INTRODUÇÃO: A apneia obstrutiva do sono (AOS) é um problema de saúde pública, com grande prevalência e graves consequências. O tratamento considerado padrão-ouro para AOS grave é a aplicação do aparelho de pressão positiva aérea contínua (CPAP) durante o sono. Porém a adesão ao CPAP é baixa, em especial nos pacientes com ronco primário e AOS leve. Estudo prévio do nosso laboratório demonstrou que a terapia miofuncional orofacial (TMO) é efetiva em pacientes com AOS moderada (Guimaraes et. al, AJRCCM 2009:(179);962-966). No entanto, no trabalho inicial o número de pacientes foi relativamente pequeno (n=31), avaliou-se apenas pacientes com AOS moderada. Adicionalmente, a quantidade de exercícios orofaríngeos realizados foi relativamente grande (n=10) dificultando a adesão ao tratamento e os potenciais mecanismos de ação da terapia não foram elucidados. OBJETIVO: O objetivo primário do trabalho é avaliar a efetividade na redução da gravidade da AOS de um programa com um número reduzido de exercícios de TMO (6 exercícios) em pacientes com ronco primário, AOS leve, moderada e grave. Os objetivos secundários foram avaliar o impacto da TMO no índice de apneia hipopneia (IAH) em pacientes estratificados pelo IAH basal, a anatomia da via aérea superior (VAS) por meio da ressonância magnética (RM), a fisiologia da VAS por meio da força e fadiga da língua e a pressão crítica de fechamento (Pcrit). METODOLOGIA: Foram incluídos pacientes de ambos os sexos, com idade entre 20 e 65 anos, recentemente diagnosticados com ronco primário, AOS leve, moderada ou pacientes com AOS grave que se recusaram a utilizar o CPAP. Foram excluídos pacientes com índice de massa corpórea (IMC) >= 35 kg/m2, malformações craniofaciais, desdentados, uso regular de medicação hipnótica, doença obstrutiva nasal grave, pacientes já submetidos a outros tipos de tratamentos e pacientes com indisponibilidade de comparecimento semanal durante o estudo. Os pacientes foram avaliados no início e final do estudo por questionário de sonolência (Epworth, variando de 0 a 24 pontos), qualidade de sono (Pittsburgh, variando de 0 a 21 pontos), avaliação fonoaudiológica específica para AOS (variando de 0 a 20 pontos), RM da via aérea superior, força e fadiga de língua, Pcrit e polissonografia. Os pacientes foram sorteados para 3 meses de TMO (6 exercícios) ou controle (dilatador nasal durante o sono e exercícios respiratórios inespecíficos). Todos os pacientes foram acompanhados semanalmente por uma fonoaudióloga e orientados a realizar os exercícios três vezes por dia. Foi realizada ANOVA de dois caminhos para medidas repetidas para avaliar a eficácia dos tratamentos nos diferentes desfechos. Secundariamente também avaliamos o efeito dos tratamentos por meio do teste t pareado. RESULTADOS: Inicialmente 251 pacientes foram avaliados, e após avaliação dos critérios de inclusão e exclusão, 60 pacientes entraram no estudo, sendo que 30 foram randomizados para TMO e 30 para o grupo Controle. Os dois grupos foram semelhantes para todos os parâmetros na entrada. Finalizaram o estudo 58 pacientes (58,6% do sexo masculino, média de idade 45,9 ± 12,2 anos, IMC 28,8 ± 4,3 kg/m2, IAH=18,4 ± 12,6 eventos/h e saturação mínima de oxigênio 84,6 ± 6,4%). O grupo Controle não teve modificações em nenhuma das variáveis ao longo do estudo. O grupo TMO não modificou o IMC e não apresentou mudança significativa nos questionários Epworth e Pittsburgh. Em relação ao início do estudo, o grupo TMO apresentou uma redução significativa na circunferência cervical (38,8±3,3 vs 38,4±4 cm), índice de despertar (21,3±10,9 vs 16,9±7,9 despertares/h), IAH (19,5 ± 14,2 vs 15 ± 10,2 eventos/h) e avaliação fonoaudiológica específica para AOS (9,3 ± 2,9 vs 3,6 ± 2,4). O efeito da TMO sobre o IAH foi significativo somente nos pacientes que apresentavam na entrada AOS moderada (23,8 ± 5,2 vs 17,7 ± 5,2) e grave (43,9 ± 19,5 vs 24,7 ± 21,4). Não foram observadas modificações significativas quando avaliado por meio do teste de ANOVA de duas vias para medidas repetidas na RM da via aérea superior em 24 pacientes (10 Controle e 14 TMO) e fisiologia avaliados por força e fadiga de língua em 38 pacientes (19 Controle e 19 TMO) e Pcrit em 17 pacientes (7 Controle e 10 TMO). No entanto, observamos uma redução significativa (teste t pareado) com diminuição do volume da língua (p=0.031), quantidade de gordura da língua (p=0.008) e aumento significativo da força da língua (p=0,046) no grupo TMO. CONCLUSÃO: Um programa reduzido de TMO é efetivo e capaz de reduzir a gravidade da apneia do sono em pacientes com AOS moderada e grave. A tendência ao aumento da força de língua e redução da gordura de língua podem auxiliar a explicar os efeitos benéficos da TMO em pacientes com AOS / INTRODUCTION: Obstructive sleep apnea (OSA) is a public health problem, with high prevalence and severe consequences. The gold standard treatment for severe OSA is the application of continuous positive airway pressure (CPAP) during sleep. However, adherence to CPAP is low, especially in patients with primary snore and mild OSA. A previous study from our laboratory demonstrated that oropharyngeal exercises are effective in patients with moderate OSA (Guimaraes et. al, AJRCCM 2009:(179);962-966). Nonetheless, in this first study the number of patients included in the randomized trial was relatively small (n=31) and evaluated only patients with moderate OSA. Moreover, the number of oropharyngeal exercises the patients had to do 3 times a day was large (n=10) and raised doubt about the compliance to treatment, and the mechanism by which the therapy was effective was not elucidated. OBJECTIVE: The primary objective was to evaluate the effectiveness to reduce OSA severity of a short program of oropharyngeal exercises (6 exercises) in patients with primary snore, mild, moderate and severe OSA. The secondary objective was to evaluate the impact of reduced oropharyngeal exercises program on apnea hypopnea index (AHI) in patients stratified by baseline AHI, the anatomy of upper airway by magnetic resonance (MR), strength and fatigue of the tongue and critical closing pressure (Pcrit). METHODOLOGY: Patients of both sexes, with age between 20 and 65 years old, recently diagnosed with primary snore, mild, moderate or severe OSA who refused to use CPAP were included. Patients with body mass index (BMI) >= 35kg/m2, craniofacial deformities, edentulous, regular use of hypnotic medication, severe nasal obstruction, patients undergoing other treatments for OSA and patients with unavailability to comply with the protocol were excluded. The patients were evaluated at the beginning and end of the study by questionnaire of daytime sleepiness (Epworth, ranging from 0 to 24 points), quality of sleep (Pittsburgh, ranging from 0 to 21 points), oral myofunctional evaluation for OSA (ranging from 0 to 20 points), MR of the upper airway, tongue strength and fatigue, critical closing pressure (Pcrit) and polysomnography. The patients were randomized to 3 months of oropharyngeal exercises (6 exercises) or Control (use of nasal dilator strip and respiratory non specific respiratory exercises). All patients were instructed to perform the exercises 3 times a day and evaluated by a speech pathologist once a week. The primary endpoints were evaluated primarily by two-way repeated-measures ANOVA. A paired t test was also used as a secondary evaluation. RESULTS: A total of 251 patients were evaluated and 60 patients were randomized. The 2 groups (n=30) were similar at study entry for all the parameters and 58 patients completed the study (58.6% males, age: 45.9±12.2 years, BMI: 28.8±4.3 kg/m2, AHI=18.4±12.6 events/h and minimum saturation84.9±6.4%). All variables remained unchanged in the Control group. There were no changes in Epworth and Pittsburgh questionnaires as well as BMI in patients randomized to oropharyngeal exercises. As compared to study entry, there was a significantly reduction on neck circumference (38.8 ± 3.3 vs 38.4±4.4cm), arousals index (21.3 ± 10.9 vs 16.9 ± 7.9 arousals/h), AHI (19.5 ± 14.2 vs 15 ± 10.2 events/h), oral myofunctional evaluation for OSA (9.3 ± 2.9 vs 3.6 ± 2.4) in the patients randomized for oropharyngeal exercises. Oropharyngeal exercises only reduced AHI significantly among patients with moderate OSA (23.8 ± 5.2 vs 17.7 ± 5.2) and severe OSA (43.9 ± 19.5 vs 24.7 ± 21.4) at study entry. No significantly changes as evaluated by two-way repeated-measures ANOVA were observed on upper airway MR anatomy (10 Control and 14 oropharyngeal exercises), tongue force and fatigue (19 Control and 19 oropharyngeal exercises) and Pcrit (7 Control and 10 oropharyngeal exercises). As compared to study entry there was a significant reduction as evaluated by paired T test on tongue volume (p=0.031), tongue fat (p=0.008) and a significant increase of tongue strength (p=0.046) of patients randomized to oropharyngeal exercises. CONCLUSION: A short program of oropharyngeal exercises is effective to reduce OSA severity in patients with moderate and severe OSA. The trend to increase tongue strength and reduce tongue fat may explain the beneficial effects of oropharyngeal exercises

<p>Hronična opstruktivna bolest pluća (HOBP) jedna je od vodećih uzroka morbiditeta i mortaliteta &scaron;irom sveta. Uprkos stalnom napretku u medicini, uvođenju novih prognostičkih biomarkera, otkrivanju novih bronhodilatatornih, antiniflamatornih i antiinfektivnih lekova, ova bolest i danas beleži stalan porast broja obolelih i umrlih. Prema savremenom tumačenju HOBP je heterogena bolest koja je udružena sa brojnim komorbiditetima i sistemskim manifestacijama. Zajednički faktori rizika su osnova za javljanje udruženih hroničnih bolesti. Komorbiditeti i akutne egzacerbacije doprinose ukupnoj težini bolesti. S obzirom da se HOBP manifestuje i izvan pluća kod svakog pacijenta je neophodno proceniti postojanje sistemskih manifestacija i tragati za komorbiditetima. U reviziji &bdquo;Globalne strategije za dijagnozu, lečenje i prevenciju hronične opstruktivne bolesti pluća GOLD‖ iz 2011. godine navedene sledeće pridružene bolesti za kojima je potrebno aktivno tragati: kardiovaskularne bolesti, disfunkcija skeletnih mi&scaron;ića, metabolički sindrom, osteoporoza, depresija i karcinom pluća, bronhiektazije. Lečenje HOBP delimo u dve velike grupe: farmakolo&scaron;ko i nefarmakolo&scaron;ko. Farmakolo&scaron;ko lečenje prema GOLD-u, danas se zasniva na stepenastom pristupu. Treba ga sprovodi kod svakog pacijenta sa simptomima. Poslednjih godina na značaju veoma dobija nefarmakolo&scaron;ko lečenje pacijenata sa HOBP, zbog sve vi&scaron;e dokaza o pozitivnom efektu na smanjenje simptoma bolesti, popravljanja tolerancije na napor, smanjenje egzacerbacija. U nefarmakolo&scaron;ko lečenje ubrajamo: aktivno izbegavanje faktora rizika, prestanak pu&scaron;enja, oksigenoterapiju, vakcinaciju protiv gripa, psihosocijalnu podr&scaron;ku, respiratornu rehabilitaciju (RR) i hirur&scaron;ko lečenje. Danas se zna da RR ostvaruje brojne benefite kod pacijenata sa HOBP, kao i da je većina tih benefita zasnovana na dokazima (GOLD 2013): pobolj&scaron;ava kapacitet za vežbanje, smanjene osećaja nedostatka vazduha, pobolj&scaron;ava kvalitet života, smanjuje broj hospitalizacija i dužinu hospitalizacije, smanjuje anksioznost i depresiju povezane sa HOBP, efekti traju i nakon zavr&scaron;enog programa rehabilitacije, pobolj&scaron;ava preživljavanje ovih pacijenata. Primarni ciljevi na&scaron;eg istraţivanja bili su da se utvrdi procenat ispitanika kod kojih je ostvaren pozitivan ishod respiratorne rehabilitacije, da se odredi povezanost sledećih faktora sa ishodom respiratorne rehabilitacije: pol, godine života, &bdquo;pack/years―, dužina trajanja bolesti, broj egzacerbacija u prethodnoj godini, pridružena oboljenja: ishemijska bolest srca, srčana insuficijencija, hipertenzija, osteoporoza, depresija, dijabetes, bronhiektazije, karcinom pluća, tuberkuloza pluća. Takođe smo želeli da utvrdimo i uticaj sledećih parametara na ishod rr:FEV1, BMI, satO2, 6-minutni test hoda, &bdquo;CAT― upitnik, &bdquo;mMRC― upitnik, BODE indeks. Urađena je retrospektivno-prospektivna studija, koja je uključila 500 pacijenata sa HOBP, svih stadijuma I-IV , u stabilnoj fazi bolesti, koji su u toku dvogodi&scaron;njeg perioda odradili kompletan program ambulantne respiratorne rehabilitacije. Program je sprovođen u Poliklinici za plućne bolesti, Instituta za plućne bolesti Vojvodine. Dobijeni rezultati pokazali su da je 452 pacijenta (90,4%) ostvarilo pozitivan ishod RR: najvi&scaron;e ispitanika 142 (28,4%) bilo je u kategoriji vrlo dobar, potom slede kategorije dobar sa 129 ispitanika (25,8%), zadovoljavajući sa 102 ispitanika (20,4%), i na kraju kategorija odličan sa ukupno 79 (15,8%) ispitanika. Nakon programa RR do&scaron;lo je do statistički značajnih pobolj&scaron;anja u vrednostima FEV1, 6MTH, satO2, CAT, mMRC, BODE indeksa. Pol, starost, pu&scaron;ački status, dužina trajanja bolesti i &ge;2 egzacerbacije u prethodnoj godini nemaju uticaja na uspe&scaron;an ishod RR. Utvrđeno je postojanje statistički značajne negativne korelacije između srčane slabosti i pozitivnog ishoda respiratorne rehabilitacije, dok nije nađena statistički značajna povezanost ostalih ispitivanih komorbiditeta sa pozitivnim ishodom respiratorne rehabilitacije. Kao statistički značajni univarijantni prediktori pozitivnog ishoda respiratorne rehabilitacije jesu: manji broj pridruženih bolesti, odsustvo srčane slabosti, niža saturacija hemoglobin kiseonikom, veći BMI, mMRC &ge; 2, CAT &ge; 10, B i D stadijumi bolesti, dok je multivarijantnom logističkom regresionom analizom pokazano da su nezavisni prediktori pozitivnog ishoda respiratorne rehabilitacije: manji broj pridruženih bolesti, odsustvo srčane slabosti, veći BMI, CAT &ge; 10.</p> / <p>Chronic obstructive pulmonary disease (COPD) is one of the leading morbidity and mortality causes all over the world. Despite the steady advance in scientific research, introduction of novel prognostic biomarkers, new and potent bronchodilation, anti-inflammatory and anti-infectious drugs, a constant increase in the number of the affected and deceased from chronic obstructive pulmonary diseas has still been permanently evidenced in the 21st century. In a modern concept, the chronic obstructive pulmonary disease (COPD) is understood as a heterogenous disorder associated with numerous comorbidities and systemic manifestations. Common risk factors represent the basis for concomitant chronic diseases to develop. Comorbidities and acute exacerbations contribute to the overall disease severity. As a COPD may develop extrapulmonary manifestations as well, each patient should be evaluated for systemic manifestations and comorbidities. The 2011 update of the &bdquo;Global Strategy for Chronic Obstructive Lung Disease Diagnosis, Management, and Prevention &ndash;GOLD‖ lists the following comorbidities to be actively searched for: cardiovascular diseases, skeletal muscle dysfunction, metabolic syndrome, osteoporosis, depression, lung cancer and bronchiectases. The treatment of COPD can be devided in two groups: pharmacological and non-pharmacological. Pharmacological treatment is today, according to GOLD, based on incremental approach. It should be carry out in every patient with simptoms. In last few years, non-pharmacological treatment of COPD is very popular, due to the evidence of positive effects on decreasing the simptoms, increasing the tolerance to exertion and decreasing the exacerbations. Non-pharmacological treatment consider: active avoiding the risk factors, smoking cessation, oxigenotherapy, vaccination against the flu, psicho-social support, respiratory rehabilitation and surgery. It is well known today that respiratory rehabilitation achieve numerous benefits in COPD patients and most of that benefits are evidence based (GOLD 2013): increasing the exercise capacity, decreasing the shortness of breath, increasing the quality of life, reduces the number and length of hospital stay, decreasing the anxiety and depression conected to COPD, the effects lasts and after the rehabilitation program, improves the survival of this patients. The primary goals of this investigation were to establish the percentage of patients with positive outcome after the respiratory rehabilitation, to determine the conection of the following factors with the outcome of respiratory rehabilitation: gender, age, &bdquo;pack/years―, duration of the disease, the number of exacerbations in previous year, comorbidities: ischemic heart disease, heart failure, arterial hypertension, osteoporosis, depression, diabetes mellitus, bronchiectasis, lung cancer, tuberculosis. The other goals were to establish the influence of some parametars on the outcome of respiratory rehabilitation: FEV1, BMI, SaO2 ,6 minute walk test, &bdquo;CAT― questionnaire, &bdquo;mMRC― questionnaire, BODE index. This was retrospective-prospective study the included 500 patients with COPD, from I to IV stadium, in stable disease, who have done the two years complete program of ambulatory respiratory rehabilitation. The program have been done in polyclinic for respiratory diseases, Institute for pulmonary disesases of Vojvodina, Sremska Kamenica. The results showed that 452 patients (90,4%) achieved positive outcome of respiratory rehabilitation. The majority of patients 142 (28,4%) were in ―very good‖ caterogy, the 129 patients (25,8%) in category ―good‖, ―satisfied‖ 102 patients (20,4%) and ―excellent‖ 79 patients (15.8%). After completion of the respiratory rehabilitation program, statistically significant improvements of the following parameters have been achieved: FEV1, 6MTH, SaO2, mMRC, BODE index. Gender, age, smoking, duration of the disease and &ge;2 exacerbations in previous year did not have influence on the successful respiratory rehabilitation outcome. The statistically significant negative correlation between the heart failure and positive respiratory rehabilitation outcome has been achieved, while there were no statistically significant correlations among other comorbidities and the successful respiratory rehabilitation outcome. The statistically significant univariant predictors of positive outcome of respiratory rehabilitation are: less comorbidities, absence of heart failure, lower oxygen saturation, higher BMI, , mMRC &ge; 2, CAT &ge; 10, B i D stadium of disease, while multivariant logistic regression analysis showed that the independent predictors of positive outcome of respiratory rehabilitation are: less comorbidities, absence of heart failure, higher BMI, CAT &ge; 10.</p>

<p>Uvod: Sindrom lumbalne radikulopatije obuhvata disfunkciju nervnog korena lumbalne kičme, prouzrokovano kompresijom, nastalom usled hernijacije (protruzije, prolapsa) intervertebralnog diska ili zbog inflamatornih i degenerativnih promena (najče&scaron;će osteofita) u foraminalnom otvoru. Kvalitet života predstavlja savremeni koncept posmatranja ishoda oboljenja i uspe&scaron;nosti terapijske procedure kako u svim oblastima medicine, tako i u problematici lumbalne radikulopatije.<br />Cilj: Proceniti kvalitet života operativno i neoperativno lečenih pacijenata sa lumbalnom radikulopatijom na početku lečenja i 3 meseca, odnosno 6 meseci nakon sprovedene medicinske rehabilitacije.<br />Metode: Istraživanje predstavlja prospektivnu kliničku studiju kojom je analiziran kvalitet života bolesnika sa lumbalnom radikulopatijom. Obuhvaćen je randomiziran i stratifikovan uzorak pacijenata sa lumbalnom radikulopatijom diskalne geneze starosti 20 do 65 godina, oba pola (n=100), lečenih u Specijalnoj bolnici za progresivne mi&scaron;ićne i neuromi&scaron;ićne bolesti Novi Pazar. Jedna grupa ispitanika (n=50) lečena je isključivo neoperativnim metodama, dok je druga grupa bolesnika (n=50) lečena hirur&scaron;kim i neoperativnim metodama. Kod svih pacijenata sproveden je konzervativni tretman primenom fizikalnih procedura, kineziterapijskih procedura, ergonomske edukacije. Medikamentna terapija je kod svih bila identična. Za procenu stanja pacijenata, kvaliteta života i efekta rehabilitacionog tretmana kori&scaron;ćena su dva standardizovana upitnika: op&scaron;ti zdravstveni upitnik Medical Outcomes Study Short Form 36 (SF 36) i upitnik specifičan za oboljenje The Oswestry Disability Index (ODI).<br />Rezultati: Vrednosti SF-36 upitnika prikazanih sumarnim fizičkim (SFS) i mentalnim (SMS) skorom, i kod neoperativno lečenih ispitanika (FSFS=450,221 i p&lt;0,001; FSMS=106,543 i p&lt;0,001), ali i kod operativno lečenih (FSFS=490,721 i p&lt;0,001; FSMS=72,055 i p&lt;0,001) značajno su se menjale u toku ispitivanja. Vrednosti SFS kod neoperativno lečenih pacijenata (početak tretmana, 3 meseca, 6 meseci): 35,5 / 44,7 / 50,8; kod operativno lečenih: 28,8 / 42,8 / 49,2. Vrednosti SMS kod neoperativno lečenih pacijenata: 40,6 / 44,8 / 52,6; kod operativno lečenih: 37,8 / 45,2 / 52,5.<br />Najveće pobolj&scaron;anje SFS, kod obe grupe pacijenata, je registrovano u prva tri meseca od početka rehabilitacionog tretmana, dok je najveći napredak SMS registrovan u prva tri meseca od početka rehabilitacionog tretmana kod druge grupe pacijenata.<br />Vrednosti skora Osvestri indeksa nesposobnosti (ODI), i kod pacijenata prve grupe (F=432,810 i p&lt;0,001), ali i kod pacijenata druge grupe (F=1341,180 i p&lt;0,001) značajno su se menjale u toku ispitivanja. Vrednosti ODI kod neoperativno lečenih pacijenata su: 51,5% / 36% / 22,5%; a kod pacijenata druge grupe: 56,1% / 38,9% / 23,7%. Najveće pobolj&scaron;anje je registrovano u prva tri meseca od početka rehabilitacionog tretmana kod druge grupe pacijenata. Postoje statistički značajne korelacije glavnih sumarnih skorova i domena SF-36 (SFS i SMS) i ODI skorova.<br />Zaključak: Kvalitet života i funkcionalni status i neoperativno i operativno lečenih pacijenata je značajno bolji u komparaciji stanja, na 3 meseca i na 6 meseci u odnosu na početak rehabilitacije, kao i na 6 meseci u odnosu na stanje na 3 meseca.</p> / <p>Introduction: The syndrome of lumbar radiculopathy involves dysfunction of nerve roots of the lumbar spine, caused by compression, resulting due to herniation (protrusion, prolapse) intervertebral disc, or due to inflammatory and degenerative changes (usually osteophytes) in foraminal opening. Quality of life is the modern concept of observing the outcome of disease and therapeutic procedures in performance in all areas of medicine, as well as the problems of lumbar radiculopathy.<br />Aim: Assess the quality of life for surgically and conservatively treated patients with lumbar radiculopathy at initiation of treatment and 3 months, and 6 months after conducting medical rehabilitation.<br />Methods: The study is a prospective clinical study, which analyzed the quality of life of patients with lumbar radiculopathy. Also included is randomized and stratified sample of patients with lumbar radiculopathy of discal genesis aged 20 to 65 years, of both sexes (n=100) treated at the Special Hospital for progressive muscular and neuromuscular diseases Novi Pazar. One group of patients (n=50) were treated exclusively non-surgical methods, while the second group of patients (n=50) treated with surgical and non-surgical methods. In all patients was conducted by applying the conservative treatment of physical procedures, kinesitherapy procedures, ergonomic education. Medication treatment is at all were identical. To assess the condition of patients, quality of life and the effect of rehabilitation treatment used two standardized questionnaires: a general health questionnaire Medical Outcomes Study Short Form 36 (SF 36) and disease-specific questionnaire The Oswestry Disability Index (ODI).<br />Results: Values SF-36 questionnaire presented summary physical (SFS) and mental (SMS) scores, with non-surgical treated subjects (FSFS=450.221, p&lt;0.001; FSMS=106.543, p&lt;0.001), but also at surgical treated (FSFS=490.721, p&lt;0.001; FSMS=72.055, p&lt;0.001) were significantly changed during the study. Values at SFS non-surgical treated patients (beginning of treatment, 3 months, 6 months): 35.5 / 44.7 / 50.8; at surgical treated: 28.8 / 42.8 / 49.2. Values SMS with the non-surgical treated patients: 40.6 / 44.8 / 52.6; with surgical treated: 37.8 / 45.2 / 52.5. The biggest improvement of SFS, in both groups of patients were registered in the first three months of the start of the rehabilitation treatment, while the biggest progress SMS is registered in the first three months of the start of treatment in other patient groups. The Oswestry Disability Index (ODI) values score, in patients of the first group (F=432.810, p&lt;0.001), and in second group of patients (F=1341.180, p&lt;0.001) were significantly changed during the study. ODI values at non-surgical treated patients were: 51.5% / 36% / 22.5%; the second group of patients: 56.1% / 38.9% / 23.7%. The bigest improvement was registered in the first three months of the start of treatment in second group patients. There are statistically significant correlations main summary scores and SF-36 domains (SFS and SMS) and ODI scores.<br />Conclusion: The quality of life and functional status of both groups patients was significantly better in comparison to the situation, at 3 months and 6 months compared to the beginning of rehabilitation, as well as at 6 months compared to 3 months.</p>

<p>Uvod: Reumatoidni artritis (RA) je bolest koja dovodi do ireverzibilnog o&scaron;tećenja zglobova usled čega je neophodno pri postavljanju dijagnoze započeti lečenje. TNF-alfa inhibitori predstavljaju revolucionarno otkriće u lečenju RA, pri čemu su najče&scaron;će kori&scaron;ćeni Etanercept i Adalimumab. Oni nisu efikasni kod svih pacijenata kod kojih se primene, a mehanizmi gubitka odgovora nisu jasni. Cilj rada je odrediti uticaj Etanercepta i Adalimumaba na aktivnost bolesti (merenjem DAS28 SE i DAS28 CRP skora) i funkcionalni status pacijenata (merenjem HAQ-DI upitnika), broj bolnih i otečnih zglobova pre i tokom godinu dana primene ovih lekova, kao i utvrditi povezanost koncentracije Etanercepta i Adalimumaba u krvi sa vrednostima DAS28 SE u momentu odreĎivanja koncentracije leka. Praćena je i učestalost neželjenih efekata kod pacijenata lečenih sa ova dva leka. Ispitan je i uticaj primene Metotreksata na nivoe lekova u krvi, kao i doza Metotreksata pre i 6 meseci nakon uvoĎenja Etanercepta ili Adalimumaba. Metode: Studija je sprovedena u Specijalnoj bolnici za reumatske bolesti i Klinici za nefrologiju i kliničku imunologiju, Kliničkog centra Vojvodine u Novom Sadu i obuhvatila je 88 pacijenata kod kojih je postavljena dijagnoza RA, od kojih je 49 bilo lečeno Etanerceptom, a 39 Adalimumabom. Analizirana je medicinska dokumentacija, a nakon početka primene TNF-alfa inhibitora svim ispitanicima je u toku godinu dana svaka tri meseca raĎena kontrola koja je podrazumevala anamnezu i fizički pregled, analizu biohemijskih nalaza krvi, merena je aktivnost bolesti merenjem indeksa aktivnosti bolesti DAS28 SE i DAS28 CRP i raĎena procena funkcionalnog statusa tako &scaron;to je pacijent popunjavao HAQ-DI upitnik. Rezultati: Aktivnost RA merena DAS28 SE i DAS28 CRP indeksima, funkcionalni status meren HAQ-DI upitnikom, broj bolnih i otečenih zglobova i vrednosti reaktanata akutne faze značajno su veći pre početka terapije Etanerceptom i Adalimumabom i smanjuje se tokom prvih 6 meseci lečenja ovim lekovima i potom se taj efekat terapije održava do kraja perioda praćenja. Nema statistički značajne razlike u poreĎenju Etanercepta i Adalimumaba u odnosu na učestalost neželjenih dejstava. Doza Metotreksata je statistički značajno manja 6 meseci nakon upotrebe biolo&scaron;kog leka Etanercept i Adalimumab. Pacijenti lečeni Metotreksatom uz Adalimumab imali su statistički značajno veće nivoe leka, nego oni koji ga nisu koristili. Zaključak: TNF-alfa inhibitori ne dovode do zaustavljanja bolesti kod svih pacijenata kod kojih se primene. Mehanizam gubitka odgovora na terapiju TNF-alfa inhibitorima nije jasan. Kako bi se donela najbolja odluka za pacijenta, neophodno je odrediti nivo leka u krvi, kao i nivo antitela na lek prilikom svake promene stanja pacijenta. Za sada nema dovoljno studija koje ukazuju da li postoji veza izmeĎu ekspresije TNF-alfa gena i nivoa TNF-alfa u krvi, te da li bi se merenjem TNF-alfa u krvi mogla korigovati terapija i doza TNF-alfa inhibitora &scaron;to će verovatno biti predmet budućih istraživanja.</p> / <p>Rheumatoid Arthritis (RA) is a disease that leads to irreversible joint damage, which makes necessary to start treatment when the diagnosis is set. TNF-alpha inhibitors represent a revolutionary discovery in the treatment of RA, and the most commonly used are Etanercept and Adalimumab. They are not effective in all patients, and the mechanisms of loss of response are not clear. The aim of this study is to determine the effect of Etanercept and Adalimumab on disease activity (by measuring DAS28 SE and DAS28 CRP score) and the functional status of patients (by measuring the HAQ-DI questionnaire), the number of painful and swollen joints before and during the first year of administration of these drugs. Also, it was determined a correlation between the concentration of Etanercept and Adalimumab in blood and the values of DAS28 SE at the moment of drug concentration measurement. The incidence of adverse effects in patients treated with these two drugs was also observed. It was examined the effect of Methotrexate on drug levels in the blood as well as the dose of Methotrexate before and 6 months after the introduction of Etanercept or Adalimumab. Methods: The study was conducted at the Special Hospital for Rheumatic Diseases and the Clinic of Nephrology and Clinical Immunology, Clinical Center of Vojvodina in Novi Sad. It included 88 patients with RA, 49 were treated with Etanercept and 39 with Adalimumab. Medical documentation was analyzed, and during the first year of TNF-alpha inhibitor administration, every three months were done anamnesis and physical examination, analysis of blood biochemical findings, measurements of the disease activity with DAS28 SE and DAS28 CRP score and a functional status assessment with the HAQ-DI questionnaire. Results: Disease activity measured by DAS28 SE and DAS28 CRP scores, functional status measured with HAQ-DI questionnaire, number of painful and swollen joints and acute phase reactant values are significantly higher before Etanercept and Adalimumab therapy and decreased during the first 6 months of treatment with these drugs and then this effect of therapy is maintained until the end of the monitoring period. There is no statistically significant difference in the comparison of Etanercept and Adalimumab with respect to the frequency of adverse events. The dose of Methotrexate was statistically significantly lower for 6 months after the use of Etanercept and Adalimumab. Patients treated with Methotrexate and Adalimumab had statistically significantly higher drug levels than those who did not use it. Conclusion: TNF-alpha inhibitors are not effective in all patients who used them. The mechanism of loss of response to TNF-alpha inhibitors is not clear. In order to make the best decision for the patient, it is necessary to determine the drug level in the blood as well as the level of antibodies to the drug in each change in the patient&#39;s condition. For now, there are not enough studies to indicate whether there is a link between expression of the TNF-alpha gene and the level of TNF-alpha in the blood, and whether the measurement of the TNF-alpha in blood could be used for therapy correction and change of dose of TNF-alpha inhibitor, which is likely to be the subject of the future research.</p>

<p>Osnovni cilj rekonstrukcije prednjeg ukr&scaron;tenog ligamenta kolena je dobijanje pune stabilnosti kolena u celom obimu pokreta. Bez obzira na razvoj operativne tehnike i rehabilitacije i dalje postoji jedan broj pacijenata koji nije u potpunosti zadovoljan rezultatom rekonstrukcije prednjeg ukr&scaron;tenog ligamenta kolena, te je potrebno izvr&scaron;iti ponovnu operaciju. Smatra se da je najče&scaron;ći uzrok rane ponovne nestabilnosti lo&scaron;a pozicija kalema, tj. pozicija tunela koja nije na anatomskom mestu. Većina hirurga koji se bave ovom problematikom procenjuju poziciju kalema u golenjači na osnovu standardnih radiograma: prednje-zadnje i bočne projekcije, &scaron;to svakako nije dovoljno precizno. U ekonomski&nbsp; razvijenim zemljama poziciju kalema određuju analizirajući snimke kompjuterizovane tomografije (CT) ili magnetne rezonance (MRI). Prvenstveno zbog smanjenja doze zračenja kojoj se izlažu pacijenti prilikom kompjuterizovane tomografije, ali i iz ekonomskih razloga bilo bi korisno razvijanje jednog lako dostupnog, jeftinog ali preciznog i jednostavnog metoda određivanja položaja kalema u golenjači. Osnovni cilj ovog istraživanja bio je da se dokaže značaj pozicije kalema u golenjači i mogućnost svakodnevne kliničke primene novorazvijenog kompjuterskog programa u cilju određivanja prostorne pozicije kalema u golenjači iz samo dva standardna radiograma. Studija je bila eksperimentalno-prospektivnog karaktera. Eksperimentalni deo istraživanja sproveden je na Fakultetu tehničkih nauka (FTN) u Novom Sadu na Departmanu za proizvodno ma&scaron;instvo gde je na osnovu standardnih RTG snimaka (prednje-zadnje i bočne projekcije) razvijen kompjuterski program za određivanje prostornog položaja kalema u golenjači. U cilju verifikacije novorazvijenog programa realizovano je prostorno određivanje položaja kalema u golenjači obradom standardnih RTG snimaka (prednje-zadnje i bočne projekcije) kod 10 pacijenata kod kojih je izvr&scaron;ena primarna rekonstrukcija prednjeg ukr&scaron;tenog ligamenta kolena. Dobijeni rezultati su upoređeni sa položajem kalema na CT snimcima koji su obezbeđeni za sve pacijente. Na taj način je eksperimentalnim putem utvrđena preciznost novorazvijenog softvera u određivanju prostornog položaja kalema u golenjači. Drugi deo istraživanja bilo je prospektivno kliničko ispitivanje koje je sprovedeno na Klinici za ortopedsku hirurgiju i traumatologiju Kliničkog centra Vojvodine u Novom Sadu. Ispitivanu grupu je činilo 120 pacijenata, oba pola, sa prekidom prednjeg ukr&scaron;tenog ligamenta levog ili desnog kolena. Metodom slučajnog izbora pacijenti su podeljeni u četiri grupe od po 30 pacijenata prema veličini sagitalnog ugla (S) bu&scaron;enja kanala u golenjači (S 60&ordm;-69,9&ordm; i S 70&ordm;-80&ordm;) i prema veličini transverzalnog ugla (T) bu&scaron;enja kanala u golenjači (T 60&ordm;-69,9&ordm; i T 70&ordm;-80&ordm;). Grupa I 30 pacijenata (S 60&ordm;-69,9&ordm; i T 60&ordm;-69,9&ordm;), grupa II 30 pacijenata (S 60&ordm;-69,9&ordm; i T 70&ordm;-80&ordm;), grupa III 30 pacijenata (S 70&ordm;-80&ordm; i T 60&ordm;-69,9&ordm;), grupa IV 30 pacijenata (S 70&ordm;-80&ordm; i T 70&ordm;-80&ordm;). Svi pacijenti su godinu dana nakon operacije pro&scaron;li klinička ispitivanja po bodovnim skalama (Tegner bodovna skala, Lysholm bodovna skala i IKDC standard) i artrometrijska merenja. Rezultati dobijeni merenjem položaja kalema u golenjači, kliničkim ispitivanjima i artrometrijskim merenjima poređani su unutar svake grupe posebno, a izvr&scaron;eno je i poređenje dobijenih rezultata između svih grupa. U ispitivanje su uključeni samo oni pacijenti koji su dali potpisani informisani pristanak da učestvuju u ispitivanju nakon detaljnog upoznavanja sa planiranom procedurom. Svaki pacijent je bio informisan o svrsi i načinu sprovođenja istraživanja, kao i o pregledima i merenjima koja će biti vr&scaron;ena. Statističkom analizom rezultata utvrđeno je da veličina gre&scaron;ke prostornog određivanja položaja kalema u golenjači posle rekonstrukcije prednjeg ukr&scaron;tenog ligamenta kolena novorazvijenim kompjuterskim programom nije statistički značajna, a kompjutersko određivanje položaja kalema u golenjači omogućava iste rezultate kao i CT snimci. Sumiranjem zaključaka nakon sveobuhvatne analize dobijenih rezultata istraživanja, može se zaključiti da pozicija kalema u golenjači posle rekonstrukcije prednjeg ukr&scaron;tenog ligamenta kolena utiče na postoperativni funkcionalni rezultat.</p> / <p>The main goal of reconstruction of the anterior cruciate ligament of the knee is to obtain complete knee stability in the full range of movement. Regardless of the development of operational techniques and rehabilitation, there is still a number of patients who are not completely satisfied with the result of reconstruction of the anterior cruciate ligament, and a re-operation is required. It is believed that the most common cause of the instability is the bad position of the graft, i.e. position of the tunnel that is not at the anatomical place insertion. Most surgeons who deal with this problem evaluate the position of the graft in the tibia based on standard radiograms: anterior-posterior and lateral projections, which is not precise enough. In economically developed countries, the position of the graft is determined by analyzing images of computerized tomography (CT) or magnetic resonance (MRI). Primarily due to a decrease in the radiation dose exposed to patients during computerized tomography, but also for economic reasons, it would be useful to develop an easily accessible, inexpensive but precise and simple method for determining the position of the graft in the tibia. The main goal of this examination was to prove the significance of the position of the graft and the possibility of daily clinical use of the newly developed computer program in order to determine in-space position of the graft in only two standard radiograms. The study was experimental-prospective. The experimental part of the research was conducted at the Faculty of Technical Sciences (FTN) in Novi Sad at the Department of Production Engineering, where a computer program for determining in-space position of the graft in the tibia was developed on the basis of standard RTG images (anterior-posterior and lateral projections). In order to verify the newly developed program, in-space determination of the position of the graft in the tibia by processing standard RTG images (anterior-posterior and lateral projections) was performed in 10 patients in which the primary reconstruction of the anterior cruciate ligament was performed. The obtained results were compared with the position of the grafts on CT images provided to all patients. In this way, the accuracy of newly developed software in determining in-space position of the graft in the tibia was determined experimentally. The second part of the study was a prospective clinical trial conducted at the Clinic for Orthopedic Surgery and Traumatology at the Clinical Center of Vojvodina in Novi Sad. The investigated group consisted of 120 patients, both sexes, with a break of the anterior cruciate ligament of the left or right knee. By random selection, patients were divided into four groups of 30 patients according to the size of the sagital angle (S) of the tunnel drilling in the tibia (S 60&ordm;-69,9&ordm; and S 70&ordm;-80&ordm;) and according to the transversal angle (T) of the drill tunnel in the tibia ( T 60&ordm;-69.9&ordm; and T 70&ordm;-80&ordm;). Group I 30 patients (S 60&ordm;-69.9&ordm; and T 60&ordm;-69.9&ordm;), group II 30 patients (S 60&ordm;-69.9&ordm; and T 70&ordm;-80&ordm;), group III 30 patients (S 70&ordm;-80&ordm; and T&ordm;60&ordm; -69.9&ordm;), group IV 30 patients (S 70&ordm;-80&ordm; and T 70&ordm;-80&ordm;). All of the patients underwent clinical trials by scales (Tegner score scale, Lysholm score scale and IKDC standard) and arthrometric measurements one year after surgery. The results obtained by measuring the position of the graft in the tibia, clinical trials and arthrometric measurements were classified separately in each group, and obtained results were compared between all groups. The study included only those patients who gave signed informed consent to participate in the study after being thoroughly informed about planned procedure. Each patient was informed about the purpose and method of conducting the research, as well as the examinations and measurements to be performed. Statistical analysis of the results showed that the size of the error in measuring in-space determination of the position of the graft in tibia after reconstruction of the anterior cruciate ligament of the knee by a newly developed computer program was not statistically significant, and the computer determination of the position of the graft in the tibia provides the same results as the CT images. Summarizing the conclusions after a comprehensive analysis of the obtained results of the study, it can be concluded that the position of the graft in tibia after reconstruction of the anterior cruciate ligament affects the postoperative functional result.</p>

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Normal";mso-tstyle-rowband-size:0;mso-tstyle-colband-size:0;mso-style-noshow:yes;mso-style-priority:99;mso-style-qformat:yes;mso-style-parent:"";mso-padding-alt:0in 5.4pt 0in 5.4pt;mso-para-margin-top:0in;mso-para-margin-right:0in;mso-para-margin-bottom:10.0pt;mso-para-margin-left:0in;line-height:115%;mso-pagination:widow-orphan;font-size:11.0pt;font-family:"Calibri","sans-serif";mso-ascii-font-family:Calibri;mso-ascii-theme-font:minor-latin;mso-hansi-font-family:Calibri;mso-hansi-theme-font:minor-latin;mso-bidi-font-family:"Times New Roman";mso-bidi-theme-font:minor-bidi;}</style><![endif]-->Uvod: Traumatsko moždano o&scaron;tećenje (TMO) predstavlja globalni zdravstveni problem koji pogađa oko 10 miliona ljudi godi&scaron;nje &scaron;irom sveta. Te&scaron;ka traumatska moždana o&scaron;tećenja (TTMO) čine 10% svih TMO i imaju visoku stopu mortaliteta i neizvestan oporavak. Ranije prepoznavanje sistemskih faktora koji utiču na ishod lečenja može da ima značajan uticaj na pravovremeno započinjanje terapijskih mera i smanjivanje morbiditeta i mortaliteta. Cilj istraživanja: Identifikovati sistemske faktore koji imaju značajan uticaj na ishod lečenja povređenih sa TTMO u Jedinici intenzivnog lečenja (JIL) tokom prvog dana hospitalizacije. Metodologija: Ispitivanje je sprovedeno kao retrospektivno-prospektivna studija koja je obuhvatila 115 povređenih ispitanika sa TTMO koji su hospitalizovani u JIL Urgentnog centra Kliničkog centra Vojvodine (UC KCV) u periodu od 1.01.2014.-1.10.2017. Iz medicinske dokumentacije, za svakog ispitanika uključenog u istraživanje su uzeti u razmatranje i analizu sledeći parametri u toku prvih 24 časa od momenta prijema u JIL: demografske i op&scaron;te karakteristike ispitanika od značaja za istraživanje i sistemski prediktivni faktori (sistolni i srednji arterijski pritisak- SAP/MAP, glikemija-&Scaron;UK, telesna temperatura-TT, pH, parcijalni pritisak kiseonika-PaO2 i parcijalni pritisak ugljem dioksida- PaCO2) registrovani u pet vremenskih tačaka (0h, 6h, 12h,18h, 24h). Svi gore navedeni podaci su posmatrani i analizirani kao prediktorski faktori tj. nezavisne varijable u odnosu na zavisnu varijablu &bdquo;ishod lečenja&ldquo; definisanu kao Glazgovska skala ishoda (Glasgow outcome scale-GOS) nakon otpusta povređenih iz JIL na Kliniku za neurohirurgiju KCV i GOS nakon otpusta iz Klinike za neurohirurgiju KCV i &bdquo;tok lečenja&ldquo; definisan kroz dužinu boravka povređenih u JIL UC KCV, dužinu boravka na Klinici za neurohirurgiju KCV, odnosno ukupno trajanje hospitalizacije u KCV, kao i otpust kući ili u odgovarajući rehabilitacioni centar. Statistička analiza je izvr&scaron;ena pomoću statističkog paketa IBM SPSS 23. Podaci su predstavljeni tabelarno i grafički, a statistička značajnost određivana je na nivou p &lt; 0,05. Prikupljeni podaci su obrađeni adekvatnim statističkim metodima. Rezultati: Sistemski faktori koji su se izdvojili kao prediktori smrtnog ishoda (GOS 1) kod povređenih sa TTMO tokom prvog dana boravka u JIL su upotreba vazoaktivne potpore i glikemija. Upotreba vazoaktivne potpore povećava verovatnoću za smrtni ishod 4,7 puta (OR=0,214; 95%CI: 0,096-0,479; p&lt;0,05). i vrednosti glikemije &gt; 10 mmol/l povećavaju verovatnoću za smrtni ishod u nultom satu (OR= 0,240, 95%CI: 0,087-0,662; p=0,05) i u 24 satu (OR=0,206, 95%CI: 0,037 &ndash; 0,929; p=0,05). Sa svakim porastom telesne temperature za jednu jedinicu u posmatranom intervalu raste verovatnoća za pozitivan ishod (OR =2,118 , 95%CI: 1,097 &ndash; 4,091; p&lt;0,05) i vrednosti glikemije u intervalu od 4-8 mmol/l povećavaju verovatnoću za pozitivan ishod 2,5 puta. Sistemski faktori koji su se izdvojili u smislu predikcije ishoda lečenja ispitanika nakon otpusta iz JIL su vrednosti glikemije i telesna temperatura. Vrednost glikemije na prijemu u intervalu od 6,9 do 7,4 mmol/l povećavaju verovatnoću boljeg oporavka (GOS 4-5 vs. GOS 2-3). Niže vrednosti glikemiije u narednim vremenskim tačkama (6h, 12h, 18h) takođe povećavaju verovatnoću za bolji oporavak. Ukoliko je telesna temperatura u 6-om i 12-om satu, vi&scaron;a od 36,5 &deg;C veća je verovatnoća za bolji neurolo&scaron;ki oporavak, prilikom otpusta iz JIL, odnosno Klinike za neurohirurgiju KCV. Ispitanici koji su imali vi&scaron;e vrednosti telesne temperature su imali duže trajanje hospitalizacije (OR=4,096; 95%CI; 0,709-7,483;p&lt;0,05). Na dužinu boravka u JIL, kao i na otpust kući ili odgovarajući rehabilitacioni centar nije imao uticaj nijedan posmatrani sistemski faktor. Zaključak: Sistemski prediktivni faktori toka i ishoda lečenja povređenih sa TTMO su upotreba vazoaktivne potpore, glikemija i telesna temperatura.</p> / <p>Introduction: Traumatic brain injury (TBI) is a global health problem that affects about 10 million people worldwide annually. Severe traumatic brain injury (STBI) account for 10% of all TBI and has high morbidity and unreliable recovery. Early recognition of systemic factors that affect the treatment outcome can have a significant impact on the timely initiation of therapeutic measures and the reduction of morbidity and mortality. The objective of the research: to identify systemic factors that have a significant impact on the treatment outcome of the STBI patients in the Intensive Care Unit (ICU) during the first day of hospitalization. Methodology: The study was conducted as a retrospective-prospective study that included 115 injured patients with STBI who were hospitalized in the ICU, Emergency Center (EC) of the Clinical Center of Vojvodina (CCV) in the period from 01.01.2014 to 1.10.2017. From the medical documentation, for each participant involved in the research, the following parameters within the first 24 hours after the admission were considered and analyzed: demographic and general characteristics of the participants of importance for research and systemic predictive factors (systolic and mean arterial pressure-SAP / MAP, glycemia, body temperature -TT, pH, partial pressure of oxygen-PaO2 and partial pressure of carbon dioxide-PaCO2) registered at five time points (0h, 6h, 12h,18h, 24h). All of the above data were observed and analyzed as predictors, ie, independent variables in relation to the dependent variable &quot;treatment outcome&quot; defined as the Glasgow Outcome Scale (GOS) after the transfer from the ICU to the Clinic of neurosurgery of the CCV and GOS after discharge from a Clinic of neurosurgery and &quot;treatment course&quot; defined by length of stay in ICU, or the total duration of hospitalization in CCV, as well as the release to the home or the appropriate rehabilitation center. Statistical analysis was performed using the IBM SPSS 23 statistical package. The data are presented in tables and graphs, and the statistical significance was determined at p &lt;0.05. The collected data were processed with adequate statistical methods. Results: Systemic factors that had predictive value for the lethal outcome (GOS 1) in STBI during the first day of ICU stay were the use of vasopressors and glycemia. The use of vasopressors increases the likelihood of fatal outcome 4.7 times (OR= 0,214; 95%CI: 0,096-0,479; p&lt;0,05) and glycemic values &gt; 10 mmol/l increase the likelihood of fatal outcome on admission (OR=0,240, 95%CI: 0,087-0,662; p=0,05) and after 24 hours (OR=0,206, 95%CI: 0,037 &ndash; 0,929; p=0,05). With each increase in body temperature for one unit in the observed interval, the probability of a positive outcome increases (OR=2,118, 95%CI: 1,097 &ndash; 4,091;p&lt;0,05) and glycemic values in the range 4-8 mmol/l increase the probability of a positive outcome 2.5 times. Systemic factors that predict the treatment outcome of the patients after their discharge from ICU are glycemia and body temperature. The blood sugar on admission in the ICU in the range from 6.9 to 7.4 mmol/l increases the opportunity of a better recovery (GOS 4-5 vs. GOS 2-3). Lower glycemic values at the next time points (6h, 12h, 18h) also increase the opportunity of a better recovery. If the body temperature in the 6th and 12th-hour postadmission is higher than 36.5&deg; C, the greater opportunity for better neurological improvement when the patient is discharged from ICU, or from the Clinic of neurosurgery. Participants who had higher values of body temperature had a longer duration of hospitalization (OR 4.096; 95% CI; 0.709-7.483;p&lt;0,05). The length of the stay in ICU, as well as the release to the home or the appropriate rehabilitation center, was not affected by any observed systemic factor. Conclusion: Systemic predictive flow factors and outcome of treatment factors with STBI use of vasopressors, glycemia and body temperature.</p>

<p>Uvod: Individualno kreiran program vežbi lumbalne stabilizacije, mogao bi da doprinese boljem oporavku pacijenata sa hroničnim bolom u donjem delu leđa. Program vežbi u lečenju hroničnog lumbalnog bola je prilično raznolik, ali je dokazano da su vežbe stabilizacije najefikasnije, posebno vežbe u zatvorenom kinetičkom lancu. Cilj: je bio da se uporedi program vežbi lumbalne stabilizacije u otvorenom i zatvorenom kinetičkom lancu, u odnosu na program vežbi lumbalne stabilizacije i torakalne mobilizacije u zatvorenom kinetičkom lancu kao i da se proceni klinička efikasnost oba programa vežbi. Metode: Istraživanje je sprovedeno kao prospektivna, eksperimentalna studija na 80 ispitanika oba pola (35 mu&scaron;karaca, 45 žena), prosečne životne dobi (48.45+/- 10.22 godina) sa hroničnim lumbalnim bolom. Istraživanje je sprovedeno na Klinici za rehabilitaciju &bdquo;dr Miroslav Zotović&ldquo; u Beogradu u periodu od juna 2017. do marta 2018. godine. Ispitanici su podeljeni u dve grupe od 40 pacijenata. Prva grupa ispitanika je sprovodila program vežbi lumbalne stabilizacije i torakalne mobilizacije u zatvorenom kinetičkom lancu (LSTMZ), a druga program vežbi lumbalne stabilizacije u zatvorenom i otvorenom kinetičkom lancu (LSZO). Pored op&scaron;tih demografskih, antropometrijskih podataka o ispitanicima, kori&scaron;ćeni su sledeći upitnici i testovi: za procenu intenziteta bola u leđima i donjim ekstremitetima- vizuelna analogna skala (VAS), za procenu neuropatske komponente bola- DN4 (Douleur Neuropathique en 4 Questions), za procenu funkcionalnog statusa kori&scaron;ćen je Osvestrijev upitnik o onesposobljenosti (ODI), procena sagitalne pokretljivosti lumbosakralne kičme Schober testom, procena mi&scaron;ićne snage - manuelnim mi&scaron;ićnom testom; Ispitivanje senzitivnosti na ključnim senzornim tačkama za dermatome je vr&scaron;eno prema ASIA (American Spinal Injury Association) skali, testom istezanja ishiadičnog (Lazarevićev) i femoralnog nerva ispitivano je prisustvo kompresije nervnih korenova, za procenu stabilnosti lumbosakralne kičme- je kori&scaron;ćen test nestabilnosti u proniranom položaju (Prone Instability test). Ispitanici su ergonomski edukovani, sprovedena je transkutana elektro-nervna stimulacija (TENS) i primenjivana je laseroterapija male snage. Pacijentima je određena osmonedeljna kineziterapija koja je obuhvatala vežbe za jačanje dubokih stabilizatora lumbalne kičme. Retestiranje je rađeno nakon 4 i 8 nedelja. Rezultati: Kod obe grupe ispitanika u svim intervalima merenja je nađena visoka statistički značajna (p&lt; 0,001) redukcija intenziteta bola prema VAS skali za lumbalnu kičmu i donje ekstremitete,&nbsp;&nbsp; pobolj&scaron;anje funkcionalnog statusa (Oswestry) i sagitalne pokretljivosti (Schober). Statistički značajan (p&lt;0,05) oporavak ispitanika grupe 1 u odnosu na grupu 2, ostvaren je u svim intervalima merenja kod parametara: Intenzitet bola (VAS LS i VAS za nogu), stepen onesposobljenosti (ODI),vrednost motornog skora za trup merenog ASIA skalom i vrednost neuropatske komponente bola (DN4). Statistički značajan (p&lt; 0,05) oporavak ispitanika u grupi 2 u odnosu na grupu 1, ostvaren je posle 8 nedelja kod parametra za procenu vrednosti&nbsp; senzornog skora dodir prema ASIA skali. Utvrđeno je da veće početne vrednosti intenziteta bola prema skalama Vas ls i Vas za nogu i stepena onesposobljenosti prema ODI, negativno utiču na krajnji ishod ovih parametara kod pacijenata sa HLB-om u obe grupe (p&lt;0,05). Pacijenti sa pozitivnom neuropatskom komponentom bola imaju lo&scaron;iji ishod lečenja HLB-a vežbama stabilizacije i torakalne mobilizacije (p&lt;0,05). Zaključci: Pacijenti koji su radili program vežbi lumbalne stabilizacije i torakalne mobilizacije u zatvorenom kinetičkom lancu su imali bolji funkcionalni oporavak i značajniju redukciju intenziteta bola u odnosu na ispitanike koji su radili program vežbi lumbalne stabilizacije u zatvorenom i otvorenom kinetičkom lancu.</p> / <p>Introduction: An individual program of lumbar stabilization exercises could contribute to a better recovery of patients with chronic lower back pain. The exercise program in the treatment of chronic lumbar pain is quite diverse, but it has been proven that stabilization exercises are most effective, especially in a closed kinetic chain. Objective: was to compare the program of lumbar stabilization exercises in the open and closed kinetic chain, in relation to the program of lumbar stabilization exercises and thoracic mobilization in a closed kinetic chain, and to evaluate the clinical efficacy of both exercise programs. Methods: The study was conducted as a prospective, experimental study of 80 subjects of both sexes (35 men, 45 women), average life expectancy (48.45 +/- 10.22 years) with chronic lumbar pain. The research was conducted at the Rehabilitation Clinic &quot;Dr. Miroslav Zotović&quot; in Belgrade in the period from June 2017 to March 2018. Respondents were divided into two groups of 40 patients. The first group of respondents carried out a lumbar stabilization and thoracic mobilization program in a closed kinetic chain (LSTMZ) and the second, program of lumbar stabilization exercises in closed and open kinetic chain (LSZO). In addition to general demographic, anthropometric data on respondents, the following questionnaires and tests were used: for assessing the intensity of back pain and lower extremities - visual analogue scale (VAS), for assessing the neuropathic pain component DN4 (Douleur Neuropathique en 4 Questions),&nbsp; for functional status assessment was used Oswestry disability index (ODI), for assessment of sagittal mobility of the lumbosacral spine- Schober test, muscular strength assessment - manual muscle test; Sensitivity testing at key sensory points for dermatomas was performed according to the ASIA (American Spinal Injury Association) scale, stretching test of the ishiadic (Lazarević) and femoral nerves was udes for detection of nerve root irritation, and the Prone Instability test was used to assess the stability of the lumbosacral spine. Respondents were ergonomically educated, transcutaneous electrical-nerve stimulation (TENS) and low-power laser therapy were performed. Patients were given an eight-week kinesiotherapy that included exercises to strengthen the deep lumbar spine stabilizers. Retesting was done after 4 and 8 weeks. Results: In both groups of subjects, high statistically significant (p &lt;0.001) reduction of pain intensity to VAS scale for lumbar spine and for the leg, functional disability (Oswestry) sagital mobility of lumbar spine (Schober) improvement were found at all measurement intervals. The statistically significant (p &lt;0.05) recovery of group 1 subjects compared to group 2 was achieved at all measurement intervals in the parameters: Pain intensity (VAS LS and VAS for the leg), degree of disability (ODI), motor score value for the trunk measured by the ASIA scale and the value of the neuropathic pain component (DN4). Statistically significant (p &lt;0.05) recovery of group 2 subjects compared to group 2 was achieved after 8 weeks with the parameter for assessing the sensory touch score value to the ASIA scale. It has been found that higher initial pain intensity values to VAS ls and VAS for leg and degree of disability to ODI, negatively affect the final outcome of these parameters in patients with chronic low back pain in both groups of subject (p&lt;0,05). Patients with a positive neuropathic pain component have a lower outcome of chronic low back pain treatment with lumbar stabilization and thoracic mobilization exercises (p&lt;0,05). Conclusions: Patients who performed lumbar stabilization and thoracic mobilization exercises program in a closed kinetic chain had better functional recovery and a significant reduction in pain intensity compared to respondents who performed a lumbar stabilization program in a closed and open kinetic chain.</p>

The IDSA Community-Acquired Pneumonia (CAP) Guideline recommends ceftriaxone in combination with doxycycline as an alternative to combination therapy with ceftriaxone and azithromycin for non-intensive care unit (ICU) patients hospitalized with CAP. This is an attractive alternative regimen due to recent concerns of increased cardiovascular risk associated with azithromycin. The objective of this study was to compare the clinical outcomes of azithromycin and doxycycline each in combination with ceftriaxone for non-ICU Veterans hospitalized with CAP.

<p>Radioterapija (RT) je jedan od najvažnijih modaliteta lečenja solidnih malignih tumora i koristi je vi&scaron;e od 50% pacijenata (52,3%) sa malignim tumorima. Nauka koja proučava efekte elektromagnetnog zračenja na biolo&scaron;ke sisteme naziva se radiobiologija. Radiobiologija se fokusira na odgovor ćelija, tkiva i organizma kao celine na jonizujuće zračenje i proučava mehanizme radiobiolo&scaron;kog odgovora. Izlaganje ćelija niskim dozama JZ koje su nakon određenog vremenskog intervala praćene uobičajenim radioterapijskim dozama naziva se radioadaptivno zračenje. Adaptivni odgovor u sebi može da sadrži nekoliko fenomena: hiperradiosenzitaciju/radiorezistenciju, &ldquo;bystander&rdquo; efekat i radioadaptivni efekat u užem smislu. O molekularnim mehanizmima koji stoje iza navedenih efekata ne zna se dovoljno. U ovom radu ispitivan je odgovor malignih i zdravih ćelija na različite modalitete jonizujućeg zračenja u cilju boljeg poznavanja puteva ćelijske smrti i preživljavanja. Potpuno razumevanje molekularnih puteva koji vode u apoptozu ili u preživljavanje ćelija nakon izlaganja jonizujućem zračenju moglo bi koristiti u iznalaženju novih i efikasnijih strategija i modaliteta lečenja malignih tumora u cilju njihove potpune eredikacije. U istraživanju su kori&scaron;tene dve humane ćelijske linije ćelijska linija humanog kolorektalnog karcinoma HT-29 i ćelijska linija humanih fetalnih fibroblasta pluća MRC-5. Ćelije su zračene u dva režima različitim pre-iradijacionim dozama(0,03; 0,05 i 0,07Gy) i istom kurativnom dozom (2Gy) tokom 4 dana. Vi&scaron;ekratna primena niskih doza JZ nije značajno smanjila vijabilnost HT-29 ćelija, dok su dve radioadaptivne doze (0,05+2Gy i 0,07+2Gy), adekvatne doze JZ za radioterapijski postulat po&scaron;tede zdravih ćelija i bolji antitumorski efekat u odnosu na neradioadaptivno zračenje od 2Gy u toku 4 dana. Pokazana je mogućnost modulisanja ćelijskog odgovora na JZ uz pomoć niskih doza JZ koje su praćene dozom od 2Gy (radioadaptivni tip zračenja) u oba dizajnirana režima zračenja. Stepen o&scaron;tećenja hromozoma za većinu isporučenih doza pokazao dozno zavisni trend. Dozno-zavisno o&scaron;tećenje naslednog materijala izazvano radioadaptivnim zračenjem potvrđuje hipotezu da je stepen o&scaron;tećenja zdravih, MRC-5, ćelija manji nego u ćelijama kolorektalnog adenokarcinoma. Fragmentacija DNK je zabeležena za pojedine doze JZ u obe ćelijske linije, a uočena je i razlika u odgovoru zdrave i tumorske ćelijske linije. Detekcijom mutacija primarne sekvence fragmenta p53 gena pokazano je da se broj mutacija povećava sa povećanjem doze JZ. Oba režima radioadaptivnog zračenja, u obe ćelijske linije izazivaju vi&scaron;i nivo ekspresije p53. Ekspresija p38 MAPK proteina u HT-29 ćelijama bila je niža za sve isporučene doze JZ u odnosu na nezračene ćelije. U MRC-5 ćelijama, povi&scaron;ena ekspresija p38 MAPK utvrđena je samo u uzorcima koji su jednokratno primili samo niske doze JZ i dozu od 2Gy dnevno tokom 4 dana, u odnosu na nezračenu kontrolu. Razlike u ekspresiji ispitivanih proteina dobijene nakon primene dva režima radioadaptivnog zračenja posledica su delovanja niskih pre-iradijacionih doza JZ na modulisanje radiobiolo&scaron;kog odgovora obe ćelijske linije. Nivo ekspresije Bcl-2 i Bax proteina i njihov međusobni odnos, u obe ćelijske linije, su odraz različitog radiobiolo&scaron;kog odgovora ispitivanih ćelija koji zavisi od primenjenog režima zračenja.</p> / <p>Radiotherapy (RT) is one of the most important treatment modality for solid malignant tumors and it is applied in more than 50% of the patients (52.3%). Radiobiology id scientific discipline which studies the effects of electromagnetic irradiation on biological systems. Radiobiology focuses on the response of the cells, tissues and the organism as a whole to ionizing radiation and studying the mechanisms of radiobiological response. Exposure of cells to low-dose irradiation (priming dose) followed by challenging doses is called radioadaptive radiation. Adaptive response is described as several phenomena: hyperradiosensitivity / radiorezistence, &quot;bystander&quot; effect and radioadaptive effect in sensu strict. Molecular mechanisms underlying the above effects are not sufficiently known. In this study, the response of malignant and healthy cells on various modalities of ionizing radiation is explored in order to improve knowledge of pathways of cell death and survival. Fully understanding the molecular pathways leading to apoptosis or cell survival after exposure to ionizing radiation may be used in finding new and more effective strategies and modalities for the treatment of malignant tumors. The study used two human cell lines: human colorectal cancer HT-29 cell line and the human fetal lung fibroblast MRC-5. The cells were irradiated in two modalities using different pre-irradiation doses (0.03, 0.05 and 0,07Gy) and the same challenging dose (2Gy) for 4 days. Everyday use of low-dose did not significantly reduce the viability of HT-29 cells, while two radioadaptive doses (0.05 + 2Gy and 0.07+2Gy), are adequate doses for sparing healthy cells with better anti-tumor effects. The possibility of modulating the cellular response to the ionizing radiation was shown using low-doses followed by 2Gy (radioadaptive radiation) in both designed regimes of radiation. The level of chromosomal damage showed a dose-dependent trend. Dose-dependent damage to the genetic material caused by radiation confirms the hypothesis that the degree of damage to MRC-5 cells is smaller than the HT29 cells. DNA fragmentation differed between HT29 and MRC-5 cells. Detection of mutations in p53 gene fragment sequence increased with increasing doses. Both irradiation modalities, in both cell lines induce a higher level of p53 expression. Expression of p38 MAPK protein in the HT-29 cells was lower for all delivered doses compared to nonirradiated. In MRC-5 cells, increased expression of the p38 MAPK was found only in the samples that had only received on first day low-doses compared to the control nonirradiated cells. Differences in the expression of the tested proteins reflect different molecular mechanisms activated in normal and tumor cells. The level of Bcl.2 and Bax expression also reflected different radiobiological responses between normal and tumor cells, which depended on the applied irradiation regime.</p>

<p>Prema literaturnim podacima poslednjih godina velika pažnja je usmerena ka operativnom riziku i mortalitetu koji su postali najvažniji kriterijumi u ocenama rezultata rada hirur&scaron;kih ustanova, ali i svakog hirurga posebno. Zahvaljujući kompleksnom profilu pacijenata koji se podvrgavaju hirur&scaron;kim intervencijama, precizna procena operativnog rizika postaje sve teža. Predikcija ishoda intervencije u najvećoj meri zavisi od preoperativnih faktora rizika. Ipak, neminovno je da i faktori koji su vezani za samu operaciju u određenom stepenu utiču na ishod hirur&scaron;ke intervencije. Shodno tome, dobar model za procenu rizika treba da obuhvati faktore koji će imati najbolju prediktivnu vrednost. Thoracoscore je prvi bodovni sistem razvijen od strane Francuskog udruženja grudnih i vaskularinih hiruga. Zbog nedovoljne primene tokom poslednje decenije i nekonzistentnih rezultata nije do&scaron;lo do &scaron;irokog međunarodnog prihvatanja ovog modela i njegove rutinske upotrebe. Ova činjenica ukazuje na nedostake samog modela i potrebu za rekalibracijom u cilju postizanja bolje saglasnosti između predikcije operativnog rizika i kliničkog stanja bolesnika. Cilj rada je bio da se ustanovi realna vrednost Thoracoscore bodovnog sistema u proceni operativnog rizika i mortaliteta nakon anatomskih i neanatomskih resekcija pluća u na&scaron;im uslovima, i da se utvrdi prediktivna vrednost faktora rizika koji nisu obuhvaćeni Thoracoscore bodovnim sistemom na ishod grudno-hirur&scaron;kih operacija. Istraživanje je sprovedeno po tipu prospektivne kliničke studije i obuhvatilo je 957 bolesnika operisanih na Klinici za grudnu hirurgiju Instituta za plućne bolesti Vojvodine. Izvr&scaron;ene hirur&scaron;ke procedure bile su anatomske resekcije (lobektomija, bilobektomija, pneumonektomija, Sleeve resekcija, segmentektomija) i neanatomske resekcije pluća (Wedge resekcija i druge atipične resekcije). Thoracoscore je izračunat za svakog bolesnika na osnovu devet parametara: godine starosti, pol, ASA skor, dispnea skor, procena op&scaron;teg stanja bolesnika, dijagnostička grupa, hitnost operacije, vrsta operacije i broj komorbiditeta. S obzirom da prediktivna vrednost Thoracoscore bodovnog sistema u proceni operativnog rizika nije bila adekvatna realnom stanju, regresionom analizom je evaluiran značaj tri nova faktora: forsirani ekspiratorni volumen u prvoj sekundi (FEV1), reoperacija i hirur&scaron;ki pristup (torakotomija, video-asistirana torakoskopija &ndash; VATS). Nakon &scaron;to je univarijantnom analizom potvrđeno da su ovi faktori nezavisni prediktori operativnog ishoda, originalni Thoracoscore model je rekalibrisan. Multivarijantnom analizom putem logističke regresije izračunati su novi beta koeficijenti za originalnih devet faktora, kao i za tri nova, te je kreiran lokalni model za procenu operativnog rizika koji je prilagođen na&scaron;oj populaciji. Prosečna starosti bolesnika bila je 62 &plusmn; 7,52 godina. Većinu uzorka (60,7%) činili su pripadnici mu&scaron;kog pola. Najveći broj resekcija činile su lobektomije (61,4%). Malignitet je bio najučestalija indikacija za operaciju (90,3%). Najveći broj bolesnika imao je 1-2 komorbiditeta (64,3%). Prosečna stopa operativnog rizika na osnovu Thoracoscore-a (4,7% ) bila je veća je od stvarnog (2,9%) intrahospitalnog mortalita (p&lt;0,01). Ovaj model je pokazao zadovoljavajuće rezultate jedino u grupi niskog rizika. Predikcija mortaliteta lokalnim modelom za procenu operativnog rizika u grudnoj hirurgiji se, u statističkom smislu, ne razlikuje od stvarnog mortaliteta (p = NS). Thoracoscore ima dobru diskriminativnu moć, ali nezadovoljavajuću kalibrisanost. Shodno tome, Thoracoscore model se može koristiti za stratifikaciju rizika, ali ne i za predikciju mortaliteta. Za razliku, lokalni model je pokazao dobru diskriminaciju i kalibrisanost u na&scaron;im uslovima. Interni model za procenu rizika bi bio od velike koristi u svakodnevnom kliničkom radu, budući da bi oslikavao realno stanje populacije u kojoj je razvijen i vr&scaron;io preciznu predikciju operativnog rizika.</p> / <p>According to the literature data, over the past several years, great attention has been focused on operative risk and mortality which have become the most important criteria in evaluating the results from surgical departments and individual surgeons, as well. Because of complex profiles of patients undergoing surgical interventions, it is becoming more difficult to assess the risk precisely. Prediction of surgical outcomes mostly depends on the preoperative risk factors. However, factors related to the procedure itself effect the surgical outcome to a certain degree. Therefore, a good risk assessment model must contain factors which will have the best predictive value. Thoracoscore is the first scoring system developed by the French Association of Thoracic and Vascular Surgeons. Due to insufficient utilization over the past decade and inconsistent results, this model has not been widely accepted for routine use. This fact indicates that the model lacks certain aspects and needs to be recalibrated in order to achieve better concordance between the predicted operative risk and the clinical state of the patient. The aim of this study was to determine real value of Thoracoscore scoring system for estimation of operative risk and mortality following anatomic and non-anatomic lung resections in our settings, and to determine predictive value of factors not included in Thoracoscore on the outcome of thoracic surgeries. This prospective study included 957 patients who underwent lung resections at the Thoracic surgery clinic of Institute for Lung Diseases of Vojvodina. Performed surgical procedures were anatomic lung resections (lobectomy, bilobectomy, pneumonectomy, Sleeve resection, segmentectomy) and non-anatomic lung resections (Wedge resection and other atypical resections). Thoracoscore was calculated for each patient based on the following nine parameters: age, gender, ASA score, dyspnea score, performance status classification, diagnostic group, urgency of surgery, surgical procedure and number of comorbidities. Because predictive value of Thoracoscore did not correspond to the actual results, regression analysis was used to evaluate the significance of three new risk factors: forced expiratory volume in the first second (FEV1), reoperation, and surgical approach (thoracotomy, video-assisted thoracoscopy &ndash; VATS). After univariate analysis confirmed that these three factors are independent predictors of operative risk, the original Thoracoscore model was recalibrated. With the use of multivariate analysis by logistic regression, new beta coefficients were calculated for the original nine parameters, as well as for the new three, and consequently a local model for surgical risk assessment that is adapted to our population was created. Average age of patients was 62 &plusmn; 7.52 years. Most of the patients were males (60.7%). Lobectomies constituted the largest number (61.4%) of performed surgeries. The most common indications for surgery were malignant causes (90.3%). Most frequently, patients had 1-2 comorbidities (64.3%). Mean operative risk based on Thoracoscore (4.7%) was greater than the actual intrahospital mortality (2.9%) (p&lt;0.01). This model had adequate results only in the low risk group of patients. Predicted mortality by the local model was not statistically different from the actual mortality (p = NS). Thoracoscore had good discriminative ability, but inadequate calibration. Because of this, Thoracoscore model can be used for risk stratification, but not for mortality prediction. On the other hand, local model showed good discrimination and calibration in our population. Therefore, an internal model for risk assessment would be of great use in everyday clinical practice because it would reflect the real state of the population in which it was developed, predicting the risk more precisely.</p>