija u
Univerzitetskom kliničkom centru Tuzla
Intrahospital Infections and Antimicrobial Resistance at
University Clinical Center TuzlaAmer Čustović, Sadeta Hadžić
212 Drug Abuse in Prishtina RegionSanije Gashi, Naser Ramadani,
Merita Berisha, Musli Gashi, Valbona Zhjeqi, Rina Hoxha
216 Factors Associated with Reintegration to Normal Living After
StrokeArdiana Murtezani, Hajrie Hundozi, Sanie Gashi , Teuta
Osmani, Valbona Krasniqi, Bukurie Rama
220 Alternating Esotropia and Surgical Correction in Both
EyesMire Shoshi, Avdyl Shoshi, Aferdita Bakalli
223 Ablacija retine u različitim miopnim refrakcijama Retinal
Detachment in Various Myopic Refractions
Emina Alimanović-Halilović
225 Comparative Advantages and Shortcomings of Corticosteroids
in Comparison with Xylocaine-based Perineural Blocks in Treatment
of Bell’s PalsyBenjamin Bejtovic, Muhamed Ajanovic, Redzep
Dizdarevic
PROFESSIONAL PAPERS228 Adverse Reactions in Estimation of MMR
Vaccination Validation in Bosnian Population
Slobodan Trninic, Adnan Bajraktarevic
231 Rheumatic Fever in Kosova – Long Term StudyMyrvete I.
Kelmendi
CASE REPORT234 Minimalno invazivna hirugija patoloških prijeloma
kičme – vertebroplastika i kifoplastika
na Klinici za ortopediju i traumatologiju Kliničkog centra
Univerziteta u Sarajevu Minimally Invasive Surgery of Pathologic
Spine Fractures – Vertebroplasty and Kyphoplasty at Department
for
Orthopedics and Traumatology of Clinical Centre University of
Sarajevo
Mirza Biščević, Azmi Hamzaoglu, Farid Ljuca, Ismet
Gavrankapetanović, Amra Nadarević, Barbara Rejec-Smrke, Dragica
Smrke
238 IN MEMORIAM Prof. Dr. Dušan Vukotić (1920. – 2009.)
contents
-
184 MED ARH 2009; 63(4) • UVODNIK / EDITORIAL
The Role of European National Journals in Education
The Editors’ Network of the European Society of Cardiol-ogy
(ESC) defined its mission in the statement published across the
national cardiac journals of Europe in 2008 (1). The Network is now
considering ways in which their publi-cations can have a broader
influence in the field of postgraduate education.
The need for Cardiologists to con-tinue to learn throughout
their profes-sional life will remain essential. Indeed recognition
for the need for postgradu-ate education was highlighted by
Hip-pocrates long before it was espoused
by the Medication Educationalists and Public Relations
Departments. “Ars longa, vita brevis” is the Latin transla-tion of
Hippocrates’ recognition that for a doctor, the need to continue
learning the art of medicine, lasts for all of our professional
life. In me-dieval times, the foun-dation of modern day ethical
medical prac-tice was laid within the heart of the Universities;
the long term future of the medical profession was founded in the
con-cept of doctors as men, and women, of learning and knowledge,
rather than the purveyors of non-scientifically based remedies.
So how does the modern day Editor of a National Cardiology
Journal, crouched over his computer screen, relate to his medieval
predecessor, the Abbot in charge of the Uni-
versity Library selecting the books for scholarly enterprise?
The most obvious difference, of course, is that the Inter-net
provides modern day authors with easy access to the Editor and
conse-quently the Editor is obliged to make judgements on a much
larger number of manuscripts than his predecessor would have been
asked to do (Figure 1). The academic effort however is po-tentially
very valuable, allowing the Ed-itor to accumulate a current wisdom
of which writers combine both the knowl-edge of cardiovascular
medicine, with the style with which to communicate that knowledge,
in an authoritative way to doctors who wish to learn.
What are the characteristics of doctors who wish to learn? As
adults, they prefer a self-directed approach, in which they
identify their own learning needs, formulate learning objectives,
identify resources to achieve these ob-jectives and evaluate their
own learn-ing (2). Medical journals provide a ready resource for
meeting the aims of self-directed learning, particularly through
their commentary and review articles, but the value of the resource
is critically dependent on the quality of the content, which in
turn depends on three factors:
1. Subject selection: ideally this should be curriculum-based,
the core curriculum of the ESC intending to provide a framework for
the continuing medical education of the general Euro-pean
Cardiologist. Both mainstream and more peripheral subject
matter
The Role of European National Journals in EducationPeter Mills
MD(*), Adam Timmis MD(a), Kurt Huber MD, Hugo Ector MD(b), Patrizio
Lancellotti MD, Izet Masic MD, Mario Ivanusa MD, Loizos Antoniades
MD, Michael Aschermann MD, Alexandras Laucevicius MD, Pirjo
Mustonen MD, Jean-Yves Artigou MD, Panos Vardas MD(c),
Christodoulos Stefanadis MD, Massimo Chiarello MD, Leonardo
Bolognese MD, Giuseppe Ambrosio MD(d), Ernst E. van der Wall MD,
Piotr Kułakowski MD(e), Fausto J. Pinto MD(f), Eduard Apetrei MD,
Rafael G. Oganov MD, Gabriel Kamensky MD, Thomas F. Lüscher MD,
René Lerch MD, Habib Haouala MD, Vedat Sansoy MD, Valentin Shumakov
MD, Carlos Daniel Tajer MD(+), Chu-Pak Lau MD(+), Manlio Márquez
MD(+), Rungroj Krittayaphong MD(+), Kaduo Arai MD(+) and Fernando
Alfonso MD(g)
European Society of Cardiology (ESC) National Society
Cardiovascular Journals Editors and (+) ESC Affiliated Societies
Cardiovascular Journals Editors, see Appendix for complete
affiliations(*) Education Editor, Heart (UK), Editor´s Network Task
Force: (a) Editor-in-Chief, Heart (UK), (b) Editor-in-Chief, Acta
Cardiologica (BE), (c) Editor-in-Chief, Hellenic Journal of
Cardiology (GR), (d) Former Editor-in-Chief, Gionale Italiano di
Cardiologia (IT), (e) Editor-in-Chief, Kardiologia Polska (PL), (f)
Editor-in-Chief, Revista Portuguesa de Cardiologia (PT), (g)
Editor-in-Chief, Revista Española de Cardiología (ES) and
chairperson of the Editors’ Network
This manuscript will be simultaneously published in all ESC
National Societies and ESC Affiliated Societies’ cardiovascular
journals that consented to publicationThe Editors’ Network of the
European Society of Cardiology (ESC) defined its mission in the
statement published across the national cardiac journals of
Europe in 2008 (1). The Network is now considering ways in which
their publications can have a broader influence in the field of
postgraduate education. The need for Cardiologists to continue to
learn throughout their professional life will remain essential.
Indeed recognition for the need for postgraduate education was
highlighted by Hippocrates long before it was espoused by the
Medication Educationalists and Public Relations Departments. “Ars
longa, vita brevis” is the Latin translation of Hippocrates’
recognition that for a doctor, the need to continue learning the
art of medicine, lasts for all of our professional life. In
medieval times, the foundation of modern day ethical medical
practice was laid within the heart of the Universities; the long
term future of the medical profession was founded in the concept of
doctors as men, and women, of learning and knowledge, rather than
the purveyors of non-scientifically based remedies. So how does the
modern day Editor of a National Cardiology Journal, crouched over
his computer screen, relate to his medieval predecessor, the Abbot
in charge of the University Library selecting the books for
scholarly enterprise? The most obvious difference, of course,
is that the Internet provides modern day authors with easy
access to the Editor and consequently the Editor is obliged to make
judgements on a much larger number of manuscripts than his
predecessor would have been asked to do (Figure). The academic
effort however is potentially very valuable, allowing the Editor to
accumulate a current wisdom of which writers combine both the
knowledge of cardiovascular medicine, with the style with which to
communicate that knowledge, in an authoritative way to doctors who
wish to learn. What are the characteristics of doctors who wish to
learn? As adults, they prefer a self-directed approach, in which
they identify their own learning needs, formulate learning
objectives, identify resources to achieve these objectives and
evaluate their own learning (2). Medical journals provide a ready
resource for meeting the aims of self-directed learning,
particularly through their commentary and review articles, but the
value of the resource is
critically dependent on the quality of the content, which in
turn depends on three factors:
1. Subject selection: ideally this should be curriculum-based,
the core curriculum of the ESC intending to provide a framework for
the continuing medical education of the general European
Cardiologist. Both mainstream and more peripheral subject matter
are required for comprehensive educational coverage, and so there
will be a need for updates, particularly in areas where new
discoveries are proceeding most rapidly. 2. Author selection:
Editors are in an unrivalled position to select from currently
active authors, those best able to educate others based on their
subspecialty expertise and writing skills. Clear presentation must
be coupled with the intellectual rigor to back up assertions with
evidence derived from critical appraisal of the relevant
literature. 3. Presentation: this should be designed to help
stimulate the reader, using highly structured content, relevant
illustrations, summary box displays, and annotated references that
allow the reader to refer back to source material.
Figure 1. “Internet provides modern day authors with easy access
to the Editor”
Adults who wish to learn, however, require more of medical
journals than high quality commentary and review articles. They
also require educational feed-back provided by accrediting
organisations in order to consolidate their learning and acquire
the continuing medical education (CME) credits that in many
countries are becoming an essential
requirement for practising doctors. The European Board for
Accreditation in Cardiology (EBAC), for example, requires that
cardiologists earn a minimum of 250 CME credits over a period of 5
years, 125 of which must be “external CMEs” from formally planned
external activities, including educational articles (3). The EBAC
accreditation policy for CME articles is summarised in Table 1 and
includes
a requirement for “an objective evaluation instrument”,
recommending the use of a multiple choice questionnaire (MCQ) made
available on-line. Articles of ~3,500 words and 6 MCQs are
considered equivalent to 1 hour of educational activity and provide
1 CME credit. Nearly all the national cardiac journals of Europe
carry high quality review articles (4-7) (Table 2). Heart, the
UK-based international cardiac journal, has been a leader in the
field of journal-based education for 10 years (8), and currently
accounts for >95% of educational
articles attracting CME credits on the EBAC web site. Its
educational section runs semi-autonomously within the journal under
the direction of a dedicated editor and a team of specialist
advisors. Education in Heart is available for free access via the
Heart and ESC web sites (9,10) and its articles are among the most
highly accessed of all the journal’s papers, consistently appearing
in the top ten web-downloads during 2008 (11-15). High quality
educational content with provision of local CME credits is also
available in other national cardiac journals (16-17) (Table 2) and
The Editors’ Network now provides a real opportunity to extend
these educational initiatives throughout the national cardiology
journals of Europe (10).
Table 1. Summary EBAC criteria for accreditation of CME articles
Internationally recognised authors Disclosure of conflicts of
interest No advertising within article Provision of objective
evaluation instrument
(MCQs) Web-based system for provision of CME certificate
if ≥60% of questions are answered correctly
Table 2. Questionnaire on Education Issues : ESC National
Society Cardiovascular Journals A) Currently Published Articles:
84% Journals publish Editorials (63% peer-reviewed) 92% Journals
publish Review Articles (83% peer-reviewed) 82% Journals publish
Supplements (62% peer-reviewed) B) Clinical Practice Guidelines
(CPG): 79% Journals publish CPG: - 67% National CPG - 73% ESC CPG:
- 50% translated into national languages - 36% in English - 14%
translated into national languages and in English C) Continuous
Medical Education (CME) 42% Journals have CME programs 32% Journals
obtain national CME credits 76% Journals would be interested in
obtaining ESC CME credits D) Interest in Additional Educative
Material: 92% Journals interested in ESC joint educative papers 92%
Journals interested in “occasional” publication of educative
material directly organized by the ESC 71% Journals consider that
educative material need not to be distinct/country focused 82%
Journals believe that both undergraduate and postgraduate education
should be covered ESC= European Society of Cardiology. A 38 item
questionnaire was devised by the Editor´s Network Nucleus and sent
to ESC National Journal Editors (44 National Societies and 16
Affiliated Societies). Data was obtained from 38 National Journals
(33 National Society Journals - 75% response rate - and 5
Affiliated Societies Journals)
Adults who wish to learn, however, require more of medical
journals than high quality commentary and review articles. They
also require educational feed-back provided by accrediting
organisations in order to consolidate their learning and acquire
the continuing medical education (CME) credits that in many
countries are becoming an essential
requirement for practising doctors. The European Board for
Accreditation in Cardiology (EBAC), for example, requires that
cardiologists earn a minimum of 250 CME credits over a period of 5
years, 125 of which must be “external CMEs” from formally planned
external activities, including educational articles (3). The EBAC
accreditation policy for CME articles is summarised in Table 1 and
includes
a requirement for “an objective evaluation instrument”,
recommending the use of a multiple choice questionnaire (MCQ) made
available on-line. Articles of ~3,500 words and 6 MCQs are
considered equivalent to 1 hour of educational activity and provide
1 CME credit. Nearly all the national cardiac journals of Europe
carry high quality review articles (4-7) (Table 2). Heart, the
UK-based international cardiac journal, has been a leader in the
field of journal-based education for 10 years (8), and currently
accounts for >95% of educational
articles attracting CME credits on the EBAC web site. Its
educational section runs semi-autonomously within the journal under
the direction of a dedicated editor and a team of specialist
advisors. Education in Heart is available for free access via the
Heart and ESC web sites (9,10) and its articles are among the most
highly accessed of all the journal’s papers, consistently appearing
in the top ten web-downloads during 2008 (11-15). High quality
educational content with provision of local CME credits is also
available in other national cardiac journals (16-17) (Table 2) and
The Editors’ Network now provides a real opportunity to extend
these educational initiatives throughout the national cardiology
journals of Europe (10).
Table 1. Summary EBAC criteria for accreditation of CME articles
Internationally recognised authors Disclosure of conflicts of
interest No advertising within article Provision of objective
evaluation instrument
(MCQs) Web-based system for provision of CME certificate
if ≥60% of questions are answered correctly
Table 2. Questionnaire on Education Issues : ESC National
Society Cardiovascular Journals A) Currently Published Articles:
84% Journals publish Editorials (63% peer-reviewed) 92% Journals
publish Review Articles (83% peer-reviewed) 82% Journals publish
Supplements (62% peer-reviewed) B) Clinical Practice Guidelines
(CPG): 79% Journals publish CPG: - 67% National CPG - 73% ESC CPG:
- 50% translated into national languages - 36% in English - 14%
translated into national languages and in English C) Continuous
Medical Education (CME) 42% Journals have CME programs 32% Journals
obtain national CME credits 76% Journals would be interested in
obtaining ESC CME credits D) Interest in Additional Educative
Material: 92% Journals interested in ESC joint educative papers 92%
Journals interested in “occasional” publication of educative
material directly organized by the ESC 71% Journals consider that
educative material need not to be distinct/country focused 82%
Journals believe that both undergraduate and postgraduate education
should be covered ESC= European Society of Cardiology. A 38 item
questionnaire was devised by the Editor´s Network Nucleus and sent
to ESC National Journal Editors (44 National Societies and 16
Affiliated Societies). Data was obtained from 38 National Journals
(33 National Society Journals - 75% response rate - and 5
Affiliated Societies Journals)
-
185MED ARH 2009; 63(4) • UVODNIK / EDITORIAL
The Role of European National Journals in Education
are required for comprehensive educa-tional coverage, and so
there will be a need for updates, particularly in areas where new
discoveries are proceeding most rapidly.
2. Author selection: Editors are in an unrivalled position to
select from cur-rently active authors, those best able to educate
others based on their subspe-cialty expertise and writing skills.
Clear presentation must be coupled with the intellectual rigor to
back up assertions with evidence derived from critical ap-praisal
of the relevant literature.
3. Presentation: this should be de-signed to help stimulate the
reader, us-ing highly structured content, relevant illustrations,
summary box displays,
and annotated references that allow the reader to refer back to
source material.
Adults who wish to learn, however, require more of medical
journals than high quality commentary and review articles. They
also require educational feed-back provided by accrediting
or-ganisations in order to consolidate their learning and acquire
the continuing medical education (CME) credits that in many
countries are becoming an es-sential requirement for practising
doc-tors. The European Board for Accred-itation in Cardiology
(EBAC), for ex-ample, requires that cardiologists earn a minimum of
250 CME credits over a period of 5 years, 125 of which must be
“external CMEs” from formally planned
external activities, including educa-tional articles (3). The
EBAC accredi-tation policy for CME articles is sum-marised in Table
1 and includes a re-quirement for “an objective evaluation
instrument”, recommending the use of a multiple choice
questionnaire (MCQ) made available on-line. Articles of ~3,500
words and 6 MCQs are consid-ered equivalent to 1 hour of
educational activity and provide 1 CME credit.
Nearly all the national cardiac jour-nals of Europe carry high
quality re-view articles (4-7) (Table 2). Heart, the UK-based
international cardiac jour-nal, has been a leader in the field of
journal-based education for 10 years (8), and currently accounts
for >95% of educational articles attracting CME credits on the
EBAC web site. Its educa-tional section runs semi-autonomously
within the journal under the direction of a dedicated editor and a
team of spe-cialist advisors. Education in Heart is available for
free access via the Heart and ESC web sites (9,10) and its articles
are among the most highly accessed of all the journal’s papers,
consistently ap-pearing in the top ten web-downloads during 2008
(11-15). High quality edu-cational content with provision of local
CME credits is also available in other national cardiac journals
(16-17) (Ta-ble 2) and The Editors’ Network now provides a real
opportunity to extend these educational initiatives through-out the
national cardiology journals of Europe (10).
REfERENcEs1. Alfonso F, Ambrosio G, Pinto FJ, Van der
Wall EE, Kondili A, Nibouche D, Ada-myan K, Huber K, Ector H,
Masic I, Tar-novska R, Ivanusa M, Staněk V, Videbæk J, Hamed M,
Laucevicius A, Mustonen P, Artigou J-Y,Cohen JY, Rogava M, Böhm M,
Fleck E, Heusch G, Klawki R, Var-das P, Stefanadis C, Tenczer J,
Chiari-ello M, Elias J, Benjelloun H, Rødevand O, Kułakowski P,
Apetrei E, Lusov VA, Oganov RG, Obradovic V, Kamensky G, Kenda MF,
Höglund C, Lüscher TF, Le-rch R, Jokhadar M, Haouala H, Sansoy V,
Shumakov V, Timmis A. European National Society cardiovascular
jour-nals. Background, Rationale and Mission Statement of the
“Editors’ Club” (Task Force of the European Society of
Cardi-ology). Heart. 2008;94:e19
2. Kaufman DM. ABC of learning and teach-ing in medicine:
Applying educational the-ory in practice. BMJ 2003; 326: 213 –
216
3. European Board for Accreditation in Car-diology.
http://www.ebac-cme.org/index.
AppendixJournal names (by alphabetic order of country origin and
members (Editors-in-chief of the Editors’ Network) National Society
Name National Society Journal Editor-in-Chief Austrian Society of
Cardiology Journal für Kardiologie* Kurt Huber Belgian Society of
Cardiology Acta Cardiologica Hugo Ector Patrizio Lancellotti
Association of Cardiologists of Bosnia and Herzegovina Medicinski
Arhiv Izet Masic Croatian Cardiac Society Kardio List Mario Ivanusa
Cyprus Society of Cardiology Cyprus Heart Journal Loizos Antoniades
Czech Society of Cardiology Cor et Vasa Michael Aschermann Estonian
Society of Cardiology Seminars in Cardiovascular Medicine**
Alexandras Laucevicius Finnish Cardiac Society Sydänääni (Heart
Beat) Pirjo Mustonen French Society of Cardiology Archives des
maladies du cœur et des vaisseaux Pratique Jean-Yves Artigou
Hellenic Cardiological Society Hellenic Journal of Cardiology Panos
Vardas Christodoulos Stefanadis Italian Federation of Cardiology
Journal of Cardiovascular Medicine Massimo Chiarello Giornale
Italiano Di Cardiologia Leonardo Bolognese Latvian Society of
Cardiology Seminars in Cardiovascular Medicine** Alexandras
Laucevicius Lithuanian Society of Cardiology Seminars in
Cardiovascular Medicine** Alexandras Laucevicius Netherlands
Society of Cardiology Netherlands Heart Journal Ernst E. van der
Wall Polish Cardiac Society Kardiologia Polska – Polish Heart
Journal Piotr Kułakowski Portuguese Society of Cardiology Revista
Portuguesa de Cardiologia Fausto J. Pinto Romanian Society of
Cardiology Revista Română de Cardiologie Eduard Apetrei Russia Fed
Society of Cardiology Cardiovascular Therapy and Prevention Rafael
G. Oganov Rational Pharmacotherapy in Cardiology Rafael G. Oganov
Slovak Society of Cardiology Kardiológia Gabriel Kamensky Spanish
Society of Cardiology Revista Española de Cardiología Fernando
Alfonso Swiss Society of Cardiology Kardiovaskuläre Medizin Thomas
F. Lüscher Médecine Cardiovasculaire René Lerch Tunisian Society of
Cardiology Cardiologie Tunisienne Habib Haouala Turkish Society of
Cardiology Archives of the Turkish Society of Cardiology Vedat
Sansoy Ukrainian Association of Cardiology Ukrainian Journal of
Cardiology Valentin Shumakov British Cardiovascular Society Heart
Adam Timmis Affiliated Society Name Affiliated Society Journal
Editor-in-Chief Argentine Society of Cardiology Revista Argentina
de Cardiologia Carlos Daniel Tajer Hong Kong College of Cardiology
Journal of the Hong Kong College of Cardiology Chu-Pak Lau Mexican
Society of Cardiology Archivos de Cardiología de México Manlio
Márquez Heart Association of Thailand Thai Heart Journal Rungroj
Krittayaphong Venezuelan Society of Cardiology Avances
Cardiológicos Kaduo Arai * Not official National Society journal,
but major cardiology journal in Austria ** Common journal for the
Baltic countries
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186 MED ARH 2009; 63(4) • UVODNIK / EDITORIAL
The Role of European National Journals in Education
php (accessed 18/9/09)4. Ramos PM, Martínez VB, Granado JQ,
Juanatey JR. [Advances in hypertension and diabetes in 2007].
Rev Esp Cardiol. 2008;61 Suppl 1:58-71.
5. Selton-Suty C, Juillière Y. Non-invasive investigations of
the right heart: How and why? Arch Cardiovasc Dis.
2009;102:219-32.
6. Maas AH, Franke HR. Women’s health in menopause with a focus
on hyperten-sion. Neth Heart J. 2009;17:68-72
7. Stefanatou A. Smoking cessation in car-diovascular patients.
Hellenic J Cardiol. 2008;49:422-31.
8. Timmis AD. Education in Heart: 10th anniversary. Heart
2009;95:1555
9. Heart. http://heart.bmj.com (accessed
18/9/09)10. European Society of Cardiology. http://
www.escardio.org/membership/na-tional-societies/Pages/journals.aspx
(ac-cessed 18/9/09)
11. Peter R, Cox A, Evans M. Management of diabetes in
cardiovascular patients. Heart 2008; 94: 369-375.
12. Grayburn PA. How to measure severity of mitral
regurgitation. Heart 2008 94: 376-383
13. Konstantinides SV. Acute pulmonary embolism revisited. Heart
2008 94: 795-802
14. Wu AH. Cardiotoxic drugs: clinical mon-itoring and decision
making. Heart 2008; 94: 1503-1509.
15. Jukema JW, Bergheanu SC. Statins: es-
tablished indications and controversial subgroups. Heart 2008;
94: 1656-1662.
16. Cruz-González I, Solis J, Inglessis-Azuaje I, Palacios IF.
Patent foramen ovale: cur-rent state of the art. Rev Esp Cardiol.
2008;61:738-51
17. Badimon L, Vilahur G. Coronary ath-erothrombotic disease:
progress in an-tiplatelet therapy. Rev Esp Cardiol.
2008;61:501-13.
Address for correspondence: Adam Timmis MD, Dept cardiology,
London chest
Hospital, Bonner Road, London E2 9JX, United Kingdom (email:
[email protected])
Instructions for the authors of the journal Medical Archives
All papers need to be sent electronical-ly by web page:
www.avicenapublisher.org : Print version and signed copyright form
need to be sent by post to the Edito-rial board of journal Med Arh.
Faculty of medicine, Cekalusa str. 90, 71000 Sarajevo, BiH. Every
sent article gets its number, and author(s) will be notified if
their paper is accepted and what is the number of paper. Every
correspondence will use that number.The paper has to be typed on a
standard size paper (format A4), leaving left margins to be at
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but usually it consists of a title page, summary, text ref-erences,
legends for pictures and pictures.
Title pageEvery article has to have a title page with a title of
no more than 10 words: name(s), last and first of the author(s),
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Central part of the articleAuthentic papers contain these parts:
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Introduction is brief and clear review of problem. Methods are
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Conclu-sions have to give an answer to author’s goal.
ReferencesQuoting references must be in a scale in which they
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“unknown”. Titles of the publications are abbreviated in accordance
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the journal has to be written. Footnote – comments, explana-tions,
etc., cannot be used in the paper.
Statistical analysisTests used for statistical analysis need to
be shown in text and in tables or pic-tures containing statistical
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Tables and picturesTables have to be numbered and shown by their
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Every column needs to have title, every measuring unit (SI) has to
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backs contain illustration number, first author last name,
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Use of abbreviationsUse of abbreviations has to be re-duced to
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SupplementIf paper contains original contribution to a
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computer program, papers value will be reduced, Editorial staff
will consider possibility of publishing math-ematical/statistical
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have to sign statement that submitted paper has not been published,
nor is it currently un-der consideration for publication
elsewhere.
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187MED ARH 2009; 63(4) • ORIGINALNI ČLANCI / ORIGINAL PAPERS
Imunosupresivni tretman idiopatskog membranoznog
glomerulonefritisa sa nefrotskim sindromom
1. UVODMembranozni glomerulonefritis
(MGN) je jedan od najčešćih uzroka ne-frotskog sindroma u
odraslih i u grupi primarnih glomerulonefritisa vodeći je uzrok
renalne insuficijencije (1). U ne-kih pacijenata bolest pokazuje
benigan tok, sa mogućnošću pojave spontanih, kompletnih ili
parcijalnih remisija ne-frotskog sindroma u 20 do 30 % sluča-jeva.
Uprkos tome, u 30–50 % pacije-nata bolest napreduje prema
terminal-noj renalnoj insuficijenciji unutar 5-15 godina (2).
Proteinurija je posljedica li-tičkog djelovanja komponenti
komple-menta C5b-9 (terminalni MAC kom-pleks) na podocite. Odgovor
podocita na C5b-9 uključuje povećanu ekspresiju gena za proizvodnju
oksidanata, prote-aza, prostaglandina, faktora rasta,
tran-sformirajućeg faktora rasta (TGF) i re-ceptora TGF, što vodi
povećanoj proi-zvodnji komponenti ekstracelularnog matriksa i
rezultira depozitnim forma-cijama u obliku “šiljka” (3). Patološki
nalaz u membranoznoj glomerulopa-tiji predstavljaju normocelularni
glo-meruli, sa subepitelnim depozitima na spoljašnjoj površini
glomerularne ba-zalne membrane (4)
Tretman primarnog MGN je još uvi-jek kontraverzan i podrazumjeva
nei-munosupresivnu i imunosupresivnu te-rapiju. Rasprave oko
tretmana i odabira protokola liječenja traju i dalje. Zbog
značajnog broja pacijenata, koji ulaze u spontanu remisiju bez
terapije, većina autora imunosupresivni tretman rezer-viraju za
pacijente sa perzistentnom ne-frotskom proteinurijom i reduciranom
bubrežnom funkcijom (5). Racionalna terapijska strategija
podrazumijeva pri-mjenu odgovarajućeg konzervativnog tretmana u
nisko rizičnoj skupini, sa urednom bubrežnom funkcijom i
imu-nosupresivnu terapiju u visoko rizičnoj skupini, sa sniženom
bubrežnom funk-cijom i nefrotskim sindromom (6,7). Neke od
terapijskih mogućnosti uklju-čuju: kortikosteroide u kombinaciji sa
citotoksičnim lijekovima (hlorambucil ili ciklofosfamid) i
ciklosporin. Nove terapijske alternative podrazumijevaju primjenu
vakcina, inhibitore aktivatora tkivnog plazminogena, humana
mono-klonalna antitijela, mikofenolat mofetil (MMF), pentoksifilin
i drugo.
Cilj rada je komparirati terapijske efekte kombinacije
kortikosteroida i ci-klofosfamida, kao i primjene ciklospo-rina u
pogledu efekata na nivo protei-
Imunosupresivni tretman idiopatskog membranoznog
glomerulonefritisa sa nefrotskim sindromomImmunosuppressive
Treatment of Idiopathic Membranous Glomerulonephritis with
Nephrotic SyndromeAlma Muslimović, Senija Rašić, Damir Rebić,
Snežana UnčaninKlinika za nefrologiju, Klinički centar Univerziteta
u Sarajevu, Bosna i Hercegovina
ORIgINALNI čLANAKsAŽETAKCilj: U radu su analizirani efekti dva
terapijska protokola u pogledu uticaja na nivo proteinurije,
vrijednost serum-skog kreatinina, vrijednost kreatinin klirensa i
nivo serumskih albumina u pacijenata sa idiopatskim membra-noznim
glomerulonefritisom (IMGN) i nefrotskim sindromom (NS). Pacijenti i
metode: Ispitivanje je obuhvatilo 30 pacijenata sa IMGN i NS. U
jednoj grupi su pacijenti, tretirani kombinacijom kortikosteroida u
dozi od 1 mg/kg TT 4 nedjelje, a potom 0,5 mg/kg TT, uz postepenu
redukciju doze i bolusima i.v. ciklofosfamida u dozi od 10 mg/kg
tj.težine jednom mjesečno do šest mjeseci, a potom u tromjesečnim
intervalima. U drugoj grupi su pacijenti tretirani ciklosporinom u
dozi od 3-5 mg/kg tj. težine, uz održavanje serumskog nivoa lijeka
od 120 ± 20 ng/ml. Istraživanje je obuhvatilo period od 2000. do
kraja 2007. godine, a kontrolirani su parametri svaka 2 do ukupno
24 mjeseca. Rezultati rada: Rezultati istraživanja ukazuju da je u
obje ispitivane grupe postignuta signifikanta redukcija
proteinurije (p
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188 MED ARH 2009; 63(4) • ORIGINALNI ČLANCI / ORIGINAL
PAPERS
Imunosupresivni tretman idiopatskog membranoznog
glomerulonefritisa sa nefrotskim sindromom
nurije, nivo serumskog kreatinina, vri-jednost glomerularne
filtracije i vrijed-nost serumskih albumina.
2. IspITANIcI I METOD RADAU studiju retrospektivno-prospek-
tivnog karaktera, uključeno je 30 paci-jenata oba spola,
starijih od 18 godina, sa dijagnosticiranim primarnim mem-branoznim
glomerulonefritisom. Svi pacijenti su liječeni na Klinici za
ne-frologiju i praćeni kroz nefrološko sa-vjetovalište Kliničkog
centra Univer-ziteta u Sarajevu. Studija je obuhvatila period od
2000. do kraja 2007. godine, s prosjekom praćenja terapijskih
efekata po pacijentu u trajanju od najmanje 1 godine. Od pojave
subjektivnih tegoba pacijenta do započinjanja tretmana, po-stojao
je vremenski period od 6 mjeseci, bez pojave spontane remisije.
Pacijenti su podijeljeni u dvije grupe, ovisno o primijenjenom
terapijskom protokolu:
1) Grupa I: pacijenti tretirani kom-binacijom kortikosteroida u
dozi od 1 mg/kg TT 4 nedjelje, a potom 0,5 mg/kg TT, uz postepenu
redukciju doze i bolusima i.v. ciklofosfamida u dozi od 10 mg/kg TT
jednom mjesečno do šest mjeseci, a potom u tromjesečnim
inter-valima, najduže do 1,5 godine.
2) Grupa II: pacijenti tretirani ci-klosporinom u dozi od 3-5
mg/kg TT, uz održavanje serumskog nivoa lijeka od 100 ± 20
ng/ml.
Efekti primijenjene terapije su anali-zirani monitoriranjem:
vrijednosti pro-teinurije–kvantitativno, serumskog al-bumina.
serumskog kreatinina i krea-tinin klirensa.
3. REZULTATI RADANa osnovu analiziranih demograf-
skih podataka (spol, dob, dužina tra-janja bolesti) nije bilo
statistički zna-čajnih razlika među grupama (p=0,70; p=0,51;
p=0,64). Tretman kombinaci-jom ciklofosfamida i steroida je
rezul-tirao signifikantnim padom vrijednosti proteinurije sa 12,97
g/24 h ± 6,78 na 1,19 g/24 h ± 1,06 (p
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189MED ARH 2009; 63(4) • ORIGINALNI ČLANCI / ORIGINAL PAPERS
Imunosupresivni tretman idiopatskog membranoznog
glomerulonefritisa sa nefrotskim sindromom
ficijencije. Uočljiv je pad prosječnih vri-jednosti serumskog
kreatinina u ciklo-fosfamidskoj i porast u ciklosporinskoj
terapijskoj grupi, međutim, zabilježeni porast još uvijek ne
prelazi gornju gra-nicu referentnih vrijednosti (žene 45-90 µmol/l;
muškarci 63-109 µmol/l), niti su promjene vrijednosti serumskog
krea-tinina prije i nakon terapije unutar po-smatranih grupa
pacijenata statistički značajne. Također, ne postoji statistički
značajna razlika između prosječnih po-četnih, kao ni prosječnih
završnih vri-jednosti serumskog kreatinina posma-trano među grupama
pacijenata (po-četni kreatinin p=0,128; završni krea-tinin p=0,749)
(grafikon 2).
Prosječna vrijednost kreatinin kli-rensa prije terapije
kombinacijom ciklo-fosfamida i steroida iznosila je 96,98 ml/min ±
54,59. Nakon primijenjene tera-pije, registrujemo sličnu prosječnu
vri-jednost kreatinin klirensa, koja iznosi 91,95 ml/min ± 36,3
(p=0,906). Tre-tman ciklosporinom druge grupe pa-
cijenata je doveo do statistički nesigni-fikantnog porasta
prosječne vrijednosti kreatinin klirensa (p=0,435). Prosječna
vrijednost kratinin klirensa prije tera-pije, u ovoj terapijskoj
grupi, iznosila je 85,0 ml/min ± 36,8, a nakon tera-pije100,3
ml/min ± 31,0. Uočavamo, da su odstupanja u prosječnim
vrijedno-stima klirensa kreatinina prije i nakon terapije minimalna
i da se kreću unutar referentnih vrijednosti (žene 82-146 ml/min;
muškarci 84-162 ml/min). Nema statistički značajne razlike među
gru-pama u početnim i završnim vrijedno-stima kreatinin klirensa
(p= 0,157; p= 0,800) (grafikon 3).
Prosječna vrijednost serumskih al-bumina prije započinjanja
terapije kom-binacijom ciklofosfamida sa steroidima iznosila je
23,46 g/l ± 7,35 . Nakon pri-mijenjene terapije postignut je visoko
signifikantan porast serumskih albu-mina na 37,26 g/l ± 5,54
(p=0,00003). Prosječna vrijednost serumskih al-bumina prije
otpočinjanja terapije u
grupi pacijenata liječenih ciklospori-nom iznosila je 21,40 g/l
± 6,85. Nakon terapije bilježimo signifikantan porast prosječnih
vrijednosti serumskih al-bumina na 31,46 g/l ± 6,27 (p=0,0002).
Sličan je odgovor na oba primijenjena terapijska modela u pogledu
oparavka serumskih albumina. Paralelno sa ne-što boljim odgovorom
na terapiju ciklo-fosfamidom u pogledu restrikcije pro-teinurije, u
istoj grupi pacijenata se bi-lježi i ubjedljiviji oporavak
serumskih albumina (niže početne i više završne vrijednosti). Viša
završna vrijednost se-rumskih albumina u ciklofosfamidskoj grupi je
statistički značajna u odnosu na ciklosporinsku (p= 0,031).
Od ukupnog broja pacijenata treti-ranih ciklofosfamidom u
kombinaciji sa steroidima, 40% pacijenata je postiglo kompletnu, a
60% parcijalnu remisiju. U grupi pacijenata tretiranih
ciklos-porinom 27% je postiglo kompletnu, 60% pacijenata parcijalnu
remisiju ne-frotskog sindroma, dok je u 13% paci-jenata postignuto
smanjenje proteinu-rije, ali bez ostvarenja remisije nefrot-skog
sindroma.
4. DIsKUsIJAPreko 80% pacijenata sa MGN ima
nefrotsku proteinuriju, a oko 10% u momentu javljanja oštećenu
bubrežnu funkciju (8). Svi pacijeti, praćeni kroz ovo istraživanje,
su u momentu zapo-činjanja liječenja imali nefrotsku pro-teinuriju,
a 23% reduciranu bubrežnu funkciju.
U 100% pacijenata tretiranih kom-binacijom ciklofosfamida i
steroida, postignuta je remisija nefrotskog sin-droma (kompletna
ili parcijalna). U drugoj grupi, tretiranoj ciklosporinom, kod 2
pacijenta došlo je do pada prote-inurije, ali bez postizanja
remisije ne-frotskog sindroma, dok su ostali paci-jenti postigli
parcijalnu ili kompletnu remisiju, iz čega proizilazi nešto bolji
efekat ciklofosfamidske terapije na re-dukciju proteinurije.
Studije o primjeni ciklofosfamida sa steroidima kod paci-jenata sa
IMGN i nefrotskim sindro-mom ukazuju na pozitivan efekat ove
terapijske kombinacije, sa pojavom mi-nimalnih neželjenih efekata.
Covic sa saradnicima (9) je navedenom terapij-skom kombinacijom
postigao u niskoj i srednje rizičnoj grupi pacijenata sa IMGN
nefrotskim sindromom kom-pletnu ili parcijalnu remisiju kod svih
tretiranih, odnosno, kod 75% u visoko
133,9115,5
85100,3
020406080
100120140160180200
ciklofosfamidska grupa ciklosporinska grupa
početnezavršne
kreatinin (µmol/l)
Grafikon 2. Odnos prosječnih vrijednosti kreatinina na početku i
kraju terapije za posmatrane grupe pacijenata početni kreatinin
t=1,578; p=0,128 završni kreatinin t=0,324; p=0,749
Grafikon 3. Odnos prosječnih vrijednosti kreatinin klirensa na
početku i kraju terapije za posmatrane grupe pacijenata početni
kreatinin klirens t=1,460; p=0,157 završni kreatinin klirens
t=0,256; p=0,800
90,24 91,95 85100,3
020406080
100120140
ciklofosfamidska grupa ciklosporinska grupa
početnizavršni
kreatinin klirens (ml/min)
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190 MED ARH 2009; 63(4) • ORIGINALNI ČLANCI / ORIGINAL
PAPERS
Imunosupresivni tretman idiopatskog membranoznog
glomerulonefritisa sa nefrotskim sindromom
rizičnoj skupini (sa više od dva nega-tivna prognostička
faktora). Objavljene studije ukazuju da se incidenca kom-pletnih i
parcijalnih remisija povećava tokom perioda praćenja, što smo
uočili i tokom ovog istraživanja.
Radovi velikog broja autora izvješta-vaju o pozitivnim
rezultatima od upo-trebe ciklosporina u liječenju IMGN . Ovaj
imunosupresivni lijek, inhibitor kalcineurina, koji inhibira
aktivaciju i proliferaciju T limfocita, našao je svoje mjesto u
liječenju autoimunih oboljenja i u transplantacijskoj medicini.
Naši re-zultati govore o dobrom odgovoru u ve-ćine tretiranih
pacijenata. Većina stu-dija ukazuje na problem čestih relapsa
proteinurije nakon prekida terapije (10). Novije studije ukazuju da
su mo-noterapija CyA, kao i kombinirana te-rapija sa steroidima
tokom 12 mjeseci, efikasne u induciranju remisije kod ve-ćine
pacijenata sa IMGN i da prolon-girana terapija sa nižim dozama može
biti korisna u održavanju remisije bo-lesti. Isti postotak
kompletnih remisija (7%) je postignut kod naših pacijenata nakon 6
mjeseci tretmana, kao i u no-vijim objavljenim studijama drugih
au-tora (11,12,13). Cattran sa saradnicima izvještava o 75%
parcijalnih i komplet-nih remisija kod pacijenata tretiranih
ciklosporinom nakon 6 mjeseci (11). Alexopoulos sa saradnicima je
nakon 12-to mjesečnog tretmana u 35% paci-jenata iz terapijski
kombinirane grupe ciklosporinom sa steroidima i u 20% pa-cijenata
iz monoterapijske grupe posti-gao kompletnu remisiju, dok su ostali
bili u parcijalnoj remisiji (12). Ukupan postotak parcijalnih i
kompletnih re-misija nakon 12 mjeseci kod naših pa-cijenata iznosi
87%.
Ciklofosfamidska grupa pacijenata u prosjeku je imala nešto više
startne vrijednosti serumskog kreatinina i do kraja perioda
praćenja na primijenjenu terapiju postigla je pad kreatinina, koji
je u prosjeku bio iznad referentnih vri-jednosti. Nasuprot tome, u
ciklosporin-skoj grupi startne vrijednosti kreatinina su bile nešto
niže, a na primijenjenu te-rapiju je došlo do njegovog porasta (na
granici referentnih vrijednosti). Pad kreatinina u
ciklofosfamidskoj i porast u ciklosporinskoj grupi je statistički
ne-signifikantan, što je važan terapijski cilj u pogledu očuvanja
bubrežne funkcije. Dobijene rezultate treba posmatrati i u
kontekstu mogućeg uticaja ciklospo-rinske terapije na bubrežnu
funkciju, u
čijoj podlozi se može nalaziti neželjeni efekat ciklosporina na
bubreg, kao što su vazokonstrikcija aferentne arteriole (14),
tubulointersticijalne lezije (15) i renalna intesticijalna
inflamacija (16).
U obje ispitivane grupe vrijednosti kreatinin klirensa, prije i
nakon tera-pije, nisu pokazivale statistički signifi-kantna
odstupanja.
5. ZAKLJUčcITerapija ciklofosfamidom u kom-
binaciji sa steroidima pokazala se kao dobar izbor u liječenju
pacijenata sa IMGN, koja je kod svih tretiranih do-vela do
postizanja parcijalne (60%) ili kompletne remisije (40%) nefrotskog
sindroma.
Ciklosporin je efikasna alternativa u liječenju pacijenata sa
IMGN. Ovaj vid liječenja je do kraja perioda praćenja re-zultirao
remisijom bolesti kod 87% tre-tiranih (60% parcijalnih i 27%
komplet-nih remisija).
Na primijenjene imunomodula-torne lijekove nije došlo do
značajnog odstupanja u parametrima bubrežne funkcije (serumski
kreatinin i kreati-nin klirens).
LITERATURA1. Troyanov S, Wall CA, Miller JA, Scholey
JW, Cattran DC, Toronto Glomerulonep-hritis Registry Group.
Idiopathic mem-branous nephropathy: definition and relevance of a
partial remission. Kidney Int, 2004; 66(3);1199-205.
2. Schieppati A, Perna A, Zamora J, Giu-liano GA, Braun N,
Remuzzi G, Immu-nosuppressive treatment for idiopathic membranous
nephropathy in adults with nephrotic syndrome. Cochrane Database
Syst Rev, 2004; (4);CD004293.
3. Couser WG, Nangaku M, Cellular and molecular biology of
membranous nep-hropathy. J Nephrol, 2006;19(6):699-705.
4. Passos EM, Legallicier B, Godin M. Membranous nephropathy.
Rev Prat, 2003; 53(18):2033-8.
5. Scheippati A, Ruggenenti P, Perna A, Re-muzzi G.
Nonimmunosuppressive the-rapy of membranous nephropathy. Se-min
Nephrol, 2003;23(4):333-9.
6. Lai KN. Membranous nephropathy: when and how to treat. Kidney
Int, 2007;841-3.
7. du Buf-Vereijken PW, Branten AJ, Wet-zels JF. Idiopathic
membranous nepro-pathy: outline and rationale of treatment
strategy. Am J Kidney, 2005;46(6):1012-29.
8. M u r p h y B F, F a i r l e y K F, K i n -c a id S . Id
iopat hyc membra nou s glomerulonephritis:long-term folow-up in 139
cases In: Brenner BM (ed). Bre-nner & Rectors The Kidney WB
Saun-
ders Company, Phyladelphya, London, Toronto. 2004.
9. Covic A, Cruntu ID, Marian D, Volov C, Ghiciuc C, Costin C,
Florea L, Cotuiu C, Covic M. Prognosis and treatment of membranous
glomerulonephritis-a 5-year prospective srudy. Rev Med Chir Soc Med
Nat Lasi, 2000; 104(2):63-74.
10. Passerini P. Treatment of idiopathic membranous nephropathy.
G Ital Nep-hrol, 2004; 21(6):531-9.
11. Cattran DC, Appel GB, Hebert LA, Hun-sicker LG, Pohl MA, Hoy
WE, Maxwell DR, Kunis CL. Cyclosporine in pati-ents with
steroid-resistent membranous nephropathy:a randomized trial. Kidney
Int, 2001;59(4):1484-90.
12. Alexopoulos E, Papagianni A, Tsamelas-hvili M, Leontsini M,
Memmos D. Induc-tion and long-term treatment with cyc-losporine in
membranous nephropathy with the nephrotic syndrome. Nephrol Dial
Transplant, 2006;21(11):3127-32.
13. Cattran DC, Grenwood C, Ritchie S et al. A controlled trial
of cyclosporine in pa-tients with progresive membranous
nep-hropathy, Kodney Int, 1995; 47:1130-5.
14. Kang DH, Kim YG, Takeshi F. Andoh, Ka-therine L. Gordon,
Suga SI, Mazzali M, J. Jefferson A, Hughes J, Bennett W, Scre-iner
GF, Johnson RJ. Post-cyclosporine-mediated hypertension and
nephropa-thy: amelioration by vascular endothe-lial growth factor.
Am J Renal Physiol, 2001;280:727-36.
15. Iijima K, Hamahira K, Tanaka R, Ko-bayashi A, Nozu K,
Nakamura H, Yos-hikawa N. Risc factors for cyclosporine-induced
tubulointerstitialis lesions in children with minimal change
nephrotic syndrome. Kidney Int, 2002; 61:1801-5.
16. Can L, Yang CW, Kim WY, Jung JY, Cha JH, Kim YS, Kim J,
Benneti WM, Bang BK. Reversibility af chronic cyclosporine
nephropathy in rats after withdrawal of cyclosporine. Am J Renal
Physiol, 2003; 284(2):389-398.
Kontakt adresa autora: Mr.sci.dr. Alma Muslimović. Klinika za
nefrologiju, Klinički
centar Univerziteta u sarajevu. Bolnička 25. Tel: 033 297 154,
061 147 854. E-mail: almamsl@
bih.net.ba
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191MED ARH 2009; 63(4) • ORIGINALNI ČLANCI / ORIGINAL PAPERS
Korelacija koronarne bolesti kod bolesnika sa Diabetes
mellitusom tip 2
1. UVODŠećerna bolest ili Diabetes mellitus
Tip2 se manifestira kao relativni nedo-statak inzulina
(inzulinopenija), sa po-sljedično visokim vrijednostima glu-koze u
krvi (hiperglikemija). Loša meta-bolička kontrola hiperglikemija,
visoke vrijednosti HbA1c, hiperlipidemija, hi-pertenzija,
gojaznost, fizička neaktiv-nost su riziko faktori za razvoj
hronič-nih komplikacija na krvnim sudovima (2,3,4,8). Značajno
mjesto u komplika-cijama zauzima koronarna bolest, a sam dijabetes
je major rizik za razvoj koro-narne bolesti (1,5,6,7,9,10).
2. MATERIJAL I METODE RADACilj ovog istraživanja je bio da
poku-
šamo na našoj populaciji dokazati uče-
stalost koronarne bolesti kod dijabeti-čara Tip2, kontrolirajući
grupe dijabe-tičara životne dobi od 45-70 godina, sa dužinom
trajanja dijabetesa do 10 go-
dina i preko 10 godina i grupu nedijabe-tičara iste životne
dobi. Ukupno 150 pa-cijenata, tri grupe po 50 pacijenata, ži-votne
dobi od 45-70godina, prva grupa su oni koji imaju dijabetes do
10godina, druga grupa sa dijabetesom preko 10go-dina i treća grupa
su nedijabetičari. Pa-
cijente smo razvrstali po dobi i spolu, po dužini trajanja
dijabetesa, po vrsti i dozi terapije, po anamnestičkim po-dacima,
bola u prsima i dispnee, a pra-tili smo BMI, krvni pritisak,
frekvencu srca, zatim biohemijske analize krvi HbA1c, lipidogram,
transaminaze, EKG i ergometrijski test za one koji su imali
promjene u EKG-u, poštujući kontrain-dikacije za test. Sve podatke
smo unijeli u anketni upitnik, sve statistički obra-dili i došli do
rezultata.
Cilj ovog istraživanja bio je dokazati učestalost koronarne
bolesti kod nas.
3. REZULTATI RADAOvim istraživanjem dokazali smo
da je prateći skupine dijabetičara u od-nosu na skupinu
nedijabetičara rizik od obolijevanja od kardiovaskularnih bole-sti
veći kod dijabetičara i da je p
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192 MED ARH 2009; 63(4) • ORIGINALNI ČLANCI / ORIGINAL
PAPERS
Korelacija koronarne bolesti kod bolesnika sa Diabetes
mellitusom tip 2
a između dvije skupine dijabetičara ta-kođer, kod skupine iznad
10 godina tra-janja dijabetesa, gdje je p
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193MED ARH 2009; 63(4) • ORIGINALNI ČLANCI / ORIGINAL PAPERS
Korelacija koronarne bolesti kod bolesnika sa Diabetes
mellitusom tip 2
kantna razlika u primjeni samo oralnih hipoglikemika između
skupina dijabe-tičara do 10 godina i preko 10 godina,
gdje je p
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194 MED ARH 2009; 63(4) • ORIGINALNI ČLANCI / ORIGINAL
PAPERS
Stroke in Diabetic Patients in Cantonal Hospital Zenica
1. INTRODUcTIONCerebrovascular insult or Stroke is
a crisis in cerebrovascular circulation and central nervous
system function with focal neurologic dysfunction. Ac-cording to
American Heart Association (1996) diabetes mellitus is a changeable
risk factor which can precipitate the emergence of different types
and sub-types of stroke.
Diabetic population have increased susceptibility to
arteriosclerosis/ath-erosclerosis, hypertension, aterogenic risk
factor, obesity, abnormal blood lip-ids. Control studies of stroke
and pro-spective epidemiological studies of di-abetes reported
increased risk for cere-brovascular disease in diabetic
pop-ulations from 1.8-3.0. About the role of glucose status in the
occurrence of cerebrovascular disease (normal, low glucose
tolerance or diabetes), there are claims that the changes in sugar
metabolism have an important role in the etiology of
cerebrovascular disease, with a significant share in emergence of
ischemic cerebrovascular insults which in the diabetic population
are more as twice as much than in non diabetic population.
According to the publica-tions of Framingham Study in case of
patients with diabetes mellitus present is preinsulinaemia with
increasing in-sulin resistance. Increasing insulin re-sistance is
associated with an increase of atherosclerosis in carotid vessels,
disorders of glucose status, changes in
insulin levels, and as such is combined with other major
cardiovascular risk factors (1, 2).
Diabetes classification which was adopted by the ADA in 1997
recog-nizes idiopathic and symptomatic di-abetes. After certain
diabetic duration chronic complications occur, and hy-perglycemia
plays the most important role in their occurrence. Diabetic
pa-tients suffer gradual, progressive con-striction of lumen of
small and large vessels, which is why, based on these changes,
chronic complications are di-vided into two groups: microvascular
(microangiopathy – small blood ves-sels) and macro vascular
(macroangi-opathy - large blood vessels) (3, 4, 5). Macro
angiopathic changes include atherosclerosis of blood vessels of the
heart, brain and distal parts of the ex-tremities, most notably the
legs, and they cause coronary heart disease, cere-brovascular
disease and peripheral vas-cular disease.
Diabetes is the most common met-abolic disease and is one of the
most common endocrine diseases in gen-eral. Prevalence varies, with
the average of 1.5-2.5%. The definition of diabetes says that it is
a state of chronic hyper-glycemia, which can exist as a result of
decreased insulin secretion or action of various reinforced
anti-insulin pro-cesses. In addition to hypertension, di-abetes
leads to the development of vari-ous late complications that are
the basis
for changes in the small and large blood vessels, nerves, and
basal membranes of different tissues.
In case of diabetics more frequently also occurs the ischemic
stroke. Basis is the disorder of glycoregulation, of-ten parallel
to hyperlipidemia and obe-sity, and faster development of
athero-sclerosis process for people suffering from diabetes (6).
According to epide-miological study of Kanel (7) in patients with
cerebrovascular disease, diabetes is four times more frequent than
in the general population.
2. pATIENTs AND METHODsThe survey was in part retrospec-
tive, in part prospective. The patients were included in the
survey according to clearly defined criteria. The survey comprised
300 patients with diagnosed type 1 or 2 diabetes which were treated
at the Internal Ward of the Cantonal Hospital Zenica and Public
Medical Centers across Zenica-Doboj Canton in 1999-2004. The
patients were sub-jected to check-ups in 1999 and 2004, and were
given questionnaire (adapted information sheet – DIABCARE). The
data evaluated were age, sex, weight, risk factors (smoking,
alcohol con-sumption, and physical activity), type and duration of
the disease, degree of diabetes mellitus control (glycemia,
glycosylated hemoglobin, creatinine, proteinuria and lipids),
presence of chronic diabetic complications on eyes, heart,
peripheral blood vessels of lower limbs, kidneys with a special
accent on different types and subtypes of stroke.
3. AIMThe aim of our survey was to deter-
mine the stroke frequency in 300 type 1 and 2 diabetes mellitus
patients ob-served in two different periods with a time lag of 5
years.
The study included a group of 300 patients with previous
clinical and lab-oratory clearly diagnosed diabetes. Re-views,
interviews and laboratory test-ing are provided in 1999 in all
subjects. Out of this there were 62 patients with type 1 diabetes,
and with type 2 dia-betes 238.
Re-examinations, interviews and laboratory testing during 2004
were conducted in case of 278 patients, of whom 58 was with type 1
diabetes , and 220 were type 2 diabetic patients. Sub-sequent
anamnesis, during the exam-
stroke in Diabetic patients in cantonal Hospital ZenicaAzra
Alajbegovic1, Salem Alajbegovic2Neurology Clinic, Clinical Center
University of Sarajevo, Bosnia and HerzegovinaCantonal Hospital
Zenica, Bosnia and Herzegovina2
ORIgINAL pApERsUMMARYAim: The aim is to determine the frequency
of stroke in 300 patients with type 1 and 2 diabetes mellitus
observed in two different time periods with a five-year distance.
Materials and Methods: The survey comprised a group of 300 patients
with previously clinically and laboratory diagnosed diabetes. First
examination, question-naire and laboratory testing were performed
in all patients in 1999. There were 62 patients with type 1
diabetes and 238 type 2. The final exam, questionnaire and
laboratory test were performed on 278 patients in 2004 (diabetes
type 1 in 58 (20.9%), diabetes type 2 in 220 (79.1%) patients.
Additional anamnesis in 2004 grouped 2 patients into other specific
types, and those were two women, previously classified as diabetes
type 2. Twenty patients died between the first test in 2000 and the
last in 2004. Results: In 1999 2.2 % of tested patients suf-fered
the stroke , and in 2004, the stroke suffered 3.2%. There was no
statistically significant difference in the stroke occurrence in
the same group of diabetic patients during the two observed periods
with the 5-year time span. There was no statistically significant
difference in the occurrence of stroke between males and females,
or in type I and II diabetes groups. There were 4.3 % of patients
in total who suffered stroke during the survey. Conclusion: There
were no statistically significant changes in number of stroke
patients which indirectly confirms good treatment of diabetic
population in primary care.Keywords: diabetes type 1, diabetes type
2, chronic diabetic complications.
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195MED ARH 2009; 63(4) • ORIGINALNI ČLANCI / ORIGINAL PAPERS
Stroke in Diabetic Patients in Cantonal Hospital Zenica
ination of patients in 2004, 2 patients was classified as other
specific types, and it was about 2 women previously classified as
type 2 diabetes. In the pe-riod since the end of the first test on
31st March 2000 until the beginning of the second examination on
1st Feb-ruary 2004, 20 patients died.
Inclusion criteria: type 1 or type 2 diabetes according to the
latest revised criteria for the diagnosis and classi-fication of
diabetes ADA from 1997 and WHO from 1999. (1, 10). Patients of both
genders. Patients age 18 to 80 years, patients who signed informed
consent for inclusion in the study.
Respondents were due to diabetes and associated diseases treated
at the Department for Internal Diseases of the Cantonal Hospital in
Zenica and Primary health-care centers of the Ze-nica-Doboj Canton
during period 1999-2004. All are under the same conditions
reviewed, interviewed and taken all the laboratory in 1999 and
re-2004. Data obtained during both the tests are re-corded in the
similar questionnaire in-dividually for each patient.
4. REsULTsThere is no significant difference in
number of diabetics in relation to gen-der in case of Diabetes
type 1, contrary to diabetes type 2 where there are sta-tistically
significantly more women.
The average age of the sample was 58.22 ± 12.20 with statistical
significant difference between women and men at the level of p
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196 MED ARH 2009; 63(4) • ORIGINALNI ČLANCI / ORIGINAL
PAPERS
Stroke in Diabetic Patients in Cantonal Hospital Zenica
erage age between men and women with type 2 diabetes, t=2.653,
p
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197MED ARH 2009; 63(4) • ORIGINALNI ČLANCI / ORIGINAL PAPERS
Učestalost i klinička fenomenologija afazičkih poremećaja nakon
moždanog udara
1. UVODUpotreba govora u komunikaciji je
jedinstvena za ljude. Oštećenje govora ili njegovo potpuno
odsustvo predstav-lja vrlo težak i dubok udar za osobu i njegovu
porodicu. Jedna od najtežih i poraznih devastirajućih
nesposobno-sti u komunikaciji je afazija (1).
Afazija je stečeni poremećaj sim-boličke komunikacije uzrokovan
ošte-ćenjem mozga, koje se manfestira po-remećajem lingvističkih,
paralingvi-stičkih i kognitivnih procesa. Afazija obično zahvata
više modaliteta jezičke funkcije: usmeni govor, razumijevanje,
pisanje, čitanje i gestovni govor.
Vodeći uzrok afazija kod oko 80%
odraslih predstavljaju različita obolje-nja vezana za krvne
sudove mozga.
Ishemijski (tipa embolije ili trom-boze) ili hemoragijski
(intracerebralna hemoragija) cerebrovaskularni in-zult (moždani
udar) u po-dručiju prednje cirkulacije prije svega u slivu
središnje cerebralne arterije sa lijeve strane relativno često
do-vode do različitih afazičkih sindroma (2).
Cilj rada bio je utvrditi učestalost i kliničku fenome-nologiju
afazičkih poreme-ćaja nakon moždanog udara.
2. IspITANIcI I METODE RADAU radu je analizirano 993
pacijenta
sa cerebrovaskularnim inzultom (CVI) prosječne starosne dobi
66,77 godina (SD ± 10,98), koji su bili hospitalizirani na Klinici
za neurologiju Univerzitet-sko kliničkog centra Tuzla, u periodu od
01.01.2004. godine do 31.12.2004. godine. Svi pacijenti bili su
testirani na postojanje afazičkih poremećaja. Pro-cjena je izvršena
odmah po prijemu, od-nosno nakon što je zdravstveno stanje to
dozvoljavalo. Evaluacija poremećaja govora rađena je 2-3 puta tokom
hos-pitalizacije. Ispitivanje je realizirano tako što su svi
pacijenti sa moždanim udarom još u akutnoj fazi bili testirani sa
Internacionalnim testom za afazije– ITA (3). Također, uzeti su
podaci o nji-hovoj dobi, spolnoj strukturi, tipu mož-danog udara,
mjestu lezije i mogućim poboljšanjima tokom logopedskog tre-tmana.
Testom se procjenjuju slijedeći modaliteti govora: imenovanje,
ponav-ljanje, fluentnost, razumijevanje, čita-nje, pisanje,
artikulacija.
Nakon provedenog istraživanja dobiveni podaci su obrađeni pomoću
kompjuterskog statističkog programa Statistica 5.0. Distribucija
ispitanika prema rezultatima ispitivanja pred-stavljena je u
frekvencijama. Za potrebe testiranja značajnosti razlika između
stvarnih i očekivanih frekvencija dobi-venih na promatranim
varijablama ko-rišten je Hi kvadrat test, na razini zna-čajnosti od
5%.
3. REZULTATI RADAOd ukupnog broja ispitanih pacije-
nata sa moždanim udarom (993) muš-karaca je bilo 489 ili 49,24%,
a žena 504 ili 50,76%.
Najveći broj pacijenata imao je ishe-mijski moždani udar (758
ili 76,33%), zatim hemoragijski (135 ili 13,59%), a subarhnoidalno
krvarenje je dijagno-sticirano kod 29 ili 2,92% pacijenata. U grupi
koja je označena kao nepoznato
Učestalost i klinička fenomenologija afazičkih poremećaja nakon
moždanog udaraIncidence and Clinical Phenomenology of Aphasic
Disorders After StrokeEnsala Brkić, Osman Sinanović, Mirjana
Vidović, Dževdet SmajlovićKlinika za neurologiju, Univerzitetski
klinički centar Tuzla, Bosna i Hercegovina
ORIgINALNI čLANAKsAŽETAKAfazija je čest i ozbiljan pratilac svih
oblika cerebrovaskularne bolesti. Imajući u vidu činjenicu da je
sposobnost govora jedna od najvažnijih karakteristika ljudskog
roda, logično je da oporavak nakon tako ozbiljne bolesti kao što je
cerebrovaskularni inzult (CVI) ni u kom slučaju nije potpun ukoliko
nema zadovoljavajućeg oporavka govora. Osnovni cilj sprovedenog
istraživanja bio je da se retrospektivnom analizom podataka iz
medicinske dokumentacije utvrdi učestalost i klinička
fenomenologija afazičkih poremećaja nakon moždanog udara. U studiju
je uključeno 993 pacijenta sa moždanim udarom, a koji su bili
hospitalizirani na Klinici za neurologiju u Tuzli u periodu od
01.01.2004. godine do 31.12.2004. godine. Svi pacijenti su bili
testirani na postojanje afazije Internacionalnim testom za afazije.
Dobijeni podaci su pokazali da je učestalost afazija iznosila
20,34%, te da su signifikantno češće bili prisutni afazički
poremećaji kod pacijenata ženskog spola. Najčešća vrsta afazije
bila je globalna (48,51%), slijedi Brokina (16,33%), te Wernikeova
(8,41%). Transkortikalna senzorna, transkortikalna motorna i
konduktivna afazija su dijagnosticirane kod malog broja pacijentata
u akutnoj fazi moždanog udara. Što se tiče tipa moždanog udara,
afazije su češće verificirane kod pacijenata sa hemoragijskim
moždanim udarom (28,14%) u odnosu na ishemijski (20,58%), ali
razlika nije statistički značajna. Subarahnoidalna hemoragija za
posljedicu nije imala afazičke poremećaje.Ključne riječi: afazija,
učestalost i fenomenologia.ORIgINAL pApERsUMMARYIntroduction:
Aphasia is a common and serious condition, associated with all
forms of cerebrovascular disease. Capability of speech is one of
the most important characteristics of human kind, it is logical
that the recovery from a disease as serious as cerebrovascular
insult (CVI) is by no means complete without the satisfactory
recov-ery of the speech. Basic goal of the study was to analyze the
incidence and clinical phenomenology of aphasic disorders after
CVI. Patients and methods: We retrospectively analyzed 993 patients
with CVI hospitalized in Neurology Clinic in Tuzla in the period
from 1 January 2004 to 31 December 2004. All the patients were
tested for aphasia by the International aphasia test. Results and
conclusion: Obtained data showed that the incidence of aphasia was
20,34%, and that aphasic disorders were significantly more common
in female patients. The most frequent type of aphasia was global
(48,51%), then Broca’s (23,26%), and Wernicke’s (8,41).
Transcortical sensory, transcortical motor and conductive aphasia
were diagnosed in small number of patients in acute phase of CVI.
Aphasia was more frequently seen in patients with hemorrhagic
stroke (28,14%), compared to the ones with the ischemic stroke
(20,58%), but the difference is not statistically significant. In
patients with subarachnoidal hemorrhage aphasic disorders were not
present in any patient.Keywords: aphasia, incidence and clinical
phenomenology.
758
13529 71
0100200300400500600700800
Bro
j pac
ijena
ta ishemijahemoragijaSAHnepoznato
N= 993
Grafikon 1. Distribucija ispitivanih pacijenata prema tipu
moždanog udara
-
198 MED ARH 2009; 63(4) • ORIGINALNI ČLANCI / ORIGINAL
PAPERS
Učestalost i klinička fenomenologija afazičkih poremećaja nakon
moždanog udara
(71 ili 7,15%) bili su pacijenti kod kojih tip moždanog udara
nije potvrđen kom-pjuterizovanom tomografijom (CT), jer je smrt
nastupila prije nego što je ura-đen CT (grafikon 1).
U ukupnom broju analiziranih pa-cijenata, kod 202 ili 20.34% je
dijagno-sticirana afazija. Afazija je dijagnosti-cirana kod 156 ili
77,23% pacijenata sa ishemijskim i 38 ili 18,81% sa hemora-gijskim
moždanim udarom. Kod osam pacijenata ili 3,96% CT nije rađen, te se
sa sigurnošću nije mogao utvrditi tip moždanog udara. Pacijenti sa
su-barahnoidalnom hemoragijom (SAH) nisu imali smetnje govora
(grafikon 2).
U odnosu na vrstu afazije najzastu-pljenija je bila globalna u
98 slučajeva ili 48,51%, zatim Brokina u 47 ili 23,26%, te anomička
u 33 slučaja ili 16,33% (gra-fikon 3).
U ukupnom broju pacijenata koji su imali afaziju, nefluentne su
bile zastu-pljene u 72,28%, a fluentne sa 27,72% (grafikon 4).
Kod pacijenata ženskog spola regi-striran je veći broj afazija
nakon mož-danog udara, i to u 57,43% (tabela 1). (Hi-kvadrat =
4,19; P = 0,04).
U ovom istraživanju od svih pacije-nata sa hemoragijom, 14% je
imalo afa-ziju, a od svih sa ishemijom 20,58%, a među 202 pacijenta
sa afazijom, 156 ili
77,22% imalo je ishemijski, a 38 ili 18,82% hemoragijski moždani
udar.
4. DIsKUsIJAProcjenjuje se da čak 46%
moždanog udara nastaje u produktivnoj životnoj dobi, to jest u
dobi između 45 i 59 godina. Dvije trećine obo-ljelih se oporave do
veće ili manje samostalnosti, a tre-ćina je trajno onesposobljena
za samostalan život i ovisi o
tuđoj pomoći. Oko 20% bolesnika za-htijeva stacionarnu brigu i
do tri mje-seca nakon moždanog udara (4). Mož-dani udar je jedan od
glavnih etioloških faktora za nastanak afazije. U Švedskoj se
navodi podatak da 0,6% populacije svake godine postaje afazično, od
ko-jih 85% predstavljaju pacijenti koji su pretrpjeli
cerebrovaskularni inzult (5). Studija iz 2002. godine ukazuje da je
u Francuskoj učestalost afazija iznosila između 21% i 38% (6), a
Kauhanen i sa-radnici (7) ukazuju da je u 34% pacije-nata
dijagnostikovana afazija u akutnoj fazi moždanog udara. Prema
Vukoviću (5), učestalost afazija u bolesnika sa ce-rebrovaskularnim
oboljenjem iznosi 20% do 30%. Laska i saradnici (8) saop-
ćavaju da je od 106 pacijenata u akut-noj fazi moždanog udara
njih 36 ili 33% imalo afaziju. Ovim istraživanjem utvr-đeno je da
je od ukupno 993 pacijenta sa moždanim udarom njih 202 ili 20,34%
imalo afaziju, a što je u okviru rezultata drugih autora.
Što se tiče učestalosti različitih ti-pova afazija u akutnoj
fazi moždanog udara, Pedersen i saradnici (9) navode da je globalna
afazija bila zastupljena sa 32%, Brokina 12%, Vernikeova 16%,
anomička 25%, transkortikalna sen-zorna 7%, transkortikalna motorna
2%,
konduktivna 5% i izdvojene sa 2%. U ranijoj studiji Sutović i
sar. (10), gdje je analizirano 188 afazičkih pacijenata na-kon
moždanog udara, a koji su bili hos-pitalizirani na Klinici za
neurologiju u Tuzli, 42,5% imalo je globalnu afaziju, 24,5% imalo
je anomičku, 17% motornu i 16% imalo je senzornu afaziju. U ovoj
studiji najzastupljenija je bila globalna afazija, u 98 ili 48,51%
slučajeva, zatim Brokina u 47 ili 23,26%, te anomička u 33 slučaja
ili 16,33%. U najmanjem pro-centu zastupljenosti bile su
transkorti-kalna motorna i konduktivna afazija sa po jednim
slučajem ili 0,4%.
U studiji Franić, Matijašević i Bielen (11) učestalost
nefluentnih afazija izno-sila je 54,4%, a 45,6% činile su fluentne
afazije. Prema našem istraživanju, u od-
Grafikon 2. Distribucija pacijenata sa afazijom u odnosu na tip
moždanog udara
sa sigurnošću nije mogao utvrditi tip moždanog udara. Pacijenti
sa subarahnoidalnom
hemoragijom (SAH) nisu imali smetnje govora (slika 2).
U odnosu na vrstu afazije najzastupljenija je bila globalna u 98
slučajeva ili 48,51%, zatim
Brokina u 47 ili 23,26%, te anomička u 33 slučaja ili 16,33%
(slika 3).
23,26%
8,41%
48,51%
0,49%0,49%1,48%0,99%
16,33%
0,00%
10,00%
20,00%
30,00%
40,00%
50,00%BrokinaVernikeovaGlobalnaKonduktivnaTranskortikalna motornaTranskortikalna senzornaTalamičkaAnomička
Slika 3 - Distribucija dijagnostikovanih afazija prema tipu
U ukupnom broju pacijenata koji su imali afaziju, nefluentne su
bile zastupljene u 72,28%,
a fluentne sa 27,72% (slika 4).
Slika 4 - Distribucija afazija prema fluentnosti govora
Kod pacijenata ženskog spola registrovan je veći broj afazija
nakon moždanog udara, i to
u 57,43% (tabela 1).(Hi-kvadrat = 4,19; P = 0,04).
27,72
72,28
0
10
20
30
40
50
60
70
80
Proc
enat Fluentne
Nefluentne
N=202
N=202
Grafikon 3. Distribucija dijagnosticiranih afazija prema
tipu
sa sigurnošću nije mogao utvrditi tip moždanog udara. Pacijenti
sa subarahnoidalnom
hemoragijom (SAH) nisu imali smetnje govora (slika 2).
U odnosu na vrstu afazije najzastupljenija je bila globalna u 98
slučajeva ili 48,51%, zatim
Brokina u 47 ili 23,26%, te anomička u 33 slučaja ili 16,33%
(slika 3).
23,26%
8,41%
48,51%
0,49%0,49%1,48%0,99%
16,33%
0,00%
10,00%
20,00%
30,00%
40,00%
50,00%BrokinaVernikeovaGlobalnaKonduktivnaTranskortikalna motornaTranskortikalna senzornaTalamičkaAnomička
Slika 3 - Distribucija dijagnostikovanih afazija prema tipu
U ukupnom broju pacijenata koji su imali afaziju, nefluentne su
bile zastupljene u 72,28%,
a fluentne sa 27,72% (slika 4).
Slika 4 - Distribucija afazija prema fluentnosti govora
Kod pacijenata ženskog spola registrovan je veći broj afazija
nakon moždanog udara, i to
u 57,43% (tabela 1).(Hi-kvadrat = 4,19; P = 0,04).
27,72
72,28
0
10
20
30
40
50
60
70
80
Proc
enat Fluentne
Nefluentne
N=202
N=202
Grafikon 4. Distribucija afazija prema fluentnosti govora
Tip afazijaMuškarci Žene Ukupno
N % N % N %Brokina 20 9,99 27 13,36 47 23,26Vernikeova 6 2,97 11
5,45 17 8,41Globalna 41 20,29 57 28,21 98 48,51Konduktivna 1 0,49 /
/ 1 0,49Transkortikalna motorna 1 0,49 / / 1 0,49Transkortikalna
senzorna 1 0,49 2 0,99 3 1,48Talamička 1 0,49 1 0,49 2 0,99Anomička
15 7,42 18 8,90 33 16,33Ukupno: 86 42,57 116 57,43 202 100,00
Tabela 1. Spolna distribucija afazija
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199MED ARH 2009; 63(4) • ORIGINALNI ČLANCI / ORIGINAL PAPERS
Učestalost i klinička fenomenologija afazičkih poremećaja nakon
moždanog udara
nosu na fluentnost govora češće su bile nefluentne (72,28%) nego
fluentne afa-zije (27,72%).
U studiji Hiera i saradnika (12) afazija je bila neznatno češća
u žena (22,5%) nego u muškaraca (19,4%). Naše istraživanje je
pokazalo da je učestalost afazija kod pacijenata ženskog spola
si-gnifikantno češća nego kod muškaraca u akutnoj fazi moždanog
udara, a izno-sila je 57,43%.
Franić, Matijašević i Bielen(11) na-vode da je u 89,5% slučajeva
uzrok afa-zije bila ishemija, a u 10,5% hemoragija, a u našem
istraživanju, od ukupnog broja pacijenata sa ishemijskim možda-nim
udarom, 20,58% imalo je afaziju, a od ukupnog broja pacijenata sa
hemo-ragijskim moždanim udarom, 28,15% za posljedicu je imalo
afaziju.
5. ZAKLJUčAKUčestalost afazičkih poremećaja u
akutnoj fazi moždanog udara iznosi 20,34%. U odnosu na
fluentnost govora, češće su nefluentne (72,28%) nego flu-entne
(27,72%) afazije. Najčešća vrsta afazije je globalna (48,51%),
slijedi Bro-kina (23,36%), zatim anomička (16,33%), te Vernikeova
(8,41%). Transkortikalna
senzorna, transkortikalna motorna i konduktivna afazija se
dijagnostikuju kod malog broja pacijenata u akutnoj fazi moždanog
udara. Afazički pore-mećaju su češće verificirani kod paci-jenata
sa hemoragijskim moždanim udarom (28,15%) u odnosu na ishemij-ski
(20,58%) ali razlika nije statistički značajna. Kod pacijenata
ženskog spola signifikantno su češći (57,43%) afa-zički poremećaji
u akutnoj fazi mož-danog udara.
LITERATURA1. National Aphasia Association. Aphasia
Fact Sheet. Retrieved, 1999. December 14 2004, from
www.aphasia.org
2. Sinanović O. Afazije. U: Sinanović O, Smajlović Dž i sar.
Osnove neuropsi-hologije i neurologije ponašanja. Tuzla:
Univerzitet u Tuzli, 2005:45-51.
3. Benton AL, Hamsher K. deS. Multilin-gual Aphasia Examination.
Iowa City, Iowa: AJA Associates, 1989.
4. Demarin V, Trkanjec Z, Vuković V. Su-vremena organizacija
prevencije mož-danog udara. Medicus, 2001;10(1)13-18..
5. Vuković M. Afaziologija. Beograd, SD publik, 2002.
6. Godefroy O, Dubois C, Debachy B, Lec-lerc M, Kreisler A.
Vascular Aphasias
– Main characteristics of patients hos-pitalized in Acute stroke
units. Stroke, 2002; 33(3):702-5.
7. Kauhanen M, Kopelainen J, Hiltunen P, Moatta R, Mononen H,
Brusin E, Sota-niemi K, Myllyla V. Aphasia, depression and non –
verbal cognitive impairment in ishemic stroke. Cerebrovascular
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8. Laska A, Hellblom A, Murray V, Ka-han T, Von Arbin M. Aphasia
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9. Pedersen PM, Vinter K, Olsen T. Apha-sia after stroke: type
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11. Franić J, Matijaščić D, Bielen I. Inter-disciplinarni
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Kontakt adresa autora: Dr. Ensala Brkić, Klinika za neurologiju,
Univerzitetski klinički
centar Tuzla, 75000 Tuzla, Bosna i Hercegovina,
[email protected] 061/294-011
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200 MED ARH 2009; 63(4) • ORIGINALNI ČLANCI | ORIGINAL
PAPERS
Antenatalni kortikosteroidi u prevenciji respiratornog distres
sindroma: učinkovitost u odnosu na tretman-porod interval
1. UVODRespiratorni distres sindrom (RDS)
pogađa približno 40-50% djece gestacij-ske dobi ispod 32
nedjelje (1). Od 1972. (Liggins i Hovie) postoje dokazi da
kor-tikosteroidni tretman dat majci prije pri-jevremenog poroda,
smanjuje inciden-ciju RDS-a i intraventrikularne hemo-ragije te da
reducira stopu mortaliteta prijevremeno rođene djece (2,3).
Steroidi dati majci pasiraju placentarnu barijeru
te u pneumocitima tip II induciraju pro-dukciju surfactanta, što
pomaže u pre-venciji RDS-a. Najveći benefit od ante-natalne
primjene kortikosteroida imaju djeca između 24 i 34 nedjelje
gestacije (4).
Od početka primjene antenatalne kortikosteroidne terapije pa sve
do da-nas kroz različite studije i meta-analize vršena je
sistematska procjena ovih do-kaza te su razvijeni različiti
protokoli za primjenu kortikosteroida (3,5). Kortiko-
steroidi se sada smatraju standardnim tretmanom za sve trudnice
između 24 i 34 nedjelje kod kojih se očekuje prijevre-meni porod u
narednih od 1-7 dana (6,7). Najviše korišteni kortikosteroidi u
prote-klih 25 godina bili su dexamethazon (4x6 mg) i betamethason
(2x12 mg), u obliku jedne steroidne kure. Novije studije do-vode u
vezu primjenu deksametazona i povećanog rizika periventrikularne
le-ukomalacije kod prijevremeno rođene djece, te se preferira
upotreba betameta-zona (8,9). Ukoliko nije došlo do poroda
ponavljanje kura (buster doze) se ne pre-poručuje, prvenstveno zbog
rizika neu-rorazvojnih sekvela (10,11).
Rezultati nekih novijih istraživanja pokazali su da je efekat
jedne doze ste-roida date 4-24 h prije poroda bio je kli-nički
komparabilan sa efektom prepo-ručene sheme, što bi ukazivalo da bi
se interval prije poroda mogao smanjiti u akutnim kliničkim
stanjima (12).
Cilj ovog rada je procjena efikasnosti antenatalne primjene
kortikosteroida u redukciji incidencije RDS-a u zavisnosti od
početka tretmana u odnosu na vri-jeme poroda.
2. pAcIJENTI I METODE RADAOva prospektivno-retrospektivna
studija je obuhvatila 80 prijevremeno rođene djece gestacijske
dobi 26-34 ne-djelje čije su majke antepartalno dobile
kortikosteroidni tretman. Sedamdese-tipet (75) trudnica iz
ispitivane grupe tretirano je jednom kurom deksameta-zona, a 5
trudnica ponavljanim kurama deksametazona (buster doze). Kontrolnu
grupu činilo je 92 djece iste gestacijske dobi, čije majke
antepartalno nisu tre-tirane kortikosteroidima. Djeca dijabe-tičnih
majki, djec