Автоимун Хашимото тироидитис асоциран со автоимун хепатитис

So far, the literature data have presented a combination of several autoimmune triggered disease in patients, but the research is scarce and very limited. In this context we present a rare case of autoimmune thyroiditis with a concomitant autoimmune hepatitis. Hashimoto thyroiditis is an autoimmune disorder in which immune cells lead to impairment, destruction of the thyroid hormone producing cells and tissue fibrosis with consecutive primary hypothyroidism. Autoimmune hepatitis is a chronic liver disease with unknown etiology, which is assumed to be T cell mediated condition where immune cells produce autoantibodies responsible for inflammation, destruction and fibrosis of the hepatic parenchyma. In this case report, we discuss the possible correlation in the spectrum of autoimmune diseases concerning Hashimoto thyroiditis and autoimmune hepatitis.До сега, во литературата се среќаваат податоци за комбинација од неколку автоимуни болести кај различни пациенти, но студиите од ова поле на истражување се оскудни и ограничени. Во овој приказ на случај, претставуваме редок случај на автоимун тироидитис со истовремен авотимун хепатитис. Хашимото тироидитис е автоимуно заболување во кое клетките на имуниот систем доведуваат до оштетување и уништување на клетките коишто го произведуваат хормонот на тироидната жлезда и ткивна фиброза со последователен примарен хипотироидизам. Автоимуниот хепатитис е хронично заболување на црниот дроб со непозната етиологија, за кое се претпоставува дека е состојба посредувана од Т-клетките каде што имуните клетки произведуваат автоантитела одговорни за воспаление, уништување и фиброза на хепаталниот паренхим. Во овој приказ на случај ја дискутираме можната корелација во спектарот на автоимуни болести кои се однесуваат на Хашимото тироидитисот и автоимуниот хепатити

Вентрикуларна фибрилација по ендоскопска ретроградна холангиопанкреатографија кај пациент со вграден уред за лево вентрикуларна асистенција – приказ на случај

Congestive heart failure is a growing global health problem. Left ventricular assist device (LVAD) is a method used to extend the life of patients with congestive heart failure as a definitive treatment or to “bypass” the period until heart transplantation. Ventricular arrhythmias in patients with LVAD are not uncommon. The aim of this paper is to present the case of a patient with an already implanted LVAD and the need for appropriate interdisciplinary medical treatment. Case report: We present the case of a 54-year old patient, A. D., with implanted LVAD - HeartMate 3 due to severe congestive heart failure. The patient was admitted with jaundice at the PHIU Clinic for Gastroenterohepatology with performed endoscopic retrograde cholangiopancreatography (ERCP)) procedure and a stent was placed in the choledochus duct. Immeasurable blood pressure and pulse were recorded in this patient. The ECG was approaching VF (ventricular fibrillation) and it was all asymptomatic by the patient.  LVAD mechanical pump leads to continuous blood flow, which means that patients with LVAD not infrequently have no pulse or measurable blood pressure. Also, in patients with LVAD, ECG pulses are with electrical disturbances. VF and ventricular tachycardia (VT) are ventricular arrhythmias that are often seen on ECG in patients with implanted LVAD. Usually these arrhythmias occur with unknown duration and terminate spontaneously. Conclusion: Patients with LVAD are prone to cardiac arrhythmias. The continuous development of medical devices leads to a continuous educational and clinical approach to patients.                                                                        Конгестивната срцева слабост е растечки глобален здравствен проблем. Уредот за лево вентрикуларна асистенција (LVAD) се користи за продолжување на животот на пациентите со конгестивна срцева слабост како дефинитивен третман или за премостување на периодот до трансплантација на срце. Вентрикуларните аритмии кај пациентите со LVAD не се невообичаени. Целта на овој труд е да се прикаже случајот на пациент со веќе вграден LVAD и потребата од соодветен интердисциплинарен медицински третман. Приказ на случај: Ви претставуваме случај на 54-годишен пациент, А. Д., со вграден LVAD - HeartMate 3 поради тешка конгестивна срцева слабост. Пациентот е примен со иктерус на ЈЗУ Клиниката за гастроентерохепатологија по што е извршена ендоскопска ретроградна холангиопанкреатографија (ERCP)) и е поставен стент во холедохусниот канал. Кај овој пациент е регистрирано немерлив крвен притисок и пулс. На ЕКГ е регистрирана VF вентрикуларна фибрилација (VF) и сето тоа беше асимптоматски од страна на пациентот. Механичката пумпа на LVAD води до континуиран проток на крв, што значи дека пациентите со LVAD не ретко немаат пулс или мерлив крвен притисок. Исто така, кај пациентите со LVAD, ЕКГ импулсите се со електрични нарушувања. VF и вентрикуларна тахикардија (VT) се вентрикуларни аритмии кои често се гледаат на ЕКГ кај пациентите со имплантиран LVAD. Најчесто овие аритмии се јавуваат со непознато времетраење и спонтано завршуваат. Заклучок: Пациентите со ЛВАД се склони кон срцеви аритмии. Континуираниот развој на медицинските помагала води кон континуиран едукативен и клинички пристап во третманот на пациентите

Survey of Current Difficult Airway Management Practice

BACKGROUND: Even for the most experienced anesthesiologists “can’t ventilate can’t intubate†scenario in difficult airway management is challenging, and although rare it is life-threatening. AIM: The aim of this survey was to analyse the current practice of difficult airway management at our University teaching hospital. MATERIAL AND METHODS: A ten-question-survey was conducted in the Tertiary University Teaching Hospital “Mother Theresaâ€, Clinic for Anesthesia, Reanimation and Intensive Care. The survey included demographic data, experience in training anaesthesia, practice in management of anticipated and non-anticipated difficult airway scenario, preferable equipment and knowledge of guidelines and protocols. Responses were noted, evaluated and analysed with the SPSS statistical program. RESULTS: The overall response rate was very good; 94.5% answered the survey. During the assessment of the level of comfort with diverse airway equipment, there was diversity of answers due the experience of anaesthesia training, although the most frequent technique among all responders for anticipated difficult intubation was video laryngoscopy (48%). As for non-anticipated difficult intubation when conventional techniques failed to secure the airway most of the responders answered that they used supra-gothic airway device – laryngeal mask (38%) as a rescue measure. CONCLUSION: Airway assessment, adequate training, experience, and availability of essential equipment are the pillars of successful airway management

Identification of Sentinel Lymph Node in Breast Cancer with three Tracers (Radiocolloid, Methylene blue, and Indocyanine Green). (Case Report)

BACKGROUND: Sentinel lymph node (SNL) biopsy in breast cancer for the determination of axillary status is standard procedures in surgical treatment of early-stage breast cancer. The identification of the SNL is usually performed by radiocolloid injection or/and injection of methylene blue due. The use of indocyanine green (ICG) dye, which is fluorescent dye, which movement in breast and axillar pit, can be followed with special cameras which detect near infrared specatar of light. CASE REPORT: In this paper, we present case report of patient with breast cancer, where we perform SNL detection with three methods: Use of radiocolloid which we trace with static gamma camera, and intraoperatively with hand held gamma probe, methylene blue dye which movement we followed by eye contact and using indocyanine green which movement was followed by specially constructed multispectral camera, which can detect near-infrared fluorescence that is emitted by ICG and methyline blue, respectively. CONCLUSION: Fluorescent imaging with ICG is a sensitive, valuable, and safe method for SNL biopsy. Finding new agents that would identify the SNL, especially if they are not radioactive would be an important step in wider application of this method

OUR INITIAL EXPERIENCE WITH LAPAROSCOPIC RADICAL CYSTECTOMY

Background and objectives: In this era of minimally invasive surgeries, at the University Clinic for Urologic Surgery in Skopje, the laparoscopic radical cystectomy (LRS) was performed in 11 patients for the first time. In this paper, we have evaluated and summarized the anesthesia management, features and complications of LRC. Material and method: In a retrospective manner, we evaluated all patents who underwent LRC at our Clinic over a one-year period. We noted and analyzed the following parameters: patients’ demographic data, preoperatively and postoperatively, laboratory data, intraoperative fluid volume, estimated blood loss, allogeneic transfusion requirements. Respiratory parameters including arterial blood gas data, anesthesia time, surgical time, time of oral intake, admission to ICU, hospital stay and any adverse events during the whole period of hospitalization were also analyzed. Results: This evaluation included 11 patients who were successfully operated and their data were analyzed. Patients had similar demographic characteristics. Estimated intraoperative blood loss was 472 ml and decreased transfusion requirement was noticed. Due to prolonged surgical time and CO2 pneumoperitoneum, hypercarbia was observed in few patients. Patients had shorter period of bowel dysfunction and rapid oral intake, shorter hospital stay and fewer complications. Conclusion: We believe that these data from our initial experience with newly performed minimally invasive radical cystectomy will reflect to our daily routine practice in radical cystectomy surgery towards laparoscopy. However, some larger prospective evaluation is to be made for summarizing the overall conclusions. Key words: anesthesia consideration, laparoscopy, radical cystectom

Prediction value of oxygenation index as predictor for postoperative pulmonary complications in urologic surgery

Introduction: It is believed that pressure/flow (P/F) ratio (arterial oxygen to inspired oxygen fraction) Does not give the best expression of oxygenation status in mechanically ventilated patients. Therefore, a new oxygenation index (OI) where the mean airway pressure (MAP) is incorporated (PaO2/FiOxMAP) Is showed as superior to P/F in expression of the lung oxygenation status. In this article we wanted to assess the prediction value of OI calculated during urological surgeries as a predictive marker for Developing postoperative pulmonary complications (PPC). Material and methods: We evaluated all elective urologic patients operated in general endotracheal anesthesia, aged 18 to 65 years, without any known history of respiratory disease for the period from January till December 2017. We calculated the P/F ratio and the OI at three time points: after induction in general endotracheal anesthesia in the beginning of mechanical ventilation, 1 hour after induction in Anesthesia, and at the end of the surgery before weaning the mechanical ventilation. The primary Outcomes were PPC defined by European Society of Anesthesia. The second outcomes were: length of Hospital stay, admission to intensive care unit (ICU) and mortality. Results: A total of 240 patients who met the inclusion criteria were included in this evaluation and finally analyzed. PPC was diagnosed in 25% of patients and respectively 75% were without Complications. The postoperative hospital stay was longer in PPC group no matter they were operated laparoscopically or with classic open surgery (PPC laparoscopy 4.9 ± 2.2 vs. non PPC laparoscopy 3.3 ± 1.7, PPC laparotomy 6.8 ± 5.2 vs. non PPC 5.6 ± 2.1 laparotomy). Ten patients were admitted to ICU, 8 from PPC group and 2 from non PPC group. In PPC group patients were admitted to ICU for mean 3.7 ± 2.4 days, and in non PPC group patients were hospitalized in ICU only for 2 days. All evaluated patients were discharged from the hospital and no mortality was observed in the 30 postoperative days. In the univariate and multivariate logistic regression analysis neither OI nor P/F were significantly associated with PPC. Conclusion: This study does not offer a conclusive answer to the prediction value of OI for PPC. It would be fruitful to pursue further research about predictive variables for pulmonary complications. Keywords: oxygenation index, pressure/flow ratio, mean airway pressure, postoperative pulmonary complications

Impact of size of the tumor, persistence of estrogen receptors, progesterone receptors, HER2neu receptors and Ki67 values on positivity of axillar lymph nodes at patients with early breast cancer with clinically negative axillar examination

Aim: The aim of the study was to identify factors that influence the positivity on axillar status at patients with early breast cancer with clinical negative axilla, at which were done radical surgery to breast but also radical lymphadenectomy of axillar lymph nodes.Material and methods: In the study were included 81 surgically treated patients with early breast cancer during 08-2015 to 05-2017 year. All the cases have been analyzed by standard histological analysis including macroscopic and microscopic analysis on standard H&E staining. For determining of molecular receptors immunostaining by PT LINK immunoperoxidase has been done for HER2neu, ER, PR, p53 and Ki67.   Results: Patients age ranged between 31-73 years, average of 56.86 years. The mean size of the primary tumor in the surgically treated patient was 20.33 + 6.0 mm. On dissection from the axilary pits there were taken out 5 to 32 lymph nodes, an average of 14. Metastases have been found in 1 to 7 lymph nodes, an average 0.7. In only 26 (32.1%) of the patients have been found metastases in the axillary lymph nodes. The univariant regression analysis showed that the size of tumor and presence of HER2 neu receptors on cancer cell influence on the positivity of the axillary lymph nodes. The presence of the estrogen receptors, progesterone receptors  showed that they do not have influence on the positivity for metastatic deposits in axillary lymph nodes. Multivariant model and logistic regression analysis as independent significant factors or predictors of positivity of the axillary lymph nodes is influenced from the tumor size only.Conclusion: Our study showed that the involving of the axillary lymph nodes is mainly influenced from the size of the tumor and presence of HER2neu receptors  in the univariant analysis points the important influence of positivity in the axillary lymph nodes but only size of the tumor in multivariate regressive analysis

Evaluation of Anesthesia Profile in Pediatric Patients after Inguinal Hernia Repair with Caudal Block or Local Wound Infiltration

AIM: The aim of this study is to evaluate anesthesia and recovery profile in pediatric patients after inguinal hernia repair with caudal block or local wound infiltration.MATERIAL AND METHODS: In this prospective interventional clinical study, the anesthesia and recovery profile was assessed in sixty pediatric patients undergoing inguinal hernia repair. Enrolled children were randomly assigned to either Group Caudal or Group Local infiltration. For caudal blocks, Caudal Group received 1 ml/kg of 0.25% bupivacaine; Local Infiltration Group received 0.2 ml/kg 0.25% bupivacaine. Investigator who was blinded to group allocation provided postoperative care and assessments. Postoperative pain was assessed. Motor functions and sedation were assessed as well.RESULTS: The two groups did not differ in terms of patient characteristic data and surgical profiles and there weren’t any hemodynamic changes between groups. Regarding the difference between groups for analgesic requirement there were two major points - on one hand it was statistically significant p < 0.05 whereas on the other hand time to first analgesic administration was not statistically significant p = 0.40. There were significant differences in the incidence of adverse effects in caudal and local group including: vomiting, delirium and urinary retention.CONCLUSIONS: Between children undergoing inguinal hernia repair, local wound infiltration insures safety and satisfactory analgesia for surgery. Compared to caudal block it is not overwhelming. Caudal block provides longer analgesia, however complications are rather common

Evaluation of Total Thyroidectomy for Treatment of Benign Diseases of Thyroid Gland

BACKGROUND: The controversy of using total thyroidectomy (TT) in treatment of benign thyroid diseases still remains controversial over the rates of complication, mostly recurrence nerve palsy and hypocalcemia, compared to non-total thyroidectomies. The latest reports in this field of research showed that that the number of complications of TT is decreasing as the skills of surgeons increase. AIM: In this study, we reviewed 209 cases of total thyroidectomies for benign thyroid diseases where such surgery was indicated. The results were evaluated whether they support the previous reports that TT is save method of treatment of diffuse multinodular goiters, Graves’ disease thyroid adenomas with diffuse goiters and thyroiditis. METHODS: Two hundred and nine patients, 36 males and 173 females, medium age 47 (17–77) operated with TT between 2016 and 2018 were included in the evaluation study. We evaluated the: Diagnosis, indications for operation, pre-operative medication administration, laryngeal recurrent nerve palsy, hypocalcemia, hypoparathyroidism, and patohistology findings. The follow-up for hypocalcemia and laryngeal nerve palsy was performed 1 year postoperatively. RESULTS: The age of the patients was between 17 and 77 years, medium-range 47 years old. Of 209 patients, 173 (83%) were female and 36 (17%) male with a gender ratio of 1:4.8 males to females. Diagnoses before surgery were established as follows: Multinodular euthyroid goiter (MNEG) n = 106 (48.80%), multinodular toxic goiter n = 12 (5.74%), Graves’s disease n = 6 (2.87%), adenoma with multinodular goiter n = 73 (34.92%), and n = 16 (7.65%) patients with thyroiditis. Recurrence laryngeal nerve palsy (RLNP) occurred in 6 patients (2.87%), temporary within 3 months after the operation in 4 patients (1.92%) and permanent palsy within 6 months and more after an operation in 2 patients (0.95%). Voice hoarseness immediately and within 1 month after the operation was registered in 32 patients (15.3%). RLNP and hoarseness were registered mostly in patients with pre-operative problems, mostly with extra big MNEG. One of the permanent injuries of RLN was bilateral and all others were one sided. All patients were operated with normal pre-operative vocal cord movement findings. Post-operative hypocalcemia was registered in 35 patients (16.74%). Temporary nonsignificant hypocalcemia in 10 (4.78%), temporary significant hypocalcemia in 17 (8.13%), temporary severe hypocalcemia in 6 patients (2.87%), and permanent hypocalcemia in 2 patients (0.95%). CONCLUSION: Many studies have shown that the rate of complications is almost even for TT and NTT done for benign and malignant diseases of thyroid gland. Our data have shown that the risk of post-operative complications with TT is proportional to the number of complicated pre-operative findings of benign thyroid glands

Arterial blood gas alterations in retroperitoneal and transperitoneal laparoscopy

Background: Due to its numerous benefits laparoscopic surgery become very popular among physicians, hospitals and patients nowadays. In the urologic pathology laparoscopy can be performed with retroperitoneal or transperitoneal approach. Insufflation of CO2 for achieving visibility in both of the approaches can be absorbed in the vessels and can lead to alterations in arterial blood gasses. Material and Method: Study population was elective urologic patients scheduled for laparoscopic surgery. Investigated arterial blood gas variables were determined in three time points: T0 before induction – basal, T1 after one hour of CO2 insufflation, and T2 at the end of the surgery. Results: Alterations in arterial blood gasses were seen in T1 and T2 for PaO2 in retroperitoneal vs transperitoneal group 173.3 ± 19 vs 196.6 ± 29 (p < 0.003) and 95.5 ± 5.4 vs 101.1 ± 8.2 (p < 0.001). The PaCO2 was also statistically significant in second observed time point T1 in retroperitoneal vs transperitoneal group 45.9 ± 4.1 vs 38.2 ± 0.3 (p < 0.002). Conclusion: The findings that we have presented can suggest that both approaches are safe although hypercarbia is observed in retroperitoneal group. Key Words: arterial blood gasses, retroperitoneal laparoscopy, transperitoneal laparoscopy, urologic laparoscopy. Corresponding author: Aleksandra Gavrilovska-Brzanov, University Clinic for Anesthesia, Reanimation and Intensive Care, Skopje, Republic of North Macedoni