Volume 37 (2016): Edizione 2-3 (November 2016)

Introduction and aim: The Internet has enabled an easy method to search through the vast majority of publications and has improved the impact of scholarly journals. However, it can also pose threats to the quality of published articles. New publishers and journals have emerged so-called open-access potential, possible, or probable predatory publishers and journals, and so-called hijacked journals. It was our aim to increase the awareness and warn scholars, especially young researchers, how to recognize these journals and how to avoid submission of their papers to these journals.

Methods: Review and critical analysis of the relevant published literature, Internet sources and personal experience, thoughts, and observations of the authors.

Results: The web blog of Jeffrey Beall, University of Colorado, was greatly consulted. Jeffrey Beall is a Denver academic librarian who regularly maintains two lists: the first one, of potential, possible, or probable predatory publishers and the second one, of potential, possible, or probable predatory standalone journals. Aspects related to this topic presented by other authors have been discussed as well.

Conclusion: Academics should bear in mind how to differentiate between trustworthy and reliable journals and predatory ones, considering: publication ethics, peer-review process, international academic standards, indexing and abstracting, preservation in digital repositories, metrics, sustainability, etc.

Introduction: Independently, hormone therapy and exercise have well-established protective effects on bone parameters. The combined effects of hormone therapy and exercise, however, are less clear. We, therefore, examined the effects of hormone therapy on bone turnover markers in postmenopausal women undergoing regular high intensity exercise.

Methods: In a randomised, double blind study, postmenopausal athletes competing at Masters level, received either hormone therapy (50 μg transdermal oestradiol, 5 mg MPA, n = 8) or placebo (n = 7) for 20 weeks. Women were tested before and after treatment for plasma concentrations of oestradiol, FSH, LH, and serum bone formation marker -osteocalcin (OC); and urine bone resorption markers-pyridinoline (PYD) and deoxypyridinoline (DPD).

Results: As a result of treatment with hormone therapy there were significant reductions in levels of FSH (73.3 ± 13.7 to 48.6 ± 10.5 mmol/L, p = 0.01) and bone resorption markers (PYD, 81.9 ± 7.7 to 57.8 ± 3.7 nmol/mmol Cr, p = 0.001, and DPD, 18.5 ± 3.1 to 11.8 ± 2.1 nmol/mmol Cr, p = 0.01). Oestradiol and bone formation markers were not significantly altered as a result of hormone therapy. There were no changes to any variables with placebo treatment.

Conclusion: Hormone therapy reduced bone resorption, but not bone formation, in postmenopausal athletes. These favorable reductions in bone turnover; therefore, provide an effective treatment in combination with high intensity exercise to further reduce the subsequent risk of osteoporosis and associated fractures.

Introduction: Hormone replacement therapy (HRT) and walking were investigated independently and in combination, to determine which treatment provided most effect on bone turnover in postmenopausal women.

Methods: Using a randomised double-blind pilot study, 10 subjects received HRT (transdermal estradiol, 50 μg/day and oral MPA 5 mg/day) and 12 received placebo for 20 weeks. Following a baseline period of treatment, both groups undertook a graduated walking regimen, which increased in intensity, duration and frequency parameters from weeks 8–20. Measurements of aerobic capacity, female sex hormones, bone formation markers [osteocalcin (OC) and bone alkaline phosphatase (BAP)] and bone resorption markers [deoxypyridinoline (DPD) and pyridinoline (PYR)] were measured at baseline (T1), week 8 (T2) and week 20 (T3).

Results: Age, time of postmenopause, weight or body mass index were no different between each groups. The HRT group had significantly higher estradiol levels compared with the placebo group at T2 and T3. FSH and LH levels were significantly reduced following HRT. DPD and PYR were significantly reduced from baseline levels at T2 and T3 with HRT. No significant changes occurred in OC or BAP levels with either HRT or walking. Walking did not change bone turnover markers in either the HRT or placebo group.

Conclusion: HRT reduces bone resorption, however, walking alone at the intensity and duration prescribed, or the combination of HRT and walking, provided no additional benefit after menopause. Therefore, HRT, but not walking is an effective treatment in reducing bone turnover in postmenopause women.

As people age, chronic kidney disease becomes more common, but it rarely leads to end-stage kidney disease. When it does, the choice between dialysis and conservative care can be daunting, as much depends on life expectancy and personal expectations of medical care. Shared decision making implies adequately informing patients about their options, and facilitating deliberation of the available information, such that decisions are tailored to the individual’s values and preferences. Accurate estimations of one’s risk of progression to end-stage kidney disease and death with or without dialysis are essential for shared decision making to be effective. Formal risk prediction models can help, provided they are externally validated, well-calibrated and discriminative; include unambiguous and measureable variables; and come with readily applicable equations or scores. Reliable, externally validated risk prediction models for progression of chronic kidney disease to end-stage kidney disease or mortality in frail elderly with or without chronic kidney disease are scant. Within this paper, we discuss a number of promising models, highlighting both the strengths and limitations physicians should understand for using them judiciously, and emphasize the need for external validation over new development for further advancing the field.

The incidence of chronic kidney disease (CKD) in patients with chronic heart failure (CHF) is high as CKD and CHF share underlying risk factors such as arterial hypertension, diabetes mellitus and atherosclerosis. Cardiac failure leads to renal hypoperfusion and dysfunction and then fluid overload and need for aggressive diuretic therapy. However, development of diuretic resistance represents a significant problem in the management of these patients.

The role of Renal Replacement Therapy (RRT) is important for patients who do not response to conservative management of fluid overload facilitating the failing heart to restore function. According to the guidelines, venovenous isolated Ultrafiltration (UF) is indicated for patients with refractory congestion not responding to medical therapy with loop diuretics and infusion of dopamine. A systematic review of randomized controlled trials on the effect of UF vs. IV furosemide for decompensated heart failure showed a benefit of UF on total body weight loss and on readmissions due to heart failure in patients with decompensated heart failure and CKD. Peritoneal dialysis (PD) can provide efficient ultrafiltration and sodium extraction in volume overloaded patients followed by decline of hospitalization days, decrease of body weight and improvement of LVEF in patients with refractory heart failure. The continuous draw of ultrafiltrate is followed by a lesser risk of abrupt hypotension and better preservation of the residual kidney function. This represents a significant advantage of PD over intermittent UF by dialysis.

In conclusion, application of UF by dialysis and PD is followed by significant total body weight loss, reduced need for hospital readmissions and better quality of life. PD has a higher probability of preservation of residual kidney function and can be used by patients at home.

The terminologies of “body size”, “body mass index (BMI)”, “body weight”, “large BMI” and “obesity” are controversial for defining the effects of “adiposity” or “fat excess” on the outcomes of dialysis and transplant patients. However, probably these terminologies will be continued to be used in the future as well, because of being older and simpler terminologies.

In the general population obesity is a powerful risk factor for cardiovascular morbidity and mortality, while, it conferred a survival advantage to dialysis patients. However, this may be a oversimplification, since obesity may still be a risk factor in non-sarcopenic hemodialysis patients.

Obesity is associated with early post-transplant adverse effects (i.e. delayed graft function, graft failure, wound infections, also transplant costs) and unfavorable graft and patient survival. However, thanks to safer immunosuppressive protocols, recently graft and patient survival is similar in obese as those of the non-obese patients. On the other hand, morbid obesity may still be a cause of unfavorable patient and graft survival.

Since obese transplant recipients have better life expectancy as compared to wait-listed hemodialysis patients, they should be transplanted as well, while morbidly obese patients should be asked to lose weight before being placed in the waiting lists.

Somatization in children consists of the persistent experience and complaints of somatic distress that cannot be fully explained by a medical diagnosis.

Working at the Psychophysiological Department at the University Clinic we are dealing with more than 100 children per year manifesting this kind of disorders.

The aim of this article is to summarize some specific characteristics of the somatoform disorder in a group of 243 children, mean age 10.31 (± 2.75) years for both genders, selected randomly. The used psychometric instruments are: CBCL, EPQ for children, and MMPI-201 for mothers.

The obtained results showed high scores for somatization, extroversion and accentuated anxiety for children; as well as a typical Hs-Hy personality profile for mothers.

The treatment with cognitive-behavior therapy and biofeedback showed very positive outcome.

Introduction: Clinical manifestations of influenza range from relatively mild and self-limiting respiratory infections to severe clinical manifestations with significant morbidity and mortality. The awareness of predictive indicators for the lethal outcome of influenza is of particular significance in making timely and exact decision for adequate treatment. The aim of this study was to identify the factors in patients with a severe form of influenza, resulting in lethal outcome.

Materials and methods: The investigation was a prospective group comparison conducted at the University Clinic for Infectious Diseases in Skopje, R. Macedonia in the period from January 01, 2012 to January 01, 2015. The study included adult patients with a severe form of influenza who were further categorized into a group of either survived patients or a group of deceased patients. Demographic, clinical and biochemical data were noted in all patients included in the study on admission. The variables of the univariate analysis that showed a significant difference in terms of the outcome were used for creating multivariate logistic and regression analysis of the outcome as dependent factors. The independent predictors for lethal outcome in severe cases of influenza were identified by using logistic regression.

Results: The study included 87 patients with a severe form of clinical and laboratory confirmed influenza. The patients were divided in two groups: survived (n = 75) and deceased (n = 75). The overall mortality was 13.79%. Multivariate analysis conducted on admission to hospital identified cardiovascular comorbid diseases (p = 0.014), urea values higher than 8.3 U/L (p = 0.045) and SAPS score (p = 0.048) as independent predictors of the outcome in patients with severe form of influenza. Influenza patients with cardiovascular diseases had 2.024 times greater risk of death from influenza in comparison to the patients having influenza without history of such a disease (OR = 2.024 95% CI 1.842–17.337). Patients with serum urea values higher than 8.3 U/L had 1.89 times higher chance of death compared to patients with normal values (OR = 1.89 95% CI 1.091–11.432). The increase of the SAPS score in one point increased the chance of death in patients with influenza by 1.2% (OR = 1.12 95% CI 1.01–2.976). The ROC analysis indicated that cardiovascular diseases, increased urea values and SAPS score in combination act as a good prognostic model for the fatal outcome. The global authenticity of this predictive model to foresee lethal outcome amounts to 80%, sensitivity being 82%, and specificity 70%.

Conclusion: Cardiovascular diseases, increased values of urea over 8.3 mmol/l and SAPS score are independent predictive indicators for lethal outcome in severe influenza. Early identification of the outcome predictors in patients with severe influenza will allow implementation of adequate medical treatment and will contribute to decreasing of mortality in patients with severe form of influenza.

Background: The minimal effective analgesic concentration of opioids required for satisfactory analgesia may differ significantly among the patients. Genetic factors may contribute to the variable response to opioids by affecting their pharmacokinetics or pharmacodynamics.

Methods: Ninety nine patients undergoing abdominal surgery with colorectal anastomosis because of colorectal carcinoma were enrolled in the present study. C34535T was genotyped in all subjects and the patients were divided into three groups according to their genotype: CC-wild type homozygous, CT-mutant heterozygous and TT-mutant homozygous. Intravenous fentanyl, patient controlled analgesia was provided postoperatively for pain control in the first 24 hour after surgery. Opioid consumption, pain scores and the adverse side effects were evaluated.

Results: Our main result is that the patients in the CC genotype group consumed significantly more fentanyl (375.0 μg ± 43.1) than the patients in the TT group (295.0 μg ± 49.1) and the CT (356.4 μg ± 41.8) group in the treatment of postoperative pain. The patients in the TT group had lower VAS scores at 6h, 12h, 18 h and 24h postoperatively. There were no significant differences in the side effects among the three groups regarding the vomiting and the sedation score. The patients in the TT group had more frequently nausea score 1, than the patients in the other two groups.

Conclusion: Our study indicates that the C3435T SNPs of the ABCB1 gene is associated with differences in the opioid sensitivity. The ABCB1 polymorphism may serve as an important genetic predictor to guide the acute pain therapy in postoperative patients.

The aim of this study was to identify the participations of the serum coagulations and fibrinolysis factors that contribute to the differential diagnosis of the patients with community-acquired pneumonia (CAP) without effusion, uncomplicated parapneumonic effusion (UCPPE) and complicated parapneumonic effusion (CPPE).

The coagulations system is fundamental for the maintenance of homeostasis, and contributes to the inflammatory process responsible for CAP and the parapneumonic effusion. The factors of coagulations and fibrinolysis participate in the cellular proliferation and migration as in the synthesis of the inflammatory mediators.

We evaluated the laboratory profile of coagulations and fibrinolysis in the serum of 148 patients with CAP without effusion, 50 with UCPPE and 44 with CPPE. We determined the test of the coagulation cascade which measures the time elapsed from the activation of the coagulation cascade at different points to the fibrin generation. As a consequence, there is an activation of the fibrinolytic system with the increased D-dimer levels measured in the plasma in the three groups.

The patients were with mean age ± SD (53,82 ± 17,5) min – max 18–93 years. A significantly higher number of thrombocytes was in the group with CPPE with median 412 × 10⁹/L (rank 323–513 × 10⁹/L). The extended activation of the prothrombin time (aPTT) was significantly higher in the same group of patients with median of 32 sec. (rank 30–35 sec). The mean D-dimer plasma level was 3266,5 ± 1292,3 ng/ml in patients with CPPE, in CAP without effusion 1646,6 ± 1204 ng/ml and in UCPPE 1422,9 ± 970 ng/ml.

The coagulations system and the fibrinolysis play important role in the development and pathophysiology of CAP and the parapneumonic effusions.

Malignant skin melanoma is a tumor deriving from transformed skin melanocytes as a result of complex interactions between genetic and environmental factors. This melanoma has a potential to metastasize early and very often it is resistant to the existing modalities of the systemic therapy. As in any other neoplasms, certain types of melanoma may skip certain stages of progression.

The progression from one stage to another is accompanied by specific biological changes. Several key changes in the melanoma tumorogenesis influence the regulation of the cell proliferation and vitality, including the RAS-RAF-ERK, PI3K-AKT, and p16^INK4/CDK4/RB pathways. A key role in the dissreguarity of the RAS-RAF-ERK (MAPK) pathway in the malignant melanoma development have been demonstrated by many studies. To date, the molecular genetic alterations during melanoma development have been partially known. In the pathogenesis of the malignant melanoma, there are mutations of various genes such as NRAS, BRAF, and PTEN and mutations and deletions of CDKN2A.

In the past years, great advance has been made in the insights of the molecular aspects of the melanoma pathogenesis. However, this field yet poses a challenge to discover new details about the melanoma molecular characteristics. The research results are focused towards the improvement of the melanoma patients prognosis by introducing personalized targeted therapy.

Aim: During diabetic pregnancy, complex metabolic changes occur in the lipid profile. The aim of the study was to determine the predictive values of maternal serum lipid levels on large-for-gestational age newborns during the third trimester in pregnancies of women with type 2 diabetes mellitus (DM2) and gestational diabetes mellitus (GDM).

Material and methods: Data of forty three pregnancies of women with DM2 and two hundred women with GDM were analyzed. The analysis encompassed the following parameters: age, body mass index (BMI), lipid parameters, HbA1c in first, second and third trimester of pregnancy, preeclampsia and baby birth weight.

Results: DM2 and GDM groups showed statistically significant differences in the following variables: total lipids, triglycerides, total cholesterol, BMI, age, baby birth weight, incidence of SGA and preterm delivery (9.4 ± 2.3 vs. 11.0 ± 2.3 mmol/L, 2.4 ± 1.4 vs. 3.4 ± 1.6 mmol/L, 5.5 ± 1.2 vs. 6.4 ± 1.4 mmol/L, 30.6 ± 5.4 vs. 26.9 ± 5.2 kg/m², 34 ± 7.8 vs. 31.5 ± 5.6 years, 3183 ± 972 vs. 3533 ± 699 g., 20% vs. 7.5%, 27.9 vs. 14%, respectively, p < 0.05). Linear multiple regression analysis demonstrated that triglycerides, LDL-C and total cholesterol were independent predictors of LGA (p < 0.05).

Conclusion: Triglycerides and LDL-C in the third trimester of pregnancy are independent predictors for fetal macrosomia in DM2 and GDM pregnancies. Thus, the maternal serum triglycerides and LDL-C levels determined in the maternal blood taken in the third trimester of pregnancy may indentify women who will give birth to LGA newborns.

Regular ultrasound examinations carried out in the second trimester of pregnancy help in detecting many anomalies in the fetal urinary tract. Their percentage ranges from 1% to 3% of all controlled pregnancies. There is a wide spectrum of anomalies that affect the urinary tract, but the most significant are: uretero/hydronephrosis (unilateral or bilateral), kidney agenesis, dysplastic kidney, polycystic and multicystic kidneys, anomalies of ascent, anomalies of kidney rotation or fusion, bladder exstrophy, posterior urethra valve etc.

Many of these anomalies do not have impact either on urine flow or on kidney function and hence they can be qualified rather as a condition than as a disease. At the same time, most of the hydronephroses that are seen prenatally are being resolved spontaneously, and they are not detected neither presented postnatally as uretero/hydronephroses of unobstructed type and do not require surgical treatment. Only one tenth of these anomalies are subject to active surgical treatment.

Therefore, the assessment of these conditions should be done by a specialized team, who will make adequate therapeutic decisions based on clinical guidelines, as well as will advise the parents on the future clinical implications of the detected anomaly.

Pancreas is an extremely rare abdominal localization of the solitary fibrous tumor (SFT). It usually grows asymptomatically for a long time before a diagnosis can be made on the basis of symptoms and/or mechanical complications. Due to the rarity and nonspecific clinical presentation, this entity is diagnostically challenging.

We present a 47-year-old man with a history of progressive epigastric pain for the last two weeks, and jaundice, who was admitted to hospital for further investigation. Cystadenocarcinoma was suspected based on the radiologic findings, and a pancreatoduodenectomy was performed. The removed portion of the pancreas contained a 3.5 × 2 × 1.8 cm well-circumscribed, but not encapsulated white tumor mass with smooth cut surface, cystic component and duct dilatation within the tumor and within the adjacent pancreatic tissue. Based on the histology and immunostaining profile, a diagnosis of the solitary fibrous tumor was made. One week post-operatively, the patient died due to surgical complications.

Microscopic and immunohistochemical examinations are necessary for accurate diagnosis of cystic SFT of the pancreas. Because there is limited data regarding the biological behavior of SFT with extra-pleural localization the authors recommend clinical follow-up for SFT treatment if the criteria of malignancy are not met.

Kidney transplantations have become common surgical procedures that are associated with high success rates. Nevertheless, the detection, accurate diagnosis and timely management of the perioperative surgical complications sometimes require multidisciplinary team approach for some of the complications may result in significant morbidity, risk of graft loss and/or mortality of the recipient.

A case of a 24-year old male patient that developed a number of different surgical complications is reported. The complications included venous graft thrombosis, urinary fistula, wound infection, wound dehiscence and a completely exteriorized transplanted kidney. Despite the various complications and, accordingly, a couple of revisions, finally the patient was discharged with a regular kidney function.

This report describes a (rare) situation when a patient’s first gift to a young doctor was in money. This happened in very specific circumstances – in a refugee camp during the War in Croatia. The data are taken from a large study on gifts, conducted on a representative sample of Croatian general practitioners (GPs), N = 265, from 2358 in total.

Pro and contra factors are discussed, considering tradition and customs, but also a lack of knowledge of young doctors in handling gifts in general. The intention of this report is primarily educative, with review of (scarce) literature, and recommendations, where the generally accepted rules might have exceptions.