researchgate...editorial board editor-in-chief izet masic secretary alma zejnilovic technical editor...

See discussions, stats, and author profiles for this publication at: https://www.researchgate.net/publication/41100597

Risk factors impact on the long-term survival after hemorrhagic stroke

Article in Medical Archives · January 2009

DOI: 10.5457/ams.101.10 · Source: PubMed

CITATIONS

2READS

723

5 authors, including:

Some of the authors of this publication are also working on these related projects:

[email protected] View project

The First Mediterranean Seminar on Science Writing, Editing & Publishing, Sarajevo, 2-3 December, 2016. View project

Adnan Burina

University Clinical Center Tuzla

52 PUBLICATIONS 67 CITATIONS

SEE PROFILE

Renata Hodzic


30 PUBLICATIONS 79 CITATIONS

SEE PROFILE

Osman Sinanović


537 PUBLICATIONS 1,950 CITATIONS

SEE PROFILE

All content following this page was uploaded by Osman Sinanović on 30 May 2014.

The user has requested enhancement of the downloaded file.

https://www.researchgate.net/publication/41100597_Risk_factors_impact_on_the_long-term_survival_after_hemorrhagic_stroke?enrichId=rgreq-67e410735b84f99da71033727674ba48-XXX&enrichSource=Y292ZXJQYWdlOzQxMTAwNTk3O0FTOjEwMjQ3MjQwODM3MTIwMUAxNDAxNDQyNzM0MzEw&el=1_x_2&_esc=publicationCoverPdfhttps://www.researchgate.net/publication/41100597_Risk_factors_impact_on_the_long-term_survival_after_hemorrhagic_stroke?enrichId=rgreq-67e410735b84f99da71033727674ba48-XXX&enrichSource=Y292ZXJQYWdlOzQxMTAwNTk3O0FTOjEwMjQ3MjQwODM3MTIwMUAxNDAxNDQyNzM0MzEw&el=1_x_3&_esc=publicationCoverPdfhttps://www.researchgate.net/project/selimbvhotmilcom?enrichId=rgreq-67e410735b84f99da71033727674ba48-XXX&enrichSource=Y292ZXJQYWdlOzQxMTAwNTk3O0FTOjEwMjQ3MjQwODM3MTIwMUAxNDAxNDQyNzM0MzEw&el=1_x_9&_esc=publicationCoverPdfhttps://www.researchgate.net/project/The-First-Mediterranean-Seminar-on-Science-Writing-Editing-Publishing-Sarajevo-2-3-December-2016?enrichId=rgreq-67e410735b84f99da71033727674ba48-XXX&enrichSource=Y292ZXJQYWdlOzQxMTAwNTk3O0FTOjEwMjQ3MjQwODM3MTIwMUAxNDAxNDQyNzM0MzEw&el=1_x_9&_esc=publicationCoverPdfhttps://www.researchgate.net/?enrichId=rgreq-67e410735b84f99da71033727674ba48-XXX&enrichSource=Y292ZXJQYWdlOzQxMTAwNTk3O0FTOjEwMjQ3MjQwODM3MTIwMUAxNDAxNDQyNzM0MzEw&el=1_x_1&_esc=publicationCoverPdfhttps://www.researchgate.net/profile/Adnan-Burina?enrichId=rgreq-67e410735b84f99da71033727674ba48-XXX&enrichSource=Y292ZXJQYWdlOzQxMTAwNTk3O0FTOjEwMjQ3MjQwODM3MTIwMUAxNDAxNDQyNzM0MzEw&el=1_x_4&_esc=publicationCoverPdfhttps://www.researchgate.net/profile/Adnan-Burina?enrichId=rgreq-67e410735b84f99da71033727674ba48-XXX&enrichSource=Y292ZXJQYWdlOzQxMTAwNTk3O0FTOjEwMjQ3MjQwODM3MTIwMUAxNDAxNDQyNzM0MzEw&el=1_x_5&_esc=publicationCoverPdfhttps://www.researchgate.net/institution/University-Clinical-Center-Tuzla?enrichId=rgreq-67e410735b84f99da71033727674ba48-XXX&enrichSource=Y292ZXJQYWdlOzQxMTAwNTk3O0FTOjEwMjQ3MjQwODM3MTIwMUAxNDAxNDQyNzM0MzEw&el=1_x_6&_esc=publicationCoverPdfhttps://www.researchgate.net/profile/Adnan-Burina?enrichId=rgreq-67e410735b84f99da71033727674ba48-XXX&enrichSource=Y292ZXJQYWdlOzQxMTAwNTk3O0FTOjEwMjQ3MjQwODM3MTIwMUAxNDAxNDQyNzM0MzEw&el=1_x_7&_esc=publicationCoverPdfhttps://www.researchgate.net/profile/Renata-Hodzic?enrichId=rgreq-67e410735b84f99da71033727674ba48-XXX&enrichSource=Y292ZXJQYWdlOzQxMTAwNTk3O0FTOjEwMjQ3MjQwODM3MTIwMUAxNDAxNDQyNzM0MzEw&el=1_x_4&_esc=publicationCoverPdfhttps://www.researchgate.net/profile/Renata-Hodzic?enrichId=rgreq-67e410735b84f99da71033727674ba48-XXX&enrichSource=Y292ZXJQYWdlOzQxMTAwNTk3O0FTOjEwMjQ3MjQwODM3MTIwMUAxNDAxNDQyNzM0MzEw&el=1_x_5&_esc=publicationCoverPdfhttps://www.researchgate.net/institution/University-Clinical-Center-Tuzla?enrichId=rgreq-67e410735b84f99da71033727674ba48-XXX&enrichSource=Y292ZXJQYWdlOzQxMTAwNTk3O0FTOjEwMjQ3MjQwODM3MTIwMUAxNDAxNDQyNzM0MzEw&el=1_x_6&_esc=publicationCoverPdfhttps://www.researchgate.net/profile/Renata-Hodzic?enrichId=rgreq-67e410735b84f99da71033727674ba48-XXX&enrichSource=Y292ZXJQYWdlOzQxMTAwNTk3O0FTOjEwMjQ3MjQwODM3MTIwMUAxNDAxNDQyNzM0MzEw&el=1_x_7&_esc=publicationCoverPdfhttps://www.researchgate.net/profile/Osman-Sinanovic-2?enrichId=rgreq-67e410735b84f99da71033727674ba48-XXX&enrichSource=Y292ZXJQYWdlOzQxMTAwNTk3O0FTOjEwMjQ3MjQwODM3MTIwMUAxNDAxNDQyNzM0MzEw&el=1_x_4&_esc=publicationCoverPdfhttps://www.researchgate.net/profile/Osman-Sinanovic-2?enrichId=rgreq-67e410735b84f99da71033727674ba48-XXX&enrichSource=Y292ZXJQYWdlOzQxMTAwNTk3O0FTOjEwMjQ3MjQwODM3MTIwMUAxNDAxNDQyNzM0MzEw&el=1_x_5&_esc=publicationCoverPdfhttps://www.researchgate.net/institution/University-Clinical-Center-Tuzla?enrichId=rgreq-67e410735b84f99da71033727674ba48-XXX&enrichSource=Y292ZXJQYWdlOzQxMTAwNTk3O0FTOjEwMjQ3MjQwODM3MTIwMUAxNDAxNDQyNzM0MzEw&el=1_x_6&_esc=publicationCoverPdfhttps://www.researchgate.net/profile/Osman-Sinanovic-2?enrichId=rgreq-67e410735b84f99da71033727674ba48-XXX&enrichSource=Y292ZXJQYWdlOzQxMTAwNTk3O0FTOjEwMjQ3MjQwODM3MTIwMUAxNDAxNDQyNzM0MzEw&el=1_x_7&_esc=publicationCoverPdfhttps://www.researchgate.net/profile/Osman-Sinanovic-2?enrichId=rgreq-67e410735b84f99da71033727674ba48-XXX&enrichSource=Y292ZXJQYWdlOzQxMTAwNTk3O0FTOjEwMjQ3MjQwODM3MTIwMUAxNDAxNDQyNzM0MzEw&el=1_x_10&_esc=publicationCoverPdf

Medicinski arhivčasopis ljekara/liječnika bih

• Godina 2009 • volumen 63 • broj 4 •

Medical Archivesjournal of physicians of BiH

• Year 2009 • Volume 63 • No 4 •

Časopis je indeksiran u bazama medline (www.pubmed.gov), ebsco (www.ebscohost.com)

and index copernicus (www.indexcopernicus.com)

ISSN 0350-199 X

Tije

šić P

etar

, Bro

d u

oluj

i, 19

69.

182 MED ARH 2009; 63(4) •

BOSNIAN JOURNAL OF BASIC MEDICAL SCIENCES 2009; 9 (1): 99-100

- Cre

dit p

hoto

: Cre

atas

, Mas

terfi

le, G

etty

imag

es -

GLB.

GLA.

06.0

6.01

The only once-daily peakless insulin

EDITORIAL BOARDEditor-In-Chief

Izet MasicSecretary

Alma ZejnilovicTechnical editor

Mirza HamzicLectors: Lejla Masic,Dubravko Vanicek

MEMBERS OF THE BOARD

Sebija Izetbegovic (Sarajevo, BiH)), Izet Hozo (Split, Croatia), Zlatko

Hrgovic (Franfurt, Germany), Zdenka Krivokuca (Banja Luka,BiH)), Dragica Milinkic (Sydney, Australia),

Sahib Muminagic (Zenica, BiH), Ljerka Ostojic (Mostar, BiH),

Haris Pandza (Sarajevo,BiH), Enra Suljic-Mehmedika (Sarajevo,BiH), Selim Toromanovic (Bihac,BiH), Narcisa Vavra-Hadziahmetovic

(Sarajevo,BiH), Muharem Zildzic (Tuzla,BiH), Adnan Zubovic (Oxford,

UK)

ADDRESS OF THE BOARD

Sarajevo, Cekalusa 90,Tel: +387 33 444 714,e-mail: [email protected]

www.avicenapublisher.org

PUBLISHED BYAvicena d.o.o., Sarajevo,

Zaima Sarca 43,Bank account:

UNION banka Sarajevo, br.:1020500000020077

SWIFT Code UBKSBA22, Deutsche Bank AG, Franfurt am Main

(DEUTDEFF), Account No. 9365073 10 (EUR).

Medical Archive journal is published five to six times per year (Feb,

Apr, Jun, Oct, Dec). Subscription for individuals is 50 euros, for

institutions 100 euros, and includes VAT and postal services.

Journal is indexed in MEDLINE, EBSCO and

INDEX COPERNICUS–IC (ICV for 2008 is 5,55)

EDITORIAL184 The Role of European National Journals in Education

ORIGINAL PAPERS187 Imunosupresivni tretman idiopatskog membranoznog glomerulonefritisa sa nefrotskim

sindromom Immunosuppressive Treatment of Idiopathic Membranous Glomerulonephritis with Nephrotic Syndrome

Alma Muslimović, Senija Rašić, Damir Rebić, Snežana Unčanin

191 Korelacija koronarne bolesti kod bolesnika sa Diabetes mellitusom tip 2 Correlation of Coronary Disease in Patients with Diabetes Mellitus Type 2

Mirsada Terzić-Avdagić

194 Stroke in Diabetic Patients in Cantonal Hospital ZenicaAzra Alajbegovic, Salem Alajbegovic

197 Učestalost i klinička fenomenologija afazičkih poremećaja nakon moždanog udara Incidence and Clinical Phenomenology of Aphasic Disorders After Stroke

Ensala Brkić, Osman Sinanović, Mirjana Vidović, Dževdet Smajlović

200 Antenatalni kortikosteroidi u prevenciji respiratornog distres sindroma: učinkovitost u odnosu na tretman-porod interval

Antenatal Corticosteroids in Respiratory Distress Syndrome Prevention: Efficacy in Relation to Treatment-Delivery IntervalSuada Heljić, Hajrija Maksić, Verica Mišanović, Jadranka Dizdarević

203 Risk Factors Impact on the Long-term Survival After Hemorrhagic StrokeBiljana Kojic, Adnan Burina, Renata Hodzic, Zejneba Pasic, Osman Sinanovic

207 Intrahospitalne infekcije i antimikrobna rezistencija u Univerzitetskom kliničkom centru Tuzla

Intrahospital Infections and Antimicrobial Resistance at University Clinical Center TuzlaAmer Čustović, Sadeta Hadžić

212 Drug Abuse in Prishtina RegionSanije Gashi, Naser Ramadani, Merita Berisha, Musli Gashi, Valbona Zhjeqi, Rina Hoxha

216 Factors Associated with Reintegration to Normal Living After StrokeArdiana Murtezani, Hajrie Hundozi, Sanie Gashi , Teuta Osmani, Valbona Krasniqi, Bukurie Rama

220 Alternating Esotropia and Surgical Correction in Both EyesMire Shoshi, Avdyl Shoshi, Aferdita Bakalli

223 Ablacija retine u različitim miopnim refrakcijama Retinal Detachment in Various Myopic Refractions

Emina Alimanović-Halilović

225 Comparative Advantages and Shortcomings of Corticosteroids in Comparison with Xylocaine-based Perineural Blocks in Treatment of Bell’s PalsyBenjamin Bejtovic, Muhamed Ajanovic, Redzep Dizdarevic

PROFESSIONAL PAPERS228 Adverse Reactions in Estimation of MMR Vaccination Validation in Bosnian Population

Slobodan Trninic, Adnan Bajraktarevic

231 Rheumatic Fever in Kosova – Long Term StudyMyrvete I. Kelmendi

CASE REPORT234 Minimalno invazivna hirugija patoloških prijeloma kičme – vertebroplastika i kifoplastika

na Klinici za ortopediju i traumatologiju Kliničkog centra Univerziteta u Sarajevu Minimally Invasive Surgery of Pathologic Spine Fractures – Vertebroplasty and Kyphoplasty at Department for

Orthopedics and Traumatology of Clinical Centre University of Sarajevo

Mirza Biščević, Azmi Hamzaoglu, Farid Ljuca, Ismet Gavrankapetanović, Amra Nadarević, Barbara Rejec-Smrke, Dragica Smrke

238 IN MEMORIAM Prof. Dr. Dušan Vukotić (1920. – 2009.)

contents

184 MED ARH 2009; 63(4) • UVODNIK / EDITORIAL

The Role of European National Journals in Education

The Editors’ Network of the European Society of Cardiol-ogy (ESC) defined its mission in the statement published across the national cardiac journals of Europe in 2008 (1). The Network is now considering ways in which their publi-cations can have a broader influence in the field of postgraduate education.

The need for Cardiologists to con-tinue to learn throughout their profes-sional life will remain essential. Indeed recognition for the need for postgradu-ate education was highlighted by Hip-pocrates long before it was espoused

by the Medication Educationalists and Public Relations Departments. “Ars longa, vita brevis” is the Latin transla-tion of Hippocrates’ recognition that for a doctor, the need to continue learning the art of medicine, lasts for all of our professional life. In me-dieval times, the foun-dation of modern day ethical medical prac-tice was laid within the heart of the Universities; the long term future of the medical profession was founded in the con-cept of doctors as men, and women, of learning and knowledge, rather than the purveyors of non-scientifically based remedies.

So how does the modern day Editor of a National Cardiology Journal, crouched over his computer screen, relate to his medieval predecessor, the Abbot in charge of the Uni-

versity Library selecting the books for scholarly enterprise? The most obvious difference, of course, is that the Inter-net provides modern day authors with easy access to the Editor and conse-quently the Editor is obliged to make judgements on a much larger number of manuscripts than his predecessor would have been asked to do (Figure 1). The academic effort however is po-tentially very valuable, allowing the Ed-itor to accumulate a current wisdom of which writers combine both the knowl-edge of cardiovascular medicine, with the style with which to communicate that knowledge, in an authoritative way to doctors who wish to learn.

What are the characteristics of doctors who wish to learn? As adults, they prefer a self-directed approach, in which they identify their own learning needs, formulate learning objectives, identify resources to achieve these ob-jectives and evaluate their own learn-ing (2). Medical journals provide a ready resource for meeting the aims of self-directed learning, particularly through their commentary and review articles, but the value of the resource is critically dependent on the quality of the content, which in turn depends on three factors:

1. Subject selection: ideally this should be curriculum-based, the core curriculum of the ESC intending to provide a framework for the continuing medical education of the general Euro-pean Cardiologist. Both mainstream and more peripheral subject matter

The Role of European National Journals in EducationPeter Mills MD(*), Adam Timmis MD(a), Kurt Huber MD, Hugo Ector MD(b), Patrizio Lancellotti MD, Izet Masic MD, Mario Ivanusa MD, Loizos Antoniades MD, Michael Aschermann MD, Alexandras Laucevicius MD, Pirjo Mustonen MD, Jean-Yves Artigou MD, Panos Vardas MD(c), Christodoulos Stefanadis MD, Massimo Chiarello MD, Leonardo Bolognese MD, Giuseppe Ambrosio MD(d), Ernst E. van der Wall MD, Piotr Kułakowski MD(e), Fausto J. Pinto MD(f), Eduard Apetrei MD, Rafael G. Oganov MD, Gabriel Kamensky MD, Thomas F. Lüscher MD, René Lerch MD, Habib Haouala MD, Vedat Sansoy MD, Valentin Shumakov MD, Carlos Daniel Tajer MD(+), Chu-Pak Lau MD(+), Manlio Márquez MD(+), Rungroj Krittayaphong MD(+), Kaduo Arai MD(+) and Fernando Alfonso MD(g)

European Society of Cardiology (ESC) National Society Cardiovascular Journals Editors and (+) ESC Affiliated Societies Cardiovascular Journals Editors, see Appendix for complete affiliations(*) Education Editor, Heart (UK), Editor´s Network Task Force: (a) Editor-in-Chief, Heart (UK), (b) Editor-in-Chief, Acta Cardiologica (BE), (c) Editor-in-Chief, Hellenic Journal of Cardiology (GR), (d) Former Editor-in-Chief, Gionale Italiano di Cardiologia (IT), (e) Editor-in-Chief, Kardiologia Polska (PL), (f) Editor-in-Chief, Revista Portuguesa de Cardiologia (PT), (g) Editor-in-Chief, Revista Española de Cardiología (ES) and chairperson of the Editors’ Network

This manuscript will be simultaneously published in all ESC National Societies and ESC Affiliated Societies’ cardiovascular journals that consented to publicationThe Editors’ Network of the European Society of Cardiology (ESC) defined its mission in the

statement published across the national cardiac journals of Europe in 2008 (1). The Network is now considering ways in which their publications can have a broader influence in the field of postgraduate education. The need for Cardiologists to continue to learn throughout their professional life will remain essential. Indeed recognition for the need for postgraduate education was highlighted by Hippocrates long before it was espoused by the Medication Educationalists and Public Relations Departments. “Ars longa, vita brevis” is the Latin translation of Hippocrates’ recognition that for a doctor, the need to continue learning the art of medicine, lasts for all of our professional life. In medieval times, the foundation of modern day ethical medical practice was laid within the heart of the Universities; the long term future of the medical profession was founded in the concept of doctors as men, and women, of learning and knowledge, rather than the purveyors of non-scientifically based remedies. So how does the modern day Editor of a National Cardiology Journal, crouched over his computer screen, relate to his medieval predecessor, the Abbot in charge of the University Library selecting the books for scholarly enterprise? The most obvious difference, of course,

is that the Internet provides modern day authors with easy access to the Editor and consequently the Editor is obliged to make judgements on a much larger number of manuscripts than his predecessor would have been asked to do (Figure). The academic effort however is potentially very valuable, allowing the Editor to accumulate a current wisdom of which writers combine both the knowledge of cardiovascular medicine, with the style with which to communicate that knowledge, in an authoritative way to doctors who wish to learn. What are the characteristics of doctors who wish to learn? As adults, they prefer a self-directed approach, in which they identify their own learning needs, formulate learning objectives, identify resources to achieve these objectives and evaluate their own learning (2). Medical journals provide a ready resource for meeting the aims of self-directed learning, particularly through their commentary and review articles, but the value of the resource is

critically dependent on the quality of the content, which in turn depends on three factors:

1. Subject selection: ideally this should be curriculum-based, the core curriculum of the ESC intending to provide a framework for the continuing medical education of the general European Cardiologist. Both mainstream and more peripheral subject matter are required for comprehensive educational coverage, and so there will be a need for updates, particularly in areas where new discoveries are proceeding most rapidly. 2. Author selection: Editors are in an unrivalled position to select from currently active authors, those best able to educate others based on their subspecialty expertise and writing skills. Clear presentation must be coupled with the intellectual rigor to back up assertions with evidence derived from critical appraisal of the relevant literature. 3. Presentation: this should be designed to help stimulate the reader, using highly structured content, relevant illustrations, summary box displays, and annotated references that allow the reader to refer back to source material.

Figure 1. “Internet provides modern day authors with easy access to the Editor”

Adults who wish to learn, however, require more of medical journals than high quality commentary and review articles. They also require educational feed-back provided by accrediting organisations in order to consolidate their learning and acquire the continuing medical education (CME) credits that in many countries are becoming an essential

requirement for practising doctors. The European Board for Accreditation in Cardiology (EBAC), for example, requires that cardiologists earn a minimum of 250 CME credits over a period of 5 years, 125 of which must be “external CMEs” from formally planned external activities, including educational articles (3). The EBAC accreditation policy for CME articles is summarised in Table 1 and includes

a requirement for “an objective evaluation instrument”, recommending the use of a multiple choice questionnaire (MCQ) made available on-line. Articles of ~3,500 words and 6 MCQs are considered equivalent to 1 hour of educational activity and provide 1 CME credit. Nearly all the national cardiac journals of Europe carry high quality review articles (4-7) (Table 2). Heart, the UK-based international cardiac journal, has been a leader in the field of journal-based education for 10 years (8), and currently accounts for >95% of educational

articles attracting CME credits on the EBAC web site. Its educational section runs semi-autonomously within the journal under the direction of a dedicated editor and a team of specialist advisors. Education in Heart is available for free access via the Heart and ESC web sites (9,10) and its articles are among the most highly accessed of all the journal’s papers, consistently appearing in the top ten web-downloads during 2008 (11-15). High quality educational content with provision of local CME credits is also available in other national cardiac journals (16-17) (Table 2) and The Editors’ Network now provides a real opportunity to extend

these educational initiatives throughout the national cardiology journals of Europe (10).

Table 1. Summary EBAC criteria for accreditation of CME articles Internationally recognised authors Disclosure of conflicts of interest No advertising within article Provision of objective evaluation instrument

(MCQs) Web-based system for provision of CME certificate

if ≥60% of questions are answered correctly

Table 2. Questionnaire on Education Issues : ESC National Society Cardiovascular Journals A) Currently Published Articles: 84% Journals publish Editorials (63% peer-reviewed) 92% Journals publish Review Articles (83% peer-reviewed) 82% Journals publish Supplements (62% peer-reviewed) B) Clinical Practice Guidelines (CPG): 79% Journals publish CPG: - 67% National CPG - 73% ESC CPG: - 50% translated into national languages - 36% in English - 14% translated into national languages and in English C) Continuous Medical Education (CME) 42% Journals have CME programs 32% Journals obtain national CME credits 76% Journals would be interested in obtaining ESC CME credits D) Interest in Additional Educative Material: 92% Journals interested in ESC joint educative papers 92% Journals interested in “occasional” publication of educative material directly organized by the ESC 71% Journals consider that educative material need not to be distinct/country focused 82% Journals believe that both undergraduate and postgraduate education should be covered ESC= European Society of Cardiology. A 38 item questionnaire was devised by the Editor´s Network Nucleus and sent to ESC National Journal Editors (44 National Societies and 16 Affiliated Societies). Data was obtained from 38 National Journals (33 National Society Journals - 75% response rate - and 5 Affiliated Societies Journals)

Adults who wish to learn, however, require more of medical journals than high quality commentary and review articles. They also require educational feed-back provided by accrediting organisations in order to consolidate their learning and acquire the continuing medical education (CME) credits that in many countries are becoming an essential

requirement for practising doctors. The European Board for Accreditation in Cardiology (EBAC), for example, requires that cardiologists earn a minimum of 250 CME credits over a period of 5 years, 125 of which must be “external CMEs” from formally planned external activities, including educational articles (3). The EBAC accreditation policy for CME articles is summarised in Table 1 and includes

a requirement for “an objective evaluation instrument”, recommending the use of a multiple choice questionnaire (MCQ) made available on-line. Articles of ~3,500 words and 6 MCQs are considered equivalent to 1 hour of educational activity and provide 1 CME credit. Nearly all the national cardiac journals of Europe carry high quality review articles (4-7) (Table 2). Heart, the UK-based international cardiac journal, has been a leader in the field of journal-based education for 10 years (8), and currently accounts for >95% of educational

articles attracting CME credits on the EBAC web site. Its educational section runs semi-autonomously within the journal under the direction of a dedicated editor and a team of specialist advisors. Education in Heart is available for free access via the Heart and ESC web sites (9,10) and its articles are among the most highly accessed of all the journal’s papers, consistently appearing in the top ten web-downloads during 2008 (11-15). High quality educational content with provision of local CME credits is also available in other national cardiac journals (16-17) (Table 2) and The Editors’ Network now provides a real opportunity to extend

these educational initiatives throughout the national cardiology journals of Europe (10).

Table 1. Summary EBAC criteria for accreditation of CME articles Internationally recognised authors Disclosure of conflicts of interest No advertising within article Provision of objective evaluation instrument

(MCQs) Web-based system for provision of CME certificate

if ≥60% of questions are answered correctly

Table 2. Questionnaire on Education Issues : ESC National Society Cardiovascular Journals A) Currently Published Articles: 84% Journals publish Editorials (63% peer-reviewed) 92% Journals publish Review Articles (83% peer-reviewed) 82% Journals publish Supplements (62% peer-reviewed) B) Clinical Practice Guidelines (CPG): 79% Journals publish CPG: - 67% National CPG - 73% ESC CPG: - 50% translated into national languages - 36% in English - 14% translated into national languages and in English C) Continuous Medical Education (CME) 42% Journals have CME programs 32% Journals obtain national CME credits 76% Journals would be interested in obtaining ESC CME credits D) Interest in Additional Educative Material: 92% Journals interested in ESC joint educative papers 92% Journals interested in “occasional” publication of educative material directly organized by the ESC 71% Journals consider that educative material need not to be distinct/country focused 82% Journals believe that both undergraduate and postgraduate education should be covered ESC= European Society of Cardiology. A 38 item questionnaire was devised by the Editor´s Network Nucleus and sent to ESC National Journal Editors (44 National Societies and 16 Affiliated Societies). Data was obtained from 38 National Journals (33 National Society Journals - 75% response rate - and 5 Affiliated Societies Journals)

185MED ARH 2009; 63(4) • UVODNIK / EDITORIAL


are required for comprehensive educa-tional coverage, and so there will be a need for updates, particularly in areas where new discoveries are proceeding most rapidly.

2. Author selection: Editors are in an unrivalled position to select from cur-rently active authors, those best able to educate others based on their subspe-cialty expertise and writing skills. Clear presentation must be coupled with the intellectual rigor to back up assertions with evidence derived from critical ap-praisal of the relevant literature.

3. Presentation: this should be de-signed to help stimulate the reader, us-ing highly structured content, relevant illustrations, summary box displays,

and annotated references that allow the reader to refer back to source material.

Adults who wish to learn, however, require more of medical journals than high quality commentary and review articles. They also require educational feed-back provided by accrediting or-ganisations in order to consolidate their learning and acquire the continuing medical education (CME) credits that in many countries are becoming an es-sential requirement for practising doc-tors. The European Board for Accred-itation in Cardiology (EBAC), for ex-ample, requires that cardiologists earn a minimum of 250 CME credits over a period of 5 years, 125 of which must be “external CMEs” from formally planned

external activities, including educa-tional articles (3). The EBAC accredi-tation policy for CME articles is sum-marised in Table 1 and includes a re-quirement for “an objective evaluation instrument”, recommending the use of a multiple choice questionnaire (MCQ) made available on-line. Articles of ~3,500 words and 6 MCQs are consid-ered equivalent to 1 hour of educational activity and provide 1 CME credit.

Nearly all the national cardiac jour-nals of Europe carry high quality re-view articles (4-7) (Table 2). Heart, the UK-based international cardiac jour-nal, has been a leader in the field of journal-based education for 10 years (8), and currently accounts for >95% of educational articles attracting CME credits on the EBAC web site. Its educa-tional section runs semi-autonomously within the journal under the direction of a dedicated editor and a team of spe-cialist advisors. Education in Heart is available for free access via the Heart and ESC web sites (9,10) and its articles are among the most highly accessed of all the journal’s papers, consistently ap-pearing in the top ten web-downloads during 2008 (11-15). High quality edu-cational content with provision of local CME credits is also available in other national cardiac journals (16-17) (Ta-ble 2) and The Editors’ Network now provides a real opportunity to extend these educational initiatives through-out the national cardiology journals of Europe (10).

REfERENcEs1. Alfonso F, Ambrosio G, Pinto FJ, Van der

Wall EE, Kondili A, Nibouche D, Ada-myan K, Huber K, Ector H, Masic I, Tar-novska R, Ivanusa M, Staněk V, Videbæk J, Hamed M, Laucevicius A, Mustonen P, Artigou J-Y,Cohen JY, Rogava M, Böhm M, Fleck E, Heusch G, Klawki R, Var-das P, Stefanadis C, Tenczer J, Chiari-ello M, Elias J, Benjelloun H, Rødevand O, Kułakowski P, Apetrei E, Lusov VA, Oganov RG, Obradovic V, Kamensky G, Kenda MF, Höglund C, Lüscher TF, Le-rch R, Jokhadar M, Haouala H, Sansoy V, Shumakov V, Timmis A. European National Society cardiovascular jour-nals. Background, Rationale and Mission Statement of the “Editors’ Club” (Task Force of the European Society of Cardi-ology). Heart. 2008;94:e19

2. Kaufman DM. ABC of learning and teach-ing in medicine: Applying educational the-ory in practice. BMJ 2003; 326: 213 – 216

3. European Board for Accreditation in Car-diology. http://www.ebac-cme.org/index.

AppendixJournal names (by alphabetic order of country origin and members (Editors-in-chief of the Editors’ Network) National Society Name National Society Journal Editor-in-Chief Austrian Society of Cardiology Journal für Kardiologie* Kurt Huber Belgian Society of Cardiology Acta Cardiologica Hugo Ector Patrizio Lancellotti Association of Cardiologists of Bosnia and Herzegovina Medicinski Arhiv Izet Masic Croatian Cardiac Society Kardio List Mario Ivanusa Cyprus Society of Cardiology Cyprus Heart Journal Loizos Antoniades Czech Society of Cardiology Cor et Vasa Michael Aschermann Estonian Society of Cardiology Seminars in Cardiovascular Medicine** Alexandras Laucevicius Finnish Cardiac Society Sydänääni (Heart Beat) Pirjo Mustonen French Society of Cardiology Archives des maladies du cœur et des vaisseaux Pratique Jean-Yves Artigou Hellenic Cardiological Society Hellenic Journal of Cardiology Panos Vardas Christodoulos Stefanadis Italian Federation of Cardiology Journal of Cardiovascular Medicine Massimo Chiarello Giornale Italiano Di Cardiologia Leonardo Bolognese Latvian Society of Cardiology Seminars in Cardiovascular Medicine** Alexandras Laucevicius Lithuanian Society of Cardiology Seminars in Cardiovascular Medicine** Alexandras Laucevicius Netherlands Society of Cardiology Netherlands Heart Journal Ernst E. van der Wall Polish Cardiac Society Kardiologia Polska – Polish Heart Journal Piotr Kułakowski Portuguese Society of Cardiology Revista Portuguesa de Cardiologia Fausto J. Pinto Romanian Society of Cardiology Revista Română de Cardiologie Eduard Apetrei Russia Fed Society of Cardiology Cardiovascular Therapy and Prevention Rafael G. Oganov Rational Pharmacotherapy in Cardiology Rafael G. Oganov Slovak Society of Cardiology Kardiológia Gabriel Kamensky Spanish Society of Cardiology Revista Española de Cardiología Fernando Alfonso Swiss Society of Cardiology Kardiovaskuläre Medizin Thomas F. Lüscher Médecine Cardiovasculaire René Lerch Tunisian Society of Cardiology Cardiologie Tunisienne Habib Haouala Turkish Society of Cardiology Archives of the Turkish Society of Cardiology Vedat Sansoy Ukrainian Association of Cardiology Ukrainian Journal of Cardiology Valentin Shumakov British Cardiovascular Society Heart Adam Timmis Affiliated Society Name Affiliated Society Journal Editor-in-Chief Argentine Society of Cardiology Revista Argentina de Cardiologia Carlos Daniel Tajer Hong Kong College of Cardiology Journal of the Hong Kong College of Cardiology Chu-Pak Lau Mexican Society of Cardiology Archivos de Cardiología de México Manlio Márquez Heart Association of Thailand Thai Heart Journal Rungroj Krittayaphong Venezuelan Society of Cardiology Avances Cardiológicos Kaduo Arai * Not official National Society journal, but major cardiology journal in Austria ** Common journal for the Baltic countries

186 MED ARH 2009; 63(4) • UVODNIK / EDITORIAL


php (accessed 18/9/09)4. Ramos PM, Martínez VB, Granado JQ,

Juanatey JR. [Advances in hypertension and diabetes in 2007]. Rev Esp Cardiol. 2008;61 Suppl 1:58-71.

5. Selton-Suty C, Juillière Y. Non-invasive investigations of the right heart: How and why? Arch Cardiovasc Dis. 2009;102:219-32.

6. Maas AH, Franke HR. Women’s health in menopause with a focus on hyperten-sion. Neth Heart J. 2009;17:68-72

7. Stefanatou A. Smoking cessation in car-diovascular patients. Hellenic J Cardiol. 2008;49:422-31.

8. Timmis AD. Education in Heart: 10th anniversary. Heart 2009;95:1555

9. Heart. http://heart.bmj.com (accessed

18/9/09)10. European Society of Cardiology. http://

www.escardio.org/membership/na-tional-societies/Pages/journals.aspx (ac-cessed 18/9/09)

11. Peter R, Cox A, Evans M. Management of diabetes in cardiovascular patients. Heart 2008; 94: 369-375.

12. Grayburn PA. How to measure severity of mitral regurgitation. Heart 2008 94: 376-383

13. Konstantinides SV. Acute pulmonary embolism revisited. Heart 2008 94: 795-802

14. Wu AH. Cardiotoxic drugs: clinical mon-itoring and decision making. Heart 2008; 94: 1503-1509.

15. Jukema JW, Bergheanu SC. Statins: es-

tablished indications and controversial subgroups. Heart 2008; 94: 1656-1662.

16. Cruz-González I, Solis J, Inglessis-Azuaje I, Palacios IF. Patent foramen ovale: cur-rent state of the art. Rev Esp Cardiol. 2008;61:738-51

17. Badimon L, Vilahur G. Coronary ath-erothrombotic disease: progress in an-tiplatelet therapy. Rev Esp Cardiol. 2008;61:501-13.

Address for correspondence: Adam Timmis MD, Dept cardiology, London chest

Hospital, Bonner Road, London E2 9JX, United Kingdom (email: [email protected])

Instructions for the authors of the journal Medical Archives

All papers need to be sent electronical-ly by web page: www.avicenapublisher.org : Print version and signed copyright form need to be sent by post to the Edito-rial board of journal Med Arh. Faculty of medicine, Cekalusa str. 90, 71000 Sarajevo, BiH. Every sent article gets its number, and author(s) will be notified if their paper is accepted and what is the number of paper. Every correspondence will use that number.The paper has to be typed on a standard size paper (format A4), leaving left margins to be at least 3 cm. All materials, including tables and references, have to be typed dou-ble-spaced, so one page has no more than 2000 alphanumerical characters (30 lines). Sent paper needs to in the form of triplicate, considering that original one enclosure of the material can be photocopy. Presenting paper depends on its content, but usually it consists of a title page, summary, text ref-erences, legends for pictures and pictures.

Title pageEvery article has to have a title page with a title of no more than 10 words: name(s), last and first of the author(s), name of the insti-tution the author(s) belongs to, abstract with maximum of 45 letters (including space), footnote with acknowledgments, name of the first author or another person with who correspondence will be maintained.

SummaryThe paper needs to contain structured sum-mary (goal, methods, results, discussion, and conclusion) containing up to 300 words, including title, initials of the first name and the last name of the author as well as the name of the institution. The summa-ry has to contain a list of 3 to 4 keywords

Central part of the articleAuthentic papers contain these parts: intro-duction, goal, methods, results, discussion and conclusion. Introduction is brief and clear review of problem. Methods are shown so that interested reader is able to repeat described research. Known methods don’t need to be identified, it is cited (referenced). If drugs are listed, their genetic name is used (brand name can be written in brackets). Re-sults need to be shown clearly and logically, and their significance proven by statistical analysis. In discussion, results are inter-preted and compared to existing, previously published findings in the same field. Conclu-sions have to give an answer to author’s goal.

ReferencesQuoting references must be in a scale in which they are really used. Quoting most recent literature is recommended. Only published articles (or articles accepted for publishing) can be used as references. Not-published observations and personal notifi-cations need to be in text in brackets. Show-ing references is as how they appear in text. References cited in tables or pictures are also numbered according to quoting order. Citing paper with six or less authors must have cited names of all authors; if seven or more authors’ wrote the paper, the name of the first three authors are cited with a note “et all”. If the author is unknown, at the beginning of papers reference, the ar-ticle is named as “unknown”. Titles of the publications are abbreviated in accordance to Index Medicus, but if not listed in the index, whole title of the journal has to be written. Footnote – comments, explana-tions, etc., cannot be used in the paper.

Statistical analysisTests used for statistical analysis need to be shown in text and in tables or pic-tures containing statistical analysis.

Tables and picturesTables have to be numbered and shown by their order, so they can be understood with-out having to read the paper. Every column needs to have title, every measuring unit (SI) has to be clearly marked, preferably in footnotes below the table, in Arabian numbers or symbols. Pictures also have to be numbered as they appear in text. Draw-ings need to be enclosed on a white paper or tracing paper, while black and white photo have to be printed on a radiant pa-per. Legends next to pictures and photos have to be written on a separate A4 for-mat paper. All illustrations (pictures, draw-ings, diagrams) have to be original and on their backs contain illustration number, first author last name, abbreviated title of the paper and picture top. It is appreciated if author marks the place for table or picture.

Use of abbreviationsUse of abbreviations has to be re-duced to minimum. Conventional units can be used without their definitions.

SupplementIf paper contains original contribution to a statistical method or author believes, with-out quoting original computer program, papers value will be reduced, Editorial staff will consider possibility of publishing math-ematical/statistical analysis in-extenso.Papers with the following failure will not be accepted for publishing: grammatically or technically incorrect, materials do not rep-resent original work by author and author(s) have to sign statement that submitted paper has not been published, nor is it currently un-der consideration for publication elsewhere.

187MED ARH 2009; 63(4) • ORIGINALNI ČLANCI / ORIGINAL PAPERS

Imunosupresivni tretman idiopatskog membranoznog glomerulonefritisa sa nefrotskim sindromom

1. UVODMembranozni glomerulonefritis

(MGN) je jedan od najčešćih uzroka ne-frotskog sindroma u odraslih i u grupi primarnih glomerulonefritisa vodeći je uzrok renalne insuficijencije (1). U ne-kih pacijenata bolest pokazuje benigan tok, sa mogućnošću pojave spontanih, kompletnih ili parcijalnih remisija ne-frotskog sindroma u 20 do 30 % sluča-jeva. Uprkos tome, u 30–50 % pacije-nata bolest napreduje prema terminal-noj renalnoj insuficijenciji unutar 5-15 godina (2). Proteinurija je posljedica li-tičkog djelovanja komponenti komple-menta C5b-9 (terminalni MAC kom-pleks) na podocite. Odgovor podocita na C5b-9 uključuje povećanu ekspresiju gena za proizvodnju oksidanata, prote-aza, prostaglandina, faktora rasta, tran-sformirajućeg faktora rasta (TGF) i re-ceptora TGF, što vodi povećanoj proi-zvodnji komponenti ekstracelularnog matriksa i rezultira depozitnim forma-cijama u obliku “šiljka” (3). Patološki nalaz u membranoznoj glomerulopa-tiji predstavljaju normocelularni glo-meruli, sa subepitelnim depozitima na spoljašnjoj površini glomerularne ba-zalne membrane (4)

Tretman primarnog MGN je još uvi-jek kontraverzan i podrazumjeva nei-munosupresivnu i imunosupresivnu te-rapiju. Rasprave oko tretmana i odabira protokola liječenja traju i dalje. Zbog značajnog broja pacijenata, koji ulaze u spontanu remisiju bez terapije, većina autora imunosupresivni tretman rezer-viraju za pacijente sa perzistentnom ne-frotskom proteinurijom i reduciranom bubrežnom funkcijom (5). Racionalna terapijska strategija podrazumijeva pri-mjenu odgovarajućeg konzervativnog tretmana u nisko rizičnoj skupini, sa urednom bubrežnom funkcijom i imu-nosupresivnu terapiju u visoko rizičnoj skupini, sa sniženom bubrežnom funk-cijom i nefrotskim sindromom (6,7). Neke od terapijskih mogućnosti uklju-čuju: kortikosteroide u kombinaciji sa citotoksičnim lijekovima (hlorambucil ili ciklofosfamid) i ciklosporin. Nove terapijske alternative podrazumijevaju primjenu vakcina, inhibitore aktivatora tkivnog plazminogena, humana mono-klonalna antitijela, mikofenolat mofetil (MMF), pentoksifilin i drugo.

Cilj rada je komparirati terapijske efekte kombinacije kortikosteroida i ci-klofosfamida, kao i primjene ciklospo-rina u pogledu efekata na nivo protei-

Imunosupresivni tretman idiopatskog membranoznog glomerulonefritisa sa nefrotskim sindromomImmunosuppressive Treatment of Idiopathic Membranous Glomerulonephritis with Nephrotic SyndromeAlma Muslimović, Senija Rašić, Damir Rebić, Snežana UnčaninKlinika za nefrologiju, Klinički centar Univerziteta u Sarajevu, Bosna i Hercegovina

ORIgINALNI čLANAKsAŽETAKCilj: U radu su analizirani efekti dva terapijska protokola u pogledu uticaja na nivo proteinurije, vrijednost serum-skog kreatinina, vrijednost kreatinin klirensa i nivo serumskih albumina u pacijenata sa idiopatskim membra-noznim glomerulonefritisom (IMGN) i nefrotskim sindromom (NS). Pacijenti i metode: Ispitivanje je obuhvatilo 30 pacijenata sa IMGN i NS. U jednoj grupi su pacijenti, tretirani kombinacijom kortikosteroida u dozi od 1 mg/kg TT 4 nedjelje, a potom 0,5 mg/kg TT, uz postepenu redukciju doze i bolusima i.v. ciklofosfamida u dozi od 10 mg/kg tj.težine jednom mjesečno do šest mjeseci, a potom u tromjesečnim intervalima. U drugoj grupi su pacijenti tretirani ciklosporinom u dozi od 3-5 mg/kg tj. težine, uz održavanje serumskog nivoa lijeka od 120 ± 20 ng/ml. Istraživanje je obuhvatilo period od 2000. do kraja 2007. godine, a kontrolirani su parametri svaka 2 do ukupno 24 mjeseca. Rezultati rada: Rezultati istraživanja ukazuju da je u obje ispitivane grupe postignuta signifikanta redukcija proteinurije (p

188 MED ARH 2009; 63(4) • ORIGINALNI ČLANCI / ORIGINAL PAPERS


nurije, nivo serumskog kreatinina, vri-jednost glomerularne filtracije i vrijed-nost serumskih albumina.

2. IspITANIcI I METOD RADAU studiju retrospektivno-prospek-

tivnog karaktera, uključeno je 30 paci-jenata oba spola, starijih od 18 godina, sa dijagnosticiranim primarnim mem-branoznim glomerulonefritisom. Svi pacijenti su liječeni na Klinici za ne-frologiju i praćeni kroz nefrološko sa-vjetovalište Kliničkog centra Univer-ziteta u Sarajevu. Studija je obuhvatila period od 2000. do kraja 2007. godine, s prosjekom praćenja terapijskih efekata po pacijentu u trajanju od najmanje 1 godine. Od pojave subjektivnih tegoba pacijenta do započinjanja tretmana, po-stojao je vremenski period od 6 mjeseci, bez pojave spontane remisije. Pacijenti su podijeljeni u dvije grupe, ovisno o primijenjenom terapijskom protokolu:

1) Grupa I: pacijenti tretirani kom-binacijom kortikosteroida u dozi od 1 mg/kg TT 4 nedjelje, a potom 0,5 mg/kg TT, uz postepenu redukciju doze i bolusima i.v. ciklofosfamida u dozi od 10 mg/kg TT jednom mjesečno do šest mjeseci, a potom u tromjesečnim inter-valima, najduže do 1,5 godine.

2) Grupa II: pacijenti tretirani ci-klosporinom u dozi od 3-5 mg/kg TT, uz održavanje serumskog nivoa lijeka od 100 ± 20 ng/ml.

Efekti primijenjene terapije su anali-zirani monitoriranjem: vrijednosti pro-teinurije–kvantitativno, serumskog al-bumina. serumskog kreatinina i krea-tinin klirensa.

3. REZULTATI RADANa osnovu analiziranih demograf-

skih podataka (spol, dob, dužina tra-janja bolesti) nije bilo statistički zna-čajnih razlika među grupama (p=0,70; p=0,51; p=0,64). Tretman kombinaci-jom ciklofosfamida i steroida je rezul-tirao signifikantnim padom vrijednosti proteinurije sa 12,97 g/24 h ± 6,78 na 1,19 g/24 h ± 1,06 (p



ficijencije. Uočljiv je pad prosječnih vri-jednosti serumskog kreatinina u ciklo-fosfamidskoj i porast u ciklosporinskoj terapijskoj grupi, međutim, zabilježeni porast još uvijek ne prelazi gornju gra-nicu referentnih vrijednosti (žene 45-90 µmol/l; muškarci 63-109 µmol/l), niti su promjene vrijednosti serumskog krea-tinina prije i nakon terapije unutar po-smatranih grupa pacijenata statistički značajne. Također, ne postoji statistički značajna razlika između prosječnih po-četnih, kao ni prosječnih završnih vri-jednosti serumskog kreatinina posma-trano među grupama pacijenata (po-četni kreatinin p=0,128; završni krea-tinin p=0,749) (grafikon 2).

Prosječna vrijednost kreatinin kli-rensa prije terapije kombinacijom ciklo-fosfamida i steroida iznosila je 96,98 ml/min ± 54,59. Nakon primijenjene tera-pije, registrujemo sličnu prosječnu vri-jednost kreatinin klirensa, koja iznosi 91,95 ml/min ± 36,3 (p=0,906). Tre-tman ciklosporinom druge grupe pa-

cijenata je doveo do statistički nesigni-fikantnog porasta prosječne vrijednosti kreatinin klirensa (p=0,435). Prosječna vrijednost kratinin klirensa prije tera-pije, u ovoj terapijskoj grupi, iznosila je 85,0 ml/min ± 36,8, a nakon tera-pije100,3 ml/min ± 31,0. Uočavamo, da su odstupanja u prosječnim vrijedno-stima klirensa kreatinina prije i nakon terapije minimalna i da se kreću unutar referentnih vrijednosti (žene 82-146 ml/min; muškarci 84-162 ml/min). Nema statistički značajne razlike među gru-pama u početnim i završnim vrijedno-stima kreatinin klirensa (p= 0,157; p= 0,800) (grafikon 3).

Prosječna vrijednost serumskih al-bumina prije započinjanja terapije kom-binacijom ciklofosfamida sa steroidima iznosila je 23,46 g/l ± 7,35 . Nakon pri-mijenjene terapije postignut je visoko signifikantan porast serumskih albu-mina na 37,26 g/l ± 5,54 (p=0,00003). Prosječna vrijednost serumskih al-bumina prije otpočinjanja terapije u

grupi pacijenata liječenih ciklospori-nom iznosila je 21,40 g/l ± 6,85. Nakon terapije bilježimo signifikantan porast prosječnih vrijednosti serumskih al-bumina na 31,46 g/l ± 6,27 (p=0,0002). Sličan je odgovor na oba primijenjena terapijska modela u pogledu oparavka serumskih albumina. Paralelno sa ne-što boljim odgovorom na terapiju ciklo-fosfamidom u pogledu restrikcije pro-teinurije, u istoj grupi pacijenata se bi-lježi i ubjedljiviji oporavak serumskih albumina (niže početne i više završne vrijednosti). Viša završna vrijednost se-rumskih albumina u ciklofosfamidskoj grupi je statistički značajna u odnosu na ciklosporinsku (p= 0,031).

Od ukupnog broja pacijenata treti-ranih ciklofosfamidom u kombinaciji sa steroidima, 40% pacijenata je postiglo kompletnu, a 60% parcijalnu remisiju. U grupi pacijenata tretiranih ciklos-porinom 27% je postiglo kompletnu, 60% pacijenata parcijalnu remisiju ne-frotskog sindroma, dok je u 13% paci-jenata postignuto smanjenje proteinu-rije, ali bez ostvarenja remisije nefrot-skog sindroma.

4. DIsKUsIJAPreko 80% pacijenata sa MGN ima

nefrotsku proteinuriju, a oko 10% u momentu javljanja oštećenu bubrežnu funkciju (8). Svi pacijeti, praćeni kroz ovo istraživanje, su u momentu zapo-činjanja liječenja imali nefrotsku pro-teinuriju, a 23% reduciranu bubrežnu funkciju.

U 100% pacijenata tretiranih kom-binacijom ciklofosfamida i steroida, postignuta je remisija nefrotskog sin-droma (kompletna ili parcijalna). U drugoj grupi, tretiranoj ciklosporinom, kod 2 pacijenta došlo je do pada prote-inurije, ali bez postizanja remisije ne-frotskog sindroma, dok su ostali paci-jenti postigli parcijalnu ili kompletnu remisiju, iz čega proizilazi nešto bolji efekat ciklofosfamidske terapije na re-dukciju proteinurije. Studije o primjeni ciklofosfamida sa steroidima kod paci-jenata sa IMGN i nefrotskim sindro-mom ukazuju na pozitivan efekat ove terapijske kombinacije, sa pojavom mi-nimalnih neželjenih efekata. Covic sa saradnicima (9) je navedenom terapij-skom kombinacijom postigao u niskoj i srednje rizičnoj grupi pacijenata sa IMGN nefrotskim sindromom kom-pletnu ili parcijalnu remisiju kod svih tretiranih, odnosno, kod 75% u visoko

133,9115,5

85100,3

020406080

100120140160180200

ciklofosfamidska grupa ciklosporinska grupa

početnezavršne

kreatinin (µmol/l)

Grafikon 2. Odnos prosječnih vrijednosti kreatinina na početku i kraju terapije za posmatrane grupe pacijenata početni kreatinin t=1,578; p=0,128 završni kreatinin t=0,324; p=0,749

Grafikon 3. Odnos prosječnih vrijednosti kreatinin klirensa na početku i kraju terapije za posmatrane grupe pacijenata početni kreatinin klirens t=1,460; p=0,157 završni kreatinin klirens t=0,256; p=0,800

90,24 91,95 85100,3

020406080

100120140

ciklofosfamidska grupa ciklosporinska grupa

početnizavršni

kreatinin klirens (ml/min)



rizičnoj skupini (sa više od dva nega-tivna prognostička faktora). Objavljene studije ukazuju da se incidenca kom-pletnih i parcijalnih remisija povećava tokom perioda praćenja, što smo uočili i tokom ovog istraživanja.

Radovi velikog broja autora izvješta-vaju o pozitivnim rezultatima od upo-trebe ciklosporina u liječenju IMGN . Ovaj imunosupresivni lijek, inhibitor kalcineurina, koji inhibira aktivaciju i proliferaciju T limfocita, našao je svoje mjesto u liječenju autoimunih oboljenja i u transplantacijskoj medicini. Naši re-zultati govore o dobrom odgovoru u ve-ćine tretiranih pacijenata. Većina stu-dija ukazuje na problem čestih relapsa proteinurije nakon prekida terapije (10). Novije studije ukazuju da su mo-noterapija CyA, kao i kombinirana te-rapija sa steroidima tokom 12 mjeseci, efikasne u induciranju remisije kod ve-ćine pacijenata sa IMGN i da prolon-girana terapija sa nižim dozama može biti korisna u održavanju remisije bo-lesti. Isti postotak kompletnih remisija (7%) je postignut kod naših pacijenata nakon 6 mjeseci tretmana, kao i u no-vijim objavljenim studijama drugih au-tora (11,12,13). Cattran sa saradnicima izvještava o 75% parcijalnih i komplet-nih remisija kod pacijenata tretiranih ciklosporinom nakon 6 mjeseci (11). Alexopoulos sa saradnicima je nakon 12-to mjesečnog tretmana u 35% paci-jenata iz terapijski kombinirane grupe ciklosporinom sa steroidima i u 20% pa-cijenata iz monoterapijske grupe posti-gao kompletnu remisiju, dok su ostali bili u parcijalnoj remisiji (12). Ukupan postotak parcijalnih i kompletnih re-misija nakon 12 mjeseci kod naših pa-cijenata iznosi 87%.

Ciklofosfamidska grupa pacijenata u prosjeku je imala nešto više startne vrijednosti serumskog kreatinina i do kraja perioda praćenja na primijenjenu terapiju postigla je pad kreatinina, koji je u prosjeku bio iznad referentnih vri-jednosti. Nasuprot tome, u ciklosporin-skoj grupi startne vrijednosti kreatinina su bile nešto niže, a na primijenjenu te-rapiju je došlo do njegovog porasta (na granici referentnih vrijednosti). Pad kreatinina u ciklofosfamidskoj i porast u ciklosporinskoj grupi je statistički ne-signifikantan, što je važan terapijski cilj u pogledu očuvanja bubrežne funkcije. Dobijene rezultate treba posmatrati i u kontekstu mogućeg uticaja ciklospo-rinske terapije na bubrežnu funkciju, u

čijoj podlozi se može nalaziti neželjeni efekat ciklosporina na bubreg, kao što su vazokonstrikcija aferentne arteriole (14), tubulointersticijalne lezije (15) i renalna intesticijalna inflamacija (16).

U obje ispitivane grupe vrijednosti kreatinin klirensa, prije i nakon tera-pije, nisu pokazivale statistički signifi-kantna odstupanja.

5. ZAKLJUčcITerapija ciklofosfamidom u kom-

binaciji sa steroidima pokazala se kao dobar izbor u liječenju pacijenata sa IMGN, koja je kod svih tretiranih do-vela do postizanja parcijalne (60%) ili kompletne remisije (40%) nefrotskog sindroma.

Ciklosporin je efikasna alternativa u liječenju pacijenata sa IMGN. Ovaj vid liječenja je do kraja perioda praćenja re-zultirao remisijom bolesti kod 87% tre-tiranih (60% parcijalnih i 27% komplet-nih remisija).

Na primijenjene imunomodula-torne lijekove nije došlo do značajnog odstupanja u parametrima bubrežne funkcije (serumski kreatinin i kreati-nin klirens).

LITERATURA1. Troyanov S, Wall CA, Miller JA, Scholey

JW, Cattran DC, Toronto Glomerulonep-hritis Registry Group. Idiopathic mem-branous nephropathy: definition and relevance of a partial remission. Kidney Int, 2004; 66(3);1199-205.

2. Schieppati A, Perna A, Zamora J, Giu-liano GA, Braun N, Remuzzi G, Immu-nosuppressive treatment for idiopathic membranous nephropathy in adults with nephrotic syndrome. Cochrane Database Syst Rev, 2004; (4);CD004293.

3. Couser WG, Nangaku M, Cellular and molecular biology of membranous nep-hropathy. J Nephrol, 2006;19(6):699-705.

4. Passos EM, Legallicier B, Godin M. Membranous nephropathy. Rev Prat, 2003; 53(18):2033-8.

5. Scheippati A, Ruggenenti P, Perna A, Re-muzzi G. Nonimmunosuppressive the-rapy of membranous nephropathy. Se-min Nephrol, 2003;23(4):333-9.

6. Lai KN. Membranous nephropathy: when and how to treat. Kidney Int, 2007;841-3.

7. du Buf-Vereijken PW, Branten AJ, Wet-zels JF. Idiopathic membranous nepro-pathy: outline and rationale of treatment strategy. Am J Kidney, 2005;46(6):1012-29.

8. M u r p h y B F, F a i r l e y K F, K i n -c a id S . Id iopat hyc membra nou s glomerulonephritis:long-term folow-up in 139 cases In: Brenner BM (ed). Bre-nner & Rectors The Kidney WB Saun-

ders Company, Phyladelphya, London, Toronto. 2004.

9. Covic A, Cruntu ID, Marian D, Volov C, Ghiciuc C, Costin C, Florea L, Cotuiu C, Covic M. Prognosis and treatment of membranous glomerulonephritis-a 5-year prospective srudy. Rev Med Chir Soc Med Nat Lasi, 2000; 104(2):63-74.

10. Passerini P. Treatment of idiopathic membranous nephropathy. G Ital Nep-hrol, 2004; 21(6):531-9.

11. Cattran DC, Appel GB, Hebert LA, Hun-sicker LG, Pohl MA, Hoy WE, Maxwell DR, Kunis CL. Cyclosporine in pati-ents with steroid-resistent membranous nephropathy:a randomized trial. Kidney Int, 2001;59(4):1484-90.

12. Alexopoulos E, Papagianni A, Tsamelas-hvili M, Leontsini M, Memmos D. Induc-tion and long-term treatment with cyc-losporine in membranous nephropathy with the nephrotic syndrome. Nephrol Dial Transplant, 2006;21(11):3127-32.

13. Cattran DC, Grenwood C, Ritchie S et al. A controlled trial of cyclosporine in pa-tients with progresive membranous nep-hropathy, Kodney Int, 1995; 47:1130-5.

14. Kang DH, Kim YG, Takeshi F. Andoh, Ka-therine L. Gordon, Suga SI, Mazzali M, J. Jefferson A, Hughes J, Bennett W, Scre-iner GF, Johnson RJ. Post-cyclosporine-mediated hypertension and nephropa-thy: amelioration by vascular endothe-lial growth factor. Am J Renal Physiol, 2001;280:727-36.

15. Iijima K, Hamahira K, Tanaka R, Ko-bayashi A, Nozu K, Nakamura H, Yos-hikawa N. Risc factors for cyclosporine-induced tubulointerstitialis lesions in children with minimal change nephrotic syndrome. Kidney Int, 2002; 61:1801-5.

16. Can L, Yang CW, Kim WY, Jung JY, Cha JH, Kim YS, Kim J, Benneti WM, Bang BK. Reversibility af chronic cyclosporine nephropathy in rats after withdrawal of cyclosporine. Am J Renal Physiol, 2003; 284(2):389-398.

Kontakt adresa autora: Mr.sci.dr. Alma Muslimović. Klinika za nefrologiju, Klinički

centar Univerziteta u sarajevu. Bolnička 25. Tel: 033 297 154, 061 147 854. E-mail: almamsl@

bih.net.ba


Korelacija koronarne bolesti kod bolesnika sa Diabetes mellitusom tip 2

1. UVODŠećerna bolest ili Diabetes mellitus

Tip2 se manifestira kao relativni nedo-statak inzulina (inzulinopenija), sa po-sljedično visokim vrijednostima glu-koze u krvi (hiperglikemija). Loša meta-bolička kontrola hiperglikemija, visoke vrijednosti HbA1c, hiperlipidemija, hi-pertenzija, gojaznost, fizička neaktiv-nost su riziko faktori za razvoj hronič-nih komplikacija na krvnim sudovima (2,3,4,8). Značajno mjesto u komplika-cijama zauzima koronarna bolest, a sam dijabetes je major rizik za razvoj koro-narne bolesti (1,5,6,7,9,10).

2. MATERIJAL I METODE RADACilj ovog istraživanja je bio da poku-

šamo na našoj populaciji dokazati uče-

stalost koronarne bolesti kod dijabeti-čara Tip2, kontrolirajući grupe dijabe-tičara životne dobi od 45-70 godina, sa dužinom trajanja dijabetesa do 10 go-

dina i preko 10 godina i grupu nedijabe-tičara iste životne dobi. Ukupno 150 pa-cijenata, tri grupe po 50 pacijenata, ži-votne dobi od 45-70godina, prva grupa su oni koji imaju dijabetes do 10godina, druga grupa sa dijabetesom preko 10go-dina i treća grupa su nedijabetičari. Pa-

cijente smo razvrstali po dobi i spolu, po dužini trajanja dijabetesa, po vrsti i dozi terapije, po anamnestičkim po-dacima, bola u prsima i dispnee, a pra-tili smo BMI, krvni pritisak, frekvencu srca, zatim biohemijske analize krvi HbA1c, lipidogram, transaminaze, EKG i ergometrijski test za one koji su imali promjene u EKG-u, poštujući kontrain-dikacije za test. Sve podatke smo unijeli u anketni upitnik, sve statistički obra-dili i došli do rezultata.

Cilj ovog istraživanja bio je dokazati učestalost koronarne bolesti kod nas.

3. REZULTATI RADAOvim istraživanjem dokazali smo

da je prateći skupine dijabetičara u od-nosu na skupinu nedijabetičara rizik od obolijevanja od kardiovaskularnih bole-sti veći kod dijabetičara i da je p



a između dvije skupine dijabetičara ta-kođer, kod skupine iznad 10 godina tra-janja dijabetesa, gdje je p



kantna razlika u primjeni samo oralnih hipoglikemika između skupina dijabe-tičara do 10 godina i preko 10 godina,

gdje je p


Stroke in Diabetic Patients in Cantonal Hospital Zenica

1. INTRODUcTIONCerebrovascular insult or Stroke is

a crisis in cerebrovascular circulation and central nervous system function with focal neurologic dysfunction. Ac-cording to American Heart Association (1996) diabetes mellitus is a changeable risk factor which can precipitate the emergence of different types and sub-types of stroke.

Diabetic population have increased susceptibility to arteriosclerosis/ath-erosclerosis, hypertension, aterogenic risk factor, obesity, abnormal blood lip-ids. Control studies of stroke and pro-spective epidemiological studies of di-abetes reported increased risk for cere-brovascular disease in diabetic pop-ulations from 1.8-3.0. About the role of glucose status in the occurrence of cerebrovascular disease (normal, low glucose tolerance or diabetes), there are claims that the changes in sugar metabolism have an important role in the etiology of cerebrovascular disease, with a significant share in emergence of ischemic cerebrovascular insults which in the diabetic population are more as twice as much than in non diabetic population. According to the publica-tions of Framingham Study in case of patients with diabetes mellitus present is preinsulinaemia with increasing in-sulin resistance. Increasing insulin re-sistance is associated with an increase of atherosclerosis in carotid vessels, disorders of glucose status, changes in

insulin levels, and as such is combined with other major cardiovascular risk factors (1, 2).

Diabetes classification which was adopted by the ADA in 1997 recog-nizes idiopathic and symptomatic di-abetes. After certain diabetic duration chronic complications occur, and hy-perglycemia plays the most important role in their occurrence. Diabetic pa-tients suffer gradual, progressive con-striction of lumen of small and large vessels, which is why, based on these changes, chronic complications are di-vided into two groups: microvascular (microangiopathy – small blood ves-sels) and macro vascular (macroangi-opathy - large blood vessels) (3, 4, 5). Macro angiopathic changes include atherosclerosis of blood vessels of the heart, brain and distal parts of the ex-tremities, most notably the legs, and they cause coronary heart disease, cere-brovascular disease and peripheral vas-cular disease.

Diabetes is the most common met-abolic disease and is one of the most common endocrine diseases in gen-eral. Prevalence varies, with the average of 1.5-2.5%. The definition of diabetes says that it is a state of chronic hyper-glycemia, which can exist as a result of decreased insulin secretion or action of various reinforced anti-insulin pro-cesses. In addition to hypertension, di-abetes leads to the development of vari-ous late complications that are the basis

for changes in the small and large blood vessels, nerves, and basal membranes of different tissues.

In case of diabetics more frequently also occurs the ischemic stroke. Basis is the disorder of glycoregulation, of-ten parallel to hyperlipidemia and obe-sity, and faster development of athero-sclerosis process for people suffering from diabetes (6). According to epide-miological study of Kanel (7) in patients with cerebrovascular disease, diabetes is four times more frequent than in the general population.

2. pATIENTs AND METHODsThe survey was in part retrospec-

tive, in part prospective. The patients were included in the survey according to clearly defined criteria. The survey comprised 300 patients with diagnosed type 1 or 2 diabetes which were treated at the Internal Ward of the Cantonal Hospital Zenica and Public Medical Centers across Zenica-Doboj Canton in 1999-2004. The patients were sub-jected to check-ups in 1999 and 2004, and were given questionnaire (adapted information sheet – DIABCARE). The data evaluated were age, sex, weight, risk factors (smoking, alcohol con-sumption, and physical activity), type and duration of the disease, degree of diabetes mellitus control (glycemia, glycosylated hemoglobin, creatinine, proteinuria and lipids), presence of chronic diabetic complications on eyes, heart, peripheral blood vessels of lower limbs, kidneys with a special accent on different types and subtypes of stroke.

3. AIMThe aim of our survey was to deter-

mine the stroke frequency in 300 type 1 and 2 diabetes mellitus patients ob-served in two different periods with a time lag of 5 years.

The study included a group of 300 patients with previous clinical and lab-oratory clearly diagnosed diabetes. Re-views, interviews and laboratory test-ing are provided in 1999 in all subjects. Out of this there were 62 patients with type 1 diabetes, and with type 2 dia-betes 238.

Re-examinations, interviews and laboratory testing during 2004 were conducted in case of 278 patients, of whom 58 was with type 1 diabetes , and 220 were type 2 diabetic patients. Sub-sequent anamnesis, during the exam-

stroke in Diabetic patients in cantonal Hospital ZenicaAzra Alajbegovic1, Salem Alajbegovic2Neurology Clinic, Clinical Center University of Sarajevo, Bosnia and HerzegovinaCantonal Hospital Zenica, Bosnia and Herzegovina2

ORIgINAL pApERsUMMARYAim: The aim is to determine the frequency of stroke in 300 patients with type 1 and 2 diabetes mellitus observed in two different time periods with a five-year distance. Materials and Methods: The survey comprised a group of 300 patients with previously clinically and laboratory diagnosed diabetes. First examination, question-naire and laboratory testing were performed in all patients in 1999. There were 62 patients with type 1 diabetes and 238 type 2. The final exam, questionnaire and laboratory test were performed on 278 patients in 2004 (diabetes type 1 in 58 (20.9%), diabetes type 2 in 220 (79.1%) patients. Additional anamnesis in 2004 grouped 2 patients into other specific types, and those were two women, previously classified as diabetes type 2. Twenty patients died between the first test in 2000 and the last in 2004. Results: In 1999 2.2 % of tested patients suf-fered the stroke , and in 2004, the stroke suffered 3.2%. There was no statistically significant difference in the stroke occurrence in the same group of diabetic patients during the two observed periods with the 5-year time span. There was no statistically significant difference in the occurrence of stroke between males and females, or in type I and II diabetes groups. There were 4.3 % of patients in total who suffered stroke during the survey. Conclusion: There were no statistically significant changes in number of stroke patients which indirectly confirms good treatment of diabetic population in primary care.Keywords: diabetes type 1, diabetes type 2, chronic diabetic complications.



ination of patients in 2004, 2 patients was classified as other specific types, and it was about 2 women previously classified as type 2 diabetes. In the pe-riod since the end of the first test on 31st March 2000 until the beginning of the second examination on 1st Feb-ruary 2004, 20 patients died.

Inclusion criteria: type 1 or type 2 diabetes according to the latest revised criteria for the diagnosis and classi-fication of diabetes ADA from 1997 and WHO from 1999. (1, 10). Patients of both genders. Patients age 18 to 80 years, patients who signed informed consent for inclusion in the study.

Respondents were due to diabetes and associated diseases treated at the Department for Internal Diseases of the Cantonal Hospital in Zenica and Primary health-care centers of the Ze-nica-Doboj Canton during period 1999-2004. All are under the same conditions reviewed, interviewed and taken all the laboratory in 1999 and re-2004. Data obtained during both the tests are re-corded in the similar questionnaire in-dividually for each patient.

4. REsULTsThere is no significant difference in

number of diabetics in relation to gen-der in case of Diabetes type 1, contrary to diabetes type 2 where there are sta-tistically significantly more women.

The average age of the sample was 58.22 ± 12.20 with statistical significant difference between women and men at the level of p



erage age between men and women with type 2 diabetes, t=2.653, p


Učestalost i klinička fenomenologija afazičkih poremećaja nakon moždanog udara

1. UVODUpotreba govora u komunikaciji je

jedinstvena za ljude. Oštećenje govora ili njegovo potpuno odsustvo predstav-lja vrlo težak i dubok udar za osobu i njegovu porodicu. Jedna od najtežih i poraznih devastirajućih nesposobno-sti u komunikaciji je afazija (1).

Afazija je stečeni poremećaj sim-boličke komunikacije uzrokovan ošte-ćenjem mozga, koje se manfestira po-remećajem lingvističkih, paralingvi-stičkih i kognitivnih procesa. Afazija obično zahvata više modaliteta jezičke funkcije: usmeni govor, razumijevanje, pisanje, čitanje i gestovni govor.

Vodeći uzrok afazija kod oko 80%

odraslih predstavljaju različita obolje-nja vezana za krvne sudove mozga.

Ishemijski (tipa embolije ili trom-boze) ili hemoragijski (intracerebralna hemoragija) cerebrovaskularni in-zult (moždani udar) u po-dručiju prednje cirkulacije prije svega u slivu središnje cerebralne arterije sa lijeve strane relativno često do-vode do različitih afazičkih sindroma (2).

Cilj rada bio je utvrditi učestalost i kliničku fenome-nologiju afazičkih poreme-ćaja nakon moždanog udara.

2. IspITANIcI I METODE RADAU radu je analizirano 993 pacijenta

sa cerebrovaskularnim inzultom (CVI) prosječne starosne dobi 66,77 godina (SD ± 10,98), koji su bili hospitalizirani na Klinici za neurologiju Univerzitet-sko kliničkog centra Tuzla, u periodu od 01.01.2004. godine do 31.12.2004. godine. Svi pacijenti bili su testirani na postojanje afazičkih poremećaja. Pro-cjena je izvršena odmah po prijemu, od-nosno nakon što je zdravstveno stanje to dozvoljavalo. Evaluacija poremećaja govora rađena je 2-3 puta tokom hos-pitalizacije. Ispitivanje je realizirano tako što su svi pacijenti sa moždanim udarom još u akutnoj fazi bili testirani sa Internacionalnim testom za afazije– ITA (3). Također, uzeti su podaci o nji-hovoj dobi, spolnoj strukturi, tipu mož-danog udara, mjestu lezije i mogućim poboljšanjima tokom logopedskog tre-tmana. Testom se procjenjuju slijedeći modaliteti govora: imenovanje, ponav-ljanje, fluentnost, razumijevanje, čita-nje, pisanje, artikulacija.

Nakon provedenog istraživanja dobiveni podaci su obrađeni pomoću kompjuterskog statističkog programa Statistica 5.0. Distribucija ispitanika prema rezultatima ispitivanja pred-stavljena je u frekvencijama. Za potrebe testiranja značajnosti razlika između stvarnih i očekivanih frekvencija dobi-venih na promatranim varijablama ko-rišten je Hi kvadrat test, na razini zna-čajnosti od 5%.

3. REZULTATI RADAOd ukupnog broja ispitanih pacije-

nata sa moždanim udarom (993) muš-karaca je bilo 489 ili 49,24%, a žena 504 ili 50,76%.

Najveći broj pacijenata imao je ishe-mijski moždani udar (758 ili 76,33%), zatim hemoragijski (135 ili 13,59%), a subarhnoidalno krvarenje je dijagno-sticirano kod 29 ili 2,92% pacijenata. U grupi koja je označena kao nepoznato

Učestalost i klinička fenomenologija afazičkih poremećaja nakon moždanog udaraIncidence and Clinical Phenomenology of Aphasic Disorders After StrokeEnsala Brkić, Osman Sinanović, Mirjana Vidović, Dževdet SmajlovićKlinika za neurologiju, Univerzitetski klinički centar Tuzla, Bosna i Hercegovina

ORIgINALNI čLANAKsAŽETAKAfazija je čest i ozbiljan pratilac svih oblika cerebrovaskularne bolesti. Imajući u vidu činjenicu da je sposobnost govora jedna od najvažnijih karakteristika ljudskog roda, logično je da oporavak nakon tako ozbiljne bolesti kao što je cerebrovaskularni inzult (CVI) ni u kom slučaju nije potpun ukoliko nema zadovoljavajućeg oporavka govora. Osnovni cilj sprovedenog istraživanja bio je da se retrospektivnom analizom podataka iz medicinske dokumentacije utvrdi učestalost i klinička fenomenologija afazičkih poremećaja nakon moždanog udara. U studiju je uključeno 993 pacijenta sa moždanim udarom, a koji su bili hospitalizirani na Klinici za neurologiju u Tuzli u periodu od 01.01.2004. godine do 31.12.2004. godine. Svi pacijenti su bili testirani na postojanje afazije Internacionalnim testom za afazije. Dobijeni podaci su pokazali da je učestalost afazija iznosila 20,34%, te da su signifikantno češće bili prisutni afazički poremećaji kod pacijenata ženskog spola. Najčešća vrsta afazije bila je globalna (48,51%), slijedi Brokina (16,33%), te Wernikeova (8,41%). Transkortikalna senzorna, transkortikalna motorna i konduktivna afazija su dijagnosticirane kod malog broja pacijentata u akutnoj fazi moždanog udara. Što se tiče tipa moždanog udara, afazije su češće verificirane kod pacijenata sa hemoragijskim moždanim udarom (28,14%) u odnosu na ishemijski (20,58%), ali razlika nije statistički značajna. Subarahnoidalna hemoragija za posljedicu nije imala afazičke poremećaje.Ključne riječi: afazija, učestalost i fenomenologia.ORIgINAL pApERsUMMARYIntroduction: Aphasia is a common and serious condition, associated with all forms of cerebrovascular disease. Capability of speech is one of the most important characteristics of human kind, it is logical that the recovery from a disease as serious as cerebrovascular insult (CVI) is by no means complete without the satisfactory recov-ery of the speech. Basic goal of the study was to analyze the incidence and clinical phenomenology of aphasic disorders after CVI. Patients and methods: We retrospectively analyzed 993 patients with CVI hospitalized in Neurology Clinic in Tuzla in the period from 1 January 2004 to 31 December 2004. All the patients were tested for aphasia by the International aphasia test. Results and conclusion: Obtained data showed that the incidence of aphasia was 20,34%, and that aphasic disorders were significantly more common in female patients. The most frequent type of aphasia was global (48,51%), then Broca’s (23,26%), and Wernicke’s (8,41). Transcortical sensory, transcortical motor and conductive aphasia were diagnosed in small number of patients in acute phase of CVI. Aphasia was more frequently seen in patients with hemorrhagic stroke (28,14%), compared to the ones with the ischemic stroke (20,58%), but the difference is not statistically significant. In patients with subarachnoidal hemorrhage aphasic disorders were not present in any patient.Keywords: aphasia, incidence and clinical phenomenology.

758

13529 71

0100200300400500600700800

Bro

j pac

ijena

ta ishemijahemoragijaSAHnepoznato

N= 993

Grafikon 1. Distribucija ispitivanih pacijenata prema tipu moždanog udara



(71 ili 7,15%) bili su pacijenti kod kojih tip moždanog udara nije potvrđen kom-pjuterizovanom tomografijom (CT), jer je smrt nastupila prije nego što je ura-đen CT (grafikon 1).

U ukupnom broju analiziranih pa-cijenata, kod 202 ili 20.34% je dijagno-sticirana afazija. Afazija je dijagnosti-cirana kod 156 ili 77,23% pacijenata sa ishemijskim i 38 ili 18,81% sa hemora-gijskim moždanim udarom. Kod osam pacijenata ili 3,96% CT nije rađen, te se sa sigurnošću nije mogao utvrditi tip moždanog udara. Pacijenti sa su-barahnoidalnom hemoragijom (SAH) nisu imali smetnje govora (grafikon 2).

U odnosu na vrstu afazije najzastu-pljenija je bila globalna u 98 slučajeva ili 48,51%, zatim Brokina u 47 ili 23,26%, te anomička u 33 slučaja ili 16,33% (gra-fikon 3).

U ukupnom broju pacijenata koji su imali afaziju, nefluentne su bile zastu-pljene u 72,28%, a fluentne sa 27,72% (grafikon 4).

Kod pacijenata ženskog spola regi-striran je veći broj afazija nakon mož-danog udara, i to u 57,43% (tabela 1). (Hi-kvadrat = 4,19; P = 0,04).

U ovom istraživanju od svih pacije-nata sa hemoragijom, 14% je imalo afa-ziju, a od svih sa ishemijom 20,58%, a među 202 pacijenta sa afazijom, 156 ili

77,22% imalo je ishemijski, a 38 ili 18,82% hemoragijski moždani udar.

4. DIsKUsIJAProcjenjuje se da čak 46%

moždanog udara nastaje u produktivnoj životnoj dobi, to jest u dobi između 45 i 59 godina. Dvije trećine obo-ljelih se oporave do veće ili manje samostalnosti, a tre-ćina je trajno onesposobljena za samostalan život i ovisi o

tuđoj pomoći. Oko 20% bolesnika za-htijeva stacionarnu brigu i do tri mje-seca nakon moždanog udara (4). Mož-dani udar je jedan od glavnih etioloških faktora za nastanak afazije. U Švedskoj se navodi podatak da 0,6% populacije svake godine postaje afazično, od ko-jih 85% predstavljaju pacijenti koji su pretrpjeli cerebrovaskularni inzult (5). Studija iz 2002. godine ukazuje da je u Francuskoj učestalost afazija iznosila između 21% i 38% (6), a Kauhanen i sa-radnici (7) ukazuju da je u 34% pacije-nata dijagnostikovana afazija u akutnoj fazi moždanog udara. Prema Vukoviću (5), učestalost afazija u bolesnika sa ce-rebrovaskularnim oboljenjem iznosi 20% do 30%. Laska i saradnici (8) saop-

ćavaju da je od 106 pacijenata u akut-noj fazi moždanog udara njih 36 ili 33% imalo afaziju. Ovim istraživanjem utvr-đeno je da je od ukupno 993 pacijenta sa moždanim udarom njih 202 ili 20,34% imalo afaziju, a što je u okviru rezultata drugih autora.

Što se tiče učestalosti različitih ti-pova afazija u akutnoj fazi moždanog udara, Pedersen i saradnici (9) navode da je globalna afazija bila zastupljena sa 32%, Brokina 12%, Vernikeova 16%, anomička 25%, transkortikalna sen-zorna 7%, transkortikalna motorna 2%,

konduktivna 5% i izdvojene sa 2%. U ranijoj studiji Sutović i sar. (10), gdje je analizirano 188 afazičkih pacijenata na-kon moždanog udara, a koji su bili hos-pitalizirani na Klinici za neurologiju u Tuzli, 42,5% imalo je globalnu afaziju, 24,5% imalo je anomičku, 17% motornu i 16% imalo je senzornu afaziju. U ovoj studiji najzastupljenija je bila globalna afazija, u 98 ili 48,51% slučajeva, zatim Brokina u 47 ili 23,26%, te anomička u 33 slučaja ili 16,33%. U najmanjem pro-centu zastupljenosti bile su transkorti-kalna motorna i konduktivna afazija sa po jednim slučajem ili 0,4%.

U studiji Franić, Matijašević i Bielen (11) učestalost nefluentnih afazija izno-sila je 54,4%, a 45,6% činile su fluentne afazije. Prema našem istraživanju, u od-

Grafikon 2. Distribucija pacijenata sa afazijom u odnosu na tip moždanog udara

sa sigurnošću nije mogao utvrditi tip moždanog udara. Pacijenti sa subarahnoidalnom

hemoragijom (SAH) nisu imali smetnje govora (slika 2).

U odnosu na vrstu afazije najzastupljenija je bila globalna u 98 slučajeva ili 48,51%, zatim

Brokina u 47 ili 23,26%, te anomička u 33 slučaja ili 16,33% (slika 3).

23,26%

8,41%

48,51%

0,49%0,49%1,48%0,99%

16,33%

0,00%

10,00%

20,00%

30,00%

40,00%

50,00%BrokinaVernikeovaGlobalnaKonduktivnaTranskortikalna motornaTranskortikalna senzornaTalamičkaAnomička

Slika 3 - Distribucija dijagnostikovanih afazija prema tipu

U ukupnom broju pacijenata koji su imali afaziju, nefluentne su bile zastupljene u 72,28%,

a fluentne sa 27,72% (slika 4).

Slika 4 - Distribucija afazija prema fluentnosti govora

Kod pacijenata ženskog spola registrovan je veći broj afazija nakon moždanog udara, i to

u 57,43% (tabela 1).(Hi-kvadrat = 4,19; P = 0,04).

27,72

72,28

0

10

20

30

40

50

60

70

80

Proc

enat Fluentne

Nefluentne

N=202

N=202

Grafikon 3. Distribucija dijagnosticiranih afazija prema tipu

sa sigurnošću nije mogao utvrditi tip moždanog udara. Pacijenti sa subarahnoidalnom

hemoragijom (SAH) nisu imali smetnje govora (slika 2).

U odnosu na vrstu afazije najzastupljenija je bila globalna u 98 slučajeva ili 48,51%, zatim

Brokina u 47 ili 23,26%, te anomička u 33 slučaja ili 16,33% (slika 3).

23,26%

8,41%

48,51%

0,49%0,49%1,48%0,99%

16,33%

0,00%

10,00%

20,00%

30,00%

40,00%

50,00%BrokinaVernikeovaGlobalnaKonduktivnaTranskortikalna motornaTranskortikalna senzornaTalamičkaAnomička

Slika 3 - Distribucija dijagnostikovanih afazija prema tipu

U ukupnom broju pacijenata koji su imali afaziju, nefluentne su bile zastupljene u 72,28%,

a fluentne sa 27,72% (slika 4).

Slika 4 - Distribucija afazija prema fluentnosti govora

Kod pacijenata ženskog spola registrovan je veći broj afazija nakon moždanog udara, i to

u 57,43% (tabela 1).(Hi-kvadrat = 4,19; P = 0,04).

27,72

72,28

0

10

20

30

40

50

60

70

80

Proc

enat Fluentne

Nefluentne

N=202

N=202

Grafikon 4. Distribucija afazija prema fluentnosti govora

Tip afazijaMuškarci Žene Ukupno

N % N % N %Brokina 20 9,99 27 13,36 47 23,26Vernikeova 6 2,97 11 5,45 17 8,41Globalna 41 20,29 57 28,21 98 48,51Konduktivna 1 0,49 / / 1 0,49Transkortikalna motorna 1 0,49 / / 1 0,49Transkortikalna senzorna 1 0,49 2 0,99 3 1,48Talamička 1 0,49 1 0,49 2 0,99Anomička 15 7,42 18 8,90 33 16,33Ukupno: 86 42,57 116 57,43 202 100,00

Tabela 1. Spolna distribucija afazija



nosu na fluentnost govora češće su bile nefluentne (72,28%) nego fluentne afa-zije (27,72%).

U studiji Hiera i saradnika (12) afazija je bila neznatno češća u žena (22,5%) nego u muškaraca (19,4%). Naše istraživanje je pokazalo da je učestalost afazija kod pacijenata ženskog spola si-gnifikantno češća nego kod muškaraca u akutnoj fazi moždanog udara, a izno-sila je 57,43%.

Franić, Matijašević i Bielen(11) na-vode da je u 89,5% slučajeva uzrok afa-zije bila ishemija, a u 10,5% hemoragija, a u našem istraživanju, od ukupnog broja pacijenata sa ishemijskim možda-nim udarom, 20,58% imalo je afaziju, a od ukupnog broja pacijenata sa hemo-ragijskim moždanim udarom, 28,15% za posljedicu je imalo afaziju.

5. ZAKLJUčAKUčestalost afazičkih poremećaja u

akutnoj fazi moždanog udara iznosi 20,34%. U odnosu na fluentnost govora, češće su nefluentne (72,28%) nego flu-entne (27,72%) afazije. Najčešća vrsta afazije je globalna (48,51%), slijedi Bro-kina (23,36%), zatim anomička (16,33%), te Vernikeova (8,41%). Transkortikalna

senzorna, transkortikalna motorna i konduktivna afazija se dijagnostikuju kod malog broja pacijenata u akutnoj fazi moždanog udara. Afazički pore-mećaju su češće verificirani kod paci-jenata sa hemoragijskim moždanim udarom (28,15%) u odnosu na ishemij-ski (20,58%) ali razlika nije statistički značajna. Kod pacijenata ženskog spola signifikantno su češći (57,43%) afa-zički poremećaji u akutnoj fazi mož-danog udara.

LITERATURA1. National Aphasia Association. Aphasia

Fact Sheet. Retrieved, 1999. December 14 2004, from www.aphasia.org

2. Sinanović O. Afazije. U: Sinanović O, Smajlović Dž i sar. Osnove neuropsi-hologije i neurologije ponašanja. Tuzla: Univerzitet u Tuzli, 2005:45-51.

3. Benton AL, Hamsher K. deS. Multilin-gual Aphasia Examination. Iowa City, Iowa: AJA Associates, 1989.

4. Demarin V, Trkanjec Z, Vuković V. Su-vremena organizacija prevencije mož-danog udara. Medicus, 2001;10(1)13-18..

5. Vuković M. Afaziologija. Beograd, SD publik, 2002.

6. Godefroy O, Dubois C, Debachy B, Lec-lerc M, Kreisler A. Vascular Aphasias

– Main characteristics of patients hos-pitalized in Acute stroke units. Stroke, 2002; 33(3):702-5.

7. Kauhanen M, Kopelainen J, Hiltunen P, Moatta R, Mononen H, Brusin E, Sota-niemi K, Myllyla V. Aphasia, depression and non – verbal cognitive impairment in ishemic stroke. Cerebrovascular di-sease, 2002;10(6):450-61.

8. Laska A, Hellblom A, Murray V, Ka-han T, Von Arbin M. Aphasia in acute stroke and relation to outcome. Intern med, 2001;249(5):413-22.

9. Pedersen PM, Vinter K, Olsen T. Apha-sia after stroke: type severity and pro-gnosis. Cerebrov Dis, 2004;17:35-43.

10. Sutović N, Smajlović Dž, Sinanović O, Sutović A, Evlauation of hospital spec. therapy in aphasic stroke patient. Neu-rol Croat, 2003;53(suppl 2):110A.

11. Franić J, Matijaščić D, Bielen I. Inter-disciplinarni pristup pacijentima sa moždanim udarom i afazijom. Neurol Croat, 2007; 56(suppl 1):204-5.

12. Hier D, Yoon WB, Mohr JP, Price TR, Wolf PA.Gender and aphasia in the stroke data bank. Brain and Language, 1994;47(1):155-67.

Kontakt adresa autora: Dr. Ensala Brkić, Klinika za neurologiju, Univerzitetski klinički

centar Tuzla, 75000 Tuzla, Bosna i Hercegovina, [email protected] 061/294-011

200 MED ARH 2009; 63(4) • ORIGINALNI ČLANCI | ORIGINAL PAPERS

Antenatalni kortikosteroidi u prevenciji respiratornog distres sindroma: učinkovitost u odnosu na tretman-porod interval

1. UVODRespiratorni distres sindrom (RDS)

pogađa približno 40-50% djece gestacij-ske dobi ispod 32 nedjelje (1). Od 1972. (Liggins i Hovie) postoje dokazi da kor-tikosteroidni tretman dat majci prije pri-jevremenog poroda, smanjuje inciden-ciju RDS-a i intraventrikularne hemo-ragije te da reducira stopu mortaliteta prijevremeno rođene djece (2,3). Steroidi dati majci pasiraju placentarnu barijeru

te u pneumocitima tip II induciraju pro-dukciju surfactanta, što pomaže u pre-venciji RDS-a. Najveći benefit od ante-natalne primjene kortikosteroida imaju djeca između 24 i 34 nedjelje gestacije (4).

Od početka primjene antenatalne kortikosteroidne terapije pa sve do da-nas kroz različite studije i meta-analize vršena je sistematska procjena ovih do-kaza te su razvijeni različiti protokoli za primjenu kortikosteroida (3,5). Kortiko-

steroidi se sada smatraju standardnim tretmanom za sve trudnice između 24 i 34 nedjelje kod kojih se očekuje prijevre-meni porod u narednih od 1-7 dana (6,7). Najviše korišteni kortikosteroidi u prote-klih 25 godina bili su dexamethazon (4x6 mg) i betamethason (2x12 mg), u obliku jedne steroidne kure. Novije studije do-vode u vezu primjenu deksametazona i povećanog rizika periventrikularne le-ukomalacije kod prijevremeno rođene djece, te se preferira upotreba betameta-zona (8,9). Ukoliko nije došlo do poroda ponavljanje kura (buster doze) se ne pre-poručuje, prvenstveno zbog rizika neu-rorazvojnih sekvela (10,11).

Rezultati nekih novijih istraživanja pokazali su da je efekat jedne doze ste-roida date 4-24 h prije poroda bio je kli-nički komparabilan sa efektom prepo-ručene sheme, što bi ukazivalo da bi se interval prije poroda mogao smanjiti u akutnim kliničkim stanjima (12).

Cilj ovog rada je procjena efikasnosti antenatalne primjene kortikosteroida u redukciji incidencije RDS-a u zavisnosti od početka tretmana u odnosu na vri-jeme poroda.

2. pAcIJENTI I METODE RADAOva prospektivno-retrospektivna

studija je obuhvatila 80 prijevremeno rođene djece gestacijske dobi 26-34 ne-djelje čije su majke antepartalno dobile kortikosteroidni tretman. Sedamdese-tipet (75) trudnica iz ispitivane grupe tretirano je jednom kurom deksameta-zona, a 5 trudnica ponavljanim kurama deksametazona (buster doze). Kontrolnu grupu činilo je 92 djece iste gestacijske dobi, čije majke antepartalno nisu tre-tirane kortikosteroidima. Djeca dijabe-tičnih majki, djec

researchgate...editorial board editor-in-chief izet masic secretary alma zejnilovic technical editor...

Documents