Srpski medicinski časopis Lekarske komore
The Serbian Medical Journal of the Medical Chamber is a journal published by the Medical Chamber of Serbia as a publisher with the Institute for Medical Research of the University of Belgrade as co-publisher. The Journal publishes previously unpublished original professional and scientific papers, reviews, short communications, editorials, letters to the editor, meta-analyses, case reviews, current topics, book reviews, papers on the history of medicine and more, from all fields of medicine, pharmacy and dentistry, therefore contributing to the promotion and development of the profession and science. The Journal is published in print and electronic form four times per year.
AXILLARY BRACHIAL PLEXUS BLOCK UNDER PROCEDURAL SEDATION FOR ARTERIOVENOUS FISTULA FORMATION IN A CHILD WITH END-STAGE RENAL DISEASE – A CASE REPORT
Introduction/Objective: Arteriovenous (AV) fistula formation has become the gold standard for hemodialysis vascular access. The use of brachial plexus blocks (BPB) for antebrachial AV fistula formation in adults provides not just adequate analgesia but a potentially positive effect on primary fistula patency. Additionally, the resultant state of surgical anesthesia may enable the surgery to be performed under procedural sedation. Case report: A 12-year-old patient was admitted for AV fistula formation for the purpose of hemodialysis due to end-stage renal disease. Kyphoscoliosis of the thoracic spine, the patient’s short neck with limited mobility, and her short stature posed a potential difficulty for intubation. Despite a recently resolved upper respiratory tract infection, which raised suspicion of airway hyperreactivity, the decision was made to proceed with surgical treatment and perform an axillary BPB under procedural sedation. Basic monitoring of vital functions was applied, with oxygen support at 3 l/min via mask. The ultrasound-guided block was performed using 8 ml of 0.5% levobupivacaine (1.4 mg/kg) and 5 ml of 2% lidocaine (3.33 mg/kg). During the one-hundred-minute surgical procedure, the patient maintained hemodynamic and respiratory stability and spontaneous breathing. The patient awoke without complications and was referred to the hospital ward. Her pain was managed with acetaminophen, as needed. The total perioperative opioid consumption was limited to the induction dose of 0.83 μg/kg of fentanyl. Conclusion: In this pediatric case, the use of axillary BPB provided adequate analgesia with minimal opioid administration for the formation of an AV fistula. It also enabled the surgical team to avoid an expectedly difficult intubation. One needs to keep in mind the maximum safe dose of local anesthetics, the nuances of their use in children with comorbidities, as well as the potential complications, among which local anesthetic systemic toxicity is the most important.
PERIBULBAR ANESTHESIA WITH TARGETED INTRAVENOUS ESKETAMINE ANALGOSEDATION DURING ENUCLEATION: A CONTEMPORARY NARRATIVE REVIEW
Introduction: Enucleation is an invasive ophthalmic procedure accompanied by pronounced nociceptive and reflex stimuli, representing a significant anesthesiological challenge, particularly in elderly and comorbid patients. Contemporary anesthesiology trends increasingly favor the use of regional anesthesia combined with targeted analgosedation as a safer alternative to general anesthesia. Aim: To present current concepts of peribulbar anesthesia combined with targeted intravenous esketamine-guided analgosedation during enucleation, with special emphasis on hemodynamic stability, prevention of the oculocardiac reflex, control of perioperative pain, postoperative nausea and vomiting, and the feasibility of integrating this technique into day-surgery protocols. Methods: A narrative review of contemporary literature in the fields of ophthalmic and regional anesthesia was conducted, focusing on the pharmacological properties of esketamine, the mechanisms of action of the peribulbar block, and the clinical aspects of their combined use during enucleation. Conclusion: Peribulbar anesthesia combined with esketamine-guided targeted analgosedation represents a safe and effective contemporary anesthesiological approach for performing enucleation, particularly in elderly and comorbid patients. This approach provides stable hemodynamics, preserved spontaneous respiration, adequate pain control, a low incidence of postoperative nausea and vomiting, and rapid functional recovery, with the potential for application within a day-surgery setting.
PENILE FRACTURE ASSOCIATED WITH URETHRAL INJURY – CASE REPORT
Introduction: Penile fracture is a rare urologic emergency that may occur when the erect penis is injured, most often during sexual intercourse. In 10%-21% of cases, it is associated with urethral injury. The diagnosis is most often made by clinical examination, but additional diagnostic methods are useful in evaluating the site of rupture of the corpora cavernosa and detecting urethral injury. This medical emergency requires urgent surgical management as delays are associated with worse outcomes. Case report: A 43-year-old man reported to the Emergency Center of the University Clinical Center of Serbia due to an injury to the erect penis during sexual intercourse. The anamnestic data were that he had felt pain and heard a “popping” sound, upon which sudden detumescence of the penis occurred and penile hematoma appeared, as well as blood during urination. Suspicion of a penile fracture was established on clinical examination. An ultrasound examination showed a rupture of the tunica albuginea of the right cavernous body, and retrograde urethrocystography revealed a rupture of the penile urethra. The patient underwent surgery that same evening. The surgical approach was a median penoscrotal incision, followed by suturing of the right cavernous body and penile urethra through a gently placed urinary catheter. Postoperative recovery was uneventful. During follow-up examinations, the patient reported normal erections, regular urination and satisfaction with the appearance of his penis. Conclusion: Penile fracture is a rare urologic emergency, which is relatively rarely associated with urethral injury. The presentation of our case indicates the importance of initial ultrasound and radiographic diagnostics. In the case where the site of injury is present preoperatively, a ventral penoscrotal incision may be a suitable surgical approach. Timely recognition and surgical treatment of penile fracture associated with urethral injury gives excellent functional results.
SURGICAL TREATMENT OF RADIATION-INDUCED ANTERIOR CHEST WALL OSTEOSARCOMA AFTER BREAST CARCINOMA: A CASE REPORT
Introduction/Objective: Radiotherapy for breast cancer can rarely lead to radiation-induced osteosarcoma (RIOS), a highly aggressive malignancy. This article aims to present the specificity of the surgical treatment applied and the level of aggressiveness of this rare malignant tumor. Case report: A 63-year-old female patient was admitted to the Chest Surgery Department of the Military Medical Academy due to a large exulcerated sternal mass releasing a purulent secretion, initially misdiagnosed as recurrent breast carcinoma 15 years post-treatment, and anemia. Biopsy confirmed high-grade osteosarcoma following prior radiotherapy. After metastasis was ruled out, the patient received neoadjuvant chemotherapy and underwent radical resection of the sarcoma, sternum, anterior III–VII ribs, and adjacent soft tissues. Chest wall reconstruction was achieved using titanium bars, clips, and a latissimus dorsi myocutaneous flap. Upon local recurrence, further resection of the manubrium and anterior II ribs, with soft tissues, was performed. A year after the initial operation, a suspicious subcutaneous mass in the left pectoral region was excised for histopathological analysis. Conclusion: RIOS of the chest wall exhibits a more aggressive course and worse prognosis than sporadic chest wall sarcomas, with higher rates of recurrence despite wide resection, as demonstrated in this case. Reconstruction with titanium bars and clips, after extensive anterior chest wall resection, provides a rigid and feasible alternative for restoring stability. This case underscores the importance of recognizing RIOS as a rare but serious late complication of breast cancer radiotherapy and highlights the complexity and specificity of surgical management and reconstruction for optimal outcomes.
AGING AS A MODULATOR OF MULTIPLE SCLEROSIS PATHOPHYSIOLOGY
The number of older patients with multiple sclerosis is rising significantly, including individuals with late-onset disease (after age 50) and very late-onset disease (after age 60). Aging affects the immune and nervous systems, contributing to a shift in the clinical course towards a progressive pattern and increasing the risk of disease progression independent of relapse activity (PIRA). Additionally, late-onset multiple sclerosis is characterised by a more frequent progressive phenotype, fewer inflammatory relapses, and a shorter time to disability accumulation. Immune system aging (immunosenescence) leads to a reduced diversity of the T-cell receptor repertoire, changes in the number and function of CD4+ and CD8+ T lymphocytes, and an imbalance between effector and regulatory T cells. At the central nervous system level, aging contributes to neurodegeneration through increased oligodendrocyte degeneration, microglial dysfunction, iron accumulation, oxidative stress, mitochondrial dysfunction, and diminished neuroprotective mechanisms. Reduced proliferation and differentiation of neural stem cells, as well as structural and functional changes in glutamate receptors, primarily N-methyl-D-aspartate receptors, further compromise neuroprotective and reparative processes. Understanding the interactions between aging and the pathophysiological mechanisms of multiple sclerosis is crucial for developing targeted therapeutic strategies for the increasing population of older patients with multiple sclerosis. This paper aims to examine, through an integrative review of the available literature, the role of the aging process in modulating key pathophysiological mechanisms of multiple sclerosis.
LABORATORY PARAMETERS AND THEIR RELATIONS WITH DISEASE OUTCOME IN PATIENTS WITH NON-HODGKIN FOLLICULAR LYMPHOMA – SINGLE CENTRE FIVE-YEAR FOLLOW-UP
Introduction/Objective: Follicular lymphoma, a subtype of non-Hodgkin lymphoma, is the second most common non-Hodgkin lymphoma and the most frequent indolent lymphoma. Although rare, this disease may exhibit aggressive behavior, a tendency toward complications, as well as resistance to administered therapy and frequent relapses. This study aimed to analyze laboratory parameters at the time of diagnosis and their association with disease outcome, complications, treatment response, and survival. Material and methods: A total of 47 patients diagnosed with follicular lymphoma between 2018 and January 2024 were analyzed at our center. Baseline laboratory parameters included complete blood count, hemostasis parameters (PT, aPTT, fibrinogen, D-dimer), and biochemical parameters. During the course of the disease, treatment response to first-line therapy, progression-free survival, and overall survival were evaluated. Results: Complete blood count parameters, as well as most biochemical parameters, showed no correlation with disease course. Complete remission was achieved in patients with lower LDH levels (p = 0.029), while overall survival was longer in patients with lower fibrinogen levels (p = 0.019), a higher percentage of monocytes (p = 0.007), and lower D-dimer levels (p = 0.000). Progression-free survival was associated with lower fibrinogen levels (p = 0.019), lower D-dimer levels (p = 0.031), lower LDH levels (p = 0.019), and a higher percentage of peripheral blood monocytes (p = 0.005). Patients with initially elevated D-dimer levels had a PFS of 24.50 ± 4.81 months, whereas those with D-dimer levels within the reference range had a PFS of 36.48 ± 5.99 months (p = 0.015). Conclusion: In our center's experience, hemostasis parameters, particularly fibrinogen and D-dimer, showed a significant correlation with disease course.
IMPACT OF LEFT VENTRICULAR GEOMETRY, EXPRESSED AS INTERVENTRICULAR SEPTAL AND POSTERIOR WALL THICKNESS, ON THE OUTCOME OF ACUTE ISCHEMIC STROKE
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6"/> <w:LsdException Locked="false" Priority="52" Name="List Table 7 Colorful Accent 6"/> </w:LatentStyles> </xml><![endif]--><!-- [if gte mso 10]> <![endif]--> Introduction/Objective: Acute stroke represents a significant component of the overall health burden of the population. Parameters obtained by transthoracic echocardiography are well-established predictors of outcomes in cardiovascular diseases, while increasing evidence indicates their importance in predicting outcomes in neurovascular disorders. This study aims to test the hypothesis that changes in left ventricular geometry, expressed as an increase in left ventricular wall thickness, represent a useful marker of poor outcome in patients with acute ischemic stroke. Materials and methods: The methodology was based on the analysis of echocardiographic variables in 167 patients with acute ischemic stroke, together with variables of the modified Rankin Scale assessed at hospital discharge, used as an indicator of functional outcome. Results: The study indicates a correlation between the thickness of both the interventricular septum and the posterior wall of the left ventricle, on the one hand, and the functional status of patients, on the other. The results confirmed the study hypothesis, demonstrating that an increase in interventricular septal thickness and/or posterior left ventricular wall thickness is associated with a higher probability of unfavorable outcome. Conclusion: Both evaluated echocardiographic parameters showed positive predictive value in relation to functional outcomes.
THE PREVALENCE OF METABOLIC DISORDERS AND HYPERTENSION IN WOMEN DURING PERIMENOPAUSE AND MENOPAUSE
Introduction/Objective: Cardiometabolic diseases, including type 2 diabetes (T2D) and cardiovascular disease, and their associated factors, such as hypertension, dyslipidemia, insulin resistance, and obesity, are among the leading causes of morbidity and mortality. At a young age, the prevalence of cardiometabolic diseases is higher in men than in women, but this female advantage gradually disappears with aging, particularly after menopause, when cardiometabolic risk factors accumulate. Our research aimed to highlight the prevalence of metabolic disorders and their association with hypertension in women during perimenopause and menopause. Method: The study included 200 middle-aged women: 131 (65.5%) perimenopausal women who had experienced typical perimenopausal signs for more than 6 months, and 69 (34.5%) menopausal women with absent menstrual cycles for more than 12 months, aged 50-59 years. The patients visited their physician for a routine preventive examination in December 2024. Results: Hypertension was statistically significantly more common in women in menopause (84.1%) compared to premenopausal women (p < 0.001). Women in menopause had significantly higher rates of metabolic disorders, increased body mass and obesity, with 66.7% of the participants affected, as well as a larger waist circumference in 63.8% of the participants (p = 0.003). Menopausal women had statistically significantly higher levels of triglycerides, LDL cholesterol, and total cholesterol than premenopausal women (p = 0.002). Among women going through menopause, diabetes mellitus was statistically substantially more prevalent, affecting 27% of them (p = 0.002). Premenopausal women had a statistically significantly greater prevalence of hypothyroidism (14.7%) than did menopausal women (4.3%) (chi-square = 4.905, p = 0.027). These two groups of participants did not differ significantly in terms of sedentary habits, smoking, or family history of hypertension. Conclusion: Type 2 diabetes, obesity, dyslipidaemia, and hypertension were all substantially more common in menopausal women. Preventive screenings are therefore crucial for women going through menopause and perimenopause to promptly detect and treat cardiometabolic disorders and prevent more serious cardiovascular diseases.
DEPRESSIVE SYMPTOMS AMONG FAMILY MEMBERS PROVIDING INFORMAL CARE FOR PATIENTS RECEIVING HOME-BASED CARE: A PHQ-9 CROSS-SECTIONAL STUDY
Introduction/Objective: Family members providing informal care for patients receiving home-based care represent a population at increased risk of developing depressive symptoms. The aim of this study was to assess the presence and severity of depressive symptoms using the PHQ-9 questionnaire and to examine the association between depressive symptoms and caregivers’ daily functioning. Methods: A descriptive-analytical cross-sectional study was conducted among 77 family caregivers of patients enrolled in the Home Care Service of the Health Center Subotica between March and September 2025. Depressive symptoms were assessed using the Patient Health Questionnaire-9 (PHQ-9). Statistical analysis included the t-test, Mann–Whitney U test, Kruskal–Wallis test, and Spearman’s correlation coefficient. Results: The mean PHQ-9 score was 8.48 ± 6.14. A score ≥ 10 was recorded in 30 (38.9%) participants. Minimal or mild depressive symptoms were present in 47 (61.1%) caregivers. No statistically significant differences in PHQ-9 scores were observed according to caregiver sex (p = 0.423) or the patient’s primary diagnosis (p = 0.183). In the overall sample, a statistically significant weak positive correlation was found between PHQ-9 score and the self-reported impact of symptoms on daily functioning (r = 0.294; p = 0.009). Conclusion: Depressive symptoms are present in a substantial proportion of family caregivers providing home-based care. The intensity of depressive symptoms is associated with greater impairment in daily functioning, highlighting the importance of systematic monitoring of caregivers’ mental health.
NAVIGATING COVID-19 IN PREGNANCY: CARE PATHWAYS AND SYSTEM CHALLENGES IN KAZAKHSTAN – A QUALITATIVE STUDY
Introduction: International studies conducted during the COVID-19 pandemic have shown that pregnant women often experienced significant barriers to timely and appropriate care. However, much of the existing evidence is derived from quantitative surveillance or from settings with well-established digital infrastructure and standardized clinical pathways, which may not reflect the realities of many middle-income health systems. This study aims to qualitatively explore the experiences of pregnant women and healthcare professionals regarding COVID-19 care pathways, including symptom recognition, outpatient management, and hospitalization, in Almaty, Kazakhstan. Methods: The present study applied a qualitative, descriptive, phenomenological design to explore how pregnant COVID-19 patients and healthcare professionals experienced the organization of care during the pandemic. The study included 24 participants from local primary health care and hospital settings in Almaty, Kazakhstan. Fifteen healthcare professionals and nine pregnant or postpartum women voluntarily and anonymously provided informed consent to in-depth semi-structured interviews, either face-to-face or via secure video conferencing, between May and August 2023. Results: Healthcare professionals reported that COVID-19 substantially altered maternal health care due to increased workload, fear of infection, and a shift toward remote care. Uncertainty regarding pregnancy-specific clinical guidelines and standard operating procedures (SOPs) contributed to reliance on general protocols and informal practices, while delayed hospitalization was linked to symptom denial, fear of admission, self-treatment, and system constraints. Pregnant and postpartum women commonly misinterpreted COVID-19 symptoms as pregnancy-related or mild illness, leading to self-medication and delayed help-seeking. Follow-up was largely unstructured and based on communication via phone or messages. The experience of care varied, ranging from timely clinical support to inconsistent monitoring and preference for home-based management. Conclusion: The study offers detailed insights into a fragile and fragmented COVID-19 care pathway for pregnant women in primary and hospital care settings in Almaty. Several priorities for strengthening care organization for pregnant women with COVID-19 and for future public health emergencies include improving continuity of care, reducing delays in escalation, and enhancing the safety of maternal health services during infectious disease outbreaks.
PREVENTION AND MANAGEMENT OF VACCINE HESITANCY
Vaccine hesitancy refers to the delay in accepting or refusing vaccines despite the availability of vaccination services. Well-conducted studies and trials reviewed in this article support methods both to prevent and manage vaccine hesitancy. Clinicians should know which vaccines their patients are due to receive and should use every encounter to address this issue. Research shows clinicians’ recommendations increase vaccine uptake. Recommendations that patients perceive as stronger have a greater effect in increasing vaccine uptake. Using presumptive language to phrase the recommendation is more effective than presenting the vaccine conversationally as an option for the patient. When the patient counters the strong recommendation with hesitancy, the clinician should engage the patient with motivational interviewing, perhaps using a four-step process called the “Four A’s”.
NEONATAL BILATERAL HYPHEMA: A RARE PRESENTATION AND CLINICAL IMPLICATIONS
Introduction: Neonatal hyphema, defined as intraocular bleeding into the anterior chamber, is a rare condition that requires immediate ophthalmologic evaluation. Unlike traumatic hyphema commonly seen in older children and adults, neonatal hyphema is typically associated with non-traumatic etiologies such as birth-related mechanical stress, hematologic disorders, congenital infections, or vascular anomalies. Bilateral involvement is particularly uncommon and necessitates a comprehensive systemic and ophthalmologic workup to rule out serious underlying pathology. Case report: A female neonate was delivered at term via spontaneous vaginal delivery with normal Apgar scores and without perinatal complications. Shortly after birth, blood was observed in the anterior chambers of both eyes, more prominently in the right eye. Ophthalmologic examination confirmed bilateral hyphema with preserved corneal clarity. Systemic evaluation including complete blood count, coagulation studies, and TORCH serology ruled out coagulopathies and congenital infections. The patient was treated conservatively with topical atropine and corticosteroids. During hospitalization, the hyphema gradually resolved without evidence of elevated intraocular pressure or synechiae formation. The newborn was discharged with scheduled ophthalmologic follow-up to monitor for potential late complications. Conclusion: This case underscores the importance of early recognition and multidisciplinary management of neonatal hyphema, particularly when both eyes are affected. Although birth trauma remains a common cause, thorough diagnostic evaluation is essential to exclude hematologic and infectious etiologies. Given the rarity of bilateral neonatal hyphema, additional case reports and studies are needed to enhance understanding of its etiology, optimal management, and long-term outcomes.
COEXISTENCE OF POLYCYTHEMIA VERA AND MULTIPLE MYELOMA: A CASE REPORT
Introduction: Polycythemia vera (PV) is a chronic myeloproliferative neoplasm characterized by the clonal proliferation of erythroid, myeloid, and megakaryocytic lineages, most commonly associated with the JAK2 V617F mutation. Multiple myeloma (MM), on the other hand, is a malignant plasma cell neoplasm characterized by clonal proliferation of plasma cells in the bone marrow and the secretion of monoclonal immunoglobulin. The coexistence of PV and MM in the same patient is extremely rare, as these disorders originate from distinct hematopoietic lineages. Case report: We report the case of a patient with long-standing PV who subsequently developed MM, highlighting the diagnostic and therapeutic challenges of this unusual association. Conclusion: The prognosis of patients with concomitant hematologic malignancies depends on the type and aggressiveness of the diseases, the clinical stage at the time of detection, and the adequacy of the therapeutic approach. This case highlights the importance of avoiding automatic attribution of new clinical symptoms to a pre-existing diagnosis. A broad differential diagnosis should always be maintained, with each new symptom evaluated individually, allowing for early recognition of additional hematologic pathology and timely initiation of appropriate treatment.
ONCO-HYPERTENSION – A NEW CLINICAL ENTITY IN MODERN MEDICINE
Cardiovascular and oncological diseases represent an inevitable part of everyday medical practice at all levels of health care. Apart from common risk factors, these diseases are associated in other ways, and the potential cardiotoxicity of antineoplastic drugs is particularly significant. One of the frequent forms of cardiotoxicity is hypertension. Considering that it can manifest at any time during antineoplastic therapy and also after the completion of specific oncological treatment, onco-hypertension is a clinical entity that should always be kept in mind when caring for oncology patients. Regular arterial blood pressure checks in this population are necessary to ensure timely recognition and treatment of onco-hypertension and to carry out oncological treatment safely. Although the guidelines for the treatment of onco-hypertension are similar to the general recommendations for hypertension, some specificities primarily concern the choice of antihypertensive drugs and exceptions to target arterial blood pressure values depending on the stage of the oncological disease and its prognosis. It is crucial to recognize the time to stop cardiotoxic antineoplastic therapy or reduce the dose of the antineoplastic drug to avoid life-threatening cardiovascular complications. Numerous additional factors encountered in oncology patients, such as comorbidities, the presence of pain or other administered drugs, significantly contribute to the complexity of onco-hypertension. Given that this is a very sensitive population exposed to a specific type of psychological stress, the possibility of the "white coat effect" as well as masked hypertension should also be considered.
EFFECTS OF CONTROLLED PHYSICAL TRAINING IN PATIENTS WITH HEART FAILURE
Heart failure (HF) is a clinical syndrome characterized by cardiac symptoms (e.g., breathlessness, ankle swelling, and fatigue), which may be accompanied by signs (e.g., elevated jugular venous pressure, pulmonary crackles, and peripheral edema). Patients with HF often experience frequent hospitalizations, impaired quality of life, and shortened life expectancy. They also have decreased exercise capacity, primarily due to impaired hemodynamics within the active skeletal muscles. Patients with HF should undergo a cardiopulmonary exercise test to assess their activity level and type, as well as to perform risk stratification. The initial step should include evaluating the patient’s current exercise capacity and needs, then creating a personalized exercise program that details the types of exercises, their intensity, repetitions, duration in minutes per session, and the number of days per week allocated for training. Cycling (either on a stationary or regular bicycle) and walking are recommended because they are aerobic, dynamic forms of exercise. Aerobic training should be performed 3–5 times a week (30–60 minutes per session), with emphasis on interval training. This type of training enhances skeletal muscle strength and endurance, leading to increased muscle mass. In patients with heart failure and cachexia, resistance training is advised, combining both isotonic and isometric exercises. This type of training should be performed twice a week for 12 to 20 minutes per session. Resistance training also enhances skeletal muscle strength and endurance and encourages muscle growth. Physical training enhances skeletal muscle mass, fiber diameter, strength, endurance, and exercise capacity.
INTERSTITIAL LUNG DISEASE AND BULLOUS PEMPHIGOID ASSOCIATED WITH DIRECT ORAL ANTICOAGULANT USE: A CASE REPORT OF LITERATURE-BASED PHARMACOVIGILANCE SIGNAL DETECTION
Introduction/Objective: Direct oral anticoagulants (DOACs) have significantly improved the prevention and management of thromboembolic disorders owing to predictable pharmacokinetics, simplified dosing, and reduced monitoring compared to vitamin K antagonists. However, as clinical use increases, emerging evidence suggests that DOACs may also cause rare but clinically important non-hemorrhagic adverse events, such as interstitial lung disease (ILD) and bullous pemphigoid (BP). The aim of this study is to present and evaluate drug safety signal cases reported in the existing literature and to contextualize them in order to enhance clinician awareness of rare pulmonary and dermatologic adverse events associated with DOAC therapy. Case report: This report describes signal detection of ILD in 11 elderly male patients following exposure to apixaban, dabigatran, or edoxaban, with latency periods ranging from several days to four years. Most patients showed clinical improvement following drug discontinuation and corticosteroid therapy; however, two experienced fatal outcomes. We additionally report a signal detection case of rivaroxaban-associated bullous pemphigoid in an 86-year-old male with multiple comorbidities, who fully recovered following rivaroxaban withdrawal and corticosteroid therapy, with no recurrence after one year of treatment with apixaban. Conclusion: Prompt recognition and management are crucial for favorable outcomes. These cases underscore the importance of pharmacovigilance and the need for continued investigation to elucidate mechanisms and risk factors for such reactions.
Introduction: Osteoporosis is one of the most common extra-articular complications in many chronic inflammatory rheumatic diseases, including rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis, and systemic lupus erythematosus. Methods: We searched the PubMed, Scopus, and Web of Science databases for studies published within the last 10 years. This is a review article. Results: Most studies on postmenopausal women have found a correlation between high levels of pro-inflammatory markers and increased bone loss. Literature data indicate a link between a low risk of major osteoporotic fractures, hip fractures, and non-vertebral fractures in patients with PsA who are on disease-modifying therapies. Patient assessment in autoimmune rheumatic inflammatory diseases includes medical history, clinical examination, fracture risk assessment, laboratory tests, and bone densitometry. The lack of adequate diagnosis and treatment of osteoporosis is influenced by factors such as insufficient knowledge about osteoporosis and its therapeutic benefits, concerns about potential side effects of treatment, low motivation, and inadequate patient education on the subject. Several methods have been developed to reduce prescribing errors and oversights, with the Fracture Liaison Service proving to be the most effective. Strategies for managing osteoporosis include patient education, lifestyle modifications, fall prevention, proper nutrition, disease activity control, and the introduction of osteoporosis medication. Conclusion: Despite significant advances in prevention, diagnosis, and treatment, the prevalence of osteoporosis remains high and requires timely recognition and a more comprehensive approach. Assessing risk factors for falls and fractures, as well as recovery potential, is crucial in patients with autoimmune rheumatic inflammatory diseases.
MORPHOLOGICAL CHANGES IN KIDNEYS AND CLINICAL PRESENTATION IN PATIENTS WITH PRIMARY AND SECONDARY MEMBRANOUS NEPHROPATHY
Introduction/Aim: Membranous nephropathy (MN) typically presents as nephrotic syndrome and may be idiopathic (primary MN, pMN) or occur secondary to other diseases (secondary MN, sMN). Given the differing therapeutic approaches, this study aimed to compare clinical and pathohistological parameters between patients with pMN and sMN. Methods: Through a retrospective analysis of kidney biopsy samples diagnosed at the Institute of Pathology, Faculty of Medicine, Belgrade, between 2011 and 2023, 99 patients with membranous nephropathy were identified. These patients were divided into two groups: patients with pMN (n = 44) and patients with sMN (n = 55). Clinical and pathohistological parameters (by optical and immunofluorescence microscopy) were compared among study participants. Results: While males more frequently suffered from MN, females more frequently had sMN (p = 0.036). Haematuria was more common in subjects with sMN (p = 0.009). Proteinuria values were significantly higher among patients with pMN (p = 0.018), related to a significantly greater decrease in serum total protein values in them (p = 0.011). Endocapillary proliferation was significantly more frequent among those with sMN (p = 0.032). Marked positivity of several immunofluorescent markers was significantly more common in subjects with sMN: IgA, IgM, C1q, κ-chains, and λ-chains (p < 0.050). Conclusion: Females are more commonly affected by sMN. Characteristics of sMN include presence of haematuria, endocapillary hypercellularity and immunofluorescence positivity for markers not seen in pMN (IgA, IgM, C1q), while characteristics of pMN include significantly higher levels of proteinuria, accompanied by significantly reduced serum protein values.
HEATWAVES AND HEALTHCARE: BRIDGING DATA AND FRONTLINE PRACTICE
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Name="List Table 7 Colorful Accent 6"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true" Name="Mention"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true" Name="Smart Hyperlink"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true" Name="Hashtag"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true" Name="Unresolved Mention"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true" Name="Smart Link"/> </w:LatentStyles> </xml><![endif]--><!-- [if gte mso 10]> <![endif]--> Heatwaves and related environmental events expose critical vulnerabilities in overburdened health systems and underscore the need to integrate clinical and environmental data to support timely public health interventions. However, healthcare professionals’ participation in data collection is often limited by high workloads and fragmented, restrictive health information system architectures. This article explores strategies to strengthen the link between public health data production and clinical response to mitigate the health risks associated with heatwave events. Field immersion programs for epidemiologists enhance understanding of operational constraints and promote the design of pragmatic interventions. However, the lack of standardized health measures and a widely accepted conceptual framework limits the effectiveness of heatwave epidemiology. We argue that such approaches can systematically improve the validity, applicability, and equity of public health research and practice, and propose a framework for standardized health monitoring during heatwaves.
THIRTY YEARS OF FAMILY MEDICINE SPECIALTY IN POLAND: A CASE STUDY OF ITS INSTITUTIONALIZATION, PRACTICE, AND PATIENT PERCEPTION WITHIN PRIMARY HEALTHCARE
Background: Family medicine (FM) specialty in Poland was introduced in the early 1990s as part of broader health reforms aimed at restructuring primary healthcare (PHC) and improving access, continuity, and coordination of care. Despite three decades of development, FM continues to face systemic and professional challenges within the Polish healthcare system. Objective: This study used a case study approach to explore the evolution of family medicine specialty in Poland, examining its institutional foundation, specialist training, its role in PHC delivery, and patient satisfaction with services. Methods: An explanatory case study design was employed, drawing on policy documents, training curricula, peer-reviewed literature, and national statistics. Thematic analysis was guided by a framework for case study evaluation in healthcare systems. Results: Family medicine specialty has gained full recognition as a clinical and academic specialty in Poland. However, only a minority of PHC physicians are formally trained in FM. While the postgraduate training program aligns with European standards, it lacks longitudinal assessment and consistent quality of supervision. Patients report generally high satisfaction with interpersonal aspects of care but rate family medicine lower than specialist services in areas such as communication, empathy, and emotional support. The specialty also faces recruitment difficulties, with many FM residency slots unfilled despite financial incentives. Conclusion: Family medicine specialty in Poland has achieved significant structural milestones but remains underutilized and undervalued within the broader PHC system. Reforms should prioritize strengthening its educational pathways, improving working conditions, and addressing public perceptions. Enhancing communication skills and increasing the visibility of family physicians could improve both patient satisfaction and the attractiveness of the specialty.
SCLEROCHOROIDAL CALCIFICATION MIMICKING CHOROIDAL OSTEOMA: A CASE REPORT
Introduction: Sclerochoroidal calcifications are uncommon, benign ocular findings characterized by the deposition of calcium and phosphate within the sclera and adjacent choroid. These lesions are most frequently discovered incidentally during routine ophthalmologic evaluation, particularly in elderly individuals, and may resemble more serious intraocular pathologies. Case report: We present the case of a 62-year-old male patient referred for evaluation of a subretinal lesion in the peripheral retina of the left eye, initially detected during a routine ophthalmologic examination. The patient was asymptomatic, with no visual complaints. Fundus examination revealed a yellowish, placoid lesion with indistinct borders located suprapapillary, between the superior vascular arcades. B-scan ultrasonography demonstrated high internal reflectivity with posterior acoustic shadowing. Fluorescein angiography revealed a hypofluorescent lesion without leakage or staining. The lesion remained stable over several years, and systemic workup showed no evidence of metabolic abnormalities. Based on clinical and imaging findings (B-scan ultrasonography and fluorescein angiography), the diagnosis of sclerochoroidal calcification was established. Conclusion: Sclerochoroidal calcifications may clinically and ultrasonographically mimic more serious intraocular lesions. B-scan ultrasonography and fluorescein angiography, play a key role in distinguishing these benign findings from other conditions. In asymptomatic patients without signs of progression, annual follow-up is recommended, with no need for therapeutic intervention.
SIGNIFICANCE OF THE PREVENTIVE ULTRASOUND DIAGNOSTICS IN THE EARLY DETECTION OF RARE AND AGGRESSIVE THYROID CARCINOMAS – CASE REPORT
Introduction: Medullary thyroid carcinoma (MTC) is an aggressive tumor associated with a significantly poorer prognosis compared to other types of thyroid cancer. Doppler ultrasound and familiarity with the Thyroid Imaging Reporting and Data System (TIRADS) nodule classification are essential. Objective: This case highlights the significance of precise ultrasound imaging, crucial for early detection and subsequent management of such aggressive disease. Case report: We describe the case of a 31-year-old woman who underwent systemic ultrasound imaging. Upon ultrasound examination, a 5 mm x 4 mm x 3 mm hypoechoic, ill-defined solid nodule with echogenic foci (TIRADS 4, score 6) was identified in the mid portion of the left thyroid lobe. Given the suspicious ultrasound features, the location of the nodule, and the elevated serum calcitonin level, the micronodule raised concerns for malignancy, particularly suggesting medullary thyroid microcarcinoma. The patient underwent thyroidectomy, and histopathological analysis confirmed the diagnosis. The histopathology report described a small white nodule (5 mm) in the left lobe. There was no remarkable necrosis, and amyloid deposits were inconspicuous. Lymphovascular invasion was not observed, and mitoses were rare. The tumor stage was T1 (pTNM), and no distant metastases were found. C-cell hyperplasia was noted around the tumor. Immunohistochemical analysis showed positive reactions for calcitonin, chromogranin, and mCEA. The proliferative index was low, approximately 4%. After surgery, serum calcitonin levels decreased. Three years after the surgery, the patient is in good general condition and is under regular monitoring. In the meantime, the patient has become a mother. Conclusion: Early detection and treatment of micro-MTC are crucial, as these tumors have the potential for aggressive behavior. Adequate ultrasound imaging assessment could significantly improve the prognosis and outcome for these patients.
DUCTAL CARCINOMA IN SITU: CURRENT DIAGNOSTIC AND THERAPEUTIC APPROACHES
Advancements in breast cancer screening have significantly increased the incidence of ductal carcinoma in situ (DCIS) diagnoses. Despite its favorable prognosis, DCIS poses a clinical challenge due to its biological heterogeneity and potential progression to invasive ductal carcinoma (IDC). Mammography remains the primary diagnostic modality, with microcalcifications as the most common radiological finding. Management is primarily surgical, involving either breast-conserving surgery (BCS) or mastectomy, depending on the extent of the lesion. In patients undergoing BCS, adjuvant radiotherapy is recommended to reduce the risk of local recurrence, while hormonal therapy (tamoxifen or aromatase inhibitors) is indicated for hormone receptor-positive tumors. Axillary lymph node dissection is not routinely performed but may be considered in cases with suspected microinvasion. Recently, active surveillance has emerged as a potential alternative for selected low-risk patients. Ongoing research is focused on the identification of prognostic factors to enable more precise risk stratification. This review provides an overview of current multidisciplinary approaches to the diagnosis and treatment of DCIS, based on the latest scientific evidence.
POSSIBILITIES OF USING INERTIAL MEASUREMENT UNIT SENSOR FOR ASSESSING BALANCE ABILITIES IN THE ELDERLY
Aim: This study aimed to evaluate age-related changes in postural stability among healthy older adults using inertial measurement unit (IMU) sensors and assess the clinical potential of wearable technology for balance assessment in geriatric populations. Methods: Thirty-four healthy participants aged > 65 years were divided into two age groups (65–75 and > 75 years). Balance was assessed using a sacrum-mounted IMU sensor during a 30-second semi-tandem stance in three trials. Results: Participants > 75 years showed increased postural sway compared to younger counterparts. Gender differences revealed greater medio-lateral sway in males (p = 0.038). No significant differences were observed in sway velocity or ellipse area, suggesting effective compensatory mechanisms in static conditions. Conclusion: IMU-based balance assessment demonstrates sensitivity in detecting subtle age-related postural changes, with practical advantages for both clinical and community settings.
PUBLIC HEALTH ASPECTS – MISUSE AND INAPPROPRIATE USE OF ANTIBIOTICS
Introduction/Aim: Since their discovery, antibiotics have represented a key defense against bacterial infections, but an increasing number of strains are developing resistance through spontaneous genetic mutations and the acquisition of resistance genes, a process further stimulated by their improper and frequent use. This literature review encompasses studies published between 2010 and 2024 and analyzes four key areas: the misuse and inappropriate application of antibiotics, the development of superbugs, the global aspects of antimicrobial resistance (AMR), and preventive strategies with an emphasis on the role of vitamins. This review aims to present evidence on antibiotic misuse, resistance development, and preventive strategies, with particular attention to the importance of vitamins in maintaining immunity and improving the functioning of healthcare systems. Methods: This literature review includes studies published from 2010 to 2024, focusing on the analysis of antibiotic misuse, the development of superbugs, the global impact of AMR, and the role of vitamins in prevention strategies. Results: The results indicate that the most common causes of inadequate therapy are self-medication, prescription without microbiological confirmation, and poor communication between physicians and patients. AMR has been recognized as one of the greatest threats to public health, with significant consequences for morbidity, mortality, and healthcare system costs. Preventive measures include education of healthcare professionals and the general population, regulation of antibiotic sales, the development of new diagnostic and therapeutic methods, and the promotion of healthy lifestyle habits. Of particular importance are vitamins with antioxidant properties (retinol, tocopherol, and L-ascorbic acid), which may reduce the need for antibiotics, especially with the contribution of vitamin D, known to stimulate the immune system. Conclusion: An integrated approach, in line with the One Health concept, is crucial for preserving the effectiveness of existing drugs and reducing the public health burden caused by AMR.
THE FIRST FIVE YEARS OF THE SERBIAN JOURNAL OF THE MEDICAL CHAMBER – A BRIEF OVERVIEW AND ANALYSIS
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6"/> <w:LsdException Locked="false" Priority="52" Name="List Table 7 Colorful Accent 6"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true" Name="Mention"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true" Name="Smart Hyperlink"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true" Name="Hashtag"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true" Name="Unresolved Mention"/> <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true" Name="Smart Link"/> </w:LatentStyles> </xml><![endif]--><!-- [if gte mso 10]> <![endif]--> This is a brief overview of the Serbian Journal of the Medical Chamber, marking its fifth anniversary. It aims to inform the reader about the Journal in the context of other Serbian medical publications and present a concise analysis of the types of articles published and the topics covered to date, thus providing insight into what the Journal offers to both readers and authors.
PROMOTING RESILIENCE AND WELL-BEING FOR INDIVIDUALS, FAMILIES, AND COMMUNITIES IN PSYCHOSOCIAL CRISIS
Introduction: It is estimated that up to 70% of people experience at least one serious traumatic event during their lives. Trauma usually causes a psychosocial crisis, which is a state of instability and danger. Trauma and the psychosocial crisis are addressed at the level of the individual, the family, and the community. Promoting resilience and well-being is very useful in helping a person “bounce back” after encountering adversity. Objective: This paper explores the dynamics of psychosocial crisis and the ways of promoting resilience and well-being at the individual, family, and community levels. Materials and methods: A literature review was conducted on psychosocial crises, their causes and consequences, as well as on resilience and well-being as key resources for addressing these challenges. Results: Resilience factors – such as optimism, facing one’s fear, a strong moral compass, religion and spirituality, social support, cognitive and emotional flexibility, and a sense of meaning and purpose – play a crucial role in coping with psychosocial crises. Well-being can be further enhanced by prioritizing physical health, nurturing social connections, and engaging in mental stimulation. Conclusion: Psychosocial crises can be observed on several levels – maturational, situational, existential, spiritual, and adventitious. If trauma is not properly addressed and the crisis persists, it may lead to both intergenerational and transgenerational trauma. Strengthening resilience and enhancing well-being at the levels of the individual, family, and society are essential strategies for coping with trauma and mitigating negative outcomes such as PTSD, substance abuse, suicidality, depression, and physical health problems. By fostering resilience and well-being, traumatic experiences and psychosocial crises can be transformed into opportunities for personal, family, and social growth and development.
COLLES FRACTURE – HISTORICAL RETROSPECTION
The author presents a short historical retrospection of the most important surgeons who studied Colles fracture, in chronological order. The author also describes the eponyms most commonly used in daily surgical practice, along with the historical figures that they are linked to.
THE USE OF ROTATING HINGE KNEE PROSTHESIS IN REVISION TOTAL KNEE ARTHROPLASTY
Introduction: The number of total knee arthroplasty (TKA) procedures shows a growing trend in orthopedic hospitals worldwide. Although TKA has an excellent long-term survival rate, it is not surprising that, given the increased life expectancy and aging population with a more significant number of comorbidities, the frequency of revision TKA will also rise. Common indications for revision TKA represent aseptic loosening and periprosthetic fractures. Case reports: A 60-year-old female patient presented to our hospital with complaints of pain and instability of her right knee, accompanied by decreased range of motion. Primary TKA was performed in another institution nine years ago. Radiographic evaluation demonstrated aseptic loosening of TKA components, with subsidence of the tibial component into varus malposition. A 73-year-old female patient was admitted to our Hospital because of an injury to her left knee resulting from a fall from a standing height that happened five days before the presentation. Primary TKA was performed 14 years ago in our Hospital. A trauma X-ray series of the injured knee revealed a Lewis type IIB periprosthetic fracture of the tibial plateau. In both patients, revision TKA was performed using a rotating hinge implant with augmentation of the tibial defect caused by loosening in the first case and fracture in the second case. Postoperative recovery was successful in both cases, with radiographic imaging showing adequate position of the implant at 2-year follow-up. Conclusion: The use of rotating hinge knee prostheses in revision total knee arthroplasty demonstrates promising outcomes, particularly in cases involving significant bone loss and instability.
COMPLEX FOOT INJURY TREATMENT USING VACUUM ASSISTED CLOSURE AND PLATELET-RICH FIBRIN METHOD – CASE REPORT
Introduction: Traffic accidents are one of the leading causes of death and injuries worldwide. According to the World Health Organization (WHO), more than 1.3 million people die annually in road accidents, while between 20 and 50 million suffer injuries. The majority of these injuries involve limb trauma, with the lower limbs being most commonly affected, particularly among pedestrians and motorcyclists. Case report: This report presents the case of a 77-year-old female pedestrian involved in a road accident, sustaining open fractures of the second and third metatarsal bones of the left foot (Gustilo type II). Initial surgical treatment was performed immediately after the injury, including extensive irrigation, debridement, and fracture stabilization using K-wires, along with below-knee plaster immobilization and triple antibiotic therapy. Further complex treatment involved a combination of vacuum-assisted closure (V.A.C.), platelet-rich fibrin (PRF) application, and hyperbaric oxygen therapy (HBO). Conclusion: Timely surgical intervention was crucial for achieving a positive outcome in an elderly patient, ensuring healing without infection and functional recovery. A multidisciplinary approach was essential in this complex case, adapting therapy to the specific needs of an elderly patient and improving overall recovery.