The Macedonian Journal of Anaesthesia (MJA) is a peer-reviewed, open-access scientific journal dedicated to the publication of high-quality research in the fields of anaesthesiology, critical care medicine, perioperative medicine, pain management, and related disciplines. The journal aims to promote scientific knowledge, clinical practice, and innovation by providing a platform for clinicians, researchers, and healthcare professionals to disseminate original research, review articles, case reports, and other scholarly contributions. MJA encourages the exchange of knowledge at both national and international levels and supports the advancement of evidence-based medicine and clinical excellence. The journal adheres to internationally recognized ethical and editorial standards, including the recommendations of the International Committee of Medical Journal Editors (ICMJE), Committee on Publication Ethics (COPE), and the EQUATOR Network. All articles are published in English and are freely accessible to ensure wide dissemination of scientific knowledge. The official journal website is available at https://mja.mk
Department of Anaesthesia and Reanimation, University Clinical Center “Mother Teresa”, Skopje, North Macedonia, in collaboration with the Macedonian Society of Anaesthesia (MSA) and Macedonian Society of Critical Care Medicine (MSCCM)
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MANAGING DUAL PATHOLOGIES: NEPHRECTOMY FOR RENAL CELL CARCINOMA IN A PATIENT WITH SEVERE TRICUSPID VALVE REGURGITATION
Renal cell carcinoma (RCC) is the most prevalent form of kidney cancer. Tricuspid regurgitation is a condition marked by the reverse flow of blood from the right ventricle into the right atrium and necessitates thorough assessment to ascertain its severity and effect on heart function. In this case, we present a 57-years-old male patient with symptomatic renal cell carcinoma and a severe tricuspid valve regurgitation. The performed open nephrectomy went uneventfully. While the patient was successfully and safely managed from an anesthesiology standpoint despite his comorbidities, performing the procedure in a resource-limited setting posed significant challenges. In such environments, the lack of immediate access to advanced hemodynamic monitoring, cardiothoracic surgical support and perioperative cardiac interventions increases the complexity of managing patients with dual pathologies. Ideally, conducting nephrectomy in an operating theater equipped for simultaneous surgical interventions, addressing both the renal pathology and potential worsening of tricuspid valve regurgitation, with a cardiothoracic team on standby, would have provided a safer approach. However, in settings with constrained resources, optimizing intraoperative management, ensuring rigorous hemodynamic monitoring, and coordinating multidisciplinary teams within the available infrastructure become critical for achieving favorable outcomes.
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OBESITY AND POSTOPERATIVE DELIRIUM IN A MIDDLE-AGE SURGICAL PATIEN
The literature for bladder cancer patients outlines the role of malnutrition as one of the key factors for postoperative outcomes, including postoperative delirium (POD). However, there is still a debated question whether obesity has a protective, or etiology role in the process of occurrence of POD. Here, we present a case of a 56-years-old man with obese class 1 admitted to City General Hospital “8th of September”, Skopje, Macedonia, for an elective major surgical procedure, radical cystectomy, presenting with postoperative delirium (POD). Anthropometric measurements (weight, high) and nutrition screening tools (body mass index, NRS-2002) verified his nutrition status. We additionally performed The Confusion Assessment Method and Mini-Mental Status Examination on admission and days 1, 2, 3, and 7 to evaluate signs of POD and his cognition level. Clinical presentation and radiographic imaging confirm the diagnosis of POD. We faced a few challenges writing this case report, including the impact of older age, selection of appropriate and available laboratory markers, examination of how body mass index affects POD, and identification of precipitated factors for POD. We determined that hypoxia could be a key link that connects inflammation, nutrition status, and POD in our patient.
Bardet-Biedl syndrome (BBS) is a genetic and multisystem disease that affects the genitourinary tract, locomotory system, causes eye anomalies, cognitive disorders and characteristic truncal obesity. It is caused by mutations in certain genes, namely: BBS1 to BBS21 gene. The approach to this disease is multidisciplinary. Material and Methods: We present a 3-years-old female child who was referred to the Clinic for Pediatric Surgery due to supernumerary toes on both feet. This is postaxial polydactyly. Intrauterine lobulated kidney structure was observed. The child had problems with her peers and avoids socializing with them. The following examinations were performed: cardiological, ophthalmological and genetic. Genetic examinations confirmed the BBS syndrome. Results: The patient was operated at the clinic for pediatric surgery, the operative and postoperative period were without complications. Conclusion: BBS is a rare autosomal disease that requires timely detection and appropriate multidisciplinary treatment. This allows complications to be reduced and the child to be included in everyday activities.
SEPTIC SHOCK IN POLYTRAUMATIZED PATIENT: A CASE STUDY AND MANAGEMENT CHALLENGES
Septic shock is a life-threatening condition that represents the final stage of sepsis, where infection leads to widespread systemic inflammation, tissue hypoperfusion and multi-organ dysfunction. The management of septic shock becomes even more complicated in polytraumatized patients, where multiple severe injuries often contribute to both the patient’s clinical deterioration and the risk of infection. We present the case of a 55-years-old male with multiple traumatic injuries including thoracic contusion, fractures of the cervical and rib bones and bilateral extremity fractures, who developed severe septic shock during his hospitalization. His medical history included type II diabetes mellitus and chronic gastritis. Upon admission, the patient was intubated and mechanically ventilated, started on broad- spectrum antibiotics, anticoagulants and fluid resuscitation. Initial microbiological tests revealed no pathogens, but by day 10, Methicillin-resistant Staphylococcus aureus (MRSA), Pseudomonas aeruginosa and Acinetobacter species were identified. Despite aggressive antibiotic therapy, the patient developed worsening sepsis marked by hyperthermia, elevated inflammatory markers and oliguria by day 12. As his condition deteriorated, Cytosorb therapy was initiated on day 13, followed by hemodialysis on day 15 for acute kidney injury. On day 20, blood cultures revealed Vancomycin-resistant Enterococcus (VRE). As the infection evolved, additional pathogens including Klebsiella pneumoniae, Pseudomonas aeruginosa and Candida glabrata, were identified. Antifungal therapy with caspofungin was introduced on day 33. Despite the complexity of multiple infections and resistance patterns, the patient responded to tailored therapy, with negative blood cultures achieved by day 42. This case highlights the challenges in managing septic shock in polytraumatized patients, particularly with the emergence of multidrug-resistant organisms. A multidisciplinary approach, involving timely microbiological testing, antibiotic stewardship and supportive therapies such as Cytosorb and renal replacement was essential for improving patient’s outcome. The case also underscores the importance of vigilant management of fungal infections such as Candida glabrata in critically ill, immunocompromised patients.
UNLOCKING TENSIONS: THE SYNERGY OF POINT OF CARE ULTRASOUND AND FASCIOTOMY
Compartment syndrome is an agonizing state arising from excessive pressure buildup within muscles, hindering blood circulation and depriving nerve and muscle cells of vital oxygen and nutrients. Usually, this condition arises following injury-induced bleeding or swelling. The elevated pressure characteristic of compartment syndrome impedes the circulation of blood, oxygen and essential nutrients to and from the impacted tissues. In some cases, it necessitates immediate surgical intervention to avert lasting damage. Consensus holds that prompt intervention offers the greatest opportunity for full recovery and for averting additional tissue necrosis. Treatment primarily relies on clinical presentation, supported by corroborative measurements of compartmental pressure. A fasciotomy is an emergency procedure used to treat acute compartment syndrome. We describe a scenario involving a 19-years-old male, where in the diagnosis and postoperative outcome was swiftly facilitated by point-of-care ultrasound (POCUS), revealing a substantial thigh hematoma within the anterior compartment with vascular compromise before fasciotomy revealed by color and pulse wave doppler. Using POCUS, restorage of circulation and local hemodynamics after fasciotomy were assured by detecting normal doppler signal of previously involved peripheral arteries. Although POCUS should not serve as the sole method for evaluating potential compartment syndrome, it can significantly contribute as a supplementary tool in the diagnostic process and especially when following up patients where therapeutic actions have been done.
ULTRASOUND GUIDED SUPRACLAVICULAR BRACHIAL PLEXUS BLOCK FOR UPPER LIMB SURGERY IN CARDIOVASCULAR COMPROMISED PATIENT: CASE REPORT
Introduction: We can use the supraclavicular block as a postoperative pain management approach, as an addition to general anesthesia, or as the sole form of anesthesia for upper limb surgery. For upper limb surgery, this block is a fantastic substitute for general anesthesia in patients with pulmonary and cardiac comorbidities. Case Presentation: In order to undergo surgery for a fracture of the proximal portion of his upper arm, a 66-years-old male AA was brought to the Clinic for Orthopedic Diseases in Skopje. The anesthesiologic examination revealed that the patient had diabetes mellitus type II, cardiomyopathy, untreated ischemic heart disease and wheezing and crepitations in the distal portions of his lungs. We planned the open fixation of the fracture for the patient. A supraclavicular brachial plexus block was performed as the most non-invasive procedure for perioperative treatment, taking into consideration the patient's health. The patient's vital indicators were normal and stable during the procedure. After receiving therapy for two days, the postoperative course was uneventful, leading to the patient's discharge. Conclusion: If not addressed earlier, preoperative pulmonary and cardiac comorbidity increases the risk of perioperative and postoperative problems. With no postoperative problems, peripheral nerve block - in our case, supraclavicular brachial plexus block - proved to be a safe option for anesthesia management used for upper limb surgery.
PRE-OPERATIVE ASSESSMENT ON A PATIENT FOR LAPAROSCOPIC CHOLECYSTECTOMY WITH B12 ANEMIA
The pre-operative assessment is an opportunity to identify co-morbidities that may lead to patients’ complications during the anesthesia, surgical or postoperative period. Patients scheduled for elective procedures will generally attend a pre-operative assessment 2-4 weeks before the date of their surgery. A woman at the age of 57 years was admitted to the hospital planned for the elective laparoscopic cholecystectomy. On the preoperative assessment on laboratory analysis, we found presence of anemia with MCV levels above normal and low levels of vitamin B12. She was never treated for anemia before. Peripheral blood smear showed presence of macrocytosis. The patient was put on treatment with intramuscular injections of vitamin B12. The operation was delayed for two months. She was admitted to the hospital after two months of treatment and blood analysis were made that showed Hb levels of 115g/l, hematocrit 35%, MCV was 92. She was operated after she had been hospitalized, and laparoscopic cholecystectomy was made without complications. She was released from hospital two days after surgery. The purpose of a preoperative evaluation is not to “clear” patients for elective surgery, but rather to evaluate, and if necessary, implement measures to prepare higher risk patients for surgery. By diagnosing anemia in the preoperative assessment, we reduced the risk of complications during the surgery and during the postoperative period. Early identification and effective treatment of anemia has the potential to improve clinical outcomes in surgical patients.
TWO CASE REPORTS ON THE EFFECT OF SEVOFLURANE EXPOSURE DURATION ON SERUM LEVELS OF NEURON-SPECIFIC ENOLASE (NSE) AND S100 PROTEIN IN CHILDREN
The length of sevoflurane exposure may raise the risk of neuron-specific enolase (NSE) and S100 protein alterations in blood, which might thereafter result in postoperative cognitive dysfunction (POCD). The pathophysiology of POCD caused by the volatile anesthetic sevoflurane has been the subject of extensive research in recent years. This case study looks at preliminary findings about the effects of different sevoflurane anesthetic exposure durations on the levels of S100 protein and NSE in children's blood. Additionally, it looks into how sevoflurane affects children's early cognitive performance following surgery. To detect neurological effects during general anesthesia and ascertain the length of sevoflurane exposure, we employ the particular markers such as S100 protein and NSE. In this case study, we present two pediatric patients who underwent general anesthesia with sevoflurane for different durations. The aim was to observe potential postoperative changes in NSE and S100 protein levels, which are biomarkers associated with neuronal injury and cognitive function. After the surgery, we utilize these levels to assess any cognitive problems. The parents or guardians gave their informed consent.
postoperative cognitive dysfunction in children
NON-CARDIAC SURGERY IN CARDIAC PATIENTS: KEY INSIGHTS
The growing elderly population leads to a higher proportion of primarily non-cardiac surgeries being performed on patients with cardiac conditions. This highlights the necessity to review and update protocols for ensuring safe surgery in the patient group mentioned above. The cardiovascular complications are especially prevalent in patients with documented or asymptomatic coronary heart disease, left ventricular (LV) dysfunction, valvular heart disease (VHD) and arrhythmias, particularly when undergoing surgeries that place prolonged strain on the heart and hemodynamics. Preoperative N-terminal fragment of proBNP (NT-proBNP) measurement is the stronger predictor for postoperative complications. We should not initiate beta blockers, alpha-2 agonists, calcium channel blockers and statins, but rather continue them during the preoperative period. The risk of postoperative bleeding should not be the main reason for delaying non-cardiac surgery.
RIGHT VENTRICULAR PERFORMANCE IN MECHANICALLY VENTILATED POLYTRAUMATIZED PATIENTS BASED ON ASSESSMENT OF TRICUSPID ANNULAR PLANE SYSTOLIC EXCURSION AND RIGHT VENTRICULAR FRACTIONAL AREA CHANGE
Even in terms of using lung protective strategies, mechanical ventilation could lead to different types of lung injury with severe consequences over systemic and pulmonary hemodynamics, showing deleterious properties over the right ventricular performance as well. Fifty polytraumatized patients admitted in the ICU were included in this prospective study. They were divided into two groups regarding the need for mechanical ventilation. In all patients we have examined Right heart function by measuring Tricuspid Annular Plane Systolic Excursion (TAPSE) and Fractional Area Change (FAC) 24 hours, 7 and 14 days after admission in the ICU. Statistical analysis was done with calculating the mean value of TAPSE and FAC, as well as with using Mann Whitney U Test. In both groups, mechanically ventilated and spontaneously breathing patients, values for TAPSE were not significantly different at all examination points. The values for FAC were significantly lower in the group of mechanically ventilated patients after 7 and 14 days of mechanical ventilation initiation (U=275; 163,5; 86,5 and z= 0,7; 2,02; 1,96 for p value of 0,47; 0,04 and 0,04 respectively). TAPSE as a surrogate for the assessment of longitudinal systolic function of the right ventricle, has been intact in both groups regardless the usage of mechanical ventilation, but radial systolic function of the right ventricle was significantly lower 7 and 14 days after starting mechanical ventilation. Impairment of the radial systolic function of the right ventricle with preserved longitudinal systolic function was previously reported in patients with high pulmonary pressures and elevated right ventricular afterload. The mechanical ventilation is associated with radial right ventricular systolic dysfunction and with lower values for FAC in mechanically ventilated compared to spontaneously breathing polytraumatized patients.
PREVALENCE AND IDENTIFICATION OF POTENTIAL PREDICTORS ASSOCIATED WITH GESTATIONAL DIABETES MELLITUS IN NORTH MACEDONIA
Introduction: Gestational diabetes mellitus (GDM) is defined as the occurrence of diabetes which is discovered during pregnancy. It is a widespread global condition with many maternal and fetal health risks. Objective: The aim of this study was to identify the prevalence and potential predictors of GDM among a cohort of women from North Macedonia. Patients and Method: A total number of 154 (143) participants were included in the study. The diagnosis of GDM was made using the International Association of the Diabetes and Pregnancy Study Groups (IADPSG) criteria. Patients with known diabetes prior to pregnancy, history of GDM, in vitro fertilization (IVF), multiple gestation and severe medical conditions were excluded from the study. The recorded variables were age, nationality, religion, education, parity, family history of diabetes (FHD), pre-pregnancy body mass index (BMI), weight gain, smoking and oral contraceptive use. The statistical analysis was done calculating exact logistic regression in “R”. Results: Significant predictors: For every one-unit increase in BMI, the odds of developing GDM increased by 8.6% (coefficient=0.086, p=0.026). Women with family history of diabetes had 2.74 times higher odds of developing GDM (coefficient=1.008, p=0.011). The Orthodox participants had significantly lower odds of developing GDM compared to the Muslim ones (coefficient=-2.528, p=0.011). Two prior pregnancies raised the odds to 4.70 times higher compared to no prior pregnancies (coefficient=1.547, p=0.042). Conclusion: The study emphasizes the importance of addressing pre-pregnancy BMI and screening individuals with family history of diabetes. The high prevalence of GDM suggests a need for public health strategies focusing on preconception care, lifestyle interventions and regular screening during pregnancy.
MAPPING THE CURRENT AND FUTURE CLIMATE EXTREMES AND HEALTH THREATS TO VULNERABLE POPULATIONS IN KOSOVO
Introduction: Climate change affects human lives and health in different ways. High temperatures and heat waves are associated with excessive morbidity and mortality, especially among vulnerable categories of the population. In addition to deaths, high temperatures can increase pressure on the healthcare system by increasing emergency room visits, hospitalizations, premature births, causing mental health problems and other negative health outcomes. Infectious diseases that are transmitted through food and water have a high incidence rate and can be exacerbated by climate extremes such as heat waves, floods and droughts. As the climate continues to change, the risks to health systems and facilities including hospitals, clinics and community care centers are increasing, among others reducing the ability of health workers to protect people from a range of climate hazards. Objective: The main objective of the study is to investigate and create an initial database of data and indicators for assessing the risk of climate change on the health of the population and the health system in Kosovo, as a tool to adapt to climate changes and reduce the risks for the population health and healthcare systems and facilities – including hospitals, clinics and community-based care centers. Materials and methods: For conducting the assessment, data, information and publications in the hydrometeorological, health and other relevant sectors, as well as relevant international publications were used. A vulnerability assessment is translated through the definition and analysis of the climate, public health and environmental health profile of Kosovo and the expected climate extremes in future scenarios, the organization and preparedness of the health sector, as well as the research of the current health profile of the population in Kosovo. Results and discussion: the current and future climate profile of Kosovo is analyzed with a focus on the most important climate extremes such as heat waves and floods. Testing the RCP 4.5 and 8.5 future climate scenarios showed an increase in the average annual temperature and number of tropical days on almost the whole territory of the country with a maximum of 40C and a decrease of the precipitation especially in the summer period for more than 30% (in the period 2071-2100) compared to the baseline scenarios. We analyzed the demographic structure and some determinants of health of the population of Kosovo, vulnerable groups such as the elderly, the chronically ill, especially those with cardiorespiratory diseases, people with low incomes and low education, outdoor workers and the homeless, as well as the risk regions in the countries where the highest average temperatures or the highest atmospheric precipitation are registered. There is a particular risk in the northern part of the country, where the older population with low incomes and education is large. Fewer economic opportunities, higher poverty rates, greater distances to health centers and fewer services are available there. These structural factors thus further compromise the existing poor situation in which the aging population, including their long-term care, remains subject to lower quality care in rural and more northern areas. The highest mortality rate is expected to be registered among the most vulnerable population over 65 years of age. Finally, a mapping of the risks of climatic extremes in Kosovo was prepared with indicators for further monitoring and assessment of vulnerability. In conclusion, high temperatures, rainfall and floods are presented as the biggest current and even more future climate and health risks in the area of Kosovo, which will also be a serious threat and burden for the health system.
THE BENEFITS OF ULTRASOUND GUIDED PERIPHERAL NERVE BLOCKS IN ORTHOPEDIC SURGERY
Introduction: Peripheral nerve blocks have an increasingly important role as an anesthetic technique for surgical anesthesia, postoperative analgesia, and fast discharge of patients after surgery involving the upper or lower extremities, alone or in combination with spinal or general anesthesia. Ultrasound guidance has become the most popular for performance of peripheral nerve blocks. Methods: In our retrospective study, we included all patients that were admitted in our hospital for orthopedic procedures on lower and upper extremities who received peripheral nerve block, alone or in combination with spinal or general anesthesia in the last 5 years. Ultrasound guidance was used and local anesthetic Bupivacaine 0.5%. Dexamethasone 4 mg was given intravenously as an adjuvant to peripheral nerve blocks. Results: The total number of patients included in our study was 300, the total number of performed peripheral nerve blocks was 302. 144 (48%) patients were male and 156 (52%) - female. The type of performed blocks was: 164 (54%) femoral, adductor canal blocks 22 (7.28%), 26 supraclavicular (8.60%), 77 interscalene (25.49%), 9 axillar (2.98%), 2 popliteal (0.66%), 1 iPACK and 1 TAP block (0.33%). Peripheral nerve blocks were combined with general or spinal anesthesia or performed as a sole technique for intraoperative analgesia in 17 patients (5.67%). Discussion: In our hospital we performed ultrasound guided peripheral nerve blocks last years in combination with a general, spinal anesthesia or as a sole technic for intraoperative and postoperative analgesia. Our patients were very satisfied with good postoperative pain control, and no serious complications were observed. Conclusion: Ultrasound guided peripheral nerve blocks are good choice for intraoperative anesthesia and postoperative analgesia, especially in older patients and patients with a lot of comorbidities.
CHALLENGES IN ANALGOSEDATION MANAGEMENT IN THE INTENSIVE CARE UNIT
INHALATIONAL ANESTHETICS WITH THEIR PHARMACOKINETIC PROPERTIES
MASS CASUALTY EVENT PREPAREDNESS AND ANESTHESIA MANAGEMENT IN THE EMERGENCY DEPARTMENT AND INTENSIVE CARE UNIT
Mass casualty events whether natural disasters, terrorist attacks, pandemics or large-scale accidents overwhelm healthcare systems, emergency departments and ICUs in minutes. High acuity situations require rapid coordination, strategic resource allocation and seamless inter-disciplinary collaboration. Anesthesiologists are uniquely positioned to play a central role in all phases of the response due to their expertise in airway management, hemodynamic stabilization, pharmacologic sedation and critical care. Their role extends beyond the OR to initial triage, emergency procedural support and ongoing management of ventilated and critically ill patients in the ICU. This article reviews current evidence and operational best practices to examine the role of anesthesiology in mass casualty events preparedness and response. Key areas of focus include disaster planning, ventilator triage, crisis standards of care, sedation protocols and ICU surge capacity. By highlighting the clinical, operational and ethical aspects of anesthesia management in mass casualty events, this article synthesizes current literature and best practices, emphasizing the anesthesiologists’ role in preparedness, immediate response and postoperative care during mass casualty events.
A CRITICAL CARE PERSPECTIVE ON FAMILIAL MEDITERRANEAN FEVER
Familial Mediterranean Fever (FMF) is a rare autosomal recessive autoinflammatory disorder predominantly affecting individuals of Mediterranean origin. FMF is characterized by recurrent febrile episodes and serositis with amyloidosis being its most severe complication, often leading to end-stage renal disease (ESRD). The progression of FMF to amyloidosis is associated with increased morbidity and mortality requiring early diagnosis and effective management. This case report presents a critically ill patient with FMF, amyloidosis and vasculitis-related complications including massive hemorrhage and multi-organ failure. It highlights these complex conditions, the challenges in ICU management and the necessity of a multidisciplinary approach to optimize patients’ outcomes.
MALIGNANT PERIPHERAL NERVE SHEATH TUMOR IN THE RETROPERITONEUM NOT ASSOCIATED WITH THE RENAL OR PERIRENAL PARENCHYMA
The occurrence of an isolated malignant peripheral nerve sheath tumor (MPNST) in the retroperitoneum, unassociated with the kidney capsule, is exceedingly rare, often presenting with an insidious onset of non-specific and misleading symptoms, primarily characterized by lower back pain. We present the case of a patient with a malignant peripheral nerve sheath tumor (MPNST), without neurofibromatosis with nonspecific localization in the retroperitoneum in front of vena cava inferior non associated with the kidney. A 62-years-old male patient was referred due to the presence of an abdominal tumor without accompanying pain. Computed tomography identified a substantial soft tissue retroperitoneal tumor situated anterior to the inferior vena cava. A total resection was performed. The pathological testing verified the existence of a malignant peripheral nerve sheath tumor. The patient received additional treatment through radiotherapy and chemotherapy. This is the inaugural reported case of malignant peripheral nerve sheath tumor in the retroperitoneum without neurofibromatosis, unassociated with renal or perirenal parenchyma. We recommend incorporating malignant peripheral nerve sheath tumor into the differential diagnosis of abdominal masses.
A BILIARY LEAK FROM DUCTS OF LUSCHKA AFTER LAPAROSCOPIC CHOLECYSTECTOMY - IMAGING FINDINGS
Acute cholecystitis is a condition which treatment usually involves surgery, and the most used is laparoscopic cholecystectomy. Bile leakage is a complication of laparoscopic cholecystectomy, often caused by injury to small aberrant bile ducts, such as the ducts of Luschka. We report a case of a 25-years-old female who was presented with abdominal pain five days after laparoscopic cholecystectomy. A CT scan and MRCP scan revealed a small bile collection in the gallbladder bed and the bile leakage was suspected. A laparoscopic revision was performed, during which a biliary collection was aspirated. Further exploration of the gallbladder fossa revealed an aberrant bile duct (duct of Luschka), smaller than 1mm, actively secreting bile. The duct was successfully closed, leading to resolution of the leakage. The ducts of Luschka are one of the most common causes of bile leakage after laparoscopic cholecystectomy. Generally, most of the diagnoses are determined post operatively as a result of the post-operative complications that arise. It is important to take into consideration the imaging reports whenever we have post cholecystectomy bile leakage.
magnetic resonance cholangiopancreatography
MIGRATING PULMONARY ANEURYSM IN BEHÇET VASCULITIS
Behçet's disease (BD), also called Behçet's syndrome, is a rare multisystemic vasculitis that causes blood vessel inflammation throughout the body. It may affect multiple organs and less frequently involves the central nervous system, potentially resulting in thrombotic events and aneurysm formation, the most notably pulmonary artery aneurysms (PAA). We present a case of a 44-years-old female who sought medical attention due to prolonged hemoptysis combined with chest pain. Ascribed to these symptoms, initial computer tomography (CT) (native and arterial phases) revealed an oval mass in the left hilum. Subsequent CT angiography demonstrated an aneurysm of the left interlobar artery compressing the segmental bronchus with associated thrombus formation. The patient refused surgical intervention. One year later, a follow-up CT angiography showed the resolution of the initial aneurysm but revealed a new aneurysm in the right main pulmonary artery. This case highlights the rare migratory nature of pulmonary aneurysms in Behçet vasculitis, underscoring the need for early diagnosis, imaging follow-up and interdisciplinary management.
VAGUS NERVE STIMULATOR AS A TREATMENT FOR REFRACTORY EPILEPSY – ONE CENTER EXPERIENCE
Epilepsy is defined as a neurological disorder manifested by an excessive and abnormal electrical neuronal discharge. Refractory epilepsy still remains quite frequent condition, considered 30-40% of all patients with seizures, despite improvement in medication possibilities. Vagus Nerve Stimulator offers a neuromodulation approach when other treatment possibilities are exhausted. This minor procedure is safe but carries potential risks for anesthetic management and anesthesiologists should be aware of the physiological implications of the device and anticipate and manage possible complications.
INVESTIGATION OF DEXMEDETOMIDINE, FAMOTIDINE AND METOCLOPRAMIDE EFFICACY FOR PREVENTION OF POSTOPERATIVE NAUSEA AND VOMITUS: WHAT IS THE PREFERABLE CHOICE?
Introduction Postoperative nausea and vomitus (PONV) are serious complication subsequent to laparoscopic radical prostatectomy. Although the prevention of PONV states that a single bolus dose of one antiemetic drug is recommended, combining treatment with two or more drugs or continuous antiemetic drug infusion is more effective. Objectives To evaluate and compare the occurrence and severity of postoperative nausea and vomiting (PONV) in the postoperative phases in patients undergoing laparoscopic prostatectomy who receive various antiemetic prophylaxes. Materials and Methods This prospective, comparative study included 40 patients who underwent laparoscopic radical prostatectomy, equally divided into two groups: one receiving intraoperative antiemetic prophylaxis with a combination of two agents Group FM (intra operative receiving metoclopramide and famotidine), and the other with a single agent (receiving intra- and postoperative continuous infusion of Dexmedetomidine) Group DEX. The dry retching and nausea were assessed at five postoperative time points: immediately after extubating, and at 2, 4, 12 and 24 hours. Results Postoperatively, PONV was identified in total 8 (20%) patients in the two groups. The incidence of PONV in group DEX was lower, and it was 15% or 3 patients with grade 1 PONV, versus 25% or 5 patients with grade 2 PONV in group FM. Conclusion Our results indicate that Dexmedetomidine could significantly lower the occurrence and gradus of PONV compared, with combination of Famotidine and Metoclopramide after laparoscopic prostatectomy.
HYPERBILIRUBINEMIA AS A BIOMARKER FOR COMPLICATED APPENDICITIS: A RETROSPECTIVE STUDY
Introduction: Hyperbilirubinemia has been proposed as a potential biomarker for predicting complicated appendicitis. This study aims to evaluate the role of serum bilirubin in differentiating complicated from uncomplicated appendicitis and to compare its diagnostic performance with other inflammatory markers. Material and Method: A retrospective analysis was conducted on 30 patients diagnosed with acute appendicitis, including 10 with complicated and 20 with uncomplicated appendicitis. Laboratory parameters, including white blood cell (WBC) count, neutrophil-to-lymphocyte ratio (NLR), platelet (PLT) count, interleukin-6 (IL-6) and serum bilirubin levels, were compared between the two groups. Statistical analyses were performed to determine the predictive value of hyperbilirubinemia for complicated appendicitis. Results: Patients with complicated appendicitis exhibited significantly higher serum bilirubin levels than those with uncomplicated appendicitis (p<0.01). Additionally, CRP and IL-6 were notably elevated in the complicated appendicitis group. However, the combination of serum bilirubin with other inflammatory markers, such as CRP and IL-6, enhanced diagnostic accuracy. Conclusion: Hyperbilirubinemia is a valuable biomarker for predicting complicated appendicitis and may serve as a useful adjunct to existing diagnostic tools. Further large-scale prospective studies are warranted to validate these findings and establish standardized cutoff values for clinical application.
CORRELATION OF GLUCOSE AND LIPID STATUS IN PATIENTS WITH GESTATIONAL DIABETES MELLITUS
Introduction: Gestational diabetes mellitus, characterized by glucose intolerance during pregnancy, poses heightened risks to both the mother and fetus. It emerges due to increased insulin resistance during pregnancy. Adipose tissue plays a vital role in regulating various biological processes through the secretion of adipokines, which influence both pregnancy and the development of gestational diabetes. Hyperlipidemia, a well-known contributor to atherosclerosis, directly impacts the onset of cardiovascular diseases. Pregnancy leads to an increase in serum levels of total cholesterol and triglycerides, driven by increased levels of hormones such as estrogens, progesterone and lactogen. Material and Methods: This study presents prospective clinical research involving 65 individuals, excluding 6 patients with spontaneous abortion. A total of 59 patients were incorporated into the statistical analysis. The patients underwent three follow-up visits. During the initial visit, the participants were enrolled in the study; all of them were healthy individuals in the first trimester of pregnancy. In the second visit, an oral glucose tolerance test (OGTT) with 75 grams of glucose was conducted between 24 and 28 weeks of gestation, and the patients were categorized. Patients exhibiting a positive OGTT were diagnosed with gestational diabetes. The third visit occurred in the third trimester of gestation. Results: Gestational diabetes mellitus was registered in 14 (23.73%) patients. Body mass index had significantly higher values in the group with gestational diabetes (34.59 ± 3.9 vs 29.95 ± 5.4 kg/m2, p=0.0044). The comparison of the two groups regarding the lipid status presented significantly higher triglycerides in the group with gestational diabetes (4.01 ± 2.3 vs 2.62 ± 0.9, (p=0.0017). The other parameters of lipid status were similar between the two groups. In both groups, the changes in glucose parameters were statistically insignificant in the third, compared to the first trimester of pregnancy. Conclusion: Dyslipidemia during pregnancy is a common but complex condition with consequences for both the mother and the fetus.
TELOMERASE GENE EXPRESSION IN URINARY BLADDER CARCINOMA
Urinary bladder carcinoma (UBC) is the most prevalent malignancy of the urinary tract and is associated with high recurrence and mortality rates. Histologically, urothelial carcinoma is the predominant form, accounting for nearly 90% of all bladder cancer cases. One of the most frequent molecular alterations in malignant neoplasms, including UBC, is the abnormal activation of the telomerase gene. This study aimed to quantitatively assess the expression of the TERT gene using Real-Time PCR in tissue samples obtained from patients with UBC. In total 34 patients, with histopathological confirmed urothelial bladder carcinoma, were included, along with a control group of 17 individuals without bladder malignancy. The mean TERT gene expression level in the low-grade subgroup was 1.268 ± 0.472, compared to 2.137 ± 0.942 in the high-grade subgroup. This difference was statistically highly significant (p< 0.0001). Logistic regression analysis revealed that patients with high-grade UBC were 7.39 times more likely to exhibit elevated TERT gene expression compared to those with low-grade UBC (p< 0.001). The area under the ROC curve (AUC) was calculated to be 7.89, indicating that the model is highly effective in predicting tumor grade based on TERT expression levels. The study established a positive correlation between histological grade and TERT gene expression levels. These findings suggest that molecular detection of abnormal telomerase transcriptional activity could serve as a useful auxiliary biomarker in the personalized management of patients with bladder carcinoma.
ECHOCARDIOGRAPHIC ESTIMATION OF PULMONARY CAPILLARY WEDGE PRESSURE LEVELS IN MECHANICALLY VENTILATED VERSUS SPONTANEOUSLY BREATHING PATIENTS WITH PULMONARY CONTUSIONS
Pulmonary contusions mediated immunological lung injury characterized with interstitial involvement, as well as therapeutically applied positive pressures over the already damaged alveoli could lead to elevation of the pressures inside pulmonary circulation. Fifty patients were included in the study and divided into two groups, whereby 26 were mechanically ventilated while 24 were spontaneously breathing patients. In all patients Pulmonary Capillary Wedge Pressure (PCWP) was measured non-invasively using echocardiography. Measurements of Left Atrial Pressure (LAP) were made 24 hours after admission, on the 7th and 14th day of admission in the ICU. PCWP was calculated using the LAP values and the Nagueh formula (LAPx1.24+1.98). Lung ultrasound was used for the measurement of severity of the lung injury according to the BLUE Protocol. Mean values for PCWP were calculated in both groups and the difference was examined using the Student T Test. It was found that the values for PCWP did not differ significantly between the groups when measured 24 hours and 7 days after admission and mechanical ventilation initiation (t = -0.11 and 1.13 for value for p 0.45 and 0.13),but were significantly higher in mechanically ventilated patients after 14 days of mechanical ventilation commencement (mean 10.52 vs. 7.88, t=1.89 for p of 0.03). Lung injury in patients with pulmonary contusions, as well as inflammation during the process of damage and repair, involves interstitial changes which can lead to affection of small pulmonary vessels as well. Therapeutically applied positive pressure ventilation and alveolar distension could impair blood flow through small pulmonary capillaries and vessels. When both combined, they can lead to elevation of small circulation pressures. Mechanical ventilation in patients with pulmonary contusions is associated with higher PCWP after 14 days of positive pressure ventilation in comparison to spontaneously breathing patients. Duration of mechanical ventilation is associated with higher levels of PCWP.
ASSOCIATION BETWEEN VITAMIN D DEFICIENCY AND INSULIN RESISTANCE IN EARLY PREGNANCY: A CROSS-SECTIONAL STUDY
Introduction: Vitamin D is crucial in the metabolism of calcium and phosphorus, as well as in bone health, while also contributing to numerous other bodily functions. Vitamin D deficiency in pregnant women is very common worldwide. It is associated with an increased risk of preeclampsia, gestational diabetes mellitus and cesarean section. Consequences in the newborn are most often associated with low birth weight, risk of neonatal hypocalcemia, asthma, and/ or type 1 diabetes mellitus. A lack of vitamin D during pregnancy is linked to various metabolic issues, including insulin resistance. It is considered that increased body weight has a negative effect on the concentration of vitamin D. Deficiency of 25-hydroxyvitamin D has long been considered a risk factor for glucose intolerance and most likely 1,25-dihydroxyvitamin D has a role in the regulation of insulin secretion. Objective: To investigate how a deficiency in vitamin D impacts the onset of insulin resistance in pregnant women. Material and Methods: A cross-sectional clinical study was conducted in the University Clinic for Endocrinology, Diabetes and Metabolic Diseases, Skopje, from March 2022 to March 2023 with 55 pregnant women in the first trimester of pregnancy. According to vitamin D values, the sample subjects were divided into three groups: a) Group 1: <20ng/ml; b) Group 2: 20-44ng/ml; and c) Group 3: >44ng/ml. We analyzed the level of insulinemia, glycemia and homeostatic model assessment for insulin resistance (HOMA IR) in the three groups. Results: Among 55 pregnant women assessed in their first trimester, 30 (54.54%) showed a vitamin D deficiency (below 20ng/ml). Nineteen patients (34.54%) had normal vitamin D levels (ranging from 20 to 44ng/ml), while 6 (19.91%) had elevated levels (above 44ng/ml). In the group with vitamin D deficiency, the average HOMA IR value was higher at 3.14±1.59, compared to an average of 2.57±1 in the group with normal vitamin D levels. Conclusion: A shortage of vitamin D during the first trimester of pregnancy is linked to increased insulin resistance, which can complicate metabolic health. Therefore, adequate supstituion of vitamin D during pregnancy is necessary for mother’s and offspring’s wellbeing.
Copyright (c) 2025 Dragana Unic-Stojanovic (Author) https://creativecommons.org/licenses/by/4.0
REFLECTION ON VOLUNTEERING IN ANESTHESIOLOGY AND INTENSIVE CARE: A YOUNG DOCTOR’S PERSPECTIVE
AT THE EDGE OF PATHOLOGY AND THE PROMISE OF SCIENCE: WHERE CANCER GENOMICS MEETS INSPIRATION - A PATHOLOGY RESIDENT’S PERSPECTIVE ON ESHG 2025