8 January/June 2022 1, 2

Journal of the Discipline for Research and Development

Clinical Center University of Sarajevo

DISCIPLINA ZA
NAUKU I NASTAVU
ČUVAJTE SVOJE ZDRAVLJE!

31. maj
Svjetski dan nepušenja
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 Mirza Dilić, Enra Suljić-Mehmedika,
Amela Begić, Semir Bešlija,
Alen Džubur, Amina Valjevac,
Nermir Granov, Nermina Babić

Ivan Knežević (Slovenia), Slobodan

Janković (Serbia), Tomaž Marš (Slovenia),
Grazyna Adler (Poland), Narea Alonso
(UK), Bilgin Kaygisiz (Turkey), Şazin
Tüzün (Turkey), Silva Butković-Soldo
(Croatia), Raffaele Bugiardini (Italy), Erol
Ćetin (Turkey), Oktay Ergen (Turkey),
Zlatko Fras (Slovenia), Dan Gaita
(Romania), Steen Dalby Kristensen
(Denmark), Mimoza Lezhe (Albania),
Herman Haller (Germany), Fausto Pinto
(Portugal), Mihailo Popovici (Moldova),
Nadan Rustemović (Croatia), Kenan
Arnautović (USA), Georges Saade
(Lebanon), Panos Vardas (Greece),
Gordan Vujanić (UK)

KOPIKOMERC, East Sarajevo

KOPIKOMERC, East Sarajevo

 Medical Journal (2022) Vol. 28, No 1,2

Original articles

The efficacy of intra-umbilical vein administration of carboprost versus oxytocin in the

management of retained placenta: surgical and non-surgical risk factors 7
Mohammad Abou El-Ardat, Sebija Izetbegović, Vajdana Tomić

Vitamin D deficiency and hypothyroidism in individuals with Down syndrome 13

Rubina Alimanović-Alagić, Jasmina Fočo-Solak, Ismana Šurković, Gorana Sulejmanpašić

MSCT coronarography as part of the diagnostic modality of complex heart 18

pathology: single center experience
Nermir Granov, Damir Rebić, Alen Džubur, Almir Fajkić, Zlatan Zvizdić, Muhamed Djedović

Uroflowmetry and post-void residual urine as tests to diagnose asymptomatic urethral

obstruction in boys following urethral surgery or trauma 23
Zlatan Zvizdić, Ermina Begović, Asmir Jonuzi, Emir Milišić, Danka Miličić-Pokrajac

Early results of carotid endarterectomy in diabetic patients with symptomatic stenosis 27

Muhamed Djedović, Slavenka Štraus, Amel Hadžimehmedagić, Nermir Granov, Samed Djedović

Clinical significance of neutrophil to lymphocytes ratio in differential diagnosis

of cervical lymphadenopathy 32
Zehra Sarajlić, Amina Blekić

Comparison of efficacy of femoral AO/OTA 31-A2 intertrochanteric fractures treated

with dynamic hip screw (DHS) and proximal femoral nail (PFNA) 37
Faruk Lazović, Đemil Omerović, Adnan Papović, Mirza Sivro

Professional articles

Prehospital time of severe trauma in Canton Sarajevo 42

Amela Ahmić, Tatjana Jevtić

Case reports

Segmental portal hypertension as a cause of bleeding from the upper parts of the
digestive tract: case report 47
Edin Hodžić, Sadat Pušina, Jasmin Perviz

Instructions to authors 51

Instrukcije autorima 53
Medical Journal (2022) Vol. 28, No 1,2 Original article

The efficacy of intra-umbilical vein administration of

carboprost versus oxytocin in the management of
retained placenta: surgical and non-surgical risk factors

Efikasnost intra-umbilikalne venske aplikacije

karboprosta i oksitocina u tretmanu zaostale posteljice:
hirurški i nehirurški faktori rizika

Mohammad Abou El-Ardat1*, Sebija Izetbegović 2,Vajdana Tomić 3

1
Clinic of Obstetrics and Gynecology, Clinical Center University of Sarajevo , Jezero, 71000 Sarajevo, Bosnia and Herzegovina
2
University Clinical Center Management, Bolnička 25, 71000 Sarajevo, Bosnia and Herzegovina
3
Clinic of Obstetrics and Gynecology, University Clinical Hospital Mostar, Bijeli Brijeg b.b, 88000 Mostar, Bosnia and Herzegovina

*Corresponding author

ABSTRACT injection of carboprost versus oxytocin in the management of

retained placenta. The time for placental expulsion was significantly
Introduction: retained placenta is one of the major causes of shorter and postpartum hemoglobin (117.3±1.3) was significantly
primary and secondary post-partum hemorrhage (PPH) and active higher in the intra-umbilical oxytocin groups than in the carboprost
management of the third stage of labor reduces the risk of PPH. Aim: groups.
to compare the efficacy of intra-umbilical vein injection of carboprost
versus oxytocin by different medication doses and surgical and non - Keywords: retained placenta, oxytocin, carboprost, placental expulsion
surgical risk factors in the management of retained placenta. Materials
and methods: this prospective clinical study was conducted at the
Clinic of Obstetrics and Gynecology of the Clinical Center University SAŽETAK
of Sarajevo, in the two-year period. Patients were randomized in 4
groups and 8 subgroups, respectively: A 1(n=25) (carboprost, surgical Uvod: zaostala posteljica predstavlja jedan od glavnih uzroka
risk factors, 1 amp. a 0.5 mg in 30 ml of 0.9%NaCl); A 2(n=25) primarne i sekundarne postpartalne hemoragije (PPH), te aktivno
(carboprost, surgical risk factors, 1 amp. a 1.0 mg in 30 ml of vođenje trećeg porođajnog doba smanjuje rizik od PPH. Cilj: uporediti
0.9%NaCl);B1(n=25) (oksytocin, surgical risk-factors, 10 UI in 20 ml efikasnost intra-umbilikalne venske aplikacije karboprosta i oksitocina
of 0.9% NaCl); B2(n=25)(oksytocin, surgical risk-factors, 20 UI in 20 prema vremenu i učestalosti ekspulzije posteljice. Materijali i metode:
ml of 0.9% NaCl); C1(n=25) (carboprost, non-surgical risk factors, 1 sprovedena je prospektivna klinička studija na Klinici za ginekologiju i
amp. a 0.5 mg in 30 ml of 0.9%NaCl); C 2(n=25) (carboprost, non- porodiljstvo Kliničkog centra Univerziteta u Sarajevu u 2-godišnjem
surgical risk factors, 1 amp. a 1.0 mg in 30 ml of 0.9%NaC l); periodu. Ispitanice su randomizirane u 4 grupe, odnosno 8 podgrupa:
D1(n=25) (oksytocin, non-surgical risk-factors, 10 UI in 20 ml of 0.9% A1(n=25) (karboprost, hirurški faktori rizika, otopina 1 amp. a 0,5 mg
NaCl); D2(n=25) (oksytocin, non-surgical risk-factors, 20 UI in 20 ml karboprosta u 30 ml 0,9%NaCl); A2(n=25) (karboprost, hirurški
of 0.9% NaCl). The main outcome variable was expulsion of retained faktori rizika, otopina 1 amp. a 1,0 mg karboprosta u 30 ml
placenta and second outcome variables were: duration of time from 0,9%NaCl);B1(n=25) (oksitocin, hirurški faktori rizika, otopina 10 UI u
intra-umbilical vein administration of drug to expulsion of retained 20 ml 0,9% NaCl); B2(n=25) (oksitocin, hirurški faktori rizika, otopina
placenta, the number of cases who required blood transfusion and 20 UI u 20 ml 0,9% NaCl); C1(n=25) (karboprost, nehirurški faktori
antibiotics, postpartum hemoglobin after 24h. Results: the group B2 rizika, otopina 1 amp. a 0,5 mg karboprosta u 30 ml 0,9%NaCl);
(UVI oxytocin 20 IU in 20 mL saline, surgical risk factors) and the C2(n=25) (karboprost, nehirurški faktori rizika, otopina 1 amp. a 1,0
group D2 (UVI oxytocin 20 IU in 20 mL saline, non-surgical risk mg karboprosta u 30 ml 0,9%NaCl); D1(n=25) (oksitocin, nehirurški
factors) had shorter expulsion time (minutes) (Me=5; IQR=4 to 5; faktori rizika, otopina 10 UI u 20 ml 0,9% NaCl); D2(n=25) (oksitocin,
Me=5; IQR=4.3 to 6, respectively) compared with other groups nehirurški faktori rizika, otopina 20 UI u 20 ml 0,9% NaCl). Glavna
(p<0.001). The success rates of total expulsion of the placenta by mjera ishoda je bila ekspulzija zaostale posteljice, te su praćene i
groups were not statistically significant (70% vs. 82% vs. 72% vs. 78%, zamjenske mjere ishoda: vrijeme od intra-umbilikalne venske
respectively; p=0.483). Post-intervention hemoglobin concentrations aplikacije lijeka do ekspulzije posteljice, uč4estalost transfuzije krvi i
was statistically significantly greater in the group B (117.3±1.3) vs. the aplikacije antibiotika, postpartalna vrijednost hemoglobin anakon 24h.
group A (112.1±1.3) , (p =0.028). Conclusion: there is no difference Rezultati: grupa B2 (intra-umbilikalna venska aplikacija oksitocina 20
in the rates of the total expulsion of the placenta comparing IUV i.j.u 20 ml 0,9% fiziološke otopine, hirurški riziko-faktori) i grupa D2
8 M. Abou El-Ardat et al.

(intra-umbilikalna venska aplikacija oksitocina 20 i.j.u 20 ml 0,9% A (112,1±1,3), (p=0,028). Zaključak: vrijeme ekspulzije zaostale
fiziološke otopine, nehirurški riziko-faktori) su imali kraće vrijeme posteljice je signifikantno kraće, dok su postpartalne vrijednosti
ekspulzije posteljice (minute) (Me=5, IQR=4 to 5; Me=5, IQR=4,3 to hemoglobin (117,3±1,3) znatno više kod intra-umbilikalne venske
6, zaredom) u poređenju sa ostalim grupama (p<0,001).Ne postoji aplikacije oksitocina u poređenju sa karboprostom, pri aktivnom
statistički značajna razlika u stopi uspješnosti totalne ekspulzije tretmanu zaostale posteljice.
zaostale posteljice među grupama: A, B, C i D (70%, 82% 72%, 78%,
zaredom; p=0,483). Post - intervencijski nivo hemoglobina je bio Ključne riječi: zaostala posteljica, oksitocin, karboprost, ekspulzija
statistički značajno veći u grupi B (117,3±1,3) u poređenju sa grupom posteljice

INTRODUCTION of tocolytics in current pregnancy. The term 'retained placenta' is

used when the placenta has not been delivered within one hour after
Retained placenta is one of the major causes of primary and the birth of the baby (11). The length of the third stage of labor is a
secondary post-partum hemorrhage (PPH), associated with increased potential modifiable risk factor for PPH at vaginal delivery, but there
risk of maternal morbidity and mortality (1). PPH accounts for nearly is no definitive evidence that early intervention to remove the
one quarter of all maternal deaths world-wide with an estimated placenta manually will prevent PPH.
125,000 deaths per year (2). One of the main causes of PPH is The usage of uterotonic agent in the management of retained
retained placenta, which affects 0.5% to 3.0% of women following placenta is under debate. This study aimed to compare the efficacy of
delivery, and a further 15% to 20% of the PPH maternal deaths are intra - umbilical vein injection of carboprost versus oxytocin by
due to retained placenta (3,4). There are three main types of different medication doses and surgical and non-surgical risk factors
retained placenta following the vagina delivery: placenta adherens in the management of retained placenta.
(when there is failed contraction of the myometrium behind the
placenta), trapped placenta (a detached placenta trapped behind a
closed cervix) and partial accreta (when there is a small area of MATERIALS AND METHODS
accreta preventing detachment) (5,6). Risk factors that can lead to
retained placenta can be divided into surgical and non-surgical risk This prospective clinical study was conducted at the Clinic of
factors (7,8,9,10). Surgical risk factors are: the number of cesarean Obstetrics and Gynecology, Clinical Center of University of Sarajevo
sections, the number of spontaneous abortions and their gestational in the two-year period and included 200 patients. Informed consent
age, the number of artificial abortions and gestational age, the was obtained in all cases and risk factors were identified, via a
number of uterine cavity abrasions, hysterosalpingography (HSG), questionnaire, additionally. We studied all the patients prospectively
hysteroscopy (diagnostic and operative), myomectomy, Sy Asherman and by computerized randomization. All patients underwent a
(surgical etiology). Non-surgical risk factors are: congenital anomalies gynecological sonography with Voluson E6 Ultrasound General
of the uterus, endometrial synechiae (Sy Asherman) of inflammatory Electric (EG), upon admission to the Clinic. Patients were randomized
etiology, amnioinfection syndrome, untreated endometritis, pluripara in 2 groups by surgical risks factors (Table 1 and Table 2) and 8
(more than 3 births), placenta membranacea (large placenta), usage subgroups by medication and doses.

All women RP (n=200)

Surgical risks factors (n=100) Non-surgical risks factors (n=100)

Group A (n=50) Group B (n=50) Group D (n=50)

Group C (n=50)
UVI carboprost UVI oxytocin UVI oxytocin
UVI carboprost
GroupA1 (n=25) Group B1 (n=25) Group C1 (n=25) Group D1 (n=25)
1 amp. a 0.5 mg 10 IU in 20 mL 1 amp. a 0.5 mg 10 IU in 20 mL
in 30 mL saline saline in 30 mL saline saline
GroupA2 (n=25) Group B2 (n=25)
1 amp. a 1.0 mg 20 IU in 20 mL Group C2 (n=25) Group D 2 (n=25)
in 30 mL saline saline 1 amp. a 1.0 mg 20 IU in 20 mL
in 30 mL saline saline

Flowchart for the study Abbreviations: RP retained placenta, UVI umbilical vein injection, IU international unit
The efficacy of intra-umbilical vein administration of carboprost versus oxytocin in the
management of retained placenta: surgical and non-surgical risk factors 9

The exclusion criteria were uterine atony and bleeding > 500 ml; Table 1 The frequency of surgical risk factors by groups.
maternal hemodynamic instability (pulse ≥ 120 b.p.m., or a decrease
in diastolic blood pressure of more than 20mm Hg after delivery,
Group A (n=50) Group B (n=50)
associated medical disorders (e.g., cardiac disease, anemia, Surgical risk factors
hypertension and diabetes), multiple pregnancy. The main outcome n % n %
variable was expulsion of retained placenta and second outcome
variables were: duration of time from intra-umbilical vein C - sections 5 10.0 5 10.0
administration of drug to expulsion of RP, t he number of cases who Premature birth 8 16.0 2 4.0
required blood transfusion and antibiotics, postpartum hemoglobin Stillbirth 2 4.0 1 2.0
after 24h.
The included women were with a singleton living fetus, achieved Exploration 18 36.0 19 38.0
vaginal delivery, and failed to deliver the placenta after 30 minutes of Artificial abortion
active management of the third stage of labor (intravenous
0 38 76.0 18 36.0
administration of 5 IU of Syntocinon in the presence of an intact
umbilical cord, fundal pressure and controlled cord traction after 5, 1 5 10.0 9 18.0
10 and 15 minutes) in all patients. A retained placenta was diagnosed 2 6 12.0 18 36.0
when separation did not occur 30 minutes after delivery and UVI is
followed. The appropriate solution was injected into the umbilical 3 1 2.0 5 10.0
vein for 15 seconds by type of treatment and the umbilical cord was Spontaneous abortion
clamped again. At 5 and 10 minutes after administration of the 0 22 44.0 20 40.0
medication, or in the case of clinical signs of placental separation, an
attempt to deliver the placenta was made. If the final attempt to 1 5 10.0 6 12.0
deliver the placenta failed, manual removal was performed by the 2 18 36.0 17 34.0
usual maneuver under general anesthesia. Standard management of
3 5 10.0 7 14.0
the third stage of labor was continued, including blood transfusion
and uterotonic agents for continued bleeding. Evaluation of the drop Myomectomy 6 12.0 7 14.0
in hemoglobin level was done by comparing the hemoglobin Hysterescopy 13 26.0 15 30.0
concentration on admission and 24h after delivery.

Statistical analysis Table 2 The frequency of non - surgical risk factors by groups.

The results are presented as the means and standard deviations Group C Group D
(±SD) for numerical variables and as numbers and percentages for Non – surgical factors (n=50) (n=50)
categorical variables. Statistical significance for differences was n % n %
analyzed using the One-Way ANOVA, One -Way ANCOVA , Kruskal Intrauterine adhesions (IUAs) 6 12,0 7 14,0
Wallis H test. Post-hoc analysis was performed using Independent 12,0
Sample T test or Mann Whitney U test with Bonferroni correction Pluriparous (>3 births) 5 10,0 6
for multiple testing. Statistical analysis was performed by using the Placenta membranacea/diffusa 8 16,0 11 22,0
Statistical Package for the Social Sciences (SPSS Release 19.0; SPSS Tocolytics 31 62,0 26 52,0
Inc., Chicago, Illinois, United States of America) software. Statistical
significance was accepted for p-values< 0.05.
The demographic and obstetric data of the study groups were
RESULTS comparable, except for the level of education (p<0.05) and term
or preterm delivery (p<0.01) (Table 3).
The frequency of surgical and non - surgical risk factors by groups
is shown in Tables 1 and 2.
10 M. Abou El-Ardat et al.

Table 3 Demographic and clinical characteristics.

Surgical risk factors Non – surgical risk factors

Group A (n=50) Group B (n=50) Group C (n=50) Group D (n=50)

UVI carboprost UVI oxytocin UVI carboprost UVI oxytocin P-value

Maternal age (y)a 27.7±3.7 26.5±4.7 28.7±5.2 26.2±5.4 >0.05

Gestational age (weeks)a 38.4±3.1 39.0±1.0 38.8±1.4 39.0±1.0 >0.05
Birth length (cm)c 52.0 (50 to 53) 52.0 (51 to 53) 52.0 (52 to 53) 51.0 (50 to 53) >0.05
3500 3425
3400 3700
Birth weight (grams)c (3175 to 3.862) (2987 to 3912) >0.05
(3000 to 3825) (3200 to 3950)
Level of education b
Elementary school 4 8.0 3 6.0 6 12.0 6 12.0
High school 43 86.0 38 76.0 33 66.0 29 58.0 0.037
Higher education 3 6.0 9 18.0 11 22.0 15 30.0
Deliveryb
Term 43 86.0 50 100.0 46 92.0 50 100.0 0.001
Preterm 7 14.0 0 0.0 4 8.0 0 0.0
Smokingb
No 35 70.0 32 64.0 33 66.0 35 70.0
>0.05
Yes 15 30.0 18 36.0 17 34.0 15 30.0
a
Smoking duration (y) 4.9±1.6 4.3±1.9 4.9±1.5 4.7±1.9 >0.05
examination
Data are presented as: a mean±SD, b number or percentage (%), c median (IQR)

The results for the main and secondary outcomes and the to 5) and D2 (Me=5; IQR=4.3 to 6) compared with groups: A1
success rate are presented in Table 4. The time for placental (Me=9; IQR=8 to 9) (p<0,001), A2 (Me=8; IQR=6.3 to 9)
expulsion was significantly shorter in the intra-umbilical oxytocin (p<0,001), B1 (Me=7; IQR=6.3 to 8) (p<0,001), C1 (Me=8.5;
groups than in the carboprost groups ( p< 0.001). The post hoc IQR=8 to 9) (p<0,001), C2 (Me=7; IQR=6.5 to 9) (p<0,001) and
analysis revealed statistically significant differences in the time for D1 (Me=7; IQR=5.8 to 9) (p<0,001), but not between the B2 and
placental expulsion (minutes) between the groups B2 (Me=5; IQR=4 D2 groups or any other group combination (Figure 1).

Table 4 The outcome of the third stage of labor.

Surgical risk factors Non – surgical risk factors

Group A (n=50) Group B (n=50) Group C (n=50) Group D (n=50)
UVI carboprost UVI oxytocin UVI carboprost UVI oxytocin P-value

Placental expulsion (min)a (years)a 8.5 (7.0 to 9.0) 6.0 (4.9 to 7.0) 8.0 (6.5 to 9.0) 6.0 (4.5 to 8.0) <0.001
35 70.0 41 82.0 36 72.0 39 78.0 >0.05
Placenta expelled spontaneouslyb

Manual removal of placentab 15 30.0 9 18.0 14 28.0 11 22.0 >0.05

Secondary postpartum 0 0.0 0 0.0 0 0.0 0 0.0 -

hemorrhageb
Blood transfusionb 4 8.0 2 4.0 8 16.0 3 6.0 >0.05
Antibioticsb 18 36.0 16 32.0 38 76.0 17 34.0 <0.001
Success rate (%) 70.0 82.0 72.0 78.0 >0.05

Data are presented as: a median (IQR), b number or percentage (%)

The efficacy of intra-umbilical vein administration of carboprost versus oxytocin in the
management of retained placenta: surgical and non-surgical risk factors 11

(12). In placenta adherens, oxytocics have been used to contract the

p<0.001 retro-lacental myometrium. However, if injected locally through the
umbilical vein, they bypass the myometrium and perfuse directly into
the venous system (13). In the randomized clinical study of Elfayomy
AK., the success rate in the carbetocin group was 86.84% compared
to 77.5% in the intra-umbilical oxytocin group (14). In the study of
Habek D, et al., there were no statistically significant differences
among groups: 20 IU of oxytocin in 20 ml saline; 0.5 mg of
carboprost tromethamine; or 0.2 mg of methylergometrine injected
in the umbilical vein after clamping (76.9% vs.85.7% vs.64.2% (15).
We did not find a significant difference in the rates of the total
expulsion of the placenta comparing IUV injection of carboprost
versus oxytocin in the management of retained placenta by using
different doses of medications. In our study, the subgroups that
received oxytocin 20 IU in 20 ml saline, with both surgical and non-
Figure 1 Time for placental expulsion (min.) by diff erent groups
surgical risk factors, had the highest frequency of placental expulsion
in the study. Data are presented as median (IQR).
(80-88%) compared to the groups that received carboprost with
doses 0.5 mg or 1.0 mg in 30 ml saline (68- 76%). However, the
There was no statistically significant difference between A, B, C
difference did not reach the level of statistical significance.
and D groups and subgroups in the success rates of the total
In the study of Nankali A, et al., the women who received
expulsion of placenta (70% vs. 82% vs. 72% vs. 78%, respectively,
intraumbilical vein oxytocin had a shorter third stage of labor as
p=0.483). The frequency of blood transfusion was not statistically
compared with the placebo group (4.24 ± 3.27 min vs. 10.66 ± 7.41)
different between the four groups ( Table 4 ). Of the total number of
(p < 0.001) (16). The present study showed a statistically significant
patients in group A (n=50), 4 (8.0%) of them had a blood transfusion
reduction in the median of duration of third stage of labor in the
(M=525±150 ml), in group B (n=50) only 2 (4.0%) patients had a
group B2 (UVI oxytocin 20 IU in 20 mL saline, surgical risk factors)
blood transfusion (M=300 ml), in group C (n=50) 8 (16%) patients
and the group D2 (UVI oxytocin 20 IU in 20 mL saline, non-surgical
had a blood transfusion (M=375±70 ml) and in group D ( n=50) 3
risk factors) (Me=5; IQR=4 to 5; Me=5; IQR=4.3 to 6, respectively)
(6.0%) patients had a blood transfusion (M=300 ml).
compared with other groups. The present study did not demonstrate
any differences between the groups in the amount of blood
Table 5 Adjusted and unadjusted means and variability for 24h
transfusion. Hemoglobin concentration 24h after delivery was lower
post-partum hemoglobin concentration (g/L) with pre-
in carboprost group than in the oxytocin group for surgical risk
intervention hemoglobin concentration as a covariate.
factors. Five women required blood transfusion in oxytocin gr oup for
excessive bleeding and twelve women in carboprost group. This
Adjusted Unadjusted indicates positive effect of oxytocin in reducing bleeding
Groups means means F3,195 p η²p complications.
M SE M SE The time until manual removal of placenta in the absence of
bleeding varies widely between different countries, from under 30
A 110.2 1.1 112.1 1.3
minutes (Spain and Hungary) to 60 minutes and more (The
B 118.2 1.0 117.3 1.3 3.08 0.02 0.04 Netherlands) (17). In the study of Cummings K et al., the optimal
C 115.8 1.2 114.7 1.3 1 9 5 length of the third stage of labor to prevent PPH was 18min (18). In
the study of over 12,000 births, Combs and Laros found that the risk
D 116.1 1.1 116.2 1.3
of hemorrhage increased after 30 minutes of placental retention
M – mean; SE – standard error; F – value of test; η²p –effect size (19). Active management of the third stage of labor involves
administration of intravenous oxytocin, early cord clamping,
After adjustment for pre-intervention hemoglobin concentration, transabdominal manual massage of the uterus, and controlled traction
there was a statistically significant difference in post-intervention of the umbilical cord. Should this appear insufficient, the next step is
hemoglobin concentrations between the interventions. F(3, 195) = usually manual removal of the placenta (20). In the guidelines of
3.081, p = 0.029, partial η2 = 0.045. Post-intervention hemoglobin Leduc D. et al., it is concluded that active management of the third
concentrations was statistically significantly greater in the group B stage of labor reduces the risk of PPH and should be offered and
(117.3±1.3) vs. the group A (112.1±1.3), (p =0.028). After recommended to all women (21).
adjustment for pre-intervention hemoglobin concentration, there A limitation of our study is that it is done at single center, thus,
was not a statistically significant difference in post-intervention results may not be applicable to other populations.
hemoglobin concentrations between subgroups.
CONCLUSION
DISCUSSION
There is no difference in the rates of the total expulsion of the
In this study we compared efficacy of the intra-umbilical vein placenta comparing IUV injection of carboprost versus oxytocin in
administration carboprost versus oxytocin in the management of the management of retained placenta. The time for placental
retained placenta by surgical and non-surgical risk factors and expulsion was significantly shorter and postpartum hemoglobin was
different doses of medication. Oxytocin is the most commonly used significantly higher in the intra-umbilical oxytocin groups than in the
uterotonic and has been well known in midwifery for a long time carboprost groups.
12 M. Abou El-Ardat et al.

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2013;1–11. Mohammad Abou El-Ardat, MD, PhD
7. Habek D, Franicevic D. Intraumbilical injection of uteroton ics for retained
Clinic of Obstetrics and Gynecology
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7. Declaration of patient consent: the authors certify that they have
11. World Health Organization. The Prevention and Management of Postpartum
Hemorrhage. Report of a Technical Working Group, Geneva. 3 -6 July 1989. obtained all appropriate patient consent forms. In the form, patient s
Document WHO/MCM/90.7. Geneva: World Health Organization, 1990. have given their consent for their images and other clinical
12. Roach MK, Abramovici A, Tita AT. Dose and duration of oxy tocin to prevent information to be reported in the journal.
postpartum hemorrhage: a review. Am J Perinatol. 2013;30(7):523-8.
Authors' Contributions: MAEl-A, SI and VT gave substantial
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Acta Obstet Gynecol Scand. 2016;95(5):501-4. contribution to the conception or design of the article and in the
14. Elfayomy AK. Carbetocin versus intra -umbilical oxytocin in the management of acquisition, analysis and interpretation of data for the work. Each
retained placenta: a randomized clinical study. J Obstet Gynaecol Res. author had role in article drafting and in process of revision. Each
2015;41(8):1207-13.
15. Habek D, Franicević D. Intraumbilical injection of uterotonics for retained author gave final approval of the version to be published and they
placenta. Int J Gynaecol Obstet. 2007;99(2):105-9. agree to be accountable for all aspects of the work in ensuring that
16. Nankali A, Keshavarzi F, Fakheri T, Zare S, Rezaei M, Daeichin S. Effect of questions related to the accuracy or integrity of any part of the work
intraumbilical vein oxytocin injection on third stage of labor. Taiwan J Obstet
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17. Deneux-Tharaux C, Macfarlane A, Winter C, Zhang W-H, Alexander S, Bouvier- Financial support and sponsorship: nil.
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variations in timing within Europe. BJOG. 2009;116(1):119-24.
Medical Journal (2022) Vol. 28, No 1,2 Original article

Vitamin D deficiency and hypothyroidism in individuals

with Down syndrome

Nedostatak vitamina D i hipotireoza kod osoba sa

Downovim sindromom

Rubina Alimanović-Alagić1, Jasmina Fočo-Solak2, Ismana Šurković 1, Gorana

Sulejmanpašić3
1
Clinic of Nuclear Medicine and Endocrinology, Clinical Center University of Sarajevo, Bolnička 25, 71000 Sarajevo, Bosnia and Herzegovina
2
Clinical Chemistry and Biochemistry, Clinical Center University of Sarajevo, Bolnička 25, 71000 Sarajevo, Bosnia and Herzegovina
3
Clinic of Psychiatry, Clinical Center University of Sarajevo, Bolnička 25, 71000 Sarajevo, Bosnia and Herzegovina

*Corresponding author

ABSTRACT SAŽETAK

Introduction: vitamin D deficiency is a global health problem and Uvod: nedostatak vitamina D je globalni zdravstveni problem koji
leads to serious problems. Hypothyroidism is a condition in which the dovodi do ozbiljnih problema. Hipotireoza je stanje u kojem štitna
thyroid gland is not able to produce enough thyroid hormone. Aim: to žlijezda nije u stanju proizvesti dovoljno hormona. Cilj: istražiti
investigate the prevalence of Hypothyroidism and vitamin D prevalenciju hipotireoze i nedostatka vitamina D kod bolesnika s
deficiency in patients affected with Trisomy 21. Materials and trisomijom 21. Materijali i metode: ovo je retrospektivna studija
methods: this is a retrospective study conducted in the three-year provedena u trogodišnjem periodu, od 1. maja 2019. do 31. aprila
period, specifically from 1 May 2019 to 31 April 2021, and it included 2021. godine, koja je obuhvatila 60 ispitanika s Downovim
60 respondents with Down syndrome whose blood samples were sindromom čiji su uzorci krvi prikupljeni i analizirani na Kliničkom
collected and analysed at the Clinical Center University of Sarajevo. centru Univerziteta u Sarajevu. Prikupljeni podaci uključivali su
Data collected included laboratory reports such as profiles of both D laboratorijske nalaze koji su se odnosili na vrijednosti vitamina D i
vitamin and thyroid hormonws. Laboratory tests were performed at hormona štitne žlijezde. Laboratorijska ispitivanja obavljena su na
the Institute of Clinical Chemistry and Biochemistry of the Clinical Institutu za kliničku hemiju i biohemiju Kliničkog centra Univerziteta u
Center University of Sarajevo using standard determination Sarajevu standardnim metodama određivanja. Rezultati: od ukupno
methods. Results: out of the total of 60 examined patients tested for 60 pregledanih pacijenata kojima je testiran nivo vitamina D i TSH,
vitamin D and TSH levels, females were in majority with 60% and najviše je bilo žena sa 60%, a muškaraca sa 40%. Razlike u
males with 40%. Differences in Vitamin D values between intervals vrijednostima vitamina D između intervala (1-4 kontrole) Kruskal
(1-4 Check-up) with Kruskal Wallis te st showed a statistically Wallis testom pokazale su statistički značajnu razliku u vrijednostima
significant difference in values of Vitamin D (ng/mL) between check- vitamina D (ng/mL) između kontrola, sa p<0,001. Razlike u
ups, with p <0.001. Differences in TSH values between intervals (1-4 vrijednostima TSH između intervala (1-4 kontrole) Kruskal Wallis
check-up) with Kruskal Wallis test showed a statistically significant testom pokazale su statistički značajnu razliku u vrijednostima TSH
difference in values of TSH (uIU/mL) between check-ups, with p (uIU/mL) između kontrola, sa p<0,001. Korelacija između vrijednosti
<0.001. Correlation between Vitamin D (ng/mL) and TSH values vitamina D (ng/mL) i TSH (uIU/mL) sa Spearmanovom korelacijom
(uIU/mL) with Spearman's correlation between TSH and Vitamin D između TSH i vitamina D pokazala je statistički značajnu negativnu
showed a statistically significant negative correlation between the korelaciju između te dvije vrijednosti, p <0,001. Zaključak: istraživanje
two, with p <0.001. Conclusion: the research showed the occurrence je pokazalo pojavu hipotireoze i nedostatka vitamina D kod ispitanika
of hypothyroidism and vitamin D deficiency in subjects with Dawn s Dawnovim sindromom.
syndrome.
Ključne riječi: vitamin D, hipotireoza, Downov sindrom
Keywords: vitamin D, hypothyroidism, Down syndrome

INTRODUCTION deficiency plays a significant role in a dozens of numerous disorders

(3).
Vitamin D deficiency is a global health problem (1) and leads to Hypothyroidism is a condition in which the thyroid gland
serious problems, can result in low bone mass (2). The effects of produces less thyroid hormone than itshould. TSH normal values
vitamin D independent of calcium, magnesium, and Vitamin D are 0.3-4.2 mIU/L. High TSH levels indicate that the thyroid is
underactive and that it needs more stimulation in order to work. The
14 R. Alimanović-Alagić et al.

thyroid gland produces two hormones: triiodothyronine (T3) and

thyroxine (T4). These hormones play an important role in
metabolism. The thyroid gland is controlled (regulated) by thyroid -
stimulating hormone (TSH). TSH is produced by the pituitary gland,
which is located in the brain. When the thyroid gland produces less 24; 40%
thyroid hormone than it should (hypothyroidism), metabolism slows
down and causes a variety of symptoms (4,5).The main test used to 36; 60%
detect hypothyroidism is measuring blood levels of TSH.
Down syndrome (DS), or trisomy of chromosome 21, is the
most common genetic disorder when a child is born with an extra
copy of chromosome (6).

AIM

The aim of this study was to investigate the prevalence of Females Males
Hypothyroidism and vitamin D deficiency in patients affected with
Trisomy 21.

Figure 1 Distribution of participants by gender.

MATERIALS AND METHODS
Out of total number of participants (60), majority were females
This is a retrospective study conducted in the three-year period, (60 %, i.e. 36) and 40% (24) were males.
specifically from 1 May 2019 to 31 April 2021, and it included 60
respondents with Down syndrome whose blood samples were Table 1 Distribution of participants by age.
collected and analysed at the Clinical Center University of Sarajevo.
Data collected included laboratory reports such as profiles of both D
Age category Cumulative
vitamin and thyroid hormones. Total of with 60 samples were taken No (%)
(years) frequency (ω)
and analysed. Laboratory tests were performed at the Institute of
Clinical Chemistry and Biochemistry of the Clinical Center of the 18-25 22 (36,7) 36.7
University of Sarajevo using standard determination methods.
Elecsys Vitamin D total is used for calibrating the quantitative
26-35 29 (48,3) 85,0
Elecsys Vitamin D total assay reagents on the Elecsys and cobas e 36-42 9 (15,0) 100.0
immunoassay analyzers. Serum 25(OH) vitamin D in human serum
matrix and Thyroid hormone values were measured using Rosche Total 60 (100.0)
Elecsys system on Cobas e 6000 analyzers by ECLIA method.
D vitamin and TSH were measured at the beginning of the study
and after 3, 6, 9 and 12 months. Referral values for using this method
D vitamin ranges are 30.0-100.0 ng/mL. Normal TSH value is (0.3-4.2
mlU/l).
Age category (years)

36-42 9
Statistical analysis

Data were analysed using MS Office Excel 2016 and SPSS 26-35 29
Statistics 21.0, by descriptive and inferential statistical methods.
Numeric variables were described by appropriate measures of
central tendency and variability (mean/median and standard
deviation/interquartile range, normality tested using Kolmogorov- 18-25 22
Smirnov abd Shapiro-Wilk tests), while qualitative variables were
described using absolute and relative frequencies. Null hypotheses
were tested with appropriate statistical tests (Mann-Whitney, 0 10 20 30
Kruskal-Wallis). Results were also presented in tables and graphs.

Figure 2 Distribution of participants by age.

RESULTS

Samples were taken from total of 60 patients. Their distribution The values of serum 25(OH)D level registered participants are
by gender is presented in Figure 1, and age distribution (by age are showed in the box plot diagram (Figure 3).
categories) in Table 1 and Figure 2
Vitamin D deficiency and hypothyroidism in individuals with Down syndrome 15

Table 2 Descriptive statistics of D vitamin (ng/mL).

120
1 2 3 4 100
Checkup Check up Checkup Checkup

TSH (uIU/mL)
80
Minimum 1.8 5,8 18 25
25th 6.115 18 26 33 60
Percentile
40
Median 8.875 21 29 37
75th 12.85 26 31 40.25 20
Percentile
Maximum 20.3 31 41 55 0
Mean 9.518 21.29 28.57667 37.415 1 Check-up 2 Ceck-up 3 Check-up 4 Check-up
Range 18.5 25.2 23 30
Standard 4.810 5.176 4.597 5.807 Figure 4 Boxplot TSH levels.
deviation

Table 4 Diff erences in Vitamin D values (ng/mL) between intervals

60 (1-4 check-up).

50 N Mean Chi P value

Vitamin D (ng/mL)

Rank Square
40 Checkup I 60 33.55
30 Checkup II 60 96.68
198.821 <0.001
Checkup III 60 146.86
20
Checkup IV 60 204.92
10
0 Kruskal Wallis test showed a statistically significant difference in
1 Check- 2 Check- 3 Check- 4 Check- values of Vitamin D (ng/mL) between check-ups, with p <0.001.
up up Up Up

Table 5 Differences in TSH values (uIU/mL) between intervals

Figure 3 Boxplot of serum vitamin D levels. (1-4 Check-up).

N Mean Chi P value

Table 3 Descriptive statistics of TSH values (uIU/mL).
Rank Square
1 2 3 4 Check-up Checkup I 60 204.34
Check- Check- Check- Checkup II 60 146.13
191.265 <0.001
up up up Checkup III 60 94.71
Minimum 7.9 2,6 3.4 2.9 Checkup IV 60 36.82
25th Percentile 22 6.075 4.2 3.6
Median 28.5 9.6 4.85 3.85 Kruskal Wallis test showed a statistically significant
75th Percentile 35.5 14.25 5.275 4 difference in values of TSH (uIU/mL) between check-ups, with p
<0.001.
Maximum 100 42 12.1 4.2
Mean 32.2683 11.71 5.35833 3.748333 Table 6 Correlation between Vitamin D (ng/mL) and TSH values
3 3 (uIU/mL).
Range 92.1 39.4 8.7 1.3
Vitamin
Standard 17.464 7.741 1,887 0.354
D
deviation
Spearmans
-0,836
Spearman's correlation TSH rho
P value <0,001

Spearman's correlation between TSH and Vitamin D, showed a

statistically significant negative correlation between the two,
with p <0.001.
16 R. Alimanović-Alagić et al.

DISCUSSION CONCLUSION

Down's syndrome (DS), or trisomy of chromosome 21, is the The results of the study show that hypovitaminosis D and
most common genetic disorder associated with autoimmune diseases hypothyroidism are very frequent in DS individuals and that it is
(7,8). DS is associated with increased risk of medical problems critical to assess the importance of vitamin D prophylaxis in these
including gastrointestinal, cardiac, and pulmonary anomalies as well as subjects and prescribe therapy with levothyroxine tablets. DS
developmental delay and endocrine abnormalities (4). Among the patients who have a history of autoimmune diseases may need more
endocrine abnormalities, thyroid dysfunction is the commonest. It is 25(OH)D supplementation.
estimated to occur in 4-8% of children with Down syndrome. The
spectrum of thyroid dysfunction in patients with DS include
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Institute of Medicine: what clinicians need to know. J Clin Endocrinol Metab. Reprint requests and correspondence:
2011;96(1):53-8.
29. Pludowski P, Karczmarewicz E, Bayer M, Carter G, Chlebna-Sokół D, Czech -
Rubina Alimanović-Alagić, MD, PhD
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Declaration of patient consent: the authors certify that they have

obtained all appropriate patient consent forms. In the form, patients
have given their consent for their images and other clinical
information to be reported in the journal.
Authors' Contributions: RA-A, JF-S, IŠ and GS gave substantial
contribution to the conception or design of the article and in the
acquisition, analysis and interpretation of data for the work. Each
author had role in article drafting and in process of revision. Each
author gave final approval of the version to be published and they
agree to be accountable for all aspects of the work in ensuring that
questions related to the accuracy or integrity of any part of the work
are appropriately investigated and resolved.
Financial support and sponsorship: nil.
Conflict of interest: there are no conflicts of interest.
Medical Journal (2022) Vol. 28, No 1,2 Original article

MSCT coronarography as part of the diagnostic modality

of complex coronary artery disease: single center
experience

MSCT koronarografija kao dio dijagnostičkog modaliteta

kompleksne koronarne arterijske bolesti: iskustvo jednog
centra
Nermir Granov1*, Damir Rebić2, Alen Džubur 3, Almir Fajkić4, Zlatan Zvizdić5,
Muhamed Djedović 1
1
Clinic of Cardiovascular Surgery, Clinical Centre University of Sarajevo, Bolnička 25, 71000 Sarajevo, Bosnia and Herzegovina
2
Clinic of Nephrology, Clinical Centre University of Sarajevo, Bolnička 25, 71000 Sarajevo, Bosnia and Herzegovina
3
Clinic of Heart Diseases, Blood Vessels and Rheumatisam, Clinical Centre University of Sarajevo, Bolnička 25, 71000 Sarajevo, Bosnia and
Herzegovina
4
Department of Pathophysiology, Faculty of Medicine, University of Sarajevo, Čekaluša 90, 71000 Sarajevo, Bosnia and Herzegovina
5
Clinic of Pediatric Surgery, Clinical Center University of Sarajevo, Patriotske lige 81, 71000 Sarajevo, Bosnia and Herzegovi na
*
Corresponding author

ABSTRACT SAŽETAK

Introduction: MSCT coronarography is non-invasive cardiac Uvod: MSCT koronarografija je neinvazivni modalitet snimanja
imaging modality as alternative to invasive cardiac angiography. The srca kao alternativa invazivnoj angiografiji srca. Zlatni standard za
gold standard for diagnosing CAD is coronarography. Aim: to present dijagnosticiranje CAD je koronarna angiografija. Cilj: predstaviti
the use of Multi-Slice Computed Tomography (MSCT) for the upotrebu višeslojne kompjuterizovane tomografije (MSCT) u svrhu
purpose of diagnostic evaluation of patient with complex coronary dijagnostičke evaluacije pacijenata sa složenom patologijom
artery pathology. Materials and methods: in a period of two-year koronarnih arterija. Materijal i metode: u periodu od dvije godine
three groups of patients with calcium score (CAC) at the Clinic of pregledane su tri grupe pacijenata sa calcium score (CAC) na Klinici
Cardiovascular Surgery of the Clinical Canter University of Sarajevo za kardiovaskularnu hirurgiju Kliničkog centra Univerziteta u Sarajevu.
were reviewed. We analysed CAD findings based on calcium score Analizirali smo CAD nalaze zasnovane na riziku na osnovu kalcijum-
risk. Results: we examined three groups of patients with CAC score; skor izračuna. Rezultati: ispitivali smo tri grupe pacijenata sa CAC
group with a low to mild risk of CAD (calcium score 0-99) n-320 skorom; grupa sa niskim do blagim rizikom od CAD (kalcij skor 0 -99)
(39.6%), moderate risk of CAD (calcium score 100-400) n-314 n-320 (39,6%), umjerenim rizikom od CAD (kalcij skor 100-400) n-
(38.8%) and high risk of CAD (Calcium score >400) n-174 (21.6%). 314 (38,8%) i visokim rizikom od CAD (kalcij skor >400) n-174
Patients with a low CAD risk had a mean CAC score of 54.1±13.2. (21,6%). Pacijenti sa niskim rizikom od CAD imali su srednji CAC
Even though patients with low to mild CAC score have a low risk of skor od 54,1±13,2. Iako pacijenti sa niskim do blagim CAC skorom
future cardiovascular events, in two cases, on coronary angiography imaju nizak rizik od budućih kardiovaskularnih događaja, u dva slučaja
we found: subocclusion of the ramus intermedius with soft tissue koronarografijom smo utvrdili: subokluziju ramus intermediusa sa
plaque (calcium score was 96), and in the second case presence of a mekim tkivnim plakom (kalcijumski skor 96), u drugom slučaju
bridge on the left anterior descending (LAD) artery (calcium score prisustvo mosta na levoj prednjoj silaznoj (LAD) arteriji (kalcijumska
was 0). In group with moderate CAD risk, CAC score was 245.5 ocjena je bila 0). U grupi sa umjerenim rizikom od CAD, CAC skor je
± 16.3. In this group the vast majority did conduct coronary bio 245,5±16,3. U ovoj grupi velika većina je radila koronarografiju.
angiography. Here we found significant CAD stenosis in n-195 Ovdje smo pronašli značajnu CAD stenozu u n-195 (62,0%). U grupi
(62.0%). In group of high risk of CAD (>400), we found calcium visokog rizika od koronarne bolesti (>400) nalazimo calcium score
score 643.9±53.2. In this group patients with a calcium score > 1000 643,9±53,2. U ovoj grupi, pacijenti sa skorom kalcijuma > 1000 bili su
were immediately referred for coronary angiography. Conclusion: odmah upućeni na koronarografiju bez obzira na to. Zaključak: MSCT
MSCT coronary angiography is an important factor in the diagnostic koronarna angiografija je važan faktor u dijagnostičkoj evaluaciji
evaluation of patient referred to cardiac surgery as well for a follow pacijenata upućenih na kardiohirurgiju, kao i za praćenje nakon
up after coronary angiography or surgery. koronarne angiografije ili operacije.

Keywords: MSCT, calcium score, cardiac surgery Ključne riječi: MSCT, kalcijum skor, kardiohirurgija
MSCT coronarography as part of the diagnostic modality of complex heart pathology: single center experience 19

INTRODUCTION MATERIALS AND METHODS

A Heart Team (HT) was organised at the Clinical Canter A total of 1105 patients were treated at the Clinic of
University of Sarajevo (CCUS), consisting of cardiovascular surgeon, Cardiovascular Surgery of the CCUS in the period from January
interventional cardiologist and cardiologist in addition to them other 2020 to December 2021. Based on Calcium score (CAC) patients
specialities or even family doctor for palliative care can be included. were divided into three groups: low, medium and high score group.
Multi-Slice Computed Tomography (MSCT) is a non -invasive For each of the groups we calculate percentage of confirmed severe
diagnostic radiological-cardiology method, which records changes in coronary artery disease by coronarography.
coronary blood vessels with the help of multi-slice detectors and The Coronary calcium score is used to quantify coronary calcium
computer software, and after the application of contrast medium - level (5). It is a test that measures the location and extent of calcium
intravenously (1). MSCT represents a diagnostic method that is of in the coronary arteries. Based on that finding we can suggest
great importance for HT. The final result is a three-dimensional presence of subclinical or advances coronary artery disease. Also it
representation of the coronary artery system. MSCT has the ability can be used as substitute for standard risk factors in predicting CAD
to determine the calcium score, observe the qualitative risk.
characteristics of the atherosclerotic plaque, the ability to detect Any calcium score over 400 is correlated with an increased risk
"suspicious" findings - e.g. thrombus in the heart cavities, display of cardiac death (over 20%), while a score over 1000 represents
anomalous starting points of the coronary system, and the patency of extensive calcium accumulation (6).
aortocoronary bypass grafts, as well as vein drainage route, other Vulnerable soft tissue plaques do not contain calcium in their
congenital heart diseases. (Figure 1) (2,3). Patients with a previously composition, and for this reason this grading is not specific, but it is
placed stent are not the best candidates for MSCT due to the used in assessing the degree of development of atherosclerosis, as
possible occurrence of a blurring phenomenon, when calcifications well as assessing the prognosis of the disease and grading the risk of
that are more expressive mask the lumen of the coronary blood cardiac death.
vessel located below the stent. Prior MSCT procedure beta blocker and sublingual nitrates have
Generally, MSCT coronarography is commonly indicated to rule to be administered in order to lower heart rate, avoid arrhythmia
out obstructive CAD in symptomatic patients, ergo test positive or and dilate the coronary arteries. Also, synchronous ECG monitoring
borderline with low or intermediate risk for CAD, in high risk non- is applied. Although the most desirable heart rate is between 50-
cardiac surgery where invasive coronarography can be dangerous, 55/min, the rate of up to 65/min is tolerated. As MSCT use contrast
acquired and congenital heart disease with low risk for CAD (4). medium that could be nefrotoxic, urea and creatinine laboratory
AHA/ACC did not recommend use of MSCT for screening of CAD findings are obligatory.
in every asymptomatic patient.
MSCT coronarography have high negative predictive value and is RESULTS
most useful for evaluation patients at low to intermedium risk for
CAD and who are at borderline or clearly symptomatic. The Clinic of Cardiovascular Surgery performed 1105 cardiac
procedures in the period from January 2020 to December 2021.
Out of the total number of patients to whom MSCT was indicated,
297 (26.9%) failed an attempt of the MSCT performing (Figure 2). In
3 (0.3%) patients who were with previously implanted
electrostimulator, the MSCT was performed only after therapy
optimization.

Failed to perform MSCT

Total procedures

Figure 1 Multi-Slice Computed Tomography (MSCT). 0 500 1000 1500

AIM Figure 2 Number of patients that failed to perform MSCT.

The aim of the study was to present the use of Multi-Slice In 2 (0.2%) cases, the examination was stopped before the last
Computed Tomography (MSCT) for the purpose of diagnostic contrast series due to a rhythm disturbance, and in one patient
evaluation of patients with complex coronary artery pathology. (0.1%) the examination was brought to an end, but it was not
possible to read it due to artefacts. In 3 (0.3%) cases, we had patients
with a rhythm disorder of the type of atrial fibrillation with a
ventricular response above the cut-off value of 65/min. In two (0,2%)
cases, we had patients with atrial fibrillation with proper ventricular
20 N. Granov et al.

response, below 65/min, who regularly underwent MSCT. Given that Table 1 CAD risk, sex, age, risk factors and CAC score among
the Clinic of Radiology offers the possibility of repeating the MSCT observed patients between 2020 and 2021.
procedure for the same patient up to 4 times, that protocol was
used, and two patients managed to undergo MSCT in the third CAC CAC CAC score
attempt. Of the total number of patients, 212 (19.2%) were patients score score (>400)
who, in addition to valvular disease, were also diagnosed with (0-99) (100- (N=174)
coronary disease (Figure). (N=320) 400)
(N=314)
CAD Low to Moderate Higher
Risk mild
Coronary disaese with Sex Male 239 213 95
valve pathology (74.7%) (67.8%) (54.6%)
Female 81 101 79
(25.3%) (32.2%) (45.4%)
Total procedures Age mean±SD 53.5 58.2 65
±3.4 ±5.3 ±4.3
Risk Hypertension 240 234 105
0 500 1000 1500 factors (75.0%) (74.5%) (60.3%)
Diabetes 67 73 46
mellitus (20.9%) (23.3%) (26.4%)
Figure 3 Patients with coronary disease along with valve Hyperlipidemia 74 83 58
pathology. (23.1%) (26.4%) (33.3%)
Overweight 143 152 105
We examined three groups of patients with C alcium (CAC) (44.6%) (48.4%) (60.3%)
score and compared CAD risk with CAC score. The group with a Smoking 174 123 95
low to mild risk of CAD included n-320 (39.6%) patients, the group (54.3%) (39.1%) (54.6%)
with moderate risk of CAD n-314 (38.8%) and the group with higher CAC mean±SD 54.1 245.5 643.9
risk of CAD n-174 (21.6%) patients. score ± 13.2 ± 16.3 ±53.2
Patients with a low CAD risk had a mean CAC score of
54.1±13.2 ranging from 0 to 99. The majority of patients 318 Table 2 Comparison of Calcium score and Coronarography.
(99.4%) in this group were discharged from hospitalisation with an
advice on risk factors control (hypertension, diabetes mellitus, MSCT Calcium Confirmed on Futher plan
obesity, diet and other factors) Even though patients with low to mild score (mean±SD) coronarograpgy
CAC score have a low risk of future cardiovascular events, in two Low group 1 (0,1%) HT decission to stay on
cases, patients with a low calcium score were also sent for coronary (54.1 ± 13.2) MSCT or to perform
angiography on the recommendation of the interventional Coronarography
cardiologist. In the first case, due to the described soft tissue plaque
Medium group 195 (17,5%) Perform Coronarography
that leads to subocclusion of the ramus intermedius (Ca score=96),
(245.5 ± 16.3)
and in the second Ca score=0 due to the presence of a bridge on
High group 172 (15,0%) Perform Coronarography
the left anterior descending (LAD) artery.
(643.9±53.2)
The group of moderate CAD risk had CAC score of 245.5±16.3
ranging from 100 to 400. All patients were recommended to do a
Our results, showed that higher CAC score on MSCT
coronary angiography due to moderate risk of CAD. The vast
angiography, followed by a coronary angiography led to a more
majority did conduct coronary angiography with significant stenosis of
rational use of coronary angiography and more precise target of
the coronary arteries n-195 (62.0%)
severe CAD patients.
In the group of higher risk for CAD (>400), mean CAC score
was 643.9±53.2 ranging from 400 to 1400. Patients with a CAC
DISCUSSION
score>1000 were referred for mandatory coronary angiography.
Part of this group related to patients who were already in
In recent decades, due to the socio-epidemiological situation, as
preoperative preparation at the Clinic of Cardiovascular Surgery n-
well as congenital and uncontrolled acquired risk factors, our society
54, and 2 patients had already undergone surgery (RE-DO operation
has been struggling with the tendency of a constant increase in the
was performed after coronary angiography).
number of people suffering from cardiovascular dise ases; coronary
All CAD risk, sex, age, risk factors and CAC score among
and valvular. Patients with pronounced cardiac symptoms are
patients presented to the HT between 2020 and 2021 are presented
referred for diagnostic procedures, on the basis of which an
in Table 1.
indication for active cardio surgical treatment can be established.
Nevertheless, the gold standard in diagnostic terms, when it comes to
patients with coronary artery disease, is coronary angiography (7).
Coronary angiography is an interventional cardiology procedure, with
the help of which the coronary blood vessels are visualized with X-
rays, after the intravenous application of an iodine contrast agent
with the help of a catheter, using the Seldinger method. However,
MSCT coronarography as part of the diagnostic modality of complex heart pathology: single center experience 21

the question arises, is coronary angiography, as a preoperative diagnostic protocol will be adopted as a standard not only in the field
diagnostic procedure, necessary for patients with valvular heart of cardiac surgery but also in other branches of medicine.
disease. This is important especially in age groups (<40 and
>40years) (8).
Waiting lists for coronary angiography are long. Regardless of all CONCLUSION
the human resources, daily work and commitment of doctors,
patients can wait up to a year for this examination. In that year, MSCT coronary angiography is an important factor in the
according to the criteria, reversible changes in the myocardium can perioperative treatment of cardiac surgery patients. Our study,
become irreversible, satisfactory heart power - reduced, insignificant showed that higher CAC score on MSCT angiography, followed by a
changes in the coronary blood vessels can become subocclusions, and coronary angiography led to a more rational use of coronary
mild or moderate changes in the valves become severe, even in old angiography and more precise target of severe CAD patients. A
age. A patient in good psychophysical condition, with potentially good multidisciplinary approach should be the path to the development of
"timing" for surgery and an expected good outcome, becomes an modern cardiac surgery.
inoperable, psychologically altered, dissatisfied patient, with
premature heart valve changes. REFERENCES
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The role of multislice computed tomography (MSCT) in the detection of blunt
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horizontal position with the limb extended for 6 or 12 hours after Neth Heart J. 2020;28(1):44-50.
the procedure, and verticalization is performed the day after the 7. Łukasz W, Mariusz K, Weronika P, Witold R, Zofia Dz , Cezary K, et al. Coronary
CTA enhanced with CTA based FFR analysis provides higher diagnostic value
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possible. All this makes the given method more expensive and 8. Juan-Salvadores P, Jiménez Díaz VA, Iglesia Carreño C, Guitián González A, Veiga
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best possible medical service in which the individual patient - an
individual, different from all others, received an individual diag nostic
and therapeutic approach, with the reduction of the waiting list,
reduced costs of medical services, and ideal "timing" for the
operation. As it was said at the beginning, HT is at the very beginning
of its activity, with the hope that this approach to the patient and
22 N. Granov et al.

Reprint requests and correspondence:

Nermir Granov, MD, PhD
Clinic of Cardiovascular Surgery
Clinical Center University of Sarajevo
Bolnička 25, 71000 Sarajevo
Bosnia and Herzegovina
Email: [email protected]
ORCID ID: 0000-0002-6228-6230

Declaration of patient consent: the authors certify that they have

obtained all appropriate patient consent forms. In the form, patients
have given their consent for their images and other clinical
information to be reported in the journal.
Authors' Contributions: NG, DR, ADž, AF, ZZ and MĐ gave
substantial contribution to the conception or design of the article and
in the acquisition, analysis and interpretation of data for the work.
Each author had role in article drafting and in process of revision.
Each author gave final approval of the version to be published and
they agree to be accountable for all aspects of the work in ensuring
that questions related to the accuracy or integrity of any part of the
work are appropriately investigated and resolved.
Financial support and sponsorship: Nil.
Conflict of interest: there are no conflicts of interest.

Bosnia and Herzegovina versions of Guidelines for Patients!

Bosanskohercegovaka verzija Vodia za pacijente!
Medical Journal (2022) Vol. 28, No 1,2 Original article

Uroflowmetry and post-void residual urine as tests to

diagnose asymptomatic urethral obstruction in boys
following urethral surgery or trauma

Uroflowmetrija i rezidualni postmikcioni urin kao testovi

za dijagnosticiranje asimptomatske opstrukcije uretre
kod dječaka nakon operacije uretre ili traume

Zlatan Zvizdić1*, Ermina Begović1, Asmir Jonuzi 1, Emir Milišić 1,

Danka Miličić-Pokrajac2
1
Clinic of Pediatric Surgery, Clinical Center University of Sarajevo, Patriotske lige 81, 71000 Sarajevo, Bosnia and Herzegovina
2
Pediatric Clinic, Clinical Center University of Sarajevo, Patriotske lige 81, 71000 Sarajevo, Bosnia and Herzegovina

* Corresponding author

ABSTRACT Keywords: uroflowmetry, post-void residual urine, urethral surgery,

urethral trauma
Introduction: Uroflowmetry (UF) and post-void residual urine
(PVR) are the first steps in the evaluation of lower urinary tract
symptoms (LUTS) and voiding dysfunction (VD) for both adults and SAŽETAK
children. Aim: to analyse and evaluate the accuracy of UF and PVR in
the evaluation of children with LUTD caused by acquired infravesical Uvod: urofloumetrija (UF) i rezidualni urin nakon mokrenja
obstruction of the urinary tract. Materials and methods: 68 boys with (PVR) predstavljaju prve korake u evaluaciji simptoma donjeg
a history of previous urethral surgery or trauma were evaluated by urinarnog trakta (LUTS) i disfunkcije mokrenja (VD) kod odraslih i
studying their voiding history, a physical examination, UF, and djece. Ovo istraživanje je imalo za cilj analizirati tačnost urofloumetrije
suprapubic ultrasonography. The children were divided into two i rezidualnog urina u procjeni i dijagnosticiranju opstrukcije uretre kod
groups according to the existence or absence of LUTS: the first dječaka nakon operacije uretre ili traume. Cilj: analizirati i ocijeniti
group included 33 boys with LUTS (obstructive group) and the točnost UF i PVR u evaluaciji djece s LUTD-om uzrokovanom
second group included 35 asymptomatic boys with the absence of stečenom infravezikalnom opstrukcijom urinarnog trakta.Materijali i
LUTS (non-obstructive group). All uroflowmetry data, including metode: 68 dječaka s historijom prethodnih operacija uretre ili
maximum flow rate (Qmax), voided volume (VV), time to Qmax, traume evaluirano je proučavanjem njihove historije mokrenja,
voiding time (Vt), average flow rate (Qave), uroflow patterns as well fizikalnim pregledom, UF-om i suprapubičnim ultrazvukom. Djeca su
as post-void residual urine (PVR) are recorded and analyzed. Results: podijeljena u dvije grupe prema prisustvu ili odsustvu LUTS-a: u prvoj
the mean age was 3.84 ± 3.08 years. Except for VV and flow time, all grupi bilo je 33 dječaka s LUTS-om (opstruktivna skupina), a u drugoj
UF components were significantly different between obstructive and grupi 35 asimptomatskih dječaka s odsustvom LUTS-a
non-obstructive groups. Qmax was smaller in the obstructive group (neopstruktivna skupina). Svi podaci urofloumetrije, uključujući
(4.9 ± 2.32 vs. 10.34 ± 4.82, p<0.001). Time to Qmax was greater in maksimalni protok (Qmax), izmokrenu količinu mokraće (VV),
the obstructive group (66.27 ± 197.7 vs. 12.97 ± 25.7, p<0.001). vrijeme do Qmax, vrijeme mokrenja (Vt), prosječnu brzinu protoka
Also, Vt was greater in the obstructive group (100.36 ± 234.07 vs. (Qave), obrasce uroflowa, kao i rezidualni ur in nakon mokrenja
28.71 ± 26.41, p<0.001). Qave was smaller in the obstructive group (PVR) su bili zabilježeni i analizirani. Rezultati: prosječna dob bila je
(3.27 ± 1.71 vs. 5.58 ± 3.09, p<0.001). PVR was greater in the 3,84 ± 3,08 godina. Osim VV i vremena protoka, sve komponente UF
obstructive group (37.78 ± 48.75 vs. 13.17 ± 28.91, p<0.001). The su se značajno razlikovale između opstruktivne i neopstruktivne
boys in the obstructive group had a significantly increased risk of non- grupe. Qmax je bio manji u opstruktivnoj grupi (4,9 ± 2,32 prema
bell-shaped urination (plateau or interrupted patterns) compared 10,34 ± 4,82, p<0,001). Vrijeme do Qmax bilo je veće u
with boys in the non-obstructive group. Conclusion: our findings opstruktivnoj grupi (66,27 ± 197,7 naspram 12,97 ± 25,7, p<0,001).
suggest that UF and PVR used in daily pediatric urology practice are Također, Vt je bio veći u opstruktivnoj grupi (100,36 ± 234,07 prema
methods capable of identifying asymptomatic meatal or urethral 28,71 ± 26,41, p<0,001). Qave je bio manji u opstruktivnoj grupi
obstruction in boys with a previous history of urethral surgery or (3,27 ± 1,71 naspram 5,58 ± 3,09, p<0,001). PVR je bio veći u
trauma determining response to treatment of lower urinary tract opstruktivnoj grupi (37,78 ± 48,75 prema 13,17 ± 28,91, p<0,001).
disorders. Dječaci u opstruktivnoj skupini imali su značajno povećan rizik od ne-
zvonolikog oblika krivulje mokrenja (plato ili isprekidani uzorci) u
24 Z. Zvizdić et al.

poređenju s dječacima u neopstruktivnoj grupi. Zaključak: naši prethodnom historijom uretralnih operacija ili trauma, determinirajući
rezultati sugerišu da su UF i PVR koji se koriste u svakodnevnoj odgovor na liječenje poremećaja donjeg urinarnog trakta.
pedijatrijskoj urološkoj praksi metode koje mogu identificirati
asimptomatsku meatalnu ili uretralnu opstrukciju kod dječaka s Ključne riječi: urofloumetrija, rezidualni urin nakon mokrenja,
uretralna operacija, uretralna trauma,

INTRODUCTION and were read by a single pediatric urologist who was not blinded to
patients voiding symptoms. The flow rate was considered valid if the
Uroflowmetry (UF) and post-void residual urine (PVR) are the voided volume was more than two-thirds of the expected bladder
most frequently used initial screening urodynamic tests when lower capacity. We analyzed study pediatric patients concerning age,
urinary tract dysfunction (LUTD), also known as dysfunctional maximal flow rate (Qmax), voided volume, postvoid residual volume,
voiding, is suspected (1). UF and PVR are screening tests that allow serum PSA level, prostate volume, I-PSS, and the urodynamic
the proper selection of patients for more complex urodynamic variables.
testing and provide the information necessary to determine the
appropriate treatment strategy (2).
Although tabularized incised plate (TIP) urethroplasty or Statistical analysis
Snodgrass procedure has gained worldwide acceptance for distal
hypospadias repair due to highly acceptable functional and cosmetic Statistical analysis used: Statistical Package for Social Science for
results, complications associated with this procedure can be Windows version 16.0 (SPSS Inc., Chicago, Il., USA). Student t-test
significant and include meatal stenosis, urethral fistula, dehiscence, and and Mann-Whitney test were used to confirm statistical differences
diverticulum (3). Some studies also determined the link between between analyzed groups. Statistical significance was considered as p
increased PVR and urinary tract infections (UTIs) in hypospadias < 0.05.
operated by TIP (4,5) and found that the mentioned link can be
attributable to a degree of increased resistance and outflow
obstruction in the created neo-urethra (6). Lower urinary tract RESULTS
trauma, although relatively uncommon in blunt trauma, also can cause
substantial morbidity with marked effects on quality of life (7,8). A total of 68 patients were included in the study, 33 (48.5%) in
the obstructive group and 35 (51.5%) in the non-obstructive group.
AIM The mean age of the entire cohort was 3.84 ± 3.08 years. The age
distribution of patients with a history of previous urethral surgery or
The aim of the study was to analyse and evaluate the accuracy of trauma is shown in Table 1.
UF and PVR in the evaluation of children with LUTD caused by
acquired infravesical obstruction of the urinary tract. Table 1 The age distribution of patients with previous urethral
surgery or trauma.

MATERIALS AND METHODS Age range Number (No.) Percentage of total

(years) (%)
A retrospective medical records rev iew was undertaken of all
consecutive patients with a history of previous urethral surgery or 0-1 yr 14 20.6
trauma who underwent uroflowmetry and determining post-void
residual urine from January 2017 to Mart 2018. Formal approval for 2-3 yr 29 42.6
the review of the medical records was obtained from the Ethics
Committee of the Clinical Center University of Sarajevo. 4-6 yr 16 23.5
UF and PVR were performed at the Pediatric Surgery/Urology
Outpatient Department of the Clinical Center University of Sarajevo. 7-10 yr 4 5.9
PVR is defined as the volume of urine left in the bladder at the end
of micturition. PVR measurement was performed immediately after 11-15 yr 5 7.4
the completion of uroflowmetry by ultrasonography. Voiding
dysfunction (VD), a diagnosis by symptoms and urodynamic Total 68 100
investigations, is defined as abnormally slow and/or incomplete
micturition and abnormally high post-void residuals. Lower urinary
tract symptoms (LUTSs) were the term used to describe a range of
symptoms related to problems of the lower urinary tract (bladder, UF and PVR were done for the following clinical entities: post-
prostate, and urethra), although no such correlation exists between hypospadias repair in 57 (83.8%), post-urethral valve fulguration in 3
symptoms and underlying pathophysiology. By the type of symptoms, (4.4%), post-circumcision meatal stenosis in 5 (7.4%), post-traumatic
LUTS is divided into irritating symptoms (IS) and obstructive urethral stricture in 2 (2.9%) and post epispadias reconstructive
symptoms (OS). IS was defined as frequency, urgency, and urge surgery in 1 (1.5%). The age distribution of patients with or without
incontinence. OS was defined as hesitancy, weak stream, straining, acquired infravesical obstruction of the urinary tract is shown in
intermittency, and incomplete emptying. According to the definition Table 2.
provided by the International Children's Continence Society (ICCS),
the urinary flow patterns (voiding curves) were divided into five
groups: bell-shaped, tower-shaped, plateau, staccato, and interrupted,
Uroflowmetry and post-void residual urine as tests to diagnose asymptomatic urethral
25
obstruction in boys following urethral surgery or trauma

Table 2 The age distribution of patients with vs without 20

obstruction.
18

Obstructive group Non-obstructive 16

group 14
Number (No.) and Number (No.) and
Age range Percentage of total Percentage of total 12
(years) (%) (%) 10
0-1 yr 7 (21.2%) 7 (20.0%)
8
2-3 yr 12 (36.4%) 17 (47.6%)
4-6 yr 10 (30.3%) 6 (17.1%) 6
7-10 yr 3 (9.1%) 1 (2.9%) 4
11-15 yr 1 (3.0%) 4 (11.4%)
2
Total 33 (100%) 35 (100%)
0
A significant difference between obstructive and non-obstructive Plateau
Bell-shaped Interrupted Tower-shaped
groups (p<0.05) was detected in maximum flow rate (Qmax), time
to Qmax, voiding time (Vt), average flow rate (Qave), and post -void Figure 1 Voiding flow patterns (voiding curves) in non-
residual urine PVR (Table 3). obstructive group.
Table 3 Baseline data of patients and test results after evaluation
18
with uroflowmetry and PVR in obstructive vs non-obstructive
groups. 16

14
Parameter Infravesical obstruction P value
YES NO 12
Age (yr) 3.75 ± 2.70 3.94 ± 3.81 0.819 10
Voided volume 173.3 ± 130.7 130.8 ± 97.84 0.149
(VV) 8
Maximum flow 4.9 ± 2.32 10.34 ± 4.82 0.0001 6
rate (Qmax)
Time to Qmax 66.27 ± 197.7 12.97 ± 25.7 0.0001 4
Voiding time (Vt) 100.36 ± 28.71 ± 26.41 0.0001
2
234.07
Flow time 93.24 ± 145.6 77.2 ± 148.53 0.394 0
Average flow 3.27 ± 1.71 5.58 ± 3.09 0.0001 Bell-shaped Plateau Staccato
Interrupted
rate (Qave)
Post-void residual 37.78 ± 48.75 13.17 ± 28.91 0.001 Figure 2 Voiding flow patterns (voiding curves) in obstructive
urine (PVR) group.

In the uroflowmetric analysis, 20/35 (57.1%), 7/35 (20%), 6/35

(17.1%), and 2/35 (5.7%) boys in the non-obstructive group showed DISCUSSION
a bell-shaped, interrupted, plateau and tower-shaped patterns,
respectively (Figure 1). In contrast, 1/33 (3.0%), 18/33 (54.5%), 11/33 This study highlights the role of UF and PVR as non-invasive tests
(33.3%), and 3/33 (9.1%) boys in the obstructive group showed a in the detection of acquired infravesical obstruction of the urinary
bell-shaped, interrupted, plateau and staccato patterns, respectively tract and voiding dysfunction (VD) in pediatric patients with previous
(Figure 2). Therefore, the boys in the obstructive group had a urethral surgery or trauma.
significantly increased risk of non-bell-shaped urination (plateau or VD represents a broad term used to describe a voiding pattern
interrupted patterns) compared with boys in the non-obstructive that is abnormal for a child's age. Diagnosis of VD in children is often
group (OR 12.3, 95%CI 3.54-42.5). a challenging task for pediatric urologists. Although the full
urodynamic examination is a reliable test, it is also very invasive and
traumatic for children. Also, some studies have shown a limited value
of full urodynamic testing in diagnosing VD in children (9). In
conjunction with a history of illness and physical examination, UF is a
useful tool for identifying children with voiding dysfunction as well as
for determining responses to the treatment of lower urinary tract
disorders of this age population (2). Some studies have shown the
utility of UF in the functional evaluation of children with
reconstructed urethra due to hypospadias, especially in the detection
of symptomatic and asymptomatic urethral strictures (10-12). These
studies have shown that children with a flow rate of 2 SD below the
26 Z. Zvizdić et al.

mean or those with flat voiding curves have a high likelihood of 7. Kong JP, Bultitude MF, Royce P, Gruen RL, Cato A, Corcoran NM. Lower urinary
tract injuries following blunt trauma: a review of contemporary management. Rev
postoperative urethral pathology in the form of urethral obstruction Urol. 2011;13(3):119-30.
(10-12). Our study confirmed these findings. 8. Basta AM, Blackmore CC, Wessells H. Predicting urethral injury from pelvic
Based on ICCS recommendations, uroflowmetry curves are fracture patterns in male patients with blunt trauma. J Urol. 2007;177(2):571-5.
classified into five types, bell, tower, plateau, staccato and interrupted 9. Schewe J, Brands FH, Pannek J. Voiding dysfunction in children: Role of uro dynamic
studies. Urol Int 2002;69(4):297-301.
(fractionated) of which only bell-shaped curves are considered as 10. Marte A, Di Iorio G, De Pasquale M, Cotrufo AM, Di Meglio D. Functional
normal (5,9). Recorded rates of a normal bell-shaped uroflow evaluation of tubularized-incised plate repair of midshaft-proximal hypospadias
pattern in healthy children range from 63% to 97.2% (13-15). In our using uroflowmetry. BJU Int. 2001;87(6):540-3.
11. Garibay JT, Reid C, Gonzalez R. Functional evaluation of the results of hypospadias
research, 57.1% of children who did not have symptoms of LUTS and surgery with uroflowmetry. J Urol. 1995;154(2 Pt 2):835-6.
who were included in the non-obstructive group had bell-shaped 12. Kaya C, Kucuk E, Ilktac A, Ozturk M, Karaman MI. Value of urinary flow patterns in
uroflow patterns. There are several possible explanations for our the follow-up of children who underwent Snodgrass operation. Urol Int.
findings of a somewhat lower frequency of bell-shaped patterns in 2007;78(3):245-8.
13. Bower WF, Kwok B, Yeung CK. Variability in normative urine flow rates. J Urol .
children without symptoms of LUTS. Some of the possible 2004;171 (6 Pt 2):2657-9.
explanations include the simple fact that non-bell-shaped curves are 14. Gutierrez Segura C. Urine flow in childhood: A study of flow chart parameters
noticeably more frequent in voiding with bladder overdistension than based on 1,361 uroflowmetry tests. J Urol. 1997;157(4):1426-8.
15. Mattsson S, Spangberg A. Urinary flow in healthy schoolchildren. Neurourol
those without overdistension (16,17). Contrary to the above, we Urodyn. 1994;13(3):281-96.
found that 3.0%, 54.5%, 33.3%, and 9.1% of boys in the obstructive 16. Shei-Dei Yang S, Chiang IN, Chang SJ. Interpretation of uroflowmetry and post -
group showed bell-shaped, interrupted, plateau, and staccato void residual urine in children: Fundamental approach to pediatric non-neurogenic
patterns, respectively. These findings are in agreement with the voiding dysfunction. Incont Pelvic Floor Dysfunct. 2012;6(1):9-12.
17. Chang SJ, Yang SS, Chiang IN. Large voided volume suggestive of abnormal
findings of other studies (18,19). uroflow pattern and elevated post-void residual urine. Neurourol Urodyn.
The findings of previous studies on normal average PVR indicate 2011;30(1):58-61.
that PVP is less than 10 ml, with no relationship with age, sex, or 18. Alyami F, Farhat W, Figueroa VH, Romao RL. Utility and cost -effectiveness of
uroflowmetry in a busy pediatric urology practice. Can Urol Assoc J. 2014;8(9-
voided volume in children with a normal voiding pattern (5,20,21). 10):E615-8.
Jansson et al reported that the mean PVP in the age group of children 19. Tuygun C, Bakirtas H, Gucuk A, Cakici H, Imamoglu A. Uroflow findings in older
up to 6 years with normal voiding pattern was from 0 to 5.5 ml (22). boys with tubularized incised plate urethroplasty. Urol Int. 2009;82(1):71 -6.
On the other hand, the absence of PVR does not exclude infravesical 20. Feldman AS, Bauer SB. Diagnosis and management of dysfunctional voiding. Curr
Opin Pediatr. 2006;18:139 -47.
obstruction or bladder-sphincter dysfunction (23). Although mean 21. Koh CJ, DeFilippo RE, Borer JG, Khoshbin S, Bauer SB. Bladder and external
PVR values for boys include in the present study were higher than urethral sphincter function after prenatal closure of myelomeningocele. J Urol.
the normal values for children with normal voiding pattern and no 2006;176(5):2232-6.
22. Jansson UB, Hanson M, Sillen U, Hellström AL. Voiding pattern and acquisition of
LUDT (13.17 ± 28.91), it should be noted that the boys in the non- bladder control from birth to age 6 years – a longitudinal study. J Urol.
obstructive group had previous operative procedures on their 2005;174(1):289-3.
urethra. The assessment of the success of surgical treatment in the 23. Wen J, Wang Q, Zhang X. Normal voiding pattern and bladder dysfunction in
non-obstructive group in relation to the obstructive group is infants and children. Life Sci J . 2007;4(4):1-9.
24. Zivkovic V, Lazovic M, Vlajkovic M, Slavkovic A, Dimitrijevic L. Correlation
reflected in statistically significantly smaller PVR in the non- between uroflowmetry parameters and treatment outcome in children with
obstructive group (p=0.001) which is in agreement with the results dysfunctional voiding. J Pediatr Urol. 2010;6(4):396-402.
of other studies (24).

Reprint requests and correspondence:

CONCLUSION Zlatan Zvizdić, MD, PhD
Clinic of Pediatric Surgery
Uroflowmetry and post-void residual urine are important Clinical Center University of Sarajevo
screening tools in the evaluation of LUDT because they can detect Patriotske lige 81, 71000 Sarajevo
the general performance of bladder contractility and bladder outlet Bosnia and Herzegovina
resistance and thus select patients who require additional medical Phone: +381 250 484,
and/or surgical treatment. Email: [email protected]
ORCID ID: 0000-0003-1238-880X
REFERENCES Declaration of patient consent: the authors certify that they have
1. Hoebeke P, Bower W, Combs A, De Jong T, Yang S. Diagnostic evaluation of obtained all appropriate patient consent forms. In the form, patient s
children with daytime incontinence. J Urol. 2010;183(2):699-703. have given their consent for their images and other clinical
2. Hjälmås K, Hoebeke PB, de Paepe H. Lower urinary tract dysfunction and information to be reported in the journal.
urodynamics in children. Eur Urol. 2000;38(5):655-65.
3. Braga LH, Pippi Salle JL, Lorenzo AJ, Skeldon S, Dave S, Farhat WA, et al.
Authors' Contributions: ZZ, EB, AJ, EM and DM-P gave substantial
Comparative analysis of tubularized incised plate versus onlay island flap contribution to the conception or design of the article and in the
urethroplasty for penoscrotal hypospadias. J Urol. 2007;178(4 Pt 1):1451-6. acquisition, analysis and interpretation of data for the work. Each
4. Wehbi E, Patel P, Kan aroglou N, Tam S, Weber B, Lorenzo A, et al. Urinary tract author had role in article drafting and in process of revision. Each
abnormalities in boys with recurrent urinary tract infections after hypospadias
repair. BJU Int. 2014;113(2):304 -8. author gave final approval of the version to be published and they
5. Truzzi JCI, Almeida FMR, Nunes EC, Sadi MV. Residual urinary volume and urinary agree to be accountable for all aspects of the work in ensuring that
tract infection-when are they linked? J Urol. 2008;180(1):182-5. questions related to the accuracy or integrity of any part of the work
6. Jesus LE, Schanaider A, Patterson G, Marchenko A, Aitken KJ, Leslie B, et al.
Urethral compliance in hypospadias operated by tabularized incised urethral plate
are appropriately investigated and resolved.
(TIP) with and without a dorsal inlay graft: an experimental controlled study. Financial support and sponsorship: nil.
World J Urol. 2013;31 (4):971-5. Conflict of interest: there are no conflicts of interest.
Medical Journal (2022) Vol. 28, No 1,2 Original article

Early results of carotid endarterectomy in diabetic

patients with symptomatic stenosis

Rani rezultati karotidne endarterektomije kod

dijabetičara sa simptomatskom stenozom

Muhamed Djedović 1*, Slavenka Štraus 1, Amel Hadžimehmedagić 1, Nermir

Granov 1, Samed Djedović2
1
Clinic of Cardiovascular Surgery, Clinical Center University of Sarajevo, Bolnička 25, 71000 Sarajevo, Bosnia and Herzegovina
2
Medical Institute Bayer, Tuzla, Alekse Šantića 8, 75000 Tuzla, Bosnia and Herzegovina

*Corresponding author

ABSTRACT SAŽETAK

Introduction: Carotid endarterectomy (CEA) is an effective and Uvod: karotidna endarterektomija (CEA) je učinkovit i siguran
safe treatment for carotid artery stenosis. Aim: to compare early tretman stenoze karotidnih arterija. Cilj: uporediti rane ishode nakon
outcomes after carotid endarterectomy between patients with karotidne endarterektomije (CEA) između bolesnika s dijabetesom i
diabetes mellitus (DM) and patients without diabetes mellitus with nedijabetičara sa simptomatskom stenozom karotidnih arterija.
symptomatic carotid artery stenosis. Materials and methods: we Metode: retrospektivno smo analizirali 161 CEA, koji su provedeni
retrospectively analyzed 161 CEAs, which were performed in pacijenatima sa simptomatskom stenozom karotinih arterija, između
patients with symptomatic carotid artery stenosis, between January januara 2018. i maja 2022. CEA su podijeljeni u skupinu sa
2018 and May 2022. CEAs were divided into a DM group (n=58; dijabetesom (DM) (n=58; 36%) i ne-DM skupinu (n=103; 64%).
36%) and a non-DM group (n=103; 64%). Study outcomes included Rezultati studije uključivali su incidenciju velikih nuspojava (MAE),
the incidence of major adverse events (MAEs), defined mortality, definirani kao smrtonost, nefatalni moždani udar i infarkt miokarda
stroke and myocardial infarction (MI) during the early perioperative tokom ranog perioperativnog perioda (o-30 dana), nakon CEA, kod
period (0-30 days). Results: there was no statistically significant pacijenata sa sinptomatskom stenozom. Rezultati: nije bilo statistički
difference between the analyzed groups regarding total complications značajne razlike između analiziranih skupina u pogledu ukupnih
(3.4% vs 2.9%; P>0.05). Statistically significant differences were koplikacija (3,4% vs. 2,9%; P>0,05). Evidentirana je statistički zvačajna
recorded in the presence of bilateral stenosis (31% vs 16.5%; razlike u prisustvu bilateralne stenoze (31% vs 16,5%; P=0.046))
P=0.046), peripheral arterial occlusive disease (32.8% vs 16.5%; periferne arterijske okluzivne bolesti (32,8% vs. 16,5%; P=0,029 kod
P=0.029) in patients with DM. Despite these differences, patients pacijenata sa DM. Unatoč tim razlikama, bolesnici sa dijabetesom imali
with DM had similar perioperative outcomes compared with non- su slične perioperativne ishode u komparaciji sa pacijentima bez
diabetic patients, including perioperative MI (1.7% vs. 0.97%; dijabetesa, uključujući perioperativni infarkt miokarda (1,7%%
P=0,974), perioperative death (1.7% vs. 0.97%; P=0,974), and naspram 0,97%; P=0,974), perioperativnu smrt (1,7% naspram
perioperative neurologic events such as stroke (0% vs. 0.97%; 0,97%; P=0,974) i perioperativne neurološke komplikacije kao što je
P=0,770). No differences in demographic factors were noted moždani udar (0% naspram 0,97%; P=0,770). Nisu zabilježene razlike
between diabetic and non-diabetic patients. Conclusions: despite the u demografskim faktorima između dijabetičara i nedijabetičara.
increased prevalence of bilateral stenosis and peripheral arterial Zaključak: i pored povećane prevalence bilateralne stenoze i
occlusive disease in patients with diabetes who underwent CEAs, the periferne arterijske okluzivne bolesti kod bolesnika s dijabetesom koji
rates of perioperative morbidity and mortality were without su bili podvrgnuti CEA, stope perioperativnog morbiditeta,
statistically significant differences. mortaliteta su bile bez staisitčki značajne razlike

Keywords: symptomatic carotid artery stenosis, carotid Ključne riječi: simptomatska stenoza karotidne arterije, karotidna
endarterectomy, diabetes mellitus endarterektomija, dijabetes melitus

INTRODUCTION in industrialized countries, the most common neurological diagnosis

requiring hospitalization (1), as well as the leading cause of long-term
Cerebrovascular insult (CVI) as a consequence of carotid artery
disability (2). Carotid endarterectomy (CEA), even according to the
disease (stenosis, occlusion) is the third most common cause of death
latest guidelines, remains a recommendation and the "gold standard"
28 M. Djedović et al.

in the treatment of symptomatic carotid artery stenosis and and the motor function was tested by squeezing a squeaky rubber
prevention of cerebrovascular events (3 -6). dummy with the contralateral hand, the carotid shunt was inserted
Diabetes mellitus is one of the main risk factors for the immediately after speech or motor dysfunction. The shunt was used
development of stroke. Patients with DM compared to non-diabetic in patients operated in general anesthesia, in case the return pressure
patients have two times more chance to suffer from a stroke (7). In in the interlan carotid artery after clamping was less than 40 mmHg
addition, stroke in diabetic patients compared to non -diabetic All patients were monitored postoperatively in the intensive care unit
patients is associated with worse functional outcome and higher for at least 24 hours with strict blood pressure control (19).
mortality (8-10). Several authors have described DM as a factor that The degree of stenosis was determined by Doppler ultrasound
significantly influences CEA results (11-13), but there are also studies and CT angiography/MR angiography. The main sources of data were
that give other results (14,15). the computerized database and the standard medical histories of
Moreover, in the analysis of risk factors affecting early and late hospitalized patients (medical history, operating list, patient's daily
outcomes in diabetic patients, there is insufficient data in the therapy list, discharge letter). Anesthesiologist, vascular surgeon and
literature (16), and there is also insufficient data in the literature on neurologist participated independently in the assessment of the
the influence of DM on the early outcome of carotid patients' clinical condition. For this study, patients were monitored for
endarterectomy. But, there is sufficient evidence for increased early 30 days after surgery.
morbidity after other vascular surgical interventions in patients with Exclusion criteria were patients with carotid artery restenosis,
DM (17,18). carotid artery stenosis with associated supra-aortic branch stenosis,
carotid artery dissection, carotid artery aneurysms, simultaneous
AIM CEA surgery and aorto-coronary bypass or peripheral
revascularization, and patients with asymptomatic carotid artery
The aim of this study was to compare early outcomes after stenosis.
carotid endarterectomy between diabetic and non-diabetic patients All patients were followed up for 30-day complications, such as
with symptomatic stenosis. stroke, MI and mortality. Postoperatively, neuroimaging was
performed only in those patients who had a neurological deficit.

MATERIALS AND METHODS Statistical analysis

This retrospective study included 161 patients who underwent Baseline characteristics were collected and presented as number
CEAs due to symptomatic carotid artery stenosis (stenosis > 50%), in of cases and percentage representation. Categorical values were
the period from January 2018 to May 2022 at the Clinic of analyzed with the χ2 test and Fisher's test. Student's T-test and Mann-
Cardiovascular Surgery, Clinical Center University of Sarajevo. The Whitney U test were used to analyze quantitative values. Statistical
performed CEAs were divided into two groups: the group with DM hypotheses were tested at the level of α = 0.05, (significant if p <
(n=58; 36%) and the group of patients without DM (n = 103; 64%). 0.05). Statistical analyzes were performed using IBM SPSS Statistics
Our study was conducted according to the Declaration of ver. 21.0.
Helsinki in 1975, written informed consent was obtained from all
patients.
Patients were considered symptomatic if they had transient RESULTS
ischemic attacks, vertigo, amaurosis fugax, or non-disabling stroke
ipsilateral to symptomatic carotid stenosis in the past 6 months. In In our retrospective comparative study, a total of 161 patients
patients with bilateral carotid stenosis, the choice of carotid artery, who underwent CEAs were included, 101 (62.7%) male and 60
which was the first surgically treated, was made according to the (37.3%) female underwent CEAs. In 36% of cases with DM and in
degree of carotid stenosis. 64% of cases without DM CEAs was performed.
The following data were collected for each patient: age, gender, The average age of patients was 67.85 years (SD ±8.5, in the
history of hypertension (HTA), hyperlipidemia (HLP), smoking status, range from 46 to 86 years), the average age of the patients in DM
history of non-surgically treated coronary artery disease (CAD), group was 68.12 years (SD ± 7.9, in the range from 53 to 86 years) ,
history of peripheral arterial disease (PAOD), CEAs technique data while the average age in patients without DM was 67.7 years (SD
(eversion/classic), type of anesthesia (local, general) and use of shunt ±8.8, in the range from 46 to 84 years, P=0.966). Number of male
during operative treatment. Due to the type of symptoms the was higher in both groups (60.3% vs. 64.1%) but without statistical
following data were collected: dizziness, transient ischemic attack significance, P=0.764. The preoperative risk factors and
(TIA), amaurosis fugax non-disabling CVI. Concerning CVI, comorbidities, in the examined groups, are without statistical
myocardial infarction (MI) and mortality were analyzed. significance: smokers 21 (36.2%) vs 40 (38.8%), P= 0.872;
Patients were surgically treated under local anesthesia or, hypertension 52 (89.7%) vs 97 (94.2%), P=0.353; hyperlipidemia 49
alternatively, under general anesthesia whenever local anesthesia was (84.5%) vs 87 (84.5%), P=0.998; cardiac artery disease 17 (29.3%) vs
not feasible for patient-related reasons. CEA was performed by 23 (22.3%); P=0.427. Unlike the previously mentioned variables, in
eversion and classical technique with patch plastic (dacron patch was the group of patients with DM the number of patients with
used), with selective use of shunt. In patients operated under the peripheral arterial occlusive disease was higher and this difference
local anesthesia, the shunt was used depending on the state of was statistically significant (32.8% vs 16.5%, P=0.029*), (Table 1).
consciousness and motor functions after trial clamping of the carotid
arteries, the tests to assess consciousness included counting numbers
Early results of carotid endarterectomy in diabetic patients with symptomatic stenosis 29

Table 1 Demographic characteristics, risk factors and comorbidities of patients with symptomatic carotid artery stenosis.

Variables Total (n=161) Diabetes mellitus group No diabetes mellitus group P

(n=58; 36%) (n=103; 64%)
Age, years (SD) 67.85±8.5 68.12±7.9 67.7±8.8 0.966
Gender 0.764
Male 101 (62.7%) 35 (60.3%) 66 (64.1%)
Female 60 (37.3%) 23 (39.7%) 37 (35.9%)
Comorbidites
CAD 40 (24.8%) 17 (29.3%) 23 (22.3%) 0.427
PAO D 36 (22.3%) 19 (32.8%) 17 (16.5%) 0.029*
Risk factor
HTA 151 (93.7%) 52 (89.7%) 97 (94.2%) 0.353
HLP 134 (81.3%) 49 (84.5%) 87 (84.5%) 0.998
Smoking 61 (37.8% ) 21 (36.2%) 40 (38.8%) 0.872
Values are presented as mean ± SD or n (%). SD: Standard deviation, CAD: Coronary artery disease; PAOD: Peripheral arterial occlusive disease;
HTA- hypertensio; HLP: hyperlipidemia

Analyzing the data on the preoperative status of the carotid CEAs: CEAs with patch angioplasty 18 (25.3%) vs 26 (25.2%),
arteries and the CEAs procedure, there was no statistically significant eversion technique 40 (69%) vs 77 (74.8%), P=0.544, CEAs with a
difference between the analyzed groups in the prevalence of shunt 7 (12.1%) vs 8 (7.8%), P=0.536.The group with DM had a
contralateral occlusion 5 (8.6%) vs. 7 (6.8%), P=0.758; anesthesia higher, statistically significant, number of patients with bilateral
technique used during the procedure (local anesthesia 74.2% vs stenosis (31% vs 16.5%; P=0.046*), (Table 2.)
76.4%, general anesthesia 27.6% vs 23.3%), P=0.679; the type of

Table 2 Preoperative and operative data.

Variables Total (n=161) Diabetes mellitus group No diabetes mellitus group P

(n=58; 36%) (n=103; 64%)
Bilateral stenosis 35 (21.7%) 18 (31%) 17 (16.5%) 0.046*
Contralateral occlusion. 12 (7.5%) 5 (8.6%) 7 (6.8%) 0.758
CEA
General anesthesia 40 (24.8%) 16 (27.6%) 24 (23.3%) 0.679
Local anesthesia 121 (75.2%) 42 (72.4%) 79 (76.4%)
Use of shunt 23 (8.4%) 7 (12.1%) 8 (7.8%) 0.536
Reconstruction technique 0.544
Patch angioplasty 44 (27.3%) 18 (25.3%) 26 (25.2%)
Eversion 117 (72.7%) 40 (69%) 77 (74.8%)
CEA: Carotid endarterectomy

Table 3 shows the perioperative outcomes. For all patients, the and mortality (1.7% vs 0.97%; P=0.974). The percentage of total
30-day rate of any type of stroke was 0.6%, MI 1.25%, while the 30- complications (morbidity and mortality) in the group of patients with
day mortality rate for all patients was 1.25%. The total percentage of DM was higher compared to the group of patients without DM, but
observed complications in our research was 3.1%. There was no this difference was not statistically significant (3.4% vs 2.91%;
statistically significant difference between the compared groups in any P=0.273).
type of stroke (0% vs 0.6%; P=0.770), MI (1.7% vs 0.97%; P=0.974),

Table 3 Thirty-day morbidity and mortality following CEA.

Within 30-day outcomes after CEA

Variables Total (161) Diabetes mellitus group No diabetes mellitus group P
(n=58;36%) (n=103,64%)
CVI 1 (0.6%) 0 1 (0.97%) 0.770
IM 2 (1.25%) 1 (1.7%) 1 (0.97%) 0.974
Death 2 (1.25%) 1 (1.7%) 1 (0.97%) 0.974
Total 5 (3.1%) 2 (3.4%) 3 (2.91%) 0.835
MI myocardial infarction; CVI cerebrovascular incident

Data on the symptomatology of carotid stenosis by group is 45.6%; P=0.570), amaurosis fugax (18.6% vs 16.5%; P=0.858), non-
shown in Table 4. There was no statistically significant difference disabling CVI (24.1% vs 20.4%; P=0.723), as well as in TIA as a
between the analyzed groups in the presence of dizziness (39.5% vs symptom of carotid artery stenosis (19% vs 17.5%; P=0.982).
30 M. Djedović et al.

Table 4 Clinical presentation of patients with symptomatic carotid artery stenosis.

Variables Total (161) Diabetes mellitus group No diabetes mellitus group P

(n=58;36%) (n=103,64%)
Vertigo 70 (43.5%) 23 (39.5%) 47(45.6%) 0.570
Amaurosis
fugax 27 (17.4%) 10 (18.6%) 17 (16.5%) 0.858
CVI 35 (21.4%) 14 (24.1%) 21 (20.4%) 0.723
TIA 29 (18%) 11 (19%) 18 (17.5%) 0.982
CVI cerebrovascular incident, TIA transient ischemic attack.

DISCUSSION The total postoperative morbidity (cardiac and neurological) was

present in 1.7% of patients with DM and 1.94% of non-DM patients,
After the first CEA performed by De Bakey ME, (20), it was while mortality was higher in patients with DM 1.7% compared to
established as a safe and effective method to reduce the risk of CV I non-DM patients 0.97% (P=0.974), while total postoperative
in patients with carotid stenosis. Today, CEA s is a method with low mortality and morbidity was in the group of patients with DM 3.4%
mortality and frequency of perioperative complications, in and in patients without DM 2.91% (P=0.273). Some studies reported
symptomatic (21) and asymptomatic carotid artery stenosis (22). that DM patients had higher 30-day mortality rates (3.2 vs. 1.4%;
Stroke is one of the leading causes of death in Western P=0.02) (26). Overall postoperative complications were observed in
countries, and the most common neurological diagnosis requiring 8.5% of non-diabetics and in 18.3% patients with DM (P<0.001).
hospitalization (1). Also, stroke has major adverse effects on a Patients with DM were at more than two-fold increased risk of
person's physical, psychological, social and economic status. postoperative complications. Research by Dorigo W, et al., indicated
Atherosclerotic disease of the carotid arteries is a disease of the that the risk of postoperative complications is twice as high in patients
elderly population group (22). In our study, patients with DM were suffering from DM (24). Similar to our results, other studies
slightly older. Our study was in accordance with others where an concluded that patients with DM were not at greater risk of 30-day
increased number of male was recorded (23). morbidity and mortality after CEAs than those without DM (27).
In earlier studies, evaluating the relationship between DM and
higher operative risk during CEAs, results are quite mixed. In
previous studies, which included patients operated on for stenotic CONCLUSION
occlusive disease of the carotid arteries, the percentage of patients
with DM in most cases ranged from 13 to 23.6% (24,25). Our study Despite the increased prevalence of bilateral stenosis and
included 36% of patients with DM, which is significantly higher peripheral arterial occlusive disease in patients with diabetes who
compared to the study conducted by Ahari A, et al., which had 13% underwent CEA, the rates of perioperative morbidity and mortality
of patients with DM (26). The study by Dorig W, et al., reported a were not statistically significantly different compared to patients
percentage of patients with DM of 20.05%, while the study by without diabetes.
Rockman CB, et al., reports 23.5% of patients with DM (24,15).
Other studies, in accordance with our, reported a high percentage of
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21. Barnett H, Taylor W, Eliasziw M, Fox A, Gary F, Brian H , et al. Benefit of Carotid obtained all appropriate patient consent forms. In the form, the
Endarterectomy in Patients with Symptomatic Moderate or Severe Stenosis. patients have given their consent for their images and other clinical
North American Symptomatic Carotid Endarterectomy Trial Collaborators. N information to be reported in the journal.
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Disabling and Fatal Strokes by Successful Carotid Endarterectomy in Patients acquisition, analysis and interpretation of data for the work. Each
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Medical Journal (2022) Vol. 28, No 1,2 Original article

Clinical significance of neutrophil to lymphocytes ratio in

differential diagnosis of cervical lymphadenopathy

Klinički značaj odnosa neutrofila i limfocita u

diferencijalnoj dijagnostici cervikalne limfadenopatije

Zehra Sarajlić1*, Amina Blekić 2

1
Clinic for Ear, Nose and Throat Diseases and Head and Neck S urgery, Clinical Centre University of Sarajevo, Bolnička 25, 71000 Sarajevo, Bosnia
and Herzegovina
2
Department of Family Medicine, Health Care Centre of Sarajevo Canton, Vrazova 11, 71000 Sarajevo, Bosnia and Herzegovina

*Corresponding author

ABSTRACT SAŽETAK

Introduction: cervical lymphadenopathy refers to swelling of Uvod: pojam cervikalne limfadenopatije odnosi se na otok vratnih
lymph nodes in the neck and is a common presentation of various limfonoda, entitet koji se često javlja u različitim oboljenjima.
diseases. An emerging new prognostic marker, neutrophil to Novootkriveni prognostički marker , odnos neutrofila i limfocita
lymphocyte ratio, is proving to be useful in differentiating between (NLR-neutrophil to lymphocyte ratio), može poslužiti u diferencijaciji
malignant and non-malignant lymphadenopathy. Aim: to investigate između maligne i nemaligne limfadenopatije. Cilj: ispitati korist
whether a neutrophil to lymphocyte ratio helps with determining procjene odnosa neutrofila i limfocita u ranom određivanju uzroka
early the cause of cervical lymphadenopathy. Materials and methods: cervikalne limfadenopatije. Materijali i metode: retrospektivna studija
a retrospective case-control study was conducted at the Department slučaja sprovedena je na Klinici za uho, grlo, nos i hirurgiju glave i vrata
of Otorhinolaryngology of the Clinical Centre University of Sarajevo. na Univerzitetskom Kliničkom Centru u Sarajevu. Historije pacijenata
Records of patients with cervical lymphadenopathy who underwent a sa cervikalnom limfadenopatijom koji su podvrgnuti dijagnostičkoj
diagnostic excisional lymph node biopsy in a five-year period ekcizionoj biopsiji limfonoda u petogodišnjem periodu od 2016. do
between 2016 and 2021 were retrospectively reviewed and NLR 2021. godine retrospektivno su pregledane, a njihovi NLR su
ratios were compared. Results: a total of 37 patients were reviewed upoređivani. Rezultati: od ukupno 37 razmatranih pacijenata, 21
and 21 patients were included and sorted into three groups: Reactive pacijent je uključen u studiju i pomenuti su sortirani u tri grupe:
lymphadenopathy (RAL), Hodgkin’s lymphoma (HL) and non - reaktivna limfadenopatija (RAL), Hodgkin limfom (HL), i non-Hodgkin
Hodgkin’s lymphoma (NHL). There was no statistically significant limfom (NHL). Nije bilo statistički signifikantne razlike između grupa
difference between th e groups (p=0.2798) in age and gender (p=0.2798) po dobu i spolu (p=0,8487). Gotovo statistički
(p=0.8487). An almost statistically significant difference was recorded signifikantna razlika zabilježena je između NHL i HL grupa u
between the NHL and HL groups in the obtained values of the ratio dobivenim vrijednostima NLR (p=0.073). Zaključak: pažljiva procjena
of NLR (p=0.073). Conclusion: careful assessment of the complete kompletne krvne slike i diferencijalne krvne slike može biti korisna u
blood count and differential blood count can be useful in diferencijaciji između benignih i malignih oboljenja. Mjerenje NLR i
differentiating between benign and malignant diseases. Measurement upalnih markera jednostavan je i isplativ način u procjenjivanju
of NLR and established inflammation marker is an easy and cost- potencijalnih maligniteta u cervikalnoj limfadenopatiji. Završna
effective way of assessing the potential of malignancy in cervical dijagnostika bi svakako trebala biti izvršena ekscizionom biopsijom.
lymphadenopathy. The final diagnosis should be done by excisional
Ključne riječi: odnos neutrofila i limfocita, cervikalna limfadenopatija,
biopsy.
maligni limfom, prediktivni marker
Keywords: neutrophil to lymphocyte ratio, cervical
lymphadenopathy, malignant lymphoma, predictive marker

as chronic inflammatory conditions. It is reasonable that lymphoma is

INTRODUCTION frequently identified in the neck because the head and neck area
contain a dense lymphatic system and around one-third of the body's
Cervical lymphadenopathy refers to swelling of lymph nodes in lymph nodes. Due to the extreme opposing severity of these two
the neck and is a common presentation of various diseases. It occurs diagnoses it is crucial to attempt a prompt differentiation.
most frequently due to infectious processes localised in the head and The clinicians are then faced with a choice: either to follow up
neck region such as tonsillitis, otitis or dental decay (1). However, it the patient or to perform a biopsy. In case of evaluation via follow up,
can occasionally be a harbinger of haematological malignancies as well the diagnosis of lymphoma may be delayed, while an open biopsy is
Clinical significance of neutrophil to lymphocytes ratio in differential diagnosis of cervical lymphadenopathy 33

associated with surgical risks and costs. Methods such as ultrasound, compared via statistical analysis. The NLR was calculated by dividing
MRI, PET/CT, and biopsy are frequently used to consolidate a the number of neutrophils with the number of lymphocytes.
diagnosis. However, an emerging new prognostic marker - neutrophil Majority of patients were at least 18 years of age, with the
to lymphocyte ratio - is proving to be useful in differentiating exception of two children aged 10 and 2, with no etiological cause by
between malignant and non-malignant conditions (2). history and they underwent a complete ear, nose, and throat
The neutrophil to lymphocyte ratio (NLR) is a powerful examination, as well as ultrasound of the suspect lymph node. Blood
predictive marker for patients with a variety of illnesses (3). The samples of the patients were retrieved from the peripheral veins on
innate immune response, which is primarily supported by neutrophils, admission. Histopathological preparations of all patients were
and adaptive immunity, supported by lymphocytes, is combined in the evaluated at the Department of pathology of the Clinical Centre
neutrophil-to-lymphocyte ratio (NLR), which is determined as a University of Sarajevo.
simple and direct ratio between the counts of neutrophils and
lymphocytes in peripheral blood. A recent study by Song M, et al. Statistical analysis
indicates that NLR could also forecast overall population mortality
(4). NLR's prognostic significance in many solid tumours is evident; it The study was conducted in accordance with the principles of
is still ambiguous in leukemias and lymphomas. Therefore, the aim of the Helsinki Declaration. Statistical analysis was done in MedCalc
this study was to determine effectiveness of predictive markers, Statistical Software version 19.0.3. (MedCalc Software bvba, Ostend,
specifically NLR, as well as the neutrophil and lymphocyte counts in Belgium). The D'Agostino - Pearson test was applied to assess the
establishing a diagnosis of lymphoma versus reactive distribution of the results. Descriptive data are presented in
lymphadenopathy. frequencies (n) and percentages (%) for categorical variables and
mean (median) value with interquartile range (IQR) for numerical
AIM variables that did not have a normal distribution. Chi-square test was
applied for comparison of categorical variables, Kruskal Wallis test for
The aim of the paper was to investigate whether a neutrophil to comparison of numerical variables between groups. The non-
lymphocyte ratio helps in early differentiation of the cause of cervical parametric Mann-Whitney test was used to analyze differences
lymphadenopathy. Prompt diagnosis is vital for a successful treatment. between groups, and Dunn's post-hoc test was used for post-hoc
pairwise comparisons between the groups. Values of p<0.05 were
considered statistically significant.
MATERIALS AND METHODS

Study design RESULTS

This retrospective case-control study was conducted at the
Department of Otorhinolaryngology of the Clinical Centre University Demographic characteristics
of Sarajevo. Records of patients with cervical lymphadenopathy who
underwent a diagnostic excisional lymph node biopsy in a five-year Out of the total number of patients included in the study 21 had
RAL, HL, or NHL. The remaining 16 had unusual presentations, and
period, between 2016 and 2021, were retrospectively reviewed. A
as such were excluded during the final analysis. These patients were
total of 37 patients who underwent cervical lymph node biopsy were
reviewed and 21 patients were included and sorted into three divided into three groups, reactive lymphadenopathy (RAL), Hodgkin
Lymphoma (HL) and non-Hodgkin lymphoma. The median age of
groups: Reactive lymphadenopathy (RAL), Hodgkin’s lymphoma (HL)
patients in the RAL group was 38 years, in the NHL group 51 and in
and non-Hodgkin’s lymphoma (NHL).
A questionnaire was developed and demographic data, medical the HL group 43 years. There was no statistically significant difference
between the groups (p=0.2798). There was no statistically significant
history and blood count were ascertained from the said
difference in the distribution of patients by gender (p=0.8487), which
questionnaire. Data on age, gender, complete blood count, and NLR
can be observed in Table 1.
in the HL, NHL and RAL groups were added into a data base and

Table 1 Demographic data.

Variable RAL (n=9) NHL (n=8) HL (n=4) p

Age median (IQR) 38,0 (22-65) 51 (47,25-68) 43,5 (33,25-53,5) 0,2798*
Sex, n (%) 0,8487**
Females 3 (33%) 3 (37,5%) 2 (50%)
Males 6 (67%) 5 (62,5%) 2 (50%)
*Kruskal-Wallis test applied **Chi square test applied
34 Z. Sarajlić et al.

Table 2 Haematologic findings.

Variable Median (IQR) Median (IQR) Median (IQR)

RAL (n=9) NHL (n=8) HL (n=4) p*

Leukocytes x103 μL (3.4-9.7) 7.4 (6.5-8.2) 6.4 (6.1-7.5) 9.9 (9.1-11.35) 0.069

Neutrophils x10 3 μL (1.8-7.8; 4.1 (3.3-5.0) 3.97 (3.1-4.5) 7.4 (7.2-7.6) 0.024
44 -72%,)

Lymphocytes x10 3 μL (0.8-4.6; 1.95 (1.4-3.0) 1.7 (1.2-2.8) 1.7 (0.97-2.6) 0.780
20-46%)

Thrombocytes x103 μL (158- 277 (210-344) 203 (174.8-237.5) 288.5 (258.5-317.5) 0.133
424)

MPV fl (6.8-10.4) 7.7 (7.0-8.7) 8.2 (7.2-9.6) 7.8 (7.29-7.85) 0.695

NLR 1.72 (1.35-4.01) 1.85 (1.37-3,20) 4.54 (2.92-8.97) 0.138

PLR 145.5 (91.0-170.2) 112.6 (73.6-138.8) 157.2 (112.2-326.8) 0.439

* Kruskal-Wallis test applied

The mean number of leukocytes was 7.4 x 103 μL in the RAL number of platelets was not statistically significant (p=0.133). The
group, 6.4 x 103 μL in the NHL group, and 9.9 x 103 μL in the HL mean values of the average volume of platelets in the RAL group
group. The difference in the number of leukocytes was not were 7.7 fl, in the NHL group 8.2 fl and 7.8 fl in the HL group. The
statistically significant (p=0.069). The mean number of neutrophils in difference between the groups in the average platelet volume was
the RAL group was 4.1 x 103 μL, 3.97 x 103 μL in the NHL group, not statistically significant (p=0.695) (Table 2).
and 7.4 x 103 μL in the HL group. In Table 2 , the difference between The mean values of neutrophil to lymphocyte ratio (NLR) in the
the groups in the number of neutrophils is visible; and is shown to be RAL group were 1.72, 1.85 in the NHL group and 4.54 in the HL
statistically significant (p=0.024). The mean number of lymphocytes in group. The difference between the groups in the ratio of neutrophils
the RAL group was 1.95 x 103 μL, 1.7 x 103 μL in the NHL group, to lymphocytes was not statistically significant (p=0.138). The mean
and 1.7 x 103 μL and 1.7 x 103 μL in the HL group. The difference values of platelet-lymphocyte ratio (PLR) in the RAL group were
between the groups in the number of lymphocytes was not 145.5, 112.6 in the NHL group and 157.2 in the HL group. The
statistically significant (p=0.780). The mean platelet count in the RAL difference between groups in the ratio of neutrophils to lymphocytes
group was 277 x 103 μL, 203 x 103 μL in the NHL group, and 288.5 was not statistically significant (p=0.439) (Table 2).
x 103 μL in the HL group. The difference between the groups in the

Table 3 Haematological variables.

Variable p ***

RAL:NHL RAL:HL NHL:HL

Leukocytes x10 3 μL (3.4-9.7) 0.441 0.031 0,073
3
Neutrophils x10 μL (1.8-7.8; 44-72%,) 0.743 0.034 0.004
3
Lymphocytes x10 μL (0.8-4.6; 20-46%, ) 0.673 0.604 0,808
3
Thrombocytes x10 μL (158-424) 0.139 0.825 0.073
MPV fl (6.8-10,4) 0.672 0.782 0,305
NLR 0.815 0.106 0.073
PLR 0,606 0.414 0,283
*** Mann-Whitney test applied
Clinical significance of neutrophil to lymphocytes ratio in differential diagnosis of cervical lymphadenopathy 35

neutrophils was highest in the HL group, and there was statistically

significant difference between the group s.
Lymphocytes produce adaptive immune responses to
eradicate particular infections, infected cells, and occasionally
precancerous or cancerous cells. Furthermore, it has been
demonstrated that lymphocytes, as opposed to neutrophils, inhibit
inflammation and tumor growth in the microenvironment of tumor
tissue (9). However, our data did not indicate a statistically significant
difference between the number of lymphocytes in the three groups.
NLR, which can be an indicator for both an increased neutrophil
count and suppressed lymphocytes, are thought to show the balance
between pro-inflammatory status and anti-tumor immunity. Under
physiologic stress, the number of neutrophils increases, while the
number of lymphocytes decreases (10,11). The NLR is a combination
of both of these changes, making it more sensitive than either alone.
Interestingly, our study showed an almost significan t difference in the
NLR ratio between the groups, and a significant difference in the sole
number of neutrophils.
Figure 1 Neutrophil count HL and NHL. The prognostic value of NLR, which is one of the indicators of
systemic inflammation, in many cancer types and hematological
In the pairwise comparison of the obtained results, statistically malignancies, especially lymphoma subtypes, has been validated (12).
significant differences were recorded in the number of leukocytes The physiologic range of NLR is between 1-2, with values below 0.7
between the RAL and HL groups (p=0.031), similar differences were and higher than 3 are suggestive of disease. Forget P, et al., in a large
recorded in the number of neutrophils between the RAL and HL retrospective case-control study, noted that normal NLR values in an
groups (p=0.034) as well as between the NHL and HL groups adult, non-geriatric population in good health may be between 0.78
(p=0.004). It is particularly important to emphasize that an almost and 3.53 (13). However, the cut off point for NLR is still debated as
statistically significant difference was recorded between the NHL and the range between 2.3 and 3 represents a grey zone.
HL groups in the obtained values of the ratio of neutrophils to Karakonstantis S, et al., observed numerous factors that could
lymphocytes NLR (p=0.073) (Table 3, Figure 2). cause a “false” increase in NLR (14). These factors were age,
exogenous steroid intake, sexual hormones, active haematological
diseases, such as leukemia, cytotoxic drugs, obesity, diabetes, and
even emotional stress. Therefore, it is self-evident that NLR cannot
be used as the sole factor in differentiating inflammation from
malignancy.
Limits of the study were a relatively low number of participants,
as the complete number of patients coming to the clinic for cervical
lymphadenopathy could not be taken in account. This is due to the
fact that number of patients had unusual and rare presentations of
diseases such as metastasis of urothelial carcinoma, Whipple disease
and tuberculosis of lymph nodes. Our study did not correct for
confounding factors mentioned above given that full patient history
was sometimes unavailable. Assessing the dynamics of the white
blood cell count during the disease period could be of interest for
further research (15).

CONCLUSION

Careful assessment of the complete blood count and differential

Figure 2 Neutrophil count comparison in the groups. blood count can be useful in differentiating between benign and
malignant diseases. Measurement of NLR and established
DISCUSSION inflammation marker is an easy and cost-effective way of assessing
the potential of malignancy in cervical lymphadenopathy. The final
diagnosis should be done by excisional biopsy. However, it is
As discussed earlier, role of systemic inflammation in malignancies
important to note major confounding factors such as age, sex,
is irrefutable (5,6). Neutrophils play a major role in inflammation in
chemotherapy, and hematologic disease.
pathologic conditions such as microbial infection, chronic tissue
damage, and most importantly cancer. There is also evidence that
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neutrophil-to-lymphocyte ratio and platelet-to-lymphocyte ratio predicts breast
Financial support and sponsorship: nil.
cancer prognosis. BMC Cancer. 2020;20(1):1206. Conflict of interest: there are no conflicts of interest.
Medical Journal (2022) Vol. 28, No 1,2 Original article

Comparison of efficacy of femoral AO/OTA 31 -A2

intertrochanteric fractures treated with dynamic hip
screw (DHS) and proximal femoral nail (PFNA)

Učinkovitost osteosinteze intertrohanternih AO/OTA

31-A2 preloma femura tretiranih sa dinamičkim vijkom
(DHS) u odnosu na intramedularnu fiksaciju (PFNA)

Faruk Lazović1*, Đemil Omerović 1, Adnan Papović1, Mirza Sivro 2

1
Clinic of Orthopedic Surgery and Traumatology, Clinical Center University of Sarajevo, Bolnička 25, 71000 Sarajevo, Bosnia and Herzegovina
2
Cantonal Hospital Zenica, Department of Orthopedics and Traumatology, Crkvice 67, 72000 Zenica, Bosnia and Herzegovina

*Corresponding author

ABSTRACT SAŽETAK

Introduction: surgical treatment of intertrochanteric fractures Uvod: operativni tretman intertrohanternih preloma čine
consists of intramedullary and extramedullary fixation. Aim: to intramedularna i ekstramedularna fiskacija. Cilj: uporediti
compare intramedullary and extramedullary osteosynthesis in stable intramedularnu i ekstramedularnu osteosintezu kod stabilnih
intertrochanted AO/OTA 31 -A2 fractures treated with intertrohantenih preloma AO/OTA 31 -A2 tretiranih sa
intramedullary nail (PFNA) or dynamic screw plate (DHS). Materials intramedulanim čavlom (PFNA) odnosno pločicom sa dinamičkim
and methods: the study included 80 patients with verified AO/OTA vijkom (DHS). Materijali i metode: u istraživanje je uključeno 80
31-A2 fracture. After satisfying the inclusive factors were ispitanika sa verifikovanim AO/OTA 31-A2 prelomom.
randomized into two groups, intraoperative and postoperative Randomizacijski su podijeljeni u dvije skupine, zabilježene su
variables were noted. The Harris score was used to assess functional intraoperativne i postoperativne varijable. Harris skor je korišten za
status. Results: the operative treatment time in the PFNA group was procjenu funkcionalnog stanja. Rezultati: vrijeme operativnog
40.50 min ± 10.87 while in the DHS group the average operative tretmana u PFNA grupi je bilo 40,50min ± 10,87 dok je u DHS grupi
treatment duration was 48.50 min ± 9.21 (p=0.031). In the PFNA prosječno vrijeme trajanja operativnog tretmana bilo 48,50min ±
group, there was 270.92 ml of blood in the drain, while in the DHS 9,21 (p=0,031). U PFNA grupi u drenu je bilo 270,92 ml krvi dok u
group there were 380.53 ml (p=0.003). A total of postoperatively DHS grupi je bilo 380,53ml (p=0,003). Ukupno postoperativno
administered blood transfusions were performed in 7 patients (two ordinirane transfuzije krvi je bilo kod 7 ispitanika (dvije doze krvi) u
blood doses) in the PFNA group, while in the DHS group a total of PFNA grupi dok u DHS grupi ukupno 15 ispitanika je primilo po dvije
15 patients received two blood doses (p=0.003). The total number doze krvi (p=0,003). Ukupan broj dana hospitalizacije u PFNA grupi
of hospitalization days in the PFNA group was 10.125 and in the DHS je bio 10,125 a u DHS grupi je bio 12,787 (p=0,023). U
group it was 12.787 (p=0.023). In the postoperative course, patients postoperativnom toku ispitanici tretirani sa čavlom su imali dozirani
treated with nail had a dosed support of 40.87 ± 4.35 days and oslonac 40,87 ± 4.35 dana a ispitanici tretirani sa DHS-om 60,42 ±
patients treated with DHS for 60.42 ± 3.48 days, (p=0.002). Fracture 3,48 dana, (p=0,002). Do konsolidacije preloma je u PFNA grupi
consolidation occurred in the PFNA group in 88.02 ± 1.58 days and došlo za 88,02 ± 1.58 dana a u DHS grupi za 104 ± 8.71 dana
in the DHS group in 104 ± 8.71 days (p=0.007). There was a (p=0,007). Razlika je bila i u Harris skoru između dvije skupine tri
difference in the Hip Harris score between the two groups thr ee mjeseca (p<0,05) ali nije šest mjeseci od operacije (p>0,05).
months after surgery (p<0.05) and six months after surgery there Zaključak: obje metode se mogu koristi kod stabilnih
was not difference (p<0.05). Conclusion: both methods can be used intertrohanternih preloma, mada intramedularna fiksacija se pokazala
in stable intertrochanteric fractures, although intramedullary fixation boljom zbog kraće hospitalizacije, manje potrebe za transfuzijom i
has been shown to be better due to shorter hospital stays, less need bržom rehabilitacijom.
for transfusions, and faster rehabilitation.
Ključne riječi: intertrohanterni prelomi, DHS, PFNA
Keywords: intertrochanteric fractures, DHS, PFNA
38 F. Lazović et al.

INTRODUCTION months, three months and six months from the operation when the
final observation of the patients was made.
Intertrochanteric fractures of the femur are common injuries,
most often caused by a fall (1) and are constantly increasing, taking AIM
into account that the life expectancy of the world's population has
significantly increased in recent decades (2). In younger people, the The aim of this research was to compare intramedullary and
most common cause of this type of fracture is the action of strong extramedullary osteosynthesis in stable intertrochanted AO/OTA
force, such as traffic accident s, falling from a great height (3). In 31-A2 fractures treated with intramedullary nail (PFNA) or dynamic
general, intertrochanteric fractures belong to the group of fractures screw plate (DHS).
of the proximal end of the femur that can be int racapsular and
extracapsular. Extracapsular fractures include trochanteric fractures, RESULTS
which are divided into: intertrochanteric, pertrochanteric and
subtrochanteric (4). Given that the world's population is living a In the group of patients treated with proximal femoral nails,
longer life, the number of such fractures is increasing, which is a great there were a total of 18 men and 22 women with an average age
burden on the health and economic sector. In general, fractures of 75.05. In the group of patients treated with DHS there were 20 men
the proximal femur are among th e top ten causes of disability (5). and the same number of women and the average age was 72.30
The goal of treatment is the earliest possible surgical treatment with (p=0.784). Also, the average height of the patients treated
an adequate type of osteosynthesis, which will enable the earliest with the nail was 176.05 cm while their weight was 78.85 kg. In the
possible verticalization and training for activities that the patient had group of patients treated with DHS the average height was 177.45
before the injury (6,7). The type of surgical treatment directly cm and the weight was 82.81 kg (Table 1), there was no statistically
depends on the type of fracture and its stability (8). The use of a significant difference in the above data (p=0.684).
dynamic screw plate (DHS) as well as a proximal femoral nail (PFNA)
are the methods of choice in stable fractures and we consider it Table 1 Demographic data.
important to compare these two methods in AO/OTA 31 -A2. The
aim of this study was to compare the functional outcome in patients PFNA (n=40) DHS (n=40)
with stable AO/OTA 31 -A2 femoral fractures treated with two Age 75.05 72,30 p>0.05
different methods (DHS vs. PFNA - extramedullary vs. Sex (m:f) 18:22 20:20 p>0.05
intramedullary osteosynthesis). The null hypothesis of the research is Height (m) 176.05 177.45 p>0.05
that intramedullary fixation of stable intertrochanteric fractures is Weight (kg) 78.85 82.81 p>0.05
more efficient in relation to stabilization with a plate and a dynamic Hip (left:right) 16:24 21:19 p>0.05
screw.
The operative treatment time in the PFNA group was 40.50 min
MATERIALS AND METHODS ± 10.87, while in the DHS group the average duration of operative
treatment was 48.50 min ± 9.21 (p=0.031). In all patients, the drain
An analysis of 80 patients with verified AO/OTA 31 -A2 femoral was placed under the fascia which was removed on the second
fractures treated with a dynamic screw plate (DHS) or a short postoperative day. The length of the incision in the group of patients
proximal femoral nail PFNA (SuperNail GT) was performed. Criteria treated with the nail was 8.15 ± 1.88cm compared to the group
for inclusion in the study: (1) adult patients, (2) X-ray or CT verified treated with the plate where the length of the incision was 16.80 ±
AO/OTA 31 - A2 femoral fracture, (3) patients who walked 2.55cm (p=0.001). In the PFNA group, there was 270.92ml of blood
independently before the injury. Exclusion criteria in the study: (1) in the drain, while in the DHS group there were 380.53ml (p=0.003).
pathological fractures, (2) multiple trauma, (3) metabolic diseases, (4) A total of postoperatively administered blood transfusions were in 7
open fractures, (5) poor general condition, (6) periprosthetic patients (two blood doses) in the PFNA group while in the DHS
fractures. Patients were divided into two groups. The first group group a total of 15 patients received two blood doses each, which
consists of 40 patients treated with DHS and the second group was a significant difference (p=0.003). The number of days spent in
comprised 40 patients treated with multiple SuperNail GT (PFNA). the hospital until surgical treatment was 4.25 in the PFNA group
Upon admission, all patients were prescribed thromboprophylaxis while it was 4.92 days in the DHS group and there was no significant
(Enoxaparin) and the necessary preoperative preparation was difference (F=1.87, p=0.120). The total number of hospitalization
performed. After preoperative preparation and antibiotic therapy days in the PFNA group was 10.125 and in the DHS group it was
(cefazolin) all patients were operated by the same operative team 12.787 (p=0.023). In the postoperative course, patients treated with
with a standardized operative technique, in the supine position. nail had a weight bearing of 40.87 ± 4.35 days and patients treated
Patients treated with DHS had plate with four diaphysical screws and with DHS 60.42 ± 3.48 days, and there is a significant difference in
a dynamic screw 130⁰ while a group of patients treated with an relation to the PFNA group (p = 0.002). Fracture consolidation
intramedullary nail was used a short SuperNail GT 130⁰ with a closed occurred in the PFNA group in 90.02 ± 1.58 days and in the DHS
fracture reposition. Drains were placed in all patients and removed group in 104 ± 8.71 days, which is a significant difference (p=0.007)
on the second postoperative day. On th e first postoperative day, all (Table 2).
patients began rehabilitation, in the morning exercises for extension
and flexion in the hip and knee, and then verticalization with crutches
under the supervision of a physiatrist and therapist. Intraoperative
and postoperative complications were noted in both groups. The first
control of the patients was four weeks after the operative treatment
when the control X-ray was done. The next controls were two
Comparison of efficacy of femoral AO/OTA 31-A2 intertrochanteric fractures treated
39
with dynamic hip screw (DHS) and proximal femoral nail (PFNA)

Table 2 Intraoperative and postoperative variables. Table 4 Hip Harris score (3 months postop).

PFNA (n=40) DHS (n=40) PFNA DHS (n=40)

(n=40)
Time of surgery (min) 40.50 ±10.87 48.50±9.21 Excellent(90-100) 22 14
(p=0.031) Good (80-89) 14 15
Incision (cm) 8.15± 1.88 16.80±2.55
(p=0.001) Fair (70-79) 3 7
Drain blood (ml) 270.92 380.53
Poor (<70) 1 4
(p=0.003)
Blood transfusion 7 (40) 15 (40) Excellent and good (%) 90.0% 72.5% (p<0.05)
(p=0.003)
Time to surgery (days) 4.25 4.92
(p=0.121)
Hospitalization (days) 10.125 12.787 Six months after the operative treatment, a Harris score test was
(p=0.023) performed and it was shown that 92.5% of the patients treated with
Weight bearing (days) 40.87 ± 4.35 60.42 ± 3.48 nail had an excellent and good result, while in the group of patients
(p=0.002) treated with DHS there were 80% with excellent and good results,
Fracture consolidation 88.02 ± 1.58 104 ± 8.71 which there was no significant difference (p> 0.05) (Table 5).
(days) (p=0.007)
Table 5 Hip Harris score (6 months postop).

PFNA DHS (n=40)

The total follow-up was six months and during and there were
(n=40)
no cases of non-union in both groups. In the group of patients
Excellent (90-100) 26 18
treated with the nail, there was no cut out, while in the DHS group
Good (80-89) 11 15
there were a total of two cases of cut out, which is a significant
difference (p <0.05). Reoperation was performed in both patients
treated with DHS. A total of two cases of pulmonary Fair (70-79) 3 3
thromboembolism (PTE) were reported in the PFNA group while Poor (<70) 0 2
one case was in the DHS group of patients. Two cases of deep vein Excellent and good (%) 92.5% 82.5% (p>0.05)
thrombosis (DVT) were reported in the DHS group while in the
PFNA group there was a total of one case of deep vein thrombosis.
There was one case of superficial infection in both groups. DISCUSSION
Postoperative hematoma was noted in nine patients of the PFNA In the research, a radiological and functional analysis of two types
group while in the DHS group there were seven patients with of the most commonly used methods in the stable type of fracture of
postoperative hematoma. No deaths or cerebrovascular insults were the proximal end of the femur AO/OTA 31 -A2 was performed. The
reported. There were no cases of intraoperative and/or research aimed to gain insight into which method is more effective in
postoperative fracture of the material or bone. terms of the number of complications, shorter hospitalizations, faster
rehabilitation and faster healing of fractures. Numerous studies have
Table 3 Postoperative complications. been performed on the efficacy of intramedullary and
PFNA (n=40) DHS (n=40) extramedullary fixation of proximal femoral fractures. According to
demographic data, there was no difference between the two groups.
Death rate 0 0 NS All patients underwent the necessary preoperative preparation and
Non union 0 0 NS the mean time to surgical treatment was similar in both groups
Cut out 0 2 (p<0.05) (PFNA 4.25 days; DHS 4.92 days). The duration of operative
Revision surgery 0 2 (p<0.05) treatment was shorter in patients treated with intramedullary nail 40
PTE 2 1 ( p=0.025) minutes while in the group treated with DHS it was 48 minutes
DVT 1 2 (p=0.035) (p=0.031). According to the research of Rathva J, et al., (2018), the
Superficial infection 1 1 NS length of the operative treatment with DHS was 50 minutes and 35
minutes with the operative treatment with a nail (9). The length of
CVI 0 0 NS
the operative incision in the patients treated with the nail was 8 cm
Postop. hematoma 9 7 (p<0.05) and in the patients treated with DHS 16cm (p=0.001). According to
Huang SG, et al., (2015), the length of the operative incision in nail-
treated patients was 8cm and in DHS-treated subjects 18 cm (10).
Three months after the operative treatment, a functional analysis Considering the blood collected in the drains postoperatively, there
was performed via the Harris score. In patients operated with was a significant difference between the two groups (p=0.0017). In
intramedullary nail, an excellent result after three months was in 90% the group of patients treated with the nail, the total blood in the
of patients and 72.5% in patients treated with DHS (p <0.05) (Table drain was 270ml and in the group of patients treated with DHS it
4). was 380ml. According to Singh NK, et al., (2019), the total number of
drains in patients treated with DHS was 207ml (11). In a study by
Sharma A, et al., (2017) on 60 patients divided into two groups, in
40 F. Lazović et al.

patients treated with DHS the average amount of blood in the drain excellent results had 14 patients, 15 had good (average 72.5%) and
was 221ml and in patients treated with nail it was 116ml and in there is a significant difference (p<0.05). According to Sharma A, et
patients treated with nail it was 109ml (p<0.01) (12). A study by al., (2017), three months after surgery, the average Harris score in
Rathva J, et al., (2018) showed that there was an average of 100ml of nail-treated patients was 47.6 and in DHS-treated patients it was 53.4
blood in the drain in patients treated with DHS and 30ml in patients (p<0.01). In the same study, six months after Harris surgery, the
treated with nail (9). According to the same study, there was a score in nails operated on was 82.7 and in those operated on DHS
significant difference in the number of patients who received a blood 88.7 (p <0.01) (13). According to Rathva J, et al., (2018), three
transfusion postoperatively (p=0.003). In our study, seven nail- months after surgery, patients operated on with a nail had an average
treated patients received a blood transfusion while fifteen DHS- score of 59 and 53.76 in those operated on DHS (p<0.001). In the
treated patients received a transfusion. All patients were started to same study, six months after surgery, 92 had a score in nail surgery
walk on the first postoperative day and were allowed partial weight and 88.3 in DHS surgery (p<0.001) (10). A study by Huang SG, et al.,
bearing. There is a significant difference between the two groups (2015) on 60 patients measured Harris almost a year after surgery
with regard to the length of movement with the partial weight showed that in patients treated with intramedullary nail 20 had an
bearing (p=0.002). Patients operated with the nail were moved with excellent result, 8 good and in patients treated with DHS had an
partial weight bearing for 40 days and patients treated with DHS for excellent result of 15 patients and good 10 respondents. According
60 days. According to Huang SG, et al., (2017) patients treated with to the same study, the average excellent and good result in patients
nail moved with partial weight bearing for 42 days and patients treated with intramedullary nail is 93.30% and in patients treated with
treated with DHS for 57 days. There was no difference between the DHS 70% (11). In our study, six months after surgery, patients
two groups in the time spent until surgical treatment but there was a treated with intramedullary nail 26 had an excellent result, a good 11
significant differe nce in total hospitalization (p=0.023) (11). In a study patients (average 92.5%) and patients treated with DHS excellent
by Sharma A, et al., (2017) patients treated with DHS moved with results had 18 patients, 15 had a good (average 82.5%) and there is a
partial weight bearing for 7.8 weeks and patients treated with a nail significant difference (p<0.05). However, it is important to note that
for 7.2 weeks (p=0.412) (12). In the group of patients treated with the proportion of patients with an excellent and good score after six
the nail, the hospitalization lasted a total of 10 days, while in the other months is significant compared to the period after three months.
group it lasted 14 days. In a study by Muller, et al. (2020), there was
no difference in longer hospital stays between the two groups (13).
According to Sharma A, et al., (2017) the average hospitalization in CONCLUSION
patients treated with DHS was 10.1 days and in patients treated with
Based on the results of our study, it was shown that both
nail 9.29 days (p=0.13) (12). The time elapsed until fracture
methods can be used in stable intertrochanteric fractures, although
consolidation was different in the two groups and represe nts a
intramedullary fixation (PFNA) proved to be superior due to shorter
significant difference (p=0.007). Patients treated with the nail had a
hospitalization, less need for transfusion and faster rehabilitation.
fully consolidated fracture 88 days after surgical treatment and
patients treated with DHS 102 days after surgical treatment.
According to a study by Foulongne, et al. (2009), fracture
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Faruk Lazović, MD, MSc
14. Foulongne E, Gilleron M, Roussignol X, Lenoble E, Dujardin F. Mini-invasive nail Clinic of Orthopedic Surgery and Traumatology
versus DHS to fix pertrochanteric fractures: A case-control study. Orthop Clinical Center University of Sarajevo
Traumatol Surg Res. 2009;95 (8):592-8. Bolnička 25, 71000 Sarajevo
15. Fu CW, Chen JY, Liu YC, Liao KW, Lu YC. Dynamic Hip Screw with Trochanter -
Stabilizing Plate Compared with Proximal Femoral Nail Antirotation as a Bosnia and Herzegovina
Treatment for Unstable AO/OTA 31 -A2 and 31-A3 Intertrochanteric Fractures. Email: fl[email protected]
Biomed Res Int. 2020;2020:1896935. ORCID ID: 0000-0002-2707-4240

Declaration of patient consent: the authors certify that they have

obtained appropriate patient consent form. In the form, patients
have given their consent for their images and other clinical
information to be reported in the journal.
Authors' Contributions: FL, ĐO, AP and MS gave substantial
contribution to the conception or design of the article and in the
acquisition, analysis and interpretation of data for the work. Each
author had role in article drafting and in process of revision. Each
author gave final approval of the version to be published and they
agree to be accountable for all aspects of the work in ensuring that
questions related to the accuracy or integrity of any part of the work
are appropriately investigated and resolved.
Financial support and sponsorship: nil.
Conflict of interest: there are no confli cts of interest.
Medical Journal (2022) Vol. 28, No 1,2 Professional article

Prehospital time of severe trauma in Canton Sarajevo

Prehospitalno vrijeme kod teških trauma u Kantonu
Sarajevo
Amela Ahmić 1*, Tatjana Jevtić 2
1
Clinic of Emergency Medicine, Clinical Center University of Sarajevo, Bolnička 25, 71000 Sarajevo, Bosnia and Herzegovina
2
Institute for Emergency Medical Aid of Sarajevo Canton, Kolodvorska 4, 71000 Sarajevo, Bosnia and Herzegovina

*Corresponding author

ABSTRACT SAŽETAK
Introduction: prolonged prehospital time increases mortality and Uvod: produženje prehospitalnog vremena povećava mortalitet i
affects functional outcome of traumatised patients. It is optimal to smanjuje funkcionalni ishod kod traumatiziranih pacijenata. Optimalno
primary treat and transport the patient during the “golden hour” je primarno zbrinuti i transportovati pacijenta u okviru “zlatnog sata”
what refers to a first 60 minutes from injury onset. Aim: to što se odnosi na prvih 60 minuta nakon povrede. Cilj: ispitati trajanje
investigate prehospital time duration for severely traumatised prehospitalnog zbrinjavanja u Kantonu Sarajevo za teško
patients in Canton Sarajevo and the modifiable factors that can lead traumatizirane pacijente te faktore čija modifikacija može rezultirati
to its shortening. Materials and methods: retrospective study included njegovim skraćenjem. Materijali i metode: retrospektivna studija
155 patients with life threatening traumas (ISS ≥16) primarily uključila je 155 pacijenata sa životno ugrožavajućim povredama koji su
treated and transported by emergency medical teams of the Institute u toku jedne godine primarno zbrinuti i transportovani od strane
of Emergency Medical Aid of Sarajevo Canton and accepted to the Zavoda za hitnu medicinsku pomoć Kantona Sarajevo na Kliniku
Clinic of Emergency Medicine of the CCUS during a one-year period. urgentne medicine Kliničkog Centra Univerziteta u Sarajevu. Rezutati:
Results: A majority (89.03%) of patients were treated and većina (89,03%) pacijenata je primarno zbrinuta i transportovana u
transported to the hospital within the „golden hour“ (median time 29 hospitalnu ustanovu u okviru “zlatnog sata” (medijan 29 minuta).
minutes). Time needed to reach the scene of the accident, on scene Vrijeme odlaska na mjesto povrede, vrijeme na mjestu povrede i
and for transport to the hospital had median values 6, 10 and 12 vrijeme tranporta imali su medijan 6, 10 i 12 minuta respektivno. ISS
minutes, respectively. ISS value very weakly positively correl ated with vrijednost je veoma slabo pozitivno korelirala sa prehospitalnim
total prehospital time (Spearman coefficient 0.17, p=0.038). There vremenom ( Spearmanov koeficijent 0.17, p=0.038).Nije bilo
was no significant difference in prehospital time length between signifikantne razlike u trajanju ukupnog prehospitalnog vremena
polytraumas and monotraumas (p>0.05), but there was a significant između pacijenata sa politraumom i monotraumom ( p>0.05) ali je
difference in relation to the mechanism of injur y (p<0.05). Puncture bila signifikantna razlika u odnosu na mehanizme povrede ( p<0.05).
and gunshot wounds required the shortest and falls the longest time Najkraće je bilo kod uboda i povreda vatrenim oružjem a najduže
(median time 23 and 32 minutes, respectively). Conclusion: Total kod padova (medijan 23 i 32 minute respektivno). Zaključak: ukupno
prehospital time of severely traumatised patients in the Canton prehospitalno vrijeme kod pacijenata sa teškom traumom u Kantonu
Sarajevo can be considered satisfactor y with a majority being treated Sarajevo je zadovoljavajuće a kod velike većine pacijenata se uklapa u
within the „golden hour“. This heavily depends on the territorial „zlatni sat“. Ovisi o teritorijalnoj udaljenosti mjesta povrede od
distance between the accident location and the hospital and injury hospitalne ustanove te mehanizmu povrede, ali ne ovisi o težini
mechanism, but does not depend on the severity of injuries. povreda. Poboljšanje saobraćajne infrastrukture i politike te
Advancing traffic infrastructure and regulation as well as uključivanje i provođenje mjera prevencije traume mogu znatno
implementing means of trauma prevention can greatly contribute to uticati na skraćenje prehospitalnog vremena zbrinjavanja.
the further decrease in total prehospital time.
Ključne riječi: zlatni sat, ukupno prehospitalno vrijeme, teška trauma
Keywords: golden hour, total prehospital time, severe trauma

INTRODUCTION injury onset up to the time that definitive hospital treatment should
commence (1). During this time frame, it is necessary to recognize
The goal of the emergency physicians work day is to quickly and and treat the „ABCDE“ priorities as identified by Advanced Trauma
correctly manage patients. Time is a very important factor, especially Life Support (ATLS ) guidelines and transport the patient to the
in heavily traumatised patients. Total prehospital time duration and appropriate hospital (2).
possibilities of its shortening but also improving quality of care for the Clinical experience tells us that time is of the essence in the
patients during this period are points of particular concern. The term heavily traumatised patient and authors of a limited number of
„golden hour“ in trauma patients refers to the first 60 minutes from
Prehospital time of severe trauma in Canton Sarajevo 43

studies carried out on this subject agree that it should be as short as dispatch, time of arrival on scene, time on scene, time of leaving the
possible and prompt (3,4). scene and time of arrival to the hospital were also included.
Most of the studies have shown that prolonged transport time Definitions:
increases hospital mortality and affects functional outcome (5,6). The total prehospital time is defined as the time from the initial
Contradictory results authors attributed to the evolution in call regarding the injured patient to the dispatch centre of Institute of
organization of emergency medical services as well as the additional Emergency Medical Aid of Sarajevo Canton as this is the first
effort of these services to tend to critically ill earlier than those less in documented time in patient medical documentation, to the time of
need (7). It has also been shown that the influence of prehospital the arrival of the patient with emergency medicine service to the
treatment on mortality differs based on the types of injuries and Clinic. Within this time, there are three different intervals: time of
affected regions and organ systems (8,9). dispatch to arrival on scene, time at the scene and time of transport
Shortening prehospital time, as useful as it is, should not be from the scene to the hospital. The time from the patient injury to
imperative if it lowers the quality of care provided to patients or if the time of call wasn't taken into account given the retrospective
done at the expense of means of initial care (8). Also, the safety of character of the study and inability of taking anamnestic and
medical staff and other road traffic participants should not be heteroanamnestic data from these patients and bystanders.
brought into danger during excessively fast driving. Correctly trained
medical teams, being mindful of safety and patient care quality as well Statistical methods
as some general system solutions, could be factors which contribute
to this aim. All data were calculated and graphically developed in the IBM
This study focused on critically ill trauma patients in Canton SPSS 20 programme. The Shapiro Wilk test was used for normal
Sarajevo. The Clinic of Emergency Medicine of the CCUS is the distribution of continuous variables. Measures of descriptive statistics
referent tertiary care facility specialised in the acceptance and were also used: number, percentage, mean value, median and
treatment of these kinds of patients. Most patients in Canton interquartile range. Data was compared using non parametric
Sarajevo are initially treated and transported to this clinic by physician methods: Kruskal- Wallis test for mult iple independent data, the
led emergency medical teams of the Institute for Emergency Medical Mann Whitney test for two groups of independent data, Friedman
Aid of Sarajevo Canton. test for multiple dependent data. For the correlation we used the
Spearman coefficient. A value of p<0.05 was considered statistically
AIM significant.

The aim of this study was to investigate prehospital time duration

RESULTS
for severely traumatised patients in Canton Sarajevo. This concretely
means to investigate whether the current organisation of the Institute
for Emergency Medical Aid of Sarajevo Canton met the criteria for Among the patients included in the study 80.65% were male and
19.35% were female with the average age of patients being 54.68
transporting patients to a tertiary care facility within the „golden
years (SD +/-22.12) The median ISS score was 25 (IQR 25-75
hour“. Another goal was to investigate factors which contribute to
total prehospital time length and identify the possibility of percentiles 20-34) , with more patients fitting the criteria for
polytrauma (65.8%) than monotrauma (34.19%).
modifications with the goal of shortening this time frame.
The total time from the call to the dispatch regarding the injured
patient up until the patient’s arrival in hospital with EMS is shown in
MATERIALS AND METHODS Figure 1. The mean value is 36 minutes, median 29 and interquartile
range is 25.75 percentile with a confidence interval of 23-45.
This research was carried out retrospectively and included 155
patients with life threatening traumas primarily treated and
transported by emergency medical teams of the Institute of
Emergency Medical Aid of Sarajevo Canton and accepted to the
Clinic of Emergency Medicine of CCUS during a one-year period.
Inclusion criteria was an Injury Severity Score (ISS) ≥16 and patients
primarily treated at the scene by Institute of Emergency Medical Aid
of Sarajevo Canton staff.
Exclusion criteria were patients with ISS values ≤16, patients who
died before diagnostic procedures were finalised (due to the fact that
an ISS score could not be assigned to such patients), as well as
patients with incomplete medical documentation. Given that the
CCUS is the referent emergency department for the Federation of
Bosnia and Herzegovina it treats incoming patients from other cities
and cantons, these patients weren't included seeing that they are
usually not directly transported from the scene of the injury and
therefore the golden hour cannot be estimated correctly. Patients
transported with private vehicles as well as walk in patients were also
excluded from the study.
Patient data collected from the hospital digital registry BIS and the Median 29 minutes, interquartile range (25-75 percentiles) 23-45
patient registry and protocol documentation from Institute of Average value 36 minutes
Emergency Medical Aid of Sarajevo Canton included sex, age but also
quality, severity and mechanism of injury. Data on call time to the Figure 1 Total prehospital time.
44 A. Ahmić et al.

In a vast majority of patients (89.03%) the total prehospital time hospital admission is positive, statistically linear and although
was shorter than 60 minutes, while it was prolonged in 10.97% of significant, weak as is shown in Figure 4. Spearman coefficient was
cases (Figure 2). The total prehospital time refers to the summation 0.17 (very low), p= 0.038
of time needed for EMS to arrive to the scene of the accident after
dispatch, patient assessment and treatment on scene and time R2 Linear = 0.007

needed to transport the patient to the hospital.

< 60 MINUTES 89,03%

> 60 MINUTES 10,97%

0,00% 20,00% 40,00% 60,00% 80,00%100,00%

Figure 2 Ratio of patients that reached the hospital within the

“golden hour”.

The analysis of the lengths of these intervals has shown a Figure 4 Correlation between ISS value and the total prehospital
statistically significant difference (p<0.05). Time needed to reach the time.
scene of the accident was shown to be the shortest in our research,
with a median value of 6 minutes and an average value of 9 minutes,
whilst the longest time was shown to be the time taken to transport Similarly to the individual intervals assessed, the total prehospital
the patient to the hospital with a median value of 12 and an average time did not differ in accordance to the severity of injuries, whether
value of 15 minutes (Figure 3). they were single or polytrauma (Table 1).

Table 1 The relationship between the assessed time intervals and

aff ected organ systems.

Variables Time to Time at Time Time

scene of scene¹ needed from call
accident¹ for to
transport dispatch
from until
scene to hospital
hospital¹ admission¹

Single 6 (3) 7 (8) 12 (9) 27 (11)

trauma
Polytrauma 6.50 (9) 10 (11) 13 (14) 30 (26)
²P-value 0.637 0.198 0.087 0.069
¹ Median ( Interquartile range 25-75 percentiles)
² Mann-Whitney test
Time to scene: median 6 minutes, interquartile range (25-75
percentile) 4-11, average value 9 The total prehospital time shows a statistically significant
Time at scene of accident: median 10 minutes, interquartile range difference in relation to the mechanism of the injury (p<0.05). There
(25-75 minutes) 6-15, average value 11 was also a statistically significant difference of time needed to reach
Time of transport from scene to hospital: median 12, interquartile the scene of the accident and transport duration between these
range (25-75 percentile) 8-19, average value 15 groups of patients (p<0.05). In all of the cases assessed the shortest
X²= 49.635, P= 0.000 (Friedman test) time intervals were in the cases of gunshot wounds. The total
prehospital time was the shortest in puncture and gunshot wounds
Figure 3 Prehospital time intervals.
(median 23 minutes) and the longest in falls (median 32 minutes)
(Table 2).
The correlation between the severity of injuries expressed by ISS
value and the total amount of time from the first call to dispatch to
Prehospital time of severe trauma in Canton Sarajevo 45

Table 2 The relationship between time intervals and injury efficient when it comes to territorial placement. The hospitals in
mechanisms. Canton Sarajevo are located in the city centre, meaning transport
from the outskirts of the Canton can have a longer duration.
However, all the ambulance teams of Institute of Emergency Medical
Variables ¹Time to ¹Time ¹Duration ¹Time Aid of Sarajevo Canton are physician led and equipped to provide
scene of on of from call advanced life support meaning that time in transport cannot be
accident scene transport to dispatch considered „lost time“. The problem of distance and length of
to hospital until transport depends tremendously on traffic infrastructure, traffic
hospital conditions and density in Canton Sarajevo.
admission¹ The severity of injuries doesn’t significantly influence the length of
total prehospital time. The total time before hospital admission very
lightly positively correlates with the ISS score and there is no
Fall 6 (6) 10 (12) 14 (12) 32 (24) significant difference in its length between single and polytrauma.
Multiple organ affliction does not generate longer treatment and
Car 7 (9) 10 (9) 11 (15) 29.5 (20)
immobilization times before transport begins, meaning there was no
accident
significant difference in time spent on the scene between patients
Physical 8 (7) 7 (19) 6 (24) 28 (49) with injuries of one or more organ systems. In contrast to our results,
altercation the research carried out by Al Thani H, et al., showed that higher ISS
scores meant longer on scene times (13). In this research, the
Puncture 4 (4) 6 (9) 9 (5) 23 (8) average time spent on scene was 24 minutes which is significantly
and gun longer than the average time of 11 minutes we found. This can be
injuries attributed to the fact that these authors included all trauma patients,
²P-value 0.022 0.236 0.024 0.02 including those with less severe injuries who did not require such
prompt action. Our results can be explained by quality EMS training
²X² 9.639 4.249 9.478 9.791 leading to decreased on scene times seeing that all of the patients
¹ Median ( Interquartile range 25-75 percentiles) included in our study were suffering from life threatening injuries.
² Kruskall-Wallis test Furthermore, these results were in contrast to those found by
Maegele M, (14) which testified to longer on scene times (OST) in
physician staffed EMS teams due to an increased number of
DISCUSSION
interventions performed by these teams in comparison to paramedic
The injuries assessed in our patients fit the criteria for major only teams. This would mean that a higher count of injuries would
trauma and could be classified into the subgroup of very severe also mean more interventions. However, it is impossible to evaluate
trauma given that the median ISS value was 25. The average age of the exact degree of injuries or exclude injuries for lack of physical
the patients was 54.68 years and this group of patients has the findings on certain body parts before definitive hospital evaluation.
highest expected mortality rate. The American College of Surgeons For this reason, ATLS guidelines, which are considered to be the
Committee on Trauma /ASC COT/ patients with this severity of golden standard in trauma patient care, are followed in the field (15).
injuries over the age of 45 have an expected mortality up to 35.37% Our results are a confirmation of the effectiveness of this protocol.
(10). Some research have shown that the length of prehospital Based on the data collected in our study, we found a statistically
treatment affects the final outcome of injured patients (1,6), significant difference in the duration o f total prehospital time in
especially those with major trauma (5). We deemed it useful to regards to different injury mechanisms. The total prehospital time
evaluate the length of prehospital time in these patients with an was the longest in patients hurt by falls and shortest in puncture and
already expected high mortality rate. Our research proved to be gunshot wounds. On scene time did not statistically differ among
accounted for, seeing that a great majority of patients (89.03%) were different injury mechanisms, unlike the time of transport. This lead to
treated and transported to the hospital within the „golden hour“ and the conclusion that falls as accidents are more frequent in areas
the average prehospital time shorter than an hour, with a median further from the centre, which results in longer durations of
time of 29 minutes from call to dispatch to scene arrival, length of transport to the hospital, whilst puncture and gunshot wounds, as
time spent on scene and transport duration. violent mechanism injuries, are more often seen in central city areas.
As already proven by previous research on this subject, This data could contribute to accurate trauma prevention complying
territorial factors regarding the location of the accident have the to European and worldwide trends (10,16). Also, it would result in a
most influence on the length of prehospital treatment and transport decrease of heavily traumatised patients requiring prolonged
(11,12). This was also confirmed by our research with the exemption prehospital treatment times.
that the distance of the scene of the accident to the hospital affects
the total prehospital time the most given that the median time of CONCLUSION
transport from the scene of the accident was 12 minutes. On the
other hand, the median time it took for teams to arrive to the scene The average time of prehospital treatment and transport in
was only 6 minutes which is significantly less. Institute of Emergency Canton Sarajevo can be considered satisfactory, with a majority of
Medical Aid of Sarajevo Canton is organised into 8 points which are patients being treated within the „golden hour“. This heavily depends
territorially placed in the area of Canton Sarajevo in order to assure on the territorial distance of the scene of the accident from the
the shortest possible time to arrival on scene at any point in this hospital as well as injury mechanism but doesn't depend on severity
territory, a strategic placement that has proven to be effective by the and quality of injuries. Advancing traffic infrastructure and regulation
results of our study. The time-to-scene has been reduced to a as well as implementing means of trauma prevention can greatly
minimum, proving that the organisation of this emergency service is
46 A. Ahmić et al.

contribute to the decrease in total prehospital time in trauma 11. Vanderschuren M, McKune D. Emergency care facility access in rural areas within
the golden hour?: Western Cape case study. Int J Health Geogr. 2015;14:5.
patients. 12. Hu W, Freudenberg V, Gong H, Huang B. The "Golden Hour" and field triage
pattern for road trauma patients. J Safety Res. 2020;75:57 -66.
13. Al-Thani H, Mekkodathil A, Hertelendy AJ, Frazier T, Ciottone GR, El-Menyar A.
LIMITATIONS Prehospital Intervals and In-Hospital Trauma Mortality: A Retrospective Study
from a Level I Trauma Center. Prehosp Disaster Med. 2020 ;35(5):508-15.
14. Maegele M. In Acute Trauma Care, Time Matters but Is Not Everything. JAMA
A limitation can be found in the fact that we did not record the Surg. 2019;154(12):1125.
time before call to dispatch meaning that the actual patient 15. Feller R, Furin M, Alloush A, Reynolds C. EMS Immobilization Techniques. In:
StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 .
prehospital time is longer for this time period.
16. Available at : https://www.eurosafe.eu.com/

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every minute in the golden hour matters. Eur J Trauma Emerg Surg. have given their consent for their images and other clinical
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Conflict of interest: there are no conflicts of interest.
Medical Journal (2022) Vol. 28, No 1,2 Case report

Segmental portal hypertension as a cause of bleeding

from the upper parts of the digestive tract: case report

Segmentalna portalna hipertenzija kao uzrok krvarenja

iz gornjih partija digestivnog trakta: prikaz slučaja

Edin Hodžić1*, Sadat Pušina1, Jasmin Perviz 2

1
Clinic of General and Abdominal Surgery, University Clinical Center Sarajevo, Bolnička 25, 71000 S arajevo, Bosnia and Herzegovina
2
Clinic of Gastroenterohepatology, University Clinical Center Sarajevo, Bolnička 25, 71000 Sarajevo, Bosnia and Herzegovina

*Corresponding author

ABSTRACT SAŽETAK

Introduction: segmental portal hypertension (SPH) is a rare cause Uvod: segmentalna portalna hipertenzija (SPH-segmental portal
of bleeding from the upper parts of the digestive tract. It is most hypertension) je rijedak uzrok krvarenja iz gornjih partija probavnog
often caused by diseases of the pancreas, which with their trakta. Najčešće je uzrokuju bolesti pankreasa koje svojom
progression lead to involvement of the splenic vein, which leads to its progresijom dovode do zahvatanja splenične vene što dovodi do
thrombosis. Aim: to present a case of segmental portal hypertension nastanka njene tromboze. Cilj: prikazati slučaj segmentane portalne
caused by thrombosis of the lienal vein as one of the rare causes of hipertenzije uzrokovan trombozom lienalne vene kao jednim od
bleeding from the upper parts of the digestive tract. Case report: a rijetkih uzroka krvarenja iz gornjih partija digestivnog trakta. Prikaz
patient admitted to the Clinic of Gastroenterohepatology of the slučaja: pacijentica primljena na Kliniku za gastroenterohepatologiju
Clinical Center University of Sarajevo due to recurrent bleeding Kliničkog Centra Univerziteta u Sarajevu radi recidivirajućeg krvarenja
from the upper parts of the digestive tract. A proximal endoscopy iz gornjih partija digestivnog trakta. Uradi se proksimalna endoskopija
was performed, which proved varicosities in the fundic region of the koja je dokazala varikozitete fundične regije želudca, bez znakova
stomach, without signs of acute bleeding. Then a CT scan of the akutnog krvarenja. Potom se učini CT abdomena sa kontrastom koji
abdomen with contrast was performed, which showed thrombosis of je pokazao trombozu lienalne vene sa posljedičnom splenomegalijom
the lienal vein with consequent splenomegaly and numerous dilated i brojnim dilatiranim perigastričnim kolateralnim krvnim sudovima.
perigastric collateral blood vessels. An indication for operative Postavi se indikacija za operativni tretman, a intraoperativno se dobila
treatment was set, and intraoperative confirmation of clinical, potvrda kliničke, endoskopske i radiološke sumnje na segmentalnu
endoscopic and radiological suspicion of segmental portal portalnu hipertenziju. Klasičnom hirurškom tehnikom se učini
hypertension was obtained. A splenectomy was performed using a slenektomija, postoperativni tok je protekao uredno. Na kontrolnom
classical surgical technique, the postoperative course was uneventful. pregledu tri mjeseca nakon operacije endoskopski se dokazala
At the follow-up examination three months after the operation, the potpuna regresija varikoziteta fundične regije želudca, laboratorijski
endoscopy showed a complete regression of the varicosities of the nalazi krvi u poboljšanju, a klinički status zadovoljavajući. Zaključak: na
fundic region of the stomach, the laboratory blood findings were segmentalnu portalnu hipertenziju kao uzrok krvarenja iz gornjih
improving, and the clinical status was satisfactory. Conclusion: partija digestivnog trakta bi trebalo posumnjati kod svih pacijenata sa
segmental portal hypertension as a cause of bleeding from the upper uvećanom slezenom, ranijom bolesti pankreasa, a sa isključenom
parts of the digestive tract should be suspected in all patients with an bolesti ili povredom jetre.
enlarged spleen, previous pancreatic disease, and in whom liver
disease or injury has been ruled out. Ključne riječi: krvarenje, splenomegalija, portalna, hipertenzija,
splenektomija
Keywords: hemorrhage, splenomegaly, portal hypertension,
splenectomy

INTRODUCTION patient to the doctor is the appearance of black, tarry stools

accompanied by cramping pains throughout the abdomen (1-4).
Segmental portal hypertension (SPH), also known as left-sided SPH differs from other forms of portal hypertension in that liver
portal hypertension, is a rare cause of bleeding from the upper parts function is often preserved, and the extrahepatic part of the portal
of the digestive tract. The most common symptom that brings a vein is intact. SPH is most often caused by diseases of the pancreas
48 E. Hodžić et al.

such as acute or chronic pancreatitis, pseudocysts of the pancreas Based on the anamnesis, it was evident that patient was
and pancreatic carcinomas, which with their progression lead to previously treated for Crohn's disease when a right hemicolectomy
involvement of the splenic vein, which leads to its thrombosis (1 -5). with ileo-transverse anastomosis was performed, she underwent a
Under normal anatomical and functional circumstances, venous gallbladder surgery and was also surgically treated for pancreatitis, but
blood is drained by the force of gravity via the short gastric arteries without appropriate medical documentation attached. She states that
into the splenic vein, which at the confluence is handed over to the in January this year she was in a coma due to acute renal failure when
central portal blood flow. In the case of thrombosis of the lienal vein, she was treated for hepatorenal syndrome.
arterial blood enters the spleen unimpeded via the lienal artery, while Upon admission, a clinical examination was performed, followed
the flow of venous blood is partially or completely obstructed. In this by esophagogastroduodenoscopy after resuscitation therapy. After
case, due to the increased pressure in the vein segment from the removal of the coagulum, endoscopic signs of portal hypertensive
hilus due to the thrombus, blood begins to move upward through gastropathy III degree with fundic varices were observed, two of
the short gastric veins, opening the portocaval shunt of the which had a fibrin plug. One of them was particularly pronounced,
gastroesophageal region. As a result of the aforementioned swollen. Taking into account the duration of the procedure and the
mechanisms, isolated fundic varicosities typical for SPH occur. The patient's general condition, the decision was made in favor of
schematic view of the physiological and pathophysiological circulation repeated conservative treatment. There were no signs of active
caused by vein thrombosis is shown in Figure 1 (6,7). bleeding.
A day later, a contrast enhanced computerized tomography (CT)
of the abdomen was performed, which showed that the liver was in
a regular position, shape and size, with a craniocaudal diameter of the
right lobe up to 167 mm. The liver parenchyma was homogeneous
with no signs of cirrhosis or tumor changes. The portal vein was of
the appropriate width of the main stem (diameter up to 11 mm),
with neat contrasting opacification and arborization. In contrast, the
lienal vein did not opacify in the region of the portal vein confluence.
The upper mesenteric vein was of adequate width and properly
opacified with contrast along the entire course. It was a reanalyzed
and extremely tortuous gastroepiploic vein filled prehilarly from the
lienal vein. The left gastric vein was also recanalized, which continues
to the extremely dilated and tortuous perigastric venous blood
vessels, which was especially pronounced near the fundus, without
visible signs of active extravasation. The spleen was in an orderly
position and markedly enlarged, with an interpolar diameter of up to
220 mm, and in the parenchyma of the interpolar part and towards
the upper pole, wedge-shaped and mutually confluent hypodense
areas of the type of stasis changes could be seen subcapsularly. The
pancreas was in an orderly position, extremely gracile in shape,
chronically altered, and in the area of the trunk and tail, two cystoid
formations with slightly thicker walls, up to 33 and 26 mm in
diameter, were recorded. As an incidental finding, it was noted that
Figure 1 Physiological and pathological flow of venous blood caused
the common hepatic artery originates from the upper mesenteric
by thrombosis of the lienal vein (6,7).
artery, and the left gastric artery originates from the lienal artery. The
most important details of the CT findings are shown in Figure 2.
The treatment of choice for symptomatic patients with recurrent
variceal bleeding is splenectomy, which interrupts the flow of arterial
blood to the spleen and with the consequent relief of the portocaval
anastomoses (5,8).

AIM

To present a case of segmental portal hypertension caused by

thrombosis of the lienal vein as one of the rare causes of bleeding
from the upper parts of the digestive tract and thus draw attention
to the importance of differential diagnosis in patients with
splenomegaly and varicosities of the stomach in the region of the
fundus, without proven primary liver disease.

CASE REPORT

A 48 years old patient was referred to the Clinic of

Gastroenterohepatology of the CCUS due to clinical and laboratory
signs of acute bleeding from the upper parts of the digestive tract.
Two weeks earlier, she also visited a gastroenterologist due to
bleeding, which was resolved with conservative treatment.
Figure 2 The most important details of CT finding.
Segmental portal hypertension as a cause of bleeding from the upper parts of the digestive tract: case report 49

DISCUSSION
From the gastroenterological side, primary liver disease was ruled
out as the cause of bleeding in the field of portal hypertension, and SPH and generalized portal hypertension can cause upper
an abdominal surgeon was called, who set an indication for elective gastrointestinal bleeding, but SPH is often associated with
surgical treatment. splenomegaly and normal liver function (9). In our case, we had a
Due to previous intra-abdominal procedures, we decided to patient with splenomegaly and normal liver function, which in the
perform a splenectomy using a classic open approach, where an available literature is considered a sine qua non finding in SPH.
enlarged spleen was found intraoperatively, along with extremely Therefore, SPH should be suspected in all patients with a normal
enlarged and tortuous venous blood vessels in the region of the hilus liver, splenomegaly and acute bleeding from the upper parts of the
of the spleen and fundus of the stomach, as well as an accentuated digestive tract.
gastroepiploic venous arcade. The spleen was freed from the The most common cause of thrombosis of the lienal vein is
surrounding adhesion and luxated forward and medially. The lienal chronic pancreatitis and pseudocysts of the pancreas due to close
artery and vein were shown. The lienal vein appeared thrombosed anatomical relationships (10). An increased frequency of pancreatic
on palpation. Figure 2 shows the most important details of the pathology, in the form of acute or chronic pancreatitis, was recorded
intraoperative findings. in patients with inflammatory bowel disease (IBD) compared to the
Afterwards, the mentioned vascular structures were cut and the general population (11). Considering that our patient was treated for
spleen was completely removed from its socket. Following the Crohn's disease, radiologically verified chronic pancreatitis does not
application of additional hemostatic sutures in the area of the tail of surprise us, although the patient denies its previous existence, and the
the pancreas and fundus of the stomach, as well as a pair of metal pains she had were attributed to the underlying disease.
clips, the hemostasis and integrity of the stomach lumen were CT with contrast and proximal endoscopy are the methods of
checked. An abdominal drain was placed in the splenic cavity, the choice for demonstrating SPH (12). In our patient, SPH was
operative wound was closed, and the patient was placed suspected by gastroscopy, and confirmed by CT enhanced
postoperatively in the standard care surgical department. The spleen radiological diagnostics. A detailed description of portocaval
preparation was sent for regular PH analysis. The postoperative collaterals, morphological characteristics of the pancreas is given, and
course went smoothly, and the complete reduction of gastric varices primary liver disease that would lead to generalized (central) portal
was confirmed by endoscopy of the upper gastrointestinal tract hypertension is ruled out in the differential diagnosis. An aberrant
3 months after the surgery. starting point of the common hepatic artery is mentioned as an
incidental finding, which is valuable information in the case of
resection operative treatment due to chronic pancreatitis.
The treatment of SPH includes the surgical treatment of the
underlying condition of SPH with splenectomy (13,14). With
splenectomy, the blood flow to the left portal basin is cut off, and in
this way the collaterals, that is, the varicosities of the fundic region,
are relieved (15). Considering that the basic indication for the
operative treatment of chronic pancreatitis was a chronic and
unbearable pain syndrome, which our patient did not describe in the
anamnestic, there was no indication for pancreatic resection, but only
splenectomy (16).
In the available medical literature, it is stated that the
characteristic operative finding in SPH implies dilated, tortuous
vessels around the spleen and stomach. The gastroepiploic vein is
particularly prominent, the liver is normal and there are no dilated
blood vessels on the right side of the abdomen. Sometimes it is
possible to show the site of thrombosis of the lienal vein (17). During
our operative procedure, we were able to show the key
characteristics of findings in SPH with palpatory identification of the
site of lienal vein thrombosis (Figure 2).
Splenectomy brings numerous benefits in symptomatic patients,
reduces/eliminates the risk of life-threatening bleeding, risks
Figure 3 The most important details of the intraoperative finding: associated with multiple blood transfusions and removes
A- Dilated fundic blood vessels; B-Lienal vein; C- Enlarged spleen. hypersplenism, thereby correcting leukopenia and thrombocytopenia
(18).
Control laboratory findings after three months showed a
Pathohistological analysis confirmed the clinical, radiological and significant improvement in the blood count, but without complete
intraoperative picture of changes in the spleen as part of vein normalization, which could be attributed to the chronic impact of
thrombosis. Hyalinized blood vessels were found, distended red pulp Crohn's disease on the patient's condition. Although there is no clear
with reduced white pulp with an enlarged marginal zone and mildly surgical consensus on the use of prophylactic splenectomy in patients
noticeable sinus hyperplasia. with SPH, its eventual clinical benefit can be seen from the above,
while additional prospective studies are needed for a definitive
opinion.
50 E. Hodžić et al.

CONCLUSION 14. Ono Y, Matsueda K, Koga R, Takahashi Y, Arita J, Takahashi M et al. Sinistral portal
hypertension after pancreaticoduodenectomy with splenic vein ligation. British
Journal of Surgery. 2014;102(3):219 -228.
Isolated obstruction of the lienal vein is a rare but important 15. Katz M, Lee J, Pisters P, Skoracki R, Tamm E, Fleming J. Retroperitoneal Dissection
clinical condition that can lead to severe bleeding from the upper in Patients with Borderline Resectable Pancreatic Cancer: Operative Principles
parts of the digestive tract. Segmental portal hypertension should be and Techniques. Journal of the American College of Surgeons. 2012;215(2):e11-
suspected as the cause of bleeding in all patients with an enlarged e18.
16. Bouwense SAW, Kempeneers MA, van Santvoort HC, Boermeester MA, van
spleen, previous pancreatic disease, and liver disease or injury Goor H, Besselink MG. Surgery in Chronic Pancreatitis: Indication, Timing and
excluded. Procedures. Visc Med. 2019;35(2):110-8.
17. Kovacs T, Jensen D. Varices. Clinics in Liver Disease. 2019;23(4):625 -642.
18. Isolated Gastric Variceal Bleeding Due To Segmental Portal Hypertension
Developed As A Consequence of Pancreatic Ductal Adenocarcinoma: A case
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