CONFLICT OF INTEREST: NONE DECLARED PAPERAIM SUMMARY. The development of the digital Information Communication Technology (ICT) has definitely changed healthcare system in all its areas. The development of standardized electronic medical record (EMR) make possible other forms of E-Health like transmural care, telemedicine etc. In this paper was described Health Information System (HIS) of Tuzla Canton and Brčko DC (whose citizens gravitate toward Tuzla Clinical Center). Tuzla Clinical Center is the only Clinic for tertiary healthcare in this region. To estimate level and types of the HIS, telecommunications and information management we have designed questionnaire. Based on this research we have presented current state of E-Health in Canton and the most important problems in this area. Also, based on this research and our experiences, we have identified the main directions of the HIS development, its standardization and integration as the base for E-Heath in Bosnia.
The treatment of patient with relapse of bleeding after application of minimally invasive treatment of hemorrhoidal disease such as elastic band ligation, cryosurgical treatment Hemorrhoidal Arterial Ligation (HAL) can be presented as serious clinical problem in patients with concomitant diseases that can be contraindication for radical surgical treatment. We compared the Simple Digital Method and standard above mentioned minimally invasive ambulatory treatment. We used special proctoscope with Doppler Flowmeter in order to identify all branches of hemorrhoidal artery in the anal canal creating graphical presentation using specially adapted software. HAL method is then used to perform ligation of hemorrhoidal artery branches. The elastic ligatures (called gummiligatures) are then applied to the piles in which most prominent flow was registered using Doppler Flowmeter. Antibiotic prophylaxis and sedation was administered preoperatively. Special computer program registered all steps. Hemorrhoidal ointments and paracetamol were used after surgical procedure. Average number of identified hemorrhoid arteries branches was six, and total duration of the procedure was in average 28 min. We compared patient treatment with our method and standard methods. In tested group we noticed significantly fewer complications (after eight days the number of complications 11% vs. 74%, p<0.001, after 15 days 3% vs. 11%: p=0.101). One year after procedure, the treatment was successful in 91.4%, or 32 out of 35 patients according to proctoscopy and Doppler Flowmeter exam. There were three patients with relapse of symptoms. In 77% of patients hat were treated with rubber bands ligation relapse occurred. Our method is significantly more successful in comparison to classical methods of ambulatory treatment and can be alternative to radical surgical treatment.
Objective: We tried to probe different aspects of ultrasound use in primary care team, to evaluate possibilities of the use of certain ultrasound methods in diagnostic procedure in the first examination and on the primary care level, to evaluate indications for specific ultrasound diagnostic and therapeutic procedures on the secondary and tertiary levels and we conducted an analysis of cost and cost effectiveness. Methods: This study was conducted in primary care clinic over period of six months. The clinic is based in Gracanica, an urban area of some 10,000 inhabitants. The control group is represented by a clinic in a town of similar demographic characteristics (11,000 inhabitants) - Primary Care clinic Doboj East in Klokotnica. This clinic does not have a direct access to an ultrasound thus all patients from this clinic are referred to secondary care unit. The results are written in a separate questionnaire. Conclusion: The results from the experimental primary care clinic with a direct access to an ultrasound have showed that the use of ultrasound on this level is of special social and medical importance: it shortens time for establishing the final diagnosis, makes use of expensive X-ray and other expensive test unnecessary and can be used to give an early diagnosis of benign and malignant tumors. The results have showed, trough the frequency of use, that the most efficient use would be if one ultrasound is available per five primary care clinics.
Technical systems for endoscopy diagnostics are suitable for application of computer technology. Endoscopic methods can make use of hardware-software packages for the digitalization of images, after which it is possible to store and subsequently analyze, as well as transfer pictures to the local information and communication systems. After installation of these packages follow up of the examination is on the computer monitor, and the examination of patient receives the additional quality and speed. Endoscopic methods enable provision of following functions: Entering basic demographic data about patients, Following use of material, invoice production, etc. Recording video in real time, Review of existing material, image analysis, sequences, Image processing and printing preparation, Creation of own interface, or appearance of doctor’s reports, Data back-up from the software, recording on CD or DVD media,Conversion into any format and recording of data directly on CD or DVD, Easy access to previous patients examinations, Statistical data analysis. analysis and interpretation as basis for writing scientific and professional articles, Networking possibilities with other users. Special advantages for users of these methods are: Safer work for doctors and patients, Application of teleeducation system in process of knowledge transfer to the large number of participants (video conferences, workshops with transfer of “live” image and immediate analysis and comments) Functional dynamic analysis, Possibility for additional consultation or teleconsultation with other experts, Possibility to send image on distance using internet. Imaging views from endoscope, radiological (CT, MRI) or ultrasound obtained during the examination of the patients can be stored on appropriate media. In radiology and gastroenterology used are Pacs / Ris (System for archiving and communicating through images/ Radiology information system) systems. It is a system for work with images, and their purpose is to exclude use of films and start digital data processing. With this project, it is possible to transfer complete series of recordings with modalities such as CT, MRI, and diascopy, endoscopy ultrasound, to a system for archiving and communications, and after that all doctors who are in the network can view the images, give their opinions and seek the opinions of colleagues. This kind of software allows the processing and postprocesing (analysis) of recordings with the help of appropriate tools–zoom, filtering, invert, three-dimensional reconstruction, etc., all with the goal of more accurate diagnosis when viewing recordings. Such analysis is particularly important in the preparation or during the surgeries, and three-dimensional reconstruction of the liver is particularly important in preparation for transplantation. Network access is possible from any networked computer. With this software it is possible to seek via Internet the opinion of radiologists or gastroenterologist from
The field of diagnostic radiology continues to evolve, particularly in refinements to crosssectional techniques. Imaging of the urinary tract, as a result, has become more precise, with new digital procedures offering a great selection of options, and new imaging algorithms being implemented. Ultrasonography, computed tomography (CT) and magnetic resonance imaging (MRI) provide higher soft-tissue contrast resolution than conventional radiography, as well as multiplanar imaging capability, resulting in significant advances in almost all areas of uroradiology. While such advances have produced new algorithms to approach the diagnostic imaging evaluation, each particular case also depends greatly on the equipment and professional available. In summary, ever changing uroradiology remains indispensable in the diagnosis and treatment of patients with urologic disorders. We discuss the digital imaging techniques used in uroradiology, with summaries of the advantages and disadvantages of the various techniques, and will end with a discussion comparing different Doppler imaging methods.
Gall disease and gall tract diseases, except anamnesis characteristics, physical examination and biochemical findings, require application of modern visual technology which with its high sensitivity and specificity allows quick, accurate and verifiable diagnosis and favorable outcome of disease, a false positive and false negative findings are reduced to a very low percentage. Data from the literature shows the sensitivity of Transabdominal ultrasound (TUS) up to 90% and specificity from 20 to 85%, while CT shows sensitivity up to 87% and specificity up to 90%. In our research, which included 366 patients with gall and gall tract pathology and 147 of them were treated surgically, shows TUS sensitivity up to 87.5%, but the low specificity of 28.5%, mainly caused by a large number of patients with gall tract pathology. CT shows high sensitivity of 100% and 100% specificity, which diverge from data from the literature because CT was done after TUS and with the selection of diagnostically complicated cases. In all these complicated cases surgical findings have confirmed CT diagnosis. From this we can conclude that the application of image technology allows fast and accurate diagnostic and treatment of gall and gall tracts.
Emergency medicine is a clinical and academic discipline that does not deal with certain specific diseases or organic systems. This discipline is characterized with a comprehensive approach to the patients which is in a state of vital threat regardless of the nature and etiology of the disease which leads to such state. In the institutions of emergency medicine all patients arrives at any time of the days regardless of age and a range of symptoms so that emergency medicine applies clinical diagnostic and therapeutic methods of all other clinical disciplines in order that in the short period of time discover the cause of vital functions disturbance and apply emergency therapeutic procedures. All emergency states from all clinical disciplines belongs to the emergency medicine which leads practical management based on specific principles and approach to this kind of patients. Development of technology and application of new diagnostic procedures enabled doctors in emergency medicine to introduce effective diagnostic management during the first contact with the patient and to avoid costly and long hospital procedures. Ultrasonography examination is already for a long time important methods in all clinical disciplines, so it is inevitably applied in emergency medicine. Ultrasonography diagnosis has a high sensitiveness and specificity of most frequent illnesses at the departments and emergency wards, so the mobile ultrasonic device as an integral part of the equipment of family doctors may constitute “visual stethoscope “, especially important and indispensable in emergencies. This method applies the ideal technology achievement for nearly all the emergency sates and which is proven based on the needs in practice, on the basis of scientific facts based medicine and the recommendations of the World Health Organization (WHO) for the obligatory of application of this method in centers for emergency medicine. Additional benefits are simple handling of the machine and the possibility of repeated examination and monitoring of the dynamic pathological changes. Necessary practical and theoretical knowledge can be gained during under and post-graduate education within the framework of existing programs.
Smoking causes decrease of HDL-cholesterol (HDL-C) levels and increase of total cholesterol, triglyceride and LDL-cholesterol (LDL-C) levels. Low HDL-C levels and high cholesterol and LDL-C levels are associated with a higher risk for cardiovascular diseases. The aim of this study was to examine the effect of smoking status on serum lipid and lipoproteins levels among patients in family medicine practice. This trial was designed to detect differences in serum total cholesterol, triglyceride, LDL-C and HDL-C levels between smokers and non-smokers. We had placed a limit of 300 patients for data collection. We excluded 195 patients who met excluding criteria (diagnosis of diabetes mellitus, renal and hepatic failure, hypothyroidism; using beta blockers, thiazide diuretics, hormonal replacement therapy and corticosteroids; more than light physical activity; alcohol consumption and obesity), so the sample size included 105 randomly selected patients from Family Medicine Teaching Center Tuzla, mean age 52.05 +/- 11.61 years. Main outcomes were smoking status in all participants and serum total cholesterol, triglyceride, LDL-C and HDL-C levels in smokers and non-smokers. Our results showed that smoking prevalence was 49.52%. Smokers had significantly higher serum total cholesterol (P=0.01), triglyceride (P=0.002) and LDL-C level (P=0.03) and significantly lower HDL-C level (P=0.003) comparing with nonsmokers. There was no significant difference in serum lipid and lipoprotein levels between ex-smokers and never smokers. These results suggest that cigarette smoking adversely affects serum lipid and lipoprotein levels which further increases the risk for cardiovascular morbidity and mortality.
Ultrasound (US) has been recognized as a powerful tool for use in the diagnosis and evaluation of many diseases in clinical practice. The possibility of immediate bedside US examinations in the evaluation of specific emergent complaints makes it an ideal tool for the emergency specialist. Correct diagnosis of potential life-threatening emergencies such as hematoperitoneum following blunt trauma, abdominal emergencies, ectopic pregnancy, pericardial tamponade, and aortic aneurysms with US evaluation can be easily made. Emergency physicians now view screening ultrasonography as highly focused and limited to answer on select set of questions. These questions include: Is there a pericardial effusion present? Are there gallstones present? Is there hydronephrosis evident? Is there free peritoneal fluid? Is there intrauterine pregnancy? Is there an abdominal aortic aneurysm (AAA) present? Is there a foreign body? It is clear that emergency screening ultrasound is now accepted tool for the rapid evaluation of the emergency patient. Using this effective diagnostic and therapeutic tool in emergency units our patients will have efficient, safe, and accurate health care.
SUMMARY Acute mesenteric ischemia is one of the most important urgent states in internal medicine. Diagnosis set on time is the key to success in treatment of this disease. In practice, setting adequate diagnosis is usually lat, because the first symptoms and physical findings were not proportioned to pathogenic changes. When a complete clinical picture of illness develops with signs of ileus and septic shock it is usually too late for adequate treatment. Early diagnosis can be set, if during the occurrence of acute abdominal pain in patients who have status with precipitating factors for the formation of emboli, thrombosis and mesenteric vasospasm, in the early evaluation of disease thought to the possibility of acute mesenteric ischemia, and undertake specific diagnostic procedures. In the first place we must distinguish urgent situations of mesenteric vascular diseases that are made by embolism and thrombosis of superior mesenteric artery (AMS) from chronic states such as chronic mesenteric ischemia or intestinal angina, celiac compression, ischemic colitis and chronic mesenteric venous thrombosis. This article shows the case of patient with acute mesenteric ischemia – arterial thrombosis, which had predisposing factors and has developed an image of vascular ileus. Color Doppler and standard abdominal ultrasound can detect the disease at an early stage, and set the indication for arteriography procedures and surgical procedures.
Cavernous transformation of the portal vein occurs with long-standing portal vein thrombosis (PVT) because of the development and dilatation of multiple small vessels in and around the recanalising main portal vein. Thrombosis and occlusion of the portal vein leads to portal hypertension with enlarged spleen and the development of porto-systemic collaterals. The main clinical presentation is gastroesophageal variceal bleeding and hematologic abnormalities due to splenomegaly (hyperspleenismus-pancytopenia). We described the young patient with splenomegaly and extensive cavernous transformation of portal vein. The patient had thrombosis portal vein in early childhood and massive bleeding from large oesophageal varices at age 13. Full clinical evaluation is required because of abdominal pain. The liver is histologicaly and functionally normal. Diagnosis of cavernous transformation of the portal vein is confirmed by abdominal ultrasography, color Doppler ultrasonography and CT angiography. Oesophagogastroscopy reveals almost complete reduction of oesophageal varices, but confirms portal gastropathy as a source of patient's complaints. Natural course of PVT in this patient shows possibility of full reduction of oesophageal varices, but still the presence of different consequences of portal hypertension.
Color Doppler sonography (CDS--spectral, color and power), harmonic imaging techniques (THI, PHI), possibility of 3D analysis of picture, usage of contrast agents, have raised the values of ultrasound as a diagnostic method to a very high level. THI--non-linear gray scale modality, is based on the processing of higher reflected frequencies, that has improved a picture resolution, which is presented with less artifacts and limiting effects of obesity and gases. Ultrasound contrast agents improve analysis of micro and macro circulation of the examined area, and with the assessment of velocity of supply in ROI (wash in), distribution and time of signal weakening (wash out), are significantly increasing diagnostic value of ultrasound. Besides the anatomical and topographic presentation of examined region (color, power), Color Doppler sonography gives us haemodynamic-functional information on vascularisation of that region, as well as on pathologic vascularisation if present. Avascular aspect of a focal pathologic lesion corresponds to a cyst or haematoma, while coloration and positive spectral curve discover that anechogenic lesions actually represents aneurysms, pseudoaneurysms or AVF. In local inflammatory lesion, abscess in an acute phase, CDS shows first increased, and then decreased central perfusion, while in a chronic phase, a pericapsular vascularisation is present. Contribution of CDS in differentiation of hepatic tumors (hemangioma, HCC and metastasis) is very significant. Central color dots along the peripheral blood vessels and the blush phenomenon are characteristics of capillary hemangioma, peritumoral vascular ring "basket" of HCC, and "detour" sign of metastasis. The central artery, RI from 0.45 to 0.60 and radial spreading characterize FNH. Hepatic adenoma is characterized by an intratumoral vein, and rarely by a vascular hallo. Further on, blood velocity in tumor defined by Color Doppler, distinguishes malignant from benign lesion, where 40 cm/s is a rough border value. Values of DPI (Doppler perfusion index) over 0.3 and tumor index over 1.0 characterize primary, and lower values characterize secondary liver malignancies. In differentiation of benign and malign tumors of kidneys, besides the aspect of vascularisation, the maximal frequency altitude in tumor artery (the limit around 2.5 kHz) is very important. However, peripheral and penetrating blood vessels are most usually seen in RCC, less often in AML and bigger oncocytomas. CDS with contrast agent is very useful in making differential diagnosis of the focal lesions with 95% specificity for some lesions.
The subject of the family medicine on the medical faculties in Bosnia and Herzegovina existed from recently as a separate curiculum of the medical study. Until recently the contents of this discipline interpreted within the subject of the social medicine or the object of the primary healthcare protection, and programs of teaching were based mainly on Anglosaxon experiences. The fact is that some teachers of the medical faculty in Sarajevo had their own visions and programs of the family medicine which by years were tested in the units of the family healthcare protection in Sarajevo, Mostar, and Banja Luka, about what was published in our and foreign literature. New approach from the family medicine should be based on as follows: greater use of the standardized procedures for the improvement of the communication skills; revised educational procedure of all the participants 6 interdisciplinaryilly in the education of the family medicine; improvement of knowledge about methodlogy and the principles of the research; improvement of the techniques and knowledge about the maipulatin of the medical informations; development of the skills of the continued studying through the total working aga; to the development of the capability of the critical estimation of the own work important; by the defining of the important educational goals in the curriculum of the urgent medicine; to the development and use of the methods feed-back informations from the students; to the modernizing of the methods of the evaluation of the educational process-adopted knowledge and the attitudes and the carrying out of the practice of the patients, and the ethic values in that process. In this work the authors consider the stated experiences in the education from the subject family medicine at our faculties realting to the foreign, and suggest that new concept of the education on the basis of these experiences in the practice.
Aim of this paper is to provide substantial and organizational help to emergency medical service as a part of primary health care and other health care levels in the interdisciplinary cooperation. Projects of interdisciplinary cooperation, that could be implemented within BiH as pilot projects are proposed in this paper as well. Legal regulations, that serve as a base for the organisation and a scope of emergency medicine work served as a draft for elaboration. Legal base is found in the Constitution of Bosnia and Herzegovina and Federation of Bosnia and Herzegovina, Law on health care, Articles 3, 16, 20 and 59 in particular. We point out item 7 concerning temporarily standards and norms of health care. This item should be considered seriously by experts in this field and Public Health as well, and elaborate its revision and new proposals. The Law on the records in the health care regulates monitoring of the work of this service. 2 OB form should be reviewed in a way that gives us good quality monitoring, more significant data which will enable us to take better attitude toward the organization and work framework. The same should be done with individual data to facilitate a work concerning emergency medical procedures. There are 14 emergency medicine units in Tuzla Canton: 51 doctors are employed (37 general practitioners and 14 specialists). They provide emergency medical care for 537.000 inhabitants together with 114 other health workers with secondary and advanced education. In 1999, there were 216.162 check-ups by doctors, 2700 home visits and 29.705 patients were referred to specialists and laboratories for further treatment. Other health workers provided 584.432 services and 3.889 home visits These data will be especially discussed from the inhabitants' point of view concerning their needs, quality of services and record keeping forms for emergency medical service. The following projects are proposed for the future interdisciplinary co-operation in emergency medical care providing: Education of inhabitants (especially certain population) for mutual help, self-help and first aid. Research about inhabitants' needs and demands concerning emergency medical care. Framework of emergency medicine organisation, required resources and having higher levels of medical care as a support. Prevention of emergencies through health promotion. Doctrinarian attitude toward the emergency medical service work, stage by stage treatment and a role of comfortable transport. Emergency situations in a mass disasters and ways of organization and scope of emergency medical service work and others in the interdisciplinary and intersectional co-operation. Proposed projects are the result of our present knowledge about the medical service organisation in our country. The aim is to meet the needs of the population concerning emergency medical services in the interdisciplinary co-operation in the health care system through realisation of these projects.
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