Band 3, Heft 2

Surfactin, a highly powerful biosurfactant produced by various strains of the genus Bacillus, exhibits antibacterial, antiviral, antitumor and hemolytic action. This anionic cyclic lipopeptide is constituted by a heptapeptide interlinked with a β-hydroxy fatty acid. Due to its amhipathic nature surfactin incorporates into the phospholipid bilayer and induces permeabilization and perturbation of target cells. The rising antibiotic resistance as well as a number of remarkable surfactin activities shows that it deserves special interest and is considered as a candidate compound for combating several health related issues. In this review, the current state of knowledge of surfactin properties, biomedical potential and limitations for its application is presented.

Neuroendocrine tumors arise from the diffuse neuroendocrine system and secrete several peptides and bioactive amines (serotonin, histamine, dopamine, norepinephrine, corticotropin, calcitonin, bradykinin, kalikrein, gastrin, cholecystokinin, prostaglandins). The most common occurrence site of neuroendocrine tumors is the ileum. The symptoms of small bowel carcinoids are represented by intermittent intestinal obstruction and carcinoid syndrome. Presence of the carcinoid syndrome usually indicates hepatic or retroperitoneal metastases. The typical carcinoid syndrome is characterized by flushing, diarrhea, nonspecific abdominal pain and bronchospasm. The diagnosis of small bowel tumors is often difficult due to their rarity and the nonspecific and variable nature of the presenting signs and symptoms. The most useful initial diagnostic test for the carcinoid syndrome is to measure 24-hour urinary excretion of 5-hydroxyindolacetic acid (5 HIAA), which is the end product of serotonin metabolism. Capsule endoscopy is a more recent diagnostic tool. Surgery is the radical form of curative therapy for carcinoid tumors. Numerous therapies are available for palliation including surgery, pharmacologic therapy, interventional radiologic therapy, embolization and chemoembolization of hepatic metastases, immunotherapy (Interferon alfa) and chemotherapy. We carefully reviewed the available literature on this topic before beginning our study.

Traditionally, the average code of conduct within Western health care starts from the autonomy of the patient. In addition, medicine today is ‘evidence based’ and the patient is an ‘informed consent’. Yet, the individual autonomy of the patient in health care is not simply enhancing today. Quite a few fundamental changes have and are currently at work within health care, which I will summarize here with the paradigm of predictive medicine. One of the characteristics of this paradigm is the increase of medical consults which are not autonomously chosen by an individual. For reasons of public health and diminishing of health risks or for reasons of prevention, on one hand we are dealing with ethical codes centered around the autonomy of patients and the face-to-face relations with health care workers, on the other, we are dealing with a society that takes an increasingly greater medical initiatives. Therefore, the question arises if predictive medicine confronts us with the limits of an ethical code as we know it today. Is there not an urgent need for a political code of conduct in health care?

The aim of the study was to describe the exposure to dog (Can f 1) and cat (Fel d 1) allergens within homes of very young children living with and without pets, and to assess the validity of the interview on pets for predicting the actual exposure to pet allergens in house dust. House dust samples were collected in 275 dwellings from the mattresses, children’s bedroom and kitchen floors. In the laboratory, dust samples were analyzed for Can f 1 and Fel d 1 using monoclonal antibody enzyme-linked immunosorbent assays (ELISA). The majority of households (79.3%) had neither a dog nor a cat living in the home over the past 6 months preceding the survey. Dog allergen above 2 μg/g dust were found in 22.5% of homes and 14.2% of homes contained dog allergen above 10 μg/g of house dust. In the total study sample, cat allergen above 1 μg/g of dust were found in 12.7% of homes, and 3.3% of homes contained Fel d 1 levels greater than 8 μg/g of dust. The majority of children (75.0%) with reported ownership of dogs were exposed to Can f 1 levels above 2 μg/g of house dust, and 73.1% of children with cats at home were exposed to Fel d 1 concentrations above 1 μg/g house dust. The results of the study showed that post-test probability of the true exposure to Can f 1 above 2 μg/g dust in houses with positive interview on indoor dogs was 75.0% (95%CI: 61.7–84.8%). On the other hand, the prediction of exposure estimated from the interview data on indoor dogs produced 12.6% of false negatives (95% CI: 9.9–15.8%). Similarly, the post-test probability of the true exposure to Fel d 1 above 1 μg/g dust in houses with positive interview on indoor cats was 73.1% (95%CI: 55.1–85.7%). On the other hand, the interview data produced 6.4% false negatives (95% CI: 4.6–9.0%). In conclusion, the study demonstrated that homes in Poland with pet ownership are important reservoir of Can f 1 and Fel d 1 allergens with levels that might induce allergic symptoms. Even in homes of children without a dog or cat indoors, there was a higher prevalence of pet allergens at the levels above allergic sensitisation thresholds. This may have an important implication for epidemiologic studies on pet related allergy and prevention practice.

Direct detection of Burkholderia cepacia complex (BCC) and its genomovars from sputum by molecular tests emerges as a method for rapid identification. In this study, four DNA extraction methods were evaluated for the identification for BCC from sputum of CF patients. Sputa from 28 CF patients were aliquoted and spiked with BCC reference strain. Boiling, phenol-chloroform, CTAB methods and a commercial spin column kit was used for DNA extraction. Total DNA yields were determined by spectrophotometry and single-round recA PCR was used for detection of BCC. No significant difference was observed in DNA yields from different extraction methods. Lower limit of detection for recA PCR was determined as 106 cfu/ml. Amplification was observed in 7/16 (43.7%) of sputa for boiling, 8/16 (50%) of sputa for CTAB and 13/16 (81.2%) of sputa for phenol-chloroform method and spin column kit in the assay sensitivity range determined in the study. Phenol-chloroform and commercial spin column kit were found to be better suited for DNA purification from sputum of CF patients for BCC identification. Diagnostic impact of single-round recA PCR directly from sputum was limited to chronically-infected patients.

Atorvastatin is a synthetic inhibitor of 3-hydroxy 3-methylglutaryl coenzyme A (HMG-CoA) reductase inhibitor. It has a longer half life and longer duration of action than that of all other available HMG-CoA inhibitors. We evaluated the efficacy of alternate-day dosing of atorvastatin in comparison with the standard one-daily dose on total cholesterol, low and High-density lipoprotein (LDL and HDL) and triglycerides. This study is a randomized, blinded, and controlled clinical trial. Sixty-six patients with LDL cholesterol of more than 100 mg/dl were enrolled. Baseline fasting lipid profile (total cholesterol, LDL, HDL and triglyceride), liver function tests and creatine kinase were drawn. Patients were randomized to three atorvastatin dose groups. Group I received 10 mg of atorvastatin every day, group II received 20 mg of atorvastatin every day, and group III received 20 mg every other day. After 6 weeks of treatment with atorvastatin, fasting lipid profiles, liver function tests and creatine kinase concentrations were re-taken. Compliance to treatment was assessed at each visit. Of the sixty-six patients enrolled, sixty completed the study. All three regimens significantly reduced total cholesterol and LDL compared to baseline. No statistically significant difference existed between the three groups in regards to total or a percentage decrease in total cholesterol and LDL cholesterol at 6 weeks compared to baseline. All regimens were well tolerated and none of the patients showed significant elevation of liver enzyme or creatine kinase during the course of the study. In conclusions the alternate-day dosing of atorvastatin is an efficacious and safe alternate to daily dosing and yet inexpensive.

Arabs have a lower incidence of atherosclerosis than other ethnicities, but few studies have examined homocysteine (HCYS) as a risk factor for cardiovascular disease in this population. Here, we investigated the association between serum HYCS levels and risk factors for cardiovascular disease (smoking, hypertension, and family history of diabetes) in Saudi males. A total of 50 smokers and 72 nonsmokers completed a general health questionnaire. In addition, their lipid profiles were measured using routine methods and HCYS levels by high-performance liquid chromatograph with electrochemical detection. Regression analysis showed negative associations between HCYS and glucose (r = −0.22; P < 0.05) as well as family history of diabetes (r = −0.21; P < 0.05). HCYS levels were similar between hypertensive and nonhypertensive smokers, but they were significantly elevated in hypertensive nonsmokers (P = 0.027) and lower in smokers with family history of diabetes (P = 0.01). Levels of HCYS among nonsmokers inversely correlated with history of diabetes and elevated glucose. Nonsmokers’ HCYS levels were significantly elevated in the presence of hypertension and correlated with diastolic blood pressure. Thus, HCYS may be a predictor of hypertension among nonsmokers. Until further trials are conducted, we recommend vitamin B6/folic acid supplementation for the Saudi hypertensive population as an adjuvant therapy.

Hypertension, diabetes, hyperlipidaemia, obesity and smoking are known to be the most important modifiable risk factors for cardiovascular disease (CVD). Because the elderly population has been increasing globally, CVD may become a more important public health problem in the future. This report examines the prevalence of cardiovascular risk factors in the elderly in Ankara, Turkey. This was a cross-sectional survey and included a total of 2720 individuals living in the Ankara district. Trained research staff administered a standard questionnaire in the participants’ homes and worksites. The questionnaire collected information on clinical and demographic characteristics and a self-reported medical history, including past history of hypertension, diabetes, hyperlipidemia, coronary artery disease, coronary artery by-pass graft operation, and cerebrovascular accident. The mean age of the study participants was 69.5 ± 7.2 years. The study identified 1298 women (78.1%) and 753 men (71.2%) with hypertension, and the overall prevalence of hypertension was 75.4%. A total of 739 (27.2%) people had diabetes mellitus, and, of these people, 603 (81.6%) were hypertensive. A total of 1361 people had hyperlipidemia, and 1103 of these patients were also hypertensive. The overall prevalence of obesity was 27.2%. A total of 553 (20.3%) people were smokers. Our findings indicate that cardiovascular risk factors are very common in the elderly. To maximize risk reduction, physicians must take aggressive measures to decrease cardiovascular risk factors.

The 12-lead surface electrocardiogram adjacent QTc dispersion, which is the maximum difference of corrected QT interval between two adjacent leads, is a simple method to determine regional variation in repolarization and refractoriness. The aim of this study is to evaluate adjacent QTc dispersion as a marker of susceptibility to ventricular arrhythmias after myocardial infarction. A total of 135 consecutive patients with acute myocardial infarction were enrolled in the study. Adjacent QTc, measured by lens magnifier, was calculated on the first, second and third days after acute myocardial infarction. On the second day after acute myocardial infarction, adjacent QTc dispersion was significantly greater in patients with ventricular arrhythmias (P < 0.001). Adjacent QTc dispersion on the first and fifth day after acute myocardial infarction was not associated with development of ventricular arrhythmias. On the second day after acute myocardial infarction, adjacent QTc dispersion is a simple and feasible method for prediction of ventricular arrhythmias.

The aim of this clinical case study is evaluation of possible intrapartal complication of the uncritical Kristeller’s expression. In this retrospective clinical study, data on seven parturients with significant maternal or fetal intrapartum complications during the second labor stage and Kristeller expression, associated with the maneuver, were analyzed. Data was obtained from patient files: history of delivery delivery room protocol and neonatal reports from two tertiary maternal wards. There were five uterine ruptures that were treated by laparotomy and uterine sutures. Atypical rupture location on the uterine fundus occurred in one case, isthmus rupture in three cases, and rupture of the scar left after a previous cesarean section as a potential risk factor for uterine rupture in one case. Complex uterine cervicoisthmic rupture with incomplete colporrhexis occurred during the delivery of a macrosomic child at an outpatient ward. In one case, unilateral fracture of the tenth and eleventh ribs resolved spontaneously without complications. One case of peripartum trauma, possibly associated with extensive expression was observed in one neonates: cutaneous and subcutaneous hematoma on the back with traumatic unilateral adrenal hemorrhage. Both newborns were monitored, successfully treated, and discharged from the hospital free from complications. In conclusion, in the obstetrics as a high risk profession, a very critical approach should be exercised on choosing this maneuver, which should be reserved for the rare and strictly indicated cases, thereby strictly following the professional rules to avoid generally unnecessary and unpleasant litigation and forensic expertise.

To investigate the influence of the wars in Croatia and Bosnia and Herzegovina on incidence and perinatal outcome of singleton preterm births at the Department of Gynecology and Obstetrics in the Split University Hospital. Data were collected by reviewing patients’ files at the Department of Gynecology and Obstetrics from three periods: the three years before the war (1988–1990), during the war (1992–1994), and after the war (1996–1998). A total of 2,358 patients’ files of singleton preterm delivery were analyzed. Singleton preterm delivery rate decreased during the war (5.02%) and post-war period (4.74%) compared to the pre-war period (6.19%). Stillbirth and early neonatal mortality rates of singleton premature babies significantly increased during the war to 226%, compared to 193% before the war and 134% after the war. Early neonatal mortality rate was 215% during the war, 209% in the pre-war period, and 156% after the war. Despite the continuous decrease in singleton preterm birth rate throughout the observed periods, the increase in stillbirth rate and early neonatal mortality rate during the war might have been caused by the war. This may be due to primary gynecological care being inadequate for many pregnant women.

In a hospital-based study we investigated the prevalence of Parkinson’s disease among inhabitants of the Vilnius city, the capital of Lithuania. The study group was selected from patients who were diagnosed with Parkinson’s disease during the time frame of 1978-2005. Patients’ time of diagnosis were based on the data of dispensary cards, registration journals and/or other documentation. A questionnaire and Mini Mental State Examination provided data for analysis on the conditions of the patients. The prevalence of Parkinson’s disease in Vilnius is 1.32/1000 inhabitants and is higher in men than in women (p < 0.05). The age of Parkinson’s disease onset in men and women is the same (63.77 ± 0.70 years). The rigidity-tremor form of Parkinson’s disease is the most frequent (76.8% of all cases). The PD prevalence rate in Vilnius inhabitants are close to the mean levels observed in studies made in Finland, Austria, Germany. The prevailing form of Parkinson’s disease is rigidity-tremor.

Cytokines regulate the immune reactions elicited by renal transplantation (RT). This study was designed to investigate the blood serum levels of IL-2, IL-6, IL-8 in 25 RT patients (10 female and 15 male, mean 5.4±2.7 yrs after RT) three times over a six-month period during standard immunosuppressive therapy with cyclosporine A, azathioprine and prednisolone. The levels of IL-2, IL-6 and IL-8 were tested with ELISA Quantikine Human Interleukin Immunoassay (R&D Systems, detection level 7,0.7 and 10 pg/cm3, respectively). There was no significant alternation of blood serum levels of IL-2, IL-6 and IL-8 in the study patients.

Giardiasis is a parasitic infection of the digestive tract, most commonly occurring in closed communities such as schools, kindergartens, prisons, and campuses. The civil war in the former Yugoslav republics and in Kosovo caused a large number of refugees to take shelter in the territory of Serbia. Such large numbers of refugees could be accommodated only in the collective centers. Our aim was to examine the differences in the prevalence of asymptomatic giardiasis among 122 refugees from the former Yugoslav republics who lived in the collective centers in Nis, Serbia, and 241 native Nis inhabitants. Conventional microscopic examination (CME) of three stool samples with or without concentration technique and the enzyme immunoassay (EIA) methods were used. The CME method of three stool samples is considered the gold standard in our statistical survey. Asymptomatic giardiasis is found in 7 refugees (5.7%) using the EIA method, while using the CME (3 samples) Giardia duodenalis (G. duodenalis) was detected in 6 persons (4.9%). Using the EIA method and the CME (3 samples) G. duodenalis was detected in only 1 person in the population group of native inhabitants (0.4%). Asymptomatic giardiasis was more prevalent in the population group of refugees accommodated in collective centers than in native inhabitants in the Nis municipality, Serbia.

The number of complications after primary total hip arthroplasty for displaced intracapsular fractures of the femoral neck is higher than that after operations for osteoarthritis. The aim of this study is to evaluate the number of complications and mid-term functional and radiological findings of patients after primary THA for displaced intracapsular fractures of the femoral neck. Between 1995 and 1998, we operated on a total of 89 patients for acute displaced intracapsular fractures of the femoral neck, i.e. Garden Type 3 and 4. In all the patients we evaluated intraoperative and early postoperative complications. We reviewed clinical and radiological results in 65 patients. The only intraoperative complication was abruption of the greater trochanter. Early postoperative complications occurred in 13 patients (15%). The specific complications, THA dislocation, occurred in 3 patients. Non-specific complications were recorded in 10 patients. No delayed healing of the surgical wound, neural lesion or early, delayed or late infection was recorded. Of 65 patients followed-up for an average of 78 months (range, 62–109 months), 8 patients underwent revision surgery. Of 57 patients with primary THA, very good and good clinical results according to the Harris Hip Score were recorded in 48 patients (84%) and poor results in only 2 patients (4%). Nine of 57 followed-up patients showed radiological signs of loosening (16%). The radiolucent line could be seen in 3 patients in the region of the cup, in 1 patient in the region of the femoral component and in 5 patients in both components. Clinical complaints that would result in indication for reimplantation were recorded in none of the mentioned patients. Number of complications, functional results and resumption of full self-reliance by patients after THA for an intracapsular fracture of the femoral neck are so positive that we consider the indication of THA for a displaced femoral neck fracture fully justified.

Atopic dermatitis is characterized by impaired skin and mucous membrane barrier function. Measures improving barrier integrity decrease the influence of environmental factors that might exacerbate inflammation. Ten adult patients with mild-to-moderate atopic dermatitis consumed for three months fermented with potent antioxidative probiotic, L. fermentum ME-3 (DSM 14241) goat milk 200 mg/day. A control group consisted of six patients, not supplemented by probiotic. All patients used emollients regularly. Skin iron levels, glutathione redox ratios (GSSG/GSH), diene conjugate (DC) amounts, blood glutathione status, oxidized low-density lipoprotein (oxLDL), and total antioxidativity was measured at the baseline and after three months. A significant decrease in skin iron levels, DC amounts, and glutathione redox ratio occurred in the probiotic-supplemented group compared to the control group (P < 0.05 for all indices). In the same group, blood levels of oxLDL decreased (p < 0.05), and GSH levels increased (P < 0.001) with concomitant improvement in the GSSG/GSH ratio. Blood antioxidativity markers also showed an improvement. The results of our study demonstrate that regular use of probiotics with antioxidative properties coupled with the use of lipid-containing emollients considerably decreases inflammation and concomitant oxidative stress in adult patients with mild-to-moderate atopic dermatitis. This effect was observed both in the skin and in the blood.

The study was undertaken to assess job satisfaction among health care workers (HCWs) who work with disabled patients and to identify the factors that contribute to their job satisfaction. This was a cross-sectional study conducted at nine rehabilitation centers in Serbia. The study sample consisted of doctors, nurses, physiotherapists, and other HCWs (social workers, work and speech therapists, and psychologists). A self-administrated questionnaire was distributed to 170 HCWs. Chi square testing and multivariate logistic regression analyses were applied. The response rate was 97.1% (165/170). Overall job satisfaction was reported by 22.4% of the respondents and was associated with hospital politics (odds ratio [OR], 4.16; 95% confidence interval [CI], 1.13–15.30], personal relationships (OR, 13.96; 95% CI, 4.07–47.92) and the feeling of being able to provide a good quality of care (OR, 5.24; 95% CI, 1.62–16.99). Profession, age, and gender did not affect job satisfaction. In conclusion, the results show very low job satisfaction among HCWs. Improving contributing factors may lead to higher job satisfaction and a better quality of health care.

We describe a woman who first presented with gestational diabetes at 26 weeks gestation and was managed with insulin. Following delivery of a healthy baby she had an abnormal OGTT (oral glucose tolerance test) 6 weeks post partum and was managed with diet. In her second pregnancy she was diagnosed with gestational diabetes at 10 weeks and required insulin. Following delivery she was again managed on diet alone. Four years later, during her third pregnancy, she was managed with insulin from the outset. She remained on insulin post partum and for several years. Later her two younger children, aged 11 years and 7 years, were found to have GCK mutation causing MODY (Maturity Onset Diabetes Of the Young) subtype glucokinase. Following this she underwent molecular genetic testing and was also shown to have the GCK mutation. She was gradually taken off insulin and is now managed on diet alone with excellent glycaemic control. Her two children are under regular follow up care and on no medication for diabetes.

We report a case of a woman with bilateral silicone breast implants who presented with recurrent high grade fever, joint and muscle aches. An extensive workup failed to indicate an infectious source of her illness, so based on her symptoms a clinical diagnosis of Adult Onset Still’s disease was made. However, subsequent investigations revealed raised IgA paraprotein levels in her serum which led to a bone marrow examination. Bone marrow examination was consistent with IgA Myeloma. Chemotherapy was commenced which led to a decrease in the paraprotein level. In addition, she was treated with non steroidal anti-inflammatory drugs and intraarticular steroid injections which provided marked symptomatic relief. The case indicates a possible association of Myeloma and Adult Onset Still’s Disease in a patient with bilateral silicone breast implant.

A huge schwannoma, located in the retroperitoneal space, is found very rarely. The main purpose of this paper is to present the case of a giant retroperitoneal schwannoma which partly invaded L4 vertebral body. The secondary purpose is to summarize the case-report articles on retroperitoneal schwannomas. A circumscribed heterogenic tumour was revealed on transabdominal sonography. It extended into the right retroperitoneal space. CT and MRI revealed a paravertebral tumour in the size of 11 cm × 9 cm, which is causing a partial lysis of L4 vertebral body (15% of vertebral capacity), expanding intravertebral foramen and filling the right retroperitoneal space. A preoperative core needle biopsy was performed and a benign schwannoma was diagnosed. A complete surgical excision of the tumour was achieved by a two-step operation. During the first step, the neurosurgeons made L4 hemilaminectomy, facetectomy and a transverse process resection by posterior extended approach. The general surgeons excised the residual retroperitoneal part of the tumour by midline transabdominal approach 10 days later. The diagnosis of benign schwannoma was verified histochemically. There were no sign of tumour recurrence or spine destabilization at the six-month follow-up. In conclusion, although majority of giant retroperitoneal schwannomas can be completely removed performing one-step operation, a preoperative consideration about rationality of two-step operation should be mandatory when tumour destructs a part of vertebral body. Our case shows that the combined two stage complete surgical excision of a giant retroperitoneal schwannoma, eroding 15% of L4 vertebra’s osseous capacity, is effective and does not have any negative influence on spinal stability.