Veterinary medicine - Repository of PHD, master's thesis
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Multimodal approach to cancer-pain management
No full textMultimodalni pristup liječenju karcinomske boli podrazumijeva kombinaciju različitih terapijskih metoda kako bi se postigla što učinkovitija kontrola boli kod onkoloških bolesnika. Ova bol često ima kompleksan uzrok, uključujući i nociceptivne i neuropatske mehanizme, stoga zahtijeva individualizirani i sveobuhvatan terapijski pristup. Farmakološke strategije uključuju primjenu neopioidnih analgetika, opioida te adjuvantnih lijekova poput antidepresiva, antikonvulziva i kortikosteroida. Uz to, nefarmakološke metode – poput fizikalne terapije, invazivnih procedura i komplementarnih tehnika – dodatno poboljšavaju ishode. Poseban naglasak stavlja se na psihološki aspekt boli, koji može modulirati njezinu percepciju, ali i pogoršati stanje ukoliko se zanemari. Kognitivno-bihevioralna terapija, edukacija pacijenata, relaksacijske tehnike i tjelesna aktivnost pokazuju analgetski potencijal te pridonose kvaliteti života. Multidisciplinarni tim, koji obuhvaća anesteziologe, psihologe, onkologe i druge relevantne specijaliste, ima ključnu ulogu u planiranju i provođenju integrirane skrbi za onkološke bolesnike, osobito u uznapredovalim i terminalnim fazama bolesti. Cilj ovog rada je prikazati različite modalitete liječenja karcinomske boli koji omogućuju donošenje individualizirane terapijske odluke unutar multidisciplinarnog pristupa, utemeljenog na aktualnim znanstvenim smjernicama.The multimodal approach to cancer pain management entails the combination of various therapeutic strategies to achieve optimal pain control in oncology patients. Cancer pain often results from a mix of nociceptive and neuropathic mechanisms, necessitating individualized and comprehensive treatment. Pharmacological options include non-opioid analgesics, opioids, and adjuvant drugs such as antidepressants, anticonvulsants, and corticosteroids. Non-pharmacological interventions – such as physical therapy, invasive procedures, and complementary techniques – further improve patient outcomes. Particular emphasis is placed on the psychological component of pain, which not only influences perception but can exacerbate suffering if overlooked. Cognitive-behavioral therapy, patient education, relaxation techniques, and physical activity have shown analgesic benefits and contribute to better quality of life. The multidisciplinary team, comprising anesthesiologists, psychologists, oncologists, and other relevant specialists, plays a pivotal role in planning and delivering integrated care for oncology patients, particularly in advanced and terminal stages of the disease. The aim of this thesis is to present various modalities of cancer pain management that support individualized therapeutic decision-making within a multidisciplinary framework, based on current evidence-based guidelines
Hip endoprosthesis in rheumatoid arthritis
No full textReumatoidni artritis (RA) česta je sustavna upalna bolest koja, zbog dugotrajne sinovijalne upale, osteoklastne aktivnosti i glukokortikoidno inducirane osteoporoze, nerijetko uzrokuje tešku destrukciju zgloba kuka. Za razliku od primarne koksartroze, kod bolesnika s RA, pojava komplikacija u smislu periprotetičkih fraktura, infekcija te tromboembolijskog događaja i ranog labavljenja proteze je prisutna u nešto većem postotku. Ovaj diplomski rad analizira specifičnosti preoperativne pripreme, izbora implantata, kirurških tehnika, te postoperativnog oporavka bolesnika s RA u usporedbi s pacijentima koji imaju primarnu koksartrozu. Ključ uspjeha jest multidisciplinarna suradnja reumatologa, ortopeda, anesteziologa, fizijatra i medicinskih sestara, te individualizirani plan rehabilitacije i dugoročne antiresorptivne terapije. Totalna endoproteza kuka ostaje sigurna i iznimno učinkovita metoda koja pruža trajno olakšanje boli, obnavlja pokretljivost te značajno poboljšava kvalitetu života kod bolesnika s reumatoidnim artritisom kada se izvodi uz precizno planiranu perioperativnu skrb.Rheumatoid arthritis (RA) is a common systemic inflammatory disease that, due to longstanding synovial inflammation, osteoclast activation and glucocorticoid induced osteoporosis, frequently causes severe destruction of the hip joint. In comparison with primary coxarthrosis, RA patients exhibit a slightly higher incidence of complications such as periprosthetic fractures, prosthetic joint infection, thromboembolic events, and early implant loosening. This thesis analyses the specific aspects of preoperative optimization, implant selection, surgical techniques and postoperative recovery in RA patients compared to those with primary coxarthrosis. Success depends on multidisciplinary collaboration among rheumatologists, orthopaedic surgeons, anaesthesiologists, physiatrists and nursing staff, together with an individualised rehabilitation plan and long term antiresorptive therapy. Total hip arthroplasty remains a safe and highly effective intervention that delivers lasting pain relief, restores mobility and greatly improves quality of life in patients with rheumatoid arthritis when performed with carefully planned perioperative care
Early Diagnosis and Management of Keratoconus
No full textKeratokonus je najčešća degenerativna bolest rožnice koja dovodi do postupnog stanjivanja i koničnog izbočenja rožnice, što uzrokuje pojavu nepravilnog astigmatizma i smanjenje vidne oštrine. Bolest se najčešće javlja u mlađoj životnoj dobi, a njezina progresija može značajno utjecati na kvalitetu života. Etiologija keratokonusa nije potpuno razjašnjena, a smatra se da u nastanku sudjeluju genetski čimbenici, promijenjena biokemija rožnice, mehanički stres, različiti okolišni čimbenici te hormonski čimbenici. Klinička slika varira ovisno o stupnju bolesti. U ranijim stadijima simptomi su često blagi i nespecifični, dok uznapredovali oblici mogu dovesti do izraženog gubitka vidne funkcije. Rano prepoznavanje bolesti omogućuju dijagnostičke metode poput kornealne topografije, tomografije, OCT-a i biomehaničkih mjerenja, a u posljednje vrijeme sve se češće primjenjuju algoritmi umjetne inteligencije. Liječenje ovisi o stupnju keratokonusa i uključuje optičku korekciju naočalama i kontaktnim lećama, postupke kao što su cross-linking, implantacija intrakornealnih prstenova, površinske refraktivne metode te transplantacijske tehnike poput PKP i DALK. U razvoju su i eksperimentalni pristupi, uključujući primjenu biomaterijala, umjetnih rožnica i genske terapije.Keratoconus is the most common degenerative disease of the cornea, leading to progressive thinning and conical protrusion of the corneal surface. This results in irregular astigmatism and reduced visual acuity. The disease typically appears in younger individuals, and its progression can significantly affect quality of life. The etiology of keratoconus is not fully understood, and it is believed that genetic factors, altered corneal biochemistry, mechanical stress, various environmental influences, and hormonal factors all contribute to its development. The clinical presentation varies depending on the stage of the disease. In the early stages, symptoms are often mild and nonspecific, while advanced forms may result in significant visual impairment. Early detection is made possible by diagnostic methods such as corneal topography, tomography, optical coherence tomography (OCT), and biomechanical measurements. Recently, artificial intelligence algorithms have also been increasingly used in the detection of early and subclinical changes. Treatment depends on disease severity and includes optical correction with glasses and contact lenses, procedures such as corneal collagen cross-linking, implantation of intrastromal corneal ring segments, surface refractive techniques, and transplant procedures such as penetrating keratoplasty (PKP) and deep anterior lamellar keratoplasty (DALK). Experimental approaches are also being developed, including the use of biomaterials, artificial corneas, and gene therapy
Surgical treatment of portal hypertension in children
No full textPortalna hipertenzija je porast tlaka u portalnom venskom sustavu, iznad 10 mmHg. Najčešći uzrok portalne hipertenzije u djece je ekstrahepatalna opstrukcija portalne vene uzrokovana trombozom. Klinički se bolest najčešće prezentira krvarenjem iz varikoziteta jednjaka, splenomegalijom i hipersplenizmom. Krvarenje iz varikoziteta jednjaka je najčešća komplikacija i često inicijalna manifestacija bolesti s visokom stopom smrtnosti. Incijalno se zbrinjava endoskopski, no u slučaju neuspjeha endoskopskog liječenja ili pojave varikoziteta visokog rizika od krvarenja liječenje je kirurško. Kirurško liječenje može biti usmjereno na kontrolu krvarenja devaskularizacijom ezofago-gastričnog spoja (modificirana operacija po Sugiuri) ili na smanjenje tlaka u portalnoj cirkulaciji (formiranje šanta ili transplantacija jetre). Smanjenje tlaka u portalnoj veni dovodi do smanjenja hipersplenizam i prevenira krvarenje iz varikoziteta. U djece, portalna hipertenzija može biti prehepatalna (tromboza portalne vene) ili hepatalna (ciroza jetre). Kod prehepatalne portalne hipertenzije je očuvana funkcija jetre pa je kirurška metoda izbora formiranje šanta. Cilj ovog rada je prikazati kiruršku tehniku i ishode liječenja prehepatalne portalne hipertenzije u djece na Kliničkom bolničkom centru Zagreb mezokavalnim šantom. Učinjena je retrospektivna analiza 5 pacijenata kod kojih je u razdoblju od siječnja 2020. godine do siječnja 2025. godine formiran mezokavalni šant na Zavodu za dječju kirurgiju Kliničkog bolničkog centra Zagreb. Analizirani su podaci 2 dječaka i 3 djevojčice, srednje dobi od 8 godina i 1 mjesec. Indikacije za operativni zahvat su bile recidivno krvarenje iz varikoziteta jednjaka i progresija stupnja varikoziteta. Postoperativno je prohodnost šanta potvrđena Dopplerom u 4 od 5 pacijenata, dok se u jedne pacijentice šant nije uspio prikazati neinvazivnim radiološkim metodama. U svih pacijenata je došlo do smanjenja hipersplenizma, regresije varikoziteta jednjaka i smanjenja veličine slezene. Kod dva pacijenta je u ranom postoperativnom tijeku učinjena revizija, kod jednog zbog hematemeze i sumnje na trombozu šanta na CT angiografiji, a u drugog zbog pogoršanja hiperplenizma i sumnje na trombozu šanta. U oba pacijenta je na reviziji nađen uredno prohodan šant. Nije bilo smrtnih ishoda ili dugoročnih komplikacija. Mezokavalni šant je na KBC-u Zagreb sigurna i učinkovita metoda za liječenja portalne hipertenzije uzrokovane trombozom portalne vene u djece.Portal hypertension is an increase in pressure within the portal venous system, above 10 mmHg. In children, the most common cause is extrahepatic portal vein obstruction caused by thrombosis. Clinically, the disease most often presents with esophageal variceal bleeding, splenomegaly, and hypersplenism. Esophageal variceal bleeding is the most frequent and often the initial manifestation of the disease, with a high mortality rate. Initial management is endoscopic, but if endoscopic management fails or if varices with a high risk of bleeding are present, surgical treatment is indicated. Surgical options aim either to control bleeding by devascularizing the esophagogastric junction (a modified Sugiura procedure) or to reduce pressure in the portal circulation (shunt formation or liver transplantation). Lowering the pressure in the portal vein leads to hypersplenism reduction and the prevention of variceal bleeding. In children, portal hypertension may be prehepatic (portal vein thrombosis) or hepatic (liver cirrhosis). In prehepatic portal hypertension, liver function is preserved, making shunt formation the surgical method of choice. The aim of this paper is to present the surgical technique and outcomes of treating prehepatic portal hypertension in children at the University Hospital Centre Zagreb using a mesocaval shunt. A retrospective analysis was performed on 5 patients who underwent mesocaval shunt surgery between January 2020 and January 2025 at the University Hospital Centre Zagreb Department of Pediatric Surgery. Data of 2 boys and 3 girls was analysed with a mean age of 8 years and 1 month. Indications for surgery were recurrent esophageal variceal bleeding and progression of variceal grade. Postoperative shunt patency was confirmed with Doppler ultrasound in 4 out of 5 patients, meanwhile, in one girl, the shunt could not be visualized using non-invasive radiological methods. All of the patients showed reduced hypersplenism, regression of varices, and decreased spleen size. Two patients required early postoperative revision, one due to hematemesis and suspected shunt thrombosis seen on CT angiography, and the other due to worsening hypersplenism and suspected thrombosis. In both cases, revision surgery confirmed the shunts were patent. There were no deaths or long-term complications. The mesocaval shunt at the University Hospital Centre Zagreb is a safe and effective method for treating portal hypertension caused by portal vein thrombosis in children
Treatment-resistant depression: New insights into the etiopathogenesis and the role of esketamine in treatment
No full textTerapijski rezistentna depresija (TRD) javlja se u oko 30% bolesnika koji boluju od velikog depresivnog poremećaja i kod kojih se ne postigne adekvatan terapijski odgovor nakon dvije ili više linija liječenja antidepresivima, uz uvjet da su svaki izabrani antidepresiv uzimali dovoljno dugo i u odgovarajućoj dozi. Brojni su čimbenici povezani s etiopatogenezom TRD, a jedan od značajnih je neurotransmiter glutamat. U prekomjernoj koncentraciji u ekstracelularnom prostoru, on uzrokuje ekscitotoksičnost koja dalje dovodi do otpuštanja proinflamatornih citokina i razvoja neuroupale. To ima za posljedicu oštećenje neurona u područjima mozga koja su odgovorna za emocionalno ponašanje i reguliranje raspoloženja, što se klinički može manifestirati kao TRD.
Liječenje TRD predstavlja veliki izazov za kliničare jer unatoč brojnim dosadašnjim farmakološkim i nefarmakološkim metodama liječenja, postoji velika potreba za novim učinkovitijim strategijama liječenja. Esketamin predstavlja novu terapijsku mogućnost u liječenju TRD. Za razliku od dosadašnjih antidepresiva, djeluje kao antagonist glutamatnih NMDA receptora, primjenjuje se intranazalno i ima akutno djelovanje. Zahvaljujući jedinstvenom mehanizmu djelovanja može biti učinkovit u liječenju TRD tako što pojačava signalizaciju neurotrofičnih čimbenika i sinaptogenezu. Esketamin se danas sve više pozicionira kao dobrodošla nova farmakološka strategija u liječenju TRD, a inhibicijom ekscitotoksičnog učinka glutamata stavlja ovaj neurotransmiter sve više u središte znanstvenih istraživanja.Treatment-resistant depression (TRD) occurs in approximately 30% of patients suffering from major depressive disorder who fail to achieve an adequate therapeutic response after two or more lines of antidepressant treatment, provided that each selected antidepressant was taken for a sufficient duration and at an appropriate dosage. Numerous factors are associated with the etiopathogenesis of TRD, with one significant factor being the neurotransmitter glutamate. In excessive extracellular concentrations, glutamate causes excitotoxicity, which subsequently leads to the release of pro-inflammatory cytokines and the development of neuroinflammation. This results in neuronal damage in brain regions responsible for emotional behavior and mood regulation, which can clinically manifest as TRD.
Treating TRD poses a major challenge for clinicians, as despite numerous existing pharmacological and non-pharmacological treatment methods, there remains a strong need for new and more effective therapeutic strategies. Esketamine represents a new therapeutic option in the treatment of TRD. Unlike traditional antidepressants, it acts as an antagonist of glutamate NMDA receptors, is administered intranasally, and has an acute effect. Thanks to its unique mechanism of action, esketamine may be effective in treating TRD by enhancing neurotrophic factor signaling and synaptogenesis. Esketamine is increasingly being positioned as a welcome new pharmacological strategy in the treatment of TRD, and by inhibiting the excitotoxic effects of glutamate, it brings this neurotransmitter further into focus in scientific research
Anatomical basis of pelvic floor defects
No full textPFDs (eng. Pelvic Floor Disorders) uključuju prolaps zdjeličnih organa i urinarnu inkontinenciju. Riječ je o dijagnozi koja pogađa velik broj žena različite dobi. Svaki prolaps zdjeličnih organa uzrokovan je specifičnim anatomskim defektom. Razumijevanje normalne anatomije dna zdjelice i patološke anatomije u podlozi prolapsa ključno je za uspješno liječenje ovog kompleksnog stanja. Prolaps organa male zdjelice označava spuštanje zdjeličnih organa u ili kroz vaginalni kanal. To uključuje mokraćni mjehur, maternicu, vaginalnu zaraslicu, tanko i debelo crijevo. Postoje tri skupine prolapsa: prednji, stražnji i apikalni. Prolapsi nastaju zbog oštećenja fibromuskularnog potpornog sustava koji održava zdjelične organe u prirodnom položaju. Normalna se vaginalna potpora sastoji od tri razine. Prvu razinu potpore čine kardinalni i uterosakralni ligamenti. Potpora se druge razine sastoji od pubocervikalne i rektovaginalne fascije. Treću razinu potpore čini spoj rodnice s okolnim strukturama. Svaki prolaps nastaje zbog oštećenja pojedinih razina potpore. Tako su defekti endopelvične fascije prepoznati kao ključni u patofiziologiji nastanka prolapsa zdjeličnih organa. Rizični čimbenici za nastanak defekata dna zdjelice narušavaju normalnu anatomiju i histologiju zdjeličnog dna. Riječ je o trudnoći, porođaju, starijoj dobi, menopauzi, pretilosti, bolestima vezivnog tkiva, kronično povećanom intraabdominalnom tlaku, obiteljskoj anamnezi prolapsa te rasi. Defekti dna zdjelice uzrokuju narušavanje statike zdjeličnih organa te pojavu različitih simptoma. Najčešći su simptomi ispupčenja i pritiska u zdjelici, urinarna inkontinencija, fekalna inkontinencija te seksualna disfunkcija. Uspostava izvornih anatomskih odnosa temelj je liječenja defekata dna zdjelice.Pelvic Floor Disorders (PFDs) include pelvic organ prolapse and urinary incontinence. These are diagnoses that affect a large number of women of various ages. Each pelvic organ prolapse is caused by a specific anatomical defect. Understanding the normal anatomy of the pelvic floor, as well as the pathological anatomy underlying prolapse, is essential for the successful treatment of this complex condition. Pelvic organ prolapse refers to the descent of pelvic organs into or through the vaginal canal. This includes the bladder, uterus, vaginal vault, small intestine, and rectum. There are three categories of prolapse: anterior, posterior, and apical. Prolapse occurs due to damage to the fibromuscular support system that maintains the pelvic organs in their natural position. Normal vaginal support consists of three levels. The first level is formed by the cardinal and uterosacral ligaments. The second level includes the pubocervical and rectovaginal fasciae. The third level of support is the connection between the vagina and the surrounding structures. Each type of prolapse results from damage to one or more of these support levels. Defects in the endopelvic fascia have been recognized as key contributors in the pathophysiology of pelvic organ prolapse. Risk factors for the development of pelvic floor defects compromise the normal anatomy and histology of the pelvic floor. These include pregnancy, childbirth, advanced age, menopause, obesity, connective tissue disorders, chronically increased intra-abdominal pressure, a family history of prolapse, and ethnicity. Pelvic floor defects lead to disruption of pelvic organ support and the appearance of various symptoms. The most common symptoms include a sensation of bulging or pressure in the pelvis, urinary incontinence, fecal incontinence, and sexual dysfunction.
Restoration of the original anatomical relationships is the cornerstone of treatment for pelvic floor defects
Facial Transplantation Techniques from 2005 to Today
No full textOvaj diplomski rad opisuje razvoj transplantacije lica naglašavajući njezinu važnost u funkcionalnoj i estetskoj rehabilitaciji kod pacijenata s teškim ozljedama i deformacijama lica. Od prve djelomične transplantacije izvedene 2005. godine u Francuskoj došlo je do velikog napretka u kirurškim tehnikama i imunološkoj terapiji. Osim slučaja iz Francuske, obrađeni su i oni iz Španjolske 2010. godine te SAD-a 2012., predstavljajući te godine kao ključne prekretnice ovog područja.
Osim na kirurške tehnike, poseban naglasak je stavljen na složenost anatomskih struktura uključenih u sam zahvat, poput kože, mišića, krvnih žila, živaca te kostiju. Usporedbom transplantacije s autolognom rekonstrukcijom prikazana je svrha obiju metoda i važnost individualnog pristupa svakom pacijentu. Kada se govori o uspješnosti ovakvog zahvata, poseban se naglasak stavlja na funkcionalnu obnovu tkiva poput govora, mimike, gutanja, osjeta te zadovoljavajući estetski rezultat.
Kao neizostavan dio svakog posttransplantacijskog perioda, razvijeni su imunosupresivni protokoli. Uobičajena terapija uključuje primjenu takrolimusa, mikofenolat mofetila i kortikosteroida. Također su obrađeni i izazovi dugotrajne imunosupresivne terapije kao što je odbacivanje transplantata, infekcije različite etiologije i druge sistemske komplikacije. Posebno se ističe povećani rizik od razvoja malignoma poput posttransplantacijskog limfoproliferativnog poremećaja.
Tehnološki napredak koji uključuje 3D planiranje, regenerativne pristupe i primjenu umjetne inteligenciju dodatno unaprijeđuje sigurnost, preciznost i uspješnost zahvata.
Osim tehničkih i imunoloških izazova, transplantacija lica otvara važna psihosocijalna i etička pitanja. Vrlo bitan dio predoperativnog procesa je psihološka evaluacija pacijenta, informirani pristanak i priprema za moguće komplikacije. Također je istaknuta potreba za multidisciplinarnim timom kako bi se svakom pacijentu pružila potpuna rehabilitacijska podrška i omogućio povratak u svakodnevne životne aktivnostiThis thesis describes the development of face transplantation, emphasizing its importance in restoring function and appearance in patients with severe facial injuries and deformities. Since the first partial transplant performed in France in 2005, there has been great progress in surgical techniques and immune system treatment. In addition to the case from France, the thesis also discusses cases from Spain in 2010, and in the USA in 2012, showing these years as important turning points in this medical field.
Besides surgical techniques, special attention is given to the complexity of the body parts involved in the procedure, such as the skin, muscles, blood vessels, nerves, and bones. By comparing face transplantation with autologous reconstruction, the purpose of both methods is explained, along with the need for a personal approach for each patient. When talking about the success of the procedure, focus is placed on regaining functions like speaking, facial expression, swallowing, and facial sensation, as well as achieving a good cosmetic result.
As a necessary part of recovery, special treatment with drugs that suppress the immune system has been developed. Standard therapy usually includes tacrolimus, mycophenolate mofetil, and corticosteroids. The thesis also describes problems related to long-term use of these medicines, such as transplant rejection, infections, and other systemic complications. Special attention is drawn to the increased risk of developing malignacy, such as post- transplant lymphoproliferative disorder.
Modern technology, including 3D planning, regenerative approach and the use of artificial intelligence, has improved the safety, accuracy, and success of these operations.
In addition to the medical side, face transplantation also raises important psychological and ethical questions. A very important step before the operation is the psychological evaluation of the patient, getting informed consent, and preparing for possible complications. The need for a multidisciplinary team is also highlighted, to give full support during recovery and help the patient return to everyday life
The role of minimally invasive gynecologic surgery in treating infertility
No full textMinimalno invazivna ginekološka kirurgija (MIGK) sve više se ističe kao važna komponenta u liječenju ženskog infertiliteta. Osim što može povećati uspješnost medicinski potpomognute oplodnje (MPO), MIGK u mnogim slučajevima omogućuje spontanu trudnoću, čime se smanjuje potreba za složenim, emocionalno i financijski zahtjevnim MPO postupcima. U određenim slučajevima potpuno uklanja potrebu za IVF-om te pruža mogućnost za višestruke spontane trudnoće, a nekada se sam uzrok neplodnosti u potpunosti i razriješi.
Uključuje tehnike poput laparoskopije i histeroskopije, koje omogućuju preciznu dijagnostiku i terapiju uz minimalnu traumu tkiva, manji rizik od komplikacija i brži oporavak. Kirurški su pristupi raznoliki ovisno o stanju koje je dovelo do neplodnosti. Uklanjanje hidrosalpinksa prije IVF-a potvrđeno povećava uspješnost implantacije i smanjuje rizik od neuspjelih ciklusa. Kod endometrioze i mioma, MIGK omogućuje ciljano uklanjanje lezija koje ometaju implantaciju, dok se kod istmocela i intrauterinih malformacija poboljšavaju uvjeti za uspješan embrionalni razvoj. Histeroskopski zahvati, poput resekcije uterinog septuma i adheziolize, poboljšavaju plodnost kod žena s poremećajima implantacije i spontanim pobačajima, dok se kod pažljivo odabranih pacijentica laparoskopske metode poput adheziolize i fimbrioplastike povezuju s visokom stopom spontanih trudnoća.
Pristup temeljen na individualizaciji liječenja i pravilnoj selekciji pacijentica otvara mogućnost boljih reproduktivnih ishoda, manjih rizika i veće kontrole nad terapijskim procesom. MIGK time postaje ne samo dodatak MPO-u, već ravnopravan terapijski put u liječenju strukturnih uzroka neplodnosti, s potencijalom da poboljša kvalitetu skrbi i ishode liječenja u suvremenoj reproduktivnoj medicini.Minimally invasive gynecologic surgery (MIGS) is increasingly being recognized as an important component in the treatment of female infertility. In addition to improving the success rates of medically assisted reproduction (MAR), MIGS can, in many cases, enable spontaneous conception, thereby reducing the need for complex, emotionally and financially demanding assisted reproductive procedures. In certain cases, it may completely eliminate the need for in vitro fertilization (IVF) and allow for multiple spontaneous pregnancies, while in others, the underlying cause of infertility may be fully resolved.
MIGS includes techniques such as laparoscopy and hysteroscopy, which allow for precise diagnostics and treatment with minimal tissue trauma, reduced risk of complications, and faster recovery. Surgical approaches vary depending on the condition causing infertility. Removal of hydrosalpinx prior to IVF has been shown to improve implantation rates and reduce the risk of failed cycles. In cases of endometriosis and myomas, MIGS enables targeted removal of lesions which interfere with implantation, while treatment of isthmocele and uterine malformations secures for successful embryonic development. Hysteroscopic procedures such as uterine septum resection and adhesiolysis enhance fertility in women with implantation disorders and recurrent miscarriages, while laparoscopic methods like adhesiolysis and fimbrioplasty are associated with high spontaneous pregnancy rates in carefully selected patients.
An individualized treatment approach and proper patient selection offer the potential for better reproductive outcomes, fewer risks, and greater control over the therapeutic process. MIGS thus becomes not merely an adjunct to MAR, but an equally valid therapeutic pathway in treating structural causes of infertility, with the potential to improve the quality of care and treatment outcomes in modern reproductive medicine
Paroxysmal autonomic dysfunction in severe brain damage
No full textParoksizmalna autonomna disfunkcija (PAD) najčešće se javlja nakon stečenih oštećenja mozga, osobito nakon traumatske ozljede mozga, a karakterizira je skup simptoma: tahikardija, hipertenzija, tahipneja, povišena tjelesna temperatura, znojenje te poremećaji posture i pokreta. Unatoč napretku u razumijevanju kliničkih značajki ovog sindroma, patofiziološki mehanizmi još nisu u potpunosti razjašnjeni. Najčešće teorije uključuju diskonekcijsku teoriju, model omjera ekscitacije i inhibicije te neuroendokrine poremećaje. Dijagnosticiranje ovog sindroma u ranoj fazi i dalje je izazovno zbog nespecifičnih simptoma i ograničenih dijagnostičkih mogućnosti. Alat za procjenu PAD-a (PSH-AM sustav bodovanja) pokazao se korisnim za rano prepoznavanje i određivanje težine simptoma, a njegova primjena sve je češća u kliničkoj praksi. Kliničke strategije liječenja usmjerene su na smanjenje podražaja, modulaciju simpatičkog odgovora i sprječavanje oštećenja ciljnih organa. Ipak, ujedinjeni protokoli liječenja još ne postoje, a terapijski pristupi često ovise o iskustvu kliničara i dostupnim resursima. Osim lijekova, važnu ulogu u liječenju imaju i nefarmakološke mjere poput kontrole okoline, nutritivne podrške i fizikalne terapije, koje pridonose ublažavanju simptoma i prevenciji komplikacija. PAD može značajno produljiti hospitalizaciju, povećati rizik od sekundarnih oštećenja te negativno utjecati na dugoročni funkcionalni oporavak. Rana identifikacija, multidisciplinarni pristup i individualizirano liječenje ključni su za poboljšanje ishoda liječenja. S obzirom na utjecaj PAD-a na dugoročni neurološki ishod, nužna su daljnja istraživanja kako bi se razjasnila povezanost težine simptoma sa stupnjem oporavka te razvili precizniji dijagnostički i terapijski standardi koji bi bili primjenjivi u različitim kliničkim okruženjima.Paroxysmal autonomic dysfunction (PAD) most commonly occurs after acquired brain injuries, especially following traumatic brain injury, and is characterized by a cluster of symptoms including tachycardia, hypertension, tachypnea, elevated body temperature, sweating, and postural or movement abnormalities. Despite advances in understanding the clinical features of this syndrome, its pathophysiological mechanisms remain incompletely understood. The most commonly discussed theories include the disconnection theory, the excitation/inhibition ratio model and neuroendocrine disturbances. Early diagnosis of PAD remains challenging due to the nonspecific nature of its symptoms and limited diagnostic tools. The PAD assessment tool (PSH-AM scoring system) has proven useful for the early identification and grading of symptom severity and is increasingly adopted in clinical practice. Treatment strategies are generally focused on reducing external stimuli, modulating sympathetic activity, and preventing damage to target organs. However, standardized treatment protocols are still lacking, and therapeutic approaches often depend on clinician experience and available resources. In addition to pharmacological interventions, non-pharmacological measures such as environmental control, nutritional support, and physical therapy play an important role in symptom management and complication prevention. PAD can significantly prolong hospitalization, increase the risk of secondary injuries, and negatively affect long-term functional recovery. Early recognition, a multidisciplinary approach, and individualized treatment plans are essential for improving outcomes. Given PAD’s potential impact on long-term neurological prognosis, further research is needed to clarify the relationship between symptom severity and recovery, and to develop more precise diagnostic and therapeutic standards applicable across various clinical settings
Spinal muscular atrophy and pregnancy
No full textSpinalna mišićna atrofija (SMA) nasljedna je neurodegenerativna bolest koja zahvaća motoneurone prednjih rogova kralježnične moždine, što rezultira progresivnom mišićnom slabošću i atrofijom mišića. Trudnoća kod žena oboljelih od SMA predstavlja poseban klinički izazov koji je utemeljen na multisistemskoj prirodi bolesti, a koja uključuje moguće smetnje disanja, endokrinološke poremećaje, poremećaje koagulacije, povećan rizik različitih oblika anestezije i drugo.
Tijekom trudnoće dolazi do značajnih fizioloških i hormonskih promjena koje uzrokuju promjene u zdrave trudnice, ali i specifične promjene u trudnica sa SMA. Među ključnim prilagodbama ističu se povećanje minutnog volumena srca i ukupnog volumena krvi, pomicanje dijafragme sa smanjenjem respiratornog kapaciteta te brojne metaboličke i endokrinološke promjene. Oslabljena respiratorna muskulatura kod žena sa SMA može dodatno povećati rizik od respiratornih komplikacija, osobito u trećem tromjesečju i tijekom poroda. Također, oslabljena muskulatura zdjeličnog dna može otežati spontani vaginalni porod pa je nužna individualna procjena optimalnog načina poroda. Preporučuje se planirani porod u suradnji s multidisciplinarnim timom te primjena anestezije, najčešće epiduralne, kako bi se smanjili rizici povezani s općom anestezijom. Skrb o trudnici sa SMA zahtijeva koordiniran timski pristup u kojem sudjeluju neurolog, pulmolog, ginekolog i anesteziolog.
Neizostavan dio prekoncepcijske skrbi uključuje genetsko savjetovanje zbog autosomno recesivnog načina nasljeđivanja SMA. Postoji rizik prijenosa patogene varijante SMN1 gena na potomstvo u slučaju da je majka bolesna, a otac zdravi heterozigot, i u tom slučaju je vjerojatnost da dijete oboli od SMA 50%. U postpartalnom razdoblju potrebno je osigurati kontinuirano praćenje respiratorne funkcije majke te prilagoditi njegu novorođenčeta uzimajući u obzir moguća fizička ograničenja majke u skrbi.
Zaključno, trudnoća kod žena sa spinalnom mišićnom atrofijom zahtijeva individualiziran, pažljivo planiran i multidisciplinarno vođen pristup kako bi se osigurala optimalna skrb za majku i dijete te smanjili potencijalni rizici povezani s bolešću.Spinal muscular atrophy (SMA) is an inherited neurodegenerative disorder that affects the motor neurons of the anterior horns of the spinal cord, resulting in progressive muscle weakness and atrophy. Pregnancy in women with SMA poses a specific clinical challenge due to the multisystemic nature of the disease, which may include respiratory impairment, endocrine disturbances, coagulation disorders, and increased anesthetic risk.
During pregnancy, substantial physiological and hormonal changes occur that affect all pregnant women but may cause distinct complications in those with SMA. Key adaptations include increased cardiac output and blood volume, upward displacement of the diaphragm leading to reduced respiratory capacity, and numerous metabolic and endocrine alterations. Weakness of the respiratory muscles in women with SMA can further elevate the risk of respiratory complications, particularly in the third trimester and during labor. Additionally, pelvic floor muscle weakness may complicate spontaneous vaginal delivery, making individualized assessment of the optimal mode of delivery essential. A planned delivery involving a multidisciplinary team and regional anesthesia, most commonly epidural, is recommended to reduce the risks associated with general anesthesia. Care for pregnant women with SMA requires a coordinated team approach involving a neurologist, pulmonologist, obstetrician, and anesthesiologist.
Genetic counseling is a crucial component of preconception care due to the autosomal recessive inheritance pattern of SMA. There is a 50% risk of the child being affected if the mother has SMA and the father is a healthy carrier of a pathogenic SMN1 gene variant. In the postpartum period, continuous monitoring of maternal respiratory function is necessary, along with adapting newborn care to account for potential physical limitations of the mother.
In conclusion, pregnancy in women with spinal muscular atrophy demands an individualized, carefully planned, and multidisciplinary approach to ensure optimal maternal and neonatal outcomes while minimizing disease-related risks