The association between urine amylase levels and the development of post-operative complications after Whipple resection is still unknown. The aim of this study was to determine the prognostic value of urine amylase levels for post-operative complications in patients who underwent Whipple resection. In this retrospective-prospective cohort study we analyzed amylase levels in urine, serum, and drains in 52 patients who underwent Whipple resection preoperatively and on Post-operative Day 1 (POD1) after the intervention. Patients were followed up for 3 months to assess their predictive value for post-operative complications. In patients with complications, urine amylase levels were significantly higher on POD1 than before resection (198.89 ± 28.41 vs. 53.70 ± 7.44, p=0.000). Considering the sensitivity and specificity of the urine amylase level on POD1, an area under the ROC curve of 0.918 was obtained (p<0.001, 95% Confidence interval [CI]: 0.894-0.942). Patients with urine amylase levels ≥140.00 U/L had significantly higher risks of post-operative pancreatic fistula (POPF) grade C (definition of POPF done according to the ISGP) (RR:20.26; 95% CI: 1.18-347.07; p=0.038), readmission to hospital (RR: 6.61; 95% CI: 1.53-28.58; p=0.011), reoperation (RR: 5.67; 95% CI: 1.27-25.27; p=0.023), and mortality (RR:17.00; 95% CI: 2.33-123.80; p=0.005) than patients with urine amylase levels <140.00 U/L. Urine amylase levels on POD1 displayed strong and significant positive correlations with serum amylase levels (r=0.92, p=0.001) and amylase levels in drains (r=0.86, p=0.002). We can conclude that urine amylase levels on POD1 have good prognostic value for post-operative complications after Whipple resection and might be used as an additional predictive risk factor.

ABSTRACT Objectives: To examine a relationship between protein C (PC) and antithrombin III (AT III) activities with ejection fraction of left ventricle (EFLV), in the early phase of acute ST-elevation myocardial infarction (STEMI) treated with primary percutaneous coronary intervention (pPCI), and to investigate whether PC and AT III are associated with major adverse cardiovascular events (MACE) within 6 months following from pPCI. Patients and methods: The research had a prospective character and included 357 patients who had, following the diagnosis of the STEMI, undergone pPCI at the Clinic of Cardiology and Emergency Internal Medicine, Military Medical Academy, Belgrade, Serbia, from January 2010 until April 2019. Results: The EFLV positively correlated with PC values (rho = 0.229). There was a statistically significant increase in the PC values between patients with MACE compared with those without MACE at 6 months’ follow-up evaluation (p < 0.0001). Also, significant difference in PC values between patients who died in hospital and those who were alive at 6 months’ follow-up (p < 0.01) was observed. PC values were different across different EFLV groups (p < 0.001), increasing from the 1st to the 4th EFLV quartiles: the median and the interquartile values for the 1st, 2nd, 3rd and 4th quartiles were 1.0400IU/l ± 0.15, 1.1400IU/l ± 0.15, 1.1350IU/l ± 0.16 and 1.2200IU/l ± 0.14, respectively. Conclusion: Increased PC activity in the early phase of STEMI is associated with higher EFLV 5 days after the pPCI as well as with MACE at 6 months after the pPCI.

Introduction: Osteoporosis is a chronic progressive bone disease where the bone tissue resorption exceeds its regenerative capacities. Such a process leads to the reduction of bone mineral density (BMD), and distortion of trabecular microarchitectonics, which creates the basis for an increased fracture risk on a “low trauma” for osteoporosis patients. The notion of low trauma implies a stressor that will not cause a fracture in a healthy person under normal circumstances. BMD is a strong predictor of future fractures. However, many fractures occur in persons with BMD values beyond the defined osteoporosis threshold, and BMD measurement only partially identifies the part of the population with increased fracture risk. Also, it is known that risk factors are influencing the bone mass reduction as predictors of future fractures, and their association may lead to an increased fracture risk irrespective of the bone mass and T-score. Aim: The 10-year individual risk assessment for osteoporotic fracture and the analysis of impact of individual and multiple osteoporosis risk factors on the degree of osteoporotic fracture risk. Methods: The research is a retrospective-prospective study which analyzed 120 patients divided into two groups: 1) asymptomatic patients with known risk factors for osteoporosis in the age group of 40-65 (n=60), 2) asymptomatic patients with known risk factors for osteoporosis in the age group of 65-90 (n=60). FRAX® algorithm was used as a tool for the 10-year hip fracture risk assessment, with prior approval of the Centre for Metabolic Bone Diseases, University of Sheffield from the United Kingdom. Fracture risk assessment was calculated using the online FRAX® calculator. High risk is defined as the hip fracture risk higher than 3% or the risk of a “big” osteoporotic fracture higher than 20%. Results are expressed as mean values with a standard deviation. A comparison between tested patient groups was made applying the student T-test. Results: 32% of patients of average age of 65.8±12.6 years are under high hip fracture risk, 28% of patients are under the hip fracture risk higher than 3%, and the risk for 0.03% patients is higher than 20%. Patients with high fracture risk are of advanced age, female, with lower body weight and height values, lower bone mineral density (BMD) and T score values than patients who are not under a high fracture risk. A positive family anamnesis to osteoporosis and fractures, earlier fractures, smoking, rheumatoid arthritis, and use of glucocorticoids are risk factors that are more represented in patients with high fracture risk and osteoporosis. The impact of the majority of individual risk factors for osteoporosis and fracture is moderate, and their joint effect is significant. The contribution of individual risk factors to the overall 10-year fracture risk depends on the type, number and association of risk factors. Conclusion: This research is a contribution to the resolution of polemics among authors, i.e. a dilemma whether persons with multiple clinical risk factors for osteoporosis with T score values beyond the defined threshold for osteoporosis are candidates for therapy with bisphosphonates, and a dilemma whether persons without any clinical risk factors for osteoporosis with T score values within the defined osteoporosis threshold require therapy with bisphosphonates, or only monitoring is sufficient.

Objectives: To assess the prognostic value of pentraxin 3 (PTX3) in patients with ST-elevation myocardial infarction (STEMI) after bare-metal stent (BMS) implantation. Methods: In this prospective study, PTX3, interleukin (IL-6), IL-10, high-sensitivity c-reactive protein (hsCRP), and cardiac troponin I (cTnI) plasma values were determined before and 24hours after BMS implantation in 97 consecutively enrolled patients with STEMI who were admitted to University Clinical Center Tuzla, Tuzla, Bosnia and Herzegovina between February 2016 and February 2017. Patients were followed for 24 months to assess major adverse cardiovascular events (MACEs). Results: At 24 hours after percutaneous coronary intervention (PCI), plasma values of PTX3, IL-6, hsCRP, and cTnI were significantly increased; and IL-10 levels were significantly decreased compared with the values determined before PCI. Patients with MACEs had significantly higher plasma PTX3 levels at 24 hours after BMS-PCI than in patients without MACEs. Patients with PTX3 plasma values ≥5042 ng/ml had a significantly higher risk of MACEs than patients with PTX3 levels <5.042 ng/mL. Pentraxin 3 levels exhibited strong and significant correlations with IL-6 and IL-10 levels. Pentraxin 3, cTnI, and IL-6, but not hsCRP levels have showed independent association with MACEs, according to the multivariate Cox regression analysis. Conclusion: Pentraxin 3 might be better serum prognostic marker than IL-6, IL-10 or high sensitivity CRP for MACEs after BMS-PCI. It might help to make better risk stratification of those patients who are undergoing BMS-PCI.

Introduction: Metabolic syndrome (METS) represent a simultaneous presence of multiple metabolic disorders in one person. Prevalence is increasing worldwide, which is probably related to increased obesity and sedentary lifestyle. Non-alcoholic steatosis or “fatty liver” is a metabolic disease caused by fat dysfunction. It can be a sign of some other disease, and can often be found in patients with metabolic disorders. Ultrasound is an acceptable method for the identification of fatty steatosis. There is evidence that when turmeric is used as a herbal diet, with its active metabolite of curcumin, can repair fatty acidosis and thus prevent progression of fatty steatosis complications such as cirrhosis and liver cancer. Goal. The aim of the study was to determine the effects of 400 mg curcuminaddition to the nutrition on ultrasound morphological characteristics of the liver in METS patients. Methodology: A prospective cohort study was conducted on 100 subjects with METS, treated in the family medicine practice of the Tuzla Canton, aged 35-70 years. The therapeutic effects of 400 mg curcumin on ultrasound-morphological characteristics of the liver were followed, validated by ultrasound in 50 respondents of experimental groups with METS. The data were processed by the IBM SPSS Statistics 21 statistical analysis program using parametric techniques andStudent’s t-test for paired samples. Results: There were 65% of women in the study. There were no statistically significant differences in the age of respondents within the analyzed groups. The use of 400 mg curcumin per day was statistically significantly improved ultrasound morphological characteristics of the liver in subjects with METS. Conclusion: All respondents with METS who used curcumin had beneficial effects on the morphological characteristics of the liver. Curcumin had stronger effects on subjects with METS and DM type 2 than others.

Objective: analysis and monitoring of the effectiveness of beta-blockers (BB) in the treatment and prognosis of acute coronary syndrome (ACS).Background: Heart and blood vessels disease are the most common chronic disease and the leading cause of death in the world. The largest proportion of deaths from cardiovascular disease is coronary ischemic disease, which represents a broad spectrum of clinical manifestations starting from acute coronary syndrome until stable coronary heart disease, various forms of angina pectoris, chronic myocardial infarction, valvular disease, and eventually heart failure. ACS is a manifestation of atherosclerosis which is usually preceded by acute thrombosis caused by ruptured or eroded atherosclerotic plaque, with or without accompanying vasoconstriction, causing a sudden and critical reduction in blood flow. Patients with ACS, especially older ones, are at high risk of death. Beta-blockers (BB) are drugs that are recommended for early use of ACS in acute myocardial infarction (AMI), and for long-term use in the secondary prevention after AMI, unless there is a contraindication. Early therapy BB is recommended as part of a doubt for the emergency treatment of AMI, especially if the patient with tachycardia or hypertensive. Also, analysis and monitoring of patients in acute myocardial infarction who were subjected to emergency primary coronary intervention (PCI) pointed to the significant reduction in mortality if BB administered to patients before the intervention.Sustained use BB recommended in patients with reduced LVEF after AMI, and in patients with chronic heart failure NYHA II-IV. Early use of BB in the treatment of ACS in our case, together with antiplatelet medication-administration in the prehospital setting, improve the prognosis of stabilization of tachycardia, hypertension, chest pain and reducing the possible "abort"of ECG diagnosed myocardial infarction, and their application in permanent treatment, has shown a significant efficacy in reducing the complications of ACS. Conclusion: The use of BB, unless contraindicated, should begin in the early stages in most patients with ACS, intravenously or orally. The use of BB is particularly justified in tachyarrhythmias and high blood pressure in the ACS, and as adjunctive therapy for the relief of angina attacks. Secondary prevention using hygienic dietary regimen and medical therapy BB, with maximum control of all risk factors improves prognosis and reduces the complications of ACS.

Objective: Analysis of application of contemporary therapeutic modalities in patients with ischemic heart disease (IHD).Background: Acute Coronary Syndrome (Acs) Is One Of A Number Of Syndromes In A Range Of Clinical Manifestations Of Atherosclerosis Of The Coronary Arteries Or Ischemic Heart Disease, Along With Other Clinical Manifestations Such As Angina Pectoris, Chronic Myocardial Infarction, Valvular Disease, And Eventually Cardiac Failure. Access to the management of ischemic heart disease depending on symptoms, functional and anatomical complexity, includes a variety of therapeutic modalities beginning from medical treatment until emergent treatment using percutaneous coronary interventions or aortocoronary bypass surgery. All patients with ischemic heart disease, for the prevention of disease progression and recurrence of cardiovascular events, should be managed by Guideline directed medical therapy (GDMT). The most important groups of drugs are anti-ischemic drugs, antithrombotic (antiplatelet) drugs, anticoagulants and statins. Even revascularization is indicated in patients with IHD and progressive or refractory symptoms, regardless of the management of medicament. In our patient after admission and during hospitalization there was no progression of symptoms. Abrupt cessation and pain relief, rapid return of ST-segment according to the isoelectric line, with optimal pharmacotherapeutic management led to the stabilization of the patient. If there is an occlusion of the coronary artery, the most important is to establish reperfusion as soon as possible. In our patient reperfusion assessment is determined really fast (coronary angiography), and according to the TIMI (Thrombolysis In Myocardial Infarction) levels are classified in the TIMI 2 (there was no thrombotic occlusion of coronary arteries and a partial reperfusion is established). Despite the fact that percutaneous coronary intervention (PCI) is the method of choice in the treatment of ACS, positive effect of antiischemic drug therapy in our patients influenced the decision to cancel the emergency treatment and continue the treatment only by using medical therapy.Conclusion: The initial therapeutic approach by GDMT (Guideline directed medical therapy) for patients with ischemic heart disease (IHD) reduces the progression of atherosclerosis and prevent coronary thrombosis. In patients with ischemia, routine revascularization (with percutaneous coronary intervention or coronary artery bypass graft surgery) plus GDMT improve prognosis and reduce complications and improve quality of life compared to treatment only by using GDMT. The optimal drug therapy, primary and secondary prevention of IHD by the European Society of Cardiology (ESC) guidelines have almost thesame prognostic significance as revascularization

Aim: The aim of the study was to evaluate efficiency of hypertensive urgency treatment using inhibitors of α1-adrenergic receptors and angiotensin converting enzyme inhibitors–ACE inhibitors in the Emergency Room of Outpatient Hospital and Polyclinic „dr Mustafa Šehovic“ Tuzla in relation to age, duration and severity of hypertension. Methods: The study was conducted from June 2011 to May 2012 and included 120 patients of both sexes diagnosed with arterial hypertension, aged 40 to 80 with verified hypertensive urgency. The patients were divided into two groups: the control group treated with sublingual captopril and the experimental group treated intravenously with urapidil. Results: The results show that the largest number of patients belonged to age group from 60 to 69 years (34,16%), and the average age was 58 (11). The largest number of patients (38,0%) had verified hypertension for 11 to 20 years. The average systolic/diastolic artery blood pressure at reception was 213 (19) / 130 (4) mmHg. The average systolic/diastolic artery blood pressure after the first dose of 12,5 mg captopril in the control group was 177,42 (10,91) / 112,33 (3,50) mmHg, while after the first dose of 12,5 mg urapidil it was 179,25 (16,62) / 110,33 (8,78) mmHg. The average systolic/diastolic artery blood pressure after the second dose of 12,5 mg of captopril in the control group was 152,00 (6,32) / 95,50 (3,76) mmHg, while after the second dose of 12,5 mg of urapidil it was 152,55 (7,17) / 95,29 (5,04) mmHg. Conclusion: Urapidil is more efficient in hypertensive urgency treatment, since the decrease of middle artery pressure (MAP) in the group treated with urapidil was statistically significant (p<0,001). No statistical significance was found between the efficiency of urapidil and the patient’s age, while captopril was more efficient in older patients (p=0,02). Also, no statistically significant difference was found between the efficiency of captopril and urapidil in relation to duration of hypertension.

Objective: Timely recognition and optimal management of atherogenic dyslipidemia (AD) and residual vascular risk (RVR) in family medicine. Background: The global increase of the incidence of obesity is accompanied by an increase in the incidence of many metabolic and lipoprotein disorders, in particular AD, as an typical feature of obesity, metabolic syndrome, insulin resistance and diabetes type 2. AD is an important factor in cardio metabolic risk, and is characterized by a lipoprotein profile with low levels of high-density lipoprotein (HDL), high levels of triglycerides (TG) and high levels of low-density lipoprotein (LDL) cholesterol. Standard cardiometabolic risk assessment using the Framingham risk score and standard treatment with statins is usually sufficient, but not always that effective, because it does not reduce RVR that is attributed to elevated TG and reduced HDL cholesterol. RVR is subject to reduction through lifestyle changes or by pharmacological interventions. In some studies it was concluded that dietary interventions should aim to reduce the intake of calories, simple carbohydrates and saturated fats, with the goal of reaching cardiometabolic suitability, rather than weight reduction. Other studies have found that the reduction of carbohydrates in the diet or weight loss can alleviate AD changes, while changes in intake of total or saturated fat had no significant influence. In our presented case, a lifestyle change was advised as a suitable diet with reduced intake of carbohydrates and a moderate physical activity of walking for at least 180 minutes per week, with an recommendation for daily intake of calories alignment with the total daily (24-hour) energy expenditure (24-EE), depending on the degree of physical activity, type of food and the current health condition. Such lifestyle changes together with combined medical therapy with Statins, Fibrates and Omega-3 fatty acids, resulted in significant improvement in atherogenic lipid parameters. Conclusion: Unsuitable atherogenic nutrition and insufficient physical activity are the new risk factors characteristic for AD. Nutritional interventions such as diet with reduced intake of carbohydrates and calories, moderate physical activity, combined with pharmacotherapy can improve atherogenic dyslipidemic profile and lead to loss of weight. Although one gram of fat release twice more kilo calories compared to carbohydrates, carbohydrates seems to have a greater atherogenic potential, which should be explored in future.

Introduction: Diabetes mellitus is characterized by the lack of glycemic control, which may cause damage to the small and large blood vessels and nerves, which could, among the other things, lead to changes in the foot. Most of diabetic foot complications that resulted in amputation begin with the formation of skin ulcers. The most important risk factors and predictors of diabetic ulcers are the presence of diabetic neuropathy and structural foot deformities, infections and peripheral occlusive arterial disease. Smoking, hypertension and hyperlipidemia also contribute to the increased prevalence. Objective: To analyze the effectiveness of recommended interventions, conducted by family medicine team, for the prevention of diabetic foot ulcers. Patients and methods: Data from the medical records of all patients with type 2 diabetes in the family medicine team 1 of Public Health Institution - Healthcare Center Kalesija were retroactively analyzed. Interventions that were implemented in the prevention of diabetic ulcers are as follows: screening for diabetic neuropathy using Semmes- Weinstein’s monofilament, regular and systematic examination of footwear and feet, education of patients and family members about proper hygiene and foot care, daily foot inspection by the patient, and other possible effective clinical interventions such as: optimizing the values of blood pressure, blood glucose, hyperlipidemia and smoking cessation. Results: From total of 80 patients with type 2 diabetes, in 45 (56%) was established peripheral neuropathy. From these 45 patients with neuropathy, in 40 (88%) there has been no development of ulcers due to regular implementation of recommended interventions for prevention during each visit, and in 5 patients (12.5%) the disease led to the development of diabetic ulcers. Of these 5 patients with diabetes that developed diabetic ulcer, 2 (40%) underwent amputation due to poor communication and cooperation, irregular visits and the impossibility of implementing intervention and prevention measures. Conclusion: The family medicine has a central role in the prevention and early diagnosis of diabetic foot complications. Patients with diabetes may benefit from preventive interventions, including screening for neuropathy, educating patients on every visit, wearing proper footwear, intensive care and supervision, as well as early identification of high risk for amputation and evaluation for surgical intervention. A multidisciplinary team approach is vital in the management of diabetic foot. Regular, careful and systematic review of the feet of patients with diabetes is one of the easiest, cheapest and most effective preventive intervention and measure for the prevention of diabetic foot complications.

BACKGROUND Postoperative infection after posterior spondylodesis of thoracic and lumbal spine is the most common complication, and a reason for revision surgery. Aim of this work is to analyze rate of postoperative spine infections at our institution, and to determine eventual risk factors. SUBJECTS AND METHODS In our paper we analyze incidence of deep surgical infections after posterior spondylodesis, performed on our Spine department during last 5 years (September 1, 2008 - September 1, 2013). Including criteria were: posterior spondylodesis with transpedicular screws from Th1 to S2 due to different spine indications (injuries, degenerations, deformities, tumors), absence of local or general infection prior the index surgery, surgery performed by the same surgeon (MB). Excluding criteria were: needle procedures (kypho/vertebro-plasties, nerve root and faset blocades), anterior spine surgeries, cervical spine surgeries, and decompresive surgeries. RESULTS One hundred sixty five patients with 183 surgeries have been included in this study. Early surgical infection (within a month after the surgery) has appeared at five patients (2.7%). There have been no late surgical infections. Analyzing patients' charts, we have found that Meticillin-susceptible Staphylococcus aureus (MSSA) and Methicillin-resistant Staphylococcus aureus (MRSA) have caused infections in two patients, while Clebisiela pneumoniae ESBL has caused infection in one patient. Those five patients with infections have had further risk factors: long preoperative hospitalization at four patients, polytrauma, diabetes and advanced age at one patient, each. Three patients with postoperative infection had completely non-titanium surface of implants, and other two had about 20% of non-titanium implant surface, although vast majority of surgeries have been performed by implants whose surface was completely titanium alloy. Infections have appeared between 10-30 postoperative days. In two patients where revision surgeries (debridement, drainage, antibiotic according the species) had been performed in two weeks after appearance of infection, infections have been cured. In three patients where revisions had been postponed for longer than two weeks, additional surgeries (removal of implants) were necessary for curing the infections. CONCLUSIONS This study presented that rate of infection, microbiological species and risk factors are similar to the other orthopedics procedures and other institutions. Early revision is preferable, since it effectively avoids implant removal.

ABSTRACT Introduction: Correction of pediatric spine deformities is challenging surgical procedures. This fragile group of patients has many risk factors, therefore prevention of most fearing complication-paraplegia is extremely important. Monitoring of transmission of neurophysiological impulses through motor and sensor pathways of spinal cord gives us an insight into cord's function, and predicts postoperative neurological status. Goal: Aim of this work is to present our experiences in monitoring of spinal cord motor function - MEP during surgical corrections of the hardest pediatric spine deformities, pointing on the most dangerous aspects. Material and methods: We analyzed incidence of MEP changes and postoperative neurological status in patients who had major spine correcting surgery in period April ‘11- April ‘14 on our Spine department. Results: Two of 43 patients or 4.6% in our group experienced significant MEP changes during their major spine reconstructive surgeries. We promptly reduced distractive forces, and MEP normalized, and there were no neurological deficit. Neuromonitoring is reliable method which allows us to “catch” early signs of neurological deficits, when they are still in reversible phase. Although IONM cannot provide complete protection of neurological deficit (it reduces risk of paraplegia about 75%), it at least afford a comfort to the surgeon being fear free that his patient is neurologically intact during long lasting procedures.