AIM To compare clinical and cost outcomes of psoriasis in non-biological treatment of adherent and non-adherent patients in a developing Balkans country going through socio-economic transition. METHODS The study was designed as a retrospective cohort study involving patients with psoriasis adherent and non-adherent to the prescribed treatment regimen. The patients were followed for a period of one year, through four visits with intervals of three months. The adherence to the prescribed regimen was measured at the end of the follow-up period by the medication possession ratio. Clinical outcomes of the treatment were estimated by the Psoriasis Area Severity Index (PASI) at each visit and the treatment costs were collected from patients' files at each visit. RESULTS The study enrolled 108 patients, 61 (56.5%) were adherent to the prescribed treatment, and 47 (43.5%) were non-adherent. A signiicant decrease of PASI score was noted in the patients adherent to prescribed therapy (p < 0.001). The costs also decreased significantly in the group of adherent patients (p=0.001), and the drop of costs was the highest from the visit 3. The decrease in PASI score and costs were less rapid in non-adherent patients. CONCLUSION Better treatment adherence leads to faster clinical improvement and a more rapid decrease in costs of treatment, which diminish overall expenditure of the health system and society, leaving room for treatment of other diseases more efficiently. Therefore, health systems of developing countries should support additional research of causes of treatment non-adherence in patients with psoriasis, in order to minimize this fenomenon more efficiently, and make significant savings.

Considering high prices of biologic drugs, using a cost-effective option for treatment of patients with rheumatoid arthritis who did not respond well to first biologic drug would have highly beneficial impact on health insurance budget. The aim of this study was to explore impact on budget of Republic Fund for Health Insurance (RFHI) caused by replacing etanercept with rituximab for treatment of rheumatoid arthritis patients who failed to respond to the first-line biologic drug. A Markov model with 5 states was constructed, having eight 6-months cycles. The perspective of the RFHI was used in the model, and annual savings in Serbia caused by using rituximab instead of etanercept were calculated. Using rituximab instead of etanercept for treatment of 20% of rheumatoid arthritis patients who failed to respond to the first-line biologic drug in would lead to absolute annual savings of 144,115,218.09 ± 431,906,009.46 RSD. The annual drug budget of RFHI would be decreased for 0.24 ± 0.73 %, while total annual budget of RFHI would drop for 0.07 ± 0.21 % . Based on the results of our study, using rituximab instead of etanercept for treatment of rheumatoid arthritis patients who failed to respond to the first-line biologic drug is a cost-effective option in Serbia, which would bring significant savings to RFHI.

IntroductionDuring normal pregnancy there are significant changes in hypothalamic-pituitary-adrenal axis, with increased levels of plasma cortisol and adrenocorticotropic hormone which sometimes reach values observed in patients with Cushing’s syndrome. Cushing’s syndrome (CS) is rarely encountered during pregnancy, but is associated with serious maternal and fetal complications.Case presentationA 31-year-old female was admitted to our institution four weeks after delivery. Physical examination revealed moon face, purple striae throughout the abdomen, bruising over the legs, a dorsocervical fat pad and hirsutism. She delivered a eutrophic preterm newborn at 34 weeks gestation, without any maternal or fetal complications during delivery. Imaging showed a mass in the right suprarenal gland with a normal pituitary. After four weeks the patient underwent a right adrenalectomy. The mass was eventually identified as an adrenocortical adenoma.ConclusionIn our case the diagnosis of CS was established only after pregnancy, which enabled the development of numerous adverse consequences secondary to increased plasma cortisol. If CS is recognized during pregnancy, treatment and its timing could be carefully chosen according to the patient’s individual characteristics.

BACKGROUND An aneurysmal subarachnoid hemorrhage could be complicated with cerebral vasospasm and resultant ischemia, causing neurological deficit. OBJECTIVES The aim of our study was to compare early and late outcomes in patients with subarachnoidal hemorrhage (SAH) treated by endovascular coiling, who either received or did not receive prophylaxis of cerebral vasospasm with nimodipine. MATERIAL AND METHODS In this retrospective cross-sectional study, the data was collected from the histories of 68 patients (38 females and 30 males, age range 29-71 years) with spontaneous aneurysmal SAH in clinical stage HH I-IV, treated at Kragujevac Clinical Center, Serbia, from January 2008 till June 2009. The study population was divided into two groups: (1) the group of 42 patients who received intravenous prophylaxis with nimodipine for 3 weeks, and (2) the group of 26 patients who did not receive nimodipine prophylaxis. RESULTS Prophylactic use of nimodipine did not decrease the rate of neurological deficit after one month, but the rates of both cerebral vasospasm (symptomatic and asymptomatic) and the morphological signs of ischemia using nuclear magnetic resonance imaging (MRI) were significantly lower in the nimodipine-protected group. Cerebral vasospasm was detected by Digital Subtraction Angiography (DSA) in the group protected by nimodipine as discrete in 2 patients (5%), and as apparent in 0 patients (0%). On the other hand, in the group unprotected by nimodipine, cerebral vasospasm was detected by DSA as discrete in 9 patients (35%), and as apparent in 6 patients (23%). Up to one month after the endovascular coiling, in the nimodipine-protected group, the T1W hypointense zones were detected by MRI as "small" in 5 patients (12%), as "medium" in 1 patient (2.5%), as "large" in 1 patient (2.5%), and as "multiple" in 2 patients (5%). In the nimodipine-unprotected group, the T1W hypointense zones were detected by MRI as "small" in 4 patients (16%), as "medium" in 2 patients (8%), as "large" in 3 patients (12%), and as "multiple" in 4 patients (16%). The difference between the groups was significant. CONCLUSIONS When a patient with SAH is treated with the endovascular clipping procedure, prophylactic administration of nimodipine is mandatory due to the reduced rate of cerebral vasospasm and delayed cerebral ischemia.

The aim of this work is to compare the results of estimation of radioiodine uptake using three methods in a study on mice, and to test reliability of the radioiodine uptake estimation by gamma camera. The study is conducted on 21 white, Swiss-type mice of both sex at age of 10 weeks, weighing between 25 g and 34 g. The mice were injected intraperitoneally with 0.37 ± ± 0.03 MBq of radioiodine 131I. After 72 hours the mice were anesthetized, and radioactivity of thyroid region was measured by gamma camera (the 1st method, in situ). After the measurement, the animals were sacrificed, their thyroid glands were carefully excised together with adjacent trachea and placed at the bottom of a test tube. The radioactivity of the excised tissue was then measured by both gamma camera (the 2nd method) and gamma counter (the 3rd method). This method is treated as a standard and the most accurate. In the study we used Siemens e_cam gamma camera and Wallac Wizard 1470 Automatic Gamma counter. The radioiodine fixation determined using those three methods was 25.25 ± 7.32%, 26.08 ± ± 8.55% and 25.74 ± 7.18%, without statisticaly significant difference s between methods (p > 0.05). The high correlation between the three methods of measuring radioiodine fixation in thyroid gland was observed: (1) the correlation coefficient between the fixation rate obtained by gamma camera in situ and the fixation rate obtained by measuring the radioactivity of extirpated thyroids by gamma camera was 0.869 (p < 0.01); (2) the correlation coefficient between fixation rate obtained by gamma camera in situ and the fixation rate obtained by measuring radioactivity of extirpated thyroids by gamma counter was 0.890 (p < 0.01); (3) the correlation coefficient between fixation rate obtained by measuring radioactivity of extirpated thyroids by gamma camera and the fixation rate obtained by measuring radioactivity of extirpated thyroids by gamma counter was 0.835 (p < 0.01).

Cardiorespiratory endurance, which is also known as aerobic endurance, is the ability of the whole body to sustain prolonged exercise involving relatively large muscle groups. Muscle endurance is defi ned as the ability of a muscle group to execute repeated contractions over a period of time that is suffi cient to cause muscular fatigue or as the ability to maintain a specifi c percentage of the maximum voluntary contraction for a prolonged period of time. Each version of muscle endurance plays a unique role in sport activities, and each has a special importance to various athletes. Cardiorespiratory endurance is thought to be the most important component of physical fi tness. Low endurance capacity leads to exhaustion, even in sports and activities characterised by low dynamics. Th e combination of spiroergometric testing (with appropriate testing protocols) and the measurements of lactate thresholds is believed to be the gold standard in the assessment of cardiorespiratory endurance. Th e generated parameters are then used to defi ne the training objectives, to preparefor a precise training plan and program, and to evaluate the eff ects of the subsequent training eff ect evaluation. Muscular endurance is specifi c for each group of muscle, type , and velocity of contraction. Due to the specifi city of muscular endurance, a universal assessment of the muscular endurance of the whole body has not yet been developed. Isokinetic and isoinertial dynamometry and numerous fi eld tests are used to assess muscular endurance. By understanding and monitoring endurance in athletes, the training workload during the preparation period and the the pre-competition and competition seasons can be implemented and corrected. Th e achievement and maintenance of optimal fi tness should be regarded as a dynamic concept that requires continual monitoring that is aided by the modern methods of functional diagnoses.

A medication error is any event that occurs during the medical treatment, which leads to inappropriate medication use and may harm the patient. Because of its high frequency and serious consequences, investigations dealing with the medication errors and their risk factors are getting increasing attention. As the national clinical studies are lacking, case reports of the medication errors can help in gaining insight into the problem. During the drug administration to the hospitalized patient, ceftriaxone was mistakenly mixed with the calciumcontaining solution. The precipitation that was observed was caused by a well-known incompatibility of ceftriaxone with calcium, characterized by the formation of the insoluble ceftriaxone-calcium salt. Due to the characteristics of the infusion line, the precipitates did not get into the blood stream. However, the described medication error should be considered as a potential adverse drug event, as it could have led to the serious outcome. Medication errors do not necessarily lead to an adverse event, nevertheless they represent a serious burden for the health care systems worldwide. As most of the medication errors are preventable, in order to improve patient safety we need to recognize and reduce both the errors and their possible causes.

OBJECTIVES The objective of our study was to investigate whether submissiveness to medical authorities could interfere with practicing of evidence-based medicine by family physicians. METHODS A qualitative, semi-structured interview on a sample of family physicians in Podgorica, Montenegro, was conducted. The interview schedule was developed through consultations with fellow clinical pharmacists and pharmacologists, and its face and content validity was checked by a pilot study. RESULTS The physicians mostly relied on non-evidence based sources of information such as opinion leaders, colleagues, unsystematic experience, pharmaceutical companies and uncritical internet search. Their main goal was to become “ encouraged” , “affirmed” and “supported” , which resulted with psychological gain, but did not guarantee benefits for the patient. The most trustworthy information sources were national experts recognized by the heath authorities, well known “professors”, regardless whether they were practicing the evidence-based medicine themselves, or not. CONCLUSIONS Although the family physicians have heard of the evidence-based medicine, and they value it as something positive, they do not have sufficient initiative to change routine behaviour and improve their practice. Such attitude has deep roots in hierarchy of power within authoritarian society, and probably will change slowly, together with gradual development of democracy.

BACKGROUND/AIM Spinal cord injuries (SCI) could be associated with a significant functional impairment in the areas of mobility, self-care, bowel and bladder emptying and sexuality. The aim of this study was to compare demographic characteristics and functional outcomes of nontraumatic and traumatic spinal cord injury patients. METHODS This study was designed as retrospective case series study. A detailed medical history including sex, age, mode of trauma, and clinical and radiological examination was taken for all patients. Hospital records were used to classify the patients according to the following: mechanism of injury, neurological level of injury, functional outcomes, associated injuries, method of treatment, secondary complications and length of stay. The following clinical scores were measured in the patients: American Spinal Injury Association standards (CASTA), Functional Independence Measure (FIM), and Modified Aschworth score (MAS). RESULTS Out of totally 441 patients with spinal cord injury, 279 were traumatic patients (TSCI) and 162 nontraumatic patients (NTSCI); 322 men and 119 women. The mean age of the patients was 46.1 +/- 19.9 years. Traumatic and nontraumatic populations showed several significant differences with regard to age, level and severity of lesion. When adjusted for these factors patients with traumatic injuries showed a significantly lower FIM score at admission and significantly better improvement in the FIM score at discharge. The two populations were discharged with similar functional outcome. CONCLUSIONS The NTSCI patients in our study were younger, more frequently female, with less complications before rehabilitation and less frequently treated operatively than the TSCI patients. Hospital rehabilitation of the TSCI patients was longer than that of the NTSCI patients, but their functional gain from admission was also higher, so at discharge. Traumatic and nontraumatic spinal cord lesion patients achieved similar results in regard to neurological and functional status.

INTRODUCTION Hospital infections (HIs), which are frequently associated with hospital treatment, increase morbidity, mortality and treatment costs. The aim of this study was to establish the incidence of HIs in a neurological intensive care unit (nICU), and to determine the most prevalent causative agents and risk factors for HIs. METHODOLOGY A cross-sectional study with nested case-control design was conducted between 1 July 2009 and 30 June 2010 at an 18-bed neurological intensive care unit at the Clinical Center Kragujevac, Serbia. RESULTS In total, 537 patients were enrolled in the study, with 6,549 patient-days. There were 89 patients with 101 HIs. The incidence of patients with HIs was 16.57%, and incidence of HIs was 18.81%, while density of HIs was 15.42 per 1,000 patient-days. The most frequent anatomical sites of HIs were urinary tract (73.27%), blood (10.89%), and skin and soft tissues (10.89%). The following risk factors were identified: co-morbidity (OR=3.9; 95% CI=1.9-7.9), surgical intervention in the last 30 days (OR=5.6; 95% CI=1.5-20.4), urinary bladder catheterization longer than seven days (OR=3.8; 95% CI=1.8-8.2), value of Glasgow coma scale ≤ 9 (OR=3.7; 95% CI=1-6.9), and longer hospital stay (OR=1.1; 95% CI=1.1-1.2). CONCLUSIONS Hospitalization in an nICU bears high risk of HIs, especially of urinary tract infections caused by Gram-negative bacteria, in patients with longer hospital stay or co-morbidities, and in those who have had surgical interventions or prolonged use of a urinary bladder catheter. Special attention should be paid to these patients to prevent HIs.

Background. The incidence of ventilator-associated pneumonia (VAP) among patients on mechanical ventilation is from 15% to 25%, and mortality ranges from 33% to 38%. Aim. The aim of our study was to analyze importance of previously un-investigated potential risk factors for death in intensive care unit (ICU) patients with VAP. Methods. A cross-sectional design was chosen for this study. The study population consisted of all patients who developed ventilator associated pneumonia in the central ICU of a tertiary care hospital (n = 65) during the period of 6 months. Cases (n=45) were patients who died during their treatment in the ICU, if their primary cause of death was ventilator associated pneumonia. Controls (n=20) were patients with VAP who survived their treatment in the ICU, and were transferred to other hospital wards. Results.  Significant associations were found between death and age over 65 (OR adjusted 10.66; CI 1.22, 93.12; p = 0.032), death and hospitalization at another hospital ward prior to ICU (OR adjusted 1.25; CI 1.03, 1.52; p = 0.28), death and infection on admission to ICU (OR adjusted 434.39; CI 3.07, 61449.65; p = 0.016), and death and administration of ceftriaxone prior to VAP (OR adjusted 69.32; 1.74, 2768.92; p = 0.024). Synergistic effect on death was found only for age over 65 and infection on admission to ICU.  Conclusions. The ICU patients with VAP have increased mortality if they receive ceftriaxone prophylactically, if they have an infection at admission to ICU and when their age is advanced.

AIM To analyze the importance of previously un-investigated (or not completely investigated) potential risk factors for new-onset intra-operative arrhythmias in general surgery patients, operated under general anesthesia. METHODS In this case-control study the population consisted of all patients who underwent elective non-cardiovascular, non-thoracic surgery under general inhalation anesthesia during the period of 12 months in a secondary care hospital in Foča, Republic of Srpska, Bosnia and Herzegovina, and were classified according to the American Society of Anesthesiologists classification to class I or II. Cases (n=57) included patients with at least one episode of ECG-recorded arrhythmia during general anesthesia, and controls (n=90) were sex and age matched. RESULTS Significant association was found between intra-operative arrhythmias and history of cardiac arrhythmias in the last five years (adjusted OR 43.5; CI 2.3, 820.1; p = 0.012). Synergistic effects on intra-operative arrhythmias were found for history of cardiac arrhythmias and history of abnormal ECG, as well as for history of cardiac arrhythmias and use of propofol for induction of anesthesia. CONCLUSION The non-cardiovascular, non-thoracic surgery patients with history of arrhythmias and ECG abnormalities deserve special attention, correction of electrolyte disturbances and avoidance of propofol for induction of general anesthesia.