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JEMSA - Journal of EMSA on Medical and Scientific Affairs

2004 Edition

CONTENTS

GENERAL Credits Letter from the editor Divo Ljubicic What is EMSA? Amanda Victorine Wong Zhi Yan From the President Ajda Skarlovnik

Becoming a doctor Hrvoje Vrazic MD By the choice of the editor: A short overview of history of medicine and urban culture in old Dubrovnik Divo Ljubicic

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Fibrinolytic therapy in acute deep vein thrombosis and arterial occlusion Emre Sivrikoz Arthroscopic meniscectomy as a method of treating meniscus injuries Slavko Kuzmanovski, Vladimir Krstic Clinical manifestations and aetiopathogenetical background of mesenteric lymphadenopathy in children Dragan Ilic Cutaneous tuberculosis in R. Macedonia during the period 1997 - 2003 Biljana Gjoneska Symptoms of gastrointestinal functional disorders in student population Melita Nesic Long-term consequences of preeclampsia - Where do we stand? Ozge Tuncalp

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EMSA ACTION: ANTI-TOBACCO! An opinion article: Smoking and physicians - Doctors as role models Anabela Diana Serranito MD In the game - for a tobacco free Europe (EMSA joins forces with WHO-Euro and the CDC) Nick Kai Schneider

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ANNOUNCEMENTS 18

News in Greece - Special Edition - 14th EMSA GA and 8th EMSCon Gefsi Mintziori Invitation to 4th ZIMS (Zagreb International Medical Summit) Nikolina Radakovic

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LIFE A summer in Dubrovnik Fiona Horneff Modus vivendi Marieta Nikolova Ivanova

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PAPERS AND REVIEWS

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FROM THE PEN OF YOUR EEB 2003/2004... A year in EEB Ajda Skarlovnik Thoughts from the desk of the secretary Fiona Horneff The new girl Emon Farrah Malik How everything started Divo Ljubicic A day in the office representing EMSA in Europe Nick Kai Schneider General Assembly (GA) from EEB's point of view Hrvoje Vrazic MD

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JEMSA - Journal of EMSA on Medical and Scientific Affairs

2004 Edition

The author of the cover Author: Nora Mojas, Study of Design, Faculty of Architecture, University of Zagreb, Croatia Contact: martha_lights@net.hr 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 creating reality. Her connection with her hometown Dubrovnik has always inspired her and given her plenty of motifs for her 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 simplicity of medical profession, but at the same time the multilateral and multicultural unification of Homo sapiens through medicine. 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, through individuality, multinationality and multiculturalism from which EMSA arises as a phoenix, in one voice for Europe. United 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), Marina Kos MD PhD (Croatia), Vladimir Krstic (Serbia and Montenegro), Slavko Kuzmanovski (Serbia and Montenegro), Slobodan Lang MD PhD (Croatia), Davor Lessel (Austria), Divo Ljubicic (Croatia), Emon Farrah Malik (United Kingdom), Matko Marusic MD PhD (Croatia), Julia Mikic (Croatia), Gefsi Mintziori (Greece), Nora Mojas (Croatia), Melita Nesic (Serbia and Montenegro), Marieta Nikolova Ivanova (Bulgaria), Nikolina Radakovic (Croatia), Nick Kai Schneider (Germany), Anabela Diana Serranito MD (Portugal), Emre Sivrikoz (Turkey), Ajda Skarlovnik (Slovenia), Ozge Tuncalp (Turkey), Amanda Victorine Wong Zhi Yan (United Kingdom), Maja Vlahovic 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 41 B-1040 Brussels Belgium

ISSN 0779-1577 Total Edition: 250

Disclaimer EMSA (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 possible, have taken care to ensure that the information given in this text is accurate and up-to-date. However, readers are strongly advised to confirm that the information is correct. Despite judicious efforts errors may have crept in and EMSA, the editor and the publisher do not accept any responsibility for this. Copyright Apart from any fair dealing for the purposes of research or private study, or criticism or review as permitted under the European copyright, design and patent laws, no part of this publication may be reproduced, stored, or transmitted, in any form or by any means, without the prior permission 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 www.emsa-europe.org

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JEMSA - Journal of EMSA on Medical and Scientific Affairs

GENERAL

2004 Edition

DIVO LJUBICIC (CROATIA) MEDICAL SCIENCE DIRECTOR & EDITOR

OF

JEMSA

DIVO.LJUBICIC@DU.HTNET.HR

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 meet most 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 to show my gratitude to the Editorial Board for their dedication, advice and critics; to Medical Science Local Coordinators for the promotion of JEMSA and their effort in collecting manuscripts and of course, to our beloved student authors, without whom nothing would have been possible and all our efforts would have been in vain. Without the authors, without a sufficient authors' pool, a journal cannot survive. Moreover, I have learned the authors are the best medium of journal promotion, because a pleased author comes back again and also spreads the news of a good new journal, recommends advertising in that journal, etc. Special thanks to Hrvoje Vrazic MD for his invaluable contribution to designing and laying out this edition of JEMSA. Cordial thanks to Medical School of University of Zagreb, Croatian Medical Journal (CMJ) and Medical Publishing CO, 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 means lots of hard work of the editors on working ethics, goals and policies, and the wisdom of finding the niche for the journal. With the editorial board and the editor-in-chief being elected annually, it is difficult to keep consistency of the journal, which is so important for the headway. For that reason I find the collaboration of previous and current editors to be 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 "Personal" section, in order to improve communication of the EEB and EMSA Members which is very, very important for EMSA. We have also made a completely new section called "EMSA Action", in which we choose one of the important EMSA actions of last year. In "From the pen of the EEB" section, you can read personal articles of EEB members, enjoy their adventures and have an insight into their problems, doubts and impressions. "EMSA Actions" is entitled "Anti-Tobacco!" in the light of EMSA's engagement for tobacco-free Europe. "Life" section brings us topics about the latest progress in dealing with the problems of Romany population in Bulgaria, an article about summer adventures in Dubrovnik, Croatia. Also, one subsection of "Life", called "By the choice of the Editor", brings a text about the history of medicine and urban culture in old Dubrovnik. "Papers and Reviews" is very specific this year, because the authors haven't shown that much interest in basic sciences, so this edition of JEMSA brings only articles from clinical science, which is also very indicative to the future editors to pay more attention in collecting more articles from the field of basic science. Articles in this section are of very high quality and the editorial team is very pleased. We would like to invite future authors to study JEMSA 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 and pacesetter of scientific activity of medical students all over Europe, uniting young scientists under the same criteria at international level. Cordially, Divo Ljubicic Medical Science Director & JEMSA Editor-in-Chief 2003/2004

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JEMSA - Journal of EMSA on Medical and Scientific Affairs

GENERAL

2004 Edition

Didn’t get a chance to publish in the 2004 Edition of JEMSA? Don’t worry! Watch out for our information leaflets, and make sure you DO NOT miss the 2005 Edition of JEMSA! More information available at:

www.emsa-europe.org www.emsa-europe.org

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JEMSA - Journal of EMSA on Medical and Scientific Affairs

2004 Edition

GENERAL

What is EMSA? Energetic, Expanding, Enthusiastic Medical Students' Association in Europe, simply the European Medical Students' Association. Founded by a handful of pioneering medical students back in 1991 in Belgium, EMSA was aimed at developing and providing a European platform for all medical students by medical students.

the President, Vice-president, Secretary General, Treasurer, Medical Education Director, Medical Ethics Director, Medical Science Director and the Internet Director. The EEB then elects a few other positions to complement its work - namely the EMSA Liaison Officer towards IFMSA, WHO-Euro Liaison Officer, Liaison Officer to European Medical Organizations and Permanent Officer, Teddy Bear Hospital Coordinator and the EMS Council Secretary General. The EEB as a whole, led by the president, is responsible for the day to day running of the whole association. In each country, you will also have the National Coordinator (NC) who is responsible for the activities of the country. In each local area, the point of reference will be the Local Coordinator (LC) who informs the NC of latest happenings and keeps the FMO up to date with activities. The FMO as such, usually has a board that collaborates with different directors on the EEB to spread EMSA's across the region.

What is this European platform and why do we want it? Simply because we are European and we do want to know what is happening to our colleagues in the European continent before wanting to explore the rest of the world. We want to form a network for medical students to communicate and share their experiences exactly for this purpose. Together in this platform we can guide one another with our medical experiences, medical policies and share our views as European medical students and if necessary to go as one body to any appropriate body for assistance. Together in an association, our voice would stronger than separate faculties or countries voicing their views as medical students.

How to join EMSA? EMSA is based on a faculty membership. Our members are Faculty Member Organizations (FMOs) and not individuals as such. The idea of FMO is to ensure that our members have good contact and communication in this European platform. Membership fee is 50 EUR per year and a registration fee of 30 EUR is applicable for new members. Once your faculty joins EMSA, automatically all students in the faculty are members of EMSA.

What is it that EMSA does? EMSA works in field of medical education, medical science and medical ethics. In each of these fields, we have directors who manage its activities. In medical education, we are actively working on the Bologna Process issue as well as comparing medical curricula in Europe. We have active discussions and workshops in Medical Ethics. With Medical Science, what you are reading now - this journal, JEMSA is one of its sweetest successes. We also have congresses, conferences, workshops in all these fields. Other than that, we have a number of projects, including Twinning Project, EMSA Summer Schools, Euro Talk, EMSA Best Buddy Project, EMSA Substance Misuse Support (SMS), Teddy Bear Hospital project, Working Abroad Database project, EMSA Ski Week and many other projects coming in the pipeline. We also run a monthly newsletter EUROMEDS for all our members including feature articles by our members, announcements and many other fun bits. EMSA has also recently organized the Inaugural EMS Council meeting in London. EMS Council is an idea by EMSA that became reality last month when medical students' representative from National Medical Students' Association attended its inaugural meeting. EMS Council aims at gathering representatives to discuss European issues and to form a European point of view through our European representatives.

Future of EMSA? The future of EMSA lies directly with the members and it is what they strive to shape it to be. We believe the future for EMSA is bright as long as everyone continues 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 eeb@emsa-europe.org or visit our website at www.emsa-europe.org

e ted w - uni

oice ne V n! O , e e ca w rop r u e E th One toge

The structure of EMSA? EMSA is made up by Faculty Member Organization. Every year at the General Assembly in October we meet and elect an EMSA European Board which consists of www.emsa-europe.org

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JEMSA - Journal of EMSA on Medical and Scientific Affairs

GENERAL

The President’s word

Dear EMSA Friends, It is with much pride and pleasure that EMSA EEB presents to you this year's edition of JEMSA - Journal of EMSA on Medical and Scientific Affairs 2004, which, traditionally, is available 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 broad spectrum of articles from all fields of medicine, including clinical medicine, public health and medical education. It contains reviewed articles on scientific work and research, as well as real-life experiences of medical students, intended to satisfy even the more demanding readers. This year, one of the Medical Science Directors greatest tasks was to prepare a new edition of JEMSA, and, even more, to upgrade its image and design as well as contents. Divo Ljubicic, EMSA's Medical Science Director 2003/2004 has certainly succeeded not only to overcome the usual obstacles and editorial troubles when successfully compiling and editing this 2004 edition of JEMSA, but has also certainly added a new dimension to it. Congratulations! The last but not the least, we must emphasize the credits of all the authors who have contributed to this journal and have made it possible for JEMSA to be published again this year. For EMSA as a young and active international association it is of vital importance to see JEMSA being re-born again each year. Keeping the traditional qualities and at the same time the development of a modern and up-to date JEMSA is definitely a challenge for future Medical Science Directors. Enough of words, let's just enjoy reading this exciting, educational and dynamic Journal of EMSA,

On behalf of EEB, Ajda Skarlovnik Acting president 2003/2004 Vice-president 2003/2004

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2004 Edition


JEMSA - Journal of EMSA on Medical and Scientific Affairs

2004 Edition

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

AJDA SKARLOVNIK (SLOVENIA) VICE-PRESIDENT AJDA@DSMS.NET AJDA_SKARLOVNIK@HOTMAIL.COM

A year in EEB Afterwards, me, das Unterwegsmaedel, I traveled more; to Venezuela to IFMSA March Meeting, to Groningen, the Netherlands, where EMSA National coordinators meeting took place, and to Geneva on the occasion of WHO General Assembly and WorldMapS preparations meeting. Each of these is a chapter of its own and there is simply not enough space to describe it all.

Well, I've been warned ☺…before deciding to run for a EEB position I asked more experienced colleagues for counsel and advice; among other things I was told it very well might happen that I will try to fight that box of PC and blame it for all the things in the world that didn't work, all the e-mails that were ignored, all the… As a matter of fact it was true, later, in retrospective, I always remembered those words while starting to get involved in intensive discussions with the computer…

On all these occasions I could get to know my colleagues and friends from different aspects; As we spent a lot of time together I got to know them as very good cooks (still remember that dinner in Jaccos apartment, Amanda, and Divo, of course I will not forget "the Berlin pancakes" ☺), poets and philosophers (yeah Anabela, we will all sue our student organization for completely changing our lives, won't we? ☺), skiers, swimmers and gourmands (Fiona, I really do hope we will have the chance to go for skiing, a spa jacuzzi and then a cup of hot chocolate some day again).

But it would be by all means wrong to imagine that the computer work comprised the majority of my activities; yes, maybe paper, pencil and internet are highly useful tools, however, you should never forget that they just help you realize things you want to do for other people and that the main purpose is to finally meet friends and be with friends. And so there I was, balancing between being just a student having fun and behaving responsibly and professionally as an EEB member in order to achieve and organize something. I will never forget the EEB meeting in Berlin; the European Students Conference, the wonderful city, the cheap kebabs, the comfortable hostel, the days spent on the Conference and the nights spent in the enthusiastic planning of EMSA's future.

All in all, it was dulce et utile - I hope I do not sound too corny but some things just cannot be expressed otherwise or more suitably. Despite the two years of previous work as EMSA National Coordinator and Leonardo Coordinator in SloMSIC this was an entirely new experience. I learned some quite new things about communication and power of persuasion; I learned about the importance of timely and accurate information; I learned, however unbelievable it may seem, even more about team work, I learned completely new things about controlling my own temper…I learned it the hard way but it was certainly worthwhile.

The meeting in Slovenia in February, together with the Bologna process workshop and Ski Week was somewhat of a highlight after a few months preparation. I hope and guess people had some good time. And we were productive too: I cannot but be proud of the Ljubljana Statement on Medical Education. And I have to admit that even I learned several new things about my own country as well as my countrymen.

And most important of all, I met a lot of amazing people whom I can now call friends. I sincerely hope we will not lose contacts - and I mean it (Hrvoje, I promise I will come to Zagreb also just for a coffee and not only for vaccination ☺). I have precious moments and unique memories for my future. Alors, je ne regrette rien… Fair winds, smooth sailing, good suntans! Ajda PS: I apologize if this article has been rather incoherent wandering in personal memories and feelings and if I skipped the utile part about my duties as EMSA vicepresident. For that you should peek in the annual report at the October GA.

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

2004 Edition

FIONA HORNEFF (GERMANY) SECRETARY GENERAL FIONAHORNEFF@WEB.DE

Thoughts from the desk of the secretary... Where do I begin, to tell the story of what a great year it has been...?

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

It all started last summer, when I found that I actually had a few weeks of summer off, no tests, and no work, nothing. Frightened by the idea of having too much time on my hands, I signed up as EMSA Heidelberg representative for the GA in Lublin, Poland, not knowing what to expect. To be honest, I didn't give it much thought at all.

I have to say, I had very nice people around me who helped, anytime, clarifying abbreviations to me, explaining things... I was not alone with my work. And when we met again for the first board meeting in Berlin, I realized that this was actually great fun as well. Hard work? Yes! Having a meeting all night long? Yes, that happens, too.

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

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

Then the actual GA sessions started, and I have to say: I was impressed. Everything was so professional; I've never seen anything like that before. And, more important, I found out how great EMSA was on a European level. Our local group is organizing all these nice events all the time, but I had no clue that EMSA was so much more.

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

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

And my family? I only saw them for 1 or 2 days in between trips, to unpack, wash and iron and re-pack again, exactly the same things I had unpacked 24 hours before, with only slight variations, depending on the climate of my next destinations. They were completely confused, could not remember where I was, for how long, with whom, when I'd get back...I hate to admit that my orientation after a while was only slightly better. It all climaxed this week in August, when I missed my flight back from London from the EMSA council because I had mixed up the departure times with the times of another flight earlier that same week.

So I decided to run for the position of secretary general. Great. Candidating was no big deal, getting elected apparently not either. And the GA was just a wonderful week. We had a blast. Took me 2 weeks to recover afterwards, which is usually a good sign to indicate the fun factor of any event. But then it hit me: gosh! What had I been thinking!!?? I felt incapable of doing that job! I could have cried (please do note the "could have"!!). What on earth should I do now? Resign immediately? Yes, perhaps the best idea. Will write an email right now. But then again, how embarrassing... And what about the job? It sounded like fun. And what would they do without a secretary? Could I be that irresponsible? No, the truth is, I

But then again, could have been worse. At least I still knew 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 time for my friends and family? Looking back: yes. A definite YES!!!! I think I'd do the exact same thing again. Actually I would, no thinking required! I just have to think about all the interesting people I have met during that year! I believe some of them will be my friends for lifetime. And my friends at home? Well, those whom I consider my true friends are still my friends. And they are the ones that matter.

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JEMSA - Journal of EMSA on Medical and Scientific Affairs

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

to type the minutes, and that is no fun at all. I am honest about it. And I always hate editing them. But then again, it is not hard; it is a small price to pay for all that you personally get from EMSA. And EUROMEDS: creating that newsletter is wonderful. It takes about half a day, you see a result immediately, and it is fun. You even get feedback for it more than for other things. And we agreed earlier that feedback is important 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 is no problem making up a whole edition by yourself, but it is not so much fun if that is what you have to do every month. I am not that creative after all… Otherwise, the secretary has to be an all-round talent. Something you cannot prepare for. But as a board you are supposed to be a team. So everybody should know roughly where EMSA is going to and which route to take.

And all the places I've been to... That actually might seem most interesting, and it sounds great: Berlin, Dubrovnik, Brussels, Slovenia, Venezuela, Amsterdam and Groningen, Macedonia... But trust me, that is not what stays in mind. What stays are the experiences you have from these places, and they are dependent on the people. People come first, before meeting venues, before work goals…

Would I do it differently? After saying that I definitely would do it again, I have to admit that I would do a few things differently.

In Macedonia I had literally 20 minutes in the whole week to bathe my feet in the lake. It was not enough time to even go back to the room to get my bikini! Don't know what I bought all that sun lotion for… But then again, it was one of the best meetings, when you look at the actual work outcome and contacts made.

First of all, I would have liked to have become involved in EMSA earlier. It always seemed that I had no time. True, but not entirely. You never have time. You have to make time. Secondly, now I know that it is not about the work you do, not about the goals, be it short term or long time goals, not about what you do or you think… it is all about the people around you. You have to be able to work with them. If you are not able to work them, get able! That is were all your effort has to go! Otherwise it is a combination of Sisyphus and his stone and Don Quixote fighting windmills.

And there are so many times you really want to throw everything away (which is usually right before a meeting, when it seems like nothing is working out and you are not prepared and have no clue as to what you'll do there and how to bluff your way out of that dreadful situation, or right after, when you are tired and knackered and don't have any energy left for writing all these reports and e-mails, actually doing all the work you enthusiastically agreed to during the meeting and keeping in contact with all the people you met). But then you just need some sleep, think about the meeting and all the enthusiasm you felt there again, and trust me, it will come back, and then you start working. And the best is when you see the results of your work. Or when people approach you, telling you what a great job you are doing, or have done on a specific project. Then you know it really is worthwhile.

Thirdly, hmmm, don't really know, maybe read more. (Just a piece of advice, I feel like in “The sun screen song”, you know, where the chorus is always: "trust me, wear sunscreen"). This was probably enough random thoughts from the secretary's desk, too much coffee, too much time or too much work, can't really define what it is. Now you have a rough idea what my life as EMSA's sec gen is like, and I bet you envy it; I would, if I read that…

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

Fiona

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JEMSA - Journal of EMSA on Medical and Scientific Affairs

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

2004 Edition

EMON FARRAH MALIK (UNITED KINGDOM) TREASURER EMON.MALIK@KCL.AC.UK

The New Girl OH MY ....

Women don't sweat, they glow. EMSA Executive Board (EEB) members exist under the three 'P' mask poise, professionalism and potential. However, whilst simultaneously awaiting my exam results, the Wimbledon final and the outcome of my application for the post of treasurer, I am "glowing" luminously with panic, paranoia and p-a-i-n (or possible peptic ulcer...).

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...

The European Medical Students' Association is something that I have worked for, passionately and persistently, for the past two years at my Faculty Member Organisation - Guy's, King's and St. Thomas' School of Medicine - and being Teddy Bear Hospital Director for a year has brought EMSA projects very close to my heart. A place on the EEB would be my chance to take this rewarding and challenging work further - to the cutting edge of Europe.

Bleurgh! Two drops of contact lens refresher and three espressos later and it slowly sinks in that I do have a little bit more intelligence than I give myself credit for and I start to filter through, respond to various congratulations, introduce myself and formulate proposals. After all, I've been dealing with these things for two years, albeit on a smaller scale and I have every intention of doing this job to the best of my ability.

Exactly two weeks later, I am safely through to the next year of medical school, Roger Federer has extended his reign as the Wimbledon champion, the Financial Times and the multiplication tables are my new mantra...and I have no nails left. Some would say that it is time to reward myself with a long sleep (as according to the First Student Commandment - "Thou shalt hibernate"...) However, being the ultimate glutton for punishment, I prise my eyes open with a speculum and settle down to login to my email account for the first time since being elected treasurer.

Plan of Action: - go through all files relating to EMSA and its financial situation - draw up a sponsorship application pack - search for sponsorship for EMSA administration and projects (possibility of pharmaceutical companies or chains?) - draw up a budget for the 2003/4 session, with statistical analysis - book flights and ferries for my first EEB meeting in Dubrovnik, Croatia, in July 2004 - read through the agendas for the National Coordinators’ Meeting and the last EEB meeting in March 2004 - analyse and familiarise myself with the Internal Rules and Statutes - learn all abbreviations (!!), i.e. AEISEC, AEGEE, ABC, PQR, XYZ, etc. (ECG, anyone?) - regularly update myself with the official European exchange rates - submit monthly reports to the EEB - analyse and critique the last EU grant application - initiate the formulation of the EU grant application for the forthcoming session 2004/2005 - book Eurostar ticket to Brussels, Belgium for meeting at the European Commission, in August 2004 - scan the Internet and official European Commission

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JEMSA - Journal of EMSA on Medical and Scientific Affairs

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

coming, accommodating and have overflowed with advice, help, descriptions of their experiences and explanations, where necessary (in addition to dubbing me the "Board Baby", at the age of twenty one!) and the beauty of this is that, in return, I can bring to the EMSA EEB my experience from the UK, confident objectivity and fresh enthusiasm for the job. EMSA provides the perfect platform for debate and bridge-building within and across Europe, never so well demonstrated as in the recent newly-founded EMS Council and my previous Euroscepticism has been proved unfounded. Well, a million lemmings can't be wrong...

websites for all available and applicable grants - update myself with all literature relating to the European Working Time Directive, the Bologna Declaration and the proposed Ba/Ma structure, in preparation for EMSA Council in London, at the end of August 2004 - negotiate discounts for EMSA members and future meetings - clean up my flat - free accommodation for delegates is not to be sniffed at! Plus, "EbenEMSA Scrooge" must now be my middle name... - register for the General Assembly in Thessaloniki, Greece, in October 2004 and prepare the Treasurer's Annual Report

Emon Farrah

Phew! Achievable? Absolutely! Two months on, I no longer regard AMSA, AMSE, ELSA, AEGEE and AEISEC with the same amount of trepidation as Onchocerciasis or trichorrhexis nodosa, but in fact have mysteriously developed the ability (or should I say magical power?!) to use these terms in everyday language and express opinions about them. Fellow EEB members are wonderfully wel-

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JEMSA - Journal of EMSA on Medical and Scientific Affairs

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

2004 Edition

DIVO LJUBICIC (CROATIA) MEDICAL SCIENCE DIRECTOR & EDITOR

OF

JEMSA

DIVO.LJUBICIC@DU.HTNET.HR

How everything started... A shiny spring day was awaking along with me, pretty self-convinced and completely unaware of the future development of life. It was one of those rather usual days when you live your well planned life according to the dates of your exams, drinking parties with your school buddies and romantic time spent with your girlfriend. I was satisfied, having everything one could desire and need to live a decent average citizen's life.

because of one appointment before, and the other task after. My preEMSA friends realized, as time went by, to appreciate my time, as well as I realized how important it was I appreciate theirs. Taking part at EMSA GA2003 in Lublin, Poland, as an FMO member and a representative of EMSA Zagreb was indeed a great experience. I had never realized how big EMSA actually was, and I finally met all the persons I had been listening about before. Exchanging opinions, ideas, constructive workshops and exciting debates... all those things were "guilty" I really felt EMSA Spirit, but the most "guilty" and the most important of all were the people I met, my colleagues, you. My enthusiasm and love for EMSA increased exponentially and I decided to ask someone of the EEB about elections, positions, tasks and responsibilities. When I uncovered my thoughts to few EEB members, I was suddenly surrounded by five of them, my new friends. You can easily imagine this situation if you remember your first jumping from a 15-meter cliff, and you don't know what is waiting for you in the abyss. Your friends are pushing you to the edge of the cliff convincing you that you can do it, they have faith in you, it is a great feeling, and you don't have to worry because the perfectly clean blue sea is waiting for you. They keep telling you they will jump after you so you wouldn't be alone... but you have this fear of alien, unpredictable terrain. You hesitate, you will-won't, won't-will, will, will...and before you know it you are.

Never thinking I could do better, I was very reserved when an acquaintance of mine asked me the other day to take part in some “EMSA organization� project here in Zagreb and come to a meeting in the afternoon. Hmm... This EMSA name was familiar to me from somewhere, because I had always been seeing those funny students running around with posters, leaflets, LCD projectors, computers, even whole copy machines. They all seemed to be in a hurry, you couldn't have seen them spending endless hours in a bar nearby, discussing usual students' themes, gossiping and laughing to empty stories and jokes. I appeared to have selfrestrained stand toward this idea of venturing upon joining EMSA. Apparently, an acquaintance of mine showed noteworthy persuasive power as I was on my way to the premises of EMSA Zagreb on that wonderful spring day. I was introduced to everyone, they welcomed me as an old friend and I started to feel I was going to like it. Projects were running as fast as months so my social life had one more segment. I was getting to know all those people and I was running with them, carrying posters, leaflets, LCD projectors, computers, even whole copy machines. My other pre-EMSA friends were telling me that I always seemed to be in a hurry, that I behaved differently and paid more attention during the classes and right after, I used to disappear somewhere instead of going to the bar nearby for a drink. They got used to planning drinks with me, according to our schedules, in crazy time periods e.g. from 12:37 until 13:12

They give you the strength to make that step, you jump and before you notice you are already swimming like a fish together with your friends towards new shores. We were swimming all around Europe, and I must confess the weather wasn't nice most of the time, but we knew we were not alone. It was a great feeling knowing you could always discuss your problem with a few people from your team and they would understand and try to help. Sending your

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JEMSA - Journal of EMSA on Medical and Scientific Affairs

2004 Edition

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

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

After every event you provided input on, you are satisfied and proud to be a part of EMSA, you have new ideas, meet more people and learn new details about yourself. I have learned I am not only Divo. I am also Fiona, Carl, Amanda, Kasia, Emon, Ajda, Nick, Hrvoje, Anabela, Marijan, Stefan and all other people I met on my voyages through Europe. My personality has become as complex as Europe itself, made up of small interactive pieces from all around making a whole structure.

There were moments when it seemed nothing was running well; you couldn’t see the point of spending your time and energy on something nobody gave a hoot about; you would wake up angry with yourself and blame everyone around you for your insomnia, bankruptcy, your sacrifice to "cosa nostra"; you were desperate and you called your friends in the other parts of Europe to have long after-midnight conversations. You might not believe how even a short call at crazy hours could help you recover, liberate you of your uncertainty and push you up.

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

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JEMSA - Journal of EMSA on Medical and Scientific Affairs

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

2004 Edition

NICK KAI SCHNEIDER (GERMANY) LIAISON OFFICER TO EUROPEAN MEDICAL ORGANIZATIONS & PERMANENT OFFICER SCHNEIDERNICK@WEB.DE

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 to look awake, and jump into the elevator. It was not too much sleep. On the third floor you step out, find you way to the CPME office. Why? You desk is there, the EMSA desk. CPME, the Standing Committee of European Doctors, is the umbrella organization for the medical profession in Brussels. Its members are the National Medical Associations, the other European Medical Organisations are their 'Associated Organisations' - EMSA is one of them. To realize a 'Domus Medica', a common house for the medical associations in Brussels, the CPME has tried to get its associated organisations to move into the office. That's why you are there; to work for EMSA, to represent the medical students' interests in Brussels and to try to give some continuity to its work. But you are also working for the doctors, for the CPME, coordinating their patient safety activities, steering some working groups and organizing events; a lot of responsibility for a student, but also a lot of fun. You do not think about that, it is nine o'clock in the morning, or maybe ten past. You enter the CPME premises - an open, spacious office. You see the team, 'good morning'. You still look tired. They realize that, they also have been students not too long ago.

patient safety conference, Internal Market conference in the Netherlands, internal business - enough work for the next hours. A bit of internet research - what are the EUrelated news? Anything relevant for the next CPMEmeeting? Any documents to be prepared? At noon you will have all up-to-date. Now to the EMSA-folder: Oh no, again 35 e-mails from the EMSA European Board, and only 2 from members! You reply to the members. The EEB can wait, you will take care of them later - they are students and will probably still be sleeping. The phone rings. It is the CPME-President. Yes, you have organized the CPME participation at the EC-conference, the session he is supposed to chair was moved to the morning, no problems on that - you are glad. Indeed, unfortunately no news yet on the other speakers, you will stay in touch. A coffee would be fine now, one of those hot espressos with full bean aroma. But you are still medical student, coffee on an empty stomach?... you prefer taking a tea. You go to the kitchen, have a chat with one of the colleagues, update yourself on the latest gossip and go back to your desk. Tea in one hand, in the other a bottle of water and maybe some cookies - or some good Belgian chocolate. Back to work.

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

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

Three post-its on your desk - the secretary already received your calls, those which came in between 8.30 and 9.00: the CPME-President, the President of one of the National Medical Associations and one of your key stakeholders in Brussels. Whom to call first? The stakeholder might give you some information, which could be required by the President. OK we start with him: mailbox. You leave a message to get back to you - now that you are in the office. The president of the NMA is next he is on the run, heading to a conference and asks for an update. 'Do we have a date from the Commission yet?', 'No, they will let us know by September'. That was short. Then you realize that it might be good to first check the e-mails. You open your mailbox, scan the most important ones. Luckily the CPME mails are mainly already filtered, they take priority: www.emsa-europe.org

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JEMSA - Journal of EMSA on Medical and Scientific Affairs

2004 Edition

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

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

press conferences (once and not in Brussels) - the president of the public relations students is on holiday. It is always good to work with IFISO, you know the girls and guys, they are, as you, representatives of their association in Brussels. You meet them frequently, mainly through the 'ngoholics-yahoogroup'.

You remember that you had a conference to attend in the afternoon. A short look on the agenda to check where it is - perfect, it is walking distance. Everything is walking distance - here in the EU-institutions area. Preparation: you print out some background documents, check if the CPME has already adopted some policies on the issues discussed and go for it. Grab a sandwich on the way - light Brussels lunch. You always eat sandwich for lunch - everything else is too expensive and takes too much time. The conference venue is great, at least compared to university settings. Interpretation is provided - you don't care. You take your notes, speak to some key stakeholders at coffee break, no unfortunately not that full bean aroma espresso, but it helps keeping awake. Some lectures were again as boring as in med school - others great, inspiring. It is good to listen to those great speakers - today two ministers they are not so good. You took your notes. You will have to write a report for the members. There was not much to lobby for today. Anyways, this word…to lobby, lobbying. What do you have in common with the hotel lobby? You realize that to be honest you have never waited in a lobby and that you don't even approach Parliamentarians who come out of the plenary room, at least not in the lobby. That was ages ago. Now, you have direct access to the European Parliament, even a badge if you are an accredited lobbyist (and of course you are), you make appointments and try to convince them, not with money, but with arguments. Too much prejudices about lobbying, it's mainly informing them about the concerns your members have. And lobbies are not really used for that. Normally the lobbies are only passed through as fast as possible to get in time to their offices or meet them at coffee breaks - maybe lobbyists should be called 'coffee breakers', because that's were you normally approach them - anyways not too easily, as everything runs a bit late here in Brussels and you never seem to have enough time. As you today, you run back to the office, there is still a call you are waiting for. The AEGEE President wanted to talk to you. The EUgrant for the running costs of European Youth NGOs. You know that EMSA, as most other students' organizations, did not get it again, for the second time in a row. EMSA and partners - mostly also conveniently located in or around Brussels - should put some political pressure on the Commission, a report and a press conference would not be bad. IFISO - the Informal Forum of International Students' Organisation, had decided so. It is on you and the AEGEE president to draft the report. You had volunteered to take care of the statistical research. You will also take care of the press conference, as you are the only one with a bit of experience in organizing

Back on your desk, you see that AIESEC has sent an e-mail - a joint application on the Bologna-Process. That sounds promising. Who is involved? The usual suspects, AEGEE and AEISEC. They want EMSA and others to join in. Deadline is in two days…Not for the reply, but for having the 50 pages application ready. No time for negotiations, you have to react and send an email expressing the interest of EMSA - hoping the EEB swallows it. They do not like to receive more work from Brussels - anyways EMSA needs money and the more grants we apply for the better the chances. Oh yes, there were still some emails left to answer. Not now, you finally go to the kitchen and get yourself one of those full bean aroma espressos, a double one. You have been waiting for it since the early morning. It tastes great!! You go back to your computer and in the best mood read all those EEB e-mails. A smile hushes over your face. Somehow you see things much more relaxed here in Brussels. Away from university, dealing with people and communication 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 are running late, some executives are unmotivated and others are arguing. Not the best circumstances for you as 'permanent officer', but with your full bean flavour at hand, 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 are scared of you. You do not know why, at the end of the day you just try to give guidance and work for the best of the organization. It is a lot of work for you, and it seems that it is again on you to send a wake up call and to be the pain somewhere... but you are used to it. Another smile as you realise where you are and how late it is - 17.30. You send mail to the EEB, that you are off. More tomorrow, and by the way at 14.00 one of the members will be arriving in town. A pleasant day to come. And you are far away, here in the heart of the capital 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, 41 Rue de la Science, Brussels, Europe. Nick

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JEMSA - Journal of EMSA on Medical and Scientific Affairs

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

2004 Edition

HRVOJE VRAZIC MD (CROATIA) EMSA LIAISON OFFICER TOWARDS IFMSA HRVOJE.VRAZIC@ZG.HTNET.HR

General Assembly (GA) from EEB’s point of view... When thinking of how to contribute to this edition of JEMSA, I thought whether or not to write a short article on my current position (EMSA Liaison Officer towards IFMSA) or to be more original. Knowing that there is no sense in re-inventing warm water, as the old proverb says, I thought it would be nice to unravel one of the oldest mysteries of working for EMSA on international level (usually known as the GA - the General Assembly).

at least few hours of spending quality-time with that lovely oval porcelain object in the bathroom, spending the rest of the day in desperate and insatiable search for water. And that is not compatible with meeting sessions starting on time. So, there are delays, everyone is always late, the Organizing Committee becomes frustrated because the delays in sessions cause further delays everywhere, cancellations and extra expenses to other parts of the programme.

GA. That's only 2 letters, but those two letters are usually the worst nightmare for every executive board. Even more for the president (I had 2 GAs under my supervision, I still remember every second of each one of them), since the president is the one responsible for everything. If you keep on reading, you will learn about some 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.

I have deliberately skipped mentioning EEB's position here. In order to understand it fully, I will start explaining the atmosphere of a few weeks prior to the GA itself. As an EEB member, you are required to attend at least two annual meetings of EMSA - the National Coordinators' Meeting and the General Assembly, majority of five-seven EEB meetings and an unspecified number of meetings that are related to your field of work. So, by this time, you have succeeded in making your parents millionaires (if they had been billionaires before you started working in EMSA), they have already been accustomed to you giving them notice only weeks before you fly to some remote corner of Europe for a week or so, and they don’t even object for longer than a day or so that they will have to help you out with buying yet another airplane ticket (because you are doing three part time jobs already, you were just rejected when applying for the fourth one and your bank account is drowning in the red zone). Your parents already know by heart how much it takes during every period of a day to get to the airport, asking you to call them not "mother" or "father" but rather "the taxi service" and they just drop you off and say "Have a nice trip!", they only waited with you at the airport after check-in for the first few times, in the first few months of your mandate. On a more academic side, since it's usually September, you would still need to pass some exam(s) before you could buy the airplane ticket (in most European countries), but luckily for you, you are already best friend with your travel agent so you know she would hold your reservation for days after the usual deadlines, performing small miracles with her keyboard and the central airline reserva-

How do our members see a GA? Although they know that in general the GA is a great opportunity to work for the future of EMSA making crucial decisions for the future of this organization (a part of the meeting), more attention is given to the fact that they will see old and meet new friends from all around the world, having a great time and parties. Of course, sometimes they do forget the fact that people in the EEB, especially the president, are also human beings who want to work within normal boundaries and also see old and meet new friends from all around the world, having a great time and parties. It has come as a big surprise to more than one person that an EEB member is not someone who is pathologically in love with motions, schedules, tables, timekeeping, eternal changes of internal rules and statutes and waking up early in the morning after only few hours of sleep or no sleep at all. And this is where the two titans usually crash - members just wanting to enjoy the entire event on one side, and the EEB and the Organizing Committee wanting to keep the schedule and do all the planned work on the other side. The big question here is - how to keep everyone satisfied? Because partying all night long, usually in such a way that if and when they wake up, people need

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JEMSA - Journal of EMSA on Medical and Scientific Affairs

2004 Edition

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

tion system. People around you tell you that the way you talk has changed, your sentence structure has changed, and you never seem to be giving a definite opinion on anything anymore. The amount of e-mails you receive every day strangely always adapts to the amount of your potential free time, so in the end you never have any free time, because you write e-mails all the time. This is the point when you conclude that the best investment you have ever made was buying a large screen and an ergonomic keyboard. You often read e-mails during weird periods of night, usually after one in the morning, and when you receive e-mails from some people, you can't stop laughing out loud. One minute later your mother comes in your room, because you woke her up, trying to see whether or not her son has gone completely crazy. When you explain to her that you laughed at an e-mail, she goes back to sleep, deeply relieved. It makes you feel much better when you send out an email at two in the morning, and within three minutes you get a reply from two or three other EEB members somehow you feel much better knowing that you are not the only one awake at this strange hour typing like mad for the prosperity of the association you love so madly and that there are others like you throughout entire Europe doing exactly the same. If you call them on the phone, they might even be crying sometimes, overwhelmed with work, with the motto: "So much to do, and so little time to do it!". You don't go out with your preEMSA friends that often anymore, somehow whenever they decided to go out on Friday night and asked you if you would go with them, you would SMS them back from some European city (the blessing of roaming with your mobile has brought you gold or platinum club status with your mobile operator months ago anyway) that you just left your hometown on Thursday and that you will be back on Sunday because you're attending one of those 3 or 4 day weekend meetings. At your medical school, everybody has already crossed you out from the list of future renowned scientists and clinicians, already placing bets that you will go into politics in the near future. You know all the administrators and you always use up all the days that you can miss from your classes, often even more, so you acquire good negotiating skills when trying to complete moderate or poor attendance of classes.

son do that work again and again. The person that is doing this masters advanced text editing options in Word, something he/she would never have the opportunity 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 time you will get to see something more of the country/city you are visiting, rather than just meeting rooms, public transport and bars/clubs. Depending on your luck, which is almost always bad, you come for the pre-GA EEB meeting and end up spending 12-16 hours a day in front of your laptop, trying to finish all the documents in time for the GA. And then, on the last night, when all is printed out in a master copy, just waiting to be photocopied in 50 or so copies, after numerous computer problems and crashes, the only photocopying machine that the OC has provided either runs out of toner or breaks down (or if you're extremely unlucky both), usually between midnight and five in the morning. A lot of people don't get any sleep night(s) before the GA, and the best part is that always all the work gets done on time (or with minimal delay) and everything turns out fine, no matter how hopeless it may look just hours before the start. Because of this, the pre-GA EEB meeting is not finished in those days before the GA, and then the participants are both amused and angry at the fact that while the social program lasts, the crazy people from the EEB have meetings at strange times of the night, never seeming to have any fun. This is largely true, unfortunately. So the EEB doesn't get enough sleep, but usually not because of partying, but because of catching up. And then, when the GA sessions start, it is always interesting and unpredictable - you never know what will happen and how they will finish. While not depriving any member to express his/her thoughts, ideas, suggestions, questions and comments, it is absolutely amazing that at every GA there are at least a few people that are incredibly active, but are unfortunately nowhere to be found or heard once when the GA finishes, even when they are offered to work on the problems identified during the GA. It always amazes me how GA participants are shy on the first day, and quiet all the time, but as soon as somebody proposes something, they can fight for 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 hours lost at the GA, along with the OC.

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

Reading all this, there is a remote possibility that, if for whatever reason you decided to run for an EEB position, you will hear the screaming voice of reason in your mind telling you "ARE YOU CRAZY?". My advice to you is that you ignore it, because working for EMSA, both locally and internationally, is something that I would definitely do again if I had the chance. It is well worth it. Trust me! â˜ş Hrvoje

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JEMSA - Journal of EMSA on Medical and Scientific Affairs

EMSA ACTION: ANTI-T TOBACCO!

2004 Edition

ANABELA DIANA SERRANITO MD (PORTUGAL) WHO-EURO

LIAISON

OFFICER

ADS_EMSA@YAHOO.COM

An Opinion Article: Smoking and Physicians - Doctors as role models - It is estimated that 30% of deaths from cardiovascular disease are due to smoking, - They have an increased risk various types of cancer, including mouth, throat, oesophageal, laryngeal, bladder, stomach and pancreas cancer - They age prematurely, - They decrease their fertility.1, 2

Smoking is a deadly habit, not only for those who smoke, but it has also become evident in recent years that those who innocently tolerate, or not, and come into regular contact with environmental tobacco smoke may also be putting their health at risk. Nevertheless it still amazes me that my medical colleagues, informed on the basic hazards of smoking, carry on smoking and some even take up the habit during or after terminating medical school.

I have many times managed to keep these questions to myself, but every so often I asked my colleagues, the mentor or even the professor what they think of this issue. Many just laugh and say it is for the pleasure of lighting up and smoking the cigarette, claiming it a social addiction, something to do whilst having coffee or when they are feeling anxious. Some feel that they have been doing it for so long that they will not have any problems or simply state that they are the part of the statistic that has no problems. I have come to believe that colleagues that smoke live happily in an addictive denial, addicted to nicotine and addicted to the denial that their personal health might not be in danger. They take a calculated risk and light up another cigarette - one more won't kill them, at least not today.

I'll never forget the words a friend once told me. She said that her small world of innocence had been brought down by the sight of a doctor in his white coat lustfully smoking his cigarette at the door of the Hospital, as she had always believed that doctors were perfect and as so obviously did not smoke. I still recall this discussion when a college sits next to me in the coffee room and lights up a cigarette. The population we work with sees us doctors as role models, an aspect we sometimes do forget. When I see them smoking, I often ask myself if they think of the consequences on their own health when they light up each cigarette? Do they remember, or at least know, that:

I on the other hand become more perplexed with this behaviour, because this brings me to another, more complex, question. Environmental tobacco smoke (ETS) also has its negative effects on the passive smoker:

- With every cigarette they light up, they lose 7 minutes of their life, - Tobacco is responsible for 90% of all lung cancers,

- ETS increases of the risk of heart disease, stroke and lung cancer. - ETS exposure lowers levels of high-density lipoproteins leading to an increased risk of atherosclerosis - Workers that are in constant contact with ETS at work have a 40-60% risk increase of developing asthma, when compared to those who have no exposure.3 It is one thing to do harm to oneself, but when our actions have consequences on the health of others we cross a delicate line as medical professionals that we are. Some colleagues and friends respect your not smoking and try not to smoke in your presence, whilst others just hypocritically blow the smoke in the other direction, so as to say I am not smoking at you, so I am not bothering or harming you. This brings me to a third group, who just affirm selfishly, in my opinion, that they may smoke wherever they wish to do so.

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JEMSA - Journal of EMSA on Medical and Scientific Affairs

EMSA ACTION: ANTI-T TOBACCO!

I live in a country where unfortunately there are not as yet strict tobacco laws being applied like in other European countries. Nevertheless, even in these countries, tobacco has managed to, due to the centuries of its existence get so encrusted in our many cultures that sometimes when, in the interest of our health, we ask that a smoker puts out the cigarette he/she still finds the courage to aggressively answer in a not so polite manner. We as physicians have an important role to play in the prevention and control of this growing epidemic as health care takers priming for the best health in the population we work with. Some of us will during our lives take up more active and direct roles in society, working directly and actively with these issues; others will play a more silent role, but will nevertheless constitute a role model for the patient that comes to see you on that day. So I leave a small message for my colleagues who smoke, and are not worried nor with your nor with their health, please do think twice before you light that cigarette... Is an innocent patient attentively observing you? And the smoke you leave behind, will it fill the lungs of a young child that already lives in a polluted city and does not 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 and Health. NY. 2003.

2

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

3

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

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2004 Edition


JEMSA - Journal of EMSA on Medical and Scientific Affairs

EMSA ACTION: ANTI-T TOBACCO!

2004 Edition

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

Author:

Nick Schneider, Medical Faculty of Heidelberg, Ruprecht-Karls-Universit채t / University of Heidelberg (Germany) EMSA Permanent Officer and Liaison Officer to European Medical Organisations 2003/2004 Contact:

schneidernick@web.de

"A very productive call. Just to recap...We briefly discussed the Global Tobacco Surveillance System that includes Global Youth Tobacco Survey, Global School Personnel Survey, and Global Health Professional Survey. Our goal is to apply a similar research model to students in medical and other health professional schools and to complete data collection in time to prepare a report for World No Tobacco Day 2005.

capacity building event taking place in Geneva 6-8 of October, where the research coordinators will be introduced to the methodology of the survey. Thereafter the pilot study will be carried out in Croatia under the supervision of Hrvoje Vrazic MD and Divo Ljubicic on national level and Nick Schneider on the European level. The first results of the pilot will be presented at the World No Tobacco Day 2005. The coordinators shall then train other European students to carry out the survey across Europe.

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

In parallel, Anabela Serranito, who designed the EMSA-Tobacco-Survey questionnaire and edited the EMSA handbook on smoking, will carry out a second pilot survey in Portugal. This genuine EMSA-survey was developed by EMSA and was especially designed for medical students. The unique target group and the specifics of this peer driven survey promise new input to tobacco activities within the medical profession. The results of both pilot studies will be compared and further analysed, ensuring that EMSA can come up with solid results through both approaches.

Since 27 July 2004 it is official, EMSA will be carrying out the European pilot survey for the Global Health Professionals Survey (GHPS). This joint project of the World Health Organisation (WHO) and the Centres for Disease Control and Prevention (CDC) in the United States, follows months of productive discussions between EMSA and WHOEuro. EMSA would like to express its gratitude to the members of the EFMATobacco Action Group, which provided the links to WHO-Euro and supported the EMSA-Anti-Tobacco activities throughout the last year. After the inclusion of EMSA in the Teaching Geriatrics in Medical Education Report (TeGeME 1) in 2000 2001, the GHPS will be the second large scale collaboration between EMSA and the WHO, in this case WHO-Euro.

HOW IT ALL BEGAN...

Having been active in the European Forum for Medical Associations and WHO (EFMA-WHO) for 3 years, EMSA joined the internal working group on tobacco (TAG-Tobacco Action Group) in Berlin 2003. As a regular member of this forum Nick Schneider, in his function as Liaison Officer, presented the activities performed so far and kept in regular contact with the other members. Seeing the need for further action within the medical profession it became clear that EMSA could be working on a survey assessing the smoking attitudes and habits of medical students in Europe. A questionnaire was drafted by Anabela Serranito, and was presented and well received by the TAGmeeting in March 2004. The so

The focus of GHPS is third year students because they are likely to be enrolled in courses at the medical school and have probably not yet started residencies at extramural locations. EMSA, the CDC and WHO-Euro would like to maintain a standardized sampling procedure across sites proven effective in the Global Youth Tobacco Survey. To start with the organisations involved agreed on a

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EMSA ACTION: ANTI-T TOBACCO!

called 'students' survey became one of the key discussion points on the 2004 agenda, leading to an extraordinary meeting solely on this issue at the 2004 EFMAMeting in Dubrovnik. All members of the Tobacco Action Group supported the EMSA initiative and jointly asked WHO-Euro for technical support. Dr Nikogosian, Head of the Tobacco Free Europe Initiative, immediately offered to see in which ways EMSA could be included in the Global Health Professionals Survey. Dr Klas Winell, in his function as TAG-chairperson, revised the questionnaire and gave feedback to the authors. At an in-person-meeting in Copenhagen, Nick Schneider had the opportunity to present the revised questionnaire and a draft action plan to the WHO-Euro officials. WHO-Euro asked for a written proposal and action plan within the following five days to bring the idea forward to the CDC, who would be funding the survey. A letter and an action plan were developed in the Brussels-Secretariat and sent to WHO-Euro. What followed was a period of uncertainty. No news from Copenhagen (WHO-Euro), no news from Atlanta (CDC). After several weeks we received the confirmation that the CDC and WHO-Headquarters had been asked to include EMSA in the GHPSImplementation plan and that a positive reply (whatever that meant) would almost be made. One day later the CDC contacted EMSA, explaining their plans and asking to start discussion on how to proceed. An eight-minutes conferencecall between Brussels and Atlanta followed. EMSA was well prepared, Portugal had already been identified as the ideal country for the pilot study, Anabela Serranito would take the lead, and the members were informed and eager to take action. No time to think, no time for further consultation. But then the shock, the CDC wants to start in a Central or Eastern European country - that was not really Portugal. What followed was in a way like betting on the blank - having in mind our membership, our strengths and weaknesses in the different countries and knowing the risks and opportunities. How ready were we in each country? Who should take the lead? We knew it was definitely worth to fight for - but it was one against three on the phone and we knew we would only have this one chance to play the right card. Only seconds to come up with a solution. Our Board was preparing for the EEBMeeting in Dubrovnik, not reachable anyways - not during a phone conference. The solution was Croatia, the country where the fundaments of this survey were laid some months earlier. It took nearly two years to be accepted to the preliminaries, but in those decisive eight minutes EMSA got into the game. The official results of the phone conference are quoted above‌ but the grey hairs it produced are to be seen on our heads.

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CONCLUSION

EMSA can be proud to be the organisation in Europe performing this survey. Without the help and support of several experts this success story would not have been written in such a short time. We would like to thank Sir Alexander Macara (UK) and Dr Klas Winell (Finland) for their ongoing support as well as Dr Haik Nikogosian and his team for the trust they are putting in EMSA. Now that we are in the game, our players will do their best to show that EMSA is able to play in one league with our partners. Two EMSA oldies, Anabela Serranito and Nick Schneider, got us on the pitch, now it is on everybody to show that EMSA can be a valuable partner and will perform this survey in the most professional way. Under the leadership of Hrvoje Vrazic and Divo Ljubicic, we are confident that our Croatian FMOs will be the first ones to show our new partners that EMSA takes up its responsibility and plays along with the best.

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A summer in Dubrovnik

Author:

Fiona Horneff, Medical Faculty of Heidelberg, Ruprecht-Karls-Universität / University of Heidelberg (Germany) EMSA Secretary General 2003/2004 Contact:

fionahorneff@web.de

The best part of this summer I spent in Dubrovnik.

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

Even though it was rather short, the stories are enough to cover a whole summer. It started with the EMSA Summer School, which was simply wonderful, combining learning all there is to know about emergency medicine, meeting great people from all over Europe and having fun. Not to forget getting to know the beautiful city of Dubrovnik. Divo has always been telling me of how unique and pretty this city is, that it is the best town in the world and that I ought to come there. "Ja, ja, ja..." I usually thought, "everybody is fond of their home town...".

After the summer school was over and the participants had left one by one, our EBB meeting started. Two days of hard work, but we really were efficient. Got everything done in 2 instead of 4 days as originally planned. Wonderful, that left me 2 more days to enjoy Dubrovnik and the Adriatic coast, together with my two local companions... not always easy, being the main target of Divo's and Hrvoje's entertainment...

Well, now I know he was right. It definitely is one of the, if not THE, most beautiful towns I've been to. And Divo and his sister, who gave a guided tour through The Town, know everything about their home town. Historical facts, where to have the best views and photo spots, where to eat the best seafood and ice-cream, and all those magical spots where you can make a wish. For example the "church of wishes�, conveniently placed on the way to the high school. You have to touch it with your hand while walking past it, at the same time making a wish.

We decided to go to Mljet. Mljet is an island, about one hour to the west by high speed boat. The unique thing about that island is, there is a lake in the middle of the island, and in the middle of the lake, there is another, smaller, island. A bit like those Russian dolls, where there is always one inside of the other. We had to get up really early, something I am usually not a fan of. But it was worth it. The boat trip was fun, we checked our personalities in magazine-psycho-tests. Turned out that I would have been a good man, if I had not opted for that xchromosome twenty-some years ago.

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

In Mljet we decided that it would be best to rent a car. Bikes would be too much work, after all, this was a holiday, and with a car we could go all the way to the other end of the island.

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We found Mini Brum. I instantly fell in love with that little yellow Polski Fiat, it was ever so cute! I am not so sure if Divo was so happy with it, he defines cute as "ugly but adorable", and also it might have been a bit too small for him, but... cute as can be. If you want to have a cute car and experience the true Monty Python feeling, you have to make some sacrifices to comfort, such as having to lean out the window every time you need to shift because you are sitting on the clutch already. Great fun was to check the windshield wipers. Though it was bright sunshine, you should always check if all the car's equipment is working. At least that is what they teach us in driving lessons here in Germany. In Croatia apparently as well. That's what Divo did anyways. And, surprise surprise, they did work. Brilliant. They were so enthusiastic about doing their work, that we almost could not stop them anymore. We tricked them at last, by shutting off the engine completely. Hilarious. So, we drove on. I asked Divo if he did not think it better to check again, if they were still working, you never know, it might rain later and maybe they were offended and sulking because we had stopped them so cruelly earlier on. Hrvoje's "NOOOOO!!!!!!!!!!!!" came a bit late. Divo apparently had agreed that it was a good idea to double-check! Fortunately they still did work absolutely fine. And this time we knew how to stop them as well. Just shut off the engine again.

Then we took the boat to the little island. It really was little: you walk around it in about 10 minutes, look at the little monastery, and then spend the rest of your time having a good strong coffee. And if you are there with Divo, you can be sure that he knows the waiter, they played water polo together, so you are his guest. Another nice thing about my company was, that they both had at least one mobile phone with them, so I did not have to have too much conversation, as they were talking to other people, who did not have the pleasure to be with us, most of the time. Fine. Next time I will bring 10 mobiles as well, just wait and see‌ Back to the main land (big island surrounding the small one), we went to a little channel with a strong current, where you can swim through. Actually you don't have to swim, the current takes you. My pleads that it was too cold to swim were ignored by my accompanying gentlemen, so I had to go in the cold water. At least I could stop them from pushing me in. And then we hitch-hiked for another boat that would take us back to where we had left our darling little Mini Brum! Have you ever been hitch-hiking on a boat? Go for it, it is great fun! The rest of the day we spend driving around the island, visiting another beach, taking millions of photos, 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 middle of nowhere. Now I know what you need all these mobile phones for, for example to call Mini Brum services and arrange for another car. Eventually it came, and we continued 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 the last boat), we were all exhausted. I tried to sleep a bit on the boat, but Hrvoje did not seem to like that idea, and kept waking me up with "wakey-wakey!". He would make a great alarm clock in the mornings!

Now you know what I meant by Monty Python feeling: The gentle giant (Divo) driving a car that is 3 numbers too small, having the windshield wipers running on full speed in 45 degree and bright sunshine, Mini Brum (which is actually more a Maxi Brum, considering the noise it made: you could not even hear that the radio was turned on from the back seat) slowly cruising around the serpentine mountain roads‌ actually not as slowly as my safety standards would have liked, but never mind, I interpreted the fact that our MiniBrum did not have safety belts as an indicator that you would not need any since there were never any accidents on that islands where Mini Brums were involved.

So that was the highlight of my Dubrovnik Summer. As I said, there would be enough stories for a whole summer, but as this is supposed to be a scientific paper and not Fiona's memoirs, I will stop here. Go and find out yourself how nice it is there. And just to close this article: special thanks to Divo and Hrvoje, I had a fantastic time with the two of you, and I really do miss you both! Fiona

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2004 Edition

Modus vivendi

Author:

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

marietanbg@yahoo.co.uk

Have you ever seen a crying barefoot child, left in the street, or a lonely old woman, begging for a piece of bread? Maybe you have, but if you haven't - just look around.

The Romany people of Central and Eastern Europe are in the unique position of suffering the worst health conditions of the industrialized world together with some of the biggest health problems associated with the third world countries. Rates of both infectious and non-communicable diseases are high.1 The proportion of Romany living in poverty exceeds 75% in countries throughout the region.2 Access to preventive and curative healthcare services is low.3

During an internship in one Romany suburb I was dumbfounded by the sights in the streets. Dirt, streetrunning waste waters, children who played there with walnuts instead of balls, but, in spite of all, healthy and cheerful. On the pavement in front of their houses women sat with all their clothes on them, who despite lots of diseases didn't follow their doctor's advice - either as a result of ignorance or as disparaging the treatment.

Romany people are the part of the population of every country and they deserve special attention. A huge part of their houses don't even have any drainage. Waste waters flow along the streets where children play. There isn't even running cold water in some houses. One room is inhabited by several generations and sometimes there are no doors or windows. Heating is mostly wood and coal. In most of the cases electricity is available. Sometimes it's a cable, which is caught from the electric post near the house or from the neighbour to light at least one bulb. Positive change of living conditions would affect the health state of the Romany.

The lady doctor, who I was with, was stopped on the streets by Romany, who were not her patients, but she however helped them despite no emergency. She checked their blood pressure, consulted them for new symptoms, calmed them - she was a healer, a psychologist and a friend for those people. She looked like a missionary, who tried to heal the whole unjust and deprived of health knowledge Romany world. During this short visit in the ward she gave them strength for life, directed attention to health and the meaning of life, supported and helped them. She was like a Messiah in their eyes - the doctor was deified and glorified. She treated them as human beings, and not as scum - she respected their arguments and listened to their opinions, corrected ignorance, encouraged attempts to learn something about the disease even with the simple questions that they asked. The children had fun with her and she was smiling and wasn't afraid to hold them. The lady doctor understood some Romany (language) and showed that she didn't put a linguistic, religious and ethnical barrier. When we went for the next visit, we had to pass through several yards, garages, under hanged out carpets to reach a room without any windows. There was a newborn child growing up. He was feverish and had never seen daylight. He was oriented towards the electric light. His mother had undiagnosed facial paresis, which had already twisted her smile and closed her right eye. In front of me was the ignorance of the patients and the carelessness of the doctors that could have been fatal for young woman's life. Insufficient health culture competed with a strong sense of motherhood and the wish to bring up a healthy child. She devoured every piece of doctor’s advice and showed interest in caring for her son.

Efforts to promote the health of Romany populations often fail to confront the social structures which shape health in the first place: inequity and discrimination in education, employment, and housing; poor access to clean water and sanitation; lack of social integration; minimal political participation; poor access to food; disparities in income distribution; etc.4 In a General Comment issued in 2000, the UN's Committee on Economic, Social and Cultural Rights noted that:

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"...the highest attainable standard of physical and mental health is not confined to the right to health care. On the contrary, the drafting history and the express wording of article 12.2 [of the ICESCR] acknowledge that the right to health embraces a wide range of socio-economic factors that promote conditions in which people can lead a healthy life, and extends to the underlying determinants of the health, such as food and nutrition, housing, access to safe and potable water and adequate sanitation, safe and health working conditions, and a healthy environment." 5

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between children, parents, teachers and civil organizations. Attention is paid to women in disadvantageous position, having problems and women victims of violence. There is a centre for delivery of social consultations to citizens, which is the place where people desperate about the unemployment and scarce social aid can solve such problems in some way. This is only a brief information on the exceptional role of the Romany NGOs for the development of the Romany society, as most favourable is the fact that a Romany acts for another Romany thus eliminating any negativism or distrust and clearing the way for solving a number of issues.

But health cannot be described or improved in isolation.

The good work of these organizations cannot, however, take the place of the state, nor have they such intention. The aim is to correct the omissions of the state legislation in respect of the rights of the Romany and stimulate their social growth. Representatives of the Romany ethnic group take part in the state government, which presupposes improvement of their status.

The limited civil skills in the promotion of health amongst Romany population have their effect upon the development of many NGOs, Romany and nonRomany. Their efforts to improve the social status of the Romany in Bulgaria deserve our admiration. Their work is directed to Romany of all ages with a common goal improvement of the health and social culture of the Romany community. Thanks to their meetings with pupils graduating from the high school, the number of Romany enrolling in higher schools grows. They are ambitious, persevering and enthusiastic about the fact that they can further their education - what was impossible for their parents due to not being well informed or lack of financial means. The success of this initiative is a result of the joint cooperation between pupils, teachers, parents and the institutions concerned.

An important point is the involvement of European organizations for solving these issues, and a greater confidence in the contingent they work with, because what is the sense of supporting anyone if they know that you do it as a part of your duty. We believe that with Bulgaria joining the European family there will be a stronger impetus for the development and improvement of their lives.

For younger pupils there is another interesting form of intellectual development - internet clubs, material arts, folklore dance club, computer courses, modern dance, language courses, football team and other, organizing by Romany organizations. The attempts to improve health culture also give good results. An ambition exists there to support these groups of Romany who do not have a general practitioner and no prophylactic examinations carried out amongst them. It has been provided for the children in the neighbourhoods to have weekly check-ups by paediatricians at the place, as well as vaccinations. The project of creating a model school for joint education of Romany and Bulgarians is also interesting. The aim is to improve the conditions of conjoint living for the Bulgarian and Roma children at school. It has been achieved through improvement of the school conditions in order to encourage the attendance and keep Romany children at school, as well as attract Bulgarian children. It is useful to involve the parents and the community as partners in the process thus improving the integration

REFERENCES: 1 Hajioff S, McKee M. The health of the Roma people: a review of the published literature. Journal of Epidemiology and Community Health. 2000. 54: p 864-9. 2 Ringold D. Roma and the Transition in Central and Eastern Europe: Trends and Challenges. Washington DC. The World Bank. 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. General Comment 14. UN ESCOR. Doc. E/C.12/2000/4. 2000. 6 Slavev A. Report for Evaluation. Project: A Resource Centre for the Development of North-Western Bulgaria. Feb 2003.

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Becoming a doctor

Author:

Hrvoje Vrazic MD, Medical School, University of Zagreb, Croatia EMSA Liaison Officer towards IFMSA 2003/2004 Contact:

hrvoje.vrazic@zg.htnet.hr

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

biggest highlights is definitely attendance of EMSA meetings. You get addicted. For real. I have experienced this feeling twice already - first time was after my first mandate as the president (2001/2002), when I ran for the position of the president again; and second time was after my second mandate as the president (2002/2003), when I ran for the position of the EMSA Liaison Officer towards IFMSA. This year, at this GA, I am finishing my involvement in EMSA. Only officialy, of course, as I will always be there to help by email, or when having an opportunity of attending an EMSA event, of course, taking into consideration the new obligations I will have. But the major difference now is that there are NO MORE extensions, my student days are over, my involvement in EMSA as a student is also over, and I know now I will miss it badly.

As much as all of us in our student days want our torments in form of exams and obligatory attendance to end as soon as possible, once when this really happens, we sometimes remember a proverb "Be careful what you wish for, you just might get it." I graduated on June 28th this year, so what I will write here is mostly based on personal experience, but also based on numerous talks I had with various people over the past few years of my active involvement in student organizations. Sometime right after the graduation day, in terms of becoming aware of many things that have changed at that moment, one of the biggest changes was the one related to EMSA.

Of course, there are various organizations for young doctors, European doctors, old doctors and all other kinds of doctors, so you can continue your activities, but it will be different. If nothing else, you will at least need to meet all the new people again to experience that feeling of being home, like I did with EMSA. And, as with any other change, you are not too thrilled about it. Because if something is good, why change it? But of course, this is different, as you age, you learn to move on.

Having spent three years in EMSA, I have got used to a more or less constant workload. You automatically allocate a part of the day as EMSA time, mostly replying e-mails or writing something. And over the time, you really stop noticing it. Just when you are about to finish some engagement with EMSA, although funny and strange, the first thing that comes into your mind is: "Oh my God, what I am going to do with all the free time after EMSA?" Ironically, all those years you spent in EMSA, you wanted some free time, and now that you actually have a chance to get some free time, you are not happy again, because you will not know what to do with it. This is what is called the "EMSA paradox" (by the way, the same paradox explains why you still want to work in EMSA again and again, although there were numerous times when you wanted to smash your computer, because you couldn't reach people, or were endlessly frustrated with the work still pending, cursing the day when you signed up for a position, swearing you will be much smarter next time). I believe that the feeling can be best described as feeling helpless and lost in a way. Then, naturally, you start looking for other ways to occupy yourself, or for further engagement in EMSA. It's not just the work and the chance of collaboration with all the various types of people you meet, but also one of the

When I was starting in EMSA, it was always funny for me to see some of the experienced EMSA people always saying that "this is their last meeting", but still they would come to one or two more, every time saying the same. From what I've seen and from my experience, you will be announcing that it is your last EMSA meeting at least one or two meetings prior to the real last one. One of life's biggest advantages is that in the long run you mostly remember only nice and pleasant things, while the unpleasant ones have a tendency to be forgotten. It is the same with me and EMSA - I finish my involvement in this organization full of nice memories, of great people I had a chance to meet, have fun with, and even to work with some of them, sharing all sorts of good and bad moments of my and their lives. That was an experience I will never forget, and it hasn't got a price - it's priceless. And if someone was to ask me whether or not I would do it all again, the answer would be a screaming and definite YES!

! S E Y

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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 of Public Health "Andrija Stampar", Medical School, University of Zagreb, Croatia. Zagreb 2001)

For many years Dubrovnik was one of the largest cultural centres in Croatia. Many famous Croatians were born in Dubrovnik: Marin Drzic, the great Croatian Renaissance playwright, Rugjer Boskovic, world renowned 17th century scientist and philosopher, and Gjuro Armeno Baglivi, famous 17th century physician. This small city-state has always, through its rich and turbulent history, been opened to the world. Its unique geographical position between the west and the east Mediterranean gave Dubrovnik's cultural tradition certain flare, a mixture of different cultural and scientific influences. The inhabitants of Dubrovnik were always willing to contribute to the development of their city. That is why they travelled all over the world to study the

- that of the culture of Dubrovnik, which still exists today. Therefore Dubrovnik has always been viewed as a world of its own within the Croatian cultural context. RECTOR'S PALACE - AESCULAPIUS' CAPITAL (the beginnings of medicine in Dubrovnik)

Dubrovnik has, ever since its foundation, been connected with medicine. Its founding fathers were the inhabitants of the nearby antic Greek colony of Epidaurus who brought to the region the cult of the Greek god Asclepius (in Latin Aesculapius) from their homeland. The reminders of these events are today the capital on Rector's palace dedicated to Aesculapius and the Latin inscription on the wall near the capital: "Munera diva patris, qui solus Apollonis artes, Invenit medicas per saecula quinque sepultas Et docuit gramen, quem usum quodque valeret Hic Aesculapius caelatus, gloria nostra Ragussi genitus, voluit quem grata realtum Esse Deos inter veterum sapientia partum Humanas laudes superaret rata quod omnes Quo melius toti nemo quasi profuit orbi." "Here the Aesculapius is carved, our glory, the one who found the arts of medicine, divine gifts of his father Apollo who were hidden for the five centuries. The one who thought (us) of the purpose of every medical herb. He was born in Dubrovnik. The praised wisdom of (our) fathers made him a god because it was thought that he had surpassed all the human praise as not helped the whole world better than he did." CHURCH AND ROLE OF ST. BLAISE

The Church of Saint Blaise is dedicated to the patron of Dubrovnik Saint Blaise. The patron on every sculpture holds the model of Dubrovnik in his hands. His blessing is considered to have protective powers against the illness of the throat. In 972 AD the citizens of Dubrovnik named as their patron St. Blaise (or, as we call him in Dubrovnik, St. Vlaho) who was a bishop and a secluded physician who lived in the wilderness. Every year on the 3rd of February there is a big procession in the name of St. Blaise in Dubrovnik where the blessing of the throat or the so called "grlicanje" is usually performed with two intertwined candles near the throat.

achievements of other nations to educate themselves at the best universities and, through successful commerce, acquire the most exotic goods for their little community. Dubrovnik has also been open to other nations and cultures that came in order to settle down within its walls for different reasons. Through this cultural exchange between Dubrovnik and the rest of the world a specific cultural blend was formed www.emsa-europe.org

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the city until the epidemic was over. Only 10 noblemen were left to watch over the city until the end of the plague. The one who was found responsible for spreading the plague to the city was punished even with the death sentence.

PUBLIC HEALTH CONDITIONS IN OLD DUBROVNIK

The statute of the City of Dubrovnik from 1272 AD is one of the oldest Croatian legal documents and where one can find a number of regulations concerning medicine and the quality if life of the population of Dubrovnik. In 1272 AD in order to improve the sanitary conditions in the city many measures were introduced. Those regulations can still be seen in the archives in "Liber statorum". All the inhabitants, both male and female, were obliged to keep the street in front of their house clean (this was usually done on Saturdays). The other regulations from "Liber Viridis" c. 7 prohibit the disposal of garbage near the city gates (there were special holes in the city walls for the disposal of the garbage). In 1272 AD a regulation was passed that the latrines should be kept in houses on wooden balconies above the street. From the year 1321 AD the latrines should only be kept in the houses and the waste from them was only to be disposed of at night. From 1407 AD to 1436 AD a sewage system was introduced to Dubrovnik. In 1336 AD people were forbidden to keep animals in the city. In 1407 AD a regulation was introduced that all the streets in Dubrovnik should be paved and in 1415 AD the first city street-sweepers were introduced.

Other epidemic diseases of that time besides the plague were also present among the population of Dubrovnik (leprosy, smallpox, dysentery, gout, urinary diseases, syphilis, rheumatic diseases and different GI infections). Those who had leprosy lived outside the city walls in special institutions, leprosarium, which were financed either by the state of by private donations. In 1784 AD variolisation was introduced to Dubrovnik to prevent the smallpox. In 1800 AD Luca Stulli, a famous physician from Dubrovnik, introduced the new Jennerian invention - vaccination to Dubrovnik. ORPHANAGE - ORGANIZATION WELFARE SYSTEM IN DUBROVNIK

OF

THE

SOCIAL

The high level of the organization of social welfare in Dubrovnik can be observed in the documents connected to the founding of the orphanage in 1432 AD. This "Ospidale della misericordia" took care of the unwanted children and had a maternity ward where mothers could give birth to their illegitimate children. Also in 1432 AD the decision was made by the city authorities to prohibit leaving unwanted children in different public places (even infanticide was not uncommon until that time). On the left side of the entrance there was a window with "ruota", a big wheel where mothers would leave their child, usually at night. They would place their child on it and then the wheel would turn and the child would find itself in the premises of the orphanage. Nobody was allowed to stop masked woman carrying the child during the night, for she and the child were protected by the law. In that way discretion was guaranteed and the identity of the mother remained a secret. When they were six years old the children would be given up for adoption or the real parents could claim them back, but they would have to prove that they were the natural parents of a child.

LAZARETI - QUARANTINE OF DUBROVNIK

Near the east city gates "Vrata od Ploca" there is the building that has the greatest significance for medical heritage of the old Dubrovnik. The complex of various buildings called "lazareti" represents the quarantine of Dubrovnik. Before entering the city the newcomers had to spend 30 days in quarantine to see whether they would develop any symptoms of a disease. Later, it was prolonged to 40 days. The name quarantine comes from the Latin word "quaranta" meaning 40 as written in the Statutes of Dubrovnik. If the plague entered the surroundings of Dubrovnik but not the city itself, in spite of quarantine measures, city gates were closed, and the entrance to the city was forbidden to those coming from the infested region under the threat of death. If the plague had spread to the city, all inhabitants abandoned

FRANCISCAN MONASTERY - PHARMACY IN DUBROVNIK

In Dubrovnik, as in the Orient, the preparation of pharmaceutical compounds was in the hands of pharmacists, not physicians as it was in the rest of Europe. In 1317 AD at the premises of the Franciscan monastery in Dubrovnik the first pharmacy was founded. Even today, there is the same public pharmacy that still serves the inhabitants of Dubrovnik.

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

DUBROVNIK'S WATER SYSTEM

The new Dubrovnik's water system was finished in 1438 AD by Onofrio della Cava. It was 11,700 meters long, situated 106 meters above sea level, with 4 big water tanks.

The Republic employed the physicians for a period of 1-2 years. If the citizens were satisfied with their service, their employment was prolonged. The difference between physician and pharmacist was clearly regulated. In 1383 AD the private practice of the physician employed by the state was prohibited. One of the most famous physicians who worked in Dubrovnik was Amatus Lusitanus (1511 AD - 1568 AD), who was a Jew from Portugal, a professor of medicine in Ferara and physician to the Pope.

DOMUS CHRISTI - HOSPITAL AND NURSING HOME

At the beginning of the 14th century Dubrovnik already had a number of hospitals, which were financed either by the state, by private donations or by fraternities. On the 30th January 1347 AD the hospital "Domus Christi", also known as "hospitale grande" was founded and served as a public hospital with its own physicians, management and staff. The physicians had to visit patients twice a day. On 20th April 1847 AD physicians Niko Pinelli and Frane Lopisic, one year after its first application, applied for the first time the ether narcosis during an operation for breast cancer. In 1888 AD all the hospitals united in the new one situated in the part of the town called Boninovo, and "Domus Christi" was converted into a nursing home for the elderly (which is how it remains today). DUBROVNIK'S PHYSICIANS

MEDICAL

PRACTITIONERS

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IN THE END

The medicine of Dubrovnik was never of the local character nor was it ever isolated from the developments in this field from the rest of the world. It was always aware of the latest achievements in medical science and praxis. Many famous physicians lived or were born in Dubrovnik. Furthermore, the citizens of Dubrovnik were aware of the significance of the latest public health and hygienic achievements for the development of their city. The respect for human dignity and ethical awareness were always of a high standard. The medicine of Dubrovnik has, during many centuries, in many aspects been more accomplished than in any other Croatian region.

AND

The physicians and surgeons of Dubrovnik were praised even outside of the state borders. They were often invited to the neighbouring countries to help those that were ill. Furthermore, government of Dubrovnik often sent medical supplies and medical textbooks to their neighbours (Turkey, Bosnia, Zeta, Serbia). Even from the Middle Ages the population of Dubrovnik strove

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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) Contact:

esivrikoz@yahoo.com

Aim. To evaluate the role and effectiveness of rt-PA in the treatment of venous-thromboembolism and arterial occlusions, as well as to clarify its indications and patient selection bias. In both sections, the fibrinolytic therapy is based on a "pulse-spray" catheter directed 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 threatening iliofemoral vein thrombosis were included. Anticoagulation was started with LMWH once a day on admission and was continued with Warfarin. A pulse spray catheter was introduced through ipsilateral popliteal vein and advanced into the thrombus under fluoroscopic control and thrombolytic agent was delivered. The infusion of rt-PA continued for 24 hours at a rate of 1 mg/hour. A phlebography was undertaken 24 hours later to evaluate efficacy, and the infusion was continued for 2 more days in insufficient thrombolysis. During the period from 1999 to 2002, 15 patients who were admitted to our Emergency Surgery Department because of peripheral arterial occlusions were included. A pulse-spray catheter was directed to the thrombus under angiographic control. Bolus injection of 5 mgr of rt-PA (Actilyse, Boehringer Mannheim, Germany) was followed by a 15 minutes interval. An angiography was performed and bolus injection of 5 mgr of rt-PA was repeated. After angiographic control, patients having insufficient thrombolysis received 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 these needed only 1 bolus injection and the other 8 needed two bolus injections and the infusion, 1 patient had partial recanalisation, 2 patients needed a balloon dilatation and 2 patients needed an embolectomy. 3 minor bleeding and 2 strokes were observed. 1 patient with a stroke and 1 patient during trombolysis were lost during the treatment. 1 patient with acute MI, and 1 patient with diabetic 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.

Deep Vein Thrombosis (DVT) may present a danger of limb loss due to the cessation of the arterial blood flow because of the compartment syndrome if the thrombus extends distally to the leg or proximally to inferior vena cava. Unless prompt and appropriate treatment is undertaken, venous gangrene may ensue. The first line treatment is anticoagulation with either standard heparin or low molecular weight heparin LMWH, followed by variable duration of oral anticoagulation. The treatment aims to inhibit the thrombotic process and the inflammatory response. Hence acute symptoms are relieved, pulmonary emboli are prevented, the veins are kept patent and the valves are preserved which helps to avoid a subsequent postthromboflebitic syndrome. Anticoagulation therapy is a standard and an effective treatment modality, though its main disadvantage is that it does not prevent postthromboflebitic syndrome in all cases. Residual venous stenosis and damage to the venous valves which together causes venous hypertension are thought to result in postthromboflebitic syndrome. In order to improve late results of the treatment in lower extremity deep vein thrombosis, the thrombus should be removed as soon as possible. The therapeutical options

for the removal of the thrombus are systemic thrombolytic therapy, surgical thrombectomy, and local thrombolysis.1, 2 Streptokinase, urokinase, and recombinant tissue plasminogen activator (rt-PA) are the ideal adjuvant thrombolytic agents to the anticoagulation therapy. Thrombolytic agents establish the vein patency rapidly and thereby may preserve valve functions. In recent years more aggressive therapy with catheter-directed thrombolysis was introduced to eliminate the venous thrombus, to restore the unobstructed venous drainage from the affected limb, to preserve the valve functions and thereby improving the health-related quality of life.3 Acute peripheral arterial obstruction is a significant cause of limb loss. Until the 1940's, amputation was the only treatment in gangrenes caused by acute arterial occlusions. Later, this treatment approach has left its place to embolectomy and operative revascularization. Today, intra arterial thrombolytic therapy is used as an alternative to surgical treatment methods, to restore arterial circulation in acute peripheral arterial occlusion.

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Due to recombinant DNA technology, the Tissue Plasminogen Activator (rt-PA) (Alteplase, Actilyse, Boehringer), which is the most preferred among these agents, is available for clinical use. This agent is fibrin specific and its reperfusion time is shorter than urokinase or streptokinase4. In addition, unlike streptokinase, rt-PA doesn't have an antigenic nature so it doesn't cause any allergic reactions when used more than once.

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ed to document the distal extent of the thrombus and to visualize collateral pathways. For local delivery of thrombolytic agent, a pulse spray catheter was positioned with its tip into the thrombus. A heparin infusion of 5000 IU was accomplished simultaneously via a peripheral route. The infusion of rt-PA (Actilyse, Boehringer Mannheim, Germany) continued for 24 hours at a rate of 1 mg/hour. In order to evaluate the efficacy of the procedure a phlebography was undertaken 24 hours later and if the thrombolysis was not sufficient enough the infusion was continued for 2 days more. The treatment was stopped in any case with a final phlebography.

In the ensuing sections, the fibrinolytic therapy of DVT and Acute Arterial Occlusions, will be covered each on their own perspectives. In both sections, the fibrinolytic therapy is based on a "pulse-spray" catheter directed infusion of rt-PA directly into the thrombus.

Results

Of 7 patients with the diagnosis of iliofemoral vein thrombosis and a threatened limb, 3 were female and 4 were male. The median age of the patients was 53 (3370). All of the patients had the clinical characteristics of iliofemoral vein thrombosis such as oedema, pain, and swelling of the affected limb. Mean admission time to the hospital was 2.5 days.

A) DEEP VEIN THROMBOSIS Material and Methods

Patients: Between 1999 and 2001, 7 patients who were admitted to the Emergency Department of Medical Faculty of Istanbul University because of a limb threatening iliofemoral vein thrombosis were included in the study. The patients with suspected deep vein thrombosis were initially evaluated with a careful history taking to discover a possible aetiology. After a thorough examination, complete blood count and Prothrombin time (PT), Partial Thromboplastin time (PTT) and INR were determined. The aetiology was researched with the laboratory tests for the deficiencies of the thrombolytic cascade, e.g. protein C, protein S, antihrombin 3, factor V Leiden mutation etc. A pelvic ultrasonography (USG) was performed to exclude any pelvic malignancy. Colour flow duplex examinations of the extremities were performed. Having an established diagnosis of iliofemoral vein thrombosis by means of both clinical and radiological examinations; the patients were enrolled to fibrinolytic treatment. The patients with a history of recent cerebrovascular accident, bleeding diathesis, gastrointestinal system bleeding during last ten days, or major neurosurgical operations or intracranial bleeding in last 3 months were excluded from the study. The leg circumferences and D-dimer levels were measured and recorded before and after thrombolytic therapy. The patients were given 150 ug/kg enoxaparine once a day on admission. Anticoagulation therapy was continued with warfarin after the thrombolytic therapy to maintain an INR (prothrombin time) between 2.0 and 3.0. The warfarin treatment was continued for 3-6 months according to the risk factors. The patients were controlled every week for the first 3 months and later for every three months for one year.

One of the patients was operated for knee prosthesis in the same leg 2 weeks ago. Deep vein thrombosis had developed 10 days after the operation. Two patients had a history of extremity trauma. One had an occupational accident with the involved leg a week ago and the other patient had a history of falling from heights. There was no fracture, but a soft tissue injury in his leg. The rest of the patients did not have any known etiological reason. Protein C, protein S, Antithrombin 3 deficiencies and Factor V Leiden mutation were checked in these patients. The laboratory results did not reveal any abnormalities. All of the patients had a Doppler USG examination on admission. The deep vein thrombosis was acute and it involved popliteal vein, superficial femoral vein, and the iliac veins. Before starting the thrombolytic therapy, the phlebography correlated with the colour flow duplex findings. In patients with an effective thrombolytic therapy, D-dimer levels were found to be increased after the thrombolytic therapy. The results were 10 to 25 X normal levels. The mean difference in the leg circumferences was 6 cm in the cruris. Five patients had nearly complete lysis of thrombus after the thrombolytic therapy (80%-95%) (Table 1). One patient had a partial lysis. The thrombus in the popliteal vein, and common femoral vein was lysed . But the common iliac vein was still thrombosed. Another patient did not have any benefit from thrombolytic therapy at all. She continued with the anticoagulation therapy and hospitalized for 1 week. She was discharged with recovery from the hospital.

Catheter - directed thrombolysis: Ipsilateral popliteal vein of the affected limb was catheterized for the entry site. With the patient prone, the popliteal vein was visualized by ultrasonography and a single wall puncture was made. The thrombosed vein was probed with a steerable wire and catheter under fluoroscopic control. After complete passage of the wire through the thrombus, the catheter was advanced and contrast was inject-

There were no complications during the infusion of the rt-PA except a patient had a sinusoidal tachycardia at 36 hours. He had a history of atrial fibrillation. The solution was stopped and the patient was followed with close monitoring. The same patient had cerebrovascular accident three days later and he died.

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One patient had dyspnoea, tachycardia, and tachypnoea three days after the procedure. Pulmonary emboli were proved by the ventilation-perfusion scintigraphy. The patient was hospitalized 22 days and did not develop any sequels. She was discharged with anticoagulation treatment from the hospital afterwards.

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not require haemodialysis and responded well to medical treatment. Recovery was complete. B) ACUTE ARTERIAL OCCLUSION Materials and Methods

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

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

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Medical Faculty because of peripheral arterial occlusions were chosen for this study. Patients had clinical symptoms and signs as pain, pallor, poikylothermia, par aesthesia and paraplegia. Doppler examination was performed in pulse less arteries and ankle-brachial index was measured.

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Results

15 patients were included in the study. There were 9 males (60%) and 6 females (40%) with an average age of 67 (range 55 - 90). Patients had clinical signs of peripheral ischemia as pain (15 patients - 100%), pallor (14 patients - 93.3%), poikylothermia (15 patients 100%), cyanosis (2 patients - 14%) and paraesthesia (2 patients - 13.3%). The duration of ischemia before their hospitalisation took an average of 46.7 hours. (Range 3 hours - 7 days) .The shortest occlusion was 6 cm and the longest was 45 cm. The average length of occlusions was 16 cm. Occluded arteries were superior mesenteric artery (1 patient - 6,7%), femoropopliteal artery (2 patients - 13.3%), iliofemoral artery (3 patients - 20%), popliteal artery (5 patients - 33.3%), posterior tibial 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 given in table 2.

Patients with symptoms of peripheral arterial occlusion were included in the study after being examined and verified with angiography. Patients with re-occlusion after a prior thrombolysis, those having a stroke, who needed urgent exploration because of severe ischemia, or those having a high bleeding risk were not included in the study. Treatment Protocol: A pulse-spray catheter was directed to the thrombus under angiographic control. Bolus injection of 5 mgr of rt-PA (Actilyse, Boehringer Mannheim, Germany) was followed by a 15 minutes interval. The extent of thrombolysis was checked by angiography and then bolus injection of 5 mgr of rt-PA was repeated. After angiographic control, patients having insufficient thrombolysis received 0.05 mgr/kg/hour of infusion for 12 hours. At the end of 12 hours, thrombolytic treatment ended with a control angiography. A thromboembolectomy operation was performed on patients still having an occlusion after thrombolysis. Moreover, to avoid re-occlusions, all of the patients received 1,5 mgr/kg/day low molecular weight heparin (enoxiparin) for 1 week. LMWH application started about six hours before thrombolysis. The algorythm of our treatment protocol is shown in figure 1.

13 patients had emboli and 2 had acute thrombosis. Besides thrombolysis a balloon angioplasty was performed on patients having acute thrombosis. 46.7% of the patients had a cardiac disease, 33.3% had diabetes and 40% had hypertension. Recanalization: At the end of thrombolysis, 10 patients had complete reperfusion. 2 of these needed only 1 bolus injection and the other 8 needed two bolus injections and the infusion. One patient, having an occlusion in superior mesenteric artery had 60% recanalisation. 2 patients (13.3%) having 90% stenosis, in the part of the superior femoral artery found in Hunter's channel, needed a balloon angioplasty following thrombolysis, and both of them had complete reperfusion. 2 patients (13.3%) needed a thromboembolectomy operation due to insufficient thrombolysis.

Treatment was considered successful if pain disappeared and/or pulses were restored, and if revascularisation was verified with angiography. Recanalisation was calculated by the ratio of the lumen restored to the normal lumen of the artery. One week after thrombolysis, patients were re-examined; during their physical examination, their cardiac functions were checked with echocardiography. Those having a source of embolus were given an oral anticoagulant (Coumadin) for lifelong use.

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

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Mortality: 1 of the patients (patient 7 in table 2) having a stroke died 2 days after thrombolytic treatment. 1 patient (patient 12 in table 2) died due to myocardial infarction during thrombolysis. He didn't have cardiac symptoms before thrombolysis.

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catheters.8, 9 Increasing age of the thrombus and a previous history of thrombosis in the same extremity are reported to affect the lysis rate negatively. Lysis of the thrombi may lead to clot fragmentation and increased risk of pulmonary embolism. In practice, symptomatic pulmonary embolism is a rare complication: The National Multicenter Registry observed 6 cases of 473 patients treated (1%), 1 of which was fatal.16 We observed one patient while developing pulmonary emboli after thrombolytic therapy. It was clinically symptomatic but the patient recovered quite well. Pulmonary embolism may also occur during conventional therapy for DVT, and in the absence of a direct randomized comparison it is difficult to judge whether the thrombolytic therapy increases the risk. Temporary vena cava filters have initially been used in some centres to prevent pulmonary embolism but later was abandoned because of the low incidence of symptomatic embolism.

Follow - Up (30 days): 1 patient (6.7%) died due to diabetic coma on the 20th day. Acute myocardial infarction 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 syndrome in the affected limb and venous gangrene may ensue. It may accompany the sensory and motor loss of function as well. Therefore it may require an immediate treatment in order to avoid the loss of involved limb. The most common therapy for deep vein thrombosis consists of anticoagulation with either standard heparin or low molecular weight heparin (LMWH), followed by oral anticoagulation. Strategies using either unfractioned heparin (UFH) or LMWH are found to be equally effective in preventing the pulmonary emboli and recurrent events. A metaanalysis of the thirteen randomized trials comparing treatment with UFH or LMWH reported on over 4000 patients. In a three to six months follow-up period, the risk of recurrent venous thromboembolism was 5.1% and 4.4% for UFH and LMWH, respectively (risk difference not statistically significant), and a risk of symptomatic pulmonary emboli of 1.8% and 1.9 % for UFH and LMWH respectively (risk difference not significant).6

DVT extending into the iliac veins or vena cava inferior is associated with significant morbidity despite adequate treatment with the standard anticoagulation therapy. Moreover, while anticoagulation therapy is clearly effective in preventing recurrent venous thromboembolism and pulmonary emboli, long-term sequels of DVT can not be prevented as efficient as pulmonary emboli. One of the important long-term sequels of the venous thromboembolism is postthromboflebitic syndrome (PTS). PTS is thought to be the result of residual venous stenosis and damage to the venous valves which together cause venous hypertension.12 Thus, early removal of the thrombus is essential in preventing PTS as experimental models have shown that the inflammatory changes in the vein wall and valves are reversible if the thrombus is dissolved early.13 Thrombectomy and thrombolysis are the two alternative therapeutic options that aim at early thrombus removal. A randomized study compared venous thrombectomy with anticoagulation.14 Thrombectomy decreased the early symptoms and preserved venous outflow and valvular function better than conservative treatment. However, after 5 years of followup, the clinical and functional differences between the two groups appeared less convincing. After 10 years of follow-up the results are encouraging in favour of thrombectomy, which is convincing the benefits of early removal of the thrombus.15 Nevertheless thrombectomy has its own complications such as inguinal haematoma, lymphatic drainage persistent for 2-3 weeks, infection etc. since it is a surgical procedure. Although the late postthromboflebitic sequel takes years to develop and the current follow-up of our study is still short, the patients with iliofemoral thrombosis benefited from thrombolytic therapy quite clearly.

Systemic administration of streptokinase enhances the lysis of the thrombi, though its clinical benefit is in question. Thrombolytic therapy with intravenous infusion of rt-PA is disappointing.7 Thrombolytic agents were compared in different studies. For the study of Braithwaite et al, rt-PA is faster and more effective than streptokinase4 but for STILE trial, made with 393 patients, tPA is not different than urokinase or streptokinase.10 For streptokinase, infusion times longer than 96 hours have been reported.11 Today, Urokinase is not available any more for unknown reasons. Anaphylaxis is rare with any of the thrombolytic agents, but allergies characterised by early flushing, vasodilatation, rashes and hypotension are a complication with Streptokinase. In recent years, a more aggressive therapy with "pulse-spray" catheter-directed thrombolysis was introduced. With this catheter, thrombolytic agents can be injected in to the thrombus with a high pressure, that's how the thrombus is separated into smaller parts and the surface of reaction is increased. Pulse - Spray technique is used to increase the speed of thrombolysis and to decrease the duration of therapy. Complete lysis in 34%, and 50-99% lysis in 52% of the patients with iliofemoral thrombosis are reported in the literature.7 However, it has been reported that after an anterograde flow in the vessel has been obtained, pulse - spray infusion catheters are not superior to classical infusion

In a study made in the General Surgery Department of Istanbul Faculty of Medicine, it has been observed that thrombolytic therapy needs a shorter hospitalisation period than surgical treatment. Thromboembolectomy and thrombolysis, had a similar rate of mortality (14% and 11,7% respectively), but limb salvage rate was much higher with thrombolysis (the amputation rate was

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15,9% for thromboembolectomy and 0% for thrombolysis).17 Moreover, although rt-PA is expensive, in total price, thromboembolectomy costs more than thrombolysis. According to STILE trial and Mc Namara, surgical reconstruction is better than thrombolysis in chronic ischemia caused by thrombosis, but the results of therapy are better in thrombolysis in acute ischemia (<14 days). However, there was no difference in amputation and in mortality rates.10, 18 In our study, all arterial occlusions progressed acutely and the aetiology was thought to be thrombosis. A claudication history was referred to a thrombosis, and patients with cardiac pathologies or patients not having a history of occlusion were referred to emboli. In 2 patients having thrombosis, angioplasty was added to thrombolysis to obtain revascularization.

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ing collaterals in embolic occlusions which causes the length of the occluded section to be estimated longer that it actually is. However, in thrombotic occlusions, as collaterals are formed, there is a correlation between the appearance of a non-occluded artery in angiography, and the rate of reperfusion. In a study, with the increasing length of an occlusion, the rate of complete recanalization decreases from 63% to 42% and also, the percentage of partial recanalization increases from 12% to 29%.5 Moreover, as the length of the occluded segment increases, the frequency of complications increases too. In our study (acute arterial occlusions), in 2 patients only partial recanalization could be obtained by thrombolysis, but in the same session complete recanalization could be obtained by adding more rt-PA.

Bleeding is the most common complication of all thrombolytic therapies. Major bleeding site is the catheter insertion place. In the National Multicenter Registry, it happened in 4% of the patients.16 There could be other sites for bleeding but they are reported to be quite rare. The most devastating complication is the intracranial bleeding. There was one fatal intracranial haemorrhage and one patient suffered a subdural haematoma, for a frequency of major neurological complications of 0.4% in the National Multicenter Registry.16 In our study we had one patient with intracerebral accident and he died three days later. He had a history of atrial fibrillation. We did not have an opportunity to make an autopsy. Therefore we do not know whether it is a hemorrhagic infarct or not.

Thrombolytic therapy is also used in aneurysm surgery. Due to thrombolytic therapy applied during the operation, the arteries distal to the aneurysm can easily be cleaned with thrombolysis. In our clinic, we applied in 2 patient thrombolytic therapy during a popliteal aneurysm operation, with good results. In literature, there are also studies, which combine thrombolysis with endovascular surgery.

In most of the studies made with rt-PA, it has been reported that the increasing dosages are not increasing the effect and the most effective dosages were reported to be 1mg/hour or 0,05mg/kg/hour.9, 19 There is not clear information about bolus injection. 0,05mg/kg/hour infusion added to 5mg bolus injection that we used in our study was not used before. Observing the 19 prospective studies made by Berridge between 1974 - 1988, the incidence of haemorrhagic stroke is 1% and the incidence of major haemorrhage is 5,1%.20 The incidence of stroke (haemorrhagic or ischemic) observed in thrombolysis with low doses is reported 1,2% and 2,1% in literature.21 Although these incidences are lower than 14% that we had in our study for acute arterial occlusions, there are big differences in the number of patients and in population types in different studies. The bolus injection that we use, can be a factor increasing the mortality and the morbidity of our study. In a study made by Decrinis et al with 210 patients. 10mg rt-PA was combined with 3000 IU heparin and the mortality rate was reported 0%. However, in 30 days follow up, 2 patients (1%) died due to CVA5. The best results in literature were obtained with the long time infusion of low - dose rt-PA and it has been decided that it would be better to follow patients in intensive care unit.22

Based upon our evaluation, the conclusions that can be drawn are that 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. In both of our studies, patients benefited from thrombolytic treatment clearly, as it gave us the opportunity to intervene quickly, to avoid the occurrence of posttrombotic syndrome as well as the complications of the surgical treatment. In order to improve the safety and effectiveness of the therapy, more trials with late results are needed. REFERENCES

In the studies made, it has been observed that there is not a correlation between the length of occlusion in embolic occlusions and the rate of reperfusion. The cause of this, is thought to be the improbability of form-

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1

Haas SK. Treatment of deep venous thrombosis and pulmonary embolism. Current recommendations. Medical Clinics of North America 1998. 82(3): 495-510.

2

Semba CP, Dake MD. Iliofemoral deep venous thrombosis: aggressive therapy with catheter-directed thrombolysis. Radiology 1994. 191: 487-494.

3

Comerota AJ, Throm RC, Mathias SD, Haughton S, Mewissen M. Catheter-directed thrombolysis for iliofemoral deep venous thrombosis 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 the role of peripheral thrombolysis but may increase the risks. Clin Radiol. Nov 1995. 50(11):747-50.


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5

Earnshaw JJ, Scott DJ, Horrocks M, Baird RN. Choice of agent for peripheral 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 with unfractionated heparin in the treatment of venous thromboembolism. Arch Intern Med. 2000. 160:18108

7

Verhaeghe R. Maleux G. Endovascular local thrombolytic therapy of iliofemoral and inferior caval vein thrombosis. Seminars in Vascular Medicine. 2001. 1: 123-127.

8

Kandarpa K, Chorpab PS, Arung JE, Meyerovitz MF, Goldhaber SZ. Intraarterial thrombolysis of lower extremity occlusion prospective randomised comparison of forced periodic infusion and conventional slow continuous infusion. Radiology. 1993. 188:861-867.

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15 Plate G et al. Venous thrombectomy for iliofemoral vein thrombosis. 10-year results of a prospective randomized study. Eur J Vasc Endovasc Surg. 1997. 14:367-374. 16 Mewissen MW et al. Catheter-directed thrombolysis for lower extremity deep venous thrombosis: report of a National Multicenter Registry. Radiology. 1999. ; 211:39-49. 17 Ustundag E, Necefli A, Kurtoglu M, Guloglu R. Acute arterial occlusions. Our results and the place of low molecular weight heparins after the operation. 3. UlusalTravma ve Acil Cerrahi Kongresi, 31 August - 4 September 1999. 18 Mc Namara TA, Fischer FR. Thrombolysis of peripheral arterial and 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 by pass grafts worthwhile? J Vasc Surg 1994. 20: 588-597.

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

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

10 STILE Investigators. Results of prospective Randomised Trial Evaluating surgery versus thrombolysis for ischemia of the lower extremity. Ann. Surg. 1994. 220: 251-268.

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

11 Decrinis M, Pilger E, Stark G, Bertuch H, Hรถnigl K. Thrombolysis with recombinant tissue -type plasminogen activator in chronic arterial occlusion a prospective randomized trial - Preliminary results. In: Strano A, Novo S, ads. Adcances in Vascular Pathology. Amsterdam: Exerpta Medica. 1990. 587 - 90

22 Working Party on Thrombolysis in the Management of Limb Ischemia. Thrombolysis in the management of lower limb peripheral arterial occlusion: A consensus document] Am J Cardiol 1998. 81: 207 - 218.

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

23 Kurtoglu M, Granit V, Necefli A, Kurtoglu M, Guloglu R. Thrombolysis 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.

13 See-Tho K, Harris EJJ. Thrombosis with outflow obstruction delays thrombolysis and results in chronic wall thickening of rat veins. J Vasc Surg.1998. 28: 115-22. 14 Plate G et al. Long-term results of venous thrombectomy combined with a temporary arteriovenous fistula. Eur J Vasc Surg. 1990. 4: 483-489.

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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 Montenegro President 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:

slavsko@eunet.yu krsticvlada9@yahoo.com

Aim. To show early results of arthroscopic meniscectomies of the knee in local anaesthesia, and also the factors that influence the 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 of eleven months after the arthroscopic procedure. There was a lesion of the medial menisci in 289 (77.3%), a lesion of the lateral menisci in 67 (17.9%) and lesion of both menisci in 18 (4.8%) patients. 69 patients were injured during sport activities, 186 at recreational activities and 119 were injured elsewhere. The average time of operation was 34 minutes (15-90). The average time for medial meniscectomy was 31.65 min. (SD 15.62) and for lateral meniscectomy 42.31 min. (SD 14.56) - statistically relevant duration 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 in matches after 30 days (20-90). The average Lyscholm score was 91.53. There was a statistically significant difference between nonathletes (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 difference between 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 procedure (dynamic evaluation of the joint, analgesic effect of long duration, one day stay in hospital, time for rehabilitation is abbreviated, general fitness is regain sooner). Lesion of the anterior cruciate ligament as well as degenerative changes at the articular surfaces has a significant influence on the final result of arthroscopic surgery. Key words: arthroscopy; meniscectomy; local anaesthesia

Meniscectomy is one of the most frequent operations in orthopaedics. With development of arthroscopic surgery, the approach to treatment of meniscus injuries is very much changed3, 4 whereas the improvement of arthroscopic technique has allowed meniscectomy to be performed with local anaesthesia.

The knee, being the largest joint in the human's body, is frequently exposed to injuries, during everyday or sport activities. Very often, in these types of injuries, the meniscus is damaged. Its role in the complicated biomechanics of the knee joint is multiple: transferring weight from femur to tibia, a significant role in maintaining the knee's stability, gliding of the joint parts, as well as lubricating the joint and protecting joint's cartilage.1, 2

MATERIAL AND METHODS

A very dynamic development of arthroscopic surgery in the past two decades caused a great number of orthopaedic surgeons to dramatically change their approach, not only towards diagnostics but towards treating the injuries and illnesses of the knee, as well. Arthroscopy allows a direct three-dimension visualization and dynamic evaluation of all joint parts, as well as therapy of injuries and illnesses of the knee. The advantage of arthroscopic procedures is in short hospitalization, small skin incisions, reduction of postoperative morbidity and lessening of the medical expenses.

In the period from January 2000 up to December 2003, at The Clinic for Orthopaedic Surgery and Traumatology (Institute for Surgery at the Faculty of Medicine in Novi Sad), 420 arthroscopic meniscectomies have been performed. Of that number 374 patients have been controlled. There were 311 men, at the average of 32 years and 63 women, at the average of 29 years (Chart 1). The average period of discomfort before operation was 881days (2 days to 10 years). The right knee was injured on 175 patients and the left one on 199 patients.

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Depending on the type of lesion, a longitudinal rupture, with or without incarceration, is dominant (Chart 3). Based on sport activities, patients are divided into non - athletes (119), recreation (186) and professional athletes (69) who compete on national level (Chart 4). Arthroscopic procedures were performed with local anaesthesia and analgosedation. After cleansing the operational area, subcutaneously at the places of stab wounds, 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 Storz arthroscope with 30 degree optics. After examining all the structures of the knee, a partial meniscectomy was performed, by using the appropriate instruments. Stab wounds were closed by individual stitching. The knee was dressed with elastic band-aid and ice was locally applied (cryotherapy). The patients were released the same day to house-care, where they were submitted to physical therapy for the following three days, in accordance with the written instructions.5, 6

Chart 1. Number and age distribution of patients underwent arthroscopic meniscectomy during our study

RESULTS

Chart 2. The percentage of meniscal lesions before arthroscopic meniscectomy was preformed

On 202 patients who underwent the partial meniscectomy, the cruciate ligaments were intact, while 170 patients were diagnosed with lesion of anterior cruciate ligament and 2 patients with lesion of posterior cruciate ligament. The knee cartilage was changed, to a variable degree on 131(35%) patients, while on 243(65%) patients no changes occurred. Evaluation of the results was based on the point scale, presented by Lyscholm i Gillquist7 (excellent result is over 90 points). Average Lyscholm score was 91.53. (Table 1) Statistic analysis did not produce any statistically significant difference in the total score, when the gender, right-left knee and the injury of the medial-lateral meniscus were compared. Statistically significant difference was obtained by comparison of the total score of nonathletes (87.83) and athletes (95.85).

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

Also, there is a statistically significant difference between the group that had degenerative changes of the knee cartilage (86.97) and the group that did not have those changes at the time of the operation (94.2) (Chart 5). There is a statistically significant difference between the group with intact LCA (92.76) and the group with ruptured LCA (88.4286) (Chart 6). Return to work was possible in average time of 34 days (7-180) after the operation. Professional athletes began training after 17 days (12 to 60) and competing after 30 days (20-90) average. Chart 4. Division of patients underwent our study, based on sport activities

DISCUSSION

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

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

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allows the optimal use of a hospital capacity and the decreasing medical expenses. Meniscectomy related complications can be surgical: injuries to blood vessels16, 17 and nerve tissue18 as well as breaking of lightsome instruments. Intraarticular breaking of instruments (scissors, and knife) was recorded in three cases. This was handled arthroscopic, i.e. there was no need for arthrotomy. Infection after arthroscopic surgeries appears in 0.07% cases.19 There is one infection recorded on our material and that was handled by giving antibiotics parenteraly and by repeating the joint punctures. Thrombophlebitis appeared as a complication on three patients. Concerning postoperative effusion, its rate varies from one author to another (up to 15% of the cases in the first week after the surgery). Within our tested group, 8 of the patients underwent knee puncture, without the influence on the treatment result.

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

Arthroscopy had to be repeated on three patients. This was due to constant pain and discomfort, which gave a clinical image of meniscus lesion. In one case, posterior cornu of medial meniscus was not completely removed. Other two patients had LCA lesion and their discomfort was related to ligament injury. Between the later results of arthroscopic and arthrotomic meniscectomies there is no difference.20 Longterm control of the patients after arthroscopic or open meniscectomy shows that partial meniscectomy, in coherence with other factors (e.g. varus-valgus deformity) leads to development of degenerative changes, mediolateral instability, etc.21, 22, 23, 24

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

Early results of arthroscopic meniscectomies on our material show that the result is better on patients which have intact LCA. Meniscectomy increases the symptoms of LCA deficiency.25, 26 Therefore, according to Hazel et al.27 a ligamentoplastic has to be performed, i.e. stabilization of the knee. Only in some cases, partial meniscectomy has to be performed isolated. Additional ligamentoplastic of anterior cruciate ligament was performed on small number of patients involved in this study. Those were mainly young active athletes. Modern point of view implies that suture of the meniscus significantly influences the restoration of normal kinematics of the knee after the reconstruction of LCA, which is shown by weaker results of LCA reconstruction via meniscectomy.28, 29

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

Roos et al.30, based on study which involved 1012 patients, concluded that, after meniscectomy, osteoarthrosis appears sooner on older patients than on younger. Partial meniscectomy on patients older than 40 years leads to clinical and radiographic signs of knee osteoarthrosis.31, 32, 33 However, Matsusue and Thomson34 consider the partial arthroscopic meniscectomy an acceptable method on patients older than 40, who do not have signs of damaged cartilage. They claim that, after 7- 8 years, 64% of their patients still indulge in sport activities, without any limitations. Roulot et al.35 feel that medial meniscectomy on older patients gives

Arthroscopic meniscectomies were performed in local anaesthesia with analgosedation without any complications related to anaesthesia. The advantages of this type of anaesthesia are in possibility for dynamic evaluation of the knee, short hospitalization of the patient and long term analgesia after the surgery.12, 13, 14, 15 This

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satisfactory results only in cases of precisely established diagnosis, i.e. in case of traumatic lesion of medial meniscus, accompanied with pain. Bonamo et al.36 in a 3 year control period, find the partial meniscectomy with a limited debridman an acceptable method in a group of patients older than 40 years, although the result is weaker on patients with degenerative changes. We found that the results are weaker with patients that already had osteoarthrotic changes at the time of arthroscopic meniscectomy than with those that did not have these type of changes of the knee.37, 38 The advantages of arthroscopic meniscectomies are primarily reflected in shortening of the rehabilitation period and sooner return to everyday activities. We detected that the postoperative rehabilitation period and the return to work very much depended on the type of work our patients performed. The return of athletes to their training and competitions was quicker than that of other population, after partial meniscectomy in the avascular zone of the meniscus. Therefore, that procedure was a method of choice to them,39 especially if there was no lesion of anterior cruciate ligament.

2

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

3

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

4

Sherman HO et al. Arthroscopy - "no problem surgery", J. Bone Joint 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 accelerates recovery postarthroscopic meniscectomy: results of a randomized controlled study. Arch. Phys. Med. Rehabil. 1994. 75(4): p 415-26.

7

Lyscholm J, Gillquist J. Evaluation of the ligament surgery results with 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 diagnosis based only on a medical history? A pilot study on women's knee joints. Arthroscopy. 1996. 12(6): p 709-714.

9

Hackenbruch W. Arthroscopy: possibilities and limitations in the diagnosis 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 During and After Knee Arthroscopy: A Comparison of Two Methods. Arthroscopy, 1998. 2: p 192-196.

Based on test results obtained, the conclusions are following:

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

Arthroscopic meniscectomy, as a method of treating individual and combined injuries of the meniscus, applied with local anaesthesia, has advantages over other methods of treatment.

13 Tsai L, Wredmark T. Arthroscopic surgery of the knee in local anaesthesia. 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 surgery. Our experience in 1,000 cases. Rev Esp Anestesiol Reanim. 1992. 39(5): p 312-5.

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

15 Ritt MJ et al. Popliteal pseudoaneurysm after arthroscopic meniscectomy. A report of two cases. Clin Orthop. 1993. (295): p 198200.

The postoperative results are mainly influenced by sport activity (in terms of better results of athletes), presence of degenerative knee changes, as well as simultaneous injury of anterior cruciate ligament (negative influence on a postoperative result).

16 Dinh A et al. Arterial complications of arthroscopic meniscectomies. Apropos of three cases. Ann. Chir. 1993. 47(6): p 547-52. 17 Rodeo SA, Sobel M, Weiland AJ. Deep peroneal-nerve injury as a result of arthroscopic meniscectomy. A case report and review of the literature.J. Bone Joint Surg. 1993. 75-A(8): p 1221-4.

There was no statistically significant influence on postoperative result in regards to gender, localization of lesion on right or left knee and in regards to spread over of medial or lateral meniscus.

18 Dandy JD. Arthroscopic management of the kneeChurchill Livingstone , Edinburgh London Melbourne and New York , 1987. 19 Rockborn P, Gillquist J. Outcome of arthroscopic meniscectomy. A 13-year physical and radiographic follow-up of 43 patients under 23 years of age.Acta Orthop. Scand. 1995. 66(2): p 113-7.

After partial meniscectomy, degenerative changes of the knee, as well as mediolateral instability are more frequent, when there is a presence of the varus-valgus deformity of the knee.

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

The advantages of arthroscopic surgery of the knee are in dramatically shorter period of hospitalization and period necessary for complete recovery and return to everyday work and/or sport activities. This lessens, to a great extent, the medical expenses, although there still is a small risk of complications.

21 Jaureguito JW et al. The effects of arthroscopic partial lateral meniscectomy in an otherwise normal knee: a retrospective review of functional, clinical, and radiographic results. Arthroscopy. 1995. 11(1): p 29-36. 22 Boszotta H et al. Long - term results of arthroscopic meniscectomy Aktuelle Traumatol. 1994. 24(1): p 30-4. 23 Bolano LE, Grana WA. Isolated arthroscopic partial meniscectomy. Functional radiographic evaluation at five years. Am. J. Sports Med. 1993. 21(3): p 432-7.

REFERENCES 1

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

24 Kwiatkowski K. Arthroscopic meniscectomy in anterior cruciate ligament deficient knees. Chir. Narzadow. Ruchu. Ortop. Pol. 1995. 60(3): 205-9.

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

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

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

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

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

34 Roulot E et al. Arthroscopic internal meniscectomy in patients over 55 years of age. Results over more than 4 years. Rev. Chir. Orthop. Reparatrice Appar Mot. 1992;78(3): p 164-8.

28 Schmitz MA, Rouse Jr LM, De Haven KE. The management of meniscal tears in the ACL-deficient knee. Clin. Sports. Med. 1996. 15(3): p 573-93.

35 Bonamo JJ, Kessler KJ, Noah J. Arthroscopic meniscectomy in patients over the age of 40. Am. J. Sports.Med. 1992. 20(4): p 422-8.

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

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

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

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

31 Muscolo D. Osteonecrosis of the knee following arthroscopic meniscectomy in patients over 50-years old. Arthroscopy. 1996. 12(3): p 273-9.

38 Wheatley WB, Krome J, Martin DF. Rehabilitation programmes following arthroscopic meniscectomy in athletes. Sports Med. 1996. 21(6): p 447-56.

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Clinical manifestations and etiopathogenetical background of mesenteric lymphadenopathy 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 Contact:

dragan_dracula@yahoo.co.uk

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 15 mm, (27.8%). ELIZA test shows that 72.2% of children were infected with HSV, 44.4% with HPV, and 44.4% with EBV, while in the control group just 8.3% of children are infected with HSV. Majority of children had great number of preconceptic, perinatal and other 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 dysfunction of immune, haematopoietic, neuroendocrine, vascular and metabolic systems. Pathogenesis of these disorders is complex, probably mediated by with altered oral tolerance, which leads to chronic inflammation. Key words: clinical manifestations; mesenteric lymphadenopathy

Inflammation as the innate mechanism of protection is in the basis of numerous processes of organism protection from pathogens and destructing products of its own tissue. In its basis are complex non-specific and specific immune mechanisms of antigen processing, presentation and recognition. Processes, which consider engagement of specific response of immune system, are realized in the lymph nodes, which are appropriate place with necessary micro - environmental conditions for proliferation and differentiation of lymphocytes. Because of it, finding enlarged lymph nodes point out on

activation of specific immunity. Therefore regionally enlarged lymph nodes are very important clinical confirmation of immune system activation.1, 2 Since the most antigens enter organism through the mouth, processing of these antigens is important process, not only for defence but also to induce immune tolerance on numerous antigens. Whatsoever, continuous inflammation may lead to mucous membrane destruction, with gastrointestinal (GIT) dysfunctions.2 Enlargement of mesenteric lymph nodes, suggest on mucosal associated lymphoid tissue (MALT) immune system activation.3 Mesenteric lymph nodes except influence on tolerance of antigens taken by food during infection may lead to hypothalamic disorders, mediated by vagal afferentation,4 which is important component of chronic inflammatory response, leading to numerous disorders on blood vessels, central nervous system (CNS), haematopoiesis, metabolism etc. MATERIAL AND METHODS

The basic methodological approach is prospective analysis of data taken from sick children, and their mothers, hospitalized on Paediatric clinic, Clinical centre Nis, SCG in period from 01. 10. 2003. to 15. 03. 2004. Study group consider 36 children (20 boys and 16 girls), six months to fourteen years old.

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

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and oxidative metabolism of phagocytes by the means of NBT test. All the results were evaluated by student's T-test. Computer program Microsoft Excel 7.0 for Windows was used for presentation of results in tables.

I. main complains: sore through, coughing, weakness, anorexia and etc.; II. other symptoms and signs: high temperature, vomiting, diarrhoea, joint pain, headache, abdominal pain; III. earlier diseases: rhinopharingitis, tonsilopharingitis, urinary tract infections, 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 pregnancy, anaemia, infections in pregnancy (respiratory, urogenital, HSV etc.), high blood pressure and legs oedema. VIII. perinatal risk factors: premature birth, adaptation disorders, child reanimation, low and high birth weight, jaundice, convulsions, early infections in the first month, (umbilical cord infection, bronchopneumonia etc.); IX: maternal chronic diseases: labial HSV, condiloma, veruccae (HPV), headache, anaemia, allergies, autoimmune disorders, lymphadenopathy, gynaecological problems etc.; X: clinical examination: body temperature measurement, lymphonodal palpation, enlarged mesenteric lymph nodes detection, liver or spleen size, inspection of visible mucosal membranes and skin etc. XI: haematological examination: red blood cells, 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 immune complexes (IC), immunoglobulines (IgA, IgG, and IgM)

RESULTS

The percentages of the main complains among the patients are shown in Table 1. However, by the detail anamnesis and clinical examination it is confirmed that patients had other complaints also (Table 1). All the children had highly expressed vascular drawings on the skin, especially on the face, neck and on the back. (Table 1). Ultrasound examination showed that the most of the children had lymph nodes from 10 to 15 mm in diameter (66.7%) and bigger (27.8%). Earlier clinical manifestations (Table 2): rhinopharingitis had 88.9% of examined children while in the control group just 16.6%; tonsilopharingitis had 88.9% of patients and even 94.4% of children had earlier vasculitis or other manifestations on the skin. By ELISA test it is proved that 72.2% of the children were infected with HSV, 44.4% with HPV, 44.4% with EBV, while in the control group just 8.3% of children are HSV infected. Preconceptic and perinatal risk factors results are shown in table 3. Even (83.3%) of the children in study group had high birth weight. Labial HSV infection had (55.5%) of mothers and clinical manifestations (for HPV), veruccae, condiloma 44.4%. Maternal chronic diseases are shown in Table 4.

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significance of MALT - activation, because of its potential to influence on oral tolerance and on inflammation control. Enlarged mesenteric lymph nodes, may suggest MALT activation, with possible consequences on numerous clinical manifestations, besides abdominal pain or appendix inflammation.5, 6 Throughout life, one encounters a multitude of antigens and pathogens that threaten his health and survival. To fend off this antigenic insult, the immune system evolved to include lymphocytes with a parallel diversity of receptor specificities. During an antigenic encounter, T-and B-lymphocytes undergo a proliferative burst that causes the expansion of a few clonotypes specific for the antigen. This response elicits a cascade of events that ultimately leads to the elimination of the inciting antigen. Following resolution of the immune response, the majority of these antigen-specific lymphocyte clones undergo apoptosis, but a small number are converted to memory cells specifically armed for future antigenic encounters. In essence, these well-orchestrated wives of oligoclonal expansion followed by apoptosis determine the efficiency of the immune system.7

Analyzing mean values of WBC count no statistically significant differences were found, even though 66.7% of children had leucocytosis, 33.3% monocytosis, and 50% granulocytosis comparing to the control group. (Table 5.)

In many chronic inflammatory and infectious diseases, however, persistent immune activation accelerates the replicative senescence of T- and B-lymphocytes. As do all somatic cells, lymphocytes have a limited proliferative capacity, such that repeated antigenic stimulation during chronic inflammation and persistent infection usually results in the accumulation of senescent lymphocytes. It may be proposed that premature replicative senescence of T cells underlies many of the immune abnormalities associated with chronic disease. Patients with inflammatory syndromes and chronic infections have high frequencies of functionally aberrant, senescent T cells provide compelling evidence for an important role of premature immunosenescence in disease pathogenesis. Many of the chronic diseases are characterized 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 repertoire because their high frequencies mask cells with rarer TCR specificities. Typical examples of inflammatory syndromes with restricted immune repertoire are autoimmune diseases.2, 7

Mean values of enzymes activity (AST, ALT, CPK, LDH) show no statistically significant differences comparing to the control group. Even though 33.3% of the children had increased AST, ALT, and LDH. (Table 6.) Mean values of IC, IgA, IgG and IgM, in the study group were not statistically significant comparing to the control group. What so ever, it is found that fourteen children (38.9%) had increased IgG level. (Table 7.) Stimulated oxidative burst of the peripheral blood phagocytes (PBP) by phorbol - miristate - acetate (PMA) in the study group is significantly reduced comparing to the control group. (Table 7.) DISCUSSION

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

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

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induction of oral tolerance to β-lactoglobulin, whereas delayed antigen exposure retarded tolerance. The induction of oral tolerance was associated with increased IL-4 and/or IL-10 production and decreased IL-12 production.10

pathogen.1, 8 Great percent of children in study group had viral infection. Even 72.2% is infected with HSV, and with HPV and EBV 44.4%. Oligoclonally expanded T cells can persist for years and accumulate to such an extent that the T-cell repertoire becomes severely contracted. Expanded T-cell clones compete for growth factors and space, so much so that large clonal populations could impede the activation and growth of naive T cells. Therefore, contraction of the repertoire is an important determinant for the increased susceptibility of patients to infection.1, 7

The primary factor determining which form of tolerance will be developed after oral administration of Ag is the Ag dosage. Thus, it is thought that low doses of antigen induce the generation of active suppression, via regulatory T cells in the GALT, which then migrate to the systemic immune system. These regulatory T cells produce down-regulatory cytokines such as IL4, IL10 and TGFβ, a Th2 / Th3 cytokine pattern. Conversely, high dose of antigen favours anergy or clonal deletion. The phenomenon in which regulatory cells, as generated by oral toleration, are primed in an antigen specific manner, but act in the respective microenvironment in a non-antigen specific manner is called bystander suppression. This phenomenon is of particular interest and explained the use of oral tolerance in T cell mediated autoimmune diseases such as rheumatoid arthritis, multiple sclerosis and type I diabetes, and some diseases in which the autoantigens remains unknown or where there are reactivities to multiple autoantigens. There were several studies demonstrating the effectiveness of orally administered antigen in different animal models of autoimmune diseases, such as experimental allergic encephalomyelitis, collagen induced arthritis, diabetes, but also uveitis, myasthenia gravis and transplantation. Inflammatory processes on mucous membranes followed by enlarged regional lymph nodes may lead to mucous tolerance break down and initiation of chronic inflammation.13, 14 Activated immune system of the gastrointestinal mucous membranes followed by enlarged lymph nodes may change hypothalamic functions mediated by vagal afferentation, trough endocrine, metabolic disorders may lead to chronic inflammation.12

The majority of research on T cells has focused on CD4+ cells, for which work has concentrated on the roles of PGE2 in the modulation of proliferation, apoptosis and cytokine production. During mucosal inflammation, for example, mucosal T cells up-regulate their expression of certain EP receptors, and there is a resulting decrease in the T-cell production of IL-2. The effects of PGE2 on the apoptosis of T cells are dependent on the maturation and activation state of the cell.9 PGE2 plays an important role in the development and activity of B cells. In contrast to its effects on mature B cells, PGE2 acts in an inhibitory manner on immature and developing B cells. For example, PGE2 suppresses the proliferation of immature B cells, but has no effect on, or even sometimes enhances, the proliferation of mature B cells.9 Growth and development of the embryo and foetus in the antigen "privileged" environment and Th2 response predominance of mother's immune system are necessary for appropriate development of the immune system (prevention of clonal abortion anergy, apoptosis) as well as for the development of other organs and tissues. Cytokines of Th1 response, oxygen free radicals and nitrites with their potential to influence gene expression may seriously interfere with cell proliferation, differentiation, apoptosis and migration.10, 11 Many acute viral infections are known to cause death of the embryo or serious anomalies. Altered cytokine profile and microenvironment during prenatal development because of acute infection or chronic disease of mother are possible factors for the immune system dysfunction and chronic diseases development in childhood.11, 12 All the children in the study group have few or many risk factors for development disorders and immune system deregulation. 44.4% of mothers had one or more artificial abortion before gave birth to the current child, as well 44.4% had hormone treatment during the pregnancy. These data are important, because during the pregnancy mother is direct carrier of immune activity, what for she has a great influence on child's immune system development during the antigen non-dependent faze of its forming.10, 12 83.3% of children had high birth weight as a consequence of insulin receptor up-regulation and insulin like cytokine effects on the cell.10

Reduced values of stimulated NBT test of PBP, points out on down regulation of oxidative metabolism and turning on "feed back" mechanisms that may have protective role from over production of oxidative products.11 As well, increased values of IgG in 38.9% prove chronic stimulation of immune system. Based upon our evaluation, the conclusions that can be drawn are that children with mesenteric lymphadenopathy are in great percent infected with HSV, HPV, CMV, EBV and show signs of chronic stimulation of immune system. Clinical manifestations are very heterogenic, involving dysfunctions of many systems: immune, haematopoietic, neuroendocrine, vascular and metabolic. Pathogenesis of these disorders is complex, probably mediated by altered oral tolerance, which leads to chronic inflammation.

The onset and duration of the immunologic responses were found to be dependent on the timing of antigen exposure. Prenatal exposure to antigen facilitated the

ACKNOWLEDGMENTS

Sonja Tasic MD (ultrasound)

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8

Karre K. Express yourself or die: peptides, MHC molecules, and NK cells. Science 1995. 267: p 675-78. Harris S, Padilla J, Koumas L, Ray D, Philips R. Prostaglandins as modulators of immunity. Trends Immunol. 2002. 23 (3): p 144-50.

1

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

9

2

Kamenov B. Imunske osnove odgovora mukoze na infekciju i njegov znacaj na tok, prognozu i komplikacije bolesti. Zbornik radova. Jugoslovenski pedijatrijski dani. Nis. 2001.

10 Bubanovic I, Kamenov B, Najman S. Imunobioloske osnove trudnoce. Mrljes. Beograd 2001.

3

De Boer WA, Maas AM, Tytgat GN. Disappearance of mesenteric lymphadenopathy with gluten-free diet in celiac sprue. J Clin Gastroenterol. 1993. 16: p 317-9.

4

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

5

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

6

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

7

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

11 Kamenov B, Dimitrijevic H, Tasic G, Pljaskic S. Chronic diseases in childhood as a consequence of immune system disfunction of mother during pregnancy. Facta Universitatis, Medicine and Biology 1999. 6 (1): p 97-102. 12 Kamenov B. Disregulacija imunskog sistema majke u trudnoci i pojava hronicnih bolesti u detinjstvu. Kongres perinatalne medicine. 1997. 4: p 84-86. 13 Mazelin L, Theodorou V, More J, Bueno L. Protective role of vagal afferents in experimentally induced colitis. J Autonomic Nervous Sys. 1998. 73: p 38-45. 14 Li P, Huang H, Liang J. Neourophysiological effects of recurent laryngeal and thoracic vagus nerves an mediating the neurogenic infalmmation of the trachea, bronchi, and esophagus of rats. 2001. 88: p 142-50.

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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 Contact:

b1le@doctor.com

Aim. To study the relationship between cutaneous and systemic tuberculosis, and their correlation with war and postwar activities. 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 Dermatovenerology" and the "Institute for tuberculosis and lung diseases" in Skopje, Macedonia. We used methods for standardized diagnosis protocol for CT. Results. In the period between January and December 2002, there were 12 documented cases of CT (1.64% of the 730 documented cases of ST). This is a six-fold increase from the number of documented occurrences of CT during the period between 1997 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 to discover 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

Tuberculosis is an infectious disease caused by the bacterium Mycobacterium tuberculosis (slightly curved, sporeless, motile, obligate aerobic, Gram - positive bacterium) which affects one third of all humans. It appears in highly variable clinical manifestations. Cutaneous tuberculosis (CT) is a label for a wide group of skin lesions. It is rare, and yet a form of the disease that is of special interest to tuberculosis experts and dermatologists as well. This comes as a consequence of the fact, that CT most often manifests itself after previous and even more serious ongoing persistence of systemic tuberculosis (ST) in the affected organism. This is the reason why the incidence of isolated CT patients usually correlates with the incidence of isolated ST patients, during the period in question. In addition, the rate of occurrence of CT should be taken as an indicator of the social, economic and even political circumstances gov-

erning the region. The two hypotheses mentioned above, provide guidance in our field of interest and research.

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

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

MATERIAL AND METHODS

In this study we used methods for standardized diagnosis protocol for CT such as: 1. Specific clinical manifestations of the skin lesions (e.g. presence of apple jelly-colored dermal infiltrates); 2. Recovery and identification of the organisms by bacterial culture; 3. Demonstration of the presence of M. tuberculosis via PCR assays for specific DNA sequences; 4. Finally, compatible histopathology consisting of granulomatous infiltrates with caseation necrosis and the presence of acidfast bacilli in the tissue sections were both suggestive, and were by no means pathognomonic of tuberculosis.

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The significant increase in the number of CT patients as opposed to the marginal increase in the total number of ST patients followed in the period between 1997 and 2002 is shown in Figure 2.

During the course of this project we obtained data from official medical records from the "Clinic for Dermatovenerology" and the "Institute for Tuberculosis and Lung Diseases" in Skopje, Macedonia. The overall number of registered patients with CT and ST concerning each of the years in the period between 1997 and 2002, can be seen in Table 1.

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

RESULTS

During the period between January and December 2002, there were 12 documented cases of CT (1.64% of the 730 documented cases of ST). This is a six-fold increase from the number of documented occurrences of CT during the period between 1997 and 2001 (average of 0.30% from the 650 documented occurrences with ST), as seen in Figure 1.

Out of the twelve documented cases with CT, 10 (83.3%) originated in crisis region (i.e. northwestern part of R. Macedonia), as seen on Figure 4. Figure 5 shows a comparison between the number of newly registered cases with Cutaneous Tuberculosis and the total number of newly registered cases during the two relevant periods (year 2002 as compared to the periond between 1997 and 2001).

The significant increase in the number of CT patients as opposed to the marginal increase in the total number of ST patients followed in the period between 1997 and 2002 is shown in Figure 2.

RELEVANT CASE STUDIES FROM OUR CLINIC

Picture 1: A 12-year-old female patient with post vaccinal BCG infection (Besegitis Colliquativa.) Clinical manifestation localized in the left shoulder area occurred one month after inoculation. Unilateral indolent, firm, non-tender, sharply-delimited ulcer, colliquation and necrosis. Scrofuloderma is evident as well.

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

Pictures 2 and 3: A 26 year old Albanian female patient with Tuberculosis colliquativa ulcerogummosa haematogenes et exogenes. Skin lesions became visible two years prior to hospitalization.

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

Picture 2: Skin lesion in initial stage - indurated, subcutaneous, cold and livid nodule, localized on the chin. Picture 3: Skin lesion in the terminal stage - multiple, colliquative abscess that perforates the skin in the distal regions of the lower extremities.

Figure 5. comparison between the number of newly registered cases with Cutaneous Tuberculosis and the total number of newly registered cases during the two relevant periods www.emsa-europe.org

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

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DISCUSSION

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

Picture 4: Plaques with a psoriatic scale, atrophy and polycyclic squamous configurations are evident on the photography.

Picture 5: Sequels of Tuberculosis colliquativa cutis are manifested thrugh irreversible, cicatrized, contractile, thick skin lesions in the abdominal region.

There is a need of additional medical check-ups and tuberculosis tests on the territory of R. Macedonia in order to discover all undocumented cases of ST. This is vital ingredient in the process of controlling and eradicating this infectious disease. REFERENCES

Picture 6: A female patient in her forties with a pasty constitution (typus rusticus.) - Erythema induratum (Bazin) - typical form. Picture 7: The photograph presents obvious skin alterations that are localized in the pretibial areas characterized by erythematous, nodular, indurative, painless vascular lesions. A 37 years old female Albanian patient with pretibial areas characterized by erythematous, nodular, indurative, painless Tuberculosis papulonecrotica (scrofuloderma). Picture 8: An older woman with TBC colliquativa and scleromyxoedema (Morbus Arndt - Gottron). TBC lesions are localized on the neck of

the patient. On the photograph, we can see fistulous colliquative abscesses and deep contractive scarrings. TBC + Scleromyxoedema are evident on the same photograph.

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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.


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2004 Edition

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 Montenegro Dusan Slankamenac MD Contact:

melitanesic@yahoo.com

Aim. To examine a frequency of gastrointestinal functional disorder's symptoms, divide the students with IBS symptoms using the Rome 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 71 males 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. Association between IBS symptoms and symptoms of other gastrointestinal functional disorders has been analyzed. We have examined the manner of managing those disorders. Statistical importance has been evaluated by Ď&#x2021;2 test. Results. 78.5% of students have at least one gastrointestinal symptom. Females, statistically important (p < 0.05), have constipation more frequently then males. The main symptom in males is heartburn. Symptoms of upper gastrointestinal disorders are present in 43.2% of population and symptoms of lower gastrointestinal disorders in 67.8%. 24.2% of examined population has a cluster of symptoms characteristic for IBS, but only 8 females fulfil the Rome criteria. The others have typical symptoms that last less than 12 weeks in one year. Diarrhoea predominant IBS is common in males. Constipation predominant and combined diarrhoea-constipation IBS subtypes are more common in females. There is considerable (p < 0.01) overlap of IBS and symptoms of upper gastrointestinal functional disorders regardless of sex. Only 7.7% of students seek advice from the doctor. 25% of them use self-help treatment to control the symptoms. Conclusion. Prevalence of gastrointestinal symptoms among university students is over- expected. People with gastrointestinal functional disorders rarely seek for doctor help. Therapeutic respond often fails. Common overlap in functional disorders is of great importance in planning further examinations. Key words: gastrointestinal system; functional disorders; irritable bowel syndrome; Rome II criteria

constipation, gas, bloating, mucus in the stool, a feeling of incomplete evacuation after bowel movement. The subjective nature of IBS symptoms, the enormous variation even within each symptom and lack of diagnostic marker associated with this disorder, make diagnosis more complicated. A large portion of IBS patients also complain of other functional disorders such as dyspepsia, heartburn, dysuria, dyspareunia, fibromyalgia, chronic fatigue syndrome.4, 6, 7, 8 Higher prevalence of psychiatry disorders is estimated in patients that suffer from IBS.9, 10

Gastrointestinal symptoms are common in the general population. In the most of cases those symptoms are result of functional disorders among which Irritable Bowel Syndrome (IBS) is the most important. Approximately 20% of people in Western countries suffer from IBS symptoms.1, 2 Although only 10% of subjects with diagnosable IBS consult a doctor those patients present common pathology not only in general practitioner's but also in gastroenterologist's everyday practice.2, 3, 4 IBS is chronic, functional gastrointestinal disorder, with unknown aetiology and higher prevalence in females.5, 6 The most frequent symptoms that IBS patients complain of are: abdominal pain, diarrhoea,

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

Figure 1. Prevalence of measured gastrointestinal symptoms Figure 2. Prevalence of measured gastrointestinal symptoms in males and females www.emsa-europe.org

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clinical presentation and by excluding other diseases which may have a similar presentation.4, 11, 12 High prevalence, pure therapeutic response, exaggerated fear of having cancer in some patients and occasional needs for expensive diagnostic work-ups contribute in presenting this disorder as a big social and economic problem.4, 5, 13 In order to make diagnosing of IBS easer and to avoid expensive diagnostic procedures there have been proposed a several diagnostic criteria: Manning, Kruise, Rome I, Rome II. None of the criteria is 100% sensitive or specific for IBS but are useful for research and can help guide the diagnostic evaluation.

Figure 3. Frequency of the most common gastrointestinal symptoms

Functional disorders of oesophagus, stomach and duodenum are also common. According to some statistics between 7% and 41% of adult population has at least one of the symptoms of these disorders.1, 4, 8 The pathophysiology of gastrointestinal functional disorders is complex and overlapping between different disorders symptoms is frequent.14 Due to unavailability of any data of large epidemiologic research in our country we decided to examine for prevalence and subjective appearance of gastrointestinal symptoms in a part of student's population at the Medical Faculty in Novi Sad.

Figure 4. Frequency of measured gastrointestinal symptoms in males and females

MATERIAL AND METHODS

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

Figure 5. Frequency of symptoms of upper gastrointestinal functional disorders in examined population

Gastrointestinal symptoms including the Rome criteria for IBS and dyspepsia were measured. The diagnostic criteria for IBS specify that for least 12 weeks in the past 12 months, a patient experienced abdominal discomfort or pain with two of the following characteristics: 1) abdominal discomfort or pain relieved with defecation; 2) onset associated with a change in the form or appearance of stool.

Figure 6. Frequency of symptoms of lower gastrointestinal functional disorders in examined population

The following symptoms cumulatively support the diagnosis of IBS: 1) abnormal stool frequency (> 3/day or < 3/week); 2) abnormal stool form (lumpy/hard or loose/watery stool); 3) abnormal stool passage (straining, urgency or feeling of incomplete evacuation); 4) passage of mucus; 5) bloating or feeling of abdominal distension. Presence of alarm symptoms suggests an organic disease rather than a functional disorder. These symptoms include fever, weight loss, anorexia, nocturnal symptoms, gastrointestinal bleeding, anaemia, and presence of an abdominal mass. Symptoms of other gastrointestinal disorders which have been measured are also defined by Rome II criteria. According to questionnaire a frequency of some gastrointestinal symptoms were measured and compared between genders. Grope that has IBS symptoms has been divided. The

Figure 7. Frequency of IBS symptoms among genders.

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dents had symptoms of upper gastrointestinal functional disorders (Figures 5 and 6). 24.2% (61 students) of examined population has a cluster of symptoms characteristic for IBS, but only 8 females fulfil the Rome criteria. The others have typical symptoms that last less than 12 weeks in one year (Figure 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 and symptoms of upper gastrointestinal functional disorders regardless of gender (Figure 9).

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

most common symptoms in this grope have been analyzed and its connection with sex and symptoms of other gastrointestinal disorders. We also have analyzed a manner in management of these symptoms. The data are statistically evaluated, results are graphically presented and statistic importance is measured by Ď&#x2021;2 test.

Only 7.7% of students with gastrointestinal symptoms asked for doctor's help. Therapy they were given by doctor was not successful in the most of cases. 25% of medical students we examined use complementary and alternative medicine (tea) to relieve their symptoms. DISCUSSION

RESULTS

The presented results are similar to those we found in literature: gastrointestinal symptoms are common in adult population. There is overlap between symptoms of upper and lower gastrointestinal functional disorders. Patients with functional disorders are much more likely to seek complementary and alternative medical care.

78.2 % of examined students have at least one of the measured symptoms that are characteristic of gastrointestinal disorders (Figure 1). The symptoms are more common in males but difference is not statistically important (Figure 2).

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

The most common symptoms are: bloating or feeling the abdominal distension (53%), constipation (32%), diarrhoea (22,3%) and heartburn (21,8%) (Figure 3). Statistically important (p < 0.05) constipation is more frequent in females and heartburn in males. Results are graphically presented in Figure 4.

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

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

Figure 9. Prevalence of dyspepsia and heartburn in screened population with IBS symptoms www.emsa-europe.org

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motility. Sex hormones may aggravate and prolong lower gastrointestinal symptoms in females. Is there any connection between those hormones and particular types of symptoms that are more common in females? The real cause responsible for different functional disorders overlap is still unknown. There is a need for exact explanation of pathophysiological mechanisms in order to improve symptoms treatment. Functional disorders present an unexamined field of medicine despite of many experiments and examinations. Great numbers of suspected factors, polysymptomatology, complex pathophysiological mechanisms need participation not only of gastroenterologist but of other scientist in order to resolve the problem of these common disorders.

2

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

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

4

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

5

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

6

Hogston P. Irritable bowel syndrome as a cause of chronic pain in women attending a gynaecological clinic. BMJ. 1987. 92: p 954959.

7

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

8

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

9

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

11 Holten KB, Wetherington A, Bankston L. Diagnosing the patient with abdominal pain and altered bowel habits: Is it Irritable Bowel Syndrome? AFP 2003. 67, 10. 12 Manojlovic B. Interna medicina. Zavod za udzbenike i nastavna sredstva. Beograd. 2000. p 678-684. 13 Holmes IM, Salter RH. Irritable bowel syndrome - a 5 years prospective study. Lancet. 1987. p 963-965. 14 Talley NJ, Boyce P, Jones M. Identification of distinct upper and lower gastrointestinal symptom groupings in an urban population. Gut. 1998. 41: p 394-398.

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

3

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

Therefore, we can conclude that the symptoms of gastrointestinal functional disorders are common in student population, frequency higher than expected and requires further investigations in order to understand a cause. People with gastrointestinal functional disorders rarely seek for doctor help and if they do it therapeutic respond fails. Common overlap in functional disorders is of great importance in planning further examinations if patients decide to consult a doctor.

1

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

Author:

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

aytac@atlas.net.tr

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

with preeclampsia in later pregnancies had increased risk of hypertension.4 It should also be noted that these women may have an inherited thrombophilia, unrecognized latent hypertension, or other genetic or environmental factor predisposing to hypertension during and after the pregnancy.

Preeclampsia has been associated with cardiovascular events, namely hypertension, ischemic heart disease and stroke, but still the pathogenesis and the long term consequences are needed to be studied further. Preeclampsia is one of the most mysterious diseases in the field of obstetrics. It is described as a "disease of theories". Nowadays, the widely supported theory is the reduced placental perfusion primarily due to abnormalities in implantation and vascular changes which are secondary to maternal genetic susceptibility and immune maladaptation. Clinically, it refers to the new onset of hypertension and proteinuria after 20 weeks of gestation in a previously normotensive woman. Depending on different factors, preeclampsia has some serious as well as debatable long - term implications, which have been under comprehensive investigation lately.

It has also been found that women who had preeclampsia are more likely to develop ischemic heart disease later in life.5 These findings bring up the question of whether the same predisposing factors for cardiovascular diseases that become more evident in later life, also predispose to preeclampsia. When the underlying risk factors are closely observed for both pathologies, common denominators like dyslipidemia, insulin resistance, and blunted endothelial relaxation are pointed out in some studies.6, 7, 8 Also endothelial injury supported by the oxidative stress is another theory which has been supported by the latest research and which can be another common cause, considering the oxidation hypothesis of atherosclerosis.

Preeclampsia is a recurring disease, primarily of first pregnancies. It has been found over three times more common in women with a previous history of disease than in nulliparas.1 However, the long-term prognosis varies with the severity of the acute episode, as well as the occurrence time in pregnancy. Mild preeclampsia in primigravidas is generally self-limited and has a low incidence of recurrence, whereas severe preeclampsia creates a high risk for recurrence and late hypertension.2, 3 Generally, the earlier it occurs during the index pregnancy, the greater the likelihood of recurrence.

A review of over 626,000 first deliveries in Norway, reported women with preeclampsia and preterm delivery were at increased risk of death from cardiovascular disease compared to preeclamptics and nonpreeclamptics who delivered at term, and also nonpreeclamptics who delivered preterm (relative hazard rates 8.12, 1.65 and 2.95 respectively).9 This study suggests that the causes may be different for early and late onset preeclampsia, in preterm deliveries.

Another important implication is the relation between preeclampsia and cardiovascular disease. According to both Current Obstetrics and Gynaecology (2003) and Williams Obstetrics (2001), preeclampsia does not cause chronic hypertension. Despite this statement, the effect of preeclampsia on subsequent development of chronic hypertension and other cardiovascular diseases such as ischemic heart disease is still debatable. Women, who had preeclampsia, have been found to be more prone to hypertensive complications in their future pregnancies. The Chesley follow-up study found that women with severe preeclampsia in only their first pregnancy did not have an increased risk of late hypertension, on the other hand, women

HELLP syndrome, a significant risk for maternal mortality, is characterized by haemolysis, elevated liver enzymes and low platelets. It typically occurs in white multiparous patients older than 25 years, but is not limited to this group. The majority of cases are diagnosed between 22 and 36 weeks of gestation. Adverse outcomes including recurrent preeclampsia, preterm delivery, foetal growth restriction, placental abruption and caesarean delivery in subsequent pregnancies are increased in women with HELLP syndrome. Latest series reported the recurrence rates between 4% and 19%.10 The incidence of

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

5

Smith GC, Pell JP, Walsh D. Pregnancy complications and maternal risk of ischemic heart disease: A retrospective cohort study of 129,290 births. Lancet. Jun 23 2001. 357(9273): p 2002-6.

As a result, when the latest research is reviewed, development of early-onset preeclampsia in primigravid women may predict remote cardiovascular events, namely hypertension, ischemic heart disease and stroke.9, 12 On the other hand, preeclampsia / eclampsia occurring late in pregnancy in primigravid women does not appear to be associated with long - term cardiovascular risk.4 Therefore, more research is needed to solidify the hypothesis of common pathophysiology of preeclampsia and cardiovascular diseases. The association between cardiovascular disease and preterm preeclampsia reported by Norway study suggests that the pathogenesis and prognosis of the early versus late preeclampsia may be different.

6

Laivuori H, Tikkanen MJ, Ylikorkala O. Hyperinsulinemia 17 years after preeclamptic first pregnancy. J Clin Endocrinol Metab. Aug 1996. 81(8): p 2908-11.

7

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

8

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

9

Irgens, HU, Reisaeter, L, Irgens, LM, Lie RT. Long term mortality of mothers and fathers after preeclampsia: population based cohort 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 subsequent gestations. Am J Obstet Gynecol. Mar 1994. 171(4): p 940-3. 11 Sibai BM, Ramadan MK, Chari RS, Friedman SA. Pregnancies complicated by HELLP syndrome (hemolysis, elevated liver enzymes, and low platelets): Subsequent pregnancy outcome and long - term prognosis. Am J Obstet Gynecol. Jan 1995. 172(1 Pt 1): p 125-9.

Despite all the efforts, preeclampsia is still a disease of blurred facts where meticulously done long-term observational studies are required to define the long term consequences, and basic science researches to clarify the multifactorial pathogenesis.

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

REFERENCES 1

Hnat MD, Sibai BM, Caritis S, Hauth J, Lindheimer MD, MacPherson C. Perinatal outcome in women with recurrent preeclampsia compared 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 of preeclamptic women: Relationship with renal impairment and week of delivery. Am J Obstet Gynecol. Aug 1994. 171(2): p 50612.

3

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

4

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

RESOURCES

www.emsa-europe.org

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1

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

2

DeCherney, Alan, editors. Current Obstetrics and Gynecology. 9th ed. McGraw Hill. 2003.

3

Lambrou NC, Morse AN, Wallach EE. The Johns Hopkins Manual of Gynecology and Obstetrics. 2nd ed. Lippincott, Williams and Wilkins, 2002.

4

August P, Sibahi B. Clinical Features and Prognosis of Preeclampsia, UpToDate Online. 11.3. 2003.

5

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


JEMSA - Journal of EMSA on Medical and Scientific Affairs

ANNOUNCEMENTS

2004 Edition

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 Assembly and EMSA Conference, that will be held in Thessaloniki, Greece from 12 to 17 of October, 2004!!! We have been working hard for many months to prepare this meeting for all of you! Dozens of hours of OC meetings, talking on the phone, arranging new meetings and hundreds of hours in front of our PCs. And now, we are so close to the event that we are both so proud and excited! The program will include workshops 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 the International 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 participate 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 team is 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

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56


JEMSA - Journal of EMSA on Medical and Scientific Affairs

ANNOUNCEMENTS

2004 Edition

INVITATION TO 4th ZIMS (ZAGREB INTERNATIONAL MEDICAL SUMMIT) Organized by SSCMA (Student Section of Croatian Medical Association) and EMSA Zagreb, ZIMS is one of the best European summits for medical students and young doctors. The summit is traditionally held in Zagreb, Croatia, this year from NOVEMBER 11th to 14th. Like every year, you can apply to ZIMS as active (oral or poster presentation) or as passive participant. We are rewarding best scientific paper, best lecturer and 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 proud to present Satellite meeting on subject "Sports medicine". Besides offering a unique discussion 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 one meal during the official part of the programme (3 nights and 4 days), coffee breaks, all congress materials, all lectures and final exam, 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

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57


JEMSA - Journal of EMSA on Medical and Scientific Affairs

2004 Edition

jemsa.emsa-europe.org & www.emsa-europe.org

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JEMSA 2004  

Journal of EMSA (European Medical Students' Association) on Medical and Scientific Affairs

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