Open Access Macedonian Journal of Medical Sciences

Do Laparoscopic Colorectal Procedures Need Fluid Optimization?

Matej Jenko — 2024-03-20

BACKGROUND: Goal-directed fluid therapy (GDFT) with hemodynamic monitoring may not be of benefit to all elective patients undergoing major abdominal surgery, particularly those managed in enhanced recovery after surgery protocols (ERAS) setting.

AIMS: We predicted different fluid and vasoactive drug consumption during the procedure and less complications in the group of patients, where invasive hemodynamic monitoring was used.

METHODS: Two groups of patients undergoing elective laparoscopic colorectal surgery were compared: A control group (CG), with standard hemodynamic monitoring, and a study group, (SG) with invasive hemodynamic monitoring and appropriate intraoperative interventions. We compared differences in intraoperative fluid consumption, length of hospital stay (LOS) and post-operative morbidity.

RESULTS: A group of 29 patients in SG had similar average intraoperative fluid balance (+438 mL) as 27 patients in CG (+345 mL) p = 0.432. Average LOS was 8 days (±4) in SG and 6 days (±1) in CG (p = 0.124). Acute renal failure, anastomotic dehiscence, and indication for antibiotic treatment were predictors of statistically significant prolongation of hospital stay 3^rdday after surgery, but independent of SG.

CONCLUSION: Since no differences between the groups were shown in overall fluid and vasoactive drug consumption, we conclude that GDFT is not needed in laparoscopic colorectal surgery, when ERAS is followed.

Effects of Adding Dexamethasone Plus Ketamine to Bupivacaine for Ultrasound-guided Serratus Plane Block as Analgesia in Major Breast Surgery: A Randomized, Double-blind Trial

Ahmed Hussein Bakeer — 2024-03-20

BACKGROUND: Post-operative pain after mastectomy is associated with poor recovery, prolonged hospital stays, and increased liability for chronic persistent pain.

AIM: This work aimed to test the analgesic efficacy of adding ketamine to a dexamethasone bupivacaine combination in ultrasound-guided serratus anterior plane block (SAPB) in patients undergoing modified radical mastectomy (MRM).

METHODS: This randomized, double-blind trial included 60 females aged 20–60 undergoing MRM. They were randomized into two groups: Group DB (n = 30) received SAPB using 30 ml of bupivacaine 0.25% and dexamethasone 4 mg. Group KD (n = 30) received the same block with the addition of ketamine 50 mg.

RESULTS: The time to the first analgesic request was significantly delayed in Group KD than in Group DB (p < 0.001). The number of patients requiring morphine and its total consumption during the first 24 post-operative hours in Group KD were significantly less than in Group DB (p = 0.001 and p < 0.001, respectively). Visual Analog Scale scores at rest and movement at 4, 6, 8, 10, 12, and 18 h were significantly lower in Group KD than in Group DB.

CONCLUSIONS: Adding ketamine to bupivacaine plus dexamethasone in ultrasound-guided SAPB is associated with better analgesic outcomes in patients undergoing MRM, including prolonged duration of analgesia and decreased post-operative morphine consumption and pain scores at rest and movement.

Avascular Necrosis of the Hip Joint and Femoral Head Related with Long COVID-19 or Post-COVID-19: Case Report Study

Sanja Petrusevska-Marinkovic — 2024-02-25

BACKGROUND: Post-COVID conditions can include a wide range of ongoing health problems. As a consequence of long COVID-19 or post-COVID-19 an increase in osteonecrosis has been detected in different series of patients.

CASE PRESENTATION: We present two patients diagnosed with COVID-19 and pneumonia, one with moderate and the other with severe clinical picture. They were treated with corticosteroid equivalent to prednisolone 993.5 mg (400–1587 mg) which correlates with steroid dose documented in the literature as causative for avascular necrosis (ANV) in patients with COVID-19. After the mean time of 65 days, due to pain in the groin and difficulty in movement, magnetic resonance imaging (MRI) was performed in both patients and AVN was diagnosed. Compared to our results, the literature records a longer time required for the development of AVN in patients without COVID-19, which is 6–36 months. This indicates the potency of the virus itself to cause disturbances in the microcirculation, and thus the development of AVN. The bone damage correlates with the degree of inflammation and the severity of the clinical picture.

CONCLUSION: After a course of COVID-19 as part of a long COVID-19, ANV should be considered a possible complication, especially in patients who have clinical manifestations. Early detection of AVN and diagnosis using MRI on clinical suspicion would help early intervention with bisphosphonate therapy in patients with osteonecrosis of the hip. If the disease is detected in the more advanced stage, it is necessary to perform a surgical intervention and even a possible hip replacement.

Dietary exposure to aflatoxin B1 and ethanol from homemade and industrial fermented beverages in South Kivu, Democratic Republic of the Congo

Aladin Ombeni Mahano — 2024-03-20

BACKGROUND: The prevalence of AFB1 contamination in agricultural products used to produce fermented alcoholic beverages is increasing, raising concerns for human health.

AIM: The aim of this study was to investigate dietary exposure to AFB1 and ethanol through homemade and industrial fermented beverages commonly consumed in South Kivu, DR Congo.

METHOD: AFB1 and ethanol were measured using reverse-phase HPLC with a fluorescence detector and a refractive index detector, respectively. Data on fermented beverage consumption were collected from 847 adults using a food frequency questionnaire (FFQ).

RESULTS: The findings revealed that industrial sample Man 8 had the highest exposure to AFB1 (77.8 ± 45.0 ng/kg b.w/day) and Man4 had the highest ethanol exposure (4.83 ± 2.40 mg/kg b.w/day); while among homemade samples, Kasiksi had the highest exposure to both AFB1 (8.8 ± 6.6 ng/kg b.w/day) and ethanol (2.46 ± 1.85 mg/kg b.w/day). The margin of exposure (MOE) for AFB1 was 1011.7 or less, and for ethanol, it was 818.2 or less. Men are more likely to be exposed.

CONCLUSION: Increased consumption of homemade and industrial fermented beverages raises the risk of developing hepatocellular cancer (HCC) because the levels of AFB1 and ethanol MOE drop below the safe limit of 10000. Further research is needed to investigate the connection between AFB1, ethanol, and HCC, especially in regions where alcohol misuse is common.

Clinical Importance of Evaluating the Results of Excused Perianal Lesions

Sümeyra Emine Bölük — 2024-03-20

BACKGROUND: Perianal and anal region lesions are mostly benign, typically polypoid formations seen adjacent and distal to the anal canal. Fibroepithelial anal polyps are benign lesions commonly found in the perianal region, composed of squamous epithelium and subepithelial connective tissue. Despite their benign nature, excision may be necessary in cases where they cause pain, progressively increase in size, or give rise to suspicion of an infectious or malignant disease, as well as during treatment for accompanying perianal conditions. Follow-up of the pathology results for all removed lesions is important, as the patient’s follow-up and treatment process may vary based on the pathology results. Based on this perspective, patients who underwent excision of perianal lesions during surgery for a preliminary diagnosis of benign anorectal diseases were retrospectively evaluated in our clinic. The importance of the excision and pathological examination of these lesions was discussed based on the results.

AIM: The study retrospectively evaluated patients who underwent surgery for anal fistula, anal fissure, or palpable lesions in the anal or perianal area and had accompanying lesions that were pre-diagnosed as sentinel tags excised.

MATERIALS AND METHODS: The patients who underwent surgery due to anal, perianal lesions, anal fistula, or anal fissures in the general surgery clinic were retrospectively evaluated between January 2017 and February 2022. Their medical history, surgical notes, and pathology results were reviewed. Patients who underwent excision of lesions from the perianal and anal regions were evaluated. The age, gender, pathology results, pre-operative diagnoses, number and size of polyps, and the presence of concomitant hemorrhoids, anal fissures, and fistulas were recorded. The Number Cruncher Statistical System (NCSS) 2020 Statistical Software (NCSS LLC, Kaysville, Utah, USA) program was used for statistical analysis for the evaluation of the findings obtained in the study.

RESULTS: A total of 49 patients were evaluated. Three patients were excluded from the study as their pathology results were not recorded, even though a lesion excision was mentioned in their surgical notes. One patient who underwent surgery for an incisional biopsy was also evaluated separately. Of the patients, 20 were female and 25 were male. The average age of the patients was 41 (ranging from 21 to 86 years old). The average diameter of the excised polypoid lesions was 1.29 cm. When the final pathology results of the cases were reviewed, it was found that 37.8% (n = 17) had anal condyloma, 35.6% (n = 16) had fibroepithelial polyp, 8.9% (n = 4) had pyogenic granuloma, 4.4% (n = 2) had hemorrhoid, 4.4% (n = 2) had inflammatory polyp, 2.2% (n = 1) had multiple squamous papilloma, 2.2% (n = 1) had basal cell carcinoma, 2.2% (n = 1) had hypertrophic anal papilla, and 2.2% (n = 1) had pilonidal sinus. One notable result was that, despite the pre-operative diagnosis not being malignant, one patient had a pathology result of basal cell carcinoma. In addition, it is important to note that low-grade dysplasia was also detected in a patient with anal condyloma.

CONCLUSION: While perianal and anal lesions are generally benign, it is noteworthy that malignant cases can still occur, although rarely. Therefore, it is important to subject every excised perianal and anal lesion to pathological evaluation, as it is crucial for the proper follow-up and treatment of patients.

Real-world Observational Multi-center Study: Retrospective Analysis of Diagnostic and Treatment Patterns for Stage III–IV Melanoma in Ukraine from 2018 to 2020

Mariia Kukushkina — 2024-03-20

BACKGROUND: Despite open-access sources with information about cancer patients (National Cancer Registry of Ukraine), there are considerable gaps about actual diagnostic methods and specific treatment patterns or any details on how different regimens are applied for melanoma treatment in Ukraine.

OBJECTIVES: This non-interventional, multicenter, retrospective medical chart review study aims to describe real-world therapeutic strategies and characterize the profile of patients with melanoma Stage III–IV in real-life clinical practice in Ukraine.

METHODS: Anonymized data were collected from medical records of 747 patients in 9 oncology centers in Ukraine - four private and five public. The data variables were retrieved, captured in electronic case report forms, and analyzed with descriptive statistical methods.

INCLUSION CRITERIA: Subjects were not enrolled unless they met all the following criteria: (1) Age >18 years at the time of being diagnosed with III–IV stage melanoma. (2) Morphologically (including cytology) confirmed diagnosis of III–IV stage melanoma. Sufficient available medical records for data abstraction to meet the objectives of the study, that is, the patient has been under the medical care of the participating site for the entirety of the patient observation period or the patient’s detailed historical data on their disease course, and clinical management are otherwise available at the participating site consent has been granted by the Institutional Review Board/Ethical Committee of the study site.

EXCLUSION CRITERIA: Subjects were not enrolled if they met any of the following criteria: (1) The patient has received treatment with anticancer systemic therapy for reasons other than melanoma. (2) Primary cancer other than melanoma. (3) The patient is participating (or was participating) in any investigational program/clinical trial with interventions outside of routine clinical practice. All the statistical tests were two sided and performed at a 0.05 significance level. p-values were rounded to three decimal places. p < 0.001 were reported as <0.001 in tables.

RESULTS: Most melanoma cases (95.05%) were diagnosed histologically, although information about the primary tumor’s characteristics and treatment are heterogeneous. Most individuals (51.05%) diagnosed with Stage III undergo surgical treatment without additional therapy. Chemotherapy constitutes the primary form of systemic therapy for Stages III and IV, accounting for 33.3% and 45.65%, respectively.

CONCLUSION: It is crucial to tackle the problems associated with diagnosing and treating melanoma in Ukraine. This involves creating a unified registry for melanoma patients, establishing uniform methods for staging and re-staging, and standardizing medical records. Nevertheless, the most critical issue is the absence of access to modern therapy, which should be addressed at the state level.

Association Between Inflammatory Markers and Cognitive Impairment in Patients with Asymptomatic Carotid Stenosis

Elena Joveva — 2024-03-20

BACKGROUND: Certain inflammatory mechanisms are involved in the carotid atherosclerotic process, and determining the inflammatory activation can be useful in the assessment of cognitive impairment in patients with asymptomatic carotid stenosis (ACS).

AIM: This study aimed to correlate these markers of inflammation with the degree of asymptomatic carotid stenosis (ACS) and the degree of cognitive impairment.

MATERIALS AND METHODS: One hundred and twenty patients with carotid stenosis and 60 patients without carotid stenosis were enrolled in the study. Clinical, neurological, and laboratory evaluations (C-reactive protein [CRP], fibrinogen, tumor necrosis factor alpha [TNF-α]) were performed, as well as evaluation of intima-media thickness (IMT) and carotid stenosis degree. Cognitive functions were assessed with the Addenbrooke’s Cognitive Examination test. Neuroimaging tests were included.

RESULTS: There was no significant correlation in the asymptomatic group between TNFα and IMT and between fibrinogen, CRP, and IMT both on the left and the right side. In the same group, there was a statistically significant association between the degree of carotid stenosis and low-to-moderate degree of cognitive impairment on the right side (p < 0.05) and left side (p < 0.05). A moderately weak negative statistically significant correlation between the severity of cognitive impairment and the degree of stenosis in the asymptomatic group was reported. A high degree of carotid stenosis (≥70%) on the right increased the chance of a moderate degree of cognitive impairment by 6 times compared to the low degree of carotid stenosis in the asymptomatic group. The high degree of carotid stenosis (≥70%) on the left increased the chance of a severe degree of cognitive impairment by 20 times compared to the low degree of stenosis in the asymptomatic group.

CONCLUSIONS: ACS increases the risk of cognitive impairment.

Aesthetic Palpebral Reconstruction Following the Excision of Basal Cell Carcinoma (BCC): A Case Report

Smilja Tudzarova-Gjorgova — 2024-03-20

BACKGROUND: Basal cell carcinoma (BCC) is the most common skin malignancy, and when considering its predilection for the face – it is most commonly found on the eyelids.

CASE PRESENTATION: In our patient’s case, the BCC was located on the left lower eyelid exemplifying the classic macroscopic appearance of a nodular basalioma. We took into account all of the patient’s variables (particularly the lesion’s difficult location) to choose the best surgical approach for excision of the tumor, as well as the reconstructive strategy that would result in the most functional and aesthetic outcome.

CONCLUSION: In this report, we present a case of our patient with BCC on the lower eyelid, our surgical method for excision and palpebral reconstruction using an autologous auricular cartilage graft, and the final outcome, which we consider was the best option for the patient in question.

Herbal Bioactive Compounds for Skin Infections and Inflammatory Conditions

Michael Tirant — 2024-04-05

Skin microbiota is an integral part of the human immune system. Staphylococcus aureus is one of the essential components of the normal flora. Approximately 20–30% of healthy individuals are persistently colonized with S. aureus, whereas the remainders are considered low-level intermittent carriers. Despite these natural aspects of existence, S. aureus can be a major opportunistic human pathogen. This versatile microorganism can infect a variety of anatomical sites, causing a broad spectrum of pathologies ranging from superficial to invasive infections. It developed a variety of strategies to adopt to a changing microenvironment. This attributed to the emergence of resistance to antibiotics of different classes during the past six decades. Methicillin-resistant S. aureus (MRSA) was originally confined to health-care settings (health-care-associated MRSA). Later on, community-acquired MRSA was identified as another source of infections. Recent figures indicate that MRSA strains have been associated with approximately 75% of all S. aureus infections worldwide. Several guidelines have been published to establish an adequate treatment of skin and soft tissue infections (SSTIs) caused by MRSA strains. In the first part of this review, we focus on current treatment guidelines with a focus on medical drug therapy, but drug therapy has its own limitations. Recently, the interest in herbal remedies has greatly increased. There is growing evidence of antimicrobial activity of medicinal plants and their extracts. The second part of this review is dedicated to herbal compounds to circumvent antibiotic resistance. Herbal compounds may potentiate the action of antibiotics and restore the activities of antibacterial agents against which S. aureus has developed a drug resistance. Part 2 focuses on the role of S. aureus in pathology of the two major inflammatory skin diseases, i.e., atopic dermatitis (AD) and psoriasis. Finally, Part 3 provides an overview on natural compounds with antimicrobial activity against S. aureus and possible use in the treatment of SSTIs,

Exploring Disparities in Life Satisfaction among LGBTQ+ Older Adults in different Living Environments: The Case of Slovenia

Mihael Nedeljko — 2024-03-20

BACKGROUND: Lesbian, gay, bisexual, transgender, and queer (LGBTQ+) older adults are an overlooked minority of the population who face discrimination, stigma, and homo-, bi-, or transphobia. We have not found any research in the European area that examines differences in life satisfaction among LGBTQ+ older adults according to the living environment.

AIM: The aim of the research was to determine differences in life satisfaction according to different living environments (big cities, small cities, and rural areas) among LGBTQ+ older adults.

METHODS: We selected a non-random purposive sample size of 318 units of LGBTQ+ older adults for the quantitative survey. In the first phase, we used exploratory factor analysis. To ascertain the normality of data distribution, the Kolmogorov–Smirnov and Shapiro–Wilk tests were used. To test the hypothesis, we used a one-way analysis of variance (ANOVA) with a post hoc analysis, with which we determined the existence of differences in the perception of life satisfaction according to the living environment.

RESULTS: We find statistically significant differences at p < 0.05, which occur in all items except the item. So far, I have gotten the important things I want in life (p = 0.150). Since there are statistically significant differences between the ratings of satisfaction with life according to the living environment, we confirm the hypothesis. With a post hoc analysis, we determined even more precise differences between the three living environments of the interviewed persons, regarding which we found that life satisfaction increases with the size of the place where they live.

DISCUSSION: As with studies from other countries, we also note that differences exist between rural and urban living environments for LGBTQ+ older adults in Slovenia in terms of life satisfaction. Further research is needed on the factors that account for these disparities among LGBTQ+ older adults.

CONCLUSION: LGBTQ+ older adults in urban settings report higher life satisfaction than those in rural areas, possibly due to factors like community support and acceptance. Further research is needed to understand the needs of LGBTQ+ older adults, especially in countries where they are hidden due to political or religious influences, to ensure optimal conditions for their life satisfaction in old age.