SECONDARY TRAUMATISATION AND SYSTEMIC TRAUMATIC STRESS

Traditionally, research has been focused on the development of symptoms in direct trauma survivors. However, during the last two decades researchers and clinicians have started exploring the way individual traumatic stress exposure affects trauma victims’ spouses, children and professional caregivers. Studying trauma within the family is a part of what is called systemic traumatology, a study of groups, institutions and other human systems that show stress reactions directly caused by a traumatic event or series of events. The effect of an individual’s traumatic stress on family members and on persons in direct contact is conceptualized as secondary traumatisation. In its narrow sense, secondary traumatisation involves a transfer of nightmares, intrusive thoughts, flashbacks and other Posttraumatic Stress Disorder symptoms, which are typically experienced by individuals suffering from PTSD, onto their immediate surroundings. In its broader sense, the term refers to any kind of distress transfer from a trauma victim to their immediate surroundings, and includes a broad spectrum of distress manifestation along with that resembling Posttraumatic Stress Disorder. Beyond that, a family member’s PTSD is potentially transferable to subsequent generations, interfering with the psychological development of children

Recidivirajući prolaps zdjeličnih organa kod 27-godišnje bolesnice s prirođenom ekstrofijom mokraćnog mjehura: prikaz slučaja

Bladder exstrophy (BE) is a rare congenital malformation estimated to occur in up to 1/250,000 female live births. The evidence supporting the incidence, uterine preservation and its overall fertility rate in patients with pelvic organ prolapse (POP) and BE is not precisely determined. We report a case of BE and POP in a 27-year-old nulliparous Caucasian. Due to the patient’s strong fertility desire, considering her extensive surgical history background, our approach was to correct POP via the Manchester-Fothergill procedure. After 36 months, the patient was still asymptomatic with no evidence for prolapse recurrence. This case demonstrates diagnostic challenges and surgical dilemmas in treatment strategy for patients with BE and co-existent POP. Furthermore, routine longterm surveillance is necessary in terms of renal function, urinary continence, malignancy and possible obstetric issues.Ekstrofija mokraćnog mjehura je rijetka prirođena malformacija za koju se procjenjuje da se javlja u do 1/250.000 ženske novorođenčadi. Prema trenutnim literaturnim navodima imamo nedovoljno podataka o incidenciji i ukupnoj reproduktivnoj sposobnosti žena koje istodobno uz ekstrofiju mokraćnog mjehura imaju i prolaps zdjeličnih organa. Prikaz slučaja obuhvaća naše iskustvo liječenja 27-godišnje bolesnice s prirođenom ekstrofijom mokraćnog mjehura i recidivirajućim prolapsom zdjeličnih organa. S obzirom na snažnu želju bolesnice za očuvanjem plodnosti te uzimajući u obzir njezinu opsežnu kiruršku povijest, naš pristup je podrazumijevao ispravak prolapsa zdjeličnih organa pomoću operacije po Manchester-Fothergillu. Nakon 36 mjeseci bolesnica je i dalje bez simptoma te bez ikakvih kliničkih dokaza recidiva prolapsa. Ovaj slučaj naglašava dijagnostičke izazove i kirurške dileme u strategiji liječenja bolesnica s ekstrofijom mokraćnog mjehura i istodobnom pojavom prolapsa zdjeličnih organa. Također, važno je naglasiti dugotrajno rutinsko praćenje u vidu kasnije bubrežne funkcije, moguće inkontinencije mokraće, maligniteta i mogućih opstetričkih komplikacija

Cervical Cancer as a Public Health Issue – What Next?

Cervical cancer is the second most common cancer in women worldwide. There are about 60,000 newly detected cases and 30,000 deaths annually in Europe, with the highest incidence reported from Eastern Europe countries. According to data from the National Institute of Public Health, in Croatia the incidence of cervical cancer was 14.9/100,000 in 2006, ranking eighth most common malignancy in women. Croatia has a lower incidence of the disease compared to many countries of Central and Southeast Europe. A large study carried out in 1995 by the International Agency for Research on Cancer, which included cervical cancer material collected from 22 countries all over the world revealed HPV genome in 99.7% of cases. Efficient methods of cervical cancer detection and screening methods for identification of precancerous lesions (conventional Pap smear) are available. Cervical cancer prevention programs should include education (of health care providers and women), stressing the benefits of screening, the age of the peak cervical cancer incidence, and the signs and symptoms of precancerous lesions and invasive disease. The aim of screening actions is to detect precancerous lesions that may lead to cancer if left untreated. Screening can only be effective if there is a well-organized system of follow up, diagnosis and treatment. Cervical cytology, or Papanicolaou (Pap) testing, has for decades been a cornerstone of cervical cancer screening. According to recent guidelines issued by the World Health Organization Regional Office for Europe, the primary task of the public health system is the introduction of secondary prevention through properly organized screening programs. Launching the national immunization program is only possible in the countries with well-organized secondary prevention programs and in those that can afford it

Učinak porođaja i epiziotomije na nastanak inkontinencije mokraće u žena: pregled literature

Episiotomy is obstetric procedure during which the incision extends the vestibule of the vagina during the second stage of labor. Episiotomy was extensively spread with gradual increase of rates in the first half of the 20th century and was performed mediolaterally in all nulliparous women with the idea to protect fetal head from trauma and pelvic floor from injuries. However, reports claiming that episiotomy had no such benefits were published. It was shown that routine mediolateral episiotomy did not protect against the appearance of urinary incontinence after vaginal delivery, while the risk of anal incontinence could be increased. The role of episiotomy in development of pelvic floor dysfunction remains quite unclear. Due to the mentioned reason, restricted episiotomy approach should be accepted. The origin of stress incontinence during pregnancy is controversial and not definitely scientifically proven. Pregnancy per se and older age at first delivery may have impact on the onset of pelvic floor dysfunction. Urinary incontinence in pregnancy increases the risk of later urinary incontinence, both postpartum and later in life. Vaginal delivery is just one of the potential risk factors for development of urinary incontinence. Mechanical pressure by fetus on the pelvic floor structures, limited denervation of the pelvic floor and soft tissue damage during delivery are some of explanations for the onset of stress urinary incontinence. On the other hand, cesarean delivery might not be protective against emergence of urinary incontinence. Further research in this field is needed.Epiziotomija je porodnička operacija u kojoj se incizijom širi predvorje vagine tijekom drugog porođajnog doba. Epiziotomija se intenzivno koristila uz postupno povećanje stope u prvoj polovici 20. stoljeća kao mediolateralni urez međice na svim prvorodiljama s idejom zaštite glave fetusa od traume i zdjeličnog dna od ozljeda. U posljednje vrijeme objavljeni su radovi koji tvrde da epiziotomija nema prije navedene koristi, odnosno da rutinska mediolateralna epiziotomija ne štiti od pojave stresne inkontinencije mokraće nakon vaginalnog porođaja, dok je rizik od pojave analne inkontinencije povećan. Uloga epiziotomije u razvoju disfunkcije zdjeličnog dna ostaje prilično nejasna. Zbog navedenih razloga restriktivni pristup uporabi epiziotomije bi trebao biti prihvaćen. Uzrok stresne inkontinencije tijekom trudnoće je proturječan i nije definitivno znanstveno dokazan. Trudnoća sama po sebi i starija dob pri prvom porođaju mogu imati utjecaj na nastanak disfunkcije zdjeličnog dna. Također pojava inkontinencije mokraće u trudnoći povećava rizik za nastanak inkontinencije mokraće poslije porođaja i u ostatku života. Vaginalni porođaj je samo jedan od potencijalnih čimbenika rizika za razvoj inkontinencije mokraće. Mehanički pritisak fetusa na zdjelično dno, ograničena denervacija zdjeličnih struktura i oštećenja mekih tkiva tijekom porođaja su neka od objašnjenja za pojavu stresne inkontinencije mokraće. Porođaj carskim rezom vjerojatno ne štiti od pojave inkontinencije mokraće. Sve upućuje na to da su daljnja istraživanja u ovom području neophodna

Efficacy of Sling Procedures for Treatment of Female Stress Urinary Incontinence

The aim of this study was to determine the efficacy and surgical outcome of the sling procedures in stress incontinent women in comparison to conventional anterior colporrhaphy. Total of 56 patients with stress urinary incontinence (SUI) were treated with sling procedure between November 2011 and March 2013, 39/56 (69.6%) with suprapubic arc (SPARC) and 17/56 (30.4%) with MiniArc method. During the same period total of 49 patients with SUI were treated with traditional anterior colporrhaphy according to Bagović method as the control group. All patients were prospectively clinically assessed over a period of 3, 6 and 12 months after surgery. The objective cure rate after the follow-up was 92.9% (52/56) in observed group of patients and 79.6% (39/49) in control group and improvement was occurred in rest of 5.4% (3/56) and 18.4% (9/49), respectively (p<0.05). The overall complications rate was significantly lower in the observed group of patients than in the control group, 12.5% (7/56) vs. 28.6% (14/49), (p<0.05). In the sling group was postoperatively noticed slightly higher rate of urinary incontinence, but in the colporrhaphy group was emphasized rate of urinary retention. Only one from the each group of patients failed the surgical procedure and required additional correction for SUI. The mean operating time for SPARC and MiniArc procedure was 19±7 and 9±5 minutes, respectively (p<0.0001). Mean duration of hospitalization was significantly shorter in the sling group of patients (2.6±1.0, range 2-7) days than in the control group of (9.6±1.8, range 6-18), (p<0.001<0.0001). According to presented results, sling is a highly effective method in patients with SUI with low incidence of perioperative complications, promising long-term results and high patient\u27s satisfaction

Recent Diagnostic and Therapeutic Approaches to Prenatally and Perinatally Diagnosed Hydronephrosis and their Implementation in the University Clinical Hospital Mostar

A shift of the diagnostics of urological malformations towards the fetal age by means of ultrasound, especially hydronephrosis which, apart from refl ux, is the most frequent developmental urological disorder, opened many dilemmas and debates. In the course of more than three decades the application of this diagnostic approach to the problem of hydronephrosis became a routine clinical practice in all modern clinics. In this paper we present the problems related to this diagnostic method and its delayed application in the Mostar University Clinical Hospital. Along with the exposition of a general approach to the problem of hydronephrosis we briefl y present our modest collection of cases which points to the most recent trend of a vigorous medical development in this region, despite unfavorable overall conditions which prevailed so far. The observation included 56 children with prenatal, perinatal and early age determination of pyelon dilatation by means of ultrasonic exploration who were treated surgically. Of this number 32 (57.14%) were male, and 24 (42.86%) female children. Of the observed patients 56 had unilateral and 6 had bilateral pyelon dilatation so that 62 kidneys in all were observed and treated. The dilatation was determined prenatally in 24 (38.7%) out of 62 kidneys observed in all, in 7 (11.29%) the disorder was observed perinatally and in remaining 31 cases (49.9%) it manifested during early childhood, school age, even at the age of pre-puberty. Of the children with prenatally and perinatally determined dilatation, in 14 (45.16%) out of 31 (100.0%) observed kidneys the ap radius of the dilated pyelon was between 10–15 mm, and in 17 (54.84%) more than 15 mm. Along with other examinations (MAG3 and DMSA) the patients were followed-up by ultrasonic exploration of the observed kidney for 6 to 30 (average 18) months after postnatal diagnosis; the ultrasonic exploration was repeated in intervals of 6 months. Within 12 months of birth surgical intervention on the pyeloureteral junction was done on all 17 kidneys with an ap radius of the pyelon greater than 15 mm, as well as on 4 kidneys in which ap radius was between 10 and 15 mm. In other 10 kidneys with prenatally and perinatally determined ap radius of 10 to 15 mm the follow-up period was 25 to 30 months (average 27.5). As the examinations (ultrasound, MAG3 and DMSA) even after this period showed no signs of regression of the dilatation, nor an improvement in patency this provided an indication for surgical intervention with the aim of establishing a normal fl ow across the pyeloureteral junction. Antibiotic prophylaxis was not applied systematically, but in a targeted manner if the uroinfection was confi rmed clinically and in the lab. Through the presentation of cases we demonstrate the relationship of earlier and more recent procedures in the treatment of hydronephrosis in the gravitational area of the Mostar University Clinical Hospital. The fact that some children were subjected to surgical treatment due to hydronephrosis at the time of pre-puberty refl ects earlier views on this clinical entity. The successfulness of surgical treatment of hydronephrosis in the observed patients is complete and comparable to medically more developed environments, and our diagnostic capabilities are getting close to that level too. We specially wish to stress the recent introduction of ultrasonic examination of pregnant women and foetus in the third trimester with the aim of an early detection of anomalies and malformations of the urotract as an indicator of a marked medical development. On the global level there are still inconclusive and opposing opinions on this subject, as is seen in recent literature. The controversies relate to the diagnostics as well as to therapy

Recent Diagnostic and Therapeutic Approaches to Prenatally and Perinatally Diagnosed Hydronephrosis and their Implementation in the University Clinical Hospital Mostar

A shift of the diagnostics of urological malformations towards the fetal age by means of ultrasound, especially hydronephrosis which, apart from refl ux, is the most frequent developmental urological disorder, opened many dilemmas and debates. In the course of more than three decades the application of this diagnostic approach to the problem of hydronephrosis became a routine clinical practice in all modern clinics. In this paper we present the problems related to this diagnostic method and its delayed application in the Mostar University Clinical Hospital. Along with the exposition of a general approach to the problem of hydronephrosis we briefl y present our modest collection of cases which points to the most recent trend of a vigorous medical development in this region, despite unfavorable overall conditions which prevailed so far. The observation included 56 children with prenatal, perinatal and early age determination of pyelon dilatation by means of ultrasonic exploration who were treated surgically. Of this number 32 (57.14%) were male, and 24 (42.86%) female children. Of the observed patients 56 had unilateral and 6 had bilateral pyelon dilatation so that 62 kidneys in all were observed and treated. The dilatation was determined prenatally in 24 (38.7%) out of 62 kidneys observed in all, in 7 (11.29%) the disorder was observed perinatally and in remaining 31 cases (49.9%) it manifested during early childhood, school age, even at the age of pre-puberty. Of the children with prenatally and perinatally determined dilatation, in 14 (45.16%) out of 31 (100.0%) observed kidneys the ap radius of the dilated pyelon was between 10–15 mm, and in 17 (54.84%) more than 15 mm. Along with other examinations (MAG3 and DMSA) the patients were followed-up by ultrasonic exploration of the observed kidney for 6 to 30 (average 18) months after postnatal diagnosis; the ultrasonic exploration was repeated in intervals of 6 months. Within 12 months of birth surgical intervention on the pyeloureteral junction was done on all 17 kidneys with an ap radius of the pyelon greater than 15 mm, as well as on 4 kidneys in which ap radius was between 10 and 15 mm. In other 10 kidneys with prenatally and perinatally determined ap radius of 10 to 15 mm the follow-up period was 25 to 30 months (average 27.5). As the examinations (ultrasound, MAG3 and DMSA) even after this period showed no signs of regression of the dilatation, nor an improvement in patency this provided an indication for surgical intervention with the aim of establishing a normal fl ow across the pyeloureteral junction. Antibiotic prophylaxis was not applied systematically, but in a targeted manner if the uroinfection was confi rmed clinically and in the lab. Through the presentation of cases we demonstrate the relationship of earlier and more recent procedures in the treatment of hydronephrosis in the gravitational area of the Mostar University Clinical Hospital. The fact that some children were subjected to surgical treatment due to hydronephrosis at the time of pre-puberty refl ects earlier views on this clinical entity. The successfulness of surgical treatment of hydronephrosis in the observed patients is complete and comparable to medically more developed environments, and our diagnostic capabilities are getting close to that level too. We specially wish to stress the recent introduction of ultrasonic examination of pregnant women and foetus in the third trimester with the aim of an early detection of anomalies and malformations of the urotract as an indicator of a marked medical development. On the global level there are still inconclusive and opposing opinions on this subject, as is seen in recent literature. The controversies relate to the diagnostics as well as to therapy

VAGINAL BIRTH AFTER FIVE PREVIOUS CAESAREAN SECTIONS

Zabrinjavajuće visoka učestalost carskih rezova i rizici ponovljenog zahvata opravdavaju pokušaj vaginalnog poroda nakon prethodnog carskog reza. Prikazan je uspješan vaginalni porod sedmorotkinje s teškom anemijom i ­pre­eklampsijom nakon prethodnih pet carskih rezova i jednog (prvog) vaginalnog poroda.A troubled high occurrence of cesarean sections and risks related to repeated C-sections justify an attempt to vaginal birth after prior C-section. A successful vaginal birth of a heptapara (a woman with 6 prior births) with severe anemia and preeclampsia who had 5 prior C-sections and one (first) vaginal birth is presented

Cervical cancer as a public health issue - what next? [Karcinom cerviksa kao javnozdravstveni problem - kako dalje?]

Cervical cancer is the second most common cancer in women worldwide. There are about 60,000 newly detected cases and 30,000 deaths annually in Europe, with the highest incidence reported from Eastern Europe countries. According to data from the National Institute of Public Health, in Croatia the incidence of cervical cancer was 14.9/100,000 in 2006, ranking eighth most common malignancy in women. Croatia has a lower incidence of the disease compared to many countries of Central and Southeast Europe. A large study carried out in 1995 by the International Agency for Research on Cancer, which included cervical cancer material collected from 22 countries all over the world revealed HPV genome in 99.7% of cases. Efficient methods of cervical cancer detection and screening methods for identification of precancerous lesions (conventional Pap smear) are available. Cervical cancer prevention programs should include education (of health care providers and women), stressing the benefits of screening, the age of the peak cervical cancer incidence, and the signs and symptoms of precancerous lesions and invasive disease. The aim of screening actions is to detect precancerous lesions that may lead to cancer if left untreated. Screening can only be effective if there is a well-organized system of follow up, diagnosis and treatment. Cervical cytology, or Papanicolaou (Pap) testing, has for decades been a cornerstone of cervical cancer screening. According to recent guidelines issued by the World Health Organization Regional Office for Europe, the primary task of the public health system is the introduction of secondary prevention through properly organized screening programs. Launching the national immunization program is only possible in the countries with well-organized secondary prevention programs and in those that can afford it