Descriptors: Thyroid neoplasms – diagnosis, pathology; Carcinoma – diagnosis, pathology; Ki-67 antigen – analysis; Proto-oncogene proteins C-bcl-2 – analysis; Tumor suppressor protein p53 – analysis
Summary. The report covers the first case of insular thyroid cancer recorded in Croatian medical literature. A 71-year old female patient presented to our hospital with symptoms of inspiratory stridor. Clinical examination disclosed an expansive tumor mass. US guided FNA indicated anaplastic cancer and total thyroidectomy was accordingly indicated. Patho- histological analysis of H/E biopsies disclosed a tumor mass with a characteristic insular growth pattern of monomorphic tumor cells. Immunohistochemical analysis confirmed diagnosis by a diffuse positive reaction to thyreoglobulin, focally to TTF-1, and scant to cytokeratin, while calcitonin, FVIII, CD34 and LCA were clearly negative. P53 and bcl-2 were expressed in 35.9% and 85% of tumor cells, respectively. The proliferation index for Ki-67 was 4.19. According to our survey we suggest a panel of immunohistochemistry for diagnosing insular cancer. Even if partly present, insular cancer should be mentioned in the pathohistological description because of its prognostic meaning.

Descriptors: Cushing syndrome – etiology, genetics; Adrenal cortex diseases – complications, genetics; Pigmentation disorders – complications, genetics; Multiple endocrine neoplasia – genetics
Summary. We report a 11 year old girl and two 14 year old boys with Cushing's syndrome due to primary pigmented nodu- lar adrenocortical disease (PPNAD). In these patients, hypercortisolism is a consequence of autonomous cortisol secretion from adrenal glands and is ACTH-independent. Besides PPNAD, the girl had lentigines, spotty pigmentation on her bucal mucosa and lips and she also had schwannoma. One of the reported boys had prolactinoma. Considering this, those two patients fulfill the criteria for Carney complex which is a type of multiple endocrine neoplasia syndromes inherited in an autosomal dominant trait. The other boy had PPNAD but no other obvious signs of Carney complex were noticed. Family study didn't reveal any clinical or laboratory signs of Carney complex in our patients' first relatives. All of our patients under- went bilateral adrenalectomy (in one of the boys laparoscopic surgery was performed). Glucocorticoid and mineralo- corticoid substitution has been started. Adrenal glands were macroscopically normal but pathohistological analysis con- firmed the diagnosis of PPNAD.

Descriptors: Lymphoma – radiography, pathology; Bone neoplasms – radiography, pathology
Summary. The purpose of our study was to retrospectively review imaging appearances of primary bone lymphoma in 13 patients (six males, seven females; mean age 30.6 years) from 1994 to 2006 on plain radiography, computed tomography (CT), magnetic resonance (MR) and scintigraphy. Lytic-sclerotic pattern was noticed in 26 of 36 bone lesions on plain radiography and in 27 of 33 lesions on CT scanning. On MR, lesions were homogeneous and hypointense on T1 weighted images, and inhomogeneous and hypointense, isointense or hyperintense with respect to fat on T2 weighted images. Increased uptake on bone scintigraphy was noticed in six out of eight patients. The most common location of primary bone lymphoma was the pelvis. Pathologic type was non-Hodgkin's lymphoma in 11 patients and Hodgkin’s disease in two patients. Primary bone lymphoma presents as mixed lytic-sclerotic lesions that might cause the soft-tissue mass and bone marrow changes associated with little cortical destruction.

Descriptors: Abdominal injuries – diagnosis, surgery; Laparoscopy; Spleen – injuries; Liver – injuries
Summary. In the past few years, laparoscopy has been increasingly used in patients with acute abdominal trauma. This metod in experienced hands enables direct eye visualisation of abdominal cavity, ensures accurate and early diagnosis and leads to prompt decision on the therapy. Reviewing the literature, laparoscopy in acute abdominal trauma is a safe and accurate procedure to yield diagnosis, enable laparoscopic interventions and help avoid unnecessary laparotomy. In acute abdominal trauma, laparoscopy is mostly used as a diagnostic method, not so often as a therapeutic method, but an expand- ing range of therapeutic interventions is available. We show our early results with diagnostic and therapeutic laparoscopy from January 1st 2003 to March 31st 2004, stressing therapeutic laparoscopy. We performed 79 laparoscopic explorations in patients with diagnosis of acute abdomen. 7 of them were explored because of acute abdominal trauma. In 3 patients there was no need for intervention after laparoscopic exploration, in 1 patient we electrocoagulates smaller bleeding from the spleen and in other 3 patients we made conversion to open surgery procedure, because of III–IV grade liver or spleen injury. In our group we didn’t have injuries of any other internal abdominal organs. Laparoscopic treatment of acute abdominal trauma with spleen or liver injury is applicable in I–III grade liver injury and I–II grade spleen injury, while in greater injuries it is necessary to make conversion to laparotomy.

Descriptors: Vertigo – diagnosis, physiopathology, therapy; Cervical vertebrae – physiopathology; Proprioception
Summary. Cervical proprioceptive system (CPS) consisting of mechanoreceptors of cervical intervertebral joints, mecha- noreceptors of neck muscles and ligament’s insertions, muscle spindles located in deep short muscles of cervical spine and sensitive fibers connecting neck’s proprioceptors with neurons of cornu posteriori of spinal cord, plays an essential part in maintaining bodily balance. CPS, via tractus spinovestibularis, is connected to vestibular nuclei. Clinical and neuro- physiological studies have shown that functional disorders and/or organic lesions of CPS cause identical symptoms as vestibular diseases: vertigo, nystagmus and balance disorders. Dysfunction (functional blockade) of craniocervical joints is the most frequent cause of cervicogenic proprioceptive vertigo (CPV). The constant tension of the capsule of a blocked joint irritates mechanoreceptors protecting the joint’s capsules. The increased activity of mechanoreceptors results in confusion of vestibular system. That is, the impulses from the blocked craniocervical joints do not correspond to the impulses from the vestibular organ and other sensory systems that take part in maintaining bodily balance. The disharmony of impulses results in an inadequate vestibulo-spinal and vestibulo-ocular reaction manifesting as vertigo and nystagmus. Hyperactivity of craniocervical mechanoreceptors also causes disturbances in reflex regulation of postural muscle tonus manifesting as »general instability«. Knowledge of CPV as a separate clinical entity is important from diagnostical and therapeutical aspect. As it concerns a peripheral vestibular disorder still unknown to a wider circle of physicians, the article describes etiopathogenesis, clinical manifestations, diagnosis and therapy of CPV with special emphasis on manual therapy.

Descriptors: Multiple sclerosis – diagnosis, pathology; Magnetic resonance imaging – methods
Summary. Multiple sclerosis is an autoimmune disease characterized by demyelination and axonal loss. Conventional magnetic resonance imaging allows the demonstration of spatial and temporal dissemination of multiple sclerosis lesions earlier than is possible from clinical assessments. A variety of conventional magnetic resonance imaging protocols, in conjunction with clinical assessment, are now routinely used to increase the accuracy of diagnosis and long-term prognosis of multiple sclerosis. T2-weighted hyperintense lesions are related primarily to increased water content and thus cannot distinguish between inflammation, edema, demyelination, Wallerian degeneration, and axonal loss, whereas the contrast gadolinium-enhanced lesions on T1-weighted images reflect increased blood-brain barrier permeability associated with active inflammatory activity. Conventional magnetic resonance imaging metrics are not sufficiently sensitive to detect invisible brain damage in the normal appearing brain tissue, and they do not show a reliable correlation with clinical measures of disability. However, numerous studies showed that they can improve accuracy in the diagnosis and prognosis of multiple sclerosis. Recently, non-conventional magnetic resonance imaging techniques have been introduced to increase the accuracy of diagnosis and prognosis of multiple sclerosis. Several studies have used brain atrophy, T1-hypointense lesion volume, magnetization transfer imaging, diffusion-weighted imaging and magnetic resonance spectroscopy to test whether the extent and severity of tissue loss in lesions and in normal appearing gray and white matter at the time of clinically isolated syndrome may have diagnostic and prognostic value. These magnetic resonance imaging techniques represent a powerful tool to non-invasively study different pathological substrates of lesions and microscopic tissue changes. Additional short- and long-term prospective studies are requested to establish their value in the diagnosis and prognosis of multiple sclerosis.

Descriptors: Anaphylaxis – chemically induced, diagnosis, therapy; Neuromuscular blocking agents – adverse effects; Anesthesia – adverse effects
Summary. The incidence of anaphylactic reactions during anesthesia is between 1:5000 and 1:25000 anesthetics. During the IgE-mediated anaphylactic reaction mast cells release proteases such as tryptase, histamine and vasoactive mediators. The release of mediators from the mast cells and basophils is responsible for the immediate clinical manifestations of anaphylaxis. Anaphylactoid reactions can be caused directly by a release of histamine and other mediators from mast cells and basophils and they don't depend on interaction of IgE antibodies with antigen. The most frequent agents that cause anaphylactic and anaphylactoid reactions during anesthesia are neuromuscular blocking agents (among them the highest percent refers to rocuronium and succinylcholine), some general anesthetics, antibiotics, blood and blood products, opioids and latex. Increased tryptase concentration in serum is a marker for systemic mast cell activation. Skin tests (in vivo) are used for verification of specific hypersensitivity to drugs in patients after anaphylactic reaction. In vitro tests prove the presence of specific IgE antibodies for drugs. The plan for the treatment of anaphylactic reactions must be established before the event. Airway maintenance, 100% oxygen administration, intravascular volume expansion and epinephrine are essential to treat the hypotension and hypoxia that result from vasodilatation, increased capillary permeability and bronchospasm. As soon as the diagnosis has been made the adrenalin should be given intravenously 1 to 3 ml of 1:10000 aqueous solution (0.1 mg/ml) over 10 minutes. Prevention is possible with methylprednisolone 125 mg i.v. 1 hour before administering of anesthetics and neuromuscular blocking agents with or without antihistaminic chlorpiramine-chloride 1 amp i.v. few minutes before anesthesia.