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Elastic Stable Intramedullary Osteosynthesis (ESIN) in the Treatment of Pediatric Fractures
No full textPrijelomi u dječjoj dobi predstavljaju značajan javnozdravstveni problem zbog učestalosti i mogućih komplikacija koje mogu nastati uslijed nepravilnog liječenja. Dječji skelet se anatomski i fiziološki razlikuje od skeleta odraslih, što zahtijeva poseban pristup dijagnostici, terapiji i rehabilitaciji. Kosti djece su elastičnije, periost je bogatiji krvnim žilama, što omogućava brže cijeljenje, ali i pojavu specifičnih tipova prijeloma, poput subperiostalnih prijeloma ili prijeloma tipa "zelene grančice". Kao najčešći uzroci prijeloma navode se padovi, različite sportske aktivnosti i prometne nesreće.
Posebnost dječjeg skeleta predstavlja epifizna ploča rasta, čija ozljeda dovodi do ozbiljnih komplikacija, poput deformiteta ili neravnomjernog rasta ekstremiteta. Prijelome dječje dobe možemo podijeliti na traumatske, patološke i spontane prijelome. Dijagnostika se temeljni na kliničkom pregledu i radiološkim metodama, poput RTG-a, CT-a i MR-a.
Povijesno gledano, razvoj intramedularnih čavala započeo je s Küntscherovim čavlom tijekom Drugog svjetskog rata, dok je ESIN metoda razvijena 1988. godine u Francuskoj pod nazivom ECMES (Embrochage Centromedullaire Elastique Stable). Od tada se metoda kontinuirano usavršava te se danas široko primjenjuje u dječjoj traumatologiji.
U liječenju prijeloma dječje dobi sve se više koristi metoda elastične stabilne osteosinteze (ESIN). ESIN metoda se koristi kod liječenja prijeloma dugih kostiju. Metoda omogućuje minimalno invazivnu stabilizaciju prijeloma s pomoću intramedularnih čavala. Ova metoda omogućuje biomehaničku stabilnost kroz fleksibilan i elastičan sustav koji smanjuje potrebu za dugotrajnom imobilizacijom i ujedno omogućava brži oporavak. Prednosti metode uključuju očuvanje cirkulacije kosti, smanjenje rizika od infekcija i mogućnost brže rehabilitacije.
Indikacije za primjenu ESIN metode uključuju poprečne prijelome dijafize i metafize dugih kostiju, prijelomi koji se ne mogu retinirati nakon manualne repozicije, juvenilne koštane ciste, otvorene prijelome, psudoartroze i kod politraumatiziranih bolesnika. Kontraindikacije uključuju pretjeranu tjelesnu težinu djeteta i intraartikularne prijelome koji zahtijevaju drugačiji pristup liječenju.
Tehnika izvođenja ESIN metode uključuje pažljivu preoperativnu pripremu, odabir čavala odgovarajuće duljine i promjera te njihovu preciznu implantaciju u medularni kanal kosti. Postupak se razlikuje ovisno o specifičnoj kosti koja se liječi – nadlaktica (humerus), podlaktica (radius i ulna), natkoljenica (femur) ili potkoljenica (tibia). Svaka lokalizacija prijeloma zahtijeva prilagođen kirurški pristup i tehniku ugradnje čavala.
Postoperativni tretman uključuje rano pokretanje pacijenta, postupno opterećenje ekstremiteta i fizikalnu terapiju. Komplikacije koje mogu nastati uslijed ESIN osteosinteze dijele se na rane i kasne. Rane komplikacije uključuju infekcije, krvarenje, ozljede živaca i žila te iritaciju kože na mjestu ulaska čavala. Kasne komplikacije mogu uključivati nepravilno cijeljenje kosti, angulacijske deformacije i potrebu za revizijskim zahvatima.Fractures in childhood represent a significant public health issue due to their frequency and the potential complications that may arise from improper treatment. The pediatric skeleton differs anatomically and physiologically from the adult skeleton, requiring a specialized approach to diagnosis, therapy, and rehabilitation. Children's bones are more elastic, and the periosteum is richer in blood vessels, allowing for faster healing but also leading to specific types of fractures, such as subperiosteal fractures or greenstick fractures. The most common causes of fractures include falls, various sports activities, and traffic accidents.
A distinctive feature of the pediatric skeleton is the growth plate (epiphyseal plate), whose injury can lead to serious complications, such as deformities or uneven limb growth. Pediatric fractures can be classified as traumatic, pathological, or spontaneous. Diagnosis is based on clinical examination and radiological methods, including X-ray, CT, and MRI.
Historically, the development of intramedullary nails began with Küntscher's nail during World War II, while the ESIN (Elastic Stable Intramedullary Nailing) method was developed in France in 1988 under the name ECMES (Embrochage Centromedullaire Elastique Stable). Since then, the method has been continuously refined and is now widely used in pediatric traumatology.
The ESIN method is increasingly used in the treatment of pediatric fractures. It is primarily used for fractures of long bones, providing a minimally invasive stabilization of fractures using intramedullary nails. This method ensures biomechanical stability through a flexible and elastic system that reduces the need for prolonged immobilization while enabling faster recovery. The advantages of this method include the preservation of bone circulation, reduced risk of infections, and faster rehabilitation.
Indications for ESIN application include transverse fractures of the diaphysis and metaphysis of long bones, fractures that cannot be retained after manual repositioning, juvenile bone cysts, open fractures, pseudoarthrosis, and cases of polytraumatized patients. Contraindications include excessive body weight in children and intra-articular fractures that require a different treatment approach.
The ESIN technique involves careful preoperative preparation, selection of nails of appropriate length and diameter, and their precise implantation into the medullary canal of the bone. The procedure varies depending on the specific bone being treated—humerus, radius and ulna, femur, or tibia. Each fracture location requires a tailored surgical approach and technique for nail insertion.
Postoperative treatment includes early mobilization of the patient, gradual weight-bearing on the affected limb, and physical therapy. Complications associated with ESIN osteosynthesis are classified as early and late. Early complications include infections, bleeding, nerve and vascular injuries, and skin irritation at the nail entry site. Late complications may include improper bone healing, angular deformities, and the need for revision surgery
Biochemistry of Carbohydrate Loading in Endurance Sports : graduation thesis
No full textThe review presents a closer view on biochemistry and effect of COH loading in endurance athletes, with the focus on the nutritional strategies, the right amount and timing and effects on the recovery after a physical event. The different protocols ranging from the classic to modified to rapid approach give a lot of range in order to suit different kind of athletes with different preferences in time expenditure. Precise timing for the consumption of COH before and during the physical event in order to achieve optimal blood glucose levels and prevention of fatigue are crucial. The role of the GI and GL are also taking in consideration prior to an endurance event. Low-GI foods are more favorable immediately prior to the physical activity, while high GI foods are more efficiently in the days before and after the event. Supplements are used widely in order to assist in the intake of more COH. Powders are more used in the course before the event while gels are used during the activity. Ultra-endurance athletes will consume up to 50% more COH and will follow the rapid loading protocol in order to meet their increased needs. In order to replenish the glycogen store after the physical activity, the insulin independent mechanism, and the insulin-dependent mechanism, are both crucial to optimize recovery. High-GI foods have better results together with the combination with fructose. The adequate intake of COH during the event helps delaying the increase in inflammatory markers and stress-related molecules.The review presents a closer view on biochemistry and effect of COH loading in endurance athletes, with the focus on the nutritional strategies, the right amount and timing and effects on the recovery after a physical event. The different protocols ranging from the classic to modified to rapid approach give a lot of range in order to suit different kind of athletes with different preferences in time expenditure. Precise timing for the consumption of COH before and during the physical event in order to achieve optimal blood glucose levels and prevention of fatigue are crucial. The role of the GI and GL are also taking in consideration prior to an endurance event. Low-GI foods are more favorable immediately prior to the physical activity, while high GI foods are more efficiently in the days before and after the event. Supplements are used widely in order to assist in the intake of more COH. Powders are more used in the course before the event while gels are used during the activity. Ultra-endurance athletes will consume up to 50% more COH and will follow the rapid loading protocol in order to meet their increased needs. In order to replenish the glycogen store after the physical activity, the insulin independent mechanism, and the insulin-dependent mechanism, are both crucial to optimize recovery. High-GI foods have better results together with the combination with fructose. The adequate intake of COH during the event helps delaying the increase in inflammatory markers and stress-related molecules
Breaking the Cycle: Enhancing Cardiovascular Health in the Elderly Through Group Exercise
No full textThe global increase in aging populations underscores the urgency of addressing cardio–kidney metabolic health indicators, particularly among sedentary elderly individuals. This study investigates the impact of an 8-month structured group exercise program on cardiovascular health indicators among 320 women aged 60 and older living independently in Rijeka. Participants engaged in biweekly sessions designed to improve mobility, balance, and strength. Key metrics, including blood pressure (BP), body mass index (BMI), waist-to-hip (WHR) and waist-to-height ratio (WHtR), and hand grip strength, were measured before and after the intervention. Results revealed significant reductions in systolic blood pressure (mean −3.4 mmHg) and pulse pressure among hypertensive participants, highlighting improved cardiovascular function. BP control significantly improved (7.2%), and 19% of untreated hypertensive subjects at the start become normotensive at the end of follow-up. Although BMI changes were minimal, WHtR improvements indicated reductions in central obesity and muscle fat redistribution. Hand grip strength increased significantly on both arms, correlating with physical capacity. The results underline the benefits of group training for improving health even in the elderly population through an organized exercise program. While these preliminary results demonstrate promising health improvements, further research with longer follow-up and inclusion of diverse participant groups is recommended to validate these outcomes and refine intervention strategies
Rectus Abdominis Muscle Endometriosis: A Unique Case Report with a Literature Review
No full textIntroduction and importance: Extrapelvic endometriosis, confined exclusively to the body of the rectus abdominis muscle, is a rare form of abdominal wall endometriosis. While its etiopathology remains unclear, it is often diagnosed in healthy women who present with atypical symptoms and localization unrelated to any incision site, or in the absence of a history of endometriosis or previous surgery. Presentation of the case: Here, we describe a unique case of intramuscular endometriosis of the rectus abdominis muscle in a healthy 39-year-old Caucasian woman. The condition was located away from any prior incisional scars and presented without typical symptoms or concurrent pelvic disease, making diagnostic imaging unclear. After partial surgical resection of the endometriotic foci, the diagnosis was confirmed histologically. Progestogen-based supportive medication was initiated to prevent the need for additional surgeries and to reduce the risk of recurrence. After 6 years of follow-up and continued progestogen treatment, the patient remains symptom-free and has shown no recurrence of the disease. Clinical discussion: Endometriosis of the rectus abdominis muscle exhibits specific characteristics in terms of localization, etiopathology, symptomatology, and diagnostic imaging, suggesting that it should be considered a distinct clinical entity. Conclusions: Although rare, primary endometriosis of the rectus abdominis muscle should be included in the differential diagnosis for women of childbearing age. Early diagnosis is essential to avoid delayed recognition, tissue damage, and to minimize the risk of recurrence or malignant transformation. Given the increasing frequency of gynecologic and laparoscopic surgeries worldwide, it is crucial to establish standardized reporting protocols, follow-up timelines, and imaging assessments during specific phases of the menstrual cycle. Standardization will help raise awareness of this disease, and further our understanding of its pathogenesis, risk factors, recurrence patterns, and potential for malignant transformation—factors that are still not fully understood
Traumatic Injuries of the Thoracic Aorta
No full textTraumatske ozljede aorte jedan su od vodećih uzroka smrtnosti kod bolesnika s politraumom. Najčešće nastaju uslijed prometnih nesreća i prilikom padova s visine. Na traumatske ozljede aorte treba posumnjati kod bolesnika s prijelomom rebara, hematotoraksom, nestabilnim prsnim košem te pri raznim intraabdominalnim ozljedama. Klinička slika može biti različita, a bolesnici s ozljedom aorte mogu biti hemodinamski stabilni ili razviti sliku hemoragijskog šoka. Od simptoma najčešće se navodi bol u prsištu sa širenjem u leđa. Traumatske ozljede aorte predstavljaju po život opasno stanje te zahtijevaju brzo prepoznavanje i intervenciju. Prehospitalna smrtnost je visoka. Traumatske ozljede aorte najčešće nastaju oko polazišta lijeve potključne arterije. Luk aorte pokretniji je u odnosu na silaznu aortu te se pri nagloj deceleraciji tijekom nesreće javljaju sile koje povećavaju napetost u navedenom području i dovode do ozljede. CT aortografija i transezofagealna ehokardiografija slikovne su metode izbora za potvrdu dijagnoze. Prikaz ozljede, odnosno osjetljivost navedenih slikovnih tehnika uvelike ovisi o stupnju ozljede. Liječenje se provodi kirurškim ili endovaskularni pristupom postavljanjem stent-grafta. S obzirom na manju invazivnost i manju stopu periproceduralnih komplikacija endovaskularni pristup uglavnom je opcija izbora. Neadekvatan izbor stent-grafta kod endovaskularnog pristupa može rezultirati razvojem komplikacija poput malpozicije, endoleaka i kolapsa. Dugotrajno postproceduralno praćenje potrebno je zbog mogućnosti razvoja komplikacija i eventualnog njihova pravovremenog rješavanja. Kirurško liječenje zbog svoje invazivnosti i opterećenosti većom stopom intraoperacijskih i poslijeoperacijskih komplikacija rjeđe se provodi.Traumatic injuries of the aorta are a leading cause of mortality in polytrauma cases, most commonly resulting from traffic accidents and less frequently from falls from heights. Traumatic aortic injuries should be suspected in patients with rib fractures, haemothorax, a flail chest, and various intra-abdominal injuries. The clinical presentation can vary greatly, with patients presenting either in a state of circulatory shock or hemodynamically stable. The most commonly reported symptom is chest pain radiating to the back. Aortic lesions are life-threatening conditions that require rapid recognition and intervention. Prehospital mortality rate is high. The most common damage occurs around the origin of the left subclavian artery. The aortic arch is more mobile compared to the descending aorta, and sudden deceleration can generate forces that increase tension in the mentioned area, leading to injury. CT aortography and transoesophageal echocardiography are the imaging methods of choice for confirming the diagnosis. The depiction of damage, or the sensitivity of these imaging techniques, greatly depends on the extent of the injury. Treatment is surgical and includes both open surgery and an endovascular approach. Given the lower invasiveness and lower rate of periprocedural complications, the endovascular approach is generally the option of choice. Inadequate choice of stent graft during endovascular approach can result in complications such as malposition, endoleak, etc. Long-term post-procedural monitoring is necessary due to the possibility of developing complications and if needed, their timely resolution. Due to its invasiveness and a high rate of intraoperative and postoperative complications, open surgery is performed less frequently
Microbiota and Radiotherapy: Unlocking the Potential for Improved Gastrointestinal Cancer Treatment
No full textRadiotherapy (RT) is one of the major cornerstones in managing gastrointestinal (GI) cancers. However, several side effects, such as intestinal inflammation, mucosal injury, and dysbiosis, often compromise this. The gut microbiota increasingly attracts much interest as an essential modulator of RT effects influencing immune responses and tissue repair. Through short-chain fatty acids such as butyrate, representatives of certain bacterial species play a crucial role under normal conditions, keeping the mucosal integrity intact and reducing oxidative stress-mediated damage. Dysbiosis, a state where diminished microbial diversity and increased pathogenic species in the microbiota are seen, amplifies RT-induced toxicity in patients. Clinical investigations highlight that microbiota-targeted interventions, including probiotics, prebiotics, and fecal microbiota transplantation, hold the means to augment RT efficacy and lessen toxicity. Increased microflora diversity and specific microbial profiles have yielded serious patient improvements. Advanced RT methods use stereotactic body radiotherapy combined with microbiota modulation as a promising technique to shield healthy tissue and maximize immune-mediated antitumor effects. Additionally, there is an implication in tumor behavior regulated by the intratumoral microbiota regarding the response to radiotherapy. Notably, the modulation of gut and tumor microbiota provides an avenue to optimize RT benefits in GI cancers, underscoring the importance of personalized therapy
Preliminary Insights into the Cyto/Genoprotective Properties of Propolis and Its Constituent Galangin In Vitro
No full textPropolis has been well known for centuries as a natural preventive and therapeutic agent. Its numerous health benefits are mainly attributed to its high content of phenolic compounds that have a remarkable antioxidant activity. Since phenolics may exert a dual nature (pro-oxidant and antioxidant) the aim of this study was to investigate the safety profile of the ethanolic extract of propolis and the related flavonoid galangin and their ability to protect lymphocytes from irinotecan-induced cyto/genotoxicity in vitro. Isolated human peripheral blood lymphocytes were exposed for 3 h to three concentrations of propolis extract and galangin corresponding to the average daily dose of 0.25 mL of extract [propolis in 70% ethanol (3:7, w/w)], as well as a five- and ten-fold higher concentration. Cyto- and genoprotective effects were tested using a cytokinesis-block micronucleus cytome assay. Treatment with propolis and galangin in the selected concentrations exerted high biocompatibility with lymphocytes and diminished the level of cytogenetic damage caused by irinotecan. Propolis at the same concentration offered a stronger protective effect than single galangin. Also, apoptosis was the prevailing mechanism of cell death in our experimental conditions. These preliminary results speak in favour of future investigations of propolis using other available cytogenetic methods and cell models
Kliničke karakteristike i utjecaj antikoagulantnih lijekova na intrakranijalna krvarenja
No full textCilj: Istražiti klinička, radiološka i laboratorijska obilježja, te razlike u njima kod bolesnika s
intrakranijalnim krvarenjima koji su prethodno uzimali antikoagulantne i antitrombocitne lijekove, u
odnosu na one koji nisu. Ispitanici i metode: Prikupili smo podatke bolesnika s intrakranijalnim
krvarenjima (IKK) hospitaliziranih u OB Pula, u razdoblju od 01. siječnja 2020. do 01. siječnja 2023.
godine. Proveli smo analizu podataka koji su uključivali dob, spol, komorbiditete, vrstu IKK, simptome
kod prijma, Glagow Coma Score pri prijmu i otpustu, laboratorijske nalaze, metode i ishod liječenja.
Rezultati: Rezultati našeg istraživanja pokazuju kako su u retrogradnom, trogodišnjem praćenju bolesnika
sa spontanim intrakranijalnim krvarenjima hospitalizirani odrasli bolesnici i jedno dijete. Jedna trećina
bolesnika je prethodno uzimala anitkoagulantne i antitrombocitne lijekove. Odnos između broja muškaraca
i žena u skupinama nije se značajno razlikovao. Prosječna dob iznosi 70 godina, dok su bolesnici koji nisu
uzimali antikoagulantne i antitrobocitne lijekove bili mlađi. Jedna polovina uzorka imala je barem jedan
komorbiditet, a tri četvrtine bolesnika (77,2%) bolovalo je od arterijske hipertenzije koja je najvažniji
čimbenik rizika za nastanak IKK. Obje skupine bolesnika razvile su umjeren poremećaj svijesti, a
intracerebralno krvarenje je bilo najčešći tip IKK. Samo jedna petina bolesnika podvrgnuta je kirurškom
tretmanu. Čimbenici koji su bili povezani s antikoagulantnom terapijom su arterijska hipertenzija, atrijska
fibrilacija, aneurizmatski SAH i subduralni hematom. Prosječan broj dana hospitalizacije iznosio je 13,72
dana, a smrtnost tijekom hospitalizacije 41,4%. Zaključak: Utvrđeno je da ne postoje klinički značajne
razlike između bolesnika. Također, utvrđeno je kako su bolesnici koji su prethodno koristili antikoagulantne
i antitrombocitne lijekove imali veću incidenciju subduralnih hematoma i izoliranog intraventrikularnog
krvarenja u odnosu na kontrolnu skupinu bez terapije. Smrtnost kod bolesnika na antikoagulatnoj terapiji
iznosila je 48,9%, dok je smrtnost kod nekoaguliranih bolesnika iznosila 37,1%, čime se naglašava važnost
ranog prepoznavanja bolesnika na antikoagulantnoj terapiji
Post-Marketing Safety of Spinal Muscular Atrophy Therapies: Analysis of Spontaneous Adverse Drug Reactions from EudraVigilance
No full textBackground/Objectives: Spinal muscular atrophy (SMA) treatment has evolved with the approval of nusinersen, onasemnogene abeparvovec, and risdiplam. This study aims to assess the post-marketing safety profile of these therapies through the spontaneous adverse drug reaction (ADR) reports available in EudraVigilance (EV). Methods: Data from EV were retrieved via adrreports.eu for the suspected ADRs associated with nusinersen, onasemnogene abeparvovec, and risdiplam from their approval in the European Economic Area (EEA) to 31 December 2024. The ADR reports were exported and analysed using descriptive statistics in Microsoft Excel. Reporting odds ratios (RORs) with 95% confidence intervals (CIs) were calculated for suspected ADRs, focusing on reactions with a lower limit of the 95% CI exceeding 1. Results: A total of 3196, 806, and 956 individual case safety reports (ICSRs) were identified for nusinersen, onasemnogene abeparvovec, and risdiplam, respectively. The most frequently reported ADRs with significantly increased RORs included post-lumbar puncture syndrome (nusinersen: 11%), pyrexia (onasemnogene abeparvovec: 23%), and pneumonia (risdiplam: 9%). While some ADRs were therapy-specific, others were consistent with SMA disease progression and complications. Onasemnogene abeparvovec showed a notable prevalence of hepatotoxicity, while risdiplam was associated with gastrointestinal and respiratory events. Conclusions: To conclude, the analysis reinforces the known safety profiles of these SMA treatments while highlighting potential areas for further investigation. ADRs related to SMA complications require careful differentiation from true drug-related effects. Future pharmacovigilance efforts should focus on long-term safety assessments and real-world evidence to optimize treatment strategies
High lymphocyte count and bleeding risk in patients with chronic lymphocytic leukemia treated with Bruton’s tyrosine kinase inhibitors
No full textBruton's tyrosine kinase inhibitors (BTKi) are being increasingly used to treat patients with chronic lymphocytic leukemia (CLL). Pathological bleeding is a well-known side effect of BTKi but identifying its predictors remains a challenge. This retrospective multicenter study analyzed whether baseline absolute lymphocyte count (ALC) may be associated with bleeding risk in CLL patients treated with BTKi. Time to bleeding (TTB) was the primary outcome of interest. A total of 108 CLL patients treated with BTKi (ibrutinib, n = 86, acalabrutinib, n = 22) were included. The median age was 70 years (range 41-88 years) and 48 (44.4%) were female. The median follow-up time was 32 months (range 1-108 months) and 17 (15.7%) bleeding events occurred during this time. Receiver operating curve analysis set the optimal cut-off value of the ALC at > 77.4 × 109/L. Patients with higher ALC presented with higher total white blood cell count (p < 0.001), lower hemoglobin (p = 0.012), higher Rai stages (p = 0.037) and higher total tumor mass (p < 0.001). Univariately, patients with higher ALC had an inferior TTB when compared to those with lower ALC (hazard ratio, HR 3.27, p = 0.016); this effect persisted in the multivariate Cox regression analysis where higher ALC (HR 4.59, p = 0.032), higher Cumulative Illness Rating Scale (CIRS, HR 4.21, p = 0.040) and the use of antiplatelets/anticoagulants (HR 3.96, p = 0.046) remained independently of each other associated with an inferior TTB. This study provides an important signal regarding the higher risk of bleeding in CLL patients treated with BTKi who present with higher ALC and higher CIRS. Further studies are needed to validate our findings and to unravel the exact pathophysiological mechanisms behind this interesting observation