The promptness of providing services to patients directly affects the success of healthcare organizations. In this regard, the implementation of contemporary concepts in healthcare organizations is synonymous with success. Subject of research: The subject being researched in this paper is the possibility of applying the SIPOC method to the clinical process in obstetrics. A more precise application of the abovementioned method would mean a prompter implementation of activities within the clinical process (pregestational counseling, antenatal care of expectant mothers, deliveries, supervision of women during puerperium). Through the activities of the abovementioned clinical process, an effort is made to meet the health needs of expectant and new mothers. The application of the SIPOC method is not sufficiently present in clinical processes, especially the clinical process in obstetrics, and therefore this paper opens a new research area. Aim: The aim of this paper is to indicate the relevance of the SIPOC method as one of the tools within the Lean methodology, which can be used to improve the clinical process in obstetrics. Materials and methods: The following materials and methods were applied in this study: the method of analysis, the inductive - deductive method, the method of synthesis, the method of description, the method of proof. Case analysis was also used in the application of the SIPOC matrix at a gynecology and obstetrics outpatient clinic. Results: The results of the research showed that there was a positive impact on improving the efficiency of the provision of health services, through the implementation of modern methods. The SIPOC method affected the improvement of the efficiency of the clinical process in obstetrics. The review of the literature and the obtained results revealed that there is no formalized concept with instructions on the implementation of clinical process improvement methods.

Introduction: Microdissection testicular sperm extraction (microTESE) is considered the gold standard method for surgical sperm retrieval among patients with non-obstructive azoospermia (NOA). Aim: This study aimed to evaluate the correlation between histopathological findings after failed microTESE procedure and outcomes of the „second-look“ procedure and to provide insight into the most common histopathological patterns after testicular biopsy within our population. Methods: The retrospective study included 33 selected patients with NOA, who had undergone unsuccessful sperm retrieval. The diagnosis of NOA was made after the assessment of the patient’s history data, a physical examination, semen analysis, the hormonal profile, and genetic studies. After negative sperm retrieval, histopathological report has been analyzed for „second-look“ microTESE attempt. Results: Five testicular histopathological patterns were found: hypospermatogenesis (9,1%), Sertoli cell-only syndrome (43%), germ cell maturation arrest (15%), seminiferous tubule hyalinization (15%), mixed pattern (21%). Y-microdeletions were detected in 5 patients, of which 3 patients showed AZFc region deletions. Only 3 patients (9,1%) underwent a „second-look“ procedure after the evaluation of histopathological reports. After the stimulation therapy and „second-look“ procedure, we had a positive outcome in a single patient (33,3%). Mean FSH value in patients with confirmed spermatogenesis was 17.26±3.11IU/l, while mean FSH value in patients without presence or germ cell statistically significantly exceeded and was 24.28±4.71IU/L (p=0.038). Conclusion: Histopathological reports following the microTESE procedure are obligatory for the proper selection of patients who are candidates for the „second-look“ microTESE attempt. Patients with Sertoli cell-only syndrome and hypospermatogenesis particularly can benefit from the “second-look” procedure.

Introduction: Preeclampsia is defined as hypertension (systolic pressure ≥140 mmHg or diastolic pressure ≥90 mmHg) after week 20 of gestation with one or more of the following symptoms: proteinuria, organ dysfunction (including renal, hepatologic, hematologic or neurological complications) and in case of stagnation of fetal development. So far, there are no valid clinical tools or tests that can tell with sufficient sensitivity and specificity in early pregnancy which pregnant woman will develop preeclampsia or have unwanted outcomes. Aim: To present the properties of biochemical parameter, uric acid, in patients with signs of preclampsia, which was confirmed by Doppler sonography. Methods: The study included 60 female subjects in the second trimester of pregnancy who were examined or were hospitalized at the Clinic of Gynecology and Obstetrics, Clinical Center University of Sarajevo. Pregnant women who had normal Doppler sonography scan of the uterine arteries in the second trimester of pregnancy were included in the control group, while pregnant women with pathologic Doppler sonographic findings in the second trimester of pregnancy were included in the group of pregnant women at risk of preeclampsia, i.e. the study group. Results: There is statistically significant difference between the average value of uric acid in the control and in the study group (213.36 ± 28.96 μmol / L vs 249.73 ± 47.06 μmol / L) (F = 12.991; p = 0.001). Applying the Wilcoxon non-parametric paired test to the average uric acid values during all measurements within the control group, no statistically significant difference was found. There was a statistically significant increase in the study group between all measurements, from 18.04 μmol / L between the first and second measurement (Z = -1.955; p = 0.043), 29.10 μmol / L between the second and third measurement (Z = -2.973; p = 0.003), 37.27 μmol / L between the third and fourth measurement (Z = -4.325; p = 0.001) and 109.87 μmol / L at the end of the study in comparison to values from the start of the study (Z = -4.309; p = 0.001). Conclusion: Uric acid values should become part of a broad biochemical range in screening and optimizing the treatment of patients diagnosed with early preeclampsia.

Ab s t r Ac t Introduction: Preeclampsia is the cause of increased morbidity in mothers, and mortality and morbidity of both mothers and fetuses and newborns. The pathological process is already complete when the symptoms occur, and nothing concrete can be done to stop the process. Early identification of women at risk of developing preeclampsia is a key goal of antenatal care. Alongside chemical tests, Doppler sonography of the uterine arteries plays a major role in the prediction of preeclampsia. Aims: To establish the probability of resistance to blood flow in the uterine arteries and the existence of notching in the control and test groups. Materials and methods: The study comprised 60 subjects in the second trimester of pregnancy who were going for check-ups during their pregnancy or had been hospitalized at the Maternity Clinic of Sarajevo UCC. All the subjects were divided into two groups, a control and a test group, in relation to the presence of pathological blood flow in the uterine arteries. As well as ultrasound results, the patients also provided an exhaustive history about their previous pregnancies, if any, and any relevant laboratory results. Results: A statistically significant difference was found in the average values of systolic and diastolic pressure during pregnancy between the control and the test group (p = 0.001). From an analysis of the resistance to blood flow in the uterine arteries in the control and test groups, we concluded that the flow on the side with the placenta and on the side without the placenta were physiological over five measurements in the control group of subjects. In the test group the largest number of cases of pathological flow were recorded, and there was also notching. Of the 21 subjects with a diagnosis of preeclampsia, there was notching in 10. Conclusion: Doppler sonography in the second trimester of pregnancy is a good prognostic marker for early discovery of preeclampsia.

Introduction: The effect of statins on risk of heart failure (HF) hospitalization and lethal outcome remains dubious. Aim: To investigate whether statin therapy improves clinical outcomes in patients hospitalized for ischemic heart failure (HF), to compare the efficacy of lipophilic and hydrophilic statins and to investigate which statin subtype provides better survival and other outcome benefits. Material and Methods: Total amount of 155 patients in the study were admitted to the Clinic for Cardiology, Rheumatology and Vascular diseases in Clinical Center University of Sarajevo in the period from January 2014- December 2017. Inclusion criteria was HF caused by ischemic coronary artery disease upon admission. For each patient the following data were obtained: gender, age, comorbidities and medications on discharge. New York Heart Association (NYHA) class for heart failure was determined by physician evaluation and left ventricle ejection fraction (LVEF) was determined by echocardiography. The patients were followed for a period of two years. Outcome points were: rehospitalization, in-hospital death, mortality after 6 months, 1 year and 2 years. All-cause mortality included cardiovascular events or worsening heart failure. Results: Overall, 58.9% of HF patients received statin therapy, with 33.9% patients receiving atorvastatin and 25.0% rosuvastatin therapy. The most frequent rehospitalization was in patients without statin therapy (66.7%), followed by patients on rosuvastatin (64.1%), and atorvastatin (13.2%), with statistically significant difference p = 0.001 between the groups. Mortality after 6 months, 1 year and 2 years was the most frequent in patients without statin therapy with a statistically significant difference (p = 0.001). Progression of HF accounted for 31.7% of mortality in patients without statin therapy, 12.8% in patients on rosuvastatin therapy and 3.8% in patients on atorvastatin therapy (p = 0.004). Conclusion: Lipophilic statin therapy is associated with substantially better long-term outcomes in patients with HF.

Introduction: Shoulder pain is the most common form of extra-articular rheumatism. We aimed to determine the efficiency of the conventional physical treatment of the shoulder pain compared to the conventional treatment plus the Mulligan's joint mobilization technique and acupuncture. Methods: We included a total of 277 patients with the shoulder pain caused by adhesive capsulitis (frozen shoulder), calcific tendinitis, rotator cuff syndrome, or the tendinitis of the biceps muscle. We used clinical and radiological diagnostic criteria to make the diagnosis. Patients were assigned into group treated with conventional physiotherapy treatment during the ten days (CP)(n=148), and the group treated with conventional physiotherapy treatment plus the Mulligan joint mobilization and acupuncture (CP+MA)(n=128). Treatment efficiency was evaluated by assessing the status of the patients before and after the treatment with the Work Abilities and Activities of Daily Living (WAADL) scale as well as the Treatment Success scale. Results: Mean treatment duration was 13.36±5.83 and 10.86±4.55 days in CP and CP+MA group, respectively (p<0.05). Mean WAADL scores after the treatment were 3.98±1.04 and 4.61±1.10 in CP and CP+MA group, respectively (p<0.05). Mean Treatment success score was 3.16±0.74 and 4.35±0.78 in CP and CP+MA group, respectively (p< 0.05). Conclusions: Conventional physical therapy plus the Mulligan's joint mobilization technique and acupuncture resulted in shorter treatment duration and higher WAADL and Treatment success scores in patients with shoulder pain.

Objective The aim of the study was to describe the prevalence of hyperlactatemia and emphasis on repeated lactate measurements in critically ill patients, and the associated mortality. Materials and methods The study included 70 patients admitted in the Medical Intensive Care Unit at the Clinical Center, University of Sarajevo, in a 6-month period (July - December 2015). The following data were obtained: age, gender, reason for admission, Simplified Acute Physiology Score II, Acute Physiology and Chronic Health Evaluation, lactate concentrations upon admission, after 24 and 48 hours, and outcome (discharge from hospital or death). Results Upon admission,hyperlactatemia was present in 91.4% patients with a mean concentration of lactate 4.13 ±1.21 mmol/L. Lactate concentration at 48 hours was independently associated within creased in-hospital mortality (P = 0.018). Conclusion Persistent hyperlactatemia is associated with adverse outcome in critically ill patients. Lactate concentration at 48 hours is independently associated within creased in-hospital mortality and it represents a statistically significant predictive marker of fatal outcomes of patients. Blood lactate concentrations > 2.25 mmol/L should be used by clinicians to identify patients at higher risk of death.

Introduction: Main categorisation of azospermic is in two grups: nonobstructive azoospermia (NOA) and obstructive azoospermia (OA). We had evaluation of prognostic factors and determinants in sperm retrieval procedures in azoospermic patients. Methods: Retrospective evaluation observed 21 selected patients with NOA and OA azoospermia, after that complete history, physical examination with ultarsound volume of testis and hormonal profile. Hormonal profile included: follicle stimulating hormone (FSH), luteinizing hormone (LH), testosteron (T) and prolactin (P) serum levels. Also karyotype and Y-deletion analysis were done and analyzed. Results: 9 OA patients (42,9%) were undergone for TESE operation and 12 NOA patients (57,1%) for Micro-TESE operation. All TESE procedures were positive (100%). Micro-TESE in 12 selected NOA patients, 5 patients (41,6%) were positive and 7 patients (58,4%) negative. Patients testicular size, serum FSH and testosterone level showed correlation in success of sperm retrieval procedures. Conclusion: TESE is elected procedure for obstructive azospermia (OA). Micro-TESE is appropriate sperm retrieval procedurec for patients with non-obstructive azoospermia (NOA) and correlate with high FSH and small volume of testis.

OBJECTIVE The aim is to determine SAPS II and APACHE II scores in medical intensive care unit (MICU) patients, to compare them for prediction of patient outcome, and to compare with actual hospital mortality rates for different subgroups of patients. METHODS One hundred and seventy-four patients were included in this analysis over a oneyear period in the MICU, Clinical Center, University of Sarajevo. The following patient data were obtained: demographics, admission diagnosis, SAPS II, APACHE II scores and final outcome. RESULTS Out of 174 patients, 70 patients (40.2%) died. Mean SAPS II and APACHE II scores in all patients were 48.4±17.0 and 21.6±10.3 respectively, and they were significantly different between survivors and non-survivors. SAPS II >50.5 and APACHE II >27.5 can predict the risk of mortality in these patients. There was no statistically significant difference in the clinical values of SAPS II vs APACHE II (p=0.501). A statistically significant positive correlation was established between the values of SAPS II and APACHE II (r=0.708; p=0.001). Patients with an admission diagnosis of sepsis/septic shock had the highest values of both SAPS II and APACHE II scores, and also the highest hospital mortality rate of 55.1%. CONCLUSION Both APACHE II and SAPS II had an excellent ability to discriminate between survivors and non-survivors. There was no significant difference in the clinical values of SAPS II and APACHE II. A positive correlation was established between them. Sepsis/septic shock patients had the highest predicted and observed hospital mortality rate.