JEMSA Edition 2004

JEMSA - Journal of EMSA on Medical and Scientific Affairs 2004 Edition

1www.emsa-europe.org

CONTENTS

GENERAL

Credits 2Letter from the editor

Divo Ljubicic 3What is EMSA?

Amanda Victorine Wong Zhi Yan 5From the President

Ajda Skarlovnik 6

FROM THE PEN OF YOUR EEB 2003/2004...

A year in EEBAjda Skarlovnik 7

Thoughts from the desk of the secretaryFiona Horneff 8

The new girlEmon Farrah Malik 10

How everything startedDivo Ljubicic 12

A day in the office representing EMSAin Europe

Nick Kai Schneider 14General Assembly (GA) from EEB'spoint of view

Hrvoje Vrazic MD 16

EMSA ACTION: ANTI-TOBACCO!

An opinion article: Smoking and physi-cians - Doctors as role models

Anabela Diana Serranito MD 18In the game - for a tobacco free Europe(EMSA joins forces with WHO-Euro andthe CDC)

Nick Kai Schneider 20

LIFE

A summer in DubrovnikFiona Horneff 22

Modus vivendiMarieta Nikolova Ivanova 24

Becoming a doctorHrvoje Vrazic MD 26

By the choice of the editor: A shortoverview of history of medicine andurban culture in old Dubrovnik

Divo Ljubicic 27

PAPERS AND REVIEWS

Fibrinolytic therapy in acute deep veinthrombosis and arterial occlusion

Emre Sivrikoz 30Arthroscopic meniscectomy as amethod of treating meniscus injuries

Slavko Kuzmanovski, Vladimir Krstic 37Clinical manifestations and aetiopatho-genetical background of mesentericlymphadenopathy in children

Dragan Ilic 42Cutaneous tuberculosis in R. Macedo-nia during the period 1997 - 2003

Biljana Gjoneska 47Symptoms of gastrointestinal function-al disorders in student population

Melita Nesic 50Long-term consequences ofpreeclampsia - Where do we stand?

Ozge Tuncalp 54

ANNOUNCEMENTS

News in Greece - Special Edition - 14th

EMSA GA and 8th EMSCon Gefsi Mintziori 56

Invitation to 4th ZIMS (Zagreb Interna-tional Medical Summit)

Nikolina Radakovic 57



The author of the cover

Author: Nora Mojas, Study of Design, Faculty of Architecture, University of Zagreb, CroatiaContact: [email protected]

Nora Mojas is a very promising and talented young designer. Her work has been meritoriously accepted in Croatia.During her productive career as a designer, she has always been searching for a new way of expressing and creat-ing reality. Her connection with her hometown Dubrovnik has always inspired her and given her plenty of motifs forher work. She likes to be thought of as "the goddess of superlights & the mother of good design".

About the cover (a comment by Nora Mojas and Divo Ljubicic)

The cover expresses individuality through multiculturalism. Style and colour selection indicate the purity and sim-plicity of medical profession, but at the same time the multilateral and multicultural unification of Homo sapiens throughmedicine. The creation of Adam and Eve, who are the symbol of our species, can also be connected to medicine,since medicine is directed towards human beings, and exists because of human beings.

The cover also presents EMSA with its potential and values. Unification of young people, medical students, throughindividuality, multinationality and multiculturalism from which EMSA arises as a phoenix, in one voice for Europe. Unit-ed we stand, together we can.

JEMSA Edition 2004 would like to thank:

Carl Robert Blesius (Germany), Ana Borovecki MD (Croatia), Marjan Conevski (FYROM), Vladimir Galic (Serbia and Montenegro),Biljana Gjoneska (FYROM), Fiona Horneff (Germany), Dragan Ilic (Serbia and Montenegro), Katarzyna Klodnicka (Poland), MarinaKos MD PhD (Croatia), Vladimir Krstic (Serbia and Montenegro), Slavko Kuzmanovski (Serbia and Montenegro), Slobodan Lang MDPhD (Croatia), Davor Lessel (Austria), Divo Ljubicic (Croatia), Emon Farrah Malik (United Kingdom), Matko Marusic MD PhD (Croa-tia), Julia Mikic (Croatia), Gefsi Mintziori (Greece), Nora Mojas (Croatia), Melita Nesic (Serbia and Montenegro), Marieta NikolovaIvanova (Bulgaria), Nikolina Radakovic (Croatia), Nick Kai Schneider (Germany), Anabela Diana Serranito MD (Portugal), EmreSivrikoz (Turkey), Ajda Skarlovnik (Slovenia), Ozge Tuncalp (Turkey), Amanda Victorine Wong Zhi Yan (United Kingdom), Maja Vla-hovic MD PhD (Croatia), Hrvoje Vrazic MD (Croatia)

CMJ - Croatian Medical Journal (Croatia) & Medical Publishing CO (Croatia)Medical School, University of Zagreb (Croatia) & Croatian Medical Association (Croatia)

Credits

Editor:Divo Ljubicic (Croatia)

Design, layout & pre-print preparation:Hrvoje Vrazic MD (Croatia) & vrazic.com

Editorial board:Carl Robert Blesius (Germany), Marjan Conevski (FYROM), Fiona Horneff (Germany), Katarzyna Klodnicka(Poland), Emon Farrah Malik (United Kingdom), Nick Kai Schneider (Germany), Anabela Diana Serranito MD(Portugal), Ajda Skarlovnik (Slovenia), Amanda Victorine Wong Zhi Yan (United Kingdom), Hrvoje Vrazic MD(Croatia)

Publisher: European Medical Students’ Association (EMSA)c/o Standing Committee of European Doctors (CPME)Rue de la Science 41B-1040 BrusselsBelgium

ISSN 0779-1577Total Edition: 250

DisclaimerEMSA (European Medical Students' Association) and the editor do not hold themselves in any way responsible for the statements made,

or the views put forward in the various articles and papers. Medical knowledge is constantly changing. The authors and the editor, as far as it is pos-sible, have taken care to ensure that the information given in this text is accurate and up-to-date. However, readers are strongly advised to confirmthat the information is correct. Despite judicious efforts errors may have crept in and EMSA, the editor and the publisher do not accept any respon-sibility for this.

CopyrightApart from any fair dealing for the purposes of research or private study, or criticism or review as permitted under the European copy-

right, design and patent laws, no part of this publication may be reproduced, stored, or transmitted, in any form or by any means, without the priorpermission in writing of the editor, the article writers and the EEB (EMSA European board).

© 2004 Journal of the European Medical Students’ Association on Medical and Scientific Affairs by EMSA



GGEENNEERRAALL

DIVO LJUBICIC (CROATIA)

MEDICAL SCIENCE DIRECTOR & EDITOR OF JEMSA

[email protected]

Letter from the editor

Respected colleagues, EMSA members,Dear readers,

I am honoured to greet you on behalf of JEMSA Editorial Team and EMSA European Board. Hoping we will meetmost of your expectations in this edition, we are presenting you one of the results of our work during the last year.As the Editor-in-Chief, I am pleased to have the privilege of being associated with JEMSA's progress. I would like toshow my gratitude to the Editorial Board for their dedication, advice and critics; to Medical Science Local Coordina-tors for the promotion of JEMSA and their effort in collecting manuscripts and of course, to our beloved studentauthors, without whom nothing would have been possible and all our efforts would have been in vain. Without theauthors, without a sufficient authors' pool, a journal cannot survive. Moreover, I have learned the authors are the bestmedium of journal promotion, because a pleased author comes back again and also spreads the news of a good newjournal, recommends advertising in that journal, etc.

Special thanks to Hrvoje Vrazic MD for his invaluable contribution to designing and laying out this edition ofJEMSA.

Cordial thanks to Medical School of University of Zagreb, Croatian Medical Journal (CMJ) and Medical PublishingCO, Croatia, who gave an outstanding input which was extremely needed to make JEMSA 2004 possible.

JEMSA started running on a long and difficult road of becoming recognised as a noteworthy journal. That meanslots of hard work of the editors on working ethics, goals and policies, and the wisdom of finding the niche for the jour-nal. With the editorial board and the editor-in-chief being elected annually, it is difficult to keep consistency of the jour-nal, which is so important for the headway. For that reason I find the collaboration of previous and current editors tobe of utmost importance.

A new visual identity has been introduced to JEMSA and we have tried to improve the general skeleton. This year,beside "Papers" section and "Life" section, we have created "From the pen of your EEB" section instead of "Person-al" section, in order to improve communication of the EEB and EMSA Members which is very, very important forEMSA. We have also made a completely new section called "EMSA Action", in which we choose one of the impor-tant EMSA actions of last year.

In "From the pen of the EEB" section, you can read personal articles of EEB members, enjoy their adventures andhave an insight into their problems, doubts and impressions. "EMSA Actions" is entitled "Anti-Tobacco!" in the light ofEMSA's engagement for tobacco-free Europe. "Life" section brings us topics about the latest progress in dealing withthe problems of Romany population in Bulgaria, an article about summer adventures in Dubrovnik, Croatia. Also, onesubsection of "Life", called "By the choice of the Editor", brings a text about the history of medicine and urban culturein old Dubrovnik. "Papers and Reviews" is very specific this year, because the authors haven't shown that much inter-est in basic sciences, so this edition of JEMSA brings only articles from clinical science, which is also very indicativeto the future editors to pay more attention in collecting more articles from the field of basic science. Articles in thissection are of very high quality and the editorial team is very pleased. We would like to invite future authors to studyJEMSA Guidelines more carefully, because they indeed provide a great help and guidance.

I hope you will enjoy reading JEMSA and help it to grow and become greater and more significant than it is today.It is upon you - EMSA members - to contribute and improve JEMSA, a journal which would become an indicator andpacesetter of scientific activity of medical students all over Europe, uniting young scientists under the same criteriaat international level.

Cordially,

Divo LjubicicMedical Science Director &JEMSA Editor-in-Chief 2003/2004



GGEENNEERRAALL

Didn’t get a chance to publish in the2004 Edition of JEMSA?

Don’t worry!

Watch out for our information leaflets, and make sure youDO NOT miss the 2005 Edition of JEMSA!

More information available at:

www.emsa-europe.org



GGEENNEERRAALL

What is EMSA?

Energetic, Expanding, Enthusiastic Medical Students'Association in Europe, simply the European MedicalStudents' Association. Founded by a handful of pioneer-ing medical students back in 1991 in Belgium, EMSAwas aimed at developing and providing a European plat-form for all medical students by medical students.

What is this European platform and why do we wantit?

Simply because we are European and we do want toknow what is happening to our colleagues in the Euro-pean continent before wanting to explore the rest of theworld. We want to form a network for medical studentsto communicate and share their experiences exactly forthis purpose. Together in this platform we can guide oneanother with our medical experiences, medical policiesand share our views as European medical students andif necessary to go as one body to any appropriate bodyfor assistance. Together in an association, our voicewould stronger than separate faculties or countries voic-ing their views as medical students.

What is it that EMSA does?

EMSA works in field of medical education, medicalscience and medical ethics. In each of these fields, wehave directors who manage its activities. In medicaleducation, we are actively working on the Bologna Pro-cess issue as well as comparing medical curricula inEurope. We have active discussions and workshops inMedical Ethics. With Medical Science, what you arereading now - this journal, JEMSA is one of its sweetestsuccesses. We also have congresses, conferences,workshops in all these fields. Other than that, we have anumber of projects, including Twinning Project, EMSASummer Schools, Euro Talk, EMSA Best Buddy Project,EMSA Substance Misuse Support (SMS), Teddy BearHospital project, Working Abroad Database project,EMSA Ski Week and many other projects coming in thepipeline. We also run a monthly newsletter EUROMEDSfor all our members including feature articles by ourmembers, announcements and many other fun bits.EMSA has also recently organized the Inaugural EMSCouncil meeting in London. EMS Council is an idea byEMSA that became reality last month when medical stu-dents' representative from National Medical Students'Association attended its inaugural meeting. EMS Coun-cil aims at gathering representatives to discuss Euro-pean issues and to form a European point of viewthrough our European representatives.

The structure of EMSA?

EMSA is made up by Faculty Member Organization.Every year at the General Assembly in October we meetand elect an EMSA European Board which consists of

the President, Vice-president, Secretary General, Trea-surer, Medical Education Director, Medical Ethics Direc-tor, Medical Science Director and the Internet Director.The EEB then elects a few other positions to comple-ment its work - namely the EMSA Liaison Officertowards IFMSA, WHO-Euro Liaison Officer, Liaison Offi-cer to European Medical Organizations and PermanentOfficer, Teddy Bear Hospital Coordinator and the EMSCouncil Secretary General. The EEB as a whole, led bythe president, is responsible for the day to day runningof the whole association. In each country, you will alsohave the National Coordinator (NC) who is responsiblefor the activities of the country. In each local area, thepoint of reference will be the Local Coordinator (LC) whoinforms the NC of latest happenings and keeps the FMOup to date with activities. The FMO as such, usually hasa board that collaborates with different directors on theEEB to spread EMSA's across the region.

How to join EMSA?

EMSA is based on a faculty membership. Our mem-bers are Faculty Member Organizations (FMOs) and notindividuals as such. The idea of FMO is to ensure thatour members have good contact and communication inthis European platform. Membership fee is 50 EUR peryear and a registration fee of 30 EUR is applicable fornew members. Once your faculty joins EMSA, automat-ically all students in the faculty are members of EMSA.

Future of EMSA?

The future of EMSA lies directly with the membersand it is what they strive to shape it to be. We believethe future for EMSA is bright as long as everyone con-tinues to support one another and the entire association.

In a nutshell that is EMSA. If you have any queries,feel free to address them to the EMSA European Board- EEB at [email protected] or visit our website atwww.emsa-europe.org

One Europe, One Voice - united we stand,

together we can!



GGEENNEERRAALL

The President’s word

Dear EMSA Friends,

It is with much pride and pleasure that EMSA EEB presents to you this year's edition ofJEMSA - Journal of EMSA on Medical and Scientific Affairs 2004, which, traditionally, isavailable to EMSA members in hard copies for free.

As you all know, JEMSA is published annually in the English Language, focused on you,medical students and young doctors throughout Europe. In this edition you will find a broadspectrum of articles from all fields of medicine, including clinical medicine, public health andmedical education. It contains reviewed articles on scientific work and research, as well asreal-life experiences of medical students, intended to satisfy even the more demandingreaders.

This year, one of the Medical Science Directors greatest tasks was to prepare a new edi-tion of JEMSA, and, even more, to upgrade its image and design as well as contents. DivoLjubicic, EMSA's Medical Science Director 2003/2004 has certainly succeeded not only toovercome the usual obstacles and editorial troubles when successfully compiling and edit-ing this 2004 edition of JEMSA, but has also certainly added a new dimension to it. Con-gratulations!

The last but not the least, we must emphasize the credits of all the authors who havecontributed to this journal and have made it possible for JEMSA to be published again thisyear.

For EMSA as a young and active international association it is of vital importance to seeJEMSA being re-born again each year. Keeping the traditional qualities and at the sametime the development of a modern and up-to date JEMSA is definitely a challenge for futureMedical Science Directors.

Enough of words, let's just enjoy reading this exciting, educational and dynamic Journalof EMSA,

On behalf of EEB,

Ajda Skarlovnik

Acting president 2003/2004Vice-president 2003/2004



Well, I've been warned ☺…before deciding to run fora EEB position I asked more experienced colleagues forcounsel and advice; among other things I was told itvery well might happen that I will try to fight that box ofPC and blame it for all the things in the world that didn'twork, all the e-mails that were ignored, all the… As amatter of fact it was true, later, in retrospective, I alwaysremembered those words while starting to get involvedin intensive discussions with the computer…

But it would be by all means wrong to imagine that thecomputer work comprised the majority of my activities;yes, maybe paper, pencil and internet are highly usefultools, however, you should never forget that they justhelp you realize things you want to do for other peopleand that the main purpose is to finally meet friends andbe with friends.

And so there I was, balancing between being just astudent having fun and behaving responsibly and pro-fessionally as an EEB member in order to achieve andorganize something. I will never forget the EEB meetingin Berlin; the European Students Conference, the won-derful city, the cheap kebabs, the comfortable hostel, thedays spent on the Conference and the nights spent inthe enthusiastic planning of EMSA's future.

The meeting in Slovenia in February, together withthe Bologna process workshop and Ski Week wassomewhat of a highlight after a few months preparation.I hope and guess people had some goodtime. And we were productive too: I cannotbut be proud of the Ljubljana Statementon Medical Education. And I have to admitthat even I learned several new thingsabout my own country as well as my coun-trymen.

Afterwards, me, das Unterwegsmaedel, I traveledmore; to Venezuela to IFMSA March Meeting, to Gronin-gen, the Netherlands, where EMSA National coordina-tors meeting took place, and to Geneva on the occasionof WHO General Assembly and WorldMapS prepara-tions meeting. Each of these is a chapter of its own andthere is simply not enough space to describe it all.

On all these occasions I could get to know my col-leagues and friends from different aspects; As we spenta lot of time together I got to know them as very goodcooks (still remember that dinner in Jaccos apartment,Amanda, and Divo, of course I will not forget "the Berlinpancakes" ☺), poets and philosophers (yeah Anabela,we will all sue our student organization for completelychanging our lives, won't we? ☺), skiers, swimmers andgourmands (Fiona, I really do hope we will have thechance to go for skiing, a spa jacuzzi and then a cup ofhot chocolate some day again).

All in all, it was dulce et utile - I hope I do not soundtoo corny but some things just cannot be expressed oth-erwise or more suitably. Despite the two years of previ-ous work as EMSA National Coordinator and LeonardoCoordinator in SloMSIC this was an entirely new expe-rience. I learned some quite new things about commu-nication and power of persuasion; I learned about theimportance of timely and accurate information; I learned,however unbelievable it may seem, even more about

team work, I learned completely new thingsabout controlling my own temper…I learned itthe hard way but it was certainly worthwhile.

And most important of all, I met a lot of amaz-ing people whom I can now call friends. I sin-cerely hope we will not lose contacts - and Imean it (Hrvoje, I promise I will come to Zagrebalso just for a coffee and not only for vaccination☺). I have precious moments and unique mem-ories for my future. Alors, je ne regrette rien…

Fair winds, smooth sailing, good suntans!

Ajda

PS: I apologize if this article has been rather incoher-ent wandering in personal memories and feelings and ifI skipped the utile part about my duties as EMSA vice-president. For that you should peek in the annual reportat the October GA.

A year in EEB

FFRROOMM TTHHEE PPEENN OOFF YYOOUURR EEEEBB 22000033//22000044......

AJDA SKARLOVNIK (SLOVENIA)

VICE-PRESIDENT

[email protected][email protected]




Where do I begin, to tell the story of what a great yearit has been...?

It all started last summer, when I found that I actuallyhad a few weeks of summer off, no tests, and no work,nothing. Frightened by the idea of having too much timeon my hands, I signed up as EMSA Heidelberg repre-sentative for the GA in Lublin, Poland, not knowing whatto expect. To be honest, I didn't give it much thought atall.

When I arrived there, I felt a bit strange; everybodyseemed to know each other, all those important people,the president, the V-P, I was glad that I knew at leastDaniel from Heidelberg, and he knew everybody else.

Then the actual GA sessions started, and I have tosay: I was impressed. Everything was so professional;I've never seen anything like that before. And, moreimportant, I found out how great EMSA was on a Euro-pean level. Our local group is organizing all these niceevents all the time, but I had no clue that EMSA was somuch more.

When I was asked if I wanted to run for an EEB posi-tion, I felt flattered, but thought I could not do it. Andfrankly, I did not want to stand in front of everybody,making a presentation, and then not be elected. Butthen again; no risk no win (or something like that...)

So I decided to run for the position of secretary gen-eral.

Great. Candidating was no big deal, getting electedapparently not either. And the GA was just a wonderfulweek. We had a blast. Took me 2 weeks to recoverafterwards, which is usually a good sign to indicate thefun factor of any event.

But then it hit me: gosh!What had I been think-ing!!?? I felt incapable ofdoing that job! I couldhave cried (please donote the "could have"!!).What on earth should I donow? Resign immediate-ly? Yes, perhaps the bestidea. Will write an emailright now. But then again,how embarrassing... Andwhat about the job? Itsounded like fun. And what would they do without a sec-retary? Could I be that irresponsible? No, the truth is, I

could not. I did not resign, but began working insteadand found out that it was not so difficult after all.

I have to say, I had very nice people around me whohelped, anytime, clarifying abbreviations to me, explain-ing things... I was not alone with my work.

And when we met again for the first board meeting inBerlin, I realized that this was actually great fun as well.Hard work? Yes! Having a meeting all night long? Yes,that happens, too.

But getting to know your fellow board members fromall over Europe very well, from a side you'd never haveexpected! - how unique is that? From cooking together,preparing presentations, working out strategies to goingclubbing, having cocktails by the sea or visiting pissingboys in Brussels: it really feels like one big family, whomeet in various places over and over again.

At times, however, it felt strange. Was it right that Isaw my EMSA friends more than my friends at home?I'd meet the EMSA bunch 3 weeks in one month, in 4 dif-ferent locations all over the world, and contact my "real"friends was through emails and, even more, postcards?That certainly did not seem right!

And my family? I only saw them for 1 or 2 days inbetween trips, to unpack, wash and iron and re-packagain, exactly the same things I had unpacked 24 hoursbefore, with only slight variations, depending on the cli-mate of my next destinations. They were completelyconfused, could not remember where I was, for howlong, with whom, when I'd get back...I hate to admit thatmy orientation after a while was only slightly better. It allclimaxed this week in August, when I missed my flightback from London from the EMSA council because I hadmixed up the departure times with the times of anotherflight earlier that same week.

But then again, could have been worse. At least I stillknew where I was and who I was. I think.

So at times I questioned myself: Is this worth it?Sacrificing so much of my time, having virtually no timefor my friends and family? Looking back: yes. A definiteYES!!!! I think I'd do the exact same thing again. Actual-ly I would, no thinking required!

I just have to think about all the interesting people Ihave met during that year! I believe some of them will bemy friends for lifetime. And my friends at home? Well,those whom I consider my true friends are still myfriends. And they are the ones that matter.

Thoughts from the desk of the secretary...

FIONA HORNEFF (GERMANY)

SECRETARY GENERAL

[email protected]




And all the places I've been to...That actually might seem mostinteresting, and it sounds great:Berlin, Dubrovnik, Brussels, Slove-nia, Venezuela, Amsterdam andGroningen, Macedonia... But trustme, that is not what stays in mind.What stays are the experiencesyou have from these places, andthey are dependent on the people.People come first, before meetingvenues, before work goals…

In Macedonia I had literally 20minutes in the whole week to bathemy feet in the lake. It was notenough time to even go back to theroom to get my bikini! Don't know what I bought all thatsun lotion for… But then again, it was one of the bestmeetings, when you look at the actual work outcomeand contacts made.

And there are so many times you really want to throweverything away (which is usually right before a meet-ing, when it seems like nothing is working out and youare not prepared and have no clue as to what you'll dothere and how to bluff your way out of that dreadful sit-uation, or right after, when you are tired and knackeredand don't have any energy left for writing all thesereports and e-mails, actually doing all the work youenthusiastically agreed to during the meeting and keep-ing in contact with all the people you met). But then youjust need some sleep, think about the meeting and allthe enthusiasm you felt there again, and trust me, it willcome back, and then you start working. And the best iswhen you see the results of your work. Or when peopleapproach you, telling you what a great job you aredoing, or have done on a specific project. Then youknow it really is worthwhile.

You could ask me what is so special about the secre-tary's job. It is not all about making coffee (in all vari-eties) for your fellow board members and taking notes.Actually, be prepared that you will encounter some teas-ing about that, sure. And taking notes. Yes, you do have

to type the minutes, and that is no fun at all. I am hon-est about it. And I always hate editing them. But thenagain, it is not hard; it is a small price to pay for all thatyou personally get from EMSA.

And EUROMEDS: creating that newsletter is wonder-ful. It takes about half a day, you see a result immediate-ly, and it is fun. You even get feedback for it more thanfor other things. And we agreed earlier that feedback isimportant to stay motivated, did we not?

The only frustrating thing is that it needs a lot of, say,persuasion, to get articles, photos etc. from others. It isno problem making up a whole edition by yourself, but it

is not so much fun if that iswhat you have to do everymonth. I am not that cre-ative after all…

Otherwise, the secretaryhas to be an all-round tal-ent. Something you cannotprepare for. But as a boardyou are supposed to be ateam. So everybody shouldknow roughly where EMSAis going to and which routeto take.

Would I do it differently?

After saying that I defi-nitely would do it again, Ihave to admit that I woulddo a few things differently.

First of all, I would haveliked to have become involved in EMSA earlier. It alwaysseemed that I had no time. True, but not entirely. Younever have time. You have to make time.

Secondly, now I know that it is not about the work youdo, not about the goals, be it short term or long timegoals, not about what you do or you think… it is allabout the people around you. You have to be able towork with them. If you are not able to work them, getable! That is were all your effort has to go! Otherwise itis a combination of Sisyphus and his stone and DonQuixote fighting windmills.

Thirdly, hmmm, don't really know, maybe read more.(Just a piece of advice, I feel like in “The sun screensong”, you know, where the chorus is always: "trust me,wear sunscreen").

This was probably enough random thoughts from thesecretary's desk, too much coffee, too much time or toomuch work, can't really define what it is.

Now you have a rough idea what my life as EMSA'ssec gen is like, and I bet you envy it; I would, if I readthat…

Fiona




EMON FARRAH MALIK (UNITED KINGDOM)

TREASURER

[email protected]

The New Girl

Women don't sweat, they glow. EMSA ExecutiveBoard (EEB) members exist under the three 'P' mask -poise, professionalism and potential. However, whilstsimultaneously awaiting my exam results, the Wimble-don final and the outcome of my application for the postof treasurer, I am "glowing" luminously with panic, para-noia and p-a-i-n (or possible peptic ulcer...).

The European Medical Students' Association issomething that I have worked for, passionately and per-sistently, for the past two years at my Faculty MemberOrganisation - Guy's, King's and St. Thomas' School ofMedicine - and being Teddy Bear Hospital Director for ayear has brought EMSA projects very close to my heart.A place on the EEB would be my chance to take thisrewarding and challenging work further - to the cuttingedge of Europe.

Exactly two weeks later, I am safely through to thenext year of medical school, Roger Federer has extend-ed his reign as the Wimbledon champion, the FinancialTimes and the multiplication tables are my newmantra...and I have no nails left. Some would say that itis time to reward myself with a long sleep (as accordingto the First Student Commandment - "Thou shalt hiber-nate"...) However, being the ultimate glutton for punish-ment, I prise my eyes open with a speculum and settledown to login to my email account for the first time sincebeing elected treasurer.

OHMY....

SIXTY SIX NEW EMAILS SENT IN THE PAST TWO HOURS??I CAN'T PRONOUNCE THESE NAMES!!IS BA/MA A TYPE OF FRENCH PASTRY?AEISEC - YES...I FEEL VERY SICK, THANKS FOR ASKING...

Bleurgh!

Two drops of contact lens refresher and three espres-sos later and it slowly sinks in that I do have a little bitmore intelligence than I give myself credit for and I startto filter through, respond to various congratulations,introduce myself and formulate proposals. After all, I'vebeen dealing with these things for two years, albeit on asmaller scale and I have every intention of doing this jobto the best of my ability.

Plan of Action:

- go through all files relating to EMSA and its financialsituation

- draw up a sponsorship application pack- search for sponsorship for EMSA administration and

projects (possibility of pharmaceutical companies orchains?)

- draw up a budget for the 2003/4 session, with statisti-cal analysis- book flights and ferries for my first EEBmeeting in Dubrovnik, Croatia, in July 2004- read through the agendas for the NationalCoordinators’ Meeting and the last EEBmeeting in March 2004- analyse and familiarise myself with theInternal Rules and Statutes- learn all abbreviations (!!), i.e. AEISEC,AEGEE, ABC, PQR, XYZ, etc. (ECG,anyone?)- regularly update myself with the officialEuropean exchange rates- submit monthly reports to the EEB- analyse and critique the last EUgrant application

- initiate the formulation of the EU grant applica-tion for the forthcoming session 2004/2005

- book Eurostar ticket to Brussels, Belgium for meetingat the European Commission, in August 2004

- scan the Internet and official European Commission



websites for all available and applicable grants- update myself with all literature relating to the Euro-

pean Working Time Directive, the Bologna Declarationand the proposed Ba/Ma structure, in preparation forEMSA Council in London, at the end of August 2004

- negotiate discounts for EMSA members and futuremeetings

- clean up my flat - free accommodation for delegates isnot to be sniffed at! Plus, "EbenEMSA Scrooge" mustnow be my middle name...

- register for the General Assembly in Thessaloniki,Greece, in October 2004 and prepare the Treasurer'sAnnual Report

Phew!

Achievable? Absolutely! Two months on, I no longerregard AMSA, AMSE, ELSA, AEGEE and AEISEC withthe same amount of trepidation as Onchocerciasis or tri-chorrhexis nodosa, but in fact have mysteriously devel-oped the ability (or should I say magical power?!) to usethese terms in everyday language and express opinionsabout them. Fellow EEB members are wonderfully wel-

coming, accommodating and have overflowed withadvice, help, descriptions of their experiences andexplanations, where necessary (in addition to dubbingme the "Board Baby", at the age of twenty one!) and thebeauty of this is that, in return, I can bring to the EMSAEEB my experience from the UK, confident objectivityand fresh enthusiasm for the job. EMSA provides theperfect platform for debate and bridge-building withinand across Europe, never so well demonstrated as inthe recent newly-founded EMS Council and my previousEuroscepticism has been proved unfounded. Well, amillion lemmings can't be wrong...

Emon Farrah




DIVO LJUBICIC (CROATIA)

MEDICAL SCIENCE DIRECTOR & EDITOR OF JEMSA

[email protected]

How everything started...

A shiny spring day was awakingalong with me, pretty self-convincedand completely unaware of the futuredevelopment of life. It was one ofthose rather usual days when youlive your well planned life accordingto the dates of your exams, drinkingparties with your school buddies andromantic time spent with your girl-friend. I was satisfied, having every-thing one could desire and need tolive a decent average citizen's life.

Never thinking I could do better, Iwas very reserved when an acquain-tance of mine asked me the otherday to take part in some “EMSAorganization” project here in Zagreband come to a meeting in the afternoon. Hmm... ThisEMSA name was familiar to me from somewhere,because I had always been seeing those funny studentsrunning around with posters, leaflets, LCD projectors,computers, even whole copy machines. They allseemed to be in a hurry, you couldn't have seen themspending endless hours in a bar nearby, discussingusual students' themes, gossiping and laughing toempty stories and jokes. I appeared to have self-restrained stand toward this idea of venturing upon join-ing EMSA. Apparently, an acquaintance of mine showednoteworthy persuasive power as I was on my way to thepremises of EMSA Zagreb on that wonderful spring day.I was introduced to everyone, they welcomed me as anold friend and I started to feel I was going to like it.

Projects were running as fast as months so my sociallife had one more segment. I was getting to know allthose people and I was running with them, carryingposters, leaflets, LCD projectors, computers, evenwhole copy machines. Myother pre-EMSA friends weretelling me that I alwaysseemed to be in a hurry, that Ibehaved differently and paidmore attention during theclasses and right after, I usedto disappear somewhereinstead of going to the barnearby for a drink. They gotused to planning drinks withme, according to our sched-ules, in crazy time periods e.g.from 12:37 until 13:12

because of one appointment before,and the other task after. My pre-EMSA friends realized, as time wentby, to appreciate my time, as well asI realized how important it was Iappreciate theirs.

Taking part at EMSA GA2003 inLublin, Poland, as an FMO memberand a representative of EMSAZagreb was indeed a great experi-ence. I had never realized how bigEMSA actually was, and I finally metall the persons I had been listeningabout before. Exchanging opinions,ideas, constructive workshops andexciting debates... all those thingswere "guilty" I really felt EMSA Spirit,

but the most "guilty" and the most important of all werethe people I met, my colleagues, you. My enthusiasmand love for EMSA increased exponentially and I decid-ed to ask someone of the EEB about elections, posi-tions, tasks and responsibilities. When I uncovered mythoughts to few EEB members, I was suddenly sur-rounded by five of them, my new friends. You can easi-ly imagine this situation if you remember your first jump-ing from a 15-meter cliff, and you don't know what iswaiting for you in the abyss. Your friends are pushingyou to the edge of the cliff convincing you that you cando it, they have faith in you, it is a great feeling, and youdon't have to worry because the perfectly clean blue seais waiting for you. They keep telling you they will jumpafter you so you wouldn't be alone... but you have thisfear of alien, unpredictable terrain. You hesitate, youwill-won't, won't-will, will, will...and before you know ityou are.

They give you the strength to make that step, youjump and before you notice you arealready swimming like a fishtogether with your friends towardsnew shores.

We were swimming all aroundEurope, and I must confess theweather wasn't nice most of thetime, but we knew we were notalone. It was a great feeling know-ing you could always discuss yourproblem with a few people fromyour team and they would under-stand and try to help. Sending your




e-mail from your small corner of Europe at 03:00 AMand having it answered at 03:03 AM makes you feelspecial and gives you strength to work even harder andbecome even more enthusiastic.

There were moments when it seemed nothing wasrunning well; you couldn’t see the point of spendingyour time and energy on something nobody gave a hootabout; you would wake up angry with yourself andblame everyone around you for your insomnia, bank-ruptcy, your sacrifice to "cosa nostra"; you were desper-ate and you called your friends in the other parts ofEurope to have long after-midnight conversations. Youmight not believe how even a short call at crazy hourscould help you recover, liberate you of your uncertaintyand push you up.

After every event you provided input on, you are sat-isfied and proud to be a part of EMSA, you have newideas, meet more people and learn new details aboutyourself. I have learned I am not only Divo. I am alsoFiona, Carl, Amanda, Kasia, Emon, Ajda, Nick, Hrvoje,Anabela, Marijan, Stefan and all other people I met onmy voyages through Europe. My personality hasbecome as complex as Europe itself, made up of smallinteractive pieces from all around making a whole struc-ture.

And here I am, after a wonderful year, still alive andglad I've jumped off that cliff in Lublin, Poland.

Divo




NICK KAI SCHNEIDER (GERMANY)

LIAISON OFFICER TO EUROPEAN MEDICAL ORGANIZATIONS & PERMANENT OFFICER

[email protected]

A day in the office representing EMSA in Europe

Brussels, 41 Rue de la Science, you enter the lobby,'Bonjour', the receptionist is already working. You try tolook awake, and jump into the elevator. It was not toomuch sleep. On the third floor you step out, find you wayto the CPME office. Why? You desk is there, the EMSAdesk. CPME, the Standing Committee of European Doc-tors, is the umbrella organization for the medical profes-sion in Brussels. Its members are the National MedicalAssociations, the other European Medical Organisa-tions are their 'Associated Organisations' - EMSA is oneof them. To realize a 'Domus Medica', a common housefor the medical associations in Brussels, the CPME hastried to get its associated organisations to move into theoffice. That's why you are there; to work for EMSA, torepresent the medical students' interests in Brusselsand to try to give some continuity to its work. But you arealso working for the doctors, for the CPME, coordinatingtheir patient safety activities, steering some workinggroups and organizing events; a lot of responsibility fora student, but also a lot of fun. You do not think aboutthat, it is nine o'clock in the morning, or maybe ten past.You enter the CPME premises - an open, spaciousoffice. You see the team, 'good morning'. You still looktired. They realize that, they also have been students -not too long ago.

Your desk is the first one - directly behind the secre-tary’s space. You think: damn, I left a big mess on thedesk - and that's the first thing externals will see whenthey enter the office. You should clean up your desk.However, you need your creative chaos, and will proba-bly leave it again - for tomorrow.

Three post-its on your desk - the secretaryalready received your calls, those which camein between 8.30 and 9.00: the CPME-Presi-dent, the President of one of the National Med-ical Associations and one of your key stake-holders in Brussels. Whom to call first? Thestakeholder might give you some information,which could be required by the President. OKwe start with him: mailbox. You leave a mes-sage to get back to you - now that you are inthe office. The president of the NMA is next -he is on the run, heading to a conference andasks for an update. 'Do we have a date fromthe Commission yet?', 'No, they will let usknow by September'. That was short. Then yourealize that it might be good to first check thee-mails. You open your mailbox, scan the mostimportant ones. Luckily the CPME mails aremainly already filtered, they take priority:

patient safety conference, Internal Market conference inthe Netherlands, internal business - enough work for thenext hours. A bit of internet research - what are the EU-related news? Anything relevant for the next CPME-meeting? Any documents to be prepared? At noon youwill have all up-to-date.

Now to the EMSA-folder: Oh no, again 35 e-mailsfrom the EMSA European Board, and only 2 from mem-bers! You reply to the members. The EEB can wait, youwill take care of them later - they are students and willprobably still be sleeping.

The phone rings. It is the CPME-President. Yes, youhave organized the CPME participation at the EC-con-ference, the session he is supposed to chair was movedto the morning, no problems on that - you are glad.Indeed, unfortunately no news yet on the other speak-ers, you will stay in touch.

A coffee would be fine now, one of those hot espres-sos with full bean aroma. But you are still medical stu-dent, coffee on an empty stomach?... you prefer takinga tea. You go to the kitchen, have a chat with one of thecolleagues, update yourself on the latest gossip and goback to your desk. Tea in one hand, in the other a bottleof water and maybe some cookies - or some good Bel-gian chocolate. Back to work.

We still have those 35 e-mails from the EEB. What dothey want? You advise here, comment there, proposefurther activities to the next and call others to order. TheSecretary General asks you to call her. The phone rings,




nobody answers. A pity, you will try it later - she will saythat she was still sleeping. At that time you had alreadybeen in the office for three hours…it is noon.

You remember that you had a conference to attend inthe afternoon. A short look on the agenda to checkwhere it is - perfect, it is walking distance. Everything iswalking distance - here in the EU-institutions area.Preparation: you print out some background documents,check if the CPME has already adopted some policieson the issues discussed and go for it. Grab a sandwichon the way - light Brussels lunch. You always eat sand-wich for lunch - everything else is too expensive andtakes too much time. The conference venue is great, atleast compared to university settings. Interpretation isprovided - you don't care. You take your notes, speak tosome key stakeholders at coffee break,no unfortunately not that full beanaroma espresso, but it helps keepingawake. Some lectures were again asboring as in med school - others great,inspiring. It is good to listen to thosegreat speakers - today two ministers -they are not so good. You took yournotes. You will have to write a report forthe members. There was not much tolobby for today. Anyways, this word…tolobby, lobbying. What do you have incommon with the hotel lobby? Yourealize that to be honest you havenever waited in a lobby and that youdon't even approach Parliamentarianswho come out of the plenary room, atleast not in the lobby. That was ages ago. Now, youhave direct access to the European Parliament, even abadge if you are an accredited lobbyist (and of courseyou are), you make appointments and try to convincethem, not with money, but with arguments. Too muchprejudices about lobbying, it's mainly informing themabout the concerns your members have. And lobbiesare not really used for that. Normally the lobbies are onlypassed through as fast as possible to get in time to theiroffices or meet them at coffee breaks - maybe lobbyistsshould be called 'coffee breakers', because that's wereyou normally approach them - anyways not too easily,as everything runs a bit late here in Brussels and younever seem to have enough time. As you today, you runback to the office, there is still a call you are waiting for.The AEGEE President wanted to talk to you. The EU-grant for the running costs of European Youth NGOs.You know that EMSA, as most other students' organiza-tions, did not get it again, for the second time in a row.EMSA and partners - mostly also conveniently located inor around Brussels - should put some political pressureon the Commission, a report and a press conferencewould not be bad. IFISO - the Informal Forum of Inter-national Students' Organisation, had decided so. It is onyou and the AEGEE president to draft the report. Youhad volunteered to take care of the statistical research.You will also take care of the press conference, as youare the only one with a bit of experience in organizing

press conferences (once and not in Brussels) - the pres-ident of the public relations students is on holiday. It isalways good to work with IFISO, you know the girls andguys, they are, as you, representatives of their associa-tion in Brussels. You meet them frequently, mainlythrough the 'ngoholics-yahoogroup'.

Back on your desk, you see that AIESEC has sent ane-mail - a joint application on the Bologna-Process. Thatsounds promising. Who is involved? The usual sus-pects, AEGEE and AEISEC. They want EMSA and oth-ers to join in. Deadline is in two days…Not for the reply,but for having the 50 pages application ready. No timefor negotiations, you have to react and send an emailexpressing the interest of EMSA - hoping the EEB swal-lows it. They do not like to receive more work from Brus-

sels - anyways EMSA needsmoney and the more grants weapply for the better the chances.Oh yes, there were still some e-mails left to answer. Not now, youfinally go to the kitchen and getyourself one of those full beanaroma espressos, a double one.You have been waiting for it sincethe early morning. It tastes great!!

You go back to your computerand in the best mood read all thoseEEB e-mails. A smile hushes overyour face. Somehow you seethings much more relaxed here inBrussels. Away from university,dealing with people and communi-

cation on a daily basis. The EEB is already overworked,so are you, so is the CPME, so is somehow Brussels.The EMSA- treasurer had dismissed, some projects arerunning late, some executives are unmotivated and oth-ers are arguing. Not the best circumstances for you as'permanent officer', but with your full bean flavour athand, you are beyond those often personal problems.You could comment on everything, OK you often do -maybe too often and often too frank. Some people arescared of you. You do not know why, at the end of theday you just try to give guidance and work for the bestof the organization. It is a lot of work for you, and itseems that it is again on you to send a wake up call andto be the pain somewhere... but you are used to it.Another smile as you realise where you are and howlate it is - 17.30. You send mail to the EEB, that you areoff. More tomorrow, and by the way at 14.00 one of themembers will be arriving in town. A pleasant day tocome. And you are far away, here in the heart of the cap-ital of Europe.

Yes, in a certain way it is a whole little world of its own- here at the EMSA desk, CPME-office, third floor, 41Rue de la Science, Brussels, Europe.

Nick




HRVOJE VRAZIC MD (CROATIA)

EMSA LIAISON OFFICER TOWARDS IFMSA

[email protected]

General Assembly (GA) from EEB’s point of view...

When thinking of how to contribute to this edition ofJEMSA, I thought whether or not to write a short articleon my current position (EMSA Liaison Officer towardsIFMSA) or to be more original. Knowing that there is nosense in re-inventing warm water, as the old proverbsays, I thought it would be nice to unravel one of the old-est mysteries of working for EMSA on international level(usually known as the GA - the General Assembly).

GA. That's only 2 letters, but those two letters areusually the worst nightmare for every executive board.Even more for the president (I had 2 GAs under mysupervision, I still remember every second of each oneof them), since the president is the one responsible foreverything. If you keep on reading, you will learn aboutsome aspects, which, if you have never been in the EEB(EMSA European Board - the executive body of EMSA)will definitely give you some new insights into GAs.

How do our members see a GA? Although they knowthat in general the GA is a great opportunity to work forthe future of EMSA making crucial decisions for thefuture of this organization (a part of the meeting), moreattention is given to the fact that they will see old andmeet new friends from allaround the world, havinga great time and parties.Of course, sometimesthey do forget the factthat people in the EEB,especially the president,are also human beingswho want to work withinnormal boundaries andalso see old and meetnew friends from allaround the world, havinga great time and parties.It has come as a big sur-prise to more than one person that an EEB member isnot someone who is pathologically in love with motions,schedules, tables, timekeeping, eternal changes ofinternal rules and statutes and waking up early in themorning after only few hours of sleep or no sleep at all.

And this is where the two titans usually crash - mem-bers just wanting to enjoy the entire event on one side,and the EEB and the Organizing Committee wanting tokeep the schedule and do all the planned work on theother side. The big question here is - how to keep every-one satisfied? Because partying all night long, usually insuch a way that if and when they wake up, people need

at least few hours of spending quality-time with thatlovely oval porcelain object in the bathroom, spendingthe rest of the day in desperate and insatiable search forwater. And that is not compatible with meeting sessionsstarting on time. So, there are delays, everyone isalways late, the Organizing Committee becomes frus-trated because the delays in sessions cause furtherdelays everywhere, cancellations and extra expenses toother parts of the programme.

I have deliberately skipped mentioning EEB's positionhere. In order to understand it fully, I will start explainingthe atmosphere of a few weeks prior to the GA itself.

As an EEB member, you are required to attend atleast two annual meetings of EMSA - the National Coor-dinators' Meeting and the General Assembly, majority offive-seven EEB meetings and an unspecified number ofmeetings that are related to your field of work. So, bythis time, you have succeeded in making your parentsmillionaires (if they had been billionaires before youstarted working in EMSA), they have already beenaccustomed to you giving them notice only weeksbefore you fly to some remote corner of Europe for a

week or so, and theydon’t even object forlonger than a day or sothat they will have to helpyou out with buying yetanother airplane ticket(because you are doingthree part time jobsalready, you were justrejected when applyingfor the fourth one andyour bank account isdrowning in the redzone). Your parentsalready know by heart

how much it takes during every period of a day to get tothe airport, asking you to call them not "mother" or"father" but rather "the taxi service" and they just dropyou off and say "Have a nice trip!", they only waited withyou at the airport after check-in for the first few times, inthe first few months of your mandate. On a more aca-demic side, since it's usually September, you would stillneed to pass some exam(s) before you could buy theairplane ticket (in most European countries), but luckilyfor you, you are already best friend with your travelagent so you know she would hold your reservation fordays after the usual deadlines, performing small mira-cles with her keyboard and the central airline reserva-




tion system. People around you tell you that the way youtalk has changed, your sentence structure has changed,and you never seem to be giving a definite opinion onanything anymore. The amount of e-mails you receiveevery day strangely always adapts to the amount of yourpotential free time, so in the end you never have anyfree time, because you write e-mails all the time. This isthe point when you conclude that the best investmentyou have ever made was buying a large screen and anergonomic keyboard. You often read e-mails duringweird periods of night, usually after one in the morning,and when you receive e-mails from some people, youcan't stop laughing out loud. One minute later yourmother comes in your room, because you woke her up,trying to see whether or not her son has gone complete-ly crazy. When you explain to her that you laughed at ane-mail, she goes back to sleep, deeply relieved. Itmakes you feel much better when you send out an e-mail at two in the morning, and within three minutes youget a reply from two or three other EEB members -somehow you feel much better knowing that you are notthe only one awake at this strange hour typing like madfor the prosperity of the association you love so madly -and that there are others like you throughout entireEurope doing exactly the same. If you call them on thephone, they might even be crying sometimes, over-whelmed with work, with the motto: "So much to do, andso little time to do it!". You don't go out with your pre-EMSA friends that often anymore, somehow wheneverthey decided to go out on Friday night and asked you ifyou would go with them, you would SMS them backfrom some European city (the blessing of roaming withyour mobile has brought you gold or platinum club sta-tus with your mobile operator months ago anyway) thatyou just left your hometown on Thursday and that youwill be back on Sunday because you're attending one ofthose 3 or 4 day weekend meetings. At your medicalschool, everybody has already crossed you out from thelist of future renowned scientists and clinicians, alreadyplacing bets that you will go into politics in the nearfuture. You know all the administrators and you alwaysuse up all the days that you can miss from your classes,often even more, so you acquire good negotiating skillswhen trying to complete moderate or poor attendance ofclasses.

So, a few weeks prior to the GA, you are well awareof all the deadlines the poor secretary has set for sub-mission of the reports, and although you know and youknow that she knows that almost nobody will obey them,you look forward to yet another extension for submis-sion of the reports. On THE last deadline, most peopleare typing their reports until weird hours of the night,secretary's mailbox (or president's, depending on who iscompiling the annual report) is rejecting e-mailsbecause somebody sent in their 8 megabyte Word doc-ument (not zipping it, or sending the images separately).The person compiling the annual report spends a weekor so in front of his/her computer screen, suddenly expe-riencing numerous computer crashes which seem tocoincide with hours of unsaved work, making that per-

son do that work again and again. The person that isdoing this masters advanced text editing options inWord, something he/she would never have the opportu-nity to experience, had it not been for a the GA.

Eventually you fly off to the city where the GA will be,one to four days prior to the GA, hoping that this timeyou will get to see something more of the country/cityyou are visiting, rather than just meeting rooms, publictransport and bars/clubs. Depending on your luck, whichis almost always bad, you come for the pre-GA EEBmeeting and end up spending 12-16 hours a day in frontof your laptop, trying to finish all the documents in timefor the GA. And then, on the last night, when all is print-ed out in a master copy, just waiting to be photocopiedin 50 or so copies, after numerous computer problemsand crashes, the only photocopying machine that theOC has provided either runs out of toner or breaks down(or if you're extremely unlucky both), usually betweenmidnight and five in the morning. A lot of people don't getany sleep night(s) before the GA, and the best part isthat always all the work gets done on time (or with min-imal delay) and everything turns out fine, no matter howhopeless it may look just hours before the start.

Because of this, the pre-GA EEB meeting is not fin-ished in those days before the GA, and then the partici-pants are both amused and angry at the fact that whilethe social program lasts, the crazy people from the EEBhave meetings at strange times of the night, neverseeming to have any fun. This is largely true, unfortu-nately. So the EEB doesn't get enough sleep, but usual-ly not because of partying, but because of catching up.And then, when the GA sessions start, it is always inter-esting and unpredictable - you never know what willhappen and how they will finish. While not depriving anymember to express his/her thoughts, ideas, sugges-tions, questions and comments, it is absolutely amazingthat at every GA there are at least a few people that areincredibly active, but are unfortunately nowhere to befound or heard once when the GA finishes, even whenthey are offered to work on the problems identified dur-ing the GA. It always amazes me how GA participantsare shy on the first day, and quiet all the time, but assoon as somebody proposes something, they can fightfor hours over the position of a full stop or a comma,fighting down to their bones. Two hours later at a party,they are best friends. And the EEB despairs over hourslost at the GA, along with the OC.

Reading all this, there is a remote possibility that, iffor whatever reason you decided to run for an EEB posi-tion, you will hear the screaming voice of reason in yourmind telling you "ARE YOU CRAZY?". My advice to youis that you ignore it, because working for EMSA, bothlocally and internationally, is something that I would def-initely do again if I had the chance. It is well worth it.Trust me! ☺

Hrvoje




EEMMSSAA AACCTTIIOONN:: AANNTTII-TTOOBBAACCCCOO!!

ANABELA DIANA SERRANITO MD (PORTUGAL)

WHO-EURO LIAISON OFFICER

[email protected]

Smoking is a deadly habit, not only for those whosmoke, but it has also become evident in recent yearsthat those who innocently tolerate, or not, and come intoregular contact with environmental tobacco smoke mayalso be putting their health at risk. Nevertheless it stillamazes me that my medical colleagues, informed onthe basic hazards of smoking, carry on smoking andsome even take up the habit during or after terminatingmedical school.

I'll never forget the words a friend once told me. Shesaid that her small world of innocence had been broughtdown by the sight of a doctor in his white coat lustfullysmoking his cigarette at the door of the Hospital, as shehad always believed that doctors were perfect and as soobviously did not smoke. I still recall this discussionwhen a college sits next to me in the coffee room andlights up a cigarette. The population we work with seesus doctors as role models, an aspect we sometimes doforget.

When I see them smoking, I often ask myself if theythink of the consequences on their own health whenthey light up each cigarette? Do they remember, or atleast know, that:

- With every cigarette they light up, they lose 7 min-utes of their life,

- Tobacco is responsible for 90% of all lung cancers,

- It is estimated that 30% of deaths from cardiovas-cular disease are due to smoking,

- They have an increased risk various types of can-cer, including mouth, throat, oesophageal, laryn-geal, bladder, stomach and pancreas cancer

- They age prematurely,- They decrease their fertility.1, 2

I have many times managed to keep these questionsto myself, but every so often I asked my colleagues, thementor or even the professor what they think of thisissue. Many just laugh and say it is for the pleasure oflighting up and smoking the cigarette, claiming it a socialaddiction, something to do whilst having coffee or whenthey are feeling anxious. Some feel that they have beendoing it for so long that they will not have any problemsor simply state that they are the part of the statistic thathas no problems. I have come to believe that colleaguesthat smoke live happily in an addictive denial, addictedto nicotine and addicted to the denial that their personalhealth might not be in danger. They take a calculatedrisk and light up another cigarette - one more won't killthem, at least not today.

I on the other hand become more perplexed with thisbehaviour, because this brings me to another, morecomplex, question. Environmental tobacco smoke(ETS) also has its negative effects on the passive smok-er:

- ETS increases of the risk of heart disease, strokeand lung cancer.

- ETS exposure lowers levels of high-density lipopro-teins leading to an increased risk of atherosclero-sis

- Workers that are in constant contact with ETS atwork have a 40-60% risk increase of developingasthma, when compared to those who have noexposure.3

It is one thing to do harm to oneself, but when ouractions have consequences on the health of others wecross a delicate line as medical professionals that weare.

Some colleagues and friends respect your not smok-ing and try not to smoke in your presence, whilst othersjust hypocritically blow the smoke in the other direction,so as to say I am not smoking at you, so I am not both-ering or harming you. This brings me to a third group,who just affirm selfishly, in my opinion, that they maysmoke wherever they wish to do so.

An Opinion Article: Smoking and Physicians - Doctors as role models



I live in a country where unfortunately there are not asyet strict tobacco laws being applied like in other Euro-pean countries. Nevertheless, even in these countries,tobacco has managed to, due to the centuries of its exis-tence get so encrusted in our many cultures that some-times when, in the interest of our health, we ask that asmoker puts out the cigarette he/she still finds thecourage to aggressively answer in a not so polite man-ner.

We as physicians have an important role to play in theprevention and control of this growing epidemic ashealth care takers priming for the best health in the pop-ulation we work with. Some of us will during our livestake up more active and direct roles in society, workingdirectly and actively with these issues; others will play amore silent role, but will nevertheless constitute a rolemodel for the patient that comes to see you on that day.So I leave a small message for my colleagues whosmoke, and are not worried nor with your nor with theirhealth, please do think twice before you light that ciga-rette... Is an innocent patient attentively observing you?And the smoke you leave behind, will it fill the lungs of ayoung child that already lives in a polluted city and doesnot need more polluting agents in his or her lungs?

Anabela

REFERENCES:1 Bowman KC, Ross G, Schneider KL, Whelan EM. Cigarettes: What the

Warn ing Labels Doesn't Tell you. American Council on Science andHealth. NY. 2003.

2 Brodish PH. The Irreversible health affects of cigarette smoking. AmericanCouncil on Science and Health. NY. 1998.

3 Enviromental Tobacco Smoke. Health Risk or Health Hype? Special Reportprepared for the American Council on Science and Health. NY. 1999.





In the game - for a tobacco free EuropeEMSA joins forces with WHO-Euro and the CDC

Author:Nick Schneider, Medical Faculty of Heidelberg, Ruprecht-Karls-Universität / University of Heidelberg (Germany)

EMSA Permanent Officer and Liaison Officer to European Medical Organisations 2003/2004Contact:[email protected]

"A very productive call. Just to recap...We briefly dis-cussed the Global Tobacco Surveillance System thatincludes Global Youth Tobacco Survey, Global SchoolPersonnel Survey, and Global Health Professional Sur-vey. Our goal is to apply a similar research model to stu-dents in medical and other health professional schoolsand to complete data collection in time to prepare areport for World No Tobacco Day 2005.

We were very happy to hear that you have activemembers in Croatia who may be willing to participate.Croatia successfully completed the GYTS in 2002 andwe are happy to expand our collaboration." (N. Jones,CDC, 27 July 2004)

Since 27 July 2004 it is official, EMSA will be carryingout the European pilot survey for the Global Health Pro-fessionals Survey (GHPS). This joint project of theWorld Health Organisation (WHO) and the Centres forDisease Control and Prevention (CDC) in the UnitedStates, follows months ofproductive discussionsbetween EMSA and WHO-Euro. EMSA would like toexpress its gratitude to themembers of the EFMA-Tobacco Action Group,which provided the links toWHO-Euro and supportedthe EMSA-Anti-Tobaccoactivities throughout thelast year. After the inclu-sion of EMSA in the Teach-ing Geriatrics in MedicalEducation - Report(TeGeME 1) in 2000 -2001, the GHPS will be thesecond large scale collab-oration between EMSAand the WHO, in this caseWHO-Euro.

The focus of GHPS is third year studentsbecause they are likely to be enrolled in courses atthe medical school and have probably not yet start-ed residencies at extramural locations. EMSA, theCDC and WHO-Euro would like to maintain a stan-dardized sampling procedure across sites proveneffective in the Global Youth Tobacco Survey. Tostart with the organisations involved agreed on a

capacity building event taking place in Geneva 6-8 ofOctober, where the research coordinators will be intro-duced to the methodology of the survey. Thereafter thepilot study will be carried out in Croatia under the super-vision of Hrvoje Vrazic MD and Divo Ljubicic on nation-al level and Nick Schneider on the European level. Thefirst results of the pilot will be presented at the World NoTobacco Day 2005. The coordinators shall then trainother European students to carry out the survey acrossEurope.

In parallel, Anabela Serranito, who designed theEMSA-Tobacco-Survey questionnaire and edited theEMSA handbook on smoking, will carry out a secondpilot survey in Portugal. This genuine EMSA-survey wasdeveloped by EMSA and was especially designed formedical students. The unique target group and thespecifics of this peer driven survey promise new input totobacco activities within the medical profession. The

results of both pilot studies will becompared and further analysed,ensuring that EMSA can come upwith solid results through bothapproaches.

HOW IT ALL BEGAN...

Having been active in the Euro-pean Forum for Medical Associationsand WHO (EFMA-WHO) for 3 years,

EMSA joined the internal workinggroup on tobacco (TAG-TobaccoAction Group) in Berlin 2003. Asa regular member of this forumNick Schneider, in his function asLiaison Officer, presented theactivities performed so far andkept in regular contact with theother members. Seeing the needfor further action within the med-ical profession it became clearthat EMSA could be working on asurvey assessing the smokingattitudes and habits of medicalstudents in Europe. A question-naire was drafted by AnabelaSerranito, and was presentedand well received by the TAG-meeting in March 2004. The so




called 'students' survey became one of the key discus-sion points on the 2004 agenda, leading to an extraordi-nary meeting solely on this issue at the 2004 EFMA-Meting in Dubrovnik. All members of the Tobacco ActionGroup supported the EMSA initiative and jointly askedWHO-Euro for technical support. Dr Nikogosian, Headof the Tobacco Free Europe Initiative, immediatelyoffered to see in which ways EMSA could be included inthe Global Health Professionals Survey. Dr Klas Winell,in his function as TAG-chairperson, revised the ques-tionnaire and gave feedback to the authors. At an in-per-son-meeting in Copenhagen, Nick Schneider had theopportunity to present the revised questionnaire and adraft action plan to the WHO-Euro officials. WHO-Euroasked for a written proposal and action plan within thefollowing five days to bring the idea forward to the CDC,who would be funding the survey. A letter and an actionplan were developed in the Brussels-Secretariat andsent to WHO-Euro. What followed was a period ofuncertainty. No news from Copenhagen (WHO-Euro),no news from Atlanta (CDC). After several weeks wereceived the confirmation that the CDC and WHO-Head-quarters had been asked to include EMSA in the GHPS-Implementation plan and that a positive reply (whateverthat meant) wouldalmost be made.One day later theCDC contactedEMSA, explainingtheir plans and ask-ing to start discus-sion on how to pro-ceed. An eight-min-utes conference-call between Brus-sels and Atlanta fol-lowed. EMSA waswell prepared, Por-tugal had already been identified as the ideal country forthe pilot study, Anabela Serranito would take the lead,and the members were informed and eager to takeaction. No time to think, no time for further consultation.But then the shock, the CDC wants to start in a Centralor Eastern European country - that was not really Portu-gal. What followed was in a way like betting on the blank- having in mind our membership, our strengths andweaknesses in the different countries and knowing therisks and opportunities. How ready were we in eachcountry? Who should take the lead? We knew it wasdefinitely worth to fight for - but it was one against threeon the phone and we knew we would only have this onechance to play the right card. Only seconds to come upwith a solution. Our Board was preparing for the EEB-Meeting in Dubrovnik, not reachable anyways - not dur-ing a phone conference. The solution was Croatia, thecountry where the fundaments of this survey were laidsome months earlier. It took nearly two years to beaccepted to the preliminaries, but in those decisive eightminutes EMSA got into the game. The official results ofthe phone conference are quoted above… but the greyhairs it produced are to be seen on our heads.

CONCLUSION

EMSA can be proud to be the organisation in Europeperforming this survey. Without the help and support ofseveral experts this success story would not have beenwritten in such a short time. We would like to thank SirAlexander Macara (UK) and Dr Klas Winell (Finland) fortheir ongoing support as well as Dr Haik Nikogosian andhis team for the trust they are putting in EMSA.

Now that we are in the game, our players will do theirbest to show that EMSA is able to play in one leaguewith our partners. Two EMSA oldies, Anabela Serranitoand Nick Schneider, got us on the pitch, now it is oneverybody to show that EMSA can be a valuable partnerand will perform this survey in the most professionalway.

Under the leadership of Hrvoje Vrazic and Divo Ljubi-cic, we are confident that our Croatian FMOs will be thefirst ones to show our new partners that EMSA takes upits responsibility and plays along with the best.



LLIIFFEE

The best part of this summer I spent in Dubrovnik.

Even though it was rather short, the stories areenough to cover a whole summer. It started with theEMSA Summer School, which was simply wonderful,combining learning all there is to know about emergencymedicine, meeting great people from all over Europeand having fun. Not to forget getting to know the beauti-ful city of Dubrovnik.

Divo has always been telling me of how unique andpretty this city is, that it is the best town in the world andthat I ought to come there. "Ja, ja, ja..." I usually thought,"everybody is fond of their home town...".

Well, now I know he was right. It definitely is one ofthe, if not THE, most beautiful towns I've been to. AndDivo and his sister, who gave a guided tourthrough The Town, know everything about theirhome town. Historical facts, where to have thebest views and photo spots, where to eat the bestseafood and ice-cream, and all those magicalspots where you can make a wish. For examplethe "church of wishes”, conveniently placed onthe way to the high school. You have to touch itwith your hand while walking past it, at the sametime making a wish.

Same principal for that little arch right next to it:you have to jump through it, make a wish andthen turn a little iron hook that hangs on the wallnext to it one time around itself, clockwise. And

then what you've wished for will come true. So they say.You just mustn't tell anybody. Of course I am not super-stitious, but you never know, these are ancient rituals,and after all, I do not want to take any risks. The prob-lem is, I jumped through that arch so many times andwalked past that church at least once every day, thatnow I cannot possibly say how many of my wishes, andwhich, have come true. I am still hoping that they will allcome true soon. If not, I have another very good reasonto go back to Dubrovnik soon. But that I have planned todo anyways. Especially because of the nice and hos-pitable company!

After the summer school was over and the partici-pants had left one by one, our EBB meeting started. Twodays of hard work, but we really were efficient. Got

everything done in 2 instead of4 days as originally planned.Wonderful, that left me 2 moredays to enjoy Dubrovnik andthe Adriatic coast, togetherwith my two local compan-ions... not always easy, beingthe main target of Divo's andHrvoje's entertainment...

We decided to go to Mljet.Mljet is an island, about onehour to the west by high speedboat. The unique thing aboutthat island is, there is a lake inthe middle of the island, and inthe middle of the lake, there isanother, smaller, island. A bitlike those Russian dolls,where there is always one

inside of the other. We had to get upreally early, something I am usuallynot a fan of. But it was worth it. Theboat trip was fun, we checked our per-sonalities in magazine-psycho-tests.Turned out that I would have been agood man, if I had not opted for that x-chromosome twenty-some years ago.

In Mljet we decided that it would bebest to rent a car. Bikes would be toomuch work, after all, this was a holi-day, and with a car we could go all theway to the other end of the island.

A summer in Dubrovnik

Author:Fiona Horneff, Medical Faculty of Heidelberg, Ruprecht-Karls-Universität / University of Heidelberg (Germany)

EMSA Secretary General 2003/2004Contact:[email protected]



LLIIFFEE

We found MiniBrum. I instantly fellin love with that lit-tle yellow PolskiFiat, it was ever socute! I am not sosure if Divo was sohappy with it, hedefines cute as"ugly but adorable",and also it mighthave been a bit toosmall for him, but...cute as can be. Ifyou want to have a cute car and experience thetrue Monty Python feeling, you have to makesome sacrifices to comfort, such as having tolean out the window every time you need to shiftbecause you are sitting on the clutch already.Great fun was to check the windshield wipers.Though it was bright sunshine, you shouldalways check if all the car's equipment is work-ing. At least that is whatthey teach us in drivinglessons here in Ger-many. In Croatia appar-ently as well. That'swhat Divo did anyways.And, surprise surprise,they did work. Brilliant.They were so enthusias-tic about doing theirwork, that we almostcould not stop them any-more. We tricked themat last, by shutting offthe engine completely.Hilarious. So, we drove on. I asked Divo if he did notthink it better to check again, if they were still working,you never know, it might rain later and maybe they wereoffended and sulking because we had stopped them socruelly earlier on. Hrvoje's "NOOOOO!!!!!!!!!!!!" came abit late. Divo apparently had agreed that it was a goodidea to double-check! Fortunately they still did workabsolutely fine. And this time we knew how to stop themas well. Just shut off the engine again.

Now you know what I meant by Monty Python feeling:The gentle giant (Divo) driving a car that is 3 numberstoo small, having the windshield wipers running on fullspeed in 45 degree and bright sunshine, Mini Brum(which is actually more a Maxi Brum, considering thenoise it made: you could not even hear that the radiowas turned on from the back seat) slowly cruisingaround the serpentine mountain roads… actually not asslowly as my safety standards would have liked, butnever mind, I interpreted the fact that our MiniBrum didnot have safety belts as an indicator that you would notneed any since there were never any accidents on thatislands where Mini Brums were involved.

Then we took the boat to the little island. Itreally was little: you walk around it in about 10minutes, look at the little monastery, and thenspend the rest of your time having a goodstrong coffee. And if you are there with Divo,you can be sure that he knows the waiter,they played water polo together, so you arehis guest.

Another nice thing about my companywas, that they both had at least one mobilephone with them, so I did not have to havetoo much conversation, as they were talking

to other people, who didnot have the pleasure tobe with us, most of thetime. Fine. Next time I willbring 10 mobiles as well,just wait and see…

Back to the main land(big island surroundingthe small one), we went toa little channel with astrong current, where you

can swim through. Actually you don't have to swim,the current takes you. My pleads that it was too coldto swim were ignored by my accompanying gentle-men, so I had to go in the cold water. At least I couldstop them from pushing me in.

And then we hitch-hiked for another boat thatwould take us back to where we had left our darlinglittle Mini Brum! Have you ever been hitch-hiking ona boat? Go for it, it is great fun!

The rest of the day we spend driving around theisland, visiting another beach, taking millions ofphotos, getting invited for lunch (Divo really knows

everybody!), and, I have no words for such a tragedy;we killed Mini Brum!!! It broke down, sadly, in the middleof nowhere. Now I know what you need all these mobilephones for, for example to call Mini Brum services andarrange for another car. Eventually it came, and we con-tinued our trip in the grey version of our Mini Brum,which was not as cute. And made less noise.

When we finally headed back (and almost missed thelast boat), we were all exhausted. I tried to sleep a bit onthe boat, but Hrvoje did not seem to like that idea, andkept waking me up with "wakey-wakey!". He wouldmake a great alarm clock in the mornings!

So that was the highlight of my Dubrovnik Summer.As I said, there would be enough stories for a wholesummer, but as this is supposed to be a scientific paperand not Fiona's memoirs, I will stop here. Go and findout yourself how nice it is there.

And just to close this article: special thanks to Divoand Hrvoje, I had a fantastic time with the two of you,and I really do miss you both!

Fiona



LLIIFFEE

Have you ever seen a crying barefoot child, left in thestreet, or a lonely old woman, begging for a piece ofbread? Maybe you have, but if you haven't - just lookaround.

During an internship in one Romany suburb I wasdumbfounded by the sights in the streets. Dirt, street-running waste waters, children who played there withwalnuts instead of balls, but, in spite of all, healthy andcheerful. On the pavement in front of their houseswomen sat with all their clothes on them, who despitelots of diseases didn't follow their doctor's advice - eitheras a result of ignorance or as disparaging the treatment.

The lady doctor, who I was with, was stopped on thestreets by Romany, who were not her patients, but shehowever helped them despite no emergency. Shechecked their blood pressure, consulted them for newsymptoms, calmed them - she was a healer, a psychol-ogist and a friend for those people. She looked like amissionary, who tried to heal the whole unjust anddeprived of health knowledge Romany world. Duringthis short visit in the ward she gave them strength forlife, directed attention to health and the meaning of life,supported and helped them. She was like a Messiah intheir eyes - the doctor was deified and glorified. Shetreated them as human beings, and not as scum - sherespected their arguments and listened to their opinions,corrected ignorance, encouraged attempts to learnsomething about the disease even with the simple ques-tions that they asked. The children had fun with her andshe was smiling and wasn't afraid to hold them. The ladydoctor understood some Romany (language) andshowed that she didn't put a linguistic, religious and eth-nical barrier.

When we went for the next visit, we had to passthrough several yards, garages, under hanged out car-pets to reach a room without any windows. There was anewborn child growing up. He was feverish and hadnever seen daylight. He was oriented towards the elec-tric light. His mother had undiagnosed facial paresis,which had already twisted her smile and closed her righteye. In front of me was the ignorance of the patients andthe carelessness of the doctors that could have beenfatal for young woman's life. Insufficient health culturecompeted with a strong sense of motherhood and thewish to bring up a healthy child. She devoured everypiece of doctor’s advice and showed interest in caringfor her son.

The Romany people of Central and Eastern Europeare in the unique position of suffering the worst healthconditions of the industrialized world together with someof the biggest health problems associated with the thirdworld countries. Rates of both infectious and non-com-municable diseases are high.1 The proportion ofRomany living in poverty exceeds 75% in countriesthroughout the region.2 Access to preventive and cura-tive healthcare services is low.3

Romany people are the part of the population of everycountry and they deserve special attention. A huge partof their housesdon't even haveany drainage.Waste watersflow along thestreets wherechildren play.There isn't evenrunning coldwater in somehouses. Oneroom is inhabitedby several gener-ations and some-times there areno doors or win-dows. Heating ismostly wood andcoal. In most ofthe cases elec-tricity is available.Sometimes it's a cable, which is caught from the electricpost near the house or from the neighbour to light atleast one bulb. Positive change of living conditionswould affect the health state of the Romany.

Efforts to promote the health of Romany populationsoften fail to confront the social structures which shapehealth in the first place: inequity and discrimination ineducation, employment, and housing; poor access toclean water and sanitation; lack of social integration;minimal political participation; poor access to food; dis-parities in income distribution; etc.4

In a General Comment issued in 2000, the UN'sCommittee on Economic, Social and Cultural Rightsnoted that:

Modus vivendi

Author:Marieta Nikolova Ivanova, Medical University of Plovdiv, Plovdiv, Bulgaria)

Contact:[email protected]



LLIIFFEE

"...the highest attain-able standard of physi-cal and mental health isnot confined to the rightto health care. On thecontrary, the draftinghistory and the expresswording of article 12.2[of the ICESCR]acknowledge that theright to healthembraces a wide rangeof socio-economic fac-tors that promote con-ditions in which peoplecan lead a healthy life,and extends to theunderlying determinants of the health, such as food andnutrition, housing, access to safe and potable water andadequate sanitation, safe and health working conditions,and a healthy environment." 5

But health cannot be described or improved in isola-tion.

The limited civil skills in the promotion of healthamongst Romany population have their effect upon thedevelopment of many NGOs, Romany and non-Romany. Their efforts to improve the social status of theRomany in Bulgaria deserve our admiration. Their workis directed to Romany of all ages with a common goal -improvement of the health and social culture of theRomany community. Thanks to their meetings withpupils graduating from the high school, the number ofRomany enrolling in higher schools grows. They areambitious, persevering and enthusiastic about the factthat they can further their education - what was impos-sible for their parents due to not being well informed orlack of financial means. The success of this initiative isa result of the joint cooperation between pupils, teach-ers, parents and the institutions concerned.

For younger pupils there is another interesting form ofintellectual development - internet clubs, material arts,folklore dance club, computer courses, modern dance,language courses, football team and other, organizingby Romany organizations. The attempts to improvehealth culture also give good results. An ambition existsthere to support these groups of Romany who do nothave a general practitioner and no prophylactic exami-nations carried out amongst them. It has been providedfor the children in the neighbourhoods to have weeklycheck-ups by paediatricians at the place, as well as vac-cinations. The project of creating a model school for jointeducation of Romany and Bulgarians is also interesting.The aim is to improve the conditions of conjoint living forthe Bulgarian and Roma children at school. It has beenachieved through improvement of the school conditionsin order to encourage the attendance and keep Romanychildren at school, as well as attract Bulgarian children.It is useful to involve the parents and the community aspartners in the process thus improving the integration

between children, par-ents, teachers and civilorganizations. Attentionis paid to women in dis-advantageous position,having problems andwomen victims of vio-lence. There is a centrefor delivery of social con-sultations to citizens,which is the place wherepeople desperate aboutthe unemployment andscarce social aid cansolve such problems insome way.

This is only a brief information on the exceptional roleof the Romany NGOs for the development of theRomany society, as most favourable is the fact that aRomany acts for another Romany thus eliminating anynegativism or distrust and clearing the way for solving anumber of issues.

The good work of these organizations cannot, howev-er, take the place of the state, nor have they such inten-tion. The aim is to correct the omissions of the state leg-islation in respect of the rights of the Romany and stim-ulate their social growth. Representatives of theRomany ethnic group take part in the state government,which presupposes improvement of their status.

An important point is the involvement of Europeanorganizations for solving these issues, and a greaterconfidence in the contingent they work with, becausewhat is the sense of supporting anyone if they know thatyou do it as a part of your duty.

We believe that with Bulgaria joining the Europeanfamily there will be a stronger impetus for the develop-ment and improvement of their lives.

REFERENCES:

1 Hajioff S, McKee M. The health of the Roma people: a review ofthe published literature. Journal of Epidemiology and CommunityHealth. 2000. 54: p 864-9.

2 Ringold D. Roma and the Transition in Central and EasternEurope: Trends and Challenges. Washington DC. The WorldBank. 2000. p 10-12.

3 Zoon I. On the Margins: Roma and Public Services in Romania,Bulgaria and Macedonia. Open Society Institute, New York. 2001.Zoon I. On the Margins: Roma and Public Services in Slovakia.Open Society Institute. New York. 2001.

4 Marmot M, Wilkinson RG, editors. Social Determinants of Health.Oxford University Press. Oxford. 1999. Berkman LF, Kawachi I,editors. Social Epidemiology. Oxford University Press. Oxford.2001.

5 Committee on Economic, Social and Cultural Rights. GeneralComment 14. UN ESCOR. Doc. E/C.12/2000/4. 2000.

6 Slavev A. Report for Evaluation. Project: A Resource Centre forthe Development of North-Western Bulgaria. Feb 2003.



I believe most of you have had that feeling duringyour first few years of medical studies that your studieswould never end, as minutes seemed like days anddays like months... But then, as you finish the first half ofyour medical studies, time suddenly seems to speed up,and before you know it, you have finished your medicalstudies, you are not a student anymore, meaning thereare no more student privileges. From a medical student,you have become a doctor.

As much as all of us in our student days want our tor-ments in form of exams and obligatory attendance toend as soon as possible, once when this really happens,we sometimes remember a proverb "Be careful whatyou wish for, you just might get it."

I graduated on June 28th this year, so what I will writehere is mostly based on personal experience, but alsobased on numerous talks I had with various people overthe past few years of my active involvement in studentorganizations. Sometime right after the graduation day,in terms of becoming aware of many things that havechanged at that moment, one of the biggest changeswas the one related to EMSA.

Having spent three years in EMSA, I have got used toa more or less constant workload. You automaticallyallocate a part of the day as EMSA time, mostly replyinge-mails or writing something. And over the time, youreally stop noticing it. Just when you are about to finishsome engagement with EMSA, although funny andstrange, the first thing that comes into your mind is: "Ohmy God, what I am going to do with all the free time afterEMSA?" Ironically, all those years you spent in EMSA,you wanted some free time, and now that you actuallyhave a chance to get some free time, you are not happyagain, because you will not know what to do with it. Thisis what is called the "EMSA paradox" (by the way, thesame paradox explains why you still want to work inEMSA again and again, although there were numeroustimes when you wanted to smash your computer,because you couldn't reach people, or were endlesslyfrustrated with the work still pending, cursing the daywhen you signed up for a position, swearing you will bemuch smarter next time). I believe that the feeling canbe best described as feeling helpless and lost in a way.Then, naturally, you start looking for other ways to occu-py yourself, or for further engagement in EMSA. It's notjust the work and the chance of collaboration with all thevarious types of people you meet, but also one of the

biggest highlights is definitely attendance of EMSAmeetings. You get addicted. For real.

I have experienced this feeling twice already - firsttime was after my first mandate as the president(2001/2002), when I ran for the position of the presidentagain; and second time was after my second mandateas the president (2002/2003), when I ran for the positionof the EMSA Liaison Officer towards IFMSA. This year,at this GA, I am finishing my involvement in EMSA. Onlyofficialy, of course, as I will always be there to help by e-mail, or when having an opportunity of attending anEMSA event, of course, taking into consideration thenew obligations I will have. But the major difference nowis that there are NO MORE extensions, my student daysare over, my involvement in EMSA as a student is alsoover, and I know now I will miss it badly.

Of course, there are various organizations for youngdoctors, European doctors, old doctors and all otherkinds of doctors, so you can continue your activities, butit will be different. If nothing else, you will at least needto meet all the new people again to experience that feel-ing of being home, like I did with EMSA. And, as withany other change, you are not too thrilled about it.Because if something is good, why change it? But ofcourse, this is different, as you age, you learn to moveon.

When I was starting in EMSA, it was always funny forme to see some of the experienced EMSA peoplealways saying that "this is their last meeting", but stillthey would come to one or two more, every time sayingthe same. From what I've seen and from my experience,you will be announcing that it is your last EMSA meetingat least one or two meetings prior to the real last one.

One of life's biggest advantages is that in the long runyou mostly remember only nice and pleasant things,while the unpleasant ones have a tendency to be forgot-ten. It is the same with me and EMSA - I finish myinvolvement in this organization full of nice memories, ofgreat people I had a chance to meet, have fun with, andeven to work with some of them, sharing all sorts ofgood and bad moments of my and their lives. That wasan experience I will never forget, and it hasn't got a price- it's priceless. And if someone was to ask me whetheror not I would do it all again, the answer would be ascreaming and definite YES!

LLIIFFEE

Becoming a doctor

Author:Hrvoje Vrazic MD, Medical School, University of Zagreb, Croatia

EMSA Liaison Officer towards IFMSA 2003/2004Contact:[email protected]

YES!YES!



By the choice of the editor:

A short overview of history of medicine and urban culture in old Dubrovnik

(text has been extracted from: Borovecki A, Lang S. A Guide to the History of medicine in old Dubrovnik. School ofPublic Health "Andrija Stampar", Medical School, University of Zagreb, Croatia. Zagreb 2001)

For many years Dubrovnik was one of the largest cul-tural centres in Croatia. Many famous Croatians wereborn in Dubrovnik: Marin Drzic, the great CroatianRenaissance playwright, Rugjer Boskovic, worldrenowned 17th century scientist and philosopher, andGjuro Armeno Baglivi, famous 17th century physician.This small city-state has always, through its rich and tur-bulent history, been opened to the world. Its unique geo-graphical position between the west and the eastMediterranean gave Dubrovnik's cultural tradition cer-tain flare, a mixture of different cultural and scientificinfluences. The inhabitants of Dubrovnik were alwayswilling to contribute to the development of their city. Thatis why they travelled all over the world to study the

achievements of othernations to educatethemselves at the bestuniversities and,through successful com-merce, acquire the mostexotic goods for their lit-tle community.Dubrovnik has alsobeen open to othernations and cultures thatcame in order to settledown within its walls fordifferent reasons.Through this cultural exchange between Dubrovnik andthe rest of the world a specific cultural blend was formed

- that of the culture of Dubrovnik, which still exists today.Therefore Dubrovnik has always been viewed as aworld of its own within the Croatian cultural context.

RECTOR'S PALACE - AESCULAPIUS' CAPITAL (the begin-nings of medicine in Dubrovnik)

Dubrovnik has, ever since its foundation, been con-nected with medicine. Its founding fathers were theinhabitants of the nearby antic Greek colony of Epidau-rus who brought to the region the cult of the Greek godAsclepius (in Latin Aesculapius) from their homeland.The reminders of these events are today the capital onRector's palace dedicated to Aesculapius and the Latininscription on the wall near the capital:

"Munera diva patris, qui solus Apollonis artes,Invenit medicas per saecula quinque sepultasEt docuit gramen, quem usum quodque valeretHic Aesculapius caelatus, gloria nostraRagussi genitus, voluit quem grata realtumEsse Deos inter veterum sapientia partumHumanas laudes superaret rata quod omnesQuo melius toti nemo quasi profuit orbi."

"Here the Aesculapius is carved, our glory, theone who found the arts of medicine, divinegifts of his father Apollo who were hidden forthe five centuries. The one who thought (us)of the purpose of every medical herb. He wasborn in Dubrovnik. The praised wisdom of(our) fathers made him a god because it wasthought that he had surpassed all the humanpraise as not helped the whole world betterthan he did."

CHURCH AND ROLE OF ST. BLAISE

The Church of Saint Blaise is dedicated to thepatron of Dubrovnik Saint Blaise. The patron onevery sculpture holds the model of Dubrovnik inhis hands. His blessing is considered to haveprotective powers against the illness of the throat.In 972 AD the citizens of Dubrovnik named astheir patron St. Blaise (or, as we call him inDubrovnik, St. Vlaho) who was a bishop and asecluded physician who lived in the wilderness.Every year on the 3rd of February there is a bigprocession in the name of St. Blaise in Dubrovnikwhere the blessing of the throat or the so called"grlicanje" is usually performed with two inter-twined candles near the throat.

LLIIFFEE



PUBLIC HEALTH CONDITIONS INOLD DUBROVNIK

The statute of the City ofDubrovnik from 1272 AD is one ofthe oldest Croatian legal documentsand where one can find a number ofregulations concerning medicineand the quality if life of the popula-tion of Dubrovnik. In 1272 AD inorder to improve the sanitary condi-tions in the city many measureswere introduced. Those regulationscan still be seen in the archives in"Liber statorum". All the inhabitants,both male and female, were obligedto keep the street in front of their house clean (this wasusually done on Saturdays). The other regulations from"Liber Viridis" c. 7 prohibit the disposal of garbage nearthe city gates (there were special holes in the city wallsfor the disposal of the garbage). In 1272 AD a regulationwas passed that the latrines should be kept in houseson wooden balconies above the street. From the year1321 AD the latrines should only be kept in the housesand the waste from them was only to be disposed of atnight. From 1407 AD to 1436 AD a sewage system wasintroduced to Dubrovnik. In 1336 AD people were forbid-den to keep animals in the city. In 1407 AD a regulationwas introduced that all the streets in Dubrovnik shouldbe paved and in 1415 AD the first city street-sweeperswere introduced.

LAZARETI - QUARANTINE OF DUBROVNIK

Near the east city gates "Vrata od Ploca" there is thebuilding that has the greatest significance for medicalheritage of the old Dubrovnik. The complex of variousbuildings called "lazareti" represents the quarantine ofDubrovnik. Before entering the city the newcomers hadto spend 30 days in quarantine to see whether theywould develop any symptoms of a disease. Later, it wasprolonged to 40 days. The name quarantine comes fromthe Latin word "quaranta" meaning 40 as written in theStatutes of Dubrovnik. If the plague entered the sur-roundings of Dubrovnik but not the city itself, in spite ofquarantine measures, city gates were closed, and theentrance to the city was forbidden to those coming fromthe infested region under the threat of death. If theplague had spread to the city, all inhabitants abandoned

the city until the epidemic was over. Only10 noblemen were left to watch over thecity until the end of the plague. The onewho was found responsible for spreadingthe plague to the city was punished evenwith the death sentence.

Other epidemic diseases of that timebesides the plague were also presentamong the population of Dubrovnik (lep-rosy, smallpox, dysentery, gout, urinarydiseases, syphilis, rheumatic diseasesand different GI infections).

Those who had leprosy lived outsidethe city walls in special institutions, lep-

rosarium, which were financed either by the state of byprivate donations.

In 1784 AD variolisation was introduced to Dubrovnikto prevent the smallpox. In 1800 AD Luca Stulli, afamous physician from Dubrovnik, introduced the newJennerian invention - vaccination to Dubrovnik.

ORPHANAGE - ORGANIZATION OF THE SOCIALWELFARE SYSTEM IN DUBROVNIK

The high level of the organization of social welfare inDubrovnik can be observed in the documents connect-ed to the founding of the orphanage in 1432 AD. This"Ospidale della misericordia" took care of the unwantedchildren and had a maternity ward where mothers couldgive birth to their illegitimate children. Also in 1432 ADthe decision was made by the city authorities to prohib-it leaving unwanted children in different public places(even infanticide was not uncommon until that time). Onthe left side of the entrance there was a window with"ruota", a big wheel where mothers would leave theirchild, usually at night. They would place their child on itand then the wheel would turn and the child would finditself in the premises of the orphanage. Nobody wasallowed to stop masked woman carrying the child duringthe night, for she and the child were protected by thelaw. In that way discretion was guaranteed and the iden-tity of the mother remained a secret. When they were sixyears old the children would be given up for adoption orthe real parents could claim them back, but they wouldhave to prove that they were the natural parents of achild.

FRANCISCAN MONASTERY - PHARMACY INDUBROVNIK

In Dubrovnik, as in the Orient, the prepara-tion of pharmaceutical compounds was in thehands of pharmacists, not physicians as itwas in the rest of Europe. In 1317 AD at thepremises of the Franciscan monastery inDubrovnik the first pharmacy was founded.Even today, there is the same public pharma-cy that still serves the inhabitants ofDubrovnik.

LLIIFFEE



DUBROVNIK'S WATER SYSTEM

The new Dubrovnik's water system was finished in1438 AD by Onofrio della Cava. It was 11,700 meterslong, situated 106 meters above sea level, with 4 bigwater tanks.

DOMUS CHRISTI - HOSPITAL AND NURSING HOME

At the beginning of the 14th century Dubrovnikalready had a number of hospitals, which were financedeither by the state, by private donations or by fraterni-ties. On the 30th January 1347 AD the hospital "DomusChristi", also known as "hospitale grande" was foundedand served as a public hospital with its own physicians,management and staff. The physicians had to visitpatients twice a day. On 20th April 1847 AD physiciansNiko Pinelli and Frane Lopisic, one year after its firstapplication, applied for the first time the ether narcosisduring an operation for breast cancer. In 1888 AD all thehospitals united in the new one situated in the part of thetown called Boninovo, and "Domus Christi" was convert-ed into a nursing home for the elderly (which is how itremains today).

DUBROVNIK'S MEDICAL PRACTITIONERS ANDPHYSICIANS

The physicians and surgeons of Dubrovnik werepraised even outside of the state borders. They wereoften invited to the neighbouring countries to help thosethat were ill. Furthermore, government of Dubrovnikoften sent medical supplies and medical textbooks totheir neighbours (Turkey, Bosnia, Zeta, Serbia). Evenfrom the Middle Ages the population of Dubrovnik strove

to bring to their city the most accomplished and the mostlearned physicians of their time from all over the Europe(Spanish, Italian, Greek, Jewish…). They paid theirphysicians well. The names of all medical practitioners(134 physicians and 102 surgeons) who worked inDubrovnik are known today from the year 1280 AD.

The Republic employed the physicians for a period of1-2 years. If the citizens were satisfied with their service,their employment was prolonged. The differencebetween physician and pharmacist was clearly regulat-ed. In 1383 AD the private practice of the physicianemployed by the state was prohibited. One of the mostfamous physicians who worked in Dubrovnik was Ama-tus Lusitanus (1511 AD - 1568 AD), who was a Jew fromPortugal, a professor of medicine in Ferara and physi-cian to the Pope.

IN THE END

The medicine of Dubrovnik was never of the localcharacter nor was it ever isolated from the develop-ments in this field from the rest of the world. It wasalways aware of the latest achievements in medical sci-ence and praxis. Many famous physicians lived or wereborn in Dubrovnik. Furthermore, the citizens ofDubrovnik were aware of the significance of the latestpublic health and hygienic achievements for the devel-opment of their city. The respect for human dignity andethical awareness were always of a high standard. Themedicine of Dubrovnik has, during many centuries, inmany aspects been more accomplished than in anyother Croatian region.

LLIIFFEE



PPAAPPEERRSS AANNDD RREEVVIIEEWWSS

Fibrinolytic therapy in acute deep vein thrombosis and arterial occlusion

Authors:Emre Sivrikoz, Faculty of Medicine, University of Istanbul (Turkey)Mehmet Kurtoglu, MD PhD, Department of Surgery, Emergency Surgery Unit, Faculty of Medicine, University of Istanbul

(Turkey)


Deep Vein Thrombosis (DVT) may present a dangerof limb loss due to the cessation of the arterial blood flowbecause of the compartment syndrome if the thrombusextends distally to the leg or proximally to inferior venacava. Unless prompt and appropriate treatment isundertaken, venous gangrene may ensue. The first linetreatment is anticoagulation with either standard heparinor low molecular weight heparin LMWH, followed byvariable duration of oral anticoagulation. The treatmentaims to inhibit the thrombotic process and the inflamma-tory response. Hence acute symptoms are relieved, pul-monary emboli are prevented, the veins are kept patentand the valves are preserved which helps to avoid asubsequent postthromboflebitic syndrome. Anticoagula-tion therapy is a standard and an effective treatmentmodality, though its main disadvantage is that it doesnot prevent postthromboflebitic syndrome in all cases.Residual venous stenosis and damage to the venousvalves which together causes venous hypertension arethought to result in postthromboflebitic syndrome. Inorder to improve late results of the treatment in lowerextremity deep vein thrombosis, the thrombus should beremoved as soon as possible. The therapeutical options

for the removal of the thrombus are systemic throm-bolytic therapy, surgical thrombectomy, and local throm-bolysis.1, 2

Streptokinase, urokinase, and recombinant tissueplasminogen activator (rt-PA) are the ideal adjuvantthrombolytic agents to the anticoagulation therapy.Thrombolytic agents establish the vein patency rapidlyand thereby may preserve valve functions. In recentyears more aggressive therapy with catheter-directedthrombolysis was introduced to eliminate the venousthrombus, to restore the unobstructed venous drainagefrom the affected limb, to preserve the valve functionsand thereby improving the health-related quality of life.3

Acute peripheral arterial obstruction is a significantcause of limb loss. Until the 1940's, amputation was theonly treatment in gangrenes caused by acute arterialocclusions. Later, this treatment approach has left itsplace to embolectomy and operative revascularization.Today, intra arterial thrombolytic therapy is used as analternative to surgical treatment methods, to restorearterial circulation in acute peripheral arterial occlusion.

Aim. To evaluate the role and effectiveness of rt-PA in the treatment of venous-thromboembolism and arterial occlusions, as wellas to clarify its indications and patient selection bias. In both sections, the fibrinolytic therapy is based on a "pulse-spray" catheterdirected infusion of rt-PA directly into the thrombus.Methods. Between 1999 and 2001, 7 patients who were admitted to our Emergency Surgery Department with a limb threateningiliofemoral vein thrombosis were included. Anticoagulation was started with LMWH once a day on admission and was continuedwith Warfarin. A pulse spray catheter was introduced through ipsilateral popliteal vein and advanced into the thrombus under flu-oroscopic control and thrombolytic agent was delivered. The infusion of rt-PA continued for 24 hours at a rate of 1 mg/hour. A phle-bography was undertaken 24 hours later to evaluate efficacy, and the infusion was continued for 2 more days in insufficient throm-bolysis.During the period from 1999 to 2002, 15 patients who were admitted to our Emergency Surgery Department because of periph-eral arterial occlusions were included. A pulse-spray catheter was directed to the thrombus under angiographic control. Bolusinjection of 5 mgr of rt-PA (Actilyse, Boehringer Mannheim, Germany) was followed by a 15 minutes interval. An angiography wasperformed and bolus injection of 5 mgr of rt-PA was repeated. After angiographic control, patients having insufficient thrombolysisreceived 0.05 mgr/kg/hour of infusion for 12 hours. Thrombolytic treatment ended with a control angiography. Results. In VTE group 5 patients had near complete lysis (80-95%), 1 patient had partial lysis, and 1 patient had no lysis at all.1 PE, 1 CVA and 1 acute renal failure was observed. Patient with CVA died, constituting the mortality. In Arterial Occlusion the average length of occlusions was 16 cm (6-45 cm). 10 patients had complete reperfusion, 2 of theseneeded only 1 bolus injection and the other 8 needed two bolus injections and the infusion, 1 patient had partial recanalisation, 2patients needed a balloon dilatation and 2 patients needed an embolectomy. 3 minor bleeding and 2 strokes were observed. 1patient with a stroke and 1 patient during trombolysis were lost during the treatment. 1 patient with acute MI, and 1 patient withdiabetic coma were lost during follow-up. Conclusion. Pulse - spray thrombolysis in selected cases of iliofemoral vein thrombosis and in acute arterial occlusions is a safe,and extremity saving procedure, an alternative to surgical treatment with at least equal results.



Due to recombinant DNA technology, the Tissue Plas-minogen Activator (rt-PA) (Alteplase, Actilyse,Boehringer), which is the most preferred among theseagents, is available for clinical use. This agent is fibrinspecific and its reperfusion time is shorter than uroki-nase or streptokinase4. In addition, unlike streptoki-nase, rt-PA doesn't have an antigenic nature so it does-n't cause any allergic reactions when used more thanonce.

In the ensuing sections, the fibrinolytic therapy ofDVT and Acute Arterial Occlusions, will be coveredeach on their own perspectives. In both sections, the fib-rinolytic therapy is based on a "pulse-spray" catheterdirected infusion of rt-PA directly into the thrombus.

A) DEEP VEIN THROMBOSIS

Material and Methods

Patients: Between 1999 and 2001, 7 patients whowere admitted to the Emergency Department of MedicalFaculty of Istanbul University because of a limb threat-ening iliofemoral vein thrombosis were included in thestudy. The patients with suspected deep vein thrombo-sis were initially evaluated with a careful history taking todiscover a possible aetiology. After a thorough examina-tion, complete blood count and Prothrombin time (PT),Partial Thromboplastin time (PTT) and INR were deter-mined. The aetiology was researched with the laborato-ry tests for the deficiencies of the thrombolytic cascade,e.g. protein C, protein S, antihrombin 3, factor V Leidenmutation etc. A pelvic ultrasonography (USG) was per-formed to exclude any pelvic malignancy. Colour flowduplex examinations of the extremities were performed.Having an established diagnosis of iliofemoral veinthrombosis by means of both clinical and radiologicalexaminations; the patients were enrolled to fibrinolytictreatment. The patients with a history of recent cere-brovascular accident, bleeding diathesis, gastrointesti-nal system bleeding during last ten days, or major neu-rosurgical operations or intracranial bleeding in last 3months were excluded from the study. The leg circum-ferences and D-dimer levels were measured andrecorded before and after thrombolytic therapy. Thepatients were given 150 ug/kg enoxaparine once a dayon admission. Anticoagulation therapy was continuedwith warfarin after the thrombolytic therapy to maintainan INR (prothrombin time) between 2.0 and 3.0. Thewarfarin treatment was continued for 3-6 monthsaccording to the risk factors. The patients were con-trolled every week for the first 3 months and later forevery three months for one year.

Catheter - directed thrombolysis: Ipsilateral poplitealvein of the affected limb was catheterized for the entrysite. With the patient prone, the popliteal vein was visu-alized by ultrasonography and a single wall puncturewas made. The thrombosed vein was probed with asteerable wire and catheter under fluoroscopic control.After complete passage of the wire through the throm-bus, the catheter was advanced and contrast was inject-

ed to document the distal extent of the thrombus and tovisualize collateral pathways. For local delivery ofthrombolytic agent, a pulse spray catheter was posi-tioned with its tip into the thrombus. A heparin infusion of5000 IU was accomplished simultaneously via a periph-eral route. The infusion of rt-PA (Actilyse, BoehringerMannheim, Germany) continued for 24 hours at a rate of1 mg/hour. In order to evaluate the efficacy of the proce-dure a phlebography was undertaken 24 hours later andif the thrombolysis was not sufficient enough the infusionwas continued for 2 days more. The treatment wasstopped in any case with a final phlebography.

Results

Of 7 patients with the diagnosis of iliofemoral veinthrombosis and a threatened limb, 3 were female and 4were male. The median age of the patients was 53 (33-70). All of the patients had the clinical characteristics ofiliofemoral vein thrombosis such as oedema, pain, andswelling of the affected limb. Mean admission time tothe hospital was 2.5 days.

One of the patients was operated for knee prosthesisin the same leg 2 weeks ago. Deep vein thrombosis haddeveloped 10 days after the operation. Two patients hada history of extremity trauma. One had an occupationalaccident with the involved leg a week ago and the otherpatient had a history of falling from heights. There wasno fracture, but a soft tissue injury in his leg. The rest ofthe patients did not have any known etiological reason.Protein C, protein S, Antithrombin 3 deficiencies andFactor V Leiden mutation were checked in thesepatients. The laboratory results did not reveal anyabnormalities.

All of the patients had a Doppler USG examination onadmission. The deep vein thrombosis was acute and itinvolved popliteal vein, superficial femoral vein, and theiliac veins. Before starting the thrombolytic therapy, thephlebography correlated with the colour flow duplexfindings. In patients with an effective thrombolytic ther-apy, D-dimer levels were found to be increased after thethrombolytic therapy. The results were 10 to 25 X normallevels. The mean difference in the leg circumferenceswas 6 cm in the cruris.

Five patients had nearly complete lysis of thrombusafter the thrombolytic therapy (80%-95%) (Table 1). Onepatient had a partial lysis. The thrombus in the poplitealvein, and common femoral vein was lysed . But the com-mon iliac vein was still thrombosed. Another patient didnot have any benefit from thrombolytic therapy at all.She continued with the anticoagulation therapy and hos-pitalized for 1 week. She was discharged with recoveryfrom the hospital.

There were no complications during the infusion ofthe rt-PA except a patient had a sinusoidal tachycardiaat 36 hours. He had a history of atrial fibrillation. Thesolution was stopped and the patient was followed withclose monitoring. The same patient had cerebrovascularaccident three days later and he died.




One patient had dyspnoea, tachycardia, and tachyp-noea three days after the procedure. Pulmonary emboliwere proved by the ventilation-perfusion scintigraphy.The patient was hospitalized 22 days and did not devel-op any sequels. She was discharged with anticoagula-tion treatment from the hospital afterwards.

Acute renal failure after contrast material injection forphlebography was encountered in one patient. He did

not require haemodialysis and responded well to med-ical treatment. Recovery was complete.

B) ACUTE ARTERIAL OCCLUSION

Materials and Methods

Between 1999 and 2002, 15 patients who wereadmitted to Emergency Surgery Department of Istanbul




Medical Faculty because of peripheral arterial occlu-sions were chosen for this study. Patients had clinicalsymptoms and signs as pain, pallor, poikylothermia, paraesthesia and paraplegia. Doppler examination wasperformed in pulse less arteries and ankle-brachialindex was measured.

Patients with symptoms of peripheral arterial occlu-sion were included in the study after being examinedand verified with angiography. Patients with re-occlusionafter a prior thrombolysis, those having a stroke, whoneeded urgent exploration because of severe ischemia,or those having a high bleeding risk were not included inthe study.

Treatment Protocol: A pulse-spray catheter wasdirected to the thrombus under angiographic control.Bolus injection of 5 mgr of rt-PA (Actilyse, BoehringerMannheim, Germany) was followed by a 15 minutesinterval. The extent of thrombolysis was checked byangiography and then bolus injection of 5 mgr of rt-PAwas repeated. After angiographic control, patients hav-ing insufficient thrombolysis received 0.05 mgr/kg/hourof infusion for 12 hours. At the end of 12 hours, throm-bolytic treatment ended with a control angiography. Athromboembolectomy operation was performed onpatients still having an occlusion after thrombolysis.Moreover, to avoid re-occlusions, all of the patientsreceived 1,5 mgr/kg/day low molecular weight heparin(enoxiparin) for 1 week. LMWH application started aboutsix hours before thrombolysis. The algorythm of ourtreatment protocol is shown in figure 1.

Treatment was considered successful if pain disap-peared and/or pulses were restored, and if revasculari-sation was verified with angiography. Recanalisationwas calculated by the ratio of the lumen restored to thenormal lumen of the artery. One week after thromboly-sis, patients were re-examined; during their physicalexamination, their cardiac functions were checked withechocardiography. Those having a source of emboluswere given an oral anticoagulant (Coumadin) for lifelonguse.

Results

15 patients were included in the study. There were 9males (60%) and 6 females (40%) with an average ageof 67 (range 55 - 90). Patients had clinical signs ofperipheral ischemia as pain (15 patients - 100%), pallor(14 patients - 93.3%), poikylothermia (15 patients -100%), cyanosis (2 patients - 14%) and paraesthesia (2patients - 13.3%). The duration of ischemia before theirhospitalisation took an average of 46.7 hours. (Range 3hours - 7 days) .The shortest occlusion was 6 cm andthe longest was 45 cm. The average length of occlu-sions was 16 cm. Occluded arteries were superiormesenteric artery (1 patient - 6,7%), femoropoplitealartery (2 patients - 13.3%), iliofemoral artery (3 patients- 20%), popliteal artery (5 patients - 33.3%), posteriortibial artery (1 patient - 6.7%), brachial artery (2 patients- 13.3%), and common iliac artery (1 patient - 6.7%).Observed symptoms, signs and prior disease are givenin table 2.

13 patients had emboli and 2 had acute thrombosis.Besides thrombolysis a balloon angioplasty was per-formed on patients having acute thrombosis. 46.7% ofthe patients had a cardiac disease, 33.3% had diabetesand 40% had hypertension.

Recanalization: At the end of thrombolysis, 10patients had complete reperfusion. 2 of these neededonly 1 bolus injection and the other 8 needed two bolusinjections and the infusion. One patient, having anocclusion in superior mesenteric artery had 60%recanalisation. 2 patients (13.3%) having 90% stenosis,in the part of the superior femoral artery found inHunter's channel, needed a balloon angioplasty follow-ing thrombolysis, and both of them had complete reper-fusion. 2 patients (13.3%) needed a thromboembolecto-my operation due to insufficient thrombolysis.

Complications: 3 patients (20%) had a minor bleedingafter thrombolytic treatment. Minor bleedings werelocalised in gums and nose. One of them also had ahaematuria, though it occurred only for one time. Thesepatients had no other complications and they had 100%reperfusion. After thrombolysis, 2 patients (13.3%) hada stroke. There were no amputations.




Mortality: 1 of the patients (patient 7 in table 2) hav-ing a stroke died 2 days after thrombolytic treatment. 1patient (patient 12 in table 2) died due to myocardialinfarction during thrombolysis. He didn't have cardiacsymptoms before thrombolysis.

Follow - Up (30 days): 1 patient (6.7%) died due todiabetic coma on the 20th day. Acute myocardial infarc-tion was the cause of death in 1 patient on the 25th day.

DISCUSSION

Deep vein thrombosis is still a major health problem.In case of an extending thrombus, compartment syn-drome in the affected limb and venous gangrene mayensue. It may accompany the sensory and motor loss offunction as well. Therefore it may require an immediatetreatment in order to avoid the loss of involved limb.

The most common therapy for deep vein thrombosisconsists of anticoagulation with either standard heparinor low molecular weight heparin (LMWH), followed byoral anticoagulation. Strategies using either unfrac-tioned heparin (UFH) or LMWH are found to be equallyeffective in preventing the pulmonary emboli and recur-rent events. A metaanalysis of the thirteen randomizedtrials comparing treatment with UFH or LMWH reportedon over 4000 patients. In a three to six months follow-upperiod, the risk of recurrent venous thromboembolismwas 5.1% and 4.4% for UFH and LMWH, respectively(risk difference not statistically significant), and a risk ofsymptomatic pulmonary emboli of 1.8% and 1.9 % forUFH and LMWH respectively (risk difference not signifi-cant).6

Systemic administration of streptokinase enhancesthe lysis of the thrombi, though its clinical benefit is inquestion. Thrombolytic therapy with intravenous infu-sion of rt-PA is disappointing.7 Thrombolytic agents werecompared in different studies. For the study of Braith-waite et al, rt-PA is faster and more effective than strep-tokinase4 but for STILE trial, made with 393 patients, t-PA is not different than urokinase or streptokinase.10 Forstreptokinase, infusion times longer than 96 hours havebeen reported.11 Today, Urokinase is not available anymore for unknown reasons. Anaphylaxis is rare with anyof the thrombolytic agents, but allergies characterisedby early flushing, vasodilatation, rashes and hypoten-sion are a complication with Streptokinase.

In recent years, a more aggressive therapy with"pulse-spray" catheter-directed thrombolysis was intro-duced. With this catheter, thrombolytic agents can beinjected in to the thrombus with a high pressure, that'show the thrombus is separated into smaller parts andthe surface of reaction is increased. Pulse - Spray tech-nique is used to increase the speed of thrombolysis andto decrease the duration of therapy. Complete lysis in34%, and 50-99% lysis in 52% of the patients withiliofemoral thrombosis are reported in the literature.7However, it has been reported that after an anterogradeflow in the vessel has been obtained, pulse - spray infu-sion catheters are not superior to classical infusion

catheters.8, 9 Increasing age of the thrombus and a pre-vious history of thrombosis in the same extremity arereported to affect the lysis rate negatively.

Lysis of the thrombi may lead to clot fragmentationand increased risk of pulmonary embolism. In practice,symptomatic pulmonary embolism is a rare complica-tion: The National Multicenter Registry observed 6cases of 473 patients treated (1%), 1 of which wasfatal.16 We observed one patient while developing pul-monary emboli after thrombolytic therapy. It was clinical-ly symptomatic but the patient recovered quite well. Pul-monary embolism may also occur during conventionaltherapy for DVT, and in the absence of a direct random-ized comparison it is difficult to judge whether the throm-bolytic therapy increases the risk. Temporary vena cavafilters have initially been used in some centres to pre-vent pulmonary embolism but later was abandonedbecause of the low incidence of symptomatic embolism.

DVT extending into the iliac veins or vena cava inferi-or is associated with significant morbidity despite ade-quate treatment with the standard anticoagulation ther-apy. Moreover, while anticoagulation therapy is clearlyeffective in preventing recurrent venous thromboem-bolism and pulmonary emboli, long-term sequels of DVTcan not be prevented as efficient as pulmonary emboli.One of the important long-term sequels of the venousthromboembolism is postthromboflebitic syndrome(PTS). PTS is thought to be the result of residual venousstenosis and damage to the venous valves whichtogether cause venous hypertension.12 Thus, earlyremoval of the thrombus is essential in preventing PTSas experimental models have shown that the inflamma-tory changes in the vein wall and valves are reversible ifthe thrombus is dissolved early.13 Thrombectomy andthrombolysis are the two alternative therapeutic optionsthat aim at early thrombus removal. A randomized studycompared venous thrombectomy with anticoagulation.14

Thrombectomy decreased the early symptoms and pre-served venous outflow and valvular function better thanconservative treatment. However, after 5 years of follow-up, the clinical and functional differences between thetwo groups appeared less convincing. After 10 years offollow-up the results are encouraging in favour ofthrombectomy, which is convincing the benefits of earlyremoval of the thrombus.15 Nevertheless thrombectomyhas its own complications such as inguinal haematoma,lymphatic drainage persistent for 2-3 weeks, infectionetc. since it is a surgical procedure. Although the latepostthromboflebitic sequel takes years to develop andthe current follow-up of our study is still short, thepatients with iliofemoral thrombosis benefited fromthrombolytic therapy quite clearly.

In a study made in the General Surgery Departmentof Istanbul Faculty of Medicine, it has been observedthat thrombolytic therapy needs a shorter hospitalisationperiod than surgical treatment. Thromboembolectomyand thrombolysis, had a similar rate of mortality (14%and 11,7% respectively), but limb salvage rate wasmuch higher with thrombolysis (the amputation rate was




15,9% for thromboembolectomy and 0% for thromboly-sis).17 Moreover, although rt-PA is expensive, in totalprice, thromboembolectomy costs more than thromboly-sis. According to STILE trial and Mc Namara, surgicalreconstruction is better than thrombolysis in chronicischemia caused by thrombosis, but the results of ther-apy are better in thrombolysis in acute ischemia (<14days). However, there was no difference in amputationand in mortality rates.10, 18 In our study, all arterial occlu-sions progressed acutely and the aetiology was thoughtto be thrombosis. A claudication history was referred toa thrombosis, and patients with cardiac pathologies orpatients not having a history of occlusion were referredto emboli. In 2 patients having thrombosis, angioplastywas added to thrombolysis to obtain revascularization.

Bleeding is the most common complication of allthrombolytic therapies. Major bleeding site is thecatheter insertion place. In the National MulticenterRegistry, it happened in 4% of the patients.16 Therecould be other sites for bleeding but they are reported tobe quite rare. The most devastating complication is theintracranial bleeding. There was one fatal intracranialhaemorrhage and one patient suffered a subduralhaematoma, for a frequency of major neurological com-plications of 0.4% in the National Multicenter Registry.16

In our study we had one patient with intracerebral acci-dent and he died three days later. He had a history ofatrial fibrillation. We did not have an opportunity to makean autopsy. Therefore we do not know whether it is ahemorrhagic infarct or not.

In most of the studies made with rt-PA, it has beenreported that the increasing dosages are not increasingthe effect and the most effective dosages were reportedto be 1mg/hour or 0,05mg/kg/hour.9, 19 There is not clearinformation about bolus injection. 0,05mg/kg/hour infu-sion added to 5mg bolus injection that we used in ourstudy was not used before. Observing the 19 prospec-tive studies made by Berridge between 1974 - 1988, theincidence of haemorrhagic stroke is 1% and the inci-dence of major haemorrhage is 5,1%.20 The incidenceof stroke (haemorrhagic or ischemic) observed in throm-bolysis with low doses is reported 1,2% and 2,1% in lit-erature.21 Although these incidences are lower than14% that we had in our study for acute arterial occlu-sions, there are big differences in the number of patientsand in population types in different studies. The bolusinjection that we use, can be a factor increasing the mor-tality and the morbidity of our study. In a study made byDecrinis et al with 210 patients. 10mg rt-PA was com-bined with 3000 IU heparin and the mortality rate wasreported 0%. However, in 30 days follow up, 2 patients(1%) died due to CVA5. The best results in literaturewere obtained with the long time infusion of low - dosert-PA and it has been decided that it would be better tofollow patients in intensive care unit.22

In the studies made, it has been observed that thereis not a correlation between the length of occlusion inembolic occlusions and the rate of reperfusion. Thecause of this, is thought to be the improbability of form-

ing collaterals in embolic occlusions which causes thelength of the occluded section to be estimated longerthat it actually is. However, in thrombotic occlusions, ascollaterals are formed, there is a correlation between theappearance of a non-occluded artery in angiography,and the rate of reperfusion. In a study, with the increas-ing length of an occlusion, the rate of complete recanal-ization decreases from 63% to 42% and also, the per-centage of partial recanalization increases from 12% to29%.5 Moreover, as the length of the occluded segmentincreases, the frequency of complications increases too.In our study (acute arterial occlusions), in 2 patients onlypartial recanalization could be obtained by thrombolysis,but in the same session complete recanalization couldbe obtained by adding more rt-PA.

Thrombolytic therapy is also used in aneurysm sur-gery. Due to thrombolytic therapy applied during theoperation, the arteries distal to the aneurysm can easilybe cleaned with thrombolysis. In our clinic, we applied in2 patient thrombolytic therapy during a poplitealaneurysm operation, with good results. In literature,there are also studies, which combine thrombolysis withendovascular surgery.

Based upon our evaluation, the conclusions that canbe drawn are that Pulse - spray thrombolysis in select-ed cases of iliofemoral vein thrombosis and in acutearterial occlusions is a safe, and extremity saving proce-dure, an alternative to surgical treatment with at leastequal results. In both of our studies, patients benefitedfrom thrombolytic treatment clearly, as it gave us theopportunity to intervene quickly, to avoid the occurrenceof posttrombotic syndrome as well as the complicationsof the surgical treatment. In order to improve the safetyand effectiveness of the therapy, more trials with lateresults are needed.

REFERENCES

1 Haas SK. Treatment of deep venous thrombosis and pulmonaryembolism. Current recommendations. Medical Clinics of NorthAmerica 1998. 82(3): 495-510.

2 Semba CP, Dake MD. Iliofemoral deep venous thrombosis:aggressive therapy with catheter-directed thrombolysis. Radiology1994. 191: 487-494.

3 Comerota AJ, Throm RC, Mathias SD, Haughton S, Mewissen M.Catheter-directed thrombolysis for iliofemoral deep venous throm-bosis improves health-related quality of life. J Vasc Surg 2000.32(1):130-7

4 Braithwaite BD, Birch PA, Poskitt KR, Heather BP, Earnshaw JJ.Accelerated thrombolysis with high dose bolus t-PA extends therole of peripheral thrombolysis but may increase the risks. ClinRadiol. Nov 1995. 50(11):747-50.





5 Earnshaw JJ, Scott DJ, Horrocks M, Baird RN. Choice of agent forperipheral thrombolysis. Br J Surgery. Jan 1993. 80(1):25-7.

6 Dolovich LR, Ginsberg JS, Douketis JD, Holbrook AM, Cheah G.A metaanalysis comparing low molecular weight heparins withunfractionated heparin in the treatment of venous thromboem-bolism. Arch Intern Med. 2000. 160:18108

7 Verhaeghe R. Maleux G. Endovascular local thrombolytic therapyof iliofemoral and inferior caval vein thrombosis. Seminars in Vas-cular Medicine. 2001. 1: 123-127.

8 Kandarpa K, Chorpab PS, Arung JE, Meyerovitz MF, GoldhaberSZ. Intraarterial thrombolysis of lower extremity occlusionprospective randomised comparison of forced periodic infusionand conventional slow continuous infusion. Radiology. 1993.188:861-867.

9 Kandarpa K ,Goldhaber SZ, Meyerovitz MF. Pulse-spray throm-bolysis: the careful analysis. Radiology 1994. 49:549-552.

10 STILE Investigators. Results of prospective Randomised TrialEvaluating surgery versus thrombolysis for ischemia of the lowerextremity. Ann. Surg. 1994. 220: 251-268.

11 Decrinis M, Pilger E, Stark G, Bertuch H, Hönigl K. Thrombolysiswith recombinant tissue -type plasminogen activator in chronicarterial occlusion a prospective randomized trial - Preliminaryresults. In: Strano A, Novo S, ads. Adcances in Vascular Patholo-gy. Amsterdam: Exerpta Medica. 1990. 587 - 90

12 Wells. PS, Forster AJ. Thrombolysis in deep venous thrombosis:Is there still an indication? Thromb Haemost. 2001. 86: 499-508.

13 See-Tho K, Harris EJJ. Thrombosis with outflow obstructiondelays thrombolysis and results in chronic wall thickening of ratveins. J Vasc Surg.1998. 28: 115-22.

14 Plate G et al. Long-term results of venous thrombectomy com-bined with a temporary arteriovenous fistula. Eur J Vasc Surg.1990. 4: 483-489.

15 Plate G et al. Venous thrombectomy for iliofemoral vein thrombo-sis. 10-year results of a prospective randomized study. Eur J VascEndovasc Surg. 1997. 14:367-374.

16 Mewissen MW et al. Catheter-directed thrombolysis for lowerextremity deep venous thrombosis: report of a National Multicen-ter Registry. Radiology. 1999. ; 211:39-49.

17 Ustundag E, Necefli A, Kurtoglu M, Guloglu R. Acute arterial occlu-sions. Our results and the place of low molecular weight heparinsafter the operation. 3. UlusalTravma ve Acil Cerrahi Kongresi, 31August - 4 September 1999.

18 Mc Namara TA, Fischer FR. Thrombolysis of peripheral arterialand graft occlusions : improved results using high dose urokinase.AJR Am J Roentgenol 1985. 144: 769-775.

19 Hye RJ et al. Is thrombolysis of occluded popliteal and tibial bypass grafts worthwhile? J Vasc Surg 1994. 20: 588-597.

20 Berridge DC, Niyakin GS, Hopkinson BR. Local low dose intraar-terial thrombolytic therapy, the risk of major stroke and haemor-rhage. Br J Surg 1989;. 76: 1230 - 1232.

21 Ouriel K, Veith FJ, Sasahara AA for the TOPAS Investigators.Thrombolysis or peripherial arterial surgery (TOPAS): Phase Iresults. J Vasc Surg 1996. 23: 64 - 75.

22 Working Party on Thrombolysis in the Management of LimbIschemia. Thrombolysis in the management of lower limb periph-eral arterial occlusion: A consensus document] Am J Cardiol 1998.81: 207 - 218.

23 Kurtoglu M, Granit V, Necefli A, Kurtoglu M, Guloglu R. Throm-bolysis of acute arterial occlusion with rt-PA. Ulus Travma Derg.Jul 2001. 7(3): 158-62. Available from URL:http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=11705216&dopt=Abstract.



Arthroscopic meniscectomy as a method of treating meniscus injuries

Authors:Slavko Kuzmanovski, Clinic for orthopaedic surgery and traumatology, Faculty of medicine, University of Novi Sad, Serbia and

MontenegroPresident of EMSA Novi Sad

Vladimir Krstic, Clinic for orthopaedic surgery and traumatology, Faculty of medicine, University of Novi Sad, Serbia and Montenegro

Menthor:Miroslav Milankov MD, PhD, Clinic for orthopaedic surgery and traumatology, Faculty of medicine, University of Novi Sad,

Serbia and Montenegro

Contact:[email protected]@yahoo.com


Aim. To show early results of arthroscopic meniscectomies of the knee in local anaesthesia, and also the factors that influencethe treatment results.Methods. In the period from January 2000 to December 2003 420 arthroscopies were done in local anaesthesia. 374 patients(311 male, average age 31,8 years old and 63 female, average age 28,98 years old) were followed up for the average time ofeleven months after the arthroscopic procedure. There was a lesion of the medial menisci in 289 (77.3%), a lesion of the lateralmenisci in 67 (17.9%) and lesion of both menisci in 18 (4.8%) patients. 69 patients were injured during sport activities, 186 atrecreational activities and 119 were injured elsewhere. The average time of operation was 34 minutes (15-90). The average timefor medial meniscectomy was 31.65 min. (SD 15.62) and for lateral meniscectomy 42.31 min. (SD 14.56) - statistically relevantduration for lateral meniscectomy (t=5.20; p=3.3234E-7).Results. Average sick leave was 34 days (7-180). Athletes started with training program after 17 days (112-60) and took part inmatches after 30 days (20-90). The average Lyscholm score was 91.53. There was a statistically significant difference betweennonathletes (87.83) and athletes (95.85) (t=2.850, p=5.46246E-3).The results were worse in patients with degenerative changes(86.97) then patients without degenerative changes (94.2), (t=4.188, p=4.26488E-5). There was a significant statistical differencebetween groups with intact (92.76) and ruptured anterior cruciate ligament (88.4286) (t=2.4344, p=0.0158).Conclusion. Arthroscopic meniscectomy in local anaesthesia has a significant advantages comparing to a standard operative pro-cedure (dynamic evaluation of the joint, analgesic effect of long duration, one day stay in hospital, time for rehabilitation is abbre-viated, general fitness is regain sooner). Lesion of the anterior cruciate ligament as well as degenerative changes at the articularsurfaces has a significant influence on the final result of arthroscopic surgery.

Key words: arthroscopy; meniscectomy; local anaesthesia

The knee, being the largest joint in the human's body,is frequently exposed to injuries, during everyday orsport activities. Very often, in these types of injuries, themeniscus is damaged. Its role in the complicated biome-chanics of the knee joint is multiple: transferring weightfrom femur to tibia, a significant role in maintaining theknee's stability, gliding of the joint parts, as well as lubri-cating the joint and protecting joint's cartilage.1, 2

A very dynamic development of arthroscopic surgeryin the past two decades caused a great number oforthopaedic surgeons to dramatically change theirapproach, not only towards diagnostics but towardstreating the injuries and illnesses of the knee, as well.Arthroscopy allows a direct three-dimension visualiza-tion and dynamic evaluation of all joint parts, as well astherapy of injuries and illnesses of the knee. The advan-tage of arthroscopic procedures is in short hospitaliza-tion, small skin incisions, reduction of postoperativemorbidity and lessening of the medical expenses.

Meniscectomy is one of the most frequent operationsin orthopaedics. With development of arthroscopic sur-gery, the approach to treatment of meniscus injuries isvery much changed3, 4 whereas the improvement ofarthroscopic technique has allowed meniscectomy to beperformed with local anaesthesia.

MATERIAL AND METHODS

In the period from January 2000 up to December2003, at The Clinic for Orthopaedic Surgery and Trau-matology (Institute for Surgery at the Faculty ofMedicine in Novi Sad), 420 arthroscopic meniscec-tomies have been performed. Of that number 374patients have been controlled. There were 311 men, atthe average of 32 years and 63 women, at the averageof 29 years (Chart 1).

The average period of discomfort before operationwas 881days (2 days to 10 years). The right knee wasinjured on 175 patients and the left one on 199 patients.




The lesion of medial meniscus was found on 289patients (77.3%), of the lateral on 67 (17.9%) and of theboth on 18 (4.8%). (Chart 2).

Depending on the type of lesion, a longitudinal rup-ture, with or without incarceration, is dominant (Chart 3).

Based on sport activities, patients are divided intonon - athletes (119), recreation (186) and professionalathletes (69) who compete on national level (Chart 4).

Arthroscopic procedures were performed with localanaesthesia and analgosedation. After cleansing theoperational area, subcutaneously at the places of stabwounds, a cystokain is applied (5-10ml) with adrenaline(2ml) and after that, 0.5% markain (10ml), adrenaline(2ml) and morphine (4mg). Surgeons used a Karl Storzarthroscope with 30 degree optics. After examining allthe structures of the knee, a partial meniscectomy wasperformed, by using the appropriate instruments. Stabwounds were closed by individual stitching. The kneewas dressed with elastic band-aid and ice was locallyapplied (cryotherapy). The patients were released thesame day to house-care, where they were submitted tophysical therapy for the following three days, in accor-dance with the written instructions.5, 6

RESULTS

On 202 patients who underwent the partial meniscec-tomy, the cruciate ligaments were intact, while 170patients were diagnosed with lesion of anterior cruciateligament and 2 patients with lesion of posterior cruciateligament. The knee cartilage was changed, to a variabledegree on 131(35%) patients, while on 243(65%)patients no changes occurred.

Evaluation of the results was based on the pointscale, presented by Lyscholm i Gillquist7 (excellentresult is over 90 points). Average Lyscholm score was91.53. (Table 1)

Statistic analysis did not produce any statistically sig-nificant difference in the total score, when the gender,right-left knee and the injury of the medial-lateral menis-cus were compared. Statistically significant differencewas obtained by comparison of the total score of non-athletes (87.83) and athletes (95.85).

Also, there is a statistically significant differencebetween the group that had degenerative changes ofthe knee cartilage (86.97) and the group that did nothave those changes at the time of the operation (94.2)(Chart 5).

There is a statistically significant difference betweenthe group with intact LCA (92.76) and the group withruptured LCA (88.4286) (Chart 6).

Return to work was possible in average time of 34days (7-180) after the operation. Professional athletesbegan training after 17 days (12 to 60) and competingafter 30 days (20-90) average.

DISCUSSION

Discomfort period (from the moment of injury untiloperation) was rather long on our material. Meniscus

Chart 1. Number and age distribution of patients underwent arthroscop-ic meniscectomy during our study

Chart 2. The percentage of meniscal lesions before arthroscopic menis-cectomy was preformed

Chart 3. Prevalence of different meniscal lesions and the comparisonsbetween medial and lateral meniscus

Chart 4. Division of patients underwent our study, based on sport activ-ities




injuries, in 80% of cases, are diagnosed based on accu-rate anamnesis information and good clinical check-up.9, 10 Diagnostically speaking, arthroscopy allows a directthree-dimensional visualization of all parts of the knee,dynamic evaluation, accurate diagnosis and classifica-tion of the knee meniscus injuries. At the same time, itallows a precise extraction of the damaged part of themeniscus, especially its posterior corn.11

Arthroscopic meniscectomies were performed in localanaesthesia with analgosedation without any complica-tions related to anaesthesia. The advantages of thistype of anaesthesia are in possibility for dynamic evalu-ation of the knee, short hospitalization of the patient andlong term analgesia after the surgery.12, 13, 14, 15 This

allows the optimal use of a hospital capacity and thedecreasing medical expenses.

Meniscectomy related complications can be surgical:injuries to blood vessels16, 17 and nerve tissue18 as wellas breaking of lightsome instruments. Intraarticularbreaking of instruments (scissors, and knife) wasrecorded in three cases. This was handled arthroscopic,i.e. there was no need for arthrotomy. Infection afterarthroscopic surgeries appears in 0.07% cases.19 Thereis one infection recorded on our material and that washandled by giving antibiotics parenteraly and by repeat-ing the joint punctures. Thrombophlebitis appeared as acomplication on three patients. Concerning postopera-tive effusion, its rate varies from one author to another(up to 15% of the cases in the first week after the sur-gery). Within our tested group, 8 of the patients under-went knee puncture, without the influence on the treat-ment result.

Arthroscopy had to be repeated on three patients.This was due to constant pain and discomfort, whichgave a clinical image of meniscus lesion. In one case,posterior cornu of medial meniscus was not completelyremoved. Other two patients had LCA lesion and theirdiscomfort was related to ligament injury.

Between the later results of arthroscopic and arthro-tomic meniscectomies there is no difference.20 Long-term control of the patients after arthroscopic or openmeniscectomy shows that partial meniscectomy, incoherence with other factors (e.g. varus-valgus deformi-ty) leads to development of degenerative changes,mediolateral instability, etc.21, 22, 23, 24

Early results of arthroscopic meniscectomies on ourmaterial show that the result is better on patients whichhave intact LCA. Meniscectomy increases the symp-toms of LCA deficiency.25, 26 Therefore, according toHazel et al.27 a ligamentoplastic has to be performed,i.e. stabilization of the knee. Only in some cases, partialmeniscectomy has to be performed isolated. Additionalligamentoplastic of anterior cruciate ligament was per-formed on small number of patients involved in thisstudy. Those were mainly young active athletes. Modernpoint of view implies that suture of the meniscus signifi-cantly influences the restoration of normal kinematics ofthe knee after the reconstruction of LCA, which is shownby weaker results of LCA reconstruction via meniscecto-my.28, 29

Roos et al.30, based on study which involved 1012patients, concluded that, after meniscectomy,osteoarthrosis appears sooner on older patients than onyounger. Partial meniscectomy on patients older than 40years leads to clinical and radiographic signs of kneeosteoarthrosis.31, 32, 33 However, Matsusue and Thom-son34 consider the partial arthroscopic meniscectomy anacceptable method on patients older than 40, who donot have signs of damaged cartilage. They claim that,after 7- 8 years, 64% of their patients still indulge insport activities, without any limitations. Roulot et al.35

feel that medial meniscectomy on older patients gives

Chart 5. Statistical difference between the group that had degenerativechanges of the knee cartilage and the group that didn't have thosechanges at the time of the operation

Chart 6. Statistically significant between the group with intact LCA andthe group with ruptured LCA




satisfactory results only in cases of precisely estab-lished diagnosis, i.e. in case of traumatic lesion of medi-al meniscus, accompanied with pain.

Bonamo et al.36 in a 3 year control period, find thepartial meniscectomy with a limited debridman anacceptable method in a group of patients older than 40years, although the result is weaker on patients withdegenerative changes. We found that the results areweaker with patients that already had osteoarthroticchanges at the time of arthroscopic meniscectomy thanwith those that did not have these type of changes of theknee.37, 38

The advantages of arthroscopic meniscectomies areprimarily reflected in shortening of the rehabilitation peri-od and sooner return to everyday activities. We detect-ed that the postoperative rehabilitation period and thereturn to work very much depended on the type of workour patients performed. The return of athletes to theirtraining and competitions was quicker than that of otherpopulation, after partial meniscectomy in the avascularzone of the meniscus. Therefore, that procedure was amethod of choice to them,39 especially if there was nolesion of anterior cruciate ligament.

Based on test results obtained, the conclusions arefollowing:

Arthroscopic meniscectomy, as a method of treatingindividual and combined injuries of the meniscus,applied with local anaesthesia, has advantages overother methods of treatment.

This advantage is most obvious on athletes where, ifthere is no LCA injury, it is a method of choice.

The postoperative results are mainly influenced bysport activity (in terms of better results of athletes), pres-ence of degenerative knee changes, as well as simulta-neous injury of anterior cruciate ligament (negative influ-ence on a postoperative result).

There was no statistically significant influence onpostoperative result in regards to gender, localization oflesion on right or left knee and in regards to spread overof medial or lateral meniscus.

After partial meniscectomy, degenerative changes ofthe knee, as well as mediolateral instability are more fre-quent, when there is a presence of the varus-valgusdeformity of the knee.

The advantages of arthroscopic surgery of the kneeare in dramatically shorter period of hospitalization andperiod necessary for complete recovery and return toeveryday work and/or sport activities. This lessens, to agreat extent, the medical expenses, although there stillis a small risk of complications.

REFERENCES

1 Mikic Z et al. Uloga meniskusa u biomehanici kolena. U koljena -Primjenjena biomehanika. Pecina M, Ed. 47-56:, JugoslovenskaMedicinska naklada, Zagreb 1982.

2 Newman AP,Daniels AU, Burks RT, Principles and decision mak-ing in meniscal surgery. Arthroscopy. 1993. 9(1): p 33-51.

3 Fruensgaard S, Johannsen VH, Outpatient arthroscopy of theknee under local anesthesia. Int. Orthop., 1990. 14: p 37-40.

4 Sherman HO et al. Arthroscopy - "no problem surgery", J. BoneJoint Surg., 1986; 68-A: p 256-265.

5 St Pierre DM. Rehabilitation following arthroscopic meniscectomy.Sports-Med. 1995. 20(5): p 338-47.

6 Moffet H et al. Early and intensive physiotherapy acceleratesrecovery postarthroscopic meniscectomy: results of a randomizedcontrolled study. Arch. Phys. Med. Rehabil. 1994. 75(4): p 415-26.

7 Lyscholm J, Gillquist J. Evaluation of the ligament surgery resultswith special emphasis on use of scoring scale. A. J. Sports Med.1982. 10: p 150-154.

8 Johnson LL et al. Is it possible to make an accurate diagnosisbased only on a medical history? A pilot study on women's kneejoints. Arthroscopy. 1996. 12(6): p 709-714.

9 Hackenbruch W. Arthroscopy: possibilities and limitations in thediagnosis and therapy of meniscus lesions, Ther.Umsch. 1996.53(10): p 767-74.

10 Milankov M. Artroskopska dijagnostika. U Dijagnostika povreda.Somer T. i Avramov S. Ed 143-145. Visio Mundi-Academic Press,Novi Sad, 1993.

11 Lundin O et al. Analgesic Effects of Intra-articular Morphine Dur-ing and After Knee Arthroscopy: A Comparison of Two Methods.Arthroscopy, 1998. 2: p 192-196.

12 Wallace DA et al. Day case arthroscopy under local anaesthesia.Ann. R. Coll. Surg. Engl. 1994. 76(5): p 330-1.

13 Tsai L, Wredmark T. Arthroscopic surgery of the knee in localanaesthesia. An analysis of age-related pathology. Arch. Orthop.Trauma. Surg. 1993. 112(3): p 136-8.

14 Monzo E et al. Local anesthesia of the knee for arthroscopic sur-gery. Our experience in 1,000 cases. Rev Esp Anestesiol Reanim.1992. 39(5): p 312-5.

15 Ritt MJ et al. Popliteal pseudoaneurysm after arthroscopic menis-cectomy. A report of two cases. Clin Orthop. 1993. (295): p 198-200.

16 Dinh A et al. Arterial complications of arthroscopic meniscec-tomies. Apropos of three cases. Ann. Chir. 1993. 47(6): p 547-52.

17 Rodeo SA, Sobel M, Weiland AJ. Deep peroneal-nerve injury as aresult of arthroscopic meniscectomy. A case report and review ofthe literature.J. Bone Joint Surg. 1993. 75-A(8): p 1221-4.

18 Dandy JD. Arthroscopic management of the kneeChurchill Living-stone , Edinburgh London Melbourne and New York , 1987.

19 Rockborn P, Gillquist J. Outcome of arthroscopic meniscectomy. A13-year physical and radiographic follow-up of 43 patients under23 years of age.Acta Orthop. Scand. 1995. 66(2): p 113-7.

20 Jaureguito JW et al. The effects of arthroscopic partial lateralmeniscectomy in an otherwise normal knee: a retrospectivereview of functional, clinical, and radiographic results.Arthroscopy. 1995. 11(1): p 29-36.

21 Jaureguito JW et al. The effects of arthroscopic partial lateralmeniscectomy in an otherwise normal knee: a retrospectivereview of functional, clinical, and radiographic results.Arthroscopy. 1995. 11(1): p 29-36.

22 Boszotta H et al. Long - term results of arthroscopic meniscecto-my Aktuelle Traumatol. 1994. 24(1): p 30-4.

23 Bolano LE, Grana WA. Isolated arthroscopic partial meniscecto-my. Functional radiographic evaluation at five years. Am. J. SportsMed. 1993. 21(3): p 432-7.

24 Kwiatkowski K. Arthroscopic meniscectomy in anterior cruciate lig-ament deficient knees. Chir. Narzadow. Ruchu. Ortop. Pol. 1995.60(3): 205-9.



25 Neyret P, Donell ST, Dejour H. Results of partial meniscectomyrelated to the state of the anterior cruciate ligament. Review at 20to 35 years. J.Bone Joint Surg. 1993. 75-B(1): p 36-40.

26 Hazel Jr WA, Rand JA, Morrey BF. Results of meniscectomy in theknee with anterior cruciate ligament deficiency. Clin. Orthop. 1993.(292): p 232-8.

27 Thompson WO, Fu FH. The meniscus in the cruciate-deficientknee. Clin. Sports. Med. 1993. 12(4): p 771-96.

28 Schmitz MA, Rouse Jr LM, De Haven KE. The management ofmeniscal tears in the ACL-deficient knee. Clin. Sports. Med. 1996.15(3): p 573-93.

29 Roos H et al. Osteoarthritis of the knee after injury to the anteriorcruciate ligament or meniscus: the influence of time and age.Osteoarthritis Cartilage. 1995. 3(4): p 261-7.

30 Rangger C et al. Osteoarthritis after arthroscopic partial meniscec-tomy.Am. J. Sports Med. 1995. 23(2): p 240-4.

31 Muscolo D. Osteonecrosis of the knee following arthroscopicmeniscectomy in patients over 50-years old. Arthroscopy. 1996.12(3): p 273-9.

32 Covall DJ, Wasilewski SA. Roentgenographic changes afterarthroscopic meniscectomy: five-year follow-up in patients morethan 45 years old. Arthroscopy. 1992. 8(2): p 242-6.

33 Matsusue Y, Thomson NL. Arthroscopic partial medial meniscec-tomy in patients over 40 years old: a 5- to 11-year follow-up study.Arthroscopy. 1996. 12(1): p 39-44.

34 Roulot E et al. Arthroscopic internal meniscectomy in patients over55 years of age. Results over more than 4 years. Rev. Chir.Orthop. Reparatrice Appar Mot. 1992;78(3): p 164-8.

35 Bonamo JJ, Kessler KJ, Noah J. Arthroscopic meniscectomy inpatients over the age of 40. Am. J. Sports.Med. 1992. 20(4): p422-8.

36 Rangger C et al. Partial meniscectomy and osteoarthritis. Implica-tions for treatment of athletes. Sports Med. 1997. 23(1): p 61-8.

37 Schimmer R et al. Arthoscopic Partial Meniscectomy: A 12-yearFollow-up and Two-Step Evaluation of the Long-term Course.Arthroscopy 1998. 2: p 136-142.

38 Wheatley WB, Krome J, Martin DF. Rehabilitation programmes fol-lowing arthroscopic meniscectomy in athletes. Sports Med. 1996.21(6): p 447-56.




Clinical manifestations and etiopathogenetical background of mesentericlymphadenopathy in children

Authors:Dragan Ilic, Medical faculty, University of Nis, Serbia and Montenegro

Menthor:Borislav Kamenov MD PhD, Paediatric clinic, Medical faculty, University of Nis, Serbia and Montenegro


Aim. To evaluate the importance of enlarged mesenteric lymph nodes as an element of mucosal associated lymphoid tissue(MALT) activation, and its influence on haematopoietic, neuroendocrine, vascular, and other systems disorders.Methods. Examination included 36 children (20 boys and 16 girls), and control group included 12 children (7 boys and 5 girls).Results. Clinical manifestations were sore trough (66.7%), coughing (55.5%), persistent fever (33.3%), weakness (88.9%),anorexia (72.2%), abdominal pain (77.8%), diarrhoea (33.3%), joint pain (44.4%), muscle pain (44.4%), often head ache (61.1%).The children had enlarged mesenteric lymph nodes, identified by ultrasound: 10 - 15 mm in diameter (66.7%), and bigger than 15mm, (27.8%). ELIZA test shows that 72.2% of children were infected with HSV, 44.4% with HPV, and 44.4% with EBV, while inthe control group just 8.3% of children are infected with HSV. Majority of children had great number of preconceptic, perinatal andother risk factors for immune system disregulation. Immunological parameters showed the chronic stimulation of immune system,like increased level of IgG in 38.9% and significantly reduced nitro - blue - tetrazolium (NBT) test.Conclusion. Research fortifies that children with mesenteric lymphadenopathy are in great percent infected with: HSV, HPV, EBV,CMV and show sighs of chronic stimulation of immune system. Clinical manifestations are very heterogenic, involving dysfunctionof immune, haematopoietic, neuroendocrine, vascular and metabolic systems. Pathogenesis of these disorders is complex, prob-ably mediated by with altered oral tolerance, which leads to chronic inflammation.

Key words: clinical manifestations; mesenteric lymphadenopathy

Inflammation as the innate mechanism of protectionis in the basis of numerous processes of organism pro-tection from pathogens and destructing products of itsown tissue. In its basis are complex non-specific andspecific immune mechanisms of antigen processing,presentation and recognition. Processes, which consid-er engagement of specific response of immune system,are realized in the lymph nodes, which are appropriateplace with necessary micro - environmental conditionsfor proliferation and differentiation of lymphocytes.Because of it, finding enlarged lymph nodes point out on

activation of specific immunity. Therefore regionallyenlarged lymph nodes are very important clinical confir-mation of immune system activation.1, 2 Since the mostantigens enter organism through the mouth, processingof these antigens is important process, not only fordefence but also to induce immune tolerance on numer-ous antigens. Whatsoever, continuous inflammationmay lead to mucous membrane destruction, with gas-trointestinal (GIT) dysfunctions.2 Enlargement ofmesenteric lymph nodes, suggest on mucosal associat-ed lymphoid tissue (MALT) immune system activation.3Mesenteric lymph nodes except influence on toleranceof antigens taken by food during infection may lead tohypothalamic disorders, mediated by vagal afferenta-tion,4 which is important component of chronic inflam-matory response, leading to numerous disorders onblood vessels, central nervous system (CNS),haematopoiesis, metabolism etc.


The basic methodological approach is prospectiveanalysis of data taken from sick children, and their moth-ers, hospitalized on Paediatric clinic, Clinical centre Nis,SCG in period from 01. 10. 2003. to 15. 03. 2004. Studygroup consider 36 children (20 boys and 16 girls), sixmonths to fourteen years old.




Control group consider 12 healthy children (7 boysand 5 girls), the same age as study group.Heteroanaemnesis of mothers is taken for all the chil-dren in order to get information about main complains,other symptoms and signs, earlier diseases, risk factorschronic diseases of mother.

I. main complains: sore through, coughing, weak-ness, anorexia and etc.; II. other symptoms and signs:high temperature, vomiting, diarrhoea, joint pain,headache, abdominal pain; III. earlier diseases:rhinopharingitis, tonsilopharingitis, urinary tract infec-tions, anaemia, skin manifestations; IV. viral infections:HSV, HPV, CMV, EBV; V. preconcepting risk factors:treated infertility, miscarriage, and artificial abortion; VII.Prenatal risk factors: hormone therapy during the preg-nancy, anaemia, infections in pregnancy (respiratory,urogenital, HSV etc.), high blood pressure and legsoedema. VIII. perinatal risk factors: premature birth,adaptation disorders, child reanimation, low and highbirth weight, jaundice, convulsions, early infections inthe first month, (umbilical cord infection, bronchopneu-monia etc.); IX: maternal chronic diseases: labial HSV,condiloma, veruccae (HPV), headache, anaemia, aller-gies, autoimmune disorders, lymphadenopathy, gynae-cological problems etc.; X: clinical examination: bodytemperature measurement, lymphonodal palpation,enlarged mesenteric lymph nodes detection, liver orspleen size, inspection of visible mucosal membranesand skin etc. XI: haematological examination: red bloodcells, lymphocytes, platelets, and haemoglobin level.XII: biochemical examinations: activity of enzymes(AST, ALT, CPK, and LDH) was determined as well CRP.XIII. immunological examinations: the level of immunecomplexes (IC), immunoglobulines (IgA, IgG, and IgM)

and oxidative metabolism of phagocytes by the meansof NBT test.

All the results were evaluated by student's T-test.Computer program Microsoft Excel 7.0 for Windows wasused for presentation of results in tables.

RESULTS

The percentages of the main complains among thepatients are shown in Table 1. However, by the detailanamnesis and clinical examination it is confirmed thatpatients had other complaints also (Table 1). All the chil-dren had highly expressed vascular drawings on theskin, especially on the face, neck and on the back.(Table 1).

Ultrasound examination showed that the most of thechildren had lymph nodes from 10 to 15 mm in diameter(66.7%) and bigger (27.8%).

Earlier clinical manifestations (Table 2): rhinopharingi-tis had 88.9% of examined children while in the controlgroup just 16.6%; tonsilopharingitis had 88.9% ofpatients and even 94.4% of children had earlier vasculi-tis or other manifestations on the skin.

By ELISA test it is proved that 72.2% of the childrenwere infected with HSV, 44.4% with HPV, 44.4% withEBV, while in the control group just 8.3% of children areHSV infected.

Preconceptic and perinatal risk factors results areshown in table 3. Even (83.3%) of the children in studygroup had high birth weight.

Labial HSV infection had (55.5%) of mothers and clin-ical manifestations (for HPV), veruccae, condiloma44.4%. Maternal chronic diseases are shown in Table 4.




Analyzing mean values of WBC count no statisticallysignificant differences were found, even though 66.7%of children had leucocytosis, 33.3% monocytosis, and50% granulocytosis comparing to the control group.(Table 5.)

Mean values of enzymes activity (AST, ALT, CPK,LDH) show no statistically significant differences com-paring to the control group. Even though 33.3% of thechildren had increased AST, ALT, and LDH. (Table 6.)

Mean values of IC, IgA, IgG and IgM, in the studygroup were not statistically significant comparing to thecontrol group. What so ever, it is found that fourteen chil-dren (38.9%) had increased IgG level. (Table 7.) Stimu-lated oxidative burst of the peripheral blood phagocytes(PBP) by phorbol - miristate - acetate (PMA) in the studygroup is significantly reduced comparing to the controlgroup. (Table 7.)

DISCUSSION

All the children in the study group show signs ofchronic inflammation and serologic evidence of (HSV,HPV, EBV, and CMV) - infection, with multi - systemmanifestations. Chronic inflammation influencesimmune system functions, neuroendocrine regulation,metabolism, haematopoiesis, blood vessels, increasingthe risk for chronic inflammatory diseases and malig-nancy development. It is very important to point out the

significance of MALT - activation, because of its poten-tial to influence on oral tolerance and on inflammationcontrol. Enlarged mesenteric lymph nodes, may suggestMALT activation, with possible consequences on numer-ous clinical manifestations, besides abdominal pain orappendix inflammation.5, 6

Throughout life, one encounters a multitude of anti-gens and pathogens that threaten his health and sur-vival. To fend off this antigenic insult, the immune sys-tem evolved to include lymphocytes with a parallel diver-sity of receptor specificities. During an antigenicencounter, T-and B-lymphocytes undergo a proliferativeburst that causes the expansion of a few clonotypesspecific for the antigen. This response elicits a cascadeof events that ultimately leads to the elimination of theinciting antigen. Following resolution of the immuneresponse, the majority of these antigen-specific lympho-cyte clones undergo apoptosis, but a small number areconverted to memory cells specifically armed for futureantigenic encounters. In essence, these well-orchestrat-ed wives of oligoclonal expansion followed by apoptosisdetermine the efficiency of the immune system.7

In many chronic inflammatory and infectious dis-eases, however, persistent immune activation acceler-ates the replicative senescence of T- and B-lympho-cytes. As do all somatic cells, lymphocytes have a limit-ed proliferative capacity, such that repeated antigenicstimulation during chronic inflammation and persistentinfection usually results in the accumulation of senes-cent lymphocytes. It may be proposed that prematurereplicative senescence of T cells underlies many of theimmune abnormalities associated with chronic disease.Patients with inflammatory syndromes and chronicinfections have high frequencies of functionally aber-rant, senescent T cells provide compelling evidence foran important role of premature immunosenescence indisease pathogenesis. Many of the chronic diseases arecharacterized by the accumulation of oligoclonal T cells.Oligoclonal T cells are found at the site of inflammation,but they can also pervade the peripheral circulation,resulting in global restriction of the T-cell repertoirebecause their high frequencies mask cells with rarerTCR specificities. Typical examples of inflammatorysyndromes with restricted immune repertoire areautoimmune diseases.2, 7

Persistent infections: viral, bacterial or parasitic, arealso associated with T-cell oligoclonality. In these cases,the antigenic specificities of the expanded T-cell clonesare generally directed against various epitopes on the




pathogen.1, 8 Great percent of children in study grouphad viral infection. Even 72.2% is infected with HSV, andwith HPV and EBV 44.4%.

Oligoclonally expanded T cells can persist for yearsand accumulate to such an extent that the T-cell reper-toire becomes severely contracted. Expanded T-cellclones compete for growth factors and space, so muchso that large clonal populations could impede the activa-tion and growth of naive T cells. Therefore, contractionof the repertoire is an important determinant for theincreased susceptibility of patients to infection.1, 7

The majority of research on T cells has focused onCD4+ cells, for which work has concentrated on theroles of PGE2 in the modulation of proliferation, apopto-sis and cytokine production. During mucosal inflamma-tion, for example, mucosal T cells up-regulate theirexpression of certain EP receptors, and there is a result-ing decrease in the T-cell production of IL-2. The effectsof PGE2 on the apoptosis of T cells are dependent onthe maturation and activation state of the cell.9

PGE2 plays an important role in the development andactivity of B cells. In contrast to its effects on mature Bcells, PGE2 acts in an inhibitory manner on immatureand developing B cells. For example, PGE2 suppressesthe proliferation of immature B cells, but has no effecton, or even sometimes enhances, the proliferation ofmature B cells.9

Growth and development of the embryo and foetus inthe antigen "privileged" environment and Th2 responsepredominance of mother's immune system are neces-sary for appropriate development of the immune system(prevention of clonal abortion anergy, apoptosis) as wellas for the development of other organs and tissues.Cytokines of Th1 response, oxygen free radicals andnitrites with their potential to influence gene expressionmay seriously interfere with cell proliferation, differentia-tion, apoptosis and migration.10, 11 Many acute viralinfections are known to cause death of the embryo orserious anomalies. Altered cytokine profile and microen-vironment during prenatal development because ofacute infection or chronic disease of mother are possi-ble factors for the immune system dysfunction andchronic diseases development in childhood.11, 12 All thechildren in the study group have few or many risk factorsfor development disorders and immune system deregu-lation. 44.4% of mothers had one or more artificial abor-tion before gave birth to the current child, as well 44.4%had hormone treatment during the pregnancy. Thesedata are important, because during the pregnancy moth-er is direct carrier of immune activity, what for she has agreat influence on child's immune system developmentduring the antigen non-dependent faze of its forming.10,12 83.3% of children had high birth weight as a conse-quence of insulin receptor up-regulation and insulin likecytokine effects on the cell.10

The onset and duration of the immunologic respons-es were found to be dependent on the timing of antigenexposure. Prenatal exposure to antigen facilitated the

induction of oral tolerance to β-lactoglobulin, whereasdelayed antigen exposure retarded tolerance. Theinduction of oral tolerance was associated withincreased IL-4 and/or IL-10 production and decreasedIL-12 production.10

The primary factor determining which form of toler-ance will be developed after oral administration of Ag isthe Ag dosage. Thus, it is thought that low doses of anti-gen induce the generation of active suppression, viaregulatory T cells in the GALT, which then migrate to thesystemic immune system. These regulatory T cells pro-duce down-regulatory cytokines such as IL4, IL10 andTGFβ, a Th2 / Th3 cytokine pattern. Conversely, highdose of antigen favours anergy or clonal deletion. Thephenomenon in which regulatory cells, as generated byoral toleration, are primed in an antigen specific manner,but act in the respective microenvironment in a non-anti-gen specific manner is called bystander suppression.This phenomenon is of particular interest and explainedthe use of oral tolerance in T cell mediated autoimmunediseases such as rheumatoid arthritis, multiple sclerosisand type I diabetes, and some diseases in which theautoantigens remains unknown or where there are reac-tivities to multiple autoantigens. There were severalstudies demonstrating the effectiveness of orally admin-istered antigen in different animal models of autoim-mune diseases, such as experimental allergicencephalomyelitis, collagen induced arthritis, diabetes,but also uveitis, myasthenia gravis and transplantation.Inflammatory processes on mucous membranes fol-lowed by enlarged regional lymph nodes may lead tomucous tolerance break down and initiation of chronicinflammation.13, 14 Activated immune system of the gas-trointestinal mucous membranes followed by enlargedlymph nodes may change hypothalamic functions medi-ated by vagal afferentation, trough endocrine, metabolicdisorders may lead to chronic inflammation.12

Reduced values of stimulated NBT test of PBP, pointsout on down regulation of oxidative metabolism andturning on "feed back" mechanisms that may have pro-tective role from over production of oxidative products.11

As well, increased values of IgG in 38.9% prove chron-ic stimulation of immune system.

Based upon our evaluation, the conclusions that canbe drawn are that children with mesenteric lym-phadenopathy are in great percent infected with HSV,HPV, CMV, EBV and show signs of chronic stimulationof immune system. Clinical manifestations are very het-erogenic, involving dysfunctions of many systems:immune, haematopoietic, neuroendocrine, vascular andmetabolic. Pathogenesis of these disorders is complex,probably mediated by altered oral tolerance, whichleads to chronic inflammation.

ACKNOWLEDGMENTS

Sonja Tasic MD (ultrasound)




REFERENCES

1 Kamenov B. Imunske osnove inflamacije. Pedijarijska skola SCG.Herceg novi. 2004.

2 Kamenov B. Imunske osnove odgovora mukoze na infekciju i nje-gov znacaj na tok, prognozu i komplikacije bolesti. Zbornik rado-va. Jugoslovenski pedijatrijski dani. Nis. 2001.

3 De Boer WA, Maas AM, Tytgat GN. Disappearance of mesentericlymphadenopathy with gluten-free diet in celiac sprue. J Clin Gas-troenterol. 1993. 16: p 317-9.

4 Santoni JR, Santoni - Williams CJ: Headache and painful lym-phadenopathy in extracranial or systemic infection: etiology ofnew daily persistent headaches. J Intern Med 1993. 32: p 530-2.

5 Vayner N, Coret A, Polliack G, Weiss B, Hertz M. Mesenteric lym-phadenopathy in children examined by US for chronic and/orrecurrent abdominal pain. J Pediatr Radiol. 2003. 33: p 864-7.

6 Watanabe M et al. Evaluation of abdominal lymphadenopathy inchildren by ultrasonography. J Pediatr Radiol 1997. 27: p 860-4.

7 Vallejo A, Weyand C, Goronzy J. T-cell senescence: a culprit ofimmune abnormalities in chronic inflamation and persistant infec-tion. Trends Molec Med. 2004. 10 (3): p 119-22.

8 Karre K. Express yourself or die: peptides, MHC molecules, andNK cells. Science 1995. 267: p 675-78.

9 Harris S, Padilla J, Koumas L, Ray D, Philips R. Prostaglandins asmodulators of immunity. Trends Immunol. 2002. 23 (3): p 144-50.

10 Bubanovic I, Kamenov B, Najman S. Imunobioloske osnove trud-noce. Mrljes. Beograd 2001.

11 Kamenov B, Dimitrijevic H, Tasic G, Pljaskic S. Chronic diseasesin childhood as a consequence of immune system disfunction ofmother during pregnancy. Facta Universitatis, Medicine and Biol-ogy 1999. 6 (1): p 97-102.

12 Kamenov B. Disregulacija imunskog sistema majke u trudnoci ipojava hronicnih bolesti u detinjstvu. Kongres perinatalne medi-cine. 1997. 4: p 84-86.

13 Mazelin L, Theodorou V, More J, Bueno L. Protective role of vagalafferents in experimentally induced colitis. J Autonomic NervousSys. 1998. 73: p 38-45.

14 Li P, Huang H, Liang J. Neourophysiological effects of recurentlaryngeal and thoracic vagus nerves an mediating the neurogenicinfalmmation of the trachea, bronchi, and esophagus of rats. 2001.88: p 142-50.




Tuberculosis is an infectious disease caused by thebacterium Mycobacterium tuberculosis (slightly curved,sporeless, motile, obligate aerobic, Gram - positive bac-terium) which affects one third of all humans. It appearsin highly variable clinical manifestations. Cutaneoustuberculosis (CT) is a label for a wide group of skinlesions. It is rare, and yet a form of the disease that is ofspecial interest to tuberculosis experts and dermatolo-gists as well. This comes as a consequence of the fact,that CT most often manifests itself after previous andeven more serious ongoing persistence of systemictuberculosis (ST) in the affected organism. This is thereason why the incidence of isolated CT patients usual-ly correlates with the incidence of isolated ST patients,during the period in question. In addition, the rate ofoccurrence of CT should be taken as an indicator of thesocial, economic and even political circumstances gov-

erning the region. The two hypotheses mentionedabove, provide guidance in our field of interest andresearch.


In this study we used methods for standardized diag-nosis protocol for CT such as: 1. Specific clinical mani-festations of the skin lesions (e.g. presence of applejelly-colored dermal infiltrates); 2. Recovery and identifi-cation of the organisms by bacterial culture; 3. Demon-stration of the presence of M. tuberculosis via PCRassays for specific DNA sequences; 4. Finally, compati-ble histopathology consisting of granulomatous infil-trates with caseation necrosis and the presence of acid-fast bacilli in the tissue sections were both suggestive,and were by no means pathognomonic of tuberculosis.

Cutaneous tuberculosis in R. Macedonia during the period 1997 - 2003

Authors:Biljana Gjoneska, Faculty of medicine, "Sts. Cyril and Methodius" University, Skopje, Macedonia

Menthor:Ass. Dr. Lidija Goleva-Mishevska, Department of Dermatovenerology, Faculty of Medicine, "Sts. Cyril and Methodius" University,

Skopje, Macedonia


Aim. To study the relationship between cutaneous and systemic tuberculosis, and their correlation with war and postwar activi-ties. A quantitative analysis of the documented number of CT and ST cases during the period 1997 - 2003 on the territory of R.Macedonia, and their respective growth as a consequence of the war and postwar activities.Methods. During the course of this project we obtained data from official medical records from the "Clinic for Dermatovenerolo-gy" and the "Institute for tuberculosis and lung diseases" in Skopje, Macedonia. We used methods for standardized diagnosis pro-tocol for CT.Results. In the period between January and December 2002, there were 12 documented cases of CT (1.64% of the 730 docu-mented cases of ST). This is a six-fold increase from the number of documented occurrences of CT during the period between1997 and 2001 (average of 0.30% from the 650 documented occurrences with ST). Conclusion. There is a need of additional medical check-ups and tuberculosis tests on the territory of R. Macedonia in order todiscover all undocumented cases of ST. This is vital ingredient in the process of controlling and eradicating this infectious disease.

Key words: cutaneous tuberculosis; systemic tuberculosis; war; crisis regions; R. Macedonia; 1997-2003

Figure 1. Six-fold increase from the number of documented occurrencesof CT during the period between 1997 and 2001 (average of 0.30% fromthe 650 documented occurrences with ST)

Figure 2. The significant increase in the number of CT patients asopposed to the marginal increase in the total number of ST patientsfollowed in the period between 1997 and 2002




During the course of this project we obtained data fromofficial medical records from the "Clinic for Dermatoven-erology" and the "Institute for Tuberculosis and LungDiseases" in Skopje, Macedonia. The overall number ofregistered patients with CT and ST concerning each ofthe years in the period between 1997 and 2002, can beseen in Table 1.

RESULTS

During the period between January and December2002, there were 12 documented cases of CT (1.64% ofthe 730 documented cases of ST). This is a six-foldincrease from the number of documented occurrencesof CT during the period between 1997 and 2001 (aver-age of 0.30% from the 650 documented occurrenceswith ST), as seen in Figure 1.

The significant increase in the number of CT patientsas opposed to the marginal increase in the total numberof ST patients followed in the period between 1997 and2002 is shown in Figure 2.

The significant increase in the number of CT patientsas opposed to the marginal increase in the total numberof ST patients followed in the period between 1997 and2002 is shown in Figure 2.

Out of the 730 documented cases for year 2002, 646were previously registered, and 84 were new cases.Figure 3 shows that 14.3% of the newly documentedcases were patients diagonsed with Cutaneous Tuber-culosis.

Out of the twelve documented cases with CT, 10(83.3%) originated in crisis region (i.e. northwestern partof R. Macedonia), as seen on Figure 4.

Figure 5 shows a comparison between the number ofnewly registered cases with Cutaneous Tuberculosisand the total number of newly registered cases duringthe two relevant periods (year 2002 as compared to theperiond between 1997 and 2001).

RELEVANT CASE STUDIES FROM OUR CLINIC

Picture 1: A 12-year-oldfemale patient with postvaccinal BCG infection(Besegitis Colliquativa.)Clinical manifestationlocalized in the left shoul-der area occurred onemonth after inoculation.Unilateral indolent, firm,non-tender, sharply-delim-ited ulcer, colliquation andnecrosis. Scrofulodermais evident as well.

Pictures 2 and 3: A26 year old Albanianfemale patient withTuberculosis colli-quativa ulcerogum-mosa haematogeneset exogenes. Skinlesions became visi-ble two years prior tohospitalization.

Picture 2: Skin lesion in initialstage - indurated, subcuta-neous, cold and livid nodule,localized on the chin.

Picture 3: Skin lesion in theterminal stage - multiple, colli-quative abscess that perforatesthe skin in the distal regions ofthe lower extremities.

Figure 3. Out of the 730 documented cases for year 2002, 646 werepreviously registered, and 84 were new cases.

Figure 4. Out of the twelve documented cases with CT, 10 (83.3%)originated in crisis region (northwestern region)

Figure 5. comparison between the number of newly registered caseswith Cutaneous Tuberculosis and the total number of newly registeredcases during the two relevant periods




Pictures 4 and 5: A 40-year-old male patient diag-nosed with Tuberculosis luposa sutis (Lupus vulgaris)with sequels of Tuberculosis colliquative cutis.

Picture 4: Plaqueswith a psoriatic scale,atrophy and polycyclicsquamous configura-tions are evident on thephotography.

Picture 5: Sequelsof Tuberculosis colli-quativa cutis aremanifested thrughirreversible, cica-trized, contractile,thick skin lesions inthe abdominal region.

Picture 6: A female patient inher forties with a pasty constitu-tion (typus rusticus.) - Erythemainduratum (Bazin) - typicalform.

Picture 7: The photographpresents obvious skin alter-ations that are localized in thepretibial areas characterized byerythematous, nodular, indura-tive, painless vascular lesions.A 37 years old female Albanian

patient with pretibial areascharacterized by erythema-tous, nodular, indurative,painless Tuberculosis papu-lonecrotica (scrofuloderma).

Picture 8: An older womanwith TBC colliquativa andscleromyxoedema (MorbusArndt - Gottron). TBC lesionsare localized on the neck of

the patient. On thephotograph, we cansee fistulous colliqua-tive abscesses anddeep contractive scar-rings. TBC +Scleromyxoedema areevident on the samephotograph.

DISCUSSION

In the months between January and December 2002,we noted a rapid increase in the number of CT occur-rences opposed to a mild increase in the number of SToccurrences, in the crisis regions as well as other partsof the country. Having in mind that a rapid increase inCT should be accompanied by a rapid increase in ST(instead of a mild one), we hypothesized that there areother, undocumented cases of ST (more specifically, inthe war afflicted regions where the increase in the num-ber of CT occurrences has been most notable).

There is a need of additional medical check-ups andtuberculosis tests on the territory of R. Macedonia inorder to discover all undocumented cases of ST. This isvital ingredient in the process of controlling and eradi-cating this infectious disease.

REFERENCES

1 Starova AU, V'lchkova - Lashkoska MT. Clinical Dermatology.Skopje. HIB Dresko; 2000. p 229-234.

2 Barret TL, Steger JW. Military Dermatology. p 355-389.3 Gracey DR. Tuberculosis in the world today in Mayo Clin. 1988. p

63:1251-1255.4 Saxe N. Mycobacterial skin infections in J. Cutan. Pathol 1985. p

12;300-312.




Gastrointestinal symptoms are common in the gener-al population. In the most of cases those symptoms areresult of functional disorders among which IrritableBowel Syndrome (IBS) is the most important. Approxi-mately 20% of people in Western countries suffer fromIBS symptoms.1, 2 Although only 10% of subjects withdiagnosable IBS consult a doctor those patients presentcommon pathology not only in general practitioner's butalso in gastroenterologist's everyday practice.2, 3, 4

IBS is chronic, functional gastrointestinal disorder,with unknown aetiology and higher prevalence infemales.5, 6 The most frequent symptoms that IBSpatients complain of are: abdominal pain, diarrhoea,

constipation, gas, bloating, mucus in the stool, a feelingof incomplete evacuation after bowel movement. Thesubjective nature of IBS symptoms, the enormous vari-ation even within each symptom and lack of diagnosticmarker associated with this disorder, make diagnosismore complicated. A large portion of IBS patients alsocomplain of other functional disorders such as dyspep-sia, heartburn, dysuria, dyspareunia, fibromyalgia,chronic fatigue syndrome.4, 6, 7, 8 Higher prevalence ofpsychiatry disorders is estimated in patients that sufferfrom IBS.9, 10

Since there is no physical or structural abnormalitythe diagnosis of IBS is based on duration of symptoms,

Symptoms of gastrointestinal functional disorders in student population

Author:Melita Nesic, Faculty of medicine, University of Novi Sad, Serbia and Montenegro

Menthors:Zoran Mrdja MD PhD, Gastroenterology and hepathology Department, Faculty of medicine, University of Novi Sad, Serbia and

MontenegroDusan Slankamenac MD


Aim. To examine a frequency of gastrointestinal functional disorder's symptoms, divide the students with IBS symptoms using theRome II criteria and to analyze association between IBS symptoms and symptoms of other gastrointestinal functional diseases.Material and methods. The presence of gastrointestinal symptoms was studied in 215 medical students, 144 females and 71males at Medical Faculty in Novi Sad. The most common gastrointestinal symptoms were investigated by using questionnaire.Gastrointestinal symptoms including the Rome criteria for Irritable Bowel Syndrome (IBS) and dyspepsia were measured. Asso-ciation between IBS symptoms and symptoms of other gastrointestinal functional disorders has been analyzed. We have exam-ined the manner of managing those disorders. Statistical importance has been evaluated by χ2 test.Results. 78.5% of students have at least one gastrointestinal symptom. Females, statistically important (p < 0.05), have consti-pation more frequently then males. The main symptom in males is heartburn. Symptoms of upper gastrointestinal disorders arepresent in 43.2% of population and symptoms of lower gastrointestinal disorders in 67.8%. 24.2% of examined population has acluster of symptoms characteristic for IBS, but only 8 females fulfil the Rome criteria. The others have typical symptoms that lastless than 12 weeks in one year. Diarrhoea predominant IBS is common in males. Constipation predominant and combined diar-rhoea-constipation IBS subtypes are more common in females. There is considerable (p < 0.01) overlap of IBS and symptoms ofupper gastrointestinal functional disorders regardless of sex. Only 7.7% of students seek advice from the doctor. 25% of them useself-help treatment to control the symptoms.Conclusion. Prevalence of gastrointestinal symptoms among university students is over- expected. People with gastrointestinalfunctional disorders rarely seek for doctor help. Therapeutic respond often fails. Common overlap in functional disorders is of greatimportance in planning further examinations.

Key words: gastrointestinal system; functional disorders; irritable bowel syndrome; Rome II criteria

Figure 1. Prevalence of measured gastrointestinal symptomsFigure 2. Prevalence of measured gastrointestinal symptoms in malesand females




clinical presentation and by excluding other diseaseswhich may have a similar presentation.4, 11, 12

High prevalence, pure therapeutic response, exag-gerated fear of having cancer in some patients andoccasional needs for expensive diagnostic work-upscontribute in presenting this disorder as a big social andeconomic problem.4, 5, 13 In order to make diagnosing ofIBS easer and to avoid expensive diagnostic proceduresthere have been proposed a several diagnostic criteria:Manning, Kruise, Rome I, Rome II. None of the criteriais 100% sensitive or specific for IBS but are useful forresearch and can help guide the diagnostic evaluation.

Functional disorders of oesophagus, stomach andduodenum are also common. According to some statis-tics between 7% and 41% of adult population has atleast one of the symptoms of these disorders.1, 4, 8

The pathophysiology of gastrointestinal functionaldisorders is complex and overlapping between differentdisorders symptoms is frequent.14

Due to unavailability of any data of large epidemiolog-ic research in our country we decided to examine forprevalence and subjective appearance of gastrointesti-nal symptoms in a part of student's population at theMedical Faculty in Novi Sad.


215 students, 144 female and 71 male, attending theFaculty of Medicine in Novi Sad have been screened.They have been given questionnaire that was speciallymade for this purpose. Sample was homogeneous,selected randomly and representative.

Gastrointestinal symptoms including the Rome crite-ria for IBS and dyspepsia were measured. The diagnos-tic criteria for IBS specify that for least 12 weeks in thepast 12 months, a patient experienced abdominal dis-comfort or pain with two of the following characteristics:1) abdominal discomfort or pain relieved with defeca-tion; 2) onset associated with a change in the form orappearance of stool.

The following symptoms cumulatively support thediagnosis of IBS: 1) abnormal stool frequency (> 3/dayor < 3/week); 2) abnormal stool form (lumpy/hard orloose/watery stool); 3) abnormal stool passage (strain-ing, urgency or feeling of incomplete evacuation); 4)passage of mucus; 5) bloating or feeling of abdominaldistension.

Presence of alarm symptoms suggests an organicdisease rather than a functional disorder. These symp-toms include fever, weight loss, anorexia, nocturnalsymptoms, gastrointestinal bleeding, anaemia, andpresence of an abdominal mass. Symptoms of othergastrointestinal disorders which have been measuredare also defined by Rome II criteria. According to ques-tionnaire a frequency of some gastrointestinal symp-toms were measured and compared between genders.Grope that has IBS symptoms has been divided. The

Figure 3. Frequency of the most common gastrointestinal symptoms

Figure 4. Frequency of measured gastrointestinal symptoms in malesand females

Figure 6. Frequency of symptoms of lower gastrointestinal functionaldisorders in examined population

Figure 5. Frequency of symptoms of upper gastrointestinal functionaldisorders in examined population

Figure 7. Frequency of IBS symptoms among genders.




most common symptoms in this grope have been ana-lyzed and its connection with sex and symptoms of othergastrointestinal disorders. We also have analyzed amanner in management of these symptoms. The dataare statistically evaluated, results are graphically pre-sented and statistic importance is measured by χ2 test.

RESULTS

78.2 % of examined students have at least one of themeasured symptoms that are characteristic of gastroin-testinal disorders (Figure 1).

The symptoms are more common in males but differ-ence is not statistically important (Figure 2).

The most common symptoms are: bloating or feelingthe abdominal distension (53%), constipation (32%),diarrhoea (22,3%) and heartburn (21,8%) (Figure 3).

Statistically important (p < 0.05) constipation is morefrequent in females and heartburn in males. Results aregraphically presented in Figure 4.

67.8% of examined students had symptoms of lowergastrointestinal disorders and 43.2% of examined stu-

dents had symptoms of upper gastrointestinal function-al disorders (Figures 5 and 6).

24.2% (61 students) of examined population has acluster of symptoms characteristic for IBS, but only 8females fulfil the Rome criteria. The others have typicalsymptoms that last less than 12 weeks in one year (Fig-ure 7).

Diarrhoea - predominant IBS is common in males.Constipation - predominant and combined diarrhoea -constipation IBS subtypes are more common in females(Figure 8).

There is considerable (p < 0.01) overlap of IBS andsymptoms of upper gastrointestinal functional disordersregardless of gender (Figure 9).

Only 7.7% of students with gastrointestinal symptomsasked for doctor's help. Therapy they were given bydoctor was not successful in the most of cases. 25% ofmedical students we examined use complementary andalternative medicine (tea) to relieve their symptoms.

DISCUSSION

The presented results are similar to those we found inliterature: gastrointestinal symptoms are common inadult population. There is overlap between symptoms ofupper and lower gastrointestinal functional disorders.Patients with functional disorders are much more likelyto seek complementary and alternative medical care.

The prevalence of gastrointestinal symptoms (78%)is higher than expected due to age of examined popula-tion (19-26 years old). Symptoms are widespreadregardless to gender but the types of main symptomsare different.

Many of exogenous factors may provoke some ofthose symptoms: life-stile, bad habits, lack of physicalactivity, infection. We shouldn't forget the role ofendogenous factors that affect visceral sensitivity and

Figure 8. Frequency of constipation and diarrhoea in students with IBScluster symptoms.

Figure 9. Prevalence of dyspepsia and heartburn in screened population with IBS symptoms




motility. Sex hormones may aggravate and prolonglower gastrointestinal symptoms in females. Is there anyconnection between those hormones and particulartypes of symptoms that are more common in females?

The real cause responsible for different functional dis-orders overlap is still unknown. There is a need for exactexplanation of pathophysiological mechanisms in orderto improve symptoms treatment. Functional disorderspresent an unexamined field of medicine despite ofmany experiments and examinations. Great numbers ofsuspected factors, polysymptomatology, complex patho-physiological mechanisms need participation not only ofgastroenterologist but of other scientist in order toresolve the problem of these common disorders.

Therefore, we can conclude that the symptoms ofgastrointestinal functional disorders are common in stu-dent population, frequency higher than expected andrequires further investigations in order to understand acause. People with gastrointestinal functional disordersrarely seek for doctor help and if they do it therapeuticrespond fails. Common overlap in functional disorders isof great importance in planning further examinations ifpatients decide to consult a doctor.

REFERENCES

1 Thompson WG, Heaton KW. Functional bowel disorders in appar-ently healthy people. Gastroenterology. 1980. 79: p 283-288.

2 Camilleri M, Choi MG. Review article: Irritable Bowel Syndrome.Aliment Pharmacol Ther. 1997. 11: p 3-15.

3 Collins SM, Azpiroz F, Coremans G, Molteni P. The Irritable BowelSyndrome Manual. 1999. Mosby International Ltd.

4 Manning AP, Thompson WG, Heaton KW, Morris AF. Towards apositive diagnosis of the irritable bowel. Br Med J 1978. 2 : 653-4.

5 Sandler RS. Epidemiology of irritable bowel syndrome in the Unit-ed States. Gastroenterology 1984. 87:314-318.

6 Hogston P. Irritable bowel syndrome as a cause of chronic pain inwomen attending a gynaecological clinic. BMJ. 1987. 92: p 954-959.

7 Whorwell PJ, McCallum M, Creed FH, Roberts CT. Non colonicfeatures of irritable bowel syndrome. Gut. 1986. 27: p 37-40.

8 Agreus L, Svardsudd K, Nyren O, Tibblin G. Irritable Bowel Syn-drome and Dyspepsia in general population: overlap and lack ofstability over time. Gastroenterology. 1995. 109: p 671-80.

9 Ford MJ, Miller PM, Eastwood J, Eastwood MA. Life events, psy-chiatric illness and the IBS. Gut 1987. 28: p 160-5.

10 Olden KW, Drossman DA. Psychologic and psychiatric aspects ofgastrointestinal disease. Med Clin North AM 2000. 42: p 835-40.

11 Holten KB, Wetherington A, Bankston L. Diagnosing the patientwith abdominal pain and altered bowel habits: Is it Irritable BowelSyndrome? AFP 2003. 67, 10.

12 Manojlovic B. Interna medicina. Zavod za udzbenike i nastavnasredstva. Beograd. 2000. p 678-684.

13 Holmes IM, Salter RH. Irritable bowel syndrome - a 5 yearsprospective study. Lancet. 1987. p 963-965.

14 Talley NJ, Boyce P, Jones M. Identification of distinct upper andlower gastrointestinal symptom groupings in an urban population.Gut. 1998. 41: p 394-398.




Preeclampsia has been associated with cardiovascu-lar events, namely hypertension, ischemic heart diseaseand stroke, but still the pathogenesis and the long termconsequences are needed to be studied further.

Preeclampsia is one of the most mysterious diseasesin the field of obstetrics. It is described as a "disease oftheories". Nowadays, the widely supported theory is thereduced placental perfusion primarily due to abnormali-ties in implantation and vascular changes which aresecondary to maternal genetic susceptibility andimmune maladaptation. Clinically, it refers to the newonset of hypertension and proteinuria after 20 weeks ofgestation in a previously normotensive woman. Depend-ing on different factors, preeclampsia has some seriousas well as debatable long - term implications, whichhave been under comprehensive investigation lately.

Preeclampsia is a recurring disease, primarily of firstpregnancies. It has been found over three times morecommon in women with a previous history of diseasethan in nulliparas.1 However, the long-term prognosisvaries with the severity of the acute episode, as well asthe occurrence time in pregnancy. Mild preeclampsia inprimigravidas is generally self-limited and has a low inci-dence of recurrence, whereas severe preeclampsia cre-ates a high risk for recurrence and late hypertension.2, 3

Generally, the earlier it occurs during the index pregnan-cy, the greater the likelihood of recurrence.

Another important implication is the relationbetween preeclampsia and cardiovascular dis-ease. According to both Current Obstetricsand Gynaecology (2003) and Williams Obstet-rics (2001), preeclampsia does not causechronic hypertension. Despite this statement,the effect of preeclampsia on subsequentdevelopment of chronic hypertension andother cardiovascular diseases such asischemic heart disease is still debatable.Women, who had preeclampsia, have beenfound to be more prone to hypertensive com-plications in their future pregnancies. TheChesley follow-up study found that womenwith severe preeclampsia in only their firstpregnancy did not have an increased risk oflate hypertension, on the other hand, women

with preeclampsia in later pregnancies had increasedrisk of hypertension.4 It should also be noted that thesewomen may have an inherited thrombophilia, unrecog-nized latent hypertension, or other genetic or environ-mental factor predisposing to hypertension during andafter the pregnancy.

It has also been found that women who hadpreeclampsia are more likely to develop ischemic heartdisease later in life.5 These findings bring up the ques-tion of whether the same predisposing factors for cardio-vascular diseases that become more evident in later life,also predispose to preeclampsia. When the underlyingrisk factors are closely observed for both pathologies,common denominators like dyslipidemia, insulin resist-ance, and blunted endothelial relaxation are pointed outin some studies.6, 7, 8 Also endothelial injury supportedby the oxidative stress is another theory which has beensupported by the latest research and which can beanother common cause, considering the oxidationhypothesis of atherosclerosis.

A review of over 626,000 first deliveries in Norway,reported women with preeclampsia and preterm deliverywere at increased risk of death from cardiovascular dis-ease compared to preeclamptics and nonpreeclampticswho delivered at term, and also nonpreeclamptics whodelivered preterm (relative hazard rates 8.12, 1.65 and2.95 respectively).9 This study suggests that the causesmay be different for early and late onset preeclampsia,

in preterm deliveries.

HELLP syndrome, a significant risk formaternal mortality, is characterized by haemol-ysis, elevated liver enzymes and low platelets.It typically occurs in white multiparous patientsolder than 25 years, but is not limited to thisgroup. The majority of cases are diagnosedbetween 22 and 36 weeks of gestation.Adverse outcomes including recurrentpreeclampsia, preterm delivery, foetal growthrestriction, placental abruption and caesareandelivery in subsequent pregnancies areincreased in women with HELLP syndrome.Latest series reported the recurrence ratesbetween 4% and 19%.10 The incidence of

Long-term consequences of preeclampsia: Where do we stand?

Author:Ozge Tuncalp, Istanbul Medical School, Istanbul, Turkey


Aim. To review the literature and understand the long-term consequences of preeclampsia.




preeclampsia varied from 19% in normotensive womento 75% in those with underlying hypertension.11

As a result, when the latest research is reviewed,development of early-onset preeclampsia in primigravidwomen may predict remote cardiovascular events,namely hypertension, ischemic heart disease andstroke.9, 12 On the other hand, preeclampsia / eclampsiaoccurring late in pregnancy in primigravid women doesnot appear to be associated with long - term cardiovas-cular risk.4 Therefore, more research is needed to solid-ify the hypothesis of common pathophysiology ofpreeclampsia and cardiovascular diseases. The associ-ation between cardiovascular disease and pretermpreeclampsia reported by Norway study suggests thatthe pathogenesis and prognosis of the early versus latepreeclampsia may be different.

Despite all the efforts, preeclampsia is still a diseaseof blurred facts where meticulously done long-termobservational studies are required to define the longterm consequences, and basic science researches toclarify the multifactorial pathogenesis.

REFERENCES1 Hnat MD, Sibai BM, Caritis S, Hauth J, Lindheimer MD, MacPher-

son C. Perinatal outcome in women with recurrent preeclampsiacompared with women who develop preeclampsia as nulliparas.Am J Obstet Gynecol. Mar 2002. 186(3): p 422-6.

2 Ferrazzani S, De Carolis S, Pomini F, Testa AC, Mastromarino C,Caruso A. The duration of hypertension in the puerperium ofpreeclamptic women: Relationship with renal impairment andweek of delivery. Am J Obstet Gynecol. Aug 1994. 171(2): p 506-12.

3 Campbell DM, MacGillivray I, Carr-Hill R. Preeclampsia in secondpregnancy. BJOG Feb 1985. 92(2): p 131-40.

4 Chesley LC. Hypertensive disorders of pregnancy. New York.Appleton - Century - Crofts. 1978.

5 Smith GC, Pell JP, Walsh D. Pregnancy complications and mater-nal risk of ischemic heart disease: A retrospective cohort study of129,290 births. Lancet. Jun 23 2001. 357(9273): p 2002-6.

6 Laivuori H, Tikkanen MJ, Ylikorkala O. Hyperinsulinemia 17 yearsafter preeclamptic first pregnancy. J Clin Endocrinol Metab. Aug1996. 81(8): p 2908-11.

7 Hubel CA et al. Dyslipoproteinaemia in postmenopausal womenwith a history of eclampsia. BJOG. Jun 2000. 107(6): p 776-84.

8 Chambers JC, Fusi L, Malik IS, Haskard DO, De Swiet M, KoonerJS. Association of maternal endothelial dysfunction withpreeclampsia. JAMA. Mar 2001. 285(12): p 1607-12.

9 Irgens, HU, Reisaeter, L, Irgens, LM, Lie RT. Long term mortalityof mothers and fathers after preeclampsia: population basedcohort study. BMJ 2001. 323:1213.

10 Sullivan CA, Magann EF, Perry Jr KG, Roberts WE, Blake PG,Martin Jr JN. The recurrence risk of the syndrome of haemolysis,elevated liver enzymes, and low platelets (HELLP) in subsequentgestations. Am J Obstet Gynecol. Mar 1994. 171(4): p 940-3.

11 Sibai BM, Ramadan MK, Chari RS, Friedman SA. Pregnanciescomplicated by HELLP syndrome (hemolysis, elevated liverenzymes, and low platelets): Subsequent pregnancy outcome andlong - term prognosis. Am J Obstet Gynecol. Jan 1995. 172(1 Pt1): p 125-9.

12 Walraven van C, Mamdani M, Cohn A, Katib Y, Walker M, RodgerMA. Risk of subsequent thromboembolism for patients withpreeclampsia. BMJ. Apr 12 2003. 326(7393): p 791-2.

RESOURCES

1 Cunningham, Gant, editors. Willliams Obstetrics. 21st edition.McGraw Hill. 2001.

2 DeCherney, Alan, editors. Current Obstetrics and Gynecology. 9thed. McGraw Hill. 2003.

3 Lambrou NC, Morse AN, Wallach EE. The Johns Hopkins Manualof Gynecology and Obstetrics. 2nd ed. Lippincott, Williams andWilkins, 2002.

4 August P, Sibahi B. Clinical Features and Prognosis of Preeclamp-sia, UpToDate Online. 11.3. 2003.

5 Roberts JM, Pearson GD, Cutler JA, Lindheimer MD. Summary ofthe NHLBI Working Group on Research on Hypertension DuringPregnancy. Hypertens Pregnancy. 2003. 22(2): p 109-27.



NEWS IN GREECE - SPECIAL EDITION!!!After The Euro 2004 Football Championship and the ATHENS 2004 OlympicGames

Another Great Event is going to stir Greece up!!!

14th EMSA GA and 8th EMSCon

The Organizing Committee of the 8th EMSA GA and EMSCon is so happy to welcome you all to the EMSA General Assemblyand EMSA Conference, that will be held in Thessaloniki, Greece from 12 to 17 of October, 2004!!!

We have been working hard formany months to prepare this meetingfor all of you! Dozens of hours of OCmeetings, talking on the phone,arranging new meetings and hundredsof hours in front of our PCs. And now,we are so close to the event that weare both so proud and excited!

The program will include work-shops on various EMSA projects (ie

Teddy Bear hospital) and European Programs' Structures. We will have the honor to have with us Prof. A. Benos, president of theInternational Association of Health Policy (IAHP), to discuss with us the contemporary dilemmas in the European health policy.

Our main topic will be the Tobacco and the Anti Tobacco Strategies. You will have the chance to attend and actively partici-pate in various sessions on this, always current, problem of our communities.

And then, when the meeting ends... Then, you will have the chance to enjoy Thessaloniki by night! ;-) Our Social Program teamis preparing many surprises for all our participants!!! We are looking really forward to get to know to you!!!

Are you curious to see us as well??? Here's your first chance:

On behalf of the Organizing Committee,

Gefsi Mintziori, President

AANNNNOOUUNNCCEEMMEENNTTSS



INVITATION TO 4th ZIMS(ZAGREB INTERNATIONAL MEDICAL SUMMIT)

Organized by SSCMA (Student Section of Croatian Medical Association) and EMSAZagreb, ZIMS is one of the best European summits for medical students and young doc-tors.

The summit is traditionally held in Zagreb, Croatia, this year from NOVEMBER11th to 114th. Like every year, you can apply to ZIMS as active (oral or poster pres-entation) or as passive participant. We are rewarding best scientific paper, best lecturerand best poster and from the last ZIMS we are also rewarding the ''person of ZIMS''.

First two days of ZIMS are reserved for invited speakers and student's presentations,and on the third day ZIMS provides interesting workshops. Also, this year we are proudto present Satellite meeting on subject "Sports medicine". Besides offering a unique dis-cussion and teaching we also offer an interesting social programme.

On the fourth day of ZIMS you can choose to go with us to a filed trip to Krapina,surrounding little town near Zagreb and the world's largest Neanderthal finding site.

We are the cheapest medical summit in Europe and registration fee is 30 EUR. This includes at least onemeal during the official part of the programme (3 nights and 4 days), coffee breaks, all congress materials, all lectures and finalexam, complete social life, all parties, gala dinner on first and final day of congress.

For more information, please visit our homepage at www.zims.hr

Hope to see you in Zagreb this November!

Best regards,

Nikolina Radakovic

President of 4th ZIMS Organizing Committee

AANNNNOOUUNNCCEEMMEENNTTSS



jemsa.emsa-europe.org

&

www.emsa-europe.org

JEMSA Edition 2004

Documents

Transcript of JEMSA Edition 2004